Procalcitonin as a Predictor of Septic Knee Arthritis: A Retrospective Cohort Study.

INTRODUCTION: Differentiating septic arthritis from aseptic arthritis (AA) of the knee is difficult without arthrocentesis. Although procalcitonin (PCT) has shown diagnostic value in identifying bacterial infections, it has not been established as a reliable marker for identifying septic arthritis (SA). Recent studies have shown promise in the use of PCT as a useful systemic marker for identifying septic arthritis versus AA. This observational retrospective review compares PCT with routine inflammatory markers as a tool for differentiating septic arthritis versus AA in patients with acute, atraumatic knee pain. METHODS: Fifty-three consecutive patients (24 SA, 29 AA) were retrospectively reviewed at one institution with concern for SA. SA was diagnosed based on a physical examination, laboratory markers, and arthrocentesis. Laboratory indices were compared between the septic arthritis and AA groups. Data analysis was conducted to define sensitivity and specificity. Receiver operator characteristic curve analysis and regression were conducted to determine the best marker for acute SA of the knee. RESULTS: Using multiple logistic regression, bacteremia (OR 6.75 ± 5.75) was determined to be the greatest predictor of SA. On linear regression, concomitant bacteremia (coef 3.07 ± 0.87), SA (coef 2.18 ± 0.70), and the presence of pseudogout crystals (coef 1.80 ± 0.83) on microscopy predicted an increase in PCT. Using a PCT cutoff of 0.25 ng/mL yields a sensitivity of 91.7% and specificity of 55.2% for predicting SA; however, the ideal cutoff in our series was 0.32 ng/mL with a sensitivity of 79.2% and specificity of 72.4%. PCT was superior to the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein in the area under the receiver-operating characteristic curve analysis. DISCUSSION: Procalcitonin seems to be the most sensitive and specific systemic marker in differentiating septic from AA.

Rapid Emergence of Potentially Transmissible Severe Acute Respiratory Syndrome Coronavirus 2 With Resistance to Combination Monoclonal Antibody Therapy.

Prolonged coronavirus disease 2019 may generate new viral variants. We report an immunocompromised patient treated with monoclonal antibodies who experienced rebound of viral RNA and emergence of an antibody-resistant (>1000-fold) variant containing 5 mutations in the spike gene. The mutant virus was isolated from respiratory secretions, suggesting the potential for secondary transmission.

Evaluation of oral tranexamic acid as a novel treatment for melasma with a high benefit-risk ratio.

BACKGROUND: Melasma is an acquired melanogenesis dysfunction resulting in chronic hyperpigmentation commonly affecting the face and other frequently sun-exposed areas of the body. Melasma typically presents in women of reproductive age and can significantly impact self-esteem, negatively affecting one's quality of life. In the United States, melasma is often treated with application of topical agents that interfere with melanin synthesis, lasers, or chemical peels; however, in some East Asian countries, oral tranexamic acid (TXA) is widely administered to alleviate hyperpigmentation during and after childbirth. TXA is currently only FDA-approved to treat hypermenorrhea and reduce blood loss in surgery but may offer women in the United States an additional therapeutic option to treat melasma. AIMS: The aim of this paper is to evaluate the safety and baseline efficacy of oral transmexic acid as a treatment for melasma. METHODS: We retrospectively surveyed 42 patients of Fitzpatrick skin types III-VI that were prescribed 650 mg of TXA ½ tablet to be taken twice daily by mouth. RESULTS: We found majority of patients saw noticeable improvement in their melasma. Of the 42 patients, only seven experienced side effects. The side effects noted were headaches, malaise and nausea, gastrointestinal upset, congestion, numbness in legs, hypomenorrhea, and hypermenorrhea. Patients who experienced unpleasant side effects discontinued taking oral TXA and were relieved of their symptoms. No long-term side effects were discovered, and the side effects experienced may be due to other confounding factors. CONCLUSION: From this data, we concluded oral TXA is a safe and effective treatment option for patients with persistent melasma.

Novel Use of a Porcine Bladder Extracellular Matrix Scaffold to Treat Postoperative Seroma in a Total Knee Arthroplasty Patient.

Seroma formation in a knee arthroplasty surgery is a rare complication. When seromas occur, they act as a nidus for bacterial growth and create an optimal environment for surgical site infections. In this case report, a 52-year-old woman presented with a seroma after multiple revision operations on the left knee. Owing to multiple failures of standard irrigation and drainage procedures to resolve the seroma, an orthoplastic colleague was consulted. Over five-and-a-half months, the patient underwent multiple procedures that failed to treat the seroma. However, in a final exploratory procedure, 3000 mg of urinary bladder matrix and negative pressure wound vacuum were placed. Seven months after the intervention, the patient had complete resolution.

A Surveillance System for the Maternal and Child Health (MCH) Population During the COVID-19 Pandemic.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the causative agent for coronavirus disease 2019 (COVID-19), and its ensuing mitigation measures have negatively affected the Maternal and Child Health (MCH) population. There is currently no surveillance system established to enhance our understanding of SARS-CoV-2 transmission to guide policy decision making to protect the MCH population in this pandemic. Based on reports of community and household spread of this novel infection, we present an approach to a robust family-centered surveillance system for the MCH population. The surveillance system encapsulates data at the individual and community levels to inform stakeholders, policy makers, health officials and the general public about SARS-CoV-2 transmission dynamics within the MCH population.

Implementation and Evaluation of the Early-Onset Sepsis Risk Calculator in a High-Risk University Nursery.

There is growing interest in the Kaiser early-onset sepsis (EOS) risk calculator though institutions are hesitant to deviate from the Centers for Disease Control and Prevention guidelines and implement this in their hospitals. We describe the process of implementing routine use of the risk calculator in term and late preterm newborns delivered to mothers with chorioamnionitis in a level III neonatal intensive care unit (NICU). A retrospective chart review of infants delivered to mothers with chorioamnionitis from 2011 to 2014 was performed. Implementation of routine use of the calculator began in January 2015; preintervention and postintervention data were analyzed after a 9-month period of routine use. Following implementation, NICU admission rates, number of blood cultures drawn, and rates of antibiotic use dropped by 54%, 42%, and 59%, respectively ( P < .001). No negative outcomes were reported. In this article, we describe how the calculator was safely implemented in our NICU while decreasing the number of interventions.

Hypothermia in Total Joint Arthroplasty: A Wake-Up Call.

BACKGROUND: Total joint patients are particularly vulnerable to perioperative hypothermia (PH) (combined effects of anesthesia, radiation, and convective heat loss from exposed skin surfaces and cool temperatures in the operating room). There are limited studies on PH in these patients. METHODS: In a retrospective review of 204 patients undergoing primary hip and 179 undergoing primary knee replacement surgeries, time and temperature parameters were collected from the electronic health records from preoperative and postoperative recovery room nursing assessments, intraoperative anesthesia records, and floor nursing notes. Basic patient demographic data was recorded. Chi-squared and paired t-tests were used to compare between hypothermic and normothermic groups. RESULTS: At the time of incision, 60 of 179 (34%) total knee arthroplasty (TKA) patients and 80 of 204 (39%) total hip arthroplasty (THA) patients were hypothermic. In THA patients, 65% remained hypothermic for the duration of anesthesia compared to 33% of TKA patients. The largest drop in core body temperature in both THA and TKA patients occurred between preoperative holding and induction of anesthesia. In THA patients, spinal anesthesia had a significantly higher occurrence of PH. No significant patient factor was found to increase risk. CONCLUSION: Emphasis on preoperative holding protocols, decreasing time from operating room entry to incision, and increasing ambient room temperature could reduce risk of hypothermia in total joint replacement patients.

Corrosion and adverse local tissue reaction after total hip arthroplasty with a modular titanium alloy femoral neck.

This report describes a case of mechanically assisted crevice corrosion and secondary adverse local tissue reaction in a patient following a total hip arthroplasty, utilizing a modular neck (bi-modular) femoral component. Radiographic evaluation demonstrated a well-positioned, stable, cementless arthroplasty. Upon further evaluation, the patient had elevated serum cobalt and chromium levels, and magnetic resonance imaging demonstrated a periprosthetic pseudotumor. Corrosion of both the neck-stem and head-neck junctions was suspected. At the time of surgery, the neck-body junction was pristine; however, the head-neck junction of the implant demonstrated severe corrosive wear, a problem that has been reported only once previously with this particular bi-modular implant. This serves as a reminder that any modular junction may be susceptible to corrosion and not all bi-modular designs behave similarly.

Teachers' Perceptions of Bullying of Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) Students in a Southwestern Pennsylvania Sample.

This study was designed to ascertain teachers' perceptions of bullying of Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) youth. In a sample of 200 educators (61.0% female; 96.5% White) from a county in southwestern Pennsylvania, there was a significant positive relationship between the teachers' perceptions of the supportiveness of school staff towards students regardless of sexual orientation and those teachers' reports of the frequency of bullying victimization experienced by LGBTQ students. Teachers' perceptions of a higher level of staff and student support was associated with higher reported frequencies of students' use of derogatory language about LGBTQ individuals and various types of bullying of LGBTQ students. Teachers with a lesbian, gay, or bisexual orientation were found to rate the school staff and students as significantly less supportive of students regardless of their sexual orientation, gender identity, or gender expression in comparison to heterosexual teachers. Finally, teachers who either were unaware of or believed that their school lacked an anti-bullying policy reported significantly higher rates of physical bullying victimization of LGBTQ students when compared to the rates observed by teachers who reported knowledge of their schools' anti-bullying policies.

Outcome analysis of helmet therapy for positional plagiocephaly using a three-dimensional surface scanning laser.

INTRODUCTION: A dramatic rise in positional plagiocephaly has been noted over the last decade. Methods for treating and following outcomes are varied. We present our results from a passive soft helmet molding therapy using a surface scanning laser to provide objective outcomes. METHODS: One hundred seventy-five infants with positional plagiocephaly were treated at our institution over a 6-month period. The helmets used were soft foam helmets modified to fit each patient. Results were measured using a three-dimensional surface scanning laser and objective measurements of asymmetry. Compliance was also documented. RESULTS: The scanning laser allowed for objective measurements of symmetry over time and was useful in following outcomes. Improvement in head shape was noted after about 4 months of therapy. Patients who were more compliant with therapy achieved better results. CONCLUSION: Use of the three-dimensional scanning laser and objective scoring system shows significant improvement in patients who were compliant with helmet therapy.

The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures.

OBJECTIVES: To evaluate the utility of negative-pressure wound therapy (NPWT) in the setting of high-energy open tibial shaft fractures. DESIGN, SETTING, AND PATIENTS/PARTICIPANTS: This was a retrospective consecutive series in a level 1 university-based trauma center. Forty-nine consecutive patients presenting to a level 1 trauma center between 1996 and 2004 with 50 grade/type III open tibial shaft fractures were assessed. INTERVENTION: The open wounds associated with each fracture were each treated with NPWT before definitive wound closure or coverage. MAIN OUTCOME MEASUREMENTS: Infection rate, need for amputation after attempted definitive coverage, problems with bony healing requiring surgical intervention, reoperation rate after definitive coverage, and the type of definitive coverage required. RESULTS: The overall infection rate for all grade/type III open fractures was 15 of 50 fractures (30%), with 11 of 50 (22%) requiring repeated surgery for infection. The infection rate was 12.5% for grade/type IIIA open fractures, 45.8% for grade/type IIIB, and 50% for grade/type IIIC. Twenty-four of 50 fractures (48%) required subsequent surgery to facilitate fracture healing. Five fractures required amputation after attempted coverage. Seven of 24 fractures initially classified as grade/type IIIA and 10 of 24 fractures initially classified as grade/type IIIB ultimately required free tissue transfer or rotational muscle flap coverage. CONCLUSIONS: Infection and nonunion rates with the use of NPWT for temporary coverage of wounds associated with grade/type III open tibial shaft fractures are similar to those of historical controls, but this technique may be beneficial in decreasing the need for free tissue transfer or rotational muscle flap coverage.

Subatmospheric pressure dressings in the temporary treatment of soft tissue injuries associated with type III open tibial shaft fractures in children.

PURPOSE: This study was designed to evaluate the use of subatmospheric pressure dressings on high-energy open tibial shaft fractures in children. We hypothesized that the use of a negative-pressure dressing in these fractures would result in a decreased incidence of infection and decreased need for pedicled muscle flaps and free tissue transfer. METHODS: A retrospective case series of 15 consecutive pediatric patients with 16 type III open tibial shaft fractures (8 type IIIA, 7 type IIIB, and 1 type IIIC). The patients' age ranged from 2 to 17 years. All patients underwent a standard protocol of serial irrigation and debridement of the open wound with bony stabilization. Temporary coverage of the open wound was obtained with the use of a subatmospheric pressure dressing until definitive wound coverage or closure. RESULTS: Infection occurred in 5 of 16 fractures, 2 requiring antibiotics alone (1 type IIIA and 1 type IIIB) and 3 requiring surgical intervention (2 type IIIB and 1 type IIIC). Seven of 16 (3 type IIIA, 3 type IIIB, and 1 type IIIC) fractures required repeat surgical intervention to facilitate bony healing. Only 3 patients required free tissue transfers or rotational muscle flaps for coverage, a 50% decrease compared with the initial classification. CONCLUSIONS: Compared with other described methods, the use of subatmospheric pressure dressings in the temporary treatment of soft tissue wounds associated with high-energy open tibial shaft may reduce the need for major soft tissue coverage procedures. Its effect on infection and fracture healing rates requires further study. SIGNIFICANCE: A reduction in the need for major soft tissue coverage procedures with the use of negative-pressure dressings in this setting should result in decreased morbidity for these patients and in decreased social and financial costs.

Vacuum-assisted closure: state of basic research and physiologic foundation.

A tremendous amount of research has been conducted in recent years investigating the mechanisms of action by which the application of subatmospheric pressure to wounds increases the rate of healing. Similarly, numerous studies have also been conducted examining the physiologic response of wounds to the applied subatmospheric pressure. However, many more need to be conducted. A series of basic studies examining the use of subatmospheric pressure to treat wounds is presented, including the original studies upon which the vacuum-assisted closure device was based (on blood flow, granulation tissue formation, bacterial clearance, and survival of random-pattern pedicle flaps). Subsequent studies analyzing removed fluids, envenomation/extravasation, burns, grafts, and in vitro tissue culture studies are also reviewed. Two broad mechanisms of action are proposed: removal of fluid and mechanical deformation. Fluid removal both decreases edema--thus decreasing interstitial pressure and shortening distances of diffusion--and removes soluble factors that may affect the healing process (both positively and negatively). The relationship of mechanical deformation to increased growth is well known to plastic surgeons, as it is the basis of tissue expansion. While much has been done, a great deal more needs to be done to elucidate the mechanisms of action responsible for the dramatic response seen clinically.

Management of an acute thermal injury with subatmospheric pressure.

OBJECTIVE: This article reports the first application of subatmospheric pressure management to a deep, partial-thickness human thermal burn. METHODS: After cleaning the wound, the decision was made to treat the hand and distal forearm with subatmospheric pressure (V.A.C., KCI, Inc, San Antonio, Tex). The sponge was applied directly to the burned skin without additional interface at approximately 6 hours after injury. The dressing was maintained at a continuous negative pressure of 125 mm Hg over the next 40 hours, with interruption only for routine clinical evaluation at 5, 16, and 24 hours after initiation of treatment. This was accomplished by opening the dressing without completely changing it. The treatment was tolerated well by the patient, requiring no excessive pain medication. After the subatmospheric pressure treatment was stopped, the wound appeared to be of indeterminate depth and the patient was started on twice daily applications of silver sulfadiazine. RESULTS: The clinical impression at this time was that the hand burn had not progressed but had stabilized and had minimal edema. He was followed as an outpatient and returned to work by 8 weeks. At approximately 4 weeks postinjury, his skin not only was functional but also appeared more normal, with less hyperemia than adjacent areas treated with topical antibacterials. CONCLUSION: The present case does not prove that subatmospheric pressure treatment prevents burn wound progression. However, when combined with the previously reported laboratory studies it suggests the need for further research. Currently, a prospective, randomized, blinded, controlled multicenter trial is underway to evaluate the clinical importance of these observations.