A guillotine amputation at the ankle level—how to quickly remove a septic foot: a case report

As of 2014, diabetes is estimated to affect 422 million people globally. It is well recognised that lower extremity amputations secondary to diabetes have a high mortality rate perioperatively. The purpose of this article is to provide a simple, step-by-step guide to surgeons who need to perform a transtibial amputation. The case report of a 62-year-old female patient with poorly controlled diabetes who developed necrotising fasciitis of the lower extremity and systemic sepsis is used to illustrate the procedure. Knowing how to complete this operation is essential due to its effectiveness in quickly eliminating a source of pedal sepsis.

Management of breast infections in primary care

Breast infections are a common presentation globally. Symptoms can range from mild discomfort and erythema of the skin to systemic sepsis and abscess formation with associated long-term physical and psychological morbidity. Although more common in the puerperium, non-lactating women, in particular, those between the ages of 18 and 50 years can be affected by the condition. Prompt recognition and treatment in primary care can reduce the incidence of abscess formation. Delayed or inappropriate treatment can lead to chronic infection with associated tissue destruction. In a minority of cases an inflammatory mass and skin changes can be a presenting feature of breast cancer.

Ectopic Expression of Human Thymosin β4 Confers Resistance to Legionella pneumophila during Pulmonary and Systemic Infection in Mice

ABSTRACT Thymosin beta-4 (Tβ4) is an actin-sequestering peptide that plays important roles in regeneration and remodeling of injured tissues. However, its function in a naturally occurring pathogenic bacterial infection model has remained elusive. We adopted Tβ4-overexpressing transgenic (Tg) mice to investigate the role of Tβ4 in acute pulmonary infection and systemic sepsis caused by Legionella pneumophila. Upon infection, Tβ4-Tg mice demonstrated significantly lower bacterial loads in the lung, less hyaline membranes and necrotic abscess, with lower interstitial infiltration of neutrophils, CD4+, and CD8+ T cells. Bronchoalveolar lavage fluid of Tβ4-Tg mice possessed higher bactericidal activity against exogenously added L. pneumophila, suggesting that constitutive expression of Tβ4 could efficiently control L. pneumophila. Furthermore, qPCR analysis of lung homogenates demonstrated significant reduction of interleukin 1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α), which primarily originate from lung macrophages, in Tβ4-Tg mice after pulmonary infection. Upon L. pneumophila challenge of bone marrow-derived macrophages (BMDM) in vitro, secretion of IL-1β and TNF-α proteins was also reduced in Tβ4-Tg macrophages, without affecting their survival. The anti-inflammatory effects of BMDM in Tβ4-Tg mice on each cytokine were affected when triggering with tlr2, tlr4, tlr5, or tlr9 ligands, suggesting that anti-inflammatory effects of Tβ4 are likely mediated by the reduced activation of Toll-like receptors (TLR). Finally, Tβ4-Tg mice in a systemic sepsis model were protected from L. pneumophila-induced lethality compared to wild-type controls. Therefore, Tβ4 confers effective resistance against L. pneumophila via two pathways, a bactericidal and an anti-inflammatory pathway, which can be harnessed to treat acute pneumonia and septic conditions caused by L. pneumophila in humans.

Bacteremia-Induced Cholestatic Jaundice as a Major Manifestation of Pneumococcal Infection in a Healthy Toddler

The development of pneumococcal conjugate vaccines has substantially decreased the incidence of invasive pneumococcal diseases. However, the incidence of bacteremia due to nonvaccine serotypes has increased. Therefore, it is important to recognize the symptoms and complications of pneumococcal infection to expedite diagnosis. Herein, we report the case of a 22-month-old patient diagnosed with pneumococcal bacteremia who presented with cholestatic jaundice and fever without any other signs of systemic sepsis. The patient's condition improved soon after antibacterial therapy. Other causes of jaundice were possibly ruled out based on the screening test for viral hepatitis, and there were no abnormal findings on abdominal ultrasonography. Therefore, the present case suggests that cholestatic jaundice could be a manifestation of pneumococcal bacteremia.

Umbilical Cord-Derived CD362+ Mesenchymal Stromal Cells Attenuate Polymicrobial Sepsis Induced by Caecal Ligation and Puncture

Mesenchymal stromal cells (MSCs) have a multimodal, immunomodulatory mechanism of action and are now in clinical trials for single organ and systemic sepsis. However, a number of practicalities around source, homogeneity and therapeutic window remain to be determined. Here, we utilised conditioned medium from CD362+-sorted umbilical cord-human MSCs (UC-hMSCs) for a series of in vitro anti-inflammatory assays and the cryopreserved MSCs themselves in a severe (Series 1) or moderate (Series 2+3) caecal ligation and puncture (CLP) rodent model. Surviving animals were assessed at 48 h post injury induction. MSCs improved human lung, colonic and kidney epithelial cell survival following cytokine activation. In severe systemic sepsis, MSCs administered at 30 min enhanced survival (Series 1), and reduced organ bacterial load. In moderate systemic sepsis (Series 2), MSCs were ineffective when delivered immediately or 24 h later. Of importance, MSCs delivered 4 h post induction of moderate sepsis (Series 3) were effective, improving serum lactate, enhancing bacterial clearance from tissues, reducing pro-inflammatory cytokine concentrations and increasing antimicrobial peptides in serum. While demonstrating benefit and immunomodulation in systemic sepsis, therapeutic efficacy may be limited to a specific point of disease onset, and repeat dosing, MSC enhancement or other contingencies may be necessary.

Adapted Murine Sepsis Score: Improving The Research In Experimental Sepsis Mice Model

Objective The Murine Sepsis Score (MSS) is used to assess the severity of sepsis in rats and mice based on observational characteristics. The quantitative variables of blood glucose, body weight and temperature are predictors of severity in experimental models of sepsis. Therefore, our study sought to adapt the MSS with the same variables to indicate earlier the severity of the disease in murine models of the disease. Results Sepsis mice presented hypoglycemia, weight loss, and hypothermia. Therefore, these variables were included in the Adapted Murine Sepsis Score (A-MSS). The A-MASS presented 100% specificity and 87.5% sensibility been able to differentiate the early sepsis symptoms and its severity. The A-MSS allows an early and more complete diagnosis of sepsis in mice and might be considered as a procedure to improve the analysis of systemic sepsis dysfunction in murine experimental models.

Pulmonary Complications and Sepsis Following Severe Acute Subdural Hematoma in Patients Who Underwent Craniotomy versus Craniectomy: A Propensity Score Matched Analysis

Background The purpose of the study was to evaluate the impact of craniotomy (CO) and decompressive craniectomy (DC) for evacuation of acute subdural hematoma (SDH) on pulmonary complications and sepsis. Methods Study data were obtained from the National Trauma Data Bank (2007–2010). Only patients who met all of the following criteria were included in this analysis: sustained blunt injuries, presented with severe traumatic brain injury, sustained an associated SDH, presented with an initial Glasgow Coma Scale (GCS) score ≤ 8 and an Abbreviated Injury Scale score of head ≥ 3, and underwent a CO or DC within 4 hours of hospital arrival. Patient characteristics and outcomes were compared between CO and DC, the two procedural groups. The data were first compared between the two unmatched groups; then propensity score matching and a matched pairs analysis were performed. Results From the total population of 2,370 patients, 1,852 (78%) of them underwent CO, and the remaining 518 (22%) underwent DC. Some differences were found between the CO and DC groups regarding age (mean [standard deviation (SD)]: 47.9 years [22.8] versus 39.6 years [20.1]; p < 0.001), sex (male: 70.1% versus 74.7%; p = 0.05), race (white: 77.4% versus 73.4%; p = 0.06), the injury mechanism (fall: 50.7% versus 33.2%; p < 0.001), Injury Severity Score (mean [SD]: 28.0 [9.3] versus 30.5 [10.0]; p < 0.001), and GCS score (median [interquartile range] 3 [3–5] versus 3 [3–4])). After the propensity score matching, no significant differences were found between the groups on the variables just listed (all p > 0.05). No significant differences were seen between the CO and DC groups in the incidences of these conditions: acute respiratory distress syndrome (ARDS) (12.0% versus 8.1%; p = 0.20), pneumonia (34.9% versus 37.6%; p = 0.60), pulmonary embolism (PE) (3.5% versus 1.6%; p = 0.30), and systemic sepsis (6.2% versus 8.1%; p = 0.5). Conclusion Although most of the patients underwent CO for acute SDH, no significant differences were observed in the incidence of ARDS, pneumonia, PE, or systemic sepsis when compared with patients who underwent DC.