Limiting Residency Applications to Dermatology Benefits Nearly Everyone.

With a 34-percent increase in dermatology residency applications in the past decade, residency programs are increasingly faced with the daunting task of reviewing more applications for a relatively fixed number of residency positions. Other specialty programs, including otolaryngology, orthopedics, plastic surgery, and ophthalmology, have called for limiting the number of residency applications. Dermatology programs have developed various ways to decrease the number of reviewed applications, from cutoffs for Step 1 board scores to Alpha Omega Alpha membership to secondary applications. While this can decrease the applicant pool, it limits a more holistic review of applications. We propose an application cap of 20 programs, which will decrease the number of applications each program receives 3- to 5-fold. Each applicant can approach the process more thoughtfully in choosing the best programs for them and will save money in application fees. As program directors rank "perceived interest" in their residency program as a primary factor for selecting applicants, a cap will allow program directors to know that all applicants are interested in their specific program. Ultimately, we contend that application caps would improve match outcomes with applicants receiving training in the best program for them, increasing the likelihood of successful fit for clinical training, opening the field to a more diverse set of applicants, and saving everyone time and money.

AKT1E17K Activates Focal Adhesion Kinase and Promotes Melanoma Brain Metastasis.

Alterations in the PI3K/AKT pathway occur in up to 70% of melanomas and are associated with disease progression. The three AKT paralogs are highly conserved but data suggest they have distinct functions. Activating mutations of AKT1 and AKT3 occur in human melanoma but their role in melanoma formation and metastasis remains unclear. Using an established melanoma mouse model, we evaluated E17K, E40K, and Q79K mutations in AKT1, AKT2, and AKT3 and show that mice harboring tumors expressing AKT1E17K had the highest incidence of brain metastasis and lowest mean survival. Tumors expressing AKT1E17K displayed elevated levels of focal adhesion factors and enhanced phosphorylation of focal adhesion kinase (FAK). AKT1E17K expression in melanoma cells increased invasion and this was reduced by pharmacologic inhibition of either AKT or FAK. These data suggest that the different AKT paralogs have distinct roles in melanoma brain metastasis and that AKT and FAK may be promising therapeutic targets. IMPLICATIONS: This study suggests that AKT1E17K promotes melanoma brain metastasis through activation of FAK and provides a rationale for the therapeutic targeting of AKT and/or FAK to reduce melanoma metastasis.

Opioid Prescribing Patterns After Micrographic Surgery: A Follow-up Retrospective Chart Review.

BACKGROUND: The abuse of opioids has reached epidemic proportions in the United States, and leftover medications are a primary source for nonmedical pain relievers. A past study at the University of Utah showed that micrographic surgeons were likely overprescribing opioids, with 35% of patients receiving a postoperative prescription. OBJECTIVE: To examine the current opioid prescribing habits of the micrographic surgeons at the University of Utah compared with those in 2010. METHODS: Retrospective chart review of the patient records of 4 micrographic surgeons between February and May 2017. RESULTS: Four hundred patient visits were reviewed. An opioid prescription was provided after 12% of encounters, 23% lower than in 2010 (p = .004). Younger patient age, increased number of stages and defect size, repair of the defect, and particular surgeons predicted opioid prescription. CONCLUSION: The percentage of patients who received an opioid prescription after undergoing micrographic surgery at the University of Utah decreased from 35% in 2010 to 12% in 2017. Reports of the minimal need of opioids after micrographic surgery, the authors' past study showing an institutional tendency to overprescribe, and reports of the national opioid epidemic likely all contributed to the decrease in opioid prescriptions at the authors' institution.

Benign melanocytic lymph node deposits in the setting of giant congenital melanocytic nevi: the large congenital nodal nevus.

BACKGROUND: Benign melanocytic rests are a frequent finding in superficial lymph nodes removed during sentinel lymph node biopsies for melanoma. Whereas the histopathology of these deposits is well understood, very little is known regarding melanocytic lymph node deposits in the setting of giant congenital melanocytic nevi. METHODS: We analyzed lymph nodes removed from the drainage basin of giant congenital melanocytic nevi in three patients who had developed melanoma within their giant congenital nevi. RESULTS: Two of three patients showed widespread, capsular and parenchymal melanocytic deposits in multiple nodes (9 of 11 nodes in one patient and 6 of 8 in the other). Melanocytes were small, non-mitotically active and resembled those in the associated giant congenital melanocytic nevus. Melanocytes were arranged singly and in small nests ∼0.05 mm in diameter, with some larger sheets up to 1 mm. Nodal melanocytes stained for Melan A and S100 on immunohistochemical evaluation, but showed negative or minimal HMB-45 reactivity. CONCLUSIONS: Evaluation of lymph nodes in the setting of giant congenital melanocytic nevi is complicated by the presence of often numerous, parenchymal melanocytic nevic deposits. Bland cytology and minimal or absent HMB-45 staining may be helpful in differentiating these nodal melanocytic nevi from metastatic melanoma. We term this phenomena large congenital nodal nevus.

Mohs appropriate use criteria: retrospectively applied to nonmelanoma skin cancers at a single academic center.

BACKGROUND: In September 2012, appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) were released by a collaboration of dermatology organizations including the American College of Mohs Surgery. OBJECTIVE: The group sought to determine adherence to the Mohs AUC at the academic institution. MATERIALS AND METHODS: The authors performed a retrospective chart review of all nonmelanoma skin cancers (NMSCs) treated within the University of Utah, Department of Dermatology, from January through March of 2012. They applied the Mohs AUC to analyze these cases. RESULTS: In total, the authors identified 724 patients and 1,026 cases of NMSCs, including 557 (54.3%) basal cell carcinomas and 469 (45.7%) squamous cell carcinomas. Of the 1,026 NMSCs, 350 (34.1%) were treated with MMS. Of these cases treated with MMS, there were 339 cases (96.9%) deemed appropriate, 4 (1.1%) uncertain, and 7 (2.0%) inappropriate per AUC. Also examined were 611 cases treated with modalities other than MMS, of which 60.7% would have met AUC for MMS. CONCLUSION: In a 3-month review of all NMSC cases at the academic center, there is a low percentage of cases performed that are inappropriate for MMS by AUC. At the institution, there is a large percentage of NMSC that meet AUC but are treated by other modalities. The use is highly appropriate for MMS, and these data suggest possible underutilization of MMS for certain NMSCs. Further studies are required to determine the effectiveness of other treatment modalities for NMSC that meet Mohs AUC.