Nephrogenic Calciphylaxis Arising after Bariatric Surgery: A Case Series.

Nephrogenic calciphylaxis is associated with multiple risk factors including long-term dialysis dependence, hyperphosphatemia, hypercalcemia, parathyroid hormone derangements, vitamin K deficiency, obesity, diabetes mellitus, warfarin use, and female sex. Bariatric surgery is known to cause altered absorption, leading to mineral and hormonal abnormalities in addition to nutritional deficiency. Prior case reports on calciphylaxis development following bariatric surgery have been published, though are limited in number. We report a case series of five bariatric patients from a single institution who developed nephrogenic calciphylaxis between 2012 and 2018. These patients had a history of bariatric surgery, and at the time of calciphylaxis diagnosis, demonstrated laboratory abnormalities associated with surgery including hypercalcemia (n = 3), hyperparathyroidism (n = 2), hypoalbuminemia (n = 5), and vitamin D deficiency (n = 5), in addition to other medication exposures such as vitamin D supplementation (n = 2), calcium supplementation (n = 4), warfarin (n = 2), and intravenous iron (n = 1). Despite the multifactorial etiology of calciphylaxis and the many risk factors present in the subjects of this case series, we submit that bariatric surgery represents an additional potential risk factor for calciphylaxis directly stemming from the adverse impact of malabsorption and overuse of therapeutic supplementation. We draw attention to this phenomenon to encourage early consideration of calciphylaxis in the differential for painful skin lesions arising after bariatric surgery as swift intervention is essential for these high-risk patients.

Assessment of diagnostic delay, morbidity, and mortality outcomes in 302 calciphylaxis patients over a 17-year period: A retrospective cohort study.

BACKGROUND: Calciphylaxis patients historically have experienced diagnostic challenges and high morbidity, however limited data is available examining these characteristics over time. OBJECTIVE: The primary goals were to a) investigate factors associated with diagnostic delay of calciphylaxis and b) assess morbidity outcomes. The secondary goal was to provide updated mortality rates. METHODS: A retrospective review of 302 adult patients diagnosed with calciphylaxis between January 1, 2006 and December 31, 2022 was conducted. Univariate and multivariate statistical analyses were performed. RESULTS: Non-nephrogenic calciphylaxis (p=0.0004) and involvement of the fingers (p=0.0001) were significantly associated with an increased diagnostic delay, whereas involvement of the arms (p=0.01) and genitalia (p=0.022) resulted in fewer days to diagnosis. Almost all patients with genitalia, finger, or toe involvement had nephrogenic disease. The number of complications per patient decreased with time, especially for wound infections (p=0.028), increase in lesion number (p=0.012), and recurrent hospitalizations (p=0.020). Updated 1-year mortality rates were 36.70% and 30.77% for nephrogenic and non-nephrogenic calciphylaxis, respectively. LIMITATIONS: Limitations include the retrospective nature and data from a single institution. CONCLUSION: Diagnostic delay, particularly in non-nephrogenic calciphylaxis, and complications per patient decreased with time, highlighting the importance of continued awareness to expedite diagnosis. Mortality rates have continued to improve in recent years.

Complicated Cellulitis is an Independent Predictor for Increased Length of Stay in the Neonatal Intensive Care Unit.

OBJECTIVE: To assess cellulitis in the neonatal intensive care unit (NICU) setting and identify risk factors for its disease severity and whether cellulitis influences length of stay (LOS). STUDY DESIGN: In this retrospective study, patients with cellulitis were identified using the electronic health record while admitted to the NICU at Massachusetts General for Children from January 2007 to December 2020. Demographic and clinical data were extracted from patient records. Two multivariable logistic regression models were constructed to assess for independent predictors for increased LOS (≥30 days) and complicated cellulitis in the hospital. RESULTS: Eighty-four patients met the study criteria; 46.4% were older than 14 days at the time of diagnosis of cellulitis, 61.9% were non-White, and 83.3% were born prematurely; 48.8% had complicated cellulitis as defined by overlying hardware (41.7%), sepsis (7.1%), requirement for broadened antibiotic coverage (7.1%), bacteremia (4.8%), and/or abscess (3.6%). The mean hospital LOS was 58.5 ± 36.1 days SD, with 72.6% having a LOS greater than 30 days. Independent predictors of increased LOS were extreme prematurity (<28 weeks' gestation) (OR: 14.7, P = .03), non-White race (OR: 5.7, P = .03), and complicated cellulitis (OR: 6.4, P = .03). No significant predictors of complicated cellulitis were identified. CONCLUSIONS: This study identifies complicated cellulitis in the NICU as an independent predictor of increased hospital LOS in neonates. Implementation of strategies to mitigate the development of cellulitis may decrease LOS among this high-risk population.

Gender disparities in isotretinoin prescribing patterns for pediatric patients before and during practice changes introduced by the COVID-19 pandemic.

Isotretinoin is a systemic therapy approved for acne and has historically required lab monitoring in addition to adherence to the iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) given the medication's teratogenic effects. The COVID-19 pandemic resulted in the expansion of telemedicine, acceptance of remote pregnancy tests, and relaxation of lab monitoring practices. A retrospective review of 142 pediatric patients was conducted, and multivariate linear regression was performed to examine differences in prescribing patterns pre-COVID and during COVID. Backward elimination identified gender and the interaction between acne severity and number of systemic treatments tried before isotretinoin as significant factors associated with increased number of visits to isotretinoin initiation, with females requiring more visits before starting isotretinoin at every acne severity level and even after accounting for systemic treatments previously tried. While the changes catalyzed by the pandemic may have improved visit-related burdens for patients and caregivers, female patients with acne continue to be delayed in receiving isotretinoin even when adjusting for acne severity and systemic treatments trialed, underscoring persistent gender disparities in prescribing practices for isotretinoin.

The Impact of Telehealth Implementation on Underserved Populations and No-Show Rates by Medical Specialty During the COVID-19 Pandemic.

A unique and sudden need for virtual medical visits created by the coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented expansion of telemedicine across nearly all medical specialties in the United States. In addition to providing essential medical services during the pandemic, telemedicine has the potential to expand health care access to underserved populations by eliminating traditional barriers to care such as transportation needs, distance from specialty providers, and approved time off from work. However, the literature regarding telehealth accessibility for low-income, non-English-speaking, and minority patients remains limited. Through a cross-sectional analysis comparing 2019 clinic visits with 2020 telehealth visits at the UMass Memorial Medical Center, we demonstrate specialty-specific changes in patient demographics, including a younger population, fewer non-English-speaking patients, and a relative preservation of minority, Medicaid, and Medicare patients among telehealth visits in comparison to clinic visits. We also demonstrate that nonsurgical specialties had significantly lower no-show rates and the greatest number of telehealth visits. Overall, our findings highlight the potential shortcomings of telemedicine in servicing non-English-speaking patients, while maintaining that it is an important tool with the potential to improve access to health care, particularly in nonprocedural specialties.

Vaccine considerations for adult dermatology patients on immunosuppressive and immunomodulatory therapies: a clinical review.

Adults with chronic inflammatory skin disease are at increased risk of vaccine-preventable illnesses and infections, likely because of the underlying disease itself and also their treatment with immunosuppressive and immunomodulatory medications. Despite the association between these agents and increased susceptibility to infection, vaccination rates in dermatology patients remain low. Although preventative care such as vaccinations is typically managed by primary care providers, dermatologists serve a critical role in spreading awareness of the specific risks of immunosuppressive and immunomodulatory agents and promoting understanding of individualized vaccine recommendations. In this review, we provide evidence-based information on vaccine recommendations for adult dermatology patients, specific to age and medication use.

Sweet syndrome in pregnancy: A narrative review.

The aim of this review is to increase obstetrician awareness of pregnancy-associated Sweet syndrome. Patients present with fever, leukocytosis, and skin eruption, which can mimic other infectious or inflammatory conditions, but do not respond to antibiotics. A search using PubMed, EMBASE, and Web of Science Core Collection was conducted to review all reported cases of pregnancy-associated Sweet syndrome, an acute febrile neutrophilic dermatosis occurring during pregnancy or postpartum. A total of 33 episodes among 30 patients were identified, with the majority (54.5% [18]) of cases occurring within the second trimester. Among the 30 patients, skin lesions most commonly affected the head and neck (73.3% [22]), with rare oral or ocular involvement. Leukocytosis was the most common laboratory finding, reported in 96.7% [29] of patients, with neutrophil predominance noted in 70.0% [21]. The diagnosis was confirmed for all patients with pathognomonic results of skin biopsies. Of the 27 cases detailing treatment, systemic corticosteroids were most frequently used (19 cases), followed by conservative management (seven cases), and dapsone (one case). The dapsone-treated patient and 15 of the 19 steroid-treated patients experienced resolution, but additional management strategies were required in the remaining four individuals. Spontaneous resolution occurred during pregnancy in six of the seven conservatively managed individuals, with one patient experiencing spontaneous abortion shortly after skin eruption at 10 weeks of gestation. No associated maternal deaths were reported. Obstetric complications of pregnancy-associated Sweet syndrome included endomyometritis, sterile placental abscesses, and abdominal wall necrosis. Delivery of healthy infants occurred in 24 of the 25 cases that presented fetal outcome, which included two infants who underwent medically indicated preterm deliveries.

Understanding patient perspectives on vaccine decision making in adults with autoimmune bullous diseases: a qualitative study.

Patients with autoimmune bullous diseases are at an increased risk of infection, both from the underlying skin disease and from immunosuppressive treatments. Limited information is available on vaccine beliefs and behaviors in dermatology patients and adults with autoimmune bullous diseases in particular. To understand vaccine decision making, identify perceived risks and benefits of vaccinations, and discuss individual experiences in patients with autoimmune bullous diseases in the United States. A qualitative study was performed utilizing semi-structured interviews, and analysis was conducted on NVivo. Patterns were identified in the coded data, and representative quotations were recorded for each major theme. Interviews were conducted between February 15, 2022 and September 15, 2022. Twenty patients with a diagnosis of bullous pemphigoid, mucous membrane pemphigoid, pemphigus vulgaris, or pemphigus foliaceous were interviewed. Of the 20 participants, 14 (70%) were female, with a mean (SD, range) age of 64.8 (13.2, 34-83) years. Key themes that emerged from qualitative analysis of the interviews included patient concerns regarding their increased susceptibility to infection, potential exacerbation of skin disease following vaccination, and the effect of immunosuppressive medications on humoral response to vaccines. Lack of appointment availability, difficulty accessing vaccines, and cost were commonly identified barriers to vaccination. These findings provide valuable knowledge for dermatologists in regard to providing counseling specific to patient concerns and to improve communication surrounding vaccination in the dermatology setting.

The patient perspective on vaccine uptake in adults with psoriasis and eczema.

Having a chronic disease is one of the most consistent factors associated with vaccine uptake for adults in the general population, but vaccination beliefs and behaviors specific to those with chronic skin diseases have not been explored. The objective of this study was to explore factors associated with vaccine uptake and barriers to vaccination in adults with psoriasis and eczema. Virtual, video-based semi-structured interviews were performed with adults who self-reported a diagnosis of psoriasis or eczema. Interviews explored themes around healthcare decision making, perceived risks/benefits to vaccination, barriers, and vaccine knowledge. Thematic analysis was used to analyze the data. Of 34 study participants, 25 participants (74%) were females and 9 (26%) were males, with a mean age of 50.8 years (SD: 16.4, range: 24-71 yrs). Half of participants (n = 17) had psoriasis, and half (n = 17) had eczema. Participants recognized both personal and societal benefits to vaccines. Common vaccination barriers identified were access to appointments, concerns about side effects, and misinformation. Physicians, friends/family, and media, including internet resources, were health information resources identified by patients. These results summarize the unique patient perspective around vaccine uptake in adults with eczema and psoriasis and represent an important first step in a multi-pronged approach to improve vaccination rates in adults with chronic skin diseases.