The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations.

Disparities in environmental and social determinants of health (DOH) are associated with morbidity in atopic dermatitis (AD). The socioecological model (SEM) is a framework that can be applied to better understand how such DOH impacts patients with AD. We include a case scenario of a remote Indigenous patient reflective of real-world situations of living with AD and examine relevant impact, gaps in knowledge, and further research needs. This review highlights a variety of social and environmental exposures as important DOH which must be addressed to achieve optimal management in AD. The "rainbow model" is a modified framework to help illustrate how complex environmental and social forces impact both AD presentation and therapeutic success. However, practical applications and outcome metrics for health promotion are limited. An inter- and transdisciplinary approach is paramount to address the complex challenges associated with AD care, as well as multistakeholder approach integrating culturally-competent equitable health frameworks. This review underscores the importance of expanding the focus of AD management beyond basic science and clinical trials to recognize and address health disparities and to promote optimal health and well-being in patients with AD, and contributes a working approach to mapping the complex interventions and patient-oriented research needed using a focus on remote North American Indigenous patients affected by AD.

An atypical presentation of extensive centrofacial microcystic adnexal carcinoma responding to radiation: A case report and review of the literature.

Microcystic adnexal carcinoma is a rare cutaneous neoplasm believed to arise from pluripotent keratinocytes capable of adnexal differentiation. Due to its insidious growth and appearance, diagnosis is often delayed. A deep incisional or excisional biopsy for histopathology is the gold standard for diagnosis. Different treatment modalities have been described in the literature, including the Mohs micrographic surgery, standard excision, radiation, chemotherapy, and observation. Currently, Mohs remains the treatment of choice. We present a unique case of a 12-month history of an extensive progressive centrofacial cutaneous induration diagnosed as microcystic adnexal carcinoma in an 83-year-old female. Due to the extensive nature of the tumor, she received radiation therapy and continues to receive ongoing assessment with no evidence of clinical recurrence at 2-year post-treatment including negative scouting biopsies. To date, there is no consensus on the optimal treatment for microcystic adnexal carcinoma.

Trichoblastomas Mimicking Basal Cell Carcinoma: The Importance of Identification and Differentiation.

Trichoblastoma is a rare, slow-growing, benign cutaneous tumor derived from follicular germinative cells. Trichoblastoma commonly appears as an asymptomatic, symmetrical, well-circumscribed, skin-colored to brown or blue-black papule or nodule. It may appear clinically and histologically similar to basal cell carcinoma, making its diagnosis challenging. Even on dermoscopy, it is challenging to differentiate trichoblastoma from basal cell carcinoma. In practice, it is important to differentiate the two, because the choice of treatment and resulting prognosis differ between the lesions. Surgical biopsy to analyze histopathological and immunohistochemical differences is the gold standard for diagnosing and differentiating trichoblastoma from basal cell carcinoma. Trichoblastoma typically has a favorable prognosis, with a low incidence of recurrence, progression or association with malignancy. This paper provides a review of the epidemiology, clinical presentation, dermoscopy, histology, immunochemistry, treatment, and prognosis of trichoblastoma.

Toluene Toxicity: A Case Report of Transdermal Exposure Causing Hypokalemic Paralysis.

RATIONALE: Hypokalemia is a common finding. Typically asymptomatic presentations of neuromuscular weakness emerge at levels below 2.5 mmol/L. Causes include gastrointestinal losses, renal losses, or intracellular shift, with gastrointestinal losses and diuretics accounting for the majority. Although the cause is often apparent on clinical assessment, a systematic approach incorporating urine biochemistry can aid in narrowing the differential in obscure cases. PRESENTATION: We describe a case of a previously healthy 27-year-old man who presented with acute ascending paralysis, with an associated severe hypokalemia and metabolic acidosis. There were no apparent causes on clinical assessment. DIAGNOSIS: Based on analysis of urine biochemistry, we concluded that a pathologic kaluresis was present, and given his acidemia and transient pathology, we diagnosed the patient with hypokalemic paralysis secondary to toluene toxicity. INTERVENTIONS: We provided supportive care and electrolyte repletion for our patient; no specific therapies for toluene were required. Our patient was counseled regarding appropriate protective measures when handling toluene. OUTCOMES: Complete neurologic recovery and biochemical normalization occurred within 48 hours of presentation with supportive care. He continued to use proper precautions when handling toluene, and experienced no symptom relapse, or further abnormalities on both blood and urine chemistry. LESSONS LEARNED: Using this case, we review an algorithmic approach incorporating urine biochemistries to aid in the workup of hypokalemia. We review toluene as a toxicologic entity and highlight its role as a cause of hypokalemia.

JUSTIFICATION: L'hypokaliémie est fréquente et généralement asymptomatique. Les symptômes de faiblesse neuromusculaire se manifestent à des concentrations inférieures à 2,5 mmol/L. Les pertes de potassium au niveau gastro-intestinal ou rénal et les déplacements intracellulaires sont parmi les causes; les pertes gastro-intestinales et les diurétiques constituant les principales causes. Bien que l'étiologie soit souvent apparente à l'évaluation clinique, une approche systématique intégrant la biochimie de l'urine pourrait aider à réduire le diagnostic différentiel dans les cas plus incertains. PRÉSENTATION DU CAS: Nous discutons du cas d'un homme de 27 ans précédemment en bonne santé qui présentait une paralysie ascendante aigüe associée à une grave hypokaliémie et à une acidose métabolique. Aucune étiologie n'était apparente lors de l'évaluation clinique. DIAGNOSTIC: L'analyse biochimique de l'urine a permis de confirmer la présence d'une kaliurèse pathologique et, compte tenu de l'acidémie et de la pathologie transitoire, de diagnostiquer une paralysie hypokaliémique consécutive à une intoxication au toluène. INTERVENTIONS: Le patient a reçu le traitement médical et la supplémentation en électrolytes appropriés. Aucun traitement spécifique pour le toluène n'était nécessaire. Le patient a été informé des mesures de protection adéquates à prendre pour la manipulation du toluène. RÉSULTATS: Une récupération neurologique complète et une normalisation biochimique ont été constatées dans les 48 heures suivant le début du traitement. Le patient a pris les mesures de protection appropriées lors de la manipulation du toluène et n'a éprouvé aucun symptôme de rechute ou anomalie biochimique du sang ou de l'urine depuis. ENSEIGNEMENTS TIRÉS: Avec ce cas, nous avons analysé une approche algorithmique intégrant la biochimie urinaire pour faciliter le diagnostic de l'hypokaliémie. Nous avons également examiné le toluène en tant qu'agent toxique et souligné son rôle comme étiologie de l'hypokaliémie.

Geographic distribution of vestibular schwannomas in West Scotland between 2000-2015.

BACKGROUND: Although the natural history of vestibular schwannomas (VS) has been previously studied, few studies have investigated associated epidemiological factors, primarily because of the lack of large available cohorts. OBJECTIVE: The objective of this study was to perform a multi-scale geographical analysis of the period prevalence of VS in West Scotland from 2000 to 2015. METHODS: Adults diagnosed with sporadic VS were identified through the National Health Services of West Scotland database and geocoded to the unit postcode. To assess whether the cohort of VS cases could be pooled into a period prevalence measure, the locations of VS cases were analyzed by sex using Cross-L and Difference-K functions. VS period prevalence was examined at two aggregate spatial scales: the postcode district and a coarser scale of NHS Health Boards. The spatial structure of period prevalence within each level of spatial aggregation was measured using univariate global and local Moran's I. Bivariate local Moran's I was used to examine the between-scale variability in period prevalence from the postcode district level to the NHS Health Boards levels. Prior to spatial autocorrelation analyses, the period prevalence at the postcode district was tested for stratified spatial heterogeneity within the NHS Health Boards using Wang's q-Statistic. RESULTS: A total of 512 sporadic VS were identified in a population of over 3.1 million. Between 2000 and 2015, VS period prevalence was highest within the NHS Health Boards of Greater Glasgow and Clyde, Ayrshire and Arran and the Western Isles. However, at the NHS scale, period prevalence exhibited no spatial autocorrelation globally or locally. At the district scale, Highland exhibited the most unusual local spatial autocorrelation. Bivariate local Moran's I results indicated general stability of period prevalence across the postcode district to Health Boards scales. However, locally, some postcode districts in Greater Glasgow and Clyde, Ayrshire and Arran exhibited unusually low district to zone spatial autocorrelation in period prevalence, as did the southern parts of the Western Isles. Some unusually high period prevalence values between the postcode district to Health Board scale were found in Tayside, Forth Valley and Dumfries and Galloway. CONCLUSION: Geographic variability in VS in West Scotland was identified in this patient population, showing that there are areas, even remote, with unusually high or low period prevalence. This can be partially attributed to links between primary and tertiary care. Potential genetic or environmental risk factors that may contribute to geographic variation in this disease within Scotland are also a possibility but require further investigation.