The Sunscreen for Kindergarteners (SKIN) Study trial protocol.

BACKGROUND: Exposure to ultraviolet radiation (UVR) is the major modifiable risk factor for skin cancers. The majority of lifetime UVR exposure occurs before age 20, underscoring an important window for risk reduction. Incorporation of skills-based sunscreen education into school health curricula may foster the development of consistent and effective use of sunscreen among children and youth. We describe the study protocol for a first-of-its-kind study that examined the feasibility of bringing skills-based sunscreen education into kindergarten classrooms. METHODS: Participants were 96 kindergarten students across four classrooms in a single elementary school. A single-blind open-label trial design was used to evaluate the feasibility of incorporating a song-based, video-guided intervention for independent application of sunscreen into the kindergarten curriculum. Students first completed a 10-day no-intervention baseline period, followed by a 10-day intervention period, and then a 10-day randomized follow-up period where students were randomly assigned to continue with the intervention or to revert to the no-intervention condition. OUTCOMES: Feasibility metrics associated with study process, resources, management, scientific outcomes and safety were gathered. The primary outcome was pre-to-post intervention changes in student engagement in the sunscreen task. The secondary outcome was pre-to-post intervention changes in the proportion of exposed skin to which a student applies sunscreen. Teacher and student perceptions of intervention value and utility were also evaluated. DISCUSSION: This is the study protocol for a clinical trial designed to determine the feasibility of implementing a skills-based sunscreen curriculum in kindergarten classrooms. Next steps include evaluation of the intervention for efficacy and effectiveness. CLINICAL TRIAL REGISTRATION: NCT03752736.

Peripheral T-cell lymphoma with erysipelaslike spread.

An 88-year-old man from the Dominican Republic with a history of gastric adenocarcinoma was admitted with one month of fatigue, anorexia, weight loss, and abdominal pain. The dermatology department was consulted to evaluate an asymptomatic, shiny, firm, red nodule on the lower left chest, with an expanding rim of erythema. Skin biopsies were performed from the nodule and surrounding rim of erythema, which were both diagnostic of peripheral T-cell lymphoma (PTCL). This case is a unique example of PTCL with erysipelaslike spread.

Persistent erythema multiforme and CMV infection.

Persistent erythema multiforme is a rare disorder with only 23 known cases reported in the literature. Persistent erythema multiforme has been reported in association with Epstein-Barr virus, herpes virus, hepatitis C virus, influenza, inflammatory bowel disease, and a variety of neoplasms. To our knowledge, this case is the first case of persistent erythema multiforme reported in association with cytomegalovirus infection.

Acquired ichthyosis as a manifestation of acute cutaneous graft-versus-host disease.

Acquired ichythosis has been described in adult hematopoietic stem cell transplant recipients. While some authors have suggested the association of acquired ichythosis with cutaneous graft-versus-host disease, the evidence to support this association is rare. We describe a patient who developed enteritis secondary to acute graft-versus-host disease and had concomitant ichthyosiform lesions. Several months later, he was diagnosed with cutaneous graft-versus-host disease. This patient is presented to suggest that acquired ichthyosis is an underrecognized manifestation of acute cutaneous graft-versus-host disease. Given the important prognostic implications of this diagnosis, we recommend a low threshold for performing a skin biopsy to rule out GVHD in the appropriate clinical setting.

Extranodal nasal-type natural killer T-cell lymphoma in an adolescent from Bangladesh.

Natural killer (NK)-cell neoplasms are relatively uncommon tumors. Classification schemes prior to that of the World Health Organization (2001) did not account clearly for these neoplasms. Advances in immunohematology over the past 10 years have aided in the recognition and categorization of NK-cell tumors. One type of tumor that belongs to this class is extranodal, nasal-type NK/T-cell lymphoma. These lymphoma cells express a cytotoxic T-cell or NK-cell phenotype, including CD56 and TIA-1. Nasal-type NK/T-cell lymphomas arise from extranasal sites such as the skin and are often associated with Epstein-Barr virus infection. Asian adults are affected most commonly. Very few pediatric cases are reported in the literature, of which only 5 presented with cutaneous involvement. We report a case of an adolescent Bangladeshi boy with extranodal, nasal-type NK/T-cell lymphoma who had cutaneous nodules on the extremities.

Reference values for long echo time MR spectroscopy in healthy adults.

BACKGROUND AND PURPOSE: There is a lack of information with regard to normal metabolic ratios acquired with MR spectroscopy utilizing a long echo time technique. Our purpose was to measure metabolic ratios in healthy adults to determine whether the metabolites varied across brain regions and by sex. METHODS: Single voxel proton spectra were acquired with an echo time of 135 milliseconds in 10 brain regions of 72 healthy subjects ranging in age from 20 to 44 years. Six gray matter sites in the cerebrum included four cortical areas in the frontal, parietal, temporal, and occipital lobes, and two deep nuclear sites in the basal ganglia and the thalamus. Two subcortical white matter regions were in the parietal and the frontal lobes. Two posterior fossa sites included the pons and the cerebellum. All 10 brain regions were not studied in each subject. For each spectrum, the metabolites n-acetylaspartate (NAA), creatine (Cr), and choline (Ch) were identified and ratios of NAA/Cr and Ch/Cr calculated for each brain region. A multifactorial analysis of variance was performed with the two metabolic ratios as dependent variables and with brain region and sex as independent variables. Post hoc statistical analysis consisted of the Scheffé F statistic for significant difference between pairs of brain regions for both metabolic ratios. RESULTS: There was significant regional variation for both the NAA/Cr ratio (P < .0001) and the Ch/Cr ratio (P < .0001). The NAA/Cr ratio was consistent within cortical gray and white matter but differed between cortical gray (smaller ratio) and white matter (larger ratio). The Ch/Cr ratio was variable in the gray matter, differed between some but not all gray and white matter regions, but was consistent within subcortical white matter regions. There was no difference between men and women for either metabolic ratio. CONCLUSION: There was variation of the NAA/Cr ratio and the Ch/Cr ratio across brain regions, but no sex differences were found. These findings provide the requisite normative values to use single voxel, long-echo-time MR spectroscopy in adult patients with neurologic disorders.

Netherton syndrome with extensive skin peeling and failure to thrive due to a homozygous frameshift mutation in SPINK5.

BACKGROUND: Netherton syndrome (NTS) is a rare autosomal recessive multisystem disorder characterized by congenital erythroderma and ichthyosis, hair shaft abnormalities and immune dysregulation. The disorder is caused by deleterious mutations in the SPINK5 gene, encoding the serine protease inhibitor LEKTI. OBJECTIVE: Our objective was to investigate if the erythrodermic variant of peeling skin syndrome is also caused by SPINK5 mutations and to study the consequences of the disease on infantile brain development. METHODS: In an infant with extensive erythroderma, peeling skin and failure to thrive, we analyzed the SPINK5 gene for pathogenic mutations by direct DNA sequencing and performed repeated brain MRI studies with diffusion-weighted imaging. RESULTS: We identified a homozygous 4-base-pair insertion in exon 5 of SPINK5, which introduces a premature termination codon and appears to be a common mutation among West Indies islanders. MRI analyses revealed a persistent diffuse volume loss. CONCLUSION: Our results confirm that early truncation mutations of the coding sequence of SPINK5 produce a severe phenotype and that generalized peeling skin is one of the manifestations of NTS. We further demonstrate for the first time that NTS may be associated with MRI abnormalities indicative of a permanent tissue injury of the brain.