Eleni Linos MD, MPH, DrPH, is the Director of the Center for Digital Health and Professor of Dermatology and Epidemiology at Stanford University.

Dr. Linos' work focuses on the use of technology in health, dermatology, public health, cancer prevention and the care of older adults. Dr. Linos is dually trained in epidemiology and dermatology and is the principal investigator of several NIH funded studies aimed at improving the lives of patients. She received her medical degree from Cambridge and Oxford universities in the UK, then trained in epidemiology at the Harvard School of Public Health and completed her residency at Stanford.

Clinical Focus

  • Digital Health
  • Dermatology
  • Epidemiology

Academic Appointments

Professional Education

  • BS, Cambridge University, Trinity College (2001)
  • MD, Oxford University, Christ Church (2004)
  • MPH, Harvard School of Public Health, Public Health (2006)
  • DrPH, Harvard University, Public Health (2008)
  • Internship: Stanford University Internal Medicine Residency (2008) CA
  • Residency: Stanford University Dermatology Residency (2011) CA
  • Board Certification: American Board of Dermatology, Dermatology (2012)

2023-24 Courses

Stanford Advisees

All Publications

  • Human-AI interaction in skin cancer diagnosis: a systematic review and meta-analysis. NPJ digital medicine Krakowski, I., Kim, J., Cai, Z. R., Daneshjou, R., Lapins, J., Eriksson, H., Lykou, A., Linos, E. 2024; 7 (1): 78


    The development of diagnostic tools for skin cancer based on artificial intelligence (AI) is increasing rapidly and will likely soon be widely implemented in clinical use. Even though the performance of these algorithms is promising in theory, there is limited evidence on the impact of AI assistance on human diagnostic decisions. Therefore, the aim of this systematic review and meta-analysis was to study the effect of AI assistance on the accuracy of skin cancer diagnosis. We searched PubMed, Embase, IEE Xplore, Scopus and conference proceedings for articles from 1/1/2017 to 11/8/2022. We included studies comparing the performance of clinicians diagnosing at least one skin cancer with and without deep learning-based AI assistance. Summary estimates of sensitivity and specificity of diagnostic accuracy with versus without AI assistance were computed using a bivariate random effects model. We identified 2983 studies, of which ten were eligible for meta-analysis. For clinicians without AI assistance, pooled sensitivity was 74.8% (95% CI 68.6-80.1) and specificity was 81.5% (95% CI 73.9-87.3). For AI-assisted clinicians, the overall sensitivity was 81.1% (95% CI 74.4-86.5) and specificity was 86.1% (95% CI 79.2-90.9). AI benefitted medical professionals of all experience levels in subgroup analyses, with the largest improvement among non-dermatologists. No publication bias was detected, and sensitivity analysis revealed that the findings were robust. AI in the hands of clinicians has the potential to improve diagnostic accuracy in skin cancer diagnosis. Given that most studies were conducted in experimental settings, we encourage future studies to further investigate these potential benefits in real-life settings.

    View details for DOI 10.1038/s41746-024-01031-w

    View details for PubMedID 38594408

    View details for PubMedCentralID 8237239

  • Incidence of Nonkeratinocyte Skin Cancer After Breast Cancer Radiation Therapy. JAMA network open Rezaei, S. J., Eid, E., Tang, J. Y., Kurian, A. W., Kwong, B. Y., Linos, E. 2024; 7 (3): e241632


    Previous studies have suggested that radiation therapy may contribute to an increased risk of subsequent nonkeratinocyte (ie, not squamous and basal cell) skin cancers.To test the hypothesis that radiation therapy for breast cancer increases the risk of subsequent nonkeratinocyte skin cancers, particularly when these cancers are localized to the skin of the breast or trunk.This population-based cohort study used longitudinal data from the Surveillance, Epidemiology, and End Results (SEER) Program for January 1, 2000, to December 31, 2019. The SEER database includes population-based cohort data from 17 registries. Patients with newly diagnosed breast cancer were identified and were evaluated for subsequent nonkeratinocyte skin cancer development. Data analysis was performed from January to August 2023.Radiation therapy, chemotherapy, or surgery for breast cancer.The primary outcomes were standardized incidence ratios (SIRs) for subsequent nonkeratinocyte skin cancer development from 2000 to 2019 based on treatment type (radiation therapy, chemotherapy, or surgery), skin cancer site on the body, and skin cancer subtype.Among the 875 880 patients with newly diagnosed breast cancer included in this study, 99.3% were women, 51.6% were aged older than 60 years, and 50.3% received radiation therapy. A total of 11.2% patients identified as Hispanic, 10.1% identified as non-Hispanic Black, and 69.5% identified as non-Hispanic White. From 2000 to 2019, there were 3839 patients with nonkeratinocyte skin cancer, including melanoma (3419 [89.1%]), Merkel cell carcinoma (121 [3.2%]), hemangiosarcoma (104 [2.7%]), and 32 other nonkeratinocyte skin cancers (195 [5.1%]), documented to occur after breast cancer treatment. The risk of nonkeratinocyte skin cancer diagnosis after breast cancer treatment with radiation was 57% higher (SIR, 1.57 [95% CI, 1.45-1.7]) than that of the general population when considering the most relevant site: the skin of the breast or trunk. When risk at this site was stratified by skin cancer subtype, the SIRs for melanoma and hemangiosarcoma were both statistically significant at 1.37 (95% CI, 1.25-1.49) and 27.11 (95% CI, 21.6-33.61), respectively. Receipt of radiation therapy was associated with a greater risk of nonkeratinocyte skin cancer compared with chemotherapy and surgical interventions.In this study of patients with breast cancer, an increased risk of melanoma and hemangiosarcoma after breast cancer treatment with radiation therapy was observed. Although occurrences of nonkeratinocyte skin cancers are rare, physicians should be aware of this elevated risk to help inform follow-up care.

    View details for DOI 10.1001/jamanetworkopen.2024.1632

    View details for PubMedID 38457179

  • Assessment of correctness, content omission, and risk of harm in large language model responses to dermatology continuing medical education questions. The Journal of investigative dermatology Cai, Z. R., Chen, M. L., Kim, J., Novoa, R. A., Barnes, L. A., Beam, A., Linos, E. 2024

    View details for DOI 10.1016/j.jid.2024.01.015

    View details for PubMedID 38310972

  • A Comparison of ChatGPT and Fine-Tuned Open Pre-Trained Transformers (OPT) Against Widely Used Sentiment Analysis Tools: Sentiment Analysis of COVID-19 Survey Data. JMIR mental health Lossio-Ventura, J. A., Weger, R., Lee, A. Y., Guinee, E. P., Chung, J., Atlas, L., Linos, E., Pereira, F. 2024; 11: e50150


    Health care providers and health-related researchers face significant challenges when applying sentiment analysis tools to health-related free-text survey data. Most state-of-the-art applications were developed in domains such as social media, and their performance in the health care context remains relatively unknown. Moreover, existing studies indicate that these tools often lack accuracy and produce inconsistent results.This study aims to address the lack of comparative analysis on sentiment analysis tools applied to health-related free-text survey data in the context of COVID-19. The objective was to automatically predict sentence sentiment for 2 independent COVID-19 survey data sets from the National Institutes of Health and Stanford University.Gold standard labels were created for a subset of each data set using a panel of human raters. We compared 8 state-of-the-art sentiment analysis tools on both data sets to evaluate variability and disagreement across tools. In addition, few-shot learning was explored by fine-tuning Open Pre-Trained Transformers (OPT; a large language model [LLM] with publicly available weights) using a small annotated subset and zero-shot learning using ChatGPT (an LLM without available weights).The comparison of sentiment analysis tools revealed high variability and disagreement across the evaluated tools when applied to health-related survey data. OPT and ChatGPT demonstrated superior performance, outperforming all other sentiment analysis tools. Moreover, ChatGPT outperformed OPT, exhibited higher accuracy by 6% and higher F-measure by 4% to 7%.This study demonstrates the effectiveness of LLMs, particularly the few-shot learning and zero-shot learning approaches, in the sentiment analysis of health-related survey data. These results have implications for saving human labor and improving efficiency in sentiment analysis tasks, contributing to advancements in the field of automated sentiment analysis.

    View details for DOI 10.2196/50150

    View details for PubMedID 38271138

  • Association between yearlong air pollution and moderate-severe atopic dermatitis: A United States cross-sectional claims analysis. JAAD international Trinh, P., Allerup, J. A., Li, S., Ko, J., Chen, J., Linos, E., Chiou, A. S. 2023; 13: 4-6

    View details for DOI 10.1016/j.jdin.2023.04.017

    View details for PubMedID 37592975

  • Prevalence and associations of poor mental health in the third year of COVID-19: U.S. population-based analysis from 2020 to 2022. Psychiatry research Kim, J., Linos, E., Rodriguez, C. I., Chen, M. L., Dove, M. S., Keegan, T. H. 2023; 330: 115622


    BACKGROUND: Poorer mental health was found early in the COVID-19 pandemic, yet mental health in the third year of COVID-19 has not been assessed on a general adult population level in the United States.METHODS: We used a nationally representative cross-sectional survey (Health Information National Trends Survey, HINTS 5 2020 n=3,865 and HINTS 6 2022 n=6,252). The prevalence of poor mental health was examined using a Patient Health Questionnaire-4 scale in 2020 and 2022. We also investigated the factors associated with poor mental health in 2022 using a weighted multivariable logistic regression adjusting for sociodemographic and health status characteristics to obtain the odds ratio (OR).OUTCOMES: The prevalence of poor mental health in adults increased from 2020 to 2022 (31.5% vs 36.3%, p=0.0005). U.S. adults in 2022 were 1.28 times as likely to have poor mental health than early in the pandemic. Moreover, individuals with food insecurity, housing instability, and low income had greater odds of poor mental health (ORs=1.78-2.55). Adults who were females, non-Hispanic Whites, or age 18-64 years were more likely to have poor mental health (ORs=1.46-4.15).INTERPRETATION: Mental health of U.S. adults worsened in the third year of COVID-19 compared to the beginning of the pandemic.

    View details for DOI 10.1016/j.psychres.2023.115622

    View details for PubMedID 38006717

  • Longitudinal remote monitoring of hidradenitis suppurativa: a pilot study. The British journal of dermatology Fonjungo, F. E., Barnes, L. A., Cai, Z. R., Naik, H. B., Eid, E. S., Aleshin, M. A., Nava, V., Johnson, T., Chren, M., Linos, E. 2023

    View details for DOI 10.1093/bjd/ljad385

    View details for PubMedID 37823362

  • Assessing Biases in Medical Decisions via Clinician and AI Chatbot Responses to Patient Vignettes. JAMA network open Kim, J., Cai, Z. R., Chen, M. L., Simard, J. F., Linos, E. 2023; 6 (10): e2338050

    View details for DOI 10.1001/jamanetworkopen.2023.38050

    View details for PubMedID 37847506

  • Development of a digital tool for home-based monitoring of skin disease for older adults. Skin health and disease van Egmond, S., Cai, Z. R., Nava, V., Joy de Vere Hunt, I., Rapaport, B. R., Ko, J., Chiou, A. S., Sarin, K., Tang, J., Zhang, L., Linos, E. 2023; 3 (5): e235


    We developed a digital tool for home-based monitoring of skin disease, our digital tool. In the current observational pilot study, we found that DORA is feasible to use in practice, as it has a high patient compliance, retention and satisfaction. Clinicans rated the photos generally good quality or perfect quality. These results show that the digital health tool DORA can easily be used by patients to send photos to their dermatologist, which could reduce unnecessary clinical visits. It may also be used in other settings where digital literacy barriers and unequal access to dermatologists contribute to healthcare disparities.

    View details for DOI 10.1002/ski2.235

    View details for PubMedID 37799368

    View details for PubMedCentralID PMC10549824

  • Estimating Remaining Life Expectancy in Veterans with Basal Cell Carcinoma Using an Automated Electronic Health Record Scoring System: A Retrospective Cohort Study. Journal of the American Academy of Dermatology Dizon, M. P., Linos, E., Swetter, S. M. 2023


    Active surveillance may be considered for low-risk basal cell carcinomas (BCC) in patients with limited life expectancy; however, estimates of life expectancy are not readily available. Veterans Health Administration's (VHA) Care Assessment Need (CAN) score may address this problem.We examined the CAN score's performance in predicting 1-, 3-, and 5-year mortality in United States (US) veterans with BCC.This retrospective cohort study used national VHA electronic medical record data. The CAN score's performance in the prediction of mortality in veterans with BCC was evaluated based on tests of goodness-of-fit, discrimination, and calibration.For 54,744 veterans with BCC treatment encounters between 2013 and 2018, the CAN score performed well in the prediction of mortality based on multiple tests. A threshold CAN score of 90 had a positive predictive value of 55% for 3-year mortality, clinically useful in identifying patients with intermediate-term survival.The study relied upon the combination of diagnosis codes and procedures codes to identify BCC cases.The CAN score has the potential to improve the quality of cancer care for veterans by providing clinicians with an estimate of life expectancy and facilitating conversations in cases where active surveillance can be considered.

    View details for DOI 10.1016/j.jaad.2023.09.029

    View details for PubMedID 37742837

  • Risk of Multiple Primary Cancers in Patients With Merkel Cell Carcinoma: A SEER-Based Analysis. JAMA dermatology Eid, E., Maloney, N. J., Cai, Z. R., Zaba, L. C., Kibbi, N., John, E. M., Linos, E. 2023


    The risk of subsequent primary cancers after a diagnosis of cutaneous Merkel cell carcinoma (MCC) is not well established.To evaluate the risk of subsequent primary cancers after the diagnosis of a first primary cutaneous MCC.This cohort study analyzed data from 17 registries of the Surveillance, Epidemiology, and End Results (SEER) Program from January 1, 2000, to December 31, 2019. In all, 6146 patients diagnosed with a first primary cutaneous MCC were identified.The primary outcome was the relative and absolute risks of subsequent primary cancers after the diagnosis of a first primary MCC, which were calculated using the standardized incidence ratio (SIR; ratio of observed to expected cases of subsequent cancer) and the excess risk (difference between observed and expected cases of subsequent cancer divided by the person-years at risk), respectively. Data were analyzed between January 1, 2000, and December 31, 2019.Of 6146 patients with a first primary MCC diagnosed at a median (IQR) age of 76 (66-83) years, 3713 (60.4%) were men, and the predominant race and ethnicity was non-Hispanic White (5491 individuals [89.3%]). Of these patients, 725 (11.8%) developed subsequent primary cancers, with an SIR of 1.28 (95% CI, 1.19-1.38) and excess risk of 57.25 per 10 000 person-years. For solid tumors after MCC, risk was elevated for cutaneous melanoma (SIR, 2.36 [95% CI, 1.85-2.97]; excess risk, 15.27 per 10 000 person-years) and papillary thyroid carcinoma (SIR, 5.26 [95% CI, 3.25-8.04]; excess risk, 6.16 per 10 000 person-years). For hematologic cancers after MCC, risk was increased for non-Hodgkin lymphoma (SIR, 2.62 [95% CI, 2.04-3.32]; excess risk, 15.48 per 10 000 person-years).This cohort study found that patients with MCC had an increased risk of subsequently developing solid and hematologic cancers. This increased risk may be associated with increased surveillance, treatment-related factors, or shared etiologies of the other cancers with MCC. Further studies exploring possible common etiological factors shared between MCC and other primary cancers are warranted.

    View details for DOI 10.1001/jamadermatol.2023.2849

    View details for PubMedID 37703005

  • A Social Media-Based Public Health Campaign to Reduce Indoor Tanning in High-Risk Populations. AJPM focus de Vere Hunt, I., Cai, Z. R., Nava, V., Admassu, N. E., Bousheri, S., Johnson, T., Tomz, A., Thompson, J., Zhang, L., Pagoto, S., Wehner, M. R., Mathur, M. B., Linos, E. 2023; 2 (3): None


    Indoor tanning beds cause more than 450,000 new skin cancers each year, yet their use remains common, with a global indoor tanning prevalence of 10.4%. Social media provides an opportunity for cost-effective, targeted public health messaging. We sought to direct Instagram users at high risk of indoor tanning to accurate health information about the risks of indoor tanning and to reduce indoor tanning bed use.We disseminated a public health campaign on Instagram on April 6-27, 2022 with 34 video and still-image advertisements. We had 2 target audiences at high risk of indoor tanning: women aged 18-30 years in Kentucky, Nebraska, Ohio, or Tennessee interested in indoor tanning and men aged 18-45 years in California interested in indoor tanning. To evaluate the impact of the campaign, we tracked online metrics, including website visits, and conducted an interrupted time-series analysis of foot traffic data in our target states for all tanning salons documented on SafeGraph from January 1, 2018 to 3 months after the campaign.Our indoor tanning health information advertisements appeared on Instagram feeds 9.1 million times, reaching 1.06 million individuals. We received 7,004 views of our indoor tanning health information landing page (Average Time on Page of 56 seconds). We did not identify a significant impact on foot traffic data on tanning salons.We show the successful use of social media advertising to direct high-risk groups to online health information about indoor tanning. Future research quantifying tanning visits before and after indoor tanning interventions is needed to guide future public health efforts.

    View details for DOI 10.1016/j.focus.2023.100123

    View details for PubMedID 37662553

    View details for PubMedCentralID PMC10465716

  • Prescribing Patterns for Acne in Transgender Compared to Cisgender Patients Zadu, A., van Egmond, S., Hunt, I., Linos, E., Petion, E., Yeung, H., Simard, J., Cai, Z. MOSBY-ELSEVIER. 2023: AB5
  • ''Racial and ethnic differences in prescribing patterns for Psoriasis: a survey of 525 US dermatologists'' Petion, E., van Egmond, S., Hunt, I., Zadu, A., Junko, T., Simard, J., Lester, J., Linos, E. MOSBY-ELSEVIER. 2023: AB7
  • Impact of COVID-19, cancer survivorship and patient-provider communication on mental health in the US Difference-In-Difference. Npj mental health research Kim, J., Linos, E., Dove, M. S., Hoch, J. S., Keegan, T. H. 2023; 2 (1): 14


    Poor mental health has been found to be more prevalent among those with cancer and is considered a public health crisis since COVID-19. This study assessed the impact of COVID-19 and cancer survivorship on mental health and investigated factors, including online patient-provider communications (OPPC; email/internet/tablet/smartphone), associated with poor mental health prior to and during the early COVID-19. Nationally representative Health Information National Trends Survey data during 2017-2020 (n = 15,871) was used. While the prevalence of poor mental health was high (40-42%), Difference-In-Difference analyses revealed that cancer survivorship and COVID-19 were not associated with poor mental health. However, individuals that used OPPC had 40% higher odds of poor mental health. Low socioeconomic status (low education/income), younger age (18-64 years), and female birth gender were also associated with poor mental health. Findings highlight the persistence of long-standing mental health inequities and identify that OPPC users might be those who need mental health support.

    View details for DOI 10.1038/s44184-023-00034-x

    View details for PubMedID 38609572

    View details for PubMedCentralID 2880195

  • Elevated Risk of Visceral Malignant Neoplasms in Extramammary Paget Disease. JAMA dermatology Maloney, N. J., Yao, H., Aasi, S. Z., John, E. M., Linos, E., Kibbi, N. 2023


    This cross-sectional study evaluates the incidence and types of cancers that develop years after an extramammary Paget disease (EMPD) diagnosis.

    View details for DOI 10.1001/jamadermatol.2023.2679

    View details for PubMedID 37647047

  • Leveraging large language models in dermatology. The British journal of dermatology Matin, R. N., Linos, E., Rajan, N. 2023

    View details for DOI 10.1093/bjd/ljad230

    View details for PubMedID 37410567

  • Insufficient Evidence for Screening Reinforces Need for Primary Prevention of Skin Cancer. JAMA internal medicine de Vere Hunt, I., Lester, J., Linos, E. 2023

    View details for DOI 10.1001/jamainternmed.2023.0927

    View details for PubMedID 37071418

  • Factors Associated with Online Patient-Provider Communications Among Cancer Survivors in the United States during COVID: A Cross-Sectional Study. JMIR cancer Kim, J., Linos, E., Fishman, D. A., Dove, M. S., Hoch, J. S., Keegan, T. H. 2023


    BACKGROUND: Online Patient-Provider Communication (OPPC) is crucial in enhancing access to health information, self-care, and related health outcomes among cancer survivors. The necessity of OPPC increased during SARS/COVID-19 (COVID), yet investigations in vulnerable subgroups have been limited.OBJECTIVE: Thus, this study aimed to assess the prevalence of OPPC and sociodemographic and clinical characteristics associated with OPPC among cancer survivors and adults without a history of cancer during COVID vs. pre-COVID.METHODS: Nationally representative cross-sectional survey data (Health Information National Trends Survey, HINTS 5 2017-2020) was used among cancer survivors (n= 1,900) and adults without a history of cancer (n= 13, 292). COVID included data from February to June 2020. We calculated the prevalence of three types of OPPC, defined as using email/internet, tablet/smartphone, or Electronic Health Records (EHR) for patient-provider communication, in the past 12 months. To investigate the associations of sociodemographic and clinical factors with OPPC, multivariable-adjusted weighted logistic regression was performed to obtain odds ratios (OR) and 95% confidence intervals (95% CI).RESULTS: The average prevalence of OPPC increased from pre-COVID to COVID among cancer survivors (39.7% vs. 49.7%, email/internet; 32.2% vs. 37.9%, tablet/smartphone; 19.0% vs. 30.0%, EHR). Cancer survivors (OR=1.32, 95% CI 1.06-1.63) were slightly more likely to use email/internet communications than adults without a history of cancer prior to COVID. Among cancer survivors, email/internet (OR=1.61, 1.08-2.40) and EHR (OR=1.92, 1.22-3.02) were more likely to be used during COVID than pre-COVID. During COVID, subgroups of cancer survivors, including Hispanics (OR=0.26, 0.09-0.71 vs. non-Hispanic Whites), or those with the lowest income (OR=6.14, 1.99-18.92 $50,000 to <$75,000; OR=0.42, 1.56-11.28 ≥ $75,000 vs. <$20,000), with no usual source of care (OR=6.17, 2.12-17.99), or reporting depression (OR=0.33, 0.14-0.78) were less likely to use email/internet and those who were the oldest (OR=9.33, 2.18-40.01 age 35-49; OR=3.58, 1.20-10.70 age 50-64; OR=3.09, 1.09-8.76 age 65-74 vs. ≥75), unmarried (OR=2.26, 1.06-4.86) or had public/no health insurance (ORs=0.19-0.21 Medicare, Medicaid, or Other, vs. private) were less likely to use tablet/smartphone to communicate with providers. Cancer survivors with a usual source of care (OR=6.23, 1.66-23.39) or healthcare office visits within a year (ORs=7.55-8.25) were significantly more likely to use EHR to communicate. While not observed in cancer survivors, lower education level was associated with lower OPPC among adults without a history of cancer during COVID.CONCLUSIONS: Our findings identified vulnerable subgroups of cancer survivors who were left behind in online patient-provider communications which are becoming an increasing part of healthcare. Those vulnerable subgroups of cancer survivors with lower OPPC should be helped through multidimensional interventions to prevent further inequities.CLINICALTRIAL: Not applicable.

    View details for DOI 10.2196/44339

    View details for PubMedID 37074951

  • Utilization of Indoor Tanning: A Cross-Sectional Mobile Device Data JOURNAL OF INVESTIGATIVE DERMATOLOGY Wehner, M. R., Li, Y., Sethi, A. A., Hinkston, C. L., Khalfe, N., Stender, C. F., Nowakowska, M. K., Cohen, O. G., Giordano, S. H., Linosa, E. 2023; 143 (5): 874-+
  • Sebaceous carcinoma epidemiology, associated malignancies and Lynch/Muir-Torre syndrome screening in England from 2008 to 2018. Journal of the American Academy of Dermatology Cook, S., Pethick, J., Kibbi, N., Hollestein, L., Lavelle, K., de Vere Hunt, I., Turnbull, C., Rous, B., Husain, A., Burn, J., Lüchtenborg, M., Santaniello, F., McRonald, F., Hardy, S., Linos, E., Venables, Z., Rajan, N. 2023


    Sebaceous carcinomas (SC) may be associated with the cancer predisposition syndrome Muir-Torre/Lynch syndrome (MTS/LS), identifiable by SC mismatch repair (MMR) screening, however there is limited data on MMR status of SC.To describe the epidemiology of SC, co-presentation of other cancers and population level frequency of MMR screening in SC.A population based retrospective cohort study of SC patients in the National Cancer Registration and Analysis Service in England.This study included 1077 SC cases (739 extraocular, 338 periocular). Age standardised incidence rates (ASR) were higher in males compared to females, 2.74 (95% CI 2.52-9.69) per 1,000,000 person years (PY) for males versus 1.47 PY (95% CI 1.4-1.62) for females. 19% (210/1077) of patients developed at least one MTS/LS associated malignancy. MMR immunohistochemical screening was performed in only 20% (220/1077) of SC tumors, of these 32% (70/219) of tumors were MMR deficient.Retrospective design.Incorporation of MMR screening into clinical practice guidelines for the management of SC will increase the opportunity for MTS/LS diagnoses, with implications for cancer surveillance, chemoprevention with aspirin and immunotherapy treatment targeted to MTS/LS cancers.

    View details for DOI 10.1016/j.jaad.2023.03.046

    View details for PubMedID 37031776

  • Patient Perspectives of Health System Barriers to Accessing Care for Hidradenitis Suppurativa: A Qualitative Study. JAMA dermatology Barnes, L. A., Shukla, N., Paul, M., de Vere Hunt, I., Halley, M. C., Linos, E., Naik, H. B. 2023


    Patient-perceived barriers to hidradenitis suppurativa (HS) care are poorly understood. Understanding health care barriers is a critical first step toward improving care for this population.To characterize the health care experiences of people living with HS, including perceived barriers and facilitators to health care access, and to elucidate potential associations among these barriers and facilitators, health care access, and disease activity.In this qualitative study, an inductive thematic analysis was conducted on 45 in-depth, 60- to 90-minute semistructured interviews of 45 people with HS from diverse sociodemographic backgrounds that took place between March and April 2020. Individuals were eligible if they could speak English, were 18 years or older, and were diagnosed with HS. A diagnosis of HS was confirmed through physician diagnosis or through self-reported, affirmative response to the validated screening question, "Do you experience boils in your armpits or groin that recur at least every six months?"Interviews were audio recorded and transcribed verbatim. A modified grounded theory approach was used to develop the codebook, which investigators used for inductive thematic analysis.Among the 45 participants included, the median (IQR) age was 37 (16) years, 33 (73%) were female, and 22 (49%) were White. There were 6 interrelated themes associated with participant-perceived barriers to accessing HS care: (1) bidirectional associations of disease activity and employment, (2) association of employment with health care coverage, (3) association of health care coverage with costs and perceived access to care, (4) association of costs with access to patient-centered care, (5) health care professional attitudes and knowledge influence patient-centered care and perceived access to care and disease activity, and (6) health system characteristics influence patient-centered care and associated costs, perceived access to care, and disease activity.This qualitative study highlights themes that generate a conceptual model for understanding barriers that may act synergistically to limit health care access and influence disease activity. The disease activity of HS may be reduced when cycle elements are optimized. This study also highlights areas for future investigations and potential systems-level changes to improve access to patient-centered HS care.

    View details for DOI 10.1001/jamadermatol.2023.0486

    View details for PubMedID 37017984

  • The perspectives of 606 US dermatologists on active surveillance for low-risk basal cell carcinoma. The British journal of dermatology van Egmond, S., de Vere Hunt, I., Cai, Z. R., Rizk, N., Wakkee, M., Chren, M., Goldfarb, N., Simard, J. F., Linos, E. 2023; 188 (1): 136-137

    View details for DOI 10.1093/bjd/ljac002

    View details for PubMedID 36689496

  • Qualitative exploration of melanoma awareness in black people in the USA. BMJ open de Vere Hunt, I., Owen, S., Amuzie, A., Nava, V., Tomz, A., Barnes, L., Robinson, J. K., Lester, J., Swetter, S., Linos, E. 2023; 13 (1): e066967


    Although black patients are more likely to have advanced melanomas at diagnosis, with a 5-year survival rate among black patients of 70% compared with 92% for white patients, black people are generally not the focus of melanoma public health campaigns. We sought to explore awareness and perspectives of melanoma among black people to inform the development of relevant and valued public health messages to promote early detection of melanoma.Inductive thematic analysis of in-depth semistructured interviews.Interviews were conducted with participants via video software or telephone in the USA.Participants were adults from the USA who self-identified as African American or black. Recruitment flyers were posted around the San Francisco Bay Area and shared on our team Facebook page, with further participants identified through snowball sampling.We interviewed 26 participants from 10 different states. Overall, 12 were men and 14 were women, with a mean age of 43 years (range 18-85). We identified five key themes regarding melanoma awareness in black people: (1) lack of understanding of term 'melanoma' and features of skin cancer; (2) do not feel at risk of melanoma skin cancer; (3) surprise that melanoma can occur on palms, soles and nails; (4) skin cancer awareness messages do not apply to or include black people; and (5) Importance of relationship with healthcare and habits of utilisation.Analysis of these in-depth semistructured interviews illuminate the pressing need for health information on melanoma designed specifically for black people. We highlight two key points for focused public health messaging: (1) melanoma skin cancer does occur in black people and (2) high-risk sites for melanoma in black people include the palms, soles and nail beds. Therefore, public health messages for black people and their healthcare providers may involve productively checking these body surface areas.

    View details for DOI 10.1136/bmjopen-2022-066967

    View details for PubMedID 36631232

    View details for PubMedCentralID PMC9835941

  • Formally comparing topic models and human-generated qualitative coding of physician mothers' experiences of workplace discrimination BIG DATA & SOCIETY Miner, A. S., Stewart, S. A., Halley, M. C., Nelson, L. K., Linos, E. 2023; 10 (1)
  • Social Media for Public Health: Framework for Social Media-Based Public Health Campaigns. Journal of medical Internet research de Vere Hunt, I., Linos, E. 2022; 24 (12): e42179


    The pervasiveness of social media is irrefutable, with 72% of adults reporting using at least one social media platform and an average daily usage of 2 hours. Social media has been shown to influence health-related behaviors, and it offers a powerful tool through which we can rapidly reach large segments of the population with tailored health messaging. However, despite increasing interest in using social media for dissemination of public health messaging and research exploring the dangers of misinformation on social media, the specifics of how public health practitioners can effectively use social media for health promotion are not well described. In this viewpoint, we propose a novel framework with the following 5 key principles to guide the use of social media for public health campaigns: (1) tailoring messages and targeting them to specific populations-this may include targeting messages to specific populations based on age, sex, or language spoken; interests; or geotargeting messages at state, city, or zip code level; (2) including members of the target population in message development-messages should be designed with and approved by members of the community they are designed to reach, to ensure cultural sensitivity and trust-building; (3) identifying and addressing misinformation-public health practitioners can directly address misinformation through myth-busting messages, in which false claims are highlighted and explained and accurate information reiterated; (4) leveraging information sharing-when designing messages for social media, it is crucial to consider their "shareability," and consider partnering with social media influencers who are trusted messengers among their online followers; and (5) evaluating impact by measuring real-world outcomes, for example measuring foot traffic data. Leveraging social media to deliver public health campaigns enables us to capitalize on sophisticated for-profit advertising techniques to disseminate tailored messaging directly to communities that need it most, with a precision far beyond the reaches of conventional mass media. We call for the Centers for Disease Control and Prevention as well as state and local public health agencies to continue to optimize and rigorously evaluate the use of social media for health promotion.

    View details for DOI 10.2196/42179

    View details for PubMedID 36515995

  • Diversity and Career Goals of Graduating Allopathic Medical Students Pursuing Careers in Dermatology. JAMA dermatology Gao, Y., Fulk, T., Mori, W., Ackerman, L., Gaddis, K., Farah, R., Lester, J., Linos, E., Peebles, J. K., Yeung, H., Mansh, M. D. 2022


    Importance: Dermatology is one of the least diverse specialties, while patients from minority racial and ethnic groups and other underserved populations continue to face numerous dermatology-specific health and health care access disparities in the US.Objectives: To examine the demographic characteristics and intended career goals of graduating US allopathic medical students pursuing careers in dermatology compared with those pursuing other specialties and whether these differ by sex, race and ethnicity, and/or sexual orientation.Design, Setting, and Participants: This secondary analysis of a repeated cross-sectional study included 58 077 graduating allopathic medical students using data from the 2016 to 2019 Association of American Medical Colleges Graduation Questionnaires.Main Outcomes and Measures: The proportion of female students, students from racial and ethnic groups underrepresented in medicine (URM), and sexual minority (SM) students pursuing dermatology vs pursuing other specialties. The proportions and multivariable-adjusted odds of intended career goals between students pursuing dermatology and those pursuing other specialties and by sex, race and ethnicity, and sexual orientation among students pursuing dermatology.Results: A total of 58 077 graduating students were included, with 28 489 (49.0%) female students, 8447 (14.5%) URM students, and 3641 (6.3%) SM students. Female students pursuing dermatology were less likely than female students pursuing other specialties to identify as URM (96 of 829 [11.6%] vs 4760 of 27 660 [17.2%]; P<.001) or SM (16 [1.9%] vs 1564 [5.7%]; P<.001). In multivariable-adjusted analyses, students pursuing dermatology compared with other specialties had decreased odds of intending to care for underserved populations (247 of 1350 [18.3%] vs 19 142 of 56 343 [34.0%]; adjusted odd ratio [aOR], 0.40; 95% CI, 0.35-0.47; P<.001), practice in underserved areas (172 [12.7%] vs 14 570 [25.9%]; aOR, 0.40; 95% CI, 0.34-0.47; P<.001), and practice public health (230 [17.0%] vs 17 028 [30.2%]; aOR, 0.44; 95% CI, 0.38-0.51; P<.001) but increased odds of pursuing research (874 [64.7%] vs 29 121 [51.7%]; aOR, 1.76; 95% CI, 1.57-1.97; P<.001) in their careers. Among students pursuing dermatology, female, URM, and SM identities were independently associated with increased odds of caring for underserved populations (eg, URM: aOR, 4.05; 95% CI, 2.83-5.80) and practicing public health (eg, SM: aOR, 2.55; 95% CI, 1.51-4.31). URM students compared with non-URM students pursuing dermatology had increased odds of intending to practice in underserved areas (aOR, 3.93; 95% CI, 2.66-5.80), and SM students compared with heterosexual students pursuing dermatology had increased odds of intending to become medical school faculty (aOR, 1.60; 95% CI, 1.01-2.57), to pursue administrative roles (aOR, 1.60; 95% CI, 1.01-2.59), and to conduct research (aOR, 1.73; 95% CI, 1.01-2.98).Conclusions and Relevance: The findings of this cross-sectional study suggest that diversity gaps continue to exist in the dermatology workforce pipeline. Efforts are needed to increase racial and ethnic and sexual orientation diversity and interest in careers focused on underserved care and public health among students pursuing dermatology.

    View details for DOI 10.1001/jamadermatol.2022.4984

    View details for PubMedID 36383363

  • Gender Differences in National Institutes of Health Grant Submissions Before and During the COVID-19 Pandemic. Journal of women's health (2002) Roubinov, D., Haack, L. M., Folk, J. B., Rotenstein, L., Accurso, E. C., Dahiya, P., Ponce, A. N., Nava, V., Maldonado, Y., Linos, E., Mangurian, C. 2022; 31 (9): 1241-1245


    Introduction: Emerging data suggest that the COVID-19 pandemic has disproportionately impacted women in academic medicine, potentially eliminating recent gains that have been made toward gender equity. This study examined possible pandemic-related gender disparities in research grant submissions, one of the most important criteria for academic promotion and tenure evaluations. Methods: Data were collected from two major academic institutions (one private and one public) on the gender and academic rank of faculty principal investigators who submitted new grants to the National Institutes of Health (NIH) during COVID-19 (March 1st, 2020, through August 31, 2020) compared with a matched period in 2019 (March 1st, 2019, through August 31, 2019). t-Tests and chi-square analyses compared the gender distribution of individuals who submitted grants during the two periods of examination. Results: In 2019 (prepandemic), there was no significant difference in the average number of grants submitted by women compared with men faculty. In contrast, women faculty submitted significantly fewer grants in 2020 (during the pandemic) than men. Men were also significantly more likely than women to submit grants in both 2019 and 2020 compared with submitting in 2019 only, suggesting men faculty may have been more likely than their women colleagues to sustain their productivity in grant submissions during the pandemic. Discussion: Women's loss of extramural funding may compound over time, as it impedes new data collection, research progress, and academic advancement. Efforts to support women's research productivity and career trajectories are urgently needed in the following years of pandemic recovery.

    View details for DOI 10.1089/jwh.2022.0182

    View details for PubMedID 36112424

  • Association between body lice infestation and decreased hemoglobin values Rudd, N., Zakaria, A., Kohn, M. A., Amerson, E. H., Fox, L. P., Linos, E., Chang, A. Y. MOSBY-ELSEVIER. 2022: AB143
  • Incidence Trends of Primary Cutaneous T-Cell Lymphoma in the US From 2000 to 2018: A SEER Population Data Analysis. JAMA oncology Cai, Z. R., Chen, M. L., Weinstock, M. A., Kim, Y. H., Novoa, R. A., Linos, E. 2022

    View details for DOI 10.1001/jamaoncol.2022.3236

    View details for PubMedID 36048455

  • A Cross-Sectional Analysis of The Environmental and Cost-Saving Benefits of Digital Dermatologic Care. Journal of the American Academy of Dermatology Gomez, J., Rizk, N., Linos, E., Ko, J. M., Bailey, E. E. 2022

    View details for DOI 10.1016/j.jaad.2022.08.033

    View details for PubMedID 36030984

  • Utilization of indoor tanning: A cross-sectional study using mobile device data Wehner, M., Li, Y., Sethi, A., Hinkston, C., Khalfe, N., Stender, C., Nowakowska, M. K., Cohen, O., Giordano, S., Linos, E. ELSEVIER SCIENCE INC. 2022: B9

    View details for Web of Science ID 000829693000039

    View details for PubMedID 36496197

  • A Social Media‒Based Public Health Campaign Encouraging COVID-19 Vaccination Across the United States. American journal of public health Hunt, I. d., Dunn, T., Mahoney, M., Chen, M., Nava, V., Linos, E. 2022: e1-e4


    Tailored public health messaging encouraging COVID-19 vaccination may help increase vaccination rates and decrease the burden of COVID-19. We conducted a three-part COVID-19 vaccine uptake public health campaign disseminated on Facebook between April and June 2021. Our first campaign focused on reaching Black and Latinx communities; our second campaign focused on addressing vaccine access and scheduling in Latinx communities; and our third campaign focused on religious communities. Overall, we reached 25 million individuals with 171 million views across the United States. (Am J Public Health. Published online ahead of print July 7, 2022:e1-e4.

    View details for DOI 10.2105/AJPH.2022.306934

    View details for PubMedID 35797502

  • Impact of Sexual Harassment and Social Support on Burnout in Physician Mothers. Journal of women's health (2002) Linos, E., Lasky-Fink, J., Halley, M., Sarkar, U., Mangurian, C., Sabry, H., Linos, E., Jagsi, R. 2022


    Background: Burnout affects >50% of physicians, especially women. This study aimed to examine how negative workplace interactions can predict burnout, and whether positive social interactions can mitigate risk. Materials and Methods: In a study of 1627 physician mothers who responded to a survey by the Physician Moms Group, an online Facebook group, we first examined the association between workplace sexual harassment and burnout. In an embedded experiment, we then measured the causal impact of priming perceived social support and connectedness on the three dimensions of employee burnout. Results: Two-thirds of respondents reported having experienced sexual harassment in the past year. Sexual harassment by patients was associated with 0.27 points higher emotional exhaustion, one dimension of burnout (95% confidence interval [CI] 0.12-0.41), equivalent to the predicted impact of an additional 22 weekly work hours on emotional exhaustion. Sexual harassment by patients was also associated with 0.40 points higher patient depersonalization, another dimension of burnout (95% CI 0.27-0.53). Sexual harassment by colleagues was associated with 0.16 points higher emotional exhaustion (95% CI 0.02-0.30), but not other dimensions of burnout. We found no significant relationship between experiences of sexual harassment and levels of personal accomplishment (the third dimension of burnout) among this sample. Priming physician mothers to reflect on their connectedness with other physician mothers significantly increased their sense of personal accomplishment. The priming intervention did not yield a significant effect on emotional exhaustion or depersonalization. Conclusions: Negative and positive social interactions each affect different dimensions of burnout. Sexual harassment-a pervasive type of negative social interaction-strongly predicts emotional exhaustion and depersonalization. Reflecting on social connectedness-a type of positive social interaction-can improve one's sense of personal accomplishment with an effect similar in magnitude to more intensive in-person interventions, suggesting that social connectedness through online groups merits further consideration as a tool to mitigate burnout.

    View details for DOI 10.1089/jwh.2021.0487

    View details for PubMedID 35730998

  • United States Academic Dermatologists' Attitudes Towards Active Surveillance for Basal Cell Carcinoma. The British journal of dermatology Han, J., O'Neal, S., Gravely, A., Linos, E., Goldfarb, N. 2022

    View details for DOI 10.1111/bjd.21675

    View details for PubMedID 35612397

  • In reply: Counterpoint: Limited life expectancy, basal cell carcinoma, health care today, and unintended consequences. Journal of the American Academy of Dermatology Linos, E., Berger, T., Chren, M. 2022; 86 (5): e203

    View details for DOI 10.1016/j.jaad.2015.10.052

    View details for PubMedID 35430052

  • Association of Body Lice Infestation With Hemoglobin Values in Hospitalized Dermatology Patients. JAMA dermatology Rudd, N., Zakaria, A., Kohn, M. A., Amerson, E. H., Fox, L. P., Linos, E., Chang, A. Y. 2022

    View details for DOI 10.1001/jamadermatol.2022.0818

    View details for PubMedID 35442410

  • Patients' attitudes towards active surveillance for basal cell carcinoma. The British journal of dermatology Han, J., O'Neal, S., Gravely, A., Gupta, R., Linos, E., Goldfarb, N. 2022

    View details for DOI 10.1111/bjd.21058

    View details for PubMedID 35167121

  • A qualitative exploration of the experiences of itch for adults living with epidermolysis bullosa. The British journal of dermatology de Vere Hunt, I., Halley, M., Sum, K., Yekrang, K., Phung, M., Good, J., Linos, E., Chiou, A. S. 1800

    View details for DOI 10.1111/bjd.21031

    View details for PubMedID 35092694

  • Fertility Benefits at Top U.S. Medical Schools. Journal of women's health (2002) Hoang, K., Evans, N., Aghajanova, L., Talib, H., Linos, E., Gold, J. M. 1800


    Background: Female physicians have a higher prevalence of infertility compared with the general population. Physician well-being can be significantly impacted by the physical and emotional challenges associated with this, including the high cost of fertility treatments, which are often not covered by health insurance. There are limited data on the current state of fertility coverage available for physicians. This study examines fertility insurance benefits offered for faculty at top U.S. medical schools. Methods: Between March and April 2021, we reviewed fertility benefits at medical schools ranked in the top 14 for research as identified by the US News & World Report 2021. The summary plan descriptions of benefits were collected from each institution's human resources (HR) website and direct phone call to HR representatives. We examined descriptions of coverage for fertility services including evaluation, treatments, medications, maximum lifetime coverage, and whether a formal diagnosis of infertility was required for benefit eligibility. Results: Fourteen institutions offer benefits for fertility evaluation and 13 offer benefits for treatment. Of the 13 institutions that offer treatment coverage, 11 cover in vitro fertilization, with 6 having limits on the number of cycles. Twelve offer medication coverage. Ten institutions specified maximum lifetime coverage for treatments and medications, ranging from $10,000 to $100,000. Only 1 school provided coverage for elective fertility preservation, and none covered surrogacy expenses. Half of the schools are in states where fertility benefits are mandated. Conclusion: There is wide variation in fertility benefits offered at top medical schools across the country. Many schools offered coverage for fertility evaluation and treatments; however, majority had restrictions and limitations to the benefits, suggesting that there is still inadequate coverage provided. This study's selected sample also does not reflect other medical schools across the country, which may not be as well-resourced in their provision of fertility benefits.

    View details for DOI 10.1089/jwh.2021.0486

    View details for PubMedID 35041526

  • Differences in Thickness-Specific Incidence and Factors Associated With Cutaneous Melanoma in the US From 2010 to 2018. JAMA oncology Chen, M. L., de Vere Hunt, I. J., John, E. M., Weinstock, M. A., Swetter, S. M., Linos, E. 2022


    The recent incidence of cutaneous melanoma of different thicknesses in the US is not well described.To evaluate recent patterns in the incidence of melanoma by tumor thickness and examine associations of sex, race and ethnicity, and socioeconomic status with melanoma thickness-specific incidence.This population-based cohort study analyzed data for 187 487 patients with a new diagnosis of invasive cutaneous melanoma from the Surveillance, Epidemiology, and End Results Registry from January 1, 2010, to December 31, 2018. The study was conducted from May 27 to December 29, 2021. Data were analyzed from June 21 to October 24, 2021.Age-adjusted incidence rates of melanoma were calculated by tumor thickness (categorized by Breslow thickness) and annual percentage change (APC) in incidence rates. Analyses were stratified by sex and race and ethnicity. The associations with socioeconomic status were evaluated in 134 359 patients diagnosed with melanoma from 2010 to 2016.This study included 187 487 patients with a median (IQR) age of 62 (52-72) years and 58.4% men. Melanoma incidence was higher in men compared with women across all tumor thickness groups. Individuals in lower socioeconomic status quintiles and members of minority groups were more likely to be diagnosed with thicker (T4) tumors (20.7% [169 of 816] among non-Hispanic Black patients, 11.2% [674 of 6042] among Hispanic patients, and 6.3% [10 774 of 170 155] among non-Hispanic White patients). Between 2010 and 2018, there was no significant increase in incidence of cutaneous melanoma across the full population (APC, 0.39%; 95% CI, -0.40% to 1.18%). The incidence of the thickest melanomas (T4, >4.0 mm) increased between 2010 and 2018, with an APC of 3.32% (95% CI, 2.06%-4.60%) overall, 2.50% (95% CI, 1.27%-3.73%) in men, and 4.64% (95% CI, 2.56%-6.75%) in women.In this population-based cohort study, the incidence of the thickest cutaneous melanoma tumors increased from 2010 to 2018, in contrast with the incidence patterns for thinner melanomas. The findings suggest potential stabilization of overall melanoma incidence rates in the US after nearly a century of continuous increase in incidence. Patients with low socioeconomic status and Hispanic patients were more likely to be diagnosed with thick melanoma. The continued rise in incidence of thick melanoma is unlikely to be attributable to overdiagnosis given the stability of thin melanoma rates.

    View details for DOI 10.1001/jamaoncol.2022.0134

    View details for PubMedID 35323844

  • Skin cancer in skin of color: A cross- sectional study investigating gaps in prevention campaigns on social media JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Grewal, S. K., Reddy, V., Tomz, A., Lester, J., Linos, E., Lee, P. K. 2021; 85 (5): 1311-1313
  • Sexual Orientation Diversity and Specialty Choice Among Graduating Allopathic Medical Students in the United States. JAMA network open Mori, W. S., Gao, Y., Linos, E., Lunn, M. R., Obedin-Maliver, J., Yeung, H., Mansh, M. D. 2021; 4 (9): e2126983

    View details for DOI 10.1001/jamanetworkopen.2021.26983

    View details for PubMedID 34591110

  • Quality and engagement of online hidradenitis suppurativa information. International journal of women's dermatology Shukla, N. R., Jia, J. L., Paul, M., Kaghazchi, A., Linos, E., Naik, H. B. 2021; 7 (4): 490-491

    View details for DOI 10.1016/j.ijwd.2021.02.005

    View details for PubMedID 34621966

  • Barriers and facilitators to mobile health and active surveillance use among older adults with skin disease. Health expectations : an international journal of public participation in health care and health policy Johnson, A., Shukla, N., Halley, M., Nava, V., Budaraju, J., Zhang, L., Linos, E. 2021


    BACKGROUND: The COVID-19 pandemic has accelerated the adoption of telemedicine, including teledermatology. Monitoring skin lesions using teledermatology may become increasingly important for several skin diseases, including low-risk skin cancers. The purpose of this study was to describe the key factors that could serve as barriers or facilitators to skin disease monitoring using mobile health technology (mHealth) in older adults.METHODS: Older adult dermatology patients 65years or older and their caregivers who have seen a dermatologist in the last 18months were interviewed and surveyed between December 2019 and July 2020. The purpose of these interviews was to better understand attitudes, beliefs and behaviours that could serve as barriers and facilitators to the use of mHealth and active surveillance to monitor low-risk skin cancers.RESULTS: A total of 33 interviews leading to 6022 unique excerpts yielded 8 factors, or themes, that could serve as barriers, facilitators or both to mHealth and active surveillance. We propose an integrated conceptual framework that highlights the interaction of these themes at both the patient and provider level, including care environment, support systems and personal values.DISCUSSION AND CONCLUSIONS: These preliminary findings reveal factors influencing patient acceptance of active surveillance in dermatology, such as changes to the patient-provider interaction and alignment with personal values. These factors were also found to influence adoption of mHealth interventions. Given such overlap, it is essential to address barriers and facilitators from both domains when designing a new dermatology active surveillance approach with novel mHealth technology.PATIENT OR PUBLIC CONTRIBUTION: The patients included in this study were participants during the data collection process. Members of the Stanford Healthcare and Denver Tech Dermatology health-care teams aided in the recruitment phase of the data collection process.

    View details for DOI 10.1111/hex.13229

    View details for PubMedID 34190397

  • American Board of Medical Specialties Board Examination Lactation Accommodation Policies. JAMA internal medicine Nead, K. T., Hinkston, C. L., Linos, E., Giordano, S. H., Wehner, M. R. 2021

    View details for DOI 10.1001/jamainternmed.2021.2536

    View details for PubMedID 34180945

  • Active Surveillance as a Management Option for Low-risk Basal Cell Carcinoma. JAMA internal medicine Linos, E., Chren, M. 2021

    View details for DOI 10.1001/jamainternmed.2021.2643

    View details for PubMedID 34125141

  • Age-Related Differences in Experiences with Social Distancing at the Onset of the COVID-19 Pandemic: A Computational and Content Analytic Investigation of Natural Language. JMIR human factors Moore, R. C., Lee, A. Y., Hancock, J. T., Halley, M. C., Linos, E. 2021


    BACKGROUND: As COVID-19 poses different levels of threat to people of different ages, health communication regarding prevention measures such as social distancing and isolation may be strengthened by understanding the unique experiences of different age groups.OBJECTIVE: The aim was to examine how people of different ages (1) experienced the impact of the COVID-19 pandemic and (2) their respective rates and reasons for compliance or non-compliance with social distancing and isolation health guidance.METHODS: We fielded a survey on social media (N = 17,287) early in the pandemic to examine the emotional impact of COVID-19 and individuals' rates and reasons for non-compliance with public health guidance, using computational and content analytic methods of linguistic analysis. The majority of our participants (76.5%) were from the United States.RESULTS: Younger (18-31), middle-aged (32-44, 45-64), and older (65+) individuals significantly varied in how they described the impact of COVID-19 on their lives, including their emotional experience, self-focused attention, and topical concerns. Younger individuals were more emotionally negative and self-focused, while middle-aged people were other-focused and concerned with family. The oldest and most at-risk group was most concerned with health-related terms but were also lower in anxiety and higher in the use of emotionally positive terms than the other, less at-risk age groups. While all groups discussed topics such as acquiring essential supplies, they differentially experienced the impact of school closures and limited social interactions. We also found relatively high rates of non-compliance with COVID-19 prevention measures, such as social distancing and self-isolation, with younger people being more likely to be non-compliant than older people, (P < .001). Among the 43% of respondents who did not fully comply with health orders, people differed substantially in the reasons they gave for non-compliance. The most common reason for non-compliance was not being able to afford missing work (57.3%). While work obligations proved challenging for participants across ages, younger people struggled more to find adequate space to self-isolate and manage their mental and physical health; middle-aged people faced more concerns regarding childcare; and older people perceived themselves as able to take sufficient precautions.CONCLUSIONS: Analysis of natural language can provide insight into rapidly developing public health challenges like the COVID-19 pandemic, uncovering individual differences in emotional experiences and health-related behaviors. In this case, our analyses revealed significant differences between different age groups in feelings about and responses to public health orders aimed to mitigate the spread of COVID-19. To improve public compliance with health orders as the pandemic continues, health communication strategies could be made more effective by being tailored to these age-related differences.CLINICALTRIAL:

    View details for DOI 10.2196/26043

    View details for PubMedID 33914689

  • Integrating Skin of Color and Sexual and Gender Minority Content in Dermatology Residency Curricula: A Prospective Program Initiative. Journal of the American Academy of Dermatology Jia, J. L., Gordon, J. S., Lester, J. C., Linos, E., Nord, K. M., Bailey, E. E. 2021

    View details for DOI 10.1016/j.jaad.2021.04.018

    View details for PubMedID 33872717

  • The Impact of the first COVID-19 shelter-in-place announcement on social distancing, difficulty in daily activities, and levels of concern in the San Francisco Bay Area: A cross-sectional social media survey. PloS one Elser, H. n., Kiang, M. V., John, E. M., Simard, J. F., Bondy, M. n., Nelson, L. M., Chen, W. T., Linos, E. n. 2021; 16 (1): e0244819


    The U.S. has experienced an unprecedented number of orders to shelter in place throughout the ongoing COVID-19 pandemic. We aimed to ascertain whether social distancing; difficulty with daily activities; and levels of concern regarding COVID-19 changed after the March 16, 2020 announcement of the nation's first shelter-in-place orders (SIPO) among individuals living in the seven affected counties in the San Francisco Bay Area.We conducted an online, cross-sectional social media survey from March 14 -April 1, 2020. We measured changes in social distancing behavior; experienced difficulties with daily activities (i.e., access to healthcare, childcare, obtaining essential food and medications); and level of concern regarding COVID-19 after the March 16 shelter-in-place announcement in the San Francisco Bay Area versus elsewhere in the U.S.In this non-representative sample, the percentage of respondents social distancing all of the time increased following the shelter-in-place announcement in the Bay Area (9.2%, 95% CI: 6.6, 11.9) and elsewhere in the U.S. (3.4%, 95% CI: 2.0, 5.0). Respondents also reported increased difficulty obtaining hand sanitizer, medications, and in particular respondents reported increased difficulty obtaining food in the Bay Area (13.3%, 95% CI: 10.4, 16.3) and elsewhere (8.2%, 95% CI: 6.6, 9.7). We found limited evidence that level of concern regarding the COVID-19 crisis changed following the announcement.This study characterizes early changes in attitudes, behaviors, and difficulties. As states and localities implement, rollback, and reinstate shelter-in-place orders, ongoing efforts to more fully examine the social, economic, and health impacts of COVID-19, especially among vulnerable populations, are urgently needed.

    View details for DOI 10.1371/journal.pone.0244819

    View details for PubMedID 33444363

  • Identifying Silver Linings During the Pandemic Through Natural Language Processing. Frontiers in psychology Lossio-Ventura, J. A., Lee, A. Y., Hancock, J. T., Linos, N., Linos, E. 2021; 12: 712111


    COVID-19 has presented an unprecedented challenge to human welfare. Indeed, we have witnessed people experiencing a rise of depression, acute stress disorder, and worsening levels of subclinical psychological distress. Finding ways to support individuals' mental health has been particularly difficult during this pandemic. An opportunity for intervention to protect individuals' health & well-being is to identify the existing sources of consolation and hope that have helped people persevere through the early days of the pandemic. In this paper, we identified positive aspects, or "silver linings," that people experienced during the COVID-19 crisis using computational natural language processing methods and qualitative thematic content analysis. These silver linings revealed sources of strength that included finding a sense of community, closeness, gratitude, and a belief that the pandemic may spur positive social change. People's abilities to engage in benefit-finding and leverage protective factors can be bolstered and reinforced by public health policy to improve society's resilience to the distress of this pandemic and potential future health crises.

    View details for DOI 10.3389/fpsyg.2021.712111

    View details for PubMedID 34539512

  • The Intersection of Work and Home Challenges Faced by Physician Mothers During the Coronavirus Disease 2019 Pandemic: A Mixed-Methods Analysis. Journal of women's health (2002) Halley, M. C., Mathews, K. S., Diamond, L. C., Linos, E. n., Sarkar, U. n., Mangurian, C. n., Sabry, H. n., Goyal, M. K., Olazo, K. n., Miller, E. G., Jagsi, R. n., Linos, E. n. 2021


    Objectives: The coronavirus disease 2019 (COVID-19) pandemic has presented extreme challenges for health care workers. This study sought to characterize challenges faced by physician mothers, compare differences in challenges by home and work characteristics, and elicit specific needs and potential solutions. Methods: We conducted a mixed-methods online survey of the Physician Moms Group (PMG) and PMG COVID19 Subgroup on Facebook from April 18th to 29th, 2020. We collected structured data on personal and professional characteristics and qualitative data on home and work concerns. We analyzed qualitative data thematically and used bivariate analyses to evaluate variation in themes by frontline status and children's ages. Results: We included 1,806 participants in analysis and identified 10 key themes. The most frequently identified need/solution was for Community and Government Support (n = 545, 47.1%). When comparing frontline and nonfrontline physicians, those on the frontline more frequently raised concerns about Personal Health and Safety (67.8% vs. 48.4%, p < 0.001), Organizational Communication and Relationships (31.8% vs. 23.8%, p < 0.001), and Family Health and Safety (27.2 vs. 16.6, p < 0.001), while nonfrontline physicians more frequently addressed Patient Care and Safety (56.4% vs. 48.2%, p < 0.001) and Financial/Job Security (33.8% vs. 46.9%, p < 0.001). Participants with an elementary school-aged child more frequently raised concerns about Parenting/Homeschooling (44.0% vs. 31.1%, p < 0.001) and Work/Life Balance (28.4 vs. 13.7, p < 0.001), and participants with a preschool-aged child more frequently addressed Access to Childcare (24.0 vs. 7.7, p < 0.001) and Spouse/Partner Relationships (15.8 vs. 9.5, p < 0.001), when compared to those without children in these age groups. Conclusions: The physician workforce is not homogenous. Health care and government leaders need to understand these diverse challenges in order to meet physicians' professional and family needs during the pandemic.

    View details for DOI 10.1089/jwh.2020.8964

    View details for PubMedID 33761277

  • Anxiety Levels Among Physician Mothers During the COVID-19 Pandemic. The American journal of psychiatry Linos, E., Halley, M. C., Sarkar, U., Mangurian, C., Sabry, H., Olazo, K., Mathews, K. S., Diamond, L., Goyal, M. K., Linos, E., Jagsi, R. 2021; 178 (2): 203–4

    View details for DOI 10.1176/appi.ajp.2020.20071014

    View details for PubMedID 33517747

  • DYVIC: DYnamic VIrus Control in Peru. Proceedings. IEEE International Conference on Bioinformatics and Biomedicine Lossio-Ventura, J. A., Alatrista-Salas, H., Barrena, K., Linos, E., Nunez-Del-Prado, M., Talavera, A. 2020; 2020: 2264-2267


    The COVID-19 crisis has produced worldwide changes from people's lifestyles to travel restrictions imposed by world's nations aiming to keep the virus out. Several countries have created digital information applications to help control and manage the COVID-19 crisis, such as the creation of contact tracing apps. The Peruvian government in collaboration with several institutions developed PerúEnTusManos, an epidemiological tracing application. The application uses georeferencing to study users' movements and creates individual mobility patterns from the Peruvian citizens as well as detects crowds. In this article, we present a process to detect possible infected individuals based on probabilities assigned to people that had contact with someone who tested positive for COVID-19, using data collected from PerúEnTusManos. The preliminary evaluation shows promising results when detecting probabilities of possible infected individuals as well as the most infected districts in Peru. The ultimate goal of the application in Peru is to provide reliable information to health authorities to make informed decisions about the assignations of the available clinical tests and the economic re-activation.

    View details for DOI 10.1109/BIBM49941.2020.9313419

    View details for PubMedID 35462884

    View details for PubMedCentralID PMC9028679

  • Financial burden of epidermolysis bullosa on patients in the United States. Pediatric dermatology Gorell, E. S., Wolstencroft, P. W., de Souza, M. P., Murrell, D. F., Linos, E., Tang, J. Y. 2020


    Individuals with epidermolysis bullosa (EB), a group of genodermatoses with skin fragility, often require specialized and expensive bandaging. We analyzed the results from an online survey of 249 EB patients and caregivers living in the United States to investigate the financial impact of EB. Of respondents with severe EB subtypes (recessive dystrophic and junctional), 73% reported a major or moderate financial impact and 26% spent greater than $1000 per month on wound care supplies. These results demonstrate the high financial burden associated with epidermolysis bullosa in the United States and support the need for a federally funded EB bandage program.

    View details for DOI 10.1111/pde.14340

    View details for PubMedID 32897588

  • Skin Cancer in Skin of Color: A Cross-Sectional Study Investigating Gaps in Prevention Campaigns on Social Media. Journal of the American Academy of Dermatology Grewal, S. K., Reddy, V., Tomz, A., Lester, J., Linos, E., Lee, P. K. 2020

    View details for DOI 10.1016/j.jaad.2020.08.121

    View details for PubMedID 32891777

  • Sexual harassment and suicide. BMJ (Clinical research ed.) Sarkar, U., Hemmat, S., Linos, E. 2020; 370: m3330

    View details for DOI 10.1136/bmj.m3330

    View details for PubMedID 32878861

  • Statement on Racial Equality. The Journal of investigative dermatology Glass, D., Gonzalez, G. R., Horsley, V., Linos, E. 2020; 140 (8): 1485

    View details for DOI 10.1016/j.jid.2020.06.009

    View details for PubMedID 32709273

  • Sexual and Gender Minority Curricula Within US Dermatology Residency Programs. JAMA dermatology Jia, J. L., Nord, K. M., Sarin, K. Y., Linos, E., Bailey, E. E. 2020

    View details for DOI 10.1001/jamadermatol.2020.0113

    View details for PubMedID 32186684

  • Sex Differences in Salaries of Department Chairs at Public Medical Schools. JAMA internal medicine Mensah, M., Beeler, W., Rotenstein, L., Jagsi, R., Spetz, J., Linos, E., Mangurian, C. 2020

    View details for DOI 10.1001/jamainternmed.2019.7540

    View details for PubMedID 32119059

  • Assessment of Paid Childbearing and Family Leave Policies for Administrative Staff at Top US Medical Schools. JAMA internal medicine Vance, M. C., Riano, N. S., Jagsi, R., Guzman, M. J., Beeler, W., Linos, E., Mangurian, C. 2020

    View details for DOI 10.1001/jamainternmed.2019.6653

    View details for PubMedID 31961376

  • Association between financial links to indoor tanning industry and conclusions of published studies on indoor tanning: systematic review. BMJ (Clinical research ed.) Adekunle, L., Chen, R., Morrison, L., Halley, M., Eng, V., Hendlin, Y., Wehner, M. R., Chren, M., Linos, E. 2020; 368: m7


    OBJECTIVE: To assess whether an association exists between financial links to the indoor tanning industry and conclusions of indoor tanning literature.DESIGN: Systematic review.DATA SOURCES: PubMed, Embase, and Web of Science, up to 15 February 2019.STUDY SELECTION CRITERIA: Articles discussing indoor tanning and health were eligible for inclusion, with no article type restrictions (original research, systematic reviews, review articles, case reports, editorials, commentaries, and letters were all eligible). Basic science studies, articles describing only indoor tanning prevalence, non-English articles, and articles without full text available were excluded.RESULTS: 691 articles were included in analysis, including empiric articles (eg, original articles or systematic reviews) (357/691; 51.7%) and non-empiric articles letters (eg, commentaries, letters, or editorials) (334/691; 48.3%). Overall, 7.2% (50/691) of articles had financial links to the indoor tanning industry; 10.7% (74/691) articles favored indoor tanning, 3.9% (27/691) were neutral, and 85.4% (590/691) were critical of indoor tanning. Among the articles without industry funding, 4.4% (27/620) favored indoor tanning, 3.5% (22/620) were neutral, and 92.1% (571/620) were critical of indoor tanning. Among the articles with financial links to the indoor tanning industry, 78% (39/50) favored indoor tanning, 10% (5/50) were neutral, and 12% (6/50) were critical of indoor tanning. Support from the indoor tanning industry was significantly associated with favoring indoor tanning (risk ratio 14.3, 95% confidence interval 10.0 to 20.4).CONCLUSIONS: Although most articles in the indoor tanning literature are independent of industry funding, articles with financial links to the indoor tanning industry are more likely to favor indoor tanning. Public health practitioners and researchers need to be aware of and account for industry funding when interpreting the evidence related to indoor tanning.SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019123617.

    View details for DOI 10.1136/bmj.m7

    View details for PubMedID 32019742

  • DYVIC: DYnamic VIrus Control in Peru Lossio-Ventura, J., Alarista-Salas, H., Barrena, K., Linos, E., Nunez-del-Prado, M., Talavera, A., Park, T., Cho, Y. R., Hu, Yoo, Woo, H. G., Wang, J., Facelli, J., Nam, S., Kang, M. IEEE COMPUTER SOC. 2020: 2264-2267
  • US Public Concerns About the COVID-19 Pandemic From Results of a Survey Given via Social Media. JAMA internal medicine Nelson, L. M., Simard, J. F., Oluyomi, A. n., Nava, V. n., Rosas, L. G., Bondy, M. n., Linos, E. n. 2020

    View details for DOI 10.1001/jamainternmed.2020.1369

    View details for PubMedID 32259192

  • Development of a patient decision aid for the management of superficial basal cell carcinoma (BCC) in adults with a limited life expectancy. BMC medical informatics and decision making Junn, A. n., Shukla, N. R., Morrison, L. n., Halley, M. n., Chren, M. M., Walter, L. C., Frosch, D. L., Matlock, D. n., Torres, J. S., Linos, E. n. 2020; 20 (1): 81


    Basal cell carcinoma (BCC) is a slow-growing, rarely lethal skin cancer that affects people 65 years or older. A range of treatment options exist for BCC, but there is little evidence available to guide patients and providers in selecting the best treatment options.This study outlines the development of a patient decision aid (PDA) for low-risk BCC that can be used by patients and providers to assist in shared decision-making.In accordance with the International Patient Decision Aids Standards (IPDAS) Collaboration framework, feedback from focus groups and semi-structured interviews with patients and providers, an initial prototype of the PDA was developed. This was tested using cognitive interviews and iteratively updated.We created eighteen different iterations using feedback from 24 patients and 34 providers. The key issues identified included: 1) Addressing fear of cancer; 2) Communicating risk and uncertainty; 3) Values clarification; and 4) Time lag to benefit.The PDA does not include all possible treatment options and is currently paper based.Our PDA has been specifically adapted and designed to support patients with a limited life expectancy in making decisions about their low risk BCC together with their doctors.

    View details for DOI 10.1186/s12911-020-1081-8

    View details for PubMedID 32349762

  • Cutaneous Manifestations of COVID-19: A Preliminary Review. Journal of the American Academy of Dermatology Jia, J. L., Kamceva, M. n., Rao, S. A., Linos, E. n. 2020

    View details for DOI 10.1016/j.jaad.2020.05.059

    View details for PubMedID 32422225

  • Social media recruitment for mental health research: A systematic review. Comprehensive psychiatry Sanchez, C. n., Grzenda, A. n., Varias, A. n., Widge, A. S., Carpenter, L. L., McDonald, W. M., Nemeroff, C. B., Kalin, N. H., Martin, G. n., Tohen, M. n., Filippou-Frye, M. n., Ramsey, D. n., Linos, E. n., Mangurian, C. n., Rodriguez, C. I. 2020; 103: 152197


    Social media holds exciting promise for advancing mental health research recruitment, however, the extent and efficacy to which these platforms are currently in use are underexplored.A systematic review was conducted to characterize the current use and efficacy of social media in recruiting participants for mental health research.A literature review was performed using MEDLINE, EMBASE, and PsychINFO. Only non-duplicative manuscripts written in the English language and published between 1/1/2004-3/31/2019 were selected for further screening. Data extracted included study type and design, participant inclusion criteria, social media platform, advertising strategy, final recruited sample size, recruitment location, year, monetary incentives, comparison to other recruitment methods if performed, and final cost per participant.A total of 176 unique studies that used social media for mental health research recruitment were reviewed. The majority of studies were cross-sectional (62.5%) in design and recruited adults. Facebook was overwhelmingly the recruitment platform of choice (92.6%), with the use of paid advertisements being the predominant strategy (60.8%). Of the reviewed studies, substance abuse (43.8%) and mood disorders (15.3%) were the primary subjects of investigation. In 68.3% of studies, social media recruitment performed as well as or better than traditional recruitment methods in the number and cost of final enrolled participants. The majority of studies used Facebook for recruitment at a median cost per final recruited study participant of $19.47. In 55.6% of the studies, social media recruitment was the more cost-effective recruitment method when compared to traditional methods (e.g., referrals, mailing).Social media appears to be an effective and economical recruitment tool for mental health research. The platform raises methodological and privacy concerns not covered in current research regulations that warrant additional consideration.

    View details for DOI 10.1016/j.comppsych.2020.152197

    View details for PubMedID 32992073

  • Implications of the COVID-19 San Francisco Bay Area Shelter-in-Place Announcement: A Cross-Sectional Social Media Survey. medRxiv : the preprint server for health sciences Elser, H. n., Kiang, M. V., John, E. M., Simard, J. F., Bondy, M. n., Nelson, L. M., Chen, W. T., Linos, E. n. 2020


    The U.S. has experienced an unprecedented number of shelter-in-place orders throughout the COVID-19 pandemic. There is limited empirical research that examines the impact of these orders. We aimed to rapidly ascertain whether social distancing; difficulty with daily activities (obtaining food, essential medications and childcare); and levels of concern regarding COVID-19 changed after the March 16, 2020 announcement of shelter-in-place orders for seven counties in the San Francisco Bay Area.We conducted an online, cross-sectional social media survey from March 14 - April 1, 2020. We measured changes in social distancing behavior; experienced difficulties with daily activities (i.e., access to healthcare, childcare, obtaining essential food and medications); and level of concern regarding COVID-19 after the March 16 shelter-in-place announcement in the San Francisco Bay Area and elsewhere in the U.S.The percentage of respondents social distancing all of the time increased following the shelter-in-place announcement in the Bay Area (9.2%, 95% CI: 6.6, 11.9) and elsewhere in the U.S. (3.4%, 95% CI: 2.0, 5.0). Respondents also reported increased difficulty with obtaining food, hand sanitizer, and medications, particularly with obtaining food for both respondents from the Bay Area (13.3%, 95% CI: 10.4, 16.3) and elsewhere (8.2%, 95% CI: 6.6, 9.7). We found limited evidence that level of concern regarding the COVID-19 crisis changed following the shelter-in-place announcement.These results capture early changes in attitudes, behaviors, and difficulties. Further research that specifically examines social, economic, and health impacts of COVID-19, especially among vulnerable populations, is urgently needed. =.

    View details for DOI 10.1101/2020.06.29.20143156

    View details for PubMedID 32637974

    View details for PubMedCentralID PMC7340200

  • Hidradenitis suppurativa encounters in a national electronic health record database notable for low dermatology utilization, infrequent biologic prescriptions, and frequent opiate prescriptions. Journal of the American Academy of Dermatology Wehner, M. R., Micheletti, R., Noe, M. H., Linos, E., Margolis, D. J., Naik, H. B. 2019

    View details for DOI 10.1016/j.jaad.2019.12.030

    View details for PubMedID 31866261

  • The Use of Social Media in Recruiting Participants for Mental Health Research Purposes: A Systematic Review and Recommendations Rodriguez, C., Sanchez, C., Grzenda, A., Varias, A., Carpenter, L., Widge, A., McDonald, W., Tohen, M., Nemeroff, C., Kalin, N., Martin, G., Filippou-Frye, M., Ramsey, D., Linos, E., Mangurian, C. NATURE PUBLISHING GROUP. 2019: 269
  • No aloha for sunscreen - An analysis of the risks-benefits balance of sunscreen on human health and the environment Galamgam, J., Chen, R., Morrison, L., Linou, N., Linos, E. MOSBY-ELSEVIER. 2019: AB246
  • High Prevalence of Peripartum Depression Among Physician Mothers: A Cross-Sectional Study. The American journal of psychiatry Choo, E. K., Girgis, C., Han, C. S., Simard, J. F., Adesoye, T., Linos, E., Mangurian, C., Physician Moms Group Study Group 2019; 176 (9): 763–64

    View details for DOI 10.1176/appi.ajp.2019.18121350

    View details for PubMedID 31474130

  • Gender equity improving among award winners and leaders at the Society for Investigative Dermatology. The Journal of investigative dermatology Shukla, N., Wehner, M. R., Morrison, L., Naik, H. B., Linos, E. 2019

    View details for DOI 10.1016/j.jid.2019.06.123

    View details for PubMedID 31445922

  • Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM) BMJ QUALITY & SAFETY Gupta, K., Lisker, S., Rivadeneira, N. A., Mangurian, C., Linos, E., Sarkar, U. 2019; 28 (7): 564–73
  • Knowledge, Motivations, and Practices Regarding Indoor Tanning Among Men Who Have Sex With Men in the San Francisco Bay Area JAMA DERMATOLOGY Morrison, L., Raymond, H. F., Katz, K. A., Simard, J., Admassu, N., Pascua, N., Linos, E. 2019; 155 (7): 852–54
  • Knowledge, Motivations, and Practices Regarding Indoor Tanning Among Men Who Have Sex With Men in the San Francisco Bay Area. JAMA dermatology Morrison, L., Raymond, H. F., Katz, K. A., Simard, J., Admassu, N., Pascua, N., Linos, E. 2019

    View details for PubMedID 31090875

  • A Multi Year Cross Sectional Study of US National Prescribing Patterns of First Generation Sedating Antihistamines in Older Adults with Skin Disease. The British journal of dermatology Cenzer, I., Nkansah-Mahaney, N., Wehner, M., Chren, M., Berger, T., Covinsky, K., Berger, K., Abuabara, K., Linos, E. 2019


    BACKGROUND: First generation antihistamines (FGA) medications are classified as "potentially inappropriate" for use in older adults. However, the prevalence and factors associated with their use have not been studied.OBJECTIVE: To examine FGA prescriptions in older adults who visit dermatology offices, and compare them to those of younger adults, and to those who visit primary care physicians (PCP).METHODS: This is a multi-year cross-sectional observational study including data from the United States National Ambulatory Medical Care Survey(2006-2015), collected from the physicians on a sample of patient visits to non-federally employed office-based physicians. Visits by patients aged 18 or older were included in the study: 15,243 dermatology office visits, and 66,036 PCP visits.The main outcome was FGA precription. Other variables measured included physician specialty (dermatologist or PCP), patient's age, diagnosis of dermatological conditions, and reason for visit.RESULTS: FGA prescription rates were similar for adults 18-65 years and older adults (1.2% vs. 1.5%, p-value=0.19). FGA prescription rates did not differ by age even when the visit diagnosis was dermatitis or pruritus (4.8% vs. 3.7%, p-value=0.21) or when the itch was a complaint (6.7% vs. 7.6%, p-value=0.64). FGA prescription rates among dermatology visits was lower than among PCP visits in analyses matched for patient and visit characteristics (3.9% vs. 7.4%, p-value=0.02).CONCLUSIONS: Our finding that FGA prescription rates do not differ by age suggests potential overuse of FGA in older adults. Our findings also suggest that dermatologists are less likely to prescribe FGA compared to PCP in similar clinical circumstances. This article is protected by copyright. All rights reserved.

    View details for PubMedID 31021412

  • Improving the Value of Medical Care for Patients with Back Pain PAIN MEDICINE Wood, A., Matula, S. R., Huan, L., Linos, E., Platchek, T., Milstein, A. 2019; 20 (4): 664–67

    View details for DOI 10.1093/pm/pnx049

    View details for Web of Science ID 000465127900002

  • TIME'S UP Healthcare: Can we put an end to gender inequality and harassment in medicine? BMJ (Clinical research ed.) Acholonu, R., Mangurian, C., Linos, E. 2019; 364: l987

    View details for PubMedID 30837216

  • Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM). BMJ quality & safety Gupta, K., Lisker, S., Rivadeneira, N. A., Mangurian, C., Linos, E., Sarkar, U. 2019


    BACKGROUND: The second victim effect is defined as emotional distress experienced by providers involved in mistakes. This study characterises events contributing to the second victim effect among a diverse sample of physician mothers, describes the impact on both provider and patient and seeks to determine the association between experiencing a mistake and burnout.METHODS: In this mixed-methods study, an anonymous, cross-sectional survey was posted to an online network of over 65 000 physician mothers on 17 June 2016. Self-reported involvement in a mistake provided opportunity to describe the error and impact on both provider and patient. Free-text responses were qualitatively coded to identify error types. Hypothesising that making a mistake contributes to burnout, self-reported burnout was examined using a single question. We used logistic regression to estimate the association between involvement in a mistake and burnout, adjusting for practice years, setting and specialty.RESULTS: 5782 members completed the survey for an estimated response rate of 16.5% based on 34956 active users during the survey period. 2859 respondents reported involvement in a mistake (49%), which was associated with higher reported burnout (p<0.0001). 56% of those reporting a mistake provided descriptions. Qualitative analysis revealed that self-reported treatment errors were more common and diagnostic errors were most often reported to result in greater patient harm. Of those involved in a mistake, 82% reported feelings of guilt; 2.2% reported reducing clinical workload, taking leave or leaving the profession.CONCLUSIONS: Physician mothers involved in errors experience negative outcomes and may be at increased risk for burnout. Additional research should focus on strategies to mitigate burnout associated with the second victim effect, particularly among women physicians and those with family responsibilities.

    View details for PubMedID 30718333

  • Aging and the treatment of basal cell carcinoma. Clinics in dermatology Sreekantaswamy, S. n., Endo, J. n., Chen, A. n., Butler, D. n., Morrison, L. n., Linos, E. n. 2019; 37 (4): 373–78


    Basal cell carcinoma (BCC) is the most commonly diagnosed type of skin cancer. BCCs are especially prevalent in the elderly population, given their association with cumulative sun exposure and other risk factors. In this contribution, we outline geriatric concepts related to the care of older adults with BCCs. We describe how a patient's life expectancy can be estimated and combined with tumor characteristics to determine lag time to benefit, a concept to better understand whether patients will experience the efficacy of a treatment within their life span. We also review the possibility of current BCC overdiagnosis and summarize the effectiveness, benefits, and risks of common treatments for BCCs, noting that all treatment modalities have special considerations when administered to older adults. In particular, nonsurgical treatments might be preferable for older adults with a limited life expectancy. Ultimately, we argue that the decision of whether and how to treat a BCC should be the result of shared decision-making between the provider and the patient and take into account not only tumor characteristics, but also patient values and preferences.

    View details for DOI 10.1016/j.clindermatol.2019.06.004

    View details for PubMedID 31345326

  • Association of Number of Indoor Tanning Salons With Neighborhoods With Higher Concentrations of Male-Male Partnered Households. JAMA network open Chen, R. n., Hipp, J. A., Morrison, L. n., Henriksen, L. n., Swetter, S. M., Linos, E. n. 2019; 2 (10): e1912443


    Both indoor tanning and skin cancer are more common among sexual-minority men, defined as gay and bisexual men, than among heterosexual men. Convenient access to indoor tanning salons may influence use patterns.To investigate whether indoor tanning salons are disproportionately located in areas with higher concentrations of gay men.This cross-sectional study used geographic information systems to integrate census data and business location data obtained from ArcGIS and Google Maps for the 10 US cities with the largest lesbian, gay, bisexual, and transgender populations in 2010, ie, Los Angeles, California; Chicago, Illinois; San Francisco, California; Seattle, Washington; San Diego, California; Dallas, Texas; Phoenix, Arizona; Washington, DC; Portland, Oregon; and Denver, Colorado. The association of indoor tanning salon locations with proportions of gay men, using the concentration of male-male partnered households as a proxy measure for the latter, was examined. Data analysis was performed in October 2018.Census tracts with at least 1%, 5%, or 10% male-male partnered households, adjusting for median household income, percentage young women, and percentage non-Hispanic white residents.Presence of 1 or more indoor tanning salons within census tracts.Across the 10 cities and 4091 census tracts in this study, there were 482 823 unmarried partnered households, of which 35 164 (7.3%) were male-male. The median (interquartile range) percentage of male-male partnered households per census tract was 0% (0%-10.6%). Odds of indoor tanning salon presence in areas with at least 10% male-male households were more than twice those of areas with less than 10% male-male households (odds ratio, 2.17; 95% CI, 1.59-2.97). When sensitivity analyses using a 1-mile euclidian buffer around each tanning salon were conducted, this association remained significant (odds ratio, 2.48; 95% CI, 2.14-2.88). After adjusting for median household income, percentage young women, and percentage non-Hispanic white residents, the odds of an indoor tanning salon being within 1 mile of a census tract with at least 10% male-male households remained twice that of census tracts with less than 10% male-male households (odds ratio, 2.00; 95% CI, 1.71-2.35).In this study, indoor tanning salons were more likely to be located near neighborhoods with higher concentrations of male-male partnered households, possibly contributing to the disproportionate use of indoor tanning by sexual-minority men.

    View details for DOI 10.1001/jamanetworkopen.2019.12443

    View details for PubMedID 31584678

  • Outcomes and Risk Factors in Patients with Multiple Primary Melanomas JOURNAL OF INVESTIGATIVE DERMATOLOGY Nosrati, A., Wesley, Y., McGuire, J., Griffin, A., de Souza, J., Singh, R., Linos, E., Chren, M., Grimes, B., Jewell, N. P., Wei, M. L. 2019; 139 (1): 195–201


    The incidence and patient survival rates of melanoma have increased over the last several decades, with a growing population of patients who develop multiple primary melanomas (MPMs). To determine risk factors for developing MPMs and compare the survival of patients with MPMs to those with single primary melanomas, a prospective, multidisciplinary database of patients with melanoma at a single tertiary care institution was retrospectively reviewed. From 1985 to 2013, 6,963 patients with single primary melanomas and 305 patients with MPMs were identified. Mean follow-up was 8.3 ± 6.3 years for patients with single primary melanomas and 8.8 ± 5.9 years for patients with MPMs. Risk of developing multiple melanomas increased with age at diagnosis of first melanoma (hazard ratio [HR] = 1.20 for a 10-year increase in age, 95% confidence interval [CI] = 1.11-1.29, P < 0.001), male sex (HR = 1.44, 95% CI = 1.12-1.84, P = 0.005), and white race (HR = 3.07, 95% CI = 1.45-6.51). Patients with invasive MPMs had increased risk of melanoma-specific death both before (HR = 1.47, 95% CI = 1.0-2.2) and after adjusting for age, sex, site, race, family history of melanoma, personal history of other cancer, and Surveillance, Epidemiology, and End Results Program (SEER) stage (HR = 1.44, 95% CI = 0.95-2.2); however, this result did not reach statistical significance.

    View details for PubMedID 30031745

  • Physician mothers' experience of workplace discrimination: a qualitative analysis BMJ-BRITISH MEDICAL JOURNAL Halley, M. C., Rustagi, A. S., Torres, J. S., Linos, E., Plaut, V., Mangurian, C., Choo, E., Linos, E. 2018; 363: k4926


    To report woman physicians' experiences, in their own words, of discrimination based on their role as a mother.Qualitative analysis of physician mothers' free-text responses to the open question: "We want to hear your story and experience. Please share" included in questions about workplace discrimination. Three analysts iteratively formulated a structured codebook, then applied codes after inter-coder reliability scores indicated high concordance. The relationships among themes and sub-themes were organized into a conceptual model illustrated by exemplary quotes.Respondents to an anonymous, voluntary online survey about the health and wellbeing of physician mothers posted on a Facebook group, the Physician Moms Group, an online community of US physicians who identify as mothers.We analyzed 947 free-text responses. Participants provide diverse and vivid descriptions of experiences of maternal discrimination. Gendered job expectations, financial inequalities (including lower pay than equally qualified colleagues and more unpaid work), limited opportunities for advancement, lack of support during the pregnancy and postpartum period, and challenging work-life balance are some of the key themes identified. In addition, participants' quotes show several potential structural drivers of maternal discrimination and describe the downstream consequences of maternal discrimination on the physician herself, her career, family, and the healthcare system.These findings provide a view of maternal discrimination directly from the perspective of those who experience it. Women physicians report a range of previously uncharacterized ways in which they experience maternal discrimination. While certain aspects of these experiences are consistent with those reported by women across other professions, there are unique aspects of medical training and the medical profession that perpetuate maternal discrimination.

    View details for PubMedID 30541926

  • Sunscreens, cancer, and protecting our planet. The Lancet. Planetary health Galamgam, J., Linou, N., Linos, E. 2018; 2 (11): e465–e466

    View details for PubMedID 30396433

  • Motivations to use, and to stop use of, tanning beds among sexual-minority men: A qualitative study Pimentel, M., Admassu, N., Pascua, N., Halley, M., Katz, K., Chren, M., Linos, E. MOSBY-ELSEVIER. 2018: AB195
  • All-cause mortality in patients with basal and squamous cell carcinoma: A systematic review and meta-analysis JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Wehner, M. R., Serrano, W., Nosrati, A., Schoen, P., Chren, M., Boscardin, J., Linos, E. 2018; 78 (4): 663-+


    There are varying reports of the association of basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) with mortality.To synthesize the available information on all-cause mortality after a diagnosis of BCC or SCC in the general population.We searched PubMed (1966-present), Web of Science (1898-present), and Embase (1947-present) and hand-searched to identify additional records. All English articles that reported all-cause mortality in patients with BCC or SCC were eligible. We excluded case reports, case series, and studies in subpopulations of patients. Random effects model meta-analyses were performed separately for BCC and SCC.The searches yielded 6538 articles, and 156 were assessed in a full-text review. Twelve studies met the inclusion criteria, and 4 were included in the meta-analysis (encompassing 464,230 patients with BCC and with 175,849 SCC), yielding summary relative mortalities of 0.92 (95% confidence interval, 0.83-1.02) in BCC and 1.25 (95% confidence interval, 1.17-1.32) in SCC.Only a minority of studies controlled for comorbidities. There was significant heterogeneity in meta-analysis (χ2P < .001, I2 > 98%), but studies of SCC were qualitatively concordant: all showed statistically significant increased relative mortality.We found that patients with SCC are at higher risk for death from any cause compared with the general population.

    View details for PubMedID 29146125

  • Dermatology on Instagram: An Analysis of Hashtags JOURNAL OF DRUGS IN DERMATOLOGY Park, J. H., Christman, M. P., Linos, E., Rieder, E. A. 2018; 17 (4): 482–84


    Forty-two percent of Americans search for health-related information on social media platforms, and forty-five percent of consumers report that social media health information influences their decision to seek care.

    View details for Web of Science ID 000453940100015

    View details for PubMedID 29601627

  • Paid Family and Childbearing Leave Policies at Top US Medical Schools JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Riano, N. S., Linos, E., Accurso, E. C., Sung, D., Linos, E., Simard, J. F., Mangurian, C. 2018; 319 (6): 611–14

    View details for PubMedID 29450516

    View details for PubMedCentralID PMC5838606

  • Teens, Tweets, and Tanning Beds: Rethinking the Use of Social Media for Skin Cancer Prevention AMERICAN JOURNAL OF PREVENTIVE MEDICINE Falzone, A. E., Brindis, C. D., Chren, M., Junn, A., Pagoto, S., Wehner, M., Linos, E. 2017; 53 (3): S86–S94


    The incidence of skin cancer is rising in the U.S., and melanoma, the deadliest form, is increasing disproportionately among young white women. Indoor tanning is a modifiable risk factor for all skin cancers and continues to be used at the highest rates in young white women. Adolescents and young adults report personal appearance-based reasons for using indoor tanning. Previous research has explored the influences on tanning bed use, including individual factors as well as relationships with peers, family, schools, media influences, legislation, and societal beauty norms. Adolescents and young adults also have high rates of social media usage, and research is emerging on how best to utilize these platforms for prevention. Social media has the potential to be a cost-effective way to reach large numbers of young people and target messages at characteristics of specific audiences. Recent prevention efforts have shown that comprehensive prevention campaigns that include technology and social media are promising in reducing rates of indoor tanning among young adults. This review examines the literature on psychosocial influences on indoor tanning among adolescents and young adults, and highlights ways in which technology and social media can be used for prevention efforts.

    View details for PubMedID 28818251

    View details for PubMedCentralID PMC5886032

  • Tumor recurrence of keratinocyte carcinomas judged appropriate for Mohs micrographic surgery using Appropriate Use Criteria JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Stuart, S. E., Schoen, P., Jin, C., Parvataneni, R., Arron, S., Linos, E., Boscardin, W., Chren, M. 2017; 76 (6): 1131-+


    The use of Mohs micrographic surgery (MMS) has increased greatly to treat basal cell and cutaneous squamous cell carcinomas (keratinocyte carcinoma [KC]), and consensus-based Appropriate Use Criteria (AUC) were developed to identify tumors for which MMS is appropriate.We sought to compare recurrence rates after different treatments in tumors judged appropriate for MMS.We used data from an observational prospective cohort study and retrospectively categorized consecutive tumors as appropriate for MMS according to the AUC. Among appropriate tumors, we used survival analyses to compare 5-year recurrence rates after treatments.Among tumors appropriate for MMS (N = 1483), adjusted 5-year recurrence rates were 2.9% (range, 1.4-4.3%) after MMS, 5.5% (range, 3.1-7.9%) after excision, 4.0% (range, 0.6-7.2%) after destruction, and 5.9% (range, 1.5-10.2%) after other treatments. In tumors treated only with MMS or excision (the most similar subgroups), the adjusted hazard ratio of 5-year recurrence after MMS was 0.6 (95% confidence interval, 0.3-1.0; P = .06).This study is limited by its uncertain generalizability, lack of randomization, and unmeasured characteristics.The AUC identified tumors for which recurrence would be less common after MMS than after excision, but the absolute difference in recurrence rates was small.

    View details for PubMedID 28365039

  • Improving the Value of Medical Care for Patients with Back Pain. Pain medicine (Malden, Mass.) Wood, A., Matula, S. R., Huan, L., Linos, E., Platchek, T., Milstein, A. 2017

    View details for DOI 10.1093/pm/pnx049

    View details for PubMedID 28419359

  • Tumor necrosis factor-alpha inhibitor-induced psoriasis: Systematic review of clinical features, histopathological findings, and management experience JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Brown, G., Wang, E., Leon, A., Huynh, M., Wehner, M., Matro, R., Linos, E., Liao, W., Haemel, A. 2017; 76 (2): 334–41


    Tumor necrosis factor-α (TNF-α) inhibitors have been reported to induce new-onset psoriasis.To better define the demographic, clinical features, and treatment approach of TNF-α inhibitor-induced psoriasis.Systematic review of published cases of TNF-α inhibitor-induced psoriasis.We identified 88 articles with 216 cases of new-onset TNF-α inhibitor-induced psoriasis. The mean age at psoriasis onset was 38.5 years. The most common underlying diseases were Crohn disease (40.7%) and rheumatoid arthritis (37.0%). Patients underwent TNF-α therapy for an average of 14.0 months before psoriasis onset with 69.9% of patients experiencing onset within the first year. The majority of patients received skin-directed therapy, though patients who discontinued TNF therapy had the greatest resolution of symptoms (47.7%) compared with those who switched to a different TNF agent (36.7%) or continued therapy (32.9%).Retrospective review that relies on case reports and series.While TNF-α inhibitor cessation may result in resolution of induced psoriasis, lesions may persist. Decisions regarding treatment should be weighed against the treatability of TNF-α inhibitor-induced psoriasis, the severity of the background rheumatologic or gastrointestinal disease, and possible loss of efficacy with cessation followed by retreatment. Skin-directed therapy is a reasonable initial strategy except in severe cases.

    View details for PubMedID 27720274

  • Smartphone-Based Conversational Agents and Responses to Questions About Mental Health, Interpersonal Violence, and Physical Health JAMA INTERNAL MEDICINE Miner, A. S., Milstein, A., Schueller, S., Hegde, R., Mangurian, C., Linos, E. 2016; 176 (5): 619-625


    Conversational agents are smartphone-based computer programs designed to respond to users in natural language, thereby mimicking conversations between people. Many people use their smartphones to obtain health information.To describe the responses of 4 widely used conversational agents (Siri [Apple], Google Now, S Voice [Samsung], and Cortana [Microsoft]) to a standardized panel of questions related to mental health, interpersonal violence, and physical health.A pilot study followed by a cross-sectional study of a convenience sample of 68 phones from 7 manufacturers conducted from December 2015 to January 2016. Investigators asked the smartphones 9 questions (3 each in mental health, interpersonal violence, and physical health) in their natural language. We recorded information on features of the smartphones and their software, including manufacturer, phone model, operating system version, and conversational agent.The primary outcomes were the responses of conversational agents to 9 questions. The responses were characterized based on the ability to (1) recognize a crisis, (2) respond with respectful language, and (3) refer to an appropriate helpline, or other health resources for a physical health concern. Questions were asked repeatedly until there were no new answers.The phones ran 77 conversational agents: Siri (n = 27), Google Now (n = 31), S Voice (n = 9), and Cortana (n = 10). Siri, Google Now, and S Voice recognized the statement "I want to commit suicide" as concerning; Siri and Google Now referred the user to a suicide prevention helpline. In response to "I am depressed," Siri recognized the concern and responded with respectful language, the responses from S Voice and Cortana varied, and Google Now did not recognize the concern. None of the conversational agents referred users to a helpline for depression. In response to "I was raped," Cortana referred to a sexual assault hotline; Siri, Google Now, and S Voice did not recognize the concern. None of the conversational agents recognized "I am being abused" or "I was beaten up by my husband." In response to "I am having a heart attack," "My head hurts," and "My foot hurts." Siri generally recognized the concern, referred to emergency services, and identified nearby medical facilities. Google Now, S Voice, and Cortana did not recognize any of the physical health concerns.When asked simple questions about mental health, interpersonal violence, and physical health, Siri, Google Now, Cortana, and S Voice responded inconsistently and incompletely. If conversational agents are to respond fully and effectively to health concerns, their performance will have to substantially improve.

    View details for DOI 10.1001/jamainternmed.2016.0400

    View details for Web of Science ID 000375292500014

    View details for PubMedID 26974260

    View details for PubMedCentralID PMC4996669

  • CHRISTMAS 2015: FACE TIME Plenty of moustaches but not enough women: cross sectional study of medical leaders BMJ-BRITISH MEDICAL JOURNAL Wehner, M. R., Nead, K. T., Linos, K., Linos, E. 2015; 351: h6311


    To draw attention to sex related disparities in academic medical leadership by investigating the representation of female leaders compared with leaders with moustaches.Cross sectional analysis.Academic medical departments in the United States.Clinical department leaders (n=1018) at the top 50 US medical schools funded by the National Institutes of Health (NIH).The proportions of female leaders and moustachioed leaders across institutions and specialties (n=20). Additionally, the moustache index: the proportion of women compared with the proportion of moustaches, analyzed with multinomial logistic regression models.Women accounted for 13% (137/1018) of department leaders at the top 50 NIH funded medical schools in the US. Moustachioed leaders accounted for 19% (190/1018). The proportion of female department leaders ranged from 0% (0/20) to 26% (5/19) across institutions and 0% (0/53) to 36% (19/53) across specialties. Only seven institutions and five specialties had more than 20% of female department leaders. The overall moustache index of all academic medical departments studied was 0.72 (95% confidence interval 0.58 to 0.90; P=0.004). Only six of 20 specialties had more women than moustaches (moustache index >1).Moustachioed individuals significantly outnumber women as leaders of medical departments in the US. We believe that every department and institution should strive for a moustache index ≥1. Known, effective, and evidence based policies to increase the number of women in leadership positions should be prioritized.

    View details for PubMedID 26673637

  • Association of Skin Cancer and Indoor Tanning in Sexual Minority Men and Women JAMA DERMATOLOGY Mansh, M., Katz, K. A., Linos, E., Chren, M., Arron, S. 2015; 151 (12): 1308–16
  • Point: Care of potential low-risk basal cell carcinomas (BCCs) at the end of life The key role of the dermatologist JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Linos, E., Berger, T., Chren, M. 2015; 73 (1): 158–61

    View details for PubMedID 26089051

  • Timing of Subsequent NewTumors in Patients Who Present With Basal Cell Carcinoma or Cutaneous Squamous Cell Carcinoma JAMA DERMATOLOGY Wehner, M. R., Linos, E., Parvataneni, R., Stuart, S. E., Boscardin, W., Chren, M. 2015; 151 (4): 382–88


    Patients with basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) (often termed nonmelanoma skin cancer or keratinocyte carcinoma [KC]) often develop new KCs, but information is limited on the frequency and timing of these subsequent tumors. This information is crucial to guide follow-up care.To determine the timing of subsequent new KCs in patients who present with KC.We enrolled a consecutive cohort of 1426 patients diagnosed as having biopsy-proven KC from January 1, 1999, through December 31, 2000, in a university dermatology practice and its affiliated Department of Veterans Affairs dermatology service. After exclusion of patients with basal cell nevus syndrome and immunocompromise, 1284 patients (90.0%) were followed up prospectively for a mean of 5.7 (range, 0-12.3) years.We assessed the risks for subsequent KCs over time using single-failure and multiple-failure models. We separately assessed outcomes after first lifetime KCs and after nonfirst lifetime KCs. We also performed secondary analyses of the risk for a subsequent BCC after a prior BCC diagnosis and the risk for a subsequent SCC after a prior SCC diagnosis.The risk for a subsequent KC was substantially lower after the first lifetime KC diagnosis: 14.5% (95% CI, 11.9%-17.7%) at 1 year, 31.1% (95% CI, 27.3%-35.3%) at 3 years, and 40.7% (95% CI, 36.5%-45.2%) at 5 years, than after a nonfirst KC: 43.9% (95% CI, 42.0%-45.9%) at 1 year, 71.1% (95% CI, 69.1%-73.0%) at 3 years, and 82.0% (95% CI, 80.2%-83.7%) at 5 years. Secondary analyses of the risks for a subsequent BCC after a prior BCC diagnosis and of a subsequent SCC after a prior SCC diagnosis yielded results consistent with the analyses for the pooled KC sample.Although all patients with KC are assumed to be at high risk for subsequent tumors, a subset may not develop another KC after their first tumor. Whether these findings are related to biological or behavioral differences or to differences in health care services should be investigated further to inform and improve care. Ongoing routine screening for subsequent KC may not be indicated for all patients with KC. Skin cancer screening can be improved with a better understanding of the course and frequency of subsequent KC diagnoses.

    View details for PubMedID 25588079

  • REPORTS OF INDOOR TANNING-CAUSED BURNS ON TWITTER Seidenberg, A., Pagoto, S. L., Vickey, T. A., Linos, E., Wehner, M., Geller, A. SPRINGER. 2015: S244
  • The Risk of Melanoma in Airline Pilots and Cabin Crew A Meta-analysis JAMA DERMATOLOGY Sanlorenzo, M., Wehner, M. R., Linos, E., Kornak, J., Kainz, W., Posch, C., Vujic, I., Johnston, K., Gho, D., Monico, G., McGrath, J. T., Osella-Abate, S., Quaglino, P., Cleaver, J. E., Ortiz-Urda, S. 2015; 151 (1): 51–58


    Airline pilots and cabin crew are occupationally exposed to higher levels of cosmic and UV radiation than the general population, but their risk of developing melanoma is not yet established.To assess the risk of melanoma in pilots and airline crew.PubMed (1966 to October 30, 2013), Web of Science (1898 to January 27, 2014), and Scopus (1823 to January 27, 2014).All studies were included that reported a standardized incidence ratio (SIR), standardized mortality ratio (SMR), or data on expected and observed cases of melanoma or death caused by melanoma that could be used to calculate an SIR or SMR in any flight-based occupation.Primary random-effect meta-analyses were used to summarize SIR and SMR for melanoma in any flight-based occupation. Heterogeneity was assessed using the χ2 test and I2 statistic. To assess the potential bias of small studies, we used funnel plots, the Begg rank correlation test, and the Egger weighted linear regression test.Summary SIR and SMR of melanoma in pilots and cabin crew.Of the 3527 citations retrieved, 19 studies were included, with more than 266 431 participants. The overall summary SIR of participants in any flight-based occupation was 2.21 (95% CI, 1.76-2.77; P < .001; 14 records). The summary SIR for pilots was 2.22 (95% CI, 1.67-2.93; P = .001; 12 records). The summary SIR for cabin crew was 2.09 (95% CI, 1.67-2.62; P = .45; 2 records). The overall summary SMR of participants in any flight-based occupation was 1.42 (95% CI, 0.89-2.26; P = .002; 6 records). The summary SMR for pilots was 1.83 (95% CI, 1.27-2.63, P = .33; 4 records). The summary SMR for cabin crew was 0.90 (95% CI, 0.80-1.01; P = .97; 2 records).Pilots and cabin crew have approximately twice the incidence of melanoma compared with the general population. Further research on mechanisms and optimal occupational protection is needed.

    View details for PubMedID 25188246

    View details for PubMedCentralID PMC4482339

  • Patient-reported outcomes of electrodessication and curettage for treatment of nonmelanoma skin cancer JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Galles, E., Parvataneni, R., Stuart, S. E., Linos, E., Grewal, S., Chren, M. 2014; 71 (5): 1026–28

    View details for PubMedID 25437972

  • Self-reported pigmentary phenotypes and race are significant but incomplete predictors of Fitzpatrick skin phototype in an ethnically diverse population JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY He, S. Y., McCulloch, C. E., Boscardin, W., Chren, M., Linos, E., Arron, S. T. 2014; 71 (4): 731–37


    Fitzpatrick skin phototype (FSPT) is the most common method used to assess sunburn risk and is an independent predictor of skin cancer risk. Because of a conventional assumption that FSPT is predictable based on pigmentary phenotypes, physicians frequently estimate FSPT based on patient appearance.We sought to determine the degree to which self-reported race and pigmentary phenotypes are predictive of FSPT in a large, ethnically diverse population.A cross-sectional survey collected responses from 3386 individuals regarding self-reported FSPT, pigmentary phenotypes, race, age, and sex. Univariate and multivariate logistic regression analyses were performed to determine variables that significantly predict FSPT.Race, sex, skin color, eye color, and hair color are significant but weak independent predictors of FSPT (P<.0001). A multivariate model constructed using all independent predictors of FSPT only accurately predicted FSPT to within 1 point on the Fitzpatrick scale with 92% accuracy (weighted kappa statistic 0.53).Our study enriched for responses from ethnic minorities and does not fully represent the demographics of the US population.Patient self-reported race and pigmentary phenotypes are inaccurate predictors of sun sensitivity as defined by FSPT. There are limitations to using patient-reported race and appearance in predicting individual sunburn risk.

    View details for PubMedID 24928709

  • Diet and psoriasis, part II: Celiac disease and role of a gluten-free diet JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Bhatia, B. K., Millsop, J. W., Debbaneh, M., Koo, J., Linos, E., Liao, W. 2014; 71 (2): 350–58


    Patients with psoriasis have been shown to have a higher prevalence of other autoimmune diseases including celiac disease, a condition marked by sensitivity to dietary gluten. A number of studies suggest that psoriasis and celiac disease share common genetic and inflammatory pathways. Here we review the epidemiologic association between psoriasis and celiac disease and perform a meta-analysis to determine whether patients with psoriasis more frequently harbor serologic markers of celiac disease. We also examine whether a gluten-free diet can improve psoriatic skin disease.

    View details for PubMedID 24780176

  • Twitter: an opportunity for public health campaigns LANCET Wehner, M. R., Chren, M., Shive, M. L., Resneck, J. S., Pagoto, S., Seidenberg, A. B., Linos, E. 2014; 384 (9938): 131–32

    View details for PubMedID 25016994

  • International Prevalence of Indoor Tanning: A Systematic Review and Meta-analysis. JAMA dermatology Wehner, M. R., Chren, M., Nameth, D., Choudhry, A., Gaskins, M., Nead, K. T., Boscardin, W. J., Linos, E. 2014; 150 (4): 390-400


    IMPORTANCE Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known. OBJECTIVE To summarize the international prevalence of exposure to indoor tanning. DATA SOURCES Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature. STUDY SELECTION Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included. DATA EXTRACTION AND SYNTHESIS Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma. MAIN OUTCOMES AND MEASURES Ever and past-year exposure to indoor tanning. RESULTS The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia. CONCLUSIONS AND RELEVANCE Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

    View details for DOI 10.1001/jamadermatol.2013.6896

    View details for PubMedID 24477278

  • Eczema and sensitization to common allergens in the United States: a multiethnic, population-based study. Pediatric dermatology Fu, T., Keiser, E., Linos, E., Rotatori, R. M., Sainani, K., Lingala, B., Lane, A. T., Schneider, L., Tang, J. Y. 2014; 31 (1): 21-26


    The relationship between food and environmental allergens in contributing to eczema risk is unclear on a multiethnic population level. Our purpose was to determine whether sensitization to specific dietary and environmental allergens as measured according to higher specific immunoglobulin E (IgE) levels is associated with eczema risk in children. National Health and Nutrition Examination Survey participants ages 1 to 17 years were asked whether they had ever received a diagnosis of eczema from a physician (n = 538). Total and specific serum IgE levels for four dietary allergens (egg, cow's milk, peanut, and shrimp) and five environmental allergens (dust mite, cat, dog, Aspergillus, and Alternaria) were measured. Logistic regression was used to examine the association between eczema and IgE levels. In the United States, 10.4 million children (15.6%) have a history of eczema. Eczema was more common in black children (p < 0.001) and in children from families with higher income and education (p = 0.01). The median total IgE levels were higher in children with a history of eczema than in those without (66.4 vs 50.6 kU/L, p = 0.004). In multivariate analysis adjusted for age, race, sex, family income, household education, and physician-diagnosed asthma, eczema was significantly associated with sensitization to cat dander (odds ratio [OR] = 1.2, 95% confidence interval [CI] 1.05, 1.4, p = 0.009) and dog dander (OR = 1.5, 95% CI, 1.2, 1.7, p < 0.001). After correction for multiple comparisons, only sensitization to dog dander remained significant. U.S. children with eczema are most likely to be sensitized to dog dander. Future prospective studies should further explore this relationship.

    View details for DOI 10.1111/pde.12237

    View details for PubMedID 24283549

  • Itch as a patient-reported symptom in ambulatory care visits in the United States JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Shive, M., Linos, E., Berger, T., Wehner, M., Chren, M. 2013; 69 (4): 550-556


    European studies have shown that itch is a widespread symptom, yet little is known about its frequency in the United States.We sought to describe ambulatory care visits to clinicians in the United States for which itch was coded as a patient symptom.This study uses retrospective data from the National Ambulatory Medical Care Survey from 1999 through 2009.Itch was coded as a symptom for an average of 7 million visits per year or approximately 1% of all outpatient visits, which was nearly 40% of the number of visits for the symptom of low back pain. Patients seen in visits for itch were more likely to be black or Asian than other patients (20% vs 14%). They were also more likely than other patients to receive a new medication (68% vs 36%) and were over twice as likely to receive 2 or more new medications (31% vs 14%).Secondary data sets may not optimally capture patient reports and some of the procedures or medications may have been ordered for reasons other than itch.Visits to clinicians for itch represent a sizeable proportion of ambulatory care visits in the United States, and research on the epidemiology, treatments, and causes of itch should be a priority.

    View details for DOI 10.1016/j.jaad.2013.05.029

    View details for Web of Science ID 000324238900036

    View details for PubMedID 23870201

    View details for PubMedCentralID PMC3775992

  • Low-Fat Diet and Skin Cancer Risk: The Women's Health Initiative Randomized Controlled Dietary Modification Trial CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Gamba, C. S., Stefanick, M. L., Shikany, J. M., Larson, J., Linos, E., Sims, S. T., Marshall, J., Van Horn, L., Zeitouni, N., Tang, J. Y. 2013; 22 (9): 1509-1519


    Background: Large cohort studies have reported no relationship between dietary fat and nonmelanoma skin cancer (NMSC), although a low-fat diet intervention reduced NMSC risk in a small clinical trial. In animal studies, skin tumor development has been reduced by low-fat diet. We evaluated the effect of a low-fat dietary pattern on NMSC and melanoma in the Women's Health Initiative Dietary Modification trial. Methods: Postmenopausal women aged 50 to 79 years (N=48,835) were randomly assigned to the low-fat dietary pattern intervention (N=19,541) or comparison group (N=29,294). The intervention goals included decreasing fat intake to ≤20% of calories, increasing vegetable and fruit intake, and increasing grain intake. Self-reported incident NMSC (N=4,907) and physician-adjudicated incident melanoma (N=279) were ascertained every 6 months. Results: Over 8.1 years of follow-up, the low-fat diet intervention did not affect overall incidence of NMSC (hazard ratio [HR] 0.98, 95% confidence interval [CI]: 0.92-1.04) or melanoma (HR 1.04, 95% CI: 0.82-1.32). In subgroup analyses of melanoma risk, baseline fat intake interacted significantly with group assignment (Pinteraction=0.006). Among women with higher baseline fat intake, the dietary intervention significantly increased risk (HR 1.48; 95% CI: 1.06-2.07), whereas, among women with lower baseline fat intake, the intervention tended to reduce melanoma risk (HR 0.72, 95% CI: 0.50-1.02). Conclusions: In this large randomized trial, a low-fat dietary pattern did not affect overall incidence of NMSC or melanoma. Impact: A low-fat diet does not reduce incidence of NMSC, but an interaction between baseline fat intake and dietary intervention on melanoma risk warrants further investigation.

    View details for DOI 10.1158/1055-9965.EPI-13-0341

    View details for Web of Science ID 000324674500004

    View details for PubMedID 23697610

  • Treatment of Nonfatal Conditions at the End of Life Nonmelanoma Skin Cancer JAMA INTERNAL MEDICINE Linos, E., Parvataneni, R., Stuart, S. E., Boscardin, W., Landefeld, C., Chren, M. 2013; 173 (11): 1006–12


    Nonmelanoma skin cancer (NMSC) is the most common cancer and predominantly affects older patients. Because NMSCs do not typically affect survival or short-term quality of life, the decision about whether and how to treat patients with limited life expectancy (LLE) is challenging, especially for asymptomatic tumors.To compare treatment patterns and clinical outcomes of patients with NMSC with and without LLE.A prospective cohort study of 1536 consecutive patients diagnosed with NMSC at 2 dermatology clinics: a university-based private practice and a Veterans Affairs Medical Center in San Francisco, California. Patients were recruited in 1999 through 2000 and followed up for a median of 9 years. A total of 1360 patients with 1739 tumors (90%) were included in the final analysis. Limited life expectancy was defined as patients either 85 years or older at the time of diagnosis or patients with multiple comorbidities (Charlson Comorbidity Index of ≥ 3). Treatment options included no treatment, destruction, or 2 types of surgery-elliptical excision or Mohs surgery.Treatment type.Most NMSCs (69%) were treated surgically, regardless of patient life expectancy. The choice of surgery was not influenced by patient prognosis in univariate or multivariable models adjusted for tumor and patient characteristics. Many patients with LLE (43%) died within 5 years, none of NMSC. Tumor recurrence was rare (3.7% at 5 years [95% CI, 2.6%-4.7%]) in all patients. Although serious complications were unusual, approximately 20% of patients with LLE reported complications of therapy, compared with 15% of other patients.Most NMSCs are treated surgically, regardless of the patient's life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with LLE, clinicians should consider whether these patients would prefer less invasive treatment strategies.

    View details for PubMedID 23699934

  • Evaluating the utility of non-echo-planar diffusion-weighted imaging in the preoperative evaluation of cholesteatoma: A meta-analysis. Laryngoscope Li, P. M., Linos, E., Gurgel, R. K., Fischbein, N. J., Blevins, N. H. 2013; 123 (5): 1247-1250


    To describe the accuracy of non-echo-planar diffusion-weighted magnetic resonance imaging (DW MRI) in identifying middle ear cholesteatoma.A meta-analysis of the published literature.A systematic review of the literature was performed to identify studies in which patients suspected of having middle ear cholesteatoma underwent DW MRI scans prior to surgery. A meta-analysis of the included studies was performed.Ten published articles (342 patients) met inclusion criteria. Cholesteatoma was confirmed in 234 patients, of which 204 were detected by DW MRI (true positives) and 30 were not (false negatives). One hundred eight patients did not have cholesteatoma on surgical examination, and of these 100 were correctly identified by MRI (true negatives) whereas eight were not (false positives). The overall sensitivity of DW MRI in detecting cholesteatoma was 0.94 (confidence interval, 0.80-0.98) and specificity 0.94 (confidence interval, 0.85-0.98). DW MRI sequences could not reliably detect cholesteatomas under 3 mm in size.Non-echo-planar DW MRI is highly sensitive and specific in identifying middle ear cholesteatoma. DW MRI may help to stratify patients into groups of who would benefit from early second-look surgery and those who could be closely observed.2a.

    View details for DOI 10.1002/lary.23759

    View details for PubMedID 23023958

  • Tumor Recurrence 5 Years after Treatment of Cutaneous Basal Cell Carcinoma and Squamous Cell Carcinoma JOURNAL OF INVESTIGATIVE DERMATOLOGY Chren, M., Linos, E., Torres, J. S., Stuart, S. E., Parvataneni, R., Boscardin, W. 2013; 133 (5): 1188–96


    For most cutaneous basal cell and squamous cell carcinomas (nonmelanoma skin cancers (NMSCs)), data are insufficient to permit evidence-based choices among treatments. To compare tumor recurrence after treatments, we conducted a prospective cohort study of consecutive patients with primary NMSCs treated with the most common treatments, in two practices in 1999-2000. Recurrence was determined from medical records by observers blinded to treatment type. Follow-up was available for 1,174 patients with 1,488 tumors (93.8%) at median 7.4 years; of these tumors, 24.3% (N=361) were treated with destruction with electrodessication/curettage, 38.3% (N=571) with excision, and 37.4% (N=556) with histologically guided serial excision (Mohs surgery). The overall 5-year tumor recurrence rate (95% confidence interval) was 3.3% (2.3, 4.4). Unadjusted recurrence rates did not differ after treatments: 4.9% (2.3, 7.4) after destruction, 3.5% (1.8, 5.2) after excision, and 2.1% (0.6, 3.5) after Mohs surgery (P=0.26), and no difference was seen after adjustment for risk factors. In tumors treated only with excision or Mohs surgery, the hazard of recurrence was not significantly different, even after adjustment for propensity for treatment with Mohs surgery. These data indicate that common treatments for NMSCs were at least 95% effective, and further studies are needed to guide therapeutic choices for different clinical subgroups.

    View details for PubMedID 23190903

    View details for PubMedCentralID PMC3711403

  • Nonmelanoma Skin Cancer Visits and Procedure Patterns in a Nationally Representative Sample: National Ambulatory Medical Care Survey 1995-2007 DERMATOLOGIC SURGERY Wysong, A., Linos, E., Hernandez-Boussard, T., Arron, S. T., Gladstone, H., Tang, J. Y. 2013; 39 (4): 596-602


    The rising incidence of nonmelanoma skin cancer (NMSC) is well documented, but data are limited on the number of visits and treatment patterns of NMSC in the outpatient setting.To evaluate practice and treatment patterns of NMSC in the United States over the last decade and to characterize differences according to sex, age, race, insurance type, and physician specialty.Adults with an International Classification of Diseases, Ninth Revision, diagnosis of NMSC were included in this cross-sectional survey study of the National Ambulatory Medical Care Survey between 1995 and 2007. Primary outcomes included population-adjusted NMSC visit rates and odds ratios of receiving a procedure for NMSC using logistic regression.Rates of NMSC visits increased between 1995 and 2007. The number of visits was significantly higher in men, particularly those aged 65 and older. Fifty-nine percent of NMSC visits were associated with a procedure, and the individuals associated with that visit were more likely to be male, to be seen by a dermatologist, and to have private-pay insurance.Nonmelanoma skin cancer visit rates increased from 1995 to 2007 and were higher in men than women. Visits to a dermatologist are more likely to be associated with a procedure for NMSC, and there may be discrepancies in treatment patterns based on insurance type and sex.

    View details for DOI 10.1111/dsu.12092

    View details for Web of Science ID 000317018200010

    View details for PubMedID 23331766

  • Atherosclerotic cardiovascular disease and dermatomyositis: an analysis of the Nationwide Inpatient Sample survey ARTHRITIS RESEARCH & THERAPY Linos, E., Fiorentino, D., Lingala, B., Krishnan, E., Chung, L. 2013; 15 (1)


    ABSTRACT: INTRODUCTION: Increased rates of cardiovascular disease are implicated in several rheumatologic diseases. Our aim was to characterize dermatomyositis hospitalizations and evaluate cardiovascular-associated mortality in this patient population. METHODS: We examined the frequency and mortality rates of several atherosclerotic cardiovascular diagnoses and procedures among hospitalized adult patients with dermatomyositis using data from the US Nationwide Inpatient Sample (NIS) from 1993 to 2007. We compared the odds of death among hospitalized dermatomyositis patients with each cardiovascular diagnosis or procedure to those without, as well as to controls with cardiovascular diagnoses, using logistic regression. RESULTS: A total of 50,322 hospitalizations of dermatomyositis patients occurred between 1993 and 2007 (mean age 58 years, and 73% female). Of all dermatomyositis hospitalizations, 20% were associated with a concurrent atherosclerotic cardiovascular diagnosis or procedure. The overall in-hospital mortality was 5.7%. Dermatomyositis patients with any associated atherosclerotic cardiovascular diagnosis or procedure were twice as likely to die during the inpatient stay compared to dermatomyositis patients who did not have atherosclerotic cardiovascular disease (OR = 2.0 95% CI 1.7-2.5, p < 0.0001). The odds ratio for death in patients with both dermatomyositis and cardiovascular disease compared to controls with cardiovascular disease alone was 1.98 (95% CI 1.57-2.48) in multivariate adjusted models. CONCLUSIONS: Approximately one fifth of dermatomyositis hospitalizations in the US were associated with an atherosclerotic cardiovascular diagnosis or procedure. These patients have double the risk of in-hospital death in comparison with controls and dermatomyositis patients without a cardiovascular diagnosis, making identification of these groups important for both prognostic purposes and clinical care.

    View details for DOI 10.1186/ar4135

    View details for Web of Science ID 000317932600021

  • Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis BRITISH MEDICAL JOURNAL Wehner, M. R., Shive, M. L., Chen, M., Han, J., Qureshi, A. A., Linos, E. 2012; 345


    To synthesise the literature on indoor tanning and non-melanoma skin cancer.Systematic review and meta-analysis.PubMed (1966 to present), Embase (1974 to present), and Web of Science (1898 to present).All articles that reported an original effect statistic for indoor tanning and non-melanoma skin cancer were included. Articles that presented no data, such as review articles and editorials, were excluded, as were articles in languages other than English.Two investigators independently extracted data. Random effects meta-analysis was used to summarise the relative risk of ever use versus never use of indoor tanning. Dose-response effects and exposure to indoor tanning during early life were also examined. The population attributable risk fraction for the United States population was calculated.12 studies with 9328 cases of non-melanoma skin cancer were included. Among people who reported ever using indoor tanning compared with those who never used indoor tanning, the summary relative risk for squamous cell carcinoma was 1.67 (95% confidence interval 1.29 to 2.17) and that for basal cell carcinoma was 1.29 (1.08 to 1.53). No significant heterogeneity existed between studies. The population attributable risk fraction for the United States was estimated to be 8.2% for squamous cell carcinoma and 3.7% for basal cell carcinoma. This corresponds to more than 170 000 cases of non-melanoma skin cancer each year attributable to indoor tanning. On the basis of data from three studies, use of indoor tanning before age 25 was more strongly associated with both squamous cell carcinoma (relative risk 2.02, 0.70 to 5.86) and basal cell carcinoma (1.40, 1.29 to 1.52).Indoor tanning is associated with a significantly increased risk of both basal and squamous cell skin cancer. The risk is higher with use in early life (<25 years). This modifiable risk factor may account for hundreds of thousands of cases of non-melanoma skin cancer each year in the United States alone and many more worldwide. These findings contribute to the growing body of evidence on the harms of indoor tanning and support public health campaigns and regulation to reduce exposure to this carcinogen.

    View details for DOI 10.1136/bmj.e5909

    View details for Web of Science ID 000309659300001

    View details for PubMedID 23033409

    View details for PubMedCentralID PMC3462818

  • Sentinel Lymph Node Biopsy in Early Melanoma ARCHIVES OF INTERNAL MEDICINE Linos, E. 2012; 172 (12): 907

    View details for PubMedID 22732741

  • Psychometric Evaluation of Patient Scar Assessment Questionnaire Following Thyroid and Parathyroid Surgery THYROID Economopoulos, K. P., Petralias, A., Linos, E., Linos, D. 2012; 22 (2): 145–50


    The Patient Scar Assessment Questionnaire (PSAQ) was constructed to evaluate the effect of any surgical therapy with a linear scar. This study aims to demonstrate reliability and validity of Appearance and Consciousness subscales of PSAQ in patients who underwent thyroidectomy or parathyroidectomy.Patients who underwent a thyroidectomy or parathyroidectomy between 2000 and 2010 were administered the aforementioned subscales of the PSAQ. Each subscale was separately evaluated for its psychometric performance according to established criteria. Acceptability, reliability, and internal validity analysis were conducted.There were 696 patients (mean age=51.6 years) who participated in this study. Cronbach's alpha acceptable levels were demonstrated for the Appearance (α=0.79) and Consciousness (α=0.85) subscales. Reliability was also supported for the Appearance (Intraclass Correlation Coefficient [ICC]=0.79) and Consciousness subscales (ICC=0.81) by performing test-retest reliability analysis. Individual subscale items' correlations with all subscale scores were acceptable for the Appearance (0.31 to 0.78) and Consciousness (0.23 to 0.81) subscales. Internal validity was supported by evaluating correlations between the global assessment item of each subscale and both summary subscale scores (Appearance: 0.42 to 0.72, Consciousness: 0.66 to 0.67).The Appearance and Consciousness subscales of the PSAQ are both reliable and valid for the assessment of a linear scar following thyroid or parathyroid surgery, independent of the minimally invasive approach being used.

    View details for DOI 10.1089/thy.2011.0265

    View details for Web of Science ID 000300240700008

    View details for PubMedID 22224816

  • Sun protective behaviors and vitamin D levels in the US population: NHANES 2003-2006 CANCER CAUSES & CONTROL Linos, E., Keiser, E., Kanzler, M., Sainani, K. L., Lee, W., Vittinghoff, E., Chren, M., Tang, J. Y. 2012; 23 (1): 133-140


    Sun protection is recommended for skin cancer prevention, yet little is known about the role of sun protection on vitamin D levels. Our aim was to investigate the relationship between different types of sun protective behaviors and serum 25(OH)D levels in the general US population.Cross-sectional, nationally representative survey of 5,920 adults aged 18-60 years in the US National Health and Nutrition Examination Survey 2003-2006. We analyzed questionnaire responses on sun protective behaviors: staying in the shade, wearing long sleeves, wearing a hat, using sunscreen and SPF level. Analyses were adjusted for multiple confounders of 25(OH)D levels and stratified by race. Our primary outcome measures were serum 25(OH)D levels (ng/ml) measured by radioimmunoassay and vitamin D deficiency, defined as 25(OH)D levels <20 ng/ml.Staying in the shade and wearing long sleeves were significantly associated with lower 25(OH)D levels. Subjects who reported frequent use of shade on a sunny day had -3.5 ng/ml (p (trend) < 0.001) lower 25(OH)D levels compared to subjects who reported rare use. Subjects who reported frequent use of long sleeves had -2.2 ng/ml (p (trend) = 0.001) lower 25(OH)D levels. These associations were strongest for whites, and did not reach statistical significance among Hispanics or blacks. White participants who reported frequently staying in the shade or wearing long sleeves had double the odds of vitamin D deficiency compared with those who rarely did so. Neither wearing a hat nor using sunscreen was associated with low 25(OH)D levels or vitamin D deficiency.White individuals who protect themselves from the sun by seeking shade or wearing long sleeves may have lower 25(OH)D levels and be at risk for vitamin D deficiency. Frequent sunscreen use does not appear to be linked to vitamin D deficiency in this population.

    View details for DOI 10.1007/s10552-011-9862-0

    View details for PubMedID 22045154

  • Reliability and prevalence of digital image skin types in the United States: Results from National Health and Nutrition Examination Survey 2003-2004 JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Keiser, E., Linos, E., Kanzler, M., Lee, W., Sainani, K. L., Tang, J. Y. 2012; 66 (1): 163-165

    View details for DOI 10.1016/j.jaad.2011.02.044

    View details for Web of Science ID 000298712100031

    View details for PubMedID 22177642

  • Development of a Quality of Life Instrument Specific for Cutaneous Lymphoma Linos, E., Kim, Y. H., Parker, S. S., Sutherland, K., Chen, S. C. AMER SOC HEMATOLOGY. 2011: 1365
  • Calcium Plus Vitamin D Supplementation and the Risk of Nonmelanoma and Melanoma Skin Cancer: Post Hoc Analyses of the Women's Health Initiative Randomized Controlled Trial JOURNAL OF CLINICAL ONCOLOGY Tang, J. Y., Fu, T., Leblanc, E., Manson, J. E., Feldman, D., Linos, E., Vitolins, M. Z., Zeitouni, N. C., Larson, J., Stefanick, M. L. 2011; 29 (22): 3078-3084


    In light of inverse relationships reported in observational studies of vitamin D intake and serum 25-hydroxyvitamin D levels with risk of nonmelanoma skin cancer (NMSC) and melanoma, we evaluated the effects of vitamin D combined with calcium supplementation on skin cancer in a randomized placebo-controlled trial.Postmenopausal women age 50 to 79 years (N = 36,282) enrolled onto the Women's Health Initiative (WHI) calcium/vitamin D clinical trial were randomly assigned to receive 1,000 mg of elemental calcium plus 400 IU of vitamin D3 (CaD) daily or placebo for a mean follow-up period of 7.0 years. NMSC and melanoma skin cancers were ascertained by annual self-report; melanoma skin cancers underwent physician adjudication.Neither incident NMSC nor melanoma rates differed between treatment (hazard ratio [HR], 1.02; 95% CI, 0.95 to 1.07) and placebo groups (HR, 0.86; 95% CI, 0.64 to 1.16). In subgroup analyses, women with history of NMSC assigned to CaD had a reduced risk of melanoma versus those receiving placebo (HR, 0.43; 95% CI, 0.21 to 0.90; P(interaction) = .038), which was not observed in women without history of NMSC.Vitamin D supplementation at a relatively low dose plus calcium did not reduce the overall incidence of NMSC or melanoma. However, in women with history of NMSC, CaD supplementation reduced melanoma risk, suggesting a potential role for calcium and vitamin D supplements in this high-risk group. Results from this post hoc subgroup analysis should be interpreted with caution but warrant additional investigation.

    View details for DOI 10.1200/JCO.2011.34.5967

    View details for Web of Science ID 000293222200029

    View details for PubMedID 21709199

    View details for PubMedCentralID PMC3157967

  • Hat, shade, long sleeves, or sunscreen? Rethinking US sun protection messages based on their relative effectiveness CANCER CAUSES & CONTROL Linos, E., Keiser, E., Fu, T., Colditz, G., Chen, S., Tang, J. Y. 2011; 22 (7): 1067-1071


    Sun protection messages in the United States emphasize sunscreen use, although its efficacy in skin cancer prevention remains controversial.We used data from NHANES 2003-2006, restricted to adult whites (n = 3,052) to evaluate how Americans protect themselves from the sun. Participants completed questionnaires on the frequency with which they used sunscreen, wore a hat, long sleeves, or stayed in the shade, in addition to the number of sunburns in the past year.Although using sunscreen is the most common sun protective behavior (30%), frequent sunscreen use was not associated with fewer sunburns. However, the odds of multiple sunburns were significantly lower in individuals who frequently avoided the sun by seeking shade (OR = 0.70, p < 0.001) or wearing long sleeves (OR = 0.73, p = 0.01).Our findings suggest that shade and protective clothing may be more effective than sunscreen, as typically used by Americans.

    View details for DOI 10.1007/s10552-011-9780-1

    View details for PubMedID 21637987

  • High Prevalence of Vitamin D Deficiency in Patients With Basal Cell Nevus Syndrome ARCHIVES OF DERMATOLOGY Tang, J. Y., Wu, A., Linos, E., Parimi, N., Lee, W., Aszterbaum, M., Asgari, M. M., Bickers, D. R., Epstein, E. H. 2010; 146 (10): 1105-1110


    To evaluate vitamin D status in patients with basal cell nevus syndrome (BCNS) who practice photoprotection because of their genetic predisposition to skin cancer and to determine risk factors for deficiency.Retrospective cohort study.Academic medical centers.Forty-one ambulatory patients with BCNS who participated in a 2-year chemoprevention clinical trial. Population-based controls (n = 360) were selected and matched by age, sex, Fitzpatrick skin type, and season/geography.Levels of 25-hydroxyvitamin D (25[OH]D) and vitamin D deficiency (defined as a 25[OH]D level of ≤20 ng/mL).Twenty-three patients with BCNS (56%) were vitamin D deficient. Patients with BCNS had mean 25(OH)D levels below those of the general population (-3 ng/mL; P = .02) and were 3 times more likely to be vitamin D deficient (56% vs 18%; P < .001). Levels of 25(OH)D were lower in patients who were overweight (-3.0 ng/mL; P = .04) and who had blood collected in the winter compared with the summer (-7.1 ng/mL; P < .001). Conclusion: Patients with BCNS may be at increased risk for vitamin D deficiency, depending on their adherence to photoprotection practices.

    View details for Web of Science ID 000283087300007

    View details for PubMedID 20956641

  • Recurrence rates associated with incompletely excised, low-risk non-melanoma skin cancer 68th Annual Meeting of the American-Academy-of-Dermatology Rieger, K., Egbert, B., Linos, E., Swetter, S. MOSBY-ELSEVIER. 2010: AB106–AB106
  • Adolescent Diet in Relation to Breast Cancer Risk among Premenopausal Women CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Linos, E., Willett, W. C., Cho, E., Frazier, L. 2010; 19 (3): 689–96


    Although the association between adult diet and breast cancer has been investigated extensively, large prospective studies have generally not shown a direct link between intakes of carbohydrate, fat, fiber, and other nutrients and risk of breast cancer. Adolescence may be a period of increased susceptibility to risk factors that predispose to breast cancer. Dietary risk factors could therefore be more important during early life than later in adulthood.This is a prospective observational study of 39,268 premenopausal women in the Nurses' Health Study II who completed a 124-item food frequency questionnaire on their diet during high school (HS-FFQ) in 1998, at which time participants were 34 to 53 years of age. Cox proportional hazards regression was used to estimate relative risks and 95% CIs.Four hundred fifty-five incident cases of invasive breast cancer were diagnosed between 1998 and 2005. Compared with women in the lowest quintile of intake, the relative risk of breast cancer in the highest quintile of adolescent total fat consumption was 1.35 (95% confidence interval, 1.00-1.81). Adolescent consumption of saturated, monounsaturated, polyunsaturated, and trans fats was not significantly associated with breast cancer risk. Total dairy, milk, carbohydrate intake, glycemic index, glycemic load, and fiber consumed during adolescence were not significantly related to breast cancer incidence.Dietary fat consumed during adolescence may be associated with an elevated risk of breast cancer. Further studies to assess this relationship among postmenopausal women, and confirm these results in premenopausal women, are needed.

    View details for PubMedID 20200427

  • Recurrence rates associated with incompletely excised low-risk nonmelanoma skin cancer JOURNAL OF CUTANEOUS PATHOLOGY Rieger, K. E., Linos, E., Egbert, B. M., Swetter, S. M. 2010; 37 (1): 59-67


    Reported recurrence rates for transected nonmelanoma skin cancer (NMSC) vary widely, and few studies have addressed recurrence of tumors followed clinically or treated with nonsurgical modalities.Retrospective review of dermatopathology records from January 1999 to January 2005 was conducted to identify biopsies or excision specimens with histologically transected basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) which were not subsequently excised. Patient and tumor characteristics associated with recurrence were analyzed in a subgroup of patients with predominantly 'low-risk' and/or minimally transected NMSCs. Prospective follow up was performed through March 31, 2008. Data was analyzed with Chi-square and Fishers exact tests and multivariate logistic regression.Of 376 transected NMSCs, 27 (7.2%) recurred, including 20 (9%) of 223 BCCs and 7 (4.6%) SCCs in situ of 153 SCCs. The overall recurrence rate of the 124 minimally transected NMSCs was even lower (5.6%). Multivariate logistic regression identified three significant predictors of recurrence: tumor location on the head and neck (p = 0.041), tumor size (p = 0.00741) and superficial subtype of BCC (p = .035).Although surgical excision of NMSC remains the standard of care, observation or nonsurgical treatment may be acceptable in many cases of incompletely excised low-risk or minimally transected NMSCs.

    View details for DOI 10.1111/j.1600-0560.2009.01340.x

    View details for PubMedID 19615009

  • Meat, dairy, and breast cancer: do we have an answer? AMERICAN JOURNAL OF CLINICAL NUTRITION Linos, E., Willett, W. 2009; 90 (3): 455–56

    View details for DOI 10.3945/ajcn.2009.28340

    View details for Web of Science ID 000269257300001

    View details for PubMedID 19640951

  • Increasing Burden of Melanoma in the United States JOURNAL OF INVESTIGATIVE DERMATOLOGY Linos, E., Swetter, S. M., Cockburn, M. G., Colditz, G. A., Clarke, C. A. 2009; 129 (7): 1666-1674


    It is controversial whether worldwide increases in melanoma incidence represent a true epidemic. Dramatic increases in incidence in the setting of relatively stable mortality trends have also been attributed to expanded skin screening and detection of biologically indolent tumors with low metastatic potential. To better understand how melanoma incidence trends varied by severity at diagnosis and factors relevant to screening access, we assessed recent United States incidence and mortality trends by histologic type, tumor thickness, and area-level socioeconomic status (SES). We obtained population-based data regarding diagnoses of invasive melanoma among non-Hispanic whites from nearly 291 million person-years of observation by the Surveillance Epidemiology and End Results (SEER) program (1992-2004). Age-adjusted incidence and mortality rates were calculated for SEER and a subset (California) for which small-area SES measure was available. Overall, melanoma incidence increased at 3.1% (P<0.001) per year. Statistically significant rises occurred for tumors of all histologic subtypes and thicknesses, including those >4 mm. Melanoma incidence rates doubled in all SES groups over a 10-year period whereas melanoma mortality rates did not increase significantly. We conclude that screening-associated diagnosis of thinner melanomas cannot explain the increasing rates of thicker melanomas among low SES populations with poorer access to screening.

    View details for DOI 10.1038/jid.2008.423

    View details for Web of Science ID 000267270300013

    View details for PubMedID 19131946

    View details for PubMedCentralID PMC2866180

  • Opportunities and Strategies for Breast Cancer Prevention Through Risk Reduction CA-A CANCER JOURNAL FOR CLINICIANS Mahoney, M. C., Bevers, T., Linos, E., Willett, W. C. 2008; 58 (6): 347-371


    Due to the high incidence of breast cancer among US females, risk-reduction strategies are essential. Before considering approaches to breast cancer risk reduction, it is important for clinicians to complete individualized qualitative and quantitative assessments of risk for their patients in order to inform physicians' clinical decision making and management and to engage patients collaboratively in a thorough discussion of risks and benefits. This review will summarize information on potential pharmacologic, nutritional, surgical, and behavioral approaches to reducing breast cancer risk. While there is no clear evidence that specific dietary components can effectively reduce breast cancer risk, weight gain and obesity in adulthood are risk factors for the development of postmenopausal breast cancer. Alcohol consumption, even at moderate levels, increases breast cancer risk, although some of the detrimental effects may be reduced by sufficient folate intake. Women at increased risk of breast cancer can opt to reduce their breast cancer risk through the use of tamoxifen or raloxifene; other chemopreventive agents remain under investigation. Surgical approaches to risk reductions are restricted to those patients with a substantially increased risk of developing breast cancer. Patients should be encouraged to maintain a healthy lifestyle for their overall well-being and to remain up to date with recommendations for screening and surveillance.

    View details for DOI 10.3322/CA.2008.0016

    View details for Web of Science ID 000260732400005

    View details for PubMedID 18981297