Identifying critical quality metrics in Mohs Surgery: A national expert consensus process

BACKGROUND

Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care.

OBJECTIVE

The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS.

METHODS

Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives.

RESULTS

Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback.

LIMITATIONS

Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes.

CONCLUSION

With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

Dermatologic Conditions of the External Ear: Basics, Updates, and Pearls

Cutaneous diseases of the ear encompass a wide range of symptoms, complaints, and factors that negatively impact patients' well-being. These observations are frequently encountered by otolaryngologists and other physicians who treat individuals with ear-related issues. In this document, we aim to offer up-to-date information on diagnosing, predicting outcomes, and treating commonly occurring ear diseases.

Needs and Gaps in Resident Trainee Education, Clinical Patient Care, and Clinical Research in Cosmetic Dermatology: Position Statement of the Association of Academic Cosmetic Dermatology

Cosmetic dermatology is a key subspecialty of academic dermatology. As such, academic centers are expected to demonstrate excellence in the teaching of cosmetic dermatology skills to trainees, the clinical delivery of cosmetic dermatology services to patients, and the performance of clinical research that advances knowledge and uncovers new therapies in cosmetic dermatology. The Association of Academic Cosmetic Dermatology (AACD), a newly formed medical professional society, includes as its principal aims the support of all of these areas. AACD is comprised of group of board-certified dermatologists who teach cosmetic and laser dermatology at US dermatology residency programs. An expert panel constituted by the AACD recently convened a workshop to review gaps pertaining to academic cosmetic dermatology. This panel considered needs and potential corrective initiatives in three domains: resident education, patient experience, and clinical research. The work of the panel was used to develop a roadmap, which was adopted by consensus, and which will serve to guide the AACD moving forward.

Review of Cutaneous Repairs on the Hand and Fingers Following Dermatologic Surgery

Removal of cutaneous malignancies on the hand and fingers can result in challenging surgical defects to close. The dermatologic surgeon must not only be highly skilled, but also be knowledgeable regarding the complex anatomy of this area to perform reconstruction that provides optimal functional and cosmetic results. This review highlights key anatomic factors that must be considered when operating in this region. Wound management options discussed below include secondary intention, primary linear repair, local skin flaps, interpolation flaps, and skin grafting. The surgeon's choice is based on defect size, the presence/absence of adjacent skin laxity, and other patient-specific factors that may impact healing such as medical comorbidities, utilization of anticoagulant medications, and smoking status. This manuscript serves as an up-to-date review of closure considerations and techniques for physicians who surgically treat cutaneous malignancies of the hand and fingers.

Perspectives of Dermatology Program Directors on the Impact of Step 1 Pass/Fail

INTRODUCTION

The shift of Step 1 to Pass/Fail has generated several questions and concerns about obtaining residency positions among allopathic and osteopathic students alike. Determining the perspectives of Dermatology Program Directors in regards to post-Step 1 Pass/Fail is critical for students to better prepare for matching into dermatology.

METHODS

After receiving Institutional Review Board (IRB) exemption status, the program directors were chosen from 144 Accreditation Council for Graduate Medical Education (ACGME) and 27 American Osteopathic Association (AOA) Dermatology programs using contact information from their respective online website databases. An eight-item survey was constructed on a three-point Likert scale, one free text response, and four demographic questions. The anonymous survey was sent out over the course of three weeks with weekly individualized reminder requests for participation.

RESULTS

A total of 54.54% of responders had "Letters of Recommendation" in their top 3. Forty-five percent of responders had "Completed Audition Rotation at Program" in their top 3. And, 38.09% of responders had "USMLE Step 2 CK Scores" in their top 3.

CONCLUSION

Approximately 50% of responders agreed that all medical students will have more difficulty matching dermatology. Based on the survey study, Dermatology program directors want to focus more on letters of recommendation, audition rotations, and Step 2 CK scores. Because each field seems to prioritize different aspects of an application, students should attempt to gain as much exposure to different fields such as through research and shadowing to narrow down their ideal specialties. Consequently, the student will have more time to tailor their applications to what residency admissions are looking for.

A rare case of lues maligna in an HIV-negative woman

We describe an HIV-negative 43-year-old woman presenting with a diffuse ulceronodular eruption and positive serological tests for syphilis consistent with lues maligna. Lues maligna is a severe and rare variant of secondary syphilis characterized by prodromal constitutional symptoms followed by the formation of multiple well-circumscribed nodules with ulceration and crust. This case depicts a particularly rare presentation as lues maligna usually involves HIV-positive men. The clinical presentation of lues maligna can pose a diagnostic challenge, with infections, sarcoidosis, and cutaneous lymphoma as just a few entities in its broad differential diagnosis. However, with a high index of suspicion, clinicians can diagnose and treat this entity earlier and reduce morbidity.

Stepping back: Impact of pass-fail Step 1 scoring on dermatology applicants

The United States Medical Licensing Examination (USMLE) Step 1 recently transitioned to a pass-fail system from their three-digit scoring system. The implications of this change will ultimately influence medical students, residency programs, and, most importantly, patients. This article seeks to address some of the varying ethical and practical effects of this conversion to a pass/fail examination.

Postoperative Surgical Site Infection Rate in Patients with Diabetes following Mohs Micrographic Surgery: A Retrospective Analysis

BACKGROUND

Incidence of surgical site infection (SSI) following Mohs micrographic surgery (MMS) among patients with diabetes is largely unknown.

OBJECTIVE

Evaluate diabetes as a potential SSI risk factor in MMS by comparing SSI incidence in a cohort of patients with and without diabetes.

METHODS

5-year retrospective review to determine SSI rate in patients with diabetes compared to patients without diabetes. SSI incidence in patients with diabetes was further compared by A1c, and the impact of antibiotics on SSI rate was also examined.

RESULTS

Overall rate of SSI was 1.47% (53/3,597 cases). SSI rate among patients with diabetes was 1.95% (14/719 cases) compared to 1.35% (39/2,878 cases) in patients without diabetes, with a non-significant odds ratio for SSI of 1.45 (95% CI = 0.78-2.68, p = 0.241). Multivariable logistic regression analysis revealed no difference in SSI. Stratification of diabetic patients by A1c into ≥7.0 and <7.0 compared to patients without diabetes yielded no statistically significant difference in SSI among all groups (p = 0.815). Whether an antibiotic was prescribed did not significantly impact SSI rate between groups.

CONCLUSION

No significant difference in postoperative SSI was found in patients with diabetes compared to patients without diabetes following MMS regardless of degree of glycemic control.

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement

IMPORTANCE

There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs).

OBJECTIVE

To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs.

EVIDENCE REVIEW

Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses.

FINDINGS

The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC.

CONCLUSIONS AND RELEVANCE

Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Healthcare Students’ Perception of Social Distancing during the 2019 Coronavirus Pandemic: A Cross-Sectional Survey

Background: Since the implementation of social distancing practices during the global coronavirus disease 2019 (COVID-19) pandemic there have been a myriad of definitions for ‘social distancing.’ The objective of this study was to determine students’ awareness of the various definitions of social distancing, how strictly they adhered to social distancing guidelines, and how they perceived the importance of various social distancing practices.  Methods: This cross-sectional survey was distributed via email to students at Emory-affiliated graduate schools, including the Medical, Nursing, and Public Health Schools. Results: Of the 2,453 recipients of the survey, 415 students responded (16.9% response rate). The majority of respondents were medical students (n=225, 55.6%). Of the respondents, 357 noted that they “frequently” or “always” abided by social distancing. The most common definition of social distancing with which respondents were familiar was the Centers for Disease Control and Prevention (CDC)’s (n=276 of 369 responses, 74.8%). There were significant differences across groups  when grouping students by the definition of social distancing that they were aware of, the social distancing guideline they most closely followed, and their school of attendance regarding the importance of specific social distancing examples (p<0.05 for each). Conclusions: A survey of healthcare students identified differences in the importance of social distancing practices based on the definition of social distancing that they were aware of. The results of this study underscore the importance of having unified definitions of public health messaging, which ultimately may impact disease spread.

Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus

BACKGROUND

Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence.

OBJECTIVE

To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction.

METHODS

This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval.

RESULTS

Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid.

CONCLUSION

Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

Cannabinoids in dermatologic surgery

Though known as a medicinal herb for centuries, the recent legalization of cannabinoids across many states has ushered in a new era where cannabinoids have become a popular treatment option among clinicians and patients alike. Cannabinoids have demonstrated efficacy in wound healing, reducing inflammation, ameliorating pain, and have shown potential as an antitumor agent. As a result, cannabinoids have been rapidly woven into the fabric of modern medicine. However, the utility of cannabinoids in dermatologic surgery has not been explored to date. In this article, we review the current literature to discuss the potential impact of cannabinoid use in dermatologic surgery.

Augmented reality: a novel means of measurement in dermatology

Accurate measurement of skin lesions influences diagnosis, treatment, disease monitoring, prognosis, and even reimbursement in the practice of dermatology. As dermatologists expand technology that is integrated in patient care, measurement has the opportunity to become more accurate, more easily integrated into daily practice, and more easily incorporated into the realm of research. Herein, we review the benefits, limitations, and future direction of augmented reality (AR) in relationship to measurement of dermatologic conditions. This can include simple linear dimensions, area calculations, and even assessments that will drive clinical interventions. Additionally, we highlight current baseline mobile application tools that may lay the groundwork for further validation, augmentation, and utility of these technologies.

Educational video promotes durable knowledge about actinic keratoses in patients with field cancerization: a pseudorandomized, single-blind, controlled pilot study

Background: Diffuse actinic keratoses (AKs) have multiple treatment options. Patient understanding of treatment options may enhance patient autonomy, satisfaction, treatment adherence, and clinical outcomes. Delivering effective and consistent verbal counseling on AK treatment can be challenging.Objective: We investigated the effect on patient knowledge of implementing, prior to standard counseling, a novel video decision aid explaining diffuse AK treatment options.Methods & Materials: Participants were recruited from an academic Mohs surgery clinic and randomized to receive the video decision aid plus standard verbal counseling (video) or standard verbal counseling alone (control). Both groups completed baseline, immediate post-intervention, and 1-2 week delayed durable knowledge assessments. Secondary endpoints included participant satisfaction and verbal counseling duration.Results: Thirty-one eligible patients (16 control, 15 video) participated. No baseline differences existed between the groups. The video group had significantly higher mean durable knowledge scores than the controls (video 10.00 ± 1.48, control 8.36 ± 1.69, p = .018). Patients were highly satisfied with the video. Verbal counseling duration did not significantly differ between groups.Conclusion: A video decision aid for treatment of diffuse AKs improved durable patient knowledge.

Keloids: A Review of Etiology, Prevention, and Treatment

Keloids are abnormal scars that cause significant emotional and physical distress in patients when inadequately treated. Keloid formation is theorized to occur as a result of an imbalance between an increased synthesis of collagen and extracellular matrix and decreased degradation of these products. Inflammatory mediators- namely, transforming growth factor beta-have been proposed to influence the dysregulation of collagen remodeling in the scar healing process. Though limited, current knowledge of keloid pathophysiology has guided clinicians to explore novel therapies for keloid prevention and treatment. In addition to conducting research refining the use of common therapies, such as steroids and radiation, clinicians have evaluated the potential of anti-inflammatory and chemotherapeutic molecules to suppress keloid recurrence. Procedural focused therapies, such as cryotherapy and lasers, have also found a role in reducing keloid symptomatology. The purpose of this report is to examine the current literature and review the mechanisms of action, efficacy, and side effects of different keloid therapies. Despite the growing literature investigating reliable methods for keloid management, there are no standardized guidelines or treatment protocols supported by academic governing bodies. Stronger evidence with high-fidelity randomized clinical trials will be needed to determine the optimal therapy regimens for keloids.

Multiple keratin granulomata: A potential histologic clue to cutaneous squamous cell carcinoma responding to programmed cell death protein 1 inhibitor therapy

We present histologic features of a locally advanced cutaneous squamous cell carcinoma (cSCC) treated with the programmed cell death protein-1 (PD-1) antagonist, pembrolizumab, with a partial response. This contributes to a growing body of literature supporting the efficacy of pembrolizumab in treatment of surgically unresectable cSCC. We also provide a detailed description of the histologic features, particularly keratin granulomata with adjacent lymphocytic aggregates and fibrosis, observed in cSCC under treatment with a PD-1 antagonist.

Utilization and cost of electronic brachytherapy by dermatologists from 2012 to 2015

Electronic brachytherapy (EBT) garnered interest among dermatologists as a noninvasive treatment for keratinocyte carcinomas. While the magnitude of use and cost burden had not yet been quantified, this interest prompted an official statement from the American Academy of Dermatology supporting its use as secondary option in special circumstances, and led to changes to billing and coding for the procedure. Using provider level Medicare claims, this study demonstrates increased use of EBT between 2012 and 2015. We also showed that very few dermatologists utilized EBT, with only 39 dermatologists billing for EBT in 2015. This study documents that large scale policy changes were implemented in response to the practice behaviors of a small number of dermatologists, and provides information regarding the cost of EBT for consideration on how to best optimize its use in clinical practice.

Objective Melanin Measurements: Review of Novel Dosimetry Guidance Device for Intense Pulsed Light in Aesthetic Treatments

A melanin meter has been created to assess real time skin pigmentation to optimize settings for visible light aesthetic applications.

METHODS

A handheld meter was applied to non sun-damaged skin on the back of volunteers to measure skin pigmentation prior to treatment with IPL light sources over a range of pulse widths and ascending fluences. Curves for maximum epidermal tolerances as a function of pigmentation were determined. These curves were then tabulated for each pulse width in device software to provide guidance in the selection of fluences. Based on these findings, the device was applied in over 300 patients at a comprehensive laser and cosmetic dermatology center.

RESULTS

A pigment meter evaluation led to treatment parameter guidance in intense pulsed light applications. These suggested ranges for settings based on the melanin index score proved useful, accurate, and safe in applications over a broad range of skin colors and across various anatomic units of the skin.

CONCLUSION

A pigment meter can be used to identify appropriate settings with IPL treatments in order to enhance safety and efficacy when treating epidermal pigmented lesions, vessels, general photodamage and excessive hair (where the principles of selective photothermolysis are applied).

Rare case of acral calcified angioleiomyoma with macroscopic calcium extrusion

Acral calcified angioleiomyoma is an uncommon tumor that presents as a non-descript papule or subcutaneous nodule, classically on the foot. Biopsy or excision is typically the diagnostic method of choice as well as the treatment for these sometimes painful tumors. We report an uncommon clinical presentation of acral calcified angioleiomyoma with considerable extrusion of calcium perforating through the skin.

A case of generalized red sweating

We report a case of a 70-year-old man with a 5-year history of red pigmented sweating on the axillae, groin, forearms, trunk, and and peri-nuchal sites. No identifiable cause of the pigmented sweat was identified. Biopsy revealed lipofuscin pigment leading to the diagnosis of idiopathic chromhidrosis. This case represents an unusual presentation of chromhidrosis that was not limited to the apocrine sweat gland distribution and ultimately revealed no identifiable cause. After failing multiple treatment options, the patient elected for a trial of treatment with 20% aluminum chloride solution.