Performance measurement part I: Foundational knowledge for measure development

As medicine is moving toward performance and outcome-based payment and is transitioning away from productivity-based systems, value is now being appraised in healthcare through "performance measures." Over the past few decades, assessment of clinical performance in health care has been essential in ensuring safe and cost-effective patient care. The Centers for Medicare & Medicaid Services is further driving this change with measurable, outcomes-based national payer incentive payment systems. With the continually evolving requirements in health care reform focused on value-based care, there is a growing concern that clinicians, particularly dermatologists, may not understand the scientific rationale of health care quality measurement. As such, in order to help dermatologists understand the health care measurement science landscape to empower them to engage in the performance measure development and implementation process, the first article in this 2-part continuing medical education series reviews the value equation, historic and evolving policy issues, and the American Academy of Dermatology's approach to performance measurement development to provide the required foundational knowledge for performance measure developers.

"Kissing" basaloid follicular hamartomas of the eyelid

Basaloid follicular hamartomas (BFH) are rare, benign, cutaneous adnexal tumors characterized by branching cords and anastomosing strands of basaloid cells in a loose, fibrous stroma. BFH exhibit variable clinical presentations although they are commonly observed as skin to flesh colored papules and are diagnosed based on histological features. Common systemic diseases associated with BFH include alopecia, myasthenia gravis, and palmoplantar pitting. BFH of the eyelid is extremely rare with only five cases reported in the literature to date. Congenital "kissing" lesions have only previously been reported with nevi. Here we present a novel case of congenital "kissing" basaloid follicular hamartoma of the right upper and right lower eyelid and histological examination revealed intradermal nodules of basaloid cells forming reticulated strands, pseudohorn cysts, mucinous stroma and palisading with CD34 and Bcl-2 expression in the stromal fibroblasts and periphery, respectively. This article is protected by copyright. All rights reserved.

Secondary Syphilis With Elastophagocytosis: An Unusual Histologic Finding

ABSTRACT

Elastophagocytosis is a characteristic finding of granulomatous and elastolytic disorders. It is defined by phagocytosed elastic fibers within histiocytes, multinucleated giant cells, or both. This finding has also been associated with certain medications, malignancies, inflammatory conditions, and infectious disorders. Although Drs Ragaz and Ackerman reported elastophagocytosis in a secondary syphilis lesion in a review of actinic granuloma in 1979, more recent publications have not recognized this finding. We present a case of elastophagocytosis within a lesion of secondary syphilis in a 65-year-old man. Biopsy from his left forearm demonstrated features of secondary syphilis including subtle vacuolar alteration with mild superficial and mid perivascular lymphoplasmacytic inflammation. There were interstitial giant cells with phagocytosed elastic fibers within the superficial dermis. Spirochete immunostain was positive with confirmatory Treponema pallidum IgG antibody and RPR titer. In this report, we present a unique case of secondary syphilis.

Optical conductivity-based ultrasensitive mid-infrared biosensing on a hybrid metasurface

Optical devices are highly attractive for biosensing as they can not only enable quantitative measurements of analytes but also provide information on molecular structures. Unfortunately, typical refractive index-based optical sensors do not have sufficient sensitivity to probe the binding of low-molecular-weight analytes. Non-optical devices such as field-effect transistors can be more sensitive but do not offer some of the significant features of optical devices, particularly molecular fingerprinting. We present optical conductivity-based mid-infrared (mid-IR) biosensors that allow for sensitive and quantitative measurements of low-molecular-weight analytes as well as the enhancement of spectral fingerprints. The sensors employ a hybrid metasurface consisting of monolayer graphene and metallic nano-antennas and combine individual advantages of plasmonic, electronic and spectroscopic approaches. First, the hybrid metasurface sensors can optically detect target molecule-induced carrier doping to graphene, allowing highly sensitive detection of low-molecular-weight analytes despite their small sizes. Second, the resonance shifts caused by changes in graphene optical conductivity is a well-defined function of graphene carrier density, thereby allowing for quantification of the binding of molecules. Third, the sensor performance is highly stable and consistent thanks to its insensitivity to graphene carrier mobility degradation. Finally, the sensors can also act as substrates for surface-enhanced infrared spectroscopy. We demonstrated the measurement of monolayers of sub-nanometer-sized molecules or particles and affinity binding-based quantitative detection of glucose down to 200 pM (36 pg/mL). We also demonstrated enhanced fingerprinting of minute quantities of glucose and polymer molecules.

Real-Time Monitoring of Insulin Using a Graphene Field-Effect Transistor Aptameric Nanosensor

This paper presents an approach to the real-time, label-free, specific, and sensitive monitoring of insulin using a graphene aptameric nanosensor. The nanosensor is configured as a field-effect transistor, whose graphene-based conducting channel is functionalized with a guanine-rich IGA3 aptamer. The negatively charged aptamer folds into a compact and stable antiparallel or parallel G-quadruplex conformation upon binding with insulin, resulting in a change in the carrier density, and hence the electrical conductance, of the graphene. The change in the electrical conductance is then measured to enable the real-time monitoring of insulin levels. Testing has shown that the nanosensor offers an estimated limit of detection down to 35 pM and is functional in Krebs-Ringer bicarbonate buffer, a standard pancreatic islet perfusion medium. These results demonstrate the potential utility of this approach in label-free monitoring of insulin and in timely prediction of accurate insulin dosage in clinical diagnostics.

Pemphigus: Pathogenesis to Treatment

Pemphigus vulgaris (PV), pemphigus foliaceus (PF), and paraneoplastic pemphigus (PNP) are a group of rare and fatal blistering diseases involving autoantibodies that target desmosomal proteins. The pathogenesis of pemphigus involves the production of activated B-cells and IgG with stimulation by IL-4 by T-helper 2 cells. Clinically these diseases present most often with epidermal erosions of the mucosae and skin caused by rapid rupturing of flaccid bullae. These lesions correlate histologically with splits forming in the epidermis, leaving a blister roof composed of a few cell layers. Standard treatment of pemphigus involves oral corticosteroids, often with the addition of adjuvant therapies, to improve disease control, minimize corticosteroids side-effects, and increase the odds of remission. [Full article available at http://rimed.org/rimedicaljournal-2016-12.asp].