Acquired Ichthyosis in the Setting of Active Pulmonary Tuberculosis.

Acquired ichthyosis is an uncommon disorder of cornification. It characteristically presents as symmetric scaling of the skin on the trunk and extensor surfaces of the extremities. It is clinically and histologically similar to ichthyosis vulgaris; however, acquired ichthyosis develops later in life and has been associated with various malignancies, infections, medications, autoimmune diseases, metabolic disorders, and malnutrition. We describe a case of a 35-year-old woman with active pulmonary tuberculosis and a history of breast cancer who presented with a several-month history of a widespread, scaly, pruritic skin eruption. Physical examination revealed fine, scaly patches on the extremities with relative sparing of the flexures and larger, scaly, ichthyosiform patches on the chest and back. Skin biopsy revealed orthokeratotic hyperkeratosis and a diminished granular layer, consistent with a diagnosis of acquired ichthyosis. Further evaluation, including positron-emission tomography/computed tomography scan, revealed hypermetabolic infiltrates and cavitation in the lungs, consistent with active pulmonary tuberculosis; there was no evidence of new or recurrent malignancy. The patient was treated with antituberculosis drugs and topical ammonium lactate cream. With incident cases rarely reported in the literature, this case of new-onset ichthyosis in the setting of active pulmonary tuberculosis highlights the distinctive clinical and histologic features of acquired ichthyosis and emphasizes the relationship of acquired ichthyosis with underlying systemic disease, particularly infection.

Relapse of Juvenile Idiopathic Arthritis-Associated Uveitis after Discontinuation of Immunomodulatory Therapy.

Purpose: To assess treatment outcomes in juvenile idiopathic arthritis (JIA)-associated uveitis and relapse rates upon discontinuation of immunomodulatory therapy (IMT). Methods: Medical records of patients with JIA-associated uveitis seen at the University of Illinois at Chicago and the F.I. Proctor Foundation uveitis clinics from September 14, 1988 to January 5, 2011 were reviewed. The main outcome was time to relapse after attempting to discontinue IMT.Results: Of 66 patients with JIA-associated uveitis, 51 (77%) received IMT as either sole or combination therapy. Of a total of 51, 41 (80%) patients achieved corticosteroid-sparing control. Attempts were made to discontinue treatment in 19/51 (37%) patients. Of a total of 19 patients, 13 (68%) attempting to discontinue IMT relapsed, with a median time to relapse of 288 days from the time of attempted taper/discontinuation (IQR: 108-338).Conclusions: Corticosteroid-sparing control of inflammation was achieved in the majority of patients; however, attempts to stop IMT were often unsuccessful. Close follow-up of patients after discontinuation of therapy is warranted.

Association Between Thyroid Disease and Uveitis: Results From the Pacific Ocular Inflammation Study.

Importance: Common pathophysiological mechanisms may be responsible for immune dysregulation in both thyroid disease and uveitis. Studies investigating a possible association are limited. Objective: To determine the association between thyroid disease and uveitis. Design, Setting, and Participants: A retrospective, population-based case-control study was conducted from January 1, 2006, to December 31, 2007, among 217 061 members of the Kaiser Permanente Hawaii health system during the study period. A clinical diagnosis of uveitis was determined through a query of the electronic medical record followed by individual medical record review for confirmation by a uveitis specialist. Thyroid disease was determined based on International Classification of Diseases, Ninth Revision, coding. Two control groups were chosen at a 4:1 ratio for comparison with patients with uveitis. A logistic regression analysis was performed with uveitis as the main outcome variable and thyroid disease as the main predictor variable, while adjusting for age, sex, race, smoking status, and history of autoimmune disease. Data analysis was conducted between 2014 and 2016. Main Outcomes and Measures: A diagnosis of thyroid disease among patients with uveitis and respective controls. Results: Of the 224 patients with uveitis (127 women and 97 men; mean [SD] age, 54.1 [17.8] years) identified during the study period, 29 (12.9%) had a diagnosis of thyroid disease, compared with 62 of 896 patients (6.9%) in the control group (P = .01) and 78 of 896 patients (8.7%) in the ophthalmology clinic control group (P = .06). Using the general Kaiser Permanente Hawaii population control group, patients who had thyroid disease had a 1.7-fold (95% CI, 1.03-2.80; P = .04) higher odds of having uveitis compared with patients who did not have thyroid disease when controlling for age, sex, race, smoking status, and autoimmune disease. A similar association was found using the ophthalmology clinic control group (odds ratio, 1.8; 95% CI, 1.1-2.9; P = .02) while adjusting for these factors. Conclusions and Relevance: These findings suggest that a history of thyroid disease has a weak to moderate association with uveitis. Similar autoimmune mechanisms could explain the pathogenesis of both conditions. If future studies corroborate these findings, they may have further clinical implications in the laboratory workup of uveitis.

Instruction in teaching and teaching opportunities for residents in US dermatology programs: Results of a national survey.

BACKGROUND: Dermatology residents routinely teach junior co-residents and medical students. Despite the importance of teaching skills for a successful academic career, no formal teaching instruction programs for dermatology residents have been described to our knowledge, and the extent of teaching opportunities for dermatology residents is unknown. OBJECTIVE: We sought to describe the range of teaching opportunities and instruction available to dermatology residents and to assess the need for additional teaching training from the perspective of dermatology residency program directors nationwide. METHODS: A questionnaire was administered to 113 US dermatology residency program directors or their designees. Descriptive statistics were used to analyze questionnaire item responses. RESULTS: The response rate was 55% (62/113). All program directors reported that their residents teach; 59% (33/56) reported offering trainees teaching instruction; 11% (7/62) of programs offered a short-term series of formal sessions on teaching; and 7% (4/62) offered ongoing, longitudinal training. Most program directors (74%, 40/54) believed that their residents would benefit from more teaching instruction. LIMITATIONS: Response rate and responder bias are potential limitations. CONCLUSION: Dermatology residents teach in a broad range of settings, over half receive some teaching instruction, and most dermatology residency program directors perceive a need for additional training for residents as teachers.

Boston keratoprosthesis type I in the elderly.

BACKGROUND/AIMS: To determine the outcomes of Boston type I keratoprosthesis implanted in elderly patients. METHODS: A retrospective case series was performed on patients at least 75 years old who received the Boston type I keratoprosthesis between 1 January 2007 and 31 December 2012. Preoperative diagnosis, interval visual acuity, keratoprosthesis retention and postoperative complications were recorded for each patient. RESULTS: Forty-four Boston type I keratoprostheses were implanted in 44 eyes of 43 patients. The most common indication for surgery was corneal graft failure (n=23; 52.3%) followed by corneal scar (n=8; 18.2%) and limbal stem cell dysfunction (n=8; 18.2%). All patients had preoperative visual acuity of ≤20/200. Thirty-six of 44 (82%) patients achieved visual acuity of 20/200 or better postoperatively, and 20 of those (55.6%) maintained 20/200 or better for 1 year after surgery. The median length of follow-up was 825 days (range: 27-2193 days), and at the last follow-up visit, 20 of 44 (45.5%) had 20/200 or better vision. The median best-corrected visual acuity (logMAR) improved from 2.6 preoperatively to 1.0 at 1 year postoperative (p<0.00001). Device retention at 1 year postoperative was 88.9%. The most common postoperative complications were retroprosthetic membrane formation in 20 patients (45.5%) and cystoid macular oedema in six patients (13.6%). One patient developed keratitis and consecutive endophthalmitis 2 months after surgery and required enucleation. CONCLUSIONS: Boston type I keratoprosthesis is an effective modality in corneal blindness in elderly patients. Failure to restore or maintain ambulatory vision was typically due to non-corneal comorbidities, often unrelated to the keratoprosthesis.

Is a higher boost dose of radiation necessary after breast-conserving therapy for patients with breast cancer with final close or positive margins?

To determine rates of loco-regional recurrence (LRR), distant failure and overall survival for patients with breast cancer treated with breast-conserving therapy (BCT) with a close or positive surgical margin (C/PM) treated with standard dose boost radiation compared with a higher boost of radiation. We retrospectively studied 1476 patients with T1-T3 invasive breast cancer treated with BCT between 1992 and 2009. Median age was 57 years. Patients were divided into three groups: Group I included 1197 patients (81 %) with negative margins who received a standard boost (median 60 Gy) total dose to the lumpectomy cavity; Group II included 116 patients (8 %) with C/PM who received a standard boost (median 60 Gy); and Group III included 163 patients (11 %) with C/PM who received a higher boost (median 68 Gy). Biological subtypes (e.g., ER, PR, HER2/neu) were available for 858 patients (58 %) and were also assessed for any relationship to LRR rate. The Kaplan-Meier, Cox-regression, and log-rank tests were used to estimate rates of LRR and the significance of risk factors. Median follow-up was 8.6 years. The overall 5- and 10-year cumulative incidences of LRR were 2.1 % (95 % CI 0.8-2.1 %) and 4.5 % (95 % CI 3.4-6.0 %), respectively. The 5- and 10-year cumulative incidences of LRR for Group I (negative margins + standard boost) were 1.9 and 4.4 %; for Group II (C/PM + standard boost) were 3.9 and 7.0 %; and for Group III (C/PM + higher boost) were 2.9 and 3.8 %, respectively. No statistically significant differences in LRR rates were found among the three groups (p = 0.4). Similar results were obtained for distant failure (p = 0.3) and overall survival (p = 0.4). On multivariate analysis, tumor grade (p = 0.03), systemic-therapy (p = 0.005), node positivity (p = 0.05), young age (p = 0.001), and biological subtype (p = 0.04) were statistically significantly associated with higher LRR. Higher boost dose and margin positivity were not significant. Our data suggest that the 10-year risk of local recurrence for patients with close or positive margins receiving a standard boost was 7 % compared to 3.8 % for those receiving a higher boost; however, this difference was not significant. A higher boost dose did not significantly improve local control, nor did margins impact LRR risk in our cohort of patients.

Incidence of scleritis and episcleritis: results from the Pacific Ocular Inflammation Study.

PURPOSE: To ascertain the incidence of scleritis and episcleritis in a Hawaiian population and describe variations by age, sex, and race. DESIGN: Retrospective, population-based cohort study. METHODS: All electronic medical records for enrollees in Kaiser Permanente Hawaii (n = 217,061) from January 1, 2006 to December 31, 2007 were searched for International Classification of Diseases, 9th Edition (ICD-9) codes associated with ocular inflammation. Chart review was conducted to verify a clinical diagnosis of scleritis or episcleritis. Confirmed cases were used to calculate incidence rates per 100,000 person-years. Ninety-five percent confidence intervals (CI) were calculated for each incidence rate, including age-, sex-, and race-specific rates, using bias-corrected Poisson regression. To assess for confounding, a multivariate analysis adjusting for age, sex, and race was also performed. RESULTS: Of 217,061 eligible patients, 17 incident scleritis cases and 93 incident episcleritis cases were confirmed. The overall incidence rates of scleritis and episcleritis were 4.1 (95% CI: 2.6-6.6) and 21.7 (95% CI: 17.7-26.5) cases per 100,000 person-years, respectively. Women were overrepresented among scleritis patients (P = .049). Pacific Islanders were the most underrepresented racial group among cases of scleritis and episcleritis (P = .006, P = .001). Blacks had the highest incidence of scleritis (P = .004). CONCLUSIONS: These results provide a population-based estimate of the incidence of scleritis and episcleritis in a diverse population and highlight differences in patients' demographic characteristics. Differences in incidence by sex and race raise questions about genetic and environmental influences on the development of these conditions.