Questions for a Review Article
◾How has reading the article changed your practice?
◾What information had you believed in previously that were debunked by reading this article?
◾What new information did you learn from reading this article?
◾What are current areas of uncertainty on this topic that can be potential areas for research?
1. Prior to reading this article, I wouldn’t have thought about an ophthalmology consult for patients w/ SJS or TEN (unless they had obvious ocular involvement), which is of great importance as corneal scarring and blindness are the most common sequellae.
2. When I thought of necrotizing fasciitis, I always thought the hallmark finding was crepitus, which I found after reading this article is only present in 35% of patients.
3. I didn’t realize that RMSF had such classically associated laboratory findings (thrombocytopenia, hyponatremia, elevated transaminases, normal WBC).
4. What factors portend a poor prognosis in SJS/TEN?
great reminder of the ocular complications of SJS/TEN and need for optho eval for corneal/conjunctival damage. Additionally, parameters for helping to differentiate NF from other skin infections ((WBC >14K, Na 15) good to keep in mind when assessing patients -especially etch, trauma, IVDU, nsaids.
◾How has reading the article changed your practice?
-Particularly now that it is summer time, will start to ask more about potential tick exposures when evaluating patients with viral like syndromes and myalgias. Especially all the dog-walkers out there.
◾What information had you believed in previously that were debunked by reading this article?
-I was not aware that the sensitivities for CT and MRI were so high for determining the presence and extend of necrotizing fasciitis. I thought the surgical exploration and debridement were the end all, be all.
◾What new information did you learn from reading this article?
– I was not aware that the mortality rate for RMSF was so high. Definitely surprising.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
– In the cases of SJS and TEN, would like to know more about the treatment. Would like to see more treatment trials including a large number of patients would be very helpful to determine the efficacy and safety of immunomodulating therapies in SJS/TEN, e.g. steroids, IVIG, cyclosporine. Or other things that we can start in the ED.
1) How has reading this article changed your practice?
I will pay more attention to the travel history in patients who present with a “viral syndrome” and a rash keeping RMSF in my differential. If there is any question this could be it I will treat given the increase in mortality rate with delay treatment
2) What information had you believe in previously that were debunked by reading this article?
I thought NSAIDs were a very safe drug but apparently they put you at risk for scary infections like necrotizing fasciitis and SJS
3) What new information did you learn from reading this article?
-Such high mortality rate for RMSF and triple the rate with 5-day delay treatment. Also how severe the disease can get
-That necrotizing fasciitis risk factors are NSAID use and alcoholism. I always take alcohol use as a type of immunosuppression just because of the malnutrition that goes with it but was not really aware that is also puts you at a higher risk for this type of infection
-SJS and TEN can be caused by sunlight exposure (I will be using more sunblock now especially since I am pregnant (double whammy)…
-Ophthalmology consultation is required for SJS and TEN patients
4) What are current areas of uncertainty on this topic that can be potential areas of research?
It takes 10 days at least to see titers for RMSF, researching other ways to diagnose this disease earlier.
Same for SJS and TEN given a biopsy takes time and specialty intervention, though less important given treatment is mainly supportive or empiric
◾How has reading the article changed your practice?
-Will definitely keep RMSF in mind, especially since being in New England makes me think of Lyme and not RMSF when I think “tick exposure,” but now I’ll ask about travel hx, headaches, etc.
◾What information had you believed in previously that were debunked by reading this article?
-I didn’t think chloramphenicol was a safe drug for pregnant women…but this article says to prescribe it for RMSF in pregnant women.
◾What new information did you learn from reading this article?
-That RMSF is the most prevalent tick-related disease (not Lyme), and that it has a higher mortality than I thought.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
-We need better tick repellents.
-Also for SJS and TEN – are there certain genotypes or characteristics that make someone more likely to develop these?
1) How has reading the article changed your practice?
It reminded me of how many, many drugs we prescribe have side effects. I prescribe NSAIDs and antibiotics every single day, and it’s scary to realize that a small percentage of patients who take these meds will get SJS. It reminded me of a patient I took care of in medical school who got bactrim inappropriately (a male patient who had asymptomatic bacteruria) and developed TEN, stayed in a burn unit for 1 month, and required multiple skin grafts over his whole body.
2) What information had you believed in previously that were debunked by reading this article?
I had forgotten that RMSF isn’t really in the Rocky Mountains – rather is more concentrated in the SE atlantic and central states (also throughout the Americas)
3) What new information did you learn from reading this article?
I didn’t know NSAIDs can cause SJS/TEN
4) What are current areas of uncertainty on this topic that can be potential areas for research?
I’d be interested in what other therapies might be useful for necrotizing fasciitis – the paper discusses IVIG and hyperbarics as controversial therapies.
◾How has reading the article changed your practice?
It reminded me that many of these serious illnesses can begin with vague symptoms that can be easily dismissed. I will keep these diagnoses in the back of my mind when seeing patients even if they have no cutaneous manifestations. Also a good reminder of how many symptoms can become involved in RMSP and SJS/TEN.
◾What information had you believed in previously that were debunked by reading this article? I thought that because skin involvement in SJS was less than TEN, it was not quite as dangerous as TEN. From the article, it sounds like the treatment is the same and complications can be severe for both.
◾What new information did you learn from reading this article? Men are more likely to develop SJS/TEN. Also, that the most common sites for necrotizing fasciitis are lower extremities, perineum, and abdomen.
◾What are current areas of uncertainty on this topic that can be potential areas for research? How many of these cases are missed on first presentation to PCP or ED. Proven ways to reduce the number of post-surgical necrotizing fasciitis infections.
1. In my practice will now know that RMSF is a reportable disease. I was not aware of this.
2. I thought CT was not particularly useful in dx of necrotizing fasciitis, shouldn’t delay treatment, and that clinical diagnosis is emphasized but the table in the article cites a 85% sensitivity and is useful
3. I didn’t know SJS is more prevalent in the winter spring months
4. It would be useful to know through data what labs or clinical aspects of RSMF portend a higher mortality rate.
1. Considering that the overall mortality rate (5-10%) in RMSF triples if not treated w/I 5 days of onset, I’ll be more likely to consider it (ie, exposure to dogs).
2. I thought because of their associations with meds, TEN/SJS were not seasonal but apprarently I was mistaken. Is it because people are more likely to be prescribed meds over winter?
3. I wasn’t aware that there were 2 type of nec fasc. – polymicrobial a/w trauma/surgery and type II which is a single organism.
4. Although it mentions several of the common labs abnormalities, the review article doesn’t mention the LRINCEC score for nec fasc – http://www.mdcalc.com/lrinec-score-necrotizing-soft-tissue-infection/. Perhaps it’s because the studies and subsequent validations were small. I mean what good is a score if “less than <5” still carries a “<50% chance” of nec fasc! Perhaps further validation would be welcomed.
◾How has reading the article changed your practice?
In the future, I will try to have a broader differential for cutaneous findings. Also, I will be more thoughtful about outdoor activities when the weather is nicer as tick-borne illness is not something I think too much about except for bull’s eye rashes on test questions.
◾What information had you believed in previously that were debunked by reading this article?
I didn’t realize that necrotizing fasciitis can take days to fully manifest. I had thought that once it developed, it would lead to loss of limb or life within a day.
◾What new information did you learn from reading this article?
I was surprised to learn that the rash in RMSF may not develop until as late as 5 days after the onset of other symptoms, and that the mortality risk jumps 3 fold 5 days after symptom onset. Perhaps because of the name, I hadn’t known (or, more, likely had forgotten from med school) that patients presented with headache and (for children) abdominal pain.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
It sounds like there’s a lot to discover in terms of the pathogenesis of SJS and TEN. It seems counter-intuitive that it’s more common in the winter and early spring yet sunlight is one of the apparent triggers.
12 comments
Questions for a Review Article
◾How has reading the article changed your practice?
◾What information had you believed in previously that were debunked by reading this article?
◾What new information did you learn from reading this article?
◾What are current areas of uncertainty on this topic that can be potential areas for research?
1. Prior to reading this article, I wouldn’t have thought about an ophthalmology consult for patients w/ SJS or TEN (unless they had obvious ocular involvement), which is of great importance as corneal scarring and blindness are the most common sequellae.
2. When I thought of necrotizing fasciitis, I always thought the hallmark finding was crepitus, which I found after reading this article is only present in 35% of patients.
3. I didn’t realize that RMSF had such classically associated laboratory findings (thrombocytopenia, hyponatremia, elevated transaminases, normal WBC).
4. What factors portend a poor prognosis in SJS/TEN?
great reminder of the ocular complications of SJS/TEN and need for optho eval for corneal/conjunctival damage. Additionally, parameters for helping to differentiate NF from other skin infections ((WBC >14K, Na 15) good to keep in mind when assessing patients -especially etch, trauma, IVDU, nsaids.
Nice short concise review of the basics. I wasn’t aware that NSAID’s are associated with development of nec fasc or SJS/TEN. Happy reading!
◾How has reading the article changed your practice?
-Particularly now that it is summer time, will start to ask more about potential tick exposures when evaluating patients with viral like syndromes and myalgias. Especially all the dog-walkers out there.
◾What information had you believed in previously that were debunked by reading this article?
-I was not aware that the sensitivities for CT and MRI were so high for determining the presence and extend of necrotizing fasciitis. I thought the surgical exploration and debridement were the end all, be all.
◾What new information did you learn from reading this article?
– I was not aware that the mortality rate for RMSF was so high. Definitely surprising.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
– In the cases of SJS and TEN, would like to know more about the treatment. Would like to see more treatment trials including a large number of patients would be very helpful to determine the efficacy and safety of immunomodulating therapies in SJS/TEN, e.g. steroids, IVIG, cyclosporine. Or other things that we can start in the ED.
1) How has reading this article changed your practice?
I will pay more attention to the travel history in patients who present with a “viral syndrome” and a rash keeping RMSF in my differential. If there is any question this could be it I will treat given the increase in mortality rate with delay treatment
2) What information had you believe in previously that were debunked by reading this article?
I thought NSAIDs were a very safe drug but apparently they put you at risk for scary infections like necrotizing fasciitis and SJS
3) What new information did you learn from reading this article?
-Such high mortality rate for RMSF and triple the rate with 5-day delay treatment. Also how severe the disease can get
-That necrotizing fasciitis risk factors are NSAID use and alcoholism. I always take alcohol use as a type of immunosuppression just because of the malnutrition that goes with it but was not really aware that is also puts you at a higher risk for this type of infection
-SJS and TEN can be caused by sunlight exposure (I will be using more sunblock now especially since I am pregnant (double whammy)…
-Ophthalmology consultation is required for SJS and TEN patients
4) What are current areas of uncertainty on this topic that can be potential areas of research?
It takes 10 days at least to see titers for RMSF, researching other ways to diagnose this disease earlier.
Same for SJS and TEN given a biopsy takes time and specialty intervention, though less important given treatment is mainly supportive or empiric
◾How has reading the article changed your practice?
-Will definitely keep RMSF in mind, especially since being in New England makes me think of Lyme and not RMSF when I think “tick exposure,” but now I’ll ask about travel hx, headaches, etc.
◾What information had you believed in previously that were debunked by reading this article?
-I didn’t think chloramphenicol was a safe drug for pregnant women…but this article says to prescribe it for RMSF in pregnant women.
◾What new information did you learn from reading this article?
-That RMSF is the most prevalent tick-related disease (not Lyme), and that it has a higher mortality than I thought.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
-We need better tick repellents.
-Also for SJS and TEN – are there certain genotypes or characteristics that make someone more likely to develop these?
1) How has reading the article changed your practice?
It reminded me of how many, many drugs we prescribe have side effects. I prescribe NSAIDs and antibiotics every single day, and it’s scary to realize that a small percentage of patients who take these meds will get SJS. It reminded me of a patient I took care of in medical school who got bactrim inappropriately (a male patient who had asymptomatic bacteruria) and developed TEN, stayed in a burn unit for 1 month, and required multiple skin grafts over his whole body.
2) What information had you believed in previously that were debunked by reading this article?
I had forgotten that RMSF isn’t really in the Rocky Mountains – rather is more concentrated in the SE atlantic and central states (also throughout the Americas)
3) What new information did you learn from reading this article?
I didn’t know NSAIDs can cause SJS/TEN
4) What are current areas of uncertainty on this topic that can be potential areas for research?
I’d be interested in what other therapies might be useful for necrotizing fasciitis – the paper discusses IVIG and hyperbarics as controversial therapies.
◾How has reading the article changed your practice?
It reminded me that many of these serious illnesses can begin with vague symptoms that can be easily dismissed. I will keep these diagnoses in the back of my mind when seeing patients even if they have no cutaneous manifestations. Also a good reminder of how many symptoms can become involved in RMSP and SJS/TEN.
◾What information had you believed in previously that were debunked by reading this article? I thought that because skin involvement in SJS was less than TEN, it was not quite as dangerous as TEN. From the article, it sounds like the treatment is the same and complications can be severe for both.
◾What new information did you learn from reading this article? Men are more likely to develop SJS/TEN. Also, that the most common sites for necrotizing fasciitis are lower extremities, perineum, and abdomen.
◾What are current areas of uncertainty on this topic that can be potential areas for research? How many of these cases are missed on first presentation to PCP or ED. Proven ways to reduce the number of post-surgical necrotizing fasciitis infections.
1. In my practice will now know that RMSF is a reportable disease. I was not aware of this.
2. I thought CT was not particularly useful in dx of necrotizing fasciitis, shouldn’t delay treatment, and that clinical diagnosis is emphasized but the table in the article cites a 85% sensitivity and is useful
3. I didn’t know SJS is more prevalent in the winter spring months
4. It would be useful to know through data what labs or clinical aspects of RSMF portend a higher mortality rate.
1. Considering that the overall mortality rate (5-10%) in RMSF triples if not treated w/I 5 days of onset, I’ll be more likely to consider it (ie, exposure to dogs).
2. I thought because of their associations with meds, TEN/SJS were not seasonal but apprarently I was mistaken. Is it because people are more likely to be prescribed meds over winter?
3. I wasn’t aware that there were 2 type of nec fasc. – polymicrobial a/w trauma/surgery and type II which is a single organism.
4. Although it mentions several of the common labs abnormalities, the review article doesn’t mention the LRINCEC score for nec fasc – http://www.mdcalc.com/lrinec-score-necrotizing-soft-tissue-infection/. Perhaps it’s because the studies and subsequent validations were small. I mean what good is a score if “less than <5” still carries a “<50% chance” of nec fasc! Perhaps further validation would be welcomed.
◾How has reading the article changed your practice?
In the future, I will try to have a broader differential for cutaneous findings. Also, I will be more thoughtful about outdoor activities when the weather is nicer as tick-borne illness is not something I think too much about except for bull’s eye rashes on test questions.
◾What information had you believed in previously that were debunked by reading this article?
I didn’t realize that necrotizing fasciitis can take days to fully manifest. I had thought that once it developed, it would lead to loss of limb or life within a day.
◾What new information did you learn from reading this article?
I was surprised to learn that the rash in RMSF may not develop until as late as 5 days after the onset of other symptoms, and that the mortality risk jumps 3 fold 5 days after symptom onset. Perhaps because of the name, I hadn’t known (or, more, likely had forgotten from med school) that patients presented with headache and (for children) abdominal pain.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
It sounds like there’s a lot to discover in terms of the pathogenesis of SJS and TEN. It seems counter-intuitive that it’s more common in the winter and early spring yet sunlight is one of the apparent triggers.