Teledermoscopic triage of melanoma-suspicious skin lesions is safe: A retrospective comparative diagnostic accuracy study with multiple assessors.

BACKGROUND: The rising incidence of melanoma and the high number of benign lesions excised due to diagnostic uncertainty highlight the need for effective patient triage. This study assesses the safety and accuracy of teledermoscopic triage on a high-prevalence case set with pre-triaged, challenging, melanoma-suspicious lesions. METHODS: Five dermatologists independently reviewed 250 retrospectively extracted patient cases. Teledermoscopy assessments were simulated for panels of 1, 2, 3 and 5 assessors using two distinct consensus strategies, Caution Protocol and Majority Vote, and the sensitivity and specificity of the patient triages were calculated. RESULTS: Triage by a single teledermatologist showed a sensitivity of 92.3% and a specificity of 58.7%. Sensitivity improved with the number of assessors, particularly when using the Caution Protocol, though with a considerable drop in specificity. The Majority Vote showed a more balanced improvement in sensitivity and specificity. Safety analyses indicated that diagnostic accuracy decreased with poor image quality and increased case difficulty. DISCUSSION: Expert teledermoscopic triage of melanocytic skin lesions is highly sensitive and lowers the need for unnecessary excision procedures by half while dismissing as few as 0.4% (95% confidence interval 0-0.6%) of melanomas, even when applied to a high-prevalence pre-triaged subpopulation. Implementation of safety procedures increases accuracy. Using multiple teledermatologists increases sensitivity but at the cost of specificity unless a Majority Vote consensus strategy is applied. Future teledermoscopy guidelines should encompass safety procedures and protocols for disagreement between assessors.

Hidradenitis suppurativa in a cohort of overweight and obese children and adolescents.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, inflammatory, and recurring disease mainly observed in adults. Obesity is considered an important independent factor in HS development and is associated with a higher prevalence of HS in children. We aimed to characterize the clinical presentation of HS in overweight and obese children and adolescents. METHODS: We performed a cross-sectional observational study during January 2007-April 2015. Overweight and obese patients (5-17 years of age, BMI> 90th percentile) referred to The Children's Obesity Clinic, Department of Paediatrics, Copenhagen University Hospital Holbaek, Denmark, underwent screening for dermatological conditions. A dermatologist ascertained the diagnosis of HS, and disease severity was assessed using Hurley staging and Sartorius score. Tobacco smoke exposure, body mass index (BMI) standard deviation score (SDS), and psychiatric comorbidities were recorded. Our cohort was compared with a reference cohort recruited in a previous study. RESULTS: A total of 195 children and adolescents underwent screening for dermatological conditions. Nine patients screened positive, and six of these patients were available for examination of whom five presented with HS. All HS cases were mild (median Sartorius score of 9). Four of the five patients (with varying constellations) reported tobacco exposure, a positive family history of HS, and exhibited psychiatric comorbidities. CONCLUSION: Our findings support that the presence of pediatric HS is correlated with familial disposition to HS and psychiatric comorbidities.

Two cases of tick-borne transmitted tularemia on Southern Zealand, Denmark.

Francisella tularensis is a zoonotic bacterium which causes the infection tularemia. It colonizes invertebrates and vertebrates, counting wildlife animals and rodents. Humans can become infected through several pathways including contaminated food, water, and handling animals and due to bites from vectors. Ticks are known to cause tularemia in humans, though their role as a disease transferring vector is not well understood. We describe two case reports of tularemia transferred by ticks on Southern Zealand, Denmark. Case 1: A 49-year-old woman presented with lymphadenopathy and an unhealed sifting wound after a tick bite. Serology tests for F. tularensis were initially negative but turned positive five weeks after symptom onset, when abscess drainage was performed. Gentamicin and ciprofloxacin treatment improved the patient's clinical condition, and she completely recovered. Case 2: A 74-year-old man presented with malaise, fever, and an abdominal ulcer allegedly caused after a vector bite. CRP and leukocytes were increased, while serology tests for F. tularensis were negative. Doxycycline treatment improved the patient's clinical condition, and he completely recovered. Three weeks after symptom onset, renewed serology tests for F. tularensis were positive.

Historical Study (1986-2014): Improvements in Nutritional Status of Dialysis Patients.

OBJECTIVE: Malnutrition is common in dialysis patients and is associated with adverse clinical outcomes. Despite an increased focus on improved nutrition in dialysis patients, it is claimed that the prevalence of malnutrition in this group of patients has not changed during the last decades. Direct historical comparisons of the nutritional status of dialysis patients have never been published. To directly compare the nutritional status of past and current dialysis patients, we implemented the methodology of a study from 1986 on a population of dialysis patients in 2014. DESIGN: Historical study comparing results of two cross-sectional studies performed in 1986 and 2014. SETTING: We compared the nutritional status of hemodialysis (HD) and peritoneal dialysis (PD) patients attending the dialysis center at Roskilde Hospital, Denmark, in February to June 2014, with that of HD and PD patients treated at the dialysis center at Fredericia Hospital, Denmark, in April 1986. SUBJECTS: Maintenance PD and HD patients (n = 64 in 2014 and n = 48 in 1986). METHODS: We performed anthropometry (body weight, triceps skinfold, and midarm muscle circumferences [MAMCs]) and determined plasma transferrin. MAIN OUTCOME MEASURE: Relative body weight, triceps skinfold, MAMC, body mass index, and prevalence of protein-caloric malnutrition as defined in the original study from 1986. RESULTS: Average relative body weight, triceps skinfold, MAMC, and body mass index were significantly higher in 2014 compared with 1986. The prevalence of protein-caloric malnutrition was significantly lower in 2014 (18%) compared with 1986 (52%). CONCLUSIONS: The nutritional status of maintenance dialysis patients has improved during the last 3 decades. The reason for this improvement could not be identified in the present study, but the most likely contributors are the higher prevalence of obesity in the general population, less predialytic malnutrition, and an improved focus on nutrition in maintenance dialysis patients.

Nutritional Status of Maintenance Dialysis Patients: Low Lean Body Mass Index and Obesity Are Common, Protein-Energy Wasting Is Uncommon.

BACKGROUND AND AIMS: Maintenance dialysis patients are at increased risk of abnormal nutritional status due to numerous causative factors, both nutritional and non-nutritional. The present study assessed the current prevalence of protein-energy wasting, low lean body mass index and obesity in maintenance dialysis patients, and compared different methods of nutritional assessment. METHODS: In a cross-sectional study conducted in 2014 at Roskilde Hospital, Denmark, we performed anthropometry (body weight, skinfolds, mid-arm, waist, and hip circumferences), and determined plasma albumin and normalized protein catabolic rate in order to assess the prevalence of protein-energy wasting, low lean body mass index and obesity in these patients. RESULTS: Seventy-nine eligible maintenance dialysis patients participated. The prevalence of protein-energy wasted patients was 4% (95% CI: 2-12) as assessed by the coexistence of low lean body mass index and low fat mass index. Low lean body mass index was seen in 32% (95% CI: 22-44). Obesity prevalence as assessed from fat mass index was 43% (95% CI: 32-55). Coexistence of low lean body mass index and obesity was seen in 10% (95% CI: 5-19). The prevalence of protein-energy wasting and obesity varied considerably, depending on nutritional assessment methodology. CONCLUSIONS: Our data indicate that protein-energy wasting is uncommon, whereas low lean body mass index and obesity are frequent conditions among patients in maintenance dialysis. A focus on how to increase and preserve lean body mass in dialysis patients is suggested in the future. In order to clearly distinguish between shortage, sufficiency and abundance of protein and/or fat deposits in maintenance dialysis patients, we suggest the simple measurements of lean body mass index and fat mass index.

[Renal angiomyolipoma with spontaneous retroperitoneal bleeding]. / Renalt angiomyolipom medspontan retroperitoneal blødning

Angiomyolipoma (AML) is a benign tumour composed predominantly of blood vessels, smooth muscle tissue and adipose tissue. It is a rare disorder found in 0.1% of men and 0.22% of women. AML is most often manifested as a solitary tumour, but can also be found with multiple lesions in various organs. AML is predominantly asymptomatic, but may present with different symptoms depending on the size and position. Patients often have flank pain and microscopic or macroscopic haematuria. AML can also debut with spontaneous atraumatic bleeding in the retroperitoneum, Wunderlich's syndrome.

Does switching from oral to subcutaneous administration of methotrexate influence on patient reported gastro-intestinal adverse effects?

INTRODUCTION: When treating patients with methotrexate (MTX) the most frequently reported adverse effects (AE) are gastrointestinal (GI) with nausea being reported by 10-20%. If intolerable AE of oral MTX persist, switching from oral to subcutaneous (SC) or intramuscular (IM) administration is common. However, this approach is largely empirical and the evidence is inconsistent. To our knowledge, this will be the first study to estimate the change in GI AE of switching from oral to SC MTX. METHODS: A retrospective postal survey was sent to patients who had changed from oral MTX to SC MTX. GI AE was rated by visual analogue scale (VAS) regarding frequency and intensity of nausea, frequency of vomiting and frequency of discomfort. All participants gave informed consent. No further ethical clearance was necessary according to national law. RESULTS: Of the sample 39/57 (68.4%) responded. Significant reductions in VAS were found in three of four primary outcome measures for GI AE. Only frequency of vomiting was not significantly reduced. CONCLUSION: Our findings support the common practice of switching from oral to SC MTX to alleviate GI AE, however, additional research is needed in order to clarify this rarely studied subject.

Effect of engaging trainees by assessing peer performance: a randomised controlled trial using simulated patient scenarios.

INTRODUCTION: The aim of this study was to explore the learning effect of engaging trainees by assessing peer performance during simulation-based training. METHODS: Eighty-four final year medical students participated in the study. The intervention involved trainees assessing peer performance during training. Outcome measures were in-training performance and performance, both of which were measured two weeks after the course. Trainees' performances were videotaped and assessed by two expert raters using a checklist that included a global rating. Trainees' satisfaction with the training was also evaluated. RESULTS: The intervention group obtained a significantly higher overall in-training performance score than the control group: mean checklist score 20.87 (SD 2.51) versus 19.14 (SD 2.65) P = 0.003 and mean global rating 3.25 SD (0.99) versus 2.95 (SD 1.09) P = 0.014. Postcourse performance did not show any significant difference between the two groups. Trainees who assessed peer performance were more satisfied with the training than those who did not: mean 6.36 (SD 1.00) versus 5.74 (SD 1.33) P = 0.025. CONCLUSION: Engaging trainees in the assessment of peer performance had an immediate effect on in-training performance, but not on the learning outcome measured two weeks later. Trainees had a positive attitude towards the training format.

The influence of body weight on the prevalence and severity of hidradenitis suppurativa.

The prevalence of hidradenitis suppurativa (HS) has been estimated to be 1% of the population. Obesity is considered a co-morbidity, but the prevalence of HS in obese population is not known. A retrospective questionnaire was distributed to 383 patients over 2 years after bariatric surgery. Data on pre- and post-surgery HS symptoms and disease severity were studied. Disease severity was assessed by number of involved sites. General skin problems rated numerically on an anchored 1-10 scale. Valid responses were obtained from 249/383 (65%). A point prevalence of 18.1% (45/249) HS was found. The number of patients reporting HS symptoms after weight loss decreased by 35% and the mean number of involved sites was reduced from 1.93 to 1.22 following weight loss (p = 0.003). The prevalence of HS appears higher in the obese than in the background population, and a weight loss of more than 15% is associated with a significant reduction of disease severity.

Recurrent furunculosis - challenges and management: a review.

Furunculosis is a deep infection of the hair follicle leading to abscess formation with accumulation of pus and necrotic tissue. Furuncles appear as red, swollen, and tender nodules on hair-bearing parts of the body, and the most common infectious agent is Staphylococcus aureus, but other bacteria may also be causative. In some countries, methicillin resistant S. aureus is the most common pathogen in skin and soft tissue infections which is problematic since treatment is difficult. Furunculosis often tends to be recurrent and may spread among family members. Some patients are carriers of S. aureus and eradication should be considered in recurrent cases. Solitary lesions should be incised when fluctuant, whereas patients with multiple lesions or signs of systemic disease or immunosuppression should be treated with relevant antibiotics. The diagnostic and therapeutic approach to a patient suspected of staphylococcosis should include a thorough medical history, clinical examination, and specific microbiological and biochemical investigations. This is particularly important in recurrent cases where culture swabs from the patient, family members, and close contacts are mandatory to identify and ultimately control the chain of infection. Focus on personal, interpersonal, and environmental hygiene issues is crucial to reduce the risk of contamination and recurrences.

Short- and long-term transfer of urethral catheterization skills from simulation training to performance on patients.

BACKGROUND: Inexperienced interns are responsible for most iatrogenic complications after urethral catheterization (UC). Although training on simulators is common, little is known about the transfer of learned skills to real clinical practice. This study aimed to evaluate the short- and long-term effects of UC simulated skills training on performance on real patients and to examine whether watching a video of the procedure immediately before assessment enhanced clinical performance. METHODS: This was an experimental study of the effect of a UC simulation-based skills course on medical students' short-term (after one week) and long-term (after six weeks) performance. The additional effect of video instruction before performance testing on real patients was studied in a randomized trial. Sixty-four students participated in the study, which was preceded by a pilot study investigating the validity aspects of a UC assessment form. RESULTS: The pilot study demonstrated sufficient inter-rater reliability, intra-class correlation coefficient 0.86, and a significant ability to discriminate between trainee performances when using the assessment form, p= 0.001. In the main study, more than 90% of students demonstrated an acceptable performance or better when tested on real patients. There was no significant difference in the total score between the one-week and the six-week groups when tested on real patients and no significant difference between the video and the control groups. CONCLUSIONS: Medical students demonstrated good transfer of UC skills learned in the skills lab to real clinical situations up to six weeks after training. Simulated UC training should be the standard for all medical school curricula to reduce avoidable complications. However, this study did not demonstrate that an instructional video, as a supplement to simulated skills training, improved clinical UC performance. TRIAL REGISTRATION: Current Controlled Trials ISRCTN:ISRCTN90745002.

A case of cola dependency in a woman with recurrent depression.

BACKGROUND: Cola is an extremely popular caffeinated soft drink. The media have recently cited a poll in which 16% of the respondents considered themselves to be addicted to cola soft drinks. We find the contrast between the apparent prevalence of cola addiction and the lack of scientific literature on the subject remarkable. To our knowledge, this is the first case of cola dependency described in the scientific literature. CASE PRESENTATION: The patient is a 40-year-old woman, who when feeling down used cola to give her an energy boost and feel better about herself. During the past seven years her symptoms increased, and she was prescribed antidepressant medication by her family doctor. Due to worsening of symptoms she was hospitalised and later referred to a specialised outpatient clinic for affective disorders. At entry to the clinic she suffered from constant tiredness, lack of energy, failing concentration, problems falling asleep as well as interrupted sleep. She drank about three litres of cola daily, and she had developed a metabolic syndrome.The patient fulfilled the ICD-10 criteria for dependency, and on the Yale Food Addiction Scale (YFAS) she scored 40 points. Her clinical mental status was at baseline assessed by the Major Depression Inventory (MDI) = 41, Hamilton Depression - 17 item Scale (HAMD-17) = 14, Young Mania Rating Scale (YMRS) = 2 and the Global Assessment of Functioning (GAF) Scale = 45.During cognitive therapy sessions she was guided to stop drinking cola and was able to moderate her use to an average daily consumption of 200 ml of cola. Her concentration improved and she felt mentally and physically better. At discharge one year after entry her YFAS was zero. She was mentally stable (MDI =1, HAMD-17 = 0, YMRS = 0 and GAF = 85) and without antidepressant medication. She had lost 7.2 kg, her waistline was reduced by 13 cm and the metabolic syndrome disappeared. CONCLUSION: This case serves as an example of how the overconsumption of a caffeinated soft drink likely was causing or accentuating the patient's symptoms of mental disorder. When diagnosing and treating depression, health professionals should pay attention to potential overuse of cola or other caffeinated beverages.

[Test of knowledge and skills enhances learning]. / Test af viden og færdigheder øger indlæring.

Test-enhanced learning is an evidence-based pedagogical tool for enhancing retention of both knowledge and skills. The phenomenon is independent of external factors such as feedback and intention to learn. The mechanism is complex and possibly related to stress and gender. Tests immediately after learning are most effective - and formats that support test-enhanced learning most effectively involve composing an answer or actively performing a skill. Use of tests in education should be integrated in the curriculum ensuring that the tests relevantly complement and enhance learning of knowledge or skills.

[Subphrenic Meckel's diverticulum as a differential diagnosis to Chilaiditi's syndrome]. / Subfrenisk Meckels divertikel som differentialdiagnose til Chilaiditis syndrom.

Meckel's diverticulum (MD) occurs in 2-4% of the population and is the most common congenital abnormality of the gastrointestinal tract. A 67 year-old woman was admitted with acute abdomen. Abdominal X-ray showed pneumoperitoneum. During explorative laparoscopy a large perforated MD was found over the right hepatic lobe. CT-scans from an earlier admission revealed the MD but it was misinterpreted on that occasion. An MD in this place and in a person of this age is extremely rare. This case can primarily serve as differential diagnosis when CT-scans reveal mysterious subphrenic configurations.

Test-enhanced learning may be a gender-related phenomenon explained by changes in cortisol level.

CONTEXT: testing increases memory of a topic studied more than additional study or training. The mechanisms by which this occurs are not clearly understood. Testing can be stressful and studies suggest that the stress hormone cortisol has modulating effects on memory, predominantly in men. The aim of this study was to investigate whether cardiopulmonary resuscitation (CPR) skills testing induce a cortisol increase, whether the cortisol increase enhances retention of CPR skills, and how this relates to gender. METHODS: we randomised a convenience sample of medical students attending a mandatory course to one intervention and one control group. Students received a 4-hour course on CPR skills. During the final half-hour of the intervention course, participants were tested in CPR scenarios, whereas the control group underwent additional training. We assessed learning outcomes 2 weeks later by rating student performance in a CPR scenario using a checklist and a single blinded assessor. We measured salivary cortisol pre-course, half an hour before the end of the course and post-course, and compared learning outcomes and cortisol responses between groups and genders. RESULTS: in total, 146 of 202 (72%) students completed the study. We found a significant difference in learning outcome between the intervention and control groups for both genders (mean ± standard deviation, 5.0 ± 3.5; p = 0.006). We found a significant effect of increase in cortisol on learning outcome in men. The correlation between learning outcome and cortisol increase was medium to large for men (r = 0.38), but not for women (r = -0.05). CONCLUSIONS: cardiopulmonary resuscitation skills testing induces a rise in cortisol in men, which is related to the better retention of skills in men. Cortisol modulates test-enhanced learning in men.

The effect of testing on skills learning.

OBJECTIVES: In addition to the extrinsic effects of assessment and examinations on students' study habits, testing can have an intrinsic effect on the memory of studied material. Whether this testing effect also applies to skills learning is not known. However, this is especially interesting in view of the need to maximise learning outcomes from costly simulation-based courses. This study was conducted to determine whether testing as the final activity in a skills course increases learning outcome compared with an equal amount of time spent practising the skill. METHODS: We carried out a prospective, controlled, randomised, single-blind, post-test-only intervention study, preceded by a similar pre- and post-test pilot study in order to make a power calculation. A total of 140 medical students participating in a mandatory 4-hour in-hospital resuscitation course in the seventh semester were randomised to either the intervention or control group and were invited to participate in an assessment of learning outcome. The intervention course included 3.5 hours of instruction and training followed by 30 minutes of testing. The control course included 4 hours of instruction and training. Participant learning outcomes were assessed 2 weeks after the course in a simulated scenario using a checklist. Total assessment scores were compared between the two groups. RESULTS: Overall, 81 of the 140 students volunteered to participate. Learning outcomes were significantly higher in the intervention group (n = 41; mean score 82.8%, 95% confidence interval [CI] 79.4-86.2) compared with the control group (n = 40; mean score 73.3%, 95% CI 70.5-76.1) (P < 0.001). Effect size was 0.93. CONCLUSIONS: Testing as a final activity in a resuscitation skills course for medical students increases learning outcome compared with spending an equal amount of time practising the skills.