Naseem S. Miller

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Committee annual March report to Congress.

“For a long time, I've been able to sit before this subcommittee and say that SGR is a problem but we don't see an imminent threat to access,” Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified at a hearing of the Health Subcommittee of the House Ways and Means Committee. But “we think we're getting closer to that tipping point” when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that “among the 1 million clinicians in Medicare's registry, about half are physicians who actively bill Medicare.” MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers.

In addressing the SGR, the report notes that “a main flaw of the SGR is its blunt approach. In setting across-the-board updates to Medicare's physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR's cumulative target.”

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, just about every year, Congress has stepped in to legislate a way to avoid those cuts. The avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion. But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is “whether we're going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we're going to spend more strategically to achieve important goals for the Medicare program,” he said.

MedPAC's struggles to find a way around the SGR formula were on display at a February meeting where staff analysts presented options to commissioners. Multiple options exist to permanently fix the formula, but each has its cost to physicians, patients, and the program.

Among those options were adjusting the SGR's spending targets so that they are no longer cumulative, but are calculated on an annual basis and allowing some flexibility in the target. Both of those options would forgive any excess over the target, removing the annual pay cut threat doctors have endured since 2002 under the SGR, according to Cristina Boccuti, a principal policy analyst for MedPAC. However, forgiving any overage will lead to higher costs for the Medicare program. Neither option would leave any room to offer incentives for improved quality and efficiency, she added.

In the past, MedPAC has recommended setting target growth rates – and payment rates – according to particular service categories; the commission is looking in this direction again. For example, separate categories could be established for primary care, imaging, minor procedures, and anesthesia, allowing rates to more closely track volume of services.

Alicia Ault contributed to this article.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Committee annual March report to Congress.

“For a long time, I've been able to sit before this subcommittee and say that SGR is a problem but we don't see an imminent threat to access,” Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified at a hearing of the Health Subcommittee of the House Ways and Means Committee. But “we think we're getting closer to that tipping point” when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that “among the 1 million clinicians in Medicare's registry, about half are physicians who actively bill Medicare.” MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers.

In addressing the SGR, the report notes that “a main flaw of the SGR is its blunt approach. In setting across-the-board updates to Medicare's physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR's cumulative target.”

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, just about every year, Congress has stepped in to legislate a way to avoid those cuts. The avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion. But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is “whether we're going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we're going to spend more strategically to achieve important goals for the Medicare program,” he said.

MedPAC's struggles to find a way around the SGR formula were on display at a February meeting where staff analysts presented options to commissioners. Multiple options exist to permanently fix the formula, but each has its cost to physicians, patients, and the program.

Among those options were adjusting the SGR's spending targets so that they are no longer cumulative, but are calculated on an annual basis and allowing some flexibility in the target. Both of those options would forgive any excess over the target, removing the annual pay cut threat doctors have endured since 2002 under the SGR, according to Cristina Boccuti, a principal policy analyst for MedPAC. However, forgiving any overage will lead to higher costs for the Medicare program. Neither option would leave any room to offer incentives for improved quality and efficiency, she added.

In the past, MedPAC has recommended setting target growth rates – and payment rates – according to particular service categories; the commission is looking in this direction again. For example, separate categories could be established for primary care, imaging, minor procedures, and anesthesia, allowing rates to more closely track volume of services.

Alicia Ault contributed to this article.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Committee annual March report to Congress.

“For a long time, I've been able to sit before this subcommittee and say that SGR is a problem but we don't see an imminent threat to access,” Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified at a hearing of the Health Subcommittee of the House Ways and Means Committee. But “we think we're getting closer to that tipping point” when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that “among the 1 million clinicians in Medicare's registry, about half are physicians who actively bill Medicare.” MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers.

In addressing the SGR, the report notes that “a main flaw of the SGR is its blunt approach. In setting across-the-board updates to Medicare's physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR's cumulative target.”

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, just about every year, Congress has stepped in to legislate a way to avoid those cuts. The avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion. But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is “whether we're going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we're going to spend more strategically to achieve important goals for the Medicare program,” he said.

MedPAC's struggles to find a way around the SGR formula were on display at a February meeting where staff analysts presented options to commissioners. Multiple options exist to permanently fix the formula, but each has its cost to physicians, patients, and the program.

Among those options were adjusting the SGR's spending targets so that they are no longer cumulative, but are calculated on an annual basis and allowing some flexibility in the target. Both of those options would forgive any excess over the target, removing the annual pay cut threat doctors have endured since 2002 under the SGR, according to Cristina Boccuti, a principal policy analyst for MedPAC. However, forgiving any overage will lead to higher costs for the Medicare program. Neither option would leave any room to offer incentives for improved quality and efficiency, she added.

In the past, MedPAC has recommended setting target growth rates – and payment rates – according to particular service categories; the commission is looking in this direction again. For example, separate categories could be established for primary care, imaging, minor procedures, and anesthesia, allowing rates to more closely track volume of services.

Alicia Ault contributed to this article.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. "Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation," according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509-13).

"Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions," the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. "States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis," she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states.

From 2003 to 2009, the percent change of the prevalence ranged from 26.2% in Wisconsin, to –19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461-77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65:519-25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16-21).

"However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis," said the authors (Ann. Fam. Med. 2011;9:136-41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report’s findings "do have a ring of truth to them." He said that he recommends diet and exercise to his patients, although "it is very difficult to get people to modify their lifestyle." He added that the 15-minute office visits don’t leave much time for him to delve into counseling, "but I do think it’s important."

Dr. Hootman also stressed the importance of counseling patients to lose weight. "People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function," she said.

The study has several limitations. Because the data are self-reported, they’re subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. "Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation," according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509-13).

"Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions," the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. "States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis," she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states.

From 2003 to 2009, the percent change of the prevalence ranged from 26.2% in Wisconsin, to –19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461-77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65:519-25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16-21).

"However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis," said the authors (Ann. Fam. Med. 2011;9:136-41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report’s findings "do have a ring of truth to them." He said that he recommends diet and exercise to his patients, although "it is very difficult to get people to modify their lifestyle." He added that the 15-minute office visits don’t leave much time for him to delve into counseling, "but I do think it’s important."

Dr. Hootman also stressed the importance of counseling patients to lose weight. "People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function," she said.

The study has several limitations. Because the data are self-reported, they’re subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. "Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation," according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509-13).

"Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions," the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. "States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis," she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states.

From 2003 to 2009, the percent change of the prevalence ranged from 26.2% in Wisconsin, to –19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461-77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65:519-25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16-21).

"However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis," said the authors (Ann. Fam. Med. 2011;9:136-41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report’s findings "do have a ring of truth to them." He said that he recommends diet and exercise to his patients, although "it is very difficult to get people to modify their lifestyle." He added that the 15-minute office visits don’t leave much time for him to delve into counseling, "but I do think it’s important."

Dr. Hootman also stressed the importance of counseling patients to lose weight. "People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function," she said.

The study has several limitations. Because the data are self-reported, they’re subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. "Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation," according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509-13).

"Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions," the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. "States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis," she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states.

From 2003 to 2009, the percent change of the prevalence ranged from 26.2% in Wisconsin, to –19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461-77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65:519-25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16-21).

"However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis," said the authors (Ann. Fam. Med. 2011;9:136-41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report’s findings "do have a ring of truth to them." He said that he recommends diet and exercise to his patients, although "it is very difficult to get people to modify their lifestyle." He added that the 15-minute office visits don’t leave much time for him to delve into counseling, "but I do think it’s important."

Dr. Hootman also stressed the importance of counseling patients to lose weight. "People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function," she said.

The study has several limitations. Because the data are self-reported, they’re subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. "Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation," according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509-13).

"Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions," the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. "States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis," she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states.

From 2003 to 2009, the percent change of the prevalence ranged from 26.2% in Wisconsin, to –19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461-77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65:519-25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16-21).

"However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis," said the authors (Ann. Fam. Med. 2011;9:136-41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report’s findings "do have a ring of truth to them." He said that he recommends diet and exercise to his patients, although "it is very difficult to get people to modify their lifestyle." He added that the 15-minute office visits don’t leave much time for him to delve into counseling, "but I do think it’s important."

Dr. Hootman also stressed the importance of counseling patients to lose weight. "People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function," she said.

The study has several limitations. Because the data are self-reported, they’re subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. "Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation," according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509-13).

"Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions," the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. "States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis," she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states.

From 2003 to 2009, the percent change of the prevalence ranged from 26.2% in Wisconsin, to –19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461-77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65:519-25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16-21).

"However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis," said the authors (Ann. Fam. Med. 2011;9:136-41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report’s findings "do have a ring of truth to them." He said that he recommends diet and exercise to his patients, although "it is very difficult to get people to modify their lifestyle." He added that the 15-minute office visits don’t leave much time for him to delve into counseling, "but I do think it’s important."

Dr. Hootman also stressed the importance of counseling patients to lose weight. "People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function," she said.

The study has several limitations. Because the data are self-reported, they’re subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

Most of the patients Dr. Michele Wylen sees are low-income women, many of whom are on Medicaid or have no health insurance.

As an ob.gyn. at the Arlington County (Va.) Public Health Division, she is aware of the statistics: Preterm birth rates are higher among women who have less access to health care services, and the nation has a high infant mortality rate, higher than many other industrialized counties. She is an advocate for reliable tools that would better inform her patients, even if it’s outside of her office. So Dr. Wylen and the county health department embraced the text4baby program when it launched early last year.

The free text messaging service keeps her patients informed about their pregnancy and the first year of motherhood through simple text messages sent out regularly, tailored to the mother’s due date or the age of the infant.

"Patients may not understand everything, but they can ask about it," she said in an interview. "It’s a springboard for patients to ask questions.

"And what’s compelling is that everyone, at least most people, have access to a cell phone," she said. "And this is a great way to disseminate information."

In an era that some researchers call the "Wild West" of social media, this simple texting program that targets pregnant women and new moms, especially those who are lower income and have less access to health care services, is showing promise. Most researchers and industry experts agree that the program is the first of its kind in the United States to reach such a wide audience of women in a significant and delicate stage of their lives.

Since its inception in February 2010, more than 150,000 women have signed up to receive the free texts. The National Healthy Mothers, Healthy Babies Coalition (HMHB), the nonprofit group that has been nurturing the program and writing the text messages, has an ambitious goal of reaching 1 million women by the end of 2012.

"It’s a tool we can reach women with, instead of putting an ad on the bus." With text4baby, they will have the ability to reach women wherever they are, according to Judy Meehan, executive director of the HMHB, referring to the participants enrolled in the texting program.

Each text message contains a small snippet of information, explained Ms. Meehan; one idea per message and why it is important for the mom to pay attention to that idea.

This is how the program works: Women send the word BABY (or BEBE in Spanish) to 511411. They then put in their due date and their zip code and they’re enrolled in the free texting program. They will first receive a "starter pack" of about six text messages and then they receive three messages per week in early afternoons, tailored to their due date or the age of their newborn. The messages range from health tips, to numbers to call to find a provider, to urgent messages such as notification about recalls or new guidelines.

Behind the scenes, a team of 19 individuals edit the text messages, making sure they’re accurate and based on evidence-based medicine that comes from some of the prominent sources of information in the country, such as the Centers for Disease Control and Prevention. The program has nearly 500 partner organizations, including health departments, community health centers, and physician offices. Its main financial sponsor is Johnson & Johnson, along with other sponsors including with WellPoint, Pfizer, and CareFirst, but there are no promotions in the text messages. And 19 mobile carriers have gotten on board to make the texting program available for free. The program was developed by Voxiva and rolled out by the White House Office of Science and Technology Policy.

So how effective has it been?

It’s too soon to tell, according to W. Douglas Evans, Ph.D., director of Public Health Communications and Marketing at the George Washington University in Washington. Dr. Evans has been involved in studies evaluating the effectiveness of text4baby. Two large studies are underway, but the final data won’t be available until early 2012, he said.

There has been little research done on the impact of texting (short messaging service or SMS) on health behaviors, partly because such social media and tools as texting have begun to take a more prominent role in health care only in recent years. "Mobile health has existed for only a few years. It’s a very new field, that’s why there’s not much research," said Dr. Evans.

But several factors make text4baby appealing and potentially successful in modifying behaviors.

The texts are free and their medium, a mobile phone, is widely used by Americans. In 2010, 96% of the U.S. population had a form of wireless connection, according to the Wireless Association CTIA. "One of the potentials of text4baby is to reach a lot of people – and that’s a leveler," said Dr. Evans. In addition, although the information isn’t interactive, at least not yet, it’s targeted and based on the mother’s pregnancy due date and continuing until the baby turns 1-year-old.

"Part of the movement of social media is that you want to tailor it to the user and what they want," said Dr. Megan A. Moreno of the department of pediatrics at University of Wisconsin, Madison. "I think about what new moms would want, and I think they’d like to have that feeling of companionship – to be connected via texting all through pregnancy and when they’re isolated."

Although the health care community is still testing the waters when it comes to social media, researchers say that it’s important for physicians to talk to their patients about social media programs and be involved and aware of the types of information they receive.

"Social media, texting, and digital media are here, and that is what our patients are using or could use," said Dr. Terry Kind, director of Pediatrics Medical Student Education at Children’s National Medical Center at GW University. "We as the doctor community should get on board. ... Social media is a rapidly evolving area. There are doctors who won’t go near it. But there’s a huge potential for new ways to serve the public health message."

Social media or tools like texting aren’t, of course, the answer for everything. But, "sharing good information is never a bad thing," said Dr. Reuben Varghese, health director of the Arlington public health division. "Even if they don’t listen to it but pass it along to someone else, it’s a success."

Repetition, after all, is powerful, added Dr. Wylen.

Ms. Meehan of HMHB said the group is now looking at ways to keep up with the growth of the program, automating parts of the process, and getting more women to sign up for the service. She also said she looks forward to seeing the results of the ongoing studies on the program to get a broader look at how women understand the messages and how they’re learning.

"This is really version 1.0," said Dr. Evans, referring to mobile health. "There will be a version 2.0 and 3.0."

Most of the patients Dr. Michele Wylen sees are low-income women, many of whom are on Medicaid or have no health insurance.

As an ob.gyn. at the Arlington County (Va.) Public Health Division, she is aware of the statistics: Preterm birth rates are higher among women who have less access to health care services, and the nation has a high infant mortality rate, higher than many other industrialized counties. She is an advocate for reliable tools that would better inform her patients, even if it’s outside of her office. So Dr. Wylen and the county health department embraced the text4baby program when it launched early last year.

The free text messaging service keeps her patients informed about their pregnancy and the first year of motherhood through simple text messages sent out regularly, tailored to the mother’s due date or the age of the infant.

"Patients may not understand everything, but they can ask about it," she said in an interview. "It’s a springboard for patients to ask questions.

"And what’s compelling is that everyone, at least most people, have access to a cell phone," she said. "And this is a great way to disseminate information."

In an era that some researchers call the "Wild West" of social media, this simple texting program that targets pregnant women and new moms, especially those who are lower income and have less access to health care services, is showing promise. Most researchers and industry experts agree that the program is the first of its kind in the United States to reach such a wide audience of women in a significant and delicate stage of their lives.

Since its inception in February 2010, more than 150,000 women have signed up to receive the free texts. The National Healthy Mothers, Healthy Babies Coalition (HMHB), the nonprofit group that has been nurturing the program and writing the text messages, has an ambitious goal of reaching 1 million women by the end of 2012.

"It’s a tool we can reach women with, instead of putting an ad on the bus." With text4baby, they will have the ability to reach women wherever they are, according to Judy Meehan, executive director of the HMHB, referring to the participants enrolled in the texting program.

Each text message contains a small snippet of information, explained Ms. Meehan; one idea per message and why it is important for the mom to pay attention to that idea.

This is how the program works: Women send the word BABY (or BEBE in Spanish) to 511411. They then put in their due date and their zip code and they’re enrolled in the free texting program. They will first receive a "starter pack" of about six text messages and then they receive three messages per week in early afternoons, tailored to their due date or the age of their newborn. The messages range from health tips, to numbers to call to find a provider, to urgent messages such as notification about recalls or new guidelines.

Behind the scenes, a team of 19 individuals edit the text messages, making sure they’re accurate and based on evidence-based medicine that comes from some of the prominent sources of information in the country, such as the Centers for Disease Control and Prevention. The program has nearly 500 partner organizations, including health departments, community health centers, and physician offices. Its main financial sponsor is Johnson & Johnson, along with other sponsors including with WellPoint, Pfizer, and CareFirst, but there are no promotions in the text messages. And 19 mobile carriers have gotten on board to make the texting program available for free. The program was developed by Voxiva and rolled out by the White House Office of Science and Technology Policy.

So how effective has it been?

It’s too soon to tell, according to W. Douglas Evans, Ph.D., director of Public Health Communications and Marketing at the George Washington University in Washington. Dr. Evans has been involved in studies evaluating the effectiveness of text4baby. Two large studies are underway, but the final data won’t be available until early 2012, he said.

There has been little research done on the impact of texting (short messaging service or SMS) on health behaviors, partly because such social media and tools as texting have begun to take a more prominent role in health care only in recent years. "Mobile health has existed for only a few years. It’s a very new field, that’s why there’s not much research," said Dr. Evans.

But several factors make text4baby appealing and potentially successful in modifying behaviors.

The texts are free and their medium, a mobile phone, is widely used by Americans. In 2010, 96% of the U.S. population had a form of wireless connection, according to the Wireless Association CTIA. "One of the potentials of text4baby is to reach a lot of people – and that’s a leveler," said Dr. Evans. In addition, although the information isn’t interactive, at least not yet, it’s targeted and based on the mother’s pregnancy due date and continuing until the baby turns 1-year-old.

"Part of the movement of social media is that you want to tailor it to the user and what they want," said Dr. Megan A. Moreno of the department of pediatrics at University of Wisconsin, Madison. "I think about what new moms would want, and I think they’d like to have that feeling of companionship – to be connected via texting all through pregnancy and when they’re isolated."

Although the health care community is still testing the waters when it comes to social media, researchers say that it’s important for physicians to talk to their patients about social media programs and be involved and aware of the types of information they receive.

"Social media, texting, and digital media are here, and that is what our patients are using or could use," said Dr. Terry Kind, director of Pediatrics Medical Student Education at Children’s National Medical Center at GW University. "We as the doctor community should get on board. ... Social media is a rapidly evolving area. There are doctors who won’t go near it. But there’s a huge potential for new ways to serve the public health message."

Social media or tools like texting aren’t, of course, the answer for everything. But, "sharing good information is never a bad thing," said Dr. Reuben Varghese, health director of the Arlington public health division. "Even if they don’t listen to it but pass it along to someone else, it’s a success."

Repetition, after all, is powerful, added Dr. Wylen.

Ms. Meehan of HMHB said the group is now looking at ways to keep up with the growth of the program, automating parts of the process, and getting more women to sign up for the service. She also said she looks forward to seeing the results of the ongoing studies on the program to get a broader look at how women understand the messages and how they’re learning.

"This is really version 1.0," said Dr. Evans, referring to mobile health. "There will be a version 2.0 and 3.0."

Most of the patients Dr. Michele Wylen sees are low-income women, many of whom are on Medicaid or have no health insurance.

As an ob.gyn. at the Arlington County (Va.) Public Health Division, she is aware of the statistics: Preterm birth rates are higher among women who have less access to health care services, and the nation has a high infant mortality rate, higher than many other industrialized counties. She is an advocate for reliable tools that would better inform her patients, even if it’s outside of her office. So Dr. Wylen and the county health department embraced the text4baby program when it launched early last year.

The free text messaging service keeps her patients informed about their pregnancy and the first year of motherhood through simple text messages sent out regularly, tailored to the mother’s due date or the age of the infant.

"Patients may not understand everything, but they can ask about it," she said in an interview. "It’s a springboard for patients to ask questions.

"And what’s compelling is that everyone, at least most people, have access to a cell phone," she said. "And this is a great way to disseminate information."

In an era that some researchers call the "Wild West" of social media, this simple texting program that targets pregnant women and new moms, especially those who are lower income and have less access to health care services, is showing promise. Most researchers and industry experts agree that the program is the first of its kind in the United States to reach such a wide audience of women in a significant and delicate stage of their lives.

Since its inception in February 2010, more than 150,000 women have signed up to receive the free texts. The National Healthy Mothers, Healthy Babies Coalition (HMHB), the nonprofit group that has been nurturing the program and writing the text messages, has an ambitious goal of reaching 1 million women by the end of 2012.

"It’s a tool we can reach women with, instead of putting an ad on the bus." With text4baby, they will have the ability to reach women wherever they are, according to Judy Meehan, executive director of the HMHB, referring to the participants enrolled in the texting program.

Each text message contains a small snippet of information, explained Ms. Meehan; one idea per message and why it is important for the mom to pay attention to that idea.

This is how the program works: Women send the word BABY (or BEBE in Spanish) to 511411. They then put in their due date and their zip code and they’re enrolled in the free texting program. They will first receive a "starter pack" of about six text messages and then they receive three messages per week in early afternoons, tailored to their due date or the age of their newborn. The messages range from health tips, to numbers to call to find a provider, to urgent messages such as notification about recalls or new guidelines.

Behind the scenes, a team of 19 individuals edit the text messages, making sure they’re accurate and based on evidence-based medicine that comes from some of the prominent sources of information in the country, such as the Centers for Disease Control and Prevention. The program has nearly 500 partner organizations, including health departments, community health centers, and physician offices. Its main financial sponsor is Johnson & Johnson, along with other sponsors including with WellPoint, Pfizer, and CareFirst, but there are no promotions in the text messages. And 19 mobile carriers have gotten on board to make the texting program available for free. The program was developed by Voxiva and rolled out by the White House Office of Science and Technology Policy.

So how effective has it been?

It’s too soon to tell, according to W. Douglas Evans, Ph.D., director of Public Health Communications and Marketing at the George Washington University in Washington. Dr. Evans has been involved in studies evaluating the effectiveness of text4baby. Two large studies are underway, but the final data won’t be available until early 2012, he said.

There has been little research done on the impact of texting (short messaging service or SMS) on health behaviors, partly because such social media and tools as texting have begun to take a more prominent role in health care only in recent years. "Mobile health has existed for only a few years. It’s a very new field, that’s why there’s not much research," said Dr. Evans.

But several factors make text4baby appealing and potentially successful in modifying behaviors.

The texts are free and their medium, a mobile phone, is widely used by Americans. In 2010, 96% of the U.S. population had a form of wireless connection, according to the Wireless Association CTIA. "One of the potentials of text4baby is to reach a lot of people – and that’s a leveler," said Dr. Evans. In addition, although the information isn’t interactive, at least not yet, it’s targeted and based on the mother’s pregnancy due date and continuing until the baby turns 1-year-old.

"Part of the movement of social media is that you want to tailor it to the user and what they want," said Dr. Megan A. Moreno of the department of pediatrics at University of Wisconsin, Madison. "I think about what new moms would want, and I think they’d like to have that feeling of companionship – to be connected via texting all through pregnancy and when they’re isolated."

Although the health care community is still testing the waters when it comes to social media, researchers say that it’s important for physicians to talk to their patients about social media programs and be involved and aware of the types of information they receive.

"Social media, texting, and digital media are here, and that is what our patients are using or could use," said Dr. Terry Kind, director of Pediatrics Medical Student Education at Children’s National Medical Center at GW University. "We as the doctor community should get on board. ... Social media is a rapidly evolving area. There are doctors who won’t go near it. But there’s a huge potential for new ways to serve the public health message."

Social media or tools like texting aren’t, of course, the answer for everything. But, "sharing good information is never a bad thing," said Dr. Reuben Varghese, health director of the Arlington public health division. "Even if they don’t listen to it but pass it along to someone else, it’s a success."

Repetition, after all, is powerful, added Dr. Wylen.

Ms. Meehan of HMHB said the group is now looking at ways to keep up with the growth of the program, automating parts of the process, and getting more women to sign up for the service. She also said she looks forward to seeing the results of the ongoing studies on the program to get a broader look at how women understand the messages and how they’re learning.

"This is really version 1.0," said Dr. Evans, referring to mobile health. "There will be a version 2.0 and 3.0."

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute of Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute of Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute of Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

WASHINGTON  – On the last night of the American Society of Addiction Medicine’s annual conference, four actors took the place of panelists in a ballroom that earlier had served as a space for discussing various aspects of addiction medicine, from drugs to alcohol to practice management.

The actors – Blythe Danner, Harris Yulin, Bryce Pinkham, and Sara Waisanen – sat in their chairs behind a long table facing a packed room of mostly addiction specialists and played out the third act of Eugene O’Neill’s "Long Day’s Journey Into Night."

Mary Tyrone, the mother played by Ms. Danner, needs morphine and more of it, but it’s just for her arthritic hands. Her husband, James, played by Mr. Yulin, wallows in drinking. And the sons, one of whom (Mr. Edmund) was played by Mr. Pinkham, have their own issues.

But why do a play in front of a group of addiction specialists who see real-life versions of such scenarios day after day?

"Our goal is to elicit empathy through the felt experience of emotion," said Bryan Doerries, artistic director of the play and social impact theater company Outside the Wire (www.outsidethewirellc.com). "The play is a catalyst for a sincere and honest discussion.

"We want to convey a sense of moral obligation for people to apply [empathy] to their clinical practice to do better with patients. It’s a huge goal," Mr. Doerries said.

Like other plays that the company has produced, this performance of "Long Day’s Journey" was followed by a discussion – an emotional reaction from the audience, or, in some cases, a reaction to a single line in the play. Physicians were quick to line up behind the microphones in the room.

The play was set in 1912 and nearly 100 years later, much stigma and shame continue to be attached to addiction among the general public as well as the physician community, said the panelists who took the place of actors after the half-hour performance.

The National Institute on Drug Abuse (NIDA) approached Mr. Doerries’s theater company asking for a play that would elicit such a response.

The stigma still carried by addiction in the health care community has been nothing but deleterious, said Dr. Nora Volkow, director of NIDA, because physicians don’t screen for drug addiction. Also, if they find out that the patient has an addiction, "they won’t even approach it."

The performance was part of the NIDAMED (www.drugabuse.gov/nidamed) program, which aims to educate physicians on the importance of screening their patients. The playbook was not about the play, but rather about how physicians can start a conversation with their patients about drug use. To learn more, visit ww1.drugabuse.gov/nmassist.

Subacute atopic dermatitis of the vulva has been described by Dr. Albert Altchek, which he said "has never been described before."

Atopic dermatitis is a clinical diagnosis, according to Dr. Altchek, clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, New York. "There's no corresponding biopsy."

His findings are based on his observations of a large number of the same girls over a long period of time at three separate clinics as well as his continuing private office consultation, which he presented at the 15th Annual Postgraduate CME Course on Pediatric, Adolescent, and Young Adult Gynecology held at New York's Mount Sinai Hospital. He also has written a chapter on the topic in "Pediatric, Adolescent, & Young Adult Gynecology" (Oxford: Wiley-Blackwell, 2009), edited by Dr. Altchek and Dr. Liane Deligdisch.

The symptoms include recurrent itching, redness, fissures, and vulva dysuria. Diagnosis of vulvar atopic dermatitis includes gathering a family history of allergies, asthma, hay fever; looking at the past history of the patient; and conducting a physical examination starting from the head, said Dr. Altchek.

Atopic dermatitis fissures are symmetrical and narrow, and look as if they were "made with an artist with a scalpel," he said. The hymen is intact. In early stages, vulvar atopic dermatitis' most pronounced part is bilateral symmetrical fissures between labia minora and majora. Sometimes the fissures are deep and may cause bleeding. In addition, there is a midline sagittal perineal fourchette to the anterior anus at 12 o'clock, where there is usually a papule. The latter is the result of an anterior anal fissure with red inflamed edges. When red and present for a long time, there is severe permanent swelling simulating a hemorrhoid. In more severe cases there is a fissure anterior to clitoris.

In younger girls, the fissures may cause a sudden jump up from sitting because of pain, which is at times misdiagnosed as a neurologic condition.

The condition is sometimes confused with sexual molestation or lichen sclerosis. In sexual molestation cases there may be general signs of trauma and any vulvar fissures are irregular, with lacerations in addition to the history. "Lichen sclerosis of the vulva has coarse, wide irregular fissures in the same areas. With slight trauma the labia and vulva have transient dark blue subcutaneous blood boils," said Dr. Altchek, also an attending ob.gyn. at Lenox Hill Hospital in New York. Lichen sclerosis has a specific biopsy finding, which vulvar atopic dermatitis does not.

Patients with vulvar atopic dermatitis also have the condition on other parts of their body, including behind the ears, in axilla, elbows, or behind the knees, highlighting the importance of whole body exam.

The condition is managed by avoiding things that could irritate the vulva, including wet bathing suits, hot water, perfume, and certain clothing such as leotards and tights. Otherwise, treatment is individualized to reduce irritation and symptoms, Dr. Altchek said.

The condition is most common among prepubertal and young pubertal girls, it may or may not disappear at puberty, and it is less common in adults, said Dr. Altchek.

"Basically, my message is 'wake up, world.' This is how you diagnose [vulvar atopic dermatitis], which has never been described before," said Dr. Altchek.

Dr. Altchek said he had no relevant financial disclosures.

Subacute atopic dermatitis of the vulva has been described by Dr. Albert Altchek, which he said "has never been described before."

Atopic dermatitis is a clinical diagnosis, according to Dr. Altchek, clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, New York. "There's no corresponding biopsy."

His findings are based on his observations of a large number of the same girls over a long period of time at three separate clinics as well as his continuing private office consultation, which he presented at the 15th Annual Postgraduate CME Course on Pediatric, Adolescent, and Young Adult Gynecology held at New York's Mount Sinai Hospital. He also has written a chapter on the topic in "Pediatric, Adolescent, & Young Adult Gynecology" (Oxford: Wiley-Blackwell, 2009), edited by Dr. Altchek and Dr. Liane Deligdisch.

The symptoms include recurrent itching, redness, fissures, and vulva dysuria. Diagnosis of vulvar atopic dermatitis includes gathering a family history of allergies, asthma, hay fever; looking at the past history of the patient; and conducting a physical examination starting from the head, said Dr. Altchek.

Atopic dermatitis fissures are symmetrical and narrow, and look as if they were "made with an artist with a scalpel," he said. The hymen is intact. In early stages, vulvar atopic dermatitis' most pronounced part is bilateral symmetrical fissures between labia minora and majora. Sometimes the fissures are deep and may cause bleeding. In addition, there is a midline sagittal perineal fourchette to the anterior anus at 12 o'clock, where there is usually a papule. The latter is the result of an anterior anal fissure with red inflamed edges. When red and present for a long time, there is severe permanent swelling simulating a hemorrhoid. In more severe cases there is a fissure anterior to clitoris.

In younger girls, the fissures may cause a sudden jump up from sitting because of pain, which is at times misdiagnosed as a neurologic condition.

The condition is sometimes confused with sexual molestation or lichen sclerosis. In sexual molestation cases there may be general signs of trauma and any vulvar fissures are irregular, with lacerations in addition to the history. "Lichen sclerosis of the vulva has coarse, wide irregular fissures in the same areas. With slight trauma the labia and vulva have transient dark blue subcutaneous blood boils," said Dr. Altchek, also an attending ob.gyn. at Lenox Hill Hospital in New York. Lichen sclerosis has a specific biopsy finding, which vulvar atopic dermatitis does not.

Patients with vulvar atopic dermatitis also have the condition on other parts of their body, including behind the ears, in axilla, elbows, or behind the knees, highlighting the importance of whole body exam.

The condition is managed by avoiding things that could irritate the vulva, including wet bathing suits, hot water, perfume, and certain clothing such as leotards and tights. Otherwise, treatment is individualized to reduce irritation and symptoms, Dr. Altchek said.

The condition is most common among prepubertal and young pubertal girls, it may or may not disappear at puberty, and it is less common in adults, said Dr. Altchek.

"Basically, my message is 'wake up, world.' This is how you diagnose [vulvar atopic dermatitis], which has never been described before," said Dr. Altchek.

Dr. Altchek said he had no relevant financial disclosures.

Subacute atopic dermatitis of the vulva has been described by Dr. Albert Altchek, which he said "has never been described before."

Atopic dermatitis is a clinical diagnosis, according to Dr. Altchek, clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, New York. "There's no corresponding biopsy."

His findings are based on his observations of a large number of the same girls over a long period of time at three separate clinics as well as his continuing private office consultation, which he presented at the 15th Annual Postgraduate CME Course on Pediatric, Adolescent, and Young Adult Gynecology held at New York's Mount Sinai Hospital. He also has written a chapter on the topic in "Pediatric, Adolescent, & Young Adult Gynecology" (Oxford: Wiley-Blackwell, 2009), edited by Dr. Altchek and Dr. Liane Deligdisch.

The symptoms include recurrent itching, redness, fissures, and vulva dysuria. Diagnosis of vulvar atopic dermatitis includes gathering a family history of allergies, asthma, hay fever; looking at the past history of the patient; and conducting a physical examination starting from the head, said Dr. Altchek.

Atopic dermatitis fissures are symmetrical and narrow, and look as if they were "made with an artist with a scalpel," he said. The hymen is intact. In early stages, vulvar atopic dermatitis' most pronounced part is bilateral symmetrical fissures between labia minora and majora. Sometimes the fissures are deep and may cause bleeding. In addition, there is a midline sagittal perineal fourchette to the anterior anus at 12 o'clock, where there is usually a papule. The latter is the result of an anterior anal fissure with red inflamed edges. When red and present for a long time, there is severe permanent swelling simulating a hemorrhoid. In more severe cases there is a fissure anterior to clitoris.

In younger girls, the fissures may cause a sudden jump up from sitting because of pain, which is at times misdiagnosed as a neurologic condition.

The condition is sometimes confused with sexual molestation or lichen sclerosis. In sexual molestation cases there may be general signs of trauma and any vulvar fissures are irregular, with lacerations in addition to the history. "Lichen sclerosis of the vulva has coarse, wide irregular fissures in the same areas. With slight trauma the labia and vulva have transient dark blue subcutaneous blood boils," said Dr. Altchek, also an attending ob.gyn. at Lenox Hill Hospital in New York. Lichen sclerosis has a specific biopsy finding, which vulvar atopic dermatitis does not.

Patients with vulvar atopic dermatitis also have the condition on other parts of their body, including behind the ears, in axilla, elbows, or behind the knees, highlighting the importance of whole body exam.

The condition is managed by avoiding things that could irritate the vulva, including wet bathing suits, hot water, perfume, and certain clothing such as leotards and tights. Otherwise, treatment is individualized to reduce irritation and symptoms, Dr. Altchek said.

The condition is most common among prepubertal and young pubertal girls, it may or may not disappear at puberty, and it is less common in adults, said Dr. Altchek.

"Basically, my message is 'wake up, world.' This is how you diagnose [vulvar atopic dermatitis], which has never been described before," said Dr. Altchek.

Dr. Altchek said he had no relevant financial disclosures.

Subacute atopic dermatitis of the vulva has been described for the first time by Dr. Albert Altchek, clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, New York, according to the physician.

Atopic dermatitis is a clinical diagnosis, according to Dr. Altchek. "There’s no corresponding biopsy."

His findings are based on his observations of a large number of the same girls over a long period of time at three separate clinics as well as his continuing private office consultation, which he presented at the 15th Annual Postgraduate CME Course on Pediatric, Adolescent, and Young Adult Gynecology held at New York’s Mount Sinai Hospital. He also has written a chapter on the topic in "Pediatric, Adolescent, & Young Adult Gynecology" (Oxford: Wiley-Blackwell, 2009), edited by Dr. Altchek and Dr. Liane Deligdisch.

The symptoms include recurrent itching, redness, fissures, and vulva dysuria. Diagnosis of vulvar atopic dermatitis includes gathering a family history of allergies, asthma, hay fever; looking at the past history of the patient; and conducting a physical examination starting from the head, said Dr. Altchek.

Atopic dermatitis fissures are symmetrical and narrow, and look as if they were "made with an artist with a scalpel," he said. The hymen is intact. In early stages, vulvar atopic dermatitis’ most pronounced part is bilateral symmetrical fissures between labia minora and majora. Sometimes the fissures are deep and may cause bleeding. In addition, there is a midline sagittal perineal fourchette to the anterior anus at 12 o’clock, where there is usually a papule. The latter is the result of an anterior anal fissure with red inflamed edges. When red and present for a long time, there is severe permanent swelling simulating a hemorrhoid. In more severe cases there is a fissure anterior to clitoris.

In younger girls, the fissures may cause a sudden jump up from sitting because of pain, which is at times misdiagnosed as a neurologic condition.

The condition is sometimes confused with sexual molestation or lichen sclerosis. In sexual molestation cases there may be general signs of trauma and any vulvar fissures are irregular, with lacerations in addition to the history. "Lichen sclerosis of the vulva has coarse, wide irregular fissures in the same areas. With slight trauma the labia and vulva have transient dark blue subcutaneous blood boils," said Dr. Altchek, also an attending ob.gyn. at Lenox Hill Hospital in New York. Lichen sclerosis has a specific biopsy finding, which vulvar atopic dermatitis does not.

Patients with vulvar atopic dermatitis also have the condition on other parts of their body, including behind the ears, in axilla, elbows, or behind the knees, highlighting the importance of whole body exam.

The condition is managed by avoiding things that could irritate the vulva, including wet bathing suits, hot water, perfume, and certain clothing such as leotards and tights. Otherwise, treatment is individualized to reduce irritation and symptoms, Dr. Altchek said.

The condition is most common among prepubertal and young pubertal girls, it may or may not disappear at puberty, and it is less common in adults, said Dr. Altchek.

"Basically, my message is ‘wake up, world.’ This is how you diagnose [vulvar atopic dermatitis], which has never been described before," said Dr. Altchek.

Dr. Altchek said he had no relevant financial disclosures.

Subacute atopic dermatitis of the vulva has been described for the first time by Dr. Albert Altchek, clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, New York, according to the physician.

Atopic dermatitis is a clinical diagnosis, according to Dr. Altchek. "There’s no corresponding biopsy."

His findings are based on his observations of a large number of the same girls over a long period of time at three separate clinics as well as his continuing private office consultation, which he presented at the 15th Annual Postgraduate CME Course on Pediatric, Adolescent, and Young Adult Gynecology held at New York’s Mount Sinai Hospital. He also has written a chapter on the topic in "Pediatric, Adolescent, & Young Adult Gynecology" (Oxford: Wiley-Blackwell, 2009), edited by Dr. Altchek and Dr. Liane Deligdisch.

The symptoms include recurrent itching, redness, fissures, and vulva dysuria. Diagnosis of vulvar atopic dermatitis includes gathering a family history of allergies, asthma, hay fever; looking at the past history of the patient; and conducting a physical examination starting from the head, said Dr. Altchek.

Atopic dermatitis fissures are symmetrical and narrow, and look as if they were "made with an artist with a scalpel," he said. The hymen is intact. In early stages, vulvar atopic dermatitis’ most pronounced part is bilateral symmetrical fissures between labia minora and majora. Sometimes the fissures are deep and may cause bleeding. In addition, there is a midline sagittal perineal fourchette to the anterior anus at 12 o’clock, where there is usually a papule. The latter is the result of an anterior anal fissure with red inflamed edges. When red and present for a long time, there is severe permanent swelling simulating a hemorrhoid. In more severe cases there is a fissure anterior to clitoris.

In younger girls, the fissures may cause a sudden jump up from sitting because of pain, which is at times misdiagnosed as a neurologic condition.

The condition is sometimes confused with sexual molestation or lichen sclerosis. In sexual molestation cases there may be general signs of trauma and any vulvar fissures are irregular, with lacerations in addition to the history. "Lichen sclerosis of the vulva has coarse, wide irregular fissures in the same areas. With slight trauma the labia and vulva have transient dark blue subcutaneous blood boils," said Dr. Altchek, also an attending ob.gyn. at Lenox Hill Hospital in New York. Lichen sclerosis has a specific biopsy finding, which vulvar atopic dermatitis does not.

Patients with vulvar atopic dermatitis also have the condition on other parts of their body, including behind the ears, in axilla, elbows, or behind the knees, highlighting the importance of whole body exam.

The condition is managed by avoiding things that could irritate the vulva, including wet bathing suits, hot water, perfume, and certain clothing such as leotards and tights. Otherwise, treatment is individualized to reduce irritation and symptoms, Dr. Altchek said.

The condition is most common among prepubertal and young pubertal girls, it may or may not disappear at puberty, and it is less common in adults, said Dr. Altchek.

"Basically, my message is ‘wake up, world.’ This is how you diagnose [vulvar atopic dermatitis], which has never been described before," said Dr. Altchek.

Dr. Altchek said he had no relevant financial disclosures.

Subacute atopic dermatitis of the vulva has been described for the first time by Dr. Albert Altchek, clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, New York, according to the physician.

Atopic dermatitis is a clinical diagnosis, according to Dr. Altchek. "There’s no corresponding biopsy."

His findings are based on his observations of a large number of the same girls over a long period of time at three separate clinics as well as his continuing private office consultation, which he presented at the 15th Annual Postgraduate CME Course on Pediatric, Adolescent, and Young Adult Gynecology held at New York’s Mount Sinai Hospital. He also has written a chapter on the topic in "Pediatric, Adolescent, & Young Adult Gynecology" (Oxford: Wiley-Blackwell, 2009), edited by Dr. Altchek and Dr. Liane Deligdisch.

The symptoms include recurrent itching, redness, fissures, and vulva dysuria. Diagnosis of vulvar atopic dermatitis includes gathering a family history of allergies, asthma, hay fever; looking at the past history of the patient; and conducting a physical examination starting from the head, said Dr. Altchek.

Atopic dermatitis fissures are symmetrical and narrow, and look as if they were "made with an artist with a scalpel," he said. The hymen is intact. In early stages, vulvar atopic dermatitis’ most pronounced part is bilateral symmetrical fissures between labia minora and majora. Sometimes the fissures are deep and may cause bleeding. In addition, there is a midline sagittal perineal fourchette to the anterior anus at 12 o’clock, where there is usually a papule. The latter is the result of an anterior anal fissure with red inflamed edges. When red and present for a long time, there is severe permanent swelling simulating a hemorrhoid. In more severe cases there is a fissure anterior to clitoris.

In younger girls, the fissures may cause a sudden jump up from sitting because of pain, which is at times misdiagnosed as a neurologic condition.

The condition is sometimes confused with sexual molestation or lichen sclerosis. In sexual molestation cases there may be general signs of trauma and any vulvar fissures are irregular, with lacerations in addition to the history. "Lichen sclerosis of the vulva has coarse, wide irregular fissures in the same areas. With slight trauma the labia and vulva have transient dark blue subcutaneous blood boils," said Dr. Altchek, also an attending ob.gyn. at Lenox Hill Hospital in New York. Lichen sclerosis has a specific biopsy finding, which vulvar atopic dermatitis does not.

Patients with vulvar atopic dermatitis also have the condition on other parts of their body, including behind the ears, in axilla, elbows, or behind the knees, highlighting the importance of whole body exam.

The condition is managed by avoiding things that could irritate the vulva, including wet bathing suits, hot water, perfume, and certain clothing such as leotards and tights. Otherwise, treatment is individualized to reduce irritation and symptoms, Dr. Altchek said.

The condition is most common among prepubertal and young pubertal girls, it may or may not disappear at puberty, and it is less common in adults, said Dr. Altchek.

"Basically, my message is ‘wake up, world.’ This is how you diagnose [vulvar atopic dermatitis], which has never been described before," said Dr. Altchek.

Dr. Altchek said he had no relevant financial disclosures.