Mary-Margaret Chren

Measurement properties of Skindex-16: a brief quality-of-life measure for patients with skin diseases.

BackgroundAn accurate, sensitive, but brief quality-of-life outcomes measure is needed for studies of dermatologic care.ObjectiveTo construct a single-page version of Skindex (a dermatologic quality-of-life instrument) that would have two new features compared with the current 29-item version: (1) fewer items to which a majority of patients choose the same response, and (2) measurement ofbother rather than frequency of patient experiences.MethodsRandom samples of patients waiting for dermatology appointments in clinics of Veterans Affairs hospitals and in private dermatology practices completed questionnaires; 692 patients responded to the parent instrument and 541 additional patients responded to the brief version. Reproducibility, internal consistency reliability, validity, and responsiveness of the brief version of Skindex were determined.ResultsFor 16 items of the current 29-item version (55%), more than 50% of patients responded “Never.” After an explicit process of item analysis and elimination, a single-page 16-item version was composed that asks patients about bother from their experiences; responses are reported as three scales, Symptoms, Emotions, and Functioning. For 6 items of the 16-item version (38%), more than 50% of patients responded “Never.” Scale scores were reproducible after 72 hours (r = 0.88-0.90) and were internally reliable (Cronbach’s α = 0.86-0.93). The instrument demonstrated both content and construct validity: Most patients’ responses to an open-ended question about their skin disease was addressed by the items; patients with inflammatory dermatoses had higher scores than those with isolated lesions; and in an exploratory principal axes factor analysis with an oblique rotation, 74% of the common variance was explained by three factors that correlated with thea priori scales. Mean scale scores stayed the same or changed in the expected direction in patients who reported that their skin was the same or had improved.ConclusionThis brief single-page version of Skindex accurately and sensitively measures how much patients are bothered by their skin conditions.SommaireAntécédentsLa mesure des résultats relatifs à la qualité de vie lors d’études sur les soins dermatologiques doit être précise, sensible mais concise.ObjectifÉlaborer une version en une seule page du Skindex (instrument de mesure de la qualité de vie sur le plan dermatologique) qui comporterait deux nouvelles caractéristiques par rapport à la version actuelle de 29 questions: (1) moins de questions pour lesquelles la majorité des patients choisissent la même réponse, et (2) la mesure des ennuis causés par la maladie plutôt que celle de la fréquence des épisodes.MéthodesDes échantillonnages randomisés de patients en attente de rendezvous à la clinique de dermatologie des hôpitaux des Anciens Combattants et en cabinets privés ont rempli les questionnaires; 692 patients ont répondu à l’instrument de mesure principal et 541 à la version simplifiée. La reproductibilité, la cohérence interne, la fiabilité, la validité et la réactivité de la version simplifée du Skindex ont été évaluées.RésultatsPlus de 50% des patients ont répondu «jamais» à 16 des 29 questions de la version actuelle (55%). Après un travail en profondeur d’analyse et d’élimination des questions, on a rédigé une version d’une page comportant 16 questions sur les ennuis causés par la maladie, les réponses étant rapportées selon trois échelles: symptômes, émotions et fonctionnement. Plus de 50% des patients ont répondu «jamais» à 6 des 16 questions (38%). Les résultats de l’échelle étaient reproductibles après 72 heures (r = 0, 88-0,90) et fiables sur le plan interne (Cronbach’s α = 0,86-0,93). L’instrument de mesure a permis de démontrer la validité du contenu et de la conception: la plupart des réponses des patients à une question ouverte sur leur affection cutanée étaient abordées dans la question; les patients atteints de dermatoses inflammatoires avaient des résultats plus élevés que ceux présentant des lésions isolées; et dans une analyse factorielle exploratoire des principaux axes, la variance commune s’expliquait à 74% par trois facteurs qui étaient en corrélation avec les échelles établies a priori. Les résultats moyens sont demeurés les mêmes ou ont changé dans le sens attendu chez les patients qui avaient rapporté que l’état de leur peau était le même ou qu’il s’était amélioré.ConclusionCette version simplifiée d’une page du Skindex mesure de façon précise et sensible l’importance des ennuis que causent les affections cutanées aux patients.

Effects of atopic dermatitis on young American children and their families

Objective. The psychologic, physical, and social impact of atopic dermatitis is complex and varies among children of different ages, and the effects of atopic dermatitis on the quality of life of very young American children and their families are not well understood. This study was conducted to document these effects of atopic dermatitis on young children and their families. Methods. Directed focus sessions were performed with parents of 26 young children with atopic dermatitis and 6 expert clinicians. Specific mentions of the ways in which atopic dermatitis affected the children and parents were reviewed, rank ordered, and categorized according to similarity in content. The categories were examined to determine the domains represented, and the domains were used to compose a conceptual framework of all of the ways that atopic dermatitis affects children and their families. Results. Parents and experts mentioned a total of 181 specific quality-of-life effects. A conceptual framework, developed from the 181 effects, contains the domains of physical health, emotional health, physical functioning, and social functioning; each domain includes effects on both the child and the parents. Conclusions. Atopic dermatitis greatly affects the quality of life of afflicted children and their families. The comprehensive conceptual framework summarizes the ways in which atopic dermatitis affects the quality of life in young American children. This conceptual framework forms the basis from which quality-of-life instruments can be developed.

Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis

Objective To synthesise the literature on indoor tanning and non-melanoma skin cancer. Design Systematic review and meta-analysis. Data sources PubMed (1966 to present), Embase (1974 to present), and Web of Science (1898 to present). Study selection All articles that reported an original effect statistic for indoor tanning and non-melanoma skin cancer were included. Articles that presented no data, such as review articles and editorials, were excluded, as were articles in languages other than English. Data extraction Two investigators independently extracted data. Random effects meta-analysis was used to summarise the relative risk of ever use versus never use of indoor tanning. Dose-response effects and exposure to indoor tanning during early life were also examined. The population attributable risk fraction for the United States population was calculated. Results 12 studies with 9328 cases of non-melanoma skin cancer were included. Among people who reported ever using indoor tanning compared with those who never used indoor tanning, the summary relative risk for squamous cell carcinoma was 1.67 (95% confidence interval 1.29 to 2.17) and that for basal cell carcinoma was 1.29 (1.08 to 1.53). No significant heterogeneity existed between studies. The population attributable risk fraction for the United States was estimated to be 8.2% for squamous cell carcinoma and 3.7% for basal cell carcinoma. This corresponds to more than 170 000 cases of non-melanoma skin cancer each year attributable to indoor tanning. On the basis of data from three studies, use of indoor tanning before age 25 was more strongly associated with both squamous cell carcinoma (relative risk 2.02, 0.70 to 5.86) and basal cell carcinoma (1.40, 1.29 to 1.52). Conclusions Indoor tanning is associated with a significantly increased risk of both basal and squamous cell skin cancer. The risk is higher with use in early life (<25 years). This modifiable risk factor may account for hundreds of thousands of cases of non-melanoma skin cancer each year in the United States alone and many more worldwide. These findings contribute to the growing body of evidence on the harms of indoor tanning and support public health campaigns and regulation to reduce exposure to this carcinogen.

International prevalence of indoor tanning: a systematic review and meta-analysis.

IMPORTANCE Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known. OBJECTIVE To summarize the international prevalence of exposure to indoor tanning. DATA SOURCES Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature. STUDY SELECTION Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included. DATA EXTRACTION AND SYNTHESIS Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma. MAIN OUTCOMES AND MEASURES Ever and past-year exposure to indoor tanning. RESULTS The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia. CONCLUSIONS AND RELEVANCE Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

Development and validation of a health-related quality of life instrument for women with melasma.

Background  Melasma can have significant emotional and psychological effects on those affected with the condition. In the past, the impact of melasma on health‐related quality of life (HRQoL) has been assessed using general measures of skin disease that equally weigh both the physical and psychosocial distress arising from the presence of a dermatological condition.

Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation?

OBJECTIVE: To determine the opinions of selected physicians in our community about use of warfarin for patients with nonrheumatic atrial fibrillation, and to determine the relation of the physicians’ opinions to their practices.DESIGN: Survey of physicians, using eight hypothetical clinical vignettes to characterize physicians’ opinions about use of warfarin in patients with nonrheumatic atrial fibrillation, according to patient age, risk of bleeding, and risk of stroke.SETTING: Two teaching hospitals and five community-based practices.PARTICIPANTS: Eighty physicians who cared for 189 consecutive patients with nonrheumatic atrial fibrillation.MEASUREMENTS AND MAIN RESULTS: The survey response rate was 73%. Nearly all responding physicians (90%) recommended warfarin for at least one vignette. However, physicians recommended warfarin less often for vignettes depicting 85-year-old patients than for matched vignettes depicting 65-year-old patients (odds ratio [OR] 0.03; 95% confidence interval [CI] 0.01, 0.08), and less often for cases with specified risk factors for bleeding than for matched cases without the risk factors (OR 0.01; 95% CI 0.004, 0.03); warfarin was recommended more often for cases with a recent stroke than for matched cases without this history (OR 8.2; 95% CI 3.6, 18). In practice, warfarin was prescribed more often (p<-.05) by physicians reporting good personal experience and by those who had favorable opinions about its use. However, even physicians with good experience and favorable opinions did not prescribe warfarin to half of their patents for whom warfarin was independently judged appropriate.CONCLUSIONS: Physicians’ opinions frequently opposed warfarin for older patients with nonrheumatic atrial fibrillation, and for those with bleeding risk factors. Physicians’ opinions, as well as other barriers to warfarin therapy, most likely contribute to its infrequent prescription.

Impact of Renal Insufficiency on Mortality in Advanced Lower Extremity Peripheral Arterial Disease

Renal insufficiency predicts mortality among patients who are treated for myocardial infarction and congestive heart failure, but its clinical significance in advanced peripheral arterial disease has not been evaluated. A national cohort of 5787 male veterans who received an initial diagnosis of rest pain, ischemic ulceration, or gangrene between January 1, 2000, and September 30, 2002, and had at least one serum creatinine measurement within 3 mo before diagnosis were identified. Sixty-two percent (n = 3561) of cohort members had normal or mildly reduced renal function (GFR > or =60 ml/min per 1.73 m(2)), 30% (n = 1742) had moderate renal insufficiency (GFR 30 to 59 ml/min per 1.73 m(2)), and 8% (n = 484) had severe renal insufficiency or renal failure (GFR <30 ml/min per 1.73 m(2)) but were not on dialysis. The percentages of patients who presented with gangrene or ischemic ulceration rather than rest pain increased with declining renal function (70, 77, and 87%; P < 0.001), as did 1-yr mortality risk (17, 27, and 44%; P < 0.001). After adjustment for demographic and clinical characteristics, patients with a GFR of 30 to 59 ml/min per 1.73 m(2) (odds ratio, 1.32; 95% confidence interval, 1.13 to 1.53) and <30 ml/min per 1.73 m(2) (odds ratio, 2.97; 95% confidence interval, 2.39 to 3.69) had a significantly increased odds of death within 1 yr of cohort entry. Both moderate and severe renal insufficiency are associated with an increased odds of death in patients with critical limb ischemia. Death rates were particularly high among those with a GFR <30 ml/min per 1.73 m(2). This finding may be partly explained by their more frequent presentation with ischemic ulceration or gangrene rather than rest pain.

Association between poorer quality of life and psychiatric morbidity in patients with different dermatological conditions

Objective: To determine the relationship between skin-related quality of life and psychiatric morbidity in patients with different skin conditions. Methods: We recruited all adults attending the outpatient clinics of the Dermatological Institute IDI-IRCCS, Rome, Italy, during 14 predetermined days. Eligible patients, who gave their informed consent, completed the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). We used a stringent cut-off threshold (≥5 on the GHQ-12) for identification of psychiatric morbidity. Skindex-29 scale scores were computed separately for GHQ noncases and GHQ cases. Results: A total of 2,136 patients were included in the analysis. For all skin conditions, GHQ cases had substantially poorer score in all 3 domains of quality of life, Symptoms, Emotions, and Functioning. Most differences remained significant after adjusting for clinical severity, age, sex, and education in multiple regression models. These differences were not as marked in the Symptoms scale for some conditions known to be nearly asymptomatic (eg, alopecia, vitiligo, nevi), suggesting that, although patients with psychiatric morbidity might be more burdened by their symptoms, nevertheless they do not perceive nonexistent symptoms. Conclusion: In most skin conditions we considered, psychiatric morbidity was strongly associated with poorer quality of life. Although the cross-sectional nature of our study does not allow identification of the direction of this association, care for the psychological condition of patients might have an impact on their quality of life.

Age, gender, quality of life and psychological distress in patients hospitalized with psoriasis

Background  Psoriasis has a great impact on the quality of life of patients, and the ageing population is an important public health issue.

Further Evidence of the Validity and Reliability of the Skindex-29: An Italian Study on 2,242 Dermatological Outpatients

Background: Quality of life is increasingly recognized as an important measure in dermatology. The Skindex-29 is a self-administered questionnaire recently developed to measure comprehensively the complex effects of skin diseases on patients’ quality of life. Objective: We aimed to provide further evidence of the reliability and validity of the Skindex-29 in a large sample of patients affected by a wide variety of skin diseases. Methods: An Italian version of the Skindex-29 was produced following accepted guidelines for the cross-cultural adaptation of questionnaires. All adult outpatients attending a dermatological hospital on predetermined days were given the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). Results: A total of 2,242 complete questionnaires were analyzed. The internal consistency and test-retest reliability of each scale were high. The factor structure of the Skindex-29 was strikingly similar to the one originally observed in American patients. The pattern of correlation with the GHQ-12 provided evidence of convergent validity of the Skindex-29. Conclusion: The instrument seems to measure three fundamental dimensions of skin health-related quality of life.