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Summary: 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. 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. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: 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. What's already known about this topic? Dermatology Life Quality Index (DLQI), 5‐dimensions (5‐D) itch and ItchyQoL are quality‐of‐life assessments that have been used to assess the burden of inflammatory and/or pruritic skin disorders.Conflicting and/or limited results have been demonstrated about their validity, reliability and feasibility, particularly in atopic dermatitis. What does this study add? This study demonstrates that DLQI, ItchyQoL and 5‐D itch had good construct validity and responsiveness, and similar amounts of time for completion in the assessment of adult atopic dermatitis, with no observed floor or ceiling effects. What are the clinical implications of this work? DLQI, ItchyQoL and 5‐D itch all appear to have sufficient validity and feasibility to be used as assessments of burden in adults with atopic dermatitis in clinical practice. Linked Comment: Apfelbacher and Ofenloch. Br J Dermatol 2019; 180:979–980. Respond to this article [ABSTRACT FROM AUTHOR]

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: 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.)

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.)

Atopic dermatitis (AD) is driven by a complex gene-environment interaction. Many of the risk factors and genetic underpinning previously observed for pediatric AD may not apply to adult atopic dermatitis, suggesting that these may largely be different disorders. Whereas AD is classically thought of as a pediatric disease, recent studies have shown high rates of disease in adults as well. Risk factors for persistence of childhood-onset AD, as well as adult-onset AD, are reviewed. Adults with AD are particularly vulnerable to exogenous insults from the outside environment, including climate, ultraviolet exposure, pollution, irritants and pruritogens, and microbes. Finally, adult AD is associated with a substantial health care burden, with increased utilization, direct and indirect costs of care, and lost work productivity., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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.)

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: Bleach baths have been proposed as a treatment for decreasing the severity of atopic dermatitis (AD). However, conflicting results have been found regarding their efficacy., Objective: To determine the efficacy of bleach vs water baths at decreasing AD severity., Methods: We performed a systematic review of all studies evaluating the efficacy of bleach baths for AD. Cochrane, EMBASE, GREAT, LILACS, MEDLINE, and Scopus were searched. Two authors independently performed study selection and data extraction., Results: Five studies were included in the review. Four studies reported significantly decreased AD severity in patients treated with bleach on at least 1 time point. However, of 4 studies comparing bleach with water baths, only 2 found significantly greater decreases in AD severity with bleach baths, 1 found greater decreases with water baths, and 1 found no significant differences. In pooled analyses, there were no significant differences observed between bleach vs water baths at 4 weeks vs baseline for the Eczema Area and Severity Index (I 2  = 98%; random effect regression model, P = .16) or body surface area (I 2  = 96%; P = .36)., Conclusion: Although bleach baths are effective in decreasing AD severity, they do not appear to be more effective than water baths alone. Future larger-scale, well-designed randomized controlled trials are needed., (Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this article is to report the long-term rate and timing of complications associated with postmastectomy radiation therapy (PMRT) following immediate breast reconstruction in a large patient population., Methods and Materials: We identified and reviewed the charts of all patients with stages I through IIIC breast cancer who underwent mastectomy with immediate reconstruction followed by subsequent radiation therapy between November 1997 and May 2010. We aimed to assess the rate of major complications, defined as events requiring a separate and distinct procedure. Statistical analysis between variables was evaluated using Fisher exact test and Pearson χ 2 Elder et al. (2005) test., Results: In total, 134 patients met inclusion criteria for having adequate long-term follow-up and documentation. The median follow-up for all patients was 77.4 months (range, 6-185 months). The overall major complication rate was found to be 44%. Nine patients (6.7%) experienced complications for which a secondary procedure could not be performed to retain a reconstructed breast. The average time between initiation of PMRT and the first major complication was 13.5 months, with 68.3% of first major complications occurring within 1 year of PMRT initiation and 81.7% within 2 years. The difference in incidence of major complications for patients undergoing immediate tissue expander/implant reconstruction followed by PMRT was not statistically different when compared with that for patients with immediate autologous tissue reconstruction followed by PMRT (47.3% vs 30.4%, P = .168)., Conclusions: The risk of first major complications and reconstruction loss in patients undergoing PMRT on immediately reconstructed breasts is greatest within 1 year of beginning radiation therapy and decreases significantly with time. Immediate autologous tissue reconstruction followed by PMRT can be performed with reasonable complication rates., (Copyright © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Proteus mirabilis is an opportunistic pathogen that is frequently associated with urinary tract infections. In the lab, P. mirabilis cells become long and multinucleate and increase their number of flagella as they colonize agar surfaces during swarming. Swarming has been implicated in pathogenesis; however, it is unclear how energetically costly changes in P. mirabilis cell morphology translate into an advantage for adapting to environmental changes. We investigated two morphological changes that occur during swarming--increases in cell length and flagellum density--and discovered that an increase in the surface density of flagella enabled cells to translate rapidly through fluids of increasing viscosity; in contrast, cell length had a small effect on motility. We found that swarm cells had a surface density of flagella that was ∼5 times larger than that of vegetative cells and were motile in fluids with a viscosity that inhibits vegetative cell motility. To test the relationship between flagellum density and velocity, we overexpressed FlhD(4)C(2), the master regulator of the flagellar operon, in vegetative cells of P. mirabilis and found that increased flagellum density produced an increase in cell velocity. Our results establish a relationship between P. mirabilis flagellum density and cell motility in viscous environments that may be relevant to its adaptation during the infection of mammalian urinary tracts and movement in contact with indwelling catheters.