Leukocytoclastic vasculitis in association with linear epidermal basement membrane zone immunoglobulin deposition: Linear vasculitis

Cutaneous leukocytoclastic vasculitis (LCV) has a distinctive clinical and light microscopic presentation; however, the etiologic basis of LCV is varied. Most cases are attributable to immune complex deposition within a vessel wall and represent an Arthus type III immune complex reaction. The prototypic immunoreactant profile is characterized by granular deposits of components of complement activation in concert with immunoglobulin within the cutaneous vasculature. We encountered nine patients with vasculitic and/or vesiculobullous clinical presentations exhibiting an LCV in association with an immunoreactant profile characterized by homogeneous linear deposits of immunoglobulin along the dermal epidermal junction in a fashion resembling an autoimmune vesiculobullous disease.Among the clinical presentations were palpable purpura, urticarial vasculitis, and vesiculobullous eruptions with supervening purpura. Two patients with Crohn disease presented with classic palpable purpura with biopsy-proven LCV, and direct immunofluorescence (DIF) studies demonstrated linear immunoglobulin G (IgG) with floor localization on the salt-split skin assay. Four patients with systemic lupus erythematosus (SLE) showed purpuric vesiculobullous lesions, with evidence of a neutrophilic interface dermatitis and LCV in three of the four. The remaining patient had urticarial nonbullous lesions showing small-vessel vasculitiswith a neutrophilic interface dermatitis. In all of the patients with SLE, DIF studies showed linear immunoglobulin deposits within the basement membrane zone (BMZ). These constellation of findings clinically, light microscopically, and by immunofluorescence were those of a vasculitic presentation of bullous systemic lupus erythematosus. Two patients had linear IgA disease, which was drug induced in one and paraneoplastic in the other, and the dominant morphology on biopsy in both cases was an LCV. One patient microscopically demonstrated drug-associated and eosinophilic enriched LCV with DIF studies showing striking linear deposits of IgG suggestive of bullous pemphigoid, which was consistent with a vasculitic presentation of drug-induced bullous pemphigoid. In all cases, typical granular vascular immunoglobulin and complement deposition compatible with immune complex mediated vasculitis was observed. It is likely that local immune complexes derived from BMZ antigen bound to antibody are pathogenically relevant. We propose the designation of linear vasculitis for this unique scenario of LCV and linear immunoglobulin epidermal BMZ staining, which in some cases represents a vasculitic presentation of conventional autoimmune vesiculobullous disease.     

Localized lymphomatoid papulosis: Unilesional lymphomatoid papulosis,regional lymphomatoid papulosis,and persistent agmination of lymphomatoid papulosis

Lymphomatoid papulosis (LYP), the most common primary cutaneous CD30-positive lymphoproliferative disorder, is heralded by multiple papular and nodular lesions at anatomically discontiguous cutaneous sites. The histologic patterns are protean. An uncommon form of LYP is one that is anatomically confined. Cases of unilesional LYP, regional LYP, and persistent agmination of LYP were encountered in the routine and consultative practices of Weill Cornell Medicine, Division of Dermatopathology. The clinical presentation, outcomes, light microscopic findings, and phenotypic profile are reviewed. There were 10 cases of LYP presenting as solitary plaques or nodules primarily occurring in older patients and without a relevant medical history in most. Most cases occurred at an acral site with many localized to the foot; the morphology was one of a necrotizing angiocentric type E pattern and borderline type C morphology. Two of the unilesional patients in our series went on to develop mycosis fungoides, one at the initial site of unilesional type A LYP, and the other at a discontiguous site. Excluding one case, the solitary lesions underwent complete regression; after the lesions regressed, some cases had no apparent recurrence. The second anatomically confined variant of LYP in our series was regional LYP exhibiting a type E morphology in two cases and a hybrid type A and granulomatous eccrinotropic morphology in one case. There was no subsequent development of lymphoma, nor was there any spread to additional anatomic sites. The final category was persistent agmination of LYP, whereby the agminated papules of LYP were superimposed on a plaque of cutaneous T-cell lymphoma represented by mycosis fungoides in two and follicular helper T-cell lymphoma in one. In conclusion, anatomically confined LYP defines an uncommon form of LYP, but it is an important one to recognize because the histology can be worrisome despite an indolent clinical course. The clinical presentation, the infrequent association with lymphoma/leukemia, and histology are similar to conventional LYP, although there appears to be a greater tendency for complete regression without recurrence, excluding cases of persistent agmination of LYP whereby the clinical course warrants categorization as a form of cutaneous T cell lymphoma cutaneous T cell lymphoma (CTCL).     

An Imperative Need for Further Genetic Studies of Alopecia Areata

Human genetic studies of diseases that are multifactorial and prevalent have generated a wealth of knowledge about the genetic architecture of chronic diseases. Generalizable attributes are shaping the development of models to explain how the human genome influences our health and can be leveraged to improve it. Importantly, both rare and common genetic variants contribute to disease risk and provide complementary information. Although initial genetic studies of alopecia areata have yielded insight with high clinical impact, there remains a number of important unanswered questions pertaining to disease biology and patient care that could be addressed by further genetic investigations.     

Clinical outcomes of high-risk cutaneous squamous cell carcinomas treated with Mohs surgery alone: An analysis of local recurrence,regional nodal metastases,progression-free survival,and disease-specific death

BackgroundThe incidence of cutaneous squamous cell carcinoma (cSCC) continues to increase, and it is now predicted that the number of deaths from cSCC will surpass that of melanoma within the next 5 years. Although most cSCCs are successfully treated, there exists an important subset of high-risk tumors that have the highest propensity for local recurrence (LR), nodal metastasis (NM), and disease-specific death (DSD).ObjectiveWe investigated the clinical outcomes of high-risk cSCCs treated with Mohs surgery (MS) alone, analyzing LR, NM, distant metastasis, and DSD. In addition, we analyzed progression-free survival and DSD in patients who underwent salvage head/neck dissection for regional NMs.MethodsRetrospective review of all high-risk cSCC treated in our clinics between January 1, 2000, and January 1, 2020, with follow-up through April 1, 2020.SettingTwo university-affiliated, private-practice MS referral centers.ResultsIn total, 581 high-risk primary cSCCs were identified in 527 patients, of which follow-up data were obtained for 579 tumors. The 5-year disease-specific survival was 95.7%, with a mean survival time of 18.6 years. The 5-year LR-free survival was 96.9%, the regional NM-free survival was 93.8%, and the distant metastasis–free survival was 97.3%. The 5- and 10-year progression-free survival rates from metastatic disease were 92.6 and 90.0%, respectively. In patients who experienced regional NMs and underwent salvage head and neck dissection with or without radiation, the 2-year disease-specific survival was 90.5%.ConclusionOur cohort, which is the largest high-risk cSCC cohort treated with MS to date, experienced lower rates of LR, NM, and DSD than those reported with historical reference controls using both the Brigham and Women’s Hospital and American Joint Committee on Cancer, Eighth Edition, staging systems. We demonstrated that MS confers a disease-specific survival advantage over historical wide local excision for high-risk tumors. Moreover, by improving local tumor control, MS appears to reduce the frequency of regional metastatic disease and may confer a survival advantage even for patients who develop regional metastases.     

Diversity within US dermatology residency programs and opportunities to care for underserved populations: A 2020 survey study

Dermatology is the second-least diverse medical specialty. In this survey study, we identified the current proportion of underrepresented in medicine (UIM) residents and faculty in dermatology residency programs, perceptions on the importance of program diversity, and various opportunities for dermatology residents to care for underserved populations. We found that programs that provided greater resident exposure to the care of underserved populations and those that strongly considered residency applicants’ desire to work with underserved populations had greater percentages of UIM residents. These findings illustrate the importance of expanding diversity among residency programs as this may be key to improving health disparities among underserved populations. Additionally, we identified various barriers that programs have to incorporating service-oriented curricula, including faculty time and cost.     

Self-supporting wound care mobile applications for nurses: A scoping review protocol

AimMobile health (mHealth) is playing an increasingly important role in the computerization of wound care on an international scale with an aim to improve care. The aim of this scoping review protocol is to present a transparent process for how we plan to search and review the existing evidence related to self-supporting mobile wound care applications used by nurses.Materials and methodsThe scoping review will follow the Joanna Briggs Institute (JBI) methodology. An exploratory search was performed using MEDLINE (Ovid), Embase, CINAHL (Ebsco), to identify concepts, keywords, MeSH terms, and headings to identify study types looking for mobile applications in wound care. The findings of this search will determine the final search strategy. Data sources will include MEDLINE, Embase, CINAHL, Web of Science, LiSSa, Cochrane Wounds (Cochrane Library) and Erudit. The titles and abstracts of the identified articles will be screened independently by two authors for relevance. Full texts will also be screened by two independent reviewers and data extraction will be performed in accordance with a pre-designed extraction form. All types of studies and literature linked to self-supporting mobile wound care application used by nurses will be included (quantitative, qualitative, mixed methods and grey literature).ConclusionThe results of the scoping review will give an overview of the existing self-supporting mobile applications in wound care used by nurses. These will also help to identify the existing applications, and describe knowledge in nursing about their utilisation, development, and evaluation, as well as synthesize the available literature on their impacts.     

Implementing local cooling to increase skin tolerance to ischemia during normal seating in people with spinal cord injury

The purpose of this study was to investigate the effectiveness of local cooling in reducing reactive hyperemia after ischemia at the ischial tuberosities for people with spinal cord injury (SCI) during normal seating. The degree of the reactive hyperemic response is indicative of the extent of cellular stress caused by the ischemia. We hypothesized that reactive hyperemic skin blood flow (SBF) responses will be lower when local cooling is implemented by the wheelchair seat cushion. This study used a repeated measures design, and each subject underwent two conditions: normal seating with temperature control ‘on’ (cooling) and ‘off’ (non-cooling) for 30 min. Twenty-three participants with traumatic SCI were recruited. SBF and skin temperature were collected before, during and after seating. SBF signals were processed with short-time Fourier analyses to examine the underlying vascular control mechanisms, including the following (corresponding frequency bands): metabolic (0.0095–0.02 Hz), neurogenic (0.02–0.05 Hz), and myogenic (0.05–0.15 Hz) spectral densities. Our results showed that with cooling, skin temperature decreased (range −0.4 ~ −3.1 °C, p = 0.002), and reactive hyperemia parameters (normalized peak SBF and perfusion area) were reduced (p = 0.02, p = 0.033, respectively). In addition, changes in normalized peak SBF (non-cooling – cooling) was moderately correlated with changes in normalized metabolic and neurogenic spectral densities. Our findings suggested that local cooling has a positive effect on reducing the cellular stress caused by ischemia during normal seating. Metabolic and neurogenic SBF control mechanisms may play a minor role. Further exploration of the effect of temperature control on pressure injury prevention is warranted.     

Nutrition and connective tissue disease

Despite an incomplete overall understanding, nutrition plays an important role in connective tissue disease. Assessment of patients with connective tissue disease for nutritional status and metabolic disturbances may significantly contribute to patient outcomes. Several studies have indicated the multifactorial role of macronutrients, micronutrients, and supplements in the setting of connective tissue disease. There is additional evidence regarding the roles of weight, obesity, and malnutrition. This contribution reviews a growing body of data regarding nutrition in the development and treatment of various connective tissue diseases, including systemic lupus erythematosus, dermatomyositis, and systemic sclerosis.     

The development of a nomogram model for the individualized prediction of diaper dermatitis risk in pediatric hospitalized children aged 1–36 months

Aims and objectiveTo develop a nomogram model for individualized prediction of diaper dermatitis in pediatric hospitalized infants and toddlers aged 1–36 months.BackgroundDiaper dermatitis is a common skin health problem in pediatrics, which brings pain and discomfort to the child. However, there is a scarcity of risk prediction tools for diaper dermatitis in infants and toddlers hospitalized in pediatrics.DesignA cross-sectional study.Methods210 cases each for caregivers and hospitalized children aged 1–36 months were selected as the research objects. A prediction nomogram model was established based on the risk factors according to the results of univariate analysis and multivariate logistic regression analysis. The predictive performance of the nomogram model was evaluated by discrimination and calibration. The clinical utility of the model was evaluated by decision curve analysis. This study was reported using the TRIPOD checklist.Results41 hospitalized children with diaper dermatitis with a prevalence of 19.52%. The risk factors included: age in months, diarrhea, history of diaper dermatitis, without prophylactic application of buttock protection products, frequency of diaper change per day ≤6.6 times, and the level of caregivers’ knowledge of infantile diaper dermatitis. The results showed that the C-index of the nomogram model was 0.891(95% CI: 0.832, 0.950), the calibration curve manifested a satisfactory consistency, and the net benefit was satisfactory.ConclusionsThe nomogram has a good predictive ability and satisfactory clinical utility, which is useful for pediatric medical staff screening high-risk patients with diaper dermatitis.Relevance to clinical practiceThe prediction nomogram model can help pediatric medical staff to calculate the risk probability of diaper dermatitis in pediatrics, formulate interventions timely, and optimize pediatric DD standardized care protocols.No patient or public contributionthe children's caregivers enrolled in this study only for the data collection.     

Ultrasound assessment of deep tissue on the wound bed and periwound skin: A classification system using ultrasound images

AimsGiven the utility of ultrasonography in assessing pressure injury, some ultrasonographic findings have already been used as indicators of deep tissue pressure injury. Despite reports showing that a cloud-like ultrasonographic pattern reflected the presence of deep tissue necrosis, identifying cloud-like patterns was difficult given the presence of similar findings, such as a cobblestone-like pattern. This case series reports patients with pressure injuries who presented with a cloud-like (five cases) and cobblestone-like (four cases) pattern during ultrasonography.MethodsThis study was conducted at a Japanese university hospital. Participants included patients who underwent routine examination by an interdisciplinary pressure injury team. Pressure injury severity was assessed using the DESIGN-R® scoring system and the wound size were measured using ImageJ software based on the wound photograph.ResultsAmong the five cases showing a cloud-like pattern upon ultrasonography, all exhibited an increase in the total DESIGN-R® score, while three exhibited an increase in wound size. On the other hand, all four cases showing a cobblestone-like pattern displayed no increase in the total DESIGN-R® score and a decrease in wound size.ConclusionThis study suggested that distinguishing between cloud-like and cobblestone-like ultrasonography patterns is necessary for determining the presence or absence of deep tissue pressure injury. In order to comprehensively assess pressure injuries with ultrasonography, future studies should be conducted in a large number of participants.     

Factors associated with cesarean delivery in Bangladesh: A multilevel modeling

BackgroundIn recent decades, the number of C-section deliveries has increased over the world, including Bangladesh. The study aimed to identify individual- and community-level factors associated with C-section childbirth in Bangladesh and investigate the annual average increase rate of C-section childbirth. C-section.MethodsData were derived from four waves of the Bangladesh Demographic and Health Survey (BDHS) conducted between 2007 and 2017–18. Chi-square test of association was run to check the bivariate association between dependent and independent factors. For the individual- and community-level factors deliveries among Bangladeshi married women, a multilevel logistic regression model was carried out.ResultOver the last ten years, the average annual increase of C-section rates during delivery was 13.09% in Bangladesh, while this rate was 33.25%according to 2017–18 BDHS.C-section 33.25% of women have access to C-section birth. Women who had four or more than four ANC visits, women and their husbands with secondary and above education, middle and rich-wealth households, and community-level factors such as high media access, secondary and above educational experience women used C-sectionC-section delivery compared to their respective counterpart.ConclusionThe findings of the study revealed the association of some individual and community-level factors that need to be taken into account to minimize the rising rate of C-section deliveries in Bangladesh, which has increased drastically over the survey years.     

Cost-Effectiveness of PHMB & betaine wound bed preparation compared with standard care in venous leg ulcers: A cost-utility analysis in the United Kingdom

BackgroundWounds cost £8.3 billion per year in the United Kingdom (UK) annually. Venous leg ulcers (VLUs) account for 15% of wounds and can be complicated to heal, increasing nurse visits and resource costs. Recent wound bed preparation consensus recommends wound cleansing and biofilm disrupting agents. However, inert cleansers such as tap water or saline are inexpensive, an evaluation of evidence is required to justify the higher upfront costs of treatment with active cleansers. We undertook a cost-effectiveness analysis of the use of a biofilm disrupting and cleansing solution and gel, Prontosan® Solution and Gel X, (PSGX) (B Braun Medical), as compared to the standard practice of using saline solution, for treating VLUs.MethodsA Markov model was parameterised to one-year costs and health-related quality of life consequences of treating chronic VLUs with PSGX versus saline solution. Costs are viewed from a UK healthcare payer perspective, include routine care and management of complications. A systematic literature search was performed to inform the clinical parameters of the economic model. Deterministic univariate sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) were undertaken.ResultsFor PSGX an Incremental Net Monetary Benefit (INMB) of £1,129.65 to £1,042.39 per patient (with a Maximum Willingness to Pay of £30k and £20k per QALY respectively), of which cost savings are £867.87 and 0.0087 quality-adjusted life years (QALYs) gain per patient. PSA indicates a 99.3% probability of PSGX being cost-effective over saline.ConclusionsPSGX for the treatment of VLUs is dominant compared with saline solution in the UK with expected cost-savings within a year and improved patient outcomes.     

IL17A Blockade with Ixekizumab Suppresses MuvB Signaling in Clinical Psoriasis

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IL17A blockade with ixekizumab suppresses MuvB complex-mediated cell cycle progression in clinical psoriasis.

     

Comparative effectiveness of heel-specific medical devices for the prevention of heel pressure ulcers: A systematic review

BackgroundPressure ulcers (PUs) impact on patient's quality of life and are costly for healthcare providers. Heels are a particular concern due to specific risk factors. Relative effectiveness of medical devices, e.g., dressings, off-loading devices, heel cushioning devices, to reduce PU development is unknown.MethodsSystematic review of the effectiveness of heel-specific medical devices for the prevention of heel PU (HPU)s. Database searches were performed from inception to June 2021 for RCTs. The primary outcome was incidence of new HPUs. Trials were assessed for risk of bias and data analysed with risk ratios, mean difference or hazard ratios as appropriate.ResultsFifteen RCTs (4724 participants) were identified.Dressings, as constant low pressure (CLP) devices vs standard care: eight trials (very low quality) showed no-significant difference in effectiveness (RR 0.31, 95%CI 0.10 to 1.01).Off-loading devices vs standard care: three trials (low quality), showed significant reduction in development of Category≥1 HPUs (RR 0.20, 95%CI 0.05 to 0.80) two trials (medium quality), showed significant reduction in development of Category≥2 HPUs (RR 0.08, 95%CI 0.01 to 0.67).Comparisons between off-loading devices: two trials (low quality) showed no clear difference in HPU incidence.In a paediatric post-surgical population, one trial of off-loading device and one of a dressing (CLP device), both versus standard care, showed no clear difference in HPU incidence (RR 0.19 95%CI 0.02 to 1.55 and RR 0.89 95%CI 0.56 to 1.42 respectively).ConclusionsOff-loading devices may reduce HPU incidence, from low-quality evidence. There is insufficient evidence to suggest that dressings reduce HPU incidence.     

Development of a core outcome set for venous leg ulceration (CoreVen) research evaluations (protocol)

BackgroundA venous leg ulcer is a chronic leg wound caused by poor venous blood circulation in the lower limbs. It is a recurring condition causing pain, malodour, reduced mobility, and depression. Randomised controlled trials evaluating treatments for venous leg ulcers provide important evidence to inform clinical decision-making. However, for findings to be useful, outcomes need to be clinically meaningful, consistently reported across trials, and fully reported. Research has identified the large number of outcomes reported in venous leg ulcer trials, impacting both synthesis of results, and clinical decision-making. To address this, a core outcome set will be developed. A core outcome set is an agreed standardised set of outcomes which should be, as a minimum, measured and reported in all trials which evaluate treatment effectiveness for a given indication. A core outcome set has the potential to reduce research waste, improve the utility of RCTs, reduce reporting bias, facilitate treatment comparisons across different sources of evidence and expedite the production of systematic reviews, meta-analyses and evidence-based clinical guidelines.AimThe aim of this project is to develop a core outcome set for research evaluating the effectiveness of interventions for treating venous leg ulceration.MethodsThrough a scoping review of the literature on venous leg ulceration, we will firstly identify a list of candidate outcome domains (broad categories in relation to what is being measured) from randomised controlled trials and qualitative research, and outcomes (specific methods in relation to what is being measured). In two further stages, we will use the resulting lists of outcome domains and outcomes to design two online surveys. A range of stakeholders will be invited to participate in the surveys and they will be asked to indicate which outcome domains and outcomes are most important and should be considered as core in future research reports.     

Healthcare providers’ experiences of comprehensive emergency obstetric care in Somaliland: An explorative study with focus on cesarean deliveries

ObjectiveThis study aimed to explore the experiences of healthcare providers (HCPs) regarding the provision of emergency obstetric care (EmOC) with a focus on cesarean deliveries in a referral hospital and maternal and child health centers in Somaliland.MethodsAn exploratory qualitative approach using focus group discussions was employed at the main referral and teaching hospital and four maternal and child health centers in Hargeisa, Somaliland. Twenty-eight HCPs were divided into groups of 6–8 for discussions lasting 1 to 2 h. All HCPs included in the study had experiences with the provision of EmOC. Data were analyzed using thematic analysis.ResultsCollective family decision making was identified by HCPs as a barrier to the provision of EmOC. This tradition of decision making at a group level was perceived as time-consuming and delayed HCPs from obtaining informed consent for EmOC. Low socioeconomic status and poor knowledge about maternal healthcare among users affected care seeking among women. Suboptimal EmOC at the hospital was reported to be due to miscommunication, inadequate interprofessional collaboration and lack of infrastructure.ConclusionsHCPs encountered difficulties with the provision of EmOC. A broad array of strategies targeting the community and healthcare system is needed, including training of HCPs on intracultural communication competence, interprofessional collaboration and use of alternative birth methods other than CS. Antenatal care can be used to prepare families for potential obstetric emergencies and as an opportunity to obtain written informed consent.     

Minors are the most affected by Chlamydia trachomatis in Reunion Island: A cross-sectional study, 2017–2018

ObjectivesTo determine the prevalence of Chlamydia trachomatis (CT) in the population screened at sexually transmitted infection (STI) clinics on Reunion Island and to identify risk factors for CT infection.Patients and methodsThis cross-sectional multicenter study was conducted in 2017–2018. Data were obtained from self-administered questionnaires and multiplex PCR tests.ResultsThe overall prevalence of CT in the screened population was 8.6% (95% CI 7.7–9.5%). The prevalence of urogenital CT was highest in women under 18 (13.2%, 95% CI 9.3–18.1%) and in men who have sex with men under 18 (13.3%, 95% CI 1.6–48.2%). Risk factors associated with CT infection in multivariate analysis were: female gender, being born in Reunion Island, having had a large number of sexual partners in the past year, and being co-infected with another STI.ConclusionsThe prevalence of CT in the screened population is higher in Reunion Island than in mainland France, especially in minors. Prevention campaigns targeting minors should be strengthened.