Necrotizing fasciitis caused by perforated appendicitis: a case report

Acute appendicitis is one of the most common causes of acute abdominal pain. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in diagnosis or treatment may result in increased risks of complications, such as perforation, which is associated with increased morbidity and mortality rates. Necrotizing fasciitis caused by perforated appendicitis is extremely rare. We herein report a case of 50-year-old man presenting with an appendiceal abscess in local hospital. After ten days of conservative treatment with intravenous antibiotics, the patient complained about pain and swelling of the right lower limb and computed tomography (CT) demonstrated a perforated appendix and gas and fluid collection extending from his retroperitoneal cavity to the subcutaneous layer of his right loin and right lower limb. He was transferred to our hospital and was diagnosed with necrotizing fasciitis caused by perforated appendicitis. Emergency surgery including surgical debridement and appendectomy was performed. However, the patient died of severe sepsis and multiple organ failure two days after the operation. This case represents an unusual complication of a common disease and we should bear in mind that retroperitoneal inflammation and/or abscesses may cause necrotizing fasciitis through lumbar triangles.     

Emergence of multidrug resistant infection in patients with severe acute pancreatitis

Background/objectivesInfection is the most important risk factor contributing to death in severe acute pancreatitis. Multidrug resistant (MDR) bacterial infections are an emerging problem in severe acute pancreatitis.MethodsFrom January 2009 to December 2011 the medical records of 46 patients with infected severe acute pancreatitis were reviewed retrospectively to identify risk factors for the development of MDR bacterial infection and assess the related outcomes.ResultsThe mean age of the 46 patients was 55 years; 38 were males. Thirty-six patients (78.3%) had necrotizing pancreatitis and all of enrolled 46 patients had suspected or proven pancreatic infection. MDR microorganisms was found in 29 (63%) of the 46 patients. A total of 51 episodes of MDR infection were collected from 11 cases of infected pancreatic pseudocysts, 36 cases of infected necrosis/infected walled-off necrosis and 4 cases of bacteremia. The most frequent MDR bacteria was methicillin-resistant Staphylococcus aureus (n = 15). Transferred patients had a higher incidence of MDR infections than primarily admitted patients (72% vs. 35%, P = .015). The mean intensive care unit stay was significantly longer in patients with MDR bacterial infections (20 vs. 2 days, P = .001). Mortality was not significantly different in the patients with MDR infections vs. those without it (14% vs. 6%, P = .411).ConclusionsClinicians should be aware of the high incidence of MDR bacterial infections in patients with severe acute pancreatitis, especially referred patients. Empiric therapy directed at these pathogens may be used in patients where severe sepsis persists, until definitive culture results are obtained.     

抵抗素样分子-α在急性胰腺炎继发急性肺损伤中的表达和作用

背景:抵抗素样分子-α(RELM-α)是一个富含半胱氨酸的分泌蛋白,具有促进肺血管生成和收缩、抗细胞凋亡、诱导肺成纤维细胞分化和细胞外基质沉积的功能。然而,RELM-α在急性胰腺炎(AP)继发急性肺损伤中的作用尚未完全明确。目的:探讨RELM-α在AP继发急性肺损伤中的表达和作用。方法:45只Sprague-Dawley大鼠随机分为急性坏死性胰腺炎(ANP)组、急性水肿性胰腺炎(AEP)组和正常对照组,分别以3.5%牛磺胆酸钠和20%L-精氨酸建立ANP和AEP模型。光学显微镜下观察肺组织病理学表现;测定肺湿/干重系数、支气管肺泡灌洗液炎性细胞数量以及血清CRP、淀粉酶水平;蛋白质印迹法和免疫组化法检测肺组织RELM-α的表达和定位。结果:ANP组肺组织病理学评分、肺湿/干重系数、支气管肺泡灌洗液炎性细胞数量、血清CRP和淀粉酶水平、肺组织RELM-α表达水平均较AEP组和正常对照组显著升高(P0.05)。Spearman等级相关系数分析显示,肺组织RELM-α表达水平与肺组织病理学评分、肺湿/干重系数、支气管肺泡灌洗液炎性细胞数量呈正相关(P0.01)。线性回归模型分析显示,肺组织RELM-α表达水平与血清CRP、淀粉酶水平呈正相关(P0.05)。结论:RELM-α在AP急性肺损伤的肺组织中表达增高,其作为促炎细胞因子,参与激活炎性细胞,介导急性肺损伤发生,可作为监测AP预后的生物学标记物。     

Necrotizing soft tissue infection of the upper extremities in patients with diabetes mellitus in a tertiary care center-a retrospective study

BackgroundNecrotizing soft tissue infection (NSTI) of the upper extremities is a rare, but potentially life-threatening infection in patients with type 2 diabetes mellitus (T2DM). We analyzed the clinical characteristics and the outcome of NSTI of upper extremities in these patients.MethodsThis was a retrospective study analyzing the clinical characteristics and the outcomes of 33 T2DM patients with NSTI of upper extremities, who were treated in the department of hand surgery between January 2011 and December 2017.ResultsPredisposing factors for NSTI were recognized in 16 (48.5%) patients. Eleven (33.3)% patients had septic shock while ten (30.3%) had acute renal insufficiency at the time of presentation, of which six required dialysis. The mean glycosylated hemoglobin was 9.6(±2.6)% and the random plasma glucose at admission was 271(±96) mg/dl. Monomicrobial infection was seen in 16(49%) patients and polymicrobial infection in 9(27%) patients. Gram-positive causation was found in 25(66%) patients. Twelve (36.4%) patients required amputation, six (18.2%) of which were major. Death occurred in more than one-fifth (21.2%) of the patients during treatment.ConclusionNecrotizing soft tissue infection of the upper extremities in T2DM is associated with increased risk of severe infection, amputation and mortality.     

Inflammatory signals that regulate intestinal epithelial renewal,differentiation, migration and cell death: Implications for necrotizing enterocolitis

Necrotizing enterocolitis is a disease entity with multiple proposed pathways of pathogenesis. Various combinations of these risk factors, perhaps based on genetic predisposition, possibly lead to the mucosal and epithelial injury that is the hallmark of NEC. Intestinal epithelial integrity is controlled by a tightly regulated balance between proliferation and differentiation of epithelium from intestinal epithelial stem cells and cellular loss by apoptosis. various signaling pathways play a key role in creating and maintaining this balance. The aim of this review article is to outline intestinal epithelial barrier development and structure and the impact of these inflammatory signaling and regulatory pathways as they pertain to the pathogenesis of NEC.     

NEC诱导的SIRS模型大鼠肠道中组织因子mRNA表达水平的变化

目的研究SIRS模型肠组织中TFmRNA的表达,探讨TF在SIRS发生中的作用。方法40只新生Wistar大鼠,出生36h～48h,随机分成正常对照组（A组）10只及模型组（B组）30只。48小时后处死动物,根据血液白细胞总数及呼吸改变确定为SIRS。将B组分为未发生SIRS组（B1组）和发生SIRS组（B2组）。实时荧光定量聚合酶链反应（QRT—PCR）检测肠组织TFmRNA的表达。结果肠组织Ⅱ1瑚RNA表达水平（2-△△Ct值）：A组1．01±0．04,B1组2．14±0．19,B2组3．78±1．2,三组间比较差异有显著性（P〈0．05）。结论从转录水平证实,SIRS新生大鼠模型中,TF水平增加．提示TF参与炎症反应。     

Breastfeeding: An overview of oral and general health benefits

Background

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Breastfeeding is the reference against which alternative infant feeding models must be measured with regard to growth, development and other health outcomes. Although not a systematic review, this report provides an update for dental professionals, including an overview of general and oral health–related benefits associated with breastfeeding.Types of Studies ReviewedThe authors examined the literature regarding general health protections that breastfeeding confers to infants and mothers and explored associations between breastfeeding, occlusion in the primary dentition and early childhood caries. To accomplish these goals, they reviewed systematic reviews when available and supplemented them with comparative studies and with statements and reports from major nongovernmental and governmental organizations.ResultsWhen compared with health outcomes among formula-fed children, the health advantages associated with breastfeeding include a lower risk of acute otitis media, gastroenteritis and diarrhea, severe lower respiratory infections, asthma, sudden infant death syndrome, obesity and other childhood diseases and conditions. Evidence also suggests that breastfed children may develop a more favorable occlusion in the primary dentition. The results of a systematic review in which researchers examined the relationship between breastfeeding and early childhood caries were inconclusive.Conclusions and Clinical ImplicationsThe American Academy of Pediatric Dentistry, Chicago, suggests that parents gently clean infants' gums and teeth after breastfeeding. The American Academy of Pediatrics, Elk Grove Village, Ill., recommends that breastfeeding should be exclusive for about the first six months of life and should continue, with the introduction of appropriate complementary foods, to at least age 12 months or beyond, as desired by mother and child. Dentists and staff members can take steps to ensure they are familiar with the evidence and guidelines pertaining to breastfeeding and to oral health. They are encouraged to follow the surgeon general's recommendations to promote and support optimal breastfeeding and oral health practices among their patients.     

Mucosal loss with increased expression of IL-6, IL-8, and COX-2 in a formula-feeding only neonatal rat model of necrotizing enterocolitis

Introduction

The aim of our study is to establish a reliable neonatal rat model by formula feeding only for evaluation of early surgical intervention on the course of experimental necrotizing enterocolitis (NEC).

Material and methods

Newborn Sprague–Dawley rats were divided into 50 breast-fed (group 1) and 38 formula fed (Similac/Esbilac, group 2) animals. The pups were sacrificed on the 4th, 5th, and 6th day of life and the terminal intestine examined for macroscopic and histologic changes as well as cytokine expression.

Results

The histological mucosal damage was significantly higher of group 2 compared to group 1. The area of the vital mucosa of group 2 was significantly (58.57%, p < 0.001) lower compared to group 1 (75.12%). The mRNA expression of the inflammatory cytokines IL-6, IL-8 and COX-2 was significantly 2-, 5- and 10-fold increased in group 2 compared to group 1.

Discussion

Formula fed newborn rats displayed an inflammatory enterocolitis similar to human NEC. Our study demonstrates a significant loss of mucosa in animals with NEC having increased expression levels of IL-6, IL-8 and COX-2. Mucosal loss appears to be a distinct feature of experimental NEC and has to be correlated with the human disease.