Association between tissue loss type and amputation risk among Medicare patients with concomitant diabetes and peripheral arterial disease.

OBJECTIVE: Prior studies have described risk factors associated with amputation in patients with concomitant diabetes and peripheral arterial disease (DM/PAD). However, the association between the severity and extent of tissue loss type and amputation risk remains less well-described. We aimed to quantify the role of different tissue loss types in amputation risk among patients with DM/PAD, in the context of demographic, preventive, and socioeconomic factors. METHODS: Applying International Classification of Diseases (ICD)-9 and ICD-10 codes to Medicare claims data (2007-2019), we identified all patients with continuous fee-for-service Medicare coverage diagnosed with DM/PAD. Eight tissue loss categories were established using ICD-9 and ICD-10 diagnosis codes, ranging from lymphadenitis (least severe) to gangrene (most severe). We created a Cox proportional hazards model to quantify associations between tissue loss type and 1- and 5-year amputation risk, adjusting for age, race/ethnicity, sex, rurality, income, comorbidities, and preventive factors. Regional variation in DM/PAD rates and risk-adjusted amputation rates was examined at the hospital referral region level. RESULTS: We identified 12,257,174 patients with DM/PAD (48% male, 76% White, 10% prior myocardial infarction, 30% chronic kidney disease). Although 2.2 million patients (18%) had some form of tissue loss, 10.0 million patients (82%) did not. The 1-year crude amputation rate (major and minor) was 6.4% in patients with tissue loss, and 0.4% in patients without tissue loss. Among patients with tissue loss, the 1-year any amputation rate varied from 0.89% for patients with lymphadenitis to 26% for patients with gangrene. The 1-year amputation risk varied from two-fold for patients with lymphadenitis (adjusted hazard ratio, 1.96; 95% confidence interval, 1.43-2.69) to 29-fold for patients with gangrene (adjusted hazard ratio, 28.7; 95% confidence interval, 28.1-29.3), compared with patients without tissue loss. No other demographic variable including age, sex, race, or region incurred a hazard ratio for 1- or 5-year amputation risk higher than the least severe tissue loss category. Results were similar across minor and major amputation, and 1- and 5-year amputation outcomes. At a regional level, higher DM/PAD rates were inversely correlated with risk-adjusted 5-year amputation rates (R2 = 0.43). CONCLUSIONS: Among 12 million patients with DM/PAD, the most significant predictor of amputation was the presence and extent of tissue loss, with an association greater in effect size than any other factor studied. Tissue loss could be used in awareness campaigns as a simple marker of high-risk patients. Patients with any type of tissue loss require expedited wound care, revascularization as appropriate, and infection management to avoid amputation. Establishing systems of care to provide these interventions in regions with high amputation rates may prove beneficial for these populations.

Role of diverting colostomy and reconstruction in managing Fournier's gangrene-a narrative review.

OBJECTIVE: To examine the role of bowel diversion and reconstructive surgeries in managing Fournier's gangrene (FG) to facilitate multidisciplinary collaboration between urologists, colorectal and plastic surgery teams. METHODS: A review of the literature was conducted using the databases Medline, Embase, PubMed in June 2023. The review included studies that evaluated the outcomes of FG following reconstructive surgeries or diverting colostomies. RESULTS: The existing evidence suggests that bowel diversion and colostomy formation could reduce the need for further debridement, shorten the time to wound healing, and facilitate skin graft or flap uptake in patients with FG. Additionally, the psychological impact of a stoma was shown not to be a major concern for patients. However, stoma carries a risk of perioperative complications and therefore may prolong the length of hospital stay. In reviewing the evidence for reconstruction in FG, large and deep defects seem to benefit from skin grafts or flaps. Noticeably, burial of testicles in thigh pockets has grown out of favour due to concerns regarding the thermoregulation of the testicles and the psychological impact on patients. CONCLUSION: The use of bowel diversion and reconstructive surgeries in managing FG is case dependent. Therefore, it is important to have close discussions with colorectal and plastic surgery teams when managing FG.

Variables that predict hospital stay and the outcome of Fournier gangrene at King Abdulaziz University Hospital: a retrospective study.

BACKGROUND: The aggressive nature of Fournier gangrene and the associated health issues can result in a more complex clinical course and potentially a longer hospital stay. This study aimed to assess factors that affect the length of hospital stay (LHS) and its relation to the outcome of Fournier gangrene patients. METHODS: A retrospective study was performed at King Abdulaziz University Hospital (KAUH), Saudi Arabia, on patients diagnosed with Fournier gangrene between 2017 and 2023. Data about length of hospital stay (LHS), age, BMI, clinical and surgical data and outcome was obtained. RESULTS: The mean age of the studied patients was 59.23 ± 11.19 years, the mean body mass index (BMI) was 26.69 ± 7.99 kg/m2, and the mean duration of symptoms was 10.27 ± 9.16 days. The most common presenting symptoms were swelling or induration (64%), 88% had comorbidities with diabetes mellitus (DM) (84%), and 76% had uncontrolled DM. of patients, 24% had a poly-microbial infection, with E. coli being the most common (52%). The mean length of hospital stay (LHS) was 54.56 ± 54.57 days, and 24% of patients had an LHS of more than 50 days. Longer LHS (> 50 days) was associated with patients who did not receive a compatible initial antibiotic, whereas shorter LHS was associated with patients who received Impenem or a combination of vancomycin and meropenem as alternative antibiotics following incompatibility. Reconstruction patients had significantly longer LHS and a higher mean temperature. However, none of the studied variables were found to be predictors of long LHS in the multivariate regression analysis. CONCLUSION: Knowledge of the values that predict LHS allows for patient-centered treatment and may be useful in predicting more radical treatments or the need for additional treatment in high-risk patients. Future multicenter prospective studies with larger sample sizes are needed to assess the needed variables and predictors of long LHS.

Can the SIARI score be used at initial admission to predict testes involvement in patients with fournier's gangrene; a single-centre, retrospective study.

BACKGROUND: To predict testicular involvement in patients diagnosed with Fournier's gangrene (FG) using the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score and the site other than lower limb (SIARI) score. METHODS: The medical records of 51 patients operated for FG in our clinic between December 2012 and April 2022 were evaluated retrospectively in this study. Patients' demographics, and laboratory test results were compared with the testisticular involvement status. Patients with testisticular involvement (n = 10) were compared with patients without testicular involvement (n = 41). The SIARI score at initial admission was analysed using logistic regression analyses for its performance in predicting testicular involvement with FG. Receiver operating characteristics (ROC) curves and the area under the receiver operating characteristic curve (AUROC) were used to evaluate its discriminating ability. RESULTS: The SIARI score had modest performance for diagnosing testicular involvement in FG patients, with ROC analysis showing an AUROC value of 0.83 (p < 0.001). With a SIARI cut-off score of ≥ 3, the sensitivity was 90% and the specificity was 68%. For a SIARI cut-off score of ≥ 5, the sensitivity was 40% and the specificity was 97%. CONCLUSIONS: The ability of the SIARI score to discriminate FG with testicular involvement is modest. The SIARI score should be employed cautiously as a routine diagnostic tool for the prediction of testicular involvement in FG at the initial admission. More research is needed to develop a better understanding of the relationship between the SIARI score and testicular involvement in FG.

Autopsy of tetanus with foot gangrene as portal of entry.

Non-traumatic chronic skin lesions are the second most common cause of tetanus. Herein, we describe an 85-year-old woman who presented with a chronically infected skin lesion. She developed tetanus while in hospital and died of respiratory failure, after refusing mechanical ventilation. Routine immunization against tetanus began in Japan during 1968; hence many people born before 1968 are unvaccinated. Mortality due to tetanus is high and the proportion with protective antibodies is low in older adults. Therefore, we recommend tetanus vaccination for older persons in Japan who have chronic skin lesions and have never been vaccinated.

Reliability of superficial swab culture results compared with deep wound culture results in Fournier's gangrene: A retrospective study.

OBJECTIVES: To compare isolates from deep wound and superficial swab cultures to evaluate the detectability of pathogens by each culture in Fournier's gangrene; and evaluate the association between microorganisms isolated from deep wounds and those isolated from blood or urine. METHODS: Patients with Fournier's gangrene who underwent debridement between October 2006 and January 2023 were retrospectively reviewed. In addition to comparing the isolates from deep wound cultures at initial debridement with those from superficial swab, blood, and urine cultures, the relationship between the traits of the organisms from deep wounds and patient disease severity and prognosis was examined. RESULTS: Among 25 patients, deep wound and superficial swab cultures were obtained from 25 to 18 patients, respectively. The frequency of anaerobic isolates was significantly lower in the superficial cultures than in the deep wound cultures (31/76 versus 13/56, p = 0.034). Bacteria not isolated from deep wounds were isolated from superficial cultures in 55.6 % of the patients; the concordance rate between deep and superficial cultures was 27.8 % (5/18). The positive rates of blood and urine cultures were 20.8 % and 35.7 %, respectively; all isolates from the urine and blood cultures reflected the results of the deep wound culture. No significant association was observed between the severity or mortality and the type of causative bacteria. CONCLUSIONS: Superficial swab cultures cannot be substituted for deep wound cultures in Fournier's gangrene. Although the positivity rates for blood and urine cultures were not high, they were helpful in determining antibiotic de-escalation.

Case report of an abdominal wet gangrene caused by Acidaminococcus.

The Acidaminococcus genus is a part of the normal flora in gastrointestinal tract. It is a strictly anaerob Gram-negative coccus that is rarely pathogenic. We report the case of a 58-year-old man, who presented to surgery department A of the Charles Nicolle hospital, complaining of a wide inflammatory lesion in the anterior abdominal wall evolving for two weeks. Patient's anamnestic data included smoking, hypertension, and diabetes mellitus with poor compliance. The patient underwent flattening with excision of necrotic tissues and surgical drainage using a DELBET blade. Empirical antibiotic therapy with imipenem 1gx3/d, teicoplanin 400 mg 1 inj x2/d and gentamicin 400 mg 1 inj/d was administered pending bacteriological results. The bacteriological examination of a sample of necrotic tissue, after 72 h of incubation at 37 °C in anaerobic atmosphere, was able to detect a Gram-negative coccus, that the VITEK2 ANC system identified as Actinomyces canis with an accuracy of 80%. Whole genome sequencing was subsequently performed, that identified Acidaminococcus sp. AM33-14BH and demonstrated the following resistance genes: cfxa, tet(X) and tet(Q). An antibiogram for anaerobes was performed showing that the strain was resistant to amoxicillin but sensitive to amoxicillin-clavulanic acid, piperacillin-tazobactam, ertapenem, imipenem, meropenem and rifampin. Patient's condition improved after treatment with imipenem for 2 weeks, followed by oral amoxicillin-clavulanic acid for 16 days.This work highlights the role of molecular biology in the diagnosis of infections caused by anaerobes. Although the Vitek 2 ANC card provides rapid and acceptable identification of the most common anaerobic bacteria, improvements are needed for the identification of bacteria in the genera Acidaminococcus and Actinomyces.

Fournier's gangrene originating from the perianal region or the urogenital area: does it make a difference?

OBJECTIVE: Fournier's gangrene (FG) is a rare and serious disorder which is associated with high mortality. In the literature, there is no study evaluating clinician-, patient- and disease-related factors affecting disease outcomes according to aetiological variation in FG. In our study, laboratory results and Uludag Fournier's Gangrene Severity Index (UFGSI) score, clinical characteristics and mortality rates were compared between FG originating from perianal or from urogenital regions. METHOD: Platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and UFGSI risk scores were calculated in patients with FG at presentation to the emergency department. The patients were assigned to two groups according to FG aetiology. RESULTS: It was observed that the number of debridement interventions and the need for colostomy were significantly greater in the perianal FG group, while the need for flap or reconstruction was significantly (p=0.002) higher in the genitourinary FG group. No significant difference was detected in mortality between groups and the difference in aetiology had no significant effect on the results of the neutrophil-to-lymphocyte ratio, LRINEC or UFGSI scores. CONCLUSION: Laboratory results and UFGSI score were helpful in assessing disease severity independently from aetiology. The higher number of debridement interventions to protect anal function in the perianal group and the greater need for reconstructive surgery in the urogenital group were identified as factors that prolonged length of hospital stay.

Volumetric computed tomography measurements as predictors for outcomes in a cohort of Fournier's gangrene patients.

PURPOSE: This study evaluates the prognostic value of CT findings, including volumetric measurements, in predicting outcomes for patients with Fournier gangrene (FG), focusing on mortality, ICU admission, hospital stay length, and healthcare costs. METHODS: A retrospective study was conducted on 38 FG patients who underwent CT scans before surgical debridement. We analyzed demographic data, CT volumetric measurements, and clinical outcomes using logistic and linear regression models. RESULTS: No single CT measurement significantly predicted mortality or ICU admission. The best model for mortality prediction included age, air volume, NSTI score, and male sex, with an AUC of 0.911. Intubation likelihood was modeled with an AUC of 0.913 using age, NSTI score, and visceral to subcutaneous fat ratio. The ICU admission model achieved an AUC of 0.677. Hospital stay was predicted by air volume (ß = 0.0002656, p = 0.0505) with an adjusted R-squared of 0.1287. Air volume significantly predicted hospital costs (ß = 2.859, p = 0.00558), resulting in an adjusted R-squared of 0.2165. CONCLUSION: Volumetric CT findings provide valuable prognostic insights for FG patients, suggesting a basis for informed clinical decisions and resource allocation. Further validation in larger, multi-center studies is recommended to develop robust predictive models for FG outcomes.

Absent in Melanoma 2 Mediates Inflammasome Signaling Activation against Clostridium perfringens Infection.

Absent in melanoma 2 (AIM2), a key component of the IFI20X/IFI16 (PYHIN) protein family, is characterized as a DNA sensor to detect cytosolic bacteria and DNA viruses. However, little is known about its immunological role during pathogenic Clostridium perfringens (C. perfringens) infection, an extracellular bacterial pathogen. In a pathogenic C. perfringens gas gangrene model, Aim2-/- mice are more susceptible to pathogenic C. perfringens soft tissue infection, revealing the importance of AIM2 in host protection. Notably, Aim2 deficiency leads to a defect in bacterial killing and clearance. Our in vivo and in vitro findings further establish that inflammasome signaling is impaired in the absence of Aim2 in response to pathogenic C. perfringens. Mechanistically, inflammasome signaling downstream of active AIM2 promotes pathogen control. Importantly, pathogenic C. perfringens-derived genomic DNA triggers inflammasome signaling activation in an AIM2-dependent manner. Thus, these observations uncover a central role for AIM2 in host defense and triggering innate immunity to combat pathogenic C. perfringens infections.

Fournier's Gangrene as an Adverse Event Following Treatment with Sodium Glucose Cotransporter 2 Inhibitors.

We present the case of a 51-year-old male with known congestive heart failure and acute myocarditis who presented to the emergency department (ED) with swollen testicles and urinary symptoms two weeks after the initiation of sodium glucose cotransporter 2 (SGLT2) inhibitor treatment. Abdominal and pelvic computed tomography (CT) scan was consistent with the diagnosis of Fournier's gangrene (FG). Intravenous antibiotics were administered and surgical exploratory intervention and excision of necrotic tissue were performed, stopping the evolution of necrotizing fasciitis. FG, a reported adverse event, may rarely occur when SGLT2 inhibitors are administered in patients with diabetes. To our knowledge, there have been no reported cases of FG in Romania since SLGT2 inhibitors were approved. The distinguishing feature of this case is that the patient was not diabetic, which emphasizes that patients without diabetes who are treated for heart failure with SGLT2 inhibitors may also be at risk of developing genitourinary infections. The association of predisposing factors may have contributed to the development of FG in this case and even though the benefits of SGLT2 inhibitors outweigh the risks, serious adverse events need to be voluntarily reported in order to intervene promptly, verify the relationship, and minimize the risk of bias.

Reconstruction of penile skin loss by superficial circumflex iliac perforator (SCIP) pedicled flap after Fournier's gangrene.

INTRODUCTION: Fournier's gangrene is a serious pathology with a high mortality rate. Treatment requires a large debridement of necrotized tissues, conducing to a skin loss, requiring a reconstruction, which may involve different surgical techniques, depending on the context as well as the size and location of the skin loss. The most common covering technique uses split-thickness skin grafting, which however presents a risk of contracture. CASE: Our 63 years old patient presented a Fournier's gangrene, leading to pubic and circular penile skin defects after multiple debridements. We decided to practice a right superficial circumflex iliac perforator (SCIP) pedicled flap to reconstruct the penile skin sheath. The flap was rotated 180 degrees and rolled around the penis. DISCUSSION: The inguinal pedicle flap is described for penile reconstruction, the SCIP flap for perineal reconstruction, and even bilateral SCIP flaps for performing phalloplasty, but SCIP pedicled flap is not already described for isolated penile skin sheath reconstruction. Skin loss in our patient was not extensive, permitting us to perform this surgical technique. To go further, note the possibility of carrying out this reconstruction by a super-thin SCIP flap, as a pure skin graft flap. CONCLUSION: The SCIP pedicled flap seems us to be a safe technique for penile skin reconstruction and a good alternative to the usual skin grafts, especially regarding the lower risk of contracture, and low donor-site morbidity.

Scrotal reconstruction after Fournier's Gangrene using the superficial circumflex iliac artery perforator (SCIP) propeller flap: A case report.

INTRODUCTION: Fournier's gangrene, a rare infectious condition affecting the external genitalia, often requires aggressive medical-surgical interventions, resulting in variable scrotal tissue loss. Despite numerous proposed reconstruction techniques, achieving a consensus on the most effective approach that balances aesthetics and function remains elusive. This case report presents a one-year follow-up on scrotal reconstruction using a pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) propeller flap. CASE REPORT: A 56-year-old patient with significant scrotal tissue loss due to Fournier's gangrene underwent scrotal reconstruction using a pedicled SCIP propeller flap. Optimal placement was ensured through a subcutaneous tunnel, with a thin thigh skin graft applied to cover the penile skin defect. DISCUSSION: The SCIP flap is distinguished by its thin and pliable characteristics, rapid harvesting and featuring a discreet donor site. It stands as a compelling alternative to skin grafts, providing advantages in sensory restoration, color congruence, and resilience against tension. Considering the thickness of the reconstruction helps both in recovering testicular function and improving the appearance by restoring the natural contour. CONCLUSION: The utilization of the pedicled SCIP propeller flap for scrotal tissue loss resulting from Fournier's gangrene has demonstrated both aesthetic and functional success, underscoring its potential as an effective reconstructive option.

Types A and F Clostridium perfringens in healthcare wastewater from Ghana.

IMPORTANCE: Clostridium perfringens causes gas gangrene and food poisoning in humans, and monitoring this bacterium is important for public health. Although whole-genome sequencing is useful to comprehensively understand the virulence, resistome, and global genetic relatedness of bacteria, limited genomic data from environmental sources and developing countries hamper our understanding of the richness of the intrinsic genomic diversity of this pathogen. Here, we successfully accumulated the genetic data on C. perfringens strains isolated from hospital effluent and provided the first evidence that predicted pathogenic C. perfringens may be disseminated in the clinical environment in Ghana. Our findings suggest the importance of risk assessment in the environment as well as the clinical setting to mitigate the potential outbreak of C. perfringens food poisoning in Ghana.

The real-world safety profile of sodium-glucose co-transporter-2 inhibitors among older adults (≥ 75 years): a retrospective, pharmacovigilance study.

BACKGROUND: As indications for sodium-glucose co-transporter-2 inhibitors (SGLT2i) are expanding, a growing number of older adults have become candidates for treatment. We studied the safety profile of SGLT2i among older adults. METHODS: A retrospective, pharmacovigilance study of the FDA's global database of safety reports. To assess reporting of pre-specified adverse events following SGLT2i among adults (< 75 years) and older adults (≥ 75), we performed a disproportionality analysis using the sex-adjusted reporting odds ratio (adj.ROR). RESULTS: We identified safety reports of 129,795 patients who received non-insulin anti-diabetic drugs (NIAD), including 24,253 who were treated with SGLT2i (median age 60 [IQR: 51-68] years, 2,339 [9.6%] aged ≥ 75 years). Compared to other NIAD, SGLT2i were significantly associated with amputations (adj.ROR = 355.1 [95%CI: 258.8 - 487.3] vs adj.ROR = 250.2 [79.3 - 789.5]), Fournier gangrene (adj.ROR = 45.0 [34.5 - 58.8] vs adj.ROR = 88.0 [27.0 - 286.6]), diabetic ketoacidosis (adj.ROR = 32.3 [30.0 - 34.8] vs adj.ROR = 23.3 [19.2 - 28.3]), genitourinary infections (adj.ROR = 10.3 [9.4 - 11.2] vs adj.ROR = 8.6 [7.2 - 10.3]), nocturia (adj.ROR = 5.5 [3.7 - 8.2] vs adj.ROR = 6.7 [2.8 - 15.7]), dehydration (adj.ROR = 2.5 [2.3 - 2.8] vs adj.ROR = 2.6 [2.1 - 3.3]), and fractures (adj.ROR = 1.7 [1.4 - 2.1] vs adj.ROR = 1.5 [1.02 - 2.1]) in both adults and older adults, respectively. None of these safety signals was significantly greater in older adults (Pinteraction threshold of 0.05). Acute kidney injury was associated with SGLT2i in adults (adj.ROR = 1.97 [1.85 - 2.09]) but not in older adults (adj.ROR = 0.71 [0.59 - 0.84]). Falls, hypotension, and syncope were not associated with SGLT2i among either adults or older adults. CONCLUSION: In this global post-marketing study, none of the adverse events was reported more frequently among older adults. Our findings provide reassurance regarding SGLT2i treatment in older adults, although careful monitoring is warranted.

Phagocyte extracellular traps formation contributes to host defense against Clostridium perfringens infection.

Clostridium perfringens (C. perfringens) is an important Gram-positive anaerobic spore-forming pathogen that provokes life-threatening gas gangrene and acute enterotoxaemia, although it colonizes as a component of the symbiotic bacteria in humans and animals. However, the mechanisms by which C. perfringens is cleared from the host remains poorly understood, thereby impeding the development of novel strategies for control this infection. Here, we uncover a beneficial effect of extracellular traps (ETs) formation on bacterial killing and clearance by phagocytes. C. perfringens strain ATCC13124, and wild-type isolates CP1 and CP3 markedly trigger ETs formation in macrophages and neutrophils. As expected, visualization of DNA decorated with histone, myeloperoxidase (MPO) and neutrophils elastase (NE) in C. perfringens-triggered classical ETs structures. Notably, the bacteria-induced ETs formation is an ERK1/2-, P38 MAPK-, store-operated calcium entry (SOCE)-, NADPH oxidase-, histone-, NE-, and MPO-dependent process, and is independent of LDH activity. Meanwhile, the defect of bactericidal activity is mediated by impairing ETs formation in phagocytes. Moreover, In vivo studies indicated that degradation of ETs by DNase I administration leads to a defect in the protection against experimental gas gangrene, with higher mortality rates, exacerbated tissue damage, and more bacterial colonization. Together, these results suggest that phagocyte ETs formation is essential for the host defense against C. perfringens infection.

Use of prostaglandin and cyclophosphamide for pediatric lupus with digital gangrene: Back to safety before hitting the axe!

Digital gangrene is a rare presenting feature of childhood lupus and only a reported incidence of 1.3%. We describe two cases of pediatric onset systemic lupus erythematosus (SLE), both 16 years old, presenting with digital gangrene and the successful salvage of the digits after using intravenous cyclophosphamide for immunosuppression and use of intravenous prostaglandin E1 infusions for limb reperfusion. Both of the patients responded exceptionally to the infusions with resolution of gangrene and near-total preservation of the functionality of toes.

A review of the development of gangrene in patients with systemic lupus erythematosus - A 44-year follow-up study.

OBJECTIVES: This review addresses the question of what happens long-term to those systemic lupus erythematosus (SLE) patients who develop gangrene. It also seeks to find common clinical and serological features, risk factors and triggers and how best to manage this challenging complication. METHODS: We reviewed 850 patients with SLE attending a UK tertiary referral center, followed up over 44 years, assessing their demographics, clinical and serological features, treatment in the acute phase, their long-term outcome and long-term management. RESULTS: Ten out of 850 patients (1.2%) developed gangrene; the mean age of onset was 17 years (range 12-26 years) Eight out of 10 patients had a single episode of gangrene. One of the other two was not willing to have anticoagulation. The first episode of gangrene ranged from presentation to 32 years after SLE onset, mean duration of SLE at the onset of the gangrene was 18.5 years SD 11.5 years. Anti-phospholipid (PL) antibodies were over-represented in the patients with gangrene. All had active SLE at the time the gangrene developed. All patients were treated with intravenous (IV) iloprost infusions, and the antiphospholipid-antibody positive patients were anti-coagulated, most staying on long term anticoagulation. Underlying possible triggers were treated appropriately. Two patients who did not respond to the initial treatment needed further immunosuppression. All patients suffered digit loss. CONCLUSION: Although rare, gangrene is a sinister, potentially late developing complication of SLE, it rarely recurs. It is associated with anti-phospholipid antibodies, active disease, and other possible triggers such as infection and cancer. Anticoagulation therapy, steroids and iloprost, and further immunosuppression may be needed to stop the evolution of gangrene.

Comparison of different scoring systems for predicting in-hospital mortality for patients with Fournier gangrene.

PURPOSE: To compare different scoring systems for predicting in-hospital mortality in patients with Fournier gangrene (FG). METHODS: A comprehensive literature search was performed to find all scoring systems that have been proposed previously as a predictor for in-hospital mortality in patients with FG. Data of all patients with FG who were hospitalized in one of Indonesia's largest tertiary referral hospitals between 2012 and 2022 were used. The receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of the scoring systems. RESULTS: Ten scoring systems were found, i.e., Fournier's Gangrene Severity Index (FGSI), Uludag FGSI, simplified FGSI, NUMUNE Fournier score (NFS), Laboratory Risk Indicator for Necrotizing Fasciitis, age-adjusted Charlson comorbidity index, sequential organ failure assessment (SOFA), quick SOFA, acute physiology and chronic health evaluation II, and surgery APGAR score (SAS). Of 164 FG patients included in the analyses, 26.4% died during hospitalization. All scoring systems except SAS could predict in-hospital mortality of patients with FG. Three scoring systems had areas under the ROC curve (AUROC) higher than 0.8, i.e., FGSI (AUROC 0.905, 95% confidence interval (CI) 0.860-0.950), SOFA (AUROC 0.830, 95% CI 0.815-0.921), and NFS (AUROC 0.823, 95% CI 0.739-0.906). Both FGSI and SOFA had sensitivity and NPV of 1.0, whereas NFS had a sensitivity of 0.74 and an NPV of 0.91. CONCLUSION: This study shows that FGSI and SOFA are the most reliable scoring systems to predict in-hospital mortality in FG, as indicated by the high AUROC and perfect sensitivity and NPV.

Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform?

INTRODUCTION: Fournier's gangrene (FG) is a necrotizing fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound. MATERIAL AND METHODS: A retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, the Fournier gangrene severity index (FGSI), and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected. RESULTS: A total of 149 patients met the inclusion criteria. FG's most frequent cause was a perianal abscess (107 patients-72%). Eighteen patients (12%) died of a specific cause of FG. Age (p = 0.014) and patients with an oncological history (p = 0.038) both were the only mortality risk factors for mortality according to logistic regression. Fifty patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 Flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality. CONCLUSIONS: One in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.