Citations

AbstractBackgroundChildhood obesity is underdiagnosed in primary care practices. Our study aimed to compare rates of documentation of diagnosis of obesity and counselling for nutrition and physical activity at an academic primary care practice prior to and following implementation of a body mass index (BMI)‐based electronic point of care clinical reminder tool.MethodsWe performed a retrospective record review of children aged 2–18 years undergoing well child visits during any of three calendar years (2009, 2011 and 2013). The electronic clinical reminder tool was implemented in September 2010. Records of children with BMI > 95th percentile were electronically searched for terms of documentation of diagnosis of obesity and nutrition and physical activity counselling. Multivariable logistic regression models were used to adjust for potential patient and provider confounders.ResultsAmong those with BMI ≥ 95th percentile, there was a statistically significant increase in documentation of diagnosis of obesity (45.5% in 2009 vs. 52.4% in 2011; P < 0.001; adjusted odds ratio 1.36; 95% CI 1.13–1.65) and in counselling for physical activity and nutrition (66.8% in 2009 vs. 75.2% in 2011; P < 0.001; adjusted odds ratio 1.33; 95% CI 1.06–1.66) following implementation of the tool. Compared with 2011, there was no statistically significant increase in documentation of obesity (50.4%) or nutrition and physical activity counselling (77.9%) in 2013.ConclusionsThe implementation of a point of care clinical reminder tool was associated with improvement in documentation of diagnosis of obesity and counselling for nutrition and physical activity. Further studies are needed to determine the impact of these automated tools on weight outcomes in children.

Objectives This study aimed to determine factors influencing the selection of Mayo-McCall culdoplasty (MMC), open abdominal sacrocolpopexy (ASC), or robotic sacrocolpopexy (RSC) for posthysterectomy vaginal vault prolapse. Methods We retrospectively searched for the records of patients undergoing posthysterectomy apical vaginal prolapse surgery between January 1, 2000, and June 30, 2012, at our institution. Baseline characteristics and explicit selection factors were abstracted from the electronic medical records. Factors were compared between groups using χ2 tests for categorical variables, analysis of variance for continuous variables, and Kruskal-Wallis tests for ordinal variables. Results Among the 512 patients identified who met inclusion criteria, the MMC group (n = 174) had more patients who were older, had American Society of Anesthesiologists class 3+ or greater, had anterior vaginal prolapse grade 3+, desired to avoid abdominal surgery, and did not desire a functional vagina. Patients in the ASC (n = 237) and RSC (n = 101) groups had more failed prolapse surgeries, suspected abdominopelvic pathologic processes, and chronic pain. Advanced prolapse was more frequently cited as an explicit selection factor for ASC than for either MMC or RSC. Conclusions The most common factors that influenced the type of apical vaginal vault prolapse surgery overlapped with characteristics that differed at baseline. In general, MMC was chosen for advanced anterior vaginal prolapse and baseline characteristics that increased surgical risks, ASC for advanced apical prolapse, and ASC or RSC for recurrent prolapse, suspected abdominal pathology, and patients with chronic pain or lifestyles including heavy lifting. Thus, efforts should be made to attempt to control for selection bias when comparing these procedures.

Objective: To compare the rate of persistence of ADHD into adulthood as determined by a norm-referenced versus non-norm-referenced diagnostic interview, and by standardized questionnaires. Method: Adults from a birth cohort, including research-identified childhood ADHD cases ( N = 232; M age = 27.0 years; 167 males, 65 females) and controls ( N = 335; M age = 28.6 years; 210 males, 125 females), were administered the M.I.N.I. International Neuropsychiatric Interview, the Murphy–Barkley Symptoms Checklist (MB), and the Wender Utah Rating Scale (WURS) Results: Among the childhood ADHD cases, 29.3% fulfilled criteria for adult ADHD using a norm-referenced approach to M.I.N.I. scoring, versus 13.8% using published M.I.N.I. criteria. Among participants meeting norm-referenced diagnostic criteria, 41.8% and 69.1% were classified as adult ADHD using the MB and WURS, respectively. Conclusion: A non-norm-referenced approach resulted in a significant underestimate of the rate of adult ADHD. Reliance on either of two adult ADHD questionnaires would have further reduced this estimate.

Background: Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods. Methods: Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF–12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test. Results: A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 ( p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 ( p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF–12 scores improved for global physical function ( p < .001) and mental function ( p = .002). Conclusions: Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.

AbstractBackgroundMerkel cell carcinoma (MCC) is a rare, aggressive, often cutaneous malignancy. The incidence has been estimated from national registries in the USA and elsewhere, and data indicate variations depending on the region studied. The objective of this study was to determine the incidence of MCC in Olmsted County (MN, USA).MethodsUsing the Rochester Epidemiology Project, which contains health records for all the residents of Olmsted County, we retrospectively reviewed the records for all cases of MCC from 1976 to 2011.ResultsThe overall annual age‐ and sex‐adjusted incidence of MCC in Olmsted County during 1976–2011 was 0.35 per 100,000 person‐years (95% CI, 0.14–0.57). The incidence tended to be higher among men than women with 0.69 per 100,000 (95% CI, 0.24–1.14) and 0.10 per 100,000 (95% CI, 0–0.24), respectively.ConclusionsThese data are within the range of previous MCC incidence reports, and the incidence of MCC in Olmsted County is consistent with rates reported in the remainder of the USA.

Purpose Less than 20% of patients with melanoma who undergo sentinel lymph node (SLN) biopsy based on American Society of Clinical Oncology/Society of Surgical Oncology recommendations are SLN positive. We present a multi-institutional study to discover new molecular risk factors associated with SLN positivity in thin and intermediate-thickness melanoma. Patients and Methods Gene clusters with functional roles in melanoma metastasis were discovered by next-generation sequencing and validated by quantitative polymerase chain reaction using a discovery set of 73 benign nevi, 76 primary cutaneous melanoma, and 11 in-transit melanoma metastases. We then used polymerase chain reaction to quantify gene expression in a model development cohort of 360 consecutive thin and intermediate-thickness melanomas and a validation cohort of 146 melanomas. Outcome of interest was SLN biopsy metastasis within 90 days of melanoma diagnosis. Logic and logistic regression analyses were used to develop a model for the likelihood of SLN metastasis from molecular, clinical, and histologic variables. Results ITGB3, LAMB1, PLAT, and TP53 expression were associated with SLN metastasis. The predictive ability of a model that included these molecular variables in combination with clinicopathologic variables (patient age, Breslow depth, and tumor ulceration) was significantly greater than a model that only considered clinicopathologic variables and also performed well in the validation cohort (area under the curve, 0.93; 95% CI, 0.87 to 0.97; false-positive and false-negative rates of 22% and 0%, respectively, using a 10% cutoff for predicted SLN metastasis risk). Conclusion The addition of cell adhesion–linked gene expression variables to clinicopathologic variables improves the identification of patients with SLN metastases within 90 days of melanoma diagnosis.

Frozen section pathology is routinely used for margin assessment of non‐melanoma skin cancer ( NMSC ). Frozen section can also be used for the primary diagnosis of several skin lesions. Limited data exist on the accuracy of frozen section in the diagnosis of NMSC . We performed a retrospective chart review of 300 cases in which frozen section diagnoses were compared with permanent section diagnoses of NMSC . Frozen section and permanent section pathology were concordant 83.3% of the time, with the highest concordance rates noted for basal cell carcinoma (145/153, 95%). Our results show a high level of concordance between frozen section and corresponding permanent section pathology diagnosis for NMSC . The rapidity of frozen section tissue processing and pathology reporting makes this technique useful in dermatologic practice for immediate diagnosis and management of NMSC . Further studies should explore strategies to decrease or eliminate discrepancies between frozen and permanent section diagnosis.

AbstractBackgroundPatients with chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), or non‐Hodgkin lymphoma (NHL) are at increased risk for the development of skin malignancies.ObjectivesThis study was conducted to estimate the incidences of rare skin malignancies in patients with CLL/SLL or NHL.MethodsPatients with a diagnosis of CLL/SLL or NHL recorded in the Surveillance, Epidemiology and End Results (SEER) database during 1992–2007 were identified. Diagnoses of specific skin malignancies were identified from SEER files.ResultsDuring 1992–2007, a total of 128,674 patients with first diagnoses of CLL/SLL or NHL were recorded in SEER; 4743 were excluded because follow‐up data were unavailable. Among the remaining 123,931 patients, 28,964 had CLL/SLL and 94,967 had NHL. Standardized incidence ratios (SIRs) for invasive malignant melanoma, Merkel cell carcinoma, malignant fibrous histiocytoma, dermatofibrosarcoma protuberans, Kaposi's sarcoma, and sebaceous carcinoma were 2.3, 8.2, 3.6, 2.5, 2.9, and 1.4, respectively, in CLL/SLL patients and 1.6, 3.2, 1.5, 1.3, 17.6, and 0.8, respectively, in NHL patients. When invasive melanoma was stratified by patient age and sex, the highest SIR (17.8) was found in men aged 0–49 years with CLL (P < 0.001).ConclusionsPatients with CLL/SLL or NHL have a higher risk for the subsequent development of rare skin cancers. Given the more aggressive nature of these malignancies in this setting, regular monitoring for the development and prompt treatment of cutaneous malignancy is prudent in patients with NHL and particularly in patients with CLL. Regular use of sun protection may decrease the morbidity associated with skin cancer in this immunosuppressed population.

Objective: The purpose of our study was to compare the clinical utility of administering 2 recommended developmental screening instruments, the Infant Developmental Inventory (IDI) and the Ages and Stages Questionnaire (ASQ), at 9-month well-child visits in paper format. Methods: Outcomes of the 2 screens, including correct completion and interpretation by clinician, time of visit, and screen outcome were compared. Results: Out of 33 children administered the ASQ and with documented scores, 12 (36.4%) did not receive passing scores, while 5 (12.2%) of the 41 children administered the IDI did not receive passing scores ( P = .014). Out of 41 IDI screens, 12 (29.3%) were completed incorrectly, while there were no ASQ screens completed incorrectly ( P < .001) by caregivers. Conclusion: In our pilot study, the ASQ is more often completed correctly by caregivers and identifies more children at risk for delay as compared with the IDI. Additional larger scale studies are needed to evaluate the usefulness of developmental screening tools when used within primary care practice.