Caroline A. Nelson

The Reliability of Teledermatology to Triage Inpatient Dermatology Consultations

IMPORTANCE Many hospitals do not have inpatient dermatologic consultative services, and most have reduced availability of services during off-hours. Dermatologists based in outpatient settings can find it challenging to determine the urgency with which they need to evaluate inpatients when consultations are requested. Teledermatology may provide a valuable mechanism for dermatologists to triage inpatient consultations and increase efficiency, thereby expanding access to specialized care for hospitalized patients. OBJECTIVE To evaluate whether a store-and-forward teledermatology system is reliable for the initial triage of inpatient dermatology consultations. DESIGN, SETTING, AND PARTICIPANTS Prospective study of 50 consenting adult patients, hospitalized for any indication, for whom an inpatient dermatology consultation was requested between September 1, 2012, and April 31, 2013, at the Hospital of the University of Pennsylvania, an academic medical center. The participants were evaluated separately by both an in-person dermatologist and 2 independent teledermatologists. MAIN OUTCOMES AND MEASURES The primary study outcomes were the initial triage and decision to biopsy concordance between in-person and teledermatology evaluations. RESULTS Triage decisions were as follows: if the in-person dermatologist recommended the patient be seen the same day, the teledermatologist agreed in 90% of the consultations. If the in-person dermatologist recommended a biopsy, the teledermatologist agreed in 95% of cases on average. When the teledermatologist did not choose the same course of action, there was substantial diagnostic agreement between the teledermatologist and the in-person dermatologist. The Kendall τ rank correlation coefficients for initial triage concordance between the in-person dermatologist and teledermatologists were 0.41 and 0.48. The Cohen κ coefficients for decision to biopsy concordance were 0.35 and 0.61. The teledermatologists were able to triage 60% of consultations to be seen the next day or later. The teledermatologists were able to triage, on average, 10% of patients to be seen as outpatients after discharge. CONCLUSIONS AND RELEVANCE Teledermatology is reliable for the triage of inpatient dermatology consultations and has the potential to improve efficiency.

Teledermatology as pedagogy: Diagnostic and management concordance between resident and attending dermatologists

We performed a prospective study between January and November 2013 with inclusion of 84 consults encompassing 90 dermatologic conditions. This study received approval from the Philadelphia Field Initiating Group of Human Immunodeficiency Virus Trials, Philadelphia Department of Public Health, and University of Pennsylvania institutional review boards. Verbal informed consent and Health Insurance Portability and Accountability Act authorization were obtained from patients; written informed consent was obtained from providers. Consults were submitted to the University of Pennsylvania by 25 primary care providers at the Jonathan Lax Center, the Dr. Bernett L. Johnson, Jr. Sayre Health Center, and eight Philadelphia Department of Public Health centers using the AccessDerm (Vignet Corporation, Fairfax, VA) mobile platform.4 Diagnoses and management plans, initially drafted by dermatology residents, were reviewed, edited, and submitted by attending dermatologists. Nine residents and nine attending dermatologists responded to consults. For each dermatologic condition, two investigators (CAN, JT) independently determined the concordance of differential diagnoses and management plans between resident and attending dermatologists. Cohen’s κ assessing inter-rater reliability (95% confidence interval) for diagnostic and management concordance between the two investigators were 0.94 (0.91–0.98) and 0.87 (0.78–0.90), respectively. Statistical analyses were performed in Stata 12.1 (StatCorp LP, College Station, TX). Each resident responded to a median (interquartile range) of 9 (4–15) consults. The number of responses stratified by dermatology training year was: 10 (12%) first, 29 (34%) second, and 45 (54%) third year residents. Based on the leading diagnosis of the attending dermatologist or definitive diagnosis when available, dermatologic conditions were classified into the following categories: 24 (27%) eczematous conditions, 13 (14%) infectious diseases, 7 (8%) benign tumors or proliferations, 6 (7%) papulosquamous conditions, 5 (6%) pigmented disorders, 4 (4%) acneiform or follicular occlusion disorders, 4 (4%) premalignant or malignant lesions, 23 (26%) other, and 4 (4%) indeterminate. Diagnoses and management plans between resident and attending dermatologists were fully concordant for 53% and 65% of dermatologic conditions, respectively (Figure 1). Table I categorizes the changes made by attending dermatologists for those conditions with at least partial management discordance (adapted from Lamel et al5). Most changes were consistent with recommendation for education or observation (53%) and medication initiation or discontinuation (50%). Recommendation for in-person evaluation was concordant in 93% of consults. Figure 1 Diagnostic and management concordance between resident and attending dermatologists. Table I Categories of change in management With the development of sustainable teledermatology programs, it is important for dermatologists to become familiar with the strengths and limitations of this practice model. Our data revealed at least partial diagnostic and management discordance between resident and attending dermatologists for 47% and 35% of dermatologic conditions, respectively. Although limited by small sample size, this study suggests that teledermatology provides residents an opportunity for practice-based learning. Further research is required to evaluate educational outcome measures.

The Association of Age With Clinical Presentation and Comorbidities of Pyoderma Gangrenosum

Importance Pyoderma gangrenosum is an inflammatory neutrophilic dermatosis. Current knowledge of this rare disease is limited owing to a lack of validated diagnostic criteria and large population studies. Objective To evaluate the association of age with the clinical presentation and comorbidities of pyoderma gangrenosum. Design, Setting, and Participants This was a multicenter retrospective cohort study performed at tertiary academic referral centers in urban settings. Adults (≥18 years) who were evaluated and diagnosed as having pyoderma gangrenosum at the Brigham and Women’s and Massachusetts General Hospitals from 2000 to 2015 and the University of Pennsylvania Health System from 2006 to 2016 were included. Main Outcomes and Measures Patient demographics, clinical features, medical comorbidities, and treatment. Results Of the 356 validated cases of pyoderma gangrenosum included in the study, 267 (75%) were women and 284 (84.8%) were white. The mean (SD) age at presentation was 51.6 (17.7) years. Pathergy was recorded in 100 patients (28.1%). A total of 238 patients (66.9%) had associated medical comorbidities: inflammatory bowel disease in 146 patients (41.0%); inflammatory arthritis in 73 patients (20.5%); solid organ malignant neoplasms in 23 patients (6.5%); hematologic malignant neoplasms in 21 patients (5.9%); and hematologic disorders, specifically monoclonal gammopathy of undetermined significance, myelodysplastic syndrome, and polycythemia vera in 17 patients (4.8%). When stratified by age, pathergy was more common in patients 65 years or older (36.3% vs 24.3%; P = .02). Inflammatory bowel disease was the only medical comorbidity that was more common in patients younger than 65 years (47.7% vs 26.6%; P < .001), while a number of medical comorbidities were more common in those 65 years or older, including rheumatoid arthritis (13.3% vs 6.2%; P = .03), ankylosing spondylitis (1.8% vs 0%; P = .04), solid organ malignant neoplasms (13.3% vs 3.3%; P < .001), hematologic malignant neoplasms (9.7% vs 4.1%; P = .04), and the aforementioned hematologic disorders (10.6% vs 2.1%; P < .001). Conclusions and Relevance Although clinical presentation in this large cohort was similar between different age groups, disease associations varied by age. The findings of this study may allow for a more focused, age-specific evaluation of patients with pyoderma gangrenosum.

The Guatemala-Penn Partners: An Innovative Inter-Institutional Model for Scientific Capacity-Building, Healthcare Education, and Public Health

Population health outcomes are directly related to robust public health programs, access to basic health services, and a well-trained health-care workforce. Effective health services need to systematically identify solutions, scientifically test these solutions, and share generated knowledge. The World Health Organization (WHO)’s Global Healthcare Workforce Alliance states that the capacity to perform research is an essential factor for well-functioning public health systems. Low- and middle-income countries have greater health-care worker shortages and lower research capacity than higher-income countries. International global health partnerships between higher-income countries and low-middle-income countries aim to directly address such inequalities through capacity building, a process by which human and institutional resources are strengthened and developed, allowing them to perform high-level functions, solve complex problems, and achieve important objectives. The Guatemala–Penn Partners (GPP) is a collaboration among academic centers in Guatemala and the University of Pennsylvania (Penn), in Philadelphia, Pennsylvania that echoes the vision of the WHO’s Global Healthcare Workforce Alliance. This article describes the historical development and present organization of the GPP according to its three guiding principles: university-to-university connections, dual autonomies with locally led capacity building, and mutually beneficial exchanges. It describes the GPP activities within the domains of science, health-care education, and public health, emphasizing implementation factors, such as sustainability and scalability, in relation to the guiding principles. Successes and limitations of this innovative model are also analyzed in the hope that the lessons learned may be applied to similar partnerships across the globe.

Sweet syndrome in patients with and without malignancy: A retrospective analysis of 83 patients from a tertiary academic referral center

Background Sweet syndrome is a neutrophilic dermatosis that may be categorized into classic, malignancy‐associated, and drug‐induced subtypes. Few studies have systematically analyzed this rare disorder. Objective To describe the clinicopathologic characteristics and treatment of Sweet syndrome and identify characteristics associated with concurrent malignancy. Methods We retrospectively reviewed patients with Sweet syndrome at the University of Pennsylvania from 2005 to 2015. Results We identified 83 patients (mean age, 57 years; 51% male) with Sweet syndrome: 30% with the classic form, 44% with the malignancy‐associated form, 24% with the drug‐induced form in the setting of malignancy, and 2% with the drug‐induced form. Acute myeloid leukemia was the most common malignancy (in 24 of 83 patients [29%]). Filgrastim was the most common medication (used in 8 of 83 patients [10%]). Leukopenia (P < .001), anemia (P = .002), thrombocytopenia (P < .001), absence of arthralgia (P < .001), and histiocytoid or subcutaneous histopathology (P = .024) were associated with malignancy (χ2 test). Limitations This was a retrospective study that represents patients from a single tertiary academic referral center, which may limit its generalizability to other settings. Conclusion When caring for patients with Sweet syndrome, dermatologists should be aware of the potential association of leukopenia, anemia, thrombocytopenia, absence of arthralgia, and histiocytoid or subcutaneous histopathology with malignancy.

Neutrophilic dermatoses. Part II. Pyoderma gangrenosum and other bowel and arthritis associated neutrophilic dermatoses

&NA; Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The second article in this continuing medical education series reviews the epidemiology, clinical characteristics, histopathologic features, diagnosis, and management of pyoderma gangrenosum as well as bowel‐associated dermatosis‐arthritis syndrome and the arthritis‐associated neutrophilic dermatoses rheumatoid neutrophilic dermatitis and adult Still disease.

An atypical case of papular necrobiosis lipoidica masquerading as sarcoidosis

Necrobiosis lipoidica (NL) is a rare granulomatous disorder characterized by well-circumscribed yellowish plaques affecting the anterior shins, often in patients with diabetes. Clinical examination is typically sufficient to make the diagnosis, but skin biopsy is sometimes required. Here we present a patient who received a misdiagnosis of sarcoidosis that was unsuccessfully treated who was found on re-examination and biopsy to have an atypical papular presentation of NL.

Conjunctivitis, mucosal erosions, and moist cutaneous plaques

Departments of Dermatology and Pathology and tory Medicine, Perelman School of Medicine at the ity of Pennsylvania and the Department of Medicine, of Dermatology, Pritzker School of Medicine at the ity of Chicago. ources: None. f interest: None declared. dence to: Caroline A. Nelson, MD, 3600 Spruce Street, 2 y Building, Philadelphia, PA 19104. E-mail: Caroline. @uphs.upenn.edu. JAAD Case Reports 2018;4:117-9. 2352-5126 a 2017 by the American Academy of Dermatology, Inc. Published by Elsevier, Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/). http://dx.doi.org/10.1016/j.jdcr.2017.04.017

Human-computer symbiosis: enhancing dermatologic care while preserving the art of healing

In 1997, the International Business Machines supercomputer Deep Blue defeated world chess champion Garry Kasparov in what was widely viewed as a symbolic event for the coming of age of artificial intelligence (AI). Since that time, AI applications have been explored across medicine. In dermatology, for example, researchers are evaluating the potential of deep convolutional neural networks to classify skin lesions. These new technologies have heightened concerns that AI will displace dermatologist jobs or disrupt the doctor–patient relationship. In fact, this discussion has been ongoing since the first Electronic Numerical Integrator And Computer was built in the 1940s. Many notable scientists have sought to develop AI applications to match or surpass human intelligence. Others, such as J.C.R. Licklider, have focused on understanding how humans and computers can work together to augment human intelligence. In “Man-Computer Symbiosis,” Licklider outlined a strategy in which humans provide strategic input while computers provide depth of analysis. As AI applications improve, rather than competing, we should strive to identify how best to integrate them into our practice, potentially improving efficiency, patient outcomes, and access to dermatologic care. At the same time, we must remain attuned to possible and inherent weaknesses, such as inaccurate/incomplete training or validation data, improper use, and inability to view the patient holistically. Moreover, the dermatology landscape is shifting under the pressure of forces ranging from evolving pathogens to novel therapeutics. While computers are adept at solving formulated problems, humans need to formulate and prioritize the problems to be solved. Another advantage of a collaborative approach between humans and AI is maintaining the doctor–patient relationship. In his plenary address at the 2018 annual meeting of the American Academy of Dermatology, Dr. Abraham Verguese referenced an 1891 painting by Sir Luke Fildes entitled, “The Doctor.” The subject of the painting, devoid of any diagnostic tools or treatments, is training his attention on a sick child. The attention of a dermatologist may have unique import for patients with skin diseases that are often socially stigmatizing and have a profound impact on health-related quality of life. For example, in a well-known study by Rapp and colleagues, patients with psoriasis reported similar Short Form-36 Health Survey Questionnaire (SF-36) scores to other chronic diseases like arthritis, cancer, chronic lung disease, congestive heart failure, depression, dermatitis, type two diabetes, hypertension, and myocardial infarction. Only congestive heart failure had a worse Physical Component Summary score, and only chronic lung disease and depression had worse Mental Component Summary scores. For many of us, the call to practice dermatology comes from a desire to improve patients’ lives through the healing power of human interaction. We have witnessed the emotional impact of touching the skin of a patient whom others are afraid to touch and experienced the satisfaction derived from a longitudinal patient relationship. Our intuitive understanding of this healing power is borne out by epidemiological data. In a meta-analysis of 148 studies including 308,849 participants, Holt-Lunstad and colleagues found a statistically significant 50% decreased likelihood of all-cause mortality for participants with stronger social relationships. This finding remained consistent across age,