December 2015 Clinical Advisor by The Clinical Advisor

THE CLINICAL ADVISOR • DECEMBER 2015

A PEER-REVIEWED FORUM FOR NURSE PRACTITIONERS

NEWSLINE

■ Intensive BP lowering ■ Early antibiotic treatment ■ Acute low back pain FEATURE Relief for Insomnia

Effective OTC treatments LEGAL ADVISOR

DECEMBER 2015

| www.ClinicalAdvisor.com

A PRIMARY CARE GUIDE FOR

INFLUENZA

Seasonal influenza virus is one of the most common respiratory virus infections.

Emergency in an alcoholic

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■ Featured Course

PERCEPTIONS OF THE FLU VACCINE PAGE 40

■ Dermatologic Look-Alike VOLUME 18, NUMBER 12

DEPIGMENTED PATCHES PAGE 67 SAVE THE DATE April 7–9, 2016

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Editor Colby Stong, editor@ClinicalAdvisor.com Senior editor Sandhya George Associate digital content editor Hannah Dellabella Assistant editor Lauren Biscaldi 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

“I hate open-mike night.”

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“I don’t know anything about global warming, but these ice cubes are melting like crazy.”

All correspondence to: The Clinical Advisor 114 West 26th Street, 4th Floor, New York, NY 10001 For advertising sales, call 646.638.6085. For reprints, contact Wright’s Reprints at 877.652.5295. Persons appearing in photographs in “Newsline,” “The Legal Advisor,” and “Clinical Challenge” are not the actual individuals mentioned in the articles.They appear for illustrative purposes only. The Clinical Advisor® (USPS 017-546, ISSN 1524-7317), Volume 18, Number 12, is published 12 times a year, monthly, for $75.00 per year in the United States; $85.00 in Canada; $110.00 for all other foreign, in U.S. dollars, by Haymarket Media, Inc., 114 West 26th Street, 4th Floor, New York, NY 10001. Single copy: $20 U.S.; $30 foreign. www.ClinicalAdvisor.com. To order or update your paid subscription, call 800.436.9269. Periodicals postage rate paid at New York, NY, and additional mailing offices. POSTMASTER: Send address change to DMD Data Inc. ,10255 W. Higgins Rd, Suite 280, Rosemont, IL 60018. Subscription inquiries: call 800.430.5450 to change your address or make other subscription inquiries. Requests for subscriptions from outside the United States must be accompanied by payment. All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright © 2015

“When I was your age, our nannies had to carry backpacks.”

Senior vice president, clinical communications John Pal

8 THE CLINICAL ADVISOR • DECEMBER 2015 • 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 — and to collect a fee in the bargain! We pay an honorarium for every submission we accept. We’ll be glad to work with you to develop your ideas into compelling articles. As for length, that depends on which kind of article you submit. CLINICAL FEATURES update our readers on the latest information about conditions seen in everyday practice. Running approximately 2,500 to 5,000 words, including the references, features can be written either as regular narratives or as a series of questions and answers. Topics should be selected with the busy primary-care clinician in mind; specialists should review specialty topics from the primary-care point of view. If at all possible, articles should be accompanied by clinical photos. Charts, tables, and algorithms are also encouraged. Please include your title and affiliation. CLINICAL CHALLENGE is our popular department comprising histories of difficult cases. Each case is presented as a step-by-step, chronological account, revealing the author’s thought processes along the way. It is divided into sections in this order: the patient presentation; the patient history; the twists and turns eventually leading to a diagnosis; the treatment and outcome; and a discussion of the lessons learned or of the condition in general. The length should be about 1,500 words, and accompanying images are encouraged. Please include your title and affiliation. DERMATOLOGY CLINIC is a department that presents photos of actual cases and asks readers to identify the condition. Each case opens with one or two color photos and a 75-to-100-word description of the patient presentation, without giving away the diagnosis. This is followed by a 750-to-1,000-word summary that includes a fuller description of the ailment, an explanation of how the correct diagnosis was reached, a general review of the condition along with a differential diagnosis, and a description of the patient’s treatment and outcome. Topics must be approved by the editor prior to submission. Please include your title and affiliation. COMMENTARY is our guest editorial page. It gives you the opportunity to sound off on an issue of importance to your colleagues nationwide. A typical Commentary runs about 600 words in length. Please include your title and affiliation. To discuss your editorial ideas, contact us by phone at 646.638.6078; by e-mail to editor@ClinicalAdvisor.com; or by mail to The Clinical Advisor, 114 West 26th Street, 4th Floor, New York, NY 10001. www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • DECEMBER 2015 9

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CONTENTS DECEMBER 2015

NEWS AND COMMENT

FEATURES

18 Newsline ■■Intensive blood pressure lowering may provide a greater reduction of major cardiovascular events. ■■Clinicians can reduce the risk of severe respiratory tract illness in sick children prone to wheezing by administering an antibiotic at the first signs of symptoms. ■■Patients with asthma that is wellcontrolled by their current level of medication can step down their treatments safely, while at same time reducing the cost of therapy. ■■Combining either cyclobenzaprine or oxycodone/acetaminophen with naproxen does not improve acute, nontraumatic, nonradicular low back pain for patients presenting to the emergency department. ■■A combination of brief interactions with primary care providers and follow-up coaching calls may keep psychoactive drug use from becoming an addiction ■■The AHA and ATS publish the first guidelines for the diagnosis and treatment of children with pulmonary hypertension. ■ Mortality rates increased significantly among non-Hispanic whites in the United States aged 45 to 54 years between 1999 and 2013. ■■And more.

26 Influenza: complications, diagnosis, and treatment A primary care provider’s role

91 Commentary The flu shot remains a vital healthcare tool for clinicians.

MAKING CONTACT

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40 CME/CE Managing patient perceptions of the influenza vaccine Dealing with patients’ concerns and promoting flu vaccination. Intensive blood pressure lowering 18

48 CME/CE Feature posttest

DEPARTMENTS 16 Web Roundup A summary of our most recent opinion, news, and multimedia content from ClinicalAdvisor.com

OTC treatment for insomnia 78

59 Legal Advisor An emergency is ignored in an alcoholic. 62 CME/CE Dermatology Clinic n Nonpruritic blue-gray macules n Purple papules on the genitalia Continues on page 14

Is coconut oil beneficial for CVD? 90

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CONTENTS DEPARTMENTS, cont’d 67

CME/CE Dermatologic Look-Alikes

Depigmented patches on forearms 71

CME/CE Dermatology posttest

OTC Corner Insomnia—Using natural modalities and OTC treatments. A balance of good sleep hygiene, healthy sleep habits, and OTC agents can relieve insomnia. Alternative Meds Update Coconut oil

“Next time we’re shopping at Wal-Mart.”

ADVISOR FORUM 54

Your Comments ■ The CDC’s statistics on influenza— fact or hype? ■ Analogies for patients in the battle against medical noncompliance

Clinical Pearl The right touch

“Look, just finish college, get your MBA, have a career, and then if you want to try your hand at acting, you’ll have my blessing.”

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TO SUBMIT A CLINICAL QUESTION FOR PUBLICATION:

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BER 2015

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FEATUR E

Relief for

TO CONTACT THE EDITOR: • editor@ClinicalAdvisor.com • Call 646.638.6078

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treatments

LEGAL ADV

Emergency

ISOR

in an alcoholic

✶ FREE CE COURS

NERS

DECE MBER

2015

| www.Clin icalA

dvisor.com

A PRIMAR Y CARE GU IDE FOR

INFLUENZ

Seasonal influenza virus is one of the most com mon respirato ry virus infections .

ES!

• Send it by e-mail to editor@ClinicalAdvisor.com

ER 12

• Mail it to The Clinical Advisor, 114 W. 26th St., 4th Floor, New York, NY 10001

■ Featured

Cour

PERCEPTIOse FLU VACCINNS OF THE E PAGE 40

18, NUMB

TOC_CA1215.indd 14

Insomnia

Effective OTC

VOLUM E

TO SUBMIT AN ARTICLE: • editor@ClinicalAdvisor.com

IEWE D FORU M FOR NUR SE PRAC TITIO

NEWSLIN

■ Intensive BP ■ Early antib lowering iotic treatme ■ Acute low nt back pain

■ Dermatolo gic

Look-Alik e DEPIGMENT PATCHES ED PAGE 67

SAVE THE DATE

April 7–9,

2016

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EXCLUSIVE TO THE WEB AT

ClinicalAdvisor.com Web Exclusives ClinicalAdvisor.com/News As the NP profession continues to grow, legal barriers to full practice authority remain Nurse practitioners are still prevented from exercising their full practice authority, leading to increased frustration as the primary care shortage grows.

The Waiting Room Official Blog of The Clinical Advisor ClinicalAdvisor.com/TheWaitingRoom Jillian Knowles, MMS, PA-C A new method for closing skin tears in elderly patients Using a combination of suture and SteriStrips can help close skin tears in elderly patients with fragile skin.

USPSTF recommends new screening guidelines for type 2 diabetes Clinicians should screen all asymptomatic, obese adults for abnormal blood glucose levels, says the U.S. Preventive Services Task Force.

Processed meats cause colorectal cancer in humans, according to WHO Researchers found that processed meat causes colorectal cancer, and red meat is positively associated with several cancers.

Robyn Carlisle, MSN, CNM Debunking the dangers of pitocin While many pregnant patients have reservations about pitocin, it has many benefits for labor when administered correctly. Jim Anderson, MPAS, PA-C, DFAAPA, ATC Are immunization schedules negotiable? Providers should consider both medical ethics and scientific evidence when parents want to delay the vaccine schedule for their child.

Cartoon slideshow

Multimedia

ClinicalAdvisor.com/Cartoons

ClinicalAdvisor.com/Multimedia Carrying extra weight in the waist more deadly than obesity A study has found that normal-weight central obesity is linked to a higher mortality rate. Alexander van Tulleken, MD, discusses how belly fat puts you at a greater risk of health problems. Watch it here: ClinicalAdvisor.com/BeerGutVid

“Why won’t you cuddle?”

MAKING CONTACT

New mammogram guidelines better balance risks and benefits The ACS recommends that women begin regular breast cancer screenings at age 45, instead of 40. Watch it here: ClinicalAdvisor.com/BreastCancerVid

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Advisor Dx

EXCLUSIVE TO THE WEB

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

Ortho Dx

In partnership with

TheJopa.org

Journal of Orthopedics for Physician Assistants

Wrist pain years after a dirt bike accident A 57-year-old man presents with right wrist pain. He believes the pain started years ago after falling off his bike onto his outstretched hand. X-rays of the wrist show chronic degenerative changes of the wrist associated with prior avascular necrosis of the scaphoid. WHAT IS THE NEXT BEST STEP?

• Proximal row carpectomy • Four-corner fusion • Bone grafting and internal fixation of the scaphoid fracture • Radial styloidectomy ● See the full case at ClinicalAdvisor.com/OrthoDx_Dec15

Derm Dx Mass under the skin of the index finger A 60-year-old woman presents for evaluation of a mass affecting her left index finger. The lesion has been gradually increasing in size during the past 3 years and has only recently become bothersome. She denies arthritis, gout, and history of trauma to the affected area. CAN YOU DIAGNOSE THE CONDITION?

• Subcutaneous granuloma annulare • Myxoid cyst • Giant cell tumor of tendon sheath • Picker’s nodule ● See the full case at ClinicalAdvisor.com/DermDx_Dec15

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • DECEMBER 2015 17

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Newsline D E C E M B E R 2 015

Stepping down asthma meds safely page 23

PCP intervention for psychoactive drug use page 23

Death rates rise in middle-aged white Americans page 24

INTENSIVE BLOOD pressure lowering may provide a greater reduction of major cardiovascular events, compared with standard regimens, according to a metaanalysis published online ahead of print November 6 in The Lancet. Xinfang Xie, MD, and colleagues analyzed 19 studies (44,989 total participants) from 1950 to October 2015. Patients in the more intensive blood pressure–lowering treatment group had mean blood pressure levels of 133/76 mmHg, compared with 140/81 mmHg in the less intensive treatment group. The researchers found that intensive blood pressure–lowering

treatment achieved relative risk reductions for major cardiovascular events (14%), myocardial infarction (13%), stroke (22%), albuminuria (10%), and retinopathy progression (19%). However, more intensive treatment had no clear effects on heart failure (15%), cardiovascular death (9%), total mortality (9%), or end-stage kidney disease (10%), according to the investigators. “In high-risk patients, there are additional benefits from more intensive blood pressure lowering, including for those with systolic blood pressure below 140 mmHg,” stated Dr. Xie and colleagues. “The net absolute

Intensive blood pressure lowering may provide greater CVD benefits Intensive blood pressure lowering may lead to lower risk of major CV events, myocardial infarction, and stroke.

benefits of intensive blood pressure lowering in high-risk individuals are large.” Serious adverse events occurred in similar numbers among both intensive and standard treatment groups. The intensive treatment group, however, had an almost threefold risk of hypotension. The researchers believe that more research can help reduce the risk of hypotension by determining the safest methods for achieving lower blood pressure.

Early antibiotics for children with respiratory infections, wheezing CLINICIANS CAN REDUCE the risk of severe respiratory tract illness in sick children prone to wheezing by administering an antibiotic at the first signs of symptoms, according to research published online ahead of print November 17 in JAMA. Researchers tested azithromycin against a placebo in 607 children aged 12 months to 6 years. Although equal numbers of respiratory infections were reported in both the antibiotic and placebo groups, the investigators found a notable difference in the severity of infections. A total of 92 illnesses were deemed severe—57 in the placebo group, compared with 35 in the antibiotic group. “Oral corticosteroids … have become the standard of care for these situations,” said Leonard B. Bacharier, MD, lead investigator and professor of pediatrics at Washington University. “There are some studies that suggest these treatments don’t consistently

work for young children .... Once the episode gets going, standard interventions are less effective than would be desired.” The researchers worked with the families of each study participant to identify the symptoms of an oncoming respiratory tract illness. Parents were encouraged to administer a course of azithromycin as soon as symptoms were presented. Concerned over the potential development of antibioticresistant organisms, Dr. Bacharier and colleagues studied azithromycin resistance in a subset of 86 study patients at St. Louis Children’s Hospital and noted that a larger study would be necessary to determine whether differing rates of azithromycin resistance are clinically meaningful. “We want to be prudent with our antibiotic use,” said Dr. Bacharier. “Our study suggests we can reduce the risk of severe respiratory illness by giving azithromycin treatment earlier.”

18 THE CLINICAL ADVISOR • DECEMBER 2015 • www.ClinicalAdvisor.com

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Newsline Stepping down Drug combos not more effective than asthma meds naproxen alone for acute low back pain can be safe mg and acetaminophen at 325 COMBINING EITHER cyclobenzaprine or oxycodone/acetaminophen with naproxen does not improve acute, nontraumatic, nonradicular low back pain for patients presenting to the emergency department, according to a study published in the October 20 issue of JAMA. Benjamin W. Friedman, MD, MS, and colleagues randomly assigned 323 patients who visited the emergency department for acute low back pain to a 10-day course of naproxen (20 500-mg tablets, taken twice daily) with 1 of 3 treatments added: placebo (n=107; 60 tablets); cyclobenzaprine (n=108; 1 or 2 5-mg tablets every 8 hours as needed); or oxycodone/acetaminophen (n=108; 1 or 2 tablets of oxycodone at 5

Findings do not support use of these additional drugs in in the ED.

mg every 8 hours as needed). The researchers found that measures of pain, functional impairment, and use of health care resources were not different between the groups at 1 week or 3 months later. However, all the regimens did improve low back pain. At 1-week follow-up, nearly two-thirds of the study participants had clinically significant improvement in low back pain and function. At that point, 40% of the group reported moderate or severe pain, approximately 50% reported functional impairment, and nearly 60% were still using medication. At the 3-month follow-up, nearly 25% reported moderate or severe pain and were using medications, although less than 3% were using an opioid.

Risky drug use reduced by primary care interventions A COMBINATION of brief interactions with primary care providers and follow-up coaching calls may keep psychoactive drug use from becoming an addiction, according to a study published in the November 2015 issue of Addiction. Patients receiving the intervention reduced their risky drug use—the use of illicit drugs such as cocaine, heroin, and methamphetamine or the misuse of prescription medications, without the physiological or psychological signs of addiction—by 33%. Lead author Lillian Gelberg, MD, and colleagues studied an intervention in which clinicians provided 3 to 4 minutes of advice on quitting or reducing drug use, which was followed by a 2-minute “video doctor”

message, an educational booklet, and 2 to 6 weeks later, 2 or fewer coaching sessions over the telephone for 20 to 30 minutes. The initial conversation with the primary care provider discussed drug addiction as a chronic brain disease, the physical and mental effects of drug use, and how reducing or quitting drugs can prevent addiction whereas use of multiple drugs can lead to addiction. The study included 334 individuals: 171 in the intervention group and 163 in the control group. Mean age was 41.7 years, 62.9% were male, and 37.7% were white. After 3 months, the intervention group reported that they used drugs an average of 3.5 fewer days in the previous month, compared with the control group.

PATIENTS with asthma that is well-controlled by their current level of medication can step down their treatments safely, while at same time reducing the cost of therapy, according to a study published online ahead of print October 21 in the Journal of Allergy and Clinical Immunology. Lead author Matthew Rank, MD, and colleagues identified patients with asthma from the US Medical Expenditure Panel Survey collected from 2000 to 2010. Data on each patient were available for a 2-year period that was divided into 5 periods of 4 to 5 months each. Study participants were considered eligible to step down their medications if they had not been hospitalized or had gone to the emergency department for asthma during the first 3 periods and if they had taken no systemic corticosteroids and no more than 3 rescue inhalers in periods 2 and 3. Of the patients studied, the researchers determined that 4,235 (29.9%) were eligible to step down. Patients who decreased their medications were able to maintain control over their asthma symptoms that was comparable to no change in medication levels (89.4% of those who stepped down vs. 83.5% of those who did not). The researchers determined that study participants who stepped down their treatments saved $34.02 per month on average.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • DECEMBER 2015 23

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Newsline Pediatric pulmonary hypertension guidelines issued

hypertension, approved and recommended treatments, proven and emerging medical and surgical therapies, optimal comprehensive care including advice on supportive and social aspects of care, and pulmonary hypertension centers. They also include practical advice

Death rates increase among middle-aged white Americans MORTALITY RATES increased significantly among non-Hispanic white men and women in the United States aged 45 to 54 years between 1999 and 2013, according to a study published online ahead of print November 2 in the Proceedings of the National Academy of Sciences. Suicide, drug and alcohol poisoning, and chronic liver diseases and cirrhosis were the main causes of death. Analyzing data from the CDC and other sources, Anne Case, PhD, and Angus Deaton, PhD, found that the mortality rate for middle-aged white Americans in the United States increased by 0.5% each year. Before that, from 1978 to 1998, the mortality rate for this population decreased by an average of 2% every year, which is similar to the rate of decline found in France, Germany, Canada, Australia, Sweden, the United Kingdom, and countries in the European Union. After 1998, the mortality rates in other rich countries continued to decline at approximately 2% each year, the authors said.

AHA/ATS publish the first guidelines for pulmonary hypertension in children.

on issues such as whether these children should receive blood thinners, how to determine if a child with pulmonary hypertension can safely exercise or travel on a plane, and how high altitude can affect pulmonary hypertension. “These children suffer with health issues throughout their lives or die prematurely—particularly if they’re not properly diagnosed and managed. But with the proper diagnosis and treatment at a specialized center for pulmonary hypertension, the prognosis for many of these children is excellent,” said Steven H. Abman, MD, lead author and cochair of the guidelines committee.

Young patients, women unaware of modifiable cardiac risk factors PROVIDERS ARE missing opportunities to speak with their younger patients who are at higher risk for heart disease, especially women, according to a study published online ahead of print October 26 in the Journal of the American College of Cardiology. Less than half of individuals aged 55 years or younger who had been hospitalized with an acute myocardial infarction reported that their healthcare providers told them they had significant cardiac risk factors; women were 11% less likely to report that they had been informed of their risk. Lead author Erica C. LeifheitLimson, PhD, and colleagues studied 5 modif iable cardiac risk factors—diabetes, high

cholesterol, hypertension, obesity, and smoking status—in 3,501 patients aged 18 to 55 years hospitalized for an acute myocardial infarction. Almost all of the patients (98%) had 1 or more cardiac risk factors; 64% had 3 or more risk factors. About 53% of the patients thought that they were at risk for heart disease, 46% said their healthcare provider had told them they were at risk, and 49% reported a discussion with their provider on heart disease and risk modification. Women were less likely than men to report that their providers told them they were at risk for heart disease (relative risk, 0.89) or had discussed with them ways to modify their risks (relative risk, 0.84). n

THE FIRST GUIDELINES for the diagnosis and treatment of children with pulmonary hypertension have been issued by the American Heart Association and the American Thoracic Society and published online ahead of print November 3 in Circulation. Children with pulmonary hypertension typically have blockages in the pulmonary arteries, which make it difficult for the heart’s right ventricle to pump blood through the lungs. Symptoms include shortness of breath, fainting, and cyanosis. The new guidelines include information on how to determine the type of pulmonary

24 THE CLINICAL ADVISOR • DECEMBER 2015 • www.ClinicalAdvisor.com

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FEATURE: BLEN TESFAYESUS, DNP, RN, FNP; CATHERINE HILL, DNP, RN, GNP; SUSAN CHANEY, EdD, RN, FNP-c, FAANP

Influenza: complications, diagnosis, and treatment Patients need to be educated regarding the prevalence of influenza, its potential complications, and ways to prevent the disease. Flu virus particles on red blood cells, as shown on a colored scanning electron micrograph.

easonal influenza virus is one of the most common viral respiratory infections and primarily occurs in the winter season in the United States.1 It is a highly contagious airborne disease that infects the nose, throat, and lungs. At times, the infection can lead to hospitalization or even death secondary to a fatal pulmonary condition.1 Yearly, this infection accounts for approximately 226,000 hospitalizations and 36,000 deaths.2 The influenza virus is a negativestrand RNA virus representing three of the five types of the Orthomyxoviridae family.3,4 Every season, the virus may present differently and may mutate. The best prevention against this infection and its associated complications is the seasonal influenza vaccine that is administered annually.2 Health care providers should take the opportunity to educate their patients on the prevalence of influenza, its potential complications, and available prevention options. Providers should offer the influenza vaccine as soon as it is available to all eligible patients. Pathophysiology

The influenza virus is a single-stranded RNA virus. The main nucleoproteins are used to differentiate among the three types of influenza virus (A, B, and C). Although all three types of influenza virus have the capacity to infect humans, the most pathogenic are types A and B.5 Influenza A is responsible for all avian infections and most of the infections in humans,6 whereas influenza B and C primarily infect humans.3 Influenza C may cause some mild respiratory conditions.5 26 THE CLINICAL ADVISOR • DECEMBER 2015 • www.ClinicalAdvisor.com

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INFLUENZA: COMPLICATIONS, DIAGNOSIS, AND TREATMENT

According to the CDC, it is very difficult to predict what virus will appear, when it will start, how bad the season will be, and how long it will last. All three viruses share a common genetic origin; however, they are genetically different through the exchange of RNA segments or reassortment.4 Each of the three groups has negative RNA segments that are used as a template for production of two types of positive RNA, messenger RNA (mRNA) and complementary RNA (cRNA); mRNA is used for production of protein and cRNA is used for replication of the virus.3 Influenza A is identified by two proteins: hemagglutinin (H) and neuraminidase (N). These proteins play a key role in causing the influenza virus by neutralizing antibodies of the obtained immunity. The H protein binds to respiratory epithelial cell receptors and facilitates entry of the virus, causing cellular infection. The N protein facilitates the spread of the infection as it cleaves sialic acid from glycoproteins.6,7 These two proteins are used in the typing of influenza A. There are 16 distinct genetic subtypes for the H protein and 9 subtypes for the N protein; of these, only three types of the H protein (H1, H2, and H3) and two types from the N protein (N1 and N2) are capable of infecting humans.4 This virus causes a moderate-to-severe illness and can affect any age group.8 Influenza A and B virus are structurally similar under a microscope; both are spherical and fi lamentous in shape.4 However, unlike influenza A virus, influenza B contains four envelope proteins: H and N (similar to influenza A), plus NB and BM2.4 The NB protein is encoded by RNA segment 6. Although it is not essential for influenza B virus replication in cell culture, the NB protein is a protein that is incorporated into virus particles, and its function is currently unknown.9 The BM2 protein is encoded by RNA segment 7 and is essential for virus uncoating.9,10 Influenza B infection is less severe than influenza A infection and commonly affects children.8 Influenza B has less antigenic drift, which makes it more stable than influenza A.8 This means that annual vaccinations are more effective against influenza B virus than influenza A. Influenza C structurally differs from types A and B because it has one major surface glycoprotein, the hemagglutininesterase-fusion protein.4 This protein has a similar function to H and N, seen in types A and B, and another minor envelope protein, CM2.4 Although the function of the CM2 protein in viral replication is not clearly understood, it has been proposed that it plays a potential role in genome packaging and the uncoating process of the replication.11 Influenza C virus infection is very mild and is rarely reported.

Epidemiology and transmission

There are many factors that make influenza seasons unpredictable. According to the Centers for Disease Control and Prevention (CDC), it is very difficult to predict what virus will appear, when it will start, how bad the season will be, and how long it will last. Influenza is an acute but highly infectious disease that contributes to significant morbidity and mortality during epidemic seasons.12 Every year 5% to 20% (15 to 61 million) of the U.S. population contract it; more than 200,000 individuals are hospitalized13 and 36,000 die.2 This number varies each year based on the rate of vaccination and the success of matching the vaccine to that year’s mutating strain.13 Serious complications from the influenza virus are seen mostly among those with underlying medical conditions and elderly individuals aged older than 65 years.12,13 Although the elderly frequently have immunologic memory against influenza virus infection, their advanced age reduces their ability to fight off the infection.13 Yearly, new influenza viruses evolve through mutation or reassortment. Mutation may cause some changes in the H and N antigens of the virus, causing drift.14 This constant antigenic drift is responsible for causing an epidemic.15 Antigenic drift changes the gene of the virus gradually, and ultimately, these changes result in viruses that are antigenically different enough that the immune system fails to recognize them. The mode of transmission for influenza is primarily through respirable droplets.12 The distribution of transmission during an epidemic of influenza is estimated to be 30% within households, 33% in the community, and 37% at school or in

POLL POSITION

Regarding the flu vaccine, most of your patients: n=415

■ Are eager to receive it ■ Need counseling regarding its benefi ts and success rate ■ Do not want the vaccine

31.57% 53.25% 15.18%

For more polls, visit ClinicalAdvisor.com/Polls.

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INFLUENZA: COMPLICATIONS, DIAGNOSIS, AND TREATMENT

the workplace.12 According to the CDC, an individual with influenza may spread it to another person who is 6 feet away via coughing, sneezing, or talking.16 Influenza virus can be transmitted from one person to another, from 1 day prior to up to 7 days after symptom development.16

Table 1. Influenza pandemics of the 20th century Spanish flu

Asian flu

Hong Kong flu

Influenza type

Viral subtype

H1N1

H2N2

H3N2

Pandemic

Year of pandemic

1918

1957

1968

Influenza A virus infection causes severe illnesses because the virus has the capacity to mutate and change constantly.17 Pandemic influenza spreads rapidly, causing higher mortality rates than seasonal influenza.17 There were three worldwide influenza outbreaks in the 20th century (Table 1).6 The 2009–2010 influenza seasons initiated the 21st century influenza pandemic, which involved the H1N1 virus, also known as the swine flu. Unlike other seasonal influenza outbreaks, 60% of individuals affected by this virus were younger than age 18 years.18 This virus was found to have originated from the Spanish flu of 1918.18 The CDC estimated that there were a total of 60.8 million cases, 274,304 hospitalizations, and 12,469 deaths associated with the influenza pandemic of 2009.19

Deaths in the United States

500,000–700,000

70,000

34,000

Total deaths worldwide

30–40 million

1–2 million

700,000–1 million

Main age group among deaths

15–35 y

>65 y

Presenting symptoms

The majority of individuals (67%) with influenza virus infection are symptomatic, whereas the rest are not.20 According to the CDC, the incubation period for influenza virus ranges from 1 to 4 days, and its severity is dependent on previous exposure and immunity.8 Common presenting symptoms include sudden onset of fever, generalized body ache, headache, and fatigue that is accompanied by coughing, nasal congestion/drainage, and sore throat.21 Coughing is secondary to tracheal epithelial destruction. Other symptoms that may be associated with influenza are ocular and substernal chest discomfort. Myalgias tend to be worse in the back and lower extremities.8 Influenza symptoms commonly last from 2 to 5 days but may last as long as 2 weeks.8

TABLE 2. Individuals at high risk for complications from influenza Children <2 y Adults >65 y Individuals with chronic medical conditions: pulmonary, cardiovascular (except hypertension), renal, hepatic, hematologic, metabolic, and neurologic disorders, and hemoglobinopathies Immunosuppressed individuals Pregnant women and women up to 2 weeks postpartum American Indians/Alaskan Natives Morbidly obese individuals (body mass index >40 kg/m2) Residents of long-term care facilities Adapted from the Centers for Disease Control and Prevention.28

episodes than those who are not vaccinated.24 Annual vaccination is believed to be the cornerstone of prevention from influenza virus infection and its associated complications.25

Complications

Individuals who are at increased risk of complication from seasonal influenza are the very young (age <1 year), the elderly (age >65 years), pregnant women, and individuals with certain chronic medical conditions.22 Pulmonary complications, such as bronchitis and pneumonia, secondary to influenza virus infection are most common.22 Neuromuscular and cardiac complication, although rare, may occur.22 Other minor complications include sinusitis and acute otitis media.23 Individuals who are vaccinated against seasonal influenza virus have milder symptoms of cough, fever, and wheezing

Diagnosis

Although diagnosis appears to be fairly simple, it can be a challenging task for clinicians. According to the CDC, diagnosis by presenting symptoms alone may lead to misdiagnosis. Initial symptoms of the influenza may be closely related to other viral or bacterial infections, such as Mycoplasma pneumoniae, respiratory syncytial virus, and parainfluenza viruses.26 Timely and accurate diagnosis of influenza virus infection is essential to provide appropriate antiviral treatment. However, it is also imperative for clinicians to consider primary or secondary bacterial infection that may or may not be related.26

30 THE CLINICAL ADVISOR • DECEMBER 2015 • www.ClinicalAdvisor.com

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INFLUENZA: COMPLICATIONS, DIAGNOSIS, AND TREATMENT

When individuals are classified as high risk for influenza virus infection, initiating antiviral treatment can reduce the risk of complications. Although there are several available methods to test for influenza virus infection, the CDC only recommends using diagnostic tests if the result will affect the clinician’s decision making or if there is a respiratory outbreak in a community, caused by influenza, that needs to be identified. 26 Diagnostic tests include viral culture, serologic testing, and rapid influenza diagnostic tests (RIDTs) that must be collected via nasal swab within 4 days of illness. Other than RIDTs, tests take anywhere from 1 to 10 days to produce a result. The RIDTs provide results within 15 minutes and have a high specificity (>90%) but a lower sensitivity (50–70%).26 This translates into a potentially higher number of false-negative results; therefore, the test results must be evaluated in conjunction with clinical presentation and prevalence of influenza infection. Management of influenza should be based on the potential risk of complications from the virus.27

in those who present with severe symptoms but do not have risk factors.29 Antiviral treatments available and approved by the U.S. Food and Drug Administration (FDA) are listed in Table 3.28 In addition, amantadine and rimantadine are FDA-approved antiviral medications used for treatment and chemoprophylaxis of influenza A virus. However, due to resistance in circulating influenza A virus, these drugs are currently not recommended for the prevention or treatment of influenza virus infection.30 Symptomatic management of influenza includes increased hydration and rest. Antipyretic medications, including acetaminophen and nonsteroidal anti-inflammatory drugs, are recommended for management of malaise and fever. In the pediatric population (those aged ≤18 years), it is imperative to avoid medications containing any aspirin products due to the risk of Reye syndrome. Prevention

Treatment

Influenza virus infection is a self-limiting illness for the general healthy population. However, when individuals are classified as high risk, initiating antiviral treatment can reduce the risk of complications. Individuals who are classified as high risk for complications and who should receive antiviral treatment in cases of influenza diagnosis are listed in Table 2.28 These individuals, if left untreated, may develop potentially life-threatening complications, such as viral and bacterial pneumonia. Antiviral treatments should be initiated as soon as the diagnosis is made in all high-risk individuals or within 48 hours

Influenza virus infection can be prevented to a certain degree. The CDC states that there are three preventive actions to avoid influenza, but the gold standard for prevention is annual vaccination. Other means of prevention include everyday measures such as avoiding exposure and hand hygiene and chemoprophylaxis with antiviral drugs.31 Previous seasonal influenza vaccination or exposure provided some form of protection from the 2009 H1N1 influenza pandemic.18 In 1940, the inactivated influenza vaccine was developed.32 Soon after the discovery of the inactivated vaccine, a live vaccine was developed, but the United States did not approve

TABLE 3. Antiviral treatment options for influenza Antiviral agents

Activity against

Treatment age recommendation

Oseltamivir

Influenza A and B

Zanamivir

Peramivir

Contraindications

Adverse events

Any age

Kidney failure (dosage adjustment recommended for renal insufficiency)

Nausea, vomiting, serious and sporadic skin reaction, transient neuropsychiatric event

Influenza A and B

≥7 y

Milk allergy; underlying respiratory condition

Diarrhea, nausea, sinusitis, bronchitis, cough, headache, dizziness, and ear, nose, and throat infections; allergic reaction: oropharyngeal or facial edema

Influenza A and B

≥18 y

None

Diarrhea, serious and sporadic skin reaction, transient neuropsychiatric event

Adapted from Centers for Disease Control and Prevention.28

32 THE CLINICAL ADVISOR • DECEMBER 2015 • www.ClinicalAdvisor.com

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Gaylord Palms, Orlando, FL April 7-9, 2016

This activity is provided by Haymarket Medical Education This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standard

Are you ready to fill the imminent gap in primary care? There is no time to lose. Attend the 3-day Clinical Advisor Summit, for a state-of-the-art educational and concentrated networking opportunity featuring the following benefits: • 14 CME/CE credits for your professional advancement at $10 per credit* • An interactive and engaging setting to learn from experts on evidence-based practice information, incorporating an interprofessional perspective with a focus on primary care • First-hand perspective on emerging issues: international travel and infectious diseases, phases of diabetes management, and much more

WANTED: POSTER PRESENTATIONS FOR THE 2016 CLINICAL ADVISOR SUMMIT Present a poster on your cutting-edge research or new ideas in the area of primary care.To submit an abstract or review guidelines visit http://bit.ly/CAPOSTERDEC

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PHYSICIAN CREDIT DESIGNATION Haymarket Medical Education designates this live activity for a maximum of 14 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PHYSICIAN ASSISTANT CREDIT DESIGNATION The AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 14 hours of Category I Credit for completing this program.

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11/30/15 9:45 AM

INFLUENZA: COMPLICATIONS, DIAGNOSIS, AND TREATMENT

In the 2014–2015 season, the influenza vaccine was 19% effective among individuals of all ages.The most common strain was influenza A (H3N2). its use until 2003.32 Currently, there are several options for influenza virus vaccine (Table 4). Annual vaccination is recommended for all individuals aged more than 6 months who do not have any of the contraindications for vaccination.33 According to the Committee on Immunization Practices, children between ages 2 and 8 years may require two doses. If the child has received either one dose of influenza vaccine during the previous season, or has received two doses of influenza vaccine since 2010, only one dose is required in the current year. However, if the child has not received any doses, then two doses of the influenza vaccine spaced 4 weeks apart are needed for the current year.33 In a study conducted by Yokouchi and colleagues,7 influenza A virus was detected in 17.2% of children who were vaccinated, compared with 55.2% children who were not. The authors further emphasized that children with chronic medical conditions such as asthma had higher rates of contracting influenza virus than those without any medical conditions. The study concluded that children who were vaccinated again influenza A had reduced rates of infection and reduced incidence of asthma exacerbations.7 Chemoprophylaxis is another form of prevention; however, it should not replace annual vaccination.34 During an influenza epidemic, antiviral chemoprophylaxis may be used by high-risk individuals within 2 weeks of vaccination until an immune response develops. Antiviral prophylaxis therapy

may also be considered in high-risk individuals who have one or more contraindications to receiving the vaccine to help prevent subsequent complications. All individuals who reside in a community setting that has experienced an outbreak (eg, nursing home) should receive chemoprophylaxis therapy. Prophylactic and chemoprophylaxis treatment can be administered in high-risk populations or after exposure; however, the recommendation continues to focus on annual vaccination for all qualified individuals.34 Influenza Season 2014–2015

The influenza vaccine of 2014–2015 did not offer optimal coverage. However, the vaccination was still of value. According to the CDC, in the 2014–2015 season, the influenza vaccine was 19% effective among individuals of all ages.35 Influenza viruses, as previously stated, are constantly mutating and changing, which poses significant challenges to scientists when attempting to develop the annual vaccination. The most common strain of the influenza seen in the 2014–2015 season was influenza A (H3N2), which mutated from the vaccine’s predicted strain.36 Although that season’s influenza virus vaccine was mismatched from the circulating strain, it provided protection against other influenza viruses, and it decreased the severity of illness caused by the circulating strain.36 Influenza vaccines cause the body to develop antibodies against the viruses that are contained

TABLE 4. Currently available influenza vaccinations TRIVALENT Protection against two influenza A strains (H1N1 and H3N2) and one influenza B strain

QUADRIVALENT Protection against two influenza A strains and two influenza B strains

Types

Approved age

Delivery route

Live or inactivated

Contraindications

Standard dose

≥6 mo

Inactivated

Egg allergy

18-64 y

Inactivated

Egg allergy Age limit

High dose

>65 y

Inactivated

Egg allergy Age limit

In-cell culture

>18 y

Inactivated

Age limit

Recombinant (egg-free)

>18 y

Inactivated

Age limit

Injection

≥6 mo

Inactivated

Egg allergy

Nasal spray

2-49 y

Nasal

Live

Pregnancy Weak immune system Age limit

ID, intradermal; IM, intramuscular.

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INFLUENZA: COMPLICATIONS, DIAGNOSIS, AND TREATMENT

in the vaccine 2 weeks following vaccination and continue to protect against future exposures.

Blen Tesfayesus, DNP, RN, FNP, Catherine Hill, DNP, RN, GNP, and Susan Chaney, EdD, RN, FNP-C, FAANP, are affiliated with Texas Woman’s University in Dallas.

Role of the primary care provider

Primary care providers assess, diagnose, and treat patients in many healthcare settings. This provides an excellent opportunity to provide education on influenza-related prevalence, complications, and prevention measures. Providers should offer influenza vaccines as soon as they are available, and preferably by October.33 Vaccination against influenza virus infection should continue to be offered as long as the virus is circulating within the community.33 To avoid missed vaccinations, it is best practice for providers to offer the influenza vaccine to all of their patients during any encounter, be it a wellness check or sick visit. One study concluded that one of the top motivators for patients to receive the influenza vaccine was provider recommendation.37 Efficacy of the vaccine may vary based on the circulating strain, the patient’s age, or a number of other health-related factors. Providers can play a vital role in prevention of influenza by getting vaccinated. Although the CDC recommends an annual influenza vaccine for all healthcare professionals, the rate of vaccination remains between 41% and 57%.38 Because of this, there is an initiative to move toward mandatory vaccination of healthcare professionals who work in certain facilities.38 Studies have shown that vaccination of healthcare professionals reduces the morbidity and mortality of their patients.38 Providers should be alert with regard to influenza activity within their communities and educate patients about appropriate preventive measures.

References 1. Göya C, Yavuz A, Hamidi C, et al. The role of initial radiologic and clinical manifestations in predicting the prognosis for pneumonia caused by H1N1 influenza virus. J Thorac Dis. 2014;6(6):752-759. 2. Phillips CJ, Woolpert T, Sevick C, et al. Comparison of the effectiveness of trivalent inactivated influenza vaccine and live, attenuated influenza vaccine in preventing influenza-like illness among U.S. military service members, 2006–2009. Clin Infect Dis. 2013;56(1):11-19. 3. Dela-Moss LI, Moss WN, Turner DH. Identification of conserved RNA secondary structures at influenza B and C splice sites reveals similarities and differences between influenza A, B, and C. BMC Res Notes. 2014;7:22. 4. Bouvier NM, Palese P. The biology of influenza viruses. Vaccine. 2008;26(suppl 4):D49-D53. 5. Schub T, Buckley L. Avian influenza. Glendale, CA: CINAHL Informations; 2014:2. 6. Derlet RW, Nguyen HH, Sandrock CE. Influenza. Medscape website. http://emedicine.medscape.com/article/219557-overview. Updated October 21, 2015. 7. Yokouchi Y, Katsumori H, Shirakawa S, et al. Protective effects of influenza A (H1N1) pandemic 2009 vaccination against the onset of influenza-like illness and asthma exacerbation in Japanese children. J Asthma. 2014;51(8):825-831. 8. Influenza: epidemiology and prevention of vaccine-preventable diseases. Centers for Disease Control and Prevention website. http://www.cdc.gov/ vaccines/pubs/pinkbook/flu.html#epi. Updated September 8, 2015. 9. Jackson D, Elderfield RA, Barclay WS. Molecular studies of influenza B

Conclusions

virus in the reverse genetics era. J Gen Virol. 2011;92(Pt 1):1-17.

Seasonal influenza virus is a viral respiratory infection that has the potential to cause many serious medical complications. Every year, this infection has a high prevalence of morbidity and mortality. The most pathogenic types of the influenza virus are types A and B, which are the two strains that are covered by the annual influenza vaccine. Because these viruses are continuously mutating, a new formulation of the influenza vaccine is available annually for protection. The Advisory Committee on Immunization Practices recommends annual influenza vaccination for every person aged 6 months or older. FDA-approved antiviral medications are also available for use as prophylaxis or treatment for the virus in an attempt to decrease potential complications. Providers play a vital role in preventing influenza in their patients and should themselves get vaccinated annually against the influenza virus. n

10. Ma C, Soto CS, Ohigashi Y, et al. Identification of the pore-lining residues of the BM2 ion channel protein of influenza B virus. J Biol Chem. 2008;283(23):15921-15931. 11. Furukawa T, Muraki Y, Noda T, et al. Role of the CM2 protein in the influenza C virus replication cycle. J Virol. 2011;85(3):1322-1329. 12. Santos JR, May L, Haimar AE. Risk-based input-output analysis of influenza epidemic consequences on interdependent workforce sectors. Risk Anal. 2013;33(9):1620-1635. 13. Klepser ME. Socioeconomic impact of seasonal (epidemic) influenza and the role of over-the-counter medicines. Drugs. 2014;74(13):1467-1479. 14. Boni MF, Gog JR, Andreasen V, Feldman MW. Epidemic dynamics and antigenic evolution in a single season of influenza A. Proc Biol Sci. 2006;273(1592):1307-1316. 15. Wolf YI, Viboud C, Holmes EC, et al. Long intervals of stasis punctuated by bursts of positive selection in the seasonal evolution of influenza A virus. Biology Direct. 2006;1:34-19.

36 THE CLINICAL ADVISOR • DECEMBER 2015 • www.ClinicalAdvisor.com

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16. How flu spreads. Centers for Disease Control and Prevention website.

32. Kaslow RA, Stanberry LR, Le Duc JW, eds. Viral Infections of Humans:

http://www.cdc.gov/flu/about/disease/spread.htm. Updated September 12,

Epidemiology and Control. New York, NY: Springer Science+Business

2013.

Media; 2014.

17. Nicholls H. Pandemic influenza: the inside story. PLoS Biol.

33. Grohskopf LA, Olsen SJ, Sokolow LZ, et al; Centers for Disease

2006;4(2):e50.

Control and Prevention. Prevention and control of seasonal influenza with

18. Placzek HE, Madoff LC. Association of age and comorbidity on

vaccines: recommendations of the Advisory Committee on Immunization

2009 influenza A pandemic H1N1-related intensive care unit stay in

Practices (ACIP), United States, 2014-15 influenza season. MMWR Morb

Massachusetts. Am J Public Health. 2014;104(11):e118-e125.

Mortal Wkly Rep. 2014;63(32):691-697.

19. Shrestha SS, Swerdlow DL, Borse RH, et al. Estimating the burden of

34. Harper SA, Bradley JS, Englund JA, et al; Expert Panel of the Infectious

2009 pandemic influenza A (H1N1) in the united states (April 2009-April

Diseases Society of America. Seasonal influenza in adults and children—

2010). Clin Infect Dis. 2011;52(suppl 1):S75-S82.

diagnosis, treatment, chemoprophylaxis, and institutional outbreak man-

20. Carrat F, Vergu E, Ferguson NM, et al. Timelines of infection and

agement: Clinical practice guidelines of the Infectious Diseases Society of

disease in human influenza: a review of volunteer challenge studies. Am J

America. Clin Infect Dis. 2009;48(8):1003-1132.

Epidemiol. 2008;167(7):775-785.

35. D’Mello T, Brammer L, Blanton L, et al; Centers for Disease Control

21. Kidd M. Influenza viruses: update on epidemiology, clinical features,

and Prevention (CDC). Update: influenza activity—United States,

treatment, and vaccination. Curr Opin Pulm Med. 2014;20(3):242-246.

September 28, 2014-February 21, 2015. MMWR Morb Mortal Wkly Rep.

22. Rothberg MB, Haessler SD, Brown RB. Complications of viral influenza.

2015;64(8):206-212.

Am J Med. 2008;121(4):258-264.

36. What you should know for the 2014-2015 influenza season. Centers

23. Flu symptoms and severity. Centers for Disease Control and

for Disease Control and Prevention website. http://www.cdc.gov/flu/

Prevention website. http://www.cdc.gov/flu/about/disease/symptoms.htm.

about/season/flu-season-2014-2015.htm. Updated March 12, 2015.

Updated August 19, 2015.

37. Mayo AM, Cobler S. Flu vaccines and patient decision making: what we

24. VanWormer JJ, Sundaram ME, Meece JK, Belongia EA. A cross-section-

need to know. J Am Acad Nurse Pract. 2004;16(9):402-410.

al analysis of symptom severity in adults with influenza and other acute

38. Cortes-Penfield N. Mandatory influenza vaccination for health care

respiratory illness in the outpatient setting. BMC Infec Dis. 2014;14:231.

workers as the new standard of care: a matter of patient safety and non-

25. Lang PO, Mendes A, Socquet J, et al. Effectiveness of influenza vac-

maleficent practice. Am J Public Health. 2014;104(11):2060-2065.

cine in aging and older adults: comprehensive analysis of the evidence. Clin Interv Aging. 2012;7:55-64.

All electronic documents accessed on October 27, 2015.

26. Influenza symptoms and the role of laboratory diagnostics. Centers for Disease Control and Prevention website. http://www.cdc.gov/flu/professionals/diagnosis/labrolesprocedures.htm. Updated October 1, 2015. 27. Suryaprasad A, Redd JT, Ricks PM, et al. Effect of rapid influenza diagnostic testing on antiviral treatment decisions for patients with influenza© The New Yorker Collection 2015 from cartoonbank.com. All Rights Reserved.

like illness: Southwestern U.S., May-December 2009. Public Health Rep. 2014;129(4):322-327. 28. Influenza antiviral medications: summary for clinicians. Centers for Disease Control and Prevention website. http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Updated February 25, 2015. 29. Fiore AE, Fry A, Shay D, et al; Centers for Disease Control and Prevention (CDC). Antiviral agents for the treatment and chemoprophylaxis of influenza—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(1):1-24. 30. Antiviral dosage: guidance on the use of influenza antiviral agents. Centers for Disease Control and Prevention website. http://www.cdc. gov/flu/professionals/antivirals/antiviral-dosage.htm. Updated February 25, 2015. 31. CDC says “take 3” actions to fight the flu. Centers for Disease Control and Prevention website. http://www.cdc.gov/flu/protect/preventing.htm. Updated August 17, 2015.

“You need two more gazelles.”

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CME CE FEATURED COURSE

n LEARNING OBJECTIVES After completing the activity, the participant should be better able to: • Assess the actual influenza vaccination side effects, as well as precautions and contraindications to obtaining the influenza vaccination • Demonstrate a solid understanding of the factors preventing influenza vaccination in children, adolescents, and adults • Define the methods to tackle and defeat misconceptions surrounding the influenza vaccination n COMPLETE THE POSTTEST: Page 48 n ADDITIONAL CME/CE CREDIT: Page 62, 67, 71

This activity is provided by Haymarket Medical Education (HME) for physician credit. This activity is co-provided by Medical Education Resources (MER) for nursing contact hours. Release Date: December 15, 2015 Expiration Date: December 15, 2016 Estimated time to complete the educational activity: 30 minutes Statement of Need: Though some health care professionals may be fully knowledgeable of the most common reasons why patients choose not to receive the annual influenza vaccine, some clinicians may not be able to effectively apply this knowledge in their practice when discussing with their patients their varying concerns regarding the vaccine. This article will address this particular knowledge gap. Target Audience: This activity has been designed to meet the educational needs of primary care health care professionals who will treat patients with influenza. Faculty Allexa Hammond, MS3, medical student Baylor College of Medicine, Houston Maura Holcomb, MD, dermatology resident Baylor College of Medicine, Houston Accreditation Statements Physician Credit: HME is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Credit Designation: HME designates this enduring material for a maximum of 0.5 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nursing Credit: MER is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Credit Designation: This CE activity provides 0.5 contact hour of continuing nursing education. MER is a provider of continuing nursing education by the California Board of Registered Nursing, Provider #CEP 12299, for 0.5 contact hour. This activity qualifies for 0.25 pharmacotherapy credit. American Academy of Physician Assistants (AAPA) The AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hour of Category I credit for completing this program.

reported, or used in a CME/CE activity conforms to the generally accepted standards of experimental design, data collection, and analysis. HME is committed to providing its learners with high-quality CME/CE activities that promote improvements in health care and not those of a commercial interest. The faculty reported the following financial relationships with commercial interests whose products or services may be related to the content of this CME activity: Faculty Disclosures

Name of faculty

Reported Financial Relationship

Allexa Hammond, BA

No relevant financial relationships

Maura Holcomb, MD

No relevant financial relationships

Staff/Planners’ Disclosures The planners, managers, and reviewers for this program reported the following financial relationships with commercial interests whose products or services may be related to the content of this CME activity: HME planners, managers, and reviewers have no relevant financial relationships to disclose. MER planners, managers, and reviewers have no relevant financial relationships to disclose. Disclosure of Unlabeled Use: This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. HME and MER do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Method of Participation: There are no fees for participating in and receiving CME/CE credit for this activity. During the period of November 13, 2015, through November 12, 2016, participants must: 1) read the learning objectives and faculty disclosures; 2) study the educational activity; 3) complete the posttest and submit it online (clinicians may register at www.myCME.com); and 4) complete the evaluation form online. A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better. Disclaimer: The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of HME or MER. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. The information presented in this activity is not meant to serve as a guideline for patient management.

Disclosure Policy In accordance with the ACCME Standards for Commercial Support, HME requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. HME resolves all conflicts of interest in an effort to ensure independence, objectivity, balance, and scientific rigor in all its educational programs. Furthermore, HME seeks to verify that all scientific research referred to,

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CME CE FEATURED COURSE: ALLEXA HAMMOND, BA, AND MAURA HOLCOMB, MD

Managing patient perceptions of the influenza vaccine Clinicians can promote vaccination by understanding patients’ concerns about and current research on the influenza vaccine’s safety and efficacy.

hroughout the past century, many medical advances have been made to combat some of the most devastating diseases known to humankind. Perhaps one of the most significant innovations in recent history is the creation of the vaccine, primarily responsible for saving millions of lives from many debilitating viral illnesses. The influenza virus vaccine can prevent many people from acquiring influenza infection during the winter season each year. Despite this fact, there remains an atmosphere of uncertainty and doubt among many people in the United States regarding the vaccine’s safety and efficacy. Therefore, to better understand the reasoning behind such sentiments in the patient population, this article explores various studies evaluating patient perceptions toward the influenza vaccine, so that ultimately primary care clinicians can help identify the specific concerns their patients may have about influenza vaccination, inform them of the current scientific data detailing the importance of this vaccine, and successfully encourage patients to get vaccinated in order to protect themselves and others from a potentially devastating illness.

Clinicians can take steps to increase flu vaccination rates among their patients.

Overview: Influenza and the influenza vaccine

Over the course of history, influenza has become infamous for its multiple pandemics affecting millions worldwide, from the “Spanish Flu” outbreak in the early 20th century, to the first “Avian Flu” outbreak in 2003, to the first “Swine Flu” outbreak

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CME CE

FEATURED COURSE

TABLE 1. Common symptoms of infection with the influenza virus • Fever

• Runny nose

• Headache

• Cough

• Body aches

• Sore throat

• Fatigue

in 2009.1,2 The symptoms of influenza virus infection can vary and may include fever, cough, general fatigue, and body aches, which may last from 3 to 7 days (Table 1).3-5 However, those who are more susceptible to influenza virus infection, including young children, the elderly, and the immunocompromised, may have more severe symptoms with a higher risk of complications from the disease, including death.3,4 Furthermore, someone infected with the influenza virus may acquire a bacterial superinfection as a result of his or her acute immunocompromised state, often presenting as pneumonia or otitis media; other complications of influenza infection include myositis, cardiac pathologies (eg, myocarditis), and toxic shock syndrome.4,5 The influenza vaccine has the capacity to significantly counter many of the symptoms that accompany the illness

and is thus recognized as the most effective strategy for preventing seasonal influenza virus infection if given each year.5,6 Due to the ever-changing morphology and genetic make-up of the influenza virus, known as “antigenic drift” if minor (an epidemic), or rarely, an “antigenic shift” if major (a pandemic), the medical community creates a new vaccine each year that reflects which influenza subtypes are particularly prominent in the region, with the ultimate hope that the vaccine will prevent the population from contracting these particular subtypes.4 To ensure that the vaccine can be used in all age groups and in those with certain medical conditions, multiple types of influenza vaccine are available for administration: the inactivated influenza vaccine, the live attenuated intranasal vaccine, and the recombinant influenza vaccine are examples of such. Of these three options, inactivated influenza vaccine is the most popular, as it can prevent influenza virus infection up to 65% of the time. However, for those with egg allergies, the recombinant influenza vaccine is most suitable, as this vaccine is made using cultured animal cells instead of fertilized eggs. Furthermore, to ensure that individuals are protected against different influenza subtypes, both the trivalent (covering 3 different subtypes of influenza virus) and the quadrivalent (covering 4 different subtypes

TABLE 2. Side effects, precautions, and contraindications of the influenza vaccine Inactivated influenza vaccine

Live attenuated intranasal vaccine

Recombinant influenza vaccine

Noted side effects

• Soreness/irritation at injection site • Headache • Fatigue • Muscle aches • Low-grade fever • Cough • Allergic reaction

• Fatigue • Headache • Low-grade fever • Runny nose • Sore throat • Cough • Fatigue • Wheezing

• Pain at injection site • Headache • Fatigue • Muscle aches

Precautions/ Contraindications

• <age 6 months • Egg allergy • History of Guillain-Barré syndrome • Pregnancy • History of severe allergic reaction to inactivated influenza vaccine in the past • Presence of acute illness requiring hospitalization

• <age 2 years • >age 50 years • Asthmatics aged 2-4 years • History of Guillain-Barré syndrome • Immunosuppression • Egg allergy • Pregnancy • Presence of acute illness requiring hospitalization • History of severe allergic reaction to any influenza vaccine • Children/adolescents receiving aspirin/salicylates • Taking influenza antiviral medication within past 48 hours

• <age 18 years • Known severe allergic reactions to recombinant influenza vaccine Note: safety/efficacy not established for children or women who are pregnant, or breastfeeding

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of influenza virus) vaccines are available for use. Due to increased protection against the various influenza strains, the CDC recommends administration of the quadrivalent vaccine over the trivalent vaccine to individuals without contraindications for receiving this vaccine type. For those aged 65 years and older, a more potent vaccination option induces a stronger immune response against influenza in comparison to the regular flu shot. However, for those with egg allergies, the recombinant influenza vaccine is most suitable, as this vaccine is made using cultured animal cells instead of fertilized chicken eggs.6 Common side effects with vaccination against influenza infection include fever, fatigue, headache, and joint pain, which usually resolve within a week; though cases are much more rare, Guillain-Barré syndrome, a disorder affecting the peripheral nervous system that may result in paralysis, has also been associated with administration of the influenza vaccine (Table 2).5 Of note, there are still some individuals who should not receive the influenza vaccine; depending on the type of vaccine, such contraindications include those with an egg allergy, those who have had Guillain-Barré syndrome in the past, and pregnant women.3,4,6 All this aside, the influenza vaccine’s benefits still largely outweigh the risks and potential adverse side effects, and it is therefore recommended for individuals as young as 6 months in the United States (Table 3).6 Patient perceptions of the influenza vaccine

For years, Americans have had mixed opinions regarding the efficacy and benefits of receiving vaccinations, including the influenza vaccine. Some studies have noted that a common reason why patients refuse the influenza vaccine is their perception that they do not need one, as they rarely become ill; others recall having had a negative experience as a result of the vaccine and believe that they may become infected with the virus if they receive the shot.7-9 Another important component that largely influences how patients perceive the influenza vaccine is the array of side effects that have been highly publicized and subsequently feared by the community. In a study analyzing how patients perceived the influenza vaccine during the H1N1 outbreak, research participants tended to believe that acquiring the H1N1 virus was less likely than having some of the adverse side effects associated with the corresponding vaccine, which ultimately served as a deterrent to vaccination.10 The media has also played a role in how the population perceives the influenza vaccine, often portraying vaccination in a negative light, overemphasizing the serious adverse reactions without

TABLE 3. Recommended ages and routes of administration for influenza vaccines Inactivated influenza vaccine

Live attenuated intranasal vaccine

Recombinant influenza vaccine

Route of administration

Injectable

Nasal spray

Injectable

Minimum age requirement

6 months

2 years

18 years

TABLE 4. Common beliefs preventing influenza vaccination in children The child has a low chance of contracting influenza. Even if the child gets vaccinated, he/she can still contract influenza. The vaccine can cause influenza. The vaccine can cause unwanted side effects, such as runny nose and congestion. The vaccine contains unwanted toxins such as thimerosal and mercury.

adequate mention of the advantages vaccines provide to a population at risk of infection.8,9,11 Negative depictions of and attitudes toward the influenza vaccine can place the patient population at serious risk, especially those who have increased susceptibility to influenza virus infection and its resultant severe complications. To further understand the perceptions Americans have regarding influenza vaccination, discussions of how different age groups and patient populations may view the annual vaccine follow. Children and adolescents

Of all age groups, children are among the most susceptible to succumbing to seasonal influenza infection, especially during the initial stages of the influenza season.12,13 Therefore, vaccination is currently recommended in children aged as young as 6 months. In spite of this recommendation, however, influenza vaccination rates in the pediatric population remain low; in the state of Washington, for example, only 58.3% of children received an influenza vaccine in the 2012-2013 season.13 Of the studies that explore theories explaining the suboptimal vaccination rate in children, most agree that parents play the largest role in determining whether their offspring will

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Case study Mr. O is a 20-year-old man with asthma, well-controlled on an albuterol inhaler used as needed, who presents for his annual physical examination prior to returning to college. It is fall, and the updated influenza vaccine has just been made available to the clinic for appropriate administration to the patient population. Mr. O is aware of the upcoming influenza season; however, he has a few questions regarding the potential side effects of the vaccine. He mentions further that he recently heard on a popular celebrity television show that the vaccine does more harm than good, as one can develop brain damage and may become severely ill from the vaccine. Mr. O asks you for more information. His vital signs are as follows: • Temperature: 98.6°F • Heart rate: 82 beats/min • Respiration rate: 16 breaths/min • Blood pressure: 119/63 mm Hg • Oxygen saturation on room air: 98%

After obtaining a better grasp on the patient’s perceptions regarding the influenza vaccine, you should ask if the patient would like to hear why you recommend the vaccine. If the patient agrees to discussion, respectfully explain what

the influenza vaccine is, its purpose, and the common side effects people can have after getting vaccinated. Proper education through simple dialog in an unbiased setting is critical to increasing the likelihood of the patient getting vaccinated. You should make a point to directly address the patient’s concerns in a polite, nonjudgmental fashion. Furthermore, sharing with the patient educational materials that display the background and benefits of the vaccine in a concise format is encouraged. If the patient is still hesitant, you should allow some time for the patient to digest the material discussed, making sure to avoid excessive swaying or bullying. If the patient leaves without getting his vaccine, you can also remind him about the vaccine at a later date through the mail or by phone.

be vaccinated against the influenza virus.7 Among parents who vaccinate their children each year, common reasons influencing their decision include recommendation by their child’s healthcare provider to get the vaccine each year, their belief that the vaccine will prevent acquisition of influenza virus, and their understanding that if their children do end up contracting influenza, the symptoms will not be as severe if their children have been vaccinated.7,14

Common reasons why parents decide not to vaccinate their children against influenza include the belief that children should acquire a natural immunity to influenza, that the vaccine can cause influenza, and that receiving multiple vaccines during one visit to the doctor may harm the child.7,14 Additional reasons include the belief that children have a low chance of contracting influenza, that the vaccine can cause unwanted side effects, such as a runny

A reasonable approach to the patient’s concerns includes respectfully discussing the following: • Assess the patient’s current understanding of what the influenza vaccine is, why it is given, and the risks and benefits associated with vaccination. • Ask if the patient was vaccinated in the previous year. If not, politely ask why. • If the patient exhibits a negative perception about the vaccine, ask why he or she feels that way.

Results of a complete physical examination are unremarkable.

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nose and muscle aches, and that some components of the vaccine may be toxic (Table 4).7,14 Although their parents play a large role in deciding whether or not they get vaccinated against influenza, children may also have substantial influence on the overall decision to get vaccinated. Therefore, clinicians should also understand some of the common perceptions children have about the influenza vaccine. One study comparing the different opinions children have regarding the vaccine found that, in general, children younger in age (6-8 years) are less likely to agree to get vaccinated as compared with older children. Reasons for the greater opposition to vaccination include the severity of pain that comes with getting the shot and a general lack of understanding of the benefits that come with getting the influenza vaccine.6 For those who did receive the vaccine, common reasons why they thought influenza vaccines were helpful included the belief that vaccination prevents influenza, that vaccination can lower the chance of acquiring influenza, and that vaccination can help them avoid missing school, which would allow them to spend more time with friends.5,12 Furthermore, these studies also observed that children may carry a particular bias against the different methods of vaccine delivery; most children, especially those of younger age, tended to prefer the intranasal route of vaccination, primarily to avoid any pain associated with the shot.5,12 Interestingly, many of the perceptions both adolescents and their guardians have regarding the influenza vaccine are similar to those expressed in the younger age group. In the same study previously noted, some of the most common reasons why either the adolescent or the parent refused the influenza vaccine included the belief that the adolescent did not need the vaccine, the vaccine is ineffective and may even cause influenza, the vaccine can cause unwanted side effects, and the adolescent’s natural immunologic response is enough, or even preferred, to fight an influenza virus infection.15,16 Of note, if the adolescent had a minor illness, almost 25% of parents surveyed refused the option of giving their child the vaccine, primarily due to the belief that the vaccine would not work as effectively because the child was sick and the fear that the child’s immune system would be overwhelmed if given a vaccine while fighting an illness, therefore causing unwanted and potentially more severe side effects (Table 5).15 Consent from parents or guardians is no longer an issue for individuals aged 18 years and older. Despite the relatively recent shift in the recommendation to provide annual influenza vaccines to healthy adults aged 18 to 49 years, there still remains a lag in the number of young adults who actually get the vaccine yearly.17 One study observing how proactive

college students are in getting their yearly influenza vaccine found that a suboptimal percentage of students reported obtaining their vaccination, even when such shots were made readily available on campus. Theories explaining the lack of participation include nonacceptance of the insurance coverage provided to students by their parents or guardians at some vaccination venues or that the students may not be able to afford the cost of the shot.17 General indifference was also reported as a significant reason for not getting vaccinated, as well as not knowing where to obtain the vaccine, either on campus or in the community.17 Adults

Adults have similar perceptions toward the influenza vaccine as do other age groups; those who do not favor the vaccine often believe that the vaccine is not efficacious.9,18 Other reasons for remaining unvaccinated included the belief that the vaccine can cause unwanted side effects, having had a negative reaction to the vaccine previously, and that they do not need to be vaccinated because they rarely become ill.9,18 For those who do get vaccinated, common reasons that explain their decision include taking their doctor’s recommendation, the belief that the vaccine will prevent illness, and among those of older age, understanding they are more susceptible to acquiring the illness.18 Aside from the pediatric population, the most common age group affected by influenza is the elderly. Up to 90% of the mortalities from influenza virus infection are in those aged at least 65 years, and during the 2014-2015 influenza season, an estimated 60% of hospitalizations due to influenza virus infection were in patients aged at least 65 years.19,20 Thus, because the elderly are very susceptible to contracting influenza, it is imperative for primary care providers to understand why many individuals who are older do not get vaccinated. Factors that have been associated with overall perception of the influenza vaccine among the elderly include social TABLE 5. Common beliefs/barriers preventing influenza vaccination in adolescents The vaccine is not very efficacious. The vaccine will result in unwanted side effects or even death. The benefits of vaccination are unclear due to lack of education. Parents are unwilling or unable to miss work to bring their child to the clinician’s office for vaccination. Parents are unaware of clinics or community centers where the vaccine is available.

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TABLE 6. Strategies clinicians can use to encourage influenza vaccination Take the time to listen carefully and have a detailed discussion with the patient regarding his or her thoughts on vaccination. Provide supplementary material/resources for patients to read regarding the vaccine (eg, pamphlets and other educational materials). Remind patients to get their vaccination by phone or with postcards by mail. Post educational flyers throughout the clinic to increase awareness of the vaccine.

TABLE 7. Efforts the community can use to increase influenza vaccination Workplace vaccination programs for convenience and to lower the cost of getting the vaccine Vaccination programs made available at schools for added convenience Educational fairs to inform the public on the influenza virus and benefits of receiving the annual vaccine

influences and perceived consequences of getting the shot.19 Those who received the influenza vaccine were more likely to believe that getting the shot is the most logical choice.19 Individuals who have at least a high school diploma are also more likely to view the vaccine in a more positive light and therefore get the shot.19 In contrast, among those who decided against getting the vaccine, common explanations included the simple lack of awareness that the influenza vaccine is highly recommended and necessary to prevent influenza virus infection and concerns that vaccination would increase the risk of acquiring influenza or cause adverse side effects.8,19 Susceptible populations

Certain populations are at an even higher risk for influenza infection due to their medical conditions, including cystic fibrosis, diabetes, and asthma.3,21,22 The rate of vaccination is suboptimal among these susceptible patients. Although the American Academy of Pediatrics and the Immunization Practices Advisory Committee recommend that patients with asthma obtain an influenza vaccine each year, one study has found that fewer than 10% of children with moderate-tosevere asthma follow this recommendation.22 Similar to the

populations previously discussed, common reasons why the vaccine is declined among individuals in this group include concern about the vaccine’s potential side effects.22 Overcoming misconceptions

Although many studies address some of the more negative perceptions people may have about getting an annual influenza vaccination, progress needs to be made to find a way to combat common misconceptions. However, there are various ways in which clinicians can help correct their patients’ bias toward acquiring the vaccine so that, ultimately, more patients get vaccinated against influenza, become less susceptible to acquiring influenza, and become less likely to spread influenza virus infection. Many reports indicate that the physician’s recommendation heavily influences the patient’s opinion about vaccination.7,9,15,23 Furthermore, the physician must also take the time to discuss in detail with hesitant patients the particular reasons why they perceive the influenza vaccine in a negative light. The physician should respectfully inform the patient of the benefits and risks of the vaccine and correct any misinformation.9,15 By doing so, the physician may be able to provide reassurance based on solid evidence, so that patients will feel that their concerns have been taken into consideration and addressed instead of pushed aside or criticized and thus may be more inclined to change their previous beliefs about getting vaccinated.9,24 Providing supplementary material for patients to review can also be helpful in debunking the myths associated with influenza vaccination; these are accessible through organizations such as the Centers for Disease Control and Prevention and, for the pediatric population, the American Academy of Pediatrics (Table 6).15 In a similar vein, a community approach emphasizing proper education on the benefits and side effects associated with the influenza vaccine may also be useful, especially when these include other preventive medical provisions such as blood pressure screenings.19 Although many individuals who choose not to accept the influenza vaccine have negative perceptions regarding its efficacy or benefits, there are many others who are either indifferent to or appreciate the vaccine but forget to obtain one. In such cases, numerous suggestions have been made to remind these patients to get vaccinated. According to the Advisory Committee of Immunization Practices, reminder/ call systems may prove useful.3 Mailing postcards can be sent as both helpful reminders and educational tools to help keep patients informed of the reasons why the influenza vaccine is recommended by their physicians.8 Similarly, in those who are more susceptible to influenza virus infection as a result of

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chronic medical conditions, a database and reminder system can be used to both track and call these patients to inquire about their current vaccine status and educate them about the significance of getting the influenza vaccine.22 In addition, there are still others who, although they want to get the vaccine, are unable to do so due to lack of access to healthcare providers who can administer the vaccine. Many measures have been suggested to help resolve this particular issue. To help parents get their children vaccinated, vaccine clinics associated with school systems can make vaccination at school possible for many districts, making convenience and greater accessibility to preventive care a priority.22 For healthcare workers, multiple employers have made vaccination not only readily available at on-site locations but also have made vaccination a requirement, thus effectively increasing accessibility, convenience, and the number of vaccinations administered to an especially susceptible population.23 In all, with measures such as those discussed in place in their practice and in the community (Table 7), clinicians can hopefully develop a successful strategy aimed at increasing influenza vaccination rates among their patients. n

10. Renner B, Reuter T. Predicting vaccination using numerical and affective risk perceptions: the case of A/H1N1 influenza. Vaccine. 2012;30(49):7019-7026. 11. Abramson ZH, Levi O. Influenza vaccination among primary healthcare workers. Vaccine. 2008;26(20):2482-2489. 12. Flood EM, Ryan KJ, Rousculp MD, et al. A survey of children’s preferences for influenza vaccine attributes. Vaccine. 2011;29:4334-4340. 13. Strelitz B, Gritton J, Klein EJ, et al. Parental vaccine hesitancy and acceptance of seasonal influenza vaccine in the pediatric emergency department. Vaccine. 2015;33(15):1802-1807. 14. Daley MF, Crane LA, Chandramouli V, et al. Influenza among healthy young children: changes in parental attitudes and predictors of immunization during the 2003 to 2004 influenza season. Pediatrics. 2006;117(2):e268-e277. 15. Rand CM, Humiston SG, Schaffer SJ, et al. Parent and adolescent perspectives about adolescent vaccine delivery: practical considerations for vaccine communication. Vaccine. 2011;29(44):7651-7658. 16. Bhat-Schelbert K, Lin CJ, Matambanadzo A, et al. Barriers to and facilitators of child influenza vaccine—perspectives from parents, teens, marketing and healthcare professionals. Vaccine. 2012;30(14):2448-2452. 17. Bednarczyk RA, Chu SL, Sickler H, et al. Low uptake of influenza vaccine among university students: evaluating predictors beyond cost and safety concerns. Vaccine. 2015;33(14):1659-1663.

Allexa Hammond, BA, is a medical student and Maura Holcomb, MD, is a dermatology resident at Baylor College of Medicine.

18. Fiebach NH, Viscoli CM. Patient acceptance of influenza vaccination. Am J Med. 1991;91(4):393-400. 19. Wooten KG, Wortley PM, Singleton JA, Euler GL. Perceptions matter:

References

beliefs about influenza vaccine and vaccination behavior among elderly

1. H1N1 - originally referred to as Swine Flu. FLU.gov website. http://www.

white, black, and Hispanic Americans. Vaccine. 2012;30(48):6927-6934.

flu.gov/about_the_flu/h1n1

20. D’Mello T, Brammer L, Blanton L, et al; Centers for Disease

2. H5N1 Avian Flu - H5N1 Bird Flu. FLU.gov website. http://www.flu.gov/

Control and Prevention. Update: Influenza activity—United States,

about_the_flu/h5n1/index.html

September 28, 2014-February 21, 2015. MMWR Morb Mortal Wkly Rep.

3. Tran C, Pitts J. Improving influenza vaccine compliance through

2015;64(8):206-212.

patient education for patients with cystic fibrosis. J Pediatr Health Care.

21. Remschmidt C, Wichmann O, Harder T. Vaccines for the prevention of

2007;21(1):57-61.

seasonal influenza in patients with diabetes: systematic review and meta-

4. Hart AM. Respecting influenza: an evidence-based overview for primary

analysis. BMC Med. 2015;13:53.

care nurse practitioners. J Nurse Pract. 2015;11(1)41-47.

22. Szilagyi P, Rodewald LE, Savageau J, et al. Improving influenza vaccination

5. Flood EM, Block SL, Hall MC, et al. Children’s perceptions of influenza illness

rates in children with asthma: a test of a computerized reminder system

and preferences for influenza vaccine. J Pediatr Health Care. 2011;25(3):171-179.

and an analysis of factors predicting vaccination compliance. Pediatrics.

6. Seasonal influenza vaccine safety: a summary for clinicians. Centers for

1992;90(6):871-875.

Disease Control and Prevention website. Updated October 16, 2015.

23. Godoy P, Castilla J, Mayoral JM, et al; Working Group for the Survey

http://www.cdc.gov/flu/professionals/vaccination/vaccine_safety.htm

on Influenza Vaccination in Primary Health Care Professionals. Influenza

7. Flood EM, Rousculp MD, Ryan KJ, et al. Parents’ decision-making

vaccination of primary healthcare physicians may be associated with

regarding vaccinating their children against influenza a: a web-based survey.

vaccination in their patients: a vaccination coverage study. BMC Fam Pract.

Clin Ther. 2010;32:1448-1467.

2015;16:44.

8. Zimmerman RK, Santibanez TA, Janosky JE, et al. What affects influenza

24. Poland CM, Poland GA. Vaccine education spectrum disorder: the

vaccination rates among older patients? An analysis from inner city,

importance of incorporating psychological and cognitive models into

suburban, rural, and veterans affairs practices. Am Med. 2003;114(1):31-38.

vaccine education. Vaccine. 2011;29(37):6145-6148.

9. Chapman GB, Coups EJ. Predictors of influenza vaccine acceptance among healthy adults. Prev Med. 1999;29(4):249-262.

All electronic documents accessed on November 4, 2015.

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CME CE

POSTTEST Expiration date: December 15, 2016

FEATURED COURSE CREDITS: 0.5

For more credit information, please turn to p. 40. 1. The parents of a healthy 7-month-old female come to the clinic seeking advice regarding influenza vaccination for their child. They tell you that their friends mentioned at a dinner party that influenza vaccines should not be given to any children within their first year of life, as the vaccine can cause serious side effects, such as severe developmental delay, in infants. In response, you mention that the influenza vaccine can be administered to certain age groups. How do you proceed with the discussion? a. Inform them that their friends were correct, and their daughter should not get the influenza vaccine because she is too young. b. Tell the parents that their daughter is old enough to receive the inactivated injectable vaccine only. c. Tell the parents that their daughter can get either the live attenuated vaccine or the inactivated injectable vaccine, based on their preference. d. State that their daughter cannot get any kind of influenza vaccine unless she has been already vaccinated against hepatitis B. 2. An 18-year-old male without a significant past medical history who comes to your office to get an influenza vaccine for the first time. He would like to get the inactivated injectable vaccine, but is concerned about the common side effects associated with this type of vaccine. Your response should include which of the following? a. There are no side effects associated with this type of influenza vaccine. b. Some studies have found that vaccination can result in lifelong seizures in approximately 1 out of every 150 individuals vaccinated against influenza. c. The most common side effects include itchy eyes, diarrhea, and jaundice, which usually resolve within 1 week after vaccination. d. The most common side effects include fever, fatigue, and joint pain, which usually resolve within 1 week after vaccination. 3. A mother brings her healthy 5-year-old child for a well-child visit. Per the provider’s recommendations, she wants to get her child vaccinated against influenza, but she wants to know which vaccine her child should receive. You tell her that both the inactivated influenza vaccine (IIV) and live attenuated intranasal vaccine (LAIV) are effective and can be used. How

do you explain what is understood about the preference of children for one route of vaccination over the other? a. When given the choice, younger children often prefer IIV, because the shot does not cause any side effects, as compared with LAIV, which does. b. When given the choice, younger children prefer IIV over LAIV because, if they get the IIV, they will not have to get another influenza vaccine for the next 2 years because IIV may be more effective than LAIV in healthy children aged 2 to 8 years old. c. When given the choice, younger children prefer LAIV over IIV, because the spray also helps them breathe better. d. When given the choice, younger children prefer LAIV over IIV, because IIV is more painful than LAIV. Furthermore, recent studies suggest that LAIV may be more effective than IIV for healthy children aged 2 to 8 years. 4. A 39-year-old man with a history of asthma, well-controlled with albuterol, comes in for his annual well visit. You mention that influenza season is about to begin and ask if he has thought about getting the vaccine. He replies that he has been hesitant about getting vaccinated, as he has heard from friends and the media that the vaccine can cause influenza virus infection, along with other unwanted side effects such as permanent paralysis. However, he is willing to obtain information from you regarding the benefits of getting vaccinated. How do you respond? a. Chastise him for his opinions regarding the vaccine and tell him that if he does not get vaccinated he will likely contract the influenza virus and have severe complications as a result. b. Tell him that you respect his beliefs and forego further discussion about influenza vaccination . c. Respectfully ask him to share more information regarding why he has been hesitant to get vaccinated; afterward, provide a concise yet thorough explanation for why the influenza vaccine is beneficial, and provide supplemental information about the vaccine. d. Respectfully ask him to share more information regarding why he has been hesitant to get vaccinated; afterward, mention that there are no current recommendations for getting vaccinated against influenza, particularly because the vaccine does not cover all of the different types of influenza virus infection.

TO TAKE THE POSTTEST please go to: myCME.com/Dec15CAfeature

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

YOUR COMMENTS THE CDC’S STATISTICS ON INFLUENZA— FACT OR HYPE? The influenza death rate is much overstated [“Influenza: complications, diagnosis, and treatment, p. 26]. According to the National Vital Statistics System, which records death rates from death certificates, the flu death rate in 2010 was 500. Of that total, maybe 10% to 15% resulted from influenza. The 36,000 total quoted includes all the pneumonias. There are many causes of pneumonia. It is very inaccurate to be quoting this same number that the CDC and TV networks state. Three years ago, the CDC was scolded for not having the vaccine committees of more than 200 people reveal their financial ties to vaccine manufacturers. More than 65% had some relationship with them. Does that create a bias to inflate these statistics? Look at the vaccine inserts. They state no evidence of efficacy proven and are not sure about safety with young children and pregnant women. 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.

What other drug do we prescribe that we encourage people to take on such a wide scale? Influenza vaccines should be offered for those who desire it, but please inform them of the correct data to make an informed decision.—PAUL BATTLE, PA-C, Denver (206-1) Not everyone is tested for influenza, so the numbers are going to be skewed. The 36,000 people with pneumonia, many possibly undiagnosed with the flu, need to be considered in the statistics, especially if a viral syndrome is described prior to death. Even in our small community, the death rate is calculated in association with a recent viral syndrome. If we had no vaccine for the flu (even considering the poor “match” years), how many people would be ill and die? Do we need to go there again?—THERESA RUCKER, PA, Orlando, Fla. (206-2)

ANALOGIES FOR PATIENTS IN THE BATTLE AGAINST MEDICAL NONCOMPLIANCE Simple analogies could enhance medical compliance. Medical noncompliance is a large deterrence to the achievement of treatment goals. There are many reasons to explain why patients are noncompliant. Among them is the fact that patients are unaware or do not understand the negative impact that their uncontrolled chronic medical problem has on their well-being.

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, Ala.

Laura A. Foster, CRNP, FNP,

Abby A. Jacobson, PA-C,

practices family medicine with Palmetto Primary Care Physicians in Charleston, S.C.

is a physician assistant at Delaware Valley Dermatology Group in Wilmington, Del.

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For instance, many times a patient who is not taking his or her blood pressure medications presents to the clinic with a high blood pressure reading. After questioning, the patient will tell his or her provider, “My blood pressure is always high,” and appear not at all concerned about it. Some will admit to not taking their medications despite knowing that their blood pressure is high. Many of the patients are unaware of the actual damage that their uncontrolled medical problems has on their bodies and specifically their end organs. Even though limited by time constraints, some healthcare providers are able to educate their patients on the negative impact of uncontrolled chronic medical problems. The problem that may arise though is whether the patient understands this information. For example, when a provider tells a patient that high blood pressure damages the kidneys, does the patient understand how this occurs? Some patients may become more compliant with their treatment if they understood this information and it was provided at a very simple and easy to understand level. Alternatively, using simple analogies may be beneficial in ensuring that understanding. It would be important, however, to make the patient aware that the actual occurrence in the body is more complicated than the analogy used. For uncontrolled blood pressure, for instance, an analogy a provider could use is that of comparing the cardiovascular system to a city water system, with the heart being one main water pump just as in a city water system. If the pressure within the city water system piping became elevated, it would be likely for one of the pipes to break or burst. The pipe that would be most likely to burst would be the weakest. Relating that to the human body, high pressures within the blood vessels would put the weakest/smallest vessels at risk of a burst or a break. Further elaborating, these weakest blood vessels are in the human brain, in the kidneys, in the

Debra August King, PhD, PA,

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

Mary Newberry, CNM, MSN,

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

eyes, and in the heart. If the break or burst occurred in the brain, that would be a hemorrhagic stroke. In the kidneys and in the eyes, these high pressures cause micro-aneurysms or even small bursts that are not visible to the patient. Due to the lack of an outward manifestation, the patient may be unaware of the breaks/bursts until extensive damage has been done to the organ for long periods of time. Similarly, in uncontrolled diabetes, analogies relating to the microvascular and macrovascular complications would be of benefit—for example, a simple analogy of a clogged water pipe due to rust and other accumulation inside the pipe that deters free flow of water. Similarly, accumulation of plaque in the blood vessels caused by uncontrolled blood glucose and other factors deters the flow of blood to the intended areas such as in the muscles of the heart, the distal parts of extremities, and others areas leading to issues that include heart attacks and peripheral vascular disease that can lead to loss of limb. Compliance with medical treatment takes a lot of effort on the part of the patient and the provider, and many factors determine the success of these efforts. Analogies could be a small part of this large effort to enhance compliance. Every area of practice could have applicable analogies.—SAM MBUGUA, MSN, FNP-C, Arlington, Texas. (206-3)

CLINICAL PEARL THE RIGHT TOUCH When I taught PAs years ago, I told them that they should ALWAYS touch the patient, especially the area of complaint— i.e., touch the head for a headache. So often we just get a history, especially today with computers.—MICHAEL QUIRK, PA-C, MBA, DFAAPA, Cudjoe Key, Fla. (206-4) n

Claire O’Connell, MPH, PA-C,

Katherine Pereira, DNP, FNP,

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

is assistant professor, Duke University School of Nursing, Durham, N.C.

Sherril Sego, FNP-C, DNP,

is an independent consultant in Kansas City, Mo.

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LEGAL ADVISOR CASE

Emergency ignored in an alcoholic

BY ANN W. LATNER, JD

When Ms. M walked into the hospital emergency department (ED) at 6 am to start her shift, the 42-year old nurse practitioner was hoping for a quiet day. Initially, that seemed possible. The waiting room was largely empty and despite the usual beeping and humming of medical equipment, the ED seemed fairly calm. Then, the nurse at the triage desk informed her that Mrs. B, aged 64 years, had come in. Mrs. B was a frequent visitor to the ED who would typically be brought in heavily intoxicated in the middle of the night and stay at the hospital until she was sober. Once she was released, the pattern would repeat. Ms. M had tended to this patient on several occasions. Mrs. B was a widow; her husband had died of an alcohol-related disease several years earlier. She said that she had a grown son who lived in another state, but Ms. M had never met any of Mrs. B’s family members. The pattern was always the same: Mrs. B would be found unresponsive on the street or in a bar and would be taken to the hospital. Ms. M checked in with the emergency medicine physician who had admitted Mrs. B. The

Clinicians assume symptoms in a patient who regularly presents intoxicated are due to alcohol. Clinicians did not provide the standard of care that the patient was due, which led to her being untreated and ultimately resulted in her death.

physician, who was going off duty, told Ms. M that the patient had been brought in by ambulance at approximately 1:30 am. “She was very intoxicated,” the physician said, “but was in no acute distress and could be aroused by touch or by saying her name. This has all been noted in the chart.” The physician left, and Ms. M went to check on the patient. Mrs. B seemed to be sobering up. By 7 am, Ms. M noted that the patient could move her limbs, possessed motor strength, and could walk with a relatively normal gait. At 7:15 am, the patient was awake, responsive, and requesting food. “I think she’s good to go,” Ms. M said to another clinician. The paperwork was filled out, and Mrs. B was taken to the door. Ms. M hoped she would not be seeing the patient again for at least a month, but within 15 minutes, Mrs. B was brought back in. Hospital Cases presented are based on actual occurrences. Names of participants and details have been changed. Cases are informational only; no specific legal advice is intended. Persons pictured are not the actual individuals mentioned in the article.

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LEGAL ADVISOR The purpose of the act was to prevent hospitals from refusing to treat patients who were unable to pay for their services. In this case, however, the plaintiff argued that Mrs. B was not provided with “an appropriate medical screening exam.” Instead, she was assumed to be drunk because of past behaviors, and simply kept until, it was hoped, she would sober up. No proper examination was performed and, with the exception of the two blood alcohol draws and the CT scan, no lab work or diagnostic testing took place. Mrs. B had to be readmitted before even the first blood alcohol test was done, and then, it was almost 20 hours later before any other tests were ordered. This could not be considered an “appropriate medical screening examination” under any circumstance, and the hospital wisely settled out of court. Protecting yourself

Making assumptions is a dangerous thing, but on some level, clinicians have to make assumptions every day as they assess patients to make a diagnosis. In this case, however, the assumption was that, because Mrs. B was drunk and had a history of coming to the ED intoxicated, this would always be the case. This time, it was not the case. By assuming that she was merely drunk, without taking a blood alcohol test for hours or doing any sort of examination or lab work, the clinicians, including Ms. M, failed their patient. They did not provide the standard of care that the patient was due, and their assumptions about her condition led to her being untreated and eventually, resulted in her death. Even if you think you know the issue, take the time needed to properly assess each patient. n Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.

Legal background

The plaintiff in this case sued the hospital under the Emergency Medical Treatment and Active Labor Act (EMTALA). Enacted in 1986, EMTALA was created to ensure public access to emergency services regardless of ability to pay. EMTALA basically states that any patient who comes to the ED requesting treatment must be provided with “an appropriate medical screening examination” to determine if the patient has an “emergency medical condition.” If so, the hospital is obligated to provide treatment until the patient is stable.

staff had witnessed her stumbling outside and having difficulty walking. Once back in the ED, Ms. M ordered a blood alcohol test, which was the first one for this visit, as no tests had been ordered at all earlier. The patient’s blood alcohol level came back as 0.261. Mrs. B was readmitted and placed in a bed to “sleep it off.” However, as the day wore on, Mrs. B’s condition did not improve, and it seemed to worsen. In addition to problems walking, the patient also seemed to be having problems speaking. No one thought much of this, however, as she often slurred her speech when she was drunk. No other tests were ordered. As the day passed, the ED became increasingly busy. Ms. M was called away to care for other patients. Someone would check on Mrs. B periodically, but no other action was taken. Notes in the chart indicated that the patient continued to have difficulty walking and talking. Sometime after 3 am the following morning, hospital staff noted that Mrs. B remained unable to walk and had begun to moan loudly. Ms. M consulted with the ED physician. “I think we should order another blood alcohol test,” Ms. M said. “I agree,” the physician said, “and a head CT, just in case.” A CT scan was performed at 4:30 am. The results of the tests and scan revealed that Mrs. B had a blood alcohol level of zero but had had a stroke. By this point, Mrs. B had stopped responding and could not be revived. The patient died three days later, without having regained consciousness. An autopsy fixed the cause of death as vascular thromboses of the left internal carotid and left middle cerebral arteries. Some months later, Ms. M and several of the staff who had been working that day were informed that the hospital had been sued and that those who treated Mrs. B would have to participate in depositions and possibly testify at trial. Much to Ms. M’s relief, however, the hospital settled the case out of court.

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CME CE DERMATOLOGY COURSES

n LEARNING OBJECTIVES After completing the activity, the participant should be better able to:

For Dermatology Clinic

• Examine the etiology and clinical presentation of erythema dyschromicum perstans and lichen planus • Formulate diagnostic procedures and treatment protocols for patients presenting with erythema dyschromicum perstans and lichen planus

For Dermatologic Look-Alikes

• Differentiate between skin manifestations of vitiligo and discoid lupus erythematosus while considering their underlying cause • Demonstrate proficiency in identifying and treating vitiligo and discoid lupus erythematosus n COMPLETE THE POSTTEST: Page 71 n ADDITIONAL CME/CE CREDIT: Page 40

This activity is provided by Haymarket Medical Education (HME) for physician credit. This activity is co-provided by Medical Education Resources (MER) for nursing contact hours. Release Date: December 16, 2015 Expiration Date: December 15, 2016 Estimated time to complete the educational activity: 30 minutes Statement of Need: Undertraining in dermatology for primary-care providers is a common phenomenon. Thus, primary-care clinicians need additional educational outlets devoted to the diagnosis and treatment of specific dermatologic conditions. For clinicians out of training, CME becomes the most accessible route. Target Audience: This activity has been designed to meet the educational needs of primary-care health-care professionals who treat patients with various dermatologic conditions. Faculty Shehni Nadeem, BA, Baylor College of Medicine, Houston Nicole R. Bender, MD, Medical College of Wisconsin, Milwaukee Yasmin Qaseem, BS, BA, Baylor College of Medicine, Houston Maura Holcomb, MD, Baylor College of Medicine, Houston Accreditation Statements Physician Credit: HME is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Credit Designation: HME designates this enduring material for a maximum of 0.5 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nursing Credit: MER is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Credit Designation: This CE activity provides 0.5 contact hour of continuing nursing education. MER is a provider of continuing nursing education by the California Board of Registered Nursing, Provider #CEP 12299, for 0.5 contact hour. This activity qualifies for 0.25 pharmacotherapy credit. American Academy of Physician Assistants (AAPA) The AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hour of Category I credit for completing this program. Disclosure Policy In accordance with the ACCME Standards for Commercial Support, HME requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. HME resolves all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.

committed to providing its learners with high-quality CME/CE activities that promote improvements in health care and not those of a commercial interest. The faculty reported the following financial relationships with commercial interests whose products or services may be related to the content of this CME activity: Faculty Disclosures

Name of faculty

Reported Financial Relationship

Shehni Nadeem, BA

No relevant financial relationships

Nicole R. Bender, MD

No relevant financial relationships

Yasmin Qaseem, BS, BA

No relevant financial relationships

Maura Holcomb, MD

No relevant financial relationships

Staff/Planners’ Disclosures The planners, managers, and reviewers for this program reported the following financial relationships with commercial interests whose products or services may be related to the content of this CME activity: HME planners, managers, and reviewers have no relevant financial relationships to disclose. MER planners, managers, and reviewers have no relevant financial relationships to disclose. Disclosure of Unlabeled Use: This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. HME and MER do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Method of Participation: There are no fees for participating in and receiving CME/CE credit for this activity. During the period of December 16, 2015, through December 15, 2016, participants must: 1) read the learning objectives and faculty disclosures; 2) study the educational activity; 3) complete the posttest and submit it online (clinicians may register at www.myCME.com); and 4) complete the evaluation form online. A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better. Disclaimer: The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of HME or MER. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. The information presented in this activity is not meant to serve as a guideline for patient management.

Furthermore, HME seeks to verify that all scientific research referred to, reported, or used in a CME/CE activity conforms to the generally accepted standards of experimental design, data collection, and analysis. HME is

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Dermatology Clinic

CME CE DERMATOLOGY COURSES

CASE #1

Nonpruritic, painless, ashen blue-gray macules on the neck and trunk SHEHNI NADEEM, BA, AND MAURA HOLCOMB, MD

A Hispanic woman, aged 30 years, presents with ashen blue-gray macules spread diffusely on her neck and trunk. The lesions are nonpruritic and painless, and no other systemic symptoms are noted. These lesions are concerning to the patient, since they developed sporadically 2 years ago and continue to worsen. On physical examination, blue-gray macules of varying sizes and shapes are observed scattered in the neck and trunk region. Some lesions have raised borders, whereas others do not. What is your diagnosis? Turn to page 64.

CASE #2

Purple papules in an arcuate pattern on the genitalia NICOLE R. BENDER, MD, AND MAURA HOLCOMB, MD

An African-American man, aged 35 years, presents with a 3-month history of pruritic penile lesions. Examination reveals an arcuate pattern of raised violaceous-to-flesh-colored papules with central clearing on the glans penis and a few scattered, raised violaceousto-flesh-colored polygonal papules of the glans penis and distal penile shaft. Results of the remainder of the skin examination are normal, and there is no inguinal lymphadenopathy. His sexual history includes no previous sexually transmitted diseases and no new sexual partners within the past year. What is your diagnosis? Turn to page 65. www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • DECEMBER 2015 63

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CME CE

CASE #1

Dermatology Clinic

Erythema dyschromicum perstans

Er ythema dyschromicum perstans (EDP) is an exceptionally rare form of lichen planus. Also referred to as ashy dermatosis, it is a benign, hyperpigmented cutaneous eruption. The condition often presents in children and young adults of Asian and Latin American origin who are predominantly darker-skinned; however, EDP has been found in all age groups and in individuals of all skin coloring.1-3 Most cases are diagnosed in El Salvador, the site of the first described case.1 EDP varies in presentation from its earlier stages to its later stages. In the beginning, erythematous and elevated borders emerge around gray macules on the face, neck, trunk, or upper extremities in a symmetrical fashion. These are the active lesions. Patients do not have any related symptoms, either in the areas of the lesions or in the rest of the body. As the lesions progress, they take on a more blue-brown color, and the erythematous border flattens. Patients often present with multiple ashy lesions of different shapes and sizes. These lesions persist longer in some patients than in others; in many, the lesions disappear after a few years.1-3 Although it is not clear why EDP develops in certain individuals, indigenous environmental exposures, such as infection with whipworm or another intestinal parasite, chlorothalonil exposure (in banana farm workers), ingestion of ammonium nitrate found commonly in fertilizers, and contact with other pesticides, are considered to play a role. In instances of whipworm infection, it was found that Causative agents implicated in erythema dyschromicum perstans4 Intestinal parasitic infections Chlorothalonil exposure Ammonium nitrate (pesticide) ingestion Benzodiazepines Penicillin

when individuals were treated for the parasitic infection, EDP subsequently resolved. Others have postulated that medications such as benzodiazepines and penicillin may place individuals at greater risk for developing EDP.4 Genetic studies have also been conducted, specifically for association with the human leukocyte antigen class II major histocompatibility complex (HLA-DR). In a population of Mexican Mestizo patients, HLA-DR4 was found in 65% of EDP-positive patients, compared with 23% of control subjects.5 Although it is not clear that this implies a direct genetic association, it makes for a greater case that there may be a genetic component for the disease.

Because erythema dyschromicum perstans is so uncommon, it can be difficult to diagnose the condition. Because EDP is so uncommon, it can be difficult to diagnose the condition. It is often mistaken for atrophic lichen planus, lichenoid drug reactions, lichen planus pigmentosus, pigmented contact dermatitis, postinflammatory hyperpigmentation, and tuberculoid leprosy. Clinical context must be considered in the differentiation of EDP from these other conditions, such as if the patient had begun taking any new medications, if the patient is immunocompromised, the age of the patient, and other comorbidities and exposures of the patient. Additionally, EDP has a characteristic erythematous raised rim around lesions that is nonpruritic and not present on mucosal surfaces. For further confirmation, laboratory testing should be conducted to rule out any infectious etiologies, glucose intolerance, and liver dysfunction. A biopsy of the lesion may also be taken specifically from the raised erythematous border of a macule. However, biopsy results can be nonspecific and limited in value. Histologic examination shows vacuolar degeneration of the basal layer and an upper dermis with increased melanophages. The epidermis shows some thinning and some colloid bodies may be seen.1-3 Therapeutic intervention is not required for EDP. However, treatment may be considered in a patient with cosmetic concerns. Although many modalities have been tested, none have produced strong results indicative of

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a clear treatment plan. This is in part limited by sample size, as EDP is so rare and often remits spontaneously in individuals who had it previously. Clofazimine, a lipophilic rhimophenazine dye originally developed to treat tuberculosis, holds the most promise. It showed good or excellent response in seven of eight patients maintained on the drug for 3 months, although it is not apparent whether a cure was achieved. This drug targets the initial inflammatory phase of EDP. However, adverse effects can result in difficulties with compliance and undue risk in some patients. Adverse effects of clofazimine include orange discoloration of the skin and eye, development of ichthyosis, potentially fatal enteropathy secondary to crystal deposition in the intestine, eosinophilic enteritis, and splenic infarction.6 Antibiotics, ultraviolet exposure, chemical peels, corticosteroids, psychotherapy, and vitamins have shown no improvement in EDP. In our case, the patient was determined to have EDP because of the classic appearance of her lesions. She opted not to have a confirmatory biopsy. The patient was advised that the lesions can spontaneously disappear and that current treatments often produce disappointing results. The patient opted not to pursue treatment after counseling. Ms. Nadeem is a medical student and Dr. Holcomb is a dermatology resident at Baylor College of Medicine in Houston. References 1. Convit J, Kerdel-Vegas F, Rodriguez G. Erythema dyschromicum perstans a hitherto undescribed skin disease. J Invest Dermatol. 1961;36(6):457-462. 2. Cestari TF, Dantas LP, Boza JC. Acquired hyperpigmentations. An Bras Dermatol. 2014;89(1):11-25. Available at ncbi.nlm.nih.gov/pmc/articles/ PMC3938350 3. Berger RS, Hayes TJ, Dixon SL. Erythema dyschromicum perstans and lichen planus: are they related? J Am Acad Dermatol. 1989;21 (2 Pt 2):438-442. 4. Penagos H, Jimenez V, Fallas V, et al. Chlorothalonil, a possible cause of erythema dyschromicum perstans (ashy dermatitis). Contact Dermatitis. 1996;35(4):214-218. 5. Correa MC, Memije EV, Vargas-Alarcón G, et al. HLA-DR association with the genetic susceptibility to develop ashy dermatosis in Mexican Mestizo patients. J Am Acad Dermatol. 2007;56(4):617-620. 6. Arbiser JL, Moschella SL. Clofazimine: a review of its medical uses and mechanisms of action. J Am Acad Dermatol. 1995;32(2 Pt 1):241-247. All electronic documents accessed November 2, 2015.

CASE #2

Lichen planus

Lichen planus is an acutely occurring inflammatory skin disease characterized by a papulosquamous eruption of the skin, scalp, nails, and mucous membranes.1 Lichen planus has an estimated frequency of approximately 1% in the general population.2 Approximately 25% of men with lichen planus have lesions on the genitalia; the glans penis is the most commonly affected area.3 One study of women with oral lichen planus found that more than 75% also had genital involvement, and half of these cases were asymptomatic.4 In consideration of this statistic, it is important that all patients with lichen planus should undergo a systematic genital examination, especially those with involvement of the oral mucosa.2 The classic presentation of cutaneous lichen planus is characterized by the “4 Ps”: purple, polygonal, pruritic, papules.5 However, the most common clinical expression of genital lichen planus is leukokeratotic lesions, consisting of flat, white papules that coalesce into compact patches or networks.2 The lesions may also manifest similar to the classical cutaneous description described in the introductory case or as arcuate groupings of individual papules that develop rings or peripheral extension of clustered papules with central clearing.3 Fine white streaks (Wickham striae) may appear on the surface of the lesions. In uncircumcised patients, the lesions assume a lacy, white, reticulated pattern.1 Genital lichen planus often has a dominant erosive component, which is much more frequent in women and varies in intensity and area.2 Erosive lichen planus in men mainly affects the glans, manifesting as bright red lesions that must be differentiated from Zoon balanitis.2 Patients with lichen planus often complain of pruritus and soreness. Lesions may be associated with ulceration or induration, which may suggest squamous cell carcinoma and require biopsy.1 Although its pathogenesis is not fully understood, there is evidence that an imbalance of immunologic cellular reactivity is central.5 One theory includes an autoimmune reaction in which CD8+ T lymphocytes attack basal keratinocytes leading to the apoptosis of these basal cells.6 Various potential triggers of this autoimmune reaction include viral or bacterial antigens, metal ions, drugs, or physical factors.

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CME CE

Dermatology Clinic

One frequently cited trigger includes the hepatitis virus (hepatitis B and hepatitis C virus), due to its association with mucosal lichen planus, including the genital mucosa.2 The incidence of mucosal lichen planus seen with hepatitis infection or carrier status varies, but is particularly significant in geographical areas where there is a high frequency of hepatitis virus infections.2 On this basis, it is advisable to test all patients with genital lichen planus, especially those with erosive lesions, for markers of viral hepatitis. Clinical variants of lichen planus include annular, hypertrophic, atrophic, ulcerative, bullous, lichen planus pemphigoides, lichen planus pigmentosus, erythrodermic, inverse, linear, follicular, and actinic.6 These variants can be distinguished from the classical form of lichen planus based on morphology and distribution. Diagnosis of variants may be ensured with biopsy, which demonstrates the same characteristic histology of classical lichen planus.6

Despite challenges, many penile lesions can be diagnosed and managed by primary care providers. Diseases of the male genitalia range from infectious lesions to inflammatory and neoplastic conditions. Differential diagnosis of lichen planus affecting the genitalia should include common sexually transmitted diseases (herpes simplex viral lesions, primary syphilis), other inflammatory disorders (guttate psoriasis, lichen nitidus, lichenoid drug eruption), scabies infestation, and Zoon balanitis. The diagnosis of genital lichen planus is easy for the classical forms, especially when associated with oral localizations. Biopsy may, however, be necessary in the event of a questionable diagnosis; the lesional specimen should be taken from the edge of any eroded areas.2 The histopathologic findings of lichen planus include orthohyperkeratosis, circumscribed wedge-shaped hypergranulosis (representing histopathologic substrate of the Wickham striae), and sawtooth-like acanthosis of the epidermis. In the upper dermis, a band-like infiltrate (primarily lymphocytes) with possibly scattered histiocytes and neutrophils is seen. Vacuolar degeneration is observed along the dermoepidermal junction with colloid bodies (apoptotic keratinocytes).6 The diagnosis and management of penile cutaneous lesions can be challenging because of a lack of familiarity and patient embarrassment. Despite these challenges, many

Classic histopathologic findings in lichen planus Sawtooth acanthosis of the epidermis Wedge-shaped hypergranulosis Orthohyperkeratosis Band-like infiltrate of lymphocytes in the upper dermis Vacuolar degeneration of the dermoepidermal junction Colloid bodies (apoptotic keratinocytes) in the epidermis

penile lesions can be diagnosed and managed by primary care providers. Response to treatment of lichen planus is variable, and the condition usually spontaneously resolves within a few months.5 Daily potent topical corticosteroids are usually effective but carry a risk of atrophy; however, weekend dosing of ultrapotent topical corticosteroids may be effective. These treatments have been shown to expedite recovery and alleviate symptoms.5 For isolated lichen planus of the prepuce, circumcision is indicated when medical management fails.1 Resolution of lesions may be accompanied by postinflammatory hyperpigmentation.5 For the patient in our case, a biopsy of the genital lesions confirmed the diagnosis of lichen planus. Topical triamcinolone 0.1% ointment was prescribed, and the lesions resolved by the 2-month follow-up. n Dr. Bender is an internal medicine intern in the dermatology residency program at the Medical College of Wisconsin in Milwaukee, and Dr. Holcomb is a dermatology resident at Baylor College of Medicine in Houston. References 1. Teichman JM, Sea J, Thompson IM, Elston DM. Noninfectious penile lesions. Am Fam Physician. 2010;81(2):167-174. 2. Andreassi L, Bilenchi R. Noninfectious inflammatory genital lesions. Clin Dermatol. 2014;32(2):307-314. 3. Buechner SA. Common skin disorders of the penis. BJU Int. 2002;90(5):498-506. 4. Di Fede O, Belfiore P, Cabibi D, et al. Unexpectedly high frequency of genital involvement in women with clinical and histologic features of oral lichen planus. Acta Derm Venereol. 2006;86(5):433-438. 5. Sharma A, Bialynicki-Kirula R, Schwartz RA, Janniger CK. Lichen planus: an update and review. Cutis. 2012;90(1):17-23. 6. Wagner G, Rose C, Sachse MM. Clinical variants of lichen planus. J Dtsch Dermatol Ges. 2013;11(4):309-319.

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Dermatologic Look-Alikes

CME CE DERMATOLOGY COURSES

Depigmented patches on forearms YASMIN QASEEM, BS, BA, AND MAURA HOLCOMB, MD

CASE #1

CASE #2

A man, aged 25 years, presents with patchy areas of depigmentation on his forearm, umbilicus, and groin. The centers of the lesions are hypopigmented, and the borders are hyperpigmented. The patient states that, initially, the lesions had been expanding but following that period, the lesions did not increase in size for several years. Upon further questioning, the patient admits to constipation and cold sensitivity. He also reported that he gained weight recently.

A woman, aged 50 years, presents with a several-week history of a large erythematous patchy area of depigmentation with central scaling on her left forearm and scalp. She states that the rash is new. Upon further physical examination, the patient has no other rashes and has no oral or nasopharyngeal ulceration. She denies sensitivity to sunlight and has no history of renal dysfunction. Biopsy of one of the lesions reveals squamous cell carcinoma.

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CME CE

CASE #1

Dermatologic Look-Alikes

Vitiligo

Vitiligo is an acquired autoimmune disease that typically affects young adults at approximately age 20 years, although it can appear earlier.1 It affects men and women equally and is found in 0.1% to 2% of the population.2 Patchy areas of depigmentation are commonly found on the fingers, wrists, axillae, and groin;1 they may also affect the mucous membranes and hair.2 Some individuals have a genetic predisposition to vitiligo.2,3 Several susceptibility genes have been implicated in the pathogenesis of vitiligo, including several human leukocyte antigen (HLA) types.2 Infection, stress, toxins, and trauma may also contribute to the development of the disease.2 Autoantibodies targeting melanocytes, resulting in their destruction, are frequently found in patients with vitiligo.2 Vitiligo is also associated with other autoimmune diseases, particularly autoimmune thyroid dysfunction such as Hashimoto and Grave disease, and patients should undergo additional screening to rule out these conditions.1 This chronic progressive disease generally exhibits periods during which there is a pause in disease activity, interspersed with episodes during which further depigmentation occurs.1 A Wood lamp may be used to reveal larger areas of depigmentation correlating to activity of disease and can also be used to reveal areas of repigmentation.1 Repigmentation can occur spontaneously, although it is rare, seen in only 10% to 20% of cases.1,2 There are several forms of classification of vitiligo, and the pattern of involvement may affect ease of diagnosis. Vitiligo may be divided into nonsegmental (type A) and segmental (type B).2 Segmental vitiligo affects specific dermatomes, which has led to speculation regarding involvement of the nervous system in this form of the disease.2 It may also be categorized as generalized, universal, segmental, and acrofacial.2 Histopathologic findings in vitiligo include basal hypopigmentation and inflammation of the dermis, as well as absence of melanocytes and melanin from the epidermis, although in some rare cases melanocytes may still be present.3 Biopsy to confirm vitiligo is performed using immunohistochemical stains targeting melanocytes.3 Cytotoxic T-cell infiltrate and increased circulating cytokine levels are additional findings.2

The differential diagnosis for vitiligo is extensive and includes postinflammatory hypopigmentation, tinea versicolor, piebaldism, nevus depigmentosus, discoid lupus erythematosus (DLE), and hypopigmented mycosis fungoides.2,3 In the case of tinea versicolor, lesions are mostly truncal and potassium hydroxide treatment reveals yeast.2 Lesions in piebaldism and nevus depigmentosus are usually noted at birth, unlike those of vitiligo, which develop over time.2 There are several methods, beyond photographing the involved areas, to determine extent of involvement in a patient. To determine area of depigmentation and repigmentation, the Vitiligo Area Scoring Index may be used.1 Another useful system is the Vitiligo European Task Force tool, which takes into account both areas of depigmentation and repigmentation, as well as staging and spreading of the disease, but it has been found to be less consistent.1 There are many treatment options available for vitiligo, although treatment very rarely results in complete repigmentation of the skin.1 The first-line treatment is topical steroids, such as fluticasone or clobetasol.1 This may be combined with ultraviolet (UV)-A light to improve repigmentation.1 The use of topical vitamin D analogues such as calcipotriol, in addition to psoralen plus UV light therapy, may be used to enhance initial repigmentation.1 Narrow-band UVB light may also have beneficial effects, especially if depigmentation is extensive or fails to respond to topical medication.1 Topical calcineurin inhibitors such as pimecrolimus are noted to improve repigmentation in some patients, and tacrolimus is especially helpful for central depigmentation

Autoantibodies targeting melanocytes, resulting in their destruction, are frequently found in patients with vitiligo. (face and trunk).1 Systemic immunosuppressive regimens have been tried in the treatment of vitiligo, including oral corticosteroids or azathioprine, but are generally not recommended due to side effects.1 For adult patients, sunscreen and cosmetics are sometimes recommended rather than treatment.1 Topical self-tanning products can result in an increased quality of life but do not impact the course of the disease.1 Common side effects of medications used in the treatment of vitiligo include skin atrophy with the use of steroids and burning sensation with the use of topical calcineurin inhibitors, as well as photodamage with UV

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light treatment.1 Surgical management, especially splitskin grafting, may also be used in adults if the disease is not actively spreading.1 Vitiligo causes significant reduction in quality of life and requires disease-specific treatment and psychologic therapy to elicit coping mechanisms.1 Further psychologic implications are severe and include anxiety, depression, and adjustment disorders; it is unclear whether these contribute to the pathogenesis of vitiligo or are consequences of the disease on mental health.2 Cognitive behavioral therapy has been shown, in several studies, to improve quality of life and coping,1 which can be valuable to patients (in addition to treatment of the skin disease itself ).1 The patient in our case was offered a biopsy, but given his classic clinical presentation of vitiligo, he declined. As the patient was bothered by the cosmetic appearance of the lesions, therapy with medium-potency topical corticosteroids was initiated. Thyroid studies revealed hypothyroidism, which was managed by another provider. At the 3-month follow-up visit, macules of repigmentation were noted. The patient was happy with the improvement and chose to continue therapy with topical corticosteroids.

CASE #2

Discoid lupus erythematosus

Discoid lupus erythematosus (DLE) is an autoimmune disease on the spectrum of lupus erythematosus but is limited to skin involvement. Only 5% of patients with DLE transition to systemic lupus erythematosus (SLE), with a higher risk of progression in DLE patients with generalized rather than localized disease.4,5 DLE is the most common subtype of chronic cutaneous lupus erythematosus (CCLE).5 Women are affected more frequently than men, and the initial presentation usually occurs between age 40 years to 60 years.5 Localized DLE generally affects patients above the neck and has a higher rate of remission, whereas generalized DLE may be present anywhere on the body but is especially common on extensor surfaces and has a much lower rate of remission.5,6 Initial lesions may present as erythematous macules that later appear as discoid scaly plaques with

central hypopigmentation.5 Hair follicle involvement can occur and may lead to cicatricial alopecia.5 Complications of DLE include secondary development of squamous cell carcinoma within lesions or progression to SLE.5 Genes and environmental cues are implicated in the development of lupus erythematosus.4 The exact mechanism of development of DLE is not completely understood, although molecular mimicry and autoantibodies are thought to play a role.6 Ultraviolet (UV) light is considered an inciting factor in the development of DLE and causes exacerbations of the

Ultraviolet light is considered an inciting factor in the development of discoid lupus erythematosus. chronic disease, so protection from the sun is necessary for patients with DLE.4 Additionally, DLE is often associated with generalized photosensitivity.6 The differential diagnosis of DLE includes psoriasis, cutaneous T-cell lymphoma, sarcoidosis, and vitiligo.5 The distribution of generalized DLE on extensor surfaces5 may result in an incorrect diagnosis of psoriasis.5 The classic central hypopigmentation and peripheral hyperpigmentation may be mistaken for vitiligo, although the distribution of lesions of DLE differs. DLE may be distinguished not only based on clinical appearance, but also on biopsy.5,7 The diagnosis of DLE requires clinical suspicion and biopsy; it is also critical to search for systemic signs such as ulcers or photosensitivity, which may indicate SLE.7 It is important to make this diagnosis early in order to reduce morbidity and mortality.4 If the diagnosis is suspected, patients should receive a thorough evaluation, including a complete blood count, measurement of antinuclear antibody levels, a urine sample, and possibly measurement of anti窶電ouble-stranded DNA and C3 and C4 levels.4 Tissue biopsy results show basement membrane thickening on periodic acid-Schiff staining.4 A hematoxylin and eosin stain of the biopsy specimen shows basal cell liquefaction and vacuolar degeneration, inflammatory infiltrate, hyperkeratosis, and follicular plugging.4,5,7 Another common finding is dermoepidermal junction immune complex deposits, most frequently immunoglobulin G, via direct immunofluorescence.7 This is commonly known as the lupus band test and is useful in making a histopathologic diagnosis of DLE, but it may not be reflective in early cases.7

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CME CE

Dermatologic Look-Alikes

In the management of DLE, earlier treatment leads to better results.4 Topical corticosteroids, such as clobetasol and triamcinolone, are used as first-line treatment of DLE but should be used cautiously in case of side effects.4 Chronic scarring lesions may benefit from intralesional steroid injections.4 Common side effects include striations of the skin with topical corticosteroids and atrophy with topical or intralesional steroids.4 Topical calcineurin inhibitors, such as tacrolimus, are another option, as are systemic retinoids.5,6 Antimalarial agents, such as hydroxychloroquine, are also used in the management of DLE, but they take several weeks to show any effect and carry the risk of retinal toxicity; therefore, patients should be under regular surveillance by an ophthalmologist.4,5 Thalidomide may be used if the DLE is unresponsive to steroids and antimalarial agents, but it is associated with birth defects if used during pregnancy.5 Other agents that may be used to treat resistant DLE include immunosuppressants such as methotrexate, mycophenolate mofetil, cyclosporine A, and azathioprine.5 Use of sunscreens and general avoidance of exposure to the sun is important to prevent worsening of lesions.5,6 There is a significant psychologic effect on patients with DLE, as skin lesions may be large and may cause hair loss in affected areas.5 Disguising lesions with the use of makeup and/or wigs may be beneficial to patients.5 The presence of discoid lesions on the skin is detrimental to a patient’s mood and quality of life, and patients with DLE are found to have a lower perceived quality of life than patients with SLE.8 This psychologic aspect of the disease is important to keep in mind when diagnosing and managing DLE, in order to maximize patients’ quality of life and improve mood.

For the patient in our case, two biopsies were performed, one of which revealed follicular plugging, vacuolar degeneration, and an interface inflammatory infiltrate. A diagnosis of DLE was made. Therapy with oral hydroxychloroquine and topical corticosteroids was initiated, and strict sun protection was advised. After one month of therapy, significant improvement was noted. The patient continued to show improvement at her 6-month follow-up. n Ms. Qaseem is a medical student and Dr. Holcomb is a dermatology resident at Baylor College of Medicine in Houston. References 1. Gawkrodger DJ, Ormerod AD, Shaw L, et al. Guideline for the diagnosis and management of vitiligo. Br J Dermatol. 2008;159(5):1051-1076. 2. Yaghoobi R, Omidian M, Bagherani N. Vitiligo: a review of the published work. J Dermatol. 2001;38(5):419-431. 3. Kim YC, Kim YJ, Kang HY, et al. Histopathologic features in vitiligo. Am Dermatopathol. 2008;30(2):112-116. 4. Panjwani S. Early diagnosis and treatment of discoid lupus erythematosus. J Am Board Fam Med. 2009;22(2):206-213. 5. Okon LG, Werth VP. Cutaneous lupus erythematosus: diagnosis and treatment. Best Pract Res Clin Rheumatol. 2013;27(3):391-404. 6. Farley-Loftus R, Mahlberg M, Merola JF, et al. Generalized discoid lupus erythematosus. Dermatol Online J. 2009;15(8):18. 7. Naqqash S, Asad F, Pal SS. Direct immunofluorescence and histopathology in chronic discoid lupus erythematosus. Journal of Pakistan Association of Dermatologists. 2011;21:98-101. 8. Martins PR, Skare T, Ferrari TA, et al. Comparative analysis of the quality of life of patients with discoid lupus erythematosus and systemic lupus erythematosus with skin injuries. An Bras Dermatol. 2012;87(2):326-328.

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CME CE

POSTTEST

Expiration date: December 15, 2016

DERMATOLOGY COURSES CREDITS: 0.5

For more credit information, please turn to p. 62.

Dermatology Clinic

Dermatologic Look-Alikes

page 63

Case #1: Erythema dyschromicum perstans 1. The gray-blue or blue-brown macules of erythema dyschromicum perstans (EDP) have a characteristic early period that helps to differentiate them from other similar presentations. What is this early presentation of EDP? a. Gray-colored, annular lesions of varying sizes on the face b. Blue-gray polygonal papules of uniform size on the back c. Raised, erythematous borders of varying sizes on the neck d. Raised, targetoid lesions of varying sizes on the lower extremities 2. A 12-year-old Indian female has multiple ashy macules with raised, erythematous borders on her upper extremities that you determine to be EDP. Her parents desire a treatment to at least reduce the intensity of the appearance of the lesions. Which treatment modality would you recommend to her parents as the one that holds the most promise for cosmetic improvement? a. Chemical peels and psychotherapy b. Treatment of any underlying infections and clofazimine c. Ethambutol and psychotherapy d. Ultraviolet exposure and antibiotics Case # 2: Lichen planus 3. An uncircumcised man, aged 38 years, presents with pruritic, polygonal violaceous papules on the glans penis. A lesional biopsy confirms genital lichen planus. What initial treatment is most appropriate? a. Observation b. Oral prednisone, 40 mg daily (with 10-day taper) c. Clobetasol propionate 0.05% ointment (weekend days only) d. Circumcision 4. Which of the following is not a component of the classic “4 Ps” used to describe the lesions in lichen planus? a. Polygonal b. Purple c. Plaques d. Papules

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Case #1: Vitiligo 1. A patient who has recently started treatment for vitiligo on her hands bilaterally presents to her physician complaining of a burning sensation in her fingers. What is the most likely cause of this? a. Diabetic-related neuropathy b. Drug side effect c. Hypocalcemia d. Raynaud disease 2. A 58-year-old woman presents for the first time with bilateral depigmented patches on the axillae and wrists. Biopsy results reveal dermal inflammation and basal hypopigmentation, accompanied by lack of melanocytes. What is the next appropriate course of action? a. Reassurance b. Start treatment with topical clobetasol c. Start treatment with topical hydroxychloroquine d. Refer the patient to rheumatology Case #2: Discoid lupus erythematosus 3. Treatment of discoid lupus erythematosus should include initiation of topical steroids as well as which of the following? a. Screening for its impact on mental health b. Avoiding use of sunscreens when outdoors c. Referral to an oncologist d. Referral to an infectious disease specialist 4. A 30-year-old African-American woman presents with a scaly discoid plaque with central hypopigmentation on the neck. Of note, she has recently complained of increasing fatigue, weight loss, and arthralgia, and her face and palms appear pale. A presumed diagnosis of discoid lupus erythematosus is made. Which of the following biopsy findings would support this diagnosis? a. Basement membrane thickening on periodic acid-Schiff staining b. Absence of melanocytes and melanin in the epidermis c. Leukocytoclastic vasculitis d. Epidermal spongiosis

TO TAKE THE POSTTEST please go to: myCME.com/Dec15CAderm

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Beyond Rx: OTC Corner Insomnia—Using natural modalities and OTC treatments JANE F. MYERS, APRN, CNP, MSN

A balance of good sleep hygiene, healthy sleep habits, and over-the-counter agents can relieve insomnia. Melatonin is a hormone secreted by the pineal gland in the brain and helps regulate sleep.

Insomnia is defined as difficulty falling or staying asleep, the absence of restful sleep, or poor quality of sleep. There are many causes of insomnia, but some of the most common are medications, stress, anxiety, depression, and environmental changes. Other causes include excessive daytime napping, caffeine consumption, and poor sleep habits.1 It is important to note that insomnia is a symptom and not a disease. It is a frequent complaint expressed by patients to healthcare providers. Although there are prescription medications for insomnia, this article focuses on nonprescription medications and modalities. Self-treatment with over-the-counter (OTC) medications should only be used for short periods of time, along with instituting better sleep hygiene. The most common OTC medications used for insomnia are listed in Table 1.2 It is always important to verify that the medications used do not interact with any other medications a patient may be taking. Certain OTC medications for insomnia may worsen some medical conditions. Melatonin has become a popular OTC agent for insomnia.3 Melatonin is a hormone secreted by the pineal gland in the brain. It helps regulate sleep. It assists synchronization of the circadian “clock” with the day-night cycle and attenuates the wake-promoting signal. The circadian rhythm is an internal 24-hour clock that plays a critical role in when we fall asleep and when we wake up. When it is dark, the body produces more melatonin. During daylight hours, the production of melatonin decreases. Being exposed to bright lights in the

This article is part of an ongoing series entitled, Beyond Rx: OTC Corner, which will include topics such as OTC medications, dietary supplements, and other health care approaches that will help nurse practitioners and physician assistants provide patients with tools to manage their health. Robert D. Sheeler, MD, is guest editor of the series. He is an associate professor of family medicine, Mayo Clinic, in Rochester, Minn. He is board certified in family medicine, integrative medicine, and holistic medicine.

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TABLE 1. Common over-the-counter medications that can be used in patients with insomnia2 Agent

Considerations

Diphenhydramine (oral antihistamine)

Dry mouth/throat/nose, blurred vision, urinary outlet difficulties, constipation, drowsiness, weakness, upset stomach

Doxylamine (oral antihistamine)

Dry mouth, blurred vision, urinary outlet difficulties, constipation, drowsiness, weakness, upset stomach

Melatonin (natural hormone)

Can treat or cause headaches, vivid dreams possible, daytime drowsiness, dizziness, upset stomach, confusion; best taken after the evening meal rather than right before bed (1–6 mg/d)

Magnesium (mineral)

Avoid if a bleeding disorder is present; diarrhea, upset stomach, nausea, vomiting (<350 mg/d)

Hops (female flowers from plant)

May worsen depression, may have estrogen effect; stop 2 weeks before surgery

Valerian extract (herb)

Headache, excitability, uneasiness, drowsiness in the morning; wean off over 2 weeks when stopping, may take 2 to 3 weeks to become effective (400–900 mg/d, 2 hours before bedtime)

Lemon balm plant

Avoid if glaucoma or thyroid problems are present (1.5–4.5 g/d)

evening, or too little light during the day, can disrupt the body’s normal melatonin cycles. For example, jet-lag, shift work, and poor vision can all disrupt melatonin cycles.4 Because melatonin has beneficial effects on sleep, in addition to affecting the 24-hour circadian clock, melatonin therapy can relieve insomnia. A meta-analysis demonstrated that melatonin had a significant benefit in reducing sleep latency.5 Subjects were noted to fall asleep earlier when using melatonin therapy. Studies have also demonstrated that melatonin significantly increased total sleep time when compared with placebo. Melatonin may interact with blood-thinning medications, diabetes medications, birth control pills, and medications that suppress the immune system. Improving sleep hygiene is as important as using OTC medications. Sleep hygiene can be improved by implementing some of the steps listed in Table 2. Evaluating sleep habits and changing behavior may sometimes eliminate underlying sleep issues (Table 3). Using the right balance of sleep hygiene, healthy sleep habits, and OTC medications can alleviate the symptoms of insomnia, but individuals must listen to their bodies’ cues to know which methods are right. There are many OTC medications available for patients to use for insomnia.

Steps to promote better sleep hygiene 1. Get routine exercise but not close to scheduled bedtime. 2. Limit caffeine during the day, and have none in the evening. 3. Do not go to bed unless you are tired. 4. Do not use your bed to read or watch television. 5. Sleep at regularly scheduled times (including on weekends). 6. Darken the bedroom. 7. Turn the clock away from the bed. 8. Avoid stimulants such as alcohol, tobacco, and caffeine. 9. Avoid naps during the day. 10. Use relaxation techniques such as yoga, meditation, and deep breathing.

Good habits to improve sleep 1. Decrease any noise in bedroom; earplugs can help eliminate sound 2. Do not use electronic devices 1 hour before bedtime; this includes computers, TV, mobile phones, and video games 3. Meditation—clear the mind from the day’s activities; deep breathing can help relax muscles 4. Drinking warm milk or decaffeinated tea before bed can help with sleep

Healthcare providers must always verify that these medications do not interact with any prescription medications and medical conditions. n Ms. Myers is a family nurse practitioner in the Department of Family Medicine and an assistant professor of family medicine in the College of Medicine at the Mayo Clinic in Rochester, Minn. References 1. Cunha JP, Shiel WC Jr. Insomnia treatment: sleep aids and stimulants. MedicineNet.com website. Available at: www.medicinenet.com/sleep_aids_ and_stimulants/article.htm 2. Cunha JP. Insomnia treatment: sleep aids and stimulants. Available at: www.medicinenet.com/sleep_aids_and_stimulants/article.htm 3. Roth T, Nir T, Zisapel N. Prolonged-release melatonin for improving sleep in totally blind subjects: a pilot placebo–controlled multicenter trial. Nat Sci Sleep. 2015;7:13-23. 4. Altun A, Ugur-Altun B. Melatonin: therapeutic and clinical utilization. Int J Clin Pract. 2007;61(5):835-845. 5. Ferracioli-Oda E, Qawasmi A, Bloch MH. Meta-analysis: melatonin for the treatment of primary sleep disorders. PLoS One. 2013;8(5):e63773.

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Stat Consult

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

Description

Influenza in adults BY ALAN DRABKIN, MD

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

• respiratory infection caused by the influenza virus Pathogen

• influenza is a member of the Orthomyxoviridae family • influenza A and B are the 2 types of influenza viruses that cause epidemic human disease • influenza C is a third subtype that causes mild respiratory illness but is not thought to cause epidemics Transmission

• direct human-to-human transmission occurs largely via large-particle respiratory droplets ——requires close contact between infected and susceptible individuals ——large-particle droplets travel ≤6 feet • alternative modes of transmission ——indirect transmission via hand contact with influenza-contaminated surface and subsequent transfer to nose or mouth ——airborne transmission via small-particle aerosols over short distances • duration of viral shedding varies with host factors ——adults shed virus before symptoms present and continue through 5–10 days following onset of illness ——children may be infectious for ≥10 days ——severely immunocompromised persons can shed virus for months • temperate countries of northern and southern hemispheres have peak activities in winter months Clinical presentation

Diagnostic tests include rapid antigen detection tests, viral culture, and serology.

• pattern of illness varies from mild respiratory illness (similar to common cold) to severe prostration without characteristic signs and symptoms • common symptoms include ——fever ——myalgia

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——arthralgia ——anorexia ——headache ——dry cough ——malaise ——fatigue ——weakness ——chest discomfort • less frequently, symptoms may also include ——nasal congestion ——sneezing ——sore throat • signs, symptoms, or complications that may be present in severe or progressive stages of infection ——central nervous system abnormalities including altered mental status, drowsiness, difficult to awaken, recurring or persistent convulsions, confusion, severe weakness or paralysis ——cardiopulmonary insufficiency indicated by shortness of breath, dyspnea, tachypnea, cyanosis, bloody or colored sputum, chest pain, low blood pressure, or hypoxia ——severe dehydration with decreased activity, dizziness, decreased urine output, or lethargy ——signs and symptoms of secondary complications including bacterial infection, renal or multi-organ failure, septic shock, rhabdomyolysis, myocarditis ——exacerbation of underlying chronic disease Diagnosis

• diagnosis made clinically with confirmatory testing in selected cases ——accuracy of clinical diagnosis on basis of symptoms alone is limited due to overlap of symptoms of other illnesses ——once influenza activity has been documented in community or geographic area, clinical diagnosis of influenza without testing is acceptable, especially during periods of peak influenza activity ——diagnostic testing should be considered if ■■ results would change management, such as deciding whether to use influenza antiviral agents ■■ patients are hospitalized with suspected influenza ■■ institutional outbreak of influenza suspected (to allow prompt implementation of control measures) • diagnostic tests available for influenza include rapid antigen detection tests, viral culture, serology, reverse transcriptase-polymerase chain reaction (RT-PCR), and immunofluorescence assays

——rapid antigen detection tests may provide results early enough to guide individual patient management ■■ a negative rapid antigen test does not exclude influenza in symptomatic patients, and antivirals should not be withheld if test is negative and influenza is suspected ■■ sensitivity and specificity of tests vary between laboratories, types of tests, specimen source, and timing of specimen collection from illness onset ■■ results should be interpreted in the context of other clinical and epidemiologic information ——consider confirmatory testing by RT-PCR or culture when rapid antigen test is negative and clinical suspicion is high Differential diagnosis

• upper respiratory infection • pneumonia • acute bronchitis • acute exacerbation of chronic obstructive pulmonary disease • asthma exacerbation • Streptococcal pharyngitis • acute sinusitis in adults • allergic rhinitis • infectious mononucleosis • acute myeloid leukemia • acute HIV infection • malaria • babesiosis • recent vaccination with live, attenuated influenza vaccine Treatment

• Influenza antiviral treatment is recommended for any patient with confirmed or suspected influenza who ——is hospitalized ——has severe, complicated, or progressive illness ——is at high risk for complications or severe disease • Consider antiviral treatment for any outpatient with confirmed or suspected influenza, regardless of rapid diagnostic testing results, if treatment can be initiated within 48 hours of illness onset • antiviral therapy should be started as soon as possible ——ideally within 48 hours of symptoms ——may be continued beyond 48 hours to benefit patients with severe, progressive, or complicated disease ——do not delay treatment while awaiting confirmatory test results

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Stat Consult

Infection control

• patients with influenza-like illness should remain isolated (out of school, work, and away from gatherings) until free of fever (100°F [37.8°C]) for ≥24 hours • patients in high-risk or healthcare settings may be encouraged to isolate for 7 days after symptom onset or until free of fever for ≥24 hours, whichever is longer • encourage good hand hygiene and respiratory etiquette Risk factors for complicated or severe disease course

• high-risk conditions for increased risk of influenza complications include ——children <5 years old, especially children <2 years old ——adults ≥65 years old ——pregnant women and women ≤2 weeks postpartum ——persons with chronic medical conditions including ■■ pulmonary disease including asthma ■■ cardiovascular disease (except hypertension alone) ■■ renal disease ■■ hepatic disease ■■ hematologic disease including sickle cell disease ■■ metabolic disorders including diabetes mellitus ■■ neurologic or neurodevelopment disorders ——persons with immunosuppression due to medications or disease, such as HIV infection ——persons <19 years old on long-term aspirin therapy (who might be at risk for Reye syndrome after influenza virus infection) ——American Indians/Alaskan Natives ——patients in chronic care facilities ——persons with morbid obesity (BMI ≥40 kg/m2)

• less common complications include ——Reye syndrome in children and adolescents taking aspirin ——myocarditis ——pericarditis ——myositis ——myoglobinuria ——neurological sequelae ■■ Guillain-Barré syndrome ■■ transverse myelitis ■■ encephalitis Prognosis

• uncomplicated influenza illness typically resolves after 3–7 days, but cough and malaise can persist >2 weeks Prevention

• annual immunization for all individuals aged >6 months remains the most effective method of reducing influenza infection and related complications • Post-exposure chemoprophylaxis ——consider early treatment as alternative to chemoprophylaxis ——consider postexposure prophylaxis with oseltamivir or zanamivir for higher-risk persons exposed to patients with influenza; this may be limited to patients in healthcare settings such as transplant units, neonatal units, or other patients with severe immunosuppression or other highly vulnerable patients ——drug of choice for antiviral chemoprophylaxis is either oseltamivir or zanamivir, but monitor local antiviral resistance surveillance data. n

Complications

• common complications include ——pneumonia ——otitis media ——tracheobronchitis ——acute sinusitis ——exacerbations of chronic pulmonary or cardiac disease

“Who tipped off the turkey?”

• neuraminidase inhibitors are considered first-line therapy based on antiviral resistance patterns ——oseltamivir 75 g orally twice daily for 5 days (consider oseltamivir 150 mg orally twice daily and longer treatment durations for immunocompromised patients) ——zanamivir 10 mg (2 inhalations) twice daily for 5 days ——peramivir 300 mg or 600 mg IV single dose

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ALTERNATIVE MEDS UPDATE

What you should know about the herbs and supplements patients use By Sherril Sego, FNP-C, DNP Ms. Sego is an independent consultant in Kansas City, Mo.

Coconut oil

The coconut is versatile in its many forms, be it shredded or flaked as a popular dessert ingredient, or as preparations that yield coconut milk, water, and oil. Recently, nutritionists and medical professionals have been taking a closer look at coconut oil for its medicinal properties. Aside from being rich in antioxidants and medium-chain fatty acids (MCFAs), it also possesses some unique constituents that offer insight into the way brain cells function and perform their own self-repair and maintenance.

Background Coconut (Cocos nucifera L.) is a tropical tree from the palm family, with the Philippines and India producing the bulk of the world’s supply.1 For thousands of years, the coconut has been considered an essential product in folk medicine, with mentions dating back nearly 4,000 years to the ancient Sanskrit language.2 During World War II, medics in the south Pacific who were experiencing shortages of essential medical supplies used coconut water as a substitute for normal saline in intravenous infusions to save lives.2

Science Routine consumption of virgin coconut oil (VCO) has been associated with increased levels of high-density lipoprotein (HDL) cholesterol—the “good” cholesterol and a known cardioprotective marker—even in the presence of increased total cholesterol (TC).1 Despite this finding, earlier published

studies had criticized the use of coconut oil, owing in part to its high content of saturated fats; however, some of these studies had used hydrogenated coconut oils or did not differentiate among saturated fats.3 Today, research shows a place for VCO in our diets, since nonhydrogenated VCO may help balance the ratio of HDL to low density lipoprotein (LDL) cholesterol (HDL/LDL).4 Researchers believe that this is largely due to the fact that MCFAs, which are rapidly metabolized in the liver and do not enter into the biosynthesis of cholesterol, make up the majority of the fat content of VCO.5 In addition, data indicate that consumption of VCO flattens the postprandial spiking of plasminogen and lipoprotein-a, both important markers of cardiovascular disease.5 These actions and other metabolic effects of VCO have been shown to help reduce abdominal (visceral) adiposity.6 Results from a population study conducted in the Philippines suggest that consuming significant amounts of dietary VCO has beneficial effects on lipid profiles and cardiovascular disease risk.3 Nearly 2,000 women were followed for more than

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ALTERNATIVE MEDS UPDATE 20 years with data collected on dietary habits, socioeconomic information, menstrual status, and medication profile. A positive correlation was noted between the amount of VCO consumed per day and elevation of total cholesterol and HDL, yielding a favorable TC/HDL ratio. Mary T. Newport, MD, attempted to use VCO for her husband, who was coping with the progressive effects of Alzheimer’s disease. Based on her research, she began supplementing his diet with a large daily quantity of VCO. After 2 weeks, Dr. Newport reported that her husband’s cognitive function had improved. Although anecdotal, the case sparked interest in further study. The operative hypothesis for the effect of VCO on symptoms of Alzheimer’s disease is based on the brain’s cellular uptake of glucose, which is essential for proper function. Although this uptake system seems to be impaired in persons with dementia, ketones supplied by MCFAs act as a glucose substitute in the brain. Findings from other studies may offer a strategy for increasing dietary ketosis by combining a low-carbohydrate diet8 with supplementation with VCO,9 which may help improve cognitive functioning in these patients.

Safety, interactions

2 ounces per day taken in 3 divided doses one half-hour before meals is adequate.5

Summary

Authentic virgin coconut oil can cost up to $20 per 32 ounces.

Virgin coconut oil may be beneficial for lipid levels and the risk of cardiovascular disease.

In the search for effective treatments for Alzheimer’s disease, VCO sounds promising. However, more in-depth research into its potential as a therapeutic treatment is necessary. The data indicating that coconut oil has a role in the improvement of lipid profiles and reductions in visceral adiposity are also promising. Controlling these known cardiovascular risk factors, especially in those individuals who are most susceptible to heart disease, would be a valuable intervention. For these health concerns, providers should consider recommending VCO for its benefits to their patients. Just tell them to skip the pie! n References 1. DebMandal M, Mandal S. Coconut (Cocos nucifera L.: Arecaceae): In health promotion and disease prevention. Asia Pac J Tropical Med. 2011;4(3):241-247. 2. Atkinson M. History of coconut oil. Available at virgincoconut.lk/history-of-coconut-oil 3. Feranil AB, Duazo PL, Kuzawa CW, Adair LS. Coconut oil is associated with a beneficial lipid profile in premenopausal women in the Philippines. Asia Pac J Clin Nutr. 2011;20(2):190-195.

Overall, VCO is extremely safe. Due to its action on serum lipid profiles, patients should have a discussion with their healthcare provider about adding it to their diets prior to use. The most commonly reported adverse effects were gastrointestinal upset. Allergic potential exists, but is not widely reported.

How supplied, dose, cost

4. Nevin KG, Rajamohan T. Beneficial effects of virgin coconut oil on lipid parameters and in vitro LDL oxidation. Clin Biochem. 2004;37(9):830-835. 5. Liau KM, Lee YY, Chen CK, Rasool AH. An open-label pilot study to assess the efficacy and safety of virgin coconut oil in reducing visceral adiposity. ISRN Pharmacol. 2011;2011:949686. 6. Assunção ML, Ferreira HS, dos Santos AF, et al. Effects of dietary coconut oil on the biochemical and anthropometric profiles of women presenting abdominal obesity. Lipids. 2009;44(7):593-601. 7. Doty L. Coconut oil for Alzheimer’s disease? Clin Practice. 2012;1(2):12-17. 8. Krikorian R, Shidler MD, Dangelo K, et al. Dietary ketosis enhances memory in mild cognitive impairment. Neurobiol Aging. 2012;33(2):425.e19-425.e27. 9. Fernando WM, Martins IJ, Goozee KG, et al. The role of dietary coconut for the prevention and treatment of Alzheimer’s disease: Potential mechanisms of action. Br J Nutr. 2015;114(1):1-14.

Consumers should be careful to assure that the products they use are truly “virgin,” nonhydrogenated coconut oil. Coconut oil may be purchased in bulk and is also supplied in capsule form. One study administered VCO to the participants at 30 mL (1 ounce) 3 times daily before meals.5 It should be noted that maintaining this level might prove to be cost-prohibitive, as authentic VCO can cost up to $20 per 32 ounces. For routine daily consumption, however, 1 to 90 THE CLINICAL ADVISOR • DECEMBER 2015 • www.ClinicalAdvisor.com

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COMMENTARY Lori Sanders, BSN, FNP, works in the intensive care unit at Jefferson Hospital in Pittsburgh.

The flu shot remains a vital healthcare tool We have all heard people say it before: “I don’t believe in the flu shot.” Whether it is because they think they are too healthy to require one, only get sick when they get the shot, or believe that the flu shot does not work in general, many well-educated, logical folks become rather emotional when it comes to the subject of influenza vaccines. Even some individuals who accept every other vaccination waffle when it comes to the seasonal influenza vaccine. This uncertainty is not completely unfounded. Unlike most other vaccines that are essentially static in their composition from year to year, the influenza vaccine is a unique combination of influenza strains that changefrom year to year.

Even if the flu shot “misses,” as it did last year, it remains one of the best tools we have to help our patients live healthier lives.

This is a necessity, as, unlike many other disease- causing organisms, the influenza virus is a highly evolved, rapidly mutating pathogen. Scientists have to make an educated guess on what strains will prevail several months in advance of use. Getting the influenza shot right is like hitting a moving target, only the stakes are much higher. More than 100 countries with surveillance centers collect influenza samples throughout the year, sending them to laboratories run by the World Health Organization (WHO). This year’s 2015–2016 influenza vaccine for the northern hemisphere was announced on February 26, 2015 (www.cdc.gov/flu/news/updated-vaccineeffectiveness-2014-15.htm) with the trivalent vaccine containing two strains of influenza A and one strain of influenza B and the quadrivalent vaccine containing an additional B virus (www.who.int/influenza/vaccines/virus/ recommendations/2015_16_north/en). The vaccine is most effective when circulating strains of influenza in the population “match” the strains that were chosen to be in the vaccine. During seasons when vaccine viruses and circulating influenza viruses are well matched, a vaccine effectiveness (VE) between 50% and 60% has been observed (www.cdc.gov/flu/news/ updated-vaccine-effectiveness-2014-15.htm). For the 2014–2015 influenza vaccine, the overall VE estimate was 19%. This means that last year’s influenza vaccine was only 19% effective

at reducing a person’s need to seek medical care for an influenza-related illness. This “miss” was attributed to a predominant strain of H3N2 virus that was mutated and that did not appear until after the vaccine composition had already been chosen and manufactured. As providers, talking patients into a vaccine that was only 19% effective last year is a tough sell. As it remains, however, annual vaccination is the best option we have for preventing influenza and influenza-related illness. Everyone aged 6 months and older should get the influenza vaccine every season, as recommended by the CDC since 2010 (www.cdc.gov/media/pressrel/2010/r100224.htm). An average of 36,000 deaths and more than 200,000 hospitalizations associated with influenza occur each year in the United States ( JAMA. 2000;284[13]:1655-1663). While most healthy individuals will develop only mild illness from influenza, vaccination in healthy working adults can reduce rates of influenza-like illness, lost workdays, and physician visits. Vaccination is even more important for vulnerable populations such as children, adults aged 65 years and older, pregnant women, residents of nursing homes, and people with asthma, heart disease, and diabetes. So what is the take-home message? Vaccinate everyone aged 6 months and older annually. Even if the influenza shot “misses” as it did last year, it remains one of the best tools we have to help our patients live healthier lives. n

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • DECEMBER 2015 91

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