A Polygenic Risk Score for Predicting Racial and Genetic Susceptibility to Prurigo Nodularis

Prurigo nodularis (PN) is an understudied inflammatory skin disease characterized by pruritic, hyperkeratotic nodules. Identifying the genetic factors underlying PN could help to better understand its etiology and guide the development of therapies. In this study, we developed a polygenic risk score that predicts a diagnosis of PN (OR = 1.41, P = 1.6 × 10-5) in two independent and continentally distinct populations. We also performed GWASs, which uncovered genetic variants associated with PN, including one near PLCB4 (rs6039266: OR = 3.15, P = 4.8 × 10-8) and others near TXNRD1 (rs34217906: OR = 1.71, P = 6.4 × 10-7; rs7134193: OR = 1.57, P = 1.1 × 10-6). Finally, we discovered that Black patients have over a two-times greater genetic risk of developing PN (OR = 2.63, P = 7.8 × 10-4). Combining the polygenic risk score and self-reported race together was significantly predictive of PN (OR = 1.32, P = 4.7 × 10-3). Strikingly, this association was more significant with race than after adjusting for genetic ancestry. Because race is a sociocultural construct and not a genetically bound category, our findings suggest that genetics, environmental influence, and social determinants of health likely affect the development of PN and may contribute to clinically observed racial disparities.

Risk of incident sleep disorders in patients with prurigo nodularis: A population-level analysis using The Health Improvement Network

Background

Prurigo nodularis (PN) is a chronic inflammatory skin condition characterized by severely itchy and often painful bumps on the arms, legs, and trunk. It is unknown whether patients with PN have increased risk of developing sleep disorders.

Objective

To evaluate the association of PN with sleep disorders.

Methods

This retrospective, population-level, matched-cohort study was conducted using The Health Improvement Network. The study included 4193 patients with newly diagnosed PN and 4193 age, sex, and race/ethnicity-matched controls. A Cox regression model was used to assess the development of sleep disorders, including insomnia, sleep apnea, and restless legs syndrome, in patients with PN compared with control patients.

Results

Compared with controls, PN was associated with insomnia (adjusted hazard ratio [aHR] = 1.77; 95% CI = 1.48-2.12) and overall sleep disorder (aHR = 1.72; 95% CI = 1.46-2.02), but not with sleep apnea (aHR = 1.51; 95% CI = 0.93-2.44) or restless legs syndrome (aHR = 1.54; 95% CI = 0.92-2.57).

Limitations

As a retrospective cohort study, our analysis is subject to potential confounders not already included.

Conclusions

PN was associated with subsequent development of insomnia. Thus, clinicians should consider insomnia among patients with PN and develop strategies for treatment and prevention.

Demographics, Cutaneous Manifestations, and Comorbidities Associated with Progressive Cutaneous Sarcoidosis: A Retrospective Cohort Study

Background: Sarcoidosis is a multisystem granulomatous disease with a wide variety of presentations and clinical courses. Cutaneous manifestations and comorbidities associated with sarcoid prognosis remain understudied. Methods: An EPIC query was run for patients age 18+ at the Johns Hopkins Hospital with a diagnosis of sarcoidosis of the skin according to the ICD-10-CM code D86.3. Data were obtained from a population-based sample of 240 patients from 2015 to 2020. Results: A total of 240 patients were included in the cohort study. The mean (SD) age was 43.76 (11.72) years, and 30% of participants were male; 76.25% of patients identified as black, 19.58% as white, and 4.17% as other. The average age of onset in remissive patients was significantly higher than progressive (47 ± 12 vs. 40 ± 10, p = 0.0005); 49% of black patients experienced progressive sarcoid compared to 32.6% of white patients (p = 0.028). Progressive disease was associated with the presence of lupus pernio (aOR = 3.29, 95% CI, 1.60-6.77) and at least one autoimmune comorbidity (aOR 6.831, 95% CI 1.819-11.843). Conclusions: When controlling for patient demographics, lupus pernio and the presence of at least one autoimmune condition were associated with progressive cutaneous sarcoidosis.

Reduced serum pyridoxine and 25-hydroxyvitamin D levels in adults with chronic pruritic dermatoses

Little is known about the role nutritional factors play in the pathogenesis of chronic pruritic dermatoses (CPD). In this study, we analyzed nutritional deficiencies in CPD patients compared to matched controls. We conducted a population-based study from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2006. The main outcomes of the study were laboratory data on serum vitamin levels in participants who answered affirmatively to the questionnaires on CPD as well as matched healthy controls. We identified 877 cases of CPD among 9817 adults in the US aged 20 to 59 years. These findings revealed a slightly higher percentage of females with CPD. Low vitamin B6 (OR 0.697; 95% CI: 0.696-0.699, p = 0.025) and vitamin D (OR 0.794; 95% CI: 0.789-0.799, p = 0.037) levels were associated with a higher rate of CPD compared to healthy controls. Our study suggests that low levels of Vitamin B6 and Vitamin D inversely correlates with the presence of CPD. These vitamin deficiencies suggest further studies on the effect of vitamin supplementation may help in patients with CPD.

A propensity score matched cohort study identifying an association of acne, but not oral antibiotic or isotretinoin use, with risk of incident inflammatory bowel disease

BACKGROUND

Concerns remain regarding whether oral antibiotic or isotretinoin use for acne is associated with increased risk of inflammatory bowel disease (IBD); little is known about whether acne itself is associated with IBD.

OBJECTIVE

To determine whether isotretinoin exposure, oral tetracycline-class antibiotic exposure, and/or acne itself are associated with IBD.

METHODS

A propensity score matched cohort study was performed using TriNetX between 2001 and 2022 to compare the 1-year incidence of IBD between those without acne compared to those with acne managed without systemic medications, acne managed with oral tetracycline-class antibiotics, and acne managed with isotretinoin.

RESULTS

There was a statistically significant association between acne and risk of incident IBD (odds ratio: 1.42; 95% confidence interval: 1.23-1.65). There was no statistically significant association between oral tetracycline-class antibiotic or isotretinoin exposure and IBD.

LIMITATIONS

Use of electronic health data; potential for misclassification bias.

CONCLUSION

This matched cohort study identifies an association between acne and IBD. These data provide further reassurance regarding the use of isotretinoin in the treatment of acne.

Cutaneous Toxicities Associated with Immune Checkpoint Inhibitors: An Observational, Pharmacovigilance Study

Cutaneous immune-related adverse events (cirAEs) are the most prevalent complication to arise from immunotherapy and cause significant morbidity. We aimed to determine the spectrum, timing, clinical features, and outcomes of cirAEs by conducting an observational pharmacovigilance study using VigiBase, the World Health Organization's global database of individual case safety reports from over 130 member countries (ClinicalTrials.gov, number NCT04898751). We compared adverse event reporting in patients who received immune checkpoint inhibitors (91,323 adverse events) with those of the full reporting database (18,919,358 adverse events). There were 10,933 cases of cirAEs within 51 distinct dermatologic types, with 27 specific eruptions with disproportionate signal represented (information component [IC]025 > 0). Of these 27 eruptions, there were eight cirAEs with n > 100 reports, including vitiligo (IC025 = 4.87), bullous pemphigoid (IC025 = 4.08), lichenoid dermatitis (IC025 = 3.69), erythema multiforme (IC025 = 1.03), toxic epidermal necrolysis (IC025 = 0.95), Stevens‒Johnson syndrome (IC025 = 0.41), drug eruption (IC025 = 0.11), and eczematous dermatitis (IC025 = 0.11). There were differences in time to onset after immune checkpoint inhibitor initiation, with a median of approximately 1 month (erythema multiforme, Stevens‒Johnson syndrome, and toxic epidermal necrolysis), 2 months (drug eruption and eczematous dermatitis), 4 months (lichenoid dermatitis), and 5‒6 months (bullous pemphigoid and vitiligo). CirAEs are diverse, dependent on cancer type, and have distinct and different onset times that are linked to the cirAE subtype.

Use of Triggers to Detect Adverse Events After Outpatient Orthopedic Surgery at a Single Ambulatory Surgery Center

Literature on adverse events (AEs) after outpatient orthopedic surgery is relatively sparse, and efforts to detect, measure, and track AEs after outpatient surgery lag behind those for the inpatient setting. Detection of AEs has traditionally relied on patient safety indicators (from billing data) and self-reporting, but these methods have been shown to have low sensitivity, missing up to 90% of AEs. There is growing recognition that the trigger method, which uses "triggers" as red flags to initiate more detailed chart audits, can serve as a more sensitive alternative to detect AEs. Moreover, the recent widespread adoption of electronic health records (EHRs) can provide faster automated methods for identifying triggers and estimating AE rates. This study evaluates the ability of 6 separate EHR-based triggers to predict AEs after outpatient orthopedic surgery and compares this trigger method with AE self-reporting. Triggers have the potential to decrease postoperative morbidity after outpatient orthopedic surgery and may lead to quality improvement. Further research is needed to qualify triggers as screening tools in the outpatient setting. [Orthopedics. 2022;45(2):116-121.].

Most common pediatric skin conditions managed in outpatient dermatology clinics in the United States stratified by race and ethnicity

A better understanding of what skin conditions are most commonly diagnosed in different pediatric racial and ethnic groups in outpatient dermatology clinics could help guide the development of pediatric dermatology educational initiatives for primary care providers and general dermatologists who have limited access to pediatric dermatologists. Using a nationally representative dataset, we evaluated the most common diagnoses in patients younger than 15 years of age (children) and 15-24 years of age (youth) who present to outpatient dermatology clinics, stratified by race and ethnicity. While acne and dermatitis were among the top ten most common diagnoses in all racial and ethnic groups studied, Black children were also commonly diagnosed with dermatophytosis and impetigo, and Black and Hispanic children were often diagnosed with seborrheic dermatitis; pigmentary disorders were among the top three most common diagnoses in Black, Asian, and Hispanic youth. Training more physicians how to evaluate and treat common skin conditions in children and youth of diverse racial and ethnic backgrounds may improve access to care for skin disease in the United States.

Outpatient prescribing of opioids to adults diagnosed with mental disorders in the United States

BACKGROUND

Adults with mood and anxiety disorders have an increased likelihood of being prescribed opioids. The influence of other mental disorders, such as psychotic and attention disorders, on opioid prescribing patterns is less known.

METHODS

We studied a population-representative sample of 166,927 outpatient visits for adults with painful conditions from the 2002-2016 National Ambulatory Medical Care Survey and the 2002-2011 National Hospital Ambulatory Medical Care Survey. Logistic regression analyses examined the likelihood of opioid prescription among visits with specific mental disorder diagnoses (anxiety, attention, mood, psychotic, post-traumatic stress disorder (PTSD), opioid use, and non-opioid substance use), adjusted for covariates and weighted for the complex survey design. Secondary analyses stratified results by whether opioids were newly initiated or continued.

RESULTS

Opioids were prescribed at 16.8 % of visits. Mood, anxiety, and non-opioid substance use disorders were associated with higher likelihoods of opioid prescriptions, particularly for continued rather than first-time prescriptions. Psychotic disorders were strongly negatively associated with opioid prescriptions (adjusted odds ratio 0.44, 95 % CI 0.22-0.86). Diagnoses of PTSD and attention disorders were not associated with opioid prescribing.

CONCLUSIONS

Outpatient physicians are more likely to prescribe and refill opioids for adults with pain who present with mood, anxiety, and non-opioid substance use disorders, but not for those who present with PTSD or attention disorders. Patients with psychotic disorders and pain are markedly less likely to be prescribed opioids.

Thermal singularity and contact line motion in pool boiling: Effects of substrate wettability

The dynamic van der Waals theory [Phys. Rev. E 75, 036304 (2007)] is employed to model the growth of a single vapor bubble in a superheated liquid on a flat homogeneous substrate. The bubble spreading dynamics in the pool boiling regime has been numerically investigated for one-component van der Waals fluids close to the critical point, with a focus on the effect of the substrate wettability on bubble growth and contact line motion. The substrate wettability is found to control the apparent contact angle and the rate of bubble growth (the rate of total evaporation), through which the contact line speed is determined. An approximate expression is derived for the contact line speed, showing good agreement with the simulation results. This demonstrates that the contact line speed is primarily governed by (1) the circular shape of interface (for slow bubble growth), (2) the constant apparent contact angle, and (3) the constant bubble growth rate. It follows that the contact line speed has a sensitive dependence on the substrate wettability via the apparent contact angle which also determines the bubble growth rate. Compared to hydrophilic surfaces, hydrophobic surfaces give rise to a thinner shape of bubble and a higher rate of total evaporation, which combine to result in a much faster contact line speed. This can be linked to the earlier formation of a vapor film and hence the onset of boiling crisis.

Microchip isoelectric focusing using a miniature scanning detection system

A miniature scanning fluorescent detector has been developed for plastic microchannel isoelectric focusing (mIEF) analysis. The detector, comprised of a lamp and photomultiplier tube (PMT) on a moving stage, measured the real-time distribution of fluorescently labeled peptides subjected to gel-free mIEF. During the run, the effective length of the 6-cm channel was scanned every 9 s. Analysis was completed within 5 min while still obtaining high resolution and sensitivity. In addition, the scanning detector was used to characterize peptide migration properties within the channel by providing simultaneous temporal and spatial measurements.

Lysing bacterial spores by sonication through a flexible interface in a microfluidic system

Cell disruptions using ultrasonic energy transmitted through a flexible interface into a liquid region has limitations because the motion of the vibrating tip is not completely transferred into the liquid. To ensure that some degree of contact will be maintained between the ultrasonic horn tip and the flexible interface, the liquid must be pressurized. The pressure conditions that yield consistent coupling between the ultrasonic horn tip and the liquid region were explored in this study by using an analytical model of the system and test fixture experiments. The nature of the interaction between the horn tip and the flexible interface creates pulses of positive pressure rises, increase in temperature, streaming flow, and almost no cavitation in the liquid. There was sufficient energy to create a cloud of microspheres, or beads, that maintain a consistent pattern of ballistic motion in the liquid. The sonication was found to be repeatable by studying video recordings of bead motion and was shown to be statistically consistent using measurements of temperature rise. Sonication of bacterial spores to obtain measurements of released nucleic acid and SEM images of damaged spores were used to verify the effects of liquid pressure on the horn-interface-liquid coupling.

Sulindac sulfone inhibits K-ras-dependent cyclooxygenase-2 expression in human colon cancer cells

Both the sulfide and sulfone metabolites of sulindac, a nonsteroidal anti-inflammatory drug, display anticarcinogenic effects in experimental models. Sulindac sulfide inhibits cyclooxygenase (COX) enzyme activities and has been reported to suppress ras-dependent signaling. However, the mechanisms by which sulindac sulfone suppresses cancer growth are not as defined. We studied the effects of these sulindac metabolites in human colon cancer-derived Caco-2 cells that have been transfected with an activated K-ras oncogene. Stable transfected clones expressed high levels of COX-2 mRNA and protein, compared with parental cells. K-ras-transfected cells formed tumors more quickly when injected into severe combined immunodeficiency disease mice than parental cells, and this tumorigenesis was suppressed by treatment with sulindac. Sulindac sulfone inhibited COX-2 protein expression, which resulted in a decrease in prostaglandin synthase E2 production. Sulindac sulfide had little effect on COX-2 in this model, but did suppress prostaglandin synthase E2 production, presumably by inhibiting COX enzyme activity. These data indicate that the sulfide and sulfone derivatives of sulindac exert COX-dependent effects by distinct mechanisms.

Allosteric modulation of [(3)H]gabapentin binding by ruthenium red

Gabapentin is an anticonvulsant with an unknown mechanism of action. However, it has been proposed that gabapentin acts by binding to voltage-gated calcium channels. To further characterize the interaction of gabapentin with its endogenous binding site in cerebral cortex, we tested for competitive and allosteric interactions between [(3)H]gabapentin and a variety of calcium channel binding ligands. Most ligands for voltage- or ligand-gated calcium channels (verapamil, the omega-conotoxins MVIIC and GVIA, ryanodine, caffeine, capsaicin, MK-801) had no significant effect on [(3)H]gabapentin binding. However, ruthenium red, a relatively nonselective calcium channel ligand, was found to robustly modulate [(3)H]gabapentin binding. Ruthenium red slowed the association and dissociation kinetics of [(3)H]gabapentin while increasing the number of detectable binding sites. Spermine and MgCl(2), which also bind to calcium channels and modulate [(3)H]gabapentin binding, were found to act in a similar manner. These findings support the contention that the principal endogenous binding site for gabapentin is a calcium channel; they characterize the nature of the allosteric interaction of spermine, MgCl(2) and ruthenium red with this binding site; and they suggest possible mechanisms by which gabapentin may modulate calcium channel function and ultimately produce therapeutic actions.

Molecular weight-dependent paracellular transport of fluorescent model compounds induced by palmitoylcarnitine chloride across the human intestinal epithelial cell line Caco-2

Long-chain acylcarnitines, such as palmitoylcarnitine chloride (PCC), are endogenous compounds which have been shown to increase intestinal transport of small hydrophilic compounds (including some pharmaceutical agents) through the paracellular pathway. However, the size range of the compounds whose absorption can be improved by PCC has not been fully investigated. In the present study, we systematically examined the effect of PCC on the transport rate of a series of hydrophilic fluorescent model compounds of varying molecular weights (0.3-71.2 kD) across cultured monolayers of the human intestinal epithelial cells Caco-2. Mucosal addition of 100 or 200 microM PCC resulted in comparable time-dependent decreases in the transepithelial electric resistance (T1/2, approximately 15 min). PCC addition induced a striking increase in the transport of sodium fluorescein (Flu-Na; 0.3 kD) and a slight or moderate increase in transports of fluorescent compounds of 0.6-11 kD. The effect of PCC on transport of compounds with molecular weights of > or = 17 kD appeared to be negligible. Examination by confocal laser scanning microscopy clearly revealed dilated paracellular spaces in Caco-2 monolayers which had been mucosally pretreated with PCC, confirming that PCC increases intestinal permeability by opening a paracellular transport pathway. Our results suggest that PCC is particularly effective in enhancing intestinal absorption of small hydrophilic compound like Flu-Na and may also have limited use in promoting the transport of compounds of < or = 10 kD.

Comparison between cefprozil and penicillin to eradicate pharyngeal colonization of group A beta-hemolytic streptococci

BACKGROUND

Our objective was to perform a prospective, randomized, double blinded study of cefprozil and penicillin therapy to eradicate group A beta-hemolytic streptococci (GABHS) in children who were bacteriologic failures after receiving a standard 10-day course of penicillin treatment for GABHS pharyngitis.

METHODS

Children and adolescents 2 to 18 years of age were eligible for the study. From 3 to 7 days after completing oral penicillin therapy for pharyngitis caused by GABHS, the study was explained, informed consent was obtained, a history and physical examination were completed and a throat culture was performed. Children with throat cultures positive for GABHS were randomized to receive either cefprozil or penicillin for 10 days. Children who were bacteriologic failures after administration of the first study drug were crossed over to receive the alternate drug.

RESULTS

Of 180 enrolled children 66 (37%) had throat cultures positive for GABHS. Seventeen were excluded from the study, leaving 49 who completed the protocol. Of the 49 participants 26 received cefprozil initially whereas 23 received penicillin. GABHS were eradicated from the pharynx of 73% of children who received cefprozil as the first antibiotic compared with 39% of penicillin recipients (chi square, 5.748, 0.01 < P < 0.025). After crossover of failures, the final efficacy rate for cefprozil was 65% compared with 36.7% for penicillin (chi square, 5.523, 0.01 < P < 0.025).

CONCLUSIONS

Cefprozil was more effective than penicillin in treating children who were bacteriologic failures after a standard 10-day course of oral penicillin.

The epidemiology of fractured femurs and the effect of these factors on outcome

We have analysed 250 cases of fractured shaft of the femur with the objective of highlighting any preventative measures and anticipating morbidity associated with cause and type of injury. The younger patients typically injure themselves as pedestrians, motorcyclists and bicyclists in Summer. The older patients tend to have falls in late Summer and Winter. The outcome varies depending on the cause, type and age of the injured person. The greatest morbidity was found in high-velocity accidents involving motorcyclists, pedestrians and car accidents. Knee flexion is a particular problem with these injuries and we are currently using continuous passive motion in conjunction with a continuous opiate infusion where this is likely to be a problem. The results also suggest that the mechanism of injury and its possible prevention, particularly in motorcycle design, could be as important as the type of treatment. Elderly females following falls also form a distinct group, suggesting that osteoporosis is a major factor with the best outcome associated with treatment by internal fixation. We feel that age alone should not be a reason for exclusion from intramedullary fixation and this merits further study.

Injuries associated with a fractured shaft of the femur

A knowledge of injury patterns, both from the mechanism of injury and from their associations, allows specific injuries to be suspected and actively excluded. We have reviewed fractures of the femoral shaft to highlight the patterns of their associated high morbidity and mortality. Our survey shows that accidents involving motorcyclists, pedestrians and motor cars have the highest incidence of associated injury. Common associations include chest, head, pelvis and ipsilateral leg injuries in pedestrians, and pelvic and ipsilateral leg injuries in motorcyclists. Rarer associations with femoral shaft fractures include ipsilateral tibia and talus/navicular fractures in motorcyclists, knee injuries and contralateral acetabular fractures in pedestrians and contralateral necks of femur in motor car passengers.

Galvanic reactions between cerclage wires and Kuntscher nails

Four patients are presented who had closed femoral shaft fractures and developed either extensive callus or osteomyelitis following open Kuntscher nailing and cerclage wiring of a butterfly fragment. Both the Kuntscher nail and cerclage wire are made of stainless steel but with different percentages of constituent elements. We looked at the galvanic reactions between the two and showed potential differences of up to 4.5 m.v. in wound drainage fluid. Potential differences in this range have been reported in other studies to be associated with extensive callus and infections associated with stainless steel anode corrosion.

T3 and T4 carcinoma of the larynx--a retrospective study

T3 and T4 lesions of the larynx were reviewed and the five year survival figures compared for radiotherapy, surgery, and combined therapy. Glottic T3N0M0 lesions gave an acceptable five year survival figure of 66 per cent. Radiotherapy is advised as the modality of treatment for T3N0M0 lesions. Larger glottic and supraglottic lesions responded poorly to all modalities of treatment and a more aggressive treatment policy may be advisable.

Avitene -- its value in the control of anterior epistaxis

Microfibrillar collagen (Avitene) was used on a series of 61 consecutive patients with anterior epistaxis. Avitene controlled bleeding in 38 of 49 patients with idiopathic epistaxis (77 per cent). Initial control of bleeding was obtained in two out of two patients with hereditary telangiectasia, two out of three patients with septal perforations, and two of seven patients with thrombocytopenia. Overall bleeding was initially controlled in 44 of 61 patients (72 per cent) while 17 patients (28 per cent) required packing or cautery. The morbidity with Avitene is minimal. Mucosal healing is rapid, and since approximately 10 patients can be treated with one gram of the material, the cost is low. It is suggested as a simple, effective form of treatment for anterior epistaxis that emergency room and family physicians can use.