Stephanie Savory

Reliability assessment and validation of the postacne hyperpigmentation index (PAHPI), a new instrument to measure postinflammatory hyperpigmentation from acne vulgaris

BACKGROUND There are no validated outcome measures for postinflammatory hyperpigmentation (PIH). OBJECTIVE We sought to determine the reliability and validity of an outcome measure for PIH after acne in patients with skin of color. METHODS A postacne hyperpigmentation index (PAHPI) was developed. Six raters scored 21 patients with PIH twice. Reliability was determined within and between raters, whereas validity was evaluated by comparing scores with severity ranking by an independent dermatologist. The pigment intensity scores were compared with the melanin index of each patient using a narrowband reflectance spectrophotometer. A quality-of-life score (Skindex-29) was also compared with PAHPI scores. RESULTS Total PAHPI scores showed good reliability within and between raters and were valid when compared with clinical severity and melanin indices. Good correlation was achieved between the total PAHPI score and the emotion subscale of the Skindex-29. LIMITATIONS Generalizability of results is limited to African American females. CONCLUSION The PAHPI shows good reliability and validity when scored on patients with PIH from acne vulgaris. The PAHPI also correlates well with the emotional impact of PIH as measured by the Skindex-29. Future studies should assess the ability of the PAHPI to change with improvement of PIH from acne after treatment.

The Integrated Skin Exam film: An educational intervention to promote early detection of melanoma by medical students

BACKGROUND Knowledge of the skin cancer examination (SCE) and its practice remain relevant competency gaps among medical students. OBJECTIVE We elaborate on a method of SCE known as the Integrated Skin Exam and discuss the development of an instructional film that illustrates its principles. We assess the tools effect on knowledge, attitudes, and perceptions related to the SCE. METHODS Second-year students among 8 randomized schools viewed the film and completed pre-post questionnaires. RESULTS After viewing The Integrated Skin Exam film, students demonstrated improved melanoma knowledge, including identification of high-risk demographic groups (61% vs 42.9%, P < .001), high-risk anatomic sites in women (88.6% vs 46.5%, P < .001) and men (92.1% vs 34.8%, P < .001), and the ABCDEs of melanoma (98.4% vs 91.2%, P < .001). Students demonstrated increased confidence in the SCE (66.93% vs 16.40%, P < .001) and augmented intentions to practice it (99.05% vs 13.9%, P < .001). A greater proportion (70.4% vs 41.9%, P < .001) of students thought less than 3 minutes were required to integrate SCE into the routine examination. LIMITATIONS Longitudinal impact of the film was not assessed. CONCLUSION The Integrated Skin Exam film introduces an integrated approach to the SCE that addresses knowledge gaps, mitigates perceived barriers, and augments intention related to practice of the SCE.

MYC amplification in angiosarcomas arising in the setting of chronic lymphedema of morbid obesity

Angiosarcoma is a malignancy of vascular endothelial cells which may arise secondarily as a complication of lymphedema, including chronic lymphedema of morbid obesity. Amplifications in MYC are frequently present in secondary angiosarcoma (arising in irradiated sites and chronic lymphedema) and less frequently in primary cutaneous angiosarcoma.

Post-inflammatory Hyperpigmentation

Post-inflammatory hyperpigmentation is an acquired hypermelanosis that commonly follows traumatic or inflammatory injury to the skin. While it may affect all skin types, it is most evident and lingering in patients with skin of color. Diagnosis is usually straightforward given a history of prior inflammatory dermatosis or injury in the area but may be aided by Wood’s lamp examination or skin biopsy. Differential diagnoses of post-inflammatory hyperpigmentation include melasma, tinea versicolor, and drug-induced hyperpigmentation. Treatment can be challenging. In this chapter we will review the epidemiology, etiology, clinical presentations, differential diagnoses, and recommended treatments of post-inflammatory hyperpigmentation.

Satisfaction with care and likelihood to recommend ratings attributed to dermatology trainees

To the Editor: The Affordable Care Act directs value-based adjustments to Medicare payments that account for quality measures, including patient satisfaction. However, federally mandated or third-party vendor surveys do not capture unique considerations for academic institutions, including trainee involvement in patient care. Trainees typically have the initial, most durable, and sometimes the most consistent contact with the patient, yet little is known about care experiences attributed to them. We sought to prospectively evaluate the factors associated with highest ratings for satisfaction-withcare (SWC) and likelihood-to-recommend (LTR) attributed to dermatology trainees at Northwell Health and 6 other institutions with accredited programs ranging in size and location. Adults (n 1⁄4 1520) participated in an anonymous survey immediately after completing an encounter with 1 of 84 trainees (Table I). Survey responses, which were based on 5-point Likert scales, were dichotomized to identify factors associated with the highest ratings. Covariates having P values\.25 in bivariate analyses were included in multivariable regression models for each primary outcome. Fixed effects indicator variables were added to account for clustering. Final regression models used complete data from 81.9% (1245/1520) of patients. Highest SWC and LTR ratings were provided to trainees in 86.7% and 83% of encounters, respectively. Patients rating their skin health as good and excellent were more likely to provide highest SWC and LTR ratings, as were those rating overall experience with the health care institution as excellent (Table II). Importantly, factors such as sex concordance, postgraduate year, continuity encounters or number of prior visits with the trainee, and expecting to see a trainee had less (or no) influence on experience ratings than factors unrelated to the trainees themselves. In a study involving family medicine trainees, 92% of patients rated their satisfaction as good to excellent. Prior studies also support the association of satisfaction with self-reported health status and with system performance. With respect to achievement of training milestones, our results on satisfaction attributed to dermatology trainees should reassure training directors, faculty, and residents. If asked, most patients might also endorse the same sense of reassurance. However, based on institutional and national benchmarking, raw scores #90 points typically translate into below target percentile scores for dermatology providers. Whether ratings attributed to dermatology trainees have an influence on experience scores ultimately assigned to the provider of record needs to be explored further. Curricular opportunities might exist for trainees aimed at improving the patient experience, in particular for patients with poor skin health. Trainees must also appreciate that, as stewards of the patient experience, their halo effect facilitates learning opportunities for others. Likewise, we may speculate that institutional reputation might afford trainees initial trust from patients. In balancing the interests of programmatic training objectives, including advancement of graduated autonomy, programs can also make a deliberate effort to educate patients on its training mission, the roles of trainees and their prior education, and the responsibilities maintained by attending physicians throughout the episode of care. Institutions must also support these educational initiatives while also recognizing the complexities accounting for the patient experience.