A Case of a Micronesian Woman in Hawai'i with Lymphoma and the Role of Implicit Bias in Medicine Affecting Her Care.

Medically indigent patients, patients of color, those with insufficient health insurance, or patients with severe diseases have a high rate of poor health care quality caused by unconscious implicit and explicit biases. Awareness of the relationship between unconscious implicit bias and negative health care outcomes is increasing in the health care community. The objective of this case study was to examine implicit biases that negatively affected the patient care of a young Micronesian woman with a severe cutaneous disease in Hawai'i. Her medical care and death may have been affected by a combination of implicit biases, including bias based on her race, type of health insurance, and underlying disease. Implicit biases and their role in health care disparities are often unintentional and not obvious. Increased awareness by health care providers may help to avoid inequities in clinical decision-making and improve outcomes.

Diagnosis and management of atopic dermatitis.

ABSTRACT: Atopic dermatitis is a chronic inflammatory skin condition that affects patients of all ages. The disease is characterized by xerosis (dry skin) and intensely pruritic lesions distributed throughout the body. This article reviews diagnostic features and treatments for atopic dermatitis.

Staphylococcus aureus Antibiotic Susceptibilities in Infections in an Outpatient Dermatology Office on O'ahu.

Staphylococcus aureus is a pathogen that causes skin and soft tissue infections (SSTIs) in dermatology patients. There is an increasing rate of methicillin-resistant S aureus (MRSA) reported in the dermatology literature since 1987. This report profiles the antibiotic susceptibilities of methicillin-sensitive S aureus (MSSA) and MRSA in an outpatient office in Hawai'i. This is a retrospective study done by chart review from 2012 to 2014. Demographics, anatomical site of infection, clinical diagnoses and antimicrobial susceptibility patterns were analyzed and compared. Of the 66 samples, 57% were males and 43% were females. S aureus was more commonly found in impetigo, folliculitis, furuncles and secondarily infected psoriasis and more commonly located on the extremities. MSSA accounted for 73% (48) of the cases and MRSA accounted for 27% (18) of the cases. The antibiotics most effective against all S aureus cultures for outpatients were linezolid (100%), trimethoprim sulfamethoxazole (95%) and tetracyclines (94%). Linezolid (100%), trimethoprim sulfamethoxazole (100%) were most effective against MRSA isolates. Our S aureus and MRSA antimicrobial susceptibility results are similar to the local Hawai'i outpatient antibiogram collected from a large private laboratory in Hawai'i in 2014 and the current Infectious Disease Society of America guidelines. This study may be helpful in guiding empiric treatment of SSTIs suspected to be caused by S aureus.

Dermatologically challenging syphilis presentation.

An atypical early primary syphilis case presentation with multiple umbilicated papular lesions on the penis and a nonreactive syphilis serology was misdiagnosed as molluscum contagiosum. Over a period of eight weeks, prior to dermatologic consultation, the papules enlarged, ulcerated, and healed. New plaque and patch formation on the penis and scrotum led to a differential diagnosis of inverse psoriasis vs. syphilis. Histological examination of a shave biopsy specimen revealed numerous Treponema pallidum organisms and repeat syphilis serological test results confirmed a syphilis diagnosis. Lesions responded to treatment with benzathine penicillin. One must keep a high index of suspicion for syphilis in light of its diverse presentation and increasing incidence.

Identification of allergens by IgE-specific testing improves outcomes in atopic dermatitis.

INTRODUCTION: IgE quantitative assaying of allergens (IgEQAA) has long been implemented by allergists in determining patients' reactivities for allergic rhinitis and asthma, two of the three diagnoses in atopic syndrome. This test operates by measuring the patient's IgE response to different allergens and can identify potential triggers for a patient's symptoms. Despite this, IgEQAA has yet to see the same widespread use in the field of dermatology, specifically in the treatment of patients with atopic dermatitis (AD). MATERIALS AND METHODS: The affected body surface area (BSA) at first presentation, IgEQAA classes, and total immunoglobulin E (IgE) concentration were taken retrospectively for 54 patients with AD. RESULTS: Of the 54 patients observed, 41 had an abnormally high total IgE concentration (76%). Additionally, it was observed that nine (17%) of our patients significantly improved after making lifestyle changes. CONCLUSION: Knowledge of the identified specific antigens can guide patients to make lifestyle modifications that may improve disease outcomes. IgEQAA and avoidance of allergens may help some patients with AD.

Silicon Nanowire Sensors Enable Diagnosis of Patients via Exhaled Breath.

Two of the biggest challenges in medicine today are the need to detect diseases in a noninvasive manner and to differentiate between patients using a single diagnostic tool. The current study targets these two challenges by developing a molecularly modified silicon nanowire field effect transistor (SiNW FET) and showing its use in the detection and classification of many disease breathprints (lung cancer, gastric cancer, asthma, and chronic obstructive pulmonary disease). The fabricated SiNW FETs are characterized and optimized based on a training set that correlate their sensitivity and selectivity toward volatile organic compounds (VOCs) linked with the various disease breathprints. The best sensors obtained in the training set are then examined under real-world clinical conditions, using breath samples from 374 subjects. Analysis of the clinical samples show that the optimized SiNW FETs can detect and discriminate between almost all binary comparisons of the diseases under examination with >80% accuracy. Overall, this approach has the potential to support detection of many diseases in a direct harmless way, which can reassure patients and prevent numerous unpleasant investigations.

Institutional Enrollment and Survival Among NSCLC Patients Receiving Chemoradiation: NRG Oncology Radiation Therapy Oncology Group (RTOG) 0617.

BACKGROUND: The purpose of this analysis is to evaluate the effect of institutional accrual volume on clinical outcomes among patients receiving chemoradiation for locally advanced non-small cell lung cancer (LA-NSCLC) on a phase III trial. METHODS: Patients with LA-NSCLC were randomly assigned to 60 Gy or 74 Gy radiotherapy (RT) with concurrent carboplatin/paclitaxel +/- cetuximab on NRG Oncology RTOG 0617. Participating institutions were categorized as low-volume centers (LVCs) or high-volume centers (HVCs) according to the number of patients accrued (≤3 vs > 3). All statistical tests were two-sided. RESULTS: Range of accrual for LVCs (n = 195) vs HVCs (n = 300) was 1 to 3 vs 4 to 18 patients. Baseline characteristics were similar between the two cohorts. Treatment at a HVC was associated with statistically significantly longer overall survival (OS) and progression-free survival (PFS) compared with treatment at a LVC (median OS = 26.2 vs 19.8 months; HR = 0.70, 95% CI = 0.56 to 0.88, P = .002; median PFS: 11.4 vs 9.7 months, HR = 0.80, 95% CI = 0.65-0.99, P = .04). Patients treated at HVCs were more often treated with intensity-modulated RT (54.0% vs 39.5%, P = .002), had a lower esophageal dose (mean = 26.1 vs 28.0 Gy, P = .03), and had a lower heart dose (median = V5 Gy 38.2% vs 54.1%, P = .006; V50 Gy 3.6% vs 7.3%, P < .001). Grade 5 adverse events (AEs) (5.3% vs 9.2%, P = .09) and RT termination because of AEs (1.3% vs 4.1%, P = .07) were less common among patients treated at HVCs. HVC remained independently associated with longer OS (P = .03) when accounting for other factors. CONCLUSION: Treatment at institutions with higher clinical trial accrual volume is associated with longer OS among patients with LA-NSCLC participating in a phase III trial.

Pretreatment 18F-FDG PET Textural Features in Locally Advanced Non-Small Cell Lung Cancer: Secondary Analysis of ACRIN 6668/RTOG 0235.

UNLABELLED: In a secondary analysis of American College of Radiology Imaging Network (ACRIN) 6668/RTOG 0235, high pretreatment metabolic tumor volume (MTV) on (18)F-FDG PET was found to be a poor prognostic factor for patients treated with chemoradiotherapy for locally advanced non-small cell lung cancer (NSCLC). Here we utilize the same dataset to explore whether heterogeneity metrics based on PET textural features can provide additional prognostic information. METHODS: Patients with locally advanced NSCLC underwent (18)F-FDG PET prior to treatment. A gradient-based segmentation tool was used to contour each patient's primary tumor. MTV, maximum SUV, and 43 textural features were extracted for each tumor. To address overfitting and high collinearity among PET features, the least absolute shrinkage and selection operator (LASSO) method was applied to identify features that were independent predictors of overall survival (OS) after adjusting for MTV. Recursive binary partitioning in a conditional inference framework was utilized to identify optimal thresholds. Kaplan-Meier curves and log-rank testing were used to compare outcomes among patient groups. RESULTS: Two hundred one patients met inclusion criteria. The LASSO procedure identified 1 textural feature (SumMean) as an independent predictor of OS. The optimal cutpoint for MTV was 93.3 cm(3), and the optimal SumMean cutpoint for tumors above 93.3 cm(3) was 0.018. This grouped patients into three categories: low tumor MTV (n = 155; median OS, 22.6 mo), high tumor MTV and high SumMean (n = 23; median OS, 20.0 mo), and high tumor MTV and low SumMean (n = 23; median OS, 6.2 mo; log-rank P < 0.001). CONCLUSION: We have described an appropriate methodology to evaluate the prognostic value of textural PET features in the context of established prognostic factors. We have also identified a promising feature that may have prognostic value in locally advanced NSCLC patients with large tumors who are treated with chemoradiotherapy. Validation studies are warranted.

Quality of Life Analysis of a Radiation Dose-Escalation Study of Patients With Non-Small-Cell Lung Cancer: A Secondary Analysis of the Radiation Therapy Oncology Group 0617 Randomized Clinical Trial.

IMPORTANCE: A recent randomized radiation dose-escalation trial in unresectable stage III non-small-cell lung cancer (NSCLC) (Radiation Therapy Oncology Group [RTOG] 0617) showed a lower survival rate in the high-dose radiation therapy (RT) arm (74 Gy) than in the low-dose arm (60 Gy) with concurrent chemotherapy. OBJECTIVE: The primary QOL hypothesis predicted a clinically meaningful decline in quality of life (QOL) via the Functional Assessment of Cancer Therapy (FACT)-Lung Cancer Subscale (LCS) in the high-dose RT arm at 3 months. DESIGN, SETTING, AND PATIENTS: The RTOG 0617 trial was a randomized phase 3 study (conducted from November 2007 to November 2011) in stage III NSCLC using a 2 × 2 factorial design and stratified by histology, positron emission tomography staging, performance status, and irradiation technique (3-dimensional conformal RT [3D-CRT] vs intensity-modulated RT [IMRT]). A total of 185 institutions in the United States and Canada took part. Of 424 eligible patients with stage III NSCLC randomized, 360 (85%) consented to QOL evaluation, of whom 313 (88%) completed baseline QOL assessments. INTERVENTION: Treatment with 74-Gy vs 60-Gy RT with concurrent and consolidation carboplatin/paclitaxel with or without cetuximab. MAIN OUTCOMES AND MEASURES: The QOL data were collected prospectively via FACT Trial Outcome Index (FACT-TOI), calculated as the sum of the following measures: Physical Well Being (PWB), Functional Well Being (FWB), and the LCS. Data are presented at baseline and 3 and 12 months via minimal clinically meaningful changes of 2 points or more for PWB, FWB, and LCS or 5 points or more for TOI. RESULTS: Of the 313 patients who completed baseline QOL assessments, 219 patients (70%) completed the 3-month QOL assessments, and 137 of the living patients (57%) completed the 12-month assessment. Patient demographics and baseline QOL scores were comparable between the 74-Gy and 60-Gy arms. Significantly more patients in the 74-Gy arm than in the 60-Gy arm had clinically meaningful decline in FACT-LCS at 3 months (45% vs 30%; P = .02). At 12 months, fewer patients who received IMRT (vs 3D-CRT) had clinically meaningful decline in FACT-LCS (21% vs 46%; P = .003). Baseline FACT-TOI was associated with overall survival in multivariate analysis. CONCLUSIONS AND RELEVANCE: Despite few differences in clinician-reported toxic effects between treatment arms, QOL analysis demonstrated a clinically meaningful decline in QOL in the 74-Gy arm at 3 months, confirming the primary QOL hypothesis. Baseline QOL was an independent prognostic factor for survival. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00533949.

Automated 3-dimensional morphologic analysis of sputum specimens for lung cancer detection: Performance characteristics support use in lung cancer screening.

BACKGROUND: The LuCED Lung Test comprises an automated 3-dimensional morphologic analysis of epithelial cells in sputum. For each cell, 594 morphology-based features are measured to drive algorithmic classifiers that quantitatively assess whether neoplastic cells are present. The current interim clinical study involves sputum samples from patients with known benign and malignant outcomes to assess the feasibility of LuCED as an adjunctive test after suspicious low-dose computed tomography (LDCT) results or as an independent screening test for lung cancer. METHODS: Sputum samples were fixed, enriched for epithelial cells, and analyzed with a 3-dimensional cell scanner called Cell-CT. Candidate abnormal cells were identified by the classifiers for manual review. The sensitivity, specificity, and negative and positive predictive values were calculated for the detection of neoplastic cases. RESULTS: A total of 91 sputum samples from patients with confirmed lung cancer (49 patients) and patients with no known malignancy (42 patients) were evaluated. After cytology review, sensitivity in the positive group was 91.8%, and specificity was 95.2%. Specificity was not 100% because there were 2 cases in which abnormal cells were identified by the Cell-CT that were confirmed as such at the time of manual cytology review. However, at the time of last follow-up, malignancy had not been detected in these 2 cases. Modeling in a population with a 1% prevalence of lung cancer, the positive and negative predictive values would be 95.4% and 99.9%, respectively. CONCLUSIONS: LuCED testing is highly sensitive and specific for the detection of lung cancer and has potential value as an adjunctive test after suspicious LDCT findings or as a primary screening test in which LuCED-positive cases would be triaged to diagnostic CT. Further prospective studies currently are underway to evaluate its full usefulness.

Cherry Picking in the 'Aina: Inequalities of Access to Dermatologic Care in Hawai'i.

There is evidence that people who are insured by Medicaid have difficulty accessing health care from private providers. This study documents access to dermatology care for a hypothetical patient insured by Medicaid in the State of Hawai'i. Posing as young Medicaid patient with a changing mole, we called all dermatologists listed on the American Academy of Dermatology website and requested an appointment to be seen. Only 23% of dermatologists contacted accept all Medicaid plans and an additional 12% accept some. Thus 65% of dermatologists called do not provide specialist care to Hawai'i's Medicaid population.

Pretreatment FDG-PET metrics in stage III non-small cell lung cancer: ACRIN 6668/RTOG 0235.

BACKGROUND: ACRIN 6668/RTOG 0235 evaluated the prognostic value of positron emission tomography with (18)F-fluorodeoxyglucose (FDG-PET) uptake before and after definitive, concurrent, platinum-based chemoradiotherapy for locally advanced non-small cell lung cancer (NSCLC). In this secondary analysis, we evaluate volumetric pretreatment PET measures as predictors of clinical outcomes. METHODS: Patients with stage III NSCLC underwent FDG-PET prior to treatment. A commercially available gradient-based segmentation tool was used to contour all visible hypermetabolic lesions on each scan. For each patient, the maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total glycolytic activity (TGA) for all contoured lesions were recorded. Cox proportional hazards regression models were used to evaluate clinical variables and PET metrics as predictors of overall survival (OS) and locoregional control (LRC). Time-dependent covariables were added to the models when necessary to address nonproportional hazards. All statistical tests were two-sided. RESULTS: Complete data were available for 214 patients in the OS analysis and 189 subjects in the LRC analysis. In multivariable analysis incorporating clinical and imaging data available prior to treatment, MTV was an independent predictor of OS (HR = 1.04 per 10 cm(3) increase, 95% CI = 1.03 to 1.06, P < .001). High MTV was also associated with increased risk of locoregional failure at baseline (HR = 1.16 per 10 cm(3) increase, 95% CI = 1.08 to 1.23, P < .001) and at six months (HR = 1.05 per 10 cm(3) increase, 95% CI = 1.02 to 1.07, P < .001) but not at 12 months or later time points. CONCLUSION: Pretreatment MTV is a predictor of clinical outcomes for NSCLC patients treated with chemoradiotherapy. Quantitative PET measures may serve as stratification factors in clinical trials for this patient population and may help guide novel trial designs.

Transcutaneous electrical nerve stimulation for chronic post-herpetic neuralgia.

Postherpetic neuralgia remains a therapeutic challenge for the clinician. Many modalities have been utilized with limited success. In this pilot randomized study of patients who were refractory to previous medicinal treatment, the patients were treated with transcutaneous nerve stimulation with a biofeedback capability. After every two treatments with the sham and true device, the patients were required to fill out a standard neuropathic pain scale score. The patients were allowed to select the other device after three consecutive treatments if they felt an inadequate decrease in their pain. The true device was chosen over the sham device by all patients. The majority of these patients treated by the true device reported a statistically significant decrease in pain scores (P < 0.001). Further investigation of this Food and Drug Administration, class 2 accepted, electronic device for relief of pain is warranted for patients with a history of recalcitrant postherpetic neuralgia.

Prediction of survival by [18F]fluorodeoxyglucose positron emission tomography in patients with locally advanced non-small-cell lung cancer undergoing definitive chemoradiation therapy: results of the ACRIN 6668/RTOG 0235 trial.

PURPOSE: In this prospective National Cancer Institute-funded American College of Radiology Imaging Network/Radiation Therapy Oncology Group cooperative group trial, we hypothesized that standardized uptake value (SUV) on post-treatment [(18)F]fluorodeoxyglucose positron emission tomography (FDG-PET) correlates with survival in stage III non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Patients received conventional concurrent platinum-based chemoradiotherapy without surgery; postradiotherapy consolidation chemotherapy was allowed. Post-treatment FDG-PET was performed at approximately 14 weeks after radiotherapy. SUVs were analyzed both as peak SUV (SUVpeak) and maximum SUV (SUVmax; both institutional and central review readings), with institutional SUVpeak as the primary end point. Relationships between the continuous and categorical (cutoff) SUVs and survival were analyzed using Cox proportional hazards multivariate models. RESULTS: Of 250 enrolled patients (226 were evaluable for pretreatment SUV), 173 patients were evaluable for post-treatment SUV analyses. The 2-year survival rate for the entire population was 42.5%. Pretreatment SUVpeak and SUVmax (mean, 10.3 and 13.1, respectively) were not associated with survival. Mean post-treatment SUVpeak and SUVmax were 3.2 and 4.0, respectively. Post-treatment SUVpeak was associated with survival in a continuous variable model (hazard ratio, 1.087; 95% CI, 1.014 to 1.166; P = .020). When analyzed as a prespecified binary value (≤ v > 3.5), there was no association with survival. However, in exploratory analyses, significant results for survival were found using an SUVpeak cutoff of 5.0 (P = .041) or 7.0 (P < .001). All results were similar when SUVmax was used in univariate and multivariate models in place of SUVpeak. CONCLUSION: Higher post-treatment tumor SUV (SUVpeak or SUVmax) is associated with worse survival in stage III NSCLC, although a clear cutoff value for routine clinical use as a prognostic factor is uncertain at this time.

Complications after 90Y microsphere radioembolization for unresectable hepatic tumors: An evaluation of 112 patients.

PURPOSE: The aim of this study was to estimate the incidence of complications after (90)Y microsphere radioembolization for unresectable hepatic tumors and evaluate risk factors for late complications. METHODS AND MATERIALS: A cohort of 112 consecutive patients from two institutions underwent (90)Y microsphere radioembolization for unresectable hepatic tumors. Complications were graded according to the Common Terminology Criteria for Adverse Events, version 3.0. Symptoms secondary to postradioembolization syndrome occurring within 30 days were recorded as early complications, and all other complications were considered late complications. RESULTS: Seventy-eight patients (70%) experienced postradioembolization syndrome, including fatigue, abdominal pain, nausea, vomiting, anorexia, or fever. Three patients (3%) experienced a Grade 3 early complication; no Grade 4 or 5 early toxicity occurred. Two patients (2%) experienced clinically significant liver dysfunction; 13 patients (12%), 27 patients (24%), and 9 patients (8%) had an elevation of bilirubin, aspartate aminotransferase, and alanine aminotransferase, respectively. Eleven patients (10%) experienced gastrointestinal ulceration, including two Grade 3 complications and one Grade 4 complication. Cholecystitis occurred in 7 patients (6%), including two Grade 3 complications. Grade 2 pancreatitis occurred in 1 patient (1%). No radiation pneumonitis was observed. The cumulative incidence of late Grade 3 or 4 complications at 12 months after radioembolization was 8%. No Grade 5 toxicity occurred. CONCLUSIONS: (90)Y microsphere radioembolization is a well-tolerated treatment for unresectable hepatic tumors with a low risk of Grade 3 or higher early or late toxicity.

Investigation of habitat effects on the spatial distribution of Lutzomyia shannoni across heterogeneous environments, with note of respective mosquito species compositions.

Sand flies are small blood feeding dipterans that are primary vectors of numerous human and livestock pathogens. Control efforts are often complex and multidimensional. A fundamental step in the development and implementation of any integrated pest management (IPM) program is the refining of effective surveillance and identification techniques. Before this study, the presence of two species, Lutzomyia shannoni (Dyar) and Lutzomyia vexator (Coquillett) became known in Kentucky and surrounding states. To understand the spatial distribution of these species across heterogeneous landscapes in this region, trapping was conducted at random locations in previously designated habitats. Although a lack of clear data prevented any conclusions to be drawn for the preferences of L. vexator, the species of greater medical and veterinary importance, L. shannoni, was documented to show a strong preference for habitats along the wooded edges of pasture lands. In the region of study, these lands are frequently used in the production of beef cattle and other livestock, reinforcing the veterinary significance of the findings. Because of their familiarity to vector control officials and operators, mosquito species compositions were compared with the recorded abundance of L. shannoni across the varied habitats. The linking of this information should prove useful to management plans for the phlebotomine, if warranted in the future.

Wax structures of Scymnus louisianae attenuate aggression from aphid-tending ants.

The cuticular wax structures of Scymnus louisianae J. Chapin larvae were investigated as a defense against ant aggression by Lasius neoniger Emery. The presence of wax structures provided significant defense against ant aggression compared with denuded larvae in that these structures attenuated the aggressive behavior of foraging ants. Furthermore, reapplication of wax dissolved in hexane partially restored defenses associated with intact structures, showing an attenuation of aggression based in part on cuticular wax components rather than solely on physical obstruction to ant mouthparts.