Kate V. Viola

A national study of attrition in general surgery training: which residents leave and where do they go?

Objective(s):Implementation of the 80-hour mandate was expected to reduce attrition from general surgery (GS) residency. This is the first quantitative report from a national prospective study of resident/program characteristics associated with attrition. Methods:Analysis included all categorical GS residents entered on American Board of Surgery residency rosters in 2007 to 2008. Cases of attrition were identified by program report, individually confirmed, and linked to demographic data from the National Study of Expectations and Attitudes of Residents in Surgery administered January 2008. Results:All surgical categorical GS residents active on the 2007–2008 resident rosters (N = 6,303) were analyzed for attrition. Complete National Study of Expectations and Attitudes of Residents in Surgery demographic information was available for 3959; the total and survey groups were similar with regard to important characteristics. About 3% of US categorical residents resigned in 2007 to 2008, and 0.4% had contracts terminated. Across all years (including research), there was a 19.5% cumulative risk of resignation. Attrition was highest in PGY-1 (5.9%), PGY-2 (4.3%), and research year(s) (3.9%). Women were no more likely to leave programs than men (2.1% vs. 1.9%). Of several program/resident variables examined, postgraduate year-level was the only independent predictor of attrition in multivariate analysis. Residents who left GS whose plans were known most often pursued nonsurgical residencies (62%), particularly anesthesiology (21%) and radiology (11%). Only 13% left for surgical specialties. Conclusions:Attrition rates are high despite mandated work hour reductions; 1 in 5 GS categorical residents resigns, and most pursue nonsurgical careers. Demographic factors, aside from postgraduate year do not appear predictive. Residents are at risk for attrition early in training and during research, and this could afford educators a target for intervention.

Outcomes of Referral to Dermatology for Suspicious Lesions: Implications for Teledermatology

OBJECTIVES To determine the proportion of suspicious lesions referred by nondermatologists that are found to be malignant and the number of incidental skin cancers identified at the time of dermatology referral. DESIGN Retrospective cohort study. SETTING Veterans Affairs Connecticut Healthcare System. PATIENTS Four hundred patients referred by nondermatologists for skin lesions suspected of being malignant between January 1, 2006, through December 31, 2009. MAIN OUTCOME MEASURES Data collected included the type of referring provider, the final diagnosis by the dermatologist, and the number and type of incidental lesions. RESULTS Only 22.0% of the index lesions (ie, the lesions that prompted the referral) were found to be cancerous. In aggregate, 149 cancerous lesions were noted in 98 patients. However, only 88 (59.1%) were identified in the index lesion; 111 incidental lesions were biopsied by the consulting dermatologist, with 61 (55.0%) additional skin cancers identified. Twelve of the 61 incidental cancers (19.7%) were found in patients whose index lesion was clinically benign and was not biopsied. CONCLUSIONS Nondermatologists may benefit from focused educational initiatives on skin cancer detection, particularly the significance of the total body skin examination and the expectations for and limitations of teledermatology. A substantial proportion of malignant lesions was incidentally identified by the consulting dermatologist in addition to the primary lesion of concern. The use of teledermatology to assess a specific lesion of concern may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician. Therefore, teledermatology must not be used as a substitute for a total body skin examination.

Current advances in the diagnosis and treatment of pancreatic endocrine tumors

Purpose of review A comprehensive literature review of more than 200 original manuscripts published in the last 18 months was conducted to summarize landmark studies performed on the molecular biology, diagnosis, imaging, and treatment of endocrine tumors of the pancreas. Recent findings Recent achievements occurred on many fronts. Identification of a novel insulin splice variant with increased translation efficiency moved forward the understanding of the molecular biology of insulinomas. Results of a 29-year prospective study from the National Institutes of Health clarified the epidemiology of multiple endocrine neoplasia-1 syndrome. Chromogranin A was identified as a promising marker for pancreatic endocrine tumors. New imaging, including 18F-dopa positron emission tomography and laparoscopic ultrasound, and the effective combination of existing modalities localized and staged tumors with greater accuracy. Nonoperative treatment strategies show promise; discovery of the antiangiogenic properties of octreotide and the overexpression of tyrosine kinase receptors such as c-kit, epidermal growth factor receptor, and platelet-derived growth factor receptor on malignant endocrine pancreatic tumors may lead to promising pharmacologic treatment. Summary There have been exciting recent advancements in research surrounding endocrine pancreas that hopefully will pave the way for potential improvement in clinical outcomes for patients with these tumors.

Ustekinumab Associated With Flares of Psoriatic Arthritis

IMPORTANCE Ustekinumab is a human monoclonal antibody that binds to the shared p40 subunit of interleukin (IL) 12 and IL-23. It is approved in the United States for adults (>18 years) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. In 1 phase 2 trial of ustekinumab for treatment of psoriatic arthritis, joint disease improved. OBSERVATION We report 4 cases of ustekinumab monotherapy for plaque psoriasis that resulted in disabling flares of known psoriatic arthritis or unmasked previously occult joint disease. In all of our cases, psoriasis improved dramatically with ustekinumab therapy while psoriatic arthritis flared. CONCLUSIONS AND RELEVANCE Despite early results of a phase 2 ustekinumab trial suggesting efficacy for both plaque psoriasis and psoriatic arthritis, our case series raises concern that ustekinumab may unmask or aggravate joint disease in selected patients. These data underscore the need for further investigation of ustekinumabs effects on psoriatic arthritis.

High-dose isotretinoin in acne vulgaris: improved treatment outcomes and quality of life.

Background  Isotretinoin, for acne treatment, is associated with high rates of permanent remission. However, at recommended doses of 0.5‐1.0 mg/kg/day for 5‐6 months [average cumulative dose: 120‐150 mg/kg], more than 20% of patients experience a relapse within two years that requires further medical management.

Skin cancer screening and primary prevention: Facts and controversies

Skin cancer is both common and responsible for significant morbidity and mortality. Opportunities for both primary and secondary prevention are available to both dermatologists and non-dermatologists. Counseling selected patients about ultraviolet avoidance and proper use of sunscreens is recommended. Due to technical and financial barriers, no study has conclusively confirmed the benefits of skin cancer screening. Both dermatologists and non-dermatologists often do not perform total body skin examinations during clinical encounters, despite high acceptance rates by patients. Many non-dermatologists would benefit from additional education pertaining to the diagnosis of cutaneous malignancy. Teledermatology may have a role in areas with poor access to dermatologists. There are ample opportunities for more to be learned in the future.

National utilization patterns of Mohs micrographic surgery for invasive melanoma and melanoma in situ

BACKGROUND Although wide local excision continues to be commonly used for melanoma treatment, Mohs micrographic surgery (MMS) for the treatment of melanomas remains controversial. OBJECTIVE We sought to determine national utilization patterns for MMS in the treatment of invasive melanoma and melanoma in situ. METHODS A retrospective analysis of patients receiving surgical excision (MMS or wide local excision) for the treatment of invasive melanoma and melanoma in situ was performed using data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program. RESULTS A total of 195,768 melanomas were diagnosed from 2003 through 2009 from the 17 SEER registries. Utilization of MMS for invasive melanoma and melanoma in situ increased by 60% from 2003 to 2008. Of all SEER-captured lesions treated by surgical excision in this time period, 3.5% (6872) were excised by MMS. LIMITATIONS Patient insurance status, physician reimbursement practices, and health care provider type were not addressed in this article. CONCLUSION Use of MMS for melanoma appears to be increasing. Future studies should explore whether this is associated with better outcomes.

Intralesional Bleomycin for Warts: Patient Satisfaction and Treatment Outcomes.

Background: The treatment of warts is challenging with regards to both tolerability and efficacy. Objective: Ascertain the efficacy, tolerability, and patient satisfaction of intralesional bleomycin in the treatment of warts. Methods: Retrospective chart review followed by telephone interviews with patients from university-based dermatology referral centers. Results: Seventy-four percent (34/46) of patients had complete resolution (CR) of all warts. Of 34 patients who experienced CR, an average of 1.7 treatments were required. Pain experienced during the procedure and recovery, irrespective of outcome, was rated 5.8 out of 10 (range, 1-10; SD, 2.72; SEM, 0.40). Approximately 70% of patients had pain that lasted less than 2 days after treatment. Seventy-eight percent (36/46) of patients in the study were satisfied with treatment and would recommend it to others. Conclusion: Patients felt bleomycin to be an effective treatment modality for warts, offering high rates of CR in lesions resistant to more traditional therapies.

Effective use of teledermatology: Defining expectations and limitations as we move forward

To the Editor: The American Academy of Dermatology’s recent support of teledermatology is an important step toward incorporation of a novel technology that possesses the potential to improve patient care and lead to early detection of skin cancers and other cutaneous disease. This evolution in innovation will undoubtedly spread at a rapid pace and become an integrative component of the dermatology consultation process. Before we jump on the ‘‘teledermatology bandwagon,’’ it is important to proceed with caution. Our recent study found that a very large percentage of skin cancers within our health care system were diagnosed at sites remote from the lesion of concern prompting referral. Of the 149 skin cancers found by dermatologists, 61 (41%) were found at other areas that presumably might not have been included in a teledermatology consult. Although in our study we did not review teledermatology per se, we believe that these findings are provocative and warrant further study. Clearly, in areas of the world that are either remote or underserved, we agree that teledermatology may play an important role in allowing patients increased access to dermatologists. However, as physicians integrate teledermatology into their health care systems globally, both expectations and limitations must be defined to maximize effective use. If teledermatology is going to play an important role in our armamentarium to detect skin cancer, nondermatologists should have a lower threshold to include images of all lesions that represent potential concern after a total body skin examination. Assessment solely of one specific lesion of concern as may occur with teledermatology may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician, and therefore must not be used as a substitute for a total body skin examination when skin cancer is suspected.

Nondermatologists' use of predictive terms for a potentially malignant lesion.

Background: Skin cancer is frequently suspected by nondermatologists. Many dermatology practices currently do not triage referrals from nondermatologists. Little is known how nondermatologists describe lesions of concern when making referrals. Objective: We sought to assess the descriptive terminology used by nondermatologists when referring patients with potential cutaneous malignancies. Methods: We completed a retrospective chart review of 400 patients referred by nondermatologists for skin lesions suspicious of malignancy. We collected the reason for the consult, all terminology used to characterize the lesion, and the final diagnosis. Results: Clinicians documented 680 reasons for referring patients with suspicious lesions. General concern (rule out malignancy) without specific descriptors was used in 78 referrals, of which 23% (n = 18) were found to be associated with malignancy. Specific descriptive terminologies used most frequently by nondermatologists to describe suspicious lesions were: hyperpigmented (n = 71), changing size (n = 69), nonhealing (n = 55), irregular border (n = 52), irritated and/or scaly (n = 40), and raised (n = 33). A statistically significant correlation (P < 0.05) was found between skin cancer and the following terms: nonhealing, ulcerated, and rule out basal cell carcinoma. Conclusion: The descriptive terminology of potential cutaneous malignancies utilized by nondermatologists may provide important clues to aid dermatologists in triage decisions. Specifically, ulcerated, nonhealing, and rule out basal cell carcinoma may be terms that indicate the patient should be seen by the dermatologist in a timely manner.