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PCR assay quicker but less sensitive at penicilliosis diagnosis
A real-time PCR assay was effective at rapidly diagnosing penicilliosis caused by Talaromyces marneffei, according to Thuy Le, MD, and her associates.
Sensitivity of the assay was better when samples were collected from plasma prior to antifungal therapy. In a group of 27 HIV-infected patients from whom samples were collected prior to antifungal therapy, the assay detected the T. marneffei MP1 gene in 19 samples, while in a group of 23 HIV-infected patients from whom samples were collected within 48 hours of antifungal therapy, the assay successfully detected the MP1 gene in 12 samples.
In an additional sample of 20 HIV-infected patients without penicilliosis, the assay found no signals of the T. marneffei MP1 gene in any of the tested plasma samples, giving a specificity of 100%. All testing was completed within 5-6 hours, significantly less than the 5 days needed for Bactec system testing.
“This real-time PCR assay should not replace the need for conventional microbiology methods in diagnosing penicilliosis. However, in conjunction with culturing, it can be used as a rapid rule-in test that can make a significant difference in patient management by allowing antifungal therapy to begin sooner, particularly in patients without skin lesions, and has the potential to improve the outcomes of T. marneffei–infected patients,” the investigators concluded.
Find the full study in Mycoses (doi: 10.1111/myc.12530).
A real-time PCR assay was effective at rapidly diagnosing penicilliosis caused by Talaromyces marneffei, according to Thuy Le, MD, and her associates.
Sensitivity of the assay was better when samples were collected from plasma prior to antifungal therapy. In a group of 27 HIV-infected patients from whom samples were collected prior to antifungal therapy, the assay detected the T. marneffei MP1 gene in 19 samples, while in a group of 23 HIV-infected patients from whom samples were collected within 48 hours of antifungal therapy, the assay successfully detected the MP1 gene in 12 samples.
In an additional sample of 20 HIV-infected patients without penicilliosis, the assay found no signals of the T. marneffei MP1 gene in any of the tested plasma samples, giving a specificity of 100%. All testing was completed within 5-6 hours, significantly less than the 5 days needed for Bactec system testing.
“This real-time PCR assay should not replace the need for conventional microbiology methods in diagnosing penicilliosis. However, in conjunction with culturing, it can be used as a rapid rule-in test that can make a significant difference in patient management by allowing antifungal therapy to begin sooner, particularly in patients without skin lesions, and has the potential to improve the outcomes of T. marneffei–infected patients,” the investigators concluded.
Find the full study in Mycoses (doi: 10.1111/myc.12530).
A real-time PCR assay was effective at rapidly diagnosing penicilliosis caused by Talaromyces marneffei, according to Thuy Le, MD, and her associates.
Sensitivity of the assay was better when samples were collected from plasma prior to antifungal therapy. In a group of 27 HIV-infected patients from whom samples were collected prior to antifungal therapy, the assay detected the T. marneffei MP1 gene in 19 samples, while in a group of 23 HIV-infected patients from whom samples were collected within 48 hours of antifungal therapy, the assay successfully detected the MP1 gene in 12 samples.
In an additional sample of 20 HIV-infected patients without penicilliosis, the assay found no signals of the T. marneffei MP1 gene in any of the tested plasma samples, giving a specificity of 100%. All testing was completed within 5-6 hours, significantly less than the 5 days needed for Bactec system testing.
“This real-time PCR assay should not replace the need for conventional microbiology methods in diagnosing penicilliosis. However, in conjunction with culturing, it can be used as a rapid rule-in test that can make a significant difference in patient management by allowing antifungal therapy to begin sooner, particularly in patients without skin lesions, and has the potential to improve the outcomes of T. marneffei–infected patients,” the investigators concluded.
Find the full study in Mycoses (doi: 10.1111/myc.12530).
FROM MYCOSES
The role of lymphadenectomy in endometrial cancer, Part 1
Endometrial cancer is the most common gynecologic malignancy in the United States. Fortunately, most endometrial cancers present at an early stage with excellent overall survival – approximately 85% – in clinical stage I disease. Since 1988, the International Federation of Gynecology and Obstetrics (FIGO) staging of endometrial cancer has required surgical staging reflecting increasing data on the prognostic significance of lymph node metastasis and the treatment implications for node positive cancers.
Indeed, lymph nodes represent the most common location for extrauterine spread in endometrial cancer. The lymphatic drainage from the uterus is to both the pelvic and the para-aortic lymph nodes. Lymphatic channels from the uterus can drain directly from the fundus via the infundibulopelvic ligament to the aortic lymph node chain, thereby bypassing the pelvic lymph nodes. As a result, there is a 2%-3% risk of isolated aortic metastasis with negative pelvic lymph nodes.
The extent of lymph node evaluation required for staging is debatable. The National Comprehensive Cancer Network (NCCN) guidelines recommend complete hysterectomy with bilateral salpingo-oophorectomy and additional procedures based on preoperative and intraoperative findings. During surgery, the surgeon should evaluate all peritoneal surfaces and the retroperitoneal lymphatic chains for abnormalities. All suspicious lymph nodes should be removed, but the extent of lymphadenectomy should be based on the NCCN guidelines.1 The NCCN offers the option for use of sentinel lymph node evaluation with adherence to specific staging algorithms for this technology.
Proponents of lymphadenectomy cite the need for accurate staging to guide adjuvant therapies, to provide prognostic information, and to eradicate metastatic lymph nodes with possible therapeutic benefit. However, criticisms of lymphadenectomy include a lack of randomized studies demonstrating a therapeutic benefit and the morbidity of lymphedema with its corresponding quality of life and cost implications. As a result, practices regarding lymph node evaluation vary widely.
There is conflicting data on whether there is a therapeutic benefit to performing lymphadenectomy. Retrospective studies have shown a benefit, but this was not seen in two prospective trials. There appears to be clear benefit for debulking of clinically enlarged nodal metastasis,2,3 and likely benefit to resection of microscopic metastasis, particularly with combined pelvic and aortic lymphadenectomy in high-risk endometrial cancers.4,5,6,7,8
The ASTEC trial by Kitchener et al and an Italian collaborative trial by Benedetti et al, however, both evaluated the role of lymph node dissection in predominantly low-risk endometrial cancer and found no benefit.9,10 Both studies documented no difference in overall survival, but increased morbidity with lymphadenectomy. No prospective trials have evaluated the role of lymphadenectomy in high-risk endometrial cancers.
Universal use of complete lymphadenectomy in all patients with endometrial cancer would subject a large percent of low risk patients to undo surgical risk. The two most commonly utilized strategies are risk factor based lymphadenectomy and sentinel lymph node evaluation.
Tumors are considered low risk if they are less than 2cm in size, grade 1 or 2, and superficially invasive (less than 50% myometrial invasion).11 The risk of lymph node metastasis in these patients was exceedingly low with no lymph node metastasis detect in more than 400 women who prospectively underwent this evaluation, thus lymphadenectomy can be safely avoided. Utilizing risk factor based lymphadenectomy does require the availability of reliable frozen section pathology evaluation, which may be a limitation for some institutions.
A key argument against routine use of systematic lymphadenectomy is the concern for postoperative complications and lymphedema. The estimated incidence of lymphedema following lymphadenectomy is 20%-30%.12 However, there are challenges in studying lymphedema that likely limit our understanding of the true incidence. The ASTEC trial and Italian cooperative trial have demonstrated that there is an eight-fold increased risk of lymphedema in women who undergo lymphadenectomy, compared with those who do not.13 The development of lymphedema requires ongoing treatment with associated costs of care. Thus, the selective lymphadenectomy or sentinel nodes have the ability to reduce healthcare costs.14 Sentinel lymph nodes will be covered in Part Two of this article.
References
1. J Natl Compr Canc Netw. 2014 Feb;12(2):248-80.
2. Gynecol Oncol. 2005 Dec;99(3):689-95.
3. Int J Gynecol Cancer. 2003 Sep-Oct;13(5):664-72.
4. Gynecol Oncol. 1995 Jan;56(1):29-33.
5. J Clin Oncol. 2005 Jun 1;23(16):3668-75.
6. Lancet. 2010 Apr 3;375(9721):1165-72.
7. Gynecol Oncol. 1998 Dec;71(3):340-3.
8. Cancer. 2006 Oct 15;107(8):1823-30.
9. Lancet. 2009 Jan 10;373(9658):125-36.
10. J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16.
11. Gynecol Oncol. 2008 Apr;109(1):11-8.
12. Obstet Gynecol. 2014 Aug;124(2 Pt 1):307-15.
13. Cochrane Database Syst Rev. 2015 Sep 21;(9):CD007585.
14. Gynecol Oncol. 2014 Dec;135(3):518-24.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark is a fellow in the division of gynecologic oncology, department of obstetrics and gynecology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].
Endometrial cancer is the most common gynecologic malignancy in the United States. Fortunately, most endometrial cancers present at an early stage with excellent overall survival – approximately 85% – in clinical stage I disease. Since 1988, the International Federation of Gynecology and Obstetrics (FIGO) staging of endometrial cancer has required surgical staging reflecting increasing data on the prognostic significance of lymph node metastasis and the treatment implications for node positive cancers.
Indeed, lymph nodes represent the most common location for extrauterine spread in endometrial cancer. The lymphatic drainage from the uterus is to both the pelvic and the para-aortic lymph nodes. Lymphatic channels from the uterus can drain directly from the fundus via the infundibulopelvic ligament to the aortic lymph node chain, thereby bypassing the pelvic lymph nodes. As a result, there is a 2%-3% risk of isolated aortic metastasis with negative pelvic lymph nodes.
The extent of lymph node evaluation required for staging is debatable. The National Comprehensive Cancer Network (NCCN) guidelines recommend complete hysterectomy with bilateral salpingo-oophorectomy and additional procedures based on preoperative and intraoperative findings. During surgery, the surgeon should evaluate all peritoneal surfaces and the retroperitoneal lymphatic chains for abnormalities. All suspicious lymph nodes should be removed, but the extent of lymphadenectomy should be based on the NCCN guidelines.1 The NCCN offers the option for use of sentinel lymph node evaluation with adherence to specific staging algorithms for this technology.
Proponents of lymphadenectomy cite the need for accurate staging to guide adjuvant therapies, to provide prognostic information, and to eradicate metastatic lymph nodes with possible therapeutic benefit. However, criticisms of lymphadenectomy include a lack of randomized studies demonstrating a therapeutic benefit and the morbidity of lymphedema with its corresponding quality of life and cost implications. As a result, practices regarding lymph node evaluation vary widely.
There is conflicting data on whether there is a therapeutic benefit to performing lymphadenectomy. Retrospective studies have shown a benefit, but this was not seen in two prospective trials. There appears to be clear benefit for debulking of clinically enlarged nodal metastasis,2,3 and likely benefit to resection of microscopic metastasis, particularly with combined pelvic and aortic lymphadenectomy in high-risk endometrial cancers.4,5,6,7,8
The ASTEC trial by Kitchener et al and an Italian collaborative trial by Benedetti et al, however, both evaluated the role of lymph node dissection in predominantly low-risk endometrial cancer and found no benefit.9,10 Both studies documented no difference in overall survival, but increased morbidity with lymphadenectomy. No prospective trials have evaluated the role of lymphadenectomy in high-risk endometrial cancers.
Universal use of complete lymphadenectomy in all patients with endometrial cancer would subject a large percent of low risk patients to undo surgical risk. The two most commonly utilized strategies are risk factor based lymphadenectomy and sentinel lymph node evaluation.
Tumors are considered low risk if they are less than 2cm in size, grade 1 or 2, and superficially invasive (less than 50% myometrial invasion).11 The risk of lymph node metastasis in these patients was exceedingly low with no lymph node metastasis detect in more than 400 women who prospectively underwent this evaluation, thus lymphadenectomy can be safely avoided. Utilizing risk factor based lymphadenectomy does require the availability of reliable frozen section pathology evaluation, which may be a limitation for some institutions.
A key argument against routine use of systematic lymphadenectomy is the concern for postoperative complications and lymphedema. The estimated incidence of lymphedema following lymphadenectomy is 20%-30%.12 However, there are challenges in studying lymphedema that likely limit our understanding of the true incidence. The ASTEC trial and Italian cooperative trial have demonstrated that there is an eight-fold increased risk of lymphedema in women who undergo lymphadenectomy, compared with those who do not.13 The development of lymphedema requires ongoing treatment with associated costs of care. Thus, the selective lymphadenectomy or sentinel nodes have the ability to reduce healthcare costs.14 Sentinel lymph nodes will be covered in Part Two of this article.
References
1. J Natl Compr Canc Netw. 2014 Feb;12(2):248-80.
2. Gynecol Oncol. 2005 Dec;99(3):689-95.
3. Int J Gynecol Cancer. 2003 Sep-Oct;13(5):664-72.
4. Gynecol Oncol. 1995 Jan;56(1):29-33.
5. J Clin Oncol. 2005 Jun 1;23(16):3668-75.
6. Lancet. 2010 Apr 3;375(9721):1165-72.
7. Gynecol Oncol. 1998 Dec;71(3):340-3.
8. Cancer. 2006 Oct 15;107(8):1823-30.
9. Lancet. 2009 Jan 10;373(9658):125-36.
10. J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16.
11. Gynecol Oncol. 2008 Apr;109(1):11-8.
12. Obstet Gynecol. 2014 Aug;124(2 Pt 1):307-15.
13. Cochrane Database Syst Rev. 2015 Sep 21;(9):CD007585.
14. Gynecol Oncol. 2014 Dec;135(3):518-24.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark is a fellow in the division of gynecologic oncology, department of obstetrics and gynecology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].
Endometrial cancer is the most common gynecologic malignancy in the United States. Fortunately, most endometrial cancers present at an early stage with excellent overall survival – approximately 85% – in clinical stage I disease. Since 1988, the International Federation of Gynecology and Obstetrics (FIGO) staging of endometrial cancer has required surgical staging reflecting increasing data on the prognostic significance of lymph node metastasis and the treatment implications for node positive cancers.
Indeed, lymph nodes represent the most common location for extrauterine spread in endometrial cancer. The lymphatic drainage from the uterus is to both the pelvic and the para-aortic lymph nodes. Lymphatic channels from the uterus can drain directly from the fundus via the infundibulopelvic ligament to the aortic lymph node chain, thereby bypassing the pelvic lymph nodes. As a result, there is a 2%-3% risk of isolated aortic metastasis with negative pelvic lymph nodes.
The extent of lymph node evaluation required for staging is debatable. The National Comprehensive Cancer Network (NCCN) guidelines recommend complete hysterectomy with bilateral salpingo-oophorectomy and additional procedures based on preoperative and intraoperative findings. During surgery, the surgeon should evaluate all peritoneal surfaces and the retroperitoneal lymphatic chains for abnormalities. All suspicious lymph nodes should be removed, but the extent of lymphadenectomy should be based on the NCCN guidelines.1 The NCCN offers the option for use of sentinel lymph node evaluation with adherence to specific staging algorithms for this technology.
Proponents of lymphadenectomy cite the need for accurate staging to guide adjuvant therapies, to provide prognostic information, and to eradicate metastatic lymph nodes with possible therapeutic benefit. However, criticisms of lymphadenectomy include a lack of randomized studies demonstrating a therapeutic benefit and the morbidity of lymphedema with its corresponding quality of life and cost implications. As a result, practices regarding lymph node evaluation vary widely.
There is conflicting data on whether there is a therapeutic benefit to performing lymphadenectomy. Retrospective studies have shown a benefit, but this was not seen in two prospective trials. There appears to be clear benefit for debulking of clinically enlarged nodal metastasis,2,3 and likely benefit to resection of microscopic metastasis, particularly with combined pelvic and aortic lymphadenectomy in high-risk endometrial cancers.4,5,6,7,8
The ASTEC trial by Kitchener et al and an Italian collaborative trial by Benedetti et al, however, both evaluated the role of lymph node dissection in predominantly low-risk endometrial cancer and found no benefit.9,10 Both studies documented no difference in overall survival, but increased morbidity with lymphadenectomy. No prospective trials have evaluated the role of lymphadenectomy in high-risk endometrial cancers.
Universal use of complete lymphadenectomy in all patients with endometrial cancer would subject a large percent of low risk patients to undo surgical risk. The two most commonly utilized strategies are risk factor based lymphadenectomy and sentinel lymph node evaluation.
Tumors are considered low risk if they are less than 2cm in size, grade 1 or 2, and superficially invasive (less than 50% myometrial invasion).11 The risk of lymph node metastasis in these patients was exceedingly low with no lymph node metastasis detect in more than 400 women who prospectively underwent this evaluation, thus lymphadenectomy can be safely avoided. Utilizing risk factor based lymphadenectomy does require the availability of reliable frozen section pathology evaluation, which may be a limitation for some institutions.
A key argument against routine use of systematic lymphadenectomy is the concern for postoperative complications and lymphedema. The estimated incidence of lymphedema following lymphadenectomy is 20%-30%.12 However, there are challenges in studying lymphedema that likely limit our understanding of the true incidence. The ASTEC trial and Italian cooperative trial have demonstrated that there is an eight-fold increased risk of lymphedema in women who undergo lymphadenectomy, compared with those who do not.13 The development of lymphedema requires ongoing treatment with associated costs of care. Thus, the selective lymphadenectomy or sentinel nodes have the ability to reduce healthcare costs.14 Sentinel lymph nodes will be covered in Part Two of this article.
References
1. J Natl Compr Canc Netw. 2014 Feb;12(2):248-80.
2. Gynecol Oncol. 2005 Dec;99(3):689-95.
3. Int J Gynecol Cancer. 2003 Sep-Oct;13(5):664-72.
4. Gynecol Oncol. 1995 Jan;56(1):29-33.
5. J Clin Oncol. 2005 Jun 1;23(16):3668-75.
6. Lancet. 2010 Apr 3;375(9721):1165-72.
7. Gynecol Oncol. 1998 Dec;71(3):340-3.
8. Cancer. 2006 Oct 15;107(8):1823-30.
9. Lancet. 2009 Jan 10;373(9658):125-36.
10. J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16.
11. Gynecol Oncol. 2008 Apr;109(1):11-8.
12. Obstet Gynecol. 2014 Aug;124(2 Pt 1):307-15.
13. Cochrane Database Syst Rev. 2015 Sep 21;(9):CD007585.
14. Gynecol Oncol. 2014 Dec;135(3):518-24.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark is a fellow in the division of gynecologic oncology, department of obstetrics and gynecology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].
FBI questions legality of telemedicine compact laws
The FBI is raising concerns that language in the Interstate Medical Licensure Compact violates federal regulations over criminal background checks. The government pushback could mean implementation delays of telemedicine legislation that 17 states have enacted.
In a letter to the Minnesota Bureau of Criminal Apprehension, an FBI attorney wrote that the state’s compact law does not meet federal rules that allow the sharing of information with states for purposes of criminal background checks. In addition, no federal statutory authority exists for the FBI to share criminal files with a “private” entity such as the interstate commission, wrote Christopher B. Chaney, an attorney in the FBI Office of the General Counsel in Clarksburg, W.Va. The FBI sent a letter expressing the same concerns to the Montana Department of Justice regarding Montana’s compact law.
The Minnesota Board of Medical Practice has requested that the FBI reverse its findings, writing in an Aug. 3 letter that the agency does not appear to fully understand how the compact works. The board is scheduled to begin issuing licenses via the compact in January 2017, said Ruth Martinez, the board’s executive director.
“We believe it’s an erroneous conclusion that they’ve drawn,” Ms. Martinez said in an interview. “We are very actively engaged in rule-writing and in preparing technology and so forth to be ready to issue licenses, and we feel very confident that this determination will be overturned.”
The Montana Board of Medical Examiners meanwhile is aware of the FBI’s letter and is closely monitoring the situation in Minnesota before taking action, said Ian Marquand, executive officer for the Montana Board of Medical Examiners.
“We are still digesting this and are anxious to see what happens with the Minnesota situation,” Mr. Marquand said in an interview. “That may provide the road map.”
The Interstate Medical Licensure Compact is aimed at making it easier for telemedicine physicians to gain licenses in multiple states. Under the model legislation, developed by the Federation of State Medical Boards (FSMB), physicians designate a member state as the state of principal licensure and select the other states in which they wish to be licensed. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.
In July 2015, the U.S. Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.
There is nothing unique about Minnesota’s compact law, Ms. Martinez said. The statute is based on the same model legislation that passed in 16 other states. She believes that Minnesota’s law is merely one of the first to be reviewed by the FBI. Both Minnesota and Montana officials had requested that their respective state departments of justice determine if the compact laws met public law standards pertaining to criminal history records.
Ms. Martinez said that she hopes that the board’s letter to the FBI will help explain how the compact process works and prevent further federal rejections in other jurisdictions. She notes for example that the FBI incorrectly characterizes the interstate commission as a “private” entity in its letter, when the commission is a corporate body and a joint agency of the member states. The FBI also misunderstands how the commission interacts with the individual state licensing boards and the process of licensure, according to the board’s reply letter. It is not the commission that will be using FBI data, but the member states that will be utilizing the information in the course of verification, writes Rick Masters, special counsel to the National Center for Interstate Compacts.
The Federation of State Medical Boards is closely watching the matter and supports the Minnesota Board of Medical Practice, said Lisa A. Robin FSMB’s chief advocacy officer.
“The FSMB, along with the Council of State Governments (CSG), agrees with and supports the Minnesota board’s position in this matter,” Ms. Robin said in an emailed statement. “The compact’s statutory language does not alter state-based responsibility for the administration of criminal background checks, nor does it seek to extend this responsibility beyond individual state medical boards.”
At press time, the FBI’s Mr. Chaney had not responded to a message seeking comment.
On Twitter @legal_med
The FBI is raising concerns that language in the Interstate Medical Licensure Compact violates federal regulations over criminal background checks. The government pushback could mean implementation delays of telemedicine legislation that 17 states have enacted.
In a letter to the Minnesota Bureau of Criminal Apprehension, an FBI attorney wrote that the state’s compact law does not meet federal rules that allow the sharing of information with states for purposes of criminal background checks. In addition, no federal statutory authority exists for the FBI to share criminal files with a “private” entity such as the interstate commission, wrote Christopher B. Chaney, an attorney in the FBI Office of the General Counsel in Clarksburg, W.Va. The FBI sent a letter expressing the same concerns to the Montana Department of Justice regarding Montana’s compact law.
The Minnesota Board of Medical Practice has requested that the FBI reverse its findings, writing in an Aug. 3 letter that the agency does not appear to fully understand how the compact works. The board is scheduled to begin issuing licenses via the compact in January 2017, said Ruth Martinez, the board’s executive director.
“We believe it’s an erroneous conclusion that they’ve drawn,” Ms. Martinez said in an interview. “We are very actively engaged in rule-writing and in preparing technology and so forth to be ready to issue licenses, and we feel very confident that this determination will be overturned.”
The Montana Board of Medical Examiners meanwhile is aware of the FBI’s letter and is closely monitoring the situation in Minnesota before taking action, said Ian Marquand, executive officer for the Montana Board of Medical Examiners.
“We are still digesting this and are anxious to see what happens with the Minnesota situation,” Mr. Marquand said in an interview. “That may provide the road map.”
The Interstate Medical Licensure Compact is aimed at making it easier for telemedicine physicians to gain licenses in multiple states. Under the model legislation, developed by the Federation of State Medical Boards (FSMB), physicians designate a member state as the state of principal licensure and select the other states in which they wish to be licensed. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.
In July 2015, the U.S. Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.
There is nothing unique about Minnesota’s compact law, Ms. Martinez said. The statute is based on the same model legislation that passed in 16 other states. She believes that Minnesota’s law is merely one of the first to be reviewed by the FBI. Both Minnesota and Montana officials had requested that their respective state departments of justice determine if the compact laws met public law standards pertaining to criminal history records.
Ms. Martinez said that she hopes that the board’s letter to the FBI will help explain how the compact process works and prevent further federal rejections in other jurisdictions. She notes for example that the FBI incorrectly characterizes the interstate commission as a “private” entity in its letter, when the commission is a corporate body and a joint agency of the member states. The FBI also misunderstands how the commission interacts with the individual state licensing boards and the process of licensure, according to the board’s reply letter. It is not the commission that will be using FBI data, but the member states that will be utilizing the information in the course of verification, writes Rick Masters, special counsel to the National Center for Interstate Compacts.
The Federation of State Medical Boards is closely watching the matter and supports the Minnesota Board of Medical Practice, said Lisa A. Robin FSMB’s chief advocacy officer.
“The FSMB, along with the Council of State Governments (CSG), agrees with and supports the Minnesota board’s position in this matter,” Ms. Robin said in an emailed statement. “The compact’s statutory language does not alter state-based responsibility for the administration of criminal background checks, nor does it seek to extend this responsibility beyond individual state medical boards.”
At press time, the FBI’s Mr. Chaney had not responded to a message seeking comment.
On Twitter @legal_med
The FBI is raising concerns that language in the Interstate Medical Licensure Compact violates federal regulations over criminal background checks. The government pushback could mean implementation delays of telemedicine legislation that 17 states have enacted.
In a letter to the Minnesota Bureau of Criminal Apprehension, an FBI attorney wrote that the state’s compact law does not meet federal rules that allow the sharing of information with states for purposes of criminal background checks. In addition, no federal statutory authority exists for the FBI to share criminal files with a “private” entity such as the interstate commission, wrote Christopher B. Chaney, an attorney in the FBI Office of the General Counsel in Clarksburg, W.Va. The FBI sent a letter expressing the same concerns to the Montana Department of Justice regarding Montana’s compact law.
The Minnesota Board of Medical Practice has requested that the FBI reverse its findings, writing in an Aug. 3 letter that the agency does not appear to fully understand how the compact works. The board is scheduled to begin issuing licenses via the compact in January 2017, said Ruth Martinez, the board’s executive director.
“We believe it’s an erroneous conclusion that they’ve drawn,” Ms. Martinez said in an interview. “We are very actively engaged in rule-writing and in preparing technology and so forth to be ready to issue licenses, and we feel very confident that this determination will be overturned.”
The Montana Board of Medical Examiners meanwhile is aware of the FBI’s letter and is closely monitoring the situation in Minnesota before taking action, said Ian Marquand, executive officer for the Montana Board of Medical Examiners.
“We are still digesting this and are anxious to see what happens with the Minnesota situation,” Mr. Marquand said in an interview. “That may provide the road map.”
The Interstate Medical Licensure Compact is aimed at making it easier for telemedicine physicians to gain licenses in multiple states. Under the model legislation, developed by the Federation of State Medical Boards (FSMB), physicians designate a member state as the state of principal licensure and select the other states in which they wish to be licensed. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.
In July 2015, the U.S. Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.
There is nothing unique about Minnesota’s compact law, Ms. Martinez said. The statute is based on the same model legislation that passed in 16 other states. She believes that Minnesota’s law is merely one of the first to be reviewed by the FBI. Both Minnesota and Montana officials had requested that their respective state departments of justice determine if the compact laws met public law standards pertaining to criminal history records.
Ms. Martinez said that she hopes that the board’s letter to the FBI will help explain how the compact process works and prevent further federal rejections in other jurisdictions. She notes for example that the FBI incorrectly characterizes the interstate commission as a “private” entity in its letter, when the commission is a corporate body and a joint agency of the member states. The FBI also misunderstands how the commission interacts with the individual state licensing boards and the process of licensure, according to the board’s reply letter. It is not the commission that will be using FBI data, but the member states that will be utilizing the information in the course of verification, writes Rick Masters, special counsel to the National Center for Interstate Compacts.
The Federation of State Medical Boards is closely watching the matter and supports the Minnesota Board of Medical Practice, said Lisa A. Robin FSMB’s chief advocacy officer.
“The FSMB, along with the Council of State Governments (CSG), agrees with and supports the Minnesota board’s position in this matter,” Ms. Robin said in an emailed statement. “The compact’s statutory language does not alter state-based responsibility for the administration of criminal background checks, nor does it seek to extend this responsibility beyond individual state medical boards.”
At press time, the FBI’s Mr. Chaney had not responded to a message seeking comment.
On Twitter @legal_med
You oughta be in pictures - And maybe you are
The 2016 Vascular Annual Meeting photos are now available in our Flickr albums.
Since there were thousands and thousands of photos (we couldn’t even count them) chances are that if you attended VAM you are in at least one of them. If you won an award, your acceptance photo should be in the collection. All photos are large and high res, perfect for enlarging, printing and framing.
The photos are arranged by day, and within each day, by session.
Browse the photos here on Flickr, relive the memories, and be sure to type your name in the caption when you find your charming face.
The 2016 Vascular Annual Meeting photos are now available in our Flickr albums.
Since there were thousands and thousands of photos (we couldn’t even count them) chances are that if you attended VAM you are in at least one of them. If you won an award, your acceptance photo should be in the collection. All photos are large and high res, perfect for enlarging, printing and framing.
The photos are arranged by day, and within each day, by session.
Browse the photos here on Flickr, relive the memories, and be sure to type your name in the caption when you find your charming face.
The 2016 Vascular Annual Meeting photos are now available in our Flickr albums.
Since there were thousands and thousands of photos (we couldn’t even count them) chances are that if you attended VAM you are in at least one of them. If you won an award, your acceptance photo should be in the collection. All photos are large and high res, perfect for enlarging, printing and framing.
The photos are arranged by day, and within each day, by session.
Browse the photos here on Flickr, relive the memories, and be sure to type your name in the caption when you find your charming face.
SVS Adds Community Practice Spot to Executive Committee
The SVS Executive Committee, at its July retreat, approved the appointment of the chair of the SVS Community Practice Committee (currently Dr. Richard Lynn) as an interim ex officio member of the SVS Executive Committee. As part of the same change, Dr. Lynn also has been appointed to the Nominating Committee.
The SVS Executive Committee, at its July retreat, approved the appointment of the chair of the SVS Community Practice Committee (currently Dr. Richard Lynn) as an interim ex officio member of the SVS Executive Committee. As part of the same change, Dr. Lynn also has been appointed to the Nominating Committee.
The SVS Executive Committee, at its July retreat, approved the appointment of the chair of the SVS Community Practice Committee (currently Dr. Richard Lynn) as an interim ex officio member of the SVS Executive Committee. As part of the same change, Dr. Lynn also has been appointed to the Nominating Committee.
New guidelines to focus on mixed features in depression, bipolar
WASHINGTON – A sea change is underway in how major depressive and bipolar disorders are diagnosed and treated.
Historically, the absence of an accurate, comprehensive nosology of depression has led to much suffering and confusion. People with bipolar disorder in particular are either not diagnosed early enough or are not diagnosed with the correct “flavor” of depression, according to Roger S. McIntyre, MD, author of updated treatment guidelines for bipolar depression, and the first-ever treatment guidelines for mixed features in major depressive disorder. “Twenty years ago, we would have described bipolar as episodic breakthroughs of mania and depression, with well intervals in between,” Dr. McIntyre said at Summit in Neurology & Psychiatry. “But now, we’ve really changed our fundamental thinking about bipolar disorder.”
Although reasons for the evolution in thinking are many, one of the strongest currents of change flows from the 2013 publication of the DSM-5, according to Dr. McIntyre, professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at University Health Network in Toronto.
“The DSM-5’s authors took a neo-Kraepelinian view that mood disorders are dimensional,” Dr. McIntyre said in an interview. As a result, there’s been a reversal of what he called the “social construct imposed upon the cosmos of mood disorders by the DSM-III that divided that world into either depression or bipolar disorder.”
This return to thinking of mood disorders as existing on a continuum, as psychiatrist Emil Kraepelin, MD, theorized around the turn of the last century, pivots on the decision to do away with mixed states and to instead add the mixed features specifier.
“The move to mixed features is the necessary bridge between bipolar disease and major depressive disorder,” Dr. McIntyre said in the interview.
Therefore, for a period of time between the 1980 publication of the DSM-III and the DSM-5, “real-world” presentations of subsyndromal, opposite-pole symptoms that are common in major depressive disorder (MDD) and in bipolar disorder were not accounted for.
In practical terms, the addition of mixed features means that a patient with mania who presents with subsyndromal depressive symptoms would be seen, for example, to have mania with mixed features. A patient with a depressive episode who presents with subsyndromal hypomanic symptoms would be seen to have depression with mixed features. Therefore, depression with mixed features can be present not only in MDD, but in both bipolar I and II.
New treatment algorithms
This dimensional approach of assessing mixed features along a continuum could lead to better and earlier diagnosis of bipolar depression and more targeted therapies, according to Dr. McIntyre. What he thinks it won’t do is lead to an overzealousness in the overdiagnosis of bipolar depression.
“That is false. We wouldn’t say we’re not going to diagnose bowel cancer because we hear it’s overdiagnosed. But to get the diagnoses right, what we need is fidelity to diagnostic criteria.”
Enter the state of Florida. As part of its best practices for psychotherapeutic use in adults, Florida is the first state to have published evidence-based guidelines for depression with mixed features. Dr. McIntyre is one of the guidelines’ coauthors.
Antidepressants bad, olanzapine worse
Some changes to treatment algorithms might come as a surprise. Despite being among the most commonly prescribed treatments for bipolar disorder, monotherapy with antidepressants is not approved in the guidelines. “Period,” said Dr. McIntyre. “Many patients do well on antidepressants, but the most common outcome is inefficacy.”
It might be better to combine an antidepressant with an atypical antipsychotic, or a mood stabilizer to avoid treatment-emergent mania, or, more commonly, destabilization in patients who are susceptible to subsyndromal mania, he said.
In addition to mitigating symptoms of a depressive episode, atypicals can help suppress hypomanic symptoms. Dr. McIntyre said this is critical to remember, because patients with these combinations of symptoms are “the very persons who shouldn’t get an antidepressant but are also the ones most likely to be prescribed them,” according to old ways of thinking.
As for maintenance in bipolar disorder, Dr. McIntyre believes the axiom, “What gets you well keeps you well,” is a good rule of thumb when going through the algorithm. “It’s not always true, but it’s almost always true.”
Management of MDD with mixed features includes the introduction of atypicals or mood stabilizers such as lithium or lamotrigine in patients with any prior history of hypomania or mania, something Dr. McIntyre said already is beginning to happen in practice.
Olanzapine monotherapy as a first-line treatment of bipolar disorder initially was “demoted” by Dr. McIntyre and his coauthors in Florida’s bipolar treatment guidelines. In the updated version, the atypical remains a second-line therapy behind lurasidone as the recommended first-line therapy because of olanzapine’s tendency to interfere with metabolic processes. Quetiapine also is a first-line therapy, but with the qualification that it, too, could interfere with metabolic processes. Combination therapy with olanzapine plus fluoxetine is second-line.
“Lurasidone does not have the metabolic changes of quetiapine. It doesn’t make sense to treat mania and then erase 25 years of a person’s life because of weight gain,” Dr. McIntyre said.
The average lifespan of people with bipolar disorder is about 20 years shorter than it is for those without serious mental illness.
Inflammation harms cognition
The changes are indicative of how seriously the field has begun to take metabolic disturbance as an adverse event in serious mental illness. Literature on obesity as a “psycho-toxin” is growing, and Dr. McIntyre is among the pioneers.
One study by Dr. McIntyre and his colleagues, currently in press, explores how obesity-related inflammation disturbs the brain’s dopamine system, resulting in interference with executive function. Because it is well established that people with bipolar disorder are more likely to be obese (J Affect Disord. 2008 Sep;110[1-2]:149-55), they also are more susceptible to cognitive impairment than are people of normal weight, according to Dr. McIntyre.
In a 2013 study, Dr. McIntyre and his colleagues showed that a first episode of mania in a person with obesity creates the same level of cognitive impairment as that found in the brains of normal-weight individuals who have experienced five episodes of mania (Psychological Med. 2014 Feb;44[3]:533-41). “There is something about obesity that is brain toxic,” he said.
Proof of concept of this is that cognitive outcomes for people before bariatric surgery are worse than postsurgery outcomes (Am J Surg. 2014 Jun;207[6]:870-6).
Systemic inflammation elevates levels of C-reactive protein, interleukin-1, and other cytokines, and interferes with insulin signaling; all have deleterious effects on cognition, as well as metabolic health. Those disturbances negatively affect emotional regulation, sleep, appetite, and sex drive, as well as executive function, he said.
“Inflammation is a convergent system, implicated across many brain- and body-based disorders. People with bipolar disorder not only have systemic increases in inflammation, but also neuroinflammation,” Dr. McIntyre said.
Accordingly, controlling inflammation becomes essential to chronic management of depression in general and bipolar in particular since, with each successive episode of untreated mania, patients’ ability to think clearly takes a hit. “Cognitive function is the principal determinant of psychosocial function, of workplace visibility, [and] of quality of life in most patient-reported outcomes,” Dr. McIntyre said.
Cognitive impairment also can lead to a worsening of the ability to balance reward and impulse control, leading to higher rates of substance abuse or other psychiatric comorbidities after onset of bipolar disease; a vicious cycle can ensue.
“As cognitive difficulties rise, comorbidities rise. But also, some of the comorbidities we see are reflections of cognitive impairment,” Dr. McIntyre said. To wit, binge eating disorder and bulimia nervosa are common in people with bipolar disorder (J Affect Disord. 2016 Feb;191:216-2).
Citing a recent scientific statement from the American Heart Association recommending that bipolar disorder and MDD should be considered tier II risk factors for cardiovascular disease among youth, the Florida guidelines urge clinicians to regularly screen patients for cardiometabolic disorders – not only for their medical implications but for their potential to flag emergent psychiatric issues.
Pharmacotherapeutics specifically targeting neuroinflammation are not yet ready for clinical practice, but Dr. McIntyre said other, more conventional therapies are available for bipolar disorder that have anti-inflammatory properties, including selective serotonin reuptake inhibitors and lithium. “Lithium is also anti-amyloid and has an anti-suicide effect. It is a drug I would definitely use as first line.”
Some behavioral therapies also are protective against inflammation and are recommended in the guidelines. Those include attention to sleep hygiene, diet, and exercise. “Social rhythm therapy is underutilized. These patients need their day organized. They need aerobics; they need sleep,” Dr. McIntyre said.
Future is now
Although the “whole-person” approach is still nascent – seeing depression as a collection of what Dr. McIntyre said are alterations in the neural circuitry amounting to a series of “disconnection syndromes” – psychiatry already has entered a new era where disease models are more comprehensive, he said.
This new way of thinking can connect the dots between why, for example, so many people with bipolar depression also have drug and alcohol abuse. It also could help explain why in bipolar there is so much obesity, or why there is so much anxiety, he said. “We’ve moved away from the rather silly, overly simplistic notions that you have too much or too little serotonin. Or that there was too much or too little dopamine causing mania. It made for convenient sound bytes, but it was probably just superstition we were gravitating to.”
The guidelines have been peer reviewed and will be published in the Journal of Clinical Psychiatry later this year, Dr. McIntyre said.
The meeting was held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Dr. McIntyre disclosed that he has numerous industry relationships, including with AstraZeneca, Eli Lilly, Janssen Ortho, Lundbeck, Pfizer, and Shire.
On Twitter @whitneymcknight
This more holistic way of thinking about depression is one I endorse. It makes sense to conceptualize bipolar disorder as a whole body disorder rather than a condition that is specific to the brain. The clinical implications are that we need to consider integration of care approaches that can reduce stress and inflammation generally, and minimize the complications of medical conditions seen in people with bipolar disorder. Some behavioral therapies are protective against inflammation and are recommended in the guidelines. These include attention to sleep, diet, and exercise. Social rhythm therapy is underutilized, as are other types of psychosocial approaches. Appropriate access to and use of medical care to help manage medical conditions is important, and integrated medical care that considers both body and mind may be helpful.
Martha Sajatovic, MD, is the Willard Brown Chair in Neurological Outcomes Research, and director of the Neurological Outcomes Center at the University Hospitals Case Medical Center in Cleveland. She is professor of psychiatry and of neurology at Case Western Reserve University, also in Cleveland. Dr. Sajatovic reported she has several industry relationships, including with Janssen, Merck, Ortho-McNeil, and Pfizer.
This more holistic way of thinking about depression is one I endorse. It makes sense to conceptualize bipolar disorder as a whole body disorder rather than a condition that is specific to the brain. The clinical implications are that we need to consider integration of care approaches that can reduce stress and inflammation generally, and minimize the complications of medical conditions seen in people with bipolar disorder. Some behavioral therapies are protective against inflammation and are recommended in the guidelines. These include attention to sleep, diet, and exercise. Social rhythm therapy is underutilized, as are other types of psychosocial approaches. Appropriate access to and use of medical care to help manage medical conditions is important, and integrated medical care that considers both body and mind may be helpful.
Martha Sajatovic, MD, is the Willard Brown Chair in Neurological Outcomes Research, and director of the Neurological Outcomes Center at the University Hospitals Case Medical Center in Cleveland. She is professor of psychiatry and of neurology at Case Western Reserve University, also in Cleveland. Dr. Sajatovic reported she has several industry relationships, including with Janssen, Merck, Ortho-McNeil, and Pfizer.
This more holistic way of thinking about depression is one I endorse. It makes sense to conceptualize bipolar disorder as a whole body disorder rather than a condition that is specific to the brain. The clinical implications are that we need to consider integration of care approaches that can reduce stress and inflammation generally, and minimize the complications of medical conditions seen in people with bipolar disorder. Some behavioral therapies are protective against inflammation and are recommended in the guidelines. These include attention to sleep, diet, and exercise. Social rhythm therapy is underutilized, as are other types of psychosocial approaches. Appropriate access to and use of medical care to help manage medical conditions is important, and integrated medical care that considers both body and mind may be helpful.
Martha Sajatovic, MD, is the Willard Brown Chair in Neurological Outcomes Research, and director of the Neurological Outcomes Center at the University Hospitals Case Medical Center in Cleveland. She is professor of psychiatry and of neurology at Case Western Reserve University, also in Cleveland. Dr. Sajatovic reported she has several industry relationships, including with Janssen, Merck, Ortho-McNeil, and Pfizer.
WASHINGTON – A sea change is underway in how major depressive and bipolar disorders are diagnosed and treated.
Historically, the absence of an accurate, comprehensive nosology of depression has led to much suffering and confusion. People with bipolar disorder in particular are either not diagnosed early enough or are not diagnosed with the correct “flavor” of depression, according to Roger S. McIntyre, MD, author of updated treatment guidelines for bipolar depression, and the first-ever treatment guidelines for mixed features in major depressive disorder. “Twenty years ago, we would have described bipolar as episodic breakthroughs of mania and depression, with well intervals in between,” Dr. McIntyre said at Summit in Neurology & Psychiatry. “But now, we’ve really changed our fundamental thinking about bipolar disorder.”
Although reasons for the evolution in thinking are many, one of the strongest currents of change flows from the 2013 publication of the DSM-5, according to Dr. McIntyre, professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at University Health Network in Toronto.
“The DSM-5’s authors took a neo-Kraepelinian view that mood disorders are dimensional,” Dr. McIntyre said in an interview. As a result, there’s been a reversal of what he called the “social construct imposed upon the cosmos of mood disorders by the DSM-III that divided that world into either depression or bipolar disorder.”
This return to thinking of mood disorders as existing on a continuum, as psychiatrist Emil Kraepelin, MD, theorized around the turn of the last century, pivots on the decision to do away with mixed states and to instead add the mixed features specifier.
“The move to mixed features is the necessary bridge between bipolar disease and major depressive disorder,” Dr. McIntyre said in the interview.
Therefore, for a period of time between the 1980 publication of the DSM-III and the DSM-5, “real-world” presentations of subsyndromal, opposite-pole symptoms that are common in major depressive disorder (MDD) and in bipolar disorder were not accounted for.
In practical terms, the addition of mixed features means that a patient with mania who presents with subsyndromal depressive symptoms would be seen, for example, to have mania with mixed features. A patient with a depressive episode who presents with subsyndromal hypomanic symptoms would be seen to have depression with mixed features. Therefore, depression with mixed features can be present not only in MDD, but in both bipolar I and II.
New treatment algorithms
This dimensional approach of assessing mixed features along a continuum could lead to better and earlier diagnosis of bipolar depression and more targeted therapies, according to Dr. McIntyre. What he thinks it won’t do is lead to an overzealousness in the overdiagnosis of bipolar depression.
“That is false. We wouldn’t say we’re not going to diagnose bowel cancer because we hear it’s overdiagnosed. But to get the diagnoses right, what we need is fidelity to diagnostic criteria.”
Enter the state of Florida. As part of its best practices for psychotherapeutic use in adults, Florida is the first state to have published evidence-based guidelines for depression with mixed features. Dr. McIntyre is one of the guidelines’ coauthors.
Antidepressants bad, olanzapine worse
Some changes to treatment algorithms might come as a surprise. Despite being among the most commonly prescribed treatments for bipolar disorder, monotherapy with antidepressants is not approved in the guidelines. “Period,” said Dr. McIntyre. “Many patients do well on antidepressants, but the most common outcome is inefficacy.”
It might be better to combine an antidepressant with an atypical antipsychotic, or a mood stabilizer to avoid treatment-emergent mania, or, more commonly, destabilization in patients who are susceptible to subsyndromal mania, he said.
In addition to mitigating symptoms of a depressive episode, atypicals can help suppress hypomanic symptoms. Dr. McIntyre said this is critical to remember, because patients with these combinations of symptoms are “the very persons who shouldn’t get an antidepressant but are also the ones most likely to be prescribed them,” according to old ways of thinking.
As for maintenance in bipolar disorder, Dr. McIntyre believes the axiom, “What gets you well keeps you well,” is a good rule of thumb when going through the algorithm. “It’s not always true, but it’s almost always true.”
Management of MDD with mixed features includes the introduction of atypicals or mood stabilizers such as lithium or lamotrigine in patients with any prior history of hypomania or mania, something Dr. McIntyre said already is beginning to happen in practice.
Olanzapine monotherapy as a first-line treatment of bipolar disorder initially was “demoted” by Dr. McIntyre and his coauthors in Florida’s bipolar treatment guidelines. In the updated version, the atypical remains a second-line therapy behind lurasidone as the recommended first-line therapy because of olanzapine’s tendency to interfere with metabolic processes. Quetiapine also is a first-line therapy, but with the qualification that it, too, could interfere with metabolic processes. Combination therapy with olanzapine plus fluoxetine is second-line.
“Lurasidone does not have the metabolic changes of quetiapine. It doesn’t make sense to treat mania and then erase 25 years of a person’s life because of weight gain,” Dr. McIntyre said.
The average lifespan of people with bipolar disorder is about 20 years shorter than it is for those without serious mental illness.
Inflammation harms cognition
The changes are indicative of how seriously the field has begun to take metabolic disturbance as an adverse event in serious mental illness. Literature on obesity as a “psycho-toxin” is growing, and Dr. McIntyre is among the pioneers.
One study by Dr. McIntyre and his colleagues, currently in press, explores how obesity-related inflammation disturbs the brain’s dopamine system, resulting in interference with executive function. Because it is well established that people with bipolar disorder are more likely to be obese (J Affect Disord. 2008 Sep;110[1-2]:149-55), they also are more susceptible to cognitive impairment than are people of normal weight, according to Dr. McIntyre.
In a 2013 study, Dr. McIntyre and his colleagues showed that a first episode of mania in a person with obesity creates the same level of cognitive impairment as that found in the brains of normal-weight individuals who have experienced five episodes of mania (Psychological Med. 2014 Feb;44[3]:533-41). “There is something about obesity that is brain toxic,” he said.
Proof of concept of this is that cognitive outcomes for people before bariatric surgery are worse than postsurgery outcomes (Am J Surg. 2014 Jun;207[6]:870-6).
Systemic inflammation elevates levels of C-reactive protein, interleukin-1, and other cytokines, and interferes with insulin signaling; all have deleterious effects on cognition, as well as metabolic health. Those disturbances negatively affect emotional regulation, sleep, appetite, and sex drive, as well as executive function, he said.
“Inflammation is a convergent system, implicated across many brain- and body-based disorders. People with bipolar disorder not only have systemic increases in inflammation, but also neuroinflammation,” Dr. McIntyre said.
Accordingly, controlling inflammation becomes essential to chronic management of depression in general and bipolar in particular since, with each successive episode of untreated mania, patients’ ability to think clearly takes a hit. “Cognitive function is the principal determinant of psychosocial function, of workplace visibility, [and] of quality of life in most patient-reported outcomes,” Dr. McIntyre said.
Cognitive impairment also can lead to a worsening of the ability to balance reward and impulse control, leading to higher rates of substance abuse or other psychiatric comorbidities after onset of bipolar disease; a vicious cycle can ensue.
“As cognitive difficulties rise, comorbidities rise. But also, some of the comorbidities we see are reflections of cognitive impairment,” Dr. McIntyre said. To wit, binge eating disorder and bulimia nervosa are common in people with bipolar disorder (J Affect Disord. 2016 Feb;191:216-2).
Citing a recent scientific statement from the American Heart Association recommending that bipolar disorder and MDD should be considered tier II risk factors for cardiovascular disease among youth, the Florida guidelines urge clinicians to regularly screen patients for cardiometabolic disorders – not only for their medical implications but for their potential to flag emergent psychiatric issues.
Pharmacotherapeutics specifically targeting neuroinflammation are not yet ready for clinical practice, but Dr. McIntyre said other, more conventional therapies are available for bipolar disorder that have anti-inflammatory properties, including selective serotonin reuptake inhibitors and lithium. “Lithium is also anti-amyloid and has an anti-suicide effect. It is a drug I would definitely use as first line.”
Some behavioral therapies also are protective against inflammation and are recommended in the guidelines. Those include attention to sleep hygiene, diet, and exercise. “Social rhythm therapy is underutilized. These patients need their day organized. They need aerobics; they need sleep,” Dr. McIntyre said.
Future is now
Although the “whole-person” approach is still nascent – seeing depression as a collection of what Dr. McIntyre said are alterations in the neural circuitry amounting to a series of “disconnection syndromes” – psychiatry already has entered a new era where disease models are more comprehensive, he said.
This new way of thinking can connect the dots between why, for example, so many people with bipolar depression also have drug and alcohol abuse. It also could help explain why in bipolar there is so much obesity, or why there is so much anxiety, he said. “We’ve moved away from the rather silly, overly simplistic notions that you have too much or too little serotonin. Or that there was too much or too little dopamine causing mania. It made for convenient sound bytes, but it was probably just superstition we were gravitating to.”
The guidelines have been peer reviewed and will be published in the Journal of Clinical Psychiatry later this year, Dr. McIntyre said.
The meeting was held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Dr. McIntyre disclosed that he has numerous industry relationships, including with AstraZeneca, Eli Lilly, Janssen Ortho, Lundbeck, Pfizer, and Shire.
On Twitter @whitneymcknight
WASHINGTON – A sea change is underway in how major depressive and bipolar disorders are diagnosed and treated.
Historically, the absence of an accurate, comprehensive nosology of depression has led to much suffering and confusion. People with bipolar disorder in particular are either not diagnosed early enough or are not diagnosed with the correct “flavor” of depression, according to Roger S. McIntyre, MD, author of updated treatment guidelines for bipolar depression, and the first-ever treatment guidelines for mixed features in major depressive disorder. “Twenty years ago, we would have described bipolar as episodic breakthroughs of mania and depression, with well intervals in between,” Dr. McIntyre said at Summit in Neurology & Psychiatry. “But now, we’ve really changed our fundamental thinking about bipolar disorder.”
Although reasons for the evolution in thinking are many, one of the strongest currents of change flows from the 2013 publication of the DSM-5, according to Dr. McIntyre, professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at University Health Network in Toronto.
“The DSM-5’s authors took a neo-Kraepelinian view that mood disorders are dimensional,” Dr. McIntyre said in an interview. As a result, there’s been a reversal of what he called the “social construct imposed upon the cosmos of mood disorders by the DSM-III that divided that world into either depression or bipolar disorder.”
This return to thinking of mood disorders as existing on a continuum, as psychiatrist Emil Kraepelin, MD, theorized around the turn of the last century, pivots on the decision to do away with mixed states and to instead add the mixed features specifier.
“The move to mixed features is the necessary bridge between bipolar disease and major depressive disorder,” Dr. McIntyre said in the interview.
Therefore, for a period of time between the 1980 publication of the DSM-III and the DSM-5, “real-world” presentations of subsyndromal, opposite-pole symptoms that are common in major depressive disorder (MDD) and in bipolar disorder were not accounted for.
In practical terms, the addition of mixed features means that a patient with mania who presents with subsyndromal depressive symptoms would be seen, for example, to have mania with mixed features. A patient with a depressive episode who presents with subsyndromal hypomanic symptoms would be seen to have depression with mixed features. Therefore, depression with mixed features can be present not only in MDD, but in both bipolar I and II.
New treatment algorithms
This dimensional approach of assessing mixed features along a continuum could lead to better and earlier diagnosis of bipolar depression and more targeted therapies, according to Dr. McIntyre. What he thinks it won’t do is lead to an overzealousness in the overdiagnosis of bipolar depression.
“That is false. We wouldn’t say we’re not going to diagnose bowel cancer because we hear it’s overdiagnosed. But to get the diagnoses right, what we need is fidelity to diagnostic criteria.”
Enter the state of Florida. As part of its best practices for psychotherapeutic use in adults, Florida is the first state to have published evidence-based guidelines for depression with mixed features. Dr. McIntyre is one of the guidelines’ coauthors.
Antidepressants bad, olanzapine worse
Some changes to treatment algorithms might come as a surprise. Despite being among the most commonly prescribed treatments for bipolar disorder, monotherapy with antidepressants is not approved in the guidelines. “Period,” said Dr. McIntyre. “Many patients do well on antidepressants, but the most common outcome is inefficacy.”
It might be better to combine an antidepressant with an atypical antipsychotic, or a mood stabilizer to avoid treatment-emergent mania, or, more commonly, destabilization in patients who are susceptible to subsyndromal mania, he said.
In addition to mitigating symptoms of a depressive episode, atypicals can help suppress hypomanic symptoms. Dr. McIntyre said this is critical to remember, because patients with these combinations of symptoms are “the very persons who shouldn’t get an antidepressant but are also the ones most likely to be prescribed them,” according to old ways of thinking.
As for maintenance in bipolar disorder, Dr. McIntyre believes the axiom, “What gets you well keeps you well,” is a good rule of thumb when going through the algorithm. “It’s not always true, but it’s almost always true.”
Management of MDD with mixed features includes the introduction of atypicals or mood stabilizers such as lithium or lamotrigine in patients with any prior history of hypomania or mania, something Dr. McIntyre said already is beginning to happen in practice.
Olanzapine monotherapy as a first-line treatment of bipolar disorder initially was “demoted” by Dr. McIntyre and his coauthors in Florida’s bipolar treatment guidelines. In the updated version, the atypical remains a second-line therapy behind lurasidone as the recommended first-line therapy because of olanzapine’s tendency to interfere with metabolic processes. Quetiapine also is a first-line therapy, but with the qualification that it, too, could interfere with metabolic processes. Combination therapy with olanzapine plus fluoxetine is second-line.
“Lurasidone does not have the metabolic changes of quetiapine. It doesn’t make sense to treat mania and then erase 25 years of a person’s life because of weight gain,” Dr. McIntyre said.
The average lifespan of people with bipolar disorder is about 20 years shorter than it is for those without serious mental illness.
Inflammation harms cognition
The changes are indicative of how seriously the field has begun to take metabolic disturbance as an adverse event in serious mental illness. Literature on obesity as a “psycho-toxin” is growing, and Dr. McIntyre is among the pioneers.
One study by Dr. McIntyre and his colleagues, currently in press, explores how obesity-related inflammation disturbs the brain’s dopamine system, resulting in interference with executive function. Because it is well established that people with bipolar disorder are more likely to be obese (J Affect Disord. 2008 Sep;110[1-2]:149-55), they also are more susceptible to cognitive impairment than are people of normal weight, according to Dr. McIntyre.
In a 2013 study, Dr. McIntyre and his colleagues showed that a first episode of mania in a person with obesity creates the same level of cognitive impairment as that found in the brains of normal-weight individuals who have experienced five episodes of mania (Psychological Med. 2014 Feb;44[3]:533-41). “There is something about obesity that is brain toxic,” he said.
Proof of concept of this is that cognitive outcomes for people before bariatric surgery are worse than postsurgery outcomes (Am J Surg. 2014 Jun;207[6]:870-6).
Systemic inflammation elevates levels of C-reactive protein, interleukin-1, and other cytokines, and interferes with insulin signaling; all have deleterious effects on cognition, as well as metabolic health. Those disturbances negatively affect emotional regulation, sleep, appetite, and sex drive, as well as executive function, he said.
“Inflammation is a convergent system, implicated across many brain- and body-based disorders. People with bipolar disorder not only have systemic increases in inflammation, but also neuroinflammation,” Dr. McIntyre said.
Accordingly, controlling inflammation becomes essential to chronic management of depression in general and bipolar in particular since, with each successive episode of untreated mania, patients’ ability to think clearly takes a hit. “Cognitive function is the principal determinant of psychosocial function, of workplace visibility, [and] of quality of life in most patient-reported outcomes,” Dr. McIntyre said.
Cognitive impairment also can lead to a worsening of the ability to balance reward and impulse control, leading to higher rates of substance abuse or other psychiatric comorbidities after onset of bipolar disease; a vicious cycle can ensue.
“As cognitive difficulties rise, comorbidities rise. But also, some of the comorbidities we see are reflections of cognitive impairment,” Dr. McIntyre said. To wit, binge eating disorder and bulimia nervosa are common in people with bipolar disorder (J Affect Disord. 2016 Feb;191:216-2).
Citing a recent scientific statement from the American Heart Association recommending that bipolar disorder and MDD should be considered tier II risk factors for cardiovascular disease among youth, the Florida guidelines urge clinicians to regularly screen patients for cardiometabolic disorders – not only for their medical implications but for their potential to flag emergent psychiatric issues.
Pharmacotherapeutics specifically targeting neuroinflammation are not yet ready for clinical practice, but Dr. McIntyre said other, more conventional therapies are available for bipolar disorder that have anti-inflammatory properties, including selective serotonin reuptake inhibitors and lithium. “Lithium is also anti-amyloid and has an anti-suicide effect. It is a drug I would definitely use as first line.”
Some behavioral therapies also are protective against inflammation and are recommended in the guidelines. Those include attention to sleep hygiene, diet, and exercise. “Social rhythm therapy is underutilized. These patients need their day organized. They need aerobics; they need sleep,” Dr. McIntyre said.
Future is now
Although the “whole-person” approach is still nascent – seeing depression as a collection of what Dr. McIntyre said are alterations in the neural circuitry amounting to a series of “disconnection syndromes” – psychiatry already has entered a new era where disease models are more comprehensive, he said.
This new way of thinking can connect the dots between why, for example, so many people with bipolar depression also have drug and alcohol abuse. It also could help explain why in bipolar there is so much obesity, or why there is so much anxiety, he said. “We’ve moved away from the rather silly, overly simplistic notions that you have too much or too little serotonin. Or that there was too much or too little dopamine causing mania. It made for convenient sound bytes, but it was probably just superstition we were gravitating to.”
The guidelines have been peer reviewed and will be published in the Journal of Clinical Psychiatry later this year, Dr. McIntyre said.
The meeting was held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Dr. McIntyre disclosed that he has numerous industry relationships, including with AstraZeneca, Eli Lilly, Janssen Ortho, Lundbeck, Pfizer, and Shire.
On Twitter @whitneymcknight
EXPERT ANALYSIS AT SUMMIT IN NEUROLOGY & PSYCHIATRY
LAIV no better than IIV for influenza protection in children
Live attenuated influenza vaccine (LAIV) was no more effective than inactivated influenza vaccine (IIV) in small, compact, rural communities, according to Mark Loeb, MD, and his associates.
For the study, vaccinations were given to children aged 36 months to 15 years living in Hutterite colonies in Canada. Hutterite colonies are isolated, their residents live communally, and influenza is prevalent, making them suited for this cluster randomized trial.
Of the 1,186 children included in the study, mean coverage was 76.7% in the LAIV group, compared with 72.4% in the IIV group. Incidence of influenza was 5.3% in the LAIV group and 5.2% in the IIV group. Compared to IIV, the hazard ratio for LAIV for influenza A or B was 1.03.
Children vaccinated with LAIV were at a higher risk for influenza A (hazard ratio, 1.62), but were at lower risk for influenza B (HR, 0.66). Influenza attack rates were similar in children younger and older than 6 years old. Adverse reactions were more likely in the IIV group than in the LAIV group, but no serious adverse events were reported.
“Although influenza transmission networks in Hutterite communities may differ from that in other communities, there are no data to confirm this. In fact, there may be more variability in social networks between urban and rural communities – or even among various urban communities – than between Hutterite and other (rural) communities. Even if variability exists, if a clear benefit of LAIV over IIV in reducing influenza-associated illness cannot be detected in this setting it is unlikely to be seen in other communities,” the investigators noted.
Find the full study in Annals of Internal Medicine (doi: 10.7326/M16-0513).
Live attenuated influenza vaccine (LAIV) was no more effective than inactivated influenza vaccine (IIV) in small, compact, rural communities, according to Mark Loeb, MD, and his associates.
For the study, vaccinations were given to children aged 36 months to 15 years living in Hutterite colonies in Canada. Hutterite colonies are isolated, their residents live communally, and influenza is prevalent, making them suited for this cluster randomized trial.
Of the 1,186 children included in the study, mean coverage was 76.7% in the LAIV group, compared with 72.4% in the IIV group. Incidence of influenza was 5.3% in the LAIV group and 5.2% in the IIV group. Compared to IIV, the hazard ratio for LAIV for influenza A or B was 1.03.
Children vaccinated with LAIV were at a higher risk for influenza A (hazard ratio, 1.62), but were at lower risk for influenza B (HR, 0.66). Influenza attack rates were similar in children younger and older than 6 years old. Adverse reactions were more likely in the IIV group than in the LAIV group, but no serious adverse events were reported.
“Although influenza transmission networks in Hutterite communities may differ from that in other communities, there are no data to confirm this. In fact, there may be more variability in social networks between urban and rural communities – or even among various urban communities – than between Hutterite and other (rural) communities. Even if variability exists, if a clear benefit of LAIV over IIV in reducing influenza-associated illness cannot be detected in this setting it is unlikely to be seen in other communities,” the investigators noted.
Find the full study in Annals of Internal Medicine (doi: 10.7326/M16-0513).
Live attenuated influenza vaccine (LAIV) was no more effective than inactivated influenza vaccine (IIV) in small, compact, rural communities, according to Mark Loeb, MD, and his associates.
For the study, vaccinations were given to children aged 36 months to 15 years living in Hutterite colonies in Canada. Hutterite colonies are isolated, their residents live communally, and influenza is prevalent, making them suited for this cluster randomized trial.
Of the 1,186 children included in the study, mean coverage was 76.7% in the LAIV group, compared with 72.4% in the IIV group. Incidence of influenza was 5.3% in the LAIV group and 5.2% in the IIV group. Compared to IIV, the hazard ratio for LAIV for influenza A or B was 1.03.
Children vaccinated with LAIV were at a higher risk for influenza A (hazard ratio, 1.62), but were at lower risk for influenza B (HR, 0.66). Influenza attack rates were similar in children younger and older than 6 years old. Adverse reactions were more likely in the IIV group than in the LAIV group, but no serious adverse events were reported.
“Although influenza transmission networks in Hutterite communities may differ from that in other communities, there are no data to confirm this. In fact, there may be more variability in social networks between urban and rural communities – or even among various urban communities – than between Hutterite and other (rural) communities. Even if variability exists, if a clear benefit of LAIV over IIV in reducing influenza-associated illness cannot be detected in this setting it is unlikely to be seen in other communities,” the investigators noted.
Find the full study in Annals of Internal Medicine (doi: 10.7326/M16-0513).
FROM ANNALS OF INTERNAL MEDICINE
Debunking Psoriasis Myths: Can Psoriasis Be Treated?
Myth: Psoriasis Cannot Be Treated
At the Summer Meeting of the American Academy of Dermatology in Boston, Massachusetts (July 28-31, 2016), Dr. Alexa Kimball presented on dermatology research advances at the plenary session and referenced the revolution in psoriasis treatment that has been experienced in the last several years, noting that dermatologists previously were relegated to treating patients with tar treatments. Today, many options for the treatment of psoriasis exist, though the disease is not curable.
According to the Mayo Clinic, psoriasis treatment is aimed at stopping the skin cells from growing so quickly, which reduces inflammation and plaque formation, and removing scales and smoothing skin. It is important for patients to understand the different treatment options so that they are aware that a variety of therapies may be tried until the right regimen with the fewest potential side effects is found. Options include:
- Biologics: given by injection or intravenous infusion for moderate to severe psoriasis that has not responded to other treatments
- Experimental medications: new medications undergoing clinical trials
- Oral treatments: inhibit specific molecules associated with inflammation and can be taken by mouth rather than injection or infusion (eg, retinoids, methotrexate, cyclosporine)
- Phototherapy or other light therapy: involves exposing the skin to UV light on a regular basis and under medical supervision (eg, UVB phototherapy, narrowband UVB therapy, psoralen plus UVA, excimer laser)
- Systemics: given orally or by injection and work throughout the body for moderate to severe psoriasis
- Topicals: applied to the skin and typically used for mild to moderate psoriasis (eg, topical corticosteroids, vitamin D analogues, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, coal tar, moisturizers)
In a 2014 analysis of data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey of the National Center for Health Statistics, the frequency of phototherapy treatments for psoriasis significantly decreased from 1993 to 2010 (P<.001), while the frequency of biologics significantly increased, becoming the most frequently used treatment from 2008 to 2010 (P<.0001).
However, psoriasis has been noted to be undertreated. A 2007 survey of 1657 psoriasis patients (28% with severe disease and 41% with moderate disease) from the National Psoriasis Foundation contact database indicated that 39% of respondents with severe psoriasis and 37% with moderate psoriasis were not currently receiving any treatment. Among those receiving treatment, only 43% with severe psoriasis received either traditional systemic therapy, biologic therapy, or phototherapy.
Access to care and cost of treatment are some of the reasons why psoriasis may go untreated. In 2013 the National Psoriasis Foundation reported results of a survey of 5600 patients with psoriasis and psoriatic arthritis, which revealed that patients did not see a specialist (ie, dermatologist, rheumatologist) to treat their disease because they had given up on treatment (28%), it was too expensive (21%), or it was too much of a hassle (11%). Although approximately 91% of patients were covered by medical insurance, the majority spent more than $2500 per year in out-of-pocket costs for their disease.
Patient satisfaction with treatment also is a concern. A 2002 National Psoriasis Foundation survey reported that 33% of patients are unsatisfied with current treatments and 78% do not use more aggressive therapies to treat their disease because of their side effects and lack of effectiveness. The advent of biologic therapies and new oral treatments has afforded psoriasis patients the opportunity to have a frank discussion with their health care provider if they are not satisfied with treatment or are not seeing the type of improvement that would make a substantial impact on their quality of life. Additionally, over time skin may become resistant to various treatments. Therefore, open communication with psoriasis patients is key.
Expert Commentary
We are in the midst of a second revolution in the treatment of psoriasis. We have multiple new biologic and oral agents available for the treatment of this condition. In addition, there are a large number of treatments currently in development. Not only can psoriasis be treated, it can be treated highly effectively and safely.
—Jeffrey M. Weinberg, MD (New York, New York)
1. Horn EJ, Fox KM, Patel V, et al. Are patients with psoriasis undertreated? results of National Psoriasis Foundation survey. J Am Acad Dermatol. 2007;57:957-962.
2. Mayo Clinic. Psoriasis treatments and drugs. http://www.mayoclinic.org/diseases-conditions/psoriasis/basics/con-20030838. Updated June 17, 2015. Accessed August 12, 2016.
3. New National Psoriasis Foundation survey shows psoriasis diminishes quality of life for millions [news release]. Portland, OR: National Psoriasis Foundation; May 15, 2002. http://www.prnewswire.com/news-releases/new-national-psoriasis-foundation-survey-shows-psoriasis-diminishes-quality-of-life-for-millions-77445457.html. Accessed August 12, 2016.
4. Psoriasis treatments. National Psoriasis Foundation website.https://www.psoriasis.org/about-psoriasis/treatments. Accessed August 12, 2016.
5. Shaw MK, Davis SA, Feldman SR, et al. Trends in systemic psoriasis treatment therapies from 1993 through 2010.J Drugs Dermatol.2014;13:917-920.
6. Study: people with psoriasis and psoriatic arthritis spend thousands on health care [news release]. Portland, OR: National Psoriasis Foundation; January 14, 2013.https://www.psoriasis.org/media/press-releases/study-people-psoriasis-and-psoriatic-arthritis-spend-thousands-health-care. Accessed August 12, 2016.
Myth: Psoriasis Cannot Be Treated
At the Summer Meeting of the American Academy of Dermatology in Boston, Massachusetts (July 28-31, 2016), Dr. Alexa Kimball presented on dermatology research advances at the plenary session and referenced the revolution in psoriasis treatment that has been experienced in the last several years, noting that dermatologists previously were relegated to treating patients with tar treatments. Today, many options for the treatment of psoriasis exist, though the disease is not curable.
According to the Mayo Clinic, psoriasis treatment is aimed at stopping the skin cells from growing so quickly, which reduces inflammation and plaque formation, and removing scales and smoothing skin. It is important for patients to understand the different treatment options so that they are aware that a variety of therapies may be tried until the right regimen with the fewest potential side effects is found. Options include:
- Biologics: given by injection or intravenous infusion for moderate to severe psoriasis that has not responded to other treatments
- Experimental medications: new medications undergoing clinical trials
- Oral treatments: inhibit specific molecules associated with inflammation and can be taken by mouth rather than injection or infusion (eg, retinoids, methotrexate, cyclosporine)
- Phototherapy or other light therapy: involves exposing the skin to UV light on a regular basis and under medical supervision (eg, UVB phototherapy, narrowband UVB therapy, psoralen plus UVA, excimer laser)
- Systemics: given orally or by injection and work throughout the body for moderate to severe psoriasis
- Topicals: applied to the skin and typically used for mild to moderate psoriasis (eg, topical corticosteroids, vitamin D analogues, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, coal tar, moisturizers)
In a 2014 analysis of data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey of the National Center for Health Statistics, the frequency of phototherapy treatments for psoriasis significantly decreased from 1993 to 2010 (P<.001), while the frequency of biologics significantly increased, becoming the most frequently used treatment from 2008 to 2010 (P<.0001).
However, psoriasis has been noted to be undertreated. A 2007 survey of 1657 psoriasis patients (28% with severe disease and 41% with moderate disease) from the National Psoriasis Foundation contact database indicated that 39% of respondents with severe psoriasis and 37% with moderate psoriasis were not currently receiving any treatment. Among those receiving treatment, only 43% with severe psoriasis received either traditional systemic therapy, biologic therapy, or phototherapy.
Access to care and cost of treatment are some of the reasons why psoriasis may go untreated. In 2013 the National Psoriasis Foundation reported results of a survey of 5600 patients with psoriasis and psoriatic arthritis, which revealed that patients did not see a specialist (ie, dermatologist, rheumatologist) to treat their disease because they had given up on treatment (28%), it was too expensive (21%), or it was too much of a hassle (11%). Although approximately 91% of patients were covered by medical insurance, the majority spent more than $2500 per year in out-of-pocket costs for their disease.
Patient satisfaction with treatment also is a concern. A 2002 National Psoriasis Foundation survey reported that 33% of patients are unsatisfied with current treatments and 78% do not use more aggressive therapies to treat their disease because of their side effects and lack of effectiveness. The advent of biologic therapies and new oral treatments has afforded psoriasis patients the opportunity to have a frank discussion with their health care provider if they are not satisfied with treatment or are not seeing the type of improvement that would make a substantial impact on their quality of life. Additionally, over time skin may become resistant to various treatments. Therefore, open communication with psoriasis patients is key.
Expert Commentary
We are in the midst of a second revolution in the treatment of psoriasis. We have multiple new biologic and oral agents available for the treatment of this condition. In addition, there are a large number of treatments currently in development. Not only can psoriasis be treated, it can be treated highly effectively and safely.
—Jeffrey M. Weinberg, MD (New York, New York)
Myth: Psoriasis Cannot Be Treated
At the Summer Meeting of the American Academy of Dermatology in Boston, Massachusetts (July 28-31, 2016), Dr. Alexa Kimball presented on dermatology research advances at the plenary session and referenced the revolution in psoriasis treatment that has been experienced in the last several years, noting that dermatologists previously were relegated to treating patients with tar treatments. Today, many options for the treatment of psoriasis exist, though the disease is not curable.
According to the Mayo Clinic, psoriasis treatment is aimed at stopping the skin cells from growing so quickly, which reduces inflammation and plaque formation, and removing scales and smoothing skin. It is important for patients to understand the different treatment options so that they are aware that a variety of therapies may be tried until the right regimen with the fewest potential side effects is found. Options include:
- Biologics: given by injection or intravenous infusion for moderate to severe psoriasis that has not responded to other treatments
- Experimental medications: new medications undergoing clinical trials
- Oral treatments: inhibit specific molecules associated with inflammation and can be taken by mouth rather than injection or infusion (eg, retinoids, methotrexate, cyclosporine)
- Phototherapy or other light therapy: involves exposing the skin to UV light on a regular basis and under medical supervision (eg, UVB phototherapy, narrowband UVB therapy, psoralen plus UVA, excimer laser)
- Systemics: given orally or by injection and work throughout the body for moderate to severe psoriasis
- Topicals: applied to the skin and typically used for mild to moderate psoriasis (eg, topical corticosteroids, vitamin D analogues, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, coal tar, moisturizers)
In a 2014 analysis of data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey of the National Center for Health Statistics, the frequency of phototherapy treatments for psoriasis significantly decreased from 1993 to 2010 (P<.001), while the frequency of biologics significantly increased, becoming the most frequently used treatment from 2008 to 2010 (P<.0001).
However, psoriasis has been noted to be undertreated. A 2007 survey of 1657 psoriasis patients (28% with severe disease and 41% with moderate disease) from the National Psoriasis Foundation contact database indicated that 39% of respondents with severe psoriasis and 37% with moderate psoriasis were not currently receiving any treatment. Among those receiving treatment, only 43% with severe psoriasis received either traditional systemic therapy, biologic therapy, or phototherapy.
Access to care and cost of treatment are some of the reasons why psoriasis may go untreated. In 2013 the National Psoriasis Foundation reported results of a survey of 5600 patients with psoriasis and psoriatic arthritis, which revealed that patients did not see a specialist (ie, dermatologist, rheumatologist) to treat their disease because they had given up on treatment (28%), it was too expensive (21%), or it was too much of a hassle (11%). Although approximately 91% of patients were covered by medical insurance, the majority spent more than $2500 per year in out-of-pocket costs for their disease.
Patient satisfaction with treatment also is a concern. A 2002 National Psoriasis Foundation survey reported that 33% of patients are unsatisfied with current treatments and 78% do not use more aggressive therapies to treat their disease because of their side effects and lack of effectiveness. The advent of biologic therapies and new oral treatments has afforded psoriasis patients the opportunity to have a frank discussion with their health care provider if they are not satisfied with treatment or are not seeing the type of improvement that would make a substantial impact on their quality of life. Additionally, over time skin may become resistant to various treatments. Therefore, open communication with psoriasis patients is key.
Expert Commentary
We are in the midst of a second revolution in the treatment of psoriasis. We have multiple new biologic and oral agents available for the treatment of this condition. In addition, there are a large number of treatments currently in development. Not only can psoriasis be treated, it can be treated highly effectively and safely.
—Jeffrey M. Weinberg, MD (New York, New York)
1. Horn EJ, Fox KM, Patel V, et al. Are patients with psoriasis undertreated? results of National Psoriasis Foundation survey. J Am Acad Dermatol. 2007;57:957-962.
2. Mayo Clinic. Psoriasis treatments and drugs. http://www.mayoclinic.org/diseases-conditions/psoriasis/basics/con-20030838. Updated June 17, 2015. Accessed August 12, 2016.
3. New National Psoriasis Foundation survey shows psoriasis diminishes quality of life for millions [news release]. Portland, OR: National Psoriasis Foundation; May 15, 2002. http://www.prnewswire.com/news-releases/new-national-psoriasis-foundation-survey-shows-psoriasis-diminishes-quality-of-life-for-millions-77445457.html. Accessed August 12, 2016.
4. Psoriasis treatments. National Psoriasis Foundation website.https://www.psoriasis.org/about-psoriasis/treatments. Accessed August 12, 2016.
5. Shaw MK, Davis SA, Feldman SR, et al. Trends in systemic psoriasis treatment therapies from 1993 through 2010.J Drugs Dermatol.2014;13:917-920.
6. Study: people with psoriasis and psoriatic arthritis spend thousands on health care [news release]. Portland, OR: National Psoriasis Foundation; January 14, 2013.https://www.psoriasis.org/media/press-releases/study-people-psoriasis-and-psoriatic-arthritis-spend-thousands-health-care. Accessed August 12, 2016.
1. Horn EJ, Fox KM, Patel V, et al. Are patients with psoriasis undertreated? results of National Psoriasis Foundation survey. J Am Acad Dermatol. 2007;57:957-962.
2. Mayo Clinic. Psoriasis treatments and drugs. http://www.mayoclinic.org/diseases-conditions/psoriasis/basics/con-20030838. Updated June 17, 2015. Accessed August 12, 2016.
3. New National Psoriasis Foundation survey shows psoriasis diminishes quality of life for millions [news release]. Portland, OR: National Psoriasis Foundation; May 15, 2002. http://www.prnewswire.com/news-releases/new-national-psoriasis-foundation-survey-shows-psoriasis-diminishes-quality-of-life-for-millions-77445457.html. Accessed August 12, 2016.
4. Psoriasis treatments. National Psoriasis Foundation website.https://www.psoriasis.org/about-psoriasis/treatments. Accessed August 12, 2016.
5. Shaw MK, Davis SA, Feldman SR, et al. Trends in systemic psoriasis treatment therapies from 1993 through 2010.J Drugs Dermatol.2014;13:917-920.
6. Study: people with psoriasis and psoriatic arthritis spend thousands on health care [news release]. Portland, OR: National Psoriasis Foundation; January 14, 2013.https://www.psoriasis.org/media/press-releases/study-people-psoriasis-and-psoriatic-arthritis-spend-thousands-health-care. Accessed August 12, 2016.
Preventing, Identifying, and Managing Cosmetic Procedure Complications, Part 2: Lasers and Chemical Peels
The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.
Lasers
In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.1,2 Ablative resurfacing lasers such as the CO2 laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.3 With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.1-3
Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.3 When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.1-3 Some tattoo inks may paradoxically darken when treated with lasers.3 A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.2,3
Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.1-3 For all laser procedures, strict sun protection is advised before and after the procedure.
Chemical Peels
Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).4 Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.4,5 Strict sun protection should be advised both before and after a chemical peel.
While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.4 Glycolic acid and SA are known to be safer for patients with skin of color.4,5
Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.4 Skin of color may benefit from hydroquinone used before and after a chemical peel.5 At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.4 Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.
Final Thoughts
For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.
- Hirsch R, Stier M. Complications and their management in cosmetic dermatology. Dermatol Clin. 2009;27:507-520.
- Oliaei A, Nelson JS, Fitzpatrick R, et al. Laser treatment of scars. Facial Plast Surg. 2012;28:518-524.
- Al Nomair N, Nazarian R, Marmur E. Complications in lasers, lights, and radiofrequency devices. Facial Plast Surg. 2012;28:340-346.
- Khunger N, IADVL Task Force. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74(suppl):S5-S12.
- Sarkar R, Bansal S, Garg VK. Chemical peels for melasma in dark-skinned patients. J Cutan Aesthet Surg. 2012;5:247-253.
The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.
Lasers
In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.1,2 Ablative resurfacing lasers such as the CO2 laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.3 With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.1-3
Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.3 When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.1-3 Some tattoo inks may paradoxically darken when treated with lasers.3 A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.2,3
Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.1-3 For all laser procedures, strict sun protection is advised before and after the procedure.
Chemical Peels
Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).4 Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.4,5 Strict sun protection should be advised both before and after a chemical peel.
While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.4 Glycolic acid and SA are known to be safer for patients with skin of color.4,5
Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.4 Skin of color may benefit from hydroquinone used before and after a chemical peel.5 At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.4 Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.
Final Thoughts
For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.
The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.
Lasers
In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.1,2 Ablative resurfacing lasers such as the CO2 laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.3 With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.1-3
Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.3 When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.1-3 Some tattoo inks may paradoxically darken when treated with lasers.3 A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.2,3
Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.1-3 For all laser procedures, strict sun protection is advised before and after the procedure.
Chemical Peels
Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).4 Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.4,5 Strict sun protection should be advised both before and after a chemical peel.
While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.4 Glycolic acid and SA are known to be safer for patients with skin of color.4,5
Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.4 Skin of color may benefit from hydroquinone used before and after a chemical peel.5 At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.4 Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.
Final Thoughts
For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.
- Hirsch R, Stier M. Complications and their management in cosmetic dermatology. Dermatol Clin. 2009;27:507-520.
- Oliaei A, Nelson JS, Fitzpatrick R, et al. Laser treatment of scars. Facial Plast Surg. 2012;28:518-524.
- Al Nomair N, Nazarian R, Marmur E. Complications in lasers, lights, and radiofrequency devices. Facial Plast Surg. 2012;28:340-346.
- Khunger N, IADVL Task Force. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74(suppl):S5-S12.
- Sarkar R, Bansal S, Garg VK. Chemical peels for melasma in dark-skinned patients. J Cutan Aesthet Surg. 2012;5:247-253.
- Hirsch R, Stier M. Complications and their management in cosmetic dermatology. Dermatol Clin. 2009;27:507-520.
- Oliaei A, Nelson JS, Fitzpatrick R, et al. Laser treatment of scars. Facial Plast Surg. 2012;28:518-524.
- Al Nomair N, Nazarian R, Marmur E. Complications in lasers, lights, and radiofrequency devices. Facial Plast Surg. 2012;28:340-346.
- Khunger N, IADVL Task Force. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74(suppl):S5-S12.
- Sarkar R, Bansal S, Garg VK. Chemical peels for melasma in dark-skinned patients. J Cutan Aesthet Surg. 2012;5:247-253.
Communication Crossroads: Managing Patient Interactions, Online Personas on Social Media
The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.
“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.
But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.
Professional Guidelines
To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.
- Maintain standards of professional ethics in online communications, including respect for patient privacy.
Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)
“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”
It would also be wise to seek advice from colleagues before posting patient information, she notes.
- Do not blur the boundaries between your professional and social spheres.
In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.
- Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.
Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.
“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.
- Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.
Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.
- Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.
Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.
Deliver Better Healthcare through Social Media
Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8
Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”
Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.
“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”
Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”
Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH
Maybelle Cowan-Lincoln is a freelance writer in New Jersey.
References
- Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
- Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
- Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
- Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
- New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
- Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
- HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
- FOAM. Life in the Fastlane website. Accessed September 6, 2015.
HIPPA Identifiers
- Names
- Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
- Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
- Phone numbers
- Fax numbers
- Email addresses
- Social Security numbers
- Medical record numbers
- Health plan beneficiary numbers
- Account numbers
- Certificate/license numbers
- Vehicle identifiers including license plate numbers and VINs
- Device identifiers and serial numbers
- URLs
- IP addresses
- Biometric identifiers, including finger and voice prints
- Full face (or any comparable image) photographs
- Any other unique identifying number, characteristic, or code
How Hospitalists Can Use Social Media to Improve Their Institution’s Care
“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”
According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.
Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH
—Maybelle Cowan-Lincoln
The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.
“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.
But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.
Professional Guidelines
To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.
- Maintain standards of professional ethics in online communications, including respect for patient privacy.
Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)
“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”
It would also be wise to seek advice from colleagues before posting patient information, she notes.
- Do not blur the boundaries between your professional and social spheres.
In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.
- Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.
Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.
“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.
- Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.
Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.
- Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.
Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.
Deliver Better Healthcare through Social Media
Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8
Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”
Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.
“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”
Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”
Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH
Maybelle Cowan-Lincoln is a freelance writer in New Jersey.
References
- Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
- Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
- Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
- Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
- New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
- Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
- HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
- FOAM. Life in the Fastlane website. Accessed September 6, 2015.
HIPPA Identifiers
- Names
- Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
- Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
- Phone numbers
- Fax numbers
- Email addresses
- Social Security numbers
- Medical record numbers
- Health plan beneficiary numbers
- Account numbers
- Certificate/license numbers
- Vehicle identifiers including license plate numbers and VINs
- Device identifiers and serial numbers
- URLs
- IP addresses
- Biometric identifiers, including finger and voice prints
- Full face (or any comparable image) photographs
- Any other unique identifying number, characteristic, or code
How Hospitalists Can Use Social Media to Improve Their Institution’s Care
“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”
According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.
Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH
—Maybelle Cowan-Lincoln
The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.
“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.
But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.
Professional Guidelines
To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.
- Maintain standards of professional ethics in online communications, including respect for patient privacy.
Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)
“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”
It would also be wise to seek advice from colleagues before posting patient information, she notes.
- Do not blur the boundaries between your professional and social spheres.
In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.
- Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.
Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.
“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.
- Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.
Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.
- Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.
Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.
Deliver Better Healthcare through Social Media
Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8
Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”
Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.
“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”
Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”
Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH
Maybelle Cowan-Lincoln is a freelance writer in New Jersey.
References
- Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
- Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
- Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
- Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
- New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
- Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
- HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
- FOAM. Life in the Fastlane website. Accessed September 6, 2015.
HIPPA Identifiers
- Names
- Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
- Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
- Phone numbers
- Fax numbers
- Email addresses
- Social Security numbers
- Medical record numbers
- Health plan beneficiary numbers
- Account numbers
- Certificate/license numbers
- Vehicle identifiers including license plate numbers and VINs
- Device identifiers and serial numbers
- URLs
- IP addresses
- Biometric identifiers, including finger and voice prints
- Full face (or any comparable image) photographs
- Any other unique identifying number, characteristic, or code
How Hospitalists Can Use Social Media to Improve Their Institution’s Care
“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”
According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.
Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH
—Maybelle Cowan-Lincoln
