Performance of ABCD-10 and SCORTEN mortality prediction models in a cohort of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis.

BACKGROUND: Age, bicarbonate, cancer, dialysis, 10% body surface area risk model (ABCD-10) has recently been proposed as an alternative to the SCORe of toxic epidermal necrolysis (SCORTEN) model for predicting in-hospital mortality in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). In contrast to SCORTEN, ABCD-10 incorporates prior dialysis and upweights the impact of cancer. OBJECTIVE: To determine the performance of ABCD-10 compared with that of SCORTEN in mortality prediction at a large, tertiary burn center. METHODS: A retrospective analysis of 192 patients with SJS/TEN admitted to the North Carolina Jaycee Burn Center from January 1, 2009, to December 31, 2019, was conducted. Data on these patients were collected using the burn registry and a manual chart review. The performance of both the mortality prediction models was assessed using univariate logistic regression and the Hosmer-Lemeshow test. RESULTS: The overall mortality was 22% (n = 43). Nine (5%) patients had cancer, and 7 (4%) had undergone prior dialysis; neither factor was associated with mortality (P = .11 and P = .62, respectively). SCORTEN was well calibrated to predict inpatient mortality (P = .82), whereas ABCD-10 appeared to have a poorer fit (P < .001) in these patients. Both the models showed good discrimination. LIMITATIONS: Small sample size. CONCLUSION: SCORTEN was a better predictor of inpatient mortality than ABCD-10 in a North American cohort of patients treated at the tertiary burn center.

Chief resident selection in US dermatology residency programs.

Chief residents are typically selected as leaders from the senior-most residents in a residency program. The definition of the role likely varies widely between various residency programs. We aimed to gain a better understanding of responsibilities of chief residents in dermatology programs and to identify selection methods. After institutional review board review, we created a Qualtrics survey distributed through a listserv of program directors (PDs) from US dermatology residency programs. Of 51 survey responses, 100% had chief residents, and 35.3% had all senior residents designated as chief residents. The majority of programs used several selection processes, but most frequently PD selection (n = 20). Programs (76%) reported other leadership opportunities for seniors. The most important attribute in selecting a chief resident was helpfulness, and PDs rated their perceived resident satisfaction with the selection process as an 8.24 out of 10, with 10 being most satisfied. Additional benefits for chief residents were reported at 86.9% (n=40) of programs. Most programs select chief residents based on merit. There is perceived satisfaction of residents regarding this process, and most programs report additional benefits for their chief residents.

Photodistributed Toxic Epidermal Necrolysis: Case Report and Review of Current Literature.

Importance: Cases of photodistributed Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been infrequently reported since the first documented case in 1989. This emerging clinical entity and its underlying mechanism have yet to be fully characterized. Objective: To report a case of photodistributed SJS/TEN and highlight similarities to other cases reported in the literature. Design, Setting, and Participants: Case report and literature review of published cases of photodistributed SJS/TEN. The case report describes a 29-year-old woman with recent lamotrigine and trimethoprim-sulfamethoxazole exposure who developed TEN in a photodistributed pattern 1 day after prolonged sun exposure. A search of PubMed using the keywords toxic epidermal necrolysis, Stevens-Johnson syndrome, photo-distributed, photo-induced, and sun-exposed was performed to identify other cases reported in the literature. Results: Literature review revealed 8 previously reported cases of healthy individuals with known drug and UV radiation (UVR) exposures who subsequently developed SJS or TEN with photodistribution. Cases reviewed were skewed demographically to young women aged 19 to 48 years (8 of 9 patients) with all cases reporting UVR exposure 24 to 72 hours prior to the onset of symptoms. Conclusions and Relevance: Photodistributed TEN has been increasingly described in the literature and may represent a distinct variant of SJS/TEN. While the pathogenesis remains unclear, the role of UVR as a "second hit" is suggested by the data presented in the cases documented thus far.

Cutaneous adverse reactions in B-RAF positive metastatic melanoma following sequential treatment with B-RAF/MEK inhibitors and immune checkpoint blockade or vice versa. A single-institutional case-series.

BACKGROUND: With the advent of immune-checkpoint inhibitors and targeted treatments (TT), there have been unprecedented response rates and survival in advanced melanoma, but the optimal sequencing of these two treatments modalities is unknown. Combining or sequencing these agents could potentially result in unique toxicities. Cutaneous adverse events (CAE) after sequential exposure to these agents represents one toxicity that needs further description. METHODS: After retrospectively reviewing charts of patients from 2015 to 2018, we identified six patients who experienced CAEs after recent exposure to sequential immunotherapy and TT or vice versa for the treatment for metastatic melanoma at the University of North Carolina, Chapel Hill. Skin biopsies were available in five patients. RESULTS: Five patients received TT after immunotherapy, and one patient received immunotherapy after TT. TT consisted of vemurafenib/cobimetinib (V/C) in five patients with four patients starting V/C immediately before manifesting with a CAE. In patients receiving V/C after immunotherapy, the median time from beginning V/C to development of CAE was 14.5 days. The clinical presentation of diffuse morbilliform rash, fevers, hypotension, and end-organ damage raised concern for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. Histopathological features of lympho-eosinophilic infiltrate were supportive of a drug eruption. Immunotherapy or TT were re-initiated in five patients within 1-8 weeks after resolution of the index CAE. This resulted in two patients re-experiencing the CAE. Both of these patients were off prednisone at the time of therapy re-initiation, whereas none of the patients who were restarted on targeted therapy with a steroid overlap had a rash recurrence. CONCLUSIONS: Sequential treatment using immunotherapy and TT, especially the sequence of V/C after immunotherapy appears to be the most common trigger for CAE with a median time to onset of approximately 2 weeks. Although the clinical presentation of these CAEs can be dramatic, they respond well to prednisone therapy. This unique presentation suggests that it may be reasonably safe to re-challenge certain patients with a steroid overlap after rash resolution.

Mexican immigrants' attitudes and interest in health insurance: a qualitative descriptive study.

Mexican immigrants to the U.S. are nearly three times more likely to be without health insurance than non-Hispanic native citizens. To inform strategies to increase the number of insured within this population, we elicited immigrants' understanding of health insurance and preferences for coverage. Nine focus groups with Mexican immigrants were conducted across the State of North Carolina. Qualitative, descriptive methods were used to assess people's understanding of health insurance, identify their perceived need for health insurance, describe perceived barriers to obtaining coverage, and prioritize the components of insurance that immigrants value most. Individuals have a basic understanding of health insurance and perceive it as necessary. Participants most valued insurance that would cover emergencies, make care affordable, and protect family members. Barriers to obtaining insurance included cost, concerns about immigration status discovery, and communication issues. Strategies that address immigrants' preferences for and barriers to insurance should be considered.