Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(2):e2024057 1 Disparities in Financial Burden, Outcomes, and Comorbidities Among Pediatric Patients With Pyoderma Gangrenosum With and Without Mental Health Disorders in a Multivariate Analysis of the 2016 Kids’ Inpatient Database Amar D. Desai1, Angela Lu2, Faraz Yousefian3, Shari R. Lipner4 1 Rutgers New Jersey Medical School, Newark, NJ, USA 2 Albert Einstein Medical School, Bronx, NY, USA 3 Center for Clinical and Cosmetic Research, Aventura, FL, USA 4 Weill Cornell Medicine, Department of Dermatology, New York, NY, USA Key words: pyoderma gangrenosum, mental health, pediatric, management, outcomes Citation: Desai AD, Lu A, Yousefian F, Lipner SR. Disparities in Financial Burden, Outcomes, and Comorbidities Among Pediatric Patients With Pyoderma Gangrenosum With and Without Mental Health Disorders in a Multivariate Analysis of the 2016 Kids’ Inpatient Database. Dermatol Pract Concept. 2024;14(2):e2024057. DOI: https://doi.org/10.5826/dpc.1402a57 Accepted: November 1, 2023; Published: April 2024 Copyright: ©2024 Desai et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: Mr. Desai, Ms. Lu, and Dr. Yousefian have no conflicts of interest. Dr. Lipner has served as a consultant for Ortho-Dermatologics, BelleTorus Corporation, Moberg Pharmaceuticals, and Hoth Therapeutics. Authorship: All authors have contributed significantly to this publication. Amar D. Desai and Angela Lu should be considered as joint co-first author. Corresponding Author: Shari R. Lipner Weill Cornell Medicine, Department of Dermatology, New York, NY, USA. Email: shl9032@med.cornell.edu Introduction Pyoderma gangrenosum (PG) is a neutrophilic dermatosis, with painful and rapidly progressing skin ulcers [1]. An association between PG and mental, behavioral, and neurodevelopmental disorders (MBNDs), including depression, has been described in adult patients [2] but has not been studied in pediatric or inpatient populations. We aimed to assess differences in demo- graphics, severity of disease, comorbidities, and outcomes in pediatric inpatients with PG with and without MBNDs. The 2016 Kids’ Inpatient Database (KID), a database on hospital stays for children ages 0–20 years old, was queried for patients with PG (ICD10-CM: L88) with and without MBNDs (ICD-10: F01-F99). Univariate analysis with Chi- square and two-tailed t-test statistics, alpha-value of 0.05, and multivariable analysis were performed to identify statis- tical associations with MBNDs. A total of 107 pediatric inpatients were diagnosed with PG, with mean age 15.6 years (SE: 0.5), 70.8% female, 46.8% White, and 26.6% Black. Age, race, household 2 Research Letter | Dermatol Pract Concept. 2024;14(2):e2024057 income, and severity of illness varied with MBND status (P<0.05). PG patients with vs. without MBNDs more of- ten had Crohn’s disease or ulcerative colitis (87.5% vs. 48.2%, P<0.001), musculoskeletal and connective tissue disease (45.8% vs. 21.7%), and were overweight or obese (33.3% vs. 13.3%, P=0.023). On multivariable analyses, patients with vs. without MBNDs had greater total charges ($153,022 vs. $90,506, P=0.019), length of stay (21.5 vs. 8.3 days, P=0.001), and number of procedures performed (5.7 vs. 2.6, P<0.001) (Table 1). Table 1: Demographics, management, charges, and outcomes of pediatric patients with pyoderma gangrenosum by mental health diagnosis status. No Mental Health Diagnosis Mental Health Diagnosis Total P value n = 83 n = 24 n = 107 −77.70% −22.30% Age Age, years 15.05 17.37 15.57 0.001 (mean [SE]) [0.61] [0.37] [0.49] Sex Male 31.30% 21.70% 29.20% 0.371 Female 68.70% 78.30% 70.80% Race White 41.70% 63.60% 46.80% 0.012 Black 34.70% 0.00% 26.60% Hispanic 15.30% 18.20% 16.00% Other 8.30% 18.20% 10.60% Primary payer status Medicare 1.20% 0.00% 0.90% 0.09 Medicaid 34.10% 33.30% 34.00% Private insurance 59.80% 45.80% 56.60% Self-pay 3.70% 8.30% 4.70% Other 1.20% 12.50% 3.80% Comorbidity Crohn’s disease or ulcerative colitis 48.20% 87.50% 57.00% < 0.001 Skin and subcutaneous infections 38.60% 17.40% 34.00% 0.058 Musculoskeletal & connective disease 21.70% 45.80% 27.10% 0.019 Overweight and obesity 13.30% 33.30% 17.80% 0.023 Hypertensive disease 8.40% 12.50% 9.30% 0.547 Diabetes mellitus 8.40% 0.00% 6.50% 0.141 Dermatitis & eczema 1.20% 12.50% 3.80% 0.011 Total Charges Charges (US$) 90,505.94 153,021.59 104,288.36 0.289 (mean [SE]) [15,166.55] [55,634.25] [17,065.09] Length of stay Number of days 8.27 21.48 11.22 0.207 (mean [SE]) [1.08] [10.12] [2.43] Number of procedures Number of procedures 2.6 5.73 3.3 0.014 (mean [SE]) [0.31] [1.15] [0.37] Time until 1st procedure Number of days 2.27 11.98 4.41 0.15 (mean [SE]) [0.30] [6.41] [1.48] Mortality Mortality rate (%) 3.60% 0.00% 2.80% 0.345 Sepsis Complication rate (%) 16.90% 21.70% 17.90% 0.59 Pneumonia Complication rate (%) 3.60% 0.00% 2.80% 0.345 Acute kidney failure Complication rate (%) 8.40% 4.30% 7.50% 0.512 GI bypass of ileum Procedure rate (%) 3.60% 8.30% 4.70% 0.335 GI excision Procedure rate (%) 14.50% 47.80% 21.70% < 0.001 Research Letter | Dermatol Pract Concept. 2024;14(2):e2024057 3 Case Presentation We found that pediatric PG patients with vs. without MBNDs had greater physical and financial burden. Similarly, in a 2002–2012 National Inpatient Sample (NIS) retrospec- tive study of 7,569 adult PG inpatients, those with vs. with- out MBNDs had 30% greater inpatient mortality rates and $9 million greater hospitalization costs annually [3]. In our study, PG patients with MBNDs had almost twice the prevalence of Crohn’s disease or ulcerative colitis than PG patients without MBNDs. In a retrospective study of 259 PG patients from German dermatologic wound care centers, 25.8% had ulcerative colitis, 10.6% had Crohn’s disease, 22.5% had GI disorders, 69.5% had diabetes mellitus, and 36.7% had another endocrine disorder, with the presence of multiple comorbidities being associated with more severe PG [4]. Therefore, our study and others highlight the con- nection between PG and MBNDs as well as consideration of the mental health status of PG patients, which may impact overall health outcomes [5]. KID may not be representative of all United States pe- diatric PG patients. The study was limited to inpatient data and did not include outpatient data. Cases were retrospec- tively reported without dermatologist or psychiatrist con- firmation, clinical examination, or treatment information, limiting our analysis. Conclusion We conclude that pediatric PG patients with vs. without MBNDs have significant disparities in financial burden, hospitalization outcomes, and comorbidities. Therefore, we recommend screening PG patients for MBNDs. We advocate for a multidisciplinary collaboration between dermatologists and psychiatrists to provide mental and behavioral support to PG patients with MBNDs, which may improve patient quality of life and reduce health care costs [6]. References 1. Fletcher J, Alhusayen R, Alavi A. Recent advances in manag- ing and understanding pyoderma gangrenosum.  F1000Res. 2019;8:F1000 Faculty Rev-2092. Published 2019 Dec 12. doi:10.12688/f1000research.19909.1 2. McPhie ML, Fletcher J, Machado MO, Carvalho AF, Piguet V, Alavi A. A Systematic Review of Depression and Anxiety in Adults with Pyoderma Gangrenosum. Adv Skin Wound Care. 2021 Aug 1;34(8):432-436. doi: 10.1097/01.ASW.0000755920.76330.21. PMID: 34260421. 3. Narla S, Silverberg JI. The inpatient burden and comorbidi- ties of pyoderma gangrenosum in adults in the United States.  Arch Dermatol Res. 2021;313(4):245-253. doi:10.1007/s00403 -020-02098-7 4. Al Ghazal P, Herberger K, Schaller J, et al. Associated factors and comorbidities in patients with pyoderma gangrenosum in Germany: a retrospective multicentric analysis in 259 patients.  Orphanet J Rare Dis. 2013;8:136. Published 2013 Sep 8. doi:10.1186/1750-1172-8-136 5. Sanchez-Melendez, SN, Malik, R, Patel, PM, Milosavljevic, S, Patel, S, Nambudiri, VE. Pyoderma gangrenosum and impact on quality of life: A narrative review. Exp Dermatol. 2023; 00: 1-6. doi:10.1111/exd.14876 6. Nusbaum KB, Ortega-Loayza AG, Kaffenberger BH. 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