Osteomyelitis

Using the electronic medical records system at each site, we searched the following ICD-9-CM codes to identify possible visits for hypoglycemia: 250.3 (diabetes with other coma), 250.8 (diabetes with other specified manifestations) 251.0 (hypoglycemic coma), 251.1 (other specified hypoglycemia), 251.2 (hypoglycemia, unspecified), 270.3 (leucine-induced hypoglycemia), 775.0 (hypoglycemia in an infant born to a diabetic mother), 775.6 (neonatal hypoglycemia), and 962.3 (poisoning by insulins and antidiabetic agents).
Given the diversity of potential ICD-9-CM codes, we searched this broad range of codes and in all diagnosis fields (up to ten listed) in an attempt to capture all possible ED hypoglycemia visits. For admitted patients, we examined only ED-based codes, to avoid inclusion of incident hypoglycemia that occurred during inpatient hospitalization. In cases where multiple candidate codes were present, we recorded only the first-listed code. The exception to this was for the more ambiguous codes 250.3 and 250.8, for which we preferentially recorded any of the other candidate codes if present. We based this strategy on detailed examination of the ICD-9-CM coding manual [9 ], review of the experience from previously reported approaches [10 (link)-14 (link)], and discussion with coding experts.
The code 250.8 may be used for other specific diabetes-associated complications in addition to hypoglycemia, including: 259.8 (secondary diabetic glycogenosis), 272.7 (diabetic lipidosis), 707.xx (ulcers of the lower extremity), 709.3 (Oppenheim-Urbach syndrome), and 730.0–730.2, 731.8 (osteomyelitis). Based on discussion with coding experts, we determined that 681.xx (cellulitis of fingers/toes), 682.xx (other cellulitis), and 686.9x (local skin infection) may also be utilized as a co-diagnoses for 250.8, although not specifically mentioned in the manual. We prospectively proposed the coding algorithm displayed in Figure 1 and validated its accuracy through chart review.
We identified all ED visits with candidate ICD-9-CM codes between July 1, 2005 and June 30, 2006 at each site, and obtained written ED charts. For patients with multiple ED visits during the data collection period, we requested only the first visit to avoid overrepresentation by certain patients. Trained research staff abstracted all charts using a standardized form, and the research group met weekly to discuss data collection and resolve abstraction issues. Additionally, two reviewers independently abstracted 10% of charts to evaluate inter-rater agreement in data collection. To enhance the reliability of our chart review, we abstracted only charts with complete ED triage assessment, nursing notes, and emergency physician notes and considered all other charts incomplete.

In addition to identifying a cause list and mapping this cause list across various revisions of the ICD, the largest impediment to comparability is the presence of a different set of GCs in each ICD revision. To more fully understand the problem of garbage codes, we created a typology of these codes that distinguishes four types of GCs. This typology has been developed taking into consideration the following: the likelihood that a condition can be an underlying cause of death; the need for codes that provide a location for unspecified or ambiguous causes of death; and the need for codes that represent causes that are not underlying but intermediate or final events in the chain leading to death. Four categories were identified:
1. Causes that cannot or should not be considered as underlying causes of death. These are codes that are included in the ICD because of its use for classifying health service encounters but that do not signify underlying cause of death. Examples of this type of GC are all the codes under chapter 18 of ICD-10 or R codes. This category also includes two special cases in the cardiovascular area: essential primary hypertension and atherosclerosis. Essential primary hypertension is included in the ICD to classify clinical encounters, but for most physicians, it should be considered a risk factor for cardiovascular disease and not the underlying cause. This distinction between what is a risk factor and what is an underlying cause is somewhat arbitrary but necessary to enhance comparability across revisions. Finally, we included in this category a number of causes that are described as the long-term sequelae of disease, such as G82, paraplegia and tetraplegia, or O94, sequelae of complication of pregnancy, childbirth, and the puerperium. In these cases, for public health purposes, it is more useful to assign these deaths to the underlying cause despite the long time lag between disease and death.
2. Intermediate causes of death such as heart failure, septicemia, peritonitis, osteomyelitis, or pulmonary embolism. These are clearly defined clinical entities, but each has an underlying cause that would have precipitated the chain of events leading to death. Physicians who have not been adequately trained in the principles of the ICD underlying cause of death often use these causes on death certificates.
3. Immediate causes of death that are the final steps in a disease pathway leading to death. Examples of this include disseminated intravascular coagulation or defibrination syndrome (D65). The pathway to death includes the final immediate cause, an intermediate cause, and the underlying cause that triggered the chain of events. Cardiac arrest (I46) and respiratory failure, not elsewhere classified (J96), are other examples.
4. Unspecified causes within a larger cause grouping. For many diseases, such as neoplasms, a code is included within the grouping for an unspecified site. This is an illustration of a GC that is not important for assessing aggregate deaths from neoplasms from all sites but is important when assessing site-specific death rates. Another important example is the injury category in which some injuries are coded to unspecified factors or intent.
Table 2 provides a listing of the number of each type of GC that we identified related to our 56-cause list. The largest category of GCs is type 1. Assessment of the number of GCs, especially in category 4, is a function of the level of detail in the final cause list that is being developed.

Clinical, demographic, diagnostic, and prescription data were manually collected from electronic medical records and stored in a password-protected data collection sheet. Privacy was guaranteed by assigning to each patient a unique, anonymized study code, and not collecting personally identifying data.
The investigations were carried out following the rules of the Declaration of Helsinki of 1975 (https://www.wma.net/what-we-do/medical-ethics/declaration-of-helsinki/), revised in 2013. The ELECTRIC study (ostEomyeLitis and sEptiC arThritis tReatment In Children) was approved by the Ethical Committee of Padua University Hospital (n.0065692). Due to the nature of the study (observational retrospective), no informed consent was required from the patients' parents or legal guardians.

All consecutive patients aged 3 months to 18 years old with a diagnosis of acute OM and/or SA according to the International Classification of Diseases, 9th Revision, Clinical Modification code were evaluated for inclusion. A case was defined by diagnosis of OM or SA on imaging, preferably magnetic resonance imaging (MRI, gold standard) for OM, or in alternative computed tomography (CT scan), Tc99 bone scintiscan, PET-TC scan, or ultrasound (US)/MRI for SA. Long bones were considered the typical site of infection for OM. The hips were considered a high-risk site for both OM and SA. Exclusion criteria were diagnosis of immunodeficiency or hemoglobinopathy or chronic granulomatous disease, immunosuppressive therapy, concomitant systemic bacterial infection, and ongoing antibiotic treatment on admission. Patients with complicated infections, not fully vaccinated, and/or with incomplete follow-up were excluded, as well as those with chronic osteomyelitis and Brodie's abscess.
The population was divided into two main groups, OM and SA. Each group was further divided into three groups: pre-intervention, post-intervention not following the guidelines (no GL), and post-intervention group with adherence to the guidelines (GL).
The following variables, selected a priori, were evaluated: age, sex, weight, fever, vaccination status, white blood cells, and neutrophil count, CRP, erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) at onset, IV and oral antibiotic treatment with duration, diagnosis and imaging type, typical vs. atypical site, results of blood, pus, synovial fluid cultures, MRSA colonization status, Quantiferon results, PVL test positivity, treatment failure (defined as treatment escalation to broad spectrum antibiotics and/or need for surgery) and relapse at six months of follow-up. PCR tests for identification of K. kingae or other pathogens in case of culture-negative infections were not performed, as not included as standard of care at our facility.

The institutional review board (IRB) approval has been obtained from the ethics committee of Xi’an Hong Hui hospital. A written informed consent has been gotten from patients or their families. All methods were carried out based on relevant guidelines and regulations. Fifty cases with tibial segmental defects were collected from June 2011 to June 2019 in our institution. Twenty-nine patients were treated using PBT technique (the PBT group) while 21 cases were managed by DBT technique (the DBT group). Each patient was selected according to the following inclusion and exclusion criteria. The inclusion criteria encompassed the following points: (1) Patients over 18 years; (2) Patients were diagnosed with bone defects in the middle third of the tibia; (3) Patients with tibial defects longer than five centimeters; (4) Patients were treated by Ilizarov annular bone transport technique; (5) Patients with complete medical records. The exclusion criteria included five points: (1) Patients younger than 18 years; (2) Patients with major comorbidities and were unable to tolerate anaesthesia or surgery; (3) Patients were managed by other methods, not bone transport; (4) Patients with final amputation; (5) Patients with incomplete medical records or lost patients.
Based on each medical record in our institution, basic data of all patients were collected, including age, sex, bone loss, etiology, Gustilo-Anderson (GA) classification, body mass index (BMI) and follow-up duration. Acute trauma and osteomyelitis were the main causes for tibial segmental defects. Initial open injuries were classified according to GA classification. Bone loss was measured after radical debridement by the picture archiving and communication system (PACS). VAS of each patient was assessed at one month after operation. Time in frame and external fixation index were calculated when the transport fixator was removed. At the last follow-up, the Hospital for Special Surgery (HSS) score was used to evaluate knee functions, including pain (30 points), function (22 points), range of motion (18 points), muscle strength (10 points), knee flexion deformity (10 points), and stability (10 points)^{14 (link)}. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to assess ankle functions^{15 (link)}. The total score is on a scale of 0 to 100, with 100 indicating no symptoms or impairments. For HSS and AOFAS scores, a higher score indicates better joint functions. Postoperative complications were recorded and divided into “problems” (treated nonoperatively), “obstacles” (treated operatively) or “sequelae” based on the principles proposed by Paley^{16 (link)}. The clinical effects and functional recovery scales of the two groups were evaluated by trained and experienced surgeons.