Psoriasis and mortality in the United States: Data from the National Health and Nutrition Examination Survey

BACKGROUND

Psoriasis is a multifactorial disease that has been associated with multiple systemic disorders. Despite its role in mediating cardiovascular, metabolic, and pulmonary disorders, few studies have examined the independent mortality risk associated with psoriasis.

OBJECTIVE

To determine the independent relationship between psoriasis and all-cause mortality in a nationally representative sample of the US population.

METHODS

Retrospective population-based cohort study of adults and adolescents older than 10 years (N = 13 031) who participated in National Health and Nutrition Examination Surveys (2003-2006 and 2009-2010). Psoriasis status was determined from a self-reported medical history questionnaire. Mortality data are linked from national databases.

RESULTS

Psoriasis was present in 2.7% of the study population. Over an average median follow-up of 52.3 months, psoriasis was significantly associated with increased mortality risk (HR, 1.99; 95% CI, 1.01-3.93; P = .047) with adjustment for demographics, smoking, and comorbidities including cardiovascular disease, diabetes, chronic obstructive pulmonary disease, cancer, chronic kidney disease, and stroke. These comorbidities mediated 15.5%, 5.9%, 8.7%, 11.7%, 4.2%, and 4.7% of the association between psoriasis and mortality, respectively.

CONCLUSION

Psoriasis is independently associated with an increased risk of mortality. This relationship is partially mediated by an increased prevalence of the cardiovascular, infectious, and neoplastic disorders seen among patients with psoriasis.

Case Studies in Neuroscience: Instability of the visual near triad in traumatic brain injury-evidence for a putative convergence integrator

Deficits of convergence and accommodation are common following traumatic brain injury, including mild traumatic brain injury, although the mechanism and localization of these deficits have been unclear and supranuclear control of the near-vision response has been incompletely understood. We describe a patient who developed profound instability of the near-vision response with inability to maintain convergence and accommodation following mild traumatic brain injury, who was identified to have a structural lesion on brain MRI in the pulvinar of the caudal thalamus, the pretectum, and the rostral superior colliculus. We discuss the potential relationship between posttraumatic clinical near-vision response deficits and the MRI lesion in this patient. We further propose that the MRI lesion location, specifically the rostral superior colliculus, participates in neural integration for convergence holding, given its proven anatomic connections with the central mesencephalic reticular formation and C-group medial rectus motoneurons in the oculomotor nucleus, which project to extraocular muscle nontwitch fibers specialized for fatigue-resistant, slow, tonic activity such as vergence holding.NEW & NOTEWORTHY Supranuclear control of the near-vision response has been incompletely understood to date. We propose, based on clinical and anatomic evidence, functional pathways for vergence that participate in the generation of the near triad, "slow vergence," and vergence holding.

The neural basis of motion sickness

Although motion of the head and body has been suspected or known as the provocative cause for the production of motion sickness for centuries, it is only within the last 20 yr that the source of the signal generating motion sickness and its neural basis has been firmly established. Here, we briefly review the source of the conflicts that cause the body to generate the autonomic signs and symptoms that constitute motion sickness and provide a summary of the experimental data that have led to an understanding of how motion sickness is generated and can be controlled. Activity and structures that produce motion sickness include vestibular input through the semicircular canals, the otolith organs, and the velocity storage integrator in the vestibular nuclei. Velocity storage is produced through activity of vestibular-only (VO) neurons under control of neural structures in the nodulus of the vestibulo-cerebellum. Separate groups of nodular neurons sense orientation to gravity, roll/tilt, and translation, which provide strong inhibitory control of the VO neurons. Additionally, there are acetylcholinergic projections from the nodulus to the stomach, which along with other serotonergic inputs from the vestibular nuclei, could induce nausea and vomiting. Major inhibition is produced by the GABA_B receptors, which modulate and suppress activity in the velocity storage integrator. Ingestion of the GABA_B agonist baclofen causes suppression of motion sickness. Hopefully, a better understanding of the source of sensory conflict will lead to better ways to avoid and treat the autonomic signs and symptoms that constitute the syndrome.

Association Between Psoriasis with Arthritis and Hearing Impairment in US Adults: Data from the National Health and Nutrition Examination Survey

Objective.

Emerging data has linked inflammatory arthritis with hearing impairment (HI). The objective of this study was to investigate the relationship between psoriasis with arthritis (PsA) and HI in the US population. Given the known association of HI and depression, a secondary aim is to investigate the effect of PsA on mental well-being.

Methods.

Cross-sectional study using the National Health and Nutrition Examination Survey for adults aged ≥ 20 years (n = 10,747). Association of PsA with above outcomes was examined using multivariable generalized linear and ordinal logistic regression models, adjusted for demographics and medical comorbidities. Structural equation models examined the extent to which HI mediated the effect of PsA on mental health.

Results.

Individuals with PsA were more likely to report hearing difficulties (OR 1.50, p = 0.043), visit a mental health provider (OR 1.62, p = 0.084), have 1.62 more days of poor mental health over the previous month (p = 0.033), and have depression (OR 2.01, p = 0.015) compared to controls. HI mediated 6.5%, 8.3%, and 5.0% of the effect of PsA on the above mental health outcomes, respectively.

Conclusion.

PsA is independently associated with a significantly increased risk of HI, which partially mediates an association with worsened psychiatric outcomes.

Health supervision for people with Bloom syndrome

Bloom Syndrome (BSyn) is an autosomal recessive disorder that causes growth deficiency, endocrine abnormalities, photosensitive skin rash, immune abnormalities, and predisposition to early-onset cancer. The available treatments for BSyn are symptomatic, and early identification of complications has the potential to improve outcomes. To accomplish this, standardized recommendations for health supervision are needed for early diagnosis and treatment. The purpose of this report is to use information from the BSyn Registry, published literature, and expertise from clinicians and researchers with experience in BSyn to develop recommendations for diagnosis, screening, and treatment of the clinical manifestations in people with BSyn. These health supervision recommendations can be incorporated into the routine clinical care of people with BSyn and can be revised as more knowledge is gained regarding their clinical utility.

Effect of intraoperative hyperoxia on the incidence of surgical site infections: a meta-analysis

BACKGROUND

Whether supplemental intraoperative oxygen reduces surgical site infections remains unclear. Recent recommendations from the World Health Organization and Center for Disease Control to routinely use high inspired oxygen concentrations to reduce infection risk have been widely criticized. We therefore performed a meta-analysis to evaluate the influence of inspired oxygen on infection risk, including a recent large trial.

METHODS

A systematic literature search was performed. Primary analysis included all eligible trials. Sensitivity analyses distinguished studies of colorectal and non-colorectal surgeries, and excluded studies with high risk of bias. Another post-hoc sensitivity analysis excluded studies from one author that appear questionable.

RESULTS

The primary analysis included 26 trials (N=14,710). The RR [95%CI] for wound infection was 0.81 [0.70, 0.94] in the high vs. low inspired oxygen groups. The effect remained significant in colorectal patients (N=10,469), 0.79 [0.66, 0.96], but not in other patients (N=4,241), 0.86 [0.69, 1.09]. When restricting the analysis to studies with low risk of bias, either by strict inclusion criteria (N=5,047) or by researchers' judgment (N=12,547), no significant benefit remained: 0.84 [0.67, 1.06] and 0.89 [0.76, 1.05], respectively.

CONCLUSIONS

When considering all available data, intraoperative hyperoxia reduced wound infection incidence. However, no significant benefit remained when analysis was restricted to objective- or investigator-identified low-bias studies, although those analyses were not as well-powered. Meta-analysis of the most reliable studies does not suggest that supplemental oxygen substantively reduces wound infection risk, but more research is needed to fully answer this question.

Depigmented plaques on vulva

A mother brought her 8-year-old daughter to our office for evaluation of vitiligo "down there". The skin eruption first appeared on her vulva a year earlier and was intermittently pruritic. The lesions were initially smaller and red, but had since lightened in color, coalesced, and had begun to spread to the perianal area. The patient's mother had received a call from her daughter's teacher who observed that her daughter was scratching the area and might be masturbating in class. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?

Hypothesis: The Vestibular and Cerebellar Basis of the Mal de Debarquement Syndrome

The Mal de Debarquement syndrome (MdDS) generally follows sea voyages, but it can occur after turbulent flights or spontaneously. The primary features are objective or perceived continuous rocking, swaying, and/or bobbing at 0.2 Hz after sea voyages or 0.3 Hz after flights. The oscillations can continue for months or years and are immensely disturbing. Associated symptoms appear to be secondary to the incessant sensation of movement. We previously suggested that the illness can be attributed to maladaptation of the velocity storage integrator in the vestibular system, but the actual neural mechanisms driving the MdDS are unknown. Here, based on experiments in subhuman primates, we propose a series of postulates through which the MdDS is generated: (1) The MdDS is produced in the velocity storage integrator by activation of vestibular-only (VO) neurons on either side of the brainstem that are oscillating back and forth at 0.2 or 0.3 Hz. (2) The groups of VO neurons are driven by signals that originate in Purkinje cells in the cerebellar nodulus. (3) Prolonged exposure to roll, either on the sea or in the air, conditions the roll-related neurons in the nodulus. (4) The prolonged exposure causes a shift of the pitch orientation vector from its original position aligned with gravity to a position tilted in roll. (5) Successful treatment involves exposure to a full-field optokinetic stimulus rotating around the spatial vertical countering the direction of the vestibular imbalance. This is done while rolling the head at the frequency of the perceived rocking, swaying, or bobbing. We also note experiments that could be used to verify these postulates, as well as considering potential flaws in the logic. Important unanswered questions: (1) Why does the MdDS predominantly affect women? (2) What aspect of roll causes the prolongation of the tilted orientation vector, and why is it so prolonged in some individuals? (3) What produces the increase in symptoms of some patients when returning home after treatment, and how can this be avoided? We also posit that the same mechanisms underlie the less troublesome and shorter duration Mal de Debarquement.

Scabies in babies

The clinical manifestations of scabies infestation vary according to age, making the diagnosis challenging, particularly for primary care providers and dermatologists who do not routinely care for young children. We present seven cases of newborns and infants who developed inflammatory burrows and nodules early in the course, which is not typical of the eruption seen in older children and adults. We review the cutaneous features, differential diagnosis, and treatment recommendations for scabies in different age groups.

Use of antibiotics in paediatric long-term care facilities

BACKGROUND

Adult long-term care (LTC) facilities have high rates of antibiotic use, raising concerns about antimicrobial resistance. Few studies have examined antibiotic use in paediatric LTC facilities.

AIM

To describe antibiotic use in three paediatric LTC facilities and to describe the factors associated with use.

METHODS

A retrospective cohort study was conducted from September 2012 to December 2015 in three paediatric LTC facilities. Medical records were reviewed for demographics, healthcare-associated infections (HAIs), antimicrobial use and diagnostic testing. Logistic regression was used to identify predictors for antibiotic use. The association between susceptibility testing results and appropriate antibiotic coverage was determined using Chi-squared test.

FINDINGS

Fifty-eight percent (413/717) of residents had at least one HAI, and 79% (325/413) of these residents were treated with at least one antibiotic course, totalling 2.75 antibiotic courses per 1000 resident-days. Length of enrolment greater than one year, having a neurological disorder, having a tracheostomy, and being hospitalized at least once during the study period were significantly associated with receiving antibiotics when controlling for facility (all P < 0.001). Diagnostic testing was performed for 40% of antibiotic-treated HAIs. Eighty-six percent of antibiotic courses for identified bacterial pathogens (201/233) provided appropriate coverage. Access to susceptibility testing was not associated with appropriate antibiotic choice (P = 0.26).

CONCLUSION

Use of antibiotics in paediatric LTC facilities is widespread. There is further need to assess antibiotic use in paediatric LTC facilities. Evaluation of the adverse outcomes associated with inappropriate antibiotic use, including the prevalence of resistant organisms in paediatric LTC facilities, is critical.