The use of notable protagonists in dermatology clinical cases: A quasi-randomized controlled trial.

BACKGROUND: Educators have attempted several methods to create more entertaining problem-based learning (PBL) experiences and more engaging PBL patients. To this end, our study compared the use of unique, memorable PBL characters with generic, unmemorable characters. METHODS: This prospective quasi-randomized controlled study utilized 476 university students. All subjects read ten medical cases that focused on dermatological illnesses. Cases were identical for everyone except subjects were allocated to have notable protagonists (NP) (i.e. cartoon characters or celebrities) or generic protagonists (GP) as patients in their cases. Surveys and tests were completed immediately, 7-10 days later, and 28-31 days later. RESULTS: There were no significant differences in post-test scores at any point between the groups. The only significant difference with regard to the subjective learning experience was for the entertainment level of the cases. The NP mean was 64.1±24.2, whereas the GP mean was 56.0±24.6 (t[444]=3.52, P=0.0005). The NP group also had a significantly higher proportion of subjects who researched dermatology/medicine topics after reading the cases (10.6% versus 2.7%, χ²(1,N=215)=5.47, P=0.02). CONCLUSIONS: The current study found that cases utilizing NPs, while still preserving the same educational value as cases using GPs, can provide a more entertaining learning experience and stimulate outside learning.

Meta-analysis on the effect of text message reminders for HIV-related compliance.

For the treatment of HIV, compliance in regard to appointment attendance and medication usage is critical. Various methods have been attempted to increased HIV care compliance, and a method that has inspired many published studies is text message reminders. We conducted a meta-analysis of the literature from inception through May 2016 using the following databases: Pubmed, Embase, CINAHL, Web of Science, and Cochrane. Examples of terms used in the search included exploded versions of "HIV, "AIDS", "cell phone", "SMS", "text message", "reminder". After abstract and manuscript review, articles were discussed with co-author and included based on consensus. We excluded qualitative analyses, observational studies without an intervention, and studies without a control or pre-intervention group. We used random-effects models to calculate odds ratios (OR) and standardized mean differences (SMDs) for the text message intervention. Thirty-four unique studies were found and included in the meta-analysis. For the seven articles relating to non-attendance, text message reminders significantly reduced the rates of non-attendance (OR, 0.66; 95% CI, 0.48-0.92; P = .01; I2 = 52%). For the 20 articles on drug adherence, text message reminders significantly increased adherence (SMD, 0.87; 95% CI, 0.06-1.68; P = .04; I2 = 99%). For the 11 articles with physiologic measures (CD4 count or viral load), text message reminders led to significant improvement (SMD, 1.53; 95% CI, 0.52-2.55; P = .003; I2 = 99%). This meta-analysis reveals that text message reminders are a promising intervention that can be used to increase HIV care compliance when logistically feasible. Further study should focus on which populations benefit the most from this intervention, and successful implementers could create an established technological infrastructure for other clinics to adopt when seeking to boost compliance.

Enforcement Provisions of Indoor Tanning Bans for Minors: An Analysis of the First 6 US States.

Several states have passed legislation banning minors from indoor tanning; however, concern has been raised regarding enforcement. We explored the statutes pertaining to enforcement in the first 6 US states to pass legislation banning minors younger than 18 years from indoor tanning. The findings reflect significant variability in enforcement provisions across the 6 states. Further investigations are needed to determine whether the statutes are successful in curbing indoor tanning among youths and ultimately whether indoor tanning bans among minors help to reduce skin cancer incidence.

Nodular melanoma serendipitously detected by airport full body scanners.

BACKGROUND: Nodular melanoma is the most dangerous form of melanoma and often evades early detection. METHODS: We present a frequently traveling businessman whose nodular melanoma was detected by airport full body scanners. RESULTS: For about 20 flights over 2 months, the airport full body scanners singled out an area on his left lower leg for a pat-down. Dermatologic examination discovered a nodular melanoma in this area, and after surgical excision, the man traveled without incident. CONCLUSION: This case raises the possibility of using full body imaging in the detection of melanomas, especially of the nodular subtype. In its current form, full body scanning would most likely not be sensitive or specific enough to become a recommended screening tool. Nonetheless, for travelers with areas repeatedly singled out by the machines without a known justification, airport scanners could serve as incidental free screening for suspicious nodular lesions that should prompt dermatologist referral.

The impact of indoor tanning legislation: newspaper coverage of the risks of indoor tanning before and after the California indoor tanning ban for minors.

On June 1, 2011, the California Senate passed a bill banning minors from indoor tanning. We aimed to determine whether the bill's passage was associated with longer-term media coverage regarding skin protection and the risks associated with indoor tanning. Articles from 31 English-language California newspapers between June 2010-May 2011 (PRE) and June 2011-May 2012 (POST) were searched using terms related to skin protection. Ninety articles were found for in-depth coding and analysis. There were more skin protection articles in the POST period than in the PRE period (57 vs 33; p < .05). In addition, there were more POST articles mentioning the risks of indoor tanning (33 vs 10; p < .001), and a POST article was more likely to mention the risks (58 vs 30%; p < .05). The higher number of POST articles mentioning the risks persisted throughout all quarters. Therefore, the California indoor tanning ban was associated with increased longer-term news coverage of skin protection and the risks associated with indoor tanning. This finding has potential influence on the many states that are considering comparable legislation.

Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part I. Epidemiology, high-risk groups, clinical strategies, and diagnostic technology.

While most cancers have shown both decreased incidence and mortality over the past several decades, the incidence of melanoma has continued to grow, and mortality has only recently stabilized in the United States and in many other countries. Certain populations, such as men >60 years of age and lower socioeconomic status groups, face a greater burden from disease. For any given stage and across all ages, men have shown worse melanoma survival than women, and low socioeconomic status groups have increased levels of mortality. Novel risk factors can help identify populations at greatest risk for melanoma and can aid in targeted early detection. Risk assessment tools have been created to identify high-risk patients based on various factors, and these tools can reduce the number of patients needed to screen for melanoma detection. Diagnostic techniques, such as dermatoscopy and total body photography, and new technologies, such as multispectral imaging, may increase the accuracy and reliability of early melanoma detection.

Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part II. Screening, education, and future directions.

New evidence has accumulated over the past several years that supports improved melanoma outcomes associated with both clinician and patient screening. Population-based and workplace studies conducted in Australia and the Unites States, respectively, have shown decreases in the incidence of thick melanoma and overall melanoma mortality, and a year-long statewide screening program in Germany has shown a nearly 50% reduction in mortality 5 years after the screening ended. Current melanoma screening guidelines in the United States are inconsistent among various organizations, and therefore rates of both physician and patient skin examinations are low. As policymaking organizations update national screening recommendations in the United States, the latest research reviewed in part II of this continuing medical education article should be considered to establish the most effective recommendations. Patient and provider education will be necessary to ensure that appropriate patients receive recommended screening.

Attitudes and practice among dermatologists regarding indoor tanning.

The aim of this study was to explore dermatologists' practices and attitudes related to educating and counseling their adolescent patients about indoor tanning. An online survey was carried out with a convenience sample of 100 dermatologists. Findings indicated that the majority of the dermatologists are actively engaged in discussing tanning bed use and sun protection with their adolescent patients. Most expressed positive attitudes toward educating patients on the risks of tanning bed use. Limited time was the most commonly reported barrier for the lack of discussion regarding indoor tanning. Of note, more than half of the dermatologists (65%) had patients suffering from tanning addiction. For tanning-addicted patients, dermatologists can encourage lifestyle changes, the use of sunless tanning products, and referrals when the patient's needs extend beyond the scope of the dermatologist.

Diffuse cutaneous breast cancer metastases resembling subcutaneous nodules with no surface changes.

Cutaneous metastases typically occur in only a small minority of breast cancer patients. Clinical appearance can vary, but lesions often present as isolated dermal nodules with superficial discoloration or a change in texture on the chest ipsilateral to the primary breast malignancy. We report the case of a woman with metastatic adenocarcinoma of the breast presenting with diffuse cutaneous nodules with no surface changes. The nodules were almost undetectable clinically and had minimal elevation, making them difficult to detect, especially without palpation. A punch biopsy showed positive cytokeratin immunostaining consistent with the markers for the primary breast cancer. A review of the literature on cutaneous metastases from breast adenocarcinomas also is provided.

Association of Skin Examination Behaviors and Thinner Nodular vs Superficial Spreading Melanoma at Diagnosis.

Importance: Early melanoma detection strategies include skin self-examination (SSE), physician skin examination (PSE), and promotion of patient knowledge about skin cancer. Objective: To investigate the association of SSE, PSE, and patient attitudes with the detection of thinner superficial spreading melanoma (SSM) and nodular melanoma (NM), the latter of which tends to elude early detection. Design, Setting, and Participants: This cross-sectional, questionnaire-based, multicenter study identified patients with newly diagnosed cutaneous melanoma at 4 referral hospital centers in the United States, Greece, and Hungary. Among 920 patients with a primary invasive melanoma, 685 patients with SSM or NM subtype were included. Interventions: A standardized questionnaire was used to record sociodemographic information, SSE and PSE practices, and patient perceptions in the year prior to diagnosis. Main Outcomes and Measures: Data were analyzed according to histologic thickness, with a 2-mm cutoff for thinner SSM and NM. Results: Of 685 participants (mean [SD] age, 55.6 [15.1] years; 318 [46%] female), thinner melanoma was detected in 437 of 538 SSM (81%) and in 40 of 147 NM (27%). Patients who routinely performed SSE were more likely to be diagnosed with thinner SSM (odds ratio [OR], 2.61; 95% CI, 1.14-5.40) but not thinner NM (OR, 2.39; 95% CI, 0.84-6.80). Self-detected clinical warning signs (eg, elevation and onset of pain) were markers of thicker SSM and NM. Whole-body PSE was associated with a 2-fold increase in detection of thinner SSM (OR, 2.25; 95% CI, 1.16-4.35) and thinner NM (OR, 2.67; 95% CI, 1.05-6.82). Patient attitudes and perceptions focusing on increased interest in skin cancer were associated with the detection of thinner NM. Conclusions and Relevance: Our findings underscore the importance of complementary practices by patients and physicians for the early detection of melanoma, including regular whole-body PSE, SSE, and increased patient awareness.

Arsenic and skin cancer in the USA: the current evidence regarding arsenic-contaminated drinking water.

BACKGROUND: Studies carried out in developing countries, such as Bangladesh and Taiwan, have reported an association between exposure to arsenic in drinking water and increased rates of non-melanoma skin cancer. However, it is unclear whether this correlation can be extended to the populations of developed countries such as the USA, which have lower levels of arsenic exposure and differ in other factors, such as genetics, nutrition, sun exposure, and socioeconomic status. OBJECTIVES: This report examines the current evidence in an attempt to resolve whether populations in the USA have rates of skin cancer that correlate with higher arsenic concentrations. METHODS: A systematic literature search was conducted using the PubMed, EMBASE, CINAHL, and Cochrane databases. RESULTS: Six key studies were found and reviewed. Several studies conducted in US populations indicate an association between arsenic-contaminated water and skin cancer, which may in some cases occur at arsenic concentrations of <10 µg/l, the 2001 Environmental Protection Agency (EPA) maximum allowable concentration for municipal water. CONCLUSIONS: Private wells are not regulated by the EPA's rule, and many have concentrations above the EPA maximum. In order to help curb the rising incidence of skin cancer, arsenic contamination of water warrants the attention of policymakers. Greater testing of well water and increased education and skin cancer surveillance by dermatologists in arsenic-endemic areas may help to reduce exposure to arsenic and facilitate the early recognition of skin cancer.

Total Nevi, Atypical Nevi, and Melanoma Thickness: An Analysis of 566 Patients at 2 US Centers.

IMPORTANCE: Nevi are among the strongest risk factors for melanoma. However, little is known about the association of many total nevi (TN) or atypical nevi (AN) with tumor thickness. OBJECTIVES: To examine the association between age and the number of TN and AN and to explore whether there was a relationship between TN or AN and tumor thickness, controlling for multiple variables. DESIGN, SETTING, AND PARTICIPANTS: Survey of patients with melanoma at 2 academic sites and an affiliated Veteran Affairs medical center. Participants included 566 patients surveyed within 3 months of diagnosis. Patients were surveyed in the melanoma clinics from May 17, 2006, through March 31, 2009, within 3 months of diagnostic biopsy. The dates of the analysis were April 1, 2015, to August 1, 2015. MAIN OUTCOMES AND MEASURES: Counts of TN and AN were performed at the first visit after diagnosis and were categorized as 0 to 20, 20 to 50, or more than 50 for TN and as 0, 1 to 5, or more than 5 for AN. Tumor thickness was categorized as 2.00 mm or less or as 2.01 mm or greater. All analyses were stratified by patient age (<60 or ≥60 years). Logistic regression was used to test associations, controlling for age, sex, anatomic location of melanoma, institution, histologic subtype, marital status, performance of skin self-examination, number of health care visits in the past year, mode of melanoma discovery, and receipt of skin examination by a physician. RESULTS: The study population included 566 patients. Their mean (SD) age was 56.7 (15.9) years, and 39.0% (n = 221) were female. Of 566 patients, the number of TN was classified as 0 to 20 (66.4% [n = 376]), 20 to 50 (20.5% [n = 116]), or more than 50 (13.1% [n = 74]). Atypical nevus counts were 0 (73.3% [n = 415]), 1 to 5 (14.5% [n = 82]), or more than 5 (12.2% [n = 69]). For those younger than 60 years, the presence of more than 50 TN was associated with a sharply reduced risk of thick melanoma (odds ratio, 0.32; 95% CI, 0.12-0.81), and the presence of more than 5 AN compared with no AN was associated with thicker melanoma (odds ratio, 2.43; 95% CI, 1.02-5.75). CONCLUSIONS AND RELEVANCE: Most patients with melanoma had few nevi and no AN. In younger patients (<60 years), thick melanomas were commonly found in those with fewer TN but more AN, suggesting that physicians and patients should not rely on the total nevus count as a sole reason to perform skin examinations or to determine a patient's at-risk status. Younger patients should be educated on the increased risk of thicker melanomas that is associated with having more AN.

Association of nevus count with prevention attitudes and behaviors before melanoma diagnosis.

Although melanoma risk factors are commonly known to healthcare professionals, the extent to which the at-risk public is either aware of these factors or perceives their risk accordingly has rarely been studied. We sought to investigate whether the presence of known melanoma risk factors, such as high total nevus and atypical nevus counts, was associated with increased prevention attitudes and behaviors, such as skin self-examinations and physician skin examinations. This was a retrospective study of 566 individuals recently diagnosed with melanoma in two large academic centers. Most prevention attitudes and behaviors did not vary on the basis of total nevi or atypical nevi counts. However, younger patients (<60 years) with many total nevi (>50) were more likely than those with fewer nevi (<20) to believe that they were at-risk for melanoma (42 vs. 23%; P<0.05), and more likely to state that they had been instructed on the signs of melanoma (36 vs. 21%; P<0.05). Patient and health provider recognition of the impact of nevus count on melanoma risk presents a unique and mostly untapped opportunity for earlier detection.

Injuries Attributable to Cosmetic Procedures Performed by Unlicensed Individuals in the United States.

OBJECTIVE: Although only licensed professionals should be performing cosmetic procedures for patients, there are often news stories of unlicensed individuals performing procedures with serious consequences. This brief report seeks to determine the scope and magnitude of the problem by determining the number of cases of unlicensed procedures and determining the people, procedures, and states that are involved. DESIGN: Various databases were used to find lawsuits and United States English-language news reports from January 1, 2013, through December 31, 2013, which described cosmetic procedures performed by unlicensed individuals. SETTING: The United States. PARTICIPANTS: All publicly reported cases. MEASUREMENTS: Number of cases, case location, type of procedures and injuries, and demographics of the victims and perpetrators. RESULTS: Twenty-eight unique cases were found. The three states with the highest number of cases were Florida (35.7%; n=10), Texas (14.3%; n=4), and California (10.7%; n=3). The type of procedures (n=28) performed were buttocks injections (n=1), face injections (n=7), laser facial procedures (n=2), liposuctions (n=4), and other cosmetic surgeries (n=4). The reported injuries (n=16) were hospitalization (n=8), death (n=4), amputation (n=1), burn (n=1), ptosis (n=1), and scar (n=1). Women and minorities appeared to be disproportionately affected by these illegal procedures. CONCLUSION: This study likely only provides a small snapshot of a much larger problem, as many cases are presumably not taken to the news or courts. The availability of illegal cosmetic procedures can be diminished with complementary efforts carried out both by law enforcement and the communities themselves.

Treatment of eccrine porocarcinoma with Mohs micrographic surgery: a cases series and literature review.

BACKGROUND: Eccrine porocarcinoma (EPC) is a rare malignant tumor of the eccrine sweat gland. It is a potentially fatal neoplasm that is locally aggressive and commonly recurs. Wide surgical excision has traditionally been the treatment of choice and is curative in approximately 70-80% of cases. The disease is metastatic to lymph nodes and distant sites in 20% and 10% of cases, respectively. Metastatic EPC has not shown any great response to adjuvant chemotherapy or radiation. OBJECTIVE: The purpose of this study was to evaluate the efficacy of Mohs micrographic surgery (MMS) for EPC as an alternative to wide local excision. METHODS: Five patients diagnosed with EPS between 2011 and 2014 at the University of Louisville and treated with MMS were studied. Recurrence-free periods subsequent to the treatment of EPC with MMS were measured. RESULTS: The five patients with EPC treated by MMS remained recurrence-free for a mean of 11 months (range: 2-26 months). CONCLUSIONS: Mohs micrographic surgery is a highly effective treatment for EPC. Given the high rate of recurrence, propensity for lymph node metastases, and the often ineffective options for treating advanced disease, MMS should be considered in the treatment of all cases of EPC.

The window of opportunity for indoor tanning legislation.

As of August 2014, 11 states in the USA have passed under-age-18 bans on indoor tanning. The Society of Behavioral Medicine, the American Academy of Dermatology, and the American Academy of Pediatrics have all issued statements in support of an under-age-18 ban. The World Health Organization and the Food and Drug Administration have both declared indoor tanning devices as carcinogenic, and this year, the Surgeon General for the first time issued a warning on the dangers of UV radiation and indoor tanning. This essay highlights how the awareness of the risks of indoor tanning, effective policies, and a conducive political atmosphere have aligned to create a window of opportunity for further under-age-18 indoor tanning legislation. The rising number of preventable skin cancers and mortalities is an issue that transcends political party lines, and now, there is a need for support from health professionals and advocates to motivate legislators to push new under-age-18 bills past their sticking points.