Infantile Stevens Johnson syndrome and toxic epidermal necrolysis: A systematic review of clinical features and outcomes in children ages 12 months and under.

BACKGROUND/OBJECTIVES: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening mucocutaneous hypersensitivity reactions that carry significant morbidity and mortality. While clinical features are well documented in adult and pediatric patients, infantile cases are rarely reported. Our objective was to synthesize clinical features and outcomes in this population. METHODS: A literature search was performed from three large databases (PubMed, EMBASE, and Web of Science) to systematically identify reports of SJS/TEN in the infantile period (defined as less than 12 months of age) between 1962 and 2019. Cases determined to represent SJS/TEN based on defined criteria were included. Each case was scored based on Quality Rating Scheme for Studies and Other Evidence. The initial search yielded 4856 publications, of which 19 (n = 26) met final inclusion criteria. RESULTS: All cases for which body surface area (BSA) involvement was available or able to be approximated (n = 18/26) met criteria for TEN. All cases (n = 26) had mucous membrane involvement, with the oral mucosa most commonly affected (85.7%). Mortality was high within our population with 39.1% of infants expiring, 77.8% secondary to bacterial sepsis. The most common triggers were medications (52.4%), infections (33.3%), and vaccinations (14.3%). CONCLUSIONS: This review highlights several unique clinical findings amongst infants with SJS/TEN, including increased BSA involvement, higher rates of bacterial sepsis, and higher mortality rates compared to older children and adults. Infants are more likely to present as TEN over SJS. More research is needed to identify triggers, successful treatments, and specific outcomes in this population.

A Case of Red Retching?

This piece features a 14-year-old young man who presented with epigastric pain and bright red emesis. His father brought both a photo and sample of the vomitus, which guided initial management in one direction, and then on closer inspection, diverted his diagnostic trajectory. Through a traditional case report and accompanied image and prose, we explore how we process and reinterpret visual data to help guide our management of hematemesis.

Infantile toxic epidermal necrolysis: Successful treatment of an 8-week-old with intravenous immunoglobulin and amniotic membrane transplant.

Stevens-Johnson syndrome and toxic epidermal necrolysis comprise a spectrum of severe mucocutaneous hypersensitivity reactions. A paucity of data limits current understanding of the etiology, treatment options, and prognosis of this entity in the infantile population compared to that in the adult and pediatric literature. We describe the case of an 8-week-old male with toxic epidermal necrolysis treated successfully with intravenous immunoglobulin and amniotic membrane transplant. This patient is the youngest surviving infant with toxic epidermal necrolysis to be reported.

Rapid brain MRI protocols reduce head computerized tomography use in the pediatric emergency department.

BACKGROUND: Rapid magnetic resonance imaging (MRI) protocols may be effective in the emergency department (ED) to evaluate nontraumatic neurologic complaints. We evaluate neuroimaging (rapid MRI [rMRI]), head computerized tomography [HCT], and full MRI) use following widespread implementation of rMRI protocols in a pediatric emergency department (ED). METHODS: We conducted a retrospective study in a tertiary care pediatric ED of encounters with neuroimaging during two 9-month periods: one prior to (control period) and one after generalized availability of 4 rMRI protocols (rMRI period). The primary outcome was differences in neuroimaging rates between the two periods. Secondary outcomes included ED process measures, unsuccessful imaging, and undetected pathology, with full MRI within 14 days as the reference standard. RESULTS: There were 1052 encounters with neuroimaging during the control and 1308 during the rMRI periods. Differences in neuroimaging between periods were 27.7% for rMRI (95% CI, 24.4, 31.0), - 21.5% for HCT (95% CI, - 25.5, - 17.5), and - 6.2% for full MRI (95% CI, - 9.3, - 3.1%.) Time to imaging (182 [IQR 138-255] versus 86 [IQR 52-137] minutes) as well as ED length of stay (396 [IQR 304-484] versus 257 [IQR 196-334] minutes) was longer for rMRI versus HCT (p < 0.01). Between the control and rMRI periods, there were differences in types of neuroimaging performed for patients with altered mental status, headache, seizure, shunt dysfunction, stroke, syncope, trauma, vomiting, infection, and other neurologic complaints (p < 0.05). rMRI studies were unsuccessful in 3.6% of studies versus 0.0% of HCTs (p < 0.01). The 22 unsuccessful rMRI studies were unsuccessful due to artifacts from dental hardware (n = 2) and patient motion (n = 20). None of the rMRI studies with full MRI follow-up imaging had undetected pathology; the false negative rate for the HCT exams was as high as 25%. CONCLUSIONS: After routine ED use of 4 rMRI protocols, there was a more than 20% decrease in HCT use without missed diagnoses. Time to neuroimaging and length of stay were longer for rMRI than HCT, with higher rates of unsuccessful imaging. Despite these limitations, rMRI may be an alternative to HCT for nontraumatic complaints in the ED.

Timeliness of Treatment Initiation in Newly Diagnosed Patients With Breast Cancer.

BACKGROUND: Evidence-based timeliness benchmarks have been established to assess quality of breast cancer care, as delays in treatment are associated with poor clinical outcomes. However, few studies have evaluated how current breast cancer care meets these benchmarks and what factors may delay the timely initiation of treatment. PATIENTS AND METHODS: Demographic and disease characteristics of 377 newly diagnosed patients with breast cancer who initiated treatment at Tufts Medical Center (2009-2015) were extracted from electronic medical records. Time from diagnosis to initial surgery and time from diagnosis to initiation of hormone therapy were estimated with Kaplan-Meier curves. Multivariable regression analysis was used to identify factors associated with treatment delays. Thematic analysis was performed to categorize reasons for delay. RESULTS: Of 319 patients who had surgery recommended as the first treatment, 248 (78%) met the 45-day benchmark (median, 28 days; 25th-75th %, 19-43). After adjusting for potential confounders, multivariable regression analysis revealed that negative hormone receptor status (odds ratio, 3.48; 95% confidence interval, 1.44-8.43) and mastectomy (odds ratio, 4.07; 95% confidence interval, 2.10-8.06) were significantly associated with delays in surgery. Delays were mostly owing to clinical complexity or logistical/financial reasons. Of 241 patients eligible for hormone therapy initiation, 232 (96%) met the 1-year benchmark (median, 147 days; 25th-75th %, 79-217). CONCLUSION: Most patients met timeliness guidelines for surgery and initiation of hormone therapy, although risk factors for delay were identified. Knowledge of reasons for breast cancer treatment delay, including clinical complexity and logistical/financial issues, may allow targeting interventions for patients at greatest risk of care delays.

Inpatient eDermatology (Teledermatology) Can Help Meet the Demand for Inpatient Skin Disease.

Background: Currently, the number of inpatient dermatology providers cannot meet the overall burden of inpatient skin disease in the United States. Introduction: We seek to determine whether inpatient eDermatology can meet the need for inpatient skin disease in hospitals without access to a dermatology hospitalist. Methods: This retrospective cohort study reviewed inpatient eDermatology consults at the University of Pittsburgh eDermatology Consult Service between July 1, 2014 and June 30, 2018. This included a diverse group of 1,320 patients admitted to 10 different community hospitals. Study data were reviewed for demographics, diagnostic impressions, time to discharge, and diagnostic discordance between referring and consultant physicians. Results: Forty percent of inpatient eDermatology consults were admitted with a primary dermatologic diagnosis. Referring diagnosis most commonly was rash not otherwise specified. eDermatology consulting impressions, conversely, were specific and varied. Ninety-one percent of patients received a consultant impression by the end of day, or within 8 hours. Overall, 89.3% of patients with a referring diagnosis of "cellulitis" were given a different diagnosis by the consultant. Discussion: Although this study lacked concordance data to compare the Inpatient eDermatologist with a live Inpatient Dermatologist, overall, eDermatology consultants were able to provide rapid consult recommendations that aided patient management. Conclusions: Inpatient eDermatology appears to be an effective medium to provide dermatologic care to patients at hospitals without a dermatology presence. This delivery of health care can help prevent misdiagnosis, unnecessary costs, and inappropriate systemic therapies.

Positive and Negative Experiences on Social Media and Perceived Social Isolation.

PURPOSE: To examine the association between positive and negative experiences on social media (SM) and perceived social isolation (PSI). DESIGN: Cross-sectional survey. SETTING: One large mid-Atlantic University. PARTICIPANTS: A total of 1178 students aged 18 to 30 were recruited in August 2016. MEASURES: Participants completed an online survey assessing SM use and PSI. We assessed positive and negative experiences on SM by directly asking participants to estimate what percentage of their SM experiences involved positive and negative experiences, respectively. Social isolation was measured using the established Patient-Reported Outcomes Measures Information System scale. ANALYSIS: We used multivariable logistic regression to assess associations between both positive and negative experiences on SM and PSI. Primary models controlled for sex, age, race/ethnicity, educational status, relationship status, and living situation. RESULTS: Participants had an average age of 20.9 (standard deviation = 2.9) and were 62% female. Just over one-quarter (28%) were nonwhite. After controlling for all sociodemographic covariates, each 10% increase in positive experiences was not significantly associated with social isolation (adjusted odds ratio [AOR] = 0.97; 95% confidence interval [CI]: 0.93-1.005). However, each 10% increase in negative experiences was associated with a 13% increase in odds of PSI (AOR = 1.13; 95% CI: 1.05-1.21). CONCLUSION: Having positive experiences on SM is not associated with lower social isolation, whereas having negative experiences on SM is associated with higher social isolation. These findings are consistent with the concept of negativity bias, which suggests that humans tend to give greater weight to negative entities compared with positive ones.

The association between valence of social media experiences and depressive symptoms.

BACKGROUND: Social media (SM) may confer emotional benefits via connection with others. However, epidemiologic studies suggest that overall SM is paradoxically associated with increased depressive symptoms. To better understand these findings, we examined the association between positive and negative experiences on SM and depressive symptoms. METHODS: We conducted a cross-sectional survey of 1,179 full-time students at the University of West Virginia, aged 18 to 30, in August 2016. Independent variables were self-reported positive and negative experiences on SM. The dependent variable was depressive symptoms as measured using the Patient-Reported Outcomes Measurement Information System. We used multivariable logistic regression to assess associations between SM experiences and depressive symptoms controlling for sociodemographic factors including age, sex, race/ethnicity, education, relationship status, and living situation. RESULTS: Of the 1,179 participants, 62% were female, 28% were non-White, and 51% were single. After controlling for covariates, each 10% increase in positive experiences on SM was associated with a 4% decrease in odds of depressive symptoms, but this was not statistically significant (adjusted odds ratio [AOR] = 0.96; 95% confidence interval [CI] = 0.91-1.002). However, each 10% increase in negative experiences was associated with a 20% increase in odds of depressive symptoms (AOR = 1.20; 95% CI = 1.11-1.31). When both independent variables were included in the same model, the association between negative experiences and depressive symptoms remained significant (AOR = 1.19, 95% CI = 1.10-1.30). CONCLUSIONS: Negative experiences online may have higher potency than positive ones because of negativity bias. Future research should examine temporality to determine if it is also possible that individuals with depressive symptomatology are inclined toward negative interactions.