September 2013 Clinical Advisor by The Clinical Advisor

The Clinical ADVISOR • september 2013

A 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

■■The glucose/dementia link ■■Sex after a heart attack ■■AD lowers risk of cancer

advisor forum

■■Antipsychotics and PE ■■Triamcinolone for allergies ■■Frequency of spirometry

| septem b er 2 013 | www.ClinicalAdvisor.com

young athletes and

concussions MRI shows a slowly developing bleed (upper left) caused by head trauma.

✶ free cE courses!

n CE Feature

safety first in infant feeding page 44

Volume 16, Number 9

n Dermatologic Look-Alikes

growing pruritic chest lesion page 85 Expanded job listings! www.ClinicalAdvisor.com/Jobs

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Editor Joe Kopcha, editor@clinicaladvisor.com Managing editor Marina Galanakis Senior editor Delicia Yard Web editor Nicole Blazek Contributing editors Bruce D. Askey, MSN, CRNP; Rebecca H. Bryan, APRN, CNP; Eileen F. Campbell, MSN, CRNP; Philip R. Cohen, MD; Deborah L. Cross, MPH, CRNP, ANP-BC; Sharon Dudley-Brown, PhD, FNP-BC; Maria Kidner, DNP, FNP-C; Joan W. Kiely, MSN, CRNP; Debra August King, PhD, PA; Ann W. Latner, JD; Claire B. O’Connell, MPH, PA-C; Kathy Pereira, MSN, FNP-BC; Sherril Sego, FNP, DNP; Julee B. Waldrop, MS, PNP; Kim Zuber, PA-C Art director Andrew Bass Group art director, Haymarket Medical Jennifer Dvoretz Production director Kathleen Millea Circulation manager Paul Silver Audience development director John Crewe National accounts manager Alison McCauley, 646.638.6098 alison.mccauley @ haymarketmedical.com Group publisher Thomas P. Hennessy, 646.638.6085 tom.hennessy @ haymarketmedia.com Editorial director Jeff Forster Vice president, medical magazines and digital products Jim Burke CEO, Haymarket Media, Inc. Lee Maniscalco All correspondence to: The Clinical Advisor 114 West 26th Street, 4th Floor, New York, NY 10001 For advertising sales, call 646.638.6085. For reprints, contact Wright’s Reprints at 877.652.5295. Persons appearing in photographs in “Newsline,” “The Legal Advisor,” and “Clinical Challenge” are not the actual individuals mentioned in the articles.They appear for illustrative purposes only. The Clinical Advisor® (USPS 017-546, ISSN 1524-7317), Volume 16, Number 9, is published 12 times a year, monthly, for $75.00 per year in the United States; $85.00 in Canada; $110.00 for all other foreign, in U.S. dollars, by Haymarket Media, Inc., 114 West 26th Street, 4th Floor, New York, NY 10001. Single copy: $20 U.S.; $30 foreign. www.ClinicalAdvisor.com. To order or update your paid subscription, call 800.436.9269. Periodicals postage rate paid at New York, NY, and additional mailing offices. POSTMASTER: Send all address changes to: The Clinical Advisor, c/o DMDData Inc., 2340 River Road, Des Plaines, IL 60018. Call 800.430.5450 to change your address or make other subscription inquiries. Requests for subscriptions from outside the United States must be accompanied by payment. All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright © 2013.

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contents september 2013

News and comment

departments

22 Newsline ■■Studies explore glucose/dementia link ■■Resistant hypertension common in CKD ■■Smokers with clear lungs still have cancer signs ■■Probiotics don’t stop diarrhea ■■Sex after a heart attack ■■Resveratrol blocks exercise benefits in men ■■AD lowers risk of cancer in older people ■■Men don’t rely on prostate-screen decision aids ■■Back pain treatment is overly expensive ■■Other conditions likely in psoriasis patients

60 Derm Dx Read the clinical descriptions, view the images, and make your diagnosis at ClinicalAdvisor.com.

Resistant hypertension in kidney disease 24

75 Legal Advisor Two clinicians are charged with medical malpractice for failing to follow up after referring a patient with significant prostatic symptoms. 79 CME/CE Dermatology Clinic n A man with a history of tpye 2 diabetes and alcoholic cirrhosis presented with erythema and scaling of the finger and nail bed.

92 Commentary

features 34 Traumatic brain injury in youth athletics Accurate identification, assessment, and evaluation of concussions will allow the clinician to determine when it is safe to return to competition. 44 CME/CE Counseling parents on the avoidance of feeding-associated infections Clinicians are in an ideal position to educate and train mothers and other caregivers in best safety practices for expressed breast milk and commerically prepared infant formula.

making contact

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64 Clinical Challenge Hypertension and substance abuse mask an underlying condition in a man who presented with palpitations, tachycardia, tremors, and extreme anxiety.

Young athletes and concussions 34

n Yellow reticulated plaques resembling

“plucked chicken skin” developed in the bilateral inguinal folds of a blind man with a family history of angioid streaks.

Continues on page 8

A homeless veteran with panic attacks 64

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LEVEL

S:6.875”

In patients already taking ELIQUIS (apixaban) at a dose of 2.5 mg twice daily, avoid coadministration with strong dual inhibitors of both CYP3A4 and P-gp [see Dosage and Administration (2.2) and Clinical Pharmacology (12.3) in full Prescribing Information]. Strong Dual Inducers of CYP3A4 and P-gp Avoid concomitant use of ELIQUIS with strong dual inducers of CYP3A4 and P-gp (e.g., rifampin, carbamazepine, phenytoin, St. John’s wort) because such drugs will decrease exposure to apixaban [see Clinical Pharmacology (12.3) in full Prescribing Information]. Anticoagulants and Antiplatelet Agents Coadministration of antiplatelet agents, fibrinolytics, heparin, aspirin, and chronic NSAID use increases the risk of bleeding. APPRAISE-2, a placebo-controlled clinical trial of apixaban in high-risk post-acute coronary syndrome patients treated with aspirin or the combination of aspirin and clopidogrel, was terminated early due to a higher rate of bleeding with apixaban compared to placebo. The rate of ISTH major bleeding was 2.77%/year with apixaban versus 0.62%/year with placebo in patients receiving single antiplatelet therapy and was 5.91%/year with apixaban versus 2.50%/year with placebo in those receiving dual antiplatelet therapy. In ARISTOTLE, concomitant use of aspirin increased the bleeding risk on ELIQUIS from 1.8% per year to 3.4% per year and the bleeding risk on warfarin from 2.7% per year to 4.6% per year. In this clinical trial, there was limited (2.3%) use of dual antiplatelet therapy with ELIQUIS. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category B There are no adequate and well-controlled studies of ELIQUIS in pregnant women. Treatment is likely to increase the risk of hemorrhage during pregnancy and delivery. ELIQUIS should be used during pregnancy only if the potential benefit outweighs the potential risk to the mother and fetus. Treatment of pregnant rats, rabbits, and mice after implantation until the end of gestation resulted in fetal exposure to apixaban, but was not associated with increased risk for fetal malformations or toxicity. No maternal or fetal deaths were attributed to bleeding. Increased incidence of maternal bleeding was observed in mice, rats, and rabbits at maternal exposures that were 19, 4, and 1 times, respectively, the human exposure of unbound drug, based on area under plasma-concentration time curve (AUC) comparisons at the maximum recommended human dose (MRHD) of 10 mg (5 mg twice daily). Labor and Delivery Safety and effectiveness of ELIQUIS during labor and delivery have not been studied in clinical trials. Consider the risks of bleeding and of stroke in using ELIQUIS in this setting [see Warnings and Precautions]. Treatment of pregnant rats from implantation (gestation Day 7) to weaning (lactation Day 21) with apixaban at a dose of 1000 mg/kg (about 5 times the human exposure based on unbound apixaban) did not result in death of offspring or death of mother rats during labor in association with uterine bleeding. However, increased incidence of maternal bleeding, primarily during gestation, occurred at apixaban doses of ≥25 mg/kg, a dose corresponding to ≥1.3 times the human exposure. Nursing Mothers It is unknown whether apixaban or its metabolites are excreted in human milk. Rats excrete apixaban in milk (12% of the maternal dose). Women should be instructed either to discontinue breastfeeding or to discontinue ELIQUIS therapy, taking into account the importance of the drug to the mother. Pediatric Use Safety and effectiveness in pediatric patients have not been established.

Geriatric Use Of the total subjects in clinical studies of apixaban, >69% were 65 and older, and >31% were 75 and older. The effects of ELIQUIS (apixaban) on the risk of stroke and major bleeding compared to warfarin were maintained in geriatric subjects. OVERDOSAGE There is no antidote to ELIQUIS. Overdose of ELIQUIS increases the risk of bleeding [see Warnings and Precautions]. In controlled clinical trials, orally administered apixaban in healthy subjects at doses up to 50 mg daily for 3 to 7 days (25 mg twice-daily for 7 days or 50 mg once-daily for 3 days) had no clinically relevant adverse effects. In healthy subjects, administration of activated charcoal 2 and 6 hours after ingestion of a 20-mg dose of apixaban reduced mean apixaban AUC by 50% and 27%, respectively. Mean apparent half-life of apixaban decreased from 13.4 hours when apixaban was administered alone to 5.3 hours and 4.9 hours, respectively, when activated charcoal was administered 2 and 6 hours after apixaban, indicating that charcoal blocked the continued absorption of apixaban from the gut [see Clinical Pharmacology (12.3) in full Prescribing Information]. Thus, administration of activated charcoal may be useful in the management of apixaban overdose or accidental ingestion by leading to a more rapid fall in apixaban blood levels. PATIENT COUNSELING INFORMATION See FDA-approved patient labeling (Medication Guide). Advise patients of the following: • They should not discontinue ELIQUIS without talking to their physician first. • They should be informed that it might take longer than usual for bleeding to stop, and they may bruise or bleed more easily when treated with ELIQUIS. Advise patients about how to recognize bleeding or symptoms of hypovolemia and of the urgent need to report any unusual bleeding to their physician. • They should tell their physicians and dentists they are taking ELIQUIS, and/or any other product known to affect bleeding (including nonprescription products, such as aspirin or NSAIDs), before any surgery or medical or dental procedure is scheduled and before any new drug is taken. • They should tell their physicians if they are pregnant or plan to become pregnant or are breastfeeding or intends to breastfeed during treatment with ELIQUIS [see Use in Specific Populations]. • If a dose is missed, the dose should be taken as soon as possible on the same day and twice daily administration should be resumed. The dose should not be doubled to make up for a missed dose. Manufactured by: Bristol-Myers Squibb Company Princeton, New Jersey 08543 USA Marketed by: Bristol-Myers Squibb Company Princeton, New Jersey 08543 USA and Pfizer Inc New York, New York 10017 USA Rotachrom® is a registered trademark of Diagnostica Stago. 1289808 / 1298500 / 1289807

Issued December 2012 432US13PBS00304

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S:9.5”

“My woman done left me, ran off with my best friend. Well, my woman done left me, said she ran off with my best friend. Details are sketchy at this time, so let’s go to Jennnifer Diaz standing by in Washington.”

“YOLO.”

6/7/13 11:45 AM 8/26/13 12:22 PM

contents 84 Alternative Meds Update Lutein is a naturally-occurring and potent antioxidant that is primarily used as a daily supplement to prevent such eye diseases as cataracts and age-related macular degeneration. 87 CME/CE Dermatologic Look-Alikes Two patients present with firm, pink trunk plaques—one that had darkened and developed irregular nodules, and the other that started as an scar following an excision of an eipidermal inclusion cyst.

Dark green, leafy vegetables are good sources of lutein 84

91 CME/CE Posttest

advisor forum 56 Consultations ■■Do antipsychotics increase the risk of pulmonary embolism? ■■Is triamcinolone safe for seasonal allergies? ■■Frequency of spirometry in stable patients with asthma 58 Your Comments ■■Is referral to endocrinology a must for primary aldosteronism?

A firm, erythematous plaque with irregular nodules 87

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INVOKANA™ (canagliflozin) tablets

“And exhale.”

“You can stop knocking now.”

overdosage There were no reports of overdose during the clinical development program of INVOKANA (canagliflozin). In the event of an overdose, contact the Poison Control Center. It is also reasonable to employ the usual supportive measures, e.g., remove unabsorbed material from the gastrointestinal tract, employ clinical monitoring, and institute supportive treatment as dictated by the patient’s clinical status. Canagliflozin was negligibly removed during a 4-hour hemodialysis session. Canagliflozin is not expected to be dialyzable by peritoneal dialysis. PatIent coUnseLIng InForMatIon See FDA-approved patient labeling (Medication Guide). Instructions: Instruct patients to read the Medication Guide before starting INVOKANA (canagliflozin) therapy and to reread it each time the prescription is renewed. Inform patients of the potential risks and benefits of INVOKANA and of alternative modes of therapy. Also inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1C testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. Advise patients to seek medical advice promptly during periods of stress such as fever, trauma, infection, or surgery, as medication requirements may change. Instruct patients to take INVOKANA only as prescribed. If a dose is missed, advise patients to take it as soon as it is remembered unless it is almost time for the next dose, in which case patients should skip the missed dose and take the medicine at the next regularly scheduled time. Advise patients not to take two doses of INVOKANA at the same time. Inform patients that the most common adverse reactions associated with INVOKANA are genital mycotic infection, urinary tract infection, and increased urination. Inform female patients of child bearing age that the use of INVOKANA during pregnancy has not been studied in humans, and that INVOKANA should only be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Instruct patients to report pregnancies to their physicians as soon as possible. Inform nursing mothers to discontinue INVOKANA or nursing, taking into account the importance of drug to the mother. Laboratory Tests: Due to its mechanism of action, patients taking INVOKANA will test positive for glucose in their urine. Hypotension: Inform patients that symptomatic hypotension may occur with INVOKANA and advise them to contact their doctor if they experience such symptoms [see Warnings and Precautions]. Inform patients that dehydration may increase the risk for hypotension, and to have adequate fluid intake. Genital Mycotic Infections in Females (e.g., Vulvovaginitis): Inform female patients that vaginal yeast infection may occur and provide them with information on the signs and symptoms of vaginal yeast infection. Advise them of treatment options and when to seek medical advice [see Warnings and Precautions]. Genital Mycotic Infections in Males (e.g., Balanitis or Balanoposthitis): Inform male patients that yeast infection of penis (e.g., balanitis or balanoposthitis) may occur, especially in uncircumcised males and patients with prior history. Provide them with information on the signs and symptoms of balanitis and balanoposthitis (rash or redness of the glans or foreskin of the penis). Advise them of treatment options and when to seek medical advice [see Warnings and Precautions]. Hypersensitivity Reactions: Inform patients that serious hypersensitivity reactions such as urticaria and rash have been reported with INVOKANA. Advise patients to report immediately any signs or symptoms suggesting allergic reaction or angioedema, and to take no more drug until they have consulted prescribing physicians. Urinary Tract Infections: Inform patients of the potential for urinary tract infections. Provide them with information on the symptoms of urinary tract infections. Advise them to seek medical advice if such symptoms occur. Active ingredient made in Belgium Finished product manufactured by: Janssen Ortho, LLC Gurabo, PR 00778 Manufactured for: Janssen Pharmaceuticals, Inc. Titusville, NJ 08560 Licensed from Mitsubishi Tanabe Pharma Corporation © 2013 Janssen Pharmaceuticals, Inc. 10282400 K02CAN13080B

“At high noon I’m takin’ her to the zoo. How’s one-thirty?”

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Large-scale hypertension program doubles BP control rates Approach includes instituting a comprehensive patient registry, performance metrics, and evidence-based guidelines.

College health risks College is full of exciting experiences for teen patients, from meeting new people to living away from home. But college can also be stressful, as young adults try to develop new routines, maintain a healthy diet and manage responsibilities independently. Offer your college-aged patients these tips and information to help them stay safe and healthy at school.

More NPs, PAs choosing subspecialty practice Just under half of physician assistants and slightly more than half of nurse practitioners choose to work in primary care. Poor infection control behind severe conjunctivitis outbreaks Lax infection-control measures played a role in six unrelated outbreaks of keratoconjunctivitis linked to human adenovirus.

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Robyn Carlisle, MSN, CNM, WHNP Learning from the new hire The many demands and stressors of practicing medicine can be draining. A new practitioner can remind you why you chose your career. Julee Waldrop, DNP, PNP, FNP, Jessica Swanson, FNP, MSN Mobile health strategies useful for migrant workers Innovative strategies are necessary to provide quality health care to this vulnerable population. Jim Anderson, MPAS, PA-C, ATC Are you prepared to treat methadone patients? One of the major challenges for clinicians is the almost complete lack of knowledge about methadone treatment that pervades the medical community.

Painful purulent nodules on the scalp A Hispanic man presents with a history of painful and progressively enlarging nodules that drain purulent fluid when compressed.

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Leigh Montejo, MSN, FNP-BC Auscultating the heart helps find “humanity” in medicine We must not let time constraints and busy schedules eliminate the most important aspect of the patient encounter: human touch.

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Newsline

Signs of cancer found in smokers with clear lungs page 24

s e p t e m b e r 2 0 13

Resveratrol blocks benefits of exercise page 28

Psoriasis raises risk of other major diseases page 34

Studies explore glucose/dementia link

MRI shows atrophied frontal (left) and temporal (center) lobes.

dementia (mean age at baseline: 76 years) to examine the relationship between glucose levels and dementia risk. A total of 232 participants had diabetes; 1,835 did not. Dementia developed in 524 participants (74 with diabetes and 450 without) during a median follow-up of 6.8 years. Higher average glucose levels within the preceding five years were related to an increased risk of dementia both for persons with diabetes and for persons without. In the diabetes group, the risk for dementia was 40% higher for persons with an average glucose level of 190 mg/dL than for persons with an average glucose level of 160 mg/dL. Among persons without diabetes, dementia risk was 18% higher for those with an average glucose level of 115 mg/dL than for those with an average glucose level of 100 mg/dL.

Drug expenditures for persons under age 40 years Total expenditures for antidiabetics increased 126% between 2000 and 2010. Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2000 and 2010

1,843.0

2,000

■ 2000 ■ 2010

1,500

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Two new studies on the relationship between blood glucose levels and dementia risk have reached divergent conclusions: One set of investigators has determined that neither glucose intolerance nor insulin resistance appears to be associated with pathological features of Alzheimer disease (AD), whereas another has found higher blood glucose levels to be associated with higher dementia risk. Madhav Thambisetty, MD, PhD, and colleagues focused on data collected from 197 participants in the Baltimore Longitudinal Study of Aging (BLSA) who had undergone at least two oral glucose tolerance tests (OGTTs) during their lifetime and a complete brain autopsy after death. The research also included an additional 53 living subjects from the BLSA neuroimaging study.

As the team reported in JAMA Neurology, no significant correlations were found between measures of brain AD pathology or beta-amyloid load and glucose intolerance or insulin resistance in persons who had a mean of 6.4 OGTTs during 22.1 years of follow-up. Thirty subjects with frank diabetes mellitus also had AD pathology scores similar to those of the cohort as a whole. Separately, Paul K. Crane, MD, MPH, and associates stated in The New England Journal of Medicine that their own findings suggest higher glucose levels may be a risk factor for dementia, even among persons without diabetes. Crane’s group used 35,264 clinical measurements of glucose levels and 10,208 measurements of glycated hemoglobin levels from 2,067 participants without

1,000

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22 the clinical advisor • september 2013 • www.ClinicalAdvisor.com

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Newsline More than 50% of persons with moderate chronic kidney disease (CKD) have medication-resistant hypertension, a recent analysis presented in Clinical Journal of the American Society of Nephrology has demonstrated. Apparent treatment-resistant hypertension was defined as BP >140/90 mmHg with concurrent use of three or more antihypertensive medication classes, or use of four or more such drugs regardless of BP level. CKD was defined as an albumin-to-creatinine ratio of >30 mg/g, or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Investigators Rikki Tanner, MPH, and colleagues found that among 10,700 participants from the Reasons for Geographic and Racial Differences in Stroke

study, the prevalence of apparent treatment-resistant hypertension was 15.8% for persons with eGFR >60 mL/min/1.73 m2, compared with 24.9% for persons with eGFR 45–59 mL/min/1.73 m 2 and 33.4% for persons with eGFR <45 mL/min/1.73 m2. Apparent treatment-resistant hypertension rates were 12.1%, 20.8%, 27.7%, and 48.3%, respectively, for persons with albumin-to-creatinine ratios <10 mg/g, 10–29 mg/g, 30–299 mg/g, and >300 mg/g. Some factors associated with apparent treatment-resistant hypertension in CKD included male gender, black race, larger waist circumference, diabetes, history of myocardial infarction or stroke, statin use, and lower eGFR and higher albumin-tocreatinine ratio levels.

Resistant hypertension common in CKD

Kidney stones (shown) are a symptom of renal hypertension.

Identifying CKD patients who are at high risk of developing resistant hypertension and who may benefit from intensive BP monitoring and early therapeutic interventions should be a high priority for clinicians, Tanner noted in a statement from the American Society of Nephrology.

Smokers whose lungs appear to be clear are in fact harboring airway cells that show early signs of impairment similar to that found in lung cancer, researchers have discovered. Physical examinations, lung function tests, and chest x-rays are not sensitive enough to pick up these very early changes, leading patients to mistakenly believe that they have incurred no smoking-related lung damage. Activation of the human embryonic stem cell (hESC)–signature genes has been observed in various epithelial cancers, explained

The hESC genes are not normally functioning in the healthy lung.

a team led by Ronald G. Crystal, MD, in a Stem Cells paper. These genes are normally expressed in developing embryos, but are also activated in the most aggressive lung cancers. In their own study of airway epithelial cells from 21 healthy nonsmokers and 31 smokers with no symptoms of lung disease and with normal x-ray and chest findings, Dr. Crystal and colleagues found that the hESC signature is selectively induced in the airway basal stem/progenitor cell population of healthy smokers, with a pattern similar to that activated

in all major types of lung cancer found in humans. “We were surprised to see that the smokers were expressing these very primitive human embryonic stem cell genes,” Dr. Crystal affirmed in a separate statement. “These genes are not normally functioning in the healthy lung.” As Dr. Crystal noted, smoking strips lung cells of some of their genetic programming, and they take on the appearance of more primitive cells. “It doesn’t necessarily mean you will develop cancer, but the soil is fertile to develop cancer.”

Smokers with clear lungs still have cancer signs

24 the clinical advisor • september 2013 • www.ClinicalAdvisor.com

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Newsline

Probiotic supplements do not appear to prevent antibioticassociated diarrhea (AAD) or diarrhea caused by Clostridium difficile in elderly patients. AAD occurs most frequently in inpatients aged 65 years and older who are exposed to broadspectrum antibiotics, and can be life-threatening when caused by C. difficile. Previous research has suggested that probiotic preparations might reduce the incidence of AAD, perhaps by restoring gut flora, or microbiome—the socalled “friendly bacteria”—disrupted by antibiotic use, according to a statement from The Lancet, in which this new study by Stephen J. Allen, MD, and fellow investigators appears. The earlier research was of variable quality and did not yield enough data for the reliable assessment of effectiveness. Allen’s group conducted a multicenter efficacy trial involving inpatients aged 65 years and older who had been exposed to at least one oral or parenteral antibiotic. AAD, including C. difficile diarrhea (CDD), occurred in 10.8% of patients receiving a microbial preparation, and in 10.4% of patients receiving placebo. CDD was an uncommon cause of AAD, occurring in just 0.8% of patients in the microbialpreparation group and 1.2% in the placebo group. The frequency of serious adverse events was similar between the two sets of patients.

Sex after a heart attack A new consensus statement from the American Heart Association (AHA) and the European Society of Cardiology (ESC) urges healthcare providers to counsel patients and their partners about resuming sexual activity following a cardiac event or stroke. The scientific statement, by Elaine E. Steinke, PhD, APRN, and others was published online ahead of print in the AHA journal Circulation. The authors recommend that clinicians routinely: assess all patients after a cardiac event and during follow-up visits to determine whether the person is healthy enough to resume sexual activities; give individualized, structured counseling based on specific needs and medical condition; and discuss how to be intimate without having intercourse, when to resume sexual activity, and even recommended positions. Among many other recommendations, the AHA/ESC document advises that clinicians review patient medications to

Review medications to consider any impact on sexual function.

consider any impact on sexual function; encourage patients and their partners to use comfortable, familiar settings and positions to minimize cardiac stress associated with sexual activity; and instruct the patient to report any symptoms he or she experiences with sexual activity. Female cardiac patients may be especially grateful for such discussions, based on the findings of a recent telephone-interview study involving 17 partnered women who resumed sexual activity within four weeks after having suffered a heart attack. Emily M. Abramsohn, MPH, and coinvestigators reported in Journal of the American Heart Association (available at jaha.ahajournals. org/content/2/4/e000199.long; accessed August 15, 2013) that sexual problems and concerns were prevalent among the women and their partners, but few of the women received counseling about such matters or about the safety of returning to sex.

Resveratrol blocks exercise benefits in men Older men who take resveratrol supplements may be depriving themselves of the cardiovascular benefits they should be getting from exercise. To test whether resveratrol supplementation enhances training-induced improvements in the cardiovascular health of older men, Lasse Gliemann and colleagues randomized 27 healthy, physically inactive men aged 65 years and older to eight weeks of trans resveratrol administration (250 mg/day) or

placebo, as they explained in The Journal of Physiology. Both groups also underwent highintensity exercise training. Unexpectedly, exercise training led to a 45% greater increase in maximal oxygen uptake in the placebo group than in the resveratrol group. Among other unanticipated, unfavorable outcomes, resveratrol supplementation abolished the positive effects on exercise on LDL levels, on ratio of total cholesterol to HDL, and on triglyceride levels.

Probiotics don’t stop diarrhea

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Newsline Although the occurrences of both cancer and Alzheimer disease (AD) increase exponentially with age, an inverse relationship between the two illnesses has been found: Older persons with cancer have a reduced risk for developing AD, and older persons with AD have a reduced risk for developing cancer. “AD dementia, cancer, and senescence could be manifestations of a unique phenomenon related to human aging,” wrote Massimo Musicco, MD, of the National Research Council of Italy, in Milan, and fellow investigators in Neurology (2013;81[4]:322-328), the medical journal of the American Academy of Neurology. Musicco and colleagues used various health registries to derive cancer incidence as well as AD

incidence. They then calculated the expected cases of AD dementia in persons with a new diagnosis of cancer and the expected cases of cancer in persons with AD. During the six-year period covered, among 204,468 residents of Northern Italy aged 60 years and older, 21,451 developed cancer and 2,832 developed AD. Although 281 of persons with cancer were expected to have AD and 246 with AD were expected to have cancer, only 161 subjects had both diseases. Persons with AD had a 50% reduced risk for cancer, and people with cancer had a 35% reduced risk for AD. These results were maintained in almost all subgroup analyses. Musicco noted that the reduced risks for cancer and AD in patients who already had one of these

AD lowers risk of cancer in older people

Cancer risk was reduced by half in people with AD.

diseases has been seen in other studies, but that his team’s was the largest such study to date. Musicco also pointed out that his research has several strengths over previous studies, such as looking for the presence of the second disease both before and after the diagnosis of the first disease.

Print-based and online tools presenting the benefits and limitations of prostate-specific antigen (PSA) testing served to help men resolve their own conflicts regarding such screening, but did not affect their decision as to whether or not to undergo this type of testing. The conflicting recommendations for prostate cancer screening and the mixed messages regarding the effectiveness of such testing make it critical to assist men in making informed decisions about undergoing PSA testing, asserted Kathryn

Decision aids did not affect actual screening rates.

L. Taylor, PhD, and associates in JAMA Internal Medicine. The team conducted an analysis of male outpatients from three sites who had been randomized to a print-based decision aid (n=628), a Web-based interactive decision aid (n=625), or usual care (n=626). The men, aged 45 to 70 years, were interviewed by telephone at baseline, at 1 month, and at 13 months. Taylor and colleagues found that prostate cancer knowledge was signif icantly improved and decisional conf lict was signif icantly reduced in the

intervention groups compared with the usual-care patients at 1 month and at 13 months. However, screening rates at 13 months did not differ significantly among groups. The researchers concluded that both print-based and Web-based decision aids helped men make more informed choices regarding screening for prostate cancer up to 13 months later, but did not affect actual screening rates. Taylor and coauthors suggested that dissemination of such decision aids may be a valuable public-health tool.

Men don’t rely on prostate-screen decision aids

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AD lowers risk of cancer in older people

Cancer risk was reduced by half in people with AD.

Decision aids did not affect actual screening rates.

Men don’t rely on prostate-screen decision aids

www.ClinicalAdvisor.com • the clinical advisor • september 2013 31

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Newsline Although unsupported by guidelines, management of routine back pain has increasingly relied on advanced diagnostic imaging, referrals, and narcotics, with a concomitant reduction NSAID or acetaminophen use, and no change in referrals to physical therapy. These findings were reported in JAMA Internal Medicine by John M. Mafi, MD, and associates, who noted that more than 10% of visits to primary-care clinicians relate to back and neck pain. The investigators identified 23,918 such outpatient visits from January 1999 through December 2010.

Dr. Maf i’s team found that NSAID or acetaminophen use per visit fell from 36.9% in 1999-2000 to 24.5% in 2009-2010, while narcotic use rose from 19.3% to 29.1%. Physical therapy referrals remained at approximately 20% throughout the entire study period, but referrals to other clinicians (presumably for procedures or surgery) increased from 6.8% to 14%. The use of radiograph exams remained stable at approximately 17%, but the use of computed tomography and magnetic resonance imaging jumped from 7.2% to 11.3%.

Back pain treatment is overly expensive

Physical therapy and NSAIDs are recommended for routine back pain.

“Improvements in the management of back pain represent an area of potential cost savings, while also improving the quality of care,” the authors concluded.

Bring instant relief to your patient’s face » is the ONLY instant, multi-use topical anesthetic. Pain doesn’t wait. Ease it in an instant and prepare your patient for a needle procedure or minor surgery with Gebauer’s Pain Ease.® The world’s first fast, topical anesthetic skin refrigerant for multiple uses temporarily controls pain and anxiety in as few as 4 to 10 seconds.* » multi-use, so can be applied to intact skin, minor open wounds, and intact oral mucous membranes » nondrug, nonflammable formula » may be used by any licensed healthcare practitioner without the order of a physician

See next page for important risk and safety information regarding Pain Ease.

GEBA-0012 Clinical Advisor Faces Ad.indd 1

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Newsline

Previous studies may not accurately reflect disease severity.

Among the patients with psoriasis, 51.8% had mild disease, 35.8% had moderate disease, and 12.4% had severe disease (defined as involvement of more than 10% of their body-surface area). Most previous studies suggesting a higher prevalence of comorbid disease

in individuals with psoriasis used treatment with systemic therapies or phototherapy as a surrogate marker for moderate to severe disease, but that approach may not accurately reflect disease severity. Psoriasis was associated with higher prevalence of chronic pulmonary disease, diabetes mellitus, diabetes with systemic complications, mild liver disease, MI, peptic ulcer disease, peripheral vascular disease, renal disease, and rheumatologic disease. Trend analysis revealed significant associations between psoriasis severity and each of those diseases. n

People with psoriasis have a heightened risk for at least one additional major medical disease, researchers found. Joel M. Gelfand, MD, MSCE, and colleagues described in JAMA Dermatology their efforts to determine the prevalence of major medical comorbidity among 9,035 persons in the United Kingdom, aged 25 to 64 years, with mild, moderate, or severe psoriasis. The analysis also included 90,350 controls without psoriasis (available at archderm.jamanetwork.com/ article.aspx?articleid=1724035; accessed August 15, 2013).

IN 4 TO 10 SECONDS FLAT.

{

That’s how fast it works!

{

important risk and safety information: Published clinical trial results support the use in children three years of age and older. Do not use on large areas of damaged skin, puncture wounds, animal bites or serious wounds. Do not spray in eyes. Over spraying may cause frostbite. Freezing may alter skin pigmentation. Use caution when using product on diabetics or persons with poor circulation. Apply only to intact oral mucous membranes. Do not use on genital mucous membranes. The thawing process may be painful and freezing may lower resistance to infection and delay healing. If skin irritation develops, discontinue use. Rx only.

Other conditions likely in psoriasis patients

TRY PAIN EASE TODAY www.Gebauer.com/Speed 1. 8 0 0 .3 2 1 . 93 4 8

*Farion, Ken J.; Splinter, Karen L.; Newhook, Kym; Gaboury, Isabelle; and Splinter, William M. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. CMAJ. 2008 July 1; 179(1): 31–36. doi: 10.1503/cmaj.070874.

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feature: Nancy J. Denke, MSN, FNP-BC, ACNP-BC

Traumatic brain injury in youth athletics Accurate identification, assessment, and evaluation of concussions will allow the clinician to determine when it is safe to return to competition.

Slowly developing bleeds (upper left) may be easier to detect on MRI.

or many participants of youth and highschool sports, concussion, or mild traumatic brain injury (mTBI), may always be a risk. However, by educating players, coaches, and parents about the factors that contribute to concussions and affect recovery from these injuries, clinicians may be able to improve treatment choices and minimize the rate and severity of sports-related brain injuries in the pediatric population. Increasing participation in youth and highschool sports can help lower rates of childhood obesity, but also increases the risk of injuries. Approximately 30 million to 45 million children and adolescents aged 6 years to 18 years participate in organized sports, and more than half of these youths compete in multiple sports.1 According to the National Federation of State High School Associations, approximately 7.7 million students participated in sports during the 2011-2012 school year.2 The CDC reports that sports- and recreationrelated mTBIs have increased by 60% over the past decade, and each year emergency departments (EDs) treat an estimated 173,285 of these injuries among children and adolescents, from birth to age 19 years.3 A 2012 study looked at data from the High School Reporting Information Online injury surveillance system, a representative sample of 100 schools with injury incidence data for 20 different sports, and found that concussions represented 13.2% of all reported sportsrelated injuries.4 A 10-year examination of 25 high schools found that the rate of reported

34 the clinical advisor • september 2013 • www.ClinicalAdvisor.com

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traumatic brain injury

concussions increased more than fourfold between 1998 and 2008.5 The authors went on to note that these increases may have been partly attributable to increased awareness, reporting, and diagnosis of concussions. In spite of increased incidence and awareness of TBI in the child-and-adolescent population, the research on sports-related concussions specific to children and adolescents is lagging.6 This dearth of research takes on added significance when combined with the knowledge that the evidence clearly shows children and adolescents take longer to recover after a concussion than do their adult counterparts. What is a concussion?

The American Academy of Neurology defines a concussion as any trauma-induced alteration in mental status that may or may not include a loss of consciousness. A consensus statement released following the Third International Conference on Concussion in Sport in 2008 noted that a concussion could be defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”7 Common features that can be used to describe the nature of a concussive head injury include the following: 1. May be caused either by a direct blow to the head, face, or neck, or a blow elsewhere on the body with an impulsive force transmitted to the head 2. Typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously 3. May result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury 4. Results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. In a small percentage of cases, however, post-concussive symptoms may be prolonged

5. No abnormality on standard structural neuroimaging studies is seen in concussion.7 With such diverse definitions, it is little wonder that considerable confusion about concussions exists among clinicians, researchers, coaches, parents, and players. A 2010 study highlighted a common misunderstanding about concussions: Both professional and lay populations felt that an injury described as a concussion is less severe than one described as mTBI. This misunderstanding leads to different clinical impressions and expectations, resulting in a premature return to activity.8 The term concussion will be used throughout the remainder of this article, but bear in mind that concussion and mTBI are to be considered the same injury. Assessment of concussion

The signs and symptoms of concussion fall into four categories: physical, cognitive, emotional, and sleep, with headache being the most reported symptom. Table 1 describes the most common signs and symptoms in each category. It must be noted here that having a concussion does not necessarily involve a loss of consciousness. Only 10% of concussions have been reported to result in an altered level of consciousness.9 Of course, any detected loss of consciousness must be considered a red flag indicating the need for additional testing. Preparticipation physical

The vast majority of states require high-school and middleschool athletes to undergo a preparticipation physical examination (PPE).11 The Preparticipation Physical Evaluation is an evidence-based guideline that describes how to conduct a thorough medical history and a targeted physical exam, with a focus on activity-related risks to various organ systems.12 This guideline emphasizes the importance of the neurologic history and how it can provide the practitioner with information to prevent future injury. The neurologic

Table 1. Signs and symptoms of concussion Physical

Cognitive

Emotional

Sleep

Headache/migraine

• Feeling “foggy”

• Feeling irritable

• Sleepiness

Nausea/vomiting

• Difficulty thinking

• Feeling sad or depressed

• Difficulty sleeping (too much or too little)

Balance

• Difficulty remembering

• Increased sensitivity to noise

• Difficulty falling asleep

Visual problem

• Dazed

• Impulsive behavior

• Hyperexcitability

Sensitivity to noise and/or light

• Difficulty concentrating

• Poor coping skills; increased sensitivity to stress

Fatigue

• Unable to understand complex issues • Falling behind in school

• Change in personality • Outbursts of anger

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traumatic brain injury

history can also be a good time to educate the young athlete regarding the significance of a concussion and how to avoid worsening a current disability. Previous symptoms of concussions should be discussed during the PPE. Such computerized neurocognitive programs as the Immediate Post-Concussion Assessment and Cognitive Test (www.impacttest.com) and the Axon Sports Computerized Cognitive Assessment Tool (www.axonsports.com) have been found to be valuable tools for baseline and concussion assessment. By measuring multiple aspects of cognitive activity (i.e., memory, reaction time, and attention span), these tools provide a quantitative assessment of an athlete’s brain function.

poll position

n=138 9%

91% n Yes n No

On-the-field identification

Recognition of signs and symptoms of concussion may be difficult due to the subtlety of symptoms. Many times, athletes are reluctant to report symptoms out of fear of letting their teammates down or losing their place on the team. Accurate on-field identification of concussion entails education of athletic trainers, coaches, health-care professionals, parents, and athletes to ensure that common acute symptoms are readily recognized. In cases of suspected head injury, an instrument such as the Sport Concussion Assessment Tool (SCAT2) should be used to evaluate the athlete.13 The SCAT2 is a standardized method of evaluating injured athletes for concussion and can be used in individuals aged 10 years and older. Other assessment tools that can be used on the field include testing for orientation (“What team are you playing? What is the score?”), concentration (word/number recall), and neurologic defects (speech, eye movement, balance). Any sports participant suspected of having a concussion must be removed from play.

Has increased attention to concussions changed the way you talk to parents about youth sports?

For more polls, visit CliniAd.com/10TDwDb.

should include a thorough neurologic history. The clinician should obtain information from the athlete, parents, and any teammates that can add pertinent facts to the assessment. The need for emergent neuroimaging to exclude severe brain injury must be determined; not every athlete who sustains a TBI requires imaging. In general, imaging is required if there is a suspicion of intracerebral structural lesions, loss of consciousness lasting longer than one minute, focal neurologic deficits, worsening of symptoms, repeated and uncontrolled vomiting, or persistent cognitive symptoms.7 There has been recent research on the use of functional MRI, positron emission tomography (PET) scans, and diffusion tensor imaging of sports-related concussion in adolescents.14 Unfortunately, there are no imaging techniques that can diagnose a concussion. When to return to play

Emergency evaluation

An athlete who elicits signs of neurologic deterioration must undergo a detailed evaluation in the ED. This examination

The cornerstone of concussion management is physical and cognitive rest.15 Any activities that require attention and concentration must be limited so as not to exacerbate

Table 2. Return-to-play protocol 1. No activity, complete rest; once asymptomatic, proceed to step 2. 2. Light aerobic exercise, no resistance training 3. Sport-specific exercise, progressive addition of resistance training in steps 3 and 4 4. Noncontact drills 5. Full contact after medical clearance 6. Game play • If symptoms relapse, the athlete must revert to the most recent asymptomatic step and wait 24 hours until progressing again. Adapted from McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train. 2009;44:434-448. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2707064/.

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traumatic brain injury

symptoms. Cognitive rest should include limited use of computers, cell phones (texting), and video games; limited television viewing; and even limited socializing. At the Third International Conference on Concussion in Sport, a stepwise protocol for return to play was recommended (Table 2).7 The protocol begins with no activity or complete rest until the concussed athlete is asymptomatic. Once asymptomatic, light aerobic exercise with no resistance training is allowed. If the athlete continues to be asymptomatic, he or she is allowed to move on to the next step. Each remaining stage must be completed without symptoms returning over a 24-hour period. If symptoms reappear, the athlete must go back to the preceding stage until asymptomatic and then restart the stepwise progression. Once the athlete can complete noncontact drills without experiencing symptoms, he or she is medically cleared to begin full contact drills and return to competition.16

3. Centers for Disease Control and Prevention. Concussion in sports and play: Get the facts. Available at www.cdc.gov/concussion/sports /facts.html. 4. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40:747-755. 5. Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39:958-963. 6. Guskiewicz KM, Valovich McLeod TC. Pediatric sports-related concussion. PM R. 2011;3:353-364. 7. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train. 2009;44:434-448. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2707064/. 8. Halstead ME, Walter KD. Clinical report—sport-related concussion in children and adolescents. Pediatrics. 2010;126:597-615. Available at pediatrics.aappublications.org/content/126/3/597.long.

What else can clinicians do?

9. Collins MW, Iverson GL, Lovell MR, et al. On-field predictors of

Above all else, clinicians must educate the young athlete and his or her parent about the serious nature of concussions. Explain the details of the injury and provide realistic expectations. Emphasize the fact that activities that require concentration and attention, such as schoolwork, video games, television, and text messaging, may exacerbate concussion symptoms and possibly delay recovery. Provide a reminder that an injury to the developing brain may increase the risk of long-term effects in children and adolescents. Finally, no athlete who suffers even a mild concussion should ever return to play on the same day of an injury. When in doubt, sit them out. n

neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med. 2003;13:222-229. 10. Johnson EW, Kegel NE, Collins MW. Neuropsychological assessment of sport-related concussion. Clin Sports Med. 2011;30:73-88. 11. Peterson AR, Bernhardt DT. The preparticipation sports evaluation. Pediatr Rev. 2011;32:e53-65. 12. Womack J. Give your sports physicals a performance boost. J Fam Pract. 2010;59:437-444. 13. Jinguji TM, Bompadre V, Harmon KG, et al. Sport Concussion Assessment Tool-2: baseline values for high school athletes. Br J Sports Med. 2012;46:365-370. 14. Virji-Babul N, Borich MR, Makan N, et al. Diffusion tensor imaging of sports-related concussion in adolescents. Pediatr Neurol. 2013;48:24-29.

Ms. Denke is a family and acute care nurse practitioner for trauma services at Scottsdale Healthcare Osborn Medical Center in Scottsdale, Ariz.

15. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med. 2002;12:6-11.

References

16. Covassin T, Elbin R 3rd, Stiller-Ostrowski JL. Current sport-related

1. Luke A, Lazaro RM, Bergeron MF, et al. Sports-related injuries in youth

concussion teaching and clinical practices of sports medicine profession-

athletes: is overscheduling a risk factor? Clin J Sport Med. 2011;21:307-314.

als. J Athl Train. 2009;44:400-404. Available at www.ncbi.nlm.nih.gov/pmc/

2. National Federation of State High School Associations. High school

articles/PMC2707074/.

sports participation achieves all-time high. Available at www.nfhs.org/ CoachingTodayContent.aspx?id=7728.

All electronic documents accessed August 15, 2013.

For additional news, opinion, and clinical features on issues that affect young athletes, visit our Pediatrics Information Center at

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CME CE

program outline september 2013

0.5 credits

Page 43 Feature Counseling parents on the avoidance of feeding-associated infections Nancy Murray, RN, BSN, MS Nancy Murray, RN, BSN, MS, has no relationships to disclose relating to the content of this article.

■■ Learning objectives: • Discuss strategies to counsel parents who choose to formula-feed their infants on practices for safe use. • Review safety protocols for expressing breast milk with appropriate parents. 0.5 credits

Page 77 Dermatology Clinic Erythema and scaling of the finger and nail bed Audrey Chan, MD Audrey Chan, MD, has no relationships to disclose relating to the content of this article.

Yellow plaques in bilateral inguinal creases Vicky Ren, Apphia Wang, Kerri Robbins, MD Vicky Ren, Apphia Wang, and Kerri Robbins, MD, have no relationships to disclose relating to the content of this article.

■■ Learning objectives: • To identify and diagnose dermatologic conditions and review up-to-date treatment.

Page 85 Dermatologic Look-Alikes Firm pink trunk plaques Kerri Robbins, MD Kerri Robbins, MD, has no relationships to disclose relating to the content of this article.

■■ Learning objective: • To distinguish and properly treat dermatologic conditions with similar presentations.

Page 54, 90 posttest

This program has been reviewed and is approved for a maximum of 1 hour of AAPA Category I CME credit by the Physician Assistant Review Panel. Approval is valid for one year from the issue date of September 2013. Participants may submit the self-assessment at any time during that period. This program was planned in accordance with AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs. Nurse Practitioner Associates for Continuing Education (NPACE) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. NPACE designates this educational activity for a maximum of 1 contact hour of credit. Participants should only claim credit commensurate with the extent of their participation in the activity.

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CME CE

n educational objectives: After completing the activity, the participant should be better able to: • Discuss strategies to counsel parents who choose to formula-feed their infants on practices for safe use. • Review safety protocols for expressing breast milk with appropriate parents. n complete the posttest: Page 54 n additional CME/CE credit: Pages 77, 85

featured course

Turn to page 43 for additional information on this month’s CME/CE courses.

This activity is supported by an educational grant from Mead Johnson and jointly sponsored by Medical Education Resources (MER), Nurse Practitioner Associates for Continuing Education (NPACE), and Haymarket Medical Education (HME). Faculty Nancy Murray, RN, BSN, MS Director of Research and Special Projects Neonatal Care, PC Omaha, Neb. Release Date: September 2013 Expiration Date: September 2014 Estimated time to complete the educational activity: 30 minutes Target Audience: This activity has been designed to meet the educational needs of Primary Care Physicians, Pediatricians, Physician Assistants, Nurse Practitioners, and Dietitians. Physician Credit: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of MER and HME. MER is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: MER designates this educational activity for a maximum of 0.5 AMA PRA Category 1 creditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Dietitian Credit: Medical Education Resources (Provider Number ME110) is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered Dietitians (RDs) and Dietetic Technicians (DTRs) will receive 0.5 continuing professional education unit (CPEU) for completion of this program/material. Nursing Credit: NPACE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (ANCC). Credit Designation: NPACE designates this educational activity for a maximum of 0.5 contact hour of credit. Participants should only claim credit commensurate with the extent of their participation in the activity. Disclosure Policy—MER MER ensures balance, independence, objectivity, and scientific rigor in all our educational programs. In accordance with this policy, MER identifies conflicts of interest with its instructors, content managers, and other individuals who are in a position to control the content of an activity. Conflicts are resolved by MER to ensure that all scientific research referred to, reported, or used in a CME activity conforms to the generally accepted standards of experimental design, data collection, and analysis. MER is committed to providing its learners with high-quality CME activities that promote improvements or quality in health care and not the business interest of a commercial interest. Disclosure Policy—NPACE NPACE is committed to ensuring all educational activities are balanced and free from bias. All faculty participating in our programs disclose any relationships they may have with commercial interest whose products or services are related to the content of the activity. NPACE’s status as an accredited

provider of continuing nursing education does not imply endorsement by NPACE or ANCC of any commercial products discussed in conjunction with this program. NPACE maintains content integrity and prevents bias in the presence of commercial support through: 1) disclosure by activity planners, authors, and content reviewers of relevant relationships with any commercial interest, or lack thereof; 2) disclosure of commercial support; 3) removal of individuals with conflict of interest from the activity; 4) revising the role of the individual with the conflict so that the relationship is no longer relevant to the activity; 5) not awarding contact hours for a portion or all of the activity; 6) undertaking review of the activity by a content reviewer to evaluate for bias, balance, evidence-based content or other indicators of integrity; 7) monitoring the activity to evaluate for bias; and/or 8) reviewing participant feedback. Faculty Disclosures Nancy Murray, RN, BSN, MS, has no financial relationships to disclose. Staff/Planners’ Disclosures Joe Kopcha, Marina Galanakis, Krista Sierra, Susan Basilico, and Marjorie Hale of HME have no financial relationships to disclose. MER Content Manager has no financial relationships to disclose. Marjorie Crabtree, MSN, DNP; Karen Windle, RNC, MS, MHNP-BC; and R. Mimi Secor, MS, MEd, FNP-BC, FAANP, of NPACE have no financial relationships to disclose. Method of Participation: There are no fees for participating in and receiving CME/CE credit for this activity. During the period September 2013 through September 2014, participants must: 1) read the learning objectives and faculty disclosures; 2) study the educational activity; 3) complete the posttest and submit it online. Physicians may register at www.mycme.com (September 2013); and 4) complete the evaluation form online. A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better. Disclaimer: The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of MER, NPACE, HME, or Mead Johnson. The authors have disclosed if there is any discussion of published and/or investigational uses of agents that are not indicated by the FDA in their presentations. The opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of MER, NPACE, HME, and/or Mead Johnson. Before prescribing any medicine, primary references and full prescribing information should be consulted. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. The information presented in this activity is not meant to serve as a guideline for patient management.

jointly sponsored by

Commercial support for this activity was provided through an educational grant from

Nurse Practitioner Associates

for Continuing Education

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Nancy Murray, RN, BSN, MS

Safety First in Infant Feeding

Counseling parents on the avoidance of feeding-associated infections

rom a nutritional standpoint, the first year of an infant’s life is critical to future health. Appropriate nutrition is a major concern of parents and clinicians during these most important months of growth and development. While breastfeeding is strongly recommended for the first year of every child’s life, choosing an infant feeding method, whether breast milk or formula, is ultimately the decision of the parent.1,2 Clinicians can provide parents with accurate and objective information to help them choose or switch to a formula that will best meet the individual infant’s nutritional needs. Although the advice of health-care professionals is critical for parents to make the best possible feeding choices for their infants, parents often make infant feeding decisions without the advice of a health-care professional and may lack important knowledge regarding safe preparation, handling, and storage practices for commercial formulas.3 In addition, mothers who express breast milk may not be aware of the implications of unsafe handling and cleaning practices related to bottles and breast-pump kits.2,3 Clinicians must communicate to parents the importance of following safety and hygiene protocols when feeding their breastfed or formula-fed infants to prevent contamination.

Case study

It is recommended that all infants be breastfed exclusively for the first six months of life.

Ava M. is a 2-week-old infant who was born three and a half weeks prematurely after her mother developed preeclampsia during the latter part of her pregnancy. Since birth, Ava’s mother has pumped breast milk for bottle feeding but was not expressing enough for Ava’s caloric needs. As a result, breast-milk feeding was supplemented by ready-to-feed formula, beginning while Ava was in the hospital. Continues on page 46

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CME CE

PREVENTING FEEDING-ASSOCIATED INFECTION

Ava’s mother would like to continue using formula. She asks whether powdered formula can be used instead of the ready-to-feed variety, as it is less expensive. If so, she wants to know how to safely prepare it. Nutrition in early infancy

The American Academy of Pediatrics (AAP) recommends that all infants should be breastfed exclusively for the first six months of life and that feeding with breast milk continue until age 12 months.1 These recommendations are based on the nutritional and health benef its of breastfeeding, particularly among premature infants, who receive significant benefits with regard to host protection and improved developmental outcomes compared with formula-fed premature infants. The development of the premature infant’s immature host defenses with breastfeeding is realized in lower rates of sepsis and necrotizing enterocolitis, as well as fewer hospital readmissions for illness in the first year after discharge from the neonatal intensive care unit.1 In addition, infants of any gestational age fed human milk benefit from a decrease in infectious diseases; lower rates of postneonatal mortality and sudden death syndrome; and lower incidences of type 1 and type 2 diabetes, hematologic cancers, overweight and obesity, hypercholesterolemia, and asthma in older children and adults.4,5

or the fact that infant formula is the only safe, nutritious, and recommended alternative to breast milk according to the AAP and other national authorities.2,8,9 Commercially prepared formulas provide the necessary protein, fat, carbohydrates, vitamins, and minerals that allow infants to sustain a rapid rate of growth and development without compromising their developing organ systems.2 Before opening, the commercial preparations will remain free of microbiologic contaminants, provided they are stored properly and the container is not damaged.2 Safe practices for expressed breast milk

The proportion of mothers who express milk has increased in recent years due, at least in part, to legislation that requires workplaces to accommodate nursing mothers, health-insurance plans that cover breastfeeding support, and federal allowance for breast pumps as a deductible medical expense.8 Expressing breast milk for bottle-feeding helps mothers overcome several challenges to nursing, including separation from the infant during work hours or social occasions, such physical conditions as mastitis or engorgement, maintaining or increasing the milk supply, and providing an emergency milk supply when the mother is unexpectedly separated from the infant or needs to take medication contraindicated during breastfeeding.8

Commercial Infant Formula

Expressing Breast Milk Is a Common Practice

Although breastfeeding is recommended for an infant’s first year, about half of all U.S. mothers either supplement breast milk with commercial infant formula or switch to formula entirely by the time a child is aged 6 months, and only about 25% continue breastfeeding until the infant is a year old, according to a CDC survey.6 These trends are consistent regardless of the race or ethnicity of the child or the mother’s age or level of education.7 The Healthy People 2020 initiative goals are for 60.6% of infants to be breastfed for six months and for 34.1% to be breastfed for one year.6 Mothers choose not to initiate breastfeeding or to supplement with or switch to commercial formula for myriad reasons, including maternal employment, lack of family and societal support, lack of guidance and encouragement from health-care professionals, lack of timely follow-up care and postpartum home-health visits, and insufficient prenatal education.4

The Infant Feeding Practices Study (IFPS) II of more than 3,600 nursing mothers with infants aged 1.5 to 9.5 months found that the prevalence of expressing breast milk on a regular schedule was similar across infant age groups—between 20% and 30%.8 The study also found that electric breast pumps are the most widely used method for milk expression, followed by manual pumps, for infants of any age up to 9.5 months.8

Recommended Alternative to Breast Milk

Many mothers who choose to use commercial formula, whether as a complement to or in place of breastfeeding, are not well informed about the nutritional content of formulas

Safe Cleaning, Handling, Storage, and Warming Practices for Feeding Expressed Breast Milk

Guidelines for the safe handling and storage of expressed breast milk have been issued by the AAP, the CDC, the Academy of Breastfeeding Medicine (ABM), and other health-care organizations.7-12 Although the breast or nipple does not require cleansing before nursing or expressing milk, these agencies do make recommendations for cleanliness of hands and containers, and for labeling and thawing frozen expressed milk. (See “How to safely thaw breast milk” on page 47.) The ABM recommends that in addition to handwashing, containers and breast-pumping equipment should be washed in hot, soapy water and rinsed, followed by cleaning in a

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dishwasher or by boiling.10 Storing breast milk in small portions (2 oz to 4 oz) is a good strategy to minimize waste.10 When expressing several times a day, milk chilled for one hour in the refrigerator can be added to previously chilled milk expressed the same day. Fresh breast milk should not be added to previously frozen milk. Breast milk is not homogenized and will separate during storage, with the cream rising to the top appearing thicker and whiter; therefore, the container should be gently swirled to mix the milk. The AAP, CDC, and ABM also have guidelines for the safe storage of expressed milk at room temperature, under refrigeration, and in the freezer before feeding to healthy, full-term infants (Table 1).7,11,12 Although breast milk may be kept at room temperature for brief periods in some situations, temperatures >77°F (>25°C) may not be safe for storage.10 When refrigerating breast milk, keep in mind that the back of the refrigerator has the coolest temperature. Breast milk can be frozen for extended periods, but the

timetable is determined by type of freezer (e.g., within the refrigerator, with a separate door, or a deep freezer).10 However, prolonged storage of breast milk at temperatures <0°F (-20°C) significantly reduces the concentrations of major host defense proteins, including lysozymes and immunoglobulin A (IgA).13 Breast milk should never be thawed or warmed in a microwave oven because the uneven heating can cause burns to the infant.10 In addition, thawing or heating milk in a microwave can reduce the anti-infective properties of lysozymes and IgA.14,15 These anti-infective properties are best preserved in frozen breast milk by thawing overnight in the refrigerator or under warm running water.15 Breast milk should not be refrozen after it is thawed or partially thawed.10 Suggested Practices for Cleaning Breast-Pumping Equipment

There are no specific federal or health-care organization guidelines or recommendations that address cleaning

How to safely prepare and store expressed breast milk7,11,12 • Wash your hands before expressing or handling breast milk. • When collecting milk, store it in clean containers (e.g., screw-cap bottles, hard plastic cups with tight caps, or heavyduty plastic bags that fit directly into nursery bottles). Plastic drop-in bags should be used only for short-term storage (<72 hours). Avoid using ordinary plastic storage bags or formula bottle bags, as they could easily leak or spill. • Containers should be washed in hot, soapy water and rinsed, then boiled to improve cleanliness. Containers may be cleaned in a dishwasher, if available. Alternatively, micro-steam bags are available from some breast-pump manufacturers. • Store milk in small portions (2 oz to 4 oz, or 60 mL to 120 mL) to minimize waste. Consider storing smaller portions (1 oz to 2 oz, or 30 mL to 60 mL) for unexpected situations, e.g., if the mother is delayed in nursing. • If expressing several times a day, chill the milk for one hour in the refrigerator before adding it to previously chilled milk expressed the same day. • Do not add fresh breast milk to previously frozen milk, as it will partially thaw the frozen milk. • If possible, clearly label the milk with the date it was expressed—in ink on a waterproof label—to facilitate using the oldest milk first. • If delivering milk to a child-care provider, clearly label the container with the child’s name and the date. • When freezing milk, leave space at the top of the container for expansion. • Do not save milk from a used bottle for use at another feeding.

How to safely thaw breast milk7 • As time permits, thaw frozen breast milk by transferring it to the refrigerator for thawing or by swirling it in a bowl of warm water. • Avoid using a microwave oven to thaw or heat bottles of breast milk. • Microwave ovens do not heat liquids evenly, and uneven heating could easily scald a baby or damage the milk. • Bottles may explode if left in the microwave too long. - Excess heat can destroy the nutrient quality of the expressed milk. • Do not refreeze breast milk once it has been thawed.

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practices for milk bottles and their components or the need to sterilize breast-pump collection kits. However, breastpump manufacturers recommend cleaning the detachable milk-collection kit with hot, soapy water, and the FDA offers general information about breast-pump cleaning.8,16 Although it is not possible to completely sterilize breastpump parts in the home, sterilization is not necessary to keep them safe and sanitary. Parts that come in contact with breast milk—bottles, valves, and breast shields—should be washed thoroughly with dishwashing soap and warm water; if recommended by the manufacturer, some parts can be cleaned in the dishwasher. Micro-steam bags can also be used to clean breast-pump components. Breast-pump parts should be allowed to air-dry on clean paper towels or a drying rack and not dried with cloth towels that carry microorganisms. The breast-pump tubing does not need to be cleaned unless it comes in contact with breast milk; it should be washed and air-dried before the next use. After the parts have dried, the breast pump should be reassembled before storing. Commercial breast pumps should not be shared. Rationale for good hygienic practices when preparing and handling powdered infant formula

Because such sterilization techniques as steam or dry heat would destroy the nutritional content of powdered infant formula (PIF), it cannot be manufactured to be commercially sterile and free of viable microorganisms that may reproduce in the reconstituted formula.17,18 Before reconstitution and under proper storage conditions, PIF has a low water content,

prohibiting bacterial growth.18 Furthermore, formula manufacturers routinely test their products to exclude any microorganisms that may cause a significant health concern.18 Minimizing the Risk for Foodborne Illness in Infants

One bacterium of clinical significance that can survive in PIF is Cronobacter sakazakii.19 Even a small number of C. sakazakii cells can cause illness, and the risk is exacerbated when bacteria multiply if the reconstituted formula is held at inappropriate temperatures for prolonged periods.20 In the United States, a rate of C. sakazakii infection of 1 per 100,000 infants has been reported, with the highest incidence of 9.4 per 100,000 infants in infants of very low birth weight (<1.5 kg). The CDC was informed of a total of 13 cases in 2011.19 C. sakazakii is an opportunistic pathogen that poses little risk to healthy, full-term infants but can cause serious infections that can lead to severe and life-threatening conditions, including meningitis, in high-risk infants.19 C. sakazakii was first implicated in a case of neonatal meningitis in 1958, and about 70 cases have been reported since.20 In 2004, isolated outbreaks of C. sakazakii infection linked to PIF were reported in New Zealand and France among infants in hospital settings.20 All of those cases were associated with improper preparation, handling, and storage of feeding bottles, storage of reconstituted PIF for >24 hours in refrigerators with no temperature controls, or the administration of reconstituted PIF at room temperature.19,20 Continues on page 50

Table 1. Academy of Breastfeeding Medicine recommendations for storage of fresh human milk.7,10 Location

Temperature

Duration

Comments

Table or countertop

Room temperature (up to 77°F or 25°C)

6 to 8 hours

Containers should be covered and kept as cool as possible. Covering the container with a cool towel may keep the milk cooler.

Insulated cooler bag

5°F to 39°F (-15°C to -4°C)

24 hours

Keep ice packs in contact with milk containers at all times. Limit opening the cold bag.

Refrigerator

39°F (-4°C)

5 days

Store milk in the back of the main body of the refrigerator.

5°F (-15°C)

2 weeks

0°F (-18°C)

3 to 6 months

-4°F (-20°C)

6 to 12 months

Freezer • F reezer compartment of a refrigerator • F reezer compartment of a refrigerator with separate doors • C hest or upright deep freezer

Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations is safe but may have lower quality due to degradation of lipids.

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Seven steps to safe preparation of infant formula20-22 Parents should follow these seven steps to make sure they are measuring infant formula correctly, storing it properly, and keeping the utensils clean: 1. Check the expiration date and condition of the container. • Do not purchase or use infant formula with a “use by” or expiration date that has passed, because the quality of the product cannot be ensured. • Inspect the container for any bulges, dents, leaks, or rust spots; the formula in a damaged container may be unsafe. • Clean the formula container by washing the top with soap and water before opening and rinsing well. • Wash the can opener with soap and water, and dry it before opening the formula can. 2. Wash hands and clean preparation surfaces. • Wash hands thoroughly before preparing infant formula, especially after using the toilet or changing a diaper. • Use warm running water and rub hands vigorously with soap for at least 20 seconds. • Make sure to wash under fingernails and between fingers. 3. Prepare the bottle. • Sterilize bottles, nipples, caps, and rings before using them for the first time. Boil in water for five minutes in a pot deep enough so that water covers all the pieces. Remove the pieces from the pot with tongs, and let them air-dry. • After the first use, sterilization is not necessary but the items should be washed with soap and water and allowed to air-dry. • Bottles and other parts can also be washed in the dishwasher; dishwasher-safe baskets are available to hold these items. • When preparing formula in the bottle, a liquid measuring cup should be used to make sure the measurements are accurate, especially if drop-in liners are used. 4. Add water to liquid-concentrate formula. • Follow the manufacturer’s instructions for how much water to use. Adding too little water can put a burden on the baby’s digestive system, and adding too much might dilute the formula and deny the baby needed calories and nutrients. • Use any type of clean water—tap or bottled—but consider sterilizing it before adding it to the bottle, especially if you use private well water. • If lead or other contamination is a concern, let tap water run until it is as cold as it will get and then boil it in a pan for one or two minutes; let the water cool to no lower than 158°F (70°C), and pour in the amount needed. 5. Measure the formula. • For liquid-concentrate formula: - Shake the container well before opening.

- Pour the amount of formula for one serving into the bottle, which already contains the appropriate amount of water. - Attach the nipple and cap, and shake well. • For powdered formula: - Add water first. - Use the scoop that came with the formula container; make sure the scoop is dry. - Follow the instructions on the container to determine the amount of formula to prepare, and note the number of scoops required. Note that the total volume of formula may be slightly more than originally measured. - Fill the scoop with powdered formula, shaving off any excess formula using the flat side of a knife, not a spoon or other curved surface. - Pour the powdered formula into the bottle. - Attach the nipple and cap, and shake well. 6. Warm the formula, if needed. • Do not warm bottles in the microwave. The formula might heat unevenly and create hot spots that could burn the baby’s mouth. • If the baby prefers warm formula (feeding formula at room temperature or even cold is acceptable): - Place a filled bottle in a bowl or pan of hot, but not boiling, water, and let it stand for a few minutes. Or, warm the bottle under running water. - Shake the bottle after warming it. - Turn the bottle upside down, and test one or two drops of formula on your wrist or the back of your hand. - The formula should feel lukewarm rather than hot. • Shake the bottle well, and feed the formula to the baby immediately. Discard any formula that remains in the bottle after a feeding. 7. Store formula safely. • Store unopened containers of formula in a cool, dry place. • Do not store formula containers outdoors or in a car or garage, where temperature extremes can affect the quality of the formula. • Do not store formula containers near or next to such products as bags of dry pet food that could contaminate the lid of the formula container. • Cover and refrigerate any leftover ready-to-use formula from a freshly opened container. Discard any leftover formula that has been in the refrigerator more than 48 hours.

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Safe preparation and storage of powdered infant formula

Cleaning the Equipment Used for Infant Formula

PIF can become contaminated by dirty utensils or when the preparation environment is unclean.20 However, healthcare workers, parents, and other caregivers can protect infants against infection by following simple safe-handling practices. (Seee “Seven steps to safe preparation of infant formula” on page 49.)8,20

It is preferable that formula be prepared fresh for each feeding and consumed immediately in order to avoid the growth of bacteria.20 Cleanliness is critical to prevent contamination of PIF and the bottles and components used for feeding any commercial formula. Harmful bacteria can be carried on preparation utensils, preparation surfaces, and hands,

Table 2. Storage and handling practices for expressed breast milk among mothers in the Infant Feeding Practices Study II.23 Infant Age (months) >4.5 to 6.5

1.5 to 4.5 Practice

All (n=1,060)

No Formula (n=672)

Also Fed Formula (n=388)

All (n=665)

No Formula (n=439)

>6.5 to 9.5

Also Fed Formula (n=226)

All (n=436)

No Formula (n=121)

Also Fed Formula (n=388)

Percentage of Mothers (>10) Storage at room temperature (hours)* Never <1 1 to 2

38 32 17

44 26 16

30 41 18

40 33 15

40 32 15

39 37 14

43 34 13

47 33 11

35 37 17

Storage in refrigerator (days)*† Never <1 2 to 3

16 38 34

17 34 36

13 46 31

10 39 40

11 32 44

10 52 32

12 37 40

13 35 41

10 43 36

19 10 16 45 10

14 6 17 50 13

27 19 15 35 4

16 9 18 40 12

13 7 17 43 14

24 13 21 34 6

Time stored in freezer†‡ Never <1 week 1-4 weeks -3 months 4-5 months Heated pumped milk in microwave*¶ Never Rinsed bottle nipples with water only§ Never Less than half the time Sterilized pumpcollection kit§ After each use Every day

83 11

86 8

79 13

83 12

86 10

79 14

86 9

87 9

85 9

36 8

34 9

32 8

31 9

34 13

37 8

38 8

*P<0.001 between mothers of infants 1.5 to 4.5 months of age who also fed formula and those who did not. †P<0.001 between mothers of infants >4.5 to 6.5 months of age who also fed formula and those who did not. ‡P=0.001 between mothers of infants >6.5 to 9.5 months of age who also fed formula and those who did not. ¶P=0.002 between mothers of infants >4.5 to 6.5 months of age who also fed formula and those who did not. §P=0.01 between mothers of infants 1.5 to 4.5 months of age who also fed formula and those who did not.

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particularly after using the toilet or changing a diaper.20 The same cleaning practices should be followed before cleaning the feeding and preparation equipment and before preparing the formula.20,21 Bottles, bottle nipples, cups, scoops, and spoons should be washed in hot, soapy water, and clean bottle and nipple brushes should be used to thoroughly remove any remaining formula.21 Bottles and their components should be rinsed in clean water. They also can be sterilized in a commercial home sterilizer or by boiling. If not used immediately, all bottle components should be fully assembled to prevent the inside of the bottle and the bottle nipple from becoming contaminated. Guidelines for Reconstituting PIF With Water

The temperature of the water used to reconstitute PIF plays a vital role in reducing the risk for C. sakazakii in infants of all ages.20 The World Health Organization (WHO) recommends that safe tap, and even bottled, water be boiled and cooled to 158°F (70°C), which will kill any C. sakazakii in the powder and remain effective even for slow-feeding infants or infants in warmer climates.20 Cooling the water prevents PIF from clumping and thereby diminishing its nutritional value.21 If parents or caregivers do not have access to boiled water, fresh, safe water from the tap or bottled water at room temperature may be used.21 Plain bottled water, however, may contain additional vitamins, minerals, or other additives that are not necessary for infants, despite aggressive marketing to the contrary.21 Many families obtain their water from private, unregulated wells, and preparing formula with well water may pose a risk for nitrate poisoning in infants.21 The AAP recommends that well water used for drinking and food preparation be tested every three months for one year, and annually thereafter, for nitrate levels. A nitrate level >10 should not be used to prepare infant formula.21 The AAP also recommends that infants younger than age 6 months should not receive fluoride supplements, but fluoride may be supplemented for children aged 6 months to 3 years living in communities where the water contains concentrations of fluoride <0.3 parts per million.1 Recommendations for Storing, Rewarming, and Transporting Prepared Formula

Although freshly prepared formula is preferred, it may be more practical for parents to prepare formula for multiple feedings in advance.20 The same safe-handling practices as for preparation of a single-feeding formula should be

followed. The prepared formula should be divided into single-serving bottles and refrigerated at a temperature no higher than 41°F (5°C) for up to 24 hours. Stored, prepared formula should be removed from the refrigerator just before use and reheated for not more than 15 minutes in warm water or a bottle warmer, shaking the container occasionally.20 Formula should never be rewarmed in a microwave oven because uneven heating can occur and may scald the infant’s mouth. Rewarming for extended periods, including in a bottle warmer, creates an ideal environment for the growth of bacteria and has been reported as a probable cause of an outbreak of C. sakazakii infection. As with single-serving preparation, the temperature of rewarmed formula should be checked before feeding, and any formula left over from a feeding should be discarded. Prior to transporting, prepared formula should be cooled in the refrigerator at <41°F (<5°C) and removed only immediately before transporting in a cooler bag with ice packs.20 Feedings transported in cooler bags should be consumed within two hours to ensure they remain adequately chilled. If the destination is reached within two hours, the formula can be stored in the refrigerator for up to 24 hours after preparation. Rewarm the formula at the destination just as for a refrigerated feeding. As an alternative, individual portions of PIF can be transported in sterilized bottles, and hot water no lower than 158°F (70°C) can be used to prepare the feeding, using sterilized preparation equipment. What parents and caregivers of infants need to know

The increasing prevalence of expression of breast milk and the use of commercial infant formula as a supplement to breast milk or as the sole source of nutrition provides healthcare professionals with important opportunities to educate parents and infant caregivers on safe handling practices for breast milk and infant formula. Several recent studies underscore a need for this education to reduce the risk for foodborne infection.8,23-25 A survey of 1,500 U.S. mothers who participated in the IFPS II explored their practices for handling and storing expressed breast milk.23 Regardless of infant age (from 1.5 to 9.5 months), more than 95% of mothers followed the recommendations for safe milk storage at room temperature and in the refrigerator or freezer; however, up to 12% of mothers reported heating expressed milk in the microwave contrary to recommendations, and up to 17% reused bottle nipples after rinsing with water only, at least some of the time (Table 2). Mothers who also fed formula stored their milk in

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the refrigerator or freezer for the shortest time, but were more likely than mothers who breastfed exclusively to follow suboptimal heating and cleaning practices. The proportion of mothers who sterilized pump-collection kits ranged widely, from more than one-third sterilizing after each use to nearly another one-third never sterilizing the kit. The IFPS II also surveyed 1,500 mothers who formula-fed their infants on safe practices regarding handling and storage of infant formula.8 Fully one-third did not receive instruction on formula preparation from a health-care professional, and nearly as many did not receive instruction on formula storage. Nearly one-third of the mothers surveyed did not read some of the safe-use directions on the formula package label, including how to store an opened formula package, how to store prepared formula, and how to handle formula left after a feeding (Figure 1). Although 85% believed safe-storage directions were important, many mothers surveyed did not follow safe practices for formula preparation: More than half did not always wash their hands with soap prior to preparing formula, one-third reused bottle nipples after rinsing only in water, and even more heated formula in a microwave oven. Unfortunately, unsafe cleansing practices may occur because mothers do not associate them with an increased risk for infant illness. Additional evidence for the need to provide education and support for mothers and other infant caregivers regarding

safe practices for bottle feeding is provided in a systematic review of six qualitative and 17 quantitative studies comprising more than 13,000 participants.25 Although the studies differed in design, focus, and quality, several themes were consistent throughout and matched the IFPS II findings. These included receiving inadequate information from health-care providers, which was more prevalent among bottle-feeding mothers than breastfeeding mothers. Women who did not receive information from a health-care provider were more likely to rely on friends and family members; furthermore, incorrect practices are often handed down from one generation to the next. Recommended hygiene and safety practices for preparing formula often were not followed, and in some studies mothers reported over- or under-concentrating the reconstituted formula, or adding cereal to the bottle. Several studies noted that others often changed the type of formula due to the infant regurgitating after a feeding, which may have been more likely a result of overfeeding than intolerance to the formula. Conclusions

Breastfeeding is universally recommended as the optimal source of infant nutrition, but many infants are fed with formula instead of, or as a supplement to, breast milk. To reduce the risk for foodborne illness in breast- and/or

Left formula at room temperature >2 h Practiced unsafe handling

Reused bottle nipples without washing Heated bottle in microwave Did not wash hands before preparing

Storing open formula container

Did not read directions for

Leftover formula Storing after preparation Formula preparation 0 20 40 60 Percentage of respondents

Figure 1. Lack of information and unsafe handling practices regarding infant formula among 1,500 mothers in the Infant Feeding Practices Study II (2005-2007).8 52 the clinical advisor â&#x20AC;˘ September 2013 â&#x20AC;˘ www.ClinicalAdvisor.com

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bottle-fed infants, mothers and other infant caregivers require education and training in best safety practices for expressed breast milk and commercially prepared infant formula. Health-care providers are in an ideal position to provide this education and should emphasize the importance of safe practices for all items involved in the collection, storage, and feeding of expressed breast milk, and particularly the preparation, handling, and storage of formula that is a source of nutrition for a significant number of infants. n

13. Akinbi H, Meinzen-Derr J, Auer C, et al. Alterations in the host defense properties of human milk following prolonged storage or pasteurization. J Pediatr Gastroenterol Nutr. 2010;51:347-352. 14. Quan R, Yang C, Rubinstein S, et al. Effects of radiation on antiinfective factors in human milk. Pediatrics. 1993;89:667-669. 15. Sigman M, Burke KI, Swarner OW, Shavlik GW. Effects of microwaving human milk: changes in IgA content and bacterial count. J Am Diet Assoc. 1989;89:690-692. 16. U.S. Food and Drug Administration. Cleaning a breast pump. Available at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/

References

HomeHealthandConsumer/ConsumerProducts/BreastPumps/

1. Section on Breastfeeding. Breastfeeding and the Use of Human Milk.

UCM061950.htm.

Pediatrics. 2012;129:e827. Available at pediatrics.aappublications.org

17. International Formula Council. Formula feeding. Available at

/content/129/3/e827.long.

www.infantformula.org/for-health-professionals#Formula-Feeding.

2. International Formula Council. What mothers need to know about

18. International Formula Council. Formula feeding. Available at www.

infant formula. The International Formula Council. www.infantformula.org/

infantformula.org/for-health-professionals#Good-Manufacturing-Practices.

sites/default/files/IFC_What_Mothers_Need_to_Know_About_Infant_

19. International Formula Council. Cronobacter sakazakii. Available at

Formula_Brochure.pdf.

www.infantformula.org/for-health-professionals#Cronobacter-Sakazakii.

3. Labiner-Wolfe J, Fein SB, Shealy KR. Infant formula—handling education

20. World Health Organization. Safe preparation, storage and handling

and safety. Pediatrics. 2008;122:S85-S90. Available at pediatrics

of powdered infant formula: guidelines. Geneva, Switzerland; 2007.

.aappublications.org/content/122/Supplement_2/S85.long.

21. Mayo Clinic. Infant formula: 7 steps to prepare it safely. Available at

4. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of

www.mayoclinic.com/health/infant-formula/MY00193.

human milk. Pediatrics. 2005;115:496-506. Available at pediatrics

22. Hancock ME, Brown J. Formula-feeding safety. What nurses need

.aappublications.org/content/115/2/496.long.

to teach parents who choose to formula-feed. Nurs Womens Health.

5. Office on Women’s Health. Why Breastfeeding Is Important.

2010;14:302-309.

Available at www.womenshealth.gov/breastfeeding/why-breastfeeding-is-

23. Labiner-Wolfe J, Fein SB. How US mothers store and handle their

important/index.html.

expressed breast milk. J Hum Lact. 2013;29:54-58.

6. Centers for Disease Control and Prevention. Breastfeeding report

24. Calamusa G, Valenti RM, Guida I, Mammina C. A survey on knowledge

card—United States, 2012. Available at www.cdc.gov/breastfeeding/data

and self-reported formula handling practices of parents and child care

/reportcard.htm.

workers in Palermo, Italy. BMC Pediatr. 2009;9:75.

7. Centers for Disease Control and Prevention. Proper handling and

2 5. Lakshman R, Ogilve D, Ong KK. Mothers’ experiences of bottle-

storage of human milk. www.cdc.gov/breastfeeding/recommendations

feeding: a systematic review of qualitative and quantitative studies. Arch

/handling_breastmilk.htm.

Dis Child. 2009;94:596-601.

8. Labiner-Wolfe J, Fein SB, Shealy KR, Wang C. Prevalence of breast milk expression and associated factors. Pediatrics. 2008;122:S63-S68.

All electronic documents accessed August 15, 2013.

9. FamilyDoctor.org. Formula feeding: some common concerns. Available at familydoctor.org/familydoctor/en/pregnancy-newborns /caring-for-newborns/breastfeeding-formula/formula-feeding-somecommon-concerns.html. 10. The Academy of Medicine Breastfeeding Protocol Committee. Protocol #8: Human milk storage information for home use for healthy full-term infants. Breastfeeding Med. 2010;5:127-130. 11. Medela. Hygiene and nipple care. Available at www.medela.com/IW/en/ breastfeeding/good-to-know/hygiene-and-nipple-care.htm. 12. HealthyChildren.org. Storing and preparing expressed breast milk. Available at www.healthychildren.org/English/ages-stages/baby/ breastfeeding.

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posttest Expiration date: September 2014

Credit Designation: MER is accredited by the ACCME to provide continuing medical education for physicians. MER designates this educational activity for a maximum of 0.5 AMA PRA Category l Credit™. Nurse Practitioner Associates for Continuing Education (NPACE) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. NPACE designates this educational activity for a maximum of 0.5 contact hours of credit. Dietitian Credit: Medical Education Resources (Provider Number ME110) is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered Dietitians (RDs) and Dietetic Technicians (DTRs) will receive 0.5 continuing professional education unit (CPEU) for completion of this program/material. Participants should only claim credit commensurate with the extent of their participation in the activity. A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better. Posttest must be completed and submitted online. Please go to CliniAd.com/12adqLQ. credits: 0.5

| Safety first in infant feeding: counseling parents on the avoidance of feeding-associated infections

1. The American Academy of Pediatrics (AAP) recommends that: a. All infants should be breastfed exclusively for the first three months of life and that feeding with breast milk continue until age 6 months. b. All infants should be breastfed exclusively for the first three months of life and that feeding with breast milk continue until age 9 months. c. All infants should be breastfed exclusively for the first six months of life and that feeding with breast milk continue until age 9 months. d. All infants should be breastfed exclusively for the first six months of life and that feeding with breast milk continue until age 12 months. 2. In contrast with AAP guidelines, only __ of U.S. mothers continue breastfeeding their infants for the recommended time period. a. 10% c. 15% b. 20% d. 25%

4. The overwhelming majority of cases of Cronobacter sakazakii associated with infant feeding have been linked with: a. Improper preparation, handling, and storage of feeding bottles/formula b. Contamination of infant formula during manufacture c. Pre-existing health conditions in affected infants d. Use of tap water during preparation 5. To safely reconstitute powdered infant formula, the World Health Organization recommends that: a. Only bottled water should be used. b. W ell water should not be used. c. If bottled water is used for infants age 6 months or younger, it must contain fluoride. d. Either tap or non-fluoridated bottled water can be used, but should be boiled first and then cooled.

3. According to the Academy of Breastfeeding Medicine: a. Fresh breast milk can be safely added to previously frozen milk b. B reast milk can be safely frozen for indefinite periods of time c. B reast milk should never be thawed or warmed in a microwave oven because the uneven heating can cause burns to the infant d. B reast milk should be used within 24 hours of being expressed, whether refrigerated or frozen

To take the Posttest please go to CliniAd.com/12adqLQ

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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.

Inside the Forum september 2013

Consultations Do antipsychotics increase the risk of pulmonary embolism?. . . . . . . . . . . 56 Is triamcinolone safe for seasonal allergies?. . . . . . . . . . . . . . . 57 Frequency of spirometry in stable patients with asthma. . . . . . . . 57

Your Comments Is referral to endocrinology a must for primary aldosteronism?. . . . . . . . 58

Send us your letters with questions and comments to: The Clinical Advisor, 114 West 26th Street, 4th Floor, New York, NY 10001. You may also fax (646) 638-6117, or contact us by e-mail at letters@ 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.

Consultations Congratulations, Denise Cologne and Lydia Miller, the Grand Prize winners of the Medical Pursuit contest on ClinicalAdvisor.com.

Do antipsychotics increase the risk of pulmonary embolism? I treat a number of hospitalized psychiatric patients. My colleagues and I have noticed an unusually high occurrence of pulmonary emboli in patients taking psychiatric medications. Is there any support for the theory that psychiatric medications contribute to a greater risk of pulmonary emboli?—DENISE COLOGNE, PA-C, Hartford, Conn. A study conducted in New Zealand looked at pulmonary embolism (PE) cases in individuals with psychiatric diseases from 1990 through 1998 (Pharmacoepidemiol Drug Saf. 2003;12:647-652). A significant increase in risk of PE was found in those patients who were taking antipsychotics and antidepressants; no increased risk was found in those taking other psychotropic drugs (i.e., anxiolytics and benzodiazepines). Another study looked at patients older than age 65 years and found no association between deep vein thrombosis (DVT) or PE and use of antipsychotics or antidepressants (Thromb Haemost. 2002;88:205-209). A few additional studies have found a significantly higher risk of PE in patients with depression, especially those with catatonic features. The prevailing opinion is that increased risk may be due to confounding factors and not the medication. The

Our Consultants

Rebecca H. Bryan, APRN, CNP,

Eileen Campbell, MSN, CRNP,

Philip R. Cohen, MD,

is a lecturer in the Family Health NP Program, University of Pennsylvania School of Nursing, Philadelphia.

is associate program director, Family Health NP Program, University of Pennsylvania School of Nursing, Philadelphia.

is clinical associate professor of dermatology, University of Texas Medical Center, Houston.

Deborah L. Cross, MPH, CRNP, ANP-BC, is associate program

director, Gerontology NP Program, University of Pennsylvania School of Nursing, Philadelphia.

Maria Kidner, DNP, FNP-C,

is a nurse practitioner with Cheyenne Cardiology Associates in Cheyenne, Wyo.

56 the clinical advisor • september 2013 • www.ClinicalAdvisor.com

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most frequently discussed confounding factor is the risk associated with immobility—a known risk factor for DVT and, thus, PE (Pharmacoepidemiol Drug Saf. 2004;13:659-660).—Claire Babcock O’Connell, MPH, PA-C (179-1)

Is triamcinolone safe for seasonal allergies? Many people ask for a triamcinolone injection for summer allergies. I understand that this is not the standard of care, but most of my patient population cannot afford the recommended nasal steroids and eyedrops. What are the risks of triamcinolone injections for treatment of seasonal allergies?—LYDIA MILLER, ARNP, Centralia, Wash. The evidence regarding the effectiveness of steroid injections for allergic rhinitis is conflicting. A review of 18 mostly older studies concluded that a single intramuscular injection of a corticosteroid was superior to placebo in relieving subjective symptoms of nasal allergies and resulted in approximately three weeks of relief (Prim Care Respir J. 2005;14:124-130). One comparison of glucocorticoid injections and intranasal steroids noted equal efficacy between the two; a second trial showed superior effect of injected corticosteroids. Side effects of steroid injections included tissue atrophy, gastritis, uveitis, and some mild suppression of the hypothalamic pituitary axis. All of these studies involved healthy volunteers, but pregnant women and individuals with diabetes, glaucoma, renal insufficiency, congestive heart failure, and peptic ulcer disease may experience more severe side effects from corticosteroid injections. Other case reports describe muscle atrophy and adverse drug interactions with such classes of drugs as protease inhibitors, seizure medications, and macrolide antibiotics. Steroid injections may also diminish the effect of any recent vaccines. Given the somewhat short duration of relief provided by injectable corticosteroids, those with chronic allergy symptoms would not be

Debra August King, PhD, PA,

is senior physician assistant at New York-Presbyterian Hospital, New York City.

Mary Newberry, CNM, MSN

provides well-woman gynecologic care as a midwife with Prima Medical Group, Greenbrae, Calif.

good candidates for this option. The American Academy of Allergy, Asthma & Immunology does not recommend the use of systemic corticosteroids for allergic rhinitis; nasal steroids are considered the first-line and safest treatment approach (J Allergy Clin Immunol. 2008;122:S1-S84). The nasal corticosteroids fluticasone propionate (Flonase) and flunisolide (Nasalide, Nasarel) are now available as a generic preparation at a cost of about $15 a month. Nasal corticosteroids start to provide symptom relief within three to 12 hours and provide effective treatment for extended symptoms. These medications can also be used as preventive treatment at the start of the allergy season, with usually only local side effects (i.e., nasal irritation and bleeding). Nasal corticosteroids are considered safe for use in pregnancy and have no contraindications other than previous allergy to the compounds themselves. Although injectable corticosteroids may provide some short-lived relief from symptoms, the risk of side effects remains problematic. Some argue that an injectable glucocorticoid would be reasonable for individuals who are not able to use nasal steroids because of total nasal obstruction from allergic rhinitis.—Kathy Pereira, MSN, FNP-BC, assistant professor, co-coordinator, family nurse practitioner program, Duke University School of Nursing, Durham, N.C. (179-2)

Frequency of spirometry in stable patients with asthma How often should stable patients with asthma undergo spirometry?—ROBERT MARSH, ARNP, Fordland, Mo. According to a joint clinical practice guideline from the Department of Veterans Affairs and the Department of Defense (available at www. healthquality.va.gov/asthma/ast_2_ full.pdf, accessed August 15, 2013), spirometry should be performed at least every one to two years on stable patients with persistent mild, moderate, or severe asthma (more frequently if the asthma is not well controlled). Spirometry

Claire O’Connell, MPH, PA-C,

teaches in the PA Program at the New Jersey Medical School and Rutgers University, Piscataway, N.J.

Sherril Sego, FNP-C, DNP,

is a primary-care nurse practitioner at the Department of Veterans Affairs Medical Center in Kansas City, Mo.

Julee B.Waldrop, DNP,

is associate professor at the University of Central Florida (UCF), and practices pediatrics at the UCF Health Center.

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Advisor Forum is appropriate for patients aged 5 years and older.—Sherril Sego, FNP-C, DNP (179-3)

Your comments Is referral to endocrinology a must for primary aldosteronism? Dr. Thanavaro’s article (“Raising awareness of primary aldosteronism,” June 2013) was an excellent introduction to this commonly undiagnosed problem. I was disappointed to learn that the referral to endocrinology is recommended for all positive screens. Are there any studies on the sensitivity and specificity of making the diagnosis using the aldosterone/ renin ratio (ARR), which can be done at the PCP’s office, or on the effectiveness of just adding spironolactone (Aldactone) to patients with resistant hypertension? – JEFF COHEN, PA-C, Boynton Beach, Fla.

Primary aldosteronism (PAL) is a common and treatable form of secondary hypertension. ARR testing has made it feasible to identify this clinical entity. However, ARR has a relatively poor predictive value, with a high percentage of false-positive results. Day-to-day variability reduces the value of a single measurement of this test, as does diet, posture, time of day, presence of hypokalemia, medications, age, and renal function. Attempts should be made to control these variables as much as possible. A repeat test is necessary before the PAL diagnosis can be confirmed with certainty, and further testing for independent aldosterone hypersecretion and plasma renin suppression should be undertaken. This confirmatory test can be accomplished in a variety of ways, including measuring serum or urine aldosterone levels with fludrocortisone (Florinef) suppression, a captopril (Capoten) challenge, IV saline, or an oral-sodium loading test. Finally, use adrenal CT and adrenal venous sampling to determine the subtype of PAL and the appropriate treatment modality (i.e., medical treatment for bilateral secreting adrenal lesions or surgical treatment for unilateral adrenal adenoma). An endocrinology referral is recommended because of the complexity of this testing. Many providers may want to collaborate with a specialist to determine treatment plans and/or referral for surgery. The goal of PAL treatment is to normalize circulating aldosterone or to achieve adequate aldosterone-receptor blockade to prevent the morbidity and mortality associated with hypertension, hypokalemia, and end-organ damage. While nonselective (spironolactone) and selective aldosterone receptor antagonists (eplerenone [Inspra]) are effective for the treatment of hypokalemia and hypertension, hyperaldosterone-induced end-organ damage persists if the secreting tumor is not eliminated; adrenalectomy for aldosterone-producing adenoma is more cost-effective than long-term medical treatment.—Joni Thanavaro, DNP (179-4) n

“Nobody unsubscribes from fluffykitty.com.”

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Derm Dx

exclusive to the web

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 CliniAd.com/10KIbCF. Learn more about diagnosing and treating these conditions, and see how you compare with your colleagues.

Painful purulent nodules on the scalp A 45-year-old Hispanic man presents with a six-year history of painful and progressively enlarging nodules on his occipital scalp and posterior neck. The nodules drain purulent fluid when compressed. What is your diagnosis?

• Central centrifugal cicatricial alopecia • Lichen planopilaris • Discoid lupus erythematosus • Dissecting cellulitis of the scalp • Acne keloidalis nuchae ● See the full case at CliniAd.com/16ROAE2

A dishwasher with discolored fingernails A woman, aged 40 years, complains of a discolored fingernail. She reports no other medical problems. The woman used to wear acrylic gel nails and is employed as a dishwasher. What is your diagnosis?

• Minocycline-induced discoloration • Melanoma • Pseudomonas green nail syndrome • Subungual hematoma ● See the full case at CliniAd.com/19DTnLu

Have you missed any recent Derm Dx cases? Go to CliniAd.com/10KIbCF for a complete archive of past quizzes as well as additional images of last month’s other cases.

Erythematous annular plaque

Rash following a sore throat

60 the clinical advisor • september 2013 • www.ClinicalAdvisor.com

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Clinical Challenge Hypertension and substance abuse mask an underlying condition April Bigelow, PhD, ANP-BC; Chin Hwa Dahlem, PhD, RN, NP-C; and Michelle Pardee, DNP, FNP-BC

A middle-aged man presents with palpitations, tachycardia, tremors, and extreme anxiety.

Mr. T, a white man aged 51 years, presented to a free clinic for management of hypertension and to obtain prescriptions. Although he had insurance through the U.S. Department of Veterans Affairs (VA), Mr. T stated that he felt safer coming to the free clinic. Mr. T had previously obtained medications through a variety of free clinics but was looking for a location where he could receive regular care. With a history of homelessness, substance abuse, and mental illness, Mr. T thought the free clinic would be a good solution. He reported no other comorbidities, family history, or past medical issues. He stated that his hypertension was well managed with a two-drug regimen. After several visits, the clinic staff members noted that Mr. T’s pulse and BP fluctuated drastically. He was on a beta blocker to manage hypertension, but he also reported consuming at least two pots of coffee per day. Additionally, Mr. T stated that he had increased anxiety when he came to the clinic because there he would see people with whom he had previously used drugs. Mr. T routinely refused laboratory evaluation and would not return for follow-up appointments with any regularity. Given his nonadherence to medication and follow-up, the providers began to question other causes of his tachycardia and hypertension, notably extreme anxiety and possibly substance use.

CASE

1. History

The patient’s pulse and BP fluctuated on repeat examination.

Mr. T’s history indicated polysubstance abuse and increased anxiety, with self-diagnosed panic attacks that occurred weekly. Mr. T reported attending Narcotics Anonymous meetings several times per week. He noted previous attempts to cut down his caffeine consumption but found that his anxiety continued. Mr. T was previously homeless but was working in sales at the time of his appointment. He reported no current use of alcohol

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Clinical Challenge or illicit drugs but admitted to smoking one to three packs of cigarettes a day, depending on his anxiety level. Mr. T also reported taking metoprolol (Lopressor, Toprol) 50 mg b.i.d. and hydrochlorothiazide 25 mg once daily for treatment of hypertension.

2. Examination On presentation, Mr. T appeared anxious. His speech was rapid, he displayed minimal eye contact during consultation, and he tapped his feet throughout the visit. The patient’s BP was mildly hypertensive (145/82 mm Hg), and his pulse was 68 beats per minute. Mr. T’s BMI was 20.87. Head and neck exam were unremarkable, lung sounds were clear, and heart rhythm was regular without extra sounds. An abdominal exam was also unremarkable with normoactive bowel sounds. No peripheral edema was noted.

3. Laboratory Data and Diagnosis After a lengthy discussion, the patient agreed to venipuncture. Given Mr. T’s history of polysubstance abuse, and his anxiety symptoms, the providers doubted he would return for additional testing. Thus, a battery of tests were ordered, including a lipid panel, hemoglobin A1c, a complete blood count and comprehensive metabolic panel, and several thyroid tests (triiodothyronine [T3], thyroxine [T4], and thyroid-stimulating hormone [TSH]). All labs returned within normal limits except for the thyroid studies. Mr. T’s total T3 was 481 ng/dL (normal 80-175 ng/dL), total T4 >30.0 µg/dL (normal 4.9-12 µg/dL), and TSH <0.01 mIU/L (normal 0.3-5.50 mIU/L). Given these results, Mr. T was sent for a thyroid uptake study. The 24-hour uptake was 59%, which was well above the normal range of 7% to 30%. Hyperthyroidism, specifically toxic diffuse goiter with mention of thyrotoxic crisis or thyroid storm, was diagnosed.

4. Treatment Endocrinology was consulted, and Mr. T was started on methimazole (Tapazole) daily in addition to his metoprolol. Within a week, the patient noted decreased anxiety, and his BP and pulse began to normalize. The endocrinology team recommended that Mr. T continue the current regimen for one year with close follow-up. The patient understood all this and agreed to comply.

5. Discussion There are many challenges associated with providing health care to homeless or unstably housed individuals. The health of homeless individuals can be influenced by increased exposure to communicable disease, increased prevalence of psychosocial problems, and limited or fragmented access to health services. In addition, stress, lack of access to healthful food, chemical dependency, and mental illness can result in an increase in chronic disease.1 A lack of continuity in their health care, nonadherence to treatment, and low literacy can further complicate the health and well-being of the individuals.2 The symptoms of a homeless patient presenting for care can be complicated by the fact that these symptoms can be caused by both medical and psychological disorders, and careful evaluation needs to be completed.3 Mr. T initially presented to the clinic with a history of polysubstance abuse, untreated anxiety, and consumption of significant amounts of coffee. His hypertension was being treated with metoprolol and hydrochlorothiazide, while other health-care concerns were being managed at the VA hospital. Unfortunately, Mr. T had lapses in care for long periods of time. Following recommendations for the care of homeless patients,4 a comprehensive and ongoing history was obtained at each clinic visit. Mr. T’s physical exams, while normal, did elicit tachycardia, which he explained was the result of his anxiety and walking to the clinic. His caffeine consumption also explained his tachycardia symptoms, as overconsumption can lead to cardiac side effects. While hyperthyroidism, anxiety, and substance abuse should be differential diagnoses when a patient presents with caffeine intoxication,5 Mr. T’s refusal of baseline labs and the medical management of his hypertension complicated and delayed his diagnosis for more than one year. Typical symptoms of hyperthyroidism include tachycardia, increased BP, nervousness, and anxiety—all of which were reported by this patient. These same symptoms are typically seen in individuals with untreated anxiety, an overconsumption of caffeine, polysubstance abuse, and hypertension. Furthermore, Mr. T’s hypertension (and treatment with a beta blocker) complicated this diagnosis because it masked many of the symptoms associated with hyperthyroidism. The beta blocker lowered his BP and kept his heart rate at a level that wasn’t a concern. Because, Mr. T had declined treatment for his anxiety, it was not known what symptoms would have persisted had his anxiety been adequately managed. Continues on page 69

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Clinical Challenge 6. Summary

patients. Clinicians must find a way to establish a trusting relationship with this very vulnerable population. n

Mr. T’s hyperthyroidism was masked by excessive caffeine consumption, a history of untreated anxiety and polysubstance abuse, and the lack of prominent physical signs of hyperthyroidism. In addition, Mr. T’s long-term treatment for his hypertension controlled his palpitations, tachycardia, tremors, and anxiety, which further delayed the diagnosis.6 There are conflicting guidelines regarding screening for hyperthyroidism. The U.S. Preventive Services Task Force concludes that the evidence is insufficient to recommend for or against routine thyroid-disease screening in adult patients.7 The American Association of Clinical Endocrinologists recommends screening older patients, especially women, but age is not specified.8 The American Thyroid Association recommends TSH testing for women and men older than age 35 years and every five years thereafter.9 The American Academy of Family Physicians recommends routine screening for all individuals aged 60 years and older.10 TSH screening is supported for people with a history of: autoimmune disease; pernicious anemia; neck radiation (potentially affecting the thyroid gland); thyroid surgery; abnormal thyroid examination; psychiatric disorders; amiodarone (Cordarone, Pacerone) or lithium (Lithobid) maintenance; and ICD-9 diagnoses that support TSH testing (i.e., anemia, constipation, dysmenorrhea, hypercholesterolemia, malaise and fatigue, and weight gain).11 Considering his history of anxiety, Mr. T should have been screened for TSH and diagnosed with hyperthyroidism. Mr. T’s hyperthyroid condition might have been caught at an earlier stage if he had been adequately housed and accessible to medical personnel (provided that appropriate lab work had been obtained and follow-up care utilized). Unfortunately, those who are homeless and precariously housed typically experience ongoing health complications and a worsening of existing health problems. They are at increased exposure to communicable diseases, live in dangerous and unsanitary environments, and have limited access to care.1 Furthermore, their chronic conditions are exacerbated by poor nutrition, high stress, substance abuse, behavioral health issues, and limited access to and safe storage of medications.12 Other barriers to care for those who are homeless include the lack of continuity of care, lack of health insurance, perceived discrimination and provider bias, issues in patient-provider trust, and communication difficulties.2, 13, 14 It is of utmost importance that health-care providers be aware of the complex factors faced by inadequately housed

Dr. Bigelow, Dr. Dahlem, and Dr. Pardee are clinical assistant professors at the University of Michigan School of Nursing in Ann Arbor. References 1. Koon AD, Kantayya VS, Choucair B. Homelessness and health care: Considerations for evaluation, management, and support within the primary care domain. Dis Mon. 2010 ;56:719-733. 2. Rabiner M, Weiner A. Health care for homeless and unstably housed: overcoming barriers. Mt Sinai J Med. 2012;79:586-592. 3. Muse M, Moore BA Eds. Handbook of Clinical Psychopharmacology for Psychologists. Hoboken, N.J.: Wiley & Sons, Inc.; 2012:283-320. 4. National Health Care for the Homeless Council. Adapting Your Practice: General Recommendations for the Care of Homeless Patients. Available at www.nhchc.org/wp-content/uploads/2011/09/ GenRecsHomeless2010.pdf. 5. Pohler H. Caffeine intoxication and addiction. J Nurse Practitioners. 2010;6;49-52. 6. Geffner DL, Hershman JM. Beta-adrenergic blockade for the treatment of hyperthyroidism. Am J Med. 1992;93:61-68. 7. U.S. Preventive Services Task Force. Screening for thyroid disease: recommendation statement. Ann Intern Med. 2004;140:125–127. 8. Baskin HJ, Cobin RH, Duick DS, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. Endocr Pract 2002;8:457-469. 9. Ladenson PW, Singer PA, Ain KB, et al. 2000 American Thyroid Association guidelines for detection of thyroid dysfunction. Arch Intern Med 2000;160:1573-1575. 10. Ressel G. Introduction to AAFP Summary of Recommendations for Periodic Health Examinations. American Academy of Family Physicians. Am Fam Physician. 2002;65:1467. 11. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012;22:1200-1235. 12. National Health Care for the Homeless Council. What is the relationship between health, housing, and homelessness. . Available at www.nhchc.org/faq/relationship-health-housing-homelessness. 13. Bralock AR, Farr NB, Kay J, et al. Issues in community-based care among homeless minorities. J Natl Black Nurses Assoc. 2011;22:57-67. 14. Hudson AL, Nyamathi A, Sweat J. Homeless youths’ interpersonal perspectives of health care providers. Issues Ment Health Nurs. 2008;29: 1277-1289. All electronic documents accessed August 15, 2013.

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LEGAL ADVISOR CASE

Wrongful death case dismissed

By Ann W. Latner, JD

Sometimes a lawsuit can fail because of a technicality. Unfortunately, this does not spare the defendants in the case from having to cope with the stress of being sued or having to deal with due process. Dr. V was a general practitioner who had been running a solo practice for the past 30 years. Within the past 10 years, his practice expanded so much that Dr. V came to rely heavily on the services of his physician assistant, Ms. S, who had been working with Dr. V for her entire medical career. Mr. G had been seeing Dr. V and Ms. S for many years. Mr. G basically needed the routine care that accompanies the transition to middle age, but he was often in the office to manage his diabetes, hypertension, and several other medical issues that arose as a result of his morbid obesity. One day, Mr. G came in complaining that he was having trouble urinating. His legs were visibly swollen, and he noted slight discomfort in the pelvic area. In addition, Mr. G complained of back pain. Ms. S spoke to Dr. V about having

Two clinicians fail to follow up after referring a patient with significant prostatic symptoms.

The patient was having trouble urinating, his legs were visibly swollen, and he noted slight discomfort in the pelvic area.

the patient’s prostate-specific antigen (PSA) measured. The physician ordered a PSA test, which revealed a PSA level of 10.96 ng/mL. Because PSA was significantly elevated, Dr. V referred Mr. G to a urologist, Dr. K. The urologist met with the patient and explained what the elevated PSA level could indicate. Mr. G elected to have a repeat PSA test rather than an immediate biopsy. The second PSA showed a level of 12 ng/mL. In the next month, a biopsy was performed with benign results. Dr. K told Mr. G that he intended to perform repeat PSA tests and instructed the patient to schedule an appointment. However, Mr. G never returned for follow-up. Three months later, the urologist sent Dr. V a letter explaining, “This is a follow-up on Mr. G. He had a prostate ultrasound and biopsy in January of 2001, which was negative. Enclosed 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.

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LEGAL ADVISOR is a copy of the report. I have had trouble contacting Mr. G. He is frequently out of town.” Dr. V put the letter in the patient’s folder, and promptly forgot about it. Over the next several years, Mr. G returned to see Dr. V for treatment of his diabetes, hypertension, and high cholesterol, as well as for a skin infection and swelling of his hand. Blood work was often done, but Mr. G’s PSA was never retested. In April 2004, Mr. G came to see Dr. V with complaints of left flank pain and hematuria. The physician admitted Mr. G into the hospital, where a PSA test was performed. At this point, the PSA results again indicated a dangerously high level. After being admitted to the hospital, Mr. G was diagnosed with advanced prostate cancer that had metastasized to his bones and kidneys.

The case hinged on the determination of when the patient could have possibly been treated successfully. Mr. G died a little more than one year later. Prior to his death, he filed a medical malpractice case against Dr. V and Ms. S. After his death, the suit was dismissed, but a new lawsuit was brought a year later by Mr. G’s adult children. Dr. V and Ms. S. each met with the defense attorney provided by their insurance company. The attorney explained to the physician and the PA that they were being sued for wrongful death based on medical malpractice. “Specifically,” said the attorney, “the complaint says that you should have properly advised Mr. G and treated him when his prostate cancer was at an earlier stage. This case will hinge on the determination of when the patient could have possibly been treated successfully. That is the pivotal point in this argument.” The case dragged on for more than a year through discovery and depositions. A deposition from the medical expert for the plaintiff indicated that Mr. G would more than likely not have died had his prostate cancer been diagnosed prior to December 2001. After that deposition, the defense attorney called Dr. V and Ms. S in to update them. “We may have caught a lucky break,” said the attorney. “The plaintiff’s expert clinician testified that the cancer would have to have been diagnosed before December 2001 for Mr. G to have had a chance at survival. The state has a three-year statute of limitations on medical malpractice

cases. The statute begins to run when the injury or act of negligence allegedly took place—not when it was discovered. In this case, the time will start running from when Mr. G no longer had a chance of survival—December 2001)—as their expert testified. The plaintiffs did not file this case until 2006. I believe they missed the window of opportunity to sue; hopefully, the judge will agree. I will file a motion to dismiss.” The judge later dismissed the case, much to the relief of Dr. V and Ms. S, and to the disappointment of the plaintiffs. Legal background

Lawsuits are dismissed on the basis of a technicality all the time. There are many different reasons why a case may fail based on a technicality. Such reasons include (1) filing after the statute of limitations has run out; (2) improper filing of the case; and (3) not having an expert certify a medical malpractice case in states that require it. While it sometimes seems unfair, particularly to the plaintiffs, the rules are in place for a reason, mainly to limit the number of unnecessary lawsuits. Protecting yourself

While Dr. V and Ms. S were not found liable in this case, they still had to go through the unpleasant experience of being the subjects of a lawsuit. In all likelihood, Dr. V could have prevented this malpractice case by taking one of several actions. He could have (and should have) regularly tested Mr. G’s PSA, especially given that the level was high on first testing. Dr. V also should have contacted the urologist to learn whether Dr. K was testing the patient’s PSA. Dr. V also could have discussed with the patient (and, very important, noted in the patient’s medical file) whether the PSA level was being monitored by the urologist, and the importance of the continued testing. But after referring the patient to the urologist in 2001, Dr. V never discussed this issue with the patient, nor did he retest the patient’s PSA. Furthermore, Dr. V did not write anything relating to Mr. G’s prostate issue in the patient’s chart until three years later when Mr. G showed up with an obvious problem. Simply referring a patient for specialist care does not absolve a clinician from following up with the patient, the specialist, or both. While, unfortunately, it is unlikely that the end result would have different for Mr. G, it does not alter the fact that Dr. V—and by extension, Ms. S—should have taken action to ensure that an appropriate standard of care was being maintained. n

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CME CE

Dermatology Clinic n Learning objectives: To identify and diagnose dermatologic conditions and review up-to-date treatment. n complete the posttest: Page 90

n additional CME/CE: Pages 44, 85

Turn to page 43 for additional information on this month’s CME/CE courses.

CASE #1

Erythema and scaling of the finger and nail bed Audrey Chan, MD

A Hispanic man, aged 45 years, presented with changes to the nail and distal fingertip that first appeared two years ago. The man’s medical history includes type 2 diabetes mellitus and alcoholic cirrhosis. Review of systems was negative for fever and chills. Erythema and scaling of the distal right third finger, including the nail fold, was noted on physical exam. The proximal nail plate was separated from the nail bed with a purulent base. Well-demarcated erythematous plaques with silvery scale were also noted on the trunk and on the extensor extremities. What is your diagnosis? Turn to page 78

CASE #2

Yellow plaques in bilateral inguinal creases Vicky ren, apphia wang, and kerri robbins, MD

A 51-year-old legally blind man was referred to the dermatology clinic by ophthalmology after being diagnosed with angioid streaks. The man reported no history of a rash. Physical examination revealed yellow reticulated plaques that looked like “plucked chicken skin” in bilateral inguinal folds. No lesions were appreciated in the oral mucosa. The inguinal lesions were asymptomatic and had never been previously diagnosed or treated. No history of stroke, MI, or GI bleeding was reported. The man’s father and brother had also been diagnosed with angioid streaks. What is your diagnosis? Turn to page 79

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CME CE

CASE #1

Dermatology Clinic

Acrodermatitis

Acrodermatitis continua of Hallopeau (ACH) is a recurrent inflammatory condition, usually of the distal finger. Although some clinicians classify ACH as a distinct entity, others believe the condition to be a variant of pustular psoriasis, as it has been observed to occur in patients with palmoplantar or generalized pustular psoriasis. ACH may be more prevalent in middle-aged women; however, it can present at any age.1,2 In a study of 1,262 patients with infantile psoriasis, 4.7% of patients were noted to have ACH.3 The pathogenesis of ACH is not known, but the condition often occurs after minor trauma or infection of the involved digit.1 Recently, an autosomal recessively inherited mutation in the IL36RN gene, which encodes interleukin-36 receptor antagonist (IL-36Ra), was identified in a male patient with ACH and in his sister with generalized pustular psoriasis.4 This shared genetic mutation lends evidence to the belief that ACH is one manifestation of pustular psoriasis. Medications have also been implicated in ACH: An 81-year-old man developed ACH two weeks after starting oral terbinafine (Lamisil) for treatment of tinea pedis.5 ACH usually affects one digit, and its course is chronic and relapsing. The disease usually starts as a pustule in the nail bed or as paronychia. The patient may later develop an eruption of fresh pustules around and under the nail plate with hyperkeratosis and crusting.6 Patients may also variably complain of onycholysis, onychomadesis, and scaling of the nail bed and periungual skin.7 Onycholysis is defined as separation of the nail plate from the distal nail bed; onychomadesis refers to separation of the nail plate from the proximal nail bed. After many relapses, anonychia and/or tapering of the fingertips to long keratotic points may result. A full-body skin exam should be performed and a dermatologic history should be obtained for evidence of concomitant palmoplantar or generalized pustular psoriasis. The most common locations for palmoplantar pustulosis are the thenar or hypothenar eminences or the central portion of the palms and soles. Early on, pustules will be visible. In later lesions, only denuded areas, crusts, or

collarettes of scale may be visible where the pustules had been. Generalized pustular psoriasis typically presents with the sudden onset of lakes of pus most prominently in the flexures and at the edges of psoriatic plaques. The diagnosis of ACH can easily be made when patients also present with palmoplantar pustulosis or generalized pustular psoriasis. The diagnosis can be challenging when only one digit is affected. A bacterial, fungal, and viral culture is often obtained to rule out infectious paronychia. A skin biopsy can confirm the diagnosis and rule out other etiologies. Histologically, intraepithelial spongiform pustules may be seen in the acute stage. This histopathologic finding is indistinguishable from pustular psoriasis. Older lesions may show hyperkeratosis with parakeratosis or atrophy.6 The differential diagnosis of ACH includes acute contact dermatitis, dyshidrotic hand eczema, acute paronychia, viral paronychia, and onychomycosis caused by nondermatophyte molds. In acute contact dermatitis, the lesions are usually vesicular rather than pustular. There is usually a significant amount of surrounding erythema and edema with weeping, and the condition is not usually limited to the distal digit. A detailed history will often reveal exposure to an allergenic agent. A geometric appearance is highly suggestive of an exogenous exposure. Dyshidrotic eczema is a chronic skin condition characterized by the recurrent onset of tense and deep-seated vesicles. The most common location of dyshidrotic eczema is the lateral fingers, followed by the palms and soles. Unlike allergic contact dermatitis and ACH, there is no surrounding erythema in cases of dyshidrotic eczema. These vesicles typically resolve without rupturing, so in later stages, only desquamation may be evident. Acute paronychia may also present with a swollen, red, and painful distal digit and is usually limited to a single episode. Compression of the nail fold may produce purulent drainage. The most common causative bacteria are Staphylococcus aureus and Strepotococcus pyogenes. ACH can be distinguished from acute paronychia by a negative bacterial culture and chronic relapsing course. Viral paronychia caused by herpes simplex virus is also known as herpetic whitlow. This condition presents with pain, swelling, and vesicular lesions of the digits. Recurrences are common. Although the nail plate can be affected during flares, the nail heals completely between episodes, unlike in ACH. A viral culture, direct fluorescent antibody test, or polymerase chain reaction can confirm the diagnosis of herpetic whitlow.

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Finally, onychomycosis due to non-dermatophyte molds may also be confused with ACH. Onychomycosis attributable to molds presents with periungual or subungual inflammation and a purulent discharge. Unlike ACH, onychomycosis tends to be chronic and progressive, not chronic with flares. A fungal culture is required for diagnosis, but this can take weeks to months. For mild disease, potent topical corticosteroids, vitamin D3 analogues (calcipotriene [Dovonex, Sorilux], calcitriol [Rocaltrol]), or tacrolimus 0.1% ointment (Protopic) alone or in combination may be initiated.8,9 Occlusion with plastic gloves at night may increase efficacy of topical therapies. Success with topical fluorouracil 5% cream (Carac, Efudex, Fluoroplex) has been reported; however, skin lesions recurred after discontinuing medication.10 For severe disease, systemic therapies may be necessary and should be managed by a dermatologist familiar with these medications. Acitretin (Soriatane) may be attempted, but it may be several weeks before improvement is noted. Phototherapy and systemic therapies commonly used for psoriasis have been used with success in the treatment of ACH. Improvement with methotrexate (Rheumatrex, Trexall), cyclosporine (Gengraf, Neoral, Sandimmune), tumor necrosis factor (TNF) inhibitors (etanercept [Enbrel], adalimumab [Humira], infliximab [Remicade]), and ustekinumab (Stelara) has been reported.11 A case of acitretin- and TNF-inhibitor-resistant ACH responding to anakinra (Kineret), an interleukin-1 receptor antagonist, has been reported.12 Because of this patient’s history of cirrhosis, a contraindication for treatment with methotrexate and TNF inhibitors, he was started on cyclosporine. At his two-week follow-up visit, his skin had improved, but his creatinine had increased by more than 50%, and cyclosporine was discontinued. No further treatment was initiated because of the patient’s failing health related to his cirrhosis. Dr. Chan is a third-year dermatology resident at Baylor College of Medicine in Houston. References 1. Yerushalmi J, Grunwald MH, Hallel-Halevy D, et al. Chronic pustular eruption of the thumbs. Diagnosis: acrodermatitis continua of Hallopeau (ACH). Arch Dermatol. 2000;136:925-930. 2. Kiszewski AE, De Villa D, Scheibel I, Ricachnevsky N. An infant with acrodermatitis continua of Hallopeau: successful treatment with thalidomide and UVB therapy. Pediatr Dermatol. 2009;26:105-106. 3. Morris A, Rogers M, Fischer G, Williams K. Childhood psoriasis: a clinical review of 1262 cases. Pediatr Dermatol. 2001;18:188-198.

4. Abbas O, Itani S, Ghosn S, et al. Acrodermatitis continua of Hallopeau is a clinical phenotype of DITRA: evidence that it is a variant of pustular psoriasis. Dermatology. 2013;226:28-31. 5. Nishiwaki F, Matsumura Y, Morita N, et al. Acrodermatitis continua of Hallopeau due to oral terbinafine. Br J Dermatol. 2007;157:1073-1074. 6. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, Pa.: Saunders-Elsevier; 2011:201. 7. Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. St. Louis, Mo.: Elsevier-Mosby; 2008:1026. 8. Sehgal VN, Verma P, Sharma S, et al. Acrodermatitis continua of Hallopeau: evolution of treatment options. Int J Dermatol. 2011;50:1195-1211. 9. Thielen AM, Barde C, Marazza G, Saurat JH. Long-term control with etanercept (Enbrel) of a severe acrodermatitis continua of Hallopeau refractory to infliximab (Remicade). Dermatology. 2008;217:137-139. 10. Tsuji T, Nishimura M. Topically administered fluorouracil in acrodermatitis continua of Hallopeau. Arch Dermatol. 1991;127:27-28. 11. Sopkovich JA, Anetakis Poulos G, Wong HK. Acrodermatitis continua of hallopeau successfully treated with adalimumab. J Clin Aesthet Dermatol. 2012;5:60-62. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3315880/. 12. Lutz V, Lipsker D. Acitretin- and tumor necrosis factor inhibitor-resistant acrodermatitis continua of hallopeau responsive to the interleukin 1 receptor antagonist anakinra. Arch Dermatol. 2012;148:297-299. All electronic documents accessed August 15, 2013.

CASE #2

Pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE) is an autosomal recessive disease with an estimated prevalence of 1 in 50,000 and a carrier frequency of 1 in 150-300.1 PXE exhibits no racial or geographic predilection but affects women slightly more than men. 2 Recent focus on the molecular genetics and pathomechanisms of PXE has promising therapeutic implications. PXE is a disorder of abnormal mineralization of connective tissue. Most patients have loss-of-function mutations in both copies of the ABCC6 gene, which encodes an efflux transporter primarily expressed in the liver. Other patients have mutations in both copies of the GGCX gene, which encodes an enzyme involved in the activation of several anti-mineralization proteins and coagulation factors. These

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Dermatology Clinic

patients present with both PXE-like skin findings and a deficiency in vitamin K-dependent coagulation factors. PXE is also associated with a significant reduction in serum fetuin-A, a GGCX-independent anti-mineralization protein that is secreted from the liver into the blood. Because PXE skin findings have also been reported in patients who have a combination of heterozygous mutations in both ABCC6 and GGCX, it is possible that defective ABCC6 prevents the proper export of a GGCX cofactor and/or fetuin-A into the circulation, thereby resulting in abnormal calcification of elastic fibers in the skin, arteries, and eyes.2 Although PXE is fully penetrant, there is significant phenotypic heterogeneity. Cutaneous manifestations are most common but may not be noticeable or may be regarded with suspicion until serious ocular or cardiovascular complications develop. Yellow papules appear in such flexural sites as the lateral neck, wrists, groin, and axillae during the first or second decade of life and may coalesce into pebbly plaques that resemble plucked chicken skin. Perforating PXE, which refers to the expression of yellowish substance across the epidermis, occurs occasionally. Other cutaneous manifestations include saggy skin, chin creases, and yellow papules on the lower lip. Ocular angioid streaks attributable to breaks in the calcified Bruch’s membrane are seen in almost all PXE patients by age 30 years and may result in choroidal neovascularization with subsequent progressive loss of central vision, possibly leading to blindness. Cardiovascular consequences of PXE can result in significant morbidity and mortality and are most concerning. Arterial calcification of the elastic intima and media of medium-sized arteries can lead to accelerated atherosclerosis and vascular complications ranging in severity from intermittent claudication, to GI bleeding, to MI and stroke.2 Histopathologically, PXE is characterized by fragmented elastic fibers in the reticular dermis or media of midsized arteries. In advanced PXE, purple clumps of calcium deposits are seen on hematoxylin and eosin staining with normal serum calcium and phosphate levels. Verhoeff-Van Gieson stain for elastin or von Kossa stain for calcium may be necessary for visualization early in the disease.2 In patients with angioid streaks but normal-looking skin, biopsy of normal-appearing flexural skin or preexisting scars may be helpful in diagnosis.3 The differential diagnosis of PXE includes xanthomas, actinic damage, late-onset focal dermal elastosis, and fibroelastolytic skin disorders. Similar but reversible skin changes are seen in patients who have been exposed to potassium nitrate or D-penicillamine, or those who have chronic end-stage renal disease. In these patients, however, ocular and cardiovascular findings are absent. PXE-like skin findings with or without

angioid streaks can also be seen in patients with β-thalassemia or sickle-cell anemia without accompanying mutation in the ABCC6 gene. Amyloid elastosis may also produce PXE-like skin findings but is distinguished histologically by amyloid deposits surrounding elastic fibers.2 Although there are currently no specific systemic treatments for PXE, intravitreal injection of VEGF antagonists to treat ocular neovascularization has proven beneficial, along with regular ophthalmologic and cardiovascular monitoring with diet and lifestyle counseling.4 Translational research suggests that oral phosphate binders or increased dietary magnesium may ameliorate ectopic mineralization of peripheral tissues by preventing calcium phosphate deposition.5 Surgical excision may be an option for cutaneous manifestations of PXE that are aesthetically undesirable to the patient. Further development of more sophisticated molecular therapies is dependent on greater understanding of the pathophysiology of PXE.2 In the case described here, a right inguinal punch biopsy revealed fragmented basophilic elastic fibers in the dermis consistent with PXE. The patient has scheduled follow-up appointments with his primary-care provider, cardiologist, gastroenterologist, and ophthalmologist. Given the patient’s family history, genetic testing is currently under way in light of a possible autosomal dominant inheritance pattern. n Ms. Ren is a third-year student and Ms. Wang is a fourth-year student at Baylor College of Medicine in Houston, where Dr. Robbins is an instructor in the Department of Dermatology. References 1. Uitto J, Bercovitch L, Terry SF, Terry PF. Pseudoxanthoma elasticum: progress in diagnostics and research towards treatment : Summary of the 2010 PXE International Research Meeting. Am J Med Genet A. 2011;155A:15171526. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3121926/. 2. Ringpfeil F, Uitto J. Heritable disorders of connective tissue. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd ed. Philadelphia, Pa.: Elsevier Saunders; 2012:1612-1615. 3. Lebwohl M, Phelps RG, Yannuzzi L, et al. Diagnosis of pseudoxanthoma elasticum by scar biopsy in patients without characteristic skin lesions. N Engl J Med. 1987;317:347-350. 4. Finger RP, Charbel Issa P, Schmitz-Valckenberg S, et al. Long-term effectiveness of intravitreal bevacizumab for choroidal neovascularization secondary to angioid streaks in pseudoxanthoma elasticum. Retina. 2011;31:1268-1278. 5. Yoo JY, Blum RR, Singer GK, et al. A randomized controlled trial of oral phosphate binders in the treatment of pseudoxanthoma elasticum. J Am Acad Dermatol. 2011;65:341-348. All electronic documents accessed August 15, 2013.

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alternative meds update

What you should know about the herbs and supplements patients use

By Sherril Sego, FNP-C, DNP. Ms. Sego is a staff clinician at the VA Hospital in Kansas City, Mo., where she practices adult medicine and women’s health. She also teaches at the nursing schools of the University of Missouri and the University of Kansas.

Lutein

Lutein is a naturally occurring vitamin belonging to the carotenoid family.1 It is best known for its deep yellow-green pigment.2 Like many complex nutrients, lutein is not manufactured in the human body so it must be consumed in foods.1 Because of its intense color, lutein is also considered a xanthophyll, from the Greek words for “yellow” and “leaf.”2 Similar to most carotenoids, lutein known for its potent antioxidative qualities.3 Cellular protection against oxidative damage is well established as an essential mechanism of many phytonutrients. Lutein, however, has a second, unique function in the way it protects cells from high-frequency blue light.3 Background Shortly after the turn of the century, researchers discovered a specific photoreceptor in the retina that is very sensitive to the high-energy blue light that is the part of the light spectrum most damaging to cells, especially retinal cells.4 Scientists have long known that the central retinal cells (i.e., the macula) contain high concentrations of lutein.4 Research animals fed diets devoid of lutein quickly developed macular degeneration as well as cataracts.5 Measurement of the optical density of affected macular cells showed both a decreased optical pigment density and a decreased lutein concentration. This has led to a search for a preventive intervention for these conditions.

Science Age-related macular degeneration (AMD) accounts for at least 45% of all vision loss in the Western world,6 equating to 9.1

million people, and by 2050 this will increase to an estimated 17.8 million.7 The total cost attributed to AMD in the United States alone is more than $700 billion.8 Numerous trials support the efficacy of lutein supplementation in the reduction or prevention of AMD, as well as other age-related conditions such as cataracts. However, as is the case with many herbal and nutritional supplements, conflicting reports are also found: One review of both interventional and observational studies found insufficient evidence to support lutein for AMD or cataract prevention,9 whereas a more recent review, showed evidence that lutein supplementation was efficacious for these degenerative eye diseases.10 One research team followed 108 patients with known or suspected early AMD for 48 weeks.11 In this randomized, double-blind, placebo-controlled study, patients showed a significant dose-response effect when given lutein supplementation, with statistically significant improvements in macular pigment optical density (MPOD) and visual acuity.11 In a similar study, 27 patients with early AMD were followed for

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alternative meds update one year.12 Positive outcomes were noted in the lutein-supplementation group, specifically those relating to the density of macular pigmentation and visual acuity.12 A subsequent trial involved 90 adult men with atrophic AMD studied for one year.6 Outcomes showed an increased MPOD and improved visual acuity in the treatment group.6 In another extension study from the Women’s Health Initiative (WHI), women aged 50-79 years in three states were grouped into cohorts of either high intake or low intake of lutein and zeaxanthin.13 These women were evaluated for the incidence of nuclear cataracts from four to seven years post WHI. Women in the highest vs. lowest intake quintiles were found to be 32% less likely to develop cataracts.13

Safety, interactions Lutein is safe for consumption. As a supplement, it is also generally recognized as safe by the FDA. Antioxidants (in very large doses) can interact with lutein, potentially causing GI distress and some elevation in warfarin (Coumadin, Jantoven) activity.

Dose, how supplied, cost Lutein is usually found in powder-filled capsules. The studies reviewed used an average 10-mg supplement per day in oral form.The cost is approximately $15 for a one-month supply. For those who would rather eat a lutein-enhanced natural diet, kale, spinach, turnip and collard greens all contain approximately 10 mg of lutein per serving.

2. Ribaya-Mercado JD, Blumberg JB. Lutein and zeaxanthin and their potential roles in disease prevention. J Am Coll Nutr. 2004;23(6 Suppl):567S-587S. 3. Alves-Rodrigues A, Shao A.The science behind lutein. Toxicol Lett. 2004;150:57-83. 4.Thompson CL, Bowes Rickman C, Shaw SJ, et al. Expression of the blue-light receptor cryptochrome in the human retina. Invest Ophthalmol Vis Sci. 2003;44:4515-4521. Available at www.iovs.org/content/44/10/4515.long. 5. Kijlstra A,Tian Y, Kelly ER, Berendschot TT. Lutein: more than just a filter for blue light. Prog Retin Eye Res. 2012;31:303-315. 6. Richer S, Stiles W, Statkute L, et al. Double-masked, placebo-

Lutein has been used to prevent degenerative eye diseases, such as cataracts.

Age-related macular degeneration accounts for at least 45% of all vision loss in the Western world, equating to 9.1 million people.

Summary

controlled, randomized trial of lutein and antioxidant supplementation in the intervention of atrophic age-related macular degeneration: the Veterans LAST study (Lutein Antioxidant Supplementation Trial). Optometry. 2004;75:216-230. 7. Caban-Martinez AJ, Davila EP, Lam BL, et al. Age-related macular degeneration and smoking cessation advice by eye care providers: a pilot study. Prev Chronic Dis. 2011;8:A147. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3221586/. 8. BrightFocus Foundation. Macular Degeneration Facts & Statistics. Available at www.brightfocus.org/macular/about /understanding/facts.html. 9.Trumbo PR, Ellwood KC. Lutein and zeaxanthin intakes and risk of age-related macular degeneration and cataracts: an evaluation using the Food and Drug Administration’s evidence-based review system for health claims. Am J Clin Nutr. 2006;84:971-974. Available at ajcn.nutrition.org/content/84/5/971.long. 10. Barker FM 2nd. Dietary supplementation: Effects on visual performance and occurrence of AMD and cataracts. Curr Med Res Opin. 2010;26:2011-2023. 11. Ma L,Yan SF, Huang YM, et al. Effect of lutein and zeaxanthin on macular pigment and visual function in patients with early age-related macular degeneration. Ophthalmology. 2012;119:2290-2297. 12. Parisi V,Tedeschi M, Gallinaro G, et al. Carotenoids and antioxidants in age-related maculopathy Italian study: multifocal electroretinogram modifications after 1 year. Ophthalmology. 2008;115:324-333. 13. Moeller SM,Voland R,Tinker L, et al. Associations between age-related nuclear cataract and lutein and zeaxanthin in the diet and serum in the Carotenoids in Age-Related Eye Disease Study (CAREDS), an ancillary study of the Women’s Health

References

Initiative. Arch Ophthalmol. 2008;126:354-364. Available at

1. Mozaffarieh M, Sacu S, Wedrich A.The role of the

archopht.jamanetwork.com/article.aspx?articleid=484355.

carotenoids, lutein and zeaxanthin, in protecting against agerelated macular degeneration. Nutr J. 2003;2:20.

All electronic documents accessed August 15, 2013.

When consumed in recommended doses whether as a supplement or in natural form, lutein was associated with no significant adverse events.The potential long-range benefit of lutein intake is tremendous, especially in the case of AMD. n

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Dermatologic Look-Alikes n Learning objective: To distinguish and properly treat dermatologic conditions with similar presentations. n complete the posttest: Page 90

n additional CME/CE: Pages 44, 77

Turn to page 43 for additional information on this month’s CME/CE courses.

Firm pink trunk plaques Kerri Robbins, MD

CASE #1

CASE #2

A man, aged 41 years, presented with a painful growing “lump” on his right upper back that he first noted 10 months earlier. At first, the lump was skin-colored and firm, but it had recently become darker in color and had developed surface irregularities. Review of symptoms was otherwise negative. Medical and surgical history was unremarkable. On physical examination, a firm erythematous plaque with irregular nodules was appreciated on the right upper back. Several indurated erythematous papules were also noted in the surrounding the area.

A 42-year-old woman presented with a slowly enlarging pruritic lesion on her chest. She stated that the lesion started two years ago as a firm scar that developed after an elective excision of an epidermal inclusion cyst. However, the lesion had continued to enlarge and was growing outside the confines of the original wound. Physical examination revealed a large and slightly erythematous firm plaque on the mid-chest. Claw-like extensions were noted on the peripheral borders of the plaque, while centrally, the plaque was skin-colored and softer.

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CASE #1

Dermatologic Look-Alikes

Dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) is an uncommon and locally aggressive intermediate malignancy with a high recurrence rate. In the United States, DFSP accounts for approximately 1% of all soft tissue sarcomas. Although DFSP may be seen in all ages, those most affected are young to middle-aged adults; males may have a slight predominance over females. DFSP is seen equally in all races, but an uncommon pigmented variant of DFSP (Bednar tumor) has been reported to occur much more frequently in blacks. The exact pathogenesis and cellular origin of DFSP remains unknown. Some have suggested that pluripotent progenitor cells may be the origin of DFSP. These pluripotent cells have the capacity of differentiating into fibroblastic, histiocytic, and neuroectodermal cells, and all three of these cell lines are thought be a component of DFSP.1 Recent studies have also found such cytogenetic

As the skin-colored lesion enlarges, it may become painful and develop violaceous to red-brown nodules. abnormalities as reciprocal translocations (t17;22) and supernumerary ring chromosomes containing sequences from chromosomes 17 and 22.1,2 These rearrangements fuse together the collagen type I alpha 1 (COL1A1) and the platelet-derived growth factor beta-chain (PDGFB) gene. This puts the PDGFB gene under control of the COL1A1 promoter, which drives fusion protein production. The fusion protein is later processed into functional PDGFB, which subsequently interacts with the PDGF receptor on the surface of DFSP tumor cells and triggers tumor-cell proliferation. It is estimated that approximately 90% of DFSP tumors harbor this translocation. Initially, DFSP presents as a slow-growing, asymptoÂ matic, firm, skin-colored plaque. As the lesion enlarges, it may become painful and develop violaceous to red-brown nodules that measure one to several centimeters in diameter.

The lesions are indurated and firm due to their attachment to the subcutaneous tissues. DFSP favors the trunk in 50% to 60% of patients, with a predilection for the shoulder and pelvic areas. The tumors may also be seen on the proximal extremities in 20% to 30% of patients; head and neck lesions account for 10% to 15% of cases. Depending on the clinical subtype, DFSP may be clinically confused with a large dermatofibroma, dermatomyofibroma, morphea, keloid, leiomyoma, metastatic tumors, and malignant melanoma. Early lesions of plaque DFSP are poorly circumscribed with a diffuse infiltration of slender, spindle-shaped cells arranged in fascicles that run parallel to the skin surface. Often, the adnexal structures are obliterated and the spindle cells infiltrate into the subcutaneous tissue, forming a multilayered pattern. Nodular-stage tumors become more cellular, and the spindle cells form short fascicles, which are arranged into what is known as a cartwheel or storiform pattern. A cartwheel pattern is one in which the spindle cells have elongated nuclei that radiate from a center point. A storiform pattern describes spindle cells that are arranged in a matted, irregularly whorled pattern that resembles a straw mat. At the base of the lesion, neoplastic cells infiltrate the subcutaneous tissue in a honeycomb pattern. Cytologically, the cells may have a deceptively bland appearance, with rare mitotic activity and minimal cellular atypia. Bednar tumors are an uncommon variant of DFSP that contains melanin-producing cells with schwannian differentiation. Other histologic variants include atrophic, myxoid, and fibrosarcomatous. The histologic differential diagnosis for DFSP is broad and includes dermatofibroma, dermatomyofibroma, fibrosarcoma, neurofibroma, malignant peripheral nerve sheath tumor, leiomyoma, leiomyosarcoma, spindle-cell squamous cell carcinoma, desmoplastic melanoma, and atypical fibroxanthoma. Immunostaining of DFSP demonstrates that the spindle cells are strongly positive for the anti-CD-34 antibody and are negative for factor XIIIa. This feature distinguishes DFSP from large dermatofibromas, which are CD34-negative and factor XIIIa-positive. Presence of the S100 protein may help to differentiate neural tumors and desmoplastic melanoma from DFSP. Spindle-cell squamous cell carcinomas are pankeratin-positive, and smooth-muscle tumors are smooth-muscle actin- and desmin-positive. Atypical fibroxanthomas are usually seen on sun-exposed skin in older patients, have a high degree of cellular atypia, and may show positivity with multiple stains including CD68, CD10, smooth-muscle actin, and pro-collagen I. DFSP and keloids are histologically distinct.

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The treatment of choice for DFSP is complete surgical excision. Because of the tendency for DFSP to invade locally and recur frequently, Mohs micrographic surgery is often advocated because of its tissue-sparing advantage and lower recurrence rates.3 In general, DFSP carries a low risk of metastasis; however, the fibrosarcomatous variant of DFSP tends to have a higher rate of local recurrence and risk for distant metastasis. When distant metastases are present, the lung is the most commonly involved site. In locally advanced or metastatic disease, imatinib mesylate (Gleevec), which targets the PDGF receptor, may serve as a beneficial adjuvant treatment. A recent study showed a complete response to this medication in 50% of patients with locally advanced disease.4 In this case, a biopsy of the man’s lesion revealed the diagnosis of DFSP. Treatment with Mohs micrographic surgery resulted in histologic clearance of the tumor. The patient continues to be followed in the dermatology clinic with no evidence of recurrent disease to date.

CASE #2

Keloid

Beyond the second trimester of fetal development, only the epidermis has the potential to fully regenerate. Therefore, wounds that extend into the dermis will always heal with a scar. Hypertrophic scarring occurs when the wound heals with far more than what is considered to be normal scar tissue. When the exuberant scar tissue extends beyond the boundaries of the original wound, it is referred to as a keloid. Keloid comes for the Greek word chele, or crab claw. The incidence of keloids is highly variable and ranges from 0.09% in predominantly white populations to as high as 16% in darkly pigmented populations.5 Keloids can occur at any age but are rarely seen in children and the elderly. Slight gender differences have been reported, with women outnumbering men; however, these differences are likely skewed by the fact that ear-piercing is more commonly seen in females, and women may more readily seek medical consultation for cosmetic improvement. Despite the fact that keloids have been described for centuries, little is known about the exact pathogenesis. Familial

tendency and prior skin trauma are the most consistently seen risk factors, but keloid formation without prior trauma can occur. Infection, acne, excessive wound tension, and the presence of foreign material can lead to increased inflammation, which is also thought to be associated with keloid formation. It has been hypothesized that melanin-producing melanocytes may play a role in the pathogenesis since keloids are seen more frequently in darkly pigmented individuals and have never been reported to occur in those with oculocutaneous albinism. Others have proposed that mastcell mediators, which are known to upregulate collagen synthesis, may be the culprit because increased numbers of mast cells are often observed in keloids. Transforming growth factor-β (TGF-β) is another likely instigator as this protein is expressed at higher concentrations in keloidal fibroblasts than in normal control fibroblasts. In addition, a recent study revealed that athymic mice formed keloidlike nodules after injection of genetically modified human fibroblasts that overexpressed TGF-β.6 Keloids are pink, erythematous, or hyperpigmented fibrous plaques that occur most frequently in the sternal region. Other commonly affected areas include the neck, ears, extremities, and/or trunk. The face, genitals, palms, and soles are rarely affected. The overlying epidermis is often smooth and shiny, while the dermis is firm to palpation. Keloids are often multiple and may occur as pinpoint papules or large plaques. Hypertrophic scars remain in the area of original injury and tend to resolve with time. Keloids extend beyond the area of original injury and may have claw-like projections at the borders, with regression in the central portion of the lesion. Patients may complain of pain, pruritus, or both. Histologically, hypertrophic scars contain nodular and whorled masses of excess collagen admixed with fibroblastic cells. Keloids are less cellular and contain a dense nodular growth of myofibroblasts and thickened eosinophilic collagen bundles. The dermal nodule may cause thinning of the papillary dermis and atrophy of adjacent appendages. Elastic tissue is decreased, just as in a normal scar. Mucopolysaccharides are often increased, and mast cells may be present. Hypertrophic scars have vertically oriented vessels, whereas keloids have reduced vascularity. Differentiating keloids from hypertrophic scars can be difficult. As mentioned earlier, keloids extend beyond the original injury, while hypertrophic scars are limited to the area of injury. Dermatofibromas are small, firm papules that are most commonly observed on the extremities and often

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have a characteristic tethering of the overlying epidermis to the underlying lesion with lateral compression (i.e., the dimple sign). DFSP also commonly presents as a firm plaque on the trunk. However, there is usually no history of trauma, and irregular nodules may be present within the firm plaque. With time, DFSP may also become attached to deeper structures and ulcerate. Other entities in the differential diagnosis include sarcoidosis, the sclerotic form of xanthoma disseminatum, lobomycosis, and the keloidal forms of scleroderma and morphea. Keloids are frequently recalcitrant to therapy, so treatment can be challenging. Because of this, many treatment modalities have been employed, most of which feature off-label uses of prescription medication. The best treatment is prevention. Elective procedures should be avoided in people who are prone to developing keloids. Wound

The patient in this case was treated with monthly intra lesional acetonide 20 mg/mL until the lesion flattened and the pruritus subsided. n Dr. Robbins is an instructor in the Department of Dermatology at Baylor College of Medicine in Houston. References 1. Dimitropoulos VA. Dermatofibrosarcoma protuberans. Dermatol Ther. 2008;21:428-432. 2. Pedeutour F, Simon MP, Minoletti F, et al. Translocation, t(17;22) (q22;q13), in dermatofibrosarcoma protuberans: a new tumor-associated chromosome rearrangement. Cytogenet Cell Genet. 1996;72:171-174. 3. Hollmig ST, Sachdev R, Cockerell CJ, et al. Spindle cell neoplasms encountered in dermatologic surgery: a review. Dermatol Surg. 2012;38:825-850. 4. McArthur GA, Demetri GD, van Oosterom A, et al. Molecular and clinical analysis of locally advanced dermatofibrosarcoma protuberans treated with

Many treatment modalities have been employed, most of which feature off-label uses of prescription medication.

imatinib: Imatinib Target Exploration Consortium Study B2225. J Clin Oncol. 2005;23:866-873. Available at jco.ascopubs.org/content/23/4/866.long. 5. Bloom D. Heredity of keloids; review of the literature and report of a family with multiple keloids in five generations. N Y State J Med. 1956;56:511-519. 6. Campaner AB, Ferreira LM, Gragnani A, et al. Upregulation of TGF-b1 expression may be necessary but is not sufficient for excessive scarring. J Invest Dermatol. 2006;126:1168-76. Available at www.nature.com/jid /journal/v126/n5/full/5700200a.html. 7. Love PB, Kundu RV. Keloids: an update on medical and surgical treatments. J Drugs Dermatol. 2013;12:403-409. Available at jddonline.com /articles/dermatology/S1545961613P0403X. All electronic documents accessed August 15, 2013. © The New Yorker Collection 2013 from cartoonbank.com. All Rights Reserved.

closure should be performed with minimal tension, and adjunctive therapies should be considered before abnormal wound healing has occurred. Intralesional corticosteroids are the most commonly used therapy; repeated injections are typically performed every four to eight weeks with most doses ranging from 10 mg/mL to 40 mg/mL. Ideally, such treatment will lead to flattening of the lesion and improvement of any associated pain and/or pruritus. Risk factors associated with intralesional corticosteroids include surrounding hypopigmentation and atrophy caused by lymphatic spread of the corticosteroid. Topical corticosteroids have been used as well, but the results are less reliable. Surgical excision alone leads to recurrence of keloids in approximately 80% of cases. However, many clinicians combine surgery (to debulk the lesion) with such other treatment modalities as postoperative intralesional triamcinolone acetonide (Kenalog), intralesional interferon-α-2b (Intron A), x-ray irradiation, pressure, topical mitomycin C (Mitosol, Mutamycin), and topical imiquimod (Aldara, Zyclara).7 Other treatment options include silicone gel sheets, laser (flashlamp-pumped pulsed dye), 5-fluorouracil, intralesional bleomycin, cryotherapy, topical tacrolimus (Protopic), topical retinoids, and intralesional verapamil (Cala, Covera, Isoptin, Verelan).7

“Howard takes all the flu shots that other employees refuse to take.”

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posttest Expiration date: September 2013

Nurse Practitioner Associates for Continuing Education (NPACE) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Nurse Practitioner Associates for Continuing Education designates this educational activity for a maximum of 0.5 contact hours of credit. Participants should only claim credit commensurate with the extent of their participation in the activity. Posttests must be completed and submitted online. NPs may register at no charge at www.mycme.com.You must receive a score of 70% or better on each test taken to obtain credit.

credits: 0.5

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page 85

Case #1: Acrodermatitis continua of Hallopeau

Case #1: Dermatofibrosarcoma protuberans

1. Which characteristic of acute paronychia distinguishes it from acrodermatitis continua of Hallopeau (ACH)? a. Purulent drainage is positive for bacteria. b. The lesions are usually vesicular. c. The lesions typically resolve without rupturing. d. The nail heals completely between episodes.

1. In 50% to 60% of patients with dermatofibrosarcoma protuberans (DFSP), the lesion appears on the a. Proximal extremities b. Head and neck c. Trunk d. Extensor surfaces

2. What is the treatment for mild ACH? a. Topical corticosteroids b. Vitamin D3 analogues c. Tacrolimus ointment (Protopic) d. All of the above

2. What is the most commonly involved site when distant DFSP metastases are present? a. Brain b. Bone c. Liver d. Lung

Case #2: Pseudoxanthoma elasticum 3. What is the clinical appearance of pseudoxanthoma elasticum (PXE)? a. Soft, velvety papules around the eyelids b. Small, red, scaly plaques with induration c. Yellow plaques appearing in flexural sites d. Itchy, red areas with scaling and peeling

Case #2: Keloid

4. What is a related consequence of PXE? a. Intermittent claudication b. Restrictive lung disease c. Chronic cirrhosis d. Diminished renal function

4. What is the most common treatment for keloids? a. Surgical excision b. X-ray irradiation c. Intralesional corticosteroids d. Cryotherapy

3. Which is a risk factor for keloid formation? a. Familial tendency b. Sun exposure c. Immunosuppression d. Advanced age

To take the Posttest please go to CliniAd.com/15NxrEZ

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CME

posttest Expiration date: September 2013

This program has been reviewed and is approved for a maximum of 0.5 hour of AAPA Category I CME credit by the Physician Assistant Review Panel. Approval is valid for one year from the issue date of September 2013. Participants may submit the self-assessment at any time during that period. This program was planned in accordance with AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs. Posttests must be completed and submitted online. PAs may register at no charge at www.mycme.com. To obtain 0.5 hour of AAPA Category I CME credit, you must receive a score of 70% or better on each test taken. credits: 0.5

Dermatology Clinic

Dermatologic Look-Alikes

page 77

page 85

Case #1: Acrodermatitis continua of Hallopeau

Case #1: Dermatofibrosarcoma protuberans

1. In 50% to 60% of patients with dermatofibrosarcoma protuberans (DFSP), the lesion appears on the a. Proximal extremities b. Head and neck c. Trunk d. Extensor surfaces

2. What is the treatment for mild ACH? a. Topical corticosteroids b. Vitamin D3 analogues c. Tacrolimus ointment (Protopic) d. All of the above

2. What is the most commonly involved site when distant DFSP metastases are present? a. Brain b. Bone c. Liver d. Lung

Case #2: Keloid

4. What is a related consequence of PXE? a. Intermittent claudication b. Restrictive lung disease c. Chronic cirrhosis d. Diminished renal function

4. What is the most common treatment for keloids? a. Surgical excision b. X-ray irradiation c. Intralesional corticosteroids d. Cryotherapy

3. Which is a risk factor for keloid formation? a. Familial tendency b. Sun exposure c. Immunosuppression d. Advanced age

To take the Posttest please go to CliniAd.com/15NxrEZ

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COMMENTARY Rachael Buitrago, DNP, CPNP, is an ANCC board-certified pediatric nurse practitioner in a private office in South Florida, and has taught as adjunct nursing faculty at local universities.

How to “just say no” to a patient Health care is an ever-changing environment. Scientific discoveries and evidence-based m edicine allow for disease diagnosis and treatment regimens to adjust to new guidelines quite often. Accompanying these changes are insurance companies, whether private or government, that alter policies and frequently dictate how health-care providers should administer care. And if this were not frustrating enough, add to the equation the demanding patient who believes he or she is an expert in health and insists on telling you how to care for him or her. The most familiar scenario involves the patient who walks in and states, “This is my problem and I need you to prescribe me this.”

A patient might ask for a CT scan of the abdomen to assess a vague complaint of on-and-off abdominal discomfort.

Then there is the parent who is sure his or her child needs an antibiotic, and is not leaving until you prescribe one. Granted, some patients are def initely an expert in their own health care, and rightfully should be. Patients often have an intuitive feeling that something is wrong, and many times a problem is indeed discovered. This also can be said for the parent who knows there is something wrong with his or her child and is later proven right. Providers should not ignore these gut feelings from their patients. However, there are appropriate ways of saying “No” to a demanding patient. Nonspecific or vague complaints of illness can be investigated by obtaining a detailed history and performing a thorough physical exam. The information yielded often helps the clinician establish the differential diagnosis and guides him or her toward noninvasive tests or treatments that can offer more insight. For example, a patient might ask for a CT scan of the abdomen to assess a vague complaint of abdominal discomfort that has been occurring on and off for a few weeks with some nausea but no vomiting, diarrhea, or fever. The cause could be Helicobacter pylori, a food allergy, constipation, or an unexpected pregnancy. Explain to the patient that a urine or blood test can easily confirm or rule out these conditions. This is one way to say no to the costly test the patient

is requesting without being dismissive of his or her request for a particular diagnostic or therapeutic strategy. There will always be the patient who knows what needs to be ordered and attempts to dictate how the clinician should practice, but providers can reassure these patients and gain their trust by communicating clearly and concisely the steps needed to best address the healthcare issue at hand. Trust in one’s health-care provider is the underlying issue here. Patients may no longer fully trust the clinician due to the abundant medical errors that occur every day. They may feel rushed during the office visit and feel that their complaints are not being heard. These patients may then seek medical advice from friends, relatives, or the Internet. This poses a problem due to the variable quality and accuracy of the answers they receive from those sources. The health-care provider needs to gain the patient’s trust and simply find a way to work with the patient’s requests in a more respectful manner than just immediately and harshly saying, “No.” This, in turn, will reduce patient demands for services that take a higher toll than necessary on the patient, the provider, and the insurer. Saying “no” must be followed up with educating the patient as to why the answer is no and how a different approach to resolving the issue will benefit the patient. n

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“I want to catch just enough of the plague to remove these unsightly lines and wrinkles.”

“My parents won’t allow sugar in the house, so I’ve had to learn about it on the street.”

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