Validation of a novel patient-operated device for measuring skin barrier function in atopic dermatitis.

BACKGROUND: Transepidermal water loss (TEWL) and capacitance are used in atopic dermatitis (AD) trials to provide objective data on clinical change and response to therapy. Many barrier devices are costly, limiting their utility. GPSkin is a novel low-cost, patient-operable device that measures both TEWL and capacitance via smartphone application. OBJECTIVE: This validation study investigated the correlation of GPSkin with the AquaFlux and Corneometer, and the reliability of these devices, in patients with AD. METHODS: Fifty AD patients with varying disease severity performed self-measurements with GPSkin, while investigators collected data with all 3 devices, on both nonlesional and lesional skin. CONCLUSION: GPSkin and AquaFlux demonstrated strong correlation for TEWL on nonlesional and lesional skin by Spearman's correlation (rs ), independent of device user. For capacitance, GPSkin and the Corneometer showed moderate correlation when obtained by patients, yet a strong correlation when obtained by a clinician. Despite good correlation, GPSkin showed poor agreement with both the AquaFlux and Corneometer in Bland-Altman plots. GPSkin underestimated both TEWL and capacitance. Overall, the devices had good test-retest reliability. None of the devices could discriminate between AD severity states. While GPSkin marks an exciting advancement in barrier technology, further study is needed for validation on AD skin.

The socioeconomics of atopic dermatitis.

OBJECTIVE: To review the current state of the literature regarding the socioeconomics of atopic dermatitis (AD)-more specifically how socioeconomic status (SES) affects AD risk and how the presence of AD may affect one's SES-as well as discuss the cost of the disease to society. DATA SOURCES: A PubMed search was performed to include English-language articles with the keywords atopic dermatitis, cost, finances, economic, income, career, socioeconomic, with preference to those written in the last 5 years. STUDY SELECTIONS: Studies were included if they provided information pertaining to socioeconomics in relation to disease severity, disease incidence, direct costs, indirect costs, and effects on work, education, and career choice. RESULTS: Many studies have reported that higher SES is associated with increased AD prevalence, whereas lower SES is associated with increased AD severity. Regardless of patient SES, AD creates substantial direct costs that affect the patient, patient's family, and the payer. Additionally, the effects of the disease create indirect costs from absenteeism and presenteeism, as well as opportunity costs from hinderances in learning, affecting patient SES and the economy. CONCLUSION: Given the substantial and growing burden on the patient and the economy when access to appropriate treatment is limited, the socioeconomic burden of AD represents a tangible public health concern that must be addressed.

Medication Adherence in Children and Adolescents with Acne Vulgaris in Medicaid: A Retrospective Study Analysis.

OBJECTIVES: The objectives of the study were to evaluate and compare medication adherence associated with acne drugs in children and adolescents with acne vulgaris. METHODS: Data from MarketScan Medicaid enrollees with acne vulgaris were included if patients were ages 6 to 17 years on the index date, had at least one acne-related medication claim, and were enrolled in Medicaid during January 2004 to December 2007. The adherence rate was measured using the medication possession ratio. The medication possession ratio was dichotomized to categorize patients as adherent (≥0.8) or nonadherent (<0.8). Multivariate logistic regressions were used for analyses of the medication possession ratio. RESULTS: Of 20,039 eligible patients, 2,860 patients were children and 17,179 patients were adolescent. Approximately 6.96% of children and 16.75% of adolescents had at least one acne-related medication refill. The mean adherence rate to acne medication was significantly different between children (0.22) and adolescents (0.32). In addition, only 3.71% of children were adherent to acne medication while 13.38% of adolescents were adherent. After controlling for covariates, adolescents were 2.06 times more likely to get an acne-related medication refilled and were 2.40 times more likely to be adherent to acne-related medication. The analyses also showed that acne-related medication adherence was associated with the patient's characteristics and acne medication type. CONCLUSION: Neither patient population was considered adherent to acne-related medications, nor was there a significant difference between the two patient populations. This study also revealed that medication type is a contributing factor towards adherence. Health care providers should strive to educate patients on the importance of medication adherence.

Comparative utility of vestibular function tests in patients with peripheral and central vestibular dysfunction.

Background: Bithermal caloric irrigation, video head impulse test (vHIT), and rotational testing are commonly used to assess peripheral vestibular function, but the relative clinical utility of each test in differentiating patients with peripheral vestibulopathy is debated. Objectives: To determine whether (1) the combination of two or more vestibular tests enhances diagnostic utility over a single test; (2) abnormal test results on vestibular tests correlate with one another. Methods: Retrospective analysis of data collected from multidisciplinary vestibular clinics at two academic medical centers from 2016 to 2022. Results: 150 patients (54.10 ± 15.09 years, 88 females) were included. No individual test was significantly better at predicting the presence of peripheral vestibular damage (p > 0.05). vHIT test results improved significantly when combined with either the caloric test (p = 0.007) or rotary chair test (p = 0.039). Caloric and rotational testing had high sensitivity (74.65% and 76.06%, respectively) and specificity (83.54% and 78.48%, respectively). vHIT demonstrated excellent specificity (89.87%) but poor sensitivity (47.89%). Caloric, vHIT, and rotary chair tests results did not correlate with one another (p > 0.05). Conclusions: Vestibular function tests have comparable diagnostic utility, yet each offers unique advantages. Caloric and rotational testing may be best suited for screening peripheral damage and vHIT may function ideally as a confirmatory test.

Predictors of non-primary auditory and vestibular symptom persistence following surgical repair of superior canal dehiscence syndrome.

Objective: Patients with superior canal dehiscence syndrome (SCDS) can present with a plethora of auditory and/or vestibular symptoms associated with a bony defect of the superior semicircular canal. While surgical repair is a reasonable option for patients with significant localizing symptoms, the degree of clinical improvement will vary among patients and poses challenges in outcome prediction. This study aims to assess the relationship between preoperative and postoperative symptoms and identify predictors of symptom persistence following repair. Study design: Retrospective chart review. Setting: Tertiary neurotology single-institution care center. Main outcome measures: The primary outcome was to determine the proportion of resolved and persistent primary (most bothersome) and non-primary audiologic and vestibular symptoms following SCD repair. Secondary outcomes included comparison of patient, operative and radiologic characteristics between patients with resolved vs. persistent symptoms. Standardized patient questionnaires including 11 auditory and 8 vestibular symptoms were administered to patients at their preoperative and follow-up visits. Patient pre- vs. postoperative survey results, demographic and clinical characteristics, operative characteristics, audiometric data and cervical vestibular evoked myogenic potential (cVEMP) thresholds were compared via univariate χ2 and multivariate binary logistic regression analyses between those patients reporting full postoperative resolution of symptoms and persistence of one or more symptoms. Radiologic computed tomography (CT) measurements of superior canal dehiscence (SCD) defect size, location, and laterality were also compared between these two groups. Results: Of 126 patients (132 ears) included in our study, 119 patients (90.2%) reported postoperative resolution (n = 82, 62.1%) or improvement (n = 37, 28.0%) of primary (most bothersome) symptoms, while 13 patients (9.8%) reported persistence of primary symptoms. The median (interquartile range) and range between surgery and questionnaire completion were 9 (4-28), 1-124 months, respectively. Analyzing all symptoms (primary and non-primary) 69 (52.3%) and 68 (51.1%) patients reported complete postoperative auditory and vestibular symptom resolution, respectively. The most likely persistent symptoms included imbalance (33/65/67, 50.8%), positional dizziness (7/20, 35.0%) and oscillopsia (44/15, 26.7%). Factors associated with persistent auditory symptoms included history of seizures (0% vs. 7.6%, p = 0.023), auditory chief complaint (50.0% vs. 70.5%), higher PTA (mean 19.6 vs. 25.1 dB, p = 0.043) and higher cervical vestibular evoked myogenic potential (cVEMP) thresholds at 1000 Hz (mean 66.5 vs. 71.4, p = 0.033). A migraine diagnosis (14.0% vs. 41.9% p < 0.010), bilateral radiologic SCD (17.5% vs. 38.1%, p = 0.034) and revision cases (0.0% vs. 14.0%, p = 0.002) were associated with persistent vestibular symptoms. Neither SCD defect size nor location were significantly associated with symptom persistence (P > 0.05). Conclusions: Surgical repair for SCDS offers meaningful reduction in the majority of auditory and vestibular symptoms. However, the persistence of certain, mostly non-primary, symptoms and the identification of potential associated factors including migraines, PTA thresholds, cVEMP threshold, bilateral SCD, and revision cases emphasize the importance of individualized patient counseling and management strategies.

Trends in non-focal neurological chief complaints and CT angiography utilization among adults in the emergency department.

Prudent imaging use is essential for cost reduction and efficient patient triage. Recent efforts have focused on head and neck CTA in patients with emergent concerns for non-focal neurological complaints, but have failed to demonstrate whether increases in utilization have resulted in better care. The objective of this study was to examine trends in head and neck CTA ordering and determine whether a correlation exists between imaging utilization and positivity rates. This is a single-center retrospective observational study at a quaternary referral center. This study includes patients presenting with headache and/or dizziness to the emergency department between January 2017 and December 2021. Patients who received a head and neck CTA were compared to those who did not. The main outcomes included annual head and neck CTA utilization and positivity rates, defined as the percent of scans with attributable acute pathologies. Among 24,892 emergency department visits, 2264 (9.1%) underwent head and neck CTA imaging. The percentage of patients who received a scan over the study period increased from 7.89% (422/5351) in 2017 to 13.24% (662/5001) in 2021, representing a 67.4% increase from baseline (OR, 1.14; 95% CI 1.11-1.18; P < .001). The positivity rate, or the percentage of scans ordered that revealed attributable acute pathology, dropped from 16.8% (71/422) in 2017 to 10.4% (69/662) in 2021 (OR, 0.86; 95% CI 0.79-0.94; P = .001), a 38% reduction in positive examinations. Throughout the study period, there was a 67.4% increase in head and neck CTA ordering with a concomitant 38.1% decrease in positivity rate.

Patulous Eustachian tube: Deep breath for a diagnosis.

Significance Statement: Eustachian tube disorders are common outpatient otologic presentations that can present a diagnostic challenge due to overlapping symptoms. This article will focus on patulous Eustachian tube, how the symptoms can overlap with those of Eustachian tube dysfunction, and the diagnostic insight offered by a close inspection of the tympanic membrane.

Subjective Cognitive Symptoms and Dizziness Handicap Inventory (DHI) Performance in Patients With Vestibular Migraine and Menière's Disease.

OBJECTIVE: Cognitive symptoms in patients with vestibular disorders are far from rare, but identification of patients at risk for cognitive impairment remains poor. The Dizziness Handicap Inventory (DHI) is a widely used patient-reported outcome questionnaire for dizzy patients with several questions that address cognitive function. However, the relationship between subjective cognitive symptomatology in patients with vestibular disorders and performance on DHI is poorly characterized. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care vestibular clinic. SUBJECTS: Individuals with diagnoses of vestibular migraine (VM), Menière's disease (MD), and concomitant vestibular migraine and Menière's disease (VMMD) presenting to clinic between January 2007 and December 2019. RESULTS: Of 761 subjects, 365 had VM, 311 had MD, and 85 had VMMD. Symptoms of brain fog and chronic fatigue occurred more frequently in the VM and VMMD groups compared with the MD group (χ2 (df = 2, n = 761) = 67.8, 20.9, respectively, p < 0.0001). DHI scores were significantly higher in patients with VM and VMMD compared with those with MD (F[2,758] = 63.5, p < 0.001). A DHI score ≥ 13 suggested that the patient suffered from brain fog (sensitivity = 47.4%, specificity = 72.3%), whereas a score ≥ 15 indicated that the patient complained of chronic fatigue (sensitivity = 81.5%, specificity = 57.7%). CONCLUSION: Our results indicate a high prevalence of interictal cognitive symptoms in patients with episodic vestibular disorders. The DHI cannot be reliably used to differentiate between vestibular disorders nor detect cognitive impairment in these patient populations. Alternative methods must be used to identify vestibulopathic patients with cognitive symptoms to initiate strategies for prevention and treatment.

An Atypical Case of a Common Pregnancy Issue: Appendicitis-Like Hyperemesis Gravidarum.

Hyperemesis gravidarum (HG) is a severe subtype of nausea and vomiting in pregnancy (NVP) that typically affects women in their first trimester of pregnancy. Because HG is a diagnosis of exclusion, a thorough work-up ruling out organic causes must be performed. Herein, we describe a case of a pregnant woman with HG who presented with intractable pain mimicking appendicitis. While her clinical picture and ultrasound findings were only mildly consistent with appendicitis, the only therapy that provided pain relief was empiric antibiotic treatment that was prescribed due to a mildly elevated procalcitonin of 0.61. Thereby, the detection and treatment of concurrent organic causes is important as it may provide significant symptomatic relief in cases of concurrent HG.

Malignant Degeneration of Biopsy-Proven Hamartoma to Chondrosarcoma.

Pulmonary hamartomas are benign lesions that are often managed conservatively in the absence of respiratory symptoms. Increasing reports of malignant transformation question if a more aggressive treatment or surveillance practice for these lesions is warranted in adult patients. Herein, we describe a case of a 67-year-old man with a long history of pulmonary hamartoma that demonstrated malignant degeneration into spindle cell malignancy with chondromatous differentiation. This case illustrates the aggressive nature of sarcomatous disease arising from hamartomas and, with a handful of other cases in the literature, points to the question of whether pulmonary hamartomas arising in late adulthood should follow a more intensive treatment or surveillance algorithm given increased concern for malignant potential.

Network meta-analysis to compare VenaSeal with other superficial venous therapies for chronic venous insufficiency.

OBJECTIVE: Several randomized controlled trials (RCTs) have compared different interventions for chronic venous insufficiency (CVI) management, but mixed comparison of these interventions is lacking. The aim of this network meta-analysis was to compare VenaSeal closure system (Medtronic, Minneapolis, Minn) with endovenous laser ablation (EVLA), radiofrequency ablation (RFA), mechanochemical ablation, sclerotherapy, and surgery for management of CVI to achieve anatomic success (complete closure of treated vein within 6 months after intervention) as the primary outcome and health-related quality of life (HRQoL; EuroQol-5 Dimension, Aberdeen Varicose Vein Questionnaire), Venous Clinical Severity Score (VCSS), pain scores, and adverse events as secondary outcomes. METHODS: A systematic review of journal databases was undertaken, and RCTs between January 1996 and September 2018 comparing different treatment options were included. Risk of bias and quality of publications were assessed using the Cochrane bias tool; Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study selection and reporting. Twenty RCTs comprising 4570 patients were analyzed. Data for anatomic success, VCSS, HRQoL, pain score, and adverse events were extracted and analyzed using mixed treatment comparison in a network meta-analysis. A Bayesian fixed or random effects model was selected for analysis. Rank probability graphs were generated for various treatments and corresponding ranks obtained to estimate their probability of being best. Relative treatment effects were calculated in terms of log odds ratios for anatomic success and adverse events. Mean difference was calculated for VCSS, HRQoL, and pain score. RESULTS: For the primary outcome measure (anatomic success), VenaSeal system had the highest probability of being ranked first (P = .980); RFA was ranked second (P = .365), EVLA third (P = .397), surgery fourth (P = .290), mechanochemical ablation fifth (P = .695), and sclerotherapy sixth (P = .982). For secondary outcome measures, VenaSeal system ranked third for VCSS (P = .332), fifth for EuroQol-5 Dimension (P = .420), and third for Aberdeen Varicose Vein Questionnaire (P = .300). Although, VenaSeal system was slightly inferior to some of the other interventions for HRQoL, the 95% credible interval of log odds ratio indicated insufficient evidence for any concrete conclusion to be drawn. VenaSeal system ranked first in reduction of postoperative pain score from baseline (P = .690) and was lowest in occurrence of adverse events (P = .650). Odds of occurrence of adverse events was 3.3 times in the sclerotherapy arm, 2.7 times in the EVLA arm, 1.6 times with surgery, and 1.1 times with RFA vs VenaSeal system arm. CONCLUSIONS: VenaSeal system is a promising therapeutic option for anatomic success at 6 months, with fewer occurrences of adverse events (wound and groin infection, pulmonary embolism) in CVI patients compared with other interventions in this study. Additional economic analysis including cost-effectiveness analysis would provide interesting perspectives on real-world insights to patients, payers, and providers.

Injectable Therapeutic Organoids Using Sacrificial Hydrogels.

Organoids are becoming widespread in drug-screening technologies but have been used sparingly for cell therapy as current approaches for producing self-organized cell clusters lack scalability or reproducibility in size and cellular organization. We introduce a method of using hydrogels as sacrificial scaffolds, which allow cells to form self-organized clusters followed by gentle release, resulting in highly reproducible multicellular structures on a large scale. We demonstrated this strategy for endothelial cells and mesenchymal stem cells to self-organize into blood-vessel units, which were injected into mice, and rapidly formed perfusing vasculature. Moreover, in a mouse model of peripheral artery disease, intramuscular injections of blood-vessel units resulted in rapid restoration of vascular perfusion within seven days. As cell therapy transforms into a new class of therapeutic modality, this simple method-by making use of the dynamic nature of hydrogels-could offer high yields of self-organized multicellular aggregates with reproducible sizes and cellular architectures.

Quality of Life and Disease Impact of Atopic Dermatitis and Psoriasis on Children and Their Families.

Atopic dermatitis (AD) and psoriasis are common chronic skin diseases affecting children. These disorders negatively impact the quality of life (QoL) of patients in health-related aspects such as physical, psychosocial, and mental functioning. This health impact is more accurately represented when accounting for the numerous comorbidities associated with each disorder, and the impact the disorders have on patients' families. A number of QoL tools have been developed and can be routinely implemented in the evaluation of QoL in pediatric patients and their caregivers. Ways to improve QoL include a multidisciplinary approach to care, education, and psychological support.

Factors That Predict the Use of Psychotropics Among Children and Adolescents With PTSD: Evidence From Private Insurance Claims.

OBJECTIVE: This study aimed to determine which characteristics of youths with posttraumatic stress disorder (PTSD) were associated with receiving prescriptions for antidepressants, antipsychotics, or benzodiazepines. METHODS: A 2011-2012 retrospective cohort of children and adolescents with a new episode of PTSD was extracted from medical and pharmacy claims from a nationally representative sample of privately insured persons. Multivariate logistic regression assessed attributes (demographic characteristics, mental and general medical comorbidities, insurance arrangements, specialty type, and geographic location) associated with utilization of antidepressants, antipsychotics, and benzodiazepines. RESULTS: Among 7,726 youths with a new episode of PTSD in 2012, just less than 60% received psychotherapy alone, about 6% received pharmacotherapy, and about 35% received neither psychotherapy nor pharmacotherapy. Among utilizers of medications, 71.3% used antidepressants and 21.6% used antipsychotics. Youths prescribed medication tended to be older and have more general medical and mental comorbidities. Provider specialty, capitated insurance arrangements, and more comorbidities predicted being prescribed antidepressants. History of hospitalization, noncapitated insurance arrangements, nonuse of psychotherapy, and more comorbidities predicted being prescribed antipsychotics. Antidepressants and antipsychotics were more likely to be used in the South. CONCLUSIONS: Only three-fifths of youths with PTSD received first-line treatment (psychotherapy). More than one in 20 received pharmacotherapy, which appeared to be associated with the most severe and complex presentations. More than one-third of youths with PTSD received neither therapy nor medication, signaling compromised quality of care. Future research should confirm the factors associated with pharmacotherapy prescription and explore ways to increase the use of psychotherapy in primary care.

A direct tissue-grafting approach to increasing endogenous brown fat.

There is widespread evidence that increasing functional mass of brown adipose tissue (BAT) via browning of white adipose tissue (WAT) could potentially counter obesity and diabetes. However, most current approaches focus on administration of pharmacological compounds which expose patients to highly undesirable side effects. Here, we describe a simple and direct tissue-grafting approach to increase BAT mass through ex vivo browning of subcutaneous WAT, followed by re-implantation into the host; this cell-therapy approach could potentially act synergistically with existing pharmacological approaches. With this process, entitled "exBAT", we identified conditions, in both mouse and human tissue, that convert whole fragments of WAT to BAT via a single step and without unwanted off-target pharmacological effects. We show that ex vivo, exBAT exhibited UCP1 immunostaining, lipid droplet formation, and mitochondrial metabolic activity consistent with native BAT. In mice, exBAT exhibited a highly durable phenotype for at least 8 weeks. Overall, these results enable a simple and scalable tissue-grafting strategy, rather than pharmacological approaches, for increasing endogenous BAT and studying its effect on host weight and metabolism.