Improving Consistency in the Use of Sucrose With Comfort Measures During Minor Painful Procedures.

BACKGROUND: Inconsistent pain management practices can have negative physiologic and neurodevelopmental consequences in the neonate. Low rates of oral sucrose use with comfort measures for pain management during minor painful procedures were identified at a level III neonatal intensive care unit. Underutilization of pain management resources occurs despite the availability of evidence-based pain management interventions. PURPOSE: To improve consistency in the use of oral sucrose solution with comfort measures during peripheral intravenous catheter insertion attempts in the neonatal intensive care unit in patients greater than or equal to 32 0/7th weeks postmenstrual age. METHODS: Quality improvement methods were used to implement an evidence-based procedural pain algorithm for minor painful procedures and optimize pain management processes over a 15-week period in a 26-bed, level III neonatal intensive care unit. RESULTS: There was an increase in the average percentage of documented use of sucrose with comfort measures during peripheral intravenous catheter insertion attempts from 20% to 27%. There was a 41% increase in the average presence of a sucrose order indicated for procedural pain. There were improvements in staff knowledge of sucrose dosing and perceived behavior of staff after completing the education. IMPLICATIONS FOR PRACTICE AND RESEARCH: Procedural pain management should be used as a quality indicator and guidelines should be established with the support of key stakeholders in neonatal intensive care settings. Future projects should address barriers related to workflow and accessibility of sucrose, include other common needlestick procedures, and expand the role of parent participation in pain management practices.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/pages/video.aspx?v=60 .

Dermatofibrosarcoma protuberans with platelet-derived growth factor-D rearrangement; two cases with morphologically distinct presentations.

Dermatofibrosarcoma protuberans (DFSP) is a mesenchymal neoplasm that is usually located in the dermis or subcutis and is locally aggressive. Rarely, these lesions may undergo fibrosarcomatous transformation, which is thought to increase their metastatic potential. DFSP is classically associated with a 17;22 translocation (or ring chromosome thereof) resulting in fusion of the COL1A1 and PDGFB genes. However, variant fusions involving PDGFD have been recently reported. Herein, we present two morphologically diverse cases of DFSP with PDGFD rearrangement. Case 1 is a 68-year-old female with a left dorsal foot lesion. Morphologically, the lesion is unusual as it is a well-circumscribed, hypercellular, subcutaneous nodule with uniform CD34-positive spindle cells arranged in a herringbone pattern without storiform arrangement or "honeycombing" fat entrapment. It was diagnosed as pure fibrosarcomatous DFSP. Case 2 is a 37-year-old male with a right supra-auricular lesion. Morphologically, the lesion displays classic DFSP features including bland CD34-positive spindle cells with storiform growth, fat entrapment, and infiltrative borders. Both lesions were negative for COL1A1-PDGFB fusion but positive for PDGFD rearrangement by fluorescence in situ hybridization (FISH) analysis. FISH testing for PDGFD rearrangement should be performed in cases where there is a high suspicion for DFSP but initial studies for COL1A1-PDGFB are negative.

Validation of a Novel Cutaneous Neoplasm Diagnostic Self-Efficacy Instrument (CNDSEI) for Evaluating User-Perceived Confidence With Dermoscopy.

BACKGROUND: Accurate medical image interpretation is an essential proficiency for multiple medical specialties, including dermatologists and primary care providers. A dermatoscope, a ×10-×20 magnifying lens paired with a light source, enables enhanced visualization of skin cancer structures beyond standard visual inspection. Skilled interpretation of dermoscopic images improves diagnostic accuracy for skin cancer. OBJECTIVE: Design and validation of Cutaneous Neoplasm Diagnostic Self-Efficacy Instrument (CNDSEI)-a new tool to assess dermatology residents' confidence in dermoscopic diagnosis of skin tumors. METHODS: In the 2018-2019 academic year, the authors administered the CNDSEI and the Long Dermoscopy Assessment (LDA), to measure dermoscopic image interpretation accuracy, to residents in 9 dermatology residency programs prior to dermoscopy educational intervention exposure. The authors conducted CNDSEI item analysis with inspection of response distribution histograms, assessed internal reliability using Cronbach's coefficient alpha (α) and construct validity by comparing baseline CNDSEI and LDA results for corresponding lesions with one-way analysis of variance (ANOVA). RESULTS: At baseline, residents respectively demonstrated significantly higher and lower CNDSEI scores for correctly and incorrectly diagnosed lesions on the LDA (P = 0.001). The internal consistency reliability of CNDSEI responses for the majority (13/15) of the lesion types was excellent (α ≥ 0.9) or good (0.8≥ α <0.9). CONCLUSIONS: The CNDSEI pilot established that the tool reliably measures user dermoscopic image interpretation confidence and that self-efficacy correlates with diagnostic accuracy. Precise alignment of medical image diagnostic performance and the self-efficacy instrument content offers opportunity for construct validation of novel medical image interpretation self-efficacy instruments.

Eruption of squamous cell carcinomas after beginning nilotinib therapy.

Chronic myelogenous leukemia (CML) is characterized by a reciprocal translocation between the long arms of chromosomes 9 and 22 leading to the formation of a constitutively active tyrosine kinase. Tyrosine kinase inhibitors (TKIs) are the treatment of choice for patients diagnosed with CML and have many associated side effects including the rarely-reported eruption of squamous cell carcinomas (SCCs). Herein, we report a patient with CML who presented with sudden onset of multiple scaly lesions on his legs and trunk after beginning treatment with nilotinib, a novel TKI. Six biopsies were performed at his initial presentation and four of these lesions were confirmed to be keratoacanthoma-type SCCs. One month later, the patient reported the development of multiple new similar lesions on his legs, arms, and face. Four more biopsies were performed revealing keratoacanthoma-type and well-differentiated SCCs. Certain tyrosine kinase inhibitors such as sorafenib and quizartinib have been reported to cause eruptive keratoacanthoma (KA)-type SCCs as seen in our patient. However, there is only one other report in the literature of nilotinib promoting the development of SCCs or KAs. Physicians should be aware of this potential adverse effect and patients taking nilotinib should be closely monitored by a dermatologist.

Testing Pediatric Acuity With an iPad: Validation of "Peekaboo Vision" in Malawi and the UK.

PURPOSE: To evaluate two builds of the digital grating acuity test, "Peekaboo Vision" (PV), in young (6-60 months) populations in two hospital settings (Malawi and United Kingdom). METHODS: Study 1 evaluated PV in Blantyre, Malawi (N = 58, mean age 33 months); study 2 evaluated an updated build in Glasgow, United Kingdom (N = 60, mean age 44 months). Acuities were tested-retested with PV and Keeler Acuity Cards for Infants (KACI). Bland-Altman techniques were used to compare results and repeatability. Child engagement was compared between groups. Study 2 included test-time comparison. RESULTS: Study 1 (Malawi): The mean difference between PV and KACI was 0.02 logMAR with 95% limits of agreement (LoA) of 0.33 to 0.37 LogMAR. On test-retest, PV demonstrated 95% LoA of -0.283 to 0.198 logMAR with coefficient of repeatability (CR) 0.27. KACI demonstrated 95% LoA of -0.427 to 0.323 logMAR, and larger CR was 0.37. PV evidenced higher engagement scores than KACI (P = 0.0005). Study 2 (UK): The mean difference between PV and KACI was 0.01 logMAR; 95% LoA was -0.413 to 0.437 logMAR. Again, on test-retest, PV had narrower LoA (-0.344 to 0.320 logMAR) and lower CR (0.32) versus KACI, with LoA -0.432 to 0.407 logMAR, CR 0.42. The two tests did not differ in engagement score (P = 0.5). Test time was ∼1 minute shorter for PV (185 vs. 251 s, P = 0.0021). CONCLUSIONS: PV gives comparable results to KACI in two pediatric populations in two settings, with benefits in repeatability indices and test duration. TRANSLATIONAL RELEVANCE: Leveraging tablet technology extends reliable infant acuity testing to bedside, home, and rural settings, including areas where traditional equipment cannot be financed.

Antineutrophil cytoplasmic antibodies negative levamisole-induced leukocytoclastic vasculitis: a presumed case and literature review.

Levamisole-contaminated cocaine toxicity is a serious emerging public health concern, and providers should be aware of its presentation and management. Most cases of levamisole-induced vasculitis/vasculopathy (LIV) are associated with high antineutrophil cytoplasmic antibodies (ANCA). We describe a unique case of a cocaine user who presented with an acute purpuric eruption and negative ANCA laboratory findings. A brief clinical overview of LIV, spanning from patient presentation to treatment, is provided. In addition, we present a summary of all cases of ANCA-negative vasculitis identified via a PubMed literature review.

Trypophobia, skin, and media.

Trypophobia is the fear of patterns of clustered holes, bumps, or nodules. Trypophobia has a special relationship with dermatology because of its effects on individuals with skin disease, its relationship with disease avoiding behavior, and its utilization in many online skin disease hoaxes. Trypophobic patterns on skin and characters can be found in movies, TV shows, and videogames. Several popular horror villains take advantage of trypophobic patterns like Freddy Kreuger, Jason Vorhees, and Pinhead. Most recently, another blockbuster villain has joined their ranks - Killmonger. Public health messaging about these biases and the often noncontagious nature of skin disease is warranted to attenuate public stigma of skin disease perpetuated by media.

Nephrogenic systemic fibrosis: A 15-year retrospective study at a single tertiary care center.

BACKGROUND: Despite multiple therapeutic approaches for nephrogenic systemic fibrosis (NSF), no single treatment has convincingly shown consistent benefit. The most successful outcomes have been associated with recovery of renal function, although evidence remains limited and past studies have been inconclusive. OBJECTIVE: We sought to investigate whether improvement of renal function via successful transplantation or via return of renal function after acute kidney injury correlates with improvement of NSF, and to further characterize the clinical features and progression of NSF. METHODS: A retrospective medical chart review led to the identification of patients (n = 8) diagnosed with NSF who presented to a single academic tertiary referral center over a 15-year period. These 8 patients were contacted by phone to obtain information related to treatment and clinical course of their NSF and renal function. Statistical analysis was performed using Fisher's exact test. RESULTS: There is a significant correlation (P = .0286) of improved renal function with improvement of NSF. All 4 patients who had improvement of renal function also had improvement of NSF. Two of these patients had end-stage renal disease and a successful kidney transplant, and two had acute kidney injury that resolved. No improvement in NSF was observed without kidney function resolution. LIMITATIONS: Our study is limited by a small sample size (n = 8) and a retrospective study design, which increased its potential for selection and recall bias. CONCLUSION: Improvement of renal function through either transplantation or resolution of acute kidney injury with medical management is significantly associated with improvement of NSF.

The measurement of New Zealand health care.

The effective and economical measurement of the quality and safety of health and disability services in New Zealand is of signal importance. The Health Quality and Safety Commission has overseen the introduction of an architecture of interacting measures. These include quality and safety indicators, or QSIs, which are whole-system measures; quality and safety markers, or QSMs, which are targeted measures of quality and safety interventions comprising process and outcome measures in sets; and the New Zealand Atlas of Healthcare Variation, which illustrates the differences in the health care received in different regions and by different groups of patients within New Zealand.