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Archive for December, 2014

Dr. William Silver to Join the Atlanta Institute for Aesthetic Facial Surgery

Thursday, December 18th, 2014
William E. Silver, MD

William E. Silver, MD

Dr. William Silver, who has practiced facial plastic surgery in North Atlanta for over 30 years, is moving practices. He is now undertaking a new assignment at the Atlanta Institute for Aesthetic Facial Surgery. He is joining Dr. Pradeep Sinha and will be seeing his old and new patients at his new office.

Dr. Silver is very active in local, state and national medical societies. He has been president of the Medical Association of Atlanta and the Medical Association of Georgia, and  he was the first president of the Atlanta Otolaryngology/Head and Neck Surgery Society. He also served as president of the Georgia Society of Otolaryngology/Head and Neck Society, where he was awarded the Gerald Gussik Teaching Award and the Lester Brown Service award. On a national level, Dr. Silver served as the vice president of the American Academy of Otolaryngology/Head and Neck Surgery and the American Academy of Facial Plastic and Reconstructive Surgery. He is a board examiner for the American Board of Facial Plastic and Reconstructive Surgery and is triple board certified by the American Board of Otolaryngology, the American Board of Facial Plastic and Reconstructive Surgery, and the American Board of Cosmetic Surgery. Dr. Silver continues to educate others on Facial Plastic Surgery through his writings and local and national lectures. He is a clinical professor at both the Medical College of Georgia and Emory University Otolaryngology Departments, where he interacts with the residency teaching programs.

Dr. Silver also serves as a fellowship director for the American Academy of Facial Plastic and Reconstructive Surgery, where he has been teaching new fellows for the past 20 years. In addition to his background in cosmetic facial procedures such as blepharoplasties, facelifts, and otoplasties, he is world-renowned for his experience with rhinoplasty and revision rhinoplasty, having performed over 10,000 rhinoplasties in his practice career.

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National Multiple Sclerosis Society Research Highlights in 2014

Thursday, December 18th, 2014

Significant research progress occurred in 2014, offering new leads that are driving efforts to stop MS, restore function lost, and end MS forever. In 2014, the National Multiple Sclerosis Society invested $50.6 million in 380 new and ongoing research projects and initiatives. Here is a brief summary of the research highlights reflecting the National Multiple Sclerosis Society’s commitment to pursue promising opportunities wherever they exist, while focusing on three priority areas: progressive MS, nervous system repair, and wellness/lifestyle, which have been singled out under each research goal below when applicable.

STOPPING MS

  • A team funded by the Society shed new light on immune cells known as macrophages, discovering a way to tell the difference between good and bad types of these immune cells during MS-like disease in mice. If it holds true for people with MS, this opens up possibilities for therapies that target bad cells and spare good cells.
  • The FDA approved Plegridy™ (peginterferon beta-1a, Biogen Idec) and Lemtrada™ (alemtuzumab, Genzyme, a Sanofi Company) for people with relapsing forms of MS. This now brings the number of disease modifying treatment options for those with the most common form of MS to 12.
  • African Americans with MS were found to have more visual impairment and faster thinning of the nerve fibers in the back of the eye than Caucasians with MS, in a multicenter study.
  • The MS Outcome Assessments Consortium established data standards and is leveraging clinical trials data from at least 16,000 patients to develop a new FDA-approved tool for measuring effectiveness of treatments in MS clinical trials.

Progressive MS:

  • A phase II, placebo-controlled clinical trial of high-dose oral simvastatin (a medication used for high cholesterol) involving 140 people with secondary-progressive MS suggested that this pill was able to slow the rate of brain tissue loss over two years.
  • An international team funded by the Society found that levels of vitamin D in serum early in the course of MS may be predictive of later disease activity and progression.
  • The International Progressive MS Alliance awarded its first round of 22 research grants with the goal of removing barriers to developing treatments for progressive MS – the start of an ambitious program that will invest at least $30 million over six years.
  • The Society is funding clinical trials of nervous system-protecting approaches including a phase II trial of ibudilast in 250 people with progressive MS.
  • Innate Immunotherapeutics leveraged National MS Society commercial seed funding to launch a clinical trial of a treatment for progressive MS.

Lifestyle/Wellness:

  • Society-funded researchers at Dartmouth published findings in mice related to how gut bacteria may be able to modulate immune attacks in MS. If results are confirmed, it may lead to a strategy that “resets” the immune system to stop immune attacks in MS.
  • Previous studies suggest that smoking can increase the risk of getting MS and the risk of progression; researchers in the U.K. found that for every year that passed after a person with MS stopped smoking, the risk for progression was reduced by as much as five percent.

RESTORING WHAT’S BEEN LOST

Nervous System Repair:

  • A small phase I clinical trial at Cleveland Clinic tested the ability of an individual’s own mesenchymal stem cells to inhibit immune mechanisms and augment intrinsic tissue repair processes when infused into the veins of people with relapsing forms of MS. Results suggested that this approach was safe and warrants a phase 2 trial, which is now in planning stages.
  • Results were published from two phase I safety trials of Biogen Idec’s BIIB033 (anti-LINGO monoclonal antibody, an exploratory treatment aimed at repairing myelin). No serious adverse events were reported. Phase II trials are underway.
  • A team supported by the Society at University of California at San Francisco identified compounds approved by the FDA for various disorders that might also stimulate myelin repair. A clinical trial stemming from this approach is underway.
  • Infusions of stem cells derived from placenta (a formulation known as “PDA-001” manufactured by Celgene Cellular Therapeutics) were shown to be safe in a small, phase I study of 16 people with relapsing-remitting or secondary-progressive MS. The next step, a proof-of-concept clinical trial, is planned.
  • The Society is supporting 15 research projects exploring various types of stem cells, including cells derived from bone marrow, fat and skin.
  • Canbex leveraged Society commercial seed funding to gain additional funding to launch a clinical trial of a novel Cannabis-like treatment for MS spasticity.

Lifestyle/Wellness:

  • In a large sleep study that surveyed more than 2,300 people with MS, researchers found that 70% reported having at least one sleep disorder, but that 12% or fewer had received a diagnosis of, or treatment for, a sleep disorder. Treating sleep disorders experienced by people with MS could significantly improve quality of life.
  • In a study of 109 women with MS, researchers pinpointed an area of the brain with reduced tissue volume; this reduction was linked to high levels of depression.
  • Society-funded researchers at the University of Alabama at Birmingham used constraint-induced movement therapy (immobilizing a favored arm, forcing the weaker arm to do exercises and skilled movements) in 20 people with progressive MS, showing that weakness improved and brain tissue increased significantly. A larger trial is underway.
  • A clinical trial showed strong evidence that a specific type of memory training improves learning in people with MS and benefits other aspects of quality of life.  Additionally, a pilot study revealed that clinical and MRI improvements were maintained six months after training ended.
  • Brown University researchers found promise in a preliminary study of a salsa dance program for people with MS, seeing improvements in gait and balance even three months after the 4-week program ended. The Society is now funding a larger, longer study that may lead to the use of dance as physical therapy for MS.
  • The Society convened a Wellness Strategy Meeting with leaders in the fields of diet, exercise and psychology, including individuals who also directly live with MS, to identify gaps in knowledge and programming and to map out next steps for how these gaps might best be addressed.

ENDING MS FOREVER

  • Cutting-edge genomic research earned Philip De Jager, MD, PhD, of Brigham and Women’s Hospital/Harvard, the 2014 Barancik Prize for Innovation in MS Research. He has played a role in nearly every key gene discovery and advancement over the past decade.
  • In studies involving over 80,000 people, the International MS Genetics Consortium has now identified more than 159 genetic variations related to MS; this Society-funded effort and additional genetics research were reported at ACTRIMS/ECTRIMS meeting.
  • Collaborators at Yale, MIT, Harvard and elsewhere reported a new approach to understand how subtle changes in genes may lead to the risk of developing MS and other immune diseases, promising new insights for interrupting the MS disease process.

Lifestyle/Wellness

  • Researchers in Sweden and California showed that adolescent obesity increased risk for MS, and this risk increased substantially in those with specific immune genes.
  • Harvard researchers looked at outcomes in women who had tried five popular diets, and found that none were associated with higher or lower risk of developing MS. Read more about this and other studies from the ACTRIMS/ECTRIMS meeting.
  • Investigators found that those who reported taking cod liver oil at ages 13-18 had nearly half the risk of developing MS compared to those who never took cod liver oil or took it at other ages. Read more about this and other studies from ACTRIMS/ECTRIMS.

 

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Lightbulb Radiology Provides Online Face-to-Face Imaging Consults Between Patient and Radiologist

Thursday, December 18th, 2014

Millions of imaging tests are performed in the United States each year.  Although most of these exams are interpreted by a radiologist, patients usually receive their results from the ordering physician. In many cases, the radiologist, as the imaging expert, is actually the physician best equipped to explain imaging findings. Lightbulb Radiology bridges this gap between the radiologist and the patient.

“I came up with the idea after helping several friends and family members with questions about their own imaging,“says Dr. Rourke Stay, the founder of Lightbulb Radiology.”  I found I was often able to give them a better appreciation for their imaging findings and what they really mean.”

The site, lightbulbradiology.com, allows a patient to upload his/her imaging test through a secure network and then schedule a consult with the radiologist.  From the comfort of their own home, patients can see and understand their imaging test (such as an MRI, CT scan, or ultrasound) and see and talk with the radiologist.  This enables the patient to ask questions and empowers them to make the best choices about their health care.

“Whether it be a lumbar spine MRI in a patient with chronic back pain, an incidental liver lesion seen on a CT scan of the abdomen, or a PET scan in a patient with cancer, the online consult provides a great way for patients to understand what is going on in their own body,” says Dr. Stay.

The launch of Lightbulb Radiology coincides with three converging trends in medicine: 1) the use of more accessible telemedicine platforms to deliver care, 2) radiologists becoming more visible and 3) the increased availability of radiology reports and other medical records through patient portals.

About the radiologist: Dr. Stay is a board certified radiologist who trained at the University of Virginia and also completed a fellowship in magnetic resonance imaging (MRI) at the U of California—San Diego.

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Northside Hospital’s Sleep Disorders Center Announces Expansion of Services

Thursday, December 18th, 2014

Northside Hospital’s Sleep Disorders Center has announced the expansion of its services with additional locations, including a new facility in Sandy Springs.

According to the National Sleep Foundation, approximately seven out of 10 Americans are affected by a sleep problem, although most remain undiagnosed and untreated.  Northside Hospital has cared for Atlanta’s sleep deprived for more than 25 years and was the first fully accredited sleep center in Georgia.

Over the last year, Northside has made its sleep disorders services increasingly more accessible to patients. In March 2014, the hospital moved its original Sleep Disorders Center on Peachtree Dunwoody to a renovated space in the medical offices directly across the street from the hospital. The new space allows Northside to grow from a six-bed facility to 10 beds and accommodate more patients.

All sleep rooms are complete with new furniture and linens, flat-screen televisions with cable, DVD players, complimentary WiFi, sound machines and more. Each sleep room is equipped with a private bathroom and its own thermostat for individual climate control. Turn-down service with breakfast in bed is complimentary with all rooms.

Northside’s comprehensive sleep disorders services also include additional sleep labs in Sandy Springs, Canton and Cumming, as well as another recently renovated Sleep Disorders Center in Roswell. Together, these facilities treat more than 1,000 patients a month for problems such as sleep apnea, insomnia, narcolepsy and more.

At all of the Northside Hospital Sleep Disorders Centers, Northside’s specialized team of sleep professionals utilizes the latest software and technology in diagnosing and treating sleep/wake disorders. In addition, each center offers portable in-home sleep studies, Continuous Positive Airway Pressure (CPAP) set-ups and trouble shooting, with personalized instruction and fitting.

“Nearly everyone is going to suffer a sleep problem at some point in their lives,” said David Westerman, M.D., medical director, Northside Hospital Sleep Disorders Center.  “We hope that these renovations and expanded services will exceed our patients’ expectations for comfort and continue to help Northside diagnose and treat sleep problems for thousands of Atlantans.”

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Sleep Medicine: Getting a Good Night’s Sleep Can be Difficult for Almost Half of the U.S. Population

Thursday, December 18th, 2014

By Helen K. Kelley

From ATLANTA Medicine, Vol. 85, No. 5

Scott M. Leibowitz, M.D.

Scott M. Leibowitz, M.D.

Sleep disturbances and disorders can cause, and are often intertwined, with a myriad of health issues, including hypertension, diabetes, obesity and more. Physicians who specialize in sleep medicine evaluate, diagnose and manage conditions such as sleeplessness, sleepiness, fatigue and abnormal behaviors during sleep.

Sleep Disorders by the Numbers

Scott M. Leibowitz, M.D., a board-certified sleep medicine specialist with Laureate Medical Group, which has six metro Atlanta locations, cites the most common sleep disorders as classic insomnia, obstructive sleep apnea, circadian rhythm disorders, restless leg syndrome, narcolepsy and parasomnias. Many of these disorders, he says, are markedly common.

“Sleep problems can affect about 35 to 40 percent of the general population at any one time,” he says. “And there are certain populations in which we see an increase in the prevalence of sleep-related complaints.”

According to Dr. Leibowitz:

  • Between 10 to 15 percent of the general population experience chronic insomnia, defined as difficulties falling or staying asleep with subsequent daytime symptoms such as fatigue or reduced cognitive function.
  •  The elderly have the greatest number of sleep-related complaints.
  •  Adolescents also have a significant number of sleep disorders.
  •  Women are at greater risk for sleep disorders than men.
  •   Roughly 40 percent of people age 60+ complain of insomnia or disrupted sleep.
  •  Sleep apnea is prevalent in post-menopausal women, and the incidence nears that of men at that same age.

Additionally, several diseases and conditions carry increased risks associated with sleep pathology, including heart failure, irregular heartbeat, hypertension, sleep apnea, stroke and diabetes.

Robert J. Albin, M.D.

Robert J. Albin, M.D.

Risky Business

Sleep deprivation poses health risks to people of all ages. Robert J. Albin, M.D., who specializes in pulmonary disease and sleep medicine with North Atlanta Pulmonary and Sleep Specialists, says that lack of sleep not only causes or exacerbates many health problems, but also affects critical thinking, which can influence a person’s ability to judge risks and make decisions.

“Many accidents and man-made disasters have been linked to sleep deprivation. For example, Three Mile Island, the Exxon Valdez oil spill, Chernobyl, the tugboat accident in New York City … these were all caused by someone who fell asleep at the switch or had impaired judgment,” he says. “There’s a lot of speculation now about single car crashes – that they may be related to sleep deprivation. Both quality and quantity of sleep can affect decision-making.”

Sleep performs several critical health functions, including repairing neural damage and consolidating thoughts and memories. Chronic sleep deprivation can result in decreased performance and alertness, memory and cognitive impairment, stress, reduced quality of life and even physical injury.

“Sleep is somewhat like rebooting or restoring a computer,” Dr. Albin says. “If we’re not sleeping well, we’re not repairing our hard drive properly.”

Targeted Treatments

While drug therapy, cognitive-behavior modification and CPAP and other mouth devices remain the primary treatments for sleep disorders, there are some new medications that hold promise for people experiencing sleep deprivation. These medications, such as Baclofen and Belsomra, allow for more targeted treatment of specific disorders.

Baclofen, a drug used to treat muscle spasticity for more than 50 years, is undergoing testing in mice by researchers at SRI International. Their findings show that Baclofen, which targets a deficiency of the neurotransmitter hypocretin, works better at treating narcolepsy than the best drug currently available for the disorder.

Belsomra (suvorexant) is a medication recently approved by the U.S. Food and Drug Administration for use as needed to treat insomnia. An orexin receptor antagonist, Belsomra is the first approved drug of this type. Orexins are chemicals that help regulate the sleep-wake cycle and play a role in keeping people awake. Belsomra alters the signaling of orexin in the brain.

Trending

Research suggests the growing possibility of a link between lack of sleep and obesity. In fact, a recent study conducted by MassGeneral Hospital for Children in Boston found compelling evidence that chronic sleep deprivation increases both obesity and adiposity in children as young as seven.

According to Dr. Albin, sleep abnormalities contribute to the abnormal regulation of neurohormones, which control appetite.

“Ghrelin is the hormone that signals hunger, and leptin is the hormone that signals satiety,” he says. “People with sleep disorders frequently have increased ghrelin levels and decreased levels of leptin, and the result is weight gain.”

Another growing trend in sleep disorders in both adults and children is related to technology. While it’s certainly not a new trend, Dr. Leibowitz says that sleep deprivation has evolved and escalated continuously since the invention of electricity.

“Everyone has an internal biological clock that determines his or her optimal window for sleeping and waking. Light has an affect on these circadian rhythms,” he says. “When we introduce light that is in close proximity to our eyes – from sources like computers, cell phones and televisions – it signals our brains to suppress the output of melatonin, which is a hormone that is critical for regulating our sleep and wake patterns. So we can see a more pronounced delay in the sleep patterns of those people who are addicted to their technology.”

In the news: treating sleep apnea in cardiac patients reduces hospital readmission.

A study of hospitalized cardiac patients is the first to show that effective treatment with positive airway pressure therapy reduces 30-day hospital readmission rates and emergency department visits in patients with both heart disease and sleep apnea.

Results show that none of the cardiac patients with sleep apnea who had adequate adherence to PAP therapy were readmitted to the hospital or visited the emergency department for a heart problem within 30 days from discharge. In contrast, hospital readmission or emergency department visits occurred in 30 percent of cardiac patients with sleep apnea who had partial PAP use and 29 percent who did not use PAP therapy.

The study results are published in the Oct. 15, 2014, issue of the Journal of Clinical Sleep Medicine, which is published by the American Academy of Sleep Medicine.

The study involved 104 consecutive patients who reported symptoms of sleep apnea while being hospitalized for a cardiac condition such as heart failure, arrhythmias or myocardial infarction.

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Pearls for Various Skin Manifestations: Dermatology More Than an Outpatient Specialty

Thursday, December 18th, 2014

By Asha R. Patel, M.D.

From ATLANTA Medicine, Vol. 85, No. 5

Asha R. Patel, M.D.

Asha R. Patel, M.D.

While primarily thought of as an outpatient specialty, the practice of dermatology also plays a vital role in certain hospital settings. By providing assistance for an efficient assessment, application of diagnostic studies and suggestion of treatment plans for cutaneous disease, the dermatologist can be a valuable asset to medical and surgical teams. Recognition of cutaneous manifestations of systemic disease is central to the consultant dermatologist’s role and adds invaluable insight into perplexing diagnostic cases.

The following are clinical pearls relating to common dermatologic manifestations found in the inpatient setting. (For a discussion of serious skin eruptions secondary to medication reactions, see page 10.)

Erythema

Erythema, or redness of the skin, can have various presentations. Examples of causes leading to erythema include toxin-mediated erythema (bacterial/viral infectious etiology vs medication), Graft vs Host Disease (GvHD) or Kawasaki disease. Morbilliform eruptions (measles-like eruptions) are commonly due to drug eruptions, viral exanthems and GvHD. However, disseminated deep fungal infections such as histoplasmosis, cryptococcosis, and coccidiomycosis can also mimic the morbilliform pattern.

Erythroderma is defined as full-body erythema associated with skin scaling, also known as exfoliative dermatitis. There are numerous common and rare causes for erythroderma, such as drug reactions, psoriasis, cutaneous T-cell lymphoma (CTCL), Sézary syndrome, atopic dermatitis, pityriasis rubra pilaris (PRP), systemic lupus erythematosus, pemphigus foliaceus, pemphigus vulgaris, seborrheic dermatitis, cutaneous manifestations of reactive arthritis, atypical pityriasis rosea, lichen planus, GvHD, diffuse histoplasmosis and nutritional disorders. Though literature reports suggest approximately 25 percent of erythroderma may also be idiopathic, some of these patients go on to develop CTCL and therefore should be monitored closely.

Management that is usually warranted in these cases includes a full body skin examination and diagnostic skin biopsies by a dermatologist for the underlying etiology. Diagnostic laboratory workup may be necessary on a case-by-case basis, but baseline labs – such as a complete blood count with differential, comprehensive metabolic panel and urine studies – are usually warranted at the time of the dermatology consultation.

Erythroderma is best managed in the inpatient setting, as these patients are prone to life-threatening systemic disorders such as thermodysregulation from insensible water and protein loss, peripheral edema and tachycardia. Meticulous nursing care is of the utmost importance, as patients are also prone to skin breakdown and sepsis. Patients may also benefit from occlusion suits or extremity wraps over application of topical steroids. Communication between the hospitalist team, nursing team and the consultant dermatologist should be clear because of the complexity of care required.

“Cellulitis”

A great mimic of bilateral lower extremity “cellulitis” is acute venous congestion and venous stasis dermatitis. Patients with congestive heart failure, kidney dysfunction, hepatic disease, vascular disease and/or diabetes are more prone to this noninfectious cause of bilateral lower extremity erythema and edema. Supportive care, leg elevation, compression and treatment of the underlying systemic disease are recommended. Vascular surgery input may be necessary depending upon the clinical picture.

Cellulitic-like plaques that are a cause for concern include carcinoma erysipeloides, deep fungal infections (i.e. cryptococcus), and acute neutrophilic dermatoses (aka Sweet syndrome). If plaques are ulcerating and/or not responding to standard antibiotic treatment, especially in the immunocompromised patient, these other etiologies need be considered, which would require skin biopsies.

Necrotizing fasciitis, commonly known as flesh-eating bacteria, is obviously a life-threatening emergency and classically described as pain out of proportion to clinical exam with rapidly progressing edema, erythema, overlying bullae, cyanosis and eventually gangrene. Emergent surgical consultation for evaluation and treatment is necessary, with diagnostic blood cultures and tissue cultures at time of surgical debridement.

Other differential diagnoses that may appear to be similar to a “deep cellulitis” include panniculitis, diabetic muscle infarction and pyomyositis. A low threshold for radiologic imaging must be used as these can be quite serious and painful. Panniculitides may also need additional biopsies to elicit an etiology, based on the clinical exam.

Vesicles/Bullae

A presentation of generalized vesicles and bullae can be quite alarming, as this can represent serious infections or autoimmune blistering conditions. Varicella is one of the most common infectious causes of generalized vesicles, with the appearance of a classic “dew drop on a rose petal” appearance. Although this is classically seen in pediatrics, with the advent of varicella immunization, it is now common to see cases in adults that were once vaccinated. In patients who were vaccinated, it is common to see “abortive” cases of varicella, a milder presentation with shorter duration. Patients who are immunocompromised are also at risk for generalized varicella, even if they have already had primary varicella. Furthermore in pediatric patients, aspirin is an absolute contraindication in varicella cases as this may lead to Reye Syndrome.

Herpes simplex virus can also have increase morbidity and mortality in certain situations. Lesions around the eye can lead to herpetic keratoconjunctivitis, which may lead to scarring and vision loss. In these cases, an urgent ophthalmology consult is warranted. Eczema herpeticum is a condition in which herpes simplex disseminates in a generalized distribution on compromised skin such as atopic dermatitis, pemphigus, Darier’s disease (DAR) or on burn patients. Treatment with oral or IV antiviral medication, depending on the extent of surface area involved and immune status, with meticulous wound care is necessary in these patients. Herpetic encephalitis is a severe complication of herpes when it affects the temporal lobes, presenting as decreased level of consciousness, seizures and fevers.

Autoimmune blistering conditions usually present as numerous and larger bullae and commonly require special diagnostic biopsies for confirmation of diagnosis, such as a direct immunofluorescence (DIF) skin biopsy. Bullous pemphigoid (BP) is the most common autoimmune blistering condition with large tense bullae and typically presents in the elderly. Occasionally, urticarial plaques may precede the bullous stage of BP.

Components of the junctional adhesion complex within the skin and mucosa are targeted by specific circulating autoantibodies. There can be significant morbidity due to skin breakdown and resultant infection. Treatment is usually a combination of topical and systemic medications; these cases may necessitate a variety of immunosuppression, from corticosteroids to long-term steroid sparing agents.

Pemphigus vulgaris and pemphigus foliaceous are other autoimmune blistering conditions in which the autoantibodies are directed at cell adhesion proteins in the skin and sometimes the mucosa. These are more superficial than BP. Therefore, these bullae are more flaccid and may not even be clinically present; widespread erosions may be the only evidence of pemphigus.

These patients are also at risk for significant morbidity due to skin breakdown and resultant infection, and a treatment plan may be similar to a BP patient. However, as pemphigus can have debilitating mucosal findings, otolaryngology and ophthalmology colleagues may need to be involved to prevent long-term mucosal scarring and strictures.

Linear IgA bullous disease is another blistering condition that may occur in the inpatient setting, as the adult form is essentially drug-induced, particularly in patients exposed to vancomycin. Penicillin, cephalosporins, ACE-inhibitors, and NSAIDs are also some well-known culprits.

It is thought that these medications stimulate a patient’s predisposed immune system to create IgA antibodies against specific proteins in the skin. Supportive care and withdrawal of culprit medications are key in management, with remission of eruption within two to six weeks of drug termination.

Pustules

Cutaneous pustules are a manifestation of a spectrum of dermatologic disease from drug eruptions, psoriasis, insect bites, contact dermatitis and various infections. Generalized pustules may herald a case of generalized pustular psoriasis (von Zumbusch variant). This is considered a dermatologic emergency and may require inpatient monitoring and systemic immunosuppression with cyclosporine, acitretin, or methotrexate. Intravenous steroids must be avoided, as this can exacerbate pustular psoriasis.

Generalized pustules in an immunocompromised patient may also be caused by disseminated candidiasis. These lesions may first appear as numerous erythematous papules with pale centers, but typical pustular lesions may present later. The patient should also be evaluated by an ophthalmologist as eye findings, including candida endophthalmitis, can be present.

Disseminated gonococcal infection may also present as pustules in a febrile patient, but more classically localized over affected joints (i.e. knees, elbows, wrists, ankles). The pustules are larger, surrounded by erythema, and may be hemorrhagic. Gram stain cultures from the urethra, endocervical canal or posterior pharynx is usually the gold standard for diagnosis.

Papules/Nodules

Papules on the skin are common and have an innumerable list of differential diagnoses; most can be handled appropriately in the outpatient setting. However, if there is either a papule or nodule of a deep violaceous color (known as a “purple plum”), the differential is more of an urgent matter as diagnoses such as cutaneous metastases, lymphomas, melanoma, sarcomas, vascular tumors and vascular infections are more concerning. A skin biopsy is diagnostic, but in cases of unusual tumors it may take special staining and outside dermatopathologic consultation for a confirmatory diagnosis.

Immunocompromised inpatients may also be at risk for scabies; classic lesions are typically pruritic pink to skin-colored small papules on volar wrists, finger webspaces, peri-areolar and peri-umbilical skin. Scrotal papules are pathognomonic for scabies and can sometimes be the only finding.

Crusted scabies is typical of the immunosuppressed and appears as marked hyperkeratosis, particularly of acral sites. If a patient is found to have crusted scabies, hospital infection control may need to be involved as it is likely to have spread to hospital staff and patients.

Purpura (palpable and retiform)

Palpable purpura is typically a small vessel vasculitis issue, which has an array of etiologies such as infection, medications, systemic inflammatory conditions and malignancy. Histology is important to confirm the diagnosis, but a DIF skin biopsy may also be obtained for further etiology.

Laboratory testing, such as complete blood count with differential, comprehensive metabolic panel, urine studies, fecal occult blood test and a hepatitis panel, may be necessary for a thorough systemic work-up. Other testing such as a RPR, ANA, HIV, SPEP, UPEP, RF, Total complement/C3/C4, ANCAs, cryoglobulins and an up-to-date age appropriate malignancy screening may also be necessary to tease out the etiology of the vasculitis if necessary.

Retiform purupra is more disturbing as it can quickly lead to necrosis of overlying skin. Embolization or thrombosis of vasculature can cause the distinct retiform (netlike) pattern via intraluminal occlusion (extraluminal occlusion may also occur). Diagnoses to strongly consider are calciphylaxis, cryoglobulinemia or cryofibrinogenemia, septic vasculitis, severe acute meningococcemia, levamisole exposure or a hypercoagulable state such as catastrophic antiphospholipid syndrome (CAPS). If one comes across periumbilical “thumbprint purpura” in an intensive care unit patient (usually on a respiratory vent), one must strongly consider hyperinfection of strongyloidiasis, which can quickly disseminate and lead to increased mortality. These cases are urgent and require quick diagnosis so treatment may be instituted.

Ulcers

Ulcers are commonly found in the inpatient setting and can be from a variety of conditions such as chronic venous insufficiency, a range of infectious etiologies and inflammatory conditions such as lichen planus or pyoderma gangrenosum. Chronic herpes simplex virus infections on the buttocks are very common in bedridden immunocompromised patients and should be cultured by the primary team. Ecthyma gangrenosum is another necrotic type of ulcer with raised erythematous borders classically associated with Pseudomonas aeruginosa bacteremia; these patients are critically ill and generally immunocompromised.

Pyoderma gangrenosum is a rare but chronic ulcerative disease that is usually associated with a variety of underlying systemic diseases. These can become large and painful with dusky borders and cribiform scarring; this requires a multi-disciplinary approach with the involvement of a wound care nurse for management. Chronic non-healing ulcers, especially in venous stasis wounds or old burn scars, may need to be evaluated for a Marjolin’s ulcer, a squamous cell carcinoma that arises in previously traumatized and/or chronically inflamed skin.

References:

Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology. 3rd edition.

Schneiderman PI, Grossman ME. A Clinician’s Guide to Dermatolgoic Differential Diagnosis. Volume I The Text.

Boschert, Sherry. Inpatient Dermatologist offers rules to diagnose by. Skin & Allergy News. December 2013, page 36.

Mancusi S, Neto CF. Inpatient dermatological consultations in a university hospital. Clinics 2010; 65 (9): 851-855.

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Georgia Society of Otolaryngology/Head and Neck Surgery Fall Meeting

Saturday, December 6th, 2014

December 6-7, 2014, The Ritz Carlton Lodge Reynolds Plantation, Lake Oconee, Ga. For more information, visit Georgia Society of Otolaryngology/Head and Neck Surgery

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56th ASH Annual Meeting and Exposition

Saturday, December 6th, 2014

December 6-9, 2014, Moscone Center, San Francisco, CA. For more information, visit American Society of Hematology

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Georgia Neurological Society Annual Fall Meeting

Saturday, December 6th, 2014

December 6-7, 2014, The Ritz Carlton Lodge Reynolds Plantation, Lake Oconee, Ga. For more information, visit Georgia Neurological Society 

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Bruce W. Bode, MD, FACE

Monday, December 1st, 2014

Dr. Bruce W. BodeDr. Bruce W. Bode is a diabetes specialist with Atlanta Diabetes Associates in Atlanta, Georgia, and is currently on the faculty of Emory University, as a Clinical Associate Professor in the Department of Medicine. He received his medical degree from Emory University School of Medicine and completed an internship and residency in internal medicine at Emory University Affiliated Hospitals and a fellowship in diabetes with Paul C. Davidson, MD.

He has a strong affinity for working with children and young adults with diabetes and is considered one of the leading experts in the world on insulin delivery and glucose sensing. He is very active in clinical research on new diabetes products including pharmacological agents to prevent diabetes and control glucose and new insulin and glucose sensors. He is a prolific writer with over 200 articles and books in the field of diabetes discussing current and future therapies for people with diabetes. He also sits on the advisory board of many of the leading companies in the field of diabetes care and research including the Juvenile Diabetes Research Foundation, the American Diabetes Association (ADA), and the Georgia diabetes camps.

Dr. Bode wrote Glucose Management in the Hospital from ATLANTA Medicine, Diabetes, Vol. 85, No. 4

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