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2.
Dermatol Online J ; 27(1)2021 Jan 15.
Artículo en Inglés | MEDLINE | ID: mdl-33560789

RESUMEN

Orf virus causes a self-limited infection in humans that resolves without scarring within 6-12 weeks. However, lesions in the immunocompromised can be progressive and disfiguring. The lesions frequently recur after treatment. To our knowledge, there are eleven published cases of these infections. We propose the name orf progressiva to call attention to this progressive, treatment-resistant entity. We present a 43-year-old male ranch owner with a history of renal transplantation who contracted an orf infection from his lamb. The infection recurred despite attempts at debridement, but achieved near complete resolution after treatment with imiquimod and valacyclovir. The histologic findings of orf progressiva are identical to the early stages of classic orf infection and are characterized by epithelial hyperplasia, intracytoplasmic eosinophilic inclusions, and an edematous, vascular dermis. There is no standard treatment for orf progressiva. Surgical excision has frequently resulted in rapid reoccurrence. Topical therapies such as imiquimod and cidofovir cream in combination with excision have been successful in some cases. Acyclovir or valacyclovir with imiquimod has been reported to be effective. Two patients achieved cure with imiquimod alone. We summarize these cases to prompt recognition of orf progressiva as a distinct clinical entity that requires treatment.


Asunto(s)
Ectima Contagioso/inmunología , Huésped Inmunocomprometido , Adulto , Antibacterianos/uso terapéutico , Antivirales/uso terapéutico , Ciprofloxacina/uso terapéutico , Desbridamiento , Quimioterapia Combinada , Ectima Contagioso/diagnóstico , Ectima Contagioso/tratamiento farmacológico , Ectima Contagioso/patología , Humanos , Imiquimod/uso terapéutico , Trasplante de Riñón , Masculino , Infecciones por Pseudomonas/diagnóstico , Infecciones por Pseudomonas/tratamiento farmacológico , Infecciones por Pseudomonas/inmunología , Infecciones por Pseudomonas/patología , Pseudomonas aeruginosa , Sobreinfección , Valaciclovir/uso terapéutico
4.
Pediatr Dermatol ; 35(2): e110-e113, 2018 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-29314211

RESUMEN

Congenital syphilis is an infection transmitted from mother to fetus and can present with early but variable cutaneous manifestations. In rare situations, a bullous eruption known as pemphigus syphiliticus may develop. We present an unusual case of broad desquamation of the extremities in a newborn infant who was found to have congenital syphilis. Pemphigus syphiliticus should be considered in the differential diagnosis of neonatal bullous eruptions and erosions.


Asunto(s)
Pénfigo/etiología , Sífilis Congénita/diagnóstico , Sífilis Cutánea/diagnóstico , Antibacterianos/uso terapéutico , Diagnóstico Diferencial , Humanos , Recién Nacido , Pénfigo/diagnóstico , Penicilinas/uso terapéutico , Piel/patología , Sífilis Congénita/tratamiento farmacológico
5.
Dermatol Online J ; 24(10)2018 Oct 15.
Artículo en Inglés | MEDLINE | ID: mdl-30677813

RESUMEN

Angiokeratomas are benign vascular ectasias in the papillary dermis associated with epidermal changes in the form of hyperkeratosis and/or acanthosis. Clinically, angiokeratomas appear as solitary or multiple dark red to purple-black macules and/or papules, mostly with a verrucous surface. Five subtypes of angiokeratoma have been proposed - angiokeratoma corporis diffusum, angiokeratoma of Mibelli, angiokeratoma of Fordyce, angiokeratoma circumscriptum, and "solitary and multiple" angiokeratomas. We report an unusual case of multiple angiokeratomas in a zosteriform distribution with onset at age 74.


Asunto(s)
Angioqueratoma/patología , Neoplasias Primarias Múltiples/patología , Neoplasias Cutáneas/patología , Edad de Inicio , Anciano , Angioqueratoma/diagnóstico , Nalgas , Humanos , Masculino , Neoplasias Primarias Múltiples/diagnóstico , Neoplasias Cutáneas/diagnóstico
7.
Am J Dermatopathol ; 39(4): 296-299, 2017 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-28328616

RESUMEN

INTRODUCTION: Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae, an intracellular acid-fast bacillus that tends to infect the skin and peripheral nerves. Because of the wide array of cutaneous manifestation, diagnosis is not always straightforward, especially in nonendemic regions of the world such as the United States. CASE REPORT: The authors report an unusual case of borderline tuberculoid leprosy in an 80-year-old white woman from California. Clinical examination revealed multiple nonscaly annular plaques, with central clearing and absence of lesional anesthesia, distributed over the trunk and extremities initially clinically diagnosed as granuloma annulare (GA). After 2 years of unsuccessful treatment with topical corticosteroid, biopsy revealed a palisaded and interstitial granulomatous infiltrate with necrobiosis, without discrete granulomas, compatible with GA. However, the presence of perineural lymphocytes in the reticular dermis prompted a Fite stain, which revealed acid-fast bacilli within the Schwann cells of a small peripheral nerve, pathognomonic for leprosy. CONCLUSION: This is the first reported case of leprosy masquerading both clinically and histologically as GA. Dermatopathologists should be aware of the possibility of leprosy given the presence of perineural lymphocytes amidst any pattern of granulomatous infiltrate and obtain a Fite stain.


Asunto(s)
Granuloma Anular/diagnóstico , Lepra Dimorfa/diagnóstico , Anciano de 80 o más Años , Errores Diagnósticos , Femenino , Humanos
8.
JAAD Case Rep ; 3(2): 93-94, 2017 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-28280767
9.
Dermatol Online J ; 23(7)2017 Jul 15.
Artículo en Inglés | MEDLINE | ID: mdl-29469709

RESUMEN

We present a 42-year-old woman with no history of diabetes or glucose intolerance who had a 5-year history of ulcerative necrobiosis lipoidica (NL). Despite failure of multiple medications, she experienced clearing of her ulcers after her treatment was changed to ustekinumab. We discuss our patient's disease course and elaborate upon mechanistic reasons for her improvement related to ustekinumab therapy.


Asunto(s)
Fármacos Dermatológicos/uso terapéutico , Necrobiosis Lipoidea/tratamiento farmacológico , Ustekinumab/uso terapéutico , Adulto , Femenino , Granuloma/tratamiento farmacológico , Granuloma/etiología , Humanos , Interleucina-12/antagonistas & inhibidores , Necrobiosis Lipoidea/complicaciones , Necrobiosis Lipoidea/fisiopatología , Úlcera Cutánea/tratamiento farmacológico , Úlcera Cutánea/etiología
10.
Am J Sports Med ; 45(1): 23-33, 2017 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-27590175

RESUMEN

BACKGROUND: Competitive athletes value the ability to return to competitive play after the treatment of anterior cruciate ligament (ACL) injuries. ACL reconstruction has high success rates for return to play, but some studies indicate that patients may do well with nonoperative physical therapy treatment. PURPOSE: To evaluate the cost-effectiveness of the treatment of acute ACL tears with either initial surgical reconstruction or physical therapy in competitive athletes. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: The incremental cost, incremental effectiveness, and incremental cost-effectiveness ratio (ICER) of ACL reconstruction compared with physical therapy were calculated from a cost-effectiveness analysis of ACL reconstruction compared with physical therapy for the initial management of acute ACL injuries in competitive athletes. The ACL reconstruction strategy and the physical therapy strategy were represented as Markov models. Costs and quality-adjusted life-years (QALYs) were evaluated over a 6-year time horizon and were analyzed from a societal perspective. Quality of life and probabilities of clinical outcomes were obtained from the peer-reviewed literature, and costs were compiled from a large academic hospital in the United States. One-way, 2-way, and probabilistic sensitivity analyses were used to assess the effect of uncertainty in variables on the ICER of ACL reconstruction. RESULTS: The ICER of ACL reconstruction compared with physical therapy was $22,702 per QALY gained. The ICER was most sensitive to the quality of life of returning to play or not returning to play, costs, and duration of follow-up but relatively insensitive to the rates and costs of complications, probabilities of return to play for both operative and nonoperative treatments, and discount rate. CONCLUSION: ACL reconstruction is a cost-effective strategy for competitive athletes with an ACL injury.


Asunto(s)
Lesiones del Ligamento Cruzado Anterior/cirugía , Reconstrucción del Ligamento Cruzado Anterior/economía , Atletas , Análisis Costo-Beneficio , Traumatismos Ocupacionales/terapia , Modalidades de Fisioterapia/economía , Reconstrucción del Ligamento Cruzado Anterior/estadística & datos numéricos , Atletas/estadística & datos numéricos , Técnicas de Apoyo para la Decisión , Humanos , Traumatismos Ocupacionales/economía , Traumatismos Ocupacionales/cirugía , Modalidades de Fisioterapia/estadística & datos numéricos , Años de Vida Ajustados por Calidad de Vida
13.
Vasc Med ; 15(5): 387-97, 2010 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-20926498

RESUMEN

The role of venous stasis syndrome (VSS) mechanisms (i.e. venous outflow obstruction [VOO] and venous valvular incompetence [VVI]) on quality of life (QoL) and activities of daily living (ADL) is unknown. The objective of this study was to test the hypotheses that venous thromboembolism (VTE),VSS,VOO and VVI are associated with reduced QoL and ADL. This study is a follow-up of an incident VTE case-control study nested within a population-based inception cohort of residents from Olmsted County, MN, USA, between 1966 and 1990. The study comprised 232 Olmsted County residents with a first lifetime VTE and 133 residents without VTE. Methods included a questionnaire and physical examination for VSS; vascular laboratory testing for VOO and VVI; assessment of QoL by SF36 and of ADL by pertinent sections from the Older Americans Resources and Services (OARS) and Arthritis Impact Measurement Scales (AIMS2) questionnaires. Of the 365 study participants, 232 (64%), 161 (44%), 43 (12%) and 136 (37%) had VTE, VSS, VOO and VVI, respectively. Prior VTE was associated with reduced ADL and increased pain, VSS with reduced physical QoL and increased pain, and VOO with reduced physical QoL and ADL.VVI was not associated with QoL or ADL. In conclusion,VSS and VOO are associated with worse physical QoL and increased pain. VOO and VTE are associated with impaired ADL. We hypothesize that rapid clearance of venous outflow obstruction in individuals with acute VTE will improve their QoL and ADL.


Asunto(s)
Actividades Cotidianas , Síndrome Postrombótico/psicología , Calidad de Vida , Insuficiencia Venosa/psicología , Tromboembolia Venosa/psicología , Válvulas Venosas/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Costo de Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Minnesota , Dolor/etiología , Dolor/psicología , Dimensión del Dolor , Síndrome Postrombótico/complicaciones , Encuestas y Cuestionarios , Insuficiencia Venosa/complicaciones , Insuficiencia Venosa/fisiopatología , Tromboembolia Venosa/complicaciones
14.
J Stroke Cerebrovasc Dis ; 19(3): 225-229, 2010 May.
Artículo en Inglés | MEDLINE | ID: mdl-20434051

RESUMEN

BACKGROUND: Intracerebral hemorrhage (ICH) is associated with a greater average initial stroke severity, higher mortality, and poorer long-term neurologic outcomes than ischemic stroke. The purpose of this study was to determine whether the poorer prognosis of ICH is independent of initial stroke severity. METHODS: We analyzed data from the Glycine Antagonist in Neuroprotection (GAIN) Americas trial, in which 1604 non-obtunded patients with acute stroke were treated within 6 hours of symptom onset irrespective of hemorrhagic (N = 237) versus ischemic (N = 1367) subtype. Multiple logistic regression analysis was performed to evaluate predictors of mortality and neurologic outcome (modified Rankin scale [mRS] score of 0-1 v 2-6 at 3 months) adjusting for baseline National Institutes of Health Stroke Scale score, stroke risk factors, clinical and demographic characteristics, and gavestinel treatment group. Multiple linear regression techniques were used to assess the impact of various predictors on the full mRS score at 3 months. RESULTS: ICH significantly increased the odds of a poor neurologic outcome (odds ratio 1.94, 95% confidence interval 1.23-3.06) and was independently associated with a mean 0.25-point increase in the 3-month mRS score (P = .04). ICH had no effect on mortality compared with ischemic stroke (odds ratio 1.01, 95% confidence interval .68-1.49) after adjusting for initial stroke severity (National Institutes of Health Stroke Scale score) and other baseline characteristics. CONCLUSIONS: Among conscious stroke patients, ICH is an independent predictor of poor neurologic outcome, nearly doubling the odds of long-term disability. However, ICH is not associated with higher mortality compared with ischemic stroke after adjusting for initial stroke severity and other baseline characteristics.


Asunto(s)
Isquemia Encefálica/complicaciones , Isquemia Encefálica/terapia , Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/terapia , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/terapia , Enfermedad Aguda , Anciano , Estudios de Cohortes , Evaluación de la Discapacidad , Método Doble Ciego , Femenino , Glicina/antagonistas & inhibidores , Humanos , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/etiología , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Resultado del Tratamiento
15.
Clin Orthop Relat Res ; 468(9): 2301-12, 2010 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-20232182

RESUMEN

BACKGROUND: Metal-on-metal hip resurfacing arthroplasty (MoM HRA) may offer potential advantages over total hip arthroplasty (THA) for certain patients with advanced osteoarthritis of the hip. However, the cost effectiveness of MoM HRA compared with THA is unclear. QUESTIONS/PURPOSES: The purpose of this study was to compare the clinical effectiveness and cost-effectiveness of MoM HRA to THA. METHODS: A Markov decision model was constructed to compare the quality-adjusted life-years (QALYs) and costs associated with HRA versus THA from the healthcare system perspective over a 30-year time horizon. We performed sensitivity analyses to evaluate the impact of patient characteristics, clinical outcome probabilities, quality of life and costs on the discounted incremental costs, incremental clinical effectiveness, and the incremental cost-effectiveness ratio (ICER) of HRA compared to THA. RESULTS: MoM HRA was associated with modest improvements in QALYs at a small incremental cost, and had an ICER less than $50,000 per QALY gained for men younger than 65 and for women younger than 55. MoM HRA and THA failure rates, device costs, and the difference in quality of life after conversion from HRA to THA compared to primary THA had the largest impact on costs and quality of life. CONCLUSIONS: MoM HRA could be clinically advantageous and cost-effective in younger men and women. Further research on the comparative effectiveness of MoM HRA versus THA should include assessments of the quality of life and resource use in addition to the clinical outcomes associated with both procedures. LEVEL OF EVIDENCE: Level I, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.


Asunto(s)
Artroplastia de Reemplazo de Cadera/instrumentación , Prótesis de Cadera , Metales , Osteoartritis de la Cadera/cirugía , Factores de Edad , Anciano , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/economía , Análisis Costo-Beneficio , Árboles de Decisión , Femenino , Costos de la Atención en Salud , Prótesis de Cadera/economía , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Modelos Económicos , Selección de Paciente , Diseño de Prótesis , Años de Vida Ajustados por Calidad de Vida , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del Tratamiento
16.
Vasc Med ; 14(4): 339-49, 2009 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-19808719

RESUMEN

Venous stasis syndrome may complicate deep vein thrombosis (DVT; i.e. post-phlebitic syndrome), but, in most cases, venous stasis syndrome is not post-phlebitic. The objective of this study was to determine the risk factors (including prior DVT) for venous stasis syndrome, and to assess venous outflow obstruction and venous valvular incompetence as possible mechanisms for venous stasis syndrome. This was a case-control study nested within a population-based inception cohort. The study population consisted of 232 Olmsted County, MN residents with a first lifetime venous thromboembolism (VTE) and 133 residents without VTE. Measurements included a questionnaire and physical examination for venous stasis syndrome; strain gauge outflow plethysmography, venous continuous wave Doppler ultrasonography and passive venous drainage and refill testing for venous outflow obstruction and venous valvular incompetence. Altogether, 161 (44%), 43 (12%), and 136 (38%) subjects respectively, had venous stasis syndrome, venous outflow obstruction and venous valvular incompetence. Independent risk factors for venous stasis syndrome included increasing patient age and body mass index (BMI), prior DVT, longer time interval since DVT, and varicose veins. Both venous outflow obstruction (p = 0.003) and venous valvular incompetence (p < 0.0001) were strongly associated with venous stasis syndrome. Increasing age and prior DVT were significantly associated with venous outflow obstruction, while prior DVT, varicose veins and venous stasis syndrome diagnosed prior to the incident DVT were significantly associated with venous valvular incompetence. The risks of venous outflow obstruction, venous valvular incompetence and venous stasis syndrome were higher with left leg DVT. In conclusion, increasing patient age and BMI, prior DVT (particularly left leg DVT), longer time interval since DVT and varicose veins are independent risk factors for venous stasis syndrome. Venous stasis syndrome related to DVT is due to venous outflow obstruction and venous valvular incompetence, while venous stasis syndrome related to older age and to varicose veins is due to venous outflow obstruction and to venous valvular incompetence, respectively.


Asunto(s)
Síndrome Postrombótico/etiología , Válvulas Venosas/fisiopatología , Adulto , Factores de Edad , Anciano , Índice de Masa Corporal , Estudios de Casos y Controles , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Minnesota , Oportunidad Relativa , Pletismografía , Vigilancia de la Población , Síndrome Postrombótico/fisiopatología , Flujo Sanguíneo Regional , Medición de Riesgo , Factores de Riesgo , Encuestas y Cuestionarios , Ultrasonografía Doppler , Várices/complicaciones , Várices/fisiopatología , Trombosis de la Vena/complicaciones , Trombosis de la Vena/fisiopatología
18.
Proc (Bayl Univ Med Cent) ; 21(4): 363-72, 2008 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-18982076

RESUMEN

The objective of the study was to develop and validate predictors of 30-day hospital readmission using readily available administrative data and to compare prediction models that use alternate comorbidity classifications. A retrospective cohort study was designed; the models were developed in a two-thirds random sample and validated in the remaining one-third sample. The study cohort consisted of 29,292 adults aged 65 or older who were admitted from July 2002 to June 2004 to any of seven acute care hospitals in the Dallas-Fort Worth metropolitan area affiliated with the Baylor Health Care System. Demographic variables (age, sex, race), health system variables (insurance, discharge location, medical vs surgical service), comorbidity (classified by the Elixhauser classification or the High-Risk Diagnoses in the Elderly Scale), and geographic variables (distance from patient's residence to hospital and median income) were assessed by estimating relative risk and risk difference for 30-day readmission. Population-attributable risk was calculated. Results showed that age 75 or older, male sex, African American race, medical vs surgical service, Medicare with no other insurance, discharge to a skilled nursing facility, and specific comorbidities predicted 30-day readmission. Models with demographic, health system, and either comorbidity classification covariates performed similarly, with modest discrimination (C statistic, 0.65) and acceptable calibration (Hosmer-Lemeshow χ² = 6.08; P > 0.24). Models with demographic variables, health system variables, and number of comorbid conditions also performed adequately. Discharge to long-term care (relative risk, 1.94; 95% confidence interval, 1.80- 2.09) had the highest population-attributable risk of 30-day readmission (12.86%). A 25% threshold of predicted probability of 30-day readmission identified 4.1 % of patients ≥65 years old as priority patients for improved discharge planning. We conclude that elders with a high risk of 30-day hospital readmission can be identified early in their hospital course.

19.
Proc (Bayl Univ Med Cent) ; 21(3): 227-35, 2008 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-18628969

RESUMEN

Indicators of the performance of clinical preventive services (CPS) have been adopted in the ambulatory setting to improve quality of care. The impact of CPS was evaluated in a network of 49 primary care practices providing care to an estimated 245,000 adults in the Dallas-Fort Worth area through a sample chart review to determine delivery of recommended evidence-based CPS combined with medical literature estimates of the effectiveness of CPS. In this population in 2005, CPS were estimated to have prevented 36 deaths and 97 incident cases of cancer; 420 coronary heart disease events (including 66 sudden deaths) and 118 strokes; 816 cases of influenza and pneumonia (including 24 hospital admissions); and 87 osteoporosis-related fractures. Thus, CPS have substantial benefits in preventing deaths and illness episodes.

20.
J Bone Joint Surg Am ; 89(11): 2389-97, 2007 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-17974880

RESUMEN

BACKGROUND: Total knee arthroplasty is one of the most clinically successful and cost-effective interventions in medicine. However, implant malalignment, especially in the coronal plane, is a common cause of early failure following total knee arthroplasty. Computer-assisted surgery has been employed during total knee arthroplasty to improve the precision of component alignment. The purpose of the present study was to evaluate the cost-effectiveness of computer-assisted surgery to determine whether the improved alignment achieved with computer navigation provides a sufficient decrease in failure rates and revisions to justify the added cost. METHODS: A decision-analysis model was used to estimate the cost-effectiveness of computer-assisted surgery in total knee arthroplasty. Model inputs, including costs, effectiveness, and clinical outcome probabilities, were obtained from a review of the literature. Sensitivity analyses were performed to evaluate the impact of component-alignment precision with use of computer-assisted and mechanical alignment guides, total knee arthroplasty failure rates secondary to malalignment, and costs of computer-assisted surgery systems on the cost-effectiveness of computer navigation in total knee arthroplasty. RESULTS: Computer-assisted surgery is both more effective and more expensive than mechanical alignment systems. Given an additional cost of $1500 per operation, a 14% improvement in coronal alignment precision (within 3 degrees of neutral mechanical axis), and an elevenfold increase in revision rates at fifteen years with coronal malalignment (54% compared with 4.7%), the incremental cost of using computer-assisted surgery is $45,554 per quality-adjusted life-year gained. Cost-savings is achieved if the added cost of computer-assisted surgery is $629 or less per operation. Variability in published clinical outcomes, however, introduces uncertainty in determining the cost-effectiveness. CONCLUSIONS: Computer-assisted surgery is potentially a cost-effective or cost-saving addition to total knee arthroplasty. However, the cost-effectiveness is sensitive to variability in the costs of computer navigation systems, the accuracy of alignment achieved with computer navigation, and the probability of revision total knee arthroplasty with malalignment.


Asunto(s)
Artroplastia de Reemplazo de Rodilla/economía , Programas Informáticos , Cirugía Asistida por Computador/economía , Análisis Costo-Beneficio , Árboles de Decisión , Humanos , Factores de Tiempo
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