Caring for transgender populations: A primer for the dermatopathologist.

With increasing access to electronic health records, patients may encounter dermatopathology reports more readily. Dermatopathologists should consider their impact and interactions with transgender patients, who may face specific health and healthcare inequities. Rendering accurate diagnosis for skin diseases requires accurate information about patient's sex assigned at birth and gender identity. Understanding how sex and gender identity data flow between electronic health records, laboratory information systems, insurance billing systems, and patients will be important to avoid patient misgendering, to render accurate diagnoses, to maintain consistency in dermatopathology reports, and to avoid insurance billing denials. Dermatopathologists have important roles to build patient trust in the healthcare system and to help dermatologists diagnose, treat, and characterize skin diseases in transgender populations.

Preordering Periodic Acid-Schiff Staining: A Quality Improvement Study.

ABSTRACT: Periodic acid-Schiff (PAS) stain is a commonly used ancillary test for inflammatory and infectious dermatoses, yet infrequently changes the diagnosis. Previous studies have shown that clinical suspicion and histopathologic features are poor predictors of PAS positivity. Current appropriate use criteria from the American Society of Dermatopathology supports PAS staining when histopathologic features could be consistent with a dermatophyte infection. At the authors' institution, PAS stains are preordered on biopsies of inflammatory and infectious diagnoses to aid in a timelier sign out. Our aim was to reduce the percentage of PAS stains preordered on all dermatology specimens over a 6-month period without reducing the percentage of fungal infections identified. Review of a 12-month preintervention period found that our laboratory received 6104 biopsies for which PAS stain was preordered on 616 (10.1%). Based on a review of the preintervention period, preordering PAS on cases with clinical suspicion for cutaneous T-cell lymphoma was stopped unless there was clinical suspicion for eczematous dermatitis, vesiculobullous disorders, or fungal infection. The proposed intervention resulted in a 3.7% reduction in the number of PAS stains ordered while PAS-positivity rate remained unchanged. The described quality improvement process may be used as a model for other laboratories.

Ethical and professionalism issues in dermatopathology: A cross-sectional survey of American Society of Dermatopathology Members.

BACKGROUND: Data regarding ethical/professional issues affecting dermatopathologists are lacking despite their importance in establishing policy priorities and educational content for dermatopathology. METHODS: A 14-item cross-sectional survey about ethical/professional issues in dermatopathology was distributed over e-mail to members of the American Society of Dermatopathology from June to September 2019. RESULTS: Two hundred sixteen surveys were completed, with a response rate of 15.3%. Respondents ranked appropriate and fair utilization of healthcare resources (n = 83 or 38.6%) as the most often encountered ethical/professional issue. Conflict of interest was ranked as the most urgent or important ethical/professional issue (n = 83 or 39.3%). One hundred thirty-three (61.6%) respondents felt "somewhat" or "not at all" well equipped to handle ethical dilemmas in practice and 47 (22.8%) respondents identified a major or extreme burden (eg, have considered resigning/retiring) due to ethical challenges. CONCLUSIONS: Areas of priority in ethics and professionalism issues can guide future policy and educational content in dermatopathology.

S-100 protein and SOX10-positive breast carcinoma mimicking metastatic melanoma.

We present a case detailing a 70-year-old female with a history of triple-negative breast carcinoma (TNBC) of the left breast and contralateral stage pT2a nodular melanoma of the right upper arm who underwent sentinel lymph node biopsy of the right axilla demonstrating a metastatic epithelioid tumor that was strongly positive for S-100 protein and SOX10. The tumor cells were negative for HMB-45 and Melan-A and positive for CK7 and other breast markers (GCDFP15, mammaglobin, and GATA3). While concerning for metastatic melanoma based on clinical history and initial immunohistochemistry, tumor morphology and subsequent immunohistochemistry was supportive of metastatic breast adenocarcinoma. This case demonstrates a rare but perilous diagnostic pitfall of triple-negative breast carcinomas that strongly and diffusely express S-100 protein and SOX10 mimicking melanoma.

Introducing a curriculum in ethics and professionalism for dermatology residencies.

There is general agreement on what constitutes ethical reasoning and professional behavior, but standardized methods to teach these skills in dermatology residency are currently unavailable. We introduce a model curriculum designed to impart the knowledge and skills to meet the Accreditation Council for Graduate Medical Education Dermatology Milestones for Professionalism over a 3-year cycle.

Diagnostic accuracy of whole slide imaging for cutaneous, soft tissue, and melanoma sentinel lymph node biopsies with and without immunohistochemistry.

BACKGROUND: Diagnostic accuracy with whole slide imaging (WSI) for complex inpatient and outpatient dermatopathology cases with immunohistochemistry (IHC) is unknown. METHODS: WSI (Leica Aperio AT2 Digital Pathology scanner, N = 151 cases) was performed for Emory inpatient and outpatient skin (N = 105), soft tissue (N = 30), and melanoma sentinel lymph node biopsies (N = 16) collected between 2000 and 2016. Resultant images were uploaded to an online cloud storage system for review by 2 board-certified dermatopathologists (reviewers 1 and 2) with greater than 5 years of dermatopathology experience and 1 dermatopathology fellow (reviewer 3). RESULTS: Reviewers 1 (diagnostic accuracy = 97%) and 2 (diagnostic accuracy = 95%) demonstrated high diagnostic accuracy with WSI. Diagnostic accuracy was greater than 90% for inpatient biopsies, melanocytic lesions, melanoma sentinel lymph node biopsies, and cases with immunohistochemistry, but was slightly lower for soft tissue cases (reviewer 1 = 89%; reviewer 2 = 89%). The dermatopathology fellow (reviewer 3) demonstrated lower diagnostic accuracy (84%). CONCLUSIONS: Diagnostic accuracy with WSI for skin, soft tissue, and melanoma sentinel lymph node biopsies with and without immunohistochemistry was greater than 95% for 2 reviewers with greater than 5 years of dermatopathology experience. Professional experience signing out dermatopathology cases may impact diagnostic accuracy with WSI.

Video-based education about systemic corticosteroids enhances patient knowledge more than verbal education: A randomized controlled trial.

BACKGROUND: Video-based patient education about long-term systemic corticosteroid treatment has not been assessed. OBJECTIVE: To compare video-based versus verbal education in patient knowledge gained and satisfaction. METHODS: English-speaking adults (≥18 years) were recruited from March-August 2013 from medical dermatology clinics. Study provider clinics were the unit of randomization. Verbal subjects heard a script based on the standard discussions of two top systemic corticosteroid prescribers at Emory. Video subjects viewed a video developed by the investigators. A 12-item survey created by the the investigators assessed baseline and post-education knowledge (immediate, one-, three-, and six-month). RESULTS: Baseline knowledge scores averaged 7.2±2.2 correct answers with no between-group differences. Post-education, the video group's (N=39) mean paired score difference was 0.9±2.0 higher than the verbal group's (p<0.04). After 1 month, most scores maintained gains with no between-group differences. 97% of patients in each group were satisfied (none were unsatisfied) with their education. LIMITATIONS: Our cohort was more literate than the general public, and a minority of subjects completed long-term follow up assessments. CONCLUSION: Video education enhanced near-term patient knowledge more than verbal education and maintained patient satisfaction.