Letters to the Editor

1202

(a)

the reviewers have accepted such a study full of scientifically incorrect arguments. This kind of publication harms the effort of a great number of dermatologists who try to promote the utility of MMS with scientific correct arguments. A.M. Skaria* Centre de Dermatochirurgie, University of Bern, 1800 Vevey, Switzerland *Correspondence: A.M. Skaria. E-mail: [email protected]

References

(b)

1 Tuerdi M, Yarbag A, Maimaiti A et al. Standard surgical excision and reconstruction of giant basal cell carcinoma of the face: may be an alternative to the Mohs micrographic surgery. J Eur Acad Dermatol Venereol 2014; 28: 1572–1573. 2 Skaria A. Staged surgical therapy of basal cell carcinoma in the head and neck region. Swiss Med Wkly 2010; 140: 31–33. 3 Ravitskiy L, Brodland DG, Zitelli JA. Cost analysis: Mohs micrographic surgery. Dermatol Surg 2012; 38: 585–594. 4 Basal Cell and Squamous Cell Skin Cancers http://www.nccn.org/professionals/. . .gls/f_guidelines.asp 5 Acosta AE. Clinical parameters of tumescent anesthesia in skin cancer reconstructive surgery. A review of 86 patients. Arch Dermatol 1997; 133: 451–454. DOI: 10.1111/jdv.13122

Figure 2 (a) Giant BBC after excision with MMS in a 43-year-old patient . (b) Reconstruction with a medial forehead flap 1 year later.

case of recurrence (3 years)) and the re-excison of these tumours are mostly very difficult. This leads us to another point that the secure lateral tumour margin control is in this tumour a far less important aspect than the deep tumour margin control. The authors are not discussing how to manage correctly these aspects because a 1 cm security margin in the deep is often not possible without damage to the noble structures. The authors pretend that the investigation was done with intra-operative frozen sections, which does not provoke sloughing of the tissue, and argue that MMS would be more expensive. There are several studies which have shown that intra-operative frozen sections are much more expensive and far less efficient.3 The authors argue that MMS should only be used for highrisk tumours. It seems that the authors and the reviewers are not aware of the criteria of high-risk tumours which is not only a question of localization but also a question of size.4 The authors are pretending that this kind of tumour cannot be operated under local anaesthesia, which is incorrect. I suggest the literature of Acosta et al. on tumescent anaesthesia in skin cancer reconstuctive surgery from 1997.5 Although I can agree that in large tumours eventually slow Mohs can show some advantages because of the difficulty of freezing big tumour parts. This problem can be solved but would need more slides because the excised tumour has to be divided into smaller parts (Figs. 1 and 2). Finally, it is astonishing that

JEADV 2016, 30, 1195–1252

Sexually transmitted infections in older adults – raising awareness for better screening and prevention strategies Editor, Although sexually transmitted infections (STIs) are commonly associated with adolescents and young adults, sexually active older adults are also at risk of infection.1 Data regarding epidemiology, clinical presentation and diagnosis of STIs in older adults is still lacking, although a number of studies show that the incidence of STIs, including Human Immunodeficiency Virus (HIV) infection, is significant and may be increasing over the years.2–5 All patients aged 60 years or older attending the STI Clinic of a University Hospital (Centro Hospitalar S~ao Jo~ao, Porto) for the first time between December 2003 and November 2013 were included in this study. Clinical information recorded by a doctor is subsequently entered onto a database which was previously approved by the ethical committee of the hospital. Controls were defined as attendees of the STI Clinic without any STI diagnosed. Different stages of syphilis were classified according to ECDC criteria.6 During the study period, 2703 patients attended the STI Clinic, 267 (9.9%) of them were 60 years old or older. Four

© 2015 European Academy of Dermatology and Venereology

Letters to the Editor

1203

Table 1 Demographic and sexual behaviour differences between 167 STI subjects and 96 attendees without a STI diagnosis* Subjects n (%) 167 (63.5)

Controls n (%) 96 (36.5)

Relative risk [CI 95%]

P†

Demographic characteristics Age (median, years)

67

68

0.235‡

Gender Males Females

127 (60.8)

82 (39.2)

40 (74.1)

14 (25.9)

0.820 [0.677–0.994]

0.070

Education degree§ Illiteracy Primary education Secondary education

22 (91.7)

2 (8.3)

119 (61.3)

75 (38.7)

10 (47.6)

11 (52.4)

Tertiary education

9 (81.8)

2 (18.2)

Unknown

7 (53.8)

6 (46.2)

0.011

Marital status Married Single/Divorced/Widowed

118 (71) 49 (69.2)

Unknown

75 (29)

1.162 [0.962–1.402]

0.143

1.569 [1.429–1.722]

0.094

1.304 [1.079–1.575]

0.024

1.478 [1.253–1.742]

0.003

20 (30.8)

0 (0)

1 (100)

160 (63.7)

91 (36.3)

Sexual behaviour characteristics Sexual orientation Heterosexual MSM

5 (100)

0

Unknown

2 (28.6)

5 (71.4)

None or one

127 (61.4)

80 (38.6)

Two or more

32 (80)

8 (20)

8 (50)

8 (50)

Number of partners during the previous year

Unknown Past history of STI Yes

25 (89.3)

3 (10.7)

No

142 (60.4)

93 (39.6)

*Variables were compared using Pearson chi-squared test unless otherwise specified. Data analysis was performed using SPSS 20.0 for Windows (SPSS Inc, Chicago,IL, USA). †The significance level used was 0.05. ‡Mann–Whitney U-test. §In Portugal, primary education includes elementary school, secondary education includes middle and high school and tertiary education refers to university or higher education.

patients were excluded due to incomplete data. The majority of the remaining 263 attendees were male (79.5%) and aged between 60–87 years (median 67 years) (Table 1). Five male attendees stated to have male partners (1.9%) and 40 patients (15.2%) had two or more partners in the preceding year [31 (11.8%) had 2–4 partners, 7 (2.7%) had 5–9 and two patients (0.8%) declared over 10 different partners]. The majority of the patients (211, 80.2%) reported to be sexually active in the preceding year; 65 of them (28.9%) acknowledged having casual sexual contacts, and 25 (38.5%) recognized contact with sex workers. Twelve patients were known HIV positive. The characteristics associated with a STI diagnosis were having a past history of STI (RR 1.478 CI 95% 1.253–1.742), two or more partners during the previous year (RR 1.304 CI 95% 1.079–1.575) and being men who have sex with men (MSM) (RR 1.569 CI 95% 1.429–1.722).

JEADV 2016, 30, 1195–1252

From the 263 patients admitted to the STI clinic, 167 (63.5%) were diagnosed with a STI, 83 (31.6%) were found to have nonsexually transmitted genital dermatosis and in 13 (4.9%) there was not any pathological condition found. Overall, there was a mean 1.1 STI diagnosis per patient, with 27 (16.3%) patients having more than one STI diagnosis. Late syphilis (70, 37.8%) was the most common diagnosis, followed by anogenital warts (28.6%) and genital herpes (16.8%) (Table 2). Older patients were close to 10% of the patients referred to our STI clinic. Two thirds of them were diagnosed with an STI. The leading STI diagnoses were non-acute infections as late syphilis and anogenital warts in accordance with other studies.2,7 Nevertheless, acute STI was diagnosed in 16% in our patients. This figure ranged between 3.5 and 50% in literature.2,7–9 The majority of the elderly population in this study was sexually

© 2015 European Academy of Dermatology and Venereology

Letters to the Editor

1204

Table 2 STI diagnosis in the 167 STI clinic attendees Male n (%)

STI Diagnosis

Female n (%)

Total n (%)

Late syphilis*

51 (72.9)

19 (27.1)

70 (37.8)

Anogenital warts

49 (87.5)†

7 (12.5)

56 (30.3)

Genital herpes

22 (71)

9 (29)

31 (16.8)

HIV infection‡

14 (100)

0

14 (7.6) 10 (5.4)

Molluscum contagiosum

8 (80)

2 (20)

Early syphilis

4 (80)

1 (20)

5 (2.7)

Hepatitis B

4 (100)

0

4 (2.2)

Non-gonococcal urethritis

2 (100)

0

2 (1.1)

Ducrey’s disease

2 (100)

0

2 (1.1)

Gonococcal urethritis

1 (100)

0

1 (0.5)

Scabies

1 (100)

0

1 (0.5)

Hepatitis C

1 (100) 147 (79.5)

0 38 (20.5)

DOI: 10.1111/jdv.13124

1 (0.5) 185 (100)

*Two patients suffered from neurosyphilis and the remaining 68 had late latent syphilis. †Four men with penile squamous cell carcinoma associated with HPV infection. ‡Two patients with HIV infection previously undiagnosed.

active, and a significant proportion of patients engage in casual sexual encounters, often with sexual workers. Current life expectancy in western Europe is increasing. Older people are likely to be sexually active for longer with the increasing better controlled comorbidities and the use of drugs to ameliorate sexual performance. On the other hand, social changes, as the rise of divorce and new relationships among older people also affects the likelihood of engaging in risky sexual behaviour. Around 5% of the patients referred to our clinic were HIV infected, and the majority had newly acquired STIs, which demonstrates the need for better secondary prevention strategies. Health care workers must address the topic of sexuality with their older patients and be aware of STIs in this age group. S. Nunes,1,* F. Azevedo,2 C. Lisboa2,3 1

Infectious Diseases Department, Centro Hospitalar do Baixo Vouga, EPE, Aveiro, Portugal, 2Dermatovenereology Department, Centro ~o Joa ~o, EPE, Porto, Portugal, 3Microbiology Department, Hospitalar de Sa Faculty of Medicine, University of Porto, Porto, Portugal *Correspondence: S. Nunes. E-mail: sofi[email protected]

References 1 Lindau ST, Schumm LP, Laumann EO et al. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357: 762–774. 2 David N, Rajamanoharan S, Tang A. Sexually transmitted infections in elderly people. Sex Transm Infect 2000; 76: 222. 3 Vasconcelos C, Guimar~aes JM, Lisboa C, Ramos AS. Sexually transmitted diseases in the elderly. Review of 28 cases. Eur J Dermatol 2000; 10: 567. 4 Bodley-Tickell AT, Olowokure B, Bhaduri S et al. Trends in sexually transmitted infections (other than HIV) in older persons: analysis of data from an enhanced surveillance system. Sex Transm Infect 2008; 84: 312–317. 5 Fish R, Robinson A, Copas A et al. Trends in attendances to genitourinary medicine services by older women. Int J STD AIDS 2012; 23: 595–596.

JEADV 2016, 30, 1195–1252

6 European Union. European Centre for Disease prevention and Control. http://www.ecdc.europa.eu/ 7 Griffiths M, David N. Sexually transmitted infections in older people. Int J STD AIDS 2013; 24: 756–757. 8 Bourne C, Minichiello V. Sexual behaviour and diagnosis of people over the age of 50 attending a sexual health clinic. Australas J Ageing 2009; 28: 32–36. 9 Bilenchi R, Poggiali S, Pisani C et al. Sexually transmitted diseases in elderly people: an epidemiological study in Italy. J Am Geriatr Soc 2009; 57: 938–940.

Response to: ‘Standard excision and reconstruction as an alternative to MMS for giant basal cell carcinoma? – Commentary’ Editor We thank Mr Skaria for commenting on the content of our article. However, we were surprised at his comments not only being offensive but also he may have misunderstood the basic message and some important details of this peer-reviewed article. First, the focus of the article, as clearly stated in the title and result, is the reconstruction of postoperative defects. From this point of view, we mentioned the tissues paring properties of Mohs Micrographic Surgery (MMS) which may result in less complex and more successful aesthetic reconstructions, but it does not mean that we denied the low recurrence rate regarding tumour excision. Second, we emphasized the immediate reconstruction by surgical excision because all patients in our study presented favourable outcomes without causing any severe postoperative complications. Sloughing of soft tissue after Mohs surgery has been reported in a few articles,1 may Mr Skaria not familiar with those literatures and did not encountered sloughing his 22 years of Mohs surgery. Third, there is some misunderstanding regarding the surgical margin. The >1 cm surgical margin in our patients is the lateral tumour margin, not a deep tumour margin. Time consuming, labour intensity and high cost are reported as the limitation of MMS.1 Besides that the cost effects may very different from countries to countries. Finally, we did not mean to confine MMS’s usage only for high risk tumours because we are well aware of its other application in large tumours, tumours with aggressive histology and recurrent BCC and SCC. Because MMS is time consuming and is used to treat tumours of a size and anatomic location

© 2015 European Academy of Dermatology and Venereology

Sexually transmitted infections in older adults - raising awareness for better screening and prevention strategies.

Sexually transmitted infections in older adults - raising awareness for better screening and prevention strategies. - PDF Download Free
208KB Sizes 0 Downloads 8 Views