Preoperative computed tomography in Fournier's gangrene does not delay time to surgery.

PURPOSE: Fournier's gangrene (FG), a rapidly progressive necrotizing soft tissue infection of the external genitalia and perineum, necessitates urgent surgical debridement. The time to surgery effect of preoperative computed tomography (CT) in managing this condition is yet to be fully explored. The purpose of this study was to assess whether obtaining a preoperative CT in patients with FG impacts the time to surgical intervention. METHODS: This was a single-center retrospective study of patients who underwent CT prior to surgical debridement of FG during a 9-year period vs patients who did not undergo CT. In 76 patients (male = 39, mean age = 51.8), 38 patients with FG received a preoperative CT, and 38 patients with FG did not receive CT prior to surgical debridement. Time to operating room and outcome metrics were compared between CT and non-CT groups. RESULTS: The time from hospital presentation to surgical intervention was not significantly different between patients who underwent CT and those who did not (6.65 ± 3.71 vs 5.73 ± 4.33 h, p = 0.37). There were also no significant differences in cost ($130,000 ± $102,000 vs $142,000 ± $152,000, p = 0.37), mortality (8 vs 7, p = 1), duration of hospital stay (15.5 ± 15 vs 15.7 ± 11.6 days, p = 0.95), average intensive care unit stay (5.82 ± 5.38 days vs 6.97 ± 8.58 days, p = 0.48), and APACHE score (12 ± 4.65 vs 13.9 ± 5.6, p =0.12). CONCLUSION: Obtaining a preoperative CT did not delay surgical intervention in patients with FG.

Reduction of Surgical Site Infection After Trauma Laparotomy Through Use of a Specific Protocol for Antibiotic Prophylaxis.

Background: Emergency laparotomy for abdominal trauma is associated with high rates of surgical site infection (SSI). A protocol for antimicrobial prophylaxis (AMP) for trauma laparotomy was implemented to determine whether SSI could be reduced by adhering to established principles of AMP. Patients and Methods: A protocol utilizing ertapenem administered immediately before initiation of trauma laparotomy was adopted. Compliance with measures of adequate AMP were determined before and after protocol implementation, as were rates of SSI and other infections related to abdominal trauma. Univariable and multivariable analyses were performed to determine risk factors for development of infection related to trauma laparotomy. Results: Over a four-year period, 320 patient operations were reviewed. Ertapenem use for prophylaxis increased to 54% in the post-intervention cohort. Compliance with individual measures of appropriate AMP improved modestly. Overall, infections related to trauma laparotomy decreased by 46% (absolute decrease of 13%) in the post-intervention cohort. Multivariable analysis confirmed that treatment during the post-intervention phase was associated with this decrease, with a separate analysis suggesting that ertapenem use was an important factor in this decrease. Conclusions: Development of a standardized protocol for AMP in trauma laparotomy led to decreases in infectious complications after that procedure.

Developing a National Trauma Research Action Plan: Results from the trauma systems and informatics panel Delphi survey.

BACKGROUND: The National Academies of Sciences, Engineering, and Medicine 2016 report on the trauma care system recommended establishing a National Trauma Research Action Plan to strengthen and guide future trauma research. To address this recommendation, the Department of Defense funded a study to generate a comprehensive research agenda spanning the trauma and burn care continuum. Panels were created to conduct a gap analysis and identify high-priority research questions. The National Trauma Research Action Plan panel reported here addressed trauma systems and informatics. METHODS: Experts were recruited to identify current gaps in trauma systems research, generate research questions, and establish the priorities using an iterative Delphi survey approach from November 2019 through August 2020. Panelists were identified to ensure heterogeneity and generalizability, including military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: patient/population, intervention, compare/control, and outcome. In subsequent surveys, panelists prioritized each research question on a 9-point Likert scale, categorized as low-, medium-, and high-priority items. Consensus was defined as ≥60% agreement. RESULTS: Twenty-seven subject matter experts generated 570 research questions, of which 427 (75%) achieved the consensus threshold. Of the consensus reaching questions, 209 (49%) were rated high priority, 213 (50%) medium priority, and 5 (1%) low priority. Gaps in understanding the broad array of interventions were identified, including those related to health care infrastructure, technology products, education/training, resuscitation, and operative intervention. The prehospital phase of care was highlighted as an area needing focused research. CONCLUSION: This Delphi gap analysis of trauma systems and informatics research identified high-priority research questions that will help guide investigators and funding agencies in setting research priorities to continue to work toward Zero Preventable Deaths after trauma. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Socioecological model-based design and implementation principles of lower limb preservation programs as partners for limb-loss rehabilitation programs- A mini-review.

People with lower limb loss, especially of dysvascular etiology, are at substantial risk for both ipsilateral and contralateral reamputation. Additionally, while not as well documented for reamputation, there is recognition that amputation incidence is influenced by not only sociodemographic factors such as sex, race, socioeconomic status, but also by system factors such as service access. A systems strategy to address this disparity within the field of limb-loss rehabilitation is for Limb-loss Rehabilitation Programs (LRP) to partner with medical specialists, mental health professionals, and Limb Preservation Programs (LPP) to provide comprehensive limb care. While LPPs exist around the nation, design principles for such programs and their partnership role with LRPs are not well established. Using a socioecological model to incorporate hierarchical stakeholder perspectives inherent in the multidisciplinary field of limb care, this review synthesizes the latest evidence to focus on LPP design and implementation principles that can help policymakers, healthcare organizations and limb-loss rehabilitation and limb-preservation professionals to develop, implement, and sustain robust LPP programs in partnership with LRPs.

IL-7 Immunotherapy in a Nonimmunocompromised Patient With Intractable Fungal Wound Sepsis.

A nonimmunocompromised patient developed life-threatening soft tissue infection with Trichosporon asahii, Fusarium, and Saksenaea that progressed despite maximum antifungal therapies and aggressive debridement. Interleukin-7 immunotherapy resulted in clinical improvement, fungal clearance, reversal of lymphopenia, and improved T-cell function. Immunoadjuvant therapies to boost host immunity may be efficacious in life-threatening fungal infections.

Physiologic and biochemical rationale for treating COVID-19 patients with hyperbaric oxygen.

The SARS-Cov-2 (COVID-19) pandemic remains a major worldwide public health issue. Initially, improved supportive and anti-inflammatory intervention, often employing known drugs or technologies, provided measurable improvement in management. We have recently seen advances in specific therapeutic interventions and in vaccines. Nevertheless, it will be months before most of the world's population can be vaccinated to achieve herd immunity. In the interim, hyperbaric oxygen (HBO2) treatment offers several potentially beneficial therapeutic effects. Three small published series, one with a propensity-score-matched control group, have demonstrated safety and initial efficacy. Additional anecdotal reports are consistent with these publications. HBO2 delivers oxygen in extreme conditions of hypoxemia and tissue hypoxia, even in the presence of lung pathology. It provides anti-inflammatory and anti-proinflammatory effects likely to ameliorate the overexuberant immune response common to COVID-19. Unlike steroids, it exerts these effects without immune suppression. One study suggests HBO2 may reduce the hypercoagulability seen in COVID patients. Also, hyperbaric oxygen offers a likely successful intervention to address the oxygen debt expected to arise from a prolonged period of hypoxemia and tissue hypoxia. To date, 11 studies designed to investigate the impact of HBO2 on patients infected with SARS-Cov-2 have been posted on clinicaltrials.gov. This paper describes the promising physiologic and biochemical effects of hyperbaric oxygen in COVID-19 and potentially in other disorders with similar pathologic mechanisms.

Rapidly Developing Large Bilateral Cataracts in a 58-Year-Old Woman After Only 46 Hyperbaric Oxygen Treatments.

We are reporting a 52-year-old female that developed documented vision impairing, large, bilateral nuclear and cortical cataracts during therapy after 46 treatments of a planned 60 treatment course of HBO2 for a non-healing post-radiation leg wound. A review of the available literature makes this one of the earliest cases of cataract formation.

Hyperbaric Oxygen Therapy Emergencies.

Emergent indications for HBO2 are not only for some of the most serious conditions, but also may be the only modality to directly target the patient's pathophysiology. They are to begin emergently or urgently, but may be limited by either the instability of the patient's condition or transfer logistics. Often these emergent treatments involve several treatments in the first 24 hours for best outcomes. If one considers the effects of HBO2 upon the body while breathing 100% oxygen at pressure many benefits become evident. This article will concisely review hyperbaric oxygen's emergent indications.

Hyperbaric Oxygen Therapy as an Elective Treatment.

Hyperbaric oxygen therapies may have grown out of emergencies such as those for Decompression Sickness (DCS), but more commonly in the U.S., hyperbaric oxygen is used for much more elective problems. Wound healing applications lead this trend. Nationally many more hyperbaric centers exist to treat elective problems adjunctively, and this is a concise review of these indications as well as pointing out where even elective centers might be able to broaden their practices.

Hyperbaric Oxygen Indications: Diabetic Foot Ulcers and Intractable Management.

Wound care remains an interdisciplinary specialty that can confront primary care physicians, emergency medicine physicians, and even specialists with increasingly challenging clinical dilemmas as well as an increasing array of possible additional therapies, like HBO2. As everyone tries to offer what's best, it remains to each individual clinician to weigh the patient's presenting problem, like a lower extremity or diabetes mellitus foot ulcer and potential therapies, such as HBO2.

The Diagnosis of Decompression Sickness in Sport Divers.

Hyperbaric oxygen therapy (HBO2) remains the primary treatment for decompression sickness (DCS)-which can be obviously serious or infrequently more minor and can get missed outside of centers that routinely handling diving medicine. This review will point out the salient items for how sport or amateur divers might present for HBO2.

Hyperbaric Oxygen Therapy and Radiation-Induced Injuries.

Initial clinical uses of hyperbaric oxygen (HBO2) capitalized upon physical effects to drive offending gases back into solution and deliver more oxygen to tissues in early treatments of decompression sickness. HBO2 has a myriad of other effects, including stimulating angiogenesis and new cellular in growth for healing.

Patient Engagement and Cost Savings Achieved by Automated Telemonitoring Systems Designed to Prevent and Identify Surgical Site Infections After Joint Replacement.

BACKGROUND: We designed two telemonitoring text and voice messaging interventions, EpxDecolonization (EpxDecol) and EpxWound, to improve management of orthopedic joint replacement patients at Washington University. We reviewed the use of these tools for a period of 88 weeks. METHODS: Cohorts of 1,392 and 1,753 participants completed EpxDecol and EpxWound, respectively. All patients who completed EpxDecol also completed EpxWound. We assessed patient use of and satisfaction with these interventions. A return on investment (ROI) analysis was conducted to determine the cost savings generated by EpxWound and EpxDecol. RESULTS: The proportions of patients who responded daily to EpxDecol and EpxWound were 91.9% and 77.7%, respectively, over the lengths of each intervention. The percent of daily responders declined <5% during each intervention. Ultimately, 88.4% of EpxDecol patients and 67.8% of EpxWound patients responded to ≥80% of all messages. Median patient survey responses (n = 1,246) were 9/9 (best possible) for care, 8/9 for improved communication, and 5/9 (perfect number) for number of messages received. ROI analysis for this 88-week period showed that using EpxDecol and EpxWound to engage patients (instead of nurses calling patients) saved the equivalent of 2.275 full-time nursing equivalents per week. We calculated net savings of $260,348 with an ROI of 14.85x for 1,753 patients over 88 weeks. One-year cost savings from these interventions were $153,800 with an ROI of 14.79x. CONCLUSIONS: EpxDecol and EpxWound may serve important roles in the perioperative process for orthopedic joint reconstruction surgery given high patient usage of and satisfaction with these interventions. Implementing EpxDecol and EpxWound for a large patient population could yield substantial cost savings and ROI.

Preoperative CT Findings and Interobserver Reliability of Fournier Gangrene.

OBJECTIVE: The objective of our study was to delineate CT findings and anatomic areas of involvement of surgically proven Fournier gangrene (FG) and determine interobserver reliability. MATERIALS AND METHODS: This study was a single-center retrospective study of patients with FG who underwent CT before surgical débridement of FG during a 9-year period. Thirty-eight patients with FG, 17 male and 21 female patients, underwent preoperative CT. Two radiologists reviewed the CT studies and recorded findings and anatomic areas of involvement. CT findings were categorized according to a previously described CT scoring system for necrotizing fasciitis and included the presence or absence of fascial air, muscle or fascial edema, fluid tracking, lymphadenopathy, and subcutaneous edema. Cohen kappa was calculated for interobserver reliability. RESULTS: Mean body mass index (BMI [weight in kilograms divided by height in meters squared]) was 42, and 22 of 38 (58%) patients had diabetes. Mean BMI and proportion of patients with diabetes were significantly higher in female patients (mean BMI = 46; 16/21 with diabetes) than male patients (mean BMI = 36; 6/17 with diabetes). CT studies of most patients showed fascial air (36/38 [95%], both readers 1 and 2). Interobserver reliability was substantial to almost perfect for all CT findings except lymphadenopathy, for which it was fair (κ = 0.37). Genital, perineal, and ischiorectal involvement were seen in 87% (33/38), 87% (33/38), and 32% (12/38) of patients for reader 1 and 84% (32/38), 84% (32/38), and 26% (10/38) of patients for reader 2 (κ = 0.29, penis; κ = 0.65, scrotum; κ = 0.91, vulva and labia; κ = 0.68, perineal involvement; κ = 0.80, ischiorectal involvement). CONCLUSION: Most CT findings of FG and anatomic areas of involvement showed good interobserver reliability. A high proportion of female patients with FG were observed in this study compared with prior series.

Accessible Communication Tools for Surgical Site Infection Monitoring and Prevention in Joint Reconstruction: Feasibility Study.

BACKGROUND: The National Surgical Quality Improvement Program logs surgical site infections (SSIs) as the most common cause of unplanned postoperative readmission for a variety of surgical interventions. Hospitals are making significant efforts preoperatively and postoperatively to reduce SSIs and improve care. Telemedicine, defined as using remote technology to implement health care, has the potential to improve outcomes across a wide range of parameters, including reducing SSIs. OBJECTIVE: The purpose of this study was to assess the feasibility and user satisfaction of two automated messaging systems, EpxDecolonization and EpxWound, to improve perioperative care in a quality improvement project for patients undergoing total joint replacement. METHODS: We designed two automated text messaging and calling systems named EpxDecolonization, which reminded patients of their preoperative decolonization protocol, and EpxWound, which monitored pain, wound, and fever status postoperatively. Daily patient responses were recorded and a post-usage survey was sent out to participants to assess satisfaction with the systems. RESULTS: Over the 40-week study period, 638 and 642 patients were enrolled in EpxDecolonization (a preoperative decolonization reminder) and EpxWound (a postoperative surgical site infection telemonitoring system), respectively. Patients could be enrolled in either or both EpxDecolonization and EpxWound, with the default option being dual enrollment. The proportion of sessions responded to was 85.2% for EpxDecolonization and 78.4% for EpxWound. Of the 1280 patients prescribed EpxWound and EpxDecolonization, 821 (64.14%) fully completed the postoperative system satisfaction survey. The median survey score (scale 1-9) was 9 for patient-rated overall care and 8 for whether the telemonitoring systems improved patient communication with providers. The majority of patients (69.0%, 566/821) indicated that the systems sent out an ideal number of messages (not too many, not too few). CONCLUSIONS: EpxDecolonization and EpxWound demonstrated high response rates and improved patient-rated communication with providers. These preliminary data suggest that these systems are well tolerated and potentially beneficial to both patients and providers. The systems have the potential to improve both patient satisfaction scores and compliance with preoperative protocols and postoperative wound monitoring. Future efforts will focus on testing the sensitivity and specificity of alerts generated by each system and on demonstrating the ability of these systems to improve clinical quality metrics with more authoritative data.

Student views on the role of self-regulated learning in a surgery clerkship.

BACKGROUND: Self-regulated learning, including student-generated learning goals and flexibility in the learning structure are increasingly being used to enhance medical education. The role of these practices in surgical education of medical students has not been studied. MATERIALS AND METHODS: We administered an 18-question electronic survey to all third-year medical students at Washington University in St. Louis School of Medicine. Of the 126 students invited, 64 responded and 56 were included in the analysis. RESULTS: We found that third-year medical students develop learning goals at the beginning of the surgery clerkship. Although these learning goals theoretically can be a mechanism for enhanced student-faculty engagement, students are not aware of formal mechanisms for sharing these goals with faculty members. Furthermore, students report a lack of flexibility within the surgery clerkship and discomfort with requesting specific learning opportunities. Finally, students report that they believe increased flexibility could improve student engagement, learning, and the overall clerkship experience. CONCLUSIONS: We therefore propose that a mechanism for students to share their learning goals with faculty and an infrastructure in which student learning experiences can be tailored to fit with these individualized goals would enhance student surgical learning.

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review.

PURPOSE: To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis. METHODS: Guidelines, expert opinion, and local institutional policies were reviewed. RESULTS: Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. Unique aspects of care for SSTIs in the ICU are discussed, including the role of prosthetic devices, risk factors for bacteremia, and the need for surgical consultation. SSTI mimetics, the role of dermatologic consultation, and the unique features of SSTIs in immunocompromised hosts are also described. CONCLUSIONS: We provide recommendations for clinicians regarding optimal SSTI management in the ICU setting.

Early protection and compression of residual limbs may improve and accelerate prosthetic fit: a preliminary study.

BACKGROUND: The goal of rehabilitation following lower extremity amputation is to restore the highest level of independent function. As much as possible, this includes the functional use of a prosthetic device fitted to the residual limb. Early prosthetic fit depends, in turn, on rapid healing of the amputation site. METHODS: We hypothesized that compliance with a novel custom-designed amputation protection and compression system (CAPCS) to the residual limb can accelerate and improve the likelihood of successful prosthesis use. We conducted a retrospective study of all patients who were offered CAPCS by certified prosthetists (Hanger Prosthetics and Orthotics, Bethesda, MD) during the period between April 2004 and November 2009. Variables included age, sex, indication for amputation, and compliance with CAPCS. Compliance was defined as consistent observed wearing of the CAPCS as directed. The primary end point was the fitting of a prosthetic device to the amputated limb, with time to prosthetic fit being the secondary outcome. RESULTS: Out of 100 patients who were offered CAPCS (n = 100) during the study period, 76% were considered compliant (n = 76). Sixty five patients (65%) were ultimately fitted with prosthetic limbs. In multivariate analysis, we found that patients who had compliant use of CAPCS were significantly more likely to be successfully fit with prosthesis (72 vs. 42%, p = 0.005). At 100 days post amputation, the cumulative incidence of prosthesis fitting was significantly higher in CAPCS compliant patients (69.7 vs. 22.2%, p = 0.012). CONCLUSIONS: Compliant use of a CAPCS following amputation is associated with earlier and more frequent use of a prosthetic. Based on this limited data set, a conclusion can be drawn that the potential exists to significantly improve functional outcomes after amputation, but well-designed prospective studies are needed to confirm this association.