Introducing a curriculum in ethics and professionalism for dermatology residencies.

There is general agreement on what constitutes ethical reasoning and professional behavior, but standardized methods to teach these skills in dermatology residency are currently unavailable. We introduce a model curriculum designed to impart the knowledge and skills to meet the Accreditation Council for Graduate Medical Education Dermatology Milestones for Professionalism over a 3-year cycle.

Merkel cell carcinoma, version 1.2014.

Merkel cell carcinoma is a rare, aggressive cutaneous tumor that combines the local recurrence rates of infiltrative nonmelanoma skin cancer with the regional and distant metastatic rates of thick melanoma. The NCCN Guidelines for Merkel Cell Carcinoma provide recommendations on the diagnosis and management of this aggressive disease based on clinical evidence and expert consensus. This version includes revisions regarding the use of PET/CT imaging and the addition of a new section on the principles of pathology to provide guidance on the analysis, interpretation, and reporting of pathology results.

Dermatofibrosarcoma protuberans, version 1.2014.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor characterized by a relatively high risk of local recurrence and low risk of metastasis. The NCCN Guidelines for DFSP provide multidisciplinary recommendations on the management of patients with this rare disease. These NCCN Guidelines Insights highlight the addition of the Principles of Pathology section, which provides recommendations on the pathologic assessment of DFSP. Because DFSP can mimic other lesions, immunohistochemical studies are often required to establish diagnosis. Cytogenetic testing for the characteristic translocation t(17;22)(q22;q13) can also be valuable in the differential diagnosis of DFSP with other histologically similar tumors.

Absolute lymphocyte count: a potential prognostic factor for Merkel cell carcinoma.

BACKGROUND: Absolute lymphocyte count (ALC) is a laboratory value commonly obtained during workup of patients with Merkel cell carcinoma (MCC). OBJECTIVE: We report the prognostic impact of ALC as a surrogate of immune status in MCC. METHODS: A complete blood cell count was available for 64 patients with MCC in the month before definitive surgery, chemotherapy, or radiation. Statistical analysis was performed with classification and regression tree analysis, log rank test, and Cox model. RESULTS: Median overall survival (OS) for the cohort was 97 months. Median OS for patients with an ALC less than 1.1 k/mm(3) was 18.8 versus 110.1 months for those with ALC greater than or equal to 1.1 k/mm(3) (P = .002, hazard ratio 0.29). Multivariate analysis of OS controlling for ALC, sex, stage, adjuvant chemotherapy, hematologic malignancy, and immunosuppression demonstrated ALC as a prognostic factor (P = .03). Disease-free survival at 36 months for ALC less than 1.1 k/mm(3) was 26.9% versus 64.4% for those with ALC greater than or equal to 1.1 k/mm(3) (P = .01). ALC was not a significant predictor for disease-free survival on multivariate analysis (P = .12). LIMITATIONS: This is a single-institution retrospective data set. CONCLUSION: ALC is associated with OS but not disease-free survival in MCC using a threshold of less than 1.1 k/mm(3). This test may provide additional prognostic information for patients with MCC.

Primary cutaneous adenoid cystic carcinoma.

Primary cutaneous adenoid cystic carcinoma is a rare, slow-growing malignancy first described by Boggio in 1975. This tumor characteristically consists of basophilic cells with a distinct adenoid or cribriform pattern in the mid to deep reticular dermis. Modified myoepithelial cells with prominent basement membrane material often surround true lumina. Definitive diagnosis relies on the characteristic histologic features and the exclusion of metastatic disease. We describe two patients who presented with painful papules of the scalp and were successfully treated with wide local excision.

Characteristics of Mohs practices in the United States: a recall survey of ACMS surgeons.

OBJECTIVE: The purpose of this study is to better characterize the typical Mohs practice in the United States and to generate data that may be useful in future practice models. METHODS: A survey was mailed in 2004 to all 599 members of the American College of Mohs Surgery with United States addresses listed in the 2003 directory. RESULTS: Most respondents were part of a single speciality group, in a suburban or urban setting, performed between 501-1,000 cases per year, and had been in practice from 0-5 years. The vast majority of Mohs excisions are for basal cell cancers and squamous cell cancers, followed by melanoma. Primary closure is the most common method of repair, followed by the use of flaps. Only 6% of cases were referred to other specialties for closure. Many surgeons augment their practice with non-Mohs cosmetic procedures. CONCLUSION: The characteristics of current Mohs surgery practices in the United States provides useful data for training programs, potential trainees, workforce issues, statistical modeling systems, and Mohs surgeons in the evaluation of their own practices.

Surgery and Adjuvant Radiation for High-risk Skin Adnexal Carcinoma of the Head and Neck.

OBJECTIVES: Skin adnexal carcinoma (SAC) is a rare cutaneous malignancy that arises from sebaceous and sweat glands. These carcinomas are believed to behave more aggressively than cutaneous squamous cell carcinomas (SCC) with a propensity for local recurrence. The role of adjuvant radiotherapy in SAC is undefined. METHODS: We retrospectively reviewed all cases of head and neck SAC treated with surgery and adjuvant radiation from 2000 to 2012 at a single institution. RESULTS: Nine cases were identified. Median age was 67 (range, 52 to 88) years. The histologies were: adnexal carcinoma (n=1), adnexal carcinoma with sebaceous differentiation (n=1), adnexal carcinoma with squamous differentiation (n=1), skin appendage carcinoma (n=1), sclerosing sweat duct carcinoma (n=1), mucinous carcinoma (n=1), ductal eccrine adenocarcinoma (n=1), porocarcinoma (n=1), and trichilemmal carcinoma (n=1). All tumors were reviewed by a dermatopathologist to confirm the SAC diagnosis.All patients had undergone surgery. Indications for adjuvant radiation included involved lymph nodes (n=4), perineural invasion (n=2), nodal extracapsular extension (n=2), positive margin (n=1), high-grade histology (n=6), multifocal disease (n=2), and/or recurrent disease (n=5). Radiation was delivered to the primary site alone (n=3), to the draining lymphatics alone (n=2), or to both (n=4). One patient received concurrent cisplatin. Median dose to the primary site was 60 Gy and to the neck was 50 Gy.Median follow-up was 4.0 years (range, 0.6 to 11.4 y). Locoregional control was 100%. Five-year progression-free survival was 89%. There was 1 acute grade 3 toxicity and no greater than or equal to grade 2 late toxicities were recorded. CONCLUSIONS: Surgery and adjuvant radiation for high-risk SAC offers excellent locoregional control with acceptable toxicity.

Physician Payments from Industry Are Associated with Greater Medicare Part D Prescribing Costs.

BACKGROUND: The U.S. Physician Payments Sunshine Act mandates the reporting of payments or items of value received by physicians from drug, medical device, and biological agent manufacturers. The impact of these payments on physician prescribing has not been examined at large scale. METHODS: We linked public Medicare Part D prescribing data and Sunshine Act data for 2013. Physician payments were examined descriptively within specialties, and then for association with prescribing costs and patterns using regression models. Models were adjusted for potential physician-level confounding features, including sex, geographic region, and practice size. RESULTS: Among 725,169 individuals with Medicare prescribing data, 341,644 had documented payments in the OPP data (47.1%). Among all physicians receiving funds, mean payment was $1750 (SD $28336); median was $138 (IQR $48-$394). Across the 12 specialties examined, a dose-response relationship was observed in which greater payments were associated with greater prescribing costs per patient. In adjusted regression models, being in the top quintile of payment receipt was associated with incremental prescribing cost per patient ranging from $27 (general surgery) to $2931 (neurology). Similar associations were observed with proportion of branded prescriptions written. CONCLUSIONS: While distribution and amount of payments differed widely across medical specialties, for each of the 12 specialties examined the receipt of payments was associated with greater prescribing costs per patient, and greater proportion of branded medication prescribing. We cannot infer a causal relationship, but interventions aimed at those physicians receiving the most payments may present an opportunity to address prescribing costs in the US.

Industry sponsorship and financial conflict of interest in the reporting of clinical trials in psychiatry.

OBJECTIVE: Financial conflict of interest has been reported to be prevalent in clinical trials in general medicine and associated with a greater likelihood of reporting results favorable to the intervention being studied. The extent and implications of industry sponsorship and financial conflict of interest in psychiatric clinical trials have not been investigated, to the authors' knowledge. METHOD: The authors examined funding source and author financial conflict of interest in all clinical trials published in the American Journal of Psychiatry, the Archives of General Psychiatry, the Journal of Clinical Psychopharmacology, and the Journal of Clinical Psychiatry between 2001 and 2003. RESULTS: Among 397 clinical trials identified, 239 (60%) reported receiving funding from a pharmaceutical company or other interested party, and 187 studies (47%) included at least one author with a reported financial conflict of interest. Among the 162 randomized, double-blind, placebo-controlled studies examined, those that reported conflict of interest were 4.9 times more likely to report positive results; this association was significant only among the subset of pharmaceutical industry-funded studies. CONCLUSIONS: Author conflict of interest appears to be prevalent among psychiatric clinical trials and to be associated with a greater likelihood of reporting a drug to be superior to placebo.

Extent and impact of industry sponsorship conflicts of interest in dermatology research.

BACKGROUND: Many published clinical trials are authored by investigators with financial conflicts of interest. The general medical literature documents the pervasive extent and sometimes problematic impact of these conflicts. Accordingly, there is renewed discussion about author disclosure and clinical trial registry to minimize publication bias from financial conflicts of interest. Despite this evolving discussion in the general medical literature, little is known about the extent or role of financial conflicts of interest in dermatology research. OBJECTIVE: Our purpose was to determine the extent and impact of industry sponsorship conflicts of interest in dermatology research. METHODS: We recorded potential financial conflicts of interest, study design, and study outcome in 179 clinical trials published between Oct 1, 2000 and Oct 1, 2003 in four leading dermatology journals. RESULTS: Forty-three percent of analyzed studies included at least one author with a reported conflict of interest. These studies were more likely to report a positive result, demonstrate higher methodological quality, and include a larger sample size. CONCLUSIONS: Conflict of interest in clinical investigations in dermatology appears to be prevalent and associated with potentially significant differences in study methodology and reporting.

Multicolor microRNA FISH effectively differentiates tumor types.

MicroRNAs (miRNAs) are excellent tumor biomarkers because of their cell-type specificity and abundance. However, many miRNA detection methods, such as real-time PCR, obliterate valuable visuospatial information in tissue samples. To enable miRNA visualization in formalin-fixed paraffin-embedded (FFPE) tissues, we developed multicolor miRNA FISH. As a proof of concept, we used this method to differentiate two skin tumors, basal cell carcinoma (BCC) and Merkel cell carcinoma (MCC), with overlapping histologic features but distinct cellular origins. Using sequencing-based miRNA profiling and discriminant analysis, we identified the tumor-specific miRNAs miR-205 and miR-375 in BCC and MCC, respectively. We addressed three major shortcomings in miRNA FISH, identifying optimal conditions for miRNA fixation and ribosomal RNA (rRNA) retention using model compounds and high-pressure liquid chromatography (HPLC) analyses, enhancing signal amplification and detection by increasing probe-hapten linker lengths, and improving probe specificity using shortened probes with minimal rRNA sequence complementarity. We validated our method on 4 BCC and 12 MCC tumors. Amplified miR-205 and miR-375 signals were normalized against directly detectable reference rRNA signals. Tumors were classified using predefined cutoff values, and all were correctly identified in blinded analysis. Our study establishes a reliable miRNA FISH technique for parallel visualization of differentially expressed miRNAs in FFPE tumor tissues.

Psychosocial correlates of sunburn among young adult women.

Skin cancer is an increasingly common disease, particularly among young adult women. Sunburn early in life is a risk factor for skin cancer. Few studies have reported on psychosocial correlates of sunburn. The current study consisted of an online survey of undergraduate women from a university in the northeastern part of the USA. A logistic regression demonstrated that young women who reported a history of four or more sunburns were significantly more likely to report fair skin, higher perceived susceptibility to skin cancer, greater perceived benefits of tanning (e.g., appearance enhancement), lower perceived control over skin protection, and more frequent sunscreen use. Sunbathing was not associated with a greater number of sunburns. These results suggest that young women who sunburn more often possess other skin cancer risk factors, are aware of their susceptibility to skin cancer, and try to use sunscreen, but feel limited control over their skin protection behavior and are not less likely to sunbathe than others. Therefore, interventions are needed to assist high risk young women in asserting more control over their sun protection behavior and perhaps improve the effectiveness of the sunscreen or other skin protection methods they do employ.

NCCN Task Force Report: Management of dermatologic and other toxicities associated with EGFR inhibition in patients with cancer.

This NCCN Task Force Report describes the management of dermatologic and ocular toxicities that occur in patients treated with epidermal growth factor receptor (EGFR) inhibitors. Task force members are from NCCN member institutions and include oncologists, dermatologists, an ophthalmologist, and a mid-level oncology provider. This report describes commonly used therapies that the task force agreed are appropriate standards of care for dermatologic and ophthalmologic toxicities associated with EGFR inhibitors, which generally are supported only by anecdotal evidence. Few recommendations are evidence based; however, some commonly used therapies have data supporting their use. Conclusions from completed clinical trials are generally limited by the small numbers of patients enrolled. The information in this report is based on available published data on treating toxicities associated with EGFR inhibitors, data from treatment of clinically similar toxicities from different etiologies, and expert opinion among the NCCN Task Force members.

Incidence of and risk factors for medical malpractice lawsuits among Mohs surgeons.

BACKGROUND: Despite rising medical malpractice costs, little is known about the factors associated with claims filed against Mohs surgeons. OBJECTIVE: We sought to define the scope of medical malpractice claims filed against Mohs surgeons and to identify salient factors associated with the filing and disposition of those claims. METHODS: A comprehensive survey was mailed to 599 physicians with US addresses listed in the 2003 directory of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. RESULTS: Of the 300 completed surveys returned, 33 (11%) reported ever having been sued. Physicians who practiced Mohs surgery for a longer period of time were more likely to have been sued for malpractice. Physicians reported the wrong site and functional outcome as the most frequent causes of malpractice lawsuits.

Gentamicin ointment versus petrolatum for management of auricular wounds.

BACKGROUND: Surgeons frequently create defects on the ear in the treatment of cutaneous malignancies. Potentially significant complications of second-intention healing on the ear are suppurative and inflammatory chondritis. Consequently, many physicians advocate the use of oral or topical prophylactic antibiotics after auricular surgery. OBJECTIVE: The purpose of this study is to compare the efficacy of gentamicin ointment with that of petrolatum for the prevention of suppurative chondritis during second-intention healing of auricular wounds after Mohs surgery. METHODS: One hundred forty-two patients with a total of 147 second-intention wounds were prospectively selected to receive either gentamicin ointment or petrolatum postoperatively. RESULTS: One hundred forty-four wounds were evaluated in a follow-up examination or by telephone interview. Eight (5.56%) wounds developed suppurative chondritis. Four wounds received gentamicin and four received petrolatum, for incidences of 4.76% and 6.67%, respectively. Twelve (8.33%) other wounds developed inflammatory chondritis. Ten (11.90%) received gentamicin and two (3.33%) received petrolatum. CONCLUSIONS: There is no statistically significant difference between the use of gentamicin ointment and petrolatum in the prevention of postoperative auricular suppurative chondritis. The data also demonstrate a disproportionate number of cases of inflammatory chondritis in the gentamicin-treated group. This study supports the cost-effective and potentially less irritating use of petrolatum for wound care in this difficult to manage area.