Publications by authors named "Erik J Stratman"

59 Publications

Vulvovaginal pyoderma gangrenosum associated with rituximab use in 2 patients with rheumatoid arthritis.

JAAD Case Rep 2021 Apr 23;10:75-77. Epub 2021 Feb 23.

Department of Dermatology, Marshfield Clinic Health System, Marshfield, Wisconsin.

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http://dx.doi.org/10.1016/j.jdcr.2021.02.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985273PMC
April 2021

Psoriasis Flares Following Systemic Glucocorticoid Exposure in Patients With a History of Psoriasis.

JAMA Dermatol 2021 02;157(2):198-201

Department of Dermatology, Marshfield Clinic Health System, Marshfield, Wisconsin.

Importance: To our knowledge, this study is the first to assess the rate of any type of psoriasis flare during or immediately following the administration of systemic corticosteroids in patients with a known history of psoriasis.

Objective: To determine the rates and types of psoriasis flares during or within 3 months after concluding systemic corticosteroid administration in adult patients with a known history of psoriasis.

Design, Setting, And Participants: This retrospective cohort study assessed adult patients (≥18 years at the time of psoriasis diagnosis) evaluated in the Marshfield Clinic Health System (Marshfield, Wisconsin) with an established diagnosis of psoriasis and exposure to at least 1 systemic corticosteroid from October 31, 2012, to July 1, 2018. Exclusion criteria were patients younger than 18 years, patients with a diagnosis of psoriatic arthritis, and patients receiving only topical, intraarticular, or intrabursal corticosteroids.

Main Outcomes And Measures: The primary outcome was rate of psoriasis flares during or within 3 months of discontinuation of the patient's first course of systemic corticosteroids. Secondary measures included rates of specific types of psoriasis flares, including pustular, erythrodermic, and worsening plaque stage psoriasis.

Results: Of 516 cohort patients, 288 (55.8%) were women, and the mean (SD) age at first psoriasis diagnosis was 49.6 (17.0) years. Among 1970 patients with a diagnosis of psoriasis before receiving systemic corticosteroids, a 1.42% (95% CI, 0.72%-2.44%) psoriasis flare rate of any type was identified when prescribed their first course of systemic corticosteroids. Further stratification identified only 1 severe flare (erythroderma) among all flares reported, with no pustular psoriasis flares identified (0.07%; 95% CI, 0.00%-0.26%).

Conclusions And Relevance: In this study, the rates of psoriasis flares were low, especially for severe psoriasis flares. Our results suggest that systemic steroids may be much less likely to trigger severe flares in patients with psoriasis than what is traditionally taught in dermatology.
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http://dx.doi.org/10.1001/jamadermatol.2020.4219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675213PMC
February 2021

The heightened focus on wellness in dermatology residency education.

Clin Dermatol 2020 May - Jun;38(3):336-343. Epub 2020 Feb 19.

Department of Psychology, Marshfield Clinic Health System, Marshfield, Wisconsin, USA.

Dermatology residents and dermatology faculty members experience stress in the workplace, placing them at risk for burnout. As a profession, dermatologists have one of the fastest growing rates of burnout clinical manifestations across all specialties. The Accreditation Council for Graduate Medical Education has revised its program requirements for residency programs to include greater emphasis on actions to promote wellness. Examples of actions to promote wellness that are used currently in dermatology and other residency and medical education settings are explored.
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http://dx.doi.org/10.1016/j.clindermatol.2020.02.011DOI Listing
September 2020

Persistent and nonprogressive cutaneous blastomycosis in a pregnant adolescent.

JAAD Case Rep 2020 Mar 12;6(3):169-171. Epub 2020 Feb 12.

Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin.

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http://dx.doi.org/10.1016/j.jdcr.2019.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019037PMC
March 2020

Dermatology continuing certification changes for the better.

Authors:
Erik J Stratman

Cutis 2020 Jan;105(1):14-15

Marshfield Clinic Health System, Wisconsin, USA.

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January 2020

Methodology of Evaluating the Laboratory Monitoring of Terbinafine Therapy-Reply.

JAMA Dermatol 2019 06;155(6):756-757

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

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http://dx.doi.org/10.1001/jamadermatol.2019.0136DOI Listing
June 2019

Assessment of Topical Corticosteroid Prescribing, Counseling, and Communication Among Dermatologists and Pharmacists.

JAMA Dermatol 2019 07;155(7):838-843

Department of Dermatology, Marshfield Clinic Health System-Marshfield Campus, Marshfield, Wisconsin.

Importance: Topical corticosteroids (TCs) are common treatments for many dermatologic conditions. Anecdotal experience and literature suggest that dermatologists and pharmacists differ in their beliefs about TCs and approach to TC counseling, creating the opportunity for patient confusion.

Objective: To examine interprofessional practice gaps between dermatologists and pharmacists with regard to how each group views TCs, counsels patients on TC use, and communicates modifications to TC prescriptions.

Design, Setting, And Participants: An electronic survey was disseminated statewide in Wisconsin to 117 board-certified or eligible dermatologist members of the Wisconsin Dermatological Society and 2954 licensed pharmacists. The survey was performed from October 11, 2017, to January 2, 2018. Survey responses and demographic information were compiled and analyzed for each population.

Exposures: Study participants completed and returned a 17-question survey recalling experiences with TC prescribing from the past year along with self-reported demographic information.

Main Outcomes And Measures: Dermatologists' and pharmacists' self-reported counseling of patients regarding TC application, duration of use, and adverse effects; frequency of communication of changes to TC prescriptions and instructions; and demographic data were tabulated and compared.

Results: Of the 117 dermatologists, 52 (44.4%) completed and returned the survey; of the 2954 pharmacists, 111 (3.8%) returned the survey. Those no longer in active practice (3 dermatologists, 1 pharmacist) were excluded from analysis. A substantial proportion of pharmacists (51 [46.4%]) advised patients to limit TC use to 2 weeks or less, which was an uncommon strategy among dermatologists (3 [6.1%]) (P < .001). Discordance also was noted in the adverse effects that are emphasized in counseling, pharmacist-perceived and dermatologist-observed adverse effects in patients, and resources that inform counseling content. Only 8 (16.3%) dermatologists perceived that pharmacists made no unauthorized modifications to their TC prescriptions or instructions; however, 77 (70.0%) pharmacists reported not doing so (P < .001).

Conclusions And Relevance: An interprofessional practice gap appears to exist between dermatologists and pharmacists in Wisconsin regarding TC beliefs and counseling strategies. Collaborative education and improved communication between the 2 groups may be necessary to ensure that patients receive a unified, clear message about TC application and adverse effects. Larger studies are needed to further investigate this potential practice gap.
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http://dx.doi.org/10.1001/jamadermatol.2018.5353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583821PMC
July 2019

Assessment of Percentage of Women in the Dermatology Workforce Presenting at American Academy of Dermatology Annual Meetings, 1992-2017.

JAMA Dermatol 2019 03;155(3):384-386

Department of Dermatology, Marshfield Clinic Health System-Marshfield Campus, Marshfield, Wisconsin.

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http://dx.doi.org/10.1001/jamadermatol.2018.5481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439889PMC
March 2019

A Simulation-Based Workshop to Improve Dermatologists' Communication Skills: A Pilot for Continuing Medical Education.

Dermatol Ther (Heidelb) 2019 Mar 17;9(1):179-184. Epub 2018 Nov 17.

Department of Dermatology, University of California San Francisco, San Francisco, CA, USA.

Introduction: Communication skills influence the quality of health care and patient experience; both may affect provider reimbursement. There are few opportunities available for practicing physicians to receive direct feedback on communication in patient encounters. The purpose of this simulation-based patient encounter workshop was for dermatologists to practice and obtain feedback on their communication skills.

Methods: In March 2016, dermatologists participated in a workshop with four simulated patient encounters. Cases were developed based on a prior needs assessment. Standardized patient educators evaluated participants' communication using the Master Interview Rating Scale and provided verbal feedback. Physicians rated the usefulness of the simulation and the feedback received through a survey upon workshop completion.

Results: Of the 170 physicians who registered, 103 participated in the simulation. The workshop was highly rated in meeting its three learning objectives (score of 4.5-4.6 out of a maximum score of 5). The lowest-rated communication skills were as follows: allowing the patient to share their narrative thread (3.1), summarizing the patient's history from the provider (3.8), and assessing patient understanding (3.8).

Conclusions: Participants reported that this communication workshop effectively satisfied its learning objectives. Opportunities to practice and improve communication skills as part of continuing medical education will benefit the clinical experience of patients and physicians alike, and the workshop may be formatted to serve physicians of other specialties. The lowest-scoring communication areas identified in this study present an opportunity to develop a tailored curriculum for physician-patient communication in the future.
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http://dx.doi.org/10.1007/s13555-018-0270-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380981PMC
March 2019

Utility of Laboratory Test Result Monitoring in Patients Taking Oral Terbinafine or Griseofulvin for Dermatophyte Infections.

JAMA Dermatol 2018 12;154(12):1409-1416

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

Importance: Terbinafine hydrochloride and griseofulvin are effective oral treatments for dermatophyte infections but have been associated with hepatic and hematologic abnormalities. The prevalence of alanine aminotransferase elevations, aspartate aminotransferase elevations, anemia, lymphopenia, and neutropenia among adults and children taking terbinafine and griseofulvin is unclear.

Objective: To measure the rate of laboratory test result abnormalities in healthy adults and children taking terbinafine or griseofulvin for dermatophyte infections.

Design, Setting, And Participants: This retrospective study assessed adults and children taking terbinafine or griseofulvin for dermatophyte infections from January 1, 2006, to December 31, 2016. Data were collected from one Midwest health care system. Exclusion criteria were preceding diagnosis of hepatic or hematologic condition and preceding or concurrent use of oral ketoconazole, amphotericin, or itraconazole.

Main Outcomes And Measures: The rates of elevated alanine aminotransferase measurements, elevated aspartate aminotransferase measurements, anemia, lymphopenia, and neutropenia in adults and children taking terbinafine, griseofulvin microsize, or griseofulvin ultramicrosize were calculated. Secondary measures included rates of baseline abnormalities, frequency of laboratory test results that required additional testing or discontinued use of medication, and laboratory test result monitoring practices.

Results: This study included laboratory data from 4985 patients (mean [SD] age, 42.8 [20.3] years; 2288 [45.9%] female) receiving 4309 courses of terbinafine, 634 courses of griseofulvin microsize, and 159 courses of griseofulvin ultramicrosize. We identified a low rate of laboratory test result abnormalities in patients taking terbinafine or griseofulvin. When laboratory test result abnormalities occurred, most were low grade (212 [93.4%] grade 1) and did not require subsequent laboratory test result evaluation or discontinued use of medication (15 051 [99.9%]). Elevations in alanine aminotransferase measurements were detected infrequently and were comparable to baseline detection rates (61 [3.5%] vs 95 [3.6%] for terbinafine, 2 [2.1%] vs 3 [3.7%] for griseofulvin microsize, and 0 vs 2 [5.0%] for griseofulvin ultramicrosize). Rates of elevated aspartate aminotransferase measurements, anemia, lymphopenia, and neutropenia were also infrequent and comparable to baseline rates.

Conclusions And Relevance: In this study. the rates of alanine aminotransferase elevations, aspartate aminotransferase elevations, anemia, lymphopenia, and neutropenia in adults and children taking terbinafine or griseofulvin were low and equivalent to the baseline rates of abnormalities in this population. Routine interval laboratory test result monitoring appears to be unnecessary in adults and children without underlying hepatic or hematologic conditions taking terbinafine or griseofulvin for dermatophyte infections. Abandoning frequent laboratory monitoring can decrease unnecessary health care spending, decrease patient psychological angst associated with blood draws, and allow for expanded use of these effective oral medications.
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http://dx.doi.org/10.1001/jamadermatol.2018.3578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583317PMC
December 2018

Measuring the Depth of Perineural Invasion in Cutaneous Squamous Cell Carcinoma: Implications on Biopsy Technique.

Dermatol Surg 2018 Sep;44(9):1170-1173

Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

Background: Perineural invasion (PNI) is a high-risk feature of cutaneous squamous cell carcinoma (CSCC). Depths at which PNI occurs are unknown.

Objective: To determine the most superficial depth at which PNI occurs in CSCC and stratify by tumor clinical diameter and body location.

Methods And Materials: Single-institution retrospective review of CSCC specimens reporting PNI on pathology reports between January 2004 and August 2014. Depth was defined as distance from top of granular layer to middle of nerve invaded by CSCC or distance from erosion to middle of nerve affected by CSCC.

Results: Of 66 specimens identified with PNI, 45 specimens were included. Mean histopathologic depth to PNI was 2.7 mm (SD = 1.8 mm, median depth = 2.2 mm, range 0.5-12 mm). Perineural invasion depth varied by anatomic location, with the head associated with most superficial average PNI depth (2.2 mm) and trunk with greatest average PNI depth (4.3 mm). Perineural invasion depth correlated with clinical tumor diameter. The largest percentage of specimens with PNI were of clinical diameter of at least 2 cm (20/45 = 44%).

Conclusion: Clinicians encountering lesions suspicious for CSCC have the greatest chance of detecting PNI using biopsy techniques that reach at least 3 to 4 mm deep.
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http://dx.doi.org/10.1097/DSS.0000000000001581DOI Listing
September 2018

Biologic Agent-Associated Cutaneous Adverse Events: A Single Center Experience.

Clin Med Res 2018 06 2;16(1-2):41-46. Epub 2018 Apr 2.

Marshfield Clinic Health System, Department of Pathology, Marshfield, WI 54449 USA.

Biologic agents are regarded as an effective treatment for a variety of autoimmune diseases. These drugs have an acceptable safety and tolerability profile, although an increasing number of autoimmune conditions have been reported with their use. Additionally, a variety of cutaneous diseases have been associated with their use. Here we report our experience of adverse cutaneous events with the use of biologic agents. An alternative explanation for patients presenting with adverse cutaneous events including drug interactions must be carefully investigated.
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http://dx.doi.org/10.3121/cmr.2017.1364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6108513PMC
June 2018

Tanning Salon Compliance Rates in States With Legislation to Protect Youth Access to UV Tanning.

JAMA Dermatol 2018 01;154(1):67-72

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

Importance: The US Food and Drug Administration has classified tanning beds as carcinogenic. Most states have enacted legislation to prevent or create barriers for minors accessing tanning establishments. Determining tanning salon compliance with legislation would provide an indication of the influence of legislation at preventing exposure to the carcinogen in minors.

Objectives: To investigate compliance rates in the 42 states and the District of Columbia with legislation restricting tanning bed use in minors and to identify differences in compliance based on population, regional location, salon ownership, age group being regulated, and time since the law was enacted.

Design, Setting, And Participants: This investigation was a cross-sectional telephone survey conducted between February 1, 2015, and April 30, 2016, by callers posing as minors attempting to schedule a tanning appointment. The setting was tanning salons in the 42 states and the District of Columbia that currently have legislation restricting tanning bed use in minors. Included in the study were 427 tanning salons, 10 randomly selected from each state or territory with tanning legislation.

Main Outcomes And Measures: Overall compliance of tanning salons with state tanning legislation and differences in compliance based on community population, regional location, independent vs chain tanning salon, age group being regulated, and time since the law was enacted.

Results: Of the 427 tanning salons surveyed, overall noncompliance with state legislation was 37.2% (n = 159). There were more noncompliant tanning salons in rural locations (45.5%; 95% CI, 37.5%-53.7%; P = .009), southern regions of the United States (49.4%; 95% CI, 41.4%-57.4%; P = .001), independently owned salons (43.9%; 95% CI, 37.3%-50.6%; P = .003), states with younger age groups being regulated (53.5%; 95% CI, 45.7%-61.2%; P < .001), and states with more than one tanning regulation (50.0%; 95% CI, 42.0%-58.0%; P < .001). No difference was found based on time since the law was enacted.

Conclusions And Relevance: Compliance with state legislation aimed at limiting tanning bed use among US minors is unsatisfactory, indicating that additional efforts to enforce the laws and education of the harmful effects of UV tanning are necessary, especially in rural, independently owned, and tanning salons in southern regions, which have decreased compliance rates.
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http://dx.doi.org/10.1001/jamadermatol.2017.3736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833576PMC
January 2018

Noninvasive Testing for Nonalcoholic Steatohepatitis and Hepatic Fibrosis in Patients With Psoriasis Receiving Long-term Methotrexate Sodium Therapy.

JAMA Dermatol 2017 Oct;153(10):977-982

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

Importance: The long-term implications of hepatotoxic effects in patients with psoriasis remains uncharacterized, and a method is needed for the noninvasive monitoring of the development and progression of hepatic fibrosis in patients with psoriasis receiving long-term methotrexate therapy.

Objective: To evaluate if NASH FibroSure, a noninvasive test for nonalcoholic steatohepatitis (NASH) and hepatic fibrosis, can be used for patients with psoriasis to aid in determining eligibility for methotrexate sodium (MTX) therapy, monitor for the development of MTX-induced hepatotoxic effects, and monitor for worsening of hepatic fibrosis scores during MTX therapy.

Design, Setting, And Participants: A retrospective descriptive analysis was conducted among a cohort of patients with psoriasis treated with MTX who underwent NASH FibroSure testing between January 1, 2007, and December 31, 2013, at a dermatology referral center at a single institution. Data analysis was performed from January 1 to December 31, 2014.

Main Outcomes And Measures: NASH FibroSure risk scores suggesting the development and progression of hepatic fibrosis in patients with psoriasis receiving long-term MTX therapy.

Results: Included in the institutional experience portion of the study were 129 patients with psoriasis undergoing treatment with MTX, while 107 patients (57 women and 50 men; mean [SD] age, 83.3 [13.5] years) underwent NASH FibroSure testing during MTX therapy and were eligible for correlation analysis. Of the 129 patients with psoriasis undergoing treatment with MTX, 69 (53.5%) underwent NASH FibroSure testing prior to starting MTX; 19 of those patients (27.5%) had elevated fibrosis scores, and 54 (78.3%) had elevated steatosis scores. Among the 107 patients who underwent NASH FibroSure testing during MTX therapy, the cumulative MTX dose corresponded to a statistically significant association of a higher NASH FibroSure hepatic fibrosis score in women (Spearman ρ = 0.21; P = .02) but not in men (Spearman ρ = 0.17; P = .11). All patients in the cohort except 1 were managed without a liver biopsy.

Conclusions And Relevance: The patients with psoriasis in this study had a high prevalence of elevated hepatic steatosis scores. The NASH FibroSure test can be used to monitor changes in fibrosis score in patients with psoriasis receiving MTX. In a single-institution cohort, these results suggest that NASH FibroSure may be used, especially among female patients, to help monitor for risk of worsening fibrosis during MTX therapy.
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http://dx.doi.org/10.1001/jamadermatol.2017.2083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710330PMC
October 2017

Repurposing Medications-Chicken Manure, Erectile Dysfunction, and Finding the Golden Needle in the Haystack of Absurdity.

Authors:
Erik J Stratman

JAMA Dermatol 2017 10;153(10):969-970

Marshfield Clinic, Marshfield, Wisconsin.

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http://dx.doi.org/10.1001/jamadermatol.2017.2447DOI Listing
October 2017

Relationship Between Physicians' Active Participation in Maintenance of Certification and Patients' Perspective of Care Surveys.

J Patient Exp 2016 Jun 8;3(2):43-47. Epub 2016 Jun 8.

Department of Dermatology, Marshfield Clinic, Marshfield, WI, USA.

Objective: Medical specialty boards have a Maintenance of Certification (MOC) paradigm whose intention is to ensure high-quality patient care. How the patient experience is affected by physician MOC enrollment/participation is unknown. Our goal was to determine if patient experience is associated with physician board certification and MOC status.

Methods: We analyzed physician experience and MOC databases to determine the relationships among physicians' patient experience national percentile rankings and board certification status and MOC enrollment and activity status.

Results: Board-certified physicians enrolled in MOC did not have statistically significant different patient experience scores compared to board-certified physicians not enrolled in MOC. Mid-career physicians enrolled in MOC had patients more likely to recommend them and reported higher confidence in them. Patients did not perceive physicians participating in MOC patient safety modules as more cautious in providing patient care.

Conclusion: Although most analyses did not demonstrate significant differences in patient experience scores for physicians actively participating in MOC compared to those not, some differences were noted. Higher provider-specific patient experience scores were noted, particularly for mid-career physicians.
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http://dx.doi.org/10.1177/2374373516652232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513620PMC
June 2016

Nasal septal and mucosal disease associated with pyoderma gangrenosum in a cocaine user.

JAAD Case Rep 2017 Jul 22;3(4):284-287. Epub 2017 Jun 22.

Department of Dermatology, Marshfield Clinic Health System, Marshfield, Wisconsin.

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http://dx.doi.org/10.1016/j.jdcr.2017.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5484981PMC
July 2017

Are You Ready for Maintenance of Certification Self-Assessment 2.0?: It's Here, It's Cheaper, and It's Easier.

JAMA Dermatol 2016 05;152(5):515-6

Department of Dermatology, Massachusetts General Hospital, Boston.

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http://dx.doi.org/10.1001/jamadermatol.2016.0877DOI Listing
May 2016

Skin biopsy: Identifying and overcoming errors in the skin biopsy pathway.

J Am Acad Dermatol 2016 Jan;74(1):19-25; quiz 25-6

Department of Dermatology, Johns Hopkins Hospital, Baltimore, Maryland.

The skin biopsy pathway involves numerous communication requirements, technical events, human handoffs, and cognitive decisions. Every step in the process has an error rate >0. To deliver the highest quality care, dermatologists obtaining skin biopsy specimens should implement systems in their office to minimize errors. This includes the prevention of wrong-site surgery, which in most instances involves accurate communication of the correct biopsy location to the performing surgeon. Part II of this continuing medical education article presents techniques for assessing and planning improvement to the skin biopsy pathway in your office, and provides a simple online quality improvement activity that allows Board-certified dermatologists the opportunity to potentially improve aspects of the skin biopsy process in their own practices, and in the process obtain Maintenance of Certification credit.
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http://dx.doi.org/10.1016/j.jaad.2015.06.034DOI Listing
January 2016

Skin biopsy: Biopsy issues in specific diseases.

J Am Acad Dermatol 2016 Jan;74(1):1-16; quiz 17-8

Department of Dermatology, Johns Hopkins Hospital, Baltimore, Maryland.

Misdiagnosis may result from biopsy site selection, technique, or choice of transport media. Important potential sources of error include false-negative direct immunofluorescence results based on poor site selection, uninformative biopsy specimens based on both site selection and technique, and spurious interpretations of pigmented lesions and nonmelanoma skin cancer based on biopsy technique. Part I of this 2-part continuing medical education article addresses common pitfalls involving site selection and biopsy technique in the diagnosis of bullous diseases, vasculitis, panniculitis, connective tissue diseases, drug eruptions, graft-versus-host disease, staphylococcal scalded skin syndrome, hair disorders, and neoplastic disorders. Understanding these potential pitfalls can result in improved diagnostic yield and patient outcomes.
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http://dx.doi.org/10.1016/j.jaad.2015.06.033DOI Listing
January 2016

Perianal North American blastomycosis.

Cutis 2015 Aug;96(2):E23-6

Department of Dermatology (4K5), Marshfield Clinic, 1000 North Oak Ave, Marshfield, WI 54449, USA.

Cutaneous North American blastomycosis most often results from the hematogenous spread of Blastomyces dermatitidis following pulmonary infection. Cutaneous lesions, which may be either verrucous or ulcerative plaques, commonly occur on or around orifices contiguous to the respiratory tract. We report the case of a 57-year-old man with cutaneous North American blastomycosis who presented with a well-demarcated, firm, moist, verrucous perianal plaque 4 months following the onset of a prolonged upper respiratory tract infection. Dissemination of B dermatitidis to the perianal skin is rare, but North American blastomycosis should be considered in the broad differential diagnosis of perianal lesions in any patients who have lived in or traveled to endemic regions.
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August 2015

Identifying Performance Gaps in Comorbidity and Risk Factor Screening, Prevention, and Counseling Behaviors of Providers Caring for Children with Psoriasis.

Pediatr Dermatol 2015 Nov-Dec;32(6):813-8. Epub 2015 Sep 4.

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

Background/objectives: Comorbidities and risk factors are associated with pediatric psoriasis. It is unknown whether pediatricians and dermatologists ask about, record, or counsel on pediatric psoriasis risk factors and comorbidities. The aim of our study was to assess the rate at which pediatricians and dermatologists inquire about, counsel on, and document pediatric psoriasis risk factors and comorbidities in a stable population.

Methods: This was a retrospective chart review from 2011 to 2013 in a large, rural multidisciplinary clinic, the Marshfield Epidemiologic Study Area. Participants were children ages 18 years and younger with plaque psoriasis. Rates of counseling and screening for pediatric psoriasis risk factors and comorbidities by pediatricians and dermatologists were determined.

Results: Thirty patients qualified for the study. Data were collected on body mass index (BMI) and tobacco exposure. Caregiver counseling rates on these factors were low; 66.7% and 60% did not receive counseling on BMI reduction or family member smoking cessation, respectively. Counseling on stress as a risk factor was performed at only one patient's dermatology visit (3.3%). Lipid panels were collected for 40% of patients and fasting glucose levels for 33.3% since the date of first psoriasis diagnosis. Blood pressure was collected for all patients. Only 13.3% of patients were counseled on the psoriasis comorbidity hyperlipidemia, 10% on hypertension, and 3.3% on diabetes mellitus.

Conclusions: Dermatologists and pediatricians have a low rate of counseling, documenting, and screening for pediatric psoriasis risk factors and comorbidities, suggesting that psoriasis comorbidity education is an aspect of the patient visit that may need improvement. Pediatric psoriasis counseling and screening guidelines are needed.
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http://dx.doi.org/10.1111/pde.12669DOI Listing
September 2016

Assessing the impact of a medical librarian on identification of valid and actionable practice gaps for a continuing medical education committee.

J Contin Educ Health Prof 2014 ;34(3):186-94

Introduction: Identifying educational needs related to professional practice gaps can be a complex process for continuing medical education (CME) committees and for physicians who submit activity applications. Medical librarians possess unique skills that may be useful for identifying practice gaps relevant to CME committees. We assessed this assumption by assessing a medical librarian's contributions to practice gap identification for the Marshfield Clinic's CME Committee.

Methods: We reviewed all locally relevant, locally actionable practice gaps identified annually by various stakeholders and presented to our CME Committee from 2010 to 2013. Total numbers of practice gaps identified, total categorized as actionable, and numbers of subsequent activities resulting from these gaps were calculated for each year. Medical librarian totals were compared to those of other CME committee stakeholders to determine the relative contribution.

Results: The medical librarian identified unique, actionable published practice gaps that directly contributed to CME activity planning. For each study year, contributions by the medical librarian grew, from 0 of 27 actionable gaps validated by CME Committee in 2010 to 49 of 108 (45.4%) in 2013. With the librarian's assistance, the number of valid practice gaps submitted between 2010 and 2013 by stakeholders climbed from 23 for 155 activities (14.8%) to 133 for 157 activities (84.7%).

Conclusion: Medical librarians can provide a valuable service to CME committees by identifying valid professional practice gaps that inform decisions about educational activities aimed at improving clinical practice. Medical librarians bring into deliberations unique information, including national health policy priorities, practice gaps found in the literature, and point-of-care search engine statistics.
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http://dx.doi.org/10.1002/chp.21244DOI Listing
September 2016

Granuloma inframammary adultorum.

JAMA Dermatol 2014 Oct;150(10):1113-5

Department of Dermatology, Marshfield Clinic-Saint Joseph's Hospital, Marshfield, Wisconsin.

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http://dx.doi.org/10.1001/jamadermatol.2014.352DOI Listing
October 2014

Practice gaps in patient safety among dermatology residents and their teachers: a survey study of dermatology residents.

JAMA Dermatol 2014 Jul;150(7):738-42

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

Importance: Curriculum and role modeling adjustments are necessary to address patient safety gaps occurring during dermatology residency.

Objective: To identify the source of clinical practices among dermatology residents that affect patient safety and determine the best approach for overcoming gaps in knowledge and practice patterns that contribute to these practices.

Design, Setting, And Participants: A survey-based study, performed at a national medical dermatology meeting in Itasca, Illinois, in 2012, included 142 dermatology residents from 44 residency programs in the United States and Canada.

Main Outcomes And Measures: Self-reported rates of dermatology residents committing errors, identifying local systems errors, and identifying poor patient safety role modeling.

Results: Of surveyed dermatology residents, 45.2% have failed to report needle-stick injuries incurred during procedures, 82.8% reported cutting and pasting a previous author's patient history information into a medical record without confirming its validity, 96.7% reported right-left body part mislabeling during examination or biopsy, and 29.4% reported not incorporating clinical photographs of lesions sampled for biopsy in the medical record at their institution. Residents variably perform a purposeful pause ("time-out") when indicated to confirm patient, procedure, and site before biopsy, with 20.0% always doing so. In addition, 59.7% of residents work with at least 1 attending physician who intimidates the residents, reducing the likelihood of reporting safety issues they witness. Finally, 78.3% have witnessed attending physicians purposefully disregarding required safety steps.

Conclusions And Relevance: Our data reinforce the need for modified curricula, systems, and teacher development to reduce injuries, improve communication with patients and between physicians, residents, and other members of the health care team, and create an environment free of intimidation.
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http://dx.doi.org/10.1001/jamadermatol.2013.7541DOI Listing
July 2014

Cosmetic dermatologic surgical training in US dermatology residency programs: identifying and overcoming barriers.

JAMA Dermatol 2014 Feb;150(2):125-9

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin.

Importance: The public and other medical specialties expect dermatologists who offer cosmetic dermatology services to provide competent care. There are numerous barriers to achieving cosmetic dermatology competency during residency. Many dermatology residents enter the workforce planning to provide cosmetic services. If a training gap exists, this may adversely affect patient safety.

Objectives: To identify resources available for hands-on cosmetic dermatology training in US dermatology residency training programs and to assess program director (PD) attitudes toward cosmetic dermatology training during residency and strategies, including discounted pricing, used by training programs to overcome barriers related to resident-performed cosmetic dermatology procedures.

Design, Setting, And Participants: An online survey in academic dermatology practices among PDs of US dermatology residency programs.

Main Outcomes And Measures: Frequency of cosmetic dermatology devices and injectables used for dermatology resident hands-on cosmetic dermatology training, categorizing PD attitudes toward cosmetic dermatology training during residency and describing residency-related discounted pricing models.

Results: Responses from PDs were received from 53 of 114 (46%) US dermatology residency programs. All but 3 programs (94%) offered hands-on cosmetic dermatology training using botulinum toxin, and 47 of 53 (89%) provided training with hyaluronic acid fillers. Pulsed dye lasers represented the most common laser use experienced by residents (41 of 52 [79%]), followed by Q-switched Nd:YAG (30 of 52 [58%]). Discounted procedures were offered by 32 of 53 (60%) programs, with botulinum toxin (30 of 32 [94%]) and fillers (27 of 32 [84%]) most prevalent and with vascular lasers (17 of 32 [53%]) and hair removal lasers (12 of 32 [38%]) less common. Various discounting methods were used. Only 20 of 53 (38%) PDs believed that cosmetic dermatology should be a necessary aspect of residency training; 14 of 52 (27%) PDs thought that residents should not be required to perform any cosmetic dermatology procedures.

Conclusions And Relevance: Although almost every program provides hands-on cosmetic dermatology training, there are barriers to training, including patient preferences, costs of procedures and products, and PD attitudes toward cosmetic dermatology training. To promote patient safety, procedural competency is imperative.
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http://dx.doi.org/10.1001/jamadermatol.2013.6713DOI Listing
February 2014

Measuring impact of JAMA Dermatology Practice Gaps section on training in US dermatology residency programs.

JAMA Dermatol 2013 Jul;149(7):819-24

Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin 54449, USA.

Importance: JAMA Dermatology Practice Gaps commentaries are intended to aid in the interpretation of the literature to make it more practical and applicable to daily patient care. Practice Gaps commentaries have had an impact on physician clinical practice and dermatology residency curricula.

Objective: To assess the impact of JAMA Dermatology Practice Gaps commentaries on dermatology residency training programs in the United States, including journal club discussions and local quality improvement activities.

Design, Setting, Participants: A web-based questionnaire of 17 questions was sent via e-mail to US dermatology residency program directors (PDs) in February 2012.

Main Outcomes And Measures: Program director report of incorporating Practice Gaps themes and discussions into resident journal club activities, clinical practice, quality improvement activities, or research projects in the residency programs, as a result of a Practice Gaps commentary.

Results: Of the 114 surveys distributed to US dermatology residency PDs, 48 were completed (42% response rate). Sixty percent of PDs reported familiarity with the Practice Gaps section of JAMA Dermatology, and 56% discuss these commentaries during resident journal club activities. Quality improvement and research projects have been initiated as a result of Practice Gaps commentaries.

Conclusions And Relevance: Practice Gaps commentaries are discussed during most dermatology residency journal club activities. Practice Gaps have had an impact on physician practice and dermatology residency curricula and can serve as a tool for enhanced continuing medical education and quality improvement initiatives.
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http://dx.doi.org/10.1001/jamadermatol.2013.389DOI Listing
July 2013

Aminolevulinic acid photodynamic therapy in the treatment of erosive pustular dermatosis of the scalp.

Arch Dermatol 2011 Dec;147(12):1368-70

University of Minnesota Medical School, Minneapolis, USA.

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http://dx.doi.org/10.1001/archdermatol.2011.299DOI Listing
December 2011
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