Improved overall survival of melanoma of the head and neck treated with Mohs micrographic surgery versus wide local excision.

BACKGROUND: Optimal surgical management for melanoma of the head and neck remains controversial. OBJECTIVE: Assess outcomes for melanomas of the head and neck treated with Mohs micrographic surgery (MMS) versus wide local excision (WLE) from the National Cancer Database. METHODS: Head and neck melanoma data from the National Cancer Database from years 2004-2015 were analyzed. RESULTS: In total, 50,397 cases of head and neck melanoma were reviewed; 3510 (7%) were treated with MMS and 46,887 (93%) with WLE. After controlling for potential confounding variables, patients treated with MMS were more likely than patients treated with WLE to survive after 5 years (hazard ratio [HR] 1.181, 95% confidence interval [CI] 1.083-1.288; P < .001). Factors associated with a statistically significant survival disadvantage included male sex (HR 1.287, 95% CI 1.242-1.357; P = 0), tumor ulceration (HR 1.687, 95% CI 1.616-1.760; P = 0), and positive surgical margins (HR 1.395, 95% CI 1.306-1.490; P = 0). Patient survival was inversely proportional to tumor Breslow depth. LIMITATIONS: Database study, limited number of MMS treated melanomas. CONCLUSION: MMS is a valid treatment option for melanoma of the head and neck; National Cancer Database data suggests that MMS might confer a survival benefit over WLE.

Advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers: a systematic review.

BACKGROUND: Nonhealing ulcers affect patient quality of life and impose a substantial financial burden on the health care system. PURPOSE: To systematically evaluate benefits and harms of advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers. DATA SOURCES: MEDLINE (1995 to June 2013), the Cochrane Library, and reference lists. STUDY SELECTION: English-language randomized trials reporting ulcer healing or time to complete healing in adults with nonhealing ulcers treated with advanced therapies. DATA EXTRACTION: Study characteristics, outcomes, adverse events, study quality, and strength of evidence were extracted by trained researchers and confirmed by the principal investigator. DATA SYNTHESIS: For diabetic ulcers, 35 trials (9 therapies) met eligibility criteria. There was moderate-strength evidence for improved healing with a biological skin equivalent (relative risk [RR], 1.58 [95% CI, 1.20 to 2.08]) and negative pressure wound therapy (RR, 1.49 [CI, 1.11 to 2.01]) compared with standard care and low-strength evidence for platelet-derived growth factors and silver cream compared with standard care. For venous ulcers, 20 trials (9 therapies) met eligibility criteria. There was moderate-strength evidence for improved healing with keratinocyte therapy (RR, 1.57 [CI, 1.16 to 2.11]) compared with standard care and low-strength evidence for biological dressing and a biological skin equivalent compared with standard care. One small trial of arterial ulcers reported improved healing with a biological skin equivalent compared with standard care. Overall, strength of evidence was low for ulcer healing and low or insufficient for time to complete healing. LIMITATIONS: Only studies of products approved by the U.S. Food and Drug Administration were reviewed. Studies were predominantly of fair or poor quality. Few trials compared 2 advanced therapies. CONCLUSION: Compared with standard care, some advanced wound care therapies may improve the proportion of ulcers healed and reduce time to healing, although evidence is limited. PRIMARY FUNDING SOURCE: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative.

Clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial.

We assessed the clinical course of patients after store and forward teledermatology in comparison with conventional consultations. Patients being referred from primary care to dermatology clinics were randomly assigned to teledermatology or a conventional consultation. A total of 392 patients were randomized; 261 patients completed the study and were included in the analysis. Their clinical course was rated on a five-point scale by a panel of three dermatologists, blinded to study assignment, who reviewed serial digital image sets. The clinical course was assessed by comparing images sets between baseline and first clinic visit (if one occurred) and between baseline and nine months. There was no evidence to suggest a difference between the two groups in either clinical course between baseline and nine months post-referral (P = 0.88) or between baseline and the first dermatology clinic visit (P = 0.65). Among teledermatology referrals, subsequent presentation for an in-person dermatology clinic visit was significantly correlated with clinical course (P = 0.023). Store and forward teledermatology did not result in a significant difference in clinical course at either of two post-referral time periods.