Randomized trial of the effect of video training on residents' surgical skills in facial skin reconstructive surgery: A SQUIRE study

OBJECTIVES

The purpose of this study was to evaluate the impact of facial skin reconstruction training videos for head and neck and maxillofacial surgery residents.

MATERIAL AND METHODS

This randomized trial, conducted in France, involved residents in head and neck and maxillofacial surgery. A website was created containing facial skin reconstruction training videos. Selected residents performed facial skin flap dissections in the Paris School of Surgery. They were randomized into two groups, one receiving a standard course before the dissection, and the other a standard course plus a video of the flap ("no-video" and "video" groups). Each resident performed 4 facial flaps and was graded (blindly) during dissection. The main study endpoint was intergroup difference in grading score (out of 15). The article was written up following the SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in EDUcation) criteria.

RESULTS

Eighteen residents were included. For the main endpoint, scores were significantly higher in the "video" than the "no-video" group (6 [IQR, 4: 9] vs. 10 [9: 12]; P<0.001). In addition, as secondary endpoint, "no-video" group residents requested more assistance (3 [2: 4] vs. 1 [1: 2] P<0.001). Power was lacking for any subgroup analysis according to year of residency or to the 4 flaps.

CONCLUSION

Videos improved surgical residents' performance during dissections. However, these results would be difficult to transpose to real clinical conditions. They need validating in a larger study evaluating performance in real-life procedures.

[Atypical hand, foot and mouth disease in adults: A note on 6 cases]

INTRODUCTION

Hand, foot and mouth disease (HFMD) is form of viral dermatosis well known among the pediatric population, in whom it has a typical presentation. However, it is less common in adults, with a more heterogeneous presentation, potentially making diagnosis extremely challenging for the clinician.

PATIENTS AND METHODS

This was a retrospective case series from 2013 to 2018 of HFMD in adults, with all cases being confirmed by cutaneous polymerase chain reaction (PCR). We studied the clinical, epidemiological and viral characteristics of each patient.

RESULTS

This series of 6 cases comprised 4 men and 2 women, with a mean age of 42.5 years. Five patients presented extended purpuric lesions, four had bullous lesions, and three showed cutaneous signs without any mucosal lesions. Extended lesions on the trunk were found in four patients. One patient presented rosette-shaped pustular lesions on the limbs, one had eczema-like lesions on the scalp, and one presented extended purpuric lesions on the soles.

DISCUSSION

These different cases of adult HFMD raise questions about differential diagnosis in relation to other acute cutaneous and mucous diseases. It is essential to be aware of these different types of presentation of the disease in order to determine the diagnosis and discuss preventive measures.

[Cholesterol crystal embolism mimicking a DRESS]

INTRODUCTION

Clinical presentation of cholesterol crystal embolism (CCE) can be dermatologic when cholesterol crystals become lodged in small cutaneous arteries resulting in ischemia. We report a case of CCE with erythroderma misleading to a diagnostic of drug reaction with eosinophilia and systemic symptoms (DRESS).

CASE REPORT

A 66 year-old woman presented with erythroderma few months after initiation of allopurinol. Acute renal failure was present with elevation in plasma creatinine concentration (523μmol/L) and hypereosinophilia (HE) (5666/mm³). Finally, the REGISCAR score helped to rule out DRESS diagnostic. Past blood-count tests were analyzed revealing chronic HE present before allopurinol initiation. Renal biopsy identified CCE.

CONCLUSION

This case is the first to report a DRESS like presentation of CCE. Clinical findings are secondary to HE and not to occlusion of cutaneous arteries.

Age-specific characteristics of neutrophilic dermatoses and neutrophilic diseases in children

BACKGROUND

Our suggested 'modern' concepts of 'neutrophilic dermatoses' (ND) and 'neutrophilic disease' were based on observations in adult patients and have not been studied in paediatric patients. Only a minority of ND occurs in children, and little is known about age-specific characteristics.

OBJECTIVES

To describe age-specific characteristics of ND in children and to study whether our suggested 'modern' classification of ND may be applied to children.

METHODS

We conducted a retrospective multicentre study in a French cohort of 27 paediatric patients diagnosed with pyoderma gangrenosum (PG) or Sweet's syndrome (SS).

RESULTS

Demographics and distribution of typical/atypical forms were similar in patients diagnosed with PG and SS. Atypical ND were more frequent in infants (90%), when compared to young children (60%) and adolescents (33%). Neutrophilic disease was observed in 17/27 patients and was most frequent in infants. Neutrophilic disease of the upper respiratory tract, as well as cardiac neutrophilic disease, was only observed in infants, whereas other locations were similarly found in infants, young children and adolescents. In infants and young children, ND were associated with a large spectrum of general diseases, whereas in adolescents associations were limited to inflammatory bowel disease and Behçet's disease.

CONCLUSIONS

Our study describes the concept of ND in paediatric patients and shows that they have some characteristics different from ND occurring in adults. ND occurring in infants can be associated with a large spectrum of general diseases. Occurrence of neutrophilic disease is frequent in children. Thus, ND occurring in young paediatric patients should incite clinicians to schedule complementary explorations in order to search for involvement of other organs and to rule out monogenetic autoinflammatory syndromes.

[Contraception for women after 40: CNGOF Contraception Guidelines]

INTRODUCTION

Choosing contraception for women over 40 can be sometimes difficult but it is crucial since fertility and pregnancy's risks still exist. It requires a thorough evaluation of the situation, in order to identify any vascular and metabolic risk factors, along with the uterine and mammary benign pathologies already diagnosed.

OBJECTIVE

The objective of this review was to elaborate some guidelines for clinical practice regarding contraception's prescription for women over 40.

METHODS

A systematic review of the French and English existing literature was conducted. Pubmed and the Cochrane library were used to identify studies about contraception for perimenopausal women. International guidelines published by scientific societies were also reviewed (RCOG, FSRH, ESHRE, ACOG, WHO, HAS).

RESULTS

No contraceptive methods are contraindicated on the sole basis of age alone. However, because age is a risk factor for vascular and metabolic diseases, combined hormonal contraception and DMPA should not be prescribed at first intention. Copper IUD and progestin-only contraceptives (pill, implant, intrauterine device) should primarily be considered, since they offer good efficacy with lower risks.

CONCLUSIONS

Contraception for women over 40 should not be put aside. Long acting reversible contraception and progestin-only pill have to be prescribed as first-ine. Contraception is no longer needed for women over 50 who use non-hormonal contraception, after a 12 month-amenorrhea. Patients treated with combined hormonal contraception must stop using it over 50. Measuring hormonal levels while using hormonal contraception is not recommended. An hormonal-contraception-free interval must be considered, while using barrier contraception method. If an ovarian activity persists, a non-hormonal contraception or progestin-only contraception (except for DMPA) should be (re-)established.

[Misdiagnosis of hidradenitis suppurativa continues to be a major issue. The R-ENS Verneuil study]

OBJECTIVE

To provide physicians with an understanding of the factors behind significant delays in the diagnosis of hidradenitis suppurativa (HS) in France.

PATIENTS AND METHODS

This prospective multicentre national study conducted from October 2015 to March 2016 included all patients consulting for HS. Patient data were collected by means of a standardized questionnaire. Univariate and multivariate analyses were conducted to collect factors associated with a significant time to diagnosis of at least 5.5years, defined as the period between the onset of initial clinical signs and the time of formal diagnosis.

RESULTS

The 16 participating centres enrolled 312 patients (62% women), of average age 35years. The average age at onset of HS was 22years. Before formal diagnosis by a dermatologist (64% of cases), 170 (54%), 114 (37%) and 45 (15%) patients had previously consulted at least 3, 5 and 10 general physicians, respectively. The average time between the initial clinical signs of HS, the first dermatology visit and the definitive diagnosis was 6.2 and 8.4 years, respectively. Active smoking (OR adjusted 1.85; P=0.027) and disease onset at a younger age (adjusted OR 0.92; P<0.001) were both associated with significant delays in diagnosis.

CONCLUSION

These results emphasized misdiagnosis among HS patients but did not evidence any association between either sociodemographic or economic characteristics and the existence of significant times to diagnosis.

Idiopathic linear IgA bullous dermatosis: prognostic factors based on a case series of 72 adults

BACKGROUND

Linear IgA bullous dermatosis (LABD) is a clinically and immunologically heterogeneous, subepidermal, autoimmune bullous disease (AIBD), for which the long-term evolution is poorly described.

OBJECTIVES

To investigate the clinical and immunological characteristics, follow-up and prognostic factors of adult idiopathic LABD.

METHODS

This retrospective study, conducted in our AIBD referral centre, included adults, diagnosed between 1995 and 2012, with idiopathic LABD, defined as pure or predominant IgA deposits by direct immunofluorescence. Clinical, histological and immunological findings were collected from charts. Standard histology was systematically reviewed, and indirect immunofluorescence (IIF) on salt-split skin (SSS) and immunoblots (IBs) on amniotic membrane extracts using anti-IgA secondary antibodies were performed, when biopsies and sera obtained at diagnosis were available. Prognostic factors for complete remission (CR) were identified using univariate and multivariate analyses.

RESULTS

Of the 72 patients included (median age 54 years), 60% had mucous membrane (MM) involvement. IgA IIF on SSS was positive for 21 of 35 patients tested; 15 had epidermal and dermal labellings. Immunoelectron microscopy performed on the biopsies of 31 patients labelled lamina lucida (LL) (26%), lamina densa (23%), anchoring-fibril zone (AFz) (19%) and LL+AFz (23%). Of the 34 IgA IBs, 22 were positive, mostly for LAD-1/LABD97 (44%) and full-length BP180 (33%). The median follow-up was 39 months. Overall, 24 patients (36%) achieved sustained CR, 19 (29%) relapsed and 35% had chronic disease. CR was significantly associated with age > 70 years or no MM involvement. No prognostic immunological factor was identified.

CONCLUSIONS

Patients with LABD who are < 70 years old and have MM involvement are at risk for chronic evolution.

Rosacea fulminans during pregnancy

BACKGROUND

Rosacea fulminans (RF) is a severe form of facial dermatosis presenting with a sudden onset of numerous facial pustules, papules, and erythema. During pregnancy its treatment may be difficult and can have an impact on obstetrical outcomes.

CASE

A 37-year-old woman during the 37th week of her fourth pregnancy presented RF that was associated with ocular manifestations. The usual treatment with isotretinoin was contraindicated during pregnancy and the patient started an alternative treatment with prednisone and azithromycin. After delivery at 38 weeks of gestational age, there was a significant improvement.

CONCLUSION

RE is a severe dermatological disease with unknown etiology and with a rapid improvement in the immediate postpartum period.

Evaluation of risk factors for body weight increment in psoriatic patients on infliximab: a multicentre, cross-sectional study

BACKGROUND

A significant weight gain has been reported in patients with psoriasis treated with anti-tumour necrosis factor-alpha agents. Among these patients, there are contradictory results about risk factors for weight gain.

OBJECTIVE

Assessing risk factors for weight increment in psoriatic patients on infliximab (IFX).

METHODS

This study was a 4-month, non-interventional, cross-sectional, multicentre study on adults with psoriasis performed in 19 French dermatological centres. All the patients who received IFX for at least 1 year were prospectively included, with retrospective analysis of data. Impact of sex, age, severity of the disease, cardiovascular and metabolic comorbidities, and previous and simultaneous systemic treatments on weight changes, was analysed. Weight gain was defined as an increment of more than 2% of baseline weight.

RESULTS

Overall, 191 psoriatic patients (males: 68.6%; mean age: 46.9 years) were included. Mean weight gain was 1.6 kg (2.1%) after 1 year of IFX. Half (48.2%) suffered from a weight gain, and 9.9% from a weight increment of 10% or more. Baseline weight and Body Mass Index, and cardiovascular and metabolic comorbidities did not influence weight. Men (P=0.007) and patients with severe psoriasis (BSA, P=0.005) had a tendency to put on weight. Patients with a hospital dietary follow-up (P=0.01; OR=0.36 [0.16-0.79]) and patients on methotrexate (P=0.03; OR=0.41 [0.18-0.93]) during IFX treatment are thinner, in a multivariate analysis.

CONCLUSION

Severe weight increment is frequent on IFX treatment, mainly in men, and patients with severe psoriasis. Dietary follow-up or simultaneous use of methotrexate could limit this weight increment.