S1 guideline: Differential diagnosis of acute and chronic redness of the lower legs.

Acute or chronic redness of the lower leg is a frequent reason for visits to clinics and practices. The differential diagnosis is often challenging. The aim of this guideline is to define criteria and procedures for the differential diagnosis of acute or chronic, unilateral or bilateral redness of the lower leg. Finding the correct diagnosis is essential for selecting an appropriate treatment and can help to reduce the inappropriate use of antibiotics. The guideline committee identified the most relevant differential diagnoses: 1. erysipelas, 2. stasis dermatitis, 3. hyperergic ictus reaction, 4. superficial and deep vein thrombosis, 5. gout, 6. chronic allergic contact dermatitis, and 7. acute toxic or allergic contact dermatitis. Algorithms/diagnostic pathways, each of which can be broken down into anamnesis, clinical examination, and diagnostics, have been developed for these seven diagnoses. In addition, the guideline group identified over 40 other relevant diagnoses and summarized their characteristics in a table to facilitate further differential diagnoses.

[Lymphedema-clinical picture and therapy]. / Lymphödem ­ Klinik und Behandlung.

Local edema is a common symptom in many skin diseases, especially in inflammatory or allergic reactions. Diseases of the lymphatic system can also lead to edema with specific changes in the skin. Lymphedema is the result of primary genetic changes, which can also occur in the context of syndromes and can be traced to abnormal development of the lymphatic system. Secondary lymphedema usually develops after surgery, inflammatory reactions or chronic venous insufficiency (CVI). The microfiltrate that is transported in the tissue in healthy individuals via the lymphatic system is rich in proteins and induces fibrosis of the epidermis and dermis. In addition to edema, clinical signs include pachydermia, papillomatosis cutis lymphostatica, hyperkeratosis, lymph cysts, lymph fistulas, nail dystrophies and yellow nails. Basic therapy comprises complex decongestive therapy (CDT: manual lymph drainage, compression, physical exercise/sports, skin care and instructions regarding self-management). Intermittent compression can also be applied. Comorbidities such as obesity and diabetes mellitus may aggravate the situation and must be treated. Adequate therapy can reduce sequelae of the skin.

S1 Guidelines - Dermatoses associated with dermal lymphostasis.

The objective of the present S1 guidelines is to present current knowledge about dermatologically relevant diseases associated with localized dermal lymphostasis, thus facilitating their early detection, diagnostic workup, and targeted treatment. Whenever possible, treatment should be based on stage-appropriate and clearly defined algorithms. The numerous issues regarding differential diagnosis and treatment clinicians are confronted with in everyday clinical practice seem to warrant the publication of up-to-date guidelines. These guidelines focus on patients of all age groups and genders exhibiting skin lesions caused by dermal lymphostasis. Specific recommendations are provided with respect to the diagnosis and differential diagnosis of the various clinical manifestations. In this context, comorbid skin diseases such as atopic dermatitis, psoriasis, hidradenitis suppurativa, urticaria, and contact dermatitis will be highlighted, including their treatment and associated specific risks. Several other relevant current guidelines are referenced as regards the distinction from and treatment of common cofactors and comorbid conditions.

S1-Leitlinie - Dermatosen bei dermaler Lymphostase.

Das Ziel dieser S1-Leitlinie ist es, aktuelles Wissen über dermatologisch relevante Krankheitsbilder bei lokal begrenzter dermaler Lymphostase an allen Lokalisationen des Hautorgans zu vermitteln, um diese frühzeitig zu erkennen, diagnostisch zu sichern und gezielt zu behandeln. Wann immer möglich, sollte diese Therapie anhand klar definierter Algorithmen stadiengerecht erfolgen. Die im klinischen Alltag häufig auftauchenden differenzialdiagnostischen und therapeutischen Fragen lassen eine aktuelle Leitlinie notwendig erscheinen. Diese Leitlinie fokussiert auf Patienten jeglichen Alters und Geschlechts mit Hautveränderungen, die im kausalen Zusammenhang mit dermaler Lymphostase stehen. In konkreten Handlungsempfehlungen werden die Diagnostik und Differenzialdiagnostik der verschiedenen Manifestationsformen bei gleichzeitig auftretender dermatologischer Komorbidität wie beispielsweise atopische Dermatitis, Psoriasis vulgaris, Acne inversa, Urtikaria, Kontaktekzeme sowie ihre Therapien unter Berücksichtigung besonderer Risiken veranschaulicht. Für die Abgrenzung und Behandlung häufiger therapierelevanter Kofaktoren und Komorbidität wird auf mehrere andere hierfür relevante aktuelle Leitlinien verwiesen.

Impact of seamless compression garments on limb functionality, comfort and quality of life.

Lymphoedema is a chronic disease affecting the patients' quality of life (QoL) especially with regard to mobility and daily activities. Lymphoedema cannot be cured but symptoms can effectively be improved by a comprehensive approach and the continuous use of compression therapy. An appropriate fitted compression garment is essential for compliance and thus a prerequisite for successful lymphoedema management. Compression garments with bulky seams are not only uncomfortable they also can lead to severe pressure marks or even reduce the mobility and function of the affected limb, which may negatively impact the already reduced QoL of lymphoedema patients. A prospective multicentre observational study was conducted to compare compression garments without and with a seam for hands and toes in 143 patients with lymphoedema. Product performance, lymphoedema symptoms, functionality of hands/toes, QoL and patient satisfaction were documented for the previously worn compression garment as well as for the 3D flat knitted JOBST® Elvarex Plus compression garment without a seam. The JOBST Elvarex Plus glove was perceived very positively by patients, who rated the mobility of the fingers, the adaptability to the shape of the hand/fingers, the fit of cuffs/welts, and the tactile sense of the fingers to be significantly better compared to the previous glove. Also pressure marks between fingers/toes and pressure marks due to cuffs/welts were significantly less frequent when wearing JOBST Elvarex Plus. Also pain, sensation of heaviness, swelling, tightness and dryness of skin were significantly improved when wearing JOBST Elvarex Plus gloves. Furthermore, 80% of the patients rated the wearing comfort of JOBST Elvarex Plus to be better than their previous garments with a seam. Regarding functionality, patients were significantly less limited in their daily activities when wearing JOBST Elvarex Plus garments. Finally, when wearing JOBST Elvarex Plus gloves and toe caps, patients rated the negative effect of their lymphoedema on their QoL to be significantly lower. In conclusion, the application of anatomically adapted compression garments without a seam led to improving patient's reported lymphoedema symptoms, increased patient's satisfaction with the compression garment and supported a better QoL.

S1 guidelines: Lipedema.

The present, revised guidelines on lipedema were developed under the auspices of and funded by the German Society of Phlebology (DGP). The recommendations are based on a systematic literature search and the consensus of eight medical societies and working groups. The guidelines contain recommendations with respect to diagnosis and management of lipedema. The diagnosis is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. Treatment consists of four therapeutic mainstays that should be combined as necessary and address current clinical symptoms: complex physical therapy (manual lymphatic drainage, compression therapy, exercise therapy, and skin care), liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy if necessary. Surgical procedures are indicated if - despite thorough conservative treatment - symptoms persist, or if there is progression of clinical findings and/or symptoms. If present, morbid obesity should be therapeutically addressed prior to liposuction.

S1-Leitlinie Lipödem.

Die vorliegende überarbeitete Leitlinie zum Lipödem wurde unter der Federführung der Deutschen Gesellschaft für Phlebologie (DGP) erstellt und finanziert. Die Inhalte beruhen auf einer systematischen Literaturrecherche und dem Konsens von acht medizinischen Fachgesellschaften und Berufsverbänden. Die Leitlinie beinhaltet Empfehlungen zu Diagnostik und Therapie des Lipödems. Die Diagnose ist dabei auf der Basis von Anamnese und klinischem Befund zu stellen. Charakteristisch ist eine umschriebene, symmetrisch lokalisierte Vermehrung des Unterhautfettgewebes an den Extremitäten mit deutlicher Disproportion zum Stamm. Zusätzlich finden sich Ödeme, Hämatomneigung und eine gesteigerte Schmerzhaftigkeit der betroffenen Körperabschnitte. Weitere apparative Untersuchungen sind bisher besonderen Fragestellungen vorbehalten. Die Erkrankung ist chronisch progredient mit individuell unterschiedlichem und nicht vorhersehbarem Verlauf. Die Therapie besteht aus vier Säulen, die individuell kombiniert und an das aktuelle Beschwerdebild angepasst werden sollten: komplexe physikalische Entstauungstherapie (manuelle Lymphdrainage, Kompressionstherapie, Bewegungstherapie, Hautpflege), Liposuktion und plastisch-chirurgische Interventionen, Ernährung und körperliche Aktivität sowie ggf. additive Psychotherapie. Operative Maßnahmen sind insbesondere dann angezeigt, wenn trotz konsequent durchgeführter konservativer Therapie noch Beschwerden bestehen bzw. eine Progredienz des Befundes und/oder der Beschwerden auftritt. Eine begleitend zum Lipödem bestehende morbide Adipositas sollte vor einer Liposuktion therapeutisch angegangen werden.

In-office vs. operating room procedures for recurrent respiratory papillomatosis.

We conducted a study to analyze hospital and patient costs, outcomes, and patient satisfaction among adults undergoing in-office and operating room procedures for the treatment of recurrent respiratory papillomatosis. Our final study population was made up of 17 patients-1 man and 16 women, aged 30 to 86 years (mean: 62). The mean number of in-office laser procedures per patient was 4.2, and the mean interval between procedures was 5.4 months (although 10 patients underwent only 1 office procedure); the mean number of operating room procedures was 13.5, and the mean interval between procedures was 14.3 months. An equal number of patients reported complications or adverse events with the two types of procedures-5 each. The difference in cost between the office procedure (mean: $3,413.00) and the operating room procedure (mean: $12,382.59) was almost $9,000, but these savings were offset by the fact that the office procedures needed to be performed three times as often. Patients reported slightly more anxiety and discomfort during the office procedures and, overall, they appeared to prefer the operating room procedure. We conclude that office procedures are significantly more cost-effective than operating room procedures, but their use may be limited by patient tolerance and the increased frequency of the procedure.

Chronic otitis media with effusion following radiation therapy.

The incidence of chronic otitis media with effusion (COME) after radiotherapy for nasopharyngeal or sinonasal tumors is relatively high. It is often a difficult-to-treat problem in these patients. In this retrospective study, we sought to describe the clinical course of COME in 51 patients-33 men and 18 women, aged 39 to 90 years (mean: 58.9 ± 15)-who had been referred to the Henry Ford Health System in Detroit between 2001 and 2011 for management of a tumor that had involved either the nasopharyngeal area or the sinonasal area. The median length of follow-up from the time of cancer diagnosis was 32 months. Of the 51 patients, 23 (45.1%) developed COME before, during, or after radiation therapy. Of these 23 patients, 13 (56.5%) did not experience any improvement after treatment with various combinations of therapies, including myringotomy, tympanostomy tube placement, otic drops, oral antibiotics, and corticosteroid nasal sprays. No patient- or tumor-specific factors were found to be significantly associated with the incidence of COME after irradiation to the sinonasal area. Older age and squamous cell tumor pathology were found to be significant factors for the resolution of COME after it had developed, whereas treatments with tympanostomy tubes and ear drops were not. Because of the high incidence of COME after radiotherapy and the high rate of COME's failure to resolve after tympanostomy tube insertion, we suggest that these patients require an alternative treatment.

Bleeding risk associated with resection of the middle turbinate during functional endoscopic sinus surgery.

BACKGROUND: The decision to resect the middle turbinate (MT) during functional endoscopic sinus surgery is controversial. Although there have been a variety of studies that examined the functional outcome related to this maneuver, very few studies evaluated the potential for complications, in particular, epistaxis. OBJECTIVE: We sought to determine if resection of the MT during functional endoscopic sinus surgery leads to an increased risk for postoperative bleeding. METHODS: Patients who underwent functional endoscopic sinus surgery for chronic sinusitis or nasal polyposis between 2004 and 2014 at a single institution were analyzed for bleeding and other complications after resection of the MT. RESULTS: Between 2004 and 2014, 1185 sinus surgeries were performed by 18 surgeons. A propensity matched set of 228 patients who underwent turbinate resection, and 228 controls were selected based on predicted probabilities from a logistic regression that predicted turbinate resection and that was adjusted for age, sex, and procedure. There were 89 patients with bilateral turbinates removed and 139 with unilateral turbinates removed. There was no significant difference in major bleeding or other complication rates between the two groups. Patients who underwent resection of at least one MT were 3.95 times more likely to have minor bleeding compared with those who did not; this risk increased with the number of turbinates resected (trend p = 0.008). Patients on anticoagulation medications were at a significant risk of bleeding if their MT was removed (p = 0.007), whereas patients on aspirin or antiplatelet therapy were not at a significant risk. CONCLUSION: There was no increased risk of major bleeding or other complication associated with resection of the MT. However, there was a significantly increased minor bleeding rate associated with MT resection, particularly if the patient was on anticoagulants.

Predictors of repeated "no-showing" to clinic appointments.

OBJECTIVE: To determine the variables that contribute to repeated patient non-compliance with showing up to clinic appointments. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care academic institution. SUBJECTS AND METHODS: Patients who did not show up to 3 or more clinic appointments in the otolaryngology department in the Henry Ford Health System in metro Detroit, Michigan between July 1, 2011 to June 30, 2012 area were compared to control patients randomly chosen from those who had appointments on the same day with the same provider as the no-show patients. RESULTS: 105 patients were identified who no-showed to 3 or more clinic appointments. Younger age, black race, and lower income were all found to be significant factors for patients missing appointments in a multiple variate model. On logistic regression, Medicaid insurance, closer distance from home to appointment, less bus transfers, and less time by bus travel were also found to correlate with no-showing. CONCLUSION: Age, race, and income are significantly related to patient non-compliance with clinic appointments. Paradoxically, proximity to the clinical appointment location is also significantly related - we hypothesize this may be the result of significant income inequality in the metro Detroit population distribution. Follow up studies include analyzing factors that precluded patient access and interventions to improve compliance and decrease cost.

Correlation between sleep disruption on postoperative pain.

OBJECTIVES: To identify the amount of sleep disruption that occurs in the postoperative inpatient hospital setting, determine the relationship between sleep disruption and the quantity of narcotics taken for postoperative pain, and determine if hospital length of stay is related to sleep disruption. STUDY DESIGN: Prospective cohort study. SETTING: Single tertiary care academic institution. SUBJECTS AND METHODS: Fifty patients undergoing total hip or knee arthroplasty at Henry Ford Hospital in Detroit, Michigan, between January 2013 and November 2013 were asked to wear an actigraph during their postoperative hospital stay. Total sleep time, sleep efficiency, awake index, total narcotic use, visual analog pain scores, and postoperative complications were analyzed. RESULTS: Overall sleep efficiency was 61.2% and 66.5% with an awake index of 5.5 and 5.4 for each of the postoperative nights measured. A significant correlation was found between increased self-reported pain scores and decreased total sleep time (r = -0.31; P = .03). Spearman correlations between total sleep time, sleep efficiency, and awake index were made with narcotic use on postoperative day (POD) 0 and 1. Longer hospital length of stay was significantly correlated with decreased sleep efficiency (r = -0.35, P = .01). Complication rates were not statistically different compared with sleep parameters. CONCLUSION: Better control of a patient's pain is associated with greater sleep efficiency and total sleep time. Improvements in sleep efficiency in hospitalized patients may be associated with a decrease in length of stay.