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BACKGROUND: Nonphysician practitioners (NPPS), including nurse practitioners (NPs) and physician assistants (PAs) are expanding their scope of practice outside of primary care and performing more procedures in dermatology. OBJECTIVE: To understand the scope and geographic pattern of practice by NPs and PAs in dermatology in the United States. METHODS: Cross-sectional retrospective cohort analysis of dermatology practices in the 2014 Medicare Physician/Supplier Procedure Summary master file, which reflects Part B carrier and durable medical equipment fee-for-service claims in the United States. RESULTS: Over 4 million procedures were billed independently by NPs and PAs, which accounted for 11.51% of all procedures. Injection, simple repair, and biopsy were the most commonly billed by the nonphysician practitioners, but complex procedures were also increasingly billed independently by NPs and PAs. Proportions of their claims are higher on the East Coast, Midwest, and Mountain states. LIMITATIONS: Data were collected at the state level and limited to Medicare beneficiaries, and did not include billing incident to physicians. CONCLUSIONS: This study demonstrated the increasing scope of practice of NPs and PAs in dermatology; this increase is alarming because of their limited training and the lack of uniform regulations guiding their practices. To ensure quality and safety of care, it is prudent to set benchmarks for proper supervision and utilization of procedures in dermatology.
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Enfermeras Practicantes , Asistentes Médicos , Médicos , Anciano , Humanos , Estados Unidos , Medicare , Estudios Retrospectivos , Estudios Transversales , Planes de Aranceles por ServiciosRESUMEN
This study aimed to investigate whether magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF) can be a viable noninvasive alternative to liver biopsy for the quantification of living liver donor steatosis. Hepatic steatosis for 143 donors was graded by MRI-PDFF. Study endpoints included liver volume regeneration in donors, recipient outcomes including length of hospital stay, deaths, primary non-function (PNF), early allograft dysfunction (EAD), and small for size syndrome (SFSS). Correlation between MRI-PDFF determined donor steatosis and endpoints were analyzed. Donors had lower steatosis grade than non-donors. Donor remnant liver regenerated to an average of 82% of pre-donation volume by 101 ± 24 days with no complications. There was no correlation between percent liver regeneration and steatosis severity. Among recipients, 4 underwent redo-transplantation and 6 died, with no association with degree of steatosis. 52 recipients (36%) fulfilled criteria for EAD (driven by INR), with no difference in hepatic steatosis between groups. MRI-PDFF reliably predicted donor outcomes. Living donors with no or mild steatosis based on MRI-PDFF (ie, <20%) and meeting other criteria for donation can expect favorable post-surgical outcomes, including liver regeneration. Recipients had a low rate of death or retransplantation with no association between mild hepatic steatosis and EAD.
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Enfermedad del Hígado Graso no Alcohólico , Protones , Biopsia , Humanos , Hígado/diagnóstico por imagen , Donadores Vivos , Imagen por Resonancia MagnéticaRESUMEN
Non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) are becoming the leading causes of chronic liver disease worldwide, significantly impacting public health and healthcare cost. The development of fibrosis is the main factor leading to early mortality and morbidity in NAFLD and ALD. Thus, it is important to timely and reliably evaluate these diseases at early stages, when fibrosis is not advanced or when steatosis predominates. Liver biopsy has been the standard of reference for fibrosis and steatosis, however, its invasiveness precludes its widespread use. There is growing research on non-invasive methods for diagnosing and stratifying fibrosis and steatosis in NAFLD and ALD. This review presents clinical evidence on the use of non-invasive assessment of liver disease (blood-based and imaging-based) in patients with NALFD and ALD, and proposes algorithms incorporating these tests into their management.
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Medical imaging has dramatically transformed the practice of medicine, especially the field of dermatology. Imaging is used to facilitate the transfer of information between providers, document cutaneous disease, assess response to therapy, and plays a crucial role in monitoring and diagnosing skin cancer. Advancements in imaging technology and overall improved quality of imaging have augmented the utility of photography. We provide an overview of current imaging technologies used in dermatology with a focus on their role in skin cancer diagnosis. Future technologies include three-dimensional, total-body photography, mobile smartphone applications, and computerassisted diagnostic devices. With these advancements, we are better equipped to capture and monitor skin conditions longitudinally and achieve improved diagnostic accuracy of skin cancer.
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Dermatología/métodos , Diagnóstico por Imagen/métodos , Enfermedades de la Piel/diagnóstico , HumanosRESUMEN
Photodynamic therapy (PDT) stands to benefit from improved approaches to real-time treatment monitoring. One method is to use activatable photosensitizers that can both induce cell death (via singlet oxygen) and monitor it (via caspase detection). Here, we report porphyrins as caspase-responsive Forster Resonance Energy Transfer (FRET) acceptors to organic fluorophore donors. Compared to porphyrin FRET donor constructs, singlet oxygen generation was unquenched prior to caspase activation, resulting in more efficient photosensitization in HT-29 cancer cells. The donor 5-Carboxy-X-Rhodamine (Rox) formed a robust FRET pair with the pyropheophorbide (Pyro) acceptor. The large dynamic range of the construct enabled ratiometric imaging (with Rox excitation) of caspase activation in live, single cells following induction of cell death (with Pyro excitation) using a single agent. Quantitative, unquenched activatable photosensitizers (QUaPS) hold potential for new feedback-oriented PDT approaches.
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Apoptosis , Técnicas Citológicas , Porfirinas/química , Caspasas/química , Caspasas/metabolismo , Transferencia Resonante de Energía de Fluorescencia , Células HT29 , Humanos , Microscopía Confocal , Estructura Molecular , Oxígeno Singlete/análisis , Oxígeno Singlete/químicaRESUMEN
We demonstrate that porphyrins can be used as efficient cross-linkers to generate a new class of hydrogels with enabling optical properties. Tetracarboxylic acid porphyrins reacted with PEG diamines to form a condensation polyamide in a range of appropriate conditions, with respect to reaction time, diisopropylethylamine initiator concentration, porphyrin-to-PEG ratio, porphyrin concentration, and PEG size. The network structure of the hydrogel maintained a porphyrin spacing that prevented excessive fluorescence self-quenching despite high porphyrin density. The near-infrared properties readily enabled low background, noninvasive fluorescence monitoring of the implanted hydrogel in vivo, as well as its image-guided surgical removal in real time using a low-cost fluorescence camera prototype. Emission could be tuned by incorporating copper metalloporphyrins into the network. The approach of creating hydrogels using cross-linking porphyrin comonomers creates opportunities for new polymer designs with strong optical character.