Aggressive Surgical Treatment Research Articles

Clinical Characteristics and Outcomes of Staphylococcus lugdunensis Prosthetic Joint Infections: A Multicenter Retrospective Analysis.

Staphylococcus lugdunensis has been increasingly recognized as a cause of serious infections, particularly prosthetic joint infections (PJIs). The aim of this study was to describe the clinical characteristics, treatments, and outcomes of S lugdunensis PJIs. This was a retrospective multicenter study of consecutive adult patients with S lugdunensis PJIs from January 2007 through December 2017; 28 patients met inclusion criteria. The knee was the most commonly affected joint (67.9%), followed by the hip (25%). Clinical and microbiologic characteristics, treatment modalities, and outcomes were evaluated. Thirteen (46.4%) patients had two-stage revision, 9 (32.1%) had debridement with or without revision, 5 (21.4%) had no surgical intervention, and 1 (3.6%) had one-stage revision. Twenty-four (85.7%) patients had monomicrobial infection with S lugdunensis, whereas 4 had polymicrobial. Two patients had concomitant bacteremia. All isolates, except 1, were susceptible to oxacillin. Three patients with no surgical intervention received oral antibiotics, 2 were not treated, and 1 was discharged to hospice. Relapse was observed in 2 of 13 (15%) patients who had two-stage revision, 4 of 9 (44%) who had debridement, and 6 of 6 (100%) who had no surgical intervention or one-stage revision regardless of antibiotic treatment regimen. There was a significant difference in cure rate for patients who underwent two-stage revision compared with other treatment modalities (85% vs 33%, P=.009). Appropriate management of S lugdunensis PJI includes both aggressive surgical treatment and a prolonged course of antibiotics and is associated with excellent clinical response. Regardless of route or duration of antibiotic therapy, relapse is high for patients not treated with two-stage revision. [Orthopedics. 2020;43(6):345-350.].

RARE COMPLICATION OF BILATERAL BRONCHOESOPHAGEAL FISTULAS DUE TO INVASIVE MUCORMYCOSIS AFTER RENAL TRANSPLANTATION

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bronchoesophageal fistula (BEF) is a rare pathological connection between the esophagus and bronchi. Most are acquired due to esophageal or lung cancer. A small subset is caused by opportunistic infections in the immunocompromised. To our knowledge, this is the first case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. CASE PRESENTATION: 67 year old male with hypertension, diabetes, ESRD status post kidney transplant one month prior presents with two weeks of dysphagia, cough, and fatigue. Initial labs were significant for leukocytosis. Computed Tomography (CT) of the chest showed nonspecific pulmonary nodules and a mediastinal mass contiguous with the esophagus concerning for malignancy. EGD revealed an esophageal ulcer that was biopsied. Flexible bronchoscopy with bronchoalveolar lavage and EBUS of subcarinal lymph node was also obtained. Over the course of 72 hours, patient’s clinical status deteriorated. His oxygen requirements increased from nasal canula to high flow in a matter of hours and was ultimately intubated due to hypoxic respiratory failure. After intubation, patient had persistent air leak and remained hypoxic despite being on 100% FiO2. His ET tube was upsized from 7.5mm to 8.5mm due to concern for tracheomalacia. At this time, BAL cultures and esophageal cultures grew mucor. Amphotericin B was initiated. Repeat chest CT showed possible BEFs. Bedside bronchoscopy revealed bilateral white exudate at the level of the right and left mainstem bronchi. Gas bubbles from the esophagus were visible, confirming the bilateral BEFs. During this time patient developed septic shock requiring multiple pressors and persistent hypoxia despite maximal ventilatory settings. Cardiothoracic surgery team offered last-resort surgery including total esophagectomy and lobectomy with reconstruction of BEFs. However, given the extremely high mortality risk, the family declined. The patient passed away shortly after. DISCUSSION: Invasive mucormycosis is a rare, opportunistic fungal infection that presents in immunocompromised patients with underlying diabetes mellitus. Rhino-orbital-cerebral and pulmonary infections are the most common sources. Diagnosis can be made by tissue histopathology with culture confirmation. Due to its aggressive nature, local invasion often leads to multi-organ dysfunction. BEFs are extremely rare complications of invasive mucormycosis. Unfortunately, even with aggressive anti-fungal and surgical intervention, invasive mucormycosis carries extremely high mortality rate. CONCLUSIONS: To our knowledge, this is the first reported case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. Our EGD and bronchoscopy images illustrate the aggressive nature of this fungi. Due to its high mortality rate, early detection, anti-fungal therapy, and surgical debridement are critical. Reference #1: Lee et al. Rare complication of bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia: a case report. Journal of Medical Case Reports (2016) 10:195 DISCLOSURES: No relevant relationships by Dafang Chen, source=Web Response No relevant relationships by Keith Killu, source=Web Response No relevant relationships by Brett Lindgren, source=Web Response No relevant relationships by Neha Mehta, source=Web Response

Does intervention always essential for aorto-right ventricular outflow tract fistula after surgical aortic valve replacement? : A case report

Surgical aortic valve replacement is an effective treatment for symptomatic severe aortic stenosis in patients with low-intermediate operative risk. Prosthetic valve endocarditis is a complication after aortic valve replacement and accounts for 20% of infective endocarditis. Prosthetic valve endocarditis sometimes complicates with abscess formation, pseudoaneurysm and aorto-cardiac fistula. Although severity of symptoms mostly depend on shunt’s size, aorto-cardiac fistula has high mortality rate despite aggressive surgical and percutaneous intervention. Rarely, small shunts can be tolerated. We describe a case of aorto-right ventricle outflow tract fistula presented with signs and symptoms of congestive heart failure and remained asymptomatic under medical therapy.

Group B Streptococcus Infected Tenosynovitis in Diabetic Foot Ulcers

Category:Diabetes; OtherIntroduction/Purpose:The incidence of Streptococcus agalactiae (Group B Streptococcus, GBS) infection in diabetic foot ulcers (DFU) has been on the rise. Severe soft tissue damage, which often leads to septicemia and amputation, has been reported in many cases. With the paucity of literature, we aimed to investigate the clinical outcome of GBS infected DFU patients. We hypothesize that GBS patients have a greater severity of infection as indicated by elevated inflammatory markers, more frequent wound complication, and a higher rate of unplanned readmission and reoperation.Methods:Data was retrospectively collected in a single academic orthopedic surgeon’s practice from February 2015 to October 2019. Seventy-eight patients with infected DFUs who underwent surgical treatment formed the basis of this study. Infected bone samples were obtained intraoperatively and sent for standard culture. The microbe data, demographic data (age, gender, race, ethnicity, and BMI), comorbidities, and initial lab values (HgA1C, CRP, ESR, WBC, and glucose) were recorded for all patients. Sixteen GBS infected DFU patients (20.5%) were identified. Among them, GBS infection occurred in 9 acute (<2 wks), 2 subacute (4-6 wks), and 5 chronic (>6 wks) DFUs. Clinical outcome was assessed by surgical outcome, wound healing status, post-operative complications, unplanned readmission, and unplanned reoperation within 3 months following initial surgery. Mean, standard deviation, percentage and range were calculated for patient demographics and inflammatory markers. Statistical significance of inflammatory markers between patients with and without GBS was also calculated.Results:The initial procedures were irrigation and debridement (n=11), toe amputation (n=1), ray amputation (n=2), transmetatarsal amputation (n=1), and a partial calcanectomy (n=1). Five GBS patients (31.3%), as compared to eighteen (29%) DFU patients without GBS, developed post-surgical complications (wound dehiscence, recurrent infection, septicemia) which required unplanned readmission and reoperation. Repeat operations were irrigation and debridement (n=1), metatarsal ray amputation (n=1), ray amputation (n=1), and below knee amputation (n=2) with average number of 2 repeat operations (range: 1 - 5). Hemoglobin A1C (p=.0067) was statistically higher in GBS patients. When comparing acute GBS ulcers (n=9) and acute ulcers without GBS (n=18), CRP (p=.037), HgA1C (p=.026), and blood glucose (p=.046) were all found to be significantly higher in patients with GBS DFUs.Conclusion:GBS infected DFU patients generally showed more extensive and severe soft tissue inflammation, as indicated by higher inflammatory markers at initial presentation. Compared to other patients with DFUs, GBS patients had significantly higher HgA1C values, and in those experiencing acute ulcers, had higher CRP, HgA1C, and blood glucose values. They have higher rates of post-operative complications that required unplanned readmission and reoperation at more proximal level. Surgeons should consider time sensitive and aggressive surgical treatment for GBS infected DFUs and counsel patients on the high risk of post- operative complications and repeat surgery.

Necrotizing fasciitis caused by the treatment of chronic non-specific back pain

BackgroundChronic back pain is a multifactorial disease that occurs particularly in adults and has many negative effects on the quality of daily life. Therapeutic strategies are often multimodal and designed for a long-term therapy period. In some cases, one option is joint infiltration or intrathecal injection with local anaesthetics. An adverse effect of this intervention may be necrotic fasciitis, a disease with high mortality and few therapeutic options.Case presentationThis case shows a 53-year-old female patient who developed necrotic fasciitis after infiltrations of the sacroiliac joint and after epidural-sacral and intrathecal injections.ConclusionThanks to early and aggressive surgical intervention, antibiotic treatment and hyperbaric oxygenation, she survived this serious complication and was able to return to life.

Pocket-Size Mobile Echocardiographic Screening of Thoracic Aortic Aneurysms in Hypertensive Patients

Patients with hypertension may develop a thoracic aortic aneurysm (TAA) that can be asymptomatic but potentially life-threatening. We sought to assess the prevalence of asymptomatic TAA among hypertensive patients with a point-of-care screening program using pocket-size mobile echocardiographic (PME) devices. We prospectively performed transthoracic aortic ultrasound using a PME device on patients attending our hypertension clinics between June 2016 and July 2018. The echo examinations were performed by a research fellow to obtain aortic diameter measurements including the aortic sinus, sinotubular junction, ascending aorta, aortic arch, and descending thoracic aorta through various standard echo views. Images were stored on the PME and transferred to a desktop computer for measurements and further statistical analysis. During the study period 1529 hypertensive patients (mean age, 62 years [range, 30-85]; 824 men) were recruited. The prevalence of TAA (defined as maximum aortic diameter ≥ 4.5 cm and/or >50% larger than the diameter of the adjacent normal aorta) in our study population was 7.5% (115/1529). Multiple logistic regression analysis identified male gender (odds ratio, 2.120; P < .001) and older age (odds ratio, 1.031; P < .001) as independent factors associated with TAA. Silent TAA is common among hypertensive patients in Hong Kong. We found the PME device to be effective in detecting TAA in a clinic setting. Such an approach may be useful for early detection of TAA among at-risk patients, allowing aggressive blood pressure control and early surgical intervention to prevent catastrophic complications.

Aetiology of Ludwig’s Angina: A Hospital Based Study

Introduction: Ludwig’s angina is potentially life-threatening spreading cellulites of neck with high level of morbidity and mortality. Dental caries and diabetes mellitus are most common aetiological factor for Ludwig’s angina. Bad oral hygiene and poor socioeconomic condition are also responsible for this grave disease. This disease was frequently fatal; mortality rates for Ludwig’s angina exceeded 50% in the pre antibiotic era; however, antibiotics and aggressive surgical intervention have significantly reduced mortality recent series quote mortalities of 0-10%. Objectives: To find out the aetiology of patient’s of Ludwig’s angina.&#x0D; Materials and Methods: This cross sectional descriptive study was conducted among 89 patients admitted in the Department of ENT and Head-Neck Surgery in Dhaka Medical College Hospital from 01.07.2010 to 30.06.2012. Patients were selected by specified inclusion and exclusion criteria. Data were collected in a structured questionnaire and analysed by SPSS 16.0 for Windows.&#x0D; Results: Among 89 patients about 69% were from rural area and55% from poor socio-economic class. Sixty-four patients (74.2%) suffered from dental caries and 15.7% were diabetic.&#x0D; Conclusion: Study shows some factors like dental caries, bad oral hygiene, oral mucosal infections, diabetes mellitus were associated with Ludwig’s angina, which may be preventable and curable by early diagnosis and intervention. The public awareness regarding aetiology of Ludwig’s angina may contribute great role in reduction of this disease prevalence.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 81-83

Surgical management of infectious and noninfectious melting corneal ulcers in cats

A melting ulcer, characterized by the stromal dissolution of the cornea, is an important eye lesion that develops due to various reasons and threatens vision. Restoration of this lesion, which causes loss of corneal transparency, requires aggressive medical and surgical treatment. In medical treatment, stromal degeneration is controlled with agents that support topical antibacterial and stromal healing. Surgical treatment is applied using various techniques to remove structures damaged due to the progression of corneal melting and to promote corneal healing. In this study, lamellar keratectomy and the third eyelid flap techniques were combined with topical medical therapy in 20 cat cases with melting ulcers. The aim of this study was to alert to general practitioners that this condition is an important cause of progressive eye loss and necessitates urgent intervention and to show that this treatment approach is easy to implement and has successful results. Key words:

The aggressive surgical treatment and outcome of a colon cancer patient with COVID-19 in Wuhan, China

BackgroundCancer patients are at increased risk of novel coronavirus disease 2019 (COVID-19). Currently, surgeries for cancer patients with COVID-19 are generally suggested to be properly delayed.Case presentationWe presented a 69-year-old Chinese female colon cancer patient with COVID-19, the first case accepted the surgical treatment during the pandemic in China. The patient developed a fever on January 28, 2020. After treatments with Ceftriaxone and Abidol, her fever was not moderated yet. A repeat chest computed tomography (CT) scan showed significantly exacerbated infectious lesions with a positive result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid. An abdomen CT scan indicated the tumor of ascending colon with local wrapped changes. She was diagnosed with ‘Severe novel coronavirus pneumonia’ and ‘Incomplete bowel obstruction: Colon cancer?’. After actively anti-inflammatory and anti-viral therapies, a right colectomy with lymph node dissection was performed on March 11, followed by a pathological examination. The patient successfully recovered from COVID-19 pneumonia and incomplete bowel obstruction after surgery without any postoperative related complications and was discharged on the 9th day after operation. Significant degeneration, necrosis and slough of focal intestinal and colonic mucosal epithelial cells were observed under microscope. No surgeons, nurses or anesthetists in our team were infected with SARS-CoV-2.ConclusionsIt is meaningful and imperative to share our experience of protecting health care personnels from SARS-CoV-2 infection and providing references for optimizing treatment of cancer patients, at least for the operative intervention with absolute necessity or surgical emergency, during the outbreak of COVID-19.

Primary melanotic tumors of the nervous system: a consecutive case series.

Primary melanotic tumors of the nervous system (PMTNS) are thought to be an exceedingly rare group of tumors not captured by tumor registries. We aimed to determine relative incidence, clinical presentation, diagnostic findings, patient management, and outcome. We retrospectively searched the database of the Section of Neuro-Oncology at the Yale Cancer Center for patients with primary or metastatic melanotic lesions of the nervous system. For patients with PMTNS, we recorded demographic data, clinical presentation, histopathological and imaging findings, therapy, and outcome. A total of 116 patients with melanotic lesions were identified, including four patients with PMTNS. The relative incidence of PMTNS was therefore calculated as 3.4%. Histology of PMTNS patients revealed melanocytoma in three patients and psammomatous melanotic schwannoma in one patient. Symptoms were non-specific and attributed to tumor mass effect. Magnetic resonance imaging showed hyperintensity on pre-contrast T1-weighted imaging, hypointensity on T2-weighted imaging, and homogenous contrast enhancement in all PMTNS patients. Definitive diagnosis was based on tissue analysis, with detection of melanin-containing cells on conventional histology and S100-positivity on immunohistochemistry. Molecular analysis for GNAQQ209L mutation assisted in establishing diagnosis when only small amounts of tissue were available. Aggressive surgical treatment showed favorable outcomes in all cases; radiation therapy was used for residual or relapsed disease. The median follow-up was 7.5±5years, and all patients were alive on the day of database closure. Primary melanotic tumors of the nervous system are rare nervous system tumors. Outcome appears excellent, and complete surgical resection may form the basis for favorable outcome. Radiation therapy may represent a therapeutic approach for residual or relapsed disease.

Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review

Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population. A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231). Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients. This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization. Systematic Review, level IV.

Inflammatory Mediators in Glioma Microenvironment Play a Dual Role in Gliomagenesis and Mesenchymal Stem Cell Homing: Implication for Cellular Therapy.

Glioblastoma is the most aggressive malignant primary brain tumor, with a dismal prognosis and a devastating overall survival. Despite aggressive surgical resection and adjuvant treatment, average survival remains approximately 14.6 months. The brain tumor microenvironment is heterogeneous, comprising multiple populations of tumor, stromal, and immune cells. Tumor cells evade the immune system by suppressing several immune functions to enable survival. Gliomas release immunosuppressive and tumor-supportive soluble factors into the microenvironment, leading to accelerated cancer proliferation, invasion, and immune escape. Mesenchymal stem cells (MSCs) isolated from bone marrow, adipose tissue, or umbilical cord are a promising tool for cell-based therapies. One crucial mechanism mediating the therapeutic outcomes often seen in MSC application is their tropism to sites of injury. Furthermore, MSCs interact with host immune cells to regulate the inflammatory response, and data points to the possibility of using MSCs to achieve immunomodulation in solid tumors. Interleukin 1β, interleukin 6, tumor necrosis factor α, transforming growth factor β, and stromal cell–derived factor 1 are notably up-regulated in glioblastoma and dually promote immune and MSC trafficking. Mesenchymal stem cells have widely been regarded as hypoimmunogenic, enabling this cell-based administration across major histocompatibility barriers. In this review, we will highlight (1) the bidirectional communication of glioma cells and tumor-associated immune cells, (2) the inflammatory mediators enabling leukocytes and transplantable MSC migration, and (3) review preclinical and human clinical trials using MSCs as delivery vehicles. Mesenchymal stem cells possess innate abilities to migrate great distances, cross the blood-brain barrier, and communicate with surrounding cells, all of which make them desirable “Trojan horses” for brain cancer therapy.

Risk factors and treatment outcomes of 239 patients with testicular granulosa cell tumors: a systematic review of published case series data

PurposeTesticular granulosa cell tumors (tGrCT) are rare sex cord-stromal tumors. This review aims to synthesize the available evidence regarding the clinical presentation and clinicopathological characteristics, treatment and outcomes.MethodsWe conducted a systematic literature search using the most important research databases. Whenever feasible, we extracted the data on individual patient level.ResultsFrom 7863 identified records, we included 88 publications describing 239 patients with tGrCT. The majority of the cases were diagnosed with juvenile tGrCT (166/239, 69%), while 73/239 (31%) patients were diagnosed with adult tGrCT. Mean age at diagnosis was 1.5 years (± 5 SD) for juvenile tGrCT, and 42 years (± 19 SD) for adult tGrCT. Information on primary treatment was available in 231/239 (97%), of which 202/231 (87%) were treated with a radical orchiectomy and 20/231 (9%) received testis sparing surgery (TSS). Local recurrence after TSS was observed in 1/20 (5%) cases. Metastatic disease was never observed in men with juvenile tGrCT but in 7/73 (10%) men with adult tGrCT. In 5/7 men with metastatic tGrCT, metastases were diagnosed at initial staging, while 2/7 patients developed metastases after 72 and 121 months of follow-up, respectively. Primary site of metastasis is represented by the retroperitoneal lymph nodes, but other sites including lungs, liver, bone and inguinal lymph nodes can also be affected. In comparison with non-metastatic adult tGrCT, men with metastatic adult tGrCT had significantly larger primary tumors (70 vs 24 mm, p 0.001), and were more likely to present with angiolymphatic invasion (57% vs 4%, p 0.002) or gynecomastia (29% vs 3%, p 0.019). In five out of seven men with metastatic disease, resection of metastases or platinum-based chemotherapy led to complete remission.ConclusionJuvenile tGrCT represent a benign entity whereas adult tGCTs have metastatic potential. Tumor size, presence of angiolymphatic invasion or gynecomastia represent risk factors for metastatic disease. The published literature supports the use of testis sparing surgery but there is only limited experience with adjuvant therapies. In the metastatic setting, the reviewed literature suggests that aggressive surgical and systemic treatment might cure patients.

A Multidisciplinary Pathway for the Diagnosis and Treatment of Infectious Endocarditis.

Clinical pathways can be useful when disparate clinical-pathologic groups converge on a common diagnostic and therapeutic trajectory. The progressive increase in the incidence of endocarditis in the US has included higher-risk subjects whose candidacy for aggressive cardiac surgical intervention may be highly resource-intensive, prohibitively high risk, or delayed and possibly deferred by comorbidities. We sought to define the sequence, application, and resolution of multidisciplinary endocarditis team decision-making in 4 distinct clinical groups.

Acute Infectious Bilateral Vasitis Complicated by Fournier’s gangrene

Acute infectious vasitis is a rare disease of inflammation of the vas deferens and spermatic cord and it is usually unilateral disease Herein we present a case of a 62-year-old male with acute infectious bilateral vasitis. The patient initially was managed conservatively with antibiotics. However, during the course, the scrotum became heavily inflamed, with the production of exudate and the formation of blisters and required surgical exploration. We performed debridement and left orchiectomy due to Fournier’s gangrene. Fortunately, the patient had an uneventful recovery. Vasitis is a rare disease which although it has a benign courses it may be complicated by Fournier’s gangrene. In such a case aggressive surgical treatment will resolve the situation.

One-year postoperative mortality rate among the elderly with hip fractures at a single tertiary care center.

ABSTRACTBACKGROUND: Hip fractures are one of the leading causes of disability and dependency among the elderly. The rate of hip fractures has been progressively increasing due to the continuing increase in average life expectancy. Surgical intervention is the mainstay of treatment, but with an increasing prevalence of comorbid conditions and decreased functional capacity in elderly patients, more patients are prone to postoperative complications.OBJECTIVES: Assess the value of surgical intervention for hip fractures among the elderly by quantifying the 1-year mortality rate and assessing factors associated with mortality.DESIGN: Medical record review.SETTING: Tertiary care center.PATIENTS AND METHODS: All patients 60 years of age or older who sustained a hip fracture between the period of 2008 to 2018 in a single tertiary healthcare center. Data was obtained from case files, using both electronic and paper files.MAIN OUTCOME MEASURES: The 1-year mortality rate for hip fracture, postoperative complications and factors associated with mortality.SAMPLE SIZE: 802 patients.RESULTS: The majority of patients underwent surgical intervention (93%). Intra- and postoperative complications were 3% and 16%, respectively. Four percent of the sample died within 30 days, and 11% died within one year. In a multivariate analysis, an increased risk of 1-year mortality was associated with neck of femur fractures and postoperative complications (P=.034, <.001, respectively)CONCLUSION: The 1-year mortality risk in our study reinforces the importance of aggressive surgical intervention for hip fractures.LIMITATION: Single-centered study.CONFLICT OF INTEREST: None.

A Retrospective Cohort and Systematic Review of Non-Operative Management of Exposed Calvaria Post-Radiotherapy.

Scalp defects with exposed calvaria that have previously been irradiated present a unique reconstructive challenge. Patients with previously radiated scalp defects often have few reconstructive options due to poor health or personal choice. The aim of this study was to evaluate the results of non-operative management for patients with prior radiotherapy to the scalp who developed exposed calvaria. The outcomes of interest were major and minor complications related to exposed calvaria with a time frame of follow-up of greater than one year or death from any cause.A retrospective chart review was performed to identify patients with prior radiotherapy and surgery for skin cancer to the scalp who subsequently developed exposed calvaria. Data from four surgeons from 2008 to 2019 was collected. Next, a systematic review of PubMed, EMBASE, Cochrane Library, and CINAHL was conducted to identify articles in which non-operative management was utilized for exposed calvaria post-radiotherapy.Nineteen patients were identified who received radiotherapy either before developing recurrent malignancy requiring operation or requiring radiation postoperatively because of close or involved margins and who subsequently developed exposed calvaria. Six of these patients had an additional attempt at local flap or skin grafting that failed. All patients had an American Society of Anesthesiologists score of three or four. All were managed with local wound care. Ten patients had near-complete healing with wound care alone. Eight patients are still alive from one to six years after the presentation. One patient, who remains alive, developed an intracranial abscess requiring long-term antibiotics but was medically compromised by concomitant myelodysplastic syndrome, mantle cell lymphoma on chemotherapy, atrial fibrillation on anticoagulation, and heart failure. Three patients developed new malignancies requiring re-operation with watchful waiting. Two of the three cases resulted in failure to control disease, but control of malignancy occurred in one case with resection of recurrent cancer and exposed bone. The systematic review of the literature yielded three studies that met the inclusion criteria. None of the studies encountered cases of meningitis, encephalitis, or death due to the non-operative treatment of exposed calvaria post radiation.Coverage of the calvaria with well-vascularized tissue is the reconstructive goal in the majority of circumstances. This case series and systematic review found that non-operative management of exposed calvaria post-radiotherapy can be an option for patients who are either not candidates for aggressive surgical treatment or who refuse surgery.

Impact of treatment modalities on patients with recurrent hepatocellular carcinoma after liver transplantation: Preliminary experience

Post-liver transplantation (LT) hepatocellular carcinoma (HCC) recurrence still occurs in approximately 20% of patients and drastically affects their survival. This study aimed to evaluate the efficacy of various treatments for recurrent HCC after LT in a Chinese population. A total of 64 HCC patients with tumor recurrence after LT were enrolled in this study. Univariate and multivariate analyses were performed to identify factors affecting post-recurrence survival. Of the 64 patients with recurrent HCC after LT, those who received radical resection followed by nonsurgical therapy had a median overall survival (OS) of 20.9 months after HCC recurrence, significantly superior to patients who received only nonsurgical therapy (9.4 months) or best supportive care (2.4 months). The one- and two-year OS following recurrence was favorable for patients receiving radical resection followed by nonsurgical therapy (93.8%, 52.6%), poor for patients receiving only nonsurgical therapy (30.8%, 10.8%), and dismal for patients receiving best supportive care (0%, 0%; overall P < 0.001). Median OS in sorafenib-tolerant patients treated with lenvatinib was 19.5 months, far surpassing the patients that discontinued sorafenib or were treated with regorafenib after sorafenib failure (12 months, P < 0.001). Compared with tacrolimus-based immunosuppressive therapy, OS was significantly increased with sirolimus-based therapy at one and two years after HCC recurrence (P = 0.035). Multivariate analysis showed radical resection combined with nonsurgical therapy for recurrent HCC and sorafenib-lenvatinib sequential therapy were independent favorable factors for post-recurrence survival. Aggressive surgical intervention in well-selected patients significantly improves OS after recurrence. A multidisciplinary treatment approach is required to slow down disease progression for patients with unresectable recurrent HCC.

Gas Forming Infection of the Spine: a Case Report

Gas-forming infection is a rapidly progressive and life-threatening soft tissue infection. Gas-forming infection with spine manifestations is extremely rare and can be a result of several entities including necrotizing fasciitis (NF) and emphysematous osteomyelitis. We present a case of a 68-year-old man who presented with a 1 week back pain and fever. His lab results supported a high-intensity inflammation process. Due to a positive urinalysis, he was treated for a urinary tract infection as the suspected origin to his symptoms. Shortly following admission, the patient’s condition declined. Following an orthopedic surgeon consultation, a CT scan of the lumbar spine was obtained and demonstrated gas-forming infection process that involved the spine, epidural space, and surrounding muscles. The patient underwent several surgical procedures in attempt to reduce the infected tissues and the local pressure. Despite aggressive debridement of the spine and maximal medical therapy, the patient passed away due to multisystem organ failure. Spine involvement in gas-forming infection is a rare entity with very poor prognosis, requiring early and aggressive surgical treatment. A multidisciplinary approach is necessary for management. Nevertheless, even with proper and optimal management, multisystem failure and mortality still may occur.

Tumor inflamatorio de pott. Descripción de un caso

RESUMEN Introducción y objetivo: El tumor inflamatorio de Pott se describe como una inflama-ción en la región frontal debido la formación de un absceso subperióstico y osteo-mielitis del hueso frontal; debido en la mayoría de las ocasiones, a una sinusitis fron-tal. Es más frecuente observarlo en adolescentes. El objetivo de nuestro estudio es presentar un diagnóstico un tanto olvidado y poco frecuente; así como su descrip-ción como entidad en la discusión de los artículos más relevantes de la literatura. Descripción: Presentamos el caso de un varón de 61 años con cefalea punzante a nivel supraciliar derecha, sin insuficiencia respiratoria nasal y con fibroscopia prácti-camente anodina. En la inspección se observa una inflamación, dolorosa a la palpa-ción, del tejido blando con una pequeña fistulización hacia la piel y salida de material purulento. En el TC de senos paranasales se observa una sinusitis crónica frontal derecha. Dicho seno presenta una solución de continuidad en su pared anterior que comunica las partes blandas. Se realiza Draf III del seno frontal derecho guiado con neuronavegador con abordaje combinado externo y vancomicina IV intrahospitalaria. Actualmente el paciente se encuentra asintomático sin clínica infecciosa. Discusión: el tumor inflamatorio de Pott es una complicación rara, pero potencialmente mortal de la sinusitis bacteriana, que consiste en un absceso subperióstico y osteomielitis del hueso frontal. Se diagnostica con tomografía computarizada con contraste o reso-nancia magnética y se trata con antibióticos de amplio espectro, así como interven-ción quirúrgica de forma precoz. Es necesario conocer la fisiopatología y manejo del cuadro; evitando así las posibles complicaciones intracraneales. Conclusiones: el diagnóstico precoz de esta entidad y el tratamiento antibiótico y endoscópico son esenciales para evitar el riesgo de progresión hacia complicaciones neurológicas graves subsidiarias de tratamientos quirúrgicos más agresivos.