Can paronychia cause a remote necrotizing soft tissue infection?

Remote necrotizing soft tissue infection (NSTI) resulting from paronychia is very unusual but potentially lethal. We report a case of a 39-year-old woman affected by this unusual infection. The paronychia completely resolved in less than 2 weeks, however, a NSTI involved the right chest and flank and the left thigh. The patient required intensive care and multiple surgical debridements. This recent experience and literature data suggest that paronychia can cause a remote NSTI that can rapidly spread and become life-threatening. Broad spectrum antibiotics and aggressive surgical debridement are essential to a successful outcome.

Ogilvie syndrome and herpes zoster: case report and review of the literature.

BACKGROUND: The very unusual association between herpes zoster and Ogilvie syndrome has received scant attention in the published literature. OBJECTIVES: This review discusses the published experience since 1950 and attempts to increase clinical awareness about the co-existence of both conditions. CASE REPORT: An 84-year-old male patient affected by herpes zoster presented with advanced acute colonic pseudo-obstruction and was successfully treated with colonic diversion. DISCUSSION: Twenty published studies (1950-2008) of 28 patients in whom the two conditions co-existed are reviewed. The review included 22 male and 7 female patients (24%) aged 32-87 years (mean, 61 years). Significant co-morbidities were present in 45% of the patients. The majority of patients were observed and treated conservatively (83%). Two patients died (7%), both suffering from respiratory complications and malignancy. CONCLUSION: Recognition of the combined syndrome may help to avoid unnecessary surgery. Laparotomy should be reserved as a last resort for when the obstruction cannot be successfully managed by endoscopy. A diverting colostomy can be used to monitor the blood supply and thus provide early warning for an impending abdominal catastrophe.

Outcome predictors in African-American deceased-donor renal allograft recipients.

The relative importance of donor and recipient risk factors in predicting outcomes in African-American (AA) renal allograft recipients receiving contemporary immunosuppression, including early steroid withdrawal, has not been previously examined. We assessed the impact of 21 risk factors on five primary outcomes in 132 deceased-donor AA renal allograft recipients transplanted from July 2001 to August 2006 with follow-up 6-67 (mean 35 +/- 17) months by univariate and multivariate analysis. Thymoglobulin or basiliximab was given for induction, and mycophenolate mofetil with either tacrolimus or sirolimus (SRL) +/- prednisone for maintenance. Non-compliance accounted for 26% of graft loss (GL) and 19% of acute rejection (AR) episodes, and was more prevalent in patients who were HCV+ and those on prednisone. Delayed graft function remained a significant predictor of GL, but not via increased AR, and donor ethnicity emerged as an important predictor of patient death. De novo use of SRL resulted in increased AR, and only increased recipient age significantly predicted new-onset diabetes mellitus. Our preliminary results suggest the need for improvements in patient education, pre-transplant psychosocial assessment, and late post-transplant psychosocial support and can be utilized to help guide donor/recipient selection and tailor immunosuppressive management to optimize outcomes in this challenging group of patients.

Elective inguinal hernia repair: a unified informed consent, or who wants to know what?

Informed consent is increasingly being standardized. We sought to evaluate variability in the amount and quality of information desired by patients in choosing whether to undergo elective surgical hernia repair, a prototypical low- to moderate-risk common procedure. Consecutive stable outpatients were asked to assume that they were considering hernia repair and interviewed with a standard questionnaire that asked them to rate their interest in learning about the natural history, pathology, and management of inguinal hernia as well as herniorrhaphy complications and postoperative recovery. Ninety-eight consecutive patients exhibited substantial interpersonal variability in their level of interest in receiving information. Although interest in some types of information tended to correlate with interest in other types of information, patients' degree of interest in receiving information about anesthesia during the procedure was independent of other variables. Education and previous exposure to individuals with hernias also affected interest in receiving potentially important information before deciding whether to consent to hernia surgery. Patients may vary with regard to the information they want to receive when deciding whether to consent to an invasive procedure. It may be preferable to individualize the consent process to patients' preferences rather than adhering to standardized content.

Sternal osteomyelitis after minor trauma.

Sternal osteomyelitis secondary to minor trauma occurs rarely. Only a handful of cases have been reported. A 24-year-old male patient who had history of intravenous drug abuse and recent minor sternal trauma presented with signs and symptoms of sternal infection. Imaging studies suggested osteomyelitis and the patient underwent sternal resection, with a successful outcome. Sternal osteomyelitis should be suspected in immunocompromised patients, including intravenous drug abusers presenting with sternal inflammatory symptoms. Increased awareness, rapid diagnosis, and appropriate empiric antibiotic and radical surgical treatments can successfully manage life-threatening osteomyelitis of the sternum.

Preliminary experience with renal transplantation in HIV+ recipients: low acute rejection and infection rates.

BACKGROUND: Only four centers have reported their results with renal transplantation in human immunodeficiency virus (HIV)+ recipients on highly active antiretroviral therapy, and acute rejection (AR) rates have consistently ranged from 43% to 67%. METHODS: We examined the outcomes of eight adult HIV+ primary renal allograft recipients with median 15 (range 8-47) months follow-up with multiple other high-risk factors, including African American ethnicity, hepatitis C virus (HCV) positivity, long waiting times, prior sensitization, paucity of live donors, and delayed graft function. Our immunosuppressive protocol consisted of an anti-interleukin-2 receptor antibody for induction, and mycophenolate mofetil, cyclosporin A, and prednisone for maintenance. Initial and 3- to 6-month cyclosporin A trough level targets were 250 to 300 and 225 to 275 ng/mL, respectively, and mycophenolate mofetil dose was adjusted according to 2 to 4 week surveillance and subsequent as needed mycophenolic acid predose concentrations during the first 6 months. RESULTS: Patient and graft survival were 100% and 88%, respectively, with an AR rate of 13% and excellent renal function. No patients developed new-onset diabetes, opportunistic or other serious infections, malignancy, or progression of hepatitis C virus-related liver disease. Excellent suppression of HIV replication with maintenance of CD4 counts was noted in all cases. CONCLUSIONS: Our findings suggest that HIV+ patients on highly active antiretroviral therapy can undergo successful renal transplantation with a low incidence of both AR and AIDS-associated and non-AIDS associated infections, despite associated risk factors for poorer outcome. Our encouraging but preliminary results with this protocol will need to be verified in larger numbers of HIV+ renal allograft recipients with longer follow-up.

Breast cancer after severe burn injury: coincidence or consequence?

Malignant neoplasms arising in burn scars are well known but rarely encountered. We discuss personal experience with two patients, both female, who were diagnosed with advanced breast cancer many years after severe thermal injury to their breasts. Our experience, similar to the scant previously published data, reinforces that burn scars demand a high index of suspicion for the presence of an underlying malignant neoplasm. The literature and our study suggest that breast cancer may occur after severe thermal injury. Breast lesions in this or a similar clinical scenario should be considered malignant until proven otherwise, and a tissue diagnosis must be pursued without delay.

Preliminary experience with cinacalcet use in persistent secondary hyperparathyroidism after kidney transplantation.

BACKGROUND: There is limited experience with the use of cinacalcet in the treatment of persistent secondary hyperparathyroidism after kidney transplantation. METHODS: We retrospectively analyzed our experience in 18 renal allograft recipients who initiated cinacalcet therapy from 1 month to 23 years (median 3 years) posttransplantation and were maintained on the drug for 6 months. The daily dose was titrated from 30 mg up to a maximum of 180 mg to achieve a reduction in serum intact parathyroid hormone (PTH) levels. RESULTS: Sustainable, significant decreases in mean calcium and alkaline phosphatase were noted at 1 month and intact PTH by 3 months, with 50% of patients achieving at least a 30% drop in PTH levels at 6 months. Serum phosphorous increased at 6 months, whereas urine N-telopeptides decreased. There were no significant changes in serum osteocalcin, albumin, and hemoglobin levels. We did not observe a tachyphylaxis phenomenon. Two patients reported occasional nausea, but did not require medication discontinuation. Estimated glomerular filtration rate did decrease progressively over the 6-month period. CONCLUSION: Cinacalcet appears to be an effective drug for the treatment of posttransplant hypercalcemia due to persistent secondary hyperparathyroidism. Further studies with more patients and longer follow-up will be needed to better elucidate the efficacy/safety profile for this agent, particularly with regard to long-term bone histology and renal outcomes.

Intermediate-term outcomes with early steroid withdrawal in African-American renal transplant recipients undergoing surveillance biopsy.

BACKGROUND: There is a paucity of data regarding the use of early corticosteroid withdrawal (ESW) in African-American renal allograft recipients, and very few reports with >or=1 year follow-up in all patients. METHODS: We examined the outcomes of 57 African-American renal allograft recipients with minimum follow-up 12 months who did not receive maintenance steroids after day 4 posttransplant. All patients received thymoglobulin induction, mycophenolate mofetil, and initial tacrolimus (n = 48) or sirolimus (n = 9). RESULTS: Patient and graft survival were 98% and 96% at 1 year, and 95% and 89% over the entire follow-up period (mean, 23 +/- 8 months). Incidence of acute rejection and cytomegalovirus infection were 18% and 7%, respectively, with mean serum creatinine 1.6 +/- 0.5 and 1.7 +/- 0.9 mg/dL at 6 and 12 months. Of patients with functioning grafts, 84% remained steroid free at 1 year, of which 11 (24%) were also calcineurin inhibitor free. Twenty-seven patients underwent surveillance biopsy at 1 month and 28 at 12 months, with 15 surveyed at both time points. There were significant increases in only 2 of the 6 1997 Banff chronic allograft nephropathy (CAN) category scores in this subgroup, with all mean values remaining <1 (mild in severity) at 1 year. Overall, from 82% to 96% of the 12-month scores were

Amyand hernia: what lies beneath--a proposed classification scheme to determine management.

Acute appendicitis in a hernia sac occurs exceptionally. An 80-year-old male patient underwent emergency surgery for an incarcerated right inguinal hernia found to contain a gangrenous appendix. His brief improvement after an emergency herniotomy with appendectomy was followed by intestinal obstruction caused by advanced colon cancer. The unique features and individualized management of the four published types of Amyand hernia are reviewed. Rather than simply being an anatomical curiosity, Amyand hernias require individualized attention to decide how to manage both the appendix and the hernia. Clinical scrutiny, a high index of suspicion for surgical comorbidities, and a common sense approach may improve outcomes.

Technology insight: liver support systems.

Emergency orthotopic liver transplantation (OLT) is currently the only standard treatment for fulminant hepatic failure (FHF). The waiting time for transplantation can exceed a week-using a liver assist device to bridge patients with FHF to OLT might therefore decrease the mortality rate. Several liver support systems have been described, but no system has gained FDA approval or widespread clinical acceptance. Although the results of many experimental and clinical trials are encouraging, the field is still in its initial stages. Using nonbiologic liver support is based on the assumption that several toxins that cause hepatic coma can be removed from the circulation by blood or plasma sorption methods. As these toxins could be involved in many FHF complications recovery without the need for transplantation is the ultimate aim. Biologic liver support uses xenogeneic livers or hepatocytes to support the failed human liver, exploiting biological cell functions, namely detoxification, metabolism, and biosynthesis. The classical nonbiologic dialysis methods could decrease mortality in patients with acute-on-chronic liver failure, but definitive conclusions are impossible to draw because of the small number of patients studied and inadequate follow-up. Larger studies performed in specialty centers should provide conclusive data about the role of the bioartificial liver support system as a possible universal bridge to OLT. This article presents an overview of published experience with liver support systems since the 1960s.

Recurrent intercostal herniation of the liver.

Abdominal intercostal hernia occurs rarely, with only 26 previous cases reported in the professional literature. A 51-year-old man presented with a painful right chest protrusion. One year earlier he had experienced a severe coughing spell and spontaneous rib fracture and chest protrusion. He was treated with endogenous tissue reinforcement and had no clinical improvement. Magnetic resonance imaging revealed the liver protruding through the chest wall. The hernia was reduced and the chest wall was repaired with prosthetic mesh and cables. Attention to the chest wall anatomy and reliable tissue closure including pericostal or transcostal nonabsorbable sutures and a prosthetic bridge over the defect are the best way to eliminate the patient's risk for recurrence.

Necrotizing soft tissue infection of the chest wall.

Necrotizing soft tissue infection of the chest wall is a relatively rare but highly lethal surgical condition that has received little attention in the literature. The case of a 21-year-old female patient affected by this rare infection is reported. Our recent experience and literature data suggest that chest wall necrotizing soft tissue infection spreads rapidly and is highly lethal. High index of suspicion, early diagnosis, and aggressive approach are essential to its successful treatment.

Biomechanical comparison of median sternotomy closures.

BACKGROUND: Poor healing of median sternotomy can significantly increase morbidity, mortality, and hospital costs. Effective union requires reliable sternal fixation. Although wire has proven the most reliable and widely used sternotomy closure material, no experimental studies have compared a large variety of wiring techniques in a human model. We developed an easily reproducible experimental model using cadaveric human sterna and compared several wiring methods to assess closure strength and stability. METHODS: Fifty-three fresh adult human cadaveric sternal plates with adjacent ribs were fixed with specially designed spiked stainless steel clamps and attached to a texture analyzer. Single peristernal and transsternal, alternating single peristernal and transsternal, figure-eight peristernal, figure-eight pericostal, and Robicsek closures using no. 5 stainless steel wires were tested. We evaluated bone density, stiffness, and displacement using perpendicular, repetitive variable force loads of 800 Newtons cycling at a rate of 0.5 mm/s. RESULTS: There were no significant differences in age, sex, or bone density in outcome measures of the sternal groups. No clamp failures or clamp damage to the specimens occurred. The single peristernal and alternating peristernal and transsternal closures proved superior in strength and stability (p < 0.001). The figure-eight peristernal, then the single transsternal, then the Robicsek were next stablest groups in decreasing order. The figure-eight pericostal closure had the highest failure rate (p < 0.001). CONCLUSIONS: This novel model of sternotomy closure testing was reliable, inexpensive, and easily reproducible. The mechanical stability of peristernal and alternating peristernal and transsternal wires was significantly greater than that of the other tested methods. Pericostal figure-eight closures were not sufficiently stable to be considered a reliable method of primary sternotomy repair.

Organ-sparing surgical treatment of giant hepatic hydatid cysts.

BACKGROUND: Excision of giant hepatic hydatid cysts may be associated with loss of hepatic tissue. We describe a method for obliterating spacious residual cavities that promotes salvage of healthy liver parenchyma. METHODS: After simple cystectomy, the residual cavity is obliterated by manual compression of the healthy liver parenchyma from the left and right toward the midline of the cavity. While compression is maintained, the approximated edges of the cyst's fibrous capsule are closed with mattress sutures. Omentoplasty or gelatine sponges are used to fill the dead space prior to suturing of the fibrous capsule. RESULTS: The method was used in 8 patients between 1993 and 2000. No sepsis, postoperative bile leak, or other complications occurred. No long-term adverse effects were found. CONCLUSIONS: This method is simple and effective for obliteration of extremely large residual cavities after cystectomy for liver hydatidosis. It may be used safely in selected patients.

Combined ventral and retroperitoneal laparostomy in ballistic trauma to the colon and retroperitoneum.

Retroperitoneal spillage and infection in ballistic trauma to the large intestine is a difficult surgical problem. Experience with four consecutive cases of high-velocity gunshot wounds to the abdomen, colonic injury, and retroperitoneal fecal spillage is reviewed. The patients underwent repeat exploration of the abdomen and retroperitoneum through ventral and retroperitoneal laparostomies. All patients survived. The cavities of the posterior laparostomies were in gravitationally favorable positions, facilitating thorough debridement and drainage. Closure of the posterior abdominal wall using prosthetic materials was achieved in all patients. Retroperitoneal laparostomy is a useful adjunct in management of gunshot trauma to the abdomen with retroperitoneal fecal contamination. After eradication of sepsis, defect closure is complex. Tissue-impervious material on the peritoneal side prevents adhesions.

Disruption and infection of median sternotomy: a comprehensive review.

Disruption and infection of median sternotomy wounds are grave complications often associated with prolonged hospitalization, high cost, and significant mortality. Effective prevention techniques are still debated. Successful management requires early recognition based on a high index of suspicion, detailed physical examination, appreciation of the clinical signs and symptoms, timely imaging studies, and prompt surgical therapy. Improvements in perioperative management and critical care of patients with multisystem organ failure can reduce morbidity and mortality rates. Sternal salvage and direct sternal reclosure are possible when the infection is diagnosed early. Techniques utilizing lateral sternal support should be first-line options in the condition. Muscle flap techniques should be the next consideration when direct closure has failed or cannot be attempted.

Isolated gangrene of the round and falciform liver ligaments: a rare cause of peritonitis: case report and review of the world literature.

Isolated infection and/or gangrene of the round and falciform liver ligaments is among the rarest causes of acute abdomen. The diagnosis is based on demonstrating localized or patchy inflammatory or gangrenous changes in the ligaments without apparent etiology. We report the case of an 18-year-old male who presented with a 24-hour history of generalized abdominal pain and distention, nausea, and vomiting. With a preoperative diagnosis of probable perforated duodenal ulcus and generalized peritonitis the patient underwent emergency surgery. Multiple patchy gangrenous areas of the round and falciform ligaments were found starting from the umbilicus up to the hepatic hilum. The ligaments were resected in toto. The patient's postoperative course was unremarkable. No apparent etiology of the condition was found. We provide the first extensive review of the world literature. Isolated infection and/or gangrene of the round and falciform liver ligaments should be suspected in patients with upper abdominal complaints when imaging studies demonstrate ligament abnormality, tumor, or fluid. Treatment is only surgical. Depending on surgeon's expertise, patient's condition, and severity and extent of disease either open or laparoscopic surgery may be performed.

Recurrent spigelian hernia: a case report.

Only seven cases of spigelian hernia recurrence have been previously reported. We report the case of a 75-year-old male patient who presented with extremely large hernia after four unsuccessful suture repairs over 12 years. The abdominal wall defect was repaired with Marlex mesh. The advantage of using prosthetic mesh in both primary and recurrent spigelian hernia is supported by recent clinical research data indicating a generalized collagen metabolism disorder in patients with primary and recurrent hernia. Mesh repair allows for tension-free anatomic restoration of distorted tissues associated with repair failures.