Inflammatory bowel disease later diagnosed as strongyloides colitis in migrants to Canada: a case series.

Strongyloides colitis is a gastrointestinal manifestation of the parasitic infection, Strongyloides stercoralis, which may be misdiagnosed and treated as ulcerative colitis (UC) in patients presenting in non-endemic regions. Treatment of Strongyloides colitis as UC can lead to a lethal hyperinfection syndrome. Therefore, prior to commencing immunosuppressive treatment of UC, it is essential to use diagnostic markers to differentiate the two etiologies. In this case series, we discuss two migrant patients who were previously diagnosed with UC and treated accordingly who presented to our clinic for further investigation of suspected parasitic infection.

Association Between Atopic Dermatitis and Height, Body Mass Index, and Weight in Children.

IMPORTANCE: Atopic dermatitis may be associated with short stature and obesity in children, but most previous studies have been either small or cross-sectional. OBJECTIVE: To evaluate the association between atopic dermatitis and height, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), and weight throughout childhood. DESIGN, SETTING, AND PARTICIPANTS: TARGet Kids! (The Applied Research Group for Kids) is an ongoing prospective longitudinal cohort study that collects data at routine physician visits throughout childhood. In this cohort, children aged 5 or younger were followed up into adolescence at regular physician visits at general pediatric and family practices in Toronto, Canada, from June 2008 to February 2021. EXPOSURE: Parental report of atopic dermatitis. MAIN OUTCOMES AND MEASURES: Primary outcomes were length-for-age and BMI-for-age z scores. The secondary outcome was weight-for-age z score. Linear mixed effects models were used to estimate associations between atopic dermatitis and each outcome. In secondary analyses, interaction terms were included between atopic dermatitis and age. RESULTS: A total of 10 611 children were included in the analysis, with mean (SD) baseline age of 23 (20) months; 5070 (47.8%) participants were female. Participants were followed for a median (range) of 28.5 (0.0-158.0) months. A total of 1834 (17.3%) children had atopic dermatitis during follow-up. Atopic dermatitis was associated with lower length-for-age z score (-0.13; 95% CI, -0.17 to -0.09; P < .001), higher BMI z score (0.05; 95% CI, 0.01 to 0.09; P = .008), and lower weight-for-age z score (-0.07; 95% CI, -0.10 to -0.04; P < .001) compared with children without atopic dermatitis. The associations between atopic dermatitis and height and BMI changed with age, diminishing by age 14 years and 5.5 years, respectively. Based on World Health Organization growth tables, children with atopic dermatitis were on average 0.5 cm shorter with 0.2 more BMI units at age 2 years and 0.6 cm shorter with no difference in BMI at age 5 years than children without atopic dermatitis after adjusting for covariates. There was no evidence of interaction between atopic dermatitis and age with respect to weight. CONCLUSIONS AND RELEVANCE: In this cohort study, atopic dermatitis was associated with shorter stature, higher BMI, and lower weight in early childhood, but these associations were small and, for height and BMI, attenuated with age and resolved by adolescence.

COVID-19 Skin Manifestations in Skin of Colour.

Coronavirus disease (COVID-19) skin manifestations have been increasingly reported in medical literature. Recent discussions have identified a lack of images of skin of color (SOC) patients with COVID-19 related skin findings despite people with skin of color being disproportionately affected with the disease. There have been calls to prioritize the identification of COVID-19 skin manifestations in patients with SOC and disseminate these findings. The objective of this article is to review the existing literature on COVID-19 skin manifestations and, where possible, discuss how they may present differently in patients with SOC. Further research is needed to allow primary care physicians and dermatologists to be aware of and easily identify patients with cutaneous findings that may be secondary to COVID-19. Patients presenting with idiopathic dermatologic manifestations should be considered for COVID-19 testing and follow public health guidelines for self-isolation.

Postoperative Outcomes of Local Skin Flaps Used in Oncologic Reconstructive Surgery of the Nasal Ala: A Systematic Review.

BACKGROUND: Despite numerous options for nasal ala reconstruction, advantages and disadvantages of each method are unclear. OBJECTIVE: To summarize reported outcomes of local flaps without the use of grafts for nasal ala oncologic reconstructive surgery. METHODS: A nasal ala-specific protocol was adapted from a previous head- and neck-specific PROSPERO submission (CRD42017071596). The search was conducted in MEDLINE, EMBASE, and CENTRAL on December 23, 2017 and updated on May 10, 2019. Two reviewers screened 9,313 results from head and neck literature. Study bias was evaluated with the ROBINS-I tool. RESULTS: Subunit-based categorization of included studies identified 12 nasal ala-specific publications. Complications (flap necrosis, hematoma, wound infections, trapdoor deformities, and dehiscence), functional (nasal valve or respiratory dysfunction), and cosmetic (alar rim distortion/asymmetry/notching, secondary/revisionary procedures, and patient satisfaction) outcomes were extracted. CONCLUSION: Generally favorable outcomes are seen in all flaps. Careful consideration of donor sites for interpolation flaps is needed for optimal cosmetic outcomes. Transposition flaps, including laterally based bilobed and trilobed flaps, created good outcomes, although melolabial transposition flaps may produce poorer outcomes compared with melolabial island pedicle advancement flaps. Caution is needed for rotation flaps to prevent nasal valve/respiratory dysfunction due to alar crease contracture or ridge elevation. Further research is needed.

Postoperative Outcomes of Local Skin Flaps Used in Oncologic Reconstructive Surgery of the Upper Cutaneous Lip: A Systematic Review.

BACKGROUND: Despite many options for upper lip reconstruction, each method's advantages and disadvantages are unclear. OBJECTIVE: To summarize complications and functional and aesthetic outcomes of localized skin flaps for oncological reconstruction of the upper cutaneous lip (PROSPERO CRD42020157244). METHODS: The search was conducted in Ovid MEDLINE, Ovid EMBASE, and CENTRAL on December 14, 2019. Two reviewers screened 2,958 results for eligibility. Bias assessment was conducted using ROBINS-I criteria. RESULTS: Our search identified 12 studies reporting outcomes of V-Y advancement, ergotrid, rotation, Karapandzic, alar crescent, and propeller facial artery perforator flaps. Flap complications (infection, hemorrhage/hematoma, wound dehiscence, and flap necrosis) ranged from 0% to 7.69%. Functional outcomes (salivary continence, microstomia, and paresthesia) were poorest for Karapandzic flaps. Aesthetic outcomes, when reported, stated satisfaction rates greater than 90%. V-Y advancement flaps reported the highest rates of poor scarring (0%-20%) and need for revision surgery (0%-46.7%). CONCLUSION: Our results provide dermatologic surgeons an overview of upper cutaneous lip flap outcomes reported in the literature. In general, we noted high patient satisfaction rates and low complication rates. Additional research into outcomes of other commonly used flaps is needed. Standardization of reported outcomes could allow further comparison across different flaps or across studies of the same flap.

Psoriasis in patients of color: differences in morphology, clinical presentation, and treatment.

Psoriasis is a chronic inflammatory skin disease affecting 2% to 3% of individuals worldwide. However, the majority of clinical data are in white patients, with limited data in patients of color. We present 3 cases of psoriasis representative of patients presenting to an urban and racially diverse hospital-based dermatology clinic in Toronto, Ontario, Canada, to illustrate the differences in psoriasis in patients of color compared to white patients. We review the differences in the morphology, presentation, treatment, and psychosocial impact of psoriasis in this population. We also discuss the importance of early diagnosis, treatment considerations, and education in dermatology training programs regarding psoriasis in patients of color.

Prognostic factors for first-line therapy and overall survival of metastatic uveal melanoma: The Princess Margaret Cancer Centre experience.

Metastatic uveal melanoma (MUM) has a poor prognosis, with no established standard of care. Delineation of prognostic factors in MUM patients may enable stratified treatment algorithms of stage-specific survival. Overall, 132 MUM patients who presented to a single tertiary institution in Toronto, Canada, over 12 years were identified and data (demographics, clinical status, radiographic images, and laboratory values) were extracted. Associations with systemic first-line treatment outcome 12 weeks after first-line treatment, time to progression (TTP), and overall survival (OS) were explored by univariate and multivariable analysis. Age, presence of liver metastases, and time from primary presentation to metastatic presentation were significant variables affecting first-line treatment outcomes. Age, Eastern Cooperative Oncology Group (ECOG) score, presence of liver metastases, liver metastasis size, neutrophil lymphocyte ratio, absolute neutrophil count, lactate dehydrogenase (LDH), alkaline phosphatase, time from primary presentation to metastatic presentation, and patients receiving surgery as the first-line treatment were significant variables affecting TTP. Age, ECOG score, presence of liver metastases, liver metastasis size, neutrophil lymphocyte ratio, absolute neutrophil count, LDH, and alkaline phosphatase were significant variables affecting OS. Patients who underwent surgery, chemotherapy, immunotherapy, liver-directed therapy, or targeted therapy had better OS compared with patients not receiving treatment with surgery, associated with a significantly better OS compared with all other therapies. Multivariable analysis showed increased age, absence of liver metastases, and absence of bone metastases to be associated with positive treatment outcomes. ECOG score of at least 1, increased LDH, and decreased time from primary to metastatic presentation would predict decreased TTP. Increased LDH, older age, and ECOG score of at least 1 were associated with decreased OS. These results identified prognostic markers and models thereof of treatment benefit and survival. Further validation in larger cohorts is required.

An Approach to Minimising Risk of Adrenal Insufficiency When Discontinuing Oral Glucocorticoids.

Oral glucocorticoids are commonly used across every field of medicine; however, discontinuing them in patients can be challenging. The risk of acute adrenal crises secondary to glucocorticoid withdrawal can be fatal and arises from chronic suppression of the adrenal glands. Identifying risk factors for adrenal suppression in dermatological patients, such as doses greater than 5 to 7.5 mg of prednisone equivalent, duration of glucocorticoid use greater than 3 weeks, certain medications, and comorbidities, can help risk-stratify patients. The use of adrenal gland testing such as basal cortisol levels and adrenocorticotropic hormone stimulation tests can confirm adrenal suppression in patients. This review article provides an approach that dermatologists can use to minimise the risk of adrenal insufficiency in patients discontinuing glucocorticoids and when it may be appropriate to use adrenal gland testing.

Atopic Dermatitis, Depression, and Suicidality.

Atopic dermatitis (AD) is a common disease associated with an underappreciated increased risk of depression and suicidality. Current literature investigates associated risk factors, including severity of disease, age, sex, and atopic comorbidities, which may help identify patients with AD at high risk for depression or suicidality. Increasing severity of AD and female sex are associated with an increased risk for both depression and suicidality, while increasing age is associated with an increased risk for depression only. Further research is required to validate the studies supporting these reported associations with a particular emphasis on suicidality and AD due to lack of information. The use of these risk factors may assist in the creation of simple screening tools to screen for psychiatric comorbidity in patients with AD.

Current Status and Future of Skin Substitutes for Chronic Wound Healing.

Chronic wounds, including diabetic ulcers, pressure ulcers, venous ulcers, and arterial insufficiency ulcers, are both difficult and expensive to treat. Conventional wound care may sometimes lead to suboptimal wound healing and significant morbidity and mortality for patients. The use of skin substitutes provides an alternative therapy showing superior efficacy and, in some cases, similar cost-effectiveness compared to traditional treatments. This review discusses the different types of currently available commercial skin substitutes for use in chronic wounds as well as the paucity of strong evidence supporting their use. It then delves into the limitations of these skin substitutes and examines the most recent research targeting these limitations.

Methodologies in creating skin substitutes.

The creation of skin substitutes has significantly decreased morbidity and mortality of skin wounds. Although there are still a number of disadvantages of currently available skin substitutes, there has been a significant decline in research advances over the past several years in improving these skin substitutes. Clinically most skin substitutes used are acellular and do not use growth factors to assist wound healing, key areas of potential in this field of research. This article discusses the five necessary attributes of an ideal skin substitute. It comprehensively discusses the three major basic components of currently available skin substitutes: scaffold materials, growth factors, and cells, comparing and contrasting what has been used so far. It then examines a variety of techniques in how to incorporate these basic components together to act as a guide for further research in the field to create cellular skin substitutes with better clinical results.

Cellularized Bilayer Pullulan-Gelatin Hydrogel for Skin Regeneration.

Skin substitutes significantly reduce the morbidity and mortality of patients with burn injuries and chronic wounds. However, current skin substitutes have disadvantages related to high costs and inadequate skin regeneration due to highly inflammatory wounds. Thus, new skin substitutes are needed. By combining two polymers, pullulan, an inexpensive polysaccharide with antioxidant properties, and gelatin, a derivative of collagen with high water absorbency, we created a novel inexpensive hydrogel-named PG-1 for "pullulan-gelatin first generation hydrogel"-suitable for skin substitutes. After incorporating human fibroblasts and keratinocytes onto PG-1 using centrifugation over 5 days, we created a cellularized bilayer skin substitute. Cellularized PG-1 was compared to acellular PG-1 and no hydrogel (control) in vivo in a mouse excisional skin biopsy model using newly developed dome inserts to house the skin substitutes and prevent mouse skin contraction during wound healing. PG-1 had an average pore size of 61.69 µm with an ideal elastic modulus, swelling behavior, and biodegradability for use as a hydrogel for skin substitutes. Excellent skin cell viability, proliferation, differentiation, and morphology were visualized through live/dead assays, 5-bromo-2'-deoxyuridine proliferation assays, and confocal microscopy. Trichrome and immunohistochemical staining of excisional wounds treated with the cellularized skin substitute revealed thicker newly formed skin with a higher proportion of actively proliferating cells and incorporation of human cells compared to acellular PG-1 or control. Excisional wounds treated with acellular or cellularized hydrogels showed significantly less macrophage infiltration and increased angiogenesis 14 days post skin biopsy compared to control. These results show that PG-1 has ideal mechanical characteristics and allows ideal cellular characteristics. In vivo evidence suggests that cellularized PG-1 promotes skin regeneration and may help promote wound healing in highly inflammatory wounds, such as burns and chronic wounds.