Representation of Fitzpatrick skin phototype in dermatology surgical textbooks.

Given the importance of skin of color (SoC) representation in dermatologic education and training, this study quantified representation of Fitzpatrick skin phototypes (FST) in core dermatology surgery textbooks. Images within Surgery of the Skin: Procedural Dermatology, Dermatologic Surgery, and Facial Reconstruction after Mohs Surgery were categorized according to the Fitzpatrick skin phototype (FST) depicted and the dermatologic surgery topic addressed. 1501 images were analyzed, with only 5.6% of the images categorized as FST IV-VI representing SoC. Several topics (11/29, 37.9%) identified did not include images with SoC. Increasing access to high-quality images of SoC can enhance appreciation of various skin conditions, especially those predominant in SoC, by dermatologic trainees and clinicians.

Greater Compliance With Early Sepsis Management is Associated With Safer Care and Shorter Hospital Stay.

ABSTRACT: This retrospective, cross-sectional study of U.S. hospitals in Medicare's Inpatient Quality Reporting Program aimed to determine whether variation in Sepsis/Septic Shock (Bundle SEP-1) compliance is linked to hospital size and measures of safety and operational efficiency. Two thousand six hundred and fifty-three acute care hospitals in Medicare's Hospital Compare online database were included in the study. Relationships between SEP-1 bundle compliance, hospital size, and indices of operational excellence (including Patient Safety Index [PSI-90], average length of stay [ALOS] and readmission rate) were analyzed. SEP-1 compliance score was inversely associated with staffed bed number (r = -.14, p < .001), PSI-90 (r = -.01, p < .001), and ALOS (r = -.13, p < .001) in a multivariate analysis. Hospitals in the lowest versus highest quartile by bed number had SEP-1 compliance score of 49.8 ± 20.2% versus 46.9 ± 16.8%, p < .001. Hospitals in the lowest versus highest quartile for SEP-1 score had an ALOS of 5.0 ± 1.2 days versus 4.7 ± 1.1 days and PSI-90 rate of 1.03 ± 0.22 versus 0.98 ± 0.16, p < .001 for both. Although this does not establish a causal relationship, it supports the hypothesis that the ability of hospitals to successfully implement SEP-1 is associated with superior performance in key measures of operational excellence.

Allergen Content of Best-Selling Ethnic Versus Nonethnic Shampoos, Conditioners, and Styling Products.

BACKGROUND: Hair products are a potential cause of allergic contact dermatitis. There are limited data on the allergen content of ethnic hair products. OBJECTIVE: To identify allergens unique to ethnic hair products (shampoos, conditioners, styling products) and provide a resource for low allergen hair care products for patients with ethnic hair types. METHODS: The top 100 best-selling shampoos, conditioners, and styling products for ethnic and nonethnic hair products were determined from 3 major online retailers (Walmart, Target, Walgreens). Allergen was defined as presence on the 2017 American Contact Dermatitis Society Core 80 allergen list. RESULTS: The 2017 American Contact Dermatitis Society Core 80 allergens were tabulated for ethnic and nonethnic shampoos, conditioners, and styling products. A list of low-allergen shampoos, conditioners, and styling products was identified. Fragrance was the most common allergen for ethnic shampoos, conditioners, and styling products. Other notable allergens included methylchloroisothiazolinone/methylisothiazolinone, formaldehyde releasers, cetyl steryl alcohol, tocopherol, decyl glucoside, sodium benzoate, and phenoxyethanol. CONCLUSIONS: This study identifies important differences in allergens found in products marketed for ethnic hair compared with those marketed for nonethnic hair.

Gratitude at Work: Prospective Cohort Study of a Web-Based, Single-Exposure Well-Being Intervention for Health Care Workers.

BACKGROUND: Emotional exhaustion (EE) in health care workers is common and consequentially linked to lower quality of care. Effective interventions to address EE are urgently needed. OBJECTIVE: This randomized single-exposure trial examined the efficacy of a gratitude letter-writing intervention for improving health care workers' well-being. METHODS: A total of 1575 health care workers were randomly assigned to one of two gratitude letter-writing prompts (self- vs other focused) to assess differential efficacy. Assessments of EE, subjective happiness, work-life balance, and tool engagement were collected at baseline and 1-week post intervention. Participants received their EE score at baseline and quartile benchmarking scores. Paired-samples t tests, independent t tests, and correlations explored the efficacy of the intervention. Linguistic Inquiry and Word Count software assessed the linguistic content of the gratitude letters and associations with well-being. RESULTS: Participants in both conditions showed significant improvements in EE, happiness, and work-life balance between the intervention and 1-week follow-up (P<.001). The self-focused (vs other) instruction conditions did not differentially predict improvement in any of the measures (P=.91). Tool engagement was high, and participants reporting higher motivation to improve their EE had higher EE at baseline (P<.001) and were more likely to improve EE a week later (P=.03). Linguistic analyses revealed that participants high on EE at baseline used more negative emotion words in their letters (P=.005). Reduction in EE at the 1-week follow-up was predicted at the level of a trend by using fewer first-person (P=.06) and positive emotion words (P=.09). No baseline differences were found between those who completed the follow-up assessment and those who did not (Ps>.05). CONCLUSIONS: This single-exposure gratitude letter-writing intervention appears to be a promising low-cost, brief, and meaningful tool to improve the well-being of health care workers.

Duration of Dermatitis Before Patch Test Appointment Is Associated With Distance to Clinic and County Poverty Rate.

BACKGROUND: Contact dermatitis is a common disease that is associated with impaired quality of life. OBJECTIVE: We examined the effect of travel distance and other socioeconomic factors on duration of dermatitis before presentation at the Duke Contact Dermatitis and Patch Testing Center. METHODS: This is a retrospective study of patients who underwent patch testing from March 1, 2012, to August 1, 2018. Associations between duration of dermatitis, distance to clinic, and socioeconomic factors (age, race, payor group, county poverty rate, rural-urban status) were examined. RESULTS: The median duration of dermatitis was 14 months (Q1 = 7 months; Q3 = 36 months), and the median distance to clinic was 18 miles (Q1 = 7 miles; Q3 = 45.9 miles). For a 50-mile increase in the distance from the patient's zip code to the clinic, the median duration of dermatitis increased by 17.9% (P < 0.001). For every 5% increase in the county poverty rate, the median duration of dermatitis increased by 16.3% (n = 29; P = 0.032). Trends were noted for a longer duration of dermatitis based on insurance payor, rural-urban status, and race. CONCLUSIONS: Distance to patch test provider and county poverty status are important measures of access for patients with dermatitis.

Relationship Between HCAHPS Scores and Survey Response Rate Is Linked to Hospital Size.

Patient experience is an important dimension of health care quality and is assessed using the standard Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for inpatients. The HCAHPS scores may vary based on survey response rate and hospital size. The objective of this study was to describe the association between survey response rate and HCAHPS scores and examine whether the relationship varies based on hospital size. Medicare's Hospital Compare publicly reported HCAHPS data were used. Pearson correlation, controlling for number of staffed beds, and linear regression models were used for the analysis. Hospitals were grouped into quartiles based on number of staffed beds to delineate the effect of increasing hospital size on the relationship between survey response rate and HCAHPS scores. A significant association between HCAHPS survey response rate and all examined HCAHPS domain scores was observed. The effect size across HCAHPS domains varied based on hospital size. The relationship between HCAHPS score and survey response rate differed significantly between hospitals in the smallest and largest size quartiles for discharge information, nurse communication, and hospital quietness. While a causal relationship cannot be inferred from this study, the response rate could be a direct and/or indirect driver of HCAHPS scores. Future research should be aimed to further explore the basis of this relationship and to determine how it may inform the interpretation of HCAHPS results.

Patch Test Practice Patterns of Members of the American Contact Dermatitis Society.

BACKGROUND: Patch testing is the criterion standard for diagnosis and management of allergic contact dermatitis. Limitations on the number of allergens tested can negatively impact patient care. OBJECTIVE: This study reports clinical practice patterns of American Contact Dermatitis Society (ACDS) members. METHODS: In October and November 2018, the US-based members of the ACDS received an electronic survey regarding their procedures and experiences with patch testing. We evaluated the type of practice, number of patients tested, type of screening and supplemental series, number of allergens tested, and billing and reimbursement concerns. RESULTS: There were 149 respondents; 62% use ACDS Core 80, 70% "sometimes" or "always" test with supplemental series, and 70% "sometimes" or "always" test patient products. Participants estimated that supplemental series identify relevant allergens 35% of the time. Approximately 66% most commonly test more than 81 allergens per patient, and 78% expressed concerns regarding fair reimbursement. CONCLUSIONS: Most ACDS members routinely test more than 81 allergens per patient. Barriers to fair payment for beyond a fixed number of patches at any one visit may impede the diagnosis of allergic contact dermatitis, prolong suffering, and worsen outcomes.

Shifting Paradigms in Allergic Contact Dermatitis: The Role of Innate Immunity.

The role of the innate immune system in allergic contact dermatitis (ACD) has traditionally been confined to the initial antigen sensitization phase. However, more recent findings have shown the role of innate immunity in additional aspects of ACD, including the effector phase of the classic type IV hypersensitivity reaction. As a result, the precise immunologic mechanisms mediating ACD are more complex than previously believed. The aim of this review is to provide insight into recent advances in understanding the role of the innate immune system in the pathogenesis of ACD, including novel mechanistic roles for macrophages, innate lymphoid cells, natural killer cells, innate γδ T cells, and other signaling molecules. These insights provide new opportunities for therapeutic intervention in ACD.

Allergens in Medical Hand Skin Cleansers.

Health care workers may be at risk of occupational allergic contact dermatitis because of their frequent exposure to medical hand skin cleansers. We identified American Contact Dermatitis Society Core 80 Allergens found in medical hand skin cleansers (waterless skin soaps, water-needed skin soaps, and skin disinfectants) in the United States and developed a list of "low-allergen" medical hand skin cleansers. Waterless skin soaps most commonly contained fragrance, tocopherol, and sodium benzoate. Top allergens in water-needed skin soaps included fragrance, chloroxylenol, propylene glycol, and cocamidopropyl betaine. The most common allergens identified in skin disinfectants were chlorhexidine, cocamide diethanolamine, and fragrance. We identified 11 waterless skin soaps that were free of American Contact Dermatitis Society Core 80 Allergens. Low-allergen products were also identified for water-needed skin soaps (2 products) and skin disinfectants (4 products). This information is accurate as of the date of publication; product availability and ingredients may change over time.

A 17-Year-Old Girl With Unilateral Headache and Double Vision.

Tolosa-Hunt syndrome is characterized by a painful ophthalmoplegia secondary to a granulomatous inflammation in or adjacent to the cavernous sinus. Magnetic resonance imaging will show enhancement of the cavernous sinus and/or the orbital apex. Although this syndrome is extremely rare in children, it should be a diagnostic consideration in patients presenting with painful ophthalmoplegia with variable involvement of cranial nerves II to VI. The differential diagnosis for unilateral cavernous sinus lesion is broad, including vascular lesions (cavernous sinus thrombosis), inflammatory processes (sarcoidosis, autoimmune), neoplastic processes (schwannoma, lymphoma), as well as infectious etiologies. We describe a pediatric patient presenting with neurological symptoms from a unilateral cavernous sinus magnetic resonance imaging abnormality and the thorough diagnostic approach to arrive at the diagnosis of Tolosa-Hunt syndrome.