Diagnosis and Management of Malignant Melanoma in Store-and-Forward Teledermatology.

Background: Published studies have led to concern that store-and-forward teledermatology (SFT) diagnosis and management of melanomas may be inferior to face-to-face (FTF) dermatology care.

Introduction: To ascertain the frequency of correctly managed and diagnosed melanomas within a population of veterans in Veterans Integrated Service Network 20 SFT.

Materials And Methods: We conducted a retrospective chart review of 7,960 veterans seen by SFT between July 1, 2009 and December 31, 2011.

Unimaged Melanomas in Store-and-Forward Teledermatology.

Background: Store-and-forward teledermatology (SFT) readers can only diagnose what is imaged. This limitation has caused concern regarding the ability of primary care to direct imaging of lesions suspicious for melanoma. Melanomas not imaged by primary care providers (PCPs) are termed unimaged melanomas.

Melanoma Registry Underreporting in the Veterans Health Administration.

Use of local SNOMED codes and clerical errors led to the underreporting of melanomas despite having an in-house reporting system and understanding reporting requirements.

Teledermatology Implementation in a VHA Secondary Treatment Facility Improves Access to Face-to-Face Care.

Background: Teledermatology is a mainstream modality for delivering care in the Veterans Health Administration, especially in rural areas where access to traditional dermatology care is constrained. Previous investigations of the effect of teledermatology on improving patient access have focused largely on the metrics of visits avoided. However, the effect of teledermatology on improving patient access to face-to-face dermatology has not been well documented.

Teledermatology-directed surgical care is safe and reduces travel.

Methods: We conducted a retrospective chart review and identified 186 Veterans in the VA Corporate Data Warehouse as having malignant melanomas or severely dysplastic nevi during the four-year period of observation from 1 July 2009 to 30 June 2013 and met inclusion and exclusion criteria for analysis.

Results: Three hundred and sixty-six surgical procedures were performed for diagnosis and treatment of these conditions including biopsy and wide-local excision, of which 189 carefully selected cases were performed by primary care clinicians with 2.0% biopsy complication rate and a 7.

A 62-year-old man with skin rash and an abnormal chest radiograph.

A 62-year-old man developed a scalp rash 2 months ago, followed by bilateral eyelid swelling. The nonpruritic rash then spread to involve most of his skin. He also had fatigue, muscle weakness, mild muscle soreness with activity, and dysphagia for solid foods for the last 3 weeks.

A review of topical corrosive black salve.

Black salve is a compound derived from various inert ingredients, but it can be transformed into a corrosive ointment by the addition of bloodroot (Sanguinaria canadensis) or zinc chloride. Black salve products have been advertised as a natural remedy for many ailments, ranging from bee stings to skin cancer. This article reviews the current literature surrounding this compound, which in its corrosive form can be dangerous for use without medical supervision.

Primary care provider and imaging technician satisfaction with a teledermatology project in rural Veterans Health Administration clinics.

Objective: Assessment of a multisite rural teledermatology project between 2009 and 2012 in four Pacific Northwest states that trained primary care providers and imaging technicians in state-of-the-art techniques of telemedicine.

Materials And Methods: In 2012, we assessed provider and imaging technician acceptability and satisfaction with a 32-item survey instrument based on the Patient Satisfaction Questionnaire developed by Ware et al. (Eval Program Plann 1983;6:247-63) and modified for telemedicine by Kraai et al.

Eruptive seborrheic keratoses associated with adalimumab use.

Background: Seborrheic keratoses are common, benign cutaneous growths, however in rare situations they can acutely erupt in large numbers. Eruptive seborrheic keratoses can be associated with internal malignancy (sign of Leser-Trelat), but may also appear in conjunction with inflammatory dermatoses and adverse drug reactions.

Main Observation: A 71-year-old Caucasian man presented with acute onset of a pruritic, burning papular erythematous rash on his chest, upper extremities and lower extremities after a routine adalimumab injection for rheumatoid arthritis.

Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers?

Purpose: The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention.

Methods: From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding.

A teledermatology care management protocol for tracking completion of teledermatology recommendations.

In July 2009 we implemented a 3-year store-and-forward teledermatology project to provide dermatology care to veterans living in rural and underserved areas of the US Pacific Northwest. We also developed a follow-up protocol and tracking system. Information about all completed teledermatology consultations was entered into a database, and major procedures and select medications were tracked.

Lower limb cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis.

Several common conditions can mimic cellulitis, creating a potential for misdiagnosis and incorrect management. The most common disorders mistaken for lower limb cellulitis include venous eczema, lipodermatosclerosis, irritant dermatitis, and lymphedema. The dermatologist is often consulted when a patient has failed to respond to therapy, and a thorough knowledge of the differential diagnosis is essential.

Lower limb cellulitis and its mimics: part I. Lower limb cellulitis.

An aging population and obesity have both contributed to a rising incidence of lower limb cellulitis; the most important predisposing factors include older age, obesity, venous insufficiency, saphenous venectomy, and edema. Streptococci are the most commonly implicated pathogen, and often reside in the interdigital toes spaces. Any disruption of the skin surface can allow the organism to invade.

Teledermatology patient satisfaction in the Pacific Northwest.

Background: The aim of this quality improvement project is to assess patient satisfaction with a store-and-forward teledermatology project and to identify factors associated with patient satisfaction and dissatisfaction.

Subjects And Methods: Veterans receiving care in rural clinics in the Pacific Northwest were surveyed using a 5-point Likert scale about satisfaction with face-to-face care for a skin complaint prior to any teledermatology exposure. One year later, veterans in the same rural clinics were surveyed about satisfaction with teledermatology care using a more comprehensive survey.

Depression and incident lower limb amputations in veterans with diabetes.

Problem: Depression is associated with a higher risk of macrovascular and microvascular complications and mortality in diabetes, but whether depression is linked to an increased risk of incident amputations is unknown. We examined the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with diabetes.

Methods: This was a retrospective cohort study from 2000-2004 that included 531,973 veterans from the Diabetes Epidemiology Cohorts, a national Veterans Affairs (VA) registry with VA and Medicare data.

Foot care education and self management behaviors in diverse veterans with diabetes.

The objective of this study was to examine differences in self-reported diabetes foot care education, self management behaviors, and barriers to good foot care among veterans with diabetes by race and ethnicity. Data was collected using the Veterans Health Administration Footcare Survey, a validated tool that assessed demographic, general health, diabetes and foot self-care information, barriers to foot self-care, receipt of professional foot care, and satisfaction with current care. We mailed surveys to a random sample of patients with diabetes from eight VA medical centers.

Guideline concordant venous ulcer care predicts healing in a tertiary care Veterans Affairs Medical Center.

This study describes the impact of 80% adherence to guideline concordant care for compression therapy, moist wound-healing environment, and debridement on venous ulcer outcomes. The retrospective cohort design included patients from a tertiary care Veterans Affairs Medical Center from October 2003 to September 2007. During this 5-year interval, 155 patients with 400 venous ulcers met study inclusion.

Skin problems in individuals with lower-limb loss: literature review and proposed classification system.

Problems with skin integrity can disrupt daily prosthesis use and lead to decreased mobility and function in individuals with lower-limb loss. This study reviewed the literature to examine how skin problems are defined and diagnosed and to identify the prevalence and types of skin problems in individuals with lower-limb loss. We searched the literature for terms related to amputation and skin problems.

Blue (or purple) toe syndrome.

Unlabelled: The blue (or purple) toe syndrome consists of the development of blue or violaceous discoloration of one or more toes in the absence of obvious trauma, serious cold-induced injury, or disorders producing generalized cyanosis. The major general categories are: (1) decreased arterial flow, (2) impaired venous outflow, and (3) abnormal circulating blood. Depending on its pathogenesis, the discoloration may be blanching or nonblanching.

Detection of human papillomavirus DNA in cutaneous squamous cell carcinoma among immunocompetent individuals.

The presence of certain types of human papillomavirus (HPV) is a known risk factor for the development of anogenital squamous cell carcinomas (SCCs). A similar association has been hypothesized for cutaneous SCCs, although, to our knowledge, no studies to date have combined sensitive HPV DNA detection techniques with epidemiologic data controlling for known risk factors to explore the association. We designed a case-control study examining HPV prevalence using highly sensitive PCR-detection assays in tissue samples from 85 immunocompetent patients with histologically confirmed SCCs and 95 age-matched individuals without a prior history of skin cancer.

The process of implementing a rural VA wound care program for diabetic foot ulcer patients.

Delivering and documenting evidence-based treatment to all Department of Veterans Affairs (VA) foot ulcer patients has wide appeal. However, primary and secondary care medical centers where 52% of these patients receive care are at a disadvantage given the frequent absence of trained specialists to manage diabetic foot ulcers. A retrospective review of diabetic foot ulcer patient records and a provider survey were conducted to document the foot ulcer problem and to assess practitioner needs.

Fluoroquinolone use and risk factors for Clostridium difficile-associated disease within a Veterans Administration health care system.

Background: Prompted by the changing profile of Clostridium difficile infection and the impact of formulary policies in hospitals, we performed this study when an increase in the incidence of C. difficile-associated disease was noted at our health care center (Veterans Administration Puget Sound Health Care System, Seattle, Washington).

Methods: A retrospective, matched case-control study of patients presenting to the Veterans Administration Puget Sound Health Care System, Seattle, Washington during 2004 was performed.