Associations of pigmentary and naevus phenotype with melanoma risk in two populations with comparable ancestry but contrasting levels of ambient sun exposure

BACKGROUND

People at high risk of developing melanoma are usually identified by pigmentary and naevus phenotypes.

OBJECTIVE

We examined whether associations of these phenotypes with melanoma risk differed by ambient sun exposure or participant characteristics in two population-based, case-control studies with comparable ancestry but different ambient sun exposure.

METHODS

Data were analysed from 616 cases and 496 controls from the Australian Melanoma Family Study and 2012 cases and 504 controls from the Leeds (UK) case-control study. Questionnaire, interview and dermatological skin examination data were collected using the same measurement protocols. Relative risks were estimated as odds ratios using unconditional logistic regression, adjusted for potential confounders.

RESULTS

Hair and skin colour were the strongest pigmentary phenotype risk factors. All associations of pigmentary phenotype with melanoma risk were similar across countries. The median number of clinically assessed naevi was approximately three times higher in Australia than Leeds, but the relative risks for melanoma associated with each additional common or dysplastic naevus were higher for Leeds than Australia, especially for naevi on the upper and lower limbs. Higher naevus counts on the head and neck were associated with a stronger relative risk for melanoma for women than men. The two countries had similar relative risks for melanoma based on self-reported naevus density categories, but personal perceptions of naevus number differed by country. There was no consistent evidence of interactions between phenotypes on risk.

CONCLUSIONS

Classifying people at high risk of melanoma based on their number of naevi should ideally take into account their country of residence, type of counts (clinical or self-reported), body site on which the naevus counts are measured and sex. The presence of naevi may be a stronger indicator of a genetic predisposition in the UK than in Australia based on less opportunity for sun exposure to influence naevus development.

Dermoscopy and in vivo confocal microscopy are complementary techniques for diagnosis of difficult amelanotic and light-coloured skin lesions

BACKGROUND

Amelanotic melanomas are often difficult to diagnose.

OBJECTIVES

To find and test the best methods of diagnosis using dermoscopy and reflectance confocal microscopy (RCM) tools.

METHODS

We selected consecutive, difficult-to-diagnose, light-coloured and amelanotic skin lesions from three centres (in Australia and Italy). Dermoscopy and RCM diagnostic utility were evaluated under blinded conditions utilizing 45 melanomas (16 in situ, 29 invasive), 68 naevi, 48 basal cell carcinomas (BCCs), 10 actinic keratoses, 10 squamous cell carcinomas (SCCs) and 13 other benign lesions.

RESULTS

Sensitivity and specificity for melanoma with dermoscopy pattern analysis by two blinded observers and their 'confidence in diagnosis' were low. The amelanotic dermoscopy method had the highest sensitivity (83%) for a diagnosis of malignancy (melanoma, BCC or SCC), but specificity was only 18%. Multivariate analysis confirmed the utility of RCM features previously identified for the diagnosis of BCC and melanoma (highest odds ratio for melanoma: epidermal disarray, dark and/or round pagetoid cells). RCM sensitivity was 67% and 73% for melanoma and BCC diagnosis, respectively, and its specificity for nonmalignant lesion diagnosis was 56%. RCM reader confidence was higher than for dermoscopy; 84% of melanomas would have been biopsied and biopsy avoided in 47% of benign lesions. All melanomas misclassified by either dermoscopy or RCM were detected by the other tool.

CONCLUSIONS

Dermoscopy and RCM represent complementary/synergistic methods for diagnosis of amelanotic/light-coloured skin lesions.

Sleep bruxism associated with obstructive sleep apnoea syndrome - A pilot study using a new portable device

Sleep bruxism (SB) and obstructive sleep apnoea syndrome (OSAS) share common pathophysiologic pathways. We aimed to study the presence and relationship of SB in a OSAS population. Patients referred with OSAS suspicion and concomitant SB complains were evaluated using a specific questionnaire, orofacial evaluation and cardio-respiratory polygraphy that could also monitor audio and EMG of the masseter muscles. From 11 patients studied 9 had OSAS. 55.6% were male, mean age was 46.3±11.3 years, and apnea hypopnea index of 11.1±5.7/h. Through specific questionnaire 55.6% had SB criteria. Orofacial examination (only feasible in 3) confirmed tooth wear in all. 77.8% had polygraphic SB criteria (SB index>2/h). Mean SB index was 5.12±3.6/h, phasic events predominated (72.7%). Concerning tooth grinding episodes, we found a mean of 10.7±9.2 per night. All OSAS patients except two (77.8%) had more than two audible tooth-grinding episodes. These two patients were the ones with the lowest SB index (1.0 and 1.4 per hour). Only in one patient could we not detect tooth grinding episodes. There was a statistically significant positive correlation between tooth grinding episodes and SB index and phasic event index (R=0.755, p=0.019 and R=0.737, p=0.023 respectively, Pearson correlation). Mean apnoea to bruxism index was 0.4/h, meaning that only a minority of SB events were not secondary to OSAS. We could not find any significant correlation between AHI and bruxism index or phasic bruxism index (R=-0.632 and R=-0.611, p>0.05, Pearson correlation). This pilot study shows that SB is a very common phenomenon in a group of mild OSAS patients, probably being secondary to it in the majority of cases. The new portable device used may add diagnostic accuracy and help to tailor therapy in this setting.

Assessment of bariatric surgery efficacy on Obstructive Sleep Apnea (OSA)

A worldwide rise in weight and obesity is taking place, associated with an increase in several comorbid conditions, such as Obstructive Sleep Apnea (OSA). Bariatric surgery is an effective treatment approach for obesity, with resultant improvement in obesity-related comorbidities. However, the relationship between this type of treatment and OSA is not well established. This systematic review aims to assess and characterize the impact that different types of bariatric surgery have on obese OSA patients. 22 articles with stated preoperative apnea-hypopnea index (AHI), apnea index (AI) or respiratory disturbance index (RDI) were analyzed in this review. A significant improvement in AHI/AI/RDI occurred after surgery, in addition to the foreseeable reduction in body mass index (BMI). Moreover, almost every study stated a postoperative reduction of the AHI to < 20/h and/or a >50% postoperative reduction of AHI, with few exceptions. The interventions with a combined malabsorptive and restrictive mechanism, like roux-en-Y gastric bypass (RYGB), were more efficacious in resolving and improving OSA than purely restrictive ones, like laparoscopic adjustable gastric banding (LAGB). In conclusion, bariatric surgery has a significant effect on OSA, leading to its resolution or improvement, in the majority of cases, at least in the short/medium term (1-2 years). However, the different results must be interpreted with caution as there are many potential biases resulting from heterogeneous inclusion criteria, duration of follow-up, diagnostic methodology and assessed variables.

Optimal treatment sequence in COPD: Can a consensus be found?

There is currently no consensus on the treatment sequence in chronic obstructive pulmonary disease (COPD), although it is recognized that early diagnosis is of paramount importance to start treatment in the early stages of the disease. Although it is fairly consensual that initial treatment should be with an inhaled short-acting beta agonist, a short-acting muscarinic antagonist, a long-acting beta-agonist or a long-acting muscarinic antagonist. As the disease progresses, several therapeutic options are available, and which to choose at each disease stage remains controversial. When and in which patients to use dual bronchodilation? When to use inhaled corticosteroids? And triple therapy? Are the existing non-inhaled therapies, such as mucolytic agents, antibiotics, phosphodiesterase-4 inhibitors, methylxanthines and immunostimulating agents, useful? If so, which patients would benefit? Should co-morbidities be taken into account when choosing COPD therapy for a patient? This paper reviews current guidelines and available evidence and proposes a therapeutic scheme for COPD patients. We also propose a treatment algorithm in the hope that it will help physicians to decide the best approach for their patients. The authors conclude that, at present, a full consensus on optimal treatment sequence in COPD cannot be found, mainly due to disease heterogeneity and lack of biomarkers to guide treatment. For the time being, and although some therapeutic approaches are consensual, treatment of COPD should be patient-oriented.

Asthma control and exacerbations in patients with severe asthma treated with omalizumab in Portugal

The analysis of outcomes from patients with severe asthma treated with omalizumab, using real-life prospective data, should contribute to future informed decisions about this treatment in Portugal. The aim of this study was to assess the clinical effect of omalizumab in Portuguese patients with severe persistent allergic asthma, considering specifically asthma control and exacerbations. This was an observational, prospective, multicentre study. Data were collected at routine care over a 12-month period. Disease control was defined by Control of Allergic Rhinitis and Asthma Test (CARAT) global score >24. All asthma patients already under treatment with omalizumab in 7 departments from 6 Portuguese hospitals were included (n=48). Most (77%) patients were female and the mean (SD) age was 51.9 (10.2) years old. During the study period, asthma was controlled in 34% of the visits and the 12-month exacerbation rate was 1.7 per patient (0.6 with unscheduled medical care). One-third of the patients needed unscheduled medical care because of asthma and 29% had to start or increase oral corticosteroid. There was still a 41% reduction in the total sum of oral corticosteroids usage from the first to the last trimester of the study. During routine treatment with omalizumab, Portuguese patients with severe asthma achieved asthma control in 1/3 of the visits and only 1/3 needed unscheduled or Emergency Room care because of asthma exacerbations. These outcomes support the maintenance of the clinical effect during treatment with omalizumab in routine care in Portugal.

Comparison of NITAG policies and working processes in selected developed countries

BACKGROUND

Vaccines are specific medicines characterized by two country-specific market access processes: (1) a recommendation by National Immunization Technical Advisory Group (NITAG), and (2) a funding policy decision.

OBJECTIVES

The objective of this study was to compare and analyze NITAGs of 13 developed countries by describing vaccination committees' bodies and working processes.

METHODS

Information about NITAGs bodies and working processes was searched from official sources from June 2011 to November 2012. Retrieved information was completed from relevant articles identified through a systematic literature review and by information provided by direct contact with NITAGs or parent organizations. An expert panel was also conducted to discuss, validate, and provide additional input on obtained results.

RESULTS

While complete information, defined as 100%, was retrieved only for the UK, at least 80% of data was retrieved for 9 countries out of the 13 selected countries. Terms of references were identified in 7 countries, and the main mission for all NITAGs was to provide advice for National immunization programs. However, these terms of references did not fully encompass all the actual missions of the NITAGs. Decision analysis frameworks were identified for 10 out of the 13, and all NITAGs considered at least four criteria for decision-making: disease burden, efficacy/effectiveness, safety and cost-effectiveness. Advices were published by most NITAGs, but few NITAGs published meeting agendas and minutes. Only the United States had open meetings.

CONCLUSIONS

This study supports previous findings about the disparities in NITAGs processes which could potentially explain the disparity in access to vaccinations and immunization programs across Europe. With NITAGs recommendations being used by policy decision makers for implementation and funding of vaccine programs, guidances should be well-informed and transparent to ensure National Immunization Programs' (NIP) credibility among the public and health care professionals.

Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement

Economic evaluations of health interventions pose a particular challenge for reporting. There is also a need to consolidate and update existing guidelines and promote their use in a user friendly manner. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement is an attempt to consolidate and update previous health economic evaluation guidelines efforts into one current, useful reporting guidance.The primary audiences for the CHEERS statement are researchers reporting economic evaluations and the editors and peer reviewers assessing them for publication. The need for new reporting guidance was identified by a survey of medical editors. A list of possible items based on a systematic review was created. A two round, modified Delphi panel consisting of representatives from academia, clinical practice, industry, government, and the editorial community was conducted. Out of 44 candidate items, 24 items and accompanying recommendations were developed. The recommendations are contained in a user friendly, 24 item checklist. A copy of the statement, accompanying checklist, and this report can be found on the ISPOR Health Economic Evaluations Publication Guidelines Task Force website (www.ispor.org/TaskForces/EconomicPubGuidelines.asp). We hope CHEERS will lead to better reporting, and ultimately, better health decisions. To facilitate dissemination and uptake, the CHEERS statement is being co-published across 10 health economics and medical journals. We encourage other journals and groups, to endorse CHEERS. The author team plans to review the checklist for an update in 5 years.

Smouldering systemic mastocytosis presenting with cryptic life-threatening crises: case report and literature review

Systemic mastocytosis (SM) is a rare, clonal disorder of the mast cell (MC) and its precursor cells. It is characterized by proliferation and accumulation of MCs within various organs, most commonly the skin. The clinical course is variable with indolent or smouldering and aggressive forms being described. We report the case of a middle-aged male patient with smouldering SM presenting with atypical recurrent life-threatening crises. The patient reported a 19-year history of chronic symptoms. The patient had four inpatient stays due to atypical life-threatening crises, during which he has shown end organ damage (cardiac and renal). With each crisis the patient reported acute symptoms. The management of each of these episodes was complex and made more challenging by the patient's longstanding history of hypertension and ischaemic heart disease. In short, SM can present with unexplained life-threatening crises which can be confused for an infectious disease being acute in nature.

Efficacy evaluation of educational sessions for patients with asthma and COPD

INTRODUCTION

Asthma and COPD are respiratory diseases in which a better knowledge and understanding of the pathology allows the patients to be more involved, which is crucial in their treatment. Holding educational sessions is a good way of imparting information to the patients.

AIM

To determine the efficacy of educational sessions in helping patients with Asthma and COPD to acquire a better understanding of their condition.

METHODS

Following a Portuguese Lung Foundation initiative to improve knowledge about respiratory health, educational sessions for patients suffering from Asthma or COPD were organized. 25 randomized patients with the disease were invited to participate. Each session lasted 60 minutes. Patient knowledge was tested by means of a multiple choice questionnaire before and after the session.

RESULTS

Fifteen patients with asthma attended the sessions, they had an average age of 36 years, of which 60% were female. Within the group 60% were able to name their pathology correctly. Seventeen patients with COPD attended the sessions, they had an average age of 69 years, of which 70% were males and only 3 (17,6%) patients were able to correctly name their pathology. In both groups, there was a statistically positive improvement (p<0,05) of correct answers to the questionnaire the end of each educational session.

CONCLUSION

Patient knowledge increased in each educational session. Patients with COPD were less well informed about their disease than patients with asthma and they also had more difficulty in correctly naming their disease.