Necrosis Of Extremities Research Articles

A neonate with Amniotic Band Syndrome and osteomyelitis

Amniotic band syndrome (ABS) comprises of a broad term for a group of congenital anomalies involving the limbs more often, but any other anatomic region of fetus could be involved. The prevalence of amniotic band has been reported from 0.19 to 8.1 per 10000 live births. Different theories exist for explaining the etiology of amniotic bands, but it has been considered to have a multifactorial etiology. Fetoscopic release of amniotic bands affecting one or more extremities can prevent limb loss or preserve limb function when distal fellow is still identifiable on preoperative ultrasound scans. Congenital anomalies of amniotic band syndrome will happen approximately in 77% of fetuses. There has been reported equal involvement between male and female. In general, we do not have osteomyelitis in neonates, but it would be connected to a long-term hospital admission and possible long‐term complications if not diagnosed on time. The long bones are the most frequently affected sites. Here we are introducing a neonate with left upper extremity necrosis due to ABS which needed amputation and it was associated with severe chronic osteomyelitis.

Rapidly Progressive Bilateral Extremity Necrosis Associated with Coronavirus Disease 2019

Rapidly Progressive Bilateral Extremity Necrosis Associated with Coronavirus Disease 2019

Extremity Ischemia After Jellyfish Envenomation: A Case Report and Systematic Review of the Literature

BackgroundExtremity ischemia and necrosis after jellyfish envenomation can be mutilating and cause long-term functional deficits. The best way to manage these presentations is unknown. ObjectiveThe aim of this review was to establish an evidence-based consensus for the management of extremity ischemia after jellyfish envenomation. MethodsA systematic review of cases of extremity ischemia and necrosis after envenomation by marine cnidarians was performed to clarify what is and what is not known about management and outcomes, to draw conclusions about how best to manage these rare presentations, and to establish an evidence-based algorithm. ResultsThe ischemic sequelae of envenomation typically evolves over a few days. Close medical supervision is necessary to react promptly to the evolving clinical scenario. In the literature, 15 different pharmacologic classes have been used to manage these presentations. Only IV infusions of prostaglandin derivatives and intra-arterial thrombolytics have been found to improve the clinical picture and avoid the need for surgical fasciotomy and debridement in some cases. Anticoagulants, antiplatelet agents, steroids, antibiotics, and nitrates, which are among the most commonly prescribed pharmacologic agents, have not been observed to alter the clinical picture. ConclusionsSurgery for compartment syndrome and necrosis are common sequelae of extremity envenomation by marine cnidarians. Only prompt use of IV prostaglandins or intra-arterial thrombolytics can halt ischemic progression and avoid the need for surgery. An algorithm is proposed to guide management of these rare and mutilative presentations.

Targeted muscle reinnervation in the pediatric population

Extremity amputation due to traumatic or oncologic etiology in the pediatric population confers reduced quality of life, psychosocial trauma, and chronic pain in the form of neuroma, and residual and/or phantom limb pain. Several techniques have been described with inconsistent efficacy, yet little is available prophylactically. The advent of targeted muscle reinnervation (TMR) has shown to have strong outcomes for this purpose in adults, affording aberrant nerves an adequate growth path. This study aims to describe our experiences with using TMR in a previously undescribed pediatric cohort. TMR consisted of isolation of major residual nerves following surgical amputation. Residual nerves undergo microsurgical coaptation to motor nerves innervating remaining regional stump-muscles. Patients are followed post-operatively for development of pain and prosthetic usage. Two subjects were identified. The first was a 17-year-old female who suffered from fulminant liver failure and subsequent bilateral lower extremity necrosis necessitating bilateral below knee amputation (BKA). She concomitantly underwent TMR to both limbs. The second was a 12-year-old male with Ewing's sarcoma of the femur who previously underwent femoral resection and allograft/autograft reconstruction. On recurrence, above knee amputation (AKA) was conducted with concomitant TMR. On 16- and 12-month follow-up, respectively, both patients demonstrate use of prosthetic devices and report no pain, without the usage of pain medications. TMR is feasible in the pediatric population. This intervention may warrant consideration in pediatric patients who are undergoing amputation for a variety of etiologies and can effectively serve to mitigate risk of neuroma formation and residual or phantom limb pain. • Pediatric targeted muscle reinnervation has yet to be described, and this article presents a proof-of-concept study. • Targeted muscle reinnervation may have success in the lower extremity when undertaken in the pediatric population. • Larger populations will uncover further applications.

Calcitonin gene-related peptide-targeting drugs and Raynaud\u2019s phenomenon: a real-world potential safety signal from the WHO pharmacovigilance database

BackgroundMigraine is responsible for significant disability and societal burden. Recently, drugs targeting the calcitonin gene-related peptide (CGRP) pathway raised new hopes. CGRP, a potent vasodilator, plays a key role in the pathogenesis of migraine attacks. The deficiency of CGRP is involved in Raynaud’s phenomenon, which consists of abnormal vasoconstriction of the digits. We aimed to assess the potential association of Raynaud’s phenomenon with CGRP-targeting drugs, analyzing real-world data from the World Health Organization (VigiBase®).MethodsWe queried all reports of Raynaud’s phenomenon involving a CGRP-targeting drug. We sought disproportionate reporting of Raynaud’s phenomenon with these drugs. For this purpose, we relied on the calculation of the Information Component (IC). A positive lower end of the 95% confidence interval (CI) of the IC defines a statistically significant association. As migraine patients are prone to Raynaud’s phenomenon, we also calculated the IC of Raynaud’s phenomenon with CGRP-targeting drugs compared to 5HT1B/D agonists (triptans), and beta-blockers used in the treatment of migraine.ResultsOverall, 99 reports of Raynaud’s phenomenon involving CGRP-targeting drugs have been yielded in VigiBase®. The most reported CGRP-targeting drug was erenumab, with 56 reports (56.6%). The median time to onset was 84 days. No fatality was notified, but one patient suffered from gangrene and extremity necrosis. As a whole, CGRP-targeting drugs were significantly associated with Raynaud’s phenomenon, with an IC of 3.3 (95%CI: 3.0–3.5). There was a disproportionate reporting of Raynaud’s phenomenon with CGRP-targeting drugs compared to triptans (IC 0.4; 95%CI: 0.1–0.6) and to beta-blockers (IC 0.5; 95%CI: 0.2–0.7) as well.ConclusionsThere is a significant disproportionality signal of Raynaud’s phenomenon with CGRP-targeting. This signal stands out when CGRP-targeting drugs are compared to other drugs used in patients with migraine. This study is limited by missing data in pharmacovigilance reports. CGRP-targeting drugs may be subject to Weber effect and reporting bias. Nonetheless, CGRP blockade might be the last straw that disrupts the physiological balance of vascular response in patients at-risk of Raynaud’s phenomenon. Pending further data regarding vascular safety of CGRP-targeting drugs, caution is warranted in these patients.

Seminars AATS International Roundtable of Lung Transplantation for COVID-19

Seminars AATS International Roundtable of Lung Transplantation for COVID-19

A Neonate with Amniotic Band Syndrome and Osteomyelitis

Background: Amniotic band syndrome (ABS) comprises of a spectrum of congenital malformations involving the limbs more often, but any other anatomic region of fetus could be involved. Its prevalence has been reported to range from 0.19 to 8.1 per 10000 live births. There are different theories for explaining the etiology of amniotic bands, but it has been considered to have a multifactorial etiology. Fetoscopic release of amniotic bands affecting one or more extremities can prevent limb loss or preserve limb function when distal fellow is still identifiable on preoperative ultrasound scans. ABS occurs in 77% of fetuses with multiple anomalies. Both males and females are equally affected. Osteomyelitis in neonates is relatively uncommon, but burdened with an increased hospital stay and possible long-term sequela if not diagnosed on time. The long bones are the most frequently affected sites. Case Presentation: Here we are introducing a neonate with left upper extremity necrosis due to ABS which needed amputation and it was associated with severe chronic osteomyelitis. Conclusion: Amniotic band syndrome mostly involves the limbs. It is important to diagnose it as soon as possible, because with the interprofessional teamwork approach, an optimal patient result with fetoscopic or surgery procedures could be achieved.

Kawasaki disease with acute myocarditis in an adolescent.

A previously healthy 16-year-old adolescent was admitted to our hospital with fever, sore throat, diarrhoea, strawberry tongue, rashes on lower extremities, and pain in the neck, abdomen and joints. He was initially diagnosed with IgA vasculitis triggered by acute pharyngitis. Despite antibiotic treatment, he gradually developed multiorgan failure and cardiac shock. Cardiac catheterisation did not show any signs of coronary artery disease. Subsequently, he developed serious rhabdomyolysis and peripheral extremity necrosis, suggesting peripheral arteritis. Although blood culture results were negative, he received endotoxin adsorption therapy, but it was ineffective. Hence, we suspected Kawasaki disease (KD). We administered high-dose intravenous immunoglobulin therapy (2 g/kg), which was effective. He gradually recovered without major complications and was given ambulatory discharge 43 days after admission. Early diagnosis and administration of intensive care in adolescents with KD with acute myocarditis are critical but challenging.

Microstructural changes in the perihematomal area in case of the unfavourable course of spontaneous intracerebral hematomas

Objective ‒ to determine the dependence of unfavourable treatment outcomes of spontaneous intracerebral hematomas (ICH) on the peculiarities of microstructural changes in the perihematomal area.Materials and methods. A prospective study was conducted that included 68 patients with haemorrhagic stroke and chronic arterial hypertension, as well as signs of ICH. Patients’ clinical condition and treatment outcomes were assessed. The brain data of five patients who died at different stages after the haemorrhagic stroke were analysed using the method of optical microscopy of autopsy material. Results. Patients’ age ranged from 38 to 59. At the time of hospitalization, the Glasgow Coma Scale score was 8 to 15. The inpatient period was less than 1 day for three patients with stem and medial ICH, and 10 and 34 days in case of subarachnoid haemorrhage (in the latter cater, there was an aneurism re-rapture 3 days before death). Blood in the ventricular system was observed in all patients. Gross examination data during the autopsy showed that the cortical layer above the affected area is thin; after 12‒24 hours, the perihematomal area is swollen, with small dotted, and sometimes coalesced haemorrhaging; after 3 and more days, it increased to 4–5 mm and turned reddish-brown. During histologic examination: brain tissue with signs of the swelling, perihematomal area is cell-like with nerve cells – ranging from minor changes to extreme dystrophia and coagulative necrosis (nuclei with signs of pyknosis, rhexis, lysis), homogenous eosinophilic cytoplasm, apparent pericellular swelling, cell shaft formed by lymphocytes, leukocytes, macrophages, hemosiderophages, and reactive increase in oligodendrocytes and astrocytes.Conclusions. Perihematomal area has been found to be not just a «perihematomal swelling» as described in the literature. The unfavourable course of the ICH of different localization (basal, stem) can be explained by a complex of pathomorphological changes in this area: reactive inflammatory activation of glia, dystrophic nerve cell changes, pericellular swelling. As seen from our observations, early development of these processes – as early as on the 1st day – and their progressing indicate the presence of common mechanisms of unfavourable outcome regardless of haemorrhagic stroke localisation.

Anti-annexin V autoantibodies and vascular abnormalities in systemic sclerosis: a longitudinal study

BackgroundAnnexins are a group of conserved proteins which exert several regulatory functions on various cellular activities. Increased frequency and levels of antibodies against annexin V have already been observed in several autoimmune diseases including systemic sclerosis (SSc), but their role as a vascular biomarker is unknown. The aim of this study was to determine the serum levels and the dynamical behavior of anti-annexin V antibodies over a 24 months follow-up in patients with SSc.MethodsIn this bicentric cross-sectional study, 70 patients with SSc were consecutively selected from March 2016 to April 2017. Demographic and clinical features, including the presence of active DUs, were collected. Serum anti-annexin V IgG and IgM antibodies were measured at baseline and after 6, 12 and 24 months of follow-up. Videocapillaroscopy was performed in all patients.ResultsAmong the 70 SSc patients included anti-annexin V IgG was found in 11 patients (15.7%) (range of 15.88–39.48 U/mL) and anti-annexin V IgM in 10 patients (14.3%) (range of 14.16–22.69 U/mL) at baseline. During follow-up, the number of patients who were positive for anti-annexin V IgG and IgM remained stable over 24 months. Among the patients with positive anti-annexin V IgG at baseline the frequency of patients with necrosis or amputation of extremities, forced vital capacity less than 70% and pulmonary arterial hypertension (PAH) was significantly higher than in patients with negative anti-annexin V IgG antibodies. Patients with anti-annexin V IgG had also a higher Raynaud’s Condition Score and a higher Health Assessment Questionnaire Disability Index (HAQ-DI) than patients without these antibodies at baseline. Patients with positive anti-annexin V IgM at baseline presented a higher frequency of PAH, compared to those with negative anti-annexin V IgM at baseline.ConclusionsAnti-annexin V antibodies are stable and do not change their positivity during a 24 month follow-up in SSc patients. Anti-annexin V IgG was associated with more severe interstitial lung involvement and digital microangiopathy, and patients with anti-annexin V IgG or IgM had a higher occurrence of PAH indicating an association of these biomarker with more severe disease.

Extreme necrosis in an Italian Wall Lizard (Podarcis sicula)

Extreme necrosis in an Italian Wall Lizard (Podarcis sicula)

Current Practice of Therapeutic Hypothermia for Mild Hypoxic Ischemic Encephalopathy.

Therapeutic hypothermia is the recommended treatment for neonates with moderate or severe hypoxic ischemic encephalopathy (HIE). There is an increasing trend to use therapeutic hypothermia even in infants with mild hypoxic ischemic encephalopathy, even though there is little evidence to support/refute this. To estimate the incidences of mild hypoxic ischemic encephalopathy among infants who received therapeutic hypothermia, and its short- and long-term outcomes. PubMed, Embase, CINAHL, and Cochrane library were searched to identify observational studies reporting on therapeutic hypothermia in term and near-term infants with mild hypoxic ischemic encephalopathy. The JBI (Joanna Briggs Institute) tools were used to assess the risk of bias in the included studies. Random effects meta-analysis was conducted to find out the percentage of cooled infants who had only mild hypoxic ischemic encephalopathy. A total of 3590 citations were screened, of which 13 were included. Of the 2783 infants who received therapeutic hypothermia, 573 had mild hypoxic ischemic encephalopathy. Meta-analysis found that 22% of the infants who underwent therapeutic hypothermia had only mild hypoxic ischemic encephalopathy (95% confidence interval: 16%-27%; I2 statistic = 90.5%). Five studies provided information on adverse effects of therapeutic hypothermia in mild hypoxic ischemic encephalopathy. The reported adverse effects were extreme hypothermia, bradycardia, hypoglycemia, sepsis, skin necrosis, pulmonary hypertension, and systemic hypotension. Limitation: The limitations included relatively small sample size and the lack of data for short- and long-term neurodevelopmental outcome. A significant proportion of infants who received therapeutic hypothermia had mild hypoxic ischemic encephalopathy. Randomized trials are urgently needed to evaluate the efficacy and safety of therapeutic hypothermia in infants with mild hypoxic ischemic encephalopathy.

Candesartan and epigallocatechin-3-gallate ameliorate gentamicin-induced renal damage in rats through p38-MAPK and NF-κB pathways.

This study pointed to estimate the possible protective impacts of candesartan and/or epigallocatechin-3-gallate (EGCG) against gentamicin-induced nephrotoxicity. The current work revealed that gentamicin significantly elevated relative kidney weight and the serum level of creatinine and urea. Also, renal level of malondialdehyde was significantly increased with a concurrent decrease in renal glutathione-S-transferase and superoxide dismutase activities. Moreover, renal levels of nuclear factor-kappa B (NF-κB) and p38 mitogen-activated protein kinase (p38-MAPK) were increased together with the elevation of tumor necrosis factor-alpha and interleukin-1 beta levels after gentamicin treatment. In addition, caspase-3 expression was elevated, and histological examination revealed extreme alterations enlightening inflammation, degeneration, and necrosis. Pretreatments with candesartan and/or EGCG attenuated gentamicin-induced nephrotoxicity. Importantly, the altered expression of p38-MAPK and NF-κB may play a significant role in the protective mechanisms exerted by candesartan and EGCG. Coadministration of candesartan and EGCG exhibited more profound response compared with the monotherapy.

A Rare Case of Intravenous Pesticide Poisoning with Upper Extremity Necrosis

A Rare Case of Intravenous Pesticide Poisoning with Upper Extremity Necrosis

Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO)-also referred to as extracorporeal life support-is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange. The initiation of VA-ECMO has emerged as a salvage intervention in patients with cardiogenic shock, even cardiac arrest refractory to standard therapies. Analogous to veno-venous ECMO for acute respiratory failure, VA-ECMO provides circulatory support and allows time for other treatments to promote recovery or may be a bridge to a more durable mechanical solution in the setting of acute or acute on chronic cardiopulmonary failure. In this review, we provide a brief overview of VA-ECMO, the attendant physiological considerations of peripheral VA-ECMO, and its complications, namely that of left ventricular distention, bleeding, heightened systemic inflammatory response syndrome, thrombosis and thromboembolism, and extremity ischemia or necrosis.

Takayasu arteritis in childhood: misdiagnoses at disease onset and associated diseases.

Juvenile-Takayasu arteritis (j-TA) is a difficult diagnosis and some patients develop uncommon manifestations and associated diseases that may contribute to the delayed diagnosis. Our aim was to identify the misdiagnoses, the associated diseases and the atypical manifestations observed in a j-TA Brazilian multicentre study. 71 children and adolescents who met the classification criteria for j-TA were included. The misdiagnoses, the associated diseases and the atypical manifestations were evaluated. 19 (26.8%) patients had misdiagnoses. The most common of them was aortic coarctation in six (8.4%) patients, followed by rheumatic fever in five (7.0%) and one patient presented with both former diagnoses. Limb pain (two patients), spondyloarthropathy, juvenile idiopathic arthritis (JIA), spinal arteriovenous malformation, polyarteritis nodosa (PAN) and fever of unknown origin (FUO) were other misdiagnoses. Patients who had misdiagnoses previously to j-TA diagnosis presented a trend to have a longer diagnosis delay. 11 (15.5%) patients had 14 TA-associated diseases, such as pulmonary tuberculosis (5 patients), rheumatic fever (2 patients), spondyloarthropathy, polyarticular JIA, Crohn's disease, Prader-Willi disease, diabetes mellitus, Moyamoya and primary immunodeficiency. 7 (9.9%) patients presented 10 atypical manifestations, such as pyoderma gangrenosum, erythema nodosum, myositis, chorea, enthesitis, episcleritis, uveitis, hepatomegaly, splenomegaly and necrosis of extremities. Our study emphasizes the main misdiagnoses, associated diseases and atypical manifestations that occur in patients with j-TA and warns of the features that may alert paediatricians to this diagnosis, such as constitutional symptoms and elevated inflammatory markers.

Prevalence Antimicrobial Resistance and Pathogenicity of Enterococcus Spp. Isolated from Ducks

The present study was undertaken during a period from2013 to 2015 in different localities at Damietta Governorateto investigate the isolation prevalence of Enterococcusspp., antibacterial resistance patterensand their pathogenicity in Pekin ducks . Clinical cases from 46 duck flocks of different breedssuspected with bacterial infection (26 farms and 20backyard),were examined for the prevalence ,isolation and identification. Enterococcus faecalis. Suspected cases were confirmed after culturing on Bile esculinazid agar, biochemical testing either by conventional and bioMerieuxVitek. Prevalence were (7/26) and (4/20) in duckling farms and backyard respectively.Sensitivity testing of isolated enterococci from duck flocks to antimicrobial agents were tested using the disk diffusion method.Enterococcus faecalis showed multiple drug resistance patterns for different antibiotics ,oxytetracyclin, chloramphenicol, Erythromycin, Gentamicin, Ciprofloxacin, Neomycin, Kanamycin, Vancomycin, Nalidixic acid, and streptomycin while, susceptible to Ampicilin.Pathogencity test for isolated Enterococcus fecalis was performed .Inoculated ducks showed mainly,general clinical signs respiratory manifestation, lameness , growth retardation and pathologically airsaculitis, perihepatitis, pericarditis ,endocarditis, splenomegaly and necrosis of bone extremities (FHN) differ in severity according to the route of inoculation intravenous, intrathoracic, intranasal and orally respectively.

Levamisole-adulterated cocaine induced skin necrosis of nose, ears, and extremities: Case report.

Levamisole is an immunomodulatory and antihelminthic drug, previously removed from the United States market, and now estimated to be present in the vast majority of cocaine distributed in the United States. Levamisole-adulterated cocaine (LAC) exposure can result in neutropenia, thrombocytopenia, and vasculitis with a predilection for subsites of the face. The objective of this review is to increase awareness among otolaryngologists of the manifestations of LAC exposure. We present the case of a 33-year-old woman with a history of cocaine use, consulted for purpuric, necrotic lesions of the nose, cheeks, and ears, with accompanying leukopenia, thrombocytopenia, and positive antineutrophil cytoplasmic antibodies (ANCA). The effects of levamisole are immune mediated, with antibodies directed against neutrophils causing neutropenia, and vasculitis caused by antibody deposition or secondary to induction of antiphospholipid antibodies causing thrombosis. LAC exposure can be differentiated from other similar appearing pathologies by evaluating serology for specific ANCA. The most important treatment is cessation of cocaine use, which most often results in complete resolution of symptoms. Awareness of the presentation, complications, and treatment of LAC exposure may be especially important for otolaryngologists, who may be one of the firsts to evaluate an affected patient.

Microarray evaluation of bovine hepatic gene response to fescue toxicosis

‘Fescue toxicosis’ is a disease in livestock caused by ingestion of ergot alkaloids produced by the fungal endophyteNeotyphodium coenophialum in tall fescue; it is estimated to cost 1 billion USD in damages per year to the beef industry alone. Clinical signs include decreased reproductive fitness, necrosis of extremities, and reduced average daily gain and milk production. Little is known about the cellular mechanisms that mediate these toxic sequelae. We evaluated the effects of ergovaline-based fescue toxicosis on gene expression via oligonucleotide microarray. Liver biopsies were obtained from steers (n=4) pre- and post-exposure (0 and 29 days) to feed containing 579 ng/g ergovaline. Analyses were performed using both ANOVA with false discovery rate correction and Storey's optimal discovery procedure. Overall, down-regulation of gene expression was observed; heart contraction and cardiac development, apoptosis, cell cycle control, and RNA processing genes represented the bulk of differentially expressed transcripts. 2 CYPs (CYP2E1 and CYP4F6) were amongst the significantly upregulated results. Thus, exposure of cattle to toxic levels of ergovaline caused widespread changes in hepatic gene expression, which can both help explain macroscopic clinical signs observed in ruminant animals, and reinforce previous findings in monogastric models.

Main complications and results of treatment with intra-arterial infusion chemotherapy through the subclavian and thoracic arteries for locally advanced breast cancer

Intra-arterial infusion chemotherapy for locally advanced breast cancer (LABC) has been previously performed. However, the main complications of this type of chemotherapy remain to be clarified. In the present study, catheterization chemotherapy was carried out for 53 LABC cases (stage IIIa–IIIc) between May, 2006 and March, 2007. For IIIB and IIIC patients, the catheters were guided to the opening of the subclavian artery. For stage IIIa patients, the catheters were placed into the thoracic artery through a subcutaneous femoral artery puncture. One to four cycles of chemotherapy (mean, 1.6 cycles) were administered for the patients using taxotere, epidoxorubicin, 5-fluorouracil and/or cyclophosphamide. The interval time between the two cycles was 21 days. Seven cases were identified as complete response (CR, 13.2%), 41 cases were partial response (PR, 77.4%) with a rate of effectiveness of (CR + PR, 90.6%), 5 cases were stable disease (SD, 9.40%) and no case was progressive. Pain of the ipsilateral upper extremity was present in 7 cases. Two cases exhibited ipsilateral upper extremity atrophy following drug administration from the opening of the subclavian artery. One case experienced neck pain and headache, while in one case necrosis of local skin was evident. Hematological toxicity over grade 3 was observed in 6 cases (11.30%). Systemic toxicity was mild and did not affect the quality of life of the patients. Overall survival was identified as 18/51 (35.3%), and free-disease survival as 10/51 (19.6%). In conclusion, intra-arterial infusion chemotherapy is an effective local control treatment for LABC. The main complications are pain of the ipsilateral upper extremity and neck as well as headache. Severe complications are ipsilateral upper extremity atrophy and necrosis of local skin. During the treatment, controlling the pressure of the tourniquet and velocity of drug administration are crucial for reducing local complications.