Barbara Boone

Proximal Row Carpectomy Versus Four-Corner Arthrodesis as a Treatment for SLAC (Scapholunate Advanced Collapse) Wrist

Four-corner arthrodesis and proximal row carpectomy are motion-preserving salvage solutions for the scapholunate advanced collapse wrist. We compared both procedures in a non-randomised, retrospective study of 30 cases with a mean follow-up of 3½ years. Pain relief and functional gain were equal in both treatment groups. However, the complication rate was higher in the four-corner arthrodesis group, partly because of the need for internal fixation. The higher incidence of carpal tunnel syndrome following four-corner arthrodesis is intriguing. We also found significant differences in the duration of hospital stay and of postoperative sick leave in favour of proximal row carpectomy. If the cartilage on the capitate head is well preserved (Stages I–II), we prefer proximal row carpectomy because of the socio-economic benefits, the lower complication rate and the ease of the procedure. Degenerative changes following proximal row carpectomy may be a concern in young manual labourers, but have not been observed.

Clinical significance of the expression of c-Ski and SnoN, possible mediators in TGF-β resistance, in primary cutaneous melanoma

BACKGROUND Loss of TGF-beta growth control is considered as a hallmark of several human neoplasms including melanoma. Resistance of cancer cells to TGF-beta has been linked to mutations in proteins involved in the TGF-beta pathway. In melanoma such mutations have not been observed. C-Ski and SnoN, two structurally and functionally highly homologous proteins, are known as negative regulators in the TGF-beta signaling pathway. C-Ski and SnoN expression levels and subcellular localization have been associated with clinicopathological parameters and tumour progression in several human malignancies. In melanoma cell lines, high c-Ski and SnoN expression levels have been described. OBJECTIVE The objective of this study was to evaluate the clinical value of c-Ski and SnoN expression in primary cutaneous melanoma. METHODS We evaluated c-Ski and SnoN expression by immunohistochemical staining in 120 primary melanomas. Possible associations between c-Ski and SnoN staining patterns and clinicopathological parameters were analyzed. RESULTS Nuclear c-Ski expression was significantly associated with thicker and ulcerated tumours. The percentage of SnoN positivity was higher in ulcerated tumours and in the sentinel node positive group. CONCLUSION These results suggest that c-Ski and SnoN, mediators in TGF-beta resistance, might be implicated in melanoma growth and progression.

Mohs micrographic surgery for basal cell carcinoma: evaluation of the indication criteria and predictive factors for extensive subclinical spread

The incidence of basal cell carcinoma (BCC) is rising and BCC treatment has an important impact on healthcare budget. Mohs micrographic surgery (MMS) has the highest 5‐year cure rate but is an expensive technique.

Total-Body Examination vs Lesion-Directed Skin Cancer Screening.

IMPORTANCE Skin cancer is the most frequent cancer type. It remains unknown if and how screening programs can be organized in a cost-effective manner. OBJECTIVE To compare the 2 screening strategies of systematic total-body examination (TBE) and lesion-directed screening (LDS), with a focus on the participation rate, detection rate, anxiety, and cost. DESIGN, SETTING, AND PARTICIPANTS Population-based cross-sectional screenings by a team of 6 dermatologists were organized in 2 sociodemographically similar regions. The TBE was organized in a community of 9325 inhabitants 18 years and older (Wichelen, East Flanders, Belgium) during a 5-day screening (March 14-18, 2014). The LDS was organized in a sociodemographically comparable community (Nevele, East Flanders, Belgium) of 9484 adult inhabitants during a 4-day screening (April 22 and 25-27, 2014). The first population received a personal invitation for a standard TBE. In the second population, individuals were invited for an LDS if they had a lesion meeting 1 or more of the following criteria: ABCD rule (A, asymmetry; B, borders; C, colors; and D, differential structures), ugly duckling sign, new lesion lasting longer than 4 weeks, or red nonhealing lesions. MAIN OUTCOMES AND MEASURES In total, 1982 individuals were screened, and 47 skin cancers (2.4%) were histologically confirmed, including 9 melanomas (0.5%), 37 basal cell carcinomas (1.9%), and 1 squamous cell carcinoma or Bowen disease (0.1%). RESULTS The positive predictive value for all suspicious lesions was 56.6% (47 of 83). The participation rate was 17.9% (1668 of 9325) in the TBE group vs 3.3% (314 of 9484) in the LDS group (P < .01). The skin cancer detection rate per 100 participants did not differ significantly between the 2 groups, with rates of 2.3% (39 of 1668) in the TBE group vs 3.2% (8 of 248) in the LDS group (P = .40). The operational effectiveness per 100 invitees was 0.4% (39 of 9325) in the TBE group vs 0.1% (8 of 9484) in the LDS group (P < .01). In addition, LDS was 5.6 times less time consuming than TBE. Participants in the LDS group had significantly higher baseline anxiety levels compared with participants in the TBE group (3.7 vs 3.3 points on a visual analog scale, P < .01). In screenees without a suspicious lesion, anxiety levels significantly dropped after screening. CONCLUSIONS AND RELEVANCE Total-body examination yielded a higher absolute number of skin cancers. Lesion-directed screening had a similar detection rate of 3.2% (8 of 248) but was 5.6 times less time consuming. When performed by dermatologists, LDS is an acceptable alternative screening method in health care systems with limited budgets or long waiting lists.

Cessation of spread as a treatment objective in vitiligo : perception from the patients' point of view

DEAR EDITOR, Vitiligo is an acquired condition resulting from the progressive loss of melanocytes. It is known that the unpredictable nature of vitiligo and its tendency to progress can be psychologically overwhelming. In our previous clinical observational trials and during clinical practice we noticed frequently that disease stability is relevant for many patients. Therefore, we wanted to evaluate the perception of disease impact, the general treatment motivation and the treatment motivation if disease stabilization would be the outcome. The second aim was to evaluate whether clinical variables might influence the impact of the disease and motivation for treatment. This was a monocentre observational trial conducted at the Department of Dermatology of Ghent University Hospital. Between August 2009 and March 2015, we recruited in a consecutive manner 864 patients with nonsegmental vitiligo. The study was approved by the local ethics committee. Data were taken by history using a standardized questionnaire. Special attention was given to the questions with respect to the general treatment motivation (motivation A) and motivation for treatment if this could induce cessation of spread/ disease stability (motivation B). Patients were asked to score for both questions their motivation on a scale from 0 to 10. Statistical analyses were performed using SPSS 22.0 (IBM, Armonk, NY, U.S.A.). All values are expressed as median (interquartile range, IQR). For all tests, P-values of less than 0 05 were considered to indicate statistical significance. Adjustment for possible confounding factors was performed using a multivariate regression model. In total, 864 patients with nonsegmental vitiligo were enrolled in this study, including 400 men and 464 women (Table 1). The general motivation score for treatment (motivation A) was collected for 814 patients. Motivation to treat if stabilization could be achieved (motivation B) was available for 365 patients. The impact score was measured in 849 patients with vitiligo. The majority of included patients under treatment (68 4%) were using topical treatments (82 2%), followed by ultraviolet B (UVB) treatment (17 8%). A high number (87 6%) of patients with vitiligo reported a strong general motivation (motivation A) for treatment (score ≥ 7) (Fig. 1a). Only 3 5% mentioned a poor motivation (score < 4). Patients receiving UVB treatment and having dark skin phototypes displayed a significantly higher motivation for treatment (P = 0 019 and P = 0 008, respectively). The general motivation to treat was the highest during the first 2 years of the disease (P = 0 001). There was a drop in general treatment motivation in the age group of 11– 20 years (P = 0 036). The motivation to treat decreased slightly if disease stabilization was proposed as the treatment goal (motivation B). Still, 84 1% of patients mentioned a motivation score ≥ 7 if stable disease could be attained. Only 5 7% of patients seemed not to be willing to treat in this setting (motivation score < 4). The motivation for treatment to achieve disease stabilization was also the highest in the first 2 years of the disease (P = 0 013) and remained stable afterwards. There was a negative correlation between a higher body surface area (BSA) and motivation to treat if stabilization would be the outcome (P < 0 001) (Fig. 1b). In patients with a BSA of more than 10%, cessation of disease progression was a less important motivation for treatment (mean motivation B score BSA < 10% vs. BSA > 10%: 8 49 vs. 7 22; P = 0 001). There was a wide difference in reported impact scores of the patients (Fig. 1c–h). An impact score from 0 to 3 was found in 30 6% of patients, a score of 4–7 in 40 0% of patients and a score from 8 to 10 in 29 4% of patients. As

Classification of segmental vitiligo on the trunk

Segmental vitiligo is characterized by a unilateral and localized distribution. A classification for segmental vitiligo on the face has been proposed, while this is still unavailable for lesions on the trunk.

Scarf Osteotomy for Hallux Valgus Deformity A Prospective Study with 8 Years of Clinical and Radiologic Follow-up

BACKGROUND Scarf midshaft metatarsal osteotomy has become increasingly popular as a treatment option for moderate-to-severe hallux valgus deformities because of its great versatility. Numerous studies on Scarf osteotomy have been published. However, no prospective studies were available until 2002. Since then, only short-term follow-up prospective studies have been published. We present the results of a prospective study of 21 patients treated by Scarf osteotomy for hallux valgus with follow-up of 8 years. METHODS Between August 1, 1999, and October 31, 1999, 23 patients (23 feet) with moderate-to-severe hallux valgus deformity were included. Clinical (American Orthopaedic Foot and Ankle Society score) and radiologic (hallux valgus angle, first intermetatarsal angle, and sesamoid position) evaluations were performed preoperatively and 1 and 8 years postoperatively. RESULTS Clinical evaluation showed a significant improvement in the mean forefoot score from 47 to 83 (of a possible 100) at 1 year (P < .001). Radiographic evaluation showed significant improvement in the hallux valgus angle (mean improvement, 19 degrees ; P < .001) and in the intermetatarsal angle (mean improvement, 6 degrees ; P < .001). These clinical and radiographic results were maintained at the final evaluation 8 years postoperatively. CONCLUSIONS Scarf osteotomy tends to provide predictable and sustainable correction of moderate-to-severe hallux valgus deformities.

Fractional Carbon Dioxide Laser of Recent Surgical Scars in the Head and Neck Region: A Split-Scar, Evaluator-Blinded Study.

BACKGROUND Postoperative scarring is a common cause of patient dissatisfaction. Several strategies have been developed to improve its clinical aspects. OBJECTIVE To assess efficacy and safety of the 10,600 nm ablative fractional carbon dioxide (CO2) laser in the treatment of recent surgical scars in the head and neck region. METHODS AND MATERIALS A prospective, randomized, single-blind intrapatient controlled study was conducted on 9 postoperative scars in the head and neck region. On half of the scar, 3 treatment sessions were performed. Physician/Patient Global Assessment (PhGA/PGA) and Patient and Observer Scar Assessment Scales (POSAS) were used to evaluate treatment efficacy. Safety was evaluated by registration of pain and adverse events. RESULTS No statistically significant differences were noted in terms of PhGA or POSAS (observer). Patient Global Assessment (p = 0.058) and POSAS (patient) (p = 0.091) showed a trend toward better improvement of the treated half. Itch score (p = 0.046) and global end evaluation (patient) (p = 0.026) demonstrated a statistically significant difference in favor of the treated part. Adverse events were minor, and no long-term side effects were noted. CONCLUSION The use of CO2 fractional laser is safe and is associated with high patient satisfaction. However, objective measurements could not confirm its efficacy in the treatment of recent surgical scars.

Hypomelanoses in Children

Hypomelanosis of the skin is a frequently encountered problem in childhood, being totally innocent or representing the first sign of a multisystem disorder. Medical history, clinical examination, Wood’s light investigation, histological analysis of the skin and a multidisciplinary consultation can contribute to a correct and early diagnosis of the different types of hypopigmentations. In the present paper, we present a systematic clinical approach to the differential diagnosis of those skin disorders.

Occupational allergic contact dermatitis caused by thebaine and oripavine

A 35-year-old male was referred because of eczema on the arms and lips that occurred episodically. He worked in a drug-manufacturing plant, and noticed that the episodes of eczema coincided with the production cycles of thebaine (CAS no. 115-37-7) and oripavine (CAS no. 467-04-9), but not with the production cycles of morphine (CAS no. 57-27-2) and noscapine (CAS no. 128-62-1). The eczema started in the third production cycle, and was severely exacerbated during the fourth production cycle. In between every production cycle, the