Justin Endo

Geriatric dermatology: Part I. Geriatric pharmacology for the dermatologist.

Issues related to prescribing dermatologic drugs in the elderly are less recognized than age-related skin findings. This is related in part to the lack of a standardized residency training curriculum in geriatric dermatology. As the number of elderly patients rises in the United States, drug-related iatrogenic complications will become increasingly important. This review discusses age-related changes in pharmacokinetics and pharmacodynamics of common dermatologic drugs. These changes include volume of distribution, renal function, liver toxicity from interactions of commonly prescribed drugs, and medications that can decompensate cognition in the older patient population. We outline seven prescribing principles related to older dermatology patients, including useful strategies to reduce polypharmacy and improve drug adherence, using an evidence-based approach whenever possible.

Geriatric dermatology: Part II. Risk factors and cutaneous signs of elder mistreatment for the dermatologist.

Cutaneous signs may be the most visible hint of elder mistreatment. Dermatologists are in a unique position to recognize and report physical abuse and neglect in the older patient population. In this review, we describe the scope and impact, risk factors, cutaneous signs, and appropriate responses to suspected elder mistreatment. There is a critical need for additional evidence to inform clinical practice in the field of elder abuse and neglect. Recognition and reporting of suspected elder mistreatment by the dermatologist can be life-saving for the older patient.

A Case for Caution: Chart-Stimulated Recall.

This article reviews theoretical advantages of chart- stimulated recall (CSR), explores threats to validity due to construct underrepresentation and construct irrelevant variance using Messicks framework, and discusses possible solutions. The results can inform the GME community on considerations and potential solutions when implementing CSRs as part of an assessment system. We also identify areas for future research studies. Chart-Stimulated Recall CSR is a hybrid assessment format that combines chart review and an oral examination, with both based on a clinicians documented patient encounter. Faculty or the learner selects the clinical chart for a learners patient to be used as a stimulus for questioning. 8-16 Using the learners own clinical chart situates the examination within a realistic context, adding to the authenticity and value of the exercise. 17 Through a series of probing questions designed to inquire into the learners clinical decision-making skills, the examinee is asked to reflect on and explain his or her rationale for clinical decisions. CSR has been used extensively in the United Kingdom and in Canada for the assessment of practicing physicians; in the United States it is predominantly used to assess trainees. A variety of scoring forms have been developed for CSR, ranging from checklists with comment boxes to ordinal rating scales. 11,18,19 Feedback usually is given to the learner at the end of the encounter 11,20 and may include action plans to improve future clinical decision making. 11,18,20-22 Despite evidence to sup- port the use of CSR in assessing the competence of practicing physicians, its use for certification of physicians has diminished due to practical concerns, such as cost, time, and the need for experienced assessors. 10,11,16,23

Dermato-pharmacology in Older Patients

Safely prescribing medications to older dermatology patients is a complicated task. The practitioner is likely to encounter several age-related challenges when prescribing to older adult dermatology patients. These challenges might not be common in younger populations. First, pertinent age-related physiologic changes that can cause medications to affect older patients differently are overviewed. Next, psychosocial and ethical factors that might impact prescribing practices are discussed. Then, different types of medication errors that can occur are described. Many of these errors, such as polypharmacy, can be anticipated by applying geropharmacologic principles. Other errors, such as underprescription, might seem counterintuitive. These concepts are synthesized into evidence-based prescribing strategies for older adults, and areas of research gaps are then highlighted. Practical examples of potential prescribing pitfalls are also provided. Complementary therapies, which are increasingly being used by older adults and which can interact with dermatologic medications or even cause dermatologic problems, are also briefly outlined.

Integrating virtual dermatopathology as part of formative and summative assessment of residents: a feasibility pilot study.

To the Editor , We are writing in response to the innovative articles published by Mooney et al. and Brick et al. about employing virtual dermatopathology (DP) for clinical use and pathology education.1,2 Because the diagnostic equivalence between virtual and conventional microscopy has been supported by comparative studies, virtual DP has been implemented in the certifying examination for dermatology.3 The literature has focused on the implementation of this technology in postgraduate education but with mixed results. Brick et al. noted no preference for glass or virtual slides among their residents,1 in contrast to Koch et al. who found that residents preferred virtual DP to conventional slides as a regular study aid but not as a testing media.3 Given the rising utilization of virtual DP on certifying examinations and differing resident attitudes about this technology for formative (e.g. low stakes pop quiz, self-assessment) vs. summative (e.g. high stakes exam) purposes, we conducted a study to explore the feasibility and acceptability of implementing this technology for residents for both formative and summative purposes.1,3 This research project was conducted under the University of Wisconsin-Madison Minimal Risk Institutional Review Board (IRB) approval number M-2012-0466. Dermatology and pathology residents at the University of Wisconsin-Madison consented to participate. Our prior curriculum consisted of self-directed reading with review of corresponding glass slides followed by ‘sign out’ time with a dermatopathologist. A pretest anonymous survey was administered to assess current and ‘ideal’ DP study habits as well as perceptions of virtual DP (free-text and Likert scale ratings). Next, residents completed a 21-item multiple-choice, single correct answer, self-assessment quiz that tested recognition of inflammatory and neoplastic histopathology using whole-slide scanned images (Aperio Technologies, Inc, Vista, CA, USA) on a proprietary, server-based learning platform (University of Wisconsin, Madison, USA). Residents were permitted to take the test at any time over a 2-week period and at any location using the computer, operating system and internet browser of their choice. A posttest survey was administered that assessed difficulties experienced during the test as well as perceptions of virtual DP. Scores were linked to survey responses by a study coordinator and given as aggregated, deidentified data to the investigators. A statistician (VR) performed chi-square test for comparison analysis. Poststudy semistructured debriefing sessions with dermatology and pathology residents were conducted to discuss the study results and obtain further qualitative data. JE and RG performed qualitative analysis using open coding and constant comparative method of free-text survey items and the poststudy debriefing sessions.4 Twenty-seven residents submitted a pretest survey; 20 residents completed the self-assessment virtual DP quiz (mean completion time 85.7 min); 18 residents completed the quiz and both pretest and posttest surveys. Only nine residents who completed the pretest survey

Preliminary Validity Evidence for a Milestones-Based Rating Scale for Chart-Stimulated Recall

Background Minimally anchored Standard Rating Scales (SRSs), which are widely used in medical education, are hampered by suboptimal interrater reliability. Expert-derived frameworks, such as the Accreditation Council for Graduate Medical Education (ACGME) Milestones, may be helpful in defining level-specific anchors to use on rating scales. Objective We examined validity evidence for a Milestones-Based Rating Scale (MBRS) for scoring chart-stimulated recall (CSR). Methods Two 11-item scoring forms with either an MBRS or SRS were developed. Items and anchors for the MBRS were adapted from the ACGME Internal Medicine Milestones. Six CSR standardized videos were developed. Clinical faculty scored videos using either the MBRS or SRS and following a randomized crossover design. Reliability of the MBRS versus the SRS was compared using intraclass correlation. Results Twenty-two faculty were recruited for instrument testing. Some participants did not complete scoring, leaving a response rate of 15 faculty (7 in the MBRS group and 8 in the SRS group). A total of 529 ratings (number of items × number of scores) using SRSs and 540 using MBRSs were available. Percent agreement was higher for MBRSs for only 2 of 11 items-use of consultants (92 versus 75, P = .019) and unique characteristics of patients (96 versus 79, P = .011)-and the overall score (89 versus 82, P < .001). Interrater agreement was 0.61 for MBRSs and 0.51 for SRSs. Conclusions Adding milestones to our rating form resulted in significant, but not substantial, improvement in intraclass correlation coefficient. Improvement was inconsistent across items.

In response to “Clinical pearls: Getting the most from your dermatoscope”

To the Editor: I read with great interest the Clinical Pearl by Dr Moloney entitled ‘‘Getting the most from your dermatoscope.’’ Until someone develops a 3-dimensional model, I agree that many traditional dermatoscopes are cumbersome to use when needing to switch between contact and tangential illumination! In addition to the Heine Delta 20 Plus dermatoscope (Heine Optotechnik GmbH & Co. KG, Herrsching, Germany) that was described by Dr Moloney, another option is the DermLite hybrid product line of dermatoscopes (3Gen Inc, Orange County, CA, http://dermlite.com). These dermatoscopes allow both contact and noncontact dermoscopy by simply rotating a dial and not having to remove attachment heads (Fig 1). This feature decreases the likelihood of lost detachable parts. They are portable and lightweight in large part because they lack the bulky handle that is found on most traditional contact dermatoscopes. They come with replaceable, rechargeable batteries that have an excellent life. Separately sold adapters are also available that allows one to take photographs (for educational or patient care purposes) of dermoscopy images using a digital camera or most major brands of smartphones. One major limitation is that it is still challenging to perform contact dermoscopy in tight concave surfaces (eg, tear trough, conchal bowl of ear). Also, one must be cautious about using alcohol or other solvents near the light filter, which can become clouded over time. The company requires buyers to furnish proof of being a health care provider, but discounts are available to current and recently graduated residents.

Questionable “Rash” on Right Leg

This is the case of a 74 year old man who had initially came in for a consult for what he described as a 3-week “rash” on his right leg (Fig. 11.1). At the time, the patient was experiencing dryness, irritation, itching, and redness on the affected area. He expressed symptoms of fatigue and low energy, but noted no decrease in appetite. Exam revealed masses that were firm to palpation. He denied trauma to the area. He was not on any medications.

A 68-Year-Old Man with Brittle Nails

This elderly gentleman presents with progressively brittle nails that tend to break very easily (Fig. 32.1). He has no past history of other medical problems, and denies any history of nutritional deficiencies.

76 Year Old with a Shallow Ulcer

The patient showed indurated and hyperpigmented skin of the lower legs and a shallow ulcer on the left medical mallelous (Fig. 28.1). He had a history of hypertension.