Eligibility Criteria for Active Ulcerative Pyoderma Gangrenosum in Clinical Trials: A Delphi Consensus on Behalf of the UPGRADE (Understanding Pyoderma Gangrenosum: Review and Assessment of Disease Effects) Group.

At present, there are no standardized guidelines for determining patient eligibility for pyoderma gangrenosum (PG) clinical trials. Thus, we aim to determine which clinical features, histopathological features, or laboratory features should be included in active ulcerative PG clinical trial eligibility criteria for treatment-naïve patients and patients already treated with immunomodulating medications (treatment-exposed patients). This study employed 4 rounds of the Delphi technique. Electronic surveys were administered to 21 international board-certified dermatologists and plastic surgeon PG experts (June 2022-December 2022). Our results demonstrated that for a patient to be eligible for a PG trial, they must meet the following criteria: (i) presence of ulcer(s) with erythematous/violaceous undermining wound borders, (ii) presence of a painful or tender ulcer, (iii) history/presence of rapidly progressing disease, (iv) exclusion of infection and other causes of cutaneous ulceration, (v) biopsy for H&E staining, and (vi) a presence/history of pathergy. These criteria vary in importance for treatment-naïve versus treatment-exposed patients. Given the international cohort, we were unable to facilitate live discussions between rounds. This Delphi consensus study provides a set of specific, standardized eligibility criteria for PG clinical trials, thus addressing one of the main issues hampering progress toward Food and Drug Administration approval of medications for PG.

The "Understanding Pyoderma Gangrenosum, Review and Assessment of Disease Effects (UPGRADE)" Project: a protocol for the development of the core outcome domain set for trials in pyoderma gangrenosum.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that affects approximately 0.3-6 out of every 100,000 people worldwide. Clinical trials are scarce but there is growing interest in using newer and more targeted therapeutics to achieve disease remission. However, there are no standardized instruments to measure outcomes in PG and, therefore, future clinical trials are hampered by the absence of established and accurate means of assessment and comparison. Therefore, we aim to produce an internationally accepted core outcome set (COS) that will overcome this obstacle. This protocol outlines our intended approach to achieve the first part of this process, establishing a core outcome domain set. METHODS: An international team of PG stakeholders, consisting of physicians, wound care nurses, patients, scientists and industry representatives, has been assembled for the purpose of building a comprehensive and universally established set of core outcome domains. During the first step, we will generate items of relevance using a nominal process from all stakeholders. Items will be distilled and collapsed into potential domains and subdomains. A systematic review of current methods for reporting PG has already been published and domains identified in this work will be considered in the generation of the core domains set. During the second step, after the potential domains and subdomains are identified, stakeholders will participate in an e-Delphi exercise to rate the importance of (sub)domains. A final consensus meeting will be organized with the goal of establishing a core domain set. CONCLUSION: Pyoderma gangrenosum lacks an established COS and previously published clinical trials have used inconsistent measures established from similarly inconsistent domains. As a first step this study seeks to create a core domain set within the COS, to build the foundation for future core outcome work for PG.

Polypharmacy prevalence in older adults seen in United States physician offices from 2009 to 2016.

BACKGROUND/OBJECTIVES: With an aging population suffering from increased prevalence of chronic conditions in the United States (U.S.), a large portion of these patients are on multiple medications. High-risk medications can increase the risk for drug-drug interactions and medication nonadherence. This study aims to describe the prevalence of polypharmacy and high-risk medication prescribing in U.S. physician offices. METHODS: This was a cross-sectional study of the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. All patients over 65 years old were included. Polypharmacy was categorized as no polypharmacy (< 2 medications), minor polypharmacy (2-3 medications), moderate polypharmacy (4-5 medications), and major polypharmacy (>5 medications). Medications were further categorized into high-risk medication categories (anticholinergics, cardiovascular agents, central nervous system (CNS) medications, pain medications, and other). Comparisons between the degrees of polypharmacy were performed utilizing chi-square or Wilcoxon rank-sum tests with JMP Pro 14® (SAS Institute, Cary, NC). RESULTS: Over 2 billion patient visits were included. Overall, Polypharmacy was common (65.1%): minor polypharmacy (16.2%), moderate polypharmacy (12.1%), and major polypharmacy (36.8%). Patients with major polypharmacy were older compared to those with moderate or minor polypharmacy (75 vs. 73 years, respectively) and were most frequently prescribed pain medications (477.3 per 1,000 total visits). NSAIDs were the most frequently prescribed, with 232.4 per 1,000 total visits resulting in one high-risk NSAID prescription, while 21.9 per 1,000 total visits resulted in two or more high-risk NSAIDs. CONCLUSION: Most patients over 65 years experienced some degree of polypharmacy, with many experiencing major polypharmacy. This indicates an increased need for expanded pharmacist roles through medication therapy management and safety monitoring in this patient population.

Sensitive Detection of SARS-CoV-2-Specific Antibodies in Dried Blood Spot Samples.

Dried blood spot (DBS) samples can be used for the detection of severe acute respiratory syndrome coronavirus 2 spike antibodies. DBS sampling is comparable to matched serum samples with a relative 98.1% sensitivity and 100% specificity. Thus, DBS sampling offers an alternative for population-wide serologic testing in the coronavirus pandemic.

Change Is Happening: An Evaluation of Gender Disparities in Academic Plastic Surgery.

BACKGROUND: Gender disparities in academic plastic surgery are known; however, recently, professional societies have endorsed a culture of gender diversification. This study aims to evaluate the effects of these changes at faculty and leadership positions. METHODS: A cross-sectional study was conducted in June of 2018 to evaluate gender representation among U.S. academic plastic surgery faculty, and compare career qualifications, years of experience, and faculty positions. RESULTS: A total of 938 academic plastic surgeons were identified, of which only 19.8 percent were women. Female surgeons graduated more recently than men (2009 versus 2004; p < 0.0001) and predominantly from integrated residency programs (OR, 2.72; 95 percent CI, 1.87 to 3.96), were more likely to be an assistant professor (OR, 2.19; 95 percent CI, 1.58 to 3.05), and were less likely to be a full professor (OR, 0.20; 95 percent CI, 0.11 to 0.35) or program chair (OR, 0.32; 95 percent CI, 0.16 to 0.65). After adjustment for differences in years of postresidency experience, only disparities at the full professor position remained significant (OR, 0.34; 95 percent CI, 0.16 to 0.17), indicating that experience-independent gender inequality is prominent at the full professor level and that current differences in cohort experience are a significant contributor to many of the observed positional disparities. Lastly, programs led by a female chair employed significantly more female faculty (32.5 percent versus 18.2 percent; p = 0.016). CONCLUSIONS: Gender diversity in academic plastic surgery remains a significant issue, but may see improvement as the disproportionately high number of junior female academics advance in their careers. However, leadership and promotion disparities between men and women still exist and must be addressed.

Community-Based Health Insurance Increased Health Care Utilization and Reduced Mortality in Children Under-5, Around Bwindi Community Hospital, Uganda Between 2015 and 2017.

Introduction: Out-of-pocket fees to pay for health care prevent poor people from accessing health care and drives millions into poverty every year. This obstructs progress toward the World Health Organization goal of universal health care. Community-based health insurance (CBHI) improves access to health care primarily by reducing the financial risk. The association of CBHI with reduced under-5 mortality was apparent in some voluntary schemes. This study evaluated the impact of eQuality Health Bwindi CBHI scheme on health care utilization and under-5 mortality in rural south-western Uganda. Methods: This was a retrospective cross-sectional study using routine electronic data on health insurance status, health care utilization, place of birth, and deaths for children aged under-5 in the catchment area of Bwindi Community Hospital, Uganda between January 2015 and June 2017. Data was extracted from four electronic databases and cross matched. To assess the association with health insurance, we measured the difference between those with and without insurance; in terms of being born in a health facility, outpatient attendance, inpatient admissions, length of stay and mortality. Associations were assessed by Chi-Square tests with p-values < 0.05 and 95% confidence intervals. For variables found to be significant at this level, multivariable logistic regression was done to control for possible confounders. Results: Of the 16,464 children aged under-5 evaluated between January 2015 and June 2017, 10% were insured all of the time 19% were insured for part of the period, and 71% were never insured. Ever having had health insurance reduced the risk of death by 36% [aOR; 0.64, p = 0.009]. While children were insured, they visited outpatients ten times more, and were four times more likely to be admitted. If admitted, they had a significantly shorter length of stay. If mother was uninsured, children were less likely to be born in a health facility [adjusted odds ratio (aOR) 2.82, p < 0.001]. Conclusion: This study demonstrated that voluntary CBHI increased health care utilization and reduced mortality for children under-5. But the scheme required appreciable outside subsidy, which limits its wider application and replicability. While CBHIs can contribute to progress toward Universal Health Care they cannot always be afforded.

Diversity in dermatology: Roadmap for improvement.

The American Academy of Dermatology has taken an active stance in addressing the lack of racial and ethnic diversity in the specialty. At the American Academy of Dermatology President's Conference on Diversity in Dermatology, which was held on August 5, 2017, key action items to increase the number of practicing board-certified dermatologists who are under-represented in medicine (UIM) were identified in 3 main areas. The action items include increasing the pipeline of UIM students applying to medical school, increasing UIM medical students' exposure to the field of dermatology and their level of interest in it, and increasing the number of UIM students recruited into dermatology residency programs.

Increasing yield stability and input efficiencies with cost-effective mechanization in Nepal.

Nepal is at a crossroads of diminishing farm-labor and inadequate investment into farming operations that, among other factors, have stagnated domestic wheat yield. Cultural and economic constraints have hindered the widespread adoption of more expensive precision agriculture technologies like zero-till that have the capacity to improve labor and farm input efficiencies. To capture the benefits from added precision of application but with the ability to fit within the current semi-mechanized seed bed preparation and tillage system, we introduced a low-cost, chest mounted seed and fertilizer. We found that simple mechanization caused yield efficiencies to be positive and significant for nitrogen and phosphate. Seed rates using this method were positively associated with seedling density. This led to both yield and profit being more predictable for farmers. Conversely, hand-applied inputs caused a disassociation between inputs and end of season yield and therefore added a large measure of risk to their farming operations.

Innovative Demand Creation for Voluntary Medical Male Circumcision Targeting a High Impact Male Population: A Pilot Study Engaging Pregnant Women at Antenatal Clinics in Kampala, Uganda.

BACKGROUND: Circumcision has been shown to be an effective method of HIV prevention; however, only 27% of Ugandan men aged 15-49 years are circumcised. There is a paucity of data on the role of intimate partners in generating demand for voluntary medical male circumcision (VMMC). We conducted a pilot study to assess the feasibility of a partner-focused intervention targeting males >25 years. METHODS: Among pregnant women in their third trimester attending antenatal care we evaluated the impact of a pilot behavior change intervention on VMMC through a quasi-experimental approach. We observed VMMC numbers among spouses of women as per standard practice (comparison phase), and after introducing a behavioral change communication package (intervention phase). Logistic regression was used to compare the odds of VMMC uptake between comparison and intervention phases. We used qualitative methods to evaluate the casual chain using a thematic approach. RESULTS: Of the 601 women studied, 90% articulated the health benefits of VMMC and 99% expressed interest in their spouse getting circumcised. Women's knowledge was not increased by the intervention. Four men were circumcised in the comparison and 7 in the intervention phase. The intervention was not associated with higher odds of circumcision (odds ratio 1.5, 95% CI: 0.3 to 6.0, P = 0.65). We interviewed 117 individuals overall with the main enablers for VMMC being: free VMMC, transport reimbursement, and health benefits. Deterrents included misconceptions, lost wages and fear of pain. Most of the uncircumcised men interviewed reported interest in VMMC. CONCLUSIONS: Our pilot intervention had no significant impact on increasing VMMC demand. The study demonstrated the feasibility of pregnant women engaging their spouses to discuss VMMC.

vizHOME--A context-based home assessment: Preliminary implications for informatics.

The rapid migration of health care from the institution to the home presents a plethora of consumer health technology options.. The fit of these technologies to the users' actual task performance and environment remains to be explored. In the vizHOME study, we set out to conduct in-depth analyses of health information management tasks conducted by individuals residing in 20 homes in the Midwestern United States who self-reported with diabetes. This paper will explore early results from five of the 13 assessments we have performed to-date. Early observations are described and implications for informatics are posited.

Achieving attainable outcomes from good science in an untidy world: case studies in land and air pollution.

While scientific understanding of environmental issues develops through careful observation, experiment and modelling, the application of such advances in the day to day world is much less clean and tidy. Merseyside in northwest England has an industrial heritage from the earliest days of the industrial revolution. Indeed, the chemical industry was borne here. Land contamination issues are rife, as are problems with air quality. Through the examination of one case study for each topic, the practicalities of applied science are explored. An integrated, multidisciplinary response to pollution needs more than a scientific risk assessment. The needs of the various groups (from public to government) involved in the situations must be considered, as well as wider, relevant contexts (from history to European legislation), before a truly integrated response can be generated. However, no such situation exists in isolation and the introduction of environmental investigations and the exploration of suitable, integrated responses will alter the situation in unexpected ways, which must be considered carefully and incorporated in a rolling fashion to enable solutions to continue to be applicable and relevant to the problem being faced. This integrated approach has been tested over many years in Merseyside and found to be a robust approach to ever-changing problems that are well described by the management term, "wicked problems".

Perspectives of paediatric and adult gastroenterologists on transfer and transition care of adolescents with inflammatory bowel disease.

BACKGROUND: Programmes specific to inflammatory bowel disease (IBD) that facilitate transition from paediatric to adult care are currently lacking. AIM: We aimed to explore the perceived needs of adolescents with IBD among paediatric and adult gastroenterologists and to identify barriers to effective transition. METHODS: A web-based survey of paediatric and adult gastroenterologists in Australia and New Zealand employed both ranked items (Likert scale; from 1 not important to 5 very important) and forced choice items regarding the importance of various factors in facilitating effective transition of adolescents from paediatric to adult care. RESULTS: Response rate among 178 clinicians was 41%. Only 23% of respondents felt that adolescents with IBD were adequately prepared for transition to adult care. Psychological maturity (Mean = 4.3, standard deviation (SD) = 0.70) and readiness as assessed by adult caregiver (Mean = 4, SD = 0.72) were prioritised as the most important factors in determining timing of transfer. Self-efficacy and readiness as assessed by adult caregiver were considered the two most important factors to determine timing of transition by both groups of gastroenterologists. Poor medical and surgical handover (Mean = 4.10, SD = 0.8) and patients' lack of responsibility for their own care (Mean= 4.10, SD = 0.82) were perceived as major barriers to successful transition by both paediatric and adult gastroenterologists. CONCLUSIONS: Deficiencies exist in current transition care of adolescents with IBD in Australia and New Zealand. Standardising transition care practices with strategies aimed at optimising communication, patient education, self-efficacy and adherence may improve outcomes.

Developing independent investigators for clinical research relevant for Africa.

Sustainable research capacity building requires training individuals at multiple levels within a supportive institutional infrastructure to develop a critical mass of independent researchers. At many African medical institutions, a PhD is important for academic promotion and is, therefore, an important focal area for capacity building programs. We examine the training at the Infectious Diseases Institute (IDI) as a model for in-country training based on systems capacity building and attention to the academic environment. PhD training in Africa should provide a strong research foundation for individuals to perform independent, original research and to mentor others. Training the next generation of researchers within excellent indigenous academic centers of excellence with strong institutional infrastructure will empower trainees to ask regionally relevant research questions that will benefit Africans.

Safety-net burden hospitals and likelihood of curative-intent surgery for non-small cell lung cancer.

BACKGROUND: Black patients are less likely to undergo surgery for early-stage non-small cell lung cancer (NSCLC) compared with white patients, and are more likely to undergo resection at low-volume hospitals. However, little is known about the relationship between hospital safety-net burden and the likelihood of curative-intent surgery for black and white patients. This study analyzes whether hospital safety-net burden is associated with curative-intent surgery among adult early-stage NSCLC patients treated at facilities accredited by the American College of Surgeons Commission on Cancer. STUDY DESIGN: Adult patients diagnosed with invasive initial primary early-stage (TNM I-II) NSCLC during 2003-2005 were obtained from the National Cancer Data Base. Curative-intent surgery included anatomic resection, wedge resection, and segmentectomy. Hospital safety-net burden was defined as the percent of cancer patients per facility that were Medicaid-insured or uninsured. Generalized estimating equations and linear mixed models were used to control for clustering by facility. RESULTS: Of 52,853 evaluable patients, those treated at high safety-net burden facilities were significantly less likely (unadjusted p < 0.0001) to undergo curative-intent surgery than patients treated at low safety-net burden facilities. Controlling for patient and other facility characteristics, high safety-net burden remained significantly associated (p < 0.0001) with reduced likelihood of curative-intent surgery overall (odds ratio = 0.69; 95% CI, 0.62-0.77) and in black- and white-only models (odds ratio = 0.59, 95% CI, 0.48-0.73; odds ratio = 0.71; 95% CI, 0.63-0.80, respectively). CONCLUSIONS: Both black and white adult patients treated for early-stage NSCLC at high safety-net burden facilities are less likely to undergo curative-intent surgery than those treated at low safety-net burden facilities. Innovative solutions are needed to ensure quality cancer care at high safety-net burden facilities.

Real or illusory? Case studies on the public perception of environmental health risks in the north west of England.

Applied research in a public health setting seeks to provide professionals with insights and knowledge into complex environmental issues to guide actions that reduce inequalities and improve health. We describe ten environmental case studies that explore the public perception of health risk. We employed logical analysis of components of each case study and comparative information to generate new evidence. The findings highlight how concerns about environmental issues measurably affect people's wellbeing and led to the development of new understanding about the benefits of taking an earlier and more inclusive approach to risk communication that can now be tested further.

Strategies to optimize HIV treatment outcomes in resource-limited settings.

Although the availability of antiretroviral therapy has increased rapidly to reach over three million people in low- and middle-income countries, coverage remains low as only 31% of people in need were receiving antiretroviral therapy in sub-Saharan Africa. Antiretroviral therapy scale-up needs to continue to grow exponentially to meet the need for universal access and keep pace with or exceed the new HIV infections. This calls for strategies that will have the greatest impact on the reduction of opportunistic infections, toxicities, and early mortality after antiretroviral therapy initiation as well improve adherence, clinical, immunological, and virologic responses, patient retention in antiretroviral therapy programs, and overall quality of life of people living with HIV/AIDS. Expanding antiretroviral therapy to all those eligible requires evidence-based decisions about how, when, and where expansion should occur. In this article we highlight some of the strategies that have optimized HIV treatment outcomes within the constraints of limited resources in sub-Saharan Africa. Key strategies to optimize HIV treatment outcomes include, i) scaling up HIV testing to identify all in need of HIV treatment, ii) strengthening the links between HIV diagnosis and comprehensive HIV/AIDS care, iii) timely initiation of antiretroviral therapy, iv) optimal diagnosis and treatment of opportunistic infections and comorbidities, v) investing in laboratory tests to support clinical monitoring of patients on antiretroviral therapy, vi) maximizing adherence to antiretroviral medication and retention of patients in HIV/AIDS care, viii) improving the health infrastructure, and increasing the human resources to handle the growing numbers of people in need of HIV treatment.

Time to treatment of prostate cancer through the Calgary Prostate Institute rapid access clinic.

PURPOSE: To determine the wait time between initial referral, biopsy, diagnosis and individual treatment modalities of prostate cancer treatment through the Calgary Prostate Institute rapid access clinic (RAC) and compare to historical data estimates in Alberta and to suggested standards. Biopsy rate, rate of confirmed prostate cancer and the distribution of treatment modality for patients seen through the RAC is included. MATERIALS AND METHODS: A non-consented, retrospective chart review of 1103 patients from the Calgary Health Region referred to the RAC between September 2005 and August 2006 was completed. RESULTS: Patients experienced a median wait time of 21 days between referral from their family doctor and prostate biopsy. A total of 31.4% of patients referred to the clinic were requested to have a prostate biopsy performed and 50.8% of biopsies resulted in confirmed prostate cancer requiring treatment. Median wait time between diagnosis and treatment for all treatment types was 52.0 days with a 90th percentile of 146.2 days. Median wait time between referral and treatment for all treatment modalities was 101 days with a 90th percentile of 187.2 days. CONCLUSION: Calgary rapid access clinic reduces wait time between referral and biopsy by 78%. Stratifying across treatment type indicates that watchful waiting is the shortest time duration and radiation with hormone therapy is the longest.

[Preliminary result of dynamic contrast-enhanced MR imaging in assessment of cellularity characteristics of bone marrow in patients with haematological malignancies].

OBJECTIVE: To evaluate the correlation of bone marrow status in haemotological malignancy patient with the variable value of dynamic contrast-enhanced MR (DCE-MRI). METHODS: DCE-MRI result were obtained from 25 patients with pathologically proven haematological malignancies. Time-signal intensity curves (TIC) was generated from the region of the iliac crest corresponding to the planned biopsy site. Enhancement characteristics including peak enhance ratio (PER) , maximum slope (Slopemax), time to peak ( TP) and mean time (MT) were analyzed. The patients received bone marrow biopsy on the crest 30 min after DCE-MRI, and then the parameters of bone marrow histology including cellularity was analyzed. RESULTS: In this series, 3 patients showed type B TIC, 7 type C, 13 type D and 2 type E. The bone marrow cellularity with haematological malignancies cannot be demostrated by TIC type. The mean PER value and Slopemax value in the patients with hypercellularity was significantly higher than that with normal cellularity and hypocellularity. The mean TTP value of the patients with hypercellularity (60.20 +/- 61.62) was significantly lower than that in the patients with hypocellularity (97.43 +/- 1.07) or normal cellularity (78.44 +/- 38.02). There was no significant difference in the mean MT value among three groups. CONCLUSION: Our preliminary findings suggest that the bone marrow cellularity in the patient with haematological malignancies can not be revealed by conventional MR, but it may be demonstrated by semi-quantitative calculation of the variable value from DCE-MR imaging.

Factors associated with orthodontists' assessment of difficulty.

The difficulty of achieving an ideal or normal occlusion might lie in the pretreatment occlusion, patient-associated factors, and the treatment. The purpose of this study was to identify factors that were related to the treating orthodontist's posttreatment categorization of a case as difficult or easy. Ten orthodontists each identified 10 easy cases and 10 difficult cases that they had treated. The initial malocclusion was measured with the peer assessment rating (PAR) index and the index of orthodontic treatment need (IOTN). Patient and treatment information was obtained from the treatment records. Statistical analysis with parametric or nonparametric testing was performed. Difficult cases had greater severity and need before treatment and greater residual malocclusion and need after treatment. Difficult cases had more chart entries for problems with hygiene and compliance. They were more likely to have had extractions and changes in treatment plan. Difficult cases also required more appointments and a longer treatment duration. Three logistic regression models were developed based on malocclusion severity, patient characteristics, and treatment characteristics. The models support a correlation between greater pretreatment malocclusion severity, 1-phase treatment, and the designation as a difficult case. This study supports a model in which malocclusion severity and factors associated with the patient and the treatment contribute to an orthodontist's categorization of a case as easy or difficult.