Using Telemedicine to Diagnose Surgical Site Infections in Low- and Middle-Income Countries: Systematic Review

Expanding the Evidence on the Safety and Efficiency of 2-Way Text Messaging-Based Telehealth for Voluntary Medical Male Circumcision Follow-up Compared With In-Person Reviews: Randomized Controlled Trial in Rural and Urban South Africa

BACKGROUND

There is a dearth of high-quality evidence from digital health interventions in routine program settings in low- and middle-income countries. We previously conducted a randomized controlled trial (RCT) in Zimbabwe, demonstrating that 2-way texting (2wT) was safe and effective for follow-up after adult voluntary medical male circumcision (VMMC).

OBJECTIVE

To demonstrate the replicability of 2wT, we conducted a larger RCT in both urban and rural VMMC settings in South Africa to determine whether 2wT improves adverse event (AE) ascertainment and, therefore, the quality of follow-up after VMMC while reducing health care workers' workload.

METHODS

A prospective, unblinded, noninferiority RCT was conducted among adult participants who underwent VMMC with cell phones randomized in a 1:1 ratio between 2wT and control (routine care) in North West and Gauteng provinces. The 2wT participants responded to a daily SMS text message with in-person follow-up only if desired or an AE was suspected. The control group was requested to make in-person visits on postoperative days 2 and 7 as per national VMMC guidelines. All participants were asked to return on postoperative day 14 for study-specific review. Safety (cumulative AEs ≤day 14 visit) and workload (number of in-person follow-up visits) were compared. Differences in cumulative AEs were calculated between groups. Noninferiority was prespecified with a margin of -0.25%. The Manning score method was used to calculate 95% CIs.

RESULTS

The study was conducted between June 7, 2021, and February 21, 2022. In total, 1084 men were enrolled (2wT: n=547, 50.5%, control: n=537, 49.5%), with near-equal proportions of rural and urban participants. Cumulative AEs were identified in 2.3% (95% CI 1.3-4.1) of 2wT participants and 1.0% (95% CI 0.4-2.3) of control participants, demonstrating noninferiority (1-sided 95% CI -0.09 to ∞). Among the 2wT participants, 11 AEs (9 moderate and 2 severe) were identified, compared with 5 AEs (all moderate) among the control participants-a nonsignificant difference in AE rates (P=.13). The 2wT participants attended 0.22 visits, and the control participants attended 1.34 visits-a significant reduction in follow-up visit workload (P<.001). The 2wT approach reduced unnecessary postoperative visits by 84.8%. Daily response rates ranged from 86% on day 3 to 74% on day 13. Among the 2wT participants, 94% (514/547) responded to ≥1 daily SMS text messages over 13 days.

CONCLUSIONS

Across rural and urban contexts in South Africa, 2wT was noninferior to routine in-person visits for AE ascertainment, demonstrating 2wT safety. The 2wT approach also significantly reduced the follow-up visit workload, improving efficiency. These results strongly suggest that 2wT provides quality VMMC follow-up and should be adopted at scale. Adaptation of the 2wT telehealth approach to other acute follow-up care contexts could extend these gains beyond VMMC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04327271; https://www.clinicaltrials.gov/ct2/show/NCT04327271.

Readiness for implementation of novel digital health interventions for postoperative monitoring: a systematic review and clinical innovation network analysis

An increasing number of digital health interventions (DHIs) for remote postoperative monitoring have been developed and evaluated. This systematic review identifies DHIs for postoperative monitoring and evaluates their readiness for implementation into routine health care. Studies were defined according to idea, development, exploration, assessment, and long-term follow-up (IDEAL) stages of innovation. A novel clinical innovation network analysis used coauthorship and citations to examine collaboration and progression within the field. 126 DHIs were identified, with 101 (80%) being early stage innovations (IDEAL stage 1 and 2a). None of the DHIs identified had large-scale routine implementation. There is little evidence of collaboration, and there are clear omissions in the evaluation of feasibility, accessibility, and the health-care impact. Use of DHIs for postoperative monitoring remains at an early stage of innovation, with promising but generally low-quality supporting evidence. Comprehensive evaluation within high-quality, large-scale trials and real-world data are required to definitively establish readiness for routine implementation.

Image-based digital post-discharge surveillance in England: measuring patient enrolment, engagement, clinician response times, surgical site infection, and carbon footprint

BACKGROUND

Surgical site infections (SSIs) can have a significant impact on patients, their families and healthcare providers. With shortening inpatient periods, the post-discharge element of surveillance is becoming increasingly important. Proactive surveillance, including digital wound images using patient smartphones, may be an efficient alternative to traditional methods for collecting post-discharge surveillance (PDS).

AIM

To determine success in patient enrolment and engagement including reasons for non-response, the time for clinicians to respond to patients, SSI rates, and carbon emissions when conducting PDS using patient smartphones.

METHODS

An evaluation was undertaken for a one-month period (June 2022) in two adult cardiac surgery services which routinely used patient smartphones for PDS, using the secure Islacare (Isla) system.

FINDINGS

The initial patient response rate for Isla was 87.3%, and the majority of patients (73%) remained engaged throughout the 30-day period. There was no significant difference in age, gender, operation type or distance to hospital between Isla responders or non-responders, or if the hospital provided a photo at discharge or not. Patients using Isla had a shorter post-discharge stay (P = 0.03), although this was not attributed to the platform. Patients not owning a smartphone and a technical issue were the main barriers to participation. Overall, nine SSIs were recorded, eight through the Isla surveillance and one through a hospital transfer readmission. The carbon emission associated with the SSI ranged from 5 to 2615 kg CO2e.

CONCLUSION

In a real-world setting, using patient smartphones is an effective method to collect PDS, including wound images.

Components of Existing National Surgical Site Infection Surveillance Programs Based on a Case Series of Low- and Middle-Income Countries: Building Blocks for Success and Opportunities for Improvement

Background: Surgical site infection (SSI) surveillance programs are recommended to be included in national infection prevention and control (IPC) programs, yet few exist in low- or middle-income countries (LMICs). Our goal was to identify components of surveillance in existing programs that could be replicated elsewhere and note opportunities for improvement to build awareness for other countries in the process of developing their own national surgical site infection surveillance (nSSIS) programs. Methods: We administered a survey built upon the U.S. Centers for Disease Control and Prevention's framework for surveillance system evaluation to systematically deconstruct logistical infrastructure of existing nSSIS programs in LMICs. Qualitative analyses of survey responses by thematic elements were used to identify successful surveillance system components and recognize opportunities for improvement. Results: Three respondents representing countries in Europe and Central Asia, sub-Saharan Africa, and South Asia designated as upper middle-income, lower middle-income, and low-income responded. Notable strengths described by respondents included use of local paper documentation, staggered data entry, and limited data entry fields. Opportunities for improvement included outpatient data capture, broader coverage of healthcare centers within a nation, improved audit processes, defining the denominator of number of surgical procedures, and presence of an easily accessible, free SSI surveillance training program for healthcare workers. Conclusions: Outpatient post-surgery surveillance, national coverage of healthcare facilities, and training on how to take local SSI surveillance data and integrate it within a broader nSSIS program at the national level remain areas of opportunities for countries looking to implement a nSSIS program.

Harmonized procedure coding system for surgical procedures and analysis of surgical site infections (SSI) of five European countries

BACKGROUND

The use of routine data will be essential in future healthcare research. Therefore, harmonizing procedure codes is a first step to facilitate this approach as international research endeavour. An example for the use of routine data on a large scope is the investigation of surgical site infections (SSI). Ongoing surveillance programs evaluate the incidence of SSI on a national or regional basis in a limited number of procedures. For example, analyses by the European Centre for Disease Prevention (ECDC) nine procedures and provides a mapping table for two coding systems (ICD9, National Healthcare Safety Network [NHSN]). However, indicator procedures do not reliably depict overall SSI epidemiology. Thus, a broader analysis of all surgical procedures is desirable. The need for manual translation of country specific procedures codes, however, impedes the use of routine data for such an analysis on an international level. This project aimed to create an international surgical procedure coding systems allowing for automatic translation and categorization of procedures documented in country-specific codes.

METHODS

We included the existing surgical procedure coding systems of five European countries (France, Germany, Italy, Spain, and the United Kingdom [UK]). In an iterative process, country specific codes were grouped in ever more categories until each group represented a coherent unit based on method of surgery, interventions performed, extent and site of the surgical procedure. Next two ID specialist (arbitrated by a third in case of disagreement) independently assigned country-specific codes to the resulting categories. Finally, specialist from each surgical discipline reviewed these assignments for their respective field.

RESULTS

A total number of 153 SALT (Staphylococcus aureus Surgical Site Infection Multinational Epidemiology in Europe) codes from 10 specialties were assigned to 15,432 surgical procedures. Almost 4000 (26%) procedure codes from the SALT coding system were classified as orthopaedic and trauma surgeries, thus this medical field represents the most diverse group within the SALT coding system, followed by abdominal surgical procedures with 2390 (15%) procedure codes.

CONCLUSION

Mapping country-specific codes procedure codes onto to a limited number of coherent, internally and externally validated codes proofed feasible. The resultant SALT procedure code gives the opportunity to harmonize big data sets containing surgical procedures from international centres, and may simplify comparability of future international trial findings.

TRIAL REGISTRATION

The study was registered at clinicaltrials.gov under NCT03353532 on November 27^th, 2017.

Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving?

Background

The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.

Methods

We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.

Results

The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.

Conclusions

There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06630-w.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial

Background

The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)–led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings.

Objective

This trial assesses whether CHW’s use of a mobile health (mHealth)–facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district.

Methods

A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care.

Results

The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively).

Conclusions

Home-based post–c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy.

Trial Registration

ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399

An exploratory study comparing the quality of contraceptive counseling provided via telemedicine versus in-person visits

OBJECTIVE

Telemedicine for contraceptive services is purported to improve contraceptive access, yet few studies assess the quality of contraceptive counseling provided remotely. We assessed the quality of contraceptive counseling during telemedicine and office visits.

STUDY DESIGN

We conducted a cross-sectional study at Cleveland Clinic Women's Health Institute to compare contraceptive counseling quality between telemedicine (synchronous video) and office visits. We identified eligible patients through ambulatory encounters with primary contraceptive management or counseling ICD-10 codes. Respondents completed a survey assessing demographics, quality of contraceptive counseling, contraceptive method choice, affinity for technology, and attitudes toward telemedicine. We used the validated Interpersonal Quality of Family Planning (IQFP) scale to assess counseling quality. We used the Wilcoxon rank sum test, Pearson's chi-square test and Fisher's exact test to compare baseline characteristics.

RESULTS

Of all eligible patients, 110/380 (29%) completed the survey. Of those who were successfully contacted by phone or mail, 110/201 (55%) completed the survey. The IQFP scores were 'high quality' for 28/52 (54%) of telemedicine-visit respondents versus 37/58 (64%) of office-visit respondents (p = 0.29). The birth control pill was the most popular method, chosen by 27/52 (52%) of telemedicine-visit respondents and 24/58 (41%) of office-visit respondents (p = 0.27). Telemedicine respondents identified ease of communication and less scheduling difficulty as factors that promote telemedicine use. Office-visit respondents identified privacy and communication concerns as factors that deter telemedicine use.

CONCLUSION

When patients self-select the encounter type, their assessment of the quality of contraceptive counseling among telemedicine and office visits is similar, with no statistically significant differences in contraceptive method chosen. Results from this single-center study support the integration of telemedicine in contraceptive service provision.

IMPLICATIONS

The quality of contraceptive counseling is similar among telemedicine and office visits. Telemedicine visits for contraceptive counseling should be routinely offered, and existing services should be expanded.

Development stage of novel digital health interventions for postoperative monitoring: protocol of a systematic review

Introduction

The postoperative period represents a time where patients are at a high-risk of morbidity, which warrants effective surveillance. While digital health interventions (DHIs) for postoperative monitoring are promising, a coordinated, standardized and evidence-based approach regarding their implementation and evaluation is currently lacking. This study aimed to identify DHIs implemented and evaluated in postoperative care to highlight research gaps and assess the readiness for routine implementation.

Methods

A systematic review will be conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies describing the implementation and evaluation of DHIs for postoperative monitoring published since 2000 (PROSPERO ID: CRD42021264289). This will encompass the Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science and ClinicalTrials.gov databases, and manual search of bibliographies for relevant studies and gray literature. Methodological reporting quality will be evaluated using the Idea, Development, Exploration, Assessment and Long-term Follow-up (IDEAL) reporting guideline relevant to the IDEAL stage of the study, and risk of bias will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Data will be extracted according to the WHO framework for monitoring and evaluating DHIs, and a narrative synthesis will be performed.

Discussion

This review will assess the readiness for implementation of DHIs for routine postoperative monitoring and will include studies describing best practice from service changes already being piloted out of necessity during the COVID-19 pandemic. This will identify interventions with sufficient evidence to progress to the next IDEAL stage, and promote standardized and comprehensive evaluation of future implementational studies.

Implementation and Experiences of Telehealth: Balancing Policies With Practice in Countries of South Asia, Kuwait, and the European Union

This viewpoint summarizes the discussion that occurred during the “Translating Policy to Practice in Telehealth–Lessons from Global Implementation Experiences” panel that was held virtually at Telemedicon2020, December 18-20, 2020. This panel brought together policy and implementation experts from some countries of South Asia, Kuwait, and the European Union to share their experiences in the development and implementation of telehealth standards and of the scale up of telehealth interventions within health systems. Several common themes arose from the discussion, including the significant role of people; encouragement by respective government policymakers; addressing concerns, particularly related to privacy, confidentiality, and security; and capacity building of human resources. These are discussed in turn, along with the future directions identified by the panelists, which emphasized the need for active encouragement toward the adoption and diffusion of digital health in general and of telehealth in particular. All stakeholders, ranging from governmental policymakers to common citizens, need to come together to build trusting partnerships to realize the advantages offered by telehealth.

Association Between Neighborhood-Level Social Determinants of Health and Access to Pediatric Appendicitis Care

IMPORTANCE

Presenting with complicated appendicitis, which is associated with higher rates of complications and readmissions compared with simple appendicitis, may indicate delayed access to care. Although both patient-level and neighborhood-level social determinants of health are associated with access to care, little is known about the association between neighborhood factors and access to acute pediatric surgical care.

OBJECTIVE

To examine the association between neighborhood factors and the odds of presenting with complicated appendicitis and unplanned postdischarge health care use.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of patients aged 18 years or younger diagnosed with appendicitis was conducted. Discharge data from October 1, 2015, to September 30, 2018, were obtained from the Pediatric Health Information System Database and linked to the Child Opportunity Index (COI) 2.0 Database. Data analysis was conducted from January 1 through July 1, 2021.

EXPOSURES

The COI, a composite score of zip code neighborhood opportunity level information, divided into quintiles ranging from very low to very high opportunity.

MAIN OUTCOMES AND MEASURES

Based on COI level, the main outcome was the odds of presenting with complicated appendicitis, which was defined using the Agency for Healthcare Research and Quality-specified International Statistical Classification of Diseases, 10th Edition, Clinical Modification codes. The secondary outcome was the odds of unplanned postdischarge health care use (emergency department visits and/or readmissions) for patients with simple and with complicated appendicitis.

RESULTS

A total of 67 489 patients (mean [SD] age, 10.5 [3.9] years) had appendicitis, with 31 223 cases (46.3%) being complicated. A total of 1699 patients (2.5%) were Asian, 24 234 (35.9%) were Hispanic, 4447 (6.6%) were non-Hispanic Black, and 29 234 (43.3%) were non-Hispanic White; 40 549 patients (60.1%) were male; and 32 343 (47.9%) were publicly insured. Patients living in very low-COI neighborhoods had 28% higher odds of presenting with complicated appendicitis (odds ratio, 1.28; 95% CI, 1.20-1.35) compared with those in very high-COI neighborhoods. There was no significant association between COI level and unplanned postdischarge health care use (very high COI, 20.8%; very low COI, 19.1%).

CONCLUSIONS AND RELEVANCE

In this cohort study, children from lower-COI neighborhoods had increased odds of presenting with complicated appendicitis compared with those from higher-COI neighborhoods, even after controlling for patient-level social determinants of health factors. These findings may inform policies and programs that seek to improve access to pediatric surgical care.

Feasibility and diagnostic accuracy of Telephone Administration of an adapted wound heaLing QuestiONnaire for assessment for surgical site infection following abdominal surgery in low and middle-income countries (TALON): protocol for a study within a trial (SWAT)

Background

Surgical site infection is the most common complication of abdominal surgery, with a global impact on patients and health systems. There are no tools to identify wound infection that are validated for use in the global setting. The overall aim of the study described in this protocol is to evaluate the feasibility and validity of a remote, digital pathway for wound assessment after hospital discharge for patients in low- and middle-income countries (LMICs).

Methods

A multi-centre, international, mixed-methods study within a trial, conducted in two stages (TALON-1 and TALON-2). TALON-1 will adapt and translate a universal reporter outcome measurement tool (Bluebelle Wound Healing Questionnaire, WHQ) for use in global surgical research (SWAT store registration: 126) that can be delivered over the telephone. TALON-2 will evaluate a remote wound assessment pathway (including trial retention) and validate the diagnostic accuracy of this adapted WHQ through a prospective cohort study embedded within two global surgery trials. Embedded community engagement and involvement activities will be used to optimise delivery and ensure culturally attuned conduct. TALON-1 and TALON-2 are designed and will be reported in accordance with best practice guidelines for adaptation and validation of outcome measures, and diagnostic test accuracy studies.

Discussion

Methods to identify surgical site infection after surgery for patients after hospital discharge have the potential to improve patient safety, trial retention, and research efficiency. TALON represents a large, pragmatic, international study co-designed and delivered with LMIC researchers and patients to address an important research gap in global surgery trial methodology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05398-z.

Parental Post-operative Telephone Follow-Up After Paediatric Day Case Surgery

BACKGROUND

Paediatric day case surgeries (DCSs) are associated with minimal complications therefore the post-operative follow-up visit usually serves to calm anxious parents and is replaceable with a phone call. This study examines the safety and reliability of post-operative telephone assessment by caregivers and its acceptability to them.

METHODS

Parents of DCS patients over a 9-month period were recruited for telephone follow-up on third post-operative day for wound assessment. The remote reports were compared with the finding during the in-person visit on fourth post-operative day to determine the reliability of parents' observation. The parents' acceptance of telephone follow-up was also studied.

RESULTS

The parents of 112 children who had groin surgeries (84%), repair of umbilical hernias (4.5%) and excision of soft tissue masses (11.6%) were recruited. The M:F ratio was 10.2:1. The median age at surgery was 64 months (IQR 43.0-96.8) and median waiting time for surgery was 11.5 months (IQR 3.0-28.8). Most caregivers were mothers (83%) and had a minimum of secondary education (86.6%). The telephone and clinic assessments were matched in 98 of 101 assessed patients. Telephone follow-up would have sufficed for 104 (92.9%) patients and correctly identified those who needed clinic visits. Majority of parents found telephone follow-up acceptable in lieu of clinic visit but some preferred to be given a phone number to initiate the call if necessary.

CONCLUSION

Telephone call is safe, feasible and acceptable for follow-up after paediatric DCS. A guided parents' assessment of the wound is reliable for determining those who need hospital visit.

Diagnosing surgical site infections using telemedicine: A Systematic Review

BACKGROUND

Surgical site infections (SSI) are preventable post-operative complications. With the increase in use of telehealth modalities, there is a need to assess if telehealth modalities are safe for assessment of SSI.

AIM

This review aims to assess the accuracy of using telemedicine in the diagnosis of SSI in post-surgical adult patients as compared to in-person assessments.

METHODS

A comprehensive search on 6 databases (PubMed, MEDLINE, Embase, Web of Science, Scopus and CENTRAL) was performed from inception to 1 December 2020. Data was extracted to determine accuracy, feasibility, acceptability, and usability of using telemedicine to detect SSIs. The primary outcome of this review was to review the diagnostic accuracy of telemedicine to diagnose SSIs as compared to direct, in-person assessment. Methodological quality was evaluated using the MINORS criteria.

RESULTS

Six studies met inclusion criteria. Results were summarized qualitatively. The overall methodological quality of the studies was moderate based on the MINORS score. Four studies utilized telephone surveillance, whilst two utilized mobile applications. Telemedicine modalities were able to accurately diagnose 66 SSIs, where an additional 15 were found on direct clinical review. The diagnostic accuracy across the studies ranged from 69.5 to 100%. Between 82.5 and 100% of patients were able to be contacted through these telemedicine modalities.

CONCLUSIONS

Telemedicine modalities are a feasible option for post-operative follow-up, especially in the identification of SSIs. As technology becomes more affordable and widely available, future applications of telemedicine are limitless. However, further research is still required to ensure that telemedicine is a safe and effective tool.

Telemedicine for Musculoskeletal Rehabilitation and Orthopedic Postoperative Rehabilitation

Telehealth visits result in high-quality care, with high patient and provider satisfaction. Strong evidence suggests that virtual physical therapy is noninferior to conventional face-to-face physical therapy for a variety of musculoskeletal disorders. Postoperative telerehabilitation has a strong positive effect on clinical outcomes, and the increased intensity telerehabilitation programs offer is a promising option for patients. Studies demonstrate effective virtual postoperative management. The novel coronavirus disease 2019 pandemic has led to improved reimbursement for telehealth visits and accelerated widespread implementation of telemedicine. This article establishes experience and evidence-based practice guidelines for conducting telemedicine visits, with emphasis on the virtual physical examination.

Trapezoid Advancement Flaps for the Treatment of Severe Upper Extremity Burn Contractures Limiting the Risk of Recurrence

INTRODUCTION

Severe postburn contractures can lead to partial or total loss of function of the limbs, with devastating socioeconomic and psychosocial impact on the individual, especially in low- and middle-income countries. We present a surgical technique for the treatment of severe burn contractures with the purpose of limiting recurrence of the contracture after surgery, which was developed based on the observation that in most burn contractures, one side of a contracture has unburnt, soft, and pliable healthy skin. By advancing this skin as a flap over the joint crease, a bridge of healthy tissue is interposed. We postulate that the pliable skin, together with the fact that secondary wound contracture progresses away from the joint in the skin-grafted areas adjacent to the flap and not over a mobile joint, promote healing, prevent skin graft breakdown, and limit recurrence of the contracture in the long term.

METHODS

We retrospectively analyzed data of all patients who have undergone surgery for severe burn contractures of elbow and axilla by means of our technique on the MV Africa Mercy between January 2013 and February 2014.

RESULTS

In 27 patients (19 female, 8 male) with a mean age of 16.4 years, shoulder range of motion improved significantly from preoperative 111.0° to postoperative 149.4° of abduction-adduction. The elbow range of motion improved from preoperative 76.6° to postoperative 108.6° of flexion-extension, with a significant reduction in the residual elbow contracture from 60.5° preoperatively to 18.5° postoperatively. The average follow-up was 3 months (range, 1.5-7 months).

CONCLUSIONS

We conclude that this relatively simple and safe technique limits the risk for early postoperative healing complications and recurrence of the contractures in the long term.

The Recent Progress and Applications of Digital Technologies in Healthcare: A Review

BACKGROUND

The implementation of medical digital technologies can provide better accessibility and flexibility of healthcare for the public. It encompasses the availability of open information on the health, treatment, complications, and recent progress on biomedical research. At present, even in low-income countries, diagnostic and medical services are becoming more accessible and available. However, many issues related to digital health technologies remain unmet, including the reliability, safety, testing, and ethical aspects.

PURPOSE

The aim of the review is to discuss and analyze the recent progress on the application of big data, artificial intelligence, telemedicine, block-chain platforms, smart devices in healthcare, and medical education. Basic Design. The publication search was carried out using Google Scholar, PubMed, Web of Sciences, Medline, Wiley Online Library, and CrossRef databases. The review highlights the applications of artificial intelligence, "big data," telemedicine and block-chain technologies, and smart devices (internet of things) for solving the real problems in healthcare and medical education. Major Findings. We identified 252 papers related to the digital health area. However, the number of papers discussed in the review was limited to 152 due to the exclusion criteria. The literature search demonstrated that digital health technologies became highly sought due to recent pandemics, including COVID-19. The disastrous dissemination of COVID-19 through all continents triggered the need for fast and effective solutions to localize, manage, and treat the viral infection. In this regard, the use of telemedicine and other e-health technologies might help to lessen the pressure on healthcare systems. Summary. Digital platforms can help optimize diagnosis, consulting, and treatment of patients. However, due to the lack of official regulations and recommendations, the stakeholders, including private and governmental organizations, are facing the problem with adequate validation and approbation of novel digital health technologies. In this regard, proper scientific research is required before a digital product is deployed for the healthcare sector.

Genetic relationship between bacteria isolated from intraoperative air samples and surgical site infections at a major teaching hospital in Ghana

BACKGROUND

In low- and middle-income countries (LMICs) the rate of surgical site infections (SSI) is high, leading to negative patient outcomes and excess healthcare costs. A causal relationship between airborne bacteria in the operating room and SSI has not been established, at a molecular or genetic level. We studied the relationship between intraoperative airborne bacteria and bacteria causing SSI in an LMIC.

METHODS

Active air sampling using a portable impactor was performed during clean or clean-contaminated elective surgical procedures. Active patient follow-up consisting of phone calls and clinical examinations was performed 3, 14 and 30 days after surgery. Bacterial isolates recovered from SSI and air samples were compared by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) identification, ribotyping, whole genome sequencing (WGS), and metagenomic analysis.

RESULTS

Of 128 included patients, 116 (91%) completed follow-up and 11 (9%) developed SSI. Known pathogenic bacteria were isolated from intraoperative air samples in all cases with SSI. A match between air and SSI isolates was found by MALDI-TOF in eight cases. Matching ribotypes were found in six cases and in one case both WGS and metagenomic analysis showed identity between air- and SSI-isolates.

CONCLUSION

The study showed high levels of intraoperative airborne bacteria, an SSI-rate of 9% and a genetic link between intraoperative airborne bacteria and bacteria isolated from SSIs. This indicates the need for awareness of intraoperative air quality in LMICs.