A cross-sectional analysis of motivation and decision-making in referrals to lifestyle interventions by primary care general practitioners: a call for guidance

Aim: To explore 1) GPs´ motivation to refer to lifestyle interventions and to investigate the association between GPs’ own lifestyle-behaviors and their referral behavior, and 2) patient indicators in the decision-making process of the GPs’ referral to lifestyle interventions. Method: A cross-sectional study was conducted among 99 Dutch primary care GPs. Their motivation to refer was assessed by beliefs regarding lifestyle interventions. GPs’ referral behaviors were assessed - considering referral and self-reported actual referral - and their own lifestyle behaviors - physical activity, dieting, being overweight). Decision-making regarding referring patients to lifestyle interventions was assessed by imposed patient indicators, spontaneously suggested decisive patient indicators, and by case-based referring (vignettes). Results: A substantial group of GPs was not motivated for referral to lifestyle interventions. GPs’ refer behavior was significantly associated with their perceived subjective norm, behavioral control, and their own physical activity and diet. Most important patient indicators in referral to lifestyle interventions were somatic indicators, and patients’ motivation for lifestyle interventions. Conclusions: GPs motivation and referral behavior might be improved by providing them with tailored resources about evidence based lifestyle interventions, with support from allied health professionals, and with official guidelines for a more objective and systematic screening of patients

Hidradenitis suppurativa:The third cause of vulva carcinoma

The development of squamous cell carcinoma (SCC) is a severe complication of chronic HS (HS). HS associated SCC can present as a painful, persistent tumour or ulcer without typical HS characteristics such as sinus formation and inflammation. Especially male patients with prolonged HS in extra-axillary areas are at risk for this complication. This case of HS associated vulvar SCC emphasizes that also women can develop this complication. In addition to lichen sclerosus vulvae (via dVIN) and high risk HPV (via uVIN) there is a third disease that can lead to vulvar cancer; chronic HS. The clinician should be vigilant for the development of malignant transformation in cases of severe, chronic HS, and should have a low threshold for biopsy. Staging, therapy and follow-up should be performed by gynecologic oncologists in an academic center.</p

Angiosarcomatous transdifferentiation of metastatic melanoma

Melanoma is known to show considerable variation in its histopathological presentation. In exceptional cases, heterologous or divergent differentiation (metaplastic melanoma) can be observed. We report a case of a 69-year-old man who was diagnosed with nodular melanoma on the right upper leg. One year later, the patient presented with an inguinal lymph node metastasis and a lymph node dissection was carried out. In two out of five positive lymph nodes, an angiosarcomatous component was found next to a conventional melanoma component. Shortly after, the patient developed two in-transit metastases in which again an angiosarcomatous component was seen. The vascular component stained positive for ERG and CD31 and negative for melanocytic markers (Mart-1, S100, SOX-10), while the conventional melanoma had an opposite staining pattern. Molecular analysis on both components showed an identical mutation in the NRAS gene, which in our opinion proves the divergent differentiation. To the best of our knowledge, this is the first case report describing angiosarcomatous transdifferentiation of melanoma

Insights into clinical and diagnostic findings as well as treatment responses in patients with mucous membrane pemphigoid:A retrospective cohort study

Background: The variable clinical severity of mucous membrane pemphigoid (MMP) often leads to diagnostic and therapeutic delays. Objective: To describe the characteristics of a large cohort of patients with MMP. Methods: A retrospective review of clinical and diagnostic characteristics as well as treatment responses in 145 patients with MMP. Results: Monosite involvement was seen in 41.4% and multisite involvement in 58.6% of the patients. The oral mucosa was affected in 86.9% of the patients, followed by the ocular mucosa (30.3%), skin (26.2%), genital mucosa (25.5%), nasal mucosa (23.4%), and pharyngeal and/or laryngeal mucosa (17.2%). Ocular disease developed during the disease course in 41.7% of patients with initially other mucosal site involvement. The malignancy rate was significantly higher in patients with autoantibodies against laminin-332 than in patients with MMP without laminin-332 autoantibodies (35.3% vs 10.9%, respectively; P = .007). Systemic immunosuppressive or immunomodulatory therapy was administered to 77.1% of the patients, mainly to patients with multisite (P Limitations: Retrospective design. Conclusion: Patients with MMP present with a heterogeneous clinical presentation, and new symptoms may develop during the disease course. Cancer screening should be considered for patients with MMP and, in particular, for those with autoantibodies against laminin-332