August 2018 Clinical Advisor by The Clinical Advisor

A PEER-REVIEWED FORUM FOR NURSE PRACTITIONERS

As we celebrate 20 years, our audience shares how their practice has changed during that time PAGE 27

NEWSLINE

■■Hydrocodone upscheduling ■■CDC Shigella update ■■Managing preterm GER LEGAL ADVISOR

A HIPAA violation threatens a nurse’s career

DERMATOLOGY CLINIC

Hyperpigmented bands across all fingernails

FREE CE COURSE

Precancerous GI mucosal lesions

AUGUST 2018

| www.ClinicalAdvisor.com

CHAGAS DISEASE

Overview of a growing US public health concern These protozoa can multiply rapidly in the brain, liver, and heart.

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Editor Colby Stong editor@clinicaladvisor.com Associate editor Madeline Morr Assistant editor Rita Aghjayan Contributing editors Mark P. Brady, PA-C; Philip R. Cohen, MD; Deborah L. Cross, MPH, CRNP, ANP; Sharon Dudley-Brown, PhD, FNP; Abimbola Farinde, PharmD; Laura A. Foster, CRNP, FNP; Abby A. Jacobson, PA; Maria Kidner, DNP, FNP; Joan W. Kiely, MSN, CRNP; Debra August King, PhD, PA; Ann W. Latner, JD; Mary Newberry, CNM, MSN; Claire Babcock O’Connell, MPH, PA; Kathy Pereira, DNP, FNP; Sherril Sego, DNP, FNP; Ann Walsh, PA-C, SCT(ASCP); Kim Zuber, PA-C Production editor Kim Daigneau Group art director, Haymarket Medical Jennifer Dvoretz Production manager Krassi Varbanov Circulation manager Paul Silver National accounts manager Alison McCauley, 973.224.6414 alison.mccauley @ haymarketmedical.com Publisher Kathleen Hiltz, 201.774.1078 kathleen.hiltz@haymarketmedia.com Vice President, content, medical communications Kathleen Walsh Tulley General manager, medical communications Jim Burke, RPh CEO, Haymarket Media, Inc. Lee Maniscalco All correspondence to: The Clinical Advisor 275 7th Avenue, 10th Floor, New York, NY 10001 For advertising sales, call 646.638.6085. For reprints, contact Wright’s Reprints at 877.652.5295. Persons appearing in photographs in “Newsline,” “The Legal Advisor,” and “Features” are not the actual individuals mentioned in the articles. They appear for illustrative purposes only. The Clinical Advisor ® (USPS 017-546, ISSN 1524-7317),Volume 21, Number 8, is published 12 times a year, monthly, by Haymarket Media, Inc., 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M–F, 9am–5pm, ET). The Clinical Advisor is available on a paid subscription basis at the following annual rates: $75 USA, $85 Canada, $110 for all other foreign, in U.S. dollars, Single copy price: USA $20, Foreign $30. To order or update a paid subscription visit our website at www. ClinicalAdvisor.com or call (800) 436-9269. Periodicals postage rate paid at NewYork, NY, and additional mailing offices. Postmaster: Send changes of address to The Clinical Advisor, c/o Direct Medical Data, 10255 W. Higgins Rd., Suite 280, Rosemont, IL 60018. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Unsure about a diagnosis or treatment?

Ask our

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

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

CLINICAL PEARLS

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

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

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

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

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

Advisor F

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

orum

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

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

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

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

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PEARLS

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

Philip R.

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

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

62 THE CLINI

Deborah L. Cross, MPH, ANP-B

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

CAL ADVI

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

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Laura A.

Foster,

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

Abby A.

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 • AUGUST 2018 1

CONTENTS AUGUST 2018

NEWS AND COMMENT 9

Newsline ■■CDC surveillance information for the 2017-2018 flu season ■■FDA upscheduling of hydrocodone disadvantageous to APRNs ■■AAP recommendations for management of gastroesophageal

reflux in preterm infants 9 Flu data from the CDC

■■WHO issues recommendations on noncommunicable diseases ■■PA students report discrimination, abuse in programs ■■Amyloid imaging informs diagnosis, treatment in dementia ■■CDC issues update for resistant Shigella infections

FEATURES

33 Painless finger nodules

14 Chagas disease in the United States: a growing public health concern An infection caused by the T cruzi parasite, Chagas disease is endemic in Latin American countries. 19 CME/CE Precancerous lesions in GI mucosa: staining and screening Significant improvements in the detection of cancers of the gastrointestinal tract have contributed to recognition of lesions at a precancerous stage. 26 CME/CE Feature posttest

39 An unintentional HIPAA violation

43 Cleft lip and palate

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MORE WAYS TO FIND US!

DEPARTMENTS A PEER-REVIEWED FORUM FOR NURSE PRACTITIONERS

As we celebrate 20 years, our audience shares how their practice has changed during that time PAGE 27

THE CLINICAL ADVISOR • JUNE 2018

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

THE CLINICAL ADVISOR • JULY 2018

PEER-REVIEWED PHYSICIAN ASSISTANTS | JUNE 2 018 A PEER - R E V| I Ewww.ClinicalAdvisor.com W E D F O RU M F O R N U R S E P A R AC T I T I O N E R S | JFORUM U LY 2 01FOR 8 | www.ClinicalAdvisor.com AUGUST 2018

DERMATOLOGY CLINIC

Stat Consult ■ Cleft lip and palate

ADVISOR FORUM

Clinical Pearls Members of our audience share their perspectives on advances that have occurred in clinical practice.

FREE CME COURSE

Viewpoints in gout and hyperuricemia

FREE CME COURSE

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

VOLUME 21, NUMBER 6

Legal Advisor A HIPAA violation harms the successful career of a healthcare provider and causes problems for her former and current employers.

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

Irritative lesions in the abdomen and genital region

VOLUME 21, NUMBER 7

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

DERMATOLOGY CLINIC

Hyperpigmented bands across all fingernails

Precancerous GI mucosal lesions

Dermatologic Look-Alikes Painless nodules on the finger and hand

LEGAL ADVISOR

Diagnostic test results are ordered but never received

These protozoa can multiply rapidly in use of the brain, Increased liver, social media has and heart. been linked to depression and anxiety.

A HIPAA violation threatens a nurse’s career

FREE CE COURSE

■ Diabetes prevalence ■ Multiple sclerosis guideline

LEGAL ADVISOR

NEWSLINE

LEGAL ADVISOR

Dermatology Clinic ■ Hyperpigmented bands on the fingernails ■ Persistent itchy rash on the leg

NEWSLINE

■ Lyme neuroborreliosis

ED Multidisciplinary care How serious are the Overview■■ NPs, ofPAsandain theCHD growing Alcohol risk for maximizing function US public health concern health risks associated A clinician quits her job but and use? quality of life with social media sues for wrongful termination

■ Hydrocodone upscheduling ■ CDC Shigella update ■ Managing preterm GER

| www.ClinicalAdvisor.com

AMYOTROPHIC LATERAL SCLEROSIS SOCIAL MEDIA AND ADOLESCENTS ■ Prostate cancer screening

NEWSLINE CHAGAS DISEASE

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

PAGE 30

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EXCLUSIVE TO THE WEB AT

ClinicalAdvisor.com

NEWS ClinicalAdvisor.com/News

Corticosteroid Plus Lidocaine Injections Does Not Alleviate Pain in Central Lumbar Spinal Stenosis Adding corticosteroids to epidural lidocaine injections does not improve patientreported pain or function at 12 months.

Excessive Daytime Sleepiness Linked to Elevated β-Amyloid Accumulation in Elderly Persons

THE WAITING ROOM

Official Blog of The Clinical Advisor ClinicalAdvisor.com/WaitingRoom Jim Anderson, MPAS, PA-C, DFAAPA Food Talk Is Good Medicine Some of the most memorable moments in medical practice are the times when a patient and clinician can chit-chat like friends.

CASE STUDY Clinical Advisor.com/CaseStudy

Elderly individuals without dementia who have elevated daytime sleepiness may be at greater risk for β-amyloid accumulation.

Hearing Loss Linked to CVD Risks in Elderly Elderly patients aged 80 years and older have an increased risk of developing cardiovascular disease with worse hearing as well as hearing deterioration.

Quantification of Prevalence, Outcomes of Incidental Imaging Abnormalities Incidental abnormalities are most frequently observed in computed tomography colonoscopy, computed tomography of the chest, and cardiac magnetic resonance imaging.

Brady Pregerson, MD Sudden Abdominal Pain A 90-year-old woman with a history of coronary disease and gallstones presents to the emergency department with generalized abdominal pain that started suddenly about 7 hours prior. Read the full case here: ClinicalAdvisor.com/ SuddenAbdominalPain.

CARTOON ARCHIVE

The Clinical Advisor’s monthly cartoons are also available online. ClinicalAdvisor.com/cartoons

Researchers from the University of Bristol found no association between 25-hydroxyvitamin D level and pregnancy-related hypertensive disorders.

4 THE CLINICAL ADVISOR • AUGUST 2018 • www.ClinicalAdvisor.com

Vitamin D and Gestational Hypertension, Preeclampsia Risk: Is There a Connection?

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

DERM DX

A itchy rash on the neck and cheek The patient is a 56-year-old Hispanic man who presents with a moderately itchy rash affecting his neck and lower cheek. He spent the previous year in the Dominican Republic; despite treatment with various steroid creams, the rash persisted. Examination reveals well-defined erythematous plaques of the affected areas with raised borders and moderate scale. CAN YOU DIAGNOSE THIS CONDITION?

• Granuloma annulare • Tinea incognito

• Plaque psoriasis • Discoid lupus

● See the full case at ClinicalAdvisor.com/DermDx_Aug18

In partnership with

ORTHO DX

TheJopa.org

Journal of Orthopedics for Physician Assistants

Compression fracture from a standing-height fall A 42-year-old woman presents with a new T12 compression fracture. The fracture occurred from a standing-height fall as she fell on her bottom. She had a DXA scan that showed a T score of -3.5 at the lumbar spine and -3 at the right femoral neck. She has a medical history of hypertension, gastric reflux, seizures, and gout. WHICH MEDICATION IS THE LIKELY CAUSE?

• Hydrochlorothiazide • Allopurinol

• Omeprazole • Phenytoin

● See the full case at ClinicalAdvisor.com/OrthoDx_Aug18

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 5

Newsline A total of 171 pediatric flu deaths were reported this season.

CDC surveillance information for the 2017-2018 flu season THE 2017 TO 2018 influenza season in the United States (October 1, 2017, through May 19, 2018) was a high-severity season with high levels of emergency department visits, according to data from the Centers for Disease Control and Prevention (CDC) recently published in Morbidity and Mortality Weekly Report. Influenza A (H3N2) viruses were the predominant influenza strain through February 2018, with influenza B viruses predominating starting from March 2018. During the specified time period, public health laboratories tested 98,446 specimens, finding 54.6% positive for influenza virus (71.2% for influenza A; 28.8% for influenza B). Among positive influenza A specimens, 84.9% were influenza A(H3N2) and 15.1% were influenza A(H1N1)pdm09. Among positive influenza B specimens, 88.8% were B/Yamagata lineage and 11.2%

were B/Victoria lineage. Interim effectiveness of the 2017 to 2018 inactivated influenza vaccines were: 36% overall, 25% against illness caused by influenza A(H3N2), 67% against illness caused by influenza A(H1N1)pdm09, and 42% against illness caused by influenza B viruses. Influenza viruses were also tested for resistance to influenza neuraminidase inhibitor antiviral medications recommended for use against seasonal influenza (oseltamivir, peramivir, and zanamivir). Of the tested viruses for influenza A(H3N2) and influenza B, no resistance was detected for any of the 3 medications. Of the A(H1N1)pdm09tested viruses, none were resistant to zanamivir, but 1.0% were resistant to both oseltamivir and peramivir. Nationally, the weekly percentage of outpatient visits to healthcare providers for influenza-like illness was at or

above the national baseline level of 2.2% for 19 consecutive weeks during the 2017 to 2018 season. The percentage of outpatient visits for influenza-like illness exceeded 7.0% for 3 consecutive weeks, peaking at 7.5%. A total of 30,453 laboratory-confirmed influenza-related hospitalizations were reported.The hospitalization rate was highest among persons aged ≥65 years, who accounted for approximately 58% of reported influenzaassociated hospitalizations. Among all influenza-associated hospitalizations, 72.3% were for influenza A virus infections (83.8% H3N2; 16.2% [H1N1] pdm09), 27.0% for influenza B virus infections, 0.4% for influenza A virus and influenza B virus coinfections, and 0.3% for an influenza virus for which no type testing was done. A total of 171 pediatric deaths were reported this season, approximately half in otherwise healthy children. Less than one-fourth (22%) of vaccine-eligible children who died from influenza this season had received influenza vaccine before illness onset. The recommended composition of the 2018 to 2019 influenza trivalent vaccine contains an A/Michigan/45/2015 A(H1N1)pdm09-like virus, an A/ Singapore/INFIMH-16-0012/2016 A(H3N2)-like vir us, and a B/ Colorado/06/2017-like (B/Victoria lineage) virus; the quadrivalent vaccine recommendation includes the trivalent vaccine viruses, as well as a B/ Phuket/3073/2013-like (B/Yamagata lineage) virus. The study authors conclude that, “testing for seasonal influenza viruses and monitoring for novel influenza A virus infections should continue year-round.”

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 9

Newsline

FDA upscheduling of hydrocodone disadvantageous to APRNs

Complementary treatments may prove beneficial for pain relief.

THE UPSCHEDULING of hydrocodone combination medications (HCMs) from Schedule III to Schedule II has greatly affected the pain management practices of advanced practiced registered nurses (APRNs) in Oklahoma, a state where APRNs are prohibited from prescribing Schedule II narcotics, according to a study published in the Journal of the American Association of Nurse Practitioners. Rachel Mack, PhD, DNP, APRN, C-FNP, CNE, used a phenomenological approach to assess the clinical pain management practices employed by APRNs since the upscheduling of HCMs and to determine how these changes in prescriptive authority have affected the practice of APRNs in Oklahoma. A total of 25 individuals aged ≥21 years with a minimum of a Master’s degree as an APRN were selected.All participants demonstrated the ability to conduct personal business and legal transactions, as well as to practice and prescribe in the state of Oklahoma. In addition to demographic information, information on clinical practice in pain management, including the effects of upscheduling of HCMs, was elicited

by the use of open-ended questions posed during 60-minute interview sessions. • How much of your practice time is devoted to pain management with your patients? • Have you noticed a change in how you manage your patient’s pain since the upscheduling of hydrocodone? • Can you tell me about (story) a patient whose pain management was affected by the change in upscheduling? • As a clinician, how has this scheduling change affected you? Upscheduling of HCMs was reported by participants to have created barriers to effective pain management in the primary care setting.They reported having limited options available for the treatment of both acute and chronic pain. The number of referrals to pain management specialists also increased, as did the number of emergency department visits, resulting in increased healthcare costs. Since the upscheduling of HCMs, primary care APRNs report using alternative therapies such as physical therapy, massage, and herbal remedies more frequently. Complementary medicines such as overthe-counter rubs, patches, and stimulating units also help to alleviate chronic pain, and referral to interventional medicine specialists for steroid injections may also prove beneficial for pain relief. “Despite differences among the participants in education, number of pain management patients seen in practice, and experience, some distinct commonalities in their approach to pain management after the upscheduling of HCMs were identified,” Dr Mack concluded.“Based on these findings, it is recommended that future researchers conduct similar studies focusing on the pain management practices of APRNs after the upscheduling of HCMs.”

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

AAP recommendations for management of gastroesophageal reflux in preterm infants THE AMERICAN ACADEMY of Pediatrics has updated its list of gastroesophageal reflux (GER) diagnosis and management recommendations for preterm infants, according to a clinical report published in Pediatrics.The recommendations highlight the following: • Intolerance or aversion to feeding, poor weight gain, repeated regurgitation, apnea, desaturation, bradycardia, irritability, and perceived postprandial discomfort are commonly recognized as outcomes of GER. • Data dissociate these apparent outcomes of GER with acidic and nonacidic reflux episodes, as measured by multichannel intraesophageal impedance/pH; associated signs commonly improve without the need for treatment. • Pharmacologic agents frequently used to treat preterm infants with clinically diagnosed GER are linked to harmful events (including gastric acid blockade) and lack significant efficacy. Clinicians are strongly urged to refrain or sparingly use such agents in preterm infants. • Head elevation, more frequent but smaller feeding volumes with thickened formula, and left lateral placement of the infant, as well as similar nonpharmacologic measures to reduce reflux have not been proven to reduce clinically reported signs of GER in preterm infants. • Safe sleep recommendations, such as avoidance of elevation of the infant’s head in the crib, should be demonstrated for parents prior to hospital discharge.

WHO issues recommendations on noncommunicable diseases THE WORLD HEALTH Organization’s (WHO) Independent High-level Commission on Noncommunicable Diseases (NCDs) has released a report in The Lancet outlining their 6 recommendations to increase action against NCDs. The Commission states that all levels of government including heads of state, and not only health ministers, need to prioritize and take ownership of actions against NCDs and mental health. From here a top-down approach should engage subnational levels of government, from cities to rural leaders and villages, to take action on new and existing programs aimed at efforts to reduce air pollution, decrease consumption of tobacco and harmful alcohol use, as well as to improve traffic safety, encourage healthy eating, and promote mental health awareness. They further recommend that governments identify

and implement specific priorities rather than attempt to implement all the interventions at once, and that those health systems reorient themselves according to national context and needs. Increases in effective regulation and appropriate engagement with the private sector, academia, civil society, and com-

The commission advises that governments along with the international community should develop a “new economic paradigm for funding action on NCDs and mental health,” and that governments specifically “should strengthen accountability to their citizens for action on NCDs.”

The report is “intended for Heads of State and Government and policymakers across government sectors, as well as other stakeholders.” munities are also recommended in order to share experiences and challenges and build a whole-of-society approach to NCDs. New relationships with tobacco and food industries are needed, and the ubiquitous use of mobile phones, big data, and digital technologies “could be tapped for better health outcomes.”

The Commission and subsequent report stem from recognition that there is a “lack of adequate global progress in combating non-communicable diseases,” and that certain WHO Sustainability Development Goals may not be met.The commission met twice via teleconference and once in person to create this report.”

PA students report discrimination, abuse in programs PHYSICIAN ASSISTANT (PA) students have reported witnessing and experiencing discrimination or abuse throughout PA programs in the United States, particularly nonwhite students and students attending public institutions, according to a study published in the Journal of Physician Assistant Education. An online survey of PA studies was conducted to increase the understanding of discrimination, psychological abuse, and physical abuse in PA education programs and the impact it may have on attrition. The survey received 1159 responses, representing 6.1% of total PA student enrollment. Up to 30% of respondents had witnessed or experienced discrimination, and up to 2.3% had experienced psychological abuse while in PA school. A total of 11.6% of students reported

Surveys were mailed to PA program directors for distribution to their students.

that they had witnessed sexual harassment, 18.7% reported witnessing the use of racial slurs, 27.8% reported jokes or remarks centered on obese body habitus, and 18% reported homophobic jokes or

remarks. The majority of witnessed or experienced discrimination during PA education was not reported. Reports were not made because students feared retribution or they simply did not know who to report to, particularly if the incident involved faculty. The researchers found that 2.9% of respondents had considered quitting PA school because of issues of discrimination: 5.7% because of psychological abuse, 0.3% because of physical abuse, 0.6% because of sexual harassment, and 7.7% for another reason. The most common reasons provided in the “other” option included mental health issues (eg, anxiety, depression, and stress; 37.5%), difficulty with faculty or staff (37.5%), academic difficulty (20.8%), financial issues (2.1%), and pursuing medical school (2.1%).

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

Newsline Amyloid imaging informs diagnosis and treatment in patients AMYLOID POSITRON emission tomography (PET) changes etiologic diagnosis for patients with and without dementia, increasing diagnostic confidence and changing treatments received, according to a study published in JAMA Neurology. A prospective cohort study assessed the correlation between the effects of amyloid PET and diagnosis, confidence in diagnosis, treatment, and patients’ experience. The investigators invited 866 patients to receive amyloid PET using florbetaben; 476 (55%) of these patients participated in the study, and an additional 31 patients with mild cognitive impairment (MCI) were also invited. Primary outcomes were any diagnosis changes made post-PET, diagnostic confidence, and treatment. A preamyloid and postamyloid PET diagnosis was determined by neurologists

Neurologists also investigated treatments, medications, and patient care.

for each participant for a clinical syndrome (dementia, MCI, and subjective cognitive decline [SCD]) and a suspected etiology including Alzheimer disease (AD) or non-AD; confidence levels varied from 0 to 100%. Neurologists also investigated patient treatments, medication, and care. Of the 507 participants (average age, 65 years; 201 women), 164 had AD dementia

(32%), 70 had non-AD dementia (14%), 114 had MCI (23%), and 159 had SCD; 242 patients had positive amyloid PET results (48%). A quarter of the patients had changes in suspected etiologies postamyloid PET; negative PET results influenced these changes more than positive PET results (31% vs 18%, respectively). In addition, most post-PET changes in suspected etiology took place in older patients (>65 years). The researchers also noted an increase in diagnostic confidence.Altered patient treatments post-PET were reported in 123 individuals due to additional analysis and therapies (24%). “This prospective diagnostic study provides a bridge between validating amyloid PET in a research setting and implementing this diagnostic tool in daily clinical practice,” the authors concluded.

THE CDC HAS identified an increasing number of Shigella isolates that test within the susceptible range for the fluoroquinolone antibiotic ciprofloxacin (minimum inhibitory concentration [MIC] values of 0.12 to 1 μg/mL) but harbor 1 or more resistance mechanisms.The CDC has also identified an increasing number of Shigella isolates with azithromycin MICs that exceed the epidemiologic cutoff value. Shigellosis is a nationally notifiable condition; all cases should be reported to local health departments. Recommendations for clinicians are as follows: • If antibiotic treatment is necessary, monitor patients carefully. • If you identify or receive a report of a patient with Shigella infection and possible fluoroquinolone or azithromycin treatment failure:

——Consider consulting an infectious disease specialist to identify other treatment options, because some Shigella isolates with susceptible ciprofloxacin MICs may harbor one or more quinolone resistance mechanisms. ——Contact your local health department to coordinate reporting treatment failure information.This information should be reported to the CDC. ——Collect a stool specimen for culture, and work with your clinical microbiology laboratory to submit for additional antimicrobial susceptibility testing. ——Request that your laboratory expedite submission of the Shigella isolate to your state public health laboratory. Your state laboratory should notify the CDC at

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

EntericBacteria@cdc.gov to coordinate additional laboratory testing and/or shipment of the isolate to CDC. The CDC is particularly concerned about people who are at high risk for multidrug-resistant Shigella infections and are more likely to require antibiotic treatment, such as men who have sex with men, patients who are homeless, and immunocompromised patients. These patients often have more severe disease, prolonged shedding, and recurrent infections. The CDC is working with Clinical and Laboratory Standards Institute (CLSI) and other partners to collect isolates and clinical information from people with Shigella infection and possible clinical treatment failure occurring after treatment with a fluoroquinolone or azithromycin. ■

CDC issues update for resistant Shigella infections

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KEYNOTE Ruth Kleinpell, PhD, RN, FAAN Professor & Assistant Dean for Clinical Scholarship, Vanderbilt University School of Nursing

Advancing Your NP Career: What is Your Next Step? CALL FOR ABSTRACTS

Photo Credit: Jeff Andrew

Now accepting abstracts for podium presentations and poster presentations. Podium presentation deadline: October 1, 2018 Poster presentation deadline: April 1, 2019 Access www.npsymposium.com and click on ‘Call for Abstracts’ link for information and to submit your abstract. The National Nurse Practitioner Symposium provides CE Certification via: •ACCME •ANCC •AANP With pertinent content accepted by: •AAPA •ACNM •NAPNAP

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FEATURE: DEEDRA HARRINGTON, DNP, MSN, APRN, ACNP-BC; FRANCES STEUBEN, DNP, RN, CCRN; CHRISTY LENAHAN, DNP, MSN, FNP-BC, CNE

Chagas disease in the United States: a growing public health concern The United States has the seventh highest prevalence of Chagas infection in the Western hemisphere.

As many as 8 million people worlwide are infected with T cruzi.

14 THE CLINICAL ADVISOR • AUGUST 2018 • www.ClinicalAdvisor.com

hagas disease is a parasitic infection caused by the protozoan parasite Trypanosoma cruzi (T cruzi). T cruzi infection can be acquired through the vector-borne route, transplacentally, through transfusion of contaminated blood products, from a transplanted organ of an infected donor, or rarely from contaminated food or laboratory accidents.1 A majority of infections are transmitted via the vector-borne route, which occurs only in the Americas. The vector for T cruzi is the triatomine bug, also known as the “kissing bug.” Infection is acquired through contact with the feces of an infected triatomine bug. The triatomine bug has been found in the southern United States, Mexico, Central America, and South America—as far south as Argentina. Chagas disease is endemic in Latin American countries, including Mexico and most countries in Central and South America.2 Although the triatomine bug survives in the southern United States, the vast majority of persons infected with T cruzi living in the United States acquired the infection while living in Latin American countries. The United States is considered a nonendemic country for Chagas disease. As of 2009, more than 300,000 persons living in the United States were believed to be infected with the T cruzi parasite.3 Although a 2016 review places this number closer to 240,000, this estimate does not include undocumented immigrants, who could account for more than 100,000 cases.4 If left untreated, the parasitic infection can lead to chronic disease with

right-hand column like this one does at the top

severe and life-threatening manifestations. In approximately 20% to 30% of T cruzi infections, the disease progresses to Chagas cardiomyopathy and/or gastrointestinal Chagas disease.1 Practitioners serving communities with large populations of Latin American immigrants need to be aware of the disease prevalence in this population. Epidemiology

An estimated 8 million people worldwide are infected with T cruzi, and the United States has the seventh highest prevalence of Chagas infections. Of the estimated 300,000 US individuals infected with the parasite, 30,000 to 45,000 will develop Chagas heart disease.5 Chagas infections represents a growing public health concern in the Western hemisphere, particularly in communities with high populations of Latin American immigrants. The majority of cases of T cruzi infections in the United States are among immigrants from Latin American countries where T cruzi infections are endemic; few actual vector-borne cases of infection have been reported in the United States. According to Bern and Montgomery, only 7 cases of US vector-borne infections have been reported since 1955 despite the presence of the triatomine bug in the southern states.3 The kissing bug can be found in the southern half of the continental United States and large parts of Central and South America.1 The climate in the northern portions of North America and the southernmost portions of South America are not compatible for triatomine bug survival.Vector-borne transmission is prevalent in endemic countries where housing is poorly constructed as the bugs like to nest in cracks and holes in substandard housing. Improved housing and less-efficient vectors may explain the low risk of vectorial transmission in the United States.1,2 Plastered walls and sealed entryways help to prevent bug infestations. Risk factors

Persons at highest risk of contracting T cruzi infection are those living or who have lived in poorly constructed, triatomine buginfested houses in endemic countries.1 Other persons at risk are those who have received blood transfusions, transplant recipients, and offspring of infected mothers. Since 2012, donated blood at all US blood centers undergoes screening for T cruzi infection; therefore, US blood transfusion recipients since 2012 are not considered high risk.1 Transplant recipients who receive an organ from a donor infected with T cruzi and children born to infected mothers are at risk of developing Chagas disease.1 Pathophysiology

Transmission of T cruzi infection occurs when the triatomine bug defecates near the site of the bite wound, depositing the

T cruzi is transmitted through contact with feces from the “kissing bug.”

parasite T cruzi where it enters through mucosa located in the eyes, mouth, or skin.6 The parasite then invades macrophages at the initial entry site and enters the bloodstream, resulting in an immunoinflammatory response manifesting primarily in tissues of the heart, gastrointestinal tract, and central nervous system.6 Clinical presentation

Chagas disease may have a sudden presentation followed by a brief illness phase.The World Health Organization (WHO) categorizes disease presentation into 2 phases.The initial acute illness occurs immediately after contact with the organism and lasts a few weeks to several months. During the acute phase, which involves a high concentration of circulating parasites in the blood stream, symptom presentation may include fever,

POLL POSITION Which of the following statements regarding Chagas infection is true? ■ All kissing bugs transmit Chagas

7.52%

■ Triatomine bugs live predominantly in cracks and holes of substandard housing in the United States ■ The Romana sign is indicative of acute Chagas infection*

12.14%

39.32%

41.02%

■ An allergic reaction after a bite from a triatomine bug is indicative of Chagas infection

For more polls, visit ClinicalAdvisor.com/Polls.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 15

right-hand column like this one does at the top

CHAGAS DISEASE

TABLE 1. Signs and Symptoms of Acute vs Chronic Chagas Disease Acute • Malaise • Anorexia • Myalgia • Headache • Intermittent fever • Chagoma (inflammatory nodule at parasite entry point) • Romana sign (eyelid swelling/ purplish color)

• Schizotrypanides (nonpruritic morbilliform rash) • Hepatomegaly* • Splenomegaly* • Generalized lymphadenopathy* • Myocarditis* • Encephalitis/meningitis*

Chronic Cardiac Complications • Cardiomyopathy • Heart failure • Arrhythmias • Cardiac arrest Gastrointestinal Complications • Megaesophagus ——Weight loss ——Cachexia ——Hypertrophy of salivary glands ——Pneumonitis ——Erosive esophagitis

Neurologic Complications • Neuritis ——Altered tendon reflexes ——Sensory impairment • Other Central Nervous System Derangement ——Dementia ——Chronic encephalopathy

• Megacolon ——Abdominal distention ——Fecaloma ——Sigmoid volvulus

life-threatening and debilitating medical conditions usually complicated with cardiac, digestive, and neurologic sequelae including cardiac arrhythmias, heart failure, sudden cardiac arrest, esophageal enlargement with difficulty swallowing, and dilated colon with difficulty passing stool.1,7-9 Signs and symptoms of acute and chronic presentations of Chagas disease are listed in Table 1. Differential diagnosis

Depending on the duration of time elapsed from inoculation, severity of the infection, and the tissue and/or organ involvement, the differential diagnosis can range from simple flu or viral presentation to myocardial tissue involvement, which may include myocarditis and myopericarditis.9 Other differential diagnoses to consider are listed in Figure 1. Diagnosis

Diagnostic technique used to identify the presence of Chagas disease is dependent on the phase of the infection (eg, acute vs chronic). In the acute phase, a diagnosis of Chagas disease is made by observation of T cruzi in the bloodstream or cerebrospinal fluid.10 The presence of trypomastigotes can be noted on blood film examination during the acute phase.11 Because parasitemia is low in the chronic phase of Chagas disease, diagnosis requires careful consideration of the patient’s history and symptomatology, as well as confirmation of suspicion by 2 different serologic tests. Currently, the US Food and Drug Administration has approved 2 enzyme-linked immunosorbent assays (ELISAs) for clinical testing and one ELISA for confirmatory testing.10 Management

*More common in children

swelling at the site of infection, lymphadenopathy, fatigue, rash, myalgia, anorexia, eyelid swelling/purplish in color (Romana’s sign), headache, and/or tachycardia.1,7,8 Mortality due to myocarditis or encephalitis/meningitis has been reported in rare cases during the acute phase.9 The “chronic indeterminate” phase is characterized by a prolonged period of time during which the patient is asymptomatic, and there is no evidence of circulating parasitic infection in the blood stream.7 Untreated parasitic infection may progress to the chronic phase, which would not present until 10 to 20 years after initial infection.The chronic phase is characterized by severe inflammation of the myocardium or brain lining. According to the US Centers for Disease Control and Prevention (CDC), an estimated 20% to 30% of infected individuals will develop

As with diagnosis, management of Chagas disease is dependent on the phase of infection, as well as the age of the person infected.11 In all patients presenting with acute Chagas disease, and in patients younger than 18 years with chronic Chagas disease, the CDC recommends treatment with an antiparasitic agent, specifically nifurtimox or benznidazole. Additionally, antiparasitic treatment should be considered in patients with chronic infection who are younger than 50 years and without advanced Chagas cardiomyopathy.11 In patients with chronic Chagas disease who are 50 years of age or older, use of antiparasitic treatment should only be considered if potential benefits outweigh the risks.11 The antiparasitic agents used to treat infection with T cruzi, nifurtimox and benznidazole, are not approved by the FDA and are only available through the CDC.11 Side effects of both drugs include anorexia and weight loss, and both are contraindicated in individuals with severe hepatic and/or renal disease. Safety has not been established in infants of breastfeeding women, so current recommendations are to withhold treatment while

16 THE CLINICAL ADVISOR • AUGUST 2018 • www.ClinicalAdvisor.com

Continues on page 17

CARDIOVASCULAR

PULMONARY

• Atrioventricular dissociation • Atrioventricular nodal reentry tachycardia (AVNRT) • Cardiomyopathy • Myocardial infarction, ischemia, rupture • Noninfectious heart disease • Right ventricular infarction • Second-degree atrioventricular block • Sinus node dysfunction • Sudden cardiac death • Syncope • Third-degree atrioventricular block • Ventricular fibrillation • Ventricular tachycardia

• Coronary artery anomalies, atherosclerosis, or vasospasm • Pulmonary edema • Pulmonary embolism • Pulmonic regurgitation

GASTROINTESTINAL • • • • • • • • •

OTHER • Encephalopathy • Meningitis • Leishmaniasis • Toxoplasmosis • Malaria

Achalasia Colonic obstruction Esophageal cancer Esophageal motility disorder Esophageal spasm/rupture Gastroesophageal reflux disease Hirschsprung disease Megacolon (acute, chronic, or toxic) Splenomegaly

FIGURE 1. Differential Diagnoses in Chagas Disease

breastfeeding.11 Efficacy of these antiparasitic agents is measured via anti-T cruzi antibody titers; however, reduction in these titers may take many years, resulting in insensitive and lengthy measurement of treatment success.12 Antiparasitic treatment should not be considered in patients with chronic infection who have developed cardiac or gastrointestinal symptoms.10 Management of patients exhibiting cardiac, gastrointestinal, and/or neurologic symptoms includes referral to an appropriate specialist.10

3. Bern C, Montgomery SP. An estimate of the burden of Chagas disease in the United States. Clin Infect Dis. 2009;49:e52-e54. 4. Manne-Goehler J, Chukwuemeka AU, Montgomery SP, Wirtz VJ. Estimating the burden of Chagas disease in the United States [published online November 7, 2018]. PLOS Neglected Trop Dis. doi.org/10.1371/ journal.pntd.0005033 5. Kuehn BM. Chagas heart disease an emerging concern in the United States. Circulation. 2016;134:895-896. 6. Pearson RD. Chagas disease (American Trypanosomiasis). 2014. https:// www.merckmanuals.com/professional/infectious-diseases/extraintestinal-

Conclusion

protozoa/chagas-diseasehttp://www.merckmanuals.com/professional/

The outcomes associated with Chagas disease can be devastating if the infection is not diagnosed and managed appropriately. Practitioners serving large populations of Latin American immigrants and other persons traveling from Latin American countries where Chagas is endemic should be aware of the risk for infection with the T cruzi parasite. If acute infection is suspected, prompt diagnosis and treatment are necessary to prevent progression to chronic disease and potential life-threatening associated illnesses. If patients present to their practitioner with chronic infection, appropriate referrals should be made. ■

infectious-diseases/extraintestinal-protozoa/chagas-disease. Accessed November 22, 2016. 7. Mayo Clinic. Chagas disease. 2014. https://www.mayoclinic.org/diseasesconditions/chagas-disease/symptoms-causes/syc-20356212. Accessed November 20, 2016. 8. World Health Organization. Chagas disease (American trypanosomiasis). 2016. http://www.who.int/mediacentre/factsheets/fs340/en/. Accessed November 21, 2016. 9. Bern C, Weller PF, Baron EL. Chagas disease: natural history and diagnosis. 2016. UpToDate (Topic 14005, Version 18.0). Accessed November 20, 2016. 10. Kirchoff LV. Chagas disease (American trypanosomiasis). 2016.

References

http://emedicine.medscape.com/article/214581-overview. Accessed

1. Centers for Disease Control and Prevention. Chagas disease: what US

November 21, 2016.

clinicians need to know. 2012. http://www.cdc.gov/parasites/cme/chagas/

11. Centers for Disease Control and Prevention. American trypanosomiasis.

course.html. Accessed November 22, 2016.

2013. http://www.cdc.gov/dpdx/trypanosomiasisAmerican/dx.html. Accessed

2. Centers for Disease Control and Prevention. Triatomine bug FAQs. 2016.

November 20, 2015.

http://www.cdc.gov/parasites/chagas/gen_info/vectors/index.html. Accessed

12.Viotti R, Noya A, Araujo-Jorge T, et al.Towards a paradigm shift in the treatment

November 22, 2016.

of chronic Chagas disease. Antimicrob Agents Chemother. 2014;58(2):635-639.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 17

CME CE FEATURED COURSE EDUCATIONAL OBJECTIVES At the conclusion of this activity, participants should be better able to: • Evaluate the spectrum of chromoendoscopic staining techniques to optimally identify and assess adenomatous polyps and other precancerous lesions in the gastric mucosa • Implement qualityimprovement tools to increase adherence to oral staining products and improve overall endoscopy services COMPLETE THE POSTTEST: Page 26

Release Date: May 11, 2018 Expiration Date: May 11, 2019 Estimated Time to Complete: 30 minutes Maximum Credits: 0.50 AMA PRA Category 1 CreditTM 0.50 CNE Contact Hour Accredited Provider: This activity is provided by the American Gastroenterological Association for physician credit. This activity is provided by AKH Inc., Advancing Knowledge in Healthcare for nursing contact hours. Commercial Supporter: This activity is supported by an educational grant from Aries Pharmaceuticals, Inc. Producer: This activity is produced by Haymarket Medical Education. Program Description: Despite a decrease in the incidence of cancers of the gastrointestinal (GI) tract in recent years, these malignancies remain a significant diagnostic and treatment challenge globally. Significant improvements in detection, particularly with the advent of chromoendoscopy stains and virtual chromoendoscopy, have contributed to a better recognition of lesions in the GI mucosa at earlier precancerous stages, leading to the decrease in malignant cases. Bowel preparation also is a critical step in detecting lesions because less-than-adequate preparation will result in a higher miss rate even with newer technologies. Available stains can be reactive, absorptive, or nonabsorptive and each detects certain morphologic characteristics of adenomas or serrated lesions; virtual chromoendoscopy techniques allow precise filtering of light to detect lesion characteristics. Clinician familiarity with these diagnostic technologies and the ability to implement them are essential to identifying and classifying lesions. Intended Audience: Physicians, physician assistants, nurse practitioners, nurses, and members of the GI endoscopy care team. Conflict of Interest Disclosure Policies: In accordance with the ACCME’s Standards for Commercial Support of Continuing Medical Education, all faculty and planning partners must disclose any financial relationship(s) or other relationship(s) held within the past 12 months.The AGA Institute implements a mechanism to identify and resolve all conflicts of interest prior to delivering the educational activity to learners. It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities.The faculty must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Faculty Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other faculty for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review. Faculty Michael B.Wallace, MD, MPH Professor of Medicine Division of Gastroenterology and Hepatology Mayo Clinic Jacksonville, FL Provided by

Dr.Wallace receives consulting fees from Aries Pharmaceuticals, Inc. Accredited Provider Disclosures: No other individuals involved with planning and delivering the content disclosed any relevant financial relationships. Accreditation Statement: The AGA Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Designation Statement: The AGA Institute designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Accreditation Statement: AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Designation Statement: This activity is awarded 0.50 contact hours. Disclosure of Unlabeled Use: This educational activity may contain discussion of approved and/or investigational uses of agents that are not indicated by the FDA. AGA Institute, AKH Inc., Haymarket Medical Education, and Aries Pharmaceuticals, Inc., do not recommend the use of any agent outside of the labeled indications. The opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of AGA Institute, AKH Inc., Haymarket Medical Education, or Aries Pharmaceuticals, Inc. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Disclaimer: AGA Institute and AKH Inc. do not provide any warranty as to the accuracy or reliability of information presented either verbally or in writing by presenters. No responsibility is assumed by AGA Institute or AKH Inc. for any injury and/or damage to persons or property resulting from any use of such information. Instructions: There are no fees for participating in and receiving CME/CE credit for this activity. During the period May 11, 2018 through May 11, 2019, participants must: 1) read the learning objectives and faculty disclosures; 2) complete the pre-assessment test; 3) respond to all polling questions online; 4) study the educational activity; and 5) complete the post-test and evaluation form and submit it online. A statement of credit will be issued only upon receipt of the above elements and a post-test score of 70% or higher. All components must be completed and submitted online at ClinicalAdvisor.com/Aug18feature. If you have any questions relating to the accreditation of this activity, please contact the AGA education department at education@gastro.org or 301-654-2055. If you have any questions relating to the CE accreditation of this activity, please contact AKH Inc. at jgoldman@ akhcme.com. If you have any other questions relating to your certificate or other issues with the activity, please contact myCME. Support@haymarketmedical.com.

Produced by

CME | CE FEATURED COURSE: MICHAEL B. WALLACE, MD, MPH

Precancerous lesions in GI mucosa: Staining and screening Improved detection has led to better recognition of lesions in the GI mucosa at earlier precancerous stages, leading to fewer malignant cases.

espite a decrease in the incidence of cancers of the gastrointestinal (GI) tract in recent years, these malignancies remain a significant diagnostic and treatment challenge globally. GI tumors are the leading cause of cancer death worldwide, with colorectal cancer (CRC) ranked as the third most common cancer of men and women in the United States (US).1,2 Significant improvements in detection, particularly with the advent of chromoendoscopy stains and virtual chromoendoscopy, have contributed to a better recognition of lesions in the GI mucosa at earlier precancerous stages, leading to a decrease in malignant cases. Bowel preparation is a critical step in detecting lesions because less-than-adequate preparation will result in a higher miss rate even with newer technologies.Available stains can be reactive, absorptive, or nonabsorptive and each detects certain morphologic characteristics of adenomas or serrated lesions; virtual chromoendoscopy techniques allow precise filtering of light to detect lesion characteristics.3,4 Clinician familiarity with these diagnostic technologies and the ability to implement them are essential to identifying and classifying lesions.

Introducing Jim

Sessile serrated polyp.

Jim, a 58-year-old male and former smoker with no family history of CRC, presents for a surveillance colonoscopy. His initial screening colonoscopy at age 50 years had identified a 15-mm hyperplastic (HP) polyp in the ascending colon, and an 8-mm

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

CME | CE FEATURED COURSE

tubular adenoma polyp in the sigmoid colon. Both were removed. Five years later, Jim underwent surveillance examination, which identified a 12-mm HP polyp in the ascending colon as well as 3 other polyps measuring 5-mm to 9-mm in the transverse colon, all of which were described histologically as HP. After review of the pathology report prior to the current exam, a pathologist reclassified all HP polyps as sessile serrated polyps. You recognize that Jim has serrated polyposis syndrome (SPS). ■ CLINICAL DECISION POINT: How would you proceed diagnostically with this patient?

a. Pancolonic chromoendoscopy immediately b. Standard colonoscopy immediately c. Targeted chromoendoscopy immediately d. Surveillance colonoscopy in 1 year SPS patients present a significant challenge due to both the number and subtlety of polyps.Advanced imaging methods, such as chromoendoscopy, have enhanced sensitivity and specificity and, therefore, play an important role in increasing detection rates. In a large (> 1000 patients) randomized controlled trial, Pohl et al showed that panchromoendoscopy increased adenoma detection rates (ADR) as well as serrated polyp detection rates.5 There are limited data on SPS and chromoendoscopy, but the advantages in sporadic serrated polyps are likely relevant enough to consider panchromoendoscopy in such patients.

need special guidance on how to manage their medications in advance of the procedure.10 Several preparations are available in split-dose preparations. An oral sulfate-free solution plus sulfate-free electrolyte lavage solution (ELS) is available and studies have demonstrated it is noninferior to low-volume polyethylene glycol electrolyte lavage solution (PEG-ELS).11 Two-liter PEG-ELS with ascorbic acid, which also are available in split-dose formulations, has shown equivalent efficacy with higher-volume agents.The lower-volume solution is advantageous because consuming a large volume of fluid may not encourage adherence. However, the presence of ascorbic acid may provoke hemolysis in certain individuals. A 1-liter PEG solution containing ascorbate has demonstrated significantly better cleansing rates when compared to 2-liter PEG with ascorbic acid, given as either an evening/morning split dose or overnight split dose.12 Other products (hypo-osmotic agents, hyperosmotic agents, or combination agents) can also provide successful bowel preparation when used properly.6 The split-dose method, in which half the dose of oral purgative is taken on the day before the procedure and the other half is taken the day of the procedure, has been shown to increase patient adherence and, importantly, to increase the potential for detecting adenomas.13,14 However, careful counseling, like the conversation that should take place with Jim, is needed to ensure that doses are taken at the appropriate times. Back to Jim

Back to Jim

Given the large number of polyps seen in patients with SPS—and the endoscopic mucosal resection (EMR) techniques required to remove them—Jim was scheduled for a 1-hour exam and workup.You discuss with Jim the need for adherence to the splitdose regimen for bowel preparation prior to the colonoscopy. Bowel preparation Incomplete bowel preparation can lead to failure to precisely identify the mucosal pathology and has been linked to an increased risk for procedural adverse events.5,6 Several factors are known to predict inadequate bowel preparation: history of inadequate preparation; polypharmacy (especially with constipating medications); obesity; male sex; advanced age; inpatient status; and presence of comorbidities such as cirrhosis, diabetes, stroke, dementia, or Parkinson’s disease.7-9 Patients also may fail to follow instructions or may not time the use of bowel purgatives appropriately. Although the role of dietary restrictions has not been fully elucidated in the bowel preparation process, it is unlikely that an exclusively liquid diet is required in most patients.10 Lowfiber diets are advantageous compared with those of high-fiber content.10 Patients with diabetes or with coagulation disorders

Jim’s physician recommends the split-dose regimen and has him return for an elective surveillance colonoscopy. He also must decide which staining agent he will use in preparation for performing the chromoendoscopy. ■ CLINICAL DECISION POINT: Which chromoendoscopy stain would be best in this situation?

a. Indigo carmine b. Acetic acid c. Congo red d. Methylene blue Chromoendoscopy staining Numerous stains are available for chromoendoscopy and can be classified as absorptive, nonabsorptive, or reactive.Acetic acid is an absorptive stain that acts as a contrast agent and denatures proteins.3 Studies have demonstrated that it has a 96% sensitivity and 80% specificity for detection of neoplasia in Barrett’s esophagus, and there was a significant improvement in detection compared with white light endoscopy (WLE).15 None of the currently available agents—cresyl violet, indigo carmine, congo red, phenol red, and methylene blue—is approved by the US Food and Drug Administration (FDA) for this purpose.

20 THE CLINICAL ADVISOR • AUGUST 2018 • www.ClinicalAdvisor.com

Cresyl violet, an absorptive stain, is taken up in crypts of Lieberkühn to show pits or dots.3 It can be combined with indigo carmine or methylene blue in the colon, and should be applied in small amounts.3 Cresyl violet, however, is not frequently used in the US. Lugol is an iodine-based absorptive staining solution that detects lesions in squamous epithelium through incorporation into glycogen, resulting in a distinct reptile skin-like pattern.3 Clinicians must recognize that depleted glycogen storage, a marker of neoplastic tissue, can also be an indicator of inflammatory diseases or Barrett’s esophagus.3 Studies have shown that lugol increased sensitivity for identifying dysplasia from 62% to 96% and increased detection of additional sites of dysplasia in patients who already had at least 1 identified site.16 Though generally safe, some patients may have an allergic reaction to iodine or report retrosternal discomfort, which can be reduced with sodium thiosulfate after chromoendoscopy.3,17 Indigo carmine is a nonabsorptive stain; it pools in mucosal grooves and crevices to establish topographic definition.3 Small amounts of dye are applied during continuous extubation, and patterns identified by the Kudo pit pattern classification can predict histology.3,18 Indigo carmine is useful in identifying lesion extension as well.When combined with acetic acid vs conventional endoscopy, results demonstrated significantly increased border detection in differentiated (but not undifferentiated) adenocarcinomas.19 Indigo carmine is currently in limited supply in the US. Congo red and phenol red are reactive stains. Congo red changes from red to dark blue or black when pH is less than 3.3 Prior to endoscopy, the patient takes pentagastrin, a synthetic polypeptide that stimulates gastric acid, pepsin, and intrinsic factor secretion and increases blood flow in the gastric mucosa. During endoscopy, sodium bicarbonate is sprayed prior to Congo red.3 Congo red can be combined with methylene blue to screen for gastric intestinal metaplasia.20 Areas that do not respond to either stain appear bleached, which can increase detection. A study demonstrated that this method increased detection from 28% with standard imaging to 89% with staining.21 Phenol red changes from yellow to red in an alkaline environment and can be used to detect Helicobacter pylori.3 However, this agent is not frequently used. Back to Jim

Jim and his physician decide to select methylene blue, a commonly used stain that is absorbed by the small intestinal and colonic epithelium but not by the squamous or gastric epithelium.3 The image in Figure 1, of a sessile serrated adenoma/ polyp (SSA/P), exemplifies the appropriate use of methylene blue. When targeting biopsies, endoscopists should look for heterogeneously stained or unstained areas because high-grade

IMAGE COURTESY OF MICHAEL WALLACE, MD

FEATURED COURSE

FIGURE 1: SSA/P with chromoendoscopy.

dysplasia and early cancers have fewer goblet cells and decreased cytoplasm, thereby decreasing the degree to which these cells can absorb methylene blue.3 The most common method of administration is mixing methylene blue (4 x 10 cc vials in 250 mL water) in the water wash bottle and then injecting through a powered water pump via the endoscopy channel. For targeted use, a higher concentration (2 x 10 cc vials in 25 mL water) is preferred.22 Unlike some other agents, a mucolytic agent is required prior to administering methylene blue.3 Efficacy has been demonstrated in many studies, including one that showed improved diagnosis of neoplasia in Barrett’s esophagus compared with random biopsies.23 Methylene blue is generally safe, although there is the possibility of oxidative damage to DNA when combined with WLE.24 An oral formulation for methylene blue is currently under review with the FDA. This formulation creates a partially hydrophobic environment; its release in the colon can increase mucosal cell contrast in an effort to increase adenoma detection rate (ADR).25 Studies have shown oral methylene blue to have acceptable staining levels in patients with ulcerative colitis undergoing chromoendoscopy.The accuracy of intraepithelial neoplasia detection was 86%.26 Phase 2 data showed an ADR of nearly 50%, and a polyp was detected in 63.5% of patients.27 Oral methylene blue stains the entire colon, and the stain is sustained for an adequate period of time for endoscopy. Moreover, colonoscopy time is reduced as the methylene blue is delivered orally rather than being sprayed intravenously.25 Virtual chromoendoscopy In addition to available stains for chromoendoscopy, lesions can be detected with virtual chromoendoscopy. For example, flexible spectral imaging color enhancement (FICE) is used to

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 21

CME | CE FEATURED COURSE

IMAGES COURTESY OF MICHAEL WALLACE, MD

enhance vascular and surface tissue by selecting wavelengths in postprocessing.4,28 Narrow band imaging (NBI) assesses the mucosa surface and vessels at different depths by modifying redgreen-blue filters to enhance the contribution of blue light and discard the red component (Figure 2).3,4 Hemoglobin strongly absorbs the blue light, creating increased contrast for superficial microvessels.29,30 NBI has been shown to be effective in the upper GI tract, particularly for the detection of Barrett’s esophagus.31 A newer modality, blue light imaging (BLI), also may help overcome the dark field of view associated with other narrowspectrum technology like FICE and NBI.4 BLI combines 2 light sources: one with a wavelength of 410 nm and the other, 450 nm. A study comparing BLI and NBI found significantly increased visibility distance with BLI as well as enhanced visualization of lesions in deeper layers.32 When magnifying endoscopy with BLI was compared with conventional endoscopy with whitelight imaging (WLI), BLI showed 92% accuracy vs 72% for WLI, as well as sensitivity of 94% and specificity of 92% (vs 47% and 80%, respectively).33 Like stains, virtual chromoendoscopy techniques can be combined with other modalities.4,29 I-SCAN is another postprocessing contrast technology that allows for surface enhancement to sharpen the image; contrast enhancement to highlight depressed areas; and tone enhancement, which is a form of narrowed-spectrum imaging.4 Tone enhancement is split into red, green, and blue components, and tone enhancement can be used for intestine, esophagus, and stomach imaging.4 I-SCAN can be used for lesion detection, characterization, and demarcation.4 Autofluorescence imaging and confocal laser endomicroscopy, 2 other virtual chromoendoscopy techniques, are not frequently used. White light endoscopy High-definition WLE (HD-WLE) is now a standard of care as an imaging modality in the esophagus, stomach, and colon (Figure 3).34 Like other imaging modalities, it can be combined to enhance detection. Additionally, HD-WLE is frequently used in the control group for endoscopic imaging studies.35 HD-WLE has supplanted standard WLE, which often failed to detect small or flat lesions.36 Magnifying endoscopy Magnifying endoscopy is also useful in characterizing neoplasia.34 When combined with indigo carmine in Barrett’s esophagus, it has a sensitivity of 97% and a specificity of 100% in high-grade dysplasia.37 When combined with acetic acid, it can achieve visualization of pit patterns in Barrett’s esophagus.3

FIGURE 2: A. SSA/P shown using white light endoscopy (WLE); B. chromoendoscopy; C. NBI.

Applying chromoendoscopy in practice Each endoscopy technique has its place in clinical practice, though it can be difficult to select the method and interpret

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

TABLE 1: JNET lesion characteristics.39 Characteristic

Type 1

Type 2A

Type 2B

Type 3

Vessel pattern

None or similar to surrounding normal mucosa

Regular caliber, regular distribution (meshed/spiral pattern)a

Variable caliber, irregular distribution

Loose vessel areas, interruption of thick vessels

Surface pattern

Regular dark or white spots, similar to surrounding normal mucosa

Regular (tubular, branched, or papillary)

Irregular or obscure

Amorphous areas

Microvessels often distributed in punctate pattern; well-ordered reticular or spiral vessels may not be observed in depressed lesions.

TABLE 2: Morphologic characteristics of serrated polyps.43-47 Characteristic

SSA/P

TSA

Subcategories

• Microvesicular (MVHP) • Goblet-cell rich (GCHP) • Mucin poor

With/without cytologic dysplasia

Pit pattern

Type II

Type II – open pit

Type II, some may have type IV

Location

• MVHP right side • GCHP left side

Right side

Left side

Mucus

Common on surface

Common

Histology/pathology

• MVHP: Serrated appearance of crypts and surface epithelium, microvesicular mucin in cytoplasm • GCHP: Small degree of serration, no microvesicular mucin in goblet cells • MPHP: No cytoplasmic mucin, increased nuclear atypia without pseudostratification

• Crypt dilation • Irregularly branching crypts • Horizontally arranged crypts in basal portion

• Goblet cells • Upper-zone mitoses • Nucleoli prominence • Absence of thickened collagen table

Shape

Sessile

Pedunculated

HP, hyperplastic polyp; MPHP, mucin-poor hyperplastic polyp; SSA/P, sessile serrated adenoma/polyp; TSA, traditional serrated adenoma.

TABLE 3: BASIC classification criteria.49 Surface

Pit Pattern

Vessels

Presence of mucus

Featureless

Presence

Regular/irregular

Round/nonround

If present: lacy, pericryptal, irregular

Presence of depression/pseudodepression

Round with/without dark spots Homogeneous/heterogeneous distribution —Heterogeneous with/without focal loss

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

IMAGE COURTESY OF MICHAEL WALLACE, MD

CME | CE FEATURED COURSE

FIGURE 3: Detecting an SSA/P using WLE.

findings. Chromoendoscopy stains can aid in identifying pit patterns, which will facilitate lesion detection and classification.38 Flat or sessile serrated polyps (SSPs) are easily missed, which can be detrimental to patient health. Clinicians may draw upon 2 sets of guidelines when using NBI. The first is the Japan NBI Expert Team (JNET) classification system.This system divides lesions into types 1, 2A, 2B, and 3 based on vessel pattern, surface pattern, and most likely histology (Table 1).39 The Workgroup serrAted polypS and Polyposis (WASP) classification includes features of SSA/Ps.40 These lesions were originally thought of as benign, though research has demonstrated that they may be responsible for up to 30% of CRC cases, highlighting the importance of including features of these lesions in any classification system.41 Serrated polyps can be divided into 3 categories: hyperplastic, which are typically nonmalignant; SSA/Ps; and traditional serrated polyps (TSAs).The latter 2 categories can be malignant.42 The WASP classification system adds 4 sessile features to either type 1 or type 2 polyps identified by NICE: clouded surface, indistinctive border, irregular shape, and dark spots inside crypts. If at least 2 of these features do not exist in a type 1 polyp, it is classified as HP. If they exist from a type 1 or type 2 polyp, the SSA/Ps, and if these features do not exist for a type 2 polyp, it is classified as an adenoma.40 Each type of serrated lesion has distinctive morphologic characteristics (Table 2, Figure 4 available online at ClinicalAdvisor.com/Aug18feature). The mucous cap appears red on NBI and is useful when differentiating SSA/Ps from other types of lesions. These lesions are also characterized by type II dilation pits when the lesion lacks dysplasia, but are characterized by type III

to type V pits when they do have dysplasia.43 TSAs, when visualized using NBI, characteristically have a brownish color, and orifices appear whitish and interstitial capillaries appear blackish.43 High-definition I-SCAN can also be used to detect lesions and is based on Kudo and WASP classification systems.48 I-SCAN showed an overall sensitivity of 79%, specificity of 86%, and accuracy of 81%. Accuracy was significantly higher in nondiminutive (93%) vs diminutive polyps (74%).48 BLI, a more recent addition to the virtual chromoendoscopy armamentarium, has its own set of classifications for lesions. BLI Adenoma Serrated International Classification (BASIC) is based on surface/vascular patterns and morphologic criteria (Table 3).49 This system was validated with and without optical magnification, and strong agreement was seen in each area when expert endoscopists were polled. Optical magnification tended to increase interobserver agreement. When the above features were applied to each lesion, endoscopists were able to develop a classification system to differentiate HP, SSA/Ps, and adenomas.49 Back to Jim

Case Conclusion Jim adheres to the split-dose regimen, and there is adequate bowel cleansing before the colonoscopy. He undergoes panchromoendoscopy using methylene blue. In the ascending colon, there is a 1.5-cm sessile lesion with features typical of SSA/P. It is removed by EMR technique, using pre-injection of a blue dye containing viscous agent, followed by snare resection.Three additional sessile polyps measuring 5 mm to 9 mm are removed from the transverse colon. All are SSA/P on pathology. Based on his diagnosis of SPS, you recommend a surveillance exam in 1 year. Conclusion

The prevalence and high mortality rate of any cancer of the GI tract dictates the need for early and accurate detection. Advances from standard WLE have increased lesion detection rates through either chromoendoscopy or virtual chromoendoscopy. Clinician familiarity with these methods, as well as with morphologic characteristics of adenomas and serrated polyps, is integral to patient care. Each stain and virtual chromoendoscopy technique has its place in detecting and classifying lesions, and guidelines for many techniques and stains are available. The field will continue to progress with new techniques and stains, increasing both the need for training and updated guidelines as well as a significant potential for a decrease in the number of new cases seen every year. ■

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

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CME CE

POSTTEST

A statement of credit will be issued only upon receipt of a completed pre-assessment test, polling questions, activity evaluation form, and posttest with a score of 70% or higher. All components must be completed and submitted online at ClinicalAdvisor.com/Aug18feature. CREDITS: 0.50 | Precancerous lesions in GI mucosa: Staining and screening

1. What is an advantage that oral methylene blue may have over currently available methylene blue? a. Shorter endoscopy time b. Detects additional morphologic features c. Can be combined with additional stains d. Higher detection rate for flat polyps 2. What color does the mucus cap appear for SSA/Ps when using NBI? a. Red b. Green c. White d. Brown

3. A mucolytic agent is required prior to: a. Indigo carmine b. Acetic acid c. Lugol d. Methylene blue 4. According to the JNET classification system, which of the following is the most likely pathology for type 2A lesions? a. SSA/P b. Adenoma c. Low-grade intramucosal neoplasia d. Shallow submucosal invasive cancer

TO TAKE THE POSTTEST please go to: ClinicalAdvisor.com/Aug18feature.

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

In tandem with our 20th anniversary, we at Clinical Advisor recognize the advances that have occurred in clinical practice over the past few decades and share the perspectives of members of our audience. Send us your letters with questions and comments to: Advisor Forum, The Clinical Advisor, 275 7th Avenue, 10th Floor, New York, NY 10001.You may contact us by e-mail at editor@ clinicaladvisor.com. If you are writing in response to a published letter, please indicate so by including the number in parentheses at the end of each item. Letters are edited for length and clarity. The Clinical Advisor’s policy is to print the author’s name with the letter. No anonymous contributions will be accepted.

CLINICAL PRACTICE: THEN AND NOW WHILE ELECTRONIC medical/health records (EMR/EHR) have streamlined the charting process and have made it easier to search for medical history information and diagnostic results, it has also left many providers feeling like we are spending more time on the computer in the exam room than actually examining the patient.To offset this disparity, I will turn the computer screen so the patient can see what I’m doing, and then ask them to verify the information I am entering and to add or correct anything.This involves the patient in the process, and they feel less like a fly on the wall. I think most patients appreciate this and leave feeling that they were really heard during the visit.—PAMELA PORTER, DNP, APRN, FNP-BC, CNS, PA-C, Davis, California PRACTICE IS NOW more complex. We are caring more for patients with numerous medical diagnoses. Patients are more demanding.They use “Dr Google” and come to the office with their own diagnosis or diagnoses. It takes patience to listen and sort out their signs and symptoms. It is also a more litigious atmosphere than when I first became a nurse practitioner. I have had the blessing of being in a wonderful family practice setting with compliant patients for the last 18 years, but I do plan on retiring this year!—MELINDA O’NEIL, CANP, Albuquerque, New Mexico

WHEREAS MY EARLY practice was definitely focused more on treating a disease state with medications, now I focus more on emphasizing lifestyle measures to improve health and well-being. It is a joy to see people make healthy choices that will benefit them for the rest of their lives.—JEANNE CHASE, DNP, APRN, FNP-BC, Stanford, Kentucky I STARTED WITH AN HOURLY wage and no benefits; 25 years later, partnerships in physician groups are not uncommon like they were all those years ago. Reimbursement is better, there is greater understanding of our role in the care team model, and there is more autonomy. More federal and state laws favor PA practice, as do labor groups and industries. We now have hospice and palliative care capabilities.The biggest change I see is the acceptance by other providers—MDs and DOs—and the recognition that we are professionals and should be treated and reimbursed similarly; at least in my state of Washington that is the rule rather than the exception! Coupled with the quadrupling of my hourly pay, the provision of full benefits with short- and long-term disability, 2 weeks of CME and $3000 available for it, 6 weeks of vacation, and 20% of gross to retirement paid from the group practice like the other providers: there have been a lot of positive changes over 25 years!—KEVIN LEWIS, PHYSICIAN ASSOCIATE, Seattle,Washington IN 1979, I WAS AWARDED a certificate as an adult and geriatric nurse practitioner. I could not admit patients to facilities and required a collaborative MD agreement. Compare this to the truly autonomous role nurse practitioners now fill in hospitals, skilled nursing facilities, ambulatory primary care positions, and emergency rooms. The

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

Advisor Forum profession has evolved to truly serve populations across the health care spectrum.—B. BETTS, MS, ARNP; PsyD, LP, Mankato, Minnesota AS A FAMILY nurse practitioner in Pennsylvania since 1985, I have lived through and participated in the legislative process to advance the profession. I witnessed Pennsylvania’s nurse practitioners first become regulated solely by the board of nursing, removing dual regulation by medicine and nursing and then receiving prescriptive authority. Hopefully I will still be practicing when full practice authority is enacted.—JO ANN NICOTERI, PhD, MS, CRNP, FNP-BC, Clark’s Summit, Pennsylvania I REMEMBER carrying brown charts, with colorcoded tabs that represented various sections in the chart (eg, lab, clinic notes, etc), to the patients’ rooms. The process of flipping through the chart and trying to find pertinent information would have begun prior to the encounter in the provider’s office. Now, I manage my patients visit by using 3 separate screens to chart my notes, review labs or old records, and complete medical orders. It is a more expedient process that allows for a quicker review.—MICHELLE LASTRAES, PA, Stafford,Texas MY PRACTICE HAS SEEN a shift away from a Medical Model to more of a Business Model with dispensing.The power of insurance companies to direct healthcare has increased with their approval of procedures. We now see an increase in research along with more biologic care.There has been less hands-on care accompanied by more computerized charting, along with telemedicine. Increased utilization of medical assistants is replacing roles once held by LPNs and RNs. There are longer hours and increased responsibilities and demands for nurse practitioners, but there is also increased autonomy. However, the ever-expanding crisis of shortage in care givers is worsening; this presents a mixed-bag of blessings and problems. —JENNIFER GRAVES, FNP, ANP-BC, Elkhart, Indiana ADVANCES IN SOCIAL MEDIA and changes in insurance reimbursements have shifted patient care priorities to positive patient experiences and good

customer feedback. Here are 5 tips to help create a smoother and more positive patient experience. Establish a positive encounter.A first impression sets the tone for the duration of the encounter, and the most important step in creating that positive first impression is to leave personal and professional drama OUT of the encounter. Showing up to meet your patient while distracted, angry, or otherwise in a negative state is unprofessional and shows the patient you cannot handle difficult situations or juggle multiple tasks.Take time to change your outward appearance so as to hide any negative feelings. Practice a personal approach. Personalize your patient’s experience by using the patient’s preferred name more than once in the visit; this creates a more intimate connection and sets the foundation for a more inviting personal relationship. Engage in culturally appropriate physical contact, such as a handshake when greeting or a supportive arm to assist with ambulation.At each visit, ask about life events or favorite activities and make a note. On subsequent visits, surprise your patient by bringing up the topic in a friendly way. Give thoughtful and useful feedback. Questions may be left unasked because patients feel they are “stupid” or “embarrassing.” Encourage your patient with supportive language. If your patient feels confident discussing difficult topics or embarrassing questions with you, they are more likely to be open and honest, helping you achieve better patient care. Set realistic goals and offer praise when achieved. Discuss treatment regimens with your patients and come up with small obtainable and measurable goals. If you have a broader or larger goal that seems overwhelming, break it down into smaller more easily attainable “step-by-step” goals. Give praise when goals are achieved. Follow up when you say you will. Keeping a relationship strong means sharing responsibilities. This includes the relationship we have with our patients. Be sure to keep your word when making plans with a patient and communicate when your tasks are completed or results are known. Although EMRs make it easier for patients to look up their own results, always close the communication loop by asking for confirmation that results were received and questions are answered.—JOE CIAVARRO JR, PA-C, New York, NY ■

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

Our Consultants Philip R. Cohen, MD,

is clinical associate professor of dermatology, University of Texas Medical Center, Houston Deborah L. Cross, MPH, CRNP, ANP-BC,

is associate program director, Gerontology NP Program, University of Pennsylvania School of Nursing, Philadelphia Abimbola Farinde, PhD, PharmD,

is a professor at Columbia Southern University in Orange Beach, AL Laura A. Foster, CRNP, FNP,

practices family medicine with Palmetto Primary Care Physicians in Charleston, SC Abby A. Jacobson, MS, PA-C,

is an assistant professor at Thomas Jefferson University and a dermatology PA at Family Dermatology of Reading, PA Debra August King, PhD, PA,

is senior physician assistant at New York-Presbyterian Hospital, New York City Mary Newberry, CNM, MSN,

provides well-woman gynecologic care as a midwife with Prima Medical Group, Greenbrae, CA Claire O’Connell, MPH, PA-C,

is an associate professor at the Rutgers University Physician Assistant Program, Piscataway, NJ Katherine Pereira, DNP, FNP,

is assistant professor, Duke University School of Nursing, Durham, NC Sherril Sego, FNP-C, DNP,

is an independent consultant in Kansas City, MO.

Dermatology Clinic CASE #1

Hyperpigmented bands across all fingernails KATHERINE PARK, BS, JOAN FERNANDEZ, BA, CHRISTOPHER RIZK, MD

A 62-year-old African American man presents to establish care and to undergo skin examination, which he reports receiving regularly since his sister was diagnosed with melanoma. Examination reveals 3-mm hyperpigmented horizontal bands across the nailbeds of all fingernails, which he reports have been present since his 20s. He denies experiencing any other nail changes or pain. He takes no medications, and he has no history of skin cancer or suspicious moles. He has no relevant medical history. What is your diagnosis? Turn to page 30

CASE #2

A persistent itchy rash on the leg of a college athlete LAUREN FULLER, BA, JOAN FERNANDEZ, BA, CHRISTOPHER RIZK, MD

A 22-year-old woman complains of an itchy rash on her leg for 4 weeks. She is a collegiate swimmer and had a prior ringworm infection during her freshman year. She has been using overthe-counter antifungal cream for the past 3 weeks with no relief. Multiple round, erythematous, scaling lesions are present on her right leg, some of which are vesicular and weeping. Potassium hydroxide (KOH) test is negative for a dermatophytic infection. What is your diagnosis? Turn to page 31 www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 29

Dermatology Clinic CASE #1

Melanonychia

Melanonychia is a common dermatologic condition involving black or brown pigmentation of the nail.While typically a benign finding, it has a wide differential and requires a detailed history and examination to rule out serious and potentially lifethreatening conditions such as subungual melanoma. Classifications of melanonychia include longitudinal and, rarely, transverse melanonychia. Longitudinal melanonychia typically originates from the distal nail matrix, where melanocytes are more active. It can be further classified into exogenous pigmentation, such as blood from trauma, and endogenous pigmentation, such as melanin. The origin of pigmentation can help determine the underlying pathology; for example, there are 2 common mechanisms that result in melanin production. Melanocytic activation occurs without a change in cell number, while melanocytic hyperplasia involves an increase in the number of melanocytes.1 Melanonychia may be physiologic or pathologic. Physiologic melanonychia includes melanonychia associated with pregnancy and ethnic melanonychia in individuals with darker skin tones. Prevalence, number of bands, and band width also increase with age. One study noted that 77% of the African American population had melanonychia by 20 years of age, and melanonychia was present in nearly 100% of those aged ≥50 years.1 In comparison, the prevalence of melanonychia in the white population is 1.4%.2 Prevalence does not appear to differ based on gender.3 Pathologic causes of melanonychia can be broadly categorized as localized or systemic. Localized causes include trauma, such as poor-fitting shoes or nail biting; infectious causes, such as onychomycosis; dermatologic conditions, such as lentigines, nevi, and subungual melanoma; and postinflammatory changes. Systemic causes include chemotherapy, medications, endocrine disorders, and a variety of syndromes including AIDS, Laugier-Hunziker syndrome, Peutz-Jeghers syndrome, hemochromatosis, and porphyria.4,5 The 2 most common causes of melanonychia in adults are lentigines followed by nevi.This differs from pediatric melanonychia, for which nevi account for approximately 50% of cases.6 When a patient presents with melanonychia, it is crucial to rule out skin cancers, especially subungual melanoma. This is especially important given the fact that two-thirds of cases of subungual melanoma first present with longitudinal

melanonychia. Because presentation of the two conditions can be so similar, subungual melanoma is commonly misdiagnosed with an average delay in diagnosis of 2 years.5 This delay has a significant impact on the patient’s morbidity and mortality given that subungual melanoma has a significantly worse prognosis than its cutaneous counterpart.7 Due to the wide differential, a thorough history and physical examination are vital for the proper diagnosis and management of melanonychia. Pertinent information includes the time of onset, any corresponding trauma, changes in appearance or size, number and location of nails affected, presence of pain or ulceration, recent medications, and medical and

Despite the availability of other options, histopathology remains the gold standard for the diagnosis of melanonychia. family history. Physical examination findings should involve assessment of all 20 nails, with notation of the location of the lesion, presence or absence of extension into surrounding structures, number of bands, size, pigmentation pattern, and borders.4 Levit et al published a helpful mnemonic for identifying subungual melanoma8: A = age of patient (peaks in the fifth to seventh decade of life) and race (up to one-third of all subungual melanoma cases are in African Americans, Asians, and native Americans) B = brown-to-black with a breadth of >3 mm and borders that are variegated C = change in nail band or lack of change in nail morphology despite adequate treatment D = the digit most commonly involved (thumb > hallux > index finger, dominant hand, only one digit involved) E = extension of the pigment onto the proximal and/or lateral nail fold (ie, Hutchinson sign) F = family or personal history of dysplastic nevus or melanoma

The physical examination can help to distinguish whether the pigmentation is endogenous or exogenous as many exogenous pigments, such as potassium permanganate, can simply be scraped off of the nail surface. In cases of melanonychia, dermoscopy has been shown to be more effective than clinical observation in the evaluation of the lesions. A grey background with regular parallel lines typically represents melanocytic activation including ethnic melanonychia, lentigines, and drug-induced pigmentation. Dermoscopic findings that are concerning for

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

melanoma include wide bands and the Hutchinson sign, as well as irregular pigmentation, thickness, and borders. Subungual hematomas often present as red or purple pigmented globules with peripheral fading; however, the presence of blood does not rule out malignancy. Examination of the mucosa aids in the identification of Laugier-Hunziker and Peutz-Jeghers syndromes, which are also associated with melanonychia.4 Once melanonychia has been identified, further workup is largely dependent on the differential diagnosis developed based on the history, physical examination, and all other collateral information. This workup may include nail-clipping cultures for evaluation of infectious etiologies, regular followup for observation of benign-appearing pigmentation pattern, or histopathologic examination for suspicious pigmentation patterns or history.9 Despite the various approaches that can be taken, histopathology remains the gold standard for the diagnosis of melanonychia. The histopathologic findings characteristic of subungual melanocytic nevi include wellformed nests of melanocytes at the junction of the nail matrix and dermis. Lentigines and melanomas may be difficult to distinguish histopathologically, but melanoma is more likely to have a high concentration of melanocytes at the dermoepithelial junction and cytologic atypia, multinucleation, or florid pagetoid spread of melanocytes.10 Treatment also varies based on the underlying etiology but may include antifungal agents or antibiotics for infectious causes, discontinuation of the offending drug, or surgical excision.4 Cases of melanonychia should be referred for evaluation by a board-certified dermatologist to ensure that melanoma is ruled out. In this case, the clinical presentation was consistent with a benign form of melanonychia.The presence of nearly identical transverse melanonychia across all 10 fingernails was a reassuring sign that the hyperpigmentation was benign in origin. If the pigmentation were more irregular and only present on 1 nail, biopsy would have been strongly considered.The hyperpigmented bands were measured and the patient was followed in clinic for routine skin assessments. Katherine Park is a medical student, Joan Fernandez is a medical student, and Christopher Rizk, MD, is a dermatology resident at the Baylor College of Medicine in Houston. References 1. Andre J, Lateur N. Pigmented nail disorders. Dermatol Clin. 2006;24(3):329-339. 2. Duhard E, Calvet C, Mariotte N, Tichet J, Vaillant L. [Prevalence of longitudinal melanonychia in the white population]. Ann Dermatol Venereol. 1995;122(9):586-590. 3. Leung AK, Robson WL, Liu EK, et al. Melanonychia striata in Chinese children and adults. Int J Dermatol. 2007;46(9):920-922.

4. Braun RP, Baran R, Le Gal FA, et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol. 2007;56(5):835-847. 5. Jefferson J, Rich P. Melanonychia. Dermatol Res Pract. 2012;2012:952186. 6. Goettmann-Bonvallot S, Belaich AJ. Longitudinal melanonychia in children: a clinical and histopathologic study of 40 cases. J Am Acad Dermatol. 1999;41(1):17-22. 7. Banfield CC, Redburn JC, Dawber RPR. The incidence and prognosis of nail apparatus melanoma. A retrospective study of 105 patients in four English regions. Br J Dermatol. 1998;139:276-279. 8. Levit EK, Kagen MH, Scher RK, Grossman M, Altman E. The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol. 2000;42:269-274. 9. Piraccini BM, Dika E, Fanti PA. Tips for diagnosis and treatment of nail pigmentation of nail pigmentation with practical algorithm. Dermatol Clin. 2015;33:185-195. 10. Amin B, Nehal KS, Jungbluth AA, et al. Histological distinction between subungual lentigo and melanoma. Am J Surg Pathol. 2008;32:835-843.

CASE #2

Nummular Eczema

Nummular eczema, also known as discoid eczema or nummular dermatitis, is named for its distinct coinshaped lesions. These lesions are typically found in groups on the trunk and extremities1 and are often intensely pruritic. This condition can persist for months to years despite treatment, with frequent relapses possible.2 The prevalence of nummular eczema is approximately 0.1% to 9.1%.3 Men aged ≥40 years are more commonly affected while the condition affects women more often at age ≤30 years. The overall incidence of disease is higher in men than in women.3 Traditionally, nummular eczema was thought to be of endogenous etiology; however, the exact cause is unknown and is likely multifactorial. Risk factors include dry skin, winter and summer weather, Staphylococcus, emotional stress, allergies, poor circulation, and edema of the lower extremities.1 Two-thirds of patients with nummular eczema are found to have dry skin. Fragrances, cosmetics, chrome, nickel, alcohol, neomycin, and isotretinoin are possible triggering allergens.2 One theory of pathogenesis postulates that an impaired cutaneous barrier, caused by dry skin, allows allergens to permeate the skin and cause an immunologic reaction.4

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

Dermatology Clinic On examination, lesions typically present as 1-cm to 3-cm, well-demarcated, scaly, erythematous, coin-shaped plaques found primarily on the extremities and trunk. Commonly affected areas include the dorsum of the hands, as well as extensor surfaces. Lesions may also present with crusts, vesicles, excoriations, and serous exudate.1 A single round lesion may present initially.5 More lesions may appear and can expand to form raised plaques with peripheral vesicular borders and central erythema.6 Honey-colored crust on the lesions may indicate a secondary staphylococcal infection.7 Dermoscopic examination of the lesions may show yellow clods, scales, crusts, or red-brown globules. The yellow clods are 1-mm to 2-mm accumulations of serous exudate, best seen

The diagnosis of nummular eczema is made clinically based on patient history and physical examination findings. when the lesion is wet. Histopathologic examination can show spongiosis, irregular acanthosis, parakeratotic scaling and inflammatory cell infiltration of the superficial dermis and epidermis.8 The differential diagnosis of round, erythematous lesions includes tinea corporis, psoriasis, mycosis fungoides, lichen aureus, allergic contact dermatitis, and atopic dermatitis.2 The diagnosis of nummular eczema is made clinically based on patient history and physical examination findings. A biopsy can be obtained to rule out skin conditions like mycosis fungoides; however, histopathologic findings are similar to those found in other types of subacute or chronic eczema.5,8 A patient with lesions on the flexor surfaces or with a history of allergies, asthma, or atopy makes atopic dermatitis the more likely diagnosis.3 The presence of multiple yellow clods on dermoscopic examination can help distinguish nummular eczema from tinea corporis and psoriasis.9 Tinea corporis lesions are round with central clearing and have peripheral erythema and scaling. KOH preparation of lesion scrapings can be analyzed microscopically to rule out dermatophytic infection.4 A patient presenting with thick, silvery plaques and nail changes likely has psoriasis. Compared with nummular eczema, psoriasis lesions have a more symmetric distribution with involvement of the head and neck.3 Lichen aureus is a type of pruritic pigmented dermatosis.The lesions are round, rust-colored plaques that are found mainly on the extremities. Dermoscopy and histopathology can be used to differentiate this condition from nummular eczema.10

The role of hypersensitivity reactions in nummular eczema is unclear. Contact dermatitis can also present with round lesions after an exposure and can mimic nummular eczema. Patch testing can be used to identify allergens and irritants that contribute to lesion formation.2 Patch test will be positive in one-third to one-fourth of patients with nummular eczema.7 First-line treatment for this condition includes moderate- to high-potency topical corticosteroids or topical calcineurin inhibitors. Emollients help to keep the skin hydrated.2 Antihistamines may be prescribed to help reduce itching, especially during the night.Topical antibiotics, like mupirocin, or oral antibiotics are only necessary to treat any secondary bacterial infections that may arise. Light therapy using narrow-band ultraviolet B or psoralen plus ultraviolet A may be used for refractory cases.7 In this case, our patient was given topical corticosteroids and instructed to apply the ointment to the affected area 1 to 2 times daily. She was also advised to take short lukewarm showers and to moisturize with copious amounts of Vaseline® multiple times daily. With this regimen, the lesions mostly resolved. However, the lesions returned during the summer when the patient had multiple hours of swim practice per day. She has been able to maintain control of the disease through vigilant moisturizing and early application of topical steroids at the first sign of a developing lesion. ■ References 1. Bonamonte D, Foti C, Vestita M, Ranieri LD, Angelini G. Nummular eczema and contact allergy: a retrospective study. Dermatitis. 2012;23(4):153-157. 2. Jiamton S, Tangjaturonrusamee C, Kulthanan K. Clinical features and aggravating factors in nummular eczema in Thais. Asian Pac J Allergy Immunol. 2013;31(1):36-42. 3. Reider N, Fritsch PO. Other eczematous eruptions. In: Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed. Philadelphia, PA: Elsevier; 2018:228-241. 4. Rattan R, Tegta GR, Shanker V, et al. Role of contact allergens in chronicity and relapses of nummular eczema. Int J Res Dermatol. 2017;3(2):213-218. 5. Habif TP, Campbell JL, Chapman MS, Dinulos JGH, Zug KA. Skin Disease E-Book: Diagnosis and Treatment. Philadelphia, PA: Elsevier; 2017. 6. Halburg M. Nummular eczema. J Emerg Med. 2012;43(5):327-328. 7. James WD, Berger TG, Elston DM. Atopic dermatitis, eczema, and noninfectious immunodeficiency disorders. In: Andrews’ Diseases of the Skin. 12th ed. Philadelphia, PA: Elsevier; 2016:62-89. 8. Moore MM, Elpern DJ, Carter DJ. Severe, generalized nummular eczema secondary to interferon alfa-2b plus ribavirin combination therapy in a patient with chronic hepatitis c virus infection. Arch Dermatol. 2004;140(2):215-217. 9. Navarini AA, Feldmeyer L, Öndury BT, et al. The yellow clod sign. Arch Dermatol. 2011;147(11):1350-1350. 10. Suh KS, Park JB, Yang MH, Choi SY, Hwangbo H, Jang S. Diagnostic usefulness of dermoscopy in differentiating lichen aureus from nummular eczema. J Dermatol. 2016;44(5):533-537.

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

Dermatologic Look-Alikes Painless nodules on the fingers MCKENNA BOYD, BA, JOAN FERNANDEZ, BA, CHRISTOPHER RIZK, MD

CASE #1

CASE #2

A 35-year-old man presents with several nodules on the dorsal aspect of his left hand. These lesions have been present for several weeks. On questioning, the patient states that his brother has similar nodules on his fingers. He remembers injuring his hand at work a few days before he noticed the lesions. On examination, a grouping of flesh-colored, rough, scaly nodules is noticed on the patient’s left hand. Each nodule is characterized by several punctate black dots.The lesions do not cause the patient pain or interfere with his daily activities; however, he finds them unsightly.

A 56-year-old woman presents with a translucent nodule on her right index finger. The patient first noticed the lesion a month ago and states that it has gradually increased in size since that time. She denies pain or decreased range of motion, but she states that the lesion is tender to the touch. The patient’s medical history includes hypertension, dyslipidemia, and osteoarthritis. On examination, there is a solitary, 5-mm translucent nodule located between the proximal nail fold and the distal interphalangeal joint on her right index finger. The nail bed distal to the lesion is also slightly atrophic.

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

Dermatologic Look-Alikes CASE #1

Verruca vulgaris

Verruca vulgaris, or common warts, are caused by infection of epidermal or mucosal cells with human papillomavirus (HPV), most commonly HPV type 2.1 The virus induces proliferation of infected cells and results in circumscribed, rough, irregular lesions. Common warts are typically asymptomatic but may result in functional impairment and are often a cosmetic concern for the patient. This skin manifestation is relatively common, with an estimated prevalence of 7% to 12%.2,3 Children and adolescents are the most commonly affected populations, with risk of disease declining after the second decade of life.1,2 The infection can be transmitted by direct or indirect contact with a cutaneous wart. Accordingly, sites of trauma result in an increased risk of inoculation.2 Other risk factors for acquisition of disease include immunosuppression; close contact with infected individuals; nail biting; and the handling of meat, poultry, and fish.2,4 The diagnosis of verruca vulgaris is most often made clinically through the identification of the characteristic lesions. These lesions can present as a solitary, well-circumscribed, rough nodule with an irregular, scaly surface or as grouped lesions. The lesions most commonly occur on the hands, fingers, and knees.1 Paring or filing of the wart often reveals punctate black dots indicative of thrombosed capillaries that can aid in the diagnosis.1,2 If a biopsy is obtained, histopathology reveals papillomatosis, hyperkeratosis, acanthosis, and parakeratosis.2 Arborization, or inward bowing of rete ridges, is also typically seen. Of the common characteristics of verruca vulgaris, there are 3 features in particular that can help to distinguish this diagnosis from other papillomas: koilocytes, columns of parakeratosis, and clumped keratohyaline granules.1 The differential diagnosis for verruca vulgaris can be fairly broad, including syringoma, molluscum, lichen planus and nitidus, actinic keratosis, and seborrheic keratosis, among others.2 A syringoma is a benign tumor of eccrine cells that appears as a small, smooth bump under the skin surface. Infection with molluscum contagiosum, a pox virus, typically results in multiple round, umbilicated, waxy papules. Lichen nitidus produces many flat, flesh-colored micropapules while lichen planus produces violaceous, flat, purple papules. Seborrheic keratoses are noncancerous papules with a warty surface and a “stuck-on” appearance. Although there are

multiple pathologies to consider in the differential diagnosis, verruca vulgaris can be morphologically and histopathologically distinguished from these other diseases by the defining characteristics discussed above. As stated previously, most cases of verruca vulgaris are diagnosed clinically upon visual inspection of the lesion; however, on the occasion that a diagnosis is uncertain, shave biopsy followed by histopathologic evaluation may be performed to make a definitive diagnosis. Once the diagnosis of verruca vulgaris is made, an appropriate treatment plan can be devised. Fortunately, most warts resolve spontaneously, particularly in immunocompetent individuals.5 In two-thirds of children, spontaneous remission occurs within 2 years; however, adult lesions often take several years to resolve.6 Indications for treatment include functional impairment, patient concern, persistence, and immunosuppression.2 First-line treatment for verruca vulgaris is salicylic acid.This treatment option is commonly employed due to its efficacy, ease of use, and minimal side-effect profile. Salicylic acid is an organic acid that works primarily by helping to soften the hyperkeratosis and to exfoliate the HPV-infected epidermal cells; additionally, it activates the local immune response.2,3 Proper use of this treatment requires daily, direct application onto a dry wart. Additionally, hyperkeratotic debris may be removed periodically by soaking and paring of the wart prior to application of salicylic acid to increase the effectiveness of the treatment.

Verruca vulgaris, a common wart, is most often diagnosed by identification of the characteristic lesions. If salicylic acid is not effective in treating the affected area, then second-line treatment with a combination of cryotherapy with liquid nitrogen followed by daily salicylic acid application may be considered.2,3 It is important to note that cryotherapy is typically avoided in young children due to the pain associated with this treatment in comparison to the benign nature of the wart. The use of this combination therapy is particularly beneficial for hand warts; however, the provider must use caution when treating periungual warts in order to avoid nail matrix damage and nail dystrophy.7,8 Recommendations for cryotherapy include application every 2 to 3 weeks until resolution is achieved.Transition to another treatment should be considered if the wart persists after 3 months or 6 treatments.5,9 Treatment-refractory warts may require novel therapies such as topical immunotherapy,

34 THE CLINICAL ADVISOR • AUGUST 2018 • www.ClinicalAdvisor.com

imiquimod, intralesional bleomycin, or topical 5-fluorouracil; surgical removal may also be considered.2 Our case patient was diagnosed with verruca vulgaris. This patient was advised to apply salicylic acid to his warts daily with occlusion until resolved. He was also instructed to soak and file his warts several times a week to remove excess debris. Following this regimen, the patient’s warts resolved within 1 month.

CASE #2

Digital mucoid cyst

A digital mucoid cyst (DMC), otherwise known as a myxoid cyst or digital mucus pseudocyst, is a benign translucent cyst typically located between the dorsal surface of the distal interphalangeal joint and the proximal nail fold. 10,11 Contrary to its name, a DMC is technically a pseudocyst because of its lack of an epithelial lining. How these lesions arise remains unclear; however, 2 mechanisms have been proposed.12,13 The first way in which a DMC can arise is by the extravasation of fluid as it leaks from the neighboring joint through a communicating canal. The second method by which a DMC can arise is from the excess production of hyaluronic acid by fibroblasts. When DMCs develop by this method, they are independent of the joint and typically involve the proximal nail fold. Second to cutaneous warts, DMCs are the next most common ungual tumor.10 Osteoarthritis is the greatest risk factor for the development of a DMC, with 64% to 93% of patients with osteoarthritis having coexisting DMCs.12,14,15 The population most commonly affected by DMCs are adults aged 40 to 70 years, likely because osteoarthritis is more common in this age group.10 Additionally, women are twice as likely as men to develop a DMC.12,16 DMCs most commonly present lateral to midline on the middle or index finger of the dominant hand and can occasionally, yet uncommonly, present on the toes.10,13 This type of cyst is typically a slow-growing, localized, solitary lesion that ranges in size from 3 mm to 10 mm. A DMC typically contains clear viscous fluid that often stains positive for hyaluronic acid.17 These cysts are often asymptomatic but may cause pain, tenderness, decreased range of motion, nail deformities, and fluid drainage in some patients. Additionally,

a lesion located distal to the proximal nail fold may result in a longitudinal depression in the nail bed, commonly referred to as a “groove sign.”10 The diagnosis of a DMC can be obtained through a variety of techniques; however, the diagnosis for uncomplicated DMCs is classically made clinically. For cases more difficult to diagnose, transillumination, fine needle aspiration of clear gelatinous fluid, methylene blue infusion, and histopathologic examination may be necessary to confirm the diagnosis.10 If a biopsy is performed, microscopic examination of a DMC will show fibroblast metaplasia within the dermis and excess hyaluronic acid production. Because these lesions are pseudocysts, an epithelial lining will be noticeably absent and a lining consisting of fibroblasts and compressed connective tissue will be present instead. DMCs are filled with collagen, basophilic mucin, and acid mucopolysaccharides.10,18 The differential for a DMC includes ganglion cyst, rheumatoid nodule, heberden node, epidermoid cyst, and many other similarly appearing lesions.Although sometimes difficult to distinguish, these diagnoses all have defining characteristics that can be used to differentiate one from another. A ganglion cyst is typically larger and deeper than a DMC, and

Osteoarthritis is the greatest risk factor for the development of a digital mucoid cyst, a common ungual tumor. ganglion cysts are associated with larger joints. A rheumatoid nodule is a cutaneous manifestation of rheumatoid arthritis that presents as a firm localized swelling typically found on finger joints, elbows, forearms, knees, and heels whereas heberden nodes are hard, bony swellings at the distal interphalangeal joint. An epidermoid cyst can be differentiated from a DMC by the fact that an epidermoid cyst is a true cyst with a squamous epithelial lining containing keratin and lipid. These lesions, unlike DMCs, are more common in men. Despite the varied differential, the presentations described above can help elucidate the correct diagnosis. In most cases, a clinical diagnosis is sufficient, but as described previously, for complex cases imaging and or histopathology can provide a definitive answer. While observation of asymptomatic lesions is appropriate, treatment is typically required for elimination of troublesome DMCs as spontaneous regression rarely occurs.10 Even with treatment, recurrence is common. One noninvasive treatment option involves several weeks of daily firm compression. For

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

Dermatologic Look-Alikes Verruca Vulgaris

Digital Mucoid Cyst

Dermatologic presentation

• Circumscribed, rough nodules with an irregular scaly surface • Solitary or grouped lesions • Punctate black dots of thrombosed capillaries • Asymptomatic to functional impairment

• Translucent nodule containing clear viscous, gelatin-like fluid • Slow-growing, localized, solitary lesion • 3 mm to 10 mm in size • Often asymptomatic • Symptoms include pain, tenderness, decreased range of motion, nail deformities, and discharge

Associations

• Most common in children and adolescents • Impaired epithelial barrier • Nail biting • Immunosuppression • Meat handling

• Most common in adults aged 40 to 70 • Coexistence with osteoarthritis • Female gender

Etiology

• Human papillomavirus (HPV)

• Communicating canal from joint OR • Fibroblastic excess production of hyaluronic acid

Characteristic location

• Hands, fingers, and knees

• Between the dorsal surface of the distal interphalangeal joint and the proximal nail fold • Most often on middle or index finger of dominant hand

Histology

• Papillomatosis • Hyperkeratosis • Acanthosis • Vertical columns of parakeratosis • Arborization • Koilocytes • Clumped keratohyaline granules

• Fibroblast metaplasia within the dermis • Excess hyaluronic acid • Fibroblast/connective tissue lining (not epithelial) • Lesion filled with collagen, basophilic mucin, and acid mucopolysaccharides

Diagnosis

• Clinical

• Clinical • Transillumination • Fine needle aspiration • Methylene blue infusion • Histopathology

Treatment

• Observation/spontaneous resolution • Salicylic acid with occlusion • Salicylic acid and cryotherapy • Treatment-refractory lesions may require topical immunotherapy, imiquimod, bleomycin, 5-fluorouracil, surgery

• Observation • Firm compression • Needling • Intralesional steroid injection • Percutaneous sclerotherapy • Cryotherapy • Surgery

painful or cosmetically unappealing lesions, surgical removal may be required.This approach boasts the lowest rates of recurrence. Cure rates for surgical removal are high at 90%; however, there is an associated risk of developing septic osteoarthritis following surgery.11 Additional options include repeated needling to induce fibrosis and close the communicating canal, intralesional steroid injection with a triamcinolone solution, percutaneous sclerotherapy with sodium tetradecyl sulfate or polidocanol, and cryotherapy with liquid nitrogen.10,19,20 The case patient was diagnosed with a digital mucoid cyst. She was advised to apply a firm compress to the lesion daily for 2 weeks.The lesion regressed; however, one month after treatment

it returned. Annoyed by the cyst, the patient opted for surgical removal and at 1-year follow-up is happy to report no recurrence. ■ McKenna Boyd is a medical student, Joan Fernandez is a medical student, and Christopher Rizk, MD, is a dermatology resident at the Baylor College of Medicine in Houston. References 1. Fazel N, Wilczynski S, Lowe L, Su LD. Clinical, histopathologic, and molecular aspects of cutaneous human papillomavirus infections. Dermatol Clin. 1999;17(3):521-536.

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Dermatologic Look-Alikes 2. Lynch MD, Cliffe J, Morris-Jones R. Management of cutaneous viral warts.

12. Jabbour S, Kechichian E, Haber R, Tomb R, Nasr M. Management of

BMJ. 2014;348:3339-3345.

digital mucous cysts: systemic review and treatment algorithm. Int J Dermatol.

3. Ockenfels HM. Therapeutic management of cutaneous and genital warts.

2017;56(7):701-708.

J Dtsch Dermatol Ges. 2016;14(9):892-899.

13. Zuber TJ. Office management of digital mucous cysts. Am Fam Physician.

4. Kilkenny M, Marks R. The descriptive epidemiology of warts in the

2001;64:1987-1990.

community. Australas J Dermatol. 1996;37(2):80-86.

14. Kleinert HE, Kutz JE, Fishman JH, McCraw LH. Etiology and treatment of the

5. Pyrhönen S, Johansson E. Regression of warts. An immunological study.

so-called mucous cyst of the finger. J Bone Joint Surg Am. 1972;54:1455-1458.

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15. Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst

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16. Sonnex TS. Digital myxoid cysts: a review. Cutis. 1986;37:89-94.

cutaneous warts 2014. Br J Dermatol. 2014;171(4):696-712.

17. Nishimura M, Kohda H, Takazono I, Tanaka Y. Chemical components of

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jelly-like matrix in digital mucous cyst. Clin Exp Dermatol. 1985;10:116-120.

cutaneous warts. Cochrane Database Syst Rev. 2012;9:CD001781.

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19. Park SE, Park EJ, Kim SS, Kim CW. Treatment of digital mucous cysts

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with intralesional sodium tetradecyl sulfate injection. Dermatol Surg.

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As we celebrate our 20th anniversary, we thank our audience for making The Clinical Advisor its go-to source for information to improve clinical practice and patient care.

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

LEGAL ADVISOR CASE

HIPAA Violation Derails NP’s Career The career of a healthcare provider is put in jeopardy. BY ANN W. LATNER, JD

Ms L was a nurse practitioner working in the neurology department of a major medical center. She had been working at that job for more than 10 years and had worked in the field of neurology for more than 2 decades. Ms L specialized in treating patients with multiple sclerosis, as well as those with headache disorders. Although she enjoyed her work, Ms L felt that it was time for a change and accepted a job offer from a large neurology practice. As she was winding down her work at the medical center, she asked her administrator for a list of patients she had treated so that she could ensure their continuity of care. The administrator, believing this to be a legitimate request to assist in ensuring that the patients had a smooth transition to a new practitioner, provided Ms L with a document including information on more than 3000 patients she had treated during her time at the medical center. The list included the patients’ names, addresses, dates of birth, and diagnoses. To Ms L, “continuity of care” meant letting the patients know where she was going so that they could switch providers if they chose. To the

Personally identifiable information is protected and must be treated with care and caution.

administrator,“continuity of care” meant ensuring that the next clinician to care for that patient would understand the patient’s case. Ms L gave the document to her future new employer, the neurology practice. A representative of the practice then sent letters to all of Ms L’s patients, notifying them that Ms L would be working at the practice and advising them about how to switch their care from the medical center to the neurology practice. Staff at the medical center discovered that Ms L had shared the document when they began receiving angry calls from patients who had received the letter and were upset that their personal information had been shared. Officials at the medical center interviewed Ms L; she was subsequently suspended and ultimately terminated. The medical practice where Ms L was to have started working was notified that neither the 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 • AUGUST 2018 39

LEGAL ADVISOR medical center nor its patients had consented to the sharing of the document containing the patient information. Upon being notified, the medical practice immediately returned the document and deleted any patient information it had. It also rescinded its job offer to Ms L. The incident triggered an investigation by both the state attorney general and the federal Office of Civil Rights, which is the agency that enforces violations of the Health Insurance Portability and Accountability Act (HIPAA). The medical center was accused of not protecting the personal health information of its patients and not properly training its employees on policies and procedures to protect such health information. A settlement was reached with the state attorney general, requiring the medical center to pay a $15,000 fine, to train staff on the handling of protected health information, and to report any breaches that may occur over the next 3 years to the attorney general. The medical center also contacted the affected patients to explain what had happened and instituted a new privacy policy paying particular attention to how patient information is handled when employees leave or join the medical center. The Office of Civil rights, aware of the action by the state attorney general, ultimately decided against launching its own enforcement action.

To protect yourself from inadvertently violating HIPAA, be sure you know your practice’s policies and procedures. “This settlement strengthens protections for patients,” said the attorney general in a statement, “and it puts other healthcare entities on notice that my office will enforce HIPAA data breach provisions. Other medical centers, hospitals, healthcare providers and healthcare entities should view this settlement as a warning and take the time now to review and amend, as needed, their own policies and procedures to better protect private patient information.” Ms L’s troubles were not over, however. In addition to losing her current job with the medical center and her future job with the medical practice, the state licensing board began an action against her. Upon the advice of her attorney, and because she felt that she had few options, Ms L signed a consent order with the state nursing board’s Office for Professional Discipline in which she admitted to violating HIPAA. As part of the settlement, Ms L’s license was suspended for a year, and she received another year of

a stayed suspension and 3 years’ probation. Following this period, she returned to practice. Legal Background

Enforcement of the HIPAA privacy rule protecting personally identifiable patient information began in 2003. The Health and Human Service’s Office for Civil Rights is responsible for enforcing the rule, and they are the body that generally does so. However, in 2009, the Health Information Technology for Economic and Clinical Health (HITECH) act was enacted to promote the adoption and meaningful use of health information technology.The HITECH act empowers state attorneys general to enforce HIPAA rules by permitting civil actions against violators, which is what happened to the medical center in this case. The handful of state attorneys general who have pursued HIPAA enforcement cases thus far includes those from the states of New York, Connecticut, and Massachusetts. Protecting Yourself

Personally identifiable patient health information is protected and must be treated with great care and caution. This case, however, highlights the challenges that can be faced when a healthcare practitioner changes practices. Healthcare practitioners consider themselves to have an ongoing relationship with their patients from a treatment perspective. Thus, they may believe that they can take a patient list with them when they move from one practice to another. However, absent an agreement to the contrary, the patient list belongs to the former employer, not the healthcare practitioner who was being employed by that employer. Without consent from both the former employer and the patients, their information should not be transferred elsewhere. It is likely that Ms L was doing what she thought was best for her patients: providing them with an opportunity to continue their care with her, albeit at a different practice. However, she did not tell her current employer (the medical center) what she intended to do with the list, and the medical center clearly provided it because they believed it was going to be used to ease the transition of care for patients from Ms L to another of the medical center’s practitioners. To best protect yourself from inadvertently violating HIPAA, be sure you know your practice’s policies and procedures, and be clear about what you plan to use the information for in advance. ■ Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, NY.

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

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Writers’ Guidelines The Clinical Advisor welcomes submissions from its readers. Writing for us is an opportunity to share your knowledge and experience with your colleagues. We’ll be glad to work with you to develop your ideas into compelling articles. As for length, that depends on which kind of article you submit. We are available to assist you in crafting both short clinical pearls or an indepth review of a topic that is of interest to you. CLINICAL FEATURES update our readers on the latest information about conditions seen in everyday practice. Running approximately 2500 to 5000 words, including references, features can be written either as regular narratives or as a series of questions and answers. Topics should be selected with the busy primary care clinician in mind; specialists should review specialty topics from the primary care point of view. If at all possible, articles should be accompanied by clinical photos. Charts, tables, and algorithms are also encouraged. Please include your title and affiliation. CLINICAL CHALLENGE is our popular department comprising histories of difficult cases. Each case is presented as a step-by-step, chronological account, revealing the author’s thought processes along the way. It is divided into sections in this order: the patient presentation; the patient history; the twists and turns eventually leading to a diagnosis; the treatment and outcome; and a discussion of the lessons learned or of the condition in general. The length should be about 1500 words, and accompanying images are encouraged. Please include your title and affiliation. Dermatology Clinic CASE #1

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

The patient is a 12-year-old Hispanic girl who presents with a 6-month history of nail dystrophy involving all of her fingernails. On examination, all 10 of her fingernails exhibit longitudinal ridging, pitting, fragility, thinning, and distal notching. The patient’s mother is very concerned about the cosmesis of her daughter’s nails. The patient has no systemic symptoms. On review of systems, the patient’s mother noted that her daughter has started to develop circular patches of hair loss that appear to resolve on their own. The patient has no relevant social or family history and does not take any medications. What is your diagnosis? Turn to page 54

CASE #2

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

A 42-year-old man presents with a four-day history of experiencing headache, malaise, and stabbing right-sided headache. Two days after his initial symptoms appeared, he developed a rash over the area of pain. He reports that he went hiking through the Texas hill country prior to becoming ill. The patient is otherwise in good health and has an unremarkable medical history. Physical examination reveals unilateral erythematous, thin, raised plaques over the right forehead. In addition, he has no relevant social or family history. What is your diagnosis? Turn to page 55 www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • DECEMBER 2017 53

DERMATOLOGY CLINIC is a department that presents photos of actual cases and asks readers to identify the condition. Each case opens with 1 or 2 color photos and a 75- to 100-word description of the patient presentation, without giving away the diagnosis. This is followed by a 750- to 1000-word summary that includes a fuller description of the ailment, an explanation of how the correct diagnosis was reached, a general review of the condition along with a differential diagnosis, and a description of the patient’s treatment and outcome. Topics must be approved by the editor prior to s ubmission. Please include your title and affiliation. COMMENTARY is our guest editorial page. It gives you the opportunity to sound off on an issue of importance to your c olleagues nationwide. A typical commentary runs about 600 words in length. Please include your title and affiliation. To discuss your editorial ideas, contact us by phone at 646.638.6078; by e-mail to editor@ClinicalAdvisor.com; or by mail to The Clinical Advisor, 275 7th Avenue, 10th Floor, New York, NY 10001.

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

Stat Consult

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

Description

Cleft Lip and Palate ALAN DRABKIN, MD

Dr Drabkin is a senior clinical writer for DynaMed (www.ebscohost. com/dynamed), a database of comprehensive updated summaries covering more than 3200 clinical topics, and assistant clinical professor of population medicine at Harvard Medical School.

• congenital malformation of the upper lip and/ or oral cavity disrupting normal facial structure and oromotor function Definitions

• World Health Organization definitions from the International Perinatal Database of Typical Oral Clefts (IPDTOC) — cleft lip and palate: congenital malformation with partial or complete clefting of upper lip and alveolar ridge and/or hard palate, not including the oral cleft palate of holoprosencephaly — cleft lip: congenital malformation with partial or complete clefting of upper lip, not including median cleft lip (holoprosencephaly) — cleft palate: congenital malformation with closure defect of hard and/or soft palate behind foramen incisivum without cleft lip (excluding submucous cleft palate, occult cleft palate, and cleft uvula) — Pierre Robin sequence: cleft palate associated with significant micrognathia, with or without retroposition of the tongue (glossoptosis) or respiratory distress

Types

Orofacial clefting is reported to occur in 1 in 700 live births.

• cleft lip with or without cleft palate — appears to develop from malformation of fetal primary palate with or without secondary palate malformation — 68% to 86% of cleft lip cases associated with cleft palate — other genetic anomalies (syndromic) in 14% to 30% of cases — subtypes include ■ microform cleft (dehiscence of orbicularis muscle with vermilion notching but intact overlying skin) ■ cleft lip and alveolus ■ incomplete unilateral cleft lip and palate (less severe congenital scar, notch in vermillion border, or partial clefting) www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 43

Stat Consult complete unilateral cleft lip and palate complete bilateral cleft lip and palate • cleft palate alone (lip not affected) ——appears to develop from malformation of fetal secondary palate ——can range from submucous clefting to complete bilateral clefting through maxillary alveolus ——other genetic anomalies (syndromic) in 42% to 54% of cases ■■ ■■

Who is most affected

• cleft palate alone twice as common in female infants • cleft lip with or without cleft palate more common in male infants and usually more severe than in female infants Incidence/prevalence

• 1 in 700 live births overall report to have orofacial clefting (cleft lip and/or palate) • reported prevalence for orofacial clefts varies worldwide ——1.3 to 25.3 per 10,000 live births for cleft palate alone ——3.4 to 22.9 per 10,000 live births for cleft lip, with or without cleft palate Likely risk factors

Parental exposures: • maternal factors ——history of fever ——cold without a fever ——history of skin disease ——maternal passive smoking ——maternal negative life events ——maternal use of ■■ antipyretics or analgesics ■■ anti-infectious drugs ■■ antiepileptics ——maternal occupational exposure to ■■ organic solvents ■■ heavy metals ■■ pesticides • paternal factors associated with increased risk for orofacial clefting ——paternal alcohol consumption ——paternal smoking • other factors ——pregestational hypertension ——lower parental education level ——maternal Western diet ——low myo-inositol level in mother or child ——low red blood cell zinc concentration in child

Hereditary risk factors • family history of first-degree relative with oral cleft MTHFR C677T polymorphism with TT genotype Factors not associated with increased risk

• maternal ——alcohol consumption ——topical corticosteroid use during first trimester of pregnancy ——antibiotic use during early pregnancy • prematernal obesity • water fluoridation Associated conditions

• cleft palate may be a feature of more than 400 specific genetic or chromosomal syndromes, including ——Robin sequence (previously called Pierre Robin sequence) ——Loeys-Dietz syndrome ——X-linked cleft palate with ankyloglossia ——Down syndrome ——Prader-Willi syndrome • cleft lip with or without cleft palate is a feature of more than 200 specific genetic or chromosomal syndromes, including ——Down syndrome ——van der Woude syndrome ——trisomy 13 ——Smith-Lemli-Opitz syndrome • sensorineural hearing loss Making the diagnosis

• clefts of lip and/or palate are generally recognizable upon newborn examination as visible or palpable disruption of normal lip and palate structure • routine prenatal ultrasound screening may help detect orofacial clefts in utero Differential diagnosis

• determine whether patients with cleft lip and/or palate have either ——nonsyndromic cleft ——cleft in conjunction with a genetic or chromosomal syndrome Testing overview

• ultrasound and magnetic resonance imaging may be used for prenatal screening for orofacial cleft • routine second-trimester prenatal ultrasound

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

Treatment overview

• clearance of airway (most immediate concern in new infant), followed by adequate nutrition due to feeding complications • multidisciplinary approach typically required for comprehensive care • preoperative dentofacial orthopedics may be used to approximate soft tissue prior to surgery (newer nasoalveolar molding technique more commonly used) • primary treatment is surgery, but high-quality evidence is lacking to determine best surgical techniques for cleft repair ——goals of surgery include normalized appearance, language, speech, hearing and psychosocial development with intact palate, airway, masticatory function, and dental health ——timing of surgical repair ■■ cleft lip repair traditionally performed at age 10 to 12 weeks ■■ most craniofacial surgeons suggest complete repair of palatal clefts between age 9 and 12 months (prevent negative effects of delayed repair on language and speech development) • choice of surgical techniques typically based on size and extent of cleft, as well as surgeon experience • consider rhinoplasty for cleft lip nasal deformity ——primary (simultaneous rhinoplasty and lip reconstruction) ——secondary (after lip reconstruction) • discharge when oral alimentation sufficient

Prognosis

• isolated cleft palate, but not isolated cleft lip, may be associated with increased morbidity and mortality • higher palatal arch and wider maxillary tuberosity may each be associated with increased risk for postsurgical hypernasality following cleft palate repair • incomplete cleft palate and Hispanic ethnicity each associated with reduced need for second surgery following isolated cleft palate repair • may have reduced academic achievement and increased need for special education • early growth delay in infants with cleft lip with or without cleft palate may not be associated with long-term effect on growth parameters Complications

• feeding complications • ear disorders • speech pathology • dental anomalies • obstructive sleep apnea • altered facial and dental appearance associated with negative psychological impact in patients with craniofacial anomalies Prevention

• periconceptional multivitamin use (including folic acid supplementation) may reduce risk of oral clefts, with greatest risk reduction seen for women starting multivitamin prior to conception ■

Complications of surgery

• oronasal fistulae (3.4% to 29% of cases) postoperatively • other surgical complications may include ——bleeding ——infection ——irregular healing of scars and contractures Additional treatments

• perform audiologic follow-up per American Cleft PalateCraniofacial Association recommendations • amplification therapies, such as hearing aids or auditory training systems, if persistent hearing loss is present • insufficient evidence to evaluate electropalatography for treating articulation problems associated with cleft palate www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • AUGUST 2018 45

——may detect cleft lip with or without cleft palate ——limited ability to detect cleft palate alone • videonasopharyngoscopy and multiplanar videofluoroscopy may provide anatomic and dynamic data useful for correcting velopharyngeal insufficiency