Local Inflammatory Signs Research Articles

A retrospective study of clinico-epidemiological profile of snakebite related deaths at a Tertiary care hospital in Midnapore, West Bengal, India.

Snakebite is one of the neglected tropical diseases that World Health Organization (WHO) aimed to eradicate. The objective of the study is to investigate the mortality and morbidity due to snakebite at Midnapore Medical College & Hospital in Paschim Medinipur district, West Bengal, India. This is a record-based, retrospective, descriptive epidemiological study conducted from January 2012 to December 2016 at Midnapore Medical College and Hospital(MMCH), Paschim Medinipur district, West Bengal. The incidence and determinants of snakebite related mortality with reference to types of envenomation, age, sex, site of bite, clinical manifestations of snakebite, bite to hospital and bite to AVS treatment time, first aid and management of snakebite were investigated during the study. The data was analyzed by SPSS (Version 18) software.All results were expressed as percentage. Total number of snakebite deaths in Midnapore Medical College and Hospital(MMCH) was 222 from the period 2012-2016. Number of males was 134(60.36%) and female 88 (39.63%). Maximum snakebite deaths occurred in the age group of 31-40years during agricultural and outdoor activities. Most of the snakebites occurred during June-September. Out of the 222 cases of snakebite, 182(82%) cases were due to viper envenomation. Maximum number of cases(n=162) were detected in the interval between 4.00 PM to 8.00 PM. The bite to hospital time was found to be 180±3.5mins (n=190 cases) and bite to AVS injection time was found to be 240±3.5mins (n=190 cases). The mean bleeding time was 12.55±3.2min (n=190 cases). The mean clotting time was found to be 20.1±2.55min (n=190 cases). The symptoms of envenomation included local signs of inflammation(100% cases), blisters and necrosis (45% cases), renal failure (20% cases), coagulopathies(57% cases), ptosis(10% cases), dysphagia(2%) and respiratory distress(15% cases). The WHO protocol for snakebite management was followed for treatment of snakebite victims. Snake bite is a neglected, life-threatening emergency in developing countries such as India and demands immediate anti-venom therapy. Hospital studies are a key source of information about snake bites. The ready availability and appropriate use of AVS, close monitoring of patients, the institution of ventilator support and if required, early referral to a larger hospital all help to reduce the mortality. Thus knowledge of the varied clinical manifestations of snake bite is important for effective management in hospitals by a complete health care team.

Érysipèle sans fièvre ni syndrome inflammatoire lors d’un traitement par tocilizumab

Tocilizumab (TCZ) is a monoclonal antibody that inhibits the interleukin 6 (IL-6) signalling pathway. This treatment is extremely effective in rheumatoid arthritis (RA), which may well be accompanied by serious infections presenting misleading clinical pictures. Herein we report a case of a typical bacterial dermo-hypodermitis in a female patient treated with TCZ. An 80-year-old woman treated with methotrexate (MTX) and TCZ for RA presented dermo-hypodermitis on her left leg 8 days after receiving her 13th infusion of TCZ. She exhibited neither fever nor biological inflammatory syndrome. Oral amoxicillin (3g/d) was initiated on an outpatient basis. Two weeks later, the patient was apyretic and her laboratory results were normal, although local inflammatory signs persisted. TCZ infusion was postponed and she was given intravenous amoxicillin (4g/d) for 2days, followed by oral amoxicillin, resulting in rapid recovery. Subsequent courses of TCZ were administered without incident. During the course of treatment with TCZ, this patient presented delineated bacterial cellulitis in the form of erysipelas, which was noteworthy on account of the absence of fever and of biological inflammatory syndrome. While there have been reports of severe cases of cellulitis during TCZ treatment, to our knowledge, there have been none of erysipelas. Attenuation of local and systemic inflammatory symptoms is widely reported, and is directly associated with the anti-IL-6 action of TCZ. Patients with RA are especially susceptible to opportunistic or severe infections as a result of the disease itself and of associated treatments, and increased vigilance is called for with regard to infections that may be transformed and potentially more severe as a result of TCZ.

Hematogenous vertebral osteomyelitis associated with intravascular device-associated infections – A retrospective cohort study

IntroductionAim of the study was to investigate the clinical, microbiological, radiological, and treatment characteristics of hematogenous vertebral osteomyelitis originating from infected intravascular devices. Patients and MethodsPatients with secondary hematogenous vertebral osteomyelitis caused by an infected intravascular device were included in this retrospective cohort study. Patients with prior spinal surgery were excluded. Categorical variables were compared using χ2 or Fisher's exact tests and continuous variables using the Mann–Whitney U test. ResultsSixty-seven patients with hematogenous vertebral osteomyelitis were included. Intravenous catheters were the source of infection in 45 patients (67%) and cardiovascular devices in 22 (33%). Fever was present in 21 patients (45%). The main pathogens were coagulase-negative staphylococci, isolated in 42 patients (63%), which grew from blood culture in 52 patients (87%), from vertebral tissue in 29 patients (56%) and from the explanted intravascular device in 18 patients (60%), where it was sampled. Infective endocarditis was diagnosed in 14 of 45 patients (31%), more common with cardiovascular devices than with intravascular catheters (56% versus 15%; P=0.008). ConclusionsIn patients with vertebral osteomyelitis, growth of coagulase-negative staphylococci in blood is highly suggestive for intravascular device-associated infection. Despite absence of systemic or local signs of inflammation at the site of the device, blood cultures should be collected and echocardiography performed in these patients.

Clinical impact of positive Propionibacterium acnes cultures in orthopedic surgery

BackgroundThe clinical significance of a positive culture to Propionibacterium acnes in orthopedic specimens remains unclear, whether about its role as a contaminant or a pathogen, or its impact as a coinfectant. Therefore, we performed a retrospective study to provide a more accurate description of the clinical impact of P. acnes in an orthopedic population aiming to determine: 1) if there is a clinical difference between P. acnes infection and contamination? 2) If there is a clinical difference between P. acnes monoinfection, and coinfection. HypothesisThere is a clinical difference between P. acnes infection and contamination. Materials and methodsPatients were selected over a five-year period, and those with a minimum of one positive culture for P. acnes, from any intraoperative orthopedic tissue sample, were included in the study. P. acnes infection was defined as the isolation of P. acnes from≥2 specimens, or in only one specimen, in the presence of typical perioperative findings and/or local signs of infection. ResultsA total of 68 patients had a positive P. acnes culture, 35 of which were considered to be infected. The infections affected mostly males (29/35–83%), occurred mostly in shoulders (22/35–63%), and at a site already containing an orthopedic implant (32/35–91%). Local inflammatory signs were present in half of the cases when an infection was diagnosed. Coinfection with other pathogens was present in 31% of patients (11/35). When comparing patients coinfected with P. acnes, and those who were monoinfected, the latter presented less often with local inflammatory signs. Recurrence rate was 24% (8/35) and the only risk factor for recurrence was the presence of a monoinfection. DiscussionThis study confirms the pathogenicity of P. acnes in an orthopedic population, as it is present in multiple samples in the same patient, and because it is present in cultures from cases with clinical recurrence. Our study showed that monoinfections differ from coinfections mainly by their higher risk of recurrence. Level of evidenceLevel IV retrospective case series.

Osteoid osteoma of the scapula mimicking a pathology of the shoulder

A 14-year-old patient presented with chronic shoulder pain evolving since three years. The pain persisted despite the various medicated and physical treatments followed. The clinical examination noted a normal shoulder examination with pain facing the right scapula without local inflammatory signs. There were no abnormalities in the biological examinations, in particular absence of biological inflammatory syndrome, rheumatoid factor negative and normal calcemia. Radiographs of the shoulder and scapula were normal. Bone scintigraphy showed hyperfixation of the radiotracer regarding the right scapular spine evoking an osteoid osteoma (A). CT scan of the right scapula showed a very limited osteolytic lesion without osteocondensation edges with a non-enhanced hypodense matrix after injection of contrast agent (B). MRI showed lesion of the right scapular spine in hypersignal T1 and T2 without cortical rupture or periosteal reaction suggestive of a benign lesion such as osteoid osteoma (C, D). The patient had a biopsy with surgical resection of the lesion. The diagnosis of osteoid osteoma was confirmed histologically. The peculiarity of this observation lies in the rarity of this localization and the deceptive clinical picture suggesting a shoulder pathology in first intention. In cases of diagnostic doubt and in the presence of normal radiographs, the most specific examination is thin-section CT scans, the sensitivity of which can be improved by association with an MRI.

Patellar Subacute Hematogenous Osteomyelitis in Children Due To K. Kingae: A Report of Two Cases

Isolated osteomyelitis of the patella is a rare condition mainly occurring in the pediatric population. Diagnosis is often delayed as clinical presentation manifests with vague anterior knee pain, sometimes with mild local signs of inflammation but frequently without any local signs at all. While falls on the knee can explain mild knee pain, erythema, swelling and persistent peripatellar pain should raise a high index of suspicion for local infection. We present two cases of subacute osteomyelitis of the patella in young children. In both cases bone lesions presented as an osteolytic lesion of the patella. After open biopsy of the lesion, bacteriological analysis confirmed infection with Kingella kingae.

Evaluation of bone microstructure in CRPS-affected upper limbs by HR-pQCT.

Complex regional pain syndrome (CRPS) is a major complication after trauma, surgery, and/or immobilization of an extremity. The disease often starts with clinical signs of local inflammation and develops into a prolonged phase that is characterized by trophic changes and local osteoporosis and sometimes results in functional impairment of the affected limb. While the pathophysiology of CRPS remains poorly understood, increased local bone resorption plays an undisputed pivotal role. The aim of this retrospective clinical study was to assess the bone microstructure in patients with CRPS. Patients with CRPS type I of the upper limb whose affected and unaffected distal radii were analyzed by high-resolution peripheral quantitative computed tomography (HR-pQCT) were identified retrospectively. The osteology laboratory data and dual-energy X-ray absorptiometry (DXA) images of the left femoral neck and lumbar spine, which were obtained on the same day as HR-pQCT, were extracted from the medical records. Five patients were identified. The CRPS-affected upper limbs had significantly lower trabecular numbers and higher trabecular thicknesses than the unaffected upper limbs. However, the trabecular bone volume to total bone volume and cortical thickness values of the affected and unaffected sides were similar. Trabecular thickness tended to increase with time since disease diagnosis. CRPS associated with significant alterations in the bone microstructure of the affected upper limb that may amplify as the duration of disease increases.

Unexpectedly high incidences of chronic non-bacterial as compared to bacterial osteomyelitis in children.

Historically, osteomyelitis was considered an infectious disorder. More recently, inflammatory mechanisms were recognized causing a significant proportion of pediatric osteomyelitis. This study was to compare characteristics of children with chronic non-bacterial (CNO) and bacterial osteomyelitis (BOM). A chart review of osteomyelitis patients from the departments of pediatrics, pediatric surgery, orthopedic surgery, and oral and maxillofacial surgery was conducted in a tertiary referral center, covering the years 2004-2014. Institutional incidences of CNO (n=49) and BOM (n=56) were comparable. Differentiation between CNO and BOM based on clinical or laboratory findings was mostly impossible. However, children with BOM more frequently presented with local inflammatory signs (47 vs. 68%, p=0.040), fever (12 vs. 38%, p=0.003), and abscesses (0 vs. 39%, p<0.001). Peripheral arthritis (14 vs. 0%, p<0.001), inflammatory bowel disease (10 vs. 2%, p=ns), and hyperostosis (29 vs. 4%, p=0.001) were more common in CNO. Whole-body MRI was performed in 76% of CNO patients, unveiling multifocal lesions in 80% (CRMO). Though considered a rare disorder, institutional incidences of CNO were comparable to BOM, and the discrimination between CNO and BOM solely based on clinical aspects was mostly impossible. This is of special interest, since a correct and timely diagnosis is of utmost importance for long-term outcomes in both disorders. Whole-body MRIs should be considered in chronic osteomyelitis to (1) detect clinically inapparent lesions in CNO and (2) indirectly exclude (usually unifocal) chronic bacterial infections. Prospective studies are warranted to establish evidence-based diagnostic and therapeutic approaches to CNO.

Shoulder periprosthetic joint infection caused by Propionibacterium acnes

Propionibacterium acnes is increasingly recognized as an important cause of shoulder periprosthetic joint infection (PJI). We performed a retrospective cohort study of P. acnes shoulder PJI to analyze the clinical, diagnostic, and treatment characteristics. Patients diagnosed with shoulder PJI caused by P. acnes were retrospectively analyzed in two university hospitals. Patient data were retrieved through chart review. The outcome was evaluated at patient follow-up visits. The study included 20 patients with shoulder PJI (median age, 65 years; range, 54–77 years); 75 % were males. The median time from prosthesis implantation to diagnosis of PJI was 34 months (range, 2–60 months). Most PJI (55 %) were diagnosed >24 months after arthroplasty, followed by delayed manifestation 3–24 months after arthroplasty in 30 %. The diagnosis of PJI was preoperatively confirmed in 50 % of patients and suspected in 20 %. Persistent pain was present in 90 %, local signs of inflammation in 60 %, and radiological signs of loosening in 70 % of patients. P. acnes was cultured in joint aspirate in 33 %, periprosthetic tissue in 60 %, and sonication fluid in 89 % of patients. In four patients, coinfection with coagulase-negative staphylococci was found. One-stage prosthesis exchange was performed in four patients (20 %) and two-stage exchange in 15 patients (75 %); in one patient the prosthesis was not re-implanted. After a median follow-up of 26 months (range, 12–47 months), 18 patients (90 %) showed no signs or symptoms of infection. P. acnes PJI typically manifested several years after implantation. In 30 % of patients, PJI was not suspected before surgery. In patients with persistent pain or prosthesis loosening, low-grade PJI should be excluded, including infection caused by P. acnes.

Specific Prevention Against Infection of Local Catheters in Postoperative Pain Management

Background: The guideline for postoperative pain management therapy recommends several obligate measures and permissive provisions keeping catheters hygienic. An organized Pain Nurse is generally regarded as convenient. But some recommendations are still discussed. The guideline is based on only few large studies and the number of catheter-related infections differs from technique and risk profile. However, all recommendations for improvement have to be compared with the guideline. This prospective study was initiated to investigate the influence of catheter fixing, the frequency of changing dressings and the use of bacterium-filters on the rate of inflammation and infection. Methods: 2545 consecutive patients, who were under treatment of the Pain Nurse, were included in the study. 1624 patients received epidural catheters, 921 patients received continuous peripheral nerve blocks. The catheters were immediately placed and fixed by stitching before performing the operation. A bacterium-filter was always interposed and after some time a second filter was added in tandem circuit. After 4 days the transparent tape was changed. The assessment of the infection severity was oriented towards the criteria of the guideline. The results of the study were statistically compared to the data of the S3-guideline. Results: 34 (14.4%) of all catheters in the sample were colonized. Catheters placed in the groin were statistically significant more often colonized than epidural catheters (28.1% vs. 6.6%, p<0.01). 5 Catheters (0.2% vs. 4.2%, p<0.01) had signs of local inflammation. Only one fairly serious infection (placement in the groin) (0.04% vs. 2.4% p<0.01) and no severe infection were observed. Conclusion: Catheter-fixing by stitching and changing catheter-dressing on the first postoperative day to avoid dampness are important measures to prevent catheter related infections. Using consequently bacterium-filters with tandem circuit is supposed to reduce the rate of catheter-related inflammations and infections.

First Crio-extraction of Cherry Pit after Aspiration

Introduction: Vegetable foreign bodies (FB) are most commonly aspirated in children, these are very dangerous as most of them are hygroscopic, they swell up within a few days causing blockage of the lumen of the bronchus and retention of secretion distal to it. Method: We report on a 75 yr old patient who aspirated a cherry pit one month prior to clinical presentation. He originally presented with cough and a right lower lobe infiltrate on x-ray. The patient underwent therapeutic videobronchoscopy via the oral route, a cherry pit was detected at the distal end of the bronchus intermedius with signs of local inflammation. Result: We used saline rising and a flexible cryoprobe and it was activated for 15 s which resulted into a solid contact with the FB and immediate removal without complications. Conclusion: We have found that by using flexible cryoprobe through video bronchoscopy is possible remove a cherry pit under conscious sedation, which should be considered as a therapeutic option.

IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes.

RecommendationsClassification/diagnosis Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low). Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate). Osteomyelitis For an infected open wound, perform a probe‐to‐bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high‐risk patient, a positive test is largely diagnostic (strong; high). Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate). A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate). A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe‐to‐bone, serum inflammatory markers, plain X‐ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak). Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate). Obtain plain X‐rays of the foot in all cases of non‐superficial diabetic foot infection (strong; low). Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate). When MRI is not available or contraindicated, consider a white blood cell‐labelled radionuclide scan, or possibly single‐photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine‐18‐fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate). Assessing severity At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate). At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low). Microbiological considerations Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high). Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low). Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low). Surgical treatment Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low). Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low). Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X‐ray or bone protruding through the ulcer (strong; low). Antimicrobial therapy While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low) Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate). A course of antibiotic therapy of 1–2 weeks is usually adequate for most mild and moderate infections (strong; high). Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low). Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high). For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate). We suggest not using any adjunctive treatments for diabetic foot infection (weak; low). When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low).

Parotidite aigue néonatale suppurative: à propos de trois cas cliniques avec revue de la littérature

Cet article fait mention de trois cas de parotidite bactérienne néonatale observés pendant une période de sept mois. Ce diagnostic est souvent clinique: on retrouve classiquement hyperthermie, tuméfaction, érythème, chaleur ainsi que sensibilité locale et écoulement purulent au niveau du canal de Sténon lors du massage de la parotide. Le diagnostic clinique est confirmé par échographie et culture de la sécrétion parotidienne purulente. Elles sont le plus souvent d’origine nosocomiale, favorisées par la prématurité et la déshydratation. Traitées précocement, leur évolution est favorable. Les risques liés à l’âge doivent faire débuter une antibiothérapie empirique puis fonction de l'examen direct du pus extrait du canal de Sténon. On isole le plus communément le Staphylocoque aureus; le Streptocoque Viridans et les germes anaérobies. Les parotidites aigues sont très rares en période néonatale: moins de 50 cas ont été rapportés dans la littérature. Nous rapportons trois observations assez particulières. Le diagnostic avait été suspecté sur les signes inflammatoires locaux.

Factor Analysis Influencing Postoperative Hospital Stay and Medical Costs for Patients with Definite, Suspected, or Unmatched Diagnosis of Acute Cholecystitis according to the Tokyo Guidelines 2013.

Purpose. To identify significant independent preoperative factors influencing postoperative hospital stay (PHS) and medical costs (MC) in 171 patients who underwent cholecystectomy for benign gallbladder diseases and had definite, suspected, or unmatched acute cholecystitis (AC) diagnosis according to the Tokyo Guidelines 2013 (TG13). Methods. The 171 patients were classified according to the combination of diagnostic criteria including local signs of inflammation (A), systemic signs of inflammation (B), and imaging findings (C): A+ B+ C (definite diagnosis, n = 84), A+ B (suspected diagnosis, n = 25), (A or B) + C (n = 10), A (n = 41), and B (n = 11). Results. The A+ B + C and (A or B) + C groups had equivalent PHS and MC, suggesting that imaging findings were essential for AC diagnosis. PHS and MC were significantly increased in the order of severity grades based on TG13. Performance status (PS), white blood cell count, and severity grade were identified as preoperative factors influencing PHS by multivariate analysis, and significant independent preoperative factors influencing MC were age, PS, preoperative biliary drainage, hospital stay before surgery, albumin, and severity grade. Conclusion. PS and severity grade significantly influenced prolonged PHS and increased MC.

Uma improvável dor de cotovelo: relato de um caso de tuberculose dos tecidos moles

Introduction: Extrapulmonary tuberculosis is found in 29% of cases in Portugal. The most common sites are lymph nodes, pleura, bone, joints, and meninges. The high prevalence of tuberculosis in Portugal and the scarcity of reported cases of tuberculosis of soft tissues highlight the importance of this case report. Case presentation: A 17 year-old female was healthy until February of 2013 when she began to complain of pain on movement of the right elbow. There was no history of trauma. She was treated with anti-inflammatory medication. Because of persistent pain and the appearance of signs of local inflammation, an ultrasound examination of the elbow was requested by the family doctor. This revealed an area of edema and cellulitis in the peri-articular soft tissues. After failure of treatment with two courses of oral antibiotics, she went to the emergency department of Centro Hospitalar Povoa do Varzim/Vila do Conde where she was admitted to the pediatric department. She presented with swelling of the lateral aspect of the elbow with fluctuation and tenderness to palpation, but without restriction of mobility of the joint. A local aspiration was performed and culture of the fluid was positive for Mycobacterium tuberculosis. The tuberculin skin test showed an induration of 13 mm. Nuclear magnetic resonance imaging of the elbow was suggestive of an infectious lesion of tuberculosis etiology. The patient was referred to the Centre for Pulmonary Diagnosis with a diagnosis of tuberculosis of soft tissues. She began triple tuberculostatic therapy, with clinical improvement after one month of treatment. Discussion: Although it is rare, tuberculosis of soft tissues should be considered in localized, persistent lesions that are resistant to antibiotic treatment, especially in geographical areas with a high prevalence of tuberculosis.

Pathomimie en chirurgie esthétique, à propos d’un cas

Pathomimia is defined as a dummy pathology self-induced deliberately and is neither associated with mental confusion nor disturbance of consciousness. This article reports a case of pathomimia in plastic surgery. One of our patients had intentionally injected physiological saline solution into her breast implants in order to increase their volume. Implants removal was necessary because of severe local inflammatory signs. Psychiatric assessment revealed body dysmorphic disorder (BDD) developed on an hysterical personality, which explained the self-induced injuries. This nosologic entity must be promptly identified because it's diagnosis remains problematic and a multidisciplinary medical management is essential.

A novel biodegradable frontal sinus stent (MgNd2): a long-term animal study.

The frontal sinus recess consists of anatomically narrow passages that are prone to stenosis in endonasal frontal sinus surgery for chronic sinus disease. Over the past 100years, diverse frontal sinus stents have been developed and evaluated in clinical and animal studies. However, superinfection, formation of granulations tissue, stent dislocation and late stenosis of the duct have remained challenges and subject of debate in the literature. Currently developed biodegradable materials, including rare earth-containing magnesium alloys are promising candidates for application as temporary implant materials. The Mg 2% wt Nd alloy (MgNd2) was used to design a nasal stent that fit the porcine anatomy. In the current study, we evaluate biocompatibility, biodegradation and functionality of a frontal sinus stent in 16 minipigs over 6months. Intraoperative endoscopy revealed free stent lumen in all cases. Blood examination and clinical examinations indicated no systematic or local inflammation signs. The histopathology and elements analysis showed a very good biocompatibility. The μ-computed tomography-based volumetric analysis showed substantial stent degradation within 6 months. Our MgNd2 based stent appears to be a promising, solid basis for the development of a frontal sinus stent for clinical use.

The culturome of the human nose habitats reveals individual bacterial fingerprint patterns

The complex anatomy of the human nose might offer distinct microbial niches. Microbiota composition may affect nose inflammatory diseases and Staphylococcus aureus carriage. Considering different nasal cavity locations, microbial colonization was analysed across individuals exhibiting chronic nasal inflammatory diseases (n = 18) and those without local inflammation signs (n = 16). Samples were collected systematically during surgery and examined by an extensive culture-based approach and, for a subset, by 16S rRNA gene community profiling. Cultivation yielded 141 taxa with members of Staphylococcus, Corynebacterium and Propionibacterium as most common isolates comprising the nasal core culturome together with Finegoldia magna. Staphylococcus aureus was most frequently found in association with Staphylococcus epidermidis and Propionibacterium acnes, and the posterior vestibules were redefined as S. aureus' principle habitat. Culturome analysis revealed host-specific bacterial 'fingerprints' irrespective of host-driven factors or intranasal sites. Comparisons between cultivable and molecular fingerprints demonstrated that only a small fraction of phylotypes (6.2%) was correlated. While the total number of different phylotypes was higher in the molecular dataset, the total number of identifications down to the species level was higher in the culturomic approach. To determine host-specific microbiomes, the advantages of molecular approaches should be combined with the resolution and reliability of species identification by culturomic analyses.

Neutrophil extracellular trap formation in supragingival biofilms

BackgroundOral biofilms are the causative agents of the highly prevalent oral diseases periodontitis and caries. Additionally, the host immune response is thought to play a critical role in disease onset. Neutrophils are known to be a key host response factor to bacterial challenge on host surfaces. Release of neutrophil extracellular traps (NETs) as a novel antimicrobial defense strategy has gained increasing attention in the past years. Here, we investigated the influx of neutrophils into the dental plaque and the ability of oral bacteria to trigger intra-biofilm release of NETs and intracellular proteins. MethodsSupragingival biofilms and whole saliva were sampled from systemically healthy subjects participating in an experimental gingivitis study. Biofilms were analysed by immunofluorescence followed by confocal and fluorescence microscopy. Moreover, concentrations of cytokines and immune-associated proteins in biofilm suspensions and saliva were assessed by ELISA. Neutrophils obtained from blood were stimulated with twelve bacterial species isolated from cultured biofilms or with lipopolysaccharide to monitor NET formation. ResultsNeutrophils, NETs, neutrophil-associated proteins (myeloperoxidase, elastase-2, cathepsin G, cathelicidin LL-37), interleukin-8, interleukin-1β and tumor necrosis factor were detected within plaque samples and saliva. All tested bacterial species as well as the polymicrobial samples isolated from the plaque of each donor induced release of NETs and interleukin-8. The degree of NET formation varied among different subjects and did not correlate with plaque scores or clinical signs of local inflammation. ConclusionsOur findings indicate that neutrophils are attracted towards dental biofilms, in which they become incorporated and where they are stimulated by microbes to release NETs and immunostimulatory proteins. Thus, neutrophils and NETs may be involved in host biofilm control, although their specific role needs to be further elucidated. Moreover, inter-patient variability suggests NET formation as a potential factor influencing the individual course of disease.

Challenges in diagnosing infection in the diabetic foot.

Diagnosing the presence of infection in the foot of a patient with diabetes can sometimes be a difficult task. Because open wounds are always colonized with microorganisms, most agree that infection should be diagnosed by the presence of systemic or local signs of inflammation. Determining whether or not infection is present in bone can be especially difficult. Diagnosis begins with a history and physical examination in which both classic and 'secondary' findings suggesting invasion of microorganisms or a host response are sought. Serological tests may be helpful, especially measurement of the erythrocyte sedimentation rate in osteomyelitis, but all (including bone biomarkers and procalcitonin) are relatively non-specific. Cultures of properly obtained soft tissue and bone specimens can diagnose and define the causative pathogens in diabetic foot infections. Newer molecular microbial techniques, which may not only identify more organisms but also virulence factors and antibiotic resistance, look very promising. Imaging tests generally begin with plain X-rays; when these are inconclusive or when more detail of bone or soft tissue abnormalities is required, more advanced studies are needed. Among these, magnetic resonance imaging is generally superior to standard radionuclide studies, but newer hybrid imaging techniques (single-photon emission computed tomography/computed tomography, positron emission tomography/computed tomography and positron emission tomography/magnetic resonance imaging) look to be useful techniques, and new radiopharmaceuticals are on the horizon. In some cases, ultrasonography, photographic and thermographic methods may also be diagnostically useful. Improved methods developed and tested over the past decade have clearly increased our accuracy in diagnosing diabetic foot infections.