July 2018 Clinical Advisor

A P E E R - R E V I E W E D F O RU M F O R N U R S E P R AC T I T I O N E R S

NEWSLINE

■■Lyme neuroborreliosis ■■NPs, PAs in the ED ■■Alcohol and CHD risk LEGAL ADVISOR

A clinician quits her job but sues for wrongful termination

Irritative lesions in the abdomen and genital region

FREE CME COURSE

Inflammatory bowel disease: a collaborative approach Social media and health care: a closer look at Internet challenges and what clinicians can do to keep teens safe PAGE 30

J U LY 2 01 8

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SOCIAL MEDIA AND ADOLESCENTS

How serious are the health risks associated with social media use?

Increased use of social media has been linked to depression and anxiety.

DERMATOLOGY CLINIC

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Editor Colby Stong editor@clinicaladvisor.com Associate editor Madeline Morr Assistant editor Rita Aghjayan Contributing editors Mark P. Brady, PA-C; Philip R. Cohen, MD; Deborah L. Cross, MPH, CRNP, ANP; Sharon Dudley-Brown, PhD, FNP; Abimbola Farinde, PharmD; Laura A. Foster, CRNP, FNP; Abby A. Jacobson, PA; Maria Kidner, DNP, FNP; Joan W. Kiely, MSN, CRNP; Debra August King, PhD, PA; Ann W. Latner, JD; Mary Newberry, CNM, MSN; Claire Babcock O’Connell, MPH, PA; Kathy Pereira, DNP, FNP; Sherril Sego, DNP, FNP; Ann Walsh, PA-C, SCT(ASCP); Kim Zuber, PA-C Production editor Kim Daigneau Group art director, Haymarket Medical Jennifer Dvoretz Production manager Krassi Varbanov Circulation manager Paul Silver National accounts manager Alison McCauley, 973.224.6414 alison.mccauley @ haymarketmedical.com Publisher Kathleen Hiltz, 201.774.1078 kathleen.hiltz@haymarketmedia.com Editorial director Kathleen Walsh Tulley General manager, medical communications Jim Burke, RPh CEO, Haymarket Media, Inc. Lee Maniscalco All correspondence to: The Clinical Advisor 275 7th Avenue, 10th Floor, New York, NY 10001 For advertising sales, call 646.638.6085.

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Unsure about a diagnosis or treatment?

Ask our

EXPERTS If a patient has you stumped, write us and we’ll forward your query to one of our consultants and publish the response in Advisor Forum.You can also use this space to contribute a clinical pearl of your own or comment on another letter.

Advisor Forum These are letters from practitioners around the country who want to share their clinical problems and successes, observations, and pearls with their colleagues. Responding consultants are identified below. We invite you to participate.

CLINICAL PEARLS

It cannot be beat.—TERRI JORDAN, ARNP, Daytona Beach, Fla. (202-2)

NEUTROPHILS AND LYMPHOCYTES In interpreting a complete blood count with differential, anytime the neutrophils and lymphocytes are numerically close, it is a viral cause; when the neutrophils and lymphocytes are numerically distant, it is a bacterial cause.

This is very helpful in determining treatment.—DONNA CARTER, FNP-C, Scottsburg, Ind. (202-1) GENERIC “CAINE” IS EFFECTIVE FOR WOUND CARE For pain relief, most pharmacies offer a “caine” at 2-510%, and basically nothing higher, for between $5 and $30 per tube. I work in wound care and use Walmart’s

INTRA-ARTICULAR INJECTIONS FOR SEVERE OSTEOARTHRITIS Patients with severe osteoarthritis in the knees seem to do better with intra-articular injections if you have them sit up and dangle their legs off the examination table and distract the knee slightly when administering the injection.—ROSEMARY LEDBETTER, PhD, PA, Troy, Ill. (202-3)

YOUR COMMENTS SLIPPED CAPITAL FEMORAL EPIPHYSIS IN OBESE ADOLESCENTS I just read the CME/CE article by Marilou Shreve, DNP, APRN, entitled, “Assessing and treating pediatric obesity” [ June 2015]. I was concerned regarding the oversight of a critical issue in obese adolescents: the increased risk of slipped capital femoral epiphysis (SCFE). This was not addressed in the article.

The case study (p. 55) gave incomplete advice regarding the evaluation of an obese adolescent male with knee pain.

The most common etiology of the insidious onset of knee pain in children is the hip, due to referred pain from the

Equate brand—vagicaine 20% benzocaine. When using this before debriding a wound, give it three minutes to sedate the nerves, then perform the procedure. I get good results, as patients say. It relieves pain and burning for $1.88.

Advisor F

Send us your letters with questions and comments to: Advisor Forum, The Clinical Advisor, 114 West 26th Street, 4th Floor, New York, NY 10001. You may contact us by e-mail at editor@ clinicaladvisor.com. If you are writing in response to a published letter, please indicate so by including the number in parentheses at the end of each item. Letters are edited for length and clarity. The Clinical Advisor’s policy is to print the author’s name with the letter. No anonymous contributions will be accepted.

orum

These are lette and successe rs from practitioners s, observat around the below. We ions, and country who OUR CONSULTANTS pearls with invite you want to shar to participa their colle e their clinic agues. Resp te. al problems onding cons ultants are identified CON SULTAT IONS

TREATM ENT FOR INFECT URINAR ION SGLT2 REC MALE CHI S IN THE UNC Y TRACT IRCUMCI LD FOR DIA EPTOR BLOCKE If a male SED child conti Deborah L. Cross, MPH, CRNP, Laura A.BET Foster,ES CRNP, FNP, Abby A. Jacobson, PA-C, RS Abimbola Farinde, PhD, PharmD, With the nues toassociate ANP-BC, is practices family medicine is a physician assistant is a professor redevprogram adven t ofPrimary circu SGLT2 recep at Delaware Valley urinaryattract director, Gerontology NP elop Program, mcisi Columbia Southern moda litywith Palmetto on be perfo for type tor infecPhysicians Dermatology University of Pennsylvania School blockersGroup University 2 diabe rmed? regarding inCare as a treatm in Wilmington, Del. in Orange Beach, Ala. useCharleston, S.C. tes, is there ent urology is of Nursing, Philadelphia. any evide NATHAN in patients with to protect the is well advise nce or data type 1 diabe GARDNE d tes mellitus?— R, PA-C, continues to to recommend a circum upper tracts, the kidne CPAAPA, ys. develo cision It p recurr•ent 44 THE ADVISOR AUGUST 2015 •on www.ClinicalAdvisor.com Castleton, severaCLINICAL l consideration urinary tract the male child who As it currently stands N.Y. , SGLT2 s that infections. for glycemic impede the receptor blocke There are control in ability to cleansenter into this decisio rs are FDA adults with n. Poor hygien should the e and quell -approved child have e may appro diet and exercise, but with type 2 diabetes phimosis, simpl infection potential. appropriate the in ved conjun FDA for use in patien Moreover, AdvisorForum_CA0815.indd urine 44 9/29/15ction 2:38 PM e cathet culture can ts with type has stated that they ketoacidosi steroid cream be a challenge. erization to obtain s, or those are not may tempo an FAR with severe 1 diabetes, patients with Having a short tion of the rarily solve renal functi diabetic steroid the trial of informINDE, PhD, Pharm these issues tenden , though after for infection D (See bottom on.—ABIMBOL ation about once again.—C cy redevelops, placin cessaA Dr. Farinde.) of this page Milwaukee g (203-2) for more , Wis. (203- OLEEN ROSEN, the child at risk 1) DNP, FNP -C, CLI Philip R. Cohen, MD,

is clinicaltions associate professor , shou ld of dermatology, University a of Texas Medical Center, The focus of Houston.

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Send us your letter Advisor Forum, The s with questions New York, and comm Clinical Advisor ents to: , 114 clinicaladvisoNY 10001. You may contacWest 26th Street , please indicatr.com. If you are writing in t us by e-mail at 4th Floor, each item. e so by including response editor@ to a the Letters are policy is edited for number in parent published letter, to heses at length and contribution print the author ’s name with clarity. The Clinicathe end of s will be accepted. l Advisor the letter.

No anonym ’s ous

Write us today.

OUR CO

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VAGINA L RESULT DISCHARGE AND ING FRO If a female M TAMPON ODOR patient has USE a ask if she uses tamp history of vaginal disch ons. If she the pelvic arge with says “yes,” exam when cond odor, that you woul , do not enter ucting the rotating of d to take a pap smea vagina in the same the specu way r. Instead, the cervix. lum Most retain from side to side start shallow until reach ed tampons ing are lodge d in the fold

Philip R.

Cohen, MD, is clinical associa te profess of dermat or ology, of Texas MedicaUniversity l Center, Houston.

SEND TO The Clinical Advisor 275 7th Avenue, 10th floor New York, NY 10001

62 THE CLINI

Deborah L. Cross, MPH, ANP-B

CRNP, C, is associa te program director, Geronto logy NP Program University of Pennsyl vania School , of Nursing , Philadelphia.

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Laura A.

Foster,

practices familyCRNP, FNP, with Palmett medicine o Primary Care Physicia ns in Charles ton, S.C.

Abby A.

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is a physicia n, PA-C, n at Delawa assistant re Dermatology Valley in Wilmington,Group Del.

.indd 62

9/29/15

2:44 PM

E-MAIL editor@clinicaladvisor.com

Copyright © 2018

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 1

CONTENTS J U LY 2 0 1 8

NEWS AND COMMENT 12 Newsline ■■Lyme neuroborreliosis: long-term survival and outcomes ■■Practice varies for NPs, PAs in US emergency departments ■■ECG not advised in low-risk CVD ■■Alcohol consumption and CHD risk ■■Hand grip strength and all-cause mortality 12 B burgdorferi, which causes Lyme disease

FEATURES 19 Social media and adolescents: What are the health risks?

Primary care providers should screen for depression and other health-related risks associated with the use of social media.

30 Internet challenges pose healthcare risks

30 Internet “challenges” and teenagers: a guide for primary care providers A sensitive discussion is needed between clinician and patient.

34 CME Smoothing the course of IBD: A collaborative approach to care Optimal management depends on clear communication.

44 CME Feature posttest

51 A dark patch of raw skin in an infant

Continues on page 8

63 A clinician sues for wrongful termination

Follow us on Twitter @ClinicalAdvisor

Like us on Facebook facebook.com/TheClinicalAdvisor Visit us on the web ClinicalAdvisor.com Download the app ClinicalAdvisor.com/App

www.ClinicalAdvisor.com

MORE WAYS TO FIND US!

CONTENTS J U LY 2 0 1 8

DEPARTMENTS, cont’d A P E E R - R E V I E W E D F O RU M F O R N U R S E P R AC T I T I O N E R S

NEWSLINE

■ Lyme neuroborreliosis ■ NPs, PAs in the ED ■ Alcohol and CHD risk LEGAL ADVISOR

A clinician quits her job but sues for wrongful termination

LEGAL ADVISOR

Diagnostic test results are ordered but never received

Legal Advisor A case of wrongful termination?

ADVISOR FORUM 62

My Most Memorable Patient ■ Medical lessons learned

62

Clinical Pearl ■ Auscultating and palpating

Oral Anticoagulation

Advances in reversal agents key for preventing bleeding LEGAL ADVISOR

A patient dies after a missed diagnosis

A motor neuron from the anterior horn of the spinal cord with an inclusion from ALS

DVT typically consists of pain and swelling in a lower extremity.

DERMATOLOGY CLINIC

DERMATOLOGY CLINIC

A pink rash with fine scale in a 7-year-old boy

FREE CME COURSE

Viewpoints in gout and hyperuricemia

FREE CME COURSE

Inflammatory bowel disease: a collaborative approach Social media and health care: a closer look at Internet challenges and what clinicians can do to keep teens safe PAGE 30

A history of race and the emerging role of genetics: understanding their influence in primary care PAGE 22

VOLUME 21, NUMBER 5

63

FEATURE

Dry, scaly skin on the lower extremities in a young boy

VOLUME 21, NUMBER 6

Dermatologic Look-Alikes Dark patch of skin

■ Skin cancer prevention ■ Antibiotic-resistant bacteria ■ Allergic disease risk ■ IBD and DPP-4 inhibitors

■ Diabetes prevalence ■ Multiple sclerosis guideline

Increased use of social media has been linked to depression and anxiety.

VOLUME 21, NUMBER 7

51

| www.ClinicalAdvisor.com

NEWSLINE

care How serious are the Multidisciplinary Emergence of NOACs functiontreatment health risks associatedfor maximizingexpands with social media use?and quality of life options for patients

Irritative lesions in the abdomen and genital region

Dermatology Clinic ■ Irritative lesions in the abdomen and genital region ■ Horn-like projection on a man’s skull

FORUM FOR PHYSICIAN | www.ClinicalAdvisor.com J UALYPEER-REVIEWED 2 01 8 | www.ClinicalAdvisor.com A P E ASSISTANTS E R - R E V I E W E D| JUNE F O RU2M018 FOR N U R S E P R AC T I T I O N E R S | M AY 2 01 8

NEWSLINE AMYOTROPHIC LATERAL SCLEROSIS SOCIAL MEDIA AND ADOLESCENTS DEEP VEIN THROMBOSIS ■ Prostate cancer screening

DERMATOLOGY CLINIC

45

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THE CLINICAL ADVISOR • MAY 2018

THE CLINICAL ADVISOR • JUNE 2018

Web Roundup A summary of our most recent opinion, news, and multimedia content from ClinicalAdvisor.com

THE CLINICAL ADVISOR • JULY 2018

10

FREE CME COURSE

Rheumatoid arthritis: a journey toward remission

SUBSCRIPTIONS & SUBMISSIONS SUBSCRIBE ClinicalAdvisor.com/subscribe CONTACT THE EDITOR • editor@ClinicalAdvisor.com • Call 646.638.6078 SUBMIT AN ARTICLE editor@ClinicalAdvisor.com SUBMIT A QUESTION FOR PUBLICATION • ClinicalAdvisor.com/AdvisorForum • editor@ClinicalAdvisor.com DO YOU HAVE A CLINICAL PEARL? Share your clinical pearl on a diagnosis or treatment tip with your colleagues.

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“Isn’t it great to get away from it all?”

EXCLUSIVE TO THE WEB AT

ClinicalAdvisor.com

NEWS ClinicalAdvisor.com/News

CDC: Measles Vaccine Needed Before Traveling

THE WAITING ROOM

Official Blog of The Clinical Advisor ClinicalAdvisor.com/WaitingRoom Sharon M. O’Brien, MPAS, PA-C When Prejudice Influences Patient Care Although clinicians must treat all patients, regardless of their illness or their past, circumstances may influence the emotional connection that a care provider establishes.

Individuals who are not vaccinated for measles before traveling internationally have an increased risk of contracting the disease, which spreads easily through coughing and sneezing, as well as bringing the disease back into the United States.

Improving Insulin Access: ADA Public Policy Recommendations The ADA’s recommendations include increasing transparency across the entire insulin supply chain and streamlining the approval process for biosimilar insulins.

CASE STUDY Clinical Advisor.com/CaseStudy George Marzouka, MD Cardiac Conditions of Rheumatoid Arthritis A 69-year-old man with no prior medical history presents during the course of several months with new-onset nonspecific joint pain and swelling without evidence of erosions. Read the full case here: ClinicalAdvisor.com/ CaseRheumatoidArthritis

UTI Guideline Implementation Improves Diagnoses in Postop Orthopedic Patients Implementing a urinary tract infection quality improvement program resulted in a decrease in UTI diagnoses among orthopedic patients.

Long-Term Antidepressant Use Linked to Weight Gain Widespread use of antidepressants may be contributing to a long-term increased risk of weight gain at the population level.

© GETTY IMAGES

Physician Assistant Students Report Discrimination, Abuse in PA Programs Physician assistant students report witnessing and experiencing discrimination or abuse throughout PA programs in the United States.

CONFERENCE COVERAGE ClinicalAdvisor.com/Meeting-Coverage AAPA 2018 Check out The Clinical Advisor’s coverage of AAPA 2018, which includes original research, case studies, and professional outreach and advocacy news from leading PAs in many specialty areas.

AANP 2018 The Clinical Advisor’s coverage of AANP 2018 includes the latest news and clinically relevant practice information from the nation’s leading nurse practitioners in a variety of therapeutic areas.

10 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

Advisor Dx Interact with your peers by viewing the images and offering your diagnosis and comments. To post your answer, obtain more clues, or view similar cases, visit ClinicalAdvisor.com/AdvisorDx. Learn more about diagnosing and treating these conditions, and see how you compare with your fellow colleagues.

Check out some of our latest cases below!

DERM DX

A lesion on the cheek from shaving The patient is an 84-year-old man requesting removal of a lesion on his cheek due to chronic irritation from shaving. The growth has been present for several months and is otherwise asymptomatic. He is a smoker and currently on antihypertensive and lipid-lowering medications, and he does not have a history of cancer.

CAN YOU DIAGNOSE THIS CONDITION?

• Trichilemmoma • Sebaceous carcinoma

• Verruca • Basal cell carcinoma

● See the full case at ClinicalAdvisor.com/DermDx_July18

ORTHO DX

In partnership with

TheJopa.org

Journal of Orthopedics for Physician Assistants

Toe pain in a runner A 35-year-old man complains of right great toe pain for several months. He is very active and enjoys running. On examination, he has pain and limited dorsiflexion of the first metatarsophalangeal (MTP) joint. Pain is felt with passive hyperdorsiflexion, but otherwise range of motion of the toe is nonpainful.

WHAT IS THE BEST TREATMENT OPTION?

• Cheilectomy • Cheilectomy and phalangeal osteotomy • Arthrodesis • Arthroplasty ● See the full case at ClinicalAdvisor.com/OrthoDx_July18

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 11

Newsline LYME NEUROBORRELIOSIS diagnosis has no substantial effect on longterm survival, health, or educational/ social functioning yet may be associated with an increased risk of hematologic and nonmelanoma skin cancers, according to a 30-year study published in the BMJ. Eligible participants were Danish residents who were diagnosed with Lyme neuroborreliosis between 1986 and 2016.

A total of 3,200 people were identified with a positive B burgdorferi intrathecal test. After exclusions, 2,067 patients and 20,670 members of the population comparison cohort remained in the study.

Mortality among patients with Lyme neuroborreliosis was not higher than in the general population (mortality rate ratio, 0.90). Lyme neuroborreliosis

patients had an increased risk of hematologic (incidence rate ratio, 3.07) and nonmelanoma skin cancers (1.49). At diagnosis, Lyme neuroborreliosis patients had slightly higher employment and lower disability pension rates.

After 5 years, patients and comparison cohort members had similar numbers of hospital contacts (difference −0.22, 95% confidence interval −0.45 to 0.02, in-hospital days/year; 0.37, −0.10 to 0.83, outpatient visits/year), employment rates (difference 1.5%, −2.1% to 5.1%), income (difference −1000, −20 000 to 18 000, Danish kroner), days of sick leave (difference −0.3, −3.5 to 3.0, per year), rates of receipt of a disability pension (difference −0.9%, −3.2% to 1.3%), and number of children (difference –0.10,

© DAVID M. PHILLIPS / SCIENCE SOURCE

Lyme neuroborreliosis: long-term survival outcomes

Color-enhanced TEM image of Borrelia burgdorferi, which causes Lyme disease.

−0.27 to 0.08). More patients were married (difference 4.8%, 2.2% to 7.4%) and had completed high school education (difference 7%, 1% to 12%).

“Compared with members of a general population cohort, mortality was not increased among Lyme neuroborreliosis patients,” the authors concluded.

Practice varies for NPs, PAs in US emergency departments GREAT VARIATION exists in emergency departments (EDs) across the United States with regard to scope of practice, expectations, team dynamics, and training requirements for physician assistants (PAs) and nurse practitioners (NPs), according to a study published in JAAPA. Participants were asked to provide responses with respect to their current primary clinical location. For the online survey, 208 of 371 registered councilors responded, yielding a 56.1% response rate. About 72% of respondents were male, and the mean age was 47.7 years.

About 51% of 327 respondents to the audience response system survey reported that they generally regarded PAs and NPs as subordinate in relation to attending physicians. Nearly 12% considered the relationship equivalent, 0.92% considered it similar to that of a medical student, 22.9% liked working with a resident, and 13.2% reported an unspecified relationship not described in the previously mentioned categories. In 30% of EDs, PAs and NPs see ESI level 1 patients (most urgent, requiring resuscitation). More than 90% of PAs and NPs see ESI levels 3 (urgent) to 5 (nonurgent) patients.

12 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

No statistically significant difference was found regarding type of provider (PA or NP) hired between different ED settings. Slightly more than 63% of councilors reported that their institutions hired PAs with less than 5 years’ experience and 58.1% reported hiring less-experienced NPs. The ED setting was not significantly associated with hiring less-experienced PAs (yes for 64.3% rural, 60.8% suburban, and 65.4% urban of 117 respondents), nor for less experienced NPs (yes for 71.4% rural, 54.9% suburban, and 57.7% urban of 117 respondents).

ECG not advised in low-risk CVD IN ASYMPTOMATIC adults at low risk for cardiovascular disease (CVD) events, the US Preventive Services Task Force (USPSTF) does not recommend screening with resting or exercise electrocardiography (ECG), according to a statement published in JAMA. The USPSTF stated that is “very unlikely” that information obtained from an ECG screening would result in a change in risk category as assessed by the Framingham Risk Score or Pooled Cohort Equations in adults with a low risk for CVD events (a 10-year CVD event risk <10%) that would lead to treatment changes or improvements in health outcomes.

The USPSTF also noted several potential harms that could result from unnecessary screening across all risk categories, such as radiation exposure from invasive

confirmatory testing, angiography, and revascularization.The latter 2 procedures are associated with bleeding, contrastinduced nephropathy, allergic reaction to the contrast agent, cardiac arrhythmia, stroke, myocardial infarction, coronary artery dissection, and death.

This recommendation is an update of the USPSTF’s 2012 recommendation statement, which advocated against ECG screening in adults with a low risk for coronary heart disease (D recommendation).A lack of evidence for recommending screening in intermediate- or high-risk adults was also noted at that time (I statement).

For other methods of CVD prevention, the USPSTF points to high blood pressure screening, smoking cessation counseling, and diet/exercise intervention, as well as low-dose aspirin in certain individuals at an increased risk for CVD events.

Alcohol consumption and CHD risk

© AROON PHUKEED / GETTY IMAGES

ALCOHOL CONSUMPTION is inversely linked to the risk of nonfatal coronary heart disease (CHD) but not to other cardiovascular events such as ischemic and hemorrhagic strokes, according to a study published in the BMJ. Participants included 32,549 volunteers without baseline CVD (ages 35-70; 52% women). The investigators reported 9307 nonfatal CHD events, 1699 fatal CHD events, 5855 nonfatal strokes, and 733

fatal strokes.The consumption of alcohol at baseline was inversely correlated with nonfatal CHD (hazard ratio [HR], 0.94 per 12 g/day higher intake).

Hazard ratios for total alcohol intake of 5.0 to 14.9 g/day, 15.0 to 29.9 g/day, and 30.0 to 59.9 g/day were 0.83, 0.65, and 0.82, respectively, compared with 0.1 to 4.9 g/day.

At baseline, nonfatal and fatal stroke risks (HR, 1.04 and 1.05) had similar results as ischemic and hemorrhagic strokes for alcohol consumption of 12 g/day.

“Alcohol intake was inversely associated with non-fatal CHD risk but positively associated with the risk of different stroke subtypes,” wrote the authors.“This highlights the opposing associations of alcohol intake with different CVD types and strengthens the evidence for policies to reduce alcohol consumption.”

Hand grip strength and all-cause mortality GRIP STRENGTH is strongly and inversely associated with all-cause mortality and incidence of and mortality from cardiovascular disease, respiratory disease, chronic obstructive pulmonary disease (COPD), all cancer, and subtypes of cancer, with associations being modestly stronger in the younger age groups, according to a study published in the BMJ. Of the 502,293 participants included in the analysis, 28,059 (5.6%) participants developed cardiovascular disease, 10,542 (2.1%) developed respiratory disease, and 27,704 (5.5%) developed cancer. In addition, 13,322 (2.7%) participants died: 3,033 (0.6%) from cardiovascular disease, 2,062 (0.4%) from respiratory disease, and 5,738 (1.1%) from cancer.

In women and men, respectively, hazard ratios per 5-kg lower grip strength were higher for all-cause mortality (1.20 and 1.16) and cause-specific mortality from cardiovascular disease (1.19 and 1.22), all respiratory disease (1.31 and 1.24), COPD (1.24 and 1.19), all cancer (1.17 and 1.10), colorectal cancer (1.17 and 1.18), lung cancer (1.17 and 1.08), and breast cancer (1.24) but not prostate cancer (1.05).

Muscle weakness (defined as grip strength <26 kg for men and <16 kg for women) was associated with a higher hazard for all health outcomes, except colon cancer in women and prostate cancer and lung cancer in both men and women. The addition of handgrip strength improved the prediction ability of an office-based risk score for all-cause (0.013) and cardiovascular mortality (0.012) and incidence of cardiovascular disease (0.009). ■

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 13

FEATURE: JESSICA DURBIN, DNP, FNP-BC, CRISTINA R. DENAPOLES, MSN, FNP, HAYLEY LUNDEEN, MSN, FNP

Social media and adolescents: What are the health risks?

Primary care providers should screen for depression and other healthrelated risks associated with the use of social media by adolescents.

The Internet has had a tremendous impact on health care during the past two decades. As part of The Clinical Advisor’s 20th Anniversary, this article explores the effects of social media use on adolescents, who may be at risk for depression, anxiety, and cyberbullying with increased use of social media sites.

© WESTEND61 / GETTY IMAGES

S

Clinicians can help reduce the potential negative effects of social media use.

ocial media use has become increasingly popular among teens and adolescents during the past decade.Technologic advancements have led to an increase in Internet use and virtual communication through computers, cellphones, and tablets. The prevalence of social media use is leading to an increased understanding of the risks associated with it.1 According to Lenhart, about 92% of teens state that they use the Internet daily, and 71% use at least two different types of social media sites.2 Social media sites can be defined as online communities that allow an individual to create a profile in which they can view and communicate with others. Examples of social media sites include Facebook, Instagram,Twitter, Myspace, and Snapchat.3 With the increased use of social media, parents worry that their children are spending too much time on social media and are having less interaction with school and family.3 Overuse of social media can have negative consequences on the well-being of adolescents. Social media use has been linked to lower self-esteem, increased depression, risk-taking behavior, and cyberbullying.4 According to Bhagat,5 social media use is

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 19

SOCIAL MEDIA AND ADOLESCENTS: WHAT ARE THE HEALTH RISKS?

Social media use may be associated with psychosocial problems and can be even worse in those predisposed to depression and anxiety. associated with psychosocial problems and can be even worse for an individual who is already predisposed to depression, anxiety, or mental illness.

The use of social media continues to increase among adolescents, who may not be aware of what it exposes them to or the influence it may have on their well-being/self-esteem.4 The purpose of this systematic review is to explore the recent literature and research on how the use of social media affects the well-being/self-esteem of adolescents.

Social media: a literature search

A literature search for studies was conducted using online databases: CINAHL, ERIC, and PsychInfo. Search terms used in multiple combinations included: social media, social network, adolescents, youth, well-being, self-esteem, mental health, depression, and cyberbullying. All articles included in the search reflected the population of adolescents and the intervention of social media/social networking. Studies that encompassed the effects of social media on the well-being/ self-esteem of adolescents were included. Well-being/selfesteem was measured by accounts of depression, cyberbullying, self-esteem, anxiety, sleep quality, and body image.

The literature search yielded 236 results.The search was further narrowed to include only high-evidence, peer-reviewed articles published in English, limited to the adolescent age group of 13 to 18 years. All articles from 2012 to present were included, and all articles that identified college students were excluded, yielding 133 results. The abstracts of these articles were reviewed to identify relevant research studies and systematic reviews, which resulted in 7 articles that are presented in this review.

Evidenced-based findings

A systematic review of literature on social media and the health of young people was conducted by Richards and colleagues.4 The purpose of the study was to seek an understanding of the potential impact that social media may have on the health of young people.The results of the review concluded that social media had the greatest health impact on self-esteem, well-being, and body image, with related issues regarding cyberbullying and “Facebook depression.”4 Pantic6 conducted a systematic review on social networking and mental health from research published between 2004 and 2014.The purpose of the review was to determine if there was a connection between social networking use in adolescents and mental health issues such as depression and low self-esteem.The

results of the review concluded that the relationship between social networking use and depressive symptoms and self-esteem is inconclusive. Several studies indicated that signs and symptoms of depression may be related to prolonged use of social network sites, such as Facebook, and low self-esteem may be associated with certain social networking activities. Other studies presented a more positive effect on self-esteem with social networking use.6 Blomfield Neira and Barber7 conducted a survey of 1,819 high school students in Western Australia on their use of social network sites. The authors sought to determine if there was an association between the use of social networking sites and social self-concept, self-esteem, and depressed mood. The students responded to questions on their social network use, frequency, and investment, as well as to questions on social self-concept, self-esteem, and depressed mood. The study concluded that having a social networking profile was correlated with a higher social self-concept. However, the study also concluded that lower self-esteem and a higher depressed mood were associated with an investment in social networking sites (Blomfield Neira and Barber).7 A 2016 survey study of 467 Scottish students, aged 11 to 17, was conducted by Woods and Scott.8 The study’s purpose was to examine how social media use relates to an adolescent’s anxiety and depression, low self-esteem, and poor sleep quality. The survey was used to measure overall social media use, anxiety and depression, self-esteem, sleep quality, and emotional investment in social media.The items were assessed using the Pittsburgh Sleep Quality Index (PSQI), the Hospital Anxiety and Depression Scale (HADS), the Rosenberg Self-Esteem Scale (RSES), and a modified Social Integration and Emotional Connections subscale of the Social Media Use Integration Scale.

The study concluded that overall social media use, emotional investment in social media, and nighttime-specific social media use were associated with higher levels of anxiety and depression, lower self-esteem, and poorer sleep quality in adolescents.8 A descriptive study using a relational survey design was conducted by Kiracaburun9 of 1,130 participants aged 12 to 18 who were attending schools in the Aegean region (2016).

The authors sought to examine the relationship between depression, self-esteem, daily internet use, and social media addiction. Data from the participants were collected using the Children’s Depression Inventory (CDI) tool, the Rosenberg Self-Esteem Scale (RSES), daily Internet use, and Social Media Addiction Scale. Data were then analyzed using the structural equation model, descriptive statistics, and Pearson

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SOCIAL MEDIA AND ADOLESCENTS: WHAT ARE THE HEALTH RISKS?

correlation.The study demonstrated significant relationships between self-esteem, depression, social media addiction, and daily internet use. Self-esteem and depression were associated with each other, and both caused an increase in daily internet use, while social media positively affected depression levels in an indirect way. An increased risk was observed for depression in adolescents who spend a greater amount of time on social media. In conclusion, depression can be predicted by social media addiction, self-esteem, and daily Internet use in adolescents. It can be concluded that adolescents who have low self-esteem gravitate to the cyber world for interactions.

This allows them to act anonymously and say and do what they please, while avoiding real world interactions.9 An observational, population-based, cross-sectional study was conducted by Pantic et al10 of 160 high school participants from Central Serbia. The purpose of the study was to determine the relationship between social networking and depression indicators in the adolescent population. Participants were asked questions from a structured questionnaire, as well as the Beck Depression Inventory, second edition (BDI-II-II).

Statistical analysis and descriptive statistics were used after the data were collected. The results showed a statistically significant correlation between the amount of time that students reported using social networking and scores on the BDI-II-II, indicating that social networking in adolescents is related to depression. The depression score increased as the amount of time reported using social media increased.10 In 2016, a survey study was conducted by Chapin11 of 1488 adolescents. The purpose was to document adolescent experience with cyberbullying in relationships on Facebook.

Participants answered questions related to Facebook use and experience with cyberbullying using a Likert-type scale.The information was applied to the Precaution Adoption Process Model (PAPM) to understand how adolescents use safety to secure their social media worlds and to understand their lack of precaution.The study documented that 84% of the population used Facebook daily, and 30% of the participants stated that they were cyberbullied. Of the 30% who were cyberbullied, 12.5% ceased use of the social media site, while 18% reported the cyberbullying to a parent. In conclusion, cyberbullying may be a consequence of Facebook use, and most adolescents are aware of the problem but have not intervened. In addition, adolescents still maintained the belief that they would not be cyberbullied when compared with their peers.

Summary

A search of the literature shows that studies have highlighted the points that social media use is correlated with decreased self-esteem and depression, with a positive correlation as time spent on social media increases.9 The findings from Pantic et al10

are in agreement, as they found that depression in adolescents increases as the amount of time spent on social media increases.

The survey findings from Blomfield Neira and Barber7 also indicated that adolescents invested in social media are more likely to have lower self-esteem and a higher depressed mood.

Nighttime-specific social media use and emotional investment in social media have been found to be associated with lower self-esteem, poorer sleep quality, and higher levels of anxiety and depression.8 Social media can have a negative health impact on the self-esteem and body image of youth.4 Additionally, social media can have an impact on adolescents through cyberbullying, which can have a detrimental effect on youth.11 Limitations and strengths

The study conducted by Kiracaburn9 was well done and provides valuable information about social media use.The study had a well-defined target population, as well as a large sample size. These features are important because they yield results specific to the target population, prevent error, and control bias.12 The 2016 study was up-to-date and did not note any biases. In addition, the study used evidenced-based tools to collect data, including the Children’s Depression Inventory, the Social Media Addiction Scale, and the Rosenberg Self-Esteem Scale. Limitations included that it was a foreign study and included participants from a single city in the Aegean region.

It may have been more beneficial to use samples from various cities and even more beneficial to have participants from the United States to get a better representation of US adolescents.

Also, as the study used self-reports and quantitative scales, it may have been beneficial to use more detailed, qualitative instruments to provide further evidence.9 The study conducted by Pantic et al10 yielded statistically significant results that concluded that depression could be correlated to the time spent on social media sites in the adolescent population. Statistically significant results strengthen a study’s findings because they mean that the results have a low probability that they occur due to chance.12 Confounding factors were taken into account to test the causal relationship between depression and time spent on social media.The study used a valid instrument, the BDI-II-II for depression screening. In addition, the study was up-to-date, conducted in 2012, and did not mention any biases that were encountered. Limitations included a small sample size.The smaller the sample size, the lower the chance of having an accurate representation of the population of interest.12 The study also used foreign participants from Central Serbia. Although, the study did take into account confounding factors, factors of socioeconomic status and physical activity were not considered.10 The strengths of the study conducted by Chapin11 include a large sample size that represented the adolescent population.

22 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

TABLE 1. Popular social media platforms Social Media Platform

Description

Usage demographics

Facebook

Facebook can be accessed from a large range of devices with Internet connectivity, such as desktop computers, laptops and tablet computers, and smartphones. After registering, users can create a customized profile indicating their name, occupation, schools attended, etc. Users can add other users as “friends,” exchange messages, post status updates, share photos, videos, and links, use various software applications (“apps”), and receive notifications of other users’ activity. Additionally, users may join common-interest user groups organized by workplace, school, hobbies, or other topics, and categorize their friends into lists such as “People From Work” or “Close Friends.”

Additionally, users can report or block unpleasant people.

Facebook has more than 2.2 billion monthly active users as of January 2018.

Reddit

Reddit is an American social news aggregation, web content rating, and discussion website. Registered members submit content to the site such as links, text posts, and images, which are then voted up or down by other members. Posts are organized by subject into user-created boards called “subreddits,” which cover a variety of topics, including news, science, movies, video games, music, books, fitness, food, and imagesharing. Submissions with more up-votes appear toward the top of their subreddit and, if they receive enough votes, ultimately on the site’s front page. Despite strict rules prohibiting harassment, Reddit’s administrators spend considerable resources on moderating the site

As of February 2018, Reddit had 542 million monthly visitors (234 million unique users), ranking as the #3 most visited website in US and #6 in the world, according to Alexa Internet, with 57.4% of its user base coming from the United States, followed by the United Kingdom at 7.5% and Canada at 6.3%. In 2015, Reddit had 82.54 billion page views, 73.15 million submissions, 725.85 million comments, and 6.89 billion up-votes from its users

Pinterest

Pinterest is a web and mobile application company that operates a software system designed to discover information on the World Wide Web, mainly using images and on a shorter scale, GIFs, and videos

Pinterest has reached 200 million monthly active users.

Instagram

The app allows users to upload photos and videos to the service, which can be edited with various filters, and organized with tags and location information. An account’s posts can be shared publicly or with pre-approved followers. Users can browse other users’ content by tags and locations, and view trending content. Users can “like” photos and follow other users to add their content to a feed

In January 2018, Instagram Direct had 800 million users.

Twitter

Twitter is an online news and social networking service on which users post and interact with messages known as “tweets.” Tweets were originally restricted to 140 characters, but on November 7, 2017, this limit was doubled for all languages except Japanese, Korean, and Chinese. Registered users can post tweets, but those who are unregistered can only read them. Users access Twitter through its website interface, through Short Message Service (SMS) or mobile-device application software

Active US Twitter users in the first quarter of 2018: 69 million

Snapchat

Snapchat is a multimedia messaging app used globally.

One of the principal concepts of Snapchat is that pictures and messages are only available for a short time before they become inaccessible. The app has evolved from originally focusing on person-to-person photo sharing to presently featuring “Stories” of 24-hour chronologic content, along with “Discover” to let brands show ad-supported short-form entertainment. Snapchat has become notable for representing a new, mobile-first direction for social media and places significant emphasis on users interacting with virtual stickers and augmented reality objects.

As of February 2018, Snapchat has 187 million daily active users.

YouTube

YouTube allows users to upload, view, rate, share, add to favorites, report, comment on videos, and subscribe to other users. It offers a wide variety of user-generated and corporate media videos. Available content includes video clips,TV show clips, music videos, short and documentary films, audio recordings, movie trailers, live streams, and other content such as video blogging, short original videos, and educational videos. Most of the content on YouTube is uploaded by individuals, but media corporations including CBS, the BBC, Vevo, and Hulu offer some of their material via YouTube as part of the YouTube partnership program. Unregistered users can only watch videos on the site, while registered users are permitted to upload an unlimited number of videos and add comments to videos.Videos deemed potentially inappropriate are available only to registered users affirming themselves to be at least 18 years old.

There are more than 400 hours of content uploaded to YouTube each minute, and one billion hours of content are watched on YouTube every day. The website is ranked as the second-most popular site in the world by Alexa Internet, a web traffic analysis company.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 23

SOCIAL MEDIA AND ADOLESCENTS: WHAT ARE THE HEALTH RISKS?

POLL POSITION Which of the following statements about social media use do you most agree with?

■ I frequently discuss this issue with my patients.

25.16%

30.19%

■ I discuss this issue with my patients on occasion.

■ I have yet to discuss this issue with my patients.

44.65%

For more polls, visit ClinicalAdvisor.com/Polls.

The study also used a valid instrument, PAPM. This instrument was applied to the adolescent population and used to test cyberbullying.The study was up-to-date and conducted in 2016, and it did not mention any biases that were encountered during the study’s conduction. Limitations included a sample that was limited to Pennsylvania adolescents who participated in particular antiviolence programs. In addition, the participants were aware of the topic of the study, which could have skewed the results.11 Richards and colleagues identified a negative impact on self-esteem, well-being, and body image in adolescents with the use of social media.4 The strengths of their systematic review included the use of relevant studies on the impact of social media and the targeted youth population. There was no evidence of bias in the review. A limitation of the review was the range of social media tools included in the studies.

Many studies included the social media sites Facebook and MySpace. However, the social media sites popular to adolescents such as Instagram, Pinterest,Twitter, Snapchat, Linkedin, and Google+ were not popular or even developed at the time that the studies were conducted.4 The strengths of the systematic review conducted by Pantic include a concise review on recent research, suggesting a relationship between social networking use and psychiatric disorders.6 The review of studies indicates that prolonged social networking use may be associated with depression and low self-esteem.6 There was no evidence of bias in the conducted review. One limitation of the review is that not all social networking sites are the same. Most of the studies focused on Facebook as the most widely used social networking site.

Facebook is based on creating profiles and uploading comments, photos, and videos. Twitter is based on user posting and reading short “tweets.”6 The survey study conducted by Blomfield Neira and Barber7 yielded statistically significant results on the use of social media associated with a lower self-esteem and a higher depressed mood in adolescents. Strengths include a large sample size of high school students and the use of statistical methods and tools to test reliability, relationship, and significance.To measure reliability of the Likert scale, the Cronbach’s alpha was used.

Pearson’s correlation was conducted to measure the strength of the relationship between having a social network profile, social network frequency, and social network adjustment and the indicators of adjustment, which include self-esteem, selfconcept, and depressed mood. Analysis of variance (ANOVAs) was conducted to examine the relationship between having a social networking profile and the effect on self-esteem, self-concept, and depressed mood. To test if frequency and investment in social networking is linked to self-esteem, selfconcept, and depressed mood, the hierarchical regression was conducted.7 The researchers did not mention any biases that were encountered during the study. One limitation was that the researchers did not establish causality; youth with lower self-esteem and depression could be more prone to invest in social networking than their peers. Another limitation was that the study only included adolescents from Western Australia.7 The survey study conducted by Woods and Scott8 concluded that overall social media use, emotional investment, and nighttime-specific social media use were associated with higher levels of anxiety and depression, lower self-esteem, and poorer sleep quality. Strengths of the study include a large sample size, well-defined target population, and up-todate information that was gathered in 2016. In addition, the study used evidence-based tools to measure data, including the Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale, the Rosenberg Self-esteem Scale, and the Social Integration and Emotional Connection subscale of the Social Media Use Integration Scale. The researchers did not mention any biases in the study. One limitation was the potential language barrier and the level of literacy. Many participants did not speak English as their primary language, and some had poor literacy. Poor understanding of questions from certain participants may have resulted in less accurate data.8 There was a risk for social desirability bias in the study, especially on reporting measures of mood and self-esteem, due to the language support that was given to some participants.8 Implications of social media use

The findings from this literature review have practical value for healthcare providers, parents, and teachers who care for

24 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

the adolescent population.An important role for primary care providers, parents, and teachers includes becoming familiar with the different types of social media outlets and the use of these sites, as well as the length of time spent using social media by the adolescent population they care for. Some of the most popular social media websites for adolescents include Facebook, Snapchat, Twitter, and Instagram. These sites are outlets for adolescents to send and receive different information about themselves to friends as well as strangers.

Providers, parents, and teachers should be aware that profiles on these sites are open for the public to see unless there is a privacy setting that is manually chosen. Another important role for providers is to include routine screenings to assess the risk of depression associated with social media use.Tools could be developed to help providers engage in conversations that inquire about online contacts, incidence of being cyberbullied, and assessing the time that adolescents spend on social media.

3. Oberst U, Wegmann E, Stodt B, Brand M, Chamarro A. Negative consequences from heavy social networking in adolescents: The mediating role of fear of missing out. J Adolesc. 2017;55:51-60. doi: 10.1016/j. adolescence.2016.12.008 4. Richards D, Caldwell PH, Go H. Impact of social media on the health of children and young people. J Paediatr Child Health. 2015;51:1152-1157. doi: 10.1111/jpc.13023 5. Bhagat S. Is Facebook a planet of lonely individuals? A review of literature.

Int J Indian Psychol. 2015;3:5-9.

6. Pantic I. Online social networking and mental health. Cyberpsychol Behav Soc Netw. 2014;17:652-657.

7. Blomfield Neira CJ, Barber BL. Social networking site use: linked to adolescents’ social self-concept, self-esteem, and depressed mood. Austral J Psychol. 2014;66:56-64.

8. Woods HC, Scott H. #Sleepyteens: social media use in adolescence is associated with poor sleep quality, anxiety, depression, and low self-esteem.

J Adolesc. 2016;51:41-49.

9. Kircaburun K. Self-esteem, daily internet use and social media addiction as predictors of depression among Turkish adolescents. J Educ Pract.

Conclusion

2016;7:64-72.

10. Pantic I, Damjanovic A, Todorovic J, et al. Association between online social networking and depression in high school students: behavioral physiology viewpoint. Psychiatr Danub. 2012;24:90-93.

11. Chapin J. Adolescents and cyber bullying: The precaution adoption process model. Educ Info Technol. 2016;21:719-728.

12. Brown SJ. Evidenced-Based Nursing: The Research-Practice Connection. 3rd ed.

Burlington, MA: Jones & Bartlett Learning, LLC; 2014.

Jessica Durbin, DNP, FNP-BC, Cristina R. DeNapoles, MSN, FNP, and Hayley Lundeen, MSN, FNP, are affiliated with the Department of Advanced Practice Nursing, College of Health and Human Services, Indiana State University, in Terre Haute.

References 1. American Academy of Child & Adolescent Psychiatry. Facts for families: children and social networking. November 2011. Retrieved from: http://www. aacap.org/App_Themes/AACAP/docs/facts_for_families/100_children_and_ social_networking.pdf 2. Lenhart A. Teens, social media & technology overview 2015. Pew Research Center. Retrieved from: http://www.pewinternet.org/2015/04/09/ teens-social-media-technology-2015/

“It’s been a wonderfully buggy summer, hasn’t it?”

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 25

© The New Yorker Collection 2018 from cartoonbank.com. All Rights Reserved.

The use of social media can have negative consequences on the adolescent population. It is important for healthcare providers, parents, teachers, and the adolescent population to be aware of these effects and to take precautions to prevent depression, decreased self-esteem, and acts of cyberbullying.

When precautions and screening are in place, there is a better chance of combating the negative effects of social media.

Further research is needed to identify adolescents who have a higher risk for negative consequences of social media and to provide strategies that will allow them to avoid or manage those risks. Additional research could also focus on the amount of time that adolescents are invested in their social networking and focus less on how they are using their social networking sites. In addition, further guidance is needed for healthcare providers and parents on the appropriate social media use with adolescents. ■

Stat Consult

A quick review of common conditions, using the best global evidence

Description

Chronic low back pain

• Chronic low back pain (LBP) defined as persistent or fluctuating musculoskeletal pain of lower back and lumbar spine lasting >3 months Incidence/prevalence

• 10.2% in United States in 2006 • 13th most common diagnosis in family physician visits Possible risk factors

ALAN DRABKIN, MD

Dr Drabkin is a senior clinical writer for DynaMed (www.ebscohost. com/dynamed), a database of comprehensive updated summaries covering more than 3,200 clinical topics, and assistant clinical professor of population medicine at Harvard Medical School.

• psychosocial factors (not mechanical factors) may be associated with LBP in children • overweight/obesity • cigarette smoking Factors not associated with increased risk

• epidural anesthesia • occupational factors (such as manual handling or patient-assisting, lifting, pushing, pulling) • insufficient evidence to support — bending or twisting — standing or walking Associated conditions

• impaired health-related quality of life in children • trochanteric bursitis • sleep disturbances

© BSIP / SCIENCE SOURCE

Causes

Cauda equina syndrome.

Radiograph of the pelvis, frontal view.

26 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

• cauda equina syndrome • specific mechanical causes — low back DJD — herniated disk — spinal stenosis — vertebral fracture — spondylolysis — spondylolisthesis — scoliosis • nonmechanical spinal conditions — cancer — infection (such as osteomyelitis, paraspinous abscess) — inflammatory arthritis ( such as ankylosing spondylitis)

——Crohn disease or ulcerative colitis ——Paget disease ——Scheuermann disease (osteochondrosis) • visceral disease (nonspinal disease with referred pain) ——pelvic organ disease ——renal disease ——aortic aneurysm ——shingles ——gastrointestinal disease • in children, chronic LBP often does not have definitive diagnosis History

• chief concern (CC) ——LBP • history of present illness (HPI) ——duration > 3 months for chronic LBP ——red flag findings may indicate serious SPECIFIC causes of chronic LBP and include ■■ age >50 years ■■ fever ■■ chills ■■ recent UTI or skin infection ■■ significant trauma ■■ unrelenting night pain ■■ pain at rest ■■ progressive motor or sensory deficit ■■ saddle anesthesia ■■ bilateral sciatica or leg weakness ■■ difficulty urinating ■■ fecal incontinence ■■ unexplained weight loss ■■ history or strong suspicion of cancer ■■ history of osteoporosis ■■ immunosuppression ■■ chronic oral steroid use ■■ IV drug use ■■ substance abuse ■■ failure to improve after 6 weeks conservative therapy • past medical history (PMH) ——ask about previous problems with back pain ——ask about depression and previous treatment success or failures • social history (SH) ——ask about substances abuse and disability compensation • review of systems (ROS) ——ask about ■■ unexplained fevers ■■ weight loss ■■ morning stiffness

■■ ■■ ■■ ■■

gynecologic symptoms urinary problems gastrointestinal problems psychological symptoms

Physical

• neurology ——straight leg raise exam ■■ positive test is pain with leg fully extended at knee and flexed at hip between 30 and 70 degrees ■■ may detect lumbar disk herniation »» contralateral pain more specific for detecting herniation »» ipsilateral pain more sensitive for ruling out herniation) ——focused neuromuscular exam may help identify involved nerve roots Making the diagnosis

• American College of Physicians/American Pain Society (ACP/ APS) joint guideline recommendations on diagnosis of LBP ——conduct focused history (including psychosocial risk factors) and physical exam to categorize LBP ■■ nonspecific LBP (excluding pathology of specific cause) ■■ back pain potentially associated with radiculopathy or spinal stenosis ■■ back pain potentially associated with another specific spinal cause Testing

• ACP/APS joint guideline recommendations ——do not routinely obtain imaging studies or other diagnostic tests in patients with nonspecific LBP ——perform diagnostic imaging (preferably with MRI) and testing for patients with LBP if severe or progressive neurologic deficits or serious underlying conditions suspected ——radiograph ■■ consider if risk factor for cancer without signs of spinal cord compression ■■ delaying imaging for 1 month may be reasonable if age > 50 years is only risk factor ——evaluate patients with persistent LBP and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or computed tomography ONLY if they are potential candidates for ■■ surgery ■■ epidural steroid injection (for suspected radiculopathy) • testing to consider if “red flags” may also include ——CBC ——ESR ——C-reactive protein

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 27

Stat Consult ——urinalysis if UTI suspected ——calcium and alkaline phosphatase if metabolic bone disorder suspected

——radiofrequency denervation ——spinal cord stimulation Consultation and referral

Treatment

• noninvasive therapies with efficacy for chronic LBP include ——brief educational interventions, typically with advice to remain active ——exercise therapy ——spinal manipulation ——CBT (recommended by most guidelines as secondline therapy) ——massage therapy ——percutaneous nerve stimulation (PENS) ——acupuncture ——spa therapy • oral pharmacologic treatments ——acetaminophen suggested as first-line therapy but insufficient evidence to determine efficacy ——nonsteroidal anti-inflammatory drugs (NSAIDs) recommended in most guidelines and may reduce pain in chronic LBP ——opioids ■■ may have short-term efficacy in chronic LBP but associated with adverse effects ■■ long-term efficacy data lacking ■■ weak opioids typically recommended in patients unresponsive to other therapies ——benzodiazepines (risk of adverse effects unclear) ——nonbenzodiazepine muscle relaxants have insufficient evidence ——antidepressants ■■ duloxetine (magnitude of benefit unclear) ■■ other antidepressants (including tricyclic antidepressants and SSRIs) may not reduce pain in patients with nonspecific LBP ——some herbal medicines (Devil’s claw, white willow bark, topical capsaicin) appear effective in short-term trials • epidural steroid injections may provide short-term pain relief in patients with both ——lumbosacral radicular pain or neurogenic claudication ——imaging-confirmed nerve root involvement • epidural nonsteroid injections ——may have higher positive response rate than nonepidural injection in adults with back or neck pain • limited evidence to support any surgical or destructive procedure for treatment of chronic LBP including ——spinal fusion surgery ——disk replacement surgery

• refer to behavioral specialist and/or physical therapy for nonpharmacologic treatment modalities • consider referral for epidural steroid injection in patients with radicular symptoms • consider surgery referral in patients with ——significant functional disabilities ——pain lasting > 1 year not responding to multiple nonsurgical treatments ——pain consistent with an anatomic abnormality • referral to pain management may be appropriate for patients with severe functional impairment and uncontrolled pain Prognosis

• back pain appears to improve in first 6 weeks, moderate pain may persist with little difference at 1 year • about 35% of patients with chronic LBP may be pain-free at 9 to 12 months • many treatments for nonspecific LBP may have small analgesic effect • psychosocial “yellow flag” findings predicting poor prognosis/long-term disability include ——anxiety ——depression ——feelings of uselessness ——irritability ——poor coping strategies ——pain-interrupted sleep ——history of sexual or physical abuse ——history of substance abuse ——inadequate social support ——older age ——overprotective environment ——occupational factors (such as expectation that pain will increase with work, pending litigation, problems with worker’s compensation claims Prevention

• addition of daily exercise to education may prevent LBP in children • no clear evidence of benefit for ——back belts or lumbar supports ——early behavioral intervention ——shoe insoles ——worksite back pain prevention program ■

28 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

Writers’ Guidelines The Clinical Advisor welcomes submissions from its readers. Writing for us is an opportunity to share your knowledge and experience with your colleagues — and to collect a fee in the bargain! We pay an honorarium for every submission we accept.

We’ll be glad to work with you to develop your ideas into compelling articles. As for length, that depends on which kind of article you submit.

CLINICAL FEATURES update our readers on the latest information about conditions seen in everyday practice. Running approximately 2,500 to 5,000 words, including the references, features can be written either as regular narratives or as a series of questions and answers. Topics should be selected with the busy primary-care clinician in mind; specialists should review specialty topics from the primary-care point of view.

If at all possible, articles should be accompanied by clinical photos.

Charts, tables, and algorithms are also encouraged. Please include your title and affiliation.

CLINICAL CHALLENGE is our popular department comprising histories of difficult cases. Each case is presented as a step-by-step, chronological account, revealing the author’s thought processes along the way. It is divided into sections in this order: the patient presentation; the patient history; the twists and turns eventually leading to a diagnosis; the treatment and outcome; and a discussion of the lessons learned or of the condition in general.

The length should be about 1,500 words, and accompanying images are encouraged. Please include your title and affiliation.

Dermatology Clinic CASE #1

Fingernail dystrophy in a young child SIMO HUANG, BS, CHRISTOPHER RIZK, MD

The patient is a 12-year-old Hispanic girl who presents with a 6-month history of nail dystrophy involving all of her fingernails. On examination, all 10 of her fingernails exhibit longitudinal ridging, pitting, fragility, thinning, and distal notching. The patient’s mother is very concerned about the cosmesis of her daughter’s nails. The patient has no systemic symptoms. On review of systems, the patient’s mother noted that her daughter has started to develop circular patches of hair loss that appear to resolve on their own. The patient has no relevant social or family history and does not take any medications.

What is your diagnosis? Turn to page 54

CASE #2

Headache, malaise, and a rash ZACHARY SOLOMON, BS, DAVID RIZK, BA, CONNIE WANG, MD

A 42-year-old man presents with a four-day history of experiencing headache, malaise, and stabbing right-sided headache. Two days after his initial symptoms appeared, he developed a rash over the area of pain. He reports that he went hiking through the Texas hill country prior to becoming ill. The patient is otherwise in good health and has an unremarkable medical history. Physical examination reveals unilateral erythematous, thin, raised plaques over the right forehead. In addition, he has no relevant social or family history.

What is your diagnosis? Turn to page 55 www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • DECEMBER 2017 53

DERMATOLOGY CLINIC is a department that presents photos of actual cases and asks readers to identify the condition. Each case opens with one or two color photos and a 75-to-100-word description of the patient presentation, without giving away the diagnosis.

This is followed by a 750-to-1,000-word summary that includes a fuller description of the ailment, an explanation of how the correct diagnosis was reached, a general review of the condition along with a differential diagnosis, and a description of the patient’s treatment and outcome. Topics must be approved by the editor prior to submission. Please include your title and affiliation.

COMMENTARY is our guest editorial page. It gives you the opportunity to sound off on an issue of importance to your colleagues nationwide. A typical Commentary runs about 600 words in length. Please include your title and affiliation.

To discuss your editorial ideas, contact us by phone at 646.638.6078; by e-mail to editor@ClinicalAdvisor.com; or by mail to The Clinical Advisor, 275 7th Avenue, 10th Floor, New York, NY 10001. www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 29

FEATURE: MARGARET QUINN, DNP, CPNP, CNE

Internet “challenges” and teenagers: a guide for primary care providers Discussions involving Internet challenges with children and adolescents should be as sensitive as those about sexuality and drug or alcohol use.

The age of social media has led to Internet challenges, which involve users video recording themselves taking sometimes dangerous dares that can have serious health consequences.As part of The Clinical Advisor’s 20th Anniversary, this article summarizes popular Internet challenges for clinicians to be aware of.

© KYLETPERRY / GETTY IMAGES

R

Ingesting or inhaling laundry pods can lead to vomiting, seizures, and even death.

30 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

ecent news stories have brought attention to the Tide pod challenge. Teenagers are ingesting laundry pods, which can cause severe burns to the mouth, respiratory tract, or esophagus, vomiting, diarrhea, and seizure, and can lead to death.1 In 2017, more than 10,500 calls to US poison control centers were made due to ingestion of laundry pods in children younger than 5 years of age. In the first month of 2018, there were 86 cases of adolescents ingesting a pod, a significant increase from the 53 reported cases among adolescents in 2017.2 The Tide pod challenge is not unique to social media influences affecting teenagers. Social media, online videos, and the Internet are a major influence on this generation. Platforms such as chat rooms, blogging web sites (ie, BlogSpot), video sites (ie, YouTube), social networking sites (ie, Facebook, Twitter, Google+), and picture sites (ie, Snap chat, Instagram) have changed communication by allowing an interactive sharing of information.3 Social media can be very useful to explore trends, but it can also lead to copycats without moral concerns and social warnings.4 This presents numerous challenges for parents, including the norm of social

right-hand column like this one does at the top

media being a part of their teen’s life. It allows for communication between friends, but it can also lead to cyberbullying and at-risk behaviors such as selfies and sexting, as well as learning and repeating the numerous Internet “challenges.”5 A primary concern with suicide or self-harm videos is that they may normalize and reinforce self-injurious behaviors or cause disinhibition.6 An Internet challenge is a cultural phenomenon defined as “Internet users recording themselves taking a challenge and then distributing the resulting video through social media sites, often inspiring or daring others to repeat the challenge.”3 Due to these online influences and seeking attention by “liking” a behavior with global encouragement, there are no boundaries or limits to whom you can reach. Many challenges are from prior years, but with the immortalization of the Internet, these challenges tend to resurface with each season and varied cohorts of teens.

Acceptance in school and within peer groups is paramount, regardless of the choices or risk of injury, and the acceptance and attempt of the challenge can have grave consequences.

There is actually scientific reasoning within the developing teenage brain that causes the teen to accept and perform these challenges. The teen brain is programmed to seek out new and pleasurable experiences that help the brain learn, but they have not yet developed the tools to make rational decisions or choices.4 Dopamine, the pleasure-seeking hormone, is increased during adolescence.This causes adolescents to seek acceptance as a pleasurable experience to feel good. Rewards can include money, food, sex, and within an Internet-influenced environment may include sharing of the video or posting, known as “retweets,” “followers,” and “likes.”7 A 2011 American Academy of Pediatrics statement relevant to social media encouraged all pediatric primary care providers to “increase their knowledge of digital technology to have a more educated frame of reference of the tools their patients and families are using and providing timely and relevant anticipatory media guidance as well as diagnosing media-related issues should they arise.”8 Accurate history taking and complete physical assessments are routine in our everyday care of patients. But what happens when the providers are not abreast of current “challenges” that can mimic other diagnosis? Primary care providers must identify correct diagnosis and treatments plans for these patients.This article will describe some of the current online “challenges” and risks identified for clinical practice.

Cinnamon challenge

One of the first recorded challenges was the cinnamon challenge, dating as far back as 2001, which was pre-streaming video.

The oldest video channel video dates back to 2006 relative to this challenge,9 which involves taking a teaspoon of cinnamon orally and keeping it in one’s mouth for as long as possible without taking in fluids.After a bit of time, the spice triggers a

gag reflex in response to a caustic sensation in the mouth and throat.10 Within time, the response is that the person must spit out the cinnamon—causing a cough and expulsion of the cinnamon into the air that can then be inhaled.This challenge was acknowledged in a study in Pediatrics in 2013, which addressed the concerns of choking, aspiration, and pulmonary damage, together with the number of calls to US poison control centers and emergency department visits and hospitalizations for teens requiring ventilator support for collapsed lungs.10,11 Duct tape challenge

This challenge encourages the use of duct tape to tape a person’s extremities together, or to an inanimate object such as a chair or wall, and the “challenge” is to remove oneself from the tape while being recorded. Risks are encountered if oral or nasal passages are taped shut, and suffocation can occur. Removal of the tape can remove skin layers and cause superficial infections.

Musculoskeletal injuries can occur as the person is attempting to break free from the bondage and who could then fall onto a hard surface. Fractures, muscle sprains, and additional injuries can occur as a result of the fall. A teen in Washington state had a fractured orbit and traumatic brain injury as well as loss of vision after being taped and falling to the ground.12 Emotional and psychological risks can also occur as a person could experience anxiety, claustrophobia, and fear, which can lead to a panic attack.13 A number of online videos are available for viewing this challenge, many involving a person who is trying to imitate or seek pleasure in watching the effects of this challenge on the (taped) person.

Condom challenge

In 2012, a phenomenon started in which teens would inhale a condom into their nasal passage to pull out through their mouth. Risks included potential choking hazards and aspiration of the condom. In 2015, this challenge was reinvented with the filling of a condom with water and dropping it over a person’s head. Rather than exploding, the latex material forms a bubble of water over the person’s head, potentially suffocating him or her.14 Challengers have to leave the condom in place long enough to take a video or picture. Condoms are thicker than ordinary balloons and can stretch more than balloons.

Together with the weight of water, the risk of aspiration and suffocation is greater. Videos supporting this challenge are numerous, but teens do not understand the full effects of the risks associated with placing a latex condom over their heads.

Salt and ice challenge

The chemical processes within this challenge make this especially painful. As water freezes at 32° F, adding salt causes the freezing point to decrease to as low as 0° F. When ice is applied,

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 31

INTERNET “CHALLENGES” AND TEENAGERS: A GUIDE FOR PRIMARY CARE PROVIDERS

Taking a supportive team approach with the teen and parent can lead to open communication and appropriate treatment for the adolescent. energy is pulled from the skin and causes second-degree burns and frostbite.15 Within the competition, the challenge is to keep the ice on as long as possible, which causes deeper tissue damage.Within a few hours, the blisters appear. Risks include skin infection and may require the use of pain medication and antibiotics. Skin grafting and scarring are long-term effects of this challenge.

Eraser challenge

A kin to the salt and ice challenge, the eraser challenge has also been around for many years, and new videos are always available.This can be part of an individual or group competition in which kids and teens recite a song or poem repeatedly while rubbing erasers hard and fast on their skin. The game continues until the last child tolerating the friction is declared the winner.16 An initial rush of adrenaline can block the initial pain of this challenge, but the intense pain can outlast the contest, as the abrasive effects of the eraser can cause a burntype effect. Scabbing and scarring are the consequences of this challenge, as well as skin infections and bloodborne infections if teens are sharing erasers.

Kylie Jenner challenge

In this “do it yourself ” challenge, teens place a shot glass over their lips and suck forcefully in, causing a suction around their lips, in the attempt to cause “lip plumping” to look more like the teen idol Kylie Jenner. Significant pain, swelling, and bruising can occur from these suction techniques, and there is a risk for scarring and permanent disfigurement with repeated attempts.17 Banana Sprite challenge

In this challenge a person eats 2 bananas and quickly drinks a can of Sprite soda. Allegedly, this causes a chemical reaction in the stomach causing violent and projectile vomiting.

Others suggest that the stomach cannot hold that much food, and others state a psychosomatic response to the challenge.18 Risks can include dehydration and electrolyte imbalances due to the excessive vomiting if it continues for a prolonged period of time.

The chubby bunny challenge or cracker challenge

This challenge involves how many marshmallows or Saltine crackers someone can stuff in his or her mouth at once without any liquid.19 This is a choking hazard, and an airway can become blocked, with risks of aspiration up to and including

death. In 2017, a college student died from asphyxiation after ingesting too many pancakes at a fund-raising competition and began to choke.20 The first responders had difficulty clearing her airway, and she succumbed to hypoxia.

The fire spray challenge and the fire challenge

Both of these challenges are especially risky. In the Fire Spray challenge, the teen exhales some form of combustible liquid (frequently alcohol) and lights it on fire, creating a dragonlike fire-breathing burst, which is captured on video. The fire challenge is a more intense form of the challenge, with a combustible liquid being placed on the skin and people lighting themselves on fire. Both can cause serious burns, scarring, disfigurement, and death.19 Implications for patient care

Parents may not be aware of their teen’s attempts with any of these challenges.An acute care visit to an office or urgent care site may be scheduled for lip swelling, projectile vomiting, skin infection, burn, or respiratory symptoms, and unbeknown to the parent or provider, a “challenge” may be presenting. Any patient who may have attempted a “challenge” must be handled with the care and confidence as with any of the sensitive adolescent issues such as discussions about sexuality and drug or alcohol use. Speaking privately with the teen before discussion in front of the parents may be a helpful option to discuss the truth in what has occurred as part of a “challenge.” Taking a supportive team approach with the teen and parent can lead to open communication and appropriate treatment. Identification of the risk behavior should also be further explored to determine if this was a copycat prank or an attempt at self-harm or suicide. There are limited correlations between these online “challenges” and documentation of nonsuicidal self-injury in adolescents, but we must be aware of the risk that this can pose in our mental health assessments.There are no data on whether the Internet has increased the incidence of self-harm, but it has “normalized” the behaviors. Teens who are doing these challenges must be thoroughly screened for other self-harm behaviors, with the identification of depression, anxiety, stress, and bullying within the personal or online social arena. Any adolescent who has an identified plan for self-harm should be immediately referred to a mental health professional.

Additional considerations include collaboration between primary care providers, school nurses, and guidance counselors to acknowledge current trends in their geographic location

32 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

Continues on page 33

INTERNET “CHALLENGES” AND TEENAGERS: A GUIDE FOR PRIMARY CARE PROVIDERS

There are no data on whether the Internet has increased the incidence of self-harm among teens, but it has “normalized” the behaviors. to best determine these high-risk presentations within the school environment. Community awareness, as well as parents, children, and teens, can help in decreasing the inherent risk behaviors. Providers must remain astute to current trends and be nonbiased in discussing their concerns with the adolescent and parent to provide adequate treatment and support through these “challenging” adolescent years. ■

com/what-duct-tape-challenge-mother-warns-about-dangerous-youtubetrend-after-teenage-son-2283024 13. Wikihow to warn teens about the duct tape challenge (n.d.). Retrieved from https://www.wikihow.com/Warn-Teens-About-the-Duct-Tape-Challenge 14. Al-Othman H. Condom challenge: Dangerous new craze sweeps the web.

2015. Retrieved from http://www.standard.co.uk/news/uk/condom-challengedangerous-new-craze-sweeps-the-web-a3123131.html 15. Jaslow R. “Ice and salt challenge” leaves 12 year old Pittsburg boy with second

Margaret Quinn, DNP, CPNP, CNE, is a clinical associate professor and specialty director of the Pediatric Nurse Practitioner Program, Rutgers University, in Newark, NJ.

degree burns. 2012. Retrieved from https://www.cbsnews.com/news/ice-and-saltchallenge-leaves-12-year-old-pittsburgh-boy-with-second-degree-burns/ 16. Oliver D. Why your kids should stop doing the “eraser challenge.”

2017. Retrieved from https://health.usnews.com/wellness/health-buzz/

References

articles/2017-03-14/why-your-kids-should-stop-doing-the-eraser-challenge

1. Choshi N. Yes, people really are eating Tide pods. No it is not safe. January

17. Denton E. See the terrifying way some girls are attempting to get Kylie Jenner’s

20, 2018 retrieved from https://www.nytimes.com/2018/01/20/us/tide-pod-

famous pout. And why you should think twice before trying it yourself. 2015.

challenge.html

Retrieved from http://www.seventeen.com/beauty/celeb-beauty/news/a30202/

2. Pirani F. Are people really eating Tide pods? Doctors warn parents about

twitter-is-blowing-up-with-girls-trying-to-get-kylie-jenners-lips-and-its-not-pretty/

dangerous “Tide pod challenge.” 2018. Retrieved from http://www.ajc.com/news/

18. Shipman D. “Dr. Food Science” mixes bananas and Sprite, conducts other

national/are-people-really-eating-tide-pods-doctors-warn-parents-about-

questionable food experiments. 2008. Retrieved from http://www.joplinglobe.

dangerous-tide-pod-challenge/fgGxrYa6z5pAGuFoAJXpDI/

com/news/lifestyles/dr-food-science-mixes-bananas-and-sprite-conducts-

3. Luxton DD, June JD, Fairall JM. Social media and suicide: a public health

other-questionable/article_77087d87-16e4-5520-9ef6-dd7e98f2116f.html

perspective. Am J Public Health. 2012;102(Suppl 2):S195-S200.

19. Teensafe. Why are social media challenges so popular with teens? 2017.

4. Tanka S. Social media challenge approaching social moral concern. 2014.

Retrieved from https://www.teensafe.com/blog/why-are-social-media-

Retrieved from http://www.pcccourier.com/opinion/social-media-challenge-

challenges-popular-teens/

approaching-social-moral-concern.html

20. Miller J. Student dies after choking during pancake eating competition.

5. Campbell S. 6 Major challenges social media creates for our teenagers,

2017. Retrieved from https://nypost.com/2017/04/03/student-dies-after-

and how to parent them. 2015. Retrieved from http://www.huffingtonpost.

choking-during-eating-competition/

com/sherrie-campbell-phd/6-major-challenges-social-media-creates-for-ourteenagers-and-how-to-parent-them_b_6852614.html 6. Guynn J. Youtube cracks down on Tide pod challenge video. 2018. youtube-cracks-down-tide-pod-challenge-videos/1042847001/ 7. Firger J. Why teenagers get suckered in by social media dares. 2016. http:// www.newsweek.com/2016/05/27/teens-social-media-dares-459419.html 8. Shurgin-O’Keeffe G, Clark-Pearson K. The impact of social media on children, adolescents, and families. Pediatrics. 2011;127:800-804.

9. Kroll D. 5 reasons not to take the cinnamon challenge. 2013. Retrieved from https://www.forbes.com/sites/davidkroll/2013/04/23/5-reasons-not-totake-the-cinnamon-challenge/#48a5ba3d6405 10. Grant-Alfieri A, Schaechter J, Lipshultz SE. Ingesting and aspirating dry cinnamon by children and adolescents. The “cinnamon challenge.” Pediatrics.

2013;131:833-835.

11. Akron Children’s Hospital. KidsHealth. 2013. Retrieved from https://www. akronchildrens.org/cms/kidshealth/5a3cc0151bd7c7e8/ 12. Silva C. What is the duct tape challenge? Mother warns about dangerous youtube trend after son nearly dies. 2016. Retrieved from http://www.ibtimes.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 33

© The New Yorker Collection 2018 from cartoonbank.com. All Rights Reserved.

Retrieved from https://www.usatoday.com/story/tech/2018/01/17/

CME

Release Date: June 25, 2018 Expiration Date: July 31, 2019 Estimated Time to Complete: 1 hour Maximum Credits: 1.00 AMA PRA Category 1 CreditTM Accredited Provider: This activity is provided by Albert Einstein College of Medicine.

FEATURED COURSE EDUCATIONAL OBJECTIVES At the conclusion of this activity, participants should be better able to: • Recognize the manifestations of inflammatory bowel disease (IBD) and make the diagnosis on a timely basis, differentiating it from irritable bowel syndrome and other gastrointestinal disorders commonly seen in primary care practice • Make timely referrals of IBD patients to specialist care while continuing to oversee the general health of the patient, using an approach based on shared decisionmaking and multidisciplinary collaboration • Describe the benefits and side effects of newer IBD therapies, including biologics, and their role in a comprehensive treatment plan COMPLETE THE POSTTEST: Page 44

Producer: This activity is produced by Haymarket Medical Education.

Commercial Supporter: This activity is supported by an educational grant from Janssen Biotech and AbbVie Pharmaceuticals.

Program Description: Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, is a chronic, often debilitating, lifelong condition. Primary care providers need to know how to distinguish IBD from other gastrointestinal (GI) disorders and when to refer patients to GI specialists for a more detailed workup and treatment. Ideally, care of the patient with IBD should be co-managed by a GI and a primary care provider.This educational program is designed to help primary care providers recognize the manifestations of IBD and make timely referrals to specialists while ­continuing to oversee the patient’s general health. It is also designed to acquaint clinicians with the spectrum of available treatments for Crohn’s disease and ­ulcerative colitis, including newer biologic agents.

Intended Audience: This activity is designed for primary care clinicians—especially nurse practitioners (NPs) and physician assistants (PAs) working in primary care (family medicine and internal medicine).

Course Director Lawrence J. Brandt, MD Professor, Department of Medicine—Gastroenterology Professor, Department of Surgery Montefiore Medical Center Bronx, NY Lawrence J. Brandt, MD, has no relevant financial relationships to disclose.

Faculty Michele Kissous-Hunt, PA-C, DFAAPA Gastroenterology Physician Assistant, practice of Arthur Asher Kornbluth, MD, PC/Fifth Avenue GI Chair of the Nurse and Advanced Practice Provider, Crohn’s & Colitis Foundation National Scientific Advisory Committee Adjunct Faculty, Physician Assistant Program, Touro College of Health Sciences New York, NY Michele Kissous-Hunt, PA-C, DFAAPA, serves on the speakers’ bureaus for AbbVie Pharmaceuticals and Janssen Biotech.

Provided by

Staff/Planners’ Disclosures Haymarket Medical Education staff involved in the planning and content review of this activity have no relevant financial relationships to disclose.

The staff of the Center for Continuing Medical Education of Albert Einstein College of Medicine have no relevant financial relationships to disclose.

Accreditation Statement: Albert Einstein College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation Statement: Albert Einstein College of Medicine designates this enduring activity for a maximum of 1.00 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Policy: In accordance with the ACCME Standards for Commercial Support, the Albert Einstein College of Medicine and Haymarket Medical Education (HME) require that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. Albert Einstein College of Medicine and HME resolve all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all their educational activities.

Disclaimer: The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of Janssen Biotech, AbbVie Pharmaceuticals, Albert Einstein College of Medicine, or Haymarket Medical Education.

Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Instructions: There are no fees for participating in and receiving CME credit for this activity. During the period June 25, 2018 through July 31, 2019, participants must: 1) read the learning objectives and faculty disclosures; 2) complete the preassessment test; 3) study the educational activity; and 5) complete the post-test and evaluation form and submit it online.

A statement of credit will be issued only upon receipt of the above elements and a post-test score of 70% |or higher. All components must be completed and submitted online at ClinicalAdvisor.com/July18feature.

If you have any questions relating to the accreditation of this activity, please contact cme@montefiore.org. If you have any technical trouble or other questions, please contact myCME.support@haymarketmedical.com.

Produced by

Supported by Janssen Biotech and AbbVie Pharmaceuticals

CME FEATURED COURSE: MICHELE KISSOUS-HUNT, PA-C, DFAAPA

Smoothing the course of IBD: A collaborative approach to care Optimal management of IBD depends on clear communication between patients and clinicians and a healthy balance of primary and specialty care.

© SPL / SCIENCE SOURCE

I

Severe ulcerative colitis in a 30-year-old man.

nflammatory bowel disease (IBD)—consisting of ulcerative colitis (UC), Crohn’s disease (CD), and a small proportion of indeterminate colitis— is a set of chronic relapsing and remitting conditions characterized by inflammation of the gastrointestinal (GI) tract.1 As a lifelong pathophysiological process typically starting in adolescence or young adulthood, IBD is costly to manage2 and is associated with a higher risk of work disability,3 anxiety and depression,4 and lower quality of life (QoL)5 compared with non-IBD controls.

Many IBD symptoms are common and nonspecific, complicating early diagnosis. Primary care providers need to know how to distinguish IBD from other GI conditions and when to refer patients to GI providers for a more detailed workup. Delayed diagnosis is common and has been associated with an increased risk of intestinal complications and surgery.6,7 Biologic therapies have improved the quality of care for IBD, thereby improving outcomes and reducing the risk of progression to structural damage.8 Primary care providers need to be familiar with these therapies and their clinical benefits and side effects.

Ideally, IBD should be managed by a GI provider in conjunction with a primary care clinician.9-11 Yet many patients see only their GI provider and view that individual as their primary provider, leading to possible gaps in preventive care. Data indicate that patients with IBD do not receive preventive health services at the same rate as do general medical patients.9,12

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 35

CME FEATURED COURSE

FIGURE: Extraintestinal manifestations of IBD

Uveitis, one of the most common eye complications of IBD, may include painful inflammation, blurred vision, and sensitivity to light.

A survey of family medicine providers found that only 37% felt comfortable providing primary care to a range of patients with IBD.13 Coordination and communication between the primary care and GI provider is pivotal to improving the care of patients with IBD. With that objective in mind, it is important for primary care providers to be familiar with the potential risks and benefits of IBD therapies, the impact of immunosuppressive agents, and the recommendations for vaccines and preventive care in IBD patients.

LEFT, RIGHT: © DR P. MARAZZI / SCIENCE SOURCE

Prevalence and course of illness

IBD is most frequently diagnosed in adolescence or young adulthood, between the ages of 15 and 35.14 Roughly one-fourth of patients with IBD are diagnosed before the age of 20.15 About 1.3% of US adults, or 3.1 million people, reported having the diagnosis of IBD in the 2015 National Health Interview Survey (NHIS).16 With IBD prevalence rated at 1 to 2 per 1000 children in the United States, a recent review suggests that “most pediatricians will treat children with IBD.”15 Data from around the world suggest that IBD incidence and prevalence are rising.17-19 Crohn’s disease can affect any part of the GI tract, from mouth to anus, is transmural, and may be patchy, with “skip” areas of unaffected bowel,14 whereas UC is by definition confined to the colonic mucosa, beginning in the rectum, extending proximally and involving part of the colon or the entire colon in continuous fashion.20,21 Analysis of NHIS data found that adults with IBD were twice as likely as those without the disease to report experiencing serious psychological distress (7.4% and 3.4%, respectively).22

Oral aphthous ulcers may occur in patients with IBD, often on the lips or buccal mucosa, and are more common in CD than in UC.

Half of adults with CD will require surgery within 10 years of diagnosis, with a 44% to 55% risk of postoperative recurrence after 10 years, according to an analysis of populationbased cohort studies.23 Evaluation of 306 patients with CD reported that half of them experienced stricturing or penetrating complications after 20 years.24 A more recent study of 260 patients with CD found that after 5 years (2005-2009), 15.4% of patients had strictures and 10.6% had penetrating disease.25 These figures may reflect improvements in therapy along with a shorter duration of follow-up.

In adults with UC, a recent analysis of population-based cohort studies (N=15,316) found a 70% to 80% risk of relapse at 10 years.26 Nearly 50% of patients required hospitalization, and 5-year rehospitalization risk was roughly 50%. The 5and 10-year cumulative risk of colectomy was 10% to 15%.

Most patients experienced a mild to moderate course, with high disease activity at diagnosis followed by remission or mild activity. About 10% to 15% of patients had an aggressive form of UC.26 IBD is also associated with an increased risk of colorectal cancer in extensive UC and colonic CD.14 A retrospective analysis of data from the US Medical Expenditure Panel Survey (1996-2009) estimated total annual direct costs incurred by health insurers and patient out-ofpocket expenses due to CD and UC at $2.29 billion and $610 million, respectively.2 The number of emergency department visits with a primary diagnosis of IBD rose by 51.8% from 2006 to 2014, according to analysis of the Nationwide Emergency Department Sample.27 Cost of medications is rising with the increasing adoption of biologic therapies.28

36 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

Erythema nodosum—tender red nodules—may appear on the shins and ankles, just prior to or in conjunction with a flare-up of IBD.

■ TAKE-HOME MESSAGES: Impact of IBD

Systemic manifestations may include fatigue, fever, loss of appetite, night sweats, weight loss, anemia and, for females, loss of normal menstrual cycle.14,15 Presenting symptoms in children include growth failure, anemia, perianal disease, or other extraintestinal manifestations.15 Up to half of IBD patients develop at least one extraintestinal manifestation,31 which can serve as a diagnostic clue (see Figure above). Extraintestinal manifestations may include skin disease (eg, erythema nodosum, pyoderma gangrenosum), eye inflammation (eg, episcleritis, iritis, uveitis), oral findings (eg, aphthous ulcers), and arthropathies (eg, central and peripheral joints).20,21,31,32 Presence of these IBD extraintestinal manifestations along with GI symptoms should prompt consideration of IBD.30

• IBD is common and most often diagnosed in adolescents and young adults • IBD can be associated with significant morbidity, including other chronic conditions, and higher risk of work disability, anxiety, and depression • IBD represents a high economic burden on our healthcare system Diarrhea, abdominal pain: When is it IBD?

IBD diagnosis is complicated in that symptoms can be nonspecific, mimicking other GI conditions. Gastrointestinal symptoms associated with IBD include abdominal pain, cramps, diarrhea with passage of blood and/or mucus, bowel urgency, nocturnal diarrhea, and a sense of incomplete evacuation, known as tenesmus.20,21,29 Diarrhea persisting more than 2 weeks should prompt consideration of IBD.30 Clinical signs of bowel obstruction, perirectal disease (eg, abscesses, fissures, fistulas, skin tags), and oral manifestations (eg, aphthous ulcers) should raise suspicion of CD.21,30 Mouth ulcers also can herald UC. Patients with UC usually experience pain across their lower abdomen as well as in the left lower quadrant, with worsening pain during bowel movements, and usually present with rectal bleeding, urgency, and tenesmus. Pain in patients with CD and ileitis typically is located in the right lower quadrant but can present differently depending on the location, behavior, and severity of the disease. It may manifest with diarrhea in inflammatory disease and with nausea and vomiting in obstructive disease.A palpable mass representing matted loops of adjacent bowel may or may not be present.30

IBS vs IBD

Confusion with irritable bowel syndrome (IBS) can lead to misdiagnosis of IBD. Like IBD, IBS commonly affects young patients and presents with abdominal pain and change in bowel habits, with a relapsing and remitting course.A case-control study in the United Kingdom (UK) found that persons newly diagnosed with IBD (n=20,193) were 3 times as likely as controls (n=201,393) to have a prior diagnosis of IBS (15% of IBD patients vs 5% of controls).33 Of those with a prior diagnostic code for IBS, 40% had such a diagnostic code for 5 years or more prior to being diagnosed with IBD.33 Blood in the stool, anemia, weight loss, fever, and/or nocturnal symptoms, so-called “alarm symptoms,” should signal consideration of IBD rather than IBS.30,34 The presence of symptoms usually associated with IBD in a young patient with a family history of the condition should raise suspicion of IBD.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 37

LEFT: © BIOPHOTO ASSOCIATES / SCIENCE SOURCE; RIGHT: © CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST, UK / SCIENCE SOURCE

Pyoderma gangrenosum in patients with IBD typically starts with non-infectious nodules that develop into deep and painful ulcers.

CME FEATURED COURSE

TABLE 1. Laboratory workup for suspected IBD39,40 • Complete blood count • Comprehensive metabolic panel

• Fe (iron) studies; B12 (Crohn’s disease)

• C-reactive protein (CRP)

• Clostridium difficile assay

• Erythrocyte sedimentation rate (ESR)

• Fecal calprotectin • Stool cultures

TABLE 2. Symptoms and laboratory markers associated with IBD in patients under 50 years old29,a Symptom/laboratory marker

OR (95% CI)

Rectal bleeding

40.0 (31.0-53.0)

Change in bowel habits

22.0 (15.0-33.0)

Diarrhea

9.5 (7.9-12.0)

Abdominal pain

3.5 (3.0-4.1)

Elevated inflammatory markersb

6.1 (5.1-7.3)

Elevated platelets

5.4 (4.0-7.2)

Low mean red cell volume

2.4 (1.8-3.2)

Low hemoglobin

2.2 (1.8-2.8)

Elevated white cell count

1.7 (1.4-2.1)

Abnormal liver testsc

1.4 (1.2-1.7)

IBD, inflammatory bowel disease; OR, odds ratio. a

Incident cases (aged <50 years) of IBD (n=9578) diagnosed between 2000 and 2013 were each matched with up to 3 controls (n=22,947) in the Clinical Practice Research Datalink, UK. Odds ratios estimated for symptoms and laboratory markers in the year before diagnosis, after multivariate analysis. b Abnormal erythrocyte sedimentation rate, C-reactive protein, or plasma viscosity. c Elevations of any hepatic enzymes included in liver biochemical testing.

cohort, the median time to diagnosis was 4 months for patients with UC and 9 months for those with CD.36 Diagnosis was delayed by 24 months for one-quarter of CD patients and by 12 months for one-quarter of those with UC.36 Other studies have also reported longer diagnostic delays for CD than UC.37 Time to GI provider referral accounts for much of the delay.37 Delayed diagnosis has been associated with progression of disease—including higher risk of perianal disease, stricturing disease, and surgery at diagnosis (in CD)38—and with an increased risk for intestinal surgery in both UC and CD.7 Table 1 lists the suggested laboratory workup for suspected IBD.39,40 A UK-based case-control study identified symptoms and laboratory markers within the prior 12 months significantly associated with IBD in patients younger than age 50. In this analysis, rectal bleeding and change in bowel habits combined with abnormal laboratory values strongly predicted IBD as well as an increased risk of colorectal cancer (Table 2).29 Patients with such symptoms and abnormal laboratory test results should be referred to a GI provider for further evaluation.

The gold standard for diagnosing UC is a colonoscopy with biopsies. For CD, a colonoscopy with biopsies and small-bowel imaging (computed tomography enterography or magnetic resonance enterography) is needed to establish the diagnosis and determine the extent, type (inflammatory, stricturing, or penetrating) and severity of the disease.30,39-43 Fecal calprotectin, a protein released by neutrophils and found in the stool of patients with IBD and other inflammatory diseases, has emerged as a laboratory marker with a high degree of accuracy and costeffectiveness for identifying patients likely to have IBD from among those with GI symptoms.44-46 A Health Technology Assessment performed by a division of the UK National Health Service concluded that fecal calprotectin is “highly sensitive” for detecting IBD, based on a 28-study meta-analysis.44 A normal fecal calprotectin value does not rule out IBD, however.

■ TAKE-HOME MESSAGES: Screening for IBD

Other conditions to consider in the differential diagnosis include infectious diarrhea (eg, parasitic, viral, or bacterial, such as Clostridium difficile), ischemic colitis, microscopic colitis, celiac sprue, lactose intolerance, small intestinal bacterial overgrowth, appendicitis, and Behçet disease.20,21,30 A flare of GI symptoms when a patient stops smoking can be a diagnostic clue to UC. Cigarette smoking reduces the risk of UC and is associated with a milder disease course among those who develop UC.20,35 In CD, on the other hand, smoking raises the risk of disease progression and worsening outcome. Compounding diagnostic difficulty, IBD can coexist with other causes of GI symptoms, such as IBS. Delayed diagnosis is a problem in both UC and CD, though time to diagnosis is more prolonged in CD. In a Swiss IBD

• Rectal bleeding, change in bowel habits, anemia, extraintestinal manifestations, and family history combined with abnormal laboratory values should raise suspicion of IBD • Fecal calprotectin is a highly sensitive inflammatory marker that is used in addition to erythrocyte sedimentation rate and C-reactive protein when suspecting IBD • Smoking cessation can be associated with the development or exacerbation of UC, thus serving as a clue to diagnosis • Patients in whom IBD is suspected should be referred to a GI provider for further evaluation Advances in therapy

The introduction of biologic therapies for IBD—tumor necrosis factor (TNF)-α inhibitors, anti-integrin monoclonal antibodies,

38 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

anti-interleukin (IL)-12/23 antibodies (for CD), and a recently approved janus kinase (JAK) inhibitor for UC—have revolutionized the management of IBD (Table 3). Treatment goals now include not only symptom relief and rapid, safe induction of clinical remission but also mucosal healing, assessed by endoscopy; steroid-free durable maintenance of remission; prevention of disease progression, hospitalization, surgery, and disability; and improved QoL.8,20,21,47 The goal is to achieve these outcomes while avoiding drug- and disease-related complications.

Mucosal healing has been associated with improved outcomes. Endoscopic remission in patients with moderate to severe ileocolonic CD has been associated with fewer hospitalizations and surgeries for CD.55 Endoscopic healing in UC was associated with lower colectomy rates,56 longer time free of colectomy, and longer duration of corticosteroid-free remission.47 Adding infliximab to azathioprine (AZA) in patients with moderate to severe CD has been associated with higher rates of achieving both clinical remission and mucosal healing compared with either infliximab or azathioprine alone.57 Use of anti-TNF therapy in CD has been associated with a 12% lower risk of death, as well as significantly lower risks of hip fracture and major cardiovascular events, compared with prolonged corticosteroid therapy (odds ratio for death 0.78, 95% CI, 0.65-0.93).58 These data come from a retrospective cohort study of Medicare and Medicaid beneficiaries with IBD (2001-2013). Prolonged steroid therapy was defined as more than 3000 mg of prednisone or equivalent or more than 800

mg of budesonide divided between at least 2 prescriptions over 12 months with no anti-TNF prescriptions during that time.58 Initial therapy for patients with mild UC includes oral/rectal therapy with the following: aminosalicylate (5-ASA) agents and/or budesonide followed by tapering and maintenance with 5-ASA therapy. Options for initial therapy in patients with moderate to severe UC and those patients who do not respond to 5-ASA treatment include a short course of steroids plus a thiopurine, an anti-TNF agent with or without a thiopurine, and vedolizumab (an anti-integrin monoclonal antibody), with or without a thiopurine. Patients started on a steroid plus thiopurine can be maintained on the thiopurine with a steroid taper, an anti-TNF agent with or without a thiopurine, vedolizumab with or without a thiopurine,40 or tofacitinib, recently approved for moderate to severe UC, which should not be used in combination with a thiopurine.40 Initial therapy for patients with mild CD includes a­ zulfidine (colonic CD) and budesonide (ileocecal CD) with or without an immunomodulator—6-mercaptopurine (6-MP), ­azathioprine (AZA), or methotrexate (MTX)—followed by a budesonide taper. Methotrexate should not be used in women of childbearing age given its teratogenicity.59 Initial therapy for patients with moderate to severe CD includes anti-TNF monotherapy; anti-TNF with a thiopurine; MTX in combination with antiTNF or MTX monotherapy for patients who do not tolerate thiopurine or any other biologic; anti-integrin with or without an immunomodulator; and anti–IL-12/23 with or without an

TABLE 3. Biologic therapies for moderate or severe IBD Medication

MOA

FDA approval in IBD

Mode of delivery

Adalimumab48

Anti-TNF

CD, UC

SC injection

Certolizumab49 pegol

Anti-TNF

CD

SC injection

Golimumab50

Anti-TNF

UC

SC injection

Infliximab51

Anti-TNF

CD, UC

IV infusion

Natalizumab52

Anti-integrin

CD

IV infusion

Vedolizumab53 (gut selective)

Anti-integrin

CD, UC

IV infusion

Ustekinumab54

Anti–IL-12/23

CD

IV infusion followed by SC injection

Tofacitinib

JAK inhibitor

UC

oral

CD, Crohn’s disease; FDA, US Food and Drug Administration; IBD, inflammatory bowel disease; IL, interleukin; IV, intravenous; JAK, janus kinase inhibitor; MOA, mechanism of action; TNF, tumor necrosis factor; UC, ulcerative colitis; SC, subcutaneous.

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CME FEATURED COURSE

immunomodulator. During remission, patients can be maintained on anti-TNF therapy, anti-integrin, or anti–IL-12/23 alone or with an immunomodulator.39 Table 3 lists US Food and Drug Administration–approved biologic therapies for IBD. ■ TAKE-HOME MESSAGES: IBD therapies • In UC, anti-TNF agents and anti-integrin monoclonal antibody vedolizumab are recommended with or without an immunomodulator for use in patients with moderate to severe disease. Tofacitinib is also recommended in these patients, but as monotherapy.

• In CD, anti-TNF agents, anti-integrin therapy, and antiIL therapies are recommended as monotherapy or in combination with an immunomodulator (6-MP/AZA or MTX) for patients with moderate to severe disease • Goals of IBD therapy include not only clinical remission and symptom relief but also preventing disease progression and achieving mucosal healing • Prolonged corticosteroid therapy is associated with higher rates of death, cardiovascular events, and hip fracture compared with anti-TNF therapy TABLE 4. IBD medication safety Medication class

Increased risks

Corticosteroid therapy

Osteopenia/osteoporosis, avascular necrosis, cataracts, cervical neoplasia, diabetes, hyper­ tension, glaucoma, herpes zoster, mood changes, insomnia, weight gain, opportunistic infection, pneumonia9,63-65

Thiopurines (azathioprine/ 6-mercaptopurine [6-MP])

Myelotoxicity, hepatotoxicity, herpes zoster, acute pancreatitis, lymphoma, pneumonia, NMSC9,66-68

Methotrexate

Hepatotoxicity, myelotoxicity, opportunistic infection, teratogenicity, pulmonary toxicity59

Cyclosporine

Nephrotoxicity, hypertension, neuropathy69

TNF-α inhibitors (adalimumab, certolizumab pegol, infliximab, golimumab)

Hepatitis B virus reactivation, herpes zoster, pneumonia,63 lymphoma, melanoma, opportunistic infections, reactivation of latent TB, lupus-like syndrome, demyelination, congestive heart failure48-51

Anti-integrin agents (vedolizumab, natalizumab)

Infections, PML (natalizumab), liver function abnormalities52,53

IL-12/23 inhibitors (ustekinumab)

Reactivation of latent TB, low-risk infections, low-risk malignancies54

Tofacitinib

Malignancy, opportunistic infections

IL, interleukin; NMSC, nonmelanoma skin cancer; PML, progressive multifocal leukoencephalopathy; TB, tuberculosis; TNF, tumor necrosis factor.

Preventive care in IBD: The collaborative approach

Patients with IBD receive vaccinations and preventive health services at lower rates than recommended and at lower rates than the general population.9,12,60-62 Yet they face increased risk for some vaccine-preventable infections, including herpes zoster, influenza, and pneumococcal pneumonia.The risk of these conditions is exacerbated by treatment with immunosuppressive therapies used to manage IBD in some patients (Table 4).9 The pneumococcal vaccine is recommended for adults 65 years of age or older and for younger patients who are immunocompromised and have chronic health conditions. Analysis of 10 years of data from the Veterans Health Administration (VHA; 2004-2014) showed that only 39% of patients with IBD had ever received a pneumococcal vaccine compared to 56% to 61% of adults age 65 or over in the general population.62 IBD and its therapies raise the risk of certain conditions for which preventive screening can be performed. IBD itself is associated with a higher risk of melanoma, as are the TNF-α inhibitors commonly used to treat IBD. Use of thiopurines is associated with higher risk of nonmelanoma skin cancer.9 Only 15% of IBD patients accessed a dermatology clinic in the 10-year VHA data analysis.62 Rates of Pap smears among women veterans with IBD also were lower than those of the general population.62 The American College of Gastroenterology (ACG) recently issued a list of preventive care recommendations for patients with IBD.The Crohn’s and Colitis Foundation has created a health maintenance checklist for adults with IBD incorporating those recommendations and other guidance (Table 5).

The ACG advises GI providers to communicate with primary care clinicians about their IBD patients’ needs for vaccinations and health screenings.9 It is important to note that live virus vaccines should not be used in patients receiving immunosuppressive therapy.63 Patient education and shared decision making are important elements of caring for the patient with any chronic disease, including IBD.70 Some GI providers may view lack of time as an obstacle to applying a shared decision-making approach.71 Yet intervention to improve vaccination rates need not be onerous in terms of provider or patient time. Distributing a 1-page educational form at office visits, asking about vaccination status for influenza and pneumococcal pneumonia, and offering vaccination at the visit to those who have not received those vaccines led to a significant increase in the proportion of patients reporting influenza and pneumococcal vaccination over 15 months in one practice (23% to 47% reporting annual influenza vaccination, 21% to 32% reporting pneumococcal vaccination).72

40 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

TABLE 5. Health maintenance checklist for adult IBD patients Vaccine-preventable illnesses

Which patients

How often

Influenza (inactive)

All

Annually

Pneumococcal PCV13

If on/planning immunosuppression

Once1

Pneumococcal PPSV23

If on/planning immunosuppression

At baseline, repeat in 5 years and again after age 65

Tdap

All

Every 10 years

HPV

All aged 11–26 years

Once1

Meningococcal meningitis

All adult patients at risk of meningitis

Once1

Hepatitis A

If non-immune

Once1

Hepatitis B

If non-immune

Once1

MMR (live vaccine)

If non-immune2

Once1

Varicella (live vaccine)

If non-immune2

Once1

Herpes zoster

All aged >50 years3

Once1

Cancer prevention

Which patients

How often

Cervical PAP smear

All on systemic immunosuppression4

Annual

Skin screen

All on systemic immunosuppression4

Annual

Colonoscopy

All with colonic disease for >8 years

Every 1-3 years

Other screenings

Which patients

How often

DEXA Scan

High risk; women with low BMI, postmenopausal, chronic steroid exposure

At least 2 years apart

PPD or IGRA

Prior to anti-TNF or anti-IL-12/23

Once (repeat if TB exposure)

Smoking status

All

Annual

Depression check

All

Annual

DEXA, dual-energy X-ray absorptiometry; HPV, human papillomavirus; IGRA, interferon-gamma (γ) release assay; MMR, measles, mumps, rubella; PCV, pneumococcal conjugate vaccine; PPD, purified protein derivative; PPSV, pneumococcal polysaccharide vaccine; Tdap, tetanus, diphtheria, pertussis.

1. Recommended timing and spacing of vaccines available in ACIP recommendation 2. Patients treated with systemic immunosuppressive therapy (steroids, thiopurines, anti-TNFs) should not receive live (attenuated) vaccines e.g. measles, mumps, rubella, nasal influenza, varicella, and yellow fever 3. The CDC’s ACIP recommends the subunit vaccine (Shingrix) over the live vaccine (Zostavax), and that Shingrix can be administered to patients who have already received Zostavax.

Patients receiving anti-TNFs, anti IL-12/23 or >20 mg prednisone should NOT be given the live zoster vaccine.

4. “Systemic immunosuppression” currently includes azathioprine, mercaptopurine, methotrexate, anti-TNFs, anti-IL-12/23 The evidence base for this checklist varies from “insufficient to assess benefits” to “moderate net benefits.” Developed by the Crohn’s & Colitis Foundation’s Professional Education Committee Sub-Group: Alan Moss, MD, Francis Farraye, MD, MSc, Glenn Gordon, MD, Raluca Vrabie, MD • Approved by Committee Chairs: Millie Long, MD, Samir Shah, MD • V3_January_2018

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 41

CME FEATURED COURSE

■ TAKE-HOME MESSAGES: Vaccinations and screenings • Patients with IBD receive vaccinations and health screenings at lower rates than others, despite higher risk of health conditions in some cases • The ACG has issued recommendations for preventive health services for patients with IBD; the Crohn’s & Colitis Foundation has developed a 1-page health maintenance checklist reflecting these recommendations and other guidance • The ACG suggests that primary care clinicians assume responsibility for delivering or coordinating delivery of these services, with guidance from GI providers about how to apply ACG recommendations to individual patients • Patients with IBD receiving immunosuppressive therapy should not receive live virus vaccines

9. Farraye FA, Melmed GY, Lichtenstein GR, Kane SV. ACG Clinical Guideline: preventive care in inflammatory bowel disease. Am J Gastroenterol.

2017;112(2):241-258.

10. Borren NZ, Conway G,Tan W, et al. Distance to specialist care and disease outcomes in inflammatory bowel disease. Inflamm Bowel Dis. 2017;23(7):1234-1239.

11. Nguyen GC, Nugent Z, Shaw S, Bernstein CN. Outcomes of patients with Crohn’s disease improved from 1988 to 2008 and were associated with increased specialist care. Gastroenterology. 2011;141(1):90-97.

12. Selby L, Kane S, Wilson J, et al. Receipt of preventive health services by IBD patients is significantly lower than by primary care patients. Inflamm Bowel Dis. 2008;14(2):253-258.

13. Selby L, Hoellein A, Wilson JF. Are primary care providers uncomfortable providing routine preventive care for inflammatory bowel disease patients?

Dig Dis Sci. 2011;56(3):819-824.

14. Crohn’s & Colitis Foundation of America (CCFA). The Facts About

Summary

Inflammatory Bowel Diseases. New York, NY: CCFA; November 2014. http://

IBD is a common, lifelong condition that typically surfaces in adolescence or young adulthood and is associated with substantial comorbidity. Optimal management involves communication between the GI and primary care provider, and between the patient and the medical team. IBD and its therapies affect patients’ risks of preventable health conditions; therefore, recommendations for vaccination and surveillance are essential. Primary care clinicians can contribute substantially by delivering preventive care to IBD patients, in conjunction with the GI provider.Awareness of disease manifestations, symptoms, and medication side effects enables the primary care and GI providers to collaborate in monitoring patients for disease exacerbation and treatment of adverse events. ■

www.crohnscolitisfoundation.org/assets/pdfs/updatedibdfactbook.pdf.

15. Rosen MJ, Dhawan A, Saeed SA. Inflammatory bowel disease in children and adolescents. JAMA Pediatr. 2015;169(11):1053-1060.

16. Dahlhamer JM, Zammitti EP, Ward BW, et al. Prevalence of inflammatory bowel disease among adults aged ≥18 years - United States, 2015. MMWR. 2016;65(42):1166-1169.

17. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46-54.e42; quiz e30.

18. Kappelman MD, Moore KR, Allen JK, Cook SF. Recent trends in the prevalence of Crohn’s disease and ulcerative colitis in a commercially insured US population. Dig Dis Sci. 2013;58(2):519-525.

19. Bahler C, Vavricka SR, Schoepfer AM, et al. Trends in prevalence, mortality,

References

health care utilization and health care costs of Swiss IBD patients: a claims data

1. Weimers P, Munkholm P. The natural history of IBD: lessons learned. Curr

based study of the years 2010, 2012 and 2014. BMC Gastroenterol. 2017;17(1):138.

Treat Options Gastroenterol. 2018;16(1):101-111.

20. Ordas I, Eckmann L,Talamini M, et al. Ulcerative colitis. Lancet. 2012;380(9853):

2. Gunnarsson C, Chen J, Rizzo JA, et al. Direct health care insurer and out-

1606-1619.

of-pocket expenditures of inflammatory bowel disease: evidence from a US

21. Baumgart DC, Sandborn WJ. Crohn’s disease. Lancet. 2012;380(9853):

national survey. Dig Dis Sci. 2012;57(12):3080-3091.

1590-1605.

3. Hoivik ML, Moum B, Solberg IC, et al. Work disability in inflammatory

22. Xu F, Dahlhamer JM, Zammitti EP, et al. Health-risk behaviors and chronic

bowel disease patients 10 years after disease onset: results from the IBSEN

conditions among adults with inflammatory bowel disease - United States,

Study. Gut. 2013;62(3):368-375.

2015 and 2016. MMWR. 2018;67(6):190-195.

4. Walker JR, Ediger JP, Graff LA, et al. The Manitoba IBD cohort study: a pop-

23. Peyrin-Biroulet L, Loftus EV Jr, Colombel JF, Sandborn WJ. The natural his-

ulation-based study of the prevalence of lifetime and 12-month anxiety and

tory of adult Crohn’s disease in population-based cohorts. Am J Gastroenterol.

mood disorders. Am J Gastroenterol. 2008;103(8):1989-1997.

2010;105(2):289-297.

5. Knowles SR, Graff LA,Wilding H, et al. Quality of life in inflammatory bowel dis­ease:

24. Thia KT, Sandborn WJ, Harmsen WS, et al. Risk factors associated with

a systematic review and meta-analyses-part I. Inflamm Bowel Dis. 2018;24(4):742-751.

progression to intestinal complications of Crohn’s disease in a population-

6. Li Y, Ren J, Wang G, et al. Diagnostic delay in Crohn’s disease is associated

based cohort. Gastroenterology. 2010;139(4):1147-1155.

with increased rate of abdominal surgery: a retrospective study in Chinese

25. Ronnblom A, Holmstrom T, Karlbom U, et al. Clinical course of Crohn’s disease

patients. Dig Liver Dis. 2015;47(7):544-548.

during the first 5 years. Results from a population-based cohort in Sweden

7. Lee DW, Koo JS, Choe JW, et al. Diagnostic delay in inflammatory bowel disease

(ICURE) diagnosed 2005-2009. Scand J Gastroenterol. 2017;52(1):81-86.

increases the risk of intestinal surgery. World J Gastroenterol. 2017;23(35):6474-6481.

26. Fumery M, Singh S, Dulai PS, et al. Natural history of adult ulcerative colitis

8. Ferrari L, Krane MK, Fichera A. Inflammatory bowel disease surgery in the

in population-based cohorts: a systematic review. Clin Gastroenterol Hepatol.

biologic era. World J Gastrointest Surg. 2016;8(5):363-370.

2018;16(3):343-356.e3.

42 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

27. Ballou S, Hirsch W, Singh P, et al. Emergency department utilisation

43. Gomollon F, Dignass A, Annese V, et al. 3rd European Evidence-Based

for inflammatory bowel disease in the United States from 2006 to 2014.

Consensus on the Diagnosis and Management of Crohn’s Disease 2016:

Aliment Pharmacol Ther. 2018;47(7):913-921.

Part 1: diagnosis and medical management. J Crohns Colitis. 2017;11(1):3-25.

28. Yu H, MacIsaac D, Wong JJ, et al. Market share and costs of biologic

44. Waugh N, Cummins E, Royle P, et al. Faecal calprotectin testing for differentiat-

therapies for inflammatory bowel disease in the USA. Aliment Pharmacol Ther.

ing amongst inflammatory and non-inflammatory bowel diseases: systematic

2018;47(3):364-370.

review and economic evaluation. Health Technol Assess. 2013;17(55):xv-xix, 1-211.

29. Stapley SA, Rubin GP, Alsina D, et al. Clinical features of bowel disease in

45. Walker GJ, Moore L, Heerasing N, et al. Faecal calprotectin effectively

patients aged <50 years in primary care: a large case-control study. Br J Gen

excludes inflammatory bowel disease in 789 symptomatic young adults

Pract. 2017;67(658):e336-e344.

with/without alarm symptoms: a prospective UK primary care cohort study.

30. Gikas A,Triantafillidis JK.The role of primary care physicians in early diagnosis

Aliment Pharmacol Ther. 2018;47(8):1103-1116.

and treatment of chronic gastrointestinal diseases. Int J Gen Med. 2014;7:159-173.

46. Yang Z, Clark N, Park KT. Effectiveness and cost-effectiveness of measuring

31. Harbord M, Annese V, Vavricka SR, et al. The first European Evidence-based

fecal calprotectin in diagnosis of inflammatory bowel disease in adults and

consensus on extra-intestinal manifestations in inflammatory bowel disease.

children. Clin Gastroenterol Hepatol. 2014;12(2):253-262.e2.

J Crohns Colitis. 2016;10(3):239-254.

47. Shah SC, Colombel JF, Sands BE, Narula N. Mucosal healing is associated with

32. Long MD. Assessing extraintestinal manifestations of IBD. Gastroenterol

improved long-term outcomes of patients with ulcerative colitis: a systematic

Hepatol (N Y). 2015;11(2):118-120.

review and meta-analysis. Clin Gastroenterol Hepatol. 2016;14(9):1245-1255.e8.

33. Card TR, Siffledeen J, Fleming KM. Are IBD patients more likely to have a

48. Humira [package insert]. North Chicago, IL: AbbVie Inc; 2017.

prior diagnosis of irritable bowel syndrome? Report of a case-control study

49. Cimzia [package insert]. Smyrna, GA: UCB Inc; 2018.

in the General Practice Research Database. United European Gastroenterol J.

50. Simponi [package insert]. Horsham, PA: Janssen Biotech Inc; 2018.

2014;2(6):505-512.

51. Remicade [package insert]. Horsham, PA: Janssen Biotech Inc; 2017.

34. Crohn’s & Colitis Foundation of America (CCFA) National Headquarters.

52. Tysabri [package insert] Cambridge, MA: Biogen Inc; 2017.

Guidelines for IBD Advanced Provider. http://www.crohnscolitisfoundation.

53. Entyvio [package insert]. Deerfield, IL:Takeda Pharmaceuticals America Inc; 2018.

org/science-and-professionals/programs-materials/ibd-nurses/best-practices/

54. Stelara [package insert]. Horsham, PA: Janssen Biotech Inc; 2018.

guidelines-for-ibd-app.pdf. Published July 17, 2014. Accessed April 25, 2018.

55. Colombel JF, Rutgeerts PJ, Sandborn WJ, et al. Adalimumab induces

35. Parkes GC, Whelan K, Lindsay JO. Smoking in inflammatory bowel disease:

deep remission in patients with Crohn’s disease. Clin Gastroenterol Hepatol.

impact on disease course and insights into the aetiology of its effect. J Crohns

2014;12(3):414-422.e5.

Colitis. 2014;8(8):717-725.

56. Colombel JF, Rutgeerts P, Reinisch W, et al. Early mucosal healing with inf-

36. Vavricka SR, Spigaglia SM, Rogler G, et al. Systematic evaluation of risk

liximab is associated with improved long-term clinical outcomes in ulcerative

factors for diagnostic delay in inflammatory bowel disease. Inflamm Bowel Dis.

colitis. Gastroenterology. 2011;141(4):1194-1201.

2012;18(3):496-505.

57. Colombel JF, Reinisch W, Mantzaris GJ, et al. Randomised clinical trial: deep

37. Ricciuto A, Fish JR, Tomalty DE, et al. Diagnostic delay in Canadian children

remission in biologic and immunomodulator naive patients with Crohn’s dis-

with inflammatory bowel disease is more common in Crohn’s disease and

ease - a SONIC post hoc analysis. Aliment Pharmacol Ther. 2015;41(8):734-746.

associated with decreased height. Arch Dis Child. 2018;103(4):319-326.

58. Lewis JD, Scott FI, Brensinger CM, et al. Increased mortality rates with prolonged

38. Nguyen VQ, Jiang D, Hoffman SN, et al. Impact of diagnostic delay and

corticosteroid therapy when compared with antitumor necrosis factor-alpha-direct-

associated factors on clinical outcomes in a U.S. inflammatory bowel disease

ed therapy for inflammatory bowel disease. Am J Gastroenterol. 2018;113(3):405-417.

cohort. Inflamm Bowel Dis. 2017;23(10):1825-1831.

59. Herfarth HH, Kappelman MD, Long MD, Isaacs KL. Use of methotrexate in the

39. Sandborn W, Binion D, Persley K, et al. AGA Institute Guidelines for the

treatment of inflammatory bowel diseases. Inflamm Bowel Dis. 2016;22(1):224-233.

Identification, Assessment and Initial Medical Treatment in Crohn’s Disease:

60. Case DJ, Copeland LA, Stock EM, et al. Pneumococcal vaccination rates in VHA

Clinical Decision Support Tool [300-086PNQ_14-1]. http://campaigns.gastro.org/

patients with inflammatory bowel disease. Medicine (Baltimore). 2015;94(6):e417.

algorithms/IBDCarePathway/pdf/IBDCarePathway.pdf. Accessed March 20, 2018.

61. Caldera F, Saha S, Wald A, et al. Comparing guideline-based care quality

40. Dassopoulos T, Cohen R, Scherle R, et al. American Gastroenterological Asso­

for inflammatory bowel disease and rheumatoid arthritis patients within a

cia­tion. Identification, assessment and initial medical treatment of ulcerative colitis.

medical home. Expert Rev Gastroenterol Hepatol. 2016;10(6):759-766.

Clinical care pathway. https://s3.amazonaws.com/aga-guidelines/pdf/ibd/Ulcerative_

62. Pandey N, Herrera HH, Johnson CM, et al. Preventative care for patients

Colitis_Care_Pathway.pdf. Published September 5, 2014. Accessed March 20, 2018.

with inflammatory bowel disease in the Veterans Health Administration.

41. Magro F, Gionchetti P, Eliakim R, et al. Third European Evidence-Based

Medicine (Baltimore). 2016;95(27):e4012.

Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: defini-

63. Reich J, Wasan SK, Farraye FA. Vaccination and health maintenance issues

tions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance,

to consider in patients with inflammatory bowel disease. Gastroenterol

surgery, and ileo-anal pouch disorders. J Crohns Colitis. 2017;11(6):649-670.

Hepatol (N Y). 2017;13(12):717-724.

42. Annese V, Daperno M, Rutter MD, et al. European evidence based consensus for

64. Chan K, Mok C. Glucocorticoid-induced avascular bone necrosis: diagnosis

endoscopy in inflammatory bowel disease. J Crohns Colitis. 2013;7(12):982-1018.

and management. Open Orthop J. 2012;6:449-457.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 43

CME FEATURED COURSE

65. Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and

hepatotoxicity during azathioprine therapy. Neth J Med. 2005;63(11):444-446.

management of the complications of systemic corticosteroid therapy.

69. Neoral [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2017.

Allergy Asthma Clin Immunol. 2013;9(1):30.

70. Rubin DT, Krugliak Cleveland N. Using a treat-to-target management

66. Lemaitre M, Kirchgesner J, Rudnichi A, et al. Association between use of

strategy to improve the doctor-patient relationship in inflammatory bowel

thiopurines or tumor necrosis factor antagonists alone or in combination

disease. Am J Gastroenterol. 2015;110(9):1252-1256.

and risk of lymphoma in patients with inflammatory bowel disease. JAMA.

71. Siegel CA, Lofland JH, Naim A, et al. Gastroenterologists’ views of shared

2017;318(17):1679-1686.

decision making for patients with inflammatory bowel disease. Dig Dis Sci.

67. Teich N, Mohl W, Bokemeyer B, et al. Azathioprine-induced acute

2015;60(9):2636-2645.

pancreatitis in patients with inflammatory bowel diseases—a prospective

72. Reich JS, Miller HL, Wasan SK, et al. Influenza and pneumococcal

study on incidence and severity. J Crohns Colitis. 2016;10(1):61-68.

vaccination rates in patients with inflammatory bowel disease. Gastroenterol

68. de Boer NK, Mulder CJ, van Bodegraven AA. Myelotoxicity and

Hepatol (N Y). 2015;11(6):396-401.

CME CE

POSTTEST Expiration date: July 31, 2019

A statement of credit will be issued only upon receipt of a completed pre-assessment test, polling questions, activity evaluation form, and post-test with a score of 70% or higher. All components must be completed and submitted online at ClinicalAdvisor.com/July18feature.

CREDITS: 1.00 | Smoothing the course of IBD: A collaborative approach to care

1. Which of the following sets of findings is most consistent with a diagnosis of IBD? a. Young adult patient with abdominal pain during the day at work but with no pain or other GI symptoms at night, no change in bowel habits, no blood during stool passage, and no rectal bleeding b. Adolescent patient with a family history of IBD, rectal bleeding, and bloody nocturnal diarrhea that awakens the patient c. Older adult with diarrhea and anemia without rectal or any other identified source of bleeding d. College student with diarrhea that started during and after a 3-week trip volunteering in rural India 2. Which of the following best describes the relationship between smoking and IBD? a. IBD occurs more commonly among patients with a pack-a-day cigarette smoking habit b. Cigarette smoking raises the risk of progression in CD and UC c. Cigarette smoking raises the risk of CD progression but is associated with a milder disease course in UC d. No identified relationship between smoking and IBD 3. A definitive diagnosis of IBD is based on: a. Colonoscopy with biopsies for UC and CD, as well as small bowel imaging for CD b. Colonoscopy for UC and CD c. Patient history, physical examination, and blood/stool analyses d. Patient history, physical examination, laboratory tests ruling out infectious causes of symptoms, and a fecal calprotectin value consistent with IBD

4. Anti-TNF therapy for IBD is: a. Recommended only for patients who develop side effects to the first-line treatment: long-term cortico­ steroid therapy b. A first-line option for those with moderate or severe disease, but only in combination with a thiopurine c. The only category of biologic agents recommended for use in IBD therapy d. Associated with decreased mortality, infections, and osteoporosis in comparison with prolonged cortico­ steroid therapy.

5. Which of the following best reflects the American College of Gastroenterology recommendation regarding the primary care provider’s role in caring for a patient with IBD? a. Turn over all aspects of both GI and general medical care to the GI provider managing the patient’s IBD b. Deliver health maintenance services as one would to any other individual of that patient’s age and gender, as neither IBD nor its therapies affect these services c. Assume responsibility for delivering or coordinating delivery of vaccinations and other preventive health services, with input from GI providers about how the patient’s IBD and IBD therapies affect these issues d. Assume that the GI provider managing the patient’s IBD will notify the primary provider about the patient’s health maintenance needs

TO TAKE THE POSTTEST please go to: ClinicalAdvisor.com/July18feature

44 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

Dermatology Clinic CASE #1

Irritative lesions in the abdomen and genital region THANH DANG, BA, JOAN FERNANDEZ, BS, CHRISTOPHER RIZK, MD

A 43-year-old African American woman presents to the clinic with irritative lesions in the folds of her abdomen and in her genital region as well as painful ulcers in her oral mucosa.The patient reports noticing some flaccid blisters in addition to the lesions she presents with. On examination, erythematous, vegetative lesions are found. She states that the affected areas are painful but not pruritic. She has a previous history of herpes simplex virus (HSV).

What is your diagnosis? Turn to page 46

CASE #2

Horn-like projection on a man’s skull YELENA DOKIC, BSA, JOAN FERNANDEZ, BS, CHRISTOPHER RIZK, MD

A 60-year-old man presents to the clinic with a 1-cm long horn-like projection coming from the skin on the superior aspect of the skull just lateral to midline. The structure is yellowish-white in color and feels very firm to the touch.

He states that he noticed a small, hard lesion a few months ago and that it has grown progressively larger from the time of initial presentation to now. The patient denies any pain at rest but states that he experiences pain when the lesion is struck accidentally.

What is your diagnosis? Turn to page 48 www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 45

Dermatology Clinic CASE #1

Pemphigus vegetans

Pemphigus vegetans is a rare variant of pemphigus vulgaris, an autoimmune bullous disease of the skin and mucous membranes.1-2 This disease presents as a reactive pattern of the skin in response to the autoimmune insult incurred in pemphigus vulgaris.The vegetans variant occurs in less than 5% of all pemphigus vulgaris cases, and only 1% to 2% of cases are seen in children, with the vast majority of cases presenting in middle-aged women.2- 4 These epidemiologic characteristics are similar to pemphigus vulgaris, in which the average age of onset in the United States ranges from 50 to 60 years of age, with women 5 times more likely to be affected then men.5 If left untreated, pemphigus vulgaris has been shown to be uniformly fatal within 5 years as a result of the severe blistering of the skin and mucous membranes that is seen in the disease, which leads to malnutrition, dehydration, and sepsis.5 Pemphigus vegetans is characterized by purulent lesions that evolve to form vegetative plaques, often affecting intertriginous areas, including the axillary, anogenital, inguinal, and mammary regions, as well as areas on the scalp and face.2, 5-6 When the disease spreads to include mucosal sites, areas of involvement can include the oropharyngeal, upper esophageal, vaginal, nasal, and conjunctival mucosa, with the oropharyngeal mucosa being the most commonly affected.

Additionally, cerebriform changes of the tongue and desquamative gingivitis can also be observed.7 Although many different manifestations of the disease are possible, the most characteristic finding seen in pemphigus vegetans is the presence of vegetating plaques at the site of cutaneous erosions.

Pemphigus vegetans is categorized under one of two subtypes: Neumann and Hallopeau.The Neuman subtype is more aggressive and occurs more frequently.2 Early manifestations of disease may resemble pemphigus vulgaris with the formation of vesicles and bullae; however in Neuman pemphigus vegetans these lesions will progress to form dry, hyperkeratotic plaques with fissures that persist for long periods of time.7 Additionally, periorificial papillomatous vegetations are often present.1 The Hallopeau pemphigus vegetans subtype is less aggressive and is characterized by pustules that evolve into vegetations, usually involving the intertriginous areas.1-2 As with pemphigus vulgaris, the pathogenesis of pemphigus vegetans involves autoantibodies against desmoglein 3 (Dsg3) +/- desmoglein 1 (Dsg1).1 Mucosal dominant disease is

associated with Dsg3 antibodies, while mucocutaneous disease is associated with Dsg3 and Dsg1. Some cases of pemphigus vegetans are associated with IgG and IgA antibodies against desmocollins, although this association has yet to be clearly elucidated.1 The mechanisms surrounding the autoimmune system’s attack on desmogleins are unknown, although certain MHC class II molecules have been implicated in pemphigus vulgaris and could potentially play a role in pemphigus vegetans as well (HLA DRB1*0402 and DQB1*0503).1 The paucity of research on the epidemiologic characteristics of pemphigus vegetans has made it difficult to identify associated risk factors. It is assumed that the risk factors for pemphigus vegetans are the same as those of pemphigus vulgaris, which have been more extensively studied. Risk factors for pemphigus vulgaris are associated with herpes simplex virus, exposure to pesticides and metal vapor, and an increased number of pregnancies.8,9

Initial treatment typically consists of a high-dose systemic corticosteroid and a steroid-sparing immunosuppressant.

Punch or shave biopsy obtained from an affected area in a patient with pemphigus vegetans followed by histopathologic examination may or may not demonstrate epidural blister formation; however, suprabasal acantholysis resulting in a blister just above the basal cell layer is usually seen.7 While the basal keratinocytes remain attached to the basement membrane by hemidesmosomes, they lose attachments to each other, resulting in the “row of tombstones” that is classically described in pemphigus vulgaris.10 Additionally, most blisters will demonstrate a neutrophilic and or eosinophilic pustule or abscess in the epidermis with associated acantholysis and epidermal hyperplasia.1,3 Because the occurrence of pemphigus vegetans is so rare, it is important to consider diseases that can cause a similar presentation when formulating a differential.The exclusion of more common diseases on the differential is a large part of the process that must occur to accurately diagnose pemphigus vegetans. Bacterial infections caused by enterococcus faecalis, E coli, morganella morganii, and gram-postive cocci, as well as multiple types of fungal infections, should be considered on the differential with pemphigus vegetans. Other diseases to test for and rule out include vegetating herpes simplex infection, acrodermatitis continua supperativa, proderma gangraneosum, Bowen’s disease, and squamous cell carcinoma.1

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Continues on page 48

Dermatology Clinic The diagnosis of pemphigus vegetans is confirmed via the identification of autoantibodies to the keratinocyte cell surface, either by direct/indirect immunofluorescence or ELISA. Skin biopsy followed by immunofluorescence microscopy stains keratinocytes positive for IgA and IgG antibody, and, sometimes, C3 intracellular deposits in the epidermis.7,9 Further confirmation for a diagnosis of pemphigus vegetans can be obtained with ELISA detection of anti-Dsg3 and/ or anti-Dsg1 antibodies, similar to the ELISA findings seen in pemphigus vulgaris.1 Of note, antigen-specific ELISAs have been found to be more sensitive and specific (>97%) for pemphigus vulgaris than indirect immunofluorescence; however, there has been limited use of it as a diagnostic tool for pemphigus vegetans.7 Treatment for pemphigus vegetans is similar to the treatment for pemphigus vulgaris—long-term systemic corticosteroids.1,4 The initial treatment typically consists of a high-dose systemic corticosteroid, such as prednisolone, along with a steroid-sparing immunosuppressant, such as azathioprine.2 However, long-term treatment with systemic corticosteroids is associated with adverse side effects, so the risks and benefits of treatment must be considered and the patient counseled appropriately. In addition to steroid therapy, antibiotics should be administered if a coexisting infection is present.3 As always, supportive care with intravenous fluids and nutritional supplementation should be administered as necessary.

In this case, a biopsy of the lesion was performed and histopathologic examination showed a “row of tombstones” appearance. Direct immunofluorescence microscopy stained positive for IgA and IgG antibodies and anti-Dsg3 antibodies were detected with ELISA. After ruling out other diagnoses, the patient was found to have pemphigus vegetans. She was started on high-dose corticosteroid therapy and the lesions are improving.

Thanh Dang, BA, is a medical student, Joan Fernandez, BS, is a medical student, and Christopher Rizk, MD, is a dermatology resident at the Baylor College of Medicine in Houston.

References 1. Mergler R, Kerstan A, Schmidt E, Goebeler M, Benoit S. Atypical clinical and serological manifestation of pemphigus vegetans: a case report and review of the literature. Case Rep Dermatol. 2017;9:121-130.

2. Pollmann R, Schmidt T, Eming R, Hertl M. Pemphigus: a comprehensive review on pathogenesis, clinical presentation and novel therapeutic approaches.

Clin Rev Allerg Immunol. 2018;54:1-25.

3. Song Z, Li Q, Lin J, Han S. Pemphigus vegetans with the manifestations of

4. Suwarsa O, Sutedja E, Dharmadji H, et al. The rare case of pemphigus vegetans in association with malnutrition children in the multidisciplinary management. Case Rep Dermatol. 2017;9:145-150.

5. Kridin K. Pemphigus group: overview, epidemiology, mortality, and comorbidities. Immunol Res. 2018;66:255-270.

6. Khatib Y, Makhija M, Patel R, Karad G. Pemphigoid vegetans in childhood: A case report and short review of literature. Ind J Dermatol. 2015;60:422.

7. Sukakul T, Varothai S. Chronic paronychia and onychomadesis in pemphigus vegetans: an unusual presentation in a rare autoimmune disease. Case Rep Med. 2018 Jan 11;2018:5980937.

8. Brenner S, Tur E, Shapiro J, et al. Pemphigus vulgaris: environmental factors. Occupational, behavioral, medical, and qualitative food frequency questionnaire. Int J Dermatol. 2001;40:562-569.

9. Marchalik R, Reserva J, Plummer MA, Braniecki M. Pemphigus vegetans with coexistent herpes simplex infection and deep venous thrombosis of the lower extremities. BMJ Case Reports. 2015 Jul 15;2015.

10. Clinical and pathological study of autoimmune vesiculobullous disorders.

J Pakistan Assoc Dermatol. 2017;27:270.

CASE #2

Cutaneous horn

A cutaneous horn, also known as cornu cutaneum, is a benign keratinized skin tumor characterized by an unusual conical outgrowth from the surface of the skin.This horn-like growth is typically yellowish-white in color and emerges unpredictably from the surface of the skin. The first well-documented case of a cutaneous horn was in an elderly woman named Margaret Gryffith in 1588 in London. Because her condition was so unique, a showman put her on display in an attempt to earn money.This lesion was not recognized in the medical community until 1791, when it was described and operated on by Everard Home.1 Cutaneous horns are typically found in sun-exposed areas, including the face, ears, and hands.2 Thus, sun exposure is considered to be the major risk factor for their development.

These lesions can arise from actinic keratoses and squamous cell carcinomas, and because of this, lighter-skinned individuals are at a greater risk than are individuals with darker skin.2 The incidence of cutaneous horns is equal in males and females; however, males have been noted to have a slightly higher incidence of premalignant lesions than age-matched

acrodermatitis continua: A rare variant. J Dermatol. 2017;45:e41-e42.

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Continues on page 50

Dermatology Clinic females.3 Also, it is important to note that the risk of cutaneous horn development increases with age, and lesions are most commonly seen in patients who are in their 60s and 70s.3 Although more common in certain individuals, overall, cutaneous horns are considered to be fairly rare.

There are several potential etiologies leading to the development of a cutaneous horn, but common to all is the hyperkeratosis that results from an underlying hyper-proliferative lesion.

The specific etiology can be determined by examining the base of the horn. Malignant conditions, such as squamous cell carcinoma, as well as premalignant conditions, such as actinic

Treatment for cutaneous horns includes complete excision of the lesion with clear margins and cauterization of the base. keratosis, can cause a cutaneous horn to form.4,5 However, not all cutaneous horns are derived from premalignant or malignant lesions.There are also many benign lesions from which cutaneous horns can arise, some of which include: epidermal nevi, seborrheic keratosis, human papilloma virus–associated verruca vulgaris, molluscum contagiosum, cutaneous leishmaniasis and hypertrophic lichen planus.6-8 In addition to these associations, there have also been some rare case reports that have documented cornu cutaneum arising from angiokeratomas, psoriasis, discoid lupus, and Kaposi sarcoma. Cutaneous horns are most commonly associated with benign conditions; however, underlying premalignant or malignant lesions have been identified in approximately one-third of cases.2,8-9 When diagnosing a cutaneous horn, a shave biopsy is the initial step.The biopsy is necessary to identify the underlying etiology that is resulting in horn formation. The biopsy is taken at the base of the horn, and it is crucial that the biopsy goes deep enough to capture the cells in the basal layer of the epithelium so that they can be visualized under microscopy.

Characteristic findings observed on histologic examination of cutaneous horns include visualization of keratin derived from the epidermal layer (including a granular layer), compact hyperkeratosis, and associated acanthosi towards the base of the specimen.2,4,6 Because cutaneous horns can arise from a variety of lesions, the histologic findings at the base of the lesion will be unique to each underlying disease process.2 Variations from the typical cutaneous horn histologic findings exist and may include the observation of epidermal hyperplasia without atypia, as well as the presence of deep red granules instead of a granular layer, as in the case of a trichilemmal horn.10

Treatment for cutaneous horns includes complete excision of the lesion with clear margins, followed by cauterization of the base. Depending on the size of the defect, a skin graft may be required to assist with primary closure. Depending on the etiology of the cutaneous horn, additional treatments may be required, particularly if the underlying lesion is malignant.

Depending on the size and location, squamous cell carcinomas with overlying cutaneous horns can be treated by wide local excision or MOHS surgery. Although the removal of the cutaneous horn is important for comfort and cosmetic purposes, the main goal should be identification and appropriate treatment of the underlying disease.2 Our patient described in this vignette was diagnosed with a cutaneous horn based on his clinical examination.

He underwent a shave biopsy with subsequent surgical excision of the horn. The histologic results of the biopsy suggested that the horn was due to a malignancy squamous cell carcinoma.The patient was referred for MOHS surgery for definitive treatment of the squamous cell carcinoma. He was extremely satisfied with the horn removal and has not reported any recurrences. ■ Yelena Dokic, BSA, is a medical student, Joan Fernandez, BS, is a medical student, and Christopher Rizk, MD, is a dermatology resident at the Baylor College of Medicine in Houston.

References 1. Bondeson J. Everard Home, John Hunter, and cutaneous horns: a historical review. Am J Dermatopathol. 2001;23:362-369.

2. Phulari RG, Rathore R, Talegaon TP, Shah A. Cutaneous horn: A mask to underlying malignancy. J Oral Maxillofac Pathol. 2018;22(Suppl 1):S87-S90.

3. Yu RC, Pryce DW, Macfarlane AW, Stewart TW. A histopathological study of 643 cutaneous horns. Br J Dermatol. 1991;124:449-452.

4. Kusumesh R, Ambastha A, Bhadrapriya, Singh S. Well-differentiated ­squamous cell carcinoma presenting as branched eyelid cutaneous horn: a case report with review of literature. Ind Dermatol Online J. 2017;8:261-263.

5. Park H, Kim W, Kim H, Yeo H. Cutaneous horn in premalignant and malignant conditions. Arch Craniofac Surg. 2016;17:25-27.

6. Bains A, Bagga N, Vedant D, Bhardwaj A, Nalwa A. A case of cutaneous horn arising in verrucous epidermal nevus. Ind J Dermatol Venereol Leprol. 2018 Mar 12.

7. Chen S, Zhou Y, Xia X, Song W. Cutaneous horn masquerading as a seborrheic keratosis. Am J Ophthalmol Case Rep. 201631;4:64-66.

8. Karthikeyan K. Penile cutaneous horn: An enigma-newer insights and perspectives. Indian J Sex Transm Dis. 2015;36:26-29.

9. Kost DM, Smart DR, Jones WB, Bain M. A perforating pilomatricomal horn on the arm of an 11-year-old girl. Dermatol Online J. 2014;16;20:22371.

10. Haro R, González-Guerra E, Fariña MC, Martín-Moreno L, Requena L. Trichilemmal horn: a new case and review of the literature. Actas Dermosifiliogr. 2009;100:65-68.

50 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

Dermatologic Look-Alikes Dark patch of skin ZACHARY SOLOMON, BA, JOAN FERNANDEZ, BS, CHRISTOPHER RIZK, MD

CASE #1

CASE #2

A 1-month old male infant whose family recently moved to the area presents to your office to establish care. The patient’s father says that he was born with “a patch of raw skin,” but he cannot recall the specific diagnosis.The patient is otherwise healthy and developing normally; there is no family history of similar occurrences. They were instructed to apply Vaseline ointment twice a day and to cover the defect with gauze.

A 6-year-old female is brought to your office by her parents for the evaluation of a “spider web birthmark” on her left leg. The lesion has been present since birth. The girl’s parents report that the lesion was initially darker in color but has regressed over time. It does not bleed or itch and has never ulcerated. The patient otherwise enjoys good health, and nobody in her family has ever had a similar condition.

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Dermatologic Look-Alikes CASE #1

Aplasia cutis congenita

Aplasia cutis congenita (ACC) is a rare congenital condition present at birth characterized by absence of the skin.1 The first description of the condition affecting the extremities dates from 1767, and the first report of skull involvement was from 1826.2 Roughly 80% of cases involve the skin overlying the skull, and 15% to 30% of those cases feature deeper involvement of underlying structures such as the epicranial aponeurosis, the skull itself, or even the dura or cerebrovasculature.3 The incidence of ACC is estimated to be about 3 in 10,000 live births.4 However, given the heterogeneity of the disease in terms of severity, the true incidence is likely higher as milder cases are thought to be underreported.5 ACC can be an isolated finding, or it can coexist with other syndromic features, such as in Trisomy 13,Adams-Oliver syndrome, Johanson-Blizzard syndrome, and Golt syndrome, among others.3,6 The etiology of ACC is thought to be multifactorial.When ACC exists as part of a syndrome, certain genes have been implicated, such as in Adams-Oliver Syndrome.6 For isolated ACC, genetic influence is still likely as both autosomal dominant and recessive inheritance patterns have been described.7 Sporadic ACC has several proposed etiologies, mostly related to perinatal insults, including intrauterine infections, vascular insufficiency or placental infarcts, amniotic membrane adhesions, ectodermal dysplasia, neural tube defects, or teratogenic effects.8 Several case series have implicated methimazole exposure during pregnancy to ACC, and other drugs such as carbamazepine, misoprostol, and valproic acid also have proposed associations.9 Outside of known family history or genetic syndromes, along with exposure to previously discussed teratogens, there are few established risk factors for ACC. However, it has been noted to be more common in females than in males.8 Diagnosis of ACC can be difficult given its highly varied presentation. The defect can range from large with associated skull deformities to small atrophic scars present on the extremities.7 The morphology of the lesions is also highly variable, with reports ranging from multiple bullous ulcers arranged along blaschkos lines to membranous corporal stellate lesions.7,10 The hair collar sign (long, dark hair encircling the lesion), midline lesions, and nodular features can be important clues to suggest deeper involvement.4 Histologic analysis reveals the absence of structures such as sweat and sebaceous glands, hair follicles, and collagen in the dermis.8 The Freiden

classification is commonly used to help specify the location of the lesions and any associated syndromes or features.11 The diagnosis of ACC is based primarily on clinical features.

For larger defects, there is a possibility of making a prenatal diagnosis via ultrasound, although the vast majority of cases are diagnosed postnatally.5,8 The differential diagnosis includes: neonatal herpes simplex, other developmental defects including atretic cephalocele or heterotopic brain or glial tissues, bullous impetigo, or trauma from forceps, vacuum extractors, or even scalp electrodes.7 One must exclude epidermolysis bullosa, a group of genetic bullous disorders characterized by extremely fragile skin.7 After diagnosis of ACC, it is important to evaluate for other

There is no treatment consensus for ACC, but the general goal should be the complete and stable coverage of the defect. associated anomalies that could have important management or diagnostic implications.7 For example,Adams-Oliver syndrome should be suspected with ACC associated with malformations of the limbs or digits or in a patient with a strong family history.7 A patient with coexisting nevus sebaceous or a large pigmented nevi should be evaluated for SCALP syndrome, which would mandate an MRI.12 As mentioned, large scalp defects or those with concerning features such as the hair collar sign should also raise the possibility of skull and dural involvement.7,8 There is no treatment consensus for ACC, but the general goal should be complete and stable coverage of the defect to avoid infectious complications.7 The general health of the infant, as well as the size and location of the lesion, should all be taken into consideration when formulating a treatment plan.7 For smaller lesions, conservative management with simple dressing changes can be adequate.7 Treatment options for more significant lesions range from topical bacitracin, betadine, silver sulfadiazine, or even synthetic biologic skin substitutes.7 Larger defects may require surgical interventions, including skin grafting, excision and closure, and tissue expansion.7 Common complications include infections, desiccation with bleeding, and delayed healing.7 For many cases, atrophic plaques, prominent scars and cicatricial alopecia are common after healing of the defect.7 The patient described in this case was diagnosed with ACC based on history and clinical examination.A thorough evaluation revealed no associated abnormalities to suggest syndromic ACC. Conservative management with Vaseline and dressing changes was continued. At the 3-month follow-up appointment the patientâ&#x20AC;&#x2122;s lesion had healed without complications.

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Dermatologic Look-Alikes CASE #2

Cutis marmorata telangiectatica congenita

Cutis marmorata telangiectatica congenita (CMTC) is an uncommon and heterogeneous congenital vascular abnormality that can present with a broad spectrum of morphologies, distribution, and sizes.13 The condition closely resembles cutis marmorata, a benign and transient reticular mottling pattern of the skin that is normally seen in newborn infants secondary to dilatation of small superficial vessels in response to cold temperatures.14 It was first characterized byVan Lohuizen in 1922 and has taken many different names, including Van Lohuizen syndrome, congenital livedo reticularis, and congenital generalized phlebectasia, among others.15 Although the condition is generally benign, estimates for patients with associated abnormalities range from 20% to 80%.14,16 CMTC is a relatively rare condition, with roughly 300 reported cases.15 However, given that the condition is often localized, heterogenous in terms of size, presents with few complications, and can ultimately regress, it is likely to be underreported.16 The pathogenesis underlying CMTC is currently unknown.

One theory postulates that CMTC is due to a failure of mesodermic vessels in an early embryologic stage, while others suggest

it is secondary to peripheral neural dysfunction.13 Teratogenic or environmental exposures might also play a role, as there have been reports of geo-temporal clustering.13 Many have speculated that the disease demonstrates a mosaic pattern of inheritance, as there are no reported cases of whole body involvement.16 There are also few reported familial cases, which along with the absence of whole body involvement, could be explained by the lethal gene theory.13 There are few established risk factors for the development of CMTC. In several case series, a slight preponderance for males has been noted, as has a tendency for infants born to fathers with increased paternal age.17 Clinically, the condition is characterized by the presence of persistent skin changes typical of cutis marmorata type with accompanying telangiectasias.16 Patients may also display contiguous skin atrophy or ulcerations.16 In most cases, the lesions tend to involute and can spontaneously and completely resolve later in life.16 Histologic analysis normally reveals an increase in both the number and size of capillaries and veins, but it has been shown to be inconsistent for diagnosis and is typically not necessary.18,19 The differential diagnosis for CMTC includes physiologic cutis marmorata, persistent cutis marmorata, reticular capillary malformations (port-wine stain), and neonatal lupus erythematous.14,19 Physiologic cutis marmorata should regress after several weeks, and persistent cutis marmorata is a separate diagnosis seen in Down syndrome, de Lange syndrome, and homocystinuria.14 CMTC can also exist as a feature of certain syndromes; thus, a thorough history and physical should seek to evaluate for other concerning

TABLE 1. Aplasia cutis congenita vs cutis marmorata telangiectatica congenita Aplasia cutis congenita2,4-5,7-10

Cutis marmorata telangiectatica congenita13-14,16-18

Dermatologic Presentation

Focal regions of dermal aplasia with varying morphology. Can have Purplish reticulated vasculature visible through skin, resembles underlying osseous defects. Normally on scalp but can appear anywhere. cutis marmorata of the newborn. Can involve any area of body.

Associations

Normally isolated finding, but can be associated with SCALP syndrome, Adams-Oliver syndrome, Trisomy 13, Johanson-Blizzard syndrome, Golt syndrome.

Normally isolated finding, but can be associated with Limb length discrepancies, macrocephaly-CMTC syndrome, Adams-Oliver syndrome, Bockenhemier syndrome, and Klippel-TrĂŠnaunay syndrome. Other sporadic ocular and neurologic associations.

Etiology

Unknown, perinatal insult (teratogen, infection, placental insufficiency) versus genetic influence.

Unknown, teratogen versus genetic. Mosaic lethal gene theory.

Histology

Absence of structures such as sweat and sebaceous glands, hair follicles, and collagen in the dermis.

Increase in both the number and size of capillaries and veins.

Unreliable and generally not necessary for diagnosis

Diagnosis

Clinical diagnosis. Histology and hair collar sign can be helpful.

Must evaluate for associated anomalies.

Clinical diagnosis. Generally diagnosed when neonatal cutis marmorata does not regress or is extensive. Proposed criteria discussed in text. Must evaluate for associated anomalies.

Treatment

Varied treatment from conservative daily dressing to topical ointments to major surgical interventions.

Treatment generally unnecessary, condition is normally self-resolving.

60 THE CLINICAL ADVISOR â&#x20AC;˘ JULY 2018 â&#x20AC;˘ www.ClinicalAdvisor.com

anomalies.14 Specific syndromes include: macrocephaly-CMTC syndrome (macrocephaly, CMTC, asymmetric of head, face or body, developmental delay) and Adams-Oliver syndrome (ACC, CMTC, abnormalities of hands or feet, neurologic problems).14,17 Many patients also have associated abnormalities not consistent with named syndromes, including limb length discrepancies, hemangiomas, ocular abnormalities, cardiac malformations, hypospadias, stenotic large vessels, and café au lait spots.14,19 Diagnostic criteria for CMTC have been proposed and include demonstration of all three major criteria: (1) congenital reticular erythema; (2) absence of venectasia; (3) unresponsive to

5. Hioki T, Takama H, Makita S, Akiyama M. Infant bald patch: ultrasonographic diagnosis of aplasia cutis congenita. J Eur Acad Dermatology Venereol.

2017;31:e276-e277. doi:10.1111/jdv.14018.

6. Jones KM, Silfvast-Kaiser A, Leake DR, Diaz LZ, Levy ML. Adams-Oliver syndrome type 2 in association with compound heterozygous DOCK6 mutations. Pediatr Dermatol. 2017;34:e249-e253. doi:10.1111/pde.13239.

7. Humphrey SR, Hu X, Adamson K, Schaus A, Jensen JN, Drolet B. A practical approach to the evaluation and treatment of an infant with aplasia cutis congenita. J Perinatol. 2018;38:110-117. doi:10.1038/jp.2017.142.

8. Shrager S, Voin V, Iwanaga J, Tubbs RS, Johnston J. Extreme aplasia cutis congenita involving the skull. Child Nerv Syst. 2017;33:1395-1398. doi: 10.1007/s00381-017-3426-x.

9. Cristina R, Sorahaya G, Angela H, Nuria P, Rosalba S, Antonio T.

CMTC is characterized by persistent skin changes typical of cutis marmorata type with accompanying telangiectasias.

Aplasia cutis congenita and other anomalies associated with ­methimazole exposure during pregnancy. Pediatr Dermatol. 2011;28:743-745. doi:10.1111/j.1525-1470.2011.01572.x.

10. Kwon HS, Lee JH, Bae JM, Kim GM. Case of linear bullous aplasia cutis congenita. J Dermatol. 2017;44:e310-311. doi:10.1111/1346-8138.

13972.

warming—and two or more minor criteria: (1) fading within 2 years; (2) port-wine stain or (3,4,5) ulcerations, atrophy, or telangiectasias within the affected area.14 As the disorder is self-limiting and tends to regress, treatment is generally not necessary.18 However, the clinician should have a high index for suspicion in regards to associated abnormalities. It is suggested that after an initial screen for additional anomalies, yearly follow-ups should be done for a minimum of 3 years.14 A thorough history and physical of this patient revealed no evidence of limb abnormalities, developmental delays, or other concerning features.The patient continued to be followed in the clinic with gradual improvement at each visit. ■

11. Perry BM, Maughan CB, Crosby MS, Hadenfeld SD. Aplasia cutis congenita type V: a case report and review of the literature. Int J Dermatol.

2017;56:e118-121. doi:10.1111/ijd.13611.

12. Lam J, Dohil MA, Eichenfield LF, Cunningham BB. SCALP syndrome: Sebaceous nevus syndrome, CNS malformations, aplasia cutis congenita, limbal dermoid, and pigmented nevus (giant congenital melanocytic nevus) with neurocutaneous melanosis: A distinct syndromic entity. J Am Acad Dermatol. 2008;58:884-888. doi:10.1016/j.jaad.2007.09.029.

13. Amitai D Ben, Fichman S, Merlob P, Morad Y, Lapidoth M, Metzker A. Cutis marmorata telangiectatica congenita: ­clinical findings in 85 patients. Pediatr Dermatol. 2000;17:100-104. doi:10.1046/j.1525-1470.2000.01723.x.

14. Levy R, Lam JM. Cutis marmorata telangiectatica congenita: A mimicker of a common disorder. CMAJ. 2011;183. doi:10.1503/cmaj.091749.

Zachary Solomon, BA, is a medical student, Joan Fernandez, BS, is a medical student, and Christopher Rizk, MD, is a dermatology resident at the Baylor College of Medicine in Houston.

15. Kienast AK, Hoeger PH. Cutis marmorata telangiectatica congenita: A prospective study of 27 cases and review of the literature with proposal of diagnostic criteria. Clin Exp Dermatol. 2009;34:319-323. doi:10.1111/j.1365-2230.2008.03074.x.

References

16. De Maio C, Pomero G, Delogu A, Briatore E, Bertero M, Gancia P. Cutis

1. Tincopa Wong O, Pelaez Gutierrez R, Melendez Guevara G, Paoli Razuri C,

marmorata telangiectatica congenita in a preterm female newborn: case

Sanchez Aznaran N. [Aplasia cutis congenita. Report of 2 cases]. Med Cutan

report and review of the literature. La Pediatr Medica E Chir. 2014;36:578-583.

Ibero Lat Am. 1986;14:199-204.

doi:10.4081/pmc.2014.90.

2. Maillet-Declerck M, Vinchon M, Guerreschi P, et al. Aplasia cutis congenita:

17. Lapunzina P, Gairí A, Delicado A, et al. Macrocephaly-cutis marmorata

Review of 29 cases and proposal of a therapeutic strategy. Eur J Pediatr Surg.

telangiectatica congenita: Report of six new patients and a review. Am J Med

2013;23:89-93. doi:10.1055/s-0032-1322539.

Genet Part A. 2004;130A:45-51. doi:10.1002/ajmg.a.30235.

3. Silberstein E, Pagkalos VA, Landau D, et al. Aplasia cutis congenita:

18. Lunge SB, Mahajan P. Cutis marmorata telangiectatica congenita restricted

Clinical management and a new classification system. Plast Reconstr Surg.

to both breasts in a young female. Dermatol Pract Concept. 2014;4:89-92.

2014;134:766e–774e. doi:10.1097/PRS.0000000000000638.

doi:10.5826/dpc.0403a20.

4. Patel DP, Castelo-Soccio L, Yan AC. Aplasia cutis congenita: Evaluation

19. Van Schaik SM, Reneman L, Engelen M, Roos YBWEM, Poll-The BT.

of signs suggesting extracutaneous involvement. Pediatr Dermatol. 2018;35:

Strokelike episodes and cutis marmorata telangiectatica congenita. J Child

e59–61. doi:10.1111/pde.13340.

Neurol. 2014;30:129-132. doi:10.1177/0883073813516675.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 61

Advisor Forum These are letters from practitioners around the country who want to share their clinical problems and successes, observations, and pearls with their colleagues. Responding consultants are identified below. We invite you to participate.

MY MOST MEMORABLE PATIENT

Send us your letters with questions and comments to: Advisor Forum, The Clinical Advisor, 275 7th Avenue, 10th Floor, New York, NY 10001.You may contact us by e-mail at editor@ clinicaladvisor.com.

If you are writing in response to a published letter, please indicate so by including the number in parentheses at the end of each item. Letters are edited for length and clarity. The Clinical Advisor’s policy is to print the author’s name with the letter.

No anonymous contributions will be accepted.

MEDICAL LESSONS LEARNED I don’t often think of the 48 years I have been in medicine as an aggregate, but I do muse occasionally on changes that have occurred in my medical lifespan.

There are vaccines against hepatitis and human papilloma virus, the leading cause of death by cervical cancer. I was 5 years old when the first polio vaccines were given and among the first children in Chicago to receive it, thanks to my mother.

The one aggregate, though, that illustrates the leaps and bounds medicine has made during the course of my career is a guy named Jack. Jack had what we called “a stormy hospital course.”

I remember his case as clearly as I remember anything in my life. He was my patient when I was a student nurse in 1968.

Jack was admitted to the hospital for abdominal pain and suspected gastric ulcers. He was on bed rest, and they anticipated doing an exploratory laparotomy the next day.There were no fancy little endoscopes in those days. He had done his bed bath, and I grabbed the wash basin and emptied it. As I got ready to return it to his cabinet, he asked me to hand it to him. I did, and he filled it to the brim with bloody emesis.

He had 6 IV lines in record time, but his doctor was in Chicago for the day, so another surgeon took Jack to the OR. (That was pure luck for Jack.

His admitting surgeon was a terrible surgeon, and the substitute was a genuinely gifted surgeon.)

During the next few days, he had 64 units of blood and a second operation, but the crisis passed.

His recovery was slow, and about 2 weeks postop, he developed a blood clot in his leg.And, of course, he developed a pulmonary embolus. He was cared for on the regular surgical floor, because our small community hospital was in the process of building, but had not yet opened, its first ICU.

62 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

Jack was weak and struggled mightily to survive his PE. Slowly, he improved and we got him ambulatory and he was actually getting to the point that discharge was being considered. One morning, about 6 weeks postop, Jack woke up and was as yellow as a banana. He had developed hepatitis from the multiple blood transfusions.

Because he was so debilitated, that was a mighty struggle as well, but Jack made it through again.

Jack was discharged 2 months after the day of his massive GI bleed. His home was near the hospital, along the route we student nurses took when we walked home. During warm weather, he would sit on the porch and wave to us as we walked by: “There’s my girls!” he would tell his friends.

So much of what occurred with Jack would not happen today. He would have had an EGD as an outpatient. The blood he received would have been screened for hepatitis. He would have worn compression stockings and been ambulated early. Or he would have had a filter put in to prevent the PE. Medicine as a whole learned a lot from patients such as Jack. It is amazing to think of how much medicine has evolved as I’ve watched. It’s hard to believe that I have been around long enough (25 years as an RN, and 22 years as a PA) to see all these changes occur. But remembering Jack, and all his lessons, is very easy.—RUTH BROUWER, PA-C, Huntsville, Texas (237-1)

CLINICAL PEARLS AUSCULTATING AND PALPATING Close your eyes when auscultating or palpating.

It makes you focus on what you are hearing and feeling. An old country doctor told me to do this when I was a student.—BARBARA WITHERSPOON, MSN, Knoxville, Tenn.

(237-2) ■

LEGAL ADVISOR CASE

© FOTOSTORM / GETTY IMAGES

A case of wrongful termination?

A clinician quits her job but afterward sues for wrongful termination.

BY ANN W. LATNER, JD

When Ms H was offered the job of director of nursing for a home healthcare provider group, she was delighted. The pay was generous, the hours were regular, and the job would allow her to spend more time with her young children, something her previous job did not.

The home healthcare group would receive referrals of patients from other healthcare providers (physicians, hospitals, or nursing homes) for specific home healthcare services, such as physical therapy. As director of nursing, it was Ms H’s job to review the patient referrals and determine whether her employer had available staff to fulfill the doctor’s orders and care for the patient. Ms H could either accept the patient or recommend that the referral be declined.

If Ms H accepted the patient, the enrollment process began with a clinical assessment of the patient’s medical needs to determine whether the home healthcare plan should differ from the doctor’s orders. Clinical staff might find that the prescribed services were not appropriate for the patient or that the patient needed additional services. In either case, the doctor would

Ms H found that several colleagues were bypassing the proper procedure and admitting patients without the required clinical assessment.

be notified and given an opportunity to make the final decision as to whether the change was appropriate.After the patient was accepted, it was Ms H’s job to complete the paperwork necessary to bill Medicaid, Medicare, or private insurance.

After working there for several months, Ms H began noticing some disturbing things. She found out that several employees were regularly bypassing the proper procedure and were admitting patients without the required clinical assessment or documentation. She also found that patients were being admitted for services even when the home healthcare company could not accommodate their medical needs. The doctor’s orders were being changed to match the availability of clinical staff. In some cases, patients were being admitted without proper documentation from a medical doctor.

Ms H continued to do everything by the book, but she became increasingly concerned about Cases presented are based on actual occurrences.

Names of participants and details have been changed.

Cases are informational only; no specific legal advice is intended. Persons pictured are not the actual individuals mentioned in the article.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • JULY 2018 63

LEGAL ADVISOR what others were doing, which she considered fraud. After discussing the situation with her husband, she decided to bring it up to management.Timidly, she brought up some of the issues she had been noticing, but management brushed off her concerns.

As the months passed, Ms H tried again on numerous occasions to report the issues but was invariably ignored by management. One senior manager actually laughed when she reported the issue, telling her that the fraudulent scheme brought in $6 million annually.

Ms H did not know what to do. Although she was not manipulating the patient enrollment process, her duties required her to allocate clinical staff to new patients and to fill out

Being put in a position in which one must either quit or commit an illegal act can be considered a constructive discharge. payment paperwork from Medicare, Medicaid, and private insurers. Continuing to fulfill these duties, she believed, would inevitably require her to commit fraud and violate her nursing license. In this no-win situation, she believed that resigning from the position was preferable to being party to an illegal scheme. She quit her job and then hired an attorney.

The attorney filed a lawsuit against Ms H’s former employer, alleging that it violated the law by constructively discharging her. The employer made a motion to dismiss, claiming that Ms H quit and was not discharged.The district court agreed with the employer, holding that Ms H had failed to state a valid cause of action. While the court understood Ms H’s decision to quit to avoid participating in fraud, it held that the employer did not demonstrate a specific intent to force Ms H from her job.Without that intent by the employer, according to the court, Ms H’s claims failed.The lower court dismissed the case. Ms H appealed.

On appeal, the appellate court reversed the lower court’s decision and held that Ms H could sue her employer for wrongful termination, even though she had quit the job rather than be fired.

Legal Background

Ms H was suing under the federal False Claims Act, which provides a cause of action to an employee who is “discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment” because of acts by the employee to stop fraud

against the government.The question before the appellate court was whether the employer must have a “specific intent” for the employee to resign.The court concluded that “the intent required by the statute is a more general intent that takes into account all of the circumstances in addition to the employer’s ‘specific intention.’The case must therefore be remanded for trial not limited to the defendant corporation’s ‘specific’ or subjective intent but including all of the factors that led to the plaintiff ’s resignation,” wrote the court in its decision.

“If the employee is left to think she may be charged with fraud by the government if she remains as Director of Nursing,” continued the court in its decision, “a jury may find that the employer’s alleged fraudulent behavior is imposing on her fear that would cause a reasonable employee to resign. The jury may find that the employer’s alleged fraudulent behavior plus the employee’s moral conscience and reasonable fear of being accused of participating in the employer’s fraud enough to justify quitting. Whether we call her resignation a ‘constructive discharge,’ ‘harassment’ or a form of discrimination, the employee should be made ‘whole’ under the statute and accorded” the relief set out in the False Claims act if the jury finds in her favor, wrote the court.

The case was remanded back to the lower court for trial.

Protecting yourself

Ms H was put in a terrible position by her employer.Although she was processing patients properly, she was aware that other employees were not. Reporting the issue to her employer had repeatedly proved fruitless, and a senior manager had confirmed that the employer was aware of the fraud and the company was happily profiting from it. Ms H’s job included processing the Medicare and Medicaid paperwork. Faced with the choice of committing fraud herself or quitting her job, Ms H resigned. But being put in this position, in which one must either quit or commit an illegal act, can be considered a constructive discharge, as the appellate court held.

Never do anything that will put your license in danger. Ms H was aware that continuing at that job would be putting her license in danger, and she did the wise thing, which was to resign. If you are in a position in which you realize that your employer is defrauding the government, you should be aware that the False Claims Act is in place to protect you.

As with everything legal, documentation is key, so keep notes about interactions with managwement, reports of potential fraud issues, and reactions by management when such issues are reported to best protect yourself in the event you must quit. ■ Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.

64 THE CLINICAL ADVISOR • JULY 2018 • www.ClinicalAdvisor.com

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