Cutaneous dysbiosis may amplify barrier dysfunction in patients with atopic dermatitis.

Atopic dermatitis (AD) is associated with cutaneous dysbiosis, barrier defects, and immune dysregulation, but the interplay between these factors needs further study. Early-onset barrier dysfunction may facilitate an innate immune response to commensal organisms and, consequently, the development of allergic sensitization. We aimed to compare the cutaneous microbiome in patients with active dermatitis with and without a history of childhood flexural dermatitis (atopic dermatitis). Next-gen Ion-Torrent deep-sequencing identified AD-associated changes in the skin bacterial microbiome ("bacteriome") and fungal microbiome ("mycobiome") of affected skin in swabs from areas of skin affected by dermatitis. Data were analyzed for diversity, abundance, and inter-kingdom correlations. Microbial interactions were assessed in biofilms using metabolic activity (XTT) assay and scanning electron microscopy (SEM), while host-pathogen interactions were determined in cultured primary keratinocytes exposed to biofilms. Increased richness and abundance of Staphylococcus, Lactococcus, and Alternaria were found in atopics. Staphylococcus and Alternaria formed robust mixed-species biofilms (based on XTT and SEM) that were resistant to antifungals/antimicrobials. Furthermore, their biofilm supernatant was capable of influencing keratinocytes biology (pro-inflammatory cytokines and structural proteins), suggesting an additive effect on AD-associated host response. In conclusion, microbial inter-kingdom and host-microbiome interactions may play a critical role in the modulation of atopic dermatitis to a greater extent than in non-atopic adults with allergic contact dermatitis.

Art of prevention: Allergic sensitization through damaged skin: Atopic, occupational, and stasis dermatitis.

The prevention of allergic contact dermatitis hinges on maintaining the integrity of the skin barrier and responding appropriately when it is disturbed. Although intact skin is subject to sensitization via highly irritating allergens, such as poison ivy, acutely inflamed and chronically inflamed skin is subject to sensitization to allergens without inherent irritant potential. In the chronically inflamed state of atopic dermatitis, sensitization to proteins, such as food, also carries a risk for systemic contact dermatitis via ingestion of the allergen. Minimizing the development of irritant dermatitis is key to preventing sensitization. However, in patients with already chronically inflamed skin, reducing the use of products to the involved areas, recommending hypoallergenic products with caution, and taking measures to prevent biofilm formation are also integral to preventing sensitization to chemicals and proteins, such as food and commensal organisms.

Acral and digital angioleiomyomata: 14-year experience at the Cleveland Clinic and review of the literature.

BACKGROUND: Angioleiomyoma is a benign neoplasm thought to derive from the tunica media of small venous vessels. Angioleiomyomata most frequently occur in the lower extremities with less common occurrences on the trunk, head and upper extremities. Few cases of acral and digital angioleiomyoma have been described in the literature. METHODS: We add a series of 21 patients with acral angioleiomyoma including 6 cases of digital angioleiomyoma to the body of clinical and histological findings along with a review of the literature of digital angioleiomyomata. RESULTS: Digital angioleiomyoma are equally distributed between male and female patients and are more often painful than the angioleiomyoma of all body sites. Acral angioleiomyomata favor the feet over hands at a ratio of 2.5:1, while digital angioleiomyoma favor the fingers over toes at a ratio of 4.3:1. CONCLUSIONS: We suggest that vascular leiomyoma be included in the differential diagnosis of smooth muscle tumors with particular regard to the digits of both the hands and the feet. Digital angioleiomyomata differ from acral angioleiomyomata in their equal gender distribution, increased tendency to cause pain and preponderance for the fingers over the toes.

Food Avoidance Diets for Dermatitis.

Food allergy is relatively common in both children and adults, and its prevalence is increasing. Early exposure of food allergens onto skin with an impaired epidermal barrier predisposes to sensitization and prevents the development of oral tolerance. While immediate-type food allergies are well described, less is known about delayed-type food allergies manifesting as dermatitis. This is due, in part, to limitations with current diagnostic testing for delayed-type food allergy, including atopy patch testing. We conducted a systematic review of food avoidance diets in delayed-type food allergies manifesting as dermatitis. While beneficial in some clinical circumstances, avoidance diets should be used with caution in infants and children, as growth impairment and developmental delay may result. Ultimately, dermatitis is highly multifactorial and avoidance diets may not improve symptoms of delayed-type food allergy until combined with other targeted therapies, including restoring balance in the skin microbiome and re-establishing proper skin barrier function.

Prevention of methicillin-resistant Staphylococcus aureus infections in spinal cord injury units.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) are a concern in the 22 acute care Veterans Affairs (VA) spinal cord injury units where patients with unique rehabilitation and medical needs and a high risk of infection are treated. METHODS: A bundle was implemented in VA spinal cord injury units consisting of nasal surveillance for MRSA on admission/in-hospital transfer/discharge, contact precautions for patients colonized or infected with MRSA, an emphasis on hand hygiene, and an institutional culture change where infection control became everyone's responsibility. RESULTS: From October 2007, through June 2011, there were 51,627 admissions/transfers/discharges and 816,254 patient-days of care in VA spinal cord injury units. The percentage of patients screened increased to >95.0%. The mean admission MRSA prevalence was 38.6% ± 19.1%. Monthly HAI rates declined 81% from 1.217 per 1,000 patient-days to 0.237 per 1,000 patient-days (P < .001). Bloodstream infections declined by 100% (P = .002), skin and soft-tissue infections by 60% (P = .007), and urinary tract infections by 33% (P = .07). CONCLUSION: Universal surveillance, contact precautions, hand hygiene, and an institutional culture change was associated with significant declines in MRSA HAIs in a setting with a high prevalence of MRSA colonization and a high risk for infection.

Association between obesity and diabetes mellitus in veterans with spinal cord injuries and disorders.

OBJECTIVES: To examine the association between body mass index (BMI) and clinically diagnosed diabetes in veterans with spinal cord injuries and disorders. We also sought to determine whether there is evidence to support a 10% reduction in BMI cut points, which would lower the upper limit of normal BMI from 24.99 to 22.49 kg/m, for persons with spinal cord injuries and disorders. DESIGN: Cross-sectional analysis using clinical data on 1938 male veterans. Prevalence ratios (95% confidence intervals) were calculated using a generalized linear model and adjusted for age, race, tobacco use, and paraplegia/tetraplegia status. RESULTS: Compared with the National Heart Lung Blood Institute normal BMI category (18.5-24.99 kg/m), the prevalence of diabetes was 50% higher (adjusted prevalence ratio: 1.50, 95% CI: 1.11-2.01) in the overweight category (25-29.99 kg/m) and approximately 3-fold higher (for obese classes 1-3, adjusted prevalence ratio: 2.74-3.03) in the obese category (BMI >or= 30 kg/m). Compared with the World Health Organization low-normal category (BMI, 18.5-22.99 kg/m), there was no significant difference in the prevalence of diabetes for those in the high normal weight (BMI, 23-24.99 kg/m) or low overweight (BMI, 25-27.49 kg/m) categories. However, the prevalence of diabetes was 2-fold higher among those in the high overweight category (BMI, 27.5-29.99 kg/m; adjusted prevalence ratio: 2.00, 95% CI: 1.33-2.99). CONCLUSIONS: BMI >or=25 kg/m was associated with significantly higher diabetes prevalence in male veterans with spinal cord injuries and disorders, and this risk was especially pronounced at BMI >or=27.5 kg/m. These findings do not support the need to create spinal cord injuries and disorder-specific BMI definitions of overweight for purposes of determining diabetes risk.

What parents and carers think medical students should be learning about communication with children and families.

OBJECTIVE: Our objective was to dynamically engage with parents and carers of children treated in a large children's hospital as experts by experience, to find out what they thought medical students should be learning about communicating with children and families in order to inform our communication teaching. METHODS: We used focus groups to facilitate parents and carers in articulating the communication issues they felt were important for medical students to learn. These data were analysed, using qualitative and quantitative methods, to produce a survey for a Delphi consultation. The results of this stage were mapped onto the Calgary-Cambridge framework for the medical interview. RESULTS: There was considerable overlap of the data on the Calgary-Cambridge framework. There was, however, an emphasis by respondents on perceptual skills, self-awareness and partnership. Within the main tasks of the Calgary-Cambridge framework, new objectives emerged, including giving information in the right place, and the importance of the family in the multidisciplinary team. A new main task, Preparation, was highlighted. CONCLUSION: Active collaboration with parents and carers revealed areas for enhancement in our communication skill teaching, particularly with regard to relational and perceptual skills. PRACTICE IMPLICATIONS: Ways of including effective teaching of perceptual skills and the relational and humanistic aspects of communication must be explored in order to meet the needs of child patients and their families.

Provider perspectives on soldiers with new spinal cord injuries returning from Iraq and Afghanistan.

OBJECTIVE: The military conflicts in Iraq and Afghanistan have resulted in many soldiers returning with serious combat injuries, including spinal cord injuries (SCIs). The purpose of this study was to query providers regarding any unique problems or needs in a cohort of these soldiers treated in Veterans Health Administration (VHA) SCI Centers. DESIGN: Semistructured questionnaire. SETTING: Seventeen VHA SCI Centers. PARTICIPANTS: Thirty-eight providers, including physicians, nurses, therapists, social workers, and psychologists who volunteered to return completed questionnaires. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Identification of medical and psychosocial issues, rehabilitation delays, therapy and vocational needs, social support, and discharge planning. RESULTS: Providers identified several injuries and conditions beyond SCI that were experienced by these soldiers including fractures, pressure ulcers, traumatic brain injuries, posttraumatic stress disorder, and resistant infections. Rehabilitation was often delayed because these problems needed to be addressed first. Soldiers' family and friends provide considerable support. Vocational needs include use of technology, especially computers; education; and participation in sports. Although most return to the community after discharge, many soldiers are still active duty, and some return to military base housing. CONCLUSIONS: Combat soldiers returning with SCI often have additional medical and psychosocial problems that require appropriate and timely intervention. They have strong support from family and friends and are motivated to integrate back into the community after discharge.

Trends in diabetes mellitus indicators in veterans with spinal cord injury.

OBJECTIVE: Persons with spinal cord injury (SCI) are at increased risk for developing diabetes mellitus (DM). However, published data on the care provided to this population are minimal. The purpose of this study was to examine a set of measures of quality of DM care in veterans with SCI. DESIGN: Retrospective analysis of the External Peer Review Program data for veterans with SCI and DM from 2002 to 2004 in the Veterans Healthcare System. Trends in DM measures were examined using generalized estimation equation models. RESULTS: The percentage of veterans who received testing for lipids, retinal, and renal exams significantly increased during this period. This was accompanied by significant improvements in intermediate outcomes, glycemic, lipid, and blood pressure (BP) control. The percentage of veterans with glycosylated hemoglobin (HbA1c) (levels < or = 9%; P < 0.001) and those with poorly controlled levels (HbA1c > 9.5%; P = 0.022) improved. BP (140/90) rates increased from 59% in fiscal year (FY) 2002 to nearly 70% in 2004 (P < 0.001). The percentage of veterans who received renal screening (anatomical tests, physiologic test, and urine microalbumin) increased significantly (P < 0.001). Retinopathy exam rates also increased from 55.1% in FY 2002 to 70.8% in FY 2004 (P < 0.001). CONCLUSIONS: Significant improvements were made in a set of DM measures used to evaluate care provided to veterans with SCI. The positive trends in DM care seen in the general veteran population were also evident in the SCI population.

Owners 'perception of their cats' quality of life during COP chemotherapy for lymphoma.

Questionnaires regarding the perceptions of chemotherapy and its impact on the quality of life (QoL) of their cat were received from owners of 31 cats treated for lymphoma between 2002 and 2006 with COP (cyclophosphamide, vincristine, prednisolone) chemotherapy. The QoL scores prior to the onset of cancer (mean 9.5, range 6-10) were significantly higher than the ratings given after the onset of cancer but before commencement of chemotherapy (mean 3.9, range 1-9.4). The QoL scores during chemotherapy (mean 6.3, range 1-10) were also significantly lower than prior to the onset of cancer, but significantly higher during treatment than prior to starting treatment. Adverse effects were experienced by 27 (87%) cats during the course of chemotherapy. Twenty-five (83%) of clients were happy they treated their cat and 27 owners (87%) would treat another cat. The results suggest that COP chemotherapy is perceived by owners to be tolerated by cats.

Interventions to increase influenza vaccination rates in veterans with spinal cord injuries and disorders.

OBJECTIVE: To increase the percentage of veterans with spinal cord injuries and disorders (SCI&D) who receive annual influenza vaccinations. DESIGN: A repeated measures quality improvement project using several integrated evidence-based interventions. SETTING: 23 Veterans Affairs (VA) SCI Centers. PATIENTS: Veterans with SCI&D average age = 57.3 years (range 21-102 y). INTERVENTIONS: Patient reminder letters and education; provider reminders and posters; computerized clinical reminders for vaccination targeted to SCI & D; standing orders. MAIN OUTCOME MEASURES: Patient self-reported vaccination status. RESULTS: Baseline vaccination rate was 33% in fiscal year (FY) 2001. The percentage of veterans with SCI&D who reported receiving vaccinations increased from 62.5% in year 1 (FY2002) to 67.4% in FY2003 (P = 0.004); for individuals younger than 50 years of age, rates increased from 50% to 54%. Predictors of vaccination were age 65 years of age or older, VA health care visit in past year, nonsmoker, believing vaccination is important, having a health condition that may contribute to respiratory complications, and self-reported influenza in prior year. CONCLUSIONS: Vaccination rates were higher than baseline and higher than reported for other high-risk groups. Interventions that incorporate system-wide approaches plus patient and provider education and reminders were moderately effective in increasing vaccination rates. Targeting younger persons, smokers, and those who do not use VA care may further improve rates.

Improving respiratory vaccination rates in veterans with spinal cord injury/disorders: lessons learned.

The burden of respiratory disease following a spinal cord injury/disorder (SCI/D) is well-described and experienced by patients, families, health care providers, and the health care delivery system. Despite the effectiveness of respiratory vaccinations (influenza and pneumococcal), vaccination rates in this population have been historically low. The Veterans Health Administration (VHA) Spinal Cord Injury Quality Enhancement Research Initiative (QUERI) developed a program to increase vaccination rates for veterans with SCI/D. Patient, provider, and system-level strategies were used. The purpose of the study was to improve vaccination rates in this population using multiple strategies. The result was significant improvement in vaccination rates following intervention. This paper describes the lessons learned in implementing best practices for vaccination. In addition, the basic elements of this program, and the similarities with the Chronic Care Model, are described.

Doctors' and nurses' observations on the Geriatric Depression Rating Scale.

BACKGROUND: Screening older patients routinely for depression using the Geriatric Depression Scale is recommended, but there is little evidence that this practice is widespread. This study explored doctors' and nurses' attitudes towards the Geriatric Depression Scale in order to identify possibilities for improving practice. DESIGN: structured interviews. SETTING: Acute Care of the Elderly wards in the Royal Liverpool University Hospital. PARTICIPANTS: 20 junior doctors and 25 nurses. RESULTS: Only 10% of respondents would consider using the Geriatric Depression Scale for routine screening. Objections were to process as well as content. The Geriatric Depression Scale was felt to be 'too depressing' for routine use and a barrier to rapport with the patient. In addition to screening for possible depression, doctors and nurses expressed different requirements from a depression scale. Doctors wanted a formal method of rating and documenting symptoms. Nurses required a therapeutic structure within which they could help patients to explore feelings. Nurses also wanted the option of offering counselling for their patients but felt they needed training. CONCLUSIONS: Lack of enthusiasm for the Geriatric Depression Scale reduces its usefulness as a screening tool. A screening method that is more acceptable to nurses and doctors might improve depression screening practice.

Can a short period of micronutrient supplementation in older institutionalized people improve response to influenza vaccine? A randomized, controlled trial.

OBJECTIVES: To test the hypothesis that a micronutrient supplement can improve seroconversion after influenza immunization in older institutionalized people. DESIGN: : Randomized, double-blind, placebo-controlled study. SETTING: Nursing and residential homes in Liverpool, United Kingdom. PARTICIPANTS: One hundred sixty-four residents aged 60 and older from 31 homes were initially randomized; of these, 119 (72.6%) completed the study. INTERVENTION: Participants were randomized to receive a micronutrient supplement providing the reference nutrient intake for all vitamins and trace elements or identical placebo. Tablets were taken over an 8-week period during September and October 2000; influenza vaccine was administered 4 weeks after their commencement. MEASUREMENTS: The hemagglutination-inhibiting antibody response as defined by a fourfold or greater titer rise over 4 weeks and assessed separately for each of the three antigens contained in the 2000/2001 influenza vaccine (A/New Caledonia/20/99 (H1N1), A/Moscow/10/99 (H3N2), B/Beijing/184/93 (B)). RESULTS: Despite a significant increase in serum concentrations of vitamins A, C, D3, E, folate, and selenium in the supplemented group, there was no significant difference between groups (supplemented vs placebo, respectively) in the proportion of participants seroconverting to H1N1 (41% vs 49%, P=.374), H3N2 (49% vs 58%, P=.343), or B (41% vs 40%, P=.944). CONCLUSION: A micronutrient supplement providing the reference nutrient intake administered over 8 weeks had no beneficial effect on antibody response to influenza vaccine in older people living in long-term care.

Influenza vaccination among veterans with spinal cord injury: Part 2. Increasing vaccination rates.

BACKGROUND/OBJECTIVE: Respiratory complications are the leading cause of morbidity and mortality among individuals with spinal cord injury (SCI). Influenza vaccination is effective in reducing the likelihood of contracting influenza and of subsequent respiratory complications, hospitalizations, and deaths. Historically, vaccination rates for veterans with SCI treated in Veterans Affairs (VA) facilities have been low. The objective of this study was to increase vaccination rates in this population using a multipronged strategy. METHODS: A quasi-experimental design involving 2,284 veterans treated at 8 VA SCI Centers was used. Patients at 4 centers received reminder letters and educational materials tailored to SCI. Provider education included mailed reminders and posters in SCI clinical areas. Clinical champions were identified at each site. Four other centers, matched to the study sites in program size and prior vaccination rates, served as comparison sites providing usual care. Vaccination rates were assessed using mailed surveys with telephone follow-up. RESULTS: The influenza vaccination rate was significantly higher in the intervention group than in the comparison group (60.5% vs 54.3%; P = 0.01 ). Vaccine recipients were older than nonrecipients (mean age 60.8 vs 53.1 years; P < 0.0001). Reasons for not receiving a vaccination included refusal, feeling that being vaccinated was not worth the trouble, and not believing that the vaccine would prevent influenza. CONCLUSIONS: Use of low-cost mailed reminders and educational materials resulted in significantly higher vaccination rates. Further efforts to reach targeted subgroups of nonrecipients, such as patients who are younger or from an ethnic minority, are warranted.