admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

https://www.caraderm.org/upload/reco-EUR-Merkel.pdf

Diagnosis and treatment of Merkel Cell Carcinoma. European consensus-based interdisciplinary guideline

Basal cell carcinoma (BCC) is the most common form of human cancer, with a continually increasing annual incidence in the United States. When diagnosed early, the majority of BCCs are readily treated with office-based therapy, which is highly curative. In these evidence-based guidelines of care, we provide recommendations for the management of patients with BCC, as well as an in-depth review of the best available literature in support of these recommendations. We discuss biopsy techniques for a clinically suspicious lesion and offer recommendations for the histopathologic interpretation of BCC. In the absence of a formal staging system, the best available stratification based on risk for recurrence is reviewed. With regard to treatment, we provide recommendations on treatment modalities along a broad therapeutic spectrum, ranging from topical agents and superficially destructive modalities to surgical techniques and systemic therapy. Finally, we review the available literature and provide recommendations on prevention and the most appropriate follow-up for patients in whom BCC has been diagnosed.

https://escholarship.org/content/qt9wh716h4/qt9wh716h4.pdf?t=p3d6qk

Guidelines of care for the management of basal cell carcinoma.

Retinoic acid receptors: from molecular mechanisms to cancer therapy.

Skin cancer is less prevalent in people of color than in the white population. However, when skin cancer occurs in non-whites, it often presents at a more advanced stage, and thus the prognosis is worse compared with white patients. The increased morbidity and mortality associated with skin cancer in patients of color compared with white patients may be because of the lack of awareness, diagnoses at a more advanced stage, and socioeconomic factors such as access to care barriers. Physician promotion of skin cancer prevention strategies for all patients, regardless of ethnic background and socioeconomic status, can lead to timely diagnosis and treatment. Public education campaigns should be expanded to target communities of color to promote self-skin examination and stress importance of photoprotection, avoidance of tanning bed use, and early skin cancer detection and treatment. These measures should result in reduction or earlier detection of cutaneous malignancies in all communities. Furthermore, promotion of photoprotection practices may reduce other adverse effects of ultraviolet exposure including photoaging and ultraviolet-related disorders of pigmentation.

https://www.jaad.org/article/S0190-9622(13)01296-6/pdf

Skin cancer and photoprotection in people of color: A review and recommendations for physicians and the public

Background
Sun protection is recommended for skin cancer prevention, yet little is known about the role of sun protection on vitamin D levels. Our aim was to investigate the relationship between different types of sun protective behaviors and serum 25(OH)D levels in the general US population.

/pdf/sun-protective-behaviors-and-vitamin-d-levels-in-the-us-ji302fpl3v.pdf

Sun protective behaviors and vitamin D levels in the US population: NHANES 2003–2006

Objectives: To evaluate vitamin D status in patients with basal cell nevus syndrome (BCNS) who practice photoprotection because of their genetic predisposition to skin cancer and to determine risk factors for deficiency. Design: Retrospective cohort study. Setting: Academic medical centers. Patients: Forty-one ambulatory patients with BCNS who participated in a 2-year chemoprevention clinical trial. Population-based controls (n=360) were selected and matched by age, sex, Fitzpatrick skin type, and season/ geography. Main Outcome Measures: Levels of 25-hydroxyvitamin D (25[OH]D) and vitamin D deficiency (defined as a 25[OH]D level of 20 ng/mL). Results: Twenty-three patients with BCNS (56%) were vitamin D deficient. Patients with BCNS had mean 25(OH)D levels below those of the general population (�3 ng/mL; P=.02) and were 3 times more likely to be vitamin D deficient (56% vs 18%; P .001). Levels of 25(OH)D were lower in patients who were overweight (�3.0 ng/mL; P = .04) and who had blood collected in the winter compared with the summer (�7.1 ng/mL; P.001). Conclusion: Patients with BCNS may be at increased risk for vitamin D deficiency, depending on their adherence to photoprotection practices. Trial Registration: clinicaltrials.gov Identifier: NCT00023621

https://jamanetwork.com/journals/jamadermatology/articlepdf/422132/dst05022_1105_1110.pdf

High Prevalence of Vitamin D Deficiency in Patients With Basal Cell Nevus Syndrome

Sporadic human basal cell carcinomas (BCC) are generally well managed with current surgical modalities. However, in the subset of high-risk patients predisposed to developing large numbers of BCCs, there is an unmet need for effective, low-morbidity chemoprevention. This population includes fair-skinned patients with extensive sun exposure and those with genodermatoses such as the basal cell nevus (Gorlin) syndrome (BCNS). Tazarotene (Tazorac, Allergan) is a topical retinoid with relative specificity for RAR-β and RAR-γ receptors. We previously demonstrated tazarotene's robust anti-BCC efficacy in Ptch1+/− mice, a murine equivalent of BCNS, and others have found it to have some efficacy against sporadic human BCCs. We report here results of a randomized, double-blind, vehicle-controlled study in patients with BCNS evaluating the efficacy of topically applied tazarotene for BCC chemoprevention ( N = 34 subjects), along with an open-label trial evaluating tazarotene's efficacy for chemotherapy of BCC lesions ( N = 36 subjects) for a maximum follow-up period of 3 years. We found that only 6% of patients had a chemopreventive response and that only 6% of treated BCC target lesions were clinically cured. Our studies provide no evidence for either chemopreventive or chemotherapeutic effect of tazarotene against BCCs in patients with BCNS. Cancer Prev Res; 7(3); 292–9. ©2014 AACR .

See related article by So et al., [Cancer Prev Res 7(4):407–17][1]

 [1]: /lookup/volpage/7/407?iss=4

Tazarotene: Randomized, Double-Blind, Vehicle-Controlled and Open-Label Concurrent Trials for Basal Cell Carcinoma Prevention and Therapy in Patients with Basal Cell Nevus Syndrome

Reliability and prevalence of digital image skin types in the United States: results from National Health and Nutrition Examination Survey 2003-2004.

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Sun protective behaviors and vitamin D levels in the US population: NHANES 2003–2006

High Prevalence of Vitamin D Deficiency in Patients With Basal Cell Nevus Syndrome

Tazarotene: Randomized, Double-Blind, Vehicle-Controlled and Open-Label Concurrent Trials for Basal Cell Carcinoma Prevention and Therapy in Patients with Basal Cell Nevus Syndrome

Reliability and prevalence of digital image skin types in the United States: results from National Health and Nutrition Examination Survey 2003-2004.