Evaluation of predictive factors of septic wrist to avoid overdiagnosis.

BACKGROUND: The existing diagnostic criteria for septic wrist are nonspecific, exposing patients with noninfectious etiologies to surgical morbidity. This study aimed to identify predictors differentiating septic wrist from other etiologies. METHODS: An institutional review board-approved retrospective review was conducted on patients with a presumed diagnosis of septic wrist (2003-2022). Bivariate and multiple regression analyses were performed to identify correlation between confirmed septic wrist and comorbidities (autoimmune diseases, immunosuppression, crystalline arthropathy, intravenous [IV] drug use, smoking), penetrating trauma, fever, multi-joint involvement, inflammatory markers (erythrocyte sedimentation rate [ESR]/C-reactive protein [CRP]/white blood cells [WBC]), serum uric acid level, blood cultures, imaging findings, and synovial fluid analysis. Categorical data were reported as median [interquartile range]. RESULTS: Hundred and sixty-eight (58 females and 110 males) patients were included. The median length of hospitalization and follow-up were 6[7] days and 1[3] months. Eighty-nine (53%) patients had septic wrist confirmed with Gram stain/culture, 48 (29%) patients received alternative diagnoses, and 31 (18%) patients had undetermined diagnoses. Concomitant septic wrist and crystalline arthropathy were identified in 9 patients (6.6% of total patients). Out of the 48 patients who received alternative diagnoses, 12 (25%) underwent open drainage. Elevated synovial WBC count (95,409.4 ± 85,926.2) showed a trend of association with septic wrist (p = 0.08). Negative synovial crystals (p = 0.01), positive blood culture (p = 0.04), negative history of crystalline arthropathy (p = 0.08), and multi-joint involvement (p = 0.05) were identified as predictors of septic wrist with a combined sensitivity of 87.5%, specificity of 86.2%, and area under the curve 0.93. CONCLUSIONS: Current diagnostic criteria for septic wrist have low specificity. Negative history of crystalline arthropathy, multi-joint involvement, absence of synovial crystals, and positive blood culture are helpful indicators for predicting septic wrist in patients presenting with a painful, erythematous, and swollen wrist.

Efficacy of virtual plastic surgery encounters in establishment of care and surgical conversion.

BACKGROUND: The efficacy of virtual visits in converting new patients into established patients undergoing surgical treatment has not been demonstrated. The aim of this study was to evaluate patient retention and surgical conversion rate after an initial virtual plastic surgery consultation. METHODS: An IRB-approved retrospective review of all new plastic surgery patients seen between May and August 2020 at a single institution was conducted. The initial encounter type, chief complaint, demographics, treatment recommendation, insurance approval rate, number and modality of pre- and postoperative visits, time to procedure, follow up, and complications were recorded. Patient retention and surgery conversion rate were calculated. Statistical analysis was performed with Chi-squared test, Fisher's exact test, and unpaired t-test. RESULTS: In total, the records of 1889 new patients were reviewed (1635 in-person, 254 virtual). Virtual patients were younger (44.5 ±â€¯19.0 versus 49.5 ±â€¯20.7 years, p < 0.001), and nearly half resided greater than 50 miles away (42% versus 16%, p < 0.001). Virtual patients more frequently presented for cosmetic surgery (14% versus 7%, p < 0.001), lymphedema (15% versus 3%, p < 0.001), and gender dysphoria (11% versus 2%, p < 0.001). In-person patients presented more often for trauma (18% versus 5%, p < 0.001), elective hand complaints (16% versus 3%, p < 0.001), and breast reconstruction (9% versus 4%, p < 0.01). There were no differences in patient retention (p = 0.45) and procedure conversion rate (p = 0.21) between the groups. CONCLUSION: Telemedicine provides an opportunity to increase the practice catchment area and is as effective as in-person first encounters for establishing care and transition to surgery.

Comparing the educational quality of free flap technique videos on public and paid platforms.

BACKGROUND: Surgical videos are reshaping the landscape for surgical education. As this form of education has rapidly grown and become a valuable resource for experienced surgeons, residents, and students, there is great variability in the presentation of what is offered. This study aimed to assess and compare the educational quality of free flap instructional videos on public and paid platforms. METHODS: Free flap videos from public (YouTube) and paid (American Society of Plastic Surgeons Education Network and Plastic and Reconstructive Surgery Journal) sources were screened independently by three reviewers. Sample size was calculated to reach 80% power. The educational quality of the videos was determined using a modified version of Laparoscopic Surgery Video Educational Guidelines (0-6 low, 7-12 medium, 13-18 high). Professionally-made videos were identified per lighting, positioning, and video/imaging quality. Interrater reliability between the three reviewers was calculated. The educational quality of the videos was compared between public and paid sources using Mood's median test. Pearson's correlation coefficient was utilized to assess the correlation between video length and educational quality. RESULTS: Seventy-six videos were included (40 public, 36 paid). The median video lengths for public and paid platforms were 9.43(IQR = 12.33) and 5.07(IQR = 6.4) min, respectively. There were 18 high, 16 medium, and 6 low-quality public videos, versus 13 high, 21 medium, and 2 low-quality paid videos. Four public and seven paid videos were identified as professionally made. Interrater reliability was high (α = .9). No differences in educational quality were identified between public and paid platforms. Video length was not correlated with quality (p = .15). A video library compiling public high-quality videos was created (https://www.youtube.com/playlist?list=PL-d5BBgQF75VWSkbvEq6mfYI--9579oPK). CONCLUSIONS: Public and paid platforms may provide similar surgical education on free tissue transfer. Therefore, whether to subscribe to a paid video platform for supplemental free flap education should be determined on an individual basis.

Effect of SPARC Suppression in Mice, Perfused Human Anterior Segments, and Trabecular Meshwork Cells.

Purpose: Secreted protein, acidic and rich in cysteine (SPARC) elevates intraocular pressure (IOP), increases certain structural extracellular matrix (ECM) proteins in the juxtacanalicular trabecular meshwork (JCT), and decreases matrix metalloproteinase (MMP) protein levels in trabecular meshwork (TM) endothelial cells. We investigated SPARC as a potential target for lowering IOP. We hypothesized that suppressing SPARC will decrease IOP, decrease structural JCT ECM proteins, and alter the levels of MMPs and/or their inhibitors. Methods: A lentivirus containing short hairpin RNA of human SPARC suppressed SPARC in mouse eyes and perfused cadaveric human anterior segments with subsequent IOP measurements. Immunohistochemistry determined structural correlates. Human TM cell cultures were treated with SPARC suppressing lentivirus. Quantitative reverse transcriptase polymerase chain reaction (PCR), immunoblotting, and zymography determined total RNA, relative protein levels, and MMP enzymatic activity, respectively. Results: Suppressing SPARC decreased IOP in mouse eyes and perfused human anterior segments by approximately 20%. Histologically, this correlated to a decrease in collagen I, IV, and VI in both the mouse TM and human JCT regions; in the mouse, fibronectin was also decreased but not in the human. In TM cells, collagen I and IV, fibronectin, MMP-2, and tissue inhibitor of MMP-1 were decreased. Messenger RNA of the aforementioned genes was not changed. Plasminogen activator inhibitor 1 (PAI-1) was upregulated in vitro by quantitative PCR and immunoblotting. MMP-1 activity was reduced in vitro by zymography. Conclusions: Suppressing SPARC decreased IOP in mice and perfused cadaveric human anterior segments corresponding to qualitative structural changes in the JCT ECM, which do not appear to be the result of transcription regulation.