A systematic review and meta-analysis to inform cancer screening guidelines in idiopathic inflammatory myopathies.

OBJECTIVES: To identify clinical factors associated with cancer risk in the idiopathic inflammatory myopathies (IIMs) and to systematically review the existing evidence related to cancer screening. METHODS: A systematic literature search was carried out on Medline, Embase and Scopus. Cancer risk within the IIM population (i.e. not compared with the general population) was expressed as risk ratios (RR) for binary variables and weighted mean differences (WMD) for continuous variables. Evidence relating to cancer screening practices in the IIMs were synthesized via narrative review. RESULTS: Sixty-nine studies were included in the meta-analysis. DM subtype (RR 2.21), older age (WMD 11.19), male sex (RR 1.53), dysphagia (RR 2.09), cutaneous ulceration (RR 2.73) and anti-transcriptional intermediary factor-1 gamma positivity (RR 4.66) were identified as being associated with significantly increased risk of cancer. PM (RR 0.49) and clinically amyopathic DM (RR 0.44) subtypes, Raynaud's phenomenon (RR 0.61), interstitial lung disease (RR 0.49), very high serum creatine kinase (WMD -1189.96) or lactate dehydrogenase (WMD -336.52) levels, and anti-Jo1 (RR 0.45) or anti-EJ (RR 0.17) positivity were identified as being associated with significantly reduced risk of cancer. Nine studies relating to IIM-specific cancer screening were included. CT scanning of the thorax, abdomen and pelvis appeared to be effective in identifying underlying asymptomatic cancers. CONCLUSION: Cancer risk factors should be evaluated in patients with IIM for risk stratification. Screening evidence is limited but CT scanning could be useful. Prospective studies and consensus guidelines are needed to establish cancer screening strategies in IIM patients.

Wellness, burnout, and the dermatologist: Fundamentals for practice longevity.

Physician wellness is a critical component of any effective health care system, as physicians serve essential roles as diagnosticians, surgeons, and leaders in medical care. Physician burnout, defined as a combination of the presence of emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment, is an increasingly recognized problem in the US health care system, as rates of burnout among physicians are on the rise, now exceeding 50%. To date, few studies have examined the impact of burnout on dermatologists specifically, but existing studies evaluating physicians collectively have shed light on the problem that exists in our specialty. This review focuses on the causes of physician dissatisfaction and burnout and provides an overview on interventions to mitigate them while emphasizing wellness; where applicable, special emphasis is placed on dermatologists.

Computer-Based Video Instruction for Training Medical Students on Skin Biopsies.

BACKGROUND: The development of procedural skills is necessary for medical students. Computer-based video instruction (CBVI) increases knowledge and procedural skills. OBJECTIVE: This pilot study's aim was to investigate the usefulness of CBVI in dermatologic procedure training for medical students and secondarily assess students' overall perception of the field of dermatology. METHODS: Twenty-nine first- and second-year medical students were randomly assigned to the CVBI group or control group, in addition to in-person instructor demonstration of shave and punch biopsies using fresh cadaver tissue. Blinded evaluators graded student performances using a five-point Likert scale immediately after demonstration, and 1 week later to assess knowledge retention. RESULTS: In overall performance, the CBVI group demonstrated higher scores both in shave (3.54 vs 2.59, p = .01) and punch biopsies (3.63 vs 2.88, p = .01) at immediate recall and knowledge retention (3.68 vs 2.67, p = .01; 4.00 vs 2.99, p < .001, respectively). Approximately 33.3% of the students stated that the experience increased their interest in the field of dermatology. CONCLUSION: Incorporation of CBVI into the dermatology curriculum augments medical students' procedural skills. The CBVI group performed significantly better in all 7 grading categories for shave biopsy and in 5 of 7 categories for punch biopsy. Integration of procedural laboratory tests raises students' interest in dermatology.

The 100 top-cited publications in psoriatic arthritis: a bibliometric analysis.

BACKGROUND: Citation analysis is a quantitative, bibliometric method that analyzes the frequency and pattern of citations in any given scientific discipline. Over the last two decades, the study of psoriatic arthritis has undergone substantial progress, which has enhanced our ability to assess and treat the disease, and yet an updated citation analysis that reflects these advances is lacking. OBJECTIVE: To highlight the scientific progress in psoriatic arthritis by identifying and analyzing the 100 top-cited psoriatic arthritis articles from the last 40 years. METHODS: Publications on psoriatic arthritis were identified using the Scopus citation database and Web of Science. No date range limits were applied. Data on the 100 top-cited publications were extracted and analyzed. RESULTS: Of the 100 top-cited publications, the median number of citations per publication was 265.9. Articles originated from 29 different countries. Publication dates ranged from 1973 to 2014. The majority (n = 88) were published after 1994, and the greatest number of highly cited psoriatic arthritis publications were reported between 2001 and 2007 (n = 36). Journals with the highest number of top-cited articles included Arthritis and Rheumatology (formerly Arthritis and Rheumatism) (n = 26), followed by Annals of Rheumatic Diseases (n = 21) and Journal of Rheumatology (n = 11). The top six journals with the most highly cited psoriatic arthritis articles were rheumatology journals, with the exception of the Journal of American Academy of Dermatology, a dermatology-based periodical. General medical journals published only nine of the 100 top citations. Impact factors ranged from 2.133 to 44.002, with a mean impact factor of 9.103. There were five authors with 10 or more highly cited psoriatic arthritis publications and 30 authors with five or more of the top publications. Subgroup analysis of the top 25 articles included nine randomized clinical trials, nine observational studies, five reviews, and two guideline statements. Additional subgroup analysis identified the top five hallmark trials in the field. Key publications provided data on classification criteria, disease prevalence, patterns of clinical and radiographic presentation, disease outcomes, associated cardiovascular disease risk, immunologic features and HLA associations, and efficacy and therapeutic benefit of TNFα inihbitors, interleukin-12/23 antagonists, and sulfasalazine. CONCLUSIONS: The study of psoriatic arthritis is rapidly evolving. This bibliometric analysis delineates the landmark publications in psoriatic arthritis that have defined innovative therapeutic modalities and provided critical reviews, guidelines, and other key studies, which highlight the important progress made in the field.

Inflammatory arthritis and crystal arthropathy: Current concepts of skin and systemic manifestations.

Systemic inflammatory disorders frequently involve the skin, and when cutaneous disease develops, such dermatologic manifestations may represent the initial sign of disease and may also provide valuable prognostic information about the underlying disorder. Familiarity with the various skin manifestations of systemic disease is therefore paramount and increases the likelihood of accurate diagnosis, which may facilitate the implementation of an appropriate treatment strategy. An improvement in quality of life and a reduction in the degree of morbidity may also be a realized benefit of accurate recognition of these skin signs. With this context in mind, this review highlights the salient clinical features and unique dermatologic manifestations of rheumatoid arthritis, adult-onset Still's disease, and the crystal arthropathy, gout.

Psoriatic arthritis and the dermatologist: An approach to screening and clinical evaluation.

Psoriatic arthritis is a common form of inflammatory arthritis that frequently accompanies psoriasis of the skin-up to 30% of patients with psoriasis are affected. Recognition of the clinical features of psoriatic arthritis is critical, as delayed detection and untreated disease may result in irreparable joint injury, impaired physical function, and a significantly reduced quality of life. Recent epidemiologic studies have also supported that psoriatic arthritis is associated with cardiometabolic and cerebrovascular comorbidities, including coronary heart disease, diabetes mellitus, hypertension, dyslipidemia, and cerebrovascular accidents, further highlighting the importance of identifying affected patients. Dermatologists are poised for the early detection of psoriatic arthritis, as psoriasis predates its development in as many as 80% of patients. In an effort to further acquaint dermatologists and other clinicians with psoriatic arthritis, this review provides a detailed overview, emphasizing its salient clinical features, and discusses classification criteria, validated screening tools, and simple musculoskeletal examination maneuvers that may facilitate earlier detection and treatment of the disorder.

Psoriasis and Psoriatic Spectrum Disease: A Primer for the Primary Care Physician.

Psoriasis is a chronic, immune-mediated disorder that affects approximately 7.5 million people in the United States. Individuals with psoriasis may develop cutaneous, articular, and systemic manifestations, which are a source of significant morbidity and a heightened risk of mortality, and may adversely impact patient-reported quality of life measures. Psoriasis is now recognized as a risk factor for cardiovascular disease, metabolic syndrome, peripheral vascular disease, inflammatory bowel disease, certain malignancies, and chronic renal disease. Therefore, it has become increasingly relevant that primary care physicians have a basic working knowledge and an understanding of fundamental management principles of psoriasis. This review highlights the salient clinical features of psoriasis and psoriatic spectrum disease, emphasizing key updates with respect to systemic disease and associated conditions, and briefly outlines a therapeutic algorithm for the primary care physician.

Factors associated with advanced-stage Merkel cell carcinoma at initial diagnosis and the use of radiation therapy: Results from the National Cancer Database.

BACKGROUND: The stage of disease at initial diagnosis and the use of radiation therapy (RT) are important determinants of survival in patients with Merkel cell carcinoma (MCC). OBJECTIVE: To define factors that are associated with advanced-stage MCC at the time of initial diagnosis and the use of RT. METHODS: Cross-sectional, retrospective analysis of patients with MCC registered in the National Cancer Database during the period from 2004 to 2013. RESULTS: A total of 11,917 patients were identified; 3152 and 4586 patients were excluded from the staging and RT analyses, respectively, because of lack of available data. African American ethnicity (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.06-2.10; P = .023), lack of medical insurance (OR, 2.15; 95% CI, 1.40-3.30; P < .001), Charlson-Deyo comorbidity score of at least 1 (OR, 1.21; 95% CI, 1.09-1.34; P < .001), residence more than 26 miles from a treatment facility (OR, 1.18; 95% CI, 1.03-1.35; P = .015), tumor located on the lower limb/hip (OR, 1.59; 95% CI, 1.42-1.78; P < .001) or trunk (OR, 2.05; 95% CI, 1.81-2.33; P < .001), and poorly (OR, 2.57; 95% CI, 1.13-5.82; P = .024) or undifferentiated (OR, 3.11; 95% CI, 1.36-7.15; P = .007) tumor histology predicted advanced-stage MCC at the time of initial diagnosis. The use of RT was associated with Native American ethnicity (OR, 5.04; 95% CI, 1.10-22.99; P = .037), tumor size between 1.5 and 2.7 cm (OR, 1.27; 95% CI, 1.10-1.47; P = .001), electing not to have surgery (OR, 2.77; 95% CI, 1.90-4.03; P < .001), positive postsurgical margins (OR, 1.39; 95% CI, 1.18-1.63; P < .001), and receiving treatment at a comprehensive cancer program (OR, 1.25; 95% CI, 1.03-1.50; P = .020). LIMITATIONS: Retrospective design limits generalizability of the results, and precise details of RT regimens utilized were not available. CONCLUSIONS: A number of factors are associated with advanced-stage MCC at initial diagnosis and the use of RT. Health care models should account for these factors, and efforts should be directed toward improving those that are modifiable.

A systematic review and meta-analysis of the efficacy and safety of the interleukin (IL)-12/23 and IL-17 inhibitors ustekinumab, secukinumab, ixekizumab, brodalumab, guselkumab and tildrakizumab for the treatment of moderate to severe plaque psoriasis.

OBJECTIVE: To systematically analyze the efficacy and safety of interleukin (IL)-12/23, IL-17, and selective IL-23 inhibitors in moderate to severe plaque psoriasis. METHODS AND RESULTS: Twenty-four randomized placebo-controlled trials were included. Compared to placebo, risk ratios (RR) of achieving PASI-75 and PGA/IGA 0/1 respectively were 20.20 (95% CI 13.82-29.54, p < .00001) and 14.55 (10.42-20.31, p < .00001) for ustekinumab 90 mg, 13.75 (8.49-22.28, p < .00001) and 9.81 (5.70-16.89, p < .00001) for ustekinumab 45 mg, 17.65 (12.38-25.17, p < .00001) and 26.13 (16.05-42.53, p < .00001) for secukinumab 300 mg, 15.36 (10.76-21.94, p < .00001) and 20.91 (12.82-34.13, p < .00001) for secukinumab 150 mg, 18.22 (10.63-31.23, p < .000001) and 18.82 (10.36-34.16, p < .00001) for ixekizumab 80 mg every 4 weeks, 19.83 (11.07-35.52, p < .00001) and 20.41 (11.01-37.81, p < .00001) for ixekizumab 80 mg every 2 weeks, 14.79 (9.86-22.16, p < .00001) and 21.93 (15.52-31.01, p < .00001) for brodalumab 210 mg, 11.55 (7.77-17.18, p < .00001) and 16.59 (11.72-23.49, p < .00001) for brodalumab 140 mg, 12.40 (8.87-17.34, p < .00001) and 10.84 (7.91-14.85, p < .00001) for guselkumab 100 mg, 11.45 (7.45-17.58, p < .00001) and 10.97 (6.44-18.69, p < .00001) for tildrakizumab 200 mg, 11.02 (7.17-16.93, p < .00001) and 10.03 (6.45-15.59, p < .00001) for tildrakizumab 100 mg. Similar outcomes were seen for PASI-90. Safety was satisfactory for each therapy at any dose, but a slightly increased risk of withdrawal due to toxicity was observed in individuals receiving ixekizumab compared to placebo. CONCLUSION: Ustekinumab, secukinumab, ixekizumab, brodalumab, guselkumab, and tildrakizumab were highly efficacious and generally well-tolerated when used as treatments for moderate to severe plaque psoriasis.

Anti-melanoma differentiation-associated gene 5 (MDA5) dermatomyositis: A concise review with an emphasis on distinctive clinical features.

Melanoma differentiation-associated gene 5 (MDA5) is a recently described autoantigen target in a subset of patients with dermatomyositis. Anti-MDA5 dermatomyositis is characterized by a unique mucocutaneous and systemic phenotype that includes cutaneous and oral ulceration, painful palmar papules, alopecia, panniculitis, arthritis, a lower incidence of myositis, and, importantly, an elevated risk of interstitial lung disease with a potentially fatal course. Because the clinical features can differ substantially from those typically observed in cutaneous dermatomyositis, the diagnosis is often overlooked, which might negatively affect patient outcomes. This review aims to familiarize the clinician with the distinctive clinical features of anti-MDA5 dermatomyositis in order to enhance its recognition and to facilitate an appropriate screening and management strategy.