Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care.

BACKGROUND: Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy. METHODS: A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither. RESULTS: Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features. CONCLUSIONS: This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection.

Diabetes update: screening and diagnosis.

Busy primary care physicians who want their patients with type 2 diabetes to live longer and better should, as much as possible, base screening and management decisions on patient-oriented evidence that affects morbidity and mortality. Because patients with dual diagnoses of diabetes and hypertension have a high risk of cardiovascular mortality, asymptomatic patients with hypertension should be screened for type 2 diabetes. Screening is conducted using a fasting plasma glucose test, a random A1c test, or a 2-hour oral glucose tolerance test. For obese patients, efforts to prevent diabetes focus on weight reduction and moderate physical activity. In high-risk patients, use of metformin could delay diabetes onset. Diabetes is diagnosed on the basis of an abnormal A1c level, fasting plasma glucose level, or 2-hour oral glucose tolerance test or a symptomatic random plasma glucose level. After diabetes is diagnosed, the physician should obtain blood pressure, body mass index, a lipid panel (fasting not required), kidney function tests, and A1c test, and review vaccination and smoking status. Increased exercise and dietary modification should be recommended. For most patients with newly diagnosed diabetes, metformin should be initiated. Risk factors for cardiovascular disease should be evaluated; use of daily low-dose aspirin may be considered. Patients who meet treatment criteria for high cholesterol levels should take a statin, and patients with unacceptably elevated blood pressure should take an antihypertensive drug.

Diabetes update: long-term treatment of adults.

Current evidence supports a less interventional, less aggressive, and more patient-oriented approach to the care of patients with diabetes than is commonly followed. When treating an adult patient with type 2 diabetes, the physician must focus on the following (in order of importance): smoking cessation and other lifestyle interventions, blood pressure control, metformin use, lipid control, and glycemic control. Patients also should receive influenza and pneumococcal vaccinations. Management goals should be individualized, but general target values are blood pressure of 140/80 mm Hg, low-density lipoprotein less than 100 mg/dL (or 70 mg/dL in a patient with diabetes and coronary artery disease, according to consensus opinion), and A1c less than 8%. Hypertension control is important; a thiazide or angiotensin-converting enzyme inhibitor might be the best first-line treatment. Metformin is the foundation of treatment for most patients with type 2 diabetes; in patients who are overweight, use of metformin delays premature mortality regardless of achieved glucose levels. Statin drugs are superior to other drugs for cholesterol reduction. The use of combination or high-intensity drugs does not appear to confer additional benefit.