Methods Reporting Quality and its Association with Methods Section Length: A Cross-sectional Assessment of STROBE and CONSORT Reporting Adherence in Top-cited Dermatology Journals.

Background: Adequate methods reporting in observational and trial literature is critical to interpretation and implementation. Objective: Evaluate methodology reporting adherence in the dermatology literature and compare this to internal medicine (IM) literature. Methods: We performed a cross-sectional review of randomly-selected dermatology and IM manuscripts published between 2014-2018. Observational and trial articles were retrieved from PubMed. The primary outcome was percent adherence to STROBE or CONSORT methods-related checklist items (methods reporting score, MRS). Secondary outcomes included the relationship between methods section length (MSL) and MRS. We additionally compared these with IM literature. MRS and MSL were compared by overall article length, checklist type, field, journal, study topic, and funding source. Comparisons were assessed using univariable and multivariable linear regression. Results: We identified 389 articles (172 dermatology and 217 IM). Within dermatology, we identified 83 clinical trials and 89 observational studies. Mean MRS was 61.4 percent. A one word increase in MSL corresponded to a 0.02 percent increase MRS (ß=0.02, 95% CI 0.01-0.03). Mean MRS was 12.8 percent lower in the dermatology literature compared with IM (ß=-12.8%, -15.6-[-9.91]). Mean dermatology MSL was 345 words shorter (ß=-345, -413-[-277]). Studies from JAMA Dermatology, Journal of Investigative Dermatology, and British Journal of Dermatology, with government funding, and having supplemental methods had higher mean MRS's. Conclusion: Methods reporting quality was low in dermatology. A weak relationship between MRS and MSL was observed. These data support enhancing researcher emphasis on methods reporting, editorial staff, and peer reviewers that more strictly enforce checklist reporting.

The continued inappropriate use and overuse of combination topical clotrimazole-betamethasone.

OBJECTIVE: Combination topical clotrimazole/ betamethasone dipropionate (C-BM) contains a high-potency topical corticosteroid and is not infrequently prescribed for inappropriate patient groups and body sites. Use of C-BM can lead to inadequate clearance or exacerbation of fungal infections as well as cutaneous atrophy, striae, and other skin maladies. METHODS: We performed a retrospective chart review of 1,978 clinical visits where C-BM was prescribed within the University of Utah Health system between 2014 and 2018 to better understand current prescribing patterns. RESULTS: 1,974 prescriptions were written for C-BM. 91.6% of patients were at least the recommended age of 17 years. C-BM was most commonly prescribed for rashes of an inflammatory (42.2%) or fungal nature (38.1%). Clotrimazole/betamethasone dipropionate was prescribed for sensitive areas (face, axillae, groin or diaper region) in 48.9% of patients. Family medicine clinicians prescribed 58.3% of C-BM prescriptions, whereas dermatology clinicians accounted for 3.4%. CONCLUSION: We strongly recommend clinicians use alternative treatments for rashes or refer to dermatologists.

Risk Factors and Predictors of Survival Among Patients with Amelanotic Melanoma Compared to Melanotic Melanoma in the National Cancer Database.

BACKGROUND: Amelanotic melanoma (AM) is a rare form of melanoma lacking pigment. Data on AM risk factors and factors predicting survival are limited. OBJECTIVES: We sought to identify predictors of AM, survival differences in AM and melanotic melanoma, and AM-specific survival rates. METHODS: Using 2004 through 2015 National Cancer Database data, we compared 358,543 melanoma cases to 1,384 AM cases. Multivariable logistic regression identified AM risk factors, and AM survival was explored using Kaplan-Meier and multivariable Cox regression. RESULTS: Increased age; tumor location on the face, scalp, and neck; increased Breslow thickness; metastatic disease; ulceration; and higher mitotic rate were associated with AM. Five- and ten-year survival rates were higher for patients with MM (melanotic melanoma) than AM tumors (75.4% vs. 58.8% and 62.4% vs 45.1%; log-rank P<0.0001). No survival difference was seen after adjusting for staging factors. Among patients with AM, more recent diagnosis was associated with improved survival. Increased age, T4 tumor size, higher N-stage, metastasis, and ulceration predicted poorer survival. No survival advantage was seen for chemotherapy, immunotherapy, or radiation therapy, likely due to confounding. CONCLUSION: AM is more common in older patients on sun-exposed skin and is diagnosed at later stages. Advanced staging at diagnosis explains the survival differences. In patients with AM, regional and metastatic disease were the primary contributors of poorer outcomes. In at-risk patients, the threshold to biopsy should be lower for suspicious nonpigmented lesions.

Administrative Burden and Costs of Prior Authorizations in a Dermatology Department.

Importance: Insurance companies use prior authorizations (PAs) to address inappropriate prescribing or unnecessary variations in care, most often for expensive medications. Prior authorizations negatively affect patient care and add costs and administrative burden to dermatology offices. Objective: To quantify the administrative burden and costs of dermatology PAs. Design, Setting, and Participants: The University of Utah Department of Dermatology employs 2 full-time and 8 part-time PA staff. In this cross-sectional study at a large academic department spanning 11 clinical locations, these staff itemized all PA-related encounters over a 30-day period in September 2016. Staff salary and benefits were publicly available. Data were analyzed between December 2018 and August 2019. Main Outcomes and Measures: Proportion of visits requiring PAs, median administrative time to finalize a PA (either approval or denial after appeal), and median cost per PA type. Results: In September 2016, 626 PAs were generated from 9512 patient encounters. Staff spent 169.7 hours directly handling PAs, costing a median of $6.72 per PA. Biologic PAs cost a median of $15.80 each and took as long as 31 business days to complete. The costliest PA equaled 106% of the associated visit's Medicare reimbursement rate. Approval rates were 99.6% for procedures, 78.9% for biologics, and 58.2% for other medications. After appeal, 5 of 23 (21.7%) previously denied PAs were subsequently approved. Conclusions and Relevance: Prior authorizations are costly to dermatology practices and their value appears limited for some requests. Fewer unnecessary PAs and appeals might increase practice efficiency and improve patient outcomes.

Using Google Search Data for Sunburn as a Surrogate for Sunburn Prevalence in the United States.

Objective: The investigators sought to evaluate the feasibility of using state-based Google Trends® search volume data for sunburn as a surrogate marker for state sunburn prevalence. Design: State-based search volumes for sunburn were assessed for associations with environmental risk factors for ultraviolet (UV) exposure. Setting: Search volume data for sunburn were queried from google.trends.com for all United States (US) searches from January 2004 to December 2017. UV exposure data came from publicly available databases. Participants: This analysis included searches occurring in the US. Main Outcomes and Measures: Risk factors for UV exposure included degrees latitude, annual number of clear days, average annual temperature, mean state elevation, number of low/moderate/high/very high/extreme UV index days, state outdoor recreation tax revenue, and state consumer spending on outdoor recreation. Regressions and correlations between state searches for sunburn and risk factors for UV exposure were assessed using linear regression and Pearson correlations. Results: Searches for sunburn were significantly associated with state degree latitude (coef= -0.59, r=-0.47, p=0.001); number of low UV index days (coef= -0.37, r=-0.46, p=0.001); moderate UV index days (coef=1.46, r=0.36, p=0.01); high UV index days (coef=0.30, r=0.43, p=0.002); and average annual temperature (coef=0.37, r=0.45, p=0.001). Conclusion: Searches for sunburn in the United States are directly correlated with certain UV exposure measures. These data suggest that search volume for sunburn may be used as a surrogate marker for state sunburn prevalence.

Melanoma prognosis in the United States: Identifying barriers for improved care.

BACKGROUND: Despite improvements in melanoma mortality, disparities in melanoma survival persist. We evaluated possible sociodemographic and health care-based predictors of differences in melanoma survival in the United States by using the melanoma mortality-to-incidence ratio (MIR). METHODS: State-based MIRs were calculated by using US cancer statistics data from 1999 to 2014. Pearson correlations and linear regressions were used to determine associations between MIR and dermatologist density, primary care provider density, number of physicians by state, number of National Cancer Institute-designated cancer centers, health care spending per capita, average household income, racial/ethnic makeup of the population, percentage of uninsured individuals, and percentage with a bachelor's degree. RESULTS: The mean overall MIR was 0.15 ± 0.04; only Alaska was an outlier (0.24). No state MIRs increased significantly over time; MIR decreased for most states. Multivariable analysis revealed that states with more active physicians (P = .02) and a higher percentage non-Hispanic whites (P = .004) had higher MIRs (poorer survival). Significant Pearson correlations were seen between MIR and melanoma incidence (r = -0.72, P < .001), melanoma mortality (r = 0.38, P < .001), dermatologist density (r = 0.32, P < .001), and National Cancer Institute-designated cancer center count (r = -0.12, P = .001). CONCLUSIONS: Melanoma survival is improved in higher-incidence areas and areas with higher dermatologist density. These findings highlight areas of poorer melanoma survival and the need for local studies evaluating disparities in melanoma survival.

Biogenesis of the Flagellar Switch Complex in Escherichia coli: Formation of Sub-Complexes Independently of the Basal-Body MS-Ring.

Direction switching in the flagellar motor of Escherichia coli is under the control of a complex on the rotor formed from the proteins FliG, FliM, and FliN. FliG lies at the top of the switch complex (i.e., nearest the membrane) and is arranged with its C-terminal domain (FliGC) resting on the middle domain (FliGM) of the neighboring subunit. This organization requires the protein to adopt an open conformation that exposes the surfaces engaging in intersubunit FliGC/FliGM contacts. In a recent study, Baker and coworkers [13] obtained evidence that FliG in the cytosol is monomeric and takes on a more compact conformation, with FliGC making intramolecular contact with FliGM of the same subunit. In the present work, we examine the conformational preferences and interactions of FliG through in vivo crosslinking experiments in cells that lack either all other flagellar proteins or just the MS-ring protein FliF. The results indicate that FliG has a significant tendency to form multimers independently of other flagellar components. The multimerization of FliG is promoted by FliF and also by FliM. FliM does not multimerize efficiently by itself but does so in the presence of FliG. Thus, pre-assemblies of the switch-complex proteins can form in the cytosol and might function as intermediates in assembly.

Architecture of the Flagellar Switch Complex of Escherichia coli: Conformational Plasticity of FliG and Implications for Adaptive Remodeling.

Structural models of the complex that regulates the direction of flagellar rotation assume either ~34 or ~25 copies of the protein FliG. Support for ~34 came from crosslinking experiments identifying an intersubunit contact most consistent with that number; support for ~25 came from the observation that flagella can assemble and rotate when FliG is genetically fused to FliF, for which the accepted number is ~25. Here, we have undertaken crosslinking and other experiments to address more fully the question of FliG number. The results indicate a copy number of ~25 for FliG. An interaction between the C-terminal and middle domains, which has been taken to support a model with ~34 copies, is also supported. To reconcile the interaction with a FliG number of ~25, we hypothesize conformational plasticity in an interdomain segment of FliG that allows some subunits to bridge gaps created by the number mismatch. This proposal is supported by mutant phenotypes and other results indicating that the normally helical segment adopts a more extended conformation in some subunits. The FliG amino-terminal domain is organized in a regular array with dimensions matching a ring in the upper part of the complex. The model predicts that FliG copy number should be tied to that of FliF, whereas FliM copy number can increase or decrease according to the number of FliG subunits that adopt the extended conformation. This has implications for the phenomenon of adaptive switch remodeling, in which the FliM copy number varies to adjust the bias of the switch.