Wound Checks Research Articles

Groin Complications Among Obese Patients Undergoing Vascular Procedures

Groin incision wound complications (WC) are common among vascular surgery patients. Obesity is a known risk factor, but there is no consensus on the best way to prevent WC in obese patients after vascular procedures. The objective of this study was to identify risk factors for WC and strategies to prevent these complications specifically in obese patients. All patients who had longitudinal groin incisions at a single institution from 2021-2022 were included. The medical records were reviewed and all groin-related WC were identified. WC were stratified into major and minor WC where major WC were those requiring reoperation or hospital readmission. Patients were stratified into obese (body mass index > 30kg/m2) and nonobese cohorts. A total of 238 groin incisions were included. There were 46 (19.3%) obese and 192 (80.7%) nonobese patients. One hundred fifty six (65.5%) were closed with nylon, 49 (20.6%) were closed in a subcuticular fashion, and 32 (13.4%) were closed with staples. There were 45 (18.9%) WC: 15 (33.3%) major and 30 (66.7%) minor. Obesity was associated with a higher WC rate (39.1% vs. 14.1%, P<0.001), which was driven by minor WC (32.6% vs. 7.8%, P<0.001) rather than major WC (6.5% vs. 5.7%, P=0.873). On multivariable analysis, obesity remained a predictor for overall (odds ratio [OR] 4.953, P<0.001) and minor WC (OR 7.389, P<0.001). Additionally, female sex was associated with a higher rate of WC on unadjusted (27.6% vs. 12.8%, P=0.016) and adjusted analysis (OR 2.411, P=0.014). Among obese patients, subcuticular closure was associated with higher rates of minor complications (OR 8.454, P=0.044). Obese patients with major complications less frequently had close follow-up including rehab disposition, discharge with visiting nurse, or frequent office wound checks than those with minor complications (33.33% vs. 86.67%, P=0.043). Groin WC are more common in obese and female patients. Among obese patients, this difference is driven primarily by minor WC. Avoiding a subcuticular skin closure may reduce the risk of minor WC in obese patients. In addition, close postoperative follow-up using rehab, visiting nurse services, and frequent office wound checks may prevent minor complications from escalating to major complications.

Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma.

The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients. We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups. A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks. This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.

Store-and-Forward Teledermatology Wound Checks Following Mohs Surgery: A Pilot Study.

Store-and-forward telemedicine is a form of electronic transmission in which patient images or clinical information are transmitted to clinicians for asynchronous clinical decision making. This study evaluated the use, feasibility, savings, and patient satisfaction of postoperative store-and-forward wound checks following Mohs surgery. Select patients were asked to participate in a virtual postoperative wound check after receiving Mohs surgery. Participants sent photos of their wound site and subsequently completed an anonymous survey. One hundred and ten patients were enrolled, mean age 68 (range 32-87). Patients saved an average of $14.16, 78.6 miles of travel, and 90 min of travel time. Ninety-eight percent of respondents felt their quality of care in teledermatology was "about the same" to "much better" than compared with traditional in-person care. Sixty-four of the respondents (90.1%) reported they would prefer their next Mohs wound check to be conducted through teledermatology. Store-and-forward telemedicine in patients undergoing Mohs micrographic surgery is a safe, effective, and efficient method for postoperative wound care.

Implementing a New Remote Monitoring Program in the Developing World – The Cleveland Clinic Abu Dhabi Experience

Background: Remote monitoring (RM) for cardiac implantable electronic devices (CIED) is a class 1A recommendation by expert consensus. RM incorporation into CIED management allows for early detection of abnormalities, improved patient satisfaction, and enhanced device clinic efficiency. Cleveland Clinic Abu Dhabi (CCAD) established the first RM program in the United Arab Emirates in 2015, with over 1000 patients enrolled. We report patient RM compliance as an indicator of the overall benefit of our service, aiming to encourage the widespread application of RM technology in the Middle East and other emerging markets. Objective: To detail the implementation and efficacy of RM service for CIED patients at CCAD to be modeled after as the standard of care for the region. Methods: Patients are enrolled in RM before hospital discharge and undergo device and wound checks one week later in the device clinic. Additional patient education is provided at that time. Subsequent follow-up includes routine in-person evaluations as well as scheduled RM transmissions. Patient compliance is measured as the proportion of received RM transmissions in relation to all scheduled transmissions. Results: A total of 1084 patients were enrolled in RM between December 2015 and May 2022. The overall RM compliance rate at 1-year post-implant was 85%. Conclusion: Our study shows that the establishment of a large-scale RM program in the Middle East region is feasible and associated with excellent patient participation and compliance. We encourage RM integration as the standard of care for CIED patients in our region and areas of the world where such integration has been lagging.

Reflecting on Plastic Surgery Training During Early COVID-19 Pandemic: Resident Exposure and Telemedicine.

Coronavirus disease 2019 (COVID-19) pandemic has been an unprecedented public health crisis. As hospitals took measures to increase their capacity to manage COVID-19 patients, plastic surgeons have also had to modify their routine to continue serving their vital role within the hospital environment. In an effort to reduce exposure to COVID-19 and conserve hospital resources, many plastic surgery programs drastically modified call schedules, restructured inpatient teams, triaged operative cases, and expanded telemedicine encounters. Plastic surgery programs focused on craniofacial procedures were impacted by precautionary preventative protocol and shifts in case load made to protect both the healthcare teams and the patients. At academic centers, plastic surgery trainees of all domains felt the impact of these changes. Recognizing the implications on future craniofacial surgical practice, the pandemic has made, the goal of the authors' study is to measure initial impacts of COVID-19 on plastic surgery trainees using a nationwide survey. The authors' results present the first quantitative analysis of plastic surgery trainees' exposure to COVID-19, deployment to other medical specialties, usage of personal protective equipment, and implementation of telemedicine during the pandemic. While healthcare systems have greatly adapted to pandemic complications and can anticipate vaccination, resurgence of COVID-19 cases linked to the delta variant heightens the authors' urgency in understanding the early pandemic, and its lasting impacts on healthcare. In the months following pandemic onset, telemedicine has become a mainstay in healthcare, trainees have adapted and become integrated in patient care in novel ways, and visits unable to transition to telemedical settings received substantial attention to ensure patient and provider safety. An institutional review board-approved anonymous, multiple-choice and short-answer, Qualtrics survey regarding plastic surgery resident experiences with COVID-19 exposure. It was sent to all US plastic surgery program directors and program coordinators on April 23, 2020 with the request to distribute the survey to their residents. Residents were given the option to participate in a raffle for a $50 gift card. Outcomes measured included demographics, exposure to COVID-19, availability of resources, and adjustments to residency training practices. Sixty-nine plastic surgery residents throughout all years of training from 18 states responded. Gender, year of training, and location did not significantly impact these reports.Sixteen percent of residents reported covering a COVID-19 team. Twelve percent reported covering a shift not within their scope of practice. From these reports, residents mostly worked in the intensive care unit (50%) and the emergency department (29%).Half of the residents believe they were exposed to high-risk patients. This was reported in a variety of settings: the emergency department for plastic surgery consults (34%), caring for plastic surgery inpatients (16%), performing trauma reconstruction surgery (16%), cancer reconstruction surgery (12%), elective surgery (6%), and intraoperative consults (6%).Seventy-two percent of residents reported adequate access to personal protective equipment. Equipment type varied by patient exposure. When attending to a non-COVID-19 inpatient, most residents used a standard mask (62%) rather than an N95 mask (21%). N95 masks were generally used in patients with unknown COVID-19 status. Residents reported using eye and face shields when attending to non-COVID-19 ICU patients (17%), patients with unknown COVID-19 status (27%), and in the operating room (34%).Forty percent of residents implemented telemedicine to see patients for new consults, follow-up visits, postop checks, and wound checks. Eighty-five percent of residents report that they would continue to incorporate telemedicine in the future. Most significant reported barrier to using telemedicine is the limited ability to perform a physical examination (33%) followed by limited patient access to telemedicine (21%). Other challenges included poor ease of use for patients or providers, billing questions, and lack of interpersonal connection with patients. This study, to the best of the authors' knowledge, is the first to quantitatively investigate how plastic surgery residents have been affected by the widespread impacts of the COVID-19 pandemic. It reports resident exposure to COVID-19 and their associated concerns, resident access to and perceived adequacy of personal protective equipment, as well as changes to clinical practice.

Discharge instructions given to women following delivery by cesarean section in Sub-Saharan Africa: A scoping review.

A scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA). Studies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system. We identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity. Few studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

Noninvasive Skin Expansion Strips to Decrease Wound Issues after Total Ankle Replacement

Category:Ankle; Ankle Arthritis; Basic Sciences/Biologics; OtherIntroduction/Purpose:Total ankle arthroplasty through the anterior approach (TAR-AA) is an increasingly popular treatment for ankle arthritis. This approach carries significant risk for wound complications. Several products have been investigated to mitigate this risk, but these are either costly or invasive. Noninvasive skin expansion strips (NSESs) have two nonelastic adhesive strips, one on either side of the incision, with an elastic band connecting them. These were designed to induce new skin growth at the edges of the strips for plastic surgery applications. In the postoperative setting, the NSES functions to transfer tension away from the site of the incision to the edge of the strips. We hypothesize that postoperative application of NSESs will decrease unplanned clinic visits and wound complications after TAR-AA.Methods:This is a prospective cohort study with retrospectively identified historical controls designed to evaluate the effectiveness of NSESs. Prospectively enrolled patients undergoing TAR-AA at a single institution (3 surgeons) received application of NSESs in the operating room after routine wound closure. At their two-week postoperative visit, each wound was assessed and new NSESs were applied. No other changes were made to the surgeons' wound closure technique, immobilization, follow-up cadence, or rehabilitation protocols. Patients following up with providers outside the institution were excluded. Thirty five consecutive historical controls were identified for comparison. Primary outcomes included (1) Additional clinic visit required for wound assessment or suture removal, (2) superficial wound complication before 8 weeks, and (3) deep infection before 8 weeks. Z-score test was used to calculate statistically significant (p<=0.05) differences between the two groups.Results:To date, 20 patients (62.5 +- 11.8 years; 6 females, 14 males) received application of NSESs. Baseline demographics did not differ significantly from our 35 consecutively identified historical controls (62.2 +- 13.3 years; 16 females, 19 males). Additional clinic visits for suture removal were needed for 15% (3/20) of patients in the treatment group compared to 46% (14/35) of patients in the control group (p=0.021). There were significantly fewer unplanned visits per patient in the treatment group compared to the control group (0.15 vs. 0.54, p=0.004). The superficial wound complication rate in the treatment group vs. control group was 0% and 11%, respectively (p=0.12). There were no deep infections in either group.Conclusion:Noninvasive skin expansion strips are an effective means to improve early wound healing and decrease unplanned clinic visits for wound checks or delayed suture removal after TAR-AA. There was a trend toward significance for NSESs decreasing superficial wound complications. Further high volume studies are needed to clarify their cost effectiveness and effect on deep infections.

TP8.1.11 Discussing results and breaking bad news in breast video consultations: a pilot questionnaire

Abstract Aim Virtual consultations (VC) in Breast Surgery have become well-established during the COVID pandemic. They are successfully utilised in routine follow ups and low-risk new referrals. We aimed to assess the utility of VC in more complex clinical discussions. Methods We collected feedback anonymously via electronic link from 20 consecutive patients who specifically had more challenging video-VC including: 12 diagnostic MDT results (10 patients received bad news of new cancer diagnosis, 2 had benign results); 6 post-operative wound checks with therapeutic MDT outcomes; 2 new consultations for chest wall reconstruction. Results The time saved by patients was between 1 and 3 hours (median=2). All patients felt that booking and joining a VC was either very easy (12) or easy (8). 18 patients were satisfied with the quality of sound and picture and all 18 felt they were able to communicate everything to the clinician during their VCs. Compared to a face-to-face consultation, 14 patients felt that VC was better (70%), 4 felt it was similar (20%) and 2 thought it was worse (10%). Most received comments were themed around VC had allowed patients to get their results, discuss their management plans and ask questions while they were safely at home with other family members, at times when COVID restrictions applied to outpatient clinical settings. Conclusion VC may be utilised selectively to provide complex consultations including discussing results, breaking bad news and wound inspections. Qualitative studies in this field can be beneficial.

Robotic Revisional Single Anastomosis Duodenoileal Bypass After Sleeve Gastrectomy.

Introduction: Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a metabolic operation emerging as an option for patients with morbid obesity. It is a promising revisional procedure for weight regain or suboptimal weight loss after sleeve gastrectomy (SG). Currently, there is limited literature describing robotic revisional SADI-S. This study describes the safety, feasibility, and early outcomes of robotic revisional SADI-S after previous SG. Methods: This is a retrospective review from May 26 2019 to January 31 2021. Perioperative outcomes were analyzed. Results: A total of 16 patients underwent the procedure. There were 11 females (69%) with a mean age of 39 ± 11 years. Mean body mass index (BMI) was 44.0 ± 5.1 kg/m2 and median ASA was two. Comorbidities included hypertension (25%), hyperlipidemia (19%), and obstructive sleep apnea (13%). Mean interval from primary to revisional surgery among patients was 5.5 ± 1.4 years. Median operative console time was 110 minutes (IQR = 103-137). There were no intraoperative complications. The median hospital stay was 2 days (IQR = 2-3). Perioperative outcomes included no reoperations, perioperative complications, or deaths. There were two (12.5%) emergency department visits for wound checks without infection but no readmissions. At a median follow-up of 4.5 months (IQR = 1-10), patients had a mean BMI of 38.3 ± 7.3 kg/m2 and a mean percent total body weight loss (%TBW) of 12.7%. Conclusions: Initial outcomes suggest that robotic revisional SADI-S after previous SG is feasible and safe. Future studies are needed to evaluate intermediate- and long-term postoperative outcomes.

Wound care practices after orthopaedic trauma surgery are highly variable and not evidence based

ObjectiveGiven the tremendous medical, social and financial costs of surgical site infections, the pressure to minimize these complications has been mounting. There remains a substantial gap in evidence-based practice for postoperative wound care after orthopaedic trauma surgery. The purpose of this study is to determine what standards are currently in practice for postoperative wound management. MethodsA 16-question web-based survey was published on the Orthopaedic Trauma Association website and disseminated to members through the association's quarterly email. The survey gathered data on postoperative wound care practices; specifically, when wound checks are performed, and when providers allow patients to get the incisions wet. Results102 Orthopaedic surgeons completed the survey. Ninety-one percent were trauma fellowship trained, and 95% worked at either a Level I (76%) or Level II (19%) trauma center. There were over 100 different proposed protocols captured by the survey. The majority of surgeons (54%) perform a wound check within the first three days after surgery. Additionally, half of surgeons (50%) do not permit patients to get their incisions wet until sutures and staples are removed. ConclusionWound care routines following surgical management of orthopaedic trauma injuries are highly variable. Diverse protocols are performed at the discretion of the treating surgeon without scientific basis. This study defines immense variability in one aspect of peri-operative care that could play an important role in surgical site infections and provides a foundation for future studies to explore the potential influence of standardized wound care routines on post-operative infections and wound healing.

Abstract P3-13-11: The outcomes of ReFilx soft tissue filler as an immediate reconstruction technique for lumpectomy followed by radiotherapy

Abstract Introduction: Lumpectomy for breast cancer can often result in poor cosmetic outcomes which can lead to long-lasting impairment of quality of life. ReFilx is a synthetic porous degradable polyurethane scaffold that has mechanical properties comparable to that of native healthy breast tissue. It has been shown in two previous porcine studies to preserve breast shape and volume over 9 months when inserted into the cavities immediately after lumpectomy. We observed minimal foreign body reaction with good integration of the host tissue while the material degraded over time. In this study, we examined the healing process of lumpectomy treated with radiation. Radiotherapy is currently a standard adjuvant therapy after lumpectomy for breast cancers; and radiation is known to affect the healing process in general. Objective: To evaluate ReFilx, as soft tissue fillers for lumpectomy cavities in combination with standard radiotherapy. Hypothesis: ReFilx will preserve breast shape and volume by supporting tissue infiltration with minimal inflammation in the presence of clinically relevant radiotherapy. Methods: 3 female Yucatan minipigs received lumpectomies carried out using electrocautery to remove normal breast tissue of approximately 2 cm diameter, after which the cavities were filled with (case) or without ReFilx (sham control) (n=3 for each condition, each pig has 12-13 breasts). 6 weeks post-implantation, 2 of the pigs received radiation directed at the right half of their bodies (6 breasts per pig) for a total dose of 42.4 Gy delivered over 15 fractions using a clinical linear accelerator. The delivered doses to target sites and the adjacent tissue were confirmed with optically stimulated luminescent dosimeters (OSLDs). A third pig was maintained as a non-irradiated control. Ultrasound examinations were performed every 3 weeks post-implantation. At week 24 and 36, samples consisted of n=3 for irradiated and non-irradiated ReFilx and sham sites for the half-irradiated pigs, and n=3 for non-irradiated ReFilx and sham sites for the non-irradiated control pig were excised by mastecomy, the tissue samples were fixed in 10% buffered formalin for subsequent histological (H&amp;E, Masson's Trichrome) studies. Potential side effects were monitored by vital signs, pain control, wound checks, ultrasound and blood tests. Necropsies were performed at the conclusion of the study. Results: Ultrasound examination indicated no difference between ReFilx's ability to maintain breast shape and volume with or without the presence of radiation treatment, in contrast to the collapse of the sham sites by 24 weeks. Similarly, the histology of irradiated and non-irradiated ReFilx samples showed similar levels of tissue infiltration, inflammatory changes and degradation of ReFilx. There was no significant side effects observed. Conclusions: ReFilx's ability to act as a soft tissue filler for breast volume restoration post-lumpectomy does not appear to be significantly impacted by the presence of clinically relevant radiation treatment. Longer-term follow-up is currently in progress for this study. Acknowledgements: Connaught Innovation Award (University of Toronto) and Joule Innovation Fund (Canadian Medical Association). Citation Format: Leong WL, Battiston K, Cheung F, Fulton C, Lin A, Levin W, Done S, Santerre P. The outcomes of ReFilx soft tissue filler as an immediate reconstruction technique for lumpectomy followed by radiotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-11.

Abstract 16612: The Feasibility, Safety, and Value of a Virtual Cardiac Implantable Electronic Device Wound Check

Introduction: In-person wound checks are standard of care for patients implanted with cardiac implantable electronic devices (CIEDs), which include pacemakers and implantable cardioverter-defibrillators. However, in-person wound checks burden patients, providers, and health systems. A virtual wound check may be a safe alternative, but the feasibility, safety, and costing savings of a virtual CIED wound check are unknown. Methods: We performed a single-center pilot study of a virtual wound check following CIED implantation. Eligible patients included those implanted with a CIED and scheduled for an in-person wound check at our center, and who had a smartphone or digital camera and internet access. Virtual wound checks consisted of 1) patients taking and uploading a digital photograph of their wound, and 2) a phone conversation with a CIED nurse regarding signs and symptoms of wound complication. The safety of a virtual wound check as compared to an in-person wound check was assessed by examining the agreement between virtual and in-person wound checks regarding wound abnormalities detected and recommended treatments. The value of a virtual wound check was assessed with time-driven activity-based costing (TDABC), a micro-costing approach in which time is assigned to each task in both the virtual and in-person wound checks. Results: We enrolled 67 of 76 (88.2%) eligible patients, of whom 50 (74.6%) completed a virtual wound check. No abnormality was seen in either virtual or in-person checks for 42 (62.7%) patients. An abnormality was seen in the virtual but not in-person wound check in 5 patients, and in the in-person but not virtual wound check in 5 patients. Pocket swelling was detected in 6 patients during virtual wound checks, and 7 during in-person wound checks. Erythema was detected in 1 patient during an in-person wound check that was not detected during a virtual wound check. The overall agreement was 71.4%. All complications that led to a clinical action (i.e. prescription of antimicrobial drugs, placement of pressure dressing) were detected in both the virtual and in-person wound checks. TDABC analysis demonstrated virtual visits used an average of 5 minutes less of provider time, and a total cost savings of $153. Conclusions: A virtual CIED wound check is feasible, safe, and associated with cost-savings to health systems. Further work is needed to improve the processes of care for virtual CIED wound checks.

Screw fixation for supracondylar humerus fractures in children: a report of seventeen cases.

Supracondylar fractures in the pediatric population are common. For years, K-wires have been the preferred method of surgical fixation. However, fixation with K-wires alone may lead to multiple complications. This study reports the results of surgical care of supracondylar humerus fractures using screw fixation with K-wires or screw fixation alone. This study retrospectively reviewed all patients with supracondylar humerus fractures treated with screw fixation between 2007 and 2013. Patients treated only with smooth wires, or having a displaced medial epicondyle, or presenting with lateral condyle fractures were excluded from the study. Flynn's criteria were used to determine the outcome. Seventeen patients who met inclusion criteria formed the study group. All patients were followed until union, resolution of complications, and return to preinjury activity level. Satisfactory outcome was reported in 70.6% of patients with less than 15° loss of either flexion or extension. Mean time to union was 6.5weeks (range 3.3-12.1weeks). Screw fixation alone had a shorter mean time to union (5.5weeks) than compared screw fixation with K-wires group (6.9weeks). Full range of motion following surgical invention was associated with Flynn's criteria (p value = 0.044). Screw fixation for pediatric supracondylar fractures is a viable option to achieve healing and early motion in highly unstable fractures as well as fractures which require (1) increased stability, (2) maintenance of stability during wound checks in the immediate postoperative period and after discontinuation of the cast, or (3) if further exploration like associated vascular injury is warranted.

Utilization of Postpenile Surgery Illustrated Healing Atlas: A Comparative Study

To determine the effect of the postpenile surgery illustrated healing atlas on caregivers' anxiety levels pre- and postoperatively, the frequency of family's postoperative communication with the urology care team, and the number of unplanned emergency room (ER) return for wound checks. A prospective cohort enrolled children who underwent penile surgeries (distal hypospadias repair and phalloplasty) with no concomitant procedures from December 2016 to June 2017. A 6-item short-form Spielberger State-Trait Anxiety Inventory (STAI) was used to determine baseline and postoperative anxiety levels of the caregivers. Two groups were created: caregivers who did not view the illustrated atlas vs caregivers who were shown the atlas. Baseline characteristics and demographics were compared, along with caregiver's pre- to postoperative anxiety level difference, frequency of postoperative communication, and number of unplanned ER return for wound checks. Fifty-four patients were enrolled with 27 families in each group. Baseline characteristics and demographics were comparable with no significant differences. The assessment of the pre- to postoperative anxiety levels in both groups showed no significant differences (median difference -5 [interquartile range -8 to -5] vs -5 [interquartile range -8 to -4], P = .94). Although no differences were noted for ER-return rates between the groups (18% vs 11.1%, P = .704), significantly less postoperative calls and e-mails were noted among families who received or viewed the postpenile surgery illustrated healing atlas (51.9% vs 11.1%, P = .003). The utilization of a postpenile surgery illustrated healing atlas as part of the postoperative support provided to families was able to decrease postoperative calls and e-mails.

Mandatory Operative Re-Exploration after Initial Debridement of Necrotizing Soft Tissue Infections: Is it Mandatory?

Necrotizing soft tissue infections (NSTIs) are aggressive infections requiring prompt diagnosis and extensive surgical debridement. Traditionally, patients undergo mandatory re-exploration to ensure adequacy of source control. The purpose of this study is to determine if re-exploration in the operating room is mandatory for all patients with NSTIs. An eight-year retrospective analysis of adult patients with NSTIs was performed comparing two groups: mandatory operative re-exploration versus operative re-exploration based on clinical examination findings. Outcomes measured included mortality, number of debridements, and length of stay (LOS). Twenty-two per cent of patients underwent a mandatory re-exploration. These patients were older, had a higher incidence of diabetes, and a longer duration of symptoms. There were no significant differences between groups with regard to the physical examination, severity of sepsis, time to repeat debridements, or in-hospital mortality, whereas LOS and the total number of debridements were increased in mandatory re-exploration. Bacteremia and septic shock were predictive of the need for further debridement in patients in the operative re-exploration based on clinical examination findings group. Mandatory re-exploration after initial debridement may not be necessary in all patients with NSTIs. Instead, bedside wound checks may be a safe strategy to determine the need for further operative debridement.

Impact of smartphone digital photography, email, and media communication on emergency room visits post-hypospadias repair.

Advances in communication technology are shaping our medical practice. To date, there is no clear evidence that this mode of communication will have any effect on unnecessary postoperative emergency room (ER) visits. We aim to evaluate the effect of email and media communication with application of smartphone digital photography on post-hypospadias repair ER visit rates. This prospective cohort study included all patients who underwent hypospadias repair performed by a single surgeon from October 2014 to November 2015. Patients were categorized into two groups: Group A consented for smartphone photography and email communication and Group B declined. Reason for ER visits within 30 days postoperatively was assessed by another physician, who was blinded of patient group assignment. The reasons were categorized as: unnecessary ER visit, indicated ER visit, or visit unrelated to hypospadias surgery. Chi-square test and T-test were used for statistical analysis. Relative risk (RR) and corresponding 95% confidence interval (CI) were also calculated. Statistical significance was set at p<0.05. Over a 14-month period, 96 patients underwent hypospadias repair (81 in Group A, 15 in Group B 5). No significant difference was noted between groups for overall ER return rate (RR 0.46, 95% CI 0.21, 1.0). However, the number of ER visits for wound check not requiring intervention was significantly lower in Group A than in Group B (RR 0.14, 95% CI 0.035, 0.56); likewise, a higher number of ER visits requiring intervention was noted in Group A compared with Group B, although statistically this was not significant (RR 1.67, 95% CI 0.23, 12.21). Email communication with the use of smartphone digital photography significantly reduced the number of unnecessary ER visits for post-hypospadias wound checks.

Role of Joshi's external stabilization system with percutaneous screw fixation in high-energy tibial condylar fractures associated with severe soft tissue injuries

PurposeThe treatment of high-energy tibial condylar fractures which are associated with severe soft tissue injuries remains contentious and challenging. In this study, we assessed the results of Joshi's external stabilization system (JESS) by using the principle of ligamentotaxis and percutaneous screw fixation for managing high-energy tibial condylar fractures associated with severe soft tissue injuries. MethodsBetween June 2008 and June 2010, 25 consecutive patients who were 17–71 years (mean, 39.7), underwent the JESS fixation for high-energy tibial condylar fractures associated with severe soft tissue injuries. Out of 25 patients, 2 were lost during follow-up and in 1 case early removal of frame was done, leaving 22 cases for final follow-up. Among them, 11 had poor skin condition with abrasions and blisters and 2 were open injuries (Gustilo-Anderson grade I & II). The injury mechanisms were motor vehicle accidents (n = 19), fall from a height (n = 2) and assault (n = 1). The fractures were classified according to Schatzker classification system. ResultsThere were 7 type-V, 14 type-VI and 1 type-lV Schatzker's tibial plateau fractures. The average interval between the injury and surgery was 6.8 days (range 2–13). The average hospital stay was 13 days (range, 7–22). The average interval between the surgery and full weight bearing was 13.6 weeks (range 11–20). The average range of knee flexion was 121° (range 105º–135°). The normal extension of the knee was observed in 20 patients, and an extensor lag of 5º–8º was noted in 2 patients. The complications included superficial pin tract infections (n = 4) with no knee stiffness. ConclusionJESS with lag screw fixation combines the benefit of traction, external fixation, and limited internal fixation, at the same time as allowing the ease of access to the soft tissue for wound checks, pin care, dressing changes, measurement of compartment pressure, and the monitoring of the neurovascular status. In a nutshell, JESS along with screw fixation offers a promising alternative treatment for high-energy tibial condylar fractures associated with severe soft tissue injuries.

Evaluation of tri-steps modified styrene-butadiene-styrene block copolymer membrane for wound dressing

Tri-steps modified styrene-butadiene-styrene block copolymer (SBS) membrane was prepared with epoxidation, ring opening reaction with maleated ionomer and layer-by-layer assembled polyelectrolyte technique. The tri-steps modified SBS membrane was characterized by infrared spectroscopy and X-ray photoelectron spectroscope (XPS). The structures of the modified SBS membranes were identified with methylene blue and azocarmine G. The content of amino group on the surface of the modified membrane was calculated from uptake of an acid dye. The values of the contact angle, water absorption, water vapor transmission rate and the adsorption of fibronectin on the membranes were determined. To evaluate the biocompatibility of the tri-steps modified SBS membrane, the cytotoxicity, antibacterial and growth profile of the cell culture of 3T3 fibroblasts on the membrane were evaluated. The bactericidal activity was found on the modified SBS. From the cell culture of 3T3 fibroblasts on the membrane, it revealed that the cells not only remained viable but also proliferated on the surface of the tri-steps modified SBS membranes. As the membranes are sterile semipermeable with bactericidal activity and transparent allowing wound checks, they can be considered for shallow wound with low exudates.

To-Go medications for decreasing ED return visits

ObjectivesThe primary objective was to determine if providing patients with a complete course of antibiotics for select conditions would decrease the rate of return to the emergency department (ED) within 7 days of the initial visit. MethodsIn an urban, academic medical center, we compared patients who received medications at discharge (To-Go medications) with patients who received standard care (a prescription at discharge). Emergency department patients were included if they were older than 18 years; had a discharge diagnosis International Classification of Diseases, Ninth Revision, code for urinary tract infection, pyelonephritis, cellulitis, or dental infection; and presented initially between January and December 2010. Candidates had limited health insurance or were discharged when nearby pharmacies were closed. Return visits were included if the condition was related to the initial diagnosis. Wound checks and scheduled revisits were excluded. Medications dispensed were penicillin, clindamycin, sulfamethoxazole-trimethoprim, and nitrofurantoin. ResultsA total of 4257 individuals were seen in initial ED visits for the included conditions. Comparing the 243 individuals given medications with the 4014 who were not given medications, the To-Go medications group was less likely to return than the comparison group (2.5% vs 5.9%; P = .026). The cellulitis subgroup also showed a significant reduction in return visits (1.6% vs 6.9%; P = .024). Three hundred eighteen courses of medication were given to the 243 individuals for a total cost of $1123. ConclusionsFor a 1-year expense of $1123, we demonstrated a 50% reduction in ED return visits for patients who were given a free, complete course of antibiotics at discharge for select conditions.

Telemedicine Through the Use of Digital Cell Phone Technology in Pediatric Neurosurgery

Advances in medicine have largely followed advances in technology. Medical strides have been made when physicians and researchers have adapted growing science to target specific problems. A new medical field, telemedicine, has emerged that links physicians with colleagues and patients. Cell phone technology is affordable for almost everyone, and basic models include digital photography. We present a case series exhibiting the utility of digital pictures taken with patients' cell phones. Our patients had wound infections requiring daily intravenous antibiotics and dressing changes. In years past, these patients would have required prolonged hospitalizations. In the era of managed care, patients with these infections are discharged from the hospital, but close outpatient observation is required to monitor the wound. Our patients lived up to 8 hours away from the hospital. Daily appointments for wound checks in the clinic were not practical. Wounds were thus monitored via cell phone images without the inconvenience of travel and the expense of staying in a local hotel, along with leaving appointments in the clinic available for others with new neurosurgical issues. Wound evaluations were conducted with the cameras on patients' cell phones. These images were transmitted to the surgeon via text messaging and emails. This application of cell phone technology has been documented previously in the literature of other specialties and could attain greater stature as a legitimate method for close outpatient observation by neurosurgeons if medicolegal issues are addressed.