The American Academy of Dermatology and International League of Dermatological Societies Monkeypox Registry: Expanding the COVID-19 registry to emerging infections

The World Health Organization declared the global monkeypox outbreak a public health emergency of international concern in July 2022. In response, the American Academy of Dermatology and International League of Dermatological Societies expanded the existing COVID-19 Dermatology Registry to become the "AAD/ILDS Dermatology COVID-19, Monkeypox, and Emerging Infections Registry." The goal of the registry is to rapidly collate cases of monkeypox and other emerging infections and enable prompt dissemination of findings to front-line healthcare workers and other members of the medical community. The registry is now accepting reports of monkeypox cases and cutaneous reactions to monkeypox/smallpox vaccines. The success of this collaborative effort will depend on active case entry by the global dermatology community.

High-frequency devices effect in vitro: promissing approach in the treatment of acne vulgaris?

BACKGROUND

Acne vulgaris is an inflammatory skin disorder leading to an impairment of quality of life and is therefore not only a cosmetic issue. Its pathogenesis is multifactorial - of particular importance is the colonization with the bacterium Propionibacterium acnes. A wide range of different treatment options exists including topical and systemic treatments depending on severity. High Frequency (HF) therapy, historically developed in the 19^th century, claims antimicrobial effects on acne skin, but solid data on its efficacy and mechanism of action is lacking.

OBJECTIVES

The main objective of this study was to determine the efficacy of HF therapy on skin flora and P. acnes in vitro using a commercial device as well as to review studies on the mechanism of action.

METHODS

The plasma source was investigated regarding electrical settings, heat, and ozone development. Bacterial skin flora, fungal isolates, and P. acnes were exposed to HF in vitro and compared to unexposed controls by evaluating the number of colonies on agar plates. To further analyze bacterial species from normal skin flora, 16S-sequencing was performed. Statistical analyses were carried out using row analysis and unpaired t-test.

RESULTS

HF treatment led to a significant reduction of almost every bacterial and fungal species investigated in this study. Moreover, the number of colonies forming units was significantly decreased in P. acnes after HF treatment compared to controls in vitro.

STUDY LIMITATIONS

The experiments were performed in vitro only. To assess clinical effects further in vivo experiments are necessary.

CONCLUSIONS

The results collected in this study, although in vitro, provide a mechanistic basis for HF as a complementary treatment option for patients with acne. It might also have a beneficial effect on patients with superficial infectious skin of the skin.

Assessment of Treatment Approaches and Outcomes in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Insights From a Pan-European Multicenter Study

Importance

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe drug reactions associated with a high rate of mortality and morbidity. There is no consensus on the treatment strategy.

Objective

To explore treatment approaches across Europe and outcomes associated with the SJS/TEN disease course, as well as risk factors and culprit drugs.

Design, Setting, and Participants

A retrospective pan-European multicenter cohort study including 13 referral centers belonging to the ToxiTEN ERN-skin subgroup was conducted. A total of 212 adults with SJS/TEN were included between January 1, 2015, and December 31, 2019, and data were collected from a follow-up period of 6 weeks.

Main Outcomes and Measures

Risk factors for severe acute-phase complications (acute kidney failure, septicemia, and need for mechanical ventilation) and mortality 6 weeks following admission were evaluated using a multivariable-adjusted logistic regression model. One tool used in evaluation of severity was the Score of Toxic Epidermal Necrolysis (SCORTEN), which ranges from 0 to 7, with 7 the highest level of severity.

Results

Of 212 patients (134 of 211 [63.7%] women; mean [SD] age, 51.0 [19.3] years), the mean (SD) body surface area detachment was 27% (32.8%). In 176 (83.0%) patients, a culprit drug was identified. Antibiotics (21.2%), followed by anticonvulsants (18.9%), nonsteroidal anti-inflammatory drugs (11.8%), allopurinol (11.3%), and sulfonamides (10.4%), were the most common suspected agents. Treatment approaches ranged from best supportive care only (38.2%) to systemic glucocorticoids (35.4%), intravenous immunoglobulins (23.6%), cyclosporine (10.4%), and antitumor necrosis factor agents (3.3%). Most patients (63.7%) developed severe acute-phase complications. The 6-week mortality rate was 20.8%. Maximal body surface area detachment (≥30%) was found to be independently associated with severe acute-phase complications (fully adjusted odds ratio [OR], 2.49; 95% CI, 1.21-5.12; P = .01) and SCORTEN greater than or equal to 2 was significantly associated with mortality (fully adjusted OR, 10.30; 95% CI, 3.82-27.78; P < .001). Cyclosporine was associated with a higher frequency of greater than or equal to 20% increase in body surface area detachment in the acute phase (adjusted OR, 3.44; 95% CI, 1.12-10.52; P = .03) and an increased risk of infections (adjusted OR, 7.16; 95% CI, 1.52-33.74; P = .01). Systemic glucocorticoids and intravenous immunoglobulins were associated with a decreased risk of infections (adjusted OR, 0.40; 95% CI, 0.18-0.88; P = .02). No significant difference in 6-week mortality was found between treatment groups.

Conclusions and Relevance

This cohort study noted differences in treatment strategies for SJS/TEN in Europe; the findings suggest the need for prospective therapeutic studies to be conducted and registries to be developed.

Integrating Patient Data Into Skin Cancer Classification Using Convolutional Neural Networks: Systematic Review

Background

Recent years have been witnessing a substantial improvement in the accuracy of skin cancer classification using convolutional neural networks (CNNs). CNNs perform on par with or better than dermatologists with respect to the classification tasks of single images. However, in clinical practice, dermatologists also use other patient data beyond the visual aspects present in a digitized image, further increasing their diagnostic accuracy. Several pilot studies have recently investigated the effects of integrating different subtypes of patient data into CNN-based skin cancer classifiers.

Objective

This systematic review focuses on the current research investigating the impact of merging information from image features and patient data on the performance of CNN-based skin cancer image classification. This study aims to explore the potential in this field of research by evaluating the types of patient data used, the ways in which the nonimage data are encoded and merged with the image features, and the impact of the integration on the classifier performance.

Methods

Google Scholar, PubMed, MEDLINE, and ScienceDirect were screened for peer-reviewed studies published in English that dealt with the integration of patient data within a CNN-based skin cancer classification. The search terms skin cancer classification, convolutional neural network(s), deep learning, lesions, melanoma, metadata, clinical information, and patient data were combined.

Results

A total of 11 publications fulfilled the inclusion criteria. All of them reported an overall improvement in different skin lesion classification tasks with patient data integration. The most commonly used patient data were age, sex, and lesion location. The patient data were mostly one-hot encoded. There were differences in the complexity that the encoded patient data were processed with regarding deep learning methods before and after fusing them with the image features for a combined classifier.

Conclusions

This study indicates the potential benefits of integrating patient data into CNN-based diagnostic algorithms. However, how exactly the individual patient data enhance classification performance, especially in the case of multiclass classification problems, is still unclear. Moreover, a substantial fraction of patient data used by dermatologists remains to be analyzed in the context of CNN-based skin cancer classification. Further exploratory analyses in this promising field may optimize patient data integration into CNN-based skin cancer diagnostics for patients’ benefits.

Combining CNN-based histologic whole slide image analysis and patient data to improve skin cancer classification

BACKGROUND

Clinicians and pathologists traditionally use patient data in addition to clinical examination to support their diagnoses.

OBJECTIVES

We investigated whether a combination of histologic whole slides image (WSI) analysis based on convolutional neural networks (CNNs) and commonly available patient data (age, sex and anatomical site of the lesion) in a binary melanoma/nevus classification task could increase the performance compared with CNNs alone.

METHODS

We used 431 WSIs from two different laboratories and analysed the performance of classifiers that used the image or patient data individually or three common fusion techniques. Furthermore, we tested a naive combination of patient data and an image classifier: for cases interpreted as 'uncertain' (CNN output score <0.7), the decision of the CNN was replaced by the decision of the patient data classifier.

RESULTS

The CNN on its own achieved the best performance (mean ± standard deviation of five individual runs) with AUROC of 92.30% ± 0.23% and balanced accuracy of 83.17% ± 0.38%. While the classification performance was not significantly improved in general by any of the tested fusions, naive strategy of replacing the image classifier with the patient data classifier on slides with low output scores improved balanced accuracy to 86.72% ± 0.36%.

CONCLUSION

In most cases, the CNN on its own was so accurate that patient data integration did not provide any benefit. However, incorporating patient data for lesions that were classified by the CNN with low 'confidence' improved balanced accuracy.

Effects of Label Noise on Deep Learning-Based Skin Cancer Classification

Recent studies have shown that deep learning is capable of classifying dermatoscopic images at least as well as dermatologists. However, many studies in skin cancer classification utilize non-biopsy-verified training images. This imperfect ground truth introduces a systematic error, but the effects on classifier performance are currently unknown. Here, we systematically examine the effects of label noise by training and evaluating convolutional neural networks (CNN) with 804 images of melanoma and nevi labeled either by dermatologists or by biopsy. The CNNs are evaluated on a test set of 384 images by means of 4-fold cross validation comparing the outputs with either the corresponding dermatological or the biopsy-verified diagnosis. With identical ground truths of training and test labels, high accuracies with 75.03% (95% CI: 74.39–75.66%) for dermatological and 73.80% (95% CI: 73.10–74.51%) for biopsy-verified labels can be achieved. However, if the CNN is trained and tested with different ground truths, accuracy drops significantly to 64.53% (95% CI: 63.12–65.94%, p < 0.01) on a non-biopsy-verified and to 64.24% (95% CI: 62.66–65.83%, p < 0.01) on a biopsy-verified test set. In conclusion, deep learning methods for skin cancer classification are highly sensitive to label noise and future work should use biopsy-verified training images to mitigate this problem.

B-57 Post-traumatic Stress Disorder is a Stronger Predictor of Long-term Neurobehavioral Outcome than Traumatic Brain Injury Severity in U.S. Military Service Members

Objective

The purpose of this study was to examine long-term neurobehavioral outcome in SMVs with versus without PTSD following TBI of all severities.

Methods

Participants were 536 SMVs recruited into three experimental groups (TBI, injured controls [IC], non-injured controls [NIC]). Participants completed the PTSD Checklist and the TBI-Quality of Life (TBI-QOL). Participants were divided into six subgroups based on the three experimental categories, two PTSD categories (i.e., present/absent), and two broad TBI severity categories (i.e., ‘unMTBI’ [includes uncomplicated mild TBI]; and ‘smcTBI’ [includes severe TBI, moderate TBI, and complicated mild TBI): (1) NIC/PTSD-Absent, (2) IC/PTSD-Absent, (3) unMTBI/PTSD-Absent, (4) unMTBI/PTSD-Present, (5) smcTBI/PTSD-Absent, and (6) smcTBI/PTSD-Present.

Results

There were significant main effects across the six groups for all TBI-QOL measures (p < .001). Select pairwise comparisons revealed significantly worse scores (p < .001) on all TBI-QOL measures in all PTSD-Present groups compared to the PTSD-Absent groups (i.e., Group 3v4 and 5v6; d = 0.90 to 2.11). In contrast, when controlling for PTSD, there were no significant differences between the TBI severity groups for all TBI-QOL measures (i.e., Group 3v5 and 4v6). In the TBI sample, a series of step-wise regression analyses revealed that PTSD, but not TBI severity, was consistently a strong predictor of all TBI-QOL scales (all p’s < .001), accounting for up to 64% of the variance.

Conclusions

These results provide support for the very strong influence of PTSD, but not TBI severity, on long-term neurobehavioral outcome following TBI. Concurrent PTSD and TBI of all severities should be considered a risk factor for poor long-term neurobehavioral outcome that requires ongoing monitoring.

B-58 Post-traumatic Stress Symptoms Are Associated with Worse Neuropsychological Functioning, but not Diffusion Tensor Imaging Findings, in Military Service Members Following Mild Traumatic Brain Injury

Objective

The purpose of this study was to examine neurobehavioral and neurocognitive functioning, and white matter integrity (using Diffusion Tensor Imaging [DTI]), in service members with versus without PTSD following mild traumatic brain injury (MTBI).

Method

Participants were 101 U.S. military service members who had sustained an uncomplicated MTBI (n = 80) or an injury without TBI (i.e., Injured Control [IC], n = 21) prospectively enrolled from the Walter Reed National Military Medical Center (Bethesda, Maryland). Participants completed a battery of neuropsychological tests, as well as DTI of the brain, on average 4-years post-injury. Measures of FA, MD, AD, and RD were generated for 18 regions of interest [ROIs]. Participants in the MTBI group were divided into two sub-groups based on DSM-IV-TR diagnostic criteria for PTSD: MTBI/PTSD-Present (n = 22) and MTBI/PTSD-Absent (n = 58).

Results

The MTBI/PTSD-Present group reported a significantly higher number of postconcussion symptoms, had higher scores on the majority of MMPI-2-RF scales, and had worse scores on the vast majority of cognitive domains (i.e., Attention, Processing Speed, Immediate Memory, Delayed Memory, Executive Functioning, Visuospatial Ability) compared to both the MTBI/PTSD-Absent group (all p’s < .05) and IC/PTSD-Absent group (all p’s < .05). For the DTI variables, there were no significant group differences for all DTI measures in all regions of the brain, with the exception of a handful of measures (i.e., right cingulum–cingulate gyrus, and bilaterally in the corticospinal tract).

Conclusion

These results provide support for a (a) strong relationship between PTSD and poor neurobehavioral and neurocognitive outcome following MTBI, and (b) weak relationship between PTSD and white matter integrity following MTBI.

B-46 Caring for a Service Member or Veteran following Traumatic Brain Injury Influences Caregiver Mental Health

Objective

To examine factors related to poor mental health in a sample of caregivers assisting service members/veterans (SMV) following a traumatic brain injury (TBI).

Methods

Caregivers (N = 201, 96.0% female; 86.1% spouse; Age: M = 39.2 years, SD = 10.2) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center (Maryland) and community outreach to participate in the Defense and Veterans Brain Injury Center 15-Year Longitudinal TBI Study (Sec721 NDAA FY2007). Caregivers completed the SF-36v2 Health Survey (SF-36v2), Caregiver Appraisal Scale (CAS), Mayo-Portland Adaptability Inventory-4 (MPAI-4), and Caregiver Questionnaire. The sample was divided into two mental health groups: Poor (n = 108) and Good Mental Health (n = 93).

Results

A higher proportion of caregivers in the Poor Mental Health group reported worse functioning on the SF-36v2 and CAS scales (d = .43 to d = 2.09), except CAS Ideology; helping with symptoms of depression, post-traumatic stress disorder (PTSD), and physical expressions of irritability, anger, or aggression (p’s < .01); less time for themselves (d = .42); more unmet needs (d = .87); an impact on employment (p = .00); and burdensome out-of-pocket caregiving expenses (p = .04). A higher proportion of SMVs of caregivers in the Poor Mental Health group had a mild TBI; worse scores on the MPAI-4 scales (d = .29 to d = .64); PTSD, depression, or other anxiety; received mental health and physical rehabilitation treatment; and did not have significant hospitalization post-injury (p = .04 to p = < .001).

Conclusions

Services for caregivers helping SMVs with comorbid mental health problems are required to ensure the burden of care does not undermine the caregiver’s health and impact the SMV’s recovery and reintegration.

B-60 Resilience is Associated with Overall Health-related Quality of Life in Caregivers of Service Members and Veterans Following Traumatic Brain Injury

Objective

To examine the influence of caregiver resilience on health-related quality of life (HRQOL) in caregivers of service members/veterans (SMVs) following a traumatic brain injury (TBI).

Methods

Caregivers (N = 346, Female = 96.2%; Spouse = 91.0%%; Age: M = 40.6 years) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center and via community outreach to participate in the Defense and Veterans Brain Injury Center 15-Year Longitudinal TBI Study (Sec721 NDAA FY2007). Caregivers completed the Caregiver Appraisal Scale and 15 HRQOL measures. Caregivers were divided into three groups using the Resilience scale from the TBI-QOL: (1) Low Resilience [n = 125], (2) Moderate Resilience [n = 122], and (3) High Resilience [n = 99].

Results

There were significant main effects across groups for all HRQOL measures (ps < .001). The Low Resilience group had consistently worse scores compared to both the Moderate and High Resilience groups (d = .50-1.60). The largest effect sizes were found for the Caregiving Satisfaction, Anxiety, Depression, Anger, Social Isolation, Perceived Stress, Caregiver Strain, and Feelings of Loss-Self scales (d = .91-1.60). Step-wise regression analyses revealed that Perceived Stress was the most significant predictor of resilience (R2 = 33.3%), with Caregiver Satisfaction (R2change = 5.0%), Depression (R2change = 1.8%), Caregiver Mastery (R2change = 1.7), Caregiver Specific Anxiety (R2change = 1.2) and Feelings of Loss-Self (R2change = 1.1%) contributing some additional variance in subsequent steps.

Conclusions

There was a moderate to high relationship between resilience and overall HRQOL in caregivers of SMVs following TBI. Targeted interventions to increase caregiver resilience may be warranted to ensure that burden of care does not undermine the caregiver’s heath and impact the SMV’s recovery and reintegration.

Die Dermatologische Klinik am UniversitätsSpital Zürich heute

Die Dermatologische Klinik des UniversitätsSpitals Zürich fokussiert als eines der renommiertesten universitären Zentren Europas primär darauf, eine fundierte, breite und möglichst innovative Grundversorgung der Patientinnen und Patienten sicherzustellen. Dies basierend auf einer aktiven und sehr zielgerichteten klinischen und Grundlagen-Forschung in den Bereichen schwere entzündliche Hautkrankheiten und Dermatoonkologie unter der Prämisse und langjährigen Tradition der translationalen Forschung. Ziel ist es, mit einem hochprofessionellen Mitarbeiterstab und entsprechender Nachwuchsförderung die führende Position der Klinik und ihre Kompetitivität auf die Zukunft langfristig zu halten und weiter zu entwickeln durch innovativste Forschung und Behandlung/Diagnostik-Methoden in der Patientenversorgung. Der Rolle in der Gesellschaft als führendes Dermatologie-Zentrum wird die Klinik gerecht durch engen Austausch mit den zuweisenden Ärzten – in Sinne der Weitergabe von aktuellstem Knowhow für die Patienten in den Praxen. Durch gezielte Öffentlichkeitsarbeit soll das Bewusstsein der Bevölkerung auf häufige und risikoreiche Hautkrankheiten sensibilisiert und damit das Verständnis für das Fach der Dermatologie gestärkt werden.

European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology

BACKGROUND AND OBJECTIVES

Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011.

METHODS

The European guidelines presented here were prepared by a panel of experts nominated by the EDF and EADV. The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN.

RESULTS AND CONCLUSION

The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.