Multifaceted Strategy Improves Outcomes of Patients Hospitalized with a Diabetic Foot Infection.

Diabetic foot infections (DFIs) are associated with major morbidity, reduced quality of life and increased mortality. Osteomyelitis is a leading cause of lower-extremity amputation in diabetic patients. We aimed to examine whether a multifaceted strategy for treating hospitalized patients with a DFI effectively influenced microbiological culture results and outcomes. A retrospective cohort-study in a 1100-bed, tertiary-care university hospital was conducted. Adult patients with a DFI admitted to the orthopedics department between 2015 and 2019 were included. During the pre-intervention period (2015-2016), one general orthopedic department was in operation. In the post-intervention period (2017-2019), a second department was created with a designated "complicated wound unit". The multifaceted strategy included revising local guidelines for DFI culturing emphasizing bone cultures, correct sample handling, and adjusting antibiotic treatment to culture results. Additionally, a weekly multidisciplinary-team grand round was instigated and post-discharge outpatient follow-up was scheduled. 652 patients with DFIs were included; 101 during the pre-intervention period and 551 during the post-intervention period. Compared to the pre-intervention, during the post-intervention period mainly bone or deep-tissue cultures were performed (9.7% vs. 98.2%, P < 0.001). Bacteriology cultures in the pre-intervention versus post-intervention period revealed: among staphylococcus isolates, fewer methicillin-resistant Staphylococcus aureus detected (20.4% vs. 9.8%, P = 0.010); within Enterobacteriaceae isolates, fewer extended-spectrum ß-lactamase producing bacteria detected (51.6% vs. 23.6%, P < 0.001); a decrease in Pseudomonas aeruginosa isolates (28% vs. 10.6%, P < 0.001) and an increase in anaerobic bacterial isolates (0 vs. 11.1%, P < 0.001). On multivariate regression, the post-intervention period (ie multifaceted strategy) was a protective measure against readmissions (P = 0.007 OR 0.50 95% CI 0.30-0.82). We conclude that our interventive multifaceted strategy led to accurate bacterial diagnosis, de-escalation of antibiotic treatment and readmission reduction.

Telemedicine versus face-to-face care for treatment of patients with lower extremity ulcers.

OBJECTIVE: Lower extremity ulcers (LEUs) are associated with a decline in patients' quality of life (QoL). Better healthcare availability in remote regions, facilitated by telemedicine (TM), may improve patient wellbeing. The aim of this study was to compare the QoL of patients treated via synchronous video TM with that of patients treated with standard face-to-face (FTF) care. METHOD: The study was performed in a large health services provider in Israel (Maccabi Healthcare Services). TM was used in four remote locations; the FTF method was applied in two regional clinics. The treatment protocol was performed by a nurse and supervised by the regional physician in both treatment modes. A validated Wound-QoL questionnaire in Hebrew was used to assess patient outcomes. RESULTS: A total of 83 patients were treated via TM and 94 patients were treated FTF. The mean QoL for patients treated via TM was 0.546±0.249 compared with 0.507±0.238 for the FTF group. A similarity relating to outcomes in both treatment methods was demonstrated by a difference of 0.039 (95% confidence interval -0.33-0.111) and p=0.291. The probability of the difference being within the limits of the interval in a replicated study was 83.4%. The equivalence/non-inferiority was established within the accepted Δ=0.12 range. CONCLUSION: The results indicated no reduced QoL for patients with LEUs treated with telemedicine versus with standard FTF care. DECLARATION OF INTEREST: The authors have no conflicts of interest.

The impact of a multimodel approach to designing a new orthopedic department.

OBJECTIVE: To determine whether a multifaceted approach effectively influenced antibiotic use in an orthopedics department. DESIGN: Retrospective cohort study comparing the readmission rate and antibiotic use before and after an intervention. SETTING: A 1,000-bed, tertiary-care, university hospital. PATIENTS: Adult patients admitted to the orthopedics department between January 2015 and December 2018. METHODS: During the preintervention period (2015-2016), 1 general orthopedic department was in operation. In the postintervention period (2017-2018), 2 separate departments were created: one designated for elective "clean" surgeries and another that included a "complicated wound" unit. A multifaceted strategy including infection prevention measures and introducing antibiotic stewardship practices was implemented. Admission rates, hand hygiene practice compliance, surgical site infections, and antibiotic treatment before versus after the intervention were analyzed. RESULTS: The number of admissions and hospitalization days in the 2 periods did not change. Seven-day readmissions per annual quarter decreased significantly from the preintervention period (median, 7 days; interquartile range [IQR], 6-9) to the postintervention period (median, 4 days; IQR, 2-7; P = .038). Hand hygiene compliance increased and surgical site infections decreased in the postintervention period. Although total antibiotic use was not reduced, there was a significant change in the breakdown of the different antibiotic classes used before and after the intervention: increased use of narrow-spectrum ß-lactams (P < .001) and decreased use of ß-lactamase inhibitors (P < .001), third-generation cephalosporins (P = .044), and clindamycin (P < .001). CONCLUSIONS: Restructuring the orthopedics department facilitated better infection prevention measures accompanied by antibiotic stewardship implementation, resulting in a decreased use of broad-spectrum antibiotics and a significant reduction in readmission rates.

A Novel Recombinant Human Collagen-based Flowable Matrix for Chronic Lower Limb Wound Management: First Results of a Clinical Trial.

BACKGROUND: Chronic ulcers pose a significant health concern and economic burden. Numerous products, including animal-derived collagen products, have been designed to provide the injured site with a biocompatible structural matrix that promotes tissue regeneration. Yet, animal-derived collagens can evoke immune responses, bear risk of disease transmission, and fail to closely mimic the function of native collagen. OBJECTIVE: This study aims to assess the safety and performance of a novel flowable wound matrix, formulated from tobacco plant-purified fibrillated recombinant human type I collagen (rhCollagen), in patients with chronic lower limb ulcers. MATERIALS AND METHODS: This single-arm, open-label, multicenter trial took place at 5 treatment centers. Wounds were photographed and preliminary surgical debridement was performed prior to rhCollagen application. Patients received a single application of rhCollagen to the wound bed, followed by weekly assessments of the wound. RESULTS: Twenty patients (mean age, 63 years), presenting with a chronic ulcer of neuropathic (45%), posttraumatic (35%), postoperative (10%), and venous (10%) origin, underwent rhCollagen treatment. Initial wound area ranged between 0.2 cm3 to 9.2 cm3. At 4-weeks posttreatment, median wound area reduction was 94%. Fifteen ulcers exhibited ≥ 70% wound closure, 9 of which achieved complete closure. Only 1 participant suffered a local self-resolving wound infection. No significant device-related adverse events were reported throughout the study. CONCLUSIONS: A single, easy-to-use rhCollagen flowable gel application for chronic lower limb ulcers may promote wound closure with minimal adverse events.

Synchronous video telemedicine in lower extremities ulcers treatment: A real-world data study.

INTRODUCTION: With growing prevalence of lower extremity ulcers (LEU) and shortage of wound specialists, gaps in access to care may occur, particularly in remote areas. This gap can be mitigated with high-quality telemedicine (TM). This study aims to explore the effectiveness of synchronous video TM compared to the conventional face-to-face treatment (FTF). METHODS: The study was conducted at Maccabi Healthcare Services, a 2.2-million-member sick fund in Israel. We reviewed all consecutive visits of LEU patients to wound care specialists between Jan 2013 and Jun 2017. Both TM and FTF modalities were implemented using identical treatment settings with the same nurse at each location. Study endpoint was ulcer healing as assessed by the treating specialist. RESULTS: The study population included 650 LEU cases (nTM = 277, nFTF = 373) and contained 5203 visits. Comparable (P = 0.475) proportions of healed ulcers (52% in TM vs. 55% in FTF) were detected. Survival analyses found a non-significant advantage of TM (0.887; 0.650-1.212) compared to FTF. The non-inferiority of TM was demonstrated within the Δ = 0.15 range limits and 80% statistical power. Trial replication probability is 0.93. CONCLUSIONS: Synchronous video-conferencing based telemedicine may be a feasible and efficient method of LEU management.

Topical oxygen therapy stimulates healing in difficult, chronic wounds: a tertiary centre experience.

OBJECTIVE: Oxygen plays a central role in wound healing. Recent technological advances have miniaturised oxygen delivery systems, with novel topical oxygen therapy allowing patients to receive oxygen therapy 24 hours a day while remaining completely mobile. Here we aim to examine the efficacy and safety of continuous topical oxygen diffusion in a 'real-world' setting. METHODS: Topical oxygen therapy (TOT) was evaluated in patients with chronic, non-healing wounds in a tertiary referral specialist clinic. RESULTS: The mean wound duration before TOT was 15 months. Regardless of treatment duration, in this previously non-healing group complete wound closure was observed in 32% of the total patients treated with the TOT device. However, optimal wound healing occurred when the device was used for >25 days, with an 83% wound area reduction and 47% wound closure rate seen in venous leg ulcers (VLUs) and a 74% reduction and a 57% wound closure rate in arterial foot ulcers. CONCLUSION: Use of TOT in chronic wounds stimulates a healing state. In our study, almost half of the previously non-healing wounds closed.

Validation of "Wound QoL" Hebrew version disease-specific questionnaire for patients with lower extremity ulcerations.

The slow healing process and high recurrence rate of lower extremity ulcerations (LEU) impose a considerable medical and economic burden and affect quality of life (QoL). Analyses of LEU-related QoL in Israel are limited due to lack of a validated Hebrew disease-specific evaluation instrument. The aim of this study was to validate the disease-specific Hebrew "Wound QoL" questionnaire. The validation of the "Wound QoL" disease-specific instrument, translated from English to Hebrew, was based on a comparison with the valid Hebrew version of the SF12v.2 health-related questionnaire. The convenience sample for the "Wound QoL" validation (n = 32) was obtained from patient populations in the Maccabi Health Services' outpatient clinics at the northern and southern parts of Israel. The study was conducted between June and September 2017. Face/construct validity was accepted by specialists' consensus. Internal consistency assessed by Cronbach's α was .893. Concurrent validity reflected by Pearson's correlations between the tools was in the range of 0.830 to 0.950. The Wound QoL Hebrew version is a valid and reliable instrument suitable for implementation in an Israeli cultural environment.

[Wrist arthroscopy].

Reports on arthroscopic treatment of wrist disorders have been published as early as the 1980s. However, wrist arthroscopy has been poorly established in most centers, and only a relatively small number of orthopedic surgeons across the globe perform wrist arthroscopy on a regular basis. The wrist is a labyrinth of eight carpal bones, multiple articular surfaces with intrinsic and extrinsic ligaments, and a triangular fibrocartilage complex, all within a five-centimeter interval. Arthroscopic wrist surgery allows excellent visualization of and access to the articular surface of the carpal bones and ligaments that is not possible via an arthrotomy. It allows for evaluation of the intracarpal structures under bright, magnified conditions, with minimum morbidity compared with that associated with arthrotomy. Recent improvements of the surgical techniques, advanced imaging modalities, and the establishment of specifically designed instrumentation have helped to overcome many challenges and increased the indications for wrist arthroscopy.