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1.
Nature ; 542(7639): 115-118, 2017 02 02.
Artigo em Inglês | MEDLINE | ID: mdl-28117445

RESUMO

Skin cancer, the most common human malignancy, is primarily diagnosed visually, beginning with an initial clinical screening and followed potentially by dermoscopic analysis, a biopsy and histopathological examination. Automated classification of skin lesions using images is a challenging task owing to the fine-grained variability in the appearance of skin lesions. Deep convolutional neural networks (CNNs) show potential for general and highly variable tasks across many fine-grained object categories. Here we demonstrate classification of skin lesions using a single CNN, trained end-to-end from images directly, using only pixels and disease labels as inputs. We train a CNN using a dataset of 129,450 clinical images-two orders of magnitude larger than previous datasets-consisting of 2,032 different diseases. We test its performance against 21 board-certified dermatologists on biopsy-proven clinical images with two critical binary classification use cases: keratinocyte carcinomas versus benign seborrheic keratoses; and malignant melanomas versus benign nevi. The first case represents the identification of the most common cancers, the second represents the identification of the deadliest skin cancer. The CNN achieves performance on par with all tested experts across both tasks, demonstrating an artificial intelligence capable of classifying skin cancer with a level of competence comparable to dermatologists. Outfitted with deep neural networks, mobile devices can potentially extend the reach of dermatologists outside of the clinic. It is projected that 6.3 billion smartphone subscriptions will exist by the year 2021 (ref. 13) and can therefore potentially provide low-cost universal access to vital diagnostic care.


Assuntos
Dermatologistas/normas , Redes Neurais de Computação , Neoplasias Cutâneas/classificação , Neoplasias Cutâneas/diagnóstico , Automação , Telefone Celular/estatística & dados numéricos , Conjuntos de Dados como Assunto , Humanos , Queratinócitos/patologia , Ceratose Seborreica/classificação , Ceratose Seborreica/diagnóstico , Ceratose Seborreica/patologia , Melanoma/classificação , Melanoma/diagnóstico , Melanoma/patologia , Nevo/classificação , Nevo/diagnóstico , Nevo/patologia , Fotografação , Reprodutibilidade dos Testes , Neoplasias Cutâneas/patologia
3.
Australas J Dermatol ; 62(3): 292-299, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34117779

RESUMO

BACKGROUND/OBJECTIVES: Vulval lichen sclerosus (VLS) is a chronic inflammatory skin condition predominantly affecting the anogenital region in women and children. To date, there is lack of agreement amongst experts on a severity scale to aid assessment, research and treatment stratification on VLS. Furthermore, literature on best practice for long-term management of VLS is lacking. The aim of this consensus is to provide broad guidelines on the short and long-term management of VLS. METHODS: An initial focus group of Australasian experts in vulval dermatology developed a draft consensus statement for the management of VLS. Based on the results of the draft statement, a consensus panel of 22 Australasian experts, comprised of the initial and additional members, participated in an anonymous four-stage eDelphi process. Round 1 involved generation and voting on statements from the draft consensus statement developed by the focus group. In Rounds 2, 3 & 4, panel members were presented formal feedback from previous rounds and asked to indicate their level of agreement. Consensus was reached if there was ≥70% agreement on the importance of an item in the 4 (agree) to 5 (strongly agree) range. RESULTS: The expert panel, with a total of 504 collective years of experience in the field of VLS, reached consensus on a core set of 51 management statements related to diagnosis, severity, initial and long-term management, follow-up, and complications of VLS. CONCLUSIONS: This study has identified a set of management statements for VLS that may be useful in clinical practice in the Australasian population.


Assuntos
Consenso , Líquen Escleroso e Atrófico/terapia , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Líquen Escleroso Vulvar/terapia , Dermatologistas/normas , Feminino , Humanos , Líquen Escleroso e Atrófico/prevenção & controle , Líquen Escleroso Vulvar/prevenção & controle
4.
J Am Acad Dermatol ; 83(3): 839-846, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32344071

RESUMO

BACKGROUND: An Investigator Global Assessment (IGA) is recommended by health agencies for drug registration in atopic dermatitis (AD). Current IGA scales lack standardization. OBJECTIVES: To develop an IGA scale, training module, and clinical certification examination for use in AD trials; establish content validity; and assess reliability. METHODS: Expert dermatologists participated in the development of the validated IGA for AD (vIGA-ADTM). Reliability (interrater and intrarater) was assessed by 2 web-based surveys. Clinical certification for investigators consisted of a training module and examination. RESULTS: Expert consensus was achieved around a 5-point IGA scale including morphologic descriptions, and content validity was established. Survey 1 showed strong interrater reliability (Kendall's coefficient of concordance W [Kendall's W], 0.809; intraclass correlation [ICC], 0.817) and excellent agreement (weighted kappa, 0.857). Survey 2, completed 5 months after training of dermatologists, showed improvements in scale reliability (Kendall's W, 0.819; ICC, 0.852; weighted kappa, 0.889). In this study, 627 investigators completed vIGA-AD training and certification. LIMITATIONS: Ratings were assessed on photographs. CONCLUSION: A validated IGA scale and training module were developed with the intent of harmonizing assessment of disease severity in AD trials. Strong reliability and excellent agreement between assessments were observed.


Assuntos
Consenso , Dermatite Atópica/diagnóstico , Avaliação de Resultados em Cuidados de Saúde/normas , Índice de Gravidade de Doença , Adulto , Criança , Conferências de Consenso como Assunto , Dermatite Atópica/terapia , Dermatologistas/normas , Dermatologistas/estatística & dados numéricos , Humanos , Variações Dependentes do Observador , Fotografação , Reprodutibilidade dos Testes , Pele/diagnóstico por imagem , Inquéritos e Questionários/estatística & dados numéricos , Telecomunicações
5.
J Am Acad Dermatol ; 83(4): 1150-1159, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32569797

RESUMO

Dermatologists treating immune-mediated skin disease must now contend with the uncertainties associated with immunosuppressive use in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Although the risk of infection with many commonly used immunosuppressive agents remains low, direct data evaluating the safety of such agents in coronavirus disease 2019 (COVID-19) are scarce. This article reviews and offers guidance based on currently available safety data and the most recent COVID-19 outcome data in patients with immune-mediated dermatologic disease. The interdisciplinary panel of experts emphasizes a stepwise, shared decision-making approach in the management of immunosuppressive therapy. The goal of this article is to help providers minimize the risk of disease flares while simultaneously minimizing the risk of iatrogenic harm during an evolving pandemic.


Assuntos
Infecções por Coronavirus/prevenção & controle , Dermatologia/normas , Terapia de Imunossupressão/normas , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto , Dermatopatias/terapia , Comitês Consultivos/normas , Betacoronavirus/imunologia , Betacoronavirus/patogenicidade , COVID-19 , Tomada de Decisão Clínica , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/virologia , Tomada de Decisão Compartilhada , Dermatologistas/normas , Dermatologia/métodos , Suscetibilidade a Doenças/imunologia , Médicos Hospitalares/normas , Humanos , Terapia de Imunossupressão/efeitos adversos , Terapia de Imunossupressão/métodos , Comunicação Interdisciplinar , Pneumonia Viral/epidemiologia , Pneumonia Viral/imunologia , Pneumonia Viral/virologia , SARS-CoV-2 , Dermatopatias/imunologia , Sociedades Médicas/normas , Exacerbação dos Sintomas
6.
Dermatol Surg ; 46(12): 1676-1682, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33165083

RESUMO

BACKGROUND: Laser procedures are becoming more prevalent across multiple medical specialties for a variety of indications. The plumes created by these lasers have raised concern for the dissemination of an infectious material. OBJECTIVE: To review and summarize the information on viral dissemination in laser plumes available in the literature. MATERIALS AND METHODS: Data Sources A systematic review was performed on English and non-English articles using the PubMed and the Cochrane databases. A manual search of bibliographies from relevant articles was also performed to collect additional studies. STUDY SELECTION: Only articles in the English language with full texts available that pertained to viral particles in laser plumes were included. Data Extraction Two authors performed independent article selections using predefined inclusion and exclusion criteria. RESULTS: There have been case reports of possible transmission of human papillomavirus (HPV) by inhalation of laser-produced aerosols. Multiple investigators have attempted to recreate this scenario in the laboratory to qualify this risk. Others have conducted clinical experiments to determine the presence of HPV in laser plumes. CONCLUSION: The current body of the literature suggests that laser surgeons are at a risk for HPV exposure by inhalation of laser-derived aerosols. We offer best practice recommendations for laser operators.


Assuntos
Aerossóis/efeitos adversos , Terapia a Laser/efeitos adversos , Doenças Profissionais/prevenção & controle , Exposição Ocupacional/efeitos adversos , Infecções por Papillomavirus/transmissão , Alphapapillomavirus/patogenicidade , Dermatologistas/normas , Dermatologistas/estatística & dados numéricos , Neoplasias de Cabeça e Pescoço/epidemiologia , Neoplasias de Cabeça e Pescoço/prevenção & controle , Neoplasias de Cabeça e Pescoço/virologia , Humanos , Incidência , Exposição por Inalação/efeitos adversos , Exposição por Inalação/normas , Exposição por Inalação/estatística & dados numéricos , Doenças da Laringe/epidemiologia , Doenças da Laringe/prevenção & controle , Doenças da Laringe/virologia , Terapia a Laser/normas , Terapia a Laser/estatística & dados numéricos , Máscaras/normas , Doenças Profissionais/epidemiologia , Doenças Profissionais/virologia , Exposição Ocupacional/estatística & dados numéricos , Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/cirurgia , Infecções por Papillomavirus/virologia , Guias de Prática Clínica como Assunto , Roupa de Proteção/normas , Pele/efeitos da radiação , Pele/virologia , Neoplasias Cutâneas/cirurgia , Neoplasias Cutâneas/virologia , Carcinoma de Células Escamosas de Cabeça e Pescoço/epidemiologia , Carcinoma de Células Escamosas de Cabeça e Pescoço/prevenção & controle , Carcinoma de Células Escamosas de Cabeça e Pescoço/virologia , Cirurgiões/normas , Cirurgiões/estatística & dados numéricos
7.
J Med Internet Res ; 22(9): e18091, 2020 09 11.
Artigo em Inglês | MEDLINE | ID: mdl-32915161

RESUMO

BACKGROUND: Early detection of melanoma can be lifesaving but this remains a challenge. Recent diagnostic studies have revealed the superiority of artificial intelligence (AI) in classifying dermoscopic images of melanoma and nevi, concluding that these algorithms should assist a dermatologist's diagnoses. OBJECTIVE: The aim of this study was to investigate whether AI support improves the accuracy and overall diagnostic performance of dermatologists in the dichotomous image-based discrimination between melanoma and nevus. METHODS: Twelve board-certified dermatologists were presented disjoint sets of 100 unique dermoscopic images of melanomas and nevi (total of 1200 unique images), and they had to classify the images based on personal experience alone (part I) and with the support of a trained convolutional neural network (CNN, part II). Additionally, dermatologists were asked to rate their confidence in their final decision for each image. RESULTS: While the mean specificity of the dermatologists based on personal experience alone remained almost unchanged (70.6% vs 72.4%; P=.54) with AI support, the mean sensitivity and mean accuracy increased significantly (59.4% vs 74.6%; P=.003 and 65.0% vs 73.6%; P=.002, respectively) with AI support. Out of the 10% (10/94; 95% CI 8.4%-11.8%) of cases where dermatologists were correct and AI was incorrect, dermatologists on average changed to the incorrect answer for 39% (4/10; 95% CI 23.2%-55.6%) of cases. When dermatologists were incorrect and AI was correct (25/94, 27%; 95% CI 24.0%-30.1%), dermatologists changed their answers to the correct answer for 46% (11/25; 95% CI 33.1%-58.4%) of cases. Additionally, the dermatologists' average confidence in their decisions increased when the CNN confirmed their decision and decreased when the CNN disagreed, even when the dermatologists were correct. Reported values are based on the mean of all participants. Whenever absolute values are shown, the denominator and numerator are approximations as every dermatologist ended up rating a varying number of images due to a quality control step. CONCLUSIONS: The findings of our study show that AI support can improve the overall accuracy of the dermatologists in the dichotomous image-based discrimination between melanoma and nevus. This supports the argument for AI-based tools to aid clinicians in skin lesion classification and provides a rationale for studies of such classifiers in real-life settings, wherein clinicians can integrate additional information such as patient age and medical history into their decisions.


Assuntos
Inteligência Artificial/normas , Dermatologistas/normas , Dermoscopia/métodos , Diagnóstico por Imagem/classificação , Melanoma/diagnóstico por imagem , Neoplasias Cutâneas/diagnóstico por imagem , Humanos , Internet , Melanoma/diagnóstico , Neoplasias Cutâneas/diagnóstico , Inquéritos e Questionários
8.
J Cancer Educ ; 35(4): 819-825, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32193871

RESUMO

The early diagnosis of cutaneous melanoma provides less aggressive treatment reducing mortality. General practitioners are responsible for cancer diagnoses in the Brazilian Public Health System and therefore play a crucial role in the prevention and early detection of melanoma. To assess the melanoma knowledge of a primary healthcare physician, the general practitioner, compared to a dermatologist. General practitioners and dermatologists answered a questionnaire about melanoma and the management of suspected cases. The results of both groups were compared. The sample consisted of 80 specialists and 160 general practitioners. When asked about the "ABCDE" rule, 96.2% of the dermatologists knew about it, compared to 34.4% of the general practitioners. The percentage of dermatologists who examined the whole skin of the patient at high risk for melanoma was 90% vs. 24.5% amongst general practitioners. The most cited reasons for the absence of the examination of patients at risk for melanoma were lack of time at the consultations (17.6% specialists, 66.1% generalists) and an excessive number of patients (17.6% specialists, 61.5% generalists). General practitioner has less knowledge about melanoma compared to the dermatologists and presents deficient behaviors about patients at risk or who have suspicious lesions, indicating the need for training and continuing education.


Assuntos
Dermatologistas/estatística & dados numéricos , Erros de Diagnóstico/estatística & dados numéricos , Clínicos Gerais/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Melanoma/diagnóstico , Padrões de Prática Médica/normas , Neoplasias Cutâneas/diagnóstico , Adulto , Brasil/epidemiologia , Estudos Transversais , Dermatologistas/normas , Feminino , Clínicos Gerais/normas , Humanos , Masculino , Melanoma/epidemiologia , Neoplasias Cutâneas/epidemiologia , Inquéritos e Questionários , Melanoma Maligno Cutâneo
9.
Br J Dermatol ; 180(6): 1420-1429, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30597525

RESUMO

BACKGROUND: Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood. OBJECTIVES: To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored. METHODS: A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software. RESULTS: Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care. CONCLUSIONS: A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.


Assuntos
Assistência ao Convalescente/normas , Carcinoma Basocelular/terapia , Dermatologia/normas , Uso Excessivo dos Serviços de Saúde/prevenção & controle , Neoplasias Cutâneas/terapia , Adulto , Idoso , Atitude do Pessoal de Saúde , Dermatologistas/normas , Feminino , Grupos Focais , Clínicos Gerais/normas , Humanos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Pesquisa Qualitativa
10.
Br J Dermatol ; 181(3): 544-553, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30636037

RESUMO

BACKGROUND: The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources. OBJECTIVES: To gain insight in to the healthcare utilization of people with AK in a population-based cohort, and the management of AK in a primary and secondary care setting. METHODS: A retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment and follow-up of patients with AK in the Netherlands. Data sources consisted of a population-based cohort study (Rotterdam Study), routine general practitioner (GP) records (Integrated Primary Care Information) and nationwide claims data (DRG Information System). RESULTS: In the population-based cohort (Rotterdam Study), 69% (918 of 1322) of participants diagnosed with AK during a skin-screening visit had no previous AK-related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e. ≥ 10 AKs; n = 270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41-56%). Topical agents were the second most used treatment by dermatologists (13-21%) but were rarely applied in primary care (2%). During the first AK-related GP visit, 31% (171 of 554) were referred to a dermatologist, and the likelihood of being referred was comparable between low- and high-risk patients, which is inconsistent with the Dutch general practitioner guidelines for 'suspicious skin lesions' from 2017. Annually, 40 000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow-up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years. CONCLUSIONS: AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow-up in secondary care result in the inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. What's already known about this topic? The prevalence of actinic keratosis (AK) is high and, in particular, multiple AKs are a strong skin cancer predictor. The high prevalence of AK requires optimal use of healthcare resources. Nevertheless, (population based) AK healthcare utilization and management data are very rare. What does this study add? Although AK-related care already consumes substantial resources, about 70% of the AK population has never received care. Primary care AK management demonstrated underutilization of topical therapies and high referral rates without proper risk stratification, while in secondary care the extensive follow-up schedules were applied. This inefficient use of healthcare resources highlights the need for better harmonization and risk stratification to increase the efficiency of AK care.


Assuntos
Ceratose Actínica/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Atenção Secundária à Saúde/estatística & dados numéricos , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Assistência ao Convalescente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Crioterapia/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Fármacos Dermatológicos/uso terapêutico , Dermatologistas/normas , Dermatologistas/estatística & dados numéricos , Feminino , Clínicos Gerais/normas , Clínicos Gerais/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Ceratose Actínica/diagnóstico , Masculino , Pessoa de Meia-Idade , Países Baixos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Atenção Primária à Saúde/normas , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/normas , Medição de Risco/estatística & dados numéricos , Atenção Secundária à Saúde/normas
11.
J Wound Ostomy Continence Nurs ; 46(2): 113-116, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30747799

RESUMO

PURPOSE: The primary aim of this study was to compare patient reported versus clinician-observed nonulcerative foot conditions in patients attending a diabetic foot clinic and deemed at risk for diabetic foot ulcers. DESIGN: Retrospective review of medical records. SUBJECTS AND SETTING: The medical records of 126 patients with diabetes mellitus and deemed at risk for developing diabetic foot ulcers were reviewed. All patients received care from a diabetic foot outpatient clinic in a university-based hospital in Tokyo, Japan, between November 2008 and October 2009. METHODS: We compared patients' self-identified foot complaints with clinically observable conditions affecting the feet of these individuals with diabetes mellitus. Patients' medical records were retrieved, and patient complaints and identified preulcerative signs of the foot were documented. All clinical observations were made by nurse specialists with knowledge of diabetic foot conditions. Nonulcerative diabetic foot conditions we observed included calluses, corns, abnormal nails, fissures, tinea pedis, and tinea unguium. Patient sensitivity to correctly identify these signs was calculated using the following formula: patient-reported foot signs divided by clinically identified preulcerative signs. RESULTS: Patient sensitivity for identifying nonulcerative signs varied based on the foot condition was 51.4% for calluses, 47.8% for pincer nails, 44.4% for corns, 33.3% for fissures, 19.4% for nail abnormalities, 3.9% for scales/maceration between the toes, 2.6% for interdigital tinea pedis, and 18.2% for tinea unguium. CONCLUSION: These findings suggest that persons with diabetes vary in their awareness of conditions affecting their feet and enhancing their risk for the development of diabetic foot ulcers. We recommend additional education on foot-related self-care including how often to observe their feet and how to recognize symptoms that may elevate their risk for diabetic foot ulcers.


Assuntos
Dermatologistas/psicologia , Pé Diabético/diagnóstico , Pacientes/psicologia , Idoso , Calo Ósseo/anormalidades , Dermatologistas/normas , Complicações do Diabetes/diagnóstico , Complicações do Diabetes/psicologia , Diabetes Mellitus/fisiopatologia , Pé Diabético/psicologia , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Unhas/lesões , Unhas/fisiologia , Estudos Retrospectivos , Fatores de Risco , Autogestão/métodos
12.
J Am Acad Dermatol ; 78(2 Suppl 1): S1-S23.e1, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29127053

RESUMO

Scientific advances are continually improving the knowledge of acne and contributing to the refinement of treatment options; it is important for clinicians to regularly update their practice patterns to reflect current standards. The Global Alliance to Improve Outcomes in Acne is an international group of dermatologists with an interest in acne research and education that has been meeting regularly since 2001. As a group, we have continuously evaluated the literature on acne. This supplement focuses on providing relevant clinical guidance to health care practitioners managing patients with acne, with an emphasis on areas where the evidence base may be sparse or need interpretation for daily practice.


Assuntos
Acne Vulgar/tratamento farmacológico , Dermatologistas/normas , Gerenciamento Clínico , Guias de Prática Clínica como Assunto , Acne Vulgar/diagnóstico , Administração Oral , Administração Tópica , Antibacterianos/administração & dosagem , Consenso , Quimioterapia Combinada , Feminino , Humanos , Internacionalidade , Masculino , Melhoria de Qualidade , Retinoides/uso terapêutico , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
13.
Dermatology ; 234(3-4): 86-91, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30086541

RESUMO

BACKGROUND: Due to the increasing incidence of basal cell carcinoma (BCC) and rising health care costs, health care insurance companies seek ways to shift skin surgery for BCC from secondary to primary care. OBJECTIVES: To study the differences in complete excision of BCC by general practitioners (GPs), dermatologists, and plastic surgeons. METHODS: A retrospective cross-sectional study of pathology records of 2,986 standard excisions of primary BCCs performed by a GP, dermatologist, or plastic surgeon in the area of Southwest Netherlands between 2008 and 2014. To compare the risk of an incomplete BCC excision between the specialties, the odds ratio (OR) was used adjusted for patient age, sex, tumor site, size, and histological subtype. RESULTS: BCCs were completely excised by GPs in 70%, which was lower than the 93% by dermatologists and 83% by plastic surgeons (p < 0.001). Compared to the dermatologist, BCCs which were excised by a GP were 6 times higher at risk of an incomplete excision (adjusted OR 6, 95% CI 5-8) and 2 times higher at risk when excised by a plastic surgeon (adjusted OR 2, 95% CI 2-3). CONCLUSION: BCCs were more often completely excised by dermatologists than by GPs and plastic surgeons. Dermatologists probably perform better because of their extensive training and high experience in BCC care. To minimize incomplete BCC excision, GPs should receive specific training before the shift of BCC care from secondary to primary care is justifiable.


Assuntos
Carcinoma Basocelular/patologia , Carcinoma Basocelular/cirurgia , Dermatologia/normas , Medicina Geral/normas , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Cirurgia Plástica/normas , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Estudos Transversais , Dermatologistas/normas , Feminino , Clínicos Gerais/normas , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estudos Retrospectivos , Cirurgiões/normas
14.
J Drugs Dermatol ; 17(3): 253-262, 2018 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-29537443

RESUMO

BACKGROUND: Recently, experience and knowledge have been gained using effective topical treatment for onychomycosis, a difficult-to-treat infection. METHODS: This project aims to help understand and improve patient-focused quality of care for fungal nail infections. A panel of dermatologists who treat onychomycosis convened on several occasions to review and discuss recent learnings in the treatment of onychomycosis. The panel developed and conducted a survey on diagnosis, treatment and prevention, discussed the results, and provided recommendations. RESULTS: The survey was sent out digitally to the Canadian Dermatology community. Ninety-two dermatologists completed the questionnaires, which were included in the analysis. The survey respondents and panel members agreed that the diagnosis of toe onychomycosis should be confirmed with a positive microscopic examination for fungus or a positive mycological culture when oral therapy and/or topical treatment is prescribed, except when it is not clinically feasible, in which case topical therapy could be started based on clinical presentation. The panel and survey respondents also agreed that treatment is to be based on percentage of nail involvement: less than 20%=topical efinaconazole; 20%-60%=topical efinaconazole±oral terbinafine (for greater than 3 nails); greater than 60%=oral terbinafine±topical therapy. CONCLUSIONS: The current treatment paradigm for onychomycosis may have shifted from mainly oral antifungals to topical treatment, improving patient-focused quality of care.

J Drugs Dermatol. 2018;17(3):253-262.

.


Assuntos
Antifúngicos/administração & dosagem , Consenso , Dermatologistas/normas , Onicomicose/diagnóstico , Onicomicose/tratamento farmacológico , Inquéritos e Questionários/normas , Administração Oral , Administração Tópica , Adulto , Dermatologistas/tendências , Feminino , Humanos , Masculino , Resultado do Tratamento
15.
J Law Med ; 25(4): 1100-1105, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29978687

RESUMO

Risk mitigation practices are essential to protecting patients from harm and reducing medical practitioner exposure to unnecessary reputational damage and economic loss. Despite traditionally being perceived as a low-risk specialty, published data on medico-legal claims against dermatologists in Australia are currently lacking. This article reviews the sources of medico-legal claims against dermatologists in Australia from a single medical indemnity insurer over the most recent three years. The failure to meet patient expectations was the largest source of claims against dermatologists, followed by adverse outcomes. Improved communication from practitioner to patient remains the most effective step to preventing medico-legal claims. Medico-legal claims, when they occur, are more successfully defended when thorough documentation processes are in place.


Assuntos
Dermatologistas/legislação & jurisprudência , Seguradoras/estatística & dados numéricos , Imperícia , Austrália , Dermatologistas/normas , Documentação , Humanos , Responsabilidade Legal
16.
Br J Dermatol ; 176(3): 677-686, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27373236

RESUMO

BACKGROUND: Psoriasis is a common long-term, immune-mediated skin condition associated with behavioural factors (e.g. smoking, excess alcohol, obesity), which increase the risk of psoriasis onset, flares and comorbidities. Motivational interviewing (MI) is an evidence-based approach to health-related behaviour change that has been used successfully for patients with long-term conditions. This study assessed change in clinicians' MI skills and psoriasis knowledge following Psoriasis and Wellbeing (Pso Well® ) training. OBJECTIVES: To investigate whether the Pso Well training intervention improves clinicians' MI skills and knowledge about psoriasis-related comorbidities and risk factors; and to explore the acceptability and feasibility of the Pso Well training content, delivery and evaluation. METHODS: Clinicians attended the 1-day training programme focused on MI skills development in the context of psoriasis. MI skills were assessed pre- and post-training using the Behaviour Change Counselling Index. Knowledge about psoriasis-related comorbidity and risk factors was assessed with a novel 22-point measure developed for the study. Interviews with clinicians were analysed qualitatively to identify perceptions about the feasibility and acceptability of the training. RESULTS: Sixty-one clinicians completed the training (35 dermatology nurses, 23 dermatologists and three primary-care clinicians). Clinicians' MI skills (P < 0·001) and knowledge (P < 0·001) increased significantly post-training. Clinicians found the training valuable and relevant to psoriasis management. CONCLUSIONS: Attendance at the Pso Well training resulted in improvements in clinicians' knowledge and skills to manage psoriasis holistically. Clinicians deemed the training itself and the assessment procedures used both feasible and acceptable. Future research should investigate how this training may influence patient outcomes.


Assuntos
Competência Clínica/normas , Conhecimentos, Atitudes e Prática em Saúde , Entrevista Motivacional/métodos , Psoríase/terapia , Comunicação , Comorbidade , Aconselhamento , Dermatologistas/normas , Dermatologia/educação , Educação Médica/métodos , Feminino , Humanos , Capacitação em Serviço , Masculino , Enfermeiras e Enfermeiros/normas , Satisfação do Paciente , Relações Médico-Paciente , Médicos de Atenção Primária/normas , Fatores de Risco
17.
J Drugs Dermatol ; 16(7): 661-666, 2017 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-28697217

RESUMO

BACKGROUND: Signs of facial aging include wrinkles, loss of subcutaneous volume, decreased tone, texture, and sagging of the skin. The objective of this review is to determine whether facial suspension absorbable sutures are a safe and effective modality for facial rejuvenation.

METHOD: A group of US plastic surgeons and dermatologists who practice medical aesthetics convened to review evidence obtained from literature searches and to reach a consensus on clinical practice guidelines for the use of facial absorbable suspension sutures.

RESULTS: Currently, there are different types of lifting sutures available. Absorbable, facial suspension sutures allow for superior repositioning of tissue along a vector line together with the added benefit of volumization of the area. These benefits are for patients who have moderate facial aging and require treatment beyond the use of injectable products only.

CONCLUSIONS: Treatment with absorbable facial suspension sutures, when performed properly, is associated with minor and infrequent complications and offers a beneficial clinical alternative to traditional facial rejuvenation techniques.

J Drugs Dermatol. 2017;16(7):661-666.

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Assuntos
Consenso , Técnicas Cosméticas/tendências , Rejuvenescimento/fisiologia , Ritidoplastia/tendências , Envelhecimento da Pele/fisiologia , Implantes Absorvíveis/normas , Implantes Absorvíveis/tendências , Técnicas Cosméticas/normas , Dermatologistas/normas , Dermatologistas/tendências , Humanos , Ritidoplastia/métodos , Ritidoplastia/normas , Cirurgia Plástica/métodos , Cirurgia Plástica/normas , Cirurgia Plástica/tendências
18.
J Drugs Dermatol ; 16(5): 428-431, 2017 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-28628677

RESUMO

Importance: Current guidelines for cutaneous malignant melanoma (CMM) provide general recommendations regarding surveillance while indicating that management should be tailored to patients' individual probability of recurrence. A 31-gene expression profile (31-GEP) test to predict metastatic risk has been previously validated, and classifies patients as either Class 1 (low risk) or Class 2 (high risk).

Objective: To determine the impact of the 31-GEP test's result on clinical decision-making.

Design, Setting, and Participants: Dermatology residents who attended a national educational conference were presented with clinical validity evidence for the 31-GEP. Respondents were given six CMM patient vignettes with descriptions of clinical features and answered questions about their willingness to recommend sentinel lymph node biopsy (SLNBx) or imaging based on each scenario. Additionally, respondents were asked to provide the Breslow thickness (BT), ranging from 0.7-1.5mm in 0.1mm increments, at which they would recommend SLNBx, imaging, or oncology referral.

Main Outcomes and Measures: The number of respondents who would recommend each management modality based upon three outcomes (no result, Class 1, or Class 2) was quantified. Differences between response groups were assessed using Fisher's exact test.

Results: The majority of respondents (62%, 57%, and 55%, respectively) indicated a 1.0mm BT as the guiding modality, reflecting adherence to current guidelines. After inclusion of a Class 2 result, the BT used to guide SLNBx, oncology referral, and imaging was changed in 47%, 50% and 47% of the responses, respectively, with 95%, 84% and 97% of the cases, respectively, changed in a risk-appropriate direction (decreased BT). Based on a 31-GEP Class 1 or Class 2 result, risk appropriate recommendations were more likely to be made for each management modality tested in five of the six patient vignettes (P less than 0.05).

Conclusions and Relevance: The 31-GEP test had a significant and appropriate impact on management while remaining within the context of established guidelines.

J Drugs Dermatol. 2017;16(5):428-431.

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Assuntos
Tomada de Decisão Clínica , Dermatologistas/normas , Perfilação da Expressão Gênica/normas , Melanoma/diagnóstico , Melanoma/genética , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/genética , Adulto , Idoso , Tomada de Decisão Clínica/métodos , Feminino , Perfilação da Expressão Gênica/métodos , Humanos , Masculino , Melanoma/terapia , Pessoa de Meia-Idade , Neoplasias Cutâneas/terapia , Inquéritos e Questionários , Melanoma Maligno Cutâneo
19.
J Drugs Dermatol ; 16(3): 250-255, 2017 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-28301621

RESUMO

Introduction: Atopic dermatitis (AD) affects both adult and pediatric patients, and multiple practitioners encounter and manage AD. However, differences with regard to the treatment of AD between specialties are not well characterized. OBJECTIVE: The primary objective of this study was to determine if there is a difference between dermatologists and non-dermatology specialties with regard to treatment strategies for AD and to describe those differences. METHODS: Data from the 1993-2010 National Ambulatory Medical Care (NAMCS) and National Hospital Ambulatory Care (NHAMCS) Surveys were used to characterize outpatient visits made for AD. Differences in demographic, geographic and seasonal characteristics were obtained and compared. Additionally, the frequency of medications prescribed at dermatologist visits were compared to other specialties. PRIMARY OUTCOME MEASURES: Frequency of modalities used in the treatment of atopic dermatitis between dermatologists and non-dermatology specialties. RESULTS: An estimated 3.7 million visits for AD were made to outpatient offices and hospital departments from 1993 to 2010. The rates per capita of visits for atopic dermatitis were similar when evaluated by gender and season. However, Caucasians were almost 50% less likely than African Americans or individuals of other minority races to have visits for AD. Topical corticosteroids (TCS) were mentioned at 52% of visits, and dermatologists were more likely than non-dermatologists to prescribe TCS, emollients, and topical calcineurin inhibitors. CONCLUSIONS: Dermatologists were more likely to recommend TCS, emollients, and topical calciuneurin inhibitors for the treatment of AD. Dermatologists were also more likely to prescribe higher potency TCS in comparison to non-dermatology specialties, and these differences may ultimately affect patient care. As a result, there remains a disparity between dermatologists and non-dermatology specialties with regard to evidence-based approaches to the treatment of AD.

J Drugs Dermatol. 2017;16(3):250-255.

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Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Inibidores de Calcineurina/uso terapêutico , Dermatite Atópica/tratamento farmacológico , Dermatologistas/estatística & dados numéricos , Emolientes/uso terapêutico , Medicina Baseada em Evidências/estatística & dados numéricos , Glucocorticoides/uso terapêutico , Pesquisas sobre Atenção à Saúde/estatística & dados numéricos , Administração Cutânea , Adolescente , Negro ou Afro-Americano/estatística & dados numéricos , Assistência Ambulatorial/normas , Inibidores de Calcineurina/administração & dosagem , Dermatologistas/normas , Emolientes/administração & dosagem , Medicina Baseada em Evidências/normas , Feminino , Glucocorticoides/administração & dosagem , Humanos , Masculino , Visita a Consultório Médico/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estados Unidos , População Branca
20.
J Med Internet Res ; 19(9): e326, 2017 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-28935619

RESUMO

This viewpoint reviews the perspectives for dermatology as a specialty to go beyond the substantial impact of smoking on skin disease and leverage the impact of skin changes on a person's self-concept and behavior in the design of effective interventions for smoking prevention and cessation.


Assuntos
Dermatologistas/normas , Aplicativos Móveis/estatística & dados numéricos , Envelhecimento da Pele/fisiologia , Prevenção do Hábito de Fumar/métodos , Fumar/terapia , Humanos
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