The Curious Case of a Painful Leg Ulcer.

Sickle cell disease is a condition that can involve numerous organ systems secondary to vascular occlusion. Herein, we present a case of a 21-year-old male with sickle cell disease requiring long-term hydroxyurea therapy. Upon migrating to the United States from Yemen, the patient developed a rapidly progressive, exquisitely painful ulcer on his right lower extremity. Given his country of origin, a broad differential, including select infectious diseases, was essential. Moreover, establishing the unequivocally correct diagnosis was crucial to determine proper and safe therapy. Ultimately, a lesional biopsy demonstrated numerous sickled red blood cells occluding blood vessels, leading to the diagnosis of sickle cell disease-related leg ulceration.

Prolonged Intractable Hiccups Associated with HSV (I&II) Esophagitis and H. pylori Gastritis.

An immunocompetent male presented with an intractable hiccup. EGD revealed circumferential ulceration of middistal esophagus and biopsies confirmed HSV (I&II) esophagitis and H. pylori gastritis. He was prescribed triple therapy for H. pylori and acyclovir for HSV esophagitis. HSV esophagitis and H. pylori should be included in differential for intractable hiccups.

Recruitment of diverse community health center patients in a pragmatic weight gain prevention trial.

Introduction: Pragmatic trials are needed to establish evidence-based obesity treatment in primary care settings, particularly in community health centers (CHCs) that serve populations at heightened risk of obesity. Recruiting a representative trial sample is a critical first step to informing care for diverse communities. We described recruitment strategies utilized in a pragmatic obesity trial and assessed the sociodemographic characteristics and odds of enrollment by recruitment strategy. Methods: We analyzed data from Balance, a pragmatic trial implemented within a network of CHCs. We recruited participants via health center-based and electronic health record (EHR)-informed mail recruitment. We analyzed associations between sociodemographic characteristics and the return rate of patient authorization forms (required for participation) from EHR-informed mail recruitment. We also compared sociodemographic characteristics and randomization odds by recruitment strategy after returning authorization forms. Results: Of the individuals recruited through EHR-informed mail recruitment, females were more likely than males to return authorization forms; however, there were no differences in rates of return by preferred language (English/Spanish) or age. Females; underrepresented racial and ethnic groups; Spanish speakers; younger adults; and those with lower education levels were recruited more successfully in the health center. In contrast, their counterparts were more responsive to mail recruitment. Once authorization forms were returned, the odds of being randomized did not significantly differ by recruitment method. Conclusion: Health center-based recruitment was essential to meeting recruitment targets in a pragmatic weight gain prevention trial, specifically for Hispanic and Spanish-speaking communities. Future pragmatic trials should consider leveraging in-person recruitment for underrepresented groups in research.

When Bullous Pemphigoid Is Not Bullous Pemphigoid: The Importance of Going Beyond Direct Immunofluorescence.

Bullous pemphigoid (BP) is the most common autoimmune bullous disease, but rarer forms of pemphigoid may appear identical to BP on routine histopathology and direct immunofluorescence (DIF). Here, we present the case of a 60-year-old man, who was initially thought to have BP, with supportive findings on routine histopathology and DIF. However, prominent oral involvement and cutaneous lesions refractory to conventional treatment suggested an alternate diagnosis. Further workup was performed, including indirect immunofluorescence (IIF) on salt-split skin, which showed binding of antibodies to the dermal floor rather than to the blister roof, and enzyme-linked immunosorbent assay for pemphigus and pemphigoid antibodies. With these additional tests, we concluded that the patient does not have BP but rather anti-p200 pemphigoid, anti-p105 pemphigoid, or a yet undiscovered form of pemphigoid. We reached a presumptive diagnosis of anti-p200 pemphigoid, as it is the most common pemphigoid with serum antibodies to the dermal floor of human salt-split skin by IIF. This case demonstrates that suspicion for other autoimmune bullous diseases in cases of treatment-refractory and clinically aberrant BP is essential. A limited workup may lead to a missed diagnosis and ultimately less efficient disease management.

Designing Ruby: Protocol for a 2-Arm, Brief, Digital Randomized Controlled Trial for Internalized Weight Bias.

BACKGROUND: Weight bias internalization, also known as weight self-stigma, is a serious health concern for individuals with higher body weight. Weight bias internalization is associated with the greater avoidance of health care and health-promoting activities, disordered eating, social isolation, and weight gain. Elevated weight bias internalization has been associated with low self-compassion, yet few investigations have explored self-compassion as a potential mechanism for reducing internalized weight bias. OBJECTIVE: Ruby is a 2-arm randomized controlled trial that was designed to test the efficacy of a 4-week digital self-compassion intervention to reduce internalized weight bias compared with a wait-list control. METHODS: Adults with elevated internalized weight bias and a BMI of >30 kg/m2 (N=80) were recruited. Ruby is a standalone digital trial that will be delivered entirely via a smartphone and will involve web-based data collection and text messages. The intervention content will include psychoeducation and daily mindfulness practices with a focus on self-compassion and body concerns. We will use intent-to-treat analyses to examine changes in weight bias internalization throughout time by treatment arm. The analyses will be conducted by using one-way analysis of covariance models and linear mixed models. RESULTS: The protocol was designed in May 2020 and approved in December 2020. Data collection is currently underway. CONCLUSIONS: Ruby will be the first digital standalone, self-compassion-based intervention designed to reduce internalized weight bias. Owing to its standalone digital delivery, Ruby may be a highly scalable treatment for internalized weight bias that can be delivered on its own or combined with other treatments. We expect Ruby to be accessible to many, as participants can access the digital intervention at times of the day that are the most convenient in their schedule and are not burdened by in-person time commitments, which can be a barrier for participants with competing demands on their time and resources. If efficacious, Ruby will be poised to expand a burgeoning body of literature related to psychological intervention in this area. TRIAL REGISTRATION: ClinicalTrials.gov NCT04678973; https://clinicaltrials.gov/ct2/show/NCT04678973. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31307.

Acyclovir-Resistant Cutaneous Herpes Simplex Virus in DOCK8 Deficiency.

Patients with dedicator of cytokinesis 8 (DOCK8) deficiency are susceptible to development of severe viral cutaneous infections, including herpes simplex virus (HSV). We report a 32-month-old girl with homozygous DOCK8 deficiency who developed a posterior auricular cutaneous lesion that was culture positive for HSV despite acyclovir prophylaxis. Resolution of this lesion was only observed after addition of foscarnet to the treatment regimen. Prophylactic acyclovir may be insufficient for suppression of cutaneous HSV in patients with DOCK8 deficiency, and a high index of suspicion for viral resistance is necessary for prompt initiation of appropriate antiviral treatment in these patients.

The Nourish Protocol: A digital health randomized controlled trial to promote the DASH eating pattern among adults with hypertension.

INTRODUCTION: Over 100 million adults in the United States have hypertension. The DASH (Dietary Approaches to Stop Hypertension) eating pattern is an evidence-based first-line treatment option for hypertension; however, adherence to the DASH eating pattern at a population level remains low. To address this gap, we will implement Nourish, a randomized controlled efficacy trial that will leverage a commercially-available smartphone application and evidence-based behavior change principles to improve adherence to the DASH eating pattern among adults with hypertension. METHODS: The Nourish trial is a two-arm, 12-month randomized control trial that will enroll adults (N = 300) with hypertension, defined as a systolic blood pressure of 120-159 mmHg; a diastolic blood pressure of 80-99 mmHg; and/or adults on blood pressure-lowering medication. Nourish will test the efficacy of a digital health intervention, as compared to the attention control arm, on DASH eating pattern adherence and blood pressure. Intervention components will include skills training, self-monitoring, personalized feedback, and responsive coaching. The primary outcome of the trial is 6-month changes in adherence to the DASH eating pattern, as measured by 24-h dietary recalls. DISCUSSION: Millions of Americans remain in need of effective behavioral interventions to manage and improve their hypertension and its adverse consequences. The ubiquity of smartphones offers a promising approach to disseminate the DASH eating pattern. By leveraging these widely used smartphone applications, combined with evidence-based behavior change principles and the DASH eating plan, Nourish will demonstrate the effectiveness of a digital health intervention to improve DASH adherence, and ultimately, to reduce blood pressure. Trial Number: NCT03875.

Prolonged, Controlled Daytime versus Delayed Eating Impacts Weight and Metabolism.

A delayed eating schedule is associated with increased risk of obesity and metabolic dysfunction in humans.1-9 However, there are no prolonged, highly controlled experimental studies testing the effects of meal timing on weight and metabolism in adults with a body mass index (BMI) of 19-27 kg/m2.10-18 Twelve healthy adults (age: 26.3 ± 3.4 years; BMI: 21.9 ± 1.7 kg/m2; 5 females) participated in a randomized crossover study in free-living conditions. Three meals and two snacks with comparable energy and macronutrient contents were provided during two, 8-week, counterbalanced conditions separated by a 2-week washout period: (1) daytime (intake limited to 0800 h-1900 h) and (2) delayed (intake limited to 1200 h-2300 h). Sleep-wake cycles and exercise levels were held constant. Weight, adiposity, energy expenditure, and circadian profiles of hormones and metabolites were assessed during four inpatient visits occurring before and after each condition. Body weight, insulin resistance (homeostatic model assessment of insulin resistance [HOMA-IR]), trunk-to-leg fat ratio, resting energy expenditure, respiratory quotient, and fasting glucose, insulin, total and high-density lipoprotein (dHDL) cholesterol, and adiponectin decreased on the daytime compared to the delayed schedule. These measures, as well as triglycerides, increased on the delayed compared to the daytime schedule (effect size range: d = 0.397-1.019). Circadian phase and amplitude of melatonin, cortisol, ghrelin, leptin, and glucose were not differentially altered by the eating schedules. Overall, an 8-week daytime eating schedule, compared to a delayed eating schedule, promotes weight loss and improvements in energy metabolism and insulin in adults with BMI 19-27 kg/m2, underscoring the efficacy and feasibility of daytime eating as a behavioral modification for real-world conditions.

A survey of dermatology residents and program directors assessing the transition to dermatology residency.

The transition from internship to residency is a critical period for trainees. This study investigated factors that influence the transition of residents from postgraduate year 1 (PGY-1) to dermatology residency. In June 2019, a program director-specific survey and a resident-oriented survey were administered via Survey Monkey. An email containing survey hyperlinks was sent via the Association of Professors of Dermatology Listserv to program directors, who were asked to forward the email to their current trainees. A total of 44 dermatology residents and 33 program directors responded. More than 58% of program directors identified a preliminary year in internal medicine as most beneficial. Both residents and program directors indicated rheumatology, infectious disease, and allergy and immunology as the most relevant PGY-1 electives. Eighty-two percent of program directors expected <1 h/week or no independent preparation for dermatology residency during PGY-1. The stress of incoming residents as perceived by program directors was significantly less than the self-reported stress of residents during their transition to dermatology residency (Mann-Whitney U, two-sided, P = 0.011).

Spiradenoma With Adenoid Cystic Carcinoma-Like Features.

Spiradenoma is a benign cutaneous adnexal neoplasm that characteristically presents as a painful dermal nodule, often on the head or trunk. It has a distinct histologic phenotype and management involves surgical excision with low risk of recurrence. In comparison, adenoid cystic carcinoma (ACC) is a low-grade malignancy manifesting as an often painless subcutaneous mass with potential for local invasion, perineural extension, and high rates of recurrence after excision. We report the case of a 63-year-old male patient with a recurrent, painful hematoma-like cyst overlying the left lower extremity tibial tuberosity. A firm nodule was located at the base of the cyst, which was histologically consistent with spiradenoma. Interestingly, the lesion contained multifocal ACC-like components composed of epithelial basaloid cells surrounding pseudocystic structures filled with mucinous material. The ACC-like components did not demonstrate infiltration or perineural invasion. To the best of our knowledge, this is the second publication in the English literature regarding spiradenoma with an ACC-like pattern. Although a benign entity, knowledge of this morphological variant of spiradenoma is essential for diagnostic accuracy in these cases. If a limited biopsy captures only the ACC-like component of a spiradenoma, the lesion may be incorrectly diagnosed as ACC.

Comparing Self-Monitoring Strategies for Weight Loss in a Smartphone App: Randomized Controlled Trial.

BACKGROUND: Self-monitoring of dietary intake is a valuable component of behavioral weight loss treatment; however, it declines quickly, thereby resulting in suboptimal treatment outcomes. OBJECTIVE: This study aimed to examine a novel behavioral weight loss intervention that aims to attenuate the decline in dietary self-monitoring engagement. METHODS: GoalTracker was an automated randomized controlled trial. Participants were adults with overweight or obesity (n=105; aged 21-65 years; body mass index, BMI, 25-45 kg/m2) and were randomized to a 12-week stand-alone weight loss intervention using the MyFitnessPal smartphone app for daily self-monitoring of either (1) both weight and diet, with weekly lessons, action plans, and feedback (Simultaneous); (2) weight through week 4, then added diet, with the same behavioral components (Sequential); or (3) only diet (App-Only). All groups received a goal to lose 5% of initial weight by 12 weeks, a tailored calorie goal, and automated in-app reminders. Participants were recruited via online and offline methods. Weight was collected in-person at baseline, 1 month, and 3 months using calibrated scales and via self-report at 6 months. We retrieved objective self-monitoring engagement data from MyFitnessPal using an application programming interface. Engagement was defined as the number of days per week in which tracking occurred, with diet entries counted if ≥800 kcal per day. Other assessment data were collected in-person via online self-report questionnaires. RESULTS: At baseline, participants (84/100 female) had a mean age (SD) of 42.7 (11.7) years and a BMI of 31.9 (SD 4.5) kg/m2. One-third (33/100) were from racial or ethnic minority groups. During the trial, 5 participants became ineligible. Of the remaining 100 participants, 84% (84/100) and 76% (76/100) completed the 1-month and 3-month visits, respectively. In intent-to-treat analyses, there was no difference in weight change at 3 months between the Sequential arm (mean -2.7 kg, 95% CI -3.9 to -1.5) and either the App-Only arm (-2.4 kg, -3.7 to -1.2; P=.78) or the Simultaneous arm (-2.8 kg, -4.0 to -1.5; P=.72). The median number of days of self-monitoring diet per week was 1.9 (interquartile range [IQR] 0.3-5.5) in Sequential (once began), 5.3 (IQR 1.8-6.7) in Simultaneous, and 2.9 (IQR 1.2-5.2) in App-Only. Weight was tracked 4.8 (IQR 1.9-6.3) days per week in Sequential and 5.1 (IQR 1.8-6.3) days per week in Simultaneous. Engagement in neither diet nor weight tracking differed between arms. CONCLUSIONS: Regardless of the order in which diet is tracked, using tailored goals and a commercial mobile app can produce clinically significant weight loss. Stand-alone digital health treatments may be a viable option for those looking for a lower intensity approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT03254953; https://clinicaltrials.gov/ct2/show/NCT03254953 (Archived by WebCite at http://www.webcitation.org/72PyQrFjn).

Weight-Related Terms Differentially Affect Self-Efficacy and Perception of Obesity.

OBJECTIVE: Little work has explored the effect of weight-related terms on treatment initiation; only one study has investigated weight-related terms and the psychological constructs associated with treatment uptake. The present study examines the effects of four common weight-related terms on treatment initiation and the moderating effect of weight bias internalization. METHODS: Adult participants with overweight and obesity (n = 436) were recruited online and asked to read three vignettes describing clinical encounters; the weight-related term (i.e., "weight," "BMI," "obesity," or "fat") was varied randomly. Participants then reported self-efficacy, cognitive and emotional illness beliefs about obesity (i.e., illness perception), and interest in a weight loss program. RESULTS: The term "obesity" resulted in the greatest self-efficacy and perceived control over obesity. "Fat" resulted in the least illness coherence (i.e., understanding of obesity). Weight bias internalization did not moderate the effect of term on self-efficacy, nor did it moderate illness perception. No differences in weight loss program enrollment were observed. CONCLUSIONS: Use of the term "obesity" may promote patients' perceived control and self-efficacy. Use of "fat" should be avoided. Results suggest that, despite patient and clinician preference for euphemistic weight terms, use of clinical language such as "obesity" may perform better in provider intervention.

Combined Treatment for Obesity and Depression: A Pilot Study.

OBJECTIVE: Obesity and depression frequently co-occur, and each increases risk for cardiovascular disease (CVD). This study tested whether a combined treatment, targeting obesity and depression simultaneously, would yield greater improvements in weight, mood, and CVD risk factors than treatments that targeted each disease individually. METHODS: Seventy-six participants with obesity and major depression were randomly assigned to (1) behavioral weight control (BWC), (2) cognitive behavioral therapy for depression (CBT-D), or (3) BWC combined with CBT-D. Participants were provided 18 group treatment sessions over 20 weeks. Mood, weight, and CVD risk were assessed at baseline and weeks 8 and 20, with a follow-up visit at week 46. RESULTS: At week 20, participants in combined treatment lost significantly (P < 0.02) more weight (5.2% ± 1.2%) than those assigned to CBT-D (0.8% ± 1.3%) and comparable amounts as those in BWC (3.5% ± 1.3%). Depression scores decreased significantly from baseline levels in each group, with no significant differences between groups. All three groups showed significant improvements in 10-year CVD risk, with no significant differences between groups. Groups did not differ significantly on any of these measures at week 46. CONCLUSIONS: BWC yielded short-term improvements in weight, mood, and CVD risk, comparable to a combined treatment that incorporated CBT-D. Results require replication with a larger sample size.

Group cognitive-behavioral treatment for internalized weight stigma: a pilot study.

OBJECTIVE: This study tested a novel group-based, cognitive-behavioral intervention designed to reduce internalized weight stigma among individuals with obesity. METHODS: A total of eight men and women with obesity who had experienced weight stigma and reported high levels of internalized weight stigma attended the Weight Bias Internalization and Stigma (BIAS) Program. The program provided eight weekly sessions of cognitive-behavioral treatment to cope with weight stigma. Participants completed questionnaires pre- and post-intervention, including the Weight Bias Internalization Scale (WBIS), Fat Phobia Scale, Weight Efficacy Life-Style Questionnaire (WEL), and Beck Depression Inventory-II (BDI-II). Six additional participants were included in a quasi-control group that received no intervention until after completing all study measures. RESULTS: Participants in the Weight BIAS Program reported significantly greater decreases in WBIS and Fat Phobia scores, and greater increases in WEL scores than participants in the quasi-control group (ps < .04). Changes in BDI-II scores did not differ between groups. Treatment-acceptability ratings were high among participants who received the intervention. CONCLUSION: Including cognitive-behavioral strategies to address weight stigma in weight management programs could potentially reduce internalized weight stigma and enhance treatment outcomes.