Necrotizing Soft Tissue Fasciitis after Intramuscular Injection

A Case Report of Necrotizing Fasciitis Managed With the Application of Negative Pressure Wound Therapy to Achieve Better Wound Closure

Necrotizing fasciitis is a severe and potentially life-threatening infection of the soft tissues that involves the skin, subcutaneous fat, fascia, and muscle. It can rapidly spread and lead to tissue death, sepsis, toxic shock syndrome, cardiopulmonary failure, and even death, especially in patients with chronic diseases, immunocompromised status, or immobility. To control the spread of necrosis, prompt diagnosis and aggressive surgical intervention with radical debridement of the affected tissues are essential, along with the administration of broad-spectrum antibiotics and intensive care support, when required. The application of negative pressure wound therapy has been utilized in the management of acute and complicated wounds with good outcomes. Here, we present a case of an 82-year-old female who presented with fever, tachycardia, and hypotension with underlying comorbid conditions of diabetes mellitus, hypertension, and spinal stenosis. On further exploration, she was found to have necrotizing fasciitis involving the left gluteal region. The present article describes the use of a vacuum-assisted closure dressing as an adjunct to serial debridement in the treatment of severe necrotizing fasciitis.

Cerebroventricular Microinjections of MPTP on Adult Zebrafish Induces Dopaminergic Neuronal Death, Mitochondrial Fragmentation, and Sensorimotor Impairments

Mitochondria are dynamic organelles that mediate the energetic supply to cells and mitigate oxidative stress through the intricate balance of fission and fusion. Mitochondrial dysfunction is a prominent feature within Parkinson disease (PD) etiologies. To date, there have been conflicting studies of neurotoxin impact on dopaminergic cell death, mitochondrial function and behavioral impairment using adult zebrafish. Here, we performed cerebroventricular microinjections (CVMIs) of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) on adult transgenic zebrafish that resulted in significant reductions in dopaminergic neurons within the telencephalon and olfactory bulbs (OB) of Tg(dat:eGFP) fish. Visualization of mCherry and mitochondrial gene expression analysis in Tg(dat:tom20 MLS:mCherry) fish reveal that MPTP induces mitochondrial fragmentation in dopaminergic neurons and the activation of the pink1/parkin pathway involved mitophagy. Moreover, the loss of dopaminergic neurons translated into a transient locomotor and olfactory phenotype. Taken together, these data can contribute to a better understanding of the mitochondrial impact on dopaminergic survivability.

Clinical Decision Support Reduces Unnecessary Tetanus Vaccinations in the Emergency Department

STUDY OBJECTIVE

Tetanus is the most common vaccination given in the emergency department; yet, administrations of tetanus vaccine boosters in the ED may not comply with the US Centers for Disease Control and Prevention's recommended vaccination schedule. We implemented a clinical decision support alert in the electronic health record that warned providers when ordering a tetanus vaccine if a prior one had been given within 10 years and studied its efficacy to reduce potentially unnecessary vaccines in the ED.

METHODS

This was a retrospective, quasi-experimental, 1-group, pretest-posttest study in 3 hospital EDs in Boston, MA. We studied adult patients for whom tetanus vaccines were ordered despite a history of vaccination within the prior 10 years. We compared the number of potentially unnecessary tetanus vaccine administrations in a baseline phase (when the clinical decision support alert was not visible) versus an intervention phase.

RESULTS

Of eligible patients, 22.1% (95% confidence interval [CI] 21.8% to 22.4%) had prior tetanus vaccines within 5 years, 12.8% (95% CI 12.5% to 13.0%) within 5 to 10 years, 3.8% (95% CI 3.6% to 3.9%) more than 10 years ago, and 61.3% (95% CI 60.9% to 61.7%) had no prior tetanus vaccination documentation. Of 60,983 encounters, 337 met the inclusion criteria. A tetanus vaccination was administered in 91% (95% CI 87% to 96%) of encounters in the baseline phase, compared to 55% (95% CI 47% to 62%) during the intervention. The absolute risk reduction was 36.7% (95% CI 28.0% to 45.4%), and the number of encounters needed to alert to avoid 1 potentially unnecessary tetanus vaccine (number needed to treat) was 2.7 (95% CI 2.2% to 3.6%). For patients with tetanus vaccines within the prior 5 years, the absolute risk reduction was 47.9% (95% CI 35.5 % to 60.3%) and the number needed to treat was 2.1 (95% CI 1.7% to 2.8%).

CONCLUSION

A clinical decision support alert that warns ED clinicians that a patient may have an up-to-date tetanus vaccination status reduces potentially unnecessary vaccinations.