Necrotising soft tissue infections Gundersen, Ingunn Margareetta; Bruun, Trond; Almeland, Stian Kreken ...
Tidsskrift for den Norske Lægeforening,
2024-Feb-27, Letnik:
144, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in ...extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.
We investigated total, free and protein-bound plasma homocysteine, cysteine and cysteinylglycine in 13 subjects aged 24-29 y after a breakfast at 0900 h containing 15-18 g of protein and a dinner at ...1500 h containing approximately 50 g of protein. Twelve subjects had normal fasting homocysteine (mean +/- SD, 7.6 +/- 1.1 mumol/L) and methionine concentrations (22.7 +/- 3.5 mumol/L) and were included in the statistical analyses. Breakfast caused a small but significant increase in plasma methionine (22.2 +/- 20.6%) and a brief, nonsignificant increase followed by a significant decline in free homocysteine. However, changes in total and bound homocysteine were small. After dinner, there was a marked increase in plasma methionine by 16.7 +/- 8.9 mumol/L (87.9 +/- 49%), which was associated with a rapid and marked increase in free homocysteine (33.7 +/- 19.6%, 4 h after dinner) and a moderate and slow increase in total (13.5 +/- 7.5%, 8 h) and protein-bound (12.6 +/- 9.4%, 8 h) homocysteine. After both meals, cysteine and cysteinylglycine concentrations seemed related to changes in homocysteine, because there were parallel fluctuations in the free:bound ratios of all three thiols. Dietary changes in plasma homocysteine will probably not affect the evaluation of vitamin deficiency states associated with moderate to severe hyperhomocysteinemia but may be of concern in the risk assessment of cardiovascular disease in patients with mild hyperhomocysteinemia. Synchronous fluctuations in the free:bound ratio of the plasma aminothiol compounds indicate that biological effects of homocysteine may be difficult to separate from effects due to associated changes in other aminothiol compounds.
Cobalamin deficiency accompanied by bone marrow dysfunction and impaired central nervous system development has been reported in infants who were born to mothers with low cobalamin intake. We ...investigated the relation between cobalamin status in newborns and in their healthy mothers who consumed an omnivorous diet.
Serum cobalamin and the functional markers plasma methylmalonic acid (MMA) and total homocysteine (tHcy) were determined in 173 newborns and their mothers. Forty-five children and mothers were reinvestigated after 6 weeks.
At birth, median (interquartile range) serum cobalamin levels were 245 (175-323) pmol/L in the mothers and 314 (238-468) pmol/L in the newborns. In the neonates, serum cobalamin, but not folate, was inversely associated with MMA and tHcy. Among maternal factors, low serum cobalamin was the strongest predictor of impaired cobalamin function (defined as low cobalamin, high tHcy, or high MMA levels) in the newborns. After 6 weeks, the maternal cobalamin levels had increased (to 421 271-502 pmol/L), whereas the newborn levels had declined (to 230 158-287 pmol/L). In the same interval, the infants had a marked increase in plasma MMA (from 0.29 0.24-0.38 to 0.81 0.37-1.68 micromol/L). At 6 weeks, parity was a strong predictor of cobalamin status in the infant.
The cobalamin status in the neonatal period is strongly associated with maternal cobalamin status and parity. A reduction in serum cobalamin and an increase in metabolite levels are consistent with impaired cobalamin function in a significant portion of the infants who were born to healthy, nonvegetarian mothers.
Background: Plasma cystathionine measurement may be a useful complement to total homocysteine measurement in the assessment of B vitamin status. Information on the within-person variation in ...cystathionine is currently sparse. Objective: The goal was to study the daily variation in plasma cystathionine concentrations in healthy subjects. Design: Twelve subjects (aged 22-29 y) were followed for 24 h. During the observation period, the subjects received a breakfast (containing 15-18 g protein) at 0900 and a beef dinner (containing approximately equal to 50 g protein) at 1500. Multiple blood samples for metabolite analyses were collected during the day, and a final sample was obtained the next morning. The results are expressed as medians and interquartile ranges. Results: All subjects had normal fasting cystathionine concentrations 0.120 (0.100-0.160) micromol/L. Cystathionine concentrations increased significantly after breakfast, reached a maximum after 4 h of 142.4% (100.0-170.3%) of the fasting concentration, and then declined to fasting concentrations before dinner. After dinner, plasma cystathionine started to increase within 0.5 h and reached a maximum after 6 h 281.3% (194.1-351.4%) of the concentration measured before dinner. The changes in plasma methionine and total homocysteine concentrations during the day were less pronounced. Conclusion: Food intake, even of foods with low protein content, causes an increase in plasma cystathionine concentrations that is more pronounced than the concomitant changes in total homocysteine and methionine. In studies including plasma cystathionine measurement, blood sampling in the fasting state should be considered.
Newborn screening for total homocysteine (tHcy) in blood may identify babies with vitamin B12 (B12) deficiency or homocystinuria, but data on the causes of increased tHcy in screening samples are ...sparse.
Serum concentrations of tHcy, cystathionine, methionine, folate, and B12 and the methylenetetrahydrofolate reductase (MTHFR) 677C > T polymorphism were determined in 4992 capillary blood samples collected as part of the routine screening program in newborn children. Methylmalonic acid (MMA), gender (SRY genotyping), and the frequency of six cystathionine beta-synthase (CBS) mutations were determined in 20-27% of the samples, including all samples with tHcy > 15 micromol/L (n = 127), B12 < 100 pmol/L (n = 159), or methionine > 40 micromol/L (n = 154).
The median (5th-95th percentile) tHcy concentration was 6.8 (4.2-12.8) micromol/L. B12 status, as determined by serum concentrations of B12, tHcy, and MMA, was moderately better in boys than in girls. tHcy concentrations between 10 and 20 micromol/L were often associated with low B12, whereas tHcy > 20 micromol/L (n = 43) was nearly always explained by increased methionine. tHcy did not differ according to folate concentrations or MTHFR 677C > T genotypes. None of the babies had definite CBS deficiencies, but heterozygosity led to low cystathionine, increased methionine, but normal tHcy concentrations.
Increased tHcy is a common but not specific finding in newborns. The metabolite and vitamin profiles will point to the cause of hyperhomocysteinemia. Screening for tHcy and related factors should be further evaluated in regions with high prevalence of homocystinuria and in babies at high risk of B12 deficiency.
From 1992-93, we screened 18,043 subjects, aged 40-67 yr, and found 67 cases (0.4%) with total plasma homocysteine (tHcy) > or = 40 micromol/liter. Compared to 329 controls, the cases had lower ...plasma folate and cobalamin levels, lower intake of vitamin supplements, consumed more coffee, and were more frequently smokers. Homozygosity for the C677T mutation in the methylenetetrahydrofolate reductase gene was observed in 73.1% of the cases and 10.2% of the controls. Only seven cases with cobalamin deficiency and one with homocystinuria received specific therapeutic instructions. 2 yr after the screening, 58 subjects were reinvestigated. 41 still had tHcy > 20 micromol/liter, and in 37 of these, intervention with low dose folic acid (0.2 mg/d) was started. Notably, 34 of 37 (92%) had homozygosity for the C677T mutation. Plasma tHcy was reduced in all but two after 7 wk, and became normal within 7 mo in 21 of 37 subjects. Most of the remaining subjects obtained a normal tHcy level with 5 mg/d of folic acid. We conclude that most subjects with hyperhomocysteinemia > or = 40 micromol/liter in the general population have the C677T mutation combined with low folate status. Daily supplement of low dose folic acid will reduce and often normalize their tHcy level.
Background: In the perioperative setting multiple agents can cause anaphylaxis. Often the reactions are dramatic, and due to their lifethreatening potential it is crucial that the responsible agent ...is identified in order to avoid future adverse reactions. The aim of the present study was to measure the concentration of serum mast cell tryptase (MCT), to investigate the prevalence of serum IgE antibodies against ammonium groups, choline, morphine, suxamethonium, thiopentone and latex and to perform skin prick tests (SPTs) in 18 patients experiencing an anaphylactic reaction during induction of general anaesthesia.
Methods: Serum samples from 18 patients with an anaphylactic reaction during general anaesthesia were analyzed for MCT and specific IgE against ammonium groups, choline, morphine, suxamethonium, thiopentone and latex. Skin prick tests were performed in 11 out of 18 patients.
Results: Ten patients had elevated MCT levels and specific IgE against ammonium ion, morphine and (with the exception of patient nos 3, 9 and 10) suxamethonium. Seven of these patients had positive SPTs to suxamethonium. One of the patients tested positive to latex in addition to suxamethonium. Two patients showed elevated MCT, while specific IgE against the drugs tested was not detected. Three patients tested positive to ammonium ion, morphine and suxamethonium, but negative to MCT. Three patients tested negative to both MCT and specific IgE.
Conclusions: Fifteen out of 18 sera tested positive for MCT and/or specific IgE against neuromuscular blocking drugs (NMBDs). Ten of the 18 patients experienced an IgE‐mediated anaphylactic reaction to NMBDs during anaesthesia, verified by detection of specific IgE and elevated levels of MCT.
Background: Cardiopulmonary distress during obstetrical anaesthesia may result from a drug‐induced allergic reaction, but, in the obstetrical setting, allergic anaphylaxis may be inseparable from ...amniotic fluid embolism in terms of the clinical presentation. Further investigations, using allergy tests and other laboratory analyses, are then needed to pursue a diagnostic clarification.
Methods: Twelve women suspected of having developed anaphylaxis during obstetrical anaesthesia underwent allergy follow‐up investigations and further serological tests with the amniotic fluid embolism marker sialyl Tn and complement factors (C3 and C4) in an attempt to differentiate amniotic fluid embolism from drug‐induced allergic anaphylaxis.
Results: The diagnostic programme revealed one case of probable amniotic fluid embolism and four cases of probable drug‐induced allergic anaphylaxis. Of the remaining seven cases, there were two cases that, by diagnostic exclusion, could be classified as possible cases of amniotic fluid embolism. The cause of the reactions remained unresolved in five cases.
Conclusions: It can be difficult to differentiate between anaphylaxis and amniotic fluid embolism, especially amongst survivors. Diagnostic markers that can be applied on peripheral blood samples are promising, but larger studies are needed to validate their use in the diagnosis of causes of cardiopulmonary distress during obstetrical anaesthesia.
Background: At present there are limited data about the effects of high frequency oscillatory ventilation (HFOV) in adult patients with acute respiratory distress syndrome (ARDS). This study ...evaluates efficacy of HFOV in such patients.
Methods: Sixteen ARDS patients, mean age 38.2 years (range 18–76), that underwent HFOV between 1997 and 2001 were enrolled in the study and evaluated in retrospect. FIo2, arterial blood gases, mean airway pressure (mean Paw), blood pressure, heart rate and central venous pressure were recorded by 4, 8, 12, 24, 48 and 72 h of HFOV and compared to conventional mechanical ventilation (CMV) at baseline (4 h prior to HFOV).
Results: On admission to the ICU, mean Simplified Acute Physiology score (SAPS II) was 40.3 (SD 12.6). Main causes of ARDS were pneumonia (9/16) and burn injuries (4/16). At baseline the patients had severe ARDS as noted by a mean lung injury score (LIS) of 3.2 (SD 0.3) and Pao2/FIo2 ratio 12.2 (SD 3.2) kPa. Within 4 h of HFOV, Pao2/FIo2 increased to 17.3 (SD 5.9) kPa (P = 0.016). Throughout HFOV, Pao2/FIo2 was significantly higher than at baseline. There were no significant changes in haemodynamic parameters. Ending HFOV after 6.6 (SD 3.2) days, survivors (n = 11) significantly reduced their Sequential Organ Failure Assessment Score (SOFA) compared to baseline. Survival at 3 months was 68.8%.
Conclusion: HFOV effectively improves oxygenation without haemodynamic compromise. During HFOV, the SOFA score may predict outcome.
PDF
