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Aim: To evaluate the feasibility and impact of using CYP2C19 genotype to guide selection of antiplatelet therapy in patients undergoing intracranial aneurysm treatment with a flow diversion stent in a real-world clinical setting. Patients & methods: A single-center, retrospective, observational cohort study was conducted in 112 patients undergoing intracranial aneurysm repair with flow-diversion stenting from 2014 to 2021. Data were abstracted from health records. The frequency of clopidogrel or alternative therapy (ticagrelor or prasugrel) use was compared across CYP2C19 status (intermediate or poor metabolizer [IM/PM] vs. normal, rapid, or ultrarapid metabolizer [NM/RM/UM]). Results: In the study population, CYP2C19 genotype testing was performed on 110 (98.2%) patients; of these, 106 (97.2%) had results available prior to the stent procedure and 28 (25.5%) were IM/PMs. Alternative therapy was used more frequently in IM/PMs compared with NM/RM/UMs (57.1 vs. 8.5%, respectively, p  < 0.0001). The frequency of thromboembolic events over 12 months did not significantly differ across clopidogrel-treated IM/PMs, clopidogrel-treated NM/RM/UMs and patients on alternative therapy ( p  = 0.352); although, event numbers were low. Conclusion: A pre-emptive CYP2C19 genotyping strategy to guide antiplatelet therapy selection in intracranial aneurysm repair patients is feasible in a real-world clinical setting. Larger studies are needed to assess the impact on clinical outcomes.

Competing Interests: Drs Freeman, Hruza, Rosenbach, and Fox are members of the American Academy of Dermatology COVID-19 Ad Hoc Task Force. Dr Freeman is an Editor for BJD. Dr French is the President and Dr Lim is a board member of the International League of Dermatological Societies. Dr Freeman is an author of COVID-19 dermatology for UpToDate. Dr Blumenthal and Authors Prasad, Ali, Singh, and Tyagi have no conflicts of interest to declare.

Reservation communities are among emerging communities for gang activity, in which reports of a rise in youth and/or criminal gangs began occurring after the 1980s. Gang membership has been found to pose a public health risk, strain community resources, and risk a number of individual negative life outcomes. Perceived increases in reservation gang activity have been observed by law-enforcement and community stakeholders, but comparatively little empirical research has focused specifically on these communities. Utilizing data from an existing public dataset, analysis of variance and regression analysis were utilized to examine cross sectional trends in gang involvement among 14,457 American Indian adolescents in reservation communities between 1993-2013. Results of this study failed to establish a consistent pattern of either growth or decline in gang membership across time when examining all reservations communities, with data suggesting that consistent trends may exist only within specific communities. Gang members were found to endorse significantly more alcohol and marijuana use, anger, depressed mood, and victimization as a whole. Only alcohol and marijuana use, violent behavior, and depressed mood demonstrated a significant interaction with time and gang membership. Finally, self-reported substance use, criminal behavior/delinquency, and violence perpetration significantly increased as gang affiliation increased.

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe mucocutaneous reaction with few large cohorts reported. This multicenter retrospective study included patients with SJS/TEN seen by inpatient consultative dermatologists at 18 academic medical centers in the United States. A total of 377 adult patients with SJS/TEN between January 1, 2000 and June 1, 2015 were entered, including 260 of 377 (69%) from 2010 onward. The most frequent cause of SJS/TEN was medication reaction in 338 of 377 (89.7%), most often to trimethoprim/sulfamethoxazole (89/338; 26.3%). Most patients were managed in an intensive care (100/368; 27.2%) or burn unit (151/368; 41.0%). Most received pharmacologic therapy (266/376; 70.7%) versus supportive care alone (110/376; 29.3%)-typically corticosteroids (113/266; 42.5%), intravenous immunoglobulin (94/266; 35.3%), or both therapies (54/266; 20.3%). Based on day 1 SCORTEN predicted mortality, approximately 78 in-hospital deaths were expected (77.7/368; 21%), but the observed mortality of 54 patients (54/368; 14.7%) was significantly lower (standardized mortality ratio = 0.70; 95% confidence interval = 0.58-0.79). Stratified by therapy received, the standardized mortality ratio was lowest among those receiving both steroids and intravenous immunoglobulin (standardized mortality ratio = 0.52; 95% confidence interval 0.21-0.79). This large cohort provides contemporary information regarding US patients with SJS/TEN. Mortality, although substantial, was significantly lower than predicted. Although the precise role of pharmacotherapy remains unclear, co-administration of corticosteroids and intravenous immunoglobulin, among other therapies, may warrant further study., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Patients with chronic graft versus host disease may exhibit a range of sclerotic features. Herein we present a patient with confirmed porphyria cutanea tarda who subsequently developed chronic graft versus host disease.

The development of a program to provide complete anesthesia coverage for obstetrics in a community hospital was undertaken as a prospective project which emphasized continuous caudal techniques. Mutually acceptable guidelines were formulated by a group of anesthesiologists and the Department of Obstetrics and Gynecology. A computerized study involving 3,500 labor patients was carried out to thoroughly evaluate the experience over 16 months. The data confirmed the feasibility, safety and wide acceptance of the program. Major complications were few and the anesthesia service to patients was excellent.

Studies by California Maternal Mortality Study Committees over a period of six years have revealed many avoidable inadequacies in the care of pregnant patients. Other reviews have shown a high incidence of non-fatal complications arising early in pregnancy when care is often inadequate. Since antenatal care is justly credited with the vast improvement of the incidence of maternal mortality, maternal morbidity and perinatal salvage, it is time for a reevaluation and upgrading of present-day practices. Responsibility is shared by the medical and auxiliary professions and the community. The public as well as those who care for the expectant mother must have improved educational exposure to achieve better results.

Specialists are having many difficulties defining and developing more effective methods in the area of continuing medical education. Present unorganized multifaceted mechanisms are too little utilized by the majority to be acceptable. A cooperative effort by parent specialty organizations, accredited hospital staffs and the State Board of Medical Examiners could explore the possibility of establishing standards by which a qualitative and quantitative review of the level of performance of physicians could be done. The initiative must be exercised by these groups to forestall governmental intervention.