Prognostic Role of Subsequent Thrombocytopenia in Necrotizing Fasciitis Without Liver Disease.

BACKGROUND: Necrotizing fasciitis (NF) is a life-threatening disease with a fulminant presentation. Although early diagnosis can be aided by combining physical examination, the Laboratory Risk Indicator for Necrotizing Fasciitis score, and computed tomography, a mortality rate of 30% is still reported. In the modern times, an economical and efficient biomarker for predicting mortality in NF patients is still lacking. Platelet count is typically measured in routine blood tests and aids in predicting disease severity. We aimed to clarify the role of platelet count as a predictive factor for aspects of prognosis, such as mortality and surgical outcomes, in patients with NF. METHODS: We identified 285 patients with NF between 2018 and 2020 in a single medical center in southern Taiwan. Medical records were collected for the evaluation of patients with thrombocytopenia. Univariate and multivariate analyses were performed for different outcomes. RESULTS: We included 115 patients with confirmed diagnoses of NF. Twelve patients died with a mortality rate of 10.4%. Patients with thrombocytopenia exhibited a higher mortality rate (20.9% vs 4.2%, P = 0.006), more shock episodes (51.2% vs 11.1%, P < 0.001), higher intensive care unit admission rate (46.5% vs 13.9%, P < 0.001), and longer hospital length of stay (37.49 ± 24.12 days vs 28.82 ± 14.63 days, P = 0.037) than those without thrombocytopenia. All patients infected with Vibrio species exhibited thrombocytopenia. In multivariate analysis, independent risk factors for mortality were thrombocytopenia (odds ratio, 4.57; 95% confidence interval, 1.08-19.25) and single gram-negative bacterial culture from the wound (odds ratio 6.88; 95% confidence interval, 1.58-29.96). CONCLUSIONS: In patients with NF and subsequent thrombocytopenia, a higher mortality rate, greater numbers of shock episodes, higher demand for intensive care unit, and longer hospital length of stay were observed than in those without thrombocytopenia. In patients with NF, platelet count is a valuable and economic indicator of prognosis. Once thrombocytopenia developed in patients with necrotizing fasciitis, aggressive antibiotic treatment and surgical management are required to improve the chances of recovery.

Bisphosphonate-Related Osteonecrosis of the Jaw.

OBJECTIVES: Antiresorptive agents for bone pain were widely used to treat patients with advanced osteoporosis, multiple myeloma, and bone metastatic cancer. In recent years, however, bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been a rare but major complication of this therapy. Most patients with BRONJ undergo dental procedures during treatment with antiresorptive agents. However, BRONJ may also occur spontaneously. This study reports 13 BRONJ patient cases at Kaohsiung Veterans General Hospital, Taiwan, and their related treatments. We also compare patients with cancer with patients with osteoporosis in treatment outcomes. METHODS: Thirteen symptomatic patients with BRONJ were reviewed between 1985 and 2018 at Kaohsiung Veterans General Hospital. We included patients at advanced stage who were hospitalized for infection control of osteonecrosis of the jaw and excluded asymptomatic patients at stage 0 and stage 1. Four multiple myeloma, 3 patients with bone metastatic breast cancer and 6 patients with advanced osteoporosis (average ages, 63.57 ± 14.54 years in cancer patients and 79.5 ± 9.31 years in osteoporosis patients; average drug durations, 25.86 ± 27.23 months in cancer patients and 58.33 ± 23.87 months in osteoporosis patients; average follow-up times, 22.71 ± 14.46 months in cancer patients and 28.08 ± 36.35 months in osteoporosis patients) were included. RESULTS: Seven patients were defined as having stage 3 (53.8%) and 6 as having stage 2 (46.2%) medication-related osteonecrosis of the jaw, according to the American Association of Oral and Maxillofacial Surgeons classification. The complete response rate with totally healed mucosa was 61.5%. Four cancer patients received free fibular flap (FFF) reconstruction with a high complete response rate (100%). All of them had a relatively better performance status, and the average age was also younger than osteoporosis patients. CONCLUSION: Free fibular flap with a high complete response rate may improve pain relief and infection control for patients with BRONJ. Younger age is seemed to be a great indicator for FFF, but poor self-care ability (Eastern Cooperative Oncology Group status >3) is not suitable for these surgical treatments.

Haematogenous Klebsiella pneumoniae osteomyelitis.

OBJECTIVES: Klebsiella pneumoniae infection has been associated with alcoholic and diabetic patient populations, especially in Asian populations. K. pneumonia wound infection is common, but K. pneumonia without wound osteomyelitis (OM) is relatively rare. However, the pathogenesis of haematogenous K. pneumonia without open wound OM still unclear until now. In our research, we are trying to collect patients with haematogenous K. pneumonia osteomyelitis (K.p OM) at our hospital and to evaluate their contributing factors. METHODS: We compiled a retrospective database of haematogenous K. pneumonia osteomyelitis (K.p OM) from 1990 to 2019 at our hospital. Patients' bone cultures without K. pneumonia infection were excluded. Sixteen patients with haematogenous K.p OM were recruited. Patients' basic information, comorbidities, wound history, the biochemical examination of the blood, bacterial blood, bone, urine, and liver abscess cultures, the location of OM, corresponding treatments, and post operation K.p wound infection history were reviewed retrospectively. The collected data were analyzed using SPSS software. RESULTS: Unwounded haematogenous K.p OM had a statistically significant and positive correlation with liver insufficiency (P = .037; OR = 2.200), advanced age (≥ 65 years) (P = .037; OR = 2.200) and male gender (P = .03; OR = 1.833). DM, hypertension, steroid usage, GI or GU tract K.p infection, post operation K.p wound infection, hypoalbuminemia, and the location of K.p OM had no significant relationship to outcomes. CONCLUSION: Male patients of advanced age (> 65 years) and patients with liver insufficiency, including liver cirrhosis and hepatitis, have a strong correlation with unwounded haematogenous K.p OM.

Clinical Importance and Risk Factors for Postoperative Late-Onset Pneumonia After Major Oral Cancer Surgery With Microvascular Reconstruction.

BACKGROUND: Pulmonary complications are common among patients who have undergone major oral cancer surgery with microvascular reconstruction. Current literatures focused on early-onset pneumonia in the postoperative acute stage. In contrast, we are aiming to identify the clinical importance and the risk factors associated with late-onset pneumonia in oral cancer patients after acute stage. METHODS: In total, 195 patients were included from May 2014 to December 2016 and followed up for up to 1 year after surgery. Their medical histories were reviewed to identify the risk factors of late-onset pneumonia and outcome. Primary outcome was late-onset pneumonia. Other outcome measures included early-onset pneumonia, tumor recurrence, and death within 1 year after surgery. RESULTS: Patients with late-onset pneumonia have demonstrated a significantly higher rate of tumor recurrence (P < 0.001) and death within 1 year (P < 0.001). Independent risk factors of late-onset pneumonia identified were age (P = 0.031), previous radiotherapy (P = 0.017), postoperative radiotherapy (P = 0.002), flap size (P = 0.001), flap type other than osteocutaneous fibula flap (P = 0.009), and tumor recurrence (P < 0.001). CONCLUSIONS: Late-onset pneumonia can act as a warning sign for oral cancer patients who have received microsurgical reconstruction, for its high correlation with tumor recurrence and mortality rate.

Comparison between anterolateral thigh, radial forearm, and peroneal artery flap donor site thickness in Asian patients-A sonographic study.

PURPOSE: This study aimed to determine the thicknesses of the three locations used as donor sites for radial forearm (RF), anterolateral thigh (ALT), and peroneal flaps and to determine probable contributing factors of the thickness. METHODS: This study included 201 healthy participants (mean age: 45.8 ± 17.2 years; male: 114; female: 87; BMI: 24.3 ± 4.3). Sonography was used to measure the thickness of flap donor sites. Forward stepwise regressions were conducted to determine the contributing factors of flap thickness. RESULTS: The RF flap (0.28 ± 0.08 cm) was thinner than peroneal flap (0.47 ± 0.17 cm) (P < 0.0001), and peroneal flap was thinner than ALT flap (0.98 ± 0.4 cm) (P < 0.0001). Flap type (P < 0.001, 95%CI: 0.33-0.41), BMI (P < 0.001, 95%CI: 0.02-0.033), gender (P < 0.001, 95%CI: -0.3 to -0.17), and age (P = 0.002, 95%CI: -0.005 to -0.001) were the contributing factors of flap thickness. In the subgroup analysis, BMI was the only contributing factor of RF flap thickness (P < 0.001). For ALT and peroneal flaps, age, gender, and BMI were the contributing factors (P < 0.001). The coefficient of BMI was 0.005 in RF flap, 0.01 in peroneal flap, and 0.04 in ALT flap. CONCLUSIONS: The RF flap was found thinner than peroneal flap, and peroneal flap was found thinner than ALT flap. The BMI effects on RF and peroneal flaps were much less than that on ALT flap. Therefore, the RF and peroneal flaps would be the better choice in obese patients with soft tissue defects where a thin flap is needed.

High risk of rhabdomyolysis and acute kidney injury after traumatic limb compartment syndrome.

PURPOSE: Rhabdomyolysis often occurs after traumatic compartment syndrome, and high morbidity and mortality have been reported with the acute kidney injury that develops subsequently. We focused on the risk factors for rhabdomyolysis and acute kidney injury in patients with traumatic compartment syndrome. We also analyzed the relation between renal function and rhabdomyolysis in these patients. MATERIALS AND METHODS: A retrospective chart review was conducted from January 2006 to March 2012. Inpatients with traumatic compartment syndrome were included. We evaluated patients' demographics, history of illicit drugs use or alcohol consumption, mechanism of injury, symptoms, serum creatine kinase levels, and kidney function. RESULTS: A total of 52 patients with a mean age of 40.9 years were included; 23 patients had rhabdomyolysis (44.2%), of which 9 patients developed acute kidney injury (39.1%). Significant predictive factors for rhabdomyolysis were history of illicit drugs or alcohol use (P=0.039; odds ratio, 5.91) and ischemic injury (P=0.005). We found a moderate correlation between serum creatine kinase levels and serum creatinine levels (R=0.57; P<0.0001). The correlation coefficient (R) between serum creatine kinase levels and the estimated creatinine clearance rate was -0.45. Rhabdomyolysis was a predisposing factor for acute kidney injury (P=0.011; odds ratio, 8.68). Four patients with rhabdomyolysis required a short period of renal replacement therapy. CONCLUSION: A high percentage of patients with traumatic compartment syndrome developed rhabdomyolysis (44.2%). Patients with rhabdomyolysis had a higher possibility of developing acute kidney injury (39.1%), and rhabdomyolysis was correlated to renal function. Early diagnosis, frequent monitoring, and aggressive treatment are suggested once compartment syndrome is suspected. The overall prognosis is good with early diagnosis and proper treatment.

Development of seven secondary neoplasms in a nevus sebaceous: a case report and literature review.

Nevus sebaceous of Jadassohn is a congenital cutaneous hamartoma with epidermal, sebaceous, follicular, and apocrine structures that usually appears at birth or in early childhood. It has the potential to generate a variety of secondary neoplasms of different lineages, and the risk increases with patient age. Although multiple neoplasms may occasionally arise within the same lesion, the coexistence of more than five secondary tumors is extremely rare. Here we report a case of seven secondary tumors including syringocystadenoma papilliferum, desmoplastic trichilemmoma, sebaceoma, trichoblastoma, pigmented trichoblastoma, sebaceous adenoma, and tumor of follicular infundibulum arising within a nevus sebaceous. The complete diagnosis relies on the histopathological analysis of multipoint biopsies and delicate pathological sections.