LAKE TAHOE, CALIF. – The way Stanley Vance Jr., MD, sees it, the No. 1 priority in the care of transgender youth is respecting their gender identity.

“This can really help with rapport and also help them continue to engage with your care,” he said at the annual meeting of the Society for Pediatric Dermatology.

One of the first steps is to establish the patient’s chosen name and pronouns. “Ask, use, and be consistent,” said Dr. Vance, an adolescent medicine specialist at the University of California, San Francisco. “Taking it to another level, you can implement system-level tools to ensure that all of your staff consistently use the chosen name and pronouns. Something we’ve found helpful is including questions about chosen name and pronouns on patient intake forms, and working with the IT department to have a place in our electronic medical record to put the chosen name and preferred pronouns.”

In a study published in the Journal of Adolescent Health, researchers found that the use of chosen names and pronouns for transgender use was associated with reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.

Dr. Vance, who also holds a staff position at the UCSF Child and Adolescent Clinic, went on to discuss dermatologic considerations for gender diverse youth. In transgender females, estrogens can reduce the quantity and density of body and facial hair, “but it doesn’t necessarily get rid of the hair, so we may refer to dermatology for hair removal or hair reduction. There can also be a decrease in sebum production, which can lead to dry skin for those who are at risk.”

Transgender females often seek laser hair removal or electrolysis to aid in “blendability,” or how they perceive as being female or feminine. “We know that this can help in psychosocial outcomes for these young people,” Dr. Vance said. “Another reason why hair reduction and removal may be important is preoperatively for vaginoplasty.”

In transgender males, testosterone increases male pattern hair growth and can increase male pattern hair loss. “Minoxidil does not interact with gender-affirming hormone treatment. If finasteride needs to be considered, it may interfere with the development of secondary sex characteristics.” Testosterone also increases sebum production and can increase acne, particularly in the first 6 months to 1 year after initiation, and with increased titration. “Some transmasculine youth may need oral isotretinoin, as stopping testosterone can be psychologically damaging,” Dr. Vance said.

“Unfortunately, the iPLEDGE program requirements can be perceived as gender nonaffirming, because patients must register by the sex assigned to them at birth, they must take pregnancy tests, and there can be provider assumptions about sexuality which does not equate with gender identity.”

He recommended having “open and honest” conversations with patients about the requirements and limitations of dispensing oral isotretinoin. “Assure the patient that you will be respectful and affirming of their gender identity while they’re in your office,” Dr. Vance advised. “If the patient has a mental health provider, you can strategize with them to reduce gender dysphoria around this process. Finally, advocating to change the system can not only be helpful for the patient in front of you, but for other patients who are in the same situation.”

He concluded his presentation by describing transgender youth as “some of the most resilient young people I’ve had the pleasure of working with.

“I think that we can all work to make sure they feel supported in who they are,” he said.

Dr. Vance reported having no relevant financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – The way Stanley Vance Jr., MD, sees it, the No. 1 priority in the care of transgender youth is respecting their gender identity.

“This can really help with rapport and also help them continue to engage with your care,” he said at the annual meeting of the Society for Pediatric Dermatology.

One of the first steps is to establish the patient’s chosen name and pronouns. “Ask, use, and be consistent,” said Dr. Vance, an adolescent medicine specialist at the University of California, San Francisco. “Taking it to another level, you can implement system-level tools to ensure that all of your staff consistently use the chosen name and pronouns. Something we’ve found helpful is including questions about chosen name and pronouns on patient intake forms, and working with the IT department to have a place in our electronic medical record to put the chosen name and preferred pronouns.”

In a study published in the Journal of Adolescent Health, researchers found that the use of chosen names and pronouns for transgender use was associated with reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.

Dr. Vance, who also holds a staff position at the UCSF Child and Adolescent Clinic, went on to discuss dermatologic considerations for gender diverse youth. In transgender females, estrogens can reduce the quantity and density of body and facial hair, “but it doesn’t necessarily get rid of the hair, so we may refer to dermatology for hair removal or hair reduction. There can also be a decrease in sebum production, which can lead to dry skin for those who are at risk.”

Transgender females often seek laser hair removal or electrolysis to aid in “blendability,” or how they perceive as being female or feminine. “We know that this can help in psychosocial outcomes for these young people,” Dr. Vance said. “Another reason why hair reduction and removal may be important is preoperatively for vaginoplasty.”

In transgender males, testosterone increases male pattern hair growth and can increase male pattern hair loss. “Minoxidil does not interact with gender-affirming hormone treatment. If finasteride needs to be considered, it may interfere with the development of secondary sex characteristics.” Testosterone also increases sebum production and can increase acne, particularly in the first 6 months to 1 year after initiation, and with increased titration. “Some transmasculine youth may need oral isotretinoin, as stopping testosterone can be psychologically damaging,” Dr. Vance said.

“Unfortunately, the iPLEDGE program requirements can be perceived as gender nonaffirming, because patients must register by the sex assigned to them at birth, they must take pregnancy tests, and there can be provider assumptions about sexuality which does not equate with gender identity.”

He recommended having “open and honest” conversations with patients about the requirements and limitations of dispensing oral isotretinoin. “Assure the patient that you will be respectful and affirming of their gender identity while they’re in your office,” Dr. Vance advised. “If the patient has a mental health provider, you can strategize with them to reduce gender dysphoria around this process. Finally, advocating to change the system can not only be helpful for the patient in front of you, but for other patients who are in the same situation.”

He concluded his presentation by describing transgender youth as “some of the most resilient young people I’ve had the pleasure of working with.

“I think that we can all work to make sure they feel supported in who they are,” he said.

Dr. Vance reported having no relevant financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – The way Stanley Vance Jr., MD, sees it, the No. 1 priority in the care of transgender youth is respecting their gender identity.

“This can really help with rapport and also help them continue to engage with your care,” he said at the annual meeting of the Society for Pediatric Dermatology.

One of the first steps is to establish the patient’s chosen name and pronouns. “Ask, use, and be consistent,” said Dr. Vance, an adolescent medicine specialist at the University of California, San Francisco. “Taking it to another level, you can implement system-level tools to ensure that all of your staff consistently use the chosen name and pronouns. Something we’ve found helpful is including questions about chosen name and pronouns on patient intake forms, and working with the IT department to have a place in our electronic medical record to put the chosen name and preferred pronouns.”

In a study published in the Journal of Adolescent Health, researchers found that the use of chosen names and pronouns for transgender use was associated with reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.

Dr. Vance, who also holds a staff position at the UCSF Child and Adolescent Clinic, went on to discuss dermatologic considerations for gender diverse youth. In transgender females, estrogens can reduce the quantity and density of body and facial hair, “but it doesn’t necessarily get rid of the hair, so we may refer to dermatology for hair removal or hair reduction. There can also be a decrease in sebum production, which can lead to dry skin for those who are at risk.”

Transgender females often seek laser hair removal or electrolysis to aid in “blendability,” or how they perceive as being female or feminine. “We know that this can help in psychosocial outcomes for these young people,” Dr. Vance said. “Another reason why hair reduction and removal may be important is preoperatively for vaginoplasty.”

In transgender males, testosterone increases male pattern hair growth and can increase male pattern hair loss. “Minoxidil does not interact with gender-affirming hormone treatment. If finasteride needs to be considered, it may interfere with the development of secondary sex characteristics.” Testosterone also increases sebum production and can increase acne, particularly in the first 6 months to 1 year after initiation, and with increased titration. “Some transmasculine youth may need oral isotretinoin, as stopping testosterone can be psychologically damaging,” Dr. Vance said.

“Unfortunately, the iPLEDGE program requirements can be perceived as gender nonaffirming, because patients must register by the sex assigned to them at birth, they must take pregnancy tests, and there can be provider assumptions about sexuality which does not equate with gender identity.”

He recommended having “open and honest” conversations with patients about the requirements and limitations of dispensing oral isotretinoin. “Assure the patient that you will be respectful and affirming of their gender identity while they’re in your office,” Dr. Vance advised. “If the patient has a mental health provider, you can strategize with them to reduce gender dysphoria around this process. Finally, advocating to change the system can not only be helpful for the patient in front of you, but for other patients who are in the same situation.”

He concluded his presentation by describing transgender youth as “some of the most resilient young people I’ve had the pleasure of working with.

“I think that we can all work to make sure they feel supported in who they are,” he said.

Dr. Vance reported having no relevant financial disclosures.

[email protected]

Current migraine forecasting models represent an important first step in accurately predicting future headache activity, according to a recent investigation. However, to utilize these models in a preemptive treatment paradigm where the risk of headache is treated prior to the actual experience of pain, these models must achieve greater precision with good calibration and generate predictions that are clinically actionable by individuals in their real-time home environments.

A substantial pool of candidate migraine trigger factors could be considered in the creation of forecasting models. However, since mechanistic information about causal factors that precede a migraine attack is not well understood, and such factors are difficult to measure, empirical models that are based on trigger factors that are merely associated with the onset of headache activity are likely to be the focus of forecasting efforts. Of such factors, stress has considerable empirical support and has been used to successfully forecast future headache attacks within individuals over time. At present, however, existing models possess only modest levels of discrimination and lack strong resolution in generated predictions.

Curr Pain Headache Rep. Forecasting migraine attacks and the utility of identifying triggers. 2018;22:62. doi:10.1007/s11916-018-0715-3.

Current migraine forecasting models represent an important first step in accurately predicting future headache activity, according to a recent investigation. However, to utilize these models in a preemptive treatment paradigm where the risk of headache is treated prior to the actual experience of pain, these models must achieve greater precision with good calibration and generate predictions that are clinically actionable by individuals in their real-time home environments.

A substantial pool of candidate migraine trigger factors could be considered in the creation of forecasting models. However, since mechanistic information about causal factors that precede a migraine attack is not well understood, and such factors are difficult to measure, empirical models that are based on trigger factors that are merely associated with the onset of headache activity are likely to be the focus of forecasting efforts. Of such factors, stress has considerable empirical support and has been used to successfully forecast future headache attacks within individuals over time. At present, however, existing models possess only modest levels of discrimination and lack strong resolution in generated predictions.

Curr Pain Headache Rep. Forecasting migraine attacks and the utility of identifying triggers. 2018;22:62. doi:10.1007/s11916-018-0715-3.

Current migraine forecasting models represent an important first step in accurately predicting future headache activity, according to a recent investigation. However, to utilize these models in a preemptive treatment paradigm where the risk of headache is treated prior to the actual experience of pain, these models must achieve greater precision with good calibration and generate predictions that are clinically actionable by individuals in their real-time home environments.

A substantial pool of candidate migraine trigger factors could be considered in the creation of forecasting models. However, since mechanistic information about causal factors that precede a migraine attack is not well understood, and such factors are difficult to measure, empirical models that are based on trigger factors that are merely associated with the onset of headache activity are likely to be the focus of forecasting efforts. Of such factors, stress has considerable empirical support and has been used to successfully forecast future headache attacks within individuals over time. At present, however, existing models possess only modest levels of discrimination and lack strong resolution in generated predictions.

Curr Pain Headache Rep. Forecasting migraine attacks and the utility of identifying triggers. 2018;22:62. doi:10.1007/s11916-018-0715-3.

Although unilateral pain location can be helpful in making a migraine diagnosis, it does not appear to have additional clinical implications, according to a recent study. Additionally, its absence does not rule out a diagnosis of migraine since more than half of migraineurs have bilateral head pain. Medical record information was extracted for 477 randomly selected patients with migraine seen in 2011 in a tertiary headache clinic. This included demographic data, pain location, handedness, comorbid psychiatric diagnoses, medical and emergency department visits, and use of selected headache medications. Researchers found:

• Of 477 patients, 228 (47.8%) reported lateralized pain, of which 107 (47.9%) patients were right-sided compared with 65 (28.5%) left-sided patients, while 56 (24.5%) reported unilateral pain with no side predominance.
• Contrary to expectations, with the exception of self-reported posttraumatic stress disorder, there were no statistically significant differences between left and right in measures of psychiatric distress, emergency department visits, or healthcare use.

Migraine pain location and measures of healthcare use and distress: An observational study. Pain Res Manag. 2018;6157982. doi:10.1155/2018/6157982.

Although unilateral pain location can be helpful in making a migraine diagnosis, it does not appear to have additional clinical implications, according to a recent study. Additionally, its absence does not rule out a diagnosis of migraine since more than half of migraineurs have bilateral head pain. Medical record information was extracted for 477 randomly selected patients with migraine seen in 2011 in a tertiary headache clinic. This included demographic data, pain location, handedness, comorbid psychiatric diagnoses, medical and emergency department visits, and use of selected headache medications. Researchers found:

• Of 477 patients, 228 (47.8%) reported lateralized pain, of which 107 (47.9%) patients were right-sided compared with 65 (28.5%) left-sided patients, while 56 (24.5%) reported unilateral pain with no side predominance.
• Contrary to expectations, with the exception of self-reported posttraumatic stress disorder, there were no statistically significant differences between left and right in measures of psychiatric distress, emergency department visits, or healthcare use.

Migraine pain location and measures of healthcare use and distress: An observational study. Pain Res Manag. 2018;6157982. doi:10.1155/2018/6157982.

Although unilateral pain location can be helpful in making a migraine diagnosis, it does not appear to have additional clinical implications, according to a recent study. Additionally, its absence does not rule out a diagnosis of migraine since more than half of migraineurs have bilateral head pain. Medical record information was extracted for 477 randomly selected patients with migraine seen in 2011 in a tertiary headache clinic. This included demographic data, pain location, handedness, comorbid psychiatric diagnoses, medical and emergency department visits, and use of selected headache medications. Researchers found:

• Of 477 patients, 228 (47.8%) reported lateralized pain, of which 107 (47.9%) patients were right-sided compared with 65 (28.5%) left-sided patients, while 56 (24.5%) reported unilateral pain with no side predominance.
• Contrary to expectations, with the exception of self-reported posttraumatic stress disorder, there were no statistically significant differences between left and right in measures of psychiatric distress, emergency department visits, or healthcare use.

Migraine pain location and measures of healthcare use and distress: An observational study. Pain Res Manag. 2018;6157982. doi:10.1155/2018/6157982.

A recent study found a much higher prevalence of vestibular migraine (VM) in the United States than previously reported. These results, therefore, indicate a likely under-diagnosis of VM. Researchers evaluated the responses of participants (n=21,781) in the 2008 National Health Interview Survey (NHIS) balance and dizziness supplement, which were analyzed using statistical software. They found:

• The 1-year prevalence of a dizziness or balance problem in the United States was 11.9% (2490 respondents).
• Of respondents with dizziness, 584 (23.4%) met the case definition of VM, which represents a prevalence of VM in 2.7% of adults.
• There was a female preponderance (64.1%) and a slightly younger mean age (40.9 years) for those with VM as compared with all respondents (51.7% females and 46 years, respectively).
• Multivariate analysis showed that age <40, female sex, anxiety, depression, and prior head trauma were all associated with significantly increased odds of experiencing VM.
• Only 10% of subjects meeting criteria for VM were told that migraine was the cause of their dizziness.

The epidemiology of vestibular migraine: A population-based survey study. [Published online ahead of print July 16, 2018]. Otol Neurotol. doi:10.1097/MAO.0000000000001900.

A recent study found a much higher prevalence of vestibular migraine (VM) in the United States than previously reported. These results, therefore, indicate a likely under-diagnosis of VM. Researchers evaluated the responses of participants (n=21,781) in the 2008 National Health Interview Survey (NHIS) balance and dizziness supplement, which were analyzed using statistical software. They found:

• The 1-year prevalence of a dizziness or balance problem in the United States was 11.9% (2490 respondents).
• Of respondents with dizziness, 584 (23.4%) met the case definition of VM, which represents a prevalence of VM in 2.7% of adults.
• There was a female preponderance (64.1%) and a slightly younger mean age (40.9 years) for those with VM as compared with all respondents (51.7% females and 46 years, respectively).
• Multivariate analysis showed that age <40, female sex, anxiety, depression, and prior head trauma were all associated with significantly increased odds of experiencing VM.
• Only 10% of subjects meeting criteria for VM were told that migraine was the cause of their dizziness.

The epidemiology of vestibular migraine: A population-based survey study. [Published online ahead of print July 16, 2018]. Otol Neurotol. doi:10.1097/MAO.0000000000001900.

A recent study found a much higher prevalence of vestibular migraine (VM) in the United States than previously reported. These results, therefore, indicate a likely under-diagnosis of VM. Researchers evaluated the responses of participants (n=21,781) in the 2008 National Health Interview Survey (NHIS) balance and dizziness supplement, which were analyzed using statistical software. They found:

• The 1-year prevalence of a dizziness or balance problem in the United States was 11.9% (2490 respondents).
• Of respondents with dizziness, 584 (23.4%) met the case definition of VM, which represents a prevalence of VM in 2.7% of adults.
• There was a female preponderance (64.1%) and a slightly younger mean age (40.9 years) for those with VM as compared with all respondents (51.7% females and 46 years, respectively).
• Multivariate analysis showed that age <40, female sex, anxiety, depression, and prior head trauma were all associated with significantly increased odds of experiencing VM.
• Only 10% of subjects meeting criteria for VM were told that migraine was the cause of their dizziness.

The epidemiology of vestibular migraine: A population-based survey study. [Published online ahead of print July 16, 2018]. Otol Neurotol. doi:10.1097/MAO.0000000000001900.

This marks my last editorial as medical editor of Vascular Specialist. It has been more than a privilege to have been offered this position. After all, how lucky am I to be provided with an opportunity to rant about things that annoy me or laugh in print at some of the absurdities of our professional life.

Before I put down my pen, or should I more correctly say close my word processor, I would like to add an epithet that I have yet to coin publicly. I am suggesting that we lay to rest the term “Endoleak” and replace it with “Endofill.”

At the outset, I must commend doctors White, Yu, and May for recognizing and publicizing this important potential complication of aortic endografts (White GH, Yu W, May J., J Endovasc Surg. 1996.3:124-5). However, the term “Endoleak,” which they used to describe the continuation of free-flowing blood within the aneurysm sac, has created confusion amongst nonvascular surgeons and the lay public. Often such misunderstanding has resulted in deleterious consequences. I’m sure many vascular surgeons have been summoned to the emergency room after an emergency physician incorrectly interpreted a radiologist’s report of an Endoleak as a life-threatening rupture. Others may have had to explain to a referring physician that an Endoleak does not imply the vascular surgeon had performed an inadequate procedure. Further, patients have absolutely no concept of the meaning of this term and are often frightened when they learn they have an Endoleak. So prior to consenting them for an endograft, I always bring out a plastic model of an aneurysm with an endograft in place and go through a time-consuming explanation. Seldom do they remember this account. When I see patients back who have an Endoleak, I once again find myself placating terrified individuals who think they are about to die.

So that is why we should replace the alarming “Endoleak” with the less disturbing and more descriptive “Endofill.” After all, there is no “leak” but rather a “filling” of the sac with blood. Certainly, a Type 1 “Endofill” is still dangerous, but I doubt the uninitiated would consider it an immediate problem. “Endofill” may still take some explaining, but it is less likely to cause patient anxiety or an overzealous panic in a referring physician.

Let’s face it. Even the term “leak” has led to many errors in the treatment of patients with an abdominal aortic aneurysm. For example, it is not unusual that an emergency room physician, hospitalist, or internist will triage a “leaking” aneurysm as nonurgent because it has not “ruptured.”

I think we should ban “leaking” and “leak” from the medical vernacular. Let Washington politicians use the words. Rather, vascular surgeons and radiologists should describe exactly what is happening when a limited amount of blood escapes the wall of an aneurysm by using the term “contained rupture.” I’m sure that will get the nonvascular surgeon's attention!

I’m hopeful that you will also remember some of my other epithets and aphorisms from columns. Such as “Vascular surgeons Operate, Medicate and Dilate,” that TLR (Target Lesion Revascularization) should really be “The Least Relevant.” That a nervous surgeon will not be proficient so “The most important heart in the Operating room is the surgeon’s.” That vascular surgeons are all “Knights of the rectangular table,” and that rapacious doctors are committing “White Coat Crime.” That atheroembolism to the buttocks should be called “Trash Can.” That we should always ask for long-term outcomes before accepting new technologies otherwise, we would be encouraging “Premature congratulation.” That Societies that refuse to rein in their members by refusing to use the word “inappropriate” are being “Anti-semantic.” Further, that shared decision making is essential but that “Insecurity is the price patients must pay for sharing in the decision-making process.” And, of course, my request that we all join the SOS, the “Save Our Saphenous” society.

I am also hopeful that, with time, my exhortations will aid Vascular Surgery in getting the recognition that it deserves. I have suggested many ways we can expedite this goal including possibly changing the name of the Society to The American College of Vascular Surgery and offering members the opportunity to refer to themselves as Fellows of that College. I have encouraged all who are trying to achieve a separate Residency Review Committee, and I fully support an independent American Board of Vascular Surgery.

Over the last 5 years, I have penned almost all that I believe needs to be said about vascular surgery, vascular surgeons, our patients, and the Society for Vascular Surgery. However, although my contract still allows one more year as medical editor, I felt it was time for new insights from a new generation of surgeons.

It is with great pleasure, therefore, that I pass the reins to Malachi Sheahan III, MD. Vascular Specialist has become the primary news source for our Society, and its educational articles and news items offer learning experiences not found in peer-reviewed journals. I encourage all to submit interesting news items for print, add some unusual Tips and Tricks, write letters to the editor, and tell us about your accomplishments inside and out of vascular surgery.

Please also volunteer to write Point/Counter Point articles. Vascular Specialist is your resource, and it’s not only in print but also in all forms of electronic and social media. It is up to you to make sure that it continues to thrive as a valuable resource for all our members.

I want to publicly thank the Associate Editors for their many contributions. This magazine would not be the same without their insightful comments. However, in the background is the actual “hero,” Mark Lesney. Mark has been the editor who sends Mal and me news items to review, urges us to be punctual, and is responsible for putting Vascular Specialist together. He works tirelessly under the pressure of producing a monthly periodical. Vascular Specialist is indebted to his efforts.

Finally, I want to thank you all so much for bearing with my rantings these last few years. Your letters and emails of appreciation have been an inspiration. 

This marks my last editorial as medical editor of Vascular Specialist. It has been more than a privilege to have been offered this position. After all, how lucky am I to be provided with an opportunity to rant about things that annoy me or laugh in print at some of the absurdities of our professional life.

Before I put down my pen, or should I more correctly say close my word processor, I would like to add an epithet that I have yet to coin publicly. I am suggesting that we lay to rest the term “Endoleak” and replace it with “Endofill.”

At the outset, I must commend doctors White, Yu, and May for recognizing and publicizing this important potential complication of aortic endografts (White GH, Yu W, May J., J Endovasc Surg. 1996.3:124-5). However, the term “Endoleak,” which they used to describe the continuation of free-flowing blood within the aneurysm sac, has created confusion amongst nonvascular surgeons and the lay public. Often such misunderstanding has resulted in deleterious consequences. I’m sure many vascular surgeons have been summoned to the emergency room after an emergency physician incorrectly interpreted a radiologist’s report of an Endoleak as a life-threatening rupture. Others may have had to explain to a referring physician that an Endoleak does not imply the vascular surgeon had performed an inadequate procedure. Further, patients have absolutely no concept of the meaning of this term and are often frightened when they learn they have an Endoleak. So prior to consenting them for an endograft, I always bring out a plastic model of an aneurysm with an endograft in place and go through a time-consuming explanation. Seldom do they remember this account. When I see patients back who have an Endoleak, I once again find myself placating terrified individuals who think they are about to die.

So that is why we should replace the alarming “Endoleak” with the less disturbing and more descriptive “Endofill.” After all, there is no “leak” but rather a “filling” of the sac with blood. Certainly, a Type 1 “Endofill” is still dangerous, but I doubt the uninitiated would consider it an immediate problem. “Endofill” may still take some explaining, but it is less likely to cause patient anxiety or an overzealous panic in a referring physician.

Let’s face it. Even the term “leak” has led to many errors in the treatment of patients with an abdominal aortic aneurysm. For example, it is not unusual that an emergency room physician, hospitalist, or internist will triage a “leaking” aneurysm as nonurgent because it has not “ruptured.”

I think we should ban “leaking” and “leak” from the medical vernacular. Let Washington politicians use the words. Rather, vascular surgeons and radiologists should describe exactly what is happening when a limited amount of blood escapes the wall of an aneurysm by using the term “contained rupture.” I’m sure that will get the nonvascular surgeon's attention!

I’m hopeful that you will also remember some of my other epithets and aphorisms from columns. Such as “Vascular surgeons Operate, Medicate and Dilate,” that TLR (Target Lesion Revascularization) should really be “The Least Relevant.” That a nervous surgeon will not be proficient so “The most important heart in the Operating room is the surgeon’s.” That vascular surgeons are all “Knights of the rectangular table,” and that rapacious doctors are committing “White Coat Crime.” That atheroembolism to the buttocks should be called “Trash Can.” That we should always ask for long-term outcomes before accepting new technologies otherwise, we would be encouraging “Premature congratulation.” That Societies that refuse to rein in their members by refusing to use the word “inappropriate” are being “Anti-semantic.” Further, that shared decision making is essential but that “Insecurity is the price patients must pay for sharing in the decision-making process.” And, of course, my request that we all join the SOS, the “Save Our Saphenous” society.

I am also hopeful that, with time, my exhortations will aid Vascular Surgery in getting the recognition that it deserves. I have suggested many ways we can expedite this goal including possibly changing the name of the Society to The American College of Vascular Surgery and offering members the opportunity to refer to themselves as Fellows of that College. I have encouraged all who are trying to achieve a separate Residency Review Committee, and I fully support an independent American Board of Vascular Surgery.

Over the last 5 years, I have penned almost all that I believe needs to be said about vascular surgery, vascular surgeons, our patients, and the Society for Vascular Surgery. However, although my contract still allows one more year as medical editor, I felt it was time for new insights from a new generation of surgeons.

It is with great pleasure, therefore, that I pass the reins to Malachi Sheahan III, MD. Vascular Specialist has become the primary news source for our Society, and its educational articles and news items offer learning experiences not found in peer-reviewed journals. I encourage all to submit interesting news items for print, add some unusual Tips and Tricks, write letters to the editor, and tell us about your accomplishments inside and out of vascular surgery.

Please also volunteer to write Point/Counter Point articles. Vascular Specialist is your resource, and it’s not only in print but also in all forms of electronic and social media. It is up to you to make sure that it continues to thrive as a valuable resource for all our members.

I want to publicly thank the Associate Editors for their many contributions. This magazine would not be the same without their insightful comments. However, in the background is the actual “hero,” Mark Lesney. Mark has been the editor who sends Mal and me news items to review, urges us to be punctual, and is responsible for putting Vascular Specialist together. He works tirelessly under the pressure of producing a monthly periodical. Vascular Specialist is indebted to his efforts.

Finally, I want to thank you all so much for bearing with my rantings these last few years. Your letters and emails of appreciation have been an inspiration. 

This marks my last editorial as medical editor of Vascular Specialist. It has been more than a privilege to have been offered this position. After all, how lucky am I to be provided with an opportunity to rant about things that annoy me or laugh in print at some of the absurdities of our professional life.

Before I put down my pen, or should I more correctly say close my word processor, I would like to add an epithet that I have yet to coin publicly. I am suggesting that we lay to rest the term “Endoleak” and replace it with “Endofill.”

At the outset, I must commend doctors White, Yu, and May for recognizing and publicizing this important potential complication of aortic endografts (White GH, Yu W, May J., J Endovasc Surg. 1996.3:124-5). However, the term “Endoleak,” which they used to describe the continuation of free-flowing blood within the aneurysm sac, has created confusion amongst nonvascular surgeons and the lay public. Often such misunderstanding has resulted in deleterious consequences. I’m sure many vascular surgeons have been summoned to the emergency room after an emergency physician incorrectly interpreted a radiologist’s report of an Endoleak as a life-threatening rupture. Others may have had to explain to a referring physician that an Endoleak does not imply the vascular surgeon had performed an inadequate procedure. Further, patients have absolutely no concept of the meaning of this term and are often frightened when they learn they have an Endoleak. So prior to consenting them for an endograft, I always bring out a plastic model of an aneurysm with an endograft in place and go through a time-consuming explanation. Seldom do they remember this account. When I see patients back who have an Endoleak, I once again find myself placating terrified individuals who think they are about to die.

So that is why we should replace the alarming “Endoleak” with the less disturbing and more descriptive “Endofill.” After all, there is no “leak” but rather a “filling” of the sac with blood. Certainly, a Type 1 “Endofill” is still dangerous, but I doubt the uninitiated would consider it an immediate problem. “Endofill” may still take some explaining, but it is less likely to cause patient anxiety or an overzealous panic in a referring physician.

Let’s face it. Even the term “leak” has led to many errors in the treatment of patients with an abdominal aortic aneurysm. For example, it is not unusual that an emergency room physician, hospitalist, or internist will triage a “leaking” aneurysm as nonurgent because it has not “ruptured.”

I think we should ban “leaking” and “leak” from the medical vernacular. Let Washington politicians use the words. Rather, vascular surgeons and radiologists should describe exactly what is happening when a limited amount of blood escapes the wall of an aneurysm by using the term “contained rupture.” I’m sure that will get the nonvascular surgeon's attention!

I’m hopeful that you will also remember some of my other epithets and aphorisms from columns. Such as “Vascular surgeons Operate, Medicate and Dilate,” that TLR (Target Lesion Revascularization) should really be “The Least Relevant.” That a nervous surgeon will not be proficient so “The most important heart in the Operating room is the surgeon’s.” That vascular surgeons are all “Knights of the rectangular table,” and that rapacious doctors are committing “White Coat Crime.” That atheroembolism to the buttocks should be called “Trash Can.” That we should always ask for long-term outcomes before accepting new technologies otherwise, we would be encouraging “Premature congratulation.” That Societies that refuse to rein in their members by refusing to use the word “inappropriate” are being “Anti-semantic.” Further, that shared decision making is essential but that “Insecurity is the price patients must pay for sharing in the decision-making process.” And, of course, my request that we all join the SOS, the “Save Our Saphenous” society.

I am also hopeful that, with time, my exhortations will aid Vascular Surgery in getting the recognition that it deserves. I have suggested many ways we can expedite this goal including possibly changing the name of the Society to The American College of Vascular Surgery and offering members the opportunity to refer to themselves as Fellows of that College. I have encouraged all who are trying to achieve a separate Residency Review Committee, and I fully support an independent American Board of Vascular Surgery.

Over the last 5 years, I have penned almost all that I believe needs to be said about vascular surgery, vascular surgeons, our patients, and the Society for Vascular Surgery. However, although my contract still allows one more year as medical editor, I felt it was time for new insights from a new generation of surgeons.

It is with great pleasure, therefore, that I pass the reins to Malachi Sheahan III, MD. Vascular Specialist has become the primary news source for our Society, and its educational articles and news items offer learning experiences not found in peer-reviewed journals. I encourage all to submit interesting news items for print, add some unusual Tips and Tricks, write letters to the editor, and tell us about your accomplishments inside and out of vascular surgery.

Please also volunteer to write Point/Counter Point articles. Vascular Specialist is your resource, and it’s not only in print but also in all forms of electronic and social media. It is up to you to make sure that it continues to thrive as a valuable resource for all our members.

I want to publicly thank the Associate Editors for their many contributions. This magazine would not be the same without their insightful comments. However, in the background is the actual “hero,” Mark Lesney. Mark has been the editor who sends Mal and me news items to review, urges us to be punctual, and is responsible for putting Vascular Specialist together. He works tirelessly under the pressure of producing a monthly periodical. Vascular Specialist is indebted to his efforts.

Finally, I want to thank you all so much for bearing with my rantings these last few years. Your letters and emails of appreciation have been an inspiration. 

Whether you attended VAM18 or not, if you need more meeting, we have you covered. All things VAM are available here. For example:

• Find link to CME claim info
• Watch on-site videos and enjoy slide shows
• Find a link to the full schedule, with abstracts, moderators, faculty bios, exhibitors

VAM On Demand slides and videos will soon be available for purchase; watch Pulse and/or your inbox for the announcement!

Whether you attended VAM18 or not, if you need more meeting, we have you covered. All things VAM are available here. For example:

• Find link to CME claim info
• Watch on-site videos and enjoy slide shows
• Find a link to the full schedule, with abstracts, moderators, faculty bios, exhibitors

VAM On Demand slides and videos will soon be available for purchase; watch Pulse and/or your inbox for the announcement!

Whether you attended VAM18 or not, if you need more meeting, we have you covered. All things VAM are available here. For example:

• Find link to CME claim info
• Watch on-site videos and enjoy slide shows
• Find a link to the full schedule, with abstracts, moderators, faculty bios, exhibitors

VAM On Demand slides and videos will soon be available for purchase; watch Pulse and/or your inbox for the announcement!

The deadline to submit applications for the SVS Foundation Research Career Development Travel Award is Aug. 15. This award aims to develop strong leaders in vascular surgery. Awardees are assigned an SVS research mentor and are provided with funds to attend an establish research career development course.

The deadline to submit applications for the SVS Foundation Research Career Development Travel Award is Aug. 15. This award aims to develop strong leaders in vascular surgery. Awardees are assigned an SVS research mentor and are provided with funds to attend an establish research career development course.

The deadline to submit applications for the SVS Foundation Research Career Development Travel Award is Aug. 15. This award aims to develop strong leaders in vascular surgery. Awardees are assigned an SVS research mentor and are provided with funds to attend an establish research career development course.

The deadline for applications for the SVS International Scholars Program has been extended to Sept. 1. The program provides up to four scholarships to qualified young vascular surgeons from countries other than the United States or Canada. Awardees receive $5,000 each, to attend the 2019 Vascular Annual Meeting and to visit clinical, teaching and research facilities in the U.S. and Canada. Apply today.

The deadline for applications for the SVS International Scholars Program has been extended to Sept. 1. The program provides up to four scholarships to qualified young vascular surgeons from countries other than the United States or Canada. Awardees receive $5,000 each, to attend the 2019 Vascular Annual Meeting and to visit clinical, teaching and research facilities in the U.S. and Canada. Apply today.

The deadline for applications for the SVS International Scholars Program has been extended to Sept. 1. The program provides up to four scholarships to qualified young vascular surgeons from countries other than the United States or Canada. Awardees receive $5,000 each, to attend the 2019 Vascular Annual Meeting and to visit clinical, teaching and research facilities in the U.S. and Canada. Apply today.

PCOS Update 2018
R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education

Polycystic ovary syndrome is the most common reproductive endocrine disorder, affecting 1 in 15 women in the United States. Secor reviewed the signs, symptoms, risk factors, and pathophysiology of the condition, as well as new research pointing toward its relationship with the gut microbiome. She also covered the work-up, differential, and considerations if pregnancy is desired. The treatment discussion included off-label use of metformin and letrozole.

Hypercalcemia/Parathyroid Disease Unraveled: 3 Cases to Consider
Ji Hyun (CJ) Chun, PA-C, MPAS, BC-ADM, American Society of Endocrine PAs

Chun reviewed the physiology of calcium homeostasis and presented a work-up plan for hypercalcemia and hyperparathyroidism. He shared the surgical criteria for parathyroidectomy, as well as nonsurgical treatment options, and discussed the development, potential consequences, and treatment of vitamin D deficiency.

Osteoporosis: Sticks and Stones May or May Not Break My Bones?
Richard S. Pope, MPAS, PA-C, DFAAPA, CPAAPA, Quinnipiac University

FRAX^® (fracture risk assessment tool), bone mineral density (BMD), vertebral fracture assessment, and trabecular bone score are all validated tools for evaluating osteoporosis, began Pope. Age and previous fractures are perhaps the strongest, independent predictors of fracture risk. Antiresorptive therapy produces a modest increase in BMD. Anabolic therapy with parathyroid hormone increases BMD more than antiresorptive treatment, but it is not yet obvious that fracture protection is greater.

Osteoporosis: Case Studies for Consideration
R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education, and Richard S. Pope, MPAS, PA-C, DFAAPA, CPAAPA, Quinnipiac University

How long should you treat patients with bisphosphonates? How is osteoporosis treatment best monitored? What is the best definition of successful treatment of osteoporosis? Secor and Pope answered these questions and emphasized reviewing with patients diet and lifestyle modifications and their importance to bone health. They also explained how to analyze risk factors beyond the DXA (dual-energy x-ray absorptiometry) score (eg, height loss), and how to target therapy based on co‐morbidities.

Continue to: Men's and Women's Health Issues and Endocrine Disease

Men’s and Women’s Health Issues and Endocrine Disease
Ji Hyun (CJ) Chun, PA-C, MPAS, BC-ADM, American Society of Endocrine PAs, and R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education

Chun and Secor reviewed the physiology and pathophysiology of male hypogonadism, the elements of a comprehensive diagnostic protocol, and appropriate monitoring of patients taking testosterone replacement therapy (TRT). They said that differentiating organic hypogonadism and late-onset hypogonadism (LOH) is of utmost importance to prevent long-term complications of true hypogonadism. While the benefits of treatment clearly outweigh the risks for patients with organic hypogonadism, the benefit-risk ratio for patients with LOH is unclear.

PCOS Update 2018
R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education

Polycystic ovary syndrome is the most common reproductive endocrine disorder, affecting 1 in 15 women in the United States. Secor reviewed the signs, symptoms, risk factors, and pathophysiology of the condition, as well as new research pointing toward its relationship with the gut microbiome. She also covered the work-up, differential, and considerations if pregnancy is desired. The treatment discussion included off-label use of metformin and letrozole.

Hypercalcemia/Parathyroid Disease Unraveled: 3 Cases to Consider
Ji Hyun (CJ) Chun, PA-C, MPAS, BC-ADM, American Society of Endocrine PAs

Chun reviewed the physiology of calcium homeostasis and presented a work-up plan for hypercalcemia and hyperparathyroidism. He shared the surgical criteria for parathyroidectomy, as well as nonsurgical treatment options, and discussed the development, potential consequences, and treatment of vitamin D deficiency.

Osteoporosis: Sticks and Stones May or May Not Break My Bones?
Richard S. Pope, MPAS, PA-C, DFAAPA, CPAAPA, Quinnipiac University

FRAX^® (fracture risk assessment tool), bone mineral density (BMD), vertebral fracture assessment, and trabecular bone score are all validated tools for evaluating osteoporosis, began Pope. Age and previous fractures are perhaps the strongest, independent predictors of fracture risk. Antiresorptive therapy produces a modest increase in BMD. Anabolic therapy with parathyroid hormone increases BMD more than antiresorptive treatment, but it is not yet obvious that fracture protection is greater.

Osteoporosis: Case Studies for Consideration
R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education, and Richard S. Pope, MPAS, PA-C, DFAAPA, CPAAPA, Quinnipiac University

How long should you treat patients with bisphosphonates? How is osteoporosis treatment best monitored? What is the best definition of successful treatment of osteoporosis? Secor and Pope answered these questions and emphasized reviewing with patients diet and lifestyle modifications and their importance to bone health. They also explained how to analyze risk factors beyond the DXA (dual-energy x-ray absorptiometry) score (eg, height loss), and how to target therapy based on co‐morbidities.

Continue to: Men's and Women's Health Issues and Endocrine Disease

Men’s and Women’s Health Issues and Endocrine Disease
Ji Hyun (CJ) Chun, PA-C, MPAS, BC-ADM, American Society of Endocrine PAs, and R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education

Chun and Secor reviewed the physiology and pathophysiology of male hypogonadism, the elements of a comprehensive diagnostic protocol, and appropriate monitoring of patients taking testosterone replacement therapy (TRT). They said that differentiating organic hypogonadism and late-onset hypogonadism (LOH) is of utmost importance to prevent long-term complications of true hypogonadism. While the benefits of treatment clearly outweigh the risks for patients with organic hypogonadism, the benefit-risk ratio for patients with LOH is unclear.

PCOS Update 2018
R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education

Polycystic ovary syndrome is the most common reproductive endocrine disorder, affecting 1 in 15 women in the United States. Secor reviewed the signs, symptoms, risk factors, and pathophysiology of the condition, as well as new research pointing toward its relationship with the gut microbiome. She also covered the work-up, differential, and considerations if pregnancy is desired. The treatment discussion included off-label use of metformin and letrozole.

Hypercalcemia/Parathyroid Disease Unraveled: 3 Cases to Consider
Ji Hyun (CJ) Chun, PA-C, MPAS, BC-ADM, American Society of Endocrine PAs

Chun reviewed the physiology of calcium homeostasis and presented a work-up plan for hypercalcemia and hyperparathyroidism. He shared the surgical criteria for parathyroidectomy, as well as nonsurgical treatment options, and discussed the development, potential consequences, and treatment of vitamin D deficiency.

Osteoporosis: Sticks and Stones May or May Not Break My Bones?
Richard S. Pope, MPAS, PA-C, DFAAPA, CPAAPA, Quinnipiac University

FRAX^® (fracture risk assessment tool), bone mineral density (BMD), vertebral fracture assessment, and trabecular bone score are all validated tools for evaluating osteoporosis, began Pope. Age and previous fractures are perhaps the strongest, independent predictors of fracture risk. Antiresorptive therapy produces a modest increase in BMD. Anabolic therapy with parathyroid hormone increases BMD more than antiresorptive treatment, but it is not yet obvious that fracture protection is greater.

Osteoporosis: Case Studies for Consideration
R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education, and Richard S. Pope, MPAS, PA-C, DFAAPA, CPAAPA, Quinnipiac University

How long should you treat patients with bisphosphonates? How is osteoporosis treatment best monitored? What is the best definition of successful treatment of osteoporosis? Secor and Pope answered these questions and emphasized reviewing with patients diet and lifestyle modifications and their importance to bone health. They also explained how to analyze risk factors beyond the DXA (dual-energy x-ray absorptiometry) score (eg, height loss), and how to target therapy based on co‐morbidities.

Continue to: Men's and Women's Health Issues and Endocrine Disease

Men’s and Women’s Health Issues and Endocrine Disease
Ji Hyun (CJ) Chun, PA-C, MPAS, BC-ADM, American Society of Endocrine PAs, and R. Mimi Secor, DNP, FNP-BC, FAANP, Nurse Practitioner Associates for Continuing Education

Chun and Secor reviewed the physiology and pathophysiology of male hypogonadism, the elements of a comprehensive diagnostic protocol, and appropriate monitoring of patients taking testosterone replacement therapy (TRT). They said that differentiating organic hypogonadism and late-onset hypogonadism (LOH) is of utmost importance to prevent long-term complications of true hypogonadism. While the benefits of treatment clearly outweigh the risks for patients with organic hypogonadism, the benefit-risk ratio for patients with LOH is unclear.

Morning session
Managing Thyroid Disease: Preparing for Battle
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

What lab tests should I order when patients present with signs and symptoms suggestive of thyroid disease, and how should I interpret results? In answering these questions, Kessler and Sadler described the inverse relationship of T3 and T4 to thyroid stimulating hormone (TSH), why free T4 is superior to total T4, and how to proceed when FT4 and TSH seem discordant. They also discussed additional tests that may be needed based on initial screening results, and factors (eg, agents such as biotin) that can affect the accuracy of thyroid test results.

Case Studies in Hypo and Hyperthyroidism for Clinical Consideration
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

Hypothyroidism and hyperthyroidism can be difficult to diagnose, especially in the elderly. In addition to pointing out the aspects of the physical exam and lab studies that can aid in diagnosing both conditions, Kessler and Sadler presented strategies to safely initiate, titrate, and monitor therapies; addressed controversies surrounding the management of subclinical forms; and identified triggers and early symptoms of acute thyrotoxicosis (thyroid storm) and myxedema coma.

Thyroid Concerns in Pregnancy
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

Kessler reviewed the physiologic changes of pregnancy that influence thyroid conditions and associated lab tests, the potential complications to mother and fetus of untreated thyroid disease, and strategies for managing hypo- and hyperthyroidism throughout pregnancy and lactation. She reminded that pregnant women with hypothyroidism generally require 30% to 50% more of their thyroid medications. And when treating hyperthyroidism, use the lowest dose of antithyroid drugs that keeps maternal free T4 and free T3 near the upper limit of the normal range.

Managing the “Hot” Mess of Thyroiditis
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

While thyroiditis is transient in most patients, it requires ongoing follow-up because of the increased risk of permanent hypothyroidism. Kessler and Sadler reviewed the work-up and differential for suspected acute and subacute thyroiditis and how to interpret laboratory and thyroid scan data. They also discussed postpartum thyroiditis (the signs of which are often misdiagnosed as anxiety and stress about motherhood) and silent thyroiditis, which is similar to postpartum thyroiditis but is unassociated with pregnancy.

Continue to: Expert Tips on Evaluating Thyroid Nodules

Expert Tips on Evaluating Thyroid Nodules
Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

In the United States, up to 68% of randomly selected adults have thyroid nodules. While most are benign, the number of those that are cancerous is increasing. To assist with determining which are malignant, Sadler provided insight on the clinical and ultrasound findings that suggest increased malignant potential. He also detailed an appropriate work-up, noting that ultrasound-guided fine needle aspiration remains the best means for evaluation.

Lifestyle Interventions: A New Narrative for Diabetes Management and Metabolic Health
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

Mandel discussed diabetes self-management education and support. She highlighted what works and what doesn’t among various diets, that sugar isn’t the only target, that dieting is only half the equation and must be coupled with physical activity (which is not the same as exercise), and that patient involvement in self-management correlates with greater long-term success.

Gut Grief: The Enteroendocrine Connection in Autoimmune Diseases
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

“We need to look to the gut as the biggest player in chronic health and autoimmune disease,” said Kessler. Kessler went on to explain how altered gut flora impacts immune, endocrine, cardiovascular, neuropsychologic, reproductive, and metabolic health. She identified 12 endocrine-disrupting chemicals associated with autoimmunity. And she reviewed the causes of microbiome dysbiosis, the bidirectional nature of the gut-microbiome-brain axis, and strategies for promoting microbiome health.

Mind and Body: The Vicious Cycle of Depression in Diabetes and Chronic Illness
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

One in 4 American adults experiences mental illness in a year, and having a serious mental illness increases the risk of having a chronic medical condition. Because emotional well‐being is associated with positive diabetes outcomes, it’s imperative that diabetes self‐management education and support address psychosocial issues. It’s also important to screen for depression. To that end, Mandel shared a time-saving 2-question screening tool. 

Cold Case Studies in Renal Medication Dosing: The Good, the Bad, and the Iatrogenic
Kim Zuber, PA-C, MS, American Academy of Nephrology PAs

Using actual cases of incorrect management, Zuber pointed out the most common medications taken by patients with chronic kidney disease (CKD) by disease stage and the most common errors made with those medications. She also reviewed the over-the-counter medications that can be dangerous for patients with CKD. When prescribing for patients with CKD, Zuber reminded, go low, go slow, and rerun lab tests often.

Morning session
Managing Thyroid Disease: Preparing for Battle
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

What lab tests should I order when patients present with signs and symptoms suggestive of thyroid disease, and how should I interpret results? In answering these questions, Kessler and Sadler described the inverse relationship of T3 and T4 to thyroid stimulating hormone (TSH), why free T4 is superior to total T4, and how to proceed when FT4 and TSH seem discordant. They also discussed additional tests that may be needed based on initial screening results, and factors (eg, agents such as biotin) that can affect the accuracy of thyroid test results.

Case Studies in Hypo and Hyperthyroidism for Clinical Consideration
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

Hypothyroidism and hyperthyroidism can be difficult to diagnose, especially in the elderly. In addition to pointing out the aspects of the physical exam and lab studies that can aid in diagnosing both conditions, Kessler and Sadler presented strategies to safely initiate, titrate, and monitor therapies; addressed controversies surrounding the management of subclinical forms; and identified triggers and early symptoms of acute thyrotoxicosis (thyroid storm) and myxedema coma.

Thyroid Concerns in Pregnancy
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

Kessler reviewed the physiologic changes of pregnancy that influence thyroid conditions and associated lab tests, the potential complications to mother and fetus of untreated thyroid disease, and strategies for managing hypo- and hyperthyroidism throughout pregnancy and lactation. She reminded that pregnant women with hypothyroidism generally require 30% to 50% more of their thyroid medications. And when treating hyperthyroidism, use the lowest dose of antithyroid drugs that keeps maternal free T4 and free T3 near the upper limit of the normal range.

Managing the “Hot” Mess of Thyroiditis
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

While thyroiditis is transient in most patients, it requires ongoing follow-up because of the increased risk of permanent hypothyroidism. Kessler and Sadler reviewed the work-up and differential for suspected acute and subacute thyroiditis and how to interpret laboratory and thyroid scan data. They also discussed postpartum thyroiditis (the signs of which are often misdiagnosed as anxiety and stress about motherhood) and silent thyroiditis, which is similar to postpartum thyroiditis but is unassociated with pregnancy.

Continue to: Expert Tips on Evaluating Thyroid Nodules

Expert Tips on Evaluating Thyroid Nodules
Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

In the United States, up to 68% of randomly selected adults have thyroid nodules. While most are benign, the number of those that are cancerous is increasing. To assist with determining which are malignant, Sadler provided insight on the clinical and ultrasound findings that suggest increased malignant potential. He also detailed an appropriate work-up, noting that ultrasound-guided fine needle aspiration remains the best means for evaluation.

Lifestyle Interventions: A New Narrative for Diabetes Management and Metabolic Health
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

Mandel discussed diabetes self-management education and support. She highlighted what works and what doesn’t among various diets, that sugar isn’t the only target, that dieting is only half the equation and must be coupled with physical activity (which is not the same as exercise), and that patient involvement in self-management correlates with greater long-term success.

Gut Grief: The Enteroendocrine Connection in Autoimmune Diseases
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

“We need to look to the gut as the biggest player in chronic health and autoimmune disease,” said Kessler. Kessler went on to explain how altered gut flora impacts immune, endocrine, cardiovascular, neuropsychologic, reproductive, and metabolic health. She identified 12 endocrine-disrupting chemicals associated with autoimmunity. And she reviewed the causes of microbiome dysbiosis, the bidirectional nature of the gut-microbiome-brain axis, and strategies for promoting microbiome health.

Mind and Body: The Vicious Cycle of Depression in Diabetes and Chronic Illness
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

One in 4 American adults experiences mental illness in a year, and having a serious mental illness increases the risk of having a chronic medical condition. Because emotional well‐being is associated with positive diabetes outcomes, it’s imperative that diabetes self‐management education and support address psychosocial issues. It’s also important to screen for depression. To that end, Mandel shared a time-saving 2-question screening tool. 

Cold Case Studies in Renal Medication Dosing: The Good, the Bad, and the Iatrogenic
Kim Zuber, PA-C, MS, American Academy of Nephrology PAs

Using actual cases of incorrect management, Zuber pointed out the most common medications taken by patients with chronic kidney disease (CKD) by disease stage and the most common errors made with those medications. She also reviewed the over-the-counter medications that can be dangerous for patients with CKD. When prescribing for patients with CKD, Zuber reminded, go low, go slow, and rerun lab tests often.

Morning session
Managing Thyroid Disease: Preparing for Battle
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

What lab tests should I order when patients present with signs and symptoms suggestive of thyroid disease, and how should I interpret results? In answering these questions, Kessler and Sadler described the inverse relationship of T3 and T4 to thyroid stimulating hormone (TSH), why free T4 is superior to total T4, and how to proceed when FT4 and TSH seem discordant. They also discussed additional tests that may be needed based on initial screening results, and factors (eg, agents such as biotin) that can affect the accuracy of thyroid test results.

Case Studies in Hypo and Hyperthyroidism for Clinical Consideration
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

Hypothyroidism and hyperthyroidism can be difficult to diagnose, especially in the elderly. In addition to pointing out the aspects of the physical exam and lab studies that can aid in diagnosing both conditions, Kessler and Sadler presented strategies to safely initiate, titrate, and monitor therapies; addressed controversies surrounding the management of subclinical forms; and identified triggers and early symptoms of acute thyrotoxicosis (thyroid storm) and myxedema coma.

Thyroid Concerns in Pregnancy
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

Kessler reviewed the physiologic changes of pregnancy that influence thyroid conditions and associated lab tests, the potential complications to mother and fetus of untreated thyroid disease, and strategies for managing hypo- and hyperthyroidism throughout pregnancy and lactation. She reminded that pregnant women with hypothyroidism generally require 30% to 50% more of their thyroid medications. And when treating hyperthyroidism, use the lowest dose of antithyroid drugs that keeps maternal free T4 and free T3 near the upper limit of the normal range.

Managing the “Hot” Mess of Thyroiditis
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

While thyroiditis is transient in most patients, it requires ongoing follow-up because of the increased risk of permanent hypothyroidism. Kessler and Sadler reviewed the work-up and differential for suspected acute and subacute thyroiditis and how to interpret laboratory and thyroid scan data. They also discussed postpartum thyroiditis (the signs of which are often misdiagnosed as anxiety and stress about motherhood) and silent thyroiditis, which is similar to postpartum thyroiditis but is unassociated with pregnancy.

Continue to: Expert Tips on Evaluating Thyroid Nodules

Expert Tips on Evaluating Thyroid Nodules
Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

In the United States, up to 68% of randomly selected adults have thyroid nodules. While most are benign, the number of those that are cancerous is increasing. To assist with determining which are malignant, Sadler provided insight on the clinical and ultrasound findings that suggest increased malignant potential. He also detailed an appropriate work-up, noting that ultrasound-guided fine needle aspiration remains the best means for evaluation.

Lifestyle Interventions: A New Narrative for Diabetes Management and Metabolic Health
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

Mandel discussed diabetes self-management education and support. She highlighted what works and what doesn’t among various diets, that sugar isn’t the only target, that dieting is only half the equation and must be coupled with physical activity (which is not the same as exercise), and that patient involvement in self-management correlates with greater long-term success.

Gut Grief: The Enteroendocrine Connection in Autoimmune Diseases
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

“We need to look to the gut as the biggest player in chronic health and autoimmune disease,” said Kessler. Kessler went on to explain how altered gut flora impacts immune, endocrine, cardiovascular, neuropsychologic, reproductive, and metabolic health. She identified 12 endocrine-disrupting chemicals associated with autoimmunity. And she reviewed the causes of microbiome dysbiosis, the bidirectional nature of the gut-microbiome-brain axis, and strategies for promoting microbiome health.

Mind and Body: The Vicious Cycle of Depression in Diabetes and Chronic Illness
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

One in 4 American adults experiences mental illness in a year, and having a serious mental illness increases the risk of having a chronic medical condition. Because emotional well‐being is associated with positive diabetes outcomes, it’s imperative that diabetes self‐management education and support address psychosocial issues. It’s also important to screen for depression. To that end, Mandel shared a time-saving 2-question screening tool. 

Cold Case Studies in Renal Medication Dosing: The Good, the Bad, and the Iatrogenic
Kim Zuber, PA-C, MS, American Academy of Nephrology PAs

Using actual cases of incorrect management, Zuber pointed out the most common medications taken by patients with chronic kidney disease (CKD) by disease stage and the most common errors made with those medications. She also reviewed the over-the-counter medications that can be dangerous for patients with CKD. When prescribing for patients with CKD, Zuber reminded, go low, go slow, and rerun lab tests often.