RESUMO
BACKGROUND: Calciphylaxis patients historically have experienced diagnostic challenges and high morbidity; however limited data is available examining these characteristics over time. OBJECTIVE: The primary goals were to a) investigate factors associated with diagnostic delay of calciphylaxis and b) assess morbidity outcomes. The secondary goal was to provide updated mortality rates. METHODS: A retrospective review of 302 adult patients diagnosed with calciphylaxis between January 1, 2006 and December 31, 2022 was conducted. Univariate and multivariate statistical analyses were performed. RESULTS: Nonnephrogenic calciphylaxis (P = .0004) and involvement of the fingers (P = .0001) were significantly associated with an increased diagnostic delay, whereas involvement of the arms (P = .01) and genitalia (P = .022) resulted in fewer days to diagnosis. Almost all patients with genitalia, finger, or toe involvement had nephrogenic disease. The number of complications per patient decreased with time, especially for wound infections (P = .028), increase in lesion number (P = .012), and recurrent hospitalizations (P = .020). Updated 1-year mortality rates were 36.70% and 30.77% for nephrogenic and nonnephrogenic calciphylaxis, respectively. LIMITATIONS: Limitations include the retrospective nature and data from a single institution. CONCLUSION: Diagnostic delay, particularly in nonnephrogenic calciphylaxis, and complications per patient decreased with time, highlighting the importance of continued awareness to expedite diagnosis. Mortality rates have continued to improve in recent years.
Assuntos
Calciofilaxia , Recidiva , Humanos , Calciofilaxia/epidemiologia , Calciofilaxia/diagnóstico , Calciofilaxia/etiologia , Fatores de Risco , Prevalência , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , AdultoAssuntos
Staphylococcus aureus Resistente à Meticilina , Dermatopatias , Infecções Estafilocócicas , Humanos , Criança , Celulite (Flegmão)/diagnóstico , Celulite (Flegmão)/tratamento farmacológico , Virilha , Estudos Retrospectivos , Nádegas , Abscesso/diagnóstico , Abscesso/tratamento farmacológico , Pacientes Internados , Antibacterianos/uso terapêutico , Infecções Estafilocócicas/diagnóstico , Dermatopatias/tratamento farmacológicoRESUMO
Cellulitis is an infection of the skin and skin-associated structures with many clinical mimickers known collectively as pseudocellulitis. Dermatology or infectious disease consultation is considered the gold standard for diagnosis. We evaluated a prospective cohort of adult patients presenting to the emergency department (ED) with concern for lower extremity cellulitis who received dermatology consultation with conferral of a final diagnosis. Possible risk factors independently associated with cellulitis diagnosis (P<.1) were included in a logistic regression model for prediction of cellulitis diagnosis. Factors having odds ratios with a confidence interval excluding 1 were identified as significant independent predictors. The study identified factors that should be considered in evaluation of patients with suspected uncomplicated lower extremity cellulitis.
Assuntos
Celulite (Flegmão) , Dermatologia , Adulto , Humanos , Celulite (Flegmão)/diagnóstico , Estudos Prospectivos , Fatores de Risco , Serviço Hospitalar de Emergência , Encaminhamento e ConsultaRESUMO
The clinical features of 588 pediatric inpatients admitted with a diagnosis of cellulitis were reviewed with attention to diagnostic accuracy of true cellulitis (95.1%) versus pseudocellulitis (4.9%) and utilization of specialist consultations (28.1% infectious disease, 6.1% dermatology). Laboratory abnormalities were unable to distinguish cellulitis from pseudocellulitis, supporting previous studies that routine laboratory evaluation may be unnecessary for this diagnosis. Higher rates of pseudocellulitis were identified in cases involving specialist consultation by both dermatology (44.8% pseudocellulitis, 4.1% true cellulitis, p < .001) and infectious disease (48.3% pseudocellulitis, 27.0% true cellulitis, p = .01). Thus, consultation may improve the diagnostic accuracy of suspected cellulitis among pediatric inpatients.
Assuntos
Celulite (Flegmão) , Pacientes Internados , Celulite (Flegmão)/diagnóstico , Criança , Hospitalização , Humanos , Encaminhamento e Consulta , Estudos RetrospectivosAssuntos
Staphylococcus aureus Resistente à Meticilina , Infecções Estafilocócicas , Abscesso/diagnóstico , Abscesso/tratamento farmacológico , Antibacterianos/uso terapêutico , Nádegas , Celulite (Flegmão)/diagnóstico , Celulite (Flegmão)/tratamento farmacológico , Criança , Virilha , Humanos , Pacientes Internados , Estudos Retrospectivos , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/tratamento farmacológicoRESUMO
BACKGROUND: Patients of color are disproportionately impacted by vitiligo. Access to treatment depends greatly on insurance coverage. We, therefore, assessed current vitiligo treatment coverage policies across major United States health insurers to determine current patterns and coverage gaps for vitiligo. METHODS: The study surveyed 15 commercial health care insurers, 50 BlueCross BlueShield (BCBS) plans, Medicare, Medicaid, and Veterans Affairs. Information on treatment coverage for vitiligo, specifically pimecrolimus and tacrolimus, excimer laser therapy, PUVA, and narrow-band (nb)UVB, was collected via an online review of insurance policy documents, confirmed with phone calls to organization representatives, or via a survey of Medicaid providers, and state Medicaid directors. RESULTS: Of 17 organizations with regional or national coverage policies, 12% did not cover topical calcineurin inhibitors, 56% did not cover nbUVB phototherapy, 53% did not cover PUVA phototherapy, and 41% did not cover laser therapy. For BCBS, pimecrolimus and tacrolimus were not covered in 39% and 35% of states, respectively. NbUVB and PUVA therapy were not covered in 20% and 10% of states, respectively. Excimer laser therapy was not covered in 82% of states. Out of 32 states with accessible Medicaid information, 11 did not cover topicals, 5 did not cover nbUVB, 4 did not cover PUVA, and 7 did not cover laser. Two commonly cited reasons for coverage denial were that the treatment indication was considered cosmetic, and certain therapies are not FDA-approved. CONCLUSIONS: There is inequity in the distribution of health among vitiligo patients given current patterns of insurance coverage for treatment, which may have disproportionate impact on patients of color.
Assuntos
Vitiligo , Idoso , Criança , Atenção à Saúde , Humanos , Cobertura do Seguro , Medicare , Terapia PUVA , Estados Unidos , Vitiligo/terapiaRESUMO
BACKGROUND: Calciphylaxis is an ischemic vasculopathy with high morbidity and mortality. Early and accurate diagnosis is critical to management of calciphylaxis. Clinical mimickers may contribute to delayed or misdiagnosis. OBJECTIVE: To assess the rate and risk factors for misdiagnosis and to identify clinical mimickers of calciphylaxis. METHODS: A retrospective medical record review was conducted of patients with calciphylaxis at a large urban tertiary care hospital between 2006 and 2018. RESULTS: Of 119 patients diagnosed with calciphylaxis, 73.1% were initially misdiagnosed. Of patients not initially misdiagnosed, median time to diagnosis from initial presentation was 4.5 days (interquartile range, 1.0-23.3), compared to 33 days (interquartile range, 13.0-68.8) in patients who were initially misdiagnosed (P = .0002). The most common misdiagnoses were cellulitis (31.0%), unspecified skin infection (8.0%), and peripheral vascular disease (6.9%). Patients who were misdiagnosed frequently received at least 1 course of antibiotics. Patients with end-stage renal disease were less likely to be misdiagnosed than those without this disease (P = .001). LIMITATIONS: Single-center, retrospective study. CONCLUSIONS: Understanding the risk factors for misdiagnosis of calciphylaxis is an opportunity for further education concerning this rare disease.
Assuntos
Calciofilaxia , Falência Renal Crônica , Doenças Vasculares , Calciofilaxia/diagnóstico , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/diagnóstico , Estudos Retrospectivos , Fatores de RiscoAssuntos
COVID-19/complicações , Tempo de Internação/estatística & dados numéricos , Úlcera por Pressão/epidemiologia , Púrpura/sangue , Centros Médicos Acadêmicos , Adulto , Idoso , Feminino , Hospitais Urbanos , Humanos , Incidência , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Úlcera por Pressão/sangue , Úlcera por Pressão/etiologia , Decúbito Ventral , Púrpura/virologia , Estudos Retrospectivos , SARS-CoV-2RESUMO
BACKGROUND: Calciphylaxis is a rare disorder characterized by skin necrosis caused by calcium deposition within vessels, thrombosis, and subsequent tissue ischemia. Penile involvement may rarely occur. OBJECTIVE: To identify risk factors, diagnosis, management, and mortality of patients with penile calciphylaxis. METHODS: A retrospective medical record review was conducted of 16 patients with penile calciphylaxis treated at 2 large urban tertiary care centers between January 2001 and December 2019. A control group of 44 male patients with nonpenile calciphylaxis at the same institution was included. RESULTS: The median survival of patients with penile calciphylaxis was 3.8 months (interquartile range, 27.0 months). Mortality was 50% at 3 months and 62.5% at 6 months for penile calciphylaxis, and 13.6% at 3 months and 29.5% at 6 months for controls (P = .008). Patients with penile calciphylaxis were less likely to be obese (P = .04) but more likely to have hyperparathyroidism (P = .0003) and end-stage renal disease (P = .049). LIMITATIONS: Retrospective study design and small sample size. CONCLUSIONS: This study further defines the disease course of penile calciphylaxis, which has high mortality. Imaging may be used to aid diagnosis. Risk factors include end-stage renal disease, hyperparathyroidism, and normal body mass index.
Assuntos
Calciofilaxia , Calciofilaxia/diagnóstico , Calciofilaxia/epidemiologia , Calciofilaxia/etiologia , Estudos de Casos e Controles , Humanos , Falência Renal Crônica , Masculino , Pênis , Estudos RetrospectivosRESUMO
BACKGROUND: Biologic agents may predispose patients to skin and soft tissue infections (SSTIs). Guidelines recommend discontinuing the agent preoperatively; the true risk of infection is unclear. OBJECTIVES: To assess the incidence of SSTIs in patients receiving biologic agents for all clinical indications. A secondary aim was to assess those undergoing surgery to determine postoperative SSTI risk. METHODS: A retrospective medical record review was conducted at 2 urban tertiary care hospitals. Biologic agent use ranged from June 2013 to June 2018. Data were extracted on biologic agent injections, surgical procedures, and patient characteristics. RESULTS: Hypertension, former smoking, and corticosteroid use were significantly associated with SSTI risk (P < .05). There was no increased SSTI risk among biologic agents (P = .49). Biologic therapy with concomitant corticosteroid use increased risk of SSTI (P = .0049). There was no difference in postoperative SSTI risk in patients who stopped biologic therapy before surgery and those who did not. LIMITATIONS: This study is limited by its retrospective design. CONCLUSIONS: There was no increased risk of either postoperative or nonperioperative SSTI risk among biologic agents. Concomitant corticosteroid use increased SSTI risk. Current guidelines regarding stopping biologic agents before surgery warrant re-evaluation, because there was no difference in SSTI risk in patients who did so.
Assuntos
Infecções dos Tecidos Moles , Corticosteroides , Fatores Biológicos , Produtos Biológicos/efeitos adversos , Humanos , Incidência , Estudos Retrospectivos , Infecções dos Tecidos Moles/epidemiologiaRESUMO
BACKGROUND: Patient outcomes are improved when dermatologists provide inpatient consultations. Inpatient access to dermatologists is limited, illustrating an opportunity to use teledermatology. Little is known about the ability of dermatologists to accurately diagnose disease and manage inpatients with teledermatology, particularly when using nondermatologist-generated clinical data. METHODS: This prospective study assessed the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care center, using internal medicine referral documentation and photographs. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the κ statistic. RESULTS: There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ = 0.83), substantial agreement in laboratory evaluation decisions (median κ = 0.67), almost perfect agreement in imaging decisions (median κ = 1.0), and moderate agreement in biopsy decisions (median κ = 0.43). There was almost perfect agreement in treatment (median κ = 1.0), but no agreement in follow-up planning (median κ = 0.0). There was no association between raw photograph quality and the primary plus differential diagnosis or primary diagnosis alone. LIMITATIONS: Selection bias and single-center nature. CONCLUSIONS: Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.