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.

Surgery under siege: A case study of leg amputation in 18th century Louisbourg, Nova Scotia, Canada.

OBJECTIVE: Paleopathological analysis of a below-knee amputation was conducted to explore the sociocultural reasons why the amputation took place. MATERIALS: Older adolescent male (18-21 years) from the New Englander mass burial at the 18th century Fortress of Louisbourg. METHODS: Macroscopic assessment and archival data. RESULTS: A surgical amputation of the right tibia and fibula, distal to the knee was identified. The cross-sectional diaphysis of the leg has kerf marks and a splinter (breakaway point) at the posterior-lateral border of the tibia suggesting the leg gave way from its own weight or was manually removed once most of the sawing was complete. CONCLUSIONS: Archival records suggest frostbite from prolonged exposure to freezing temperatures and trauma from unsafe working conditions at the Fortress were the main causes that led to amputation. SIGNIFICANCE: This case study highlights the importance of contextualizing cases of amputation to understand factors leading to the amputation procedure and techniques used in the past, and the social and living conditions of the individual. LIMITATIONS: Observations were restricted to skeletal material as soft tissue decomposed and there was no material evidence suggestive of amputation associated with this individual in their grave. SUGGESTIONS FOR FUTURE RESEARCH: Full trauma assessment of the Fortress of Louisbourg skeletal collection to provide additional insight into injury sustained at Louisbourg and 18th century surgical practices.

Development of a core outcome set for basal cell carcinoma.

BACKGROUND: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions. OBJECTIVE: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials. METHODS: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group. RESULTS: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome. LIMITATIONS: English-speaking patients and professionals rated outcomes extracted from English language studies. CONCLUSION: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.

The ice age with little effect? Exploring stress in the Danish Black Friars cemetery before and after the turn of the 14th century.

The Little Ice Age, beginning in Europe in the 14th century, saw a period of climatic cooling and increased precipitation where food sources dwindled and famine became rampant, particularly in urban city centers. This study focuses on the Black Friars population (13th-17th centuries) to explore changes in stress in Denmark at the onset of the Little Ice Age. This study specifically explores the periods before and after the turn of the 14th century. Forty-five adult individuals were analyzed for cribra orbitalia, porotic hyperostosis, and enamel hypoplastic lesions. Results showed no statistically significant differences between the prevalence of these stress indicators between either time period; however, reduced age at death and increased lesion frequency was more prevalent post-1300. It was expected that increased stress would be evident in those buried after the turn of the 14th century due to the many challenges associated with wide spread climatic cooling; however, the reliance on nutrient rich marine resources and alms provisions may have helped lessen the burden of these stressors during this period of climatic hardship. Additionally, while famine characterized the beginning of the 14th century, agricultural rebound shortly after this period may have also influenced the stress levels observed.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Relative Value Scale Update Committee.

The American Medical Association-Specialty Society Relative Value Scale Update Committee, also known as the RUC, plays a critical role in assessing the relative value of physician services and procedures. This committee provides access for all physicians, including dermatologists, to the reimbursement process. Since the introduction of the Resource-Based Relative Value Scale by Medicare, the RUC has done important work to evaluate and refine reimbursement for physician services. The RUC recommendations have also led the Current Procedural Terminology (CPT) Editorial Panel to develop additional reimbursement codes as new procedures and services are developed. In this article (from the series Future Considerations for Clinical Dermatology in the Setting of 21st Century American Policy Reform), we will review the RUC, including its history and membership, the RUC update process, and a brief discussion of a few issues of particular importance to dermatologists.

A risk adjustment approach to estimating the burden of skin disease in the United States.

Direct insurance claims tabulation and risk adjustment statistical methods can be used to estimate health care costs associated with various diseases. In this third manuscript derived from the new national Burden of Skin Disease Report from the American Academy of Dermatology, a risk adjustment method that was based on modeling the average annual costs of individuals with or without specific diseases, and specifically tailored for 24 skin disease categories, was used to estimate the economic burden of skin disease. The results were compared with the claims tabulation method used in the first 2 parts of this project. The risk adjustment method estimated the direct health care costs of skin diseases to be $46 billion in 2013, approximately $15 billion less than estimates using claims tabulation. For individual skin diseases, the risk adjustment cost estimates ranged from 11% to 297% of those obtained using claims tabulation for the 10 most costly skin disease categories. Although either method may be used for purposes of estimating the costs of skin disease, the choice of method will affect the end result. These findings serve as an important reference for future discussions about the method chosen in health care payment models to estimate both the cost of skin disease and the potential cost impact of care changes.

Contribution of health care factors to the burden of skin disease in the United States.

The American Academy of Dermatology has developed an up-to-date national Burden of Skin Disease Report on the impact of skin disease on patients and on the US population. In this second of 3 manuscripts, data are presented on specific health care dimensions that contribute to the overall burden of skin disease. Through the use of data derived from medical claims in 2013 for 24 skin disease categories, these results indicate that skin disease health care is delivered most frequently to the aging US population, who are afflicted with more skin diseases than other age groups. Furthermore, the overall cost of skin disease is highest within the commercially insured population, and skin disease treatment primarily occurs in the outpatient setting. Dermatologists provided approximately 30% of office visit care and performed nearly 50% of cutaneous surgeries. These findings serve as a critical foundation for future discussions on the clinical importance of skin disease and the value of dermatologic care across the population.

The burden of skin disease in the United States.

Since the publication of the last US national burden of skin disease report in 2006, there have been substantial changes in the practice of dermatology and the US health care system. These include the development of new treatment modalities, marked increases in the cost of medications, increasingly complex payer rules and regulations, and an aging of the US population. Recognizing the need for up-to-date data to inform researchers, policy makers, public stakeholders, and health care providers about the impact of skin disease on patients and US society, the American Academy of Dermatology produced a new national burden of skin disease report. Using 2013 claims data from private and governmental insurance providers, this report analyzed the prevalence, cost, and mortality attributable to 24 skin disease categories in the US population. In this first of 3 articles, the presented data demonstrate that nearly 85 million Americans were seen by a physician for at least 1 skin disease in 2013. This led to an estimated direct health care cost of $75 billion and an indirect lost opportunity cost of $11 billion. Further, mortality was noted in half of the 24 skin disease categories.

The biochemical signatures of stress: A preliminary analysis of osteocalcin concentrations and macroscopic skeletal changes associated with stress in the 13th - 17th centuries black friars population.

OBJECTIVE: As a chemical precursor to the hard tissue changes well-studied in bioarchaeological research, osteocalcin provides a unique opportunity to assess stress via fluctuations in bone metabolism. The main objectives of this research were 1) to successfully extract osteocalcin from the Black Friars skeletal population; 2) to assess the diagenetic change between individual bone samples; and 3) to compare osteocalcin concentrations across sex, age, time period and macroscopic indicators of stress. METHODS: Twenty adult individuals were selected from the 13th-17th centuries Black Friars skeletal population with bone samples taken from the clavicle and femur. Total protein was assessed through a MicroBCA analysis with osteocalcin quantified using a Human Quantikine ELISA kit. Diagenetic change was assessed using Fourier transform infrared spectroscopy and the attenuated total reflectance method. RESULTS: Osteocalcin concentrations showed no significant differences between sex or age groups; however, between time period the post-medieval individuals showed a significant reduction of osteocalcin in both the clavicle and the femur. There were no significant differences in osteocalcin concentrations between those with and without past stress indicators and only one significant difference among the chronic indicators. The diagenetic results demonstrated a similar degree of crystallinity between all samples. CONCLUSIONS: While preliminary in nature, this study was successful in demonstrating the potential use of osteocalcin in future health-related research and how the study of osteocalcin may contribute to a better understanding of how and when stress begins to affect the skeletal tissues.

Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall.

BACKGROUND/AIMS: Surgical correction of ocular alignment in patients with third cranial nerve paralysis is challenging, as the unopposed lateral rectus muscle often pulls the eye back to exotropia following surgery. The authors present a simple surgical approach to overcome this difficulty. This approach is also applicable to removal of unwanted overactivity of the lateral rectus in Duane syndrome. METHODS: A review was made of the records of four patients with third cranial nerve paralysis and one with Duane syndrome with exotropia in which the lateral rectus muscle was removed from its scleral insertion and reattached to the orbital wall. Additional surgery to bring the eye to the midline included medial rectus resection, medial transposition of the vertical recti, and passive suturing of the eye to the medial orbit wall. RESULTS: All patients achieved satisfactory ocular alignment following surgery. Ocular ductions were limited. These results were stable for 1.5-4 years of follow up. No major complications occurred. CONCLUSION: Lateral rectus muscle disinsertion and reattachment to the orbital wall to absorb its force and thus remove abduction torque was a simple and safe surgical procedure for restoring ocular alignment in four patients with third cranial nerve paralysis and in one patient with Duane syndrome with severe exotropia.

Progressive restrictive strabismus acquired in infancy.

The authors present three cases of severely restricted motility and large angle strabismus acquired rapidly during the first months of life in otherwise normal children who had normal eye alignment and movements at birth. Surgical treatment of these cases is difficult and outcomes are variable. Myositis causing extraocular muscles fibrosis is a possible cause of the strabismus in these cases.

Are the MMPI subtle subscales subtle measures of their scales?

This study investigated the ability of the MMPI Wiener-Harmon subtle subscales (on scales D. Hy, Pd, Pa, and Ma) to serve as subtle or unobtrusive measures of their scales. Forty outpatients completed the MMPI under standard instructions, followed by a fake-good or fake-bad instructional set. First, we investigated the paradoxical effect found in the MMPI faking literature (in which, overall, the subtle subscale T-scores change in a direction opposite of the faking instructions) and found that not every subtle subscale shows this effect. Secondly, the subtle subscale T-scores achieved under faking conditions showed no significant relationship to their respective full-scale T-scores achieved under standard conditions. Therefore, our results do not support the Wiener-Harmon subtle subscales as subtle measures of their scales.

Pay for travel: protecting the employer.

Home care companies need to protect themselves from potential lawsuits regarding pay for travel time for those employees who travel between clients' homes. The costs of not doing so can be enormous, particularly as pre-empting such cases takes relatively simple policies.

Instructed faking and MMPI-2 response latencies: the potential for assessing response validity.

Differences in Minnesota Multiphasic Personality Inventory-2 (MMPI-2) response latencies between groups instructed to respond honestly or fake were explored. There were 120 undergraduate students who completed a computer administered MMPI-2 with instructions to either respond honestly, to underreport psychopathology, or to overreport psychopathology. Results showed that subjects required significantly more time to respond in a manner that was inconsistent with their response set when pattern of endorsement (acceptance vs. rejection) was considered and less time when pattern of endorsement was not considered. The differential response of subjects across groups suggests that response latencies are related to response styles and that future research may indicate a methodology for utilizing response latencies in assessing response validity.

Red flags and religious coping: identifying some religious warning signs among people in crisis.

This study attempts to identify some of the signs of ineffective religious involvement in coping. Drawing from a process/integration model of efficacious coping, three broad types of religious warning signs were defined and 11 subscales were developed. These subscales were administered to a group of Roman Catholic church members and two groups of college undergraduates who had experienced different types of negative life events in the past two years. Statistical analyses were conducted to determine the relationship between these subscales and measures of general mental health and event specific outcome. The theoretical and practical implications of these results are considered.

Preventing ptosis after botulinum treatment.

In a series of 33 blepharospasm patients who had the side effect of ptosis following therapeutic botulinum toxin type A (Botox: Allergan, Inc., Irvine, CA, U.S.A.) injection, we administered 41 injections of human botulinum immune globulin (IG) following injections of the toxin to test the dosage and timing of IG injection and its effectiveness in limiting or avoiding ptosis. An IG dose of 3.2 x 10(-3) international units (IU) per unit of Botox was effective in blocking toxin effect when injected into the same tissue site within 4 hours. An IG dose of 1.6 x 10(-2) to 3.2 x 10(-2) into the levator of the eye having more frequent ptosis in 19 patients reduced the incidence of ptosis to 11%. The fellow (control) eye had a ptosis incidence of 37%. No orbital hemorrhage or other adverse effect occurred from the IG or its injection.

Validity of the MMPI subtle items.

This article presents a review and critique of research on the Minnesota Multiphasic Personality Inventory (MMPI) subtle items in regard to their validity as measures of their scales' characteristics. The main categories of focus are their convergent and discriminative validity, the paradoxical effect, and the issue of whether removing these items would improve MMPI validity. Important problems in the methodologies are noted and discussed in some detail. These methodological concerns and the conflicting results across studies obscure firm conclusions on the validity of the subtle items, although strong support is lacking. However, more evidence is needed before deciding to remove these items from the MMPI; therefore, this article provides recommendations for future research.

Change of eye muscle sarcomeres according to eye position.

In three monkeys, the right eye was moved from the primary position to a position of 30 degrees to 45 degrees exotropia by suturing the globe to the orbital wall. In two animals perfused immediately following suturing, histological examination showed the medial rectus and its sarcomeres to be lengthened and the lateral rectus and its sarcomeres to be shortened as compared to those of the unoperated control eye. In the third monkey, after exotropia was maintained for 2 months, the muscle lengths changed but the sarcomere lengths were similar to those of the control eye. We interpret this to indicate addition of sarcomeres to the lengthened medial rectus and removal of sarcomeres from the shortened lateral rectus. This adaptation to conform muscle length to eye position may explain the altered eye position which persists following periods of eye deviation due to muscle paralysis, prior surgery, injury, or botulinum toxin treatment.

Treatment of hemifacial spasm with botulinum toxin.

The effectiveness of botulinum toxin injections in 11 patients with hemifacial spasm was investigated in a prospective placebo-controlled blinded study. The patients were treated with four sets of injections to various facial muscles, selected by clinical evaluation. Three injections were with graded doses of toxin and one was with placebo. The order of injections was random and unknown to the patients. Results were scored both subjectively by patient assessment of symptoms and objectively by blinded review of videotapes made one month after each injection. Subjective improvement occurred after 79% of injections with botulinum toxin, regardless of dose of toxin. Only 1 patient improved after placebo. Objective improvement was seen after 84% of injections with botulinum toxin. No patient showed objective improvement after placebo injection. The most frequent side effect was facial weakness, seen after 97% of injections of botulinum toxin. Facial bruising (20%), diplopia (13%), ptosis (7%), and various other mild side effects were seen less frequently. Botulinum toxin appears to be an effective and safe method of therapy for hemifacial spasm.