Would You Rather: Quantifying Traumatic Brain Injury Survivor Perceptions of Functional Status Through Their Surrogates.

OBJECTIVE: To quantify health utilities of the Glasgow Outcome Scale-Extended (GOSE) states after actual traumatic brain injury (TBI). BACKGROUND: Recovery after TBI is measured using the GOSE, a validated clinical trial endpoint. A recent public survey quantified the health utilities of some GOSE states after hypothetical TBI as worse than death. However, no health utilities exist for disability after actual TBI. METHODS: This national computer-adaptive survey followed Enhancing the Quality and Transparency of Health Research-Checklist for Reporting Results of Internet E-Surveys guidelines and recruited adult TBI survivors (injury >1 year prior) through their available surrogates. Using a standard gamble approach in randomized order, participants gave preferences for post-TBI categorical health states ranging from GOSE 2 to GOSE 8. We calculated median (interquartile range) health utilities for each GOSE state, from -1 (worse than death) to 1 (full health), with 0 as reference (death, GOSE 1). RESULTS: Of 515 eligible, 298 surrogates (58%) consented and completed the scenarios on TBI survivors' behalf. TBI survivors had a current median GOSE 5 (3-7). GOSE 2, GOSE 3, and GOSE 4 were rated worse than death by 89%, 64%, and 38%, respectively. The relationship was nonlinear, and intervals were unequal between states, with a bimodal distribution for GOSE 4. CONCLUSIONS: In this index study of actual post-TBI disability, poor neurological outcomes represented by GOSE 2 to GOSE 4 were perceived as worse than death by at least one in 3 survivors. Similar to previously reported public perceptions after a hypothetical TBI, these long-term perceptions may inform earlier post-TBI shared decision-making, as well as help shape value-based research and quality of care. LEVEL OF EVIDENCE: Level II-economic and value-based evaluations.

Surrogate Perception of Disability after Hospitalization for Traumatic Brain Injury.

BACKGROUND: The Glasgow Outcome Scale Extended (GOSE) is a measure of recovery after traumatic brain injury (TBI). Public surveys rate some GOSE states as worse than death. Direct family experience caring for patients with TBI may impact views of post-TBI disability. STUDY DESIGN: We conducted a national cross-sectional computer-adaptive survey of surrogates of TBI dependents incurring injury more than 1 year earlier. Using a standard gamble approach in randomized order, surrogates evaluated preferences for post-TBI GOSE states from GOSE 2 (bedridden, unaware) to GOSE 8 (good recovery). We calculated median (interquartile range [IQR]) health utilities for each post-TBI state, ranging from -1 to 1, with 0 as reference (death = GOSE 1), and assessed sociodemographic associations using proportional odds logistic regression modeling. RESULTS: Of 515 eligible surrogates, 298 (58%) completed scenarios. Surrogates were median aged 46 (IQR 35 to 60), 54% married, with Santa Clara strength of faith 14 (10 to 18). TBI dependents had a median GOSE5 (3 to 7). Median (IQR) health utility ratings for GOSE 2, GOSE 3, and GOSE 4 were -0.06 (-0.50 to -0.01), -0.01 (-0.30 to 0.45), and 0.30 (-0.01 to 0.80), rated worse than death by 91%, 65%, and 40%, respectively. Surrogates rated GOSE 4 (daily partial help) worse than the general population. Married surrogates rated GOSE 4 higher (p < 0.01). Higher strength of faith was associated with higher utility scores across GOSE states (p = 0.034). CONCLUSIONS: In this index study of surrogate perceptions about disability after TBI, poor neurologic outcomes-vegetative, needing all-day or partial daily assistance-were perceived as worse than death by at least 1 in 3 surrogates. Surrogate perceptions differed from the unexposed public. Long-term perceptions about post-TBI disability may inform earlier, tailored shared decision-making after neurotrauma.

Topical Moisturizer Meaningfully Reduces Disease Severity in Atopic Patients With Xerosis.

BACKGROUND: Repairing the epidermal barrier is critically important in atopic dermatitis (AD), but the effect of moisturizer on quality of life (QOL) is not well characterized.  Objective: To assess whether the use of a moisturizer improves QOL in atopic patients with xerosis.  Methods: Thirty-five (35) adults with xerosis and AD received a moisturizer designed for AD to apply daily for three months. Adherence was assessed with electronic monitors. Quality of life (QOL) was assessed with the Dermatology Life Quality Index (DLQI) at baseline and follow-up.  Results: Mean adherence to the moisturizer was 46%. Dryness improved from 1.9 at baseline to 1.4 at follow-up (P=0.02). DLQI improved from 3.3 at baseline to 1.5 at 3 months (P=0.005). The "feeling self-conscious or embarrassed due to their skin condition" DLQI item improved from 0.79 at baseline to 0.14 at 3 months (P=0.0009).  Conclusion: Moisturizers are the foundation of AD treatment. Even non-medicated topical emollients can improve QOL in patients with AD.  J Drugs Dermatol. 2023;22(12):e51-e52.     doi:10.36849/JDD.7036e.

Proficiency With Number Concepts and Operations: Replicating the Efficacy of a First-Grade Mathematics Intervention.

Conceptual replications are part and parcel of education science. Methodologically rigorous conceptual replication studies permit researchers to test and strengthen the generalizability of a study's initial findings. The current conceptual replication sought to replicate the efficacy of a small-group, first-grade mathematics intervention with 240 first-grade students with mathematics difficulties in a new geographical region. Participating students were randomized into one of three conditions: (a) 2:1 mathematics intervention group, (b) 5:1 mathematics intervention group, or (c) business-as-usual instruction. Relative to the original study, findings from the replication varied. When comparing the treatment groups to the control, results suggested positive effects on all outcome measures, including a follow-up assessment administered one year later. However, differences between the two treatment groups based on group size were not found in the mathematics outcome measures. Both groups also received commensurate levels of observed instructional interactions. Implications for unpacking contextual differences between original research and their replications as well as using future research to explore the quantity and quality of instructional interactions as ways to explain variation in findings of group size are discussed.

Topical Ivermectin Is Associated With Improved Erythematotelangiectatic, Papulopustular, and Phymatous Rosacea in a Secondary Analysis.

Rosacea has variable clinical presentation consisting of four overlapping phenotypes: erythematotelangiectatic, papulopustular, phymatous, and ocular.1 Rosacea's pathogenesis involves increased cutaneous density of Demodex folliculorum mites, which drive inflammation through activation of Toll-like receptor-2.1,2 Thus, topical ivermectin (IVM) 1.0% cream's anti-inflammatory and acaricidal activity provides an effective and targeted treatment for moderate-to-severe rosacea. However, literature assessing IVM is limited to efficacy in treating the papulopustular presentation, limiting generalizability.1,3,4 Although our primary endpoint was to assess patient adherence, the objective of this secondary analysis was to assess IVM efficacy in rosacea, regardless of clinical presentation.

Cidofovir in the Management of Non-Genital Warts: A Review.

INTRODUCTION: Cutaneous warts are one of the most frequent reasons for visits to the dermatologist. While there are many treatment options available and commonly used to treat warts, recurrence of lesions is common and complete clearance is rarely achieved. Cidofovir is an antiviral agent that has activity against various DNA viruses, including HPV, the virus that results in verrucae. OBJECTIVE: We examined the literature on the use of cidofovir in the treatment of non-genital warts to further assess its safety and efficacy.  Methods: A review of the literature using PubMed and Google Scholar databases was conducted to find relevant case reports and studies on the use of cidofovir in the treatment of non-genital warts.  Results: Thirteen case reports, five case series, six retrospective chart reviews, and one clinical study were reviewed and included. There were a total of 603 patients, 46.2% males and 53.7% females. Of 603 patients included in this review, 212 (35.2%) were treated with topical cidofovir for their warts. Clearance was achieved in 55.2%. There was no recurrence of lesions after clearance at two months to three years post-treatment (mean of 15.8 months). Of the 212 patients treated with topical cidofovir, 37 (17.4%) reported local side effects such as erythema, pruritus, and burning.  Discussion/Conclusion: Treatment options for recalcitrant non-genital warts are limited and have varying efficacy. Topical cidofovir may serve as an effective, safe, and affordable alternative for the clearance of recalcitrant non-genital warts, but controlled clinical trials are needed.J Drugs Dermatol. 2023;22(10):1009-1016  doi:10.36849/JDD.7258.

The Patient-Physician Relationship and Adherence: Observations From a Clinical Study.

Improved patient-physician relationships (PPR) are associated with better patient satisfaction and disease outcomes, however, there is limited literature assessing how PPR affects adherence in dermatology. We recruited 30 subjects with a clinical diagnosis of rosacea. Subjects were instructed to use ivermectin 1% cream once daily for 3 months and adherence was measured using the Medication Event Monitoring System cap. The Patient-Doctor Relationship Questionnaire (PDRQ-9), a validated questionnaire assessing patients’ perceived strength of the relationship with their doctor, was completed. Mean adherence for all subjects over three months of the study was 62%. PDRQ-9 scores positively correlated with adherence rates for 3 months of treatment (r(26)=0.52; P=0.006). The perceived strength of the PPR may have a role in patients’ adherence to their medications. Improving the PPR, through empathy and effective communication, may facilitate better medication adherence and treatment outcomes. Perche PO, Singh R, Cook MK, et al. The patient-physician relationship and adherence: observations from a clinical study. J Drugs Dermatol. 2023;22(8):838-839. doi:10.36849/JDD.7103.

Effect of propranolol and clonidine after severe traumatic brain injury: a pilot randomized clinical trial.

OBJECTIVE: To evaluate the safety, feasibility, and efficacy of combined adrenergic blockade with propranolol and clonidine in patients with severe traumatic brain injury (TBI). BACKGROUND: Administration of adrenergic blockade after severe TBI is common. To date, no prospective trial has rigorously evaluated this common therapy for benefit. METHODS: This phase II, single-center, double-blinded, pilot randomized placebo-controlled trial included patients aged 16-64 years with severe TBI (intracranial hemorrhage and Glasgow Coma Scale score ≤ 8) within 24 h of ICU admission. Patients received propranolol and clonidine or double placebo for 7 days. The primary outcome was ventilator-free days (VFDs) at 28 days. Secondary outcomes included catecholamine levels, hospital length of stay, mortality, and long-term functional status. A planned futility assessment was performed mid-study. RESULTS: Dose compliance was 99%, blinding was intact, and no open-label agents were used. No treatment patient experienced dysrhythmia, myocardial infarction, or cardiac arrest. The study was stopped for futility after enrolling 47 patients (26 placebo, 21 treatment), per a priori stopping rules. There was no significant difference in VFDs between treatment and control groups [0.3 days, 95% CI (- 5.4, 5.8), p = 1.0]. Other than improvement of features related to sympathetic hyperactivity (mean difference in Clinical Features Scale (CFS) 1.7 points, CI (0.4, 2.9), p = 0.012), there were no between-group differences in the secondary outcomes. CONCLUSION: Despite the safety and feasibility of adrenergic blockade with propranolol and clonidine after severe TBI, the intervention did not alter the VFD outcome. Given the widespread use of these agents in TBI care, a multi-center investigation is warranted to determine whether adrenergic blockade is of therapeutic benefit in patients with severe TBI. Trial Registration Number NCT01322048.

Dermatology through the lens of social media: A qualitative study among adolescents.

Social media (SM) use has accelerated at an unprecedented pace and dermatology literature evaluating SM use is primarily centered on the quality and quantity of dermatologic content, with minimal research on how adolescent patients experience such content. We recruited 15 patients between the ages of 13-18 years from the Atrium Health Wake Forest Baptist Department of Dermatology to interview regarding their experience with dermatologic content on SM. Despite most participants' insightful comments on SM use and the relative lack of dermatologic content validation on SM, many participants adopted skin care advice from SM. Adolescents are particularly vulnerable to social influence and it is important dermatologists understand how pervasive skin-related content is on these platforms.

Prevalence and Risk Factors for Intensive Care Unit Delirium After Traumatic Brain Injury: A Retrospective Cohort Study.

BACKGROUND: Delirium remains understudied after traumatic brain injury (TBI). We sought to identify independent predictors of delirium among intensive care unit (ICU) patients with TBI. METHODS: This single-center retrospective cohort study evaluated adult patients with TBI requiring ICU admission. Outcomes included delirium days within the first 14 days, as assessed by the Confusion Assessment Method-ICU (CAM-ICU). Models were adjusted for age, sex, insurance, Marshall head computed tomography classification, presence of subarachnoid hemorrhage (SAH), Injury Severity Score (ISS), need for cardiopulmonary resuscitation, maximum admission Glasgow Coma motor score, glucose level, hemoglobin level, and pupil reactivity. RESULTS: Delirium prevalence was 60%, with a median duration of 4 days (interquartile range: 2-8) among ICU patients with TBI (n = 2,664). Older age, higher ISS, maximum motor score < 6, Marshall class II-IV, and SAH were associated with risk of increased delirium duration (all p < 0.001). CONCLUSIONS: In this large cohort, ICU delirium after TBI affected three of five patients for a median duration of 4 days. Age, general injury severity, motor score, and features of intracranial hemorrhage were predictive of more TBI-associated delirium days. Given the high prevalence of ICU delirium after TBI and its impact on hospitalization, further work is needed to understand the impact of delirium and TBI on outcomes and to determine whether delirium risk can be minimized.

Perception of accountability decreases with age: observations from a clinical study of patients with rosacea.

Patient adherence to medications usually increases with age, however, it can also be impacted by other factors. Accountability is a psychosocial construct that is defined as the expectation for an individual to account for their actions. Accountability may also influence patients' motivation to adhere to their treatments. We assessed the relationship between age and perception of accountability as well as efficacy of interventions to improve accountability in a clinical study of 30 rosacea patients. Accountability was assessed using the validated Accountability Measurement Tool. Interventions to improve accountability included a digital interaction group and a digital skin analysis group. All patients were given ivermectin cream 1% and informed to apply it daily for 3-months. There was a negative association between age and AMT scores in all intervention groups, including the control group. Younger patients have a baseline greater perception of accountability that responded more to our interventions.

Abrocitinib: A New FDA-Approved Drug for Moderate-to-Severe Atopic Dermatitis.

OBJECTIVE: The objective of this article is to review abrocitinib, an oral Janus kinase (JAK) 1 inhibitor, for the treatment of patients with moderate-to-severe atopic dermatitis (AD). DATA SOURCES: A literature search of MEDLINE (PubMed) was performed for articles from inception through end-March 2022 using the following search terms: atopic dermatitis, abrocitinib, PF-04965842, methotrexate, cyclosporine, dupilumab, ruxolitinib, and JAK-STAT pathway. STUDY SELECTION AND DATA EXTRACTION: English articles relating to pharmacology, pharmacokinetics, efficacy, and safety of abrocitinib, and other conventional systemic medications for AD, were included. DATA SYNTHESIS: Across phase IIb and phase III clinical trials, abrocitinib was efficacious with an average of 47.5% patients on 200 mg abrocitinib and 32.0% on 100 mg abrocitinib achieving an Investigator's Global Assessment (IGA) of 0 or 1 at 12 weeks. In comparison with dupilumab 300 mg subcutaneously every other week, patients on abrocitinib 200 mg once daily had improved disease severity and itch response. The majority of adverse events were not severe and self-limited. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Prior to Food and Drug Administration (FDA) approval of abrocitinib, prednisone was the only FDA-approved oral medication for AD. Although biologics such as dupilumab have revolutionized care, some patients prefer oral medications. Compared with clinical trials of conventional AD treatments, abrocitinib appears more effective. CONCLUSIONS: Abrocitinib is an efficacious oral JAK 1 inhibitor recently FDA-approved for patients ≥ 18 years old with moderate-to-severe AD who have not responded to systemic medications or when contraindicated otherwise.

A comprehensive review of platelet-rich plasma for the treatment of dermatologic disorders.

Platelet-rich plasma (PRP) offers anti-inflammatory and regenerative properties through angiogenesis, cell differentiation, and proliferation. Although studied in many dermatologic conditions, its efficacy is not well-understood. Our objective is to review the use and effectiveness of PRP for dermatologic conditions. A literature search was performed through PubMed and yielded 54 articles published between January 2000 and November 2021; articles written in English were reviewed. Intradermal injections were associated with increased hair density in androgenic alopecia. Successful treatment of inflammatory nail diseases with PRP has been reported. Improvement in psoriasis was described, but only two studies were available. PRP was associated with higher patient self-assessment scores of photoaging and fine lines. Treatment with PRP in melasma has been associated with improved subjective satisfaction, but not with objective measures of disease improvement. PRP can serve as a safe and potentially effective adjunct for hair loss, vitiligo, nonhealing wounds, photoaging, and acne scars. An important barrier to interpreting PRP research is lack of standardization of PRP preparation protocols, inconsistent clinical endpoints, and frequent combination treatments. However, PRP is relatively noninvasive, has a well-established safety profile, and patient satisfaction is often high as patients perceive great benefit from treatment with PRP.

The impact of complete clearance and almost complete clearance of psoriasis on quality of life: a literature review.

BACKGROUND: Psoriasis is a chronic skin condition with systemic manifestations that have a detrimental impact on a patient's quality of life, affecting social, psychological, and sexual aspects of life. Complete clearance of lesions is a meaningful end goal of treatment; however, it is often difficult for patients to achieve. In this literature review, we summarized past studies that compared patients who achieved complete clearance to those who were almost clear to highlight the effect of complete clearance on psychological distress, social stigma, self-esteem, and interpersonal relationships in adult patients with psoriasis. METHODS: A literature search was performed through the PubMed database using the keywords "clearance of psoriasis", "complete clearance of psoriasis", "psychological impact psoriasis", "social impact psoriasis", and "stigma of psoriasis". Age (< 18) and language (only articles written in English were included) were the only exclusion criteria to include adult patients only. The information was then collected and evaluated to compare complete clearance and almost complete clearance of psoriasis. RESULTS: Of the patients with complete skin clearance (sPGA of 0), 61.4-91.1% reported a Dermatology Life Quality Index (DLQI) of 0, indicating no detectable impact of psoriasis on quality of life, compared to 45.7-48.3% who were almost clear. Patients who were completely clear felt psoriasis had less of an effect on their leisure activities and daily living compared to patients who were almost clear. Patient perceptions of disease severity also differed between the two groups, with the majority (65.5%) of those achieving complete clearance reporting a Psoriasis Symptom Inventory (PSI) of 0, which is consistent with their disease being "not at all severe", compared to 32.6% of those who were almost but not completely clear. While patients with complete clearance achieve a DLQI of 0 at a higher rate than those who have only almost complete clearance, the difference in the mean DLQI between patients with sPGA of 0 (completely clear) and sPGA of 1 (almost clear) is less than the minimal clinically important difference (MCID of 3-5) of the DLQI.

Dynamic predictors of in-hospital and 3-year mortality after traumatic brain injury: A retrospective cohort study.

BACKGROUND: Mortality risks after Traumatic Brain Injury (TBI) are understudied in critical illness. We sought to identify risks of mortality in critically ill patients with TBI using time-varying covariates. METHODS: This single-center, six-year (2006-2012), retrospective cohort study measured demographics, injury characteristics, and daily data of acute TBI patients in the Intensive Care Unit (ICU). Time-varying Cox proportional hazards models assessed in-hospital and 3-year mortality. RESULTS: Post-TBI ICU patients (n = 2664) experienced 20% in-hospital mortality (n = 529) and 27% (n = 706) 3-year mortality. Glasgow Coma Scale motor subscore (hazard ratio (HR) 0.58, p < 0.001), pupil reactivity (HR 3.17, p < 0.001), minimum glucose (HR 1.44, p < 0.001), mSOFA score (HR 1.81, p < 0.001), coma (HR 2.26, p < 0.001), and benzodiazepines (HR 1.38, p < 0.001) were associated with in-hospital mortality. At three years, public insurance (HR 1.78, p = 0.011) and discharge disposition (HR 4.48, p < 0.001) were associated with death. CONCLUSIONS: Time-varying characteristics influenced in-hospital mortality post-TBI. Socioeconomic factors primarily affect three-year mortality.

Comparison of two devices for facial skin analysis.

BACKGROUND: The use of quantitative measures to assess patients' skin has turned the subjective nature of dermatology into an objective one. These measures allow for more accurate diagnosis and improved monitoring of diseases. While there are many skin analysis devices available, they often require specific equipment to function and can be costly, limiting their clinical use. AIMS: The aim of our study was to compare a new skin analysis device that is easy to incorporate into dermatologic practice to a standard validated device. METHODS: We recruited 50 patients from dermatology clinics and analyzed their skin with two facial analysis systems: an online application that can be downloaded on either an iPad or iPhone, and a computer-based analysis system that utilizes a facial imaging photobooth. Scores were recorded and compared between the two devices for the following five skin characteristics; "spots," "wrinkles," "redness," "texture," and "pores." RESULTS: The tablet and the computer analysis system had an agreement rate of 67.7%. The highest agreement was in assessing texture (72.0%) and pores (68.2%). The lowest agreeance was in assessing redness (64%) and wrinkles (67%). When assessing the relationship between patients' raw score for wrinkles and their age, there was a strong correlation with the tablet (r = 0.79, p < 0.0001) compared with the computer system (r = 0.26, p < 0.06). CONCLUSIONS: The application utilized in our study may serve as a cost-effective and clinic friendly tool to assess patients' skin. It produces similar results to other skin analysis devices and may be more sensitive in detecting and quantifying wrinkles.

Initial validation of a new device for facial skin analysis.

The field of dermatology is met with many subjective analysis methods. Due to the relative nature of subjective analysis methods, objective analysis methods with greater accuracy and reliability were developed. Many of these devices are either inaccessible to patients without being a part of a clinical trial, bulky, or costly. However, with the advances in artificial intelligence and handheld devices, measurement methods have become simplified. The purpose of our study was to validate an objective skin analysis software available on a handheld device by comparing it to a board-certified dermatologist's assessment. Participants of various ages and skin types were analyzed with the facial analysis system on an iPad Pro. The same photographs were ranked by a physician based on 14 common skin characteristics. The facial analysis system and the physician's rankings had a good agreement rate of 69%. The greatest agreement rates were with the assessment of erythema (83.7%) and wrinkles (81.6%) and the lowest with oiliness (53.1%). The analysis system's high re-test reliability and good agreement rates with physician assessment support its potential use in the clinical setting.