Limb Salvage for Streptococcal Gangrene of the Extremity
Identifieur interne : 005126 ( Istex/Corpus ); précédent : 005125; suivant : 005127Limb Salvage for Streptococcal Gangrene of the Extremity
Auteurs : Michael Schurr Md ; Sandra Engelhardt Md ; Richard Helgerson MdSource :
- The American Journal of Surgery [ 0002-9610 ] ; 1998.
Abstract
Background: Extremity soft tissue infections from group A, β-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results.Methods: Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured.Results: Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia.Conclusions: Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival.
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DOI: 10.1016/S0002-9610(97)00297-3
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<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Limb Salvage for Streptococcal Gangrene of the Extremity</title><author><name sortKey="Schurr Md, Michael" sort="Schurr Md, Michael" uniqKey="Schurr Md M" first="Michael" last="Schurr Md">Michael Schurr Md</name><affiliation><mods:affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</mods:affiliation></affiliation></author><author><name sortKey="Engelhardt Md, Sandra" sort="Engelhardt Md, Sandra" uniqKey="Engelhardt Md S" first="Sandra" last="Engelhardt Md">Sandra Engelhardt Md</name><affiliation><mods:affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</mods:affiliation></affiliation></author><author><name sortKey="Helgerson Md, Richard" sort="Helgerson Md, Richard" uniqKey="Helgerson Md R" first="Richard" last="Helgerson Md">Richard Helgerson Md</name><affiliation><mods:affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:AC903FE4159EEB99DA70E55E127B5B7AB93C3D66</idno><date when="1998" year="1998">1998</date><idno type="doi">10.1016/S0002-9610(97)00297-3</idno><idno type="url">https://api.istex.fr/document/AC903FE4159EEB99DA70E55E127B5B7AB93C3D66/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">005126</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">005126</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Limb Salvage for Streptococcal Gangrene of the Extremity</title><author><name sortKey="Schurr Md, Michael" sort="Schurr Md, Michael" uniqKey="Schurr Md M" first="Michael" last="Schurr Md">Michael Schurr Md</name><affiliation><mods:affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</mods:affiliation></affiliation></author><author><name sortKey="Engelhardt Md, Sandra" sort="Engelhardt Md, Sandra" uniqKey="Engelhardt Md S" first="Sandra" last="Engelhardt Md">Sandra Engelhardt Md</name><affiliation><mods:affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</mods:affiliation></affiliation></author><author><name sortKey="Helgerson Md, Richard" sort="Helgerson Md, Richard" uniqKey="Helgerson Md R" first="Richard" last="Helgerson Md">Richard Helgerson Md</name><affiliation><mods:affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">The American Journal of Surgery</title><title level="j" type="abbrev">AJS</title><idno type="ISSN">0002-9610</idno><imprint><publisher>ELSEVIER</publisher><date type="published" when="1998">1998</date><biblScope unit="volume">175</biblScope><biblScope unit="issue">3</biblScope><biblScope unit="page" from="213">213</biblScope><biblScope unit="page" to="217">217</biblScope></imprint><idno type="ISSN">0002-9610</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0002-9610</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Background: Extremity soft tissue infections from group A, β-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results.Methods: Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured.Results: Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia.Conclusions: Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival.</div></front></TEI><istex><corpusName>elsevier</corpusName><keywords><teeft><json:string>streptococcal</json:string><json:string>gangrene</json:string><json:string>debridement</json:string><json:string>fascia</json:string><json:string>necrotizing</json:string><json:string>streptococcal gangrene</json:string><json:string>amputation</json:string><json:string>subcutaneous</json:string><json:string>surg</json:string><json:string>fasciitis</json:string><json:string>excision</json:string><json:string>subcutaneous tissue</json:string><json:string>management protocol</json:string><json:string>tissue infections</json:string><json:string>necrotizing fasciitis</json:string><json:string>streptococcus</json:string><json:string>antibiotic</json:string><json:string>extremity streptococcal gangrene</json:string><json:string>graft</json:string><json:string>surgical referral</json:string><json:string>hemolytic streptococcus</json:string><json:string>american journal</json:string><json:string>surgical</json:string><json:string>hemolytic</json:string><json:string>syndrome</json:string><json:string>radical debridement</json:string><json:string>skin graft coverage</json:string><json:string>shock syndrome</json:string><json:string>toxic syndrome</json:string><json:string>distress syndrome</json:string><json:string>broad spectrum antibiotics</json:string><json:string>wound closure</json:string><json:string>cleavage plane</json:string><json:string>extremity</json:string><json:string>baseline level</json:string><json:string>splitthickness skin grafts</json:string><json:string>skin necrosis</json:string><json:string>gram stains</json:string><json:string>urine output</json:string><json:string>severe streptococcal infections</json:string><json:string>organ dysfunction</json:string><json:string>diabetes mellitus</json:string><json:string>operative debridement</json:string><json:string>systolic blood pressure</json:string><json:string>collective mortality</json:string><json:string>streptococcus pyogenes</json:string><json:string>upper limit</json:string><json:string>twofold elevation</json:string><json:string>wound care</json:string><json:string>intravascular coagulation</json:string><json:string>excerpta medica</json:string><json:string>acute onset</json:string><json:string>high incidence</json:string><json:string>skin grafts</json:string><json:string>intravenous antibiotics</json:string><json:string>local wound care</json:string><json:string>dressing changes</json:string><json:string>nutritional support</json:string><json:string>antibiotic therapy</json:string><json:string>deep fascia</json:string><json:string>necrotizing infections</json:string><json:string>hemolytic streptococcus gangrene</json:string><json:string>arch surg</json:string><json:string>early diagnosis</json:string></teeft></keywords><author><json:item><name>Michael Schurr, MD</name><affiliations><json:string>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</json:string></affiliations></json:item><json:item><name>Sandra Engelhardt, MD</name><affiliations><json:string>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</json:string></affiliations></json:item><json:item><name>Richard Helgerson, MD</name><affiliations><json:string>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</json:string></affiliations></json:item></author><articleId><json:string>5275</json:string></articleId><language><json:string>eng</json:string></language><originalGenre><json:string>Full-length article</json:string></originalGenre><abstract>Background: Extremity soft tissue infections from group A, β-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results.Methods: Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured.Results: Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia.Conclusions: Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival.</abstract><qualityIndicators><score>4.521</score><pdfVersion>1.2</pdfVersion><pdfPageSize>578 x 777 pts</pdfPageSize><refBibsNative>true</refBibsNative><keywordCount>0</keywordCount><abstractCharCount>1122</abstractCharCount><pdfWordCount>2649</pdfWordCount><pdfCharCount>17954</pdfCharCount><pdfPageCount>5</pdfPageCount><abstractWordCount>156</abstractWordCount></qualityIndicators><title>Limb Salvage for Streptococcal Gangrene of the Extremity</title><pii><json:string>S0002-9610(97)00297-3</json:string></pii><genre><json:string>research-article</json:string></genre><host><title>The American Journal of Surgery</title><language><json:string>unknown</json:string></language><publicationDate>1998</publicationDate><issn><json:string>0002-9610</json:string></issn><pii><json:string>S0002-9610(00)X0002-5</json:string></pii><volume>175</volume><issue>3</issue><pages><first>213</first><last>217</last></pages><genre><json:string>journal</json:string></genre></host><categories><wos><json:string>science</json:string><json:string>surgery</json:string></wos><scienceMetrix><json:string>health sciences</json:string><json:string>clinical medicine</json:string><json:string>surgery</json:string></scienceMetrix><inist><json:string>sciences appliquees, technologies et medecines</json:string><json:string>sciences biologiques et medicales</json:string><json:string>sciences medicales</json:string></inist></categories><publicationDate>1998</publicationDate><copyrightDate>1998</copyrightDate><doi><json:string>10.1016/S0002-9610(97)00297-3</json:string></doi><id>AC903FE4159EEB99DA70E55E127B5B7AB93C3D66</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/document/AC903FE4159EEB99DA70E55E127B5B7AB93C3D66/fulltext/pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/document/AC903FE4159EEB99DA70E55E127B5B7AB93C3D66/fulltext/zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/document/AC903FE4159EEB99DA70E55E127B5B7AB93C3D66/fulltext/tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Limb Salvage for Streptococcal Gangrene of the Extremity</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher>ELSEVIER</publisher><availability><p>©1998 Elsevier Science Inc.</p></availability><date>1998</date></publicationStmt><notesStmt><note type="content">Section title: Scientific Papers</note><note type="content">Fig. 1: Preoperative photograph. Streptococcal gangrene in a 45-year-old woman transferred from a local hospital after 7 days of intravenous antibiotics.</note><note type="content">Fig. 2: Intraoperative photograph demonstrating cleavage plane between subcutaneous tissue and fascia.</note><note type="content">Fig. 3: Postoperative photograph. Note extent of initial debridement.</note><note type="content">Fig. 4: Photograph of healed split-thickness skin grafts prior to discharge.</note><note type="content">Fig. 5: Bacteriology of infections.</note><note type="content">Fig. 6: Summary of complications.</note><note type="content">Table I: The Case Definition for the Streptococcal Toxic Shock-like Syndrome</note><note type="content">Table II: Clinical Characteristics at Presentation</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Limb Salvage for Streptococcal Gangrene of the Extremity</title><author xml:id="author-0000"><persName><forename type="first">Michael</forename><surname>Schurr, MD</surname></persName><note type="biography">Michael J. Schurr, MD, Department of Surgery, University of Wisconsin Hospital, 600 Highland Ave., Madison, Wisconsin 53792.</note><affiliation>Michael J. Schurr, MD, Department of Surgery, University of Wisconsin Hospital, 600 Highland Ave., Madison, Wisconsin 53792.</affiliation><affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</affiliation></author><author xml:id="author-0001"><persName><forename type="first">Sandra</forename><surname>Engelhardt, MD</surname></persName><affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Richard</forename><surname>Helgerson, MD</surname></persName><affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</affiliation></author><idno type="istex">AC903FE4159EEB99DA70E55E127B5B7AB93C3D66</idno><idno type="DOI">10.1016/S0002-9610(97)00297-3</idno><idno type="PII">S0002-9610(97)00297-3</idno><idno type="ArticleID">5275</idno></analytic><monogr><title level="j">The American Journal of Surgery</title><title level="j" type="abbrev">AJS</title><idno type="pISSN">0002-9610</idno><idno type="PII">S0002-9610(00)X0002-5</idno><imprint><publisher>ELSEVIER</publisher><date type="published" when="1998"></date><biblScope unit="volume">175</biblScope><biblScope unit="issue">3</biblScope><biblScope unit="page" from="213">213</biblScope><biblScope unit="page" to="217">217</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>1998</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>Background: Extremity soft tissue infections from group A, β-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results.Methods: Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured.Results: Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia.Conclusions: Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival.</p></abstract></profileDesc><revisionDesc><change when="1997-11-14">Modified</change><change when="1998">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/AC903FE4159EEB99DA70E55E127B5B7AB93C3D66/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="Elsevier, elements deleted: ce:floats; body; tail"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//ES//DTD journal article DTD version 4.5.2//EN//XML" URI="art452.dtd" name="istex:docType"><istex:entity SYSTEM="gr1" NDATA="IMAGE" name="gr1"></istex:entity><istex:entity SYSTEM="gr2" NDATA="IMAGE" name="gr2"></istex:entity><istex:entity SYSTEM="gr3" NDATA="IMAGE" name="gr3"></istex:entity><istex:entity SYSTEM="gr4" NDATA="IMAGE" name="gr4"></istex:entity><istex:entity SYSTEM="gr5" NDATA="IMAGE" name="gr5"></istex:entity><istex:entity SYSTEM="gr6" NDATA="IMAGE" name="gr6"></istex:entity></istex:docType><istex:document><converted-article version="4.5.2" docsubtype="fla" xml:lang="en"><item-info><jid>AJS</jid><aid>5275</aid><ce:pii>S0002-9610(97)00297-3</ce:pii><ce:doi>10.1016/S0002-9610(97)00297-3</ce:doi><ce:copyright year="1998" type="full-transfer">Elsevier Science Inc.</ce:copyright></item-info><head><ce:dochead><ce:textfn>Scientific Papers</ce:textfn></ce:dochead><ce:title>Limb Salvage for Streptococcal Gangrene of the Extremity</ce:title><ce:author-group><ce:author><ce:indexed-name>Schurr</ce:indexed-name><ce:given-name>Michael</ce:given-name><ce:surname>Schurr</ce:surname><ce:suffix>MD</ce:suffix><ce:cross-ref refid="AFF1">A</ce:cross-ref><ce:cross-ref refid="CORR1">*</ce:cross-ref></ce:author><ce:author><ce:indexed-name>Engelhardt</ce:indexed-name><ce:given-name>Sandra</ce:given-name><ce:surname>Engelhardt</ce:surname><ce:suffix>MD</ce:suffix><ce:cross-ref refid="AFF1">A</ce:cross-ref></ce:author><ce:author><ce:indexed-name>Helgerson</ce:indexed-name><ce:given-name>Richard</ce:given-name><ce:surname>Helgerson</ce:surname><ce:suffix>MD</ce:suffix><ce:cross-ref refid="AFF1">A</ce:cross-ref></ce:author><ce:affiliation id="AFF1"><ce:label>A</ce:label><ce:textfn>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</ce:textfn></ce:affiliation><ce:correspondence id="CORR1"><ce:label>*</ce:label><ce:text>Michael J. Schurr, MD, Department of Surgery, University of Wisconsin Hospital, 600 Highland Ave., Madison, Wisconsin 53792.</ce:text></ce:correspondence></ce:author-group><ce:date-received day="16" month="6" year="1997"></ce:date-received><ce:date-revised day="14" month="11" year="1997"></ce:date-revised><ce:date-accepted day="14" month="11" year="1997"></ce:date-accepted><ce:abstract class="author"><ce:section-title>Abstract</ce:section-title><ce:abstract-sec><ce:simple-para view="all" id="simple-para.0060">Background: Extremity soft tissue infections from group A, β-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results.</ce:simple-para><ce:simple-para view="all" id="simple-para.0065">Methods: Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured.</ce:simple-para><ce:simple-para view="all" id="simple-para.0070">Results: Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia.</ce:simple-para><ce:simple-para view="all" id="simple-para.0075">Conclusions: Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival.</ce:simple-para></ce:abstract-sec></ce:abstract></head></converted-article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Limb Salvage for Streptococcal Gangrene of the Extremity</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Limb Salvage for Streptococcal Gangrene of the Extremity</title></titleInfo><name type="personal"><namePart type="given">Michael</namePart><namePart type="family">Schurr, MD</namePart><affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</affiliation><description>Michael J. Schurr, MD, Department of Surgery, University of Wisconsin Hospital, 600 Highland Ave., Madison, Wisconsin 53792.</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Sandra</namePart><namePart type="family">Engelhardt, MD</namePart><affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Richard</namePart><namePart type="family">Helgerson, MD</namePart><affiliation>Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="Full-length article"></genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">1998</dateIssued><dateModified encoding="w3cdtf">1997-11-14</dateModified><copyrightDate encoding="w3cdtf">1998</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Background: Extremity soft tissue infections from group A, β-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results.Methods: Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured.Results: Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia.Conclusions: Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival.</abstract><note type="content">Section title: Scientific Papers</note><note type="content">Fig. 1: Preoperative photograph. Streptococcal gangrene in a 45-year-old woman transferred from a local hospital after 7 days of intravenous antibiotics.</note><note type="content">Fig. 2: Intraoperative photograph demonstrating cleavage plane between subcutaneous tissue and fascia.</note><note type="content">Fig. 3: Postoperative photograph. Note extent of initial debridement.</note><note type="content">Fig. 4: Photograph of healed split-thickness skin grafts prior to discharge.</note><note type="content">Fig. 5: Bacteriology of infections.</note><note type="content">Fig. 6: Summary of complications.</note><note type="content">Table I: The Case Definition for the Streptococcal Toxic Shock-like Syndrome</note><note type="content">Table II: Clinical Characteristics at Presentation</note><relatedItem type="host"><titleInfo><title>The American Journal of Surgery</title></titleInfo><titleInfo type="abbreviated"><title>AJS</title></titleInfo><genre type="journal">journal</genre><originInfo><dateIssued encoding="w3cdtf">199803</dateIssued></originInfo><identifier type="ISSN">0002-9610</identifier><identifier type="PII">S0002-9610(00)X0002-5</identifier><part><date>199803</date><detail type="volume"><number>175</number><caption>vol.</caption></detail><detail type="issue"><number>3</number><caption>no.</caption></detail><extent unit="issue pages"><start>171</start><end>262</end></extent><extent unit="pages"><start>213</start><end>217</end></extent></part></relatedItem><identifier type="istex">AC903FE4159EEB99DA70E55E127B5B7AB93C3D66</identifier><identifier type="DOI">10.1016/S0002-9610(97)00297-3</identifier><identifier type="PII">S0002-9610(97)00297-3</identifier><identifier type="ArticleID">5275</identifier><accessCondition type="use and reproduction" contentType="copyright">©1998 Elsevier Science Inc.</accessCondition><recordInfo><recordContentSource>ELSEVIER</recordContentSource><recordOrigin>Elsevier Science Inc., ©1998</recordOrigin></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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