Duvall, Michelle J.

Introduction: Treatment of cutaneous warts with intralesional vitamin D3 has demonstrated promising results in over 35 studies with methodological limitations. Methods: We conducted a randomized, double-blind, placebo-controlled trial in our primary care procedure clinic of intralesional vitamin D3 12 000 IU vs placebo in cutaneous warts every 4 weeks up to 3 times. Warts were assessed 4, 8, 12, and 24 weeks after the initial injection. The primary outcome was complete wart resolution. Reduction in wart size was a secondary outcome. Results: Between October 2020 and April 2023, we enrolled 77 participants with 1 or more cutaneous warts (41 and 36 in vitamin D3 and placebo groups, respectively) with untreated (32%) and recalcitrant (69%) warts. At 24 weeks, the index wart had resolved in 12 (30%) of vitamin D3 and 10 (31%) placebo participants. Treatment with vitamin D3 had no effect on wart surface area in an adjusted model nor wart resolution in analysis adjusted for baseline wart size, multiple warts, and the vehicle (OR 0.31 [95% CI] 0.01-10.3; P = 0.51). Conclusions: These results demonstrate a lack of benefit of intralesional vitamin D3 in cutaneous warts. ( ClinicalTrials.gov number NCT04278573)

Objectives: To evaluate the performance of noninvasive, elastic scattering spectroscopy, algorithm-powered device (DermaSensor) to detect melanoma and basal and squamous cell cancers in the primary care setting. Patients & Methods: DERM-SUCCESS, a blinded, prospective, multicenter pivotal study, enrolled adult patients between August 17, 2020, and December 9, 2021, with lesions that their primary care physicians (PCPs) suspected of skin cancer at clinics in the US (n = 18) and Australia (n = 4). These lesions were assessed by PCPs and scanned with the DermaSensor device. Biopsy specimens were collected, and histopathologic analysis was performed by dermatopathologists. The diagnostic performance of the device, dermatopathologist discordance, and subgroup analyses of clinical interest were calculated. Results: Of the 1579 skin lesions enrolled, dermatopathologic analysis identified 224 (14.2%) cancers. Device sensitivity was 95.5% (95% CI, 91.7%-97.6%) overall and 96.3% (92.9%-98.4%) for patients in the FDA-approved age group 40 years and older (90.2% for melanoma, 97.8% for basal cell carcinoma, and 97.7% for squamous cell carcinoma). Device specificity was 20.7%. The negative predictive value was 96.6%, and the positive predictive value was 16.6% (NNB 6). The device misclassified as “ monitor ” rather than “ investigate further ” 4 keratinocyte carcinomas and 4 melanomas in patients aged 40 years or older (n = 8, 0.5% of lesions, 3.7% of cancers biopsied). Conclusions: The DermaSensor device is an easy-to-use, point-of-care, hand-held skin cancer adjunctive diagnostic device with high sensitivity and NPV to help inform PCP decision-making about skin lesions suspicious for cancer that need further evaluation and those that may be monitored.

Background Although online self-triage is easily accessible, little is known about the patients who use self-triage or their subsequent diagnoses. We compared ear/hearing self-triage subsequent diagnoses to ear/hearing visit diagnoses in emergency departments (ED) and ambulatory clinics across the United States. Methods We compared International Classification of Diseases version 10 (ICD10) coded diagnoses following online self-triage for ear/hearing concerns with those from national ED and ambulatory clinic samples. We used data from the Centers for Disease Control (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) for comparison. Using matched ear/hearing diagnostic categories for those aged 1 and over, we compared self-triage diagnosis frequencies with national ED and ambulatory diagnosis frequencies. Results Following ear/hearing self-triage, there were 1092 subsequent office visits with a primary diagnosis code. For five frequently diagnosed ear/hearing conditions (i.e., suppurative and nonsuppurative otitis media [OM], otalgia, otitis externa, and cerumen impaction), there was a strong correlation between diagnosis counts made following self-triage and estimated counts of national ED visit diagnoses (r = 0.94; CI 95% [0.37 to 0.99]; p = .016, adjusted r2 = 0.85). Seven diagnoses were available to compare with the national ambulatory sample; correlation was r = 0.79; CI 95% [0.08 to 0.97]; p = .037, adjusted r2 = 0.54. For ages 1 and over, estimated hospital admissions from the national ED visits for ear/hearing were 0.76%, CI 95% [0.28-2.1%]; estimated total national ear/hearing ED visits were 7.5 million (for 4 years, 2016 through 2019). Conclusion The strong correlation of ear-related self-triage diagnoses with national ED diagnoses and the low hospitalization risk for these diagnoses suggests that there is an opportunity for self-triage of ear/hearing concerns to decrease ED visits for these symptoms.

Introduction: Proxies can communicate with health care teams through patient portals either by using proxy login credentials or a patient's login credentials. The frequency of proxies using patient login credentials is unknown. Methods: A random selection of 3,000 portal messages sent in through adult patients' own portal account was reviewed for indicators (referring to the patient in the third person) that someone other than the patient was using the patient portal account. Results: Of the reviewed 3,000 portal messages sent through patient portal accounts, 221 (7.4%) appeared to be sent in by a proxy, 2,512 (83.8%) appeared to have been sent in by the patient and for 266 (8.9%) portal messages reviewed it was unclear who sent in the message. There was no difference in mean age between patients who had proxy messages sent through patient portal accounts versus proxy portal accounts. Patients who had proxies send messages through patient accounts were more likely to be married and male. Out of 221 manually reviewed messages apparently sent by proxies through patient portal accounts there were 113 (51%) where the proxy included their name and 56 (25.3%) where they reported their relationship to the patient. During the study period, 0.7% of total messages on adult patients were sent through proxy accounts. Discussion: Proxies appear to use patient portal accounts much more frequently than proxy accounts to communicate with the health care team on adult patients; however, when using patient accounts they only identify themselves approximately half of the time.

Introduction As use of electronic portal communication with healthcare teams increases, processes that effectively recognize messages that contain critical information are needed. This study aims to evaluate whether certain language and other characteristics of patient portal messages are associated with expressions of self-harm and suicidal ideation. Methods Using patient portal messages sent between 1 January 2013 and 30 June 2017, we searched for words and letter combinations ‘suicid’ (to identify words suicide and suicidal), ‘depress’ (for depression, depressed, depressing), ‘harm himself’ (or ‘herself ‘or ‘myself’), ‘hurt himself’ (‘herself’ or ‘myself’), ‘kill’, ‘shoot’, ‘cutting’, ‘knife’, ‘gun’, ‘overdose’, ‘over dose’ and ‘jump’. Results Of 831,009 messages, 11,174 messages contained one or more search terms. We manually reviewed 7,736 messages for content expressing self-harm or suicidality. Of the reviewed messages, 3.2% indicated thoughts of self-harm or suicide and 2.2% of messages suggested active suicidality. Of those expressing any thoughts of self-harm or suicide, 13.4% mentioned a specific plan, 20% were passively suicidal. Messages indicating thoughts of self-harm and suicide were more common in patients who were unmarried, non-white and younger than 18 years. Factors significantly associated with thoughts of self-harm were messages addressed to psychiatry or containing the letter combinations ‘suicide’, ‘die’, ‘depress’ and ‘harm/hurt my/her/himself’. Discussion Certain letter combinations and patient portal message characteristics may be associated with expressions of self-harm and suicide. These factors should be considered as we develop systems of effectively screening patient portal messages for critical clinical information.