• Comparison of Coronary Artery Calcium Scores Between Patients With Psoriasis and Type 2 Diabetes

      Mansouri, Bobbak; Kivelevitch, Dario; Natarajan, Balaji; Joshi, Aditya A.; Ryan, Caitriona; Benjegerdes, Katie; Schussler, Jeffrey M.; Rader, Daniel J.; Reilly, Muredach P.; Menter, Alan; et al. (AMER MEDICAL ASSOC, 2016-11-01)
      IMPORTANCE Psoriasis is associated with an increased risk of cardiovascular diseases. Subclinical atherosclerosis in patients with psoriasis has not been compared with other conditions associated with increased cardiovascular risk and more rigorous cardiovascular disease screening, such as type 2 diabetes. OBJECTIVE To assess the burden of asymptomatic coronary atherosclerosis measured by coronary artery calcium score in patients with moderate to severe psoriasis compared with patients with type 2 diabetes and healthy controls. DESIGN, SETTING, AND PARTICIPANTS Three single-center, cross-sectional studies were performed in patients recruited from specialty outpatient clinics with moderate to severe psoriasis without type 2 diabetes (recruited from November 1, 2013, through April 31, 2015), patients with type 2 diabetes without psoriasis or other inflammatory diseases (recruited from July 1, 2009, through June 20, 2011), and age-and sex-matched healthy controls without psoriasis, type 2 diabetes, or other inflammatory diseases (recruited from July 1, 2009, through June 20, 2011). EXPOSURES Psoriasis, type 2 diabetes, and healthy control effect on coronary artery calcium score. MAIN OUTCOMES AND MEASURES Coronary artery calcium measured by Agatston score. RESULTS A total of 387 individuals participated in the study. Mean (SD) age was 51 (7.7), 52 (8.0), and 52 (8.0) years in the psoriasis, type 2 diabetes, and healthy control cohorts, respectively. There were 64 men (49.6%) in each group, and most patients were white (119 [ 92.2%], 123 [ 95.3%], and 128 [ 99.2%] in the psoriasis, type 2 diabetes, and healthy control cohorts, respectively). Patients with psoriasis had low cardiovascular risk measured by the Framingham Risk Score but had a high prevalence of cardiovascular and cardiometabolic risk factors, similar to patients with type 2 diabetes. In a fully adjusted model, psoriasis was associated with coronary artery calcium (Tobit regression ratio, 0.89; P < .001) similar to the association in type 2 diabetes (Tobit regression ratio, 0.79; P = .04). Likelihood ratio testing revealed incremental value for psoriasis in a fully adjusted model (chi(2) = 4.48, P = .03) in predicting coronary artery calcium. Psoriasis was independently associated with the presence of any coronary artery calcium (odds ratio, 2.35; 95% CI, 1.12-4.94) in fully adjusted models, whereas the association of coronary artery calcium with type 2 diabetes was no longer significant after adding body mass index to the model (odds ratio, 2.18; 95% CI, 0.75-6.35). CONCLUSIONS AND RELEVANCE Patients with psoriasis have increased coronary artery calcium by mean total Agatston scores, similar to that of patients with type 2 diabetes, suggesting that patients with psoriasis harbor high rates of subclinical atherosclerosis beyond adjustment for body mass index. Major educational efforts for patients and physicians should be undertaken to reduce the burden of cardiovascular disease in patients with psoriasis.
    • Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

      Garrett, Giorgia L.; Blanc, Paul D.; Boscardin, John; Lloyd, Amanda Abramson; Ahmed, Rehana L.; Anthony, Tiffany; Bibee, Kristin; Breithaupt, Andrew; Cannon, Jennifer; Chen, Amy; et al. (AMER MEDICAL ASSOC, 2017-03-01)
      IMPORTANCE Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States. OBJECTIVE To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. MAIN OUTCOMES AND MEASURES Incident skin cancerwas determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). RESULTS Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). CONCLUSIONS AND RELEVANCE Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.
    • Proposed Technical Guidelines for the Acquisition of Clinical Images of Skin-Related Conditions

      Finnane, Anna; Curiel-Lewandrowski, Clara; Wimberley, Glen; Caffery, Liam; Katragadda, Chinmayee; Halpern, Allan; Marghoob, Ashfaq A.; Malvehy, Josep; Kittler, Harald; Hofmann-Wellenhof, Rainer; et al. (AMER MEDICAL ASSOC, 2017-05-01)
      IMPORTANCE Standardizing dermatological imaging is important to improve monitoring of skin lesions and skin conditions, ensure the availability of high-quality images for teledermatology, and contribute to the development of a robust archive of skin images to be used for research. OBJECTIVE To provide guidelines for the clinical application of the Standards for Dermatological Imaging set forward by the ISIC. EVIDENCE REVIEW The ISIC recommendations were developed through a hybrid Delphi methodology. Themethods for achieving consensus have been described previously. The practical application of these recommendations was evaluated by 2 clinical photographers with expertise in skin imaging. Images corresponding to each recommendation were taken by a clinical photographer and provided as visual examples of how these recommendations can be implemented in clinical practice. RESULTS The Standards for Dermatological Imaging developed by the ISIC members could be followed in the clinical setting. Images showing appropriate lighting, background color, field of view, image orientation, focus and depth of field, resolution, and scale and color calibration were obtained by the clinical photographer, by following the detailed recommendations for regional, close-up and dermoscopic images. CONCLUSIONS AND RELEVANCE Adhering to the recommendationsis both feasible and achievable in practice. Adopting these Standards is the first step in achieving international standardization of skin imaging, with the potential to improve clinical outcomes and research activities.
    • Technique Standards for Skin Lesion Imaging

      Katragadda, Chinmayee; Finnane, Anna; Soyer, H. Peter; Marghoob, Ashfaq A.; Halpern, Allan; Malvehy, Josep; Kittler, Harald; Hofmann-Wellenhof, Rainer; Da Silva, Dennis; Abraham, Ivo; et al. (AMER MEDICAL ASSOC, 2017-02-01)
      IMPORTANCE Variability in the metrics for image acquisition at the total body, regional, close-up, and dermoscopic levels impacts the quality and generalizability of skin images. Consensus guidelines are indicated to achieve universal imaging standards in dermatology. OBJECTIVE To achieve consensus among members of the International Skin Imaging Collaboration (ISIC) on standards for image acquisition metrics using a hybrid Delphi method. EVIDENCE REVIEW Delphi study with 5 rounds of ratings and revisions until relative consensus was achieved. The initial set of statements was developed by a core group (CG) on the basis of a literature review and clinical experience followed by 2 rounds of rating and revisions. The consensus process was validated by an extended group (EG) of ISIC members through 2 rounds of scoring and revisions. In all rounds, respondents rated the draft recommendations on a 1 (strongly agree) to 5 (strongly disagree) scale, explained ratings of less than 5, and optionally provided comments. At any stage, a recommendation was retained if both mean and median rating was 4 or higher. RESULTS The initial set of 45 items (round 1) was expanded by the CG to 56 variants in round 2, subsequently reduced to 42 items scored by the EG in round 3, yielding an EG set of 33 recommendations (rounds 4 and 5): general recommendation (1 guideline), lighting (5), background color (3), field of view (3), image orientation (8), focus/depth of field (3), resolution (4), scale (3), color calibration (2), and image storage (1). CONCLUSIONS AND RELEVANCE This iterative process of ratings and comments yielded a strong consensus on standards for skin imaging in dermatology practice. Adoption of these methods for image standardization is likely to improve clinical practice, information exchange, electronic health record documentation, harmonization of clinical studies and database development, and clinical decision support. Feasibility and validity testing under real-world clinical conditions is indicated.