JWST detection of a supernova associated with GRB 221009A without an r-process signature.

Identifying the sites of r-process nucleosynthesis, a primary mechanism of heavy element production, is a key goal of astrophysics. The discovery of the brightest gamma-ray burst (GRB) to date, GRB 221009A, presented an opportunity to spectroscopically test the idea that r-process elements are produced following the collapse of rapidly rotating massive stars. Here we present James Webb Space Telescope observations of GRB 221009A obtained +168 and +170 rest-frame days after the gamma-ray trigger, and demonstrate that they are well described by a SN 1998bw-like supernova (SN) and power-law afterglow, with no evidence for a component from r-process emission. The SN, with a nickel mass of approximately 0.09 M ⊙, is only slightly fainter than the brightness of SN 1998bw at this phase, which indicates that the SN is not an unusual GRB-SN. This demonstrates that the GRB and SN mechanisms are decoupled and that highly energetic GRBs are not likely to produce significant quantities of r-process material, which leaves open the question of whether explosions of massive stars are key sources of r-process elements. Moreover, the host galaxy of GRB 221009A has a very low metallicity of approximately 0.12 Z ⊙ and strong H2 emission at the explosion site, which is consistent with recent star formation, hinting that environmental factors are responsible for its extreme energetics.

Updates on coding in dermatology.

Correct coding is an important component of effective dermatology practice management. Over the past several years there have been updates to many commonly used codes within dermatology. This review highlights many of these updates, such as: the skin biopsy codes have been subdivided to reflect the different biopsy techniques. The definition of complex linear repairs has been updated and clarified. Outpatient and inpatient evaluation and management visits have new coding guidelines to determine level of care. Dermatopathology consultation codes have been updated and category III codes related to digital pathology have been created. Understanding the details and nuances of each of these categories of codes is vital to ensuring appropriate coding is performed.

International Dermatology Outcome Measures (IDEOM) - Report from the 2022 Annual Meeting.

BACKGROUND: The International Dermatology Outcome Measures (IDEOM) is a non-profit organization dedicated to the advancement of evidence-based, consensus-driven outcome measures in dermatological diseases. Researchers and stakeholders from various backgrounds collaborate to develop these objective benchmark metrics to further advance treatment and management of dermatological conditions. SUMMARY: The 2022 IDEOM Annual Meeting was held on June 17-18, 2022. Leaders and stakeholders from the hidradenitis suppurativa, acne, vitiligo, actinic keratosis, alopecia areata, itch, cutaneous lymphoma, and psoriatic disease workgroups discussed the progress of their respective outcome-measures research. This report summarizes each workgroup's updates from 2022 and their next steps as established during the 2022 IDEOM Annual Meeting. J Drugs Dermatol. 2023;22(12):1153-1159 doi:10.36849/JDD.7615.

Treatment Satisfaction and Acceptability of 20% Aminolevulinic Acid Photodynamic Therapy for the Treatment of Actinic Keratoses of the Face, Scalp, and Upper Extremities.

Background: Actinic keratoses (AKs) are precancerous, dysplastic, epidermal lesions caused by chronic sun exposure that may progress to squamous cell carcinoma. Aminolevulinic acid 20% solution with blue light photodynamic therapy (ALA-PDT) has previously been shown to be superior to vehicle plus PDT (VEH-PDT) for treatment of AKs of the face, scalp, and upper extremities. Objective: We report detailed patient satisfaction data for ALA-PDT. Methods: Patient satisfaction for ALA-PDT versus VEH-PDT and patient-reported acceptability of ALA-PDT versus previous treatments for AKs were assessed in three randomized, vehicle-controlled studies (two Phase II and one Phase III) in adults. Patients in the Phase II studies were treated on the scalp and/or face, and those in the Phase III study were treated on the upper extremities. Results: A total of 234, 166, and 269 patients were enrolled in the two Phase II studies and one Phase III study, respectively; overall, 79.8 percent of patients were male. Overall treatment satisfaction ranged from 79 to 88 percent for ALA-PDT, compared to 35 to 56 percent for VEH-PDT. Patients generally considered ALA-PDT to be equivalent to or more acceptable than prior treatments, including cryotherapy, 5-fluorouracil, imiquimod, previous PDT, and surgery. Similar proportions of patients receiving ALA-PDT or VEH-PDT on the upper extremities considered in-office time, side effects/adverse events (AEs), and duration of side effects/AEs to be acceptable. Limitations: The majority of patients were male, and no statistical comparisons were conducted. Conclusion: Patients were generally satisfied with ALA-PDT for the treatment of AKs of the face, scalp, and upper extremities and considered ALA-PDT to be equal to or more acceptable than previous treatments. Trial Registry Information: ClinicalTrials.gov: NCT01475955; NCT02239679; NCT02137785.

Jets from Neutron-Star Merger Remnants and Massive Blue Kilonovae.

We perform three-dimensional general-relativistic magnetohydrodynamic simulations with weak interactions of binary neutron-star (BNS) mergers resulting in a long-lived remnant neutron star, with properties typical of galactic BNS and consistent with those inferred for the first observed BNS merger GW170817. We demonstrate self-consistently that within ≲30 ms postmerger magnetized (σ∼5-10) incipient jets emerge with asymptotic Lorentz factor Γ∼5-10, which successfully break out from the merger debris within ≲20 ms. A fast (v≲0.6c), magnetized (σ∼0.1) wind surrounds the jet core and generates a UV/blue kilonova precursor on timescales of hours, similar to the precursor signal due to free neutron decay in fast dynamical ejecta. Postmerger ejecta are quickly dominated by magnetohydrodynamically driven outflows from an accretion disk. We demonstrate that, within only 50 ms postmerger, ≳2×10^{-2}M_{⊙} of lanthanide-free, quasispherical ejecta with velocities ∼0.1-0.2c is launched, yielding a kilonova signal consistent with GW170817 on timescales of ≲5 d.

Economics of a Dermatology Practice.

Understanding the economics behind any medical practice comes down to one basic concept: Profit = Revenue - Expenses. This article aims to demystify the details that underlie this simple formula and to provide the budding dermatologist the information and the tools needed to determine their own profitability in the "real world."

Guidance on Documentation and Coding for Molluscum Contagiosum.

It is important for dermatologists who treat molluscum contagiosum (MC) to be aware of documentation and coding requirements for reimbursement by insurance payors when treating patients with molluscum contagiosum (MC). For example, treating 15 or more MC lesions in one patient during a single visit is coded differently than treating fewer lesions. Additionally, MC reimbursement codes are specific to the area of the body being treated. In general, coding for MC destruction should be as specific as possible, with detailed documentation and photographs. This article reviews procedures for determining reimbursement and provides guidance on accurately documenting and coding medical services for treatment of MC to optimize reimbursement from insurance carriers.

Clinical and Legal Considerations in Pharmaceutical Compounding.

It is not uncommon for dermatologists to utilize compounded drug formulations to address specific patient needs that cannot be met using commercially available drugs. Some dermatology practices may derive certain economic benefits and convenience for their patients by compounding formulations in-house. Compounded drugs are considered off-label; thus, they are not approved by the United States Food and Drug Administration (FDA). Oversight of compounding pharmacies and in-clinic compounding varies by state, although the FDA has issued guidance on compounding pharmacies and regulates outsourcing and 503(B) pharmacies. Dermatologists should be aware of the legal and regulatory issues of pharmaceutical compounding, as well as safety issues and penalties associated with compounding violations. Some controversies in compounding include the use of drug moieties that have been recalled by the FDA, compounding commercially available drugs for economic reasons (cheaper than brand names), or compounding drugs when reasonable alternatives are available commercially. This article reviews the regulatory, legal, and clinical considerations of pharmaceutical compounding in the field of dermatology.

Coding the "Spot Check": Part 1.

The updated outpatient evaluation and management (E/M) coding paradigm went into effect in January 2021, with level of visit being based on time or medical decision making (MDM). This article discusses how to effectively utilize this coding structure to correctly document for the "spot check," a common encounter within dermatology.

Coding the "Spot Check": Part 2.

The updated outpatient evaluation and management (E/M) coding paradigm went into effect in January 2021, with the coding level being based on time or medical decision making (MDM). In part 2 of this series, we describe how to best code an encounter that includes a "spot check" with other concerns.

Validation of a Market-Approved Artificial Intelligence Mobile Health App for Skin Cancer Screening: A Prospective Multicenter Diagnostic Accuracy Study.

BACKGROUND: Mobile health (mHealth) consumer applications (apps) have been integrated with deep learning for skin cancer risk assessments. However, prospective validation of these apps is lacking. OBJECTIVES: To identify the diagnostic accuracy of an app integrated with a convolutional neural network for the detection of premalignant and malignant skin lesions. METHODS: We performed a prospective multicenter diagnostic accuracy study of a CE-marked mHealth app from January 1 until August 31, 2020, among adult patients with at least one suspicious skin lesion. Skin lesions were assessed by the app on an iOS or Android device after clinical diagnosis and before obtaining histopathology. The app outcome was compared to the histopathological diagnosis, or if not available, the clinical diagnosis by a dermatologist. The primary outcome was the sensitivity and specificity of the app to detect premalignant and malignant skin lesions. Subgroup analyses were conducted for different smartphone types, the lesion's origin, indication for dermatological consultation, and lesion location. RESULTS: In total, 785 lesions, including 418 suspicious and 367 benign control lesions, among 372 patients (50.8% women) with a median age of 71 years were included. The app performed at an overall 86.9% (95% CI 82.3-90.7) sensitivity and 70.4% (95% CI 66.2-74.3) specificity. The sensitivity was significantly higher on the iOS device compared to the Android device (91.0 vs. 83.0%; p = 0.02). Specificity calculated on benign control lesions was significantly higher than suspicious skin lesions (80.1 vs. 45.5%; p < 0.001). Sensitivity was higher in skin fold areas compared to smooth skin areas (92.9 vs. 84.2%; p = 0.01), while the specificity was higher for lesions in smooth skin areas (72.0 vs. 56.6%; p = 0.02). CONCLUSION: The diagnostic accuracy of the mHealth app is far from perfect, but is potentially promising to empower patients to self-assess skin lesions before consulting a health care professional. An additional prospective validation study, particularly for suspicious pigmented skin lesions, is warranted. Furthermore, studies investigating mHealth implementation in the lay population are needed to demonstrate the impact on health care systems.

International Dermatology Outcome Measures (IDEOM): Report from the 2020 Annual Meeting.

BACKGROUND: The International Dermatology Outcome Measures (IDEOM) initiative is a non-profit organization that aims to develop evidence-based outcome measurements to evaluate the impact of treatments for patients with dermatological disease. IDEOM includes all key stakeholders in dermatology (patient, physician, industry, insurer, and government) during the process of developing such outcome measurements. SUMMARY: Here, we provide an update of IDEOM activities that were presented at the 2020 IDEOM Virtual Annual Meeting (October 23-24, 2020). During the meeting, multiple IDEOM workgroups (psoriasis, psoriatic arthritis, hidradenitis suppurativa, acne, pyoderma gangrenosum, and actinic keratosis) shared their progress to date, as well as future directions in developing and validating Patient-Reported Outcome Measures. Updates on demonstrating efficacy in clinicals trials by the US Food and Drug Administration are also summarized. KEY MESSAGES: In this report, we summarize the work presented by each IDEOM workgroup (psoriasis, psoriatic arthritis, hidradenitis suppurativa, acne, pyoderma gangrenosum, and actinic keratosis) at the 2020 IDEOM Virtual Annual Meeting.

Mobile App Usage Among Dermatology Residents in America.

Mobile applications (apps) have been a growing part of medicine for the last decade. Our cross-sectional online survey studied the role of apps in dermatology resident training. The demographic results and response rate suggest that our study sample is representative of the target population of dermatology residents in America. Our survey highlights the increasing role of apps in dermatology resident training, differences in priorities among different years of residency, and differences in information utilization between sexes. This knowledge should help guide standardization, quality assurance, and formal integration of medical mobile apps into traditional dermatology teaching.

Neutrino Fast Flavor Conversions in Neutron-Star Postmerger Accretion Disks.

A compact accretion disk may be formed in the merger of two neutron stars or of a neutron star and a stellar-mass black hole. Outflows from such accretion disks have been identified as a major site of rapid neutron-capture (r-process) nucleosynthesis and as the source of "red" kilonova emissions following the first observed neutron-star merger GW170817. We present long-term general-relativistic radiation magnetohydrodynamic simulations of a typical postmerger accretion disk at initial accretion rates of M[over ˙]∼1 M_{⊙} s^{-1} over 400 ms postmerger. We include neutrino radiation transport that accounts for the effects of neutrino fast flavor conversions dynamically. We find ubiquitous flavor oscillations that result in a significantly more neutron-rich outflow, providing lanthanide and 3rd-peak r-process abundances similar to solar abundances. This provides strong evidence that postmerger accretion disks are a major production site of heavy r-process elements. A similar flavor effect may allow for increased lanthanide production in collapsars.

E/M Coding in 2021: The Times (and More) Are A-Changin'.

Major revisions for commonly reported office and outpatient evaluation and management (E/M) codes were implemented on January 1, 2021, by the American Medical Association and Centers for Medicare and Medicaid Services. The goal of these changes was to simplify and streamline these service codes, with time and medical decision-making (MDM) now being the sole determinants of the overall E/M level. We present an overview of the new guidelines, requirements, and code descriptors to aid in accurate documentation and billing. Additional resources are provided if further billing and coding questions arise.