Updated S2 K guidelines for the management of bullous pemphigoid initiated by the European Academy of Dermatology and Venereology (EADV).

BACKGROUND: Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life. OBJECTIVES AND METHODOLOGY: The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included. RESULTS: Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations. CONCLUSIONS: The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.

Public sentiment on the global outbreak of monkeypox: an unsupervised machine learning analysis of 352,182 twitter posts.

OBJECTIVES: This study aimed to study the public's sentiments on the current monkeypox outbreaks via an unsupervised machine learning analysis of social media posts. STUDY DESIGN: This was an exploratory analysis of tweets sentiments. METHODS: We extracted original tweets containing the terms 'monkeypox', 'monkey pox' or 'monkey_pox' and posted them in the English language from 6 May 2022 (first case detected in the United Kingdom) to 23 July 2022 (when World Health Organization declared Monkeypox to be a global health emergency). Retweets and duplicate tweets were excluded from study. Bidirectional Encoder Representations from Transformers (BERT) Named Entity Recognition. This was followed by topic modelling (specifically BERTopic) and manual thematic analysis by the study team, with independent reviews of the topic labels and themes. RESULTS: Based on topic modelling and thematic analysis of a total of 352,182 Twitter posts, we derived five topics clustered into three major themes related to the public discourse on the ongoing outbreaks. These include concerns of safety, stigmatisation of minority communities, and a general lack of faith in public institutions. The public sentiments underscore growing (and existing) partisanship, personal health worries in relation to the evolving situation, as well as concerns of the media's portrayal of lesbian, gay, bisexual, transgender and queer and minority communities, which might further stigmatise these groups. CONCLUSIONS: Monkeypox is an emerging infectious disease of public concern. Our study has highlighted important societal issues, including misinformation, political mistrust and anti-gay stigma that should be sensitively considered when designing public health policies to contain the ongoing outbreaks.

Updated S2K guidelines on the management of pemphigus vulgaris and foliaceus initiated by the european academy of dermatology and venereology (EADV).

BACKGROUND: Pemphigus encompasses a group of life-threatening autoimmune bullous diseases characterized by blisters and erosions of the mucous membranes and skin. Before the era of immunosuppressive treatment, pemphigus was almost always fatal. Due to its rarity, only few randomized controlled therapeutic trials are available. Recently, rituximab has been approved as first-line treatment for moderate and severe pemphigus vulgaris in Europe and the United States. OBJECTIVES: The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology (EADV) has initiated a throughout update of the guideline for the management of patients with pemphigus. RESULTS: The guidelines for the management of pemphigus were updated, and the degree of consent among all task force members was included. The final version of the guideline was consented by the European Dermatology Forum (EDF) and several patient organizations.

Detection sensitivity of laser feedback interferometry using a terahertz quantum cascade laser.

We report on the high detection sensitivity of a laser feedback interferometry scheme based on a terahertz frequency quantum cascade laser (QCL). We show that variations on the laser voltage induced by optical feedback to the laser can be resolved with the reinjection of powers as low as ∼-125 dB of the emitted power. Our measurements demonstrate a noise equivalent power of ∼1.4 pW/√Hz, although, after accounting for the reinjection losses, we estimate that this corresponds to only ∼1 fW/√Hz being coupled to the QCL active region.

Increased risk of strontium ranelate-related SJS/TEN is associated with HLA.

UNLABELLED: Severe adverse drug reactions (ADR) of Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) in some patients receiving strontium ranelate have been reported, but the risk factors are unclear. We show that HLA-A*33:03 and B*58:01 are significantly associated with patients who developed SJS/TEN; and provide the first evidence that genetic risk factors are involved in strontium ranelate-associated SJS/TEN. INTRODUCTION: In this study, HLA as a genetic risk factor was assessed among osteoporotic patients prescribed with strontium ranelate that developed severe cutaneous adverse drug reactions (SCARs) compared with those who were tolerant. METHODS: Genomic DNA isolated from peripheral blood mononuclear cells (PBMCs) of patients was HLA typed using sequencing-based typing method to determine their HLA profiles. RESULTS: Osteoporotic patients who are currently on strontium ranelate were enrolled in the study (n = 76). Tolerant controls were defined as patients who received strontium ranelate for a minimum of 3 months (range 3 months to 8 years) with no reports of any cutaneous reactions as these reactions usually occur within the first 12 weeks after starting treatment. Retrospective cases of SJS/TEN were also identified (n = 5). The majority of the accrued samples were of Han Chinese descent: controls (n = 72) and cases (n = 4). All cases and controls were genotyped at four HLA genes, namely HLA-A, HLA-B, HLA-C, and HLA-DRB1. In comparing the samples of Han Chinese descent (72 controls and 4 cases), we found significant associations with HLA-A*33:03 (p = 0.002) and HLA-B*58:01 (p = 0.023). There was no significant association with any HLA-C or HLA-DRB1 alleles. CONCLUSIONS: This study reveals that the occurrence of SJS/TEN in Han Chinese patients receiving strontium ranelate is HLA associated. This has important clinical implications for understanding the underlying mechanisms for this ADR as well as evaluating the potential role of genetic pre-screening for osteoporotic patients who may be prescribed strontium ranelate.

Vitamin D levels in 87 Asian patients with cutaneous lupus erythematosus: a case-control study.

BACKGROUND: Cutaneous lupus erythematosus (CLE) is an autoimmune disease, often exacerbated by sun exposure. Patients are encouraged to avoid sun exposure, therefore predisposing them to vitamin D deficiency. AIM: To investigate the prevalence of and risk factors for vitamin D deficiency in patients with CLE. METHODS: Total serum 25-hydroxy vitamin D (25(OH)D) was measured in 87 consecutive patients with CLE and in 79 controls. Clinical characteristics, disease severity, medications used and lifestyle factors were analysed and compared to determine risk factors for inadequate (25(OH)D), defined as a serum (25(OH)D) level of < 20 µg/L. RESULTS: We found that 51% (n = 44) of the patients with CLE had 25(OH)D levels of < 20 µg/L compared with 73% (n = 58) of the controls (P < 0.01). No significant differences in (25(OH)D) levels were found between cases and controls with regard to age, sex, ethnicity, smoking, sun exposure, sunblock use or vitamin D supplementation. Treatment with antimalarials showed a statistically significant association with lower vitamin D levels. CONCLUSION: Low levels of vitamin D were found in both patients with CLE and controls. Despite being on vitamin D supplementation and living in an equatorial location, our Asian patients with CLE still had low levels of vitamin D. It is therefore important to ensure adequate vitamin D supplementation in patients with CLE, especially for those who are on antimalarial therapy.

Active phase-nulling of the self-mixing phase in a terahertz frequency quantum cascade laser.

We demonstrate an active phase-nulling scheme for terahertz (THz) frequency quantum cascade lasers (QCLs) under optical feedback, by active electronic feedback control of the emission frequency. Using this scheme, the frequency tuning rate of a THz QCL is characterized, with significantly reduced experimental complexity compared to alternative approaches. Furthermore, we demonstrate real-time displacement sensing of targets, overcoming the resolution limits imposed by quantization in previously implemented fringe-counting methods. Our approach is readily applicable to high-frequency vibrometry and surface profiling of targets, as well as frequency-stabilization schemes for THz QCLs.

Three-dimensional terahertz imaging using swept-frequency feedback interferometry with a quantum cascade laser.

We demonstrate coherent three-dimensional terahertz imaging by frequency modulation of a quantum cascade laser in a compact and experimentally simple self-mixing scheme. Through this approach, we can realize significantly faster acquisition rates compared to previous schemes employing longitudinal mechanical scanning of a sample. We achieve a depth resolution of better than 0.1 µm with a power noise spectral density below -50 dB/Hz, for a sampling time of 10 ms/pixel.

An update of fixed drug eruptions in Singapore.

BACKGROUND: Fixed drug eruptions (FDE) are most commonly caused by antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs). The list of causative drugs changes with time and prescribing patterns but there has been no recent data on FDE seen in an outpatient setting in Singapore. OBJECTIVE: We aimed to evaluate the epidemiology, clinical features and causative drugs in patients with FDE in Singapore. METHODS: We performed a retrospective chart review of all patients seen with suspected FDE in the National Skin Centre, Singapore between 2008 and 2012. Using criteria adapted from the WHO-UMC causality assessment criteria, patients were classified into categories of definite (confirmed with patch test or drug provocation test), probable (causative drug identified based on patient's history), possible (clinically consistent but unable to identify causative drug) or unlikely FDE. RESULTS: We reviewed the charts of 126 patients who were seen for suspected FDE. Ten patients (7.0%) were classified as having definite FDE, 52 patients (41.3%) probable FDE, 61 patients (48.4%) possible FDE and three patients (2.4%) unlikely FDE. Clinical features were similar to those described in previous studies. Among the 62 patients with definite or probable FDE, etoricoxib was the most common cause (24 patients, 38.7%). Other common causes included paracetamol, other NSAIDs and doxycycline. Antihistamines caused FDE in three patients. CONCLUSION: Etoricoxib was the most frequent cause of FDE in our study. Other NSAIDs, paracetamol and doxycycline remain common causes of FDE but we caution that antihistamines, such as cetirizine, should also be considered.

Terahertz inverse synthetic aperture radar imaging using self-mixing interferometry with a quantum cascade laser.

We propose a terahertz (THz)-frequency synthetic aperture radar imaging technique based on self-mixing (SM) interferometry, using a quantum cascade laser. A signal processing method is employed which extracts and exploits the radar-related information contained in the SM signals, enabling the creation of THz images with improved spatial resolution. We demonstrate this by imaging a standard resolution test target, achieving resolution beyond the diffraction limit.

Mortality of bullous pemphigoid in Singapore: risk factors and causes of death in 359 patients seen at the National Skin Centre.

BACKGROUND: Bullous pemphigoid (BP) is the most common autoimmune-mediated subepidermal blistering skin disease and is associated with significant morbidity and mortality. OBJECTIVES: To determine the 3-year mortality rate, risk factors and causes of death in patients with BP in Singapore, compared with the general population. METHODS: We conducted a retrospective cohort study of all newly diagnosed patients with BP seen at the National Skin Centre from 1 April 2004 to 31 December 2009. Demographic and clinical data on comorbidities and treatment were recorded. Mortality information was obtained from the National Registry of Diseases. RESULTS: In total 359 patients were included in our study. The 1-, 2-, 3-year mortality rates were 26·7%, 38·4% and 45·7%, respectively. The 3-year standardized mortality risk for patients with BP was 2·74 (95% confidence interval 2·34-3·19) times higher than for the age- and sex-matched general population. Parkinson disease, heart failure and chronic renal disease were associated with increased mortality, while combination treatment with low-to-moderate-dose corticoste-roids and immunomodulatory agents such as doxycycline and/or nicotinamide was associated with lower mortality. Overall, infections were the most common cause of death (59·8%), with the main causes of death being pneumonia (42·7%), cardiovascular disease (14·6%) and stroke (11·6%). CONCLUSIONS: This study confirms an increased 3-year mortality rate for patients with BP in Singapore. Risk factors for increased mortality include medical comorbidities, especially neurological, cardiac and renal diseases. Treatment with combination therapy, including the use of low-to-moderate-dose corticosteroid, appeared to decrease mortality risk in patients with BP.

The role of intravenous immunoglobulin in toxic epidermal necrolysis: a retrospective analysis of 64 patients managed in a specialized centre.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with a mortality of 40%. Intravenous immunoglobulin (IVIg) is widely used as a specific treatment for this reaction, although evidence of its benefit is conflicting. OBJECTIVES: We sought to evaluate whether the use of IVIg improved mortality in patients with Stevens-Johnson syndrome (SJS)/TEN overlap and TEN. METHODS: We retrospectively analysed data for 64 patients with SJS/TEN overlap and TEN who were treated with IVIg at a single referral centre. The primary outcome analysed was in-hospital mortality. Predicted mortality was calculated based on severity-of-illness score for TEN (SCORTEN) values. Secondary analyses of survival based on IVIg dosages and prior corticosteroid exposure were also performed. RESULTS: There were 28 cases of SJS/TEN overlap and 36 cases of TEN, with a mean SCORTEN value of 2·6. The mean dose of IVIg given was 2·4 g kg(-1) and the mean delay from the onset of epidermal detachment to administration of IVIg was 3·2 days. There were 20 deaths (31%) in our cohort. The standardized mortality rate was 1·10 (95% confidence interval 0·62-1·58). Subgroup analysis comparing survivors and nonsurvivors showed a higher SCORTEN in nonsurvivors (3·4 vs. 2·2). There were no differences with regard to the dosage, delay and duration of IVIg administration. When stratified according to dosage, there was no mortality difference between patients who receive high-dose (≥ 3 g kg(-1) ) vs. low-dose (< 3 g kg(-1) ) IVIg. CONCLUSIONS: This study shows that the use of IVIg does not yield survival benefits in SJS/TEN overlap and TEN, even when corrected for IVIg dosages.

Amicrobial pustulosis associated with autoimmune disease in a patient with Sjögren syndrome and IgA nephropathy.

Amicrobial pustulosis associated with autoimmune disease (APAD) is a rare clinical condition, characterized by relapsing pustular eruption, affecting mainly the skin folds. Almost all previously described cases were young women with varying underlying autoimmune diseases. We report a 36-year-old woman with the interesting triad of APAD, Sjögren syndrome and IgA nephropathy. Her rashes responded to oral prednisolone and cyclophosphamide.

The 'Epworth-China connection'.

Interventional cardiologists from China first arrived at the Epworth Hospital in Melbourne for training in percutaneous transluminal coronary angioplasty in 1988. Percutaneous transluminal coronary angioplasty was initially performed in China in 1981 in Xian. In those days, angioplasty balloons and catheters that were brought into China mainly by foreign experts were used repeatedly until they were broken. Dr. Antonio Colombo was invited to visit Beijing, China, in 1998 to demonstrate coronary stenting at the Chaoyang Hospital. By 2010, more than 300,000 cases of percutaneous coronary interventions (PCIs) had been performed throughout China. If the current rate of PCIs per population in the West was to be applied in China, more than 4 million PCIs should have been performed annually.

Impact of COVID-19 on environmental services workers in healthcare settings: a scoping review.

BACKGROUND: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, demand for deep cleaning and environmental services workers grew exponentially. Although there is extant literature examining the impact of the COVID-19 pandemic on healthcare workers, less emphasis has been placed on environmental services workers, who play an equally important front-line role. AIM: To examine the impact of the COVID-19 pandemic on environmental services workers employed in healthcare settings. METHODS: Scoping review methodology. A search strategy was developed, in consultation with a medical information specialist, employing various combinations of the keywords [(environmental services worker OR health attendant OR housekeeping) AND (COVID OR coronavirus OR pandemic OR epidemic)]. Four bibliographical databases were searched from inception to 5th July 2022: OVID Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Database. RESULTS: In total, 24 studies were included in this review. The studies were generally cross-sectional in design. Seroprevalence studies highlighted significantly higher rates of COVID-19 among environmental services workers (housekeeping, cleaning and janitorial staff) compared with other clinical and non-clinical staff in the same institutions. In addition, based on qualitative interviews, environmental services workers experienced greater psychological stress working during the pandemic. CONCLUSIONS: Environmental services workers were particularly vulnerable to increased work stress and COVID-19 during the pandemic. Health systems need to do more to support these workers. Further research could investigate specific policy and procedural changes to benefit this under-recognized group in the greater healthcare workforce.

Pruritus is a common and significant symptom of acne.

BACKGROUND: Acne is a common condition in both adolescents and adults. Characteristics of acne are well described, but itch is rarely mentioned as a clinical feature. Pruritus could be a significant contributory factor to the burden of disability in patients with acne. OBJECTIVE: We examine the prevalence of pruritus and its clinical attributes in patients with acne in an outpatient clinic. STUDY DESIGN: Descriptive study over a 15 month period from October 2005 to December 2006. PATIENTS AND METHODS: 120 consecutive patients with acne attending an outpatient clinic at National Skin Centre, Singapore were recruited. Pruritus was evaluated using a validated questionnaire. Severity of acne was determined using FDA Global Acne Grading. RESULTS: 84 patients (70%) reported itch in acne. Patients who experienced itch in acne tended to be slightly older (p = 0.05). Majority of patients (83%) reported itch at noon and most experienced itch on a transient nature. The most common descriptor of itch was tickling (68%). Severity of pruritus in acne was comparable to mosquito-bite and it significantly affected patients' mood (55%). Common aggravating factors for the pruritus were sweat (71%), heat (62%) and stress (31%). A significant proportion of patients with itch (52%) had scratched or rubbed the affected area while 37% would wash the area to find relief. CONCLUSION: Our results suggest that itch is a common and significant symptom in acne. Acne patients experienced considerable disability due to the associated pruritus.