April 2019 Clinical Advisor by The Clinical Advisor

A PEER-REVIEWED FORUM FOR NURSE PRACTITIONERS

NEWSLINE

■■ Exercise and Cognitive Function ■■CRC Screening Outreach ■■Screen Time and Children FEATURE The Counseling Connection

The Healthcare Practitioner’s Guide to Atopic Dermatitis LEGAL ADVISOR

Careful Note-Taking Wins Case

DERMATOLOGIC LOOK-ALIKES

Multiple Erythematous, Scaly Plaques

FREE CME COURSE

Dietary Interventions for the Management of Obesity

APRIL 2 019

| www.ClinicalAdvisor.com

CARDIOLOGY

Case Clinic: A 67-YearOld Man With Atrial Fibrillation Risk Factors Atrial fibrillation is the most common type of cardiac arrhythmia.

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

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

CLINICAL PEARLS

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

NEUTROPHILS AND LYMPHOCYTES In interpreting a complete blood count with differential, anytime the neutrophils and lymphocytes are numerically close, it is a viral cause; when the neutrophils and lymphocytes are numerically distant, it is a bacterial cause. This is very helpful in determining treatment.—DONNA CARTER, FNP-C, Scottsburg, Ind. (202-1) GENERIC “CAINE” IS EFFECTIVE FOR WOUND CARE For pain relief, most pharmacies offer a “caine” at 2-510%, and basically nothing higher, for between $5 and $30 per tube. I work in wound care and use Walmart’s

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

YOUR COMMENTS SLIPPED CAPITAL FEMORAL EPIPHYSIS IN OBESE ADOLESCENTS I just read the CME/CE article by Marilou Shreve, DNP, APRN, entitled, “Assessing and treating pediatric obesity” [ June 2015]. I was concerned regarding the oversight of a critical issue in obese adolescents: the increased risk of slipped capital femoral epiphysis (SCFE). This was not addressed in the article. The case study (p. 55) gave incomplete advice regarding the evaluation of an obese adolescent male with knee pain. The most common etiology of the insidious onset of knee pain in children is the hip, due to referred pain from the

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

Advisor F

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

orum

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

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

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

NICAL

Send us your letter Advisor Forum, The s with questions New York, and comm Clinical Advisor ents to: , 114 clinicaladvisoNY 10001. You may contacWest 26th Street , please indicatr.com. If you are writing in t us by e-mail at 4th Floor, each item. e so by including response editor@ to a the Letters are policy is edited for number in parent published letter, to heses at length and contribution print the author ’s name with clarity. The Clinicathe end of s will be accepted. l Advisor the letter. No anonym ’s ous

Write us today.

OUR CO

NSULTA

PEARLS

NTS

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

Philip R.

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

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

62 THE CLINI

Deborah L. Cross, MPH, ANP-B

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

CAL ADVI

AdvisorForum_

CA0915

SOR • SEPTE

MBER 2015

Abimbo la Farinde

, PhD,

is a profess PharmD, or at Columb ia Souther n Univers in Orange ity Beach, Ala.

• www.Clinic

alAdvisor.c

Laura A.

Foster,

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

Abby A.

Jacobso

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

.indd 62

9/29/15

2:44 PM

E-MAIL editor@clinicaladvisor.com

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 5

CONTENTS APRIL 2019

NEWS 12

12 Vitamin D and Hyperglycemia

Newsline ■■Low Vit D Linked to Higher Blood Glucose Levels ■■Aerobic Exercise Found to Enhance Adult Cognitive Function ■■High-Flow Oxygen Effective for Cluster Headache ■■Effect of Increased Screen Time on Child Development ■■Colorectal Cancer Screening Outreach Strategy ■■Probiotics Not Beneficial for Preventing Gestational Diabetes

FEATURES

19 CRC Screening Outreach

20 The Counseling Connection: The Healthcare Practitioner’s Guide to Managing Atopic Dermatitis For optimal outcomes, a multifaceted approach should be used for management of patients with this condition. 28 Case Clinic: A 67-Year-Old Man With Atrial Fibrillation Risk Factors Detecting asymptomatic AF may help to prevent future thromboembolic events and the onset of symptoms.

41 Multiple Erythematous, Scaly Plaques

Continues on page 8

47 Careful Note-Taking Wins Case

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CONTENTS APRIL 2019

FEATURES (cont’d)

CME Follow the Science: Dietary Interventions

for the Management of Obesity Experts provide tips for how clinicians can motivate their patients to achieve weight loss goals.

CME Feature Posttest

DEPARTMENTS

A PEER-REVIEWED FORUM FOR NURSE PRACTITIONERS

NEWSLINE

■ Exercise and Cognitive Function ■ CRC Screening Outreach ■ Screen Time and Children FEATURE

APRIL A PEER-REVIEWED 2 019 | www.ClinicalAdvisor.com FORUM FOR NURSE PRACTITIONERS A PEER-REVIEWED| FORUM MARCHFOR 2019 NURSE | www.ClinicalAdvisor.com PRACTITIONERS | FEBRUARY 2019

NEWSLINE CARDIOLOGY

■ GI Illness in Older Adults ■ Physical Activity and HCC Risk ■ Maternal Hyperglycemia ■ WHO Top Health Threat

■ IUS Safe and Effective ■ Genetic Counseling in Ovarian Cancer ■ Improving TG, Cholesterol

ADVISOR FORUM

LEGAL ADVISOR

Clinical Pearls Health Literacy and the Older Adult: A Persistent STAT CONSULT Atrial fibrillation and Widespread Problem is theHuman most Immunodeficiency Virus common type (HIV)

Careful Note-Taking Wins Case

NP Testifies in a Rape Case

The Counseling Connection

The Healthcare Practitioner’s Guide to Atopic Dermatitis

| www.ClinicalAdvisor.com

NEWSLINE PAIN MANAGEMENT DERMATOLOGY

Insights Into the Diagnosis Case Clinic: A 67-YearActinic Keratoses: of OpioidOld Man With Atrial and TreatmentField Cancerization and Induced Constipation Fibrillation Risk Factors Photodynamic Therapy FEATURE

LEGAL ADVISOR

of cardiac arrhythmia. LEGAL ADVISOR

Constipation is one of the most common adverse effects of chronic opioid therapy.

AKs are one of the most common lesions seen in dermatology practice.

To Question, or Not to Question a Supervisor

DERMATOLOGIC LOOK-ALIKES

Multiple Erythematous, Scaly Plaques

Lower Extremity Swelling and Rash

DERMATOLOGY CLINIC

Hyperkeratotic Plaques in the Axilla

FREE CME COURSE

Dietary Interventions for the Management of Obesity

Evolution of the Intestinal Microbiome

Public Health Implications of Drugs of Misuse and Abuse

SUBSCRIPTIONS & SUBMISSIONS

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

Dermatologic Look-Alikes Multiple Erythematous, Scaly Plaques

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Legal Advisor Careful Note-Taking Wins Case

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Recommend BAYER Aspirin— First for secondary prevention. CV=cardiovascular; MI=myocardial infarction. *Nonfatal MI. References: 1. Antithrombotic Trialists’ (ATT) Collaboration. Lancet. 2009;373:1849-1860. 2. Garcia Rodríguez LA, Cea Soriano L, Hill C, Johansson S. Increased risk of stroke after discontinuation of acetylsalicylic acid: a UK primary care study. Neurology. 2011;76:740-746. 3. Garcia Rodríguez LA, Cea-Soriano L, Martín-Merino E, Johansson S. Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care. BMJ. 2011;343:d4094. Bayer and the Bayer Cross are registered trademarks of Bayer. © 2018 Bayer May 2018 1773-PP-BAY-PREV-US-0873

1014535ha_Lot A.indd 1

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EXCLUSIVE TO THE WEB AT

ClinicalAdvisor.com

NEWS ClinicalAdvisor.com/News

CASE STUDY ClinicalAdvisor.com/CaseStudy Brady Pregerson, MD Gradually Worsening Elbow Pain A 51-year-old woman is sent from urgent care to the emergency department with pain in the left elbow that has gradually worsened over the past 12 hours. She denies injury, fever, or other symptoms and has never experienced pain in her elbow previously. Read the full case here: ClinicalAdvisor.com/CaseElbowPain

Does the Vaccine Injury Compensation Program Promote Immunization? Although the antivaccination movement may think the Vaccine Injury Compensation Program supports their unsubstantiated beliefs, the truth is that the program actually promotes vaccinations.

Moderate Link Between Maternal and Cord Blood HBV DNA For mothers with chronic hepatitis B virus, there is a moderate correlation between maternal HBV DNA and cord blood HBV DNA.

NSAID Allergy May Increase Risk for Opioid Use Disorder Patients with low back pain or osteoarthritis who reported adverse drug reactions to NSAIDs had significantly higher odds of receiving prescriptions for opioids.

Multispecies Probiotics for Chronic, Episodic Migraine A probiotic mixture supplement may be effective for reducing the frequency and severity of migraine attacks and the use of abortive drugs in patients with chronic and episodic migraine.

Comparison of Treatments in Crohn Disease, Ulcerative Colitis In older patients with inflammatory bowel disease, TNF-alpha antagonist therapy and vedolizumab were found to be comparable with regard to both safety and effectiveness.

MY PRACTICE ClinicalAdvisor.com/MyPractice Widespread Reform Must Be Implemented to Improve Primary Care Quality, Access in Medicaid Medicaid expansion has created an “urgent need” to engage primary care practices in serving the expanded Medicaid population.

THE WAITING ROOM

Official Blog of The Clinical Advisor ClinicalAdvisor.com/WaitingRoom Jim Anderson, MPAS, PA-C, DFAAPA The Future of the Affordable Care Act: Will the Much-Debated Policy Survive? The future of the Affordable Care Act remains unknown, but the results of the 2018 midterm elections almost certainly prevent its repeal during the current presidency. Phyllis Wood, DNP, APRN, FNP-BC The Case of Theresa S, An Undocumented Immigrant With Lung Cancer A 40-year-old woman presented with a sore throat and cough for 3 weeks. She reported a history of smoking but was unable to recall her immunization status. Work-up revealed metastatic lung cancer. She did not have health insurance, earned less than the minimum wage, and was ineligible for public assistance.

10 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Advisor Dx Interact with your peers by viewing the images and offering your diagnosis and comments. To post your answer, obtain more clues, or view similar cases, visit ClinicalAdvisor.com/AdvisorDx. Check out some of our latest cases below!

DERM DX

Burning and Pain of the Tongue and Buccal Mucosa A 72-year-old woman is referred by her dentist for evaluation of intermittent burning and pain in her tongue and buccal mucosa induced by hot beverages and spicy foods. She takes medication for hypertension. Examination reveals discolored patches on the affected areas and scattered, hyperpigmented papules and macules on her wrists and ankles. CAN YOU DIAGNOSE THIS CONDITION?

• Oral leukoplakia • Oral thrush

• Geographic tongue • Oral lichen planus

● See the full case at ClinicalAdvisor.com/DermDx_Apr19

In partnership with

ORTHO DX

TheJopa.org

Journal of Orthopedics for Physician Assistants

Chronic Ankle Pain Following Surgery A 66-year-old woman presents with chronic left ankle pain. She underwent ORIF for an ankle fracture approximately 1 year ago. Since the surgery, the patient has noticed pain and occasional swelling over the lateral ankle that is made worse with physical activities. WHICH OF THE FOLLOWING STATEMENTS IS TRUE?

• 90% of patients report improvement of pain after hardware removal • 20% to 30% of patients will have pain after ankle ORIF • 10% of patients report improvement of pain after hardware removal • Painful hardware should be removed within 6 months of surgery ● See the full case at ClinicalAdvisor.com/OrthoDx_Apr19

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 11

Newsline LOW SERUM levels of 25-hydroxyvitamin D (25[OH]D) may be associated with hyperglycemia, a major risk factor for type 2 diabetes, according to a study published in Menopause. Researchers conducted a cross-sectional study of 681 women aged 35 to 74 years to evaluate the association between vitamin D deficiency and increased glycemia. Participants were interviewed via an electronic questionnaire; blood samples were collected by a nurse after an 8-hour fasting period.Total vitamin D was equated with a total serum concentration of 25(OH)D. Blood glucose levels were categorized as <100 mg/dL vs ≥100 mg/dL; total 25(OH)D was categorized as ≥30 ng/mL vs <30 ng/mL, and as ≥20 ng/mL vs <20 ng/mL.

The minimum and maximum glucose values of the blood samples were 26 and 401 mg/dL, respectively. Approximately one-quarter reported having diabetes, with approximately one-half using at least 1 hypoglycemic medication and 17% using insulin. The minimum and maximum values of 25(OH)D were 5.8 and 55.9 ng/mL, respectively. The prevalence of serum 25(OH)D level <20 ng/mL was 26.6% and that of serum 25(OH)D level <30 ng/mL was 65.4%. Only 3.5% of women reported taking vitamin D supplementation; this was found to be negatively associated with a serum 25(OH)D level <30 ng/mL. Sun exposure was also found to be negatively associated with a serum 25(OH)D level <30 ng/mL.

Low Vit D Linked to Higher Blood Glucose Levels

Samples were collected by a nurse after an 8-hour fasting period.

A blood glucose level ≥100 mg/dL was positively associated with body mass index, age, and hypertension and with serum 25(OH)D levels <20 and <30 ng/mL. Blood glucose levels ≥100 mg/ dL were not associated with vitamin D supplementation or with sunlight exposure.

Aerobic Exercise Found to Enhance Adult Cognitive Function AEROBIC EXERCISE was associated with improved executive function and increased cortical thickness in cognitively normal adults between ages 20 and 67 years, suggesting that aerobic exercise may contribute to brain health in adults as young as 20 years, according to a study published in Neurology. Improvements in executive function were more significant as age increased, while increases in cortical thickness were not age-dependent. A total of 132 cognitively normal adults with below median aerobic capacity were randomly assigned to either aerobic

exercise or stretching/toning 4 times weekly for 6 months. Outcomes measured included aerobic capacity, cognitive function, everyday function, body mass index (BMI), and cortical thickness. Cognitive function efficacy measures included executive function, episodic memory, processing speed, language, and attention. A significant increase in aerobic capacity and a decrease in BMI were seen in participants in the aerobic cohort but not in the stretching/toning cohort. In addition, moderated by age, members of the aerobic cohort demonstrated

12 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

significant improvement in executive function. Cortical thickness was also significantly increased in the aerobic exercise cohort, but this did not interact with age. Executive function improved less among participants in the aerobic cohort with at least 1 APOE ε4 allele. “This study extends the demonstrated benefits of aerobic exercise to individuals as young as 20,” the authors noted. “These findings have strong public health implications and allow the recommendation of a feasible, flexible intervention for cognitive and brain health for adults of all ages.”

High-Flow Oxygen Effective for Cluster Headache HIGH-FLOW OXYGEN was found to be a highly effective treatment for cluster headaches, with low rates of physical, medical, emotional, and psychological adverse effects. Although triptans were equally effective, they had a higher rate of complications, according to a study published in Headache:The Journal of Head and Face Pain. Participants (N=2193) from more than 50 countries completed the Cluster Headache Questionnaire, which included questions about cluster headache diagnostic criteria, efficacy of medications, physical and medical complications, psychological and emotional complications, mood scores, and difficulty obtaining medications. Treatment was reported to be completely or very effective by 54% of participants treated with triptans or oxygen. For those taking dihydroergotamine, cafergot/ergotamine, caffeine and energy drinks, and intranasal ketamine, complete or very effective treatment was reported by 25%, 17%, 17%, and 14%, respectively.

Complete or very effective treatment was reported in 6% of participants taking opioids, in 5% of participants taking intranasal capsaicin, and in 2% of participants using intranasal lidocaine. No or minimal physical and medical complications and no or minimal psychological and emotional complications were reported by 99% and 97% of participants treated with oxygen. Results were similar

89% of participants taking cafergot/ergotamine, by 81% and 91% of participants taking dihydroergotamine, by 76% and 77% of participants taking opioids, and by 73% and 85% of participants taking triptans. The authors noted that “this study did not include all recommended acute treatments for cluster headache, notably it did not ask about octreotide.” They concluded, “[O]xygen is reported by survey

Oxygen was found to be a highly effective treatment for cluster headache, with few complications reported in a large international sample. for participants treated with intranasal lidocaine (97% and 98%), intranasal ketamine (95% and 98%), intranasal capsaicin (91% and 94%), and caffeine and energy drinks (89% and 91%). No or minimal physical and medical complications and no or minimal psychological and emotional complications were reported by 83% and

respondents to be a highly effective treatment with few complications in cluster headache in a large international sample. When choosing among acute treatments, this study suggests that oxygen be considered first-line therapy for cluster headache patients regardless of age, as supported by recent clinical trials and current guidelines.”

Effect of Increased Screen Time on Child Development EXCESSIVE SCREEN exposure can negatively affect child development, and clinicians should direct parents on appropriate lengths of and consequences associated with increased screen time, according to a study published in JAMA Pediatrics. A team of Canadian researchers assessed the association between screen time and child development in a group of mothers and children. A total of 2441 mothers and children (47.9% boys) were included in the analysis, and child data were accessed at ages 24, 36, and 60 months.The primary outcomes were screen-time behavior measured in total hours per week and developmental outcomes for children measured by maternal report via the Ages and Stages Questionnaire,Third Edition.

Children aged 24, 36, and 60 months watched nearly 17, 25, and 11 hours per week of television, respectively. For children aged 24 and 36 months, there was a significant association between higher levels of screen exposure and

Children were found to watch up to 25 hours of television per week.

poorer performance on developmental screening tests at 36 months (β, -0.08) and 60 months (β, -0.06). “To our knowledge, the present study is the first to provide evidence of a directional association between screen time and poor performance on development screening tests among very young children,” the authors noted. “As technology use is entrenched in the modern-day lives of individuals, understanding the directional association between screen time and its correlates, and taking family-based steps to engage with technology in positive ways, may be fundamental to ensuring developmental success of children growing up in a digital age.”

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 13

Newsline Colorectal Cancer Screening Outreach Strategy EVALUATION OF a colorectal cancer (CRC) screening outreach strategy by mailed invitation for completing either a fecal immunochemical test (FIT) or a colonoscopy revealed that more primary care patients chose FIT, according to a study published in Preventive Medicine. Researchers conducted post-hoc analyses of data collected from a trial of CRC screening outreach. Patients who were not up-to-date with CRC screening were mailed invitations to either complete an enclosed FIT (n=2400) or schedule and complete a colonoscopy (n=2400). Invitations for both screenings were sent every 12 months over a 3-year period; usual-care participants were advised to screen at the discretion of their primary care providers. Compared with usual-care outreach, screening completion over the study period

Offering alternative interventions may improve cancer screening.

was higher for both mailed invitation outreach groups (FIT outreach, 28%; colonoscopy outreach, 38.4%), with colonoscopy outreach >3 times higher than usual care (38.4% vs 10.7%, respectively). Among patients who received invitations to complete an enclosed FIT, 56.6%

did so after the first mailing, and 3.3% crossed over to colonoscopy. An additional 15.7% and 7.7% of nonresponders initiated screening with FIT after the second and third mailings, respectively; 30.2% of patients never completed FIT screening. Compared with other racial groups, more Hispanics (64.2%) and patients whose primary language is Spanish (66.9%) initiated FIT. Approximately 25% of patients assigned to colonoscopy outreach initiated screening after the first mailing; 18.8% crossed over to FIT. After the second and third mailings, an additional 8.4% and 4.2%, respectively, were screened for colonoscopy; 44.1% of participants never initiated screening. More patients aged 60 to 64 years (21.1%), Hispanics (21.3%), and patients whose primary language is Spanish (22.6%) crossed over to FIT.

Probiotics Not Beneficial for Preventing Gestational Diabetes IN OVERWEIGHT and obese women, administering probiotics during the second trimester of pregnancy did not reduce the risk of gestational diabetes mellitus (GDM), according to a study published in Diabetes Care. Participants were aged >18 years, had a singleton pregnancy at <20 weeks’ gestation, and had a body mass index >25 kg/m2. All women underwent random venous plasma glucose level assessment prior to enrollment; those with levels ≥8.0 mmol/L proceeded to a 75-g oral glucose tolerance test (OGTT). Participants were randomly assigned to probiotics (Lactobacillus rhamnosus and Bifidobacterium animalis subspecies lactis) or placebo (microcrystalline cellulose and dextrose anhydrate capsules). The primary outcome measure was the frequency of GDM at 28 weeks’ gestation

as determined by 75-g OGTT. Maternal secondary outcomes included gestational weight gain, preeclampsia, hypertensive disorders of pregnancy, cesarean delivery, and gestational age at delivery. Neonatal secondary outcomes included premature birth, neonatal special care admission, jaundice, hypoglycemia, birth weight, small for

compared with placebo (77.5 mg/dL). Of the women taking probiotics, 9.2% developed preeclampsia compared with 4.9% in the placebo group. Excessive weight gain occurred in 32.5% of women taking probiotics compared with 46% taking placebo, but no difference was found in mean weight gain between the groups.

Administration of probiotics during the second trimester of pregnancy was not found to prevent GDM or improve secondary outcomes in overweight and obese women. gestational age (SGA), large for gestational age, stillbirth, birth injury, congenital anomaly, fat-free mass, and percentage of fat. Rates of GDM were 12.3% in the placebo group and 18.4% in the probiotics group; mean fasting glucose was higher in those receiving probiotics (79.3 mg/dL)

Neonatal outcomes did not differ between the probiotic and placebo groups; the only statistically significant difference was found in relation to SGA, which occurred in 6.5% of infants in the placebo arm and 2.4% of infants in the probiotics arm. ■

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 19

The Counseling Connection

The Healthcare Practitionerâ&#x20AC;&#x2122;s Guide to Managing Atopic Dermatitis

topic dermatitis (AD) is an inflammatory skin disorder that can be acute, subacute, or chronic relapsing in presentation.The condition is one of the most common skin ailments in children and often begins in infancy. Characterized by dry skin that is intensely pruritic, the itch-scratch cycle of incessant rubbing and scratching leads to increased skin thickness termed lichenification.1 In many patients, the disease is associated with significant morbidity and decreased quality of life. Scratching predisposes the skin to secondary infections, and itching results in significant sleep disturbance. Structural abnormalities of the skin and dysregulation of the immune system play crucial roles in the pathophysiology of AD. For optimal outcomes, a multifaceted approach should be used for management of patients with the condition. Treatment is aimed at repairing the diseased skin, protecting and rebuilding the skin barrier, and addressing immune dysfunction.2

of children with AD will have clinical remission of the disease before they reach adolescence.5,6 In children who develop AD before 2 years of age, approximately 50% will also develop asthma.2 Individuals with concomitant asthma and allergic rhinitis are much more likely to have a severe form of AD.7 Although infrequent, initial presentation of AD can occur in adulthood. Pathogenesis

Lauren Ax, MSPAS, PA-C Lauren Ax is a nationally certified dermatology physician assistant licensed in Pennsylvania.

Epidemiology

The prevalence of AD has been increasing over the past 30 years, affecting 10% to 20% of children and 1% to 3% of adults in developed countries.3 The condition frequently presents in infancy, with 45% of cases beginning within the first 6 months of life, 60% in the first year of life, and 85% before 5 years of age.4 The incidence of AD is slightly higher in males than females.5 Approximately 70% 20 THE CLINICAL ADVISOR â&#x20AC;˘ APRIL 2019 â&#x20AC;˘ www.ClinicalAdvisor.com

The pathogenesis of AD is not entirely understood. Complex interactions between immune dysregulation, skin barrier defects, and environmental and infectious factors have been implicated. Skin barrier abnormalities have been linked to a mutation or impaired expression of the filament aggregating protein (filaggrin) gene, which encodes for proteins essential for skin barrier maintenance.8 Patients with AD often have skin that is deficient in lipid molecules known as ceramides and antimicrobial peptides such as cathelicidins, which serve as the first line of defense against infectious agents. Skin barrier dysfunction also leads to transepidermal water loss, surface pH changes, and enhanced penetration of allergens and microbes into the skin. Colonization of Staphylococcus aureus, the most common infectious agent, has been identified in approximately 90% of AD cases, and up to 12% have methicillin-resistant S aureus.9 Continues on page 22

The Counseling Connection Also contributing to increased bacterial infections is a defective immune response that induces chemokines, proinflammatory cytokines, and elevated serum immunoglobulin E (IgE) levels.1 Skin inflammation in patients with AD is often associated with biphasic activation of helper T cell type 2 (TH2). In acute AD, T-cell infiltration orchestrates expression predominance of the cytokines interleukin-4 (IL-4) and interleukin-13 (IL-13). In chronic inflammation, an increase in interleukin-5 (IL-5), granulocyte-macrophage colonystimulating factor, and interferon (IFN)-γ is seen.9 The role of allergens in the exacerbation and pathogenesis of AD is still being debated. Patients with AD often demonstrate specific IgE antibodies to foods and aeroallergens with elevated serum IgE levels and a positive skin prick test, although the clinical significance is unclear. Exposure to animal dander, pollen, house dust mites, and mold may exacerbate AD. Implementation of avoidance measures for patients who notice a worsening of their AD with allergen exposure is prudent.2 Severe AD in infancy may predispose patients to developing allergies to egg and peanuts. In a subset of infants and children with AD, flares may be triggered by exposure to eggs, milk, peanuts, soybeans, fish and wheat.2 Disruption in the skin barrier leading to increased transepidermal water loss and reduced ceramide levels will exacerbate AD. Skin barrier disruptions may be induced by frequent hand washing or bathing. Exotoxins of S aureus can activate T cells and macrophages by acting as superantigens.4 A temperate climate usually helps to improve AD, while flares are commonly seen in the winter months. Clothing, particularly wool or fur,

Atopic dermatitis exhibiting excoriations and lichenification.

exacerbates AD. Emotional stress, whether from the disease itself or other elements, is an important exacerbating factor associated with flares of AD. Clinical Manifestations

Pruritus is the sine qua non of AD, which is often referred to as “the rash that itches.”3 Acute skin lesions present as ill-defined erythematous patches, papules, and plaques absent of scaling. Skin may appear edematous with widespread involvement. Moist and cracked erosions are often present with linear or punctate lesions from scratching. If secondary infections are present, erosions may have oozing, pustules, crusting, increased warmth to touch, and surrounding erythema. Other symptoms of atopy such as conjunctival and pharyngeal itching, lacrimation, allergic rhinitis, and obstruction of nasal passages may be noted.5 In chronic AD, skin thickening (lichenification) with accentuation of natural skin markings is present. Periorbital pigmentation, infraorbital folds below the eyelids (known as the Dennie-Morgan sign), and alopecia of the lateral one-third of the eyebrow from chronic rubbing may be present. Clinical manifestations of AD vary based on age and the individual patient. The scalp, face, neck, trunk, and extensor surfaces of the extremities are areas typically affected in infants, usually sparing the diaper area. Infantile AD may present with erythema and tiny vesicles. Childhood-type AD presents on the neck, face, and antecubital and popliteal fossae as lichenified plaques, erosions, crusts, and papular lesions. In adolescent and adult-type AD, the hands, feet, and flexural surfaces of the extremities are usually affected, with the condition

A 29-year-old man with lifelong atopic dermatitis.

22 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Nummular eczema.

manifesting as excoriated and lichenified skin often with painful fissures. In severe cases, disease may be generalized. Forms of AD include hand dermatitis, nummular eczema, and exfoliative dermatitis. Ethnicity may affect the appearance of AD. In patients with dark brown and black skin, lesions may present with discrete follicular papules involving hair follicles.White dermatographism, the blanching of skin evoked by stroking, may be an associated finding. Differential Diagnosis

The differential diagnosis includes seborrheic dermatitis, irritant dermatitis, allergic contact dermatitis, lichen simplex chronicus, psoriasis, ichthyosis, cutaneous T-cell lymphoma, and infectious skin diseases such as dermatophytosis, impetigo, and scabies. Congenital immunodeficiencies such as hyper-IgE syndrome,Wiskott-Aldrich syndrome, and Omenn syndrome may have an eczematoid component. In patients presenting with AD later in life with resistance to therapy, mycosis fungoides must be considered. Diagnosis

Diagnosis is usually based on history and clinical appearance. Although various criteria have been suggested for the diagnosis of AD, there is no gold standard. Williams et al provides a simplified criteria with high sensitivity and specificity.10 The presence of itchy skin plus 3 or more minor criteria depending on the patient’s age are required for the diagnosis of AD. Minor criteria in older children and adults include history of itchiness in skin creases, personal history of asthma or allergic rhinitis, personal history of general dry skin in the last year, visible flexural dermatitis, and onset before the age of 2 years.10

Patient Education

Patient and caregiver education are important factors for successful management of AD. Chronic scratching or rubbing should be strongly discouraged. Written information and instructions should be given to reinforce the treatment plan, skin care practices, appropriate medication use, and management of flares. Addressing appropriate daily skin care practices is a key feature of management of AD. The frequency of bathing is controversial. Cleansing once per day or once every other day, as well as keeping baths or showers under 10 minutes so as not to worsen xerosis, is often recommended. Cleansing the skin allows for superficial debridement and improved penetration of topical therapies. Immediately after leaving the bath or shower, the skin should be patted dry with a towel, keeping the skin slightly wet and followed by liberal application of moisturizers or emollients. This technique helps prevent excessive drying of the skin and moisture loss. Ointments, although greasy, are generally more effective moisturizers than creams or lotions. A multitude of over-the-counter moisturizers are available both in stores and online, and greater expense may not portend greater efficacy. Moisturizers rich in ceramides are a good option. Patients should be advised to observe for signs of complications such as impetigo and herpes. Credible educational resources are available for patients and caregivers. Clinicians can direct patients to the American Academy of Dermatology (AAD), the National Eczema Association, the Eczema Society of Canada, and the Canadian Skin Alliance) for further information. For younger patients with AD, a book titled Under My Skin by Karen Crowe is a helpful resource.This “kid’s guide

Laboratory Studies

In cases with atypical presentation or if history and physical examination are not diagnostic, punch biopsy may be necessary with evaluation by a dermatopathologist. Spongiosis, a manifestation of intercellular edema, is a characteristic finding. Impetiginized or vesiculated areas may warrant bacterial or viral cultures. Course and Prognosis

When arising in childhood, approximately 70% of individuals will experience remission by adolescence.5,6 Adult-onset AD is often severe and may persist for decades. Patients with widespread disease and those with concomitant atopic conditions such as allergic rhinitis and asthma have a less sanguine prognosis.

Childhood-type atopic dermatitis.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 23

The Counseling Connection POLL POSITION Which of the following is NOT considered appropriate skin care management for patients with atopic dermatitis? ■ Cleanse affected skin twice daily ■ Limit baths and showers to less than 10 minutes ■ Keep the skin slightly wet after bathing ■ Follow bathing with the liberal application of moisturizers or emollients

4.96%

21.95%

64.42%

8.67%

For more polls, visit ClinicalAdvisor.com/Polls.

to atopic dermatitis” helps children to better comprehend their disease. Management

Management of AD is best accomplished by repairing the damaged skin barrier and minimizing inflammation. Patient education should stress the need for moisturization, avoidance of excessive scratching and rubbing, and elimination of known exacerbating factors such as wearing wool clothing and excessive bathing or hand washing. If flares are associated with emotional stress, stress reduction strategies and psychiatry referral may be indicated. First-line pharmacologic treatment for AD is topical corticosteroids, which improve AD through immunosuppressive, anti-inflammatory, and antiproliferative actions. Potency of topical steroids ranges from low to high, with the latter usually reserved for acute flares. Topical corticosteroids should be applied directly to itchy, red, or inflamed areas prior to the application of emollients or other moisturizers so as not to decrease the efficacy of the steroid.11 Choice of topical corticosteroid is often based on familiarity and patient access (ie, out-of-pocket cost). In sensitive areas where skin is the thinnest — such as the face, neck, groin, and underarms — use of a low-potency topical corticosteroid such as hydrocortisone acetate is recommended. For xerotic skin, ointment preparations are preferred over creams or lotions as they provide higher degrees of penetration and more uniform coverage. With prolonged use, topical corticosteroids may

cause skin depigmentation, striae, and atrophy. Suppression of the pituitary-adrenal axis may also occur.11 Topical calcineurin inhibitors (TCIs) are safe and effective for the treatment of AD and may prevent flares.12 These agents are commonly used as second-line intermittent therapy; both pimecrolimus and tacrolimus are approved by the US Food and Drug Administration (FDA) to treat AD in immunocompetent patients aged ≥2 years. In one study, tacrolimus 0.1% was as effective as potent topical corticosteroids such as betamethasone.13 On direct comparison of tacrolimus 0.03% against pimecrolimus 1% in children with moderate AD, no significant difference was seen.14 Due to the high cost of TCIs, these agents are typically reserved for patients with persistent disease, patients requiring frequent or continuous topical corticosteroids, or patients in whom AD affects sensitive areas of skin such as the face or neck where risk of skin atrophy from topical corticosteroid use is increased. Skin burning and irritation are the most common adverse effects seen with TCIs. Due to the theoretical risk of skin malignancy and lymphoma in patients using these agents, the FDA recommends caution when prescribing TCIs.12 A new novel topical anti-inflammatory, crisaborole 2% ointment, has been approved by the FDA to treat mild to moderate AD in patients aged ≥2 years. Crisaborole 2% ointment is a phosphodiesterase 4 (PDE4) inhibitor. In clinical studies, crisaborole ointment 2% has been shown to be well tolerated with a favorable safety profile.15 Crisaborole may provide effective long-term treatment of AD without the safety concerns associated with topical corticosteroids.15 Patients with AD may be heavily colonized with S aureus both in involved and uninvolved sites. Due to barrier impairment, patients with AD are at increased risk for secondary infection.Topical or oral antibiotic therapy is recommended when a bacterial infection is present. Patients with atopy are prone to recurrent viral infections such as eczema herpeticum (also known as Kaposi varicelliform eruption), which is a widespread herpes infection that occurs at sites of skin damage. Eczema herpeticum is most common in severe AD and may be misdiagnosed as a bacterial infection. Treatment includes systemic antiviral agents such as acyclovir or valacyclovir. Children with AD are also more prone to infection with molluscum contagiosum. This condition is often asymptomatic and self-limiting. Lesions tend to resolve slowly but may spread to other sites. Use of dilute bleach baths to prevent secondary infections is controversial.These baths can reduce S aureus colonization and, in some cases, avoid the need for systemic antibiotics. Dilute bleach baths involve adding one-quarter to one-half

24 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Continues on page 26

For 1st-line constipation relief

The gentle power of MiraLAXÂŽ (PEG 3350) is prized by both doctors and patients.1-3 AGA recommends PEG laxatives as a first-line treatment 4

#1 GI-recommended laxative

96% patient satisfaction rate3

AGA=American Gastroenterological Association. References: 1. Schiller LR, Emmett M, Santa Ana CA, Fordtran JS. Osmotic effects of polyethylene glycol. Gastroenterology. 1988;94(4):933-941. 2. Hammer HF, Santa Ana CA, Schiller LR, Fordtran JS. Studies of osmotic diarrhea induced in normal subjects by ingestion of polyethylene glycol and lactulose. J Clin Invest. 1989;84(4):1056-1062. 3. Survey of 672 consumers, August 2017, Bayer Consumer Health. 4. Bharucha AE, Dorn SD, Lembo A, Pressman A; American Gastroenterological Association. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013;144(1):211-217.

Doctor recommended, patient approved

The Bayer Cross, MiraLAX, and the MiraLAX Pink Cap are registered trademarks of Bayer. ÂŠ 2019 Bayer

1022320ha_a.indd 1

January 2019

3890-PP-MLX-BASE-US-0613

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The Counseling Connection cup of chlorine bleach to a full bath, and patients are instructed to soak for approximately 10 minutes. After soaking, patients should rinse immediately with fresh water, pat the skin dry, and apply emollient or moisturizer to avoid drying or dehydrating the skin.1 Some studies report that twice-weekly bleach baths for 3 months are effective in the management of AD.16 However, a more recent analysis found them to be no more effective than water baths alone.17 Cyclosporine, methotrexate, and azathioprine are systemic immunosuppressive agents that are used to manage patients with severe AD refractory to topical therapies.18 Due to potential adverse effects associated with these agents, all patients should be monitored frequently. Kidney impairment may be seen with cyclosporine; therefore, creatinine and blood pressure should be monitored. Myelosuppression can occur in patients treated with azathioprine, and blood counts should be closely followed, especially at the onset of therapy.19 Methotrexate can induce liver fibrosis, and obese individuals and those with alcohol dependency are at greatest risk.18 Prolonged use of oral steroids should be avoided due to the potential for osteonecrosis and bone fracture. Short-term use can raise blood sugar and blood pressure.20 Intramuscular triamcinolone administered at 3-month intervals can be effective in managing flares and maintaining low disease activity, decreasing both inflammation and pruritus.21 First-generation antihistamines such as hydroxyzine and diphenhydramine have minimal effect on the pruritus accompanying AD, but their sedative effect may improve overall quality of life for those experiencing sleep disturbance.22 Second-generation antihistamines may be recommended for AD patients with allergy-associated triggers. In patients with AD and concomitant aeroallergen sensitization, allergenspecific immunotherapy may be beneficial.23 Ultraviolet (UV) light phototherapy administered for up to 8 weeks may prove of value for those patients for whom topical therapies are ineffective.24 UVB is a carcinogen and should be used cautiously in patients with fair skin and/or a personal or family history of skin cancer. Wet-wrap therapy, which includes the application of wet bandages or dressings over AD-associated lesions after the application of emollients and/or topical corticosteroids, may be an effective therapy for flares of AD. Similarly, the use of plastic wraps over the application of topical corticosteroids or emollients may be beneficial in aiding penetration of applied topical agents when treating flares.Although wet wraps are not superior to conventional topical therapies, they have shown value when used in conjunction with topical agents such as corticosteroids and emollients.25

Dupilumab, an interleukin 4 (IL-4) receptor α-antagonist, has been approved both in the United States and Europe for the treatment of AD and has revolutionized management of severe disease. Dupilumab blocks the shared IL-4α subunit from signaling IL-4 and IL-13, thereby reducing the TH2 inflammatory response.26 Clinical trials demonstrate marked superiority to placebo, especially when used in conjunction with topical steroids.27,28 The most common adverse events reported are conjunctivitis, nasopharyngitis, upper respiratory tract infection, injection site reaction, and skin infections.26 Additional topical and systemic therapies, including the oral Janus kinase inhibitor tofacitinib citrate, have shown promise in phase 3 clinical trials29 and will further enhance our ability to manage AD. It is important to carefully monitor patients with AD and assess progress and/or exacerbations on a regular basis. These visits will allow for evaluation of the efficacy of current therapy, patient tolerability, medication risks, and patient adherence to the treatment plan. ■ Lauren Ax, MSPAS, PA-C is a nationally certified dermatology physician assistant licensed in Pennsylvania. She received her Masters of Science in Physician Assistant Studies at King’s College, where she graduated with honors. Lauren specializes in medical and cosmetic dermatology, treating both children and adults. She is passionate about providing dermatologic and medical care to underdeveloped areas around the world. She served on a medical mission trip to Portau-Prince, Haiti, in May 2018, during which time she volunteered in a local clinic and orphanage treating skin and medical disorders to those with no access to medical care. Lauren is currently working in Hazelton, Pennsylvania, as a dermatology physician assistant at DermDOX Dermatology Centers. References 1. Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics. 2008;122(4):812-824. 2. Kapur S, Watson W, Carr S. Atopic dermatitis. Allergy Asthma Clin Immunol. 2018;14(Suppl3):52. 3. Larsen FS, Hanifin JM. Epidemiology of atopic dermatitis. Immunol Allergy Clin North Am. 2002;22(1):1-24. 4. Kelleher M, Dunn-Galvin A, Hourihane JO, et al. Skin barrier dysfunction measured by transepidermal water loss at 2 days and 2 months predates and predicts atopic dermatitis at 1 year. J Allergy Clin Immunol. 2015; 135(4):930-935. 5. Pyun BY. Natural history and risk factors of atopic dermatitis in children. Allergy Asthma Immunol Res. 2015;7(2):101–105. 6. Bieber T. Atopic dermatitis. N Engl J Med. 2008;358:1483-1494. 7. Akdis CA, Akdis M, Bieber T, et al; for the European Academy of Allergology and Clinical Immunology/American Academy of Allergy,

26 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Asthma and Immunology et al. Diagnosis and treatment of atopic

23. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy:

dermatitis in children and adults: European Academy of Allergology and

a practice parameter third update. J Allergy Clin Immunol. 2011;127

Clinical Immunology/American Academy of Allergy, Asthma and

(1 Suppl):S1-S55.

Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol.

24. Patrizi A, Raone B, Ravaioli GM. Safety and efficacy of phototherapy

2006;118(1):152-169.

in the management of eczema. Adv Exp Med Biol. 2017;996:319-331.

8. Brown SJ, McLean WH. One remarkable molecule: filaggrin. J Invest

25. González-López G, Ceballos-Rodríguez RM, González-López JJ,

Dermatol. 2012;132(3 Pt 2):751-762.

Feito Rodríguez M, Herranz-Pinto P. Efficacy and safety of wet wrap therapy

9. Maliyar K, Sibbald C, Pope E, Sibbald GR. Diagnosis and management of

for patients with atopic dermatitis: a systematic review and meta-analysis.

atopic dermatitis: a review. Adv Skin Wound Care. 2018;31(12):538-550

Br J Dermatol. 2017;177(3):688-695.

10. Williams HC, Burney PG, Hay RJ, et al. The U.K. Working Party’s diagnostic

26. Gooderham MJ, Hong HC, Eshtiaghi P, Papp KA. Dupilumab: a review

criteria for atopic dermatitis. I. Derivation of a minimum set of discriminators

of its use in the treatment of atopic dermatitis. J Am Acad Dermatol. 2018;

for atopic dermatitis. Br J Dermatol. 1994;131(3):383-396.

78(3 Suppl 1):28-36.

11. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for

27. Blauvelt A, de Bruin-Weller M, Gooderham M, et al. Long-term

the management of atopic dermatitis: section 2. Management and treatment

management of moderate-to-severe atopic dermatitis with dupilumab

of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;

and concomitant topical corticosteroids (LIBERTY AD CHRONOS):

71 (1):116-132.

a 1-year, randomized, double-blinded, placebo-controlled, phase 3 trial.

12. Ashcroft DM, Dimmock P, Garside R, Stein K, Williams HC. Efficacy

Lancet. 2017;389(10086):2287-2303.

and tolerability of topical pimecrolimus and tacrolimus in the treatment of

28. Simpson EL, Bieber T, Guttman-Yassky E, et al; for the SOLO1 and

atopic dermatitis: meta-analysis of randomized controlled trials. BMJ. 2005;

SOLO2 Investigators. Two phase 3 trials of dupilumab versus placebo in

330(7490):516.

atopic dermatitis. N Engl J Med. 2016;375(24):2335-2348.

13. Reitamo S, Rustin M, Ruzicka T, et al; European Tacrolimus Ointment Study

29. Levy LL, Urban J, King BA. Treatment of recalcitrant atopic dermatitis

Group. Efficacy and safety of tacrolimus ointment compared with that of

with the oral Janus kinase inhibitor tofacitinib citrate. J Am Acad Dermatol.

hydrocortisone butyrate ointment in adult patients with atopic dermatitis.

2015;73(3):395-399.

J Allergy Clin Immunol. 2002;109(3):547-555. 14. Kempers S, Boguniewicz M, Carter E, et al. A randomized investigatorblinded study comparing pimecrolimus cream 1% with tacrolimus ointment 0.03% in the treatment of pediatric patients with moderate atopic dermatitis. J Am Acad Dermatol. 2004;51(4):515-525. 15. Hoy SM. Crisaborole 2% ointment: a review in mild to moderate atopic dermatitis. Am J Clin Dermatol. 2017;18(6):837-843. 16. Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. 2009;123(3):e808-e814. in reducing severity of atopic dermatitis: a systematic review and metaanalysis. Ann Allergy Asthma Immunol. 2017;119(5):435-440. 18. Simon D, Bieber T. Systemic therapy for atopic dermatitis. Allergy. 2013; 69(1):46-55. 19. Anstey AV, Wakelin S, Reynolds, NJ. Azathioprine: guidelines for prescribing azathioprine in dermatology. Br J Dermatol. 2004;151(6): 1123-1132. 20. Yu SH, Drucker AM, Lebwohl M, Silverberg JI. A systematic review of the safety and efficacy of systemic corticosteroids in atopic dermatitis. J Am Acad Dermatol. 2018;78(4):733-740. 21. Buys LM. Treatment options for atopic dermatitis. Am Fam Physician. 2007;15;75(4):523-528. 22. Matterne U, Böhmer MM, Weisshaar E, Jupiter A, Carter B, Apfelbacher CJ. Oral H1 antihistamines as ‘add-on’ therapy to topical treatment for eczema. Cochrane Database Syst Rev. 2019 Jan 22;1:CD012167.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 27

17. Chopra R, Vakharia PP, Sacotte R, Silverberg JI. Efficacy of bleach baths

FEATURE: CHARLES P. VEGA, MD

Case Clinic: A 67-YearOld Man With Atrial Fibrillation Risk Factors Detecting previously undiagnosed, asymptomatic AF may help to prevent future thromboembolic events and the onset of symptoms.

trial fibrillation (AF) is the most common type of cardiac arrhythmia seen in clinical practice.The prevalence of AF increases with age: approximately 1% of individuals with AF are <60 years of age, while up to 12% are between ages 75 and 84.1 Other risk factors for AF include hypertension, heart disease, diabetes, thyroid disease, and sleep apnea. AF may increase the risk of stroke by as much as 5-fold2; stroke risk also increases with advancing age.3 Symptoms commonly associated with AF include palpitations, chest discomfort, fatigue, dizziness, and/or shortness of breath. However, some people with the condition do not experience any symptoms. In fact, for approximately 20% of patients who have had a stroke associated with AF, stroke was the first clinical manifestation.4 Detecting previously undiagnosed, asymptomatic AF can potentially help prevent future thromboembolic events and the onset of symptoms, and reduce AF-related morbidity and hospitalizations. Case Presentation: Medical Evaluation and History

AF may increase the risk of stroke by as much as 5-fold.

Frank is a 67-year-old white man who has come in for a routine wellness visit and wants to know about vaccines for the flu and whooping cough because he is expecting a new granddaughter next month. His height is 5’9” and his weight is 220 lb; his BMI is 32.5 kg/m2. His blood pressure is 124/80 mm Hg, and his pulse is 115 bpm. Frank was diagnosed Continues on page 30

28 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

PHARMACOTHERAPY FOR ATRIAL FIBRILLATION

Risk factors for atrial fibrillation include increasing age, hypertension, heart disease, diabetes, thyroid disease, and sleep apnea. with hyperlipidemia 8 years ago and hypertension 5 years ago. He currently takes atorvastatin 10 mg/d and lisinopril 10 mg/d. Frank owns and manages a local restaurant. He has never smoked and consumes alcoholic beverages only on special occasions. His age and history of hypertension suggest he might be at risk for AF. During the physical exam, his heart rate is 120 bpm with an irregular rhythm. He denies experiencing fatigue, dizziness, palpitations, shortness of breath, or chest pains. Other physical examination findings include: lungs = normal; abdomen = obese, no tenderness or masses; neck = negative for thyromegaly; vision = normal; neurologic = normal reflexes and coordination. An electrocardiogram is performed and shows AF with rapid ventricular response. ■ What is the best next step in the care of Frank? • Obtain an echocardiogram? • Refer for cardiac stress testing? • Initiate anticoagulation therapy? • Start aspirin? Case Presentation, Continued

Frank’s laboratory results — including electrolytes, blood urea nitrogen, and fasting blood glucose — are all within normal limits. His creatinine clearance (CrCl) is moderately impaired at 50 mL/min. An echocardiogram shows mild concentric left ventricular hypertrophy and mild left atrial enlargement; the results are otherwise within normal limits. CHA2DS2-VASc is used to calculate stroke risk. Frank has a score of 2, which is considered “moderate-high” risk. HAS-BLED is used to calculate bleeding risk. Frank has a score of 2, which indicates that TABLE 1. Stroke Risk Stratification in Patients With NVAF CHA2DS2-VASc score

Recommendation

No anticoagulation therapy needed

Options include no anticoagulation therapy, aspirin, or anticoagulation therapy

≥2

Oral anticoagulation therapy is recommended

From Whitlock RP, et al. Chest. 2012;141(2 suppl):e576S-e600S; January CT, et al. J Am Coll Cardiol. 2014;64(21):e1-e76.

anticoagulation therapy can be considered. However, he is at moderate risk for major bleeding. ■ What would you do next? • Is anticoagulation therapy not needed at this time? • Start aspirin? • Start warfarin? • Start a direct-acting oral anticoagulant (DOAC)? Overview of Treatment Options for Stroke Prevention in Nonvalvular Atrial Fibrillation

Prior to initiating antithrombotic therapy, patients should be assessed for stroke risk and bleeding risk. Evidence-based guidelines recommend using the CHA2DS2-VASc score for stroke risk stratification in patients with nonvalvular AF (NVAF) (Table 1).1,5,6 The CHA2DS2-VASc score is preferred over the CHADS2 score due to the broader score range and larger number of risk factors included.1 Hemorrhage risk can be assessed using bleeding risk scores such as HAS-BLED or others.1,5 Clinicians should discuss the risk of both stroke and bleeding with all patients considering anticoagulation therapy. If anticoagulation therapy is deemed appropriate for a patient, several options are available. Antithrombotic agents routinely used for the prevention of thromboembolism in patients with NVAF include warfarin, DOACs (direct thrombin and factor Xa inhibitors), and antiplatelet drugs (aspirin and clopidogrel). Warfarin

Warfarin is a vitamin K antagonist that acts on multiple sites in the coagulation cascade. It has been the main option for stroke prevention in patients with AF for decades. Compared with placebo, warfarin reduces the relative risk of ischemic and hemorrhagic stroke by as much as 64%, which corresponds to an absolute risk reduction of 2.7% per year.7 Warfarin is also inexpensive, readily available, and has an easy-to-administer antidote.8 Although warfarin is highly effective, it is also cumbersome to use due to a narrow therapeutic index that necessitates frequent monitoring and dose adjustments. It also interacts with numerous foods and drugs. These limitations have translated into poor patient adherence, which is especially important for patients with a CHA2DS2-VASc score ≥2.9 Direct-Acting Oral Anticoagulants

Over the past decade, the market has seen the addition of several new oral anticoagulants that act by directly inhibiting

30 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Symptoms commonly associated with atrial fibrillation include palpitations, chest discomfort, fatigue, dizziness, and/or shortness of breath. thrombin or activated factor X (Factor Xa) (Table 2). These DOACs can be given at fixed doses without the need for routine coagulation monitoring, which simplifies treatment. Meta-analyses have found that DOACs are as or even more effective than warfarin in reducing the risk of thromboembolic events.10-12 DOACs are also associated with lower rates of intracranial hemorrhage compared with warfarin.10,11 However, most DOACs increase the risk of gastrointestinal bleeding.10-12 Dabigatran is a direct thrombin inhibitor. It is available in dose strengths of 75 mg, 110 mg, and 150 mg administered twice daily. For stroke prevention in NVAF, dabigatran should be administered at 150 mg twice daily, and the dosage should be reduced to 75 mg twice daily for patients with a CrCl of 15 to 30 mL/min.13 In clinical trials, dabigatran 150 mg twice daily was found to be superior to warfarin, and dabigatran 110 mg twice daily was found to be noninferior to warfarin for the primary outcome of stroke (any type) and systemic

embolism.13 Both the 110-mg and 150-mg doses significantly lowered the risk of hemorrhagic stroke by 74% and had lower rates of intracranial bleeding and life-threatening bleeding.13 The rate of major bleeding was similar to that seen with warfarin, while the rate of gastrointestinal bleeding was higher at the 150-mg dose.13 The most common adverse events are gastritis-like symptoms and bleeding.13 Dabigatran is primarily excreted by the kidneys; thus, plasma concentrations are increased in patients with moderate renal impairment (CrCl <50 mL/min).14 Apixaban is a direct factor Xa inhibitor. It is available in dose strengths of 2.5 mg and 5 mg administered twice daily. For stroke prevention in NVAF, apixaban should be administered at 5 mg twice daily, and the dosage should be reduced to 2.5 mg twice daily in certain conditions.15 In clinical trials, apixaban was found to be superior to warfarin in the primary outcomes of stroke and systemic embolism as well as in major bleeding.15

TABLE 2. Overview of Direct Oral Anticoagulant Therapies for Stroke Prevention in Nonvalvular Atrial Fibrillation Direct Thrombin (Factor IIa) Inhibitor

Direct Factor Xa Inhibitors

Name

Dabigatran (Pradaxa®)13

Apixaban (Eliquis®)15

Edoxaban (Savaysa®)16

Rivaroxaban (Xarelto®)17

Dosing

• 150 mg twice daily; oral • Reduce to 75 mg twice daily if CrCl 15-30 mL/min

• 5 mg twice daily; oral • Reduce to 2.5 mg twice daily if ≥2 of the following: age ≥80 y, weight ≤60 kg, or Cr ≥1.5 mg/dL

• 60 mg once daily; oral (only if CrCl <95 mL/min) • Reduce to 30 mg once daily if CrCl 15-50 mL/min

• 20 mg daily with evening meal; oral • Reduce to 15 mg daily with evening meal if CrCl 15-50 mL/min

Efficacy vs Warfarin in Nonvalvular Atrial Fibrillation

• Superior: stroke and systemic embolism, hemorrhagic stroke

• Noninferior: stroke and systemic embolism

Safety vs Warfarin in Nonvalvular Atrial Fibrillation

• Major bleeding: similar • Gastrointestinal bleeding: higher • Intracranial hemorrhage and fatal bleeding: lower

• Major bleeding: superior • Intracranial hemorrhage and fatal bleeding: lower

• Major bleeding: superior

• Major bleeding: similar • Gastrointestinal bleeding: higher • Intracranial hemorrhage and fatal bleeding: lower

Contraindications

• Active bleeding • Hypersensitivity • Mechanical heart valves • Pregnancy or nursing

• Active bleeding • Hypersensitivity • Severe hepatic impairment • Mechanical heart valves • Pregnancy or nursing

• Active bleeding • Hypersensitivity • Moderate or severe hepatic impairment • Mechanical heart valves • Pregnancy or nursing

• Active bleeding • Hypersensitivity • Severe hepatic impairment • Mechanical heart valves • Pregnancy or nursing

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PHARMACOTHERAPY FOR ATRIAL FIBRILLATION

Evidence-based guidelines recommend using the CHA2DS2 -VASc score for stroke risk stratification in patients with nonvalvular atrial fibrillation. Rates of intracranial bleeding were lower in patients treated with apixaban, and rates of gastrointestinal bleeding were similar.15 The most common adverse events are bleeding-related.15 Apixaban is metabolized in the liver via CYP3A4-dependent and CYP3A4-independent mechanisms and should not be used in patients with severe hepatic impairment.14 Edoxaban is a direct factor Xa inhibitor. It is available in dose strengths of 15 mg, 30 mg, and 60 mg administered once daily. For stroke prevention in NVAF, edoxaban should be administered at 60 mg once daily for patients with a CrCl of >50 to ≤95 mL/min, and the dosage should be reduced to 30 mg once daily for patients with a CrCl of 15 to 50 mL/min.16 In clinical trials, both edoxaban 60 mg once daily and edoxaban 30 mg once daily were found to be noninferior to warfarin with respect to the primary outcome of stroke and systemic embolism.16 Both doses also significantly lowered rates of major bleeding compared with warfarin.16 The most common adverse events are bleeding and anemia.16 Edoxaban is metabolized in the liver via a CYP3A4-dependent pathway and should not be used in patients with moderate or severe hepatic impairment.14 Rivaroxaban is a direct factor Xa inhibitor. It is available in dose strengths of 2.5 mg, 10 mg, 15 mg, and 20 mg administered once daily. It should be consumed with the evening meal to ensure adequate absorption.17 For stroke prevention in NVAF, rivaroxaban should be administered at 20 mg once daily with the evening meal, and the dosage should be reduced to 15 mg once daily for patients with a CrCl of ≤50 mL/min.17 In clinical trials, rivaroxaban was found to be noninferior to warfarin with respect to the primary outcome of stroke and systemic embolism, and major bleeding was similar.17 Gastrointestinal bleeding was higher with rivaroxaban, but rates of intracranial hemorrhage and fatal bleeding were lower.17 The most common adverse events are bleeding-related.17 Rivaroxaban is metabolized in the liver via CYP3A4-dependent and CYP3A4-independent mechanisms and should not be used in patients with severe hepatic impairment.14 Antiplatelet Therapy

The evidence supporting antiplatelet therapy for stroke prevention in patients with AF is extremely limited.Aspirin is the most common antiplatelet therapy, but no studies, with the exception of the Stroke Prevention in Atrial Fibrillation (SPAF-1) trial, have shown a benefit of aspirin alone in preventing stroke in patients with AF.1 A meta-analysis found a 19% reduction in stroke with aspirin vs no therapy, but this finding was not statistically significant and was driven by the positive findings

of the SPAF-1 trial.7 Aspirin may be considered for patients with a CHA2DS2-VASc score of 1, but it is less effective than warfarin or DOACs for preventing strokes.1,7,18 The combination of clopidogrel and aspirin has also been studied. In clinical trials, it reduced the relative risk of stroke by 28% compared with aspirin alone, but it also increased the risk of major bleeding by 57%.1 Combination clopidogrel plus aspirin has been shown to be inferior to warfarin for stroke prevention.1 Antiplatelet therapy should not be used in combination with anticoagulation therapy due to the increased risk of major bleeding.6 Case Presentation, Continued: Shared DecisionMaking and Management Plan

Following consultation with his primary care provider, shared decision-making is instituted with Frank to discuss oral anticoagulation options. Considerations covered include the risks and benefits of the proposed therapy, cost, type of follow-up needed, and any lifestyle limitations or quality-of-life concerns that may affect this choice.8 Frank does not think that the frequent monitoring required with warfarin will fit with his lifestyle. He chooses to start dabigatran 150 mg twice daily. Ongoing monitoring should be performed at follow-up visits to check for treatment adherence, thromboembolism, bleeding, side effects, and co-medications.19 Hemoglobin and renal and liver function should be monitored at regular intervals with the frequency depending on the patient’s history and CrCl values.19 In Frank’s case, blood sampling should be performed every 6 months because his CrCl is between 30 and 60 mL/min. The next year, Frank’s creatinine clearance was found to have decreased to 28 mL/min. He has had no adverse events related to his treatment with dabigatran. Summary

Patients with AF are at increased risk of stroke, but many people may not experience any symptoms. These patients may not be diagnosed with AF until a healthcare provider checks their heart rate or listens to their heart during a routine checkup. Patients diagnosed with NVAF should be assessed for stroke risk and bleeding risk to determine if antithrombotic therapy is appropriate, and clinicians should discuss both the risk of stroke and the risk of bleeding with patients. If oral anticoagulant therapy is appropriate, several options are now available for consideration including warfarin, the direct thrombin inhibitor dabigatran, and the direct factor Xa inhibitors apixaban,

32 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Factors that should be considered and discussed with patients include the risks and benefits of therapy and the feasibility of adherence. edoxaban, and rivaroxaban.When selecting an antithrombotic therapy, factors that should be considered and discussed with the patient include the risks and benefits of the therapy and the feasibility of adherence (including cost, type of follow-up required, and quality of life). Patients should return for ongoing review of their treatment on a regular basis. ■

12. Bruins Slot KM, Berge E. Factor Xa inhibitors versus vitamin K antagonists for preventing cerebral or systemic embolism in patients with atrial fibrillation. Cochrane Database Syst Rev. 2018;3:CD008980. 13. Pradaxa [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; March 2018. https://docs.boehringer-ingelheim.com/ Prescribing%20Information/PIs/Pradaxa/Pradaxa.pdf. 14. De Caterina R, Husted S, Wallentin L, et al. New oral anticoagulants in

Charles P. Vega, MD, is clinical professor of family medicine; director of the Program in Medical Education for the Latino Community (PRIME-LC); and associate dean for diversity and inclusion at the University of California-Irvine School of Medicine.

atrial fibrillation and acute coronary syndromes: ESC Working Group on Thrombosis-Task Force on Anticoagulants in Heart Disease position paper. J Am Coll Cardiol. 2012;59(16):1413-1425. 15. Eliquis [package insert]. Princeton, NJ: Bristol-Myers Squibb Company and New York, NY: Pfizer Inc; June 2018. https://packageinserts.bms.com/pi/

References

pi_eliquis.pdf.

1. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline

16. Savaysa [package insert]. Tokyo, Japan: Daiichi Sankyo Co, LTD; November

for the management of patients with atrial fibrillation: a report of the

2017. https://dsi.com/prescribing-information-portlet/getPIContent?product

American College of Cardiology/American Heart Association Task Force

Name=Savaysa&inline=true.

on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol.

17. Xarelto [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc;

2014;64(21):e1-76.

October 2018. http://www.janssenlabels.com/package-insert/product-

2. Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis,

monograph/prescribing-information/XARELTO-pi.pdf.

and predisposing conditions for atrial fibrillation: population-based estimates.

18. van Walraven C, Hart RG, Singer DE, et al. Oral anticoagulants vs aspirin

Am J Cardiol. 1998;82(8A):2N-9N.

in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA.

3. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke

2002;288(19):2441-2448.

in the elderly.The Framingham Study. Arch Intern Med. 1987;147(9):1561-1564.

19. Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm

4. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for

Association Practical Guide on the use of new oral anticoagulants in patients

atrial fibrillation with electrocardiography: US Preventive Services Task Force

with non-valvular atrial fibrillation. Europace. 2013;15(5):625-651.

Recommendation Statement. JAMA. 2018;320(5):478-484. 5. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893-2962. 6. Frost JL, Campos-Outcalt D, Hoelting D, et al. Atrial fibrillation guideline 7. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857-867. 8. Alkhouli M, Noseworthy PA, Rihal CS, Holmes DR, Jr. Stroke prevention in nonvalvular atrial fibrillation: a stakeholder perspective. J Am Coll Cardiol. 2018;71(24):2790-2801. 9. Yao X, Abraham NS, Alexander GC, et al. Effect of adherence to oral anticoagulants on risk of stroke and major bleeding among patients with atrial fibrillation. J Am Heart Assoc. 2016;5(2):e003074. 10. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962. 11. Lopez-Lopez JA, Sterne JAC, Thom HHZ, et al. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network metaanalysis, and cost effectiveness analysis. BMJ. 2017;359:j5058.

“I already have the perfect hashtag!”

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 33

summary. Ann Fam Med. 2017;15(5):490-491.

CME FEATURED COURSE EDUCATIONAL OBJECTIVES At the conclusion of this activity, participants should be better able to: • Describe the scientific evidence for interventions that achieve both lasting weight control and overall health improvement • Integrate evidencebased observations into treatment planning and dietary recommendations for healthy and sustainable weight loss • Effectively counsel patients on how to implement sustainable lifestyle changes, including following a low-carbohydrate diet COMPLETE THE POSTTEST: Page 40

Release Date: April 1, 2019 Expiration Date: April 1, 2020 Estimated Time to Complete: 30 minutes Maximum Credits: 0.50 AMA PRA Category1 Credit(s)TM 0.50 CPEU for Registered Dietitians/Registered Dietetic Technicians Accredited Provider: This activity is provided by Haymarket Medical Education. Commercial Supporter Statement: Supported by an educational grant from Atkins Nutritionals, Inc. Program Description: The epidemic of obesity and its associated comorbidities — including insulin resistance and type 2 diabetes mellitus, as well as cardiovascular disease, arthritis, and obesity-related cancer — constitutes one of the most threatening public health problems in the United States. Past paradigms that encouraged people to exercise more and consume fewer calories and less fat have clearly failed to address these alarming trends. In this panel discussion, a noted obesity medicine specialist and a dietitian provide practical tips for how clinicians can educate and motivate their patients to undertake meaningful lifestyle changes, with a focus on how to implement a low-carbohydrate diet to attain sustainable weight loss that leads to beneficial health outcomes. Intended Audience: The target audience is primary care providers, including physicians (MD/DOs), nurse practitioners (NPs), physician assistants (PAs), nurses, nutritionists, and dietitians. Conflict of Interest Disclosure Policies: In accordance with the ACCME Standards for Commercial Support, Haymarket Medical Education (HME) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. HME resolves all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational activities. Faculty Holly R. Wyatt, MD Associate Professor of Medicine University of Colorado Anschutz Medical Campus Aurora, CO Dr Wyatt receives royalties from UpToDate and research grants from DuPont, Gelesis, GI Dynamic, and Novo Nordisk. She has an ownership interest in Shakabuku LLC and is in receipt of intellectual property rights/is a patent holder for The Energy Gap. Marsha Miller, MS, RD Weight Loss Transformation Coach University of Colorado Anschutz Health and Wellness Center Aurora, CO Ms Miller has no relevant financial relationships to disclose. Accredited Provider Disclosure: Haymarket Medical Education staff involved in the planning and content review of this activity have no relevant financial relationships to disclose. Accreditation Statement: Haymarket Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation Statement: Haymarket Medical Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Accreditation Statement: This activity has been approved by the ACCME, whose approval is recognized by the Commission on Dietetic Registration and, as such, RDs/DTRs will be able to receive 0.50 CPEU. Physician Assistant Continuing Education: AAPA accepts certificates of participation for educa tional activities certified for AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society. PAs may receive a maximum of 0.50 Category 1 Credit for completing this activity. Nurse Practitioner Continuing Education: The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME. Individuals are responsible for checking with the AANPCP for further guidance. Disclosure of Unlabeled Use: This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options for a specific patient’s medical condition. Disclaimer: The opinions expressed in the educa tional activity are those of the faculty and do not necessarily represent the views of Haymarket Medical Education or Atkins Nutritionals, Inc. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Instructions: To obtain credit, a score of 70% or better on the post-test is required. This activity is offered at no cost to participants. Please proceed with the activity until you have successfully completed this program, answered all test questions, completed the post-test and evaluation, and have received a digital copy of your credit certificate. Your online certificate will be saved on myCME.com within your Profile/CME History, which you can access at any time. If you have any questions relating to the accreditation of this activity, please contact HME at cmequestions@ haymarketmedical.com. If you have any questions relating to your certificate or other issues with this activity, please contact myCME at Support@haymarketmedical.com.

Provided by

CME FEATURED COURSE: HOLLY R. WYATT, MD; MARSHA MILLER, MS, RD

Follow the Science: Dietary Interventions for the Management of Obesity Experts provide practical tips for how clinicians can educate and motivate their patients to undertake meaningful lifestyle changes to achieve weight loss goals.

Studies show that low-carbohydrate diets are safe and produce weight loss.

he epidemic of obesity and its associated comorbidities — including insulin resistance and type 2 diabetes mellitus, as well as cardiovascular disease, arthritis, and obesity-related cancer — constitutes one of the most threatening public health problems in the United States. In this discussion, Holly Wyatt, MD, a noted obesity medicine specialist, and Marsha Miller, MS, RD, a dietitian, both at the University of Colorado Anschutz Medical Campus, provide practical tips for how clinicians can educate and motivate their patients to undertake meaningful lifestyle style changes to achieve weight loss goals.

MARSHA MILLER, MS, RD: Dr Wyatt, there are so many people who need to lose weight. Why do you think so many people need our help? HOLLY R. WYATT, MD: When we look at the statistics, more than 50% of Americans are either overweight or obese and need to lose weight.1 In fact, I tell my patients, “If you don’t need to lose weight, you’re in the minority.” We have this environment that is pushing us to eat more food than we need, to eat larger portions, to eat unhealthy food, and to eat food with a lot of calories. We also have this environment that is pushing us to be sedentary, and we have devices that do everything for us. We can just www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 35

CME FEATURED COURSE

sit in a chair and our dishwasher is going, our room is being vacuumed, we can use the remote control for the TV, and we can order pizza to be delivered to our door. When you couple that with our physiology that encourages us to eat when there’s food around and encourages us to store calories, then this epidemic of obesity results. Many years ago, noted obesity researcher George Bray told me that genetics loads the gun, meaning we have a genetic predisposition for our bodies to gain weight. So, genetics loads the gun, but the environment pulls the trigger. What I think has happened is that we’ve now moved into this environment where so many people are struggling with their weight. MS MILLER: We don’t need a large weight loss.We know that even a modest weight loss of 5% to 10% can make a significant difference in our patients’ health.2,3 Why do we have such a difficult time with our patients losing weight and keeping it off? DR WYATT: You’re correct. We know that 5% can have a health benefit.That’s a small amount.And yet we still struggle with even getting that 5% off. My patients may lose it, but they regain it. They do that yo-yo, and that is so frustrating. Behavioral change is hard. We’re asking people to change behaviors and the environment is pushing back. It is difficult

Genes

Environment

• Protective and at-risk alleles for weight gain • Race (ancestral admixture) • Gene-gene interactions Body Weight Determinants • Dietary preferences • Physical activity • Psychological factors • Cultural factors • Diurnal life patterns

Behavior

• Food availability • Food quality • Built environment • Socioeconomic status • Education

• In utero environment • Birth weight • Gender • Age • Concurrent diseases

Biological Factors

FIGURE. Various factors interact to influence body weight.

to sustain those behaviors over time. In addition, clinicians aren’t necessarily trained to help their patients in this situation, so we need to get better training for clinicians to better instruct their patients. I know you’ve been involved in the Look AHEAD study, which was an intensive study, but we really struggled. Less than 50% of patients actually got to the kind of goal that we wanted, which was 5% or more of weight loss.4 MS MILLER: So even with intensive counseling, why doesn’t it always work? DR WYATT: I think it’s because there are a lot of different reasons why people struggle with their weight. The environment is one, but when we get the physiology involved, some people may struggle more than others.Therefore, one size doesn’t fit all. MS MILLER: How do you choose the right diet for a particular patient? DR WYATT: We know that adherence is key. So, it involves figuring out which diet an individual will be able to adhere to so that caloric intake will be low for an extended period of time and they can lose as much weight as possible.Although I don’t have a litmus test, you can ask questions to get information that will identify what the patient is willing to do. For example, if they are vegetarian, they are probably not going to be very adherent to a diet that has a lot of meat. Also, if it’s a diet that requires food they don’t like, that’s probably not going to be the diet for them. If they don’t cook at all, or are extremely busy, you might recommend a diet that has prepared foods or meal replacements to encourage adherence for as long as possible. So, it really is about adherence in terms of which diet is best for an individual. MS MILLER: So, in particular, what have we learned from studying low-carbohydrate diets? DR WYATT: There is evidence that low-carbohydrate diets do work. It wasn’t that long ago when if you talked about being on a low-carbohydrate diet, the science world would roll their eyes. However, in the last 10 to 15 years, there have been some good studies that have shown that the lowcarbohydrate diets do work; they produce weight loss and they are safe. We studied cholesterol and kidney function, and at least in the 2-year studies we have not found anything that concerns us in terms of safety. When we look at some of the studies short term, low-carbohydrate diets do a little bit better than some of the others. It may be because people

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can adhere to them a little easier. So, for certain individuals, I do think it’s a great option. Just like any diet, though, over time people start to not adhere to a low-carbohydrate diet.We haven’t found any diet in which adherence doesn’t start to fade over time. But I do think it’s important for the medical community to know that we have data behind lowcarbohydrate diets. For some individuals with diabetes, a low-carbohydrate diet actually may be a very good choice. Obviously, you need to work with the individual and look at his or her situation and always monitor blood glucose, but it can be a very good option for the right person. MS MILLER: Absolutely. It has worked well for many of my patients with diabetes, but the important piece is that they are following up with their physician to make sure that blood glucose is being monitored. DR WYATT: You always need to follow up with a physician, especially if they are on a lot of medications that may need to be adjusted as they lose weight. MS MILLER: What else can we do to help our patients when we put them on a diet? DR WYATT: You need to think about the other things that are going to help make that diet as effective as possible. At the University of Colorado we’ve studied the National Weight Control Registry, which involves people who have been successful at losing weight and, more importantly, keeping it off.5 Something that we’ve learned contributes to success, and that I always make sure goes hand in hand when I’m giving dietary recommendations, is physical activity. We think that approximately 1 hour most days of the week is what it takes for you to be successful at keeping the weight off. People in the National Weight Control Registry selfmonitor with a food log. They tend to watch what they’re eating, write it down, and monitor themselves with the log and with the scale.The scale is similar to monitoring blood glucose in a patient with diabetes. It helps you to know how things are going so that you can make adjustments. However, there is emotion associated with the scale, but one of the things we work on is to try to take that emotion away from the scale.They weigh themselves once a day at the same time so that it becomes a habit. MS MILLER: Some of the questions or concerns that my patients have when they come in to the clinic is the fat content in low-carbohydrate diets. Can you address that?

DR WYATT: When I put my patients on a low-carbohydrate diet, I concentrate on good fats. I tell them to decrease saturated fats, and I try to concentrate on some of the better fats. However, when we look at the safety data, when you are restricting calories — which is what a low-carbohydrate diet is doing — even though you are eating more fat, it doesn’t seem to cause any harm. It doesn’t necessarily increase your cholesterol, which is something that we were worried about. Granted, we haven’t studied these diets for 10 years, but we’ve studied them for more than 2 years, and we didn’t see a negative effect in terms of cholesterol. But I think the key is that energy restriction, that weight loss is producing a positive effect.There are some health benefits from eating healthier fats and avoiding the unhealthier fats. MS MILLER: And then the conversations we get into is that although they are healthy fats, fat is very calorically dense. So, even if they’re healthy fats, like avocados and olive oil, it is important to measure and to be accurate with your portions.

What Works for Weight-Loss Maintenance in the Real World? The National Weight Control Registry (NWCR) Established in 1994 by James Hill and Rena Wing Identified lifestyle-modification practices for achieving and maintaining weight loss • Weight loss of at least 13.6 kg (30 lb), sustained for a minimum of 1 year Common characteristics of registrants: • Eating breakfast every day: 78% • Engaging in high level of volitional physical activity: 90%, 1 h/d —— Limited TV viewing: 62% watch fewer than 10 h/w • Regular self-monitoring of weight: 75% weigh themselves at least once a week • Self-monitoring of dietary intake and activity —— Reduced fat intake: 24% of calories from fat —— Consumption of low- or no-calorie sweeteners The National Weight Control Registry. NWCR facts. http://www.nwcr.ws/Research/ default.htm. Accessed November 12, 2018.

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CME FEATURED COURSE

“We don’t need a large weight loss. We know that even a modest weight loss of 5% to 10% can make a significant difference in our patients’ health.” However, a lot of my patients have questions about fats. In your opinion, are all fats created equal? DR WYATT: There’s a lot of different types of fats out there, and I don’t think they’re all equal. Some have more of a heart health benefit, others a little bit less. But I think the question you’re really asking when it comes to weight loss is, are there differences in fat? So, for instance, I may get patients who say, “Oh, but it’s coconut oil.” There may be some health benefits to coconut oil, just as there may be some health benefits to almonds and avocados. But if you’re trying to lose weight, a fat is a fat, and I’m going to measure it the same way. I want my patients to eat healthier ones, but you can definitely overeat healthier fats and not lose weight. Just because something is healthy doesn’t mean you can eat as much as you want and expect to achieve your weight loss goal. The most significant strategy is to reduce calories. Sometimes eating a certain type of diet will help you reduce calories. So, for some people, eating a low-carbohydrate diet helps them reduce their calories. Therefore, they’re more successful. What is your strategy when you first see a patient? MS MILLER: The most important thing to me is talking with that patient and building rapport with them: asking them about why they’re here that day and why they want to lose weight. I don’t lead with the diet. I get to know the patient first, because it is about trust and building rapport so that there can be open communication. DR WYATT: Yes, because so many times what they are expecting when meeting with a registered dietitian is for you to lead with, “Here’s a diet. Don’t eat this.” MS MILLER: I would like to share that I call myself Coach Marsha in the classroom and in the clinic, and it puts patients at ease right away. I’ve seen people relax, take a deep breath, and say, “ You’re my coach. I can do this.” DR WYATT: If they believe they’re going to be successful, then I think that is just as important as giving them a diet that will work for them. I love the term “coach,” because a coach believes in his or her team, and a coach believes in his or her patients. What is your next step after you build that rapport?

MS MILLER: There are a lot of things that we talk about before we get to the diet. It is important to talk to the patient to see what their life is like in order to identify the diet that is the right fit for them, such as if they are a busy mother or if they hate protein. DR WYATT: And there’s another piece to it. It is important to start off with, “Why are you here? What is your motivation?” We just talked about the fact that adherence is so important, but part of adherence is motivation. MS MILLER: That’s correct. It might be,“Well, none of my clothes fit me anymore,” “I don’t feel good,” or “I want to have better health.” And then, as you get a little bit deeper, you learn how they really want to live or be or feel in terms of what they want their life to look like. It does get emotional when you get to the motivation behind why they want to lose weight. DR WYATT: Yes, and I imagine that is one of the reasons why you have such great results in the clinic. Although registered dietitians know all about diets, they may not focus on the motivation piece. What do you do if you determine that a low-carbohydrate diet would be a good choice? How do you get them started? MS MILLER: We talk about what they eat in a typical day, and then we talk about how they can include more lean protein food choices in the day. And my favorite topic is about eating more vegetables. I lead with, “I’m not talking about five baby carrots and two grape tomatoes. I’m talking about one and one-half to two cups of vegetables.” If I’m working with someone who is used to eating one serving of vegetables a day, I try to increase their consumption to three servings of half-cup portions. DR WYATT: Can you eat vegetables if you follow a lowcarbohydrate diet? MS MILLER: Yes, a lot of vegetables. And we talk about ways to make vegetables more exciting, like grilling them, roasting them, putting them in soup, and putting them in smoothies. DR WYATT: What do you advise people to eat less of when they go on a low-carbohydrate diet?

38 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

“Just because something is healthy doesn’t mean you can eat as much as you want and expect to achieve your weight loss goal.” MS MILLER: Well, first and foremost, we talk about added or refined sugars. There’s so much of that in people’s diet, such as in sports drinks and juices. I also talk about processed foods. DR WYATT: Sometimes when my patients start on a lowcarbohydrate diet, they complain that they feel tired and may have a headache. What kind of tips do you give them for that? MS MILLER: Well, as we’re decreasing processed foods and canned foods and things with a lot of sodium, sometimes those things can be caused by a low sodium level. It is as if they are diuresing; they are dehydrated because they are using all that glycogen in their muscles and water is coming out with that. So they need to drink plenty of water and they might need to increase their salt consumption. DR WYATT: I think that few people realize that when you lose weight in general and when you decrease your calories, especially in a low-carbohydrate diet, you use all the glycogen in your muscles, which is where your body stores the carbohydrate. When you use that glycogen as energy, it’s stored with water. So, as you burn the glycogen, you’re releasing water. In fact, it’s not uncommon to lose 3, 4, or even 5 lb of weight in a few days, especially on a lowcarbohydrate diet. Even if you increase your consumption of water, if you don’t add salt back, you may not be able to retain the water. I’ve had patients tell me, “I’m drinking a ton of water,” and my response is, “You’ve got to have salt to hold onto the water.” Another point to discuss is the actual weight loss. When people are on a low-carbohydrate diet and lose 3, 4, or 5 lb in a day or two, they’re usually happy.That gives them some motivation, which I think is good as it makes them want to continue. But then they may have a high-carbohydrate meal and they gain 3, 4, or 5 lb in a day. And now, they’re devastated. How do you address that with your patients?

DR WYATT: Might you have any dietary tips to share with clinicians? MS MILLER: I have a great one, and that’s zoodles, or zucchini noodles. They are often available in packages in the produce section at most grocery stores.You don’t even have to buy a spiralizer to do this, but you can. There are also riced vegetables, such as cauliflower, beets, and broccoli.They are available in the frozen foods section and require only a few minutes in the microwave.You then have instant vegetables to add to something that might look like a chicken fried rice. Another one of my favorites is the traditional spaghetti meal but substituting zoodles for pasta and using a nice meat sauce with lean turkey or lean beef. It is very satisfying, and you don’t have the heavy feeling you might have after eating a big plateful of pasta. This type of meal encourages people to eat more vegetables and to decrease the amount of carbohydrates in their diet. DR WYATT: What can other clinicians (physicians, nurse practitioners, and physician assistants) do to support dietitians to motivate their patients? MS MILLER: Communication is extremely important. Whatever message they’re giving the patient should be shared with the dietitian so that the patient is receiving a consistent message. ■ References 1. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Overweight & obesity statistics. https://www.niddk.nih.gov/health-information/ health-statistics/overweight-obesity. PublishedAugust 2017. March 2, 2019. 2. Torgan C. Benefits of moderate weight loss in people with obesity. NIH website. https://www.nih.gov/news-events/nih-research-matters/benefitsmoderate-weight-loss-people-obesity. Published March 1, 2016. Accessed March 2, 2019. 3. Pietrzykowska NB. Benefits of 5-10 percent weight-loss. Your Weight

MS MILLER: As they are weighing themselves every day, they’re aware of where their weight is. However, I think a lot of people miss some key data points with their weight, because weight loss is not linear and fluctuates day to day. I tell them that if you’re going to lose 3 to 5 lb in a day, that is not fat. That’s water weight. Then if you increase your carbohydrates in an indulgent meal, you would expect to see a little bump in the number on the scale, and then you get right back on your plan.

Matters Magazine. Obesity Action Coalition (OAC) website. https://www. obesityaction.org/community/article-library/benefits-of-5-10-percentweight-loss/. Published October 2013. 4. The Look AHEAD Research Group. Long term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes: four-year results of the Look AHEAD Trial. Arch Intern Med. 2010;170(17):1566‐1575. 5. The National Weight Control Registry. NWCR facts. http://www.nwcr.ws/ Research/default.htm. Accessed March 2, 2019.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 39

CME FEATURED COURSE

CME

POSTTEST Expiration date: April 1, 2020

A statement of credit will be issued only upon receipt of a completed preassessment test, activity evaluation form, and posttest with a score of 70% or higher. All components must be completed and submitted online at ClinicalAdvisor.com/Apr19feature. CREDITS: 0.50 | Follow the Science: Dietary Interventions for the Management of Obesity

1. TJ is a 48-year-old man with obesity who has been frustrated by previous efforts to lose weight. He understands that his excess weight is linked to his hypertension, dyslipidemia, and elevated blood glucose levels, all of which are currently being controlled by medication. However, he does not cook, dislikes attending support group meetings, and finds low-fat, low-calorie foods tasteless, leading him to give in to cravings for foods like cheeseburgers and ice cream. Which of the following statements is supported by research evidence? a. TJ should adhere more strictly to a very low-fat diet and increase his activity to a minimum of 30 minutes of moderate-intensity exercise daily. b. Increasing his activity to a minimum of 30 minutes of moderate-intensity exercise daily will help TJ shed weight long-term, without the need for modifications to his current diet. c. While TJ could lose more weight on a low-carbohydrate vs a low-fat dietary regimen, low-carbohydrate diets tend to worsen cardiometabolic risk factors, especially lipids. d. The optimal weight loss diet for TJ is whatever form of calorie restriction he finds most palatable and can adhere to long-term. 2. Which of the following statements regarding determinants of body weight is true? a. Biological factors interact with genetic, behavioral, and environmental factors to determine body weight. b. While members of the same family are often affected by obesity, this has more to do with dietary patterns and sedentary behavior than genetic factors.

c. Increased physical activity is the single most important predictor of weight loss success. d. Recent data show that behavioral factors, including food preferences, physical activity levels, and cultural norms, are the most important determinants of weight gain. 3. When reviewing a patient’s diet, which of the following suggestions would you make to promote weight loss and reduce cardiometabolic risk? a. Dietary fats should be avoided, regardless of their source. b. Low-carbohydrate diets tend to restrict calories de facto. c. As long as calories are restricted, their source is not important. d. Low-fat diets have metabolic advantages over lowcarbohydrate diets. 4. The National Weight Control Registry, established 25 years ago, provides data on the lifestyle-modification practices that have been associated with successful, sustained weight loss (≥30 lb, maintained ≥1 year). Which of the following statements about common characteristics of registrants is not true? a. 78% eat breakfast every day b. 90% engage in a high level of volitional physical activity (≥1 h/d) c. 62% watch fewer than 10 hours of television per week d. 75% weigh themselves at least once a week e. 76% eat a relatively high-fat diet (~35% of calories from fat)

TO TAKE THE POSTTEST please go to: ClinicalAdvisor.com/Apr19feature

40 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Dermatologic Look-Alikes Multiple Erythematous, Scaly Plaques ARIELLA NOORILY, BA

CASE #1

CASE #2

A 38-year-old man presents to the clinic complaining of numerous pruritic lesions on his right lower extremity. He claims that all of the lesions appeared within the past 3 months. He denies similar occurrence and reports no history of skin conditions, although he states that his mother often breaks out in a “rash” on her limbs during the summer months. On examination, several scaly, round, erythematous plaques with keratinic centers are noted on his anterior right leg. Biopsy is performed, revealing cornoid lamella and a thin epithelium.

A 65-year-old man presents for evaluation of multiple plaques on his forehead. He claims that he used to sunbathe without sunscreen when he was a teenager and recalls having at least 1 blistering sunburn.The plaques neither itch nor hurt, but the patient is concerned with the appearance of the lesions. He has no significant medical history but notes that his sister has had squamous cell carcinoma. On examination, the patient’s forehead is erythematous with several rough plaques. Biopsy is performed, revealing a dysplastic epidermal layer.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 41

Dermatologic Look-Alikes CASE #1

Disseminated Superficial Actinic Porokeratosis

Porokeratosis, which was first described by Mibelli and Respighi in 1893, is a genetic dermatologic condition that has at least 4 recognized variants: porokeratosis palmaris et plantaris disseminate, linear porokeratosis, porokeratosis of Mibelli, and disseminated superficial actinic porokeratosis (DSAP).1 DSAP is the most common form of porokeratosis and was differentiated as a separate variant by Chernosky in 1966.2 It is a disorder of keratinization that is characterized by multiple keratotic papules that appear in sun-exposed areas of the skin.3 DSAP is inherited in an autosomal-dominant fashion and is incompletely penetrant; development of symptoms may depend on other environmental factors. Mutations in genes related to keratinocyte differentiation and proliferation have been identified as causes for the disease.4 Histologically,

Although DSAP can develop during adolescence, it usually appears during the third or fourth decades of life. porokeratosis shows cornoid lamella (characteristic columns of parakeratotic cells), dyskeratotic cells, the absence of a granular cell layer, and an irregularly thin epithelium in the affected area.3 The cornoid lamella of DSAP lacks the central groove and is smaller than the cornoid lamella observed in classic porokeratosis.2 Other histologic findings include perivascular mononuclear lymphocytic infiltrate in the dermal layer. Because histology is similar among all types of porokeratosis, DSAP can also be differentiated based on other clinical factors, such as the location and appearance of lesions and age at onset. DSAP is slightly more common in women than in men (1.76:1). It is predominantly observed in lighter skin pigmentation and is most common in whites, particularly those of Italian heritage.3 Clinically, DSAP first presents as scattered cone-shaped plaques measuring 1 to 3 mm in diameter in follicular locations.2 As these lesions grow, they develop atrophic, erythematous, or keratotic centers and well-defined, raised, hyperkeratotic rims that may be round or irregular. Over

time, they can grow to >3 cm in diameter.4 They usually appear on areas of the body that are exposed to sunlight, including the limbs, shoulders, and back.The face is affected in only 15% of patients, despite its exposure to the sun.3 Because ultraviolet (UV) sunlight is an exacerbating factor, patients often experience worsening of symptoms during the summer months.1 Although DSAP can develop during adolescence, it usually appears during the third or fourth decades of life and progresses slowly afterward.The phenotype of the disease is variable; some patients with DSAP are asymptomatic with lesions that are mistaken for other forms of sun damage,2 while approximately one-third of patients experience pruritus or pain with their lesions.3 In addition to UV exposure and genetic predisposition, risk factors for DSAP include immunosuppression, with new cases arising in patients following organ transplant and those with AIDS.1,3 DSAP is usually benign but has been associated with the development of cutaneous malignancies in 3.4% of patients; the most common malignant lesions originating from porokeratosis are epidermoid carcinoma, carcinoma in situ, and basal cell carcinoma.5 The differential diagnosis of DSAP includes actinic keratosis, Darier disease, psoriasis, hereditary punctate keratoderma, porokeratotic eccrine ostial and dermal duct nevus, and lichen nitidus. Certain clinical factors such as the location of the plaques, age at onset, exacerbating factors, and appearance of the rash are important for the differentiation of DSAP from these other conditions. For example, porokeratotic eccrine ostial and dermal duct nevus is characterized by keratotic plaques on the extremities but is present at birth or within the first few years of life.6 In addition, the characteristic cornoid lamella on histology differentiates porokeratosis from other skin disorders. Imaging techniques such as optical coherence tomography and fluorescence confocal microscopy are also used to diagnose DSAP and differentiate it from actinic keratosis.3 A variety of methods have been used to treat DSAP, although controlled trials are lacking and data are mostly limited to case reports.The size, location, and malignancy of the lesions dictate the treatment approach. For many patients, use of moisturizers, avoidance of sunlight, and regular skin checks are sufficient methods for disease control. However, treatment modalities for more complicated cases include topical treatments, systemic treatments, laser therapy, and surgical approaches.3 Topical treatments such as 5-fluorouracil, retinoids, glucocorticoids, and salicylic acid have been used with varying degrees of success. For example, 5-fluorouracil is not always

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Continues on page 44

Dermatologic Look-Alikes an appropriate method of treatment for DSAP because it results in an inflammatory reaction. Systemic treatments such as oral retinoids have been used successfully for DSAP, but relapse may occur and prolonged use is associated with adverse effects. The use of CO2 laser therapy or ruby laser therapy can improve the appearance of DSAP-associated lesions, but recurrence is common.7 In patients with only a few large plaques or malignant lesions, surgical removal may be the treatment method of choice, although this results in scarring.3 After discussion of the various treatment options, the patient opted for short-term therapy with oral retinoids. At followup evaluation, his symptoms were noted to have improved.

CASE #2

Actinic Keratosis

First described at the end of the 19th century,8 actinic keratoses (AKs) are common epidermal keratinocytic lesions that arise in sun-exposed areas of the skin, such as the face and back of hands. AKs have the propensity to progress into cutaneous squamous cell carcinoma, although most lesions do not become malignant. Increased exposure to UV radiation from the sun or from artificial light sources (eg, tanning beds) is associated with higher numbers of AKs and a greater propensity for development of carcinoma.9 Because increased exposure to UV radiation is an important risk factor for AK, middle-aged and elderly patients are more likely to present with lesions, and the number of lesions will increase with age.10 Studies have shown that AK is more prevalent in men than in women, with baldness being the greatest risk factor in men.11 Individuals with light skin, blonde hair, and blue eyes are at higher risk for the development of AK. However, with sufficient UV exposure, AK will appear in a person with dark skin as well.9 Many AKs spontaneously regress without treatment, and studies typically show a regression rate of 20% to 30% within 1 year.8 However, when lesions do not regress, AK is associated with the development of skin cancer, with 0.1% to 10% of lesions progressing to invasive cutaneous squamous cell carcinoma.8,9,12 This is rare in individuals with 1 or few lesions of AK and more common in patients who have many lesions and signs of chronic actinic damage.13 In fact, studies estimate that if an individual has 7 to 8 lesions, there is a

10% chance of malignant transformation of at least 1 lesion within 1 year.10 UV-induced nonmelanoma skin cancer progresses in 3 stages: initiation, promotion, and malignant conversion. During initiation, the genome of the keratinocyte is mutated in a key proto-oncogene or tumor suppressor gene (eg, p53). This is followed by promotion, whereby the transformed cell is continuously exposed to proinflammatory agents, or promoters, and develops into an AK. Sunlight can act as both a promoter and an initiator. Finally, exposure to additional UV radiation will cause the benign AK to convert into a malignant neoplasm (eg, squamous cell carcinoma).9 In healthy patients, the immune system should recognize cellular mutations and prevent the progression to malignancy. Immunosuppression is therefore an important risk factor for the development of AK and nonmelanoma skin cancer, and patients who are chronically immunosuppressed (eg, transplant recipients) are at higher risk for AK and malignant transformation.10 AKs that progress to squamous cell carcinoma metastasize in 2% to 6% of cases.9 Clinically, AK presents as circumscribed, scaly, epidermal plaques that measure 2 mm to 5 mm in diameter.12 Because AKs feel rough to the touch, clinicians often palpate lesions during diagnosis. The plaques may be skin-colored, dark, or erythematous. The thickness of an AK depends on location; lesions on the neck and head are flat, while lesions on the

Histologically, AK shows characteristic epithelial dysplasia, with unusual organization and maturation of epithelial cells. hands and forearms may be thick.9 There may not be a visible difference between a benign AK and a squamous cell carcinoma, although bleeding, irritation, and hypertrophy of the plaque may suggest malignant transformation and warrant biopsy.12 Histologically, AK shows characteristic epithelial dysplasia, with unusual organization and maturation of epithelial cells. This can span the full thickness of the skin or exist only in the basal layer. Although all AKs display epithelial dysplasia, histologic variants exist and include Bowenoid, pigmented, hypertrophic, lichenoid, and acantholytic.10 In a process called field cancerization, AKs are often surrounded by clinically normal-appearing tissue that is histologically and genetically abnormal.13 The diagnosis of AK can be done in the clinic based on the appearance and location of the plaque, as well as the patient’s

44 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

Disseminated Superficial Actinic Porokeratosis (DSAP)3

Actinic Keratosis (AK)10

Dermatologic Presentation

• First present as scattered cone-shaped plaques in follicular locations 1-3 mm in diameter • Develop into lesions with atrophic, erythematous, or keratotic centers and well-defined borders

• Circumscribed, scaly, rough epidermal plaques 2-5 mm in diameter • Skin-colored, dark, or erythematous • Flat on the neck and face, thick on the hands and arms

Associations

• Risk factors: genetic propensity, immunosuppression • Appears in the third to fourth decades of life • Associated with the development of skin cancer in few cases

• Risk factors: sun exposure, immunosuppression • Associated with the development of cutaneous squamous cell carcinoma and other nonmelanoma skin cancers • Common in light-skinned, elderly population

Etiology

• Mutations in genes related to keratinocyte differentiation and proliferation • Autosomal-dominant inheritance; incomplete penetrance

• Exposure to UV radiation (sunlight, tanning beds, etc) that causes mutations in proto-oncogenes or tumor suppressor genes, especially p53

Characteristic Location

• Sun-exposed areas of the skin • Arms, shoulders, back • Usually not the face

• Sun-exposed areas of the skin • Face, backs of hands, neck

Histology

• Cornoid lamella, dyskeratotic cells, the absence of a granular cell layer, and an irregularly thin epithelium in the affected area • Lymphocytic infiltrate in dermal layer

• Epithelial dysplasia, with unusual organization and maturation of epithelial cells • Histologic variants of AK: Bowenoid, pigmented, hypertrophic, lichenoid, and acantholytic

Diagnosis

• Clinical examination and biopsy with a positive histologic report

Treatment

• Moisturizer, avoidance of sunlight, and regular skin checks • Topical treatments: 5-fluorouracil, retinoids, glucocorticoids, and salicylic acid • Oral retinoids • Surgical excision

• Sunblock and avoidance of sunlight, regular skin checks • Topical treatments: 5-fluorouracil, salicylic acid, imiquimod cream, diclofenac gel, and tretinoin cream • Oral retinoids • Cryosurgery with liquid nitrogen

history of UV exposure. However, because the presentation of AK is common but nonspecific, clinical diagnosis is not always correct and confirmation with biopsy may be performed to rule out skin cancer. The differential diagnosis of AK includes DSAP, seborrheic keratosis, discoid lupus erythematosus, psoriasis, basal cell carcinoma, squamous cell carcinoma, and Bowen disease. Biopsy and histologic findings are the most reliable ways to differentiate AK from another skin disorder, especially in patients with a history of skin cancer.12 A variety of treatment options are available for AK, including topical creams, systemic retinoids, liquid nitrogen cryosurgery, and dermabrasion. Sunblock cream and avoidance of sunlight

are also important for management, especially when patients are concerned about new lesions or the malignant transformation of current ones. Topical therapies include salicylic acid, 5-fluorouracil, imiquimod cream, diclofenac gel, and tretinoin cream. 5-fluorouracil is used most commonly and reduces AKs by 70%. Systemic retinoids may cause morbidity and should only be used in high-risk patients. Dermabrasion has been used with variable efficacy.10 Cryosurgery is very effective when it is used in combination with a topical agent.13 Because there is a chance of malignant transformation of AK in many patients, it is wise to treat the lesions as they appear.9 After recognizing the risk of malignant transformation of these lesions and discussing the different treatment options,

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Dermatologic Look-Alikes the patient decided to use liquid nitrogen cryosurgery at his office visit and to follow up every 6 months for full-body skin checks. He also will begin using sunscreen on his face every day. ■

6. Bandyopadhyay D, Saha A, Das D, Das A. Porokeratotic eccrine ostial and dermal duct nevus. Indian Dermatol Online J. 2015;6(2):117-119. 7. Lolis MS, Marmur ES.Treatment of disseminated superficial actinic porokeratosis (DSAP) with the Q‐switched ruby laser. J Cosmet Laser Ther. 2008;10(2):124-127. 8. Werner RN, Sammain A, Erdmann R, Hartmann V, Stockfleth E, Nast A. The

Ariella Noorily, BA, is a medical student at NYU School of Medicine in New York City.

natural history of actinic keratosis: a systematic review. Br J Dermatol. 2013; 169(3):502-518. 9. Callen JP, Bickers DR, Moy RL. Actinic keratoses. J Am Acad Dermatol.

References

1997;36(4):650-653.

1. Rouhani P, Fischer M, Meehan S, Pomeranz MK. Disseminated superficial

10. Berker DD, McGregor JM, Hughes BR. Guidelines for the management of

actinic porokeratosis. Dermatol Online J. 2012;18(12):24.

actinic keratoses. Br J Dermatol. 2007;156(2):222-230.

2. Shumack SP, Commens CA. Disseminated superficial actinic porokeratosis:

11. Flohil SC, van der Leest RJT, Dowlatshahi EA, Hofman A, de Vries E,

a clinical study. J Am Acad Dermatol. 1989;20(6):1015-1022.

Nijsten T. Prevalence of actinic keratosis and its risk factors in the general

3. Sertznig P, von Felbert V, Megahed M. Porokeratosis: present concepts. J Eur

population: The Rotterdam Study. J Invest Dermatol. 2013;133(8):1971-1978.

Acad Dermatol Venereol JEADV. 2012;26(4):404-412.

12. Venna SS, Lee D, Stadecker MJ, Rogers GS. Clinical Recognition of

4. Xia K, Deng H, Xia JH, et al. A novel locus (DSAP2) for disseminated

actinic keratoses in a high-risk population: how good are we? Arch Dermatol.

superficial actinic porokeratosis maps to chromosome 15q25.1–26.1. Br J

2005;141(4):507-509.

Dermatol. 2002;147(4):650-654.

13. Heppt MV, Steeb T, Ruzicka T, Berking C. Cryosurgery combined with topi-

5. Maubec E, Duvillard P, Margulis A, Bachollet B, Degois G, Avril M-F. Common

cal interventions for actinic keratosis: a systematic review and meta-analysis

skin cancers in porokeratosis. Br J Dermatol. 2005;152(6):1389-1391.

[published online November 17, 2018]. Br J Dermatol. doi:10.1111/bjd.17435

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46 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com

LEGAL ADVISOR CASE

Careful Note-Taking Wins Case An RN’s detailed documentation protects hospital from liability.

BY ANN W. LATNER, JD

This month we look at a case in which a nurse’s careful documentation of a patient’s neurologic examination findings saved the day for a hospital that had been sued. Ms L, 28, worked as a nurse in the emergency department of a large hospital in a metropolitan area. She had been working at the hospital for 2 years and was considering going back to school for her advanced practice degree. The nurse particularly enjoyed working with children and hoped to eventually move to the pediatrics department. She was working one Monday morning when Jane, a 14-month-old child, was brought in by her mother and grandmother. The mother told Ms L that Jane had a fever of 100 degrees and had been vomiting for the past 2 days, including 5 times the previous night. “Also,” mentioned the grandmother,“Jane has a bump on her left knee. She had been walking before, but a few days ago she stopped.” Ms L performed an initial assessment and noted that Jane was awake, alert, fussy, hard to console, and was vomiting clear fluid during the examination. Ms L conducted a neurologic examination

Ms L’s careful documentation proved the hospital was not negligent for not finding the child’s brain tumor sooner.

on the child and found that her responses were within the defined parameters. Ms L noted everything in the patient’s file and then introduced the family to Dr S, the emergency department physician. Dr S examined Jane and noted that she appeared acutely dehydrated, was fussy, and had dry mucous membranes. He looked at the bump on her left knee and measured it as 1 cm in diameter. The physician noted that Jane refused to extend her legs when put down to see if she would walk. He ordered a laboratory assessment, which revealed only dehydration, and a radiographic examination of the child’s left knee, which revealed no fracture or abnormality. The physician diagnosed Jane with gastroenteritis and dehydration and ordered intravenous hydration and ondansetron for nausea. The child’s condition improved, and she was later discharged with a prescription for Cases presented are based on actual occurrences. Names of participants and details have been changed. Cases are informational only; no specific legal advice is intended. Persons pictured are not the actual individuals mentioned in the article.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2019 47

LEGAL ADVISOR ondansetron and instructions to return to the emergency department if the vomiting returned. The next day, Ms L was surprised to see Jane back in the emergency department with her mother. Jane’s mother reported that the child had continued vomiting after returning home the previous day and that she would not take the ondansetron. Again, Ms L conducted an examination. She found Jane to be awake, alert, and oriented to her mother, and she noted that the child was fussy but easily consoled. Ms L noted that the child was not listless and stood on the scale with no difficulty. She conducted a neurologic examination and noted in the chart that the results were again within normal parameters. Another emergency department physician, Dr G, examined Jane this time and ordered intravenous hydration and ondansetron. The child remained in the emergency department overnight and on Wednesday morning was admitted to the pediatric department with dehydration and vomiting. Shortly after admission, the child suffered from profound neurologic deterioration, followed by acute respiratory failure. Computed tomography of the child’s head revealed a brain tumor and massive cerebral edema. A pediatric neurosurgeon performed ventriculostomy to relieve pressure on the brain followed by craniotomy to remove the tumor. Although Jane recovered from the surgery, she experienced permanent neurologic impairment. Her distraught parents sought the counsel of a plaintiff ’s attorney, and they filed a lawsuit against the hospital and physicians alleging that the treatment of Jane in the emergency department fell below the standard of care and that she experienced additional brain damage or loss of a better chance of recovery due to this.

necessary in this case. The pediatric neurosurgeon testified that he could not say whether Jane would have experienced less neurologic damage if he had performed the surgery 2 days earlier because there was no information establishing when the pressure in her brain had increased. At the end of the testimony, the defense made a motion to dismiss the case, saying that the plaintiff had not established that there was any deviation from the appropriate standard of care. The judge agreed and the case was dismissed. The plaintiff immediately appealed, arguing that since the physicians had not documented the neurologic examinations, there was a question of fact as to whether they had taken place and this question of fact should go to a jury.

Legal Background

Protecting Yourself

During the trial, Ms L testified on her care of Jane, and her detailed notes were introduced into evidence, including her notes about the 2 neurologic examinations she performed. Drs S and G testified as well, stating that they each had conducted a neurologic examination of the child but had not noted it in her chart. Two pediatricians testified. One noted that the standard of care required the physicians to perform a neurologic examination on Jane, and the expert would have preferred that the examination be documented in the patient’s record. However, the expert said that since the physicians had testified that they performed the examination, they did not breach the standard of care. The second pediatrician testified that pediatric patients with brain tumors typically present with nonspecific symptoms and there had been no indication that a radiologic study was

In this case an expert testified that although the standard of care required a neurologic examination, it did not require documentation of the examination. However, it was precisely the nurse’s documentation that allowed the court to be able to dismiss the case. Without her documentation, the case would have had to go to trial for a jury to decide whether the physicians were believable when they had testified that they had performed the examination. In almost every situation, completing documentation is the best course of action. Ms L’s conscientious note-taking saved her employer and her coworkers from significant stress and costly legal fees. ■

The clinicians were not found to have deviated from the appropriate standard of care in the emergency department. The appeals court disagreed, and specifically noted that Ms L’s testimony and documentation of the 2 normal neurologic examinations established that Jane’s neurologic function was normal during her first 2 days in the emergency department.“During the child’s first and second encounters with the nurse in the emergency room there was no objective indication she suffered from any neurological abnormality,” noted the court in its decision.“The nurse’s careful documentation of her own assessments and neurological checks proved the hospital was not negligent for not finding her brain tumor sooner.” The case was dismissed.

Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.

48 THE CLINICAL ADVISOR • APRIL 2019 • www.ClinicalAdvisor.com