ABSTRACT
Sex chromosome aneuploidies (SCAs), including 47,XXY, 47,XXX, 47,XYY, and supernumerary variants, occur collectively in approximately one of 500 live births. Clinical phenotypes are highly variable resulting in previous ascertainment rates estimated to be only 10%-25% during a lifetime. Historically, prenatal SCA diagnoses were incidental findings, accounting for ≤10% of cases, with the majority of diagnoses occurring postnatally during evaluations for neurodevelopmental, medical, or infertility concerns. The initiation of noninvasive prenatal screening (NIPS) in 2012 and adoption into standardized obstetric care provides a unique opportunity to significantly increase prenatal ascertainment of SCAs. However, the impact NIPS has had on ascertainment of SCAs is understudied, particularly for those who may defer diagnostic testing until after birth. This study evaluates the timing of diagnostic testing following positive NIPS in 152 infants with SCAs and potential factors influencing this decision. Eighty-seven (57%) elected to defer diagnostic testing after a positive NIPS until birth, and 8% (7/87) of those confirmed after birth were found to have discordant results on postnatal diagnostic testing, most of which would have influenced genetic counseling.
Subject(s)
Noninvasive Prenatal Testing , Pregnancy , Female , Humans , Aneuploidy , Prenatal Diagnosis/methods , Sex Chromosome Aberrations , CounselingABSTRACT
BACKGROUND: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions. OBJECTIVE: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials. METHODS: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group. RESULTS: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome. LIMITATIONS: English-speaking patients and professionals rated outcomes extracted from English language studies. CONCLUSION: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.
Subject(s)
Carcinoma, Basal Cell , Skin Neoplasms , Carcinoma, Basal Cell/therapy , Delphi Technique , Humans , Quality of Life , Research Design , Skin Neoplasms/therapy , Treatment OutcomeABSTRACT
BACKGROUND: The temporal branch of the facial nerve is at risk of damage during Mohs micrographic surgery (MMS). This complication leads to motor deficit in the ipsilateral upper face with resultant functional and cosmetic impairment. OBJECTIVE: To identify patient, tumor, and surgical risk factors associated with temporal nerve damage. MATERIALS AND METHODS: A single-institution, retrospective review of MMS cases involving anatomic sites within the temporal nerve danger zone was performed. Risk factors were compared between cases with and without nerve damage. RESULTS: Of 616 cases within the danger zone, 28 (4.5%) had postoperative nerve dysfunction. Variables significantly associated with dysfunction included patient immunosuppression, tumor size, aggressive tumor histology, recurrent tumors, high degree of subclinical spread, and greater average number of Mohs stages. Preoperative tumor size and postoperative defect size of ≥3 cm resulted in a ×37 and ×40 increased odds of nerve damage, respectively. Sex, age, and basal versus squamous cell carcinoma were not significantly associated with temporal nerve damage. No patients with a postoperative defect size measuring <2 cm had nerve damage. CONCLUSION: The overall risk of damage to the temporal nerve during MMS is low, but there are certain risk factors that warrant increased counseling about this potential complication.
Subject(s)
Carcinoma, Basal Cell , Skin Neoplasms , Humans , Mohs Surgery/adverse effects , Mohs Surgery/methods , Carcinoma, Basal Cell/surgery , Carcinoma, Basal Cell/pathology , Facial Nerve , Skin Neoplasms/surgery , Skin Neoplasms/pathology , Neoplasm Recurrence, Local/surgery , Retrospective StudiesABSTRACT
BACKGROUND: Traditional letters of recommendation used for postgraduate medical training applications have multiple limitations, including a lack of clarity, inflated and overly flattering assessments, and low reliability between interpreting faculty. A micrographic surgery and dermatologic oncology (MSDO) standardized letter of recommendation (SLOR) was created to improve the efficiency, validity, and stratification of applicants to dermatology fellowship training programs. OBJECTIVE: To analyze the MSDO SLOR for trends in grading based on letter-writer and applicant characteristics and to evaluate its ability to demonstrate differences between applicants. METHODS: Standardized letter of recommendations received by 4 fellowship programs from the 2019 San Francisco Match application cycle were reviewed retrospectively. RESULTS: Two hundred forty-nine SLORs were analyzed from 140 applicants. Grade inflation and limited variability in scores were evident. Higher scores correlated with the length of the relationships between letter-writers and applicants and with female letter-writer gender. There was no applicant gender or ethnicity bias detected. CONCLUSION: Despite score inflation, the MSDO SLOR allows for differentiation between fellowship applicants. Future studies are needed to further evaluate the reliability of the SLOR and find ways to improve its content.
Subject(s)
Correspondence as Topic , Dermatology/education , Medical Oncology/education , Mohs Surgery/education , Personnel Selection/standards , Clinical Competence , Fellowships and Scholarships , Female , Humans , Internship and Residency , Male , Retrospective StudiesABSTRACT
Sex chromosome trisomies (SCT), including Klinefelter syndrome/XXY, Trisomy X, and XYY syndrome, occur in 1 of every 500 births. The past decades of research have resulted in a broadening of known associated medical comorbidities as well as advances in psychological research. This review summarizes what is known about early neurodevelopmental, behavioral, and medical manifestations in young children with SCT. We focus on recent research and unanswered questions related to the risk for neurodevelopmental disorders that commonly present in the first years of life and discuss the medical and endocrine manifestations of SCT at this young age. The increasing rate of prenatal SCT diagnoses provides the opportunity to address gaps in the existing literature in a new birth cohort, leading to development of the eXtraordinarY Babies Study. This study aims to better describe and compare the natural history of SCT conditions, identify predictors of positive and negative outcomes in SCT, evaluate developmental and autism screening measures commonly used in primary care practices for the SCT population, and build a rich data set linked to a bank of biological samples for future study. Results from this study and ongoing international research efforts will inform evidence-based care and improve health and neurodevelopmental outcomes.
Subject(s)
Klinefelter Syndrome/diagnosis , Prenatal Diagnosis , Sex Chromosome Disorders of Sex Development/diagnosis , Sex Chromosome Disorders/diagnosis , Trisomy/diagnosis , Child , Child, Preschool , Chromosomes, Human, X/genetics , Female , Humans , Klinefelter Syndrome/genetics , Klinefelter Syndrome/physiopathology , Male , Neurodevelopmental Disorders/diagnosis , Neurodevelopmental Disorders/genetics , Neurodevelopmental Disorders/physiopathology , Pregnancy , Prospective Studies , Risk Factors , Sex Chromosome Aberrations , Sex Chromosome Disorders/physiopathology , Sex Chromosome Disorders of Sex Development/genetics , Sex Chromosome Disorders of Sex Development/physiopathology , Sex Chromosomes/genetics , Trisomy/genetics , Trisomy/physiopathology , XYY KaryotypeABSTRACT
BACKGROUND: Although gender disparities for those entering medicine have equalized, the number of women advancing in academia has remained low. Studies have demonstrated that women's representation at academic medical conferences has also remained low across multiple fields. Given that conference presentations and national reputation serve as metrics for academic promotion, women's representation at dermatology conferences may provide insight into women's academic productivity. OBJECTIVE: To examine the gender composition of presenters and speaking time at the 2 main national dermatologic surgery conferences. METHODS: Speaker's gender, presentation time, and topics were collected for 2009 to 2017 for the American College of Mohs Surgery (ACMS) and the American Society for Dermatologic Surgery (ASDS) Annual Meetings. RESULTS: Women had significantly fewer speaking opportunities and speaking minutes at both conferences. This disparity was most pronounced in reconstruction topics and least pronounced in cosmetics topics. The majority of top speakers, repeat speakers, and keynote speakers were men for both conferences. Oral abstracts showed no gender disparity at either conference. CONCLUSION: Women spoke less than men at both the ASDS and ACMS annual meetings over multiple years studied. Recently, this disparity in speaking opportunities has decreased. Further studies are needed to evaluate the speaking opportunities for women at other types of dermatology conferences.
Subject(s)
Congresses as Topic/statistics & numerical data , Sexism/statistics & numerical data , Societies, Medical/statistics & numerical data , Surgery, Plastic/statistics & numerical data , Female , Humans , Male , Sex Factors , Speech , United StatesABSTRACT
Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.
Subject(s)
Delphi Technique , Early Detection of Cancer/methods , Organ Transplantation/adverse effects , Skin Neoplasms/diagnosis , Consensus , Female , Guidelines as Topic , Humans , Male , Risk Assessment , Skin Neoplasms/epidemiology , Transplant Recipients , United StatesABSTRACT
Immune checkpoint modulators are becoming more prevalent in clinical use for the treatment of metastatic melanoma and other malignancies. These drugs, including programmed death 1 (PD-1) inhibitors, have a high incidence of immune adverse events, including cutaneous manifestations. Alopecia is a known side effect with these drugs, but previous reports describe chemotherapy-induced alopecia. We report a case of alopecia areata in a patient on monotherapy with pembrolizumab (PD-1 inhibitor). It is important for the dermatologist to recognize and appropriately treat to decrease morbidity for these patients.
Subject(s)
Alopecia Areata/chemically induced , Antibodies, Monoclonal, Humanized/adverse effects , Antineoplastic Agents, Immunological/adverse effects , Melanoma/drug therapy , Skin Neoplasms/drug therapy , Female , Humans , Middle AgedSubject(s)
Lip/surgery , Mohs Surgery/adverse effects , Surgical Flaps/transplantation , Surgical Wound/surgery , Adult , Carcinoma, Basal Cell/pathology , Carcinoma, Basal Cell/surgery , Esthetics , Humans , Lip/pathology , Lip Neoplasms/pathology , Lip Neoplasms/surgery , Male , Skin Neoplasms/pathology , Skin Neoplasms/surgery , Surgical Wound/etiology , Treatment OutcomeABSTRACT
BACKGROUND: Local anesthetic (LA) allergy is a concern for dermatologic surgeons given the large number of procedures performed yearly with LAs. Many patients also have anxiety about past or potential anesthesia allergy. OBJECTIVE: This article will review the symptoms of IgE-mediated allergic reactions, the prevalence of IgE-mediated LA allergy, discuss common mimics of LA, and propose a practical approach for diagnostic and therapeutic options for LA allergy for the dermatologic surgeon in practice. MATERIALS AND METHODS: A literature search of Pubmed using keywords "lidocaine," "local anesthetic," "hypersensitivity," and "allergy" was performed. RESULTS: Amide anesthetics result in the most reports of true local anesthetic immediate hypersensitivity. CONCLUSION: True IgE-mediated anaphylaxis to local anesthesia is very rare. Dermatologic surgeons should be aware of the symptoms of anesthetic allergy and its mimickers, as well as how to manage allergic reactions in their clinical practice.
Subject(s)
Anesthetics, Local/adverse effects , Dermatologic Surgical Procedures , Drug Hypersensitivity/etiology , Drug Hypersensitivity/diagnosis , Drug Hypersensitivity/drug therapy , Drug Hypersensitivity/immunology , Epinephrine/therapeutic use , Histamine Antagonists/therapeutic use , Humans , Immunoglobulin E/immunology , Sympathomimetics/therapeutic useSubject(s)
Carcinoma, Basal Cell/etiology , Catastrophic Illness , Dermatologic Surgical Procedures/adverse effects , Facial Neoplasms/surgery , Melanoma/surgery , Mohs Surgery/adverse effects , Postoperative Hemorrhage/etiology , Skin Neoplasms/surgery , Aged , Arm , Humans , Male , Middle Aged , Risk AssessmentSubject(s)
Dermatologists/statistics & numerical data , Melanoma/surgery , Mohs Surgery/statistics & numerical data , Skin Neoplasms/surgery , Surgeons/statistics & numerical data , Dermatologists/education , Humans , Internship and Residency , Melanoma/diagnosis , Melanoma/pathology , Mohs Surgery/education , Neoplasm Staging , Practice Patterns, Physicians'/statistics & numerical data , Skin/pathology , Skin Neoplasms/diagnosis , Surgeons/educationABSTRACT
BACKGROUND: The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of "milestones," standard levels of achievement keyed to particular time points, to assess trainee performance during residency. OBJECTIVE: To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. METHODS: An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. RESULTS: Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. CONCLUSION: Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.
Subject(s)
Cosmetic Techniques , Dermatologic Surgical Procedures/education , Education, Medical, Graduate , Fellowships and Scholarships , Organizational Objectives , Accreditation , Humans , Societies, Medical , United StatesABSTRACT
BACKGROUND: Undermining and hemostasis are basic surgical techniques that can have a significant impact on surgical outcomes. OBJECTIVE: To review the mechanisms and techniques of undermining and hemostasis, with an emphasis on the advantages and limitations of each modality. MATERIALS AND METHODS: The PubMed database was searched for articles with the keywords "undermining," "hemostasis," and "electrosurgery." RESULTS: Whether performing blunt, sharp, or electrosurgical techniques, undermining at the appropriate depth and width is necessary for tissue movement during closures. Both excessive and inadequate undermining can compromise surgical healing. Surgical hemostasis techniques include pressure, suture ligation, topical hemostatic agents, and electrosurgery. Dermatologic surgeons should select the appropriate amount and type of hemostasis for each procedure. Particular care should be taken in performing electrosurgery, given the potential for complications. CONCLUSION: Understanding and optimizing hemostasis and undermining will allow dermatologic surgeons to execute complex closures with minimal complications.