Microbiology of septic arthritis in young Auckland children.

BACKGROUND: Kingella kingae is an important cause of septic arthritis in young children, with modern laboratory methods leading to increased detection. Prevalence of this pathogen in New Zealand, where there are high rates of childhood infections due to Staphylococcus aureus and Streptococcus pyogenes, is not known. METHODS: We conducted a retrospective review of children <5 years with septic arthritis (without osteomyelitis) at a tertiary children's hospital in Auckland, over 10 years (2005-2014). Data were collected on demographics, microbiology, clinical presentation, investigations and management. RESULTS: Of the 68 cases of septic arthritis, 57 (83.8%) occurred in children aged <24 months. Among those <3 months, Streptococcus agalactiae (Group B streptococcus) was predominant (45.5% of 11 cases), followed by S. aureus (36.4%). The most common pathogen in those 3 to <12 months was Streptococcus pneumoniae (38.5% of 13 cases). In children aged 12 to <24 months, K. kingae was most common (30.3% of 33 cases). Of the 12 cases of K. kingae, 91.7% were identified from synovial fluid culture. All K. kingae isolates were susceptible to amoxicillin. CONCLUSIONS: K. kingae is the leading pathogen in septic arthritis in New Zealand children aged 12 to <24 months. Routine inoculation of synovial fluid into blood culture bottles at time of sample collection, in addition to use of polymerase chain reaction methods, should be encouraged to improve detection rates. For infants and preschool children presenting with single joint septic arthritis, empiric antibiotics should include cover for S. aureus and K. kingae.

Septic arthritis and acute rheumatic fever in children: the diagnostic value of serological inflammatory markers.

INTRODUCTION: Joint pain and raised inflammatory markers are features of both acute rheumatic fever (ARF) and septic arthritis, often posing a diagnostic challenge to clinicians. Important differences in the presenting serological inflammatory marker profile may assist patient diagnosis, however, as clinical experience suggests that ARF is associated with a higher erythrocyte sedimentation rate (ESR), whereas other serological markers may be similarly elevated in these 2 conditions. OBJECTIVE: The goal of this study was to determine the diagnostic value of serological inflammatory markers and white cell count (WCC) in children presenting with acute joint pain secondary to ARF or septic arthritis. METHODS: Data were obtained from the Auckland regional rheumatic fever database and hospital computer records between 2005 and 2012. Records of all patients under the age of 16 years who were admitted with a new diagnosis of ARF or septic arthritis were analyzed. The diagnosis of ARF was defined on the basis of the New Zealand modification of the Jones Criteria, and the diagnosis of septic arthritis was defined on the basis of joint fluid cytology and culture. Baseline characteristics, serological inflammatory markers, and serum WCC were compared between the ARF and septic arthritis patient groups. RESULTS: Children with ARF displayed significantly higher ESR, higher serum C-reactive protein, and lower serum WCC than children with septic arthritis on presentation to hospital. In children presenting with monoarthritis, an ESR>64.5, serum WCC<12.1×109/L, and age above 8.5 years were found to be significant independent predictors of ARF. Children with all 3 predictors had a 71% risk for ARF and a 29% risk for septic arthritis. A significant proportion (30%) of children with the final diagnosis of ARF initially presented with monoarthritis; 14% of these children (5/34) had received nonsteroidal anti-inflammatory medication before hospital presentation, and 74% of these children (25/34) had abnormal echocardiograms on admission. CONCLUSIONS: ARF and septic arthritis are important diagnoses to consider in children presenting with acute joint pain in New Zealand. A significant proportion of patients with ARF initially present with acute monoarthritis. Serological inflammatory markers and WCC on presentation differ significantly between children with ARF and septic arthritis.

Principles of Breast Re-Reduction: A Reappraisal.

BACKGROUND: This article examines outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. METHODS: A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Patient demographics, surgical technique, and outcomes were analyzed. RESULTS: Ninety patients underwent breast re-reduction surgery. The average interval between primary and secondary surgery was 14 years (range, 0 to 42 years). The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 percent)]. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 percent)]. The nipple-areola complex was repositioned in 60 percent of patients (n = 54). The mean volume of tissue resected was 250 g (range, 22 to 758 g) from the right breast and 244 g (range, 15 to 705 g) from the left breast. Liposuction was also used adjunctively in all cases (average, 455 cc; range, 50 to 1750 cc). Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 percent). CONCLUSIONS: Breast re-reduction can be performed safely and predictably, even when the previous technique is not known. Four key principles were developed: (1) the nipple-areola complex can be elevated by deepithelialization rather than recreating or developing a new pedicle; (2) breast tissue is removed where it is in excess, usually inferiorly and laterally; (3) the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and (4) skin should not be excised horizontally below the inframammary fold. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Lymphatic Response to Injury with Soft-Tissue Reconstruction in High-Energy Open Tibial Fractures of the Lower Extremity.

BACKGROUND: Severe compound tibial fractures are associated with extensive soft-tissue damage, resulting in disruption of lymphatic pathways that leave the patient at risk of developing chronic lymphedema. There are limited data on lymphatic response following lower limb trauma. Indocyanine green fluorescence lymphography is a novel, real-time imaging technique for superficial lymphatic mapping. The authors used this technique to image the superficial lymphatic vessels of the lower limbs in patients with severe compound tibial fracture. METHODS: Baseline demographics and clinical and operative details were recorded in a prospective cohort of 17 patients who had undergone bone and soft-tissue reconstruction after severe compound tibial fracture between 2009 and 2014. Normal lymphatic images were obtained from the patients' noninjured limbs as a control. In this way, the authors investigated any changes to the normal anatomy of the lymphatic system in the affected limbs. RESULTS: Of the 17 patients, eight had free muscle flaps with split-thickness skin grafting, one had a free fasciocutaneous flap, one had a full-thickness skin graft, six had local fasciocutaneous flaps, and one had a pedicled gastrocnemius flap. None of the free flaps demonstrated any functional lymphatic vessels; the fasciocutaneous flaps and the skin graft demonstrated impaired lymphatic vessel function and dermal backflow pattern similar to that in lymphedema. Local flaps demonstrated lymphatic blockage at the scar edge. CONCLUSION: Severe compound fractures and the associated soft-tissue injury can result in significant lymphatic disruption and an increased risk for the development of chronic lymphedema.

Causes of Flexor Tendon Repair Failures in Two Common Repair Techniques: A Cadaver Study.

BACKGROUND: Flexor tendon repair failures have primarily been attributed to either core suture rupture or core suture pull out. Recent studies have suggested that knot unravelling may also cause failure of a tendon repair. The aim of this study was to investigate the causes of core suture failure in two types of common flexor tendon repairs. METHODS: Twenty four cadaver tendons were divided into three groups of eight. Each group tested a specific flexor tendon repair. The repairs tested included an Adelaide repair using 4/0 Ethibond (Ethicon), an Adelaide repair using 4/0 Fiberwire (Arthrex) and the Tsai repair with 4/0 Fiberloop (Arthrex). The repaired tendons were pull-tested to failure. The mechanism of failure, maximum tensile strength and 2 mm gap force were recorded. RESULTS: The predominant mode of failure was by the knot unravelling. This occurred in 50-88% of the tendon repairs. The sequence of failure was initiated with gapping at the repair site followed by failure of the epitendinous suture. Next the core suture knot unravels. Once the knot unravels, the suture thread slips out of the tendon resulting in the repair failure. Failures due to knot slippage occurred at a lower maximum tensile strength in Ethibond and Fiberloop sutures than failure due to core rupture or pull out. However, given the small number of tendons tested, this result was not significant. CONCLUSIONS: This study has clearly demonstrated one of the main causes of flexor tendon repair failure in two common repair techniques is knot unravelling.

Thoracic outlet syndrome following breast implant rupture.

We present a patient with bilateral breast implant rupture who developed severe locoregional silicone granulomatous lymphadenopathy. Poly Implant Prothese silicone implants had been used for bilateral breast augmentation 5 years prior. Extracapsular implant rupture and bilateral axillary lymphadenopathy indicated explantation, capsulectomy, and selective lymph node excision. Histology demonstrated silicone lymphadenopathy with no evidence of malignancy. Over the subsequent 12 months, she developed progressive locoregional lymphadenopathy involving bilateral cervical, axillary, and internal mammary groups, resulting in bilateral thoracic outlet syndrome. We report the unusual presentation, progression, and the ultimate surgical management of this patient.

Transduction of human adipose-derived mesenchymal stem cells by recombinant adeno-associated virus vectors.

Human adipose-derived stem cells (ASCs) are attractive targets for genetic manipulation and cellular therapies. However, current methods of gene transfer are limited by lack of efficiency, toxicity, or safety concerns. Recombinant adeno-associated virus (rAAV) has been extensively assessed as a gene therapy vector and has an excellent safety profile. This study reports the efficient transduction of well-characterized, homogeneous cultures of human ASCs by rAAV serotypes 2, 5, and 6. Transduction with rAAV2 at high multiplicity of infection was associated with reduced cell viability; however, no adverse effect was seen with serotypes 5 and 6. A further increase in transduction efficiency was observed using a rAAV6 Y731F tyrosine capsid mutant. rAAV-transduced ASCs retained their adipogenic potential. Therefore, rAAV serotypes 2, 5, and 6 should be considered the vectors of choice for genetic manipulation of ASCs.

A case of misdiagnosed squamous cell carcinoma due to alternative medical misadventure--time for tightening regulation?

We present a patient with locally advanced squamous cell carcinoma that had grown significantly during 16 months of intensive alternative therapy. The alternative medicine practitioner allegedly repeatedly reassured the patient that her condition was benign and advised against seeking conventional medical treatment. Due to the delayed presentation, the patient required extensive surgery and postoperative adjuvant radiotherapy. This case highlights the risks of alternative therapy in the place of proven conventional medical treatment and emphasises the limitations of current regulation of complementary and alternative medicine in New Zealand.