Cystic Echinococcosis of the Ilium Treated with Curettage and Microwave Thermoablation Followed by Bone Cement Installation: A Novel Treatment Technique for a Rare Disease.

Bone cystic echinococcosis (CE) is a rare condition requiring a high level of suspicion during primary diagnosis. Wide excision of the lesion is the gold standard of treatment, posing however extreme challenges in certain parts of the skeleton, since it may well be accompanied by increased morbidity. We report the case of a 35-year-old Caucasian female with iliac bone CE, referred to our department (a regional referral center for the treatment of patients with musculoskeletal tumors). The patient reported gradually increasing dull pain at the right iliac fossa and antalgic gait, with an onset of approximately 5 years before her referral. Bone CE diagnosis was established based on physical examination, imaging studies, and two subsequent CT-guided core needle biopsies, performed within a period of 3 months, of which the second was diagnostic. Following a musculoskeletal tumor multidisciplinary meeting, it was decided that the optional treatment was the surgical removal of the cyst. Aiming to minimize the morbidity accompanying a wide resection of the lesion, we performed extended curettage of the lesion through a typical iliac spine approach, followed by microwave ablation of the walls of the remaining bone cavity. The remaining iliac defect was treated with the installation of polymethyl methacrylate bone cement. The patient reported immediate remission of symptoms postoperatively and was able to return to everyday activities two weeks postoperatively. She began oral treatment with albendazole on the 7th postoperative day. She remained symptom-free for a period of 25 months, until she developed a seroma at the gluteal area, which was treated with simple drainage. On her latest follow-up six months later, she remained symptom-free and was able to perform all her previous activities. Microwave ablation may serve as a useful adjuvant modality when treating patients with bone CE, in order to prevent relapse of the disease.

Organizing an Orthopaedic Department During COVID-19 Pandemic to Mitigate In-Hospital Transmission: Experience From Greece.

The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging in Wuhan city of China, was the cause of a rare type of pneumonia evolving rapidly in pandemic early at the beginning of 2020. The rapid human-to-human transmission of SARS-CoV-2 increases the risk of in-hospital transmission, requiring re-definement of musculoskeletal trauma management and postoperative care. Following the review of the existing literature on COVID-19 and similar infectious diseases, National and Hospital Board instructions for Infectious Diseases, as well as the consensus for surgical care by the consortium of the Orthopaedic Department Directors, we present the outline of the implemented principles in the orthopaedic departments of a tertiary academic hospital in Greece to operate during COVID-19 pandemic. Our overall objectives were to decrease the admission load and mitigate the risk of in-hospital transmission of SARS-CoV-2. The principles involve the management of the Orthopaedic medical and nursing personnel, alterations of the workflow in the wards, operating rooms and outpatient clinics from the admission to the discharge of an orthopaedic patient. In addition, we present the recommended principles of management of traumatic orthopaedic injuries highlighting those deserving admission and in-hospital care and those that can be treated in the outpatient setting or day surgery clinics.

Diagnostic Value of 18F-FDG-PET/CT in Patients with FUO.

Conventional diagnostic imaging is often ineffective in revealing the underlying cause in a considerable proportion of patients with fever of unknown origin (FUO). The aim of this study was to assess the diagnostic value of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in patients with FUO. We retrospectively reviewed 18F-FDG-PET/CT scans performed on 50 consecutive adult patients referred to our department for further investigation of classic FUO. Final diagnosis was based on histopathological and microbiological findings, clinical criteria, or clinical follow-up. Final diagnosis was established in 39/50 (78%) of the patients. The cause of FUO was infection in 20/50 (40%), noninfectious inflammatory diseases in 11/50 (22%), and malignancy in 8/50 (16%) patients. Fever remained unexplained in 11/50 (22%) patients. 18F-FDG-PET/CT scan substantially contributed to the diagnosis in 70% of the patients, either by identifying the underlying cause of FUO or by directing to the most appropriate site for biopsy. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of 18F-FDG-PET/CT for active disease detection in patients with FUO were 94.7%, 50.0%, 84.0%, 85.7%, and 75.0%, respectively. In conclusion, whole-body 18F-FDG-PET/CT is a highly sensitive method for detection of the underlining cause of FUO or for correctly targeting suspicious lesions for further evaluation.

Infections Due to Multidrug-Resistant Bacteria in Oncological Patients: Insights from a Five-Year Epidemiological and Clinical Analysis.

Bacterial infections are frequent complications in cancer patients. Among them, those caused by multidrug-resistant (MDR) bacteria increase morbidity and mortality mainly because of limited therapeutic options. Current knowledge regarding MDR infections in patients with solid tumors is limited. We assessed the epidemiology and risk factors of increased mortality in these patients. In this retrospective five-year single cohort observational study, we included all oncological patients with MDR infections. Cancer-related parameters, comorbidities, prior use of antibiotics, previous surgical interventions and hospitalization, as well as the use of invasive procedures were investigated as potential risk factors causing adverse outcomes. Seventy-three patients with MDR infection were included: 37% with carbapenem-resistant Klebsiella pneumoniae, 24% with oxacillin-resistant Staphylococcus aureus (MRSA) and 21% with carbapenem-resistant Acinetobacter baumanni. Previous colonization with MDR bacteria was detected in 14% patients, while 20% of the patients presented MDR colonization or infection at ward admission. Mortality during the infection episode was 32%. Duration of hospitalization and CRP were statistically significant risk factors of mortality, whereas administration of guided antibiotics was a protective factor. Knowledge of local epidemiology of MDR bacteria can help physicians promptly identify cancer patients at risk of MDR infections and initiate timely effective empirical antibiotic treatment that can eventually improve the overall therapeutic management.

A two-step approach improves the diagnosis of Clostridium difficile infection.

Clostridium difficile infection (CDI) is a major cause of health care-associated diarrhea. The aim of the present study was to evaluate a two-step approach for the diagnosis of CDI. The two-step procedure consisted of GDH-toxin A/B EIA (Enzyme immunoassay targeting enterotoxin A and Cytotoxin B), followed by PCR detecting toxigenic C. difficile. Results indicate that EIAs provide a rapid screening assay for the laboratory diagnosis of CDI but, in GDH-positive and toxins-negative samples, EIA should be always followed by PCR to distinguish toxigenic vs nontoxigenic strains. GDH-toxin A/B EIA-rapid test has high specificity but low sensitivity to detect CDI. The implementation of a two-step procedure significantly increases the diagnostic accuracy to detect CDI and provides a toxigenic type characterization of C. difficile isolates.

Pulmonary co-infections by Pneumocystis jirovecii and Aspergillus fumigatus in non-HIV patients: A report of two cases and literature review.

Pneumocystis jirovecii is the causative agent of Pneumocystis pneumonia (PcP), a common and often life-threatening opportunistic infection in HIV-infected patients. However, non-HIV, immunocompromised patients are at risk of PcP as well, whereas the mortality appears to be higher among these patients. Pneumocystis co-infections with other microorganisms are less frequent and only sparse reports of combined PcP and invasive pulmonary fungal infections exist in the literature, especially in the non-HIV patients. Two cases of pulmonary co-infections by P. jirovecii and Aspergillus fumigatus are presented. Both patients were non-HIV infected, the first one was suffering from crescentic IgA nephropathy under immunosuppressive treatment and the second from resistant non-Hodgkin lymphoma under chemotherapy. Both patients were treated with intravenous trimethoprim/sulphamethoxazole (TMP/SMX) combined with voriconazole. The first patient showed gradual clinical improvement while the outcome for the second patient was unfavourable. In addition, a literature review of the previous published cases of co-infection by P. jirovecii and other fungi in non-HIV patients was performed. Our target was to provide comprehensive information on this kind of infections, highlighting the importance of clinical suspicion.

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries.

PURPOSE: As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality. METHODS: Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests. RESULTS: 44,814 patients from 474 hospitals in 27 countries were available for analysis. Death was more frequent amongst patients admitted directly to critical care after surgery (critical care: 103/4317 patients [2%], standard ward: 99/39,566 patients [0.3%]; adjusted OR 3.01 [2.10-5.21]; p < 0.001). This association may differ with national income (high income countries OR 2.50 vs. low and middle income countries OR 4.68; p = 0.07). At hospital level, there was no association between mortality and critical care admission directly after surgery (p = 0.26), critical care admission to treat complications (p = 0.33), or provision of critical care beds (p = 0.70). Findings of the hospital-level analyses were not affected by national income status. A sensitivity analysis including only high-risk patients yielded similar findings. CONCLUSIONS: We did not identify any survival benefit from critical care admission following surgery.