Results | Incident report data were available for the years 2010 to 2017. A total of 464 injuries were recorded by University of Oklahoma Health Sciences Center residents. Of these 464 injuries, 19 were incurred by dermatology residents, 122 were incurred by nondermatology medical residents, 322 were incurred by nondermatology surgical residents, and 1 was excluded from the comparative analysis owing to our inability to determine the relevant residency department. Analytical results are illustrated in Figure 1 and Figure 2.Statistically significant findings included the increased mean (95% CI) proportion of suture-needle injuries among dermatology compared with nondermatology specialties (63.2% [95% CI, 41.5%-84.9%] vs 40.1% [95% CI, 36.0%-44.5%]; P = .045) and compared with nondermatology medical specialties (63.2% [95% CI, 41.5%-84.9%] vs 21.3% [95% CI, 14.0%-28.6%]; P ≤ .001), as well as the decreased proportion of hollow-needle and bladed instrument injuries among dermatology compared with nondermatology medical specialties (hollow needles, 15.8% [95% CI, 0.0%-32.2%] vs 39.3% [95% CI, 30.6%-48.0%]; P = .047; and bladed instruments, 5.3% [95% CI, 0.0%-15.3%] vs 32.0% [95% CI, 23.7%-40.3%] P = .02). No significant differences were seen for proportion of electrical instrument injuries or contextual factors leading to injury (eg, recapping needles).Discussion | Further research is necessary to confirm the external validity of this single-institution study. In addition, the data source for this study, optional incident reports, represents a potential weakness of nonresponse and voluntary response bias. Because records were deidentified prior to analysis, confounding factors, such as residents with repeated injuries, could not be evaluated.Previous studies have suggested that resident physicians, and particularly dermatology residents, may be at increased risk of injuries from sharps. 2,4,5 Our study represents the largest nonsurvey-based analysis of injuries from sharps among residents to date, to our knowledge. We demonstrated that dermatology residents, in comparison with residents of other medical specialties, incur a higher proportion of injuries involving suture needles and a lower proportion of injuries involving bladed instruments or hollow needles. This finding provides nonsurvey-based support for the recommendation of future research on injuries from sharps and education being targeted specifically toward prevention of sutureneedle injuries.
A woman in her 50s presented with a 4-day history of a diffuse, progressive, and pruritic rash. She had no known allergies and did not take any medications. She had no exposures to chemicals, detergents, or new personal care products; however, the patient consumed raw shiitake mushrooms several days before symptom onset. An examination revealed dozens of long flagellate streaks composed of red papules distributed across the trunk and extremities (Figure). She denied fever, malaise, or dyspnea. Laboratory results were remarkable for eosinophilia. The findings and history were consistent with flagellate mushroom dermatitis. The patient was treated with topical steroids, oral antihistamines, and raw shiitake mushroom avoidance, and the condition improved without sequelae.Flagellate mushroom dermatitis, also known as shiitake mushroom dermatitis, is thought to be caused by lentinan, a thermolabile toxin in shiitake mushrooms (Lentinula edodes). 1 Proposed pathogenesis includes delayed T-cell-mediated and toxinmediated reactions, as lentinan has T-cell-mediated antitumor properties, inducing vasodilation and hemorrhage reactions that can manifest as skin findings. However, the exact mechanism remains unknown. 2,3 Characteristic linear streaks of small erythematous pruritic papules appear 1 to 2 days following raw mushroom ingestion. It has been hypothesized that the linear pattern is partially produced by scratching; however, this has been disputed, as there are documented cases in which this pattern appears in the absence of scratching. 4 The distribution is commonly on the trunk and extremities. 1 The differential diagnosis for these findings is narrow and includes adult-onset Still disease, dermatomyositis, and flagellate erythema from chemotherapeutic agents, such as bleomycin. 3,4 Diagnosis of flagellate dermatitis is based on history and physical examination findings. Histology results are often nonspecific and may show spongiosis, perivascular lymphocytic and neutrophilic infiltrate, or eosinophils. 1,3 Flagellate mushroom dermatitis is self-limited, although treatment with topical steroids and oral antihistamines can be helpful. Resolution typically occurs within 1 to 8 weeks of mushroom avoidance, and thoroughly cooking mushrooms can prevent this dermatitis. Recognition of this condition may help guide patients to avoid triggers and minimize unnecessary testing.
Objective: Consensus guidelines recommend that intensive care unit (ICU) patients with blood glucose (BG) levels >180 mg/dL receive continuous intravenous insulin (CII). The effectiveness of CII at controlling BG levels among patients who are eating relative to those who are eating nothing by mouth (nil per os; NPO) has not been described. Methods: We conducted a retrospective cohort study of 260 adult patients (156 eating, 104 NPO) admitted to an ICU between January 1, 2014, and December 31, 2014, who received CII. Patients were excluded for a diagnosis of diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic syndrome, admission to an obstetrics service, or receiving continuous enteral or parenteral nutrition. Results: Among 22 baseline characteristics, the proportion of patients receiving glucocorticoid treatment (GCTx) (17.3% eating, 37.5% NPO; P<.001) and APACHE II score (15.0 ± 7.5 eating, 17.9 ± 7.9 NPO; P = .004) were significantly different between eating and NPO patients. There was no significant difference in the primary outcome of patient-day weighted mean BG overall (153 ± 8 mg/dL eating, 156 ± 7 mg/dL NPO; P = .73), or day-by-day BG ( P = .37) adjusted for GCTx and APACHE score. Surprisingly, there was a significant difference in the distribution of BG values, with eating patients having a higher percentage of BG readings in the recommended range of 140 to 180 mg/dL. However, eating patients showed greater glucose variability (coefficient of variation 23.1 ± 1.0 eating, 21.2 ± 1.0 NPO; P = .034). Conclusion: Eating may not adversely affect BG levels of ICU patients receiving CII. Whether or not prandial insulin improves glycemic control in this setting should be studied. Abbreviations: BG = blood glucose; CII = continuous insulin infusion; CV = coefficient of variation; HbA1c = hemoglobin A1c; ICU = intensive care unit; NPO = nil per os; PDWMBG = patient day weighted mean blood glucose
Background Pyoderma gangrenosum (PG) is a rare inflammatory skin condition characterized by painful, irregularly shaped skin ulcers mainly affecting the lower extremities. PG rarely affects the head and neck, making the diagnosis of this condition even more challenging. A high index of suspicion is paramount in the diagnosis of PG, especially after surgical procedures. Methods We describe a clinical case of a patient with initially undiagnosed PG of the scalp who underwent surgical excision and full thickness skin graft with subsequent graft necrosis as initial clue for the diagnosis. Results Twenty months after initial presentation, this patient healed with a multimodal medical approach of immunosuppressive therapy and wound care. Conclusion Prompt recognition of PG by physicians assessing any surgical wounds is vital in reducing misdiagnosis and improving patient outcomes.
Focal epithelial hyperplasia (FEH), or Heck's disease, is an uncommon HPV-related dermatosis that presents with multiple discrete papules or nodules on the lips, tongue, and gingival or oral mucosa. Treatment is often sought due to cosmesis, social stigma, and functional impairment. Treatment is challenging and a variety of treatment modalities have been attempted with varying degrees of success. This report describes the novel use of nano-pulse stimulation in the successful treatment of recalcitrant FEH of the upper and lower vermillion lip.
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