Pain quality of life as measured by utilities.

OBJECTIVE: Utilities are values of health-related quality of life (HRQoL) based on patient preference for a health status. The purpose of this study was to compare indirect measures to a directly elicited utility. DESIGN: Cross-sectional study. SETTING AND PATIENTS: Emory Spine Center and the Emory Center for Chronic Pain at Crawford Long Hospital. Patients at least 18 years of age with chronic pain, defined as pain that persists beyond the normal time of healing, usually beyond 6 months. MEASURES: Chronic pain subjects completed a paper-based, self-administered time trade-off (TTO) survey, EQ-5D survey, and a face-to-face (FTF) TTO interview. Current pain severity was graded using the Numeric Rating Scale-11, subsequently stratified into no (0), mild (1-3), moderate (4-6), and severe (7-10) pain. RESULTS: Paired t test comparing FTF TTO and proxy utility measures stratified by severity revealed FTF TTO utility values significantly higher than EQ-5D utility values for all pain severities (overall mean difference 0.18, standard deviation [SD] 0.30, P < 0.001; Pearson's correlation 0.34, P < 0.0001); FTF TTO utility values were lower than paper TTO utility values, reaching statistical significance for mild and moderate pain (overall mean difference 0.09, SD 0.29, P = 0.0006; Pearson's correlation 0.38, P < 0.0001). CONCLUSIONS: This study demonstrates that the EQ-5D overestimates, whereas the paper version of TTO underestimates, the impact of pain on HRQoL compared with the directly elicited FTF TTO utility. Our findings provide preliminary evidence that utilities vary by method, and directly elicited utility values differ from indirectly elicited measures.

Severity of cutaneous findings predict the presence of systemic symptoms in pediatric maculopapular cutaneous mastocytosis.

Although the prognosis of maculopapular cutaneous mastocytosis (MPCM), also referred to as urticaria pigmentosa, is often benign, clinicians lack evidence to reliably predict those at risk of associated systemic manifestations. We sought to elucidate clinical markers of disease severity to provide better treatment and prognostic information for individuals with MPCM. A retrospective chart review querying characteristics of children diagnosed with MPCM in the Emory Dermatology Clinic was performed. Follow-up was obtained through a clinical encounter or telephone interview. Linear regression was used to determine predictors of the number of MPCM-related systemic symptoms. Of 67 subjects, 57% were male, and the mean age of onset was 4.5 months. The maximum number of MPCM lesions was 1 to 10 in 16%, 11 to 30 in 33%, 31 to 50 in 25%, 51 to 100 in 6%, and more than 100 in 20% of subjects. For their MPCM lesions, 46% of subjects reported itching, 34% flushing, and 25% blistering. Reported systemic symptoms included diarrhea (22%), abdominal pain (15%), wheezing or dyspnea (13%), vomiting (10%), bone pain (10%), headaches (8%), cough (10%), rhinorrhea (8%), irritability (6%), and anaphylaxis (1.5%). In a multivariate linear regression analysis, the maximum number of MPCM lesions (p = 0.02) and the number of skin symptoms (p < 0.01) were statistically significant predictors of the number of systemic symptoms, controlling for age of onset, body sites involved, and sex. The correlation between cutaneous findings and symptomatology could aid clinicians in identifying individuals with MPCM who might warrant systemic evaluation and therapy.

Acitretin for the treatment of cutaneous T-cell lymphoma.

BACKGROUND: Bexarotene is the only Food and Drug Administration-approved retinoid for the treatment of cutaneous T-cell lymphoma (CTCL) and is associated with a relatively high frequency of adverse effects. Acitretin has anecdotally been reported to be effective for CTCL. OBJECTIVE: We sought to determine the effectiveness and tolerability of acitretin as primary or adjuvant therapy for CTCL. METHODS: We conducted a retrospective chart review of patients with CTCL treated with acitretin at a single tertiary care center. RESULTS: A total of 32 patients with CTCL were included: 29 had mycosis fungoides, 2 had Sézary syndrome, and 1 had CTCL not otherwise specified. Median patient age was 55 years; 56% were male; 47% were white, 47% black, and 6% other. In all, 3% of patients were stage IA, 69% stage IB/IIA, 16% stage IIB, 6% stage III, and 6% stage IV. Six patients received acitretin alone; 26 received acitretin in addition to another CTCL therapy. The overall response rate was 59%. In all, 25% of patients had stable disease and 16% had progressive disease. Median duration of response was 28 months. Adverse effects were generally mild with 5 patients discontinuing therapy because of these. LIMITATIONS: In this small retrospective chart review, many patients were on other CTCL therapies while on acitretin; therefore precise assessment of response to acitretin alone was difficult. CONCLUSIONS: Acitretin is well tolerated and potentially effective for early-stage CTCL. Response to acitretin, either as adjuvant therapy monotherapy, is comparable with the response to oral agents currently approved for this disease.

Mutant PIK3CA promotes cell growth and invasion of human cancer cells.

PIK3CA is mutated in diverse human cancers, but the functional effects of these mutations have not been defined. To evaluate the consequences of PIK3CA alterations, the two most common mutations were inactivated by gene targeting in colorectal cancer (CRC) cells. Biochemical analyses of these cells showed that mutant PIK3CA selectively regulated the phosphorylation of AKT and the forkhead transcription factors FKHR and FKHRL1. PIK3CA mutations had little effect on growth under standard conditions, but reduced cellular dependence on growth factors. PIK3CA mutations resulted in attenuation of apoptosis and facilitated tumor invasion. Treatment with the PI3K inhibitor LY294002 abrogated PIK3CA signaling and preferentially inhibited growth of PIK3CA mutant cells. These data have important implications for therapy of cancers harboring PIK3CA alterations.

Colorectal cancer: mutations in a signalling pathway.

Protein kinases are enzymes that are important for controlling cellular growth and invasion, and their malfunction is implicated in the development of some tumours. We analysed human colorectal cancers for genetic mutations in 340 serine/threonine kinases and found mutations in eight genes, including in three members of the phosphatidylinositol-3-OH kinase (PI(3)K) pathway. The discovery of this mutational activation of a key cell-signalling pathway may provide new targets for therapeutic intervention.

Effects of total-body digital photography on cancer worry in patients with atypical mole syndrome.

IMPORTANCE: Cancer worry about developing melanoma in at-risk patients may affect one's quality of life and adherence to screening. Little is known about melanoma-related worry in patients with atypical mole syndrome (AMS). OBJECTIVES: To quantify levels and elucidate predictors of worry related to developing melanoma in patients with AMS and to determine whether total-body digital photography (TBDP) in pigmented lesion clinics (PLCs) reduces worry. DESIGN, SETTING, AND PARTICIPANTS: In this pretest-posttest study, patients with AMS from PLCs at 2 academic medical centers were recruited from June 1, 2005, through October 31, 2008, to answer questions about cancer worry before and after undergoing TBDP. Questionnaires used included the new melanoma and recurrent melanoma Revised Impact of Event Scale (RIES), the Melanoma Worry Scale (MWS), the Hospital Anxiety and Depression Scale, and the Life Orientation Test. INTERVENTIONS: All patients underwent TBDP. MAIN OUTCOMES AND MEASURES: Changes in the MWS and new melanoma RIES scores. RESULTS: A total of 138 patients completed baseline questionnaires; 108 patients (78.3%) completed questionnaires after TBDP. Baseline levels of worry were low and reduced further after TBDP. In patients with a personal history of melanoma, worry was reduced on all scales. In patients without a personal history of melanoma, only the new melanoma RIES score was significantly decreased. Predictors of baseline MWS scores include female sex, personal history of melanoma, and higher Hospital Anxiety and Depression Scale scores, adjusted for demographics, family history of melanoma, and Life Orientation Test scores. Adjusted predictors of the baseline new melanoma RIES score were similar but also included lower educational level and did not include sex. CONCLUSIONS AND RELEVANCE: Patients with AMS have low levels of melanoma-related worry, which is similar to data from other populations at high risk of cancers. We found that TBDP is a clinically useful tool that can be used in PLCs to help decrease worry about developing melanoma in at-risk patients.

The value of Ureaplasma urealyticum tracheal culture and treatment in premature infants following an acute respiratory deterioration.

OBJECTIVE: To determine if treatment of Ureaplasma urealyticum (Uu), found at the time of an acute respiratory deterioration, decreases the incidence of chronic lung disease (CLD) in very low birth weight infants (VLBW). STUDY DESIGN: Between 1996 and 1999, medical records of all mechanically ventilated VLBW infants, who had an acute respiratory deterioration, were reviewed for gestational age (GA), birth weight (BW), gender, presence of CLD, Uu tracheal cultures, and erythromycin treatment. RESULTS: A total of 100 patients met our inclusion criteria (GA: 26.2+/-1.7 weeks, BW: 737+/-167.1 g (mean+/-SD)). Uu was present in 46.3% (38/82) of patients with CLD versus 50% (9/18) of patients without CLD (odds ratio 0.86 (CI: 0.31 to 2.39); p=0.77). Erythromycin treatment was not found to be protective against the development of CLD (odds ratio: 1.46 (CI: 0.25 to 8.31); p=0.66). CONCLUSION: Following an acute respiratory deterioration, tracheal isolation, and treatment of Uu may not decrease the incidence of CLD in VLBW infants.

Suicide by fire in a car trunk: a case with potential pitfalls.

We present an unusual case in which an adult female committed suicide by fire while enclosed in the trunk of her vehicle. A finding of suicide was reached only because several key investigative facts were uncovered. Without these discoveries the case may still remain open as a suspicious death. Fire is rarely used as a mechanism of suicide in Western culture, and, as such, similar cases should be reported to advance our recognition of this phenomenon.

Overview of health status quality-of-life measures.

The concept of quality of life (QOL) is becoming increasingly important in medicine, particularly in dermatology where many cutaneous diseases have the potential to affect the quality rather than the length of life. There is increasing interest in devising methodology to accurately measure the impact of disease on QOL for use in clinical practice, research studies, and economic analyses. The question of which dermatologic QOL instruments to choose inevitably arises. The aim of this article is to familiarize readers with health status measures and to review their use in dermatology.

Future directions in dermatology quality of life measures.

Within the last few decades, outcomes research, and in particular quality of life (QoL) outcomes research, has become integrated into clinical and research practices. QoL outcomes are important to dermatology, because many diseases carry significant psychosocial burdens and morbidity from appearance and symptoms with few cases of mortality. In this article, the authors discuss the future directions in QoL. Important areas are the determination, clinical significance and interpretation of measured QoL values. Additionally, the development of proxies for preference-based QoL measures and modules for health status QoL measures are discussed.

Clinical meaning in skin-specific quality of life instruments: a comparison of the Dermatology Life Quality Index and Skindex banding systems.

Clinical meaning can be assigned to scores of health status measures by using a variety of approaches. The anchor-based approach involves determining the difference on a quality of life (QOL) scale that corresponds to a self-reported small but important change on a global scale given concomitantly, which serves as an independent anchor. This article focuses on the anchor-based banding approach and reviews methods to assign clinical meaning to QOL measures, specifically the Dermatology Life Quality Index (DLQI) and Skindex. This article also includes pilot data that compares the DLQI and Skindex using these previously validated banding systems.

Preference-based measures in dermatology: an overview of utilities and willingness to pay.

In this overview of preference-based measures, utilities and willingness to pay (WTP) are discussed as measures relevant to dermatology for capturing the burden of skin diseases. An overview is provided of the concepts of utilities and WTP and their importance in decision making. Specific examples of elicitation methods for capturing utility and WTP measures are provided. Prior studies exploring utilities and WTP in dermatology are reviewed. Each of these measures has limitations and likely varying relevance to specific dermatologic diseases and to specific individuals.

The impact of pruritus on quality of life: the skin equivalent of pain.

OBJECTIVE: To compare the impact of chronic pruritus and chronic pain on quality of life (QoL) using directly elicited health utility scores. DESIGN: Cross-sectional study. SETTING: Convenience sample of patients attending the Emory Dermatology Clinic, Emory Spine Center, and Emory Center for Pain Management, Atlanta, Georgia. PARTICIPANTS: Adult men and women (aged ≥ 18 years) experiencing chronic pain or pruritus for 6 weeks or more. MAIN OUTCOME MEASURES: The mean utility score of patients with chronic pruritus was compared with that of patients with chronic pain. A regression analysis was performed to determine the impact of the primary predictor variable-symptom type-on the primary outcome variable-mean utility score (a metric representing the impact on QoL). RESULTS: The study included 73 patients with chronic pruritus and 138 patients with chronic pain. The mean (SD) utility among patients with pruritus was 0.87 (0.27) compared with 0.77 (0.31) for patients with pain (P < .01). After symptom severity, duration, and demographic factors were controlled for, only symptom severity (0.03 [P < .05]) and single marital status (-0.12 [P = .02]), but not symptom type (P = .43), remained significant predictors of the mean symptom utility score. CONCLUSIONS: Chronic pruritus has a substantial impact on QoL, one that may be comparable to that of pain. The severity of symptoms and the use of support networks are the main factors that determine the degree to which patients are affected by their symptoms. Addressing support networks in addition to developing new therapies may improve the QoL of itchy patients.

Utilization and rationale for the implementation of total body (digital) photography as an adjunct screening measure for melanoma.

The primary objective of our study was to update the prevalence of total body photography (TBP) utilization and the rationale for its implementation as an adjunctive screening measure by academic dermatologists across the USA, and investigate the emergence of total body digital photography (TBDP). Our secondary objective was to further examine how TBP/TBDP is being incorporated into the dermatology screening examination in academic pigmented lesion clinics. A questionnaire was mailed to 113 dermatology departments across the USA. About 43% (49/113) of surveyed departments responded. TBP was used by 67% (33/49) of the respondents. Of these respondents, 33% (11/33) used TBDP alone, 33% (11/33) used TBDP in combination with nondigitally based TBP, and 33% (11/33) used nondigital TBP with print photos. The three most frequently cited reasons for the use of full-body baseline photographs were that they reduced patient anxiety, led to fewer biopsies, and helped to find melanoma early in the curable stage. Respondents who did not use full body baseline photographs cited logistical constraints as the number one reason, followed by perceived lack of utility. In conclusion, our study shows that there is a significant number of academic dermatologists using TBP/TBDP. However, this study also shows that there are conflicting beliefs among academic dermatologists concerning the efficacy of TBP/TBDP. At this point with a documented growing trend in utilization of TBP, more studies are needed to evaluate the efficacy of this screening adjunct to diagnose melanoma early and positively impact survival because of early diagnosis.

Vitamin D levels, dietary intake, and photoprotective behaviors among patients with skin cancer.

Photoprotection against ultraviolet light is an important part of our armamentarium against actinically derived skin cancers. However, there has been concern that adherence to photoprotection may lead to low vitamin D status, leading to negative effects on patients' health. In this work we discuss previous findings in this area, which do not give a clear picture as to the relationship between vitamin D levels and photoprotection measures, as well as research performed by the authors, who did not detect a relationship between serum 25(OH)D levels and adherence to photoprotection measures in subjects with skin cancer, as assessed by the use of sunscreen, clothing, hats, sunglasses, and umbrellas/shade through the Sun Protection Habits Index. Subjects who took vitamin D oral supplementation had greater serum 25(OH)D levels than those who did not, whereas dietary intake through foods did not predict 25(OH)D levels in the authors' study. However, there was a high prevalence of vitamin D insufficiency and deficiency in the authors' study population, highlighting the importance of assessing vitamin D status and recommending oral vitamin D supplementation when indicated.

Randomized comparison of virtual microscopy and traditional glass microscopy in diagnostic accuracy among dermatology and pathology residents.

Virtual microscopy is being used in medical schools to teach histology and pathology. It is also being used in resident education, in-training examinations (dermatology), and certification examinations (pathology). There are, however, few studies comparing its diagnostic accuracy and acceptability compared with traditional glass slides. This study sought to compare residents' abilities in diagnosing dermatopathology disorders in 2 image formats (traditional microscopic slides and whole mount digitized images) and to assess their perceptions of virtual microscopy in dermatopathology. Residents in dermatology and pathology training programs at 14 institutions were given a randomized combination of 20 virtual and glass slides and were asked to identify the diagnoses from multiple foils. They were then asked to give their impressions about the virtual images. Descriptive data analysis and comparison of groups using Pearson chi(2) and Fisher exact tests for categorical variables and Student t test for continuous variables were performed. Residents in dermatology and pathology performed similarly in diagnosing dermatopathology disorders using virtual slides or glass slides (mean [SD] correct for virtual versus glass, 5.48 (1.72) versus 5.57 (2.06); P = .70). The order of administration of virtual versus glass slides did not affect the percentage of questions answered correctly. Most residents supported the use of virtual microscopy as a learning aid, whereas fewer favored its use in testing (79% versus 44%, respectively). Residents performed similarly in making dermatologic diagnoses using virtual slides compared with glass slides despite the residents' preference for the latter.

Annual direct and indirect health care costs of chronic idiopathic urticaria: a cost analysis of 50 nonimmunosuppressed patients.

OBJECTIVE: To estimate annual direct and indirect health care costs in patients with chronic idiopathic urticaria (CIU) managed with conventional therapies. DESIGN: A cost analysis consisting of a survey-guided and retrospective medical record review of direct and indirect health care costs from a societal perspective in patients with CIU. SETTING: The Johns Hopkins University allergy and dermatology ambulatory clinics. PARTICIPANTS: Fifty adults with active CIU were recruited in sequential order. Individuals who were taking corticosteroids or other immunosuppressants in the month before enrollment were excluded from the study. MAIN OUTCOME MEASURES: We estimated direct health care costs, which included laboratory, medication, outpatient visit, and emergency department and hospital visit costs. We also estimated indirect costs, which included earnings lost owing to travel to outpatient visits and absences from work owing to CIU-related illness. RESULTS: Patients with CIU consumed a mean (SD) of $2047 ($1483) annually. Because CIU is primarily an outpatient disease, medication costs alone accounted for 62.5% ($1280) of the total annual cost. Indirect costs accounted for 15.7% ($322) of the total costs. CONCLUSIONS: High medication costs, followed by total indirect costs, result in the largest economic burden among patients with CIU. High medication costs may place low-income patients at risk for suboptimal treatment and increased burden due to poorly controlled disease. Our estimated total health care costs for CIU are comparable to those of other skin diseases such as vitiligo and bullous disease.