Education and Perspectives on the Use of Oral Skin Cancer Chemoprophylaxis: A Cross-Sectional Survey of Current Fellows in Mohs Micrographic Surgery & Dermatologic Oncology

BACKGROUND

According to the curriculum guidelines of the Accreditation Council of Graduate Medical Education and the American Board of Dermatology, Mohs micrographic surgery & dermatologic oncology (MSDO) fellows must demonstrate competency in the use of oral skin cancer chemoprophylaxis. The current level of education in this area is unknown.

OBJECTIVE

To characterize oral skin cancer chemoprophylaxis education for acitretin and nicotinamide among current MSDO fellows and to compare the clinical indications felt most appropriate for prescribing to a previously published expert consensus.

METHODS

An electronic survey was distributed to all active MSDO fellows by the American College of Mohs Surgery.

RESULTS

Responses were received from 63 (69.2%) MSDO fellows. Twenty (31.7%) and 37 (58.7%) fellows reported receiving fellowship training on acitretin and nicotinamide, respectively. Fifty-seven (90.5%) intend to prescribe chemoprophylaxis after training. Sixteen (28.1%) and 43 (75.4%) report feeling very comfortable prescribing acitretin and nicotinamide, respectively. Fellow concordance with a previously published expert consensus opinion on appropriate prescribing indications is variable. Forty-one (65.1%) indicated that additional education would increase the likelihood to prescribe after training.

CONCLUSION

Although most MSDO fellows intend to prescribe oral skin cancer chemoprophylaxis, a standardized curriculum may promote increased use and concordance with expert consensus recommendations.

Comparison of Survival Outcomes With/Without Adjuvant Radiation Therapy in Desmoplastic Melanoma

BACKGROUND

Desmoplastic melanoma (DM) is a rare variant of cutaneous melanoma with a high rate of local recurrence. Recent studies have indicated a potential benefit in local control with the addition of adjuvant radiotherapy (RT).

OBJECTIVE

This study sought to evaluate the outcomes of adjuvant RT for patients with DM.

MATERIALS AND METHODS

The National Cancer Database was queried (2004-2015) for patients with newly diagnosed, nonmetastatic DM. Patients were divided into 2 groups based on the adjuvant therapy they received: RT or observation. Statistics included multivariable logistic regression to determine factors predictive of receiving adjuvant RT, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling to determine variables associated with OS.

RESULTS

There was no difference in median OS between patients treated with RT when compared with patients observed (111.4 months vs 133.9 months, p = .1312). On multivariable analysis, older age, T stage ≥2, N stage ≥1, and no receipt of immunotherapy were associated with worse OS.

CONCLUSION

In this large study evaluating efficacy of adjuvant RT in DM, no overall survival benefit was observed among patients receiving adjuvant RT.

Acute inflammatory Demodex-induced pustulosis in an immunocompetent patient related to topical steroid use

Demodex spp. mites are a common colonizer of sebaceous adult skin. Though usually clinically insignificant, demodicosis may be associated with a wide spectrum of skin diseases in immunocompetent hosts, such as erythematotelangiectatic and papulopustular rosacea, Demodex folliculorum, and blepharitis. We present a case of a healthy 9-year-old boy with an exuberant, inflammatory, Demodex-associated pustular eruption of the face, induced by the use of a high-potency topical steroid and successfully treated with oral ivermectin.

Relationship Between Scholarly Activity and Postgraduate Career Choice: A Bibliometric Analysis of the 2017 Diplomates of the American Board of Dermatology

BACKGROUND

Scholarly productivity is an assessment metric for dermatology residents and faculty. How the bibliometric h-index, a publicly available metric that incorporates the quantity and quality of publications, relates to early career choices of dermatologists has not been investigated.

OBJECTIVE

We determined the h-indices of the 2017 diplomates of the American Board of Dermatology to ascertain its association with career choice.

METHODS

A cross-sectional analysis was performed using the published list of the 2017 diplomates. Gender and PhD status were compiled. The Scopus database was queried for publications and h-indices. The primary outcome was the pursuit of an academic position, nonacademic position, or fellowship after board certification.

RESULTS

Among 475 (96%) diplomates, the median (range) h-index was 2 (0-14). Those with MD and PhD degrees had greater h-indices (6.4 ± 3.1 vs. 2.3 ± 2.3, P < .05). There was a difference (P < .05) in h-index between diplomates pursuing an academic position (3.6 ± 3.1), non-procedural fellowship (3.3 ± 3.1), procedural fellowship (2.5 ± 2.0), and non-academic position (2.1 ± 2.1).

CONCLUSIONS

The h-index quantifies academic productivity and may predict early career choices in dermatology.

Drug-induced cutaneous vasculitis and anticoagulant-related cutaneous adverse reactions: insights in pathogenesis, clinical presentation, and treatment

Drug-induced vasculitis and anticoagulant-related skin reactions are commonly encountered in the inpatient and outpatient settings. The spectrum of clinical presentation is broad and ranges from focal, skin-limited disease, to more extensive cutaneous and soft tissue necrosis, to potentially fatal systemic involvement. The prompt recognition of these adverse events can have a significant impact on patient morbidity and mortality. We highlight the key features of the clinical presentation with an emphasis on primary lesion morphology, distribution, and epidemiology of purpuric drug reactions. The proposed pathophysiology, histologic findings, and therapeutic interventions of these potentially life-threatening diseases are discussed.

Predictors of 30-day readmission in Stevens-Johnson syndrome and toxic epidermal necrolysis: A cross-sectional database study

BACKGROUND

The predictors of readmission in Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) have not been characterized.

OBJECTIVE

To determine the variables predictive of 30-day readmission after SJS/TEN hospitalization.

METHODS

We performed a cross-sectional study of the 2010-2014 Nationwide Readmissions Database. Bivariate and multivariable logistic regression was used to evaluate associations of patient demographics, comorbidities, and hospital characteristics with readmission. Aggregate and per-readmission costs were calculated.

RESULTS

There were 8837 index admissions with SJS/TEN reported; of these, 910 (10.3%) were readmitted, with diagnoses including systemic infection (22.0%), SJS/TEN (20.6%), and cutaneous infection (9.1%). Associated characteristics included age 45 to 64 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.43-2.49), Medicaid insurance (OR, 1.83; 95% CI, 1.48-2.27), and nonmetropolitan hospital admission (OR, 1.67; 95% CI, 1.31-2.13). Associated comorbidities included HIV/AIDS (OR, 2.48; 95% CI, 1.63-3.75), collagen vascular disease (OR, 2.38; 95% CI, 1.88-3.00), and metastatic cancer (OR, 2.16; 95% CI, 1.35-3.46). The median per-readmission cost was $10,019 (interquartile range, $4,788-$16,485).

LIMITATIONS

The Nationwide Readmissions Database lacks the ability to track the same patient across calendar years. The diagnostic code lacks specificity for hospitalizations <3 days.

CONCLUSIONS

Thirty-day readmissions after SJS/TEN hospitalizations are common. Dedicated efforts to identify at-risk patients may improve peridischarge continuity.

Office-based dermatologic diagnostic procedure utilization in the United States Medicare population from 2000-2016

BACKGROUND

Potassium hydroxide preparations (KOH) and tissue examinations for ova and parasites (O&P) are cost-effective office-based tests. No studies have quantified their utilization and economic impact.

METHODS

The objective is to determine the billing patterns and costs of office-based diagnostic procedures in the Medicare population. We conducted a cross sectional study using the Part B National Summary Data File (2000-2016) and the Physician and Other Supplier Public Use File (2012-2015) released by the Centers for Medicare & Medicaid Services.

RESULTS

In 2016, the total number of claims among all providers was 28,432 (KOH) and 52,182 (O&P), representing a decrease since 2000 (KOH, -41.8%; O&P, -43.4%). The total claims for in-office procedures by dermatologists per 10,000 beneficiaries decreased between 2012 and 2015 (KOH, -18.8%; O&P, -26.6%). Fewer dermatologists submitted claims for the tests (KOH, -11.3%; O&P, -16.6%). The total single (SB) and multiple (MB) biopsy claims by dermatologists per 10,000 beneficiaries decreased between 2012 and 2015 (SB, -1.8%; MB, -2.7%). The 2016 aggregate payments (% change since 2000) for KOH and O&P were $163,127.75 (-60.4%) and $299,074.18 (-61.6%), respectively; for SB and MB, they were $240,047,487.98 (+142.3%) and $38,214,117.22 (+79.2%), respectively.

CONCLUSION

Fewer dermatologists submit claims for KOH and O&P each year. Future studies should evaluate whether this is due to a loss of cost-efficacy, and secondly, if it is related to decreased reimbursement, burdensome in-office laboratory regulations, or changing provider preferences.

Percutaneous liver biopsy in Fontan patients

BACKGROUND

Patients who have undergone the Fontan operation for palliation of congenital heart disease with single-ventricle pathophysiology are at high risk for developing progressive liver fibrosis. Pathological assessment from percutaneous liver biopsy is central to the management of Fontan-associated liver disease, but liver biopsy in this vulnerable population poses unique challenges and potential risks.

OBJECTIVE

This retrospective study describes our experience with percutaneous liver biopsy performed to assess changes of Fontan-associated liver disease, with particular regard to procedural outcomes.

MATERIALS AND METHODS

Data from liver biopsy procedure reports, pathology reports, cardiac angiography pressure measurements and laboratory values of patients with single ventricle heart disease after the Fontan operation who underwent ultrasound-guided percutaneous liver biopsy performed in interventional radiology at a pediatric tertiary care center during a 3-year period were retrospectively analyzed.

RESULTS

Sixty-eight liver biopsies were performed in 67 patients (mean age: 20.2 years, range: 7.2-39 years). The technical success rate was 100%, and tissue was adequate for assessing liver disease in 100% of the procedures, including biopsies performed with a single pass. Anticoagulation was routinely suspended before biopsy, and no cardiac complications were encountered due to this suspension. A coaxial biopsy system using an 18-gauge (G) full-core instrument through a 17-G introducer trocar was most commonly used, in 41/68 cases (60%). The most common trough length was 2.3 cm, used in 37 cases (54%). One pass was made in 27 procedures (40%) and two passes in 30 (44%); tract embolization with gelatin sponge was performed in 52 (76%). The only complication was hemorrhage, which occurred in 5/68 (7.4%) of the biopsies, minor in four (5.9%) and major in one (1.5%) -- similar to rates reported for liver biopsy in non-Fontan patients. Hemorrhage had a delayed presentation in three of these five cases. Immediate post-biopsy hemoglobin decrease of ≥2 mg/dL showed a low sensitivity for hemorrhage. The mean Fontan pressure measured during cardiac angiography was 13.8 mmHg, and shunt pressures were not associated with an increased risk of hemorrhage.

CONCLUSION

Percutaneous liver biopsy in Fontan patients can be performed safely with high technical success rates and without increased complication rates. Meticulous technique and close observation are recommended to reduce post-biopsy complications. The degree of right heart pressure elevation was not associated with hemorrhage.

Safety and efficacy of topical cantharidin for the treatment of pediatric molluscum contagiosum: a prospective, randomized, double-blind, placebo-controlled pilot trial

Topical cantharidin is a commonly used treatment for molluscum contagiosum (MC). However, studies validating its safety and efficacy are limited. We conducted a 6-week, randomized, double-blind, placebo-controlled trial with subsequent open-label extension to assess the safety and effectiveness of cantharidin in treating pediatric MC. Ninety-four participants with MC were randomized to receive cantharidin or placebo, with or without occlusion. The primary outcome was complete lesion clearance. Secondary outcomes included post-treatment lesion count, adverse events, and side effects. No significant differences between the study arms, including baseline lesion count, were observed. The overall mean (SD) baseline lesion count was 22.2 (12.9). The number of participants achieving total clearance is as follows: 7/23 (30.4%) in the cantharidin only arm, 10/24 (41.7%) in the cantharidin with occlusion arm, 2/25 (8.0%) in the placebo with occlusion arm, and 3/22 (13.6%) in the placebo only arm. Post hoc analysis demonstrated that 17/47 (36.2%) participants in the combined cantharidin arms achieved clearance compared to 5/47 (10.6%) in the placebo arms (P = 0.0065). The mean (SD) lesion count change from baseline was -5.1 (12.2) in the placebo only arm; the mean change (SD) was -17.4 (12.8) in the cantharidin only arm (P = 0.0033) and -15.9 (11.6) in the cantharidin with occlusion arm (P = 0.0101). No serious adverse events or side effects were observed. Topical cantharidin was well-tolerated and associated with the resolution of MC.

IVC filter retrieval in adolescents: experience in a tertiary pediatric center

BACKGROUND

Inferior vena cava (IVC) filters are commonly implanted with the intent to prevent life-threatening pulmonary embolism in at-risk patients with contraindications to anticoagulation. Various studies have reported increases in the rate of venous thromboembolism within the pediatric population. The utility and safety of IVC filters in children has not yet been fully defined.

OBJECTIVE

To describe the technique and adjunctive maneuvers of IVC filter removal in children, demonstrate its technical success and identify complications.

MATERIALS AND METHODS

A retrospective 10-year review was performed of 20 children (13 male, 7 female), mean age: 15.1 years (range: 12-19 years), who underwent IVC filter retrieval. Eleven of 20 (55%) were placed in our institution. Electronic medical records were reviewed for filter characteristics, retrieval technique, technical success and complications.

RESULTS

The technical success rate was 100%. Placement indications included: deep venous thrombosis with a contraindication to anticoagulation (10/20, 50%), free-floating thrombus (4/20, 20%), post-trauma pulmonary embolism prophylaxis (3/20, 15%) and pre-thrombolysis pulmonary patient (1/20, 5%). The mean implantation period was 63 days (range: 20-270 days). Standard retrieval was performed in 17/20 patients (85%). Adjunctive techniques were performed in 3/20 patients (15%) and included the double-snare technique, balloon assistance and endobronchial forceps retrieval. Median procedure time was 60 min (range: 45-240 min). Pre-retrieval cavogram demonstrated filter tilt in 5/20 patients (25%) with a mean angle of 17° (range: 8-40). Pre-retrieval CT demonstrated strut wall penetration and tip embedment in one patient each. There were two procedure-related complications: IVC mural dissection noted on venography in one patient and snare catheter fracture requiring retrieval in one patient. There were no early or late complications.

CONCLUSION

In children, IVC filter retrieval can be performed safely but may be challenging, especially in cases of filter tilt or embedding. Adjunctive techniques may increase filter retrieval rates.

Pharmacogenetics of obesity drug therapy

As the prevalence and severity of obesity and its complications have risen significantly in worldwide populations, behavioral interventions alone have been inconsistent in promoting sufficient, sustained weight loss. Consequently, there has been intense interest in the development of anti-obesity medications as treatment strategies. When coupled with structured lifestyle modifications, pharmacotherapy can enhance weight loss. While less efficacious than bariatric surgery, drug therapy may be an alternative to surgery for some obese patients, and is an emerging strategy for weight maintenance. The goal of pharmacogenetics is to help identify patients who will benefit most from drug therapies while minimizing the risk of adverse effects. In this review, we summarize the pharmacogenetic literature on obesity drugs of the past (sibutramine, rimonabant), present (orlistat, lorcaserin, phentermine, topiramate), and future (buprioprion/naltrexone).

Adiponectin induces vascular smooth muscle cell differentiation via repression of mammalian target of rapamycin complex 1 and FoxO4

OBJECTIVE

The adipocyte-secreted hormone adiponectin exerts important cardioprotective and antidiabetic effects. Little is known about its effect on vascular smooth muscle cells (VSMC), key cells in restenosis, hypertension, and atherosclerosis.

METHODS AND RESULTS

Using human coronary artery VSMC, we found that recombinant adiponectin in the high-molecular-weight or trimeric forms but not the globular form induced VSMC differentiation through a mechanism similar to the classic feedback signaling used by rapamycin, a drug known to effectively inhibit restenosis on drug-eluting stents. Using a combination of pharmacological agents, small interfering RNA, and overexpression approaches, we demonstrated that adiponectin activated 5'-AMP-activated protein kinase α2 isoform, leading to inhibition of mammalian target of rapamycin complex 1 and S6K1. This in turn stabilized insulin receptor substrate-1, driving Akt2-mediated inhibition of FoxO4 and subsequent contractile protein induction. Although adiponectin and rapamycin have similarly beneficial effects on VSMC phenotype in both cell and organ culture, a direct comparison of the effects of rapamycin versus adiponectin on endothelial cells revealed distinct differences: rapamycin inhibited Akt phosphorylation, whereas adiponectin maintained it. Importantly, Akt activity preserves endothelial function.

CONCLUSION

Adiponectin promotes VSMC differentiation and preserves endothelial cell Akt signaling, suggesting that targeting the adiponectin pathway may have advantages over rapamycin in developing new drug-eluting stent therapeutics.