Mycobacterial tissue culture positivity in the work-up of suspected cutaneous infection in a rural dermatology patient population.

Dermatologists may be over-ordering mycobacterial tissue cultures when performing the broad work-up of skin infection. The objective of this study was to determine mycobacterial tissue culture positivity in the work-up of suspected skin infection. This was a retrospective cohort study including patients biopsied for mycobacterial tissue cultures performed by dermatology providers from 2006 to 2020 in a large Midwestern US rural healthcare system. Main outcomes and measures were mycobacterial tissue culture positivity rates by body location, immunocompromised status, clinical setting, and exposure history. There were 552 mycobacterial tissue culture results from 515 patients, resulting in mycobacterial culture positivity in 13 cases (2.4%). Of these, 12 (92.3%) were outpatients, 9 occurred in immunocompromised patients (69.2%, P = 0.02), and 8 (61.5%) were from upper extremity lesion biopsies (P = 0.007). Lower extremity lesions were significantly associated with decreased mycobacterial culture positivity (P = 0.038). Trauma and environmental water exposures were not associated with mycobacterial tissue culture positivity. The rate of mycobacterial tissue culture positivity is low. Mycobacterial tissue cultures should particularly be targeted in patients who are immunocompromised and patients with upper extremity lesions. Automatic inclusion of mycobacterial tissue culture for skin infection work-up may not be necessary.

Electrodesiccation and Curettage for Squamous Cell Carcinoma in Situ: The Effect of Anatomic Location on Local Recurrence.

BACKGROUND: Electrodesiccation and curettage (EDC) is a common, minimally invasive treatment of cutaneous squamous cell carcinoma in situ (SCCIS). OBJECTIVE: Determine the 5-year recurrence rate of EDC for SCCIS and to determine if this differs by anatomic location. METHOD AND MATERIALS: A retrospective, single-center, cohort study of patients treated between January 1, 2000, and January 1, 2017, with at least 5 years of follow-up. The overall 5-year recurrence rate of EDC for SCCIS was calculated and compared across low-risk (L), moderate-risk (M), and high-risk (H) anatomic zones. RESULTS: Five hundred ten tumors were randomly identified from 367 unique patients. The 5-year recurrence rate of the entire cohort was 5.3%. There was no significant difference in recurrence by clinical size or immunosuppressed status. One hundred thirty-four tumors in the L zone were matched 1:1:1 to tumors in the M and H zones. The 5-year recurrence rate of M zone tumors (8.2%) and H zone tumors (6.0%) were higher than the recurrence rate of a L zone tumors (3.0%), but this was not statistically significant ( p = .075 and p = .247, respectively). CONCLUSION: Electrodesiccation and curettage allows for a high 5-year cure rate across a broad range of anatomic sites. However, overall cure rate should be individualized by anatomic location when counseling patients.

Geographic variability in rural patient internet connectivity when accessing telehealth services from home: A retrospective analysis during the COVID-19 pandemic.

PURPOSE: Telehealth at home (TAH) is a means of providing patient care that is increasingly utilized by health care organizations. It is crucial to identify factors, such as internet accessibility, that might impact the ability of patients to make use of such services. METHODS: A retrospective analysis was conducted using real-time data from audio-visual telehealth encounters conducted using the Cisco Webex Meetings platform from April 22, 2020 to May 26, 2020, and originating from a single rural health care system in the state of Wisconsin. Quality scores were determined for each encounter, and comparative call qualities were mapped to demonstrate zones of poor and unacceptable quality throughout the service area. FINDINGS: Of 3,962 encounters meeting the study criteria, 746 (18.8%) had poor or unacceptable quality, with 116 of poor or unacceptable encounters failing to connect, and greater than 1 in 20 encounters (5.8%) requiring conversion to a telephone-only visit. Geographic mapping of encounters with poor to unacceptable quality highlights numerous locations throughout the service area that suffer from connectivity issues. CONCLUSIONS: In our study, there is wide and unpredictable variability in the quality of TAH encounters throughout the service area, which impacts the ability of patients living in rural areas to access timely and effective care. Our study supports the need for further infrastructure changes to improve internet connection quality in rural areas, with implications that extend beyond the current COVID-19 pandemic.

Milestones 2.0: An advancement in competency-based assessment for dermatology.

In 2013, Next Accreditation System and Milestones became the competency-based assessment framework required for all specialties accredited by the Accreditation Council for Graduate Medical Education. Dermatology residency programs implemented Milestones 1.0 in the 2013-2014 academic year. The Accreditation Council for Graduate Medical Education committed to review and revise Milestones 1.0 within 3 to 5 years. Subsequently, feedback from key stakeholders influenced the goals for revision, including reducing complexity, enhancing community engagement, and providing additional resources for programs. In 2019, the Dermatology Milestones 2.0 work group streamlined the specialty-specific patient care and medical knowledge subcompetencies. The harmonized milestones allowed for greater uniformity across specialties in systems-based practice, practice-based learning and improvement, professionalism, and interpersonal communication and skills. The work group developed a supplemental guide with specialty-specific context to help program directors, clinical competency committee members, and other faculty understand individual milestones. Dermatology Milestones 2.0 reduces the number of subcompetencies from 28 to 21. Milestones 2.0 represents an advancement in competency-based assessment for dermatology. The first year of reporting for Dermatology Milestones 2.0 is 2021.

Psoriasis Flares Following Systemic Glucocorticoid Exposure in Patients With a History of Psoriasis.

Importance: To our knowledge, this study is the first to assess the rate of any type of psoriasis flare during or immediately following the administration of systemic corticosteroids in patients with a known history of psoriasis. Objective: To determine the rates and types of psoriasis flares during or within 3 months after concluding systemic corticosteroid administration in adult patients with a known history of psoriasis. Design, Setting, and Participants: This retrospective cohort study assessed adult patients (≥18 years at the time of psoriasis diagnosis) evaluated in the Marshfield Clinic Health System (Marshfield, Wisconsin) with an established diagnosis of psoriasis and exposure to at least 1 systemic corticosteroid from October 31, 2012, to July 1, 2018. Exclusion criteria were patients younger than 18 years, patients with a diagnosis of psoriatic arthritis, and patients receiving only topical, intraarticular, or intrabursal corticosteroids. Main Outcomes and Measures: The primary outcome was rate of psoriasis flares during or within 3 months of discontinuation of the patient's first course of systemic corticosteroids. Secondary measures included rates of specific types of psoriasis flares, including pustular, erythrodermic, and worsening plaque stage psoriasis. Results: Of 516 cohort patients, 288 (55.8%) were women, and the mean (SD) age at first psoriasis diagnosis was 49.6 (17.0) years. Among 1970 patients with a diagnosis of psoriasis before receiving systemic corticosteroids, a 1.42% (95% CI, 0.72%-2.44%) psoriasis flare rate of any type was identified when prescribed their first course of systemic corticosteroids. Further stratification identified only 1 severe flare (erythroderma) among all flares reported, with no pustular psoriasis flares identified (0.07%; 95% CI, 0.00%-0.26%). Conclusions and Relevance: In this study, the rates of psoriasis flares were low, especially for severe psoriasis flares. Our results suggest that systemic steroids may be much less likely to trigger severe flares in patients with psoriasis than what is traditionally taught in dermatology.

The heightened focus on wellness in dermatology residency education.

Dermatology residents and dermatology faculty members experience stress in the workplace, placing them at risk for burnout. As a profession, dermatologists have one of the fastest growing rates of burnout clinical manifestations across all specialties. The Accreditation Council for Graduate Medical Education has revised its program requirements for residency programs to include greater emphasis on actions to promote wellness. Examples of actions to promote wellness that are used currently in dermatology and other residency and medical education settings are explored.

Assessment of Topical Corticosteroid Prescribing, Counseling, and Communication Among Dermatologists and Pharmacists.

Importance: Topical corticosteroids (TCs) are common treatments for many dermatologic conditions. Anecdotal experience and literature suggest that dermatologists and pharmacists differ in their beliefs about TCs and approach to TC counseling, creating the opportunity for patient confusion. Objective: To examine interprofessional practice gaps between dermatologists and pharmacists with regard to how each group views TCs, counsels patients on TC use, and communicates modifications to TC prescriptions. Design, Setting, and Participants: An electronic survey was disseminated statewide in Wisconsin to 117 board-certified or eligible dermatologist members of the Wisconsin Dermatological Society and 2954 licensed pharmacists. The survey was performed from October 11, 2017, to January 2, 2018. Survey responses and demographic information were compiled and analyzed for each population. Exposures: Study participants completed and returned a 17-question survey recalling experiences with TC prescribing from the past year along with self-reported demographic information. Main Outcomes and Measures: Dermatologists' and pharmacists' self-reported counseling of patients regarding TC application, duration of use, and adverse effects; frequency of communication of changes to TC prescriptions and instructions; and demographic data were tabulated and compared. Results: Of the 117 dermatologists, 52 (44.4%) completed and returned the survey; of the 2954 pharmacists, 111 (3.8%) returned the survey. Those no longer in active practice (3 dermatologists, 1 pharmacist) were excluded from analysis. A substantial proportion of pharmacists (51 [46.4%]) advised patients to limit TC use to 2 weeks or less, which was an uncommon strategy among dermatologists (3 [6.1%]) (P < .001). Discordance also was noted in the adverse effects that are emphasized in counseling, pharmacist-perceived and dermatologist-observed adverse effects in patients, and resources that inform counseling content. Only 8 (16.3%) dermatologists perceived that pharmacists made no unauthorized modifications to their TC prescriptions or instructions; however, 77 (70.0%) pharmacists reported not doing so (P < .001). Conclusions and Relevance: An interprofessional practice gap appears to exist between dermatologists and pharmacists in Wisconsin regarding TC beliefs and counseling strategies. Collaborative education and improved communication between the 2 groups may be necessary to ensure that patients receive a unified, clear message about TC application and adverse effects. Larger studies are needed to further investigate this potential practice gap.

A Simulation-Based Workshop to Improve Dermatologists' Communication Skills: A Pilot for Continuing Medical Education.

INTRODUCTION: Communication skills influence the quality of health care and patient experience; both may affect provider reimbursement. There are few opportunities available for practicing physicians to receive direct feedback on communication in patient encounters. The purpose of this simulation-based patient encounter workshop was for dermatologists to practice and obtain feedback on their communication skills. METHODS: In March 2016, dermatologists participated in a workshop with four simulated patient encounters. Cases were developed based on a prior needs assessment. Standardized patient educators evaluated participants' communication using the Master Interview Rating Scale and provided verbal feedback. Physicians rated the usefulness of the simulation and the feedback received through a survey upon workshop completion. RESULTS: Of the 170 physicians who registered, 103 participated in the simulation. The workshop was highly rated in meeting its three learning objectives (score of 4.5-4.6 out of a maximum score of 5). The lowest-rated communication skills were as follows: allowing the patient to share their narrative thread (3.1), summarizing the patient's history from the provider (3.8), and assessing patient understanding (3.8). CONCLUSIONS: Participants reported that this communication workshop effectively satisfied its learning objectives. Opportunities to practice and improve communication skills as part of continuing medical education will benefit the clinical experience of patients and physicians alike, and the workshop may be formatted to serve physicians of other specialties. The lowest-scoring communication areas identified in this study present an opportunity to develop a tailored curriculum for physician-patient communication in the future.

Utility of Laboratory Test Result Monitoring in Patients Taking Oral Terbinafine or Griseofulvin for Dermatophyte Infections.

Importance: Terbinafine hydrochloride and griseofulvin are effective oral treatments for dermatophyte infections but have been associated with hepatic and hematologic abnormalities. The prevalence of alanine aminotransferase elevations, aspartate aminotransferase elevations, anemia, lymphopenia, and neutropenia among adults and children taking terbinafine and griseofulvin is unclear. Objective: To measure the rate of laboratory test result abnormalities in healthy adults and children taking terbinafine or griseofulvin for dermatophyte infections. Design, Setting, and Participants: This retrospective study assessed adults and children taking terbinafine or griseofulvin for dermatophyte infections from January 1, 2006, to December 31, 2016. Data were collected from one Midwest health care system. Exclusion criteria were preceding diagnosis of hepatic or hematologic condition and preceding or concurrent use of oral ketoconazole, amphotericin, or itraconazole. Main Outcomes and Measures: The rates of elevated alanine aminotransferase measurements, elevated aspartate aminotransferase measurements, anemia, lymphopenia, and neutropenia in adults and children taking terbinafine, griseofulvin microsize, or griseofulvin ultramicrosize were calculated. Secondary measures included rates of baseline abnormalities, frequency of laboratory test results that required additional testing or discontinued use of medication, and laboratory test result monitoring practices. Results: This study included laboratory data from 4985 patients (mean [SD] age, 42.8 [20.3] years; 2288 [45.9%] female) receiving 4309 courses of terbinafine, 634 courses of griseofulvin microsize, and 159 courses of griseofulvin ultramicrosize. We identified a low rate of laboratory test result abnormalities in patients taking terbinafine or griseofulvin. When laboratory test result abnormalities occurred, most were low grade (212 [93.4%] grade 1) and did not require subsequent laboratory test result evaluation or discontinued use of medication (15 051 [99.9%]). Elevations in alanine aminotransferase measurements were detected infrequently and were comparable to baseline detection rates (61 [3.5%] vs 95 [3.6%] for terbinafine, 2 [2.1%] vs 3 [3.7%] for griseofulvin microsize, and 0 vs 2 [5.0%] for griseofulvin ultramicrosize). Rates of elevated aspartate aminotransferase measurements, anemia, lymphopenia, and neutropenia were also infrequent and comparable to baseline rates. Conclusions and Relevance: In this study. the rates of alanine aminotransferase elevations, aspartate aminotransferase elevations, anemia, lymphopenia, and neutropenia in adults and children taking terbinafine or griseofulvin were low and equivalent to the baseline rates of abnormalities in this population. Routine interval laboratory test result monitoring appears to be unnecessary in adults and children without underlying hepatic or hematologic conditions taking terbinafine or griseofulvin for dermatophyte infections. Abandoning frequent laboratory monitoring can decrease unnecessary health care spending, decrease patient psychological angst associated with blood draws, and allow for expanded use of these effective oral medications.

Measuring the Depth of Perineural Invasion in Cutaneous Squamous Cell Carcinoma: Implications on Biopsy Technique.

BACKGROUND: Perineural invasion (PNI) is a high-risk feature of cutaneous squamous cell carcinoma (CSCC). Depths at which PNI occurs are unknown. OBJECTIVE: To determine the most superficial depth at which PNI occurs in CSCC and stratify by tumor clinical diameter and body location. METHODS AND MATERIALS: Single-institution retrospective review of CSCC specimens reporting PNI on pathology reports between January 2004 and August 2014. Depth was defined as distance from top of granular layer to middle of nerve invaded by CSCC or distance from erosion to middle of nerve affected by CSCC. RESULTS: Of 66 specimens identified with PNI, 45 specimens were included. Mean histopathologic depth to PNI was 2.7 mm (SD = 1.8 mm, median depth = 2.2 mm, range 0.5-12 mm). Perineural invasion depth varied by anatomic location, with the head associated with most superficial average PNI depth (2.2 mm) and trunk with greatest average PNI depth (4.3 mm). Perineural invasion depth correlated with clinical tumor diameter. The largest percentage of specimens with PNI were of clinical diameter of at least 2 cm (20/45 = 44%). CONCLUSION: Clinicians encountering lesions suspicious for CSCC have the greatest chance of detecting PNI using biopsy techniques that reach at least 3 to 4 mm deep.