'I need to understand so we can decide together': Difficult conversations about alopecia areata.

The management of alopecia areata (AA) in pediatric patients poses unique challenges, particularly regarding treatment discussions and decision making involving both patients and their families. This commentary presents findings from unpublished research on treatment-discontinuation discussions between AA patients and their treating providers, shedding light on the hopes, expectations, and disappointments of individuals with severe AA. The study explored patient and guardian satisfaction with these discussions, emphasizing the importance of addressing psychosocial concerns, facilitating contact with support groups, and demonstrating empathy. The role of dermatologists in conversations about treatment, prognosis, and quality of life is examined, emphasizing the need for honesty, empathy, and realistic expectations. The authors propose a patient-centered approach to initiating and guiding discussions, focusing on understanding the impact of AA on patients and their families and collaboratively deciding on treatment options. The mantra: 'I need to understand how this is affecting all of you, so we can decide together what to do next' is central to this proposed approach. Special considerations for different scenarios are discussed, highlighting the importance of individualized care and effective communication. Overall, the commentary emphasizes the significance of actively listening, acknowledging emotions, and prioritizing patient and family goals to optimize care for pediatric AA patients.

Feasibility and acceptability of measuring positivity resonance in nurse-patient telehealth videoconferencing visits: A mixed-methods observational study.

AIM: To investigate the feasibility and acceptability of the training process, procedures, measures and recruitment strategies necessary for a future investigation to test the reliability and validity of using positivity resonance measures in health care encounters. BACKGROUND: Although the measurement of positivity resonance is promising, and non-participant observation is considered effective, their approaches to studying nurse-patient relationships have not been fully explored. DESIGN: A mixed-methods observational study. METHODS: Video recordings of 30 nurse-patient dyads completing telehealth video visit encounters were edited and coded using behavioural indicators of positivity resonance. A post-visit survey gathered data on the participants' perceptions of positivity resonance and the study procedures. The research team completed memos and procedural logs to provide narrative data on the study's training, coding, recruitment and operational procedures. The study included 33 persons with cancer and 13 oncology nurses engaging in telehealth video visit encounters at an academic oncology ambulatory care center located in the southeastern United States. RESULTS: Study procedures were found to be feasible and acceptable to participants. An adequate sample of participants (N = 46) were enrolled and retained in the study. Interrater reliability, as evidenced by Cohen's weighted kappa, ranged from .575 to .752 and interclass correlation coefficients >.8 were attainable within a reasonable amount of time and with adequate training. Behavioural indicators of positivity resonance were observed in all telehealth visits and reported by the participants in the perceived positivity resonance survey. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist guided reporting. CONCLUSIONS: Designing research around the concept of positivity resonance is an innovative and feasible approach to exploring how rapport is cultivated within nurse-patient relationships. RELEVANCE TO PROFESSIONAL PRACTICE: Measuring positivity resonance may hold promise for exploring patient and nurse outcomes including trust, responsiveness, health-related behaviours, well-being, resilience and satisfaction. REPORTING METHOD: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist guided the reporting of results to ensure that adequate details of the study were provided to ensure an accurate and complete report. PATIENT OR PUBLIC CONTRIBUTION: Planning of the research design and study procedures was done in consultation with nurse clinicians with experience with telehealth and managers responsible within the practice setting where the study was conducted. This ensured the study procedures were ethical, safe, secure and did not create unnecessary burden to the study participants. The study included collecting data from nurse and patient participants about the acceptability of the study procedures.

"Walking the Journey Together": Creating a unique learning module in provider-patient communication for the care of epilepsy in Uganda.

OBJECTIVE: This report documents the creation of a practical communication skills module about epilepsy care, specifically targeted at first-line care providers who treat patients with epilepsy in Uganda. METHODS: Our team conducted semi-structured interviews, utilizing Zoom video conferencing, with Ugandan physicians specializing in epilepsy care. Our interview guide promoted a semi-structured conversational interview that explored aspects related to developing a patient-provider relationship, how epilepsy is described in a culturally appropriate manner, exploration of alternative treatments, the impact of the stigma of epilepsy, and facilitators and barriers to antiepileptic drug treatment adherence. Each interview was then transcribed, and an inductive thematic content analysis approach was utilized to facilitate the development of thematic communication and care subcategories. The resulting PowerPoint presentation included numerous short audio clips of our Ugandan experts suggesting effective ways of communicating with patients and their families. RESULTS: Our interviews with experts yielded valuable results to customize the WHO mhGAP v2.0 training program to be culturally relevant and effective in Uganda. The educational content consisted of topic summaries integrated with audio clips taken directly from our interviews with the Ugandan providers. Six themes emerged that would serve as the outline for the communication module we co-created with our Ugandan colleagues: The six major themes of the module included: (1) Greeting the patient, (2) Getting the story, (3) Traditional healers, (4) Stigma of epilepsy, (5) Explaining epilepsy, and (6) Treatment adherence. CONCLUSIONS: The communications skills teaching module addresses the most critical aspects of communicating with patients and families living with epilepsy. The format of the presentation, which includes the written and spoken words of experts in epilepsy care, provides a practical approach to the provider-patient interaction, and confronts the stigma associated with this disease. This formatting highlights an effective way for international groups to co-create content in a culturally effective manner.

Evaluation of a tailored epilepsy training program for healthcare providers in Uganda.

OBJECTIVE: This study evaluated an epilepsy training program for healthcare workers that was designed to improve their knowledge of epilepsy, its treatment, and its psychosocial effects. METHODS: This single group, before and after survey was conducted in three regional referral hospitals in Uganda. Healthcare workers participated in a 3-day epilepsy training program and were assessed immediately prior to and following the program using a 39-item epilepsy knowledge questionnaire. Pretest to posttest changes and acceptability ratings were analyzed. RESULTS: Twenty healthcare workers from each of our three study hospitals (N = 60) participated in the study. The average age of the participants was 39.9 years (SD = 9.6). Female participants constituted 45% of the study population. There was a significant improvement in the knowledge of healthcare workers about epilepsy following the training (t = 7.15, p < 0.001). Improvement was seen across the three sub-scores of general knowledge about epilepsy, assessment and diagnosis of epilepsy, and management of epilepsy. Subgroup analysis showed that both high and low baseline scorers showed significant training gains. CONCLUSIONS: The study suggested that our training program was effective in improving the knowledge of health workers about epilepsy and that participants had favorable impressions of the program. Further work is needed to determine if the knowledge is retained over time and if the change in knowledge translates into a change in clinical practice.

Atopic dermatitis leading to failure to thrive: A case report.

We present an infant with severe atopic dermatitis, protein loss, and subsequent failure to thrive. With proper management, the patient's laboratory findings normalized, and he gained weight appropriately. In this report, we highlight the impact that severe atopic dermatitis may have growth and development and review the genetic conditions that can result in a similar clinical presentation.

Childhood lymphomatoid papulosis Type D, a rare and challenging diagnosis.

A 10-year-old female with a several-year history of pityriasis lichenoides (PL) presented with a new, asymptomatic, large, and necrotic ulcer of her right upper arm. Skin biopsy was consistent with lymphomatoid papulosis (LyP) Type D, a recently recognized subtype of LyP that is distinguished histologically by marked epidermotropism and a perivascular infiltrate of medium-sized pleomorphic lymphocytes with a cytotoxic phenotype (CD3+, CD8+). This is only the sixth reported case of LyP Type D in a child, and while the prognosis in children appears favorable, with no reports of progression to lymphoma to date, more experience in children with longer-term follow-up is needed. Our case highlights both the challenging clinical diagnosis, since in our patient the longstanding clinical presentation was indistinguishable from PL, as well as histopathologic diagnosis, which required expert opinion and consensus.

Exploring Nurse and Patient Experiences of Developing Rapport During Oncology Ambulatory Care Videoconferencing Visits: Qualitative Descriptive Study.

BACKGROUND: Although videoconferencing between oncology patients and nurses became routine during the pandemic, little is known about the development of clinician-patient rapport in this care environment. Evidence that virtual visits may challenge nurses' ability to form connections with patients, demonstrate empathy, and provide support suggests that videoconferencing may not ensure optimal care for persons with cancer. Establishing rapport during videoconferencing visits (VCVs) is important in oncology nursing, as rapport enables the nurse to provide emotional support and assistance to patients as they navigate their cancer journey. OBJECTIVE: This study investigated the nature of nurse-patient rapport in ambulatory cancer care videoconferencing telehealth visits. Objectives included exploring (1) how patients with cancer and nurses describe experiences of and strategies for cultivating rapport and (2) similarities and differences between rapport in videoconferencing and in-person visits (IPVs). METHODS: In this qualitative descriptive study, interviews were conducted from October 2021 to March 2022 with 22 participants, including patients with cancer (n=10, 45%) and oncology nurses (n=12, 55%), about their experiences of rapport building during VCVs. All interviews were analyzed using conventional content analysis. Data from nurses and patients were analyzed separately using identical procedures, with a comparative analysis of patient and nurse results performed in the final analysis. RESULTS: Most patients in the study had experienced 3-5 video visits within the past 12 months (n=7, 70%). Half of the nurse participants (n=6, 50%) reported having participated in over 100 VCVs, and all had experiences with videoconferencing (ranging from 3 to 960 visits) over the past 12 months. In total, 3 themes and 6 categories were derived from the patient data, and 4 themes and 13 categories were derived from the nurse data. Comparisons of themes derived from participant interviews identified similarities in how nurses and patients described experiences of rapport during VCVs. Three themes fit the collective data: (1) person-centered and relationship-based care is valued and foundational to nurse-patient rapport in oncology ambulatory care regardless of how care is delivered, (2) adapting a bedside manner to facilitate rapport during VCVs is feasible, and (3) nurses and patients can work together to create person-centered options across the care trajectory to ensure quality care outcomes. Barriers to relationship building in VCVs included unexpected interruptions from others, breaks in the internet connection, concerns about privacy, and limitations associated with not being physically present. CONCLUSIONS: Person-centered and relationship-based approaches can be adapted to support nurse-patient rapport in VCVs, including forming a personal connection with the patient and using active listening techniques. Balancing the challenges and limitations with the benefits of videoconferencing is an essential competency requiring additional research and guidelines. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/27940.

An innovative intervention to improve respectful maternity care in three Districts in Ethiopia.

BACKGROUND: Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions. METHODS: Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data. RESULTS: Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations. CONCLUSION: This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

Teledermatology: How It Is Impacting the Underserved.

The rapid mobilization of telemedicine during the COVID-19 pandemic has brought about renewed concern about the digital divide. Understanding the benefits and limitations of remote medical care is an ongoing process. Access to telemedicine appointments, as well as the experience of the virtual appointment itself, varies across demographic groups. Telemedicine has promise in dermatology. However, if it continues to expand beyond the pandemic, federal changes may be necessary to improve access to remote care for all patients moving forward. This involves creating mandates for increased broadband access, deploying digital health tools and portals usable by underserved populations, and increasing access to interpreters. Information technology personnel may also become necessary members of the clinical care team. Parity between video and phone visit reimbursement for providers is also necessary.

Neutrophilic figurate erythema of infancy: A diagnostic challenge.

Neutrophilic figurate erythema of infancy (NFEI) is a rare variant of annular erythema of infancy. It is characterized by annular erythematous plaques, occasionally with a polycyclic configuration. The main challenge is to differentiate this rare entity from other figurate erythemas associated with serious diseases such as neonatal lupus erythematosus. We present the case of a 9-month-old female admitted with a skin rash of unclear etiology. The rash started on her face at the age of 3 months and gradually spread to her extremities. She had no constitutional symptoms, and her health and development were otherwise unremarkable since birth. This persistent skin eruption consisted of many ill-defined erythematous papules and annular plaques. Histologic examination revealed perivascular neutrophils and eosinophils with abundant nuclear dust without signs of vasculitis. NFEI is a diagnostic enigma both clinically and histologically. Absence of an underlying cause, dermal neutrophilic infiltrate with leukocytoclasis, and lack of vascular damage are the keys to diagnosis.

Inflammatory linear verrucous epidermal nevus treated successfully with crisaborole ointment in a 5-year-old boy.

Inflammatory linear verrucous epidermal nevus (ILVEN) is a chronic, a linear, or whorled array of inflammatory, following the lines of Blaschko. Treatment of ILVEN is challenging with numerous therapies of varying degrees of success reported. We present a case of ILVEN in a 5-year-old-boy, treated successfully with crisaborole 2% ointment. This brief report suggests that there may be additional cellular immunologic pathways responsible for the presentation of ILVEN that may be explained by management with crisaborole use.

Chemotherapy-induced eccrine squamous syringometaplasia in an infant.

There are few reports of chemotherapy-induced eccrine squamous syringometaplasia in children. We report the first case of an infant developing this condition after treatment with busulfan, fludarabine, and antithymocyte globulin in preparation for bone marrow transplantation. Twenty-eight days after transplantation, the infant developed faintly erythematous papules and plaques on the bilateral axillae, inguinal folds, and sites of adhesives. Punch biopsy revealed eccrine glands with dyskeratotic cells and focal squamous metaplasia consistent with chemotherapy-induced eccrine squamous syringometaplasia.

Eccrine Chromhidrosis in an Adolescent with Sickle Cell Disease.

Eccrine chromhidrosis can occur secondary to hyperbilirubinemia. We report an adolescent with sickle cell disease who presented with eccrine chromhidrosis on his palmar and plantar surfaces. He had extremely high levels of conjugated bilirubin but no fever. This is the youngest known reported patient with eccrine chromhidrosis and the first in a patient with sickle cell disease.

"If you don't take a stand for your life, who will help you?": Men's engagement in HIV care in KwaZulu-Natal, South Africa.

The needs of South African men with HIV may often be overlooked in the provision of HIV services, leading to care programs that do not adequately serve the unique needs of male patients. Additionally, norms of masculinity guide men's behaviors as they navigate health decision-making and the healthcare systems. The aim of this study is to examine how masculinity influences healthcare access and utilization in South Africa, and to identify opportunities for interventions. The qualitative study took place at one primary health care clinic in a peri-urban township in KwaZulu-Natal, South Africa. In-depth individual interviews were conducted with 21 HIV-infected men recruited from the study clinic. Direct observations of the clinic waiting area were conducted to provide context. Data were analyzed using a grounded theory-informed approach involving memo writing and thematic exploration with data coding. On average, participants were 42 years old and had been on ART for 3.6 years. Participants expressed a range of ways in which masculine ideals and identity both promoted and inhibited their willingness and ability to engage in HIV care. Notions of masculinity and social identity were often directly tied to behaviors influencing care engagement. Such engagement fostered the reshaping of identity around a novel sense of clinic advocacy in the face of HIV. Our findings suggested that masculinities are complex, and are subject to changes and reprioritization in the context of HIV. Interventions focusing on reframing hegemonic masculinities and initiating treatment early may have success in bringing more men to the clinic.

Congenital hemophagocytic lymphohistiocytosis presenting as thrombocytopenia in a newborn.

Hemophagocytic lymphohistiocytosis (HLH) is a disease caused by dysregulation and hyperactivation of the immune system, and can be familial or acquired. HLH presenting in infancy can be rapidly fatal if not promptly recognized and treated. Congenital HLH can be caused by various genetic mutations or part of immunodeficiency syndromes. We present an infant with Griscelli syndrome and familial HLH with atypical genetic mutations, presenting as thrombocytopenia on the first day of life, cured with chemotherapy and unrelated cord blood transplant.

Cutaneous acquired toxoplasmosis in a child: a case report and review of the literature.

Cutaneous toxoplasmosis is a rare and diagnostically challenging entity. Today, the acquired form occurs predominantly in immunocompromised patients with human immunodeficiency virus or after hematopoietic stem cell transplantation. We report a case of cutaneous toxoplasmosis in a 6-year-old girl after allogeneic stem cell transplantation for immune-mediated encephalopathy, first manifesting at 16 months of age. In the post-transplant setting, she developed a rash consisting of approximately 8 scattered 3­4-mm round, erythematous macules and papules on her back, abdomen, and right shoulder. Sections from a biopsy of a lesion on the back revealed numerous spherules tightly packed within small cystic structures in the epidermis. The diagnosis of cutaneous toxoplasmosis was confirmed by an immunohistochemical stain for Toxoplasma gondii and polymerase chain reaction on the peripheral blood for the T. gondii genome. This case should raise awareness that acquired toxoplasmosis with cutaneous involvement can occur in the pediatric population, particularly in immunocompromised patients after stem cell transplantation. Early diagnosis and treatment of this life-threatening opportunistic infection may improve patient outcomes.

Representation of Racially Minoritized Patients on Dermatology Private Practice Websites.

Images on the homepages of private practice dermatology websites often do not reflect the racial diversity of the metropolitan area in which each practice is located. A Google Maps scraper (Apify) was used to identify websites for private practices in 27 United States metropolitan areas selected from the 2020 U.S. Census list of 100 largest areas where non-white individuals makeup more than 50% of the population. Homepages from the top ten websites listed by the search engine were analyzed for images, use of non-English language, and mention of "Skin of Color" or "Ethnic Skin." One hundred seventeen websites were included. Two mentioned "Skin of Color" or "Ethnic Skin"; seven mentioned a non-English language. A significantly lower percentage of non-white-presenting patients (p < 0.001) and providers (p < 0.001) were pictured on the selected dermatology websites than reported in the Census. These findings suggest that the images on the homepages of private practice dermatology websites were not reflective of the racial diversity of the metropolitan area in which each practice is located. Private practice dermatologists should be mindful of how their services are represented online, as it may dissuade potential minoritized patients from seeking dermatologic care.