Evaluating the nature and prevalence of glucocorticoid-induced type 2 diabetes mellitus in patients with autoimmune bullous diseases.

Glucocorticoid use in patients with autoimmune bullous disease is associated with significant morbidity, and in some cases, excess mortality. The hyperglycaemic complications arising from glucocorticoid use have been well-documented and range from mild hyperglycaemia to diabetic ketoacidosis. Patients with pre-existing glucose intolerance or type 2 diabetes mellitus are at increased risk of developing complications. Several other factors have been investigated for their association with steroid-induced hyperglycaemia, including patient age, sex, family history, dose, regimen and duration of therapy. Findings in the current literature, however, are largely conflicting and evidence is limited by methodological weaknesses. Glucocorticoids should be used with caution, and patients using steroids should be closely monitored for adverse effects.

A review of JAK and IL-23 inhibitors to treat vitiligo.

Vitiligo is an autoimmune skin disorder resulting in the depigmentation of skin characterised by patches of varying sizes and shapes. A common disorder of pigmentation that affects 0.5%-2% of the global population. Despite its well-understood autoimmune pathogenesis, the targets for effective cytokine intervention remain unclear. Current first-line treatments include oral or topical corticosteroids, calcineurin inhibitors and phototherapy. These treatments are limited, have varying efficacies, and are associated with significant adverse events or can be time-consuming. Therefore, biologics should be explored as a potential treatment for vitiligo. There are currently limited data for the use of JAK and IL-23 inhibitors for vitiligo. A total of 25 studies were identified in the review. There is promising evidence regarding the use of JAK and IL-23 inhibitors for the treatment of vitiligo.

A translation re-initiation variant in KLHL24 also causes epidermolysis bullosa simplex and dilated cardiomyopathy via intermediate filament degradation.

This study shows that gain-of-function variants in KLHL24 causing EBS and DCM, do not only originate in the start-codon and suggest that any nonsense-inducing variant affecting nucleotides c.4_84 will likely cause the same effect on protein level and a similar potential lethal phenotype.

Emergency consultants value medical scribes and most prefer to work with them, a few would rather not: a qualitative Australian study.

OBJECTIVE: The utilisation of medical scribes in the USA has enabled productivity gains for emergency consultants, though their personal experiences have not been widely documented. We aimed to evaluate the consultant experience of working with scribes in an Australian ED. METHODS: Emergency consultants working with scribes and those who declined to work with scribes were invited to participate in individual interviews (structured and semistructured questions) about scribes, scribe work and the scribe program in October 2016. RESULTS: Of 16 consultants, 13 participated in interviews, that is, 11 worked with scribes and 2 did not and 3 left Cabrini prior to the interviews. Consultants working with scribes found them most useful for capturing initial patient encounters, for finding information and completing discharge tasks. Scribes captured more details than consultants usually did. Editing was required for omissions, misunderstandings and rearranging information order, but this improved with increasing scribe experience. Consultants described changing their style to give more information to the patient in the room. Consultants felt more productive and able to meet demands. They also described enjoyment, less stress, less cognitive loading, improved ability to multitask, see complex patients and less fatigue.In interviews with the two consultants declining scribes, theme saturation was not achieved. Consultants declining scribes preferred to work independently. They did not like templated notes and felt that consultation nuances were lost. They valued their notes write-up time as time for cognitive processing of the presentation. They thought the scribe and computer impacted negatively on communication with the patient. CONCLUSION: Medical scribes were seen to improve physician productivity, enjoyment at work, ability to multitask and to lower stress levels. Those who declined scribes were concerned about losing important nuances and cognitive processing time for the case.

Acute esophageal injury and strictures following corrosive ingestions in a 27year cohort.

PURPOSE: We aimed to determine the incidence of esophageal strictures in corrosive ingestions and potential predictors of severe injury. BASIC PROCEDURES: This was a retrospective cohort study of corrosive ingestions from a toxicology unit (1987-2013) with telephone follow-up at least 1 y post-ingestion. Clinical data and investigations were obtained from a toxicology admission database. The primary outcome was esophageal stricture. Other outcomes included in-hospital mortality, endoscopy grade and early complications. MAIN FINDINGS: There were 89 corrosive ingestions; median age, 31 y [1-87 y; 46 females], including 13 strong alkalis (pH>12), 8 strong acids (pH<2), 29 domestic bleaches, 30 other domestic products, 6 non-domestic products and three unknown. Three patients died in hospital within 24 h (phenol, sodium azide, HCl). Two developed strictures (both strong alkalis): one had complete esophageal destruction; another developed a stricture after 25 d (inpatient grade 2A endoscopy). 24 patients were asymptomatic and discharged without complication. 65 patients were symptomatic (4 catastrophic injuries). 61 reported sore mouth/throat (50), abdominal pain (21), chest pain (17), dysphagia (13); 28 had an abnormal oropharyngeal examination. 25/61 symptomatic patients underwent inpatient endoscopy: normal (3), grade 1 (5), grade 2 (15) and grade 3 (2). Of 88 patients, 12 died (3 inpatients, 9 unrelated), 28 couldn't be contacted and 48 were contacted after 1.7-24 y, including two with strictures. Five couldn't be interviewed (normal endoscopy (1), no dysphagia (3) and stroke (1). 4/41 interviewed reported dysphagia but no objective evidence of stricture. PRINCIPAL CONCLUSIONS: All inpatient deaths and severe complications were apparent within hours of ingestion, and occurred with highly corrosive substances. One delayed stricture occurred, not predicted by inpatient endoscopy.

Podiatric assessment in children and adults with epidermolysis bullosa: are foot and ankle patient-reported outcome measures (PROMs) able to measure the severity of podiatric involvement among EB patients?

Epidermolysis bullosa (EB) represents a group of rare genetic skin fragility disorders characterized by (muco) cutaneous blistering upon minimal mechanical trauma. Ninety percent of EB patients experience podiatric symptoms which may affect physical functioning and emotional well-being. To date, an EB-specific podiatric assessment has not been outlined to guide clinicians in the assessment of EB podiatric involvement. This review describes the podiatric involvement of patients with EB and assesses the relevance of validated foot and ankle patient-reported outcome measures (PROMs) in measuring podiatric severity among EB patients. A literature review was conducted to identify systematic reviews and clinical studies investigating foot health and podiatric manifestations using validated foot health PROMs across foot and ankle conditions. Limited studies have documented the significance of podiatric involvement among EB patients. Existing EB-specific PROMs are not region-specific for assessing podiatric involvement. Among the foot and ankle PROMs, the Foot Health Status Questionnaire, Foot Function Index, and Manchester Oxford Foot Questionnaire were identified as potentially appropriate for assessing podiatric severity among EB patients, each with its strengths and limitations in assessment. However, they have not been widely validated for assessing dermatology-related diseases. An evaluation of the relevance of each identified PROM to EB podiatric assessment would enable future development of an appropriate EB-specific podiatric assessment tool that would guide management.

Autoimmune blistering skin diseases triggered by COVID-19 vaccinations: An Australian case series.

Autoimmune blistering skin diseases (AIBD) can be induced or flared by a multitude of sources, however, there have been some reports suggesting that this occurrence is due to COVID-19 vaccinations. At a single academic blistering disease centre in Sydney, Australia, a retrospective review was conducted, identifying 59 patients with AIBD seen between February 2021 and November 2022. Secondary to recent COVID-19 vaccination, four patients had induction of bullous pemphigoid, three patients had a flare of pre-existing bullous pemphigoid, one patient had induction of pemphigus, and two patients had a flare of pre-existing pemphigus vulgaris. This adds to our understanding of the role of vaccinations in the activity of AIBD.

The epidemiology of overtransfusion of red cells in trauma resuscitation patients in the context of a mature massive transfusion protocol.

PURPOSE: Packed red blood cell (PRBC) transfusion remains an integral part of trauma resuscitation and an independent predictor of unfavourable outcomes. It is often administered urgently based on clinical judgement. These facts put trauma patients at high risk of potentially dangerous overtransfusion. We hypothesised that trauma patients are frequently overtransfused and overtransfusion is associated with worse outcomes. METHODS: Trauma patients who received PRBCs within 24 h of admission were identified from the trauma registry during the period January 1 2011-December 31 2018. Overtransfusion was defined as haemoglobin concentration of greater than or equal to 110 g/L at 24 h post ED arrival (± 12 h). Demographics, injury severity, injury pattern, shock severity, blood gas values and outcomes were compared between overtransfused and non-overtransfused patients. RESULTS: From the 211 patients (mean age 45 years, 71% male, ISS 27, mortality 12%) who met inclusion criteria 27% (56/211) were overtransfused. Patients with a higher pre-hospital systolic blood pressure (112 vs 99 mmHg p < 0.01) and a higher initial haemoglobin concentration (132 vs 124 p = 0.02) were more likely to be overtransfused. Overtransfused patients received smaller volumes of packed red blood cells (5 vs 7 units p = 0.049), fresh frozen plasma (4 vs 6 units p < 0.01) and cryoprecipitate (6 vs 9 units p = 0.01) than non-overtransfused patients. CONCLUSION: More than a quarter of patients in our cohort were potentially given more blood products than required without obvious clinical consequences. There were no clinically relevant associations with overtransfusion.

Prehospital analgesic choice in injured patients does not impact on rates of vomiting: Experience from a New South Wales primary retrieval service.

OBJECTIVE: This study aimed to explore the analgesic regimes adopted in our contemporary retrieval practice and the incidence of vomiting in ED after prehospital analgesic use. METHOD: A retrospective review was conducted on trauma patients retrieved by the Hunter Primary Retrieval Service in the Hunter New England Local Health District, New South Wales, Australia, during 2015. RESULTS: Of the 379 patients attended by the service in 2015, 196 of them (mean age 38.6, SD 19.68, years) were selected for this review. Morphine was the most commonly used analgesic (mean 68.37%; 95% CI 61.36-74.81%), followed by fentanyl (mean 48.47%; 95% CI 41.29-55.70%) and ketamine (mean 34.18%; 95% CI 27.57-41.28%). Fourteen (7.14%, 95% CI 3.96-11.69%) patients vomited either prehospital or within the ED. Patients in both the emesis and the non-emesis group were comparable in demographics. None of the three studied analgesics were observed to be significantly associated with higher risk of vomiting than the others in this review, although a higher dose of fentanyl was given to the non-emesis group (P = 0.04). CONCLUSIONS: The frequency of vomiting in the retrieved patients observed in our study was less than previously reported in the literature. Opioids still prevailed over ketamine as the preferred initial analgesic, with ketamine most commonly used as an adjunct. Multi-centre trials in this field would be preferable in future in view of the relatively low incidence of vomiting in retrieved trauma patients.

Testing a new form to document 'Goals-of-Care' discussions regarding plans for end-of-life care for patients in an Australian emergency department.

OBJECTIVE: There is limited literature to inform the content and format of Goals-of-Care forms, for use by doctors when they are undertaking these important conversations. METHODS: This was a prospective, qualitative and quantitative study evaluating the utility of a new 'Goals-of-Care' form to doctors in a private, tertiary ED, used from December 2016 to February 2017 at Cabrini, Melbourne. A Goals-of-Care form was designed, incorporating medical aims of therapy and patient values and preferences. Doctors wishing to complete a Not-for-CPR form were also supplied with the trial Goals-of-Care form. Form use, content and patient progress were followed. Doctors completing a form were invited to interview. RESULTS: Forms were used in 3% of attendances, 120 forms were taken for use and 108 were analysed. The median patient age was 91, 81% were Supportive and Palliative Care Indicators Tool (SPICT) positive and patients had a 48% 6-month mortality. A total of 34 doctors completed the forms, 16 were interviewed (two ED trainees, 11 senior ED doctors and three others). Theme saturation was only achieved for the senior doctors interviewed. Having a Goals-of-Care form was valued by 88% of doctors. The frequency of section use was: Aims-of-Care 91%; Quality-of-Life 75% (the term was polarising); Functional Impairments 35%; and Outcomes of Value 29%. Opinions regarding the ideal content and format varied. Some doctors liked free-text space and others tick-boxes. The median duration of the conversation and documentation was 10 min (interquartile range 6-20 min). CONCLUSIONS: Having a Goals-of-Care form in emergency medicine is supported; the ideal contents of the form was not determined.

High-flow oxygen in patients undergoing procedural sedation in the emergency department: A retrospective chart review.

OBJECTIVE: Hypoxia is a recognised complication of procedural sedation. This study sought to determine whether there was an association between the use of high-flow oxygen delivery by a non-rebreather (NRB) mask during ED procedural sedation and decreased rates of hypoxia when compared with alternative oxygenation methods. METHODS: Records of all procedural sedations performed over a 12 month period in an Australian tertiary ED were reviewed retrospectively. The primary outcome was whether recorded oxygen saturations fell below 90%. Specifics of the oxygen delivery method were noted and data collected included sex, age, indication for sedation, drugs and doses administered, time of day sedation was commenced and staff grade of sedationist. RESULTS: A total of 755 procedural sedations were reviewed. Two hundred and five (27.1%) patients were administered oxygen via NRB mask from the outset of their sedation. NRB administration was associated with a statistically significant decreased rate of hypoxia (1/205 patients vs 23/550 [odds ratio: 0.112; 95% confidence interval: 0.003-0.0702]; P = 0.0090). This association remained statistically significant when adjusted for confounders. CONCLUSIONS: This study demonstrates an association with a statistically significant reduction in hypoxia when high-flow oxygen via NRB mask is administered during emergency procedural sedation. This intervention is simple, safe and inexpensive, and we would advocate that it be evaluated further in prospective trials.