Necrosis Syndrome Research Articles

Use of Direct‐Fed Microbes to Enhance Shrimp Resistance to a Vibrio Parahaemolyticus Strain Causing Early Morality Syndrome (EMS)

ABSTRACTEarly mortality syndrome (EMS) or acute hepatopancreatic necrosis syndrome (AHPND) is an epizootic bacterial infection of shrimp that has had significant negative impact on the global shrimp aquaculture industry. This disease is largely attributed to pathogenic Vibrio parahaemolyticus EMS strains (VP‐EMS). Application of probiotics was examined for control of pathogenic VP‐EMS infections in Pacific white shrimp (Litopenaeus vannamei) under laboratory‐scale conditions. Two probiotic products, a single strain (O14VRQ) of Bacillus subtilis and a blend (Plus10) of five strains of Bacillus from four different species (Bacillus amyloliquifaciens, Bacillus megaterium, Bacillus brevis, and two distinct strains of Bacillus subtilis), were evaluated at various concentrations as feed additives (applied as a top coat on commercial feed) or dosed directly into the culture water. Two trials were conducted in which shrimp were fed either a control feed (no probiotics) or probiotic‐coated feed for 7 days prior to be being challenged with VP‐EMS. Shrimp were observed for clinical signs of disease and mortalities during the disease challenge study. These experiments demonstrated that while both Bacillus probiotic products were shown to significantly (p < 0.05) improve shrimp survival, the O14VRQ strain provided the most consistent protection across the trials in top‐coated feed. Overall, better efficacy was observed with probiotic‐coated feeds. Findings were directly and positively correlated with concentration for top‐coated and even more so for direct in‐tank applications. Collectively, these findings contribute to our understanding about how probiotic strains could be applied to enhance shrimp health in aquaculture.

Functional Disability at 3 Months in Patients with Residual Limb Swelling after Snakebite Envenoming.

Limited data indicate that snakebite survivors have persistent musculoskeletal disability. We assessed the pain and functional disability at hospital discharge and after 3 months in 47 patients treated for snakebite envenoming and with at least a specified amount of local swelling at the time of hospital discharge, using the numerical pain rating scale and the Patient-Specific Functional Scale (PSFS). Russell's viper was the most common biting snake species identified. At hospital discharge, the median pain score was 2 (0-3); 9 (19%) patients reported mild persisting pain at 3 months. The median PSFS score at hospital discharge was 3.7 (3.3-4.0), which improved to 8.3 (6.3-9.0) on follow-up (P <0.001); 32 (68%) patients had a PSFS score of 8.9 or below on follow-up. We conclude that snakebite envenoming could be associated with persisting functional disability at 3 months even in the absence of local complications such as skin necrosis and compartment syndrome.

81. Assessment of the prevalence of Swine Inflammation and Necrosis Syndrome in French pig herds

81. Assessment of the prevalence of Swine Inflammation and Necrosis Syndrome in French pig herds

Identification of the pathogen of hepatopancreas necrosis syndrome (HPNS) in Litopenaeus vannamei and evaluation of the effect of plant extracts against HPNS

Hepatopancreatic necrosis syndrome (HPNS) has recently become a major epidemic in shrimp farms, resulting in enormous economic loss. However, its etiology remains controversial. Diseased Litopenaeus vannamei (L. vannamei), collected from shrimp farms, were analyzed for pathological diagnosis, bacterial isolation, and identification. After that, the effects of the three plant extracts on the primary pathogens of HPNS were analyzed in vitro and in vivo. The results revealed that the primary pathogens of HPNS were Vibrio parahaemolyticus (V. parahaemolyticus) with ToxR and TLH gene, V. cholerae with ompW gene, and Proteus vulgaris (P. vulgaris) with rpoA gene. These three bacterial strains exhibited extensive antibiotic resistance. The “Chaiyinhugan” mixture, the “Sanhuanglian” mixture, and the Polygonum hydropiper flavonoid extract inhibited the growth of all three dominant strains. Additionally, the three plant extracts reduced HPNS shrimp mortality, improved shrimp immunity, and attenuated hepatopancreatic pathology. Among them, the Polygonum hydropiper flavonoid extract displayed better effects and could be applied to prevent and treat HPNS in producing and breeding L. vannamei. In conclusion, V. parahaemolyticus, V. cholerae, and P. vulgaris are the major pathogens causing HPNS. Herbal extracts such as Polygonum hydropiper flavonoid extract can be applied to prevent and treat HPNS.

A Review of Foot-Related Lameness in Feedlot Cattle

Lameness is the second most prevalent morbidity in North American feedlot cattle and is both an animal welfare and economic concern for the industry. Lameness accounts for 30 to 40% of all feedlot treatments with greater than 70% being foot-related lameness (FRL). This review focused on foot rot (FR), digital dermatitis (DD) and toe tip necrosis syndrome (TTNS). While there are significant study-to-study differences regarding the prevalence of FR, DD and TTNS, it is unequivocal that FR is the most prevalent FRL. Poor pen conditions are risk factors for both FR and DD, but the epidemiology of the two diseases is quite different. Whereas FR is diagnosed throughout the feeding period, DD typically occurs after 80 days on feed (DOF). Toe tip necrosis syndrome is the least prevalent of the three FRL, but has the greatest negative effect on animal welfare and production performance. Most cases of TTNS occur within 50 DOF with treatment failure leading to a significant loss in production performance and even death. This review provides an overview of the epidemiology of lameness in feedlot cattle, with emphasis on the prevalence and risk factors associated with FR, DD and TTNS.

Acute esophageal necrosis syndrome as a rare complication of diabetic ketoacidosis.

Acute esophageal necrosis syndrome as a rare complication of diabetic ketoacidosis.

Acute Retinal Necrosis Complicated by Serous Retinal Detachment Associated with Varicella-Zoster Virus Infection in an Immunocompetent Young Adult

Acute retinal necrosis syndrome (ARN syndrome) is a rare, rapidly progressive viral retinitis with a grim functional prognosis. We present a case of a 43-year-old immunocompetent woman who experienced unilateral acute retinal necrosis, with Varicella-Zoster Virus (VZV) infection as the etiology. A unilateral vesicular facial rash accompanied by rapidly declining visual acuity over 7 days prompted consultation. Intravenous antiviral treatment and panretinal photocoagulation laser (PPR) were initiated, followed by antiviral prophylaxis. The patient developed ophthalmic zona lesions, peripheral retinal ischemia, and unilateral macular serous retinal detachment (SRD). Treatment included valacyclovir, corticotherapy and PPR laser. Knowledge of this condition, diagnosed clinically, is crucial due to its rapid progression and severe complications. Early intervention appears to be a significant prognostic factor, emphasizing its therapeutic urgency.

Tail Fan Necrosis syndrome in decapod crustaceans: A review.

Lobsters and crayfish in Australasia can develop a condition known as Tail Fan Necrosis (TFN syndrome). Many attempts have been made to find a primary pathogen or link the syndrome to commercial activities, but a solution remains elusive. TFN syndrome is a 'wicked problem', a problem difficult or impossible to solve because of incomplete and contradictory information forming a matrix of potential outcomes with no simple solution. Reviewing the literature shows TFN syndrome is sometimes reported to develop in association with sterile blisters on the telson and uropods which may rupture permitting invasion by environmental fungal and/or bacterial flora. Whether blisters form prior to, or because of, infection is unknown. TFN syndrome sometimes develops in captivity, sometimes requires a previous insult to the telson and uropods, and prevalence is patchy in the wild. The literature shows the cause of blisters associated with TFN syndrome remains an enigma, for which we suggest several possible initiating factors. We strongly urge that researchers not 'jump to conclusions' as to the aetiology of TFN syndrome. It cannot be explained without carefully exploring alternative aetiologies whilst being cognisant of the age-old lesson that 'correlation does not equal causation'.

Foot lesions and forelimb skin abrasions in suckling piglets: development and risk factors

BackgroundFoot lesions in suckling piglets have been associated with poor flooring in several studies and were recently proposed to be indicative of swine inflammatory and necrosis syndrome. However, identical findings are also the typical outcome of various non-infectious causes; thus, further risk analysis is needed. The objective of this study was to describe the development of heel bruising, coronary band lesions and forelimb skin abrasion in suckling pigs up to 5 days of age. Furthermore, the effects of various intrinsic and extrinsic factors were examined. On each of four commercial piglet-producing farms, piglets from two or three batches of eight sows were studied. The piglets were included within 18 h after birth. Each piglet was individually scored four times. The score for the heels differentiated six (0–5) and for the coronary band and forelimb skin abrasion three stages (0–2). The body weight was measured two times. The effect of the floor was estimated by allocating the sows randomly to farrowing pens equipped with either soft rubber mats covered with litter or fully slatted plastic floors.ResultsThe final analysis comprised data from 1045 piglets. Foot lesions were not found at birth but started to develop on day 1. On day 5, heel bruising was found in 94%, main claw coronary band lesions in 49% and forelimb skin abrasion in 73% of the piglets. In a multifactorial logistic regression analysis, it was shown that a slatted plastic floor significantly increased the odds of heel bruising and coronary band lesions, while a rubber floor with litter increased the odds of forelimb skin abrasions.ConclusionFoot and forelimb lesions in new-born piglets are mainly induced by the floor. The effect of slatted plastic floors on heel bruising showed an overwhelming OR of 52.89 (CI 26.29–106.43). Notably, coronary band lesions in young suckling piglets occur on slatted as well as non-slatted floors, indicating that the piglets incur these injuries not only from the wedging of their feet into the gaps between slats but also from contact with the floor while suckling. Based on these findings, preventive measures should be redirected to the improvement of the floor in the farrowing pen, particularly in the area under the sow’s udder.

A prospective study on skin and soft tissue infections: a fact-finding mission from a tertiary centre in north India.

Despite the high prevalence and poor outcome of skin and soft tissue infections (SSTIs), very few studies from India have dealt with the subject. We planned a prospective study of inpatients with SSTIs to study the aetiology, clinical presentation (severity) and outcome of patients with SSTIs in our facility. Patients with SSTIs involving >5% body surface area (BSA) and/or systemic signs were admitted to the surgery department of a teaching tertiary level hospital in Delhi, India, and were clinically classified into cellulitis, necrotising soft tissue infections (NSTIs), pyomyositis, and abscess. Demographic and clinical variables such as: age; sex; occupation; history of trauma/insect or animal bites; duration of illness; presenting symptoms and signs; comorbid conditions; predisposing factors such as lymphoedema or venous disease; hospital course; treatment instituted; complications; hospital outcome; presence of crepitus, bullae, gangrene, muscle necrosis and compartment syndrome were recorded. The chief outcome parameters were death and length of hospital stay; others, such as abscess drainage, the need for plastic surgical procedures and amputations were also noted. Out of 250 patients enrolled in the study, 145 (58%) had NSTIs, 64 (26%) had abscesses, 15 (6%) had cellulitis and 26 (10%) had pyomyositis. Mortality was observed with NSTIs (27/145, 19%) and with pyomyositis (3/26, 11.5%). Factors affecting mortality by univariate analysis in the NSTI group were: abnormal pulse; hypotension; tachypnea; bullae; increased blood urea and serum creatinine; inotrope or ventilator support (all with p<0.001); local tenderness, gangrene, dialysis support and BSA (9.33±6.44 versus 5.12±3.62; p<0.05 for the last four). No factor was found to be significant on multivariate analysis. Variables associated with hospital stay >12 days were immunocompromise, pus discharge, ulceration or gangrene, and after interventions such as blood transfusion, drainage or skin grafting. High prevalence of NSTI and pyomyositis with high mortality was observed in our SSTI patients, often in immunocompetent young individuals. Epidemiological studies focused on virulent strains of Staphylococcus aureus may be required to identify the cause, since Staphylococcal toxins have been implicated in other infections.

An interdigitated capacitive sensor for early detection of contrast media extravasation

Contrast Media Extravasation (CMEV) is a well-known complication of intravenous administration of contrast media during computed tomography (CT) scans. It refers to the leakage of contrast media from the blood vessel into the surrounding soft tissues. As contrast media are vesicant solutions, extravasation can result in the development of adverse side effects such as erythema, tissue necrosis, and compartment syndrome. Therefore, there is an urgent clinical need to develop a device that can detect extravasation early and minimize the severity of extravasation injuries. In this work, we present a cost-effective and wearable sensor patch to aid in the early detection of extravasation via capacitive sensing. The technical feasibility of the proposed sensor was then evaluated through a series of bench-top tests and ex-vivo tests. The results showed that the sensor patch is able to distinguish between normal contrast media administration and contrast media extravasation scenarios. Our proposed sensor has shown potential for early detection of CMEV, with a decrease in capacitance being a promising indicator of extravasation. This sensor also has the potential to reduce the occurrence of extravasation events in the hospital, especially for patients at risk of extravasation. Future work includes optimizing the sensor and validating it through a clinical trial to bring it a step closer to actual commercial use.

GWAS reveals genomic associations with swine inflammation and necrosis syndrome

The recently identified swine inflammation and necrosis syndrome (SINS) occurs in high prevalence from newborn piglets to fattening pigs and resembles an important concern for animal welfare. The primary endogenous syndrome affects the tail, ears, teats, coronary bands, claws and heels. The basis of clinical inflammation and necrosis has been substantiated by histopathology, metabolomic and liver transcriptomic. Considerable variation in SINS scores is evident in offspring of different boars under the same husbandry conditions. The high complexity of metabolic alterations and the influence of the boar led to the hypothesis of a polygenic architecture of SINS. This should be investigated by a genome-wide association study. For this purpose, 27 sows were simultaneously inseminated with mixed semen from two extreme boars. The mixed semen always contained ejaculate from a Pietrain boar classified as extremely SINS susceptible and additionally either the ejaculate from a Pietrain boar classified as SINS stable or from a Duroc boar classified as SINS stable. The 234 piglets were phenotyped on day 3 of life, sampled and genetically assigned to the respective boar. The piglets showed the expected genetic differentiation with respect to SINS susceptibility. The suspected genetic complexity was confirmed both in the number and genome-wide distribution of 221 significantly associated SNPs, and led to 49 candidate genes. As the SNPs were almost exclusively located in noncoding regions, functional nucleotides have not yet been identified. The results suggest that the susceptibility of piglets to SINS depends not only on environmental conditions but also on genomic variation.

Unilateral Multiple Evanescent White Dot Syndrome-Like Reaction Following the CyberKnife Stereotactic Radiotherapy for Choroidal Malignant Melanoma.

A 58-year-old otherwise healthy man received a diagnosis of choroidal malignant melanoma (CMM) in June 2021 and underwent a single session of (21 Gy) CyberKnife stereotactic radiotherapy (SRT). Eleven months later, we noticed 3+ anterior chamber cells with occasional vitreous cells in the left eye. Though the tumor looked regressed, there were mild optic disc leakage, early hypofluorescent and late hyperfluorescent punctate lesions scattered 360 degrees, and late staining of the mass on fluorescein angiogram. The findings were compatible with a unilateral multiple evanescent white dot syndrome (MEWDS)-like reaction that was most likely related to CyberKnife SRT-induced tumor necrosis, and a dexamethasone implant was administered intravitreally into the left eye together with topical steroids. A second intravitreal injection of dexamethasone was given three months later due to remittance of the angiographic features. As there are only a few reports on CyberKnife SRT for the treatment of CMM, we wanted to share our interesting observation of a post-treatment MEWDS-like reaction likely related to tumor necrosis syndrome with the ophthalmic community.

Incidence and outcomes of acute kidney injury including hepatorenal syndrome in hospitalized patients with cirrhosis in the US

Acute kidney injury (AKI) in cirrhosis is common and associated with high morbidity, but the incidence rates of different etiologies of AKI are not well described in the US. We compared incidence rates, practice patterns, and outcomes across etiologies of AKI in cirrhosis. We performed a retrospective cohort study of 11 hospital networks, including consecutive adult patients admitted with AKI and cirrhosis in 2019. The etiology of AKI was adjudicated based on pre-specified clinical definitions (prerenal/hypovolemic AKI, hepatorenal syndrome [HRS-AKI], acute tubular necrosis [ATN], other). A total of 2,063 patients were included (median age 62 [IQR 54-69] years, 38.3% female, median MELD-Na score 26 [19-31]). The most common etiology was prerenal AKI (44.3%), followed by ATN (30.4%) and HRS-AKI (12.1%); 6.0% had other AKI, and 7.2% could not be classified. In our cohort, 8.1% of patients received a liver transplant and 36.5% died by 90 days. The lowest rate of death was observed in patients with prerenal AKI (22.2%; p <0.001), while death rates were higher but not significantly different from each other in those with HRS-AKI and ATN (49.0% vs. 52.7%; p= 0.42). Using prerenal AKI as a reference, the adjusted subdistribution hazard ratio (sHR) for 90-day mortality was higher for HRS-AKI (sHR 2.78; 95% CI 2.18-3.54; p <0.001) and ATN (sHR 2.83; 95% CI 2.36-3.41; p <0.001). In adjusted analysis, higher AKI stage and lack of complete response to treatment were associated with an increased risk of 90-day mortality (p <0.001 for all). AKI is a severe complication of cirrhosis. HRS-AKI is uncommon and is associated with similar outcomes to ATN. The etiology of AKI, AKI stage/severity, and non-response to treatment were associated with mortality. Further optimization of vasoconstrictors for HRS-AKI and supportive therapies for ATN are needed. Acute kidney injury (AKI) in cirrhosis carries high morbidity, and management is determined by the etiology of injury. However, a large and well-adjudicated multicenter database from US centers that uses updated AKI definitions is lacking. Our findings demonstrate that acute tubular necrosis and hepatorenal syndrome have similar outcomes (∼50% mortality at 90 days), though hepatorenal syndrome is uncommon (12% of all AKI cases). These findings represent practice patterns at US transplant/tertiary centers and can be used as a baseline, presenting the situation prior to the adoption of terlipressin in the US.

Using social interaction models for genetic analysis of skin damage in gilts.

Skin damage is a trait of economic and welfare importance that results from social interactions between animals. These interactions may produce wound signs on the gilt's skin as a result of damage behavior (i.e., fighting), biting syndromes (i.e., tail, vulva, or ear biting), and swine inflammation and necrosis syndrome. Although current selection for traits that are affected by social interactions primarily focuses on improving direct genetic effects, combined selection on direct and social genetic effects could increase genetic gain and avoid a negative response to selection in cases of competitive behavior. The objectives of this study were to (1) estimate variance components for combined skin damage (CSD), with or without accounting for social genetic effects, (2) investigate the impact of including genomic information on the prediction accuracy, bias, and dispersion of CSD estimated breeding values, and (3) perform a single-step genome-wide association study (ssGWAS) of CSD under a classical and a social interaction model. Our results show that CSD is heritable and affected by social genetic effects. Modeling CSD with social interaction models increased the total heritable variance relative to the phenotypic variance by three-fold compared to the classical model. Including genomic information increased the prediction accuracy of direct, social, and total estimated breeding values for purebred sires by at least 21.2%. Bias and dispersion of estimated breeding values were reduced by including genomic information in classical and social interaction models but remained present. The ssGWAS did not identify any single nucleotide polymorphism that was significantly associated with social or direct genetic effects for CSD. Combined skin damage is heritable, and genetic selection against this trait will increase the welfare of animals in the long term. Combined skin damage is affected by social genetic effects, and modeling this trait with a social interaction model increases the potential for genetic improvement. Including genomic information increases the prediction accuracy of estimated breeding values and reduces their bias and dispersion, although some biases persist. The results of the genome-wide association study indicate that CSD has a polygenic architecture and no major quantitative trait locus was detected.

Expression levels of serine proteases, their homologs, and prophenoloxidase in the Eriocheir sinensis with hepatopancreatic necrosis syndrome (HPNS) and their expression regulation by Runt.

The occurrence of hepatopancreatic necrosis syndrome (HPNS) has seriously affected the sustainable development of Chinese mitten crab (Eriocheir sinensis) farming industry. Limited studies have focused on the immune responses in crabs with HPNS. Serine proteases (SPs) and SP homologues (SPHs) play important roles in the innate immunity of crustaceans. This study investigated the effects of HPNS on the expression levels of genes related to prophenoloxidase (proPO) activation system, and the relationship between Runt transcription factor and the transcriptions of these genes. Eight SPs and five SPHs (SPH1-4, Mas) were identified from E. sinensis. SPs contain a catalytic triad of "HDS", while SPHs lack a catalytic residue. SPs and SPHs all contain a conservative Tryp_SPc domain. Evolutionary analysis showed that EsSPs, EsSPHs, EsPO, and EsRunt were clustered with SPs, SPHs, POs, and Runts of other arthropods, respectively. In crabs with HPNS, the expression levels of six SPs (1, 3, 4, 6, 7, and 8), five SPHs, and PO were significantly upregulated in the hepatopancreas. The knockdown of EsRunt could evidently decrease the expression levels of four SPs (3, 4, 5 and 8), five SPHs (SPH1-4, Mas), and PO. Therefore, the occurrence of HPNS activates the proPO system. Furthermore, the expression levels of partial genes related to proPO system were regulated by Runt. The activation of innate immune system may be a strategy for crabs with HPNS to improve immunity and fight diseases. Our study provides a new understanding of the relationship between HPNS and innate immunity.

Virome Analysis Provides an Insight into the Viral Community of Chinese Mitten Crab Eriocheir sinensis.

Recent advances in viromics have led to the discovery of a great diversity of RNA viruses and the identification of a large number of viral pathogens. A systematic exploration of viruses in Chinese mitten crab (Eriocheir sinensis), one of the most important aquatic commercial species, is still lacking. Here, we characterized the RNA viromes of asymptomatic, milky disease (MD)-affected, and hepatopancreatic necrosis syndrome (HPNS)-affected Chinese mitten crabs collected from 3 regions in China. In total, we identified 31 RNA viruses belonging to 11 orders, 22 of which were first reported here. By comparing viral composition between samples, we observed high variation in viral communities across regions, with most of the viral species being region-specific. We proposed to establish several novel viral families or genera based on the phylogenetic relationships and genome structures of viruses discovered in this study, expanding our knowledge of viral diversity in brachyuran crustaceans. IMPORTANCE High-throughput sequencing and meta-transcriptomic analysis provide us with an efficient tool to discover unknown viruses and explore the composition of viral communities in specific species. In this study, we investigated viromes in asymptomatic and diseased Chinese mitten crabs collected from three distant locations. We observed high regional variation in the composition of viral species, highlighting the importance of multi-location sampling. In addition, we classified several novel and ICTV-unclassified viruses based on their genome structures and phylogenetic relationships, providing a new perspective on current viral taxa.

The bactericidal effects of 632.8 nm He-Ne laser on Staphylococcus aureus colonies

The bactericidal effect of 632.8 nm low level laser has been studied in order to point out both the effective power and laser exposure time on Staphylococcus aureus, which is reported to be involved in several dermatology problems. Low level laser has been reported to be useful for infected wounds, tissue necrosis, nerve injury, osteoarthritis or other chronic pain syndromes. Numerous studies have been conducted to quantify the effective laser parameters, i.e. dose, power, and exposure time, which ultimately leads toward clinical implementation. Staphylococcus aureus bacteria colonies were exposed to laser doses with powers of both 1 and 3 mW at different exposure times varies between 3 to 30 minutes. The bacterial colonies were isolated from a patient with inflamed wounds. Two sets of bacterial colonies were prepared to be exposed to laser beam. Next, the bacterial colonies were compared before and after exposing them to laser doses. The results showed that laser sessions have reduced the number of the bacterial colonies for both doses; 1 and 3 mw at the different exposure times and concentrations. The results revealed significant dose dependent bactericidal effects of He-Ne laser on Staphylococcus aureus at 3 mW for 30 minutes, which was found to be more effective in reducing the amount of bacteria to the less than 2% of its initial count. The results exhibited the reduction of the number of colonies as a function of exposure time. Appropriate doses of 632.8 nm can kill Staphylococcus aureus, suggesting that a similar effect may be used in clinical cases of bacterial infection.

The rare complication of vascular malformations of the limb after sclerotherapy: a report of 3 cases and brief literature review

BackgroundVascular malformations are common but complicated types of disease in infants, with unclear causes and lack of effective prevention. The symptoms usually do not disappear and tend to progress without medical intervention. It is extremely necessary to choose correct treatment options for different types of vascular malformations. A large number of studies have confirmed that sclerotherapy has a tendency to become the first-line treatment in near future, but it is also associated with mild or severe complications. Furthermore, to our knowledge, the serious adverse event of progressive limb necrosis has not been systematically analyzed and reported in the literature.Case presentationThree cases (two females and one male) were presented who were all diagnosed as vascular malformations and were treated by several sessions of interventional sclerotherapy. Their previous medical records showed the use of several sclerosants in different sessions including Polidocanol and Bleomycin. The sign of limb necrosis did not occur during the first sclerotherapy, but after the second and third sessions. Furthermore, the short-term symptomatic treatment could improve the necrosis syndrome, but could not change the outcome of amputation.ConclusionSclerotherapy undoubtedly tends to be the first-line treatment in near future, but the adverse reactions still remain major challenges. Awareness of progressive limb necrosis after sclerotherapy and timely management by experts in centers of experience of this complication can avoid amputation.

Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline.

Extravasation is the leakage of intravenous solutions into surrounding tissues, which can be influenced by drug properties, infusion techniques, and patient-related risk factors. Although peripheral administration of vesicants may increase the risk of extravasation injuries, the time and resources required for central venous catheter placement may delay administration of time-sensitive therapies. Recent literature gathered from the growing use of peripheral vasopressors and hypertonic sodium suggests low risk of harm for initiating these emergent therapies peripherally, which may prevent delays and improve patient outcomes. Physiochemical causes of tissue injury include vasoconstriction, pH-mediated, osmolar-mediated, and cytotoxic mechanisms of extravasation injuries. Acidic agents, such as promethazine, amiodarone, and vancomycin, may cause edema, sloughing, and necrosis secondary to cellular desiccation. Alternatively, basic agents, such as phenytoin and acyclovir, may be more caustic due to deeper tissue penetration of the dissociated hydroxide ions. Osmotically active agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a β2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.