panicolaou testing sooner than recommended by guidelines, especially after normal co-testing results. A novel benefit of co-testing is the ability to extend screening intervals immediately among women who have no prior screening or whose screening history is unavailable if both test results are normal, yet the lowest adherence to guidelines was for the vignette of a woman with unknown Papanicolaou test history and negative co-test results (3.1%, all years combined). The finding of exceedingly low adherence in this scenario is troubling because reports from a large US cohort 5 demonstrate that more than 90% of women will have normal co-testing results. The highest adherence to guidelines occurred when the recommended interval was less than 3 years, suggesting that clinicians are willing to adhere to guidelines if more vigilant testing is recommended. The ability to obtain prior screening results and the use of electronic medical records or systems changes, such as office reminders or reimbursement packages, may help achieve adherence to recommended intervals. The low response rate in 2007 (NAMCS) was a limitation of our study. However, estimates were weighted to physician population and accounted for survey nonresponse. Uncertain concordance of practitioner response to hypothetical vignette with actual practice might also be of concern. Vignettes, however, have been shown to be inexpensive and useful tools for measuring quality of care by physicians. 6 Important strengths are the inclusion of the latest NAMCS and NHAMCS data available and the consistent methodology, which make the survey a useful tool to gauge changes in clinicians' recommendations over time. Future analyses will monitor adherence to newer guidelines that recommend extending screening intervals to 5 years among women with normal co-testing results, a strategy designed to achieve a reasonable balance between benefits and harms. 7-9

No abstract

Leser-Trélat sign is characterized by the abrupt appearance of multiple seborrheic keratoses in association with underlying malignant disease. A case of Leser-Trélat sign in a 66-year-old healthy woman is presented. Evaluation and follow-up for the development of malignancy over a 2-year period failed to reveal any evidence of malignancy. To date, almost all cases of Leser-Trélat sign have been reported in association with an underlying malignancy. It is less known that Leser-Trélat sign can also occur in healthy individuals in the absence of internal malignancy.

No abstract

Darier disease (DD) is a rare dominantly inherited genodermatosis characterized by loss of intercellular adhesion (acantholysis) and abnormal keratinization. DD is often difficult to manage. Numerous treatments have reportedly been used for the treatment of DD, with limited success. Systemic retinoids are considered the drug of choice for treating DD. However, their use is limited by potential deleterious side effects. Considering the recently reported efficacy of doxycycline for Hailey-Hailey disease, an inherited acantholytic skin disorder pathogenetically similar to DD, we report the case of a patient with extensive DD who showed a dramatic response to oral doxycycline monotherapy.