Do not get stumped: multimodality imaging findings of early and late post-cholecystectomy complications.

Cholecystectomy is the most performed intra-abdominal surgical procedure in the US, with 1.2 million performed annually, and is predominantly performed laparoscopically. Although largely safe, laparoscopic cholecystectomy results in higher rates of abdominal symptoms consisting of abdominal pain and dyspepsia, which may persist or recur, collectively known as post-cholecystectomy syndrome. This article aims to (1) provide an overview of post-cholecystectomy syndrome with an emphasis on biliary complications and emergent imaging findings, (2) illustrate the spectrum of imaging findings of early and late post-cholecystectomy complications, (3) enumerate the role of various imaging modalities in evaluating post-cholecystectomy complications and address the role of selective trans-catheter coil embolization in managing bile leaks, and (4) discuss pearls and pitfalls in imaging following cholecystectomy. While common first-line imaging modalities for post-cholecystectomy complications include CT and sonography, ERCP and MRCP can delineate the biliary tree with greater detail. Scintigraphy has a higher sensitivity and specificity than CT or sonography for diagnosing bile leak and may preclude the need for ERCP. Post-operative complications include biliary duct injury or leak, biliary obstruction, remnant gallbladder/cystic duct stones and inflammation, biliary dyskinesia, papillary stenosis, and vascular injury. Subtle cases resulting in lethal outcomes, such as hemorrhage from the gallbladder bed without major vessel injury, have also been described. Cases presented will include biliary complications such as post-cholecystectomy stump cholecystitis, nonbiliary complications such as subcapsular hematoma, and normal post-surgical findings such as oxidized regenerated cellulose. Post-operative biliary complications can cause significant morbidity and mortality, and thus familiarity with the expected post-surgical appearance of the gallbladder fossa and biliary tract, as well as understanding the spectrum of complications and associated multimodality imaging findings, are essential for emergency radiologists and those practicing in the acute care setting to direct appropriate patient management. Furthermore, many of the postoperative complications can be managed by noninvasive percutaneous interventional procedures, from drain placement to cystic artery and cystic duct stump embolization.

Measurement properties of the Rajka-Langeland severity score in children and adults with atopic dermatitis.

BACKGROUND: Multiple atopic dermatitis (AD) severity scales exist, with no gold standard for use in clinical practice. OBJECTIVES: To determine the measurement properties of the Rajka-Langeland score and compare it with other clinician-reported outcomes in adults and children with AD. METHODS: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 427). RESULTS: Rajka-Langeland had good concurrent validity with the Eczema Area and Severity Index (Spearman rho = 0·63), SCORing AD (SCORAD) (rho = 0·61), objective-SCORAD (rho = 0·52) and body surface area (rho = 0·51); good convergent validity with the numeric rating scale average-itch (rho = 0·60) and worst-itch (rho = 0·59), Patient-Oriented Eczema Measure (rho = 0·57), Dermatology Life Quality Index (rho = 0·53), Patient-Reported Outcomes Measurement Information System Itch Questionnaire (rho = 0·35-0·55) in adults and/or children; fair discriminant validity for patient- and physician-reported global AD severity; good responsiveness to change of severity of AD and itch; good reliability; internal consistency; with no floor or ceiling effects. Interpretability bands (3, clear/almost clear; 4-5, mild; 6-7, moderate; 8-9, severe) and minimal clinically important difference (1 point) were established. CONCLUSIONS: The Rajka-Langeland score showed good construct validity, reliability, internal consistency and responsiveness in adults and children with AD.

Validity and reliability of Patient-Reported Outcomes Measurement Information System Global Health scale in adults with atopic dermatitis.

BACKGROUND: Patient-Reported Outcomes Measurement Information System Global Health (PGH) was validated to assess health-related quality of life in several diseases. Little is known about its measurement properties in adult atopic dermatitis. OBJECTIVE: Examine the measurement properties of PGH in adult atopic dermatitis. METHODS: A prospective dermatology practice-based study of 994 atopic dermatitis patients (18-97 years). RESULTS: PGH physical and mental health 4-item and abridged 2-item T scores, as well as mapped EuroQol-5D score, showed strong to very strong correlation with one another and moderate to strong Spearman correlations with Patient-Oriented Scoring Atopic Dermatitis, Patient-Health Questionnaire-9, Patient-Reported Outcomes Measurement Information System sleep disturbance and related impairment, Eczema Area and Severity Index, objective Scoring Atopic Dermatitis; and weak to moderate correlations with Patient Oriented Eczema Measure, numeric rating scale worst itch and average itch, and Scoring Atopic Dermatitis. The Dermatology Life Quality Index (DLQI) had stronger correlations with Patient Oriented Eczema Measure, Patient-Oriented Scoring Atopic Dermatitis, numeric rating scale worst itch and average itch, Eczema Area and Severity Index, and Scoring Atopic Dermatitis, but weaker correlations with Patient-Health Questionnaire-9 and Patient-Reported Outcomes Measurement Information System sleep disturbance and related impairment (convergent/divergent validity). PGH and DLQI scores had similarly poor ability to differentiate between levels of self-reported global atopic dermatitis severity (known-groups validity). No floor or ceiling effects were observed. No PGH or DLQI items had differential item functioning by demographics. PGH and DLQI scores showed fair to good responsiveness. Finally, PGH and DLQI showed similarly good test-retest reliability. LIMITATIONS: Single-center study. CONCLUSION: PGH scores had sufficient validity and reliability to assess health-related quality of life in atopic dermatitis.

Comparison of Patient-Oriented Eczema Measure and Patient-Oriented Scoring Atopic Dermatitis vs Eczema Area and Severity Index and other measures of atopic dermatitis: A validation study.

BACKGROUND: Little is known about the measurement properties of Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD) in adults with atopic dermatitis (AD). Even less is known about how PO-SCORAD performs compared with the Patient-Oriented Eczema Measure (POEM). OBJECTIVE: To examine the measurement properties of PO-SCORAD and compare them with those of POEM. METHODS: A prospective dermatology practice-based study of 291 patients with AD (age range, 18-72 years). RESULTS: PO-SCORAD and POEM were moderately correlated with each other (Spearman ρ = 0.56) and had weak-moderate correlations with the Numeric Rating Scale (NRS) worst itch and average itch, Dermatology Life Quality Index (DLQI), ItchyQOL, Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance (SD) and Sleep-Related Impairment (SRI), Patient Health Questionnaire-9 (PHQ-9), and Eczema Area and Severity Index (EASI) (P < .001). POEM had significantly stronger correlations with DLQI, ItchyQOL, and EASI than did PO-SCORAD. PO-SCORAD and POEM had fair discriminant validity. Changes from baseline in PO-SCORAD and POEM were moderately correlated with each other; were weakly to strongly correlated with NRS worst itch and average itch, DLQI, ItchyQOL, PROMIS SD, PROMIS SRI, PHQ-9, and EASI; and had good test-retest reliability. There was no differential item functioning of items or floor or ceiling effects for PO-SCORAD or POEM. The thresholds for meaningful change for PO-SCORAD and POEM were -15.5 and -5.0, respectively. Median completion times for PO-SCORAD and POEM were 3 minutes and 1 minute, respectively. CONCLUSION: PO-SCORAD and POEM had good construct and cross-cultural validity, reliability, and responsiveness in adults with AD and were feasible for use in clinical trials and practice. However, POEM had better measurement properties than PO-SCORAD.

Association of itch triggers with atopic dermatitis severity and course in adults.

BACKGROUND: Atopic dermatitis (AD) is associated with heterogeneous triggers of itch, which may affect AD course and severity. OBJECTIVE: To characterize the triggers of itch in adult AD. METHODS: This was a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 587). Thirteen itch triggers were assessed using the patient-reported outcomes measurement information system Itch-Triggers. RESULTS: Overall, 381 (64.9%) patients reported greater than or equal to 1 itch trigger in the past week and 212 (36.1%) reported greater than or equal to 3 itch triggers. The most commonly reported triggers were stress (35.4%), sweat (30.5%), weather change (24.7%), dry air (24.4%), and heat (24.0%). In multivariable Poisson regression models, the number of itch triggers was associated with more severe patient-reported global AD severity, Numeric Rating Scale worst itch, Patient-Oriented Eczema Measure, Scoring Atopic Dermatitis sleep, Numeric Rating Scale skin pain, Eczema Area and Severity Index, and objective Scoring Atopic Dermatitis. The seasonality of AD was associated with distinct itch triggers. In multivariable logistic regression models, the number of itch triggers was associated with less than or equal to 3 months of AD remission during the year, greater than or equal to 2 AD flares, and AD being worse during some seasons. Four patterns of itch triggers were identified using latent class analysis, each associated with different clinical characteristics. CONCLUSION: Itch triggers are common and affect the course of AD. Itch triggers are an important end point to assess in patients with AD.

Validation of four single-item patient-reported assessments of sleep in adult atopic dermatitis patients.

BACKGROUND: The optimal approaches for monitoring sleep disturbances in adults with atopic dermatitis (AD) is not established. Multiple patient-reported outcome measures for AD and itch have sleep-related items. These items have not been validated previously. OBJECTIVE: Assess the measurement properties of sleep-related items from the Patient-Oriented Eczema Measure (POEM), SCORing AD (SCORAD), 5-dimensions of itch (5D), and ItchyQOL in adults with AD. METHODS: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 115). RESULTS: There was modest overlap and weak-moderate concordance of responses to the different assessments. Regarding concurrent validity, POEM-sleep, SCORAD-sleep, 5D-sleep, and ItchyQOL-sleep showed moderate correlations with each other. Regarding convergent validity, all items showed moderate correlation with total POEM, but weak correlations with Eczema Area and Severity Index (EASI), objective and total SCORAD, moderate to strong correlations with mean ItchyQOL and Dermatology Life Quality Index (DLQI), but poor or no significant correlation with Numeric Rating Scale (NRS) for worst or average itch. Regarding discriminant validity, all items showed significant and stepwise increases with increasing self-reported and physician-reported AD severity (Kruskal-Wallis, P < .01 for all). Floor effects were observed for POEM-sleep (n = 53, 46.1%), SCORAD-sleep (n = 28, 24.4%), 5D-sleep (n = 41, 35.7%), and ItchyQOL-sleep (n = 33, 28.7%); no ceiling effects were observed. Change in sleep-related item scores showed moderate strong correlations with change in POEM, 5Ditch, mean ItchyQOL, DLQI, objective and total SCORAD, and EASI, but inconsistent correlations with change of itch severity. CONCLUSION: Sleep-related items from POEM, SCORAD, 5D and ItchyQOL showed good validity and responsiveness to monitor sleep disturbances in adult AD patients.

Association of atopic dermatitis severity with cognitive function in adults.

BACKGROUND: Atopic dermatitis (AD) is associated with itch, pain, and sleep disturbance, all of which may contribute toward cognitive dysfunction. OBJECTIVE: To determine the relationship of AD severity and cognitive function in adults. METHODS: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 386). Cognitive function was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function 8-item Short-Form. RESULTS: At baseline, 118 patients (58.1%) reported ≥1 symptoms of cognitive dysfunction in the past 4 weeks, with 29 (14.3%) having mild, 11 (5.4%) moderate, and 4 (2.0%) severe PROMIS Cognitive Function T-scores. In propensity score-weighted regression models, PROMIS Cognitive Function T-scores were inversely associated with patient-reported global AD severity, Patient Oriented Eczema Measure (POEM), Numeric Rating Scale worst itch and skin pain, SCORing Atopic Dermatitis (SCORAD)-sleep, POEM-sleep, Eczema Area and Severity Index, and SCORAD, with stepwise decreases of cognitive function with worsening AD severity. At all AD severity levels, cognitive dysfunction was associated with increased Dermatology Life Quality Index and ItchyQoL scores. Changes from baseline in PROMIS Cognitive Function T-scores were weakly to moderately inversely correlated with changes from baseline in multiple AD outcomes. LIMITATIONS: Single-center study without non-AD controls. CONCLUSION: Cognitive dysfunction is associated with AD severity. Cognitive function may be an important end point for monitoring treatment response in AD.

Measurement properties of the Patient-Reported Outcomes Measurement Information System Itch Questionnaire item banks in adults with atopic dermatitis.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) Itch Questionnaire (PIQ) was recently developed. OBJECTIVE: To validate PIQ short forms in adults with AD. METHODS: Self-administered questionnaires and skin examinations were performed in 239 adults with atopic dermatitis (AD) in a dermatology practice setting. RESULTS: PIQ items had good content validity. PIQ item bank T-scores strongly correlated with each other, moderately correlated with numeric and verbal rating scales for worst or average itch and with itch frequency, moderately to strongly correlated with patient-oriented eczema measure, and weakly to moderately correlated with the Eczema Area and Severity Index and Objective-Scoring AD (Spearman correlations, P < .0001). There were significant and stepwise increases of T-scores for all item banks with increasing patient-reported global severity (Wilcoxon rank sum test, P < .0001). However, there was limited ability to discriminate between the lowest or highest 2 levels of AD or itch severity. Item banks showed good internal consistency (Cronbach α, 0.91-0.95). No differential item functioning was identified by age, sex, race/ethnicity, or educational level. There were floor effects for total scores, particularly in almost clear/mild AD or itch. LIMITATIONS: Single-center study. CONCLUSIONS: PIQ item bank short forms showed good content and construct validity and are feasible for potential use in clinical trials and practice.

Neuronal circuitry mechanism regulating adult quiescent neural stem-cell fate decision.

Adult neurogenesis arises from neural stem cells within specialized niches. Neuronal activity and experience, presumably acting on this local niche, regulate multiple stages of adult neurogenesis, from neural progenitor proliferation to new neuron maturation, synaptic integration and survival. It is unknown whether local neuronal circuitry has a direct impact on adult neural stem cells. Here we show that, in the adult mouse hippocampus, nestin-expressing radial glia-like quiescent neural stem cells (RGLs) respond tonically to the neurotransmitter γ-aminobutyric acid (GABA) by means of γ2-subunit-containing GABAA receptors. Clonal analysis of individual RGLs revealed a rapid exit from quiescence and enhanced symmetrical self-renewal after conditional deletion of γ2. RGLs are in close proximity to terminals expressing 67-kDa glutamic acid decarboxylase (GAD67) of parvalbumin-expressing (PV+) interneurons and respond tonically to GABA released from these neurons. Functionally, optogenetic control of the activity of dentate PV+ interneurons, but not that of somatostatin-expressing or vasoactive intestinal polypeptide (VIP)-expressing interneurons, can dictate the RGL choice between quiescence and activation. Furthermore, PV+ interneuron activation restores RGL quiescence after social isolation, an experience that induces RGL activation and symmetrical division. Our study identifies a niche cell­signal­receptor trio and a local circuitry mechanism that control the activation and self-renewal mode of quiescent adult neural stem cells in response to neuronal activity and experience.

Burden of skin pain in atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is associated with itch, skin inflammation and barrier disruption, and scratching, all of which may be associated with skin pain. OBJECTIVE: To characterize the patient burden of skin pain in AD. METHODS: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist. RESULTS: Overall, 305 patients (age range, 13-97 years) were included in the study, with 564 encounters. The cohort included 195 females (63.9%) and 193 whites (63.7%). The mean (SD) age at enrollment was 42.3 (18.1) years, and the mean (SD) age of patient-reported AD onset was 29.6 (31.9) years. At baseline, 144 patients (42.7%) reported skin pain in the past week, with 42 (13.8%) reporting severe or very severe pain. Twenty-four (16.8%) thought the skin pain was part of their itch, 16 (11.2%) from scratching, and 77 (72.0%) from both. Patients with skin pain were more likely to describe their itch using terms that resembled neuropathic pain. Prevalence of skin pain was increased in patients with vs without excoriations (72.6% vs 57.6%; χ2 test P = .02) but not other morphologic characteristics. Skin pain severity was most strongly correlated with the Patient-Oriented Eczema Measure (Spearman ρ = 0.54), followed by ItchyQOL (ρ = 0.52), 5-dimensions of itch scale (ρ = 0.47), Dermatology Life Quality Index (ρ = 0.45), numeric rating scale for itch (ρ = 0.43) and sleep (ρ = 0.36), Patient Health Questionnaire 9 (ρ = 0.36), patient-reported global AD severity (ρ = 0.34), Eczema Area and Severity Index (ρ = 0.23), and objective Scoring AD index (ρ = 0.20) (P < .001 for all). Patients with both severe itch and pain vs those with only one or neither symptom being severe had significant increases in all these measures. CONCLUSION: Skin pain is a common and burdensome symptom in AD. Skin pain severity should be assessed with itch severity in AD patients and may be an important end point for monitoring treatment response.

Prevalence, comorbidities and mortality of toxic shock syndrome in children and adults in the USA.

Toxic Shock Syndrome (TSS), a superantigen-mediated illness, is characterized by rash, hypotension and multi-organ dysfunction. Predictors of TSS and related morbidity and mortality are poorly defined. In this study, data on 61,959,084 hospitalizations from the 2003-2012 Nationwide Inpatient Sample, a 20% stratified sample of US hospitalizations, were analyzed and ICD-9-CM coding used to identify 4491 hospitalizations with a diagnosis of TSS. Incidence, in-hospital mortality rate, comorbidities, length of stay and costs of care attributable to TSS were determined. In multivariate survey logistic regression models, TSS was associated with female sex (adjusted odds ratio [95% confidence interval], 1.54 [1.48-1.60]), younger age (0-17 years, 2.17 [2.06-2.29]; 40-59: 0.53 [0.50-0.56]; 60-79: 0.28 [0.26-0.30]; 80+: 0.13 [0.11-0.14] compared with 18-39) and race/ethnicity (black, 0.63 [0.59-0.67]; Hispanic: 0.60 [0.56-0.64]; Asian, 1.11 [1.00-1.11]; and other, 0.83 [0.75-0.92] compared with white). Patients with TSS had a three-fold greater cost of care (mean: $36,656 ± 942) and length of stay (LOS) (mean: 10.65 ± 0.23 days) than patients without TSS. Shared predictors of increased LOS and costs in patients with TSS were male sex; age 40-79 years; Black, Hispanic, Asian and other race/ethnicity; and more than one chronic condition. Predictors of in-hospital mortality included respiratory failure (13.66 [11.37-16.43]), liver disease/failure (3.36 [2.59-4.34]), chickenpox (91.26 [27.74-300.25]), coagulopathy (2.14 [1.85-2.48]), and higher age. In conclusion, there are significant racial/ethnic, socioeconomic, and comorbid disparities in the incidence and mortality of TSS in adults and children in the USA.

Pediatric Stevens-Johnson syndrome and toxic epidermal necrolysis in the United States.

BACKGROUND: Little is known about the epidemiology of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in children. OBJECTIVE: We sought to determine the morbidity, mortality, and comorbid health conditions of SJS and TEN in US children. METHODS: This was a cross-sectional study of the 2009 to 2012 Nationwide Inpatient Sample, which contains a representative 20% sample of all US hospitalizations. Sociodemographics, inflation-adjusted cost, length of stay, comorbidities, and mortality were analyzed using descriptive statistics and multivariate regression analyses. RESULTS: The incidences of SJS, SJS-TEN, and TEN were a mean 5.3, 0.8, and 0.4 cases per million children per year in the US, respectively. Prolonged length of stay and higher costs of care (SJS: 9.4 ± 0.6 days, $24,947 ± $3171; SJS-TEN: 15.7 ± 1.5 days, $63,787 ± $8014; TEN: 20.4 ± 6.3 days, $102,243 ± $37,588) were observed compared with all other admissions (4.6 ± 0.1 days, $10,496 ± $424). Mortality was 0% for SJS, 4% for SJS-TEN, and 16% for TEN. In regression models, predictors of mortality included renal failure (adjusted OR [aOR] 300.28, 95% confidence interval [CI] 48.59->999.99), malignancy (aOR 54.33, 95% CI 9.40-314.22), septicemia (aOR 30.45, 95% CI 7.91-117.19), bacterial infection (aOR 20.38, 95% CI 5.44-76.36), and epilepsy (aOR 5.56, 95% CI 1.37-26.2). LIMITATIONS: Data regarding treatment were not available. Date of diagnosis of comorbidities was not present, precluding temporal analysis. CONCLUSIONS: Pediatric SJS/TEN poses a substantial health burden in the United States.

Association of pemphigus and systemic corticosteroid use with comorbid health disorders: A case-control study.

BACKGROUND: Pemphigus is a group of debilitating autoimmune blistering disorders associated with painful blisters of the skin and/or mucous membranes. Identification and management of the comorbiditiesof pemphigus is critically important to minimize morbidity and decrease mortality. OBJECTIVE: To identify the comorbid health conditions of pemphigus vulgaris. METHODS: This was a case-control study of 130 cases of pemphigus verified by a clinical and laboratory diagnosis and 390 age and sex-matched controls with complete follow-up at a large metropolitanquaternary care medical center. RESULTS: Pemphigus vulgaris and its treatments were significantly associated with type 2 diabetes mellitus (adjusted odds ratio [95% confidence interval]: 5.68 [2.93-11.02]), hypertension (2.15 [1.25-3.71]), osteopenia (10.07 [3.72-27.25]), osteoporosis (4.19 [1.50-11.73]), cataracts (7.00 [1.81-27.07]), insomnia (15.00 [1.75-128.39]), and benign prostatic hyperplasia (6.84 [1.79-26.18]). A history of taking systemic corticosteroids was found in 76% of pemphigus vulgaris patients. There were significant statistical interactions between pemphigus vulgaris and a history of using systemic corticosteroids as predictors of diabetes mellitus type 2, hypertension, osteoporosis, and insomnia. CONCLUSIONS: Safer and more effective systemic treatment options are needed for pemphigus to minimize iatrogenic complications of disease.

Serious infections in hospitalized patients with psoriasis in the United States.

BACKGROUND: Patients with psoriasis have multiple risk factors for serious infections, including immune dysregulation, systemic immunosuppressive medications, and comorbid health conditions. OBJECTIVE: We sought to determine rates and predictors of serious infections in hospitalized psoriasis patients and quantify costs of care, length of stay, and mortality. METHODS: We conducted a cross-sectional study of the Nationwide Inpatient Sample from 2002 to 2012, containing a representative 20% sample of all hospitalizations in the United States. RESULTS: In multivariate logistic regression models, psoriasis was associated with multiple serious infections, including methicillin-resistant Staphylococcus aureus (odds ratio [OR] 1.76, 95% confidence intervals [CI] 1.52-2.03), cellulitis (OR 3.21, 95% CI 3.12-3.30), herpes simplex virus infection (OR 2.21, 95% CI 1.70-2.89), infectious arthritis (OR 1.82, 95% CI 1.58-2.09), osteomyelitis (OR 1.31, 95% CI 1.18-1.46), meningitis (OR 1.31, 95% CI 1.16-1.47), encephalitis (OR 1.22, 95% CI 1.02-1.47), and tuberculosis (OR 1.34, 95% CI 1.20-1.49). Among patients with psoriasis, rates of serious infections increased over all time intervals analyzed (P = .01) and were significantly higher compared with those without psoriasis across all time intervals (P < .0001). The mean length of stay (6.6 ± 0.1 days) and cost of care ($13,291 ± $166) for psoriasis patients with serious infections was higher than that of psoriasis patients without serious infections (4.6 ± 0.03 days; $11,003 ± $96; P < .0001). LIMITATIONS: The study was limited to inpatients. Medication data were not available. CONCLUSION: Serious infections are increasing in incidence in US inpatients with psoriasis.

The inpatient burden of psoriasis in the United States.

BACKGROUND: Although psoriasis has been linked to increased inpatient cardiovascular mortality, little is known about hospitalization for psoriasis and its inpatient burden in the United States in terms of frequency and cost. OBJECTIVE: We sought to determine risk factors for hospitalization for psoriasis and quantify cost of care, length of stay, and in-hospital mortality. METHODS: We conducted a cross-sectional study of the Nationwide Inpatient Sample from 2002 to 2012, containing a representative 20% sample of all US hospitalizations. RESULTS: Hospitalization for psoriasis was associated with nonwhite race (Asian odds ratio [OR] 2.08, 95% confidence interval [CI] 1.55-2.78; black OR 1.65, 95% CI 1.43-1.89; and multiracial/other OR 1.54, 95% CI 1.13-2.11) and insurance status (Medicare OR 1.33, 95% CI 1.26-1.40; Medicaid OR 1.32, 95% CI 1.25-1.40; and uninsured OR 1.94, 95% CI 1.64-2.30). Mean cost of care was lower for a primary diagnosis of psoriasis in comparison with patients without psoriasis ($7433 ± $254 vs $9956 ± $76; P = .002). Length of stay was significantly prolonged for patients with a primary diagnosis of psoriasis compared with no psoriasis (5.4 ± 0.2 vs 4.6 ± 0.02 days; P < .0001). Mean adjusted in-hospital mortality was 0.4% and 1.8% for a primary or no diagnosis of psoriasis, respectively. LIMITATIONS: We were unable to look at medication usage and its impact on hospitalization. Information regarding the severity of psoriasis and how this may have affected in-hospital procedures was not available. CONCLUSION: There are racial and health care disparities in hospitalization for psoriasis, stressing the need for improved access to dermatologic care for all patients.

An update on venom allergy.

PURPOSE OF REVIEW: Allergic reactions to stinging insects may be unexpected, frightening, and severe. A clear understanding of recent advances in the field facilitates appropriate care of children who experience severe reactions to hymenoptera stings. RECENT FINDINGS: Recent investigations have underscored the importance of appropriate patient selection for potentially life-saving venom immunotherapy. Venom immunotherapy is effective in preventing future anaphylaxis from hymenoptera stings. Immunotherapy is indicated for patients with a history of anaphylaxis. Children who develop large local swelling or strictly cutaneous systemic reactions generally do not require immunotherapy. Component resolved diagnostic testing has been investigated to clarify the possibility of multiple venom allergies in patients with sensitization to multiple venoms. SUMMARY: Rapid recognition and treatment of anaphylaxis are critical. Subsequent education about avoiding future stings and attention to emergency preparedness with appropriate prescription of self-injectable epinephrine is important. Referral of patients who have experienced venom-associated anaphylaxis for possible venom immunotherapy can prevent future severe episodes of anaphylaxis resulting from stings.

An update on hereditary angioedema.

PURPOSE OF REVIEW: To review and update the management and understanding of hereditary angioedema (HAE), while integrating insights into pediatric subtleties that exist in practice. RECENT FINDINGS: Major advances have recently been made in HAE treatment. Ecallantide (a kallikrein inhibitor approved for use in the United States in December 2009) and icatibant (a selective bradykinin B2 receptor antagonist approved for use in the United States in August 2011) represent novel subcutaneous therapies for acute HAE exacerbations. Recombinant human C1 esterase inhibitor (C1INH) serves as a promising future alternative to current mainstay acute and prophylactic treatment with plasma-derived C1INH. Recent guidelines have outlined new algorithms for short-term and long-term prophylaxis against HAE exacerbations. SUMMARY: The evolving standard of care for HAE management involves not only treatment of acute exacerbations but also individualized patient preference-sensitive short-term and long-term prophylaxis. Updated international consensus guidelines provide useful protocols, whereas recent clinical reviews have raised awareness of HAE. Further advances will likely focus on improving patient access to convenient acute and prophylactic treatment with C1INH.