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Infectious Disease Clinics of North... Sep 2017Despite advances in antibiotic and surgical management and supportive care for necrotizing soft tissue infections, morbidity and mortality remain substantial. Although... (Review)
Review
Despite advances in antibiotic and surgical management and supportive care for necrotizing soft tissue infections, morbidity and mortality remain substantial. Although there are clinical practice guidelines in place, there still remains much variability in choice and duration of antibiotic therapy, time to initial surgical debridement, and use of adjuvant medical therapies. This article offers an overview of necrotizing soft tissue infections with a focus on current diagnostic and treatment modalities.
Topics: Administration, Intravenous; Anti-Bacterial Agents; Debridement; Disease Management; Fasciitis, Necrotizing; Gangrene; Humans; Hyperbaric Oxygenation; Immunoglobulins; Sepsis; Soft Tissue Infections
PubMed: 28779832
DOI: 10.1016/j.idc.2017.05.011 -
Journal of Vascular Surgery Aug 2019
Topics: Amputation, Surgical; Gangrene; Humans; Transplantation, Homologous
PubMed: 31345478
DOI: 10.1016/j.jvs.2019.03.042 -
Critical Care Medicine Apr 2020
Topics: Gangrene; Humans; Ultrasonography
PubMed: 32205631
DOI: 10.1097/CCM.0000000000004240 -
Transfusion and Apheresis Science :... Apr 2021Symmetrical peripheral gangrene (SPG) is a disabling complication that affects a small proportion of patients who survive critical illness. Its pathogenesis reflects... (Review)
Review
Symmetrical peripheral gangrene (SPG) is a disabling complication that affects a small proportion of patients who survive critical illness. Its pathogenesis reflects profoundly disturbed procoagulant-anticoagulant balance in susceptible tissue beds secondary to circulatory shock (cardiogenic, septic). There is a characteristic SPG triad: (a) shock (hypotension, lactic acidemia, normoblastemia, multiple organ dysfunction), (b) disseminated intravascular coagulation (DIC), and (c) natural anticoagulant depletion (protein C, antithrombin). In recent years, risk factors for natural anticoagulant depletion have been identified, most notably acute ischemic hepatitis ("shock liver"), which is seen in at least 90% of patients who develop SPG. Moreover, there is a characteristic time interval (2-5 days, median 3 days) between the onset of shock/shock liver and the beginning of ischemic injury secondary to peripheral microthrombosis ("limb ischemia with pulses"), reflecting the time required to develop severe depletion in hepatically-synthesized natural anticoagulants. Other risk factors for natural anticoagulant depletion include chronic liver disease (e.g., cirrhosis) and, possibly, transfusion of colloids (albumin, high-dose immunoglobulin) lacking coagulation factors. A causal role for vasopressor therapy is unproven and is unlikely; this is because critically ill patients who develop SPG do so usually after at least 36-48 hours of vasopressor therapy, implicating a time-dependent pathophysiological mechanism. The most plausible explanation is a progressive time-dependent decline in key natural anticoagulant factors, reflecting ongoing DIC ("consumption"), proximate liver disease whether acute or chronic ("impaired production"), and colloid administration ("hemodilution"). Given these evolving concepts of pathogenesis, a rationale approach to prevention/treatment of SPG can be developed.
Topics: Critical Illness; Gangrene; Humans
PubMed: 33627309
DOI: 10.1016/j.transci.2021.103094 -
Journal of Veterinary Diagnostic... Mar 2018Gangrenous dermatitis (GD) is a disease of chickens and turkeys that causes severe economic losses in the poultry industry worldwide. Clostridium septicum, Clostridium... (Review)
Review
Gangrenous dermatitis (GD) is a disease of chickens and turkeys that causes severe economic losses in the poultry industry worldwide. Clostridium septicum, Clostridium perfringens type A, and occasionally Clostridium sordellii are considered the main causes of GD, although Staphylococcus aureus and other aerobic bacteria may also be involved in some cases of the disease. GD has become one of the most significant diseases of commercial turkeys in the United States. Several infectious and/or environmental immunosuppressive factors can predispose to GD. Skin lesions are considered to be the main portal of entry of the microorganism(s) involved. GD is characterized by acute onset of mortality associated with gross skin and subcutaneous tissue lesions consisting of variable amounts of serosanguineous exudate together with emphysema and hemorrhages. The underlying skeletal muscle can also be involved. Ulceration of the epidermis may be also noticed in cases complicated with S. aureus. Microscopically, necrosis of the epidermis and dermis, and subcutaneous edema and emphysema are commonly observed. Gram-positive rods can be identified within the subcutis and skeletal muscles, usually associated with minimal inflammatory infiltrate. A presumptive diagnosis of GD can be made based on history, clinical signs, and gross anatomic and microscopic lesions. However, confirmation should be based on demonstration of the causative agents by culture, PCR, immunohistochemistry, and/or fluorescent antibody tests.
Topics: Animal Husbandry; Animals; Chickens; Clostridium perfringens; Clostridium septicum; Dermatitis; Gangrene; Poultry Diseases; Skin; Staphylococcus aureus; Turkeys
PubMed: 29145799
DOI: 10.1177/1040638717742435 -
British Medical Journal Nov 1951
Topics: Diabetes Complications; Diabetic Angiopathies; Gangrene
PubMed: 14879060
DOI: 10.1136/bmj.2.4742.1254 -
International Wound Journal Feb 2017Diabetic foot ulcerations may determine minor or major amputation, with a high impact on patients' life expectation and quality of life and on economic burden. Among... (Review)
Review
Diabetic foot ulcerations may determine minor or major amputation, with a high impact on patients' life expectation and quality of life and on economic burden. Among minor amputations, transmetatarsal amputation (TMA) appears to be the most effective in terms of limb salvage rates and in maintaining foot and ankle biomechanics. In spite of this, TMA needs particular pre- and postoperative management in order to avoid the frequent failure rates. A systematic review was undertaken of studies concerning TMA and its care in diabetic foot gangrene. Studies were identified by searching the MEDLINE, Scopus and Science Direct databases until 13 January 2016. All studies were assessed using the Downs and Black quality checklist. Of the 348 records found, 86 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 35 manuscripts because of the following reasons: (1) no innovative or important content, (2) no multivariable analysis, (3) insufficient data, (4) no clear potential biases or strategies to solve them, (5) no clear endpoints and (6) inconsistent or arbitrary conclusions. The final set included 51 articles. In the current literature, there are less data about TMA, indication for the selection of patients, outcomes and complications. Generally, the judgment of an experienced physician is one of the best indicators of subsequent healing. Ankle brachial indices, toe pressures, laser Doppler skin perfusion pressures, angiography and Doppler assessment of foot vasculature may help physicians in this decision. In any case, despite the presumed lower healing rate, it is reasonable to pursue a TMA in a patient with a higher likelihood of continued ambulation. Furthermore, tailored wound closure, adjuvant local treatments and the choice of the most appropriate antibiotic therapy, when infection occurs, are pivotal elements for the success of TMA procedures. TMA is a valuable option for diabetic foot gangrene that can prevent major limb loss and minimise loss of function, thus improving the quality of life for diabetic patients.
Topics: Adult; Aged; Aged, 80 and over; Amputation, Surgical; Diabetic Foot; Female; Gangrene; Humans; Male; Metatarsal Bones; Middle Aged
PubMed: 27696694
DOI: 10.1111/iwj.12682 -
The Cochrane Database of Systematic... Apr 2014Below knee amputation (BKA) may be necessary in patients with advanced critical limb ischaemia or diabetic foot sepsis in whom no other treatment option is available.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Below knee amputation (BKA) may be necessary in patients with advanced critical limb ischaemia or diabetic foot sepsis in whom no other treatment option is available. There is no consensus as to which surgical technique achieves the maximum rehabilitation potential. This is the third update of the review first published in 2004.
OBJECTIVES
To assess the effects of different types of incision on the outcome of BKA in people with lower limb ischaemia or diabetic foot sepsis, or both. The main focus of the review was to assess the relative merits of skew flap amputation versus the long posterior flap technique.
SEARCH METHODS
For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched 28 March 2013) and CENTRAL (2013, Issue 2).
SELECTION CRITERIA
Randomised controlled trials comparing two or more types of skin incision for BKA were identified. People with lower limb ischaemia (acute or chronic) or diabetic foot sepsis, or both, were considered for inclusion. People undergoing below knee amputation for other conditions were excluded.
DATA COLLECTION AND ANALYSIS
One review author identified potential trials. Two review authors independently assessed trial quality and extracted the data. Additional information, if required, was sought from study authors.
MAIN RESULTS
Three studies with a combined total of 309 participants were included in the review. One study compared two-stage versus one-stage BKA; one study compared skew flaps BKA versus long posterior flap BKA; and one study compared sagittal flaps BKA versus long posterior flap BKA. Overall the quality of the evidence from these studies was moderate. BKA using skew flaps or sagittal flaps conferred no advantage over the well established long posterior flap technique (primary stump healing was 60% for both skew flaps and long posterior flap (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.71 to 1.42) and primary stump healing was 58% for sagittal flaps and 55% for long posterior flap (Peto odds ratio (OR) 1.04, 95% CI 0.45 to 2.43). For participants with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by a definitive long posterior flap amputation led to better primary stump healing than a one-stage procedure (Peto OR 0.08, 95% CI 0.01 to 0.89). Post-operative infection rate or wound necrosis, reamputation, and mobility with a prosthetic limb were similar in the different comparisons.
AUTHORS' CONCLUSIONS
There is no evidence to show a benefit of one type of incision over another. However, in the presence of wet gangrene a two-stage procedure leads to better primary stump healing compared to a one-stage procedure. The choice of amputation technique can, therefore, be a matter of surgeon preference taking into account factors such as previous experience of a particular technique, the extent of non-viable tissue, and the location of pre-existing surgical scars.
Topics: Amputation, Surgical; Diabetic Foot; Gangrene; Humans; Ischemia; Leg; Randomized Controlled Trials as Topic; Reoperation; Surgical Flaps; Treatment Outcome; Wound Healing
PubMed: 24715679
DOI: 10.1002/14651858.CD003749.pub3 -
Diabetes & Metabolic Syndrome Jan 2022The novel coronavirus disease (COVID-19) caused by SARS-CoV-2 has turned the world topsy-turvy since its onset in 2019. The thromboinflammatory complications of this... (Review)
Review
BACKGROUND AND AIMS
The novel coronavirus disease (COVID-19) caused by SARS-CoV-2 has turned the world topsy-turvy since its onset in 2019. The thromboinflammatory complications of this disease are common in critically ill patients and associated with poor prognosis. Symmetrical peripheral gangrene (SPG) is characterized by symmetrical distal gangrene in absence of any large vessel occlusion or vasculitis and it is usually associated with critical illness. Our aim was to report the clinical profile and outcome of patients diagnosed with SPG associated with COVID-19. To the best of our knowledge, no such similar cases have been reported till date.
METHODS
In this case series, we have discussed the clinical presentation, laboratory parameters and outcome in a series of two patients of SPG associated with COVID-19 and also compared those findings. Due to paucity of data, we also reviewed the literature on this under-diagnosed and rarely reported condition and association.
RESULTS
Two consecutive patients (both males, age range: 37-42 years, mean: 39.5 years) were admitted with the diagnosis of COVID-19 associated SPG. Both patients had clinical and laboratory evidence of disseminated intravascular coagulation (DIC). Leucopenia was noted in both patients. Despite vigorous therapy, both patients succumbed to their illness within a fortnight of admission.
CONCLUSION
SPG in the background of COVID-19 portends a fatal outcome. Physicians should be aware of its grim prognosis.
Topics: Adult; COVID-19; Critical Illness; Disseminated Intravascular Coagulation; Fatal Outcome; Gangrene; Humans; India; Leukopenia; Male; Prognosis; SARS-CoV-2; Severe Acute Respiratory Syndrome
PubMed: 34920197
DOI: 10.1016/j.dsx.2021.102356 -
BMJ (Clinical Research Ed.) Sep 2002
Review
Topics: Acute Disease; Cholecystectomy; Cholecystitis; Digestive System Fistula; Female; Gangrene; Humans; Pregnancy; Pregnancy Complications; Rupture, Spontaneous
PubMed: 12242178
DOI: 10.1136/bmj.325.7365.639