The Relationship Between Fluid Accumulation in Ultrasonography and the Diagnosis and Prognosis of Patients with Necrotizing Fasciitis

Necrotizing fasciitis is a severe soft-tissue infection with a high mortality rate. There is little literature on the relationship between the ultrasonographic finding of fluid accumulation along the deep fascia and the diagnosis and prognosis of necrotizing fasciitis. This retrospective study showed that when fluid accumulation was present along the deep fascia, patients with clinically suspected necrotizing fasciitis had a higher probability of having necrotizing fasciitis. The ultrasonographic finding of fluid accumulation with a cutoff point of more than 2 mm of depth had the best accuracy (72.7%) for diagnosing necrotizing fasciitis. In regard to the prognosis of necrotizing fasciitis, when fluid accumulation was present along the deep fascia, patients with necrotizing fasciitis had a longer length of hospital stay and were at risk of amputation or mortality. Ultrasonography is a point-of-care imaging tool that facilitates the diagnosis and prognosis of necrotizing fasciitis.     

Integrated clinical-ultrasonographic diagnosis in acute appendicitis

PurposeAcute appendicitis is one of the commonest diseases encountered in the field of emergency surgery. If untreated, it can rapidly develop severe complications such as perforation and peritonitis. Surgeons therefore often choose early surgical treatment also when the diagnosis is only probable, facing the risk of performing an elevated amount of unnecessary appendectomies. The aim of this study is to analyse our experience with integrated clinical-ultrasonographic diagnosis in acute appendicitis.Material and methodsFrom January 1999 to December 2006, 1447 patients underwent clinical examination, leucocyte count, evaluation of C-reactive protein level, and abdominal ultrasonography using graded compression technique and a high frequency probe.ResultsIn 368 patients (25%) ultrasonographic diagnosis was acute appendicitis; 8 patients were operated on the basis of clinical evaluation only. Ultrasonography yielded false positive results in 7 cases. In 1079 patients (75%) diagnosis was negative for acute appendicitis; 173 of these patients (12%) received a different diagnosis. The remaining 906 patients underwent clinical follow-up until the symptoms disappeared; there were no complications. In our study, sensitivity of ultrasonography was 98%, specificity 99%, positive predictive value 98%, and negative predictive value 99%. Overall diagnostic accuracy was 99%.ConclusionIntegrated diagnosis of acute appendicitis based on clinical evaluation, laboratory tests and ultrasonography is safe and saves resources by preventing unnecessary operations.     

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections

OBJECTIVE: Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. DESIGN: Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140) SETTING: Two teaching tertiary care hospitals. PATIENTS: One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively. CONCLUSIONS: The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.     

超声对小儿肠套叠治疗方法选择的价值探讨

目的 探讨超声对小儿肠套叠治疗方法选择的预测价值。方法 对44例临床拟诊为肠套叠的患儿均先行超声检查，而后行空气灌肠检查或整复。结果 74例被确诊为肠套叠，70创被排除诊断。其中空气灌肠整复成功54例，不成功20例．后者行手术治疗；超声诊斯肠套叠的敏感性、特异性和准确性分别为97．3%．97．1％和97.2%。结论 超声可以正确选择小儿肠套叠的治疗方法．套入部内层肠壁厚度大于1cm，伴有肠腔液气平或腹腔积液者，应禁止空气灌肠，尽早手术复位。     

Necrotizing fasciitis: a dramatic surgical emergency.

OBJECTIVES: Necrotizing fasciitis is a challenging and potentially lethal disease; early diagnosis is of paramount importance and aggressive multidisciplinary treatment is mandatory. Overall mortality rates of 33-73% have been reported. The aim of this study was to report the experience with necrotizing fasciitis of an emergency surgery department. METHODS: From October 1995 to December 2001 we observed 11 cases of necrotizing fasciitis. The patients were five men and six women, with ages ranging from 33 to 80 years. RESULTS: Triggering aetiological factors were found in eight cases. In all patients a multidisciplinary approach was utilized. Every patient had a daily surgical debridement of the necrotic areas in the operating room. Polyantibiotic therapy was performed, and was changed according to culture results. After surgery, nine patients were submitted to hyperbaric oxygen therapy. Seven deaths (63.6%) were observed: two cases of pulmonary embolism and five cases of septic shock. Four patients survived; three had a complete recovery with progressive healing of the wounds, whereas one patient had severe impairment of the motility of the affected hand. The mean interval between the onset of symptoms and hospital admission was 5.4 days; for patients who ultimately died it was 7.3 days, whereas for patients who ultimately survived it was 2 days (P<0.05); moreover these patients were significantly younger than those who died (P<0.05). CONCLUSION: The treatment for necrotizing fasciitis is a combination of surgical debridement, appropriate antibiotics and optimal oxygenation of the infected tissues. However, the mortality for this disease is quite high, and is related to late diagnosis and advanced age. Necrotizing fasciitis must be considered a true dramatic surgical emergency.     

Group A Streptococcal Necrotizing Fasciitis in the Emergency Department

Background

Group A Streptococcal (GAS) necrotizing fasciitis is a critical emergency. Patients with necrotizing fasciitis principally present to emergency departments (EDs), but most studies are focused on hospitalized patients.

Objective

An ED patient-based retrospective study was conducted to investigate the clinical characteristics, associated factors, and outcomes of GAS necrotizing fasciitis in the ED.

Methods

Patients visiting the ED from January 2005 through December 2011 with the diagnosis of GAS necrotizing fasciitis were enrolled. All patients with the diagnosis of noninvasive skin and soft-tissue infections caused by GAS were included as the control group.

Results

During the study period, 75 patients with GAS necrotizing fasciitis were identified. Males accounted for 84% of patients. The most prevalent underlying disease was diabetes mellitus (45.3%). Bullae were recognized in 37.3% of patients. One third of cases were complicated by bacteremia. Polymicrobial infections were found in 30.7% of patients. Overall mortality rate for GAS necrotizing fasciitis was 16%. Patients aged >60 years with diabetes mellitus, liver cirrhosis, and gout were considerably more likely to have GAS necrotizing fasciitis than noninvasive infections. Patients presenting with bacteremia, shock, duration of symptoms/signs <5 days, low white blood cell count, low platelet count, and prolonged prothrombin time were associated with increased mortality. Surgery is a significantly negative factor for mortality of patients with GAS necrotizing fasciitis (odds ratio = 0.16; 95% confidence interval 0.002−0.16; p < 0.001).

Conclusions

A better understanding of the associated factors and initiation of adequate treatments will allow for improved survival after GAS necrotizing fasciitis.     

Selective Use of Ultrasonography for the Detection of Pneumoperitoneum

OBJECTIVE: Whether ultrasonography is superior to plain radiography for the detection of pneumoperitoneum is unknown. The goal of this study was to determine the value of ultrasonography for the detection of pneumoperitoneum. METHODS: One hundred thirty-two patients with suspected hollow-organ perforation were prospectively selected for study. All 132 patients received ultrasonography, upright chest radiography, and left lateral decubitus abdominal radiography examinations. The diagnostic accuracies of chest and abdominal radiographs for the detection of pneumoperitoneum were compared with corresponding values from ultrasonography. RESULTS: Of the 125 patients who underwent laparotomy, 121 patients had hollow-organ perforation, three patients had perforated appendicitis, and one patient had acute cholecystitis. For the diagnosis of pneumoperitoneum, ultrasonography demonstrated a sensitivity of 93%, a specificity of 64%, a positive predictive value of 97%, a negative predictive value of 44%, and an accuracy of 90%. Plain radiography revealed a sensitivity of 79%, a specificity of 64%, a positive predictive value of 96%, a negative predictive value of 21%, and an accuracy of 77%. CONCLUSIONS: Ultrasonography is a more sensitive diagnosing modality than plain radiography for the diagnosis of pneumoperitoneum. The authors suggest that ultrasonography was a useful diagnostic modality when plain radiographs failed to reveal pneumoperitoneum among patients with suspected hollow-organ perforation.     

The value of ultrasonography in the detection of meniscal tears diagnosed by magnetic resonance imaging

OBJECTIVE: To evaluate the diagnostic value of ultrasonography in meniscal tears that were diagnosed by magnetic resonance imaging (MRI). DESIGN: Twenty-seven knees with meniscal tears and 14 knees without tears on MRI were prospectively evaluated. A radiologist performed the ultrasonography and evaluated the presence and locations of the meniscal tears. MRI was used as the reference standard. RESULTS: Twenty-nine menisci with tears and 53 menisci without tears were identified by MRI. Twenty-two tears were in the medial menisci, and seven tears were in the lateral menisci. In the 29 meniscal tears, the ultrasonographic diagnosis was correct in 25 (86.2%) and incorrect in 4 (13.8%) menisci. In the 53 menisci without tears, the ultrasonographic diagnosis was correct in 45 (84.9%) and incorrect in 8 (15.1%) menisci. Ultrasonography showed a sensitivity, specificity, accuracy, and positive and negative predictive values for meniscal tears of 86.2%, 84.9%, 85.4%, 75.8%, and 91.8%, respectively. Of the four intracapsular injuries observed by MRI in injured knees, an osteochondritis dessecans was only observed by ultrasonography. CONCLUSIONS: Ultrasonography is an accurate imaging study for diagnosing meniscal tears. The results correlated with those obtained by MRI; this suggests that ultrasonography can be a useful imaging modality in uninjured knees.     

超声对老年膀胱癌诊断价值的探讨

目的评价超声检查对老年膀胱癌的诊断价值。方法对临床疑似膀胱癌的40例患者首先应用超声进行检查,阳性患者再进行膀胱镜检查,检查结果与术后病理结果再进行对照分析。结果超声诊断膀胱癌的符合率为92.50%(37/40)。结论超声对老年膀胱癌在检查发现和明确诊断方面具有重要价值。     

Necrotizing fasciitis: a challenging diagnosis.

The objective of the study was to evaluate our recent experience in diagnosis and management of necrotizing fasciitis. Records of patients who were diagnosed as having necrotizing fasciitis at Al-Ain Hospital in the period between March 2003 and August 2005 were studied retrospectively with regard to clinical features, risk factors, diagnosis, causative organisms, treatment, and outcome. Eleven patients, eight of whom were men of low socio-economic status, were studied. The median age (range) was 46 (8-65) years. The main risk factor was diabetes mellitus in seven patients (64%). The provisional clinical diagnosis was incorrect in seven patients (64%). Pure beta-hemolytic streptococcus group A or B was the causative organism in five patients (46%). Most of our patients underwent multiple surgical debridements with a median range of two (1-11) operations. Two patients died (overall mortality rate 18%). High clinical suspicion is essential for the diagnosis of necrotizing fasciitis. Accurate early diagnosis, aggressive resuscitation, using proper antibiotics, and extensive surgical debridement are essential for a favorable outcome.     

Role of Doppler Ultrasonography in the Triage of Acute Scrotum in the Emergency Department

Objective. The purpose of this study was to examine the triage role of scrotal Doppler ultrasonography (DUS) as the primary preoperative diagnostic tool in patients presenting to the emergency department (ED) with acute scrotum. Methods. Patients who presented to the ED with acute scrotum and underwent scrotal DUS in the ultrasound unit over a 3‐year period (2004–2007) were included in the study. Patient characteristics, DUS findings, and clinical management were retrospectively collected and reviewed. Doppler ultrasonographic diagnoses were compared with histopathologic findings for patients who underwent exploration and with final diagnoses at the time of discharge for patients undergoing medical treatment. Results. A total of 620 consecutive patients with 669 DUS examinations were included. The most common scrotal DUS diagnoses were epididymitis, hydrocele, varicocele, and orchitis. Scrotal trauma was present in 77 cases. Hospitalization followed the initial ED evaluation for 155 patients; 68 underwent surgery. Testicular torsion was ultrasonographically suspected in 20 patients and confirmed in 18. Scrotal malignancy was incidentally diagnosed in 13 patients and testicular hematoma in 8. Doppler ultrasonography for the diagnosis of testicular torsion had 94% sensitivity, 96% specificity, 95.5% accuracy, an 89.4% positive predictive value (PPV), and a 98% negative predictive value (NPV). Doppler ultrasonography for the diagnosis of testicular malignancy had 92% sensitivity, 95% specificity, 94% accuracy, a 78.5% PPV, and a 98% NPV. Conclusions. Scrotal DUS is a highly sensitive preoperative diagnostic tool, thereby validating its routine use in the initial triage of patients with acute scrotum presenting to the ED.     

急诊B超对腹腔实质性脏器损伤的诊断评价

目的　评价急诊B超检查对腹腔实质性脏器损伤的诊断价值。方法　对 82例腹腔实质性脏器损伤的急诊B超检查结果与最后诊断结果进行对照分析。结果　腹腔实质性脏器损伤急诊B超检查的敏感性 93.9%、特异性 97.0 %、假阳性率 3.0 %、假阴性率 6.1%、阳性预测值 97.9%、阴性预测值 91.4%、阳性似然比 30 .98、阴性似然比 0 .0 63、诊断准确率 95 .1%、尤登指数 0 .90 9和卡帕值为 0 .90。结论　B超检查对腹部实质性脏器损伤的诊断具有较高的准确性和可靠性 ,它是腹腔实质性脏器损伤检查诊断的一种首选、简便及有效的方法     

小儿肠套叠超声与X线平片诊断的对比研究

目的:探讨超声与X线平片在诊断小儿肠套叠中的价值.方法:总结分析行超声及X线平片检查并经手术或X线下空气灌肠确诊的肠套叠患儿63例,以及均行超声及X线检查其他原因的腹痛患儿40例,分析其超声及X线报告结果.结果:63例肠套叠中,B超确诊肠套叠61例,X线平片确诊小儿肠套叠38例,超声灵敏度、特异度均较高.结论:小儿肠套叠应首选B超检查.     

Accuracy of ED sonography in the diagnosis of acute appendicitis

The objective was to compare the accuracy of abdominal sonography performed by emergency physicians in the diagnosis of acute appendicitis with that of the surgeons' clinical impression. Three hundred-seventeen patients with right lower abdominal pain admitted to the Department of Emergency Medicine at National Taiwan University Hospital in Taipei, Taiwan were prospectively included in this study. Patients were divided into two groups according to the time of day they visited the emergency department. Those patients visiting the emergency department during the day were included in group I and those during the night were in group II. Group I was diagnosed by sonography. Group II was diagnosed by surgeons' clinical impression without sonographic examination. The definitive diagnosis of acute appendicitis was confirmed by the pathological reports. In the diagnosis of acute appendicitis, group I had a sensitivity of 96.4%, a specificity of 67.6%, a positive predictive value of 89.8%, a negative predictive value of 86.2%, and an accuracy of 89.1%, and group II had a sensitivity of 86.2%, a specificity of 37.0%, a positive predictive value of 74.6%, a negative predictive value of 55.6%, and an accuracy of 70.6%. The overall accuracy of sonography performed by emergency physicians in the diagnosis of acute appendicitis was superior to that of the surgeons' clinical impression.     

高低频超声在腹部创伤诊断中的应用价值

目的:为提高超声对腹部创伤的诊断价值.方法:对92例腹部创伤患者进行超声检查,根据探头频率不同,分3组记录检查结果.结果:高频组准确率与低频组相近(P＞0.05),高、低频联合检查组确诊率高于低频组(P＜0.05).结论:高频彩超能直观显示腹内脏器损伤,与低频超声相结合,有助于腹部创伤的诊断.     

Ultrasound-guided mammotome vacuum biopsy for the diagnosis of impalpable breast lesions.

OBJECTIVES: To assess the diagnostic accuracy of ultrasound-guided mammotome vacuum biopsy in impalpable breast lesions. METHODS: Seventy-three patients who presented with impalpable breast lesions that were suspicious for malignancy at mammography and/or sonography were included in the study. In the first instance the women underwent ultrasound-guided fine-needle aspiration cytology, then, 3 days later, histological biopsy with an ultrasound-guided mammotome device. The patients with both cytological and histological diagnoses of malignancy underwent surgery; those with a negative (for malignancy) cytological diagnosis, but with a histological diagnosis of atypical hyperplasia or sclerosing adenosis, underwent surgical biopsy. RESULTS: The diagnostic accuracy of fine-needle aspiration cytology was 67.2%; the sensitivity was 86.7%, the specificity was 48.4%, the negative predictive value was 78.9% and the positive predictive value was 61.9%. In comparison, the diagnostic accuracy of histological sampling by mammotome vacuum biopsy was 97.3%; the sensitivity was 94.7%, the specificity was 100%, the negative predictive value was 94.6% and the positive predictive value was 100%. Thus there was a statistically significant difference in diagnostic accuracy between fine-needle aspiration cytology and mammotome vacuum biopsy (67.2% vs. 97.3%; chi2 test, P < 0.001). The 2.7% (2/73) failure rate of mammotome biopsy was likely to be due to an error in the positioning of the needle. The subsequent surgical biopsy proved that two cases, negative for malignancy by mammotome biopsy, were in fact malignant. CONCLUSIONS: Our data confirm the value of sonography for the diagnosis of breast carcinoma in the preclinical phase and the efficacy of ultrasound sampling using a mammotome device to confirm the diagnosis in impalpable breast lesions.     

经胸超声诊断纵隔淋巴瘤的临床价值

目的 探讨常规经胸超声检查在纵隔淋巴瘤诊断中的应用价值。方法 回顾性分析临床确诊的纵隔淋巴瘤患者超声图像特征,观察病灶位置、内部回声特点及周围淋巴结情况,统计分析超声诊断纵隔淋巴瘤的真实性和一致性。结果 55例纵隔淋巴瘤患者,平均年龄27.5岁。大部分纵隔淋巴瘤的声像图表现为前上纵隔实性包块,包块内部可见结节状低回声和/或网状稍强回声,肿块周围或全身其他部位可见淋巴结肿大。根据超声声像图特征诊断纵隔淋巴瘤的灵敏度为85.45(%),特异度为85.45(%),约登指数为0.79,不同医生间诊断的一致率为80.61%,Kappa值为0.612。     

Diagnosis of necrotizing fasciitis in children.

Necrotizing fasciitis is a rare but progressive soft tissue infection. This condition is difficult to recognize in the early phase, when it is often confused with cellulitis. We report the cases of four children with necrotizing fasciitis. The initial presentation in these cases was cellulitis. Fever and soft tissue swelling occurred within 24 h and spreading erythema within 4 to 12 h. Radiologic studies of the lesions showed soft tissue thickening. Ultrasonography of the lesions demonstrated distorted, thickened fascia with fluid accumulation. Well-defined, loculated abscesses were demonstrated in two cases. Although typical dusky skin and purplish patches were not found in our cases, necrotizing fasciitis was strongly suspected on the basis of the clinical course and sonographic findings. Ultrasonography also was used as a guide for aspiration of pus. Gram-stained smears and bacterial cultures yielded the pathogens. The choice of antibiotic therapy was made on the results of smears and culture. All patients survived after immediate surgical debridement, intensive antibiotic therapy, and aggressive wound care. In conclusion, ultrasonography provides a rapid and valuable diagnostic modality for necrotizing fasciitis. The pus obtained through sonographically guided aspiration for bacterial culture can allow identification of the pathogenic organisms.     

Predictors of mortality in patients with necrotizing fasciitis

Background

Necrotizing fasciitis is an uncommon and life-threatening soft tissue infection with high mortality. Though early aggressive surgical intervention is important for improving survival, the impact of mortality from different microorganisms remains uncertain. Our study aims to identify the association of mortality and different microorganisms, and the positive and negative predictors of mortality in patients with necrotizing fasciitis.

Methods

This retrospective cohort study enrolled patients admitted via the emergency department (ED) with discharged diagnosis of necrotizing fasciitis (International Classification of Diseases, Ninth Revision, code 72886). Multivariate logistic regression analysis was used to identify microbiological, clinical, and biochemical variables independently associated with the mortality of necrotizing fasciitis.

Results

Multivariate logistic regression analysis showed that Vibrio infection, Aeromonas infection, hypotension, malignancy, and band form 10% or greater were significantly associated with increase of mortality (P < .05). They were considered as positive predictors of mortality. The presence of hemorrhagic bullae, however, was significantly associated with decrease of mortality (P < .05). It was considered as negative predictor of mortality.

Conclusion

Aeromonas infection, Vibrio infection, cancer, hypotension, and band form white blood cell count greater than 10% are independent positive predictors of mortality in patients with necrotizing fasciitis. Streptococcal and staphylococcal infections, in contrast, are not predictors of mortality. The presence of hemorrhagic bullae is an independent negative predictor of mortality. Further study should focus on the accuracy of these factors.     

半月板损伤超声诊断价值的探讨

目的探讨超声检查对膝关节半月板损伤的诊断价值。方法对31例33个膝关节66个半月板术前超声检查结果与关节镜及手术结果进行对照分析。结果超声诊断半月板损伤准确性92.4%,敏感性94.1%,特异性90.6%,阳性预测值91.4%,阴性预测值93.5%,内侧半月板损伤准确性87.9%,外侧半月板损伤准确性97.0%。超声对损伤定位准确性为85.3%,对损伤类型判断的准确性为76.5%。以半月板体部最窄处宽度>15mm为标准判断盘状半月板,准确性88.9%。结论超声检查无创、方便,诊断半月板损伤准确性较高,可作为诊断半月板损伤的一种重要的辅助检查方法。