Successful use of brachytherapy for a severe hidradenitis suppurativa variant.

Hidradenitis suppurativa is a member of the follicular occlusion tetrad, along with acne conglobata, dissecting cellulitis of the scalp and pilodinal sinus. These conditions share common pathophysiologic features, including follicle occlusion, bacterial overgrowth, severe suppurative inflammation, scarring, and sinus tract formation. Treatment of severe cases is challenging, and a novel treatment modality would be of significant value. We describe a 46-year-old man who presented with a 15-year history of suppurative and scarring nodules involving his groin, scalp, neck, face, and chest. Based on their distribution and morphology, these lesions were most characteristic of hidradenitis suppurativa, although he had features of acne conglobata and dissecting cellulitis as well. Over the years, he had been treated with several antimicrobial and immunomodulatory agents, the main conventional therapies for follicular occlusion syndromes, without much success. We then treated him with superficial brachytherapy to his right groin and occiput, which led to significant improvement. No toxic side effects were noted. This case demonstrates the successful application of superficial brachytherapy for the treatment of severe hidradenitis suppurativa, and possibly for other follicular occlusion syndromes.

Failure of antibiotics in cellulitis trials: a systematic review and meta-analysis.

OBJECTIVES: The objectives of the study are to quantify trial-to-trial variability in antibiotic failure rates, in randomized clinical trials of cellulitis treatment and to provide a point estimate for the treatment failure rate across trials. METHODS: We conducted a structured search for clinical trials evaluating antibiotic treatment of cellulitis, indexed in PubMed by August 2015. We included studies published in English and excluded studies conducted wholly outside of developed countries because the pathophysiology of cellulitis is likely to be different in such settings. Two authors reviewed all abstracts identified for possible inclusion. Of studies identified initially, 5% met the selection criteria. Two reviewers extracted data independently, and data were pooled using the Freeman-Tukey transformation under a random-effects model. Our primary outcome was the summary estimate of treatment failure across intent-to-treat and clinically evaluable participants. RESULTS: We included 19 articles reporting data from 20 studies, for a total of 3935 patients. Treatment failure was reported in 6% to 37% of participants in the 9 trials reporting intent-to-treat results, with a summary point estimate of 18% failing treatment (95% confidence interval, 15%-21%). In the 15 articles evaluating clinically evaluable participants, treatment failure rates ranged from 3% to 42%, and overall, 12% (95% confidence interval, 10%-14%) were designated treatment failures. CONCLUSIONS: Treatment failure rates vary widely across cellulitis trials, from 6% to 37%. This may be due to confusion of cellulitis with its mimics and perhaps problems with construct validity of the diagnosis of cellulitis. Such factors bias trials toward equivalence and, in routine clinical care, impair quality and antibiotic stewardship. Objective diagnostic tools are needed.

Pink plaque on the arm of a man after a trip to Mexico: cutaneous leishmaniasis.

Cutaneous leishmaniasis is a parasitic infection caused by protozoa of the Leishmania genus that presents as asymptomatic pink papules that may ulcerate. There are several species of Leishmania found in 98 endemic countries and whereas all are associated with cutaneous disease, only specific species can cause mucocutaneous or visceral disease. Although the diagnosis of cutaneous leishmaniasis can be confirmed with Giemsa staining of a biopsy or "touch prep" specimen, only speciation at specialized centers such as the Centers for Disease Control (CDC) can determine the risk of mucocutaneous or visceral disease. Treatment of cutaneous leishmaniasis is varied and depends on the extent of cutaneous disease and the risk of mucocutaneous or visceral disease.

Immediate resolution of severe bullous chronic regional pain syndrome with onset of spinal paralysis.

Complex regional pain syndrome (CRPS) is an incompletely understood disorder characterized by progressive regional pain and sensory changes, with fluctuating cutaneous edema and erythema. We describe a patient with a rarely reported severe bullous CRPS variant on the left lower extremity, which resolved immediately upon developing spinal paralysis.

Scleromyxedema with histology resembling granuloma annulare.

Scleromyxedema is a generalized and progressive fibromucinous disorder associated with substantial cutaneous and systemic morbidity. The diagnosis is often challenging, as is management. We present here a patient with scleromyxedema with atypical, granuloma annulare-like histology, which contributed to delayed diagnosis and management, including a delayed workup for multiple myeloma. Ultimately, the patient did well with appropriate therapy, but his presentation illustrates the importance of more widespread familiarity among dermatologists and dermatopathologists with this variant of scleromyxedema.

Reddit and Google Activity Related to Non-COVID Epidemic Diseases Surged at Start of COVID-19 Pandemic: Retrospective Study.

BACKGROUND: Resources such as Google Trends and Reddit provide opportunities to gauge real-time popular interest in public health issues. Despite the potential for these publicly available and free resources to help optimize public health campaigns, use for this purpose has been limited. OBJECTIVE: The purpose of this study is to determine whether early public awareness of COVID-19 correlated with elevated public interest in other infectious diseases of public health importance. METHODS: Google Trends search data and Reddit comment data were analyzed from 2018 through 2020 for the frequency of keywords "chikungunya," "Ebola," "H1N1," "MERS," "SARS," and "Zika," 6 highly publicized epidemic diseases in recent decades. After collecting Google Trends relative popularity scores for each of these 6 terms, unpaired 2-tailed t tests were used to compare the 2020 weekly scores for each term to their average level over the 3-year study period. The number of Reddit comments per month with each of these 6 terms was collected and then adjusted for the total estimated Reddit monthly comment volume to derive a measure of relative use, analogous to the Google Trends popularity score. The relative monthly incidence of comments with each search term was then compared to the corresponding search term's pre-COVID monthly comment data, again using unpaired 2-tailed t tests. P value cutoffs for statistical significance were determined a priori with a Bonferroni correction. RESULTS: Google Trends and Reddit data both demonstrate large and statistically significant increases in the usage of each evaluated disease term through at least the initial months of the pandemic. Google searches and Reddit comments that included any of the evaluated infectious disease search terms rose significantly in the first months of 2020 above their baseline usage, peaking in March 2020. Google searches for "SARS" and "MERS" remained elevated for the entirety of the 2020 calendar year, as did Reddit comments with the words "Ebola," "H1N1," "MERS," and "SARS" (P<.001, for each weekly or monthly comparison, respectively). CONCLUSIONS: Google Trends and Reddit can readily be used to evaluate real-time general interest levels in public health-related topics, providing a tool to better time and direct public health initiatives that require a receptive target audience. The start of the COVID-19 pandemic correlated with increased public interest in other epidemic infectious diseases. We have demonstrated that for 6 distinct infectious causes of epidemics over the last 2 decades, public interest rose substantially and rapidly with the outbreak of COVID-19. Our data suggests that for at least several months after the initial outbreak, the public may have been particularly receptive to dialogue on these topics. Public health officials should consider using Google Trends and social media data to identify patterns of engagement with public health topics in real time and to optimize the timing of public health campaigns.

Finding New Meaning in the Practice of Medicine: A Quality Improvement Project Evaluating the Remote Communication Liaison Program During the Initial COVID Pandemic Surge.

Background: In spring 2020, the COVID-19 pandemic overwhelmed intensive care teams with severely ill patients. Even at the end of life, families were barred from hospitals, relying solely on remote communication. A Remote Communication Liaison Program (RCLP) was established to ensure daily communication for families, while supporting overstretched intensivists. Objectives: To evaluate the effectiveness and impact of the RCLP on participating liaisons and intensivists. Design: Two quality improvement surveys were developed and administered electronically. Setting/Subjects: Based in the United States, all liaisons and intensivists who participated in this program were invited to take the surveys. Measurements: Descriptive statistics were used to analyze the quantitative Likert-scale data, and qualitative analysis was used to assess themes. Results: Among respondents, all (100%) liaisons and more than 90% of intensivists agreed or strongly agreed that the RCLP provided a valuable service to families. More than 70% of intensivists agreed or strongly agreed that the program lessened their workload. More than 90% of liaisons agreed or strongly agreed that participation in the program improved their confidence and skills in end-of-life decision making, difficult conversations, and comprehension of critical care charts. Themes elicited from the liaisons revealed that participation fostered a renewed sense of purpose as physicians, meaningful connection, and opportunities for growth. Conclusions: RCLP successfully trained and deployed liaisons to rapidly develop skills in communication with beleaguered families during COVID-19 surge. Participation in the program had a profound effect on liaisons, who experienced a renewed sense of meaning and connection to the practice of medicine.

Urgent access to a specialty care melanoma clinic is associated with a higher rate of melanoma detection.

BACKGROUND: As melanoma rates increase, and the supply of dermatologists remains suboptimal to meet demand for services, detection of early melanoma has become an increasingly difficult challenge. Some authors advocate for shifting dermatologic resources from routine appointments to urgent visits for those with lesions concerning for melanoma. OBJECTIVE: We sought to investigate the potential of an urgent access track (UAT) embedded within a pigmented lesion clinic to improve early melanoma detection. METHODS: We conducted a retrospective review of patient records from a tertiary care hospital's pigmented lesion clinic and the associated UAT. Results of procedures for all 4495 patient visits to the routine track and all 316 visits to the UAT during the 21-month study period were included, as were detailed chart reviews of all UAT patient visits. RESULTS: UAT visits were more than 4 times as likely (4.1% vs 1.0%) to yield a diagnosis of melanoma as routine track visits (odds ratio 4.24; 95% confidence interval 2.28-7.88; P < .0001), and almost 25 times as likely (2.2% vs 0.1%) to yield a diagnosis of metastatic melanoma (odds ratio 25.4; 95% confidence interval 7.4-87.4; P < .0001). LIMITATIONS: This was a preliminary analysis with only limited data extracted from the routine track pigmented lesion clinic patient visits. CONCLUSION: This initial analysis of UAT strategy suggests that UATs have potential to detect patients with earlier melanomas; further research is needed to specifically delineate how resources should be best allocated between routine surveillance and urgent care to maximize melanoma early detection and survival.

Development of a Novel Communication Liaison Program to Support COVID-19 Patients and Their Families.

In the spring of 2020, our hospital faced a surge of critically ill coronavirus disease 2019 patients, with intensive care unit (ICU) occupancy peaking at 204% of the baseline maximum capacity. In anticipation of this surge, we developed a remote communication liaison program to help the ICU and palliative care teams support families of critically ill patients. In just nine days from inception until implementation, we recruited and prepared ambulatory specialty providers to serve in this role effectively, despite minimal prior critical care experience. We report here the primary elements needed to reproduce and scale this program in other hospitals facing similar ICU surges, including a checklist for replication (Appendix I). Keys to success include strong logistical support, clinical reference material designed for rapid evolution, and a liaison team structure with peer coaching.

Hand-foot syndrome (hand-foot skin reaction, palmar-plantar erythrodysesthesia): focus on sorafenib and sunitinib.

Hand-foot syndrome (HFS), also called hand-foot skin reaction, palmar-plantar erythrodysesthesia, acral erythema, and Burgdorf reaction, is a dose-limiting cutaneous toxicity of many chemotherapeutic agents. Recently, the multiple tyrosine kinase inhibitor class of novel targeted therapies, including sorafenib and sunitinib, has emerged as an important cause of HFS, with 10-28% of patients treated with sunitinib and 10-62% of patients treated with sorafenib reporting HFS. This review examines the epidemiology, clinical features, histopathology, pathogenesis models, prognostic implications, and management of HFS, with particular attention to HFS induced by sorafenib and sunitinib. The high prevalence of HFS reported by patients treated with these medications underscores the need for greater understanding of the pathogenesis and management of this syndrome.

Limiting the emergence of extended-spectrum Beta-lactamase-producing enterobacteriaceae: influence of patient population characteristics on the response to antimicrobial formulary interventions.

BACKGROUND: Effective methods to control the emergence of extended-spectrum beta -lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK) remain unclear. Variations in the patient populations at different hospitals may influence the effect of antimicrobial formulary interventions. METHODS: To examine variations across hospitals in the response to antimicrobial interventions (ie, restriction of ceftazidime and ceftriaxone) designed to curb the spread of ESBL-EK, we conducted a 5-year quasi-experimental study. This study was conducted at 2 hospitals within the same health system: Hospital A is a 625-bed academic medical center, and Hospital B is a 344-bed urban community hospital. All adult patients with a healthcare-acquired clinical culture of ESBL-EK from July 1, 1997 through December 31, 2002 were included. RESULTS: After the interventions, the use of ceftriaxone decreased by 86% at Hospital A and by 95% at Hospital B, whereas the use of ceftazidime decreased by 95% at Hospital A and by 97% at Hospital B. The prevalence of ESBL-EK at Hospital A decreased by 45% (P < .001), compared with a 22% decrease at Hospital B (P = .36). The following variables were significantly more common among ESBL-EK-infected patients at Hospital B: residence in a long-term care facility (adjusted odds ratio, 3.77 [95% confidence interval, 1.70-8.37]), advanced age (adjusted odds ratio, 1.04 [95% confidence interval, 1.01-1.06]), and presence of a decubitus ulcer (adjusted odds ratio, 4.13 [95% confidence interval, 1.97-8.65]). CONCLUSIONS: The effect of antimicrobial formulary interventions intended to curb emergence of ESBL-EK may differ substantially across institutions, perhaps as a result of differences in patient populations. Variability in the epidemiological profiles of ESBL-EK isolates at different hospitals must be considered when designing interventions to respond to these pathogens.

Impact of inadequate initial antimicrobial therapy on mortality in infections due to extended-spectrum beta-lactamase-producing enterobacteriaceae: variability by site of infection.

BACKGROUND: Infections due to extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK) have increased markedly in recent years. Risk factors for mortality among ESBL-EK infections have not been studied. METHODS: This retrospective cohort study was conducted in a 625-bed tertiary care medical center and a 344-bed urban community hospital to determine whether inadequate initial antimicrobial therapy (IIAT) (>48 hours between the time a culture was obtained and initiation of an agent to which the infecting organism was susceptible) is associated with mortality in ESBL-EK infections. All hospitalized patients with an ESBL-EK infection between June 1, 1997, and December 31, 2002, were eligible for inclusion. Subsequently, we conducted a nested case-control study to identify risk factors for IIAT. RESULTS: Of 187 subjects, 32 (17.1%) died while in the hospital. Clinical site of infection was a significant effect modifier in the association between IIAT and mortality. The presence of IIAT was an independent risk factor for mortality, but only for nonurinary ESBL-EK infections (adjusted odds ratio [95% confidence interval], 10.04 [1.90-52.96]). Independent risk factors for IIAT were (1) infection with a multidrug-resistant ESBL-EK (ie, resistant to sulfamethoxazole-trimethoprim, aminoglycosides, and quinolones) (14.58 [1.91-111.36]) and (2) health care-acquired ESBL-EK infection (4.32 [1.49-12.54]). CONCLUSIONS: Inadequate initial antimicrobial therapy is an independent risk factor for mortality in ESBL-EK infections, but only among nonurinary infections. Multidrug resistance was a strong risk factor for IIAT.

Toward an Objective Diagnostic Test for Bacterial Cellulitis.

BACKGROUND: Prior studies repeatedly showed that cultures of skin lesions diagnosed as "cellulitis" are usually negative. However, lack of a gold standard for diagnosis (against which culture might be judged) and failure to assess the human immune response are important limitations of prior work. In this pilot study, we aimed to develop a criterion standard for research on bacterial cellulitis, to evaluate the sensitivity of procalcitonin for bacterial cellulitis, and to use gene expression analysis to find other candidate diagnostic markers. METHODS: We classified lesions via biopsies, 16s rRNA gene detection, culture, and histopathology. We quantified procalcitonin expression in blood. We also used Nanostring technology to quantify transcription of immunomodulators that may distinguish cases from inflamed controls. RESULTS: Of 28 participants, 15 had a clinical diagnosis of cellulitis, six had a diagnosis of non-infectious dermatitis, and seven were normal volunteers. Of the "cellulitis" patients, three (20%) had pathogens isolated, and were designated confirmed cases. Procalcitonin was undetectable in all three. HLA-DQA1 was expressed 34-fold more in confirmed cases vs. controls (fold change of geometric mean). Heat maps depicting multiplex gene expression analysis revealed a distinct profile of gene expression in confirmed cases relative to comparators. CONCLUSIONS: Most "cellulitis" patients had microbiologically-negative biopsies. Procalcitonin was undetectable, and HLA-DQA1 elevated, in confirmed bacterial cases. Multivariable transcriptomic profiling results supported our algorithm's ability to identify patients with true bacterial cellulitis. A larger sample may allow discovery of an immunological signature capable of distinguishing bacterial cellulitis from its mimics in clinical practice.

Risk factors for increasing multidrug resistance among extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species.

BACKGROUND: The importance of infections due to extended-spectrum beta -lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK) has been increasingly recognized in recent years. ESBL-EK infections are of clinical concern, because few antimicrobials are available as therapeutic options. Increased reliance on carbapenems has led to increasing carbapenem resistance. Efforts to maintain current therapeutic options for ESBL-EK infections are essential. METHODS: We conducted a case-control study to identify risk factors for multidrug resistance (MDR) among ESBL-EK. All patients at our institution who had an inpatient clinical culture result positive for an ESBL-EK during the period of 1 June 1997 through 31 December 2002 were eligible for inclusion. An MDR ESBL-EK was defined as ESBL-EK demonstrating resistance to trimethoprim-sulfamethoxazole, aminoglycosides, and quinolones. All available ESBL-EK isolates were characterized by pulsed-field gel electrophoresis (PFGE). RESULTS: Of 361 total ESBL-EK isolates, 68 (18.8%) were MDR. During the study period, the prevalence of MDR among ESBL-EK isolates increased from 12.5% to 26.9%. The only independent risk factor for MDR ESBL-EK was the infecting organism (i.e., Klebsiella pneumoniae; adjusted odds ratio, 11.7; 95% confidence interval, 4.77-28.51; P < .001). Prior antibiotic use was not independently associated with MDR ESBL-EK. PFGE patterns from K. pneumoniae isolates indicated close genetic relatedness among a substantial proportion of isolates. CONCLUSIONS: The emergence of MDR among ESBL-EK has important implications for the future ability to treat these infections. The strong association between the species of infecting organism and MDR suggests that the epidemiology in K. pneumoniae may be unique. PFGE results suggest that horizontal spread is important in the emergence of MDR ESBL-EK.