Left ventricular assist device-associated driveline infections as a specific form of complicated skin and soft tissue infection/acute bacterial skin and skin structure infection - issues and therapeutic options

PURPOSE OF REVIEW

This review comments on the current guidelines for the treatment of wound infections under definition of acute bacterial skin and skin structure infections (ABSSSI). However, wound infections around a catheter, such as driveline infections of a left ventricular assist device (LVAD) are not specifically listed under this definition in any of the existing guidelines.

RECENT FINDINGS

Definitions and classification of LVAD infections may vary across countries, and the existing guidelines and recommendations may not be equally interpreted among physicians, making it unclear if these infections can be considered as ABSSSI. Consequently, the use of certain antibiotics that are approved for ABSSSI may be considered as 'off-label' for LVAD infections, leading to rejection of reimbursement applications in some countries, affecting treatment strategies, and hence, patients' outcomes. However, we believe driveline exit site infections related to LVAD can be included within the ABSSSI definition.

SUMMARY

We argue that driveline infections meet the criteria for ABSSSI which would enlarge the 'on-label' antibiotic armamentarium for treating these severe infections, thereby improving the patients' quality of life.

Long-term outcomes and complications of isolated anterior thoracolumbar fusion for neuromuscular scoliosis associated with myelomeningocele

PURPOSE

Neuromuscular scoliosis associated with myelomeningocele is a difficult clinical dilemma for the treating surgeon. The traditional surgical treatment consists of a posterior spinal instrumented fusion with or without a combined anterior procedure, but this has been associated with high complication rates, mostly related to deep infection. An anterior thoracolumbar fusion is not able to address the entirety of the deformity in many cases but could potentially avoid the devastating infection risks from the posterior approach by avoiding compromised skin. This study aims to evaluate the long-term outcomes and complications associated with isolated anterior thoracolumbar fusion in this high-risk group.

METHODS

This study is a retrospective analysis of patients with myelomeningocele-associated scoliosis treated with an isolated anterior spinal fusion over a 20-year time period at a single center. Surgical details, demographics, curve characteristics and complications were recorded. Comparisons were made between patients who required revision surgery and those who did not.

RESULTS

Sixteen patients were enrolled with an average age of 12.7 years at the time of surgery and average follow-up of 5.5 years. Patients had on average 7.4 levels fused anteriorly with the most common levels being T10-L4. There were no deep wound infections associated with the anterior surgery. Overall, nine patients (56%) had to be revised posteriorly due to adding-on or junctional deformity at an average of 3.7 years after index procedure. Four patients were revised due to proximal adding-on, while 1 was extended distally. Four additional patients were extended both proximally and distally. Of the posterior revisions, 2 patients developed deep wound infections, and both of these were in patients extended distally. Preoperative lumbar lordosis was higher in patients who required distal extension (100 vs. 69 degrees; p = 0.035).

CONCLUSIONS

Patients undergoing isolated anterior fusion for scoliosis associated with myelomeningocele have low infection rates but often require posterior revision. The majority of patients can avoid the deep infection risk associated with distal posterior surgery at long-term follow-up.

LEVEL OF EVIDENCE

IV.

Strategies to Minimize Sternal and Leg Wound Complications after Coronary Artery Bypass Grafting Using No-Touch Saphenous Vein Grafts

PURPOSE

The aims of the present study were to examine sternal and saphenous vein (SV) harvest site wound complication rates, and to assess the strategies to minimize the sternal and leg wound complications after coronary artery bypass grafting using a no-touch (NT) SV.

METHODS

Patients who underwent coronary artery bypass grafting (CABG) using internal thoracic artery (ITA) and/or NT SV grafts from March 2021 to June 2023 (N = 166) at a newly opened cardiac surgical program were included. We obeyed the current guidelines for the prevention of sternal wound infection. In addition, unilateral ITA was used in most of the patients and the sternal wound was meticulously closed using multiple sternal wires (≥7) and ZipFix. For the NT SV harvesting, the LigaSure device was used to minimize thermal injury, and the wound was meticulously closed.

RESULTS

Sternal wound infections developed in 3/166 (1.8%) patients; all three patients showed superficial sternal wound infections. Leg wound complications were present in 2/153 (1.3%) patients, who recovered after secondary intention healing.

CONCLUSION

Sternal wound complications after CABG could be minimized by the unilateral ITA usage, meticulous closure of the sternal wound in addition to compliance with the current guidelines. Wound complications after NT SV harvest may also be minimized by preoperative evaluation, careful harvesting, and meticulous wound closure.

Pure laparoscopic versus open left lateral hepatectomy in pediatric living donor liver transplantation: a review and meta-analysis

PURPOSE

The meta-analysis was conducted to evaluate the safety and feasibility of pure laparoscopic left lateral hepatectomy in comparison with open approach for pediatric living donor liver transplantation (LDLT).

METHODS

A systemic literature survey was performed by searching the PubMed, EMBASE and Cochrane Library databases for articles that compared pure laparoscopic left lateral living donor hepatectomy (LLDH) and open left lateral living donor hepatectomy (OLDH) by November 2021. Meta-analysis was performed to assess donors' and recipients' perioperative outcomes using RevMan 5.3 software.

RESULTS

A total of five studies involving 432 patients were included in the analysis. The results demonstrated that LLDH group had significantly less blood loss (WMD = -99.28 ml, 95%CI -152.68 to -45.88, p = 0.0003) and shorter length of hospital stay (WMD = -2.71d, 95%CI -3.78 to -1.64, p < 0.00001) compared with OLDH group. A reduced donor overall postoperative complication rate was observed in the LLDH group (OR = 0.29, 95%CI 0.13-0.64, p = 0.002). In the subgroup analysis, donor bile leakage, wound infection and pulmonary complications were similar between two groups (bile leakage: OR = 1.31, 95%CI 0.43-4.02, p = 0.63; wound infection: OR = 0.38, 95%CI 0.10-1.41, p = 0.15; pulmonary complications: OR = 0.24, 95%CI 0.04-1.41, p = 0.11). For recipients, there were no significant difference in perioperative outcomes between the LLDH and OLDH group, including mortality, overall complications, hepatic artery thrombosis, portal vein and biliary complications.

CONCLUSION

LLDH is a safe and effective alternative to OLDH for pediatric LDLT, reducing invasiveness and benefiting postoperative recovery. Future large-scale multi-center studies are expected to confirm the advantages of LLDH in pediatric LDLT.

Blood transfusions in non-major burns patients

BACKGROUND

Blood transfusions are essential to treating anaemia of burn injuries. It has recently been observed that patients with non-major burns < 20%TBSA may also develop anaemia requiring transfusion of blood products. Due to the morbidity and mortality rate associated with blood transfusions better understanding of risk factors may guide clinical practices to improve patient care.

OBJECTIVE

To determine risk factors for transfusion of blood products in patients with non-major burn injuries and assess transfusion practices to establish impact on patient outcome.

METHOD

Our study included 182 adult patients with non-major burn injuries, < 20%TBSA admitted over a 3-year period at the Department of Plastic Surgery and Burns Unit of the Emergency County Hospital Cluj-Napoca. We analysed patient and injury characteristics: age, gender, %TBSA burn, %FT burn, burn site, mechanism of injury, inhalation injury, Hb lab determinations throughout admission and surgical management. Charlson comorbidities index has been determined based on cardiovascular, neurological, gastrointestinal and renal comorbidities as well as diabetes mellitus. We selected blood transfusions, wound infections and length of hospital stay as outcome for our analysis.

RESULTS

37.9% of patients included in our study developed anaemia throughout admission and 7.7% underwent blood transfusions. Mean Hb levels triggering blood transfusions have been recorded at 7.4 (IQR=8.8-9.9) g/dL. Patients who received transfusions were older, presented with higher %TBSA and associated a higher comorbidity index. They also tended to develop coagulopathy and underwent more surgical procedures to achieve wound closure. In transfused patients who associate comorbidities we observed a higher rate of wound infections and longer hospital stay.

CONCLUSIONS

Patient related comorbidities correlate with higher transfusion rates in non-major burn injuries. Due to the risk associated with the use of blood products decision to transfuse should adhere to current guideline practices and be tailored to specific patient requirements.

Maternal obesity and the risk of postpartum infections according to mode of delivery

OBJECTIVE

The aim of the present study was to assess the impact of different maternal Body Mass Index (BMI) classes on the risk of postpartum endometritis, wound infection, and breast abscess after different modes of delivery. Secondly to estimate how the risk of postpartum infection varies with different maternal BMI groups after induction of labor and after obstetric anal sphincter injuries.

METHODS

A population-based observational study including women who gave birth during eight years (N = 841,780). Data were collected from three Swedish Medical Health Registers, the Swedish Medical Birth Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. Outcomes were defined by ICD-10 codes given within eight weeks postpartum. The reference population was uninfected women. Odds ratios were determined using Mantel-Haenszel technique. Year of delivery, maternal age, parity and smoking in early pregnancy were considered as confounders.

RESULTS

There was a dose-dependent relationship between an increasing maternal BMI and a higher risk for postpartum infections. Women in obesity class II and III had an increased risk for endometritis after normal vaginal delivery aOR 1.45 (95% CI: 1.29-1.63) and for wound infections after cesarean section aOR 3.83 (95% CI: 3.39-4.32). There was no difference in how maternal BMI affected the association between cesarean section and wound infection, regardless of whether it was planned or emergent. Women in obesity class II and III had a lower risk of breast abscess compared with normal-weight women, aOR 0.47 (95% CI: 0.38-0.58). The risk of endometritis after labor induction decreased with increasing maternal BMI. The risk of wound infection among women with an obstetrical sphincter injury decreased with increasing BMI.

CONCLUSION

This study provides new knowledge about the impact of maternal BMI on the risk of postpartum infections after different modes of delivery. There was no difference in how BMI affected the association between cesarean section and wound infections, regardless of whether it was a planned cesarean section or an emergency cesarean section.

Selective Deep Lobe Parotidectomy vs Total Parotidectomy for Patients With Benign Deep Lobe Parotid Tumors

Importance

Limited literature exists on surgical outcomes after selective deep lobe parotidectomy (SDLP) with preservation of superficial lobe for patients with benign deep lobe tumors.

Objective

To compare the following factors for SDLP vs total parotidectomy for patients with benign tumors in the deep lobe: postoperative complications, including facial nerve paresis or paralysis, Frey syndrome, first bite syndrome, cosmetic defect, sialocele formation, and wound infection; and tumor control and recurrence.

Design, Setting, and Participants

This case series included 273 adults who underwent SDLP (n = 177) or total parotidectomy (n = 96) at a single tertiary care institution for benign parotid tumors located in the deep lobe or deep lobe and parapharynx from January 1, 2000, to December 31, 2020.

Exposure

Selective deep lobe parotidectomy vs total parotidectomy.

Main Outcomes and Measures

Incidence of postoperative complications and tumor recurrence.

Results

Among 273 patients (SDLP, 177 [65%]; 122 women [69%]; median age at surgery, 58 years [IQR, 46-67 years]; total parotidectomy, 96 [35%]; 57 women [59%]; median age at surgery, 59 years [IQR, 40-68 years]), the most common tumor was pleomorphic adenoma (SDLP, 128 of 177 [72%]; total parotidectomy, 62 of 96 [65%]). An abdominal dermal fat graft was less commonly performed for patients who underwent SDLP than those who underwent total parotidectomy (2 of 177 [1%] vs 20 of 96 [21%]; difference, -20% [95% CI, -28% to -11%]). The rate of great auricular nerve preservation was higher in the SDLP group than in the total parotidectomy group (84 of 102 [82%] vs 20 of 34 [59%]; difference, 24% [95% CI, 5%-42%]). No meaningful difference in length of hospital stay was found. The percentage of patients with House-Brackmann grade I immediately after surgery was 48% (85 of 177) in the SDLP group and 21% (20 of 96) in the total parotidectomy group (difference, 28% [95% CI, 16%-40%]). There were no clinically meaningful differences in rates of hematoma, sialocele, seroma, ear numbness, wound infection, or unplanned return to emergency department or operating room. The SDLP group reported a lower rate of Frey syndrome than the total parotidectomy group (1 of 137 [1%] vs 12 of 78 [15%]; difference, -15% [95% CI, -23% to -7%]), as well as a lower rate of facial contour defect (28 of 162 [17%] vs 25 of 84 [30%]; difference, -13% [95% CI, -24% to -1%]) and a higher rate of first bite syndrome (34 of 148 [23%] vs 7 of 78 [9%]; difference, 14% [95% CI, 5%-23%]). The percentage of patients with House-Brackmann grade I at their first follow-up visit was 67% (118 of 177) in the SDLP group compared with 49% (47 of 96) in the total parotidectomy group (difference, 17% [95% CI, 4%-30%]). There was no clinically meaningful difference in House-Brackmann grade after 1 year.

Conclusions and Relevance

Findings of this case series study suggest that SDLP can be considered an effective and even superior technique for management of benign tumors in the deep parotid lobe. Advantages associated with SDLP include reduction in need for reconstruction for facial contour defect and reduction in complications, such as immediate facial nerve weakness and Frey syndrome. The incidence of first bite syndrome was higher in the SDLP group. Tumor control was not compromised by SLDP.

Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies

BACKGROUND

There is still ongoing debate about the benefits of mini-thoracotomy (MTH) approach in mitral valve surgery in comparison with complete sternotomy (STER). This study aims to update the current evidence with mortality as primary end point.

METHODS

The MEDLINE and EMBASE databases were searched through June 2022. Two randomized studies and 16 propensity score matched studies published from 2011 to 2022 were included with a total of 12,997 patients operated on from 2005 (MTH: 6467, STER: 6530). Data regarding early mortality, stroke, reoperation for bleeding, new renal failure, new onset of atrial fibrillation, need of blood transfusion, prolonged ventilation, wound infection, time-related outcomes (cross clamp time, cardiopulmonary bypass time, ventilation time, length of intensive care unit stay, length of hospital stay), midterm mortality and reoperation, and costs were extracted and submitted to a meta-analysis using weighted random effects modeling.

RESULTS

The incidence of early mortality, stroke, reoperation for bleeding and prolonged ventilation were similar, all in the absence of heterogeneity. However, the sub-group analysis showed a significant OR in favor of MTH when robotic enhancement was used. New renal failure (OR 1.67, 95% CI 1.06-2.62, p = 0.03), new onset of atrial fibrillation (OR 1.31, 95% CI 1.15-1.51, p = 0.001) and the need of blood transfusion (OR 1.77, 95% CI 1.39-2.27, p = 0.001) were significantly lower in MTH group. Regarding time-related outcomes, there was evidence for important heterogeneity of treatment effect among the studies. Operative times were longer in MTH: differences in means were 20.7 min for cross clamp time (95% CI 14.9-26.4, p = 0.001), 36.8 min for CPB time (95% CI 29.8-43.9, p = 0.001) and 37.7 min for total operative time (95% CI 19.6-55.8, p < 0.001). There was no significant difference in ventilation duration; however, the differences in means showed significantly shorter ICU stay and hospital stay after MTH compared to STER: - 0.6 days (95% CI - 1.1/- 0.21, p = 0.001) and - 1.88 days (95% CI - 2.72/- 1.05, p = 0.001) respectively, leading to a significant lower hospital cost after MTH compared to STER with difference in means - 4528 US$ (95% CI - 8725/- 326, p = 0.03). The mid-term mortality was significantly higher after STER compared to MTH: OR = 1.50, 1.09-2.308 (95% CI), p = 0.01; the rate of mid-term reoperation was reported similar in MTH and STER: OR = 0.76, 0.50-1.15 (95% CI), p = 0.19.

CONCLUSIONS

The present meta-analysis confirms that the MTH approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in ICU and in hospitalization, with finally a reduction in global cost. MTH approach appears associated with a significant reduction of postoperative mortality that must be confirmed by large randomized study.

Role of biliary drainage before pancreatoduodenectomy for pancreatic adenocarcinoma: a retrospective study

BACKGROUND

Utilization of preoperative biliary drainage prior to pancreatoduodenectomy for patients with pancreatic ductal adenocarcinoma and obstructive jaundice remains controversial.

METHODS

All patients that underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma at the authors' institution were analyzed retrospectively to evaluate the effect of endoscopic biliary drainage on postoperative outcomes and long-term survival. Age, gender, ASA-Score, operative time, blood loss, intraoperative transfusion rate, and postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, bleeding, bile fistula, wound infections, sepsis, pulmonary and cardiac complications as well as the need for relaparotomy were analyzed.

RESULTS

Two hundred eighty-five patients with similar baseline characteristics underwent pancreatoduodenectomy, 151 patients with biliary drainage (group 1) and 134 without drainage (group 2). More than 60% of patients had one or more postoperative complications, without significant difference between the two groups (P=0.140). The overall incidence of pancreatic fistula was 21.75% in both groups (group 1: 19.87% vs. group 2: 23.88%, P=0.659). Wound healing impairment was the only postoperative complication that differed significantly between the two groups (group 1: 24.50% vs. group 2: 8.96%, P<0.001). In multivariate risk analysis, biliary drainage was the only independent risk factor for wound healing impairment (OR 4.126; 95% CI: 1.295-13.143; P=0.017). The median overall survival was similar in both groups.

CONCLUSIONS

Preoperative endoscopic biliary drainage is associated with an increased risk for wound healing impairment and wound infections. Therefore, biliary drainage should not be used routinely in patients with obstructive jaundice prior to pancreatoduodenectomy.

Single blind, randomized study comparing clinical equivalence of Trusilk® and Mersilk® silk sutures for mucosal closure following surgical removal of mesioangular impacted mandibular third molar

Background: Mesioangular impacted mandibular third molar is a common dental anomaly, for which surgical extraction is required. Post-surgery closure of mucosa reduces the prevalence of pain and other surgery-associated complications. We compared tissue reaction/inflammation after 3 and 7 days of mucosal closure with Trusilk® and Mersilk® silk sutures, following impacted mandibular third molar removal. Methods: This multicenter, prospective, two-arm, parallel-group, randomized (1:1), single-blind study (July 2020-November 2021) included subjects (Trusilk®, n=65 and Mersilk®, n=64), requiring mucosal suturing following impacted mandibular third molar removal. The primary endpoint, incidence of pain, swelling and trismus at the extraction area on post-surgery day 3 and 7 was evaluated. The secondary endpoints, incidence of tissue reaction, wound infection, suture loosening, other complications, operative time, amount of anesthesia, intraoperative suture handling, time needed for complete wound healing and suture removal, and adverse events were also recorded. Results: Socio-demographic and intra-oral characteristics were comparable between the groups. In Trusilk® and Mersilk® groups, a gradually decreasing pain score, starting from day 0 post-surgery (42.17±22.38 vs. 45.97±22.20) to day 7 (8.40±11.93 vs. 8.28±12.13) to day 30 (1.98±0.89 vs. 1.75±0.76) was witnessed. After the surgery, 21.54% and 17.19% subjects in Trusilk® and Mersilk® groups, respectively, had no post-operative swelling, while at the last two visits none of the subjects had swelling. Non-significant difference in wound infection, suture loosening, wound healing, bleeding, taste changes, operative time, amount of anesthesia, intraoperative suture handling, and time needed for complete wound healing and suture removal was noted among the groups. No suture-related adverse events were recorded. Conclusions: The results indicated that the Trusilk® and Mersilk® silk sutures are clinically equivalent and can be used for mucosal closure after removal of an impacted mandibular third molar with a minimal rate of pain, swelling and trismus. Clinical Trial Registry of India Registration: CTRI/2020/03/024100 (20/03/2020)

Linear Versus Circular Laparoscopic Gastrojejunal Anastomosis of Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis of 22 Comparative Studies

PURPOSE

To compare the rate of complications of linear versus circular gastrojejunal anastomosis of laparoscopic Roux-en-Y gastric bypass.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library databases was carried out using the terms "laparoscopic," "circular," "linear," "anastomosis," "gastric bypass" in accordance to PRISMA guidelines. Only original articles in English language comparing linear versus circular anastomosis were included. No temporal interval was set. Outcome measures were wound infection, bleeding, marginal ulcer, leak, and stricture. Pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated. Heterogeneity was assessed using the I2 statistic. Funnel plots were used to detect publication bias.

RESULTS

Twenty-two articles (7 prospective and 15 retrospective) out of 184 retrieved papers were included in this study. The pooled analysis showed a reduced odd of wound infection and bleeding after linear anastomosis. Likelihood of marginal ulcer, leak, and stricture was similar after the 2 techniques. Wound infection was reported in 15 studies (OR, 0.17; 95% CI, 0.06-0.45; P=0.0003; I2=91), bleeding in 9 (OR, 0.45; 95% CI, 0.34-0.59; P=0.00001; I2=6) marginal ulcer in 11 (OR, 0.61; 95% CI, 0.26-1.41; P=0.25; I2=65), leaks in 15 (OR, 0.61; 95% CI, 0.21-1.67; P=0.34; I2=83) and stricture in 18 (OR, 0.48; 95% CI, 0.23-1.00; P=0.05; I2=68).

CONCLUSION

Laparoscopic RYGB can be safely performed both with circular and linear staplers. Rates of wound infection and bleeding were significantly lower after linear gastrojejunal anastomosis.

The incidence of wound complications following primary repair of obstetric anal sphincter injury: a systematic review and meta-analysis

OBJECTIVE

We aimed to systematically determine the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair.

DATA SOURCES

MEDLINE, Embase, CINAHL, EmCare, the Cochrane Library, and Trip Pro databases were searched from inception to February 2021.

STUDY ELIGIBILITY CRITERIA

We included observational clinical studies reporting the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. Case series and reports were excluded. Conference articles and observational study abstracts were included if they contained enough information regarding study design and outcome data.

METHODS

Data were analyzed as incidence (percentage) with 95% confidence intervals. Moreover, the prediction intervals were calculated to provide a predicted range for the potential incidence of wound complications when applied to an individual study setting. Study quality and risk of bias were assessed using the relevant tool from the Joanna Briggs Institute.

RESULTS

Of 956 studies found, 39 were selected for full-text review. Moreover, 10 studies (n=4767 women) were eligible and included in the meta-analysis. All 10 studies were conducted in high-income countries (Denmark [n=1], the United Kingdom [n=3], and the United States [n=6]). The incidences of wound infection (n=4593 women) and wound dehiscence (n=3866 women) after primary obstetric anal sphincter injury repair ranged between 0.1% to 19.8% and 1.9% to 24.6%, respectively. The overall incidences were 4.4% (95% confidence interval, 0.4-8.4) for wound infection and 6.9% (95% confidence interval, 1.6-12.2) for wound dehiscence. The prediction intervals were wide and suggested that the true incidences of wound infection and dehiscence in future studies could lie between 0.0% to 11.7% and 0.0% to 16.4%, respectively. Overall, 8 studies had a high or unclear risk of bias across ≥1 assessed element. None of the studies used the same set of clinical parameters to define wound infection or dehiscence. Furthermore, microbiological confirmation with wound swabs was never used as a diagnostic measure.

CONCLUSION

This was a systematic review and meta-analysis of wound infection and dehiscence incidences after primary obstetric anal sphincter injury repair. The incidence estimates from this review will be useful for clinicians when counseling women with obstetric anal sphincter injury and when consenting them for primary surgical repair.

Dendritic Hydrogels with Robust Inherent Antibacterial Properties for Promoting Bacteria-Infected Wound Healing

Bacterial infections are a common problem associated with wound treatment that imposes a significant burden on healthcare systems and patients. As a result, healthcare providers urgently need new treatment strategies to protect people. Hydrogel biomaterials with inherent antimicrobial properties offer an attractive and viable solution to this issue. Here, for the first time, we have developed a new efficient synthetic strategy to prepare cationic hydrogels (PHCI) with intrinsically efficient antimicrobial properties by chemically cross-linking trans-1,4-cyclohexanediamine with 1,3-dibromo-2-propanol using a condensation reaction without the use of toxic cross-linking agents. As expected, the prepared PHCI hydrogel possessed an inherent antibacterial ability that can adsorb and kill Staphylococcus aureus and Escherichia coli electrostatically. Notably, in vivo experiments on normal and diabetic rat models confirmed that the PHCI hydrogel can quickly stop bleeding, efficiently kill bacteria, promote the conversion of macrophages from the proinflammatory M1 phenotype to the repaired M2 phenotype, and accelerate collagen deposition and blood vessel formation, thereby achieving rapid wound healing. Overall, this work presents an effective antibacterial dressing that might provide a facile but effective approach for clinical wound management.

The challenge of the infected pilon tibial non-union: treatment with radical resection, bone transport and ankle arthrodesis

A significant number of patients with pilon tibial fractures develop complications, the most devastating being a combination of infection and non-union with bone loss. The results of the Ilizarov bone transport technique were retrospectively evaluated in ten patients. All underwent an extensive resection and reconstruction aiming at an ankle arthrodesis. The outcome was registered by clinical and radiographic examination as proposed by Paley's functional and bone results classification. A good healing at the level of the docking site could be obtained in all patients but with a re- intervention in 8 of the 10. In 5 of these patients, re-intervention with a transcalcaneal nailing leaded to the final healing. Other options are debridement of the docking site (2 patients) and a new Ilizarov procedure (1 patient). If patients are prepared to participate in a long-term treatment with the risk of multiple interventions a reconstruction can be performed, resulting in a limb with an acceptable function, allowing all activities of daily life and even a professional occupation. To obtain this final result with a definite union at the docking site a secondary retrograde intramedullary nailing is considered a valuable and safe procedure.

Combined therapy of photobiomodulation and adipose-derived stem cells synergistically improve healing in an ischemic, infected and delayed healing wound model in rats with type 1 diabetes mellitus

OBJECTIVE

We assessed the therapeutic effects of photobiomodulation (PBM) and adipose-derived stem cell (ADS) treatments individually and together on the maturation step of repairing of a delayed healing wound model in rats with type 1 diabetes mellitus (DM1).

RESEARCH DESIGN AND METHODS

We randomly assigned 24 rats with DM1 to four groups (n=6 per group). Group 1 was the control (placebo) group. In group 2, allograft human ADSs were transplanted. Group 3 was subjected to PBM (wavelength: 890 nm, peak power output: 80 W, pulse frequency: 80 Hz, pulsed duration: 180 ns, duration of exposure for each point: 200 s, power density: 0.001 W/cm², energy density: 0.2 J/cm²) immediately after surgery, which continued for 6 days per week for 16 days. Group 4 received both the human ADS and PBM. In addition, we inflicted an ischemic, delayed healing, and infected wound simulation in all of the rats. The wounds were infected with methicillin-resistant Staphylococcus aureus (MRSA).

RESULTS

All three treatment regimens significantly decreased the amount of microbial flora, significantly increased wound strength and significantly modulated inflammatory response and significantly increased angiogenesis on day 16. Microbiological analysis showed that PBM+ADS was significantly better than PBM and ADS alone. In terms of wound closure rate and angiogenesis, PBM+ADS was significantly better than the PBM, ADS and control groups.

CONCLUSIONS

Combination therapy of PBM+ADS is more effective that either PBM or ADS in stimulating skin injury repair, and modulating inflammatory response in an MRSA-infected wound model of rats with DM1.

Can we predict vascular status and culture result based through wound status in diabetic foot infection?

Diabetic foot infection (DFI) should be treated by a multidisciplinary team to prevent amputation and morbid status. As physicians encountering DFI in outpatient clinic, a proper selection of antibiotic treatment and diagnostic approach for a vascular status is essential. We retrospectively investigated the patients with DFI from 2016 to 2017. All patients were examined for vascular status, wound status, and pathologic culture preceding the treatment. No statistical significance was observed between PEDIS grade 1 and 2 and 3 and 4 in culture status and culture results. Association analysis between vascular status and other variables, such as wound score and culture results, has no significant difference. Through these results, the helpful epidemiologic result of microbiology and necessity of examination for peripheral arterial disease were verified.

Effect of Induced Membrane Formation Followed by Polymethylmethacrylate Implantation on Diabetic Foot Ulcer Healing When Revascularization Is Not Feasible

No study has investigated the role of induced membrane (IM) formation in treating diabetic foot ulcer (DFU). This retrospective study was aimed (1) at evaluating the potential role of a two-staged surgical approach, comprising polymethylmethacrylate (PMMA) implantation and IM formation, in the treatment of DFU and (2) at comparing the results of those with routine wound debridement in patients with DFUs and nonrevascularized peripheral arterial disease (PAD). Fifty patients with infected DFUs who were not candidates for vascular interventions were enrolled between February 2016 and April 2018 and assigned to the PMMA group (n = 28) and conventional group (n = 22). The healing rate, major amputation rate, duration of healing, frequency of debridement procedures, patient survival rate, and reulceration of DFUs were determined. The Mann-Whitney U test, independent sample t-test, and χ ² or Fisher exact test were used in statistical analysis. Overall clinical outcomes were statistically different between the groups (Z = -2.495, P = 0.013). In the PMMA group, 16 patients (57.1%) with intact IM formation achieved ulceration healing at 13.1 ± 3.7 weeks with a mean number of debridements of 1.3 ± 0.4, which were significantly different compared to those values in 5 patients of the conventional group (22.7%, P = 0.014; healing duration: 26.4 ± 7.8 weeks, P = 0.016; mean number of debridements: 3.6 ± 0.5, P ≤ 0.001). At a mean 16.8 ± 4.3-month follow-up, patient survival rates were 92.9% and 68.2% in the PMMA and conventional groups, respectively (P = 0.032). The major amputation rate and reulceration of DFUs were similar between the groups. The two-staged surgical approach is an available, effective modality for improving healing of DFUs. This study provides preliminary information of IM formation followed by PMMA implantation in the management of DFUs in PAD when revascularization is not feasible.

Morbidity and mortality of infected diabetic foot managed in general surgical department

BACKGROUND

Foot ulcers are diabetes-related complications which occur in 10%-25% in diabetic patients. They are an important cause of morbidity and mortality in diabetes. This retrospective study aimed to assess, using an administrative database, the morbidity and the mortality risk of infected diabetic ulcers.

METHODS

It's a retrospective study enrolling 644 patients operated on for a diabetic foot between January 1st, 2012 and December 31st, 2016 in the surgical department B of Charles Nicolle's Hospital. Logistic regression identified independent predictive factors of major amputation, morbidity and mortality.

RESULTS

This retrospective study showed that "Cardiac failure" (OR=5.00, 95%CI [1.08  23.25], p=0.039), "Admission in the ICU in the first 48h" (OR=12.76, 95%CI [4.92  33.33], p<0.001) and "Major amputation" (OR=6.40, 95%CI [2.41  16.94], p<0.001) were considered as independent predictive factors of mortality. As concerns morbidity, Cardiac failure (OR=0.163, 95%CI [0.055  0.479], p=0.001) and organ failure at admission (OR=0.017, 95%CI [0.004  0.066], p=0.017) were predictive factors of admission in the ICU during the first 48 hours. Besides, advanced age (OR=1.033, 95%CI [1.014  1.052], p=0.001), Pre-operative stay (OR=1.093, 95%CI [1.039  1.151], p=0.001) and admission in the ICU during the first 48 hours (OR=0.142, 95%CI [0.071  0.285], p<0.001) were predictive factors of major amputation. Moreover, Cardiac failure (OR=0.517, 95%CI [0.298  0.896], p=0.019), admission in the ICU during the first 48 hours (OR=0.176, 95%CI [0.088  0.354], p<0.001)  and Pre-operative stay (OR=1.083, 95%CI [1.033  1.134], p=0.001) were predictive variables of complicated post-operative course. Admission in the ICU during the first 48h (OR=0.140, 95%CI [0.48  0.405], p<0.001), major amputation (OR=0.170, 95%CI [0.76  0.379], p<0.001), and number of ICU stays (OR=3.341, 95%CI [1.558  7.164], p=0.002) were predictive factors of medical complications. Preoperative stay (OR=1.091, 95%CI [1.038  1.147], p=0.001) was predictive of reintervention.

CONCLUSIONS

Our retrospective study assessed that mortality rate was inferior when the patient didn't have amputation, no post-operative complications and no reintervention. The main limitation of our study was the retrospective design.

Infection Precedes Heterotopic Ossification in Combat Wounded

Heterotopic ossification is the formation of ossified bone in soft tissue, particularly after soft tissue trauma. Heterotopic ossification is known cause of pain, prosthetic/orthotic malfit, and reoperation following combat extremity injury. The purpose of this research was to examine injury and treatment characteristics that are associated with heterotopic ossification in a broader population of deployment-injured subjects. The Department of Defense Trauma Registry and Military Orthopaedic Trauma Registry was queried for a sample of deployment-injured subjects and the complication of heterotopic ossification. Heterotopic ossification was identified in 15% of subjects following 5% of all injuries. Symptoms attributed to the heterotopic bone were present in 40% of subjects with diagnosed with heterotopic ossification. Heterotopic ossification was not associated with injury severity or aggressiveness of open wound treatment. However, infection was the only positive predictor of heterotopic ossification resulting in two-times greater odds of heterotopic bone formation. This finding is consistent with prior research suggesting that heterotopic ossification requires persistent inflammation to be present in at-risk soft tissue. Among all wounds sustained during deployment injury, heterotopic may not be abundantly common; however, the risk may be further minimized by focused infection control.

Fatal Pulmonary and Cerebellar Zygomycosis due to Rhizomucor pusillus in a Ringed Seal (Pusa hispida)

A 4-year-old captive ringed seal (Pusa hispida) was treated with subcutaneous antibacterial injections for pus exuding wounds in the skin and associated blubber following a bite attack. Three months after the incident, the animal presented nystagmus and died the following day. At necropsy, there was a 25 × 18 × 25 mm well-delineated, opaque nodular mass in the lung, besides the skin ulcers and localized areas of discoloration in the blubber correlating with the bite wound and injection sites. Histopathology of the pulmonary mass demonstrated severe eosinophilic inflammatory infiltration among numerous intralesional fungal hyphae. The hyphae were irregularly branched, broad and aseptate, consistent of zygomycosis. Magnetic resonance imaging was conducted on the head, which was initially frozen intact, revealing diffuse areas of hyperintensity in the cerebellum. Restricted histopathologic examination of the cerebellum showed severe granulomatous inflammation well spread within the neuroparenchyma, associated with abundant intralesional fungal hyphae similar to those appreciated in the pulmonary mass. Molecular analyses of the fungi in the pulmonary and cerebellar tissue identified the etiologic agent in both sites as Rhizomucor pusillus. The likely route of infection is through inhalation of R. pusillus spores or fragmented hyphae from the environment that developed into an initial pulmonary infection, becoming the source of hematogenous dissemination to the cerebellum. The skin and blubber lesions likely contributed to immunosuppression. Zygomycosis is uncommon in pinnipeds, and the present report emphasizes the importance of considering zygomycete dissemination even when the primary focus is highly confined.

Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study

AIMS

To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer.

METHODS

This multicentre, prospective, observational study reviewed participants' data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants' notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence.

RESULTS

In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06).

CONCLUSIONS

Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers.

Rhizopus arrhizus Invasive Infection due to Self-Inflicted Scratch Injuries in a Diabetic Patient with Non-ketotic Acidosis

Mucormycosis is a rare infection caused by members included in the subphylum Mucoromycotina. Characterized by the histopathological hallmark of angioinvasion, these infections affect most often patients with certain underlying conditions carrying immunosuppression (haematological neoplasias, diabetic ketoacidosis and other forms of acidosis, and iron overload) or immunocompetent patients with traumatic mucocutaneous barriers breakdown and direct inoculation of the mould. A case is presented in which a rare underlying condition (non-ketotic acidosis) and a rare cause of cutaneous injuries collide. Prognosis, treatment options and management decisions are described thoroughly.

The microbiology of diabetic foot infections in patients recently treated with antibiotic therapy: A prospective study from India

AIM

Clinicians often treat clinically infected diabetic foot ulcers without information from cultures of the wound. The results of wound cultures may also be affected by previous antibiotic therapy. Thus, we aimed to study the microbial isolates, and antimicrobial sensitivity of previously treated patients with a clinically infected DFU.

RESEARCH DESIGN AND METHODS

293 consecutive patients with clinically infected DFU on prior antimicrobial treatment within the immediate past few days for a duration greater than one week were evaluated for microbial etiology, antibiotic sensitivity and final outcomes. Appropriate tissue samples i.e. purulent drainage, soft-tissue and/ or bone were obtained for aerobic/anaerobic cultures and antimicrobial sensitivities. 71 patients with missing prior antibiotic data were excluded.

RESULTS

313 tissue samples obtained from 222 patients isolated 317 causative organisms. Most of the culture results from tissue specimens were mono-microbial (93.2%) compared to 37% in our previous cohort of 60 patients. Pseudomonas aeruginosa was the most common organism isolated on culture of bone (26.9%) or soft tissue (23.2%) specimen, respectively. Only 23% and 64% of P. aeruginosa isolates and 5.6% and 44% of Acinetobacter sp. were sensitive to quinolones and cephalosporins, respectively.

CONCLUSIONS

Clinically infected DFU recently treated with antibiotics have predominant monomicrobial and multi drug-resistant infection. Quinolones as an empirical antibiotic choice may not be appropriate in this setting.

Effect of limb preservation status and body mass index on the survival of patients with limb-threatening diabetic foot ulcers

AIMS

To evaluate the effect of limb preservation status and body mass index (BMI) on the survival of patients with diabetic foot ulcers (DFUs).

METHODS

A total of 1346 patients treated for limb-threatening DFUs at a major diabetic foot center in Taiwan from 2002 to 2009 were tracked until December 2012. The patients were classified into three groups: limb-preserved (n=858), minor lower-extremity amputation (LEA) (n=249), and major LEA (n=239). Clinical data during treatment were used for survival analysis.

RESULTS

With 729 deaths, the median survival time (MST) was 6.14 (95% CI 5.63-6.65) years. Major LEA and BMI were two independent factors associated with mortality after adjusting for age, diabetic duration, HbA1c level, comorbidities and peripheral artery diseases. The mortality hazard ratios for the minor and major LEA groups were 0.92 (95% CI 0.74-1.16) and 1.34 (95% CI 1.07-1.68), respectively, to the reference group (limb-preserved). After stratifying BMI into four categories (underweight, normal weight, overweight and obesity, according to the Taiwanese definition), the MSTs for each category were 2.57, 5.24, 7.47 and 7.85years, respectively (P for trend <0.01). This "obesity paradox" was not observed in the major LEA group (P for trend 0.25). For patients with LEA, the obesity patients had lower MST than those in overweight category (7.97 and 8.84 in minor and 3.25 and 5.42 in major LEA, respectively).

CONCLUSIONS

For the patients treated for DFUs, major - but not minor - LEA was associated with poor survival compared with the limb-preserved group. The MST had positive correlation with BMI levels for patients with limb-preserved and minor LEA, but not for those with major LEA.

Local Application of Probiotic Bacteria Prophylaxes against Sepsis and Death Resulting from Burn Wound Infection

Objective

To determine if local prophylactic application of probiotic bacteria to burn wounds will prevent death in a mouse model of burn wound sepsis.

Background

Infection remains the most common complication after burn injury and can result in sepsis and death, despite the use of topical and systemic antibiotics. Pseudomonas aeruginosa is a frequently implicated pathogen. Local application of probiotics directly to burn wounds is an attractive novel intervention that avoids the pitfalls of standard antibiotic therapies.

Methods

A burn-sepsis model was established using a sub-eschar injection of bioluminescent P. aeruginosa; infection was tracked using a charge-coupled camera. Full-thickness burn injuries were placed on the dorsums of adult mice; the injured sites were then treated with vehicle (burn wound control), probiotics (Lactobacillus plantarum only), pathogenic bacteria (Pseudomonas aeruginosa only), or probiotics plus pathogen (Lactobacillus plus Pseudomonas). Animals were monitored until death/moribundity or for one week, then sacrificed. Harvested tissues were subjected to imaging and molecular assays.

Results

Control and probiotic-only animals showed no mortality (100% survival) at one week. Pseudomonas-only animals showed > 90% mortality within 40 hours of infection. In contrast, animals treated with probiotics plus Pseudomonas showed less than 10% mortality. Use of bioluminescent Pseudomonas bacteria demonstrated that probiotic therapy inhibited septicemic accumulation of the pathogen in remote organs. In addition, probiotic therapy successfully suppressed the infection-dependent induction of TNF-α and interleukins 6 and 10 in the liver.

Conclusions

Local probiotic therapy shows great potential as a valuable adjunct in the management of complicated burn injury.

Case 17: intravenous drug user injection-site wound

This patient presented with a painful, malodorous, infected wound on his right leg, which was also his main heroin injection site. Following treatment with octenilin Wound Irrigation Solution and a superabsorbent dressing, within 3 weeks all of the symptoms of infection and non-healing had gone.

HIV shedding from male circumcision wounds in HIV-infected men: a prospective cohort study

BACKGROUND

A randomized trial of voluntary medical male circumcision (MC) of HIV-infected men reported increased HIV transmission to female partners among men who resumed sexual intercourse prior to wound healing. We conducted a prospective observational study to assess penile HIV shedding after MC.

METHODS AND FINDINGS

HIV shedding was evaluated among 223 HIV-infected men (183 self-reported not receiving antiretroviral therapy [ART], 11 self-reported receiving ART and had a detectable plasma viral load [VL], and 29 self-reported receiving ART and had an undetectable plasma VL [<400 copies/ml]) in Rakai, Uganda, between June 2009 and April 2012. Preoperative and weekly penile lavages collected for 6 wk and then at 12 wk were tested for HIV shedding and VL using a real-time quantitative PCR assay. Unadjusted prevalence risk ratios (PRRs) and adjusted PRRs (adjPRRs) of HIV shedding were estimated using modified Poisson regression with robust variance. HIV shedding was detected in 9.3% (17/183) of men not on ART prior to surgery and 39.3% (72/183) of these men during the entire study. Relative to baseline, the proportion shedding was significantly increased after MC at 1 wk (PRR = 1.87, 95% CI = 1.12-3.14, p = 0.012), 2 wk (PRR = 3.16, 95% CI = 1.94-5.13, p < 0.001), and 3 wk (PRR = 1.98, 95% CI = 1.19-3.28, p = 0.008) after MC. However, compared to baseline, HIV shedding was decreased by 6 wk after MC (PRR = 0.27, 95% CI = 0.09-0.83, p = 0.023) and remained suppressed at 12 wk after MC (PRR = 0.19, 95% CI = 0.06-0.64, p = 0.008). Detectable HIV shedding from MC wounds occurred in more study visits among men with an HIV plasma VL > 50,000 copies/ml than among those with an HIV plasma VL < 400 copies/ml (adjPRR = 10.3, 95% CI = 4.25-24.90, p < 0.001). Detectable HIV shedding was less common in visits from men with healed MC wounds compared to visits from men without healed wounds (adjPRR = 0.12, 95% CI = 0.07-0.23, p < 0.001) and in visits from men on ART with undetectable plasma VL compared to men not on ART (PRR = 0.15, 95% CI = 0.05-0.43, p = 0.001). Among men with detectable penile HIV shedding, the median log10 HIV copies/milliliter of lavage fluid was significantly lower in men with ART-induced undetectable plasma VL (1.93, interquartile range [IQR] = 1.83-2.14) than in men not on ART (2.63, IQR = 2.28-3.22, p < 0.001). Limitations of this observational study include significant differences in baseline covariates, lack of confirmed receipt of ART for individuals who reported ART use, and lack of information on potential ART initiation during follow-up for those who were not on ART at enrollment.

CONCLUSION

Penile HIV shedding is significantly reduced after healing of MC wounds. Lower plasma VL is associated with decreased frequency and quantity of HIV shedding from MC wounds. Starting ART prior to MC should be considered to reduce male-to-female HIV transmission risk. Research is needed to assess the time on ART required to decrease shedding, and the acceptability and feasibility of initiating ART at the time of MC.

Lemierre's Syndrome Associated with Periodontal Injury-derived Odontogenic Infection that Did Not Respond to Meropenem

A 33-year-old previously healthy man injured his gums and subsequently developed dyspnea and fever. A chest X-ray showed nodules and infiltrates in both lungs, and the patient was initially diagnosed with pneumonia and administered meropenem hydrate, although his symptoms did not improve. A blood culture identified Fusobacterium necrophorum, and thrombophlebitis in the internal jugular vein of the neck was observed on computed tomography and ultrasound scans. We replaced the meropenem with clindamycin, sulbactam/ampicillin and metronidazole, and the patient's symptoms improved.

Contribution of infection and peripheral artery disease to severity of diabetic foot ulcers in Chinese patients

AIM

The objective of the current ongoing study was to evaluate the characteristics of diabetic patients with newly diagnosed foot ulcer in Burn & Plastic Hospital of PLA General Hospital.

METHODS

A total of 1002 consecutive patients presenting with a new foot ulcer between March 2007 and September 2013 were enrolled. All enrolled patients were classified based on presence or absence of collateral infection, disabling comorbidities and peripheral arterial disease (PAD).

RESULTS

Of patients, 70.05% had PAD, which occurred significantly more in elderly adults. Patients with PAD had higher incidence of infection (58.9% vs. 41.5% in non-PAD group) and disabling comorbidities (79% in PAD and 61% in non-PAD; p < 0.038). There was no significant difference observed in depth, size and duration of foot ulcers between the PAD and non-PAD group of enrolled diabetic patients.

CONCLUSIONS

Diabetic foot ulcer is more prominent in patients with PAD that is further reflected by significantly more underlying cases of infection and disabling comorbidity.

Hyperbaric oxygenation therapy for crush injuries reduces the risk of complications: research report

BACKGROUND

Hyperbaric oxygen (HBO2) therapy has been adopted for crush injuries, but there are few studies supporting its use. We therefore investigated the effects of HBO2 on management of patients with complicated crush injuries.

METHODS

This historic cohort study included patients with crush injuries and open fractures with severities greater than or equal to Gustilo class IIIA. We divided the patients into two groups: Control and HBO2. The control group received conventional treatment, while the HBO2 group received conventional treatment plus HBO2. We compared the groups with respect to the incidence of infection, need for additional surgery, and length of intensive care unit (ICU) and hospital stays.

RESULTS

There were 16 patients in the HBO2 group and 13 in the control group. There were no patients with infections in the HBO2 group, whereas in the control group six patients had infections and five needed another drainage procedure. These incidences were significantly lower in the HBO2 group (p = 0.003 and 0.013). However, the durations of ICU and hospital stays were similar across the two groups.

CONCLUSIONS

HBO2 is effective in the management of crush injuries from the viewpoint of reducing complications and reoperations. These observations should be verified in additional studies with larger sample sizes because the patient number is limited.

Gram negative wound infection in hospitalised adult burn patients--systematic review and metanalysis-

BACKGROUND

Gram negative infection is a major determinant of morbidity and survival. Traditional teaching suggests that burn wound infections in different centres are caused by differing sets of causative organisms. This study established whether Gram-negative burn wound isolates associated to clinical wound infection differ between burn centres.

METHODS

Studies investigating adult hospitalised patients (2000-2010) were critically appraised and qualified to a levels of evidence hierarchy. The contribution of bacterial pathogen type, and burn centre to the variance in standardised incidence of Gram-negative burn wound infection was analysed using two-way analysis of variance.

PRIMARY FINDINGS

Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter baumanni, Enterobacter spp., Proteus spp. and Escherichia coli emerged as the commonest Gram-negative burn wound pathogens. Individual pathogens' incidence did not differ significantly between burn centres (F (4, 20) = 1.1, p = 0.3797; r2 = 9.84).

INTERPRETATION

Gram-negative infections predominate in burn surgery. This study is the first to establish that burn wound infections do not differ significantly between burn centres. It is the first study to report the pathogens responsible for the majority of Gram-negative infections in these patients. Whilst burn wound infection is not exclusive to these bacteria, it is hoped that reporting the presence of this group of common Gram-negative "target organisms" facilitate clinical practice and target research towards a defined clinical demand.

Diabetic foot infections: state-of-the-art

Foot infections are frequent and potentially devastating complications of diabetes. Unchecked, infection can progress contiguously to involve the deeper soft tissues and ultimately the bone. Foot ulcers in people with diabetes are most often the consequence of one or more of the following: peripheral sensory neuropathy, motor neuropathy and gait disorders, peripheral arterial insufficiency or immunological impairments. Infection develops in over half of foot ulcers and is the factor that most often leads to lower extremity amputation. These amputations are associated with substantial morbidity, reduced quality of life and major financial costs. Most infections can be successfully treated with optimal wound care, antibiotic therapy and surgical procedures. Employing evidence-based guidelines, multidisciplinary teams and institution-specific clinical pathways provides the best approach to guide clinicians through this multifaceted problem. All clinicians regularly seeing people with diabetes should have an understanding of how to prevent, diagnose and treat foot infections, which requires familiarity with the pathophysiology of the problem and the literature supporting currently recommended care.

[Treatment of septic complications of thoracic injuries]

Treatment results of 77 patients with suppurative lung complications after injuries (n=22) and closed thoracic trauma (n=55) were analyzed. It was registered, that purulent process in lung was typical for the cases with direct primary lung tissue injury: 72.7% of patients with penetrating thoracic injuries and 83.6% of patients with closed chest trauma. Complex conservative treatment with adequate bronchial and transthoracic drainage proved to be the most effective modalities during the acute suppurative phase. Gram-negative flora proved to be the cause of chronic forms of suppuration. The overall chronisation rate of the lung abscess was 4.5% after penetrating thoracic injuries and 10.9% of patients with closed chest trauma.

[Dislocation and necrosis of the first, second and third wedges. Management with the Masquelet technique. A case report]

The induced membrane technique was first described by Masquelet in 1986. It was initially used for the reconstruction of long bone shaft defects, particularly of the femur and tibia. The technique consists of two stages. During the first stage a membrane is induced to provide support to the grafts and supply growth factors that contribute to provide a favorable receiving bed for the future graft. During the second stage the poly-methyl-methacrylate spacer is removed and replaced with bone grafts, usually harvested from the iliac crest. Given that this technique has proven good results, it started to be used at other bone sites. We present herein the case of a patient with a large bone defect in the midfoot in whom the Masquelet technique was used with iliac crest grafts. Arthrodesis with a distal radius plate was performed to improve medial column stability, with favorable clinical and functional results.

Does this patient have an infection of a chronic wound?

CONTEXT

Chronic wounds (those that have not undergone orderly healing) are commonly encountered, but determining whether wounds are infected is often difficult. The current reference standard for the diagnosis of infection of a chronic wound is a deep tissue biopsy culture, which is an invasive procedure.

OBJECTIVES

To determine the accuracy of clinical symptoms and signs to diagnose infection in chronic wounds and to determine whether there is a preferred noninvasive method for culturing chronic wounds.

DATA SOURCES

We searched multiple databases from inception through November 18, 2011, to identify studies focusing on diagnosis of infection in a chronic wound.

STUDY SELECTION

Original studies were selected if they had extractable data describing historical features, symptoms, signs, or laboratory markers or were radiologic studies compared with a reference standard for diagnosing infection in patients with chronic wounds. Of 341 studies initially retrieved, 15 form the basis of this review. These studies include 985 participants with a total of 1056 chronic wounds. The summary prevalence of wound infection was 53%.

DATA EXTRACTION

Three authors independently assigned each study a quality grade, using previously published criteria. One author abstracted operating characteristic data.

DATA SYNTHESIS

An increase in the level of pain (likelihood ratio range, 11-20) made infection more likely, but its absence (negative likelihood ratio range, 0.64-0.88) did not rule out infection. Other items in the history and physical examination, in isolation or in combination, appeared to have limited utility when infection was diagnosed in chronic wounds. Routine laboratory studies had uncertain value in predicting infection of a chronic wound.

CONCLUSIONS

The presence of increasing pain may make infection of a chronic wound more likely. Further evidence is required to determine which, if any, type of quantitative swab culture is most diagnostic.

Integrated surgical protocol for the treatment of the infected diabetic foot

Diabetes is a chronic disease with a worldwide increasing trend. Feet complication, closely related to neuropathy and obstructive peripheral vascular disease, are responsible for more than 1 million of leg amputations every year. Foot infection can dramatically improve the risk of amputation. Although many ulcer classification systems have been proposed to stratify the severity of infectious process the problem of the definition of a correct therapeutic approach to different clinical pictures still remains unresolved. A diabetic foot triage and an integrated surgical protocol are proposed to try identifying a diagnostic flowchart and a step-by-step surgical protocol that can be applied in the treatment of diabetic foot infection. Goals and technical aspects of emergent and elective surgical procedures in diabetic foot are analysed to evaluate critical aspects and to suggest proper surgical choices.

[The application of topical negative pressure in the complex treatment of acute suppurative diseases of soft tissues]

Negative pressure wound treatment (NPWT) is one of the newest methods used in the treatment of wounds. It allows speeding up and optimizing the healing process and reducing the cost of treatment. Negative pressure stimulates proliferation of granulation tissue, provides a continuous evacuation of fluid and effectively cleans wound surface. The authors present to the reader the results of treatment of acute suppurative diseases of soft tissues with the method of topical negative pressure.

Necrotising fasciitis caused by Vibrio vulnificus in the lower limb following exposure to seafood on the hand

Vibrio vulnificus infection mainly manifests as primary bacteraemia or gastroenteritis following injection of the microorganism, and wound infection through direct inoculation. Injury from exposure to the microorganism and development of necrotising fasciitis at a remote site and sepsis are rare. This report is of a high-risk patient with haemoglobin H disease who developed necrotising fasciitis in the lower limb after exposure to seafood on the hand.

A fatal case of necrotizing Aeromonas schubertii fasciitis after penetrating injury

Necrotizing fasciitis is an uncommon but life-threatening condition with a high associated mortality and morbidity. Most infections are polymicrobial, another distinct form of necrotizing fasciitis that occurred by penetrating freshwater trauma, such as fishing or wading in wet fields. Aeromonas species are responsible. The rapidity of the infectious process is similar to that of clostridial infection, but gas production is not a consistent feature. We report a patient who presented with fever, chills, and bullae on left forearm, despite antibiotics and wound debridement; the infection extend to mid humerus with a rapid onset of skin necrosis and progressive sepsis. Aeromonas schubertii fasciitis is particularly virulent. An apparent superficial cellulitis that fails to respond to standard therapy must raise suspicion of a more extensive underlying subcutaneous infection. Aggressive surgical debridement and antibiotic coverage for gram-negative rods are the essential features of treatment. Delay caused by a mistaken diagnosis of cellulitis and subsequent inadequate debridement would likely prove fatal.

Reverse sural flap cover within a ring fixator

The ring fixator is an ideal apparatus to treat infected gap nonunion of the tibia and to correct deformity in multiple planes. However soft tissue problems may arise during transport and at docking. Although various options such as free flaps, neurocutaneous flaps, fasciocutaneous flaps and cross leg flaps are available for flap cover, this is always done prior to application of a ring fixator. The versatility of the sural flap in terms of coverage of leg defects, ease of performing flap cover as well as its reliability and safety is well known. We describe an alternate way of treating soft tissue problems which occur at the lower third of the leg while being treated on an Ilizarov frame. We describe the surgical procedure followed in raising the flap and its anterior transposition within the Ilizarov frame in two patients.

Independent risk factors of morbidity in penetrating colon injuries

BACKGROUND

The present study explored the factors effective on colon-related morbidity in patients with penetrating injury of the colon.

METHODS

The medical records of 196 patients were reviewed for variables including age, gender, factor of trauma, time between injury and operation, shock, duration of operation, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), site of colon injury, Colon Injury Score, fecal contamination, number of associated intra- and extraabdominal organ injuries, units of transfused blood within the first 24 hours, and type of surgery. In order to determine the independent risk factors, multivariate logistic regression analysis was performed.

RESULTS

Gunshot wounds, interval between injury and operation > or =6 hours, shock, duration of the operation > or =6 hours, PATI > or =25, ISS > or =20, Colon Injury Score > or = grade 3, major fecal contamination, number of associated intraabdominal organ injuries >2, number of associated extraabdominal organ injuries >2, multiple blood transfusions, and diversion were significantly associated with morbidity. Multivariate logistic regression analysis showed diversion and transfusion of > or =4 units in the first 24 hours as independent risk factors affecting colon-related morbidity.

CONCLUSION

Diversion and transfusion of > or =4 units in the first 24 hours were determined to be independent risk factors for colon-related morbidity.