Ethics training in dermatology residency programs: A survey of dermatology residency program directors and assistant/associate program directors.

Professionalism, defined as a demonstrated adherence to professional and ethical principles, is one of the six core competencies of dermatology graduate medical education. We sought to assess the current educational landscape for ethics training in dermatology residency programs by surveying dermatology residency program directors and assistant/associate program directors. A sixteen-question survey was designed and distributed to dermatology program directors and assistant/associate program directors via an email list. The estimated response rate was 43.17%. Most (54.55%) dermatology residency programs did not have an ethics curriculum. Among programs with an ethics curriculum, about three-fourths were implemented in the past ten years. The most common settings for teaching ethics were "formal didactics" (31.91%) and "ad hoc during clinical encounters and other clinical settings" (27.66%). Cited barriers to implementing and/or maintaining an ethics curriculum were "lack of time" (30.10%), "lack of faculty with expertise in ethics" (24.27%), and "lack of useful resources" (20.39%). Despite requirements for ethics training, most dermatology residency programs did not report having an ethics curriculum. This study's results highlight the need for an increased emphasis on ethics training in US dermatology residency programs.

Anti-laminin 332 mucous membrane pemphigoid in a young woman treated with rituximab.

Mucous membrane pemphigoid, formerly known as cicatricial pemphigoid, is a rare and difficult-to-treat bullous disorder that occurs most commonly in older adults. We describe a 32-year-old woman who was diagnosed with anti-laminin 332 mucous membrane pemphigoid through indirect immunofluorescence for laminin 332 following nonspecific histologic and direct immunofluorescence findings. At 16 weeks following completion of her first cycle of with rituximab 375mg/m2 weekly for four weeks, her mucosal erosions had resolved. Although not widely available, this case highlights the utility of anti-laminin 332 immunofluorescence for diagnostic confirmation of this entity and the efficacy of rituximab in obtaining disease control.

Primary care providers should prescribe aspirin to prevent cardiovascular disease based on benefit-risk ratio, not age.

Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60.In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit-risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis.ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials.Primary care providers should make individual decisions whether to prescribe ASA based on benefit-risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago.

Risks of Cardiovascular Disease and Beyond in Prescription of Nonsteroidal Anti-Inflammatory Drugs.

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, naproxen, diclofenac, and ibuprofen, as well as selective cyclooxygenase 2 inhibitors such as celecoxib. Their use is common, as well as their side effects which cause 100 000 hospitalizations and 17 000 deaths annually. Recently, the US Food and Drug Administration strengthened its warning about the risks of cardiovascular disease (CVD) attributed to nonaspirin NSAIDs. METHODS: When the sample size is large, randomization provides control of confounding not possible to achieve with any observational study. Further, observational studies and, especially, claims data have inherent confounding by indication larger than the small to moderate effects being sought. RESULTS: While trials are necessary, they must be of sufficient size and duration and achieve high compliance and follow-up. Until then, clinicians should remain uncertain about benefits and risks of these drugs. Conclusions: Since the totality of evidence remains incomplete, health-care providers should consider all these aforementioned benefits and risks, both CVD and beyond, in deciding whether and, if so, which, NSAID to prescribe. The factors in the decision of whether and, if so, which NSAID to prescribe for relief of pain from inflammatory arthritis should not be limited to risks of CVD or gastrointestinal side effects but should also include potential benefits including improvements in overall quality of life resulting from decreases in pain or impairment from musculoskeletal pain syndromes. The judicious individual clinical decision-making about the prescription of NSAIDs to relieve pain based on all these considerations has the potential to do much more good than harm.

Aspirin in the Treatment and Prevention of Migraine Headaches: Possible Additional Clinical Options for Primary Healthcare Providers.

Migraine headaches are among the most common and potentially debilitating disorders encountered by primary healthcare providers. In the treatment of acute migraine and the prevention of recurrent attacks, there are prescription drugs of proven benefit. However, for those without health insurance or high co-pays, these drugs may be neither available nor affordable and, for all patients, they may be either poorly tolerated or contraindicated. The totality of evidence, which includes data from randomized trials, suggests that high-dose aspirin, in doses from 900 to 1300 mg, taken at the onset of symptoms, is an effective and safe treatment option for acute migraine headaches. In addition, the totality of evidence, including some, but not all, randomized trials, suggests the possibility that daily aspirin, in doses from 81 to 325 mg, may be an effective and safe treatment option for the prevention of recurrent migraine headaches. The relatively favorable side effect profile of aspirin and extremely low costs compared with other prescription drug therapies may provide additional options for primary healthcare providers in the treatment of both acute and recurrent migraine headaches.