Higher Odds of Adverse Cutaneous Reactions in Patients With Dermatomyositis Treated With Hydroxychloroquine Compared With Methotrexate.

OBJECTIVE: Hydroxychloroquine (HCQ) use for the treatment of dermatomyositis (DM) has been associated with adverse cutaneous reactions. We applied a new user, active comparator, retrospective design to assess differences in adverse cutaneous reactions or hospitalizations between HCQ and methotrexate (MTX) use among patients with DM. METHODS: We used a national network of data from insurance registries (TriNetX), enrolling patients with two International Classification of Diseases (ICD) codes for DM separated by 6 months or more who had a prescription for either (but not both) HCQ or MTX on or after DM diagnosis. Outcomes were adverse cutaneous reactions (ICD codes) or hospital admission (Current Procedural Terminology (CPT) codes) within 4 months from the prescription dispense date. Logistic regression was used to produce adjusted odds ratios (aORs) and 95% confidence intervals (CIs) comparing outcomes in the HCQ group (n = 1364) and the MTX group (n = 1400), adjusted for age at first DM diagnosis, year of birth, sex, and time from DM diagnosis to first prescription. RESULTS: Overall, we found no significant difference in odds of hospitalization in those taking HCQ (aOR 1.05; 95% CI: 0.79-1.39) compared with those on MTX. Patients with DM on HCQ had 30% higher odds of adverse cutaneous reaction diagnosis compared with patients on MTX (aOR 1.30; 95% CI: 1.02-1.59). Age at DM diagnosis was an effect modifier of this association, with higher odds of adverse cutaneous reaction among patients taking HCQ who were younger at diagnosis. CONCLUSION: Compared with MTX use, HCQ use, especially in younger patients, may result in higher odds of adverse cutaneous reactions.

A retrospective cohort study of the efficacy of metronidazole in oral lichen planus.

Lichen planus (LP) is an inflammatory dermatosis with mucosal variants, including oral LP (OLP). OLP has a relapsing chronic course and may significantly affect a patient's quality of life. We analysed the efficacy of metronidazole as a treatment for OLP via a retrospective chart review of patients with a diagnosis of OLP seen at our institution over 10 years. Thirty patients with OLP were treated with metronidazole 500 mg twice daily. Most patients (n = 18; 60%) showed improvement with metronidazole, including 10 (33%) who experienced complete resolution of symptoms. Our results were limited by the retrospective nature of the review and the relatively small cohort size. Given the efficacy, mild side-effect profile and the less immunosuppressive nature of metronidazole vs. alternative systemic treatment options, metronidazole is a reasonable option to try in patients with symptomatic OLP who have failed topical treatment options.

Chief resident selection in US dermatology residency programs.

Chief residents are typically selected as leaders from the senior-most residents in a residency program. The definition of the role likely varies widely between various residency programs. We aimed to gain a better understanding of responsibilities of chief residents in dermatology programs and to identify selection methods. After institutional review board review, we created a Qualtrics survey distributed through a listserv of program directors (PDs) from US dermatology residency programs. Of 51 survey responses, 100% had chief residents, and 35.3% had all senior residents designated as chief residents. The majority of programs used several selection processes, but most frequently PD selection (n = 20). Programs (76%) reported other leadership opportunities for seniors. The most important attribute in selecting a chief resident was helpfulness, and PDs rated their perceived resident satisfaction with the selection process as an 8.24 out of 10, with 10 being most satisfied. Additional benefits for chief residents were reported at 86.9% (n=40) of programs. Most programs select chief residents based on merit. There is perceived satisfaction of residents regarding this process, and most programs report additional benefits for their chief residents.

Assessing Patient Satisfaction with Teledermatology Implementation During the COVID-19 Pandemic.

The aim of this study was to assess the patient experience with teledermatology among new versus existing clinic patients in the context of the rapid practice shift to teledermatology during the COVID-19 pandemic. We analyzed survey responses from 184 teledermatology patients seen during COVID-19 at a major Southeastern medical center from May 13th to June 5th 2020. Overall patient-reported satisfaction with teledermatology was high with the majority of respondents rating their overall satisfaction as excellent (68%) or very good (18%). As teledermatology experiences wider adoption with the COVID-19 pandemic, it is essential to examine patient experience and satisfaction with teledermatology.

Postoperative Inhaled Steroids Following Glottic Airway Surgery Reduces Granulation Tissue Formation.

OBJECTIVES: Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA)) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis. METHODS: A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000 to 2019 was conducted. Surgical instances were grouped into those that received postoperative ICS and those that did not. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed. RESULTS: Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of the 23 instances where patients received immediate postoperative ICS, 0 patients developed GT; and of the 37 instances that did not receive postoperative ICS, 15 (40.5%) developed GT (P < .0001). Eight (53.3%) of these cases returned to the OR for GT removal. ICS use was solely associated with the absence of GT formation (P = .042) in the multivariate analysis. CONCLUSIONS: Immediate postoperative use of ICS seems to be a safe and effective method to prevent granulation tissue formation and subsequent surgery in patients following transoral laser airway surgery for glottic stenosis.

Vascular control of kidney epithelial transporters.

A major pathway in hypertension pathogenesis involves direct activation of ANG II type 1 (AT1) receptors in the kidney, stimulating Na+ reabsorption. AT1 receptors in tubular epithelia control expression and stimulation of Na+ transporters and channels. Recently, we found reduced blood pressure and enhanced natriuresis in mice with cell-specific deletion of AT1 receptors in smooth muscle (SMKO mice). Although impaired vasoconstriction and preserved renal blood flow might contribute to exaggerated urinary Na+ excretion in SMKO mice, we considered whether alterations in Na+ transporter expression might also play a role; therefore, we carried out proteomic analysis of key Na+ transporters and associated proteins. Here, we show that levels of Na+-K+-2Cl- cotransporter isoform 2 (NKCC2) and Na+/H+ exchanger isoform 3 (NHE3) are reduced at baseline in SMKO mice, accompanied by attenuated natriuretic and diuretic responses to furosemide. During ANG II hypertension, we found widespread remodeling of transporter expression in wild-type mice with significant increases in the levels of total NaCl cotransporter, phosphorylated NaCl cotransporter (Ser71), and phosphorylated NKCC2, along with the cleaved, activated forms of the α- and γ-epithelial Na+ channel. However, the increases in α- and γ-epithelial Na+ channel with ANG II were substantially attenuated in SMKO mice. This was accompanied by a reduced natriuretic response to amiloride. Thus, enhanced urinary Na+ excretion observed after cell-specific deletion of AT1 receptors from smooth muscle cells is associated with altered Na+ transporter abundance across epithelia in multiple nephron segments. These findings suggest a system of vascular-epithelial in the kidney, modulating the expression of Na+ transporters and contributing to the regulation of pressure natriuresis.NEW & NOTEWORTHY The use of drugs to block the renin-angiotensin system to reduce blood pressure is common. However, the precise mechanism for how these medications control blood pressure is incompletely understood. Here, we show that mice lacking angiotensin receptors specifically in smooth muscle cells lead to alternation in tubular transporter amount and function. Thus, demonstrating the importance of vascular-tubular cross talk in the control of blood pressure.

Evaluating the Experiences of New and Existing Teledermatology Patients During the COVID-19 Pandemic: Cross-sectional Survey Study.

BACKGROUND: As teledermatology has been widely adopted during the COVID-19 pandemic, it is essential to examine patients' experiences and satisfaction with teledermatology. OBJECTIVE: We aimed to assess the teledermatology experiences of new and existing clinic patients in the context of the rapid shift toward teledermatology practices during the COVID-19 pandemic. METHODS: We conducted a cross-sectional study of 184 teledermatology patients who were assessed during the COVID-19 pandemic at a major southeastern medical center from May 13 to June 5, 2020. The primary outcome was patient satisfaction levels among new and existing patients. The secondary outcome was patients' willingness to use teledermatology in the future. RESULTS: Of the 288 teledermatology patients who were assessed during the study period, 184 (63.9%) completed the survey. Patients reported high overall satisfaction with teledermatology, with 86.4% (159/184) of participants reporting positive overall satisfaction and experiences with teledermatology. New patients had significantly higher Likert scores for overall satisfaction with teledermatology than those of follow-up patients (new patients: mean 4.70; existing patients: mean 4.43; P=.03). Overall, patients' satisfaction with teledermatology did not significantly differ based on age (P=.36), race and ethnicity (P=.46), education level (P=.11), residence (P=.74), or insurance status (P=.74). There were no significant differences in overall satisfaction between patients with and without prior telehealth experience (P=.53), between the video and telephone visit types (P=.17), and among platform types (P=.22). Prior telehealth experience was associated with higher odds of being willing to use telehealth in the future (odds ratio 2.39, 95% CI 1.31-4.35; P=.004). CONCLUSIONS: This cross-sectional survey study demonstrates that during the rapid expansion of teledermatology, new clinic patients had significantly higher scores for overall satisfaction with their teledermatology experience compared to those of established clinic patients (P=.03). Prior telehealth experience was associated with higher odds of being willing to use teledermatology in the future. Overall, teledermatology expansion was met with high levels of patient satisfaction during the COVID-19 pandemic.

Combined Transverse Cordotomy- Anteromedial Arytenoidectomy for Isolated Glottic Stenosis.

OBJECTIVES/HYPOTHESIS: Glottic stenosis is a discrete cause of airway compromise. We aimed to determine the surgical outcomes of transverse cordotomy with anteromedial arytenoidectomy (TCAMA), performed in the setting of isolated glottic stenosis resulting from two discrete etiologies: bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS). STUDY DESIGN: Retrospective, analytic cohort study. METHODS: Twenty-six patients with isolated glottic stenosis were treated with TCAMA between 2006 and 2019. A retrospective analysis determined decannulation rates and intervals, voice outcomes, swallowing outcomes, and reoperation rates postoperatively. Outcomes between the two etiologic cohorts were compared. RESULTS: Of the 26 patients, 16/26 patients were diagnosed with PGS and 10/26 with BVFP. Eighteen patients required tracheotomies during their clinical course (11/16 PGS, and 7/10 BVFP), and 100% were ultimately decannulated. The PGS cohort required two-sided interventions more frequently than the BVFP cohort (45.5% vs. 0%, P = .066). Trach-dependent PGS patients required a longer time to achieve decannulation than BVFP patients by a factor of 2.38, although the difference was not statistically significant (102.3 days vs. 42.9 days, respectively, P = .113). Patients demonstrated a significant change in maximum phonation time but no statistically significant differences with preoperative versus postoperative voice outcomes like voice-related quality of life. All patients ultimately returned to their baseline swallow function postoperatively. CONCLUSION: TCAMA is an effective treatment for surgical rehabilitation of glottic stenosis caused by both BVFP and PGS. Patient-reported outcomes of postoperative vocal function remain consistent following surgical intervention. Additional, prospective studies with greater power are warranted to validate the contrasting outcomes observed when applying this discrete surgical technique across two distinct diagnostic cohorts in this retrospective study. LEVEL OF EVIDENCE: 4. Laryngoscope, 131:2305-2311, 2021.

Vascular type 1 angiotensin receptors control blood pressure by augmenting peripheral vascular resistance in female mice.

Angiotensin II (ANG II) is a major mediator of hypertension pathogenesis. In addition, there are well-documented differences in expression of the renin-angiotensin system (RAS) components and ANG II responses between males and females, which may explain sex differences in blood pressure (BP) and hypertension epidemiology. We previously showed that type 1A angiotensin (AT1A) receptors in vascular smooth muscle cells (VSMCs) play a critical role in BP regulation and hypertension pathogenesis, but these studies were carried out in male mice. Therefore, the major goal of the current studies was to examine the impact of VSMC AT1A receptors on BP and hypertension pathogenesis in female mice. We found that elimination of VSMC AT1A receptors in female mice reduced (≈8 mmHg) baseline BP without altering sodium sensitivity. The severity of ANG II-induced hypertension was diminished (≈33% reduction in BP), particularly during the last 2 wk of chronic ANG II infusion, compared with controls, but natriuresis was not altered during the first 5 days of ANG II infusion. Urinary norepinephrine levels were enhanced in female SMKO compared with control mice. There was a virtually complete elimination of ANG II-induced kidney hemodynamic responses with attenuation of acute vasoconstrictor responses in the systemic vasculature. These findings demonstrate that direct vascular actions of AT1A receptors play a prominent role in BP control and hypertension pathogenesis in female mice.