Improving Consistency in the Use of Sucrose With Comfort Measures During Minor Painful Procedures.

BACKGROUND: Inconsistent pain management practices can have negative physiologic and neurodevelopmental consequences in the neonate. Low rates of oral sucrose use with comfort measures for pain management during minor painful procedures were identified at a level III neonatal intensive care unit. Underutilization of pain management resources occurs despite the availability of evidence-based pain management interventions. PURPOSE: To improve consistency in the use of oral sucrose solution with comfort measures during peripheral intravenous catheter insertion attempts in the neonatal intensive care unit in patients greater than or equal to 32 0/7th weeks postmenstrual age. METHODS: Quality improvement methods were used to implement an evidence-based procedural pain algorithm for minor painful procedures and optimize pain management processes over a 15-week period in a 26-bed, level III neonatal intensive care unit. RESULTS: There was an increase in the average percentage of documented use of sucrose with comfort measures during peripheral intravenous catheter insertion attempts from 20% to 27%. There was a 41% increase in the average presence of a sucrose order indicated for procedural pain. There were improvements in staff knowledge of sucrose dosing and perceived behavior of staff after completing the education. IMPLICATIONS FOR PRACTICE AND RESEARCH: Procedural pain management should be used as a quality indicator and guidelines should be established with the support of key stakeholders in neonatal intensive care settings. Future projects should address barriers related to workflow and accessibility of sucrose, include other common needlestick procedures, and expand the role of parent participation in pain management practices.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/pages/video.aspx?v=60 .

Dermatofibrosarcoma protuberans with platelet-derived growth factor-D rearrangement; two cases with morphologically distinct presentations.

Dermatofibrosarcoma protuberans (DFSP) is a mesenchymal neoplasm that is usually located in the dermis or subcutis and is locally aggressive. Rarely, these lesions may undergo fibrosarcomatous transformation, which is thought to increase their metastatic potential. DFSP is classically associated with a 17;22 translocation (or ring chromosome thereof) resulting in fusion of the COL1A1 and PDGFB genes. However, variant fusions involving PDGFD have been recently reported. Herein, we present two morphologically diverse cases of DFSP with PDGFD rearrangement. Case 1 is a 68-year-old female with a left dorsal foot lesion. Morphologically, the lesion is unusual as it is a well-circumscribed, hypercellular, subcutaneous nodule with uniform CD34-positive spindle cells arranged in a herringbone pattern without storiform arrangement or "honeycombing" fat entrapment. It was diagnosed as pure fibrosarcomatous DFSP. Case 2 is a 37-year-old male with a right supra-auricular lesion. Morphologically, the lesion displays classic DFSP features including bland CD34-positive spindle cells with storiform growth, fat entrapment, and infiltrative borders. Both lesions were negative for COL1A1-PDGFB fusion but positive for PDGFD rearrangement by fluorescence in situ hybridization (FISH) analysis. FISH testing for PDGFD rearrangement should be performed in cases where there is a high suspicion for DFSP but initial studies for COL1A1-PDGFB are negative.

Eruption of squamous cell carcinomas after beginning nilotinib therapy.

Chronic myelogenous leukemia (CML) is characterized by a reciprocal translocation between the long arms of chromosomes 9 and 22 leading to the formation of a constitutively active tyrosine kinase. Tyrosine kinase inhibitors (TKIs) are the treatment of choice for patients diagnosed with CML and have many associated side effects including the rarely-reported eruption of squamous cell carcinomas (SCCs). Herein, we report a patient with CML who presented with sudden onset of multiple scaly lesions on his legs and trunk after beginning treatment with nilotinib, a novel TKI. Six biopsies were performed at his initial presentation and four of these lesions were confirmed to be keratoacanthoma-type SCCs. One month later, the patient reported the development of multiple new similar lesions on his legs, arms, and face. Four more biopsies were performed revealing keratoacanthoma-type and well-differentiated SCCs. Certain tyrosine kinase inhibitors such as sorafenib and quizartinib have been reported to cause eruptive keratoacanthoma (KA)-type SCCs as seen in our patient. However, there is only one other report in the literature of nilotinib promoting the development of SCCs or KAs. Physicians should be aware of this potential adverse effect and patients taking nilotinib should be closely monitored by a dermatologist.

Trypophobia, skin, and media.

Trypophobia is the fear of patterns of clustered holes, bumps, or nodules. Trypophobia has a special relationship with dermatology because of its effects on individuals with skin disease, its relationship with disease avoiding behavior, and its utilization in many online skin disease hoaxes. Trypophobic patterns on skin and characters can be found in movies, TV shows, and videogames. Several popular horror villains take advantage of trypophobic patterns like Freddy Kreuger, Jason Vorhees, and Pinhead. Most recently, another blockbuster villain has joined their ranks - Killmonger. Public health messaging about these biases and the often noncontagious nature of skin disease is warranted to attenuate public stigma of skin disease perpetuated by media.

Nephrogenic systemic fibrosis: A 15-year retrospective study at a single tertiary care center.

BACKGROUND: Despite multiple therapeutic approaches for nephrogenic systemic fibrosis (NSF), no single treatment has convincingly shown consistent benefit. The most successful outcomes have been associated with recovery of renal function, although evidence remains limited and past studies have been inconclusive. OBJECTIVE: We sought to investigate whether improvement of renal function via successful transplantation or via return of renal function after acute kidney injury correlates with improvement of NSF, and to further characterize the clinical features and progression of NSF. METHODS: A retrospective medical chart review led to the identification of patients (n = 8) diagnosed with NSF who presented to a single academic tertiary referral center over a 15-year period. These 8 patients were contacted by phone to obtain information related to treatment and clinical course of their NSF and renal function. Statistical analysis was performed using Fisher's exact test. RESULTS: There is a significant correlation (P = .0286) of improved renal function with improvement of NSF. All 4 patients who had improvement of renal function also had improvement of NSF. Two of these patients had end-stage renal disease and a successful kidney transplant, and two had acute kidney injury that resolved. No improvement in NSF was observed without kidney function resolution. LIMITATIONS: Our study is limited by a small sample size (n = 8) and a retrospective study design, which increased its potential for selection and recall bias. CONCLUSION: Improvement of renal function through either transplantation or resolution of acute kidney injury with medical management is significantly associated with improvement of NSF.

Synergistic cytotoxicity and DNA strand breaks in cells and plasmid DNA exposed to uranyl acetate and ultraviolet radiation.

Depleted uranium (DU) has a chemical toxicity that is independent of its radioactivity. The purpose of this study was to explore the photoactivation of uranyl ion by ultraviolet (UV) radiation as a chemical mechanism of uranium genotoxicity. The ability of UVB (302 nm) and UVA (368 nm) radiation to photoactivate uranyl ion to produce single strand breaks was measured in pBR322 plasmid DNA, and the presence of adducts and apurinic/apyrimidinic sites that could be converted to single strand breaks by heat and piperidine was analyzed. Results showed that DNA lesions in plasmid DNA exposed to UVB- or UVA-activated DU were only slightly heat reactive, but were piperidine sensitive. The cytotoxicity of UVB-activated uranyl ion was measured in repair-proficient and repair-deficient Chinese hamster ovary cells and human keratinocyte HaCaT cells. The cytotoxicity of co-exposures of uranyl ion and UVB radiation was dependent on the order of exposure and was greater than co-exposures of arsenite and UVB radiation. Uranyl ion and UVB radiation were synergistically cytotoxic in cells, and cells exposed to photoactivated DU required different DNA repair pathways than cells exposed to non-photoactivated DU. This study contributes to our understanding of the DNA lesions formed by DU, as well as their repair. Results suggest that excitation of uranyl ion by UV radiation can provide a pathway for uranyl ion to be chemically genotoxic in populations with dermal exposures to uranium and UV radiation, which would make skin an overlooked target organ for uranium exposures.

Analysis of heat-labile sites generated by reactions of depleted uranium and ascorbate in plasmid DNA.

The goal of this study was to characterize how depleted uranium (DU) causes DNA damage. Procedures were developed to assess the ability of organic and inorganic DNA adducts to convert to single-strand breaks (SSB) in pBR322 plasmid DNA in the presence of heat or piperidine. DNA adducts formed by methyl methanesulfonate, cisplatin, and chromic chloride were compared with those formed by reaction of uranyl acetate and ascorbate. Uranyl ion in the presence of ascorbate produced U-DNA adducts that converted to SSB on heating. Piperidine, which acted on DNA methylated by methyl methanesulfonate to convert methyl-DNA adducts to SSB, served in the opposite fashion as U-DNA adducts by decreasing the level of SSB. The observation that piperidine also decreased the gel shift for metal-DNA adducts formed by monofunctional cisplatin and chromic chloride was interpreted to suggest that piperidine served to remove U-DNA adducts. Radical scavengers did not affect the formation of uranium-induced SSB, suggesting that SSB arose from the presence of U-DNA adducts and not from the presence of free radicals. A model is proposed to predict how U-DNA adducts may serve as initial lesions that convert to SSB or AP sites. The results suggest that DU can act as a chemical genotoxin that does not require radiation for its mode of action. Characterizing the DNA lesions formed by DU is necessary to assess the relative importance of different DNA lesions in the formation of DU-induced mutations. Understanding the mechanisms of formation of DU-induced mutations may contribute to identification of biomarkers of DU exposure in humans.

New antibiotic therapies for acne and rosacea.

Acne and rosacea compromise a substantial portion of the dermatology clinical practice. Over the past century, many treatment modalities have been introduced with antibiotics playing a major role. Today, both oral and topical antibiotics are used in the management of acne and rosacea, with several novel formulations and/or combination regimens recently introduced. The latest studies suggest anti-inflammatory actions to be the most likely mechanism of antibiotics in acne and rosacea, shifting the focus to subantimicrobial-dose oral antibiotics and/or topical antibiotic regimens as the preferred first-line agents. Here we will discuss the most recent oral and topical antibiotic therapies available for treatment of acne and rosacea, with special focus on efficacy data, indication, dosing, and mechanism of action.

Persistent erythematous plaque after minor trauma in an immunocompromised woman.

Scedosporium apiospermum is a ubiquitous soil fungus with a worldwide distribution. It can cause a wide range of clinical disease, from cutaneous and subcutaneous infections, to pneumonia, brain abscess, and life threatening systemic illness. The diagnosis of cutaneous disease is with biopsy and culture. We discuss the case of an elderly immunocompromised woman who presented with a persistent erythematous plaque on the elbow after minor trauma. A biopsy revealed Scedosporium apiospermum. Treatment usually requires surgical resection in conjunction with antifungal therapy.

The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of platelet-rich plasma gel.

OBJECTIVE: This study investigated clinical outcomes in chronic nonhealing wounds following the short-term use of an enhanced, near-physiological concentration of platelet-rich plasma (PRP) gel (AutoloGel System, Cytomedix, Inc, Gaithersburg, Maryland). DESIGN: Study design was a large, observational case series using a multicenter registry database (all wounds included), which compared different populations within the database. SETTING: Thirty-nine centers contributed to the registry, including long-term acute-care centers, outpatient clinics, a durable medical equipment company, a home health agency, and a long-term-care center. PATIENTS: The target population included 285 chronic wounds (patient n = 200). Wound etiologies included diabetic, pressure, or venous ulcer; dehisced, surgical, or traumatic wound; and wounds of other etiologies. INTERVENTION: Therapeutic, PRP gel is produced from patient blood utilizing autologous platelets and plasma that contribute growth factors, cytokines, and chemokines, in a fibrin matrix. MAIN MEASURES: Area and volume of the wound and the linear total of undermining and sinus tracts/tunneling were calculated. Clinical relevance was determined by analyzing outcomes in wounds that responded to treatment. MAIN RESULTS: A positive response occurred in 96.5% of wounds within 2.2 weeks with 2.8 treatments. In 86.3% of wounds, 47.5% area reduction occurred, and 90.5% of wounds had a 63.6% volume reduction. In 89.4% undermined and 85.7% of sinus tracts/tunneling wounds, 71.9% and 49.3% reductions in linear total were observed, respectively. CONCLUSION: In chronic wounds recalcitrant to other treatments, utilization of PRP gel can restart the healing process. Rapid treatment response was observed in 275 of 285 wounds, and the magnitude of response was consistently high, with statistically significant outcomes reported for various subgroups.

Analysis of run-in and treatment data in a wound outcomes registry: clinical impact of topical platelet-rich plasma gel on healing trajectory.

Randomised controlled trials in chronic wounds typically exclude patients with comorbidities and confounding factors. Well-designed observational studies can provide complementary clinical evidence that randomised trials cannot address. This study determined if wound care registry outcomes could be an alternative data source and if the results would be robust and valid. Changes in wound area and depth were hypothesised to be different between run-in therapies and platelet-rich plasma (AutoloGel™, Cytomedix, Inc) treatment. From a treatment registry of 285 chronic wounds, 46 had run-in and post-treatment data. Seven chronic wound categories were identified. Mean wound age at study start was 52·4 days. General linear model repeated measures showed a credible and robust data set. Statistically significant differences for wound area and depth were observed between run-in and post-treatment period at multiple time points. Wound area and depth ≥50% reduction were analysed using Kaplan-Meier methods. During run-in, 15% of wound area improved compared to 28% post-treatment and 11% of wound depth improved during run-in compared to 39% post-treatment. Significant clinical outcomes indicated many previously non responsive wounds began actively healing in response to platelet-rich plasma therapy, indicating that registry data can be used as a complementary source of evidence.

Validation of a Novel Cutaneous Neoplasm Diagnostic Self-Efficacy Instrument (CNDSEI) for Evaluating User-Perceived Confidence With Dermoscopy.

BACKGROUND: Accurate medical image interpretation is an essential proficiency for multiple medical specialties, including dermatologists and primary care providers. A dermatoscope, a ×10-×20 magnifying lens paired with a light source, enables enhanced visualization of skin cancer structures beyond standard visual inspection. Skilled interpretation of dermoscopic images improves diagnostic accuracy for skin cancer. OBJECTIVE: Design and validation of Cutaneous Neoplasm Diagnostic Self-Efficacy Instrument (CNDSEI)-a new tool to assess dermatology residents' confidence in dermoscopic diagnosis of skin tumors. METHODS: In the 2018-2019 academic year, the authors administered the CNDSEI and the Long Dermoscopy Assessment (LDA), to measure dermoscopic image interpretation accuracy, to residents in 9 dermatology residency programs prior to dermoscopy educational intervention exposure. The authors conducted CNDSEI item analysis with inspection of response distribution histograms, assessed internal reliability using Cronbach's coefficient alpha (α) and construct validity by comparing baseline CNDSEI and LDA results for corresponding lesions with one-way analysis of variance (ANOVA). RESULTS: At baseline, residents respectively demonstrated significantly higher and lower CNDSEI scores for correctly and incorrectly diagnosed lesions on the LDA (P = 0.001). The internal consistency reliability of CNDSEI responses for the majority (13/15) of the lesion types was excellent (α ≥ 0.9) or good (0.8≥ α <0.9). CONCLUSIONS: The CNDSEI pilot established that the tool reliably measures user dermoscopic image interpretation confidence and that self-efficacy correlates with diagnostic accuracy. Precise alignment of medical image diagnostic performance and the self-efficacy instrument content offers opportunity for construct validation of novel medical image interpretation self-efficacy instruments.

Testing Pediatric Acuity With an iPad: Validation of "Peekaboo Vision" in Malawi and the UK.

PURPOSE: To evaluate two builds of the digital grating acuity test, "Peekaboo Vision" (PV), in young (6-60 months) populations in two hospital settings (Malawi and United Kingdom). METHODS: Study 1 evaluated PV in Blantyre, Malawi (N = 58, mean age 33 months); study 2 evaluated an updated build in Glasgow, United Kingdom (N = 60, mean age 44 months). Acuities were tested-retested with PV and Keeler Acuity Cards for Infants (KACI). Bland-Altman techniques were used to compare results and repeatability. Child engagement was compared between groups. Study 2 included test-time comparison. RESULTS: Study 1 (Malawi): The mean difference between PV and KACI was 0.02 logMAR with 95% limits of agreement (LoA) of 0.33 to 0.37 LogMAR. On test-retest, PV demonstrated 95% LoA of -0.283 to 0.198 logMAR with coefficient of repeatability (CR) 0.27. KACI demonstrated 95% LoA of -0.427 to 0.323 logMAR, and larger CR was 0.37. PV evidenced higher engagement scores than KACI (P = 0.0005). Study 2 (UK): The mean difference between PV and KACI was 0.01 logMAR; 95% LoA was -0.413 to 0.437 logMAR. Again, on test-retest, PV had narrower LoA (-0.344 to 0.320 logMAR) and lower CR (0.32) versus KACI, with LoA -0.432 to 0.407 logMAR, CR 0.42. The two tests did not differ in engagement score (P = 0.5). Test time was ∼1 minute shorter for PV (185 vs. 251 s, P = 0.0021). CONCLUSIONS: PV gives comparable results to KACI in two pediatric populations in two settings, with benefits in repeatability indices and test duration. TRANSLATIONAL RELEVANCE: Leveraging tablet technology extends reliable infant acuity testing to bedside, home, and rural settings, including areas where traditional equipment cannot be financed.

Antineutrophil cytoplasmic antibodies negative levamisole-induced leukocytoclastic vasculitis: a presumed case and literature review.

Levamisole-contaminated cocaine toxicity is a serious emerging public health concern, and providers should be aware of its presentation and management. Most cases of levamisole-induced vasculitis/vasculopathy (LIV) are associated with high antineutrophil cytoplasmic antibodies (ANCA). We describe a unique case of a cocaine user who presented with an acute purpuric eruption and negative ANCA laboratory findings. A brief clinical overview of LIV, spanning from patient presentation to treatment, is provided. In addition, we present a summary of all cases of ANCA-negative vasculitis identified via a PubMed literature review.