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A resident-led quality improvement project evaluating patient outcomes following biopsy diagnosis of malignancy
5527
5489
A resident-led quality improvement project evaluating patient outcomes following biopsy diagnosis of malignancy Liza McClellan, MD, Roger Williams Medical Center, Department of Dermatology; Martina Porter, MD, Roger Williams Medical Center, Department of Dermatology; Alison Fischer, MD, Roger Williams Medical Center, Department of Dermatology
A retrospective analysis of complication rates in Mohs micrographic surgery patients with clinically aggressive tumors and tumors with aggressive subclinical extension Natasha Cowan, BS, School of Medicine, University of California San Diego; Alina Goldenberg, MD, Department of Dermatology, University of California San Diego; Pallavi Basu, BS, School of Medicine, University of California San Diego; Robert Eilers, MD, Department of Dermatology, University of California San Diego; Jennifer Hau, MD, Department of Dermatology, University of California San Diego; Shang I. Brian Jiang, MD, Director of Mohs Micrographic and Dermatologic Surgery, University of California San Diego
Quality improvement (QI) projects are generally designed to identify processes with less than ideal outcomes. In this QI project, we set out to identify the percentage of patients who had a biopsy-diagnosed malignancy that completed treatment for their diagnosed skin malignancy. In this process, we also hoped to identify ways in which to improve the percentage of patients that complete treatment. We conducted a retrospective chart review of all patients who underwent biopsy at Roger Williams Medical Center Department of Dermatology who received a histologic diagnosis of skin cancer from July 1, 2014 to June 30, 2015. Chart review for evidence of completion of recommended procedure included verified in-office note documenting procedure, or return of consultation letter with documentation of treatment. A total of 372 biopsies were performed between July 1, 2014 and June 30, 2015 that were found to be malignancies. Of these 372 biopsy-confirmed malignancies, 190 were evaluated with retrospective chart review. Of the 190 biopsy-proven malignancies evaluated, 152 (80%) completed treatment. The most common reasons for not pursuing treatment in 20% of our patients included: deferred treatment due to advanced age, death, and other medical comorbidities. Other reasons for failure to complete treatment included: failed to use topical treatment that was prescribed, referred to other provider (Mohs surgery) but never went for consultation or treatment, language barrier, and lost to follow-up. Through our QI project, we plan to impose closer follow-up procedures for patients with advanced age and also non-English speaking patients in an effort to improve rates of completion of treatment within these patient populations. We also streamlined the referral process to our Mohs surgery department to ensure treatment completion. Commercial support: None identified.
Purpose: Cutaneous tumors that are clinically aggressive and those with aggressive subclinical extension (ASE) often require wider excision margins during Mohs micrographic surgery (MMS) to prevent clinical recurrence. These tumors can also require multiple MMS stages, leading to larger defects. This study examined the incidence of postoperative complications in MMS patients, with a focus on differences between clinically and subclinically aggressive tumors and non-aggressive tumors. Our goal is to improve dermatologic surgeons’ patient counseling information on perioperative and postoperative complication risks for aggressive tumors. Design: We performed a retrospective cross-sectional chart review of all MMS cases with a biopsy-confirmed diagnosis of BCC or SCC (including SCC in situ) identified to be clinically aggressive or have ASE presenting between July 1, 2011 and June 30, 2015. Clinical aggression was defined as any tumor [2 cm in diameter. Aggressive subclinical extension was defined as any tumor requiring $3 stages of MMS and $1 cm final surgical margins. Summary: Of the 4151 cases identified, 586 were clinically aggressive tumors and 892 had ASE. Larger preoperative and postoperative sizes and their corresponding margins were significantly associated with postoperative complications (P \ .001). When compared to linear closures, granulation had 6.67 times the odds of having a postoperative complication (P \.001) and graft closures had 1.884 times the odds of having a postoperative complication (P ¼ .001). Clinically aggressive tumors had 50 times the odds of having a postoperative complication as compared to all other types of tumors (P \.001). Aggressive subclinical extension was not found to be significantly associated with higher rates of postoperative complications when controlled for age, sex, closure, location, histology, surgeon type, and clinical aggression. Conclusion: Patients with clinically aggressive tumors may be at higher risk for complications following MMS. Defects created may be more prone to postoperative complications due to their larger size and need for repair with methods other than linear closures. However, the complication rates in MMS patients remain very low, even for clinically aggressive tumors. Patients with tumors with ASE were not found to be at higher risk for postoperative complications, which assures that MMS is a safe procedure to treat these challenging lesions. Commercial support: None identified.
4996 A reticulate pigmentation on abdomen: What is it? Maria Carmen Salazar-Nievas, Jaen Hospital; Pedro Aceituno-Madera, Jaen Hospital Introduction: In today’s society, we use more hours the new technologies, such as mobile phones, laptops, and tablets, so there are emerging new health problems. Clinical case: A 16-year-old consults to the dermatologist for spots on the abdomen for 3 months. The examination revealed hyperpigmented macules reticulated abdomen. Investigating possible causes the patient reports every night spends hours lying with laptop resting on his abdomen. According to the appearance and medical history erythema ab igne is suspected. Comment: Erythema ab igne is the result of repeated exposure of the skin to heat levels below the threshold of the burn. It is characterized by the appearance of an erythematous macula transitional reticulated pattern that evolves to a persistent hyperpigmentation with the same pattern. The extent and morphology of the lesion usually draw the shape of the heat source and tends to be asymptomatic or feeling ardor. Today they are new cases of erythema ab igne because using laptops. Recent studies have shown that support the laptop on the thighs in the male scrotal temperature rises to 2.88C. This temperature increase is caused by the position used as the heat from both the computer. It also has been shown that only the increase of 18C and has negative effects on spermatogenesis, which can lead to infertility if this transient increase in temperature is repeated and chronic. Therefore, since the use of laptops is becoming more common in young once, we must include the risk of infertility—in the case of men—as a possible complication. Commercial support: None identified.
AB24
J AM ACAD DERMATOL
JUNE 2017
5489
A resident-led quality improvement project evaluating patient outcomes following biopsy diagnosis of malignancy Liza McClellan, MD, Roger Williams Medical Center, Department of Dermatology; Martina Porter, MD, Roger Williams Medical Center, Department of Dermatology; Alison Fischer, MD, Roger Williams Medical Center, Department of Dermatology
A retrospective analysis of complication rates in Mohs micrographic surgery patients with clinically aggressive tumors and tumors with aggressive subclinical extension Natasha Cowan, BS, School of Medicine, University of California San Diego; Alina Goldenberg, MD, Department of Dermatology, University of California San Diego; Pallavi Basu, BS, School of Medicine, University of California San Diego; Robert Eilers, MD, Department of Dermatology, University of California San Diego; Jennifer Hau, MD, Department of Dermatology, University of California San Diego; Shang I. Brian Jiang, MD, Director of Mohs Micrographic and Dermatologic Surgery, University of California San Diego
Quality improvement (QI) projects are generally designed to identify processes with less than ideal outcomes. In this QI project, we set out to identify the percentage of patients who had a biopsy-diagnosed malignancy that completed treatment for their diagnosed skin malignancy. In this process, we also hoped to identify ways in which to improve the percentage of patients that complete treatment. We conducted a retrospective chart review of all patients who underwent biopsy at Roger Williams Medical Center Department of Dermatology who received a histologic diagnosis of skin cancer from July 1, 2014 to June 30, 2015. Chart review for evidence of completion of recommended procedure included verified in-office note documenting procedure, or return of consultation letter with documentation of treatment. A total of 372 biopsies were performed between July 1, 2014 and June 30, 2015 that were found to be malignancies. Of these 372 biopsy-confirmed malignancies, 190 were evaluated with retrospective chart review. Of the 190 biopsy-proven malignancies evaluated, 152 (80%) completed treatment. The most common reasons for not pursuing treatment in 20% of our patients included: deferred treatment due to advanced age, death, and other medical comorbidities. Other reasons for failure to complete treatment included: failed to use topical treatment that was prescribed, referred to other provider (Mohs surgery) but never went for consultation or treatment, language barrier, and lost to follow-up. Through our QI project, we plan to impose closer follow-up procedures for patients with advanced age and also non-English speaking patients in an effort to improve rates of completion of treatment within these patient populations. We also streamlined the referral process to our Mohs surgery department to ensure treatment completion. Commercial support: None identified.
Purpose: Cutaneous tumors that are clinically aggressive and those with aggressive subclinical extension (ASE) often require wider excision margins during Mohs micrographic surgery (MMS) to prevent clinical recurrence. These tumors can also require multiple MMS stages, leading to larger defects. This study examined the incidence of postoperative complications in MMS patients, with a focus on differences between clinically and subclinically aggressive tumors and non-aggressive tumors. Our goal is to improve dermatologic surgeons’ patient counseling information on perioperative and postoperative complication risks for aggressive tumors. Design: We performed a retrospective cross-sectional chart review of all MMS cases with a biopsy-confirmed diagnosis of BCC or SCC (including SCC in situ) identified to be clinically aggressive or have ASE presenting between July 1, 2011 and June 30, 2015. Clinical aggression was defined as any tumor [2 cm in diameter. Aggressive subclinical extension was defined as any tumor requiring $3 stages of MMS and $1 cm final surgical margins. Summary: Of the 4151 cases identified, 586 were clinically aggressive tumors and 892 had ASE. Larger preoperative and postoperative sizes and their corresponding margins were significantly associated with postoperative complications (P \ .001). When compared to linear closures, granulation had 6.67 times the odds of having a postoperative complication (P \.001) and graft closures had 1.884 times the odds of having a postoperative complication (P ¼ .001). Clinically aggressive tumors had 50 times the odds of having a postoperative complication as compared to all other types of tumors (P \.001). Aggressive subclinical extension was not found to be significantly associated with higher rates of postoperative complications when controlled for age, sex, closure, location, histology, surgeon type, and clinical aggression. Conclusion: Patients with clinically aggressive tumors may be at higher risk for complications following MMS. Defects created may be more prone to postoperative complications due to their larger size and need for repair with methods other than linear closures. However, the complication rates in MMS patients remain very low, even for clinically aggressive tumors. Patients with tumors with ASE were not found to be at higher risk for postoperative complications, which assures that MMS is a safe procedure to treat these challenging lesions. Commercial support: None identified.
4996 A reticulate pigmentation on abdomen: What is it? Maria Carmen Salazar-Nievas, Jaen Hospital; Pedro Aceituno-Madera, Jaen Hospital Introduction: In today’s society, we use more hours the new technologies, such as mobile phones, laptops, and tablets, so there are emerging new health problems. Clinical case: A 16-year-old consults to the dermatologist for spots on the abdomen for 3 months. The examination revealed hyperpigmented macules reticulated abdomen. Investigating possible causes the patient reports every night spends hours lying with laptop resting on his abdomen. According to the appearance and medical history erythema ab igne is suspected. Comment: Erythema ab igne is the result of repeated exposure of the skin to heat levels below the threshold of the burn. It is characterized by the appearance of an erythematous macula transitional reticulated pattern that evolves to a persistent hyperpigmentation with the same pattern. The extent and morphology of the lesion usually draw the shape of the heat source and tends to be asymptomatic or feeling ardor. Today they are new cases of erythema ab igne because using laptops. Recent studies have shown that support the laptop on the thighs in the male scrotal temperature rises to 2.88C. This temperature increase is caused by the position used as the heat from both the computer. It also has been shown that only the increase of 18C and has negative effects on spermatogenesis, which can lead to infertility if this transient increase in temperature is repeated and chronic. Therefore, since the use of laptops is becoming more common in young once, we must include the risk of infertility—in the case of men—as a possible complication. Commercial support: None identified.
AB24
J AM ACAD DERMATOL
JUNE 2017