Lower Limb Serratia marcescens Necrotizing Fasciitis Complicated by Nosocomial COVID-19.

Serratia marcescens represents an unusual yet potentially deadly cause of lower limb necrotizing fasciitis (NF). Compounding the already high mortality of NF, S. marcescens infections are usually associated with worse outcomes (i.e., amputation). Here we present the case of a 56-year-old immunocompromised man due to lupus nephritis who developed lower limb NF secondary to S. marcescens followed by nosocomial coronavirus disease 2019 (COVID-19) pneumonitis. Successful limb salvage was achieved through a multidisciplinary team approach from various specialties including plastic surgery, orthopedic surgery, anesthesiology, intensive care, respiratory medicine, and nephrology. At 11 months' follow-up, the patient was largely independent with activities of daily living and was able to ambulate. Unfortunately, he suffered a myocardial infarction at 19 months post-operatively and passed away. A review of the literature revealed only a handful of cases of lower limb NF due to S. marcescens and none with subsequent COVID-19. Therefore, this is the first report of such a case which should help with the clinical management of such cases going forward, especially with COVID-19 now becoming endemic in our communities and contributing to delayed presentations and increased mortality in NF.

Smartphone-based DIY home microsurgical training with 3D printed microvascular clamps and Japanese noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least 3.5-5x magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approx. 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current set-up however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels) and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the knojac noodle lumen can be distended or collapsed, unlike other non-living models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course, and potentially, be extended to low-middle income countries (LMICs) without routine access to microsurgical training for capacity development. That it can be utilised remotely also bodes well with the current limitations on face to-face training due to COVID restrictions and lockdowns.

Estimating (quality-adjusted) life-year losses associated with deaths: With application to COVID-19.

Many epidemiological models of the COVID-19 pandemic have focused on preventing deaths. Questions have been raised as to the frailty of those succumbing to the COVID-19 infection. In this paper we employ standard life table methods to illustrate how the potential quality-adjusted life-year (QALY) losses associated with COVID-19 fatalities could be estimated, while adjusting for comorbidities in terms of impact on both mortality and quality of life. Contrary to some suggestions in the media, we find that even relatively elderly patients with high levels of comorbidity can still lose substantial life years and QALYs. The simplicity of the method facilitates straightforward international comparisons as the pandemic evolves. In particular, we compare five different countries and show that differences in the average QALY losses for each COVID-19 fatality is driven mainly by differing age distributions for those dying of the disease.