COVID-19 Among US Dialysis Patients: Risk Factors and Outcomes From a National Dialysis Provider.

RATIONALE & OBJECTIVE: During the coronavirus disease 2019 (COVID-19) pandemic, patients receiving maintenance dialysis are a highly vulnerable population due to their comorbidities and circumstances that limit physical distancing during treatment. This study sought to characterize the risk factors for and outcomes following COVID-19 in this population. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Maintenance dialysis patients in clinics of a midsize national dialysis provider that had at least 1 patient who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from February to June 2020. PREDICTORS: Demographics, dialysis characteristics, residence in a congregated setting, comorbid conditions, measurements of frailty, and use of selected medications. OUTCOMES: COVID-19, defined as having a positive SARS-CoV-2 test result, and all-cause mortality among those with COVID-19. ANALYTICAL APPROACH: Logistic regression analyses conducted to identify clinical characteristics associated with COVID-19 and risk factors associated with mortality among patients following COVID-19. RESULTS: 438 of 7948 (5.5%) maintenance dialysis patients developed COVID-19. Male sex, Black race, in-center dialysis (vs home dialysis), treatment at an urban clinic, residence in a congregate setting, and greater comorbidity were associated with contracting COVID-19. Odds of COVID-19 were 17-fold higher for those residing in a congregated setting (odds ratio [OR], 17.10 [95% CI, 13.51-21.54]). Of the 438 maintenance dialysis patients with COVID-19, 109 (24.9%) died. Older age, heart disease, and markers of frailty were associated with mortality. LIMITATIONS: No distinction was detected between symptomatic and asymptomatic SARS-CoV-2 positivity, with asymptomatic screening limited by testing capacity during this initial COVID-19 surge period. CONCLUSIONS: COVID-19 is common among patients receiving maintenance dialysis, particularly those residing in congregate settings. Among maintenance dialysis patients with COVID-19, mortality is high, exceeding 20%.

Oral epithelial membrane-associated mucins and transcriptional changes with Sjögren's syndrome.

OBJECTIVES: To determine expression and localization of membrane-associated mucins within human keratinized and non-keratinized oral epithelia, and to explore transcriptional changes associated with primary Sjögren's syndrome. SUBJECTS AND METHODS: Mucin transcripts and glycoproteins were determined by RT-PCR and immunohistochemistry, respectively, in oral keratinized (hard palate) and non-keratinized (buccal) epithelia obtained from three cadavers. Mucin transcripts assessed by quantitative PCR were compared between cells harvested by brushing buccal and palatal epithelia of 25 female primary Sjögren's syndrome patients vs 25 healthy age-matched female control subjects. RESULTS: In hard palate, MUC4 is absent and MUC1 localized to deeper cell layers. Both mucins are within the apical layers of buccal epithelium. MUC15 is localized throughout all palatal cell layers and in all but the basal layer of buccal epithelia. MUC16, MUC20, and MUC21 glycoproteins are localized within all but the basal cell layer of both tissue types. In buccal cells of primary Sjögren's patients, MUC21 transcripts are down-regulated 3.4-fold and MUC20 2.6-fold. Dysregulation of select epithelial mucins may therefore contribute to xerostomia. CONCLUSIONS: Differential expression of multiple mucins and down-regulation in Sjögren's syndrome support further study of oral epithelial mucin physiology and pathophysiology, including their functions in hydration and lubrication of the oral mucosal pellicle.

Unique glandular ex-vivo Th1 and Th17 receptor motifs in Sjögren's syndrome patients using single-cell analysis.

Primary Sjögren's syndrome (pSS) is an autoimmune disease in which the underlying cause has yet to be elucidated. The main objective of this study was to determine the T cell receptor (TCR) repertoires of individual infiltrating T helper (Th)-1 and 17 cells of pSS patients using single-cell analysis. Single-cell analysis of ex-vivo infiltrating T cells demonstrated that pSS patients had higher frequencies of activated Th17 cells. Single-cell TCR sequencing revealed that TCRß variable (TRBV)3-1/joint (J)1-2 (CLFLSMSACVW) and TRBV20-1/J1-1 (SVGSTAIPP*T) were expressed by activated Th1 and Th17 cells in both cohorts. Uniquely, TCRα variable (TRAV)8-2/J5 (VVSDTVLETAGE) was expressed by Th1 cells present only in patients and complementarity-determining region (CDR)3α-specific motif (LSTD*E) present in both Th1/Th17 cells. The study demonstrates that both activated Th1 and Th17 cells of pSS patients showed restricted clonal diversities of which two CDR3 motifs were present in controls and patients, with another two motifs unique to pSS.

Phoenix Rising: The Evolution of Holyoke's Collaborative Organizing for Healthy Food Resilience.

In the Holyoke Food & Fitness Policy Council (HFFPC) case study, the challenges of providing equitable multistakeholder organizing are examined. The importance of housing the work in the community, power sharing, and having community representation in the leadership is made clear. The HFFPC partnership began with vigor, encountered challenges of trust, transparency, aligned goals and values; it dissolved, and reformed. Because it began with shared values of strong communities and healthy people, the partnership continues to evolve, build local leadership, change narratives, and articulate the need for racial equity in their food system, while shifting local systems and policies that frame who has access to healthy food and safe spaces to exercise in a low-income Latino community.

Salivary mucin 19 glycoproteins: innate immune functions in Streptococcus mutans-induced caries in mice and evidence for expression in human saliva.

Saliva functions in innate immunity of the oral cavity, protecting against demineralization of teeth (i.e. dental caries), a highly prevalent infectious disease associated with Streptococcus mutans, a pathogen also linked to endocarditis and atheromatous plaques. Gel-forming mucins are a major constituent of saliva. Because Muc19 is the dominant salivary gel-forming mucin in mice, we studied Muc19(-/-) mice for changes in innate immune functions of saliva in interactions with S. mutans. When challenged with S. mutans and a cariogenic diet, total smooth and sulcal surface lesions are more than 2- and 1.6-fold higher in Muc19(-/-) mice compared with wild type, whereas the severity of lesions are up to 6- and 10-fold higher, respectively. Furthermore, the oral microbiota of Muc19(-/-) mice display higher levels of indigenous streptococci. Results emphasize the importance of a single salivary constituent in the innate immune functions of saliva. In vitro studies of S. mutans and Muc19 interactions (i.e. adherence, aggregation, and biofilm formation) demonstrate Muc19 poorly aggregates S. mutans. Nonetheless, aggregation is enhanced upon adding Muc19 to saliva from Muc19(-/-) mice, indicating Muc19 assists in bacterial clearance through formation of heterotypic complexes with salivary constituents that bind S. mutans, thus representing a novel innate immune function for salivary gel-forming mucins. In humans, expression of salivary MUC19 is unclear. We find MUC19 transcripts in salivary glands of seven subjects and demonstrate MUC19 glycoproteins in glandular mucous cells and saliva. Similarities and differences between mice and humans in the expression and functions of salivary gel-forming mucins are discussed.

New ways to impact primary palliative care practices using online continuing education.

Background: Healthcare professionals trained in palliative care (PC) improve satisfaction and decrease healthcare overutilization for patients with serious illness and their families. A continuing education (CE) series on primary PC aligned to the National Clinical Practice Guidelines for Quality PC was developed by local, interdisciplinary experts for a target audience of rural, primary care healthcare professionals. The modules were accessed on an online learning management system platform. Objective: The study objectives were to assess differences in participants' knowledge, competence, performance, and ability to improve patient care as well as commitment to change practice after taking each of the CE modules. Design and Methods: To achieve these objectives, a descriptive design was used with a convenience sample of healthcare professionals who registered for the CE series and completed at least one module. Participants completed demographic questions and an evaluation survey after completing each module. Results: So far, 158 healthcare professionals have registered for the series with the majority being nurses and social workers. Although the professionals reported having extensive healthcare experience, they did not report having the same level of PC experience. The professionals represent nine different states. All the CE modules increased teamwork skills for most participants. The CE modules on cultural aspects and self-care had the biggest influence on participants' ability to improve patient outcomes. Cultural aspects, care of the actively dying, and advance care planning had the greatest impact on participants' knowledge, competence, and performance. Conclusion: The primary PC education series improved self-reported skills in teamwork, practice habits, and meeting goals of healthcare professionals from a variety of disciplines and settings. These enhanced primary PC skills will improve the incorporation of PC into a variety of practice settings, by multiple disciplines to enhance access to PC outside of, and potentially referrals to, specialty PC programs.Palliative care (PC) is an emerging field of healthcare aimed at positively affecting patients living with serious illness and their families. An important factor that influences a health professional's successful delivery of PC may be their knowledge, experiences, and confidence. PC training provided to healthcare professionals improves patients' and healthcare professionals' satisfaction and reduces healthcare expenditures through cost savings and cost avoidance.1,2.

Prophylactic recombinant erythropoietin therapy and thalidomide are predictors of venous thromboembolism in patients with multiple myeloma: limited effectiveness of thromboprophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is a significant but poorly understood complication in patients with newly diagnosed multiple myeloma (NDMM). As a result, most patients receive thromboprophylaxis with low molecular weight heparin (LMWH). The purpose of this retrospective study was to identify risk factors for VTE in NDMM and evaluate the effectiveness of LMWH. METHODS: A total of 604 patients with newly diagnosed myeloma completed 3 induction cycles with multiagent chemotherapy with up-front randomization to thalidomide between 1998 and 2004. Prophylactic enoxaparin was given to thalidomide recipients beginning in June 2001, and 122 subjects received prophylactic epoetin alfa (EPO) as part of an exercise trial. The primary study endpoint was grades 3-4 VTE. RESULTS: A total of 72 patients (11.9%) developed VTE (mostly deep venous thrombosis), with a higher incidence among EPO recipients (P = .001), although only significant for upper extremity DVT (P = .0002). The EPO-treated patients had higher hemoglobin (Hb) levels throughout the study (P < .0005), although no relationship between higher Hb levels and increasing incidence of VTE could be shown. A history of VTE was a strong predictor of VTE on univariate analysis (P < .000005). Enoxaparin did not reduce the rate of VTE (P = .158). Logistic regression analysis identified thalidomide therapy (P = .001; odds ratio [OR], 2.428; 95% confidence interval [CI], 1.418-4.159) and prophylactic EPO (P = .002; OR, 2.488; 95% CI, 1.432-4.324) as risk factors for VTE. Myeloma response and survival were not negatively affected by prophylactic EPO or VTE. CONCLUSIONS: Prophylactic EPO, thalidomide therapy, and VTE history, but not higher Hb levels, were found to increase the risk of VTE among NDMM patients receiving multiagent chemotherapy. This risk was not found to be reduced in this population by LMWH thromboprophylaxis.

Altered miR-146a expression in Sjögren's syndrome and its functional role in innate immunity.

MicroRNAs (miRNAs), small non-coding RNA molecules that post-transcriptionally regulate gene expression, are known to play key roles in regulating immune responses and autoimmunity. We investigated miR-146a expression in Sjögren's syndrome (SjS) patients as well as in the SjS-prone C57BL/6.NOD-Aec1Aec2 mouse model, to elucidate its involvement in SjS pathogenesis. Expression of miR-146a was examined in the PBMCs of 25 SjS patients and ten healthy donors, as well as in PBMCs, salivary and lacrimal glands of SjS-prone mice and WT C57BL/6J mice. Functional assays using THP-1 human monocytes were conducted to determine the biological roles of miR-146a in innate immunity. Expression of miR-146a was significantly increased in SjS patients compared with healthy controls, and was upregulated in the salivary glands and PBMCs of the SjS-prone mouse at both 8 wk (prior to disease onset) and 20 wk (full-blown disease) of age. More importantly, functional analysis revealed roles for miR-146a in increasing phagocytic activity and suppressing inflammatory cytokine production while migration, nitric oxide production and expression of antigen-presenting/costimulatory molecules are not affected in human monocytic THP-1 cells. Taken together, our data suggest that abnormal expression/regulation of microRNAs in innate immunity may contribute to, or be indicative of, the initiation and progression of SjS.

Covert medication administration: the practice of hiding medications in long-term care settings.

Covert medication administration is the purposeful hiding of medications from patients, and the topic receives little attention. Awareness and research regarding this practice is limited to a handful of studies outside of the United States. These studies suggest a larger prevalence than reported and identify significant ethical and legal implications for bedside nurses. A review of the literature, discussion of prevalence, contributing factors, and potential consequences of this practice build the foundation for practice recommendations and suggestions for future research. In addition to recommendations for nurses regarding covert medication administration, additional research and exploration of this issue in the United States are proposed.

Thunderstorm asthma: a review, risks for Aotearoa New Zealand, and health emergency management considerations.

AIM: To provide an up-to-date review of thunderstorm asthma (TA), identifying causative factors, and to discuss implications for management of TA in New Zealand. METHODS: A literature search was carried out to identify articles that investigate the characteristics and causative factors of TA. Nine electronic databases were searched, yielding 372 articles, reduced to 30 articles after screening for duplication and relevance. RESULTS: TA is globally rare, with 29 reported events since 1983, but is expected to increase in frequency as Earth warms. Triggers include both pollen (particularly ryegrass pollen) and fungal spores. Individual risk factors include outdoor exposure, sensitivity to triggering allergens and history of seasonal allergic rhinitis. History of asthma is not a strong risk factor but is associated with severity of outcome. Limited data on demographic characteristics suggests that individuals aged between 20 and 60 and (in Australasia) of Asian/Indian ethnicity are at higher risk. A single TA event has been reported in New Zealand to date, but much of New Zealand may be at risk of future events given that ryegrass pastures are widely distributed, and summer thunderstorms can occur anywhere. CONCLUSIONS: We recommend developing rapidly deployable public messaging to support the health emergency management response to future TA events, together with the instigation of routine aeroallergen monitoring.

Overexpression of dicer as a result of reduced let-7 MicroRNA levels contributes to increased cell proliferation of oral cancer cells.

Recent reports have demonstrated that Dicer, an RNase III endonuclease required for microRNA (miRNA) maturation, is aberrantly expressed in different types of cancer. Furthermore, Dicer has been reported to be regulated by the let-7 family of miRNA genes. We hypothesize that Dicer is aberrantly expressed in oral cancer cells due to altered expressions of let-7 and that Dicer contributes to the development and progression of the disease. Western blot examination of Dicer protein levels in four head and neck squamous cell carcinoma (HNSCC) cell lines, including two oral cancer cell lines, demonstrated that Dicer had between 4- and 24-fold higher expression levels when compared to normal human primary gingival epithelial cells. Furthermore, five of six oral cancer tissues analyzed by indirect immunofluorescence had increased Dicer protein expression, compared to normal gingival epithelial tissue. The Dicer mRNA levels were not found to correlate well with protein expression in the HNSCC cell lines, suggesting that Dicer protein expression was post-transcriptionally regulated. Analysis of let-7a and let-7b levels in HNSCC cell lines by real-time PCR demonstrated that let-7b, but not let-7a, was significantly reduced in the HNSCC cell lines compared to control cells. Lastly, transfection of oral cancer cells with chemically synthesized let-7b and small interfering RNAs targeting Dicer significantly inhibited cell proliferation up to 83% and >100%, respectively, as early as 3 days post-transfection. Together, these data demonstrate that elevated expression levels of Dicer in oral cancer cells correlate with downregulation of let-7b and increased cell proliferation.

Strategies for Implementing a One Welfare Framework into Emergency Management.

Responding to emergencies requires many different individuals and organisations to work well together under extraordinary circumstances. Unfortunately, the management of animal welfare in emergencies remains largely disconnected from emergency management overall. This is due predominately to professional silos and a failure to understand the importance of human-animal-environment (h-a-e) interdependencies. One Welfare (OW) is a concept with these interrelationships at its core. This paper argues that by adopting an OW framework it will be possible to achieve a transdisciplinary approach to emergency management in which all stakeholders acknowledge the importance of the h-a-e interdependencies and work to implement a framework to support this. Acknowledging that such a transformational change will not be easy, this paper proposes several strategies to overcome the challenges and optimise the outcomes for animal welfare emergency management (AWEM). These include legislation and policy changes including h-a-e interface interactions as business as usual, improving knowledge through interprofessional education and training, incorporating One Welfare champions, and recognising the role of animals as vital conduits into communities.

Development of a simulated lung fluid leaching method to assess the release of potentially toxic elements from volcanic ash.

Freshly erupted volcanic ash contains a range of soluble elements, some of which can generate harmful effects in living cells and are considered potentially toxic elements (PTEs). This work investigates the leaching dynamics of ash-associated PTEs in order to optimize a method for volcanic ash respiratory hazard assessment. Using three pristine (unaffected by precipitation) ash samples, we quantify the release of PTEs (Al, Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb, V, Zn) and major cations typical of ash leachates (Mg, Na, Ca, K) in multiple simulated lung fluid (SLF) preparations and under varying experimental parameters (contact time and solid to liquid ratio). Data are compared to a standard water leach (WL) to ascertain whether the WL can be used as a simple proxy for SLF leaching. The main findings are: PTE concentrations reach steady-state dissolution by 24 h, and a relatively short contact time (10 min) approximates maximum dissolution; PTE dissolution is comparatively stable at low solid to liquid ratios (1:100 to 1:1000); inclusion of commonly used macromolecules has element-specific effects, and addition of a lung surfactant has little impact on extraction efficiency. These observations indicate that a WL can be used to approximate lung bioaccessible PTEs in an eruption response situation. This is a useful step towards standardizing in vitro methods to determine the soluble-element hazard from inhaled ash.

Effect of certification in oncology nursing on nursing-sensitive outcomes.

The study compared certified nurses with noncertified nurses for symptom management of nausea, vomiting, and pain; patient satisfaction; and nurse satisfaction to determine the effect of certification in oncology nursing on those nursing-sensitive outcomes. A total of 93 nurses-35 (38%) of them certified in oncology nursing-and 270 patients completed surveys. Chart audits provided additional data on symptom management. Certified nurses scored higher than noncertified nurses on the Nurses' Knowledge and Attitudes Survey Regarding Pain as well as the Nausea Management: Nurses' Knowledge and Attitudes Survey. The chart audits showed that certified nurses followed National Comprehensive Cancer Network guidelines for chemotherapy-induced nausea and vomiting (CINV) management more often than noncertified nurses. The study demonstrated that job satisfaction is fairly high for oncology nurses and patient satisfaction is high. In general, cancer pain and CINV were managed well but improvements can be made. Nurses and physicians continuously should be educated on evidence-based guidelines for symptom management of cancer pain and CINV, and a CINV knowledge and attitude assessment tool should be developed.

Health Impacts of Volcanic Activity in Oceania.

Volcanoes cause a wide range of hazardous phenomena. Close to volcanic vents, hazards can be highly dangerous and destructive and include pyroclastic flows and surges, ballistic projectiles, lava flows, lahars, thick ashfalls, and gas and aerosol emissions. Direct health impacts include trauma, burns, and exacerbation of respiratory diseases. Far-reaching volcanic hazards include volcanic ashfalls, gas and aerosol dispersion, and lahars. Within Oceania, the island arc countries of Papua New Guinea (PNG), the Solomon Islands, Vanuatu, Tonga, and New Zealand are the most at-risk from volcanic activity. Since 1500ad, approximately 10,000 lives have been lost due to volcanic activity across Oceania, with 39 lives lost since 2000. While volcano monitoring and surveillance save lives, residual risks remain from small, sudden, unheralded eruptions, such as the December 9, 2019 eruption of Whakaari/White Island volcano, New Zealand which has a death toll of 21 at the time of writing. Widespread volcanic ashfalls can affect the habitability of downwind communities by contaminating water supplies, damaging crops and buildings, and degrading indoor and outdoor air quality, as well as disrupting transport and communication networks and access to health services. While the fatality rate due to volcanic eruptions may be low, far greater numbers of people may be affected by volcanic activity with approximately 100,000 people in PNG and Vanuatu displaced since 2000. It is challenging to manage health impacts for displaced people, particularly in low-income countries where events such as eruptions occur against a background of low, variable vaccination rates, high prevalence of infectious diseases, poor sanitation infrastructure, and poor nutritional status. As a case study, the 2017-2018 eruption of Ambae volcano, Vanuatu caused no casualties but triggered two separate mandatory off-island evacuations of the entire population of approximately 11,700 people. On the neighboring island of Santo, a health disaster response was coordinated by local government and provided acute care when evacuees arrived. Involving primary care clinicians in this setting enhanced local capacity for health care provision and allowed for an improved understanding of the impact of displacement on evacuee communities.

Severe Restrictive Lung Disease in One of the Oldest Documented Males With Coffin-Lowry Syndrome.

Coffin-Lowry syndrome is expressed as different phenotypes in males and females. In males, it is characterized by facial abnormalities, marked developmental disability, and skeletal changes. Approximately 80% of cases are associated with kyphoscoliosis, which can be quite severe, as seen in our patient, causing paraplegia and restrictive lung disease. In this article, we present the third oldest documented male case of Coffin-Lowry syndrome with severe kyphoscoliosis, paraplegia, and restrictive lung disease.

Salivary dysfunction and quality of life in Sjögren syndrome: a critical oral-systemic connection.

BACKGROUND: The importance of oral health to systemic health and quality of life (QOL) is gaining attention. Although several studies have examined generic (general) QOL in Sjögren syndrome (SS), little information exists on the effect of oral health on QOL and relationships among self-reported oral health, systemic health and objective clinical measures of health. The authors conducted this study to characterize these relationships in a sample of patients with SS. METHODS: Thirty-nine patients with a diagnosis of SS ascertained by means of the 2002 American-European Consensus criteria completed both the Oral Health Impact Profile (OHIP-14) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) QOL questionnaires. OHIP-14 measures pain; functional limitation; and psychological, emotional and social disability associated with the mouth. SF-36 measures physical and emotional health and the ability to perform usual activities. Additional measures included the number of self-reported autoimmune symptoms and an index of disease damage. Statistical analysis was performed by using hierarchical regression analysis. RESULTS: Both generic and oral health-related QOL were poor in these patients. Specifically, the findings indicated that salivary flow rate was correlated significantly with both Disease Damage Index and OHIP-14 ratings, the number of autoimmune symptoms was correlated significantly with both oral and generic QOL, and oral health accounted for a significant percentage of variance in SF-36 domains of general health and social function. CONCLUSIONS: Oral health appears to have an independent influence on general QOL in patients with SS. These findings underscore the importance of proactive dental management of the oral manifestations of SS. CLINICAL IMPLICATIONS: Dentists and physicians must work collaboratively to maintain oral health and quality of life for patients with Sjögren syndrome. The dentist should address patients' concerns of xerostomia and hyposalivation in an aggressive manner.

Florid cemento-osseous dysplasia mimicking multiple periapical pathology--an endodontic dilemma.

A case of florid cemento-osseous dysplasia (COD) mimicking periapical pathology is presented. The fact that the patient's lesion failed to resolve three years after root canal therapy, in addition to the presence of a mixed radiolucency with discreet radiopacities, mandated a biopsy which (along with radiographic co-relation) confirmed the diagnosis of cemento-osseous dysplasia. This case report illustrates the point that periapical radiolucencies may represent benign fibro-osseous lesions that may be overlooked or result in unnecessary endodontic treatment.

Gingival involvement in Crohn disease.

BACKGROUND: Although the oral manifestations of Crohn disease are well-established, there is little specific documentation of the gingival involvement. CASE DESCRIPTION: The authors describe four patients with significant gingival involvement and identify clinical signs and symptoms of the disease involving the gingivae, along with other oral manifestations. Patients had persistent gingival lesions manifesting as pustular ulcerations, erythema, swelling and cobblestoning. The authors also discuss the differential diagnosis, treatment options and prognostic factors. CLINICAL IMPLICATIONS: Patients with gingival and/or other oral lesions with or without other constitutional symptoms should be evaluated for Crohn disease. Dentists can play a critical role in the early diagnosis, and they can help prevent complications and improve the prognosis.

Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review.

BACKGROUND: Hyperplastic granular gingivitis or "strawberry gingivitis" is a rare manifestation of Wegener's granulomatosis (WG), but it is nearly pathognomonic for this multisystem autoimmune vasculitis. The dentist may be the first health care professional to see patients with symptoms and findings of this condition. Early diagnosis and treatment is the most important factor in the management of this potentially fatal disease. METHODS: The authors present three case reports that demonstrate the disease spectrum and conducted a literature review focused on current understanding of this disease. RESULTS: The first patient had only the classic gingival manifestations of the disease. The second patient had simultaneous typical gingival lesions, as well as dermatologic findings. The third patient had an atypical oral presentation of aphthous ulcers and erythematous gingiva, as well as respiratory and genital involvement. Reaching a definitive diagnosis sometimes is challenging owing to the subtle onset of the disease and variable clinical and laboratory findings. CONCLUSION AND CLINICAL IMPLICATIONS: Clinicians should be familiar with the broad variety of oral and systemic components of WG, as well as strategies to facilitate prompt disease recognition and to provide continued oral health care to these medically complex patients.