Trigger Finger Treatment: Identifying Predictors of Nonadherence and Cost.

BACKGROUND: Evidence-based practices in medicine are linked with a higher quality of care and lower health care cost. For trigger finger, identifying patient factors associated with nonadherence to evidence-based practices will aid physicians in treatment decisions. The objectives were to (1) determine patient factors associated with treatment nonadherence, (2) examine the success rates of steroid injections, and (3) evaluate the economic consequences of nonadherence to treatment recommendations. METHODS: The authors used data from the Clinformatics DataMart database from 2010 to 2017 to conduct a population-based analysis of patients with single-digit trigger finger. The authors calculated rates of steroid injection success and examined associations between injection success and patient factors using chi-square tests. In addition, the authors analyzed differences in the cost to the insurer, the cost to the patient, and total cost. RESULTS: A total of 29,722 patients were included in this analysis. Injection success rates were similar for diabetic (72 percent) and nondiabetic patients (73 percent), women (73 percent), and men (73 percent). Nonetheless, diabetics (OR, 1.4; 95 percent CI, 1.4 to 1.5; p < 0.001) and women (OR, 1.2; 95 percent CI, 1.1 to 1.2; p < 0.001) were significantly more likely to receive nonadherent treatment. In total, $23 million (U.S. dollars) were spent on nonadherent trigger finger care. CONCLUSIONS: Diabetics and women have increased odds of having surgery without a prior steroid injection, despite similar success rates of steroid injections compared to nondiabetics and men. Because performing surgical release before any steroid injections may represent a higher cost treatment option, providers should provide steroid injections before surgery for all patients regardless of diabetes status or sex to minimize overtreatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The infection rate of intralesional triamcinolone and the safety of compounding in dermatology for intradermal and subcutaneous injection: A retrospective medical record review.

BACKGROUND: Intralesional injection of sterile medications remains a mainstay in dermatology, enabling a tailored, low-cost, in-office therapy. After the 2012 United States outbreak of fungal meningitis from contaminated intrathecally administered corticosteroids, there has been increased regulation of in-office compounding, regardless of the administration route. Studies demonstrating the safety data of in-office corticosteroid compounding for intradermal or subcutaneous use are lacking. OBJECTIVE: To assess the incidence of infection caused by compounded in-office intralesional triamcinolone. METHODS: A retrospective medical record review identified patients who received in-office intralesional corticosteroid injections in 2016. Medical documentation within 30 days of injection was reviewed for suspected infection. RESULTS: The records of 4370 intralesional triamcinolone injections were assessed, of which 2780 (64%) were compounded triamcinolone with bacteriostatic saline. We identified 11 (0.25%) suspected localized infections, with 4 of the 11 in the compounding cohort. Of these, 7 of 11 occurred after injection of an "inflamed cyst." No hospitalizations or deaths occurred. No temporal or locational relationships were identified. LIMITATIONS: This study was limited to 2 academic institutions. A 30-day postinjection time frame was used. CONCLUSION: In-office compounding for intralesional dermal and subcutaneous administration is safe when sterile products are used by medical practitioners. There is no increased risk of compounded triamcinolone relative to noncompounded triamcinolone.

Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture.

INTRODUCTION: The use of intralesional injection of collagenase Clostridium histolyticum (CCH) has become a valid treatment option in the management of Peyronie's disease (PD). Multiple studies have shown the drug's safety and efficacy. However, sparse literature exists on the utility of the injection protocol's 14-day "observation period," in which patients are instructed to abstain from all sexual activity. AIM: To summarize the contemporary literature and report on our series of patients treated with CCH in an effort to explore the effectiveness of the postinjection observation period. METHODS: We retrospectively reviewed the clinical course of men treated with at least one CCH injection at our institution from April 2014 through February 2017. MAIN OUTCOME MEASURES: The main outcome measure for our cohort was complication rate (hematoma, fracture). Secondary outcomes included progression to corrective surgery. RESULTS: Of the 102 patients treated, 5 (4.9%) developed a corporal fracture. Four of these occurred outside the 14-day observation period. One fracture was managed conservatively and the rest underwent surgical exploration and repair. Twelve penile hematomas were reported; one of these patients was surgically explored because of suspicious magnetic resonance imaging findings. Seven patients (6.9%) progressed to corrective surgery. CONCLUSION: Penile hematoma and corporal fracture are serious complications that must be discussed with patients before initiation of intralesional CCH treatment. Little evidence exists to direct physicians on the proper management of post-CCH penile fractures; many caregivers and patients elect to treat these injuries conservatively and avoid surgical exploration. Further studies are warranted to generate discussion and reassessment regarding the safety and effectiveness of this 14-day observation period. Beilan JA, Wallen JJ, Baumgarten AS, Morgan KN, Parker JL, Carrion RE. Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture. Sex Med Rev 2018;6:272-278.

Characteristics of L3 nerve root radiculopathy.

BACKGROUND: In degenerative lumbar spinal disease with nerve root compression, the L5 and S1 nerve roots are the most often affected and the L3 nerve root is involved infrequently. The purpose of this study was to investigate the characteristics of L3 nerve root radiculopathy. METHODS: Seventeen consecutive patients with L3 radiculopathy were treated. The symptomatic nerve roots were determined by the pain distribution, the neurologic findings, and selective nerve root injection. The clinical characteristics and outcomes of these patients were assessed retrospectively. RESULTS: The average age was 76 years. The spinal diseases that were associated with L3 radiculopathy were lumbar canal stenosis in 6 patients, lumbar extraforaminal stenosis and lumbar disk herniation in 5 each, and lumbar canal stenosis with degenerative scoliosis in 1. The patients' symptoms were thigh pain in 12 patients, and hip or knee pain in 5. Four patients were nonambulatory because of severe pain. Although a sensory disturbance was reported in 9 patients, motor weakness was present in 2. Selective nerve root injection was completely effective in 10 patients. Six had decompressive surgery and/or fusion followed by a favorable outcome. Four patients were misdiagnosed and received conservative treatment for hip and/or knee joint diseases. CONCLUSIONS: L3 radiculopathy was characterized by various lower limb pain and neurologic deficit. Selective nerve root injection was effective for most patients. In elderly patients who do not respond to treatment for hip and/or knee joint diseases, L3 nerve root radiculopathy should be considered as the cause of lower limb pain.

Long-term outcome of intralesional injection of triamcinolone acetonide for the treatment of keloid scars in Asian patients.

We studied the long-term outcome of injection of triamcinolone acetonide into keloid scars in Asian patients. Between 1985 and 2003, we treated 109 keloid scars in 94 patients by injecting 1 to 10?mg of triamcinolone acetonide depending on the size of the lesion at four week intervals. There was little morbidity. Thirty-one patients gave up treatment within 10 injections because of pain and lack of immediate improvement. Improvement in subjective symptoms was seen in 52 of the remaining 63 patients (82%). In objective symptoms, fair or better results were seen in 40 of 63 (63%), and good or better results in 25 of 63 (39%). The treatment method required 20-30 injections over three to five years. Although we did not achieve as good results as other authors, we think it was safer because we used a smaller dose of a steroid.

Alopecía areata: tratamiento / Alopecia areata: treatment

El tratamiento de la alopecía areata ha cambiado notablemente en la última década. Nuevas opciones terapéuticas están disponibles para los pacientes. Es deber del dermatólogo informar al paciente de todas las alternativas posibles para su caso, sus efectos colaterales y sus cifras de éxito. La decisión final es conjunta, entre el paciente, la familia del paciente (cuando corresponda) y el dermatólogo