Person: Mostaghimi, Arash
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Mostaghimi
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Arash
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Mostaghimi, Arash
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Publication Symmetrical Drug-related Intertriginous and Flexural Exanthema Induced by Doxycycline(Cureus, 2017) Li, David G; Thomas, Cristina; Weintraub, Gil; Mostaghimi, ArashSymmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a cutaneous drug reaction characterized by erythema over the buttocks, thighs, groin, and flexural regions most commonly associated with the use of beta-lactam antibiotics. Although the exact pathophysiology of this disease remains unknown, it is theorized to be the result of a delayed hypersensitivity response presenting as a cutaneous eruption days to weeks after exposure to the drug. The treatment involves discontinuation of the suspected medication, symptomatic control of pruritus, and topical steroid therapy. A 51-year-old woman with homocystinuria and fibromyalgia was admitted with fevers, pancytopenia (later diagnosed to be acute myelogenous leukemia), and a targetoid cutaneous eruption in the setting of a recent tick bite. She was subsequently noted to have symmetric, pruritic, erythematous papules over the lateral neck, retroauricular regions, lateral aspects of the inframammary regions, medial upper arms, axillae, and the lower abdomen two weeks after starting doxycycline. Considering the morphology, distribution, and intense pruritis associated with the eruption, a diagnosis of SDRIFE was made. Doxycycline discontinuation along with topical steroid therapy resulted in the resolution of the eruption and pruritus. Given the widespread use of doxycycline, clinicians should be aware of this possible side effect.Publication Use of Health Care Resources and Costs After Patient Nonattendance in Dermatology(American Medical Association (AMA), 2016) Halim, Kareem; Weng, Qing Yu; Kuye, Ifedayo; Joyce, Cara; Mostaghimi, ArashPatient nonattendance occurs when patients miss appointments without notifying their health care professionals in advance. In dermatology, nonattendance rates range from 7.8% to 31.0% of scheduled appointments. The consequences of nonattendance range from compromised care to wasted appointment slots, decreased efficiency, and diluted residency training. We seek to define the effect of nonattendance on subsequent use of health care resources and health care spending in dermatology.Publication Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis(American Medical Association (AMA), 2017) Weng, Qing Yu; Raff, Adam; Cohen, Jeffrey Marcus; Gunasekera, Nicole; Okhovat, Jean-Phillip; Vedak, Priyanka; Joyce, Cara; Kroshinsky, Daniela; Mostaghimi, ArashQuestion What is the national health care burden of misdiagnosed lower extremity cellulitis in patients admitted to the hospital from the emergency department? Findings In this cross-sectional study that included 259 patients, 30% were misdiagnosed with cellulitis, of which 85% did not require hospitalization and 92% received unnecessary antibiotics. Combining these findings with previously published data, cost estimates, and and projections indicate that cellulitis misdiagnosis leads to 50 000 to 130 000 unnecessary hospitalizations in the United States and $195 million to $515 million in avoidable health care spending annually. Meaning Misdiagnosis of lower extremity cellulitis is common and may lead to unnecessary patient morbidity and considerable health care spending.Publication Risk of Developing Pyoderma Gangrenosum after Procedures in Patients with a Known History of Pyoderma Gangrenosum – A Retrospective Analysis(Elsevier BV, 2017) Xia, Fandi; Liu, Kristina; Lockwood, Stephen J.; Butler, Daniel Charles; Tsiaras, William; Joyce, Cara; Mostaghimi, ArashBackground The risk of postoperative pyoderma gangrenosum (PG) in patients with a known history of PG is unknown. Objective To quantify risk and identify patient/procedure-related risk factors for postsurgical PG recurrence/exacerbation in patients with known history of PG. Methods We retrospectively evaluated the likelihood of postsurgical PG recurrence/exacerbation for all patients with a confirmed diagnosis of PG at Brigham & Women’s Hospital and Massachusetts General Hospital from 2000-2015. Results 5.5% (n=33) of procedures led to recurrence of PG in 15.1% (n=25) of patients. Compared to skin biopsy, small open surgeries had an adjusted odds ratio (aOR) of 8.65 (1.55, 48.33) for PG recurrence/exacerbation; large open surgeries had an aOR of 5.97 (1.70, 21.00); and Mohs surgery/skin excision had an aOR of 6.47 (1.77, 23.61). PG chronically present at the time of procedure had an aOR of 4.58 (1.72, 12.22). Immunosuppression, time elapsed since original PG diagnosis, and procedure location did not significantly influence risk. Limitations Our study is limited by its retrospective nature and relatively small sample size. Conclusion There is a small but clinically meaningful risk of postsurgical PG recurrence/exacerbation in patients with known history of PG; higher risks occur with more invasive procedures and chronically present PG.Publication Dermatology discharge continuity clinic enhances resident autonomy and insight into transitions-of-care competencies: a cross-sectional survey study(University of California Davis, 2017) Rana, Jasmine; Mostaghimi, ArashDermatology residents perform consults on hospitalized patients, but are often limited in their ability to follow-up with these patients after discharge, leading to inadequate follow-up and understanding of post-discharge transitions of care. In 2013, a discharge continuity clinic (DCC) staffed by the inpatient consult dermatology resident and attending dermatologist was established at one of the four adult hospital sites residents rotate through in the Harvard Combined Dermatology Residency Program. Resident perceptions about the DCC and their educational experience on inpatient consult rotations with a DCC and without a DCC were obtained using a cross-sectional survey instrument in June 2016. Self-reported data from a multi-year cohort of dermatology residents (n = 14 of 20, 70% response rate) reveals that the DCC enabled resident autonomy and resident satisfaction in care of their patients,insight into the disease-related challenges and the broader social context during transitions of care from inpatient to outpatient settings, and more enriching learning experiences than inpatient consult rotations without a DCC. Dermatology residents self-report participation in an inpatient consult rotation with aDCC supports their autonomy and achievement of post-discharge transitions-of-care competencies.Publication Estimated Cost of Emergency Sunburn Visits—Validation of ICD-9-CM Search Criteria(American Medical Association (AMA), 2017) Xia, Fan; Joyce, Cara; Mostaghimi, ArashTo the Editor We applaud the evaluation by Guy and colleagues of costs for sunburn-associated visits to US emergency departments. Their analysis was performed using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) primary and secondary billing codes for sunburn (692.71, 692.76, and 692.77) in discharge records from the National Emergency Department Sample database.Publication Characteristics of Patients Presenting to the Emergency Department and Urgent Care for Treatment of Sunburn(American Medical Association (AMA), 2017) Di Xia, Fan; Fuhlbrigge, Mary; Waul, Michael; Joyce, Cara; Mostaghimi, ArashSunburn led to an estimated 33 826 visits to US emergency departments (EDs) in 2013, resulting in a cost of $11.2 million. Despite this burden, little is known about the features of patients utilizing the ED or urgent care clinic (UCC) for treatment of sunburn. Characterizing this patient population may help guide efforts of prevention, utilization reduction, and transition of care to lower cost settings. In this study we examined the demographics and characteristics of patients seen at the ED or UCC for sunburn treatment at 2 major hospitals over a 15-year period.Publication Comparing dermatology referral patterns and diagnostic accuracy between nonphysician providers, physician trainees, and attending physicians(Elsevier BV, 2016) Bae, Gordon H.; Hartman, Rebecca; Joyce, Cara; Mostaghimi, ArashPublication Cost of Routine Herpes Simplex Virus Infection Visits to U.S. Emergency Departments 2006-2013(Western Journal of Emergency Medicine, 2018-06-29) Xia, Fandi; Fuhlbrigge, Mary; Dommasch, Erica; Joyce, Cara; Mostaghimi, ArashIntroduction Little is known about emergency department (ED) utilization for herpes simplex viruses (HSV) types 1 and 2 in the United States. Our goal was to determine the utilization and cost burden associated with HSV infection visits to U.S. EDs in recent years from 2006–2013. Methods We analyzed the Nationwide Emergency Department Sample (NEDS) database, the largest national database of hospital-based ED visits in the U.S., to determine the number of visits and the cost associated with HSV visits from 2006–2013. We also analyzed trends across years. Results From 2006–2013, there were 704,728 ED visits with a primary diagnosis of HSV infection. Of these, 658,805 (93.5%) resulted in routine discharges without inpatient admission, amounting to a total ED charge of USD 543.0 million. After adjusting for inflation, there was a doubling of total ED spending for HSV from 2006 to 2013 (USD 45.0 million to USD 90.7 million) and a 24% increase in number of visits (73,227 visits in 2006, vs. 90,627 visits in 2013). ED visits for genital herpes have increased while visits for herpes gingivostomatitis have decreased. Conclusion HSV-associated ED use and associated costs have increased between 2006–2013. Most of these cases could likely be managed in non-emergent outpatient settings as 93.5% of visits resulted in routine discharges without admission. Our findings add to knowledge regarding HSV utilization and epidemiology in the U.S. and highlight the need for continued prevention, patient education, and emphasis of care in non-emergency settings to prevent unnecessary ED utilization.Publication Clinical characteristics of Merkel cell carcinoma at diagnosis in 195 patients: the AEIOU features(Elsevier BV, 2008) Heath, Michelle; Jaimes, Natalia; Lemos, Bianca; Mostaghimi, Arash; Wang, Linda; Peñas, Pablo F.; Nghiem, PaulMerkel cell carcinoma (MCC) is an aggressive skin cancer with a mortality of 33%. Advanced disease at diagnosis is a poor prognostic factor, suggesting that earlier detection may improve outcome. No systematic analysis has been published to define the clinical features that are characteristic of MCC. Objective To define the clinical characteristics present at diagnosis in order to identify features that may aid clinicians in recognizing MCC. Methods Cohort study of 195 patients diagnosed with MCC between 1980 and 2007. Data were collected prospectively in the majority of cases, and medical records were reviewed. Results An important finding was that 88% of MCCs were asymptomatic (nontender) despite rapid growth in the prior 3 months (63% of lesions) and being red or pink (56%). A majority of MCC lesions (56%) were presumed to be benign, with a cyst/acneiform lesion being the single most common diagnosis (32%) given at biopsy. The median delay from lesion appearance to biopsy was 3 months (range 1–54 months), and median tumor diameter was 1.8 cm. Similar to prior studies, 81% of primary MCCs occurred on UV-exposed sites, and our cohort was elderly (90% over age 50), predominantly Caucasian (98%), and often profoundly immune suppressed (7.8%). An additional novel finding was that chronic lymphocytic leukemia was more than 30-fold over-represented among MCC patients. Limitations The study was limited to patients seen at a tertiary care center. Complete clinical data could not be obtained on all patients. This study could not assess the specificity of the clinical characteristics of MCC. Conclusions This study is the first to define clinical features that may serve as clues in the diagnosis of MCC. The most significant features can be summarized in an acronym: AEIOU -Asymptomatic/lack of tenderness, Expanding rapidly, Immune suppression, Older than age 50, and UV-exposed site on a person with fair skin. In our series, 89% of primary MCCs had three or more of these findings. Although MCC is uncommon, when present in combination, these features may indicate a concerning process that would warrant biopsy. In particular, a lesion that is red and expanding rapidly yet asymptomatic should be of concern.