Abstract Disclosure: T. Haque: None. M. Gaddis: None. R. Asad: None. S. Simon: None. B.M. Drees: None. Objective: The global pandemic of novel SARS-COV2 virus causing Covid-19 infection, is reported to lead to development of new onset diabetes mellitus (DM). This study describes the types of DM following Covid-19 infection, the patient characteristics and the disease course up to 12 months. Methods: A database of patients with DM treated at the institution was searched for a positive PCR Covid-19 test between March 1, 2020, and November 30, 2021. Charts were manually reviewed for diagnosis of co-morbidities, laboratory results, medications, disposition, and verification of type of DM. Outcomes data were collected at 0, 6, and 12 months. Results: Among 1643 Covid-19 positive patients with DM, 96 were diagnosed with new onset DM. There were 42% Black, 24% White, and 23% Hispanic; 94 had type 2 DM and two had type 1 DM. Average age was 50; half were women. Patients with more severe Covid (inpatient and ER visits) were more likely to require insulin, multiple DM medications, and had higher HbA1c levels. Insulin use and multiple DM medications decreased over time (25% and 25% at diagnosis; 10% and 18% at 12 months, respectively). HbA1c decreased over time (9.1% at diagnosis and 7.3% at 12 months). One-year follow-up was available on 73 patients, of whom 19 were on no medications for DM. Conclusion: New onset diabetes mellitus following Covid-19 infection is common and predominantly type 2 DM. However, glucose levels tend to improve over time requiring less medication, with 26% requiring no DM medications at one year. Presentation: Thursday, June 15, 2023

Weight loss interventions seldom include individuals with neurologic disease. The aims of the present study were to: 1) develop and assess the prefeasibility of a 6-month telehealth behavioral weight loss program for people with multiple sclerosis (MS) and obesity and 2) examine changes in weight loss (primary outcome), physical activity, and fruit/vegetable consumption at follow-up. Participants with obesity and MS engaged in a 24-week weight loss program. Participants followed established diet, exercise, and self-monitoring guidelines and attended weekly online group meetings. Median percentage weight loss was 10.54 % (SD = 7.19). Participants who adhered more closely to the self-monitoring guidelines (r = 0.81, p =.02), and who averaged higher weekly active minutes (r = 0.91, p =.002) achieved greater percentage weight loss. Six of the eight pilot participants achieved clinically meaningful weight loss (>5%) after 6-months.

HIV-related stigmas contribute to disparities, and contact with HIV-positive individuals has been suggested to reduce stigma. Faith-based organizations have been recognized as important to stigma reduction efforts among African American populations; however, relatively few church-based studies have measured HIV-related stigma. This study uses baseline data (N = 1,448) from a study with 14 African American churches in Kansas City, Missouri and Kansas, to examine correlates of HIV-related stigmas among church members and community members accessing church social services using two previously validated scales that measure discomfort interacting with individuals with HIV and anticipated stigma or rejection. Knowing someone with HIV was associated with lower discomfort, even after adjusting for sociodemographic characteristics and sexual risk, HIV knowledge, previous communication about HIV at church, and mean drug and homosexuality stigmas. Knowing someone with HIV was not associated with anticipated stigma or rejection after adjustment. Contact-based interventions hold promise for reducing discomfort around people with HIV among church-affiliated populations.

BACKGROUND:Obesity is a risk factor for developing multiple sclerosis (MS) and MS-related disability. The efficacy of behavioral weight loss interventions among people with MS (pwMS) remains largely unknown.OBJECTIVE:Examine whether a group-based telehealth weight loss intervention produces clinically significant weight loss in pwMS and obesity.METHODS:Seventy-one pwMS were randomized to the weight loss intervention or treatment-as-usual (TAU). The 6-month program promoted established guidelines for calorie reduction and increased physical activity. Anthropometric measurements, mobility tasks, self-report questionnaires, and accelerometry were used to assess changes at follow-up.RESULTS:Mean percent weight loss in the treatment group was 8.6% compared to 0.7% in the TAU group (p < .001). Sixty-five percent of participants in the intervention achieved clinically meaningful weight loss (⩾ 5%). Participants in the treatment group engaged in 46.2 minutes/week more moderate-to-vigorous physical activity than TAU participants (p = .017) and showed improvements in quality of life (p = .012). Weight loss was associated with improved mobility (p = .003) and reduced fatiguability (p = .008).CONCLUSION:Findings demonstrate the efficacy of a behavioral intervention for pwMS and obesity, with clinically significant weight loss for two-thirds of participants in the treatment condition. Weight loss may also lead to improved mobility and quality of life.

Rationale Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease (SCD). Current treatment is supportive-supplemental oxygen, transfusions, and antibiotics. Prevention of ACS may reduce morbidity and mortality in patients with SCD. Acute chest syndrome appears similar to pulmonary fat embolism (PFE), a complication of severe skeletal trauma or orthopedic procedures from pulmonary micro-vessel blockage by bone marrow fat. Vascular obstruction and bone marrow necrosis occur in PFE and ACS. Pulmonary fat embolism rat models have shown that angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) mitigate damage in PFE. These medications could work similarly in ACS. We hypothesize that time to readmission after one hospitalization for ACS will be reduced in patients taking ACEI or ARB compared to patients who are not. Methods This is a retrospective cohort study. Inclusion criteria are adults (18 to 100 years) with sickle cell anaemia (HbSS), hemoglobin SC (HbSC) disease, sickle cell thalassemia (HbSβThal), hospitalized with ACS over 16 years (January 1, 2000, to March 31, 2016); patients who take and don’t take ACEI or ARB. Children (<18 years old), elderly adults (>100 years old), pregnant patients, and patients with sickle cell trait were excluded. Data was collected from the Health Facts database, which contains de-identified information from the electronic medical records of hospitals in which Cerner© has a data use agreement. Kaplan-Meier estimates explored a time-to-event model of ACS readmission. Multivariable analysis (age, gender, smoking history) was conducted using Cox proportional hazards regression. Results were reported around a 95% confidence interval. Results There were 6972 patients in total. Of which, 9.6% (n = 667) reported taking ACEI or ARB. Results for the covariates were: average age of 38 years old; 63% female (n = 4366/6969); 16% smokers (n = 1132). Readmission rates were higher for patients not taking ACEI/ARB than those who did: 0.44 (95% CI 0.43, 0.46) versus 0.28 (95% CI 0.24, 0.31) at one year, and 0.56 (95% CI 0.55, 0.58) versus 0.33 (95% CI 0.29, 0.37) at two years. Age had the strongest effect on readmission rates for patients taking ACEI/ARB (adjusted hazards ratio 0.78 [95% CI 0.68, 0.91]). Conclusion Patients with SCD who reported taking ACEI or ARB had lower readmission rates for ACS; age was the strongest covariate. Our results may have a significant impact on the prevention of ACS. Prospective studies comparing ACEI or ARB therapy versus placebo are needed to confirm this preventative effect.

Increasing access to COVID-19 testing in influential, accessible community settings is needed to address COVID-19 disparities among African Americans. We describe COVID-19 testing intervention approaches conducted in Kansas City, Missouri, African American churches via a faith-health-academic partnership. Trained faith leaders promoted COVID-19 testing with church and community members by implementing multilevel interventions using a tailored toolkit and standard education information. The local health department conducted more than 300 COVID-19 tests during or after Sunday church services and outreach ministry activities. (Am J Public Health. 2022;112(S9):S887-S891. https://doi.org/10.2105/AJPH.2022.306981).

Key Points Question What is the risk of recall and high-risk recall for devices undergoing US Food and Drug Administration (FDA) 510(k) clearance compared with premarket approval (PMA)? Findings In this cohort study using the FDA’s 510(k) and PMA medical device database, 28 556 devices were reviewed. Although 97% of recalled devices had received 510(k) clearance, devices with PMA had 2.7 times the hazard of recall and 7.3 times the hazard of high-risk recall compared with devices with 510(k) clearance. Meaning This study suggests that, despite the requirement of clinical trials, high-risk devices approved via PMA were associated with greater safety concerns than previously reported; in addition, most recalls are for 510(k) devices, raising safety issues.

Introduction The use of direct oral anticoagulants (DOACs) has gained significant traction given the lack of therapeutic monitoring and the need for anticoagulant bridging. There is a paucity of data on their effectiveness in obese patients with venous thromboembolism (VTE). Preliminary subgroup and pharmacokinetic analyses suggest reduced efficacy in those with a bodyweight >120 kg or body mass index (BMI) ≥40 kg per m2 and it is currently not recommended that these agents be used as first-line agents. We aimed to assess the rate of VTE recurrence in obese patients diagnosed with VTE and treated with DOAC therapy. Methods We utilized the Health Facts Center National Data Warehouse (Cerner) to perform a retrospective analysis of patients with VTE (acute deep venous thrombosis (DVT) or pulmonary embolism) that presented to the hospital between 2010 and 2016 and were managed with DOACs. The cohort of patients diagnosed with DVT or PE were identified using International Classification of Disease (ICD-9-CM, ICD-10-CM). Patients were divided into two groups based on their weight: 1) weight <120 kg or 2) weight>120 kg. Six-month VTE recurrence rates were recorded. Summary and univariate statistics were performed. Results A total of 18,147 patients with a mean (±SD) age of 62 (17) years were included; 48% (n=8732) were male. A total of 2,419 (13%) patients weighed >120 kg while the rest (N=15,728, 87%) weighed <120 kg. There were significantly more female patients weighing<120 kg (54% vs 42%, p<0.0001); otherwise, there was no significant difference in age or tobacco use between both groups (p>0.05). There was no significant difference in six-month readmission rates for VTE recurrence in patients that weighed <120 kg (34%) in comparison with patients >120 kg (36%) (p=0.08). Conclusion Our study suggests that the use of DOACs in obese patients is equally efficacious with similar VTE recurrence rates in comparison with non-obese patients. This study paves the way for prospective multi-institutional randomized control trials to further reinforce the safe use of such agents in this patient population.

INTRODUCTION: Improving surveillance in Hepatocellular Carcinoma (HCC) and Colorectal Cancer (CRC) is an important topic in the field of Gastroenterology and Oncology due to significant benefit associated with early detection and better outcomes. Multiple studies have been undertaken to assess association between socioeconomic status of the population and its impact on HCC/CRC screening and survival after diagnosis. Most of these studies used self-reporting surveys and faced limitations due to reporting bias. We aimed to assess the relevance of socioeconomic factors in diagnosis of HCC and CRC in Jackson County, Kansas City, Missouri by means of a census-based survey. METHODS: We retrospectively studied 190 HCC and 690 CRC cases at our institution using a census-based analysis, which consisted of geocoding home addresses of patients and then attaching block level census variables for household occupancy, education level and household income. Survival was assessed using time of last contact at our facility. Statistical analysis was performed using Cox proportional hazard model and ordinal logistic regression. RESULTS: We did not find a statistically significant association between socioeconomic factors and adherence to surveillance guidelines for HCC and CRC leading to improved overall survival. Variables that were analyzed included high school education or better ( P = 0.5), four-person households with one or more workers ( P = 0.08) and income less than 25 thousand dollars ( P = 0.58). Study results were risk adjusted for age, race and gender. Separate ordinal logistic regression analysis was done to also adjust for stage at time of eventual cancer diagnosis, no statistically significant result was obtained. CONCLUSION: Our study showed no association between socioeconomic variables and participation in HCC or CRC surveillance. The study is limited by a relatively small sample size confined to local patients seen at our institution. Multicenter census-based surveys and meta-analyses need to be conducted to determine whether socioeconomic factors really have an appreciable impact on early screening and detection of HCC and CRC.

Background: The purpose of this investigation was to examine the methodology of clinical trials used by the U.S. Food and Drug Administration (FDA) to determine the safety and effectiveness of high-risk orthopaedic devices approved between 2001 and 2015. Methods: Utilizing the FDA’s online public database, this systematic review audited study design and methodological variables intended to minimize bias and confounding. An additional analysis of blinding as well as the Checklist to Evaluate a Report of a Nonpharmacological Trial (CLEAR NPT) was applied to the randomized controlled trials (RCTs). Results: Of the 49 studies, 46 (94%) were prospective and 37 (76%) were randomized. Forty-seven (96%) of the studies were controlled in some form. Of 35 studies that reported it, blinding was utilized in 21 (60%), of which 8 (38%) were reported as single-blinded and 13 (62%) were reported as double-blinded. Of the 37 RCTs, outcome assessors were clearly blinded in 6 (16%), whereas 15 (41%) were deemed impossible to blind as implants could be readily discerned on imaging. When the CLEAR NPT was applied to the 37 RCTs, >70% of studies were deemed “unclear” in describing generation of allocation sequences, treatment allocation concealment, and adequate blinding of participants and outcome assessors. Conclusions: This study manifests the highly variable reporting and strength of clinical research methodology accepted by the FDA to approve high-risk orthopaedic devices.

Background: Aortic valve replacement (AVR) is frequently needed for congenital and acquired aortic valve abnormalities. AVR creates a life-long disease and long-term outcomes may be affected by the...

Background: Congenital mitral valve disease in children is recalcitrant and often not amenable to primary repair, thus, frequently requiring valve replacement. Long-term outcomes in those requiring...

Technical Performance Score (TPS) is based largely on the presence and magnitude of residual lesions on postoperative echocardiograms; this score correlates with outcomes following repair of congenital heart defects. We evaluated reader variability for echocardiographic components of TPS for complete repair of tetralogy of Fallot (TOF) and arterial switch operation (ASO) in two centers and measured its effect on TPS. Postoperative echocardiograms were evaluated in 67 children (39 TOF and 28 ASO). Two readers (one per center) interpreted each echocardiogram. Reader variability in image quality assessments and measurements was compared using weighted kappa (κ), percent agreement, and intra-class correlation. TPS class (1 optimal-no residua, 2 adequate-minor residua, 3 inadequate-major residua) was assigned for each echocardiographic review by an independent investigator. The effect of reader interpretation variability on TPS classification was measured. There was strong agreement for TPS between the two readers (κ = 0.88). The readers were concordant for TPS classes for 57 children (85%) and discordant for classes 2 (minor residua) versus 3 (major residua) in six (9%). Coronary arteries and branch pulmonary arteries were frequently suboptimally visualized. Although inter-reader agreement for TPS was strong, inter-reader variation in echocardiographic interpretations had a small, but important effect on TPS for TOF and ASO, particularly for the distinction between minor and major residua. Further studies of generalizability and reproducibility of TPS and refinement of scoring modules may be needed before it can be used as a tool to assess pediatric cardiac surgical performance and outcomes.

BACKGROUND:Subject recruitment for medical research is challenging. Slow patient accrual leads to increased costs and delays in treatment advances. Researchers need reliable tools to manage and predict the accrual rate. The previously developed Bayesian method integrates researchers' experience on former trials and data from an ongoing study, providing a reliable prediction of accrual rate for clinical studies.METHODS:In this paper, we present a user-friendly graphical user interface program developed in R. A closed-form solution for the total subjects that can be recruited within a fixed time is derived. We also present a built-in Android system using Java for web browsers and mobile devices.RESULTS:Using the accrual software, we re-evaluated the Veteran Affairs Cooperative Studies Program 558- ROBOTICS study. The application of the software in monitoring and management of recruitment is illustrated for different stages of the trial.CONCLUSIONS:This developed accrual software provides a more convenient platform for estimation and prediction of the accrual process.

Purpose Guidelines recommend systemic corticosteroids for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) albeit in lower doses than studies that cemented corticosteroids' place in therapy. Corticosteroids potentiate hyperglycemia, however it is undetermined how corticosteroid dose impacts hyperglycemia incidence. Objectives To establish whether a greater incidence of steroid-induced hyperglycemia (SIHGLY) exists for high- versus low-dose corticosteroids. Methods Patients with primary discharge diagnosis 491.21/491.22 in a community hospital were retrospectively reviewed and divided into tertiles based on corticosteroid dosage. Baseline characteristics and primary endpoint were statistically assessed between tertiles using logistic regression analysis. A Cox proportional hazards (CPH) model adjusted for potential covariates. Post hoc analysis for primary outcome and CPH model was run removing non-insulin dependent diabetics because of disproportionate event count. A secondary endpoint used a Kaplan-Meier curve to evaluate time to event between tertiles. Results Tertile divisions were 125 and 187.5 mg methylprednisolone equivalents. The primary outcome for incidence of SIHGLY was insignificant; post hoc analysis removing non-insulin-dependent diabetics narrowly missed significance between tertiles 1 and 3 ( P = .056). CPH analysis found significant differences in SIHGLY between tertiles 1 and 2 (hazard ratio [HR], 1.68; 95% CI, 1.02–2.76) and tertile 1 and 3 (HR, 1.79; 95% CI, 1.13–2.84), further post hoc analysis resulted in a loss of significance for the CPH analysis. Of 21 non-insulin-dependent diabetics, 20 met event status. The Kaplan-Meier analysis results were insignificant. Conclusions Study results suggest that a link between larger corticosteroid doses and hyperglycemia incidence may exist, but it requires further study. Results in non-insulin-dependent diabetics provide evidence for increased glucose monitoring upon initiation of corticosteroid therapy.

Background African Americans are disproportionately burdened by HIV. The African American church is an influential institution with potential to increase reach of HIV prevention interventions in Black communities. Purpose This study examined HIV testing rates in African American churches in the Taking It to the Pews pilot project. Using a community-engaged approach, church leaders delivered religiously-tailored HIV education and testing materials/activities (e.g., sermons, brochures/bulletins, testimonials) to church and community members. Methods Four African American churches (N=543 participants) located in the Kansas City metropolitan area were randomized to intervention and comparison groups. Receipt of an HIV test was assessed at baseline and 6 months. Results Findings indicated intervention participants were 2.2 times more likely to receive an HIV test than comparisons at 6 months. Church leaders delivered about 2 tools per month. Conclusions Church-based HIV testing interventions are feasible and have potential to increase HIV testing rates in African American communities.

Background: Postoperative echocardiography after congenital heart disease surgery is of prognostic importance, but variable image quality is problematic. We implemented a quality improvement bundle comprising of focused imaging protocols, procedural sedation, and sonographer education to improve the rate of optimal imaging (OI).Methods: Predischarge echocardiograms were evaluated in 116 children (median age, 0.51 years; range, 0.01-5.6 years) from two centers after tetralogy of Fallot repair, arterial switch operation, and bidirectional Glenn and Fontan procedures. OI rates were compared between the centers before and after the implementation of a quality improvement bundle at center 1, with center 2 serving as the comparator. Echocardiographic images were independently scored by a single reader from each center, blinded to center and time period. For each echocardiographic variable, quality score was assigned as 0 (not imaged or suboptimally imaged) or 1 (optimally imaged); structures were classified as intra-or extracardiac. The rate of OI was calculated for each variable as the percentage of patients assigned a score of 1.Results: Intracardiac structures had higher OI than extracardiac structures (81% vs 57%; adjusted odds ratio [OR], 3.47; P <.01). Center 1 improved overall OI from 48% to 73% (OR, 4.44; P <.01), intracardiac OI from 69% to 85% (OR, 3.53; P =.01), and extracardiac OI from 35% to 67% (OR, 5.16; P <.01). There was no temporal difference for center 2.Conclusions: After congenital heart disease surgery in children, intracardiac structures are imaged more optimally than extracardiac structures. Focused imaging protocols, patient sedation, and sonographer education can improve OI rates.

In a rat model of fat embolism (FE) induced by i.v. triolein (T), severe lung damage develops up to 10 weeks post treatment1. The damage which is reduced by concomitant administration of the angiotensin II type 1 receptor blocker losartan (Los)2 was associated with an elevated level of renin in the lungs.3 Reports indicate that mast cells (MCs) are associated with the renin increase observed in the lungs.4 FE damage, however, is not limited to the lungs. Hearts of the same rats had severe inflammation of the coronary arteries with medial thickening, reduced lumen patency, adventitial fibrosis, and myocardial inflammation, which was also blocked by Los.5 We have now extended our investigation of the heart to the potential role of mast cells (MCs) in the pathogenesis of cardiovascular damage.Twenty‐two Sprague Dawley rats (~300 gm BW) received either T (0.2 mL i.v.) or saline. Six weeks later, half of the rats of each subgroup were given Los or saline). Four weeks later (10 weeks post T injection), rats were euthanized with isoflurane, and necropsied. Hearts were fixed in 10% formalin and stained with H&E (morphometric scoring), trichrome (fibrosis) and CD 11‐c kit (MCs). On each heart slide 10 photographs were taken at random at 400× and MCs counted by two pathologists unaware of the slide identity.Severe vasculitis, perivascular fibrosis, and myocardial inflammation were present in the hearts of T treated rats vs saline controls. Los markedly reduced this damage, but had no effect on MCs in the presence of absence of T. MC number. T caused a non‐significant increase in MCs number compared to saline controls (20.7 +/− 5.3 vs 13.1 +/− 5.1: mean +/− STdev). The results suggest that, although MCs are present in hearts of rats 10 weeks after T where vascular inflammation and histopathological damage is similar to that observed in the lungs, their number is more modestly increased and not affected by Los treatment.The trend of an increase in MCs in the heart 10 weeks after T suggests a potential role of MCs in the pathogenesis of cardiovascular damage. Despite the severe inflammatory and vascular response and the protective effect of Los from perivascular fibrosis, the role of MCs in the heart at this late time after T may suggest different pathways or time course for histopathological changes compared to the lungs. It remains to be seen if the appearance of MCs in the heart after T is greater at earlier time points when the lung pathology is also greater.Support or Funding InformationMary Katherine Geldmacher Research Foundation, St. Louis, MO; This work was supported by a CTSA grant from NCRR and NCATS awarded to the University of Kansas Medical Center for Frontiers: The Heartland Institute for Clinical and Translational Research # TL1TR000120. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH, NCRR, or NCATS.

In a rat model of pulmonary fat embolism (FE) using triolein (T), we have shown that the long term histopathological effects of triolein‐induced FE extend to 10 weeks and are inhibited by losartan (LOS), an angiotensin II type 1 receptor blocker1 and augmented by a second hit with LPS2. These effects are associated with an increase in renin staining at 6 weeks3. Since other workers have implicated pulmonary mast cells (MC) in local renin‐angiotensin (RAS)‐mediated pulmonary pathology4, we examined whether FE in our model was associated with an increase in MC number and if their appearance would be blocked by LOS and modified by a second hit with LPS. 36 Sprague‐Dawley rats were treated with T (0.2 ml i.v.) or saline. After 6 weeks, half of the groups were given saline or LPS 0.1 ml (3 mg/kg) i.p., followed 1 hour later with saline or LOS (10 mg/kg i.p.), followed by LOS in the drinking water (50 mg/l). 4 weeks later (10 weeks after T), the animals were necropsied after isoflurane anesthesia. Lungs were fixed in 10% formalin and stained with H&E for morphometric scoring and for mast cells using CD11 (c‐kit). Portions of the lungs were frozen and stained for fat using Oil Red O. Two pathologists unaware of the slides’ identity took 10 photographs at random in each slide at 400× and then counted the mast cell number.MC number increased in T‐treated rats compared to saline controls (57.2 +/− 2.5 vs 20.0 +/− 2.3) (mean+/− SEM) (p=0.005). The MC count when T was followed by LPS rose to 66.8 +/− 14.5 (p=0.001 compared to saline). LPS or LOS alone did not cause a significant increase in MC (35.0 +/− 8.5 and 28.2 +/− 2.6, respectively.) The increases in MC caused by T and T+LPS were both blocked by LOS: (T+LOS 14.9 +/− 2.9; T+LPS+LOS 32.5 +/− 4.6; p=0.75 and 0.99 compared to LOS alone.The appearance of fat globules at 10 weeks was greatly reduced from what we reported for rats at 6 weeks3 but they were increased in T‐treated rats compared to saline controls.The results support suggestions that MC‐associated renin through its eventual product angiotensin II plays an important role in the histopathological changes produced by FE and the second hit with LPS. In addition, the presence of fat globules in the lungs 10 weeks after the initial challenge with T suggests that their continued presence may be important for the enhanced presence of MC in response to low grade inflammation. A role for macrophage signaling in this sequence is also supported5.Support or Funding InformationMary Katherine Geldmacher Research Foundation, St. Louis, MO

To the Editor: Dermatologic conditions are often addressed in the outpatient pediatric setting, but pediatric dermatology remains an underserved subspecialty and education for pediatrics providers in dermatology is lacking.1Freed G.L. Dunham K.M. Switalski K.E. Jones Jr., M.D. McGuinness G.A. Research Advisory Committee of the American Board of PediatricsRecently trained general pediatricians: perspectives on residency training and scope of practice.Pediatrics. 2009; 123: S38-S43Crossref PubMed Scopus (75) Google Scholar, 2Sellheyer K. Bergfeld W.F. A retrospective biopsy study of the clinical diagnostic accuracy of common skin diseases by different specialties compared with dermatology.J Am Acad Dermatol. 2005; 52: 823-830Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 3Prindaville B. Antaya R.J. Siegfried E.C. Pediatric dermatology: past, present, and future.Pediatr Dermatol. 2015; 32: 1-12Crossref Scopus (44) Google Scholar, 4Valderas J.M. Starfield B. Forrest C.B. Rajmil L. Roland M. Sibbald B. Routine care provided by specialists to children and adolescents in the United States (2002-2006).BMC Health Serv Res. 2009; 9: 221Crossref PubMed Scopus (27) Google Scholar We sought to identify common outpatient pediatric dermatology diagnoses to identify high-yield educational topics. We analyzed the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) databases from 2006 through 2010 for visits including patients aged 0 to 18 years. We categorized visits as dermatology-related by the presence of 1 of the 25 most common pediatric dermatology conditions identified in prior studies5Wilmer E.N. Gustafson C.J. Ahn C.S. Davis S.A. Feldman S.R. Huang W.W. Most common dermatologic conditions encountered by dermatologists and nondermatologists.Cutis. 2014; 94: 285-292Google Scholar and our clinical experience. Visits were compared using the discharge diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. Sampling error was calculated using software (Stata, Stata Corp, College Station, TX) and only sample data based on at least 30 sample records were included as recommended by the Centers for Disease Control and Prevention (CDC). Detailed information on the surveys' methodologies can be found on the CDC Web site. This study was considered exempt by our hospital institutional review board. In all, 23 million (9%) of all outpatient pediatric visits included one of the dermatology diagnoses examined in our study. Six diagnoses accounted for approximately 70% of pediatric visits for a dermatologic symptom, including contact dermatitis, acne, skin and soft-tissue infections, dermatitis not otherwise specified, viral warts, and atopic dermatitis (Table I). Contact dermatitis was the most common pediatric dermatology diagnosis seen in hospital-based and private practice outpatient clinics, but skin and soft-tissue infection was the most common in the emergency department (Fig 1). Pediatricians and family practitioners saw similar percentages of diagnoses with contact dermatitis being the most common. Approximately 60% of pediatric visits to dermatologists were for diagnoses of acne or viral warts (Fig 1).Table INumber of visits for each dermatology diagnosis and percentage of patients with each diagnosis as a proportion of all pediatric patients with a dermatology diagnosisDiagnosisNo. of visits for the diagnosis (in millions)Patients with the diagnosis, %Contact dermatitis5.423.2Acne3.012.8Skin and soft-tissue infections2.611.3Dermatitis NOS1.98.1Viral warts1.87.6Atopic dermatitis1.56.3Tinea infection1.25.4Arthropod bite1.04.4Diaper dermatitis1.04.3Viral diseases with exanthem1.04.2Urticaria0.83.5Impetigo0.83.5Benign neoplasm of the skin0.52.2Molluscum0.52.1Infestation0.51.9Seborrheic dermatitis0.41.8Vascular lesion0.31.2Dyschromia0.31.2Candida infection0.20.9Alopecia0.20.7Tinea versicolor0.20.7Pityriasis rosea0.10.6Psoriasis0.10.5NOS, Not otherwise specified. Open table in a new tab NOS, Not otherwise specified. Our study was based on diagnosis codes as coded by providers and thus relies on providers identifying and coding the correct diagnosis for each patient visit. Because of the nature of the NAMCS and NHAMCS databases, our study is also an extrapolation of representative sample data to national estimates. Thus, the percentages we have reported are approximations. Dermatologic conditions in children are commonly addressed in the outpatient setting, however, pediatricians consistently report dermatology as a specialty area in which they could have used more training.1Freed G.L. Dunham K.M. Switalski K.E. Jones Jr., M.D. McGuinness G.A. Research Advisory Committee of the American Board of PediatricsRecently trained general pediatricians: perspectives on residency training and scope of practice.Pediatrics. 2009; 123: S38-S43Crossref PubMed Scopus (75) Google Scholar Studies also indicate large discrepancies in diagnostic accuracy between dermatologists and pediatricians,2Sellheyer K. Bergfeld W.F. A retrospective biopsy study of the clinical diagnostic accuracy of common skin diseases by different specialties compared with dermatology.J Am Acad Dermatol. 2005; 52: 823-830Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar and misdiagnosis can be costly. Because of workforce shortages, pediatric dermatology is an underserved subspecialty, with the third highest referral rate, but some of the longest wait times.3Prindaville B. Antaya R.J. Siegfried E.C. Pediatric dermatology: past, present, and future.Pediatr Dermatol. 2015; 32: 1-12Crossref Scopus (44) Google Scholar Dermatology is also among the top-3 subspecialties to provide routine follow-up care to pediatric patients.4Valderas J.M. Starfield B. Forrest C.B. Rajmil L. Roland M. Sibbald B. Routine care provided by specialists to children and adolescents in the United States (2002-2006).BMC Health Serv Res. 2009; 9: 221Crossref PubMed Scopus (27) Google Scholar After a diagnosis and treatment plan are established, returning care to primary care providers for common conditions could make more appointments available to patients with urgent and complex conditions. Educating trainees and providers about common pediatric dermatology diagnoses therefore has the potential to impact many lives. Creating a targeted educational curriculum, including online tutorials, for trainees and health care providers based on the most common dermatologic diagnoses we identified could help alleviate the pediatric dermatology workforce shortage and improve quality of care for many children. We would like to acknowledge Dr Vidya Sharma for her contribution to this study's concept and her thoughtful review of the manuscript. No compensation was received for her contribution.