Comments:

1. Some rewording with the proposed change: An excisional biopsy may be recommended for the diagnosis of AK in certain circumstances^[1]. Excisional biopsy refers to the complete removal of the affected area, and may be used for thicker lesions or when certain lesions need to be distinguished from invasive skin cancer through histological examination, allowing for both goals of diagnosis and treatment at the same time^[1]. (I think removing the first part of the first sentence will make our changes sound more neutral and less confrontational. We are trying to add some information about the use of excisional biopsy in certain clinical scenarios rather than trying to emphasize the importance of it over other types of biopsy procedures)
2. I think you are very thoughtful with the potential bias of the source. Many general practitioners or family physicians have excellent procedural skills and can perform shave, punch, incisional, or excisional biopsies competently, they would exercise their clinical judgement about when to refer the patient to plastic surgery or dermatology.
   

Welcome to your sandbox!

This is place to practice clicking the "edit" button and practice adding references (via the citation button). Please see Help:My_sandbox or contact User_talk:JenOttawa with any questions.

Link: Project Homepage and Resources

• Note: Please use your sandbox to submit assignment # 3 by pasting it below. When uploading your improvements to the article talk page please share your exact proposed edit (not the full assignment 3).

• Talk Page Template: Wikipedia:CARL Medical Editing Initiative/Fall 2019/Talk Page Template

Actinic keratosis^[1]

Assignment #2

After meeting with our tutor, Dr. Ren, it was identified that the Diagnosis section of the Wikipedia article on Actinic Keratosis needed to be updated. Specifically, Dr. Ren identified that there was too much of an emphasis on shave and punch biopsies as the main approach for diagnosis of Actinic Keratosis. He mentioned that the article ought to also include information on the use of excision for diagnosing Actinic Keratosis. Therefore, the reference identified below will be used to add information to the article about the use of exicision in the diagnosis of actinic keratosis.

Reference:

De Berker, D., McGregor, J. M., Mohd Mustapa, M. F., Exton, L. S., & Hughes, B. R. (2017). British Association of Dermatologists’ guidelines for the care of patients with actinic keratosis 2017. British Journal of Dermatology, 176(1), 20-43.

1) Search strategy:

The reference identified above was found by searching “excision actinic keratosis” on the Trip database. The Trip database was accessed on the Queen’s University Library Guide: Evidence Based Practice Database list: https://guides.library.queensu.ca/evidence-based-practice/

databases

The search was filtered by “All Secondary Evidence”, and filtered by quality of evidence. The source identified was first on the list.

I chose to search the Trip database as it includes access to full-text clinical practice guidelines. Given that one of the problems with the Wikipedia article we identified was that some of the links in the references list were inaccessible and we could not therefore verify the validity of the claims in the sources, it was important to choose an open-access article that could be accessed by the general public.  

2) Potential sources identified and considered:

Two other potential sources that were identified and considered were: DynaMed and UpToDate. These resources include:

DynaMed. (2018, November 30). Actinic Keratosis. Ipswich, MA: EBSCO Information Services. Retrieved November 05, 2019, from https://www.dynamed.com/condition/actinic-keratosis

Jorizzo, J. (2019). Treatment for Actinic Keratosis. In R. Corona (Ed.), UpToDate. Retrieved November 05, 2019, from https://www.uptodate.com/contents/treatment-of-actinic-keratosis

3) Why the source was chosen:

This source was chosen as it specifically mentions the use of excision as a diagnostic method for Actinic Keratosis. Therefore, it supports the point that Dr. Ren guided us to include in the article. Although the UpToDate source included a section on when to perform a biopsy in aggressive Actinic Keratosis, it did not include any information on the use of excision. The source from DynaMed did not include information on the use of excision in the diagnosis of Actinic Keratosis either. Both sources only mentioned the use of biopsy.

Focal lesion, achieve both goals of treatment and diagnosis in one go, a plastic surgeon may be more comfortable but its the issue of real life in practice

4) Three reasons why the source meets the MEDRS criteria:

Three reasons why this source meets the MEDRS criteria include:

1. The article is a clinical practice guideline: a high quality secondary source.
2. The article is published in a reputable medical journal (British Journal of Dermatology, impact factor of 6.129)
3. The article is relatively recent, having been published in 2017.

5) How the source will be used to improve the article:

This source will be used to improve the Wikipedia article by adding information that was not present before. Namely, that excision of actinic keratosis for subsequent histological examination is a diagnostic option, especially in cases where actinic keratosis is difficult to distinguish from squamous cell carcinoma or melanoma. The Wikipedia article currently only mentions the use of biopsy techniques (punch and shave biopsy), which may not be the preferred method of diagnosis in all circumstances.

Assignment #3

Proposed Changes:

The proposed changes to the article pertain to the section on diagnosis of AK. After meeting with our tutor, Dr. Ren, it was identified that there was too much of an emphasis on shave and punch biopsies as the main approach for diagnosis of Actinic Keratosis. As the article does not mention any information on the use of excision/excisional biopsies for diagnosing Actinic Keratosis, I propose adding the following sentences to the diagnosis section of the article, specifically under the section that discusses biopsies. The new sentences I have added are indicated in bold below, and the existing sentences from the article are left unbolded:

Diagnosis

Physicians usually diagnose actinic keratosis by doing a thorough physical examination, through a combination of visual observation and touch. However a biopsy may be necessary when the keratosis is large in diameter, thick, or bleeding, in order to make sure that the lesion is not a skin cancer.

Actinic keratosis and squamous cell carcinoma (SCC) can present similarly on physical exam, and many scientists argue that they are in fact simply different stages of the same condition. In addition to SCCs, AKs can be mistaken for other cutaneous lesions including seborrheic keratoses, basal cell carcinoma, lichenoid keratosis, porokeratosis, viral warts, erosive pustular dermatosis of the scalp, pemphigus foliaceus, inflammatory dermatoses like psoriasis, or melanoma.

Biopsy

A lesion biopsy is performed if the diagnosis remains uncertain after a clinical physical exam, or if there is suspicion that the AK might have progressed to squamous cell carcinoma. The most common tissue sampling techniques include shave or punch biopsy. When only a portion of the lesion can be removed due to its size or location, the biopsy should sample tissue from the thickest area of the lesion, as SCCs are most likely to be detected in that area. If a shave biopsy is performed, it should extend through to the level of the dermis in order to provide sufficient tissue for diagnosis; ideally, it would extend to the mid-reticular dermis. Punch biopsy usually extends to the subcutaneous fat when the entire length of the punch blade is utilized.

It is important to note that shave and punch biopsies are not the only diagnostic method of choice, as an excisional biopsy may be recommended for the diagnosis of AK in certain circumstances^[1]. Excisional biopsy refers to the complete removal of the affected area, and may be used for thicker lesions or when certain lesions need to be distinguished from invasive skin cancer through histological examination, allowing for both goals of diagnosis and treatment at the same time^[1].

Rationale for Proposed Change:

The rationale for the proposed change is that it specifically discusses the use of excision as a diagnostic method for Actinic Keratosis. Previously, the article only discussed shave and punch biopsies as diagnostic methods for AK, and failed to acknowledge that excisional biopsies may actually be recommended over other biopsy techniques in certain circumstances. Therefore, the proposed changes support the original points that Dr. Ren instructed us to include in the article.

This change is necessary because it 1) adds new information to the article, 2) addresses an important recommendation from the literature outlined in the reference chosen to support the sentenced added, which came from a clinical practice guideline in the British Journal of Dermatology, and 3) the content on diagnosis in the article prior to these changes was inadequate, because it did not address the full scope of diagnostic procedures used in AK. I have also ensured to include a Wiki-Link to the term Excisional Biopsy and provide a brief description as to what it means, as it was not a term mentioned in the article prior.

Controversy or varied opinion:

There do not seem to be any significant areas of controversy or varied opinion for the proposed changes. The information supporting the changes is supported by the British Journal of Dermatology in their clinical practice guideline for the care of patients with actinic keratosis. In the practice guideline, the authors indicate that there are no conflicts of interest and no funding sources to declare, meaning that the guidelines were not affected by external/controversial third parties which could introduce bias in the clinical recommendations. The literature did not seem to point to any controversy or varied opinion around the use of excisional biopsy for diagnosis of actinic keratosis. However, because excisional biopsy is only recommended in certain circumstances, it may not be performed as commonly and may be only performed by more experienced clinicians (e.g. plastic surgeons, dermatologists), which is why the article may not have included information on excisional biopsies prior to these changes, and why not all secondary sources (such as Up To Date) may explicitly recommend the use of excisional biopsies.

Critique of Source:

There does not appear to be any validity issues or potential bias within the secondary source chosen to support the proposed changes. The clinical practice guideline used to support the proposed changes is 1) recent (published in 2017), 2) comes from a reputable secondary source (British Journal of Dermatology), and 3) is not influenced by external funding sources or conflicts of interest as mentioned above.

However, it is important to note that because this source comes from the specialty of dermatology, the information may be potentially biased from a specialists' viewpoint. As excisional biopsies may be more likely to be performed by specialists compared to primary care practitioners, the recommendations may be different compared to those that come from literature in family medicine, for example. Regardless, the source is reputable and adds valuable information to the article that was not present prior.