Multidisciplinary atopic dermatitis program: A novel approach to managing difficult-to-control atopic dermatitis patients.

BACKGROUND/OBJECTIVES: Disease improvement for difficult-to-control pediatric atopic dermatitis may be more challenging to achieve when directed by single specialties due to disjointed and conflicting dialogue with patients. METHODS: The Multidisciplinary Atopic Dermatitis Program (MADP) was developed through collaborations with the Rady Children's Hospital and UC San Diego Health Divisions of Dermatology, Allergy & Immunology and Clinical Pharmacy, to create team-based evaluation and management of children and adolescents with atopic dermatitis (AD). The MADP allows concurrent, comprehensive evaluations by multiple specialists to develop treatment plans. The program includes extensive patient education to support shared decision making, incorporating patient and family's perspectives along with those of clinical experts into their care. Objective severity measures and patient reported outcome data were collected, along with assessment of patient and family satisfaction with the MADP. RESULTS: Data showed significant improvement in AD severity as assessed by providers, patients and families by the first follow-up visit. BSA mean percentage decreased by up to 56% by the 7th visit, and pruritus (NRS), CLDQI and POEM mean scores decreased by more than 4 points, 12 points, and over 11 points, respectively. After management was initiated in the MADP, 72.73% of patients achieved an EASI 50 and 47.73% achieved an EASI 75 from a baseline mean of 21.7. Patients who continued in clinic beyond the second visit showed further clinically significant decreases in disease measures. CONCLUSIONS: The multidisciplinary approach shows success in the treatment of difficult-to-control AD patients with improvements in clinician and patient reported outcome measures.

Update on Atopic Dermatitis.

Atopic dermatitis (AD) is a chronic inflammatory skin disorder with a lifetime prevalence of up to 20% which can occur at any age but is most common among children. There is a significant burden of pediatric AD in the primary care setting; thus, the ability to recognize and manage AD is of utmost importance to pediatricians. Treatment of AD requires a multifaceted approach based on a patient's severity including behavioral modifications, topical and systemic pharmacologic therapies, and phototherapy.

Sun protection behaviors among people living with HIV.

People living with HIV (PLWH) are at increased risk for both melanoma and nonmelanoma skin cancers, but there is currently no data on sun protection behaviors among PLWH. We created a 28-question paper survey to collect information on patient demographics and sun protection behaviors among PLWH. We found that although 71.6% of respondents reported spending at least 30 minutes to two hours in the sun daily, only 29.7% reported consistent use of sunscreen. In addition, 41.9% rarely or never received sunscreen counseling by their healthcare providers. There is therefore a need for increased training for healthcare providers in sun protection behavior counseling for PLWH.

The role of the thymus in COVID-19 disease severity: implications for antibody treatment and immunization.

The thymus is a largely neglected organ but plays a significant role in the regulation of adaptive immune responses. The effect of aging on the thymus and immune senescence is well established, and the resulting inflammaging is found to be implicated in the development of many chronic diseases including atherosclerosis, hypertension and type 2 diabetes. Both aging and diseases of inflammaging are associated with severe COVID-19 disease, and a dysfunctional thymus may be a predisposing factor. In addition, insults on the thymus during childhood may lead to abnormal thymic function and may explain severe COVID-19 disease among younger individuals; therefore, measurement of thymic function may assist COVID-19 care. Those with poor thymic function may be treated prophylactically with convalescent serum or recombinant antibodies, and they may respond better to high-dose or adjuvanted COVID-19 vaccines. Treatments inducing thymic regeneration may improve patients' overall health and may be incorporated in COVID-19 management.

Neutralizing and cross-reacting antibodies: implications for immunotherapy and SARS-CoV-2 vaccine development.

The novel coronavirus SARS-CoV-2 emerged in China in 2019 and quickly spread globally, causing a pandemic. There is an urgent need to develop vaccines against the virus, and both convalescent plasma and immune globulin are currently in clinical trials for treatment of patients with COVID-19. It is unclear whether antibodies induced by SARS-CoV-2 have neutralizing capacity and whether they can protect from future infection. Seasonal human coronaviruses (HCoV) have been circulating for decades. It is currently unknown whether antibodies against seasonal HCoV may cross-neutralize SARS-CoV-2. Data from neonates suggest that trans-placental antibodies against HCoV may have neutralizing capacity. Here we briefly review the epidemiologic observations on HCoV and discuss the potential implications for neutralizing and cross-neutralizing antibodies against SARS-CoV-2.

The role of the IL-1 system in pregnancy and the use of IL-1 system markers to identify women at risk for pregnancy complications†.

The interleukin (IL)-1 system plays a major role in immune responses and inflammation. The IL-1 system components include IL-1α, IL-1ß, IL-1 receptor type 1 and IL-1 receptor type 2 (decoy receptor), IL-1 receptor accessory protein, and IL-1 receptor antagonist (IL-1Ra). These components have been shown to play a role in pregnancy, specifically in embryo-maternal communication for implantation, placenta development, and protection against infections. As gestation advances, maternal tissues experience increasing fetal demand and physical stress and IL-1ß is induced. Dependent on the levels of IL-1Ra, which regulates IL-1ß activity, a pro-inflammatory response may or may not occur. If there is an inflammatory response, prostaglandins are synthesized that may lead to myometrial contractions and the initiation of labor. Many studies have examined the role of the IL-1 system in pregnancy by independently measuring plasma, cervical, and amniotic fluid IL-1ß or IL-1Ra levels. Other studies have tested for polymorphisms in IL-1ß and IL-1Ra genes in women experiencing pregnancy complications such as early pregnancy loss, in vitro fertilization failure, pre-eclampsia and preterm delivery. Data from those studies suggest a definite role for the IL-1 system in successful pregnancy outcomes. However, as anticipated, the results varied among different experimental models, ethnicities, and disease states. Here, we review the current literature and propose that measurement of IL-1Ra in relation to IL-1 may be useful in predicting the risk of poor pregnancy outcomes.

A significant portion of college students are not aware of HPV disease and HPV vaccine recommendations.

There is limited data on the HPV immunization status of Latino/Hispanic youth in the USA. In Los Angeles County in 2015, 54,973 (34.3%) college students were of Latino/Hispanic background. We examined Los Angeles County college students' awareness of HPV and HPV-related disease, HPV vaccine recommendations, and their vaccination status. This study surveyed 212 Los Angeles college students from January to April 2018. In a convenience sampling study, a 31-question, IRB-approved survey was administered face-to-face to college students 18 years and older at California State University settings in Los Angeles County. Almost two-thirds of the male (65%) and half of the female (51.6%) respondents did not know that the HPV vaccine is recommended through 26 years of age, and 47.6% did not know they can get the HPV vaccine at the college student health center or youth-friendly clinics. Ethnicity, family income, and the highest level of education in the family had a significant impact on immunization rates. Self-reported and actual HPV knowledge levels were significantly associated with vaccination status. Educational strategies focusing on the logistics of receiving the HPV vaccine and HPV vaccine catch-up eligibility for college students may be effective in decreasing racial disparities in vaccine receipt.

Logistical and structural challenges are the major obstacles for family medicine physicians' ability to administer adult vaccines.

PURPOSE: This study was conducted to characterize the vaccination practices and challenges of family medicine physicians in Los Angeles County, California. METHODS: The Los Angeles Academy of Family Physicians (LA AFP) sent out electronic surveys to all of their active members (N = 1121) between December 2017 and January 2018, and asked them to answer questions about themselves, their practice, their patient population, and their immunization practices and challenges. We then analyzed the results through basic statistical calculations and Pearson's chi-squared tests. RESULTS: Seventy-four people (6.6%) responded to the survey, and 75% of responders stated that they administer all Advisory Committee on Immunization Practices (ACIP) recommended vaccines. The lowest vaccine administration rates were for the high-dose influenza vaccine, which 66.2% (n = 49) of respondents reported to administer, followed by the meningococcal B vaccine (68.9%; n = 51). The respondents who belonged to practices with more than 11 providers, were part of a large hospital or healthcare system, had electronic medical records (EMRs), and used the California Immunization Registry (CAIR) were more likely to report to vaccinate. The number one responding physician-reported challenge to vaccination was limited time and resources to address patient resistance followed by vaccine cost and lack of infrastructure to store vaccines. CONCLUSIONS: In this pilot study, structural and logistical challenges appeared to make the biggest impact on adult vaccination for the responding family medicine physicians. Solutions addressing these challenges will help improve the adult immunization rates.

Proposal to Reduce Adult Immunization Barriers in California.

Adult vaccination rates in the United States are consistently lower than the National Healthy People 2020 goals. Barriers to adult vaccination include inconsistency of insurance coverage of adult vaccines and difficulty in accessing vaccines. To help address the gap in adult access to vaccines, in 2016 the Department of Health Care Services--which administers the Medi-Cal program (California's version of Medicaid)--implemented the All Plan Letter (APL) 16-009, which requires coverage of recommended adult vaccines as a pharmacy benefit. Adult Medi-Cal patients can now receive the vaccines recommended for their age and underlying health conditions, and they can do so not only at a provider's office but also at local pharmacies, improving access and convenience. This policy brief recommends expanding coverage of all adult vaccines as a pharmacy benefit of all public and commercial insurance plans.

UV Protection by Natural Products: C. myrrha Oil Versus Sunscreen.

Exposure to various types of ultraviolet (UV) radiation from the sun has been linked to skin cancer. Use of sunscreen can reduce the damaging and carcinogenic effects of UV radiation. However, multiple chemicals in sunscreen can trigger allergic responses, making people less inclined to use sunscreen. Thus, finding natural, plant-based alternatives to sunscreen with similar efficacy has become an important area of research. Myrrh oil, extracted from the shrub Commiphora myrrha, has been used in the treatment of topical wounds and studies have shown that it may provide protection against solar radiation. This study sought to further investigate if C. myrrha oil can confer protection against UV radiation. A UV-sensitive strain of Saccharomyces cerevisiae was grown in petri dishes with one half covered by aluminum foil and the other half covered by clear polyethylene food wrap. The polyethylene half was treated with either SPF 15 or SPF 30 sunscreen, C. myrrha oil or a combination of C. myrrha oil and either sunscreen. The plates were exposed to sunlight. Colony death was quantified using visual estimation. While UV blocking by C. myrrha oil alone was not as effective as that by the synthetic sunscreen, the 1:1 combination of C. myrrha oil and SPF 15 sunblock was significantly more effective than SPF 15 sunblock alone to prevent S. cerevisiae death. These data suggest that naturally-based sunscreens supplemented with synthetic UV deterrents may provide a more holistic approach to prevent UV-induced skin damage. J Drugs Dermatol. 2018;17(8):905-907.

What Consumers Say About Nursing Homes in Online Reviews.

Background: Although patient-centered care is an expressed value of our healthcare system, no studies have examined what consumers say in online reviews about nursing homes (NHs). Insight into themes addressed in these reviews could inform improvement efforts that promote patient-centered NH care. Research Design and Methods: We analyzed nursing home (NH) Yelp reviews. From a list of all NHs in California, we drew a purposeful sample of 51 NHs, selecting facilities representing a range of geographical areas and occupancy rates. Two research teams analyzed the reviews using grounded theory to identify codes and tracked how frequently each code was mentioned. Results: We evaluated 264 reviews, identifying 24 codes, grouped under five categories: quality of staff care and staffing; physical facility and setting; resident safety and security; clinical care quality; and financial issues. More than half (53.41%) of Yelp reviewers posted comments related to staff attitude and caring and nearly a third (29.2%) posted comments related to staff responsiveness. Yelp reviewers also often posted about NHs' physical environment. Infrequently mentioned were the quality of health care provided and concerns about resident safety and security. Discussion and Implications: Our results are consistent with those from related studies. Yelp reviewers focus on NH aspects that are not evaluated in most other NH rating systems. The federal Nursing Home Compare website, for instance, does not report measures of staff attitudes or the NH's physical setting. Rather, it reports measures of staffing levels and clinical processes and outcomes. We recommend that NH consumers consult both types of rating systems because they provide complementary information.

Ratings game: an analysis of Nursing Home Compare and Yelp ratings.

BACKGROUND: Two strategies for rating the quality of nursing homes (NHs) in the USA are exemplified by the Nursing Home Compare (NHC) website, launched by the federal Centers for Medicare and Medicaid Services in 1998, and Yelp.com, an online consumer review site that has grown in popularity since its founding in 2004. Both sites feature a 5-star rating system. While much is known about NHC ratings, little is known about NH Yelp ratings. This study examines Yelp ratings for NHs in California and compares these ratings with NHC ratings. Understanding how these ratings relate can inform efforts to empower consumers and enhance NH decision-making. METHODS: We collected NHC and Yelp ratings for all California NHs between September and November 2016. For each NH with a Yelp review, we recorded the star rating and the total number of reviews. We also recorded the NHC 5-star rating and NHC ratings for inspections, staffing and quality measures (QMs). We conducted descriptive statistics and frequencies for these variables. We conducted correlations and tested means to compare the ratings. RESULTS: A total of 675 NHs (68.1% of the total sample of 991 NHs) had both Yelp ratings and NHC ratings. Correlations between the Yelp and NHC ratings were relatively weak. The Yelp rating was significantly lower than the 5-star NHC rating and the NHC ratings for staffing and QMs. It was significantly higher than the NHC inspection rating. CONCLUSIONS: This study found that when consumers rate NHs on Yelp, their ratings differ considerably from NHC ratings, a finding in keeping with similar studies of NH quality measurement. Further research is needed to analyse the content of Yelp reviews and compare the themes and topics consumers identify with those reported on NHC.