The Differential Effect of COVID on Total Joint Arthroplasty Between Hospital and Ambulatory Surgery Centers/Hospital Outpatient Departments: A Michigan Arthroplasty Registry Collaborative Quality Initiative Analysis.

Background: Coronavirus disease (COVID) created unprecedented challenges, especially for high-volume elective subspecialties like total joint arthroplasty. Limited inpatient capacity and resource conservation led to new outpatient selection criteria and site of service changes. As a Michigan Arthroplasty Registry Quality Collaborative Initiative quality project, demographic changes, complications, and differential effects on inpatient vs outpatient centers pre- and post-COVID were analyzed. Methods: The registry identified all total joint arthroplasty at hospitals and ASCs/HOPDs between 07/2019-12/2019 and 07/2020-12/2020. These intervals represented pre-COVID and post-COVID elective surgery shutdowns. Case volumes, demographics, and 90-day complications were compared. Results: Comparing 2020 to 2019, hospital volumes decreased (-9% total hip arthroplasty [THA], -17% total knee arthroplasty [TKA]), and ambulatory surgery center (ASC)/hospital outpatient department (HOPD) increased (+84% THA, +125% TKA). Entering 2020, ASC/HOPD patients were older (P = .0031, P < .0001: THA, TKA), had more American Society of Anesthesiologists score 3-4 (P = .0105, P = .0021), fewer attended joint class (P < .0001, P < .0001), and more hips were women (P = .023). Hospital patients had higher preoperative pain scores (P = .0117, P < .0001; THA, TKA), less joint education attendance (P < .0001, P < .0001), younger TKAs (P = .0169), and more American Society of Anesthesiologists score 3-4 (0.0009). After propensity matching, there were no significant differences between site of service for 90-day fractures, deep vein thromboses or pulmonary embolisms, infection, or hip dislocations. Hospital THAs had higher readmissions (P = .0003) and TKAs had higher 30-day emergency department visits (P = .005). ASC/HOPD patients were prescribed higher oral morphine equivalents (P < .0001, P < .0001; THA, TKA). Conclusions: COVID's elective surgery shutdown caused a dramatic site of service shift. Traditional preoperative education was negatively impacted, and older and sicker patients became outpatients. But short-term complications were not increased in ASCs/HOPDs. These site of service and associated patient demographic changes may be safely sustained.

A Reduction in Opioid Prescription Size After Total Joint Arthroplasty Can be Safely Performed Without an Increase in Complications.

BACKGROUND: Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid-related events, chronic opioid use, and unlawful opioid diversion. Decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications, such as readmissions, emergency department (ED) visits, or worsened patient-reported outcomes (PROs). The purpose of this study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. METHODS: Data originated from a statewide database prospectively abstracted, including oral morphine equivalents prescribed at discharge, readmissions, ED visits, and PROs. Data were collected from 84,998 TJA occurring 1 year before and after the creation of an opioid-prescribing protocol that had decreased prescriptions by approximately 50%. Trends were monitored using Shewhart control charts. Regression models were used to determine statistically significant changes over time. RESULTS: All groups showed a reduction in opioids prescribed by almost 50% without an increase in emergency room visits or readmissions and without a detrimental effect on PROs. Compared to baseline data before opioid reduction, opioid-naive total knee arthroplasty had significant improvements in all outcomes (P = .03, P = .02, P < .001, P < .001). Opioid-tolerant total knee arthroplasty and total hip arthroplasty had no worsened outcomes and significant improvement in (Knee Injury and Osteoarthritis Outcome score for Joint Replacement P = .03) and (Hip Disability and Osteoarthritis Outcome Score for Joint Replacement P = .03). Opioid-naive total hip arthroplasty had significant improvements in Hip Disability and Osteoarthritis Outcome Score Joint Replacement (P = .003) and Patient Reported Outcomes Measurement Information System (P = .001). CONCLUSIONS: Postoperative opioid prescription recommendations from a statewide registry decreased prescribing by approximately 50% without decreasing PROs or increasing ED visits or readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without increased complications.

Racial and ethnic variation in COVID-19 care, treatment, and outcomes: A retrospective cohort study from the MiCOVID-19 registry.

BACKGROUND: Racial and ethnic disparities in COVID-19 outcomes exist, but whether in-hospital care explains this difference is not known. We sought to determine racial and ethnic differences in demographics, comorbidities, in-hospital treatments, and in-hospital outcomes of patients hospitalized with COVID-19. METHODS AND FINDINGS: This was a cohort study using MiCOVID-19, a multi-center, retrospective, collaborative quality improvement registry, which included data on patients hospitalized with COVID-19 across 38 hospitals in the State of Michigan. 2,639 adult patients with COVID-19 hospitalized at a site participating in the MiCOVID-19 Registry were randomly selected. Outcomes included in-hospital mortality, age at death, intensive care unit admission, and need for invasive mechanical ventilation by race and ethnicity. Baseline comorbidities differed by race and ethnicity. In addition, Black patients had higher lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, creatine phosphokinase, and ferritin levels. Black patients were less likely to receive dexamethasone and remdesivir compared with White patients (4.2% vs 14.3% and 2.2% vs. 11.8%, p < 0.001 for each). Black (18.7%) and White (19.6%) patients experienced greater mortality compared with Asian (13.0%) and Latino (5.9%) patients (p < 0.01). The mean age at death was significantly lower by 8 years for Black patients (69.4 ± 13.3 years) compared with White (77.9 ± 12.6), Asian (77.6 ± 6.6), and Latino patients (77.4 ± 15.5) (p < 0.001). CONCLUSIONS: COVID-19 mortality appears to be driven by both pre-hospitalization clinical and social factors and potentially in-hospital care. Policies aimed at population health and equitable application of evidence-based medical therapy are needed to alleviate the burden of COVID-19.

John N. Insall Award: MARCQI's Pain-Control Optimization Pathway (POP): Impact of Registry Data and Education on Opioid Utilization.

BACKGROUND: In 2019, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) recommended an evidence-based opioid pain pathway to participating physicians and hospitals for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to determine if the education could influence and have lasting effects on the prescribing patterns for TJA patients. METHODS: Using the MARCQI database, the number of oral morphine equivalents (OMEs) prescribed at discharge were collected from January 2018 through December 2019 for all primary arthroplasty procedures. Periods compared included before and after July 2018 Michigan opioid laws as well as before and after the March 2019 MARCQI recommendations. The data compared total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, opioid-naive vs opioid-tolerant patients, individual surgeons, and MARCQI sites. RESULTS: The data included 84,998 TJAs: 22,774 opioid-naive THAs, 9124 opioid-tolerant THAs, 40,882 opioid-naive TKAs, and 12,218 opioid-tolerant TKAs. In all the groups and at all time periods there were a significant decrease in prescriptions (P < .001). Individual surgeons and participating sites also demonstrated decreased OMEs on discharge after the recommendations. Between the first and last months of collection, this represented an overall decrease of opioid OMEs for THA by 47.1% for opioid-naive patients and 53.4% for opioid-tolerant patients. For TKA patients, the OME decrease was 48.3% for opioid-naive patients, and 48.4% for opioid-tolerant patients. CONCLUSION: The MARCQI pain control optimization pathway (POP) program has been successful in drastically reducing opioid prescribing with lasting effects, which has substantially limited the overall opioid prescription burden for patients undergoing arthroplasty.

Impact of Early Corticosteroids on Preventing Clinical Deterioration in Non-critically Ill Patients Hospitalized with COVID-19: A Multi-hospital Cohort Study.

INTRODUCTION: While guidelines stronglyrecommend dexamethasone in critical COVID-19, the optimal threshold to initiate corticosteroids in non-critically ill patients with COVID-19 remains unclear. Using data from a state-wide COVID-19 registry, we evaluated the effectiveness of early corticosteroids for preventing clinical deterioration among non-critically ill patients hospitalized for COVID-19 and receiving non-invasive oxygen therapy. METHODS: This was a target trial using observational data from patients hospitalized for COVID-19 at 39 hospitals participating in the MI-COVID19 registry between March 16, 2020 and August 24, 2020. We studied the impact of corticosteroids initiated within 2 calendar days of hospitalization ("early steroids") versus no early steroids among non-ICU patients with laboratory-confirmed SARS-CoV2 receiving non-invasive supplemental oxygen therapy. Our primary outcome was a composite of in-hospital mortality, transfer to intensive care, and receipt of invasive mechanical ventilation. We used inverse probability of treatment weighting (IPTW) and propensity score-weighted regression to measure the association of early steroids and outcomes. RESULTS: Among 1002 patients meeting study criteria, 231 (23.1%) received early steroids. After IPTW, to balance potential confounders between the treatment groups, early steroids were not associated with a decrease in the composite outcome (aOR 1.1, 95%CI 0.8-1.6) or in any components of the primary outcome. CONCLUSION: We found no evidence that early corticosteroid therapy prevents clinical deterioration among hospitalized non-critically ill COVID-19 patients receiving non-invasive oxygen therapy. Further studies are needed to determine the optimal threshold for initiating corticosteroids in this population.

Early Benchmarking Total Hip Arthroplasty Implants Using Data from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI).

BACKGROUND: Benchmarking arthroplasty implant revision risk is an informative way to address implant performance. National benchmarking efforts exist in the United Kingdom, Netherlands, and Australia. Recently, the International Prosthesis Benchmarking Working Group, including representatives from industry, academia, and national registries, produced a guideline describing arthroplasty benchmarking methodology. The proposal was applied to data from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to assess its feasibility for benchmarking implants in the United States. METHODS: Primary elective total hip arthroplasty procedures performed for osteoarthritis between 2/15/2012 and 12/31/2018 and their associated revisions were identified in the MARCQI registry. The guidelines recommend that all prostheses combinations receive an early benchmark if they have at least 250 procedures at risk and the revision rate does not exceed the pre-determined standard of 2% at 2 years and 3% at 5 years. RESULTS: A total of 72,949 primary cases met the inclusion criteria. Of these, 1369 had revisions. Twenty-nine and six stem/cup combinations satisfied the minimum case requirement at 2 and 5 years, respectively. Three implant combinations would not receive a benchmark at 2 years: Secur-Fit/Trident, Anthology/Reflection 3, Taperloc 133/G7. CONCLUSION: The guideline can be implemented in the United States by a regional registry. Moreover, not all hip implants currently in use would receive an early benchmark. This raises concern as these implant combinations represent a significant number of cases in Michigan, some with increasing utilization.

Race, Ethnicity, and 60-Day Outcomes After Hospitalization With COVID-19.

OBJECTIVE: To examine racial and ethnic disparities in clinical, financial, and mental health outcomes within a diverse sample of hospitalized COVID-19-positive patients in the 60 days postdischarge. DESIGN: A cross-sectional study. SETTING AND PARTICIPANTS: A total of 2217 adult patients who were hospitalized with a COVID-19-positive diagnosis as evidenced by test (reverse-transcriptase polymerase chain reaction), a discharge diagnosis of COVID-19 (ICD-10 code U07.1), or strong documented clinical suspicion of COVID-19 but no testing completed or recorded owing to logistical constraints (n=24). METHODS: Patient records were abstracted for the Mi-COVID19 data registry, including the hospital and insurer data of patients discharged from one of 38 participating hospitals in Michigan between March 16, 2020, and July 1, 2020. Registry data also included patient responses to a brief telephone survey on postdischarge employment, mental and emotional health, persistence of COVID-19-related symptoms, and medical follow-up. Descriptive statistics were used to summarize data; analysis of variance and Pearson chi-squared test were used to evaluate racial and ethnic variances among patient outcomes and survey responses. RESULTS: Black patients experienced the lowest physician follow-up postdischarge (n = 65, 60.2%) and the longest delays in returning to work (average 35.5 days). More than half of hospital readmissions within the 60 days following discharge were among nonwhite patients (n = 144, 55%). The majority of postdischarge deaths were among white patients (n = 153, 21.5%), most of whom were discharged on palliative care (n = 103). Less than a quarter of patients discharged back to assisted living, skilled nursing facilities, or subacute rehabilitation facilities remained at those locations in the 60 days following discharge (n = 48). CONCLUSIONS AND IMPLICATIONS: Increased attention to postdischarge care coordination is critical to reducing negative health outcomes following a COVID-19-related hospitalization.

Negative perceptions and emotional impact of striae gravidarum among pregnant women.

BACKGROUND: The impact of striae gravidarum (SG), or stretch marks of pregnancy, on quality of life (QoL) is unclear. OBJECTIVE: The purpose of this study was to investigate how SG affect QoL in pregnant women. METHODS: In this cross-sectional survey study of healthy pregnant women who developed SG during their current pregnancy, we asked about the impact of lesions on emotional, psychological, and life-quality facets. Spearman product-moment correlation coefficients were generated to determine the strength of relationships between variables. RESULTS: We analyzed 116 valid surveys. Participants reported permanency of SG as the top physical concern (n = 87; 75%). With regard to severity, nearly three-quarters of participants rated their lesions as very prominent (n = 24; 21%) or moderate (n = 57; 49%). Among the life-quality facets queried, embarrassment/self-consciousness was the most frequently associated with SG, with over one-third of participants reporting "a lot" (n = 19; 16%) or a "moderate" (n = 26; 22%) amount of embarrassment/self-consciousness related to having SG. Lesion severity significantly correlated with the degree of embarrassment/self-consciousness (r = .543), as well as the impact of SG on other life-quality facets, including overall QoL (r = .428), clothing choice (r = .423), self-image/self-esteem (r = .417), feelings of anxiety/depression (r = .415), and social activities (r = .313; all p ≤ .001). Nearly one-quarter of participants believed that emotional distress related to SG was similar or greater than that caused by other skin problems, such as acne, psoriasis, or eczema. CONCLUSION: SG can be associated with a host of negative reactions reflecting increased psychological and emotional distress, including embarrassment and decreased QoL. These consequences may compound the emotional stress of pregnancy, potentially warranting psychological support and adjustment strategies.

Association of dermatology wait times with insurance coverage in Michigan.

OBJECTIVES: Although the Affordable Care Act has greatly expanded coverage, the physician workforce has not increased commensurately. Data on wait times, especially among dermatologists who accept Medicaid, are lacking. The objective of this study was to evaluate wait times in dermatology clinics by insurance coverage and chief complaint. STUDY DESIGN: A "secret shopper" survey was conducted. METHODS: Between June and July 2016, 186 dermatology clinics in Michigan were contacted to determine the earliest available appointment for a patient seeking an evaluation of a changing mole, a chronic rash, and botulinum toxin administration. RESULTS: The mean (standard error [SE]) wait time regardless of insurance or chief complaint was 28.8 (1.29) days. Clinics that accept Medicaid had longer wait times (32.9 [2.19] vs 25.4 [1.50] days; P = .024). The mean (SE) wait time for a mole or rash was longer for patients with Medicaid compared with those with private insurance (40.0 [4.08] vs 27.7 [1.54] days; P = .003). The mean (SE) wait time for Medicaid patients compared with patients with private insurance was also longer, even within the same clinic (39.1 [4.11] vs 27.5 [1.57] days; median, 23.5 vs 16.0 days). Patients with Medicaid were able to obtain appointments sooner for botulinum toxin administration (22.5 [2.10] days) compared with evaluation of a mole (40.0 [6.63] days) or rash (40.1 [4.99] days) (P = .004). CONCLUSIONS: Wait times for clinic appointments were longer for patients with Medicaid, especially when requesting an evaluation for a medical dermatologic issue compared with a cosmetic consultation. Delay in medical dermatologic care, especially among Medicaid patients, must be addressed.

Diffusion tensor imaging reveals microstructural differences between subtypes of trigeminal neuralgia.

OBJECTIVE: Trigeminal neuralgia (TN) is an uncommon idiopathic facial pain syndrome. To assist in diagnosis, treatment, and research, TN is often classified as type 1 (TN1) when pain is primarily paroxysmal and episodic or type 2 (TN2) when pain is primarily constant in character. Recently, diffusion tensor imaging (DTI) has revealed microstructural changes in the symptomatic trigeminal root and root entry zone of patients with unilateral TN. In this study, the authors explored the differences in DTI parameters between subcategories of TN, specifically TN1 and TN2, in the pontine segment of the trigeminal tract. METHODS: The authors enrolled 8 patients with unilateral TN1, 7 patients with unilateral TN2, and 23 asymptomatic controls. Patients underwent DTI with parameter measurements in a region of interest within the pontine segment of the trigeminal tract. DTI parameters were compared between groups. RESULTS: In the pontine segment, the radial diffusivity (p = 0.0049) and apparent diffusion coefficient (p = 0.023) values in TN1 patients were increased compared to the values in TN2 patients and controls. The DTI measures in TN2 were not statistically significant from those in controls. When comparing the symptomatic to asymptomatic sides in TN1 patients, radial diffusivity was increased (p = 0.025) and fractional anisotropy was decreased (p = 0.044) in the symptomatic sides. The apparent diffusion coefficient was increased, with a trend toward statistical significance (p = 0.066). CONCLUSIONS: Noninvasive DTI analysis of patients with TN may lead to improved diagnosis of TN subtypes (e.g., TN1 and TN2) and improve patient selection for surgical intervention. DTI measurements may also provide insights into prognosis after intervention, as TN1 patients are known to have better surgical outcomes than TN2 patients.

Atrophic and hypertrophic photoaging: Clinical, histologic, and molecular features of 2 distinct phenotypes of photoaged skin.

BACKGROUND: Exposure to the sun causes premature skin aging, known as photoaging. Clinical features of photoaging vary widely among individuals. In one form, skin appears thin with telangiectasia, and in another form, skin appears thickened with coarse wrinkles. Etiologic, clinical, and therapeutic distinctions among different forms of photoaging remain largely unknown. OBJECTIVE: To characterize the clinical, histologic, and molecular features of hypertrophic and atrophic photoaging. METHODS: In total, 53 individuals were clinically classified as having primarily atrophic or hypertrophic photoaging or neither (controls). Participants' demographic and sun exposure-related lifestyle data were captured by questionnaire. Fifteen clinical features of participants were qualitatively or quantitively scored. Facial biopsies were analyzed for gene expression and histologic characteristics. RESULTS: Actinic and seborrheic keratosis, telangiectasia, and prior incidence of skin cancers were statistically significantly greater and photoaging scale severity, coarse wrinkles, thickness, and sallowness were significantly reduced in atrophic versus hypertrophic groups. Histology also revealed significantly less elastotic material in atrophic photoaging. Gene expression of matrix metalloproteinases and collagens did not differ between the 2 forms of photoaging. LIMITATIONS: The study was not designed to identify other possible subtypes of photoaging. CONCLUSION: Systematic, categorical, and quantitative clinical and histologic assessments distinguish atrophic and hypertrophic photoaging.

Patient interest in and familiarity with anti-aging therapies: A survey of the general dermatology clinic population.

BACKGROUND: The appearance of aging skin is a common complaint among dermatology patients. There is an expanding market for anti-aging therapies, but little information is available regarding which patients utilize these treatments and patient preferences regarding treatment. AIMS: To describe the patient population utilizing anti-aging therapies, assess patient familiarity with treatment options, and learn where treatment information is most often obtained. PATIENTS/METHODS: Three hundred patients were surveyed in the University of Michigan General Dermatology Clinic. RESULTS: Fifty-three percent of the general dermatology patient population has used an anti-aging treatment in the past; 66% reported interest in the future use. Interest is high among all genders, ages, and incomes. Most subjects obtained treatment information from magazines, but subjects were more likely to pursue treatment if information was obtained from a dermatologist. CONCLUSION: Demographics of anti-aging therapy are changing, and a wide variety of patients pursue treatment. Patients are largely unfamiliar with most treatment options and are more likely to pursue treatment after receiving treatment information from a dermatologist. The information presented in this study is helpful to both dermatologists and marketers of anti-aging products.

Increased expression of EZH2 in Merkel cell carcinoma is associated with disease progression and poorer prognosis.

Enhancer of zeste homolog 2 (EZH2) is a histone methyltransferase that affects tumorigenesis by epigenetic gene silencing. Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine carcinoma that has a high risk of disease progression with nodal and distant metastases. Here, we evaluated EZH2 expression by immunohistochemistry in a cohort of 85 MCC tumors (29 primary tumors, 41 lymph node metastases, 13 in-transit metastases, and 2 distant metastases) with clinical follow-up. We show strong/moderate EZH2 expression in 54% of tumors. Importantly, weak expression of EZH2 in the primary tumor, but not nodal metastases, correlated with improved prognosis compared to moderate/strong EZH2 expression (5-year MCC-specific survival of 68% versus 22%, respectively, P=.024). In addition, EZH2 was expressed at higher levels in nodal metastases compared to primary tumors (P=.005). Our data demonstrate that EZH2 has prognostic value and may play an oncogenic role in MCC.

Sentinel Lymph Node Biopsy for Cutaneous Squamous Cell Carcinoma on the Head and Neck.

Importance: Metastasis of cutaneous squamous cell carcinoma (SCC) to the nodal basin is associated with a poor prognosis. The role of sentinel lymph node biopsy (SLNB) for regional staging in patients diagnosed with SCC is unclear. Objective: To evaluate a single institution's experience with use of SLNB for regional staging of SCC on the head and neck. Design, Setting, and Participants: A retrospective review of 53 patients who were diagnosed with SCC on the head and neck, at high risk for nodal metastasis based on National Comprehensive Cancer Network (NCCN) risk factors, and treated with wide local excision (WLE) and SLNB from December 1, 2010, through January 30, 2015, in a single academic referral center was performed. The follow-up period ended November 5, 2015. Sentinel lymph node biopsy paraffin blocks were retrieved and processed retrospectively with serial sectioning and immunohistochemical analysis (IHC) in cases with nodal recurrence following a negative SLNB. Main Outcomes and Measures: Sentinel node (SN) identification rate, SLNB positivity rate, local recurrence, regional nodal recurrence, and distant recurrence. Results: In 53 patients with 54 tumors the SN identification rate was 94%. The SLNB positivity rate was 11.3%. On more thorough tissue processing and IHC, metastatic SCC was identified in 2 of 5 (40%) cases previously deemed negative. After reclassification of these cases, the adjusted SLNB positivity rate was 15.1%. The adjusted rate of false omission was 7.1% (95% CI, 2%-19%). Nodal disease developed in 20.8% overall. Angiolymphatic invasion (Cohen d, 3.52; 95% CI, 1.83-5.21), perineural invasion (Cohen d, 0.81; 95% CI, 0.09-1.52), and clinical size (Cohen d, 0.83; 95% CI, 0.05-1.63) were associated with the presence of nodal disease. Conclusions and Relevance: Rigorous study of SLNB for cutaneous SCC incorporating prospectively-collected comprehensive data sets based on standardized treatment algorithms is justified with potential to modify clinical practice. Our study demonstrates the critical importance of serial sectioning and IHC of the SLNB specimen for accurate diagnosis. Use of the NCCN guidelines may facilitate identification of patients with SCC at high risk for nodal metastasis.

Perioral wrinkles are associated with female gender, aging, and smoking: Development of a gender-specific photonumeric scale.

BACKGROUND: Perioral wrinkling is commonly reported among older adults, but its objective evaluation and causes remain poorly understood. OBJECTIVE: We sought to develop a photonumeric scale for perioral wrinkling and to elucidate contributory lifestyle factors. METHODS: In this cross-sectional study, we recruited participants for facial photographs and a survey. A gender-specific photonumeric scale for perioral wrinkling was developed and used by 3 graders to evaluate participant photographs. Scores and survey responses were used to create a multiple regression model to predict perioral wrinkling. RESULTS: In all, 143 participants aged 21 to 91 years were enrolled. Intraclass correlation coefficient values for interrater and intrarater reliability were high (>0.8) across 2 trials and 3 graders. A multiple regression model for prediction of perioral wrinkling severity included age, gender, and years of smoking as variables. LIMITATIONS: The study was limited by sample size and a predominantly Caucasian study population. CONCLUSION: We created a photonumeric scale that accounts for gender differences in perioral wrinkling and highlighted contributory variables to photoaging in this anatomical location.

Clinical, Histologic, and Molecular Analysis of Differences Between Erythematotelangiectatic Rosacea and Telangiectatic Photoaging.

IMPORTANCE: Facial erythema and telangiectasia are commonly associated with the erythematotelangiectatic subtype of rosacea (ETR). It is important for clinicians to recognize that these findings can also be associated with a subtype of photoaging, which we term telangiectatic photoaging (TP). OBJECTIVE: To demonstrate that ETR and TP are distinct dermatologic disorders. DESIGN: A case-control observational study comparing clinical, histologic, and gene expression features of 26 participants with ETR, 20 with TP, and 11 age- and sex-matched controls in the Program for Clinical Research in Dermatology at University of Michigan. MAIN OUTCOMES AND MEASURES: Findings of clinical history and examination, light and electron microscopy, immunohistochemical analyses, and real-time quantitative reverse-transcriptase polymerase chain reaction gene expression. RESULTS: Transient erythema was greater in the ETR group (38% graded moderate to severe) than in the TP (0%; P < .001) and control groups (0%; P = .002). Nontransient erythema was also greater in the ETR group (50% graded moderate to severe) than in the TP (25%; P = .03) and control groups (0%; P < .001). Participants with ETR tended to have erythema and telangiectasia primarily on the central face (79%), whereas those with TP tended to have more lateral involvement (57%; P < .001). Those with ETR had significantly less clinical evidence of photodamage (0% graded 6-8 on a photonumeric scale) than those with TP (40% graded 6-8; P = .01). Histologically, there was less evidence of photodamage in ETR than in TP, which had wispy collagen and solar elastosis surrounding blood vessels. Immunohistologic analysis demonstrated greater geometric mean immunostained area by mast cell tryptase staining in ETR samples (0.018%) than in TP (0.004%; P = .01) or control samples (0.001%; P < .001) but no increase in mast cell number, indicative of greater mast cell degranulation. Gene expression of matrix metalloproteinase-3 was 4-fold greater in ETR samples than in TP samples (P = .004) and 5-fold higher than in control samples (P = .004). Gene expression of the neuropeptides calcitonin gene-related peptide (CGRP-α) and substance P was significantly increased in ETR compared with TP (9-fold [P < .001] and 5-fold [P = .002], respectively) and control samples (10-fold [P < .001] and 28-fold [P < .001], respectively). CONCLUSIONS AND RELEVANCE: Telangiectatic photoaging is characterized by less transient and nontransient erythema, a more lateral distribution of erythema and telangiectasia, less neurogenic mast cell activation, and less MMP-mediated matrix remodeling than ETR. These data demonstrate that TP is a distinct clinical entity from ETR that can be distinguished on the basis of clinical, histologic, and gene expression findings.

A gender-based comparison of pain tolerance during pulsed dye laser therapy.

BACKGROUND: Cosmetic laser treatments are frequently performed without anesthesia in the clinic setting and there is a need to better understand the factors that may impact patient pain levels during these procedures. There has been prior research suggesting that there are significant gender-based differences in pain experiences with a variety of interventions. AIMS: We sought to examine the influence of gender and specific emotional factors on pain perception during pulsed dye laser treatments. PATIENTS/METHODS: We conducted a questionnaire-based study of 84 adult patients (42 males and 42 females) who underwent facial pulsed dye laser treatments in our clinic for cosmetic purposes. Questionnaires were completed by each patient after his or her initial laser treatment and patients were queried as to their perceived levels of pain during the procedure. Additional information regarding quality of life measures and patient motivation was also collected. RESULTS: Contrary to prior research suggesting lower pain thresholds for women in other clinical or experimental settings, we found no statistically significant differences in mean pain levels reported between patients of each gender. There was a trend toward females being somewhat more likely than males to see the pain of the treatment as justified for an improvement in appearance. CONCLUSIONS: Patient motivation and pain tolerance levels may be similar between genders among patients undergoing non-invasive cosmetic procedures. Clinicians may, therefore, expect patients of either gender to tolerate such treatments equally well.

Hypo-collagenesis in photoaged skin predicts response to anti-aging cosmeceuticals.

BACKGROUND: Chronic sun exposure causes photoaging, the appearance of prematurely aged skin. This phenomenon is characterized by progressive alteration of the dermal extracellular matrix, including elastin and collagen fibers. While many cosmeceuticals claim to improve the appearance of photoaged skin, data are lacking regarding their ability to induce molecular responses associated with wrinkle effacement, particularly increased collagen production. AIMS: To conduct a meta-analysis to determine whether there was a factor(s) that could predict response to various cosmeceuticals. PATIENTS/METHODS: Hundred subjects enrolled in five separate studies of cosmeceuticals containing: L-ascorbic acid, pentapeptide, α-lipoic acid, yeast extract, or 1% idebenone. Five groups consisting of 16-20 volunteers applied one cosmeceutical to their photodamaged forearms for several weeks. Punch biopsies were obtained pretreatment and post-treatment and analyzed for type I procollagen by ELISA. RESULTS: Analysis of basal collagenesis reinforced the notion that hypo-collagenesis is associated with photoaging severity, independent of age or gender. Treatment outcome varied greatly among subjects, ranging from no improvement to a 7-fold increase in collagenesis. Retrospective statistical meta-analysis was conducted to determine whether age, gender, type of cosmeceutical, or evidence of hypo-collagenesis in untreated skin could predict responsiveness to cosmeceuticals. Our analysis revealed that subjects with hypo-collagenesis responded 6.4 times more often than subjects with normo-collagenesis. DISCUSSION: Hypo-collagenesis was the only factor that influenced treatment outcome. This study therefore identifies hypo-collagenesis as the unique parameter predicting anti-aging cosmeceutical treatment outcome. These findings provide a basis for future cosmetic testing and the potential development of custom formula skin care.