Necrotising fasciitis: an 8.5-year retrospective case review in a New Zealand intensive care unit.

BACKGROUND: Necrotising fasciitis is a rare, rapidly progressive soft tissue infection associated with extensive necrosis, profound shock and high morbidity and mortality. Incidence worldwide is thought to be increasing. OBJECTIVE: To investigate the demographics, comorbidities, microbiological features, resource use and outcome of patients with necrotising fasciitis. We aimed to identify factors associated with mortality. DESIGN, PARTICIPANTS AND SETTING: A retrospective case and chart review was performed in consecutive patients with necrotising fasciitis admitted to the intensive care unit of a tertiary hospital between January 2000 and June 2008. RESULTS: 58 patients with necrotising fasciitis were admitted during the study period. Pacific Islander and Maori peoples were overrepresented. Comorbidities were consistent with previous studies except for a high incidence of gout. Lower limb was the most frequent site of infection (53%). Swelling (83%) and severe pain (76%) were the most common presenting features. Type 2 infection (52%) was more common than type 1 (43%). Mortality was 29%. Recent non-steroidal antiinflammatory drug use was reported by 43% of patients but not associated with mortality. Logistic regression modelling identified Acute Physiology and Chronic Health Evaluation (APACHE) II score, pre-existing abnormal renal function and gout to be associated with mortality. CONCLUSIONS: There is an higher incidence of necrotising fasciitis at our hospital in South Auckland than reported elsewhere. Maori and Pacific Islander people are at increased risk. In our patient sample APACHE II score, preexisting abnormal renal function and gout were associated with mortality.

Long-term mechanical consequences of permanent right ventricular pacing: effect of pacing site.

INTRODUCTION: Long-term right ventricular apical (RVA) pacing has been associated with adverse effects on left ventricular systolic function; however, the comparative effects of right ventricular outflow tract (RVOT) pacing are unknown. Our aim was therefore to examine the long-term effects of septal RVOT versus RVA pacing on left ventricular and atrial structure and function. METHODS: Fifty-eight patients who were prospectively randomized to long-term pacing either from the right ventricular apex or RVOT septum were studied echocardiographically. Left ventricular (LV) and atrial (LA) volumes were measured. LV 2D strain and tissue velocity images were analyzed to measure 18-segment time-to-peak longitudinal systolic strain and 12-segment time-to-peak systolic tissue velocity. Intra-LV synchrony was assessed by their respective standard deviations. Interventricular mechanical delay was measured as the difference in time-to-onset of systolic flow in the RVOT and LV outflow tract. Septal A' was measured using tissue velocity images. RESULTS: Following 29 ± 10 months pacing, there was a significant difference in LV ejection fraction (P < 0.001), LV end-systolic volume (P = 0.007), and LA volume (P = 0.02) favoring the RVOT-paced group over the RVA-paced patients. RVA-pacing was associated with greater interventricular mechanical dyssynchrony and intra-LV dyssynchrony than RVOT-pacing. Septal A' was adversely affected by intra-LV dyssynchrony (P < 0.05). CONCLUSIONS: Long-term RVOT-pacing was associated with superior indices of LV structure and function compared with RVA-pacing, and was associated with less adverse LA remodeling. If pacing cannot be avoided, the RVOT septum may be the preferred site for right ventricular pacing.