Remote cutaneous confocal microscopy: A multicentric prospective study evaluating diagnostic accuracy for melanoma and keratinocyte carcinoma in tertiary settings.

BACKGROUND: Cutaneous confocal microscopy (CCM) facilitates in vivo visualization of skin at a cellular level. Use of a "store and forward" approach for remote-CCM interpretation (remote-CCM) across multiple sites has not been tested and may increase access to noninvasive diagnosis. OBJECTIVES: To test the diagnostic accuracy and safety of remote-CCM. METHODS: We prospectively recruited lesions selected for biopsy for skin malignancy across 5 Australian tertiary dermatology centers. CCM, clinical and dermatoscopy images were acquired prebiopsy and accessed by a cloud-based platform for interpretation by CCM readers. CCM diagnosis was compared with histopathology results. RESULTS: Among the 201 lesions included, melanoma was the most common malignancy (34/72, 47.2%). Of the 89 lesions (44.8%) potentially "saved" from biopsy, 80 (90%) were truly benign lesions and 9 (10.1%) were missed malignant lesions of melanoma in situ (n = 7) and squamous cell carcinoma (SCC) (n = 2). No invasive melanomas were missed. Sensitivity of remote-CCM for detection of malignancy was 89% (95% CI, 79%-95%) and specificity was 64% (95% CI, 55%-73%). LIMITATIONS: The study recruited from high-risk populations and excluded lesions that were not biopsied. CONCLUSIONS: Remote-CCM has comparable accuracy to bedside CCM and safely reduces unnecessary biopsies. Potential SCCs are not appropriate for remote-CCM. Follow-up of borderline melanocytic lesions is recommended.

The Barriers and Perceived Benefits to Vulvar Self-examination in the Management of Vulvar Lichen Sclerosus.

OBJECTIVES: It is common practice to advise people with vulvar lichen sclerosus to perform vulvar self-examination (VSE) to optimize topical therapy and detect changes that may represent active disease, scarring, and/or squamous cell carcinoma development. The aim of this study was to better understand people's willingness and potential barriers to performing VSE. MATERIALS AND METHOD: A cross-sectional survey was undertaken of all patients with vulvar LS presenting to a tertiary referral vulvar dermatology clinic in Australia, from June 2022 to January 2023. Patients who did not speak and read English were excluded. Ethics approval was obtained. RESULTS: Seventy-eight (66%) of 118 eligible patients completed the survey. Fifty-three (68%) of patients had examined their vulva at least once. Forty-one (49%) had been recommended VSE by a medical practitioner. All those recommended VSE had performed VSE at least once. In contrast, only 10 (27%) of the 37 patients not recommended VSE by a health professional had ever performed VSE. Seventy-nine percent of all patients reported that they were very likely or likely to perform VSE if it was recommended.Patients with higher education level and tampon use were more likely to perform VSE. Self-reported back problems were associated with being less likely to perform VSE. CONCLUSIONS: More widespread VSE may result in earlier detection of the complications of vulvar lichen sclerosus. Most women would perform VSE if recommended by a health care provider; however, currently only half are receiving this advice. Further research should be performed to determine whether VSE affects clinical outcomes.

Subcutaneous granuloma annulare: a systematic review of a rare and underdiagnosed disease.

Subcutaneous granuloma annulare (SGA) is a rare clinicopathologic subtype of granuloma annulare characterized by the presence of subcutaneous nodules. There are no present reviews synthesizing the clinical features and treatment modalities in SGA. We conducted a systematic review following PRISMA guidelines [CRD42022344672] on all peer-reviewed English-language studies that reported one or more cases of SGA. A total of 97 studies, comprising 26 case series and 71 case reports with 324 patients, were included for analysis. Most cases were predominantly pediatric, with 78.9% of the cases identified being age 16 or lower and a median age of diagnosis of 6. There was no overall gender predisposition. Although over two-thirds of patients did not have any comorbidities, diabetes mellitus was the most common comorbidity present in 4% of cases. The most common feature of SGA was nodules, which were present in 99.6% of patients. Pain or tenderness was reported in 15.4%, and erythema of overlying skin in 11.0% of cases. Surgical excision was performed in 96/141 (68.1%) patients. Among the 27/141 (18.0%) patients who were conservatively managed, 87.0% spontaneously improved, including 60.0% who completely self-resolved. Topical and intralesional steroids were used in 3.40% and 1.85% of patients, respectively, resulting in complete or partial resolution in 54.6% and 100%. Among patients who were followed up, 83/324 (25.6%) patients experienced recurrence after a median duration of 26 weeks. SGA is predominantly a pediatric disease that frequently occurs on the limbs and the head. Juxta-articular lesions are more commonly observed in adults than in children. Surgical excision is common and effective in most patients. Spontaneous improvement occurs in most untreated cases, and intralesional steroids but not topical steroids may be beneficial for non-resolving cases and to reduce time to resolution.

Transient Acquired Amegakaryocytic Thrombocytopenia in the Setting of Severe Sepsis: A Case Report.

Acquired amegakaryocytic thrombocytopenia (AATP) is a rare disorder in which severely low platelet levels occur due to reduced or complete absence of megakaryocytes in the bone marrow. The pathophysiology of this disease is not fully understood, although anti-thyroid peroxidase antibodies (anti-TPO) binding to cellular-myeloproliferative leukemia (c-mpl) receptors is a proposed mechanism. Currently, no standard published guideline for treatment exists, but immunosuppressive therapies have been used based on the proposed mechanism and associated conditions. We present a case of a 57-year-old male who presented to the hospital with a 3-day history of progressive weakness and dysphagia. He had recently been discharged from an outside health system after evaluation for suspected gastrointestinal bleeding, although esophagogastroduodenoscopy and colonoscopy did not uncover a source of bleeding. Fifteen days later, he was admitted to our hospital for septic shock and acute renal failure with suspected lower gastrointestinal bleeding (melena on presentation). He was found to have a rapidly declining platelet count with a nadir of 0. Due to severe thrombocytopenia, filgrastim was administered. A bone marrow biopsy revealed findings consistent with amegakaryocytosis with otherwise preserved cell lines. Hematologic labs improved with the initiation of appropriate treatment for severe sepsis. After performing an extensive workup, the likely etiology of transient AATP in this case was severe sepsis-induced immune dysregulation and bone marrow suppression.

The role of comprehensive stress cardiac MRI in autoimmune rheumatic disease: A review.

Cardiovascular disease is the leading cause of morbidity and mortality in patients with autoimmune rheumatic diseases. Much of this may be attributed to systemic inflammation resulting in coronary atherosclerosis and myocarditis. Cardiac magnetic resonance imaging is the gold standard for the evaluation of cardiac structure and function, including tissue characterization, which allows for detection of myocardial edema, inflammation, and fibrosis. Advances in parametric mapping and coronary flow reserve measurement techniques have the potential to change the diagnosis, risk stratification, and management of patients with autoimmune rheumatic diseases. We provide an overview of the current evidence and suggest potential future roles for the use of comprehensive cardiac magnetic resonance in patients with autoimmune rheumatic diseases in the field of cardio-rheumatology.

Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents.

BACKGROUND: Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients. METHODS: First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs. RESULTS: One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P < .001). Both technique (r = 0.34, P = .003) and identifying findings (r = 0.42, P < .001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse. CONCLUSIONS: Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Topical Calcipotriol Plus 5-Fluorouracil in the Treatment of Actinic Keratosis, Bowen's Disease, and Squamous Cell Carcinoma: A Systematic Review.

BACKGROUND/OBJECTIVES: Actinic keratoses (AK) are premalignant skin lesions caused by chronic sun exposure, topically managed by 5-fluorouracil (5-FU), diclofenac 3% gel, and imiquimod. Despite their effectiveness, long treatment duration and severe adverse local skin reactions have limited patient concordance. Calcipotriol has recently been used as a combination agent for existing topical AK treatments. A systematic review was performed to determine the clinical efficacy of 5-FU and calcipotriol for the treatment of AK, Bowen's disease, and squamous cell carcinoma (SCC). METHODS: A systematic literature search was conducted on Medline, Embase, and Cochrane Library. Among the 84 records screened, 12 were retrieved for full-text review and 8 were included in the final analysis. RESULTS: Among the 8 studies, there were 214 control patients and 288 patients who received the intervention. The combination 5% 5-FU with calcipotriol resulted in a significant reduction in the number of AKs on the face, scalp, right upper extremity, and left upper extremity for all sites at 8 weeks (P < .0001). No significant difference in SCC incidence was observed at 1 or 2 years, but there was a significant reduction observed at 3 years for SCC on face and scalp. No study assessed the combination for Bowen's disease. CONCLUSIONS: Combination 5% 5-FU with calcipotriol is an effective treatment for Aks; however, future trials may consider longer treatment and follow-up periods for the treatment and prevention of AK, SCC in situ, and SCC.

Ultrasound Surveillance in Melanoma Management: Bridging Diagnostic Promise with Real-World Adherence: A Systematic Review and Meta-Analysis.

BACKGROUND: Ultrasound surveillance has become the new standard of care in stage III melanoma after the 2017 Multicenter Selective Lymphadenectomy Trial II (MSLT-II) demonstrated non-inferior 3-year survival compared with complete lymph node dissection. OBJECTIVE: We aimed to quantify diagnostic performance and adherence rates of ultrasound surveillance for melanoma locoregional metastasis, offering insights into real-world applicability. METHODS: Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the Medline, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science databases from inception until 11 October 2023. All primary studies that reported data on the diagnostic performance or adherence rates to ultrasound surveillance in melanoma were included. R statistical software was used for data synthesis and analysis. Sensitivity and specificity were aggregated across studies using the meta-analytic method for diagnostic tests outlined by Rutter and Gatsonis. Adherence rates were calculated as the ratio of patients fully compliant to planned follow-up to those who were not. RESULTS: A total of 36 studies including 18,273 patients were analysed, with a mean age of 56.6 years and a male-to-female ratio of 1:1.11. The median follow-up duration and frequency was 36 and 4 months, respectively. The pooled sensitivity of ultrasound examination was 0.879 (95% confidence interval [CI] 0.878-0.879) and specificity was 0.969 (95% CI 0.968-0.970), representing a diagnostic odds ratio of 224.5 (95% CI 223.1-225.9). Ultrasound examination demonstrated a substantial improvement in absolute sensitivity over clinical examination alone, with a number needed to screen (NNS) of 2.95. The overall adherence rate was 77.0% (95% CI 76.0-78.1%), with significantly lower rates in the United States [US] (p <  0.001) and retrospective studies (p <  0.001). CONCLUSION: Ultrasound is a powerful diagnostic tool for locoregional melanoma metastasis. However, the real applicability to surveillance programmes is limited by low adherence rates, especially in the US. Further studies should seek to address this adherence gap.

Unremitting Asthma as a Presentation of Pulmonary Nocardiosis: A Case Report.

Severe, refractory asthma requires a combination of multiple maintenance inhalers and medications including high-dose inhaled corticosteroids and immunomodulators to achieve control of symptoms. The use of inhaled corticosteroids, however, increases the susceptibility of opportunistic bacterial infections, such as Nocardia, resulting in pulmonary nocardiosis. This case describes a 46-year-old patient with a history of severe, refractory asthma who presented with progressively worsening asthma exacerbation symptoms. She was treated with immunomodulators, high-dose inhaled corticosteroids and oral steroids, and several courses of antibiotics. CT imaging revealed bibasilar peri-bronchial thickening and tree-in-bud nodularity in the right lower lobe. Pulmonary cultures collected from bronchoscopy grew Nocardia nova complex. This was a rare case of persistent asthma exacerbation by N. nova complex bronchopulmonary infection. Broad differentials should be considered in patients with severe, refractory asthma who were previously controlled and were found to fail treatment therapies. Immunocompromised patients with chronic lung disease are at higher risk of severe infection with disseminated nocardiosis. These patients have a higher mortality and morbidity risk if early diagnosis of pulmonary nocardiosis does not occur.

Seeing beyond skin deep: High-resolution ultrasound in dermatology-A comprehensive review and future prospects.

High-resolution ultrasound (HRUS), operating at frequencies of 20-25 MHz, is a non-invasive imaging tool that offers dermatologists the ability to visualize structures beneath the skin surface. The objective of this review is to present a comprehensive overview of HRUS applications, emphasising its utility in diagnosing, characterising and managing various dermatological conditions. We undertook a comprehensive literature review on the dermatological application of HRUS across Medline, Embase and Cochrane Library databases, while also incorporating our own clinical experience of over 16 years with the tool. In normal skin, the epidermis and dermis are hyperechoic, and the subcutaneous layer is hypoechoic. Basal cell carcinomas appear hypoechoic with irregular margins, while the presence of hyperechoic inclusion bodies suggests aggressive pathology. Squamous cell carcinomas pose challenges due to acoustic shadow artefacts from the thickened stratum corneum. Melanomas are homogenous hypoechoic lesions, with HRUS used to accurately predict Breslow thickness. HRUS provides dermatologists with a valuable adjunct to traditional clinical examination. Future advancement in image resolution and the standardisation of diagnostic parameters may further expand its utility.

Procalcitonin Use for Predicting Mortality and Morbidity of Patients Diagnosed With Sepsis Within the Intensive Care Unit.

Objective Infections leading to severe sepsis and septic shock are among the top five causes requiring admission to the intensive care unit (ICU). Up to 40% of ICU admissions contain a sepsis diagnosis. Without a clear marker to diagnose and manage sepsis, procalcitonin has been extensively studied for its usefulness in the management of bacterial infections. These studies, however, have been focused toward how it can be used to help guide when antibiotics should be initiated and de-escalated. There, however, has not been a study on how this biomarker could be used to predict mortality, and morbidity and help guide a need for antibiotic escalation. Design A retrospective chart review was conducted on patients admitted to the ICU at Northeast Georgia Medical Center between January 1, 2019, to June 30, 2021. Inclusion criteria were all patients above the age of 18 admitted to the ICU with a diagnosis of sepsis and having at least two procalcitonin drawn within 10 days of each other. Exclusion criteria were any patient with a diagnosis of COVID-19. Data Analysis was conducted to identify how delta procalcitonin could identify mortality and morbidity and if there was any change in antibiotics based on the delta procalcitonin.  Conclusion There was a statistically significant association between a delta positive procalcitonin and increased ICU length of stay. There was no statistical significance in expiration based on the antibiotic change in relationship to delta positive change in procalcitonin.

Temporal trends and outcomes of patients with chronic limb-threatening ischemia with and without history of coronary artery disease: insights from the us national inpatient sample database.

BACKGROUND: The burden and prognostic significance of coronary artery disease (CAD) in adults with peripheral artery disease and chronic limb-threatening ischemia (CLTI) is unknown. METHODS: Temporal trends in prevalence of significant CAD (history of myocardial infarction or coronary revascularizations) in hospitalizations for CLTI were determined using the 2000 to 2018 National Inpatient Sample (NIS) database. A multivariable regression analysis of outcomes was performed based on presence or absence of CAD. RESULTS: Among 13 575 099 hospitalizations for CLTI (41% female, 69% white, mean age 69 years), 23% had concomitant CAD, of which 11% underwent lower extremity arterial revascularization (43.6% endovascular and 56.4% surgical). The prevalence of concomitant CAD with CLTI increased from 15.3% in 2000 to 23.1% in 2018. Furthermore, the frequency of endovascular revascularization in adults with CAD and CLTI increased from 15.1% to 48.3%, while there was a decreasing trend of surgical revascularization, from 84.9% to 51.7%. After multivariate adjustments, CLTI with CAD was associated with increased risk of in-hospital mortality (OR, 1.40; 95% CI, 1.32-1.47; P less than .0001) and bleeding requiring transfusion (OR, 1.10; 95% CI, 1.06-1.12; P less than .0001) compared with patients with CLTI without CAD. As compared with surgical revascularization, endovascular revascularization was associated with lower risk of in-hospital mortality in both patients with CLTI with CAD (OR, 0.69; 95% CI, 0.63-0.76; P less than .001) and CLTI without CAD (OR, 0.71; 95% CI, 0.67-0.76; P less than .001). CONCLUSIONS: Prevalence of CAD has increased in adults presenting with CLTI and is associated with poor outcomes, warranting the need for effective interventions and secondary prevention in this high-risk population.

Medical Specialty Interest Survey (MSIS): understanding career interest and specialty training in commencing Australian medical interns.

AIM: To assess specialisation interests in commencing interns and create a standardised survey to aid medical schools, supervisors and health services in quantifying, understanding and supporting medical career development to improve medical workforce planning. METHOD: The Medical Specialty Interest Survey (MSIS) cross-sectional study was used. Incoming interns at a multisite tertiary hospital network in Melbourne, Australia rated their desire to pursue each specialty as a career using a Likert scale (1-5). 47 Medical Board of Australia Medical Specialties were included in the survey. RESULTS: Completion rate was 123 of 124 (99.2%). The overall mean desirability was 2.62, suggesting on average more specialties were deemed less preferred. Critical care specialties were most popular, while surgical specialties had least interest. Gastroenterology and cardiology were most popular among internal medicine specialties. General practice had low correlation with other specialties (Pearson correlation mean R coefficient 0.106 compared with overall mean 0.208), suggesting interns interested in general practice exhibit less interest in other specialties, and interest in specialisation confers low interest in general practice. Psychiatry had the lowest mean R coefficient of 0.088. CONCLUSIONS: The MSIS quantifies relative interest in 47 medical specialties and specialty interest correlations among final-year medical students/incoming interns. The MSIS may be a tool for medical schools, healthcare services and government agencies to better understand the career interest among medical students and pre-vocational doctors and therefore improve doctor retention and well-being.

Update on the management of first episode primary spontaneous pneumothorax in an Australian hospital network.

International guidelines and recent research favour a less interventional approach to primary spontaneous pneumothorax (PSP). A retrospective clinical audit of 68 first-episode PSP was undertaken at a major tertiary teaching hospital network in Melbourne, Australia, found that most patients presenting with a moderate to large pneumothorax received initial intercostal catheter insertion (56%), though many (81%) would have met criteria for consideration of conservative management. The results suggest continued deviation from clinical guidelines in the management of PSP.

Visitor restrictions in hospitals during infectious disease outbreaks: An ethical approach to policy development and requests for exemptions.

In this paper, we explore the ethics of restricting visitation to hospitals during an infectious disease outbreak. We aim to answer three questions: What are the features of an ethically justified hospital visitor restriction policy? Should policies include scope for case-by-case exemptions? How should decisions about exemptions be made? Based on a critical interpretive review of the existing ethical literature on visitor restrictions, we argue that an ethically justified hospital visitor restriction policy has the following features: proportionality, comprehensiveness, harm mitigation, exemptions for specific patient populations, visitation decisions made separately from a patient's treating clinicians, transparency, and consistency in application. We also argue that an ethical policy ought to include scope for case-by-case exemptions for individual patients. We propose a process for ethical decision-making that provides a shared language and structure to decrease the risks and burdens of decision-making when clinicians or managers are considering requests for exemptions.

Naproxen-Induced Evans Syndrome.

Evans syndrome is an autoimmune disorder characterized by the simultaneous occurrence of autoimmune hemolytic anemia and immune thrombocytopenic purpura. It can further be classified as primary Evans syndrome when it occurs by itself, or secondary Evans syndrome when it is associated with other autoimmune and lymphoproliferative disorders. Corticosteroids and immunoglobulins are the first-line treatments for primary Evans syndrome, and subsequent options include other immunosuppressive medications. Medical literature provides little information about the triggers of primary Evans syndrome. Knowing such information, however, is essential to recognize, treat and prevent the recurrence of the disease effectively.  We report a 68-year-old female who presented with shortness of breath, cough, bruises, scleral icterus, and dark urine after several days of naproxen therapy for pain. Further workup noted direct antiglobulin test positive for IgG, anemia, and thrombocytopenia. Imaging studies showed deep venous thrombosis. She was diagnosed with Evans syndrome and improved following prompt treatment with corticosteroids, anticoagulants, blood transfusion therapies, and discontinuation of naproxen. The prognosis of Evans syndrome is poor, variable, and characterized by relapses. Early diagnosis and treatment are therefore associated with better prognosis.  This case is critical because it shines a light on one of the major causes of Evans syndrome, reports a practical approach to treating the condition, and paves the way for future research on Evans syndrome. This case is also the first reported naproxen-induced Evans syndrome in the world's literature.