Insights into diagnostic errors in endocrinology: a prospective, case-based, international study

BACKGROUND

Diagnostic errors in internal medicine are common. While cognitive errors have previously been identified to be the most common contributor to errors, very little is known about errors in specific fields of internal medicine such as endocrinology. This prospective, multicenter study focused on better understanding the causes of diagnostic errors made by general practitioners and internal specialists in the area of endocrinology.

METHODS

From August 2019 until January 2020, 24 physicians completed five endocrine cases on an online platform that simulated the diagnostic process. After each case, the participants had to state and explain why they chose their assumed diagnosis. The data gathering process as well as the participants' explanations were quantitatively and qualitatively analyzed to determine the causes of the errors. The diagnostic processes in correctly and incorrectly solved cases were compared.

RESULTS

Seven different causes of diagnostic error were identified, the most frequent being misidentification (mistaking one diagnosis with a related one or with more frequent and similar diseases) in 23% of the cases. Other causes were faulty context generation (21%) and premature closure (17%). The diagnostic confidence did not differ between correctly and incorrectly solved cases (median 8 out of 10, p = 0.24). However, in incorrectly solved cases, physicians spent less time on the technical findings (such as lab results, imaging) (median 250 s versus 199 s, p < 0.049).

CONCLUSIONS

The causes for errors in endocrine case scenarios are similar to the causes in other fields of internal medicine. Spending more time on technical findings might prevent misdiagnoses in everyday clinical practice.

Surgical site infection in skin surgery-An observational study

BACKGROUND

Surgical site infection (SSI) has a significant impact on patients' morbidity and aesthetic results.

OBJECTIVE

To identify risk factors for SSI in dermatologic surgery.

PATIENTS AND METHODS

This prospective, single-centre, observational study was performed between August 2020 and May 2021. Patients that presented for dermatologic surgery were included and monitored for the occurrence of SSI. For statistical analysis, we used a mixed effects logistic regression model.

RESULTS

Overall, 767 patients with 1272 surgical wounds were included in the analysis. The incidence of SSI was 6.1%. Significant risk factors for wound infection were defect size over 10cm2 (OR 3.64, 95% confidence interval [CI] 1.80-7.35), surgery of cutaneous malignancy (OR 2.96, CI 1.41-6.24), postoperative bleeding (OR 4.63, CI 1.58-13.53), delayed defect closure by local skin flap (OR 2.67, CI 1.13-6.34) and localisation of surgery to the ear (OR 7.75, CI 2.07-28.99). Wound localisation in the lower extremities showed a trend towards significance (OR 3.16, CI 0.90-11.09). Patient-related factors, such as gender, age, diabetes, or immunosuppression, did not show a statistically significant association with postoperative infection.

CONCLUSION

Large defects, surgery of cutaneous malignancy, postoperative bleeding, and delayed flap closure increase the risk for SSI. High-risk locations are the ears and lower extremities.

[Surgical site infection and perioperative antibiotics in dermatosurgery]

BACKGROUND

Postoperative wound infections represent the most common complication in dermatosurgery. Given the low incidence and heterogeneous data, no standards for perioperative antibiotic prophylaxis (PAP) have been established in clinical practice.

OBJECTIVES

To summarize the current evidence on risk factors for postoperative wound infection in dermatosurgery and the new recommendations on PAP.

MATERIALS AND METHODS

Relevant study data and current recommendations were summarized descriptively.

RESULTS

Current evidence suggests that the following factors are associated with an increased risk of wound infection after dermatosurgical procedures: surgery to the lower extremity or the ear, postoperative hemorrhage, defect closure by flap or skin graft, large wound defect, immunosuppression, and male sex. Probably not affecting the risk of infection are diabetes, obesity, age, smoking, use of a blood thinner, multiple surgeries, or wound healing by second intention. Not all risk factors affect the risk of infection equally. They must be weighted differently and only in combination do they increase the risk of wound infection in a clinically relevant way. According to a current position paper of the German Society for Dermatosurgery, the indication for PAP should be made individually and only if multiple factors are present. Furthermore, patients with increased risk for bacterial endocarditis or hematogenic endoprosthesis infection should receive PAP prior to septic skin surgery.

CONCLUSION

In dermatologic surgery, PAP should be restricted to patients at high risk for wound infection. Further indications are the prevention of bacterial endocarditis and hematogenic endoprosthesis infection in high-risk individuals prior to septic surgery.

Perioperative Antibiotikaprophylaxe in der Dermatochirurgie - Positionspapier der Arbeitsgruppe Antibiotic Stewardship der Deutschen Gesellschaft für Dermatochirurgie (DGDC), Teil 2: Spezielle Indikationen und Situationen

Neben der Vermeidung postoperativer Wundinfektionen nach dermatochirurgischen Eingriffen hat die perioperative Antibiotikaprophylaxe (PAP) das Ziel, das Auftreten weiterer postoperativer Infektionskomplikationen, insbesondere der bakteriellen Endokarditis oder hämatogener Gelenkprotheseninfektionen, zu verhindern. In der vorliegenden Arbeit werden spezielle Situationen dargestellt, in denen eine PAP notwendig werden kann. So benötigen Patienten nach Herzklappenersatz jeglicher Art, einschließlich Transkatheter‐Klappenersatz oder bei Verwendung von Prothesenmaterial zur Herzklappenkorrektur, oder Patienten nach einer durchgemachten bakteriellen Endokarditis bei zweizeitigen dermatochirurgischen Eingriffen, Eingriffen an der Schleimhaut oder ulzerierten Tumoren eine PAP.

Auch die Anwendung einer PAP in speziellen Situationen wie bei sekundärer Wundheilung, septischen dermatochirurgischen Eingriffen oder Ulcus cruris‐Chirurgie werden in dieser Arbeit anhand der aktuellen wissenschaftlichen Literatur ausführlich dargestellt und diskutiert. Die vorliegende Arbeit ist der 2. Teil des Positionspapiers der Arbeitsgruppe Antibiotic Stewardship der Deutschen Gesellschaft für Dermatochirurgie und formuliert evidenzbasierte Empfehlungen für die Verabreichung einer PAP bei dermatochirurgischen Eingriffen bei speziellen Indikationen und Situationen. Dies ist von besonderer Wichtigkeit, da bei dermatochirurgischen Eingriffen, wie im ersten Teil dargelegt, im Regelfall auf eine PAP verzichtet werden kann und sollte.

Perioperative antibiotic prophylaxis in skin surgery - Position paper of the Antibiotic Stewardship working group of the German Society for Dermatologic Surgery (DGDC), Part 2: Special indications and situations

In addition to prevention of surgical site infections after skin surgery, perioperative antibiotic prophylaxis (PAP) aims to prevent the occurrence of other postoperative infectious complications, especially bacterial endocarditis and hematogenous joint prosthesis infections. This article discusses specific indications for the use of PAP. For example, patients who have undergone any type of heart valve replacement, including transcatheter valve replacement or use of prosthetic material to correct the heart valve, or patients who have experienced bacterial endocarditis, require PAP during skin surgery on mucosal membranes or ulcerated tumors. The use of PAP in special situations such as secondary wound healing, septic dermatosurgery or ulcer surgery is also presented and discussed in detail in this paper based on the current scientific literature. This paper represents the second part of the position paper of the Antibiotic Stewardship Working Group of the German Society for Dermatologic Surgery (DGDC) and summarizes evidence-based recommendations for the administration of PAP during skin surgery for special indications and situations. This is particularly important because, as detailed in Part 1 of this position paper, PAP can and usually should be avoided in skin surgery.

Serum levels of serum amyloid A, interleukin-6 and C-reactive protein correlate with severity of hidradenitis suppurativa

BACKGROUND

Validated biomarkers enabling an objective, dynamic assessment of hidradenitis suppurativa (HS) disease severity do not exist. The aim of our study was to determine the serum concentration of four potential biomarkers with respect to HS disease severity.

METHODS

We recruited 50 patients with hidradenitis suppurativa. After obtaining informed consent, patients were requested to fill out multiple questionnaires. Severity of HS was determined based on Hurley and Sartorius scores by an experienced dermatologist. Blood sampling included Serum Amyloid A (SAA), Interleukin-6 (IL-6), C-reactive protein (CRP) and S100 protein (S100) in a certified laboratory.

RESULTS

Moderate and statistically significant correlations of SAA, IL-6 and CRP with the clinical scores Hurley and Sartorius were observed. The respective Spearman's correlation coefficients (r) were: Hurley 0.38, 0.46, 0.35 and Sartorius 0.51, 0.48, 0.48. No relevant changes were detected when comparing S100 to both Hurley (r=0.06) and Sartorius (r=0.09).

CONCLUSIONS

Our data suggest that an association between SAA, IL-6, CRP and HS disease severity could exist. Further research is needed to define their potential as biomarkers for quantifying and monitoring disease activity and response to treatment.

Has the quality of reporting improved since it became mandatory to use the Standards for Reporting Diagnostic Accuracy?

OBJECTIVES

To investigate whether making the Standards for Reporting Diagnostic Accuracy (STARD) mandatory by the leading journal 'Radiology' in 2016 improved the quality of reporting of diagnostic accuracy studies.

METHODS

A validated search term was used to identify diagnostic accuracy studies published in Radiology in 2015 and 2019. STARD adherence was assessed by two independent reviewers. Each item was scored as yes (1 point) if adequately reported or as no (0 points) if not. The total STARD score per article was calculated. Wilcoxon-Mann-Whitney tests were used to evaluate differences of the total STARD scores between 2015 and 2019. In addition, the total STARD score was compared between studies stratified by study design, citation rate, and data collection.

RESULTS

The median number of reported STARD items for the total of 66 diagnostic accuracy studies from 2015 to 2019 was 18.5 (interquartile range [IQR] 17.5-20.0) of 29. Adherence to the STARD checklist significantly improved the STARD score from a median of 18.0 (IQR 15.5-19.5) in 2015 to a median of 19.5 (IQR 18.5-21.5) in 2019 (p < 0.001). No significant differences were found between studies stratified by mode of data collection (prospective vs. retrospective studies, p = 0.68), study design (cohort vs. case-control studies, p = 0.81), and citation rate (two groups divided by median split [< 0.56 citations/month vs. ≥ 0.56 citations/month], p = 0.54).

CONCLUSIONS

Making use of the STARD checklist mandatory significantly increased the adherence with reporting standards for diagnostic accuracy studies and should be considered by editors and publishers for widespread implementation.

CRITICAL RELEVANCE STATEMENT

Editors may consider making reporting guidelines mandatory to improve the scientific quality.

Antibiotic Prophylaxis of Surgical Site Infections in Cutaneous Surgery: A Prospective Observational Study

The use of perioperative antibiotic prophylaxis in cutaneous surgery is controversial due to unclear efficacy and, thus, potentially unnecessary side-effects. This prospective observational study analysed the efficacy of oral perioperative antibiotic prophylaxis in preventing surgical site infections. Adult patients undergoing cutaneous surgery between August 2020 and May 2021 at Ludwig-Maximilian University Hospital Munich, Germany, without prior signs of infection were eligible. Propensity score weighting was used for covariate adjustment to account for non-randomized treatment assignment. Of 758 included patients, 23 received perioperative antibiotic prophylaxis (3.0%). In this group, a surgical site infection occurred in 1 of 45 lesions (2.2%) compared with 76 of 1,189 lesions (6.5%) in the group without perioperative antibiotic prophylaxis (735 patients, 97.0%). With covariate adjustment, the odds ratio for the occurrence of a surgical site infection in patients receiving perioperative antibiotic prophylaxis was 0.114 (95% confidence interval 0.073-0.182; p <0.001) on a per lesion level. The number of lesions needed to treat to prevent 1 surgical site infection was 17.6 (95% confidence interval 16.8-19.2). This prospective observational study shows a reduction in the incidence of surgical site infection in cutaneous surgery performed with perioperative antibiotic prophylaxis. The large size difference between the 2 study groups limits the study.

Has the STARD statement improved the quality of reporting of diagnostic accuracy studies published in European Radiology?

OBJECTIVES

To investigate whether encouraging authors to follow the Standards for Reporting Diagnostic Accuracy (STARD) guidelines improves the quality of reporting of diagnostic accuracy studies.

METHODS

In mid-2017, European Radiology started encouraging its authors to follow the STARD guidelines. Our MEDLINE search identified 114 diagnostic accuracy studies published in European Radiology in 2015 and 2019. The quality of reporting was evaluated by two independent reviewers using the revised STARD statement. Item 11 was excluded because a meaningful decision about adherence was not possible. Student's t test for independent samples was used to analyze differences in the mean number of reported STARD items between studies published in 2015 and in 2019. In addition, we calculated differences related to the study design, data collection, and citation rate.

RESULTS

The mean total number of reported STARD items for all 114 diagnostic accuracy studies analyzed was 15.9 ± 2.6 (54.8%) of 29 items (range 9.5-22.5). The quality of reporting of diagnostic accuracy studies was significantly better in 2019 (mean ± standard deviation (SD), 16.3 ± 2.7) than in 2015 (mean ± SD, 15.1 ± 2.3; p < 0.02). No significant differences in the reported STARD items were identified in relation to study design (p = 0.13), data collection (p = 0.87), and citation rate (p = 0.09).

CONCLUSION

The quality of reporting of diagnostic accuracy studies according to the STARD statement was moderate with a slight improvement since European Radiology started to recommend its authors to follow the STARD guidelines.

KEY POINTS

• The quality of reporting of diagnostic accuracy studies was moderate with a mean total number of reported STARD items of 15.9 ± 2.6. • The adherence to STARD was significantly better in 2019 than in 2015 (16.3 ± 2.7 vs. 15.1 ± 2.3; p = 0.016). • No significant differences in the reported STARD items were identified in relation to study design (p = 0.13), data collection (p = 0.87), and citation rate (p = 0.09).

Proposal of 0.5 mg of protein/100 g of processed food as threshold for voluntary declaration of food allergen traces in processed food-A first step in an initiative to better inform patients and avoid fatal allergic reactions: A GA²LEN position paper

BACKGROUND

Food anaphylaxis is commonly elicited by unintentional ingestion of foods containing the allergen above the tolerance threshold level of the individual. While labeling the 14 main allergens used as ingredients in food products is mandatory in the EU, there is no legal definition of declaring potential contaminants. Precautionary allergen labeling such as "may contain traces of" is often used. However, this is unsatisfactory for consumers as they get no information if the contamination is below their personal threshold. In discussions with the food industry and technologists, it was suggested to use a voluntary declaration indicating that all declared contaminants are below a threshold of 0.5 mg protein per 100 g of food. This concentration is known to be below the threshold of most patients, and it can be technically guaranteed in most food production. However, it was also important to assess that in case of accidental ingestion of contaminants below this threshold by highly allergic patients, no fatal anaphylactic reaction could occur. Therefore, we performed a systematic review to assess whether a fatal reaction to 5mg of protein or less has been reported, assuming that a maximum portion size of 1kg of a processed food exceeds any meal and thus gives a sufficient safety margin.

METHODS

MEDLINE and EMBASE were searched until 24 January 2021 for provocation studies and case reports in which one of the 14 major food allergens was reported to elicit fatal or life-threatening anaphylactic reactions and assessed if these occurred below the ingestion of 5mg of protein. A Delphi process was performed to obtain an expert consensus on the results.

RESULTS

In the 210 studies included, in our search, no reports of fatal anaphylactic reactions reported below 5 mg protein ingested were identified. However, in provocation studies and case reports, severe reactions below 5 mg were reported for the following allergens: eggs, fish, lupin, milk, nuts, peanuts, soy, and sesame seeds.

CONCLUSION

Based on the literature studied for this review, it can be stated that cross-contamination of the 14 major food allergens below 0.5 mg/100 g is likely not to endanger most food allergic patients when a standard portion of food is consumed. We propose to use the statement "this product contains the named allergens in the list of ingredients, it may contain traces of other contaminations (to be named, e.g. nut) at concentrations less than 0.5 mg per 100 g of this product" for a voluntary declaration on processed food packages. This level of avoidance of cross-contaminations can be achieved technically for most processed foods, and the statement would be a clear and helpful message to the consumers. However, it is clearly acknowledged that a voluntary declaration is only a first step to a legally binding solution. For this, further research on threshold levels is encouraged.

Ex vivo confocal laser scanning microscopy: A diagnostic technique for easy real-time evaluation of benign and malignant skin tumours

Ex vivo confocal laser scanning microscopy (ex vivo CLSM) is a novel diagnostic tool for a quick bedside evaluation of freshly excised tissue, comparable to histology. We aimed to assess the sensitivity and specificity of ex vivo CLSM in detecting malignant features, to validate its reliability in identifying various skin tumours based on a combination of confocal features and to evaluate the digital staining mode (DS). One-hundred twenty freshly excised skin samples from 91 patients were evaluated. Each lesion was screened for the presence of 23 predefined confocal criteria with ex vivo CLSM, followed by a histopathological examination. The diagnostic agreement between ex vivo CLSM and histology was 89.2%. The diagnostic accuracy of ex vivo CLSM in detecting malignancy reached a sensitivity of 98% and a specificity of 76%. Ex vivo CLSM enabled a rapid identification of the most common skin tumours, the tumour dignity and cytological features. The DS demonstrated a close resemblance to conventional histopathology.

Are Specific Body Sites Prone for Wound Infection After Skin Surgery? A Systematic Review and Meta-Analysis

INTRODUCTION

Identifying risk factors for wound infection may guide clinical practice for optimal use of perioperative antibiotic prophylaxis in dermatologic surgery.

OBJECTIVE

To summarize the current evidence whether specific body sites have higher risks for surgical site infections (SSI).

METHODS

The systematic literature search included MEDLINE, Embase, CENTRAL, and trial registers. Only observational studies qualified for inclusion and meta-analysis. We assessed the risk of bias according to the Newcastle-Ottawa Scale.

RESULTS

Eighteen studies with 33,086 surgical wounds were eligible. Eight studies were of good, 4 of fair, and 6 of poor quality. The mean infection rate was 4.08%. Meta-analysis showed that the lips had significantly higher infection rates. The lower extremity and ears had or tended toward a higher risk for infection, but studies were clinically heterogeneous. A large prospective trial found that surgical wounds on the hands were at higher risk for infection. The trunk showed the lowest infection rate. The risk for SSI in other body locations was not different or remained uncertain because of substantial heterogeneity among studies.

CONCLUSION

Lips, lower extremities, and probably ears and hands may have a higher risk for wound infection after skin surgery. The trunk showed the lowest infection rate.

Patient-dependent risk factors for wound infection after skin surgery: A systematic review and meta-analysis

Postoperative wound infection in dermatologic surgery causes impaired wound healing, poor cosmetic outcome and increased morbidity. Patients with a high‐risk profile may benefit from perioperative antibiotic prophylaxis. The objective of this systematic review was to identify risk factors for surgical site infection after dermatologic surgery. In this article, we report findings on patient‐dependent risk factors. The literature search included MEDLINE, EMBASE, CENTRAL and trial registers. We performed meta‐analysis, if studies reported sufficient data to calculate risk ratios with 95% confidence intervals. Study quality was assessed according to the Newcastle‐Ottawa‐Scale. Seventeen observational studies that analysed 31213 surgical wounds were eligible for inclusion. Fourteen studies qualified for meta‐analysis. Nine studies showed good, three fair and five poor methodological quality. The reported incidence of surgical site infection ranged from 0.96% to 8.70%. Meta‐analysis yielded that male gender and immunosuppression were significantly associated with higher infection rates. There was a tendency towards a higher infection risk for patients with diabetes, without statistical significance. Meta‐analysis did not show different infection rates after excision of squamous cell carcinoma or basal cell carcinoma, but studies were substantially heterogenous. There was no significant association between risk for wound infection and smoking, age over 60 years, oral anti‐aggregation or anti‐coagulation or excision of malignant melanoma. In conclusion, the risk for surgical site infection in dermatologic surgery is low. Infection rates were increased significantly in male as well as immunosuppressed patients and non‐significantly in diabetics.

Impact of the COVID ‐19 pandemic on patients with hidradenitis suppurativa

The COVID‐19 pandemic caused collateral damage to patients with acute and chronic conditions. In this mono‐centre cross‐sectional study, we sought to evaluate the impact of the COVID‐19 pandemic on patients with hidradenitis suppurativa (HS). In June 2020, we sent an anonymous survey to 109 patients, who were diagnosed with HS in our outpatient clinic from May 2018 to April 2020. Fifty patients (45.9%) completed and returned the survey. Forty‐five participants (90.0%) denied any cancellation of hospitalisation due to the COVID‐19 pandemic. Hospitalisation was postponed in 8% of cases and cancelled in 2%. Compared to prior to the pandemic, fewer patients consulted their primary physician for changing wound dressings and more changed the dressings themselves or were assisted by their family members. 13% of patients avoided doctor visits due to fear of COVID‐19 and 26.1% minimised doctor visits. The Dermatology Life Quality Index showed a moderate to very severe impact on patients' Quality of Life (mean score = 10.06). Only one patient used telemedicine. Due to limited access to primary care and fear of COVID‐19, the pandemic had a detectable impact on the hospital management of patients with HS in our facility. Telemedicine still plays a negligible role in primary wound care.

Machine Learning Based Prediction of Squamous Cell Carcinoma in Ex Vivo Confocal Laser Scanning Microscopy

Image classification with convolutional neural networks (CNN) offers an unprecedented opportunity to medical imaging. Regulatory agencies in the USA and Europe have already cleared numerous deep learning/machine learning based medical devices and algorithms. While the field of radiology is on the forefront of artificial intelligence (AI) revolution, conventional pathology, which commonly relies on examination of tissue samples on a glass slide, is falling behind in leveraging this technology. On the other hand, ex vivo confocal laser scanning microscopy (ex vivo CLSM), owing to its digital workflow features, has a high potential to benefit from integrating AI tools into the assessment and decision-making process. Aim of this work was to explore a preliminary application of CNN in digitally stained ex vivo CLSM images of cutaneous squamous cell carcinoma (cSCC) for automated detection of tumor tissue. Thirty-four freshly excised tissue samples were prospectively collected and examined immediately after resection. After the histologically confirmed ex vivo CLSM diagnosis, the tumor tissue was annotated for segmentation by experts, in order to train the MobileNet CNN. The model was then trained and evaluated using cross validation. The overall sensitivity and specificity of the deep neural network for detecting cSCC and tumor free areas on ex vivo CLSM slides compared to expert evaluation were 0.76 and 0.91, respectively. The area under the ROC curve was equal to 0.90 and the area under the precision-recall curve was 0.85. The results demonstrate a high potential of deep learning models to detect cSCC regions on digitally stained ex vivo CLSM slides and to distinguish them from tumor-free skin.

In vivo examination of healthy human skin after short-time treatment with moisturizers using confocal Raman spectroscopy and optical coherence tomography: Preliminary observations

Skin is our barrier against environmental damage. Moisturizers are widely used to increase hydration and barrier integrity of the skin; however, there are contrasting observations on their in vivo effects in real-life settings. In cosmetic studies, corneometers and tewameters are traditionally used to assess skin hydration. In this study, two novel noninvasive diagnostic techniques, optical coherence tomography (OCT) and confocal Raman spectroscopy, were used to analyze stratum corneum and epidermal thickness (ET), water content, blood flow in function of depth, skin roughness, attenuation coefficient, natural moisturizing factor, ceramides and free fatty acids, cholesterol, urea, and lactates in 20 female subjects aged between 30 and 45 before and after 2 weeks application of a commercially available moisturizing lotion on one forearm. The untreated forearm served as control. A third measurement was conducted 1 week after cessation of moisturizing to verify whether the changes in the analyzed parameters persisted. We noticed a reduction in skin roughness, an increase in ceramides and free fatty acids and a not statistically significant increase in ET. As a conclusion, short time moisturizing appears insufficient to provide significant changes in skin morphology and composition, as assessed by OCT and RS. Novel noninvasive imaging methods are suitable for the evaluation of skin response to topical moisturizers. Further studies on larger sample size and longer treatment schedules are needed to analyze changes under treatment with moisturizers and to standardize the use of novel noninvasive diagnostic techniques.

Line-field confocal optical coherence tomography for the in vivo real-time diagnosis of different stages of keratinocyte skin cancer: a preliminary study

BACKGROUND

The treatment of keratinocyte cancers (KC) strictly depends on their differentiation and invasiveness. Non-invasive diagnostic techniques can support the diagnosis in real time, avoiding unnecessary biopsies. This study aimed to preliminarily define main imaging criteria and histological correlations of actinic keratosis (AK), Bowen's disease (BD) and squamous cell carcinoma (SCC) using the novel device line-field confocal optical coherence tomography (LC-OCT).

METHODS

Dermoscopy and LC-OCT images of 73 histopathologically confirmed lesions (46 AKs, 11 BD and 16 SCCs) were included in the study. Exemplary lesions (10 AKs, 5 BD and 5 SCCs) were additionally investigated with optical coherence tomography and reflectance confocal microscopy.

RESULTS

Most common LC-OCT findings of KC in the descriptive statistics were hyperkeratosis/parakeratosis, disruption of stratum corneum, broadened epidermis, basal and suprabasal keratinocyte atypia, dilated vessels/neoangiogenesis and elastosis/collagen alterations. In the univariate multinomial logistic regression, a preserved DEJ was less common in SCC compared with AK and BD, BD displayed marked keratinocyte atypia involving all epidermal layers (bowenoid pattern), while SCC showed ulceration, increased epidermal thickness, keratin plugs, acantholysis, not visible/interrupted DEJ and epidermal bright particles. LC-OCT increased the diagnostic confidence by 24.7% compared with dermoscopy alone.

CONCLUSIONS

Our study describes for the first time specific LC-OCT features of different stages of KC and their histopathological correlates, focusing on keratinocyte morphology and architecture of the epidermis and DEJ. LC-OCT may open new scenarios in the bedside diagnosis, treatment planning and follow-up of KC.

Ex-vivo fluorescence confocal microscopy with digital staining for characterizing basal cell carcinoma on frozen sections: A comparison with histology

Ex-vivo fluorescence confocal microscopy (FCM) has been used on fresh tissue, but there is little experience on frozen sections. We evaluated the applicability of FCM on frozen sections of basal cell carcinomas (BCCs), stained with acridine orange and digitally colored to simulate hematoxylin and eosin (H&E) dyes. We compared our diagnostic accuracy in detecting and subtyping BCCs with FCM to our gold standard (H&E stained frozen sections used in 3D horizontal micrographic surgery). Fourty-six primary BCCs were analyzed for free margins as well as histological subtype with all FCM modes and conventional H&E staining. Adnexa, artifacts and diagnostic confidence were evaluated. Free margins were identified with a sensitivity and specificity of 92% and 91%. Concordance for tumor subtype was 88%. FCM may be used on both fresh tissue and frozen samples, although with reduced performance and different artifacts. The device is useful for the intraoperative diagnosis, subtyping and margin-mapping of BCCs.

Detection of relevant extracardiac findings on coronary computed tomography angiography vs. invasive coronary angiography

OBJECTIVES

To compare the detection of relevant extracardiac findings (ECFs) on coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA) and evaluate the potential clinical benefit of their detection.

METHODS

This is the prespecified subanalysis of ECFs in patients presenting with a clinical indication for ICA based on atypical angina and suspected coronary artery disease (CAD) included in the prospective single-center randomized controlled Coronary Artery Disease Management (CAD-Man) study. ECFs requiring immediate therapy and/or further workup including additional imaging were defined as clinically relevant. We evaluated the scope of ECFs in 329 patients and analyzed the potential clinical benefit of their detection.

RESULTS

ECFs were detected in 107 of 329 patients (32.5%; CTA: 101/167, 60.5%; ICA: 6/162, 3.7%; p < .001). Fifty-nine patients had clinically relevant ECFs (17.9%; CTA: 55/167, 32.9%; ICA: 4/162, 2.5%; p < .001). In the CTA group, ECFs potentially explained atypical chest pain in 13 of 101 patients with ECFs (12.9%). After initiation of therapy, chest pain improved in 4 (4.0%) and resolved in 7 patients (6.9%). Follow-up imaging was recommended in 33 (10.0%; CTA: 30/167, 18.0%; ICA: 3/162, 1.9%) and additional clinic consultation in 26 patients (7.9%; CTA: 25/167, 15.0%; ICA: 1/162, 0.6%). Malignancy was newly diagnosed in one patient (0.3%; CTA: 1/167, 0.6%; ICA: 0).

CONCLUSIONS

In this randomized study, CTA but not ICA detected clinically relevant ECFs that may point to possible other causes of chest pain in patients without CAD. Thus, CTA might preclude the need for ICA in those patients.

TRIAL REGISTRATION

NCT Unique ID: 00844220 KEY POINTS: • CTA detects ten times more clinically relevant ECFs than ICA. • Actionable clinically relevant ECFs affect patient management and therapy and may thus improve chest pain. • Detection of ECFs explaining chest pain on CTA might preclude the need for performing ICA.

Increased prevalence of irritant hand eczema in health care workers in a dermatological clinic due to increased hygiene measures during the SARS-CoV-2 pandemic

BACKGROUND

Hand hygiene measures in the general population and in health care workers have increased considerably since the outbreak of the COVID-19 pandemic.

OBJECTIVES

To investigate the prevalence and symptoms of hand eczema, as well as hygiene measures and concepts of care, in German health care workers.

MATERIALS & METHODS

This was an observational questionnaire study to investigate hygiene and skin care habits, as well as the prevalence and symptoms of hand eczema in 66 nurses and doctors of our dermatology department before and during the SARS-CoV-2 pandemic.

RESULTS

Hand washing and hand disinfection procedures increased significantly during the COVID-19 pandemic. Self-diagnosed hand eczema was reported by 33% of the participants, with a median duration of 14 days. The majority of staff currently affected by hand eczema were free of eczema a month previously (82%) and would treat their skin condition with emollients (77%). Erythema, scaling, burning and fissures were reported by 66.1% of the participants and were classified as predominant signs of toxic-irritant hand dermatitis rather than contact allergy.

CONCLUSION

Overall, the SARS-CoV-2 pandemic has led to a significant increase in the incidence of signs of irritant hand eczema despite intensified emollient use as a preventive measure. Awareness of the prevalence of hand eczema in health care workers in Germany during the COVID-19 pandemic should be raised, and preventive measures should be intensified.

Line-field optical coherence tomography: In vivo diagnosis of basal cell carcinoma subtypes compared to histopathology

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer in the general population. Treatments vary from Mohs surgery to topical therapy, depending on the subtype. Dermoscopy, reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) have gained a foothold in daily clinical practice to optimize diagnosis and subtype-oriented treatment. The new device Line-field confocal OCT (LC-OCT) allows imaging at high resolution and depth but its use is not yet been investigated in larger studies.

OBJECTIVES

To evaluate the main LC-OCT criteria for the diagnosis and subtyping of BCC in comparison to histopathology, OCT and RCM.

METHODS

Fifty-two histopathologically confirmed BCCs were evaluated for imaging criteria. Their frequency, predictive values and ROC curves were calculated. A multinominal regression with stepwise variables selection to distinguish BCC subtypes was performed.

RESULTS

Nodular BCCs were mainly characterized by atypical keratinocytes, altered DEJ, tumour nests in the dermis, dark clefting, prominent vascularisation and white hyperreflective stroma. Superficial BCCs showed a thickening of the epidermis due to a series of tumour lobules with clear connection to the DEJ (string of pearls pattern). Infiltrative BCCs were characterized by elongated hyporeflective tumour strands, surrounded by bright collagen (shoal of fish). The overall BCC subtype agreement between LC-OCT and conventional histology was 90.4 % (95% CI: 79.0, 96.8).

CONCLUSION

LC-OCT allows the non-invasive, real time identification of BCCs and their subtypes in vertical, horizontal and 3D mode compared to histology, RCM and OCT. Further larger studies are needed to better explore the clinical applications of this promising device.

Impact of COVID-19 on wound care in Germany

Recent studies showed that the COVID‐19 pandemic caused collateral damage in health care in terms of reduced hospital submissions or postponed treatment of other acute or chronic ill patients. An anonymous survey was sent out by mail to patients with chronic wounds in order to evaluate the impact of the pandemic on wound care. Sixty‐three patients returned the survey. In 14%, diagnostic workup or hospitalisation was cancelled or postponed. Thirty‐six percent could not seek consultation by their primary care physician as usual. The use of public transport or long travel time was not related to limited access to medical service (P = .583). In ambulatory care, there was neither a significant difference in the frequency of changing wound dressings (P = .67), nor in the person, who performed wound care (P = .39). There were no significant changes in wound‐specific quality of life (P = .505). No patient used telemedicine in order to avoid face‐to‐face contact or anticipate to pandemic‐related restrictions. The COVID‐19 pandemic impaired access to clinical management of chronic wounds in Germany. It had no significant impact on ambulatory care or wound‐related quality of life. Telemedicine still plays a negligible role in wound care.

Switch from IL-5 to IL-5-Receptor α Antibody Treatment in Severe Eosinophilic Asthma

Background

Anti-IL-5 antibodies represent an established therapy for severe eosinophilic asthma (SEA), but some patients show inadequate response. The objective of this study was to assess the effects of a switch to anti-IL-5Rα therapy in patients with inadequate response to anti-IL-5 therapy.

Methods

In this retrospective multi-centre, real-life study, we analysed all SEA patients switched from anti-IL-5 to anti-IL-5Rα therapy due to inadequate response or intolerability. Pulmonary function tests, blood gas analyses, asthma control tests (ACT) and oral corticosteroid (OCS) usage were analysed and compared at three timepoints: baseline (BL, before anti-IL-5 therapy), timepoint 1 (T1, under anti-IL-5 therapy) and timepoint 2 (T2, under anti-IL-5Rα therapy).

Results

Of 665 patients treated with anti-IL-5 antibodies, 70 were switched to anti-IL-5Rα and 60 were included in the analysis. Median treatment duration was 8 months [IQR 5; 15] for anti-IL-5 and 5 months [IQR 4; 6] for anti-IL-5Rα therapy. FEV₁ was 61% of predicted at BL [IQR 41; 74], 61% [IQR 43; 79] at T1 and 68% [IQR 49; 87] at T2 (p_T1-T2=0.011). ACT score was 10 [IQR 8; 13], 16 [IQR 10; 19] and 19 [IQR 14; 22], respectively (both p<0.001). The number of patients requiring OCS was reduced from 41 (BL) to 32 (T1) and 19 (T2) (both p<0.001). Ten patients discontinued anti-IL-5Rα therapy due to insufficient efficacy (n=7) and adverse events (n=3).

Conclusion

Switching from anti-IL-5 to anti-IL-5Rα therapy in patients with inadequate response was associated with significantly improved FEV₁, asthma control and OCS reduction.

MRI for measuring therapy efficiency after revascularisation in ST-segment elevation myocardial infarction: a systematic review and meta-regression analysis

OBJECTIVE

To summarise existing data on the relation between the time from symptom onset until revascularisation (time to reperfusion) and the myocardial salvage index (MSI) calculated as proportion of non-necrotic myocardium inside oedematous myocardium on T2-weighted and T1-weighted late gadolinium enhancement MRI after ST-segment elevation myocardial infarction (STEMI).

METHODS

Studies including patients with revascularised STEMI and stating both the time to reperfusion and the MSI measured by T2-weighted and T1-weighted late gadolinium enhancement MRI were searched in MEDLINE, EMBASE and ISI Web of Science until 16 May 2020. A mixed effects model was used to evaluate the relation between the time to reperfusion and the MSI. The gender distribution and mean age in included patient groups, the timing of MRI, used MRI sequences and image interpretation methodology were included in the mixed effects model to explore between-study heterogeneity.

RESULTS

We included 38 studies with 5106 patients. The pooled MSI was 42.6% (95% CI: 38.1 to 47.1). The pooled time to reperfusion was 3.8 hours (95% CI: 3.5 to 4.0). Every hour of delay in reperfusion was associated with an absolute decrease of 13.1% (95% CI: 11.5 to 14.6; p<0.001) in the MSI. Between-study heterogeneity was considerable (σ²=167.8). Differences in the gender distribution, timing of MRI and image interpretation among studies explained 45.2% of the between-study heterogeneity.

CONCLUSIONS

The MSI on T2-weighted and T1-weighted late gadolinium enhancement MRI correlates inversely with the time to reperfusion, which indicates that cardioprotection achieved by minimising the time to reperfusion leads to a higher MSI. The analysis revealed considerable heterogeneity between studies. The heterogeneity could partly be explained by differences in the gender distribution, timing and interpretation of MRI suggesting that the MRI-assessed MSI is not only influenced by cardioprotective therapy but also by patient characteristics and MRI parameters.

Dupilumab for the treatment of adolescents with atopic dermatitis

INTRODUCTION

Dupilumab is a treatment option newly licensed for adolescents with moderate to severe atopic dermatitis (AD). It reduces type 2 inflammation by blocking the shared receptor subunit for IL-4/-13. Dupilumab affects three disease mechanisms in atopic dermatitis: the skin barrier, the Th2-cell differentiation and the class switch to IgE. This report is based on a systematic literature search of the PubMed Database.

AREAS COVERED

Dupilumab showed promising results in improving AD signs, symptoms and quality of life in adolescents with moderate to severe AD. The safety profile of dupilumab in adolescents with moderate to severe AD closely resembled the known safety profile of dupilumab in adults with moderate to severe AD. Injection-site reactions and conjunctivitis were the relevant side-effects. Skin infections were less frequently observed compared to placebo.

EXPERT COMMENTARY

Dupilumab was approved by the Food and Drug Administration in March 2019 and by the European Medicines Agency in August 2019 for the treatment of adolescents with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical therapies or when those therapies are not advisable. Since it is the first licensed drug it will likely become the reference drug for adolescents with moderate to severe AD.

Onset of occupational hand eczema among healthcare workers during the SARS-CoV-2 pandemic: Comparing a single surgical site with a COVID-19 intensive care unit

Background

As a result of the COVID‐19 outbreak, hygiene regulations have been revised and hand sanitation has been intensified.

Objective

To investigate the onset of hand eczema during the COVID‐19 pandemic in healthcare workers (HCWs) directly involved in intensive care of COVID‐19 patients and HCWs without direct contact with COVID‐19 patients. Hereby, we aim at increasing awareness about occupational hand eczema and preventive measures that can be adopted.

Method

A survey was distributed amongst 114 HCWs at a single surgical centre and at a COVID‐19 intensive care unit of the university hospital Ludwig Maximilian University Munich, Germany. Participants were questioned about the daily frequency of hand hygiene prior to and during the pandemic. Participants self‐reported the onset of hand eczema and associated symptoms.

Results

Our study revealed a significant increase in hand washing, disinfection, and use of hand cream across all participants (P‐value <.001), regardless of having direct contact with COVID‐19 patients. A high prevalence of symptoms associated with acute hand dermatitis of 90.4% was found across all HCWs, whereas hand eczema itself was underreported (14.9%).

Conclusion

The increase in hand sanitation during the COVID‐19 pandemic impairs the skin of the hands across all HCWs, independent of direct intensive care of affected patients.

Prognostic value of the myocardial salvage index measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging after ST-segment elevation myocardial infarction: A systematic review and meta-regression analysis

In all patients with ST-segment elevation myocardial infarction, risk stratification should be performed before discharge. The measurement of therapy efficiency with magnetic resonance imaging has been proposed as part of the risk assessment, but it has not been adopted widely. This meta-analysis was conducted to summarize published data on the prognostic value of the proportion of salvaged myocardium inside previously ischemic myocardium (myocardial salvage index) measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging after ST-segment elevation myocardial infarction. Random and mixed effects models were used for analyzing the data of 10 studies with 2,697 patients. The pooled myocardial salvage index, calculated as the proportion of non-necrotic myocardium inside edematous myocardium measured by T2-weighted and T1-weighted late gadolinium enhancement MRI, was 43.0% (95% confidence interval: 37.4, 48.6). The pooled length of follow-up was 12.3 months (95% confidence interval: 7.0, 17.6). The pooled incidence of major cardiac events during follow-up, defined as cardiac death, nonfatal myocardial infarction, or admission for heart failure, was 10.6% (95% confidence interval: 5.7, 15.5). The applied mixed effects model showed an absolute decrease of 1.7% in the incidence of major cardiac events during follow-up (95% confidence interval: 1.6, 1.9) with every 1% of increase in the myocardial salvage index. The heterogeneity between studies was considerable (τ = 21.3). Analysis of aggregated follow-up data after ST-segment elevation myocardial infarction suggests that the myocardial salvage index measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging provides prognostic information on the risk of major cardiac events, but considerable heterogeneity exists between studies.

Coronary Artery Disease: Analysis of Diagnostic Performance of CT Perfusion and MR Perfusion Imaging in Comparison with Quantitative Coronary Angiography and SPECT-Multicenter Prospective Trial

Purpose To compare the diagnostic performance of stress myocardial computed tomography (CT) perfusion with that of stress myocardial magnetic resonance (MR) perfusion imaging in the detection of coronary artery disease (CAD). Materials and Methods All patients gave written informed consent prior to inclusion in this institutional review board-approved study. This two-center substudy of the prospective Combined Noninvasive Coronary Angiography and Myocardial Perfusion Imaging Using 320-Detector Row Computed Tomography (CORE320) multicenter trial included 92 patients (mean age, 63.1 years ± 8.1 [standard deviation]; 73% male). All patients underwent perfusion CT and perfusion MR imaging with either adenosine or regadenoson stress. The predefined reference standards were combined quantitative coronary angiography (QCA) and single-photon emission CT (SPECT) or QCA alone. Results from coronary CT angiography were not included, and diagnostic performance was evaluated with the Mantel-Haenszel test stratified by disease status. Results The prevalence of CAD was 39% (36 of 92) according to QCA and SPECT and 64% (59 of 92) according to QCA alone. When compared with QCA and SPECT, per-patient diagnostic accuracy of perfusion CT and perfusion MR imaging was 63% (58 of 92) and 75% (69 of 92), respectively (P = .11); sensitivity was 92% (33 of 36) and 83% (30 of 36), respectively (P = .45); and specificity was 45% (25 of 56) and 70% (39 of 56), respectively (P < .01). When compared with QCA alone, diagnostic accuracy of CT perfusion and MR perfusion imaging was 82% (75 of 92) and 74% (68 of 92), respectively (P = .27); sensitivity was 90% (53 of 59) and 69% (41 of 59), respectively (P < .01); and specificity was 67% (22 of 33) and 82% (27 of 33), respectively (P = .27). Conclusion This multicenter study shows that the diagnostic performance of perfusion CT is similar to that of perfusion MR imaging in the detection of CAD. ^© RSNA, 2017 Online supplemental material is available for this article.

Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial

OBJECTIVE

 To evaluate whether invasive coronary angiography or computed tomography (CT) should be performed in patients clinically referred for coronary angiography with an intermediate probability of coronary artery disease.

DESIGN

 Prospective randomised single centre trial.

SETTING

 University hospital in Germany.

PARTICIPANTS

 340 patients with suspected coronary artery disease and a clinical indication for coronary angiography on the basis of atypical angina or chest pain.

INTERVENTIONS

 168 patients were randomised to CT and 172 to coronary angiography. After randomisation one patient declined CT and 10 patients declined coronary angiography, leaving 167 patients (88 women) and 162 patients (78 women) for analysis. Allocation could not be blinded, but blinded independent investigators assessed outcomes.

MAIN OUTCOME MEASURE

 The primary outcome measure was major procedural complications within 48 hours of the last procedure related to CT or angiography.

RESULTS

 Cardiac CT reduced the need for coronary angiography from 100% to 14% (95% confidence interval 9% to 20%, P<0.001) and was associated with a significantly greater diagnostic yield from coronary angiography: 75% (53% to 90%) v 15% (10% to 22%), P<0.001. Major procedural complications were uncommon (0.3%) and similar across groups. Minor procedural complications were less common in the CT group than in the coronary angiography group: 3.6% (1% to 8%) v 10.5% (6% to 16%), P=0.014. CT shortened the median length of stay in the angiography group from 52.9 hours (interquartile range 49.5-76.4 hours) to 30.0 hours (3.5-77.3 hours, P<0.001). Overall median exposure to radiation was similar between the CT and angiography groups: 5.0 mSv (interquartile range 4.2-8.7 mSv) v 6.4 mSv (3.4-10.7 mSv), P=0.45. After a median follow-up of 3.3 years, major adverse cardiovascular events had occurred in seven of 167 patients in the CT group (4.2%) and six of 162 (3.7%) in the coronary angiography group (adjusted hazard ratio 0.90, 95% confidence interval 0.30 to 2.69, P=0.86). 79% of patients stated that they would prefer CT for subsequent testing. The study was conducted at a University hospital in Germany and thus the performance of CT may be different in routine clinical practice. The prevalence was lower than expected, resulting in an underpowered study for the predefined primary outcome.

CONCLUSIONS

 CT increased the diagnostic yield and was a safe gatekeeper for coronary angiography with no increase in long term events. The length of stay was shortened by 22.9 hours with CT, and patients preferred non-invasive testing.Trial registration ClinicalTrials.gov NCT00844220.