A survey assessment of combined pediatric dermatology-rheumatology clinics.

The expertise of both dermatology and rheumatology may be beneficial when managing autoimmune conditions with cutaneous and systemic manifestations in children. This survey study was directed to pediatric dermatologists who participate in combined pediatric dermatology-rheumatology clinics; 13 sites in North America responded. The results provide information regarding clinic operations, benefits, and barriers to establishment. These findings have the potential to help institutions establish or modify combined pediatric dermatology-rheumatology clinics, although further research is needed to determine their impact.

Dermatologic complications in pediatric patients after hematopoietic stem cell transplantation for sickle cell disease.

Dermatologic complications are common following allogeneic hematopoietic stem cell transplantation, but dermatologic complications among pediatric patients undergoing hematopoietic stem cell transplantation for the treatment of sickle cell disease have been poorly characterized. In this case series of 17 patients (<21 years old) with sickle cell disease who underwent hematopoietic stem cell transplantation, 16 (94.1%) experienced one or more dermatologic complications after transplant, with the most common complications including acute or chronic mucocutaneous graft-versus-host disease (GVHD) (34.1% of complications), skin eruptions of unknown origin (15.9% of complications), infections (15.9% of complications), and chemotherapy-related pigmentary changes (11.4% of complications). Patients who developed acute or chronic skin GVHD were significantly older at the time of hematopoietic stem cell transplantation. These findings highlight the need to closely monitor for dermatologic complications in pediatric patients who undergo hematopoietic stem cell transplantation for sickle cell disease and underscore the importance of involving dermatology early on when skin complications occur, although further research with a larger multicenter study could help clarify the risk for dermatologic complications and help identify potential ways to mitigate this risk.

Newly Acquired Burnout During the Coronavirus Disease 2019 (COVID-19) Pandemic: A Retrospective Cohort Study on the Experiences of New York State Primary Care Clinicians.

The well-being of primary care clinicians represents an area of increasing interest amid concerns that the COVID-19 pandemic may have exacerbated already high prevalence rates of clinician burnout. This retrospective cohort study was designed to identify demographic, clinical, and work-specific factors that may have contributed to newly acquired burnout after the onset of the COVID-19 pandemic. An anonymous web-based questionnaire distributed in August 2020 to New York State (NYS) primary care clinicians, via email outreach and newsletters, produced 1,499 NYS primary care clinician survey respondents. Burnout assessment was measured pre-pandemic and early in the pandemic using a validated single-item question with a 5-point scale ranging from (1) enjoy work to (5) completely burned out. Demographic and work factors were assessed via the self-reporting questionnaire. Thirty percent of 1,499 survey respondents reported newly acquired burnout during the early pandemic period. This was more often reported by clinicians who were women, were younger than 56 years old, had adult dependents, practiced in New York City, had dual roles (patient care and administration), and were employees. Lack of control in the workplace prior to the pandemic was predictive of burnout early in the pandemic, while work control changes experienced following the pandemic were associated with newly acquired burnout. Low response rate and potential recall bias represent limitations. These findings demonstrate that reporting of burnout increased among primary care clinicians during the pandemic, partially due to varied and numerous work environment and systemic factors.

Morphea as an isotopic response to pigmented purpuric dermatosis and lichen striatus.

Morphea is an uncommon inflammatory and fibrosing disorder that has a polymorphous clinical presentation. We report two cases of morphea developing as an isotopic response after a preceding benign skin disease, accompanied by a review of the literature. This case series highlights the importance of return to care recommendations for benign skin conditions such lichen striatus and pigmented purpuric dermatoses due to the rare possibility of subsequent morphea development.

Methotrexate for inflammatory skin disease in pediatric patients: Consensus treatment guidelines.

Methotrexate (MTX) is a readily accessible drug, first used in 1948 and employed for a wide variety of indications since then. However, despite widespread off-label use, FDA labeling does not include approved indications for the use of MTX for many inflammatory skin diseases in pediatric patients, including morphea, psoriasis, atopic dermatitis, and alopecia areata, among others. Without published treatment guidelines, some clinicians may be hesitant to use MTX off-label, or uncomfortable prescribing MTX in this population. To address this unmet need, an expert consensus committee was convened to develop evidence- and consensus-based guidelines for use of MTX to treat pediatric inflammatory skin disease. Clinicians with experience and expertise in clinical research, drug development, and treating inflammatory skin disease in pediatric patients with MTX were recruited. Five committees were created based on major topic areas: (1) indications and contraindications, (2) dosing, (3) interactions with immunizations and medications, (4) adverse effects (potential for and management of), and (5) monitoring needs. Pertinent questions were generated and addressed by the relevant committee. The entire group participated in a modified Delphi process to establish agreement on recommendations for each question. The committee developed 46 evidence- and consensus-based recommendations, each with >70% agreement among members, across all five topics. These are presented in tables and text, along with a discussion of supporting literature, and level of evidence. These evidence- and consensus-based recommendations will support safe and effective use of MTX for the underserved population of pediatric patients who may benefit from this valuable, time-honored medication.

Presenting characteristics and progression of pediatric-onset morphea: Interim analysis of a prospective registry.

Morphea is a rare fibrosing disorder with a highly variable disease course, which can complicate management. Here, we present a prospective cohort study describing the current treatments used in the management of pediatric-onset morphea and assessing responses to systemic and topical therapies. Most patients demonstrated inactive disease by 1 year, regardless of treatment, though recurrences were common in our cohort overall (39%). Our results support the need for continuous monitoring of all children with morphea following the completion of treatment, including topical treatment, due to high rates of disease relapse.

Paradoxical Psoriasiform Eruptions in Children Receiving Tumor Necrosis Factor α Inhibitors.

Importance: Tumor necrosis factor α (TNF) inhibitor-induced psoriasiform eruption is well recognized in adults, but few reports document this paradoxical effect in children. Objective: To characterize the clinical features and the clinical time course of TNF inhibitor-induced psoriasiform eruptions in children. Design, Setting, and Participants: A multicenter retrospective case series of children younger than 18 years seen between January 1, 2000, and December 31, 2016, who developed a new-onset psoriasiform eruption while taking a TNF inhibitor for a nondermatologic disorder. Participating sites were members of the Pediatric Dermatology Research Alliance. Data were entered into a Research Electronic Data Capture database at the Mayo Clinic (ie, the coordinating center). Results: Psoriasiform eruptions were identified in 103 TNF inhibitor-treated patients (median age, 13.8 years [IQR, 11.7-16.4 years]; 52 female patients [50%]; 57 White patients [55%]), with 67 patients (65%) treated with infliximab, 35 (34%) with adalimumab, and 1 (1%) with certolizumab pegol. Most patients had no personal history (101 [98%]) or family history of psoriasis (60 patients [58%]). Inflammatory bowel disease was the most common indication for treatment with TNF inhibitor (94 patients [91%]). The primary extracutaneous disease was under control in 95 patients (92%) who developed the eruption. Most patients (n = 85 [83%]) developed psoriasiform eruptions at multiple anatomic sites, with scalp involvement being most common (65 patients [63%]). Skin disease developed at a median of 14.5 months (IQR, 9-24 months) after TNF inhibitor initiation. To treat the psoriasiform eruption, topical steroidal and nonsteroidal medication was prescribed for all patients. Systemic therapy was added for 30 patients (29%): methotrexate for 24 patients (23%), oral corticosteroids for 8 patients (8%), and azathioprine for 1 patient (1%). For 26 patients (25%), suboptimal effectiveness with topical medications alone prompted discontinuation of the initial TNF inhibitor and a change to a second-line TNF inhibitor with cutaneous improvement in 23 patients (88%) by a median of 3 months (IQR, 2-4 months). Eight patients (31%) who started a second-line TNF inhibitor developed a subsequent TNF inhibitor-induced psoriasiform eruption at a median of 6 months (IQR, 4-8 months). Persistent skin disease in 18 patients (17%) prompted discontinuation of all TNF inhibitors; 11 patients changed to a non-TNF inhibitor systemic therapy, and 7 discontinued all systemic therapy. Conclusions and Relevance: In this case series, paradoxical TNF inhibitor-induced psoriasiform eruptions were seen in children treated with TNF inhibitors for any indication, and there appears to be a class effect among the varying TNF inhibitors. The majority of these children were able to continue TNF inhibitor therapy with adequate skin-directed and other adjuvant therapies.

Development and Validation of the Morphea Activity Measure in Patients With Pediatric Morphea.

Importance: Morphea is an insidious inflammatory disorder of the skin and deeper tissues. Determining disease activity is challenging yet important to medical decision-making and patient outcomes. Objective: To develop and validate a scoring tool, the Morphea Activity Measure (MAM), to evaluate morphea disease activity of any type or severity that is easy to use in clinical and research settings. Design, Setting, and Participants: This pilot diagnostic study was conducted from September 9, 2019, to March 6, 2020, in 2 phases: development and validation. During the development phase, 14 morphea experts (dermatologists and pediatric dermatologists) used a Delphi consensus method to determine items that would be included in the MAM. The validation phase included 8 investigators who evaluated the tool in collaboration with 14 patients with pediatric morphea (recruited from a referral center [Medical College of Wisconsin]) during a 1-day in-person meeting on March 6, 2020. Main Outcomes and Measures: During the development phase, online survey items were evaluated by experts in morphea using a Likert scale (score range, 0-10, with 0 indicating not important and 10 indicating very important); agreement was defined as a median score of 7.0 or higher, disagreement as a median score of 3.9 or lower, and no consensus as a median score of 4.0 to 6.9. During the validation phase, reliability (interrater and intrarater agreement using intraclass correlation coefficients), validity (using the content validity index and κ statistics as well as correlations with the modified Localized Scleroderma Severity Index and the Physician Global Assessment of Activity using Spearman ρ coefficients), and viability (using qualitative interviews of investigators who used the MAM tool) were evaluated. Descriptive statistics were used for quantitative variables. Data on race and ethnicity categories were collected but not analyzed because skin color was more relevant for the purposes of this study. Results: Among 14 survey respondents during the development phase, 9 (64.3%) were pediatric dermatologists and 5 (35.7%) were dermatologists. After 2 rounds, a final tool was developed comprising 10 items that experts agreed were indicative of morphea activity (new lesion in the past 3 months, enlarging lesion in the past 3 months, linear lesion developing progressive atrophy in the past 3 months, erythema, violaceous rim or color, warmth to the touch, induration, white-yellow or waxy appearance, shiny white wrinkling, and body surface area). The validation phase was conducted with 14 patients (median age, 14.5 years [range, 8.0-18.0 years]; 8 [57.1%] female), 2 dermatologists, and 6 pediatric dermatologists. Interrater and intrarater agreement for MAM total scores was good, with intraclass correlation coefficients of 0.844 (95% CI, 0.681-0.942) for interrater agreement and 0.856 (95% CI, 0.791-0.901) for intrarater agreement. Correlations between the MAM and the modified Localized Scleroderma Severity Index (Spearman ρ = 0.747; P < .001) and the MAM and the Physician Global Assessment of Activity (Spearman ρ = 0.729; P < .001) were moderately strong. In qualitative interviews, evaluators agreed that the tool was easy to use, measured morphea disease activity at a single time point, and should be responsive to changes in morphea disease activity over multiple time points. Conclusions and Relevance: In this study, the MAM was found to be a reliable, valid, and viable tool to measure pediatric morphea activity. Further testing to assess validity in adults and responsiveness to change is needed.

Strategies for managing marine disease.

The incidence of emerging infectious diseases (EIDs) has increased in wildlife populations in recent years and is expected to continue to increase with global environmental change. Marine diseases are relatively understudied compared with terrestrial diseases but warrant parallel attention as they can disrupt ecosystems, cause economic loss, and threaten human livelihoods. Although there are many existing tools to combat the direct and indirect consequences of EIDs, these management strategies are often insufficient or ineffective in marine habitats compared with their terrestrial counterparts, often due to fundamental differences between marine and terrestrial systems. Here, we first illustrate how the marine environment and marine organism life histories present challenges and opportunities for wildlife disease management. We then assess the application of common disease management strategies to marine versus terrestrial systems to identify those that may be most effective for marine disease outbreak prevention, response, and recovery. Finally, we recommend multiple actions that will enable more successful management of marine wildlife disease emergencies in the future. These include prioritizing marine disease research and understanding its links to climate change, improving marine ecosystem health, forming better monitoring and response networks, developing marine veterinary medicine programs, and enacting policy that addresses marine and other wildlife diseases. Overall, we encourage a more proactive rather than reactive approach to marine wildlife disease management and emphasize that multidisciplinary collaborations are crucial to managing marine wildlife health.

Utility of Poison Control Center Data for Automated Opioid Overdose Surveillance.

CONTEXT: Overdosing on opioids is a national epidemic and the number one cause of death from unintentional injury in the United States. Poison control centers (PCCs) may be a source of timely data that can track opioid exposure cases, identify clusters of opioid exposure cases by geographic region, and capture opioid exposure cases that may not seek medical attention from health care facilities. OBJECTIVE: The objectives were to (a) identify data requirements for opioid overdose case ascertainment and classification and visualization in a dashboard, and (b) assess the availability and quality of the relevant PCC data for state-based opioid overdose surveillance. DESIGN: We identified types of opioid exposure, demographic characteristics, and other features that may be relevant for public health officials to monitor and respond to opioid overdose events in the community. We operationalized case definitions for an opioid overdose event based on the Centers for Disease Control and Prevention case classification definitions. We assessed the PCC database for concepts and metrics needed to operationalize case definitions for opioid overdose events to determine the feasibility of using the PCC for automated surveillance. MAIN OUTCOME MEASURE: Quality and availability of required concepts to operationalize metrics and case definitions using PCC data. RESULTS: A subset of the probable case definition may be used for automated surveillance with available structured PCC data. In contrast, logic for confirmed, suspected, and part of the probable case definitions requires additional structured data or analysis of narrative text, which may not contain needed concepts. For example, the confirmed case definition currently requires evidence from narrative text of laboratory confirmation of an opioid in a clinical specimen or diagnosis of opioid overdose in a health care record. CONCLUSION: PCC data are a timely and potentially useful source for automated surveillance of a subset of opioid overdose events, but additional structured and/or coded data are required.

Starting a C. elegans Research Laboratory: Practical Advice.

This chapter provides practical guidance for scientists starting or reorganizing a C. elegans research group. This includes advice on joining the C. elegans community, on setting up the laboratory for C. elegans work, and on putting into place effective strategies for running a productive and inclusive research group. Also discussed are strategies for managing the group, standard practices in the C. elegans field, lists of resources, and several sample handouts for new research group members.

Body site distribution of pediatric-onset morphea and association with extracutaneous manifestations.

BACKGROUND: The distribution of pediatric-onset morphea and site-based likelihood for extracutaneous complications has not been well characterized. OBJECTIVE: To characterize the lesional distribution of pediatric-onset morphea and to determine the sites with the highest association of extracutaneous manifestations. METHODS: A retrospective cross-sectional study was performed. Using clinical photographs, morphea lesions were mapped onto body diagrams using customized software. RESULTS: A total of 823 patients with 2522 lesions were included. Lesions were more frequent on the superior (vs inferior) anterior aspect of the head and extensor (vs flexor) extremities. Linear morphea lesions were more likely on the head and neck, whereas plaque and generalized morphea lesions were more likely on the trunk. Musculoskeletal complications were more likely with lesions on the extensor (vs flexor) extremity (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.2-3.4), whereas neurologic manifestations were more likely with lesions on the anterior (vs posterior) (OR, 2.8; 95% CI, 1.7-4.6) and superior (vs inferior) aspect of the head (OR, 2.3; 95% CI, 1.6-3.4). LIMITATIONS: Retrospective nature and the inclusion of only patients with clinical photographs. CONCLUSION: The distribution of pediatric-onset morphea is not random and varies with body site and within individual body sites. The risk stratification of extracutaneous manifestations by body site may inform decisions about screening for extracutaneous manifestations, although prospective studies are needed.

Sublethal biomass loss in Egregia menziesii (Phaeophyceae) reveals diffuse meristem tissue.

Sublethal biomass loss has been found to have a variety of effects on marine macroalgae, from decreasing reproductive output to increasing individual survival and frond density. The ability of an individual to recover and persist through herbivore and wave damage is facilitated by the location of several meristematic growth regions throughout an individual. In kelps (Order Laminariales), meristems are found basally at the holdfast, at the base of each blade, and/or apically on each frond. In the intertidal kelp Egregia menziesii, fronds are thought to have an intercalary meristem at a transition zone between the main frond's midrib and a small terminal lamina. This study examined the effect of removing the terminal blade and transition zone on the elongation of the frond and found no significant difference in growth, contrary to expectations. Elongation occurred in the 30 cm of midrib at the apical end of fronds and was not isolated at the base of the terminal lamina as was previously thought. These results indicate the presence of a diffuse meristematic growth region that has not been reported in other kelps and may be an advantage for this intertidal species.

Pediatric maculopapular cutaneous mastocytosis: Retrospective review of signs, symptoms, and associated conditions.

BACKGROUND/OBJECTIVES: Though maculopapular cutaneous mastocytosis is the most common form of pediatric mastocytosis, it remains unclear which patients will experience severe symptoms. We sought to better define the presentation and the cutaneous and systemic signs and symptoms in patients with maculopapular cutaneous mastocytosis. METHODS: We analyzed retrospective data on 227 patients diagnosed with maculopapular cutaneous mastocytosis prior to age 15 years from five US clinical sites. We collected data on signs, symptoms, age of onset, and laboratory testing. RESULTS: Median age of onset of maculopapular cutaneous mastocytosis was 3 months, with 94% of patients presenting prior to age 2 (range 0-15 years). Patients presenting before age 2 had significantly lower serum tryptase level (P = .019). Greater number of skin lesions (P = .006), number of reported skin signs and symptoms (P < .001), and higher tryptase levels (P < .001) were associated with more systemic symptoms. CONCLUSION: Children with maculopapular cutaneous mastocytosis, who have greater skin involvement, higher serum tryptase level, and more skin signs and symptoms, are more likely to have systemic symptoms.

Cutaneous reactions to pediatric cancer treatment part II: Targeted therapy.

Cancer remains a leading cause of morbidity and mortality among children. Targeted therapies may improve survivorship; however, unique side-effect profiles have also emerged with these novel therapies. Changes in hair, skin, and nails-termed dermatologic adverse events (AEs)-are among the most common sequelae and may result in interruption or discontinuation of therapy. Though dermatologic AEs have been detailed in adults, these findings are not well described in the pediatric population. We reviewed the literature to characterize dermatologic AEs to anticancer targeted therapies available as of July 2020 and summarized the spectrum of clinical findings as well as treatment recommendations for children. Dermatologic AEs are among the most common AEs reported in pediatric patients receiving targeted therapy, but morphologic and histologic descriptions are often lacking in current publications. Pediatric dermatologists are uniquely poised to recognize specific morphology of dermatologic AEs and make recommendations for prevention and treatment that may improve quality of life and enable ongoing cancer therapy.

Preconditioning of Caenorhabditis elegans to anoxic insult by inactivation of cholinergic, GABAergic and muscle activity.

For most metazoans, oxygen deprivation leads to cell dysfunction and if severe, death. Sublethal stress prior to a hypoxic or anoxic insult ("preconditioning") can protect cells from subsequent oxygen deprivation. The molecular mechanisms by which sublethal stress can buffer against a subsequent toxic insult and the role of the nervous system in the response are not well understood. We studied the role of neuronal activity preconditioning to oxygen deprivation in Caenorhabditis elegans. Animals expressing the histamine gated chloride channels (HisCl1) in select cell populations were used to temporally and spatially inactivate the nervous system or tissue prior to an anoxic insult. We find that inactivation of the nervous system for 3 h prior to the insult confers resistance to a 48-h anoxic insult in 4th-stage larval animals. Experiments show that this resistance can be attributed to loss of activity in cholinergic and GABAergic neurons as well as in body wall muscles. These observations indicate that the nervous system activity can mediate the organism's response to anoxia.

The geographic distribution of the US pediatric dermatologist workforce: A national cross-sectional study.

BACKGROUND /OBJECTIVES: Although 82% of pediatricians report that their patients have difficulty accessing pediatric dermatologists, the regions with greatest need for the specialty are not well-defined. We aimed to determine the geographic distribution of pediatric dermatologists relative to the number of children and pediatric generalists. METHODS: We performed a cross-sectional study of all US board-certified pediatric dermatologists, generalists (defined as pediatricians and family medicine physicians), and children in 2020. Data were obtained from the Society for Pediatric Dermatology, American Board of Pediatrics, Centers for Medicare and Medicaid, and US Census Bureau. Number of children, pediatric dermatologists, and pediatric generalists were tabulated in each county and state, and the distributions of pediatric dermatologists and generalists relative to the population of children were quantified with the Gini coefficient. RESULTS: Of 317 pediatric dermatologists, 243 (76.7%) were women and 311 (98.1%) worked in a metropolitan county. A pediatric dermatologist was present in 41/50 (82%) states and 142/3228 (4.4%) counties. Not a single pediatric dermatologist was found in 54/92 (58.7%) counties with 100 000-199 999 children, 15/53 (28.3%) counties with 200 000-499 999 children, and 4/13 (30.8%) counties with ≥500 000 children. The Gini coefficient for the state-level distribution of pediatric dermatologists relative to population of children was 0.488 compared to 0.132 for that of pediatric generalists. CONCLUSION: There is a maldistribution of pediatric dermatologists, resulting in children with unmet dermatologic needs in nine states and 96 heavily populated counties. These results can inform initiatives to recruit pediatric dermatologists and to expand telehealth access to specific high-density areas.

Enabling health information exchange at a US Poison Control Center.

OBJECTIVE: The objective of this project was to enable poison control center (PCC) participation in standards-based health information exchange (HIE). Previously, PCC participation was not possible due to software noncompliance with HIE standards, lack of informatics infrastructure, and the need to integrate HIE processes into workflow. MATERIALS AND METHODS: We adapted the Health Level Seven Consolidated Clinical Document Architecture (C-CDA) consultation note for the PCC use case. We used rapid prototyping to determine requirements for an HIE dashboard for use by PCCs and developed software called SNOWHITE that enables poison center HIE in tandem with a poisoning information system. RESULTS: We successfully implemented the process and software at the PCC and began sending outbound C-CDAs from the Utah PCC on February 15, 2017; we began receiving inbound C-CDAs on October 30, 2018. DISCUSSION: With the creation of SNOWHITE and initiation of an HIE process for sending outgoing C-CDA consultation notes from the Utah Poison Control Center, we accomplished the first participation of PCCs in standards-based HIE in the US. We faced several challenges that are also likely to be present at PCCs in other states, including the lack of a robust set of patient identifiers to support automated patient identity matching, challenges in emergency department computerized workflow integration, and the need to build HIE software for PCCs. CONCLUSION: As a multi-disciplinary, multi-organizational team, we successfully developed both a process and the informatics tools necessary to enable PCC participation in standards-based HIE and implemented the process at the Utah PCC.