Nicole Gunasekera

Nutritional Status and Mortality in the Critically Ill.

Objectives:The association between nutritional status and mortality in critically ill patients is unclear based on the current literature. To clarify this relation, we analyzed the association between nutrition and mortality in a large population of critically ill patients and hypothesized that mortality would be impacted by nutritional status. Design:Retrospective observational study. Setting:Single academic medical center. PatientsSix thousand five hundred eighteen adults treated in medical and surgical ICUs between 2004 and 2011. Interventions:None. Measurements and Main Results:All cohort patients received a formal, in-person, standardized evaluation by a registered dietitian. The exposure of interest, malnutrition, was categorized as nonspecific malnutrition, protein-energy malnutrition, or well nourished and determined by data related to anthropometric measurements, biochemical indicators, clinical signs of malnutrition, malnutrition risk factors, and metabolic stress. The primary outcome was all-cause 30-day mortality determined by the Social Security Death Master File. Associations between nutrition groups and mortality were estimated by bivariable and multivariable logistic regression models. Adjusted odds ratios were estimated with inclusion of covariate terms thought to plausibly interact with both nutrition status and mortality. We used propensity score matching on baseline characteristics to reduce residual confounding of the nutrition status category assignment. In the cohort, nonspecific malnutrition was present in 56%, protein-energy malnutrition was present in 12%, and 32% were well nourished. The 30-day and 90-day mortality rates for the cohort were 19.1% and 26.6%, respectively. Nutritional status is a significant predictor of 30-day mortality following adjustment for age, gender, race, medical versus surgical patient type, Deyo-Charlson index, acute organ failure, vasopressor use, and sepsis: nonspecific malnutrition 30-day mortality odds ratio, 1.17 (95% CI, 1.01–1.37); protein-energy malnutrition 30-day mortality odds ratio, 2.10 (95% CI, 1.70–2.59), all relative to patients without malnutrition. In the matched cohort, the adjusted odds of 30-day mortality in the group of propensity score-matched patients with protein-energy malnutrition was two-fold greater than that of patients without malnutrition. Conclusion:In a large population of critically ill adults, an association exists between nutrition status and mortality.

Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis

Importance Inflammatory dermatoses of the lower extremity are often misdiagnosed as cellulitis (aka “pseudocellulitis”) and treated with antibiotics and/or hospitalization. There is limited data on the cost and complications from misdiagnosed cellulitis. Objective To characterize the national health care burden of misdiagnosed cellulitis in patients admitted for treatment of lower extremity cellulitis. Design, Setting, and Participants Cross-sectional study using patients admitted from the emergency department (ED) of a large urban hospital with a diagnosis of lower extremity cellulitis between June 2010 and December 2012. Patients who were discharged with a diagnosis of cellulitis were categorized as having cellulitis, while those who were given an alternative diagnosis during the hospital course, on discharge, or within 30 days of discharge were considered to have pseudocellulitis. A literature review was conducted for calculation of large-scale costs and complication rates. We obtained national cost figures from the Medical Expenditure Panel Survey (MEPS), provided by the Agency for Healthcare Research and Quality (AHRQ) for 2010 to calculate the hospitalization costs per year attributed to misdiagnosed lower extremity pseudocellulitis. Exposures The exposed group was composed of patients who presented to and were admitted from the ED with a diagnosis of lower extremity cellulitis. Main Outcomes and Measures Patient characteristics, hospital course, and complications during and after hospitalization were reviewed for each patient, and estimates of annual costs of misdiagnosed cellulitis in the United States. Results Of 259 patients, 79 (30.5%) were misdiagnosed with cellulitis, and 52 of these misdiagnosed patients were admitted primarily for the treatment of cellulitis. Forty-four of the 52 (84.6%) did not require hospitalization based on ultimate diagnosis, and 48 (92.3%) received unnecessary antibiotics. We estimate cellulitis misdiagnosis leads to 50 000 to 130 000 unnecessary hospitalizations and

A predictive model for diagnosis of lower extremity cellulitis: A cross-sectional study

195 million to

Intralesional Sodium Thiosulfate Treatment for Calcinosis Cutis in the Setting of Lupus Panniculitis

515 million in avoidable health care spending. Unnecessary antibiotics and hospitalization for misdiagnosed cellulitis are projected to cause more than 9000 nosocomial infections, 1000 to 5000 Clostridium difficile infections, and 2 to 6 cases of anaphylaxis annually. Conclusions and Relevance Misdiagnosis of lower extremity cellulitis is common and may lead to unnecessary patient morbidity and considerable health care spending.

Repigmentation of Extensive Inflammatory Vitiligo with Raised Borders Using Early and Aggressive Treatment

Background Cellulitis has many clinical mimickers (pseudocellulitis), which leads to frequent misdiagnosis. Objective To create a model for predicting the likelihood of lower extremity cellulitis. Methods A cross‐sectional review was performed of all patients admitted with a diagnosis of lower extremity cellulitis through the emergency department at a large hospital between 2010 and 2012. Patients discharged with diagnosis of cellulitis were categorized as having cellulitis, while those given an alternative diagnosis were considered to have pseudocellulitis. Bivariate associations between predictor variables and final diagnosis were assessed to develop a 4‐variable model. Results In total, 79 (30.5%) of 259 patients were misdiagnosed with lower extremity cellulitis. Of the variables associated with true cellulitis, the 4 in the final model were asymmetry (unilateral involvement), leukocytosis (white blood cell count ≥10,000/uL), tachycardia (heart rate ≥90 bpm), and age ≥70 years. We converted these variables into a points system to create the ALT‐70 cellulitis score as follows: Asymmetry (3 points), Leukocytosis (1 point), Tachycardia (1 point), and age ≥70 (2 points). With this score, 0‐2 points indicate ≥83.3% likelihood of pseudocellulitis, and ≥5 points indicate ≥82.2% likelihood of true cellulitis. Limitations Prospective validation of this model is needed before widespread clinical use. Conclusion Asymmetry, leukocytosis, tachycardia, and age ≥70 are predictive of lower extremity cellulitis. This model might facilitate more accurate diagnosis and improve patient care.

Neunjährige Nachbeobachtung von Kindern mit atopischer Dermatitis in allgemeinärztlicher Behandlung

Report of a Case | A woman in her 40s with a history of systemic lupus erythematosus presented with a 3-year history of tender subcutaneous nodules on her arms, abdomen, and lower extremities. On physical examination, she was found to have multiple depressed plaques and indurated subcutaneous nodules, some with overlying violaceous erythema, dyspigmentation, and atrophic scarring (Figure 1). Tissue culture findings were negative. Biopsy findings revealed marked interstitial dermal mucin deposition, lymphocytic inflammation involving the deep dermis and subcutis with secondary vasculitic changes, fibrinoid degeneration, subcutaneous fat necrosis, and tissue calcification (Figure 2), confirming a clinical diagnosis of lupus panniculitis with localized cutaneous calcinosis. Her laboratory results demonstrated serum calcium and renal function within normal limits; antinuclear antibody titer, 1:160 in a homogenous pattern; and positive antidouble stranded DNA, anti-cardiolipin IgM and IgG antibodies, and lupus anticoagulant. Therapy with systemic corticosteroid along with hydroxychloroquine was initiated, but the patient continued to develop new lesions over the following months. The patient’s lesions improved somewhat with a change to chloroquine, 250 mg, once daily, and methotrexate, 15 to 25 mg, subcutaneously injected once weekly. However, despite improvement of the underlying inflammatory panniculitis, she continued to experience pain and developed new calcifications in prior sites of involvement. One large area of calcinosis was excised by plastic surgery; however, further excisions were not practical given the number oflesionsandsurgery-associatedmorbidity.Atrialofintralesional

Acne Smart Club: Ein Patientenschulungsprogramm für Menschen mit Akne

Inflammatory vitiligo with raised borders (IVRB) is a rare subtype of vitiligo described as having a rim of raised erythema at the periphery of the depigmented patches. The etiology is poorly understood, and there are few reports of successful treatment of the condition in the literature. We report a 38-year-old South Asian male who presented with diffuse depigmented macules and patches surrounded by blue-gray rims involving a large body surface area. Light microscopy revealed inflammatory vitiligo. He was treated with 2 courses of oral prednisone and whole-body narrow-band ultraviolet B (NB-UVB) therapy, which resulted in cessation of disease spread as well as substantial repigmentation. Our observation suggests that early and aggressive treatment can lead to significant and rapid improvement in patients with IVRB.

Landesweite Erhebung zu Psoriasis-Schüben nach monovalenten H1N1-/saisonalen Impfungen 2009

Über die Häufigkeit von Komorbiditäten sowie die Behandlungskosten, die mit atopischer Dermatitis (AD) in der allgemeinärztlichen Praxis assoziiert sind, ist wenig bekannt. Wir führten eine retrospektive Kohortenstudie anhand einer longitudinalen elektronischen Datenbank mit Patientenakten einer Gruppe von Allgemeinärzten in Frankreich durch. Alle Patienten, bei denen im 1. Lebensjahr AD diagnostiziert worden war, wurden ausgewählt und mit Säuglingen, die nicht daran erkrankt waren, nach Geschlecht parallelisiert (1163 zu 1163). Die Patienten wurden 9 Jahre lang nachbeobachtet. Begleiterkrankungen, Medikation und verfügbare Behandlungskosten wurden detailliert angegeben. Zwischen Patienten und Kontrollpersonen wurden Vergleiche angestellt. Die AD-Patienten hatten mehr Komorbiditäten als die Kontrollgruppe, insbesondere in den Organen des respiratorischen und ophthalmischen Systems. Die Anzahl verschriebener dermatologischer Medikamente sowie die allgemeinen Gesundheitskosten (Besuche beim Allgemeinarzt und verschriebene Medikamente) waren bei den Atopie-Patienten höher; der Unterschied wurde jedoch mit zunehmendem Lebensalter geringer. Übersetzung aus Dermatology 2014;228:344-349 (DOI: 10.1159/000358296)

Immunmodulation durch orales Alitretinoin bei chronischem Handekzem

Ziel: Beurteilung der Therapietreue von Aknepatienten, die mittels Mobiltelefon und Kurznachrichten (SMS) kommunizieren.Methoden: 160 Patienten wurden per Randomisierung auf 2 Gruppen verteilt: Die SMS-Gruppe erhielt über einen Zeitraum von 12 Wochen 2-mal täglich je 1 Kurznachricht; die Kontrollgruppe erhielt keine solchen Nachrichten. Vor und nach den 12 Wochen wurden die folgenden Evaluationsmaßnahmen bei allen Patienten durchgeführt: digitale Fotos, das Global Acne Grading System, der Dermatology Life Quality Index, der Cardiff Acne Disability Index, eine Beurteilung des Arzt-Patienten-Verhältnisses mittels der Patient-Doctor Depth-of-Relationship Scale sowie eine Beurteilung der Adhärenz, indem die Patienten gefragt wurden, an wie vielen Tagen pro Woche sie die Therapievorschriften eingehalten hatten. Die statistische Auswertung erfolgte mittels Student-t-Test.Ergebnisse: Bei der SMS-Gruppe hatten sich alle Parameter deutlicher verbessert als bei der Kontrollgruppe.Schlussfolgerung: Adhärenz und Compliance sind höher, wenn die Patienten in eine Kontrollstrategie eingebunden sind.Übersetzung aus Dermatology 2014;229:136-140 (DOI: 10.1159/000362809)

Staphylokokken-Exotoxine induzieren Interleukin-22 in menschlichen TH-22-Zellen

Hintergrund: Psoriasis ist eine häufige, chronische, immunvermittelte Krankheit, die durch Wechselwirkungen zwischen genetischem Hintergrund und exogenen auslösenden Faktoren wie Stress oder Infektionen hervorgerufen wird. Informationen über die Auswirkungen von Impfstoffstimuli auf den Verlauf der Psoriasis liegen bisher nur in äußerst begrenztem Umfang vor.Ziel: Anlegen einer Fallsammlung von Psoriasis-Schüben nach Impfungen mittels einer landesweiten Erhebung.Methoden: Wir untersuchten Fälle von Psoriasis-Erstmanifestationen und -Schüben, die innerhalb von 3 Monaten nach der monovalenten H1N1-/saisonalen Impfung 2009 im Rahmen der Impfkampagne der Grippesaison 2009/2010 in Frankreich auftraten.Ergebnisse: Gemeldet wurden 10 Patienten - 6 männlich, 4 weiblich; Altersmedian 44 Jahre (Bereich 9-88 Jahre) -, die im Median 8 Tage nach der Impfung zum ersten Mal eine Psoriasis (n = 7) bzw. eine Verschlechterung einer zuvor diagnostizierten Psoriasis (n = 3) zeigten. Bei 9 der 10 Patienten lag ein gemischter klinischer Phänotyp aus Psoriasis guttata und Plaque-Form vor; bei 1 traten 2 aufeinanderfolgende Schübe generalisierter Psoriasis pustulosa (GPP) nach 2 Injektionen unterschiedlicher Impfstoffe auf.Schlussfolgerung: Die kurze Zeitspanne zwischen Vakzination und Auftreten der Psoriasis-Schübe, das Fehlen sonstiger Auslöser und die Schubsequenz nach 2 unterschiedlichen Impfstoffen bei einem GPP-Patienten deuten auf einen möglichen Zusammenhang zwischen der monovalenten H1N1-/saisonalen Vakzination 2009 und den Psoriasis-Schüben in den erfassten Fällen hin. Dessen ungeachtet unterstreicht die wahrscheinlich außerordentlich niedrige Inzidenz von Psoriasis-Schüben nach Impfungen das gute Sicherheitsprofil und die Bedeutung von Impfstrategien bei Psoriasis-Patienten, insbesondere bei Kandidaten für eine immunsuppressive Therapie.Übersetzung aus Dermatology 2014;229:130-135 (DOI: 10.1159/000362808)