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Introduction: Advance medical directives (AMD) are statements made by individuals indicating the life-sustaining treatment that they would refuse in the future when they lost their mental capacity for medical decisions. While the proposal for the AMD legislation is ongoing locally in Hong Kong SAR, there are limited reviews on the clinical outcomes associated with it., Objective: To provide a comprehensive review on clinical outcomes of signed AMD., Methodology: Retrospective, multi-center study, which includes AMD signed within five cluster hospitals. Records of signed AMD from 1 st JAN 2020 to 31 st DEC 2022 were retrieved from a central registry. Clinical information of each patient was obtained from the electronic patient record., Result: 456 patients with documented AMD were included in the study. 91.6% of AMD were signed by palliative care (PC) team. Majority (74.6%) of the patients were accompanied by family members or friends when AMD were signed. The concordance rate between the AMD and the medical care received was 89.5%. No patient revoked their AMD. Cancer and non-cancer patients showed similar rates of AMD concordance, frequency of Accident & Emergency Department (AED) visits or acute ward admissions, duration of hospital stays in the 30 days before death, and prevalence of receiving invasive or intensive treatments., Conclusion: Our study demonstrated that PC team currently plays a pivotal role in AMD completion, and AMD remains important in ensuring patients' care preferences are executed across different medical conditions. With the upcoming AMD legislation in Hong Kong SAR, adequate promotion and education should be launched., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Prior studies have indicated team members' interaction behaviors may predict creativity among nursing students., Methods: This study investigated the correlation between interaction behaviors and creativity, both individual- and team-level, among nursing students. In this cross-sectional quantitative study, data were obtained from self-reported questionnaires. Individual creativity was assessed using the Torrance Tests of Creative Thinking scale; the perceived team interaction behavior and team creativity were assessed using validated instruments. Canonical correlation analysis was conducted to determine the overall correlation between interaction behaviors, and creativity, and the moderating effect of female proportion dominance was also examined., Results: A total of 164 nursing students (84.1% female) arranged into 14 teams were included in this study. Canonical correlation analysis showed a positive correlation between interaction behaviors and creativity (correlation = 0.88). All dimensions of interactive behaviors were positively related to creativity dimensions. A stronger correlation to team creativity (correlation = 1) was found compared to individual creativity (correlation = 0.07). This study demonstrated that individual interactive behaviors including spontaneous communication and helping behavior predicted high team creativity., Conclusions: This insight may be valuable for nursing education programs seeking to foster creativity and effective teamwork. The potential moderating effect of female proportions on team interaction behaviors and creativity should be investigated further., (© 2024. The Author(s).)

The number of people suffering from diabetes in Taiwan has continued to rise in recent years. According to the statistics of the International Diabetes Federation, about 537 million people worldwide (10.5% of the global population) suffer from diabetes, and it is estimated that 643 million people will develop the condition (11.3% of the total population) by 2030. If this trend continues, the number will jump to 783 million (12.2%) by 2045. At present, the number of people with diabetes in Taiwan has reached 2.18 million, with an average of one in ten people suffering from the disease. In addition, according to the Bureau of National Health Insurance in Taiwan, the prevalence rate of diabetes among adults in Taiwan has reached 5% and is increasing each year. Diabetes can cause acute and chronic complications that can be fatal. Meanwhile, chronic complications can result in a variety of disabilities or organ decline. If holistic treatments and preventions are not provided to diabetic patients, it will lead to the consumption of more medical resources and a rapid decline in the quality of life of society as a whole. In this study, based on the outpatient examination data of a Taipei Municipal medical center, 15,000 women aged between 20 and 80 were selected as the subjects. These women were patients who had gone to the medical center during 2018-2020 and 2021-2022 with or without the diagnosis of diabetes. This study investigated eight different characteristics of the subjects, including the number of pregnancies, plasma glucose level, diastolic blood pressure, sebum thickness, insulin level, body mass index, diabetes pedigree function, and age. After sorting out the complete data of the patients, this study used Microsoft Machine Learning Studio to train the models of various kinds of neural networks, and the prediction results were used to compare the predictive ability of the various parameters for diabetes. Finally, this study found that after comparing the models using two-class logistic regression as well as the two-class neural network, two-class decision jungle, or two-class boosted decision tree for prediction, the best model was the two-class boosted decision tree, as its area under the curve could reach a score of 0.991, which was better than other models.

Competing Interests: Conflicts of interest None disclosed.

From financial improprieties to fraudulent claims, scandals and trust transgressions can incite feelings of betrayal. Can these negative reactions spillover and taint other entities that were not involved in the original transgression? We conducted six studies to investigate this question directly. Results consistently demonstrated that people who had perceived a recent betrayal by a transgressing trustee were significantly less likely to trust a new entity that shared nominal group membership with the previous trust transgressor. This betrayal spillover effect occurs both in economic game environments and can be applied to real-world charitable contexts in which people made actual donation decisions or assessed the likelihood that a charity would be embroiled in a scandal in the future. Importantly, the betrayal spillover effect only spilled over to those that shared a nominal group identity with the original trust transgressor, and this behavior was driven by a sense of distrust stemming from people's expectations having been violated. By systematically investigating whether and to what extent betrayals can contaminate subsequent trust development, this research provides a deeper and broadened understanding on how one may be vicariously affected by other entities' trust indiscretions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Little is known about the effectiveness of Interdisciplinary teaching (IDT) in higher education, particularly for healthcare education in Taiwan. It is vital to determine if IDT could enhance divergent creative thinking and team creativity among nursing students. A quasi-experimental study with a pretest-posttest design. Students enrolled in a capstone nursing course for the development of healthcare-related products were divided into two groups. The intervention group ( n = 61) was taught creative thinking skills with IDT by faculty. The control group ( n = 84) was taught by nursing faculty with traditional teaching. This study found that students who received the IDT intervention scored significantly higher on measures of creative thinking and team creativity compared with students in the control group. These findings suggest integrating IDT from nursing and design faculty into the teaching curriculum to foster students' creative thinking abilities when formulating interdisciplinary student teams to develop innovative, creative healthcare products.

Background: This study aims to determine the risk of developing anxiety and/or depression among patients with lichen planus., Methods: Based on the Longitudinal Health Insurance Database of Taiwan National Health Insurance Research Database, a total of 4012 patients with lichen planus and 16,048 matched controls (1:4) were enrolled between January 1, 2000, and December 31, 2015. After controlling for the risk variables, multivariate Cox proportional hazard regression and the log-rank test with Kaplan-Meier method were performed to assess the influence of anxiety/depression among individuals with lichen planus under a maximum follow-up period of 16 years., Results: The subsequent anxiety or depression incidence of the lichen planus group and the comparisons was 19.67% (1962.70 per 10 5 person-years) and 10.11% (982.23 per 10 5 person-years), respectively. Additionally, after adjustment of the risk variables, the hazard ratios for anxiety, depression, anxiety without depression, depression without anxiety, anxiety or depression, and both anxiety and depression combined were 1.779 (95%CI: 1.289-2.477, p < 0.001), 2.010 (95%CI: 1.454-2.790, p < 0.001), 2.015 (95%CI: 1.463-2.799, p < 0.001), 2.356 (95%CI: 1.705-3.286, p < 0.001), 2.011 (95%CI: 1.457-2.793, p < 0.001), and 1.515 (95%CI: 1.100-2.134, p < 0.001), respectively., Limitations: Individuals with lichen planus were unable to be classified into oral subtype and cutaneous subtype based on the ICD-9-CM. Moreover, the results of our study could not demonstrate the mechanism between lichen planus and anxiety and/or depression., Conclusion: Patients with lichen planus was positively associated with developing anxiety or depression. Physicians should to be aware of the signs of anxiety and/or depression while facing the patients with lichen planus during the clinical practices., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Guided by cognitive appraisal theory, we argue that wish-making is a conceptually distinct type of coping strategy and that wish-making during the COVID-19 pandemic has functional cognitive-affective consequences. Specifically, it facilitates positive appraisals of the pandemic, which then facilitate job satisfaction. Enhanced job satisfaction in turn reduces counterproductive work behavior during the pandemic. These arguments were tested via two empirical studies involving 546 Hong Kong employees surveyed on two consecutive working days during the pandemic. The individuals who made wishes during the pandemic reported more positive appraisals of the pandemic, which in turn promoted their job satisfaction and lowered their counterproductive work behavior. Crucially, wish-making had significant effects on positive appraisals above and beyond other coping strategies. Thus, we contribute to the employee coping literature by highlighting one relatively easy way for employees to combat the psychological effects of the pandemic (and other challenges in life) and regulate their affective well-being and behaviors at work. Namely, making wishes that envision a better future can enhance employees' job satisfaction, which in turn lowers counterproductive work behavior., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 Elsevier Inc. All rights reserved.)

Background: Patient-Reported Outcomes Measurement Information System Global Health (PGH) was validated to assess health-related quality of life in several diseases. Little is known about its measurement properties in adult atopic dermatitis., Objective: Examine the measurement properties of PGH in adult atopic dermatitis., Methods: A prospective dermatology practice-based study of 994 atopic dermatitis patients (18-97 years)., Results: PGH physical and mental health 4-item and abridged 2-item T scores, as well as mapped EuroQol-5D score, showed strong to very strong correlation with one another and moderate to strong Spearman correlations with Patient-Oriented Scoring Atopic Dermatitis, Patient-Health Questionnaire-9, Patient-Reported Outcomes Measurement Information System sleep disturbance and related impairment, Eczema Area and Severity Index, objective Scoring Atopic Dermatitis; and weak to moderate correlations with Patient Oriented Eczema Measure, numeric rating scale worst itch and average itch, and Scoring Atopic Dermatitis. The Dermatology Life Quality Index (DLQI) had stronger correlations with Patient Oriented Eczema Measure, Patient-Oriented Scoring Atopic Dermatitis, numeric rating scale worst itch and average itch, Eczema Area and Severity Index, and Scoring Atopic Dermatitis, but weaker correlations with Patient-Health Questionnaire-9 and Patient-Reported Outcomes Measurement Information System sleep disturbance and related impairment (convergent/divergent validity). PGH and DLQI scores had similarly poor ability to differentiate between levels of self-reported global atopic dermatitis severity (known-groups validity). No floor or ceiling effects were observed. No PGH or DLQI items had differential item functioning by demographics. PGH and DLQI scores showed fair to good responsiveness. Finally, PGH and DLQI showed similarly good test-retest reliability., Limitations: Single-center study., Conclusion: PGH scores had sufficient validity and reliability to assess health-related quality of life in atopic dermatitis., Competing Interests: Conflicts of interest Drs Chavda and Gabriel are employees of Galderma. Dr Silverberg has been a consultant and advisory board member for Galderma. Dr Janmohamed, Vakharia, Chopra, Patel, Singam, Kantor, and Hsu and Authors Schwartzman, Lei, and Yousaf have no conflicts of interest to declare., (Copyright © 2021 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Bullous pemphigoid is an autoimmune skin disease characterized by the formation of blisters between the epidermis and dermis. Comorbidities of pemphigoid have not been well-described. Identification of comorbidities associated with pemphigoid is important to decrease morbidity and mortality., Objective: To identify the comorbid health conditions of bullous pemphigoid., Methods: This was a case-control study of 91 cases of pemphigoid verified by clinical and laboratory diagnosis and 546 age- and sex-matched controls with complete follow-up at a large metropolitan quaternary care medical center., Results: The average age of bullous pemphigoid patients was 76 years and 53% of patients were female. Forty-eight (53%) of the BP patients had a history of inpatient hospitalization, of which 22 (24.2%) were hospitalized for either previously undiagnosed BP or an exacerbation of BP. Bullous pemphigoid was significantly associated with hypertension [adjusted odds ratio (95% confidence interval)]: [2.03 (1.24-3.32)], diabetes mellitus [2.59 (1.60-4.19)], chronic kidney disease [2.29 (1.19-4.40)], end-stage renal disease [3.82 (1.48-9.85)], basal cell carcinoma of the skin [6.00 (1.94-18.6)], and obstructive sleep apnea [5.23 (2.45-11.19)]. 78% of BP patients used at least one systemic immunosuppressant. There was no significant association between treatments for pemphigoid and any of the comorbidities., Conclusions: Bullous pemphigoid patients need screening for comorbid health conditions even though treatment options do not seem to be associated with these comorbidities.

Background: Few outcome measures were validated for assessing depressive symptoms in AD. Patient Health Questionnaire-9 (PHQ9) and the abridged PHQ2 are established patient-reported outcome measures of depressive symptoms., Objective: We sought to examine the measurement properties of PHQ9 and PHQ2 in adult AD. A prospective dermatology-practice based study of 458 AD patients (age 18-97 years) was conducted., Results: PHQ9 strongly correlated with Dermatology Life Quality Index, Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep-Disturbance and Sleep-Related Impairment, and PROMIS Itch Questionnaire Mood and Sleep (PIQ-MS), and moderately correlated with Patient-Oriented Eczema Measure, Numeric Rating Scale (NRS) average-itch, NRS-sleep, Eczema Area and Severity Index, Scoring AD and Rajka-Langeland scores. PHQ2 had significantly weaker correlations than PHQ9 with PROMIS SD, SRI and PIQ-MS, but similar correlations with other outcomes. PHQ9 and PHQ2 had good discriminant validity. Changes from baseline in PHQ9 and PHQ2 were poorly or weakly correlated with changes of the other outcome measures. There was no differential item functioning of PHQ items. PHQ9 showed good reliability (intraclass correlation coefficient range: 0.80-0.87). PHQ2 had slightly lower reliability (0.76-0.82)., Conclusions: PHQ9 and PHQ2 had similar measurement properties, but PHQ2 was more feasible to assess depressive symptoms in AD., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2020 American Contact Dermatitis Society. All Rights Reserved.)

Background: Multiple strategies have been used to evaluate the minimal important change (MIC) of the Eczema Area and Severity Index (EASI) and Scoring Atopic Dermatitis (SCORAD). The meaningfulness of these MICs is not well established across all severities of atopic dermatitis (AD)., Objectives: To determine the MIC of percentage and absolute improvement of EASI and SCORAD scores in adults and children with AD., Methods: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 826). An anchor-based approach was used to determine thresholds for the percentage and absolute MICs of EASI, SCORAD and objective SCORAD (O-SCORAD) at follow-up from baseline., Results: One-grade improvements of Physician's Global Assessment (PGA) and validated Investigator Global Assessment scale for AD (vIGA-AD) were associated with 50%, 35% and 35% decreases of EASI, SCORAD and O-SCORAD, respectively. The thresholds for percentage MIC of EASI (Kruskal-Wallis test, P = 0·61), SCORAD (P = 0·07) and O-SCORAD (P = 0·09) were similar across baseline AD severities. One-grade improvements of PGA and vIGA-AD were associated with 14·0- and 14·9-point decreases of EASI, 19·9- and 14·9-point decreases of SCORAD, and 15·5- and 17·4-point decreases of O-SCORAD. The thresholds for the absolute MIC of EASI (P < 0·001), SCORAD (P < 0·001) and O-SCORAD (P < 0·001) significantly differed by baseline AD severity. Percentage and absolute MICs for EASI and SCORAD were associated with improvements of AD symptoms and quality of life., Conclusions: EASI 50, SCORAD 35 and O-SCORAD 35 were meaningful percentage MICs regardless of baseline AD severity. The absolute MICs for EASI, SCORAD and O-SCORAD varied by baseline AD severity., (© 2020 British Association of Dermatologists.)

Background: The complexity of healthcare and concurrent advances in technology have promoted Interprofessional Education (IPE) in healthcare schools to prepare students to collaborate on interdisciplinary teams. Since 2016, healthcare curricula in Taiwan have incorporated IPE-based capstone courses to enhance creativity. To better understand the predictors of team creativity could help educators improve IPE and outcomes for nursing students and patients., Purpose: To determine whether nursing students' demographic characteristics, individual creativity, and perceived team interaction behaviors, team swift trust, team conflict, and team task interdependence may predict high perceived team creativity in IPE settings., Methods: A cross-sectional study design included nursing students (N = 99) at a science and technology university in Taiwan. Data from self-report questionnaires included variables for demographic characteristics, individual creativity, and perceived team characteristics. A hierarchical multiple regression analysis revealed predictors of high perceived team creativity., Results: Nursing students who perceived high team creativity also perceived higher interaction behaviors and lower process conflict than those who perceived less creativity. Spontaneous communication and team task conflict predicted high perceived team creativity., Conclusions: Nursing educators could increase team creativity in IPE by encouraging spontaneous communication and constructive task-oriented conflict management. This may benefit patient outcomes in the future., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Multiple atopic dermatitis (AD) severity scales exist, with no gold standard for use in clinical practice., Objectives: To determine the measurement properties of the Rajka-Langeland score and compare it with other clinician-reported outcomes in adults and children with AD., Methods: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 427)., Results: Rajka-Langeland had good concurrent validity with the Eczema Area and Severity Index (Spearman rho = 0·63), SCORing AD (SCORAD) (rho = 0·61), objective-SCORAD (rho = 0·52) and body surface area (rho = 0·51); good convergent validity with the numeric rating scale average-itch (rho = 0·60) and worst-itch (rho = 0·59), Patient-Oriented Eczema Measure (rho = 0·57), Dermatology Life Quality Index (rho = 0·53), Patient-Reported Outcomes Measurement Information System Itch Questionnaire (rho = 0·35-0·55) in adults and/or children; fair discriminant validity for patient- and physician-reported global AD severity; good responsiveness to change of severity of AD and itch; good reliability; internal consistency; with no floor or ceiling effects. Interpretability bands (3, clear/almost clear; 4-5, mild; 6-7, moderate; 8-9, severe) and minimal clinically important difference (1 point) were established., Conclusions: The Rajka-Langeland score showed good construct validity, reliability, internal consistency and responsiveness in adults and children with AD., (© 2020 British Association of Dermatologists.)

Background: Multiple clinician-reported outcome measures exist for atopic dermatitis (AD) severity. However, there is no gold standard for use in clinical practice., Objectives: To determine the measurement properties of the product of validated Investigator's Global Assessment for AD (vIGA) and body surface area (BSA) overall or divided into six categories (cBSA: 0%/0.1, <10%/10, <30%/30, <50%/50, <70%/70 and <90%/90-100%) and compare with other clinician-reported and patient-reported outcomes in adults and children with AD., Methods: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 653)., Results: vIGA*BSA and vIGA*cBSA had good convergent validity with BSA (Spearman's ρ = 0.97 and 0.93), eczema area and severity index (ρ = 0.94 and 0.92), and objective SCORAD (ρ = 0.88 and 0.89); and weak-to-good convergent validity with Numeric Rating Scale average itch (ρ = 0.22 and 0.22) and worst itch (ρ = 0.27 and 0.28), Patient-Oriented Eczema Measure (ρ = 0.44 and 0.43), Dermatology Life Quality Index (ρ = 0.48 and 0.49), ItchyQOL (ρ = 0.45 and 0.46), PROMIS Sleep Disturbance (ρ = 0.46 and 0.37) and sleep-related impairment (ρ = 0.31 and 0.31) in adults and/or children; very good discriminant validity for physician-reported global AD severity; good responsiveness to change of severity of AD and itch; and good reliability (intraclass correlation coefficient [95% confidence interval]: 0.72 [0.60-0.81] and 0.74 [0.62-0.82]) with no floor or ceiling effects. Thresholds for interpretability bands and clinically important difference were established., Conclusions: vIGA*BSA and vIGA*cBSA scores showed good convergent and discriminant validity, reliability, responsiveness and interpretability in adults and children with AD, and were feasible for use in clinical practice. vIGA*BSA and vIGA*cBSA had slightly lower convergent validity than EASI or objective SCORAD, but might be more efficient to collect and score., (© 2020 European Academy of Dermatology and Venereology.)

From employees' point of view, changes in ethical leadership perceptions can signal important changes in the nature of the employment relationship. Guided by social exchange theory, this study proposes that changes in ethical leadership perceptions shape how employees appraise their exchange relationship with the organization and affect their pride in or contempt for the organization. Changes in these associative/dissociative emotions, in turn, precipitate changes in behaviors that serve or hurt the organization, notably voice and turnover. Experimental data collected from 900 subjects (Study 1) and field data collected from 470 employees across 4 waves over 14 months (Study 2) converged to show that changes in ethical leadership perceptions were related to same-direction changes in employees' pride in the organization and to opposite-direction changes in their contempt for the organization above and beyond the effect of the present ethical leadership level. Changes in pride were in turn related to same-direction changes in functional voice, whereas changes in contempt were related to same-direction changes in dysfunctional voice. The field study also provided evidence that when pride increased (decreased), employees were less (more) likely to leave the organization 6 months after. These results suggest that changes in ethical leadership perceptions are meaningful on their own, that they may alter employees' organization-targeted behaviors, and that changes in associative/dissociative emotions are the mediating mechanism. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: Atopic dermatitis (AD) is associated with itch, pain, and sleep disturbance, all of which may contribute toward cognitive dysfunction., Objective: To determine the relationship of AD severity and cognitive function in adults., Methods: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 386). Cognitive function was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function 8-item Short-Form., Results: At baseline, 118 patients (58.1%) reported ≥1 symptoms of cognitive dysfunction in the past 4 weeks, with 29 (14.3%) having mild, 11 (5.4%) moderate, and 4 (2.0%) severe PROMIS Cognitive Function T-scores. In propensity score-weighted regression models, PROMIS Cognitive Function T-scores were inversely associated with patient-reported global AD severity, Patient Oriented Eczema Measure (POEM), Numeric Rating Scale worst itch and skin pain, SCORing Atopic Dermatitis (SCORAD)-sleep, POEM-sleep, Eczema Area and Severity Index, and SCORAD, with stepwise decreases of cognitive function with worsening AD severity. At all AD severity levels, cognitive dysfunction was associated with increased Dermatology Life Quality Index and ItchyQoL scores. Changes from baseline in PROMIS Cognitive Function T-scores were weakly to moderately inversely correlated with changes from baseline in multiple AD outcomes., Limitations: Single-center study without non-AD controls., Conclusion: Cognitive dysfunction is associated with AD severity. Cognitive function may be an important end point for monitoring treatment response in AD., (Copyright © 2020 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Recently, empirical researchers have observed direct associations between conflict and interaction behaviors within organizational teams. However, research concerning indirect links between conflict and interaction behaviors on interdisciplinary teams in nursing school is scant, particularly in Taiwan., Objectives: The aim of this study was to explore the relationships among various types of conflict and interaction behaviors on interdisciplinary nursing education teams., Design, Setting, and Participants: This study utilized a cross-sectional, quantitative, descriptive design. The authors collected survey data from 99 nursing students who participated in 18-week capstone courses of small interdisciplinary groups collaborating to design healthcare products in Taiwan during 2018 and 2019., Methods: Questionnaires assessed the nursing students' perceptions about their teams' conflicts (of task, process, and relationship), and interaction behaviors (constructive controversy, helping behaviors, and spontaneous communication). The authors used descriptive statistics to compare demographics, conflict scores, and interaction behavior scores for collocated and distributed interdisciplinary teams. A Pearson's analysis identified correlations among the variables and their components, and the SPSS PROCESS macro showed moderating effects of spontaneous communication on the relationship between distributed team and conflict subscales., Results: After confirming the distributed team experienced significantly more conflict than the collocated team, we found significant negative correlations between constructive controversy and both process conflict and relationship conflict on the distributed team. Another interaction behavior, spontaneous communication, had a moderating effect on the relationships between the distributed team and both task conflict and relationship conflict., Conclusion: In interdisciplinary educational settings for nursing students, spontaneous communication may moderate the types of conflict that distributed teams are more likely than collocated teams to experience. Constructive controversy may be especially effective at mitigating conflict on distributed teams. Nursing educators may refer to these insights to improve outcomes for educational interdisciplinary healthcare teams., Competing Interests: Declaration of competing interest No competing interests are declared by the authors., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Sleep disturbances are common in adults with atopic dermatitis (AD). Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance (SD) and Sleep-Related Impairment (SRI) are validated questionnaires to assess sleep in adults. Little is known about their measurement properties in adults with AD., Objectives: To assess the measurement properties of the PROMIS SD and SRI eight-item short forms in AD., Methods: We performed a prospective dermatology-practice-based study using questionnaires and evaluation by a dermatologist (n = 420)., Results: PROMIS SD and SRI showed moderate correlations to each other (ρ = 0·67), and weak correlations with Patient-Oriented Eczema Measure (ρ = 0·43 and 0·39, respectively); average (ρ = 0·31/0·30) and worst numerical rating scale for itch (ρ = 0·32/0·30); Eczema Area and Severity Index (ρ = 0·41/0·31); and Scoring Atopic Dermatitis (SCORAD) (ρ = 0·44/0·30) (Spearman correlations, P < 0·001). PROMIS SD and SRI increased significantly and stepwise with more frequent sleep disturbance, severe itch and self-reported global AD severity (ancova, P < 0·001). PROMIS SD and SRI showed good internal consistency (Cronbach alpha 0·84 and 0·91). Changes from baseline in PROMIS SD and SRI were weakly to moderately correlated with each other and with changes of multiple patient-reported and clinician-reported AD outcomes. There were no floor or ceiling effects for PROMIS SD or SRI. The median completion time for PROMIS SD and SRI was 2 min., Conclusions: PROMIS SD and SRI showed good construct validity, internal consistency, responsiveness and feasibility to assess sleep in adult patients with AD. What is already known about this topic? The Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance (SD) and Sleep-Related Impairment (SRI) scales were found to be valid in adults with chronic disease. However, the validity and feasibility of PROMIS SD and SRI in atopic dermatitis remain unknown. What does this study add? This study demonstrated that PROMIS SD and SRI had good content, concurrent, convergent and discriminant validity; feasibility; and responsiveness, with no floor or ceiling effects observed. What are the clinical implications of this work? The PROMIS SD and SRI eight-item bank short forms appear to have sufficient validity and feasibility to be used as assessments for burden of sleep in adults with atopic dermatitis in clinical practice., (© 2020 British Association of Dermatologists.)

Background: Atopic dermatitis (AD) is associated with heterogeneous triggers of itch, which may affect AD course and severity., Objective: To characterize the triggers of itch in adult AD., Methods: This was a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 587). Thirteen itch triggers were assessed using the patient-reported outcomes measurement information system Itch-Triggers., Results: Overall, 381 (64.9%) patients reported greater than or equal to 1 itch trigger in the past week and 212 (36.1%) reported greater than or equal to 3 itch triggers. The most commonly reported triggers were stress (35.4%), sweat (30.5%), weather change (24.7%), dry air (24.4%), and heat (24.0%). In multivariable Poisson regression models, the number of itch triggers was associated with more severe patient-reported global AD severity, Numeric Rating Scale worst itch, Patient-Oriented Eczema Measure, Scoring Atopic Dermatitis sleep, Numeric Rating Scale skin pain, Eczema Area and Severity Index, and objective Scoring Atopic Dermatitis. The seasonality of AD was associated with distinct itch triggers. In multivariable logistic regression models, the number of itch triggers was associated with less than or equal to 3 months of AD remission during the year, greater than or equal to 2 AD flares, and AD being worse during some seasons. Four patterns of itch triggers were identified using latent class analysis, each associated with different clinical characteristics., Conclusion: Itch triggers are common and affect the course of AD. Itch triggers are an important end point to assess in patients with AD., (Copyright © 2020 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about the validity of numeric rating scales (NRS) and verbal rating scales (VRS) for itch and itch frequency for assessing itch severity in atopic dermatitis (AD). We evaluated the Patient-Reported Outcomes Information System (PROMIS ® ) Itch Questionnaire (PIQ) - itch severity assessment, including multiple NRS, VRS and frequency of itch assessments, in adults with AD and compared their performance., Methods: Self-administered questionnaires and skin examinations were performed in 410 patients with AD (aged 18-90 years) in a dermatology practice setting., Results: PIQ NRS, VRS and frequency of itch had good content validity, strong correlations with one another (Spearman correlations P < 0·001) and weak-to-moderate correlations with patient-oriented eczema measure (POEM), Eczema Area and Severity Index (EASI), objective SCORing AD (SCORAD) and Dermatology Life Quality Index (DLQI) (P < 0·001) and very good discriminant validity. Changes from baseline in NRS, VRS and frequency of itch were moderately to strongly correlated with one another, and weakly to moderately correlated with other patient-reported (POEM, SCORAD itch, DLQI) and clinician-reported outcomes (EASI, objective SCORAD). NRS and VRS worst itch and average itch showed moderate-to-good test-retest reliability. There were no floor or ceiling effects for NRS or VRS itch, but there were ceiling effects for itch frequency. Each assessment was completed in < 1 min by all patients., Conclusions: NRS, VRS and frequency of itch items from PIQ - itch severity showed good content and construct validity, reliability, and/or responsiveness in adults with AD, and were feasible for use in clinical trials and practice. What is already known about this topic? Numeric rating scales (NRS), verbal rating scales (VRS) and frequency of itch have been used to assess the burden of itch. However, there have been limited results demonstrating their validity, responsiveness, interpretability and feasibility, particularly in atopic dermatitis (AD). What does this study add? This study demonstrated that NRS, VRS and frequency of itch items from the Patient-Reported Outcomes Information System (PROMIS ® ) Itch Questionnaire (PIQ) - itch severity assessments had good construct validity, responsiveness, reliability and feasibility in the assessment of adult AD. PIQ NRS, VRS and frequency of itch all appear to have sufficient validity, reliability and feasibility for use as assessments of itch in adults with AD in clinical practice and trials. What are the clinical implications of this work? PIQ NRS and VRS are all simple, valid, reliable and feasible for use in clinical practice and trials to assess itch in adults with AD. Linked Comment: Oosterhaven. Br J Dermatol 2020; 183:802-803., (© 2020 British Association of Dermatologists.)

Background: The ideal patient-reported outcome measure to assess sleep disturbance in atopic dermatitis (AD) has not been determined., Objective: We sought to determine the measurement properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) Itch Questionnaire Mood and Sleep (PIQ-MS), Sleep Disturbance (SD), Sleep-Related Impairment (SRI), and Epworth Sleepiness Scale (ESS) in adults with AD., Methods: A prospective dermatology practice-based study was performed using questionnaires and evaluation by a dermatologist (n=611)., Results: PIQ-MS, PROMIS SD, SRI, and ESS had good convergent validity with intensity and frequency of sleep disturbance, Patient-Oriented Eczema Measure, Eczema Area and Severity Index, total and objective-Scoring AD, Numerical Rating Scale of worst-itch and average-itch, and Dermatology Life Quality Index. PIQ-MS had significantly better correlations with other severity measures than the other sleep measures (Fisher z-scores, P≤0.007). PIQ-MS, and to lesser extent PROMIS SD, PROMIS SRI and ESS had good discriminant validity. All four sleep assessments showed fair responsiveness to change of severity of sleep-disturbance, AD and itch. PIQ-MS had the best reliability. PIQ-MS, PROMIS SD, SRI and ESS showed good internal consistency and were feasible for use in clinical practice., Conclusions: PIQ-MS, followed by PROMIS SD, had the best construct validity and reliability in adult AD.

Background: Little is known about the measurement properties of Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD) in adults with atopic dermatitis (AD). Even less is known about how PO-SCORAD performs compared with the Patient-Oriented Eczema Measure (POEM)., Objective: To examine the measurement properties of PO-SCORAD and compare them with those of POEM., Methods: A prospective dermatology practice-based study of 291 patients with AD (age range, 18-72 years)., Results: PO-SCORAD and POEM were moderately correlated with each other (Spearman ρ = 0.56) and had weak-moderate correlations with the Numeric Rating Scale (NRS) worst itch and average itch, Dermatology Life Quality Index (DLQI), ItchyQOL, Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance (SD) and Sleep-Related Impairment (SRI), Patient Health Questionnaire-9 (PHQ-9), and Eczema Area and Severity Index (EASI) (P < .001). POEM had significantly stronger correlations with DLQI, ItchyQOL, and EASI than did PO-SCORAD. PO-SCORAD and POEM had fair discriminant validity. Changes from baseline in PO-SCORAD and POEM were moderately correlated with each other; were weakly to strongly correlated with NRS worst itch and average itch, DLQI, ItchyQOL, PROMIS SD, PROMIS SRI, PHQ-9, and EASI; and had good test-retest reliability. There was no differential item functioning of items or floor or ceiling effects for PO-SCORAD or POEM. The thresholds for meaningful change for PO-SCORAD and POEM were -15.5 and -5.0, respectively. Median completion times for PO-SCORAD and POEM were 3 minutes and 1 minute, respectively., Conclusion: PO-SCORAD and POEM had good construct and cross-cultural validity, reliability, and responsiveness in adults with AD and were feasible for use in clinical trials and practice. However, POEM had better measurement properties than PO-SCORAD., (Copyright © 2020 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) Itch Questionnaire (PIQ) was recently developed., Objective: To validate PIQ short forms in adults with AD., Methods: Self-administered questionnaires and skin examinations were performed in 239 adults with atopic dermatitis (AD) in a dermatology practice setting., Results: PIQ items had good content validity. PIQ item bank T-scores strongly correlated with each other, moderately correlated with numeric and verbal rating scales for worst or average itch and with itch frequency, moderately to strongly correlated with patient-oriented eczema measure, and weakly to moderately correlated with the Eczema Area and Severity Index and Objective-Scoring AD (Spearman correlations, P < .0001). There were significant and stepwise increases of T-scores for all item banks with increasing patient-reported global severity (Wilcoxon rank sum test, P < .0001). However, there was limited ability to discriminate between the lowest or highest 2 levels of AD or itch severity. Item banks showed good internal consistency (Cronbach α, 0.91-0.95). No differential item functioning was identified by age, sex, race/ethnicity, or educational level. There were floor effects for total scores, particularly in almost clear/mild AD or itch., Limitations: Single-center study., Conclusions: PIQ item bank short forms showed good content and construct validity and are feasible for potential use in clinical trials and practice., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Prosocial organizations increasingly rely on e-pledges to promote their causes and secure commitment. Yet their effectiveness is controversial. Epitomized by UNICEF's "Likes Don't Save Lives" campaign, the threat of slacktivism has led some organizations to forsake social media as a potential platform for garnering commitment. We proposed and investigated a novel e-pledging method that may enable organizations to capitalize on the benefits of e-pledging without compromising on its mass outreach potential. In two pilot studies, we first explored whether and why conventional e-pledges may not be as effective as intended. Building on those insights, we conducted one field and two lab experiments to test our proposed e-pledge intervention. Importantly, the field study demonstrated the effectiveness of the intervention for commitment behavior across a 3-month period. The laboratory experiments provided a deeper and more refined mechanism understanding of the effect and ruled out effort, novelty, and social interaction mindset as alternative explanations for why the intervention may be effective. As technological innovations continue to redefine how people interact with the world, this research sheds light on a promising method for transforming a simple virtual acknowledgment into deeper commitment-and, ideally, to action., Competing Interests: The authors have declared that no competing interests exist.

Background: The optimal approaches for monitoring sleep disturbances in adults with atopic dermatitis (AD) is not established. Multiple patient-reported outcome measures for AD and itch have sleep-related items. These items have not been validated previously., Objective: Assess the measurement properties of sleep-related items from the Patient-Oriented Eczema Measure (POEM), SCORing AD (SCORAD), 5-dimensions of itch (5D), and ItchyQOL in adults with AD., Methods: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 115)., Results: There was modest overlap and weak-moderate concordance of responses to the different assessments. Regarding concurrent validity, POEM-sleep, SCORAD-sleep, 5D-sleep, and ItchyQOL-sleep showed moderate correlations with each other. Regarding convergent validity, all items showed moderate correlation with total POEM, but weak correlations with Eczema Area and Severity Index (EASI), objective and total SCORAD, moderate to strong correlations with mean ItchyQOL and Dermatology Life Quality Index (DLQI), but poor or no significant correlation with Numeric Rating Scale (NRS) for worst or average itch. Regarding discriminant validity, all items showed significant and stepwise increases with increasing self-reported and physician-reported AD severity (Kruskal-Wallis, P < .01 for all). Floor effects were observed for POEM-sleep (n = 53, 46.1%), SCORAD-sleep (n = 28, 24.4%), 5D-sleep (n = 41, 35.7%), and ItchyQOL-sleep (n = 33, 28.7%); no ceiling effects were observed. Change in sleep-related item scores showed moderate strong correlations with change in POEM, 5Ditch, mean ItchyQOL, DLQI, objective and total SCORAD, and EASI, but inconsistent correlations with change of itch severity., Conclusion: Sleep-related items from POEM, SCORAD, 5D and ItchyQOL showed good validity and responsiveness to monitor sleep disturbances in adult AD patients., (Copyright © 2019 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Many health care education programs, particularly those in Taiwan, have begun offering capstone product-based curricula, not only to improve nursing students' problem-solving skills but also to foster creativity and innovation regarding health care issues. This study used a cross-sectional quantitative design to explore the efficacy of teaching for creativity among nurse faculty in Taiwan. Results showed knowledge of intellectual property rights was low, as was ability to creatively evaluate trademark and patent designs. Curiosity was the main predictor associated with self-efficacy of teaching for creativity.

Background: Standardized quality-of-life (QoL) assessments can provide important and clinically relevant information. There is currently a lack of standardization in QoL assessments used in atopic dermatitis (AD)., Objectives: To determine the content validity, construct validity, internal consistency, differential reporting, responsiveness, floor or ceiling effects and feasibility of the Dermatology Life Quality Index (DLQI), Itchy Quality of Life (ItchyQoL) and 5-dimensions (5-D) itch scales for assessing burden of AD in adults and to compare their performance., Methods: Self-administered questionnaires and skin examination were performed in 340 adults with AD in a dermatology practice setting., Results: DLQI, ItchyQoL and 5-D all had good content validity. DLQI, mean ItchyQoL and 5-D itch all had strong correlations with frequency of AD symptoms (Patient-Oriented Eczema Measure) and intensity of itch (numerical rating scale for itch), and moderate correlations with AD severity (Eczema Area and Severity Index and Scoring Atopic Dermatitis) (Spearman correlations, P < 0·001 for all). DLQI and 5-D itch showed good internal consistency (Cronbach's alpha = 0·89 and 0·84), although ItchyQoL appeared to have several redundant items (alpha = 0·96). Uniform and nonuniform differential item functioning by age, sex and/or race/ethnicity was found for multiple items in DLQI, ItchyQoL and 5-D itch. DLQI, ItchyQoL and 5-D itch scores all demonstrated responsiveness, although ItchyQoL demonstrated the greatest responsiveness. There were no floor or ceiling effects for total scores. The median times for completion of DLQI, ItchyQoL and 5-D itch were 2 min., Conclusions: The DLQI, ItchyQoL and 5-D itch scales all showed good content and construct validity, and responsiveness in the assessment of AD in adults, and were feasible for use in clinical trials and practice., (© 2018 British Association of Dermatologists.)

Little is known about mental health (MH) emergencies in atopic dermatitis (AD) and their financial burden. We sought to determine hospitalization rates and costs of MH disorders in AD patients. We analyzed data from the Nationwide Inpatient Sample from 2002 to 2012, containing a representative 20% sample of US hospitalizations. Overall, 835 AD (1.36%) and 2,434,703 non-AD (0.75%) patients had a primary admission for an MH disorder. Atopic dermatitis patients admitted for MH disorders were more likely to be younger, Asian, of black race, and in a higher income quartile and have an increasing number of chronic conditions. In multivariable logistic regression models adjusting for demographics, AD was associated with a primary admission for MH disorders in adults, including mood disorders, schizophrenia, and developmental disorders. Atopic dermatitis was not associated with a primary admission for an MH disorder in children. There were an estimated US $183,821,629 excess costs of care annually for MH disorders in inpatients with versus without AD. In conclusion, AD was associated with higher odds of hospitalization for all MH disorders and substantial excess costs of inpatient care.

Background: Pemphigus and pemphigoid are blistering disorders associated with barrier disruption, immune dysregulation and use of immunosuppressing systemic therapy, all of which may predispose towards serious infections., Objectives: To determine whether pemphigus and pemphigoid are associated with increased likelihood of serious infections and the impact of such infections on mortality and cost of care., Methods: We analysed data from the 2002 to 2012 Nationwide Inpatient Sample, including a representative 20% sample of all hospitalizations in the US (total n = 72 108 077 adults)., Results: Overall, 54.6% (95% CI: 53.6-55.6%) and 50.4% (49.0-51.8%) of inpatients with either pemphigoid or pemphigus had a diagnosis of serious infection, respectively, compared with 25.4% (25.2-25.6%) in those without either diagnosis. In multivariable logistic regression models controlling for gender, age, race/ethnicity and insurance status, pemphigoid or pemphigus was associated with 26 or 21 of 48 infections examined, respectively. In particular, both pemphigoid and pemphigus were associated with higher odds of infections of the skin, bones, respiratory, gastrointestinal, genitourinary and central nervous system, septicaemia and antibiotic-resistant infections. Pemphigus was also associated with aspergillus, pharyngitis and Pneumocystis Carinii pneumonia. Associations of any serious infection in both pemphigoid and pemphigus patients were older age, non-White race, lower median household income, government or no insurance, higher number of chronic conditions, and those with a diagnosis of Cushing's syndrome, diabetes, cancer or autoimmune disease. The diagnosis of any serious infection vs. no infection was associated with increased inpatient mortality and costs in both pemphigoid (mortality: 7.85% vs. 2.84%; cost: $16 115 vs. $10 653) and pemphigus (mortality: 6.78% vs. 1.88%; cost: $17 707 vs. $11 545) inpatients (P < 0.0001 for all)., Conclusions: Adults with pemphigus or pemphigoid had increased cutaneous, respiratory, multi-organ and systemic infections, which were associated with considerable inpatient mortality and cost burden. Moreover, there were significant clinical and healthcare disparities with respect to infections in patients with pemphigus or pemphigoid., (© 2018 European Academy of Dermatology and Venereology.)

Background: Little is known about adult-onset atopic dermatitis (AD)., Objective: To determine the associations and clinical characteristics of adult-onset AD., Methods: A prospective study of 356 adults with AD (age ≥18 years) was performed using standardized questionnaires and examination. AD severity was assessed using the Patient-Oriented Eczema Measure, Eczema Area and Severity Index, Scoring Atopic Dermatitis, body surface area, and numeric rating scale for itch and sleeplessness. Latent class analysis was used to determine dominant clinical phenotypes. Multivariate logistic regression was used to determine the relationship between adult-onset AD and distinct phenotypes., Results: One hundred forty-nine adults (41.9%) reported onset of AD during adulthood, with 87 (24.4%) after the age of 50 years. Adult- versus childhood-onset AD was associated with birthplace outside the United States (χ 2 , P = .0008), but not sex, race/ethnicity, current smoking status, or alcohol consumption (P ≥ .11); and decreased personal history of asthma, hay fever, and food allergy and family history of asthma and food allergy (P ≤ .0001 for all). There was no significant difference in the Eczema Area and Severity Index, Scoring Atopic Dermatitis, body surface area, numeric rating scale for itch and sleeplessness, or Patient-Oriented Eczema Measure between adult- and childhood-onset AD (Mann-Whitney U test, P ≥ .10). Latent class analysis identified 3 classes: (1) high probability of flexural dermatitis and xerosis with intermediate to high probabilities of head, neck, and hand dermatitis; (2) high probability of flexural dermatitis and xerosis, but low probabilities of head, neck, and hand dermatitis; and (3) lower probability of flexural dermatitis, but the highest probabilities of virtually all other signs and symptoms. Adult-onset AD was significantly associated with class 1 (multivariate logistic regression; adjusted odds ratio, 5.54; 95% CI, 1.59-19.28) and class 3 (adjusted odds ratio, 14.03; 95% CI, 2.33-85.50)., Conclusions: Self-reported adult-onset AD is common and has distinct phenotypes with lesional predilection for the hands and/or head/neck., (Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

This is the first account of significant aortic injury during diagnostic rigid esophagoscopy in an adult with an esophageal stricture. We describe the resultant hemothorax and hemodynamic collapse and the successful treatment with massive volume resuscitation, vasopressors, and timely surgical intervention including thoracic endovascular aortic repair. We discuss the importance of rapid diagnosis, relevant anatomy, treatment modalities, and communication as cornerstones for learning.

Background: Several patient-reported outcomes have been used to assess the burden of atopic dermatitis (AD). Some are disease specific, such as the Patient-Oriented Eczema Measure (POEM), while others pertain to itch, for example the numerical rating scale (NRS)-itch, ItchyQoL and 5-D itch, or dermatological disease in general, for example the Dermatology Life Quality Index (DLQI). Development of severity strata is essential for proper interpretability of these assessments., Objectives: To confirm previously developed strata for POEM, DLQI and raw ItchyQoL, and develop strata for the NRS-itch, mean ItchyQoL and 5-D itch scale for use in adults with AD., Methods: Self-administered questionnaires were completed by 210 adults with AD in a dermatology practice setting. Strata were selected using an anchoring approach based on patient-reported disease severity., Results: We confirmed the existing strata for POEM (mild 0-7, moderate 8-16, severe 17-28; κ = 0·440), DLQI (mild 0-5, moderate 6-10, severe 11-30; κ = 0·398) and NRS-itch (mild 0-3, moderate 4-6, severe 7-10; κ = 0·499). However, the preferred band for raw ItchyQoL was mild 22-58, moderate 59-74 and severe 75-110 (κ = 0·379) and for mean ItchyQoL, mild 1-2·9, moderate 3·0-3·9, severe 4·0-5·0 (κ = 0·374). The preferred band for 5-D itch scale was mild 0-11, moderate 12-17 and severe 18-25 (κ = 0·331)., Conclusions: Existing strata for POEM and DLQI performed well in adult AD. Previously reported strata for visual analogue scale-itch performed best for NRS-itch. We identified banding for the raw ItchyQoL for our AD population that varies slightly from the banding published for a more heterogeneous population. Finally, we proposed strata for mean ItchyQoL and 5-D itch scale in adult AD., (© 2017 British Association of Dermatologists.)

Background: Staphylococcal scalded skin syndrome (SSSS) is a blistering dermatosis caused by exfoliative toxins released from Staphylococcus aureus., Objectives: To describe the incidence, costs, length of stay (LOS), comorbidities and mortality of SSSS in U.S. children., Methods: The Nationwide Inpatient Sample 2008-2012 was analysed, including a 20% sample of U.S. hospitalizations and 589 cases of SSSS., Results: The mean annual incidence of SSSS was 7·67 (range 1·83-11·88) per million U.S. children, with 45·1 cases per million U.S. infants age < 2 years. In multivariable logistic regression models, SSSS was significantly associated with the following (shown as adjusted odds ratio and 95% confidence interval): female sex (1·12, 1·00-1·25), age (2-5 years: 13·31, 11·82-14·99; 6-10 years: 2·93, 2·35-3·66; 11-17 years: 0·44, 0·31-0·63); race/ethnicity (black: 0·69, 0·58-0·84) and season (winter: 2·04, 1·66-2·50; summer: 3·47, 2·86-4·22; autumn: 3·04, 2·49-3·70), with increasing odds over time (2010-2011: 2·28, 2·07-2·51; 2012: 2·98, 2·69-3·30). The geometric mean (95% confidence interval) LOS and cost of hospitalization for patients with vs. without SSSS were 3·2 (3·0-3·4) vs. 2·4 (2·4-2·5) days and $4624·0 ($4250-$5030) vs. $1872 ($1782·7-$1965). Crude inpatient mortality rates (with 95% confidence intervals) were similar for children with vs. without SSSS (0·33%, 0·00-0·79% vs. 0·36%, 0·34-0·39%). SSSS was associated with other infections, including in the upper respiratory tract and skin., Conclusions: The prevalence of SSSS appears to be increasing over time, and was associated with a number of sociodemographic factors and other infections. Further studies are needed to confirm these findings and reduce rising rates of SSSS., (© 2017 British Association of Dermatologists.)

Eczema herpeticum (EH) is characterized by viral infection of a preexisting inflammatory dermatosis and is associated with considerable morbidity. In this cross-sectional study, we sought to determine the incidence, risk factors, comorbidities, costs of care, length of stay, and mortality in hospitalized U.S. children with EH. The Nationwide Inpatient Sample 2002-2012, containing a 20% sample of all U.S. hospitalizations, was analyzed. We used a validated approach involving InternationalClassification of Diseases, Ninth Revision-Clinical Modification codes to identify patients primarily admitted for EH (n = 4,655 weighted). The mean annual incidence of hospitalization for EH per million children ranged from 4.03 to 7.30, increasing significantly from 2008 to 2012. EH was associated with younger age (odds ratio [95% confidence interval] for 3-4 years = 1.29 [1.02-1.64]) and nonwhite race/ethnicity (black = 2.93 [2.35-3.66], Asian= 4.41 [3.34-5.83], Native American = 2.96 [1.51-5.78]) but was less likely to occur in areas with lower income quartiles (quartile 1, 0.66 [0.53-0.84]; quartile 2, = 0.68 [0.54-0.87]; quartile 3, 0.70 [0.56-0.88]). EH was associated with atopic dermatitis (11.72 [9.48-14.49]). Increased length of stay and costs of care were associated with Asian race. Mean length of stay was 3.86 ± 0.09 days, and mean cost of care was $5,237.6 ± 160.6. Overall mortality was 0.1%. EH in hospitalized children poses a substantial burden to the health care system., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Atopic dermatitis (AD) is associated with a heterogeneous presentation and clinical course. There is a lack of simple and validated severity assessments that are feasible for clinical practice and epidemiological research., Objectives: We sought to validate patient-reported global AD severity in adults., Methods: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 265)., Results: At baseline and follow-up, patient-reported global AD severity significantly correlated with oSCORAD (Spearman ρ = 0.56 and 0.49), SCORAD (0.64 and 0.56), EASI (0.56 and 0.50), BSA (0.52 and 0.45), NRS-itch (0.60 and 0.53), POEM (0.50 and 0.48), and DLQI (0.50 and 0.49) (P < .0001 for all). Patient-reported moderate and severe AD vs mild AD were associated with significantly higher oSCORAD, SCORAD, EASI, BSA, NRS-itch, POEM, and DLQI (P < .0001 for all). There was moderate concordance between patient-reported AD severity (mild, moderate, and severe) and previously developed severity strata for oSCORAD (κ = 0.39), SCORAD (κ = 0.47), EASI (κ = 0.37), NRS-itch (κ = 0.49), POEM (κ = 0.37), and DLQI (κ = 0.40). Among patients with severe disease at baseline, those who reported mild or moderate disease on follow-up had significantly greater absolute reductions of oSCORAD (-23.4/-9.7/-1.8), SCORAD (-33.0/-13.2/-2.3), EASI (-17.1/-9.8/-3.2), BSA (-46%/-15%/-4%), NRS-itch (-5/-2/0), POEM (-5/-2/0), and DLQI (-8/-6/-1) than those who continued to report severe disease (Kruskal-Wallis, P ≤ .0003 for all)., Conclusions: Patient-reported AD severity appears to be sufficiently valid for assessing AD severity in the clinical and epidemiological setting., (© 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Introduction: Little is known about the risk factors of hospitalization for atopic dermatitis (AD)., Objectives: We sought to determine associations of hospitalization for AD in the United States., Methods: Data were analyzed from the 2002 to 2012 National Inpatient Sample. Atopic dermatitis hospitalizations were compared with controls, which included all hospitalizations without any diagnosis of AD excluding normal pregnancy/delivery, yielding a representative cohort of US hospitalizations., Results: Both adults and children, who were admitted for AD or eczema, were more likely to have nonwhite race/ethnicity, lowest-quartile annual household income, Medicaid or no insurance, and fewer chronic conditions. Increased cost of care and prolonged length of stay were also associated with nonwhite race/ethnicities, lowest-quartile annual household income, Medicaid or no insurance, and having a higher number of chronic conditions., Conclusions: There are significant racial/ethnic and socioeconomic differences between patients hospitalized with AD versus without it, suggesting that there may be racial/ethnic and/or health care disparities in AD.

Background: Pemphigus is a group of debilitating autoimmune blistering disorders associated with painful blisters of the skin and/or mucous membranes. Identification and management of the comorbiditiesof pemphigus is critically important to minimize morbidity and decrease mortality., Objective: To identify the comorbid health conditions of pemphigus vulgaris., Methods: This was a case-control study of 130 cases of pemphigus verified by a clinical and laboratory diagnosis and 390 age and sex-matched controls with complete follow-up at a large metropolitanquaternary care medical center., Results: Pemphigus vulgaris and its treatments were significantly associated with type 2 diabetes mellitus (adjusted odds ratio [95% confidence interval]: 5.68 [2.93-11.02]), hypertension (2.15 [1.25-3.71]), osteopenia (10.07 [3.72-27.25]), osteoporosis (4.19 [1.50-11.73]), cataracts (7.00 [1.81-27.07]), insomnia (15.00 [1.75-128.39]), and benign prostatic hyperplasia (6.84 [1.79-26.18]). A history of taking systemic corticosteroids was found in 76% of pemphigus vulgaris patients. There were significant statistical interactions between pemphigus vulgaris and a history of using systemic corticosteroids as predictors of diabetes mellitus type 2, hypertension, osteoporosis, and insomnia., Conclusions: Safer and more effective systemic treatment options are needed for pemphigus to minimize iatrogenic complications of disease.

Background: Atopic dermatitis (AD) is associated with itch, skin inflammation and barrier disruption, and scratching, all of which may be associated with skin pain., Objective: To characterize the patient burden of skin pain in AD., Methods: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist., Results: Overall, 305 patients (age range, 13-97 years) were included in the study, with 564 encounters. The cohort included 195 females (63.9%) and 193 whites (63.7%). The mean (SD) age at enrollment was 42.3 (18.1) years, and the mean (SD) age of patient-reported AD onset was 29.6 (31.9) years. At baseline, 144 patients (42.7%) reported skin pain in the past week, with 42 (13.8%) reporting severe or very severe pain. Twenty-four (16.8%) thought the skin pain was part of their itch, 16 (11.2%) from scratching, and 77 (72.0%) from both. Patients with skin pain were more likely to describe their itch using terms that resembled neuropathic pain. Prevalence of skin pain was increased in patients with vs without excoriations (72.6% vs 57.6%; χ 2 test P = .02) but not other morphologic characteristics. Skin pain severity was most strongly correlated with the Patient-Oriented Eczema Measure (Spearman ρ = 0.54), followed by ItchyQOL (ρ = 0.52), 5-dimensions of itch scale (ρ = 0.47), Dermatology Life Quality Index (ρ = 0.45), numeric rating scale for itch (ρ = 0.43) and sleep (ρ = 0.36), Patient Health Questionnaire 9 (ρ = 0.36), patient-reported global AD severity (ρ = 0.34), Eczema Area and Severity Index (ρ = 0.23), and objective Scoring AD index (ρ = 0.20) (P < .001 for all). Patients with both severe itch and pain vs those with only one or neither symptom being severe had significant increases in all these measures., Conclusion: Skin pain is a common and burdensome symptom in AD. Skin pain severity should be assessed with itch severity in AD patients and may be an important end point for monitoring treatment response., (Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Scoring systems for assessing the signs of atopic dermatitis (AD) are complex and difficult to interpret. Severity strata are helpful to interpret these assessments properly., Objectives: To confirm previously reported strata for the Eczema Area and Severity Index (EASI), Scoring Atopic Dermatitis (SCORAD) and the objective component of SCORAD (oSCORAD), and to develop strata for the modified EASI (mEASI), Atopic Dermatitis Severity Index (ADSI) and body surface area (BSA) for use in adults with AD., Methods: Skin examination was performed in 673 adolescents and adults (age ≥ 13 years) with diagnosed AD, in a dermatology practice setting. Strata were selected using an anchoring approach based on a four-point Investigator's Global Assessment of severity (clear of active skin lesions, mild, moderate or severe disease)., Results: We determined potential severity strata for EASI (0 clear, 0·1-5·9 mild, 6·0-22·9 moderate, 23·0-72 severe; κ = 0·69), mEASI (0-0·9 clear, 1-8·9 mild, 9·0-29·9 moderate, 30·0-90 severe; κ = 0·71), oSCORAD (0-7·9 clear, 8·0-23·9 mild, 24·0-37·9 moderate, 38·0-83 severe; κ = 0·70), SCORAD (0-9·9 clear, 10·0-28·9 mild, 29·0-48·9 moderate, 49·0-103 severe; κ = 0·68), ADSI (0-1·9 clear, 2-5·9 mild, 6·0-8·9 moderate, 9·0-15 severe; κ = 0·55) and BSA (0 clear, 0·1-15·9 mild, 16·0-39·9 moderate, 40·0-100 severe; κ = 0·66). oSCORAD values > 0 were found in clear skin due to the presence of xerosis, which is scored in oSCORAD. Similarly, SCORAD values > 0 were found in clear skin due to the scoring of xerosis, pruritus and sleeplessness. Similarly, mEASI and ADSI scores > 0 occurred in patients with clear skin due to scoring of pruritus., Conclusions: We recommend using these strata for interpretation of their respective measures in clinical trials of AD. There are important differences between the five assessments, which profoundly impact the interpretation of their scores., (© 2017 British Association of Dermatologists.)

Toxic Shock Syndrome (TSS), a superantigen-mediated illness, is characterized by rash, hypotension and multi-organ dysfunction. Predictors of TSS and related morbidity and mortality are poorly defined. In this study, data on 61,959,084 hospitalizations from the 2003-2012 Nationwide Inpatient Sample, a 20% stratified sample of US hospitalizations, were analyzed and ICD-9-CM coding used to identify 4491 hospitalizations with a diagnosis of TSS. Incidence, in-hospital mortality rate, comorbidities, length of stay and costs of care attributable to TSS were determined. In multivariate survey logistic regression models, TSS was associated with female sex (adjusted odds ratio [95% confidence interval], 1.54 [1.48-1.60]), younger age (0-17 years, 2.17 [2.06-2.29]; 40-59: 0.53 [0.50-0.56]; 60-79: 0.28 [0.26-0.30]; 80+: 0.13 [0.11-0.14] compared with 18-39) and race/ethnicity (black, 0.63 [0.59-0.67]; Hispanic: 0.60 [0.56-0.64]; Asian, 1.11 [1.00-1.11]; and other, 0.83 [0.75-0.92] compared with white). Patients with TSS had a three-fold greater cost of care (mean: $36,656 ± 942) and length of stay (LOS) (mean: 10.65 ± 0.23 days) than patients without TSS. Shared predictors of increased LOS and costs in patients with TSS were male sex; age 40-79 years; Black, Hispanic, Asian and other race/ethnicity; and more than one chronic condition. Predictors of in-hospital mortality included respiratory failure (13.66 [11.37-16.43]), liver disease/failure (3.36 [2.59-4.34]), chickenpox (91.26 [27.74-300.25]), coagulopathy (2.14 [1.85-2.48]), and higher age. In conclusion, there are significant racial/ethnic, socioeconomic, and comorbid disparities in the incidence and mortality of TSS in adults and children in the USA., (© 2017 The Societies and John Wiley & Sons Australia, Ltd.)

Little is known about the inpatient burden of atopic dermatitis (AD). We sought to determine the risk factors and financial burden of hospitalizations for AD in the United States. Data were analyzed from the 2002-2012 National Inpatient Sample, including a 20% representative sample of all hospitalizations in the United States. Hospitalization rates for AD or eczema were highest in the northeast during the winter and south during the summer. Geometric mean cost of care (95% confidence interval) was lower for a primary diagnosis of AD or eczema versus no AD or eczema in adults ($3,502 [$3,360-$3,651] vs. $6,849 [$6,775-$6,925]; P = 0.0004) and children ($2,716 [$2,542-$2,903] vs. $4,488 [$4,302-$4,682]; P = 0.0004). However, the high prevalence of hospitalization resulted in total inpatient costs of $8,288,083 per year for adults and $3,333,868 per year for children. In conclusion, there is a substantial inpatient financial burden of AD in the United States., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Evaluation of large-scale data sets is needed to better understand the epidemiology, cost, and burden of atopic dermatitis (AD). We sought to validate the use of ICD-9-CM codes for identifying AD., Methods: Patients from a large metropolitan quaternary care medical center with a diagnostic code of either 691.8 (AD) or 692.9 (eczema and contact dermatitis) were queried. Medical records were reviewed for demographics, Hanifin & Rajka (H&R) and United Kingdom Working Party (UKWP) criteria. Sensitivity, specificity, and positive predictive values (PPV) of the codes were calculated., Results: Of 43 278 patients identified with associated ICD-9 codes of 691.8 or 692.9, 519 and 253 with 691.8 and 692.9 were randomly selected for chart review. There was extensive overlap: 34.3% had ≥1 occurrences of 691.8 and 692.9 and 25.6% had multiple occurrences of both codes. Among patients with ≥1 occurrence of 691.8, 29.9% and 30.8% met the H&R and UKWP criteria, respectively. Similarly, among patients with ≥1 occurrence of 692.9, 33.7% and 32.2% met the H&R and UKWP criteria. Increased PPV was associated with concomitant diagnoses of asthma, hay fever, and food allergy and increased disease severity., Conclusions: In the outpatient setting, the ICD-9-CM codes 691.8 and 692.9 alone have poor PPV. Incorporation of diagnoses of asthma, hay fever, and food allergy improves PPV and specificity. In the inpatient setting, a primary discharge diagnosis of 691.8 had excellent PPV. Although ICD-10 has been adopted in Europe and more recently in the USA, the same systematic errors would likely occur unless providers standardize their coding., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Little is known about the epidemiology of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in children., Objective: We sought to determine the morbidity, mortality, and comorbid health conditions of SJS and TEN in US children., Methods: This was a cross-sectional study of the 2009 to 2012 Nationwide Inpatient Sample, which contains a representative 20% sample of all US hospitalizations. Sociodemographics, inflation-adjusted cost, length of stay, comorbidities, and mortality were analyzed using descriptive statistics and multivariate regression analyses., Results: The incidences of SJS, SJS-TEN, and TEN were a mean 5.3, 0.8, and 0.4 cases per million children per year in the US, respectively. Prolonged length of stay and higher costs of care (SJS: 9.4 ± 0.6 days, $24,947 ± $3171; SJS-TEN: 15.7 ± 1.5 days, $63,787 ± $8014; TEN: 20.4 ± 6.3 days, $102,243 ± $37,588) were observed compared with all other admissions (4.6 ± 0.1 days, $10,496 ± $424). Mortality was 0% for SJS, 4% for SJS-TEN, and 16% for TEN. In regression models, predictors of mortality included renal failure (adjusted OR [aOR] 300.28, 95% confidence interval [CI] 48.59->999.99), malignancy (aOR 54.33, 95% CI 9.40-314.22), septicemia (aOR 30.45, 95% CI 7.91-117.19), bacterial infection (aOR 20.38, 95% CI 5.44-76.36), and epilepsy (aOR 5.56, 95% CI 1.37-26.2)., Limitations: Data regarding treatment were not available. Date of diagnosis of comorbidities was not present, precluding temporal analysis., Conclusions: Pediatric SJS/TEN poses a substantial health burden in the United States., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about the epidemiology of pediatric autoimmune blistering disorders (PAIBD)., Objective: We sought to determine the inpatient burden and comorbidities of PAIBD., Methods: We analyzed data from the Nationwide Inpatient Sample from 2002 to 2012, which contained a representative 20% sample of all US hospitalizations., Results: The most common PAIBD with a primary admission was pemphigus (8.0 per million), whereas the most common secondary diagnosis of PAIBD was dermatitis herpetiformis (DH; 9.6 per million). Bullous pemphigoid (BP) was inversely associated with being female and having government or no insurance but positively associated with Black and Hispanic race/ethnicity and more chronic conditions. Pemphigus was associated with being female, Hispanic, having government or no insurance, and having a higher number of chronic conditions. DH was inversely associated with non-White race but positively associated with having government insurance and more chronic conditions. BP was associated with dialysis, hypertension, and diabetes. Pemphigus was associated with osteoarthritis, renal failure, hypothyroidism, and weight loss. DH was associated with herpes simplex virus infection, rheumatoid arthritis, and fungal, viral, and other skin infections., Conclusion: PAIBD are associated with a considerable inpatient burden and comorbid health conditions.

Background: Bullous pemphigoid (BP) is associated with significant disability and comorbid health disorders that may lead to or result from hospitalization. However, little is known about the inpatient burden and comorbidities of BP., Objectives: To obtain data on the inpatient burden and comorbidities of BP in the U.S.A., Methods: We analysed data from the 2002 to 2012 National Inpatient Sample, including a representative 20% sample of all hospitalizations in the U.S.A. (72 108 077 adults)., Results: The prevalence of hospitalization for BP increased from 25·84 to 32·60 cases per million inpatients from 2002 to 2012. In multivariate logistic regression models with stepwise selection, increasing age, nonwhite ethnicity, higher median household income, being insured with Medicare or Medicaid, and increasing number of chronic conditions were all associated with hospitalization for BP (P < 0·05 for all). The top three primary discharge diagnoses for patients with a secondary diagnosis of BP were septicaemia (prevalence 5·51%, 95% confidence interval 5·03-5·99), pneumonia (4·60%, 4·19-5·01) and urinary tract infection (3·52%, 3·15-3·89). Patients with BP also had numerous autoimmune, infectious, cardiovascular and other comorbidities. Interestingly, BP was associated with multiple neuropsychiatric disorders, including demyelinating disorders, dementias (presenile, senile, vascular and other), paralysis, neuropathy (diabetic, other polyneuropathy), Parkinson disease, epilepsy, psychoses and depression. The mean annual age- and sex-adjusted in-hospital mortality rate was significantly higher in patients with a secondary diagnosis of BP compared with no BP (2·9%, range 2·8-3·9% vs. 2·1%, range 1·9-2·2%). Significant predictors of mortality in patients with BP included increasing age, nonwhite ethnicity and insurance with Medicaid or other payment status (P < 0·05 for all)., Conclusions: Hospitalization for BP increased significantly between 2002 and 2012. Moreover, there were significant ethnic and healthcare disparities with respect to hospitalization and inpatient mortality from BP., (© 2016 British Association of Dermatologists.)