Faculty Bibliography

OBJECTIVES: To determine whether radiation alters taste function and structure. RESEARCH DESIGN: Prospective, longitudinal study. METHODOLOGY: Testing prior to starting radiation, and 2 weeks, 2 months, and 6 months after completing radiation. RESULTS: Relative to controls, patients had lower taste identification test scores for bitter, salty, and sour tastes. Sour taste also showed a significant group-by-time interaction (P = .03). Taste pores were decreased in the irradiated group, with a significant group-by-time interaction (P = .03). CONCLUSION: Head and neck cancer patients have decreased taste function, and radiation adversely affected sour taste and taste pores.

We analyzed breast percent density (PD) estimated from 35 women with existing or recently detected abnormalities. Analyzed were digital mammograms (DM) and the central digital breast tomosynthesis (DBT) reconstructed slices. PD was estimated from the breast contralateral to cancer. We have examined the effect of modifying the DBT reconstruction filter on the accuracy of dense tissue segmentation; we selected the filter that effectively reduced image intensity overshoot near the breast edge, which interfered with segmentation. The Pearson correlation coefficient between PD estimates from DM and the central reconstructed DBT slices was r = 0.90. The corresponding quadratic-weighted kappa coefficient was kappa = 0.78, including substantial agreement. The observed results are comparable with the agreement between PD estimates from DM and the central DBT projection images (r = 0.89 and kappa = 0.74). This suggests that PD is robust to variations in acquisition conditions.

Studies with mammograms have demonstrated a relationship between parenchymal texture and breast cancer risk. Although promising, texture analysis in mammograms is limited by the effect of tissue superimposition. Digital Breast Tomosynthesis (DBT) is a novel tomographic x-ray breast imaging modality that allevates the effect of tissue superimposition. We explore the potential advantages of DBT texture analysis for breast cancer risk estimation. We analyzed bilateral DBT and DM images from 39 women, and compared the performance of the computed texture features in (i) reflecting characteristic parenchymal properties, and (ii) correlating to mammographic breast density, an established surrogate of breast cancer risk. Strong texture correlation was observed between contralateral and ipsilateral breasts, indicating that parenchymal properties are potentially inherent to an individual woman. Compared to DM, DBT texture features demonstrated a stronger correlation with breast density. Although preliminary, our results show that DBT texture analysis could potentially improve breast cancer risk estimation.

BACKGROUND: African American and Hispanic women, such as those living in the northern Manhattan and the South Bronx neighborhoods of New York City, are generally underserved with regard to breast cancer prevention and screening practices, even though they are more likely to die of breast cancer than are other women. Primary care physicians (PCPs) are critical for the recommendation of breast cancer screening to their patients. Academic detailing is a promising strategy for improving PCP performance in recommending breast cancer screening, yet little is known about the effects of academic detailing on breast cancer screening among physicians who practice in medically underserved areas. We assessed the effectiveness of an enhanced, multi-component academic detailing intervention in increasing recommendations for breast cancer screening within a sample of community-based urban physicians. METHODS: Two medically underserved communities were matched and randomized to intervention and control arms. Ninety-four primary care community (i.e., not hospital based) physicians in northern Manhattan were compared to 74 physicians in the South Bronx neighborhoods of the New York City metropolitan area. Intervention participants received enhanced physician-directed academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer. Control group physicians received no intervention. We conducted interviews to measure primary care physicians' self-reported recommendation of mammography and Clinical Breast Examination (CBE), and whether PCPs taught women how to perform breast self examination (BSE). RESULTS: Using multivariate analyses, we found a statistically significant intervention effect on the recommendation of CBE to women patients age 40 and over; mammography and breast self examination reports increased across both arms from baseline to follow-up, according to physician self-report. At post-test, physician involvement in additional educational programs, enhanced self-efficacy in counseling for prevention, the routine use of chart reminders, computer- rather than paper-based prompting and tracking approaches, printed patient education materials, performance targets for mammography, and increased involvement of nursing and other office staff were associated with increased screening. CONCLUSION: We found some evidence of improvement in breast cancer screening practices due to enhanced academic detailing among primary care physicians practicing in urban underserved communities.

Combined hormone replacement therapy (CHRT) containing estrogens and progestins is associated with breast cancer risk. The authors evaluated interactions between CHRT use and progestin metabolism genotypes at CYP3A4 and the progesterone receptor (PGR) and their effects on breast cancer risk using the population-based Women's Insights and Shared Experiences (WISE) Study (1999-2002) of postmenopausal Caucasian women (522 breast cancer cases, 708 controls). The authors observed an elevated risk of ductal tumors in women with 3 or more years of CHRT use and PGR 331A alleles compared with those who had neither factor (odds ratio = 3.35, 95% confidence interval (CI): 1.13, 9.99; two-sided p(interaction) = 0.035). They also observed an elevated risk of progesterone receptor-positive tumors in women who had had 3 or more years of CHRT use and PGR 331A alleles compared with those who had neither factor (odds ratio = 3.82, 95% CI: 1.26, 11.55; p = 0.028). Finally, they observed an increased risk of estrogen receptor-negative tumors in women without CHRT exposure and CYP3A4*1B alleles compared with those who had neither factor (odds ratio = 6.46, 95% CI: 2.02, 20.66; p = 0.024), although the biologic interpretation of this result requires further study. When stratified by recency of use, PGR effects were observed only in current CHRT users, while CYP3A4 effects were observed only in former CHRT users. Breast cancer risk in women who have used CHRT may be influenced by genetic factors involved in progestin metabolism.

BACKGROUND: The current diagnostic criteria for dermatomyositis (DM) exclude patients without muscle involvement. As a result there is a paucity of research related to the complete spectrum of the disease. OBJECTIVE: The goal of this study was to evaluate differences in the clinical manifestations of DM seen by dermatology relative to rheumatology. We hypothesized that patients with minimal (hypomyopathic) or no (amyopathic) muscle disease would more likely be seen in dermatology, whereas those with more severe (classic) muscle disease would be seen in rheumatology. METHODS: We performed a retrospective chart review of patients with DM seen by our dermatology and rheumatology departments to classify spectrum, presentation, and complications. Patients seen between July 1, 2003, and June 30, 2006, were identified by Current Procedural Terminology billing code 710.3. Patients with mixed connective tissue diseases or miscoded DM were excluded. RESULTS: In all, 131 (65%) patients seen in dermatology, 58 (29%) in rheumatology, and 13 (6%) in both departments were identified. In all, 83 (69%) patients seen in dermatology, 27 (23%) in rheumatology, and 10 (8%) in both departments met criteria for inclusion in the study. The number of patients seen in rheumatology given the classification of classic DM (CDM) (24 of 27 [89%]), hypomyopathic DM (2 of 27 [7%]), and amyopathic DM (ADM) (1 of 27 [4%]) differed significantly from dermatology, where CDM comprised 27 of 83 (33%), hypomyopathic DM comprised 23 of 83 (28%), and ADM comprised 33 of 83 (40%) of the population, respectively (P < .001). Sex, ethnicity, and rates of interstitial lung disease differed between departments. There was no difference in the rates of interstitial lung disease between CDM and ADM (P = .30). The degree of muscle involvement did not correlate with the rates of DM-associated malignancy (P = .57). Few patients with ADM had muscle biopsy (n = 1) or electromyography (n = 7) testing. Positive anti-Jo-1 was seen in 2 of 96 patients (2%; one CDM and one ADM, both with interstitial lung disease), reflecting an overall low prevalence of this autoantibody, or a potential problem with the laboratory assay. LIMITATIONS: Patients reflect the population in only one institution and, thus, the results may not be generalizable to other settings or referral centers. Because this is a retrospective chart review, results are limited by missing data and nonstandardized physical examinations and laboratory data across patients and physicians. CONCLUSIONS: There is a clear difference in DM presentation to dermatology and rheumatology by degree of myositis-complicated disease.

BACKGROUND: Ethnic minorities and patients of lower socioeconomic status may be more averse to the acceptance of epidural analgesia than nonminority counterparts and those of higher socioeconomic status, despite evidence for substantial benefit to the patient. METHODS: A scripted telephone survey was developed from the 2000 United States Census by a panel of experts. Contact was attempted at least twice for all patients listed for surgery at the Hospital of the University of Pennsylvania over a 4-mo period. RESULTS: Three thousand seven hundred thirty-nine patients were called and 1265 subjects were successfully contacted and 1193 consented, whereas 72 refused to participate. Seven hundred sixty-two subjects (64%) would accept an epidural if recommended by an anesthesiologist and 425 (36%) would refuse. If the epidural was recommended by both the anesthesiologist and surgeon acceptance increased to 932 (78.5%). The univariate predictor of refusal of perioperative epidural analgesia was African American race. Univariate predictors of acceptance include full- or part-time employment, total household income >$50,001/yr, college graduate, prior epidural treatment, and knowledge of what an epidural is. When the potential confounders of race, total household income, employment, and education were included in a multivariate logistic regression model, African American race predicted refusal (odds ratio [OR], 0.58; P < 0.006; confidence interval [CI], 0.41-0.81) and was the only factor that predicted refusal or acceptance of epidural analgesia. CONCLUSIONS: Acceptance of perioperative epidural analgesia is strongly affected by race and socioeconomic status. Anesthesiologists need to recognize this potential barrier when trying to maximize patient comfort and outcome.

OBJECTIVE: To determine the risk of mortality in patients with psoriasis. DESIGN: Cohort study. SETTING: General practitioners participating in the General Practice Research Database in the United Kingdom, 1987-2002. PATIENTS: Mild psoriasis, defined as any patient with a diagnostic code of psoriasis but no history of systemic therapy; severe psoriasis, any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis. The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code. Control patients were selected in a 5:1 ratio from the same practice and date in practice as the patients with psoriasis. MAIN OUTCOME MEASURE: Hazard ratio (HR) of time to death using Cox proportional hazards models adjusted for age and sex. RESULTS: There was no overall effect of mild psoriasis on mortality (HR, 1.0; 95% confidence interval [CI], 0.97-1.02), whereas patients with severe psoriasis demonstrated an increased overall mortality risk (HR, 1.5; 95% CI, 1.3-1.7). The association of severe psoriasis with mortality persisted after adjustment for risk factors for mortality (HR, 1.4; 95% CI, 1.3-1.6) and after exclusion of patients with inflammatory arthropathy (HR, 1.5; 95% CI, 1.3-1.8). Male and female patients with severe psoriasis died 3.5 (95% CI, 1.2-5.8) and 4.4 (95% CI, 2.2-6.6) years younger, respectively, than patients without psoriasis (P < .001). CONCLUSION: Severe but not mild psoriasis is associated with an increased risk of death.

BACKGROUND: The characteristics and prevalence of dermatologists reading dermatopathology slides are not well understood. METHODS: We surveyed 1406 members of the American Academy of Dermatology (AAD), including all 497 who were also members of the American Society of Dermatopathology (ASDP) along with a random sample of the remaining AAD members who were not ASDP members. Seven hundred and thirty of 1406 (51.9%) responded with a usable survey. Logistic regression was used to analyze responses by ASDP member dermatologists, non-ASDP member dermatologists and in a weighted analysis for dermatologists as a whole. RESULTS: A total of 32.7% of dermatologists as a whole generated at least one final microscopic diagnosis in the preceding year. Multivariate analysis demonstrated that men were significantly more likely to read dermatopathology slides (odds ratio (OR) = 1.90; 95% confidence interval (CI) 1.16-3.12; p = 0.01). Additionally, there was significant variation by region (p < 0.001); compared with dermatologists in the Midwest, dermatologists in the Southeast (OR = 0.39; 95% CI 0.19-0.80) were significantly less likely to read slides, while those in the Mountain (OR = 3.09; 95% CI 1.10-8.72) and West (OR = 2.01; 95% CI 1.04-3.90) regions were significantly more likely. There were no significant associations found between reading slides and the year of residency completion, the number of patients seen per week or being primarily in academics. CONCLUSIONS: The practice of dermatologists reading dermatopathology slides is relatively common, with significant regional and sex differences.