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Hamid SA, Graetz E, Schneider E, Gibbs KE. A Cross-Sectional Analysis of Pediatric Necrotizing Soft Tissue Infection Cases and Racial Disparities From the 2016 to 2020 National Inpatient Sample. J Surg Res 2024; 297:136-143. [PMID: 38518580 DOI: 10.1016/j.jss.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/05/2024] [Accepted: 02/16/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The incidence, treatment, and outcomes of necrotizing soft tissue infections (NSTIs) and associated racial disparities have been described in adults, but research in the pediatric population is limited. The purpose of this study is to provide a nationally representative characterization of pediatric NSTI and determine the presence of any racial disparities. METHODS The National Inpatient Sample was analyzed from 2016 through 2020. Patients aged less than 20 y with a diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene (based on International Classification of Diseases, Tenth Revision, Clinical Modification codes) were included for analysis. RESULTS A total of 355 patients were identified. Black and Hispanic patients accounted for the most admissions in 2016 and 2018, respectively (P = 0.024). Compared to White patients, more Black patients were insured by Medicaid (P = 0.037) and were in the first zip code-based income quartile (P = 0.005). The leading infection overall was necrotizing fasciitis and most patients (81.7%) underwent a surgical procedure by the first calendar day after admission. Although the proportion of Black patients undergoing subcutaneous tissue and fascia excisions was more than that of White patients (P = 0.005), there were no significant differences by race in the time to first procedure, the total number of procedures, or number of postoperative complications. Our amputation and mortality rates were low and unreportable, but there were no differences by race. CONCLUSIONS NSTI is rare in the pediatric population and mortality is low. Black patients are disproportionately diagnosed, but these disparities do not extend to disease treatment or outcomes.
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Affiliation(s)
- Safraz A Hamid
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Elena Graetz
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Eric Schneider
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Karen E Gibbs
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Afzal H, Dawson E, Fonseca R, Canas M, Diaz L, Filippis AD, Bochicchio KM, Bochicchio GV. Does Negative Pressure Wound Therapy Impact the Outcome for Patients With Necrotizing Soft Tissue Infection Infected With Anaerobic Bacteria? Surg Infect (Larchmt) 2024; 25:179-184. [PMID: 38381953 DOI: 10.1089/sur.2023.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
Background: A notable improvement in the treatment of necrotizing soft tissue infections (NSTIs) is the development of negative pressure wound therapy (NPWT). Clinicians are still debating whether NPWT is as successful as conventional wet-to-dry dressings at removing bacteria. Recent research has revealed potential oxygen deprivation effects of NPWT in underlying wound tissues, although clinical trials regarding the effects of reduced oxygen on anaerobic bacterial soft tissue infections remain noticeably lacking. Hypothesis: We hypothesized that NPWT-treated patients with NSTIs who were solely infected by anaerobic bacteria would have worse outcomes than those who were infected with other bacterial species. Patients and Methods: Our study included a retrospective examination of the 2008-2022 period of our Acute and Critical Care Surgery database. Patients who had been identified as having necrotizing fasciitis, Fournier gangrene, or gas gangrene and who had their conditions verified by positive wound cultures acquired during the initial debridement and subsequently received NPWT made up the study cohort. Comorbidities, surgical techniques, and clinical results were all covered by the data. Based on their wound infections, patients were divided into two groups: those with exclusively anaerobic NSTIs and those with different bacterial groups (such as polymicrobial and aerobic). Multiple regression, χ2 analysis, and analysis of variance (ANOVA) were among the analytical methods used. Results: One hundred twelve patients with NSTI who had received NPWT comprised the study cohort. Sixteen of these patients (14.3%) had NSTIs that were exclusively anaerobic, whereas the remaining 96 (85.7%) had NSTIs that were mixed aerobic, facultative, or polymicrobial. Between the two groups, there was no difference in the initial wound size. Patients with anaerobic NSTI who underwent NPWT showed a statistically significant increase in the number of debridements (3 [interquartile range {IQR},1-9] vs. 2 [IQR, 1-4]; p = 0.012) and an increased 100-day re-admission rate (37.5% vs. 12.5%; p = 0.012) when compared with patients with non-anaerobic NSTI. The 100-day re-admission rate increased three-fold in NPWT-treated anaerobic NSTIs, according to a logistic regression analysis (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.06-12.44; p = 0.04). Conclusions: In contrast to patients with other bacterial strains, our data show that patients with NSTI treated with NPWT who only have anaerobic bacterial infections have a larger number of debridements and are much more likely to require re-admission within 100 days. We call for additional prospective studies to be conducted to identify additional risk factors and consider alternate treatment options for individuals with exclusively anaerobic NSTIs in light of these findings.
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Affiliation(s)
- Hussain Afzal
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Erin Dawson
- Trauma and Surgical Critical Care, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Ricardo Fonseca
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Melissa Canas
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Leonardo Diaz
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Kelly M Bochicchio
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Grant V Bochicchio
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Kircher HL, O'Dell JC, Chollet-Hinton L, Raheel A, Blaser WJ, McCoy CC, Winfield RD, Guidry CA. Assessing Second Debridement Timing and Mortality in Necrotizing Soft Tissue Infections. Am Surg 2024; 90:725-730. [PMID: 37878367 DOI: 10.1177/00031348231209528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
BACKGROUND Patients with necrotizing soft tissue infection undergo an average of 4-5 debridements per hospital admission. Optimal timing for initial debridement is emergent. Second debridement is universally recommended to occur within 24 hours of the first, but no studies have successfully evaluated this time frame. Prior work has suggested that delays in second debridement are associated with increased mortality, and that few patients receive second debridement within 24 hours. METHODS We performed a retrospective cohort study at a single center from 01/01/08 to 09/01/2021. The explanatory variable was whether the subject received second debridement within 24 hours of initial debridement. The primary outcome was in-hospital mortality. Baseline characteristics were collected. Subjects were stratified into 2 groups by time between first and second debridement: <24 and ≥24 hours. Variables were compared using Fisher's exact and Wilcoxon rank-sum tests. RESULTS 77 patients met inclusion criteria. The median overall time to second debridement was 40 hours. 12 subjects received second debridement within 24 hours (15.6%). There was no difference in in-hospital mortality between the <24 (n = 3, 25.0%) and ≥24-hour second debridement groups (n = 4, 6.2%; P = .07). The 2 groups did not differ by secondary outcomes, including total number of debridements, ICU LOS, or wound closure. CONCLUSION No difference in mortality was observed between subjects undergoing second debridement within 24 vs after 24 hours. Only 16% of subjects received second debridement within the recommended 24-hour time interval. Further study is required to identify the optimal timing of second debridement.
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Affiliation(s)
| | - Jacob C O'Dell
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
| | - Lynn Chollet-Hinton
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas, KS, USA
| | - Amani Raheel
- Department of Surgery, University of Missouri-Kansas City, Kansas, MO, USA
| | - Wolf J Blaser
- University of Kansas School of Medicine, Kansas, KS, USA
| | - Cameron C McCoy
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
| | - Robert D Winfield
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
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Suijker J, Pijpe A, Hoogerbrug D, Heymans MW, van Zuijlen PPM, Halm JA, Meij-de Vries A. IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS. Shock 2024; 61:585-591. [PMID: 38315508 DOI: 10.1097/shk.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
ABSTRACT Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.
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Affiliation(s)
| | | | | | - Martijn W Heymans
- Amsterdam, Department of Epidemiology and Data Science, Amsterdam, The Netherlands
| | | | - Jens A Halm
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, The Netherlands
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Stallwood-Hall C, Binu V, Rajendran RK, Hiremath BV. Validating the laboratory risk indicator for necrotizing fasciitis (LRINEC) score: a prospective cohort study in a resource limited setting. ANZ J Surg 2024; 94:457-460. [PMID: 38197526 DOI: 10.1111/ans.18855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Necrotising fasciitis is a rare and fulminant soft tissue infection. Prompt surgical debridement of the involved soft tissues and necrotic fascia is its definitive treatment, with any delay associated with increased mortality. The LRINEC score is a scoring system initially designed to aid in early diagnosis of necrotising fasciitis to facilitate early surgical intervention. This score utilizes common biochemical tests to produce a score of 0-13, stratifying patients into risk categories. METHODS A prospective cohort study was designed including all patients presenting with severe soft tissue infection from June 2011 to January 2014. Exclusion criteria included: less than 15 years or above 90 years, antibiotics within 48 h of presentation or prior debridement of their soft tissue infection. All patients underwent routine blood investigations, required for calculation of the LRINEC score. RESULTS The positive predictive value of the LRINEC score was 95.42%, whilst the negative predictive value was 81.16%. There was a statistically significant correlation between white cell count, serum creatinine, blood glucose level and positive histopathology. The mortality rate for patients with histopathologically-confirmed necrotising fasciitis was 10%. CONCLUSION The LRINEC score is a clinical adjunct to risk stratify patients presenting to the emergency department with soft tissue infections. It utilizes common blood tests commonly to calculate a score, which risk stratifies patients. The use of this scoring system can facilitate better allocation of resources and aids in the decision to transfer patients in rural or regional settings, which are often complicated by being a resource limited environment.
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Affiliation(s)
- Catrin Stallwood-Hall
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Vineet Binu
- Department of Paediatric Surgery, Rajagiri Hospital, Kochi, India
| | | | - Bharati V Hiremath
- Department of General Surgery, M S Ramaiah Medical College, Bangalore, India
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Berger LE, Spoer DL, Huffman SS, Drew E, Greenwalt IT, Fan KL. A case of necrotizing fasciitis of the breast following lumpectomy and oncoplastic closure. Wounds 2024; 36:1-7. [PMID: 38417817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
BACKGROUND NF is a life-threatening soft tissue infection that most commonly occurs in the lower extremity. While presenting symptoms such as erythema, severe pain, sepsis, and wound crepitation are well documented, diagnosis of NF of the breast often is obscured by a low clinical index of suspicion due to its relative rarity as well as by the breast parenchyma that physically separates the underlying fascia and overlying skin. Several risk factors have previously been identified, such as underlying infection, diabetes, advanced age, and immunosuppression. However, the gross morbidity and high mortality associated with NF warrant continued surveillance of contributing factors across any anatomic location. Fifteen cases in the literature document the development of NF following breast surgery. CASE REPORT The authors of this case report aim to expand on the current literature through the presentation of a unique case of NF of the breast following right breast lumpectomy and oncoplastic closure with left reduction mammaplasty in an immunocompromised patient found to have concurrent perforated sigmoid diverticulitis. CONCLUSION This case exemplifies how frequent postoperative surveillance, a low threshold for intervention, and efficient coordination of care are vital to minimizing the morbidity and mortality risks associated with NF of the breast.
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Affiliation(s)
- Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Eleanor Drew
- Division of Critical Care Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Ian T Greenwalt
- Division of Breast Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
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7
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Stemkens R, Cobussen M, de Laat E, Hoefsloot W, van Crevel R, Aarnoutse RE, van Ingen J. Successful addition of topical antibiotic treatment after surgery in treatment-refractory nontuberculous mycobacterial skin and soft tissue infections. Antimicrob Agents Chemother 2023; 67:e0078823. [PMID: 38014946 PMCID: PMC10720519 DOI: 10.1128/aac.00788-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/10/2023] [Indexed: 11/29/2023] Open
Abstract
Treatment of skin and soft tissue infections with nontuberculous mycobacteria sometimes fails despite repeated debridements and long-term systemic antibiotic therapy. These treatment-refractory infections can cause significant morbidity and pose a treatment challenge. Following surgery, we treated three patients with negative pressure wound therapy with the instillation and dwell time of topical antibiotics, in addition to systemic antibiotic treatment. Treatment was successful and well tolerated, except for some local irritation.
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Affiliation(s)
- Ralf Stemkens
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maarten Cobussen
- Department of Internal Medicine and Infectious Diseases, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erik de Laat
- Department of Plastic Surgery, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wouter Hoefsloot
- Department of Pulmonary Diseases, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine and Infectious Diseases, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rob E. Aarnoutse
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jakko van Ingen
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Blanes Hernández R, Rodríguez Pérez M, Fernández Navarro J, Salavert Lletí M. Current approach to skin and soft tissue infections. Thinking about continuity of care. Rev Esp Quimioter 2023; 36 Suppl 1:37-45. [PMID: 37997870 PMCID: PMC10793549 DOI: 10.37201/req/s01.10.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
Skin and soft tissue infections are a common reason for patients seeking inpatient and outpatient medical care. Surgery is an essential part of managing in many episodes. Careful evaluation of antibiotic therapy could help clinicians in early identification to patients with treatment failure and to consider an alternative approach or a new surgical revision in "focus control". With the arrival of new drugs, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life (long-acting lipoglycopeptides such as dalbavancin or oritavancin), which allows weekly administration (or even greater), can reduce hospital admission and length of stay with fewer healthcare resources through outpatient management (home hospitalization or day hospitals). New anionic fluoroquinolones (e.g. delafloxacin), highly active in an acidic medium and with the possibility of switch from the intravenous to the oral route, will also make it possible to achieve these new healthcare goals and promote continuity of care. Therefore, management should rely on a collaborative multidisciplinary group with experience in this infectious syndrome.
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Affiliation(s)
| | | | | | - M Salavert Lletí
- Miguel Salavert Lletí. Unidad de Enfermedades Infecciosas (Infectious Diseases Unit). Área Clínica Médica. Hospital Universitario y Politécnico La Fe, Valencia. Av. Fernando Abril Martorell, nº 106; 46026-Valencia. (Spain). /
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Sandberg JM, Warner HL, Flynn KJ, Sexton SM, Pham HT, Kandler BW, Polgreen PM, Erickson BA. Favorable Outcomes With Early Component Separation, Primary Closure of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) Debridement Wound Defects. Urology 2022; 166:250-256. [PMID: 35584736 DOI: 10.1016/j.urology.2022.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/16/2022] [Accepted: 03/20/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy of early necrotizing soft-tissue infections of the genitalia (NSTIG) component separation, primary wound closure (CSC). We hypothesized that early CSC would be safe, decrease the need for split-thickness skin grafting (STSG) and decrease wound convalescence time. MATERIALS/METHODS Management of consecutive NSTIG patients from a single institution were evaluated. Three cohorts emerged: 1) those managed/closed by a reconstructive urologist (URO) using CSC principles (wide genital tissue mobilization with primary closure, when possible, +/- STSG), 2) those managed/closed by the general surgery/burn service, and 3) those managed conservatively with secondary closure. Total NSTIG anatomic extent (AE) was determined by assessing involvement of the penis, scrotum, perineum and suprapubic region, and ranged from 1 (<50% involvement of one area) to 8 (>50% involvement in all 4 areas). RESULTS Of 84 FG patients meeting study criteria, 48 (57%) were closed primarily and 36 were left to heal by secondary intention. AE was greatest in patients managed by general surgery/burn service (4.5 ± 1.5), followed by URO (2.7 ± 1.8) and secondary intention cases (1.3 ± 0.5). Secondary procedure rates were similar between closure/non-closure cohorts (6.3% v 11%; P = 0.67). STSG use was predicted by wound size (though not time to closure)-specifically with suprapubic and/or penile wounds of >50% involvement. Wound convalescence time decreased by 64% when wounds were closed versus left open, controlling for AE. CONCLUSION Early, same-admission primary closure of stable NSTIG wounds is safe and decreases wound convalescence time by over 60%.
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Affiliation(s)
- Jason M Sandberg
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Hayden L Warner
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Kevin J Flynn
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Shawn M Sexton
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Hanh Td Pham
- University of Iowa, College of Public Health, Department of Biostatistics, Iowa City, IA
| | - Blaize W Kandler
- University of Iowa, College of Public Health, Department of Biostatistics, Iowa City, IA
| | - Phillip M Polgreen
- University of Iowa, Carver College of Medicine, Department of Internal Medicine, Division of Infectious Disease, Iowa City, IA
| | - Bradley A Erickson
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA.
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Lai CS, Liu PY, Lee CH, Ho CH, Chen WL, Lai KL, Su HY, Lin WL, Chung KC, Yang YY, You CW, Chen KT, Mao YC. The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients. PLoS Negl Trop Dis 2022; 16:e0010066. [PMID: 35143522 PMCID: PMC8830662 DOI: 10.1371/journal.pntd.0010066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites. MATERIALS AND METHODS We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue. RESULTS A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries. DISCUSSION AND CONCLUSIONS From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.
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Affiliation(s)
- Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ling Chen
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Psychiatry Department, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hung-Yuan Su
- Department of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
- The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Wen-Loung Lin
- Taichung Wildlife Conservation Group, Taichung, Taiwan
| | - Kuo-Chen Chung
- Division of Traumatology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Yuan Yang
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Core Laboratory of Antibody Generation and Research, Taipei Medical University, Taipei, Taiwan
| | | | | | - Yan-Chiao Mao
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- * E-mail:
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Katabi LJ, Ascha M, Wu-Fienberg Y, Todd Bafus B, Chepla KJ. Characterization and Cost of Intravenous Drug Use-Associated Upper Extremity Infections Requiring Operative Treatment. Plast Reconstr Surg 2022; 149:155e-156e. [PMID: 34846363 DOI: 10.1097/prs.0000000000008619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Mona Ascha
- Division of Plastic Surgery, Department of Surgery, University Hospitals Cleveland Medical Center
| | - Yuewei Wu-Fienberg
- Division of Plastic Surgery, Department of Surgery, University Hospitals Cleveland Medical Center
| | | | - Kyle J Chepla
- Division of Plastic Surgery, Department of Surgery, Metrohealth Medical Center, Cleveland, Ohio
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Ulrych J, Adámková V, Gürlich R, Kolář M, Lahoda-Brodská H, Třeška V, Veverková L. Diagnosis and treatment of surgical skin and soft tissue infections - current status. Rozhl Chir 2022; 101:300-311. [PMID: 36075692 DOI: 10.33699/pis.2022.101.7.300-311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Surgical skin and soft tissue infections (SSTIs) result from microbial invasion of the skin and underlying soft tissues, often requiring surgical treatment. SSTIs encompass a variety of pathological conditions, ranging from frequent simple superficial skin infections with very good outcomes to rare, rapidly progressive necrotizing infections associated with long-lasting morbidity and high mortality. The document summarizes current knowledge of the diagnosis and therapy of these diseases and provides clinicians with current standards of care of these patients based on international guidelines. Additionally, regional specific aspects are also reflected, and thus in all cases, this paper on diagnostic-therapeutic management of individual clinical forms respects the actual clinical practice and epidemiology in the Czech Republic. The document has been prepared based on multidisciplinary consensus of experts from universities all over the Czech Republic.
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Dong CT, Liveris A, Lewis ER, Mascharak S, Chao E, Reddy SH, Teperman SH, McNelis J, Stone ME. Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter. J Trauma Acute Care Surg 2021; 91:241-246. [PMID: 34144567 PMCID: PMC8218982 DOI: 10.1097/ta.0000000000003202] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/06/2021] [Accepted: 02/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase. METHODS A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality. RESULTS A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045). CONCLUSION Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population. LEVEL OF EVIDENCE Epidemiological, level IV.
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McCarty AR, Villarreal ME, Tamer R, Strassels SA, Schubauer KM, Paredes AZ, Santry H, Wisler JR. Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States. J Surg Res 2020; 257:107-117. [PMID: 32818779 DOI: 10.1016/j.jss.2020.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/05/2020] [Accepted: 06/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking. METHODS Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05. RESULTS 1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location. CONCLUSIONS In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.
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Affiliation(s)
- Adara R McCarty
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio.
| | - Michael E Villarreal
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Robert Tamer
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Scott A Strassels
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio; Ohio State University, Wexner Medical Center Center For Surgical Health Assessment, Research And Policy (SHARP), Columbus, Ohio
| | - Kathryn M Schubauer
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Anghela Z Paredes
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Heena Santry
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio; Ohio State University, Wexner Medical Center Center For Surgical Health Assessment, Research And Policy (SHARP), Columbus, Ohio
| | - Jon R Wisler
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
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Aparicio-Sánchez D, Pintor-Tortolero J, Perea-Del Pozo E, Tallón-Aguilar L, Padillo-Ruiz FJ. Association of Negative Pressure Wound Therapy and Dermatotraction for Management of Necrotizing Soft Tissue Infections: A Case Series. Wounds 2020; 32:217-220. [PMID: 33166261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Soft tissue infections (STIs), which include infections of the skin, subcutaneous tissue, fascia, and muscle, encompass a wide variety of heterogeneous pathologies. Treatment of STIs is based on surgical debridement of the affected area. One such treatment, negative pressure wound therapy (NPWT), has improved the management of STIs. OBJECTIVE The purpose of this study is to assess the safety and utility of NPWT in conjunction with dermatotraction in the early stage management of necrotizing STIs. MATERIALS AND METHODS The authors report a retrospective series of 3 cases in which NPWT and dermatotraction (NPWT-D) were used in an attempt to manage necrotizing STI. The NPWT-D device combination was employed to approximate the edges of the wounds. The NPWT device was changed every 2 or 3 days, and dermatotraction tension was adjusted concurrently. RESULTS The NPWT-D device changes ranged from 3 to 4 times for 2 of the 3 patients, as 1 patient passed away secondary to STIs and therefore did not receive complete treatment. The total treatment ranged from 8 to 10 days in the remaining 2 patients. In both cases, complete wound closure was achieved while avoiding skin grafts. After 5 days of therapy in the incomplete treatment case, the wound area was reduced by about half. CONCLUSIONS Based on the experiences herein, NPWT-D may be a safe and useful alternative surgical treatment for the management of necrotizing STIs. In the present cases, NPWT-D improved and shortened the wound healing process, and it achieved a tertiary wound closure, thereby avoiding the need for skin grafts.
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Affiliation(s)
| | | | | | - Luis Tallón-Aguilar
- Emergency Surgery Unit, Virgen del Rocío University Hospital, Seville, Spain
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Kampouri E, Filippidis P, Lhopitallier L, Pham TT, Schuhler C, Toutous Trellu L, Mombelli M, Huttner B. [ Rubor, calor, dolor, tumor : skin and soft tissue infections]. Rev Med Suisse 2020; 16:732-738. [PMID: 32301307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Skin infections are a frequent cause of consultation, yet the diagnosis can be challenging for physicians. Microbiological documentation is rare, and empiric antibiotic regimens should cover the most commonly identified bacteria, i.e. streptococci Staphylococcus aureus. Other pathogens should be considered in case of immunosuppression or certain exposures. Necrotizing fasciitis (NF) is a severe but rare infection. Early surgical management in parallel with antibiotics is the cornerstone of treatment. Despite the high incidence of these infections, little progress has been made in their management and some areas of uncertainty exist, especially regarding the optimal duration of treatment, the prevention of recurrences and the use of polyclonal immunoglobulins for NF. This article reviews the main aspects of diagnosis and treatment of these infections.
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Affiliation(s)
| | | | | | - Truong-Thanh Pham
- Service des maladies infectieuses, HUG, 1211 Genève
- Service de chirurgie orthopédique et traumatologie de l'appareil moteur, HUG, Genève
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Abstract
INTRODUCTION Severe hand infection might cause severe morbidity including stiffness, contracture and possibly amputation. The purpose of this study was to analyse the current epidemiology of adult acute hand infections in a European Hand Surgery Centre and to identify risk factors for secondary surgery. MATERIALS AND METHODS We retrospectively analyzed a cohort of 369 consecutive patients with primary infection of the hand that were admitted to our department and required operative treatment. The following variables were recorded: demographics, medical history, cause and location of infection, laboratory values, cultured microorganisms and reoperation rate. Univariate logistical regression was used to identify variables associated with reoperation and backward selection was applied to identify the final multiple variable model. RESULTS The mean age at the time of operation was 50.5 years (SD 16.1, range 19-91) and 65.6% of patients were male. Sharp cuts or lacerations were the most common cause (29.0%) for hand infections. 81 different species were cultivated and in 47 patients (12.7%), the cultures were positive for more than one organism. Staphylococcus aureus was the most common cultured organism (19.5%). There were relatively few cases of methicillin-resistant Staphylococcus aureus (2.2%). 80 patients (21.7%) needed more than one operation. We identified three risk factors for reoperation in a multivariate analysis: an elevated value of C-reactive protein at the time of admission, involvement of multiple sites and bacterial growth in culture. CONCLUSION The rate of infections with MRSA in this European cohort was lower compared to reports from the USA. Thus, hand surgeons should choose their empiric antibiotic therapy depending on their patient population. The knowledge of risk factors for severe hand infections might help surgeons to identify patients at risk for additional surgery early.
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Affiliation(s)
- A Arsalan-Werner
- Department for Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG-Trauma Center Frankfurt am Main, Academic Hospital of the Johann Wolfgang Goethe-University Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany.
| | - P Grisar
- Department of Trauma and Orthopedic Surgery, BG-Trauma Center Frankfurt am Main, Academic Hospital of the Johann Wolfgang Goethe-University Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany
| | - M Sauerbier
- Department for Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG-Trauma Center Frankfurt am Main, Academic Hospital of the Johann Wolfgang Goethe-University Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany
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Ottofaro T, Lane M, Sciarretta JD. Use of Acellular Urinary Bladder Matrix for Accelerated Soft Tissue Recovery in Complicated Gangrenous Diabetic Foot Infections. Am Surg 2019; 85:e606-e607. [PMID: 31908243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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19
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Howell EC, Keeley JA, Woods AL, Kaji AH, Deane MR, Kim DY, Neville AL. Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection. Am Surg 2019; 85:1175-1178. [PMID: 31657319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.
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20
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Whitaker L, Priest O, Pestana IA. Necrotizing Soft Tissue Infection Complicating Levamisole-Induced Vasculitis. Am Surg 2019; 85:e145-e147. [PMID: 30947791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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21
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Kursten LJM, Visser A, Emous M, Lameijer H. [A patient with a red and swollen leg]. Ned Tijdschr Geneeskd 2018; 162:D2863. [PMID: 30500122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A 66-year-old patient was seen at the emergency department with a skin infection of the left leg, probably erysipelas, which worsened despite the use of antibiotics. The symptoms had started 5 days earlier. The patient was respiratory and haemodynamically stable, he was not clinically ill and had relatively little pain. Lab tests revealed leucocytosis, significantly elevated CRP values and signs of renal and hepatic impairment. The patient was admitted because of suspected necrotising soft tissue infection (NSTI). The diagnosis was confirmed in the operating room. Eventually the lower leg had to be amputated. This case shows that NSTIs do not always have to run a fulminant course. There are also subacute forms, which are only rarely described in the literature. However, in case of subacute skin conditions, NSTIs are low on or even absent from the list of considerations for differential diagnosis, while early diagnosis is necessary for reducing mortality associated with this disease.
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Affiliation(s)
| | | | | | - Heleen Lameijer
- Medisch Centrum Leeuwarden, afd. Spoedeisende Hulp
- Contact: H. Lameijer
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22
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Lauerman MH, Scalea TM, Eglseder WA, Pensy R, Stein DM, Henry S. Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections. Am Surg 2018; 84:1790-1795. [PMID: 30747635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique (P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.
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23
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Malcolm JG, Fox ED, Dente CJ, Patel DC. Retroperitoneal Necrotizing Soft Tissue Infection Presenting as a Concern for Missed Hollow Viscus Injury. Am Surg 2018; 84:465-466. [PMID: 29559069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Friedrich MJ, Schmolders J, Wimmer MD, Strauss AC, Ploeger MM, Wirtz DC, Gravius S, Randau TM. Two-stage knee arthrodesis with a modular intramedullary nail due to septic failure of revision total knee arthroplasty with extensor mechanism deficiency. Knee 2017. [PMID: 28622842 DOI: 10.1016/j.knee.2017.05.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Periprosthetic joint infection is a serious complication and reconstruction after failed revision total knee arthroplasty with significant bone loss and compromised soft-tissues can be challenging. Objective of this study was to assess clinical and functional results, implant survival and infection recurrence rates in patients treated with two-stage arthrodesis after failed revision TKA with extensor mechanism deficiencies due to PJI, and to identify the factors that affect outcomes after surgery. METHODS Thirty seven patients with PJI treated within a two-stage exchange and reimplantation of an arthrodesis nail between 2008 and 2014 were included. Systemic and local risk factors were graded preoperatively according to McPherson et al. All patients were treated according to a structured treatment algorithm. Clinical and functional evaluation was performed using the Oxford Knee Score and the Visual Analogue Scale. RESULTS Thirty two of 37 patients (86.5%) were graded as free of infection. Five patients (13.5%) had recurrent infection after arthrodesis with the need of revision surgery. Mean leg-length discrepancy was 2.2cm. The mean VAS for pain was three, the mean Oxford Knee Score was 38±9. Total implant survival at a 74month follow-up was 74.3% (95% CI: 45.4 to 91.1%), as determined by Kaplan-Meier survival curves. Local McPherson Score, as well as number of revisions was found to be of significant influence to the survival rate. CONCLUSIONS Septic failure of revision knee arthroplasty can be effectively treated with two-stage arthrodesis using a modular intramedullary nail, providing a stable and painless limb with satisfactory functional results and acceptable infection eradication rates.
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Affiliation(s)
- Max J Friedrich
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany.
| | - Jan Schmolders
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Matthias D Wimmer
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Andreas C Strauss
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Milena M Ploeger
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Dieter C Wirtz
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Sascha Gravius
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Thomas M Randau
- University Hospital of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
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Spence LH, Yan H, Moazzez A, Schwed A, Keeley J, Karimzada M, Allison M, Neville A, Plurad D, Putnam B, de Virgilio C, Kim D. Mandatory Operative Re-Exploration after Initial Debridement of Necrotizing Soft Tissue Infections: Is it Mandatory? Am Surg 2017; 83:1117-1121. [PMID: 29391107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Necrotizing soft tissue infections (NSTIs) are aggressive infections requiring prompt diagnosis and extensive surgical debridement. Traditionally, patients undergo mandatory re-exploration to ensure adequacy of source control. The purpose of this study is to determine if re-exploration in the operating room is mandatory for all patients with NSTIs. An eight-year retrospective analysis of adult patients with NSTIs was performed comparing two groups: mandatory operative re-exploration versus operative re-exploration based on clinical examination findings. Outcomes measured included mortality, number of debridements, and length of stay (LOS). Twenty-two per cent of patients underwent a mandatory re-exploration. These patients were older, had a higher incidence of diabetes, and a longer duration of symptoms. There were no significant differences between groups with regard to the physical examination, severity of sepsis, time to repeat debridements, or in-hospital mortality, whereas LOS and the total number of debridements were increased in mandatory re-exploration. Bacteremia and septic shock were predictive of the need for further debridement in patients in the operative re-exploration based on clinical examination findings group. Mandatory re-exploration after initial debridement may not be necessary in all patients with NSTIs. Instead, bedside wound checks may be a safe strategy to determine the need for further operative debridement.
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Affiliation(s)
- Lara H Spence
- Harbor UCLA Medical Center, Torrance, California, USA
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26
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Swickard AL, Sciarretta JD. Complicated Mammoplasty and Breast Salvage with Application of Extracellular Matrix. Am Surg 2017; 83:e243-e244. [PMID: 28738925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Vyas KS, Burns C, Ryan DT, Wong L. Prolonged Allograft Survival in a Patient With Chronic Immunosuppression: A Case Report and Systematic Review. Wounds 2017; 29:159-162. [PMID: 28682290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A 41-year-old man with past medical history of kidney-liver transplantation requiring chronic immunosuppression presented 2 years posttransplant with a necrotizing soft tissue infection of his right thigh. Serial debridement to remove necrotic tissue was performed, and a Matrix HD Allograft Fenestrated (RTI Surgical, Alachua, FL) was applied. At 5-months post grafting, the patient demonstrated fully vascularized and intact skin. Under normal circumstances, a cadaveric allograft sloughs over several weeks and is not usually considered a permanent solution for wound closure. A systematic review of transplant patients on chronic immunosuppression with skin allografts demonstrates the potential for the indefinite survival of an allograft. Necrotizing soft tissue infections can definitively be treated using serial debridement and allograft transplantation in the chronically immunosuppressed.
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Affiliation(s)
- Krishna S Vyas
- Division of Plastic Surgery, University of Kentucky College of Medicine, Lexington, KY; and Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Chase Burns
- Division of Plastic Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Dylan T Ryan
- Division of Plastic Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Lesley Wong
- Division of Plastic Surgery, University of Kentucky College of Medicine, Lexington, KY
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Viltsanyuk OA, Belyayev PV, Viltsanyuk OO, Vernygorodskyi SV. [COMPARATIVE ESTIMATION OF THE APPLICATION EFFICACY FOR THE COMPOSITION, BASING ON NANODISPERSE SILICA, OWING ANTIMICROBIAL PROPERTIES FOR LOCAL TREATMENT OF PURULENT-INFLAMMATORY PROCESSES]. Klin Khir 2017:13-15. [PMID: 30272931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Comparative estimation of the local treatment results for purulent-inflammatory diseases of soft tissues, using standard methods and composition, owing sorption and antimicrobial properties and basing on a nanodispersedsilica, was conducted. The composition application in complex of treatment have promoted more rapid clearance from necrotized tissues and microorganisms, rapid appearance of granulations, the intoxication severity reduction, the phase I of the wound process duration shortening, what have permitted to put secondary sutures on the wound on the 6 – 7th postoperative day, and total duration of the patients’ stationary treatment have reduced by 3.7 days.
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Podpryatov SE, Podpryatov SS, Korchak VP, Salata VV, Ivakha VV, Belousov IO. [IMPACT OF THE TISSUES OEDEMA ON THE RESULT OF SURGICAL TREATMENT OF INFLAMMATION]. Klin Khir 2017:59-61. [PMID: 30273456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Significance of the tissues oedema and its elimination in the course of inflammation and the wound healing was investigated. There were analyzed the results of treatment of 68 patients, suffering inflammatory and necrotic affection of soft tissues, including 65 – a lower one, 3 – an upper. In 47 observations the affection course was an acute, while in 18 – chronic. In 36 patients (control group) a local and systemic antibacterial therapy were conducted, and in accordance to indications – surgical interventions; in 32 (main group) this treatment was added with tight bandaging of the extremity, using elastic bandage. Tight squeezing of tissues with the oedema elimination on background of an adequate antibacterial therapy and surgical sanation of purulent-necrotic focus is accompanied by arrest of infiltrative and exudative stages of an acute inflammation, promotes an active course of the inflammation proliferative stage. While treatment of chronic cutaneous defect, the application of tight squeezing have promoted the granulating shaft resolution, the granulation growth in the wound and its boundary epithelization.
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Chapman T, Ilyas AM. 5 Points on Pyogenic Flexor Tenosynovitis of the Hand. Am J Orthop (Belle Mead NJ) 2017; 46:E207-E212. [PMID: 28666046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
| | - Asif M Ilyas
- Hand and Upper Extremity Surgery, Rothman Institute, and Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA.
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31
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Gerasymchuk PO, Fira DB, Pavlyshyn AV. [APPLICATION OF VACUUM-THERAPY ON STAGES OF SURGICAL TREATMENT OF THE DIABETIC FOOT SYNDROME]. Klin Khir 2017:16-18. [PMID: 30272932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Vacuum therapy of an acute and chronic wounds was used in a complex of surgical treatment of 228 patients, suffering diabetic foot syndrome. There was established a positive local and systemic action of this method for the treatment of the wound defect. Vacuum therapy of the wounds guarantees the wound process clinical course stabilization, improvement of microcirculation, reduction of their microbial soiling, stimulation of regenerative processes, elimination of endogenous intoxication.
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Abstract
In connection with the Asian tsunami disaster on December 26, 2004, a specially equipped Finnair B-757 airplane capable of evacuating badly injured patients was remodeled into an ambulance airplane. The vehicle could take up to 22 severely injured or ill patients and intensive care and limited surgical procedures could be provided to the patients. The plane was manned with a civilian medical team of 37 physicians and nurses. The plane left for Thailand to evacuate the most severely injured Finnish citizens within 10 hours of the evacuation decision. A total of 14 patients including 4 critically ill (two on ventilator) were transferred to Helsinki within 32 hours of takeoff. The medical team included a general, an orthopedic and a plastic surgeon. Soft tissue wounds, some of them severely infected, were the most common injuries, followed by extremity fractures and head injuries. The surgical procedures that were performed midair included wound surgery, to remove necrotic tissue, and external fixation and fasciotomy for a lower extremity fracture. The facilities under these circumstances would allow performing life-saving procedures to maintain airway and breathing, and surgical procedures of the soft tissues, extremity and pelvic fractures. Cavitary surgery would require additional equipment and resources.
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Affiliation(s)
- A Leppäniemi
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland.
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33
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Schmedes A, Petersen KK. [Necrotizing soft tissue infection]. Ugeskr Laeger 2016; 178:V67460. [PMID: 27237924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Gazeau P, Jaffuel S, Garo B, Ansart S, Allano V. A cervical empyema due to Panton-Valentine leukocidin Staphylococcus aureus. Med Mal Infect 2016; 46:326-7. [PMID: 27112520 DOI: 10.1016/j.medmal.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 02/17/2016] [Accepted: 03/17/2016] [Indexed: 11/19/2022]
Affiliation(s)
- P Gazeau
- Service de maladies infectieuses, hôpital de la Cavale-Blanche, BP 824, 29609 Brest cedex, France.
| | - S Jaffuel
- Service de maladies infectieuses, hôpital de la Cavale-Blanche, BP 824, 29609 Brest cedex, France
| | - B Garo
- Service de maladies infectieuses, hôpital de la Cavale-Blanche, BP 824, 29609 Brest cedex, France
| | - S Ansart
- Service de maladies infectieuses, hôpital de la Cavale-Blanche, BP 824, 29609 Brest cedex, France
| | - V Allano
- Service de neurochirurgie, hôpital de la Cavale-Blanche, BP 824, 29609 Brest cedex, France
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35
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Kulasegaran S, Fernando M, Fraser-Jones B, Hammodat H. Perforated sigmoid colon carcinoma within a left inguinal hernia with associated necrotising infection. N Z Med J 2016; 129:93-95. [PMID: 27005879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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36
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Akcaer M, Karakas A, Tok D, Coskun O, Sari S. Eosinophilic pneumonia: Daptomycin-induced lung complication. Med Mal Infect 2016; 46:166-8. [PMID: 26965755 DOI: 10.1016/j.medmal.2016.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 11/23/2015] [Accepted: 01/19/2016] [Indexed: 11/19/2022]
Affiliation(s)
- M Akcaer
- Department of Infectious Diseases and Clinical Microbiology, Gülhane Military Medical Academy and School of Medicine, Etlik, Ankara, Turkey.
| | - A Karakas
- Department of Infectious Diseases and Clinical Microbiology, Gülhane Military Medical Academy and School of Medicine, Etlik, Ankara, Turkey
| | - D Tok
- Department of Infectious Diseases and Clinical Microbiology, Gülhane Military Medical Academy and School of Medicine, Etlik, Ankara, Turkey
| | - O Coskun
- Department of Infectious Diseases and Clinical Microbiology, Gülhane Military Medical Academy and School of Medicine, Etlik, Ankara, Turkey
| | - S Sari
- Department of Radio-diagnostics, Gülhane Military Medical Academy and School of Medicine, Etlik, Ankara, Turkey
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37
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Paridaans MPM, Govaert JA, Scholten EH, de Lange DH. [Necrotising soft tissue infection of orbital area and hand: an unusual combination]. Ned Tijdschr Geneeskd 2016; 160:A9944. [PMID: 27848903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Necrotising soft tissue infection (NSTI) is an infection of the subcutaneous tissues and often follows a fulminant course if not recognised in time. CASE DESCRIPTION A 78-year-old man was brought to our emergency department in septic shock. Physical examination revealed an erythematous and painful swelling of the right eyelids and to a lesser extent of the right hand. The infection progressed at both sites, and suspicion of NSTI arose. An emergency surgical debridement was performed. Pathological examination of the excised tissue confirmed the presence of a necrotising infection of the fascia consistent with NSTI at both sites. CONCLUSION This case history describes a, not previously described, 'double' presentation of NSTI. In a patient with misunderstood sepsis in combination with a soft tissue infection, it is important to consult a surgeon immediately. This case report emphasises the need for a multidisciplinary approach when treating patients with these clinical pictures. CONFLICT OF INTEREST AND FINANCIAL SUPPORT NONE DECLARED.
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38
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de Jong VM, Goslings JC. [The pitfalls of necrotising soft tissue infection: a 'wake-up call' for surgeons]. Ned Tijdschr Geneeskd 2016; 160:D1021. [PMID: 27848910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Necrotising soft tissue infections require early consultation of an experienced surgeon, regardless of what time of day they occur. Delays in diagnosis and treatment should not occur. Necrotectomy should be skin-sparing when possible. A low threshold for consultation with a tertiary referral center is recommended.
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Affiliation(s)
- V M de Jong
- Academisch Medisch Centrum, Trauma Unit, afd. Chirurgie, Amsterdam
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39
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Bonasso PC, Vaughan RA, Hobbs GR, Shorter NA, Nakayama DK. Utility of Diagnostic Tests during Hospitalizations for Incision and Drainage of Pediatric Soft Tissue Infections. Am Surg 2015; 81:E376-E378. [PMID: 26672571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Patrick C Bonasso
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
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Oliver RA, Lovric V, Yu Y, Christou C, Aiken SS, Cooper JJ, Walsh WR. Development of a Novel Model for the Assessment of Dead-Space Management in Soft Tissue. PLoS One 2015; 10:e0136514. [PMID: 26305692 PMCID: PMC4549236 DOI: 10.1371/journal.pone.0136514] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/04/2015] [Indexed: 11/24/2022] Open
Abstract
Following extensive surgical debridement in the treatment of infection, a “dead space” can result following surgical closure that can fill with hematoma, an environment conducive to bacterial growth. The eradication of dead space is essential in order to prevent recurrent infection. This study describes a novel small animal model to investigate dead-space management in muscle tissue. Two absorbable test materials were implanted in each animal; beads of calcium sulfate alone, and beads loaded with vancomycin and tobramycin. In-life blood samples and radiographs were taken from each animal following implantation. Animals were sacrificed at 1, 7, 21, 42, and 63 days post-operatively (n = 4), and implant sites were analysed by micro-computed tomography, histology and immunohistochemistry. Complete resorption was confirmed radiographically at 3 weeks post-implantation. Histologically, the host tissue response to both materials was identical, and subsequent healing at the implant sites was observed with no dead space remaining. Vancomycin was not detected in blood serum. However, peak tobramycin levels were detected in all animals at 6 hours post-implantation with no detectable levels in any animals at 72 hours post implantation. Serological inflammatory cytokine expression for IL-6, TNF-α and IL-1β indicated no unusual inflammatory response to the implanted materials or surgical procedure. The model was found to be convenient and effective for the assessment of implant materials for management of dead space in muscle tissue. The two materials tested were effective in resolving the surgically created dead space, and did not elicit any unexpected adverse host response.
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Affiliation(s)
- Rema A. Oliver
- Surgical & Orthopaedic Research Laboratories, University of New South Wales Australia, Sydney, Australia, Prince of Wales Clinical School, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Vedran Lovric
- Surgical & Orthopaedic Research Laboratories, University of New South Wales Australia, Sydney, Australia, Prince of Wales Clinical School, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Yan Yu
- Surgical & Orthopaedic Research Laboratories, University of New South Wales Australia, Sydney, Australia, Prince of Wales Clinical School, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Chris Christou
- Surgical & Orthopaedic Research Laboratories, University of New South Wales Australia, Sydney, Australia, Prince of Wales Clinical School, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Sean S. Aiken
- Biocomposites Ltd., Keele Science Park, Staffordshire, United Kingdom
| | - John J. Cooper
- Biocomposites Ltd., Keele Science Park, Staffordshire, United Kingdom
| | - William R. Walsh
- Surgical & Orthopaedic Research Laboratories, University of New South Wales Australia, Sydney, Australia, Prince of Wales Clinical School, Prince of Wales Hospital, Randwick, NSW, Australia
- * E-mail:
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41
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Baskin SM, Abboud C, Chen W, Tolchin E, Kelly RW, Aballay AM. Subcutaneous Injection of Percocet: A Case of Severe Soft Tissue Loss. Wounds 2015; 27:174-179. [PMID: 26192735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Prescription drug abuse ranks as the second most common class of illicit drug use in the United States, and one mechanism of opiate abuse involves intravenous injection of enteral narcotics such as oxycodone or hydrocodone. The authors describe a patient who sustained significant soft tissue necrosis after intravenously injecting a solution made from crushed enteral narcotics, with a focus on the operative course that resulted due to a delay in initial definitive treatment. The patient's wounds encompassed 8% total body surface area and covered 247 cm2. A 55-year-old female was admitted to the burn unit (West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA) after she initially presented with infection and cellulitis to her bilateral upper extremities 3 weeks after intravenously injecting herself with crushed oxycodone/acetaminophen. She underwent numerous sequential operative repairs including initial debridement, placement of dermal replacement templates, and several split-thickness autografts and xenografts. Her total length of stay was 59 days, broken into an initial 47-day stay, and a subsequent 12-day readmission due to graft failure secondary to poor follow-up. As the number of prescription drug abusers rises, it is possible that an increase in attempts to intravenously abuse enteral narcotics may also rise. As such, burn centers should be prepared for the extent of potential limb necrosis and the operative treatment that may ensue.
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Affiliation(s)
| | | | - Wendy Chen
- University of Pittsburgh School of Medicine, Department of Plastic and Reconstructive Surgery, Pittsburgh, PA
| | - Eric Tolchin
- West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Robert W Kelly
- West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Ariel M Aballay
- West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA;
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42
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Marinis A, Voultsos M, Foteinos A, Tselioti P, Avraamidou A, Paschalidis N, Rizos S. Necrotizing soft tissue infection of the right anterolateral abdominal wall caused by a ruptured gangrenous appendix in an elderly diabetic patient. Infez Med 2015; 23:182-186. [PMID: 26110301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Necrotizing soft tissue infections (NSTIs) of the abdominal wall usually occur when either a common superficial soft tissue infection progresses down to, or an injury (e.g. knife stab) penetrates, the investing muscle fascia, or an intra-abdominal infection spreads directly to the muscle layers of the abdominal wall. These infections are severe and associated with significant morbidity and mortality. We present an 83-year-old female diabetic patient who was admitted to the surgical emergency department complaining of right abdominal pain after a fall to the floor. She had previously received oral antibiotics for a minor superficial skin infection attributed to her subcutaneous use of insulin. On admission she exhibited signs of agitation and dyspnoea with hypotension and tachycardia (systolic arterial pressure 90mmHg, heart rate >110 bpm, oxygen saturation 88%). Furthermore, she had a tender right abdomen but without any demonstrable pathology on her skin or crepitus. Arterial blood gases revealed metabolic acidosis and hypoxaemia. An abdominal computed tomography (CT) scan demonstrated signs of infection of the entire right anterior abdominal wall and the LRINEC score was calculated to be 13. Subsequent operative aggressive necrosectomy of all the involved layers of the right anterolateral abdominal wall sparing the peritoneum was undertaken. Unfortunately, the patient died the next day due to multiple organ failure.
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Affiliation(s)
- Athanasios Marinis
- First Department of Surgery, Department of Radiology and Intensive Care Unit, Tzaneion General Hospital, Piraeus, Greece
| | - Mavroudis Voultsos
- First Department of Surgery, Department of Radiology and Intensive Care Unit, Tzaneion General Hospital, Piraeus, Greece
| | - Argyrios Foteinos
- First Department of Surgery, Department of Radiology and Intensive Care Unit, Tzaneion General Hospital, Piraeus, Greece
| | - Paraskevi Tselioti
- First Department of Surgery, Department of Radiology and Intensive Care Unit, Tzaneion General Hospital, Piraeus, Greece
| | - Alexandra Avraamidou
- First Department of Surgery, Department of Radiology and Intensive Care Unit, Tzaneion General Hospital, Piraeus, Greece
| | - Nikolaos Paschalidis
- First Department of Surgery, Department of Radiology and Intensive Care Unit, Tzaneion General Hospital, Piraeus, Greece
| | - Spyros Rizos
- First Department of Surgery, Department of Radiology and Intensive Care Unit, Tzaneion General Hospital, Piraeus, Greece
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43
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Gostishchev VK, Lipatov KV, Komarova EA. [Streptococcal infection in surgery]. Khirurgiia (Mosk) 2015:14-17. [PMID: 26978758 DOI: 10.17116/hirurgia20151214-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Despite the advances of modern medicine purulent-inflammatory diseases of soft tissues continue to occupy a leading position in surgical practice. Streptococcal surgical infection does not refer to specific category, but it has a number of significant features and its definition as separate type is necessary. MATERIAL AND METHODS Based on the results of treatment of 312 patients with streptococcal infection of soft tissues we studied the prevalence of this disease in overall structure of surgical infection of soft tissue, main clinical courses are defined. We performed molecular genetic typing of pathogens that allows to predict the course of pathological process taking into account microorganism's characteristics. RESULTS AND DISCUSSION On the basis of obtained data basic medical and diagnostic concept of surgical care for these patients depending on clinical course of disease was formulated. It allowed to improve significantly the results of treatment of such patients.
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Affiliation(s)
- V K Gostishchev
- Chair of General Surgery, Medical Faculty of I.M.Sechenov First Moscow State Medical University
| | - K V Lipatov
- Chair of General Surgery, Medical Faculty of I.M.Sechenov First Moscow State Medical University
| | - E A Komarova
- Chair of General Surgery, Medical Faculty of I.M.Sechenov First Moscow State Medical University
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44
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Teh SH, Chi CY, Lin PC, Ho CM, Chou CH, Tsai CT, Wang JH, Ho MW. Management and outcome of adults with skin and soft tissue infection caused by methicillin-resistant Staphylococcus aureus in a tertiary hospital in central Taiwan. J Microbiol Immunol Infect 2014; 48:497-503. [PMID: 25446039 DOI: 10.1016/j.jmii.2014.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/26/2014] [Accepted: 08/28/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) has been increasingly causing skin and soft tissue infections (SSTIs). Only limited studies have made comparisons between incision and drainage (I&D) alone and I&D with adjunctive antibiotic therapy for treatment effects, and most of the studies were conducted before the emergence of MRSA. This study was to evaluate whether antibiotics provide added benefit to I&D alone for purulent MRSA SSTIs. METHODS This retrospective study collected data on SSTI patients, including patient demographics, treatment strategies, antibiotic susceptibilities of the infecting MRSA isolates, and clinical outcomes over the course of 24 months. RESULTS Antimicrobial drug susceptibility rate were 100% for vancomycin, teicoplanin, and linezolid. Among the 211 patients, 7.6% were treated solely with I&D (Group A), 62.6% were treated via I&D with adjunctive antibiotic (Group B), and 29.8% patients received only antibiotics (Group C). The cure rate was highest in Group A (93.8%), followed by Group B (90.9%) and Group C (77.8%). Combining Group B and Group C, patients who were treated appropriately demonstrated a higher cute rate (91.3% vs. 75.4%, p = 0.005). Multivariate analysis showed that Group B was more likely to be successfully treated compared to Group C (odds ratio = 2.51, 95% confidence interval = 1.01-6.25, p = 0.047), whereas no difference between Group A and Group B was found (odds ratio = 2.09, 95% confidence interval = 0.20-22.34, p = 0.542, data not shown). CONCLUSION Surgical intervention is the definitive therapy for purulent SSTIs. Adjunctive antibiotic therapy increased the cure rate and appropriateness of prescription is influential.
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Affiliation(s)
- Soon-Hian Teh
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Yu Chi
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Medicine, China Medical University, Taichung, Taiwan
| | - Po-Chang Lin
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Mao Ho
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hui Chou
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Ta Tsai
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Jen-Hsien Wang
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Mao-Wang Ho
- Division of Infectious Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.
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45
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Eckmann C. [Therapy of skin and soft tissue infections from surgeon's point of view]. Dtsch Med Wochenschr 2014; 139 Suppl 3:S91-2. [PMID: 25429540 DOI: 10.1055/s-0034-1369846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- C Eckmann
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Peine
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46
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Hakkarainen TW, Burkette Ikebata N, Bulger E, Evans HL. Moving beyond survival as a measure of success: understanding the patient experience of necrotizing soft-tissue infections. J Surg Res 2014; 192:143-9. [PMID: 24923631 DOI: 10.1016/j.jss.2014.05.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 04/15/2014] [Accepted: 05/02/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) represent a devastating spectrum of disease with high case mortality and resource intensive care. Treatment consists of wide surgical debridement and often prolonged periods of intensive care unit care. Major complications are common. The severity of the disease and the aggressive treatment requirements put survivors at risk for significant long-term sequelae related to the trauma of both disease and treatment. Information about the postdischarge impact of NSTIs on survivors is extremely limited. Qualitative approaches are typically used to explore new phenomena and to capture individuals' thoughts, feelings, or interpretations of meaning and process. Therefore, qualitative methods are ideally suited for hypothesis generation to guide future quantitative study and ensure measured outcomes are patient-centered. MATERIALS AND METHODS Semistructured interviews were conducted with survivors of NSTIs from a single regional referral center. Stratified purposive sampling was used to select interview candidates based on severity of illness. Descriptive thematic analysis was performed to identify major themes described by the patients. RESULTS Interviews with 18 survivors identified three primary domains of experience: (1) individual factors, (2) relational factors, and (3) societal factors. These domains were split into the following two categories: factors effecting the disease process and recovery, and factors that were outcomes of the disease process. Each category yielded between one and seven themes. Themes identified included physical, psychological, relationship, and employment aspects. CONCLUSIONS Patient's reported quality of life was significantly affected by their disease and recovery. The results demonstrate that many outcomes of importance for patients are not easily assessed by traditional measures of outcomes. This work illustrates the multidimensional nature of recovery from critical illness, and shows that it represents a massive transition period in the lives of survivors that affects the patient, their family, and the patient's ability to interact with society. Interviews with survivors ensure that the patient voice is heard before developing tools to assess long-term outcomes.
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Affiliation(s)
- Timo W Hakkarainen
- Department of Surgery, University of Washington Medical Center, Seattle, WA.
| | | | - Eileen Bulger
- Department of Surgery, University of Washington Medical Center, Seattle, WA
| | - Heather L Evans
- Department of Surgery, University of Washington Medical Center, Seattle, WA
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47
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Biliaieva OO, Korzhyk NP, Myronov OM. [Expedience of application of a dietic therapy in treatment of purulent-septic diseases of soft tissues]. Klin Khir 2014:53-55. [PMID: 25097980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The results of investigation of the dietotherapy impact on the course of purulent-septic process in soft tissues were analyzed. There were operated 58 patients, to 38 of them a certain diet was prescribed. Immediate impact of the diet therapy on the wound process course was established, what was demonstrated by reduction of duration of the earning capacity loss in patients, who have followed a special diet, by 2.58 days.
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48
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Vinnik IS, Salmina AB, Tepliakova OV, Drobushevskaia AI, Malinovskaia NA, Pozhilenkova EA, Morgun AV, Gitlina AG. [Dynamics of local expression of connexin-43 and basic fibroblast growth factor receptors in patients with skin and soft-tissue infections against the background of diabetes mellitus type II]. Vestn Khir Im I I Grek 2014; 173:47-52. [PMID: 25552106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Clinical results of wound healing dynamics were studied in 60 patients with soft-tissue infection against the background of diabetes mellitus type II. At the same time the study considered indices of intercellular contacts protein tissue expression such as connexin 43 (Cx43) and basic fibroblast growth factor receptors (bFGFR). The basic therapy of biopsy material of wound borders was applied. The reduction of bFGFR expression and the minor growth of Cx43 expression were observed. The pain syndrome proceeded for a long time and there were signs of perifocal inflammation, retard wound healing with granulation tissue. The application of combined method of ozone therapy which included autohemotherapy with ozone and an external management of wound by ozone-oxygen mixture facilitated to considerable shortening of inflammatory phase and regeneration. It was associated with increased Cx43 expression (in 1.9 times) in comparison with initial level and bFGFR was enlarged in 1.7 times to eighth day of postoperative period.
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Abstract
Operative foot and ankle osteomyelitis is challenging for orthopedic surgeons because of the area’s unique anatomy, high trauma incidence, local and systemic disease effects, and often limited space. Standard treatment includes aggressive operative debridement with local and systemic antibiotic administration to control infection. Dead space management is critical yet technically demanding. The authors report a modified antibiotic cement bead therapy technique in which antibiotic sticks, minnows, and mushroom-shaped plugs are used to strike a balance between the stability of the load-bearing unit and radical removal of infection to preserve a functional foot. Three cases are presented.
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50
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Herlin C. [Negative pressure therapy in the loss of perineal substance]. Soins 2014:37-38. [PMID: 24683860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Over the last ten years, negative pressure therapy has played a major role in the treatment of complex perineum wounds resulting from infection, trauma or cancer.The use of instillation has enabled its use to be extended to certain particularly difficult situations. It is also used routinely in support of dressing techniques for less complex wounds.
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