"I am busy enough ": Navigating challenges experienced by Medicaid providers serving pregnant people living with substance use disorders in Alabama.

PURPOSE: Perinatal substance use is a clinical and public health concern. The purpose of the study was to understand the perspectives and experiences of perinatal healthcare providers serving pregnant people who receive Medicaid and are living with a substance use disorder. DESIGN AND METHODS: We conducted a secondary data analysis of the responses from perinatal healthcare providers who completed a survey to assess the state of Alabama's capability to effectively identify and treat individuals with substance use disorder. We analyzed short answer responses using consensus coding. FINDINGS: Nine-hundred and ninety-five Medicaid providers completed the survey, 36 of the respondents identified that they were employed in an obstetric practice. Health insurance limitations, a lack of time and resources, and limited treatment options were the primary barriers indicated in the participants' responses. CONCLUSIONS: Structural and health system barriers negatively impact the capacity of perinatal healthcare providers in Alabama to serve pregnant people who receive Medicaid and are living with a substance use disorder. CLINICAL RELEVANCE: Perinatal healthcare providers need educational opportunities, training, and up-to-date resources to provide supportive, comprehensive care programming for perinatal populations with substance use disorders.

Impact of Pregnancy on Hidradenitis Suppurativa Disease Course: A Systematic Review and Meta-Analysis.

BACKGROUND: Hormones are thought to play a role in hidradenitis suppurativa (HS). However, data on the HS disease course during pregnancy and the postpartum period has not been well established. The objective of this study is to analyze the available literature to determine HS disease activity during pregnancy and the postpartum period. METHODS: The PubMed and Embase databases were systematically searched for relevant articles from database inception until November 22, 2020. The inclusion criteria were a study population with the diagnosis of HS and discussion of pregnancy impact on the HS disease course or postpartum flare. Study characteristics, patient demographics, HS severity, and HS disease course during pregnancy and the postpartum period were extracted by 2 independent reviewers. The quality of included studies was assessed using the Newcastle-Ottawa Scale for observational studies. Heterogeneity was assessed using Cochran's Q statistic and I2 index. The random-effects meta-analytical model was used. The primary study outcome was the pooled odds ratio of improvement or of worsening of HS disease activity during pregnancy. RESULTS: The systematic search identified 8 studies for analysis. There was a total of 672 cases for which data on the patient-reported HS disease course during pregnancy were available, and 164 cases for which data on patient-reported postpartum flare were available. In the meta-analyses, the rate of HS disease improvement was 24% (95% CI 0.13-0.40) and the rate of HS disease worsening was 20% (95% CI 0.11-0.34). Sixty percent (99/164) of patients experienced a postpartum flare. CONCLUSION: While about a quarter of women will experience an improvement in HS during pregnancy, the majority will have a stable or worsened disease course, and over half of patients will experience a postpartum flare. Close monitoring of HS patients is needed during pregnancy and postpartum periods, as patients may need continued, or even escalated, disease management.

Bibliometric analysis of the 50 most cited publications in atopic dermatitis.

Atopic dermatitis (AD) affects up to 20% of children worldwide. We identified the top 50 cited AD articles in the last seven decades and examined their characteristics. The majority were discussing the pathogenesis of AD and have paved the way for discovering targeted immunomodulatory treatments. A lack of geographic diversity was noted, thus encouraging more countries to be involved in AD research can further progress the future of AD management.

Updated understanding of Staphylococcus aureus in atopic dermatitis: From virulence factors to commensals and clonal complexes.

Atopic dermatitis (AD) is a common inflammatory dermatosis that has multiple contributing factors including genetic, immunologic and environmental. Staphylococcus aureus (SA) has long been associated with exacerbation of AD. SA produces many virulence factors that interact with the human skin and immune system. These superantigens and toxins have been shown to contribute to adhesion, inflammation and skin barrier destruction. Recent advances in genome sequencing techniques have led to a broadened understanding of the multiple ways SA interacts with the cutaneous environment in AD hosts. For example, temporal shifts in the microbiome, specifically in clonal complexes of SA, have been identified during AD flares and remission. Herein, we review mechanisms of interaction between the cutaneous microbiome and SA and highlight known differences in SA clonal complexes that contribute to AD pathogenesis. Detailed knowledge of the genetic strains of SA and cutaneous dysbiosis is becoming increasingly relevant in paving the way for microbiome-modulating and precision therapies for AD.

Radiotherapy for Hidradenitis Suppurativa: A Systematic Review.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis characterized by painful nodules, abscesses, sinus tracts, and scarring mainly in the intertriginous areas. Patients with HS often experience inadequate responses to traditional treatment consisting of lifestyle modification, topical and systemic antibiotics, hormonal modulators, biologics, and procedural modalities. Low-dose radiotherapy has been used in benign cutaneous conditions, including HS; however, there is a paucity of literature summarizing its evidence. Herein, we systematically review the current literature on the efficacy of radiotherapy for patients with HS. SUMMARY: This systematic review of the published literature reports the patient demographics, treatment regimens, efficacy, and adverse effects of radiotherapy in the treatment of HS. The historic timeline of these publications highlights the changes in management recommendations, introduction of more standardized outcome measures, and enhancements in treatment options. Radiotherapy appears to be an option for patients with treatment-resistant HS or who are poor surgical candidates. However, there remains a paucity of consensus on proper candidate selection, dosing, efficacy, and safety of the short- and long-term effects of radiotherapy.

Allergenic potential, marketing claims, and pricing of facial moisturizers.

Ingredients found in facial moisturizers can impact a myriad of skin conditions, including sensitive skin syndrome and contact dermatitis. There is a paucity of evidence on the allergenic potential and marketing claims of facial moisturizers, posing challenges to clinician recommendation and consumer selection. In this study, we systematically evaluate the 100 top-selling sun protective facial moisturizers that claim to be natural, fragrance free, expert-approved, age preventing, beneficial for sensitive skin, and sun protective. Allergenic potential of these moisturizers is evaluated based on ingredients used and prices and consumer ratings are compared. Accordingly, 75 of 100 marketed at least one additional benefit. "Anti-aging" products had the highest average price ($14.99/oz) and "expert-approved" had the lowest ($5.91/oz). Consumer rating was highest for facial moisturizers that were "fragrance-free" (4.35/5.00) whereas products that were "natural" received the lowest ratings (3.49/5.00). The most prevalent allergens found in these moisturizers were ethylenediamine tetraacetic acid (EDTA), phenoxyethanol, and cetyl alcohol. "Expert-approved" products had the fewest average allergens in their ingredient lists (P=0.033), whereas products advertising "SPF" had significantly more (P<0.001). Marketing claims play a role in product sales and ratings. When recommending products, physicians should balance allergenic risk with affordability and consumer preferences.

Healthcare providers' experiences screening for intimate partner violence among migrant and seasonal farmworking women: A phenomenological study.

BACKGROUND: Migrant and seasonal farmworking (MSFW) women patients experience substantially more intimate partner violence (IPV) than the general population, but few health-care providers screen patients for IPV. While researchers have examined screening practices in health-care settings, none have exclusively focused on MSFW women. OBJECTIVE: The aim of this phenomenological study was to explore the experiences of health-care providers who have screened for and/or addressed IPV with MSFW women patients. DESIGN: Researchers utilized descriptive phenomenology to capture the lived experiences of these health-care providers. Data were analysed using Colaizzi's seven-stage framework. SETTING AND PARTICIPANTS: Interviews were conducted with nine female participants - all of whom: (i) were clinically active health-care providers within the MSFW community, (ii) were bilingual in English and Spanish or had access to a translator, (iii) had treated MSFW patients who had experienced IPV and (iv) were at least 18 years of age. RESULTS: Participants' experiences were reflected in four emergent themes: (i) provider-centered factors, (ii) patient-centered factors, (iii) clinic-centered factors and (iv) community-centered factors. Participants described barriers to establish routine IPV assessment, decrease patient ambivalence and increase on-site support and community resources. DISCUSSION AND CONCLUSIONS: This study aimed to generate a greater understanding of the experiences of health-care providers with screening for and addressing IPV with MSFW patients. Implications and recommendations for research, clinical practice and policy are provided.

Social Determinants Associated with Substance Use and Treatment Seeking in Females of Reproductive Age in the United States.

Introduction: Females of reproductive age (FoRA; 15-49 years) are the demographic most likely to be diagnosed with a substance use disorder. Preventative treatment prior to or during pregnancy is critical. Stigma and social inequities can delay access to care. There is limited research examining social determinants of health (SDoH) and how they are related to substance use and treatment seeking in this demographic. Methods: We analyzed the 2016-2019 data from the United States National Survey on Drug Use and Health using multivariable logistic regression models. Statistically significant variables were conceptually linked to the Office of Disease Prevention and Health Promotion's (ODPHP's) SDoH framework's five domains. Results: From a total sample of 1,477,336 (weighted) pregnant people and 39,600,523 (weighted) FoRA, substance use was reported by 879,209 (2.14% [95% confidence interval = 2.13-2.15]). Pregnancy status was not associated with substance use or treatment seeking. Past-month substance use was associated with high educational attainment, an annual income <$20,000, a history of criminality, low religiosity, and having health insurance. Past-month treatment-seeking behavior was associated with older age, an annual income >$20,000, a history of criminality, and greater religiosity. Behavioral health support seeking in the past month was associated with some college education. Higher depression severity was associated with all the three models. Conclusions: Using the ODPHP's SDoH framework, we begin to elicit critical connections that can describe substance use and treatment-seeking practices in FoRA. We encourage additional research to inform public health, health care, behavioral health, and other support service programming.

Brain-wide circuit-specific targeting of astrocytes.

Astrocytes are integral components of brain circuitry. They enwrap synapses, react to neuronal activity, and regulate synaptic transmission. Astrocytes are heterogeneous and exhibit distinct features and functions in different circuits. Selectively targeting the astrocytes associated with a given neuronal circuit would enable elucidation of their circuit-specific functions but has been technically challenging to date. Recently, we constructed anterograde transneuronal viral vectors based on yellow fever vaccine YFV-17D. Among them, the replication-incompetent YFVΔNS1-Cre can selectively turn on reporter genes in postsynaptic neurons if the viral gene NS1 is expressed in postsynaptic neurons. Here we show that without exogenous expression of NS1 at the postsynaptic sites, locally injected YFVΔNS1-Cre selectively turns on reporter genes in astrocytes in downstream brain regions. The targeting of astrocytes can occur across the whole brain but is specific for the neuronal circuits traced. Therefore, YFVΔNS1-Cre provides a tool for selective genetic targeting of astrocytes to reveal their circuit-specific roles.

Directed stepwise tracing of polysynaptic neuronal circuits with replication-deficient pseudorabies virus.

Brain functions are accomplished by polysynaptic circuits formed by neurons wired together through multiple orders of synaptic connections. Polysynaptic connectivity has been difficult to examine due to a lack of methods of continuously tracing the pathways in a controlled manner. Here, we demonstrate directed, stepwise retrograde polysynaptic tracing by inducible reconstitution of replication-deficient trans-neuronal pseudorabies virus (PRVΔIE) in the brain. Furthermore, PRVΔIE replication can be temporally restricted to minimize its neurotoxicity. With this tool, we delineate a wiring diagram between the hippocampus and striatum-two major brain systems for learning, memory, and navigation-that consists of projections from specific hippocampal domains to specific striatal areas via distinct intermediate brain regions. Therefore, this inducible PRVΔIE system provides a tool for dissecting polysynaptic circuits underlying complex brain functions.

Medicaid and Medicare Part B spending on immunomodulators and biosimilars.

INTRODUCTION: Prices for immunomodulators used in dermatological conditions are rising in the United States. While Medicare Part-D solely covers medication costs, Medicare Part-B covers outpatient infusion and injection costs given by medical professionals. We aim to analyze recent trends in Medicare Part-B spending on immunomodulators and their biosimilars used in the treatment of common chronic inflammatory dermatoses. METHODS: The 2012-2018 Medicare Part-B spending data on immunomodulators commonly used for dermatologic conditions were extracted from the Centers for Medicare and Medicaid Services database. Inflation was adjusted to reflect 2012-dollar amounts using the Consumer Price Index. RESULTS: Medicare Part-B spending has increased by 27.5% from 2012 to 2018 ($2.5B, $3.2B). Average annual total spending (AATS) is greatest for rituximab ($1,522,757,520), and average annual spending per maintenance dose (AASPMD) is greatest for ustekinumab-90 mg ($12,976). The percent change in AASPMD increased for all immunomodulators with Etanercept-50 mg having the greatest percent change (+64.6%, +$285.70). Infliximab had a greater AATS and AASPMD than its biosimilars. DISCUSSION: Medicare Part-B spending is often overlooked but plays a big role in federal healthcare spending. Exploring the strategic use of less expensive biosimilars could help mitigate spending.

Improving hidradenitis suppurativa patient education using written action plan: a randomized controlled trial.

The waxing-and-waning nature of hidradenitis suppurativa (HS), complex treatment plans, along with variable responsiveness to therapy, can create management challenges for patients. In this pilot cross-over randomized controlled trial, we aim to evaluate the effectiveness a HS-written action plan (HSWAP) on patient disease understanding and confidence in recognizing flares and adjusting management. Participants were randomized into a pre-crossover control group that received a verbal consultation (VC)-only, and an intervention group which received the VC + HSWAP. The pre-crossover control group then crossed over (post-crossover control) to also receive the VC + HSWAP (ClinicalTrials.gov Identifier: NCT04600375). Patient comprehension of their disease and management steps was high after both a thorough VC and HSWAPs. However, the majority of patients prefer receiving both a VC and a HSWAP. After the addition of the HSWAP, pre-crossover control group patients' understanding and confidence of their disease and management plan increased across all surveyed questions.

Pain management modalities for hidradenitis suppurativa: a patient survey.

BACKGROUND: Pain is one of the most common and debilitating symptoms of hidradenitis suppurativa (HS). OBJECTIVE: We sought to identify pain management therapies used in HS and assess patient-perceived effectiveness. METHODS: An anonymous online survey was posted to Facebook HS support groups. Participants selected all that applied from a list of 20 therapies to indicate which ones they have tried for HS pain. For each therapy used, participants were asked to rate effectiveness on a 5-point scale: not successful (1), mildly successful (2), moderately successful (3), very successful (4), and extremely successful (5). Mean effectiveness ratings were calculated by averaging the corresponding numbers. RESULTS: Of the 438 participants, 93.8% were female. Participants classified themselves as Hurley stage I (8.2%), II (53.4%), and III (38.4%). Warm compresses were the most commonly used therapy (82.4%), followed by ibuprofen/naproxen (74.7%), Epsom salt baths (57.8%), cold compresses (45.4%), and acetaminophen (44.7%). Marijuana smoking received the highest mean effectiveness rating (2.92 ± 1.10), followed by marijuana edibles (2.87 ± 1.10), and opioids (2.83 ± 0.98). Mean effectiveness ratings were lowest for bleach baths (1.52 ± 0.80), sitz baths (1.53 ± 0.56), massage (1.61 ± 0.92), gabapentin (1.64 ± 0.73), and acetaminophen (1.71 ± 0.75). CONCLUSIONS AND RELEVANCE: Even the highest-rated pain management modalities are considered only moderately effective by HS patients.

Relationship Disturbances in Hidradenitis Suppurativa: A Patient Perspective.

Introduction: Hidradenitis suppurativa (HS) can significantly impact patients' relationships. Methods: Using an anonymous electronic survey, we aimed to determine what aspects of sexual relationships are affected by HS discomfort and patients' reluctance to discuss HS with their partner. Results: Among the 873 participants, 60.9% reported that some aspect of their relationship was affected by HS discomfort, with the greatest being their sexual encounters with spouse (49.1%). Furthermore, 43.0% (320) of participants reported feeling reluctant to discuss HS with their spouse/significant other, with the more common reason being fear of partner seeing boils and scars (84.7%). Multiple aspects of relationships can be affected by HS such as sexual encounters, overall relationship, and finding a relationship. Additionally, several communication barriers are present, such as fear of partner seeing boils and scars, partner thinking they had an infection such as a sexually transmitted disease, and fear of bloody or malodorous drainage, among others. The presence of anogenital pain, Hurley stage, gender, and age significantly affect these findings. Conclusion: Addressing HS-related relationship disturbances should be included in HS management.

Bibliometric Analysis of Hidradenitis Suppurativa Publication Trends from Asia and Australasia.

INTRODUCTION: Hidradenitis suppurativa (HS), once an orphan disease, has gained increased interest world-wide. The most highly cited works in HS are from North America and Europe despite known phenotypic and epidemiological differences globally. Herein, we perform a bibliometric analysis to characterize HS publication trends in Asia and Australasia (AA) over the last decade. METHODS: PubMed database was searched to identify HS-related articles and were analyzed for senior authorship, country of origin, article topic, and study design. RESULTS: The search criteria yielded 163 articles from AA. Rapid increase in publications started in 2015 with 75% (123/163) of total articles published in the last half of the decade. Case reports/series were consistently the most published study type yearly and overall (49%, 80/163). Efforts were made to increase high level of evidence publications with both randomized controlled trials from Japan and Turkey including all Asian patients. China, Japan, and India were the leading publishing countries with Australia, Israel, and Turkey increasingly contributing in the last half of the decade. CONCLUSIONS: Advancements in HS research are encouraging with increases in publication numbers and diversity; however, more geographical diversity is needed in order to garner a better understanding of the disease and treatment options.

Bibliometric Analysis of the 50 Most Cited Publications in Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) has historically been a neglected disease. However, research in this field has grown exponentially in the past decade. METHODS: The top-cited HS articles from 1950 to 2020 were analyzed for authorship, study topic, study design, and senior author country of origin. RESULTS: We found that nearly half of the top 50 cited articles were published in the last decade, with a recent increase in the number of highly cited randomized controlled trials. Medical treatment is the most cited topic, with more attention on biologics over time. The past decade has seen an increase in highly cited articles on HS comorbidities, pathogenesis, and clinical practice guidelines. There has been a predominance of highly cited HS research from Europe; highly cited studies from Africa, Asia, Australia, and South America are lacking. CONCLUSIONS: Recent advances in HS research have focused on investigating HS pathogenesis and drug development, highlighting disease comorbidities, and improving evidence-based care. Studies in pathogenesis have translated into a paradigm shift in medical treatment from antibiotics to incorporation of targeted therapies in recent years. Encouraging growth of HS research in countries outside of North America and Europe may help to optimize HS care globally.

Gender gaps in National Institutes of Health dermatology grant recipients.

BACKGROUND: Understanding the demographics and scholarly merit among National Institutes of Health (NIH) award recipients can help guide future applicants in the field of dermatology. OBJECTIVE: Herein, we aimed to explore gender gaps in NIH award recipient demographics and scholarly merits for dermatology-related projects. METHODS: Projects funded by the National Institutes of Arthritis and Musculoskeletal and Skin Diseases between 2015 and 2019 related to dermatology were extracted using the NIH Research Portfolio Online Reporting Tools database. The number of publications and h-index of each award recipient were collected using the Scopus database. The 2019 Blue Ridge Institute for Medical Research report was used to determine the top 20 NIH-funded dermatology departments/divisions. RESULTS: Between 2015 and 2019, there were 35.1% more unique male than unique female recipients. Award recipients had an average of 116.7 total publications and an average h-index of 37.1. However, men also had more than half as many publications and a >37% higher average h-index. Gender gaps in research merit, as well as number and type of awards, are reduced among recipients affiliated with a top 20 NIH-funded institution. CONCLUSION: A higher number of awards were granted to male recipients. Men had a higher mean publication number and h-index compared with their female counterparts. Increased support, resources, and mentorship opportunities to women in research may help mitigate these gaps.