Arpan V. Prabhu

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

Importance Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population–based incidence in the United States. Objective To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Early Oral Tongue Squamous Cell Carcinoma: Sampling of Margins From Tumor Bed and Worse Local Control

IMPORTANCE Positive margins are associated with poor prognosis among patients with oral tongue squamous cell carcinoma (SCC). However, wide variation exists in the margin sampling technique. OBJECTIVE To determine the effect of the margin sampling technique on local recurrence (LR) in patients with stage I or II oral tongue SCC. DESIGN, SETTING, AND PARTICIPANTS A retrospective study was conducted from January 1, 1986, to December 31, 2012, in 5 tertiary care centers following tumor resection and elective neck dissection in 280 patients with pathologic (p)T1-2 pN0 oral tongue SCC. Analysis was conducted from June 1, 2013, to January 20, 2015. INTERVENTIONS In group 1 (n = 119), tumor bed margins were not sampled. In group 2 (n = 61), margins were examined from the glossectomy specimen, found to be positive or suboptimal, and revised with additional tumor bed margins. In group 3 (n = 100), margins were primarily sampled from the tumor bed without preceding examination of the glossectomy specimen. The margin status (both as a binary [positive vs negative] and continuous [distance to the margin in millimeters] variable) and other clinicopathologic parameters were compared across the 3 groups and correlated with LR. MAIN OUTCOMES AND MEASURES Local recurrence. RESULTS Age, sex, pT stage, lymphovascular or perineural invasion, and adjuvant radiation treatment were similar across the 3 groups. The probability of LR-free survival at 3 years was 0.9 and 0.8 in groups 1 and 3, respectively (P = .03). The frequency of positive glossectomy margins was lowest in group 1 (9 of 117 [7.7%]) compared with groups 2 and 3 (28 of 61 [45.9%] and 23 of 95 [24.2%], respectively) (P < .001). Even after excluding cases with positive margins, the median distance to the closest margin was significantly narrower in group 3 (2 mm) compared with group 1 (3 mm) (P = .008). The status (positive vs negative) of margins obtained from the glossectomy specimen correlated with LR (P = .007), while the status of tumor bed margins did not. The status of the tumor bed margin was 24% sensitive (95% CI, 16%-34%) and 92% specific (95% CI, 85%-97%) for detecting a positive glossectomy margin. CONCLUSIONS AND RELEVANCE The margin sampling technique affects local control in patients with oral tongue SCC. Reliance on margin sampling from the tumor bed is associated with worse local control, most likely owing to narrower margin clearance and greater incidence of positive margins. A resection specimen-based margin assessment is recommended.

Improving margin revision: Characterization of tumor bed margins in early oral tongue cancer

OBJECTIVES To improve margin revision, this study characterizes the number, fragmentation, and orientation of tumor bed margins (TBM) in patients with pT1-2 pN0 squamous cell carcinoma (SCC) of the oral tongue. MATERIALS AND METHODS Pathology reports (n=346) were reviewed. TBM parameters were indexed. In Group 1 patients all margins were obtained from the glossectomy specimen and there were no TBM. In Revision Group/Group 2 (n=103), tumor bed was sampled to revise suboptimal margins identified by examination of the glossectomy specimen. In Group 3 (n=124), TBM were obtained before examination of the glossectomy specimen. RESULTS AND CONCLUSIONS Fewer TBMs were obtained per patient in Group 2 compared to Group 3 (57/103, 55% of patients with <3 vs. 117/124, 94%, ≥3 TBMs, respectively). The new margin surface was more frequently indicated in Group 2 compared to Group 3 (59/103, 57%, vs. 19/124, 15%, p<.001). If glossectomy specimen margins are accepted as the reference standard, then the TBM was 15% sensitive in Group 2 (95% confidence interval [CI], 7-29) and 32% sensitive in Group 3 (95% CI, 15-55). TBM fragmentation (23/103, 22% vs. 42/124, 34%) and frozen vs. permanent discrepancies (8/103, 3% vs. 3/124, 2%) were similar between Groups 2 and 3. The new margin surface was not indicated in 6 of 11 cases with discrepant frozen vs. permanent pathology findings, precluding judgment on final margin status. To facilitate the assessment of final margins, TBM should be represented by one tissue fragment with a marked new margin surface.

An online readability analysis of pathology-related patient education articles: an opportunity for pathologists to educate patients

Information for patients regarding their clinical conditions and treatment options is widely available online. The American Medical Association and National Institutes of Health recommend that online patient-oriented materials be written at no higher than a seventh-grade reading level to ensure full comprehension by the average American. This study sought to determine whether online patient-oriented materials explaining common pathology procedures are written at appropriate reading levels. Ten pathology procedures that patients would likely research were queried into Google search, and plain text from the first 10 Web sites containing patient education materials for each procedure was analyzed using 10 validated readability scales. We determined mean reading levels of materials grouped by readability scale, procedure, and Web site domain, the overall average reading level of all resources, and popular Web site domains. One hundred Web sites were accessed; one was omitted for short length (<100 words). The average reading grade level of the 99 materials, none of which met national health literacy guidelines (range, 7.3-17.4), was 10.9. Twenty-nine articles (29%) required a high school education for full comprehension, and 4 (4%) required an undergraduate college education. Most frequently accessed Web site domains included medlineplus.gov, webmd.com (both accessed 7 times), and labtestsonline.org (accessed 6 times). Average reading levels of the 11 most commonly accessed Web sites ranged from 8.25 (patient.info) to 12.25 (mayoclinic.org). Readability levels of most online pathology-related patient education materials exceeded those recommended by national health literacy guidelines. These patient education materials should be revised to help patients fully understand them.

Enhancing the Radiologist-Patient Relationship through Improved Communication: A Quantitative Readability Analysis in Spine Radiology

BACKGROUND AND PURPOSE: More than 75 million Americans have less than adequate health literacy skills according to the National Center for Education Statistics. Readability scores are used as a measure of how well populations read and understand patient education materials. The purpose of this study was to assess the readability of Web sites dedicated to patient education for radiologic spine imaging and interventions. MATERIALS AND METHODS: Eleven search terms relevant to radiologic spine imaging were searched on the public Internet, and the top 10 links for each term were collected and analyzed to determine readability scores by using 10 well-validated quantitative readability assessments from patient-centered education Web sites. The search terms included the following: x-ray spine, CT spine, MR imaging spine, lumbar puncture, kyphoplasty, vertebroplasty, discogram, myelogram, cervical spine, thoracic spine, and lumbar spine. RESULTS: Collectively, the 110 articles were written at an 11.3 grade level (grade range, 7.1–16.9). None of the articles were written at the American Medical Association and National Institutes of Health recommended 3rd-to-7th grade reading levels. The vertebroplasty articles were written at a statistically significant (P < .05) more advanced level than the articles for x-ray spine, CT spine, and MR imaging spine. CONCLUSIONS: Increasing use of the Internet to obtain health information has made it imperative that on-line patient education be written for easy comprehension by the average American. However, given the discordance between readability scores of the articles and the American Medical Association and National Institutes of Health recommended guidelines, it is likely that many patients do not fully benefit from these resources.

Abdominal imaging and patient education resources: enhancing the radiologist-patient relationship through improved communication.

IntroductionThe relative ease of Internet access and its seemingly endless amount of information creates opportunities for Americans to research medical diseases, diagnoses, and treatment plans. Our objective is quantitative evaluation of the readability level of patient education websites, written for the lay public, pertaining to common radiologic diagnostic test, and radiologic diagnoses specific to abdominal imaging.MethodsIn October 2015, 10 search terms were entered in the Google search engine, and the top 10 links for each term were collected and independently examined for their readability level using 10 well-validated quantitative readability scales. Search terms included CT abdomen, MRI abdomen, MRI enterography, ultrasound abdomen, X-ray abdomen, cholecystitis, diverticulitis, hepatitis, inflammatory bowel disease, and pancreatitis. Websites not written exclusively for patients were excluded from the analysis.ResultsAs a group, the 100 articles were assessed at an 11.7 grade level. Only 2% (2/100) were written at the National Institutes of Health (NIH), and American Medical Association (AMA) suggested 3rd to 7th grade level to meet the 8th grade average reading level in the United States. In fact, 49% were written at a level that required a high school education or higher (greater than 12th grade).ConclusionsWith websites like radiologyinfo.org, generating over a million visitors a month, it is that clear there is a public interest in learning about radiology. However, given the discordance between the level of readability of the majority of the Internet articles and the NIH and AMA guidelines noted in this study on abdominal imaging readability, it is likely that many readers do not fully benefit from these resources on abdominal imaging.

Quantitative analysis of the level of readability of online emergency radiology-based patient education resources

PurposeThe vast amount of information found on the internet, combined with its accessibility, makes it a widely utilized resource for Americans to find information pertaining to medical information. The field of radiology is no exception. In this paper, we assess the readability level of websites pertaining specifically to emergency radiology.MethodsUsing Google, 23 terms were searched, and the top 10 results were recorded. Each link was evaluated for its readability level using a set of ten reputable readability scales. The search terms included the following: abdominal ultrasound, abdominal aortic aneurysm, aortic dissection, appendicitis, cord compression, CT abdomen, cholecystitis, CT chest, diverticulitis, ectopic pregnancy, epidural hematoma, dural venous thrombosis, head CT, MRI brain, MR angiography, MRI spine, ovarian torsion, pancreatitis, pelvic ultrasound, pneumoperitoneum, pulmonary embolism, subarachnoid hemorrhage, and subdural hematoma. Any content that was not written for patients was excluded.ResultsThe 230 articles that were assessed were written, on average, at a 12.1 grade level. Only 2 of the 230 articles (1%) were written at the third to seventh grade recommended reading level set forth by the National Institutes of Health (NIH) and American Medical Association (AMA). Fifty-two percent of the 230 articles were written so as to require a minimum of a high school education (at least a 12th grade level). Additionally, 17 of the 230 articles (7.3%) were written at a level that exceeded an undergraduate education (at least a 16th grade level).ConclusionsThe majority of websites with emergency radiology-related patient education materials are not adhering to the NIH and AMA’s recommended reading levels, and it is likely that the average reader is not benefiting fully from these information outlets. With the link between health literacy and poor health outcomes, it is important to address the online content in this area of radiology, allowing for patient to more fully benefit from their online searches.

Reputation Management and Content Control: An Analysis of Radiation Oncologists' Digital Identities

INTRODUCTION Google is the most popular search engine in the United States, and patients are increasingly relying on online webpages to seek information about individual physicians. This study aims to characterize what patients find when they search for radiation oncologists online. METHODS AND MATERIALS The Centers for Medicare and Medicaid Services (CMS) Physician Comparable Downloadable File was used to identify all Medicare-participating radiation oncologists in the United States and Puerto Rico. Each radiation oncologist was characterized by medical school education, year of graduation, city of practice, gender, and affiliation with an academic institution. Using a custom Google-based search engine, up to the top 10 search results for each physician were extracted and categorized as relating to: (1) physician, hospital, or health care system; (2) third-party; (3) social media; (4) academic journal articles; or (5) other. RESULTS Among all health care providers in the United States within CMS, 4443 self-identified as being radiation oncologists and yielded 40,764 search results. Of those, 1161 (26.1%) and 3282 (73.9%) were classified as academic and nonacademic radiation oncologists, respectively. At least 1 search result was obtained for 4398 physicians (99.0%). Physician, hospital, and health care-controlled websites (16,006; 39.3%) and third-party websites (10,494; 25.7%) were the 2 most often observed domain types. Social media platforms accounted for 2729 (6.7%) hits, and peer-reviewed academic journal websites accounted for 1397 (3.4%) results. About 6.8% and 6.7% of the top 10 links were social media websites for academic and nonacademic radiation oncologists, respectively. CONCLUSIONS Most radiation oncologists lack self-controlled online content when patients search within the first page of Google search results. With the strong presence of third-party websites and lack of social media, opportunities exist for radiation oncologists to increase their online presence to improve patient-provider communication and better the image of the overall field. We discuss strategies to improve online visibility.

Thoracic spinal osteochondroma: A rare presentation of spinal cord compression

Osteochondromas are the most common benign bone tumor typically seen in the appendicular skeleton and are rarely found in the spine. We present a case of an osteochondroma of the spine presenting with spinal cord compression. 27-year-old male presented with lower extremity weakness and paresthesia, decreased lower extremity sensation, and decreased proprioception. MRI showed a heterogeneous mass with minimal peripheral enhancement and without restricted diffusion. CT demonstrated a calcified mass extending from the left facet joint of T11-T12 with medial extension, resulting in severe central canal stenosis and cord compression. The patient underwent surgical resection with pathology demonstrating an osteochondroma.

Readability of online allergy and immunology educational resources for patients: Implications for physicians

Over the past decade, a growing repository of health information has become available on the Internet to the lay public. Health literacy (HL), the ability to understand and use health information, is an important factor in public health, and readability is one component of HL that can be quantified to determine the complexity of text and educational level of written material. The average reading ability of the US adult population is between the seventhand eighth-grade levels, and to ensure comprehension for the typical US citizen, guidelines developed by the American Medical Association and the National Institutes of Health recommend that patient health information be written between the thirdand seventh-grade levels. Our objective was to quantitatively assess the readability of online educational resources for patients searching for information for common clinical conditions and treatments in the fields of allergy and immunology. More specifically, our aim was to quantify reading levels for these resources at the level of the individual article, clinical topic, and Web site domain. We hypothesized that average readability at all 3 levels (ie, article, topic, and Web site) would exceed the nationally recommended seventh-grade norm. We selected 17 Internet search terms on common clinical conditions and treatments related to the field of allergy and immunology on the basis of convenience sampling, considering common and simple terms patients would likely type into a search engine. In August 2016, we searched Google for each term and copied the textual information from the first 10 unique patient health education Web sites listed on Google’s search results, pasting it into Microsoft Word. We omitted supplementary material (eg, illustrations) and nonmedical information (eg, references). We recorded the exact URL address of all articles accessed, collecting only 1 article from each unique URL identified in our searches. Institutional review board approval was not required for the study because all articles were freely available online to the general public. We performed the readability analysis using Readability Studio Professional Edition Version 2012 (Oleander Software, Ltd, Vandalia, Ohio).1 applying 9 validated scales to quantify readability (see Table E1 in this article’s Online Repository at www. jaci-inpractice.org). We calculated the reading level for each article by averaging estimates derived from all 9 scales. We also calculated the reading level for each of the 17 clinical terms by averaging the individual article reading levels across all 10 articles for each term. Finally, we assessed the frequency with which unique URL domain names were accessed across all articles. For those identified 3 times or more, we calculated the average reading level at the Web site level by averaging the mean reading levels for all articles identified on that site. We quantified readability for 168 of 170 articles identified; 2 articles of insufficient length (<100 words) were excluded. The average reading level across all 168 articles was 12.5 0.77, ranging from 6.5 1.6 to 16.8 2.1. On the basis of averages of the 9 readability scales, we found that only 2 (1.2%) articles were written at the recommended thirdto seventh-grade levels, with 114 (68%) written at or beyond a high school level. When articles were aggregated by clinical terms, average reading levels ranged from 9.6 1.6 for asthma to 13.8 1.1 for systemic mastocytosis (Table I). In identifying articles, we accessed 76 different Web site domains (48 once, 16 twice, and 12 thrice or more). The 3 most frequently accessed domains (n1⁄4 access frequency) were aaaai.org (n1⁄4 13), mayoclinic.org (n1⁄4 13), and webmd.com (n1⁄4 10). Of the 12 domains accessed 3 times or more, 7 (58.3%) had an average reading level at or above the 12th-grade level and none had a reading level below the recommended 8th-grade level (Table II). The average readability of articles exceeded the 12thgrade level, suggesting that online resources addressing the 17 common clinical topics in allergy and immunology are not optimally meeting patients’ health care educational needs. Web site domains webmd.com and lung.org had average reading levels of 9.6 and 9.0, respectively, suggesting that these sites are the closest to being most suitable in meeting patient informational needs for the topics that we studied. Patients may face challenges in caring for their health. The effects of limited HL have been linked to poorer health outcomes, higher rates of hospitalization, and ultimately higher health care costs.Older adults, racial minorities, non-native English speakers, and individuals with diminished socioeconomic status are more likely to have low literacy levels. Certain patient behavior patterns may identify those at risk for low HL, including incorrectly or incompletely filled out medical forms and poor adherence to appointments or use ofmedication.Oneway to improveHL among vulnerable patient populations may be to revise online health care articles to meet recommended national guidelines. The inclusion of readability scores on articles may be useful in directing patients to preferred Web sites on the basis of readability. Alternatively, physicians could create their own readability-tested materials. Physicians are encouraged to use and explain related terminology and context in conversation before referring patients to online resources. Relatively weak readers who are motivated to read about their condition and familiar with the associated terminology from multiple conversations with medical professionals may improve their comprehension with such background knowledge. This, in turn, would strengthen the patient-physician relationship. Our study has several