Leprosy (Hansen's disease): An Update and Review.

Leprosy (Hansen's disease) is caused by infection with bacilli of the Mycobacterium leprae complex. It is considered an exotic and rare diagnosis in Missouri. Past leprosy patients diagnosed locally have typically acquired it in areas of the world where leprosy is endemic. However, a recent case in a native Missourian that appears to be locally acquired suggests that leprosy may now be endemic in Missouri, possibly due to the expanded range of its zoonotic vector, the nine-banded armadillo. Health care providers in Missouri should be aware of how leprosy manifests and suspected cases referred to centers such as ours for evaluation and early institution of appropriate treatment.

What Are the Risk Factors for an Upper Extremity Deep Venous Thrombosis After Orthopaedic Irrigation and Debridement and Peripherally Inserted Central Catheter Placement?

BACKGROUND: Peripherally inserted central catheter (PICC) placement is necessary for delivery of intravenous (IV) antibiotics to treat bone and soft tissue infections. Upper extremity deep venous thrombosis (DVT) after PICC placement is a complication with unknown incidence in the orthopaedic literature. The major objectives of this study are Identifying the rate of upper extremity PICC-associated DVTs after orthopaedic procedures;Which orthopaedic subspecialties are most likely to encounter an upper extremity PICC-associated DVT?What surgeries or medical comorbidities are risk factors for upper extremity PICC-associated DVTs?Does type of DVT chemoprophylaxis decrease the risk of an upper extremity PICC-associated DVT? METHODS: A retrospective review of electronic medical records (EMR) was performed to include all patients undergoing irrigation and debridement (I&D) for treatment of orthopaedic surgery-related infections over a 10-year period. All patients with PICC placement were included for analyses. Age, sex, and medical comorbidities were extracted from the EMR. Mann-Whitney non-parametric tests, Fisher's exact tests, Chi-square tests, and Cochran-Mantel-Haenszel (CMH) tests were used to determine associations with DVT events for those with PICCs based on medical comorbidities, PICC lumen size, team placing the PICC, impact of implant removal, and protective effect of DVT chemoprophylaxis. Significance was set at p<0.05. RESULTS: Twenty-one of 660 patients (3.18% rate) were found to have an upper extremity PICC-associated DVT. A history of DVT (OR=8.99 [95% CI: 3.39, 49.42]) was significantly associated with an upper extremity PICC-associated DVT. The greatest risk for an upper extremity PICC-associated DVT was intramedullary implant removal (OR=12.43 [95% CI: 3.13, 49.52]). The type of DVT chemoprophylaxis did not significantly affect the likelihood of an upper extremity PICC-associated DVT. CONCLUSION: Intramedullary implant removal and a history of DVT are risk factors for an upper extremity PICC-associated DVT. The results of this study should be of particular interest to surgeons who do not typically give DVT prophylaxis and plan to perform surgery on patients with CHF, a history of a DVT, or plan to manipulate the intramedullary canal.

Postoperative permanent section evaluation of Mohs micrographic surgery debulk specimens does not result in upstaging of cutaneous squamous cell carcinoma compared to stage at the completion of surgery: A retrospective case series.

Background: Mohs micrographic surgery (MMS) is used for the treatment of high-risk cutaneous squamous cell carcinoma (cSCC). MMS examines the surgical margins in real time and does not commonly examine the central component of the tumor. Objective: To determine if debulk specimens provide additional details relevant to tumor staging not gained from routine MMS. Methods: A retrospective chart review of debulk specimens taken during MMS for cSCC was performed. Dermatopathology reports were analyzed and tumors were staged using Brigham and Women's Hospital and American Joint Committee on Cancer's 8th edition staging systems. Results: Permanent section evaluation of debulk specimens did not result in clinically meaningful information for staging that could not be gained from MMS layers or initial biopsy analysis. Limitations: A single institution, and a small sample size of 39 tumors. Conclusions: Evaluation of debulk specimens during MMS may not always be an effective use of time or health care resources.

Clinical Utilities of Anti-Müllerian Hormone.

The anti-Müllerian hormone (AMH) plays an essential role in sex determination in early embryonic development. Through a series of sequential steps that follows inheriting an XY chromosome, Sertoli cell differentiation upregulates the expression of AMH-suppressing Müllerian duct development and maintains the AMH at a high level until puberty. In females, the AMH is produced by granulosa cells of follicles beginning in the second half of fetal life and continues through adulthood, with a steady decline through the reproductive years and severe decline at menopause, until levels eventually become undetectable. The AMH is essential for the regulation of follicular maturation via the recruitment of primordial follicles throughout folliculogenesis. AMH serum concentration in women strongly correlates with ovarian reserve quantity and reflects ovulation potential. Because the AMH is expressed almost exclusively by growing follicles before FSH-dependent selection, it commonly serves as a marker for ovarian function in various clinical situations, including in the diagnosis and pathogenesis of polycystic ovarian syndrome, artificial reproductive technology, and predictions of menopause or premature ovarian failure.

Management of childhood intussusception after reduction by enema.

OBJECTIVE: The objective of the study was to describe the utility of emergency department (ED)/outpatient management after enema reduction for childhood intussusception. METHODS: A retrospective medical record review of children aged 2 months to 6 years with confirmed intussusception who underwent enema reduction in a tertiary care academic children's hospital was performed. Subjects were analyzed with respect to location of care after reduction (ED/outpatient vs inpatient) and number, timing, and outcome of recurrences. RESULTS: One hundred seventeen patients were diagnosed with intussusception by contrast or air enema during the 15-year study period, and 56 fulfilled our inclusion criteria. Ten patients (18%) were admitted to hospital after enema reduction. Mean length of stay was 33.7 hours in the hospitalized group and 7 hours in the ED group. Seven of the 56 patients had recurrences (12.5% recurrence rate). Two recurred while being observed in the ED (at 30 minutes and at 2 hours after reduction), 2 recurred at home (at 10 and 28 hours after reduction), and the other 3 recurred several months later. The early recurrence rate (recurring within 24 hours) was 5.3%. No patient had an adverse event (perforation, sepsis, bowel resection). CONCLUSIONS: Outpatient management is used for the majority of patients with intussusception at our institution after enema reduction. The early recurrence rate is low, and patients with recurrence after discharge do well without adverse outcomes. Emergency department observation of patients after enema reduction appears to be safe and should be routine for uncomplicated cases of intussusception.

Implementation and Evaluation of LVN LEAD. A leadership and supervisory training program for nursing home charge nurses.

Licensed practical/vocational nurses (LVNs) play an important role in U.S. nursing homes, with primary responsibility for supervising unlicensed nursing home staff. Research has shown that the relationship between charge nurses and certified nursing assistants (CNAs) has a significant impact on CNA job satisfaction and turnover as well as quality of care, yet nurses rarely receive supervisory training. The purpose of this project was to develop, pilot, and evaluate a leadership/supervisory training program for LVNs. Upon completion of the training program, many LVNs expressed and demonstrated a new understanding of their supervisory leadership and supervisory responsibilities. Directors of staff development are a potential vehicle for supporting LVNs' development as supervisors.

Silver carboxylate and titanium dioxide-polydimethylsiloxane coating decreases adherence of multi-drug resistant Serratia marcescens on spinal implant materials.

PURPOSE: The opportunistic multi-drug resistant nosocomial gram negative bacilli Serratia marcescens (S. marcescens) is a rising contributor to spinal implant infections (Iguchi et al., Genome Biol Evol 6:2096-2110, 2014; Teresa et al., J Clin Microbiol 55:2334-2347; Dante et al., J Clin Microbiol 54:120-126). This study investigates the most effective matrix ratio of an antibiotic-independent, silver carboxylate-doped titanium dioxide (TiO2)-polydimethylsiloxane (PDMS) coating in preventing adherence of multidrug resistant pathogen S. marcescens to spinal implant materials. METHODS: This project examined an antibiotic-independent, silver carboxylate-doped titanium dioxide (TiO2)-polydimethylsiloxane (PDMS) coating on three common spinal implant materials, polyetheretherketone (PEEK), stainless steel (SS), and titanium (Ti), which previously were found to be prone to bacterial adhesion (Garcia et al., Spine Deform 8:351-359). After generation of dose response curves to find the optimal silver carboxylate concentration, 95% TiO2-5% PDMS was combined with 10× silver carboxylate and compared to 100% silver carboxylate and uncoated implants. Implants were imaged using scanning electron microscopy and confocal laser scanning microscopy to detect adherent S. marcescens. RESULTS: Ninety-five percent TiO2-5% PDMS and 10× silver carboxylate coating decreased adherence of S. marcescens on PEEK by 99.61% (p = 0.001), on titanium by 98.77% (p = 0.001), and on stainless steel by 88.10% (p = 0.001) after 24 h. The average decrease in bacterial adherence was 95.49% compared to uncoated implants. CONCLUSION: A coating composition comprised of 95% TiO2-5% PDMS matrix and 10× silver carboxylate most effectively decreases adherence of S. marcescens on spinal implants. These results suggest that the application of a non-antibiotic, bactericidal coating prior to spinal surgery may prevent the adherence and proliferation of MDR S. marcescens and decrease the incidence of spinal SSI.

Rheumatologist and Primary Care Management of Cardiovascular Disease Risk in Rheumatoid Arthritis: Patient and Provider Perspectives.

OBJECTIVE: Despite increased cardiovascular disease (CVD) risk, rheumatoid arthritis (RA) patients often lack CVD preventive care. We examined CVD preventive care processes from RA patient and provider perspectives to develop a process map for identifying targets for future interventions to improve CVD preventive care. METHODS: Thirty-one participants (15 patients, 7 rheumatologists, and 9 primary care physicians [PCPs]) participated in interviews that were coded using NVivo software and analyzed using grounded theory techniques. RESULTS: Patients and providers reported that receipt of preventive care depends upon identifying and acting on risk factors, although most noted that both processes rarely occurred. Engagement in these processes was influenced by various provider-, system-, visit-, and patient-related conditions, such as patient activation or patients' knowledge about their risk. While nearly half of patients and PCPs were unaware of RA-CVD risk, all rheumatologists were aware of risk. Rheumatologists reported not systematically identifying risk factors, or, if identified, they described communicating about CVD risk factors via clinic notes to PCPs instead of acting directly due to perceived role boundaries. PCPs suggested that scheduling PCP visits could improve CVD risk management, and all participants viewed comanagement positively. CONCLUSION: Findings from this study illustrate important gaps and opportunities to support identifying and acting on CVD risk factors in RA patients from the provider, system, visit, and patient levels. Future work should investigate professional role support through improved guidelines, patient activation, and system-based RA-CVD preventive care strategies.