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A Novel Approach to Avoid Baclofen Withdrawal When Faced With Infected Baclofen Pumps.
Hwang, RS, Sukul, V, Collison, C, Prusik, J, Pilitsis, JG
Neuromodulation : journal of the International Neuromodulation Society. 2019;(7):834-838
Abstract
BACKGROUND Intrathecal (IT) Baclofen is beneficial for spasticity, but if pumps become infected necessitating removal, baclofen withdrawal is difficult to manage and life-threatening. Furthermore there is no consistency between dosing and severity of withdrawal. Case reports detail full baclofen withdrawal at dosages of 260 μg/day. OBJECTIVE To demonstrate that in patients on stable IT baclofen for prolonged periods, externalizing a patient's original IT pump is a safe, effective way to wean IT doses. METHODS Here, we describe a technique of continuing IT baclofen when urgent pump removal is needed. Specifically, we remove the infected pump. Then using a new or existing lumbar drain based on extent of infection, we reconnect the pump after cleaning with betadine and administer therapy externally during IT weaning. RESULTS Hundred forty seven baclofen pumps were implanted or replaced within four years. Infections occurred in seven patients. We utilized this technique in five of seven patients. Mean IT dose at time of explant was 400.5 ± 285.3 μg/day. We titrated the dose by 20-50% per day based on clinical response over a mean of 6.2 ± 1.3 days. The catheter was removed at bedside once weaning was complete. No patients had any signs of withdrawal, excluding minimal spasticity increases while optimizing oral treatment. CONCLUSION Here, we show preliminary evidence that an externalized IT pump is an effective means of weaning IT baclofen when infection of the pump occurs. This treatment strategy warrants further investigation, but appears to be a safe and effective. CONFLICT OF INTEREST Dr. Pilitsis is a consultant for Medtronic, Boston Scientific, Nevro, Jazz Pharmaceuticals, Neurobridge Therapeutics, and Abbott and receives grant support from Medtronic, Boston Scientific, Abbott, Nevro, Jazz Pharmaceuticals, GE Global Research and NIH 1R01CA166379. She is medical advisor for Centauri and Karuna and has stock equity. Dr. Sukul receives consultant fees from Medtronic. Julia Prusik receives grant support from Jazz Pharmaceuticals.
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Effect on total microbial load and community composition with two vs six-week topical Cadexomer Iodine for treating chronic biofilm infections in diabetic foot ulcers.
Malone, M, Schwarzer, S, Radzieta, M, Jeffries, T, Walsh, A, Dickson, HG, Micali, G, Jensen, SO
International wound journal. 2019;(6):1477-1486
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Abstract
This study compares two vs six weeks of topical antimicrobial therapy with Cadexomer Iodine in patients with diabetic foot ulcers (DFUs) complicated by chronic biofilm infections. Patients with non-healing DFUs with suspected chronic biofilm infections were eligible for enrolment. Patients were randomised to receive either two or six weeks of treatment with topical Cadexomer Iodine. Tissue biopsies from the ulcers were obtained pre-and-post treatment and underwent DNA sequencing and real-time quantitative polymerase chain reaction (PCR) to determine the total microbial load, community composition, and diversity of bacteria. Scanning electron microscopy confirmed biofilm in all 18 ulcers with suspected chronic biofilm infections. Cadexomer Iodine resulted in 14 of 18 (78%) samples achieving a mean 0.5 log10 reduction in microbial load. Regardless of treatment duration, there was no statistical difference in the reduction of total microbial loads. No difference in the rate of wound healing in the two groups was seen at 6 weeks. Cadexomer Iodine reduces the total microbial load in DFUs with chronic biofilm infections and affects microbial community composition and diversity. All ulcers in both groups showed an initial reduction in wound size with application of Cadexomer Iodine, which might reflect its effect on biofilms.
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Identification and Management of Perioperative Anaphylaxis.
Volcheck, GW, Hepner, DL
The journal of allergy and clinical immunology. In practice. 2019;(7):2134-2142
Abstract
The authors present a case of a patient with multiple episodes of perioperative anaphylaxis. The incidence and the most common causes of perioperative anaphylaxis are reviewed. The most common causes can vary by country and the type of perioperative medications used. The unique environment and the multiple medications and substances used in the anesthesia and surgical setting that make a definitive diagnosis challenging are outlined. A systematic strategy to recognize the reaction, identify the culprit, and direct future management are demonstrated. Management of the patient experiencing perioperative anaphylaxis requires close collaboration between the anesthesia, surgical, and allergy teams.
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Incorporating Precesarean Vaginal Preparation Into Standard of Care for Obstetrics.
Duffy, CR, DʼAlton, ME, Han, YW, Goldenberg, RL, Gyamfi-Bannerman, C
Obstetrics and gynecology. 2019;(4):707-711
Abstract
Postoperative infections remain a serious concern after cesarean delivery, the most common major surgical procedure in the United States. Multiple strategies have been proposed to combat this problem, including the addition of azithromycin to the standard preoperative antibiotic prophylaxis. However, as obstetricians, we have failed to uniformly adopt precesarean vaginal preparation despite convincing evidence from randomized controlled trials that this technique reduces postoperative rates of endometritis by more than 50%. This reduction is similar to that seen with the addition of azithromycin. Vaginal preparation with povidone-iodine solution may target the same genital pathogens as azithromycin, which are commonly implicated in endometritis, a polymicrobial infection that may be under-addressed by our current antiseptic techniques. A recent review of maternal-fetal medicine fellows' practices at the time of cesarean delivery and recent publications on precesarean vaginal cleansing suggest that this practice has not yet gained hold in the United States.
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A retrospective study of antibacterial iodine-coated implants for postoperative infection.
Shirai, T, Tsuchiya, H, Terauchi, R, Tsuchida, S, Mizoshiri, N, Mori, Y, Takeuchi, A, Hayashi, K, Yamamoto, N, Ikoma, K, et al
Medicine. 2019;(45):e17932
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Abstract
Postoperative infection is one of the most serious complications in orthopedic surgery. We have developed and use iodine-coated implants to prevent and treat postoperative infection in compromised hosts. This study evaluated outcomes using iodine-coated implants for postoperative infections.We treated 72 postoperative infected patients using iodine-coated implants. Of these, 38 were males and 34 were females, with a mean age of 59.3 years. The mean follow-up period was 5.6 years. The patients included 23 with an infection following total knee arthroplasty, 20 following total hip arthroplasty, 11 following osteosynthesis, 11 following spine surgery, 6 following tumor excision, and 1 following osteotomy. Of these, 37 underwent single-stage surgery and 35 underwent staged revision surgery. We performed staged surgery in any case with active infection. The survival of iodine-coated implants was determined using Kaplan-Meier analysis. White blood cell (WBC) and C-reactive protein (CRP) levels were measured pre- and postoperatively. To evaluate the systemic effects of iodine, serum thyroid hormone levels were examined.Five patients underwent re-revision surgery. In 3 patients, periprosthetic infection recurred at an average of 18 months after surgery. The reinfection rate was 4.2%. These patients recovered following reimplantation of iodine-coated prostheses. No patients required amputation. The survival rate of iodine-coated implants was 91%. There were no signs of infection at the latest follow-up. The median WBC level was nearly in the normal range, and CRP levels returned to normal within 4 weeks after surgery. No abnormalities of thyroid gland function were detected.Iodine-coated titanium implants can be very effective in the treatment of postoperative infections. An iodine coating can be safely applied to infected regions.
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Randomized clinical trial of single skin sterilization with a povidone-iodine applicator versus conventional skin sterilization in abdominal surgery.
Kambara, Y, Hiramatsu, K, Kato, T, Sibata, Y, Yoshihara, M, Aoba, T, Aiba, T, Yamaguchi, N, Kamiya, T
BJS open. 2019;(3):282-287
Abstract
BACKGROUND The efficacy of widely used povidone-iodine applicators for skin sterilization in abdominal surgery is unclear. The aim of this trial was to evaluate whether sterilization with a povidone-iodine applicator was not inferior to a conventional sterilization method. METHODS Patients undergoing elective abdominal surgery were assigned randomly to receive single sterilization with the applicator or conventional sterilization. The primary endpoint was wound infection rate. Secondary endpoints were rate of organ/space surgical-site infection (SSI), adverse effects of povidone-iodine, amount of povidone-iodine used and total cost of sterilization. RESULTS Of 498 patients eligible for the study between April 2015 and September 2017, 240 were assigned and analysed in the applicator group and 246 in the conventional group. Wound infection was detected in 16 patients (6·7 per cent) in the applicator group and 16 (6·5 per cent) in the conventional group (absolute difference 0·0016 (90 per cent c.i. -0·037 to 0·040) per cent; P = 0·014 for non-inferiority). There was no difference between the groups in the organ/space SSI rate (11 patients (4·6 per cent) in the applicator group and 16 (6·5 per cent) in the conventional group. Both the amount of povidone-iodine used and the total cost of sterilization were higher in the conventional group than in the applicator group (median 76·7 versus 25 ml respectively, P < 0·001; median €7·0 versus €6·4, P < 0·001). Skin irritation was detected in three patients in the conventional group. CONCLUSION In abdominal surgery, this povidone-iodine applicator was not inferior to conventional sterilization in terms of the wound infection rate, and it is cheaper. Registration number: UMIN000018231 (http://www.umin.ac.jp/ctr/).
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An Overview of Skin Antiseptics Used in Orthopaedic Surgery Procedures.
Letzelter, J, Hill, JB, Hacquebord, J
The Journal of the American Academy of Orthopaedic Surgeons. 2019;(16):599-606
Abstract
Surgical site infections (SSIs) in orthopaedics are a common complication, with more than half a million SSIs occurring in the United States each year. SSIs can carry a notable burden for patients and physicians alike. Skin antiseptic solution plays an important role in preventing SSI. Many studies have looked at different skin antiseptic solution in preventing SSIs. Different surgical preps can decrease bacterial loads at surgical sites in varying degrees. Yet, the amount of bacterial load does not always correlate with a lower risk of infection.Chlorhexidine, for example, has been shown to cause markedly less SSIs compared with povidone-iodine prep in general surgery cases. Whereas chlorhexidine with alcohol may best work in the forefoot, iodine povacrylex with alcohol is equivalent in the spine. Conversely, joint arthroplasty SSIs were markedly decreased with a combination of preps. Because of all these differences, understanding which prep solution to use and when can be invaluable to the orthopaedic surgeons.
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Topical Drugs in Nursing Mothers.
Anderson, PO
Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine. 2018;(1):5-7
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Treatment of Infected Wounds in the Age of Antimicrobial Resistance: Contemporary Alternative Therapeutic Options.
Karinja, SJ, Spector, JA
Plastic and reconstructive surgery. 2018;(4):1082-1092
Abstract
As antibiotic resistance increases and antimicrobial options diminish, there is a pressing need to identify and develop new and/or alternative (non-antimicrobial-based) wound therapies. The authors describe the implications of antibiotic resistance on their current wound treatment paradigms and review the most promising non-antibiotic-based antimicrobial agents currently in research and development, with a focus on preclinical and human studies of therapeutic bacteriophages, antimicrobial peptides, cold plasma treatment, photodynamic therapy, honey, silver, and bioelectric dressings.
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Infection following strabismus surgery.
Schnall, BM, Feingold, A
Current opinion in ophthalmology. 2018;(5):407-411
Abstract
PURPOSE OF REVIEW To provide the most up to date information on postoperative infection associated with strabismus surgery, its diagnosis, management, and prevention. RECENT FINDINGS Recent studies show that topical povidone-iodide is effective in reducing the bacteria colony count at the incision site and preventing contamination during strabismus surgery. Repeating povidone-iodide 5% drops after surgical preparation and presoaking the sutures in povidone-iodide reduces bacterial contamination further. There is no single postoperative day that would be best to detect the onset of a postoperative infection. Infection can follow a normal postoperative visit. SUMMARY Infection continues to be a concerning complication of strabismus surgery. Early detection and treatment is needed to obtain a good outcome. Patients and their families should be educated on the early signs and symptoms of postoperative infection and to contact their ophthalmologist if any occur.