Starting a Solo Practice.

Opening a small private dermatology practice can be a rewarding experience. It may seem like a lot of trouble, but in no other setting will you have so much freedom, control, and directly be able to see the consequences of your efforts. Economically, you must realize that in other settings, all these "chores" you must do in a solo practice are paid for by you out of overhead, which can greatly exceed what it costs if you do it yourself in a small practice. That is, a small private practice can be economically more rewarding and flexible than working for a dermatology group, particularly a multispecialty group. It requires months of preparation, planning, hard work, persistence, and a strong desire to establish a practice that operates on your own terms.

Skin biopsy and skin cancer treatment use in the Medicare population, 1993 to 2016.

BACKGROUND: Skin biopsies are increasing at a rapid rate, and some may be unnecessary. Although skin cancer incidence is rising, there is varied biopsy accuracy between dermatologists and advanced practice professionals (APPs). A comparison of Current Procedural Terminology code (American Medical Association, Chicago, IL) use for skin biopsy and skin cancer treatment over 18 years and a comparison of provider types is needed. Excess skin biopsies increase health care costs and patient morbidity. OBJECTIVE: To examine changes in skin biopsy and skin cancer treatment utilization rates per year in the Medicare fee-for-service (FFS) population and to compare skin biopsy utilization rates between dermatologists and APPs. METHODS: Retrospective cross-sectional study of Medicare FFS paid claims using the Centers for Medicare and Medicaid Services Physician Claims databases. We calculated the number of skin biopsies and skin cancer treatments in the Medicare FFS population from 1993 to 2016, and percentage use by provider type from 2001 to 2016. Our primary outcome measurements were the number of skin biopsies and skin cancer treatments per 1000 Medicare FFS beneficiaries per year and the number of additional skin biopsies per 1000 Medicare FFS beneficiaries per year, or the difference in the number of skin biopsies and number of skin cancer treatments per 1000 Medicare FFS beneficiaries. Our secondary outcome measurements were the skin biopsy-to-skin cancer treatment ratio and the number of procedures per 1000 Medicare FFS beneficiaries per year by provider type. RESULTS: After adjusting for the number of enrollees in the Medicare FFS population from 1993 to 2016, skin biopsies per 1000 Medicare FFS beneficiaries increased 153% (from 39.31 to 99.33), and skin cancer treatments per 1000 Medicare FFS beneficiaries increased 39% (from 34.67 to 48.26). Between 1993 and 2016, the skin biopsy-to-skin cancer treatment ratio increased 81% (from 1.134 to 2.058), and the number of additional biopsies per 1000 Medicare FFS beneficiaries increased 1001% (from 4.638 to 51.072) between 1993 and 2016. Utilization data by provider type is available from 2001 to 2016. The number of skin biopsies per 1000 Medicare beneficiaries performed by APPs increased from 0.82 to 17.19 or 1996% (nurse practitioners, 2211%; physician assistants, 1916%) and the number of biopsies by dermatologists increased by 41% from 53.98 to 76.17. LIMITATIONS: Medicare claims data do not provide specific information regarding skin biopsy or skin cancer treatment use. CONCLUSION: The number of skin biopsies has risen 153% since 1993, while the number of skin cancer treatments has only increased 39%. Our data highlight the rise of biopsy use and the increase in biopsies that do not result in skin cancer diagnosis or treatment. This suggests APPs may be responsible for increasing the cost of skin cancer management by biopsying significantly more benign lesions than dermatologists.

Characterization of Patients' Quality of Life and Experience in the Course of Acne Treatment.

Few studies provide qualitative data on the acne treatment experience. This study describes patients' personal experiences of acne treatment. Video interviews were made of 27 teenagers and young adults with acne treated for 12 weeks with adapalene/benzoyl peroxide gel. Transcripts were then coded and qualitatively analyzed. Four thematic domains affecting quality of life and experience were identified: clinical manifestations, self-perception, social placement, and perception of control. Successful treatment increased self-esteem and performance at work and school. Successful acne treatment improves patients' quality of life by improving appearance and self-perception, satisfaction with social placement, and perception of control.

Preterm infant with a late presentation of blueberry muffin lesions secondary to recombinant erythropoietin.

Our patient is a 26-week-old preterm female infant delivered by caesarean section secondary to severe maternal preeclampsia who had been receiving subcutaneous recombinant erythropoietin (r-EPO) for anemia of prematurity. At 8 weeks of age after 8 doses of r-EPO, the infant developed numerous non-blanching erythematous macules and patches located on the back, posterior shoulder, and posterior arms, concerning for late-onset blueberry muffin lesions. Biopsy of the lesions confirmed dermal hematopoiesis. After r-EPO was discontinued all skin lesions gradually resolved over a period of 2 weeks and never recurred.

DNA polymerase eta participates in the mutagenic bypass of adducts induced by benzo[a]pyrene diol epoxide in mammalian cells.

Y-family DNA-polymerases have larger active sites that can accommodate bulky DNA adducts allowing them to bypass these lesions during replication. One member, polymerase eta (pol eta), is specialized for the bypass of UV-induced thymidine-thymidine dimers, correctly inserting two adenines. Loss of pol eta function is the molecular basis for xeroderma pigmentosum (XP) variant where the accumulation of mutations results in a dramatic increase in UV-induced skin cancers. Less is known about the role of pol eta in the bypass of other DNA adducts. A commonly encountered DNA adduct is that caused by benzo[a]pyrene diol epoxide (BPDE), the ultimate carcinogenic metabolite of the environmental chemical benzo[a]pyrene. Here, treatment of pol eta-deficient fibroblasts from humans and mice with BPDE resulted in a significant decrease in Hprt gene mutations. These studies in mammalian cells support a number of in vitro reports that purified pol eta has error-prone activity on plasmids with site-directed BPDE adducts. Sequencing the Hprt gene from this work shows that the majority of mutations are G>T transversions. These data suggest that pol eta has error-prone activity when bypassing BPDE-adducts. Understanding the basis of environmental carcinogen-derived mutations may enable prevention strategies to reduce such mutations with the intent to reduce the number of environmentally relevant cancers.