Eleni Linos, MD, MPH, DrPH

All Publications

• 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

  View details for DOI 10.1136/bmjqs-2018-008372

  View details for Web of Science ID 000472755500007

• 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

  Abstract

  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

  Abstract

  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

• 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

  Abstract

  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

  Abstract

  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

  View details for Web of Science ID 000440565901271

• 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-+

  Abstract

  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

  Abstract

  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

  Abstract

  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-+

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  View details for DOI 10.1001/jamadermatol.2015.3126

  View details for Web of Science ID 000367994700006

• 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

  Abstract

  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

  View details for Web of Science ID 000367825002449

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  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

  Abstract

  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

  Abstract

  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

• 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

• 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

  Abstract

  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

• 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

  View details for Web of Science ID 000299597104508

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  View details for Web of Science ID 000275880700409

• 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

  Abstract

  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

  Abstract

  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

  Abstract

  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

  Abstract

  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