Time to reconsider the role of sentinel lymph node biopsy in melanoma.

The Multicenter Selective Lymphadenectomy Trials indicate that there are no overall or melanoma-specific survival advantages to performing sentinel lymph node biopsy (SLNB) followed by immediate completion lymph node dissection compared with wide excision and observation for patients with positive sentinel nodes. These results make SLNB solely a staging procedure. The role of SLNB in the management of patients with melanoma deserves reappraisal. The potential marginal benefit of SLNB beyond the clinical and pathologic features of the melanoma has not been well studied. The use of sentinel lymph node status alone to accept and stratify patients into trials or to receive adjuvant treatment is not rational.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

The role of case reports in evidence-based practice, with suggestions for improving their reporting.

BACKGROUND: Case reports are part of the evidence hierarchy in evidence-based practice and guide an important part of dermatologic practice. OBJECTIVE: This article discusses the role of case reports and series in evidence-based practice and suggests how to improve reporting. METHODS: This article was inspired by a forum on the role of case reporting in dermatologic practice presented at a meeting of the American Academy of Dermatology. It is based on an informal literature review and the authors' experience in systematically reviewing case reports in medicine and dermatology. RESULTS: Case reports significantly influence medicine. Often they are the first line of evidence for new therapies but rarely are sufficient to establish treatment efficacy. Frequently they are the first and sometimes major source for detecting rare adverse events. Guidelines for improving the reporting of case reports and series are discussed. LIMITATIONS: This paper represents the views of the authors and is neither a systematic review of the literature nor a formal consensus document. CONCLUSION: Case reports are an important part of medical literature and need to be taken seriously.

Case reports and case series from Lancet had significant impact on medical literature.

BACKGROUND AND OBJECTIVES: Case reports and case series are often the first evidence of innovative treatment, but clinical trials need to follow to substantiate this evidence. The objective of this article was to evaluate case reports or case series describing innovative treatment concerning their impact. METHODS: Case reports and case series (n < or = 10) from a high-impact journal, The Lancet, published from 1 January 1996 to 30 June 1997, were evaluated according to predefined criteria. To assess publication impact, Pubmed, Science Citation Index, the Register of Current Controlled Clinical Trials, and the Cochrance Controlled Clinical Trials Register were searched. RESULTS: Sixty-four case reports and 39 case series were identified. They were cited in average 17 times (median 6,5; range 0-336). Twenty-Four follow-up trials were identified, nine in the register of current controlled clinical trials. CONCLUSION: Case reports and case series can be well received, and have significant influence on subsequent literature and possibly on clinical practice. Many were followed by clinical trials. Often, though, they report rare conditions for which trials may not be feasible, and more or less explicitly transfer established treatment into other conditions. Overall, there is a strong publication bias favoring positive results, and opportunity should be created for publication of follow-up reports.

Measuring atopic eczema severity visually: which variables are most important to patients?

BACKGROUND: There is wide variation in the objective visual variables used to measure atopic eczema severity in clinical trials, making comparison and interpretation of results difficult. OBJECTIVE: To provide a rationale for simplifying and standardizing objective atopic eczema scoring by investigating which visual variables provide the best measure of disease severity from the patient's perspective. SETTING: The dermatology outpatient department at the Queen's Medical Centre, University Hospital in Nottingham, and 5 local general practices. PATIENTS: One hundred eighty individuals with atopic eczema. INTERVENTIONS: Clinical examination with scoring of 7 clinical signs and disease extent, followed by regression analyses of visual variable scores against a patient-rated measure of current disease severity. RESULTS: Objective measurements account for only a quarter of the variation in patient-rated disease severity. Three clinical signs were independent predictors of patient-rated disease severity: excoriations, erythema, and edema/papulation. Disease extent measurements do not reflect patient-rated disease severity in a linear manner, with mean severity scores increasing little above 30% body surface area involvement. CONCLUSIONS: From the patient's perspective, the measurement of 3 clinical signs-excoriations, erythema, and edema/papulation-provides as much information about current atopic eczema severity as more complex scoring systems that measure multiple clinical signs and disease extent. The simplicity of the Three Item Severity score, a previously published atopic eczema score based on measurement of these 3 clinical signs, makes it a suitable tool for research studies or clinical practice.

Understanding and Evaluating Systematic Reviews and Meta-analyses.

A systematic review is a summary of existing evidence that answers a specific clinical question, contains a thorough, unbiased search of the relevant literature, explicit criteria for assessing studies and structured presentation of the results. A systematic review that incorporates quantitative pooling of similar studies to produce an overall summary of treatment effects is a meta-analysis. A systematic review should have clear, focused clinical objectives containing four elements expressed through the acronym PICO (Patient, group of patients, or problem, an Intervention, a Comparison intervention and specific Outcomes). Explicit and thorough search of the literature is a pre-requisite of any good systematic review. Reviews should have pre-defined explicit criteria for what studies would be included and the analysis should include only those studies that fit the inclusion criteria. The quality (risk of bias) of the primary studies should be critically appraised. Particularly the role of publication and language bias should be acknowledged and addressed by the review, whenever possible. Structured reporting of the results with quantitative pooling of the data must be attempted, whenever appropriate. The review should include interpretation of the data, including implications for clinical practice and further research. Overall, the current quality of reporting of systematic reviews remains highly variable.