Influence of Anatomic Locations of T1b Melanomas and Patient Age on Outcomes.

BACKGROUND: There are no guidelines on when to more strongly recommend sentinel lymph node biopsy (SLNB) for T1b melanomas. OBJECTIVE: To examine whether anatomic locations of T1b melanomas and patient age influence metastases. METHODS: We conducted a retrospective study using data from two hospitals in Los Angeles County from January 2010 through January 2020. RESULTS: Out of 620 patients with primary melanomas, 566 melanomas were staged based on the American Joint Committee on Cancer 8th edition melanoma staging. Forty-one were T1b, of which 13 were located on the face/ear/scalp and 28 were located elsewhere. T1b melanomas located on the face/ear/scalp had an increased risk of lymph node or distant metastasis compared with other anatomic sites (31% vs 3.6%, P=0.028). For all melanomas, the risk of lymph node or distant metastasis decreased with age of 64 years or greater (P<0.001 and P=0.034). For T1b melanomas, the risk of distant metastasis increased with increasing age (P=0.047). LIMITATIONS: Data were from a single county.  Conclusion: T1b melanomas of the face/ear/scalp demonstrated a higher risk of lymph node or distant metastasis and may help guide the recommendation of SLNB, imaging, and surveillance. Younger patients may be more strongly considered for SLNB and older patients with T1b melanomas may warrant imaging.  J Drugs Dermatol. 2024;23(5):306-310. doi:10.36849/JDD.7667.

Radiofrequency and Radiofrequency Microneedling in Skin of Color: A Review of Usage, Safety, and Efficacy.

BACKGROUND: Radiofrequency (RF) and radiofrequency microneedling (RFM) for rhytides, scarring, and skin rejuvenation are believed to have a lower risk of postprocedural dyspigmentation in darker skin types. OBJECTIVE: To explore the safety and efficacy of RF and RFM in Fitzpatrick skin Types III to VI. METHODS AND MATERIALS: A systematic review of PubMed/MEDLINE databases from 2000 to 2021 using combinations of the terms radiofrequency, microneedling, skin of color, and Fitzpatrick was performed. Exclusion criteria included non-Fitzpatrick skin Types III-VI patient population, nonprimary articles, nonskin radiofrequency, and nonhuman studies. RESULTS: Thirty-five articles addressing the use of RF or RFM in skin of color were identified-22 for skin rejuvenation, 7 for acne scars, 4 for nonacne scars, 1 for hyperpigmentation, and 1 for acne treatment. Seven studies noted transient postinflammatory hyperpigmentation, 1 observed mild prolonged hyperpigmentation, and only 1 study reported permanent scarring. CONCLUSION: Radiofrequency and RFM seem to have a low risk of scarring or hyperpigmentation in skin of color. This review demonstrates that these procedures have been successfully used primarily for rhytides, acne scarring, and skin rejuvenation. However, a large proportion of the studies lack strong quality evidence.

Vitamin D Levels in Alopecia Areata and Other Alopecias: A Retrospective Case- Control Study at a Single Institution.

Recent research has associated alopecia areata (AA), an autoimmune disorder, with deficiency of Vitamin D, which regulates immune processes. This retrospective study compared Vitamin D levels in AA patients to those of other alopecia diagnoses and nonalopecia controls. When compared to controls, patients with AA or other alopecia diagnoses did not demonstrate lower Vitamin D levels. However, when compared to other alopecia diagnoses, AA patients had a statistically significantly higher proportion of patients with Vitamin D deficiency and a lower mean Vitamin D level. Our findings suggest a greater association between lower Vitamin D levels and AA compared to other alopecia diagnoses. Further prospective studies investigating Vitamin D levels and supplementation in AA patients are needed to further elucidate this association and its potential relevance.

A Rapidly Enlarging Facial Abscess.

A woman in her late 70s with a history of immunoglobulin A monoclonal gammopathy of unknown significance presents with a tender, draining lesion of the central face. What is your diagnosis?

Redundant cytokine requirement for intestinal microbiota-induced Th17 cell differentiation in draining lymph nodes.

Differentiation of intestinal T helper 17 (Th17) cells, which contribute to mucosal barrier protection from invasive pathogens, is dependent on colonization with distinct commensal bacteria. Segmented filamentous bacteria (SFB) are sufficient to support Th17 cell differentiation in mouse, but the molecular and cellular requirements for this process remain incompletely characterized. Here, we show that intestine-draining mesenteric lymph nodes (MLNs), not intestine proper, are the dominant site of SFB-induced intestinal Th17 cell differentiation. Subsequent migration of these cells to the intestinal lamina propria is dependent on their upregulation of integrin ß7. Stat3-dependent induction of RORγt, the Th17 cell-specifying transcription factor, largely depends on IL-6, but signaling through the receptors for IL-21 and IL-23 can compensate for absence of IL-6 to promote SFB-directed Th17 cell differentiation. These results indicate that redundant cytokine signals guide commensal microbe-dependent Th17 cell differentiation in the MLNs and accumulation of the cells in the lamina propria.

How Accessible Is Genital Gender-Affirming Surgery for Transgender Patients With Commercial and Public Health Insurance in the United States? Results of a Patient-Modeled Search for Services and a Survey of Providers.

INTRODUCTION: In the United States, 1.4-1.65 million people identify as transgender, many of whom will seek genital gender-affirming surgery (GAS). The number of surgeons, geographic proximity thereof, and exclusionary insurance policies has limited patient access to genital GAS. AIM: To assess the accessibility of both feminizing and masculinizing genital GAS (vaginoplasty, metoidioplasty, and phalloplasty) by identifying the location of GAS surgeons, health insurance, or payment forms accepted. METHODS: Between February and April 2018, genital GAS surgeons were identified via Google search. Surgeons' offices were contacted by telephone or e-mail. MAIN OUTCOME MEASURE: We queried the type of genital GAS performed, the health insurance or payment forms accepted, and the type of medical practice (academic, private, or group managed-care practice). RESULTS: We identified 96 surgeons across 64 individual medical centers offering genital GAS. The survey response rate was 83.3%. Only 61 of 80 (76.3%) surgeons across 38 of 53 (72%) locations confirmed offering genital GAS. Only 20 (40%) U.S. states had at least one genital GAS provider. 30 of 38 (79%) locations reported accepting any form of insurance. Only 24 of 38 (63%) locations (14 academic; 10 private/group) accepted Medicaid (P = .016); 18 of 38 (47%) locations (13 academic; 5 private/group) accepted Medicare (P = .001). CLINICAL TRANSLATION: Reconciliation of the public policies regarding insurance coverage for GAS with the actual practices of the providers is necessary for improving access to GAS for transgender individuals. STRENGTHS & LIMITATIONS: We purposefully used a methodology mirroring how a patient would find GAS surgeons, which also accounts for key limitations: only surgeons whose services were featured on the internet were identified. We could not verify the services or insurance-related information surgeons reported. CONCLUSION: This study suggests that access to genital GAS is significantly limited by the number of providers and the uneven geographic distribution across the United States, in which only 20 of 50 U.S. states have at least one genital GAS surgeon. Feldman AT, Chen A, Poudrier G, et al. How Accessible Is Genital Gender-Affirming Surgery for Transgender Patients With Commercial and Public Health Insurance in the United States? Results of a Patient-Modeled Search for Services and a Survey of Providers. Sex Med 2020;8:664-672.

Body Composition Changes During Traditional Versus Intensive Cardiac Rehabilitation in Coronary Artery Disease.

PURPOSE: Intensive cardiac rehabilitation (CR) was recently approved by Medicare and includes more hours and more focus on nutrition, stress management, and group support than a traditional, exercise-focused CR. The purpose of this study was to compare changes in body composition and cardiovascular (CV) risk factors after intensive versus traditional CR programs in patients with coronary artery disease (CAD). METHODS: We studied 715 patients with CAD who completed a traditional versus intensive CR program at UCLA Medical Center between 2014 and 2018. Markers of CV health, including body composition using bioelectrical impedance analysis, were assessed pre- and post-program participation. RESULTS: In both types of CR programs, body mass index, body fat percentage, blood pressure, and cholesterol levels (total cholesterol and low-density lipoprotein cholesterol) were significantly lower post- compared with pre-program. Exercise capacity was increased in both groups. Intensive CR patients had greater reductions in body mass index, body fat percentage, visceral adipose tissue, and diastolic blood pressure. Traditional CR patients demonstrated greater increases in high-density lipoprotein cholesterol and estimated lean mass. CONCLUSIONS: In patients with CAD, both traditional and intensive CR programs led to improvements in CV risk factors, though the magnitude of the effects of the program differed between the programs. Further studies, including studies analyzing CV outcomes, are needed to help determine optimal CR program choice for CAD patients based on their risk factor and body composition profile.

The role of biologics in the treatment of chronic granuloma annulare.

BACKGROUND: Granuloma annulare (GA), a benign inflammatory skin disease, is considered a Th1-type delayed hypersensitivity reaction. Localized GA is likely to resolve spontaneously, whereas disseminated GA (DGA) may persist for decades and can be resistant to treatment. Biologics including TNF-α inhibitors have been proposed and utilized as salvage therapy for GA and other related diseases, interstitial granulomatous dermatitis (IGD), and actinic granuloma (AG). METHODS: A systematic review was conducted using the combination of search terms "granuloma annulare," "interstitial granulomatous dermatitis," or "actinic granuloma" and either "biologics," "etanercept," "adalimumab," "infliximab," "ustekinumab," "ixekizumab," "secukinumab," "guselkumab," "golimumab," "brodalumab," "tildrakizumab," or "certolizumab" from the years 1970-2017. RESULTS: Review of the literature revealed that 79.3% of the patients with GA, IGD, or AG who had been treated with demonstrated TNF-α inhibitor therapy a clinical response. CONCLUSIONS: TNF-α inhibitor therapy has been used to treat chronic GA, IGD, and AG that involved extensive body surface areas. However, the literature is limited to case series lacking control groups. Randomized, controlled trials are required to establish evidence-based treatment of GA and related cutaneous, granulomatous conditions.

Clinical Remission of Cutaneous Squamous Cell Carcinoma of the Auricle with Cetuximab and Nivolumab.

Cutaneous squamous cell carcinomas (SCC) affecting the regions of the head and neck can be challenging to resect surgically and refractory to chemotherapy or radiation therapy. Consequently; the treatment of squamous cell carcinomas of the skin is a focus of current research. One such advancement is immunotherapy. Herein we describe clinical remission of invasive, poorly differentiated squamous cell carcinoma of the pre-auricular region with external auditory canal involvement using cetuximab, an epidermal growth factor receptor (EGFR) antibody; and nivolumab, a programmed death receptor-1 (PD-1) antibody. Such durable and comprehensive disease resolution demonstrates the therapeutic potential of cetuximab and nivolumab in surgically challenging, treatment-resistant cutaneous squamous cell carcinoma.

Unilateral absence of ascending and transverse trapezius fibers accompanied by mild thoracic scoliosis: a case report

During routine anatomical dissection at the David Geffen School of Medicine at UCLA, a variation of partial unilateral trapezius muscle absence was found in a 95-year-old Caucasian female. A broad sheet of aponeurosis originating from all thoracic vertebrae completely replaced the ascending fibers of the left inferior trapezius muscle. Transverse fibers of the left trapezius muscle appeared hypotrophied and were sparsely distributed within the aponeurosis. Descending fibers of the left trapezius muscle were comparable to the right side. The main clinical finding was a grossly visible 5-degree thoracic scoliosis toward the intact trapezius muscle. No other significant abnormalities in musculature or anatomy could be found. While others have reported on unilateral, bilateral, complete, and partial absence of trapezius muscle, to our knowledge this case is unique from those previously reported in the literature

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An IL-23R/IL-22 Circuit Regulates Epithelial Serum Amyloid A to Promote Local Effector Th17 Responses.

RORγt(+) Th17 cells are important for mucosal defenses but also contribute to autoimmune disease. They accumulate in the intestine in response to microbiota and produce IL-17 cytokines. Segmented filamentous bacteria (SFB) are Th17-inducing commensals that potentiate autoimmunity in mice. RORγt(+) T cells were induced in mesenteric lymph nodes early after SFB colonization and distributed across different segments of the gastrointestinal tract. However, robust IL-17A production was restricted to the ileum, where SFB makes direct contact with the epithelium and induces serum amyloid A proteins 1 and 2 (SAA1/2), which promote local IL-17A expression in RORγt(+) T cells. We identified an SFB-dependent role of type 3 innate lymphoid cells (ILC3), which secreted IL-22 that induced epithelial SAA production in a Stat3-dependent manner. This highlights the critical role of tissue microenvironment in activating effector functions of committed Th17 cells, which may have important implications for how these cells contribute to inflammatory disease.

Focused specificity of intestinal TH17 cells towards commensal bacterial antigens.

T-helper-17 (TH17) cells have critical roles in mucosal defence and in autoimmune disease pathogenesis. They are most abundant in the small intestine lamina propria, where their presence requires colonization of mice with microbiota. Segmented filamentous bacteria (SFB) are sufficient to induce TH17 cells and to promote TH17-dependent autoimmune disease in animal models. However, the specificity of TH17 cells, the mechanism of their induction by distinct bacteria, and the means by which they foster tissue-specific inflammation remain unknown. Here we show that the T-cell antigen receptor (TCR) repertoire of intestinal TH17 cells in SFB-colonized mice has minimal overlap with that of other intestinal CD4(+) T cells and that most TH17 cells, but not other T cells, recognize antigens encoded by SFB. T cells with antigen receptors specific for SFB-encoded peptides differentiated into RORγt-expressing TH17 cells, even if SFB-colonized mice also harboured a strong TH1 cell inducer, Listeria monocytogenes, in their intestine. The match of T-cell effector function with antigen specificity is thus determined by the type of bacteria that produce the antigen. These findings have significant implications for understanding how commensal microbiota contribute to organ-specific autoimmunity and for developing novel mucosal vaccines.