Search

Background Keratinocyte carcinoma (KC) treatment accounts for approximately $5 billion in spending per year, yet no studies have evaluated the US general public's willingness to pay (WTP) for these procedures. Objective To determine the monetary value of surgical KC treatments, as perceived by society, as a measure of preference. Participants, methods and materials We performed an internet-based age-, sex-, and race-stratified cross-sectional survey of 425 subjects representative of the US general population. Stated WTP and desirability of electrodesiccation and curettage (EDC), excision, and Mohs micrographic surgery (MMS) for facial and extrafacial basal cell carcinoma (BCC) were assessed. A discrete choice experiment was performed using maximum likelihood estimation, and a secondary analysis was performed to determine the influence of framing MMS as the best treatment option. Results A total of 425 subjects finished their questionnaires, yielding a completion rate of 97%. Median (interquartile range) stated WTP for EDC, excision, and MMS were $1,000 (421-2,079), $1,503 (562-3,062), and $3,006 (1,250-5,084), respectively, when MMS was framed in a standard fashion. Stated WTP for MMS increased to $3,989 (2,015-5,801) when it was framed as the best option. For BCC on the back, WTP for MMS dropped by 12%. Conclusion There is markedly higher societal WTP for MMS on both the face and trunk, regardless of whether MMS is framed as the best option. Gold-standard bias may affect WTP and desirability in medical decision-making under uncertainty, inflating the WTP of options framed as the best while decreasing the desirability of alternatives.

Background Cutaneous manifestations of COVID-19 may be useful disease markers and prognostic indicators. Recently, post-infectious telogen effluvium and trichodynia have also been reported. Objective To evaluate the presence of trichodynia and telogen effluvium in patients with COVID-19 and describe their characteristics in relation to other signs and symptoms of the disease. Methods Patients with a history of COVID-19 presenting to the clinics of a group of hair experts because of telogen effluvium and/or scalp symptoms, were questioned with regards about their hair signs and symptoms in relation to the severity of COVID-19 and associated symptoms. Results Data from 128 patients were collected. Telogen effluvium was observed in 66.3% of patients and trichodynia in 58.4%. Trichodynia was associated to telogen effluvium in 42.4% of cases and was associated to anosmia and ageusia in 66.1% and 44.1% of cases, respectively. In the majority of patients (62.5%), hair signs and symptoms started within the first month post-COVID-19 diagnosis and in 47.8% of patients after 12 weeks or more. Limitations Recruitment of patient in specialized hair clinics, lack of a control group, and lack of recording of patient comorbidities. Conclusion The severity of the post-viral telogen effluvium observed in patients with a history of COVID-19 infection is influenced by COVID-19 severity. We identified an early onset (12 weeks) telogen effluvium.

Background In developed countries, health care delivery in dermatology is hampered by the low availability of dermatologists. Objective To analyze the feasibility of a teledermatology-based action plan to provide initial dermatologic care in areas with low availability of dermatologists. Methods A cross-sectional study describing the feasibility and cost of a 12-month action plan based on a store-and-forward teledermatology (TD) connecting primary care centers and a TD center. Teleconsultations from patients complaining of any cutaneous condition were included. The primary outcome measure was the percentage of patients not referred to the local dermatologist. Results Among the total of 15,523 teleconsultations attended in the TD-based action plan, 3360 (21.65%) required a face-to-face visit with a local dermatologist. In 32.32% (n = 5017) of the cases, a therapeutic and follow-up plan report was issued. The most common conditions managed were melanocytic nevi (15.63%, n = 2426), followed by seborrheic keratosis (14.89%, n = 2312), and actinic keratosis (8.65%, n = 1342). The average response time was 14.52 days (95% CI 14.35-15.23). The additional total investment in this action plan was $142,681.01, with a unit cost of 9.20$/patient. Limitations Noncontrolled study. Conclusions Experienced dermatologists working with store-and-forward TD can deliver a fast and effective response in health care areas with access limitations.

ObjectivesTo develop and validate the Oxford Pandemic Attitude Scale-COVID-19 (OPAS-C), a multidimensional scale that addresses seven domains over 20 items including stress, fear, loneliness, sense of community, belief that the pandemic is a hoax or exaggerated, the use of and attitude to non-pharmaceutical interventions and vaccine hesitancy, in a single measure.DesignCross-sectional validation study.SettingInternet based with respondents in the USA and UK.ParticipantsGeneral community respondents using the Prolific Academic platform.Main outcome measuresExploratory factor analyses with promax oblique rotation and confirmatory factor analysis including goodness of fit indices: root mean square error of approximation (RMSEA), standardised root mean square residual (SRMR) and comparative fit index (CFI). Reliability as internal consistency using Cronbach’s alpha. Convergent and discriminant validity using Pearson correlation coefficients.ResultsThe sample included 351 respondents in the USA and the factorial structure was confirmed using a separate set of 348 respondents in the UK. The OPAS-C had excellent goodness of fit characteristics, with an RMSEA of 0.047 (90% CI 0.037 to 0.056), SRMR of 0.043 and CFI of 0.962. Reliability was excellent, demonstrating Cronbach’s alpha of 0.87 in both the US and UK samples. Convergent validity showed correlation coefficients of 0.54 and 0.49 in the US and UK samples, respectively. Discriminant validity demonstrated correlations of 0.21 and 0.26 in the US and UK samples, respectively.ConclusionsThe OPAS-C represents the first validated scale that addresses mental health measures and public health-relevant responses to COVID-19, and may be a useful measure for use in future longitudinal and cross-sectional studies. Further international validation beyond the USA and UK may be helpful.

SUMMARY A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Nonpharmaceutical interventions (NPIs) represent the primary mitigation strategy for pandemic COVID-19. Despite this, many government agencies and members of the general public may be resistant to NPI adoption. We sought to understand public attitudes and beliefs regarding various NPIs and self-reported adoption of NPIs, and explore associations between NPI performance and the baseline characteristics of respondents. We performed a cross-sectional age-, sex-, and race- stratified survey of the general US population. Of the 1,005 respondents, 37% (95% CI 34.0, 39.9) felt that NPIs were inconvenient, while only 0.9% (95% CI 0.3, 1.5) of respondents believed that NPIs would not reduce their personal risk of illness. Respondents were most uncertain regarding the efficacy of mask and eye protection use, with 30.6% and 22.1%, respectively, unsure whether their use would slow disease spread. On univariate logistic regression analyses, NPI adherence was associated with a belief that NPIs would reduce personal risk of developing COVID-19 (OR 3.06, 95% CI [1.25, 7.48], p=0.014) and with a belief that the NPIs were not difficult to perform (OR 1.79, 95% CI [1.38, 2.31], p

Pandemic coronavirus disease 2019 (COVID-19) may lead to significant mental health stresses, potentially with modifiable risk factors. We performed an internet-based cross-sectional survey of an age-, sex-, and race-stratified representative sample from the US general population. Degrees of anxiety, depression, and loneliness were assessed using the 7-item Generalized Anxiety Disorder-7 scale (GAD-7), the 9-item Patient Health Questionnaire, and the 8-item UCLA Loneliness Scale, respectively. Unadjusted and multivariable logistic regression analyses were performed to determine associations with baseline demographic characteristics. A total of 1,005 finished surveys were returned of the 1,020 started, yielding a completion rate of 98.5% in the survey panel. The mean (standard deviation) age of the respondents was 45 (16) years, and 494 (48.8%) were male. Overall, 264 subjects (26.8%) met the criteria for an anxiety disorder based on a GAD-7 cutoff of 10; a cutoff of 7 yielded 416 subjects (41.4%), meeting the clinical criteria for anxiety. On multivariable analysis, male sex (odds ratio [OR] = 0.65, 95% confidence interval [CI] [0.49, 0.87]), identification as Black (OR = 0.49, 95% CI [0.31, 0.77]), and living in a larger home (OR = 0.46, 95% CI [0.24, 0.88]) were associated with a decreased odds of meeting the anxiety criteria. Rural location (OR 1.39, 95% CI [1.03, 1.89]), loneliness (OR 4.92, 95% CI [3.18, 7.62]), and history of hospitalization (OR = 2.04, 95% CI [1.38, 3.03]) were associated with increased odds of meeting the anxiety criteria. Two hundred thirty-two subjects (23.6%) met the criteria for clinical depression. On multivariable analysis, male sex (OR = 0.71, 95% CI [0.53, 0.95]), identifying as Black (OR = 0.62, 95% CI [0.40, 0.97]), increased time outdoors (OR = 0.51, 95% CI [0.29, 0.92]), and living in a larger home (OR = 0.35, 95% CI [0.18, 0.69]) were associated with decreased odds of meeting depression criteria. Having lost a job (OR = 1.64, 95% CI [1.05, 2.54]), loneliness (OR = 10.42, 95% CI [6.26, 17.36]), and history of hospitalization (OR = 2.42, 95% CI [1.62, 3.62]) were associated with an increased odds of meeting depression criteria. Income, media consumption, and religiosity were not associated with mental health outcomes. Anxiety and depression are common in the US general population in the context of the COVID-19 pandemic and are associated with potentially modifiable factors.

Pandemic coronavirus disease 2019 (COVID-19) may lead to significant mental health stresses, potentially with modifiable risk factors. To determine the presence of and magnitude of associations between baseline associations and anxiety and depression in the US general population, we performed an internet-based cross-sectional survey of an age-, sex-, and race-stratified representative sample from the US general population. Degrees of anxiety, depression, and loneliness were assessed using the 7-item Generalized Anxiety Disorder scale (GAD-7), the 9-item Patient Health Questionnaire (PHQ-9), and the 8-item UCLA Loneliness Scale, respectively. Unadjusted and multivariable logistic regression analyses were performed to determine associations with baseline demographic characteristics. A total of 1,005 finished surveys were returned of the 1,020 started, yielding a completion rate of 98.5% in the survey panel. The mean (SD) age of respondents was 45 (16), and 494 (48.8%) were male. Baseline demographic data were similar between those that were (n=663, 66.2%) and were not (n=339, 33.8%) under a shelter in place/ stay at home order, with the exception of sex and geographic location. Overall, 264 subjects (26.8%) met criteria for an anxiety disorder based on a GAD-7 cutoff of 10; a cutoff of 7 yielded 416 subjects (41.4%) meeting clinical criteria for anxiety. On multivariable analysis, male sex (OR 0.65, 95% CI [0.49, 0.87]) and living in a larger home (OR 0.46, 95% CI [0.24, 0.88]) were associated with a decreased odds of meeting anxiety criteria. Rural location (OR 1.39, 95% CI [1.03, 1.89]), loneliness (OR 4.92, 95% CI [3.18, 7.62]), and history of hospitalization (OR 2.04, 95% CI [1.38, 3.03]), were associated with increased odds of meeting anxiety criteria. 232 subjects (23.6%) met criteria for clinical depression. On multivariable analysis, male sex (OR 0.71, 95% CI [0.53, 0.95]), increased time outdoors (OR 0.51, 95% CI [0.29, 0.92]), and living in a larger home (OR 0.35, 95% CI [0.18, 0.69]), were associated with decreased odds of meeting depression criteria. Having lost a job (OR 1.64, 95% CI [1.05, 2.54]), loneliness (OR 10.42, 95% CI [6.26, 17.36]), and history of hospitalization (OR 2.42, 95% CI [1.62, 3.62]), were associated with an increased odds of meeting depression criteria. Income, media consumption, and religiosity were not associated with mental health outcomes. Anxiety and depression are common in the US general population in the context of the COVID-19 pandemic, and are associated with potentially modifiable factors.

BACKGROUND Dermatologists overall perform a large number of procedures billed to Medicare, though the proportion of surgical procedures attributable to general dermatologists who do not perform Mohs micrographic dermatologic surgery (MDS) is unknown. OBJECTIVE To determine the surgical volume of dermatologists who do not perform MDS and compare it to the surgical volume of MDS-performing dermatologists and all non-dermatologists. METHODS A cross-sectional analytical study was performed using the Medicare public use file for 2014. Data were divided by physician specialty (dermatologists vs all non-dermatologists), and dermatologists were then dichotomized by MDS performance. RESULTS Non-MDS dermatologists performed 42.19% of the benign excisions, 57.18% of the malignant excisions, and 46.00% of the intermediate repairs billed to Medicare in 2014. Micrographic dermatologic surgery-performing dermatologists were responsible for most of the complex repairs (67.56%), flaps (52.85%), and grafts (59.65%) billed to Medicare. CONCLUSION Dermatologists who do not perform MDS represent the single largest group billing Medicare for benign excisions, malignant excisions, and intermediate repairs. They also bill for more complex repairs than all non-dermatologists combined. Micrographic dermatologic surgery-performing dermatologists performed most of the complex repairs, flaps, and grafts billed to Medicare.

Background Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous adverse drug reaction. Although acutely patients have significant morbidity and occasional systemic involvement, the clinical course is generally self-limited. To date, there has been no consensus on treatment. Objective The aim of our current study was to evaluate the clinical features, drug association, treatment, and outcomes in a cohort of patients treated in an academic medical center. Methods A retrospective review of electronic medical records over a period of 10 years from 2009 to 2018 in a single tertiary academic medical center in Singapore was performed. Forty-three medical records with probable/definite diagnosis of AGEP were identified and analyzed for statistical significance. Results Drug association was identified in 93% of cases. The most frequent drug class was antibiotics, including penicillins, cephalosporins, and vancomycin. Systemic involvement was reported in 13.9% of patients. All cases of AGEP resolved with cessation of the offending drug. There was no mortality attributed to AGEP. Treatment with systemic steroid was associated with a decreased length of hospital stay (P = .035) in patients with AGEP. Conclusion AGEP was a self-limiting adverse drug reaction that was commonly caused by antibiotics. Although there was no difference in mortality, there was a significant reduction in the length of hospitalization with systemic corticosteroid treatment compared with that of topical corticosteroid treatment of AGEP.

BACKGROUND The relative volume of skin and soft tissue excision and reconstructive procedures performed in the outpatient office versus facility (ambulatory surgical center or hospital) differs by specialty, and has major implications for quality of care, outcomes, development of guidelines, resident education, health care economics, and patient perception. OBJECTIVE To assess the relative volume of surgical procedures performed in each setting (office vs ambulatory surgery center [ASC]/hospital) by dermatologists and nondermatologists. METHODS A cross-sectional analytical study was performed using the Medicare public use file (PUF) for 2014, which includes every patient seen in an office, ASC, or hospital in the United States billed to Medicare part B. Data were divided by physician specialty and setting. RESULT A total of 9,316,307 individual encounters were included in the Medicare PUF. Dermatologists account for 195,001 (2.1%) of the total. Dermatologists were more likely to perform surgical procedures in an office setting only (odds ratio 5.48 [95% confidence interval 5.05-5.95], p < .0001) than other specialists in aggregate. CONCLUSION More than 90% of surgical procedures are performed in an office setting, and dermatologists are more than 5 times as likely as other specialists to operate in an office setting.

Dr Mose, a busy dermatologic surgeon, regularly sees patients referred from other dermatologists and primary care providers. On a busy Monday morning, he enters the room and greets Mr Scale, a patient with an apparent history of multiple dysplastic nevi, who was referred by his general dermatologist, Dr Shade, for treatment of a severely dysplastic nevus on the left side of his neck. Mr Scale hands the dermatopathology report to Dr Mose, which reflects a total of 11 biopsy specimens taken at his last visit, 7 demonstrating banal junctional nevi, 3 showing mildly dysplastic nevi, and 1 showing the severely dysplastic nevus. Mr Scale states that he usually has this many biopsy specimens taken when he sees Dr Shade on a monthly basis. Dr Mose checks his electronic medical record system and notices that he has seen several referrals from Dr Shade in the past, all of which have come with biopsy reports reflecting 8 or more biopsy sites per visit.