Metered-dose inhalers (MDIs) have been available for more than 50 years and are routinely used to deliver inhalation therapy to patients with asthma and chronic obstructive pulmonary disease. Given the ever-escalating costs of health care, various measures have been targeted by hospitals or health systems to eke out savings. Given the ubiquity of MDIs in the ICU, collaborative efforts by administrators and clinicians have focused on MDIs. These efforts, intended to curb rising costs and waste associated with MDI use, have resulted in a variety of protocols generically referred to as common canister policies (CCPs). While the concept of CCPs came into existence in the mid-1990s, casual observation suggests they are gaining momentum at hospitals and long-term care facilities. Most data regarding CCPs come from abstracts or posters; few studies have been published in peer-reviewed journals. Data on the efficacy and safety of CCPs in the ICU are particularly limited. Although most reports on CCPs have originated in community-based hospitals, some academic medical centers have also explored this concept.

What is common canister policy?

CCPs allow a single MDI canister to be shared among patients in a designated care area (typically a ward or ICU), with each individual having his/her own one-way valve holding chamber or spacer (Larson T, et al. Curr Med Res Opin. 2015;31[4]:853). Each patient care unit or respiratory therapist has a set of inhalers to use until actuations run out, at which point new inhalers are delivered from the pharmacy. Because the holding chamber or spacer is not shared, the risk of patient-to-patient spread of disease is minimized. In addition, the provider involved in administration of the inhaler must follow a standardized cleaning protocol to ensure the common canister is sterilized after each use.

This policy is designed to be used with inhaled therapies delivered by MDI (albuterol, ipratropium, albuterol/ipratropium, fluticasone, budesonide/formoterol, fluticasone/salmeterol). CCP does not apply to other types of inhalers, such as dry powder or mist inhalers, because the use of a separate holding chamber or spacer is not feasible with these devices. CCP savings are realized through a reduction in the number of MDIs purchased and the ability of patients to be charged per inhalation of medication delivered. An alternative CCP practice is to issue an MDI to a single patient and, upon his/her discharge, to clean and reissue the patient’s partially used MDIs to subsequent patients until the medication is exhausted (Liou J, et al. Hosp Pharm. 2014;49:437).

What are the risks and benefits of CCP?

CCP was implemented to minimize costs associated with drug wasting, since patients would not need individual inhalers. Some analysts believe dispensing individual inhalers creates an inherent financial burden as the average length of stay for an acute respiratory hospitalization is 4-5 days (Larson T, et al). This concern appears valid as two studies of MDI and dry powder inhaler use in real-world practice found that 11%-13% of the total amount of drug was utilized, leaving 87%-89% of each device wasted at a cost of approximately $87,000 annually (Larson T, et al; Sakaan S, et al. Hosp Pharm. 2015;50[5]:386).

In addition to cost reductions, one study showed CCP reduced delays in delivery of MDI therapy to patients because the lag time between order entry and delivery of the MDI to the floor was eliminated (Filippelli A, et al. Abstract, ASHP Midyear Clinical Meeting, Dec 1997). In this study, CCP allowed respiratory care practitioners immediate access to the common MDI for their entire shift, creating more efficient delivery of MDI treatments. On a par with findings in prior studies, these investigators observed a 55% reduction in hospital purchase costs for MDIs. Patient-level costs were similarly reduced, as each patient was billed only for the number of doses administered from an MDI, rather than for an entire canister.

While CCP appears to reduce inhaler-related costs, it is still unclear whether CCP increases the risk of iatrogenic infection. There is a particular paucity of information on the use of CCP in high-risk patients – those with cystic fibrosis, those in isolation, patients receiving mechanical ventilation, and those who are post transplant or otherwise immunocompromised (Larson T, et al). These patients have an inherently increased risk of developing nosocomial infections including ventilator-acquired pneumonia. A recent prospective study compared MDI CCP with single-patient MDI use in 353 patients supported by mechanical ventilation. Although CCP was associated with cost savings and similar rates of ventilator-acquired pneumonia, hospital mortality, and length of stay, there was a greater frequency of ventilator-associated events among patients in the CCP arm of the study (Gowan M, et al. Respir Care. 2016 May 3. pii: respcare.04550. [Epub ahead of print]).

The safety of CCP hinges on proper cleaning of the MDI between users. Typical cleaning protocols include: 1. spraying the MDI mouthpiece with compressed air; 2. cleaning the entire MDI with 70% isopropyl alcohol spray, immersion in isopropyl alcohol for 2 minutes, or cleaning with a bleach swab; and 3. allowing the MDI to air dry before returning it to the shared stock for reissue (Larson T, et al). Although cleaning protocols minimize potential patient harm, they may not always be followed properly. Human errors that put patients at risk for nosocomial infection while utilizing CCP have been reported. In two such instances, patients isolated for methicillin-resistant Staphylococcus aureus infection had their individual MDIs put back into the common canister stock and utilized by other patients for approximately 24 hours (Larson T, et al). Once this was noticed, the patients who received inhalations from the “at-risk” MDI were monitored in isolation. No cross-infection occurred, but the mistake paradoxically increased hospital costs. In another reported instance, a bone marrow transplant patient received MDI therapy from the common canister stock (Larson T, et al). Although no harm occurred, this broke protocol as these patients were excluded from the program because of their increased risk of infection from cross-contamination. Other reports describe protocol breaches such as clinicians not returning MDIs to stock in a timely manner or keeping MDIs in their coat pockets. These events highlight the need for health care professionals associated with CCP to adhere to protocols.

Cross-contamination has been studied at institutions utilizing CCPs. While the majority of reports show no growth in postuse MDI cultures, one study reported growth of group D streptococci when alcohol disinfection did not occur and Staphylococcus epidermidis in 5% of the cultures taken after disinfection per protocol (Grissinger M. PT. 2013;38[8]:434). Although the bacteria that grew in these studies could be considered environmental contaminants, these findings reinforce the need for concern regarding iatrogenic infection.

The legal landscape

The decision to enact CCP requires careful analysis, planning, and communication by all key decision makers. State laws must be reviewed for formal statements or regulations regarding CCP. Protocol standards should also be evaluated against Joint Commission and Centers for Medicare & Medicaid Services standards for medication administration and storage. Before initiating CCP, communication should occur among risk managers, the pharmacy and therapeutics committee, pulmonologists, respiratory therapists, the medical executive committee, infection control personnel, and the professional liability insurance provider. A contingency plan should be put in place should cross-contamination occur. Note that while the goal of CCP is cost savings, no economic analysis to date has considered the incremental costs of cross-contamination and iatrogenic infection.

What alternative strategies to CCP exist?

CCP aims to turn a single-user multidose inhaler into one that is a unit-dose inhaler shared by multiple patients. One alternative strategy of unit-dose inhalations is nebulization as each treatment consists of a single-use ampule of medication. Another strategy is the use of institutional dose packages that allow hospitals to purchase single-user inhalers limited to five or seven doses of therapy. The prices for nebulized treatments and institutional dose packages may offer cost savings similar to CCP while obviating the increased risk of nosocomial infection.

Dr. Malesker is professor of pharmacy practice and medicine, department of pharmacy practice, School of Pharmacy and Health Professions, Creighton University, Omaha, Neb.

Metered-dose inhalers (MDIs) have been available for more than 50 years and are routinely used to deliver inhalation therapy to patients with asthma and chronic obstructive pulmonary disease. Given the ever-escalating costs of health care, various measures have been targeted by hospitals or health systems to eke out savings. Given the ubiquity of MDIs in the ICU, collaborative efforts by administrators and clinicians have focused on MDIs. These efforts, intended to curb rising costs and waste associated with MDI use, have resulted in a variety of protocols generically referred to as common canister policies (CCPs). While the concept of CCPs came into existence in the mid-1990s, casual observation suggests they are gaining momentum at hospitals and long-term care facilities. Most data regarding CCPs come from abstracts or posters; few studies have been published in peer-reviewed journals. Data on the efficacy and safety of CCPs in the ICU are particularly limited. Although most reports on CCPs have originated in community-based hospitals, some academic medical centers have also explored this concept.

What is common canister policy?

CCPs allow a single MDI canister to be shared among patients in a designated care area (typically a ward or ICU), with each individual having his/her own one-way valve holding chamber or spacer (Larson T, et al. Curr Med Res Opin. 2015;31[4]:853). Each patient care unit or respiratory therapist has a set of inhalers to use until actuations run out, at which point new inhalers are delivered from the pharmacy. Because the holding chamber or spacer is not shared, the risk of patient-to-patient spread of disease is minimized. In addition, the provider involved in administration of the inhaler must follow a standardized cleaning protocol to ensure the common canister is sterilized after each use.

This policy is designed to be used with inhaled therapies delivered by MDI (albuterol, ipratropium, albuterol/ipratropium, fluticasone, budesonide/formoterol, fluticasone/salmeterol). CCP does not apply to other types of inhalers, such as dry powder or mist inhalers, because the use of a separate holding chamber or spacer is not feasible with these devices. CCP savings are realized through a reduction in the number of MDIs purchased and the ability of patients to be charged per inhalation of medication delivered. An alternative CCP practice is to issue an MDI to a single patient and, upon his/her discharge, to clean and reissue the patient’s partially used MDIs to subsequent patients until the medication is exhausted (Liou J, et al. Hosp Pharm. 2014;49:437).

What are the risks and benefits of CCP?

CCP was implemented to minimize costs associated with drug wasting, since patients would not need individual inhalers. Some analysts believe dispensing individual inhalers creates an inherent financial burden as the average length of stay for an acute respiratory hospitalization is 4-5 days (Larson T, et al). This concern appears valid as two studies of MDI and dry powder inhaler use in real-world practice found that 11%-13% of the total amount of drug was utilized, leaving 87%-89% of each device wasted at a cost of approximately $87,000 annually (Larson T, et al; Sakaan S, et al. Hosp Pharm. 2015;50[5]:386).

In addition to cost reductions, one study showed CCP reduced delays in delivery of MDI therapy to patients because the lag time between order entry and delivery of the MDI to the floor was eliminated (Filippelli A, et al. Abstract, ASHP Midyear Clinical Meeting, Dec 1997). In this study, CCP allowed respiratory care practitioners immediate access to the common MDI for their entire shift, creating more efficient delivery of MDI treatments. On a par with findings in prior studies, these investigators observed a 55% reduction in hospital purchase costs for MDIs. Patient-level costs were similarly reduced, as each patient was billed only for the number of doses administered from an MDI, rather than for an entire canister.

While CCP appears to reduce inhaler-related costs, it is still unclear whether CCP increases the risk of iatrogenic infection. There is a particular paucity of information on the use of CCP in high-risk patients – those with cystic fibrosis, those in isolation, patients receiving mechanical ventilation, and those who are post transplant or otherwise immunocompromised (Larson T, et al). These patients have an inherently increased risk of developing nosocomial infections including ventilator-acquired pneumonia. A recent prospective study compared MDI CCP with single-patient MDI use in 353 patients supported by mechanical ventilation. Although CCP was associated with cost savings and similar rates of ventilator-acquired pneumonia, hospital mortality, and length of stay, there was a greater frequency of ventilator-associated events among patients in the CCP arm of the study (Gowan M, et al. Respir Care. 2016 May 3. pii: respcare.04550. [Epub ahead of print]).

The safety of CCP hinges on proper cleaning of the MDI between users. Typical cleaning protocols include: 1. spraying the MDI mouthpiece with compressed air; 2. cleaning the entire MDI with 70% isopropyl alcohol spray, immersion in isopropyl alcohol for 2 minutes, or cleaning with a bleach swab; and 3. allowing the MDI to air dry before returning it to the shared stock for reissue (Larson T, et al). Although cleaning protocols minimize potential patient harm, they may not always be followed properly. Human errors that put patients at risk for nosocomial infection while utilizing CCP have been reported. In two such instances, patients isolated for methicillin-resistant Staphylococcus aureus infection had their individual MDIs put back into the common canister stock and utilized by other patients for approximately 24 hours (Larson T, et al). Once this was noticed, the patients who received inhalations from the “at-risk” MDI were monitored in isolation. No cross-infection occurred, but the mistake paradoxically increased hospital costs. In another reported instance, a bone marrow transplant patient received MDI therapy from the common canister stock (Larson T, et al). Although no harm occurred, this broke protocol as these patients were excluded from the program because of their increased risk of infection from cross-contamination. Other reports describe protocol breaches such as clinicians not returning MDIs to stock in a timely manner or keeping MDIs in their coat pockets. These events highlight the need for health care professionals associated with CCP to adhere to protocols.

Cross-contamination has been studied at institutions utilizing CCPs. While the majority of reports show no growth in postuse MDI cultures, one study reported growth of group D streptococci when alcohol disinfection did not occur and Staphylococcus epidermidis in 5% of the cultures taken after disinfection per protocol (Grissinger M. PT. 2013;38[8]:434). Although the bacteria that grew in these studies could be considered environmental contaminants, these findings reinforce the need for concern regarding iatrogenic infection.

The legal landscape

The decision to enact CCP requires careful analysis, planning, and communication by all key decision makers. State laws must be reviewed for formal statements or regulations regarding CCP. Protocol standards should also be evaluated against Joint Commission and Centers for Medicare & Medicaid Services standards for medication administration and storage. Before initiating CCP, communication should occur among risk managers, the pharmacy and therapeutics committee, pulmonologists, respiratory therapists, the medical executive committee, infection control personnel, and the professional liability insurance provider. A contingency plan should be put in place should cross-contamination occur. Note that while the goal of CCP is cost savings, no economic analysis to date has considered the incremental costs of cross-contamination and iatrogenic infection.

What alternative strategies to CCP exist?

CCP aims to turn a single-user multidose inhaler into one that is a unit-dose inhaler shared by multiple patients. One alternative strategy of unit-dose inhalations is nebulization as each treatment consists of a single-use ampule of medication. Another strategy is the use of institutional dose packages that allow hospitals to purchase single-user inhalers limited to five or seven doses of therapy. The prices for nebulized treatments and institutional dose packages may offer cost savings similar to CCP while obviating the increased risk of nosocomial infection.

Dr. Malesker is professor of pharmacy practice and medicine, department of pharmacy practice, School of Pharmacy and Health Professions, Creighton University, Omaha, Neb.

Metered-dose inhalers (MDIs) have been available for more than 50 years and are routinely used to deliver inhalation therapy to patients with asthma and chronic obstructive pulmonary disease. Given the ever-escalating costs of health care, various measures have been targeted by hospitals or health systems to eke out savings. Given the ubiquity of MDIs in the ICU, collaborative efforts by administrators and clinicians have focused on MDIs. These efforts, intended to curb rising costs and waste associated with MDI use, have resulted in a variety of protocols generically referred to as common canister policies (CCPs). While the concept of CCPs came into existence in the mid-1990s, casual observation suggests they are gaining momentum at hospitals and long-term care facilities. Most data regarding CCPs come from abstracts or posters; few studies have been published in peer-reviewed journals. Data on the efficacy and safety of CCPs in the ICU are particularly limited. Although most reports on CCPs have originated in community-based hospitals, some academic medical centers have also explored this concept.

What is common canister policy?

CCPs allow a single MDI canister to be shared among patients in a designated care area (typically a ward or ICU), with each individual having his/her own one-way valve holding chamber or spacer (Larson T, et al. Curr Med Res Opin. 2015;31[4]:853). Each patient care unit or respiratory therapist has a set of inhalers to use until actuations run out, at which point new inhalers are delivered from the pharmacy. Because the holding chamber or spacer is not shared, the risk of patient-to-patient spread of disease is minimized. In addition, the provider involved in administration of the inhaler must follow a standardized cleaning protocol to ensure the common canister is sterilized after each use.

This policy is designed to be used with inhaled therapies delivered by MDI (albuterol, ipratropium, albuterol/ipratropium, fluticasone, budesonide/formoterol, fluticasone/salmeterol). CCP does not apply to other types of inhalers, such as dry powder or mist inhalers, because the use of a separate holding chamber or spacer is not feasible with these devices. CCP savings are realized through a reduction in the number of MDIs purchased and the ability of patients to be charged per inhalation of medication delivered. An alternative CCP practice is to issue an MDI to a single patient and, upon his/her discharge, to clean and reissue the patient’s partially used MDIs to subsequent patients until the medication is exhausted (Liou J, et al. Hosp Pharm. 2014;49:437).

What are the risks and benefits of CCP?

CCP was implemented to minimize costs associated with drug wasting, since patients would not need individual inhalers. Some analysts believe dispensing individual inhalers creates an inherent financial burden as the average length of stay for an acute respiratory hospitalization is 4-5 days (Larson T, et al). This concern appears valid as two studies of MDI and dry powder inhaler use in real-world practice found that 11%-13% of the total amount of drug was utilized, leaving 87%-89% of each device wasted at a cost of approximately $87,000 annually (Larson T, et al; Sakaan S, et al. Hosp Pharm. 2015;50[5]:386).

In addition to cost reductions, one study showed CCP reduced delays in delivery of MDI therapy to patients because the lag time between order entry and delivery of the MDI to the floor was eliminated (Filippelli A, et al. Abstract, ASHP Midyear Clinical Meeting, Dec 1997). In this study, CCP allowed respiratory care practitioners immediate access to the common MDI for their entire shift, creating more efficient delivery of MDI treatments. On a par with findings in prior studies, these investigators observed a 55% reduction in hospital purchase costs for MDIs. Patient-level costs were similarly reduced, as each patient was billed only for the number of doses administered from an MDI, rather than for an entire canister.

While CCP appears to reduce inhaler-related costs, it is still unclear whether CCP increases the risk of iatrogenic infection. There is a particular paucity of information on the use of CCP in high-risk patients – those with cystic fibrosis, those in isolation, patients receiving mechanical ventilation, and those who are post transplant or otherwise immunocompromised (Larson T, et al). These patients have an inherently increased risk of developing nosocomial infections including ventilator-acquired pneumonia. A recent prospective study compared MDI CCP with single-patient MDI use in 353 patients supported by mechanical ventilation. Although CCP was associated with cost savings and similar rates of ventilator-acquired pneumonia, hospital mortality, and length of stay, there was a greater frequency of ventilator-associated events among patients in the CCP arm of the study (Gowan M, et al. Respir Care. 2016 May 3. pii: respcare.04550. [Epub ahead of print]).

The safety of CCP hinges on proper cleaning of the MDI between users. Typical cleaning protocols include: 1. spraying the MDI mouthpiece with compressed air; 2. cleaning the entire MDI with 70% isopropyl alcohol spray, immersion in isopropyl alcohol for 2 minutes, or cleaning with a bleach swab; and 3. allowing the MDI to air dry before returning it to the shared stock for reissue (Larson T, et al). Although cleaning protocols minimize potential patient harm, they may not always be followed properly. Human errors that put patients at risk for nosocomial infection while utilizing CCP have been reported. In two such instances, patients isolated for methicillin-resistant Staphylococcus aureus infection had their individual MDIs put back into the common canister stock and utilized by other patients for approximately 24 hours (Larson T, et al). Once this was noticed, the patients who received inhalations from the “at-risk” MDI were monitored in isolation. No cross-infection occurred, but the mistake paradoxically increased hospital costs. In another reported instance, a bone marrow transplant patient received MDI therapy from the common canister stock (Larson T, et al). Although no harm occurred, this broke protocol as these patients were excluded from the program because of their increased risk of infection from cross-contamination. Other reports describe protocol breaches such as clinicians not returning MDIs to stock in a timely manner or keeping MDIs in their coat pockets. These events highlight the need for health care professionals associated with CCP to adhere to protocols.

Cross-contamination has been studied at institutions utilizing CCPs. While the majority of reports show no growth in postuse MDI cultures, one study reported growth of group D streptococci when alcohol disinfection did not occur and Staphylococcus epidermidis in 5% of the cultures taken after disinfection per protocol (Grissinger M. PT. 2013;38[8]:434). Although the bacteria that grew in these studies could be considered environmental contaminants, these findings reinforce the need for concern regarding iatrogenic infection.

The legal landscape

The decision to enact CCP requires careful analysis, planning, and communication by all key decision makers. State laws must be reviewed for formal statements or regulations regarding CCP. Protocol standards should also be evaluated against Joint Commission and Centers for Medicare & Medicaid Services standards for medication administration and storage. Before initiating CCP, communication should occur among risk managers, the pharmacy and therapeutics committee, pulmonologists, respiratory therapists, the medical executive committee, infection control personnel, and the professional liability insurance provider. A contingency plan should be put in place should cross-contamination occur. Note that while the goal of CCP is cost savings, no economic analysis to date has considered the incremental costs of cross-contamination and iatrogenic infection.

What alternative strategies to CCP exist?

CCP aims to turn a single-user multidose inhaler into one that is a unit-dose inhaler shared by multiple patients. One alternative strategy of unit-dose inhalations is nebulization as each treatment consists of a single-use ampule of medication. Another strategy is the use of institutional dose packages that allow hospitals to purchase single-user inhalers limited to five or seven doses of therapy. The prices for nebulized treatments and institutional dose packages may offer cost savings similar to CCP while obviating the increased risk of nosocomial infection.

Dr. Malesker is professor of pharmacy practice and medicine, department of pharmacy practice, School of Pharmacy and Health Professions, Creighton University, Omaha, Neb.

The FP suspected that this was tinea corporis, and after looking for other signs of tinea, found that the patient had some interdigital tinea pedis with thickened dysmorphic toenails. A potassium hydroxide (KOH) preparation was performed on the rash and toenails (See video on how to perform a KOH preparation here). Both were clearly positive for branching hyphae, confirming the diagnoses of tinea corporis and onychomycosis. While KOH preparation is the definitive test to confirm a suspected fungal infection, it is often helpful to look for other sites of fungus (such as the feet) when tinea is suspected.

The diagnosis of tinea corporis was unrelated to the patient’s deodorant, even though contact dermatitis can occur in the axilla as a result of a new deodorant containing a contact allergen. In most cases, however, the contact dermatitis will be bilateral.

The FP discussed the treatment options with the patient, including oral or topical antifungal medicines, and the patient chose to go straight to oral therapy. He stated that he had tried an over-the-counter antifungal medicine recently and did not find it very helpful. The FP explained that it would take a minimum of 3 months of oral therapy to also treat the patient’s toenails. The patient denied any history of hepatitis or heavy alcohol abuse and had normal liver function tests (LFTs) in the previous year.

The FP prescribed one month of oral terbinafine 250 mg/d to eradicate the skin infection and to begin treating the toenails. Two to 3 weeks of oral terbinafine is often adequate for tinea corporis if there is only one site involved. A follow-up appointment was set for one month later at which time the FP planned to order repeat LFTs and discuss the risks and benefits of another 2 months of oral terbinafine to eradicate the onychomycosis.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Jimenez A. Tinea corporis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:788-794.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP suspected that this was tinea corporis, and after looking for other signs of tinea, found that the patient had some interdigital tinea pedis with thickened dysmorphic toenails. A potassium hydroxide (KOH) preparation was performed on the rash and toenails (See video on how to perform a KOH preparation here). Both were clearly positive for branching hyphae, confirming the diagnoses of tinea corporis and onychomycosis. While KOH preparation is the definitive test to confirm a suspected fungal infection, it is often helpful to look for other sites of fungus (such as the feet) when tinea is suspected.

The diagnosis of tinea corporis was unrelated to the patient’s deodorant, even though contact dermatitis can occur in the axilla as a result of a new deodorant containing a contact allergen. In most cases, however, the contact dermatitis will be bilateral.

The FP discussed the treatment options with the patient, including oral or topical antifungal medicines, and the patient chose to go straight to oral therapy. He stated that he had tried an over-the-counter antifungal medicine recently and did not find it very helpful. The FP explained that it would take a minimum of 3 months of oral therapy to also treat the patient’s toenails. The patient denied any history of hepatitis or heavy alcohol abuse and had normal liver function tests (LFTs) in the previous year.

The FP prescribed one month of oral terbinafine 250 mg/d to eradicate the skin infection and to begin treating the toenails. Two to 3 weeks of oral terbinafine is often adequate for tinea corporis if there is only one site involved. A follow-up appointment was set for one month later at which time the FP planned to order repeat LFTs and discuss the risks and benefits of another 2 months of oral terbinafine to eradicate the onychomycosis.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Jimenez A. Tinea corporis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:788-794.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP suspected that this was tinea corporis, and after looking for other signs of tinea, found that the patient had some interdigital tinea pedis with thickened dysmorphic toenails. A potassium hydroxide (KOH) preparation was performed on the rash and toenails (See video on how to perform a KOH preparation here). Both were clearly positive for branching hyphae, confirming the diagnoses of tinea corporis and onychomycosis. While KOH preparation is the definitive test to confirm a suspected fungal infection, it is often helpful to look for other sites of fungus (such as the feet) when tinea is suspected.

The diagnosis of tinea corporis was unrelated to the patient’s deodorant, even though contact dermatitis can occur in the axilla as a result of a new deodorant containing a contact allergen. In most cases, however, the contact dermatitis will be bilateral.

The FP discussed the treatment options with the patient, including oral or topical antifungal medicines, and the patient chose to go straight to oral therapy. He stated that he had tried an over-the-counter antifungal medicine recently and did not find it very helpful. The FP explained that it would take a minimum of 3 months of oral therapy to also treat the patient’s toenails. The patient denied any history of hepatitis or heavy alcohol abuse and had normal liver function tests (LFTs) in the previous year.

The FP prescribed one month of oral terbinafine 250 mg/d to eradicate the skin infection and to begin treating the toenails. Two to 3 weeks of oral terbinafine is often adequate for tinea corporis if there is only one site involved. A follow-up appointment was set for one month later at which time the FP planned to order repeat LFTs and discuss the risks and benefits of another 2 months of oral terbinafine to eradicate the onychomycosis.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Jimenez A. Tinea corporis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:788-794.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

To convince parents to get their kids vaccinated against human papillomavirus (HPV), tell them “I strongly believe in the importance of this cancer-preventing vaccine for [their child’s name],” researchers concluded after an online survey of 1,504 parents of children aged 11-17 years.

Sixty-five percent of parents agreed it was a persuasive argument, the highest percentage among 15 statements in favor of vaccination; 69% of 776 surveyed physicians said they’d use it in practice, also the highest physician endorsement for the various arguments (Cancer Epidemiol Biomarkers Prev. 2016 Sep 30. doi: 10.1158/1055-9965.EPI-16-0224).

In general, parents disinclined to vaccinate were most receptive to messages about HPV infection being common, cancers caused by HPV, and HPV vaccine effectiveness.

Other persuasive arguments included “[child’s name] can get anal/cervical cancer as an adult, but you can stop that right now;” and “there will be many things in [child’s name]’s life that you can’t control. But you can control whether [he/she] gets some dangerous kinds of HPV.”

©jarun011/Thinkstock

[email protected]

To convince parents to get their kids vaccinated against human papillomavirus (HPV), tell them “I strongly believe in the importance of this cancer-preventing vaccine for [their child’s name],” researchers concluded after an online survey of 1,504 parents of children aged 11-17 years.

Sixty-five percent of parents agreed it was a persuasive argument, the highest percentage among 15 statements in favor of vaccination; 69% of 776 surveyed physicians said they’d use it in practice, also the highest physician endorsement for the various arguments (Cancer Epidemiol Biomarkers Prev. 2016 Sep 30. doi: 10.1158/1055-9965.EPI-16-0224).

In general, parents disinclined to vaccinate were most receptive to messages about HPV infection being common, cancers caused by HPV, and HPV vaccine effectiveness.

Other persuasive arguments included “[child’s name] can get anal/cervical cancer as an adult, but you can stop that right now;” and “there will be many things in [child’s name]’s life that you can’t control. But you can control whether [he/she] gets some dangerous kinds of HPV.”

©jarun011/Thinkstock

[email protected]

To convince parents to get their kids vaccinated against human papillomavirus (HPV), tell them “I strongly believe in the importance of this cancer-preventing vaccine for [their child’s name],” researchers concluded after an online survey of 1,504 parents of children aged 11-17 years.

Sixty-five percent of parents agreed it was a persuasive argument, the highest percentage among 15 statements in favor of vaccination; 69% of 776 surveyed physicians said they’d use it in practice, also the highest physician endorsement for the various arguments (Cancer Epidemiol Biomarkers Prev. 2016 Sep 30. doi: 10.1158/1055-9965.EPI-16-0224).

In general, parents disinclined to vaccinate were most receptive to messages about HPV infection being common, cancers caused by HPV, and HPV vaccine effectiveness.

Other persuasive arguments included “[child’s name] can get anal/cervical cancer as an adult, but you can stop that right now;” and “there will be many things in [child’s name]’s life that you can’t control. But you can control whether [he/she] gets some dangerous kinds of HPV.”

©jarun011/Thinkstock

[email protected]

About half of all doctors who participate in the Physician Quality Reporting System (PQRS) soon will learn that their Medicare pay will be cut by up to 2% in 2017.

The Centers for Medicare & Medicaid Services has completed its assessments for reporting year 2015 and has begun notifying physicians that a 2.0% negative payment adjustment is forthcoming for those who did not satisfactorily report PQRS quality measures or who failed to satisfactorily participate in a qualified clinical data registry.

Doctors have just 2 months to challenge findings that they believe were made in error to spare themselves the 2017 cut, according to a CMS announcement.

If doctors believe their 2017 PQRS pay cut is erroneous, they can submit an informal review request by 11:59 p.m. EST on Nov. 30. CMS will investigate the merits of all review requests and issue a decision within 90 days. All requests for informal review must be submitted via a Web-based tool on the quality reporting communication support page. There are no hardship exemptions for the PQRS pay cuts.

In addition, some 2015 PQRS performance scores will be publicly reported on the Physician Compare website. CMS is hosting two sessions in October to provide further information about such public reporting.

In 2015, approximately 1.15 million professionals were eligible and able to participate in PQRS; just over half (624,077 or 54%) of eligible professionals successfully submitted data. The rest – about 528,000, or 46% – will see a pay cut in 2017, according to CMS.

Last year, slightly more health providers – 558,885 eligible professionals – were subject to the 2016 PQRS pay cut based on their 2014 reporting experience.

Walter J. Gorski, director of regulatory affairs for the American College of Physicians, said the college will be monitoring the notifications as they go out to physicians to assess impacts at the individual practice level and overall.

“In past years, the PQRS experience reports have shown a low level of participation in the program and, thus, a large number of physicians being subject to these negative adjustments,” Mr. Gorski said in an interview. “This low level of overall participation has long been a concern of ours and something we have recommended that CMS work to mitigate by simplifying reporting – something that we are pushing strongly for as the program is rolled into the new MIPS pathway [Merit-Based Incentive Payment System] within the [Quality Payment Program].”

The new Quality Payment Program will replace both PQRS and the Value Modifier program, as well as the separate payment adjustments under the Medicare EHR Incentive Program. The streamlined program will have reduced quality reporting requirements and a flexible design that allows eligible clinicians to pick the pace of participation during the first year, according to CMS.

“The newly announced ‘pick your pace’ approach for the first year of MIPS reporting will give physicians an opportunity to get their feet wet with quality reporting in a way that will protect them from future negative adjustments,” Mr. Gorski said.
 

[email protected]

On Twitter @legal_med

About half of all doctors who participate in the Physician Quality Reporting System (PQRS) soon will learn that their Medicare pay will be cut by up to 2% in 2017.

The Centers for Medicare & Medicaid Services has completed its assessments for reporting year 2015 and has begun notifying physicians that a 2.0% negative payment adjustment is forthcoming for those who did not satisfactorily report PQRS quality measures or who failed to satisfactorily participate in a qualified clinical data registry.

Doctors have just 2 months to challenge findings that they believe were made in error to spare themselves the 2017 cut, according to a CMS announcement.

If doctors believe their 2017 PQRS pay cut is erroneous, they can submit an informal review request by 11:59 p.m. EST on Nov. 30. CMS will investigate the merits of all review requests and issue a decision within 90 days. All requests for informal review must be submitted via a Web-based tool on the quality reporting communication support page. There are no hardship exemptions for the PQRS pay cuts.

In addition, some 2015 PQRS performance scores will be publicly reported on the Physician Compare website. CMS is hosting two sessions in October to provide further information about such public reporting.

In 2015, approximately 1.15 million professionals were eligible and able to participate in PQRS; just over half (624,077 or 54%) of eligible professionals successfully submitted data. The rest – about 528,000, or 46% – will see a pay cut in 2017, according to CMS.

Last year, slightly more health providers – 558,885 eligible professionals – were subject to the 2016 PQRS pay cut based on their 2014 reporting experience.

Walter J. Gorski, director of regulatory affairs for the American College of Physicians, said the college will be monitoring the notifications as they go out to physicians to assess impacts at the individual practice level and overall.

“In past years, the PQRS experience reports have shown a low level of participation in the program and, thus, a large number of physicians being subject to these negative adjustments,” Mr. Gorski said in an interview. “This low level of overall participation has long been a concern of ours and something we have recommended that CMS work to mitigate by simplifying reporting – something that we are pushing strongly for as the program is rolled into the new MIPS pathway [Merit-Based Incentive Payment System] within the [Quality Payment Program].”

The new Quality Payment Program will replace both PQRS and the Value Modifier program, as well as the separate payment adjustments under the Medicare EHR Incentive Program. The streamlined program will have reduced quality reporting requirements and a flexible design that allows eligible clinicians to pick the pace of participation during the first year, according to CMS.

“The newly announced ‘pick your pace’ approach for the first year of MIPS reporting will give physicians an opportunity to get their feet wet with quality reporting in a way that will protect them from future negative adjustments,” Mr. Gorski said.
 

[email protected]

On Twitter @legal_med

About half of all doctors who participate in the Physician Quality Reporting System (PQRS) soon will learn that their Medicare pay will be cut by up to 2% in 2017.

The Centers for Medicare & Medicaid Services has completed its assessments for reporting year 2015 and has begun notifying physicians that a 2.0% negative payment adjustment is forthcoming for those who did not satisfactorily report PQRS quality measures or who failed to satisfactorily participate in a qualified clinical data registry.

Doctors have just 2 months to challenge findings that they believe were made in error to spare themselves the 2017 cut, according to a CMS announcement.

If doctors believe their 2017 PQRS pay cut is erroneous, they can submit an informal review request by 11:59 p.m. EST on Nov. 30. CMS will investigate the merits of all review requests and issue a decision within 90 days. All requests for informal review must be submitted via a Web-based tool on the quality reporting communication support page. There are no hardship exemptions for the PQRS pay cuts.

In addition, some 2015 PQRS performance scores will be publicly reported on the Physician Compare website. CMS is hosting two sessions in October to provide further information about such public reporting.

In 2015, approximately 1.15 million professionals were eligible and able to participate in PQRS; just over half (624,077 or 54%) of eligible professionals successfully submitted data. The rest – about 528,000, or 46% – will see a pay cut in 2017, according to CMS.

Last year, slightly more health providers – 558,885 eligible professionals – were subject to the 2016 PQRS pay cut based on their 2014 reporting experience.

Walter J. Gorski, director of regulatory affairs for the American College of Physicians, said the college will be monitoring the notifications as they go out to physicians to assess impacts at the individual practice level and overall.

“In past years, the PQRS experience reports have shown a low level of participation in the program and, thus, a large number of physicians being subject to these negative adjustments,” Mr. Gorski said in an interview. “This low level of overall participation has long been a concern of ours and something we have recommended that CMS work to mitigate by simplifying reporting – something that we are pushing strongly for as the program is rolled into the new MIPS pathway [Merit-Based Incentive Payment System] within the [Quality Payment Program].”

The new Quality Payment Program will replace both PQRS and the Value Modifier program, as well as the separate payment adjustments under the Medicare EHR Incentive Program. The streamlined program will have reduced quality reporting requirements and a flexible design that allows eligible clinicians to pick the pace of participation during the first year, according to CMS.

“The newly announced ‘pick your pace’ approach for the first year of MIPS reporting will give physicians an opportunity to get their feet wet with quality reporting in a way that will protect them from future negative adjustments,” Mr. Gorski said.
 

[email protected]

On Twitter @legal_med

The largest measles outbreak in the United States in more than 2 decades, with an attack rate several orders of magnitude larger than the usual annual nationwide incidence of the disease, could have been better controlled if clinicians had recognized the index cases sooner, according to a report published online Oct. 6 in the New England Journal of Medicine.

At 4 months’ duration, the 2014 measles outbreak in undervaccinated Amish communities across Ohio was also the longest-lasting one on record since the disease was eliminated in the United States, said Paul A. Gastañaduy, MD, of the division of viral diseases, Centers for Disease Control and Prevention, and his associates.

CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D.

The largest measles outbreak in the United States in more than 2 decades, with an attack rate several orders of magnitude larger than the usual annual nationwide incidence of the disease, could have been better controlled if clinicians had recognized the index cases sooner, according to a report published online Oct. 6 in the New England Journal of Medicine.

At 4 months’ duration, the 2014 measles outbreak in undervaccinated Amish communities across Ohio was also the longest-lasting one on record since the disease was eliminated in the United States, said Paul A. Gastañaduy, MD, of the division of viral diseases, Centers for Disease Control and Prevention, and his associates.

CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D.

The largest measles outbreak in the United States in more than 2 decades, with an attack rate several orders of magnitude larger than the usual annual nationwide incidence of the disease, could have been better controlled if clinicians had recognized the index cases sooner, according to a report published online Oct. 6 in the New England Journal of Medicine.

At 4 months’ duration, the 2014 measles outbreak in undervaccinated Amish communities across Ohio was also the longest-lasting one on record since the disease was eliminated in the United States, said Paul A. Gastañaduy, MD, of the division of viral diseases, Centers for Disease Control and Prevention, and his associates.

CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D.

Patients treated for acute MI at high-performing hospitals – those with the best performance on 30-day mortality quality measures assessed by the Centers for Medicare & Medicaid Services – had longer life expectancies than did patients treated at low-performing hospitals, according to a report published online Oct. 6 in the New England Journal of Medicine.

This survival benefit persisted through 17 years of follow-up, said Emily Bucholz, MD, of Boston Children’s Hospital, and her associates.

Until now, researchers didn’t know whether the short-term survival benefit at high-performing hospitals would wane over time, which “would lend support to the theory that these hospitals discharge more patients alive but with higher subsequent mortality.” The results of this secondary analysis of data from a nationally representative cohort study indicate that, instead, the superior quality of care delivered at high-performing hospitals appears to “produce an early benefit that endures over time,” Dr. Bucholz and her associates noted. The investigators assessed long-term life expectancy using data from the Cooperative Cardiovascular Project, which enrolled Medicare beneficiaries aged 65 years and older treated for acute MI in 1994-1996. They focused on 119,735 patients admitted to 1,824 hospitals. They grouped the hospitals according to their case mixes (a measure of patients’ severity of illness) and calculated risk-standardized mortality rates according to CMS criteria.

“We found that patients treated at high-performing hospitals ... lived, on average, between 0.74 and 1.14 years longer after acute MI than [did] those treated at low-performing hospitals. These findings were consistent across case-mix strata, which indicates that the relationship between hospital performance and long-term patient outcomes is independent of hospital case mix,” Dr. Bucholz and her associates said (N Engl J Med. 2016 Oct 6. doi: 10.1056/NEJMoa1513223).

These findings show that the early survival advantage achieved by high-performing hospitals is durable, and that “investing in initiatives to improve short-term hospital performance may also improve patient outcomes over the long term,” they added.

Patients treated for acute MI at high-performing hospitals – those with the best performance on 30-day mortality quality measures assessed by the Centers for Medicare & Medicaid Services – had longer life expectancies than did patients treated at low-performing hospitals, according to a report published online Oct. 6 in the New England Journal of Medicine.

This survival benefit persisted through 17 years of follow-up, said Emily Bucholz, MD, of Boston Children’s Hospital, and her associates.

Until now, researchers didn’t know whether the short-term survival benefit at high-performing hospitals would wane over time, which “would lend support to the theory that these hospitals discharge more patients alive but with higher subsequent mortality.” The results of this secondary analysis of data from a nationally representative cohort study indicate that, instead, the superior quality of care delivered at high-performing hospitals appears to “produce an early benefit that endures over time,” Dr. Bucholz and her associates noted. The investigators assessed long-term life expectancy using data from the Cooperative Cardiovascular Project, which enrolled Medicare beneficiaries aged 65 years and older treated for acute MI in 1994-1996. They focused on 119,735 patients admitted to 1,824 hospitals. They grouped the hospitals according to their case mixes (a measure of patients’ severity of illness) and calculated risk-standardized mortality rates according to CMS criteria.

“We found that patients treated at high-performing hospitals ... lived, on average, between 0.74 and 1.14 years longer after acute MI than [did] those treated at low-performing hospitals. These findings were consistent across case-mix strata, which indicates that the relationship between hospital performance and long-term patient outcomes is independent of hospital case mix,” Dr. Bucholz and her associates said (N Engl J Med. 2016 Oct 6. doi: 10.1056/NEJMoa1513223).

These findings show that the early survival advantage achieved by high-performing hospitals is durable, and that “investing in initiatives to improve short-term hospital performance may also improve patient outcomes over the long term,” they added.

Patients treated for acute MI at high-performing hospitals – those with the best performance on 30-day mortality quality measures assessed by the Centers for Medicare & Medicaid Services – had longer life expectancies than did patients treated at low-performing hospitals, according to a report published online Oct. 6 in the New England Journal of Medicine.

This survival benefit persisted through 17 years of follow-up, said Emily Bucholz, MD, of Boston Children’s Hospital, and her associates.

Until now, researchers didn’t know whether the short-term survival benefit at high-performing hospitals would wane over time, which “would lend support to the theory that these hospitals discharge more patients alive but with higher subsequent mortality.” The results of this secondary analysis of data from a nationally representative cohort study indicate that, instead, the superior quality of care delivered at high-performing hospitals appears to “produce an early benefit that endures over time,” Dr. Bucholz and her associates noted. The investigators assessed long-term life expectancy using data from the Cooperative Cardiovascular Project, which enrolled Medicare beneficiaries aged 65 years and older treated for acute MI in 1994-1996. They focused on 119,735 patients admitted to 1,824 hospitals. They grouped the hospitals according to their case mixes (a measure of patients’ severity of illness) and calculated risk-standardized mortality rates according to CMS criteria.

“We found that patients treated at high-performing hospitals ... lived, on average, between 0.74 and 1.14 years longer after acute MI than [did] those treated at low-performing hospitals. These findings were consistent across case-mix strata, which indicates that the relationship between hospital performance and long-term patient outcomes is independent of hospital case mix,” Dr. Bucholz and her associates said (N Engl J Med. 2016 Oct 6. doi: 10.1056/NEJMoa1513223).

These findings show that the early survival advantage achieved by high-performing hospitals is durable, and that “investing in initiatives to improve short-term hospital performance may also improve patient outcomes over the long term,” they added.

To the Editor:

Epidermodysplasia verruciformis (EV) is a rare autosomal-recessive genodermatosis characterized by widespread infection with specific strains of human papillomavirus (HPV). Patients with EV have a unique susceptibility to acquire HPV due to defects in cellular immunity to the presenting antigens.¹ These defects may be related to mutations of the EVER genes or due to acquisition of an immunosuppressive condition.^2,3 Infections with HPV-3 and HPV-10 do not lead to the development of malignancies. However, infection with HPV-5, HPV-8, and HPV-14 can lead to the development of nonmelanoma skin cancers, usually squamous cell carcinomas (SCCs), in approximately 60% of patients.^3,4 This viral condition lasts throughout the patient’s lifetime and presents as tinea versicolor–like macules and patches. These lesions may be confused with seborrheic keratosis or verruca plana.⁵ Lesions typically are hypopigmented but occasionally may be hyperpigmented or erythematous. They often are found on the trunk, but lesions on the face, arms, palms, legs, and soles have been reported.⁵ Mucous membranes are always spared. Epidermodysplasia verruciformis often presents in childhood, except in cases related to acquired immunosuppression. The condition has no sex or racial predilection and no geographical preference.⁵

A 7-year-old boy (Fitzpatrick skin type V) presented with an asymptomatic rash on the trunk (Figure 1), dorsal aspect of the hands, and forehead. The lesions first appeared 5 years prior on the upper back and upper chest and had recently spread to the forehead and frontal aspect of the scalp. The patient had a history of myelomeningocele, which was corrected at birth with surgical placement of a ventriculoperitoneal shunt. The patient was otherwise healthy and met all appropriate developmental milestones for his age group. Family history revealed consanguinity of the patient’s paternal grandparents who were first cousins. The patient’s mother denied any other family member having similar rashes or lesions.

The patient had been treated for pityriasis versicolor on and off for 2 years by another dermatologist. His mother reported faithfully applying ketoconazole cream twice daily for several months with no improvement. She also reported using topical steroids, which did not provide any benefit. The patient and mother denied any associated pruritus, bleeding, burning, or physical discomfort.

Skin examination revealed diffuse, flat, polymorphous, hypopigmented and salmon-colored hyperkeratotic macules and patches with mild scaling on the upper region of the anterior aspect of the chest and upper back (Figure 2A). Additionally, the patient had an extensive number of lesions on the forehead and frontal aspect of the scalp (Figure 2B).

A shave biopsy demonstrated a thick basket weave stratum corneum, koilocytes, and large pale keratinocytes with characteristic blue cytoplasm. These findings were characteristic for EV.

At the patient’s 3-month follow-up visit, he again denied any symptoms associated with the lesions and reported that the appearance was diminishing in severity. On examination there was no evidence of SCC. The mother was advised to discontinue all topical treatments for the patient and return to the office every 3 to 6 months for regular skin surveillance. The mother was further advised to protect the patient from UV radiation with sunscreen and sun-protective clothing.

Epidermodysplasia verruciformis was first reported by Lewandowsky and Lutz⁶ in 1922. This rare condition often presents in childhood and is characterized by a persistent HPV infection and an autosomal-recessive inheritance pattern. Reports in the literature frequently involve kindreds. Often, patients with EV have a family history of first-degree or second-degree consanguinity.⁷

The clinical presentation of EV often resembles a pityriasis versicolor–like eruption. However, pityriasis versicolor is less commonly seen in childhood and is more prevalent in patients aged 21 to 30 years, likely due to increased sebum production and changing hormone levels. Furthermore, it is unusual to see pityriasis versicolor affect the face and scalp.⁸ Lesions of EV vary from hypopigmented and pinkish red macules to confluent patches and hyperkeratotic verrucalike lesions.³ Clinical characteristics also may include dyschromic patches; lesions that resemble flat warts on the trunk, face, and distal arms; and/or lesions that appear similar to seborrheic keratoses on the dorsal aspect of the hands.^9,10

Mutations of the EVER gene downregulate a cell’s ability to adequately attack the HPV antigens.¹¹ Although some patients with EV are found to have mutations of the EVER1 and EVER2 genes, a notable portion of patients with EV lack these mutations. Three other causes of EV include acquisition of immunosuppressive conditions including lymphoma, solid organ transplant, and human immunodeficiency virus. If one suspects autosomal-recessive inheritance of EV, genetic testing such as polymerase chain reaction DNA fragment analysis can be performed to determine if there are mutations on the EVER1 or EVER2 genes.¹²

The inability of patients with EV to mount an immune response to multiple types of HPV increases the risk for developing cutaneous malignancies.⁷ Additionally, it is known that UV radiation diminishes skin cell immunity, and the combination of EV and UV radiation further increases the risk for developing SCCs.¹¹ The development of nonmelanoma skin cancers usually occurs on sun-exposed skin 20 to 30 years after the onset of lesions, with the highest occurrence of SCCs presenting in the fourth decade of life.¹

Protection from UV light exposure is critical to reduce the risk for malignancy. Treatment options for EV lesions have included topical imiquimod 5%, 5-fluorouracil, oral isotretinoin, and intralesional interferon alfa, but patients are often refractory to these interventions. Curettage, surgical excision, electrosurgery, and laser ablation can be effective for individual lesions but carry a greater risk for scarring.¹ Photodynamic therapy with aminolevulinic acid and blue light represents a promising option that deserves further study.

Epidermodysplasia verruciformis should be considered as a differential diagnosis in all patients presenting with disseminated lesions resembling pityriasis versicolor that are unresponsive to treatment. A biopsy will help to establish the diagnosis. Patients should minimize sun exposure and report any skin lesions that are changing in appearance.

To the Editor:

Epidermodysplasia verruciformis (EV) is a rare autosomal-recessive genodermatosis characterized by widespread infection with specific strains of human papillomavirus (HPV). Patients with EV have a unique susceptibility to acquire HPV due to defects in cellular immunity to the presenting antigens.¹ These defects may be related to mutations of the EVER genes or due to acquisition of an immunosuppressive condition.^2,3 Infections with HPV-3 and HPV-10 do not lead to the development of malignancies. However, infection with HPV-5, HPV-8, and HPV-14 can lead to the development of nonmelanoma skin cancers, usually squamous cell carcinomas (SCCs), in approximately 60% of patients.^3,4 This viral condition lasts throughout the patient’s lifetime and presents as tinea versicolor–like macules and patches. These lesions may be confused with seborrheic keratosis or verruca plana.⁵ Lesions typically are hypopigmented but occasionally may be hyperpigmented or erythematous. They often are found on the trunk, but lesions on the face, arms, palms, legs, and soles have been reported.⁵ Mucous membranes are always spared. Epidermodysplasia verruciformis often presents in childhood, except in cases related to acquired immunosuppression. The condition has no sex or racial predilection and no geographical preference.⁵

A 7-year-old boy (Fitzpatrick skin type V) presented with an asymptomatic rash on the trunk (Figure 1), dorsal aspect of the hands, and forehead. The lesions first appeared 5 years prior on the upper back and upper chest and had recently spread to the forehead and frontal aspect of the scalp. The patient had a history of myelomeningocele, which was corrected at birth with surgical placement of a ventriculoperitoneal shunt. The patient was otherwise healthy and met all appropriate developmental milestones for his age group. Family history revealed consanguinity of the patient’s paternal grandparents who were first cousins. The patient’s mother denied any other family member having similar rashes or lesions.

The patient had been treated for pityriasis versicolor on and off for 2 years by another dermatologist. His mother reported faithfully applying ketoconazole cream twice daily for several months with no improvement. She also reported using topical steroids, which did not provide any benefit. The patient and mother denied any associated pruritus, bleeding, burning, or physical discomfort.

Skin examination revealed diffuse, flat, polymorphous, hypopigmented and salmon-colored hyperkeratotic macules and patches with mild scaling on the upper region of the anterior aspect of the chest and upper back (Figure 2A). Additionally, the patient had an extensive number of lesions on the forehead and frontal aspect of the scalp (Figure 2B).

A shave biopsy demonstrated a thick basket weave stratum corneum, koilocytes, and large pale keratinocytes with characteristic blue cytoplasm. These findings were characteristic for EV.

At the patient’s 3-month follow-up visit, he again denied any symptoms associated with the lesions and reported that the appearance was diminishing in severity. On examination there was no evidence of SCC. The mother was advised to discontinue all topical treatments for the patient and return to the office every 3 to 6 months for regular skin surveillance. The mother was further advised to protect the patient from UV radiation with sunscreen and sun-protective clothing.

Epidermodysplasia verruciformis was first reported by Lewandowsky and Lutz⁶ in 1922. This rare condition often presents in childhood and is characterized by a persistent HPV infection and an autosomal-recessive inheritance pattern. Reports in the literature frequently involve kindreds. Often, patients with EV have a family history of first-degree or second-degree consanguinity.⁷

The clinical presentation of EV often resembles a pityriasis versicolor–like eruption. However, pityriasis versicolor is less commonly seen in childhood and is more prevalent in patients aged 21 to 30 years, likely due to increased sebum production and changing hormone levels. Furthermore, it is unusual to see pityriasis versicolor affect the face and scalp.⁸ Lesions of EV vary from hypopigmented and pinkish red macules to confluent patches and hyperkeratotic verrucalike lesions.³ Clinical characteristics also may include dyschromic patches; lesions that resemble flat warts on the trunk, face, and distal arms; and/or lesions that appear similar to seborrheic keratoses on the dorsal aspect of the hands.^9,10

Mutations of the EVER gene downregulate a cell’s ability to adequately attack the HPV antigens.¹¹ Although some patients with EV are found to have mutations of the EVER1 and EVER2 genes, a notable portion of patients with EV lack these mutations. Three other causes of EV include acquisition of immunosuppressive conditions including lymphoma, solid organ transplant, and human immunodeficiency virus. If one suspects autosomal-recessive inheritance of EV, genetic testing such as polymerase chain reaction DNA fragment analysis can be performed to determine if there are mutations on the EVER1 or EVER2 genes.¹²

The inability of patients with EV to mount an immune response to multiple types of HPV increases the risk for developing cutaneous malignancies.⁷ Additionally, it is known that UV radiation diminishes skin cell immunity, and the combination of EV and UV radiation further increases the risk for developing SCCs.¹¹ The development of nonmelanoma skin cancers usually occurs on sun-exposed skin 20 to 30 years after the onset of lesions, with the highest occurrence of SCCs presenting in the fourth decade of life.¹

Protection from UV light exposure is critical to reduce the risk for malignancy. Treatment options for EV lesions have included topical imiquimod 5%, 5-fluorouracil, oral isotretinoin, and intralesional interferon alfa, but patients are often refractory to these interventions. Curettage, surgical excision, electrosurgery, and laser ablation can be effective for individual lesions but carry a greater risk for scarring.¹ Photodynamic therapy with aminolevulinic acid and blue light represents a promising option that deserves further study.

Epidermodysplasia verruciformis should be considered as a differential diagnosis in all patients presenting with disseminated lesions resembling pityriasis versicolor that are unresponsive to treatment. A biopsy will help to establish the diagnosis. Patients should minimize sun exposure and report any skin lesions that are changing in appearance.

To the Editor:

Epidermodysplasia verruciformis (EV) is a rare autosomal-recessive genodermatosis characterized by widespread infection with specific strains of human papillomavirus (HPV). Patients with EV have a unique susceptibility to acquire HPV due to defects in cellular immunity to the presenting antigens.¹ These defects may be related to mutations of the EVER genes or due to acquisition of an immunosuppressive condition.^2,3 Infections with HPV-3 and HPV-10 do not lead to the development of malignancies. However, infection with HPV-5, HPV-8, and HPV-14 can lead to the development of nonmelanoma skin cancers, usually squamous cell carcinomas (SCCs), in approximately 60% of patients.^3,4 This viral condition lasts throughout the patient’s lifetime and presents as tinea versicolor–like macules and patches. These lesions may be confused with seborrheic keratosis or verruca plana.⁵ Lesions typically are hypopigmented but occasionally may be hyperpigmented or erythematous. They often are found on the trunk, but lesions on the face, arms, palms, legs, and soles have been reported.⁵ Mucous membranes are always spared. Epidermodysplasia verruciformis often presents in childhood, except in cases related to acquired immunosuppression. The condition has no sex or racial predilection and no geographical preference.⁵

A 7-year-old boy (Fitzpatrick skin type V) presented with an asymptomatic rash on the trunk (Figure 1), dorsal aspect of the hands, and forehead. The lesions first appeared 5 years prior on the upper back and upper chest and had recently spread to the forehead and frontal aspect of the scalp. The patient had a history of myelomeningocele, which was corrected at birth with surgical placement of a ventriculoperitoneal shunt. The patient was otherwise healthy and met all appropriate developmental milestones for his age group. Family history revealed consanguinity of the patient’s paternal grandparents who were first cousins. The patient’s mother denied any other family member having similar rashes or lesions.

The patient had been treated for pityriasis versicolor on and off for 2 years by another dermatologist. His mother reported faithfully applying ketoconazole cream twice daily for several months with no improvement. She also reported using topical steroids, which did not provide any benefit. The patient and mother denied any associated pruritus, bleeding, burning, or physical discomfort.

Skin examination revealed diffuse, flat, polymorphous, hypopigmented and salmon-colored hyperkeratotic macules and patches with mild scaling on the upper region of the anterior aspect of the chest and upper back (Figure 2A). Additionally, the patient had an extensive number of lesions on the forehead and frontal aspect of the scalp (Figure 2B).

A shave biopsy demonstrated a thick basket weave stratum corneum, koilocytes, and large pale keratinocytes with characteristic blue cytoplasm. These findings were characteristic for EV.

At the patient’s 3-month follow-up visit, he again denied any symptoms associated with the lesions and reported that the appearance was diminishing in severity. On examination there was no evidence of SCC. The mother was advised to discontinue all topical treatments for the patient and return to the office every 3 to 6 months for regular skin surveillance. The mother was further advised to protect the patient from UV radiation with sunscreen and sun-protective clothing.

Epidermodysplasia verruciformis was first reported by Lewandowsky and Lutz⁶ in 1922. This rare condition often presents in childhood and is characterized by a persistent HPV infection and an autosomal-recessive inheritance pattern. Reports in the literature frequently involve kindreds. Often, patients with EV have a family history of first-degree or second-degree consanguinity.⁷

The clinical presentation of EV often resembles a pityriasis versicolor–like eruption. However, pityriasis versicolor is less commonly seen in childhood and is more prevalent in patients aged 21 to 30 years, likely due to increased sebum production and changing hormone levels. Furthermore, it is unusual to see pityriasis versicolor affect the face and scalp.⁸ Lesions of EV vary from hypopigmented and pinkish red macules to confluent patches and hyperkeratotic verrucalike lesions.³ Clinical characteristics also may include dyschromic patches; lesions that resemble flat warts on the trunk, face, and distal arms; and/or lesions that appear similar to seborrheic keratoses on the dorsal aspect of the hands.^9,10

Mutations of the EVER gene downregulate a cell’s ability to adequately attack the HPV antigens.¹¹ Although some patients with EV are found to have mutations of the EVER1 and EVER2 genes, a notable portion of patients with EV lack these mutations. Three other causes of EV include acquisition of immunosuppressive conditions including lymphoma, solid organ transplant, and human immunodeficiency virus. If one suspects autosomal-recessive inheritance of EV, genetic testing such as polymerase chain reaction DNA fragment analysis can be performed to determine if there are mutations on the EVER1 or EVER2 genes.¹²

The inability of patients with EV to mount an immune response to multiple types of HPV increases the risk for developing cutaneous malignancies.⁷ Additionally, it is known that UV radiation diminishes skin cell immunity, and the combination of EV and UV radiation further increases the risk for developing SCCs.¹¹ The development of nonmelanoma skin cancers usually occurs on sun-exposed skin 20 to 30 years after the onset of lesions, with the highest occurrence of SCCs presenting in the fourth decade of life.¹

Protection from UV light exposure is critical to reduce the risk for malignancy. Treatment options for EV lesions have included topical imiquimod 5%, 5-fluorouracil, oral isotretinoin, and intralesional interferon alfa, but patients are often refractory to these interventions. Curettage, surgical excision, electrosurgery, and laser ablation can be effective for individual lesions but carry a greater risk for scarring.¹ Photodynamic therapy with aminolevulinic acid and blue light represents a promising option that deserves further study.

Epidermodysplasia verruciformis should be considered as a differential diagnosis in all patients presenting with disseminated lesions resembling pityriasis versicolor that are unresponsive to treatment. A biopsy will help to establish the diagnosis. Patients should minimize sun exposure and report any skin lesions that are changing in appearance.

To the Editor:

Chondroid syringoma is a rare benign mixed tumor that originates from the sweat glands, typically presenting with both epithelial and mesenchymal components.¹ It differs from pleomorphic adenoma, which arises from salivary glands. The surgical approach for complete excision is different for the 2 tumors; therefore, definitive diagnosis is important. For chondroid syringoma, total excision is recommended,² while for pleomorphic adenoma, extracapsular dissection or superficial parotidectomy is commonly indicated. We report a case of a preauricular nodule at presentation and highlight the importance of differentiating a chondroid syringoma from a pleomorphic adenoma. This case is unique because of the anatomic location of the nodule, making diagnosis difficult because the tumor was abutting the parotid gland and a biopsy included normal salivary gland cells.

A 19-year-old man with a history of moderate acne on the shoulders, back, and face presented with a rapidly growing, painless nodule on right preauricular region of 6 months’ duration. The nodule was originally thought to be acne related and monitored, as the patient was asymptomatic. On examination the patient was found to have a firm, fixed, nontender, subcutaneous nodule overlying the right temporomandibular joint just anterior to the right tragus (Figure 1). Laboratory results were unremarkable. Computed tomography showed a subcutaneous nonaggressive-appearing soft-tissue mass measuring 16×17×12 mm just anterior and inferior to the external auditory canal cartilaginous segment with no bony abnormalities. The patient was initially treated with incomplete excision of the area for a presumed sebaceous cyst; 2 months later, an abnormal biopsy prompted a complete excisional biopsy.

Histologically, the initial incomplete excision biopsy revealed myxoid and chondroid tissue with glandular elements and adjacent lymph node with strong positivity for S-100 protein and moderate positivity for glial fibrillary acid protein, consistent with chondroid syringoma (Figure 2). Histological findings on second excision biopsy performed 2 months later showed tumor cells surrounded by normal salivary gland cells; therefore, it was difficult to define the origin of this tumor. Subsequent magnetic resonance imaging showed no evidence of the tumor and normal parotid gland borders.

Chondroid syringoma is a rare nonmelanoma skin tumor of the head and neck, mostly benign in nature but with malignant potential. Predominantly, it presents in males as an asymptomatic, slow-growing, nontender nodule.² Malignant chondroid syringomas are more rare, typically appear on the trunk and legs of females, and present as rapidly growing hard nodules. They can arise de novo or from a preexisting chondroid syringoma and can metastasize.^3,4

Clinically and histologically, chondroid syringoma resembles a pleomorphic adenoma. Its diagnosis is dependent on the clinical location to exclude origin in a salivary gland.⁵ Folliculosebaceous and myoepithelial differentiation within the tumor has been reported.⁶ Immunocytochemistry is the same in both types and is used to identify 2 prominent components—epithelial and mesenchymal—found in both chondroid syringoma and pleomorphic adenoma. Immunocytochemistry differentiates the epithelial component, which expresses cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen. In contrast, the mesenchymal component expresses S-100, vimentin, and neuron‐specific enolase, and less often glial fibrillary acidic protein, smooth muscle actin, calponin, or p63.^5,7,8 Identification of both layers is a distinctive trait of both tumors, rendering it apart from other conditions in the differential diagnosis.⁵

Typical treatment options include excision, electrodesiccation, dermabrasion, and argon or CO₂ laser. Total excision is recommended if there is a benign tumor and complete excision is a cure.² One case of recurrent benign chondroid syringoma was treated by Mohs micrographic surgery on the eyebrow⁹; however, Mohs surgery was not recommended in our case due to concerns of spread if malignant as well as an unknown tumor depth, as these tumors have a tendency for deep infiltration.

Due to its anatomical location and presentation as an anterior preauricular mass, it was difficult to differentiate between chondroid syringoma from sweat gland origin and pleomorphic adenoma from the salivary gland. As seen in our case, it is important for physicians to be aware of the differential diagnosis for mixed tumors because it can have a notable effect on the type of surgical therapy and follow-up management.

To the Editor:

Chondroid syringoma is a rare benign mixed tumor that originates from the sweat glands, typically presenting with both epithelial and mesenchymal components.¹ It differs from pleomorphic adenoma, which arises from salivary glands. The surgical approach for complete excision is different for the 2 tumors; therefore, definitive diagnosis is important. For chondroid syringoma, total excision is recommended,² while for pleomorphic adenoma, extracapsular dissection or superficial parotidectomy is commonly indicated. We report a case of a preauricular nodule at presentation and highlight the importance of differentiating a chondroid syringoma from a pleomorphic adenoma. This case is unique because of the anatomic location of the nodule, making diagnosis difficult because the tumor was abutting the parotid gland and a biopsy included normal salivary gland cells.

A 19-year-old man with a history of moderate acne on the shoulders, back, and face presented with a rapidly growing, painless nodule on right preauricular region of 6 months’ duration. The nodule was originally thought to be acne related and monitored, as the patient was asymptomatic. On examination the patient was found to have a firm, fixed, nontender, subcutaneous nodule overlying the right temporomandibular joint just anterior to the right tragus (Figure 1). Laboratory results were unremarkable. Computed tomography showed a subcutaneous nonaggressive-appearing soft-tissue mass measuring 16×17×12 mm just anterior and inferior to the external auditory canal cartilaginous segment with no bony abnormalities. The patient was initially treated with incomplete excision of the area for a presumed sebaceous cyst; 2 months later, an abnormal biopsy prompted a complete excisional biopsy.

Histologically, the initial incomplete excision biopsy revealed myxoid and chondroid tissue with glandular elements and adjacent lymph node with strong positivity for S-100 protein and moderate positivity for glial fibrillary acid protein, consistent with chondroid syringoma (Figure 2). Histological findings on second excision biopsy performed 2 months later showed tumor cells surrounded by normal salivary gland cells; therefore, it was difficult to define the origin of this tumor. Subsequent magnetic resonance imaging showed no evidence of the tumor and normal parotid gland borders.

Chondroid syringoma is a rare nonmelanoma skin tumor of the head and neck, mostly benign in nature but with malignant potential. Predominantly, it presents in males as an asymptomatic, slow-growing, nontender nodule.² Malignant chondroid syringomas are more rare, typically appear on the trunk and legs of females, and present as rapidly growing hard nodules. They can arise de novo or from a preexisting chondroid syringoma and can metastasize.^3,4

Clinically and histologically, chondroid syringoma resembles a pleomorphic adenoma. Its diagnosis is dependent on the clinical location to exclude origin in a salivary gland.⁵ Folliculosebaceous and myoepithelial differentiation within the tumor has been reported.⁶ Immunocytochemistry is the same in both types and is used to identify 2 prominent components—epithelial and mesenchymal—found in both chondroid syringoma and pleomorphic adenoma. Immunocytochemistry differentiates the epithelial component, which expresses cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen. In contrast, the mesenchymal component expresses S-100, vimentin, and neuron‐specific enolase, and less often glial fibrillary acidic protein, smooth muscle actin, calponin, or p63.^5,7,8 Identification of both layers is a distinctive trait of both tumors, rendering it apart from other conditions in the differential diagnosis.⁵

Typical treatment options include excision, electrodesiccation, dermabrasion, and argon or CO₂ laser. Total excision is recommended if there is a benign tumor and complete excision is a cure.² One case of recurrent benign chondroid syringoma was treated by Mohs micrographic surgery on the eyebrow⁹; however, Mohs surgery was not recommended in our case due to concerns of spread if malignant as well as an unknown tumor depth, as these tumors have a tendency for deep infiltration.

Due to its anatomical location and presentation as an anterior preauricular mass, it was difficult to differentiate between chondroid syringoma from sweat gland origin and pleomorphic adenoma from the salivary gland. As seen in our case, it is important for physicians to be aware of the differential diagnosis for mixed tumors because it can have a notable effect on the type of surgical therapy and follow-up management.

To the Editor:

Chondroid syringoma is a rare benign mixed tumor that originates from the sweat glands, typically presenting with both epithelial and mesenchymal components.¹ It differs from pleomorphic adenoma, which arises from salivary glands. The surgical approach for complete excision is different for the 2 tumors; therefore, definitive diagnosis is important. For chondroid syringoma, total excision is recommended,² while for pleomorphic adenoma, extracapsular dissection or superficial parotidectomy is commonly indicated. We report a case of a preauricular nodule at presentation and highlight the importance of differentiating a chondroid syringoma from a pleomorphic adenoma. This case is unique because of the anatomic location of the nodule, making diagnosis difficult because the tumor was abutting the parotid gland and a biopsy included normal salivary gland cells.

A 19-year-old man with a history of moderate acne on the shoulders, back, and face presented with a rapidly growing, painless nodule on right preauricular region of 6 months’ duration. The nodule was originally thought to be acne related and monitored, as the patient was asymptomatic. On examination the patient was found to have a firm, fixed, nontender, subcutaneous nodule overlying the right temporomandibular joint just anterior to the right tragus (Figure 1). Laboratory results were unremarkable. Computed tomography showed a subcutaneous nonaggressive-appearing soft-tissue mass measuring 16×17×12 mm just anterior and inferior to the external auditory canal cartilaginous segment with no bony abnormalities. The patient was initially treated with incomplete excision of the area for a presumed sebaceous cyst; 2 months later, an abnormal biopsy prompted a complete excisional biopsy.

Histologically, the initial incomplete excision biopsy revealed myxoid and chondroid tissue with glandular elements and adjacent lymph node with strong positivity for S-100 protein and moderate positivity for glial fibrillary acid protein, consistent with chondroid syringoma (Figure 2). Histological findings on second excision biopsy performed 2 months later showed tumor cells surrounded by normal salivary gland cells; therefore, it was difficult to define the origin of this tumor. Subsequent magnetic resonance imaging showed no evidence of the tumor and normal parotid gland borders.

Chondroid syringoma is a rare nonmelanoma skin tumor of the head and neck, mostly benign in nature but with malignant potential. Predominantly, it presents in males as an asymptomatic, slow-growing, nontender nodule.² Malignant chondroid syringomas are more rare, typically appear on the trunk and legs of females, and present as rapidly growing hard nodules. They can arise de novo or from a preexisting chondroid syringoma and can metastasize.^3,4

Clinically and histologically, chondroid syringoma resembles a pleomorphic adenoma. Its diagnosis is dependent on the clinical location to exclude origin in a salivary gland.⁵ Folliculosebaceous and myoepithelial differentiation within the tumor has been reported.⁶ Immunocytochemistry is the same in both types and is used to identify 2 prominent components—epithelial and mesenchymal—found in both chondroid syringoma and pleomorphic adenoma. Immunocytochemistry differentiates the epithelial component, which expresses cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen. In contrast, the mesenchymal component expresses S-100, vimentin, and neuron‐specific enolase, and less often glial fibrillary acidic protein, smooth muscle actin, calponin, or p63.^5,7,8 Identification of both layers is a distinctive trait of both tumors, rendering it apart from other conditions in the differential diagnosis.⁵

Typical treatment options include excision, electrodesiccation, dermabrasion, and argon or CO₂ laser. Total excision is recommended if there is a benign tumor and complete excision is a cure.² One case of recurrent benign chondroid syringoma was treated by Mohs micrographic surgery on the eyebrow⁹; however, Mohs surgery was not recommended in our case due to concerns of spread if malignant as well as an unknown tumor depth, as these tumors have a tendency for deep infiltration.

Due to its anatomical location and presentation as an anterior preauricular mass, it was difficult to differentiate between chondroid syringoma from sweat gland origin and pleomorphic adenoma from the salivary gland. As seen in our case, it is important for physicians to be aware of the differential diagnosis for mixed tumors because it can have a notable effect on the type of surgical therapy and follow-up management.

The majority of lawsuits against internists stem from alleged diagnostics errors, results of a new study show.

Of 1,180 legal claims against internists, 39% were related to failed, delayed, or wrong diagnosis allegations, according to an analysis published by The Doctors Company, a nationwide medical malpractice insurer. Negligence associated with medical treatment accounted for 32% of the claims, while 19% were related to alleged medication errors.

The Doctors Company evaluated 1,180 claims from its database against internal medicine physicians that closed from 2007 to 2014. Of diagnostic-related cases, 56% alleged inadequate patient assessments, such as failure to order or delay in ordering diagnostic tests. The final diagnoses most commonly related to these allegations were myocardial infarction (6%), lung cancer (5%), and colorectal cancer (5%). More than 200 other diagnoses were seen in fewer than 2% of the claims, according to the study.

[email protected]

On Twitter @legal_med

The majority of lawsuits against internists stem from alleged diagnostics errors, results of a new study show.

Of 1,180 legal claims against internists, 39% were related to failed, delayed, or wrong diagnosis allegations, according to an analysis published by The Doctors Company, a nationwide medical malpractice insurer. Negligence associated with medical treatment accounted for 32% of the claims, while 19% were related to alleged medication errors.

The Doctors Company evaluated 1,180 claims from its database against internal medicine physicians that closed from 2007 to 2014. Of diagnostic-related cases, 56% alleged inadequate patient assessments, such as failure to order or delay in ordering diagnostic tests. The final diagnoses most commonly related to these allegations were myocardial infarction (6%), lung cancer (5%), and colorectal cancer (5%). More than 200 other diagnoses were seen in fewer than 2% of the claims, according to the study.

[email protected]

On Twitter @legal_med

The majority of lawsuits against internists stem from alleged diagnostics errors, results of a new study show.

Of 1,180 legal claims against internists, 39% were related to failed, delayed, or wrong diagnosis allegations, according to an analysis published by The Doctors Company, a nationwide medical malpractice insurer. Negligence associated with medical treatment accounted for 32% of the claims, while 19% were related to alleged medication errors.

The Doctors Company evaluated 1,180 claims from its database against internal medicine physicians that closed from 2007 to 2014. Of diagnostic-related cases, 56% alleged inadequate patient assessments, such as failure to order or delay in ordering diagnostic tests. The final diagnoses most commonly related to these allegations were myocardial infarction (6%), lung cancer (5%), and colorectal cancer (5%). More than 200 other diagnoses were seen in fewer than 2% of the claims, according to the study.

[email protected]

On Twitter @legal_med

Influenza vaccine coverage among U.S. health care personnel increased very slightly during the 2015-2016 flu season, with 79% reporting that they received the shot, compared with 77% in 2014-2015.

Hospital personnel were most likely to be covered (91%) and long-term care personnel least likely to be covered (69%), Carla L. Black, PhD, wrote in the Sept. 30 issue of Morbidity and Mortality Weekly Report (2016;65:1026-31). Coverage among health care personnel working in long-term care settings did increase, however, from 64% in the 2014-2015 seasons to 69% in the 2015-2016 season, Dr. Black and colleagues noted.

“Although low, this is the only setting with an appreciable increase in coverage, compared with last season. Influenza vaccination among health care personnel in long-term care settings is especially important because influenza vaccine effectiveness is generally lowest in the elderly,” according to Dr Black, an epidemiologist with the Centers for Disease Control and Prevention.

CDC conducted the Internet survey of 2,258 health care workers from March to April, 2016.

Physicians had the highest level of coverage (95.6%), while health care assistants and aides had the lowest (64.5%). Employers also exerted an influence on coverage. Most respondents (73%) were vaccinated at work. Coverage was highest (96.5%) at facilities where vaccination was required and lowest (45%) where vaccination was not required, promoted, or offered on site.

“Employer vaccination requirements likely contributed to the observed gradual increase in vaccination among health care personnel working in settings with the lowest coverage,” the investigators noted. “In the absence of vaccination requirements, expanding the number of health care locations offering vaccination on site, over multiple days, and at no cost might help sustain and improve influenza vaccination coverage among health care personnel, including in long-term care settings.”

As a CDC employee, Dr. Black has no financial conflicts.

[email protected]

Influenza vaccine coverage among U.S. health care personnel increased very slightly during the 2015-2016 flu season, with 79% reporting that they received the shot, compared with 77% in 2014-2015.

Hospital personnel were most likely to be covered (91%) and long-term care personnel least likely to be covered (69%), Carla L. Black, PhD, wrote in the Sept. 30 issue of Morbidity and Mortality Weekly Report (2016;65:1026-31). Coverage among health care personnel working in long-term care settings did increase, however, from 64% in the 2014-2015 seasons to 69% in the 2015-2016 season, Dr. Black and colleagues noted.

“Although low, this is the only setting with an appreciable increase in coverage, compared with last season. Influenza vaccination among health care personnel in long-term care settings is especially important because influenza vaccine effectiveness is generally lowest in the elderly,” according to Dr Black, an epidemiologist with the Centers for Disease Control and Prevention.

CDC conducted the Internet survey of 2,258 health care workers from March to April, 2016.

Physicians had the highest level of coverage (95.6%), while health care assistants and aides had the lowest (64.5%). Employers also exerted an influence on coverage. Most respondents (73%) were vaccinated at work. Coverage was highest (96.5%) at facilities where vaccination was required and lowest (45%) where vaccination was not required, promoted, or offered on site.

“Employer vaccination requirements likely contributed to the observed gradual increase in vaccination among health care personnel working in settings with the lowest coverage,” the investigators noted. “In the absence of vaccination requirements, expanding the number of health care locations offering vaccination on site, over multiple days, and at no cost might help sustain and improve influenza vaccination coverage among health care personnel, including in long-term care settings.”

As a CDC employee, Dr. Black has no financial conflicts.

[email protected]

Influenza vaccine coverage among U.S. health care personnel increased very slightly during the 2015-2016 flu season, with 79% reporting that they received the shot, compared with 77% in 2014-2015.

Hospital personnel were most likely to be covered (91%) and long-term care personnel least likely to be covered (69%), Carla L. Black, PhD, wrote in the Sept. 30 issue of Morbidity and Mortality Weekly Report (2016;65:1026-31). Coverage among health care personnel working in long-term care settings did increase, however, from 64% in the 2014-2015 seasons to 69% in the 2015-2016 season, Dr. Black and colleagues noted.

“Although low, this is the only setting with an appreciable increase in coverage, compared with last season. Influenza vaccination among health care personnel in long-term care settings is especially important because influenza vaccine effectiveness is generally lowest in the elderly,” according to Dr Black, an epidemiologist with the Centers for Disease Control and Prevention.

CDC conducted the Internet survey of 2,258 health care workers from March to April, 2016.

Physicians had the highest level of coverage (95.6%), while health care assistants and aides had the lowest (64.5%). Employers also exerted an influence on coverage. Most respondents (73%) were vaccinated at work. Coverage was highest (96.5%) at facilities where vaccination was required and lowest (45%) where vaccination was not required, promoted, or offered on site.

“Employer vaccination requirements likely contributed to the observed gradual increase in vaccination among health care personnel working in settings with the lowest coverage,” the investigators noted. “In the absence of vaccination requirements, expanding the number of health care locations offering vaccination on site, over multiple days, and at no cost might help sustain and improve influenza vaccination coverage among health care personnel, including in long-term care settings.”

As a CDC employee, Dr. Black has no financial conflicts.

[email protected]