Prognostic value of sentinel lymph node biopsy compared with that of Breslow thickness: implications for informed consent in patients with invasive melanoma.

BACKGROUND: Sentinel lymph node (SLN) status is reportedly a powerful prognosticator of survival. Breslow thickness alone provides significant prognostic information. OBJECTIVE: To assess overall survival (OS) according to tumor depth based on SLN status. MATERIALS AND METHODS: MEDLINE, EMBASE, and the Cochrane Central Database were searched for studies. Included studies evaluated overall survival according to SLNB results and were stratified according to Breslow thickness. Meta-analysis was performed if appropriate in each category for which three or more studies reported risk estimates and variability measurement. RESULTS: Twenty-nine articles met inclusion criteria. Six met the criteria for meta-analysis. In individuals with thin melanoma (<1 mm), SLN-negative status conferred no survival advantage (sign test, p > .99). Few studies were available for intermediate depths, and most reported worse survival in SLN-positive patients, although the difference was not statistically significant (p > .05). For thick melanoma (>4 mm), SLN positivity was related to worse prognosis (sign test, p = .004). Based on the pooled results of six studies of patients with tumors 4 mm thick or thicker, SLN-positive patients had a greater likelihood of dying (hazard ratio = 2.42, 95% confidence interval = 2.00-2.92). CONCLUSIONS: Sentinel lymph node biopsy may not provide more-accurate prognostic information than Breslow thickness for most melanomas.

Reviewing dermatology manuscripts and publications.

Although quality scientific publications depend on peer review, physicians rarely receive formal training on how to review a manuscript. Comprehensive guidelines direct how meta-analyses, randomized controlled trials (RTCs), and observational trials should be reported in the literature. This article provides instruction on how to effectively review a life sciences manuscript, particularly those in dermatology.

New neurotoxins on the horizon.

Toxins isolated from lethal bacteria allow for safe, versatile, and minimally invasive interventions that have revolutionized the field of cosmetic and therapeutic treatments. Botulinum toxins are high-molecular weight proteins produced by Gram-positive, spore-forming Clostridial bacteria. The toxins of 5 distinct strains (A, B, E, F, and G) affect humans. Currently, type A and B toxins are available for the treatment of human diseases in the United States, with type A being the only agent approved for cosmetic use by the U.S. Food and Drug Administration. This article reviews the history of botulinum toxin as a cosmetic intervention, discusses its current role in cosmetic treatment, and provides an update of other neurotoxins on the horizon for therapeutic and cosmetic use.

US dermatology residents' satisfaction with training and mentoring: survey results from the 2005 and 2006 Las Vegas Dermatology Seminars.

OBJECTIVE: To evaluate residents' satisfaction with dermatology training and mentorship. DESIGN: Written survey. SETTING: The Las Vegas Dermatology Seminar in 2005 and 2006. PARTICIPANTS: Graduating dermatology residents in the United States. MAIN OUTCOME MEASURES: Satisfaction with and importance of 26 training components, overall training satisfaction, satisfaction with availability and quality of mentors, and time spent outside the clinics and classroom with mentors. RESULTS: Of dermatology residents attending the 2005 and 2006 seminars, 57 (50%) and 49 (54%), respectively, completed the survey. In 2006, 38 more surveys were received by mail, for a combined total of 144 respondents. In 2005 and 2006, respectively, 44 (77%) and 66 (76%) residents scored training at or above 7 on a 10-point rating scale. Residents were most satisfied with peer teaching, medical dermatology training, pathology slide sessions, and live patient conferences and least satisfied with business management and dermoscopy training. Discrepancies between perceived importance and satisfaction were greatest for business management, time for independent study, and responsiveness to resident input. Residents spending 30 minutes (the median) or more per month outside of clinics and the classroom with someone they defined as a mentor reported higher training satisfaction (8.0 vs 7.2; P = .02). Resident-perceived program mentor availability (P = .001 in 2005, P=.002 in 2006) and quality (P =.002 in 2005, P < or = .001 in 2006) were also associated with increased overall training satisfaction. CONCLUSIONS: Of 26 training components, residents were most dissatisfied with business management training. Resident training satisfaction was associated with program mentor availability and quality, as well as time spent with mentors.

Human research review committee requirements in medical journals.

PURPOSE: Independent ethical review committees safeguard participants in human research. The purpose of this study was to describe the current ethical guidelines for human research requirements in the Instructions to Authors of the English language medical journals previously studied in 1995. METHODS: The instructions to authors of English language medicine journals from the Abridged Index Medicus were searched for any policies regarding guidance on the ethical treatment of human subjects in research. RESULTS: More medical journals require independent ethics committee approval of human research now [84/101 (83%)] than 10 years ago [48/102 (47%) (P < 0.001)], and most journals continue to require that this disclosure appear in the manuscript [71/84 (85%) vs. then 37/48 (77%) (P=0.29)]. Fewer medical journal instructions to authors provide no ethical guidelines for human research now [8/101 (8%)] than 10 years ago [25/102 (24%) (P < 0.001)]. No journal required submission of the study approval letter or of the approved protocol. CONCLUSIONS: Although medicine journals increasingly require disclosure statements of independent ethics committee approval for human research, they fail to verify such approval beyond taking authors for their word.

Similar deficiencies in procedural dermatology and dermatopathology fellow evaluation despite different periods of ACGME accreditation: results of a national survey.

BACKGROUND: Fellow evaluation is required by the Accreditation Council for Graduate Medical Education (ACGME). Procedural dermatology fellowship accreditation by the ACGME began in 2003 while dermatopathology accreditation began in 1976. OBJECTIVE: The objective was to compare fellow evaluation rigor between ACGME-accredited procedural dermatology and dermatopathology fellowships. METHODS: Questionnaires were mailed to fellowship directors of the ACGME-accredited (2006-2007) procedural dermatology and dermatopathology fellowship programs. Information was collected regarding evaluation form development, delivery, and collection. RESULTS: The response rates were 74% (25/34) and 53% (24/45) for procedural and dermatopathology fellowship programs, respectively. Sixteen percent (4/25) of procedural dermatology and 25% (6/24) of dermatopathology programs do not evaluate fellows. Fifty percent or less of program (4/8 procedural dermatology and 3/7 dermatopathology) evaluation forms address all six core competencies required by the ACGME. CONCLUSION: Procedural fellowships are evaluating fellows as rigorously as the more established dermatopathology fellowships. Both show room for improvement because one in five programs reported not evaluating fellows and roughly half of the evaluation forms provided do not address the six ACGME core competencies.

Statins, fibrates, and melanoma risk: a systematic review and meta-analysis.

BACKGROUND: Large randomized, controlled clinical trials of lovastatin and gemfibrozil for heart disease prevention have reported statistically significantly lower melanoma incidences in persons receiving these medications. Results of in vitro animal model and human case-control studies also suggest that statins and fibrates may reduce the risk of melanoma. METHODS: We performed a systematic review of trials that randomly assigned participants to receive statins or fibrates versus an alternative therapy for a minimum of 6 months. Trials were identified by searching five electronic databases and the reference lists of eligible publications. Unpublished data were solicited from trial investigators and pharmaceutical companies. A meta-analysis was performed using a fixed-effects model, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to estimate pooled treatment effects. All statistical tests were two-sided. RESULTS: We obtained data on incident melanomas from 20 of 36 qualifying randomized controlled trials (12 statin trials and eight fibrate trials), with a total of 70,820 participants. A total of 127 melanomas occurred among the 39,426 participants in the statin trials (59 among the 19,872 statin group participants and 68 among the 19,554 control group participants). A total of 27 melanomas occurred among the 31,394 participants enrolled in the fibrate trials (seven among the 12,324 fibrate group participants and 20 among the 19,070 control group participants). Overall, incidence of melanoma was not statistically significantly associated with the use of either statins (OR = 0.87, 95% CI = 0.61 to 1.23) or fibrates (OR = 0.45, 95% CI = 0.20 to 1.01). In a subgroup analysis by drug, only lovastatin use (in one trial) was statistically significantly associated with lower incidence of melanoma (OR = 0.52, 95% CI = 0.27 to 0.99). CONCLUSIONS: These findings do not validate the possibility that statins or fibrates prevent melanoma.