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      Role of ultrasound and CT in the early diagnosis and surgical treatment of primary sternal osteomyelitis caused by Salmonella: Case reports

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          Abstract

          Primary sternal osteomyelitis (PSO) caused by Salmonella is a rare condition and most commonly associated with sickle cell disease. Only one such case has been previously reported in an infant (age, <1 year) worldwide. The present study reported on two infantile cases of PSO caused by Salmonella in the absence of any hematological diseases. A total of two male infants (age, ≤1 year) were referred to our hospital for fever and rapid breathing accompanied by a chest wall mass involving the lower end of the sternum. Imaging findings on CT and ultrasound, which included sternal segment dislocation, lytic destruction and periosteal elevation, confirmed the diagnosis of PSO. Blood and purulent material cultures confirmed that the causative pathogen was Salmonella. The infants were completely cured by sequential intravenous and oral antibiotics followed by surgical debridement. The infants remained symptom-free and local recurrence of PSO was not detected at follow-up. PSO caused by Salmonella in the absence of any hematological diseases is a rare condition. Unfamiliarity with this disease may lead to a delay in diagnosis and serious complications. The current case report presents two cases of PSO along with a brief overview of the characteristics and management modalities for this condition, and it provides a comprehensive reference for pediatricians regarding this rare disease, particularly in infants.

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          Imaging tests for the detection of osteomyelitis: a systematic review.

          BACKGROUND Osteomyelitis is an infection of the bone. Medical imaging tests, such as radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET), are often used to diagnose osteomyelitis. OBJECTIVES To systematically review the evidence on the diagnostic accuracy, inter-rater reliability and implementation of imaging tests to diagnose osteomyelitis. DATA SOURCES We conducted a systematic review of imaging tests to diagnose osteomyelitis. We searched MEDLINE and other databases from inception to July 2018. REVIEW METHODS Risk of bias was assessed with QUADAS-2 [quality assessment of diagnostic accuracy studies (version 2)]. Diagnostic accuracy was assessed using bivariate regression models. Imaging tests were compared. Subgroup analyses were performed based on the location and nature of the suspected osteomyelitis. Studies of children, inter-rater reliability and implementation outcomes were synthesised narratively. RESULTS Eighty-one studies were included (diagnostic accuracy: 77 studies; inter-rater reliability: 11 studies; implementation: one study; some studies were included in two reviews). One-quarter of diagnostic accuracy studies were rated as being at a high risk of bias. In adults, MRI had high diagnostic accuracy [95.6% sensitivity, 95% confidence interval (CI) 92.4% to 97.5%; 80.7% specificity, 95% CI 70.8% to 87.8%]. PET also had high accuracy (85.1% sensitivity, 95% CI 71.5% to 92.9%; 92.8% specificity, 95% CI 83.0% to 97.1%), as did SPECT (95.1% sensitivity, 95% CI 87.8% to 98.1%; 82.0% specificity, 95% CI 61.5% to 92.8%). There was similar diagnostic performance with MRI, PET and SPECT. Scintigraphy (83.6% sensitivity, 95% CI 71.8% to 91.1%; 70.6% specificity, 57.7% to 80.8%), computed tomography (69.7% sensitivity, 95% CI 40.1% to 88.7%; 90.2% specificity, 95% CI 57.6% to 98.4%) and radiography (70.4% sensitivity, 95% CI 61.6% to 77.8%; 81.5% specificity, 95% CI 69.6% to 89.5%) all had generally inferior diagnostic accuracy. Technetium-99m hexamethylpropyleneamine oxime white blood cell scintigraphy (87.3% sensitivity, 95% CI 75.1% to 94.0%; 94.7% specificity, 95% CI 84.9% to 98.3%) had higher diagnostic accuracy, similar to that of PET or MRI. There was no evidence that diagnostic accuracy varied by scan location or cause of osteomyelitis, although data on many scan locations were limited. Diagnostic accuracy in diabetic foot patients was similar to the overall results. Only three studies in children were identified; results were too limited to draw any conclusions. Eleven studies evaluated inter-rater reliability. MRI had acceptable inter-rater reliability. We found only one study on test implementation and no evidence on patient preferences or cost-effectiveness of imaging tests for osteomyelitis. LIMITATIONS Most studies included < 50 participants and were poorly reported. There was limited evidence for children, ultrasonography and on clinical factors other than diagnostic accuracy. CONCLUSIONS Osteomyelitis is reliably diagnosed by MRI, PET and SPECT. No clear reason to prefer one test over the other in terms of diagnostic accuracy was identified. The wider availability of MRI machines, and the fact that MRI does not expose patients to harmful ionising radiation, may mean that MRI is preferable in most cases. Diagnostic accuracy does not appear to vary with the potential cause of osteomyelitis or with the body part scanned. Considerable uncertainty remains over the diagnostic accuracy of imaging tests in children. Studies of diagnostic accuracy in children, particularly using MRI and ultrasound, are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068511. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 61. See the NIHR Journals Library website for further project information. Osteomyelitis is an infection of the bone and is treated with antibiotics. Left untreated, it can cause permanent damage and can lead to amputation. The best method to diagnose osteomyelitis is to take a bone sample (bone biopsy) but this is invasive and painful. Imaging may help target the best locations for biopsies or remove the need for a biopsy entirely. Several methods are available, including radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET). This project systematically reviewed the relevant literature to determine which tests are the most accurate and relevant for clinical practice. All types of patients and all types of osteomyelitis were reviewed. Studies were pooled using statistical methods (meta-analyses) to estimate the overall accuracy of the imaging tests. The review identified 81 studies and concluded that MRI, PET and SPECT all had similar accuracy, correctly identifying over 85% of people who did have osteomyelitis and over 80% of people who did not have osteomyelitis. Radiography and computed tomography were less accurate. Modern forms of scintigraphy have accuracy similar to PET or MRI. There was no evidence that the accuracy of the imaging tests was different depending on the cause of osteomyelitis or which body part was affected. In particular, diagnostic accuracy in people with diabetic foot ulcers was similar to other types of osteomyelitis in adults. There was not enough evidence about which tests are most accurate in children, so further studies in children are needed.
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            Treatment of Sternoclavicular Joint Osteomyelitis with Debridement and Delayed Resection with Muscle Flap Coverage Improves Outcomes

            The objective of this study was to evaluate the efficacy of various treatment options for sternoclavicular joint osteomyelitis. We evaluated patients with a diagnosis of sternoclavicular joint osteomyelitis, treated at our hospital from 2002 to 2012. Four treatment options were compared. Three out of twelve patients were successfully cured with antibiotics alone (25%). Debridement with or without negative pressure therapy was successful for one of three patients (33%). Simultaneous debridement, bone resection, and muscle flap coverage of the acquired defect successfully treated one of two patients (50%). Debridement with delayed bone resection and muscle flap coverage was successful in five of five patients (100%). Osteomyelitis of the sternoclavicular joint is a rare disease that has become more prevalent in recent years and can be associated with increasing use of long-term indwelling catheters. Initial debridement with delayed bone resection and pectoralis major muscle flap coverage can effectively treat sternoclavicular joint osteomyelitis.
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              Factors associated with Salmonella infection in patients with gastrointestinal complaints seeking health care at Regional Hospital in Southern Highland of Tanzania

              Background Salmonellosis remains an important public health problem globally. The disease is among the leading causes of morbidity and mortality in developing countries that experience poor hygiene and lack of access to clean and safe water. There was an increase in reported cases of Salmonellosis in Njombe Region, Southern Highland of Tanzania between 2015 and 2016 based on clinical diagnosis. Nevertheless, little is known about the factors contributing to the transmission of this disease in the region. This study was conducted to determine the prevalence, antimicrobial susceptibility, and factors associated with Salmonella infection among patients who report gastrointestinal complaints. Methods A cross-sectional study was conducted from December 2017 to February 2018 among patients with gastrointestinal complaints at Kibena Regional Hospital. Stool samples were submitted for isolation of Salmonella spp. Identification was based on conventional biochemical tests and serotyping to differentiate typhoid and non-typhoid Salmonella (NTS). Antimicrobial susceptibility was performed using the Kirby-Bauer disc diffusion method. Multivariable logistic regression analysis was performed to examine the factors independently associated with Salmonella infection. Results The prevalence of Salmonella infection among participants with gastrointestinal complaints was 16.5% (95% CI: 12.7–21.1) of them, 83.7, 95% CI: 70.9–91.5 were NTS while 16.3, 95% CI: 8.5–29.0 were Typhoid Salmonella species. All isolates were sensitive to ceftriaxone and ciprofloxacin, whereas 27.8 and 100% were resistant to co-trimoxazole and ampicillin respectively. The odd of Salmonella infection was fourfold higher among participants with formal employment (AOR 3.8, 95% CI, 1.53–9.40). Use of water from wells/rivers (AOR 2.2, 95% CI, 1.07–4.45), drinking untreated water (AOR 2.6, 95% CI, 1.21–5.48) and often eating at a restaurant (AOR 3.4, 95% CI, 1.28–8.93) had increased odds of Salmonella infection. Likewise, having abdominal pain (AOR 8.5, 95% CI, 1.81–39.78) and diarrhea (AOR 2.3, 95% CI, 1.12–4.68) were independent symptoms that predict Salmonella infection. Conclusion There is a high prevalence of Salmonella infection among people who report gastrointestinal complaints and it is clinically predicated by diarhoea and abdominal pain. Employed participants and those eating at restaurant and drinking unsafe water had higher risk of infection. Salmonella spp. causing gastroenteritis has developed resistance to commonly used antibiotics.
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                Author and article information

                Journal
                Exp Ther Med
                Exp Ther Med
                ETM
                Experimental and Therapeutic Medicine
                D.A. Spandidos
                1792-0981
                1792-1015
                March 2021
                07 January 2021
                07 January 2021
                : 21
                : 3
                : 189
                Affiliations
                [1 ]Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
                [2 ]Department of Radiology, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
                Author notes
                Correspondence to: Dr Yuanzhong Liang, Department of Radiology, The First People's Hospital of Honghe Prefecture, 11 Nanhu South Road, Mengzi, Yunnan 661100, P.R. China qianmengjiao@ 123456sina.com

                Abbreviations: PSO, primary sternal osteomyelitis; US, ultrasound

                Article
                ETM-0-0-09620
                10.3892/etm.2021.9620
                7812590
                d6d1c31c-446b-4e29-80db-b367df814b59
                Copyright: © Qian et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

                History
                : 11 March 2020
                : 16 October 2020
                Categories
                Articles

                Medicine
                primary sternal osteomyelitis,salmonella,infancy,ct multiplanar reconstruction,ultrasound
                Medicine
                primary sternal osteomyelitis, salmonella, infancy, ct multiplanar reconstruction, ultrasound

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