Eliot N. Mostow

US Skin Disease Assessment: Ulcer and Wound Care

Chronic ulcers are a growing cause of patient morbidity and contribute significantly to the cost of health care in the United States. The most common etiologies of chronic ulcers include venous leg ulcers (VLUs), pressure ulcers (PrUs), diabetic neuropathic foot ulcers (DFUs), and leg ulcers of arterial insufficiency. Chronic wounds account for an estimated

Patient-reported outcomes and health-care resource utilization in patients with psoriasis treated with etanercept: continuous versus interrupted treatment.

6 to

Characterization of Bacterial Communities in Venous Insufficiency Wounds by Use of Conventional Culture and Molecular Diagnostic Methods

15 billion annually in US health care costs; however, it is difficult to get accurate measurements on this, because these patients are often seen in a variety of settings or simply fail to access the health care system.

The dermatology work force: A focus on urban versus rural wait times

OBJECTIVE The 24-week Etanercept Assessment of Safety and Effectiveness (EASE) study evaluated the effectiveness and tolerability of continuous versus interrupted etanercept treatment in patients with moderate to severe plaque psoriasis. The objective of this analysis was to assess patient-reported outcomes (PROs) and health-care resource utilization (HRU) data from the EASE study. METHODS Patients received open-label etanercept 50 mg twice weekly for 12 weeks and then received either continued or interrupted (single round of discontinuation and re-treatment with etanercept) etanercept 50 mg once weekly for the second 12 weeks. PROs included the following: 1) the patient global assessments of psoriasis, joint pain, and itching scores; 2) the Dermatology Life Quality Index; 3) the Medical Outcomes Study Short Form 36 vitality domain; 4) the Beck Depression Inventory; 5) the European Quality-of-Life Group Feeling Thermometer; and 6) a patient satisfaction survey. HRU was evaluated using the Economic Implications of Psoriasis patient questionnaire. RESULTS Continuous treatment with etanercept 50 mg twice weekly for 12 weeks followed by 50 mg once weekly for 12 weeks produced sustained and clinically important improvements in PROs and reductions in HRU. Reductions in some outcome measures after treatment discontinuation at week 12 were observed in the interrupted group; however, most changes did not revert to baseline levels, consistent with some residual clinical effect, and re-treatment produced improvements similar to week 12 levels. CONCLUSIONS Continuous etanercept treatment provided greater sustained improvements in PROs than interrupted therapy; however, interrupting etanercept therapy, if needed, has predictable and manageable effects.

Isolated Benign Primary Cutaneous Plasmacytosis in Children: Two Illustrative Cases

ABSTRACT Microbial infections delay wound healing, but the effect of the composition of the wound microbiome on healing parameters is unknown. To better understand bacterial communities in chronic wounds, we analyzed debridement samples from lower-extremity venous insufficiency ulcers using the following: conventional anaerobic and aerobic bacterial cultures; the Ibis T5000 universal biosensor (Abbott Molecular); and 16S 454 FLX titanium series pyrosequencing (Roche). Wound debridement samples were obtained from 10 patients monitored clinically for at least 6 months, at which point 5 of the 10 sampled wounds had healed. Pyrosequencing data revealed significantly higher bacterial abundance and diversity in wounds that had not healed at 6 months. Additionally, Actinomycetales was increased in wounds that had not healed, and Pseudomonadaceae was increased in wounds that had healed by the 6-month follow-up. Baseline wound surface area, duration, or analysis by Ibis or conventional culture did not reveal significant differences between wounds that healed after 6 months and those that did not. Thus, pyrosequencing identified distinctive baseline characteristics of wounds that did not heal by the 6-month follow-up, furthering our understanding of potentially unique microbiome characteristics of chronic wounds.

Improving Quality and Patient Satisfaction in Dermatology Office Practice

BACKGROUND Recent studies suggest a shortage of dermatologists with an average wait time of 36 days in the United States and 40 days in Ohio for a routine dermatology visit. To date, no previous studies have examined supply and demand of dermatology services in rural versus urban populations. OBJECTIVE We sought to determine the average wait time for a dermatology appointment for new and established patients in both urban and rural areas. METHODS The offices of 250 dermatologists in Ohio were contacted by telephone to determine the wait time for the next available appointment for new and established patients with a changing mole. RESULTS The average wait time for new (4.5 weeks) and established (3.1 weeks) patients was similar to times reported in previous studies. A greater density of all dermatologists and medical (general) dermatologists practice in cities, but wait times were not statistically different in rural versus urban settings. LIMITATIONS Neither insurance status or use of physician extenders were considered. The findings may not be applicable to areas outside Ohio. CONCLUSION There is a shortage of medical dermatologists throughout Ohio. Training more medical dermatologists or adding physician extenders to dermatology practices would be expected to decrease the waiting time for dermatology appointments. Providing incentives for dermatologists to practice in underserved rural areas may not be necessary judging by the similarities in wait times between rural and urban settings.

Wound healing: A multidisciplinary approach for dermatologists

BACKGROUND Plasma cells are normally found in bone marrow and the intestinal tract. They appear in the skin in malignant conditions, autoimmune diseases, infection, and idiopathic and poorly understood disorders such as primary nodular amyloidosis. It is uncommon to find collections of plasma cells in the skin in the absence of these conditions. OBSERVATIONS We present 2 cases of cutaneous plasmacytosis, one in a white, female adolescent aged 15 years with an 11-year history of a solitary, asymptomatic, violaceous plaque on the left anterior tibia and the other in a white, male child aged 7 years with a 2-year history of a solitary erythematous plaque on the right anterior tibia. In both patients, infiltration of mature polyclonal plasma cells was confined to an area on the skin with papulonodules. There was no history of previous trauma, malignant conditions, autoimmune disease, or infection in either child. CONCLUSION Although incipient or occult systemic disease cannot be definitively ruled out, the course of these 2 individuals suggests that isolated primary cutaneous plasmacytosis in children is a benign chronic process with no adverse sequelae.

Advanced therapies for chronic wounds: NPWT, engineered skin, growth factors, extracellular matrices.

M any dermatologists are under pressure to improve the efficiency and effectiveness of their clinical care in an era of stagnant reimbursement and higher office expenses. In addition, dermatologists in the United States are under increased scrutiny from payers, regulators, and patients who expect uniformly high-quality service from their physicians. The presence of increasing numbers of nondermatologist health care providers marketing themselves as skincare specialists also places increased pressure on dermatologists to demonstrate the value of their services. Patient perceptions of quality health care are important to the physician. Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims. Highly satisfied patients have improved outcomes in the management of chronic disease vs those less satisfied. This reflects increased compliance among satisfied patients. Furthermore, dissatisfied patients are 4 times more likely to seek care elsewhere within 6 months. Finally, an inverse correlation has been reported for patient satisfaction rates and medical malpractice claims. Quality improvement (QI) systems analyze processes to improve the quality of care, productivity, and efficiency. Hospitals and long-term care centers have had QI committees in place for years as a requirement for accreditation. Despite the advantages of self-assessment, many dermatologists in private practice have not implemented a system to analyze and evaluate quality of care rendered in their practice. Such a system could include quarterly meetings attended by not only the physician but also by representatives from the nursing, technical, and administrative staff. Establishing a small QI committee can also stimulate useful QI initiatives. Implementing QI systems based on information from a sampling of patients has been difficult because of their cost and inconvenience. An Internet-based system offers dermatologists a convenient and inexpensive method to obtain patient satisfaction information. The DrScore Web site (http://www.DrScore.com; Medical Quality Enhancement Corporation, Winton-Salem, North Carolina) provides an online patient satisfaction survey designed to respond to the QI needs of dermatologists by providing data to individual dermatologists to help them improve quality of care and patient perceptions of physician quality. A dermatologist could use these data to design effective strategies to improve efficiency of dermatologic care and in so doing might fulfill the requirements of the American Board of Dermatology (ABD) Dermatology Maintenance of Certification (DMOC) program that mandates practicing dermatologists to evaluate their clinical performance. Dermatologists need only provide evidence of having participated in such a program; the data received from patients through this system will not be reviewed by the ABD.

Wound dressing absorption: a comparative study.

This article has provided a review of common and some less common approaches to wound healing. Chronic wound healing is one of the more challenging areas of medicine, with a nice balance of the science and art of medicine. An evidence-based, patient-centered approach can be used to effectively improve the care of many difficult to heal ulcers in often frustrated patients. The multidisciplinary wound clinic concept can work to improve the outcomes of patients with leg ulcers.

In vivo skin elastography with high-definition optical videos.

Advanced wound care implies the use of products or procedures that are specialized. Although dermatologists are used to being specialists of the skin, hair, and nails, chronic wound care has evolved such that there are some specific treatment options that are more commonly ordered and performed in wound care clinics. Wound care clinics are staffed by specialists and generalists including dermatologists, but also orthopedic surgeons, vascular surgeons, infectious disease specialists, internists, family practitioners, hyperbaric oxygen‐trained physicians from a variety of backgrounds, podiatrists, physician assistants, and nurse practitioners. The care of chronic wounds has almost become its own specialty, with so‐called advanced therapies now including the use of growth factors, extracellular matrices, engineered skin, and negative pressure wound therapy. It is critical that the dermatologists understand the treatments such that they can appropriately apply or order them directly, or be involved with the care of their patients receiving these therapies.