Isotretinoin's Effect on Fasting Lipid Profile in Acne Patients.

OBJECTIVE: To determine the isotretinoin's effect on fasting lipid profile in patients with acne. STUDY DESIGN: Observational study. Place and Duration of the Study: Outpatient Department of Dermatology, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan, from 22nd June to 21st December 2022. METHODOLOGY: Patients of clinically moderate and severe acne were selected and prescribed a dose of 0.5mg /kg cap isotretinoin for 6 months. They were advised to get a fasting lipid profile at the baseline and then after two months of isotretinoin therapy. National Cancer Institute Common Terminology Criteria for Adverse Events v5.0 grading system and Adult Treatment Panel III were used for the grading of abnormalities. McNemar Bowker test was used to assess the difference in variables [serum triglycerides (TGs), cholesterol, high-density lipoproteins (HDL), and low-density lipoproteins (LDL)] at the baseline and after 2 months follow-up. RESULTS: A total of 214 patients were evaluated. After 2 months of isotretinoin therapy, TGs and cholesterol levels were elevated to higher grade in 2% of the patients. Likewise in 1% of patients, LDL levels rised to higher grade. Moreover, HDL levels declined to lower grade in 2% of the patients taking isotretinoin. CONCLUSION: Insignificant alterations in the various serum lipid parameters were observed in acne patients during isotretinoin therapy. It is advisable to obtain a baseline fasting lipid profile in all acne patients on isotretinoin and repeated in those with baseline abnormal levels and in patients with a clinical sign of metabolic syndrome and a family history of dyslipidemias. KEY WORDS: Acne, Hyperlipidemias, Isotretinoin, Laboratory monitoring.

Effect of Intense Pulsed Light versus Intradermal Tranexamic Acid for the Management of Melasma.

OBJECTIVE: To compare the effectiveness of intense pulsed light (IPL) and intradermal tranexamic acid (TXA) in treating melasma. STUDY DESIGN: A cross-sectional analytical study. Place and Duration of the Study: Department of Dermatology, Dow International Medical College, Dow University Hospital, Karachi, Pakistan, from 15th January to 15th July 2023. METHODOLOGY: A total of 62 patients with melasma, aged 20-50 years, were divided into two groups. Group A (32 patients) received IPL (560 nm filter was used) treatment, and Group B (30 patients) received intradermal TXA. Each group underwent four treatment sessions with varying intervals. Melasma area and severity index (MASI) scores were used to compare the effects of treatment. RESULTS: After a 3-month treatment period, both groups showed reduced mMASI scores compared to baseline with a significant initial difference between Group A (8.6 ± 4.2) and Group B (5.4 ± 2.7, p <0.001). However, post-treatment, there was no significant difference in mMASI scores (Group A: 3.8 ± 2.6; Group B: 3.2 ± 2.0, p = 0.29). IPL treatment (Group A) demonstrated a significant reduction in mMASI scores (57.1 ± 19.7) compared to intradermal TXA treatment (Group B, 42.2 ± 18.8, p = 0.0034). CONCLUSION: Both IPL and intradermal TXA treatments effectively reduced melasma, with IPL exhibiting superior results. However, post-treatment outcomes converged, emphasising the need for personalised approaches considering the unique characteristics of South East Asian skin. KEY WORDS: Intense pulsed light, Melasma, Intradermal tranexamic acid.

Association of Vitamin D with Moderate to Severe Acne Vulgaris.

OBJECTIVE: To determine the association of vitamin D deficiency in moderate to severe acne. STUDY DESIGN: A comparative study. Place and Duration of the Study: Dermatology OPD at Dow University of Health Sciences, Karachi, Pakistan, from December 2021 to May 2022. METHODOLOGY: Fifty patients with moderate acne, 50 patients with severe acne, and 50 healthy controls were inducted. Information regarding age, gender, and medical and medication history were taken. The severity of acne was rated according to the GAGS (global acne grading system) score. Levels of 25(OH) D were classified as sufficient (>20 ng/mL), insufficient (12-20 ng/mL), or deficient (<12 ng/mL). Significance was taken at p-value <0.05. RESULTS: The median concentration of vitamin D levels was 7.09 ng/ml in severe acne vulgaris, 13.7 ng/ml in moderate acne vulgaris and 21.6ng/ml in the control group. Serum vitamin D levels were significantly lower (p<0.001) in individuals with acne vulgaris as compared to the healthy controls. However, the decrease in level of vitamin D did not correspond with the severity of acne vulgaris. CONCLUSION: Vitamin D deficiency is additionally pronounced in acne vulgaris individuals, but vitamin D levels are not proportional to the severity of acne vulgaris. KEY WORDS: Acne vulgaris, Vitamin D deficiency, Pilosebaceous unit, GAGS score.

Digital health, cardiometabolic disease and ethnicity: an analysis of United Kingdom government policies from 2010 to 2022.

Recent health policies in the United Kingdom (UK) and internationally have focussed on digitisation of healthcare. We examined UK policies for evidence of government action addressing health inequalities and digital health, using cardiometabolic disease as an exemplar. Using a systematic search methodology, we identified 87 relevant policy documents published between 2010 and 2022. We found increasing emphasis on digital health, including for prevention, diagnosis and management of cardiometabolic disease. Several policies also focused on tackling health inequalities and improving digital access. The COVID-19 pandemic amplified inequalities. No policies addressed ethnic inequalities in digital health for cardiometabolic disease, despite high prevalence in minority ethnic communities. Our findings suggest that creating opportunities for digital inclusion and reduce longer-term health inequalities, will require future policies to focus on: the heterogeneity of ethnic groups; cross-sectoral disadvantages which contribute to disease burden and digital accessibility; and disease-specific interventions which lend themselves to culturally tailored solutions.

Students' and tutors' experiences of remote 'student-patient' consultations.

BACKGROUND: Remote consulting has become part of the medical student clinical experience in primary care, but little research exists regarding the impact on learning. AIM: To describe the experiences of General Practitioner (GP) educators and medical students in using student-led remote consultations as an educational tool. METHOD: A qualitative, explorative study conducted at four UK medical schools. GP educators and medical students were purposively sampled and interviewed. RESULTS: Nine themes arose: practical application, autonomy, heuristics, safety, triage of undifferentiated patients, clinical reasoning, patient inclusion in student education, student-patient interaction, and student-doctor interaction. DISCUSSION: Remote consulting has become part of the clinical placement experience. This has been found to expose students to a wider variety of clinical presentations. Verbal communication, history-taking, triage, and clinical reasoning skills were practised through remote consulting, but examination skills development was lacking. Students found building rapport more challenging, although this was mitigated by having more time with patients. Greater clinical risk was perceived in remote consulting, which had potential to negatively impact students' psychological safety. Frequent debriefs could ameliorate this risk and positively impact student-doctor relationships. Student autonomy and independence increased due to greater participation and responsibility. Pre-selection of patients could be helpful but had potential to expose students to lower complexity patients.[Box: see text].

The Use of Digital Health Interventions for Cardiometabolic Diseases Among South Asian and Black Minority Ethnic Groups: Realist Review.

BACKGROUND: Digital health interventions (DHIs) for the prevention and management of cardiometabolic diseases have become increasingly common. However, there is limited evidence for the suitability of these approaches in minority ethnic populations, who are at an increased risk of these diseases. OBJECTIVE: This study aimed to investigate the use of DHIs for cardiovascular disease and type 2 diabetes among minority ethnic populations in countries with a majority of White, English-speaking populations, focusing on people who identified as South Asian, Black, or African American. METHODS: A realist methodology framework was followed. A literature search was conducted to develop context-mechanism-outcome configurations, including the contexts in which DHIs work for the target minority ethnic groups, mechanisms that these contexts trigger, and resulting health outcomes. After systematic searches, a qualitative analysis of the included studies was conducted using deductive and inductive coding. RESULTS: A total of 15 studies on the uptake of DHIs for cardiovascular disease or diabetes were identified, of which 13 (87%) focused on people with an African-American background. The review found evidence supporting the use of DHIs in minority ethnic populations when specific factors are considered in implementation and design, including patients' beliefs, health needs, education and literacy levels, material circumstances, culture, social networks, and wider community and the supporting health care systems. CONCLUSIONS: Our context-mechanism-outcome configurations provide a useful guide for the future development of DHIs targeted at South Asian and Black minority ethnic populations, with specific recommendations for improving cultural competency and promoting accessibility and inclusivity of design.

Frameworks for Implementation, Uptake, and Use of Cardiometabolic Disease-Related Digital Health Interventions in Ethnic Minority Populations: Scoping Review.

BACKGROUND: Digital health interventions have become increasingly common across health care, both before and during the COVID-19 pandemic. Health inequalities, particularly with respect to ethnicity, may not be considered in frameworks that address the implementation of digital health interventions. We considered frameworks to include any models, theories, or taxonomies that describe or predict implementation, uptake, and use of digital health interventions. OBJECTIVE: We aimed to assess how health inequalities are addressed in frameworks relevant to the implementation, uptake, and use of digital health interventions; health and ethnic inequalities; and interventions for cardiometabolic disease. METHODS: SCOPUS, PubMed, EMBASE, Google Scholar, and gray literature were searched to identify papers on frameworks relevant to the implementation, uptake, and use of digital health interventions; ethnically or culturally diverse populations and health inequalities; and interventions for cardiometabolic disease. We assessed the extent to which frameworks address health inequalities, specifically ethnic inequalities; explored how they were addressed; and developed recommendations for good practice. RESULTS: Of 58 relevant papers, 22 (38%) included frameworks that referred to health inequalities. Inequalities were conceptualized as society-level, system-level, intervention-level, and individual. Only 5 frameworks considered all levels. Three frameworks considered how digital health interventions might interact with or exacerbate existing health inequalities, and 3 considered the process of health technology implementation, uptake, and use and suggested opportunities to improve equity in digital health. When ethnicity was considered, it was often within the broader concepts of social determinants of health. Only 3 frameworks explicitly addressed ethnicity: one focused on culturally tailoring digital health interventions, and 2 were applied to management of cardiometabolic disease. CONCLUSIONS: Existing frameworks evaluate implementation, uptake, and use of digital health interventions, but to consider factors related to ethnicity, it is necessary to look across frameworks. We have developed a visual guide of the key constructs across the 4 potential levels of action for digital health inequalities, which can be used to support future research and inform digital health policies.

Erythrodermic Psoriasis and Hepatitis C Infection Treated with Pegylated Interferon and Anti-TNFα α(Etanercept) Therapy.

Treatment of psoriasis and its variants with concomitant hepatitis C virus (HCV) infection is complex. The treatment options are limited because the immunosuppressive drugs used for managing severe psoriasis are mostly associated with end-organ damage particularly hepatotoxicity. On the other hand, Interferon therapy has the potential to exacerbate psoriasis and psoriatic arthropathy. There is emerging data regarding the use of etanercept, a TNFα inhibitor in such cases. Though its cost and availability limits its use; but when combined with Interferon therapy and ribavirin for HCV, it has shown good results. Here, we report a case of 28-year male, suffering from erythrodermic psoriasis with arthropathy and concomitant HCV infection, who was successfully treated with etanercept and pegylated interferon and ribavirin. Pegylated interferon was given for 6 months and etanercept for 8 months. At the end of the therapy, not only the patient's polymervese chain reaction (PCR) for HCV became undetectable, but his erytherodermic state also improved.

Multifaceted interventions improve adherence to the surgical checklist.

INTRODUCTION: Adherence to surgical safety checklists remains challenging. Our institution demonstrated acceptable rates of checklist utilization but poor adherence to all checkpoints. We hypothesized that stepwise, multifaceted interventions would improve checklist adherence. METHODS: From 2011 to 2013, adherence to the 14-point, pre-incision checklist was assessed directly by trained observers during three, 1-year periods (baseline, observation #1, and observation #2) during which interventions were implemented. Interventions included safety workshops, customization of a stakeholder-derived checklist, and implementation of a report card system. Chi-square and Kruskal-Wallis tests were utilized. RESULTS: Checklist performance was assessed for 873 cases (baseline, n = 144; observation #1, n = 373; observation #2, n = 356). Total checkpoint adherence increased (from 30% to 78% to 96%; P < .001), as did cases with correct completion of all checkpoints (from 0% to 19% to 61%; P < .001). The median (interquartile range) number of checkpoints completed per case improved from 4 (3-5) to 11 (10-12) to 14 (13-14; P < .001). CONCLUSION: A strategic, multifaceted approach to perioperative safety significantly improved checklist adherence over 2 years. Checklist content and process need to reflect local interests and operative flow to achieve high adherence rates. Successful checklist implementation requires efforts to change the safety culture, stakeholder buy-in, and sustained efforts over time.