Efficacy and Durability of Intravenous Ertapenem Therapy for Recalcitrant Hidradenitis Suppurativa.

Importance: Hidradenitis suppurativa (HS) is a debilitating follicular skin disorder in which bacterial colonization is typical. Oral antibiotic efficacy can be unreliable; however, selective intravenous antibiotics, specifically ertapenem, may provide favorable clinical outcomes. Objective: To explore optimal course duration, efficacy, and patient satisfaction associated with intravenous ertapenem for HS. Design, Setting, and Participants: This retrospective review of the medical records of 98 patients with HS between 2018 and 2022 measured and evaluated patient outcomes before and after treatment with intravenous ertapenem. Participants were followed up in a telephone survey assessing patient perspectives and satisfaction. All of those included in this study received medical care from the Albert Einstein College of Medicine's Montefiore HS Center. Exposures: Patients were treated with 1 g of ertapenem that was self-administered at home through a peripheral intravenous central catheter using an elastomeric pump for 12 to 16 weeks. Antiandrogens and immunomodulatory biologic therapies initiated prior to ertapenem were maintained throughout the treatment course. Main Outcomes and Measures: The primary outcomes, encompassing clinical severity (evaluated through the HS Physician Global Assessment score [a 6-point scale ranging from clear to very severe] and a numerical rating scale for pain [an 11-point scale in which a score of 0 indicates no pain and a score of 10 indicates the worst possible pain]) and markers of inflammation (such as leukocytes, erythrocyte sedimentation rate, C-reactive protein, and interleukin-6), were measured at baseline, the midcourse of intravenous ertapenem treatment, at the end of the course, and posttherapy. Bacterial abundance was also examined at these 4 points, and patient satisfaction was assessed during follow-up. Results: A total of 98 patients (mean [SD] age, 35.8 [13.0] years; 61 [62.2%] female) with HS were treated with intravenous ertapenem. The self-reported racial distribution included 3 individuals identifying as Asian (3.1%), 59 as Black/African American (60.2%), 13 as White (13.3%), and 23 as either other or unknown (23.5%). Additionally, 24 participants (24.5%) reported Spanish/Hispanic/Latino ethnicity. The mean (SD) treatment duration spanned 13.1 (4.0) weeks, with posttherapy follow-up occurring after 7.8 (3.6) weeks. From baseline to posttherapy follow-up, significant reductions were found in the mean (SD) HS Physician Global Assessment scores (3.9 [1.0] vs 2.7 [1.2]; P < .001) and the numerical rating scale for pain (4.2 [3.3] vs 1.8 [2.7]; P < .001), C-reactive protein (5.4 [11.4] vs 2.4 [2.0] mg/dL; P < .001), interleukin-6 (25.2 [21.1] vs 13.7 [13.9]; P < .001), and leukocytes (11.34 [3.9] vs 10.0 [3.4]; P < .001). At follow-up, 76 patients (78.0%) participated in the telephone survey, where 63 (80.3%) reported medium to high satisfaction; further, 69 (90.8%) would recommend ertapenem to other patients. Conclusions and Relevance: In this retrospective review of medical records and telephone survey, treating HS with intravenous ertapenem, administered for a mean of 13 weeks, was associated with improvement in clinical and inflammatory markers, as well as heightened patient satisfaction. Nonetheless, this approach should be monitored for the emergence of antimicrobial resistance given a longer than standard treatment course.

Fat Grafting to the Breast for Aesthetic Indications: Techniques and Outcomes in 165 Consecutive Patients.

PURPOSE: Fat grafting to the breast for aesthetic indications has become increasingly popular. Herein, methods, aesthetic outcomes, and complications are reviewed in a retrospective case series. METHODS: Female patients (n=165) with an average age of 45 years (range: 17-78 years) who underwent fat grafting to breast were evaluated. Demographic parameters, the type of procedure, the amount of fat transferred, the site(s) of fat harvest, operative times, and the patient's postoperative recovery and outcomes were recorded. RESULTS: Of the 165 patients, 105 had breast augmentation with fat only. Of these 105 patients, 14(8%) had implant removal with and without capsulectomy, and 61(37%) had mastopexies. Composite augmentation was performed in the remaining 60 patients. The average amount of fat used was 208 cc (range: 10 to 945 cc) per breast. Forty-five patients (27%) underwent a second procedure. Of the 165 patients, 37(22%) had adverse events unrelated to the fat graft, including suture abscesses, scarring, and minor incision cite skin breakdown. Four patients (2.4%) had a complication related to fat grafting including 'lump' formation between the breast, abnormal mammograms, and the need for simple aspiration of a lipid cyst. CONCLUSIONS: Autologous fat grafting should be considered for both primary and secondary aesthetic breast surgery to enhance outcomes. Complications related to fat grafting are uncommon. Revisional and secondary surgeries may be needed to achieve the desired outcome. Power-assisted liposuction, with vibratory infiltration of the tumescent solution, auto-infusion of fat, and Expansion Vibration Lipofilling using a closed system has become our preferred technique. Fat grafting to breast can be considered for both primary and secondary aesthetic breast surgery Complications related to fat grafting are uncommon There does not appear to be an overall increase in complications of associated mastopexy and composite augmentation LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy and Patient Satisfaction Associated With Intramuscular Triamcinolone Therapy for Acute Flares of Hidradenitis Suppurativa.

BACKGROUND: A lack of consensus exists regarding acute flare management in hidradenitis suppurativa (HS). Intramuscular triamcinolone (IMTAC) therapy is useful in numerous inflammatory conditions; however, it has not been investigated for acute HS flares. OBJECTIVE: To evaluate the efficacy and patient experience associated with IMTAC therapy for acute, severe HS flares. METHODS: Retrospective analysis and surveys of 45 HS patients were conducted at Albert Einstein College of Medicine/ Montefiore HS Center, Bronx, NY, USA. RESULTS: Follow-up visits 6.77 (4.45) weeks after IMTAC therapy revealed significant reductions in mean HS-Physician Global Assessment (PGA) (P < .001), C-Reactive Protein (CRP) (P = .03), increased hemoglobin (P = .004), and improved pain scores (P < .001). Adjusting for age, sex and concomitant medications, multivariate analysis yielded significantly reduced pain (P = .02) and increased hemoglobin (P = .03). Patient surveys indicate that IMTAC was well-tolerated, as reflected in positive mean responses for satisfaction (29 [64%]) and willingness to receive IMTAC injections again (42 [93%]). CONCLUSIONS: These novel findings demonstrate that IMTAC is a safe, effective, and well accepted adjunct for acute HS management.

Comparison of Adipocyte Viability After Short-Term Cryopreservation of Adipose Aspirates Through 3 Different Techniques.

Background: Effective cryopreservation allows for the long-term storage of living cells or tissues with the possibility of later clinical applications. Unfortunately, no successful investigations on the long-term preservation of adipose aspirates for prospective autologous fat grafting have been conducted. Objectives: In this study, we aimed to compare 3 different freezing methods to preserve adipose aspirates obtained from conventional lipoplasty to determine the optimal cryopreservation technique. Methods: To determine the optimal cryopreservation technique, hematoxylin and eosin staining, MTS assay, and Annexin assay were performed on each of the 3 groups plus a fourth control group. Group 1 served as the control, and fat tissue was analyzed immediately after adipose harvesting with no cryopreservation. For experimental Group 2, 15 mL of adipose aspirates were directly frozen at -80°C for up to 2 weeks. For experimental Group 3, 15 mL of adipose aspirates were frozen inside the adi-frosty containing 100% isopropanol and stored at -80°C for up to 2 weeks. For experimental Group 4, 15 mL of adipose aspirates were frozen with freezing solution containing 90% fetal bovine serum (v/v) and 10% dimethyl sulfoxide (v/v). Results: The results demonstrated that the experimental Group 3 had significantly more live adipocytes and greater cellular function of adipose aspirates than the experimental Groups 2 and 4. Conclusion: Cryopreservation with adi-frosty containing 100% isopropanol appears to be the best means of cryopreservation of fat.

The Effect of Hybrosome (Umbilical Cord Blood Exosome-Liposome Hybrid Vesicles) on Human Dermal Cells In Vitro.

Background: Wound healing is a process that involves multiple physiological steps, and despite the availability of various wound treatment methods, their effectiveness is still limited due to several factors, including cost, efficiency, patient-specific requirements, and side effects. In recent years, nanovesicles called exosomes have gained increasing attention as a potential wound care solution due to their unique cargo components which enable cell-to-cell communication and regulate various biological processes. Umbilical cord blood plasma (UCBP) exosomes have shown promise in triggering beneficial signaling pathways that aid in cell proliferation and wound healing. However, there is still very limited information about the wound-healing effect of UCBP exosomes in the literature. Objectives: The primary objective of this study was to investigate the "hybrosome" technology generated with calf UCBP-derived exosome-liposome combination. Methods: The authors developed hybrosome technology by fusing cord blood exosome membranes with liposomes. Nanovesicle characterization, cell proliferation assay, wound-healing scratch assay, immunohistochemistry analysis, anti-inflammation assay, real-time polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay, and cellular uptake studies were performed using the novel hybrid exosomes. Results: Experimental results showed that hybrosome increases cell proliferation and migration by 40% to 50%, depending on the dose, and induces an anti-inflammatory effect on different cell lines as well as increased wound healing-related gene expression levels in dermal cells in vitro. All in all, this research widens the scope of wound-healing therapeutics to the novel hybrosome technology. Conclusions: UCBP-based applications have the potential for wound treatments and are promising in the development of novel therapies. This study shows that hybrosomes have outstanding abilities in wound healing using in vitro approaches.

Importance of a multi-tiered treatment approach for intellectually and developmentally disabled patients with hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic, debilitating skin condition that is characterized by painful pustules, nodules, abscesses, and sinus tracts. The complicated and fast-evolving treatment of HS consists of a multi-tiered approach that includes, antibacterial, antihormonal, anti-inflammatory, and surgical options. Studies have demonstrated an earlier age of onset and increased prevalence of HS in patients with intellectual and developmental disability (IDD) compared to patients without IDD. To explore the use of an intensive multi-tiered HS management algorithm that requires monthly office visits, monthly intravenous therapy, and several daily treatment modalities in an HS population with IDD, we conducted an IRB-approved retrospective chart review of HS patients treated at the Albert Einstein College of Medicine-Montefiore HS Center (HSC) with diagnoses of concurrent IDD to investigate their demographic and diagnostic characteristics, as well as the spectrum of therapies employed in this cohort. A total of 22 HS patients with concomitant IDD, including trisomy 21, unspecified intellectual disability, autism spectrum disorder, and trisomy 13 were identified. Therapies utilized in this cohort for HS included topical and oral antibiotics, spironolactone, finasteride, oral contraceptive pills, infliximab, adalimumab, isotretinoin, intralesional and intramuscular triamcinolone injections, and excisional surgery. In conclusion, our findings indicate that despite the practical challenges, daily oral antibiotic regimens, anti-androgen combinations, oral retinoids, infliximab, adalimumab, and surgery collectively play important roles in treating HS patients with IDD. Our cases underscore the importance of utilizing the full range of modalities as the HS treatment algorithm continues to evolve.

Radiesse Rescue: A Preliminary Study for a Simple and Effective Technique for the Removal of Calcium Hydroxyapatite-Based Fillers.

BACKGROUND: Radiesse, or calcium hydroxyapatite (CaHA), is a semipermanent, biodegradable injectable filler that provides immediate aesthetic improvement, while also stimulating neocollagenesis for biological effects. The physical properties of CaHA make it difficult, if not impossible, to remove. Unlike some hyaluronic acid-based fillers, CaHA cannot be easily dissolved. OBJECTIVES: The aim of this study was to present a simple and reliable technique for debulking and removing excess CaHA in the event of nodule formation, vascular compression, or overcorrection. METHODS: An 18-gauge needle was used to make an incision near the filler excess. A 1-mm-diameter grater-type microliposuction cannula (Lipocube, Inc.; London, UK) was attached to a 5- to 10-mL syringe under negative pressure. The cannula under syringe suction was used in a back-and-forth reaming motion beginning in the base of the material and gradually moving toward the surface until the desired effect was achieved. Identification of the CaHA can be established and removal confirmed with ultrasound (Clarius, Inc.; Vancouver, BC, Canada) if available. RESULTS: Although nodules, excess material and vascular compression secondary to CaHA are very rare occurrences, 4 patients were treated with excess material and/or nodules. In 1 patient, the prominent cheek filler was reduced and a 1-cm nodule that was palpable in the buccal region was eliminated. In the other 3 other patients, the palpable excess material was easily removed, in 2 at the time of injection and in the third, 6 months later. No patient required repeat treatment or replacement. CONCLUSIONS: This removal technique has been shown to adequately remove excess CaHA filler but is not applicable to inadvertent intravascular injection.

Adalimumab efficacy is inversely correlated with body mass index (BMI) in hidradenitis suppurativa.

BACKGROUND: Adalimumab is the only FDA-approved biologic for hidradenitis suppurativa (HS). In the setting of increasing obesity rates worldwide, the relationship between adalimumab efficacy for HS and BMI is essential to understand. We assessed this relationship through markers of disease severity and inflammation. METHODS: Institutional review board-approved retrospective chart review of Montefiore/Einstein HS Center (HSC) patients (n = 57) treated with adalimumab. The relationship between BMI and adalimumab efficacy was assessed through disease severity (HS-Physician Global Assessment [HS-PGA] 0 and Numerical Rating Scale Pain [NRS-Pain]) and inflammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and interleukin-6 [IL-6]). A BMI ≥ 30 is defined as obese; BMI < 30 is defined as non-obese. RESULTS: The mean age was 35.8 ± 13.0 years. After adalimumab therapy, those with BMI < 30 experienced significant reductions in HS-PGA (-1.5 ± 0.9; P < 0.0001) and NRS-Pain (-1.6 ± 2.1; P < 0.0001), as well as mean decreases in inflammatory markers ESR, CRP, and IL-6 (-17.90 ± 23.6, -0.71 ± 1.4, -5.88 ± 7.9, respectively; P > 0.05). Obese patients (BMI ≥ 30) experienced mean increases in HS-PGA (+0.22 ± 0.8; P > 0.05) and NRS-Pain scores (+1.41 ± 3.5; P > 0.05) as well as mean increases in ESR, CRP, and IL-6 (+2.62 ± 28.3, +0.44 ± 3.0, +2.35 ± 6.9, respectively; P > 0.05). Comparing the cohorts, differences in changes in HS-PGA, NRS-Pain, ESR, and IL-6 after therapy are significantly different (P < 0.05). CONCLUSIONS: We identified significantly lower efficacy of adalimumab in HS patients with BMI ≥ 30 compared to those with BMI < 30. Those with BMI ≥ 30 demonstrated signs of both clinical and physiological deterioration while on adalimumab. Future studies are needed to examine adalimumab dosing for HS patients with high BMI, as well as a critical reconsideration of weight-based therapies.

A Multicenter, Randomized, Double-Blind, Split-Body Clinical Trial Evaluating the Efficacy and Outcomes of a Topical Product Pre and Post Aesthetic Surgical Body Procedures.

Background: Skin preconditioning prior to and following procedures, has previously been demonstrated to hasten and optimize healing, and decrease the symptoms and signs associated with invasive surgery. These trials involved the use of multiple topical products. In an effort to control costs and to increase patient compliance, a single surgical product was developed, with actives aimed at decreasing swelling, bruising, induration, and internal fibrous banding. Objectives: This multi-center trial was designed to measure the efficacy of this single product in these mentioned parameters. Methods: A double-blind, randomized, split body, clinical study was undertaken in 29 patients involving 38 surgical procedures. Assessments included photography, biopsies, ultrasound imaging, and blinded investigator and participant assessments. Results: Differentiated results between test comparator sides became apparent at postop day 10-14 (as previously observed). Thus, blinded investigator and participant assessment scores demonstrated statistical significance exclusive to the test product side at postop day 10-14 for ecchymoses and then extending to skin discoloration, edema, induration and subcutaneous fibrous banding, at weeks 3, 4, 6, and 12. Ultrasound evaluation confirmed the earlier dissolution of fibrous banding on the test side in the subcutaneous tissue at the 3-6-week postop period. In addition, biopsies assessing the pre-conditioned period prior to surgery confirmed that the topical test product stimulated a remodeled extracellular matrix without comparative changes on the opposite side. Conclusions: A single peri-surgical product designed for the use with invasive surgery produced significant differences in ecchymosis, skin discoloration, edema, induration and ongoing resolution of fibrous banding over many weeks. This study validation provides an additional adjunct to surgical procedures.

Serum inflammatory markers and leukocyte profiles accurately describe hidradenitis suppurativa disease severity.

BACKGROUND: Inflammatory markers and leukocyte profiles have not been longitudinally evaluated as objective signs of hidradenitis suppurativa (HS) severity. We sought to assess C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), and leukocyte profiles as reliable indicators of HS severity. METHODS: Retrospective cohort study of 404 patients seen at the Einstein/Montefiore HS Center, Bronx, New York, between March 2019 and November 2020. Associations of disease severity (HS-Physician Global Assessment) with inflammatory markers and leukocyte profiles were assessed by odds ratios (OR) and 95% confidence intervals (95% CI) incorporating up to four visits per patient, adjusting for baseline gender, age, BMI, and smoking status. RESULTS: Patients with severe disease had elevated CRP (OR 1.87; 95% CI 1.49, 2.34), ESR (OR 1.04; 95% CI 1.03, 1.04), IL-6 (OR 1.08; 95% CI 1.00, 1.16), leukocytes (OR 1.22; 95% CI 1.14, 1.31), neutrophils (OR 1.31; 95% CI 1.20, 1.42), eosinophils (OR 14.40; 95% CI 2.97, 69.74), basophils (OR 2.53; 95% CI 1.09, 5.85), monocytes (OR 5.36; 95% CI 2.49, 11.53), and neutrophil-lymphocyte ratios (OR 1.63; 95% CI 1.35, 1.96) but decreased lymphocytes (OR 0.86; 95% CI 0.68, 1.10). CONCLUSIONS: This novel longitudinal study of inflammatory markers and leukocyte profiles offers critical laboratory measures to confirm clinically determined disease severity over time.

Intralesional bleomycin for treatment of a recalcitrant wart in an immunocompromised patient: A safe, effective, and underutilized therapy.

Injectable bleomycin is infrequently used for recalcitrant warts despite its efficacy, acceptable safety profile, and high patient satisfaction compared with other treatment modalities. We present an immunocompromised patient with a large recalcitrant wart successfully treated with intralesional bleomycin to provide greater clinical exposure, training, and practice with intralesional bleomycin.