Store-and-forward teledermatology impact on diagnosis, treatment and dermatology referrals: Comparison between practice settings.

INTRODUCTION: Store-and-forward (SAF) teledermatology involves non-dermatologists sending clinical images to dermatologists. This improves patient care while reducing unwarranted face-to-face (FTF) specialist office visits. Comparisons between dermatologist diagnostic concordance with referring provider, treatment change recommendations, and FTF referrals have yet to be compared by type of provider and practice setting. METHODS: This retrospective chart review examined SAF teledermatology eConsults from four practice settings: Doctor of Medicine (MD)/Doctor of Osteopathic Medicine (DO) office visits, MD/DO walk-in clinics, nurse practitioner (NP)/physician assistant (PA) office visits and NP/PA walk-in clinics. The most recent 100 MD/DO office- and 100 NP/PA walk-in-referred patient charts were reviewed. There were only 71 NP/PA office and 47 MD/DO walk-in eConsults to review. RESULTS: Teledermatologists agreed with referring provider diagnoses 50% of the time for MD/DO office visits, 29.8% for MD/DO walk-in clinics, 33.8% for NP/PA office visits and 34% for NP/PA walk-in clinics. Diagnostic concordance was significantly higher for eConsults from MD/DO office visits than MD/DO walk-in clinics (p = 0.021), NP/PA office visits (p = 0.035) or NP/PA walk-in clinics (p = 0.022). There were significantly more treatment changes recommended after walk-in eConsults than office visits (67 versus 44%, p < 0.0001). FTF visits were recommended more after office visits than walk-in clinics (46 versus 27%, p = 0.001). Overall, 21% (68/318) of patients ultimately attended FTF appointments. DISCUSSION: SAF teledermatology improves diagnosis, reducing barriers to specialty care. Overall, potential FTF visit reduction was 79%. Expanding eConsult programmes, particularly in walk-in settings, and for use by NP/PAs or early career internists, may render dermatological care more expeditiously and avoid unnecessary FTF visits.

From Court to Couch: Exercise and Quality of Life after Acute Type A Aortic Dissection.

BACKGROUND: Acute Type A aortic dissection can be physically and mentally stressful with little known about survivors' postrepair activity levels, exercise habits, and quality of life (QOL). This study was aimed to describe pre- and postdissection changes regarding exercise, understand physician recommendations, quantify use of cardiac rehabilitation, and assess QOL in dissection survivors. METHODS: A total of 295 acute Type A aortic dissection survivors were surveyed about exercise, cardiac rehabilitation, QOL, sexual activity, and posttraumatic stress disorder (PTSD) with 137 (46%) respondents. RESULTS: Respondents were less likely to participate in competitive athletics after than before dissection (1/131 [0.76%] vs. 26/131 [20%], p [McNemar test] < 0.0001) or lift heavy objects (11/111 [9.9%] vs. 41/111 [37%], p < 0.0001). Forty-eight of 132 respondents (36%) did not participate in cardiac rehabilitation. Compared with general population norms, respondents reported lower median QOL physical component scores (40 [26, 51; 15th, 85th percentile], p < 0.0001); these were lower in respondents who did not exercise (Hodges-Lehmann [HL; 95% confidence interval (CI)]: -6.8 [-11, -2.4], p = 0.002), limited sexual activity (-8.0 [-13, -4.3], p = 0.0002), or screened positive for PTSD (-10 [-14, -5.3], p = 0.0002). Median mental component scores were similar to general population norms (HL [95% CI]: 55 [34, 61], p = 0.24) but were lower among respondents who did not exercise (-4.2 [-7.8, -1.0], p = 0.01), limited sexual activity (-5.5 [-10, -1.8], p = 0.003), or screened positive for PTSD (-16 [-22, -10], p < 0.0001). CONCLUSION: Physicians should prescribe cardiac rehabilitation, encourage appropriate exercise, promote resumption of sexual activity, and identify and treat PTSD after surgery for acute Type A aortic dissection.

60-year-old man • chronic cough • history of GERD & dyslipidemia • throat tickle • Dx?

► Chronic cough ► History of GERD & dyslipidemia ► Throat tickle.

WNT10A Mutation Causes Ectodermal Dysplasia in a Patient Mosaic for Turner Syndrome.

WNT10A plays a role in the proper proliferation and differentiation of ectodermal structures. Mutations in this gene can be responsible for a highly phenotypically variable range of disorders termed ectodermal dysplasias. Here, we describe the case of a five-year-old male patient who is mosaic for Turner syndrome (45,X [90%]/46,X isodicentric Y [10%]) and who presented to dermatology with anhidrosis, conical-shaped teeth, and a slowed rate of hair growth with genetic testing subsequently revealing a likely pathogenic heterozygous variant in WNT10A (c.682T>A; p.Phe228Ile). Future investigation into the WNT10A pathway, which is regulated downstream by ß-catenin, might allow topical therapeutics to be developed that promote normal ectodermal growth and differentiation. Current management for this patient includes precautions taken to prevent overheating and heat stroke and close dermatological and dental monitoring.

Utility of salivary gland biopsy in diagnosing Sjogren's syndrome in a POTS patient population.

PURPOSE: POTS patients undergo labial salivary gland biopsies (LSGB) for histologic confirmation of Sjogren's syndrome (SS). Predictive features of positive results are unknown. METHODS: 161 POTS patients underwent LSGB. Their charts were reviewed for antibody and diagnostic testing results. RESULTS: Only 11% (17/161) of POTS patients were SS positive. There were more positive ANA antibodies in those with positive LSGB (65% v 28%, p = .0026). Positive skin nerve biopsy for small fiber neuropathy (SFN) was associated with positive LSGB (p = .046). CONCLUSION: A positive ANA and skin biopsy for SFN are two helpful features in selecting POTS patients for LSGB.

Cutaneous adverse effects of biologic medications.

Biologic therapies have become widely used but often cause cutaneous adverse effects. The authors discuss the cutaneous adverse effects of tumor necrosis factor (TNF) alpha inhibitors, epidermal growth factor receptor (EGFR) inhibitors, small-molecule tyrosine kinase inhibitors (TKIs), and cell surface-targeted monoclonal antibodies, including how to manage these reactions and when to refer to a dermatologist.

From Tear to Fear: Posttraumatic Stress Disorder in Patients With Acute Type A Aortic Dissection.

Background Acute type A aortic dissection presents with abrupt onset of pain that requires emergency surgery. However, minimal research exists on posttraumatic stress disorder (PTSD) in survivors. We aimed to quantify the prevalence and describe characteristics of PTSD in patients following dissection. Methods and Results A total of 295 adult survivors of surgical dissection with an email on file were administered a cross-sectional online survey about their dissection experience; 137 returned questionnaires, and 129 (94%) responded to the 4-item Primary Care PTSD portion of the survey that was part of a larger lifestyle survey designed to study survivors of aortic dissection and surgery. In addition to the PTSD screening, it inquired about current sexual activity, exercise habits, and employment within the preceding 30 days. At a median of 6.8 years (quartile 1=2.6, quartile 3=8.9 years) after dissection, 23% of patients (30/129) screened positive for PTSD, with 44% (57/129) stating that within the past month they felt constantly on guard or watchful or were easily startled. Of those who screened positive and matched to their electronic medical record (n=27), only 2 (7.4%) had been tested and clinically diagnosed with PTSD. Patients who screened positive for PTSD were more likely to report limited current sexual activity than those who did not (odds ratio, 5.3; 95% CI, 1.9-15 [P=0.0006]). Conclusions PTSD is an important mental health consideration in aortic dissection survivors. Physicians should screen these patients for PTSD at follow-up visits to identify those who test positive and refer them for further testing and treatment, such as trauma-focused psychotherapy or medication.

Time to Stable Dose of Psychostimulants in Pediatric Patients With ADHD.

OBJECTIVES: The prevalence of attention-deficit/hyperactivity disorder (ADHD) is increasing and psychostimulants are the pharmacological standard of care. Patients benefit most when there is efficient titration to a stable dose of medication as defined by maintaining that same dose for 6 months. The aims of this study were to describe time to stable dose in a cohort of children with ADHD and examine the impact of demographic factors. METHODS: A list of pediatric patients with a diagnosis of ADHD in the electronic health record was generated, and a retrospective chart review of stimulant use was conducted on 500 patients randomly selected from 2010 to 2015 who met inclusion criteria. Time to stable dosing and its association with demographic characteristics were assessed. RESULTS: Patients were predominantly male (72%), white (81%), and privately insured (67%). Fifty-five percent of patients achieved a stable dose of medication on first attempt; therefore, the median time to stable dosing for the cohort was 0 days with the interquartile range being 0 to 133.8 days. There was significant increase in time to stable dose for patients younger than 10 years compared with those ≥10 years of age (p = 0.01). Time to stable dose was not significantly associated with race (p = 0.13), sex (p = 0.72), type of insurance (p = 0.56), or formulation being immediate or extended release (p = 0.56). CONCLUSIONS: Many patients had long titration periods when trying to reach a stable dose. Given that medication switching can be challenging for patients and families, more frequent contact with providers during titration may be necessary.

Accuracy of commercially available heart rate monitors in athletes: a prospective study.

Endurance athletes, particularly competitive runners, are using wrist worn devices with the heart rate (HR) feature to guide their training. However, few studies have assessed the effectiveness of these at high levels of exertion. The purpose of this study was to measure the accuracy of the HR monitor feature in four watches at six different treadmill speeds. This prospective study recruited 50 healthy, athletic adults (68% male, mean age of 29, and mean BMI of 23 kg/m2). All subjects wore a three lead ECG and Polar H7 chest strap monitor and two different randomly assigned wrist worn HR monitors. These included the Apple Watch III, Fitbit Iconic, Garmin Vivosmart HR, and Tom Tom Spark 3. Once all devices were on, they were asked to run at the following speeds on a treadmill (in mph): 4, 5, 6, 7, 8, and 9 for two min. HR was assessed on all devices and agreement among measurements determined with Lin's concordance correlation coefficient (CCC) (rc). The Polar H7 chest strap had the greatest agreement with the ECG (rc=98). This was followed by the Apple Watch III (rc=96). The Fitbit Iconic, Garmin Vivosmart HR, and Tom Tom Spark 3 all had the same level of agreement (rc=89). The Polar H7 chest strap was the most accurate, and the Apple Watch was superior among watches. For endurance athletes and their coaches, a chest strap device or Apple Watch may be the best choice for guiding workouts and performance.

Topical Imiquimod Induces Severe Weakness and Myalgias After Three Applications: A Case Report.

Imiquimod can be used to treat superficial basal cell carcinoma, actinic keratosis, genital warts, and other skin conditions. The adverse events associated with this topical agent commonly include application site irritation, primarily erythema, as well as headache, myalgia, and fatigue. There are usually minimal systemic symptoms. We report the case of a patient who used topical imiquimod 5% cream on nine basal cell carcinoma lesions daily for three days and developed severe muscle weakness and the inability to walk. He fell twice, went to the emergency department, and was given 125mg injection of methylprednisolone. The imiquimod was then discontinued and he recovered almost back to baseline in 48 hours. We hypothesize the patient's reaction to the imiquimod was due to an immune etiology, potentially involving TLR7 and NF-κB as precipitators of this myopathy. Overall, this report demonstrates a potential severe and rapid adverse reaction to topical imiquimod administration not previously reported in the literature.

Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach.

OBJECTIVES: Consensus regarding initial cannulation site for acute type A dissection repair is lacking. Objectives were to review our experience with systematic initial axillary artery cannulation, characterize patients on the basis of cannulation site, and assess outcomes. METHODS: From January 2000 to January 2017, 775 patients underwent emergency acute type A dissection repair. Initial axillary cannulation was performed in 617 (80%), femoral in 93 (12%), and central in 65 (8.4%). In-hospital mortality and stroke risk factors were identified using logistic regression. RESULTS: Reasons for selecting initial central or femoral instead of axillary cannulation included unsuitable axillary anatomy (n = 67; 42%), surgeon preference (n = 38; 24%), hemodynamic instability (n = 34; 22%), and preexisting cannulation (n = 19; 12%). Cannulation site was shifted or added intraoperatively in 82 (11%), with initial cannulation site being axillary (n = 23 of 617; 3.7%), central (6 of 65; 9.2%), or femoral (n = 53 of 93; 57%), for surgeon preference (n = 60; 73%), high flow resistance (n = 13; 16%), increased aortic false lumen flow (n = 6; 7.3%), and other (n = 3; 3.7%). In-hospital mortality was 8.6% (n = 67; lowest for axillary, 7.3% [P = .02]) and stroke 8.3% (n = 64). Hemodynamic instability (odds ratio [OR], 7.6; 95% confidence interval [CI], 4.2-14), limb ischemia (OR, 3.7; 95% CI, 1.5-9.3), stroke (OR, 5.5; 95% CI, 2.2-14), and aortic regurgitation (OR, 2.2; 95% CI, 1.2-4.2) at presentation were risk factors for mortality and central cannulation site (OR, 2.3; 95% CI, 1.05-5.1) and aortic stenosis (OR, 2.4; 95% CI, 1.2-4.6) for stroke. CONCLUSIONS: Systematic initial axillary cannulation for acute type A dissection repair is safe and effective and can be tailored to patients' specific needs. With this strategy, comparable outcomes are observed among cannulation sites and are largely determined according to patient presentation rather than cannulation site.

Advances in managing the noninfected open chest after cardiac surgery: Negative-pressure wound therapy.

OBJECTIVE: The objective of this study was to compare safety and clinical effectiveness of negative-pressure wound therapy (NPWT) with traditional wound therapy for managing noninfected open chests with delayed sternal closure after cardiac surgery. METHODS: From January 2000 to July 2015, 452 of 47,325 patients who underwent full sternotomy left the operating room with a noninfected open chest (0.96%), managed using NPWT in 214-with frequency of use rapidly increasing to near 100%-and traditionally in 238. Predominant indications for open-chest management were uncontrolled coagulopathy or hemodynamic compromise on attempted chest closure. Weighted propensity-score matching was used to assess in-hospital complications and time-related survival. RESULTS: NPWT and traditionally managed patients had similar high-risk preoperative profiles. Most underwent reoperations (63% of the NPWT group and 57% of the traditional group), and 21% versus 25% were emergency procedures. Reexplorations for bleeding were less common with NPWT versus traditional wound therapy (n = 63 [29%] vs 104 [44%], P = .002). Median duration of open-chest to definitive sternal closure was 3.5 days for NPWT versus 3.1 for traditionally managed patients (P[log rank] = .07). Seven patients (3.3%) were converted from NPWT to traditional therapy because of hemodynamic intolerance and 6 (2.5%) from traditional to NPWT. No NPWT-related cardiovascular injuries occurred. Among matched patients, NPWT was associated with better early survival (61% vs 44% at 6 months; P = .02). CONCLUSIONS: NPWT is safe and effective for managing noninfected open chests after cardiac surgery. By facilitating open-chest management and potentially improving outcomes, it has become our therapy of choice and perhaps has lowered our threshold for leaving the chest open after cardiac surgery.