Effectiveness and safety of an innovative silicone extender in suture reinforcement or dermatotraction: a retrospective study.

OBJECTIVE: Multiple techniques are available for closing skin defects, such as skin grafts, flaps and tissue expansion. The tissue extender MID SEW (MID, France) was developed to achieve dermatotraction or suture reinforcement. The aim of this study was to evaluate the effectiveness and safety of this innovative silicone extender for large surgical wounds. METHOD: A single-centre retrospective and observational study on an unselected consecutive cohort of patients treated with a tissue extender was conducted. Indications, initial and final wound surfaces, and adverse events (AEs) were retrieved from electronic medical records. The main outcome measure was the time to complete wound closure. RESULTS: We identified 50 patients from July 2017 to December 2018. Patients underwent cutaneous tumour-wide excision (n=44), or pilonidal disease surgical treatment (n=6). The average initial wound area was 53.3±42.4cm2. Healing was complete, without secondary dehiscence, within the first seven days after device withdrawal for 41 patients (82%). At least one AE was experienced by eight patients (16%) during the study period: five inflammation; five wound dehiscence; two skin necrosis; and one pain. CONCLUSION: This case series suggests that the tissue extender may be effective and safe in its dermatotraction and suture reinforcement indications in the treatment of large wounds after wide excision of skin cancer or treatment of pilonidal disease. DECLARATION OF INTEREST: This work was supported in part by the Hospices Civils de Lyon, France and in part by the University Claude Bernard Lyon 1, France. OB co-owns the patent on the MID SEW system. The authors have no other conflicts of interest to declare.

A single-centre experience of 29 total ankle replacement in haemophiliac patients: Therapeutic management, factor consumption and cost.

INTRODUCTION: In patients with haemophilia, repeated bleeding in large joints leads to chronic haemophilic arthropathy, a rare disease that can be managed surgically with ankle arthrodesis or with total ankle replacement (TAR). TAR has been reported to provide good surgical results in the medium/long-term and allow preservation of joint mobility but the medical therapeutic management of the patients has not been described. AIM: To describe the medical therapeutic management of TAR. METHODS: All patients with haemophilia A/B, with haemophilic ankle arthropathy, and who underwent TAR between April 2006 and October 2019 were retrospectively included. Factor consumption, perioperative and early complications, volume of blood lost, and orthopaedic data were collected. RESULTS: A total of 25 patients underwent 29 TAR (mean age was 44.7 years [range: 26-65]). In the 17 patients with HA without history of anti-FVIII inhibitor, the mean ± SD consumption the day of surgery was 116 ± 16 UI/kg when clotting factors were administered by continuous infusion, 106 ± 13 UI/kg when SHL factors were administered by bolus infusion, and 75 ± 22 UI/kg when EHL factors were administered by bolus infusion. During hospitalisation, the mean factor cost was €38,073 (83.7% of the total cost of surgery). Mean blood loss was significantly lower in patients treated with tranexamic acid (164 mL, range: 40-300) than in those not (300 mL, range: 70-800; p = .01). Six patients had haematoma. The 10-year survival free of any prosthesis removal/arthrodesis was estimated to be 92.2% (95% CI [83; 100]). CONCLUSION: The medical therapeutic management of TAR is complex, carried out by a multidisciplinary team but effective in avoiding the occurrence of complications.

Implementation assessment of a patient personalized clinical pharmacy programme (5P project) into orthogeriatric care pathway.

WHAT IS KNOWN AND OBJECTIVE: The orthogeriatric path (hip-fractured elderly patients) is composed of several transition points (emergency surgery, orthopaedic, geriatric and rehabilitation units). The intervention of clinical pharmacists can ensure the continuity of patients' drug management during their hospital stay. The aim of the study was to assess the implementation of clinical pharmacy activities in an orthogeriatric pathway, regarding its impact on medication error prevention, the healthcare professionals' and patients' satisfaction, and the estimated associated pharmaceutical workload. METHODS: Participants were aged 75 or older and managed for proximal femoral fracture. Their admission prescription was reviewed. If they were evaluated at high risk of adverse event (AE), medication reconciliation (MedRec) and pharmaceutical interviews (admission, discharge, and targeted on oral anticoagulant) were added at different steps of their care pathway. The achievement and duration of each clinical pharmacy activity were recorded. The number of pharmaceutical interventions (PI) made during prescription review, and unintentional discrepancies (UID) identified during MedRec were collected. A satisfaction questionnaire was sent to patients and healthcare professionals. RESULTS AND DISCUSSION: Among 455 included patients, 284 patients were considered at high risk of AE. Clinical pharmacy activity achievement rates varied between 12% and 98%. A total of 622 PI and 333 UID were identified. The overall patients' and healthcare professionals' satisfaction was rated from 63% to 100%. The total workload was estimated at 376 h: on average 16 min per prescription review, 43 min per admission MedRec, 26 min per discharge MedRec and 17 to 25 minutes per interview. CONCLUSION: The implementation of the programme showed a high potential of drug management securing. To sustain it, additional pharmaceutical human resources and high-performance computing tools are needed.

How a Patient Personalised Clinical Pharmacy Programme Can Secure Therapeutic Care in an Orthogeriatric Care Pathway (5P Project)?

BACKGROUND: A new model was developed for integrating a personalised clinical pharmacy programme (5P project) into the orthogeriatric care pathway. OBJECTIVE: To secure the therapeutic care of orthogeriatric patients. DESIGN AND SETTING: Prospective descriptive study in a multisite teaching hospital from June 2019 to January 2020. SUBJECTS: Patients aged ≥75 years admitted for hip fracture. METHODS: A prescription review was performed for all patients at inclusion. Other clinical pharmacy activities (additional prescription review, pharmaceutical interviews, medication reconciliation) were dedicated to "high-risk" patients. Potential medication errors (ME), either pharmaceutical interventions (PI) or unintentional discrepancies (UID), were recorded. The potential clinical impact of PI was evaluated by a pluriprofessional expert panel using a validated tool. RESULTS: In the 455 patients included, 955 potential ME were detected, that is ≥1 potential ME for 324/455 (71%) patients. In acute care, 561 PI were formulated during prescription review for 440/455 (97%) patients and 348/561 (62%) were accepted by physicians. Medication reconciliation was performed for 213 patients, 316 UID were identified. In rehabilitation units, a second prescription review was performed for 112/122 (92%) "high-risk" patients, leading to 61 PI. The clinical impact was evaluated for 519/622 (83%) PI. A consensus was obtained for 310/519 (60%) PI: 147/310 (47%) were rated as having minor clinical impact, 138/310 (45%) moderate, 22/310 (7%) major, 2/310 (0.6%) vital, and 1/310 (0.3%) null. CONCLUSION: The 5P project secured the orthogeriatric care pathway by detecting a great number of potential ME, including PI mostly considered as having a significant clinical impact.

[Tolerance and effectiveness of an alcoholic solution of 2% chlorhexidine in patients with a long-term central venous route.] / Tolérance et efficacité d'une solution alcoolique de chlorhexidine 2 % chez des patients porteurs de voie veineuse centrale au long cours.

Alcoholic chlorhexidine 2 % is recommended for the prevention of catheter infections. A retrospective study was conducted in a nutritional assistance unit in a cohort of patients with a long-term central venous route. The tolerance (number of skin reactions) and efficacy (number of infections/days of catheters) of this antiseptic used in repeated care in these patients were described.

Calculation of the aortic arch angles from three-dimensional reconstructions of computed tomography scans: Comparison between an automated program and visual assessment.

BACKGROUND: The curvature of the aortic arch is associated with the risk of endoleak formation after thoracic endovascular aortic repair (TEVAR). However, the adequate assessment of the angles of the aorta continues to represent a major difficulty. We developed a new program based on three-dimensional (3D) reconstructions of computed tomography (CT) scans to objectively identify the location of the aortic points of maximum curvature, and to automatically calculate the main aortic arch angles, comparing final values with visual assessment methods. METHODS: This is a cross-sectional validation study of a convenience sample of subjects with multislice CT angiography scans of the thoracic aorta from an institutional imaging database. The center lumen line (CLL) of the aorta was determined semi-automatically using Endosize software. The points of maximum curvature on the CLL were determined by two methods: visually by two physicians and through a custom program. RESULTS: The study enrolled 9 subjects: 4 with thoracic aneurysms and 5 with normal aortas. The inter-observer and inter-method correlation, agreement and reliability for each of the 3D spatial coordinates of the points of maximum curvature were appropriate. However, the aortic angles determined by visual assessment showed a very low to moderate correlation and reliability with those determined by our custom program. CONCLUSION: An automated custom program can reflect clinician's intuitive assessment of the location of points of maximum curvature and translate it into aortic angles with an apparently higher precision, reducing potential error and user time.

Bone cement usage modalities at a multi-site university hospital centre.

BACKGROUND: Although cements are widely used during arthroplasty procedures, few recommendations exist regarding their optimal usage modalities, which, nevertheless, govern the long-term surgical outcomes. No detailed information is available on how cements are used in French hospitals. The objectives of this questionnaire survey among surgeons working at a multi-site university hospital in France were to describe practices, determine whether these varied with surgeon experience, and look for differences compared to recommendations. HYPOTHESIS: Cementing techniques vary widely among surgeons at a university hospital. MATERIAL AND METHODS: A questionnaire was sent to the five orthopaedic departments of our university hospital to collect data on the surgeons (age, sex, years of experience), their practice (type of implants used, annual number of arthroplasties with each arthroplasty type and each indication, and proportion of cemented arthroplasties), the type of cement used, and the cementing technique. RESULTS: Of the 34 surgeons, 21 completed the questionnaire, 20 males and 1 female with a mean age of 41 years (range, 31-59 years) and a mean of 11 years (range, 1-29 years) of experience. High-viscosity antibiotic-loaded cement was preferred by 20 (95%) surgeons, notably for knee arthroplasties, of which the median annual numbers were 55 (range, 0-218) and 8 (range, 1-40) for primary and revision cemented procedures, respectively. Various cementing techniques in ambient air were used: 12/21 (57%) surgeons used pulsed lavage to prepare the bone before cementation and 18/21 (86%) applied the cement to both the bone cuts and the implant. Of the 18 surgeons who performed knee arthroplasties, 12 used pulsed lavage, including 9 of the 11 surgeons with more than 5 years of experience and only 3 of the 7 less experienced surgeons. Similarly, of the 12 surgeons who used pulsed lavage for cemented arthroplasties, 11 were among the 12 surgeons who performed more than 15 cemented arthroplasties annually and 1 was among the 6 who performed fewer cemented arthroplasties. DISCUSSION: Cementing techniques varied widely, reflecting the dearth of recommendations and controversial results of published studies. In our centre, the use of pulsed lavage to improve bone preparation and cement application to both the bone and the implant should be promoted, as both techniques are universally advocated. Our study demonstrates the need to provide surgeons with opportunities to exchange their experiences about the other aspects of cementing in order to harmonise practices and to optimise the use of cement. LEVEL OF EVIDENCE: IV, questionnaire survey.

Factors influencing field testing of alcohol-based hand rubs.

BACKGROUND: According to the World Health Organization guidelines, field tests, in the context of a bid for the supply of alcohol-based hand rubs, should take into account climatic region, test period, products already in use, and type of use (hygienic or surgical) when assessing tolerance. This laborious method is often contested. OBJECTIVE: To conduct a post hoc analysis of the data of a large bid, including 5 factors, to validate the relevance of their inclusion. METHODS: For the purposes of the bid, products were compared in terms of the 4 World Health Organization tolerance criteria (appearance, intactness, moisture content, sensation) during product testing and were separated into groups on the basis of the studied factors. The post hoc analysis method included (1) comparison of the mean before-and-after difference based on the self-evaluation of the skin with the 4 World Health Organization tolerance criteria, between climatic regions, periods, products in use, test product, and the type of use; (2) generalized linear models, taking into account all studied factors. RESULTS: The analysis included data for 1,925 pairs of professionals. The means of the differences observed were independently and significantly associated with the test period (P<.001), the hygienic or surgical use (P=.010 to .041, not significant for appearance), the product already in use (significant for appearance P=.021), and the test product (P<.001). The association with climatic region was found to be significant only in the nonadjusted analysis. CONCLUSION: The type of use, the test period, and the product in use should be taken into account when designing field tests of alcohol-based hand rubs.