Gas Gangrene of the Diabetic Foot.

A 67-year old man presented with a painful left foot and a putrid odor. His past medical history was significant for poorly controlled diabetes mellitus, coronary artery disease, and peripheral vascular disease. His surgical history included a prior right below-knee amputation for a diabetic foot infection three years prior, and a left third toe amputation for osteomyelitis one month ago. He was an active smoker. His laboratory data revealed a white blood count of 22 k/uL and a blood glucose of 381 mg/dL. Physical exam demonstrated an erythematous and edematous left foot with subcutaneous crepitus along the plantar surface. Plain film x-rays of the left foot demonstrated gas pockets in the soft tissue and acute osteomyelitis (Figure 1). The patient was diagnosed with gas gangrene and was taken emergently to the operating room. In order to obtain source control of this life threatening infection, a left below-knee amputation was performed and broad spectrum empiric antibiotics were initiated immediately with vancomycin and piperacillin/tazobactam. Cultures were not obtained at the time of surgery and the organisms causing this infection are unknown. The patient survived and was discharged to a rehabilitation facility.

Surgical site infections after lower extremity revascularization procedures involving groin incisions.

BACKGROUND: We sought to evaluate the incidence, epidemiology, and factors associated with surgical site infections (SSIs) after lower extremity revascularization procedures involving groin incisions and determine outcomes based on SSI status. METHODS: This is a single-institution, retrospective cohort study of 106 patients who underwent lower extremity revascularization procedures involving femoral artery exposure through a groin incision at a tertiary referral hospital. The primary outcome was occurrence of SSI at the groin wound. The duration of hospital stay, reoperation within 30 days, discharge disposition, and 30-day mortality were also evaluated. Independent variables included patient demographics and operative variables (i.e., procedure type, transfusion requirements, preoperative antibiotics, intraoperative vasopressors, and operative duration). Statistical analysis included chi-squared tests, t-tests, and multivariable regression analysis. RESULTS: Of the 106 patients who underwent a lower extremity revascularization procedure with a groin incision for femoral artery exposure, 62% were male, and the mean age was 62 years. Comorbidities included hypertension (93%), dyslipidemia (65%), statin use (63%), active smoker (50%), diabetes (24%), and chronic obstructive pulmonary disease (23%). All patients received preoperative antibiotics, 50% required intraoperative pressors, 21% received a blood transfusion, and the mean operative time was 296 min. The overall duration of stay was 10.7 days, the 30-day reoperation rate was 18%, and the 30-day mortality rate was 12%. Overall, 22% developed a seroma or hematoma, and 31% developed a SSI. Patients who developed an SSI compared with those who did not were more likely to have a postoperative seroma or hematoma (55% vs 5%) and to receive a blood transfusion (33% vs 15%), but less likely to be treated with a statin (47% vs 69%) or carry a diagnosis of dyslipidemia (50% vs 72%), respectively, all P < 0.05. Patients with an SSI had a longer duration of stay (14.5 vs 8.7 days) and a higher reoperative rate (49% vs 4%), but had a lower 30-day mortality (0% vs 18%) than those who did not develop an SSI (all P < 0.05). On multivariable regression analysis adjusting for differences in patient and operative variables, the occurrence of a wound seroma or hematoma remained an independent predictor for SSI (odd ratio: 27.6; 95% confidence interval: 5.4-139.6). CONCLUSIONS: The incidence of postoperative surgical site complications after lower extremity revascularization procedures involving a groin incision was 31% and was significantly associated with blood transfusion, postoperative seroma or hematoma, dyslipidemia, and statin usage. After adjusting for differences in patient and operative variables, postoperative seroma or hematoma was an independent predictor of SSI. Patients with a SSI have a longer duration of hospitalization and higher reoperative rate. Additional prospective cohort studies are warranted to delineate ways to decrease the rate of SSI.

Short term outcomes following breast cancer surgery in pregnant women.

OBJECTIVE: Breast cancer is the most common malignancy in pregnancy with an estimated prevalence of 1 per 3000 pregnancies. The National Comprehensive Cancer Network (NCCN) guidelines advocate for surgical management in all trimesters for pregnant women with breast cancer but few studies have examined the impact breast cancer surgery has on outcomes in pregnant women. We aimed to identify differences in short term outcomes after breast cancer surgery between age-matched pregnant and non-pregnant women. METHODS: This was a retrospective, cross-sectional study utilizing the Health Care Utilization Project-Nationwide Impact Sample (HCUP-NIS) database from 1999 to 2006. All pregnant women with breast cancer undergoing lumpectomy or mastectomy were compared to age-matched non-pregnant women. Demographics, in-hospital mortality, length of stay, hospital cost, and discharge disposition were reviewed. Statistical analysis was performed with chi-square, Student's t-test, and ANOVA with p<0.05 deemed significant. RESULTS: Over an 8 year period, 185 pregnant women (mean age 35 years) and 47,985 non-pregnant age-restricted women (mean age 45 years) who underwent breast cancer surgery were identified. There was no significant difference between in-hospital mortality, length of stay, cost of hospitalization, or discharge disposition in these women. CONCLUSION: Pregnant and non-pregnant women undergoing breast surgery for cancer have similar short-term outcomes.

Carotid endarterectomy national trends over a decade: does sex matter?

BACKGROUND: The objective was to evaluate the difference in timing (if any) of in-hospital carotid endarterectomy (CEA) or outcomes of CEA based on sex among men and women hospitalized for carotid artery disease. METHODS: This was a retrospective cross-sectional study using the Nationwide Inpatient Sample Database. All patients from 2000-2009 who underwent CEA during their hospitalization were examined. International Classification of Diseases, 9th revision codes were used to identify patients who underwent CEA during hospitalization, stratify asymptomatic and symptomatic patients, determine time in days from admission to CEA, and examine in-hospital complications, including perioperative stroke, cardiac events, and death. Statistical analysis was performed with chi-squared and t-tests. Linear and logistic regression models were used to evaluate relationships between sex and outcomes. The main outcome measures were time from admission to surgery, in-hospital mortality, complications, mean duration of stay, and discharge disposition. RESULTS: Two hundred twenty-one thousand two hundred fifty three patients underwent CEA during hospitalization. More than 9% (9.2%) had symptomatic carotid artery disease. Among symptomatic patients, bivariate analysis found that women had a longer mean time from admission to surgery (2.8 vs. 2.6 days; P < 0.001) and a longer duration of hospital stay (6.4 vs. 5.9 days; P < 0.001) than their male counterparts. However, there was no difference between men and women with regard to rates of perioperative stroke, cardiac complications, myocardial infarction, or death. Among asymptomatic patients, women had a longer mean time from admission to surgery (0.53 vs. 0.48 days; P < 0.001) and a trend toward increased perioperative stroke (0.6% vs. 0.5%; P = 0.06), but a lower rate of cardiac complications (1.5% vs. 1.7%; P = 0.01) and in-hospital mortality (0.26% vs. 0.31%; P = 0.05). However, on multivariable analysis adjusting for differences in age, elective status, insurance, race, hospital location, hospital region, and hospital teaching status, there was no sex disparity in time from admission to surgery, regardless of symptomatic status. In addition, asymptomatic women were less likely than men to have a cardiac complication (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) or in-hospital mortality (OR: 0.83; 95% CI: 0.70-0.98). Symptomatic women were also less likely than men to have a cardiac complication (OR: 0.78; 95% CI: 0.63-0.97). CONCLUSIONS: In this decade-long national population-based study of hospitalized patients undergoing CEA, women had lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical, and hospital factors, there is no discernible difference in timing of CEA based on sex.

Gender based differences in management and outcomes of cholecystitis.

BACKGROUND: During the reproductive years, women have a 4-fold higher prevalence of gallstones than men, making gallbladder disease a critically important topic in women's health. Among age-matched women and men hospitalized for cholecystitis, gender based differences in demographics, management, and economic and clinical outcomes were identified. METHODS: A cross-sectional study was conducted using the Nationwide Inpatient Sample. Outcomes were mortality, complications, length of stay, and cost. RESULTS: Women accounted for 65% of admissions for cholecystitis, with women more likely to have shorter time to surgery (1.6 vs. 1.9 days) and laparoscopy (86 vs. 76%) (P < .05). After cholecystectomy, women had lower mortality (.6% vs. 1.1%), fewer complications (16.9 vs. 24.1), shorter lengths of stay (4.2 vs. 5.4 days), and lower costs ($10,556 vs. $13,201) (P < .05). On multivariate analysis of age-matched patients, women had lower odds of mortality (odds ratio [OR], .75), complications (OR, .86), length of stay (OR, .95), and cost (OR, .93). Longer time to surgery and open cholecystectomy were independent predictors of worse outcomes. CONCLUSIONS: In cholecystitis and cholecystectomy, women have better clinical and economic outcomes then age-matched men.

A PCR-Based Technique for Detection of Neotyphodium Endophytes in Diverse Accessions of Tall Fescue.

A previously described polymerase chain reaction (PCR)-based method used for detection of Neotyphodium coenophialum in tall fescue detected Neotyphodium endophytes in some, but not all, infected plants from a geographically diverse sample. In the study reported here, a different set of primers, based on intervening sequences of the tubulin 2 gene, were prepared and used for PCR. PCR with these primers yielded the expected 444 base pair amplification product with DNA from 104 of the 106 infected accessions tested. In addition, one accession originally scored as endophyte-free on the basis of a tissue culture test was correctly rated as endophyte-infected using the PCR procedure. Results suggest that primers based on intervening sequences of the tubulin 2 gene can be used for PCR-based detection of Neotyphodium endophytes in tall fescue accessions of diverse origin.