New-Onset Bullous Pemphigoid in a COVID-19 Patient.

This manuscript presents a report of bullous pemphigoid rash associated with COVID-19 for the first time. The objective of this manuscript is to present a unique dermatological case in the setting of a COVID-19-positive infection to further recognize the virus symptomatology. A 37-year-old female with a past medical history of class III obesity, type II diabetes mellitus, and hypertension presented to the emergency department in September 2020 with inpatient and outpatient follow-up through to November 2020. The patient denied any personal or family history of skin disorders. The patient tested positive for COVID-19 prior to hospitalization and presented to the hospital with severe, persistent, pruritic rash meeting dermatopathological, serologic, and clinical criteria for bullous pemphigoid diagnosis. Histopathology H&E punch biopsy from her left flexor wrist demonstrated epidermal keratinocyte necrosis, subepidermal vesiculation with eosinophils, gossamer stranding of the papillary dermis, and subepidermal edema. Direct immunofluorescence punch biopsy from her left flexor wrist demonstrated strong linear IgG staining at the dermoepidermal junction, with weaker and focal linear C3 staining. Antigen-specific serology was consistent with bullous pemphigoid. There was no previously reported cutaneous association of COVID-19 infection with bullous pemphigoid making this case an important addition to the body of evidence helping to identify bullous pemphigoid in the setting of viral infection.

Ergonomic assessment of robotic general surgeons: a pilot study.

Inadequacies exist in the ergonomics of upper body positioning of robotic surgeons; these deficits in biomechanical efficacy predispose surgeons to musculoskeletal injury. Ergonomics and biomechanics may be objectively measured using the Rapid Entire Body Assessment (REBA) and the Rapid Upper Limb Assessment (RULA) to quantify ergonomic efficacy. The purpose of this study is to use validated ergonomic tools to assess the posture of robotic surgeons to examine deficiencies. Four robotic surgeons using the da Vinci model were observed for a minimum of 30 min each. An Xbox connect camera was positioned 10 feet away from the surgeon console. Kinetisense software measured position of the head, shoulders, mid-spine, hips, and knees. One image was captured every 30 s. The software measured the positions in centimeters that deviated from an ideal central postural line (plumb line). RULA and REBA were also employed to assess posture using a still image at 15 min. The average RULA score for the four surgeons was 4.75 (range 3-6). The average REBA score for the four surgeons was 7 (range 5-8). The average RULA score of 4.5/7 and the average REBA of 7/15 qualify as medium risk with the recommendation that action is needed to improve ergonomics. While this pilot study is limited in size, it demonstrates the need for further investigation. With more than half of surgeons reporting musculoskeletal pain after robotic surgery (McDonald et al. in Gynecol Oncol 134:243-247, 2014), poor posture may offer an explanation.