Novel multispectral imaging to predict disease progression in pediatric morphea.

BACKGROUND: Morphea, or localized scleroderma, is an inflammatory, fibrosing skin disorder that can be progressive and debilitating. Infrared thermography frequently has false positive results. The aim of this study was to assess the ability of multispectral imaging to predict disease progression in children with morphea. METHODS: Children with morphea were recruited between 2016 and 2022. Multispectral images of affected and matched contralateral unaffected sites were obtained using the Antera™ 3D camera. Clinical assessment was performed using the Localized Scleroderma Assessment Tool (LoSCAT). Children were followed up every 3 months for imaging and clinical review. The main outcome measurement was correlation of hemoglobin gradient between affected and matched contralateral unaffected tissue and progression. RESULTS: Of 17 children, the average age was 12 years (range 6-18 years); most were female (76.5%) and white (94.1%). Nearly two-thirds (64.7%) had linear morphea, 35.2% had plaque morphea; 58.8% had been treated with systemic agents. The average LoSCAT score was 20.6 (range 5-73). The average hemoglobin gradient between affected and matched contralateral unaffected skin was four times higher in those who had progression (average differential 0.3, range 0.1-0.4) compared to those who did not (average differential 0.08, range 0.02-0.15). Using a cut off of a 0.18 hemoglobin gradient between affected and unaffected skin, the sensitivity of multispectral imaging for detecting progression in pediatric morphea is 90% with specificity of 100%. CONCLUSIONS: Multispectral imaging is a novel assessment tool with promising accuracy in predicting progression as an adjunct to clinical assessment in pediatric morphea. Further research should examine its performance against thermography.

Biological and JAK inhibitor therapy outcomes for severe psoriasis in trisomy 21.

Little is known about biological outcomes for severe psoriasis in trisomy 21 (T21). Our aim was to review outcomes of patients with T21 and severe psoriasis treated with biologic or Janus kinase inhibitors (JAKi). Information on demographics, co-morbidities, and therapeutic responses was retrospectively collated. Twenty-one patients were identified (mean age 24.7 years). Ninety percent (18/20) of TNFα inhibitor trials failed. Almost two-thirds (7/11) of patients achieved an adequate response with ustekinumab. All three patients treated with tofacitinib achieved an adequate response following at least three biologic failures. The mean number of biologic/JAKi therapies received was 2.1 with overall survival of 36%. Eighty-one percent (17/21) of patients required conversion from their index biologic treatment due to failure. In patients with T21 and severe psoriasis, failure of TNFα inhibition is common and ustekinumab therapy should be considered as first-line therapy. The role of JAKi is emerging.

Children's Savings Programs as Public-Private Partnerships: A Tool to Advance Health Equity for Low-Income Families.

Higher education can lead to economic mobility, but cost is a barrier for low-income families. Children's savings account (CSA) programs for higher education increase educational aspirations. Early Bird, a novel health system-integrated CSA program being assessed through a randomized control trial could greatly influence families' outcomes. Three preliminary lessons have emerged.

Pembrolizumab-associated erythema nodosum in the treatment of metastatic melanoma.

A 66-year-old woman receiving pembrolizumab for metastatic melanoma presented with tender red nodules on her shins and forearms. Biopsy was consistent with erythema nodosum (EN). The eruption responded to oral minocycline and potent topical steroids. Subsequent investigations detected bihilar lymphadenopathy, biopsied as granulomatous lymphadenitis, confirming the diagnosis of pembrolizumab-associated sarcoidosis. Pembrolizumab was stopped for two cycles and was restarted without recrudescence of EN or bihilar lymphadenopathy. Immunotherapy-associated sarcoidosis is a rare but recognized adverse event related to therapy with immune checkpoint inhibitors. EN is an uncommon manifestation of immunotherapy-induced sarcoidosis. New-onset bihilar lymphadenopathy in the context of immunotherapy requires prompt histological evaluation to differentiate between immunotherapy-associated sarcoidosis and metastatic progression. We review the literature related to immunotherapy-associated EN.

Pembrolizumab (trade name Keytruda^®) is a type of immune therapy that stimulates the body's immune system to fight cancer cells. This immune therapy can cause a variety of rashes. In this article, we describe a patient who developed a red lumpy rash on her limbs that is not commonly described with pembrolizumab. A woman was diagnosed with advanced melanoma and was treated with pembrolizumab. She developed a red lumpy rash on her arms and legs, and a biopsy showed signs of a condition called erythema nodosum. Treatment with an antibiotic tablet and strong steroid ointment were helpful. Scans of her chest showed signs of sarcoidosis in her lungs, which can be associated with erythema nodosum. Pembrolizumab was stopped, and both the rash and lung sarcoidosis stayed away when it was restarted. This type of rash has rarely been described with this kind of immune therapy, and it can be a sign of lung involvement.

Anti-Poverty Medicine Through Medical-Financial Partnerships: A New Approach to Child Poverty.

Poverty threatens child health. In the United States, financial strain, which encompasses income and asset poverty, is common with many complex etiologies. Even relatively successful antipoverty programs and policies fall short of serving all families in need, endangering health. We describe a new approach to address this pervasive health problem: antipoverty medicine. Historically, medicine has viewed poverty as a social problem outside of its scope. Increasingly, health care has addressed poverty's downstream effects, such as food and housing insecurity. However, strong evidence now shows that poverty affects biology, and thus, merits treatment as a medical problem. A new approach uses Medical-Financial Partnerships (MFPs), in which healthcare systems and financial service organizations collaborate to improve health by reducing family financial strain. MFPs help families grow assets by increasing savings, decreasing debt, and improving credit and economic opportunity while building a solid foundation for lifelong financial, physical, and mental health. We review evidence-based approaches to poverty alleviation, including conditional and unconditional cash transfers, savings vehicles, debt relief, credit repair, financial coaching, and employment assistance. We describe current national MFPs and highlight different applications of these evidence-based clinical financial interventions. Current MFP models reveal implementation opportunities and challenges, including time and space constraints, time-sensitive processes, lack of familiarity among patients and communities served, and sustainability in traditional medical settings. We conclude that pediatric health care practices can intervene upon poverty and should consider embracing antipoverty medicine as an essential part of the future of pediatric care.

Nursing's leaky pipeline: Barriers to a diverse nursing workforce.

BACKGROUND: Nursing educational programs have been charged with increasing the diversity of the nursing workforce; however, this depends on having a diverse and qualified applicant pool to select from. PURPOSE: To determine the effects of student losses over time on nursing program diversity. DESIGN AND METHODS: Descriptive longitudinal study. Progression of all students from a single university enrolled as pre-nursing majors from 2012 to 2016 (N = 2498) was tracked over seven key checkpoints during a seven-year time period. RESULTS: Slightly more than half of the students (57%) were lost prior to nursing program application, which occurred at the end of the sophomore year. Losses were higher for minority students (70%), those requiring remedial coursework (65%), and first-generation students (62%). Older students, those with a prior degree, and those who started in another major were more likely to persist through some, but not all, of the checkpoints. CONCLUSIONS: Pre-nursing program losses significantly decreased the diversity of the remaining nursing applicant pool, particularly for African American students. Losses were highest during the freshman level Anatomy and Physiology course. Nursing education programs need to develop early intervention programs to support diverse students during the critical pre-nursing period to increase the diversity of the nursing workforce.

Novel agents for atopic dermatitis in patients over 50 years of age: A case series.

Lan et al recently highlighted the under-representation of older adults in clinical trials of systemic therapies for atopic dermatitis (AD). Late-onset AD is increasingly recognized in older adults. Spontaneous remission is uncommon with this phenotype. Existing drug treatments such as corticosteroids, methotrexate, ciclosporin, and azathioprine are complicated by adverse effects including increased malignancy risk, immunosuppression in the context of immunosenescence, and drug interactions in the setting of polypharmacy. A case series is presented of seven patients over 50 years of age with AD who were prescribed dupilumab or tofacitinib or upadacitinib for at least 6 months. All patients were clear or almost clear (investigator global assessment score 0/1) after 1 month of therapy. No significant adverse events were seen. This case series provides preliminary evidence about the safety and efficacy of these novel drugs for AD in older adults. Further studies with higher numbers of participants are needed to obtain real-world evidence for these drugs in older adults, given the limited data in clinical trials.

Abdominal Tuberculosis in an Infant Presenting With a Small Bowel Obstruction.

ABSTRACT: Abdominal tuberculosis (TB) is rare in children and usually spread in the peritoneum or gastrointestinal tract. Symptoms tend to be vague and nonspecific, with no extra-abdominal involvement, presenting a challenge for clinicians and delayed diagnosis. Postnatally acquired abdominal TB is most commonly transmitted through inhalation or ingestion of respiratory droplets with Mycobacterium tuberculosis from the mother.Abdominal TB in infants is rare. We present a case of a 2-month-old infant presenting with an acute bowel obstruction secondary to abdominal TB acquired through contact with maternal TB mastitis. This unique case emphasizes the importance of considering abdominal TB in the differential for at-risk infants presenting with small bowel obstruction.

Impact of order entry alerts and modifications on doses of intravenous opioids dispensed during a national drug shortage.

PURPOSE: To address the intravenous (i.v.) opioid shortage, computer-based alerts and modifications were implemented over 2 phases beginning in August 2017 and February 2018, respectively. A study was conducted to assess the impact of these interventions on dispenses of intermittent doses of i.v. opioids during a national shortage. METHODS: A retrospective, single-center, pre- and postimplementation study was conducted to compare opioid dispenses from September 2017 through December 2017 (phase 1) and March 2018 through May 2018 (phase 2) with dispenses during the same time periods of the previous year (historical control periods). Dispense data for intermittent doses of i.v. fentanyl, hydromorphone, and morphine and select oral opioids were collected from automated dispensing cabinets (ADCs) located in nonprocedural areas. The primary endpoint was the percentage of total intermittent doses of i.v. and oral opioids that were dispensed for i.v. administration. A subanalysis accounting for unit type was conducted. Key secondary endpoints were the numbers of oral and i.v. opioid dispenses by month. RESULTS: The final analysis included data from 92 ADCs. The percentage of i.v. opioid dispenses significantly decreased, by 9.8% during phase 1 (P < 0.0001) and by 16.8% during phase 2 (P < 0.0001) compared to dispenses during the historical control periods. These decreases were significant across all unit types except pediatric units during phase 1. Average monthly dispenses of i.v. opioids were 49.9% and 74.2% fewer than dispenses during the historical control periods after the phase 1 and phase 2 implementations, respectively. CONCLUSION: Order entry alerts and modifications significantly decreased dispenses of intermittent doses of i.v. opioids during a national shortage, with demonstrated sustainability of decreases over 7 months.

Benefits of prophylactic heme therapy in severe acute intermittent porphyria.

Acute intermittent porphyria (AIP), an autosomal dominant inborn error of metabolism, is the most common and severe form of the acute porphyrias. Attacks of severe abdominal pain, often with hypertension, tachycardia, are cardinal features of AIP, often requiring hospital admissions. Frequent recurrent attacks of AIP, defined as >3 attacks in one year, during which at least one attack requires intravenous heme therapy, are associated with significant morbidity, lost productivity, and health care burden. We report two patients with such frequent attacks of AIP, who have been managed with prophylactic heme therapy on a weekly basis. We describe results particularly in relation to symptom control, biochemical findings, health care costs, quality of life, and utilization of resources. During 11-month duration of weekly prophylactic heme infusions, we observed a 100% decrease in acute attacks and inpatient admissions in one subject and a 75% decrease in the other. During this time, we also observed a significant decrease in the number of emergency room visits. The decrease in number of acute attacks requiring hospital admission was associated with significantly decreased health care costs and improved quality of life. Reduction of both emergency room visits and hospital admissions decreased the utilization of health care services. Outpatient weekly infusions were also noted to be associated with better reimbursements and reduced overall costs of health care for the subjects. Both our subjects also endorsed better symptom control, quality of life and better understanding of disease. Thus, prophylactic heme therapy, through a multi-disciplinary approach, decreases the incidence of acute attacks, decreases health care costs and leads to better patient satisfaction and quality of life.

A Stab in the Back: An Unusual Case of Cutaneous Neural Infiltration as a Manifestation of Chronic Lymphoproliferative Disorder of Natural Killer Cells.

Chronic lymphoproliferative disorder of natural killer cells (CLPDNK) is a rare heterogenous indolent disorder comprising a persistent peripheral blood cell count of more than ≥2 × 10/L natural killer cells for over 6 months. We report an unusual case of cutaneous neural infiltration as a manifestation of CLPDNK. A 52-year-old woman with a background of CLPDNK was referred to dermatology with a painful rash primarily affecting her back. Skin biopsies revealed a neurotropic atypical lymphoid infiltration. Results of immunohistochemistry studies showed CD8, CD56, granzyme B, perforin positivity, and CD3 negativity in keeping with an atypical neurotropic lymphoid infiltrate consistent with cutaneous involvement by the patient's known CLPDNK. Cutaneous lesions and peripheral neuropathy in patients with CLPDNK have been reported; however, the involvement of cutaneous peripheral nerves as described in our case has not been reported before.

A one hour teaching intervention can improve end-of-life care.

BACKGROUND: It is not known if standard nursing actions are tailored to patient preferences for comfort measures during End of Life (EOL) care. OBJECTIVES: Determine the effect of a brief teaching intervention on student care of EOL patients. DESIGN: Pre-test/post-test intervention design. SETTINGS: Two large public universities and one smaller private Catholic institution (all in the United States [U.S.]). PARTICIPANTS: 471 nursing students attending class as part of their required nursing curriculum. METHODS: A previously developed aggressiveness of nursing care scale was modified to determine students' behavioral intentions for the care of the EOL patient before and after a standardized lecture. The lecture was designed to help students recognize that nursing care priorities for the EOL patient may need to be different than for other patients in order to provide the best quality of remaining life. RESULTS: Nursing students prior to the lecture had aggressiveness of care scores similar to those of experienced staff nurses, and were more likely to provide more aggressive care to younger patients without DNR orders than to older patients with a DNR order. Following the lecture, aggressiveness of nursing care scores decreased significantly for all EOL patients, and students reported similar behavioral intentions for all EOL patients, regardless of patient age or code status. Student age was marginally related to change in behavior following the lecture. Prior experience in caring for a dying patient or relative did not have a significant effect on aggressiveness of care scores before or after the lecture. CONCLUSIONS: This study demonstrates the effectiveness of a brief teaching intervention to help student nurses take patient preferences and needs into consideration when selecting nursing interventions for the EOL patient.

Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report.

OBJECTIVES: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. METHODS: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners. RESULTS: We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report. CONCLUSIONS: This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

The Interactive Effect of Major Depression and Nonsuicidal Self-Injury on Current Suicide Risk and Lifetime Suicide Attempts.

UNLABELLED: This study examined the main and interactive effects of MDD and lifetime nonsuicidal self-injury (NSSI) on current suicide risk and past suicide attempts. We predicted that individuals with a history of NSSI and current MDD would be at greater suicide risk than those with either risk factor alone. An interaction between lifetime MDD and NSSI was hypothesized for past suicide attempts. 204 substance dependent inpatients completed self-report measures and a diagnostic interview. Patients with both a history of NSSI and current MDD, relative to all other groups, had the greatest suicide risk. No support was found for the lifetime MDD by NSSI interaction. CONCLUSION: Findings suggest the relevance of both NSSI and MDD in suicide risk.