SISTER (system implementation of select transfers in emergency room) model to reduce ED boarding.

OBJECTIVE: This study describes a novel transfer model implemented between an academic, level 1 trauma center (Hospital A) and a nearby affiliate community hospital (Hospital B). Primary outcome is change in boarding hours and percentage of boarders in the Hospital A emergency department. Secondary objectives of this study include how improved flow in the emergency department to reduce boarding improves length of stay, prevents patients from escalating to more acute acuity levels of care, reduces patient morbidity and mortality and therefore improves health care costs as well. METHODS: A retrospective chart review was conducted over a consecutive 14-months period of all patients that presented to main hospital emergency department who were transferred to the Hospital B for inpatient admission. This included analysis of patient cohort characteristics, hospital LOS, return rate to the Hospital A (boomerang), rates of against medical advice (AMA) dispositions, post-discharge recidivism, in addition to enterprise data on total number of boarders, percent of boarders, and total boarding hours. RESULTS: There was a total of 718 transfer encounters during the study period. Percent boarding decreased from 70.6% in the pre-period to 63.8% in the post-period (p < 0.001). Total boarding hours decreased at both the main hospital and the sister hospital with this transfer process. The median length of stay at the sister hospital was 74 h, with 9 upgrades to ICU admissions. Five patients were dispositioned back to the hospital A after admission to hospital B. CONCLUSION: A distributive model was useful in transferring admissions within a healthcare system, reducing number of boarders, percent of boarders, and boarding hours in Hospital A emergency department. Furthermore, the Hospital B was an appropriate location for transfers, based on the low number of ICU transfers and dispositions back to the main hospital.

Telogen effluvium caused by COVID-19 in Elmhurst, New York: report of a cohort and review.

The prevalence of telogen effluvium (TE) has increased during COVID-19. In this study we describe the clinical characteristics of patients with COVID-19-related TE and review the current literature on COVID-19-associated TE. We conducted a retrospective chart review of 66 patients, all of which had COVID-19 infection (confirmed by PCR or antibodies) and had either non-scarring hair loss or TE in Elmhurst, Queens. Our data suggest that this form of TE is similar to other forms of TE, after which many patients experience regrowth within several months.

Resolution of pembrolizumab-associated lichenoid dermatitis with a single dose of methotrexate.

We present a 53-year-old woman with severe lichenoid dermatitis secondary to pembrolizumab therapy that was refractory to both topical and oral steroids. After almost three months without improvement, the rash was effectively combated with a single 15mg dose of methotrexate. We hope this case will help guide the management of the cutaneous adverse effects of anti-PD1 immunotherapy.

MalaCards: an amalgamated human disease compendium with diverse clinical and genetic annotation and structured search.

The MalaCards human disease database (http://www.malacards.org/) is an integrated compendium of annotated diseases mined from 68 data sources. MalaCards has a web card for each of ∼20 000 disease entries, in six global categories. It portrays a broad array of annotation topics in 15 sections, including Summaries, Symptoms, Anatomical Context, Drugs, Genetic Tests, Variations and Publications. The Aliases and Classifications section reflects an algorithm for disease name integration across often-conflicting sources, providing effective annotation consolidation. A central feature is a balanced Genes section, with scores reflecting the strength of disease-gene associations. This is accompanied by other gene-related disease information such as pathways, mouse phenotypes and GO-terms, stemming from MalaCards' affiliation with the GeneCards Suite of databases. MalaCards' capacity to inter-link information from complementary sources, along with its elaborate search function, relational database infrastructure and convenient data dumps, allows it to tackle its rich disease annotation landscape, and facilitates systems analyses and genome sequence interpretation. MalaCards adopts a 'flat' disease-card approach, but each card is mapped to popular hierarchical ontologies (e.g. International Classification of Diseases, Human Phenotype Ontology and Unified Medical Language System) and also contains information about multi-level relations among diseases, thereby providing an optimal tool for disease representation and scrutiny.

Treatment of Arsenic-Induced Bowen's Disease With Topical 5-Fluorouracil

Here, we present a case of arsenic-induced Bowen's disease treated with a regimen consisting of topical 5-fluouracil and oral nicotinamide. The use of this therapy modality resulted in near complete resolution of all of the patient's lesions except for those on her palms, soles, and scalp. Excellent wound care and treatment adherence were major factors contributing to the success of this treatment option. Our results ultimately provide an alternative approach to treating multiple arsenical keratoses in patients who are limited to a drug plan involving 5-FU and oral nicotinamide and who are able to be rigorously compliant with application of medication and wound care. J Drugs Dermatol. 2019;18(5):477-479.

Electrosurgical debulking of pretibial myxedema of the foot.

Pretibial myxedema or thyroid dermopathy constitutes dermal deposition of mucin, primarily hyaluronic acid and chondroitin sulfate. It is a manifestation of autoimmune thyroiditis, seen more in Graves disease than in Hashimoto thyroiditis. The time delay from treatment of hyperthyroidism to appearance of localized myxedema varies from one month to 16 years (mean 5.13 years). Despite a variety of therapeutic options, failure and relapse rates are high. Therapeutic options reported in the literature include compression, topical and intralesional corticosteroids, oral pentoxifylline, octreotide, rituximab, plasmapheresis, and high-dose intravenous immunoglobulin. We share our experience in two patients who were treated with electrosurgical debulking of selected longstanding myxedematous lesions, with one positive result and one negative result.

Isotretinoin and Surgical Extraction for Adult-Onset Nevus Comedonicus.

We present a case of postmenopausal-onset nevus comedonicus in a 58-year-old white woman with no relevant medical history. Two years before presentation, the patient had had a solitary red nodule, measuring 3.8 cm wide, on the mid lateral region of her left thigh. This progressed to a large area, 11.4 cm wide and 14 cm long, of multiple pruritic and painful red nodules, cysts, and deep open comedones extending across the lateral part of the left thigh, with less severe segmental extension to the lateral aspect of the left leg.

Apremilast for treatment of recurrent erythema multiforme.

Recurrent erythema multiforme with oralinvolvement is therapeutically challenging.Apremilast has been used with success in resolvingthe oral aphthae of Behçet disease, prompting theuse of the drug in patients with oral erosions fromerythema multiforme. Three patients with oralerythema multiforme were given apremilast at dosesof 30-60mg daily. Complete clearance of the lesionswere observed in all three patients, including thoserefractory to other standard therapies. Apremilast maypresent an effective option for recurrent erythemamultiforme for patients who have failed trials antiviraland immunosuppressive therapies.

Unique clinical presentations of pityriasis rosea: aphthous ulcers, vesicles and inverse distribution of lesions.

Pityriasis Rosea (PR) is a common skin disorderencountered in daily practice. Although its etiologyhas not been established, there has been widespreadresearch into possibilities. The lack of its characteristicmanifestations, specifically the herald patch andtruncal involvement, can lead to pitfalls in diagnosis.Whereas other conditions in the differential diagnosisshould be considered, PR can at times also manifest inan atypical manner. We wish to illustrate three casesof PR including those that presented with aphthousulcers, vesicles, and an inverse pattern.

Future therapies for pemphigus vulgaris: Rituximab and beyond.

The conventional treatment for patients with pemphigus vulgaris (PV) centers on global immunosuppression, such as the use of steroids and other immunosuppressive drugs, to decrease titers of antidesmoglein autoantibodies responsible for the acantholytic blisters. Global immunosuppressants, however, cause serious side effects. The emergence of anti-CD20 biologic medications, such as rituximab, as an adjunct to conventional therapy has shifted the focus to targeted destruction of autoimmune B cells. Next-generation biologic medications with improved modes of delivery, pharmacology, and side effect profiles are constantly being developed, adding to the diversity of options for PV treatment. We review promising monoclonal antibodies, including veltuzumab, obinutuzumab (GA-101), ofatumumab, ocaratuzumab (AME-133v), PRO131921, and belimumab.

Porokeratotic Adnexal Ostial Nevus-Report of a Case With Unusual Clinical and Histologic Features.

An 11-year-old Tanzanian girl presented with diffuse verrucous lesions of varying morphology, scarring alopecia, and keloid scars over the face with a predilection for the ears. Physical examination revealed dark keratoderma and patches of hypopigmentation near the midline of the dorsal trunk (Figure 1a). Her forearms were densely covered by verrucous lesions with the exception of a clear linear patch on the dorsal aspect of the left forearm (Figure 1b). The perioral area was notable for white spires projecting from verrucous papules (Figure 1c) while the oral mucosa and teeth appeared normal on visual examination. The rest of her body, including the palms and soles, was covered by patchy, scaly lesions of varying severity.

Skin simulators for dermatological procedures.

BACKGROUND: A variety of skin simulators are available on which to practice procedures; however, choice of a suboptimal substitute compromises realism and productive practice. OBJECTIVE: Skin simulators for basic dermatological procedures are reviewed. METHODS: The authors' anecdotal experience with various skin simulators for different procedures is shared. RESULTS: The following simulators are suggested:  an unripe banana for elliptical excision, pork belly for undermining, pork belly for simple interrupted and buried suture, capped needle on a human shoulder for intramuscular injection, ripe tomato or hotdog with skin for intradermal injection, eggplant for shave biopsy, pork belly for punch biopsy, plastic tape over a dark surface for cryosurgery, and beef liver for electrosurgery.  Flaps are best practiced with foam sandwiched between foam tape or artificial anatomical models created specifically for this purpose. LIMITATIONS: The utility of one simulator over another was not compared in a controlled study. CONCLUSION: Efficient, realistic skin simulators are readily available for practice, which should enhance the safety of the practitioner and improve outcomes of novices.

Understanding the logic of common suturing techniques in dermatologic surgery.

Although most trainees in dermatology learn that different suturing techniques are designated for a specific purpose (i.e., certain functional and cosmetic outcomes), students often have a difficult time visualizing how a given suture functions in its designated capacity. In this article, we address the logic behind the most common suturing techniques in dermatologic surgery, including the direction and magnitude of their pulling force with respect to the wound edges and the ensuing displacement of dermal and epidermal structures. To aid better understanding, we diagram the vectors of suture force with each of the techniques discussed.

The use of an imagery mnemonic to teach the porphyrin biochemical pathway.

We designed an imagery mnemonic to help medical students and residents learn the porphyrin pathway and associated diseases. Fourth year medical students at the Icahn School of Medicine at Mount Sinai in the spring of 2014 participated. One group (n=11) received the porphyrin pathway in a lecture explaining a mnemonic, whereas a second group (n=11) was simply taught the steps of the pathway. A pre-intervention assessment before the lectures was given to assess baseline differences in knowledge of the porphyrin pathway between the groups. Immediately following the lecture, 1 week after the lecture, and 3 weeks after the lecture, the students were given quizzes to assess their knowledge. Students were aware of the week 1 quiz and were asked not to study for it. The week 3 quiz was a surprise. There were no statistically significant differences in knowledge of the pathway at baseline (p=.45), at the immediate post-intervention (p=.22), or one week post-intervention (p=.40). Three weeks after the lecture, students in the mnemonic group scored 20% higher than controls (p=.02). Students who had learned the mnemonic demonstrated better long-term retention of information than students learning by the control method. This mnemonic minimizes study time while improving long-term retention.

A review of toxicity from topical salicylic acid preparations.

Topical salicylic acid is often used in dermatologic conditions because of its keratolytic, bacteriostatic, fungicidal, and photoprotective properties. The bioavailability of salicylic acid differs depending on the vehicle used and pH of transcellular fluids. Although rare, salicylic acid toxicity (salicylism) can occur from topical application. Physicians should be mindful of the potential for salicylism or even death from topically applied salicylic acid.

Long-term durability and dose escalation patterns in infliximab therapy for psoriasis.

BACKGROUND: Infliximab often requires dose escalation to maintain response. Studies regarding long-term durability and dose escalation patterns for psoriasis are few. OBJECTIVE: We sought to evaluate dose escalation patterns in psoriatic patients to identify factors of lack of optimal response to infliximab. METHODS: A retrospective cohort study included 93 patients (216.3 patient-years) treated with infliximab for psoriasis. Kaplan-Meier analysis assessed drug durability. RESULTS: A median infliximab dose of 5.42 mg/kg/mo (range: 2.71-10.83) for a mean of 28 months was administered. Two thirds of patients received a dose escalation. Concurrent methotrexate extended duration of therapy (by a mean ± SD of 19.5 ± 8.1 months, P = .034), including time until first dose escalation (by a mean ± SD of 12.0 ± 6.1 months, P = .037), and failure (by a mean ± SD of 20.7 ± 6.7 months, P = .034). Patients who increased the infusion frequency before increasing the dose remained on infliximab 8.4 months longer than those who first increased the dose (P = .045). Four patients experienced adverse events; 2 required discontinuation. LIMITATIONS: Psoriasis Area and Severity Index, infliximab levels, and antibody titers were not measured. CONCLUSIONS: Dose escalation optimizes durability of infliximab. The probability of maintaining response is enhanced by concomitant methotrexate and increasing the infusion frequency before increasing the dose.

Cantharidin: a comprehensive review of the clinical literature.

BACKGROUND: Cantharidin is a topical vesicant that causes intraepidermal acantholysis with clinical application that includes the removal of warts, molluscum contagiosum (MC), calluses, and acquired perforating dermatoses. OBJECTIVE: To provide a comprehensive literature review of the efficacy and safety of cantharidin in the management of various cutaneous conditions. METHODS: A PubMed search was conducted using the term "cantharidin" combined with "warts", "plantar warts", "verruca vulgaris", "periungal", "subungual", "topical treatment", "topical therapy for warts", molluscum contagiosum", "perforating collagenosis," and "acantholysis." RESULTS: A total of 749 articles were identified and 37 articles met inclusion criteria for this review. The majority of studies show that cantharidin is an effective and safe treatment for removal of warts and MC. Several studies also show potential novel applications of cantharidin in acquired perforating dermatosis, acute herpes zoster, and leishmaniasis. Adverse effects are generally mild but common and should be monitored, particularly in the pediatric population. LIMITATIONS: There is a paucity of high-powered clinical studies involving the use of cantharidin. CONCLUSION: Topical cantharidin is a safe and effective treatment for warts, molluscum contagiosum, and callus removal, with promising uses in perforating dermatoses and leishmaniasis.

Combination use of ustekinumab with other systemic therapies: a retrospective study in a tertiary referral center.

BACKGROUND: Patients with moderate to severe psoriasis may not respond adequately to single systemic agent and may require combination systemic therapy. OBJECTIVE: To evaluate the prevalence, indications, and response to combination systemic therapy with ustekinumab for psoriasis in a tertiary referral center. METHODS: This retrospective study comprised 102 psoriasis patients treated with ustekinumab at a single tertiary care center. Data was collected pertaining to history of psoriasis, past and current therapies including use of concomitant psoriasis agents, response to therapy, and side effects while on ustekinumab. RESULTS: Twenty-two of 102 (22%) patients were identified as receiving combination systemic treatment involving ustekinumab and at least one additional agent. The most common indication for combination therapy was psoriatic arthritis (35%), followed by bridging therapy (26%), inadequate psoriasis control (13%), prevention of non-melanoma skin cancers (17%), and control of palmoplantar disease (9%). Methotrexate was the additional agent in 12 patients, cyclosporine in 7 patients, acitretin in 5 patients, and 1 patient received a second biologic agent, first etanercept and then adalimumab. Overall, the reduction in body surface area (BSA) was 80% for patients on combination therapy. For those patients on combination therapy for psoriatic arthritis, 75% had resolution or stabilization of their symptoms. Only one patient, receiving cyclosporine, discontinued combination therapy due to adverse side effects. CONCLUSION: Combination systemic therapy with ustekinumab can be effective and well tolerated for patients who cannot be adequately treated with ustekinumab alone.

A case of lymphangioma circumscriptum successfully treated with electrodessication following failure of pulsed dye laser.

Lymphangioma circumscriptum is the most common cutaneous lymphatic malformation. It presents as a well-circumscribed, localized region of vesicles that can ooze and drain lymphatic and sanguineous fluid. The vesicles cause significant morbidity and psychological distress from itching, pain, drainage, and secondary infection. We report a case of a 16-year-old female with a life-long history of a weeping, hemorrhagic, and painful lesion on her right buttock causing significant emotional distress. We initially attempted therapeutic treatment with pulsed dye laser. The lesion appeared unchanged after two trials and we subsequently used three sessions of electrodessication to cauterize the aberrant vessels. The lesion largely resolved without complications and is no longer causing pain or emotional distress.