Cutaneous cytomegalovirus - A case of disseminated cytomegalovirus presenting with extensive ulcerative skin lesions in a renal transplant recipient.

Cytomegalovirus (CMV) reactivation is common in organ transplant recipients and can lead to significant morbidity and mortality. Cutaneous CMV findings are rarely reported in the literature and diagnosis can be delayed if not clinically recognized. We describe a case of a female patient 20 years post renal transplant who presented with extensive ulcerative skin lesions and diarrhea. She rapidly deteriorated and died on day 5 of hospitalization. Autopsy noted extensive CMV involvement of skin and gastrointestinal (GI) tract by CMV-specific immunohistochemistry. These findings, along with high-grade CMV viremia, led to the final postmortem diagnosis of disseminated CMV infection. This case focuses on the cutaneous findings of disseminated CMV as recognition of CMV skin lesions can lead to earlier initiation of appropriate therapy in transplant recipients.

Incidence, determinants and outcomes of pregnancy-associated hepatitis B flares: A regional hospital-based cohort study.

BACKGROUND & AIMS: There is limited knowledge about hepatitis B virus (HBV) flare among pregnant women. We evaluated the incidence, determinants and outcomes of HBV flare in a multicultural cohort of pregnant HBV-infected women in the United States. METHODS: We performed a retrospective cohort study of pregnant hepatitis B surface antigen-positive women cared for at hospital-based clinics of 4 medical centres in Southeastern Pennsylvania from 2006 to 2015. The main outcome was incident HBV flare (alanine aminotransferase [ALT] ≥2 times upper limit of normal) during pregnancy or within 6 months after delivery. Among patients with flare, we determined development of jaundice (total bilirubin ≥2.5 mg/dL) and hepatic decompensation. Multivariable logistic regression was used to estimate odds ratios (ORs) of HBV flare for risk factors of interest, including timing of flare (during pregnancy versus post-delivery), nulliparity, younger age, HBV e antigen (HBeAg) status, and lack of anti-HBV therapy. RESULTS: Among 310 pregnant predominantly African HBV-infected women with 388 pregnancies, the incidence of HBV flare was 14% (95% CI, 10-18%) during pregnancy and 16% (95% CI, 11-24%) post-delivery. Jaundice developed in 12% and hepatic decompensation in 2%. Positive HBeAg was associated with HBV flare (OR, 2.55; 95% CI, 1.04-6.20). HBV DNA was measured in 55% of patients, and only 50% were referred for HBV specialty care. CONCLUSIONS: Pregnancy-associated hepatitis B flare occurred in 14% during pregnancy and 16% post-delivery and rarely led to hepatic decompensation. Positive HBeAg was the main risk factor identified. Women did not have adequate HBV monitoring or follow-up during pregnancy.

Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis.

OBJECTIVES: To determine whether treatment with a protocolized sepsis guideline in the emergency department was associated with a lower burden of organ dysfunction by hospital day 2 compared to nonprotocolized usual care in pediatric patients with severe sepsis. DESIGN: Retrospective cohort study. SETTING: Tertiary care children's hospital from January 1, 2012, to March 31, 2014. SUBJECTS: Patients older than 56 days old and younger than 18 years old with international consensus defined severe sepsis and who required PICU admission within 24 hours of emergency department arrival were included. MEASUREMENTS AND MAIN RESULTS: The exposure was the use of a protocolized emergency department sepsis guideline. The primary outcome was complete resolution of organ dysfunction by hospital day 2. One hundred eighty nine subjects were identified during the study period. Of these, 121 (64%) were treated with the protocolized emergency department guideline and 68 were not. There were no significant differences between the groups in age, sex, race, number of comorbid conditions, emergency department triage level, or organ dysfunction on arrival to the emergency department. Patients treated with protocolized emergency department care were more likely to be free of organ dysfunction on hospital day 2 after controlling for sex, comorbid condition, indwelling central venous catheter, Pediatric Index of Mortality-2 score, and timing of antibiotics and IV fluids (adjusted odds ratio, 4.2; 95% CI, 1.7-10.4). CONCLUSIONS: Use of a protocolized emergency department sepsis guideline was independently associated with resolution of organ dysfunction by hospital day 2 compared to nonprotocolized usual care. These data indicate that morbidity outcomes in children can be improved with the use of protocolized care.

Identifying Pediatric Severe Sepsis and Septic Shock: Accuracy of Diagnosis Codes.

OBJECTIVES: To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. STUDY DESIGN: Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. RESULTS: A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). CONCLUSIONS: Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.

Development of a Framework for Addressing Skin Biopsy Tray Waste in Dermatology Clinics: A Quality Improvement Study.

Importance: The US health care system generates substantial global waste. Skin biopsies are frequently performed by dermatologists and represent a practical and scalable opportunity for waste reduction interventions in dermatology clinics. Objective: To develop and implement a systematic framework for decreasing skin biopsy tray waste in dermatology clinics. Design, Setting, and Participants: This quality improvement study was conducted at 4 outpatient clinic sites within a single institution between October 2021 and April 2022. The clinic site with the greatest skin biopsy tray waste production was selected for intervention. Waste audits before and after the intervention quantified the number of wasted supplies per skin biopsy tray in dermatology clinics. The participants were dermatology residents, faculty, nurses, medical assistants, and clinic managers. Interventions: Provision of educational materials about climate change and health care and standardizing biopsy tray setup to decrease wasted supplies. Main Outcomes and Measures: Quantity of wasted skin biopsy tray supplies (gauze squares, alcohol pads, cotton swabs, and adhesive bandages) before and after interventions. Results: In waste audits in 4 outpatient dermatology clinics (comprising 98 skin biopsy trays), prior to intervention, 100% of skin biopsy trays had more than 2 wasted supplies within targeted outpatient dermatology clinics at the Stanford Cancer Institute with a mean (SD) of 10.1 (3.4) wasted items per biopsy tray. Following the quality improvement-based interventions, only 16% of skin biopsy trays had more than 2 wasted supplies and the mean (SD) number of wasted supplies per tray decreased to 1.6 (1.3). Conclusions and Relevance: Results of this quality improvement study suggest that through collaboration with all members of the clinical team including physicians, medical assistants, nurses, and clinic managers, skin biopsy tray setup modifications may be associated with reduced waste in outpatient dermatology clinics. This study presents a framework that accounts for different factors in the production of waste in individual clinic settings, and thus can be adapted within additional dermatology clinics.

Preoperative Platelet Count Predicts Lower Extremity Free Flap Thrombosis: A Multi-Institutional Experience.

BACKGROUND: Thrombocytosis in patients undergoing lower extremity free tissue transfer may be associated with increased risk of microvascular complications. This study assessed whether preoperative platelet counts predict lower extremity free flap thrombosis. METHODS: All patients undergoing lower extremity free tissue transfer at Duke University from 1997 to 2013 and at the University of Pennsylvania from 2002 to 2013 were retrospectively identified. Logistic regression was used to assess whether preoperative platelet counts independently predict flap thrombosis, controlling for baseline and operative factors. RESULTS: A total of 565 patients underwent lower extremity free tissue transfer, with an overall flap thrombosis rate of 16 percent (n = 91). Elevated preoperative platelet counts were independently associated with both intraoperative thrombosis (500 ± 120 versus 316 ± 144 × 10/liter; p < 0.001) and postoperative thrombosis (410 ± 183 versus 320 ± 143 × 10/liter; p = 0.040) in 215 patients who sustained acute lower extremity trauma within 30 days before reconstruction. In acute trauma patients, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 403 × 10/liter; OR, 4.08; p < 0.001) and a two-fold increased risk of postoperative thrombosis (cutoff value, 361 × 10/liter; OR, 2.16; p = 0.005). In patients who did not sustain acute trauma, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 352 × 10/liter; OR, 3.82; p = 0.002). CONCLUSIONS: Acute trauma patients with elevated preoperative platelet counts are at increased risk for lower extremity free flap complications. Prospective evaluation is warranted for guiding risk stratification and targeted treatment strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.