Cutaneous Complications Associated With Intraosseous Access Placement.

Intraosseous (IO) access provides a potentially lifesaving means of vascular access in settings of trauma and advanced cardiovascular life support in which patients often require prompt and large volumes of fluid resuscitation, blood products, and medications. An additional benefit of IO access is the rare incidence of complications, with many studies reporting rates of less than 1%. The most commonly cited complications include compartment syndrome, osteomyelitis, traumatic bone fracture, and epiphyseal plate damage. To evaluate the dermatologic sequelae, we performed a retrospective chart review spanning 18 consecutive months to identify patients who underwent IO line placement, either at or en route to a large metropolitan level I trauma center in the Midwestern United States. Our review identified a complication rate of 2.7%, with complications including compartment syndrome, needle breakage, and a previously unreported cutaneous complication of traumatic bullae.

The relationship between stress and vitiligo: Evaluating perceived stress and electronic medical record data.

Vitiligo is a T-cell mediated skin disorder characterized by progressive loss of skin color. In individuals genetically predisposed to the disease, various triggers contribute to the initiation of vitiligo. Precipitating factors can stress the skin, leading to T-cell activation and recruitment. Though hereditary factors are implicated in the pathogenesis of vitiligo, it is unknown whether precipitating, stressful events play a role in vitiligo. To understand this, we utilized a validated perceived stress scale (PSS) to measure this parameter in vitiligo patients compared to persons without vitiligo. Additionally, we probed a clinical database, using a knowledge linking software called ROCKET, to gauge stress-related conditions in the vitiligo patient population. From a pool of patients in an existing database, a hundred individuals with vitiligo and twenty-five age- and sex-matched comparison group of individuals without vitiligo completed an online survey to quantify their levels of perceived stress. In parallel, patients described specifics of their disease condition, including the affected body sites, the extent, duration and activity of their vitiligo. Perceived stress was significantly higher among vitiligo individuals compared to those without vitiligo. ROCKET analyses suggested signs of metabolic-related disease (i.e., 'stress') preceding vitiligo development. No correlation was found between perceived stress and the stage or the extent of disease, suggesting that elevated stress may not be a consequence of pigment loss alone. The data provide further support for stress as a precipitating factor in vitiligo development.

A Comparison of Ferric Subsulfate Solution, Silver Nitrate, and Aluminum Chloride for Pain Assessment, Time to Hemostasis, and Cosmesis in Acrochordon Snip Excision.

BACKGROUND: Acrochordon (skin tag) removal by snip excision is a routine dermatologic procedure. Bleeding is a common sequelae of snip excision that requires hemostatic control. Chemical cautery is a common means of achieving hemostasis in this procedure. OBJECTIVE: The aim of this study was to evaluate three different chemical cautery solutions for their time to hemostasis, pain upon application, and associated pigmentary changes. METHODS: Twelve patients with six or more skin tags on the bilateral neck and/or axilla were enrolled. Two skin tags were cauterized with ferric subsulfate solution, two with silver nitrate, and two with aluminum chloride hexahydrate solution. Time to hemostasis and pain with application of each cautery solution to the skin tag was recorded. At a two-week follow-up appointment, patient satisfaction was assessed with a survey, and pigmentary changes were documented with digital photography. RESULTS: There was no significant variability in the time to hemostasis among the three chemical cautery solutions (p=0.57). Pain response was significantly different among the three solutions (p=0.003). Compared to silver nitrate (median=6.00, interquartile range [IQR]: 4.50-6.50), aluminum chloride hexahydrate (median=1.00, IQR: 0.50 to 6.00; Sidak p=0.02) and ferric subsulfate (median=1.50, IQR: 0.00-3.50; Sidak p=0.01) had a significantly lower pain response. Among participants, three (25%) experienced a pigmentary change with ferric subsulfate, two (17%) with aluminum chloride, and six (50%) with silver nitrate (overall p= 0.14). CONCLUSION: These results indicate that the three standard chemical cautery solutions for skin tag snip excision have significant differences in pain upon application and pigmentary changes. This might be a relevant consideration when selecting a chemical cautery solution.

Cosmetic Dermatology Training During Residency: Outcomes of a Resident-Reported Survey.

BACKGROUND: As the demand for cosmetic treatments increases, it is important for dermatology residents to be educated about and achieve proficiency in dermatologic cosmetic procedures. OBJECTIVE: To assess dermatology residents' educational exposure to cosmetic dermatology. MATERIALS AND METHODS: An anonymous 18-question survey was sent electronically to 1,266 dermatology residents requesting information about cosmetic dermatology training during residency. RESULTS: Two hundred sixty-eight residents responded to the survey (21% response rate). Most residents receive didactic instruction (94%) and hands-on training (91%) on cosmetic dermatology topics during residency. Survey participants in residency programs perceived as supportive of cosmetic dermatology training are more frequently provided lectures (70% vs 31%, p < .001) and procedural training (100% vs 69%, p < .001) in cosmetic dermatology as compared to residents in unsupportive programs. Eighty-nine percent of respondents reported hands-on training as the most effective method for developing proficiency in cosmetic procedures. CONCLUSION: Providing safe and competent patient care should serve as the impetus for expanding cosmetic dermatology education and training for residents.

Development of Asymmetric Facial Depigmentation in a Patient Treated with Dasatinib with New-Onset Hypovitaminosis D: Case Report and Review of the Literature.

Dasatinib is a second-generation tyrosine kinase inhibitor (TKI) used to treat imatinib-resistant chronic myelogenous leukemia (CML), as well as other Philadelphia chromosome-positive lymphoproliferative disorders. While the most commonly reported cutaneous side effects with this therapy include a morbilliform eruption, skin exfoliation, and skin irritation, pigmentary abnormalities have also been observed, albeit much more rarely. We present the case of a 72-year-old South Asian male with CML who presented with new-onset hypopigmentation of his face and scalp three years after a dose increase of dasatinib therapy, in the setting of newly discovered borderline hypovitaminosis D. Dasatinib and the other TKIs are believed to induce dyschromias via modulation of the c-kit receptor and its associated signaling pathway, which is involved in melanocyte survival, proliferation, and migration.

Influence of Pregnancy on Vitiligo Activity.

Background: Vitiligo vulgaris, an acquired disease related to autoimmune activity directed against melanocytes, is a common disorder of pigmentation affecting up to one percent of the population. Several autoimmune disorders are reported to improve during pregnancy-a state of relative immunosuppression. Objectives: To assess self-reported changes in vitiligo disease activity that occurred during pregnancy. Methods: A survey of 24 subjects with vitiligo was conducted by telephone using questions that pertained to vitiligo history, pregnancy history, and vitiligo disease activity prior to, during, and after pregnancy. Additional questions pertained to demographics, history of other autoimmune disease, and family history of vitiligo. Results: 18 of 24 subjects (75%) reported stable or improvement in vitiligo activity during pregnancy. Of these 18 subjects, five (27%) had discontinued vitiligo therapy during their pregnancies. Conclusion: The majority of patients surveyed reported either stable or improved vitiligo activity during pregnancy. These results support a protective effect exerted by the state of pregnancy against changing or progressing depigmentation characteristic of vitiligo vulgaris in the non-pregnant state.

Trends in Weight Regain Following Roux-en-Y Gastric Bypass (RYGB) Bariatric Surgery.

BACKGROUND: The primary purpose of this study was to assess weight loss and occurrence of weight regain among patients who underwent Roux-en-Y gastric bypass (RYGB) using categorical analysis. METHODS: Study participants were selected from patients who underwent RYGB from a single institution. Participants (n = 300, mean procedure age = 45.6 ± 9.9) completed surveys for self-reported preoperative weight, current weight, and subsequent weights over postoperative years. Measured weights and confirmed procedure dates were acquired from patient medical records. Mean preoperative weight and BMI were 140.8 kg ± 32.1 and 49.7 ± 9.9, respectively, and mean years since surgery was 6.9 ± 4.9. Study subjects were mostly Caucasian (56.7 %) and female (80.3 %). Participants were stratified a priori into four cohorts based on percent of weight loss at 1 year, <25 % (n = 39), 25-30 % (n = 51), 30-35 % (n = 73), and >35 % (n = 113). General linear model analyses were conducted to assess the effect of year one weight loss on percent weight regain. RESULTS: The mean weight regain for all patients was 23.4 % of maximum weight loss. Using categorical analysis, mean weight regain in the <25, 25-30, 30-35, and >35 % weight loss cohorts was 29.1, 21.9, 20.9, and 23.8 %, respectively. Excessive weight regain, defined as ≥25 % of total lost weight, occurred in 37 % of patients. CONCLUSION: Weight gain is a common complication following RYGB surgery. Despite the percentage of weight loss over the first year, all cohort patient groups regained on average between 21 and 29 % of lost weight. Excessive weight gain was experienced by over one third of patients. Greater initial absolute weight loss leads to more successful long-term weight outcomes.

Enhanced bleaching treatment: opportunities for immune-assisted melanocyte suicide in vitiligo.

Depigmentation in vitiligo occurs by progressive loss of melanocytes from the basal layer of the skin, and can be psychologically devastating to patients. T cell-mediated autoimmunity explains the progressive nature of this disease. Rather than being confronted with periods of rapid depigmentation and bouts of repigmentation, patients with long-standing, treatment-resistant vitiligo can undergo depigmentation treatment. The objective is to remove residual pigmentation to achieve a cosmetically acceptable result--that of skin with a uniform appearance. In the United States, only the use of mono-benzyl ether of hydroquinone (MBEH) is approved for this purpose. However, satisfactory results can take time to appear, and there is a risk of repigmentation. MBEH induces necrotic melanocyte death followed by a cytotoxic T-cell response to remaining, distant melanocytes. As cytotoxic T-cell responses are instrumental to depigmentation, we propose that combining MBEH with immune adjuvant therapies will accelerate immune-mediated melanocyte destruction to achieve faster, more definitive depigmentation than with MBEH alone. As Toll-like Receptor (TLR) agonists--imiquimod, CpG, and Heat Shock Protein 70 (HSP 70)--all support powerful Th1 responses, we propose that using MBEH in combination with these agents can achieve superior depigmentation results for vitiligo patients.

Use of insulin pumps for diabetes management.

Patients are diagnosed with diabetes mellitus in the United States at increasing rates. Nurses must maintain current knowledge of effective diabetes management strategies. An overview of the use of insulin pumps is provided, including the function, criteria for use, advantages, disadvantages, and nursing management considerations.