Skin Malignancy in the Military: A Number Needed to Biopsy Analysis.

INTRODUCTION: Skin malignancy has increased in prevalence over the last 15 years and effective diagnosis is required for adequate treatment. Retrospective data analysis of skin biopsy data has shown correlation between various independent variables, but no studies have been shown to directly assess skin malignancy risks for military personnel. Assessing correlation could lead to more effective, targeted screening programs that could lead to decreased mortality from skin malignancies. We present a 1-year analysis of the number needed to biopsy (NNB) to detect skin cancer and analysis of military-specific risk factors in a military dermatology training program. The present study aims to (1) compare skin biopsy yields to civilian institutions and patient populations and (2) determine significance of exposure variables including age, gender, military beneficiary status, branch of service, and military rank. MATERIALS AND METHODS: We performed a retrospective observational study over 1 year by identifying all skin biopsies performed in the Walter Reed National Military Medical Center dermatology clinic from August 2015 to July 2016. Utilizing the pathology reports, we manually excluded biopsies performed for the purpose of ruling out inflammatory/immunologic conditions or cosmeses and focused only on encounters performed to rule out basal cell carcinoma, squamous cell carcinoma, or melanoma. We decided to exclude malignant diagnoses that were exceedingly rare or could mimic inflammatory conditions, such as cutaneous T-cell lymphoma. For uncertain diagnoses with vague context per pathology report, previous office clinic notes and pre-biopsy differential were referenced and included only if melanoma or non-melanoma skin cancer (NMSC) diagnosis was the intended indication. RESULTS: A total of 3,098 biopsies were included in the study, diagnostic for 1,084 total skin malignancy and 54 melanoma diagnoses. Melanoma comprised 4.98% of all skin malignancy diagnosed. The NNB for all skin malignancy was 2.86 (95% CI 2.76-2.96) and NNB for melanoma and NMSC was 20.93 (95% CI 19.70-22.15) and 1.91 (95% CI 1.83-2.00), respectively. Patient age, gender, and military rank significantly impacted NNB values (P < .001). CONCLUSIONS: The proportion of melanoma skin cancers is notably increased in our population compared to published population statistics with comparable total biopsy yields. Skin biopsy for purpose of screening for malignancy should be performed in the military population and consideration should be made for gender, age, and rank. Our findings can further expand on military risk factors for skin cancer and aid in further multivariant modeling.

Anti-PD1 immune checkpoint inhibitor-induced bullous pemphigoid in metastatic melanoma and non-small cell lung cancer.

Anti-programmed cell death 1 (PD1) targeted immune checkpoint inhibitors such as nivolumab and pembrolizumab are increasingly used to treat advanced malignancies such as melanoma, non-small cell lung cancer, urothelial cancer, and renal cell carcinoma. A rare but increasingly reported adverse effect of anti-PD1 therapy is bullous pemphigoid (BP), an autoimmune blistering disease directed against BP antigen 1 and BP antigen 2 in the basement membrane of the epidermis. We present 3 cases of BP secondary to anti-PD1 immunotherapy in patients with melanoma and non-small cell lung cancer to highlight the diagnosis and treatment of this condition and emphasize the importance of the dermatologist in the care of patients with immunotherapy-related skin disease.

E-cigarette Use in Veterans Seeking Mental Health and/or Substance Use Services.

OBJECTIVE: Individuals with mental illness and substance use disorders smoke at elevated rates and tend to have greater difficulty quitting smoking as compared to the general population. Some believe that e-cigarettes may reduce harm associated with smoking, but little is known about e-cigarette use, perceptions, and motivations for their use among individuals with mental health and/or substance use disorders. METHODS: Rates and correlates of e-cigarette use, perceptions, and sources of information about e-cigarettes among smokers seeking mental health and/or substance use services (N = 188) at the VA Connecticut Healthcare System were assessed via a brief survey. The Pearson χ(2) test of independence was used to compare veterans who currently used e-cigarettes with those who did not. Logistic regression was used to examine independent attitudinal differences controlling for potentially confounding variables. RESULTS: Participants were generally male (90%), Caucasian (54%), and older than 50 (69%), with high rates of at least one mental health condition (82%), at least one substance use disorder (73%), and comorbid mental health and substance use disorders (55%). A relatively high proportion of the sample (30.9%) used e-cigarettes. These participants, compared to those who did not use e-cigarettes, were more likely to have a mental health disorder and less likely to have a substance use disorder, started smoking later in life, spent less money on smoking, and were more likely to have tried to quit "cold turkey." Knowledge of e-cigarettes originated most often from TV, radio, or personal contacts. Respondents held generally positive perceptions and motivations regarding e-cigarette use (i.e., it is socially acceptable, may help reduce/quit smoking, less harmful to others). Despite positive attributions, rates of dual use of e-cigarettes and traditional cigarettes was high (86.2%), and very few people using e-cigarettes (6.9%) indicated that e-cigarettes actually helped them quit smoking, suggesting little related harm reduction. CONCLUSIONS: E-cigarettes are commonly used by smokers with mental health conditions and/or substance use disorders, a high-risk group that feels positive about e-cigarettes. However, positive regard of e-cigarettes did not appear to translate to ability to reduce or quit cigarette smoking. Safety and effectiveness research on e-cigarettes is urgently needed.

The effects of alcohol-containing e-cigarettes on young adult smokers.

BACKGROUND: The liquids (e-liquids) used in an electronic cigarette (e-cigarette) contain myriad chemicals without adequate human inhalation safety data. Furthermore, the absence of e-liquid labeling requirements poses a formidable challenge to understanding how e-liquid constituents may promote nicotine addiction and/or have independent or synergistic biological effects when combined with nicotine. Ethyl alcohol is such a constituent, but has received little scientific interest in this context. METHODS: Using a randomized, double blind, crossover design, acute changes in subjective drug effects, motor performance and biochemical measures of alcohol and nicotine intake were evaluated after directed and ad lib puffing from two commercially available e-liquids containing nicotine (8 mg/ml), vanilla flavor and either 23.5% (high) or 0.4% (trace) alcohol. RESULTS: While no differences in subjective drug effects were observed between alcohol conditions, performance on the Purdue Pegboard Dexterity Test (PPDT) improved under the trace, but not under the 23.5% alcohol condition. Although plasma alcohol levels remained undetectable during testing, urine ethyl glucuronide (EtG), an alcohol metabolite, became measurable in three participants after puffing from the 23.5% alcohol e-cigarette. CONCLUSIONS: Brief use of a widely available type of e-cigarette containing an e-liquid purchased from an internet vendor can negatively impact psychomotor performance and in some instances, produce detectable levels of a urine alcohol metabolite. Given the widespread and unregulated use of e-cigarettes, especially by youth and other vulnerable populations, further studies are needed to evaluate both the acute safety and long-term health risks of using alcohol-containing e-cigarettes.