Reliable test of clinicians' mastery in skin cancer diagnostics

Differentiating between benign and malignant skin lesions can be very difficult and should only be done by sufficiently trained and skilled clinicians. To our knowledge there are no validated tests for reliable assessments of clinicians' ability to perform skin cancer diagnostics. To develop and gather validity evidence for a test in skin cancer diagnostics, a multiple-choice questionnaire (MCQ) was developed based on informal interviews with seven content experts from five skin cancer centers in Denmark. Validity evidence for the test was gathered from May until July 2019 using Messick's validity framework (content, response process, internal structure, relationship to other variables and consequences). Item content was revised through a Delphi-like review process and then piloted on 36 medical students and 136 doctors using a standardized response process. Results enabled an analysis of the internal structure and relationship to other variables of the test. Finally, the contrasting groups method was used to investigate the test's consequences (pass-fail standard). The initial 90-item MCQ was reduced to 40 items during the Delphi-like review process. Item analysis revealed that 25 of the 40 selected items were level I-III quality items with a high internal consistency (Cronbach's α = 0.83) and highly significant (P ≤ 0.0001) differences in test scores between participants with different occupations or levels of experience. A pass-fail standard of 12 (48%) correct answers was established using the contrasting groups' method. The skin cancer diagnostics MCQ developed in this study can be used for reliable assessments of clinicians' competencies.

Pregnancy outcome in four women with inflammatory bowel disease treated with budesonide MMX

BACKGROUND

Maintaining disease remission throughout pregnancy in women with inflammatory bowel disease is of the utmost importance to decrease the risk of adverse outcome. In general, corticosteroids are safe to use during pregnancy, but no data exist in the specific use of budesonide MMX. We report four cases of budesonide MMX in pregnancy and pregnancy outcome.

METHODS

Four women with inflammatory bowel disease experienced disease activity during pregnancy. They were treated with budesonide MMX in an attempt to obtain clinical remission. Disease activity was assessed through physician's global assessment as well as lower endoscopy.

RESULTS

Budesonide MMX proved effective in achieving remission in three out of four women. One woman had an uncomplicated colectomy in the second trimester. All children were born normal for gestational age, with no congenital abnormalities and have reached all their developmental milestones. The four children have received vaccines according to the national immunization program without complications.

CONCLUSION

No adverse pregnancy outcomes were reported after the use of budesonide MMX. To our knowledge, this is the first report on the safety of budesonide MMX treatment in pregnant women with inflammatory bowel disease.

An audit of thiopurine methyltransferase genotyping and phenotyping before intended azathioprine treatment for dermatological conditions

BACKGROUND

Determining thiopurine methyltransferase (TPMT) genotype and phenotype before azathioprine treatment predicts which patients are most likely to develop myelosuppression.

AIM

To evaluate the course of azathioprine treatment in people with TPMT heterozygosity and whether this deterred clinicians in prescribing the drug.

METHODS

This was a retrospective analysis on patients who had TPMT assays undertaken with the intention of treating their skin disorder with azathioprine. Primary outcome measurements were: (i) whether or not azathioprine was started, (ii) azathioprine dosage, and (iii) duration of treatment. Secondary outcome measures were the effect of the drug, any reported side-effects and reasons for not starting azathioprine.

RESULTS

TPMT assays were undertaken in 212 patients, of whom 90.6% were TPMT wild type and the remaining 9.4% were TPMT heterozygous. None of the patients was TPMT homozygous. Of the 192 wild-type patients, 103 (53.6%) received azathioprine, as did 7 (35%) of the 20 heterozygotes (P = 0.16). Mean azathioprine dose was 84.1 mg/day for wild-type patients and 64.3 mg/day for heterozygotes (P = 0.10). Mean treatment duration was 21.4 and 22.7 weeks for wild-type and heterozygotes, respectively (P = 0.52). Azathioprine treatment was stopped in 4 of 7 heterozygotes and 54 of 103 wild-type patients, because of side-effects, lack of effect or a combination of both. The commonest reason for not starting azathioprine treatment in heterozygous patients was their heterozygosity. For wild-type patients, the reasons were remission of disease or the patient's lack of interest in the treatment.

CONCLUSIONS

TPMT heterozygosity was a deterring factor for the prescription of azathioprine in our department, and the dose for wild-type patients was lower than recommended guidelines. Treatment duration and occurrence of adverse effects were similar for heterozygotes and wild-type patients.

Etiology of common childhood acute lymphoblastic leukemia: the adrenal hypothesis

The pattern of infections in the first years of life modulates our immune system, and a low incidence of infections has been linked to an increased risk of common childhood acute lymphoblastic leukemia (ALL). We here present a new interpretation of these observations--the adrenal hypothesis--that proposes that the risk of childhood ALL is reduced when early childhood infections induce qualitative and quantitative changes in the hypothalamus-pituitary-adrenal axis that increase plasma cortisol levels. This may directly eliminate leukemic cells as well as preleukemic cells for the ALL subsets that dominate in the first 5-7 years of life and may furthermore suppress the Th1-dominated proinflammatory response to infections, and thus lower the proliferative stress on pre-existing preleukemic cells.

Location on the chromosome of Escherichia coli of genes governing purine metabolism. Adenosine deaminase (add), guanosine kinase (gsk) and hypoxanthine phosphoribosyltransferase (hpt)

Genes coding for enzymes functioning in purine salvage pathways have been located on the chromosome of Escherichia coli. The gene add encoding adenosine deaminase was located by transduction at 31 min, the gene order was established to be man-uidA-add-aroD. A deletion covering man-uidA-add was obtained. The gene gsk encoding guanosine kinase was cotransducible with purE and shown to be located at 13 min. The gene hpt encoding hypoxanthine phosphoribosyltransferase was cotransducible with tonA indicating a location at 3 min. The location of the gene gpt encoding guanine (xanthine) phosphoribosyltransferase in the proA-proB region was confirmed.