Evaluation of laboratory risk indicator for necrotizing fasciitis score as an early diagnostic tool for necrotizing fasciitis: a prospective observational study

Introduction

From its historical identification to modern times with advancements in management modalities globally, the mortality of necrotizing fasciitis (NF) is high ranging from 19 to 30% for all affected sites. Although many diagnostic adjuncts have been developed to assist with the prompt and accurate diagnosis of NF, the primary diagnosis is still based on high clinical suspicion. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed as a tool for distinguishing NF from other soft tissue infections. The main objective of this study is to evaluate LRINEC as a tool for early diagnosis of NF and differentiating it from other soft tissue infections like cellulitis.

Methods

This is a single-centered, prospective observational study. Patients presenting with soft tissue infections of the limbs to the emergency department from November 2020 to October 2021 were included in this study. The clinical findings and blood parameters for the LRINEC score were collected and the score was calculated. Based on clinical suspicion of NF, patients underwent debridement and had a tissue biopsy to confirm the diagnosis. The data obtained was analyzed using SPSS version 24 and MS Excel. The AUC curve was used to calculate a cutoff, sensitivity, specificity, positive predictive value, and negative predictive values for the LRINEC score based on our study.

Results

Forty-five patients with 28 males and 17 females were included. The average age was 53.667 years within a range of 19-79 years. Among them 44.4% of the patients had NF and 66.6% had other minor forms of soft tissue infections. The ROC curve obtained a cutoff value of greater than or equal to 6, with an AUC of 0.751. At this cut of value study showed a sensitivity of 85% with a specificity of 52%. Similarly, positive predictive value was found to be 58.62%, negative predictive values of 81.25%, and overall accuracy of 66.67% in early diagnosis of NF.

Conclusion

In conclusion, our study showed that the LRINEC score can be a reliable tool for the early diagnosis of NF in an ED setting. This scoring system is best to be used to rule out NF.

Combined personalized therapy for the treatment of multiple giant keloids: a case report and literature review

Keloids are the result of an abnormal wound-healing process and are associated with various risk factors. The majority of diagnoses are clinical. Successful treatment of keloid is challenging due to its nonregressing and recurring nature.

Case presentation

We discuss the case of a 30-year-old mongoloid male who had multiple swellings over his body for the past 10 years. More striking are the giant keloids that are present over his bilateral scapulae. Diagnosis of keloid was made clinically. Smaller sessile lesions over his shoulder and upper limbs were subjected to intralesional 5-fluorouracil and triamcinolone injections, whereas the giant bilateral scapular keloids underwent excision and split skin grafting.

Clinical discussion

Keloids usually present with firm and rubbery masses that extend beyond the site of the previous wound/injury. Keloids are diagnosed and evaluated clinically. Its differentiation from the hypertrophic scar is done based on the presence of multiple lesions beyond the site of the previous wound/injury.

Conclusion

Treatment of keloids is difficult due to their nonregressing and recurring nature. Hence, the main goal of treatment is to tailor the therapy to the patient's needs such that the benefits outweigh the risks.

Pattern of bear maul injuries in tertiary hospital in Nepal: demographic, management and outcome

Introduction: Nepal is a country full of forests and with increase in urbanization there is encroachment into the territories of wild animals. Their encounters have been in the rise and bear maul seem to be one of the leading cause of wild animal attacks. The injuries are very disastrous and leave behind permanent disfigurements and disabilities.Methods: All of cases of bear maul treated in TU Teaching Hospital for the last 6 year were studied. Analysis of pattern and severity of the injuries were done along with the complication and its morbidities.Results: Total of 17 cases was studied. Majority of the cases were male and at age of 20 to 40 years. All but one were sudden attack by Himalayan black bear (15 cases) using their claws (in 17 cases) mostly to the face (16 cases), eyes (10 cases) and scalp (8 cases) resulting in fractures (14 cases). There were more proportion of patient with the complex wounds (10 cases) requiring initial debridement followed by closure with graft (5 cases), flap (5 cases) or free flaps (1 case) than the simple wounds which were just debridement and closed with primary (5 cases) or secondary sutures (2 cases). All patients were left with ugly scar and majority had facial disfigurements (12 cases) with major contour deformities (7 cases). Four patients had permanent vision loss in one eye.Conclusion: The rising trend of bear maul injuries, are complex injuries requiring prompt multidisciplinary approach of management. Face and eyes are the most common sites of injuries and often associated with underlying fractures. Bear maul though rarely fatal, leaves permanent disfigurement and disabilities.JSSN 2015; 18 (1), Page: 17-22

Antibiotic usage and its sensitivity pattern in the NICU

BACKGROUND

Sepsis is a major cause of mortality and morbidity in newborns affecting both developed and developing countries accounting a quarter around one million deaths per annum.

OBJECTIVE

This study was aimed to assess the prevalence of neonatal sepsis, culture isolates, pattern, antibiotic sensitivity and drug prescribing pattern.

METHODS

In present prospective study, 48 neonates admitted in pediatric ward from January to March 2011 of Dhulikhel Hospital were included. The gestation age, onset of sepsis, culture isolates, antibiotic sensitivity pattern and drug prescribing pattern were studied. Environmental air sampling of NICU (Neonatal Intensive Care Unit) was done by settle plate method for microbial examination.

RESULT

Among 48 neonates, 23 (47.92%) neonates were culture positive with predominant isolates of Klebsiella oxytoca 11(47.83%), Pseudomonas sp. 4(17.39%), Methicillin Resistant Staphylococcus Aureus (MRSA) 3(13.04%) and single case of Enterobacter spp. In environmental samples, K. oxytoca and Enterobacter sp. were isolated. Amikacin, Imepeneum and Ciprofloxacin were sensitive whereas Ampicillin in combination with Cloxacillin, Ampicillin, Aztreonam were resistant for Klebsiella. oxytoca. Amikacin, Ceftazidime and Imipenuem were sensitive to Enterobacter spp. The single or combinations of resistant antibiotics were found to be prescribed.

CONCLUSION

The emerging antibiotic resistances among the culture isolates and coherence with environmental samples were observed. Hence, special measures are imperative for reducing environmental contamination and the rational usage of antibiotics for preventing the infection and emerging antibiotic resistance. The study recommends need of the antibiotic policy to curb the present scenario.

Abortifacient effect of metoclopramide in female albino rats

BACKGROUND

Metoclopramide a dopamine receptor antagonist is commonly used to treat nausea and vomiting. Long term use can cause parkinsonism, galactorrhoea and gynaecomastia. As it is lipid soluble, it enters the brain, easily crosses the placental barrier and can affect the fetus. Hence, the present study is designed to assess the risk of metoclopramide in pregnant albino rats.

OBJECTIVES

To study the abortifacient effect of metoclopramide in pregnant albino rats.

METHODS

Eighteen pregnant rats were divided into three groups of six rats each. The abortifacient activities of metoclopramide were studied in the doses of 1 mg/kg and 3 mg/kg intramuscularly. The treatments were started on the 6th day of pregnancy and continued till the 15th day. Rats were laparotomised on 19th day of pregnancy for evaluation of abortifacient action. In both the horns of the uterus, number of implantation sites, resorption sites, dead and live fetuses were observed.

RESULTS

The mean percentage of aborted fetus was 17.22 +/= 21.13 33.88 +/= 37.73 after 1mg/kg and 85.21 +/=18.93 after 3mg/kg of metoclopramide. The abortifacient effect of higher dose was significantly larger compared to both control group and low dose group, but there was no significant difference between the mean percentage of abortion in control group and the low dose group of metoclopramide.

CONCLUSION

Metoclopramide at 3mg/kg intra muscular has abortifacient effects in female albino rats.

Pandemic (H1N1) 2009 Cases in Nepal

We analyzed the data available in Nepal during this pandemic in order to determine the epidemiological, clinical and virological characteristics of pandemic influenza A in 2009. The test was conducted by real-time Reverse Transcription – Polymerase Chain Reaction on sample from patients with suspected influenza-like illnesses. Out of 538 cases were tested, 32 % were positive for pandemic influenza A 2009 and the infection rate was highest for cases of 11-20 years and lowest in >50 years of age. Keywords: Influenza A ; pandemic; RT-PCR; surveillance.

Pandemic (H1N1) 2009 cases in Nepal

We analyzed the data available in Nepal during this pandemic in order to determine the epidemiological, clinical and virological characteristics of pandemic influenza A in 2009. The test was conducted by real-time Reverse Transcription--Polymerase Chain Reaction on sample from patients with suspected influenza-like illnesses. Out of 538 cases were tested, 32% were positive for pandemic influenza A 2009 and the infection rate was highest for cases of 11-20 years and lowest in >50 years of age.

Pandemic influenza A (H1N1) 2009 outbreak investigation in Nepal

BACKGROUND

The World Health Organization, on 24 April 2009, announced a Public Health emergency of international concern caused by a new influenza virus Pandemic Influenza A 2009. The objective of this study was to analyze the basic epidemiology and distribution of Pandemic Influenza A 2009 in order to understand the course of Pandemic Influenza A 2009 in Nepal.

METHODS

The analyses were based upon all confirmed and probable cases that consulted Avian Influenza Control Project and National Public Health Laboratory during 29 April 2009 to 21 September 2010.

RESULTS

Out of total 739 suspected samples collected, Pandemic Influenza A 2009 was detected in 210 cases in different districts of Nepal. The majority of cases were from the urban settlement of Kathmandu valley, Chitwan and Kaski and among age group 11-30 years. The clinical attack rate for Influenza like illness (ILI) was 28.48%. There was no significant difference between the clinical presentation of ILI and confirmed cases of Pandemic Influenza A 2009.

CONCLUSIONS

This study presented the investigation of outbreak that helped to inform the course of epidemic in affected population and therefore urge for public health interventions.

Epidemiological Situation of Japanese Encephalitis in Nepal

A human Japanese encephalitis (JE) case is considered to have elevated temperature (over 380C) along withaltered consciousness or unconsciousness and is generally confirmed serologically by finding of specific anti-JEIgM in the cerebro spinal fluid. No specific treatment for JE is available. Only supportive treatment likemeticulous nursing care, introduction of Ryle’s tube if the patient is unconscious, dextrose solution if dehydrationis present, manitol injection in case of raised cranial temperature and diazepam in case of convulsion. Intravenous fluids, indwelling catheter in conscious patient and corticosteroids unless indicated should be avoided.Pigs, wading birds and ducks have been incriminated as important vertebrate amplifying hosts for JE virusdue to viremia in them. Man along with bovines, ovines and caprines is involved in transmission cycle asaccidental hosts and plays no role in perpetuating the virus due to the lack of viremia in them. The species Cxtritaeniorhyncus is suspected to be the principal vector of JE in Nepal as the species is abundantly found in therice-field ecosystemof the endemic areas during the transmission season and JE virus isolates have been obtainedfrom a pool of Cx tritaeniorhyncus females. Mosquito vector become infective 14 days after acquiring the JRvirus from the viremic host. The disease was first recorded in Nepal in 1978 as an epidemic in Rupandehidistrict of the Western Development Region (WDR) and Morang of the Eastern Region (EDR). At present thedisease is endemic in 24 districts.Although JE as found endemic mainly in tropical climate areas, existense andproliferation of encephalitis causing viruses in temperate and cold climates of hills and valleys are possible.Total of 26,667 cases and 5,381 deaths have been reported with average case fatality rate of 20.2% in anaggregate since 1978. More than 50% of morbidity and 60% mortality occur in the age group below 15 years.Upsurge of cases take place after the rainy season (monsoon). Cases start to appear in the month ofApril - Mayand reach its peak during late August to early September and start to decline from October. There are fourdesignated referral laboratories, namely National Public Health Laboratory (Teku), Vector Borne DiseasesResearch and Training Center (Hetauda), B.P. Koirala Institute of Medical Sciences (Dharan) and JE Laboratory(Nepalgunj), for confirmatory diagnosis of JE. For prevention of JE infection;chemical and biological controlof vectors including environmental management at breeding sites are necessary. Segregate pigs from humanshabitation. Wear long sleeved clothes and trousersand use repellent and bed net to avoid exposure to mosquitos.For the prevention of the disease in humans, safe and efficacious vaccines are available. Therefore immunizepopulation at risk against JE. Immunize pigs at the surroundings against JE. 225,000 doses of live attenuatedSA-14-14.2 JE vaccine were received in donation from Boran Pharmaceuticals, South Korea for the first timein Nepal. Altogether 224,000 children aged between 1 to 15 years were vaccinated in Banke, Bardiya andKailali districts during 1999. From China also, 2,000,000 doses of inactivated vaccine were received in 2000and a total of 481,421 children aged between 6m to 10 yrswere protected from JE during 2001/2002. Ministryof Agriculture, Department of Livestock Services has vaccinated around 200,000 pigs against JE in terai zoneduring February 2001.Key Words: Supportive treatment, viremia, amplifying host, vectors, vaccination/immunization.

Epidemiological situation of Japanese encephalitis in Nepal

A human Japanese encephalitis (JE) case is considered to have elevated temperature (over 380 C) along with altered consciousness or unconsciousness and is generally confirmed serologically by finding of specific anti-JE IgM in the cerebro spinal fluid. No specific treatment for JE is available. Only supportive treatment like meticulous nursing care, introduction of Ryle's tube if the patient is unconscious, dextrose solution if dehydration is present, manitol injection in case of raised cranial temperature and diazepam in case of convulsion. Intra venous fluids, indwelling catheter in conscious patient and corticosteroids unless indicated should be avoided. Pigs, wading birds and ducks have been incriminated as important vertebrate amplifying hosts for JE virus due to viremia in them. Man along with bovines, ovines and caprines is involved in transmission cycle as accidental hosts and plays no role in perpetuating the virus due to the lack of viremia in them. The species Cx tritaeniorhyncus is suspected to be the principal vector of JE in Nepal as the species is abundantly found in the rice-field ecosystem of the endemic areas during the transmission season and JE virus isolates have been obtained from a pool of Cx tritaeniorhyncus females. Mosquito vector become infective 14 days after acquiring the JR virus from the viremic host. The disease was first recorded in Nepal in 1978 as an epidemic in Rupandehi district of the Western Development Region (WDR) and Morang of the Eastern Region (EDR). At present the disease is endemic in 24 districts. Although JE as found endemic mainly in tropical climate areas, existence and proliferation of encephalitis causing viruses in temperate and cold climates of hills and valleys are possible. Total of 26,667 cases and 5,381 deaths have been reported with average case fatality rate of 20.2% in an aggregate since 1978. More than 50% of morbidity and 60% mortality occur in the age group below 15 years. Upsurge of cases take place after the rainy season (monsoon). Cases start to appear in the month of April - May and reach its peak during late August to early September and start to decline from October. There are four designated referral laboratories, namely National Public Health Laboratory (Teku), Vector Borne Diseases Research and Training Center (Hetauda), B.P. Koirala Institute of Medical Sciences (Dharan) and JE Laboratory (Nepalgunj), for confirmatory diagnosis of JE. For prevention of JE infection; chemical and biological control of vectors including environmental management at breeding sites are necessary. Segregate pigs from humans habitation. Wear long sleeved clothes and trousers and use repellent and bed net to avoid exposure to mosquitos. For the prevention of the disease in humans, safe and efficacious vaccines are available. Therefore immunize population at risk against JE. Immunize pigs at the surroundings against JE. 225,000 doses of live attenuated SA-14-14.2 JE vaccine were received in donation from Boran Pharmaceuticals, South Korea for the first time in Nepal. Altogether 224,000 children aged between 1 to 15 years were vaccinated in Banke, Bardiya and Kailali districts during 1999. From China also, 2,000,000 doses of inactivated vaccine were received in 2000 and a total of 481,421 children aged between 6m to 10 yrs were protected from JE during 2001/2002. Ministry of Agriculture, Department of Livestock Services has vaccinated around 200,000 pigs against JE in terai zone during February 2001.