Disease Severity and Quality of Life Outcome Measurements in Patients With Keloids: A Systematic Review.

BACKGROUND: Keloids have been assessed by numerous methods and severity indices resulting in a lack of standardization across published research. OBJECTIVE: This study aims to evaluate published keloid randomized controlled trials (RCTs) and identify the need for a gold standard of assessment. METHODS AND MATERIALS: PubMed, MEDLINE, and Embase were searched for human RCTs on keloid treatment during a 10-year period. Eligible studies were English language RCTs reporting disease severity outcome measures after keloid treatments. RESULTS: A total of 40 disease outcome measures were used in 41 included RCTs. Twenty-four (59%) of the included studies used more than one disease severity scale. The most frequently used outcome measures were the Vancouver Scar Scale (34%) (n = 14), followed by serial photography (24%) (n = 10). These were followed by adverse events and complications (20%) (n = 8), Visual Analogue Scale (12%) (n = 5), keloid dimensions (12%) (n = 5), and Patient and Observer Scar Assessment Scale (10%) (n = 4). Only one study reported quality of life outcomes. CONCLUSION: There is wide variation in keloid outcome measures in the published literature. A standardized method of assessment should be implemented to reduce the disparities between studies and to better be able to compare the numerous treatment modalities.

Intralesional Bleomycin for Warts: Patient Satisfaction and Treatment Outcomes.

BACKGROUND: The treatment of warts is challenging with regards to both tolerability and efficacy. OBJECTIVE: Ascertain the efficacy, tolerability, and patient satisfaction of intralesional bleomycin in the treatment of warts. METHODS: Retrospective chart review followed by telephone interviews with patients from university-based dermatology referral centers. RESULTS: Seventy-four percent (34/46) of patients had complete resolution (CR) of all warts. Of 34 patients who experienced CR, an average of 1.7 treatments were required. Pain experienced during the procedure and recovery, irrespective of outcome, was rated 5.8 out of 10 (range, 1-10; SD, 2.72; SEM, 0.40). Approximately 70% of patients had pain that lasted less than 2 days after treatment. Seventy-eight percent (36/46) of patients in the study were satisfied with treatment and would recommend it to others. CONCLUSION: Patients felt bleomycin to be an effective treatment modality for warts, offering high rates of CR in lesions resistant to more traditional therapies.

National utilization patterns of Mohs micrographic surgery for invasive melanoma and melanoma in situ.

BACKGROUND: Although wide local excision continues to be commonly used for melanoma treatment, Mohs micrographic surgery (MMS) for the treatment of melanomas remains controversial. OBJECTIVE: We sought to determine national utilization patterns for MMS in the treatment of invasive melanoma and melanoma in situ. METHODS: A retrospective analysis of patients receiving surgical excision (MMS or wide local excision) for the treatment of invasive melanoma and melanoma in situ was performed using data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program. RESULTS: A total of 195,768 melanomas were diagnosed from 2003 through 2009 from the 17 SEER registries. Utilization of MMS for invasive melanoma and melanoma in situ increased by 60% from 2003 to 2008. Of all SEER-captured lesions treated by surgical excision in this time period, 3.5% (6872) were excised by MMS. LIMITATIONS: Patient insurance status, physician reimbursement practices, and health care provider type were not addressed in this article. CONCLUSION: Use of MMS for melanoma appears to be increasing. Future studies should explore whether this is associated with better outcomes.

Utilization of a novel valveless trocar system during robotic-assisted laparoscopic prostatectomy.

PURPOSE: To evaluate the effect of a novel valveless trocar system (VTS) on perioperative outcomes in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). METHODS: A single-institution retrospective review was performed of 792 patients undergoing RALP. Preoperative patient variables, tumor characteristics, and perioperative variables were collected and analyzed. The first 150 patients were excluded from analysis to account for the learning curve of robotic surgery. Univariate and multivariate linear regression models were used to assess factors affecting operative time (ORT). RESULTS: A total of 257 and 385 patients underwent RALP utilizing the VTS and conventional insufflation, respectively. There were no significant differences in American Society of Anesthesiologist score, body mass index (BMI), prostate volume, final Gleason score, estimated blood loss, and complications between the cohorts. The only difference noted was a significantly shorter mean ORT in the VTS cohort (149.5 vs. 170.1 min, p < 0.0001). In light of this finding, further analysis was performed to identify associations with ORT. Multivariable analysis demonstrated that VTS, BMI, final Gleason score, prostate volume, surgeon, and node dissection were significantly associated with ORT. The use of the VTS decreased mean ORT by 23.2 min when controlling for confounding factors (p < 0.001). The performance of a nerve sparing operation was found to decrease ORT by 15.9 min (p < 0.001), though more often performed for lower-risk disease. CONCLUSION: The use of a novel VTS demonstrated decreased ORT in patients undergoing RALP when controlling for confounding factors. Prospective randomized trials are needed to evaluate its ultimate benefit in various surgical cohorts.

Skin cancer screening and primary prevention: facts and controversies.

Skin cancer is both common and responsible for significant morbidity and mortality. Opportunities for both primary and secondary prevention are available to both dermatologists and non-dermatologists. Counseling selected patients about ultraviolet avoidance and proper use of sunscreens is recommended. Due to technical and financial barriers, no study has conclusively confirmed the benefits of skin cancer screening. Both dermatologists and non-dermatologists often do not perform total body skin examinations during clinical encounters, despite high acceptance rates by patients. Many non-dermatologists would benefit from additional education pertaining to the diagnosis of cutaneous malignancy. Teledermatology may have a role in areas with poor access to dermatologists. There are ample opportunities for more to be learned in the future.

Linear segmental neurofibromatosis in an L5 distribution.

BACKGROUND AND OBJECTIVE: Neurofibromatosis (NF) is a neurocutaneous disorder with seven subtypes;segmental NF-1 is characterized by neurofibromas and or café-au-lait macules in one or more dermatomes, primarily the thorax and abdomen. We present the rare case of a 36-year-old African-American female with isolated, multiple soft nodules in a linear configuration on the plantar and dorsal surfaces of the left foot. CONCLUSION: This is the first report of isolated segmental NF-1 in a unique linear pattern confined to the L5 dermatome.

High-dose isotretinoin in acne vulgaris: improved treatment outcomes and quality of life.

BACKGROUND: Isotretinoin, for acne treatment, is associated with high rates of permanent remission. However, at recommended doses of 0.5-1.0 mg/kg/day for 5-6 months [average cumulative dose: 120-150 mg/kg], more than 20% of patients experience a relapse within two years that requires further medical management. OBJECTIVE: To examine outcomes of high-dose isotretinoin in a cohort with cystic acne, as well as measuring its impact on quality of life (QOL). METHODS: A single dermatologist, single institution investigation within an academic tertiary care center in Bronx, NY. Eighty patients with nodulocystic acne, maintained on oral isotretinoin at a dose of 1.3 mg/kg/day or greater, were studied from 2006-2009 while additionally participating in a QOL survey. Main outcome measures included documented events, acne clearance, presence of relapse, and quality of life parameters. RESULTS: The mean daily dose of isotretinoin was 1.6 mg/kg/day for an average time course of 178 days [cumulative dose: 290 mg/kg]. No side effects or laboratory abnormalities led to discontinuation of treatment. There were no psychiatric symptoms. One-hundred percent (100%) of patients were disease-free upon completion of treatment. During the three-year study period, 10 patients (12.5%) developed a relapse that required an additional course of isotretinoin. Analysis of QOL domains (self-perception, role-social, symptoms) revealed significant improvement following isotretinoin therapy (p = 0.0124, p = 0.0066, p = 0.0265, respectively). CONCLUSIONS: Isotretinoin prescribed at 1.5 mg/kg/day or greater for 5-6 months [cumulative total dose of 290 mg/kg] is safe and effective compared to current standard dosing practices. We propose the use of high-dose isotretinoin (>1.3 mg/kg/day) as a treatment option in severe nodulocystic acne and encourage larger, prospective, multicenter studies into this therapeutic approach.

Mohs micrographic surgery and surgical excision for nonmelanoma skin cancer treatment in the Medicare population.

OBJECTIVES: To identify Medicare use rates of Mohs micrographic surgery (MMS) and surgical excision for the treatment of nonmelanoma skin cancer (NMSC) and to identify patient, lesion, and geographic characteristics associated with treatment type. DESIGN: A retrospective analysis of Medicare beneficiaries. SETTING: Surveillance, Epidemiology, and End Results database. PATIENTS: Patients undergoing MMS or other surgical intervention for the treatment of NMSC from January 1, 2001, through December 31, 2006. MAIN OUTCOME MEASURES: Surgical treatment, patient, and lesion characteristics. RESULTS: A total of 26,931 operations were performed for the treatment of NMSC from 2001 through 2006, of which 36.4% were MMS. Although the rate of surgical excision slightly increased during this period (1.8 vs 2.1 per 100 Medicare beneficiaries), the rate of MMS doubled (0.75 vs 1.5 per 100 Medicare beneficiaries). In 46.9% of facial lesions, MMS was performed, whereas MMS was used to treat 14.7% of total body lesions. Atlanta, Georgia, had the highest proportion of patients treated with MMS (45.1%); Louisiana had the lowest (11.0%). Age, race, lesion location, and area of country for patient treatment were significantly associated with MMS use (all P < .001). CONCLUSIONS: Surgical treatment of NMSC increased substantially from 2001 through 2006, primarily because of a doubling in the rate of MMS procedures. Significant differences in surgical rates, depending on patient age, race, lesion location, and geographic region, of treatment were found.

Nondermatologists' use of predictive terms for a potentially malignant lesion.

BACKGROUND: Skin cancer is frequently suspected by nondermatologists. Many dermatology practices currently do not triage referrals from nondermatologists. Little is known how nondermatologists describe lesions of concern when making referrals. OBJECTIVE: We sought to assess the descriptive terminology used by nondermatologists when referring patients with potential cutaneous malignancies. METHODS: We completed a retrospective chart review of 400 patients referred by nondermatologists for skin lesions suspicious of malignancy. We collected the reason for the consult, all terminology used to characterize the lesion, and the final diagnosis. RESULTS: Clinicians documented 680 reasons for referring patients with suspicious lesions. General concern (rule out malignancy) without specific descriptors was used in 78 referrals, of which 23% (n = 18) were found to be associated with malignancy. Specific descriptive terminologies used most frequently by nondermatologists to describe suspicious lesions were: hyperpigmented (n = 71), changing size (n = 69), nonhealing (n = 55), irregular border (n = 52), irritated and/or scaly (n = 40), and raised (n = 33). A statistically significant correlation (P < 0.05) was found between skin cancer and the following terms: nonhealing, ulcerated, and rule out basal cell carcinoma. CONCLUSION: The descriptive terminology of potential cutaneous malignancies utilized by nondermatologists may provide important clues to aid dermatologists in triage decisions. Specifically, ulcerated, nonhealing, and rule out basal cell carcinoma may be terms that indicate the patient should be seen by the dermatologist in a timely manner.

Outcomes of referral to dermatology for suspicious lesions: implications for teledermatology.

OBJECTIVES: To determine the proportion of suspicious lesions referred by nondermatologists that are found to be malignant and the number of incidental skin cancers identified at the time of dermatology referral. DESIGN: Retrospective cohort study. SETTING: Veterans Affairs Connecticut Healthcare System. PATIENTS: Four hundred patients referred by nondermatologists for skin lesions suspected of being malignant between January 1, 2006, through December 31, 2009. MAIN OUTCOME MEASURES: Data collected included the type of referring provider, the final diagnosis by the dermatologist, and the number and type of incidental lesions. RESULTS: Only 22.0% of the index lesions (ie, the lesions that prompted the referral) were found to be cancerous. In aggregate, 149 cancerous lesions were noted in 98 patients. However, only 88 (59.1%) were identified in the index lesion; 111 incidental lesions were biopsied by the consulting dermatologist, with 61 (55.0%) additional skin cancers identified. Twelve of the 61 incidental cancers (19.7%) were found in patients whose index lesion was clinically benign and was not biopsied. CONCLUSIONS: Nondermatologists may benefit from focused educational initiatives on skin cancer detection, particularly the significance of the total body skin examination and the expectations for and limitations of teledermatology. A substantial proportion of malignant lesions was incidentally identified by the consulting dermatologist in addition to the primary lesion of concern. The use of teledermatology to assess a specific lesion of concern may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician. Therefore, teledermatology must not be used as a substitute for a total body skin examination.

Impact of family and gender on career goals: results of a national survey of 4586 surgery residents.

OBJECTIVE: To determine how marriage, children, and gender influence US categorical general surgery residents' perceptions of their profession and motivations for specialty training. DESIGN: Cross-sectional national survey administered after the January 2008 American Board of Surgery In-service Training Examination. SETTING: Two hundred forty-eight US general surgery residency programs. PARTICIPANTS: All US categorical general surgery residents. INTERVENTIONS: We evaluated demographic characteristics with respect to survey responses using the chi(2) test, analysis of variance, and multivariate logistic regression. Interaction terms between variables were assessed. MAIN OUTCOME MEASURES: Perceptions of respondents regarding the future of general surgery and the role of specialty training in relation to anticipated income and lifestyle. RESULTS: The survey response rate was 75.0% (4586 respondents). Mean age was 30.6 years; 31.7% were women, 51.3% were married, and 25.4% had children. Of the respondents, 28.7% believed general surgery is becoming obsolete (30.1% of men and 25.9% of women; P = .004), and 55.1% believed specialty training is necessary for success (56.4% of men and 52.7% of women; P = .02). Single residents and residents without children were more likely to plan for fellowship (59.1% single vs 51.9% married, P < .001; 57.0% with no children vs 50.1% with children, P < .001). In our multivariate analyses, male gender was an independent predictor of worry that general surgery is becoming obsolete (P = .003). Female residents who were single or had no children tended to identify lifestyle rather than income as a motivator for specialty training. CONCLUSION: Marital status, children, and gender appear to have a powerful effect on general surgery residents' career planning.

Surgical perspectives in gastrointestinal disease: a study of quality of life outcomes in esophageal, pancreatic, colon, and rectal cancers.

Outcomes assessment in surgery traditionally has included data regarding peri-operative mortality and morbidity, as well as long-term survival and recurrence in surgical oncology. However, quality of life (QOL) is another important patient-related outcome measure. QOL data can be used to tailor treatment and improve clinical outcomes by detecting physical or psychological problems in patients that otherwise might be overlooked, but which have profound implications for the effective delivery of care. We review several well-validated QOL instruments developed specifically for use in patients with gastrointestinal malignancies, including esophageal, pancreatic and colorectal cancers, and conclude that QOL assessment routinely should be included in clinical trials of novel treatments.

Current advances in the diagnosis and treatment of pancreatic endocrine tumors.

PURPOSE OF REVIEW: A comprehensive literature review of more than 200 original manuscripts published in the last 18 months was conducted to summarize landmark studies performed on the molecular biology, diagnosis, imaging, and treatment of endocrine tumors of the pancreas. RECENT FINDINGS: Recent achievements occurred on many fronts. Identification of a novel insulin splice variant with increased translation efficiency moved forward the understanding of the molecular biology of insulinomas. Results of a 29-year prospective study from the National Institutes of Health clarified the epidemiology of multiple endocrine neoplasia-1 syndrome. Chromogranin A was identified as a promising marker for pancreatic endocrine tumors. New imaging, including F-dopa positron emission tomography and laparoscopic ultrasound, and the effective combination of existing modalities localized and staged tumors with greater accuracy. Nonoperative treatment strategies show promise; discovery of the antiangiogenic properties of octreotide and the overexpression of tyrosine kinase receptors such as c-kit, epidermal growth factor receptor, and platelet-derived growth factor receptor on malignant endocrine pancreatic tumors may lead to promising pharmacologic treatment. SUMMARY: There have been exciting recent advancements in research surrounding endocrine pancreas that hopefully will pave the way for potential improvement in clinical outcomes for patients with these tumors.