Manejo ortoplástico de fractura expuesta de pierna grave: a propósito de un caso / Orthoplastic management of severe open fractures: case report / Tratamento ortoplástico das fraturas expostas grave: relato de caso

Las fracturas expuestas de pierna son lesiones frecuentes, sus principales complicaciones son la infección y la dificultad en la consolidación ósea. El abordaje ortoplástico implica llevar a cabo principios y prácticas de ambas especialidades en forma conjunta, evitando el tratamiento por separado de los problemas que surgen de estas lesiones graves y así intentar disminuir al mínimo las complicaciones. Nuestro objetivo es transmitir la importancia del enfoque ortoplástico en las fracturas expuestas. Se reporta el caso de un paciente adulto, con una fractura de pierna, tibia y peroné expuesta, que requirió múltiples procedimientos quirúrgicos en vistas a preservar el miembro. Fueron necesarias variadas estrategias para controlar la infección ósea y reconstruir las partes blandas y óseas. Con el estímulo de la movilidad del tobillo y pie, se logró comenzar a restituir la función del miembro desde el inicio; permitiendo, a las 6 semanas de evolución, el apoyo del miembro mediante una fijación ósea estable. A los 24 meses de seguimiento clínico y radiográfico evidenciamos paciente y familia satisfechos con un excelente resultado funcional según score ASAMI. Se concluye que en pacientes con fracturas expuestas graves, es clave el abordaje ortoplástico para lograr mejores resultados.

Open leg fractures are frequent injuries; the infection and difficulty in bone healing are their main complications. The orthoplastic approach involves carrying out principles and practices of both specialties together, avoiding separate treatment of the problems that arise from these serious injuries and thus minimizing complications. The objective of the article is to convey the importance of the orthoplastic approach in open fractures. We report the case of an adult patient, with an open fractured leg, to required multiple surgical procedures to preserve the limb. Various strategies were necessary to cure the bone infection and reconstruct the soft tissue and bone. The limb function restore was possible promoting the ankle and foot mobility from the beginning and it allowed weight-bearing on the limb through stable bone fixation, at 6 weeks of evolution. We evidenced a patient and family satisfied with an excellent functional result according to the ASAMI score, at 24 moths of clinical and radiographic follow-up. It is concluding that in patients with severe open fractures, the orthoplastic approach is key to obtain better results.

As fraturas expostas da perna são lesões frequentes, suas principais complicações são infecção e dificuldade de consolidação óssea. A abordagem ortoplástica envolve a realização conjunta de princípios e práticas de ambos ases especialidades, evitando o tratamento separado dos problemas decorrentes dessas lesões graves e minimizando assim as complicações. Nosso objetivo é transmitir a importância da abordagem ortoplástica nas fraturas expostas. É relatado o caso de um paciente adulto, com fratura de perna, tíbia e fíbula expostas, necessitando de múltiplos procedimentos cirúrgicos para preservação do membro. Várias estratégias foram necessárias para curar a infecção óssea e reconstruir os tecidos moles e o osso. Foi possível começar a restaurar a função do membro desde o início, com a estimulação da mobilidade do tornozelo e do pé; com 6 semanas de evolução, concedendo cargas ao membro por meio de fixação óssea estável. Apresentou boa evolução, aos 24 meses de acompanhamento clínico y radiográfico, constatamos a satisfação do paciente e família. com um excelente resultado funcional de acordo a pontuação ASAMI. Conclui-sé que em pacientes com fraturas expostas graves, a abordagem ortoplástica é fundamental para obter melhores resultados.

Association between Endodontic Infection, Its Treatment and Systemic Health: A Narrative Review.

The 'Focal Infection Era in Dentistry' in the late 19th and early 20th century resulted in widespread implementation of tooth extraction and limited the progress of endodontics. The theory proposed that bacteria and toxins entrapped in dentinal tubules could disseminate systemically to remote body parts, resulting in many types of degenerative systemic diseases. This theory was eventually refuted due to anecdotal evidence. However, lately there has been increased interest in investigating whether endodontic disease could have an impact on general health. There are reviews that have previously been carried out on this subject, but as new data have emerged since then, this review aims to appraise the available literature investigating the dynamic associations between apical periodontitis, endodontic treatment, and systemic health. The available evidence regarding focal infection theory, bacteraemia and inflammatory markers was appraised. The review also collated the available research arguing the associations of apical periodontitis with cardiovascular diseases, diabetes mellitus, adverse pregnancy outcome and autoimmune disorders, along with the effect of statins and immunomodulators on apical periodontitis prevalence and endodontic treatment prognosis. There is emerging evidence that bacteraemia and low-grade systemic inflammation associated with apical periodontitis may negatively impact systemic health, e.g., development of cardiovascular diseases, adverse pregnancy outcomes, and diabetic metabolic dyscontrol. However, there is limited information supporting the effect of diabetes mellitus or autoimmune disorders on the prevalence and prognosis post endodontic treatment. Furthermore, convincing evidence supports that successful root canal treatment has a beneficial impact on systemic health by reducing the inflammatory burden, thereby dismissing the misconceptions of focal infection theory. Although compelling evidence regarding the association between apical periodontitis and systemic health is present, further high-quality research is required to support and establish the benefits of endodontic treatment on systemic health.

Alopecia areata y pustulosis palmoplantar: informe de 4 casos / Alopecia Areata and Palmoplantar Pustulosis: Report of 4 Cases

No disponible

Intensive care resources required to care for critically ill children with focal intracranial infections.

The authors reviewed cases in which children with a focal infection inside the head (ex: a brain abscess) were cared for in their pediatric ICU to describe the frequency of complications and quantify the ICU resources needed (ex: breathing tube, blood pressure medications, and/or an intracranial pressure monitor). This information helps clarify illness severity and has identified complications that we should further investigate to improve care for these children.

Clinical Features, Etiologic Factors, Associated Disorders, and Treatment of Palmoplantar Pustulosis: The Mayo Clinic Experience, 1996-2013.

OBJECTIVE: To further characterize clinical characteristics, etiologic factors, associated disorders, and treatment of palmoplantar pustulosis (PPP). PATIENTS AND METHODS: We conducted a retrospective review of patients with PPP at Mayo Clinic between January 1, 1996, and December 31, 2013. RESULTS: Of 215 patients with PPP identified, 179 (83%) were female, and the mean age at onset was 45.3 years. Most patients (n=165, 77%) were current or former smokers. At diagnosis, 15 patients (7%) had an anxiety diagnosis and 9 (4%) had an infection. Nineteen cases (9%) were drug induced. Comorbid conditions included thyroid disease in 18 patients (8%), gluten sensitivity in 3 (1%), and type 2 diabetes mellitus in 21 (10%). In all, 194 patients (90%) received topical corticosteroids, 55 (26%) received phototherapy, and 54 (25%) received systemic agents. CONCLUSION: More than three-fourths of the patients in this study had a history of smoking, which is considered a triggering or aggravating factor for PPP. Regarding comorbid conditions, gluten sensitivity and thyroid disease were found less frequently than previously reported in the literature. Treatment regimens and responses in this cohort varied considerably.

Infection site is predictive of outcome in acute lung injury associated with severe sepsis and septic shock.

BACKGROUND AND OBJECTIVE: Sepsis is a leading cause of acute lung injury (ALI); however, the characteristics and outcome of sepsis-associated ALI are poorly understood. We aimed to elucidate factors that predict patient outcome in sepsis-associated ALI. METHODS: Secondary analysis of a multicenter, prospective, observational study was performed. RESULTS: Among 624 patients with severe sepsis and septic shock, 251 (40.2%) fulfilled the definition of American-European Consensus Conference definition of ALI. All-cause 28-day and in-hospital mortalities were 30.7% and 38.6%, respectively. More than 40% of ALI patients had neurological, cardiovascular and haematological dysfunctions or disseminated intravascular coagulation, all of which were associated with higher mortality. We report a significant correlation between infection site and mortality in patients with ALI, but not in those without ALI. The proportion of ALI was significantly higher in pulmonary sepsis; further, a complication of ALI was associated with higher mortality in sepsis from pulmonary and other sources, but not in abdominal sepsis. Among the other sepsis sites, urinary tract, central nervous system, catheter-related and undetermined foci of infection had worse outcomes when associated with ALI. None of the individual severe sepsis bundles, including fluid resuscitation and early antibiotic administration, correlated with mortality. Compliance with a set of sepsis management bundles was associated with better outcomes. CONCLUSION: In severe sepsis and septic shock, the proportion and effect on outcome was not uniform among infection sites. The infection site was predictive of outcome in patients with ALI but not in those without ALI.

Cerebral venous thrombosis: comparing characteristics of infective and non-infective aetiologies: a 12-year retrospective study.

BACKGROUND: Most cases of cerebral venous thrombosis (CVT) have non-infective causes. Infective CVT, though less common, often results in a catastrophic outcome. The distinctive clinical characteristics of infection-associated CVT (IACVT) and non-infection-associated CVT (NIACVT) would facilitate early detection and proper management. OBJECTIVE: To compare the characteristics of IACVT and NIACVT. METHODS: All patients with CVT admitted to Songklanagarind Hospital between January 2002 and December 2013 with the ICD10 codes I636, I676, O225 and G08 were identified and recruited. We compared the clinical presentations, neuroimaging results and hospital outcomes for patients with IACVT and those with NIACVT. We analysed the differences using descriptive statistics. Additionally, for patients with IACVT, we described the primary sites of infection, associated CVT, host immune status and microbiological results. RESULTS: Twenty of the 83 patients with CVT (24.1%) had IACVT. Male gender (70.0% vs 34.9%) and pre-existing diabetes mellitus (35.0% vs 4.8%) were significantly more prevalent in the IACVT than the NIACVT group. Additionally, cavernous sinus thrombosis predominated in IACVT (80.0% vs 11.1%), whereas focal neurological syndrome was more common among patients with NIACVT (50.8% vs 15.0%). Paracranial infections, mostly sinusitis and orbital cellulitis, were common primary infections (80.0%) among patients with IACVT. Lastly, fungus was a devastating causative pathogen in IACVT-five of six patients with fungal infection had intracranial complications. CONCLUSIONS: Cavernous sinus thrombosis is a distinctive clinical presentation of IACVT, whereas focal neurological syndrome is a hallmark feature of NIACVT. Paracranial fungal infections are highly virulent and frequently associated with intracranial complications.

Adecuación de la profilaxis antibiótica en el parto por cesárea / Compliance with an antibiotic prophylaxis protocol in cesarean sections

Objetivo. Evaluar el uso de la profilaxis antibiótica en las cesáreas, estudiando el cumplimiento y la adecuación de la misma y su efecto sobre la incidencia de infección quirúrgica. Pacientes y métodos. Estudio de cohortes prospectivo. Se evaluaron el cumplimiento y la adecuación de la profilaxis antibiótica. Se describen los porcentajes de adecuación. Se estudió la relación entre la adecuación de la profilaxis antibiótica y la incidencia de infección quirúrgica con el riesgo relativo. Resultados. Se incluyó a 680 pacientes. La adecuación global fue del 95,7%. La causa más frecuente de inadecuación fue el tiempo de administración (96,6%). La incidencia de infección fue del 2,5% y no se encontró relación entre la inadecuación de la profilaxis y la infección (RR = 4,5; IC95%: 0,55-38,4; p > 0,05). Conclusiones. La adecuación de la profilaxis fue alta. La incidencia de infección de localización quirúrgica fue baja y no se relacionó con la adecuación de la profilaxis antibiótica (AU)

Objective. To evaluate compliance with a protocol for antibiotic prophylaxis in cesarean sections and its influence on the incidence of surgical wound infection. Patients and methods. A prospective cohort study was carried out to assess compliance with our antibiotic prophylaxis protocol. Percentages of compliance and the cumulative incidence of infection were calculated. The effect of compliance with the protocol for antibiotic prophylaxis on surgical wound infection was estimated with the relative risk. Results. We included 680 patients. Overall compliance with the protocol was 95.7%. The most frequent cause of lack of compliance was the time of administration (96.6%). The cumulative incidence of infection was 2.5% and there was no association between compliance with the protocol and the infection rate (RR = 4.5; 95% CI: 0.55-38.4; P>.05). Conclusions. Compliance with the protocol for antibiotic prophylaxis was high. The cumulative incidence of surgical wound infection was low and was unrelated to antibiotic prophylaxis (AU)

Extracranial head and neck infections.

This article outlines infections in the submandibular, lateral pharyngeal, retropharyngeal, danger, and prevertebral spaces, in conjunction with infections of the sinuses and mediastinum. By understanding the anatomy and pathophysiology, the reader will gain insight into the rationale for various therapeutic options.

[An update on focal infection of oral origin]. / Point actuel sur l'infection focale d'origine buccodentaire.

Focal infection of oral origin means that an oral infectious focus may have widespread effects. This concept remains controversial since it is difficult to prove the oral origin of germs responsible for an extra-oral infection. Experiments on animal models and clinical studies suggested several physiopathological mechanisms: bacteremia, toxinic and immunological mechanisms. Various operations induce the passage of bacterial flora (transcytosis) and its toxins into the bloodstream: oral care, chewing, or tooth brushing. Bacteremia is worsened by poor oral hygiene or an infection. The germs are usually destroyed by the host's reticuloendothelial system in a few minutes, but the presence of a valvular disease or a weak immune system favors focal infection. Besides infectious endocarditis, this may concern cardiovascular diseases, lung infections, prematurity and hypotrophy, diabetes, prosthetic infections, cerebral abscesses, etc. This update is based on literature review, selected according to its high level of scientific proof, as well as on a selected choice of consensus conferences. The current recommendation is to limit antibiotic prophylaxis to the high bacteremia risk procedures and to patients highly at risk of developing a focal infection.

Reactive arthritis induced by tonsillitis: a type of 'focal infection'.

OBJECTIVE: The clinical manifestation of reactive arthritis (ReA ) induced by tonsillitis is demonstrated. METHODS: Medical records of 21 patients with ReA induced by tonsillitis were analyzed. RESULTS: Nine male and 12 female patients were recorded. The mean age was 31.7 years ranging from 20 to 51 years. The mean duration of arthritis was 29.8 months (2 weeks to 10 years). Acute or recurrent origoarthritis involved in ankle, knee and sternoclavicular joints associated with Achilles tendon enthesitis were demonstrated. Thirteen of 21 (62%) patients were demonstrated positive for ASO and/or ASK. Group A streptococcus was demonstrated in 12 of 21 (57.1%) patients and other bacteria were demonstrated by culture of tonsillar swab or from resected tonsillar microabscess. No bacteria was demonstrated in synovial fluid from 3 patients. Rheumatoid factor was demonstrated only in 2 of 21 patients. HLA-B39 and BW61 (B40) were significantly demonstrated in 5 and 7 patients (p=0.0004, 0.0006, respectively) compared with those of healthy controls. All patients were treated with antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). Eight of 21 patients underwent tonsillectomy. Arthritis ceased after the treatments and no recurrence was found. DISCUSSION: Sterile inflammatory arthritis induced by tonsillitis was cured by resection of the microabscess in the tonsils. Therefore, ReA induced by tonsillitis is one form of 'focal infection'.

Tonsil-related skin diseases and possible involvement of T cell co-stimulation in chronic focal infection.

Some inflammatory skin diseases are known to be related to tonsil focal infection at their onset. Administration of antibiotics is adequate treatment in most acute or subacute cases. However, chronic focal infections in the tonsils could cause chronic skin diseases like pustulosis palmaris et plantaris (PPP), and it is our frequent experience that tonsillectomy leads to a dramatic and persistent improvement of PPP skin lesions. The expression of inducible co-stimulator (ICOS), a co-stimulatory receptor on activated T cells, was significantly higher in tonsil tissues from PPP patients than in tonsil tissues from non-PPP patients. Moreover, ICOS expression in tonsil tissues from 3 patients with psoriasis vulgaris that was strongly suspected to be related to tonsil focal infection was also high, suggesting that the activation of T cells via ICOS costimulation in focal infections likely triggers inflammation associated with tonsil-related skin diseases. PPP is notable today for paradoxically induced skin lesions in patients treated with TNF-α antagonists for rheumatoid arthritis, Crohn's disease, psoriasis and psoriatic arthritis. It is important to clarify the immunological milieu in PPP not only for the treatment approach but also for understanding these unexpected reactions.

Triggering role of focal infection in the induction of extra-palmoplantar lesions and pustulotic arthro-osteitis associated with palmoplantar pustulosis.

Palmoplantar pustulosis (PPP) is a chronic inflammatory disorder characterized by sterile pustules predominantly involving the palms and soles of middle-aged women. Whether PPP is the acral type of pustular psoriasis or a distinct entity has long been discussed; however, the clinical features of PPP are really heterogeneous and different between Asians and Caucasians, which may depend on the race with backgrounds of different HLAs. PPP is closely related with psoriasis, but considered to be a distinct entity in Japan. Although the pathogenesis of PPP is still poorly understood, PPP is a representative skin disorder showing a close relationship with focal infections such as tonsillitis, chronic sinusitis, and dental infection. In particular, tonsillitis often triggers or deteriorates PPP. In Japanese patients, regions other than the palms and soles are occasionally affected manifesting scaly erythemas which resemble psoriasis, and solitary pustules are also seen. Some of these extra-palmoplantar lesions are induced by the Koebner phenomenon or occur after focal infections. Further, arthralgia is also induced on the sternum, clavics, sacroiliac joints, and upper ribs following focal infections. This paper makes a focus on the triggering role of focal infection in the induction of extra-palmoplantar lesions as well as arthralgia (putulotic arthro-osteitis).

Tomografía computarizada y resonancia magnética en las enfermedades dolorosas del raquis: aportaciones respectivas y controversias / Computed tomography and magnetic resonance imaging for painful spinal column: contributions and controversies

Las técnicas de imagen tomográficas, tomografía computarizada (TC) y resonancia magnética (RM) se vienen usando cada vez de forma más frecuente, en sustitución o adición a la radiografía simple, para el estudio del dolor de espalda. El objetivo de este trabajo es realizar una revisión general de las manifestaciones en TC y RM del amplio espectro de enfermedades que pueden ser responsables del dolor generado en la columna vertebral. Este espectro abarca la enfermedad degenerativa, de la alineación vertebral, tumoral, inflamatoria e infecciosa. El conocimiento y la descripción exacta y uniforme de los hallazgos con dichas técnicas suponen un soporte fundamental para la toma de decisiones clínicas en los pacientes con dolor de raquis (AU)

The use of tomographic imaging techniques, computed tomography (CT) and magnetic resonance imaging (MRI), to complement or replace plain-film radiography in the study of spine pain is becoming more and more common. The aim of this paper is to provide a general review of the CT and MRI manifestations of the wide spectrum of lesions that can cause pain in the spinal column. This spectrum includes degenerative disease, malalignment, tumors, inflammatory processes, and infectious processes. Precise knowledge and accurate reporting of the findings at CT and MRI are fundamental for clinical decision making in patients with spine pain (AU)

[Infections of the head and neck leading to descending necrotizing mediastinitis: management of 9 cases].

OBJECTIVE: To report nine cases of descending necrotizing mediastinitis (DNM) and to summarize the management experience. METHODS: Between December 2005 and December 2008, nine patients (mean age, 55.7 years; age range, 38 to 78 years) with DNM were treated. Eight patients underwent surgical drainage of the involved cervical region and mediastinum (4 with cervical drainage alone; 4 with cervical drainage and right thoracotomy). RESULTS: Two patients died, one of them refused surgical therapy and the other one died of multiorgan failure related to postoperative septic shock. Seven patients recovered. The mortality rate was 22%. CONCLUSIONS: Delayed diagnosis and inadequate drainage are the main causes of high mortality rate of DNM. Aggressive surgical drainage and debridement of the neck and mediastinum by a multidisciplinary team of surgeons are very important in the treatment of DNM.

Complicación infrecuente de los reservorios subcutáneos venosos centrales permanentes: migración espontánea de la punta del catéter a la vena yugular isolateral / Rare complication of permanent central venous subcutaneous reservoirs: spontaneous migration of the catheter point to the ipsilateral jugular vein

No disponible

Enfermedad invasiva por Streptococcus pyogenes en lactante sano de 38 días / Invasive disease due to Streptococcus pyogenes in a healthy, 38-day-old infant

No disponible

Tonsillar focal infectious disease involving IgA nephropathy, pustulosis, and ossification.

We report a rare case of IgA nephropathy (IgAN), that was considered as showing tonsillar focal infection, involving pulmoplantar pustulosis (PPP), and sternocostoclavicular hyperosteosis (SCCH). A 53-year-old man with a 3-year history of PPP had hematuria and proteinuria, and he sometimes had anterior chest pain. He was also diagnosed with IgAN and SCCH. We performed tonsillectomy as a treatment. The tonsillectomy was done with the patient under general anesthesia, and this treatment was followed by steroid therapy. Interestingly, all the symptoms of IgAN, PPP, and SCCH were alleviated 6 months after the tonsillectomy. Thus, tonsillectomy and steroid therapy may be effective and could be considered as treatment for these diseases.

Aneurismas micóticos de aorta torácica / Mycotic aneurysms of the thoracic aorta

Introducción y desarrollo. Los aneurismas micóticos de la aorta torácica descendente constituyen una patología muy poco frecuente y son objeto de publicaciones esporádicas con un número de casos muy escaso (entre uno y tres casos la mayoría de ellas). El diagnóstico se fundamenta en datos poco específicos como fiebre, leucocitosis, hemoptisis u otros que requieren una gran sospecha diagnóstica, sobre todo en pacientes con alteraciones de la inmunidad por enfermedades crónicas asociadas. El tratamiento convencional se fundamenta en la resección del tejido infectado y la realización de un puente extraanatómico o la sustitución in situ de la aorta enferma por una prótesis de dacron o de un homoinjerto criopreservado. Se han comunicado pocos casos tratados mediante endoprótesis. Conclusión. Es de vital importancia el control estricto de estos pacientes para detectar una reinfección de la prótesis, en cuyo caso la única alternativa terapéutica posible es la retirada de ésta después de una revascularización extraanatómica

Introduction and development. Mycotic aneurysms of the descending thoracic aorta are a very rare pathology and have appeared in sporadic reports that contain a very scarce number of cases (between one and three cases in most of them). Diagnosis is based on rather unspecific data such as fever, leukocytosis, haemoptysis or other data that require a strong diagnostic suspicion, especially in patients with compromised immunity due to associated chronic diseases. Conventional treatment essentially consists in resection of the infected tissue and performing an extra-anatomical bypass or replacing the compromised aorta in situ with a dacron graft or cryopreserved homograft. Few reports of cases treated by means of a graft have appeared in the literature. Conclusions. Strict control of these patients is crucial to be able to detect reinfection of the graft; should this occur, the only therapeutic alternative possible is to remove it after extra-anatomical revascularisation