Melanoma: An update on systemic therapies

Despite advances in early detection as described in part 1 of this continuing medical education series, melanoma continues to be a large contributor to cutaneous cancer-related mortality. In a subset of patients with unresectable or metastatic disease, surgical clearance is often not possible; therefore, systemic and local therapies are considered. The second article in this series provides dermatologists with an up-to-date working knowledge of the treatment options that may be prescribed by oncologists for patients with unresectable stage III, stage IV, and recurrent melanoma.

Melanoma: How and When to Consider Clinical Diagnostic Technologies

In response to rising rates of melanoma worldwide, novel non-invasive melanoma detection techniques are emerging to facilitate the early detection of melanoma and decrease unnecessary biopsies of benign pigmented lesions. Because they often report similar study findings, it may be difficult to determine how best to incorporate these technologies into clinical practice based on their supporting studies alone. As an expansion of the recent article by Fried et al.¹, which reviewed the clinical data supporting these non-invasive melanoma detection techniques, the first article in this continuing medical education series provides practical advice on how and when to use various non-invasive melanoma detection techniques into clinical practice.

Invasive and in situ squamous cell carcinoma of the skin: a nationwide study in Iceland

BACKGROUND

The worldwide incidence of cutaneous squamous cell carcinoma (cSCC) is increasing.

OBJECTIVES

To evaluate the tumour burden of in situ and invasive cSCC in Iceland, where the population is exposed to limited ultraviolet radiation.

METHODS

This whole-population study used the Icelandic Cancer Registry, which contains records of all in situ and invasive cSCC cases from 1981 to 2017. Incidence of cSCC was evaluated according to age, anatomical location, residence and multiplicity, and trends were assessed using joinpoint analysis. Age-standardized rates (WSR) and age-specific incidence rates per 100 000 person-years were calculated, along with cumulative and lifetime risks.

RESULTS

Between 1981 and 2017, in situ cSCC WSR increased from 1·2 to 19·1 for men and from 2·0 to 22·3 for women. Invasive cSCC WSR rose from 4·6 to 14 for men and from 0·3 to 13·2 for women. The average number of in situ cSCC lesions was 1·71 per woman and 1·39 per man. Women developed more in situ cSCCs than invasive cSCCs in almost all anatomical locations, whereas men developed more invasive cSCCs, mostly on the head and neck. The rates of in situ cSCC were higher in Reykjavik compared with rural areas. Furthermore, women more commonly developed multiple in situ lesions. For lip cSCCs, invasive lesions occurred more frequently than in situ lesions among both sexes. Joinpoint analysis showed that in situ cSCC in women exhibited the most rapid incidence increase.

CONCLUSIONS

cSCC has become an increasingly significant public health problem in Iceland. Tanning bed use and travelling abroad may contribute to skin cancer development. Public health efforts are needed to stem the behaviours leading to this rapid rise in cSCC.

Metformin is associated with decreased risk of basal cell carcinoma: A whole-population case-control study from Iceland

BACKGROUND

Metformin has anticarcinogenic properties and is also known to inhibit the sonic hedgehog pathway, but population-based studies analyzing the potential protective effect for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are needed.

OBJECTIVES

To delineate the association between metformin use and invasive SCC, SCC in situ (SCCis), and BCC.

METHODS

A population-based case-control study design was employed using all 6880 patients diagnosed in Iceland between 2003-2017 with first-time BCC, SCCis, or invasive SCC, and 69,620 population controls. Multivariate odds ratios (ORs) were calculated using conditional logistic regression.

RESULTS

Metformin was associated with a lower risk of developing BCC (OR, 0.71; 95% confidence interval [CI], 0.61-0.83), even at low doses. No increased risk of developing SCC was observed. SCCis risk was mildly elevated in the 501-1500 daily dose unit category (OR, 1.40; 95% CI, 1.00-1.96).

LIMITATIONS

This study was retrospective in nature with the inability to adjust for ultraviolet exposure, Fitzpatrick skin type, and comorbidities.

CONCLUSION

Metformin is associated with decreased risk of BCC development, even at low doses. Metformin might have potential as a chemoprotective agent for patients at high risk of BCC, although this will need confirmation in future studies.

Association between hydrochlorothiazide and the risk of in situ and invasive squamous cell skin carcinoma and basal cell carcinoma: A population-based case-control study

BACKGROUND

Population-based studies analyzing hydrochlorothiazide's (HCTZ's) effect on keratinocyte carcinoma, and particularly invasive squamous cell carcinoma (SCC), are lacking.

OBJECTIVES

To characterize the association between HCTZ use and invasive SCC, SCC in situ (SCCis), and basal cell carcinoma (BCC).

METHODS

This population-based case-control study included all 6880 patients diagnosed with first-time BCC, SCCis, and invasive SCC between 2003 and 2017 in Iceland and 69,620 population controls. Conditional logistic regression analyses were used to calculate multivariate odds ratios (ORs) for keratinocyte carcinoma associated with HCTZ use.

RESULTS

A cumulative HCTZ dose above 37,500 mg was associated with increased risk of invasive SCC (OR, 1.69; 95% confidence interval [CI], 1.04-2.74). Users of HCTZ also had an increased risk of SCCis (OR, 1.24; 95% CI, 1.01-1.52) and BCC (OR, 1.14; 95% CI, 1.02-1.29).

LIMITATIONS

Limitations include this study's retrospective nature with the resulting inability to adjust for ultraviolet exposure, Fitzpatrick skin type, and comorbidities.

CONCLUSIONS

High cumulative exposure to HCTZ is associated with the development of keratinocyte carcinoma and, most importantly, invasive SCC. Sun protective behaviors alone may not eliminate the carcinogenic potential of HCTZ.

Dermatomyositis: Diagnosis and treatment

The second article in this continuing medical education series reviews the initial evaluation of patients with suspected dermatomyositis (DM), the relevant work-up for malignancy and interstitial lung disease once a diagnosis of DM is made, and treatment recommendations for patients with DM based on disease severity, the presence of systemic symptoms, and myositis-specific antibody (MSA) profiles. This review emphasizes the emerging role of MSAs in the diagnosis of DM and highlights how MSAs can be used to guide the appropriate work-up for malignancy and interstitial lung disease. The treatment approach proposed by this continuing medical education series discusses both established and novel therapies for DM and highlights the importance of considering lesion type, degree of muscle involvement, presence of systemic symptoms, presence of MSAs, and patient age when determining the best treatment approach for a patient with DM.

Cell phone etiquette in the clinical arena: A professionalism imperative for healthcare

Cell phones have become a routine part of daily life in the United States; 97.1% of faculty, residents, and medical students carry their personal cell phone with them at work. Concerns about professionalism and potentially inappropriate use of mobile technology have emerged, and challenges to professionalism that are associated with the use of mobile devices in the clinical setting are evolving as technology advances. These issues should be directly addressed by the medical profession. Concerns include questions of privacy/confidentiality, microbial transmission from contact with mobile devices, maintenance of personal/professional boundaries when physicians and patients use mobile devices to communicate, appropriate communication among colleagues, and prioritization of patient care over personal matters.

Professionalism of clinical photography in the pediatric setting

Photography has a wide range of use in the medical field, ranging from clinical care to publication and teaching purposes. While photography is more common in certain specialties such as dermatology and plastic surgery, the accessibility to cameras and ease of documentation provides the opportunity for all fields to utilize this technology. In pediatric dermatology, photographs are taken to determine if conditions such as rashes and moles have changed or remained stable. Photos are also taken prior to biopsies to ensure the correct site is biopsied and used for monitoring for post-excisional changes. In surgery, photography is used to capture pre- and post-operative changes. Photography is also used to document trauma and physical abuse, which may be used as legal evidence. Clinical photography has also demonstrated its usefulness in this age of team-based healthcare, where different providers see the same patients over subsequent visits, allowing for new providers to see photographical documentation of conditions at a prior state.

Using bivalve chronologies for quantifying environmental drivers in a semi-enclosed temperate sea

Annual growth increments formed in bivalve shells are increasingly used as proxies of environmental variability and change in marine ecosystems, especially at higher latitudes. Here, we document that well-replicated and exactly dated chronologies can also be developed to capture oceanographic processes in temperate and semi-enclosed seas, such as the Mediterranean. A chronology is constructed for Glycymeris pilosa from a shallow embayment of the northern Adriatic and extends from 1979 to 2016. The chronology significantly (p < 0.05) and positively correlates to winter sea surface temperatures, but negatively correlates to summer temperatures, which suggests that extreme winter lows and extreme summer highs may be limiting to growth. However, the strongest and most consistent relationships are negative correlations with an index of the Adriatic-Ionian Bimodal Oscillating System (BiOS) for which positive values indicate the inflow of the ultraoligotrophic Eastern Mediterranean waters to the Adriatic. In contrast, the substantial freshwater flows that discharge into the Adriatic do not correlate to the bivalve chronology, emphasizing the importance of remote oceanographic processes to growth at this highly coastal site. Overall, this study underscores the potential of bivalve chronologies to capture biologically relevant, local- to regional-scale patterns of ocean circulation in mid-latitude, temperate systems.

Differences in dermatology training abroad: A comparative analysis of dermatology training in the United States and in India

Dermatology residency training is not standardized internationally, and each country dictates how training is conducted within its own borders. This article highlights the types of variability in training that can occur from country to country by comparing dermatology residency training programs in the United States and India. This article specifically analyzes the differences that pertain to application and selection, residency program structure, and post-residency opportunities.

A population-based assessment of human rights abuses committed against ethnic Albanian refugees from Kosovo

OBJECTIVES

This study assessed patterns of displacement and human rights abuses among Kosovar refugees in Macedonia and Albania.

METHODS

Between April 19 and May 3, 1999, 1180 ethnic Albanian refugees living in 31 refugee camps and collective centers in Macedonia and Albania were interviewed.

RESULTS

The majority (68%) of participants reported that their families were directly expelled from their homes by Serb forces. Overall, 50% of participants saw Serb police or soldiers burning the houses of others, 16% saw Serb police or soldiers burn their own home, and 14% witnessed Serb police or soldiers killing someone. Large percentages of participants saw destroyed mosques, schools, or medical facilities. Thirty-one percent of respondents reported human rights abuses committed against their household members, including beatings, killings, torture, forced separation and disappearances, gunshot wounds, and sexual assault.

CONCLUSIONS

The present findings confirm that Serb forces engaged in a systematic and brutal campaign to forcibly expel the ethnic Albanian population of Kosovo. In the course of these mass deportations, Serb forces committed widespread abuses of human rights against ethnic Albanians.

Vaginal delivery after cesarean section: is the risk acceptable?

Recent studies and commentary have questioned the safety of vaginal births after cesarean sections (VBACs). The history of VBACs is reviewed and a framework to continue the safe practice of trials of labor in women with a prior uterine scar is presented.

Public health and complex emergencies: new issues, new conditions

Public health practice in complex emergencies has become increasingly sophisticated and well informed over the course of the past quarter century. Humanitarian relief organizations have learned many lessons in the areas of food, water and sanitation, shelter, and primary health. However, closer scrutiny from the media and funding agencies, together with changing conditions and an increasingly insecure environment, will require that changes be made. First and foremost, nongovernmental organizations must recognize that an increasing proportion of morbidity and mortality is the consequence of widespread human rights abuses. These organizations should become more familiar with international human rights and humanitarian law, and their personnel should receive clear guidance as to how to recognize and report violations. At the same time, nongovernmental organizations will have to work more closely with military forces that have a very different organizational culture. In addition, as emergencies become more complex, nongovernmental organizations should do more to attract and retain seasoned professionals. Finally, advances in both technical and operational areas will occur only through carefully designed and implemented research.

Increasing the accuracy of the Expanded Programme on Immunization's cluster survey design

The Expanded Programme on Immunization (EPI) of the World Health Organization developed a cluster survey design for the rapid assessment of children's vaccination coverage in developing countries. Because of its simplicity and familiarity, the EPI methodology has been used for additional purposes, including the detection of relatively small changes in vaccination coverage levels that are already high and the estimation of other population parameters when moderate accuracy is required. This article suggests techniques for improving the accuracy of the EPI cluster survey method, including (a) segmenting sample clusters, if necessary, so that reasonably sized areas can be counted, mapped, and listed; (b) selecting an equal probability sample of housing units within a cluster; (c) selecting a fixed number of housing units per sample cluster; and (d) performing weighted analyses. These procedures will produce accurate estimators and corresponding standard errors in EPI cluster surveys.

A canonical correlation between adaptive and maladaptive aspects of adaptive behavior

The relationship between the adaptive and the maladaptive aspects of the construct of adaptive behavior was examined by means of a canonical correlation between Part One and Part Two of the AAMD Adaptive Behavior Scale (ABS). The sample consisted of 439 institutionalized mentally retarded persons. Four significant canonical correlations (.68, .49, .39, .28) were derived, three of which were interpretable. The redundancy index was 30 percent with Part One as the criterion and 14 percent with Part Two as the criterion. A redundancy of about 30 percent was calculated. An analysis of the pattern of canonical components suggested that the three major dimensions responsible for the overlap between ABS Parts One and Two are intellectual ability, sociability, and physical ability. An attempt to cross validate these results was made using another sample of 157 mentally retarded persons. Considerable shrinkage was observed on three of the roots.

A clinical evaluation of occlusal composite and amalgam restorations: one- and two-year results

A two-year study was conducted to compare the qualitative advantages, if any, of a conventional, cold-curing composite resin to amalgam in occlusal Class I cavities in posterior teeth. The composite was placed into modified, conservative cavity preparations using the acid etch technique. Sixty-one pairs of contralateral restorations were evaluated. Forty-six percent of the amalgams and 42.6% of the composites were considered sound. The major deficiency of each material was rough or chipped margins of the amalgams (38%) and worn surfaces of the composites (26%). The use of conservative cavity preparations and the acid-etch technique with bonding agent and final glaze improved the longevity of the composite restorations compared to previous studies. However, the improvement does not suggest that this method will have a long-term effect on clinical success nor does it indicate that composite is superior to amalgam other than in marginal integrity and esthetics.

An attenuated influenza virus vaccine: protection against homologous and heterologous strains of virus

An effective influenza vaccine should be capable of providing protection against both the homologous virus strain and heterologous strains representing antigenic "drift". Two attenuated vaccines were evaluated, an A/Hong Kong/8/68 (H3N2) and an A/England/42/72 (H3N2) strain. Volunteers were immunized intranasally with either placebo or vaccine in a "double-blind" fashion in two doses, 2 weeks apart. Eighty-four subjects were challenged 30-100 days after the second dose with either the homologous or a heterologous strain. The heterologous strain for the A/Hong Kong/8/68 (H3N2) vaccinees was the A/England/42/72 (H3N2) virulent strain. The heterologous strain for the A/England/42/72 (H3N2) vaccinees was a virulent A/Dunedin/73 (H3N2) strain. Both vaccines led to good protection against both homologous and heterologous challenges. The protection rate against illness for the A/Hong Kong/8/68 (H3N2) vaccinees was 73% and 100% following homologous and heterologous challenges, respectively. The protection rate for the A/England/42/72 H3N2) vaccinees was 100% following both homologous and heterologous challenges. The protection rates against infection (as judged by antibody responses, irrespective of signs and symptoms) were also good. For the A/Hong Kong/8/68 (H3N2) vaccinees the rates were 73% (homologous) and 86% (heterologous). For the A/England/42/72 vaccinees, the rates were 72% and 60% respectively. Thus, immunity induced by these attenuated influenza vaccines extends to provide protection against related but non-identical influenza viruses.

Comparative clinical and laboratory evaluation of the prophylactic capacity of ribavirin, amantadine hydrochloride, and placebo in induced human influenza type A

The comparative prophylactic effectiveness of oral treatment with ribavirin (1-beta-D-ribofuranosyl-1,2,4,triazole-3-carboxamide; virazole) and amantadine hydrochloride against artificially induced infection with influenza A virus was evaluated in 29 seronegative men who received ribavirin capsules (200 mg) three times daily, placebo capsules three times daily, or amantadine capsules (100 mg) twice daily. Medication was started two days before the inoculation of 2 X 10(4) 50% tissue culture infective doses of A University of Maryland/2/74 (H3N2) influenza virus and was continued for eight days after challege. Nine of the 10 subjects who received ribavirin, eight of the nine subjects who received placebo, and six of the 10 subjects who received amantadine developed influenzal illness. Significantly less virus was isolated from the amantadine-treated group than from the placebo-treated or the ribavirin-treated group. Antibody responses of the ribavirin-treated and placebo-treated groups were quite similar to each other; however, prophylactic treatment with amantadine significantly reduced titers of serum antibody and febrile responses. In a separate clinical trial involving challenge with A/Dunedin/73 (H3N2) influenza virus, ribavirin also failed to show prophylactic effectiveness.

Immunoglobulin A glomerulonephritis: a clinicopathologic study

Renal biopsies from 10 patients staining predominantly for immunoglobulin A are reviewed. Historically, nine of 10 patients were less than 32 years of age; they all presented with either microscopic or gross hematuria. The initial creatinine clearances demonstrated good function in all patients; only one patient experienced a progressive decline in the creatinine clearance. Similarly, proteinuria was mild. The light and electron microscopic findings presented a variable pattern, including a group with changes confined to the mesangium, another group also having glomerular basement membrane changes, and one patient with severe, progressive glomerular sclerosis. Immunogluorescence demonstrated large amounts of IgA predominantly within the mesangium but occasionally involving the peripheral capillary loops. Serum IgA levels were elevated in six of eight patients tested, and two of five patients had elevated nasal IgA concentrations. These data suggest that there is an immunologic entity, IgA glomerulonephritis, characterized by the above clincial findings in association with elevated serum and occasionally nasal IgA levels, but that the pathologic findings are highly variable. Neither the mechanism nor the particular pathogenetic significance of the raised IgA levels is presently known. The similarities of this entity to the reported findings in anaphylactoid purpura are mentioned.