The Role of the Cutaneous Microbiome in Hidradenitis Suppurativa-Light at the End of the Microbiological Tunnel.

The development of next generation sequencing, coupled with advances in bio-informatics, has provided new insights into the role of the cutaneous microbiome in the pathophysiology of a range of inflammatory skin diseases. In fact, it has even been suggested that the identification of specific skin microbial signatures may not only be useful in terms of diagnosis of skin diseases but they may also ultimately help inform personalised treatment strategies. To date, research investigating the role of microbiota in the development of inflammatory skin diseases has largely focused on atopic eczema and psoriasis vulgaris. The role of the microbiome in Hidradenits suppurativa (HS)-also known as acne inversa-a chronic auto-inflammatory skin disease associated with significant morbidity, has received comparatively little attention. This is despite the fact that antimicrobial therapy plays a central role in the treatment of HS. After briefly outlining the clinical features of HS and current treatment strategies, we move on to review the evidence of microbial dysbiosis in HS pathophysiology. We conclude by outlining the potential for metagenomic studies to deepen our understanding of HS biology but more importantly to identify novel and much needed treatment strategies.

The reporting of race and/or ethnicity in the medical literature: a retrospective bibliometric analysis confirmed room for improvement.

OBJECTIVES: Although the collection of race and/or ethnicity data is an important way to identify and address inequalities in health care provision and disparities in access to treatment, studies examining the extent to which race and/or ethnicity data are reported in the medical literature, and the quality of these data, are lacking. Therefore, we sought to objectively determine the quality of reporting of race and/or ethnicity in original medical research papers. STUDY DESIGN AND SETTING: A retrospective bibliometric analysis was used. Two independent investigators analyzed original articles investigating race/ethnicity, published between 2007 and 2018, in the 10 top-ranking academic journals in each of the following categories: general medicine, surgery, and oncology. RESULTS: A total of 995 original articles were included in our analysis. Only 45 studies (4.52%) provided a formal definition of race/ethnicity, and 8.94% identified the investigator responsible for the classification. While race/ethnicity was a key part of study design in 31.86% of the included investigations, the method used to classify individuals into racial/ethnic groups was described in only 10.25% of articles. In terms of terminology, we identified 81 different race/ethnicity classifications, but these were often imprecise and open to interpretation. CONCLUSION: There is significant room for improvement in the collection, reporting, and publishing of data describing ethnicity and/or race in the medical literature.

No need to change the drug class: ixekizumab- following secukinumab-therapy in psoriasis.

BACKGROUND: Regarding treatment of psoriasis, dermatologists now use new, highly effective targeted therapies. Among such, biologic therapies have become a mainstay in patients with moderate to severe psoriasis; yet, a substantial proportion of patients show insufficient or no treatment response. Current literature has insufficient evidence for successful treatment when switching biologics after multiple failures, in particular when the biologics share a common mechanism of action. OBJECTIVES: To compile a case series of patients with moderate to severe psoriasis who had primary or secondary loss of response to multiple previous systemic treatments. We specifically focused on patients recently treated with the anti-IL-17A antibody secukinumab, who further received the anti-IL-17A antibody ixekizumab as subsequent therapy. PATIENTS AND METHODS: We performed a retrospective cohort analysis. Inclusion criteria were patients with moderate to severe psoriasis vulgaris (as defined by European consensus and the German guidelines), who have previously been treated with systemic therapies including three or more biological therapies. All patients treated with anti-IL-17A antibody secukinumab experienced a primary and/or secondary treatment failure and subsequently received the anti-IL-17A antibody ixekizumab. The primary outcome was treatment response to ixekizumab using PASI score; the secondary outcome was incidence of adverse events. RESULTS: Twelve patients were included. At week 6 of ixekizumab treatment, PASI 75 was achieved in 91.7%, PASI 90 in 66.7%, PASI 100 in 8.3% of patients. At week 12, PASI 75 was achieved in 100%, PASI 90 in 100%, PASI 100 in 58.3% of the cohort. Throughout the observation period, no severe adverse events were observed. CONCLUSIONS: Ixekizumab proved to be an effective and safe therapeutic option for patients with prior systemic therapies, including biological treatments with the same mechanism of action. Thus, failure of secukinumab does not preclude future therapy success with a second IL-17A-directed therapy.

Man against machine: diagnostic performance of a deep learning convolutional neural network for dermoscopic melanoma recognition in comparison to 58 dermatologists.

Background: Deep learning convolutional neural networks (CNN) may facilitate melanoma detection, but data comparing a CNN's diagnostic performance to larger groups of dermatologists are lacking. Methods: Google's Inception v4 CNN architecture was trained and validated using dermoscopic images and corresponding diagnoses. In a comparative cross-sectional reader study a 100-image test-set was used (level-I: dermoscopy only; level-II: dermoscopy plus clinical information and images). Main outcome measures were sensitivity, specificity and area under the curve (AUC) of receiver operating characteristics (ROC) for diagnostic classification (dichotomous) of lesions by the CNN versus an international group of 58 dermatologists during level-I or -II of the reader study. Secondary end points included the dermatologists' diagnostic performance in their management decisions and differences in the diagnostic performance of dermatologists during level-I and -II of the reader study. Additionally, the CNN's performance was compared with the top-five algorithms of the 2016 International Symposium on Biomedical Imaging (ISBI) challenge. Results: In level-I dermatologists achieved a mean (±standard deviation) sensitivity and specificity for lesion classification of 86.6% (±9.3%) and 71.3% (±11.2%), respectively. More clinical information (level-II) improved the sensitivity to 88.9% (±9.6%, P = 0.19) and specificity to 75.7% (±11.7%, P < 0.05). The CNN ROC curve revealed a higher specificity of 82.5% when compared with dermatologists in level-I (71.3%, P < 0.01) and level-II (75.7%, P < 0.01) at their sensitivities of 86.6% and 88.9%, respectively. The CNN ROC AUC was greater than the mean ROC area of dermatologists (0.86 versus 0.79, P < 0.01). The CNN scored results close to the top three algorithms of the ISBI 2016 challenge. Conclusions: For the first time we compared a CNN's diagnostic performance with a large international group of 58 dermatologists, including 30 experts. Most dermatologists were outperformed by the CNN. Irrespective of any physicians' experience, they may benefit from assistance by a CNN's image classification. Clinical trial number: This study was registered at the German Clinical Trial Register (DRKS-Study-ID: DRKS00013570; https://www.drks.de/drks_web/).

Reduction of Acute Shoulder Dislocations in a Remote Environment: A Prospective Multicenter Observational Study.

OBJECTIVE: Acute dislocations of the glenohumeral joint are common in wilderness activities. Emergent reduction should take place at the site of trauma to reduce the patient's pain and the risk of vascular and neurological complications. A limited number of reduction methods are applicable in remote areas. The aim of this study is to present our method of reduction of anterior shoulder luxation that is easily applicable in remote areas without medication, adjuncts, and assistants and is well tolerated by patients. METHODS: A prospective observational study was conducted during a 5-year period. The patients included underwent closed manual reduction with our technique. After each reduction, the physician who performed the reduction completed a standardized detailed history, and reexamined the patient (for acute complications). The patients were contacted 6 months after the trauma to investigate long-term postreduction complications. RESULTS: Reduction was achieved with our method in 39 (100.0%) of 39 patients. The mean pain felt during our reduction procedure was rated 1.7 ± 1.4 (on a scale of 10) using the visual analog scale scoring system. No complications were noted before or after the reduction attempts. We did not find any long-term complications. CONCLUSIONS: The reduction method presented in the present study is an effective method for the reduction of acute shoulder luxations in remote places. Our data suggest that this method could be applied for safe and effective reduction of shoulder dislocation.

Minimal-access video-assisted thyroidectomy for benign disease: a retrospective analysis of risk factors for postoperative complications.

BACKGROUND: Minimal-access video-assisted thyroidectomy (MIVAT) has now become a widespread technique in the treatment of benign thyroid disease. No studies systematically investigate risk factors for postoperative complications. The aim of our study was to investigate possible risk factors for postoperative complications in MIVAT in patients with benign disease. METHODS: One-hundred eighty-nine patients who underwent MIVAT for benign disease were retrospectively identified in a prospectively-maintained institutional register of thyroid surgery. Exclusion criteria were: (1) thyroid volume>45 mL; (2) malignant disease; (3) prior neck surgery; (4) prior neck irradiation; (5) nodule size>3 cm; (6) intrathoracic component; (7) follow-up<1 year. Age, sex, comorbidities, body mass index, existence of symptoms, duration of disease evolution, thyroid volume, hyperthyroidism, thyroiditis, and the duration of surgery were analyzed as risk factors for complications. We applied both bivariate and multivariate logistic regression analyses in order to identify risk factors associated with postoperative complications. RESULTS: Complications were presented by 28 patients (14.8%). The variables associated as independent risk factors with these complications were hyperthyroidism (OR = 4.31; P = 0.003) and thyroiditis (OR = 3.59; P = 0.035). Age, sex and thyroid volume up to 45 mL do not seem to be independent risk factors. CONCLUSIONS: In endocrine surgery units, two independent risk factors for postoperative complications could be identified in MIVAT patients: hyperthyroidism and thyroiditis. Surgeons operating on patients presenting these factors should be aware of the potential augmented risk in order to correctly adapt intraoperative and postoperative care.

Postoperative ulnar neuropathy is not necessarily iatrogenic: a prospective study on dynamic ulnar nerve dislocation at the elbow.

BACKGROUND: Patients who undergo surgery may develop ulnar neuropathy. Although the mechanism of ulnar neuropathy is still not clear, ulnar neuropathies are common causes of successful lawsuits against surgeons. Recently, the concept developed that endogenous patient factors can lead to postoperative peripheral neuropathies. We hypothesize that dynamic ulnar nerve dislocation at the elbow (DUNDE) may be a predisposing factor for ulnar irritation (i.e., neuropathy) in normal subjects. METHODS: In a prospective investigation, patients aged 20 years and older presenting in our emergency department were asked to participate. Three physicians examined both elbows of subjects included in our study for evidence of DUNDE (through clinical and sonographic examination) and for clinical symptoms related to ulnar neuropathy. RESULTS: Dynamic ulnar nerve dislocation was observed in 29.3% of examined subjects. No significant difference in its occurrence was observed in relation to gender or dominant side. Physical examination with provocation tests demonstrated significantly more positive Tinel tests and spontaneous signs of neuropathy in patients with dynamic dislocating ulnar nerves (14.7 vs. 1.1%). CONCLUSION: Dynamic ulnar nerve dislocation may be linked to ulnar nerve irritability (i.e., ulnar neuropathy) in normal subjects without history of trauma, surgical procedure, or anesthesia. Considering the high incidence of this variant in the general population, our study supports previous investigations suggesting that many postoperative ulnar nerve deficits are traceable to chronic patient conditions. Our study suggests that dynamic ulnar nerve dislocation is a predisposing factor in the development of ulnar neuropathy in the postoperative period. NOTES: (1) neuropathy should be viewed as a broad definition as signs of nerve irritation/inflammation, and independently of the pathophysiology and etiology; (2) because no specific term exists in the international anatomic nomenclature (Nomina Anatomica) to designate this variant, several synonyms have been used in the literature, leading to confusion and misleading conclusions concerning its traumatic etiologies and their consequences: (a) recurrent or habitual ulnar nerve luxation (or subluxation); (b) recurrent or habitual ulnar nerve dislocation; (c) ulnar nerve instability; (d) laxity of the ulnar nerve; and (e) ulnar nerve hypermobility.

Effect of advanced trauma life support (ATLS) on the time needed for treatment in simulated mountain medicine emergencies.

OBJECTIVE: The number of tourists exploring mountainous areas continues to increase. As a consequence, rescue operations are increasing, especially for trauma and polytrauma victims. The outcome of such patients depends greatly on the duration of the prehospital stabilization. Limited medical training of mountain rescuers may adversely affect the outcome of patients. There is no study investigating high altitude trauma treatment. The aim of this study is to analyze the impact of advanced trauma life support (ATLS) principles in mountain trauma, and to discuss a possible role of ATLS in mountain medicine education programs. METHODS: We designed 5 tasks representing life-threatening trauma problems encountered in mountain rescue. They were used to evaluate the physician's ability to adequately diagnose and react to trauma situations. We created 2 groups: 1) the ATLS group, consisting of physicians who passed the ATLS course and the mountain medicine course, and 2) the non-ATLS group, consisting of physicians who did not obtain the ATLS training but who did pass the mountain medicine course. We compared the time spent to complete the tasks in both groups. RESULTS: In 4 of the 5 tasks (airway, breathing, circulation, and combination), the ATLS group completed the task significantly faster. In the environment task, however, the ATLS group was slower. This was the only not significant result. CONCLUSIONS: ATLS principles adapted and implemented for high altitude medicine education may have a positive impact on high altitude trauma treatment and outcomes.

Occurrence and significance of odontoid lateral mass interspace asymmetry in trauma patients.

BACKGROUND: The odontoid lateral mass interspace (OLMI) is the space between the lateral aspect of the dens axis and the medial circumference of the massa lateralis atlantis. The position of OLMI asymmetry as a normal variant or pathologic finding is an area of debate and clinical interest in trauma patients. We designed this prospective study to lay a framework for proposing strategies for the appropriate use of OLMI. METHODS: A total of 301 adult patients admitted for trauma were included. Computed tomography (CT) and magnetic resonance imaging (MRI) of the cervical spine were performed and examined for the presence OLMI asymmetry and bony/ligamentous lesions of the occipitoatlantoaxial complex. RESULTS: Head rotation is linked to the occurrence of OLMI asymmetry. Reliable OLMI asymmetry evaluation is limited by observer agreement under a threshold value of 1.0 mm. In all, 86 patients (28.6 %) were found to have OLMI asymmetry on CT after trauma. Among these patients, 17.4 % had a bony/ligamentous lesion of the occipitoatlantoaxial complex. Among the patients without OLMI asymmetry, 8.8 % were found to have such lesions. CONCLUSIONS: OLMI asymmetry should only be investigated by CT scans of the head in optimal position and with the threshold value of 1.0 mm. OLMI asymmetry should not be used alone as a sign of a cervical spine lesion. MRI should be performed if: (1) the physician has a high degree of suspicion of a cervical spine lesion; (2) OLMI asymmetry was demonstrated on a technically adequate CT scan; (3) clinical symptoms persist in patients with OLMI asymmetry when no acute MRI was performed.

Effects of a cost-effective surgical workflow on cosmesis and patient's satisfaction in open thyroid surgery.

PURPOSE: In thyroid surgery, minimally invasive procedures are thought to improve cosmesis and patient's satisfaction. However, studies using standardized tools are scarce, and results are controversial. Moreover, minimally invasive techniques raise the question of material costs in a context of health spending cuts. The aim of the present study is to test a cost-effective surgical workflow to improve cosmesis in conventional open thyroid surgery. METHODS: Our study ran between January 2009 and November 2010, and was based on a prospectively maintained thyroid surgery register. Patients operated for benign thyroid diseases were included. Since January 2010, a standardized surgical workflow was used in addition to the reference open procedure to improve the outcome. Two groups were created: (1) G1 group (patients operated with the reference technique), (2) G2 group (patients operated with our workflow in addition to reference technique). Patients were investigated for postoperative outcomes, self-evaluated body image, cosmetic and self-confidence scores. RESULTS: 820 patients were included in the present study. The overall body image and cosmetic scores were significantly better in the G2 group (P < 0.05). No significant difference was noted in terms of surgical outcomes, scar length, and self-confidence. CONCLUSIONS: Our surgical workflow in conjunction with the reference technique is safe and shows significant better results in terms of body image and cosmesis than do the reference technique alone. Thus, we recommend its implementation in order to improve outcomes in a cost-effective way. The limitations of the present study should be kept in mind in the elaboration of future studies.