Total knee arthroplasty using computer-assisted navigation in patients with deformities of the femur and tibia: A report of 5 cases

Anatomic aberrations of the femur and tibia secondary to trauma, congenital defects, and prior surgery present challenges for the reconstructive knee surgeon because of an altered mechanical axis and distorted anatomic landmarks. Five patients with arthritis of the knee and extra-articular femoral and/or tibial deformity, retained hardware, or intramedullary (IM) implants underwent total knee arthroplasty using a computer navigation system. The navigation system obviated the need for an IM guide, and the normal mechanical axis of the patients was restored. Extensive dissection for hardware removal or osteotomy was not necessary in these patients. In these 5 cases, a navigation system proved to be an effective tool for restoration of limb alignment in the presence of significant extra-articular deformities and/or IM hardware. Thus, it provides an alternative approach to the traditional IM instrumentation for treating these patients in an effective manner

Quality Improvement of Diabetic Care at a Resident Clinic

Our objective was to develop a quality improvement project on diabetes mellitus at our internal medicine residency clinic. Residents developed projects aimed at improving an aspect of diabetic care. Continuity of care, achievement of clinical targets, no-show rates, patient knowledge of diabetes, and preventive care were evaluated. Our data was obtained with a questionnaire and a retrospective review of medical records. A different provider was scheduled about every 1.78 visit. The no-show rate was 25.4%. About half of patients identified goal hgbA1c and BPs, and 35% and 60% achieved their hgbA1c and SBP goals respectively. Nearly all of the charts planned for screening exams. We concluded that our clinic needs to improve diabetes education, reaching clinical targets, continuity of care and no-shows. Incorporating a QI project into the clinic with one disease such as diabetes is an efficient way to include practice based learning into an internal medicine residency’s curriculum

Weight-based vs. BSA-based Fluid Resuscitation Predictions in Pediatric Burn Patients

Fluid resuscitation for pediatric burns uses formulas that estimate fluid requirements based on weight, and/or body surface area (BSA) along with percent total burn surface area (TBSA). Adult studies have shown that these formulas can cause fluid overload in obese patients and increase risk of complications. These findings have not been validated in pediatric patients. This study provides a retrospective review conducted with 110 children (≤ 18 years old) admitted to an ABA-verified urban pediatric burn center from October 2008 to May 2020. Patients were resuscitated with the weight-based Parkland formula, and had fluids titrated to urine output every two hours. BSA-based Galveston and BSA-incorporated Cincinnati formula resuscitation predictions were also calculated. Complications were collected throughout the hospital stay. Patients were classified into CDC-defined weight groups based on percentile ranges. We found that predicted resuscitation volumes increased as CDC percentile increased for all three formulas (p=0.033, 0.092, 0.038), however there were no significant differences between overweight and obese children. Total fluid administered was higher as CDC percentile increased (p=0.023). However, overweight children received more total fluid than obese children. The difference between total fluids given and Galveston predicted resuscitation volumes were significant across all groups (p=0.042); however, the difference using the Parkland and Cincinnati formulas were not statistically significant. There were more children in the normal weight group who developed complications compared to other groups, but these findings were not significant. Overall, the Parkland formula tended to underpredict fluid needs in the underweight, normal, and overweight children, and it overpredicted fluid needs for the obese. Further research is needed to determine the value of weight-based vs BSA-based or incorporated formulas in terms of their risk of complications

Xeroform gauze is superior to silver sulfadiazine cream in promoting zone of stasis healing for mixed-depth scald burns in children

TITLE: Xeroform gauze is superior to silver sulfadiazine cream in promoting zone of stasis healing for mixed-depth scald burns in children INTRODUCTION: Silver sulfadiazine 1% cream changed daily was historically the mainstay initial treatment at our pediatric burn center. Over recent years, we transitioned to using closed Xeroform dressings (3% bismuth tribromophenate in petrolatum-soaked gauze) in the initial care of partial thickness burns. The purpose of this study is to compare patient outcomes between Xeroform only and silver sulfadiazine. METHODS: A retrospective chart review was conducted of patients age 5 years with mixed-depth scald injuries between: 1) years 2004-2008, when silver sulfadiazine was standard care, and 2) 2015-2018, when Xeroform only had become standard. Data collected included demographics, burn total body surface area (TBSA), length of hospital stay, and necessity, size, and timing of skin grafting. RESULTS: Three hundred forty-seven patients were included, of whom 200 were treated with silver sulfadiazine and 147 with Xeroform only. Burn TBSA and rates of skin grafting were similar between the groups; however, the mean area of the skin graft was significantly smaller for the Xeroform group (147cm2 vs. 336cm2, p=0.027). Of note, time from injury to grafting was significantly longer in the Xeroform group (24d vs. 9.9d, p=0.002), with a larger proportion of these patients returning for outpatient grafting. CONCLUSION: These results suggest that initial treatment with a closed dressing of Xeroform gauze may promote zone of stasis healing resulting in smaller graft sizes compared to silver sulfadiazine cream. Fewer dressing changes combined with later skin grafting could allow burn wounds to demarcate and heal more effectively, benefiting both graft and donor sites

Helping Continuing Care Retirement Communities Determine the Best Level of Care for Each Patient

Background: Continuing Care Retirement Communities (CCRCs) consists of various neighborhoods and care spaces for senior adults. The neighborhoods are organized and residents are housed based on “levels of care” (LOC), Independent, Assisted, and Nursing. During scheduled interprofessional meetings, the CCRC leadership has the critical task of understanding the residents’ needs and assigning them to the appropriate LOC. Currently, the process of completing this task lacks the necessary structure, which engenders challenges in making recommendations in a systematic way. This project seeks to offer the CCRC interprofessional team a structured approach to determine which LOC and its resources would best serve each individual resident. Methods: User-centered research began at a CCRC, The Hill at Whitemarsh, in Summer 2019. Interviews with administration, employees, and patients were organized. Meetings with employees were observed. Preliminary LOC checklists and questionnaires were tested at The Hill’s biweekly LOC meetings and a final tool was produced. Results: The administration felt the lack of structure during the biweekly LOC meetings led to inefficient discussion and decision-making. The meetings also did not take into consideration patient individuality. The Interprofessional care team preferred a list of questions that was arranged with the intent to guide discussion, with enough freedom to consider the uniqueness of each elder. Conclusion: This tool provides the CCRC Level of Care team with a format to guide their meetings and carefully consider the needs of each resident. Based on feedback, the administration believes this tool improves the efficiency and structure of their discussions. One limitation of this project is time. To improve the validity, the project can be extended to accurately determine the success of the tool for meeting efficiency and patient satisfaction

Using a Checklist to Guide Discussion in Level of Care Meetings at the Hill at Whitemarsh

Background: The Hill at Whitemarsh is a retirement facility in Lafayette Hill, Pennsylvania which has three bundles of services for residents termed levels of care (LOC). Meeting are held routinely by medical and administrative staff to determine if an individual needs to move to a different LOC to improve her/his quality of life and safety. These meetings require integration of medical, functional, cognitive, social, and subjective factors often requiring input from several staff members. In this project, we seek a checklist for staff members at the Hill to use at the LOC meetings to ensure important points of discussion for a patient are not missed. Methods: We began our research by interviewing the Hill staff including the CEO, director of nursing, social worker, director of recreational therapy, nurses, and nursing assistants. Next, we generated several iterations of the checklist. Then, we implemented the checklist at the Hill in several level of care meetings, and the responses of the staff were recorded. Results: We identified a project at the Hill, interviewed key personnel, iterated, and implemented our design. Although staff admitted that the checklist captured important points of discussion for each patient, it was not thought to improve the decision-making process because decisions were often made without all the information included in the checklist. Conclusions: In this project we found a need to improve the LOC meeting by making a tool to integrate complex impressions from multiple people; however, our solution did not adequately capture the flexibility needed in LOC meetings. A future tool would quantify both the important factors and how important they are in deciding

Animal bite infections.

Animal bites have become alarmingly common and may represent a quiet epidemic. It is estimated that between 1 and 3.5 million animal bites occur annually in the United States. The highest incidence has consistently been in 5-to-14-year-old schoolchildren, who have greater contact with animals, especially house pets, on a daily basis. This article discusses the epidemiology, microbiology, clinical findings and management of animal bites infections

Malignant external otitis and mastoiditis associated with an IgG4 subclass deficiency in a child.

We have presented the first child in Delaware with malignant external otitis associated with IgG4 deficiency. Our patient needed three courses of intravenous antibiotics and twice required mastoidectomy, but has recovered completely following the restoration of the natural barrier between the internal and external ear, using a fascial graft from the large temporalis muscle. Some hearing deficit remains

Recurrent/persistent pneumonia in a 3 1/2-year-old-girl due to acquired immune deficiency syndrome.

The following is the report of the first case of a Delaware born child who developed AIDS, born from a mother who was not in a high risk camp

Germbuster Brainteaser: A Novel Education Tool

As part of the Pediatric Infectious Diseases elective at the Alfred I. duPont Institute, pediatric residents from the Medical Center of Delaware and the Thomas Jefferson Medical College are encouraged to contribute original, educational material to our Germbusters newsletters. We thought readers of the Delaware Medical Journal would enjoy seeing one of the more innovative resident contributions