Implementation of a dermatoscopy curriculum during residency at Augsburg University Hospital in Germany.

BACKGROUND AND OBJECTIVES: To date, there is no structured program for dermatoscopy training during residency in Germany. Whether and how much dermatoscopy training is acquired is left to the initiative of each resident, although dermatoscopy is one of the core competencies of dermatological training and daily practice. The aim of the study was to establish a structured dermatoscopy curriculum during residency at the University Hospital Augsburg. PATIENTS AND METHODS: An online platform with dermatoscopy modules was created, accessible regardless of time and place. Practical skills were acquired under the personal guidance of a dermatoscopy expert. Participants were tested on their level of knowledge before and after completing the modules. Test scores on management decisions and correct dermatoscopic diagnosis were analyzed. RESULTS: Results of 28 participants showed improvements in management decisions from pre- to posttest (74.0% vs. 89.4%) and in dermatoscopic accuracy (65.0% vs. 85.6%). Pre- vs. posttest differences in test score (7.05/10 vs. 8.94/10 points) and correct diagnosis were significant (p < 0.001). CONCLUSIONS: The dermatoscopy curriculum increases the number of correct management decisions and dermatoscopy diagnoses. This will result in more skin cancers being detected, and fewer benign lesions being excised. The curriculum can be offered to other dermatology training centers and medical professionals.

Clinical course of patients with adrenal incidentalomas and cortisol autonomy: a German retrospective single center cohort study.

Background: Adrenal incidentalomas with cortisol autonomy are associated with increased cardiovascular morbidity and mortality. Specific data on the clinical and biochemical course of affected patients are lacking. Methods: Retrospective study from a tertiary referral centre in Germany. After exclusion of overt hormone excess, malignancy and glucocorticoid medication, patients with adrenal incidentalomas were stratified according to serum cortisol after 1 mg dexamethasone: autonomous cortisol secretion (ACS), >5.0; possible ACS (PACS), 1.9-5.0; non-functioning adenomas (NFA), ≤1.8 µg/dl. Results: A total of 260 patients were enrolled (147 women (56.5%), median follow-up 8.8 (2.0-20.8) years). At initial diagnosis, median age was 59.5 (20-82) years, and median tumour size was 27 (10-116) mm. Bilateral tumours were more prevalent in ACS (30.0%) and PACS (21.9%) than in NFA (8.1%). Over time, 40/124 (32.3%) patients had a shift of their hormonal secretion pattern (NFA to PACS/ACS, n=15/53; PACS to ACS, n=6/47; ACS to PACS, n=11/24; PACS to NFA, n=8/47). However, none of the patients developed overt Cushing's syndrome. Sixty-one patients underwent adrenalectomy (NFA, 17.9%; PACS, 24.0%; ACS, 39.0%). When non-operated patients with NFA were compared to PACS and ACS at last follow-up, arterial hypertension (65.3% vs. 81.9% and 92.0%; p<0.05), diabetes (23.8% vs. 35.6% and 40.0%; p<0.01), and thromboembolic events (PACS: HR 3.43, 95%-CI 0.89-13.29; ACS: HR 5.96, 95%-CI 1.33-26.63; p<0.05) were significantly less frequent, along with a trend towards a higher rate of cardiovascular events in case of cortisol autonomy (PACS: HR 2.23, 95%-CI 0.94-5.32; ACS: HR 2.60, 95%-CI 0.87-7.79; p=0.1). Twenty-five (12.6%) of the non-operated patients died, with higher overall mortality in PACS (HR 2.6, 95%-CI 1.0-4.7; p=0.083) and ACS (HR 4.7, 95%-CI 1.6-13.3; p<0.005) compared to NFA. In operated patients, prevalence of arterial hypertension decreased significantly (77.0% at diagnosis to 61.7% at last follow-up; p<0.05). The prevalence of cardiovascular events and mortality did not differ significantly between operated and non-operated patients, whereas thromboembolic events were significantly less frequent in the surgical treatment group. Conclusion: Our study confirms relevant cardiovascular morbidity in patients with adrenal incidentalomas (especially those with cortisol autonomy). These patients should therefore be monitored carefully, including adequate treatment of typical cardiovascular risk factors. Adrenalectomy was associated with a significantly decreased prevalence of hypertension. However, more than 30% of patients required reclassification according to repeated dexamethasone suppression tests. Thus, cortisol autonomy should ideally be confirmed before making any relevant treatment decision (e.g. adrenalectomy).

Optical coherence tomography-guided Nd:YAG laser treatment and follow-up of basal cell carcinoma.

OBJECTIVES: Basal cell carcinoma (BCC) is the most common skin tumor with an annually increasing incidence. Standard care requires several visits for diagnosis and treatment. Optical coherence tomography (OCT) as a diagnostic tool increases the sensitivity (95%) and specificity (77%) of the diagnosis of BCC. Although laser therapy is not the standard of care, the long-pulsed 1064 nm Nd:YAG laser seems to be a promising option. However, data are scarce. The published papers had a short follow-up (FU) time and used to some extent inferior methods to detect complete tumor clearance. To address this research gap, this study evaluates the efficiency of laser treatment by FU OCT. We pursue a patient-focused approach and combine OCT with Nd:YAG laser treatment in one procedure. MATERIALS AND METHODS: The study was conducted as a prospective, single-center trial that recruited biopsy-confirmed or OCT-proven BCC with a tumor thickness of less than 1.2 mm. Patients underwent two or three repeated sessions with the Nd:YAG laser (5-6 mm spot, fluence of 120-140 J/cm2 , pulse duration of 8-10 milliseconds). Each BCC was assessed at baseline, and 3 and 12 months after laser treatment by clinical image, dermoscopy, and OCT. Incomplete tumor clearance (ITC) was defined as a clearly detectable BCC on the OCT image or a biopsy-confirmed BCC in the treated area. RESULTS: Forty-five patients completed the 12-month FU (46.7% women; median age of 74.0 [52-88] years) with a total number of 78 BCC lesions. At baseline, all patients had their BCC diagnosed by OCT (tumor thickness of 0.6 [0.4; 0.8] mm), 15.4% lesions were additionally diagnosed by histopathology. The most common subtype of BCC was superficial (48.7%), followed by nodular (47.4%) and infiltrative (3.8%). ITC rate after the treatment using Nd:YAG laser was 30.8% (95% CI: 20.8%-42.2%) (24/78) after 3 months and 7.4% (95% CI: 2.1%-17.9%) (4/54) after 12 months. ITC was not associated with histological subtype, tumor thickness, or location. If ITC was detected, the lesion was treated again. Out of 19 lesions with at least one additional laser treatment, 7 lesions (36.8%) suffered from incomplete tumor removal. In 46.7% of the treated lesions, the cosmetic outcome was rated as moderate or severe scarring after 12 months. CONCLUSION: Our results demonstrate that the ITC rate of BCC treated with the Nd:YAG laser is much higher (up to one-third) than reported, although the laser settings were identical to prior studies. This is especially evident at the 3-month FU. In addition, we witnessed a larger number of side effects and a worse cosmetic outcome compared to previous studies.