Showing papers by "David J. Margolis published in 2003"

Treatment of Toxic Epidermal Necrolysis With High-Dose Intravenous Immunoglobulins: Multicenter Retrospective Analysis of 48 Consecutive Cases

Abstract: Objective To evaluate the effect of high-dose intravenous immunoglobulin (IVIG) in toxic epidermal necrolysis (TEN), parameters that may affect response to treatment, and the effect of different IVIG batches on Fas-mediated cell death. Design Multicenter retrospective analysis of 48 consecutive TEN patients treated with IVIG. Setting Fourteen university hospital dermatology centers in Europe and the United States. Patients Forty-eight patients with TEN (skin detachment >10% of their body surface [mean, 44.8%; range, 10%-95%]). Interventions Infusion of IVIG in all patients (range, 0.8-5.8 g/kg), and analysis of the ability of different IVIG batches to inhibit Fas-mediated cell death. Main Outcome Measures Objective response to IVIG treatment, final outcome at day 45, parameters that may affect response to IVIG treatment, and tolerance. Results Infusion of IVIG (mean total dose, 2.7 g/kg [range, 0.65-5.8 g/kg]; mean consecutive days, 4 [range, 1-5 days]) was associated with a rapid cessation (mean, 2.3 days [range, 1-6 days]) of skin and mucosal detachment in 43 patients (90%) and survival in 42 (88%). Patients who responded to IVIG had received treatment earlier in the course of disease and, on average, higher doses of IVIG. Furthermore, analysis of 35 IVIG batches revealed significant batch-to-batch variations in the capacity of IVIG to inhibit Fas-mediated cell death in vitro. Conclusions Early infusion of high-dose IVIG is safe, well tolerated, and likely to be effective in improving the survival of patients with TEN. We recommend early treatment with IVIG at a total dose of 3 g/kg over 3 consecutive days (1 g/kg per day for 3 days).

Absence of cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics.

Abstract: background The safety of sulfonamide nonantibiotics is unclear in patients with prior allergic reactions to sulfonamide antibiotics. methods We conducted a retrospective cohort study using the General Practice Research Database in the United Kingdom, examining the risk of allergic reactions within 30 days after the receipt of a sulfonamide nonantibiotic. Patients with evidence of prior hypersensitivity after the receipt of a sulfonamide antibiotic were compared with those without such evidence. Similar analyses were also performed with the use of penicillins instead of sulfonamides, to determine whether any risk was specific to sulfonamide cross-reactivity. results Of 969 patients with an allergic reaction after a sulfonamide antibiotic, 96 (9.9 percent) had an allergic reaction after subsequently receiving a sulfonamide nonantibiotic. Of 19,257 who had no allergic reaction after a sulfonamide antibiotic, 315 (1.6 percent) had an allergic reaction after receiving a sulfonamide nonantibiotic (adjusted odds ratio, 2.8; 95 percent confidence interval, 2.1 to 3.7). However, the risk of allergic reactions was even greater after the receipt of a penicillin among patients with a prior hypersensitivity reaction to a sulfonamide antibiotic, as compared with patients with no such history (adjusted odds ratio, 3.9; 95 percent confidence interval, 3.5 to 4.3). Furthermore, among those with a prior hypersensitivity reaction after the receipt of a sulfonamide antibiotic, the risk of an allergic reaction after the subsequent receipt of a sulfonamide nonantibiotic was lower than the risk of an allergic reaction after the subsequent receipt of a penicillin (adjusted odds ratio, 0.7; 95 percent confidence interval, 0.5 to 0.9). Finally, the risk of an allergic reaction after the receipt of a sulfonamide nonantibiotic was lower among patients with a history of hypersensitivity to sulfonamide antibiotics than among patients with a history of hypersensitivity to penicillins (adjusted odds ratio, 0.6; 95 percent confidence interval, 0.5 to 0.8). conclusions There is an association between hypersensitivity after the receipt of sulfonamide antibiotics and a subsequent allergic reaction after the receipt of a sulfonamide nonantibiotic, but this association appears to be due to a predisposition to allergic reactions rather than to cross-reactivity with sulfonamide-based drugs.

Lymphoma rates are low but increased in patients with psoriasis: results from a population-based cohort study in the United Kingdom.

Abstract: Objective To determine if the rate of lymphoma in patients with a history of psoriasis is different from the rate of lymphoma in patients without psoriasis. Design Cohort study. Setting Outpatient practices of general practitioners in the United Kingdom who contribute to the General Practice Research Database. Patients The population studied was a sample of 10% of the patients 65 years or older registered with a general practitioner contributing to the General Practice Research Database between 1988 and 1996. Main Outcome Measure The rate of lymphoma in patients with psoriasis compared with the rate of lymphoma in patients without psoriasis. Results There were 2718 patients who had psoriasis and 105 203 patients (the reference population) who did not have psoriasis. The median follow-up time was 46 months. We noted 276 lymphomas. Patients with psoriasis had a 2.95 relative rate of developing lymphoma (95% confidence interval, 1.83-4.76) compared with those without psoriasis. This estimate did not change after controlling for age and sex using the Cox multivariable proportional hazards model. The rate of lymphoma changed little when the patients treated with methotrexate or those who developed mycosis fungoides were excluded. Compared with the reference population, we found an additional 122 lymphomas per 100 000 patients annually among patients with psoriasis who were 65 years or older. Conclusions These results indicate that patients with psoriasis are at increased risk for developing lymphoma. Additional studies are necessary to determine if the increased rate of lymphoma is related to psoriasis severity, psoriasis treatment, or an interaction between these risk factors.

Medical conditions as risk factors for pressure ulcers in an outpatient setting

Abstract: Objectives: the purpose of this study was to evaluate the likelihood that the presence of certain medical conditions in older ambulatory patients are associated with the risk of developing a new pressure ulcer. Design: a cohort study. Setting and subjects: a large outpatient record database from the United Kingdom called the General Practice Research Database. Methods: the frequency of disease was reported as simple percentages and the associations between the medical conditions and the development of a pressure ulcer as instantaneous rate ratios. Results: we studied 75,168 older individuals. Pressure ulcers occurred in 1,211 individuals. The medical conditions that were significantly associated with the development of a pressure ulcer after adjustment were: Alzheimer’s disease, congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, diabetes mellitus, deep venous thrombosis, hip fracture, hip surgery, limb paralysis, lower limb oedema, malignancy, malnutrition, osteoporosis, Parkinson’s disease, rheumatoid arthritis, and urinary tract infections. Angina, hypertension, and pneumonia were inversely associated with the development of a pressure ulcer. Conclusions: it is important that physicians recognise that patients with many medical conditions may be at higher risk for pressure ulcers so that even in the ambulatory care environment appropriate prevention and detection strategies can be directed towards the patients who are most likely to benefit.

Effect of antibiotics on the oropharyngeal flora in patients with acne.

Abstract: Objective To estimate the prevalence and resistance patterns ofStreptococcus pyogenesandStaphylococcus aureusin the oropharynx of individuals with acne who were using or not using antibiotic therapy. Design A cross-sectional study. Setting The Dermatology Department of the Hospital of the University of Pennsylvania, Philadelphia. Patients Patients with acne. Main Outcome Measures Presence or absence ofS pyogenesandS aureusin the oropharynx as determined by culture and their resistance patterns to tetracycline antibiotics as determined by agar disk diffusion. Results Of 105 patients who participated, 42 were using oral or topical antibiotics and 63 patients were not using antibiotics. Six (10%) of those 63 not using anyantibiotics had positiveS pyogenescultures compared with 13 (33%) of those successfully evaluated using antibiotics (n = 39) (prevalence risk ratio, 3.5; 95% confidence interval, 1.4-8.6;P= .003). A total of 85% ofS pyogenescultures (11/13) from those using antibiotics were resistant to at least 1 tetracycline antibiotic compared with 20% (1/5) from those not using antibiotics (P= .01). Of those not using antibiotics, 29% (18/62) had positiveS aureuscultures compared with 22% (9/41) of those using antibiotics (prevalence risk ratio, 0.76; 95% confidence interval, 0.38-1.5;P= .42). No significant differences in resistance patterns ofS aureuswere found. Conclusions Streptococcus pyogenescolonization and resistance in the oropharynx are associated with antibiotic therapy in patients with acne. The clinical and long-term effects of this finding need to be studied further.

Surrogate End Points for the Treatment of Diabetic Neuropathic Foot Ulcers

Abstract: OBJECTIVE—The goal of this study was to determine whether surrogate markers based primarily on changes in the size of a wound can be used to correctly predict which individuals with diabetic neuropathic foot ulcers will heal after 12 or 20 weeks of care. RESEARCH DESIGN AND METHODS—This is a retrospective cohort study using the Curative Health Services database. As many as 39,918 neuropathic wounds on 20,213 individuals with diabetes were evaluated. Seven surrogates based on changes in wound size were evaluated. RESULTS—Surrogates measured after 2, 4, or 8 weeks of care and based on percentage change in area, log healing rate, and log area ratio discriminated well with respect to differentiating between those wounds that healed and those that did not heal by the 12th or 20th week of care. For example, after 4 weeks of care, the percentage change in area can be used to correctly discriminate 76% of the time between those that healed and those that did not by the 20th week of care. CONCLUSIONS—The surrogate markers can be used in clinical trials such that shorter and smaller trials can be conducted with reasonable accuracy in order to determine which potential new therapeutics should be studied in larger, longer trials. In addition, the surrogates may also benefit clinicians when they are trying to decide whether a wound care therapy will ultimately be successful.

Risk factors for pressure ulcers among elderly hip fracture patients.

Abstract: The purpose of this study was to estimate the incidence of hospital-acquired pressure ulcers among elderly patients hospitalized for hip fracture surgery and to identify extrinsic factors that are associated with increased risk. We conducted a secondary analysis of data abstracted from medical records at 20 hospitals in Pennsylvania, Texas, New Jersey, and Virginia. Participants were patients aged 60 years and older admitted with hip fracture to the study hospitals between 1983 and 1993. The incidence of hospital-acquired pressure ulcers was 8.8% (95% confidence interval 8.2%-9.4%). After adjusting for confounding variables, longer wait before surgery, intensive care unit stay, longer surgical procedure, and general anesthesia were significantly associated with higher pressure ulcer risk. Extrinsic factors may be important markers for high pressure ulcer risk in hospitalized hip fracture patients. Although it is not possible to eliminate factors such as requiring an intensive care unit stay or having a long surgical procedure, it may be possible to develop interventions that minimize pressure ulcer risk in patients who experience these factors.

Pressure ulcers and the transition to long-term care.

Abstract: OBJECTIVE To estimate the prevalence of pressure ulcers among newly admitted residents of long-term-care facilities and to determine whether patients admitted from hospitals had a higher prevalence than those admitted from home or other settings DESIGN Prospective cohort study conducted between 1992 and 1995 SETTING 59 long-term-care facilities in Maryland PARTICIPANTS 2015 residents aged 65 years and older newly admitted to participating long-term-care facilities MAIN OUTCOME MEASURE Stage II, III, or IV pressure ulcer, first mentioned in the long-term-care facility's chart within 2 days of admission MAIN RESULTS Of the 2015 residents studied, 208 (103%) had 1 or more pressure ulcers on admission to a long-term-care facility The proportion of patients with 1 or more pressure ulcers was 119% among those admitted from a hospital and 47% among those not admitted from a hospital (P<001) In multivariable analysis, admission from a hospital was significantly associated with pressure ulcer prevalence on admission (odds ratio, 22; 95% confidence interval, 13-37) A lower prevalence of pressure ulcers on admission was significantly associated with being white; a higher prevalence was associated with being chairbound or bedridden, being underweight, and having fecal incontinence CONCLUSION Admission to a long-term-care facility from a hospital is an important marker for higher pressure ulcer risk The identification of pressure ulcer risk factors is essential to the implementation of prevention activities, ensuring that appropriate interventions are targeted to the residents who are most likely to benefit

Management of leg ulcers.

Abstract: Chronic wounds, and venous ulcers in particular, are often managed by dermatologists. The first step in the management of any lower extremity ulceration is accurate diagnosis. Although there are several basic tenets of good wound care that remain static regardless of wound etiology, such as maintaining a moist and clean wound healing environment, many of the maneuvers that have been shown to improve the chances of healing must be individualized to the wound type. Many of the techniques in wound management have not changed over the past century: compression remains the cornerstone of venous ulcer management. This article summarizes some of the techniques used in the management of these wounds. We discuss the evidence for using compression, vitamin and mineral supplementation, antibiotic use, growth factors, and other interventions in the management of these wounds.