[Necrotizing fasciitis].

Necrotizing soft tissue infections (NSTI) is a serious infection with a mortality of up to 25% at three months. This review gives an overview of the diagnosis and treatment of NSTI. The prognosis is dependent on rapid surgical treatment, aggressive, prompt removal of infected tissue, broad spectrum antibiotic treatment and supportive care. In cases with suspected or verified infection with Streptococcus pyogenes, adjuvant therapy with immunoglobulins can be considered.

Healthcare professionals' experience of using in situ simulation training in preparation for the COVID-19 pandemic: a qualitative focus group study from a Danish hospital.

OBJECTIVES: The COVID-19 pandemic forced hospital organisation and healthcare professionals to prepare for large quantities of patients in isolation rooms. In situ simulation may seem promising in order to manage the organisational changes that the pandemic require. This study aims to investigate in situ simulations influence on healthcare professional's self-perceived preparedness to face the pandemic. DESIGN: A qualitative focus group study. SETTING: We conducted full scale in situ simulations over a 3-week period in April 2020, including 277 healthcare professionals, at a Danish University Hospital. Subsequently, six semistructured focus group interviews, including 22 participants from the simulations, were conducted in May 2020. PARTICIPANTS: 22 healthcare professionals participated in the focus group interviews. METHODS: The simulations consisted of a briefing, two scenarios focusing on acute respiratory insufficiency and correct use of personal protective equipment (PPE), and a debriefing. We conducted six focus group interviews using comparable semistructured interview guides focusing on the organisational restructuring of the departments and outcomes of the needs-driven simulation-based programme. We used thematic analysis to identify main themes. RESULTS: The informants perceived that the simulations resulted in positive experiences for the healthcare professionals and perceived the organisational changes as effective. They highlighted that simulation enhanced teamwork, demystified the COVID-19 disease, and improved skills, in correct use of PPE and acute treatment of COVID-19 patients. Data revealed that a predefined simulation task force including both experienced simulators and medical experts for facilitation of in situ simulation would be beneficial. CONCLUSION: In situ simulation may be useful to enhance learning on organisation and individual level during a pandemic. This educational activity could serve an important role in facilitating hospital preparation and education of large numbers of healthcare professionals during a healthcare crisis. Introduction of a simulation task force is suggested to handle coordination and rapid enrolment across the hospital.

Prognostic and discriminative accuracy of the quick Sepsis-related Organ Failure Assessment compared with an early warning score: a Danish cohort study.

BACKGROUND: The clinical benefit of implementing the quick Sepsis-related Organ Failure Assessment (qSOFA) instead of early warning scores (EWS) to screen all hospitalised patients for critical illness has yet to be investigated in a large, multicentre study. METHODS: We conducted a cohort study including all hospitalised patients ≥18 years with EWS recorded at hospitals in the Central Denmark Region during the year 2016. The primary outcome was intensive care unit (ICU) admission and/or death within 2 days following an initial EWS. Prognostic accuracy was examined using sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV). Discriminative accuracy was examined by the area under the receiver operating characteristic curve (AUROC). RESULTS: Among 97 332 evaluated patients, 1714 (1.8%) experienced the primary outcome. The qSOFA ≥2 was less sensitive (11.7% (95% CI: 10.2% to 13.3%) vs 25.1% (95% CI: 23.1% to 27.3%)) and more specific (99.3% (95% CI: 99.2% to 99.3%) vs 97.5% (95% CI: 97.4% to 97.6%)) than EWS ≥5. The NPV was similar for the two scores (EWS ≥5, 98.6% (95% CI: 98.6% to 98.7%) and qSOFA ≥2, 98.4% (95% CI: 98.3% to 98.5%)), while the PPV was 15.1% (95% CI: 13.8% to 16.5%) for EWS ≥5 and 22.4% (95% CI: 19.7% to 25.3%) for qSOFA ≥2. The AUROC was 0.72 (95% CI: 0.70 to 0.73) for EWS and 0.66 (95% CI: 0.65 to 0.67) for qSOFA. CONCLUSION: The qSOFA was less sensitive (qSOFA ≥2 vs EWS ≥5) and discriminatively accurate than the EWS for predicting ICU admission and/or death within 2 days after an initial EWS. This study did not support replacing EWS with qSOFA in all hospitalised patients.

Clinical presentation and outcomes of COVID-19 in older hospitalised patients assessed by the record-based multidimensional prognostic index, a cross-sectional study.

PURPOSE: Older people are the most frequently hospital admitted patients with COVID-19. We aimed to describe the clinical presentation of COVID-19 among frail and nonfrail older hospitalised patients and to evaluate the potential association between frailty and clinical course, decision of treatment level with outcomes change in functional capacity and survival. METHODS: We performed a multi-center, retrospective cross-sectional cohort study examining data on clinical presentation and frailty-related domains for hospitalised people aged 75 + years with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test. Frailty was assessed at admission using record-based MPI (rMPI) and Clinical Frailty Scale (CFS). Decision on treatment level about invasive ventilation and cardiopulmonary resuscitation (CPR), change in CFS-score from admission to discharge, changed need of home care, and in-hospital, 30-day and 90-day mortality were registered. RESULTS: 100 patients (median age 82 years (IQR 78-86), 56% female) with COVID-19 were included. 54 patients were assessed moderately or severely frail (rMPI-score = 2 or 3) and compared to non-frail (rMPI-score = 1). At admission, frail patients presented more frequently with confusion. At discharge, functional decline measured by change in CFS and increased home care was more prevalent among frail than the non-frail. Decisions about no invasive ventilation or CPR were more prevalent among frail older patients with COVID-19 than non-frail. Ninety-day mortality was 70% among frail patients versus 15% in non-frail. CONCLUSION: Frailty seems to be associated with confusion, more frequent decisions about treatment level, larger functional decline at discharge and a higher mortality rate among older patients with COVID-19.

The 7-day mortality associated with an early warning score varies between age groups in a cohort of adult Danish emergency department patients.

INTRODUCTION: Early warning scores are designed for monitoring hospitalized patients and enable a timely response to deviating vital signs. The aim of this study was to examine whether 7-day mortality, associated with an initial early warning score, differs between age groups. Our hypothesis was that elderly patients are at greater risk of dying compared to a younger patient with a similar early warning score. METHODS: This observational cohort study included adult emergency department patients from five hospitals in Denmark over three consecutive months in 2015. Logistic regression was used to examine the relationship between patients' initial early warning scores category (0, 1-2, 3-4, 5-6, 7+) and 7-day mortality in different age groups (16-59 years, 60-79 years, 80+ years). Mortality rates in each early warning scores category are compared between the youngest patients (16-59 years, reference group) and the two older age groups (60-79 years and 80+ years). RESULTS: A total of 19 123 emergency patients were included. The senior age groups (60-79 years and 80+ years) both displayed significantly higher 7-day mortality, in all early warning score categories, when compared to the youngest patients (16-59 years). The mortality difference between the youngest (16-59 years) and oldest age group (80+ years) remained significant in all early warning scores categories after adjusting for comorbidity. CONCLUSION: Our findings show that the oldest emergency department patients (80+ years) have a higher 7-day mortality compared to young patients (16-59 years) with a similar initial early warning score.

Severe capillary leak syndrome with cardiac arrest triggered by influenza virus infection.

Systemic capillary leak syndrome (SCLS), also known as Clarkson syndrome, is a rare disease with potential fatal outcome. The clinical picture involves leakage of fluid and protein from the bloodstream into peripheral tissues, resulting in hypoalbuminaemia, elevated haematocrit, oedema and hypotension. The spectrum of the symptoms ranges from discrete swelling/oedema of extremities to fulminant cardiogenic shock. We present a case with a 52-year-old man diagnosed with SCLS after being resuscitated from cardiac arrest, which was complicated by compartment syndrome. The severe episode of capillary leak was potentially triggered by influenza virus infection. With the benefit of hindsight, he presented with symptoms of SCLS 2 years prior the major acute episode. Here we describe this case and review some aspects of the literature on SCLS, with particular focus on the pathogenesis, treatment/prophylaxis and long-term physical and psychological complications.

Leukocyte, plasma, and organ-associated cytokine profiles in an animal model of acute inflammation.

Systemic administered lipopolysaccharide (LPS) induces a cytokine response in peripheral blood without correlations with cytokine content at the organ level. We hypothesised (1) that cytokine mRNA expression in peripheral blood mononuclear cells (PBMCs) preceded the plasma cytokine increase during endotoxaemia and (2) that statins as anti-inflammatory agents modified the LPS-induced cytokine responses. 30 pigs were randomised into 3 groups: placebo (I) or atorvastatin 80 mg (II) for 21 days, followed by LPS-infusion on day 22, or controls (III). LPS was infused at increasing concentrations (2.5 to 15 microg/kg/h) for 30 min, followed by sustained infusion (2.5 microg/kg/h) for 330 min. We measured plasma IL-6, IL-10, and TNF-alpha, and their mRNA expression in PBMCs during the LPS-infusion, and the cytokine content in kidney and heart biopsies at 360 min. LPS reduced TNF-alpha mRNA in PBMCs at 60 min, whereas IL-6 mRNA increased at 240 min. There were no correlations with plasma cytokines, which peaked at 60 min (IL-10 and TNF-alpha) and 240 min (IL-6). Cytokine content did not increase in organs, and no effects of statins could be demonstrated. In conclusion, LPS-infusion reduced leukocyte TNF-alpha mRNA and increased IL-6 mRNA, whereas plasma TNF-alpha, IL-6, and IL-10 increased markedly.