Keratinocyte carcinoma (KC) is the most common malignancy in the U.S. Because KC affects many people but has a low mortality rate, it is important to consider the impact of KC on skin-related quality of life (QoL). We aimed to determine if KCs, actinic keratoses (AKs), and several demographic and health-related factors were associated with skin- related QoL in those at high risk for KC. We used data from a double-blind, placebo- controlled trial in which 932 veterans with multiple prior KCs were randomized to apply topical 5-fluorouracil (5-FU) or vehicle control cream to the face/ears. Skin-related QoL was measured at baseline, 12, 24, and 36 months using Skindex-29 and Skin Cancer Index and participants received skin examinations semiannually. At baseline, worse skin- related QoL was strongly associated (p≤0.01) with younger age and greater functional impairments (e.g. inability to bathe, walk). It was also associated with higher comorbidities, increased sun-sensitivity and prior 5-FU use, but almost entirely unrelated to baseline AKs and prior KCs. However, participants who developed new KCs or more AKs during the trial had worse skin-related QoL, particularly in year 1. Our ability to detect these relationships in longitudinal analyses but not in cross-sectional analyses may indicate the importance of the more precise control of potential confounding factors that is inherent in comparing each individual to their own prior state. These findings suggest that additional KCs and AKs may worsen skin-related QoL in a high-risk population and individuals with worse overall health may need more dermatologic attention, not less.

Patient-reported outcomes (PROs) provide quantitative assessments of patients' experiences with their skin diseases. PROs are usually much more comprehensive than what can be gleaned from a brief clinical history and more informative than what dermatologists can gather on clinical examination. Correlations between PROs and clinician assessments (e.g., investigator global assessment, PASI) are poor to moderate at best, and therefore data from each source are not redundant and can complement one another. PROs should serve as skin vital signs in dermatology. PROs can offer snapshots of the intensity of a symptom as well as the effects of symptoms, emotions, and functioning on a patient's skin-related QOL. Just as clinicians obtain a baseline blood pressure before starting antihypertensives, dermatology-specific PROs serve as a baseline from which clinicians can monitor (even remotely) for improvement or side effects with treatment and for flares. Both PROs and conventional vital signs are usually normal. It is when they are abnormal or different than expected that they become informative. We conclude by offering a roadmap for investigators to conduct the next steps in PRO research necessary to establish guidelines for transitioning PROs from clinical research and trials to routine clinical use.

Background

Solid organ transplant recipients (OTR) are at an increased risk of developing squamous cell carcinoma (SCC) of the skin after transplantation. In predominantly white cohorts, Fitzpatrick skin type (FST) has been reported to be a risk factor for developing posttransplantation skin cancers.

Objective

Our goal was to determine if FST is a statistically significant risk factor for the development of SCC after solid organ transplantation in a diverse US population of OTR.

Methods

A cohort of OTR completed a questionnaire of demographic factors, transplant type, FST, and skin cancer history. Univariate and multivariate analyses were performed to determine the risk factors for development of SCC after transplantation.

Results

As expected, male subjects had an increased risk for SCC compared with female subjects (P = .02), and those aged 50 years and older at the time of transplantation were more likely to develop SCC compared with those younger than 50 years (P < .001). The risk of SCC increased with each incremental decrease in FST, from FST VI to FST I (linear test for trend P < .001).

Limitations

Our questionnaire did not ask specifically about immunosuppressive medications; instead, organ transplant category was used as a proxy for level of immunosuppression.

Conclusions

FST, a patient-reported variable, is an independent risk factor for the development of SCC in OTR, and should be elicited from patients who have gone or will undergo organ transplantation.

For most cutaneous basal cell and squamous cell carcinomas (nonmelanoma skin cancers (NMSCs)), data are insufficient to permit evidence-based choices among treatments. To compare tumor recurrence after treatments, we conducted a prospective cohort study of

Background

European studies have shown that itch is a widespread symptom, yet little is known about its frequency in the United States.

Objective

We sought to describe ambulatory care visits to clinicians in the United States for which itch was coded as a patient symptom.

Methods

This study uses retrospective data from the National Ambulatory Medical Care Survey from 1999 through 2009.

Results

Itch was coded as a symptom for an average of 7 million visits per year or approximately 1% of all outpatient visits, which was nearly 40% of the number of visits for the symptom of low back pain. Patients seen in visits for itch were more likely to be black or Asian than other patients (20% vs 14%). They were also more likely than other patients to receive a new medication (68% vs 36%) and were over twice as likely to receive 2 or more new medications (31% vs 14%).

Limitations

Secondary data sets may not optimally capture patient reports and some of the procedures or medications may have been ordered for reasons other than itch.

Conclusion

Visits to clinicians for itch represent a sizeable proportion of ambulatory care visits in the United States, and research on the epidemiology, treatments, and causes of itch should be a priority.

The current revolution of digital health technology and machine learning offers enormous potential to improve patient care. Nevertheless, it is essential to recognize that dermatology requires an approach different from those of other specialties. For many dermatological conditions, there is a lack of standardized methodology for quantitatively tracking disease progression and treatment response (clinimetrics). Furthermore, dermatological diseases impact patients in complex ways, some of which can be measured only through patient reports (psychometrics). New tools using digital health technology (e.g., smartphone applications, wearable devices) can aid in capturing both clinimetric and psychometric variables over time. With these data, machine learning can inform efforts to improve health care by, for example, the identification of high-risk patient groups, optimization of treatment strategies, and prediction of disease outcomes. We use the term personalized, data-driven dermatology to refer to the use of comprehensive data to inform individual patient care and improve patient outcomes. In this paper, we provide a framework that includes data from multiple sources, leverages digital health technology, and uses machine learning. Although this framework is applicable broadly to dermatological conditions, we use the example of a serious inflammatory skin condition, chronic cutaneous graft-versus-host disease, to illustrate personalized, data-driven dermatology.

Acute Care for Elders Units offer enhanced care for older adults in specially designed hospital units. The care is delivered by interdisciplinary teams, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. In a randomized controlled trial of 1,632 elderly patients, length-of-stay was significantly shorter-6.7 days per patient versus 7.3 days per patient-among those receiving care in the Acute Care for Elders Unit compared to usual care. This difference produced lower total inpatient costs-$9,477 per patient versus $10,451 per patient-while maintaining patients' functional abilities and not increasing hospital readmission rates. The practices of Acute Care for Elders Units, and the principles they embody, can provide hospitals with effective strategies for lowering costs while preserving quality of care for hospitalized elders.