Expert Consensus on Nail Procedures and Selection of CPT Codes.

BACKGROUND: Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE: To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS: A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS: Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS: Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION: Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Acquired Idiopathic True Transverse Leukonychia.

A 34-year-old man from Djibouti presented with a 14-year history of relapsing and remitting transverse white bands on the fingernails with sparing of the toenails. Examination revealed several transverse, white bands following the contour of the lunula on seven of his fingernails that did not fade upon compression of the digits (Figure). There was no onycholysis. No other skin lesions were noted. The patient reported having lived for 4 years (2000-2004) in a house that had well water as its primary water supply. This 4-year period was a stressful point in our patient's life. During that time, he had been a student at university. He had had no reported occupational exposure to arsenic. He reported being a cigarette smoker since 1996 but denied any illicit drug use or alcohol consumption. His past medical history was significant for hepatitis A infection, but he denied any history of systemic illness, including renal disease, heart disease, and lung disease. He denied any family history of leukonychia. He denied any trauma or participation in activities that require excessive use of his hands, and also denied manipulation of the cuticles. The patient's liver function tests, lipid panel, complete blood count, and urinalysis were all within normal limits. A blood test revealed normal arsenic levels. Histologic examination of the nail plate showed segmental parakeratosis, with no evidence of fungal organisms upon PAS staining.

Tracking practice effects in computation estimation.

The present study investigated college students' ability to estimate the results of multi-digit multiplication problems and the extent to which this ability improves with practice. Participants judged whether the results of multiplication problems composed of two-digit numbers were larger or smaller than a given reference number. The reference numbers were either close or far from the exact answer. The effects of practice, size, and distance of the reference number from the exact answer were examined using four measures of performance: speed, accuracy, eye movements, and strategy use. The results show that together with enhanced speed and accuracy with practice, participants also changed the pattern of eye movements and the strategies they used. The eye movement analysis showed longer dwell time and more frequent first fixations toward the reference number with practice, suggesting that participants relied more on the reference number to solve the task with practice. The strategy analysis revealed that with practice participants reduced their use of the approximate calculation strategy, which involves multiplying the rounded operands and comparing the product to the reference number, and increased their reliance on the sense of magnitude strategy which does not involve any calculation, but is grounded in the ANS. This was done especially for trials in which the reference number was far from the exact answer, thus exhibiting enhanced adaptivity in strategy choice with practice.

Estimating linear effects in ANOVA designs: the easy way.

Research in cognitive science has documented numerous phenomena that are approximated by linear relationships. In the domain of numerical cognition, the use of linear regression for estimating linear effects (e.g., distance and SNARC effects) became common following Fias, Brysbaert, Geypens, and d'Ydewalle's (1996) study on the SNARC effect. While their work has become the model for analyzing linear effects in the field, it requires statistical analysis of individual participants and does not provide measures of the proportions of variability accounted for (cf. Lorch & Myers, 1990). In the present methodological note, using both the distance and SNARC effects as examples, we demonstrate how linear effects can be estimated in a simple way within the framework of repeated measures analysis of variance. This method allows for estimating effect sizes in terms of both slope and proportions of variability accounted for. Finally, we show that our method can easily be extended to estimate linear interaction effects, not just linear effects calculated as main effects.

Neural Correlates of Numerical Estimation: The Role of Strategy Use.

INTRODUCTION: Computation estimation is the ability to provide an approximate answer to a complex arithmetic problem without calculating it exactly. Despite its importance in daily life, the neuronal network underlying computation estimation is largely unknown. METHODS: We looked at the neuronal correlates of two computational estimation strategies: approximated calculation and sense of magnitude (SOM)-intuitive representation of magnitude, without calculation. During an fMRI scan, thirty-one college students judged whether the result of a two-digit multiplication problem was larger or smaller than a given reference number. In two different blocks, they were asked to use a specific strategy (AC or SOM). RESULTS: The two strategies activated brain regions related to calculation, numerical cognition, decision-making, and working memory. AC more than SOM elicited activations in multiple, domain-specific brain regions in the parietal lobule, including the left SMG (BA 40), the bilateral superior parietal lobule (BA 7), and the right inferior parietal lobule (BA 7). The activation level of the IFG was positively correlated to individual accuracy, indicating that the IFG has an essential role in both strategies. CONCLUSIONS: These finding suggest that the analogic code of magnitude is more involved in the AC than the SOM strategy.

A randomized controlled trial of oral phosphate binders in the treatment of pseudoxanthoma elasticum.

BACKGROUND: Pseudoxanthoma elasticum (PXE) is a rare connective tissue disorder involving fragmentation and mineralization of elastic fibers predominantly in the skin, eyes, and cardiovascular system. OBJECTIVE: The objective of this study was to assess the efficacy of sevelamer hydrochloride on the reversal of elastic fiber calcification and clinical lesions of PXE. METHODS: This was a randomized, double-blind, placebo-controlled, two-part prospective study. In the first year, 40 patients with PXE were randomized to receive either sevelamer hydrochloride (800 mg by mouth three times daily) or placebo in a 1:1 ratio. In the second year, all patients received sevelamer hydrochloride (800 mg by mouth three times daily). RESULTS: In the first year, the placebo and treatment groups' mean calcium scores decreased from 29.52 to 15.97 (41.93% mean improvement) and 27.48 to 16.75 (38.37% mean improvement), respectively. In the second year, the mean calcium scores decreased to 13.36 (53.94%) and 14.03 (51.35%) in these groups. The mean clinical score in the placebo group decreased from 6.25 to 6.05 at year 1 (2% improvement) whereas the mean clinical score in the sevelamer hydrochloride group decreased from 7.10 to 6.55 (7% improvement). In year 2, the scores in the original placebo and sevelamer hydrochloride groups decreased to 5.33 (14% improvement) and 5.72 (19% improvement), respectively. LIMITATIONS: Magnesium stearate in our placebo and active drugs may have played a confounding role in this study, contributing to the small differences observed in these two groups. CONCLUSION: Sevelamer hydrochloride produced a reduction in both calcification levels and clinical scores; however, this difference was not statistically significant compared with placebo. Future clinical studies should examine the inhibitory role and potential therapeutic effect of magnesium in PXE.

Damage to the Intraparietal Sulcus Impairs Magnitude Representations of Results of Complex Arithmetic Problems.

Past research investigating the role of the intraparietal sulcus (IPS) in numerical processes focused mainly on quantity and numerical comparisons as well on single digit arithmetic. The present study investigates the involvement of the IPS in estimating the results of multi-digit multiplication problems. For this purpose, the performance a 24-year-old female (JD) with brain damage in the left IPS was compared to an age-matched control group in the computation estimation task. When required to estimate whether the results of multi-digit multiplication problems are smaller or larger than given reference numbers, JD, in contrast to controls, did not show the common patterns of distance and size effects. Her strategy use was also atypical. Most control participants used both the approximated calculation strategy that involves rounding and calculation procedures and the sense of magnitude strategy that relies on an intuitive approximated magnitude representation of the results. In contrast, JD used only the former but not the latter strategy. Together, these findings suggest that the damage to the IPS impaired JD's representations of magnitude that play an important role in this computation estimation task.

Placebo-controlled, double-blind, randomized pilot study of imiquimod 5% cream applied once per week for 6 months for the treatment of actinic keratoses.

BACKGROUND: Imiquimod 5% cream applied twice weekly for 16 weeks is effective for treating actinic keratoses but may be limited by local side effects. OBJECTIVE: We sought to explore the efficacy and safety of a once weekly for 24 weeks dosing regimen using a left versus right side of head design. RESULTS: Twenty patients were enrolled; 15 completed and 5 discontinued for reasons unrelated to adverse events. At the posttreatment visit (week 28), 7 (46.7%) of 15 patients had marked improvement or better on the imiquimod side versus one (6.7%) of 15 on the placebo side. The average investigator assessment scale score change was +2.20 for imiquimod compared with -0.27 for placebo (P = .0002, Wilcoxon signed rank test). Skin reactions were minimal or nonexistent in most patients. LIMITATIONS: Limitations of the study include a small sample size and a lack of objective measure of local side effects. CONCLUSION: Imiquimod 5% cream applied once weekly for 24 weeks was convenient for patients and resulted in improvement of actinic keratoses with minimal side effects.

Across-notation automatic numerical processing.

In this article, the authors explored the existence of across-notation automatic numerical processing using size comparison and same-different paradigms. Participants were Arabic speakers, who used 2 sets of numerical symbols -- Arabic and Indian. They were presented with number pairs in the same notation (Arabic or Indian) or in different ones (Arabic and Indian). In the size comparison paradigm, 2 digits differing both numerically and physically were compared on the physical dimension. Nevertheless, there was evidence that participants automatically processed the irrelevant numerical dimension in different notation pairs. In the same-different paradigm, 2 digits were presented either in the same or in different notations. Participants had to indicate whether the 2 digits were physically the same. The results again showed evidence for the automatic processing of numerical magnitude for pairs in different notations. Findings of both experiments suggest that numbers in different notations are automatically translated into a common representation of magnitude, in line with M. McCloskey's (1992) abstract representation model.

Negative numbers are generated in the mind.

The goal of the present study was to disentangle two possible representations of negative numbers--the holistic representation, where absolute magnitude is integrated with polarity; and the components representation, where absolute magnitude is stored separately from polarity. Participants' performance was examined in two tasks involving numbers from--100 to 100. In the numerical comparison task, participants had to decide which number of a pair was numerically larger/smaller. In the number line task, participants were presented with a spatial number line on which they had to place a number. The results of both tasks support the components representation of negative numbers. The findings suggest that processing of negative numbers does not involve retrieval of their meaning from memory, but rather the integration of the polarity sign with the digits' magnitudes.

Approximation processes in arithmetic in old adulthood.

Young and old adults estimated the results of multidigit multiplication problems relative to a reference number. Old adults were slower but slightly more accurate than young adults. They were less affected by the distance between the reference number and the exact answer than the young adults. The same strategies reported by past research-the approximated calculation strategy and the sense of magnitude strategy-were found here. The old adults showed a stronger preference toward the approximated calculation strategy than the young ones, and this probably led to the reduced effect of distance. These patterns are interpreted as reflecting two factors. The first is the extensive experience of the old adults with mental calculation, and the second is the decline in processing speed and in working memory resources with adulthood. The former is responsible for the more frequent use of the approximated calculation strategy and for the higher accuracy of the old adults, while the latter is responsible for their slower responses.

Do Exact Calculation and Computation Estimation Reflect the Same Skills? Developmental and Individual Differences Perspectives.

Groups of children in 4th, 5th, and 6th grades and college students performed exact calculation and computation estimation tasks with two-digit multiplication problems. In the former they calculated the exact answer for each problem, and in the latter they estimated whether the result of each problem was larger or smaller than a given reference number. The analyses of speed and accuracy both showed different developmental patterns of the two tasks. While the accuracy of exact calculation increased with age in childhood, the accuracy of the estimation task reached its maximum level already in 4th grade and did not change with age. The reaction time of the exact calculation task was longer than that of the estimation task. The reaction time for both tasks remained constant in childhood and decreased in adulthood, with the improvement in speed larger for the exact calculation task. Similarly, within group variability in accuracy was larger in the exact calculation task than in the computation estimation task. Finally, low correlation was found between the accuracy of the two tasks. Together, these findings suggest that exact calculation and computation estimation reflect at least in part different skills.

ADHD and math - The differential effect on calculation and estimation.

Adults with ADHD were compared to controls when solving multiplication problems exactly and when estimating the results of multidigit multiplication problems relative to reference numbers. The ADHD participants were slower than controls in the exact calculation and in the estimation tasks, but not less accurate. The ADHD participants were similar to controls in showing enhanced accuracy and speed for smaller problem sizes, for trials in which the reference numbers were smaller (vs. larger) than the exact answers and for reference numbers that were far (vs. close) from the exact answer. The two groups similarly used the approximated calculation and the sense of magnitude strategies. They differed however in strategy execution, mainly of the approximated calculation strategy, which requires working memory resources. The increase in reaction time associated with using the approximated calculation strategy was larger for the ADHD compared to the control participants. Thus, ADHD seems to selectively impair calculation processes in estimation tasks that rely on working memory, but it does not hamper estimation skills that are based on sense of magnitude. The educational implications of these findings are discussed.

Automaticity of two-digit numbers.

Automatic processing of 2-digit numbers was demonstrated using the size congruency effect (SiCE). The SiCE indicates the processing of the irrelevant (numerical) dimension when 2 digits differing both numerically and physically are compared on the relevant (physical) dimension. The SiCE was affected by the compatibility between unit and decade digits but was unaffected by the global magnitude of the numbers. Together these results suggest automatic processing of the magnitudes of the components of the 2-digit numbers but not of whole numbers. Finally, the SiCE was affected more by the magnitude of the decade digits compared with the unit digits, indicating that the syntactic roles of the digits were represented. The implications of these results for understanding the numerical representations are discussed.

Water content and other aspects of brittle versus normal fingernails.

BACKGROUND: Previous authors have claimed that dehydration of the nail plate causes brittle nails. Some experts claim that normal nails contain 18% water, and brittle nails contain less than 16%. OBJECTIVE: We sought to test the hypothesis that brittle nails contain 2% less water than normal nails. We also examined the relationship between a number of health and behavioral variables and brittle nails. METHODS: In all, 102 participants with either brittle or normal nails had two nails clipped and then analyzed for water content by a blinded investigator in the laboratory. Participants filled out a detailed questionnaire designed to reveal information about health and behavior. RESULTS: The mean water content for normal nails was 11.90% and for brittle nails was 12.48%. There was no statistically significant difference between the two groups. The odds of having brittle nails was 3.23 times greater among participants who received a professional manicure (95% confidence interval 1.21, 8.59). The frequency of professional manicures was associated with the likelihood of having brittle nails. Frequency of hand moisturizer use was significantly associated with nail brittleness (95% confidence interval 1.35, 32.10). Family history was significantly associated with the likelihood of having brittle nails (95% confidence interval 1.65, 21.11). LIMITATIONS: Analyzing nails from living participants is limiting because samples can only be collected from the distal unattached nail plate. A small subanalysis was performed and showed that the nails were losing water between the time of clipping and laboratory analysis. Therefore, our water percentage results may not be representative of in vivo nail plate water contents. CONCLUSIONS: There was no significant difference in water content of brittle compared with normal nails.

Can Dyscalculics Estimate the Results of Arithmetic Problems?

The present study is the first to examine the computation estimation skills of dyscalculics versus controls using the estimation comparison task. In this task, participants judged whether an estimated answer to a multidigit multiplication problem was larger or smaller than a given reference number. While dyscalculics were less accurate than controls, their performance was well above chance level. The performance of controls but not of those with developmental dyscalculia (DD) improved consistently for smaller problem sizes. The performance of both groups was superior when the reference number was smaller (vs. larger) than the exact answer and when it was far (vs. close) from it, both of which are considered to be the markers of the approximate number system (ANS). Strategy analysis distinguished between an approximated calculation strategy and a sense of magnitude strategy, which does not involve any calculation but relies entirely on the ANS. Dyscalculics used the latter more often than controls. The present results suggest that there is little, if any, impairment in the ANS of adults with DD and that their main deficiency is with performing operations on magnitudes rather than with the representations of the magnitudes themselves.

The Automatic Mapping of Magnitude to Temporal Order Is Space-Dependent.

Past research has shown that performance in ordinal magnitude tasks is enhanced when stimuli are presented in ascending order, suggesting that magnitude is mapped to temporal order, with small magnitude associated with early and large with late presentation. The present study addresses the automaticity of this effect and its limitations. We used the "same/different" task for numbers (Experiment 1) and physical sizes of shapes (Experiment 2) as well as identity of shapes (Experiment 3). The advantage for stimuli in ascending order was found for both numbers and physical sizes of shapes. However, it was limited to specific conditions - when magnitude processing was required for the task and when a "different" response was mapped to the right hand side. Thus, it seems that the automatic mapping of magnitude to temporal order is dependent on the mapping of magnitude to space.

Solving Math Problems Approximately: A Developmental Perspective.

Although solving arithmetic problems approximately is an important skill in everyday life, little is known about the development of this skill. Past research has shown that when children are asked to solve multi-digit multiplication problems approximately, they provide estimates that are often very far from the exact answer. This is unfortunate as computation estimation is needed in many circumstances in daily life. The present study examined 4th graders, 6th graders and adults' ability to estimate the results of arithmetic problems relative to a reference number. A developmental pattern was observed in accuracy, speed and strategy use. With age there was a general increase in speed, and an increase in accuracy mainly for trials in which the reference number was close to the exact answer. The children tended to use the sense of magnitude strategy, which does not involve any calculation but relies mainly on an intuitive coarse sense of magnitude, while the adults used the approximated calculation strategy which involves rounding and multiplication procedures, and relies to a greater extent on calculation skills and working memory resources. Importantly, the children were less accurate than the adults, but were well above chance level. In all age groups performance was enhanced when the reference number was smaller (vs. larger) than the exact answer and when it was far (vs. close) from it, suggesting the involvement of an approximate number system. The results suggest the existence of an intuitive sense of magnitude for the results of arithmetic problems that might help children and even adults with difficulties in math. The present findings are discussed in the context of past research reporting poor estimation skills among children, and the conditions that might allow using children estimation skills in an effective manner.

The use of systemic immune moderators in dermatology: an update.

In addition to corticosteroids, dermatologists have access to an array of immunomodulatory therapies. Azathioprine, cyclophosphamide, methotrexate, cyclosporine, and mycophenolate mofetil are the systemic immunosuppressive agents most commonly used by dermatologists. In addition, new developments in biotechnology have spurred the development of immunobiologic agents that are able to target the immunologic process of many inflammatory disorders at specific points along the inflammatory cascade. Alefacept, efalizumab, etanercept, and infliximab are the immunobiologic agents that are currently the most well known and most commonly used by dermatologists. This article reviews the pharmacology, mechanism of action, side effects, and clinical applications of these therapies.

A chart review of patients with early stage mycosis fungoides treated with psoralen plus UVA (PUVA).

PUVA has become a common form of treatment for early stage mycosis fungoides (MF). The purpose of this retrospective study was to review the clinical data of 51 MF patients (96% stage IA or IB) treated with PUVA at the Mt. Sinai MF clinic over the past 20 years. We analyzed the efficacy, safety, and remission duration in patients who were treated with a modified PUVA regimen. Forty-four of 51 patients (86%) achieved complete clinical clearing for all stages after initial PUVA therapy. The mean duration of remission with maintenance treatment was more than 27 months (range: 3 weeks to 130 months). The mean duration of disease from start of first PUVA therapy for all patients was 4.8 years (range: 0.7 to 130 months). PUVA for patients with early-stage MF is a safe and effective therapeutic modality with prolonged disease-free remissions, however, PUVA alone was not adequate for more advanced disease.