Archive for July 26, 2018

Scabies outbreaks in ten care homes for elderly people: a prospective study of clinical features, epidemiology, and treatment outcomes

LANCET INFECTIOUS DISEASES August 2018 V.18 N.8 P.894–902

Background

Scabies outbreaks in residential and nursing care homes for elderly people are common, subject to diagnostic delay, and hard to control. We studied clinical features, epidemiology, and outcomes of outbreaks in the UK between 2014 and 2015.

Methods

We did a prospective observational study in residential care homes for elderly people in southeast England that reported scabies outbreaks to Public Health England health protection teams. An outbreak was defined as two or more cases of scabies (in either residents or staff) at a single care home. All patients who provided informed consent were included; patients with dementia were included if a personal or nominated consultee (ie, a family member or nominated staff member) endorsed participation. Dermatology-trained physicians examined residents at initial clinical visits, which were followed by two mass treatments with topical scabicide as per local health protection team guidance. Follow-up clinical visits were held 6 weeks after initial visits. Scabies was diagnosed through pre-defined case definitions as definite, probable, or possible with dermatoscopy and microscopy as appropriate.

Findings

230 residents were examined in ten outbreaks between Jan 23, 2014, and April 13, 2015. Median age was 86·9 years (IQR 81·5–92·3), 174 (76%) were female, and 157 (68%) had dementia. 61 (27%) residents were diagnosed with definite, probable, or possible scabies, of whom three had crusted scabies. Physical signs differed substantially from classic presentations. 31 (51%) of the 61 people diagnosed with scabies were asymptomatic, and only 25 (41%) had burrows. Mites were visualised with dermatoscopy in seven (11%) patients, and further confirmed by microscopy in three (5%). 35 (57%) cases had signs of scabies only on areas of the body that would normally be covered. Dementia was the only risk factor for a scabies diagnosis that we identified (odds ratio 2·37 [95% CI 1·38–4·07]). At clinical follow-up, 50 people who were initially diagnosed with scabies were examined. No new cases of scabies were detected, but infestation persisted in ten people.

Interpretation

Clinical presentation of scabies in elderly residents of care homes differs from classic descriptions familiar to clinicians. This difference probably contributes to delayed recognition and suboptimal management in this vulnerable group. Dermatoscopy and microscopy were of little value. Health-care workers should be aware of the different presentation of scabies in elderly people, and should do thorough examinations, particularly in people with dementia.

Funding

Public Health England and British Skin Foundation.

FULL TEXT

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext?dgcid=raven_jbs_etoc_email

PDF

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(18)30347-5.pdf

July 26, 2018 at 12:40 pm

Risk factors in septic revisions following total hip arthroplasty

LANCET INFECTIOUS DISEASES August 2018 V.18 N.8

Comment

In their Article in The Lancet Infectious Diseases, Erik Lenguerrand and colleagues1 identify several risk factors associated with increased or decreased risk of revision due to prosthetic joint infection (PJI) after primary total hip arthroplasty (THA). In this cohort study, the largest to date, the authors followed a novel analytical approach in which they stratified multiple patient, surgery, and health-care system-related risk factors for developing PJI over several chronological postoperative periods. In addition to adding stronger evidence on previously known risk factors,2, 3 the study also identified novel factors, including previous native hip infections and the use of lateral surgical approach. Furthermore, the authors provided stronger evidence to the role of the bearing surface, showing a potentially lower risk with ceramic bearings than metal bearings….

FULL TEXT

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30433-X/fulltext?dgcid=raven_jbs_etoc_email

PDF

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(18)30433-X.pdf

 

July 26, 2018 at 12:37 pm

Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort study

LANCET INFECTIOUS DISEASES August 2018 V.18 N.8

Background

The risk of prosthetic joint infection (PJI) is influenced by patient, surgical, and health-care factors. Existing evidence is based on short-term follow-up. It does not differentiate between factors associated with early onset caused by the primary intervention from those associated with later onset more likely to result from haematogenous spread. We aimed to assess the overall and time-specific associations of these factors with the risk of revision due to PJI after primary total hip replacement.

Methods

We did a prospective observational cohort study analysing 623 253 primary hip procedures performed between April 1, 2003, and Dec 31, 2013, in England and Wales and recorded the number of procedures revised because of PJI. We investigated the associations between risk factors and risk of revision for PJI across the overall follow-up period using Poisson multilevel models. We reinvestigated the associations by post-operative time periods (0–3 months, 3–6 months, 6–12 months, 12–24 months, >24 months) using piece-wise exponential multilevel models with period-specific effects. Data were obtained from the National Joint Registry linked to the Hospital Episode Statistics data.

Findings

2705 primary procedures were subsequently revised for an indication of PJI between 2003 and 2014, after a median (IQR) follow up of 4·6 years (2·6–7·0). Among the factors associated with an increased revision due to PJI there were male sex (1462 [1·2‰] of 1 237 170 male-years vs 1243 [0·7‰] of 1 849 691 female-years; rate ratio [RR] 1·7 [95% CI 1·6–1·8]), younger age (739 [1·1‰] of 688 000 person-years <60 years vs 242 [0·6‰] of 387 049 person-years ≥80 years; 0·7 [0·6–0·8]), elevated body-mass index (BMI; 941 [1·8‰] 517 278 person-years with a BMI ≥30 kg/m2 vs 272 [0·9‰] of 297 686 person-years with a BMI <25 kg/m2; 1·9 [1·7–2·2]), diabetes (245 [1·4‰] 178 381 person-years with diabetes vs 2120 [1·0‰] of 2 209 507 person-years without diabetes; 1·4 [1·2–1·5]), dementia (5 [10·1‰] of 497 person-years with dementia at 3 months vs 311 [2·6‰] of 120 850 person-years without dementia; 3·8 [1·2–7·8]), previous septic arthritis (22 [7·2‰] of 3055 person-years with previous infection vs 2683 [0·9‰] of 3 083 806 person-years without previous infection; 6·7 [4·2–9·8]), fractured neck of femur (66 [1·5‰] of 43 378 person-years operated for a fractured neck of femur vs 2639 [0·9‰] of 3 043 483 person-years without a fractured neck of femur; 1·8 [1·4–2·3]); and use of the lateral surgical approach (1334 [1·0‰] of 1 399 287 person-years for lateral vs 1242 [0·8 ‰] of 1 565 913 person-years for posterior; 1·3 [1·2–1·4]). Use of ceramic rather than metal bearings was associated with a decreased risk of revision for PJI (94 [0·4‰] of 239 512 person-years with ceramic-on-ceramic bearings vs 602 [0·5‰] of 1 114 239 peron-years with metal-on-polyethylene bearings at ≥24 months; RR 0·6 [0·4–0·7]; and 82 [0·4‰] of 190 884 person-years with ceramic-on-polyethyene bearings vs metal-on-polyethylene bearings at ≥24 months; 0·7 [0·5–0·9]). Most of these factors had time-specific effects. The risk of revision for PJI was marginally or not influenced by the grade of the operating surgeon, the absence of a consultant surgeon during surgey, and the volume of procedures performed by hospital or surgeon.

Interpretation

Several modifiable and non-modifiable factors are associated with the risk of revision for PJI after primary hip replacement. Identification of modifiable factors, use of targeted interventions, and beneficial modulation of some of these factors could be effective in reducing the incidence of PJI. It is important for clinicians to consider non-modifiable factors and factors that exhibit time-specific effects on the risk of PJI to counsel patients appropriately preoperatively.

Funding

National Institute for Health Research.

FULL TEXT

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30345-1/fulltext?dgcid=raven_jbs_etoc_email

PDF

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(18)30345-1.pdf

July 26, 2018 at 12:36 pm

Vibrio vulnificus Infection

New England Journal of Medicine July 2018

Images in Clinical Medicine

Jin Park, M.D., Ph.D., and Chang-Seop Lee, M.D., Ph.D.

A 71-year-old man presented to the emergency department with a 2-day history of fever and excruciating pain in his left hand that had developed 12 hours after eating raw seafood. He had a history of type 2 diabetes mellitus and hypertension and was undergoing hemodialysis for end-stage renal disease. At the time of presentation …

FULL TEXT

https://www.nejm.org/doi/full/10.1056/NEJMicm1716464?query=TOC

PDF

https://www.nejm.org/doi/pdf/10.1056/NEJMicm1716464

July 26, 2018 at 8:35 am

Pyoderma Gangrenosum in Ulcerative Colitis

New England Journal of Medicine July 2018

Images in Clinical Medicine

Perricone and M. Vangeli

A 71-year-old man with a 5-year history of glucocorticoid-dependent ulcerative colitis presented to the gastroenterology clinic with painful, rapidly progressive ulcerative lesions involving the left chest (Panel A) and leg (Panel B). The physical examination revealed skin ulcerations with a purulent base and an irregular purple edge. The histopathological examination of …

FULL TEXT

https://www.nejm.org/doi/full/10.1056/NEJMicm1802201?query=TOC

PDF

https://www.nejm.org/doi/pdf/10.1056/NEJMicm1802201

July 26, 2018 at 8:31 am


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