Misdiagnosis of Pyoderma Gangrenosum Increases Medical Costs and Prolongs Hospital Stay: A Case Report.

Pyoderma gangrenosum (PG) is a rare, immunological ulcerative, and necrotic inflammatory skin disease that can be easily misdiagnosed as cellulitis, abscess, diabetic foot ulcer, and other infectious diseases. Misdiagnosing PG leads to unnecessary surgical incision and debridement, which further exacerbates the lesion, ultimately leading to longer treatment periods and higher medical costs. Therefore, early and accurate diagnosis of PG is extremely important for its treatment. In particular, PG should be suspected in patients with inflammatory bowel disease.

Assessment of main complications of regional anesthesia recorded in an acute pain unit in a tertiary care university hospital: a retrospective cohort

Abstract Background Regional anesthesia has been increasingly used. Despite its low number of complications, they are associated with relevant morbidity. This study aims to evaluate the incidence of complications after neuraxial block and peripheral nerve block. Methods A retrospective cohort study was conducted, and data related to patients submitted to neuraxial block and peripheral nerve block at a tertiary university hospital from January 1, 2011 to December 31, 2017 were analyzed. Results From 10,838 patients referred to Acute Pain Unit, 1093(10.1%) had side effects or complications: 1039 (11.4%) submitted to neuraxial block and 54 (5.2%) to peripheral nerve block. The most common side effects after neuraxial block were sensory (48.5%) or motor deficits (11.8%), nausea or vomiting (17.5%) and pruritus (8.0%); The most common complications: 3 (0.03%) subcutaneous cell tissue hematoma, 3 (0.03%) epidural abscesses and 1 (0.01%) arachnoiditis. 204 of these patients presented sensory or motor deficits at hospital discharge and needed follow-up. Permanent peripheral nerve injury after neuraxial block had an incidence of 7.7:10,000 (0.08%). The most common side effects after peripheral nerve block were sensory deficits (52%) and 21 patients maintained follow-up due to symptoms persistence after hospital discharge. Conclusion Although we found similar incidences of side effects or even lower than those described, major complications after neuraxial block had a higher incidence, particularly epidural abscesses. Despite this, other serious complications, such as spinal hematoma and permanent peripheral nerve injury, are still rare.

Assessment of main complications of regional anesthesia recorded in an acute pain unit in a tertiary care university hospital: a retrospective cohort.

BACKGROUND: Regional anesthesia has been increasingly used. Despite its low number of complications, they are associated with relevant morbidity. This study aims to evaluate the incidence of complications after neuraxial block and peripheral nerve block. METHODS: A retrospective cohort study was conducted, and data related to patients submitted to neuraxial block and peripheral nerve block at a tertiary university hospital from January 1, 2011 to December 31, 2017 were analyzed. RESULTS: From 10,838 patients referred to Acute Pain Unit, 1093(10.1%) had side effects or complications: 1039 (11.4%) submitted to neuraxial block and 54 (5.2%) to peripheral nerve block. The most common side effects after neuraxial block were sensory (48.5%) or motor deficits (11.8%), nausea or vomiting (17.5%) and pruritus (8.0%); The most common complications: 3 (0.03%) subcutaneous cell tissue hematoma, 3 (0.03%) epidural abscesses and 1 (0.01%) arachnoiditis. 204 of these patients presented sensory or motor deficits at hospital discharge and needed follow-up. Permanent peripheral nerve injury after neuraxial block had an incidence of 7.7:10,000 (0.08%). The most common side effects after peripheral nerve block were sensory deficits (52%) and 21 patients maintained follow-up due to symptoms persistence after hospital discharge. CONCLUSION: Although we found similar incidences of side effects or even lower than those described, major complications after neuraxial block had a higher incidence, particularly epidural abscesses. Despite this, other serious complications, such as spinal hematoma and permanent peripheral nerve injury, are still rare.

Incidence and extent of sinus procedures in treatment of pediatric orbital cellulitis.

INTRODUCTION: It is unknown the optimal extent of sinus surgery in pediatric patients with orbital cellulitis. Our aim was to determine the nationwide incidence of sinus procedures used to treat pediatric orbital cellulitis. Additionally, we sought to identify patient-factors that influence a multi-procedural approach. METHODS: Cross-sectional analysis of 15,260 cases of primary pediatric orbital cellulitis identified in the Kids' Inpatient Database (KID) from January 1, 2003 to December 31, 2012. Cases were included if they contained a primary diagnosis code of orbital cellulitis. Frequency of sinus procedures in relation to pediatric age cohort were noted (≤8 years versus 9-20 years). Comorbidities, cost, and length-of-stay were compared between age cohorts. Multivariate models investigated patient-factors associated with multiple sinus procedures and patient-factors that affected hospital costs and length-of-stay. RESULTS: Children ≤8 years of age constituted 67% of cases (n = 10,290). 1103 cases (7.2%) were treated with at least one defined sinus procedure; and, 712 of these cases documented more than one sinus procedure. The younger cohort (≤8 years) exhibited fewer sinus procedures and a lower rate of reoperation (4.6% vs 12.8%, p < .001; 5.1% vs 7.7%, p < .001, respectively). Presence of cellulitis/abscess of the face was the strongest predictor of multiple sinus procedures (OR = 1.982, p = .033). Patients with acute sinusitis and those >8 years had similarly increased odds of a multi-procedural approach (OR = 1.333, p = .049; OR = 1.367, p = .032, respectively). Multivariate analysis of cost and length-of-stay found that patients >8 years incurred 14% longer hospital stays and an increase in costs of 9% compared to younger patients (p = .001, p = .039; respectively). The secondary diagnosis with the largest effect on length-of-stay and cost was an intracranical abscess (OR = 2.352, p < .001; OR = 2.752, p < .001; respectively). CONCLUSION: In a nationwide population of pediatric patients with primary orbital cellulitis there was an incidence of sinus surgery in 7.2% of cases - with patients over 8 years having a 2.8-fold increase compared to younger patients. Additionally, nearly two-thirds of patients treated with sinus surgery had multiple sinus procedures. The high incidence of multiple sinus procedures suggests that further prospective studies are needed to elucidate the extent of drainage associated with the best patient outcomes.

Comparison of conservative versus surgical therapy for acute appendicitis with abscess in five German hospitals.

INTRODUCTION: The aim of this study was to evaluate the effectiveness of initially conservative therapy compared to immediate appendectomy for acute appendicitis with abscess in terms of medical and economic outcomes. METHODS: Of all the patients treated for appendicitis from January 2009 to December 2017 in five German hospitals, 240 were included in the study. Fifty-three patients received conservative (CON) and 195 patients received surgical (SUR) therapy as initial treatment. RESULTS: Length of stay was similar (12.5 days in CON vs. 13.3 days in SUR, p = 0.530). Readmission rate was higher in the conservative group (54.7% vs. 6.2%, p < 0.001). The majority (53.7%) of the 41 operations in CON group were appendectomies (22 procedures), 1 (4.5%) of them was in the first hospital stay because of persisting symptoms, 21 (95.5%) after a recovery interval. Seven (33.3%) of the recovery appendectomies were performed due to persisting or recurrent symptoms and 14 (66.7%) due to the request of patient. Twenty-one patients (39.6%) in the CON group did not need surgery. The rates of complication-related operations per patient (0.04 versus 0.58, p < 0.001), conversions of surgical technique (1.9% vs. 34.9%, p = 0.0287), and extended resections (1.9% vs. 31.3%, p < 0.001) were higher in SUR group. Furthermore, morbidity, hospital costs, and loss in quality of life were significantly higher in the surgical group (17.0% vs. 66.2%, p < 0.001; € 5044 vs. € 8457, p < 0.001, and 4.3 days vs. 7.5 days, p < 0.001, CON vs. SUR). CONCLUSION: Initially, conservative treatment for acute appendicitis with abscess is preferable to immediate surgical treatment in reduction of morbidity, hospital costs, and loss in quality of life.

Usefulness of two- and three-dimensional transesophageal echocardiography in the assessment of proximal left coronary system compression by a paraprosthetic aortic valve abscess.

Paraprosthetic aortic valve abscess represents a rare, but lethal complication of infective endocarditis. We report a case of proximal left coronary system compression by a paraprosthetic aortic valve abscess whose detection was augmented using live/real time three-dimensional transesophageal echocardiography. Our case illustrates the usefulness of combined two- and three-dimensional transesophageal echocardiography in detecting this finding.

Incidence of fistula after management of perianal abscess / Incidência de fistulas em seguida ao tratamento de abscesso perianal

Background: Perianal fistula is among the most common anorectal diseases encountered in adults, men are more prone to be affected than women. There is a close relationship of abscess and fistula in etiology, anatomy, pathophysiology, therapy, complications and morbidity, it is appropriate to consider them as one entity. Aim of study: To determine the incidence of fistula formation and recurrent abscess in a sample of Iraqi patients in Baghdad and decide whether primary fistulotomy should be performed at the time of incision and drainage of perianal abscesses. Patients and methods: A retrospective study of 68 patients with perianal abscess operations conducted in Baghdad. They underwent incision and drainage under either local or general anesthesia at Al-Kindy Teaching Hospitals and private hospitals over a 15-year period from January 2000 to December 2015. Their ages ranged from 20 to 68 years (40.21 ± 1.34) males (63/68) (92.64%) were more than females (5/68) (7.35%). Patients were treated with incision over the abscess under anesthesia and drainage of the abscess was done. The patients were followed up for an average 18 months (range 12-24 months) after abscess drainage or until a fistula appeared and abscess recurrence. Results: The study group comprised of 68 (92.64%) patients with perianal abscess with a median age 39 years (range 20-68 years). The mean follow-up period was identified to be 18 months (range 12-24 months). Males (63/68) (92.64%) were more than females (5/68) (7.35%). The incidence of fistula formation after follow up, the patients with perianal abscess after incision and drainage was 31/68 (45.58%) and males (30/31) (44.11%) were more than females (1/31) (1.47%). The most common site was posterior then left lateral position. The percentage of patients with recurrent abscess n = 6 (8.82%)were lower than fistula formation n = 31 (45.58%). The percentage of males n = 4/6 (5.88%) were more than females 2/6 (2.94%). Conclusions: The incidence of anal fistula in a sample of Iraqi patients with perianal abscess was 45.58% and percentage of recurrence of perianal abscess was 8.82%. To avoid division of anal sphincter muscle, secondary fistulotomy is advised to be done later when anal fistula will be formed.

Experiência: A fistula perianal está entre as mais comuns doenças anorretais observadas em adultos; os homens demonstram maior tendência para serem afetados, em comparação com as mulheres. Existe íntima relação entre abscessos e fistulas em termos e etiologia, anatomia, fisiopatologia, tratamento, complicações e morbidade; assim, é cabível considerá-los como uma mesma entidade. Objetivo do estudo: Determinar a incidência de formação de fístulas e de abscesso recorrente em uma amostra de pacientes iraquianos em Bagdá, e decidir se a fistulotomia primária deve ser realizada por ocasião da incisão e drenagem de abscessos perianais. Pacientes e métodos: Estudo retrospectivo de 68 pacientes com operações para abscesso perianal realizadas em Bagdá. Foi realizada incisão e drenagem sob anestesia local ou geral no Hospital-Escola Al-Kindy e em hospitais privados ao longo de um período de 15 anos, de janeiro de 2000 até dezembro de 2015. As idades variavam de 20 a 68 (40,21 ± 1,34) anos. Havia maior número de homens (63/68) (92,64%) do que de mulheres (5/68)(7,35%). Os pacientes tiveram o abscesso tratado sob anestesia, e foi realizada a drenagem do abscesso. Os pacientes foram monitorados, em média, durante 18 meses (variação, 12-24 meses) após a drenagem do abscesso, ou até o surgimento de uma fístula e recorrência do abscesso. Resultados: O grupo de estudo compreendeu 68 (92,64%) pacientes com abscesso perianal, com idade mediana de 39 anos (variação, 20-68 anos). O período médio de seguimento foi de 18 meses (variação, 12-24 meses). Havia maior número de homens (63/68) (92,64%) versus mulheres (5/68) (7,35%). No seguimento, a incidência de formação de fístula nos pacientes com abscesso perianal após a incisão e drenagem foi de 31/68 (45,58%), e os homens foram mais afetados (30/31) (44,11%) versus mulheres (1/31) (1,47%). O local mais comum foi a posição posterior e, em seguida, a lateral esquerda. O percentual de pacientes com abscesso recorrente (6, 8,82%) foi mais baixo do que o percentual para pacientes com formação de fístula (31, 45,58%). O percentual de homens (4/6, 5,88%) foi maior versus mulheres (2/6, 2,94%). Conclusões: A incidência de fístula anal em uma amostra de pacientes iraquianos com abscesso perianal foi de 45,58% e o percentual de recorrência de abscesso perianal foi de 8,82%. Para evitar a divisão do músculo esfinctérico anal, é aconselhável fazer uma fistulotomia secundária mais tarde, quando a fístula anal já estiver formada.

Bacteriological study in perianal abscess is not useful and not cost-effective.

BACKGROUND: The detection of gut organisms in perianal abscesses has been postulated to suggest an underlying communication with the anal canal. However, recent studies appear to contradict this observation. The aim of this study is to determine the value of bacteriological studies in perianal abscesses. METHODS: A retrospective study of all patients who have had a surgical drainage of their perianal abscesses with concomitant microbiological examination from January 2010 to December 2012 was performed. Patients with known underlying anal fistula, Crohn's disease or previous perianal operations were excluded. RESULTS: A total of 164 patients, median age of 42.0 years (range 8-87) comprising of 78.7% males formed the study group. Gut organisms were cultured in 143 (87.2%) samples while 12 (7.3%) demonstrated skin organisms and nine did not yield any bacterial growth (5.5%). Twenty-nine (17.7%) patients developed anal fistula and 34 (20.7%) patients had a recurrence of the perianal abscess. The median follow-up period was 1450 (14-2391) days. There was no significant association between the presence of gut organism and development of fistulas (odds ratio = 0.48; 95% confidence interval = 0.17-1.37) or recurrence of perianal abscess (odds ratio = 1.66; 95% confidence interval = 0.46-6.01). CONCLUSION: Bacteriological culture in perianal abscess is not useful for predicting the development of anal fistula or abscess recurrence. Hence, there is no need to perform this investigation on a routine basis.

Knowledge about breastfeeding among a group of primary care physicians and residents in Puerto Rico.

Physicians have an essential role in promoting, protecting, and supporting breastfeeding as the ideal method of infant feeding. They are in an important position to promote breastfeeding but report difficulty in advising mothers with lactation problems. The purpose of this study is to assess knowledge about breastfeeding among primary care physicians and residents and identify potential barriers to its promotion. One hundred seventy-seven residents and physicians answered an anonymous questionnaire. The participants recognized breastfeeding benefits but 26% did not encourage exclusive breastfeeding. Mastitis, breast abscess, and the use of medications by the mother were considered contraindications to breastfeeding. Temporary breastfeeding discontinuation and bilirubin levels measurement were the preferred recommendations for the jaundiced infant. Most physicians received training in breastfeeding benefits although they report fair knowledge in myths, techniques, and contraindications. Physicians demonstrated to recognize breastfeeding benefits, but formal education is needed to eliminate barriers to breastfeeding promotion and support.

Epidemiología, resultados clínicos y costos del tratamiento del absceso tuboovárico, en un hospital público de Santiago / Epidemiology, clinical results and costs of treatment of the tuvoovarian abscess, in a public hospital in Santiago

Objetivos: Conocer frecuencia y factores de riesgo del absceso tuboovárico (ATO), complicaciones y costos del tratamiento. Método: Estudio retrospectivo de 64 pacientes operadas con el diagnóstico de ATO. Las pacientes se manejaron con criterio médico-quirúrgico: uso de antibióticos y cirugía en casos de peritonitis difusa, fiebre persistente con masa palpable y masa anexial mayor de 6 cm sin fiebre. Se evaluaron en fertilidad futura y en complicaciones: infección y dehiscencia de herida operatoria, reoperación por ATO residual, lesión intestinal, lesión vesical y complicaciones médicas. Resultados: El ATO representó el 73,6 por ciento de los casos hospitalizados por enfermedad inflamatoria pélvica, con frecuencia de 1,5 casos por mes y 17,2 por ciento de actinomicosis. La edad media de las pacientes fue 40,5 años. El dispositivo intrauterino (DIU) se asoció con ATO en 84,4 por ciento de los casos, 94,4 por ciento sin control y con media de uso de 10,2 años. El ATO unilateral fue el más frecuente (57,8 por ciento) y la anexectomía unilateral la operación más común. El 17,2 por ciento de las pacientes presentaron complicaciones y el 85,9 por ciento quedaron con infertilidad. El costo total de los 64 casos fue $86.331.713 (UF 3.788), con una media de $1.348.933 (UF 59,2). Conclusión: Existe un aumento de la frecuencia del ATO y de la actinomicosis pélvica, con incremento consiguiente de la infertilidad y de los costos, asociados al uso de DIU, sin control y por tiempo prolongado.

Objective: To determine frequency and risk factors of tuboovarian abscess (TOA) and observe complications, fertility damages and surgical costs of medical-surgical treatment. Method: Retrospective study in 64 patients operated with TOA diagnosis. Patients were managed with medical-surgical treatment: use of antibiotics and then surgery in cases of peritonitis diffuse, persistent fever with palpable mass and adnexial mass greater than 6 cm without fever. They were evaluated in future fertility and complications: infection and of surgical wound dehiscence, reoperation by residual TOA, intestinal injury, bladder injury and medical complications. Results: The TOA accounted for 73.6 percent of hospitalized cases of pelvic inflammatory disease (PID), 1.5 cases per month and 17.2 percent of actinomycosis. The mean age of patients was 40.5 years. The intrauterine device (IUD) was associated with TOA in 84.4 percent of cases, 94.4 percent uncontrolled and with a 10.2 years mean use. The unilateral TOA was the most frequent (57.8 percent) and the unilateral anexectomy the most common operation. The 17.2 percent of patients presented complications and 85.9 percent remained infertile. These results showed an increase compared with those obtained in the series published in 1993. The total cost of the 64 cases was $86.331.713 (UF 3.788), with a mean of $1.348.933 (UF 59.2). Conclusion: There is an increased frequency of the TOA and of pelvic actinomycosis, with consequent increase of infertility and costs associated with the uncontrolled and long-term use of IUD.

Current best practices and guidelines. Assessment and management of complications in infective endocarditis.

The most important complications of endocarditis are congestive heart failure, paravalvular abscess formation, and embolism, especially stroke. In addition, endocarditis may be complicated by septic arthritis, vertebral osteomyelitis, pericarditis, metastatic abscesses and an array of renal problems ranging from immune-complex glomerulonephritis to renal abscesses. Adverse reactions associated with medical treatment of endocarditis can also result in significant complications such as ototoxicity and nephrotoxicity, skin rashes, and serum sickness. This review focuses on the cardiac, embolic, neurologic and renal complications of endocarditis and discusses how these complications influence the clinical management of individual cases in daily practice.

Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess.

OBJECTIVE: Our purpose was to determine the clinical effectiveness and cost-effectiveness of three antibiotic regimens for the treatment of pelvic inflammatory disease and tuboovarian abscess. STUDY DESIGN: A review of all patients' hospitalized at Hutzel Hospital, Detroit, Michigan, for treatment of pelvic inflammatory disease and tuboovarian abscess between Jan. 1, 1993, and April 30, 1997, was performed. Demographic data, antibiotic choices, changes in therapy, operative interventions, and cost of therapy were assessed. RESULTS: Two hundred three patients were admitted for treatment of pelvic inflammatory disease during the study period. We were able to evaluate the clinical efficacy of antibiotic treatment in 179 patients, including 105 patients with pelvic inflammatory disease alone (uncomplicated pelvic inflammatory disease) and 74 women whose infection was complicated by tuboovarian abscess. The three antibiotic regimens evaluated were cefotetan plus doxycycline, clindamycin plus gentamicin, and ampicillin plus clindamycin plus gentamicin. All regimens demonstrated comparable efficacy in treating uncomplicated genital tract infections. Ampicillin plus clindamycin plus gentamicin was significantly better than clindamycin plus gentamicin and cefotetan plus doxycycline in treatment of tuboovarian abscess (p = 0.001). Fifteen women with tuboovarian abscess responded to a change to ampicillin plus gentamicin plus clindamycin antibiotic therapy alone. The hospital stay was prolonged by approximately 3 days in women failing to respond to initial antibiotic therapy, and operative interventions were common in this group of patients. CONCLUSIONS: Cefotetan plus oral doxycycline is the most cost-effective regimen for treating uncomplicated pelvic inflammatory disease, whereas triple-antibiotic therapy is the treatment of choice in women with tuboovarian abscess.

Computed tomography of the abdomen in the critically ill.

In one's attempt to arrive at the most accurate diagnosis in the critically ill, the selection of the most efficacious and rapid imaging modality can be problematic to clinicians, especially if the clinical presentation is confusing. The selection most often, is between US and CT. In general, US is advantageous in that it can be performed at bedside and is a faster and less costly examination. Its main disadvantages are interference from intestinal gaseous distention, restricted field of view from surgical dressings or wounds, and operator-dependence for accuracy. With the newer and faster CT scanners, CT is gaining an increasingly important role in the evaluation of the critically ill, despite the need for patient transport to the radiology department. It is more effective in displaying and localizing abnormalities and more helpful for drainage guidance than US. The potential benefit of CT should outweight the risk of transport of the unstable patient, and because of CT's high cost, appropriate timing of the study and expected diagnostic benefit should be taken into consideration. Norwood reported that CT was not positive for abscess prior to the eighth postoperative day, only 55% of examinations aided in or altered the pre-examination diagnosis, and more than 70% were of no benefit to the patient. An organized approach is essential in solving complex diagnostic problems if one is to enhance patient care and efficacious use of personnel and resources. This can be accomplished best by direct communication between clinicians and radiologists before and after the examination. Radiologists who understand the clinical problems and are familiar with all diagnostic modalities should be consulted for the selection of the modality best suited to answering the question at hand. Similarly, critically ill patients should benefit most if clinicians and radiologists review the examination results together in light of the clinical presentation for more accurate and meaningful diagnosis.

Surgical assessment of acute anorectal sepsis is a better predictor of fistula than microbiological analysis.

Twenty-two patients with acute anorectal sepsis were examined prospectively to compare surgical assessment with microbiological analysis as predictors of the aetiology of the sepsis. Culture of gut organisms was a sensitive method of detecting an underlying fistula but was not particularly specific (80 per cent). Demonstration of sepsis in the intersphincteric space in association with an anorectal abscess was 100 per cent sensitive and 100 per cent specific for detection of an underlying fistula. The demonstration was facilitated by a radially placed incision.

SIDA en proctología / AIDS in proctology

Un equipo multidisciplinario ha tratado 257 pacientes de riesgo de infección por HIV en los últimos 6 años. El número de estos pacientes se ha incrementado anualmente y duplicado en el último año. El 86 por ciento pertenece al sexo masculino y la edad promedio es de 30,3 años. El grupo más numeroso esta constituido por varones homosexuales (164 pacientes, 64 por ciento ) en orden de frecuencia siguen los heterosexuales drogadictos (65 pacientes, 35 por ciento ) y los hemofílicos (28 pacientes, 11 por ciento ). Las úlceras anales y rectales constituyen la patología proctológica hallada con mayor frecuencia (105 pacientes, 41 por ciento ) siguen los condilomas acuminados (73 pacientes, 28 por ciento ) y las proctitis y proctocolitis (51 pacientes, 19 por ciento ). En los períodos avanzados de la enfermedad la patología anal es múltiple. La piel perianal esta húmeda, enrojecida por la micosis, el ano congestivo con exudado purupento, plicomas turgentes, condilomas y úlceras. Es aconsejable insistir en el tratamiento médico específico o sintomático de la patología proctológica que obtiene notables remisiones y mejora la calidad de vida y reservar la cirugía, atemperada en cuanto a la magnitud de las incisiones, para los procesos agudos y la cirugía electiva indispensable

Primary pituitary abscess: surgical management and endocrine assessment in three cases.

Three cases of pituitary abscess are described. All were women with varying degrees of anterior pituitary dysfunction, diabetes insipidus and headaches. None had visual disturbance. A history of prior head injury was obtained in both young women who developed secondary amenorrhoea and hyperprolactinaemia. All three had low density, thick rim intrasellar masses on computed tomography scanning. Certain aspects of the diagnosis and surgical management of this rare condition are discussed with particular emphasis on the importance of pre- and postoperative endocrine assessment and preoperative diagnosis and proper surgical management.