Implementing patient safety and quality improvement in dermatology. Part 1: Patient safety science.

Patient safety (PS) and quality improvement (QI) have gained momentum over the last decade and are becoming more integrated into medical training, physician reimbursement, maintenance of certification, and practice improvement initiatives. While PS and QI are often lumped together, they differ in that PS is focused on preventing adverse events while QI is focused on continuous improvements to improve outcomes. The pillars of health care as defined by the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" are safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. Implementing a safety culture is dependent on all levels of the health care system. Part 1 of this CME will provide dermatologists with an overview of how PS fits into our current health care system and will include a focus on basic QI/PS terminology, principles, and processes. This article also outlines systems for the reporting of medical errors and sentinel events and the steps involved in a root cause analysis.

Implementing patient safety and quality improvement in dermatology. Part 2: Quality improvement science.

Quality improvement (QI) in medicine is reliant on a team-based approach and an understanding of core QI principles. Part 2 of this continuing medical education series outlines the steps of performing a QI project, from identifying QI opportunities, to carrying out successive Plan-Do-Study-Act cycles, to hard-wiring improvements into the system. QI frameworks will be explored and readers will understand how to interpret basic QI data.

Monkeypox outbreak, vaccination, and treatment implications for the dermatologic patient: Review and interim guidance from the Medical Dermatology Society.

Rapid human-to-human transmission of monkeypox has created a public health emergency requiring prompt, multidisciplinary attention. Dermatologists are at the forefront of diagnosis due to the disease-defining skin lesions. Moreover, patients with pre-existing skin disease and those who are on immunosuppressive medications for skin disease may be at increased risk of severe infection. In this review, a panel of authors with expertise in complex medical dermatology and managing patients on immunosuppression reviews the literature and provides initial guidance for diagnosis and management in dermatology practices. Though there are knowledge gaps due to a lack of controlled studies, we support use of replication-deficit vaccines in all dermatologic patients who meet qualifying risk or exposure criteria. We offer strategies to optimize vaccine efficacy in patients with immunosuppression. We discuss alternative post-exposure treatments and their safety profiles. Finally, we outline supportive care recommendations for cutaneous manifestations of monkeypox. Large scale epidemiologic investigations and clinical trials will ultimately revise and extend our guidance.

Effect of Phosphate and Ferritin Subunit Composition on the Kinetics, Structure, and Reactivity of the Iron Core in Human Homo- and Heteropolymer Ferritins.

Ferritins are highly conserved supramolecular protein nanostructures that play a key role in iron homeostasis. Thousands of iron atoms can be stored inside their hollow cavity as a hydrated ferric oxyhydroxide mineral. Although phosphate associates with the ferritin iron nanoparticles, the effect of physiological concentrations on the kinetics, structure, and reactivity of ferritin iron cores has not yet been explored. Here, the iron loading and mobilization kinetics were studied in the presence of 1-10 mM phosphate using homopolymer and heteropolymer ferritins having different H to L subunit ratios. In the absence of ferritin, phosphate enhances the rate of ferrous ion oxidation and forms large and soluble polymeric Fe(III)-phosphate species. In the presence of phosphate, Fe(II) oxidation and core formation in ferritin is significantly accelerated with oxidation rates several-fold higher than with phosphate alone. High-angle annular dark-field scanning transmission electron microscopy measurements revealed a strong phosphate effect on both the size and morphology of the iron mineral in H-rich (but not L-rich) ferritins. While iron nanoparticles in L-rich ferritins have spherical shape in the absence and presence of phosphate, iron nanoparticles in H-rich ferritins change from irregular shapes in the absence of phosphate to spherical particles in the presence of phosphate with larger size distribution and smaller particle size. In the presence of phosphate, the kinetics of iron-reductive mobilization from ferritin releases twice as much iron than in its absence. Altogether, our results demonstrate an important role for phosphate, and the ferritin H and L subunit composition toward the kinetics of iron oxidation and removal from ferritin, as well as the structure and reactivity of the iron mineral, and may have an important implication on ferritin iron management in vivo.

Recurrent aphthous stomatitis: A comprehensive review and recommendations on therapeutic options.

Recurrent aphthous stomatitis (RAS) is a common chronic disease in the oral mucosa that affects about 20% of the population. It is characterized by solitary or multiple, recurrent, small ulcers with erythematous haloes and yellow/gray floors. RAS can be managed through a wide variety of preventative measures and therapies, intending to reduce ulcer pain, stimulate ulcer healing, and/or prevent ulcer recurrence. First-line treatment options include topical medications in the form of corticosteroids (triamcinolone acetonide), anti-inflammatory drugs (amlexanox), antibiotics (doxycycline), and antiseptics (lidocaine). In more severe cases of RAS where local treatment is insufficient, systemic drugs in the form of corticosteroids (prednisone), immunomodulatory drugs (thalidomide), and antibiotics/antimicrobials (clofazimine) can prove effective. This review will summarize current treatment options for RAS with discussion of prevention, topical measures, natural treatments, systemic therapies, and new potential therapies. Furthermore, this review will provide recommendations on therapeutic options for RAS based on disease severity and patient circumstances.

Assessing the quality of acne and rosacea treatment information on YouTube.

Cutaneous lupus erythematosus has different manifestation depending on the type. In this study, discoid lupus, extensive skin lesions, fairer skin types and scalp involvement were found to be positive predictive factors for more severe disease.

A Retrospective Study of Idiopathic Granulomatous Mastitis Treatment and Outcomes.

Granulomatous mastitis (GM) is a rare, poorly characterized inflammatory disease with a broad differential diagnosis that includes both benign and malignant conditions such as infectious mastitis, sarcoidosis, and inflammatory breast cancer. The etiology of most cases is idiopathic (IGM). In this retrospective study, we present our experience of 31 patients with IGM, underscoring management and treatment outcomes.

Post-discharge follow-up attendance after pediatric dermatology consultation in the emergency department: A retrospective analysis.

The emergency department (ED) is a frequent source of care for pediatric patients with dermatologic conditions, possibly owing to limited access to routine and urgent outpatient dermatology appointments. The demographics, clinical characteristics, follow-up scheduling practices, and attendance rates of 50 pediatric and 142 adult patients evaluated by the dermatology consult service in the ED were reviewed. High rates of follow-up attendance were observed in the pediatric and adult populations, with the majority receiving an appointment within 2 weeks. The dermatology consult service may play an important role in facilitating post-discharge access to outpatient care.

Iron Mobilization from Ferritin in Yeast Cell Lysate and Physiological Implications.

Most in vitro iron mobilization studies from ferritin have been performed in aqueous buffered solutions using a variety of reducing substances. The kinetics of iron mobilization from ferritin in a medium that resembles the complex milieu of cells could dramatically differ from those in aqueous solutions, and to our knowledge, no such studies have been performed. Here, we have studied the kinetics of iron release from ferritin in fresh yeast cell lysates and examined the effect of cellular metabolites on this process. Our results show that iron release from ferritin in buffer is extremely slow compared to cell lysate under identical experimental conditions, suggesting that certain cellular metabolites present in yeast cell lysate facilitate the reductive release of ferric iron from the ferritin core. Using filtration membranes with different molecular weight cut-offs (3, 10, 30, 50, and 100 kDa), we demonstrate that a cellular component >50 kDa is implicated in the reductive release of iron. When the cell lysate was washed three times with buffer, or when NADPH was omitted from the solution, a dramatic decrease in iron mobilization rates was observed. The addition of physiological concentrations of free flavins, such as FMN, FAD, and riboflavin showed about a two-fold increase in the amount of released iron. Notably, all iron release kinetics occurred while the solution oxygen level was still high. Altogether, our results indicate that in addition to ferritin proteolysis, there exists an auxiliary iron reductive mechanism that involves long-range electron transfer reactions facilitated by the ferritin shell. The physiological implications of such iron reductive mechanisms are discussed.

Contrasting readability and availability of Spanish language with English language patient education materials.

Spanish is the leading non-English language in the United States, with more than 41 million speakers. The Hispanic population has one of the lowest health literacy rates. Amongst Spanish speakers, limited English proficiency can contribute to poorer health outcomes and greater health disparities, such as lower quality of care received. We sought to assess the availability and readability scores of Spanish-language dermatologic patient education materials (PEMs) compared with those materials in English.

Language-centered approach to care improvement in a pediatric dermatology clinic.

Language-congruent care can improve clinical outcomes. As a quality improvement initiative supported by the Department of Dermatology at Massachusetts General Hospital, the American Academy of Dermatology, and the Society for Pediatric Dermatology, our group established monthly pediatric dermatology "Spanish clinics" that scheduled Spanish-speaking patients on the same day and utilized a dedicated, live interpreter who stayed with the clinical team throughout the clinic. Patients reported high satisfaction scores, averaging 9.8 out of 10, and 90.5% of patients preferred this model to traditional appointments. Our participating physician found "Spanish clinics" allowed for more efficient care not only in the monthly pilot clinics, but in all clinics occurring during the time period.

Analysis of common oral and topical dermatologic medication price variation by source.

Online coupon retailers and pharmacies are popular sites that patients can access discounted medications when compared to cash prices. These sources are especially important for those patients without insurance. In our study, we analyzed commonly prescribed topical and oral medications and compared the cash prices to the discounted medications based on a typical month of usage. We found savings in every one of the medications that we analyzed, some with savings up to hundreds of dollars. Savings were present in all the sources analyzed, with the coupon-based programs often having the lowest price. We suggest certain alternative prescribing guidelines when considering patients who may not be able to afford cash prices of medications. Our hopes with this study are to quantify savings for discounted medications as well as to help physicians target more affordable medications for their patients.