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Papers by John Albertini

Journal of The European Academy of Dermatology and Venereology, Feb 22, 2023

JAMA Dermatology, 2021

Importance Single-center studies have shown that patients report better skin cancer-specific qual... more Importance Single-center studies have shown that patients report better skin cancer-specific quality of life (QOL) after Mohs micrographic surgery (MMS), but it is unclear whether this improved QOL applies to patients after MMS and complex reconstruction in cosmetically sensitive areas. Objective To evaluate patient QOL after MMS and interpolation flap reconstruction for patients with nasal skin cancers. Design, Setting and Participants This multicenter prospective survey study used the Skin Cancer Index (SCI), a validated, 15-question QOL questionnaire administered at 4 time points: before MMS, 1 week after flap placement, 4 weeks after flap takedown, and 16 weeks after flap takedown. Patients age 18 years or older with a nasal skin cancer who presented for MMS and were anticipated to undergo 2-stage interpolated flap repair by a Mohs surgeon were recruited from August 9, 2018, to February 2, 2020, at 8 outpatient MMS locations across the United States, including both academic centers and private practices. Main Outcomes and Measures Mean difference in overall SCI score before MMS vs 16 weeks after flap takedown. Results A total of 169 patients (92 men [54.4%]; mean [SD] age, 67.7 [11.4] years) were enrolled, with 147 patients (75 men [51.0%]; mean [SD] age, 67.8 [11.7] years) completing SCI surveys both before MMS and 16 weeks after flap takedown. Total SCI scores improved significantly 16 weeks after flap takedown compared with pre-MMS scores, increasing by a mean of 13% (increase of 7.11 points; 95% CI, 5.48-8.76; P < .001). All 3 SCI subscale scores (emotion, appearance, and social) improved significantly (emotion subscale, increase of 3.27 points; 95% CI, 2.35-4.18; P < .001; appearance subscale, increase of 1.65 points; 95% CI, 1.12-2.18; P < .001; and social subscale, increase of 2.10 points; 95% CI, 1.55-2.84; P < .001) 16 weeks after flap takedown compared with pre-MMS. Conclusions and Relevance Removal of a nasal skin cancer and repair of the resulting defect can be distressing for patients. However, this cohort study suggests that physicians referring patients for MMS can be reassured that their patient's QOL will improve on average after surgery, even when a complex reconstruction is required.

International Journal of Dermatology, 1994

A 31-year-old Hispanic woman presented to the dermatoiogy clinic with a 1-year history of painful... more A 31-year-old Hispanic woman presented to the dermatoiogy clinic with a 1-year history of painful oral ulcers. She had seen several physicians and had been treated with various medications including acyclovir, Kenalog in orabase (triamcinolone acetonide), penicillin, and tetracycline without significant improvement. A prior trial of prednisone (5 mg per day) had reportedly improved her lesions. A review of systems was significant for fatigue, occasional hematochezia, and rare epistaxis. She had not experienced arthralgias, Raynaud's symptoms, photosensitivity, xerophthalmia, xerostomia, rashes, or genital lesions. She obtained regular gynecologic and internal medicine examinations, which were unremarkable. Her past medical history included allergic rhinitis. She reported no family history of collagen vascular disease, bullous skin diseases, oral ulcers, or drug allergies. On examination her lower labial mucosa had several 2-4 mm shallow erosions with red-brown crusting at the periphery of the lesions. Her buccal mucosa was covered with many 5-10 mm shallow red ulcerations with whitish borders and ragged edges. Similar lesions were present on her soft and hard palate. Her tongue was uninvolved. The rest of her cutaneous examination was unremarkable. Normal or negative laboratory studies included a complete blood count, SMA 17, antinuclear antibodies, herpes culture, and bacterial culture. In the more than 18 months since her disease began she has had no change in her history or physical examination that would be suspicious for a neoplastic process. During this time the blistering has been limited to her oral mucosa.

Dermatologic Surgery, 2013

ON BEHALF OF THE MOHS CONSENSUS CONFERENCE ¶ BACKGROUND Floaters are dislodged pieces of tumor ti... more ON BEHALF OF THE MOHS CONSENSUS CONFERENCE ¶ BACKGROUND Floaters are dislodged pieces of tumor tissue than can obscure Mohs micrographic surgery (MMS) frozen sections and confound their interpretation. OBJECTIVE To understand the common causes of floaters and identify management strategies. METHODS An initial virtual consensus conference of Mohs surgeons based on a 60-item questionnaire. Data were validated in interviews with randomly selected Mohs surgeons. RESULTS Based on retrospective reporting of 230 surgeon-years and 170,404 cases of MMS by 26 surgeons, the mean rate of floaters per tumor treated was 1.8%, and the rate of floaters per tissue block was 0.70%. Not wiping blades between cuts when a stage is separated into subunits can predispose to floaters. There was also strong consensus that basal cell carcinomas, ulcerated tumors, and tissue from the first stage were more likely to yield floaters. There is little consensus on how to manage floaters, with possibilities including taking additional sections, taking an additional stage, or simply noting the floater. CONCLUSION Floaters are not rare and can complicate MMS margin assessment. There is significant expert consensus regarding the causes of floaters and the tissue features that may predispose to them. Floaters may be prevented by minimizing their likely causes. There is less consensus on what to do with a floater.

Journal of Investigative Dermatology, Apr 1, 2014

Facial Plastic Surgery & Aesthetic Medicine

Additional file 3. Open-ended Survey Data

Journal of Investigative Dermatology, 2021

Background: Psoriasis is an immune-mediated disease associated with excess risk for cardiovascula... more Background: Psoriasis is an immune-mediated disease associated with excess risk for cardiovascular disease (CVD). Guidelines recognize psoriasis as a CVD risk enhancer; however, psoriasis patients often do not have CVD risk factors identified nor managed. This study examines strategies to improve CVD prevention care from the perspective of dermatologists and patients with psoriasis. Methods: Qualitative interviews were conducted using the Consolidated Framework for Implementation Research to examine the perspectives of dermatologists (N ¼ 8) and patients with psoriasis (N ¼ 8) on barriers/facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity using NVivo software. Findings: Most dermatologists confirmed that they were not regularly engaging in CVD prevention care with psoriasis patients. Reasons included a lack of familiarity or comfort with guidelines, concern about working outside of their scope of practice, confusing boundaries between other clinicians, and time constraints. Patients confirmed that it was uncommon for their dermatologists to engage them in CVD prevention care but expressed desire for their dermatologists inform them of the risk, and were open to CVD prevention care from them. Implications: These findings will inform the design of a clinical trial comparing the effectiveness of dermatologist implementation of CVD guideline-based counseling, screening and prescribing statins when appropriate in patients with psoriasis. Ultimately, this study aims to increase the lifespan and health of patients living with psoriatic disease by decreasing barriers to their receiving appropriate CVD prevention care.

Archives of Dermatological Research, 2020

Plastic & Reconstructive Surgery, 2021

SUMMARY A multi-disciplinary work group involving stakeholders from various backgrounds and socie... more SUMMARY A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

BMC Health Services Research, 2021

Background The Improving Wisely intervention is a peer-to-peer audit and feedback intervention to... more Background The Improving Wisely intervention is a peer-to-peer audit and feedback intervention to reduce overuse of Mohs Micrographic Surgery (MMS). The objective of this study was to conduct a process evaluation to evaluate Mohs surgeons’ perceptions of the implementation quality and perceived impact of the Improving Wisely intervention. Methods Surgeons in the Improving Wisely intervention arm, comprised of members of the American College of Mohs Surgeons (ACMS) who co-led the intervention, were invited to complete surveys and key informant interviews. Participants described perceptions of implementation quality (evaluated via dose, quality of implementation, reach and participant responsiveness), perceived impact of the Improving Wisely intervention (evaluated on a 1–5 Likert and qualitatively), and barriers and facilitators to changing surgeons’ clinical practice patterns to reduce Mohs overuse. Results Seven hundred thirty-seven surgeons participated in the survey. 89% were sup...

Dermatologic Surgery, 2019

BACKGROUND Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips c... more BACKGROUND Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips can lead to larger defects and tumor recurrence, which can have aesthetic and functional repercussions for patients. OBJECTIVE To review pre-, intra-, and postoperative techniques and pearls for performing MMS on the nose and lips to optimize outcomes. MATERIALS AND METHODS Technical nuances and pearls cultured from the authors' own practice, those acquired from mentors and colleagues, and information identified from the literature are discussed to provide a logical approach to performing effective MMS on the nose and lips. RESULTS When performing MMS on the nose and lips, sound preoperative preparation, precise surgical technique, and particular attention to reducing false-positives and false-negatives while harvesting Mohs layers enhances the fidelity of the MMS procedure, minimizing defect sizes and reducing tumor recurrence. CONCLUSION Refining Mohs technique on the nose and lips allows more effective performance of tumor extirpation, improved microscopic evaluation, and more conservative reconstruction, leading to better patient outcomes.

Journal of the American Academy of Dermatology, 2019

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Journal of the American Academy of Dermatology, 2017

Background: The success of Mohs micrographic surgery depends on the surgeon's ability to correctl... more Background: The success of Mohs micrographic surgery depends on the surgeon's ability to correctly interpret intraoperative frozen sections. Objective: This retrospective study analyzed the rate of concordance between Mohs surgeons and dermatopathologists in reading slides from Mohs surgery cases. Methods: A dermatopathologist reviewed all the frozen sections and the corresponding Mohs map for every 30 th Mohs case at a practice employing 6 different Mohs surgeons from 2001-2017. Cases in which the dermatopathologist and the Mohs surgeon disagreed on the interpretation were noted. Results: The concordance rate between Mohs surgeons and dermatopathologists was 99.79%. The three discordant cases included one case each of squamous cell carcinoma, superficial basal cell carcinoma, and hypertrophic squamous cell carcinoma in situ. Limitations: This analysis is limited to fellowship-trained Mohs surgeons and therefore may not be applicable to all physicians who perform Mohs. Conclusions: Fellowship-trained Mohs surgeons show very high concordance with board-certified dermatopathologists in the accurate and precise interpretation of histology slides in the setting of Mohs micrographic surgery.

JAMA Dermatology, 2019

IMPORTANCE Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions ... more IMPORTANCE Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. OBJECTIVE To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. INTERVENTIONS Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. MAIN OUTCOMES AND MEASURES The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. RESULTS Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, −1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, −0.19 to −0.09; P = .002). The total administrative cost of the intervention program was 150000,andtheestimatedreductioninMedicarespendingwas150 000, and the estimated reduction in Medicare spending was 150000,andtheestimatedreductioninMedicarespendingwas11.1 million. CONCLUSIONS AND RELEVANCE Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

Journal of Investigative Dermatology, 2014

Cutis (New York, N.Y.), 2006

Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2014

In 1991, Dr. John Zitelli edited the first Reconstructive Issue for this journal, bringing togeth... more In 1991, Dr. John Zitelli edited the first Reconstructive Issue for this journal, bringing together thosewhohavebecome theundeniablemasters in our field. In 2005, Drs. Desiree Ratner and Timothy Johnson developed another cutting edge compilation of seminal articles on advanced reconstruction. Many of us devoured these issues, striving to incorporate the lessons to optimally care for our patients with skin cancer. Our field has continued to advance in scope and quality. A decade later, it is time to revisit the “state of the art” in reconstructive dermatologic surgery.

JAMA dermatology, 2013

As melanoma incidence and mortality rise and as populationsage indevelopedcountries suchasFrancea... more As melanoma incidence and mortality rise and as populationsage indevelopedcountries suchasFranceand theUnited States, it becomesparamount fordermatologists tousediminishing resources judiciously to optimize melanoma management. Well-established guidelines of care, however, neither stratify nor adjust primarymelanoma treatment according to patient age.1,2 The article by Ciocan et al3 describes several patient and tumor characteristics of invasive melanoma in an elderly Frenchpopulationcomparedwithayounger cohort.Thestudy alsohighlights significant practice gaps in themanagement of melanoma in patients 70 years or older that present a challenge for dermatologists to understand and overcome. Age-relatedandsocioeconomic factorsmaycauseexplainabledelays indiagnosis. Prioritizinggeriatricprimarycareover dermatologic specialty care likely contributed to themore frequentlydiagnosedthicker,ulcerated, higher-grade category T3 or T4 tumors. The increased frequencyof nodular andacral lentiginousmelanomas is potentially explainable by impaired vision, selfsurveillance, and immunity in older patients. Despite these patient and tumor variances, a fundamental tenet of oncologic management protocols is their universal application toappropriatecases.Ciocanetaldescribeaclear deviation fromsuchanapproach in2 specific areas.First, older patients experienced a significant delay in treatment. Second, andmore important, definitive surgical excisionwas often inadequate. Although more elderly patients underwent an appropriate initial diagnostic excisional biopsy, almost 1 in 4 of them received no additional definitive excision when indicated, a rate 3-foldhigher than that inyoungerpatients.Thosewhounderwent additionalwide excisionwere alsodisadvantagedby inadequate surgical margins. The 5-fold increased incidence of lentigomalignamelanomaand a relative preponderance of head and neck tumors likely factored intomore conservative surgery to limit complications. Many prospective randomized clinical trials, however, have defined excisional margins that clearly reducemortality.4 The possibility that elderly patients may not receive this established standard of care represents a significant practice gap. Furthermore, regardless of the specific treatment, subsequent care was delayed beyond 6 weeks in almost a third of elderly patients. Optimal timing of definitivemelanomaexcisionhasnotbeenas rigorously studiedas surgicalmargins and represents a valuable research opportunity. Prolonged delays in treatment,however, clearly constitute anotherpracticegap. This importantstudybyCiocanetal should increaseawareness that agebias can influencedecisions inpotentially harmful ways. We do not know the dialogue exchanged between physician and patient thatmay have colored these decisions. Perhaps recovery from an illness, use of anticoagulation therapy, lack of desire for sentinel lymph node prognostic information, or the need to care for a disabled spouse strongly influenced the timing, prioritization, and/or aggressiveness of primaryoradjuvant treatment.This studyalsoneitherasksnor answers whether these older patients were satisfied with the quality of their care. The true challenge in bridging these specific melanoma managementpracticegaps in theelderlymirrorsamuchgreater challenge in modern medicine: How do we reconcile outcomes research that defines population-based best practices with our duty to provide humanistic, artful care of individual patients in the context of their age, comorbidities, and socioeconomic situation?

International Journal of Dermatology, 1994

A 58-year-old white man was seen in the dermatology clinic at the University of Chicago Medical C... more A 58-year-old white man was seen in the dermatology clinic at the University of Chicago Medical Center for a pruritic eruption that had developed on his hands. He denied using anything topicallv or exposure of his hands to any unusual contactant. He had seen another physician, who obtained a skin biopsy and some blood tests and told him that the eruption was from lupus erythematosus. At the time of the first visit he was accompanied by a daughter, who lived in the same trailer home with him and was noted to have a dermatitis of her face but refused examination. Another skin biopsy was performed (Fig. 1) and laboratory evaluation was begun. The patient was advised to use sunscreens and treatment with a midpotency topical steroid was started. After the visit, the patient's employer called to find out if the dermatitis might be contagious. During the conversation, he revealed that the patient had used "bug-bombs" in his trailer home before onset of his eruption. Further evaluation revealed that the patient had used two "bug-bombs" in his trailer home. Each of these was designed for an average size house with instructions to vacate the premises. The ingredients of the bombs included, 1,1,1-trichloroethane, propane, S-methoprene, and permethrin. One month after the index patient was seen, his daughter's dermatitis had worsened to a point that she also sought medical attention. Her eruption began about the same time as her father's. She reported gradual onset of an erythematous, nonpruritic eruption. She denied using any new cosmetics or new exposures to other facial skin contactants. Neither patient had a significant past medical history and both denied allergies to any medications. The family history is notable only for another daughter of the index patient having asthma. The father works in a gas station and his affected daughter works as a housekeeper. Both denied use of alcohol, tobacco, or intravenous drugs. Review of systems for the father was negative including the specific inquiry about mouth ulcers, joint pains, and Raynaud's symptoms. Review of systems for the daughter was notable only for new-onset amenorrhea. On physical examination, the father's facial skin was remarkable for a grey hyperpigmentation. His chest and back had closely set erythematous hyperkeratotic papules and patches with superficial erosions on many of them (Fig. 2).

Journal of The European Academy of Dermatology and Venereology, Feb 22, 2023

JAMA Dermatology, 2021

Importance Single-center studies have shown that patients report better skin cancer-specific qual... more Importance Single-center studies have shown that patients report better skin cancer-specific quality of life (QOL) after Mohs micrographic surgery (MMS), but it is unclear whether this improved QOL applies to patients after MMS and complex reconstruction in cosmetically sensitive areas. Objective To evaluate patient QOL after MMS and interpolation flap reconstruction for patients with nasal skin cancers. Design, Setting and Participants This multicenter prospective survey study used the Skin Cancer Index (SCI), a validated, 15-question QOL questionnaire administered at 4 time points: before MMS, 1 week after flap placement, 4 weeks after flap takedown, and 16 weeks after flap takedown. Patients age 18 years or older with a nasal skin cancer who presented for MMS and were anticipated to undergo 2-stage interpolated flap repair by a Mohs surgeon were recruited from August 9, 2018, to February 2, 2020, at 8 outpatient MMS locations across the United States, including both academic centers and private practices. Main Outcomes and Measures Mean difference in overall SCI score before MMS vs 16 weeks after flap takedown. Results A total of 169 patients (92 men [54.4%]; mean [SD] age, 67.7 [11.4] years) were enrolled, with 147 patients (75 men [51.0%]; mean [SD] age, 67.8 [11.7] years) completing SCI surveys both before MMS and 16 weeks after flap takedown. Total SCI scores improved significantly 16 weeks after flap takedown compared with pre-MMS scores, increasing by a mean of 13% (increase of 7.11 points; 95% CI, 5.48-8.76; P < .001). All 3 SCI subscale scores (emotion, appearance, and social) improved significantly (emotion subscale, increase of 3.27 points; 95% CI, 2.35-4.18; P < .001; appearance subscale, increase of 1.65 points; 95% CI, 1.12-2.18; P < .001; and social subscale, increase of 2.10 points; 95% CI, 1.55-2.84; P < .001) 16 weeks after flap takedown compared with pre-MMS. Conclusions and Relevance Removal of a nasal skin cancer and repair of the resulting defect can be distressing for patients. However, this cohort study suggests that physicians referring patients for MMS can be reassured that their patient's QOL will improve on average after surgery, even when a complex reconstruction is required.

International Journal of Dermatology, 1994

A 31-year-old Hispanic woman presented to the dermatoiogy clinic with a 1-year history of painful... more A 31-year-old Hispanic woman presented to the dermatoiogy clinic with a 1-year history of painful oral ulcers. She had seen several physicians and had been treated with various medications including acyclovir, Kenalog in orabase (triamcinolone acetonide), penicillin, and tetracycline without significant improvement. A prior trial of prednisone (5 mg per day) had reportedly improved her lesions. A review of systems was significant for fatigue, occasional hematochezia, and rare epistaxis. She had not experienced arthralgias, Raynaud's symptoms, photosensitivity, xerophthalmia, xerostomia, rashes, or genital lesions. She obtained regular gynecologic and internal medicine examinations, which were unremarkable. Her past medical history included allergic rhinitis. She reported no family history of collagen vascular disease, bullous skin diseases, oral ulcers, or drug allergies. On examination her lower labial mucosa had several 2-4 mm shallow erosions with red-brown crusting at the periphery of the lesions. Her buccal mucosa was covered with many 5-10 mm shallow red ulcerations with whitish borders and ragged edges. Similar lesions were present on her soft and hard palate. Her tongue was uninvolved. The rest of her cutaneous examination was unremarkable. Normal or negative laboratory studies included a complete blood count, SMA 17, antinuclear antibodies, herpes culture, and bacterial culture. In the more than 18 months since her disease began she has had no change in her history or physical examination that would be suspicious for a neoplastic process. During this time the blistering has been limited to her oral mucosa.

Dermatologic Surgery, 2013

ON BEHALF OF THE MOHS CONSENSUS CONFERENCE ¶ BACKGROUND Floaters are dislodged pieces of tumor ti... more ON BEHALF OF THE MOHS CONSENSUS CONFERENCE ¶ BACKGROUND Floaters are dislodged pieces of tumor tissue than can obscure Mohs micrographic surgery (MMS) frozen sections and confound their interpretation. OBJECTIVE To understand the common causes of floaters and identify management strategies. METHODS An initial virtual consensus conference of Mohs surgeons based on a 60-item questionnaire. Data were validated in interviews with randomly selected Mohs surgeons. RESULTS Based on retrospective reporting of 230 surgeon-years and 170,404 cases of MMS by 26 surgeons, the mean rate of floaters per tumor treated was 1.8%, and the rate of floaters per tissue block was 0.70%. Not wiping blades between cuts when a stage is separated into subunits can predispose to floaters. There was also strong consensus that basal cell carcinomas, ulcerated tumors, and tissue from the first stage were more likely to yield floaters. There is little consensus on how to manage floaters, with possibilities including taking additional sections, taking an additional stage, or simply noting the floater. CONCLUSION Floaters are not rare and can complicate MMS margin assessment. There is significant expert consensus regarding the causes of floaters and the tissue features that may predispose to them. Floaters may be prevented by minimizing their likely causes. There is less consensus on what to do with a floater.

Journal of Investigative Dermatology, Apr 1, 2014

Facial Plastic Surgery & Aesthetic Medicine

Additional file 3. Open-ended Survey Data

Journal of Investigative Dermatology, 2021

Background: Psoriasis is an immune-mediated disease associated with excess risk for cardiovascula... more Background: Psoriasis is an immune-mediated disease associated with excess risk for cardiovascular disease (CVD). Guidelines recognize psoriasis as a CVD risk enhancer; however, psoriasis patients often do not have CVD risk factors identified nor managed. This study examines strategies to improve CVD prevention care from the perspective of dermatologists and patients with psoriasis. Methods: Qualitative interviews were conducted using the Consolidated Framework for Implementation Research to examine the perspectives of dermatologists (N ¼ 8) and patients with psoriasis (N ¼ 8) on barriers/facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity using NVivo software. Findings: Most dermatologists confirmed that they were not regularly engaging in CVD prevention care with psoriasis patients. Reasons included a lack of familiarity or comfort with guidelines, concern about working outside of their scope of practice, confusing boundaries between other clinicians, and time constraints. Patients confirmed that it was uncommon for their dermatologists to engage them in CVD prevention care but expressed desire for their dermatologists inform them of the risk, and were open to CVD prevention care from them. Implications: These findings will inform the design of a clinical trial comparing the effectiveness of dermatologist implementation of CVD guideline-based counseling, screening and prescribing statins when appropriate in patients with psoriasis. Ultimately, this study aims to increase the lifespan and health of patients living with psoriatic disease by decreasing barriers to their receiving appropriate CVD prevention care.

Archives of Dermatological Research, 2020

Plastic & Reconstructive Surgery, 2021

SUMMARY A multi-disciplinary work group involving stakeholders from various backgrounds and socie... more SUMMARY A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

BMC Health Services Research, 2021

Background The Improving Wisely intervention is a peer-to-peer audit and feedback intervention to... more Background The Improving Wisely intervention is a peer-to-peer audit and feedback intervention to reduce overuse of Mohs Micrographic Surgery (MMS). The objective of this study was to conduct a process evaluation to evaluate Mohs surgeons’ perceptions of the implementation quality and perceived impact of the Improving Wisely intervention. Methods Surgeons in the Improving Wisely intervention arm, comprised of members of the American College of Mohs Surgeons (ACMS) who co-led the intervention, were invited to complete surveys and key informant interviews. Participants described perceptions of implementation quality (evaluated via dose, quality of implementation, reach and participant responsiveness), perceived impact of the Improving Wisely intervention (evaluated on a 1–5 Likert and qualitatively), and barriers and facilitators to changing surgeons’ clinical practice patterns to reduce Mohs overuse. Results Seven hundred thirty-seven surgeons participated in the survey. 89% were sup...

Dermatologic Surgery, 2019

BACKGROUND Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips c... more BACKGROUND Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips can lead to larger defects and tumor recurrence, which can have aesthetic and functional repercussions for patients. OBJECTIVE To review pre-, intra-, and postoperative techniques and pearls for performing MMS on the nose and lips to optimize outcomes. MATERIALS AND METHODS Technical nuances and pearls cultured from the authors' own practice, those acquired from mentors and colleagues, and information identified from the literature are discussed to provide a logical approach to performing effective MMS on the nose and lips. RESULTS When performing MMS on the nose and lips, sound preoperative preparation, precise surgical technique, and particular attention to reducing false-positives and false-negatives while harvesting Mohs layers enhances the fidelity of the MMS procedure, minimizing defect sizes and reducing tumor recurrence. CONCLUSION Refining Mohs technique on the nose and lips allows more effective performance of tumor extirpation, improved microscopic evaluation, and more conservative reconstruction, leading to better patient outcomes.

Journal of the American Academy of Dermatology, 2019

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Journal of the American Academy of Dermatology, 2017

Background: The success of Mohs micrographic surgery depends on the surgeon's ability to correctl... more Background: The success of Mohs micrographic surgery depends on the surgeon's ability to correctly interpret intraoperative frozen sections. Objective: This retrospective study analyzed the rate of concordance between Mohs surgeons and dermatopathologists in reading slides from Mohs surgery cases. Methods: A dermatopathologist reviewed all the frozen sections and the corresponding Mohs map for every 30 th Mohs case at a practice employing 6 different Mohs surgeons from 2001-2017. Cases in which the dermatopathologist and the Mohs surgeon disagreed on the interpretation were noted. Results: The concordance rate between Mohs surgeons and dermatopathologists was 99.79%. The three discordant cases included one case each of squamous cell carcinoma, superficial basal cell carcinoma, and hypertrophic squamous cell carcinoma in situ. Limitations: This analysis is limited to fellowship-trained Mohs surgeons and therefore may not be applicable to all physicians who perform Mohs. Conclusions: Fellowship-trained Mohs surgeons show very high concordance with board-certified dermatopathologists in the accurate and precise interpretation of histology slides in the setting of Mohs micrographic surgery.

JAMA Dermatology, 2019

IMPORTANCE Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions ... more IMPORTANCE Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. OBJECTIVE To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. INTERVENTIONS Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. MAIN OUTCOMES AND MEASURES The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. RESULTS Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, −1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, −0.19 to −0.09; P = .002). The total administrative cost of the intervention program was 150000,andtheestimatedreductioninMedicarespendingwas150 000, and the estimated reduction in Medicare spending was 150000,andtheestimatedreductioninMedicarespendingwas11.1 million. CONCLUSIONS AND RELEVANCE Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

Journal of Investigative Dermatology, 2014

Cutis (New York, N.Y.), 2006

Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2014

In 1991, Dr. John Zitelli edited the first Reconstructive Issue for this journal, bringing togeth... more In 1991, Dr. John Zitelli edited the first Reconstructive Issue for this journal, bringing together thosewhohavebecome theundeniablemasters in our field. In 2005, Drs. Desiree Ratner and Timothy Johnson developed another cutting edge compilation of seminal articles on advanced reconstruction. Many of us devoured these issues, striving to incorporate the lessons to optimally care for our patients with skin cancer. Our field has continued to advance in scope and quality. A decade later, it is time to revisit the “state of the art” in reconstructive dermatologic surgery.

JAMA dermatology, 2013

As melanoma incidence and mortality rise and as populationsage indevelopedcountries suchasFrancea... more As melanoma incidence and mortality rise and as populationsage indevelopedcountries suchasFranceand theUnited States, it becomesparamount fordermatologists tousediminishing resources judiciously to optimize melanoma management. Well-established guidelines of care, however, neither stratify nor adjust primarymelanoma treatment according to patient age.1,2 The article by Ciocan et al3 describes several patient and tumor characteristics of invasive melanoma in an elderly Frenchpopulationcomparedwithayounger cohort.Thestudy alsohighlights significant practice gaps in themanagement of melanoma in patients 70 years or older that present a challenge for dermatologists to understand and overcome. Age-relatedandsocioeconomic factorsmaycauseexplainabledelays indiagnosis. Prioritizinggeriatricprimarycareover dermatologic specialty care likely contributed to themore frequentlydiagnosedthicker,ulcerated, higher-grade category T3 or T4 tumors. The increased frequencyof nodular andacral lentiginousmelanomas is potentially explainable by impaired vision, selfsurveillance, and immunity in older patients. Despite these patient and tumor variances, a fundamental tenet of oncologic management protocols is their universal application toappropriatecases.Ciocanetaldescribeaclear deviation fromsuchanapproach in2 specific areas.First, older patients experienced a significant delay in treatment. Second, andmore important, definitive surgical excisionwas often inadequate. Although more elderly patients underwent an appropriate initial diagnostic excisional biopsy, almost 1 in 4 of them received no additional definitive excision when indicated, a rate 3-foldhigher than that inyoungerpatients.Thosewhounderwent additionalwide excisionwere alsodisadvantagedby inadequate surgical margins. The 5-fold increased incidence of lentigomalignamelanomaand a relative preponderance of head and neck tumors likely factored intomore conservative surgery to limit complications. Many prospective randomized clinical trials, however, have defined excisional margins that clearly reducemortality.4 The possibility that elderly patients may not receive this established standard of care represents a significant practice gap. Furthermore, regardless of the specific treatment, subsequent care was delayed beyond 6 weeks in almost a third of elderly patients. Optimal timing of definitivemelanomaexcisionhasnotbeenas rigorously studiedas surgicalmargins and represents a valuable research opportunity. Prolonged delays in treatment,however, clearly constitute anotherpracticegap. This importantstudybyCiocanetal should increaseawareness that agebias can influencedecisions inpotentially harmful ways. We do not know the dialogue exchanged between physician and patient thatmay have colored these decisions. Perhaps recovery from an illness, use of anticoagulation therapy, lack of desire for sentinel lymph node prognostic information, or the need to care for a disabled spouse strongly influenced the timing, prioritization, and/or aggressiveness of primaryoradjuvant treatment.This studyalsoneitherasksnor answers whether these older patients were satisfied with the quality of their care. The true challenge in bridging these specific melanoma managementpracticegaps in theelderlymirrorsamuchgreater challenge in modern medicine: How do we reconcile outcomes research that defines population-based best practices with our duty to provide humanistic, artful care of individual patients in the context of their age, comorbidities, and socioeconomic situation?

International Journal of Dermatology, 1994

A 58-year-old white man was seen in the dermatology clinic at the University of Chicago Medical C... more A 58-year-old white man was seen in the dermatology clinic at the University of Chicago Medical Center for a pruritic eruption that had developed on his hands. He denied using anything topicallv or exposure of his hands to any unusual contactant. He had seen another physician, who obtained a skin biopsy and some blood tests and told him that the eruption was from lupus erythematosus. At the time of the first visit he was accompanied by a daughter, who lived in the same trailer home with him and was noted to have a dermatitis of her face but refused examination. Another skin biopsy was performed (Fig. 1) and laboratory evaluation was begun. The patient was advised to use sunscreens and treatment with a midpotency topical steroid was started. After the visit, the patient's employer called to find out if the dermatitis might be contagious. During the conversation, he revealed that the patient had used "bug-bombs" in his trailer home before onset of his eruption. Further evaluation revealed that the patient had used two "bug-bombs" in his trailer home. Each of these was designed for an average size house with instructions to vacate the premises. The ingredients of the bombs included, 1,1,1-trichloroethane, propane, S-methoprene, and permethrin. One month after the index patient was seen, his daughter's dermatitis had worsened to a point that she also sought medical attention. Her eruption began about the same time as her father's. She reported gradual onset of an erythematous, nonpruritic eruption. She denied using any new cosmetics or new exposures to other facial skin contactants. Neither patient had a significant past medical history and both denied allergies to any medications. The family history is notable only for another daughter of the index patient having asthma. The father works in a gas station and his affected daughter works as a housekeeper. Both denied use of alcohol, tobacco, or intravenous drugs. Review of systems for the father was negative including the specific inquiry about mouth ulcers, joint pains, and Raynaud's symptoms. Review of systems for the daughter was notable only for new-onset amenorrhea. On physical examination, the father's facial skin was remarkable for a grey hyperpigmentation. His chest and back had closely set erythematous hyperkeratotic papules and patches with superficial erosions on many of them (Fig. 2).