First Reported Australian case of Fatal Streptococcal Group B Pneumonia (serotype 21) Necrotising fasciitis complicated by Toxic Shock Like Syndrome - A Case report and review.

Introduction: NF is a life-threatening infection and progressive disease resulting in widespread fulminant tissue destruction. It is rarely caused by Group B Streptococcus pneumonia. Early management with surgical removal of devitalized tissue and urgent antibiotic administration are key therapies. Aim: The aim of this report is to highlight the importance of atypical microorganisms seen in NF. Method: A case presentation and cohort summary of reported NF cases secondary to SPN from the year 2011 to 2020. Results: We report the case of a 67-year-old male, not on immune-suppressive medications, admitted to our intensive care unit with septic shock and multiorgan failure secondary to left leg NF following a 3-week history of cactus prick with an SPN bacteraemia and LRINEC score of 5 on admission. He required multiple surgical debridements and was commenced on appropriate antibiotics. Despite continuous vasopressor supportive therapy, high flux CRRT, and IVIG, our patient died after an 8-day inpatient stay. A 10-year review showed only 5 reported GBSPn NF cases with an associated mortality rate of 40%. Conclusion: A high clinical suspicion of SPN infections in NF is required to avoid high mortality with early diagnosis and targeted anti-microbial therapy. Severity scores may not align with clinical severity.

Telomere maintenance in soft tissue sarcomas.

Soft tissue sarcomas (STS) are a diverse group of heterogeneous malignant tumours derived from mesenchymal tissues. Over 50 different STS subtypes are recognised by WHO, which show a wide range of different biological behaviours and prognoses. At present, clinicians managing this complex group of tumours face several challenges. This is reflected by the relatively poor outcome of patients with STSs compared with many other solid malignant tumours. These include difficulties securing accurate diagnoses, a lack of effective systemic treatments and absence of any sensitive circulating biomarkers to monitor patients throughout their treatment and follow-up. In order to progress STS's cells must evade the usual cellular proliferative checkpoints, and then activate a telomere maintenance mechanism in order to achieve replicative immortality. The purpose of this review is to provide an overview of STS genetics focusing particularly on these mechanisms. We will also highlight some of the key barriers to improving outcome for patients with STS, and hypothesise how a better understanding of these genetic characteristics may impact on future STS management.

Improving clinical examination in acute tibial fractures by enhancing visual cues: the case for always 'cutting back' a tibial back-slab and marking the dorsalis pedis pulse.

Look, feel, move is a simple and widely taught sequence to be followed when undertaking a clinical examination in orthopaedics (Maher et al., 1994; McRae, 1999; Solomon et al., 2010). The splinting of an acute tibial fracture with a posterior back-slab is also common practice; with the most commonly taught design involving covering the dorsum of the foot with bandaging (Charnley, 1950; Maher et al., 1994; McRae, 1989). We investigated the effect of the visual cues provided by exposing the dorsum of the foot and marking the dorsalis pedis pulse. We used a clinical simulation in which we compared the quality of the recorded clinical examination undertaken by 30 nurses. The nurses were randomly assigned to assess a patient with either a traditional back-slab or one in which the dorsal bandaging had been cut back and the dorsalis pedis pulse marked. We found that the quality of the recorded clinical examination was significantly better in the cut-back group. Previous studies have shown that the cut-back would not alter the effectiveness of the back-slab as a splint (Zagorski et al., 1993). We conclude that all tibial back-slabs should have the bandaging on the dorsum of the foot cut back and the location of the dorsalis pedis pulse marked. This simple adaptation will improve the subsequent clinical examinations undertaken and recorded without reducing the back-slab's effectiveness as a splint.

Risk of statin-induced rhabdomyolysis in patients with hepatic impairment.

We describe a case of a 54-year-old man with a 2-month history of biliary colic associated with a common bile duct stone. He underwent laparoscopic cholecystectomy and developed postoperative acute kidney injury stage 3. A renal biopsy was performed and demonstrated myoglobin in the renal tubules. Retrospective creatine kinase analysis was suggestive of rhabdomyolysis. It is thought this was precipitated by simvastatin accumulation in the context of a period of hepatic impairment and elevated liver enzymes.