Orf progressiva: giant progressive and destructive infections in the immunocompromised.

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.

A rare presentation of congenital syphilis: Pemphigus syphiliticus in a newborn infant with extensive desquamation of the extremities.

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.

A case report of adult-onset multiple angiokeratomas with zosteriform distribution.

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.

Borderline Tuberculoid Leprosy Masquerading as Granuloma Annulare: A Clinical and Histological Pitfall.

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.

Ustekinumab to target granulomatous dermatitis in recalcitrant ulcerative necrobiosis lipoidica: case report and proposed mechanism.

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.

Fluoroscopy induced chronic radiation dermatitis should be included in the differential diagnosis of notalgia paresthetica.

We report a patient with radiation (fluoroscopic)-induced dermatitis that produced symptoms similar to notalgia paresthetica.

Impact of venous thromboembolism, venous stasis syndrome, venous outflow obstruction and venous valvular incompetence on quality of life and activities of daily living: a nested case-control study.

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.

Do the potential benefits of metal-on-metal hip resurfacing justify the increased cost and risk of complications?

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.

Comparison of outcomes after intracerebral hemorrhage and ischemic stroke.

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.

The Cost-Effectiveness of Anterior Cruciate Ligament Reconstruction in Competitive Athletes.

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.

Use of cost-effectiveness analysis to evaluate new technologies in orthopaedics. The case of alternative bearing surfaces in total hip arthroplasty.

BACKGROUND: Alternative bearing surfaces offer the potential to reduce wear and improve implant longevity following total hip arthroplasty. However, these technologies are associated with higher costs, the potential for unintended consequences, and uncertain benefits in terms of long-term survival of the implants. The purpose of this study was to evaluate the cost-effectiveness of the use of alternative bearings in total hip arthroplasty. METHODS: A decision-analysis model was constructed to estimate the cost-effectiveness of the use of alternative bearings for patients undergoing total hip arthroplasty. Model inputs, including costs, clinical outcome probabilities, and health utility values, were derived from a review of the literature. Sensitivity analyses were performed to evaluate the impact of patient age at the time of surgery, implant costs, and reductions in revision rates on the cost-effectiveness of alternate bearing surfaces. RESULTS: In a population of fifty-year-old patients, use of an alternative bearing with an incremental cost of 2000 dollars would be cost-saving over the individual's lifetime if it were associated with at least a 19% reduction in the twenty-year implant failure rate when compared with the failure rate for a conventional bearing. In a population of patients over the age of sixty-three years, the same implant would be associated with higher lifetime costs than would a conventional bearing, regardless of the presumed reduction in the revision rate. Conversely, an alternative bearing that adds only 500 dollars to the cost of a conventional total hip arthroplasty could be cost-saving in a population of patients over the age of sixty-five years, even if it were associated with only a modest reduction in the revision rate. In a population of patients over the age of seventy-five years, no alternative bearing would be associated with lifetime cost-savings, regardless of the cost or the presumed reduction in the revision rate. CONCLUSIONS: The cost-effectiveness of alternative bearings is highly dependent on the age of the patient at the time of surgery, the cost of the implant, and the associated reduction in the probability of revision relative to that associated with conventional bearings. Our findings provide a quantitative rationale for requiring greater evidence of effectiveness in reducing the probability of implant failure when more costly alternative bearings are being considered, particularly for older patients.

Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study.

OBJECTIVE: To assess the potential impact of controlling risk factors on the incidence of venous thromboembolism by estimating the population attributable risk (defined as the percentage of all cases of a disease in a population that can be "attributed" to a risk factor) for deep vein thrombosis and pulmonary embolism associated with venous thromboembolism risk factors. METHODS: Using data from a population-based, nested, case-control study of the 625 Olmsted County, Minnesota, residents with a definite first lifetime deep vein thrombosis or pulmonary embolism diagnosed during the 15-year period 1976 to 1990 and 625 unaffected Olmsted County residents matched for age and sex, we developed a conditional logistic regression model appropriate to the matched case-control study design and then estimated attributable risk for the risk factors individually and collectively. RESULTS: Fifty-nine percent of the cases of venous thromboembolism in the community could be attributed to institutionalization (current or recent hospitalization or nursing home residence). Hospitalization for surgery (24%) and for medical illness (22%) accounted for a similar proportion of the cases, while nursing home residence accounted for 13%. The individual attributable risk estimates for malignant neoplasm, trauma, congestive heart failure, central venous catheter or pacemaker placement, neurological disease with extremity paresis, and superficial vein thrombosis were 18%, 12%, 10%, 9%, 7%, and 5%, respectively. Together, the 8 risk factors accounted for 74% of disease occurrence. CONCLUSIONS: Factors associated with institutionalization independently account for more than 50% of all cases of venous thromboembolism in the community. Greater emphasis should be placed on prophylaxis for hospitalized medical patients. Other recognized risk factors account for about 25% of all cases of venous thromboembolism, while the remaining 25% of cases are idiopathic.

The prevalence and pattern of complementary and alternative medicine use in individuals with diabetes.

OBJECTIVE: This study compared the prevalence and pattern of use of complementary and alternative medicine (CAM) in individuals with and without diabetes and identified factors associated with CAM use. RESEARCH DESIGN AND METHODS: The 1996 Medical Expenditure Panel Survey, a nationally representative sample of the U.S. noninstitutionalized civilian population, was analyzed. Estimates of CAM use in individuals with common chronic conditions were determined, and estimates of CAM use in patients with diabetes were compared with that in individuals with chronic medical conditions. Patterns of use and costs of CAM use in patients with diabetes were compared with those in nondiabetic individuals. Multiple logistic regression was used to determine independent predictors of CAM use in individuals with diabetes, controlling for age, sex, race/ethnicity, household income, educational level, and comorbidity. RESULTS: Individuals with diabetes were 1.6 times more likely to use CAM than individuals without diabetes (8 vs. 5%, P < 0.0001). In the general population, estimates of CAM use were not significantly different across selected chronic medical conditions, but diabetes was an independent predictor of CAM use. Among individuals with diabetes, older age (> or =65 years) and higher educational attainment (high school education or higher) were independently associated with CAM use. CONCLUSIONS: Diabetes is an independent predictor of CAM use in the general population and in individuals with diabetes. CAM use is more common in individuals aged > or =65 years and those with more than high school education.

Sickle cell anaemia: epidemiology and cost of illness.

The purpose of this paper was to review the research examining the epidemiology of and costs associated with sickle cell anaemia (SCA). Although there is general acceptance that Black populations are at greatest risk of the disease, estimates of disease incidence and prevalence vary greatly among different Black populations. In addition, the sickle cell haemoglobinopathy poses a health problem to many other ethnic groups, including populations native to Italy, Greece, Turkey, Saudi Arabia, India, Pakistan, Bangladesh, China, and Cyprus. As penicillin prophylaxis has been shown to reduce the risk of sepsis among children with SCA, many governments have established newborn screening programmes to improve the health outcomes for patients with this disease. As a group, patients with SCA incur large numbers of hospital admissions, emergency department visits, and outpatient visits, often at substantial costs, hence, obtaining adequate health insurance is a problem for many patients. A common theme present in studies reviewed in this article is that a small proportion of patients tends to account for a majority of the total healthcare costs. As new diagnostic methods and treatment options become available, balancing costs associated with SCA and quality of healthcare will continue to present challenges to many healthcare providers and insurers.