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Phoenix, AZ, United States

Wukich D.K.,University of Pittsburgh | Crim B.E.,University of Pittsburgh | Frykberg R.G.,Phoenix VA Healthcare System | Rosario B.L.,University of Pittsburgh
Journal of Bone and Joint Surgery - American Volume

Background: This prospective study was designed to evaluate the frequency of surgical site infection in patients treated with foot and ankle surgery. Our hypothesis was that patients with complications of diabetes are at increased risk for surgical site infection compared with patients without diabetes and patients with diabetes who do not have diabetic complications. Another goal was to compare the association of neuropathy with surgical site infection in both nondiabetic and diabetic patients. Methods: Two thousand and sixty consecutive surgical cases were evaluated. Group 1 included nondiabetic patients without neuropathy, Group 2 included nondiabetic patients with neuropathy, Group 3 included patients with diabetes but no diabetic complications, and Group 4 included patients with diabetes who had at least one complication of diabetes. Results: The surgical site infection rate in this study was 3.1%. Patients with complicated diabetes had a 7.25-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy and a 3.72-fold increased risk compared with patients with uncomplicated diabetes. Patients with complicated diabetes had a nonsignificant 1.54-fold higher rate of surgical site infection compared with nondiabetic patients with neuropathy. Nondiabetic patients with neuropathy had a significant 4.72-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy. Despite this, nondiabetic patients with neuropathy did not have a significantly higher rate of surgical site infection than patients with uncomplicated diabetes, and the frequency of surgical site infection in the group with uncomplicated diabetes was not significantly different from that in the nondiabetic patients without neuropathy. Multivariable logistic regression analysis demonstrated that peripheral neuropathy and a hemoglobin A1c of ≥8% were independently associated with surgical site infection. Conclusions: Complicated diabetes increases the risk of surgical site infection after foot and ankle surgery. Patients who had diabetes without complications did not have a greater risk of surgical site infection compared with nondiabetic patients without neuropathy. The presence of neuropathy increases the risk of surgical site infection even in patients without diabetes. Poor long-term glycemic control is also associated with an increased risk of surgical site infection. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2014 by the Journal of Bone and Joint Surgery, Incorporated. Source

Deierhoi R.J.,The Surgical Center | Deierhoi R.J.,University of Alabama at Birmingham | Dawes L.G.,Phoenix VA Healthcare System | Vick C.,University of Alabama at Birmingham | And 2 more authors.
Journal of the American College of Surgeons

Background The Surgical Care Improvement Program endorses mandatory compliance with approved intravenous prophylactic antibiotics; however, oral antibiotics are optional. We hypothesized that surgical site infection (SSI) rates may vary depending on the choice of antibiotic prophylaxis. Study Design A retrospective cohort study of elective colorectal procedures using Veterans Affairs Surgical Quality Improvement Program (VASQIP) and SSI outcomes data was linked to the Office of Informatics and Analytics (OIA) and Pharmacy Benefits Management (PBM) antibiotic data from 2005 to 2009. Surgical site infection rates by type of IV antibiotic agent alone (IV) or in combination with oral antibiotic (IV + OA) were determined. Generalized estimating equations were used to examine the association between type of antibiotic prophylaxis and SSI for the entire cohort and stratified by use of oral antibiotics. Results After 5,750 elective colorectal procedures, 709 SSIs (12.3%) developed within 30 days. Oral antibiotic + IV (n = 2,426) had a lower SSI rate than IV alone (n = 3,324) (6.3% vs 16.7%, p < 0.0001). There was a significant difference in the SSI rate based on type of preoperative IV antibiotic given (p ≤ 0.0001). Generalized estimating equations adjusting for significant covariates of age, body mass index, procedure work relative value units, and operation duration demonstrated an independent protective effect of oral antibiotics (odds ratio [OR] 0.37, 95% CI 0.29 to 0.46), as well as increased rates of SSI associated with ampicillin/sulbactam (OR 2.21, 95% CI 1.37 to 3.56) and second generation cephalosporins (cefoxitin, OR 2.50, 95% CI 1.83 to 3.42; cefotetan, OR 2.70, 95% CI 1.72 to 4.22) when compared with first generation cephalosporin/ metronidazole. Conclusions The choice of IV antibiotic was related to the SSI rate; however, oral antibiotics were associated with reduced SSI rate for every antibiotic class © 2013 by the American College of Surgeons. Source

Holmberg M.,Phoenix VA Healthcare System
Pharmacy Times

The FDA has approved AstraZeneca and Bristol-Myers Squibb Company's Farxiga (dapagliflozin) as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. The approval carries the limitation that Farxiga is not to be used for treatment of type 1 diabetes mellitus or diabetic ketoacidosis. More than 24 million Americans are affected by diabetes, and more than 90% of all new diabetes cases diagnosed are type 2. Farxiga has already been approved in 40 countries outside the United States, where it is marketed as Forxiga. Source

Kent M.,Phoenix VA Healthcare System | Davis M.C.,Arizona State University | Stark S.L.,Arizona State University | Stewart L.A.,Southwest Behavioral Health Services
Journal of Traumatic Stress

This preliminary randomized trial examined the effect of a resilience-oriented intervention for posttraumatic stress disorder (PTSD) versus a waitlist control on anxiety and depressive symptoms, positive emotional health, and cognitive performance in 39 veterans with a variety of traumatic exposures. From pre- to posttreatment, the intervention but not the control group showed improvements that were large in magnitude for affective symptoms and positive emotional health (ds = 0.73-1.18), moderate in magnitude for memory (ds = 0.50-0.54), and small-to-moderate in magnitude for executive function (ds = 0.30-0.35). Findings suggest that treatment explicitly targeting resilience resources (e.g., positive emotional engagement, social connectedness) may provide broad benefits, including alleviation of anxiety and depressive symptoms and improved positive emotional and cognitive function. © 2011 International Society for Traumatic Stress Studies. Source

Frykberg R.G.,Phoenix VA Healthcare System | Marston W.A.,University of North Carolina at Chapel Hill | Cardinal M.,Novartis
Advances in Skin and Wound Care

OBJECTIVE: Diabetic foot ulcers (DFUs) are frequently recalcitrant and at risk for infection, which may lead to lower-extremity amputation or bone resection. Reporting the incidence of amputations/bone resections may shed light on the relationship of ulcer healing to serious complications. This study aimed to evaluate the incidence of amputations/bone resections in a randomized controlled trial comparing human fibroblast-derived dermal substitute plus conventional care with conventional care alone for the treatment of DFUs. DESIGN: Ulcer-related amputation/bone resection datawere extracted from data on all adverse events reported for the intent-to-treat population (N = 314), and amputations were categorized by type: Below the knee, Syme, Chopart, transmetatarsal, ray, toe, or partial toe. Data were analyzed retrospectively for the incidence of amputation/bone resection by treatment. SETTING: Randomized controlled trial. PATIENTS: Patients with full-thickness DFUs greater than 6 weeks' duration. INTERVENTIONS: Standard wound care plus human fibroblast-derived dermal substitute versus standard wound care alone. MAIN RESULTS: The incidence of amputation/bone resection in the study was 8.9% (28/314) overall, 5.5% (9/163) for patients receiving human fibroblast-derived dermal substitute, and 12.6% (19/151) for patients receiving conventional care (P = .031). Of the 28 cases of amputation/bone resection, 27 were preceded by ulcer-related infection. CONCLUSION: There were significantly fewer amputations/bone resections in patients who received human fibroblast-derived dermal substitute versus conventional care, likely related to the lower incidence of infection adverse events observed in the human fibroblast-derived dermal substitute treatment group. Source

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