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.

Genotype-phenotype analysis of angiotensinogen polymorphisms and essential hypertension: the importance of haplotypes.

OBJECTIVES: To better understand the relationship between angiotensinogen (AGT) genetic variation and essential hypertension, AGT genotypes and haplotypes were tested for association with hypertensive endophenotypes and essential hypertension. METHODS: Two hundred and fifty-six Hypertensive Pathotype (HyperPATH)/Specialized Center of Research (SCOR) cases and 126 controls were genotyped for 24 single-nucleotide polymorphisms (SNPs) in the AGT gene. SNPs and AGT haplotypes were tested for association with plasma AGT, renal plasma flow (RPF), and essential hypertension. RESULTS: New associations between essential hypertension, plasma AGT, and RPF are reported for alleles -1178G, 6066A, 6152A, 6233C, and 12822C. The maximum odds ratio for association of hypertension and AGT genetic variation was 2.3 [95% confidence interval (CI) 1.5-3.8; P < 0.0003] for allele 6233C. Previous associations for -1074T, -532T, -217A, -6A, and 4072C are confirmed (P < 0.05). Sodium depletion enhances associations between AGT SNPs and plasma AGT. Most individually associated SNPs, including -6A and 4072C, are found on a common complete AGT haplotype, H4 (frequency = 0.09). Individuals with haplotype H4 have significantly higher plasma AGT and reduced RPF (P < 0.003 and P < 0.0002, respectively). Other common haplotypes are not associated with increased plasma AGT levels in this data set despite the presence of the -6A and 4072C alleles, suggesting that AGT haplotype H4 is more predictive of elevated plasma AGT than is -6A or 4072C. CONCLUSION: This study demonstrates the importance of analyzing haplotypes in addition to single genotypes in association studies. By demonstrating the dependence of AGT associations on sodium depletion status, it helps to explain previous conflicting association results.

Alu repeats increase local recombination rates.

BACKGROUND: Recombination rates vary widely across the human genome, but little of that variation is correlated with known DNA sequence features. The genome contains more than one million Alu mobile element insertions, and these insertions have been implicated in non-homologous recombination, modulation of DNA methylation, and transcriptional regulation. If individual Alu insertions have even modest effects on local recombination rates, they could collectively have a significant impact on the pattern of linkage disequilibrium in the human genome and on the evolution of the Alu family itself. RESULTS: We carried out sequencing, SNP identification, and SNP genotyping around 19 AluY insertion loci in 347 individuals sampled from diverse populations, then used the SNP genotypes to estimate local recombination rates around the AluY loci. The loci and SNPs were chosen so as to minimize other factors (such as SNP ascertainment bias and SNP density) that could influence recombination rate estimates. We detected a significant increase in recombination rate within approximately 2 kb of the AluY insertions in our African population sample. To test this observation against a larger set of AluY insertions, we applied our locus- and SNP-selection design and analyses to the HapMap Phase II data. In that data set, we observed a significantly increased recombination rate near AluY insertions in both the CEU and YRI populations. CONCLUSION: We show that the presence of a fixed AluY insertion is significantly predictive of an elevated local recombination rate within 2 kb of the insertion, independent of other known predictors. The magnitude of this effect, approximately a 6% increase, is comparable to the effects of some recombinogenic DNA sequence motifs identified via their association with recombination hot spots.

HapMap tagSNP transferability in multiple populations: general guidelines.

Linkage disequilibrium (LD) has received much attention recently because of its value in localizing disease-causing genes. Due to the extensive LD between neighboring loci in the human genome, it is believed that a subset of the single nucleotide polymorphisms in a region (tagSNPs) can be selected to capture most of the remaining SNP variants. In this study, we examined LD patterns and HapMap tagSNP transferability in more than 300 individuals. A South Indian sample and an African Mbuti Pygmy population sample were included to evaluate the performance of HapMap tagSNPs in geographically distinct and genetically isolated populations. Our results show that HapMap tagSNPs selected with r(2) >= 0.8 can capture more than 85% of the SNPs in populations that are from the same continental group. Combined tagSNPs from HapMap CEU and CHB+JPT serve as the best reference for the Indian sample. The HapMap YRI are a sufficient reference for tagSNP selection in the Pygmy sample. In addition to our findings, we reviewed over 25 recent studies of tagSNP transferability and propose a general guideline for selecting tagSNPs from HapMap populations.