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PubMed2002

Antibiotic prophylaxis guideline awareness and antibiotic prophylaxis use among New York State dermatologic surgeons.

BACKGROUND: Use of antibiotic prophylaxis in dermatologic surgery patients remains controversial and several sets of guidelines exist. OBJECTIVE: We investigated dermatologic surgeon's awareness of the American Heart Association (AHA) 1997 antibiotic prophylaxis guidelines, their use of prophylactic antibiotics, and their practices as compared with the Haas and Grekin's 1995 antibiotic prophylaxis guidelines. METHODS: We mailed postage-paid questionnaires regarding AHA guideline awareness and antibiotic prophylaxis use to the 235 New York State members of the American Society for Dermatologic Surgery (ASDS). We received 87 replies. RESULTS: Most participants recognize AHA guidelines and claim to follow them. We reiterate previous studies' findings. Most dermatologic surgeons use antibiotics appropriately. However, antibiotics are occasionally overused or dosed outside the guidelines. Many participants prescribe antibiotics based on a patient's other physicians' recommendations. Notably, erythromycin is sometimes used, an antibiotic the AHA no longer recommends. CONCLUSION: Dermatologic surgeons commonly use antibiotic prophylaxis to prevent bacterial endocarditis. Based on previous studies, though, the risk of endocarditis following cutaneous surgery is low and thus the use of antibiotic prophylaxis is controversial. Although this practice is appropriate for high-risk patients when skin is contaminated, it is not recommended for noneroded, noninfected skin. We report that dermatologists may be aware of the guidelines, but only seem to partially follow them. Further studies are still needed to establish optimal guidelines.

Anti-Bacterial Agents↗

PubMed2001

Anxiolysis with oral midazolam in pediatric patients undergoing dermatologic surgical procedures.

BACKGROUND: Pediatric patients undergoing dermatologic surgical procedures often experience high levels of anxiety. Oral midazolam is a short-acting benzodiazepine that can ameliorate procedure-related anxiety. OBJECTIVE: Our purpose was to determine the safety and efficacy of oral midazolam as an adjuvant anxiolytic agent for pediatric patients undergoing dermatologic surgical procedures. METHODS: A prospective series of pediatric patients undergoing dermatologic surgical procedures who received oral midazolam were monitored, and efficacy and complications were recorded. RESULTS: Oral midazolam provided good to excellent anxiolytic effects in most pediatric patients undergoing painful dermatologic surgical procedures. Because midazolam does not provide analgesic effects, local anesthesia is necessary. Complications were uncommon and minor. CONCLUSION: Oral midazolam is an effective anxiolytic agent in pediatric patients undergoing dermatologic surgical procedures.

Administration, Oral↗

PubMed1993

An outbreak of mupirocin-resistant Staphylococcus aureus on a dermatology ward associated with an environmental reservoir.

OBJECTIVE: To investigate a cluster of mupirocin-resistant Staphylococcus aureus on a dermatology ward. DESIGN: An outbreak of mupirocin-resistant S aureus was noted on the dermatology ward during a prospective epidemiologic study of methicillin-resistant S aureus (MRSA) and borderline methicillin-susceptible S aureus (BMSSA). Pulsed-field gel electrophoresis (PFGE) of whole-cell DNA digested with Sma I was used as a marker of strain identity. SETTING AND PATIENTS: An 850-bed university hospital with a 12-bed inpatient dermatology ward. Most patients have severe, exfoliating dermatologic disorders. RESULTS: MRSA or BMSSA were isolated from 13 patients on the dermatology ward over a 14-month period. Eleven of these isolates (84.6%) were mupirocin-resistant. Nine isolates were present on admission (81.8%); 8 of these patients had been hospitalized on the same ward within the last two months. Nasal and hand cultures from 36 personnel were negative for mupirocin-resistant MRSA or BMSSA. Extensive environmental culturing revealed that a blood pressure cuff and the patients' communal shower were positive for mupirocin-resistant BMSSA. PFGE of all mupirocin-resistant isolates demonstrated that the nine patients and both environmental sources had identical DNA typing patterns. INTERVENTIONS: Changing of blood pressure cuffs between patients and more stringent cleaning of communal areas was initiated. Repeat environmental cultures were negative. CONCLUSIONS: S aureus is not usually associated with an environmental reservoir; however, these patients all had severe desquamation, which may have prolonged environmental contamination.

Blood Pressure Determination↗

PubMed2004

A randomized controlled trial using instant photography to diagnose and manage dermatology referrals.

BACKGROUND: Fifteen percent of GP consultations are for dermatological conditions; 4% of these are referred to a dermatologist. There are long waiting lists for dermatology appointments. This study examines the value of instant photography in managing dermatology referrals. OBJECTIVE: The purpose of our study was to compare outcomes of referral for dermatology appointments between patients whose referral letters do or do not include instant photograph(s). METHODS: Patients (136), referred to a dermatologist by GPs in two urban health centres, were randomly allocated to study and control groups. Instant photographs, taken by the GP, were included in the referral letters. Control group patients were given out-patient appointments in the usual way. The numbers of study group patients needing an appointment for diagnosis or management and with a changed diagnosis after face-to-face consultation were recorded. Waiting time from referral to appointment or management plan was recorded for both groups. RESULTS: For 63% of the study group (45/71), a diagnosis and a management plan were made without the patient requiring an appointment. This included 38% (27/71) who, after diagnosis and initial management, needed an appointment and 25% (18/71) who did not. The remainder of the study group (37%; 26/71) required a face-to-face consultation. The mean time for formulation of a management plan for patients without an appointment was 17 days (SD = 11); waiting times for appointments in study and control groups were similar (mean 55 days; SD = 40). CONCLUSIONS: Instant photography is helpful in managing dermatology referrals and offers the potential to reduce numbers requiring an out-patient appointment by 25%.

Adolescent↗

PubMed2005

A novel computer-assisted algorithmic method for differential diagnosis of dermatological diseases.

To deal with human surface locations electronically, it is essential to establish a designation method to code the sites. For the development of site designation methods and databases, dermatological textbooks, atlantes and clinical photographs were collected and reviewed. The sites were systematically named, numbered, and mapped on human models. The whole human surface was divided into 484 segments, and then assembled into 15 groups and 29 subgroups. After establishing the site designation method, we constructed a database of the sites of occurrence of dermatological diseases, and a database of age, sex, signs and symptoms. More than 700 diseases were analyzed and coded into the database. To gather information on the site of a particular disease, not only textbooks, and atlantes of dermatology, but also photographs obtained during clinical practices were reviewed, as clinical photos of patients can be more delicate than the descriptions in textbooks. The prototype of a computer assisted dermatological diagnosing system was made using site a designation method and the databases. This interactive computer program worked relatively well as a helpful guide or dermatological diagnosing tool. Further diseases are being added to the databases.

Algorithms↗

PubMed2006

Preferences for aspects of a dermatology consultation.

BACKGROUND: General practitioners with special interests (GPSIs) are increasingly being used to provide dermatology services in the U.K. Little is known about U.K. dermatology patient attitudes to proposed variations in secondary care service delivery or the values they attach to aspects of the care they receive. OBJECTIVES: To quantify preferences for different attributes of care within dermatology secondary care services. METHODS: Attributes of care that are important to dermatology patients were derived using in-depth qualitative interviews with 19 patients at different points in the care pathway. A discrete choice experiment using 'best-worst scaling' was sent by post to 119 patients referred to secondary care dermatology services and suitable for GPSI care who had agreed to participate in research. RESULTS: Four attributes were derived from the qualitative work: waiting, expertise, thorough care and convenience. For the discrete choice experiment, 99 patients returned questionnaires, 93 of which contained sufficient data for analysis. All attributes were found to be quantitatively important. The attribute of greatest importance was expertise of the doctor, while waiting time was of least importance. Respondents were willing to wait longer than the current 3 months maximum to receive care that was thorough, 2.1 months to see a team led by an expert and 1.3 months to attend a consultation that is easy to get to. CONCLUSIONS: Although the need to reduce outpatient waiting times is a key policy driver behind the expansion of GPSI services, this does not appear to be the most important issue for patients. The thoroughness with which the consultation is provided and the expertise of the clinician seen are higher priorities.

Attitude to Health↗

PubMed1992

An epidemiological profile of in-patient workload in dermatology.

Trends in admission rates, patterns of readmission, lengths of stay and clinical caseload for in-patient dermatology from 1976 to 1985 are described using data from the Oxford record-linkage study. Age-specific admission rates were considerably higher in people aged 50 years and over than in younger people. Admission rates declined over time in most age-sex groups below the age of 70 years, but increased over time for the over 70s. In dermatology, unlike most other specialties, the length of patients' stay did not decrease substantially over the 10 years. In-patient workload consisted predominantly of leg ulcers, psoriasis, and eczema. This did not change appreciably over time. New out-patients at dermatology clinics rose by 41% from 1976 to 1985, and all out-patient visits rose by 20% during the 10-year period. Because the profile of in-patient workload changed relatively little over time, we speculate that the impact of innovations in dermatological practice has been much greater in the ambulatory setting than in the management of those patients requiring prolonged in-patient care. Future routine measures of workload in dermatology should include demographic and clinical data on out-patients.

Adult↗

PubMed2004

Curriculum planning in dermatology.

Curriculum planners should familiarize themselves with the recommendations for medical education in the UK made by the Quality Assurance Agency and the General Medical Council. The dermatology curriculum must maximize undergraduate learning experiences in dermatology, but lengthy curricula lead to rote learning and do not promote understanding. The core dermatology curricula might be built around the clinical problems graduates are likely to encounter as preregistration house-officers, but should also prepare students for their future careers in whatever specialty. Graduates should know when it might be appropriate to refer a patient to a dermatologist. Learning experiences in dermatology might be threaded into the curriculum at a number of stages and student-selected components might provide opportunities to explore dermatological topics in depth. The views of a broad constituency will give the core curriculum validity and consensus might be reached with the Delphi technique or by using multidisciplinary groups. Temptations to overload the curriculum should be resisted. Medical curricula should give students time to experience the art of medicine as well as to explore the science behind clinical practice.

Curriculum↗

PubMed2006

Preparing nurses to prescribe medicines for patients with dermatological conditions.

BACKGROUND: From Spring 2006, independent extended nurse prescribers in the United Kingdom will be able to prescribe any licensed medicines except controlled drugs. Supplementary nurse prescribers are currently able to prescribe any medication. No other country in the world has such extended prescribing rights for nurses. Aspects of prescribing viewed positively by nurses include continuity of care, increased satisfaction, and the belief that patients receive improved information about prescriptions. There is some evidence, however, that nurses feel ill-prepared to prescribe due to poor understanding of pharmacology, physical assessment and diagnosis. AIM: This paper reports a study assessing the extent to which independent extended supplementary nurse prescribers feel prepared to prescribe medicines for patients with dermatological conditions. METHODS: A convenience sample of 1187 qualified independent extended supplementary nurse prescribers was sent a postal questionnaire. A total of 868 completed questionnaires was returned, and 638 of these nurses prescribed medicines for skin conditions. The data were collected in 2005. RESULTS: A total of 605 (94.8%) participants used independent extended prescribing and 234 (36.7%) supplementary prescribing. The majority were highly experienced and worked in primary care. In general, their prescribing programme had met their needs when prescribing medicines for patients with dermatological conditions. However, the needs of those who had undertaken a diploma-level module in dermatology and/or dermatology study days, and those working in both primary and secondary care, were met to a statistically significantly greater extent during the programme than for those nurses without this preparation, or those working in either primary or secondary care. CONCLUSION: Independent extended supplementary prescribing has extended the role that nurses in the United Kingdom are able to play in the management of skin disease. Specialist dermatology training is a prerequisite for nurses adopting this role. Further evaluative work on patient-focused outcomes, i.e. accessibility and convenience of care, and satisfaction with quality of care, is required.

Adult↗

PubMed2005

Burnout and job satisfaction comparing healthcare staff of a dermatological hospital and a general hospital.

BACKGROUND: Psychological distress among healthcare professionals can have negative effects on the well-being of the professionals and also on the quality of care they provide to patients. OBJECTIVES: To evaluate burnout and job satisfaction of dermatologists and nurses working with dermatological patients compared with physicians and nurses of other specialties. METHODS: A self-completed anonymous questionnaire was distributed to the personnel of two hospitals in Rome, Italy: a dermatological hospital (IDI) and a general hospital (GH), belonging to the same non-profit organization. Standardized instruments were used to assess burnout (Maslach Burnout Inventory) and job satisfaction. Multiple logistic regression was used to examine the association between burnout and working in dermatology vs. other specialties, job satisfaction, years of employment and respondents' sex and age. RESULTS: We distributed 929 questionnaires to clinical and non-clinical staff of IDI and 494 questionnaires to the GH staff (response rates: 53% at IDI and 50% at the GH). Among respondents there were 67 physicians and 59 nurses at IDI and 70 physicians and 148 nurses at the GH. Subsequent analyses refer only to this clinical subsample. Factor analysis showed that among physicians and nurses the two main factors explaining job satisfaction were respondents 'satisfaction with the management of their unit' and 'opportunities for personal growth'. Among nurses the likelihood of burnout decreased significantly with higher levels of job satisfaction [odds ratio (OR) = 0.78; 95% confidence interval (95% CI) 0.7-0.9] and working in dermatology compared with other specialties (OR = 0.46; 95% CI 0.2-0.9). Among physicians a lower likelihood of burnout was associated with job satisfaction (OR = 0.66; 95% CI 0.5-0.8) and older age (OR = 0.28; 95% CI 0.1-0.8). CONCLUSIONS: Among both physicians and nurses, job satisfaction was associated with a lower likelihood of burnout, independently of clinical specialty and other factors. Burnout was similar for dermatologists and other specialists. Nurses of the GH compared with those working in dermatology had a higher probability of burnout and were significantly less satisfied with the management of their units and with opportunities for personal growth.

Adult↗

PubMed2005

Case mix measures and diagnosis-related groups: opportunities and threats for inpatient dermatology.

OBJECTIVE: The changing healthcare environment world-wide is leading to extensive use of per case payment systems based on diagnosis-related groups (DRG). The aim of this study was to examine the impact of application of different DRG systems used in the German healthcare system. METHODS: We retrospectively analysed 2334 clinical data sets of inpatients discharged from an academic dermatological inpatient unit in 2003. Data were regarded as providing high coding quality in compliance with the diagnosis and procedure classifications as well as coding standards. The application of the Australian AR-DRG version 4.1, the German G-DRG version 1.0, and the German G-DRG version 2004 was considered in detail. To evaluate more specific aspects, data were broken down into 11 groups based on the principle diagnosis. MAIN OUTCOME MEASURE: DRG cost weights and case mix index were used to compare coverage of inpatient dermatological services. Economic impacts were illustrated by case mix volumes and calculation of DRG payments. RESULTS: Case mix index results and the pending prospective revenues vary tremendously from the application of one or another of the DRG systems. The G-DRG version 2004 provides increased levels of case mix index that encourages, in particular, medical dermatology. CONCLUSIONS: The AR-DRG version 4.1 and the first German DRG version 1.0 appear to be less suitable to adequately cover inpatient dermatology. The G-DRG version 2004 has been greatly improved, probably due to proceeding calculation standards and DRG adjustments. The future of inpatient dermatology is subject to appropriate depiction of well-established treatment standards.

Case Management↗

PubMed2004

Specialty clinics for the dermatologic care of solid-organ transplant recipients.

BACKGROUND: Solid-organ transplant recipients constitute a complex patient population that experiences numerous and aggressive skin cancers. Proactive, comprehensive, ongoing, and effective dermatologic care of these patients is a necessity. OBJECTIVE: The objective of this study was to emphasize the need for organized dermatologic care for transplant recipients and to collect and present various proactive paradigms established in and designed for different practice settings to manage organ transplant recipients at high risk for skin cancer. METHODS: Information about practice setting, patient demographics, and the care model used was obtained through questionnaires sent to a selection of 12 physicians known to care for transplant recipients in various practice settings. RESULTS: All 12 physicians completed the questionnaire. The organized dermatologic care of transplant recipients occurs in three basic clinic settings: multidisciplinary transplant clinics, designated dermatology transplant subspecialty clinics, and integration of transplant recipient care within existing dermatology clinics. CONCLUSIONS: Various practice settings offer both advantages and disadvantages in providing preventive and therapeutic care of organ transplant recipients at risk for skin cancer. Regardless of the clinic design used, an organized and firmly established clinic model to allow proactive and ongoing care for these patients is important for education, prevention, and early intervention.

Dermatology↗

PubMed2004

Glove perforation in outpatient dermatologic surgery.

BACKGROUND: Intact surgical gloves ensure protection of health-care employees and health-care recipients. Nevertheless, glove perforation is very common and puncture rates above 50% have been published in the literature. OBJECTIVE: It was our aim to evaluate the perforation rate of surgical gloves in outpatient dermatologic surgery. METHODS: Six-hundred and sixty latex surgical gloves used in outpatient dermatologic surgery were evaluated for perforations using the approved water-leak method. Perforations were analyzed microscopically. RESULTS: Twenty of the 660 gloves were found to have perforations, which corresponds to a perforation rate of 3.0%. Only 5 of these perforations (25%) were noticed by the wearer. Perforations were more numerous in nondominant-handed gloves. Microscopically, all perforations could be identified as needle stick injuries. CONCLUSION: The risk of glove perforation in outpatient dermatologic surgery is lower than in many other medical specialties. The relatively high number of surgical procedures performed successively in outpatient dermatologic surgery, however, emphasizes the decisive relevance of an intact barrier between surgeon and patient. In view of the major fact that most perforations go unnoticed by the wearer, dermatologic surgeons must balance the improved safety of double gloving with costs and the loss of sensitivity and dexterity.

Accidents, Occupational↗

PubMed2005

Power and sample size of therapeutic trials in procedural dermatology: how many patients are enough?

BACKGROUND: Many new devices and therapeutic interventions are continually introduced in cutaneous surgery. The efficacy of these new techniques must be compared with that of preexisting standards so that patients can be appropriately counseled. OBJECTIVES: The purpose of this article is to (1) review methods for estimating sample size and power, (2) estimate the range of sample sizes sufficient to ensure that true differences are not missed in clinical trials of new procedural dermatologic therapies, and (3) consider the reasons why the sample size may be too small in procedural dermatology trials and how this problem can be addressed. METHODS: (1) Selective review of textbooks and other relevant literature, presentation of a brief tutorial describing sample size and power determination for therapeutic clinical trials comparing two groups with continuous outcomes variables; (2) implementation of standard formulae and assumptions to estimate sample size in cutaneous surgery therapeutic trials. RESULTS: Assuming that one group receives a standard surgical intervention and another group undergoes a new technique, to identify a moderate difference in efficacy between groups, at least 50 to 200 subjects will need to be enrolled if conventional strategies are used to reduce the likelihood of finding a difference that does not really exist (Type I error), as well as the likelihood of missing a true difference (Type II error). CONCLUSION: By face validity, it is apparent that most efficacy comparisons in procedural dermatology have low sample size and a concomitant risk of failing to detect actual differences between therapeutic arms. Owing to the limitations that restrict surgeons from frequently performing large randomized controlled trials in procedural dermatology, meta-analyses may be needed to pool the results of smaller studies. When it is critically important that differences between groups be accurately identified, dermatologic surgeons may consider eschewing smaller trials in favor of collaborating on larger trials with an adequate sample size.

Dermatology↗

PubMed2005

Dermatologic surgical research and the Institutional Review Board.

BACKGROUND: Dermatologic surgical techniques have transformed cosmetic surgery over the last two decades. Many of the advances in cutaneous laser surgery, botulinum toxin injections, tumescent liposuction, and the latest filler agents have been evaluated on willing volunteers as part of organized trials under the auspices of an Institutional Review Board (IRB). OBJECTIVES: To review the developmental history of today's IRB and to provide relevance to cosmetic dermatologic research. RESULTS: Although an IRB must evaluate the "voluntariness" of a proposed research protocol, the risk-benefit ratio, particularly of elective cosmetic dermatologic surgical human studies, is of even greater importance. CONCLUSION: As more dermatologic surgeons become involved in clinical research, an understanding of the function and purpose of the IRB has become increasingly important. Research relating to cosmetic dermatologic procedures raises challenging and perplexing problems for an IRB.

Biomedical Research↗

PubMed2006

[Current situation of dermatologic surgery in Germany].

BACKGROUND: Dermatologic surgery has become an increasingly important issue in dermatology in recent years. At present, no current epidemiologic or care-related data on cutaneous surgery procedures in dermatology are available. METHODS: To determine the extent of cutaneous surgery procedures in dermatological hospitals, a national survey was performed. Both the procedure codes for 2004 based on the OPS-classification and the DRG figures grouped to the major diagnostic category 09 of G-DRG version 2004 were considered in detail. Methods of descriptive statistics were applied. RESULTS: The submitted data reveal that the contributing hospitals provided 164487 cutaneous surgery procedures in the investigation period. The vast majority is represented by extensive procedures and plastic-reconstructive operations, as opposed to less complex surgeries such as simple excisions. Analysis of DRG assignment indicates that surgical procedures account for 44.2% of inpatient cases. CONCLUSIONS: The present survey demonstrates that in Germany cutaneous surgery procedures are widely performed by dermatological hospitals and dermatologists. The increasing incidence of melanoma and nonmelanoma skin cancer including precursor lesions will increase the need for dermatologists to perform cutaneous surgery in the future.

Dermatology↗

PubMed1999

[Alternative medicine therapy in dermatology: dimensions, chances and approaches to an integrative understanding].

Skin diseases may bring considerable psychosocial stress for the affected patients. The therapist must strive to relieve the symptoms and also to provide long-lasting prevention of recurrences, especially in chronic skin diseases. Clinical experience has shown complementary procedures, especially the classical naturopathy, to be promising supplements to conventinal therapy. Proof of efficacy in dermatological applications has been found in controlled studies for some of these procedures. By far the majority of these applications in dermatology still require controlled investigation. The required efficacy studies should orient to internationally accepted criteria for clinical studies and record not only clinical efficacy but also quality of life factors and cost of treatment in a therapy comparison. Psychosomatic relationships play a particular role in dermatological treatment. In addition to their importance as occasional originators or potentiaters of skin disease, emotional factors are crucial in the secondary stress associated with the disease due to the numerous visible effects on the skin. An integrative dermatological therapy makes the attempt both to determine and to treat the co-eliciting emotional factors and to support the patient's mode of coping with the disease. The doctor-patient relationship is especially important here. In summary, conventional, complementary and psychosomatic procedures can be mutually beneficial in dermatological therapy.

Complementary Therapies↗

PubMed2004

Teaching effects of dermatological consultations on nondermatologists in the field of internal medicine. A study of 1290 inpatients.

BACKGROUND: Scarce data exist concerning dermatological consultations within departments of internal medicine. To date, no survey has been carried out in Switzerland to elucidate this issue. The aim of this study was to analyze the spectrum of skin diseases internists are confronted with and to study their diagnostic accuracy in cutaneous diseases. In addition, we wanted to evaluate the motivation for dermatologists to cooperate closely with internists. PATIENTS AND METHODS: The study included patients with dermatological problems treated at the Department of Internal Medicine at the Kantonsspital Aarau, Switzerland. All patients had been referred to the Department of Dermatology for examination between 1999 and 2001. Patient data were analyzed demographically, by referral modus, diagnoses and therapy. To evaluate the knowledge of internists and dermatologists in cutaneous medicine, 15 clinical slides of common dermatoses with a patient history were shown and asked for diagnostic suggestions to 32 internists of the Kantonsspital Aarau and to 13 dermatologists of the University Hospital Basel, Switzerland. RESULTS: 1290 patients were referred to the Department of Dermatology. 1737 dermatological diagnoses were made including 348 different dermatoses. Eczema was the single most common diagnosis (12.6%), followed by actinic and bowenoid precancerosis (6.2%), drug eruption (4.2%), verrucae (4%) and mycosis (3.8%). The top ten diagnoses accounted for 41.7% of all skin-related diagnoses. Infection-related dermatoses were most common (20.5%) followed by different types of eczema (12.6%), malignant cutaneous tumors and malignant visceral conditions (11.2%). Local therapy was prescribed in 64.2% and systemic therapy in 22.6% of the patients. 15.9% did not receive specific therapy because the consultation request was only a diagnostic one. 146 skin biopsies were performed (11.3%). Systemic diseases with cutaneous manifestations accounted for 15.7%. In general, these conditions were not commonly seen by dermatologists in daily practice. The internists recognized 51.1% of the cutaneous manifestations during examination and 49% when presented with slides. CONCLUSIONS: Internists are confronted with a different spectrum of cutaneous diseases compared with dermatologists. Due to the broad spectrum of skin diseases, it is a challenging task for internists to recognize dermatoses. Our study elucidates that patients, internists and dermatologists may profit from a close cooperation.

Aged↗