Pyoderma Gangrenosum After Insertion of a Hemodialysis Catheter: Koebner Phenomenon, Systemic Inflammatory Response Syndrome, and a Delay in Diagnosis.

Rationale: Pyoderma gangrenosum is a rare neutrophilic dermatosis. Misdiagnosis of pyoderma gangrenosum as an infection is not uncommon. Pyoderma gangrenosum can be associated with Koebner phenomenon and rarely results in systemic inflammatory response syndrome and shock. Presenting concerns of the patient: A 61-year-old woman had recently started maintenance hemodialysis, using a tunneled catheter. She was admitted with fever and signs of inflammation at the catheter exit site and along the tunnel. Diagnoses: The initial diagnosis was catheter-related tunnel infection. The exit site broke down into a 5 cm × 5 cm lesion typical of pyoderma, and a new similar lesion developed at a subcutaneous injection site in her abdomen. Clinical diagnosis of pyoderma gangrenosum was made. She remained febrile despite broad antibiotic coverage and catheter removal and developed systemic inflammatory response syndrome (SIRS) that necessitated transfer to intensive care unit. Interventions: She responded well to fluids and intravenous steroids. Viral and bacterial cultures were negative throughout; echocardiography and computed tomography were unrevealing. Insertion of a new hemodialysis catheter was deferred as long as clinically possible, was undertaken while the patient was taking steroids, and was uncomplicated. Outcomes: She remained hemodynamically stable and was discharged after rehabilitation. Her wounds slowly granulated and healed. Steroids were tapered. Teaching points: To our knowledge, this is the first case report of a patient with pyoderma gangrenosum developing at the site of tunneled hemodialysis catheter. Our patient developed SIRS with no evidence of infection. We summarize 11 previous case reports of pyoderma leading to SIRS and responsive to steroids.

Justification: Le pyoderma gangrenosum est une dermatose neutrophile rare que l'on méprend souvent d'abord pour une infection. Cette affection qui peut être associée au phénomène de Koebner entraîne rarement un syndrome de réponse inflammatoire systémique (SRIS) et un choc. Présentation du cas: Une femme de 61 ans qui avait récemment amorcé un traitement d'hémodialyse d'entretien par cathéter tunnelisé. À l'admission, la patiente présentait de la fièvre et des signes d'inflammation au point d'émergence du cathéter et le long du tunnel. Diagnostic: On a d'abord diagnostiqué une infection du tunnel liée au cathéter. Le point d'émergence s'est étendu en une lésion de 5 cm x 5 cm typique du pyoderma et une nouvelle lésion similaire s'est développée sur l'abdomen à un point d'injection sous-cutanée. Un diagnostic clinique de pyoderma gangrenosum a été établi. La fièvre a persisté malgré une antibiothérapie étendue et le retrait du cathéter; la patiente a développé un SRIS qui a nécessité son transfert à l'unité des soins intensifs. Intervention: La patiente a bien répondu à l'administration de liquides et de stéroïdes par voie intraveineuse. Les cultures virales et bactériennes sont demeurées négatives tout au long; l'échocardiographie et la tomodensitométrie étaient non révélatrices. L'insertion d'un nouveau cathéter d'hémodialyse a été reportée aussi longtemps que le permettait l'état clinique de la patiente. La réinsertion a été entreprise alors que la patiente était sous stéroïdes et elle n'a pas entraîné de complications. Résultats: La patiente est restée hémodynamiquement stable et a obtenu son congé après la réinsertion. Les plaies ont granulé et guéri lentement. Les stéroïdes ont été réduits progressivement. Enseignements tirés: À notre connaissance, il s'agit du premier cas rapporté d'une patiente atteinte de pyoderma gangrenosum développé au point d'émergence d'un cathéter d'hémodialyse tunnelisé. Notre patiente a développé un SRIS sans signe d'infection. Nous résumons 11 cas précédents de pyoderma ayant entraîné un SRIS et ayant répondu aux stéroïdes.

Willingness and Self-Perceived Competence of Final-Year Medical Students to Work as Part of the Healthcare Workforce During the COVID-19 Pandemic.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic may increase demand for healthcare professionals (HCPs), either because of a HCP shortage due to illness or because of the need to increase surge capacity. Final-year medical students are one of the resources potentially available to expand the workforce. There is a need to explore the willingness of final-year medical students to meet this demand, examine their perceived competence, and determine how their overall perceived competence correlates with their willingness. METHODS: A cross-sectional study using a self-administered electronic questionnaire was used. The questionnaire included demographic data, students' self-perceived competence derived from the patient care theme of the Saudi Medical Education Directives (SaudiMED) framework, and their willingness to be measured on a 5-point Likert scale. The study targeted final-year medical students at King Saud University, Riyadh, Saudi Arabia. RESULTS: The number of participants was 134 (56.1% response rate), of whom 47 students (34.3%) were willing to work, while 31 (23.1%) were somewhat willing. The mean total self-perceived-competence score was 58.36/88 (66.3%). Demonstration of essential clinical skills had the highest mean score 11.48/16 (71.8%) among learning outcomes. There was a positive moderate correlation between willingness and mean perceived-competence score (Spearman correlation coefficient=0.45, p<0.001). CONCLUSION: Fifty-seven percent of medical students were willing to work as part of the healthcare workforce during the COVID-19 pandemic. Better overall self-perceived competence appeared to correlate with more willingness. Students perceive themselves to be more competent in essential clinical skills. Appropriate training and supervision are suggested in all tasks assigned to them, with additional care required in areas with a lower perceived competence, such as prescription writing and essential clinical procedures.

Challenges to lifestyle modification of chronic disease patients attending primary health care centers in Riyadh.

BACKGROUND: The rate of chronic diseases is increasing due to the global pandemic of inactivity and an unhealthy diet. OBJECTIVE: We aimed to determine the dietary habits, physical activities of the participants, and challenges facing them to adapt to a healthy lifestyle. METHODOLOGY: The researchers conducted a cross-sectional study on chronic disease patients attending primary health care centers in Riyadh from January to March 2018. The estimated sample size was 250 patients. The participants completed a self-administered questionnaire. RESULT: The mean age of the 250 participants was 35.3 years old. The Overweight and obese participants accounted for 67.2% of the sample (mean BMI = 28.0). Two-thirds of the participants depend mainly on rice or pasta for their diet, and 48.4-52.0% eat fruits and vegetables less than three times a week. About 50% of the participants perceived a lack of information, skills, motivation, and family or friends support as a barrier to a healthy diet. Also, (56.4%) of males and (67.8%) of females are physically inactive. Accessibility, cost, and the hot climate were physical activity obstacles in more than 60% of the respondents. Optimal BMI showed a significant association with increased physical activity P = 0.04. CONCLUSION: Physical inactivity and consuming a non-balanced diet are common. So awareness campaigns of the benefit of a healthy lifestyle besides increasing physical exercise facilities, installing environmental changes, and subsidizing sports gyms would encourage people to be more physically active.