Arash Mostaghimi

Clinical characteristics of Merkel cell carcinoma at diagnosis in 195 patients: the “AEIOU” features

BACKGROUND Merkel cell carcinoma (MCC) is an aggressive skin cancer with a mortality of 33%. Advanced disease at diagnosis is a poor prognostic factor, suggesting that earlier detection may improve outcome. No systematic analysis has been published to define the clinical features that are characteristic of MCC. OBJECTIVE We sought to define the clinical characteristics present at diagnosis to identify features that may aid clinicians in recognizing MCC. METHODS We conducted a cohort study of 195 patients given the diagnosis of MCC between 1980 and 2007. Data were collected prospectively in the majority of cases, and medical records were reviewed. RESULTS An important finding was that 88% of MCCs were asymptomatic (nontender) despite rapid growth in the prior 3 months (63% of lesions) and being red or pink (56%). A majority of MCC lesions (56%) were presumed at biopsy to be benign, with a cyst/acneiform lesion being the single most common diagnosis (32%) given. The median delay from lesion appearance to biopsy was 3 months (range 1-54 months), and median tumor diameter was 1.8 cm. Similar to earlier studies, 81% of primary MCCs occurred on ultraviolet-exposed sites, and our cohort was elderly (90% >50 years), predominantly white (98%), and often profoundly immune suppressed (7.8%). An additional novel finding was that chronic lymphocytic leukemia was more than 30-fold overrepresented among patients with MCC. LIMITATIONS The study was limited to patients seen at a tertiary care center. Complete clinical data could not be obtained on all patients. This study could not assess the specificity of the clinical characteristics of MCC. CONCLUSIONS To our knowledge, this study is the first to define clinical features that may serve as clues in the diagnosis of MCC. The most significant features can be summarized in an acronym: AEIOU (asymptomatic/lack of tenderness, expanding rapidly, immune suppression, older than 50 years, and ultraviolet-exposed site on a person with fair skin). In our series, 89% of primary MCCs had 3 or more of these findings. Although MCC is uncommon, when present in combination, these features may indicate a concerning process that would warrant biopsy. In particular, a lesion that is red and expanding rapidly yet asymptomatic should be of concern.

The availability and nature of physician information on the internet.

BackgroundAlthough patients are commonly using the Internet to find healthcare information, the amount of personal and professional physician information and patient-generated ratings freely accessible online is unknown.ObjectiveTo characterize the nature of online professional and personal information available to the average patient searching for physician information through a standardized web search.Design, Setting, and ParticipantsWe studied 250 randomly selected internal medicine physicians registered with the Massachusetts Board of Registration in Medicine in 2008. For each physician, standardized searches via the Google search engine were performed using a sequential search strategy. The top 20 search results were analyzed, and websites that referred to the study subject were recorded and categorized. Physician rating sites were further investigated to determine the number of patient-entered reviews.Main MeasuresNumber and content of websites attributable to specific physicians.Key ResultsWebsites containing personal or professional information were identified for 93.6% of physicians. Among those with any web sites identified, 92.8% had professional information and 32.4% had personal information available online. Female physicians were more likely to have professional information available on the Internet than male physicians (97.5% vs. 91.7%, p = 0.03), but had similar rates of available personal information (32.5% vs. 32.5%, p = ns). Among personal sites, the most common categories included social networking sites such as Facebook (10.8% of physicians), hobbies (10.0%), charitable or political donations (9.6%), and family information (8.8%). Physician rating sites were identified for 86.4% of providers, but only three physicians had more than five reviews on any given rating site.ConclusionsPersonal and professional physician information is widely available on the Internet, and often not under direct control of the individual physician. The availability of such information has implications for physician–patient relationships and suggests that physicians should monitor their online information.

Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis

Importance Inflammatory dermatoses of the lower extremity are often misdiagnosed as cellulitis (aka “pseudocellulitis”) and treated with antibiotics and/or hospitalization. There is limited data on the cost and complications from misdiagnosed cellulitis. Objective To characterize the national health care burden of misdiagnosed cellulitis in patients admitted for treatment of lower extremity cellulitis. Design, Setting, and Participants Cross-sectional study using patients admitted from the emergency department (ED) of a large urban hospital with a diagnosis of lower extremity cellulitis between June 2010 and December 2012. Patients who were discharged with a diagnosis of cellulitis were categorized as having cellulitis, while those who were given an alternative diagnosis during the hospital course, on discharge, or within 30 days of discharge were considered to have pseudocellulitis. A literature review was conducted for calculation of large-scale costs and complication rates. We obtained national cost figures from the Medical Expenditure Panel Survey (MEPS), provided by the Agency for Healthcare Research and Quality (AHRQ) for 2010 to calculate the hospitalization costs per year attributed to misdiagnosed lower extremity pseudocellulitis. Exposures The exposed group was composed of patients who presented to and were admitted from the ED with a diagnosis of lower extremity cellulitis. Main Outcomes and Measures Patient characteristics, hospital course, and complications during and after hospitalization were reviewed for each patient, and estimates of annual costs of misdiagnosed cellulitis in the United States. Results Of 259 patients, 79 (30.5%) were misdiagnosed with cellulitis, and 52 of these misdiagnosed patients were admitted primarily for the treatment of cellulitis. Forty-four of the 52 (84.6%) did not require hospitalization based on ultimate diagnosis, and 48 (92.3%) received unnecessary antibiotics. We estimate cellulitis misdiagnosis leads to 50 000 to 130 000 unnecessary hospitalizations and

Cost-effectiveness of Confirmatory Testing Before Treatment of Onychomycosis

195 million to

Low Usefulness of Potassium Monitoring Among Healthy Young Women Taking Spironolactone for Acne

515 million in avoidable health care spending. Unnecessary antibiotics and hospitalization for misdiagnosed cellulitis are projected to cause more than 9000 nosocomial infections, 1000 to 5000 Clostridium difficile infections, and 2 to 6 cases of anaphylaxis annually. Conclusions and Relevance Misdiagnosis of lower extremity cellulitis is common and may lead to unnecessary patient morbidity and considerable health care spending.

Adoption of a wiki within a large internal medicine residency program: a 3-year experience.

IMPORTANCE Onychomycosis is the most common disease of the nail in adults. International guidelines urge health care professionals to perform confirmatory diagnostic testing before initiating systemic therapy. This approach was determined to be cost-effective in studies from the late 1990s but has not been evaluated more recently. The effect of testing on the costs of efinaconazole, 10%, topical solution treatment is unknown. OBJECTIVE To evaluate the cost and potential harm associated with 3 approaches to onychomycosis evaluation before treatment with oral terbinafine or efinaconazole, 10%. DESIGN, SETTING, AND PARTICIPANTS A decision analysis that compared the costs of 3 onychomycosis management algorithms based on recently published data of test statistics, disease prevalence, and relevant costs: (1) empirical therapy without confirmatory testing, (2) pretreatment confirmatory testing with potassium hydroxide (KOH) stain followed by periodic acid-Schiff (PAS) evaluation if KOH testing is negative, and (3) pretreatment testing with PAS. There was no direct patient evaluation. Selection of included studies was based on outcome variables and the quality of study design. The study was conducted from April 1, 2014, to September 1, 2015. MAIN OUTCOMES AND MEASURES Primary outcomes included direct cost of onychomycosis testing and therapy and cost to avoid harm when treating patients with oral terbinafine. RESULTS At a disease prevalence of 75%, per-patient cost savings of empirical terbinafine therapy without confirmatory testing was

Novel oral anticoagulants: what dermatologists need to know.

47 compared with the KOH screening model and

Preparing residents for future practice: report of a curriculum for electronic patient–doctor communication

135 compared with PAS testing. The cost of testing necessary to prevent a single case of clinically relevant liver toxic effects related to terbinafine at a prevalence of 75% was between

Reduced incidence of skin cancer in patients with alopecia areata: A retrospective cohort study

18.2 million and

Confidentiality in the digital age

43.7 million for KOH screening and between