Biomedical subjects

Alan B Fleischer

Publications and source records attributed to Alan B Fleischer.

At least 73 records · Page 4Linked to original sources

PubMed2003

Are there racial and sex differences in the use of oral isotretinoin for acne management in the United States?

BACKGROUND: Treatment of various diseases has been noted to vary by patient demographics. There is reason to suspect that there may be sex and racial differences in the treatment of severe acne. OBJECTIVE: We sought to determine if treatment of severe acne with oral isotretinoin varied with patient sex, race, or both. METHODS: We analyzed the demographics of patients with acne and patients using oral isotretinoin, minocycline, and tetracycline recorded in the 1990 to 1997 National Ambulatory Medical Care Survey. RESULTS: There were 35 million visits to physicians for the treatment of acne between 1990 and 1997, and isotretinoin was prescribed at 5.8 million (17%) of these visits. Per capita visit rates for acne among whites was 2.3 times that of blacks, and whites were 1.8 times more likely to receive isotretinoin at acne visits. Per capita, women had 1.4 times as many visits for acne as men, but men were 1.7 times more likely than women to receive isotretinoin at an acne visit. Dermatologists managed 83% of all isotretinoin visits. Dermatologists accounted for 100% of isotretinoin visits for which pregnancy prevention education and counseling was reported. CONCLUSIONS: Patients who are black receive less oral isotretinoin than those who are white, and the expense of isotretinoin appears to be one factor in this difference. Women are less likely than men to receive isotretinoin at acne visits. Expense does not appear to be a factor in this difference. Dermatologists have more experience than nondermatologists managing acne, prescribing isotretinoin, and counseling women treated with isotretinoin concerning pregnancy prevention. Pregnancy prevention is an essential component of isotretinoin use in women that must not be ignored.

Acne Vulgaris↗

PubMed2003

Surgical treatment of nonmelanoma skin cancer in the Medicare population.

BACKGROUND: Nonmelanoma skin cancer (NMSC) is the most common malignancy of white populations. Different surgical treatment options can be used to treat these tumors, depending on the tumor characteristics and setting. OBJECTIVE: To determine how frequently different specialists use the different types of surgical options available for the treatment of NMSC using a 1998-1999 sample of Medicare claims data. METHODS: Episodes of care of NMSC were identified by pathology claims with a diagnosis of NMSC. The surgical interventions performed within 7 days before the pathologic diagnosis of NMSC were then analyzed. The numbers of patients and the variety of surgical treatments were categorized by specialty to include dermatology, general surgery, and plastic surgery. RESULTS: Dermatologists managed 82% of the NMSC episodes. Dermatologists used a wider range of different treatment options than other specialists and performed 90% of the biopsies, 56% of the excisions, 95% of the destructions, and 100% of the Mohs micrographic surgeries for NMSC. CONCLUSIONS: Dermatologists identify and manage most of the NMSC in the United States and offer patients a broad range of surgical options. The use by dermatologists of office-based surgical methods not commonly used by other specialists may partially explain previous findings of better NMSC outcome by dermatologists. The low level of use of specific surgical options by some specialists may indicate the need for greater training/exposure to these methods.

Humans↗

PubMed2003

A systematic review of adverse effects associated with topical treatments for psoriasis.

Mild to moderate psoriasis is a disease that can often be treated with topical medications. The diversity of topical therapies and their disparate side effects complicates treatment planning. Our purpose is to compare the rates of adverse events associated with different topical psoriasis treatments. A review of medical literature from 1996 to March, 2002 was conducted using guidelines set by QUORUM statement criteria. In monotherapy studies, corticosteriods caused fewer adverse reactions compared to vitamin D analogues and tazarotene. In combination studies adverse event rates were higher than in monotherapy studies, except for the combination of topical steroid and calcipotriene which decreased irritation. Irritant contact dermatitis was the main side effect with vitamin D analogues, tazarotene, dithranol or coal tar, while side effects of topical corticosteriods included headache, viral infection and skin atrophy. Topical agents for psoriasis are usually well-tolerated without severe side effects. Formulating a patient's medication regimen should take into account the needs for short-term management and long-term control of psoriasis. Since clearance is not a realistic expectation, reasonable goals should be set as excessive use of topical treatments may increase the risk of both cutaneous and systemic side effects.

Administration, Topical↗

PubMed2003

Pruritus: a review.

The history, neurophysiology, clinical aspects and treatment of pruritus are reviewed in this article. The different forms of pruritus in dermatological and systemic diseases are described, and the various aetiologies and pathophysiology of pruritus in systemic diseases are discussed. Lack of understanding of the neurophysiology and pathophysiology of pruritus has hampered the development of adequate therapies. Nevertheless, the discovery of primary afferent neurons and, presumably, second-order neurons with typical histamine responses mediating pruritic sensations can be regarded as a breakthrough in our understanding of the mechanisms behind pruritus. The number of experimental and therapeutic studies has greatly increased during the past few years, reflecting an increased interest in this topic. However, further effort is needed to develop new therapeutic concepts and clarify some confusion arising from promising case reports and uncontrolled clinical studies. A precise work-up for evaluating patients with pruritus is proposed, which may help the physician to identify the underlying causes and thus to treat the patient appropriately.

Female↗

PubMed2003

Analysis of factors associated with increased prescription illegibility: results from the National Ambulatory Medical Care Survey, 1990-1998.

OBJECTIVE: To estimate the incidence of, and the variables affecting, illegible drug prescriptions in the United States. METHODS: Illegible notations of medications (ie, drug mentions) on the patient record form used for data collection in the National Ambulatory Medical Care Survey from 1990 to 1998 were used as a proxy for the incidence of illegible prescriptions in the United States. RESULTS: The average incidence of illegible mentions was 1.44%. Increased age of patient, female sex, urban practice setting, increased number of diagnoses and prescriptions written during the visit and seeing a family physician or internist were associated with an increased probability of at least 1 illegible drug mention. CONCLUSION: Distinct characteristics are associated with a higher incidence of illegible prescriptions. Multiple diagnoses and an increased number of prescriptions, both of which contribute to the complexity of a patient visit, are especially likely to be associated with at least 1 illegible prescription per visit. Physicians need to recognize factors contributing to illegible prescriptions to maintain high standards of care.

Adolescent↗

PubMed2002

Effects of systematic asymmetric discounting on physician-patient interactions: a theoretical framework to explain poor compliance with lifestyle counseling.

BACKGROUND: This study advances the use of a utility model to model physician-patient interactions from the perspectives of physicians and patients. PRESENTATION OF THE HYPOTHESIS: In cases involving acute care, patient counseling involves a relatively straightforward transfer of information from the physician to a patient. The patient has less information than the physician on the impact the condition and its treatment have on utility. In decisions involving lifestyle changes, the patient may have more information than the physician on his/her utility of consumption; moreover, differences in discounting future health may contribute significantly to differences between patients' preferences and physicians' recommendations. TESTING THE HYPOTHESIS: The expectation of differences in internal discount rate between patients and their physicians is discussed. IMPLICATIONS OF THE HYPOTHESIS: This utility model provides a conceptual basis for the finding that educational approaches alone may not effect changes in patient behavior and suggests other economic variables that could be targeted in the attempt to produce healthier behavior.

Age Factors↗

PubMed2002

Psoriasis and pregnancy.

BACKGROUND: Women comprise half of all psoriasis patients and because the majority of psoriasis cases present before age 40 the disease affects women who may become pregnant. Information regarding the heritability of psoriasis can be used in counseling patients who inquire about the potential risk to their children. Patients with psoriasis who become pregnant will likely notice an associated improvement of their symptoms if any change is noted at all. OBJECTIVE: Because of potential fetal effects, the treatment of chronic psoriasis in pregnancy involves prudent consideration of whether the severity of the disease warrants treatment and selection of the safest treatments available. CONCLUSION: Topical corticosteroids and topical calcipotriene as well as topical anthralin and topical tacrolimus appear to be safe choices for control of localized psoriasis in pregnancy. UVB is the safest treatment for extensive psoriasis during pregnancy, particularly when topical application of other agents is not practical. Short-term use of cyclosporine during pregnancy is probably the safest option for management of severe psoriasis that has not responded to topical or UVB treatment.

Adult↗

PubMed2002

Diagnostic codes associated with hypnotic medications during outpatient physician-patient encounters in the United States from 1990-1998.

STUDY OBJECTIVES: This investigation tabulates the most common diagnostic codes associated with use of hypnotic medications during physician-patient encounters in the U.S. DESIGN: Estimates were derived from the National Ambulatory Medical Care Survey (NAMCS) from 1990 through 1998. Diagnoses were coded according to the International Classification of Disease-Clinical Modification-9th Edition (ICD-9-CM). SETTING: The NAMCS collects outpatient visit data from nonfederal physicians of all specialties, except anesthesiology, pathology, and radiology. PARTICIPANTS: N/A. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Hypnotic medications were more commonly associated with psychiatric codes than with the symptom of insomnia. Primary insomnia did not appear among the codes most commonly associated with a hypnotic prescription. CONCLUSIONS: Hypnotics were more commonly associated with psychiatric codes than with insomnia codes, but it is unknown whether the coding accurately reflects the true diagnoses. Still, since there is minimal data on the efficacy and safety of hypnotics in persons with psychiatric disorders, these findings may signal a critical knowledge gap in the treatment of insomnia.

Drug Administration Schedule↗

PubMed2002

In the United States, blacks and Asian/Pacific Islanders are more likely than whites to seek medical care for atopic dermatitis.

BACKGROUND: There have been population-based studies conducted in England and the United States that suggest an increase in prevalence of atopic dermatitis among black and/or Asian children. OBJECTIVE: To assess whether health care utilization for atopic dermatitis differs among different ethnic groups in the United States. DESIGN: Weighted data on representative office visits by whites, blacks, and Asian/Pacific Islanders were analyzed using a cross-sectional study, the National Ambulatory Medical Care Survey (NAMCS), from 1990 through 1998 using statistical software. SETTING: The NAMCS is an ongoing data collection effort by the Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention. The survey samples representative visits to US office-based physicians during a representative week of practice. PATIENTS: All outpatient visits were analyzed and compared with those for patients diagnosed as having atopic dermatitis (International Classification of Diseases, Ninth Revision, Clinical Modification, code 691.80). MAIN OUTCOME MEASURE: Diagnosis of atopic dermatitis by race. RESULTS: Of 570 million estimated visits for skin conditions, 7.9 million were for atopic dermatitis. The numbers of per capita visits for atopic dermatitis among blacks and Asian/Pacific Islanders were 2-fold and 6-fold higher, respectively, than among whites. The odds ratios (95% confidence intervals) for atopic dermatitis visits by blacks and Asian/Pacific Islanders relative to whites were 3.4 (2.5-4.7) and 6.7 (4.8-9.5), respectively. CONCLUSIONS: Blacks and Asian/Pacific Islanders are much more likely to visit physicians for atopic dermatitis than are whites and may benefit from education and early intervention efforts concerning the disease.

Asian↗

PubMed2002

Visual discrimination testing of ultraviolet transmitting and ultraviolet blocking acrylic thermoplastics.

BACKGROUND: Visual perception has hindered the development of blinded, placebo-controlled ultraviolet light exposure conditions in humans. New acrylic thermoplastics that block or transmit ultraviolet light have visual properties that may provide a solution. METHODS: In a series of triangle taste tests, 60 subjects were tested for the ability to visually perceive ultraviolet light transmission by two of four types of acrylic thermoplastics. RESULTS: Forty-six of sixty (67%) subjects were unable to visually detect ultraviolet light transmitting acrylics among ultraviolet blocking acrylics in both an ambient light background condition and an ambient light background condition with ultraviolet A light supplementation. CONCLUSION: Acrylic thermoplastics allow for the production of blinded, placebo-controlled ultraviolet light exposure conditions by eliminating visual discrimination differences between active and control groups.

Acrylic Resins↗

PubMed2002

The safety of liposuction: results of a national survey.

BACKGROUND: Liposuction procedures are increasing in frequency and may be performed in hospitals, ambulatory surgery centers, or physician offices. Deaths associated with liposuction and previous surveys of liposuction safety have raised concern about the safety of office-based surgery. OBJECTIVE: To determine the safety of office-based, tumescent liposuction among dermatologic surgeons. METHODS: A survey mailed out to dermatologic surgeons in August 2001 requested retrospective information regarding the number of patients undergoing liposuction, the setting in which the procedures were performed, and the complications that occurred during the 7-year period from 1994 to 2000. A detailed complication record was requested for each serious adverse event or death reported. Surveys were mailed to 517 worldwide members of the American Society for Dermatologic Surgery (ASDS) listed as performing liposuction; 505 had adequate contact information. The main outcome mesure was the rate of serious adverse events (SAEs) or deaths per 1000 liposuction procedures for each service setting and for each level of conscious sedation. RESULTS: The overall response rate was 89% (450/505), and of these, 78% (349/450) perform liposuction. A total of 267 dermatologic surgeons completed the survey; 261 provided data on 66,570 liposuction procedures. No deaths were reported. The overall serious adverse event rate was 0.68 per 1000 cases. The SAE rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. SAE rates were also higher for tumescent liposuction combined with intravenous or intramuscular sedation than combined with oral or no sedation. CONCLUSION: Office-based tumescent liposuction performed by dermatologic surgeons is safe, with a lower complication rate than hospital-based procedures. Future legislation should recognize the proven safety of this procedure as performed by dermatologic surgeons in their offices.

Adult↗

PubMed2002

Phototherapy utilization for psoriasis is declining in the United States.

Phototherapy is an established treatment modality for psoriasis. The use of phototherapy for psoriasis appears to be in decline in nonfederal and non-university-based settings. We used data from the National Ambulatory Medical Care Survey to estimate the number of visits for phototherapy and psoralen ultraviolet A-range (PUVA) light therapy from 1993 to 1998. There were 873,000 visits for UV light therapy in 1993-1994, 189,000 in 1995-1996, and 53,000 in 1997-1998 (P <.0001). There were 175,000 psoralen visits in 1993-1994, 61,000 in 1995-1996, and 25,000 in 1997-1998 (P =.0053). Similar decreases in phototherapy visits occurred in our university-based practice. The decline in phototherapy represents decreased utilization of a safe and effective treatment for psoriasis.

Health Care Surveys↗

PubMed2002

Off-label prescribing in the treatment of dermatologic disease.

BACKGROUND: It is common practice for physicians to treat dermatologic conditions with medications that are not indicated for the specific condition being treated. These "off-label" prescriptions are often for medications that have both well accepted therapeutic value in the medical community and proven efficacy on the basis of results of clinical trials. OBJECTIVE: Our purpose was to quantify the use of off-label prescriptions for dermatologic disease by a representative sample of physicians in the United States. METHODS: Data from the 1990-1997 National Ambulatory Medical Care Survey, performed by the National Center for Health Statistics, were used to assess medications prescribed at office visits for dermatologic disease. We identified the most common diagnoses listed at office visits in which the primary and only diagnosis listed was dermatologic. For the leading 10 dermatologic conditions for which medications are indicated, we categorized each primary drug mention by indication. RESULTS: We found that the range of off-label prescribing varied from 17% to 73%, with a weighted mean (+/- SD) of 32% +/- 18%. The conditions most frequently managed with off-label prescriptions were acne rosacea (73%) and actinic keratosis (52%), whereas those with the fewest off-label prescriptions were atopic dermatitis (17%) and psoriasis (16%). The use of off-label prescriptions by dermatologists in the diseases studied ranged from 7% to 73% with a weighted mean (+/- SD) of 24% (+/- 24%), whereas the range for nondermatologists was 18% to 96% with a weighted mean (+/- SD) of 34% (+/- 18%). CONCLUSION: Off-label prescribing is common in the management of dermatologic conditions. From these data, we conclude that it is currently within the standard of care to use off-label prescriptions in the treatment of dermatologic disease.

Drug Labeling↗

PubMed2002

Tacrolimus ointment for the treatment of atopic dermatitis is not associated with an increase in cutaneous infections.

OBJECTIVE: The purpose of this study was to evaluate the risk of cutaneous infection in patients with atopic dermatitis treated with tacrolimus ointment. METHODS: Data for 1554 patients with atopic dermatitis, treated with tacrolimus ointment in 5 clinical trials, were analyzed. RESULTS: In 3 controlled studies, the 12-week adjusted incidence of all cutaneous infections in patients treated with the vehicle, 0.03%, and 0.1% tacrolimus ointment, respectively, was 18.0%, 24.8%, and 17.7% for adult patients, and 20.9%, 19.6%, and 23.6% for pediatric patients. The incidence of any individual cutaneous infection was not significantly higher in the tacrolimus group than in the vehicle group, with the exception of folliculitis in adults. In two open-label studies, there was no evidence of an increased risk of cutaneous infections with long-term use of 0.1% tacrolimus ointment (up to 1 year), based on the incidence of adverse events, incidence by cumulative length of exposure, or hazard rates. CONCLUSION: Treatment with tacrolimus ointment (0.03% or 0.1%) does not increase the risk of cutaneous bacterial, viral, or fungal infections in patients with atopic dermatitis.

Adolescent↗

PubMed2002

Palisaded neutrophilic granulomatous dermatitis in rheumatoid arthritis.

Palisaded neutrophilic granulomatous dermatitis (PNGD) is an entity that has not been clearly defined either clinically or histopathologically. It is seen in patients with rheumatoid arthritis and other connective tissue diseases. In the past, many cases of PNGD have been described under several different names including palisaded neutrophilic and granulomatous dermatitis, linear subcutaneous bands, interstitial granulomatous dermatitis with cutaneous cords and arthritis, rheumatoid papules, and Churg-Strauss granuloma. We report 7 additional cases of PNGD. Clinically, 6 patients presented with erythematous to violaceous plaques, papules, and nodules on multiple body sites; one presented with subcutaneous linear bands on the shoulder. Five had rheumatoid arthritis; one had adult-onset Still's disease; and one showed clinical signs of rheumatoid arthritis, although serologically the rheumatoid factor was negative. On histologic examination, a spectrum of changes was observed ranging from urticaria-like infiltrates to leukocytoclastic vasculitis and granuloma annulare with neutrophils. We report these cases to expand the histologic spectrum of this entity and to further delineate the different forms of clinical presentation.

Adult↗

PubMed2002

Characteristics of office-based physician visits for cutaneous fungal infections. an analysis of 1990 to 1994 National Ambulatory Medical Care Survey Data.

To our knowledge, visits in the ambulatory setting due to cutaneous fungal infections have not been recently characterized. To provide descriptive epidemiology on ambulatory cutaneous fungal infection visits, we analyzed office-based physician visits for cutaneous fungal infections recorded in the National Ambulatory Medical Care Survey (NAMCS) from 1990 to 1994. The International Classification of Diseases (ICD-9) was used to define the cutaneous fungal infections. Sampling weights were applied to achieve the nationally representative estimates. From 1990 to 1994, an estimated 21.6 million physician office visits at an estimated cost of $216 million/y (office visit plus medication costs) were made for cutaneous fungal infection diagnoses. The total cost of office visits (without medication costs) was approximately $116 million/y. The total cost of the top 5 medications was approximately $68 million/y. According to an analysis of visits per physician specialist, dermatologists had the largest proportion of visits for cutaneous fungal infections. The cost associated with the diagnosis and management of cutaneous fungal infections is significant. Of all the physician specialists, dermatologists treated the most cutaneous fungal infections.

Adolescent↗

PubMed2002

Capitation payment, length of visit, and preventive services: evidence from a national sample of outpatient physicians.

OBJECTIVE: To test the hypothesis that capitation payment to physicians reduces the length of physician-patient encounters but increases use of preventive and health counseling services. STUDY DESIGN: Cross-sectional analysis of data from the National Ambulatory Medical Care Survey of outpatient physicians and their office staff (1997 and 1998). PATIENTS AND METHODS: A random national sample of 46,320 ambulatory care visits was used. Weight-adjusted multivariate regression techniques were utilized to examine the effects of capitation on duration of physician visit and number of preventive and health counseling services. RESULTS: Physicians spent 5.6% less time (P < .01) with patients in capitated plans than with those in noncapitated plans. The effect of payment method on length of visit was 3.5 times stronger among physicians receiving only capitated payment, compared with physicians receiving only noncapitated payment. Patients in capitated plans were 17% more likely to receive health counseling services (P < .01) than patients in noncapitated plans. Patients under capitation were 3% more likely to receive preventive services compared to patients in non-health maintenance organizations, noncapitated plans (P < .05). CONCLUSIONS: Capitation is associated with a modest decrease in the amount of time physicians spend with their patients and with increased receipt of preventive and health counseling services, on average. These trends are driven by physicians who receive capitated payment predominantly. Physicians with a mix of patients from capitated and noncapitated plans spend approximately equal time with each type of patient, which reflects an ethic of impartiality in medical judgment.

Aged↗

PubMed2002

A survey of office visits for actinic keratosis as reported by NAMCS, 1990-1999. National Ambulatory Medical Care Survey.

Although actinic keratosis (AK) has been linked to the development of nonmelanoma skin cancer (NMSC), particularly squamous cell carcinoma (SCC), increased awareness regarding diagnosis and treatment may be an important component for reducing morbidity and even mortality from AK and NMSC. We used the National Ambulatory Medical Care Survey (NAMCS) data from 1990 to 1999 to evaluate the diagnosis and treatment of AKs among a wide variety of patients by physicians across the United States. To our knowledge, no widespread surveys of North American populations have been performed recently to determine the epidemiology of AK. AK was diagnosed in more than 47 million visits over the 10-year period surveyed and was found to occur in 14% of patients visiting dermatologists. The diagnosis of AK as determined by NAMCS does not reflect the true prevalence of AK because only patients seeking physician diagnosis were surveyed. This suggests that the actual number of patients in the United States with AK is much higher than 14%. Rates of AK diagnosis in the standard metropolitan statistical areas (SMSAs) and non-standard metropolitan statistical areas (non-SMSAs) of the West states are higher than in other states, but geographic location may not be a direct risk factor for the development of AKs. Procedures were undertaken at 70% of visits where AK was the primary diagnosis. Destruction of lesions was the most frequently performed procedure found in the survey considering only the 1993 and 1994 NAMCS data. Biopsy was the second most frequently performed procedure.

Adolescent↗