Successful use of telemedicine for evaluation of infantile hemangiomas during the early COVID-19 pandemic: A cross-sectional study.

BACKGROUND/OBJECTIVES: The COVID-19 pandemic prompted a rapid expansion in the use of telemedicine. This study aimed to assess the experiences of hemangioma specialists utilizing telemedicine during the COVID-19 pandemic to evaluate and manage infantile hemangiomas (IH), including perceived effectiveness of different modalities and barriers to care delivery. METHODS: Multicenter cross-sectional study asking providers to describe their experiences using telemedicine for initial evaluation of IH from March to September 2020. RESULTS: The study included 281 patients from 15 medical centers internationally. Median time from referral to evaluation was 17 days. Median physician confidence in performing evaluations via telemedicine was 95.0 (IQR 90.0-100.0). Most evaluations were performed via video communication with photographs or audio communication with photographs; when not initially available, photographs were requested in 51.4%. Providers preferred follow-up modalities that included photographs. CONCLUSIONS: Physicians with extensive expertise in managing IH are confident in their abilities to assess and manage IH via telemedicine including initiating treatment in patients without risk factors for beta-blocker therapy. There was a preference for hybrid modalities that included photographs. The data suggest that telemedicine can be effective for managing IH and may decrease wait times and improve specialist reach to underserved areas.

Higher rates of skin clearance and efficacy in challenging body areas are associated with better health-related quality of life following ixekizumab maintenance treatment in pediatric patients with plaque psoriasis.

BACKGROUND/OBJECTIVES: Information is limited on the relationship between skin clearance, resolution of challenging body areas, and improvement of patient-reported outcomes (PROs) in pediatric psoriasis. Ixekizumab, a high-affinity monoclonal antibody that selectively targets interleukin-17A, is approved for the treatment of moderate-to-severe psoriasis in patients aged 6 to <18 years. This study examines improvement in psoriasis clearance in challenging body areas in pediatric patients relative to health-related quality of life. METHODS: Data from the IXORA-PEDS trial (NCT03073200) were analyzed, and changes from baseline were measured for overall Psoriasis Area and Severity Index (PASI), static Physicians' Global Assessment of psoriasis (sPGA), Psoriasis Scalp Severity Index (PSSI), Palmoplantar Psoriasis Area and Severity Index (PPASI), and Nail Psoriasis Severity Index. Rates of Dermatology Life Quality Index (DLQI), or Children's DLQI (CDLQI), scores of 0 or 1 were evaluated using the Cochran-Armitage trend test. RESULTS: Higher rates of DLQI/CDLQI (0,1) scores were significantly associated with greater PASI and PSSI responses at both Week 12 and Week 48 (p < .0001). A significant association was also observed between DLQI/CDLQI (0,1) and sPGA scores (p < .0001). Significantly higher rates of DLQI/CDLQI (0,1) scores were achieved in patients with greater levels of palmoplantar clearance as measured by PPASI at Week 12 (p = .0139), but significance was not sustained at Week 48 (p = .0896). CONCLUSIONS: Greater skin clearance and scalp resolution are associated with better PROs over a short-term (12-week) and long-term (48-week) period. This demonstrates that greater improvement of skin clearance and scalp resolution may benefit quality of life in pediatric patients with psoriasis.

Pharmacokinetics and safety of apremilast in pediatric patients with moderate to severe plaque psoriasis: Results from a phase 2 open-label study.

BACKGROUND: No oral systemic treatments are approved for pediatric patients with psoriasis. OBJECTIVE: To evaluate the pharmacokinetics and safety of apremilast, an oral phosphodiesterase 4 inhibitor, in pediatric patients with psoriasis. METHODS: This phase 2, multicenter, open-label study enrolled pediatric patients with moderate to severe plaque psoriasis. Patients received apremilast twice daily without titration for 2 weeks (group 1 [age, 12-17 years; weight, ≥35 kg]: apremilast 20 or 30 mg; group 2 [age, 6-11 years; weight, ≥15 kg]: apremilast 20 mg), followed by a 48-week extension. Primary endpoints were pharmacokinetics and safety. Other endpoints were taste/acceptability and change from baseline in score on the Psoriasis Area and Severity Index. RESULTS: A total of 42 enrolled patients (21 adolescents [age, 12-17 years] and 21 children [age, 6-11 years]) received apremilast. Pharmacokinetics modeling and noncompartmental analyses showed that weight-based dosing with apremilast 20 mg twice daily in children or apremilast 20 or 30 mg twice daily in adolescents provides exposure (area under the concentration-time curve from time 0 to 12 hours after the dose) that is comparable to that achieved with apremilast 30 mg twice daily in adults. The safety profile was generally similar to that in adults. Most study participants liked the taste of the tablet. Improvements from baseline in mean Psoriasis Area and Severity Index score were 68% for adolescents (overall) and 79% for children. LIMITATIONS: No children weighing less than 20 kg were enrolled. CONCLUSIONS: This first-time-in-children phase 2 study supports weight-based apremilast dosing for future phase 3 studies of pediatric plaque psoriasis.

Reliability, Validity, and Factor Structure of the Current Assessment Practice Evaluation-Revised (CAPER) in a National Sample.

Measurement-based care (MBC) is an increasingly popular, evidence-based practice, but there are no tools with established psychometrics to evaluate clinician use of MBC practices in mental health service delivery. The current study evaluated the reliability, validity, and factor structure of scores generated from a brief, standardized tool to measure MBC practices, the Current Assessment Practice Evaluation-Revised (CAPER). Survey data from a national sample of 479 mental health clinicians were used to conduct exploratory and confirmatory factor analyses, as well as reliability and validity analyses (e.g., relationships between CAPER subscales and clinician MBC attitudes). Analyses revealed competing two- and three-factor models. Regardless of the model used, scores from CAPER subscales demonstrated good reliability and convergent and divergent validity with MBC attitudes in the expected directions. The CAPER appears to be a psychometrically sound tool for assessing clinician MBC practices. Future directions for development and application of the tool are discussed.

East Indian Sandalwood Oil Is a Phosphodiesterase Inhibitor: A New Therapeutic Option in the Treatment of Inflammatory Skin Disease.

Cyclic adenosine monophosphate phosphodiesterases (PDEs) regulate pro-inflammatory cytokine production. One isoform, PDE4, is overactive in chronic relapsing inflammatory skin diseases: psoriasis and eczema/atopic dermatitis, and in several cancers. East Indian sandalwood oil (EISO) has significant anti-inflammatory properties. Here, we report that 75% of pediatric eczema/atopic dermatitis patients treated with topical EISO formulations achieved a >50% reduction in their Eczema Area and Severity Index score. EISO treatment of a psoriasis model reduced PDE4 expression and reversed histopathology. EISO directly inhibited PDE enzymatic activity in vitro. In lipopolysaccharide-stimulated human dermal fibroblast, BEAS-2B, A549, and THP-1 cells, EISO suppressed total cellular PDE activity, PDE4, and 7 transcript levels, nuclear factor kappa B (NF-κB) activation, and pro-inflammatory cytokines/chemokine production. These results suggest that EISO anti-inflammatory activity is mediated through suppressing PDE activity, thus facilitating cAMP-regulated inhibition of NF-κB and indicate EISO as an attractive natural therapeutic for chronic and acute inflammatory disorders.

All anxiety is not created equal: Correlates of parent/youth agreement vary across subtypes of anxiety.

Research has examined patterns and correlates of parent/youth informant discrepancies in the reporting of youth anxiety. However, little work has examined whether it is better to conceptualize patterns and correlates of informant disagreement across anxiety broadly, or more useful to consider disagreement on specific symptom clusters. Using data from the Child Adolescent/Anxiety Multimodal Study (CAMS; N = 488; Walkup et al., 2008), the current study applied the most recent recommended analytic strategies to study informant discrepancies and examined differences in the magnitude and patterns of disagreement for: (a) broadband anxiety symptoms, versus (b) symptoms of specific anxiety diagnoses (or anxiety subtypes; e.g., separation, social anxiety). Correlates of informant discrepancies were also examined. Results indicated that there was variability in agreement across anxiety subtypes, with parent/youth agreement higher on separation anxiety and school refusal symptoms relative to other domains. Parental psychopathology was associated with disagreement on broadband anxiety symptoms, such that parental psychopathology was highest when parents reported higher symptoms than their children; however, this finding was largely driven by a relationship between parental psychopathology and disagreement on separation anxiety symptoms. Age was associated with disagreement on total and separation anxiety symptoms. Gender was not associated with disagreement. Clinical implications are discussed.

Anxiety Disorders in Caucasian and African American Children: A Comparison of Clinical Characteristics, Treatment Process Variables, and Treatment Outcomes.

This study examined racial differences in anxious youth using data from the Child/Adolescent Anxiety Multimodal Study (CAMS) [1]. Specifically, the study aims addressed whether African American (n = 44) versus Caucasian (n = 359) children varied on (1) baseline clinical characteristics, (2) treatment process variables, and (3) treatment outcomes. Participants were ages 7-17 and met DSM-IV-TR criteria for generalized anxiety disorder, social phobia, and/or separation anxiety disorder. Baseline data, as well as outcome data at 12 and 24 weeks, were obtained by independent evaluators. Weekly treatment process variables were collected by therapists. Results indicated no racial differences on baseline clinical characteristics. However, African American participants attended fewer psychotherapy and pharmacotherapy sessions, and were rated by therapists as less involved and compliant, in addition to showing lower mastery of CBT. Once these and other demographic factors were accounted for, race was not a significant predictor of response, remission, or relapse. Implications of these findings suggest African American and Caucasian youth are more similar than different with respect to the manifestations of anxiety and differences in outcomes are likely due to treatment barriers to session attendance and therapist engagement.

Naturalistic follow-up of youths treated for pediatric anxiety disorders.

IMPORTANCE: Pediatric anxiety disorders are highly prevalent and impairing and are considered gateway disorders in that they predict adult psychiatric problems. Although they can be effectively treated in the short term, data are limited on the long-term outcomes in treated children and adolescents, particularly those treated with medication. OBJECTIVE: To determine whether acute clinical improvement and treatment type (i.e., cognitive behavioral therapy, medication, or their combination) predicted remission of anxiety and improvement in global functioning at a mean of 6 years after randomization and to examine predictors of outcomes at follow-up. DESIGN, SETTING, AND PARTICIPANTS: This naturalistic follow-up study, as part of the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS), was conducted at 6 academic sites in the United States and included 288 youths (age range, 11-26 years; mean age, 17 years). Youths were randomized to 1 of 4 interventions (cognitive behavioral therapy, medication, combination, or pill placebo) in the Child/Adolescent Anxiety Multimodal Study (CAMS) and were evaluated a mean of 6 years after randomization. Participants in this study constituted 59.0% of the original CAMS sample. EXPOSURES: Participants were assessed by independent evaluators using a semistructured diagnostic interview to determine the presence of anxiety disorders, the severity of anxiety, and global functioning. Participants and their parents completed questionnaires about mental health symptoms, family functioning, life events, and mental health service use. MAIN OUTCOMES AND MEASURES: Remission, defined as the absence of all study entry anxiety disorders. RESULTS Almost half of the sample (46.5%) were in remission a mean of 6 years after randomization. Responders to acute treatment were significantly more likely to be in remission (odds ratio, 1.83; 95% CI, 1.08-3.09) and had less severe anxiety symptoms and higher functioning; the assigned treatment arm was unrelated to outcomes. Several predictors of remission and functioning were identified. CONCLUSIONS AND RELEVANCE: Youths rated as responders during the acute treatment phase of CAMS were more likely to be in remission a mean of 6 years after randomization, although the effect size was small. Relapse occurred in almost half (48%) of acute responders, suggesting the need for more intensive or continued treatment for a sizable proportion of youths with anxiety disorders. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00052078.

Therapist attitudes towards computer-based trainings.

Computer-based trainings are a promising avenue for increasing access to training in evidence-based practices. However, little is known about whether therapists are willing to use them. Results from a national survey of practicing therapists (N = 1,067) indicated that 26 % of therapists reported previously using a computer-based training and overall attitudes (as measured by the Computer-Based Training Attitudes Scale) were positive. Higher therapist computer fluency and greater openness to new treatments predicted positive attitudes. Therapists with more positive attitudes were more likely to have previously used a computer-based training. Implications are discussed.

Computer-assisted therapies: examination of therapist-level barriers to their use.

Despite enthusiasm in the field for their potential ease of dissemination, little work has examined whether practicing clinicians are willing and able to use computer-assisted therapies (i.e., computerized treatments designed to be administered with therapist support). For therapists to use these tools, they require access to computer equipment, the skills needed to use the equipment, and willingness to adopt the technology in treatment. This study examined these three factors using survey data from a national sample of mental health clinicians (N=1,067). Respondents reported on their access to technology and computer fluency, in addition to completing the Computer-Assisted Therapy Attitudes Scale (CATAS), a measure of therapist attitudes designed for this study. Overall, the majority of therapists (90.7%) reported access to at least one computer at work and self-reported computer fluency levels were high. On average, therapists held positive attitudes towards computer-assisted therapies, although expressed concern that these technologies might damage rapport and did not feel that these technologies would improve treatment outcomes. Predictors of positive attitudes included greater general openness toward new treatments, greater comfort with computers, and easier access to technology at work (all ps<.01). Results suggested that, on the whole, therapists may be likely to integrate computer-assisted therapies into their clinical practice. However, therapists vary both in their ability and willingness to use these tools. Implications for the dissemination of computer-assisted therapies are discussed.

Who's using treatment manuals? A national survey of practicing therapists.

Treatment manuals are currently the most common way treatments are disseminated to practicing clinicians, although little is known about the rates with which practicing therapists incorporate these manuals into their practice. In light of a widely acknowledged research-practice gap, understanding how often therapists are using manuals is important for shaping future dissemination efforts. This study collected data on rates of manual use among a national sample of mental health clinicians representative of those likely to be targeted in dissemination efforts (N = 756), as well as predictors of use. Results indicated that few clinicians (< 10%) routinely incorporated manuals into their practice, although most employed them to some degree. Predictors of manual use included greater openness to new treatments, younger age, and a cognitive-behavioral treatment orientation (ps < .05). Implications for future dissemination efforts are discussed.

A rare case of non-Hodgkins B-cell lymphoma in a psoriatic patient: a case report and literature review.

Cyclosporine has been shown to increase the risk of lymphoma when used in organ transplant patients; however, studies have failed to demonstrate an increased risk of lymphoma when used at lower dermatologic doses for psoriasis. The authors present a case of solid B-cell lymphoma occurring in a psoriasis patient with a history of intermittent exposure to high-dose methotrexate, followed by low-dose cyclosporine for two years and subsequently transitioned to treatment with adalimumab. Methotrexate, cyclosporine and adalimumab are each effective treatments for psoriasis. However, when faced with an interplay of several factors, closer surveillance for malignancy is warranted than that which is currently considered for monotherapy.