Hidradenitis suppurativa in sexual and gender minorities: A review and considerations for providers.

The literature on hidradenitis suppurativa in sexual and gender minorities remains sparse. This review article aims to discuss critical factors for providers to consider in lesbian, gay, bisexual, transgender, queer, intersex, and asexual patients with hidradenitis suppurativa, including associated comorbidities, gender-affirming hormonal therapy, squamous cell carcinoma, infections in HIV-positive patients, and creating a welcoming clinic for sexual and gender minority patients.

Dermatologic care for lesbian, gay, bisexual, and transgender persons: Terminology, demographics, health disparities, and approaches to care.

More than 10 million lesbian, gay, bisexual, and transgender (LGBT) persons live in the United States. Improving their health is a public health priority. LGBT persons have specific health concerns and face health care disparities. Awareness of those issues and disparities can enable dermatologists to provide medically appropriate and culturally competent care to LGBT patients. This review highlights terminology important in caring for LGBT persons, LGBT demographics in the United States, health care disparities faced by LGBT persons, and approaches to caring for LGBT patients.

Dermatologic care for lesbian, gay, bisexual, and transgender persons: Epidemiology, screening, and disease prevention.

Lesbian, gay, bisexual, and transgender (LGBT) persons face important health issues relevant to dermatologists. Men who have sex with men (MSM) are at higher risk of certain infectious diseases, including HIV, syphilis and other sexually transmitted diseases (STDs), methicillin-resistant Staphylococcus aureus infections, and invasive meningococcal disease, and might be at higher risk of non-infectious conditions, including skin cancer. Recommendations for preventive health care, including screening for HIV and other STDs, sexual health-related vaccinations, and HIV pre-exposure prophylaxis, differ for MSM compared with non-MSM. Women who have sex with women experience disparities in STDs, including chlamydia and HPV. Transgender patients have unique, and often unmet, dermatologic needs during gender transition (also called gender affirmation), related to hormonal therapy and gender-affirming surgery. Familiarity with LGBT health issues and disease-prevention guidelines can enable dermatologists to provide medically appropriate and culturally competent care to LGBT persons.

Prescribing isotretinoin for transgender youth: A pledge for more inclusive care.

As the transgender community has become increasingly visible in public life, a greater awareness of this group's unique health needs and obstacles to optimal medical care has developed. Unfortunately, transgender youth face multiple barriers within the health care system, including access to equitable and gender-affirming care. As dermatologists who care for children and adolescents, we must be aware of the challenges facing transgender youth and work to correct the disparities that exist for this vulnerable group. An initial step in supporting our transgender patients is to advocate for changes to the iPLEDGE system for prescribing isotretinoin (and other Risk Evaluation and Mitigation Strategy systems), specifically requesting a change to its gender-binary categorization model that compromises an individual's right to self-identify. By promoting a gender-neutral patient categorization that is based instead upon reproductive potential, a simple change to the iPLEDGE program allows us to safely treat all of our patients requiring isotretinoin, while preserving our transgender patients' rights to self-determination and self-identification.

Nonsurgical Management of Facial Masculinization and Feminization.

BACKGROUND: Transgender patients may seek nonsurgical methods for facial masculinization and feminization as an adjunct or alternative to undergoing surgical procedures. OBJECTIVES: The authors reviewed the existing literature regarding this topic and provided an overview of nonsurgical techniques for facial masculinization and feminization. METHODS: A comprehensive literature search of the PubMed and MedLine databases was conducted for studies published through December 2017 for techniques and outcomes of nonsurgical facial masculinization and feminization. Keywords were used in performing the search. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS: Four articles fit our inclusion criteria. Given the lack of published literature describing facial injectables in transgender patients, data from the literature describing techniques in cisgender patients were utilized to supplement our review. CONCLUSIONS: Facial feminization can be achieved through injectables such as neurotoxin and fillers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids. Facial masculinization can be achieved with injectables used for genioplasty, jawline augmentation, and supraorbital ridge augmentation. One must develop best practices for these techniques in the transgender patient population and increase awareness regarding nonsurgical options.

A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community.

BACKGROUND: There are an estimated 700,000 or more transgender people in the United States, however their dermatologic needs are not fully established in the medical literature. Unique needs relate to hormone therapy, prior surgeries, and other aspects of physical transitioning. OBJECTIVES: By examining attitudes and practices of transgender individuals, we aimed to identify areas for which dermatologists could contribute to their physical transformation. METHODS: This cross-sectional study used an anonymous online survey, distributed via lesbian, gay, bisexual, and transgender organizations; social media; and at targeted locations and events. RESULTS: A total of 327 people completed the survey (63% men, 29% women, 9% other). Most transgender women indicated that their face was most imperative to have changed, whereas men noted their chest, in turn influencing procedures. Of women's facial procedures, hair removal predominated, followed by surgery then injectables, mostly performed by plastic surgeons. Hormone-induced facial effects varied, usually taking over 2 years for maximal effect. When choosing procedures, money was the major barrier and good aesthetic outcome the primary concern. Participants did not think that facial procedures necessitate the currently accepted prerequisites for chest and genital surgery. LIMITATIONS: This study has limited size and convenience sampling. CONCLUSION: Dermatologists could contribute to the physical transformation of transgender patients through noninvasive procedures.

Integrated NY-ESO-1 antibody and CD8+ T-cell responses correlate with clinical benefit in advanced melanoma patients treated with ipilimumab.

Ipilimumab, a monoclonal antibody against cytotoxic T lymphocyte antigen 4 (CTLA-4), has been shown to improve survival in patients with advanced metastatic melanoma. It also enhances immunity to NY-ESO-1, a cancer/testis antigen expressed in a subset of patients with melanoma. To characterize the association between immune response and clinical outcome, we first analyzed NY-ESO-1 serum antibody by ELISA in 144 ipilimumab-treated patients with melanoma and found 22 of 140 (16%) seropositive at baseline and 31 of 144 (22%) seropositive following treatment. These NY-ESO-1-seropositive patients had a greater likelihood of experiencing clinical benefit 24 wk after ipilimumab treatment than NY-ESO-1-seronegative patients (P = 0.02, relative risk = 1.8, two-tailed Fisher test). To understand why some patients with NY-ESO-1 antibody failed to experience clinical benefit, we analyzed NY-ESO-1-specific CD4(+) and CD8(+) T-cell responses by intracellular multicytokine staining in 20 NY-ESO-1-seropositive patients and found a surprising dissociation between NY-ESO-1 antibody and CD8 responses in some patients. NY-ESO-1-seropositive patients with associated CD8(+) T cells experienced more frequent clinical benefit (10 of 13; 77%) than those with undetectable CD8(+) T-cell response (one of seven; 14%; P = 0.02; relative risk = 5.4, two-tailed Fisher test), as well as a significant survival advantage (P = 0.01; hazard ratio = 0.2, time-dependent Cox model). Together, our data suggest that integrated NY-ESO-1 immune responses may have predictive value for ipilimumab treatment and argue for prospective studies in patients with established NY-ESO-1 immunity. The current findings provide a strong rationale for the clinical use of modulators of immunosuppression with concurrent approaches to favor tumor antigen-specific immune responses, such as vaccines or adoptive transfer, in patients with cancer.

Cranial fasciitis.

A 26-year-old man presented with an 18-month history of a subcutaneous mass on his forehead that occurred shortly after being struck by a blunt object. Histopathologic examination showed a proliferation of bland spindle cells and a collagenous stroma that was consistent with cranial fasciitis. Cranial fasciitis, which is a variant of nodular fasciitis, is a benign fibroblastic neoplasm that overlies the skull and often is associated with trauma. Although its rapid onset may give the clinical impression of a malignant condition, cranial fasciitis typically is cured by simple excision without further sequelae.

Nail lichen planus in a patient with alopecia totalis.

A 67-year-old man with a three-year history of non-scarring alopecia that progressed to alopecia totalis despite intralesional glucocorticoid injections is presented. He developed 20-nail dystrophy that was recalcitrant to antifungal and anti-inflammatory treatments. Biopsy of the nail matrix showed histopathologic features of lichen planus. Alopecia totalis and isolated lichen planus of the nails are uncommon subtypes of common dermatologic disorders. Rarely reported concurrently, we provide a review of the literature of their association, which is most likely attributed to their autoimmune pathogeneses.

CTLA-4 blockade increases antigen-specific CD8(+) T cells in prevaccinated patients with melanoma: three cases.

BACKGROUND: Anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4) antibodies, such as ipilimumab, have generated measurable immune responses to Melan-A, NY-ESO-1, and gp100 antigens in metastatic melanoma. Vaccination against such targets has potential for immunogenicity and may produce an effector-memory T-cell response. METHODS: To determine the effect of CTLA-4 blockade on antigen-specific responses following vaccination, in-depth immune monitoring was performed on three ipilimumab-treated patients prevaccinated with gp100 DNA (IMF-24), gp100(209-217) and tyrosinase peptides plus GM-CSF DNA (IMF-32), or NY-ESO-1 protein plus imiquimod (IMF-11); peripheral blood mononuclear cells were analyzed by tetramer and/or intracellular cytokine staining following 10-day culture with HLA-A*0201-restricted gp100(209-217) (ITDQVPFSV), tyrosinase(369-377) (YMDGTMSQV), or 20-mer NY-ESO-1 overlapping peptides, respectively. Tumors from IMF-32 were analyzed by immunohistochemistry to help elucidate mechanism(s) underlying tumor escape. RESULTS: Following vaccination, patients generated weak to no CD4(+) or CD8(+) T-cell response specific to the vaccine antigen but demonstrated increases in effector-memory (CCR7(lo)CD45RA(lo)) tetramer(+)CD8(+) T cells. After ipilimumab induction, patients experienced a robust, although sometimes transient, antigen-specific response for gp100 (IMF-32 and IMF-24) or NY-ESO-1 (IMF-11) and produced polyfunctional intracellular cytokines. Primary and metastatic tumors expressed tyrosinase but not gp100 or class I/II MHC molecules. CONCLUSION: Vaccination induced a measurable antigen-specific T-cell response that increased following CTLA-4 blockade, potentially "boosting" the vaccine-primed response. Tumor escape may be related to antigen loss or lack of MHC expression necessary for immune activity. These results in a limited number of patients support the need for further research into combining vaccination with ipilimumab and provide insight into mechanisms underlying tumor escape.

DepoDur extended-release epidural morphine: reshaping postoperative care. What perioperative nurses need to know.

Epidural morphine as a single bolus dose has demonstrated analgesia that lasts up to 24 hours. Recent advances in drug delivery mechanisms have resulted in a formulation of morphine, DepoDur, which is a lipid-encapsulated extended-release epidural morphine that provides up to 48 hours of analgesia. The efficacy of DepoDur has been established after hip arthroplasty, lower abdominal surgery involving an incision below the umbilicus, and elective cesarean section delivery. The unique characteristics of DepoDur dictate that clinicians must be aware of the benefits and risks, and facilities must have a comprehensive system to allow for the safe administration of DepoDur. This article provides information on this novel drug delivery system, reviews research findings reported in the literature, and describes the relational collaboration system designed and implemented at Duke University Health System for safe patient care of DepoDur recipients.

Acute post-surgical pain management: a critical appraisal of current practice, December 2-4, 2005.

The Acute Pain Summit 2005 was convened to critically examine the perceptions of physicians about current methods used to control postoperative pain and to compare those perceptions with the available scientific evidence. Clinicians with expertise in treatment of postsurgical pain were asked to evaluate 10 practice-based statements. The statements were written to reflect areas within the field of acute-pain management, where significant questions remain regarding everyday practice. Each statement made a specific claim about the usefulness of a specific therapy (eg, PCA or epidural analgesia) or the use of pain-control modalities in specific patient populations (eg, epidural analgesia after colon resection). Members of the American Society of Regional Anesthesia and Pain Medicine (ASRA) were asked, via a Web-based survey, to rate their degree of agreement with each of the 10 statements; 22.8% (n = 632) of members responded. In preparation for the pain summit, a panel member independently conducted a literature search and summarized the available evidence relevant to each statement. Summit participants convened in December 2005. The assigned panel member presented the available evidence, and workshop participants then assigned a category for the level of evidence and recommendation for each statement. All participants then voted about each statement by use of the same accept/reject scale used earlier by ASRA members. This manuscript details those opinions and presents a critical analysis of the existing evidence supporting new and emerging techniques used to control postsurgical pain.

The influence of lockout intervals and drug selection on patient-controlled analgesia following gynecological surgery.

This study systematically compared 2 opioids, morphine (MOR) and fentanyl (FEN), and 2 lockout intervals, long (L) and short (S) in patients utilizing patient-controlled analgesia (PCA). Seventy-eight women undergoing gynecological surgery were randomly assigned to 1 of 4 groups: MOR-S (7 min), MOR-L (11 min), FEN-S (5 min), FEN-L (8 min). PCA measures obtained during the first 24 h after surgery included: number of demands/h, number of completed deliveries/h, dose/h, and demand/delivery ratio. Visual analog scales of pain and anxiety were also obtained. Results indicated that pain relief was equivalent with minimal side effects for both opioids. The selection of opioid, however, influenced the pattern of PCA use, with an improved demand/delivery ratio initially for FEN. The lockout intervals chosen for this study did not influence pain or anxiety levels.

Patient-specific factors affecting patient-controlled analgesia dosing.

A study was conducted to evaluate the effect of characteristics patients' gender, age, weight, height, and body surface area, as well as the concurrent or recent use of opioids, ethanol and tobacco, on opioid dose requirements during administration of patient-controlled analgesia (PCA). Data were collected retrospectively from the medical records of 150 patients who underwent open cholecystectomies during an 18 month period at one institution. Demonstrable inter-patient variability in patterns of PCA use was observed. The results of the study demonstrate that during the first 48 hours of PCA therapy, patient age, height, weight, body surface area, gender, smoking, alcohol use, and preoperative opioid use may have significant influence on opioid analgesic use (p < 0.05). The data support the hypothesis that patient-specific factors may contribute to the variability observed in patients' PCA analgesic dose requirements, and these factors should be considered when selecting a proper demand (bolus) dose for PCA therapy.

PCA safety data review after clinical decision support and smart pump technology implementation.

INTRODUCTION: Medication errors account for 20% of medical errors in the United States with the largest risk at prescribing and administration. Analgesics or opioids are frequently used medications that can be associated with patient harm when prescribed or administered improperly. In an effort to decrease medication errors, Duke University Hospital implemented clinical decision support via computer provider order entry (CPOE) and "smart pump" technology, 2/2008, with the goal to decrease patient-controlled analgesia (PCA) adverse events. METHODS: This project evaluated PCA safety events, reviewing voluntary report system and adverse drug events via surveillance (ADE-S), on intermediate and step-down units preimplementation and postimplementation of clinical decision support via CPOE and PCA smart pumps for the prescribing and administration of opioids therapy in the adult patient requiring analgesia for acute pain. DISCUSSION: Voluntary report system and ADE-S PCA events decreased based upon 1000 PCA days; ADE-S PCA events per 1000 PCA days decreased 22%, from 5.3 (pre) to 4.2 (post) (P = 0.09). Voluntary report system events decreased 72%, from 2.4/1000 PCA days (pre) to 0.66/1000 PCA days (post) and was statistically significant (P < 0.001). There was a difference in the ADE-S data for causality (P < 0.0001) with sleep apnea and renal insufficiency approaching significance. Voluntary report system safety event were statistically significant for obesity [body mass index (BMI) ≥30] and weight. CONCLUSION: This study demonstrated a decrease in PCA events between time periods in both the ADE-S and voluntary report system data, thus supporting the recommendation of clinical decision support via CPOE and PCA smart pump technology.