Leadership and organization development in health-care: lessons from the Cleveland Clinic.

Leaders in health-care today are faced with a wide array of complex issues. This chapter describes an innovative physician leadership development program at the Cleveland Clinic intended to enhance the leadership capacities of individuals and the organization. Propositions regarding the program's impact on organizational innovation, organizational commitment, social capital, and the human element of physician practice are offered for future examination.

History of Mohs surgery.

Mohs micrographic surgery (MMS) has become the gold standard for treating many forms of primary and recurrent contiguous skin cancers and offers the highest cure rates and maximum tissue conservation compared with other modalities. Developed by Dr Frederic E. Mohs in the 1930s, it was initially called chemosurgery and used zinc chloride paste in a process called fixed tissue technique. Although this technique had high cure rates, it could take days to complete, and it gradually gave way to fresh tissue technique, renamed MMS. Now, MMS is practiced widely as part of a multidisciplinary approach for treating skin cancer.

Noninvasive fluorescence monitoring of protoporphyrin IX production and clinical outcomes in actinic keratoses following short-contact application of 5-aminolevulinate.

Topical 5-aminolevulinic acid (ALA) is widely used in photodynamic therapy (PDT) of actinic keratoses (AK), a type of premalignant skin lesion. However, the optimal time between ALA application and exposure to light has not been carefully investigated. Our objective is to study the kinetics of protoporphyrin IX (PpIX) accumulation in AK after short contact ALA and relate this to erythemal responses. Using a noninvasive dosimeter, PpIX fluorescence measurements (5 replicates) were taken at 20-min intervals for 2 h following ALA application, in 63 AK in 20 patients. Data were analyzed for maximal fluorescent signal obtained, kinetic slope, and changes in erythema. Our results show that PpIX accumulation was linear over time, becoming statistically higher than background in 48% of all lesions by 20 min, 92% of lesions by 1 h, and 100% of lesions by 2 h. PpIX accumulation was roughly correlated with changes in lesional erythema post-PDT. We conclude that significant amounts of PpIX are produced in all AK lesions by 2 h. The linear kinetics of accumulation suggest that shorter ALA application times may be efficacious in many patients. Noninvasive fluorescence monitoring of PpIX may be useful to delineate areas of high PpIX accumulation within precancerous areas of the skin.

Physician management and leadership education at the Cleveland Clinic Foundation: program impact and experience over 14 years.

As the challenges of leading in healthcare become more complex, healthcare institutions have increasingly emphasized the importance of leadership training for physicians. Several institutions have offered in-house training programs. This paper describes the 14-year experience and evolution of physician leadership development training at the Cleveland Clinic. We describe the curriculum, organization, and goals of the Leading in Health Care course, which is offered to high-potential physician leaders. As a metric of the success of this physician leadership effort, we report the number and types of business plans developed in the course that have been either implemented at the Cleveland Clinic or have directly affected plans for program implementation.

Topical protease therapy as a novel method of epidermal ablation: preliminary report.

BACKGROUND: For more than 50 years, proteolytic enzymes have been extensively used in laboratory settings for the purposes of in vitro epidermal separation and keratinocyte isolation. However, the topical, in vivo pharmacologic properties of these enzymes are virtually unknown. Previous therapeutic applications for topically applied proteases have been limited to wound debridement. OBJECTIVE: To characterize the clinical and histologic effects of topically applied proteases as a method of therapeutic epidermal ablation. MATERIALS AND METHODS: SKH-1 hairless mouse and human skin samples were exposed both in vitro and in vivo to varying concentrations of the proteases subtilisin, trypsin, and dispase for different exposure durations. The effects of protease exposure were then assessed by both clinical and histologic examination. RESULTS: Exposure of both human and mouse skin samples to topical protease solutions resulted in reproducible, differential patterns of epidermal ablation: subcorneal, intraepidermal, and subepidermal. In a limited study, topical application of trypsin solution resulted in the scar-free ablation of lesions of seborrheic keratosis located on the lower extremity. CONCLUSION: Topically applied proteases represent an alternative method of epidermal ablation with several potential advantages over existing techniques. Further studies are needed to delineate ideal enzyme formulations, vehicles, and applications.

Primary melanoma of the umbilicus: report of a case and review of the relevant anatomy.

BACKGROUND: Malignant melanoma presenting on the umbilicus is rare. Treatment of melanoma on the umbilicus is difficult because of the unusual anatomy of the umbilicus. OBJECTIVE: To present the case of a patient with a primary malignant melanoma of the umbilicus and to discuss treatment concerns that are relevant to the umbilical anatomy. METHODS: This is a case report as well as a review of the pertinent anatomy. RESULTS: The initial excision was read as having clear deep and lateral margins on histopathologic examination. Postoperative complications led to a re-excision down to and including the umbilical attachment to the peritoneum. The re-excision revealed residual primary cutaneous malignant melanoma in a remnant umbilical cyst. CONCLUSION: When a malignant melanoma is located on the vertical sidewall or bottom of the umbilicus, one should consider surgical excision down to peritoneum, including the umbilical attachment to the peritoneum. Because this is beyond the scope of training for most dermatologic surgeons, it would be appropriate to refer these patients to a surgical oncologist or a plastic surgeon.

Metastatic basal cell carcinoma presenting as unilateral axillary lymphadenopathy: report of a case and review of the literature.

BACKGROUND: Although basal cell carcinoma (BCC) is one of the most common forms of cancer worldwide, the incidence of metastatic basal cell carcinoma (MBCC) is exceedingly low. Of reported cases, it is estimated that up to 85% arise in the head and neck region. OBJECTIVE: Case presentation of a BCC measuring 1.1 cm arising in a nonfacial site that presented with unilateral axillary lymphadenopathy. METHODS: Case presentation with literature review. RESULTS: Risk factors which should lead to a higher index of suspicion among clinicians for identifying these patients include large tumor size, previous irradiation, local invasion, and recurrence. The lymph nodes, lungs, bones, and skin are among the most common sites in which metastases arise. CONCLUSION: We report an unusual case of MBCC arising from a small, nonfacial primary BCC that presented with unilateral axillary lymphadenopathy.