Gaps in medical education curricula on skin of color in medical school, residency, and beyond: Part 1

Various studies have revealed a disproportionately low representation of skin of color (SOC) dermatology in the medical education system of the United States. This disparity contributes to adverse experiences, missed and/or delayed diagnoses, and overall health inequities for individuals of color. The lack of sufficient SOC education begins at the medical school level and continues throughout residency, fellowship, and beyond formal training. This lack of education can be seen in the dearth of images of common and uncommon skin conditions in darker skin in widely used textbooks and educational resources as well as in the lack of formal training in SOC in many residency programs. Thus far, there have been valuable strides to make dermatologic education more inclusive of all skin colors, but there remains significant work to be done. With the population of the United States expected to continue to diversify and with the expectation that SOC will be a trait of over half of the population of the United States by 2050, it is important to strive for health equity by ensuring that comprehensive and inclusive medical training incorporates SOC. This paper will explore the issue of gaps in medical education in SOC dermatology at all levels and offer a strategic call to action to aid in rectifying this situation.

Racial and ethnic disparities in clinical research and the dermatology workforce: Part 2

Although racial and ethnic demographics are shifting in this country, it is not reflected in the diversity of clinical trial research participants; science, technology, engineering, and mathematics pipeline programs; or the workforce in the field of dermatology. Barriers to recruitment of minority patients for research studies also exist for numerous reasons including lack of education of prospective subjects, lack of awareness of ongoing trials, and mistrust within the health care system. Gaps in the science, technology, engineering, and mathematics pipeline for racial and ethnic minorities, particularly Black, Hispanic/Latinx, and American Indian or Alaska Native, are due in large part to structural racism. Lack of exposure as well as lack of educational, mentorship, and research opportunities contribute to gaps in the dermatology workforce. Having a representative population in the dermatology workforce and in clinical research trial patients is essential for optimum patient care, excellence in the specialty, and knowledge of appropriate treatments for minority populations. This article will discuss knowledge gaps for increasing minority subjects who participate in clinical research trials and discuss mechanisms to engage this community in trial recruitment. Additionally, this article addresses lack of racial and ethnic diversity of the dermatology workforce and performance gaps in the recruitment of racial/ethnic minorities into dermatology.

Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color - Part I: Genetic, biologic, and structural differences in skin of color

Skin of color (SOC) populations include those who identify as Black/African, Hispanic/Latinx, Asian/Pacific Islander, American Indian/Native Alaskan, Indigenous Australian, Middle Eastern, biracial/multiracial, or non-White; this list is far from exhaustive and may vary between and within cultures. Recent genetic and immunological studies have suggested that cutaneous inflammatory disorders (atopic dermatitis, psoriasis, and hidradenitis suppurativa) and malignancies (melanoma, basal cell carcinoma, and cutaneous T-cell lymphoma) may have variations in their immunophenotype among SOC. Additionally, there is growing recognition of the substantial role social determinants of health play in driving health inequalities in SOC communities. It is critically important to understand that social determinants of health often play a larger role than biologic or genetic factors attributed to "race" in health care outcomes. Herein, we describe the structural, genetic, and immunological variations and the potential implications of these variations in populations with SOC. This article underscores the importance of increasing the number of large, robust genetic studies of cutaneous disorders in SOC to create more targeted, effective therapies for this often underserved and understudied population. Part II of this CME will highlight the clinical differences in the phenotypic presentation of and the health disparities associated with the aforementioned cutaneous disorders in SOC.

Increased melanocytic nevi and lentigines in two patients with harlequin ichthyosis

An increased number of melanocytic nevi and lentigines have been reported in patients with two types of autosomal recessive congenital ichthyosis (ARCI): lamellar ichthyosis and nonbullous congenital ichthyosiform erythroderma. These melanocytic lesions may have clinical and dermoscopic features of atypia, necessitating close surveillance. Here, we report two interesting cases of pediatric patients with harlequin ichthyosis (HI) who developed increased melanocytic nevi and lentigines. These cases are unique in that the patients presented at a younger age and one patient had a darker skin phototype than previously described in the literature.

A neonatal pustule:Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is a rare, clinically heterogeneous disease that most commonly occurs in pediatric populations. Congenital self-limited LCH is a benign variant of LCH. It most commonly presents as a diffuse eruption and reports of single lesion cases are infrequent in the literature. Even in the case of congenital self-limited LCH, there is potential for future multisystem relapse, making long-term follow-up important. We present a case of single lesion self-limited LCH in a full-term male infant with interesting morphology. Physical examination revealed a painless, 6 millimeter, well-demarcated, papule encircled by erythema with central hemorrhage. An infectious workup was negative and a punch biopsy was obtained, which showed a dermal infiltrate of histiocytes consistent with a diagnosis of LCH. The lesion healed without intervention within three weeks. Our case highlights the need for dermatologists to consider LCH in the differential diagnosis for lesions of varying morphology in children, as proper identification is necessary to monitor for multisystem recurrence.

A prospective, longitudinal study of functional decline in individuals with Down's syndrome

This paper used the standardized criteria proposed by Aylward et al I995 for diagnosing Alzheimer's Disease in individuals with learning disabilities to undertake a prospective, longitudinal study of 22 individuals with Down's syndrome. Results show that, after a period of up to 6 years, four individuals showed functional decline. A similar pattern of decline was found to that described in previous studies, although the mean age of onset was later. All four subjects met the criteria for probable Alzheimer's Disease.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Effect of rurality on screening for breast cancer: a systematic review and meta-analysis comparing mammography

INTRODUCTION

The lower breast cancer survival rate observed among rural women may be related to differences in screening access and utilization. We evaluated existing evidence for rural and urban differences in mammography service use in adult women.

METHODS

A systematic search was conducted on 4 April 2012 and updated on 1 November 2012, which yielded 28 studies for inclusion.

RESULTS

The rural population was less likely to have mammographic breast screening, and this difference was consistent in various areas of the USA as well as across a number of other countries. Meta-analyses using random effects models showed that women residing in rural areas were less likely than urban women to have ever had a mammogram (odds ratio (OR)=0.74, 95% confidence interval (CI)=0.62-0.89) or to have an up-to-date mammogram (OR=0.59, 95%CI=0.49-0.70).

CONCLUSIONS

Mammography is currently the best tool for the early detection and diagnosis of breast cancer. The rural disadvantage this review has identified may contribute to the lower breast cancer survival among women living outside urban areas.

Squeezing water clusters between graphene sheets: energetics, structure, and intermolecular interactions

The behavior of water confined at the nanoscale between graphene sheets has attracted much theoretical and experimental attention recently.

Safety and pharmacokinetics of subcutaneously administered recombinant activated factor VII (rFVIIa)

BACKGROUND

 Recombinant activated factor VIIa (rFVIIa) is used to treat bleeds in hemophilia patients with inhibitors. A subcutaneous formulation could potentially improve its half-life and make it suitable for prophylactic treatment.

OBJECTIVES

 A study was conducted to determine the safety of subcutaneously administered rFVIIa in patients with hemophilia and the pharmacokinetic profile (including bioavailability).

PATIENTS/METHODS

 This was a multicenter, open-label, cross-over comparison of single doses of intravenous rFVIIa 90μgkg(-1) and a new formulation of rFVIIa for subcutaneous injection at dose levels of 45, 90, 180, 270 and 360μgkg(-1) . Sixty subjects (12 per dose cohort) with hemophilia A or B were enrolled.

RESULTS

 Subcutaneously administered rFVIIa showed lower mean peak plasma concentrations and prolonged FVII activity (C(max) , 0.44-5.16IU mL(-1) [across doses]; t(1/2) , 12.4h; t(max) , 5.6h) compared with intravenously administered rFVIIa (C(max) , 51.7IUmL(-1) ; t(1/2) , 2.7h; t(max) , <10min). The absolute bioavailability of subcutaneous rFVIIa ranged from 21.1 to 30.1% across dose levels. Dose proportionality was observed within a 2-fold dose increase but not across the full dose range. No thromboembolic events, drug-related serious adverse events, severe injection-site reactions or neutralizing antibodies were reported (primary endpoint). Mild and moderate injection-site reactions were more frequent with subcutaneous than with intravenous injections.

CONCLUSION

 This phase I clinical trial did not identify safety concerns of prolonged exposure to rFVIIa administered subcutaneously in single doses to hemophilia patients.