Orbitomaxillofacial Mucormycosis Requiring Complex Multifactorial Management.

Mucormycosis is a rare fungal infection caused by ubiquitous fungi in the order Mucorales. It is the most rapidly progressing fulminant fungal infection that mimics necrotizing soft-tissue infections. Overwhelming fungal sepsis develops quickly and mortality rates approach 70%. Culture negative necrotizing infections and cutaneous necrosis following a vascular pattern should raise suspicion for this rare entity. We describe avoiding mortality in a case of orbitomaxillofacial mucormycosis multifactorially treated with: radical serial debridement, topical amphotericin B irrigation and dressings, parenteral amphotericin B, and hyperbaric oxygen therapy. Tissue biopsy was central to confirming the diagnosis and directing multimodal management that ultimately prevented dissemination to the central nervous system and mortality.

Treatment of in-transit melanoma with intra-lesional interleukin-2: a systematic review.

BACKGROUND: Several phase II studies have assessed intra-lesional interleukin-2 (IL-2) for the treatment of in-transit melanoma. This systematic review addresses the efficacy and side effect profile of IL-2. METHODS: MEDLINE, EMBASE, Cochrane Library, and Google Scholar databases were searched from 1980 to 2012 for studies evaluating the clinical response to IL-2 for in-transit melanoma. Titles and abstracts were screened by two independent researchers for suitability using predetermined inclusion and exclusion criteria. A modified quality assessment tool for observational studies was used. Data were pooled and analyzed to determine lesion and patient response rates. RESULTS: Forty-nine studies were identified. Forty-three did not meet inclusion criteria, leaving six observational trials. Heterogeneity was seen in IL-2 dosage and treatment interval. Response rate was variable as well. Overall, 2,182 lesions and 140 patients were treated in these six studies. Pooling the lesions, complete response was seen in 78%. Pooling subjects, 50% achieved a complete response. Treatment was generally well tolerated, with localized pain and swelling, and mild flu-like symptoms. There were only three grade 3 adverse events reported, including rigors, headache, and fever with arthralgia. CONCLUSIONS: Intra-lesional IL-2 safely and effectively provides locoregional control of in-transit melanoma.

Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey.

BACKGROUND: Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. METHODS: We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care. RESULTS: A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05). CONCLUSION: Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.

CONTEXTE: Le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas sont complexes. Les décisions de fin de vie reposent sur un processus hautement variable qui dépend de multiples facteurs. MÉTHODES: Nous avons administré à des médecins un sondage international qualitatif à 40 questions afin de caractériser l'impact sur les soins exercé par différents facteurs, notamment médicaux, religieux, sociaux, relatifs à la formation et systémiques. RÉSULTATS: En tout, 258 cliniciens ont participé à ce sondage international. Les participants étaient en général des spécialistes (78%), cumulaient en moyenne 16 ans d'expérience dans le domaine hépatopancréatobiliaire (96%) au sein d'un groupe affilié à une université (93%). La plupart (91%) ont dit croire que la résection est potentiellement curative. La majorité des cas faisaient l'objet de discussions préopératoires par des équipes multidisciplinaires (94%) et en clinique d'évaluation médicale (68%), mais rarement par une équipe de soins intensifs (21%). Les soins palliatifs chirurgicaux peropératoires incluaient la double dérivation ou la non intervention en présence de tumeurs non résécables localement avancées (41% et 49% c. 14% et 85%, respectivement, chez les patients porteurs de métastases hépatiques). L'admission postopératoire aux soins intensifs a eacute;té fréquente (58%). Les complications postopératoires graves étaient souvent traitées par réanimation cardiorespiratoire énergique, intubation et soins intensifs (96 %), sans critères chronologiques de futilité définis (74 %). C'est aux chirurgiens traitants que revenait la plupart des décisions de fin de vie (97 %). Peu avaient accès à des consignes formelles au sujet de la futilité des interventions médicales (26 %). La couverture d'assurance n'a modifié ni le traitement (97%) ni les soins palliatifs (95%) dans les régions où les soins n'étaient pas universels. L'expérience des médecins, la culture régionale et la formation de base ont eu un impact sur le traitement (toutes, p < 0,05). CONCLUSION: Malgré une concordance remarquable, des différences géographiques et des différences liées à la formation ont eu un impact sur le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas.

Intra-lesional interleukin-2 therapy for in transit melanoma.

Intra-lesional interleukin-2 (IL-2) is effective in treating in transit melanoma metastases. Results from multiple studies were examined to evaluate the efficacy of IL-2 for in transit disease. In the published literature, complete response ranged from 0% to 69% per patient, and 41% to 96% per lesion, with excellent tolerability. Combining the results of six studies show complete response in 50% of patients and 78% of lesions. Intra-lesional IL-2 should be considered early in the course of treatment for in transit disease, ahead of other, more toxic therapies.