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Stanton J, Knowles A, Russell L, Bevis C. Integrated lymphoedema and tissue viability service: improving patient and wound outcomes. Br J Community Nurs 2024; 29:S19-S26. [PMID: 38578928 DOI: 10.12968/bjcn.2024.29.sup4.s19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
This article will focus on the integration of tissue viability and lymphoedema services to improve outcomes for patients with leg ulceration. It will highlight why there is a need for lymphoedema specialist knowledge within the care of patients with leg ulceration and how the services are closely aligned. Lymphoedema can adversely affect wound healing and the article will provide case studies that highlight how developing a hybrid tissue viability and lymphoedema clinician or integration of the specialists can provide effective patient-centred care at reduced cost. The article offers potential strategies and suggestions on how to address inequalities in care and how to improve service provision.
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Affiliation(s)
- Julie Stanton
- Director of Nursing (community telehealth), Pioneer Wound Healing and Lymphoedema Centres
| | - Aaron Knowles
- Tissue Viability and Lymphoedema Consultant, Pioneer Wound Healing and Lymphoedema Centres
| | - Laura Russell
- Tissue Viability and Lymphoedema Consultant, Pioneer Wound Healing and Lymphoedema Centres
| | - Claire Bevis
- Tissue Viability and Lymphoedema Consultant, Pioneer Wound Healing and Lymphoedema Centres
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Tedesco A, O'Donnell T, Weycker D, Salehi P. The critical role of phlebolymphedema in cellulitis associated with lymphedema: Its incidence and economic impact in a large real-world population. J Vasc Surg Venous Lymphat Disord 2024; 12:101704. [PMID: 37977518 DOI: 10.1016/j.jvsv.2023.101704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE The aims of this study were: to define the incidence of cellulitis in patients with lymphedema (LED) overall and relate this to the etiology of LED; to determine how this rate might be affected by recurrence of cellulitis; and to quantify the contemporary economic burden of treatment. Understanding these factors is essential in developing targeted cellulitis prevention strategies and reducing health care costs. METHODS The IBM MarketScan Research Database was examined from April 2013 to March 2019 for patients with a new diagnosis of LED (n = 85,601). Based on International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, the incidence and cost of cellulitis were ascertained during the 3-year follow-up period. Incidence rates (per 100 patient-years [PYs]) and cost (per patient per year) of cellulitis were evaluated among all patients with LED and within subgroups of LED etiologies. RESULTS Among the three most common morbidities associated with LED (breast cancer-related lymphedema [BCRL], n = 17,954 [20.97%]; gynecological cancer-related LED [GCRL], n = 1256 [1.47%]; and phlebolymphedema [PLED], n = 8406 [9.82%]), rates of cellulitis were markedly lower for BCRL (8.9; 95% confidence interval [CI], 8.7-9.2) and GCRL (14.8; 95% CI, 13.4-16.4) vs PLED (47.7; 95% CI, 46.7-48.8). Patients with a history of cellulitis had markedly higher cellulitis rates during follow-up than those without-overall, 74.0% vs 16.4%; BCRL, 42.9%; 95% CI, 39.7%-46.3% vs 7.6%; 95% CI, 7.3%-7.9%; GCRL, 67.5%; 95% CI, 56.4%-80.8% vs 11.0%; 95% CI, 9.8%-12.4%; and PLED, 81.7%; 95% CI, 79.4%-84.1% vs 30.4%; 95% CI, 29.4%-31.4%, respectively. The mean $/patient/year of cellulitis-related costs for a patient with PLED ($2836; 95% CI, $2395-$3471) was significantly greater than that for BCRL ($503; 95% CI, $212-$1387) and GCRL ($609; 95% CI, $244-$1314). CONCLUSIONS The incidence of cellulitis associated with LED varies by the etiology of LED. PLED has the highest rates of both an initial cellulitis episode and recurrent cellulitis events. Additionally, PLED has one of the largest cellulitis-related total costs per patient per year. Prevention, as well as early identification and treatment of PLED-associated cellulitis, could significantly decrease health care costs and improve patient quality of life.
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Affiliation(s)
| | - Thomas O'Donnell
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Payam Salehi
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA
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Burian EA, Franks PJ, Borman P, Quéré I, Karlsmark T, Keeley V, Sugama J, Cestari M, Moffatt CJ. Factors associated with cellulitis in lymphoedema of the arm - an international cross-sectional study (LIMPRINT). BMC Infect Dis 2024; 24:102. [PMID: 38238718 PMCID: PMC10797905 DOI: 10.1186/s12879-023-08839-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/22/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Lymphoedema is a globally neglected health care problem and a common complication following breast cancer treatment. Lymphoedema is a well-known predisposing factor for cellulitis, but few have investigated the risk factors for cellulitis in this patient cohort on an international level. The aim of this study was to identify the frequency of cellulitis in patients with lymphoedema of the arm, including potential risk factors for cellulitis. METHODS An international, multi-centre, cross-sectional study including patients with clinically assessed arm lymphoedema. The primary outcome was the incidence of cellulitis located to the arm with lymphoedema within the last 12 months, and its potential associated risk factors. The secondary outcome was life-time prevalence of cellulitis. Adults with clinically-assessed arm lymphoedema/chronic oedema (all causes) and able to give informed consent were included. End-of-life-patients or those judged as not in the patient's best interest were excluded. Both univariable and multivariable analysis were performed. RESULTS A total of 2160 patients were included from Australia, Denmark, France, Ireland, Italy, Japan, Turkey and United Kingdom. Secondary lymphoedema was present in 98% of the patients; 95% of these were judged as related to cancer or its treatment. The lifetime prevalence of cellulitis was 22% and 1-year incidence 11%. Following multivariable analysis, factors associated with recent cellulitis were longer swelling duration and having poorly controlled lymphoedema. Compared to having lymphoedema less than 1 year, the risk increased with duration: 1-2 years (OR 2.15), 2-5 years (OR 2.86), 5-10 years (OR 3.15). Patients with well-controlled lymphoedema had a 46% lower risk of cellulitis (OR 0.54, 95% CI 0.39-0.73, p < 0.001). More advanced stages of lymphoedema were associated with cellulitis even after adjustment for swelling duration and control of swelling by logistic regression (stage II OR 5.44, stage III OR 9.13, p = 0.002), demonstrated in a subgroup analysis. CONCLUSION Patients with advanced arm lymphoedema are at particular risk of developing cellulitis. Prevention of lymphoedema progression is crucial. The results lend towards a positive effect of having well-treated lymphoedema on the frequency of cellulitis.
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Affiliation(s)
- Ewa Anna Burian
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark.
| | - Peter J Franks
- Centre for Research and Implementation of Clinical Practice, London, UK
| | - Pinar Borman
- Medical Faculty, Department of Physical Medicine and Rehabilitation, Ankara Medipol University, Ankara, Turkey
| | - Isabelle Quéré
- CHU Montpellier, University of Montpellier, IDESP, Montpellier, France
| | - Tonny Karlsmark
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark
| | - Vaughan Keeley
- Lymphoedema Department, University Hospitals of Derby and Burton NHS Trust, Derby and University of Nottingham Medical School, Nottingham, UK
| | - Junko Sugama
- Research Centre for Implementation Nursing Science Initiative, Research Promotion Headquarters, Fujita Health University, Aichi, Japan
| | | | - Christine J Moffatt
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Kahle B. Beinschmerz – dermatologische Ursachen. AKTUELLE DERMATOLOGIE 2022. [DOI: 10.1055/a-1753-6976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Zusammenfassung
Einleitung Als Grund für akute oder chronische Beinschmerzen werden oft vaskuläre Erkrankungen vermutet. Es stellt sich die Frage, ob auch dermatologische Krankheiten mit Beinschmerzen einhergehen.
Methode Dermatologische Krankheitsbilder werden hinsichtlich einer begleitenden oder kausalen Schmerzhaftigkeit systematisch dargestellt.
Ergebnisse Bei Infektionserkrankungen der Haut steht der Schmerz im Vordergrund, allergische oder toxische Kontaktdermatitiden, Juckreizerkrankungen sowie kutane Autoimmunerkrankungen gehen mit Schmerzen einher.
Zusammenfassung Bei unklaren Beinschmerzen sollte auch an eine zugrundeliegende dermatologische Erkrankung gedacht werden. Der Schmerz kann als Prodromalsymptom bei Herpes zoster auftreten.
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Affiliation(s)
- Birgit Kahle
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Klinik für Dermatologie, Allergologie und Venerologie
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Webb E, Bissett B, Neeman T, Bowden F, Preston E, Mumford V. Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema. Lymphat Res Biol 2022; 21:160-168. [PMID: 35997601 PMCID: PMC10125391 DOI: 10.1089/lrb.2022.0029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.
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Affiliation(s)
- Elizabeth Webb
- Physiotherapy Department, Calvary Public Hospital Bruce, Canberra, Australia.,Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Teresa Neeman
- Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine, Australian National University, Canberra, Australia
| | - Francis Bowden
- Medical School, Australian National University, Canberra, Australia
| | - Elisabeth Preston
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Ong BS, Dotel R, Ngian VJJ. Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis? Int J Gen Med 2022; 15:6561-6572. [PMID: 35983462 PMCID: PMC9379124 DOI: 10.2147/ijgm.s326459] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022] Open
Abstract
Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.
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Affiliation(s)
- Bin S Ong
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Ravindra Dotel
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Vincent Jiu Jong Ngian
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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Doub JB. Treatment of Recurrent Severe Cellulitis with a Pill in Pocket Approach. Infect Chemother 2022; 54:382-387. [PMID: 35132835 PMCID: PMC9259910 DOI: 10.3947/ic.2021.0095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/15/2021] [Indexed: 12/02/2022] Open
Abstract
Cellulitis is a common condition that plagues healthcare systems and is associated with significant healthcare costs and resource allocations. With ample antimicrobial therapy this infectious syndrome can be easily treated but recurrence is common. Many conditions predispose patients to be at risk for recurrent cellulitis with chronic lymphoedema being a significant risk factor secondary to pooling of lymphatic fluid and impaired local immune responses. Moreover, patients with chronic lymphoedema can be at risk for acute onset of severe cellulitis requiring urgent medical evaluation and treatment. Consequently, to prevent recurrent cellulitis episodes, the use of long-term oral antibiotics has been advocated, but when recurrences occur despite long-term antibiotic use limited options are available. In this case report, a unique treatment approach for preventing severe cellulitis is discussed with a pill in the pocket approach with the use of oral tedizolid. This has thwarted the need for recurrent hospitalizations and reduced health care costs for this individual patient. Herein this treatment approach is discussed as is the rationale for using tedizolid instead of other antibiotics.
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Affiliation(s)
- James B. Doub
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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The economic impact of infection requiring hospitalization on venous leg ulcers. J Vasc Surg Venous Lymphat Disord 2021; 10:96-101. [PMID: 34175503 DOI: 10.1016/j.jvsv.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/15/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the impact of infection (INF) on medical resource utilization (MRU) and cost of care in patients with venous leg ulcers (VLU). METHODS We performed a retrospective case-control study of 78 patients followed for a minimum of 12 months with C6 VLUs treated by vascular surgeons, at our wound center. To eliminate minor episodes of INF or incorrectly diagnosed episodes, only patients who had an inpatient admission specifically for INF comprised the INF group, whereas all other admissions were excluded for this group. MRU was defined as the number of clinic visits, Visiting Nurse Association (VNA) visits, and inpatient admissions. The actual cost for treatment was determined using financial data provided by both the hospital and physician organization billing units. The total cost over the 1-year follow-up period comprised individual cost centers: inpatient and outpatient facility fees, physician fees, and visiting nurse services. Mean MRU and cost data were compared using the two-sample t-test between INF and NON-INF. RESULTS Of the 78 patients with C6 VLU, 9 (11.5%) had at least one inpatient admission for INF related to their VLU in the 1-year treatment period, with an additional five recurrent admissions for a total of 14 admissions, whereas 69 NON-INF had three NON-INF-related admissions. There was no difference between INF and NON-INF for usual risk factors, but INF had a greater proportion of congestive heart failure (44%; 13%, P < .02). Regarding MRU, both the number of outpatient wound center visits (INF 16.89 ± 6.41; NON-INF 9.46 ± 7.7, P = .008) and VNA blocks (INF 3.89 ± 2.93; NON-INF 1.94 ± 2.24, P < .02) were greater for INF. Total costs for INF ($27,408 ± $10,859) were threefold higher than those for NON-INF ($11,088 ± $9343, P < .0001) and subsequent VNA costs were doubled for INF ($9956 ± $4657) vs NON-INF ($4657 ± $5486, P = .01). CONCLUSIONS INFs in patients with VLU led to an overall increase in MRU and cost of care, with the INF cohort requiring more inpatient admissions, outpatient visits, and VNA services than NON-INF. Given the major impact INF has on cost and MRU, better treatment modalities that prevent INF as well as identifying risk factors for INF in patients with VLU are needed.
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Burian E, Karlsmark T, Franks P, Keeley V, Quéré I, Moffatt C. Cellulitis in chronic oedema of the lower leg: an international cross‐sectional study. Br J Dermatol 2021; 185:110-118. [DOI: 10.1111/bjd.19803] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 01/03/2023]
Affiliation(s)
- E.A. Burian
- Department of Dermato‐Venereology & Wound Healing Centre Bispebjerg Hospital Copenhagen Denmark
| | - T. Karlsmark
- Department of Dermato‐Venereology & Wound Healing Centre Bispebjerg Hospital Copenhagen Denmark
| | - P.J. Franks
- Centre for Research and Implementation of Clinical Practice London UK
| | - V. Keeley
- Lymphoedema Department Royal Derby HospitalDerby and University of Nottingham Medical School Nottingham UK
| | - I. Quéré
- Department of Vascular Medicine Montpellier University Hospital CentreUniversity of Montpellier France
| | - C.J. Moffatt
- Department of Dermato‐Venereology & Wound Healing Centre Bispebjerg Hospital Copenhagen Denmark
- School of Social Sciences Nottingham Trent University Nottingham UK
- Nottingham University Hospitals NHS Trust Nottingham UK
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Dezoteux F, Staumont-Sallé D. [Bacterial acute non necrosing cellulitis (erysipelas) in adult]. Rev Med Interne 2020; 42:186-192. [PMID: 33176944 DOI: 10.1016/j.revmed.2020.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/30/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
Erysipelas is defined by a sudden onset (with fever) preceding the appearance of a painful, infiltrated, erythematous plaque, accompanied by regional lymphadenopathy. It is usually localized on the lower limbs, but it can occur on the face. It is due to β-hemolytic streptococcus A and more rarely to staphylococcus aureus. It is important to establish the diagnosis and eliminate the non-bacterial causes of inflammatory edema. The other diagnoses frequently found are contact eczema, acute arthritis, bursitis, inflammatory flare-up of chronic dermohypodermitis of venous origin, flare-up of chronic multifactorial eczema (venous insufficiency, vitamin deficiencies, senile xerosis and/or contact eczema), rare familial periodic fevers, rare neutrophilic dermatoses or eosinophilic cellulitis. It is necessary to identify signs of severity that would justify hospitalization. In front of a typical acute bacterial dermohypodermitis and in the absence of comorbidity, no additional investigation is necessary. Systematic blood cultures have low profitability. Locoregional causes must be identified in order to limit the risk of recurrence which remains the most frequent complication. In uncomplicated erysipelas, amoxicillin is the gold standard; treatment with oral antibiotic therapy is possible if there is no sign of severity or co-morbidity (diabetes, arteritis, cirrhosis, immune deficiency) or an unfavorable social context. In case of allergy to penicillin, pristinamycin or clindamycin should be prescribed. Prophylactic antibiotic therapy with delayed penicillin is recommended in the event of recurrent erysipelas.
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Affiliation(s)
- F Dezoteux
- Service de dermatologie, CHU de Lille, 59000 Lille, France; Université Lille, Inserm, CHU de Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, 59000 Lille, France; Université Lille, 59000 Lille, France.
| | - D Staumont-Sallé
- Service de dermatologie, CHU de Lille, 59000 Lille, France; Université Lille, Inserm, CHU de Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, 59000 Lille, France; Université Lille, 59000 Lille, France
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Rastel D, Crébassa V, Rouvière D, Manéglia B. Physician interpretation of ultrasound in the evaluation of ankle edema. Phlebology 2020; 35:623-630. [DOI: 10.1177/0268355520923195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives The aim of this study was to assess inter‑ and intra‑observer agreement of detection and grading of oedema measured by vascular physicians using ultrasonography. Method In this observational study, three investigators read 113 videos of ultrasonography of the medial lower leg of 77 patients using a 15–18 MHz linear probe and reported whether oedema was present or not and, if present, to what extent. The videos were selected by the coordinator and sent every two months for a period of six months to the three investigators. Intra‑ and interobserver agreements were calculated using the Fleiss Kappa coefficient, reported with their 95% confidence interval and interpreted using the Landis and Koch values. Results Inter-observer agreement as to whether oedema was present or not was 0.88 (0.77–0.98), 0.96 (0.89–1.0) and 0.91 (0.80–1.0) for the first, second and third readings, respectively. The concordance was considered to be “excellent.” Inter-observer agreement as to the severity of oedema was 0.52 (0.38–0.65), 0.53 (0.39–0.66) and 0.61 (0.47–0.75) for the first, second and third readings, respectively. The concordance was “moderate”. Intra-observer reliability for the diagnosis of oedema was only 0.89 (0.70–1.0), 0.93 (0.75–1.0) and 0.92 (0.74–1.0) for the first, second and third reader, respectively, which was “excellent”. Conclusions The inter-observer agreement interpreting ultrasound videos using standard probes was excellent. Only moderate agreement in grading the severity of the edema using our arbitrary criteria was shown.
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Webb E, Neeman T, Bowden FJ, Gaida J, Mumford V, Bissett B. Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med 2020; 383:630-639. [PMID: 32786188 DOI: 10.1056/nejmoa1917197] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic edema of the leg is a risk factor for cellulitis. Daily use of compression garments on the leg has been recommended to prevent the recurrence of cellulitis, but there is limited evidence from trials regarding its effectiveness. METHODS In this single-center, randomized, nonblinded trial, we assigned participants with chronic edema of the leg and recurrent cellulitis, in a 1:1 ratio, to receive leg compression therapy plus education on cellulitis prevention (compression group) or education alone (control group). Follow-up occurred every 6 months for up to 3 years or until 45 episodes of cellulitis had occurred in the trial. The primary outcome was the recurrence of cellulitis. Participants in the control group who had an episode of cellulitis crossed over to the compression group. Secondary outcomes included cellulitis-related hospital admission and quality-of-life assessments. RESULTS A total of 183 patients were screened, and 84 were enrolled; 41 participants were assigned to the compression group, and 43 to the control group. At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, 6 participants (15%) in the compression group and 17 (40%) in the control group had had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P = 0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02), and the trial was stopped for efficacy. A total of 3 participants (7%) in the compression group and 6 (14%) in the control group were hospitalized for cellulitis (hazard ratio, 0.38; 95% CI, 0.09 to 1.59). Most quality-of-life outcomes did not differ between the two groups. No adverse events occurred during the trial. CONCLUSIONS In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. (Funded by Calvary Public Hospital Bruce; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000412336.).
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Affiliation(s)
- Elizabeth Webb
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Teresa Neeman
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Francis J Bowden
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Jamie Gaida
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Virginia Mumford
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
| | - Bernie Bissett
- From the Physiotherapy Department, Calvary Public Hospital Bruce, Bruce, ACT (E.W.), the Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine (T.N.), and the Medical School (F.J.B.), Australian National University, the University of Canberra Research Institute for Sport and Exercise (J.G.), and the Discipline of Physiotherapy, Faculty of Health, University of Canberra (E.W., B.B.), Canberra, ACT, and the Australian Institute of Health Innovation, Macquarie University, Sydney (V.M.) - all in Australia
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13
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Taniyama D, Maruki T, Maeda T, Yoshida H, Takahashi T. Repetitive cellulitis caused by Streptococcus agalactiae isolates with different genotypic and phenotypic features in a patient having upper extremity with lymphedema after mastectomy and axillary lymph node dissection. IDCases 2020; 20:e00793. [PMID: 32420032 PMCID: PMC7218289 DOI: 10.1016/j.idcr.2020.e00793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 04/18/2020] [Accepted: 05/01/2020] [Indexed: 01/22/2023] Open
Abstract
•This is 3 episodes of repetitive cellulitis due to S. agalactiae (GBS) isolates. •There was the possibility of GBS colonization in the genitourinary tracts. •Blood-origin 3 isolates showed different genotypic and phenotypic features. •These findings suggest the heterogeneity in strains endogenous to this patient. •Our report supports the reinfection with endogenous GBS rather than recurrence.
Previously reported cases of recurrent cellulitis/erysipelas affecting chronically lymphedematous skin regions have been demonstrated to be due to Streptococcus agalactiae isolates with closely related genetic background which may be suggestive of relapse rather than reinfection. Herein, we report the occurrence of three episodes of repetitive cellulitis caused by S. agalactiae strains with different genotypic and phenotypic characteristics, including different antimicrobial susceptibility patterns (tetracycline, macrolide/lincosamide, and fluoroquinolone classes), in the left upper extremity of a patient with lymphedema, following left mastectomy and axillary lymph node dissection. The genotypic and phenotypic characteristics of the three isolates were confirmed based on the random amplified polymorphic DNA patterns, DNA profiles of virulence factors (bca–rib–bac–lmb–cylE), data on biofilm formation and cell invasion, antimicrobial susceptibility testing results, antimicrobial resistance (AMR) genotypes, and amino acid mutations associated with AMR. These results revealed that reinfection with S. agalactiae, rather than recurrence, occurred during the three episodes. In conclusion, microbiologic studies such as blood cultures or tissue cultures are certainly helpful in the management of recurrent infections or invasive infections such as bacteremia in order to better target antimicrobial therapy, regardless of the data previously presented.
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Affiliation(s)
- Daisuke Taniyama
- Department of General Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
- Corresponding author at: Department of General Internal Medicine, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo, 108-0073, Japan.
| | - Taketomo Maruki
- Department of General Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Takahiro Maeda
- Laboratory of Infectious Diseases, Kitasato Institute for Life Sciences & Graduate School of Infection Control Sciences, Kitasato University, Tokyo, Japan
| | - Haruno Yoshida
- Laboratory of Infectious Diseases, Kitasato Institute for Life Sciences & Graduate School of Infection Control Sciences, Kitasato University, Tokyo, Japan
| | - Takashi Takahashi
- Laboratory of Infectious Diseases, Kitasato Institute for Life Sciences & Graduate School of Infection Control Sciences, Kitasato University, Tokyo, Japan
- Corresponding author at: Laboratory of Infectious Diseases, Kitasato Institute for Life Sciences & Graduate School of Infection Control Sciences, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan.
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14
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Norazirah MN, Khor IS, Adawiyah J, Tamil AM, Azmawati MN. The risk factors of lower limb cellulitis: A case-control study in a tertiary centre. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2020; 15:23-29. [PMID: 32284801 PMCID: PMC7136668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Lower limb cellulitis is a common superficial skin infection that leads to morbidity and mortality. Cellulitis risk factors have been well studied in many countries, but to date, not in Malaysia. Geographical and climate variables may affect risk factors. Early identification of the preventable risk factors is vital to prevent cellulitis and improve holistic patient care. OBJECTIVE To determine the risk factors of lower limb cellulitis amongst hospitalized patients at a tertiary center. METHODS A prospective case-control study of hospitalized patients with a clinical diagnosis of lower limb cellulitis was conducted at UKM Medical Centre, January-August 2015. Each patient was compared to two age and gender-matched control patients. All patients were interviewed and examined for risk factors of cellulitis. RESULTS A total of 96 cellulitis patients and 192 controls participated in this study. The cellulitis patients included 61 males and 35 females with a mean age of 62.07±15.43 years. The majority of patients were experiencing their first episode of cellulitis. Multivariate analysis showed a previous history of cellulitis (OR 25.53; 95% CI 4.73-137.79), sole anomalies (OR 16.32; 95% CI 6.65-40.06), ulceration (OR 14.86; 95% CI 1.00-219.39), venous insufficiency (OR 10.46 95% CI 1.98-55.22), interdigital intertrigo (OR 8.86; 95% CI 3.33-23.56), eczema (OR 5.74; 95% CI 0.96.-34.21), and limb edema (OR 3.95; 95% CI 1.82-8.59) were the significant risk factors for lower limb cellulitis. CONCLUSION Previous cellulitis and factors causing skin barrier disruption such as sole anomalies, ulceration, venous insufficiency, eczema, intertrigo, and limb edema were the risk factors for lower limb cellulitis. Physician awareness, early detection, and treatment of these factors at the primary care level may prevent hospital admission and morbidity associated with cellulitis.
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Affiliation(s)
- M N Norazirah
- Department of Medicine, Faculty of Medicine Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - I S Khor
- Department of Medicine, Penang General Hospital, Malaysia
| | - J Adawiyah
- Department of Medicine, Faculty of Medicine Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - A M Tamil
- Department of Public Health, Faculty of Medicine Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - M N Azmawati
- Department of Public Health, Faculty of Medicine Universiti Kebangsaan Malaysia Medical Centre, Malaysia
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15
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Shallwani SM, Hodgson P, Towers A. Examining Obesity in Lymphedema: A Retrospective Study of 178 New Patients with Suspected Lymphedema at a Canadian Hospital-Based Clinic. Physiother Can 2020; 72:18-25. [PMID: 34385745 PMCID: PMC8330978 DOI: 10.3138/ptc-2018-0076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose: Physiotherapists have an important role to play in the early detection and treatment of lymphedema, a chronic inflammatory condition characterized by excess interstitial protein-rich fluid, which is estimated to affect more than one million Canadians. Obesity has been identified both as an important cause of and as a risk factor for developing lymphedema of various aetiologies. Little is currently known about obesity in Canadians affected by lymphedema. The objective of this study was to report on the prevalence of overweight and obesity in a Canadian lymphedema clinic population and the relationships among BMI; demographic, medical, and lymphedema characteristics; and cellulitis history. Method: We conducted a retrospective electronic record review of the clinical data collected from new patients evaluated for suspected lymphedema at a specialized Canadian hospital-based clinic over a 2-year period. We used descriptive analyses to characterize the sample and one-way analysis of variance and χ2 tests for comparative analyses. Results: Of the 178 patients whose records were reviewed, 36.5% were classified as overweight and 39.3% as obese. Patients with non-cancer diagnoses had a higher mean BMI than those with cancer-related diagnoses (p < 0.001). A higher BMI was associated with a longer time since lymphedema onset (p < 0.001), bilateral lymphedema (p = 0.010), and history of cellulitis (p < 0.001). Conclusions: Obesity is prevalent in the Canadian population with lymphedema and is associated with delayed referral and increased cellulitis rates. Early detection and tailored management strategies are needed to address obesity in patients with lymphedema and the complexities associated with these two related conditions.
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Affiliation(s)
- Shirin M. Shallwani
- Lymphedema Program
- Physiotherapy Department, McGill University Health Centre, Montreal
- School of Rehabilitation Sciences, University of Ottawa, Ottawa
| | | | - Anna Towers
- Lymphedema Program
- Department of Oncology, McGill University, Montreal
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16
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Webb E, Neeman T, Gaida J, Bowden FJ, Mumford V, Bissett B. Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic oedema: a randomised controlled trial protocol. BMJ Open 2019; 9:e029225. [PMID: 31420389 PMCID: PMC6701661 DOI: 10.1136/bmjopen-2019-029225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Cellulitis represents a significant burden to patients' quality of life (QOL) and cost to the healthcare system, especially due to its recurrent nature. Chronic oedema is a strong risk factor for both an initial episode of cellulitis and cellulitis recurrence. Expert consensus advises compression therapy to prevent cellulitis recurrence in individuals with chronic oedema, however, there is little supporting evidence. This research aims to determine if the management of chronic oedema using compression therapy effectively delays the recurrence of lower limb cellulitis. METHODS AND ANALYSIS A randomised controlled trial with cross-over will be used to assess the impact of compression therapy on clinical outcomes (time to next episode of cellulitis, rate of cellulitis-related hospital presentations, QOL and leg volume). Using concealed allocation, 162 participants will be randomised into the intervention (compression) or control (no compression) group. Randomisation will be stratified by prophylactic antibiotic use. Participants will be followed up at 6 monthly intervals for up to 3 years or until 45 episodes of cellulitis occur across the cohort. Following an episode of recurrent cellulitis, control group participants will cross-over to the intervention group. Survival analysis will be undertaken to assess the primary outcome measure of time to cellulitis recurrence. The hypotheses are that compression therapy to control lower limb chronic oedema will delay recurrent lower limb cellulitis, reduce the rate of associated hospitalisations, minimise affected limb volume and improve the QOL of this population. ETHICS AND DISSEMINATION Ethics approval has been obtained from the ethics committees of all relevant institutions. Results will be disseminated through relevant peer-reviewed journal articles and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12617000412336; Pre-results. The ICTOC trial is currently in progress. Participant recruitment started in May 2017 and is expected to continue until December 2019.
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Affiliation(s)
- Elizabeth Webb
- Department of Physiotherapy, Calvary Public Hospital Bruce, Canberra, Australian Capital Territory, Australia
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Teresa Neeman
- Biological Data Science Institute, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jamie Gaida
- University of Canberra Research Institute for Sport and Exercise (UC-RISE), University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Francis J Bowden
- Calvary Public Hospital Bruce, Canberra, Australian Capital Territory, Australia
- Australian National University Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
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17
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Takemoto R, Motomura Y, Kaku N, Ichimiya Y, Muraoka M, Kanno S, Tanaka T, Sakai Y, Maehara Y, Ohga S. Late-onset sepsis and encephalopathy after bicycle-spoke injury: a case report. BMC Infect Dis 2019; 19:472. [PMID: 31138139 PMCID: PMC6537365 DOI: 10.1186/s12879-019-4082-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 05/13/2019] [Indexed: 12/04/2022] Open
Abstract
Background Bicycle-spoke injuries rarely cause late complications of infection, including sepsis and sepsis-associated encephalopathy, with appropriate treatments. Case presentation We experienced a 2-year-old girl who developed the signs of encephalopathy with fever 6 months after a spoke-injury. On admission, the injured skin was inflamed with cellulitis. The blood culture was positive for methicillin-sensitive Staphylococcus aureus. Electroencephalogram showed diffuse slow-wave activity. Diffusion-weighted magnetic resonance imaging detected a high-intensity lesion with decreased diffusivity at the right frontal cortex. She received immunoglobulin and combined antibiotics treatments in the intensive care unit, and successfully overcame the sepsis-associated encephalopathy without neurological impairments. Conclusion This is the first report demonstrating that sepsis and its associated encephalopathy occurs in a remote period after the bicycle-spoke injury.
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Affiliation(s)
- Ryuichi Takemoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Yoshitomo Motomura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan.
| | - Noriyuki Kaku
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Yuko Ichimiya
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Mamoru Muraoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Shunsuke Kanno
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tamami Tanaka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiko Maehara
- Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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18
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Brishkoska-Boshkovski V, Kondova-Topuzovska I, Damevska K, Petrov A. Comorbidities as Risk Factors for Acute and Recurrent Erysipelas. Open Access Maced J Med Sci 2019; 7:937-942. [PMID: 30976336 PMCID: PMC6454161 DOI: 10.3889/oamjms.2019.214] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND: Erysipelas is a common infectious skin disease. A typical feature of erysipelas, especially on the lower limbs, is the tendency to reoccur and the study aimed to define the comorbidities associated with it. AIM: We aimed to investigate systemic and local comorbidities in patients diagnosed with erysipelas on the lower limbs. MATERIAL AND METHODS: We conducted a retrospectively-prospective, population-based cohort study which included all patients diagnosed with erysipelas on the lower limbs, during two years. Patients were divided into two groups: patients with first episode and patients with recurrent erysipelas. These two groups were compared, with particular emphasis on systemic and local comorbidities. RESULTS: The study included 313 patients, of which 187 with the first episode of erysipelas and 126 with a recurrent. Regarding the analyzed systemic risk factors, the recurrent erysipelas was significantly associated with obesity (p < 0.0001), insulin dependent diabetes mellitus (p = 0.0015), history of malignant disease (p = 0.02) and tonsillectomy (p = 0.000001). For a p-value < 0.0001, significantly more frequent finding of peripheral arterial occlusive disease, chronic oedema/lymphoedema, fungal infections of the affected leg and chronic ulcer was confirmed in recurrent erysipelas. Neuropathy had 23% of the recurrent cases and 8.6% in patients without recurrence, and the difference was found to be significant for p = 0.0003. The only dissection of the lymph nodes was found more frequently in recurrent erysipelas (p = 0.017), but no associations with other analysed local surgery on the affected leg. Patients with recurrent erysipelas had ipsilateral coexisting dermatitis p = 0.00003 significantly more frequent. Minor trauma often preceded the first episode of erysipelas p = 0.005. CONCLUSION: Identification and treatment of modifiable risk factors are expected to reduce the risk of a subsequent episode of erysipelas on the lower limbs.
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Affiliation(s)
| | - Irena Kondova-Topuzovska
- University Infectious Diseases Clinic, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje Republic of Macedonia
| | - Katerina Damevska
- University Clinic of Dermatology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje Republic of Macedonia
| | - Andrej Petrov
- Acibadem Sistina Hospital, Skopje, Republic of Macedonia.,Faculty of Medical Sciences, University Goce Delchev, Shtip, Republic of Macedonia
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19
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Woods M. Risk factors for the development of oedema and lymphoedema. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:219-222. [PMID: 30811244 DOI: 10.12968/bjon.2019.28.4.219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An important symptom of ill health in clinical medicine is the development of oedema, which represents an imbalance in the amount of fluid entering and leaving the tissues of the body. Although medical treatment for the underlying cause of oedema is required, in both cancer and non-cancer settings risk factors that may increase or decrease the potential for oedema to develop or worsen can be identified. For the patient who has risk factors for the development of oedema, advice and education can enable the risk to be modified. Reducing the risk of oedema formation will help avoid long-term problematic oedema and complex skin conditions, as well as maintaining the patient's quality of life. This article discusses some of the risk factors for oedema and lymphoedema and concludes with an outline of how the risk can be managed.
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Affiliation(s)
- Mary Woods
- Nurse Consultant, Lymphoedema Services, Royal Marsden Hospital, London
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20
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Jendoubi F, Rohde M, Prinz JC. Intracellular Streptococcal Uptake and Persistence: A Potential Cause of Erysipelas Recurrence. Front Med (Lausanne) 2019; 6:6. [PMID: 30761303 PMCID: PMC6361840 DOI: 10.3389/fmed.2019.00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/10/2019] [Indexed: 12/21/2022] Open
Abstract
Erysipelas is a severe streptococcal infection of the skin primarily spreading through the lymphatic vessels. Penicillin is the treatment of choice. The most common complication consists in relapses which occur in up to 40% or more of patients despite appropriate antibiotic treatment. They cause lymphatic damage resulting in irreversible lymphedema and ultimately elephantiasis nostras and lead to major health restrictions and high socio-medical costs. Prevention of relapses is an unmet need, because even long-term prophylactic penicillin application does eventually not reduce the risk of recurrence. In this article we assess risk factors and causes of erysipelas recurrence. A systematic literature search for clinical studies addressing potential causes and measures for prevention of erysipelas recurrence was combined with a review of experimental and clinical data assessing the ability and clinical relevance of streptococci for intracellular uptake and persistence. The literature review found that venous insufficiency, lymphedema, and intertrigo from fungal infections are considered to be major risk factors for recurrence of erysipelas but cannot adequately explain the high recurrence rate. As hitherto unrecognized likely cause of erysipelas relapses we identify the ability of streptococci for intracellular uptake into and persistence within epithelial and endothelial cells and macrophages. This creates intracellular streptococcal reservoirs out of reach of penicillins which do not reach sufficient bactericidal intracellular concentrations. Incomplete streptococcal elimination due to intracellular streptococcal persistence has been observed in various deep tissue infections and is considered as cause of relapsing streptococcal pharyngitis despite proper antibiotic treatment. It may also serves as endogenous infectious source of erysipelas relapses. We conclude that the current antibiotic treatment strategies and elimination of conventional risk factors employed in erysipelas management are insufficient to prevent erysipelas recurrence. The reactivation of streptococcal infection from intracellular reservoirs represents a plausible explanation for the frequent occurrence erysipelas relapses. Prevention of erysipelas relapses therefore demands for novel antibiotic strategies capable of eradicating intracellular streptococcal persistence.
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Affiliation(s)
- Fatma Jendoubi
- Department of Dermatology, University Clinics, Ludwig-Maximilian University of Munich, Munich, Germany.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Manfred Rohde
- Central Facility for Microscopy, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Jörg Christoph Prinz
- Department of Dermatology, University Clinics, Ludwig-Maximilian University of Munich, Munich, Germany
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21
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Affiliation(s)
- Marie Todd
- Lymphoedema Clinical Nurse Specialist, Specialist Lymphoedema Service, Glasgow
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22
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Cannon J, Dyer J, Carapetis J, Manning L. Epidemiology and risk factors for recurrent severe lower limb cellulitis: a longitudinal cohort study. Clin Microbiol Infect 2018; 24:1084-1088. [PMID: 29427799 DOI: 10.1016/j.cmi.2018.01.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/24/2018] [Accepted: 01/28/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the epidemiology and risk factors for recurrence of severe lower leg cellulitis (LLC). METHODS A longitudinal cohort study using state-wide data of adults presenting with recurrent LLC following a primary episode occurring between January 2002 and December 2013. The incidence of recurrent LLC was estimated using the cumulative incidence function, accounting for mortality. Independent risk factors for recurrence were identified using Fine-Gray sub-distribution and Cox proportional hazards models. RESULTS Of 36 276 patients presenting with their first episode of LLC, 4598 had at least one recurrence during the follow-up period. The cumulative incidence of first, second, and third recurrences at 12 months since previous infection was 6.3% (95% CI 6.0-6.5), 17.2% (95% CI 16.1-18.4), and 29.4% (95% CI 26.8-31.9), respectively, and at 5 years was 13.9% (95% CI 13.5-14.3), 35.9% (95% CI 34.2-37.5), and 52.9% (95% CI 49.5-56.2), respectively. The length of hospitalization increased from 3 days for the primary episode to 4 and 5 days for first and all subsequent recurrences, respectively. Independent risk factors for recurrent LLC included age, ethnicity (Indigenous Australian), local factors relating to lower leg pathology, conditions that commonly result in peripheral oedema, and systemic conditions that may be associated with increased leg size. CONCLUSIONS LLC recurrences are frequent, and each episode increases the likelihood of subsequent recurrence and length of hospitalization. These data provide context and scope to develop workable and effective strategies to prevent secondary episodes for all cases of primary LLC.
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Affiliation(s)
- J Cannon
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - J Dyer
- Infectious Diseases Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - J Carapetis
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia; Infectious Diseases Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - L Manning
- Infectious Diseases Department, Fiona Stanley Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.
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23
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Mallipudi A, Gornet M, Portnoy E, Barone MA. Unilateral Foot Swelling in an Adolescent With Turner Syndrome. Clin Pediatr (Phila) 2017; 56:975-978. [PMID: 28478723 DOI: 10.1177/0009922817706150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrés Mallipudi
- 1 The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan Gornet
- 1 The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elie Portnoy
- 1 The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A Barone
- 1 The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Quirke M, Ayoub F, McCabe A, Boland F, Smith B, O'Sullivan R, Wakai A. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol 2017; 177:382-394. [DOI: 10.1111/bjd.15186] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2016] [Indexed: 01/03/2023]
Affiliation(s)
- M. Quirke
- Emergency Care Research Unit (ECRU); Division of Population Health Sciences (PHS); Royal College of Surgeons in Ireland (RCSI); 123 St Stephens Green Dublin 2 Ireland
| | - F. Ayoub
- Department of Surgery; Beaumont Hospital; Dublin Ireland
| | - A. McCabe
- Emergency Care Research Unit (ECRU); Division of Population Health Sciences (PHS); Royal College of Surgeons in Ireland (RCSI); 123 St Stephens Green Dublin 2 Ireland
| | - F. Boland
- Division of Population Health Sciences (PHS); Royal College of Surgeons in Ireland (RCSI); Dublin Ireland
| | - B. Smith
- RCSI Library; Beaumont Hospital; Dublin Ireland
| | - R. O'Sullivan
- Paediatric Emergency Care Research Unit (PERU); National Children's Research Centre; Dublin Ireland
- School of Medicine; University College Cork; Cork Ireland
| | - A. Wakai
- Emergency Care Research Unit (ECRU); Division of Population Health Sciences (PHS); Royal College of Surgeons in Ireland (RCSI); 123 St Stephens Green Dublin 2 Ireland
- Department of Emergency Medicine; Beaumont Hospital; Dublin Ireland
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Mzabi A, Marrakchi W, Alaya Z, Fredj FB, Rezgui A, Bouajina E, Kechrid CL. Cellulitis in aged persons: a neglected infection in the literature. Pan Afr Med J 2017; 27:160. [PMID: 28904688 PMCID: PMC5567966 DOI: 10.11604/pamj.2017.27.160.12007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/29/2017] [Indexed: 11/11/2022] Open
Abstract
Cellulitis is a frequent soft tissue and skin infection. The lower limbs are affected in 70 to 80% of cases. Cellulitis in aged persons is not yet well described in literature. A retrospective descriptive study conducted in the Internal Medicine Department of Sahloul hospital in Sousse in Tunisia. It included patients whose age was up to 65 years old admitted into hospital for cellulitis of the legs, the arms or the face. One hundred fifty eight patients with a mean age of 73 years old (range: 65 to 94 years old) were included. Female to male sex ratio was 0.68. Among them, we noted diabetes mellitus in 81 cases (50.6%). The infection was located in the lower limbs in 155 cases (98%), in the face in two cases (1.3%) and in the upper limb in one case (0.7%). Twenty one patients (13.3%) presented with severe cellulitis and one presented with necrotizing fasciitis. All patients received intra venous antibiotic therapy. Surgical treatment was indicated in 14 cases. Cefazolin was prescribed in 77 cases (48%). Favorable evolution was noted in 144 patients (91.1%). Forty four patients (27.8%) received prophylactic antibiotics. Prevention of skin and soft tissue infection is a crucial step to preserve health in aged persons.
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Affiliation(s)
- Anis Mzabi
- Department of Internal Medicine, Sahloul Hospital, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - Wafa Marrakchi
- Department of Internal Medicine, Sahloul Hospital, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - Zeineb Alaya
- Department of Rheumatology, Farhat Hached Hospital, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - Fatma Ben Fredj
- Department of Internal Medicine, Sahloul Hospital, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - Amel Rezgui
- Department of Internal Medicine, Sahloul Hospital, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - Elyès Bouajina
- Department of Rheumatology, Farhat Hached Hospital, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - Chedia Laouani Kechrid
- Department of Internal Medicine, Sahloul Hospital, Faculty of Medicine of Sousse, Sousse, Tunisia
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Dalal A, Eskin‐Schwartz M, Mimouni D, Ray S, Days W, Hodak E, Leibovici L, Paul M. Interventions for the prevention of recurrent erysipelas and cellulitis. Cochrane Database Syst Rev 2017; 6:CD009758. [PMID: 28631307 PMCID: PMC6481501 DOI: 10.1002/14651858.cd009758.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. OBJECTIVES To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. SEARCH METHODS We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. SELECTION CRITERIA Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. DATA COLLECTION AND ANALYSIS Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. MAIN RESULTS We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. AUTHORS' CONCLUSIONS In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.
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Affiliation(s)
- Adam Dalal
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Marina Eskin‐Schwartz
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Daniel Mimouni
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
| | - Walford Days
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Emmilia Hodak
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine EKaplan StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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Rob F, Hercogová J. Benzathine penicillin G once-every-3-week prophylaxis for recurrent erysipelas a retrospective study of 132 patients. J DERMATOL TREAT 2017; 29:39-43. [DOI: 10.1080/09546634.2017.1329507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Filip Rob
- Dermatovenereology Department, Na Bulovce Hospital, 2nd Medical Faculty Charles University, Prague, Czech Republic
| | - Jana Hercogová
- Dermatovenereology Department, Na Bulovce Hospital, 2nd Medical Faculty Charles University, Prague, Czech Republic
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Rincon K, Shah P, Ramella-Roman J, Bhansali S. A Review of Engineering Approaches for Lymphedema Detection. IEEE Rev Biomed Eng 2016; 9:79-90. [PMID: 27333610 DOI: 10.1109/rbme.2016.2582178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Edema is a condition characterized by excessive swelling of a tissue due to an abnormal accumulation of interstitial fluid in the subcutaneous tissue. More specifically, disruption of the lymphatic system causes what is known as lymphedema. This condition is commonly seen in breast cancer survivors postradiotherapy treatment, chemotherapy, and surgeries; this population has shown high risk of developing lymphedema in the limbs. Throughout the years, several techniques have been developed and implemented for the detection and measurement of lymphedema, including techniques to measure the diseased limb volume, electrical techniques to measure the water content in tissues, and optical techniques to measure either tissue absorbance or limb volume. However, there is still no method that allows for continuous monitoring of the disease and provides a better understanding of its progression. This study describes the different approaches that have been used and that could be used for lymphedema measurement.
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Manian FA, Kelly E. Lower Extremity Acute Bacterial Skin and Soft Tissue Infection Following Total Knee Arthroplasty. Am J Med Sci 2016; 352:154-8. [PMID: 27524213 DOI: 10.1016/j.amjms.2016.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/06/2016] [Accepted: 05/03/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although total knee arthroplasty (TKA) is one of the most common orthopedic procedures, its association with subsequent acute bacterial skin and soft tissue infections (ABSSTIs) in the ipsilateral limb has not been studied. METHODS This was a retrospective study of patients with prior unilateral TKA who were diagnosed with ABSSTI 4 weeks or more postoperatively in the absence of surgical site infection. The odds of ABSSTI in the TKA limb was compared to that of the contralateral "control" limb in the same patient in the presence or absence of local predisposing factors for ABSSTI in the lower extremities (e.g., chronic venous insufficiency). RESULTS Of 94 patients studied, 58 (62%) were women; mean age was 74.5 years. The mean body mass index was 33.1kg/m(2). One or more local predisposing factors were present in 53 (56.4%) patients. The mean interval between TKA and ABSSTI was 65.1 months (range: 1-239 months), with cellulitis alone diagnosed in 88 (94%) patients. ABSSTI involved the TKA limb of 68 (72.3%) patients and was significantly more likely to be diagnosed in the same limb in the absence of local predisposing factors (36 of 41 patients, odds ratio = 7.2, 95% CI: 2.8-23.5); the odds of TKA limb involvement was also higher in the presence of such factors but did not quite reach statistical significance (odds ratio = 1.5, 95% CI: 0.8-2.8). CONCLUSIONS TKA appears to predispose to ABSSTIs in the ipsilateral lower extremity often years after the procedure, particularly in the absence of other local factors.
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Affiliation(s)
- Farrin A Manian
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Erik Kelly
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Daptomycin-Based 3 Week Treatment Scheme for the First Cellulitis Episode: Low Recurrence Rate Indicative of Decreased Recurrence Propensity? Dermatol Ther (Heidelb) 2016; 6:77-80. [PMID: 26838583 PMCID: PMC4799042 DOI: 10.1007/s13555-016-0095-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction Cellulitis recurrences are frequent, difficult to manage, and contribute considerably to overall disease burden. This retrospective cases series reports recurrence rates of first community-acquired lower limb disease episode initially treated with daptomycin. Methods Treatment consisted of a 21-day two substances sequential scheme: intravenous daptomycin (4 mg/kg/day) during hospitalization and roxithromycin (2 × 150 mg per os) afterwards. Primary study end-point was the rate of recurrences during follow-up; recurrence rates and their binomial 95% confidence intervals (CI) were calculated with SPSS 22.0. Recurrences were identified by (1) review of hospital records and (2) telephone questionnaires. Results Twenty-seven patients hospitalized for first lower limb cellulitis episodes were started on daptomycin and 26 patients completed the above three-week sequential treatment scheme. During follow-up (range 37–85 months) one recurrence occurred among the 26 patients who completed the treatment: 96.2% of these patients remained relapse free at the end of follow-up (CI 79.5–99.9%). Considering also treatment failure, the overall effectiveness of this combination treatment was 92.6% recurrence free after more than 3 years follow-up (25/27 patients; CI 75.5–99.0%). This study is limited by retrospective planning and the restricted number of included patients. Conclusion The choice of the treatment for the initial lower limb cellulitis episode may impact the risk of disease recurrences. Future studies should explore interventions for the first cellulitis episode as a means to modify the risk of the recurring course of this disease. Electronic supplementary material The online version of this article (doi:10.1007/s13555-016-0095-8) contains supplementary material, which is available to authorized users.
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Pitché P, Diatta B, Faye O, Diané BF, Sangaré A, Niamba P, Mandengue C, Kobengue L, Saka B, Diop A, Ly F, Dieng MT, Dicko A, Soumah MM, Cissé M, Kourouma SH, Kouassi YI, Boukari T, Akakpo S, Tchangaï-Walla K. [Risk factors associated with leg erysipelas (cellulitis) in sub-Saharan Africa: A multicentre case-control study]. Ann Dermatol Venereol 2015; 142:633-8. [PMID: 26364000 DOI: 10.1016/j.annder.2015.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/04/2015] [Accepted: 08/05/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute bacterial cellulitis of the leg (erysipelas) is a common problem involving considerable morbidity in dermatology practice in Africa. Previous studies conducted in Europe and North Africa have highlighted lymphoedema and toe-web intertrigo as independent factors associated with leg erysipelas. The aim of this case-control study was to identify risk factors associated with leg erysipelas in sub-Saharan Africa, within a different socio-economic and culture context. PATIENTS AND METHODS We conducted a prospective case-control study in hospital dermatology departments in 8 sub-Saharan African countries over a 12-month period (October 2013 to September 2014). Each case of acute leg cellulitis was matched with 2 controls for age (±5 years) and sex. We analysed the general and local factors. RESULTS During the study period, 364 cases (223 female, 141 male) were matched with 728 controls. The mean age was 42.15±15.15 years for patients and 42.11±36 years for controls. Multivariate analysis showed the following to be independent risk factors associated with leg erysipelas in our study: obesity (odds ratio [OR]=2.82 ; 95% confidence interval: 2.11-3.76), lymphoedema (OR=3.87, 95%CI: 2.17-6.89), voluntary cosmetic depigmentation (OR=4.29, 95%CI: 2.35-7.83), neglected traumatic wound (OR=37.2, 95%CI: 24.9-57.72) and toe-web intertrigo (OR=37.86, 95%CI: 22.27-64.5). CONCLUSION The results of this study confirms the major role of local risk factors (toe-web intertrigo, lymphoedema) previously identified in other geographical settings. However, the originality of our study consists of the identification of voluntary cosmetic depigmentation as a risk factor for leg erysipelas in sub-Saharan Africa.
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Affiliation(s)
- P Pitché
- Service de dermato-vénéréologie, CHU Sylvanus Olympio, université de Lomé, 08 BP 81056, Lomé 08, Togo.
| | - B Diatta
- Service de dermatologie, CHU Le Dantec, Dakar, université Cheik Anta Diop, Dakar, Sénégal
| | - O Faye
- Service de dermatologie, CNAM, Bamako, université de Bamako, Bamako, Mali
| | - B-F Diané
- Service de dermatologie-MST, CHU Donka, Conakry, université de Conakry, Conakry, Guinée
| | - A Sangaré
- Centre de dermatologie, CHU Treichville, université de Cocody, Cocody, Côte d'Ivoire
| | - P Niamba
- Service de dermatologie, CHU Yaldago Ouédraogo, Ouagadougou, université de Ouagadougou, Ouagadougou, Burkina Faso
| | - C Mandengue
- Service de dermatologie, clinique universitaire des Montagnes, Banganté, Cameroun
| | - L Kobengue
- Service de dermatologie, CHU de Bangui, université de Bangui, Bangui, Centrafrique
| | - B Saka
- Service de dermato-vénéréologie, CHU Sylvanus Olympio, université de Lomé, 08 BP 81056, Lomé 08, Togo
| | - A Diop
- Service de dermatologie, CHU Le Dantec, Dakar, université Cheik Anta Diop, Dakar, Sénégal
| | - F Ly
- Service de dermatologie, CHU Le Dantec, Dakar, université Cheik Anta Diop, Dakar, Sénégal
| | - M-T Dieng
- Service de dermatologie, CHU Le Dantec, Dakar, université Cheik Anta Diop, Dakar, Sénégal
| | - A Dicko
- Service de dermatologie, CNAM, Bamako, université de Bamako, Bamako, Mali
| | - M-M Soumah
- Service de dermatologie-MST, CHU Donka, Conakry, université de Conakry, Conakry, Guinée
| | - M Cissé
- Service de dermatologie-MST, CHU Donka, Conakry, université de Conakry, Conakry, Guinée
| | - S-H Kourouma
- Centre de dermatologie, CHU Treichville, université de Cocody, Cocody, Côte d'Ivoire
| | - Y-I Kouassi
- Centre de dermatologie, CHU Treichville, université de Cocody, Cocody, Côte d'Ivoire
| | - T Boukari
- Service de dermato-vénéréologie, CHU Sylvanus Olympio, université de Lomé, 08 BP 81056, Lomé 08, Togo
| | - S Akakpo
- Service de dermato-vénéréologie, CHU Sylvanus Olympio, université de Lomé, 08 BP 81056, Lomé 08, Togo
| | - K Tchangaï-Walla
- Service de dermato-vénéréologie, CHU Sylvanus Olympio, université de Lomé, 08 BP 81056, Lomé 08, Togo
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Rast AC, Knobel D, Faessler L, Kutz A, Felder S, Laukemann S, Steiner D, Haubitz S, Fux CA, Huber A, Mueller B, Schuetz P. Use of procalcitonin, C-reactive protein and white blood cell count to distinguish between lower limb erysipelas and deep vein thrombosis in the emergency department: A prospective observational study. J Dermatol 2015; 42:778-85. [PMID: 25982244 DOI: 10.1111/1346-8138.12922] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 03/24/2015] [Indexed: 12/13/2022]
Abstract
Early differentiation of erysipelas from deep vein thrombosis (DVT) based solely on clinical signs and symptoms is challenging. There is a lack of data regarding the usefulness of the inflammatory biomarkers procalcitonin (PCT), C-reactive protein (CRP) and white blood cell (WBC) count in the diagnosis of localized cutaneous infections. Herein, we investigated the diagnostic value of inflammatory markers in a prospective at-risk patient population. This is an observational quality control study including consecutive patients presenting with a final diagnosis of either erysipelas or DVT. The association of PCT (μg/L) and CRP (mg/L) levels and WBC counts (g/L) with the primary outcome was assessed using logistic regression models with area under the receiver-operator curve. Forty-eight patients (erysipelas, n = 31; DVT, n = 17) were included. Compared with patients with DVT, those with erysipelas had significantly higher PCT concentrations. No significant differences in CRP concentrations and WBC counts were found between the two groups. At a PCT threshold of 0.1 μg/L or more, specificity and positive predictive values (PPV) for erysipelas were 82.4% and 85.7%, respectively, and increased to 100% and 100% at a threshold of more than 0.25 μg/L. Levels of PCT also correlated with the severity of erysipelas, with a stepwise increase according to systemic inflammatory response syndrome criteria. We found a high discriminatory value of PCT for differentiation between erysipelas and DVT, in contrast to other commonly used inflammatory biomarkers. Whether the use of PCT levels for early differentiation of erysipelas from DVT reduces unnecessary antibiotic exposure needs to be assessed in an interventional trial.
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Affiliation(s)
- Anna C Rast
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Demian Knobel
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Lukas Faessler
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Alexander Kutz
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Susan Felder
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Svenja Laukemann
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Deborah Steiner
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sebastian Haubitz
- University Clinic of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - Christoph A Fux
- Division of Infectious Diseases, University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau , Switzerland
| | - Beat Mueller
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
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Karppelin M, Siljander T, Aittoniemi J, Hurme M, Huttunen R, Huhtala H, Kere J, Vuopio J, Syrjänen J. Predictors of recurrent cellulitis in five years. Clinical risk factors and the role of PTX3 and CRP. J Infect 2015; 70:467-73. [DOI: 10.1016/j.jinf.2014.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 09/22/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
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Tay EY, Fook-Chong S, Oh CC, Thirumoorthy T, Pang SM, Lee HY. Cellulitis Recurrence Score: A tool for predicting recurrence of lower limb cellulitis. J Am Acad Dermatol 2015; 72:140-5. [DOI: 10.1016/j.jaad.2014.08.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 07/30/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
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van Zuuren EJ, Fedorowicz Z, Alper B, Mitsuma SF. Penicillin to prevent recurrent leg cellulitis: a critical appraisal. Br J Dermatol 2014; 171:1300-3. [PMID: 25523263 DOI: 10.1111/bjd.13461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E J van Zuuren
- Department of Dermatology, B1-Q, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, the Netherlands.
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Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue
Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:147-59. [DOI: 10.1093/cid/ciu296] [Citation(s) in RCA: 1187] [Impact Index Per Article: 118.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.
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Affiliation(s)
- Dennis L. Stevens
- Division of Infectious Diseases, Department of Veterans Affairs, Boise, Idaho
| | - Alan L. Bisno
- Medical Service, Miami Veterans Affairs Health Care System, Florida
| | | | | | - Ellie J. C. Goldstein
- University of California, Los Angeles, School of Medicine, and R. M. Alden Research Laboratory, Santa Monica, California
| | | | - Jan V. Hirschmann
- Medical Service, Puget Sound Veterans Affairs Medical Center, Seattle, Washington
| | - Sheldon L. Kaplan
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - James C. Wade
- Geisinger Health System, Geisinger Cancer Institute, Danville, Pennsylvania
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Oh CC, Ko HCH, Lee HY, Safdar N, Maki DG, Chlebicki MP. Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta-analysis. J Infect 2014; 69:26-34. [DOI: 10.1016/j.jinf.2014.02.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/29/2014] [Accepted: 02/18/2014] [Indexed: 11/15/2022]
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Chlebicki MP, Oh CC. Recurrent Cellulitis: Risk Factors, Etiology, Pathogenesis and Treatment. Curr Infect Dis Rep 2014; 16:422. [DOI: 10.1007/s11908-014-0422-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Inghammar M, Rasmussen M, Linder A. Recurrent erysipelas--risk factors and clinical presentation. BMC Infect Dis 2014; 14:270. [PMID: 24884840 PMCID: PMC4033615 DOI: 10.1186/1471-2334-14-270] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 05/13/2014] [Indexed: 11/19/2022] Open
Abstract
Background Erysipelas is a common infection that often recurs, but the impact of specific risk factors for reoccurrence remains elusive. In the present study we aimed at clarifying predisposing conditions for reoccurrence. Methods Medical records were reviewed from all patients ≥18 years of age diagnosed with erysipelas at the Department of Infectious Diseases at Skåne University Hospital, Sweden, from January 2007 to February 2011. 502 patients were included, of which 357 were single episode erysipelas and 145 had recurrent erysipelas. These two groups were compared regarding underlying conditions and clinical presentation. Results Erysipelas in the lower limbs had the greatest propensity of recurrence. The associations between underlying conditions and recurrence were largely depending on the site of erysipelas. Overall, the most prominent risk factor for recurrence was lymphedema and other conditions causing a chronic impairment of the defence against microbes. Conditions temporarily disrupting the skin barrier (e.g. a local wound or toe web intertrigo), although likely being risk factors for erysipelas per se, did not seem to predispose to repeated episodes. Individuals with recurrent erysipelas tended to seek medical attention earlier, and were less likely to be hospitalized or receive intravenous antibiotics, but there was no evidence of any difference in inflammatory reaction when taking confounding factors into account. Conclusions In this large cross-sectional study of over 500 patients with erysipelas, lymphedema was the most prominent risk factors for recurrence although the distribution of predisposing conditions varies depending on the site of erysipelas.
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Affiliation(s)
- Malin Inghammar
- Department of Clinical Sciences, Division of Infection Medicine, Klinikgatan 1, Skåne University Hospital, Lund, Lund SE-221 85, Sweden.
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Suehiro K, Morikage N, Murakami M, Yamashita O, Ueda K, Samura M, Hamano K. A study of leg edema in immobile patients. Circ J 2014; 78:1733-9. [PMID: 24790031 DOI: 10.1253/circj.cj-13-1599] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Our objectives were to elucidate the pathophysiology of leg edema in immobile patients and to discuss reasonable management of this condition. METHODS AND RESULTS The 30 patients with leg edema had visited our clinic between April 2009 and March 2013; they suffered from severe gait disturbance, had no significant venous abnormalities detected using duplex ultrasound, and did not have any systemic diseases that could cause leg edema. Here, we review their symptoms, examinations, and treatments. Among 59 edematous legs of the 30 patients, 30 legs (51%) had symptoms that indicated advanced chronic venous insufficiency. The ankle range of motion and calf : ankle circumference ratio were abnormal in only 3 (5%) and 10 (17%) of the legs, respectively. The severity of edema and subcutaneous inflammation, which was confirmed using ultrasonography, was significantly influenced by gravity. Air plethysmography and lymphangioscintigraphy were completed in 15 and 10 patients, respectively, neither of which revealed any significant abnormalities. Reasonable success for all patients was achieved by compression therapy and physical therapy without medications. CONCLUSIONS It was assumed that leg edema in these immobile patients was mainly caused by venous stasis because of the immobility itself, not because of anatomical problems. The patients were successfully managed by compression and physical therapy alone.
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Affiliation(s)
- Kotaro Suehiro
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine
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Smith M. Interview: Monica Smith. Br J Community Nurs 2014; 19:38-42. [PMID: 24704753 DOI: 10.12968/bjcn.2014.19.sup4.s38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Monica Smith
- Lymphoedema Clinical Nurse Specialist, Birmingham Community Health Care Trust
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Mason JM, Thomas KS, Crook AM, Foster KA, Chalmers JR, Nunn AJ, Williams HC. Prophylactic antibiotics to prevent cellulitis of the leg: economic analysis of the PATCH I & II trials. PLoS One 2014; 9:e82694. [PMID: 24551029 PMCID: PMC3925077 DOI: 10.1371/journal.pone.0082694] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/04/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cellulitis (erysipelas) is a recurring and debilitating bacterial infection of the skin and underlying tissue. We assessed the cost-effectiveness of prophylactic antibiotic treatment to prevent the recurrence of cellulitis using low dose penicillin V in patients following a first episode (6 months prophylaxis) and more recurrent cellulitis (12 months prophylaxis, or 6 months in those declining 12 months). METHODS Within-trial cost-effectiveness analysis was conducted using the findings of two randomised placebo-controlled multicentre trials (PATCH I and PATCH II), in which patients recruited in the UK and Ireland were followed-up for up to 3 years. Incremental cost, reduction in recurrence, cost per recurrence prevented and cost/QALY were estimated. National unit and reference costs for England in 2010 were applied to resource use, exploring NHS and societal perspectives. A total of 397 patients from the two trials contributed to the analysis. RESULTS There was a 29% reduction in the number of recurrences occurring within the trial (IRR: 0.71 95%CI: 0.53 to 0.90, p = 0.02), corresponding to an absolute reduction of recurrence of 0.31 recurrences/patient (95%CI: 0.05 to 0.59, p = 0.02). Incremental costs of prophylaxis suggested a small cost saving but were not statistically significant, comparing the two groups. If a decision-maker is willing to pay up to £25,000/QALY then there is a 66% probability of antibiotic prophylaxis being cost-effective from an NHS perspective, rising to 76% probability from a secondary, societal perspective. CONCLUSION Following first episode or recurrent cellulitis of the leg, prophylactic low dose penicillin is a very low cost intervention which, on balance, is effective and cost-effective at preventing subsequent attacks. Antibiotic prophylaxis reduces cellulitis recurrence by nearly a third but is not associated with a significant increase in costs.
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Affiliation(s)
- James M. Mason
- Durham Clinical Trials Unit, Durham University, Queen’s Campus, Stockton-on-Tees, United Kingdom
| | - Kim S. Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Katharine A. Foster
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Joanne R. Chalmers
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Andrew J. Nunn
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Hywel C. Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
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Connell FC, Gordon K, Brice G, Keeley V, Jeffery S, Mortimer PS, Mansour S, Ostergaard P. The classification and diagnostic algorithm for primary lymphatic dysplasia: an update from 2010 to include molecular findings. Clin Genet 2013; 84:303-14. [PMID: 23621851 DOI: 10.1111/cge.12173] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 04/19/2013] [Accepted: 04/19/2013] [Indexed: 12/17/2022]
Abstract
Historically, primary lymphoedema was classified into just three categories depending on the age of onset of swelling; congenital, praecox and tarda. Developments in clinical phenotyping and identification of the genetic cause of some of these conditions have demonstrated that primary lymphoedema is highly heterogenous. In 2010, we introduced a new classification and diagnostic pathway as a clinical and research tool. This algorithm has been used to delineate specific primary lymphoedema phenotypes, facilitating the discovery of new causative genes. This article reviews the latest molecular findings and provides an updated version of the classification and diagnostic pathway based on this new knowledge.
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Affiliation(s)
- F C Connell
- Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, SE1 9RT, UK
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Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR, Nasr IS, Brindle RJ, English J, Meredith SK, Reynolds NJ, de Berker D, Mortimer PS, Williams HC. Penicillin to prevent recurrent leg cellulitis. N Engl J Med 2013; 368:1695-703. [PMID: 23635049 DOI: 10.1056/nejmoa1206300] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cellulitis of the leg is a common bacterial infection of the skin and underlying tissue. We compared prophylactic low-dose penicillin with placebo for the prevention of recurrent cellulitis. METHODS We conducted a double-blind, randomized, controlled trial involving patients with two or more episodes of cellulitis of the leg who were recruited in 28 hospitals in the United Kingdom and Ireland. Randomization was performed according to a computer-generated code, and study medications (penicillin [250 mg twice a day] or placebo for 12 months) were dispensed by a central pharmacy. The primary outcome was the time to a first recurrence. Participants were followed for up to 3 years. Because the risk of recurrence was not constant over the 3-year period, the primary hypothesis was tested during prophylaxis only. RESULTS A total of 274 patients were recruited. Baseline characteristics were similar in the two groups. The median time to a first recurrence of cellulitis was 626 days in the penicillin group and 532 days in the placebo group. During the prophylaxis phase, 30 of 136 participants in the penicillin group (22%) had a recurrence, as compared with 51 of 138 participants in the placebo group (37%) (hazard ratio, 0.55; 95% confidence interval [CI], 0.35 to 0.86; P=0.01), yielding a number needed to treat to prevent one recurrent cellulitis episode of 5 (95% CI, 4 to 9). During the no-intervention follow-up period, there was no difference between groups in the rate of a first recurrence (27% in both groups). Overall, participants in the penicillin group had fewer repeat episodes than those in the placebo group (119 vs. 164, P=0.02 for trend). There was no significant between-group difference in the number of participants with adverse events (37 in the penicillin group and 48 in the placebo group, P=0.50). CONCLUSIONS In patients with recurrent cellulitis of the leg, penicillin was effective in preventing subsequent attacks during prophylaxis, but the protective effect diminished progressively once drug therapy was stopped. (Funded by Action Medical Research; PATCH I Controlled-Trials.com number, ISRCTN34716921.).
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
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Cheville AL, Andrews K, Kollasch J, Schmidt K, Basford J. Adapting lymphedema treatment to the palliative setting. Am J Hosp Palliat Care 2013; 31:38-44. [PMID: 23423772 DOI: 10.1177/1049909112475297] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the benefits of adapting the complex techniques of formal lymphedema therapy to the more generalized forms of edema often seen in the chronic disease and palliative care settings. DATA SOURCES Peer-reviewed literature and clinical practice. CONCLUSION Lymphedema treatment modalities have much to offer beyond their well-characterized benefit in classical lymphedema. In modified forms, they may improve and lessen the burden of refractory edema originating from a diverse range of causes. Thoughtful planning and practice, however, are essential as an inadequate adaptation may result in unnecessary effort, injury for the patient, or an unsatisfactory outcome.
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Affiliation(s)
- Andrea Lynne Cheville
- 1Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
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Glatz M, Degen D, French LE, Aberer W, Müllegger RR. Erysipelas of the thigh and the gluteal region: retrospective multicenter analysis of a very rare entity in 39 patients. Dermatology 2012; 225:277-83. [PMID: 23257902 DOI: 10.1159/000345619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 11/05/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Erysipelas of the thigh and the gluteal region are rarely described and not well characterized. Therefore we aim to describe the prevalence, clinical characteristics, and risk factors of these erysipelas types. METHODS The files of 1,423 patients with erysipelas were analyzed. Data from patients with erysipelas of the thigh or the gluteal region were compared between the two groups and with a control group with erysipelas of the lower leg. RESULTS The thigh was exclusively affected in 2.1%, and the gluteal region in 0.6% of erysipelas patients. Gluteal erysipelas had conspicuous irregular borders and sometimes appeared bilaterally. Major risk factors for erysipelas of both sites were previous surgical interventions. Gluteal erysipelas was common in patients with the metabolic syndrome and required a more intense antibiotic therapy. CONCLUSION Erysipelas of the thigh and the gluteal region are rare and significantly associated with prior surgical disruption of lymphatic vessels.
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Affiliation(s)
- Martin Glatz
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.
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Lower limb cellulitis and its mimics. J Am Acad Dermatol 2012; 67:163.e1-12; quiz 175-6. [DOI: 10.1016/j.jaad.2012.03.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 03/28/2012] [Accepted: 03/29/2012] [Indexed: 12/17/2022]
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Chim H, Soltanian H. Spontaneous compartment syndrome of the forearm in association with nephrotic syndrome and transient bacteremia. J Surg Case Rep 2012; 2012:11. [PMID: 24960769 PMCID: PMC3649580 DOI: 10.1093/jscr/2012.8.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We present a patient with spontaneous compartment syndrome of the upper extremity in association with nephrotic syndrome and transient bacteremia, of which the exact cause of compartment syndrome was unclear. This is an extremely rare occurrence, and index of suspicion should be maintained even in the absence of trauma when a patient presents with acute swelling of the upper or lower extremity together with nephrotic syndrome.
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Affiliation(s)
- H Chim
- Case Western Reserve University, Ohio, USA
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Szolnoky G, Dobozy A, Kemény L. Decongestion improves cell-mediated immunity in postmastectomy arm lymphoedema: a pilot study. J Eur Acad Dermatol Venereol 2012; 27:1579-82. [DOI: 10.1111/j.1468-3083.2012.04647.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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