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Surgical Debridement (surgical + debridement)
Selected AbstractsLetter: Should We Perform Surgical Debridement in Calciphylaxis?DERMATOLOGIC SURGERY, Issue 3 2009FALK G. BECHARA MBBS No abstract is available for this article. [source] The value of debridement and Vacuum-Assisted Closure (V.A.C.) Therapy in diabetic foot ulcersDIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue S1 2008Magnus Eneroth Abstract Background Treatment of diabetic foot ulcers includes a number of different regimes such as glycaemic control, re-vascularization, surgical, local wound treatment, offloading and other non-surgical treatments. Although considered the standard of care, the scientific evidence behind the various debridements used is scarce. This presentation will focus on debridement and V.A.C. Therapy, two treatments widely used in patients with diabetes and foot ulcers. Methods A review of existing literature on these treatments in diabetic foot ulcers, with focus on description of the various types of debridements used, the principles behind negative pressure wound therapy (NPWT) using the V.A.C. Therapy system and level of evidence. Results Five randomized controlled trials (RCT) of debridement were identified; three assessed the effectiveness of a hydrogel as a debridement method, one evaluated surgical debridement and one evaluated larval therapy. Pooling the three hydrogel RCTs suggested that hydrogels are significantly more effective than gauze or standard care in healing diabetic foot ulcers. Surgical debridement and larval therapy showed no significant benefit. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in RCTs of people with diabetes. More than 300 articles have been published on negative pressure wound therapy, including several small RCTs and a larger multi-centre RCT of diabetic foot ulcers. Negative pressure wound therapy seems to be a safe and effective treatment for complex diabetic foot wounds, and could lead to a higher proportion of healed wounds, faster healing rates, and potentially fewer re-amputations than standard care. Conclusions Although debridement of the ulcer is considered a prerequisite for healing of diabetic foot ulcers, the grade of evidence is quite low. This may be due to a lack of studies rather than lack of effect. Negative pressure wound therapy seems to be safe and effective in the treatment of some diabetic foot ulcers, although there is still only one well-performed trial that evaluates the effect. Copyright © 2008 John Wiley & Sons, Ltd. [source] Necrotizing fasciitis: a deadly infectionJOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 4 2006GG Kihiczak Abstract Necrotizing fasciitis (NF) is a life-threatening condition, consisting of a soft-tissue infection with rapidly progressive, widespread fascial necrosis. NF may be caused by a wide variety of microbes. Indeed, NF may be an infection of one species of bacteria or may be polymicrobial. Prompt diagnosis and treatment are essential. Surgical debridement and antibiotic therapy are the primary treatment options. [source] Successful Treatment of Severe Iatrogenic Calcinosis Cutis with Intravenous Sodium Thiosulfate in a Child Affected by T-Acute Lymphoblastic LeukemiaPEDIATRIC DERMATOLOGY, Issue 3 2009Colombatti Raffaella M.D., Ph.D. We describe a 5-year-old boy with acute lymphoblastic leukemia who developed severe calcinosis cutis in the right forearm and hand, and in the left leg and foot after extravasation of calcium gluconate during treatment for tumor-lysis-syndrome-related hypocalcaemia. Surgical debridement, local wound care, hyperbaric oxygen therapy, and sodium thiosulfate infusion achieved a complete healing of all lesions in an eight-month period with a short discontinuation of chemotherapy. No functional or sensitive impairment remained. [source] The value of debridement and Vacuum-Assisted Closure (V.A.C.) Therapy in diabetic foot ulcersDIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue S1 2008Magnus Eneroth Abstract Background Treatment of diabetic foot ulcers includes a number of different regimes such as glycaemic control, re-vascularization, surgical, local wound treatment, offloading and other non-surgical treatments. Although considered the standard of care, the scientific evidence behind the various debridements used is scarce. This presentation will focus on debridement and V.A.C. Therapy, two treatments widely used in patients with diabetes and foot ulcers. Methods A review of existing literature on these treatments in diabetic foot ulcers, with focus on description of the various types of debridements used, the principles behind negative pressure wound therapy (NPWT) using the V.A.C. Therapy system and level of evidence. Results Five randomized controlled trials (RCT) of debridement were identified; three assessed the effectiveness of a hydrogel as a debridement method, one evaluated surgical debridement and one evaluated larval therapy. Pooling the three hydrogel RCTs suggested that hydrogels are significantly more effective than gauze or standard care in healing diabetic foot ulcers. Surgical debridement and larval therapy showed no significant benefit. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in RCTs of people with diabetes. More than 300 articles have been published on negative pressure wound therapy, including several small RCTs and a larger multi-centre RCT of diabetic foot ulcers. Negative pressure wound therapy seems to be a safe and effective treatment for complex diabetic foot wounds, and could lead to a higher proportion of healed wounds, faster healing rates, and potentially fewer re-amputations than standard care. Conclusions Although debridement of the ulcer is considered a prerequisite for healing of diabetic foot ulcers, the grade of evidence is quite low. This may be due to a lack of studies rather than lack of effect. Negative pressure wound therapy seems to be safe and effective in the treatment of some diabetic foot ulcers, although there is still only one well-performed trial that evaluates the effect. Copyright © 2008 John Wiley & Sons, Ltd. [source] Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment,DIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue S1 2008A. R. Berendt Abstract The International Working Group on the Diabetic Foot appointed an expert panel to provide evidence-based guidance on the management of osteomyelitis in the diabetic foot. Initially, the panel formulated a consensus scheme for the diagnosis of diabetic foot osteomyelitis (DFO) for research purposes, and undertook a systematic review of the evidence relating to treatment. The consensus diagnostic scheme was based on expert opinion; the systematic review was based on a search for reports of the effectiveness of treatment for DFO published prior to December 2006. The panel reached consensus on a proposed scheme that assesses the probability of DFO, based on clinical findings and the results of imaging and laboratory investigations. The literature review identified 1168 papers, 19 of which fulfilled criteria for detailed data extraction. No significant differences in outcome were associated with any particular treatment strategy. There was no evidence that surgical debridement of the infected bone is routinely necessary. Culture and sensitivity of isolates from bone biopsy may assist in selecting properly targeted antibiotic regimens, but empirical regimens should include agents active against staphylococci, administered either intravenously or orally (with a highly bioavailable agent). There are no data to support the superiority of any particular route of delivery of systemic antibiotics or to inform the optimal duration of antibiotic therapy. No available evidence supports the use of any adjunctive therapies, such as hyperbaric oxygen, granulocyte-colony stimulating factor or larvae. We have proposed a scheme for diagnosing DFO for research purposes. Data to inform treatment choices in DFO are limited, and further research is urgently needed. Copyright © 2008 John Wiley & Sons, Ltd. [source] Early diagnosis of rhinocerebral mucormycosis by cerebrospinal fluid analysis and determination of 16s rRNA gene sequenceEUROPEAN JOURNAL OF NEUROLOGY, Issue 9 2007D. Bengel A 40-year-old diabetic woman was diagnosed with rhinocerebral mucormycosis. Cerebral mucormycosis is an acute life-threatening disease, which is caused by fungi of the class Phycomycetae. Clinical suspicion and detection of the fungal hyphae in cerebrospinal fluid (CSF) led to early diagnosis, subsequently confirmed by immunohistochemistry and molecular analysis of fungal RNA. Early infiltration of the infectious agent into the central nervous system resulted in septic thrombosis of the cavernous sinus, mycotic meningoencephalitis, brain infarctions as well as intracerebral and subarachnoidal hemorrhages. Despite immediate high-dose antimycotic treatment, surgical debridement of necrotic tissue, and control of diabetes as a predisposing factor, the woman died 2 weeks after admission. Although fungal organisms are rarely detectable in CSF specimens from patients with mycotic infections of the central nervous system, comprehensive CSF examination is beneficial in the diagnosis of rhinocerebral mucormycosis. Furthermore, a concerted team approach, systemic antifungal agents and early surgical intervention seem to be crucial for preventing rapid disease progression. [source] Intravenous cyclosporine in refractory pyoderma gangrenosum complicating inflammatory bowel diseaseINFLAMMATORY BOWEL DISEASES, Issue 1 2001Dr. Sonia Friedman Abstract Background Pyoderma gangrenosum complicates inflammatory bowel disease in 2,3% of patients and often fails to respond to antibiotics, steroids, surgical debridement or even colectomy. Methods We performed a retrospective chart analysis of 11 consecutive steroid-refractory pyoderma patients (5 ulcerative colitis, 6 Crohn's disease) referred to our practice and then treated with intravenous cyclosporine. Pyoderma gangrenosum was present on the extremities in 10 patients, the face in 2, and stomas in 2. At initiation of intravenous cyclosporine, bowel activity was moderate in 3 patients, mild in 4, and inactive in 4. All patients received intravenous cyclosporine at a dose of 4 mg/kg/d for 7,22 days. They were discharged on oral cyclosporine at a dose of 4,7 mg/kg/d. Results All 11 patients had closure of their pyoderma with a mean time to response of 4.5 days and a mean time to closure of 1.4 months. All seven patients with bowel activity went into remission. Nine patients were able to discontinue steroids, and nine were maintained on 6-mercaptopurine or azathioprine. One patient who could not tolerate 6-mercaptopurine had a recurrence of pyoderma. No patient experienced significant toxicity. Conclusion Intravenous cyclosporine is the treatment of choice for pyoderma gangrenosum refractory to steroids and 6-mercaptopurine should be used as maintenance therapy. [source] The emergence of mucormycosis as an important opportunistic fungal infection: five cases presenting to a tertiary referral center for mycologyINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 4 2007Mahreen Ameen MRCP Background, Mucormycosis, a rare opportunistic fungal infection, is re-emerging in importance with the increase in prevalence of immunosuppressive states, both as a result of therapy and disease. Methods, We report five cases of mucormycosis diagnosed by the Dermatology Department and managed jointly with the Medical and Surgical Services of "Dr Manuel Gea Gonzalez" General Hospital in Mexico City, a tertiary referral center for mycology. We also review the current literature including recent advances in medical therapy. Results, Four of the five cases were of the rhino-orbital-cerebral variant, commonly associated with significant mortality, and one of these patients died despite early diagnosis and aggressive management. The fifth case was primary cutaneous mucormycosis and this patient survived infection without relapse. Diabetic ketoacidosis predisposed to infection in four cases and the other was associated with advanced human immunodeficiency virus infection. Radiologic imaging was important in cases of facial involvement in order to evaluate the extent of disease and possible intracranial involvement. All cases were managed with systemic antifungals and surgical debridement, together with the treatment of predisposing factors. Conclusions, These cases illustrate the need for early clinical recognition and prompt therapy, as well as the requirement for tissue biopsy in order to demonstrate the characteristic morphologic features of this fungal agent in the absence of positive mycology culture results. This report also highlights that, although rhino-orbital-cerebral mucormycosis requires effective multidisciplinary management, the disease not uncommonly presents to dermatologists for diagnosis. [source] Necrotizing fasciitis: delay in diagnosis results in loss of limbINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 10 2006Rajat Varma MD A 58-year-old man presented to the Emergency Room with a 1-day history of severe pain in the left lower extremity preceded by several days of redness and swelling. He denied any history of trauma. He also denied any systemic symptoms including fever and chills. His past medical history was significant for diabetes, hypertension, deep vein thrombosis, and Evans' syndrome, an autoimmune hemolytic anemia and thrombocytopenia, for which he was taking oral prednisone. Physical examination revealed a warm, tender, weeping, edematous, discolored left lower extremity. From the medial aspect of the ankle up to the calf, there was an indurated, dusky, violaceous plaque with focal areas of ulceration (Fig. 1). Figure 1. Grossly edematous lower extremity with well-demarcated, dusky, violaceous plaque with focal ulceration Laboratory data revealed a white blood cell count of 6.7 × 103/mm3[normal range, (4.5,10.8) × 103/mm3], hemoglobin of 11.5 g/dL (13.5,17.5 g/dL), and platelets of 119 × 103/mm3[(140,440) × 103/mm3]. Serum electrolytes were within normal limits. An ultrasound was negative for a deep vein thrombosis. After the initial evaluation, the Emergency Room physician consulted the orthopedic and dermatology services. Orthopedics did not detect compartment syndrome and did not pursue surgical intervention. Dermatology recommended a biopsy and urgent vascular surgery consultation to rule out embolic or thrombotic phenomena. Despite these recommendations, the patient was diagnosed with "cellulitis" and admitted to the medicine ward for intravenous nafcillin. Over the next 36 h, the "cellulitis" had advanced proximally to his inguinal region. His mental status also declined, and he showed signs of septic shock, including hypotension, tachycardia, and tachypnea. Vascular surgery was immediately consulted, and the patient underwent emergency surgical debridement. The diagnosis of necrotizing fasciitis was then made. Tissue pathology revealed full-thickness necrosis through the epidermis with subepidermal splitting. Dermal edema was also present with a diffuse neutrophilic infiltrate (Fig. 2). This infiltrate extended through the fat into the subcutaneous tissue and fascia. Tissue cultures sent at the time of surgery grew Escherichia coli. Initial blood cultures also came back positive for E. coli. Anaerobic cultures remained negative. Figure 2. Necrotic epidermis with subepidermal splitting. Marked dermal edema with mixed infiltrate and prominent neutrophils. Hematoxylin and eosin: original magnification, ×20 After surviving multiple additional debridements, the patient eventually required an above-the-knee amputation due to severe necrosis. [source] Chronic, painful lower extremity wounds: postoperative pain management through the use of continuous infusion of regional anaesthesia supplied by a portable pump deviceINTERNATIONAL WOUND JOURNAL, Issue 3 2010Christy L Scimeca Reducing and preventing postoperative pain are currently a topic of great interest. There are different modalities for providing analgesia that can provide an alternative or adjunct to opioid therapy. One mode of therapy involves the use of portable pain pump devices that can deliver continuous local anaesthesia directly to the site of interest. A considerable amount of attention in literature has been dedicated to using regional anaesthesia postoperatively for various surgical applications. However, to our knowledge, little or no work has been published concerning the use of infusion of regional anaesthesia in the treatment of painful lower extremity wounds. We present a case report of a 55-year-old gentleman with a complex past medical history, 2-year history of opioid dependency and a 2-week history of intractable pain associated with the combination of debilitating painful diabetic neuropathy and painful lower extremity wounds. After surgical debridement of the lower extremity wounds, substantial analgesia was achieved postoperatively through the implantation of a portable direct infusion pump device. The device supplied 2 ml/hour of 0·25% bupivacaine and resulted in a reduction in pain within the first hour of implantation. Although the device achieved maximal analgesia at 6 hours, we found that this could have been likely reduced through the use of a 5-ml bolus dose of 0·25% bupivacaine at the time of implantation. The device provided sufficient analgesia to the patient without any observed adverse effects, and showed significant potential in avoiding an increase in his requirement for other systemic analgesia including opioids. [source] An approach to the management of necrotising fasciitis in neonatesINTERNATIONAL WOUND JOURNAL, Issue 2 2005Soraya Zuloaga-Salcedo MD Abstract Necrotising fasciitis is a severe, life-threatening soft tissue infection. It produces an extensive cellulitis with severe involvement of subcutaneous tissue, fascia, muscle or both, resulting in necrosis of the tissue. All age groups, including neonates, can be affected. Patients with necrotising fasciitis present with more severe constitutional symptoms and have a poor outcome, unless aggressive antibiotic therapy and surgical debridement are instituted promptly. The debridement of necrotic tissue is imperative to control the infection, but results in deep wounds that require further treatment. In this study, the neonate was treated with alginate dressings and negative pressure therapy after resolution of cellulitis, with excellent results and no untoward events. [source] Necrotising fasciitis: a new management algorithm based on clinical classificationINTERNATIONAL WOUND JOURNAL, Issue 3 2004Paul S Carter Abstract Necrotising fasciitis is a rare infection of the subcutaneous tissues. If untreated, it is invariably fatal, and thus a high index of suspicion for the diagnosis is required. The disease's manifestation can range from a fulminant presentation to a subtle and insidious development. The priority in every case is to proceed to radical surgical debridement. On review of the literature and based on our clinical experience, we propose a new classification based on clinical presentation and suggest an algorithm to facilitate the management of this devastating condition. Increasing awareness should be given to the management of the large wounds resulting from the surgical debridement of necrotising fasciitis. [source] Intravascular histiocytosis presenting with extensive vulvar necrosisJOURNAL OF CUTANEOUS PATHOLOGY, Issue 2009Pedram Pouryazdanparast Intravascular histiocytosis (IVH) is a rare reactive cutaneous lesion of unknown pathogenesis. Most cases are reported in association with rheumatoid arthritis, and cutaneous eruptions typically occur near swollen joints. The skin changes have included erythematous and violaceous macules, papules, plaques and indurated patches with a livedo-like pattern of erythema. We report the first case of IVH presenting with florid vulvar necrosis in an 87-year-old patient without a history of rheumatoid arthritis. Physical examination revealed an edematous, exudative and diffusely necrotic vulva with erythema surrounding the areas of necrosis, extending out to the thighs. The debrided skin revealed an extensively necrotic epidermis and multiple clusters of markedly dilated blood vessels within the dermis. These vessels contained fibrin thrombi admixed with numerous CD68+ and CD163+ histiocytes. Her skin changes improved significantly after surgical debridement and treatment with antibiotics. Interestingly, our patient was also found to have a lupus anticoagulant with elevated anticardiolipin antibodies. This is the first report of IVH possibly related to a thrombogenic diathesis associated with a hypercoagulable state. A diagnosis of IVH is important and may necessitate further clinical evaluation to exclude the possibility of co-existent systemic disease. [source] Rapid response of severe refractory metastatic Crohn's disease to infliximabJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 8 2001Ashley M Miller Abstract A case is described of a middle-aged female who developed an aggressive form of biopsy-proven metastatic Crohn's disease involving the inguinal, perineal and submammary areas. Her condition had been unresponsive to topical and systemic corticosteroids, antibiotics, immunosuppressives, and repeated surgical debridement. Administration of infliximab resulted in a rapid clinical response with subjective improvements in pain and general well-being, and an objective decline in exudate, erythema and size of the lesions. Infliximab may be a suitable therapeutic option in patients with metastatic Crohn's disease. [source] Successful treatment of cutaneous and subcutaneous zygomycosis in an immunosuppressed patient with aplastic anaemiaJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 1-2 2007Yumin Chan Abstract: Zygomycosis in patients with persistent neutropenia had been associated with poor outcomes despite aggressive surgical and antifungal therapy. We describe the case of a 10-year-old girl with aplastic anaemia and persistent neutropenia who developed cutaneous and subcutaneous zygomycosis of her right thigh that was successfully treated with extensive surgical debridement, intravenous liposomal amphotericin B, later changed to oral posaconazole for long-term suppressive therapy and granulocyte colony stimulating factor. [source] Mucormycotic pseudoaneurysm of the common carotid artery with tracheal involvementMYCOSES, Issue 4 2008S. Hashemzadeh Summary Mucormycosis is an emerging and fatal fungal infection. A high index of suspicion and the knowledge of its potential manifestations are essential for early diagnosis. We describe a patient with acute lymphoblastic leukaemia (L2 subtype) who developed a neck mass following a course of induction chemotherapy. Doppler ultrasonography and angiography of the neck revealed a pseudoaneurysm of the right common carotid artery. The patient then developed haemoptysis. Surgical exploration revealed a necrotic right common carotid artery with anteromedial pseudoaneurysm and adjacent tracheal wall perforation. Local debridement and tracheal repair were performed. Nonseptate hypheal invasion (mucormycosis) was found on the microscopic examination of the excised arterial wall. A subsequent recurrence of pseudoaneurysm was treated with local surgical debridement and intravenous amphotericin B (Fungizone) administration. Although rare, clinicians should be aware of these possible presenting features of mucormycosis as early diagnosis and treatment may potentially improve the survival. [source] Rhinocerebral mucormycosis: the disease spectrum in 27 patientsMYCOSES, Issue 4 2007Sandeep Mohindra Summary The variable forms of clinical complaints, findings and time interval of presentation in 27 cases of mucormycosis have been described, which were encountered over a span of 8 years. The previous concept about this fungal infection attacking chronic, debilitated, immunocompromised patients does not appear to hold true. Seven of the 27 patients (22.2%) did not reveal any predisposing factors and their outcome of 42.9% survival seems to be poorer than the total outcome (66.7%). ,Chronic form' of disease presentation, the definition of which is still not delineated, was encountered in four patients (14.8%). Again, the outcome was not significantly different from the total survival. Burr-hole tap of an intracranial abscess revealing mucor in a 2-month-old infant has been described. Even in the present era, extranasal exenteration of sinuses along with disfiguring orbital exenteration is required to ensure satisfactory surgical debridement. Control of the underlying predisposing illness, along with the aggressive surgical debridement and the parenteral administration of amphotericin B, remains the treatment essentials even today. [source] Reverse latissimus dorsi musculocutaneous flap for reconstruction of lumbar radiation ulcerTHE JOURNAL OF DERMATOLOGY, Issue 8 2007Sei-ichiro MOTEGI ABSTRACT The surgical treatment of large, deep defects on the midline of the lower back or lumbar area comprises difficult reconstructive challenges. Various flaps have been designed to reconstruct the defect area. We herein report a 70-year-old Japanese woman with a large, deep ulcer in the midline of the lower back, caused by postoperative radiation therapy for eccrine porocarcinoma. The ulcer was successfully treated with surgical debridement followed by reverse latissimus dorsi musculocutaneous flap. This flap is reliable and useful for reconstruction of a large, deep midline defect of the lower back, having large and bulky tissue with a sufficient blood supply. [source] Osteonecrosis of the Mandible or Maxilla Associated with the use of New Generation BisphosphonatesTHE LARYNGOSCOPE, Issue 1 2006Matthew C. Farrugia DO Objective: The use of bisphosphonates is well established for the treatment of patients with metastatic bone disease, osteoporosis, and Paget's disease. Osteonecrosis of the mandible or maxilla associated with the use of bisphosphonates is a newly described entity never before discussed in the otolaryngology literature. In this paper, we review a series of patients diagnosed with osteonecrosis, all treated with new generation bisphosphonates. Our objective is to inform and educate others, particularly otolaryngologists/head and neck surgeons, about this drug induced entity, a condition that should be recognized early to avoid potential devastating consequences. Study Design: Retrospective chart review of a series of patients from a tertiary referral center. Methods: Pathology reports of specimens submitted from either the mandible or maxilla were reviewed from the previous 12 months. Any patient diagnosed with osteonecrosis without evidence of metastatic disease at that site was included; those with a previous history of radiation therapy were excluded. Each patient's medical history and profile were reviewed. Results: Twenty-three patients were identified with osteonecrosis of the mandible or maxilla. All of these were associated with the use of new generation bisphosphonates: zolendronate (Zometa, Novartis), pamidronate (Aredia, Novartis), and alendronate (Fosamax, Merck). Eighteen patients with known bone metastases had been treated with the intravenous form, whereas five patients with either osteoporosis or Paget's disease were using oral therapy. Patients typically presented with a nonhealing lesion, often times the result of previous dental intervention. Although the majority of these patients were treated with conservative surgical debridement, we present a case requiring a near total maxillectomy. Conclusions: Drug induced osteonecrosis of the mandible or maxilla has been recently recognized as a sequelae of treatment with the new generation of bisphosphonates. Most patients can be treated with conservative surgical debridement and cessation of bisphosphonate therapy, whereas a few may require radical surgical intervention. Other recommendations include regimented prophylactic care with an assessment of dental status before the administration of bisphosphonates, avoidance of dental procedures, and close monitoring of oral hygiene. [source] Recurrent Respiratory Papillomatosis: A Longitudinal Study Comparing Severity Associated With Human Papilloma Viral Types 6 and 11 and Other Risk Factors in a Large Pediatric Population,THE LARYNGOSCOPE, Issue S104 2004Brian J. Wiatrak MD Abstract Objectives/Hypothesis: A database was developed for prospective, longitudinal study of recurrent respiratory papillomatosis (RRP) in a large population of pediatric patients. Data recorded for each patient included epidemiological factors, human papilloma virus (HPV) type, clinical course, staged severity of disease at each surgical intervention, and frequency of surgical intervention. The study hypothesizes that patients with HPV type 11 (HPV-11) and patients younger than 3 years of age at diagnosis are at risk for more aggressive and extensive disease. Study Design: The 10-year prospective epidemiological study used disease staging for each patient with an original scoring system. Severity scores were updated at each surgical procedure. Methods: Parents of children with RRP referred to the authors' hospital completed a detailed epidemiological questionnaire at the initial visit or at the first return visit after the study began. At the first endoscopic debridement after study enrollment, tissue was obtained and submitted for HPV typing using polymerase chain reaction techniques and in situ hybridization. Staging of disease severity was performed in real time at each endoscopic procedure using an RRP scoring system developed by one of the authors (B.J.W.). The frequency of endoscopic operative debridement was recorded for each patient. Information in the database was analyzed to identify statistically significant relationships between extent of disease and/or HPV type, patient age at diagnosis, and selected epidemiological factors. Results: The study may represent the first longitudinal prospective analysis of a large pediatric RRP population. Fifty-eight of the 73 patients in the study underwent HPV typing. Patients infected with HPV-11 were significantly more likely to have higher severity scores, require more frequent surgical intervention, and require adjuvant therapy to control disease progression. In addition, patients with HPV-11 RRP were significantly more likely to develop tracheal disease, to require tracheotomy, and to develop pulmonary disease. Patients receiving a diagnosis of RRP before 3 years of age had significantly higher severity scores, higher frequencies of surgical intervention, and greater likelihood of requiring adjuvant medical therapy. Patients with Medicaid insurance had significantly higher severity scores and required more frequent surgical debridement. Birth by cesarean section appeared to be a significant risk factor for more severe disease and necessity of more frequent surgical intervention. Conclusion: Statistical analysis of the relationships among epidemiological factors, HPV type, and clinical course revealed that patients with HPV-11 and patients younger than 3 years of age at RRP diagnosis are prone to develop more aggressive disease as represented by higher severity scores at endoscopic debridement, more frequent operative debridement procedures per year, a greater requirement for adjuvant therapy, and greater likelihood of tracheal disease with tracheotomy. [source] Primary Cutaneous Fungal Infections in Solid Organ Transplantation: A Case SeriesAMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2002Peter S. Miele Cutaneous fungal infections in solid-organ transplant patients present in a variety of nonspecific ways, requiring a high index of suspicion to diagnose correctly. In the present series of four transplant recipients, subsequent primary cutaneous fungal infections presented as papules, plaques, ulcers and subcutaneous nodules. Transplantations included one cardiac, two renal and one renal,pancreatic transplant. Fungal infections were limited to the skin; there was no evidence of disseminated disease in any case. The pathogens isolated were Scedosporium apiospermum (Pseudallescheria boydii), Alternaria species, Aspergillus fumigatus, and a coelomycete in the Coniothyrium-Microsphaeropsis complex of dark molds. Individuals were successfully treated with surgical debridement, antifungal agents, and reduction of immunosuppressive therapy. All patients and allografts survived. Accurate diagnosis, aggressive surgery and appropriate antifungal therapy, combined with close outpatient follow-up, optimize the likelihood of a cure in a transplant population. [source] FACTORS AFFECTING IMPLANT RETENTION IN INFECTED JOINT REPLACEMENTSANZ JOURNAL OF SURGERY, Issue 10 2007Jean-Claude Theis Background: There is no standard treatment for infected joint replacements. The options available are varied, and treatment choices may pose problems in relation to both efficacy and cost-effectiveness. Methods: A retrospective review of 73 patient records identified in our departmental audit database as infected joint replacements treated at Dunedin Hospital between 1990 and 2000 was carried out. The findings were analysed in terms of outcome of primary treatment, final outcome including prosthesis retention and bacteriology. Results: Of the 73 patients (50 hips and 20 knees), the majority (69%) were managed by primary surgical debridement followed by intravenous antibiotics but about one-third (34%) lost their implants because of infection. Retention of implants was higher in acute infections (85,100%) as opposed to late infections (20,50%). The microbiological analysis showed that Staphylococcus and Streptococcus caused the majority (76%) of infections. Conclusion: In our series, a patient with an infected joint replacement had an approximately similar 30% chance of retaining the original prosthesis, undergoing a successful revision and having no implants in situ at the end of treatment. [source] Conservative management of Pseudomonal infectious sclerokeratitisCLINICAL AND EXPERIMENTAL OPTOMETRY, Issue 3 2008Timothy C Smith MBBS Pseudomonal sclerokeratitis is an uncommon infection with the potential for loss of vision and the eye. A 66-year-old male contact lens wearer presented with a painful red eye diagnosed as sclerokeratitis. An intensive regimen of topical, subconjunctival and oral antibiotics as well as oral steroids was used as primary treatment. An overlying, focal collection of pus was incised and drained on two occasions. After three months of treatment, the infection had resolved and the treatment ceased. The involved sclera demonstrated a focal area of scleromalacia, which has remained stable. Infectious sclerokeratitis can be managed with conservative treatment without the need for surgical debridement and scleral grafting. [source] Bartonellosis: light and shadows in diagnostic and therapeutic issuesCLINICAL MICROBIOLOGY AND INFECTION, Issue 3 2005R. Manfredi Abstract Cat-scratch disease involves a prolonged and/or complicated course, and lymph node drainage is usually required. Culture and molecular techiques often yield negative results, but immunofluorescence assays may give early information, and elevated antibodies may persist for months. Cat-scratch disease should be suspected in patients with prominent swelling of lymph nodes draining from the upper limbs, limited systemic involvement, and typical epidemiological,clinical features. The temporal antibody response during the sub-acute course remains unknown. Although biomolecular assays are available, the time between onset and investigation is an obstacle to positive results. The role of surgical debridement and the unpredictable activity of antimicrobial agents warrant further investigation. [source] Vertebral osteomyelitis caused by non-tuberculous mycobacteriaCLINICAL MICROBIOLOGY AND INFECTION, Issue 11 2004G. Petitjean Abstract Vertebral osteomyelitis caused by non-tuberculous mycobacteria is a rare disease, with only 31 cases and one nosocomial outbreak reported in the literature (MedLine review between 1965 and December 2003). The clinical features are often indistinguishable from those of pyogenic osteomyelitis. Early diagnosis of such infections is a major challenge because of the slow growth of these microorganisms. No consensus guidelines for the treatment of these infections exist. Prolonged anti-mycobacterial therapy in combination with surgical debridement is recommended. [source] Delayed stoma formation in Fournier's gangreneCOLORECTAL DISEASE, Issue 6 2004C. S. Bronder Abstract Fournier's gangrene is traditionally treated with prompt surgical debridement and in many cases a diverting colostomy is also fashioned during the same procedure. We present four cases where stoma formation was delayed until the second look procedure. The physiological states at the time of either procedure were compared using POSSUM. The results showed an improvement in the physiological condition in all patients at the time of the second operation, suggesting that a delay can potentially improve prognosis in such cases. [source] | |||||||||||||||||||||||||