Craig G. Gunderson

Psoriasis: An opportunity to identify cardiovascular risk

Psoriasis is highly prevalent and is associated with skin‐associated complaints as well as arthritis, depression and a lower quality of life. Recently, it has been demonstrated that not only do patients with psoriasis have an increased prevalence of cardiovascular risk factors, but an increased risk of myocardial infarction, and for those with severe disease, increased mortality. Dermatologists and other health professionals need to be cognizant of this association and ensure that cardiovascular risk factors are evaluated and treated appropriately in those patients with psoriasis. We review the association between psoriasis, atherosclerosis and inflammation, as well as some treatable cardiovascular risk factors that may prove beneficial in reducing a patient’s cardiovascular risk.

Cellulitis: Definition, Etiology, and Clinical Features

Cellulitis is a common condition seen by physicians. Over the past decade, skin and soft tissue infections from community-associated methicillin-resistant Staphylococcus aureus have become increasingly common. In this article, the definition, etiology, and clinical features of cellulitis are reviewed, and the importance of differentiating cellulitis from necrotizing soft tissue infections is emphasized. Empiric antimicrobial recommendations are suggested, including the most recent recommendations from the Infectious Disease Society of America.

Risk of deep vein thrombosis in patients with cellulitis and erysipelas: a systematic review and meta-analysis.

INTRODUCTION The occurrence of deep vein thrombosis (DVT) is often considered in patients with cellulitis and erysipelas because of the common presentation of unilateral limb swelling, erythema and pain. Different authors however have reached different conclusions about the prevalence of DVT in these patients and for the need for compression ultrasound (CUS). The purpose of this study is to determine the prevalence of DVT in patients with cellulitis and erysipelas, and inform the utility of CUS. METHODS A systematic literature search was conducted of Medline and Cochrane for studies that reported groups of patients with cellulitis or erysipelas who had CUS to evaluate for DVT. Study quality assessment was based on the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. The incidence rates from the included studies were pooled using a random-effects model to calculate an overall DVT rate. Individual and pooled DVT rates with corresponding upper and lower limits were graphed as a forest plot. Between-study heterogeneity was estimated using the I(2) statistic. RESULTS Nine studies were included totaling 1054 patients with cellulitis or erysipelas with 18 DVTs. The overall pooled incidence rate was 2.1% (95% confidence interval, 0.5%-9.1%) for proximal DVT and 3.1% (95% confidence interval, 1.9%-4.9%) for any DVT. When analyzed separately, the pooled incidence rate for the three retrospective studies was 1.1% (95% CI, 0.6%-2.2%), while the rate for the six prospective studies was 7.8% (95% CI, 4.2%-14.2%). CONCLUSION The risk of DVT in cellulitis and erysipelas is low compared to the average risk of patients referred for CUS and comparable to low risk patients as determined by the commonly employed Wells criteria.

Diagnostic accuracy of methicillin-resistant Staphylococcus aureus nasal colonization to predict methicillin-resistant S aureus soft tissue infections

Nasal methicillin-resistant Staphylococcus aureus (MRSA) testing at admission to the hospital was found to have a positive likelihood ratio of 8.5 and a negative likelihood ratio of 0.41 for predicting MRSA soft tissue infections. The clinical utility of this test depends on the prevalence of MRSA infection. In high prevalence populations, nasal MRSA is useful to rule in MRSA infections. In low prevalence populations it may be useful to rule out infections.

Overuse of compression ultrasound for patients with lower extremity cellulitis.

BACKGROUND Compression ultrasound (CUS) is often ordered in hospitalized patients with cellulitis to assess for deep vein thrombosis (DVT). Despite this common practice, the rate of use and utility of CUS has not been well described. METHODS We conducted a retrospective cohort study of adult patients with lower extremity cellulitis hospitalized between October 1, 2008 and September 30, 2013 at an academic medical center. Cases meeting inclusion criteria were reviewed for the use of CUS, the indication for CUS, the occurrence of DVT, and the 3 month follow-up occurrence of DVT after discharge. RESULTS A total of 239 patients were identified using ICD-9 coding data with a discharge diagnosis of cellulitis or abscess of leg. Of these, 183 met criteria for inclusion in the study, 133 of whom had CUS to assess for DVT (73%). Of the 133 who received CUS, 11 studies found DVTs (8%). Of the 11 DVTs, 8 had been previously diagnosed, and 3 were new. Of the new DVTs, only one was ipsilateral to the leg with cellulitis. CONCLUSION Most patients admitted with lower extremity cellulitis received CUS to assess for DVT. Despite this common practice, the rate of acute ipsilateral DVT was low and matched the rate of acute contralateral DVT. Previously diagnosed DVTs were commonly re-imaged. Overall the use of CUS had minimal impact on patient management and the routine use of CUS to assess for DVT in hospitalized patients with cellulitis appears to be unnecessary.

Battlefield Acupuncture: Is It Ready for Widespread Dissemination?

Abstract The use of prescription opioids for chronic pain has increased markedly within the past few decades; thus, death rates associated with opioid overdoses have increased dramatically. Nonopioid pharmacologic therapies also are associated with adverse effects. Other pain-abatement modalities such as acupuncture may be useful in the treatment of several painful conditions. Battlefield acupuncture is being promulgated as a potential low-risk, nonpharmacological therapy for pain. In this narrative review we examine the published literature to support battlefield acupuncture. We conclude that the amount and quality of published research presently do not justify wide adoption of this practice by those strictly adherent to evidence-based medicine.

Overtreatment of nonpurulent cellulitis

The “Things We Do for No Reason” (TWDFNR) series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Clinical characteristics and outcomes of veterans hospitalised with purulent soft tissue infections with and without systemic signs of infection

Abstract Objective To describe the frequency of systemic inflammatory response syndrome (SIRS) criteria in a cohort of patients hospitalised with purulent soft tissue infections and to determine their impact on clinical characteristics, microbiology and outcomes. Methods Retrospective cohort study of adults hospitalised at the West Haven Veteran’s Hospital with purulent soft tissue infections between 1 October 2008 and 30 September 2013. Results A total of 173 patients were included with purulent soft tissue infections; 60 patients had no SIRS, 48 had one SIRS and 65 had ≥ 2 SIRS. Most clinical characteristics were similar between the different SIRS groups, although patients with SIRS were more likely to have severe sepsis and acute kidney injury and to already be on antibiotics at the time of hospitalisation. The microbiology of the infections was similar between SIRS groups. All patients received parenteral antibiotics when admitted and the majority of patients in all SIRS categories received antibiotics with broad Gram-negative activity. Outcomes were generally benign for all SIRS groups, although patients with SIRS had a longer length of stay and a trend towards more bacteremia. Conclusions SIRS are common in patients hospitalised with purulent soft tissue infections, although one third had no systemic signs of infection. Severe sepsis and septic shock are rare. Clinical characteristics, microbiology and antibiotic use are similar among patients in different SIRS groups, although the group without SIRS had a shorter hospitalisation and no episodes of bacteremia. Over-use of antibiotics is common in all SIRS categories.

Web of Confusion

c t p m ( PRESENTATION The occurrence of a late-stage complication in a patient with early disease, reminds us that any illness can take an unpredictable course. A 63-year-old man presented with complaints of fatigue and rash. He had been in his usual state of health until approximately 2 months prior, when he developed decreased visual acuity in his right eye. He was seen by a local ophthalmologist, who diagnosed nonarteritic ischemic optic neuritis and prescribed a daily aspirin. Soon thereafter, the patient noticed that he was having trouble moving about his house and working, and he felt as if he needed to sit and rest often. Additionally, he admitted to night sweats and a 15-lb weight loss. Upon questioning, he also reported that he had developed a nonpruritic rash on his legs and torso. He denied headache, joint pain, myalgia, morning stiffness, jaw claudication, weakness, cough, or shortness of breath. He took no medications other than a daily adult aspirin. On examination, the patient exhibited livedo reticularis involving his lower limbs, buttocks, and lower torso circumferentially (Figures 1 and 2). He was normotensive, afebrile, and had no other rash, nodules or ulcers. His joints were normal, as were his heart, lungs, and abdomen. Peripheral pulses were present, and his temporal arteries appeared normal and were nontender.

Do Patients with Cellulitis Need to be Hospitalized? A Systematic Review and Meta-analysis of Mortality Rates of Inpatients with Cellulitis

BackgroundCellulitis is a common cause of hospitalization. In the USA, the International Classification of Diseases (ICD) code “other cellulitis and abscess” accounts for 1.4% of all admissions and