Jonathan Kantor

A multicentre study of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks

Venous leg ulcers, which may take months to heal, account for 40–70% of all lower extremity chronic wounds. New treatment options for venous leg ulcers have recently been proposed, and therefore deciding which patients are candidates for these novel—and often expensive—treatments is an important task. Moreover, researchers conducting clinical trials often wish to enrol patients who are unlikely to heal in order to minimize sample sizes needed and research costs. Our purpose was to assess the use of percentage change in venous leg ulcer area over the first few weeks of treatment as a prognostic indicator of healing or non‐healing at 24 weeks. We conducted a cohort study based on an existing data set from a multicentre randomized clinical trial that enrolled 104 patients. Wounds were measured using digital planimetry for 4 consecutive weeks following the inception of good wound care. Utilizing the Wilcoxon rank sum (Mann–Whitney) test, we found that percentage change in area over time distinguished between those who healed and those who failed to heal after 24 weeks of good wound care (P < 0·05). The rate of healing, or area healed per week, did not differentiate between those who healed at 24 weeks and those who did not, as all patients had similar rates of healing over the first 4 weeks of treatment. Percentage change in area from baseline to week 4 provided the best combination of positive and negative predictive values (68·2%, 74·7%) and the largest area under the receiver operating characteristic curve (0·75). Thus, percentage change in area over the first 4 weeks of treatment represents a practical and predictive measure of complete wound healing by 24 weeks.

Routine Dermatologist-Performed Full-Body Skin Examination and Early Melanoma Detection

OBJECTIVE To determine the proportion of patients in a private dermatology practice in whom melanoma was detected but was not the presenting complaint. DESIGN Retrospective analytical case series. SETTING Private dermatology practice in Florida, from July 2005 through October 2008. Patients Patients with 126 melanomas, of which 51 were invasive and 75 were melanomas in situ. MAIN OUTCOME MEASURES Proportion of melanomas detected as a result of patient complaint vs proportion determined by dermatologist-conducted full-body skin examination (FBSE). As a secondary analysis, we used logistic regression odds ratios (ORs) of association to examine whether dermatologist detection rather than patient complaint was associated with detecting thinner melanomas. A post hoc analysis was performed using a thickness cutoff of 1.0 mm to define a deep melanoma. RESULTS Overall, 56.3% (95% confidence interval [CI], 47.6%-65.1%) of melanomas were found by the dermatologist and were not part of the presenting complaint. Of melanomas in situ, 60.0% (95% CI, 48.7%-71.3%) were dermatologist detected. Dermatologist detection was significantly associated with thinner melanomas, with an OR of 0.42 (P = .04). We found a significant association between thinner melanomas as a group (thickness <1 mm) and dermatologist detection, with a logistic regression OR of 5.0 (95% CI, 1.0-25.3). CONCLUSIONS Most melanomas detected in a general-practice dermatology setting were found as a result of dermatologist-initiated FBSE, not patient complaint. We found that dermatologist detection was associated with thinner melanomas and an increasing likelihood of the melanoma being in situ.

Management of leg ulcers.

Chronic wounds, and venous ulcers in particular, are often managed by dermatologists. The first step in the management of any lower extremity ulceration is accurate diagnosis. Although there are several basic tenets of good wound care that remain static regardless of wound etiology, such as maintaining a moist and clean wound healing environment, many of the maneuvers that have been shown to improve the chances of healing must be individualized to the wound type. Many of the techniques in wound management have not changed over the past century: compression remains the cornerstone of venous ulcer management. This article summarizes some of the techniques used in the management of these wounds. We discuss the evidence for using compression, vitamin and mineral supplementation, antibiotic use, growth factors, and other interventions in the management of these wounds.

The accuracy of using a wound care specialty clinic database to study diabetic neuropathic foot ulcers

Few epidemiologic studies have examined the effect of clinical risk factors on the probability that a patient with a chronic wound will heal or develop another wound. Curative Health Services maintains one of the few databases that contain detailed patient record information on patients with chronic wounds. The purpose of this study was to evaluate the reliability and validity of using this database to study individuals with diabetic neuropathic foot ulcers. 154 patient medical records were randomly selected from the database and abstracted using a standardized questionnaire and protocol. We assessed three key variables: diagnosis of diabetic neuropathic foot ulcer, whether the patient healed, and if the patient received an autologous product called platelet releasate. These variables in the database very accurately agreed with the information in the patient medical records, with positive predictive values of 98% (95% confidence interval [0.89, 0.99]), 93% (95% confidence interval [0.68, 0.99]), and 100%, respectively. We have shown that, with respect to these three variables, the database is very accurate when compared to the medical record. It therefore represents a valuable tool with which to study patients with diabetic insensate foot ulcers.

Antiplatelet Agents for Secondary Prevention of Ischemic Stroke

OBJECTIVE: To review and summarize the efficacy, mechanisms of action, and cost of the options available when choosing antiplatelet agents for secondary stroke prevention. DATA SOURCES: This article is based on a review of the literature found with MEDLINE, CINAHL, and Cochrane Reviews (1980–June 2000) and abstracts from relevant international scientific meetings. We searched for the terms aspirin, ticlopidine, dipyridamole, antiplatelet, and clopidogrel. STUDY SELECTION: English-language articles, both reviews and original studies, were evaluated, and all information considered relevant was included in this review. In addition, guidelines from the American Heart Association are included. DATA SYNTHESIS: Aspirin is a relatively inexpensive and effective agent for secondary stroke prevention, and lower doses of aspirin appear as effective as higher doses. Ticlopidine has been used alone or in combination with aspirin, but serious adverse effects have limited its use. Clopidogrel has emerged as a safe and effective alternative to ticlopidine and lacks some of the serious adverse effects associated with ticlopidine, but is not superior to aspirin in secondary stroke prevention. Unlike previous studies, one recent trial showed that dipyridamole in combination with aspirin is superior to aspirin alone. CONCLUSIONS: Antiplatelet therapy is a key component of secondary prevention strategies in ischemic stroke. While aspirin has been the cornerstone in the management of stroke, other classes of antiplatelet drugs present new opportunities to optimize antiplatelet therapy.

First Look: Google Glass in Dermatology, Mohs Surgery, and Surgical Reconstruction

Technology continues to revolutionize thepracticeofdermatology, and the past decades have seen a paradigm shift in theway dermatologists practicemedicineandsurgery,deliver care topatients, andkeepabreast of developments in our field. GoogleGlass (Google Inc) is a recently developed, first-in-class wearable computer that includes an optical display, camera, microphone, bone-conduction speaker, touchpad, gyroscope, and accelerometer. I have used the Google Glass device in the context of general and surgical dermatology. Applications in the clinical dermatology setting include lesional and histopathological photography, telemedicine, education, research, and consultation. Live streamingmayalsobeused for teledermatology consultations, although store-and-forward approaches are feasible aswell. Applications in the surgical setting include perioperative photography, documentationofMohsstages,Mohsspecimenorientation,patienteducation regarding tumor and defect size and location, and reconstructive options. An advantage of this technology is the ability to activate the device in a hands-free fashion. In the surgical setting, this permits the dermatologist to record video or still photographs while maintaining a sterile field, and in the clinical setting, it permits recording photographs without the intrusion of using a camera, as photographsmay be taken with a wink of the right eye. Live streaming of procedures may be used for medical and surgical educationformedical students, residents, fellows,andcolleagues,aswell as for patient education. Thedermatologist is also able to streamaphysician’s-eye view of the skin examination to a monitor in the patient’s room, permitting easy visualization of the back and other difficult-tosee areas. For some patients, this may also be a useful adjunct in explaining and demonstrating surgical procedures, allowing patients to watch and record their procedures. There are some pitfalls to this technology, and the central concern relates toprivacy. Explaininghowthedevice records andoutliningwhat will andwill not be recordedhelps a great dealwith reassuringpatients, and, in my experience, there was no significant resistance on the part of patients to including the device in the context of their care. Moreover, given the ubiquity of smartphones and closed-circuit television monitors, the public has become increasingly accustomed to the presence of recording devices. Finally, it is important to note that the current version of the software defaults to synchronizing data to Google serverswhen the device is both plugged in and within Wi-Fi range; therefore, protected health information and patient identifiers should not be recorded unless the Wi-Fi is disabledprior to charging. Future iterations of thedevice, especially those designed for medical use, will likely include specialized encrypted technologies to obviate privacy concerns andpermit easy integration with electronic medical records.

Subacute radiation dermatitis.

SUBACUTE RADIATION DERMATITIS Subacute radiation dermatitis is a rare cutaneous disorder secondary to radiation-induced tissue damage. The histologic characteristics of this entity have been described in a few reports, and demonstrate an interface reaction with similarities to graft-versus-host disease or a fixed drug reaction. Given the increase in interventional radiologic procedures, it is important to be familiar with this entity, which may result from the cutaneous radiation exposure. In this report, we present 2 instructive cases of subacute radiation dermatitis that highlight this rarely reported disorder.

Utilizing the Patient Attitudes to Scarring Scale (PASS) to develop an outcome measure for postoperative scarring: A study in 430 patients

2. Bobadilla F, Wortsman X, Mu~ noz C, Segovia L, Espinoza M, Jemec GB. Pre-surgical high resolution ultrasound of facial basal cell carcinoma: correlation with histology. Cancer Imaging. 2008;22(8):163-172. 3. Mogensen M, Jemec G. Diagnosis of nonmelanoma skin cancer/keratinocyte carcinoma: a review of diagnostic accuracy of nonmelanoma skin cancer diagnostic tests and technologies. Dermatol Surg. 2007;33(10):1158-1174. 4. Kleinerman R, Whang TB, Bard RL, Marmur ES. Ultrasound in dermatology: principles and applications. J Am Acad Dermatol. 2012;67(3):478-487. 5. Cohen PR, Schulze KE, Nelson BR. Basal cell carcinoma with mixed histology: a possible pathogenesis for recurrent skin cancer. Dermatol Surg. 2006;32(4):542-551.

The SCAR (Scar Cosmesis Assessment and Rating) scale: development and validation of a new outcome measure for postoperative scar assessment.

DEAR EDITOR, In order to discriminate effectively between various surgical interventions, it is critical to utilize a valid and feasible outcome measure for postoperative scar quality. Despite the large number of studies published in the dermatology, general surgery and plastic surgery literature on the relative merits of various surgical techniques, no ideal scar scale exists to assess effectively the quality of postoperative scars. Until now, studies have relied on one of several scales for scar rating, many of which were developed for burn, rather than linear, scars. Moreover, none of these scales was developed or validated by dermatologists, none was developed expressly for tracking the evolution of linear postoperative scars, and none rigorously included input from patients in its development. We utilized a rigorous psychometric approach to develop a new scar rating scale, the Scar Cosmesis Assessment and Rating (SCAR) scale. We developed and validated scale items and assessed the convergent construct validity of the new scale by comparing it with existing scales – the Observer Scar Assessment Scale (OSAS) and the Vancouver Scar Scale (VSS) – as well as with an internal overall measure of scar quality. The SCAR scale was developed following standard structured protocols that have been discussed elsewhere. An iterative process was utilized to develop the final set of questionnaire items through both formal and informal interviews with an international group of board-certified dermatologists, emergency medicine physicians, plastic surgeons, physiatrists and surgical oncologists. Patient input was also elicited; this methodology has been described elsewhere. A thorough literature review was performed to assess currently available scales, evidence supporting their use, and the relative merits of the available outcome measures. Several extensive and comprehensive systematic reviews of the available literature have also recently been published. The SCAR scale consists of six items scored by the observer and two simple yes/no questions answered by the patient (Table 1). Scores may be provided via direct observation and assessment or through the use of high-quality photographic images. Patient responses for associated symptoms may be elicited via either verbal or written responses. Forty patients were included in the validation study. A wide range of scar quality outcomes was included in order to test the SCAR scale in a real-world environment. No identifying characteristics were recorded and this study was exempt from

Reliability and Photographic Equivalency of the Scar Cosmesis Assessment and Rating (SCAR) Scale, an Outcome Measure for Postoperative Scars.

Importance Until recently, no ideal valid, feasible, and reliable scar scale existed to effectively assess the quality of postoperative linear scars. The Scar Cosmesis Assessment and Rating (SCAR) scale was developed and validated as a tool to assess the quality of postoperative scars in clinical and research settings. Objective To assess the reliability of using photographs in lieu of live patient scar rating assessments, and to determine the interrater and intrarater reliability of the SCAR scale. Design, Setting, and Participants This was a reliability study to assess clinicians’ interrater and intrarater reliability, as well as the reliability of using high-quality macrophotographs of postoperative scars. Patients were from a private practice dermatology clinic, with assessed scars representing a range of surgical procedures including those performed by dermatologists, plastic surgeons, and general surgeons. Assessments were performed by an international multidisciplinary team from dermatology, plastic surgery, surgical oncology, emergency medicine, and physiatry, using photographs and live patient assessments. A single photograph was assessed for each patient’s scar. Data were obtained between August 3, 2015, and January 18, 2016. Data analysis occurred between January 18, 2016, and July 29, 2016. Using the intraclass correlation coefficient (ICC), the scale was tested for photographic equivalency as well as interrater reliability and intrarater reliability by 5 raters on a set of 80 total patient scars, 20 of which were analyzed for photographic equivalency and the remaining 60 of which were analyzed for interrater and intrarater reliability. Main Outcomes and Measures The SCAR scale that measures postoperative scar cosmesis, with scores ranging from 0 (best possible scar) to 15 (worst possible scar), based on 6 clinician and 2 patient items was used. Of those 60 in the photographic subgroup, 10 were rated using not only the SCAR scale but also the Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale, and 10 were assessed twice by the same rater at different times to assess intrarater reliability. Results Patients’ ages ranged from 18 to 96 years, with Fitzpatrick skin types I through VI. Thirty-seven were male, and 43 were female. A set of 20 live patient scars with associated photographs, as well as a separate set of 60 photographs, were rated; 10 patients were assessed twice for intrarater reliability. The SCAR scale ratings using photographs were found to be largely equivalent to live patient assessments, with ICCs of 0.99 (95% CI, 0.96-0.99) and 0.98 (95% CI, 0.96-0.99). The interrater reliability of the overall scale showed an ICC of 0.95 (95% CI, 0.96-0.99) using a 2-sample random-effects model. Intrarater reliability found ICCs ranging from 0.96 to 0.99 with 5 separate raters. Modeling the overall SCAR score predicted whether the rater would consider the scar undesirable, with an odds ratio of association of 1.76 (95% CI, 1.24-2.2). A secondary analysis of Fitzpatrick skin types IV, VI, and VI demonstrated a sustained interrater reliability, with an ICC of 0.93 (95% CI, 0.86-0.98). Conclusions and Relevance The SCAR scale is a reliable rating scale for postoperative linear scars, and photographs may reliably be used in lieu of live patient assessments. The SCAR scale therefore represents a reliable standard rating scale for postoperative scar cosmesis.