Commentary

My urologic career began in the late 1980s, just before prostate-specific antigen (PSA) testing was introduced. Ever since, a busy prostate cancer practice has given me a frontline view of the benefits and possible harms of PSA screening.

See related article

In the pre-PSA era, about half of men with newly diagnosed prostate cancer presented with incurable disease, either locally advanced or metastatic. The most common treatment was bilateral orchiectomy, which was the only safe form of androgen deprivation available.

Fast-forward a few years to the mid-1990s. Within 5 years after the introduction of PSA testing, the rate of incurable disease at diagnosis fell to just 5%, and treatment for localized disease skyrocketed, including radical prostatectomy, external beam radiation, and brachytherapy. As a result of earlier diagnosis and improved treatments, the death rate from prostate cancer in US men has fallen more than 30% since 1990.

The first-hand experience of seeing this massive stage migration to curable disease has forever convinced me that PSA screening is beneficial. Robust statistical models lend credence to this belief, with estimates that screening is responsible for 45% to 70% of this decline in mortality.¹

Fast-forward again to 2012, when the US Preventive Services Task Force (USPSTF) published a strong recommendation against screening. The recommendation had so much force that as recently as 2014, only 11% of men at highest risk of prostate cancer in the Cleveland Clinic system were screened for it,² mirroring national trends.

What happened? Colored by the experience in the era before PSA, when men presented frequently with painful metastatic disease and had an average life expectancy of 18 to 24 months, it was widely believed that all detected prostate cancer required treatment. What was not appreciated was that while PSA detects lots of prostate cancer, the most common reason for PSA levels to reach a range worrisome enough to trigger biopsy was actually benign prostatic hypertrophy.

The resulting increase in the number of biopsies resulted in the detection of a substantial number of low-grade cancers that were never destined to cause clinical harm but that got treated anyway, based on the fear that all cancers had metastatic potential. The USPSTF based its recommendation against screening on the harms caused by this overdetection and overtreatment of nonlethal disease, focusing on risks of biopsy such as sepsis, and on treatment-related adverse effects such as changes in urinary, bowel, and sexual function.

RANDOMIZED TRIALS SHOW A BENEFIT FROM SCREENING

As a result of this controversy, several large randomized trials designed to test whether PSA screening was beneficial were organized and begun in the 1990s, with one in the United States and another in Europe.^3,4 Mature data from both trials have now established that there is indeed benefit to population-level screening.

The US Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), was initially reported to show no difference in prostate cancer-specific mortality rates in those screened vs not screened, but because more than 90% of the men in the no-screening arm were screened anyway, that conclusion is erroneous.³

With 13-year follow-up and far less PSA contamination in the unscreened arm, the European Randomized Study of Screening for Prostate Cancer (ERSPC) in men ages 55 to 69 demonstrated a 27% reduction in the rate of death and a 35% reduction in the need for palliative treatments (androgen deprivation or radiation, or both) for metastatic disease in those screened vs not screened, clearly establishing substantial clinical benefit to PSA screening.⁴

A recent analysis of both trials that controlled for PSA drop-ins (comparing those actually screened with those actually not screened) concluded that the benefit of screening in terms of mortality reduction (estimated at about 30%) are equal in both trials.⁵ A large cohort study from Kaiser Permanente with 16-year follow-up has suggested that PSA screening has both a prostate cancer-specific benefit and an overall mortality benefit.⁶

In parallel with the design and completion of these trials, there was a significant effort to better identify and manage patients initially overdiagnosed with nonlethal cancers by developing active surveillance regimens.

This management strategy recognizes that most low-grade cancers pose no short-term risk to the patient’s health or longevity, that definitive therapy can be deferred, and that with regular monitoring by digital rectal examination, PSA measurement, and repeat biopsy, cancers that progress can still be cured. The result of this strategy is a marked reduction in the harms caused by overtreatment (ie, the aforementioned adverse effects), as well as the avoidance of unnecessary treatment in many patients.

A randomized trial and 2 large prospective cohort studies have confirmed the long-term safety of this approach,^7–9 and the development of commercially available, biopsy-based gene expression profiling tools promises to further improve risk stratification at diagnosis and during follow-up for individual patients.¹⁰

NEW USPSTF RECOMMENDATIONS: AN INDIVIDUAL, INFORMED DECISION

Based on the results of the ERSPC and the widespread adoption and safety of active surveillance, which together show benefit to screening and fewer harms in overdetection and overtreatment, in 2018 the USPSTF recast its recommendations. In upgrading the recommendation from “D” to “C,” the recommendation now states that for men ages 55 to 69, PSA screening should be an individual decision after a discussion with an informed provider, although men over 70 are still advised not to undergo screening at all.¹¹

Some may think that this recommendation has arrived just in time, or that it should be  made even stronger to actually recommend screening, as recent data from 2 national registries—the Surveillance, Epidemiology, and End Results program and the National Cancer Database—show that the fall in screening after the 2012 USPSTF guidelines has resulted in an increase in men presenting with advanced stage disease.^12,13 (All of you Back to the Future fans, please return to the mid to late 1980s to see how that plays out.)

So the pendulum has now swung back in favor of screening, largely supported by solid data showing meaningful clinical benefit, better understanding of PSA and prostate cancer biology, and adoption of active surveillance.

AN IDEAL SCREENING PROGRAM

An ideal screening program would detect only biologically significant cancers, thus eliminating overdetection and overtreatment. There is reason for optimism on this front.

Second-generation PSA tests have better diagnostic accuracy for high-grade disease than earlier tests. Two such tests, the Prostate Health Index (Beckman Coulter) and the 4K-score (Opko Health), are commercially available though not usually covered by commercial insurers.¹⁴ A third test, IsoPSA (Cleveland Diagnostics), is under development. Most hospital laboratories will be able to be run this test with no need for a central laboratory.¹⁵ All 3 tests have been shown to reduce unnecessary biopsies (because of a low probability of finding a biologically significant cancer) by 30% to 45% and will help reduce overdetection.

Moreover, multiparametric magnetic resonance imaging of the prostate has been shown to improve detection of high-grade cancers,¹⁶ and a randomized trial has suggested that its incorporation into a screening strategy is cost-effective and could be better than PSA testing plus transrectal ultrasonography alone (the current standard of care).¹⁷

Several risk scores based on germline genomics also hold promise for better identifying those at risk and for helping to de-intensify screening for those unlikely to have high-grade cancer.¹⁸

Screening for prostate cancer reduces mortality rates and the burden of metastatic disease, and the paradigm continues to evolve. Men at risk by virtue of age (55 to 69, and healthy men > 70), family history, race, and newly identified factors (germline genetics) all deserve an informed discussion on the benefits and risks of screening

My urologic career began in the late 1980s, just before prostate-specific antigen (PSA) testing was introduced. Ever since, a busy prostate cancer practice has given me a frontline view of the benefits and possible harms of PSA screening.

See related article

In the pre-PSA era, about half of men with newly diagnosed prostate cancer presented with incurable disease, either locally advanced or metastatic. The most common treatment was bilateral orchiectomy, which was the only safe form of androgen deprivation available.

Fast-forward a few years to the mid-1990s. Within 5 years after the introduction of PSA testing, the rate of incurable disease at diagnosis fell to just 5%, and treatment for localized disease skyrocketed, including radical prostatectomy, external beam radiation, and brachytherapy. As a result of earlier diagnosis and improved treatments, the death rate from prostate cancer in US men has fallen more than 30% since 1990.

The first-hand experience of seeing this massive stage migration to curable disease has forever convinced me that PSA screening is beneficial. Robust statistical models lend credence to this belief, with estimates that screening is responsible for 45% to 70% of this decline in mortality.¹

Fast-forward again to 2012, when the US Preventive Services Task Force (USPSTF) published a strong recommendation against screening. The recommendation had so much force that as recently as 2014, only 11% of men at highest risk of prostate cancer in the Cleveland Clinic system were screened for it,² mirroring national trends.

What happened? Colored by the experience in the era before PSA, when men presented frequently with painful metastatic disease and had an average life expectancy of 18 to 24 months, it was widely believed that all detected prostate cancer required treatment. What was not appreciated was that while PSA detects lots of prostate cancer, the most common reason for PSA levels to reach a range worrisome enough to trigger biopsy was actually benign prostatic hypertrophy.

The resulting increase in the number of biopsies resulted in the detection of a substantial number of low-grade cancers that were never destined to cause clinical harm but that got treated anyway, based on the fear that all cancers had metastatic potential. The USPSTF based its recommendation against screening on the harms caused by this overdetection and overtreatment of nonlethal disease, focusing on risks of biopsy such as sepsis, and on treatment-related adverse effects such as changes in urinary, bowel, and sexual function.

RANDOMIZED TRIALS SHOW A BENEFIT FROM SCREENING

As a result of this controversy, several large randomized trials designed to test whether PSA screening was beneficial were organized and begun in the 1990s, with one in the United States and another in Europe.^3,4 Mature data from both trials have now established that there is indeed benefit to population-level screening.

The US Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), was initially reported to show no difference in prostate cancer-specific mortality rates in those screened vs not screened, but because more than 90% of the men in the no-screening arm were screened anyway, that conclusion is erroneous.³

With 13-year follow-up and far less PSA contamination in the unscreened arm, the European Randomized Study of Screening for Prostate Cancer (ERSPC) in men ages 55 to 69 demonstrated a 27% reduction in the rate of death and a 35% reduction in the need for palliative treatments (androgen deprivation or radiation, or both) for metastatic disease in those screened vs not screened, clearly establishing substantial clinical benefit to PSA screening.⁴

A recent analysis of both trials that controlled for PSA drop-ins (comparing those actually screened with those actually not screened) concluded that the benefit of screening in terms of mortality reduction (estimated at about 30%) are equal in both trials.⁵ A large cohort study from Kaiser Permanente with 16-year follow-up has suggested that PSA screening has both a prostate cancer-specific benefit and an overall mortality benefit.⁶

In parallel with the design and completion of these trials, there was a significant effort to better identify and manage patients initially overdiagnosed with nonlethal cancers by developing active surveillance regimens.

This management strategy recognizes that most low-grade cancers pose no short-term risk to the patient’s health or longevity, that definitive therapy can be deferred, and that with regular monitoring by digital rectal examination, PSA measurement, and repeat biopsy, cancers that progress can still be cured. The result of this strategy is a marked reduction in the harms caused by overtreatment (ie, the aforementioned adverse effects), as well as the avoidance of unnecessary treatment in many patients.

A randomized trial and 2 large prospective cohort studies have confirmed the long-term safety of this approach,^7–9 and the development of commercially available, biopsy-based gene expression profiling tools promises to further improve risk stratification at diagnosis and during follow-up for individual patients.¹⁰

NEW USPSTF RECOMMENDATIONS: AN INDIVIDUAL, INFORMED DECISION

Based on the results of the ERSPC and the widespread adoption and safety of active surveillance, which together show benefit to screening and fewer harms in overdetection and overtreatment, in 2018 the USPSTF recast its recommendations. In upgrading the recommendation from “D” to “C,” the recommendation now states that for men ages 55 to 69, PSA screening should be an individual decision after a discussion with an informed provider, although men over 70 are still advised not to undergo screening at all.¹¹

Some may think that this recommendation has arrived just in time, or that it should be  made even stronger to actually recommend screening, as recent data from 2 national registries—the Surveillance, Epidemiology, and End Results program and the National Cancer Database—show that the fall in screening after the 2012 USPSTF guidelines has resulted in an increase in men presenting with advanced stage disease.^12,13 (All of you Back to the Future fans, please return to the mid to late 1980s to see how that plays out.)

So the pendulum has now swung back in favor of screening, largely supported by solid data showing meaningful clinical benefit, better understanding of PSA and prostate cancer biology, and adoption of active surveillance.

AN IDEAL SCREENING PROGRAM

An ideal screening program would detect only biologically significant cancers, thus eliminating overdetection and overtreatment. There is reason for optimism on this front.

Second-generation PSA tests have better diagnostic accuracy for high-grade disease than earlier tests. Two such tests, the Prostate Health Index (Beckman Coulter) and the 4K-score (Opko Health), are commercially available though not usually covered by commercial insurers.¹⁴ A third test, IsoPSA (Cleveland Diagnostics), is under development. Most hospital laboratories will be able to be run this test with no need for a central laboratory.¹⁵ All 3 tests have been shown to reduce unnecessary biopsies (because of a low probability of finding a biologically significant cancer) by 30% to 45% and will help reduce overdetection.

Moreover, multiparametric magnetic resonance imaging of the prostate has been shown to improve detection of high-grade cancers,¹⁶ and a randomized trial has suggested that its incorporation into a screening strategy is cost-effective and could be better than PSA testing plus transrectal ultrasonography alone (the current standard of care).¹⁷

Several risk scores based on germline genomics also hold promise for better identifying those at risk and for helping to de-intensify screening for those unlikely to have high-grade cancer.¹⁸

Screening for prostate cancer reduces mortality rates and the burden of metastatic disease, and the paradigm continues to evolve. Men at risk by virtue of age (55 to 69, and healthy men > 70), family history, race, and newly identified factors (germline genetics) all deserve an informed discussion on the benefits and risks of screening

My urologic career began in the late 1980s, just before prostate-specific antigen (PSA) testing was introduced. Ever since, a busy prostate cancer practice has given me a frontline view of the benefits and possible harms of PSA screening.

See related article

In the pre-PSA era, about half of men with newly diagnosed prostate cancer presented with incurable disease, either locally advanced or metastatic. The most common treatment was bilateral orchiectomy, which was the only safe form of androgen deprivation available.

Fast-forward a few years to the mid-1990s. Within 5 years after the introduction of PSA testing, the rate of incurable disease at diagnosis fell to just 5%, and treatment for localized disease skyrocketed, including radical prostatectomy, external beam radiation, and brachytherapy. As a result of earlier diagnosis and improved treatments, the death rate from prostate cancer in US men has fallen more than 30% since 1990.

The first-hand experience of seeing this massive stage migration to curable disease has forever convinced me that PSA screening is beneficial. Robust statistical models lend credence to this belief, with estimates that screening is responsible for 45% to 70% of this decline in mortality.¹

Fast-forward again to 2012, when the US Preventive Services Task Force (USPSTF) published a strong recommendation against screening. The recommendation had so much force that as recently as 2014, only 11% of men at highest risk of prostate cancer in the Cleveland Clinic system were screened for it,² mirroring national trends.

What happened? Colored by the experience in the era before PSA, when men presented frequently with painful metastatic disease and had an average life expectancy of 18 to 24 months, it was widely believed that all detected prostate cancer required treatment. What was not appreciated was that while PSA detects lots of prostate cancer, the most common reason for PSA levels to reach a range worrisome enough to trigger biopsy was actually benign prostatic hypertrophy.

The resulting increase in the number of biopsies resulted in the detection of a substantial number of low-grade cancers that were never destined to cause clinical harm but that got treated anyway, based on the fear that all cancers had metastatic potential. The USPSTF based its recommendation against screening on the harms caused by this overdetection and overtreatment of nonlethal disease, focusing on risks of biopsy such as sepsis, and on treatment-related adverse effects such as changes in urinary, bowel, and sexual function.

RANDOMIZED TRIALS SHOW A BENEFIT FROM SCREENING

As a result of this controversy, several large randomized trials designed to test whether PSA screening was beneficial were organized and begun in the 1990s, with one in the United States and another in Europe.^3,4 Mature data from both trials have now established that there is indeed benefit to population-level screening.

The US Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), was initially reported to show no difference in prostate cancer-specific mortality rates in those screened vs not screened, but because more than 90% of the men in the no-screening arm were screened anyway, that conclusion is erroneous.³

With 13-year follow-up and far less PSA contamination in the unscreened arm, the European Randomized Study of Screening for Prostate Cancer (ERSPC) in men ages 55 to 69 demonstrated a 27% reduction in the rate of death and a 35% reduction in the need for palliative treatments (androgen deprivation or radiation, or both) for metastatic disease in those screened vs not screened, clearly establishing substantial clinical benefit to PSA screening.⁴

A recent analysis of both trials that controlled for PSA drop-ins (comparing those actually screened with those actually not screened) concluded that the benefit of screening in terms of mortality reduction (estimated at about 30%) are equal in both trials.⁵ A large cohort study from Kaiser Permanente with 16-year follow-up has suggested that PSA screening has both a prostate cancer-specific benefit and an overall mortality benefit.⁶

In parallel with the design and completion of these trials, there was a significant effort to better identify and manage patients initially overdiagnosed with nonlethal cancers by developing active surveillance regimens.

This management strategy recognizes that most low-grade cancers pose no short-term risk to the patient’s health or longevity, that definitive therapy can be deferred, and that with regular monitoring by digital rectal examination, PSA measurement, and repeat biopsy, cancers that progress can still be cured. The result of this strategy is a marked reduction in the harms caused by overtreatment (ie, the aforementioned adverse effects), as well as the avoidance of unnecessary treatment in many patients.

A randomized trial and 2 large prospective cohort studies have confirmed the long-term safety of this approach,^7–9 and the development of commercially available, biopsy-based gene expression profiling tools promises to further improve risk stratification at diagnosis and during follow-up for individual patients.¹⁰

NEW USPSTF RECOMMENDATIONS: AN INDIVIDUAL, INFORMED DECISION

Based on the results of the ERSPC and the widespread adoption and safety of active surveillance, which together show benefit to screening and fewer harms in overdetection and overtreatment, in 2018 the USPSTF recast its recommendations. In upgrading the recommendation from “D” to “C,” the recommendation now states that for men ages 55 to 69, PSA screening should be an individual decision after a discussion with an informed provider, although men over 70 are still advised not to undergo screening at all.¹¹

Some may think that this recommendation has arrived just in time, or that it should be  made even stronger to actually recommend screening, as recent data from 2 national registries—the Surveillance, Epidemiology, and End Results program and the National Cancer Database—show that the fall in screening after the 2012 USPSTF guidelines has resulted in an increase in men presenting with advanced stage disease.^12,13 (All of you Back to the Future fans, please return to the mid to late 1980s to see how that plays out.)

So the pendulum has now swung back in favor of screening, largely supported by solid data showing meaningful clinical benefit, better understanding of PSA and prostate cancer biology, and adoption of active surveillance.

AN IDEAL SCREENING PROGRAM

An ideal screening program would detect only biologically significant cancers, thus eliminating overdetection and overtreatment. There is reason for optimism on this front.

Second-generation PSA tests have better diagnostic accuracy for high-grade disease than earlier tests. Two such tests, the Prostate Health Index (Beckman Coulter) and the 4K-score (Opko Health), are commercially available though not usually covered by commercial insurers.¹⁴ A third test, IsoPSA (Cleveland Diagnostics), is under development. Most hospital laboratories will be able to be run this test with no need for a central laboratory.¹⁵ All 3 tests have been shown to reduce unnecessary biopsies (because of a low probability of finding a biologically significant cancer) by 30% to 45% and will help reduce overdetection.

Moreover, multiparametric magnetic resonance imaging of the prostate has been shown to improve detection of high-grade cancers,¹⁶ and a randomized trial has suggested that its incorporation into a screening strategy is cost-effective and could be better than PSA testing plus transrectal ultrasonography alone (the current standard of care).¹⁷

Several risk scores based on germline genomics also hold promise for better identifying those at risk and for helping to de-intensify screening for those unlikely to have high-grade cancer.¹⁸

Screening for prostate cancer reduces mortality rates and the burden of metastatic disease, and the paradigm continues to evolve. Men at risk by virtue of age (55 to 69, and healthy men > 70), family history, race, and newly identified factors (germline genetics) all deserve an informed discussion on the benefits and risks of screening

Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.^1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.^1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.¹

olavs/Thinkstock

Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.³ And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,^1,4 and is noted for conferring antiaging benefits.⁵

Acne and other inflammatory conditions

The use of topical taurine bromamine, the physiological product of hypobromous acid and taurine, is one of the new emerging approaches to treating acne.^6,7

In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H₂O₂ production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.³

Wide-ranging protection potential

In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.²

Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.¹

Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.⁸
 

Penetration enhancement

In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.⁹

Possible skin whitening and anti-aging roles and other promising lab results

Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.¹⁰

In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.⁵

Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.¹¹

In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.⁴

Conclusion

Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].

References

1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.

2. J Invest Dermatol. 2003 Aug;121(2):354-61.

3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.

4. Adv Biomed Res. 2014 Oct 7;3:204.

5. Adv Exp Med Biol. 2015;803:481-7.

6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.

7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.

8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.

9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.

10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.

11. Adv Exp Med Biol. 2015;803:167-77.

Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.^1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.^1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.¹

olavs/Thinkstock

Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.³ And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,^1,4 and is noted for conferring antiaging benefits.⁵

Acne and other inflammatory conditions

The use of topical taurine bromamine, the physiological product of hypobromous acid and taurine, is one of the new emerging approaches to treating acne.^6,7

In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H₂O₂ production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.³

Wide-ranging protection potential

In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.²

Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.¹

Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.⁸
 

Penetration enhancement

In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.⁹

Possible skin whitening and anti-aging roles and other promising lab results

Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.¹⁰

In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.⁵

Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.¹¹

In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.⁴

Conclusion

Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].

References

1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.

2. J Invest Dermatol. 2003 Aug;121(2):354-61.

3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.

4. Adv Biomed Res. 2014 Oct 7;3:204.

5. Adv Exp Med Biol. 2015;803:481-7.

6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.

7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.

8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.

9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.

10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.

11. Adv Exp Med Biol. 2015;803:167-77.

Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.^1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.^1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.¹

olavs/Thinkstock

Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.³ And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,^1,4 and is noted for conferring antiaging benefits.⁵

Acne and other inflammatory conditions

The use of topical taurine bromamine, the physiological product of hypobromous acid and taurine, is one of the new emerging approaches to treating acne.^6,7

In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H₂O₂ production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.³

Wide-ranging protection potential

In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.²

Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.¹

Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.⁸
 

Penetration enhancement

In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.⁹

Possible skin whitening and anti-aging roles and other promising lab results

Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.¹⁰

In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.⁵

Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.¹¹

In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.⁴

Conclusion

Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].

References

1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.

2. J Invest Dermatol. 2003 Aug;121(2):354-61.

3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.

4. Adv Biomed Res. 2014 Oct 7;3:204.

5. Adv Exp Med Biol. 2015;803:481-7.

6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.

7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.

8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.

9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.

10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.

11. Adv Exp Med Biol. 2015;803:167-77.

I very much enjoyed your fascinating case report “Xenomelia: Profile of a man with intense desire to amputate a healthy limb” (Current Psychiatry, August 2018, p. 34-36, 41-43) and your hypotheses regarding neurodevelopmental correlates to xenomelia and related disorders such as apotemnophilia and body dysmorphia. However, you comment that because your patient’s desire to have a limb removed began in early childhood, before genital sexual maturation, the condition must be “…independent of sexuality.” This omits Sigmund Freud’s adumbration of infantile sexuality (oral, anal, phallic stages) with the phallic stage of infantile sexuality reaching a period of strong arousal between age 3 and 5, which is at the height of the Oedipus and Electra complexes.

Your patient traced the history of his desire to amputate his leg (as do other individuals with xenomelia) to age 4, when he saw a man with a missing limb, which made a vivid impression on him. As you discuss, this was probably a moment when he had an intensely psychosexual imprinting of this perception. However, the actual memory of the man with the amputation may well have been a screen memory for other more arousing and traumatic experiences that the patient experienced at this early age, such as castration anxiety with or without actual overstimulation of the physical body.

Nathan Szajnberg, MD, and I reported a case of a man who desired that his partner pretend to be an amputee in order to strengthen sexual arousal, an arousal that he recalled having as early as age 5 or 6.¹ The report traced this fetish back to research films of his upbringing, which indicated heightened physical stimulation in very early life.² As we wrote, “The case provides unusual information about the manner in which early childhood events interdigitate with intrapsychic processes and mental structuralisation.” This has led me to wonder if similar mental processes are at work in the current wave of young people who are convinced that they are a different gender than the one indicated by their anatomy.

I very much enjoyed your fascinating case report “Xenomelia: Profile of a man with intense desire to amputate a healthy limb” (Current Psychiatry, August 2018, p. 34-36, 41-43) and your hypotheses regarding neurodevelopmental correlates to xenomelia and related disorders such as apotemnophilia and body dysmorphia. However, you comment that because your patient’s desire to have a limb removed began in early childhood, before genital sexual maturation, the condition must be “…independent of sexuality.” This omits Sigmund Freud’s adumbration of infantile sexuality (oral, anal, phallic stages) with the phallic stage of infantile sexuality reaching a period of strong arousal between age 3 and 5, which is at the height of the Oedipus and Electra complexes.

Your patient traced the history of his desire to amputate his leg (as do other individuals with xenomelia) to age 4, when he saw a man with a missing limb, which made a vivid impression on him. As you discuss, this was probably a moment when he had an intensely psychosexual imprinting of this perception. However, the actual memory of the man with the amputation may well have been a screen memory for other more arousing and traumatic experiences that the patient experienced at this early age, such as castration anxiety with or without actual overstimulation of the physical body.

Nathan Szajnberg, MD, and I reported a case of a man who desired that his partner pretend to be an amputee in order to strengthen sexual arousal, an arousal that he recalled having as early as age 5 or 6.¹ The report traced this fetish back to research films of his upbringing, which indicated heightened physical stimulation in very early life.² As we wrote, “The case provides unusual information about the manner in which early childhood events interdigitate with intrapsychic processes and mental structuralisation.” This has led me to wonder if similar mental processes are at work in the current wave of young people who are convinced that they are a different gender than the one indicated by their anatomy.

I very much enjoyed your fascinating case report “Xenomelia: Profile of a man with intense desire to amputate a healthy limb” (Current Psychiatry, August 2018, p. 34-36, 41-43) and your hypotheses regarding neurodevelopmental correlates to xenomelia and related disorders such as apotemnophilia and body dysmorphia. However, you comment that because your patient’s desire to have a limb removed began in early childhood, before genital sexual maturation, the condition must be “…independent of sexuality.” This omits Sigmund Freud’s adumbration of infantile sexuality (oral, anal, phallic stages) with the phallic stage of infantile sexuality reaching a period of strong arousal between age 3 and 5, which is at the height of the Oedipus and Electra complexes.

Your patient traced the history of his desire to amputate his leg (as do other individuals with xenomelia) to age 4, when he saw a man with a missing limb, which made a vivid impression on him. As you discuss, this was probably a moment when he had an intensely psychosexual imprinting of this perception. However, the actual memory of the man with the amputation may well have been a screen memory for other more arousing and traumatic experiences that the patient experienced at this early age, such as castration anxiety with or without actual overstimulation of the physical body.

Nathan Szajnberg, MD, and I reported a case of a man who desired that his partner pretend to be an amputee in order to strengthen sexual arousal, an arousal that he recalled having as early as age 5 or 6.¹ The report traced this fetish back to research films of his upbringing, which indicated heightened physical stimulation in very early life.² As we wrote, “The case provides unusual information about the manner in which early childhood events interdigitate with intrapsychic processes and mental structuralisation.” This has led me to wonder if similar mental processes are at work in the current wave of young people who are convinced that they are a different gender than the one indicated by their anatomy.

Although I look forward to receiving JFP each month, I was initially disappointed in Dr. Jonathon M. Firnhaber’s article, “Newer cholesterol-lowering agents: What you must know” (J Fam Pract. 2018;67:339-341,344,345), because of what appeared to be a superficial discussion of the medication ezetimibe. The potential role of PCSK9 inhibitors in extremely high-risk individuals was well discussed, but my first read left me with the impression that ezetimibe should be used more widely.

It seemed that in the section for ezetimibe, the author was suggesting using it for primary prevention. The line, “Consider adding ezetimibe to maximally tolerated statin therapy for patients not meeting LDL-C goals with a statin alone” left me a bit confused, as the most widely used guideline (that by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines) states that there is no goal low-density lipoprotein cholesterol (LDL-C) level for primary prevention in patients without known cardiovascular disease (CVD) because studies have not been done to support this concept.¹

But upon rereading the article, I realized the statement was placed at the end of a section that discussed secondary prevention based on the IMPROVE-IT study.² This trial included only patients with previous acute coronary syndrome, one of the populations at highest risk.

I write just to reinforce the importance of considering what evidence we have for primary prevention. Although there is a value to rechecking LDL-C levels to assess compliance, there really is no convincing evidence that we should treat to a goal LDL-C level in someone who does not already have CVD. So the addition of ezetimibe to a statin in these patients is not recommended. Thus, the often-quoted strategy: “Start them on the right statin, and don’t look back.”

Bill Crump, MD
Madisonville, Ky

1. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S1-S45.

2. Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387-2397.

Continue to: Authors' response

Author’s response:

Thank you, Dr. Crump, for your feedback. I suspect that most clinicians would welcome more robust outcomes data on ezetimibe, but to date none have been published.

The IMPROVE-IT trial¹ offers the best supportive evidence for the use of ezetimibe, but still finds only a 2% absolute risk reduction (ARR) in a composite endpoint (cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization ≥30 days after randomization, or nonfatal stroke), equating to a number needed to treat (NNT) of 50.

Most clinicians would welcome more robust outcomes data on ezetimibe, but to date none have been published.

The largest meta-analysis of ezetimibe trials—published prior to IMPROVE-IT—combined 31,048 patients to find an ARR for myocardial infarction of 1.1% (NNT=91) and an ARR for stroke of 0.6% (NNT=167), with no difference in cardiovascular death.²

Because of its limited outcomes data, ezetimibe is best reserved for patients unable to tolerate statin therapy, for those in whom statin therapy is contraindicated, or for those not meeting LDL-C reduction goals with a statin alone. This position is also supported by the United Kingdom’s National Institute for Health and Care Excellence (NICE).³

Finally, you are correct that the 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk does not advocate a number-driven LDL-C goal, but rather recommends a risk-based moderate (30%-50%) or high-intensity (>50%) LDL-C reduction goal.⁴

Jonathon Firnhaber, MD
Greenville, NC

1. Cannon C, Blazing M, Giugliano R, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387-2397.

2. Savarese G, Ferrari G, Rosano G, et al. Safety and efficacy of ezetimibe: a meta-analysis. Int J Cardiol. 2015;201:247-252.

3. National Institute for Health and Care Excellence. Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia. Technology appraisal guidance [TA385]. February 24, 2016. www.nice.org.uk/guidance/ta385. Accessed September 12, 2018.

4. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2935-2959. 

Although I look forward to receiving JFP each month, I was initially disappointed in Dr. Jonathon M. Firnhaber’s article, “Newer cholesterol-lowering agents: What you must know” (J Fam Pract. 2018;67:339-341,344,345), because of what appeared to be a superficial discussion of the medication ezetimibe. The potential role of PCSK9 inhibitors in extremely high-risk individuals was well discussed, but my first read left me with the impression that ezetimibe should be used more widely.

It seemed that in the section for ezetimibe, the author was suggesting using it for primary prevention. The line, “Consider adding ezetimibe to maximally tolerated statin therapy for patients not meeting LDL-C goals with a statin alone” left me a bit confused, as the most widely used guideline (that by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines) states that there is no goal low-density lipoprotein cholesterol (LDL-C) level for primary prevention in patients without known cardiovascular disease (CVD) because studies have not been done to support this concept.¹

But upon rereading the article, I realized the statement was placed at the end of a section that discussed secondary prevention based on the IMPROVE-IT study.² This trial included only patients with previous acute coronary syndrome, one of the populations at highest risk.

I write just to reinforce the importance of considering what evidence we have for primary prevention. Although there is a value to rechecking LDL-C levels to assess compliance, there really is no convincing evidence that we should treat to a goal LDL-C level in someone who does not already have CVD. So the addition of ezetimibe to a statin in these patients is not recommended. Thus, the often-quoted strategy: “Start them on the right statin, and don’t look back.”

Bill Crump, MD
Madisonville, Ky

1. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S1-S45.

2. Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387-2397.

Continue to: Authors' response

Author’s response:

Thank you, Dr. Crump, for your feedback. I suspect that most clinicians would welcome more robust outcomes data on ezetimibe, but to date none have been published.

The IMPROVE-IT trial¹ offers the best supportive evidence for the use of ezetimibe, but still finds only a 2% absolute risk reduction (ARR) in a composite endpoint (cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization ≥30 days after randomization, or nonfatal stroke), equating to a number needed to treat (NNT) of 50.

Most clinicians would welcome more robust outcomes data on ezetimibe, but to date none have been published.

The largest meta-analysis of ezetimibe trials—published prior to IMPROVE-IT—combined 31,048 patients to find an ARR for myocardial infarction of 1.1% (NNT=91) and an ARR for stroke of 0.6% (NNT=167), with no difference in cardiovascular death.²

Because of its limited outcomes data, ezetimibe is best reserved for patients unable to tolerate statin therapy, for those in whom statin therapy is contraindicated, or for those not meeting LDL-C reduction goals with a statin alone. This position is also supported by the United Kingdom’s National Institute for Health and Care Excellence (NICE).³

Finally, you are correct that the 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk does not advocate a number-driven LDL-C goal, but rather recommends a risk-based moderate (30%-50%) or high-intensity (>50%) LDL-C reduction goal.⁴

Jonathon Firnhaber, MD
Greenville, NC

1. Cannon C, Blazing M, Giugliano R, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387-2397.

2. Savarese G, Ferrari G, Rosano G, et al. Safety and efficacy of ezetimibe: a meta-analysis. Int J Cardiol. 2015;201:247-252.

3. National Institute for Health and Care Excellence. Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia. Technology appraisal guidance [TA385]. February 24, 2016. www.nice.org.uk/guidance/ta385. Accessed September 12, 2018.

4. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2935-2959. 

Although I look forward to receiving JFP each month, I was initially disappointed in Dr. Jonathon M. Firnhaber’s article, “Newer cholesterol-lowering agents: What you must know” (J Fam Pract. 2018;67:339-341,344,345), because of what appeared to be a superficial discussion of the medication ezetimibe. The potential role of PCSK9 inhibitors in extremely high-risk individuals was well discussed, but my first read left me with the impression that ezetimibe should be used more widely.

It seemed that in the section for ezetimibe, the author was suggesting using it for primary prevention. The line, “Consider adding ezetimibe to maximally tolerated statin therapy for patients not meeting LDL-C goals with a statin alone” left me a bit confused, as the most widely used guideline (that by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines) states that there is no goal low-density lipoprotein cholesterol (LDL-C) level for primary prevention in patients without known cardiovascular disease (CVD) because studies have not been done to support this concept.¹

But upon rereading the article, I realized the statement was placed at the end of a section that discussed secondary prevention based on the IMPROVE-IT study.² This trial included only patients with previous acute coronary syndrome, one of the populations at highest risk.

I write just to reinforce the importance of considering what evidence we have for primary prevention. Although there is a value to rechecking LDL-C levels to assess compliance, there really is no convincing evidence that we should treat to a goal LDL-C level in someone who does not already have CVD. So the addition of ezetimibe to a statin in these patients is not recommended. Thus, the often-quoted strategy: “Start them on the right statin, and don’t look back.”

Bill Crump, MD
Madisonville, Ky

1. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S1-S45.

2. Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387-2397.

Continue to: Authors' response

Author’s response:

Thank you, Dr. Crump, for your feedback. I suspect that most clinicians would welcome more robust outcomes data on ezetimibe, but to date none have been published.

The IMPROVE-IT trial¹ offers the best supportive evidence for the use of ezetimibe, but still finds only a 2% absolute risk reduction (ARR) in a composite endpoint (cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization ≥30 days after randomization, or nonfatal stroke), equating to a number needed to treat (NNT) of 50.

Most clinicians would welcome more robust outcomes data on ezetimibe, but to date none have been published.

The largest meta-analysis of ezetimibe trials—published prior to IMPROVE-IT—combined 31,048 patients to find an ARR for myocardial infarction of 1.1% (NNT=91) and an ARR for stroke of 0.6% (NNT=167), with no difference in cardiovascular death.²

Because of its limited outcomes data, ezetimibe is best reserved for patients unable to tolerate statin therapy, for those in whom statin therapy is contraindicated, or for those not meeting LDL-C reduction goals with a statin alone. This position is also supported by the United Kingdom’s National Institute for Health and Care Excellence (NICE).³

Finally, you are correct that the 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk does not advocate a number-driven LDL-C goal, but rather recommends a risk-based moderate (30%-50%) or high-intensity (>50%) LDL-C reduction goal.⁴

Jonathon Firnhaber, MD
Greenville, NC

1. Cannon C, Blazing M, Giugliano R, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387-2397.

2. Savarese G, Ferrari G, Rosano G, et al. Safety and efficacy of ezetimibe: a meta-analysis. Int J Cardiol. 2015;201:247-252.

3. National Institute for Health and Care Excellence. Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia. Technology appraisal guidance [TA385]. February 24, 2016. www.nice.org.uk/guidance/ta385. Accessed September 12, 2018.

4. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2935-2959. 

Based on the magnetic resonance imaging (MRI) scans presented in the Case Report, “Bilateral wrist pain • limited range of motion • tenderness to palpation • Dx?” (J Fam Pract. 2018;67:160-162), I disagree with the diagnosis.

Contrary to the assertion by Drs. Shehata and Hizon that the patient had “fractures extending through the scaphoid waist,” this young girl actually had bilateral osseous contusions (ie, microtrabecular fractures) of the radial aspect of the scaphoid and did not have complete scaphoid waist fractures. Also, the MRI scans demonstrate intact ulnar cortices bilaterally, indicating that there is no complete scaphoid waist fracture.

These are typical “FOOSH” (fall on outstretched hand) injuries and would be expected to have an exceedingly good prognosis with immobilization. As to whether or not this affects medical management, such as how long the cast remains on the arm, I would have to defer to an orthopedic surgeon’s judgment.

David R. Pennes, MD
Grand Rapids, Mich

Continue to: Author's response

Author’s response:

Thank you for your comments. You are correct that the MRI scans shown do not demonstrate a complete fracture through the scaphoid, but rather a microtrabecular fracture. We did not intend to make the distinction between the 2 entities because management for both is similar. The teaching point of this case was to impress upon clinicians that these types of fractures may be subtle even on MRI, and that if they are not treated appropriately, they can progress to complete fracture or result in non-union and long-term pain and disability.

Jerry Hizon, MD
Riverside, Calif

Based on the magnetic resonance imaging (MRI) scans presented in the Case Report, “Bilateral wrist pain • limited range of motion • tenderness to palpation • Dx?” (J Fam Pract. 2018;67:160-162), I disagree with the diagnosis.

Contrary to the assertion by Drs. Shehata and Hizon that the patient had “fractures extending through the scaphoid waist,” this young girl actually had bilateral osseous contusions (ie, microtrabecular fractures) of the radial aspect of the scaphoid and did not have complete scaphoid waist fractures. Also, the MRI scans demonstrate intact ulnar cortices bilaterally, indicating that there is no complete scaphoid waist fracture.

These are typical “FOOSH” (fall on outstretched hand) injuries and would be expected to have an exceedingly good prognosis with immobilization. As to whether or not this affects medical management, such as how long the cast remains on the arm, I would have to defer to an orthopedic surgeon’s judgment.

David R. Pennes, MD
Grand Rapids, Mich

Continue to: Author's response

Author’s response:

Thank you for your comments. You are correct that the MRI scans shown do not demonstrate a complete fracture through the scaphoid, but rather a microtrabecular fracture. We did not intend to make the distinction between the 2 entities because management for both is similar. The teaching point of this case was to impress upon clinicians that these types of fractures may be subtle even on MRI, and that if they are not treated appropriately, they can progress to complete fracture or result in non-union and long-term pain and disability.

Jerry Hizon, MD
Riverside, Calif

Based on the magnetic resonance imaging (MRI) scans presented in the Case Report, “Bilateral wrist pain • limited range of motion • tenderness to palpation • Dx?” (J Fam Pract. 2018;67:160-162), I disagree with the diagnosis.

Contrary to the assertion by Drs. Shehata and Hizon that the patient had “fractures extending through the scaphoid waist,” this young girl actually had bilateral osseous contusions (ie, microtrabecular fractures) of the radial aspect of the scaphoid and did not have complete scaphoid waist fractures. Also, the MRI scans demonstrate intact ulnar cortices bilaterally, indicating that there is no complete scaphoid waist fracture.

These are typical “FOOSH” (fall on outstretched hand) injuries and would be expected to have an exceedingly good prognosis with immobilization. As to whether or not this affects medical management, such as how long the cast remains on the arm, I would have to defer to an orthopedic surgeon’s judgment.

David R. Pennes, MD
Grand Rapids, Mich

Continue to: Author's response

Author’s response:

Thank you for your comments. You are correct that the MRI scans shown do not demonstrate a complete fracture through the scaphoid, but rather a microtrabecular fracture. We did not intend to make the distinction between the 2 entities because management for both is similar. The teaching point of this case was to impress upon clinicians that these types of fractures may be subtle even on MRI, and that if they are not treated appropriately, they can progress to complete fracture or result in non-union and long-term pain and disability.

Jerry Hizon, MD
Riverside, Calif

Twenty years ago, the American Journal of Preventive Medicine published Felitti and colleagues’ seminal publication on the relationship between adverse childhood experiences (ACEs) and poor mental and physical health.¹ It is astonishing that mainstream medicine is only now taking this finding seriously under the current banner of “trauma informed care.” Better late than never.

In this issue of JFP, Stillerman provides a cogent summary of the research on diagnosis and treatment of ACEs performed over the past 20 years. There are good data supporting the effectiveness of identifying and treating ACEs to lessen the adverse health outcomes that can result. More important, however, is taking a public health approach to preventing the adverse health effects of ACEs by staging community interventions and providing support to new mothers and families.

Research strongly supports a causal relationship between ACEs and a host of mental and physical ailments. Felitti found that adults with 4 or more ACEs compared with none had a 4- to 12-fold increased health risk for alcoholism, drug abuse, depression, and suicide attempt. ACEs also increased the risk of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.¹

The research strongly supports a causal relationship between adverse childhood experiences and a host of mental and physical ailments.

There is need for further research on screening for, and treating, ACEs. A large randomized trial using one of the practical brief screeners would help us learn more about the impact that screening can have on the mental and physical health of those affected. Does the identification and empathetic acknowledgement of the traumatic events lead to improved health? If it does not, what type of treatment is most effective?

Continue to: Pending further research...

Pending further research, here are 3 steps that family physicians can take today:

1. Be aware of the strength of the relationship between ACEs and health problems.
2. Begin screening adults and children for ACEs using one of the simple, validated screening tools described by Stillerman. In a large follow-up study, screening along with discussion of the results with the patient’s physician led to remarkable decreases in health care utilization in the year following screening, which suggests that there are therapeutic benefits to bringing ACEs to light and fostering discussion.²
3. Remain ever compassionate in your interactions with all patients, knowing that many have significant childhood scars.

Twenty years ago, the American Journal of Preventive Medicine published Felitti and colleagues’ seminal publication on the relationship between adverse childhood experiences (ACEs) and poor mental and physical health.¹ It is astonishing that mainstream medicine is only now taking this finding seriously under the current banner of “trauma informed care.” Better late than never.

In this issue of JFP, Stillerman provides a cogent summary of the research on diagnosis and treatment of ACEs performed over the past 20 years. There are good data supporting the effectiveness of identifying and treating ACEs to lessen the adverse health outcomes that can result. More important, however, is taking a public health approach to preventing the adverse health effects of ACEs by staging community interventions and providing support to new mothers and families.

Research strongly supports a causal relationship between ACEs and a host of mental and physical ailments. Felitti found that adults with 4 or more ACEs compared with none had a 4- to 12-fold increased health risk for alcoholism, drug abuse, depression, and suicide attempt. ACEs also increased the risk of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.¹

The research strongly supports a causal relationship between adverse childhood experiences and a host of mental and physical ailments.

There is need for further research on screening for, and treating, ACEs. A large randomized trial using one of the practical brief screeners would help us learn more about the impact that screening can have on the mental and physical health of those affected. Does the identification and empathetic acknowledgement of the traumatic events lead to improved health? If it does not, what type of treatment is most effective?

Continue to: Pending further research...

Pending further research, here are 3 steps that family physicians can take today:

1. Be aware of the strength of the relationship between ACEs and health problems.
2. Begin screening adults and children for ACEs using one of the simple, validated screening tools described by Stillerman. In a large follow-up study, screening along with discussion of the results with the patient’s physician led to remarkable decreases in health care utilization in the year following screening, which suggests that there are therapeutic benefits to bringing ACEs to light and fostering discussion.²
3. Remain ever compassionate in your interactions with all patients, knowing that many have significant childhood scars.

Twenty years ago, the American Journal of Preventive Medicine published Felitti and colleagues’ seminal publication on the relationship between adverse childhood experiences (ACEs) and poor mental and physical health.¹ It is astonishing that mainstream medicine is only now taking this finding seriously under the current banner of “trauma informed care.” Better late than never.

In this issue of JFP, Stillerman provides a cogent summary of the research on diagnosis and treatment of ACEs performed over the past 20 years. There are good data supporting the effectiveness of identifying and treating ACEs to lessen the adverse health outcomes that can result. More important, however, is taking a public health approach to preventing the adverse health effects of ACEs by staging community interventions and providing support to new mothers and families.

Research strongly supports a causal relationship between ACEs and a host of mental and physical ailments. Felitti found that adults with 4 or more ACEs compared with none had a 4- to 12-fold increased health risk for alcoholism, drug abuse, depression, and suicide attempt. ACEs also increased the risk of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.¹

The research strongly supports a causal relationship between adverse childhood experiences and a host of mental and physical ailments.

There is need for further research on screening for, and treating, ACEs. A large randomized trial using one of the practical brief screeners would help us learn more about the impact that screening can have on the mental and physical health of those affected. Does the identification and empathetic acknowledgement of the traumatic events lead to improved health? If it does not, what type of treatment is most effective?

Continue to: Pending further research...

Pending further research, here are 3 steps that family physicians can take today:

1. Be aware of the strength of the relationship between ACEs and health problems.
2. Begin screening adults and children for ACEs using one of the simple, validated screening tools described by Stillerman. In a large follow-up study, screening along with discussion of the results with the patient’s physician led to remarkable decreases in health care utilization in the year following screening, which suggests that there are therapeutic benefits to bringing ACEs to light and fostering discussion.²
3. Remain ever compassionate in your interactions with all patients, knowing that many have significant childhood scars.

On Sept. 14 of this year, Apple executives took to the stage to tout the incredible benefits of their new Apple Watch Series 4. While impressively presented in typical Apple fashion, the watch appeared to be only an evolution – not a revolution – in wearable technology. Still, there were a few noteworthy aspects of the new model that seemed to shine a light on the direction of the industry as a whole, and these were all focused on health care.

Like products from FitBit, Garmin, and others, the new Apple Watch can monitor a user’s heart rate and notify if it goes too high or too low. In addition, the watch now includes “fall detection,” and can automatically call for help if its wearer has taken a spill and become unresponsive. Soon it will even be capable of recording a single-lead ECG and detecting atrial fibrillation. While this all sounds fantastic, it also raises an important question in the minds of many physicians (including us): What do we do with all of these new data?

Findings from a Digital Health Study published by the American Medical Association in 2016¹ reveal that most doctors are aware of growing advances in Mobile Health (mHealth). Interestingly, however, while 85% see potential advantages in mHealth, less than 30% have begun employing it in their practices. This speaks to an adoption divide and highlights the many barriers to overcome before we can bridge it.

First and foremost, providers need confidence in the accuracy of the monitoring equipment, and, thus far, that accuracy has been questionable. Heart rate measurement, for example, is a staple of all currently available fitness wearables, yet is replete with technological pitfalls. This is because most consumer devices rely on optical sensors to measure heart rate. While inexpensive and noninvasive, the accuracy of these sensors can be affected by the interference of sweat, movement, and even the patient’s skin conditions – so much so that FitBit is currently embroiled in a class action lawsuit² over the issue, in spite of providing disclaimers that a FitBit is “not a medical device.” To improve heart-monitoring capability, Apple has changed to a new sensor technology for this latest generation of Apple Watch. So far its accuracy has yet to be proven, and Apple’s delay in releasing the ECG features until “later this year” suggests there may still be bugs to work out.

Another significant concern raised by the onslaught of wearable health data is how to incorporate it into the electronic health record. Physicians care about efficient data integration, and, when asked in the aforementioned AMA study, physicians named this as their No. 1 functional requirement. EHR vendors have made some strides to allow patients to upload monitoring data directly through an online portal, but the large variety of available consumer devices has made standardizing this process difficult. Doctors have also made it clear that they want it to be straightforward to access and use the information provided by patients, and don’t want it to require special training. These are considerable challenges that will require collaboration between EHR vendors and wearable manufacturers to solve.

The introduction of additional players into the health care space also evokes questions of who owns this new health data set, and who is accountable for its integrity. If history is any indicator, device manufacturers will try their best to eschew any liability, and shift culpability onto patients and physicians. This is causing malpractice insurers to rethink policy coverage and forcing doctors to face a new reality of having “too much information.” While we are excited about the potential for better access to patient monitoring data, we agree that physicians need to understand where their responsibility for these data begins and ends.

Likewise, patients need to understand who has access to their personal health information, and how it’s being used. Privacy concerns will only become more evident as our society becomes ever more connected and as technologies become more invasive. The term “wearable” may soon become antiquated, as more products are coming to market that cross the skin barrier to collect samples directly from the blood or interstitial fluid. Devices such as Abbott’s new FreeStyle Libre continuous blood glucose monitor can be worn for weeks at a time, with its tiny sensor placed just under the skin. It constantly monitors trends in blood sugar and produces enough data points to determine the eating, sleeping, and activity habits of its wearer. This is all uploadable to Abbott’s servers, allowing patients and their providers to review it, thereby further expanding their personal health information footprint.

One encouraging aspect of the expansion mobile health technology is its organic, patient-led adoption. This is quite different from the epoch of electronic health records, which was motivated largely by government financial incentives and resulted in expensive, inefficient software. Patients are expressing a greater desire to take ownership of their health and have a growing interest in personal fitness. Also, the size of the consumer marketplace is forcing vendors to create competitive, high-value, and user-friendly mHealth devices. These products may seem to offer endless possibilities, but patients, vendors, and providers must fully acknowledge existing limitations in order to truly spark a revolution in wearable technology and actually improve patient care.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

References

1. Digital Health Study: Physicians’ motivations and requirements for adopting digital clinical tools. (2016) American Medical Association.

2. Kate Mclellan et al. v. Fitbit Inc. Fitbit Heart Rate Monitors Fraud & Defects Lawsuit.

On Sept. 14 of this year, Apple executives took to the stage to tout the incredible benefits of their new Apple Watch Series 4. While impressively presented in typical Apple fashion, the watch appeared to be only an evolution – not a revolution – in wearable technology. Still, there were a few noteworthy aspects of the new model that seemed to shine a light on the direction of the industry as a whole, and these were all focused on health care.

Like products from FitBit, Garmin, and others, the new Apple Watch can monitor a user’s heart rate and notify if it goes too high or too low. In addition, the watch now includes “fall detection,” and can automatically call for help if its wearer has taken a spill and become unresponsive. Soon it will even be capable of recording a single-lead ECG and detecting atrial fibrillation. While this all sounds fantastic, it also raises an important question in the minds of many physicians (including us): What do we do with all of these new data?

Findings from a Digital Health Study published by the American Medical Association in 2016¹ reveal that most doctors are aware of growing advances in Mobile Health (mHealth). Interestingly, however, while 85% see potential advantages in mHealth, less than 30% have begun employing it in their practices. This speaks to an adoption divide and highlights the many barriers to overcome before we can bridge it.

First and foremost, providers need confidence in the accuracy of the monitoring equipment, and, thus far, that accuracy has been questionable. Heart rate measurement, for example, is a staple of all currently available fitness wearables, yet is replete with technological pitfalls. This is because most consumer devices rely on optical sensors to measure heart rate. While inexpensive and noninvasive, the accuracy of these sensors can be affected by the interference of sweat, movement, and even the patient’s skin conditions – so much so that FitBit is currently embroiled in a class action lawsuit² over the issue, in spite of providing disclaimers that a FitBit is “not a medical device.” To improve heart-monitoring capability, Apple has changed to a new sensor technology for this latest generation of Apple Watch. So far its accuracy has yet to be proven, and Apple’s delay in releasing the ECG features until “later this year” suggests there may still be bugs to work out.

Another significant concern raised by the onslaught of wearable health data is how to incorporate it into the electronic health record. Physicians care about efficient data integration, and, when asked in the aforementioned AMA study, physicians named this as their No. 1 functional requirement. EHR vendors have made some strides to allow patients to upload monitoring data directly through an online portal, but the large variety of available consumer devices has made standardizing this process difficult. Doctors have also made it clear that they want it to be straightforward to access and use the information provided by patients, and don’t want it to require special training. These are considerable challenges that will require collaboration between EHR vendors and wearable manufacturers to solve.

The introduction of additional players into the health care space also evokes questions of who owns this new health data set, and who is accountable for its integrity. If history is any indicator, device manufacturers will try their best to eschew any liability, and shift culpability onto patients and physicians. This is causing malpractice insurers to rethink policy coverage and forcing doctors to face a new reality of having “too much information.” While we are excited about the potential for better access to patient monitoring data, we agree that physicians need to understand where their responsibility for these data begins and ends.

Likewise, patients need to understand who has access to their personal health information, and how it’s being used. Privacy concerns will only become more evident as our society becomes ever more connected and as technologies become more invasive. The term “wearable” may soon become antiquated, as more products are coming to market that cross the skin barrier to collect samples directly from the blood or interstitial fluid. Devices such as Abbott’s new FreeStyle Libre continuous blood glucose monitor can be worn for weeks at a time, with its tiny sensor placed just under the skin. It constantly monitors trends in blood sugar and produces enough data points to determine the eating, sleeping, and activity habits of its wearer. This is all uploadable to Abbott’s servers, allowing patients and their providers to review it, thereby further expanding their personal health information footprint.

One encouraging aspect of the expansion mobile health technology is its organic, patient-led adoption. This is quite different from the epoch of electronic health records, which was motivated largely by government financial incentives and resulted in expensive, inefficient software. Patients are expressing a greater desire to take ownership of their health and have a growing interest in personal fitness. Also, the size of the consumer marketplace is forcing vendors to create competitive, high-value, and user-friendly mHealth devices. These products may seem to offer endless possibilities, but patients, vendors, and providers must fully acknowledge existing limitations in order to truly spark a revolution in wearable technology and actually improve patient care.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

References

1. Digital Health Study: Physicians’ motivations and requirements for adopting digital clinical tools. (2016) American Medical Association.

2. Kate Mclellan et al. v. Fitbit Inc. Fitbit Heart Rate Monitors Fraud & Defects Lawsuit.

On Sept. 14 of this year, Apple executives took to the stage to tout the incredible benefits of their new Apple Watch Series 4. While impressively presented in typical Apple fashion, the watch appeared to be only an evolution – not a revolution – in wearable technology. Still, there were a few noteworthy aspects of the new model that seemed to shine a light on the direction of the industry as a whole, and these were all focused on health care.

Like products from FitBit, Garmin, and others, the new Apple Watch can monitor a user’s heart rate and notify if it goes too high or too low. In addition, the watch now includes “fall detection,” and can automatically call for help if its wearer has taken a spill and become unresponsive. Soon it will even be capable of recording a single-lead ECG and detecting atrial fibrillation. While this all sounds fantastic, it also raises an important question in the minds of many physicians (including us): What do we do with all of these new data?

Findings from a Digital Health Study published by the American Medical Association in 2016¹ reveal that most doctors are aware of growing advances in Mobile Health (mHealth). Interestingly, however, while 85% see potential advantages in mHealth, less than 30% have begun employing it in their practices. This speaks to an adoption divide and highlights the many barriers to overcome before we can bridge it.

First and foremost, providers need confidence in the accuracy of the monitoring equipment, and, thus far, that accuracy has been questionable. Heart rate measurement, for example, is a staple of all currently available fitness wearables, yet is replete with technological pitfalls. This is because most consumer devices rely on optical sensors to measure heart rate. While inexpensive and noninvasive, the accuracy of these sensors can be affected by the interference of sweat, movement, and even the patient’s skin conditions – so much so that FitBit is currently embroiled in a class action lawsuit² over the issue, in spite of providing disclaimers that a FitBit is “not a medical device.” To improve heart-monitoring capability, Apple has changed to a new sensor technology for this latest generation of Apple Watch. So far its accuracy has yet to be proven, and Apple’s delay in releasing the ECG features until “later this year” suggests there may still be bugs to work out.

Another significant concern raised by the onslaught of wearable health data is how to incorporate it into the electronic health record. Physicians care about efficient data integration, and, when asked in the aforementioned AMA study, physicians named this as their No. 1 functional requirement. EHR vendors have made some strides to allow patients to upload monitoring data directly through an online portal, but the large variety of available consumer devices has made standardizing this process difficult. Doctors have also made it clear that they want it to be straightforward to access and use the information provided by patients, and don’t want it to require special training. These are considerable challenges that will require collaboration between EHR vendors and wearable manufacturers to solve.

The introduction of additional players into the health care space also evokes questions of who owns this new health data set, and who is accountable for its integrity. If history is any indicator, device manufacturers will try their best to eschew any liability, and shift culpability onto patients and physicians. This is causing malpractice insurers to rethink policy coverage and forcing doctors to face a new reality of having “too much information.” While we are excited about the potential for better access to patient monitoring data, we agree that physicians need to understand where their responsibility for these data begins and ends.

Likewise, patients need to understand who has access to their personal health information, and how it’s being used. Privacy concerns will only become more evident as our society becomes ever more connected and as technologies become more invasive. The term “wearable” may soon become antiquated, as more products are coming to market that cross the skin barrier to collect samples directly from the blood or interstitial fluid. Devices such as Abbott’s new FreeStyle Libre continuous blood glucose monitor can be worn for weeks at a time, with its tiny sensor placed just under the skin. It constantly monitors trends in blood sugar and produces enough data points to determine the eating, sleeping, and activity habits of its wearer. This is all uploadable to Abbott’s servers, allowing patients and their providers to review it, thereby further expanding their personal health information footprint.

One encouraging aspect of the expansion mobile health technology is its organic, patient-led adoption. This is quite different from the epoch of electronic health records, which was motivated largely by government financial incentives and resulted in expensive, inefficient software. Patients are expressing a greater desire to take ownership of their health and have a growing interest in personal fitness. Also, the size of the consumer marketplace is forcing vendors to create competitive, high-value, and user-friendly mHealth devices. These products may seem to offer endless possibilities, but patients, vendors, and providers must fully acknowledge existing limitations in order to truly spark a revolution in wearable technology and actually improve patient care.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

References

1. Digital Health Study: Physicians’ motivations and requirements for adopting digital clinical tools. (2016) American Medical Association.

2. Kate Mclellan et al. v. Fitbit Inc. Fitbit Heart Rate Monitors Fraud & Defects Lawsuit.

I recently saw Anaeli (not her real name), an 8-year-old Mexican American girl, in clinic for worsening constipation. Her mother brought her in because of a year’s worth of increasingly irregular bowel movements. Looking through her chart, it was easy to find the starting point of Anaeli’s constipation – it aligned with her father’s deportation. U.S. Immigration and Customs Enforcement had arrested him while he was dropping Anaeli off at school.

Family separation at the border has reignited awareness of the effects of adverse childhood events. As a young pediatrician training in San Diego, I see both the impact of immigration policies on children and the resulting need for trauma-informed care. We need coordinated efforts in homes, schools, and hospitals to effectively treat affected kids.

For the past year, Anaeli’s caregivers have struggled to do so. She has been acting out, frequently crying and throwing fits about going to school. Anaeli has missed about 30 days of school because of behavioral issues.

What does 30 fewer days of first grade look like? Anaeli’s language skills are at a standstill. She cannot follow complex directions like her peers. Because of her academic shortcomings, Anaeli earned an individualized education plan and a teacher’s aide to help her focus. This aide has adopted a “tough love” attitude. Anaeli’s mom reports that she is often disciplined by long time-outs in the classroom bathroom and worries that this discipline is causing Anaeli to withhold stool to a point of loosing control and soiling herself. Since working with the aide, Anaeli has been having daily “accidents,” stooling in her pants, despite being toilet trained for years.

After the appointment, I called the school three times and was finally able to get in touch with Anaeli’s aide. She expressed frustration over Anaeli’s “lack of trying” and “meltdown” reaction to discipline. She said Anaeli’s mom was not enforcing limits at home. She told me she had successfully used time-outs in the bathroom with her own children. When I reviewed the impact of childhood trauma and more appropriate approaches to discipline, the aide grew defensive and challenged me by asking if I have kids of my own.

While I disagreed with the aide’s methods, I understood her frustration. Anaeli is not easy to help. But she is just one of a generation of children affected by the deportation of a family member. Like them, Anaeli’s health is deeply affected by stress in a way that she many not be able to verbalize.

Trauma-informed care should be an essential lens for caregivers of children who have been separated from their family. Resolving Anaeli’s constipation will require a concerted effort by her mom, health providers, teachers, and aides to encourage good behavior, use measured disciplinary tactics, and consume a high-fiber diet. In doing so, we can provide children like her with the appropriate environment to build resilience.

Dr. Parekh is a pediatrician in San Diego. Email her at [email protected].

I recently saw Anaeli (not her real name), an 8-year-old Mexican American girl, in clinic for worsening constipation. Her mother brought her in because of a year’s worth of increasingly irregular bowel movements. Looking through her chart, it was easy to find the starting point of Anaeli’s constipation – it aligned with her father’s deportation. U.S. Immigration and Customs Enforcement had arrested him while he was dropping Anaeli off at school.

Family separation at the border has reignited awareness of the effects of adverse childhood events. As a young pediatrician training in San Diego, I see both the impact of immigration policies on children and the resulting need for trauma-informed care. We need coordinated efforts in homes, schools, and hospitals to effectively treat affected kids.

For the past year, Anaeli’s caregivers have struggled to do so. She has been acting out, frequently crying and throwing fits about going to school. Anaeli has missed about 30 days of school because of behavioral issues.

What does 30 fewer days of first grade look like? Anaeli’s language skills are at a standstill. She cannot follow complex directions like her peers. Because of her academic shortcomings, Anaeli earned an individualized education plan and a teacher’s aide to help her focus. This aide has adopted a “tough love” attitude. Anaeli’s mom reports that she is often disciplined by long time-outs in the classroom bathroom and worries that this discipline is causing Anaeli to withhold stool to a point of loosing control and soiling herself. Since working with the aide, Anaeli has been having daily “accidents,” stooling in her pants, despite being toilet trained for years.

After the appointment, I called the school three times and was finally able to get in touch with Anaeli’s aide. She expressed frustration over Anaeli’s “lack of trying” and “meltdown” reaction to discipline. She said Anaeli’s mom was not enforcing limits at home. She told me she had successfully used time-outs in the bathroom with her own children. When I reviewed the impact of childhood trauma and more appropriate approaches to discipline, the aide grew defensive and challenged me by asking if I have kids of my own.

While I disagreed with the aide’s methods, I understood her frustration. Anaeli is not easy to help. But she is just one of a generation of children affected by the deportation of a family member. Like them, Anaeli’s health is deeply affected by stress in a way that she many not be able to verbalize.

Trauma-informed care should be an essential lens for caregivers of children who have been separated from their family. Resolving Anaeli’s constipation will require a concerted effort by her mom, health providers, teachers, and aides to encourage good behavior, use measured disciplinary tactics, and consume a high-fiber diet. In doing so, we can provide children like her with the appropriate environment to build resilience.

Dr. Parekh is a pediatrician in San Diego. Email her at [email protected].

I recently saw Anaeli (not her real name), an 8-year-old Mexican American girl, in clinic for worsening constipation. Her mother brought her in because of a year’s worth of increasingly irregular bowel movements. Looking through her chart, it was easy to find the starting point of Anaeli’s constipation – it aligned with her father’s deportation. U.S. Immigration and Customs Enforcement had arrested him while he was dropping Anaeli off at school.

Family separation at the border has reignited awareness of the effects of adverse childhood events. As a young pediatrician training in San Diego, I see both the impact of immigration policies on children and the resulting need for trauma-informed care. We need coordinated efforts in homes, schools, and hospitals to effectively treat affected kids.

For the past year, Anaeli’s caregivers have struggled to do so. She has been acting out, frequently crying and throwing fits about going to school. Anaeli has missed about 30 days of school because of behavioral issues.

What does 30 fewer days of first grade look like? Anaeli’s language skills are at a standstill. She cannot follow complex directions like her peers. Because of her academic shortcomings, Anaeli earned an individualized education plan and a teacher’s aide to help her focus. This aide has adopted a “tough love” attitude. Anaeli’s mom reports that she is often disciplined by long time-outs in the classroom bathroom and worries that this discipline is causing Anaeli to withhold stool to a point of loosing control and soiling herself. Since working with the aide, Anaeli has been having daily “accidents,” stooling in her pants, despite being toilet trained for years.

After the appointment, I called the school three times and was finally able to get in touch with Anaeli’s aide. She expressed frustration over Anaeli’s “lack of trying” and “meltdown” reaction to discipline. She said Anaeli’s mom was not enforcing limits at home. She told me she had successfully used time-outs in the bathroom with her own children. When I reviewed the impact of childhood trauma and more appropriate approaches to discipline, the aide grew defensive and challenged me by asking if I have kids of my own.

While I disagreed with the aide’s methods, I understood her frustration. Anaeli is not easy to help. But she is just one of a generation of children affected by the deportation of a family member. Like them, Anaeli’s health is deeply affected by stress in a way that she many not be able to verbalize.

Trauma-informed care should be an essential lens for caregivers of children who have been separated from their family. Resolving Anaeli’s constipation will require a concerted effort by her mom, health providers, teachers, and aides to encourage good behavior, use measured disciplinary tactics, and consume a high-fiber diet. In doing so, we can provide children like her with the appropriate environment to build resilience.

Dr. Parekh is a pediatrician in San Diego. Email her at [email protected].

The Society for Pediatric Dermatology (SPD) was established in 1975, and the pediatric dermatology workforce shortage began shortly after. In 1986, Honig and Burke¹ reported that opportunities in pediatric dermatology were limited and that pediatric dermatologists were predominantly located in larger teaching hospitals and selected private practice settings; furthermore, only approximately 20% had patient populations comprising more than 75% children.¹ Positive changes have occurred since that time, with more practitioners dedicated to pediatric dermatology and increased opportunities within the specialty. The SPD has expanded to a thriving group of collegial pediatric dermatologists now topping 1200 members worldwide.

Although the SPD has strongly influenced practice development in pediatric dermatology, there are fewer than 300 board-certified pediatric dermatologists in the United States and approximately double that number of pediatric dermatology practitioners. The deficiency is glaring based on the national population alone. The US Census Bureau reported 325,719,178 individuals living in the United States (as of July 1, 2017).² With approximately 75 million children in the United States and estimates that 22.8% of the population is younger than 18 years,³ there currently is 1 pediatric dermatologist for every 120,000 children or more.

As if the numbers alone were not adequate, a number of publications have addressed the benefits of pediatric dermatologists in both dermatology and pediatrics training and furthermore in pediatric care. A 2004 survey of dermatology program directors and chairpersons regarding the issue of the pediatric dermatology workforce shortage revealed that 45 of 94 (47.9%) programs employed a pediatric dermatologist and 24 (25.5%) had been looking to hire one for more than a year.⁴ Although more pediatric dermatologists have joined the workforce, it is not surprising that programs with no pediatric dermatologists want them. First, pediatric dermatologists dramatically improve the quality of training with regard to pediatric dermatology education and can increase dermatology residents’ comfort level with children. In a survey of a group of graduating third-year dermatology residents, dermatology residency program directors, and pediatric dermatology fellowship program directors by Nijhawan et al,⁵ residents who were trained in a program with one or more full-time pediatric dermatologists were more likely to feel competent treating children and to feel satisfied with their training program’s pediatric dermatology curriculum than residents without contact with a full-time pediatric dermatologist (50.0% vs 5.9% [P=.002] and 85.3% vs 52.9% [P<.001], respectively). The availability of a pediatric dermatology fellowship further enhanced satisfaction. Residents in programs with no full-time pediatric dermatologist on staff were more likely to be somewhat or extremely dissatisfied with their pediatric dermatology training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (P<.01).⁵

Programs with pediatric dermatologists also offer easy access to a mentor in the field. In a 2010 survey of pediatric dermatologists (published in 2014), Admani et al⁶ reported that 84% (91/109) of respondents (board-certified pediatric dermatologists) cited mentorship as the most important factor influencing their career choice. Exposure to the specialty was noted as a key motivating factor. In my opinion, the actual inclusion of a pediatric dermatology fellowship, whether the position is filled or not, appears to increase the chances of expansion and retention in the field. In the 2014 SPD workforce survey, more than 62% (61/98) of respondents were fellowship trained.⁷ In 2004 there were only 6 pediatric dermatology fellowship training programs. We have come quite far now with 36 fellowships as of August 12, 2018.⁸ The cost of education of course is not simple when pediatric dermatology fellowships are unfunded by the Accreditation Council for Graduate Medical Education; however, it is clear that the initial investment can create ongoing returns in pediatric dermatology.

Furthermore, due to the outpatient burden of skin disease in a pediatrics practice, providing pediatric trainees with contact with a pediatric dermatologist is needed. Prindaville et al⁹ performed a review from 2006 through 2010 of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases, which revealed that 9% of 23 million pediatric visits during this time period were for dermatologic diseases; therefore, knowledge of pediatric dermatology is vital to pediatrician training.

As if there was not enough evidence that pediatric dermatologists are in high demand, SPD pediatric dermatology workforce surveys from the last 5 years, which will soon be updated, show similar indications.^7,10 Fogel and Teng¹¹ showed that 60% of surveyed pediatric dermatologists (N=226) were academic and 81% were salaried. Unlike previous data,¹ the investigators showed that children constituted 79.5% of respondents’ patient populations. The academic practice environment favored by the majority of pediatric dermatologists was associated with seeing fewer patients per week and longer wait times (approximately 60 days for a pediatric dermatologist vs 15 days in other practice environments).¹¹ Therefore, the demand continues to be unmet even in many institutions with pediatric dermatology practitioners in place.

For the medical student or resident seeking a career in pediatric dermatology, it appears that finding and working on projects with mentors likely is the key to stepping in the field. From my own experience, pediatric dermatologists are extremely friendly and open to supporting career development in earnest students. Reach out to potential mentors months before starting desired electives, as you are competing with other students and pediatrics, dermatology, and emergency medicine residents. Joining and attending meetings of the SPD is a great way to find direction in this friendly and collegial field. Additionally, pediatric dermatology sessions at the annual meetings of the American Academy of Dermatology are a wonderful way to experience the excitement of the field. As a pediatric dermatologist in practice for almost 2 decades, I can honestly say that the field is always intellectually stimulating and evolving rapidly through enhanced understanding of disease pathogenesis, genetics, and therapeutics. Helping children and their parents/guardians never gets boring.

The solution to improving the size and accessibility of the pediatric dermatology workforce is not simple and likely starts from the bottom up. More than 75% of pediatric dermatologists favor implementing systems to encourage medical students to pursue a career in pediatric dermatology.⁷ Increasing resident exposure to dedicated pediatric dermatology training time enhances satisfaction.⁵ Increased funding of fellowships can help these students and residents meet their goals. Current fellowship training programs now total 36, but not all approved institutions have been able to support a postgraduate year 5 (PGY-5) or higher fellow, and in my experience some institutions have avoided adding a fellow due to lack of funding internally. The average pediatric dermatologist earns $100,000 less than colleagues who treat adults, which is an impediment to the expansion of the field.¹⁰ This disparity may chase away practitioners, especially those with medical school debt. Debt forgiveness programs, enhanced practice development, and better base pay for pediatric dermatologists could positively impact growth in this specialty. Dermatology and pediatrics training programs need to dedicate more money and developmental support for pediatric dermatologists as a way to invest in the quality of pediatric dermatology education for their trainees. By recognizing the true value of the academic contributions of pediatric dermatologists, dermatology residency programs can invest in producing trainees with greater aplomb and acumen in pediatric dermatology.

The Society for Pediatric Dermatology (SPD) was established in 1975, and the pediatric dermatology workforce shortage began shortly after. In 1986, Honig and Burke¹ reported that opportunities in pediatric dermatology were limited and that pediatric dermatologists were predominantly located in larger teaching hospitals and selected private practice settings; furthermore, only approximately 20% had patient populations comprising more than 75% children.¹ Positive changes have occurred since that time, with more practitioners dedicated to pediatric dermatology and increased opportunities within the specialty. The SPD has expanded to a thriving group of collegial pediatric dermatologists now topping 1200 members worldwide.

Although the SPD has strongly influenced practice development in pediatric dermatology, there are fewer than 300 board-certified pediatric dermatologists in the United States and approximately double that number of pediatric dermatology practitioners. The deficiency is glaring based on the national population alone. The US Census Bureau reported 325,719,178 individuals living in the United States (as of July 1, 2017).² With approximately 75 million children in the United States and estimates that 22.8% of the population is younger than 18 years,³ there currently is 1 pediatric dermatologist for every 120,000 children or more.

As if the numbers alone were not adequate, a number of publications have addressed the benefits of pediatric dermatologists in both dermatology and pediatrics training and furthermore in pediatric care. A 2004 survey of dermatology program directors and chairpersons regarding the issue of the pediatric dermatology workforce shortage revealed that 45 of 94 (47.9%) programs employed a pediatric dermatologist and 24 (25.5%) had been looking to hire one for more than a year.⁴ Although more pediatric dermatologists have joined the workforce, it is not surprising that programs with no pediatric dermatologists want them. First, pediatric dermatologists dramatically improve the quality of training with regard to pediatric dermatology education and can increase dermatology residents’ comfort level with children. In a survey of a group of graduating third-year dermatology residents, dermatology residency program directors, and pediatric dermatology fellowship program directors by Nijhawan et al,⁵ residents who were trained in a program with one or more full-time pediatric dermatologists were more likely to feel competent treating children and to feel satisfied with their training program’s pediatric dermatology curriculum than residents without contact with a full-time pediatric dermatologist (50.0% vs 5.9% [P=.002] and 85.3% vs 52.9% [P<.001], respectively). The availability of a pediatric dermatology fellowship further enhanced satisfaction. Residents in programs with no full-time pediatric dermatologist on staff were more likely to be somewhat or extremely dissatisfied with their pediatric dermatology training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (P<.01).⁵

Programs with pediatric dermatologists also offer easy access to a mentor in the field. In a 2010 survey of pediatric dermatologists (published in 2014), Admani et al⁶ reported that 84% (91/109) of respondents (board-certified pediatric dermatologists) cited mentorship as the most important factor influencing their career choice. Exposure to the specialty was noted as a key motivating factor. In my opinion, the actual inclusion of a pediatric dermatology fellowship, whether the position is filled or not, appears to increase the chances of expansion and retention in the field. In the 2014 SPD workforce survey, more than 62% (61/98) of respondents were fellowship trained.⁷ In 2004 there were only 6 pediatric dermatology fellowship training programs. We have come quite far now with 36 fellowships as of August 12, 2018.⁸ The cost of education of course is not simple when pediatric dermatology fellowships are unfunded by the Accreditation Council for Graduate Medical Education; however, it is clear that the initial investment can create ongoing returns in pediatric dermatology.

Furthermore, due to the outpatient burden of skin disease in a pediatrics practice, providing pediatric trainees with contact with a pediatric dermatologist is needed. Prindaville et al⁹ performed a review from 2006 through 2010 of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases, which revealed that 9% of 23 million pediatric visits during this time period were for dermatologic diseases; therefore, knowledge of pediatric dermatology is vital to pediatrician training.

As if there was not enough evidence that pediatric dermatologists are in high demand, SPD pediatric dermatology workforce surveys from the last 5 years, which will soon be updated, show similar indications.^7,10 Fogel and Teng¹¹ showed that 60% of surveyed pediatric dermatologists (N=226) were academic and 81% were salaried. Unlike previous data,¹ the investigators showed that children constituted 79.5% of respondents’ patient populations. The academic practice environment favored by the majority of pediatric dermatologists was associated with seeing fewer patients per week and longer wait times (approximately 60 days for a pediatric dermatologist vs 15 days in other practice environments).¹¹ Therefore, the demand continues to be unmet even in many institutions with pediatric dermatology practitioners in place.

For the medical student or resident seeking a career in pediatric dermatology, it appears that finding and working on projects with mentors likely is the key to stepping in the field. From my own experience, pediatric dermatologists are extremely friendly and open to supporting career development in earnest students. Reach out to potential mentors months before starting desired electives, as you are competing with other students and pediatrics, dermatology, and emergency medicine residents. Joining and attending meetings of the SPD is a great way to find direction in this friendly and collegial field. Additionally, pediatric dermatology sessions at the annual meetings of the American Academy of Dermatology are a wonderful way to experience the excitement of the field. As a pediatric dermatologist in practice for almost 2 decades, I can honestly say that the field is always intellectually stimulating and evolving rapidly through enhanced understanding of disease pathogenesis, genetics, and therapeutics. Helping children and their parents/guardians never gets boring.

The solution to improving the size and accessibility of the pediatric dermatology workforce is not simple and likely starts from the bottom up. More than 75% of pediatric dermatologists favor implementing systems to encourage medical students to pursue a career in pediatric dermatology.⁷ Increasing resident exposure to dedicated pediatric dermatology training time enhances satisfaction.⁵ Increased funding of fellowships can help these students and residents meet their goals. Current fellowship training programs now total 36, but not all approved institutions have been able to support a postgraduate year 5 (PGY-5) or higher fellow, and in my experience some institutions have avoided adding a fellow due to lack of funding internally. The average pediatric dermatologist earns $100,000 less than colleagues who treat adults, which is an impediment to the expansion of the field.¹⁰ This disparity may chase away practitioners, especially those with medical school debt. Debt forgiveness programs, enhanced practice development, and better base pay for pediatric dermatologists could positively impact growth in this specialty. Dermatology and pediatrics training programs need to dedicate more money and developmental support for pediatric dermatologists as a way to invest in the quality of pediatric dermatology education for their trainees. By recognizing the true value of the academic contributions of pediatric dermatologists, dermatology residency programs can invest in producing trainees with greater aplomb and acumen in pediatric dermatology.

The Society for Pediatric Dermatology (SPD) was established in 1975, and the pediatric dermatology workforce shortage began shortly after. In 1986, Honig and Burke¹ reported that opportunities in pediatric dermatology were limited and that pediatric dermatologists were predominantly located in larger teaching hospitals and selected private practice settings; furthermore, only approximately 20% had patient populations comprising more than 75% children.¹ Positive changes have occurred since that time, with more practitioners dedicated to pediatric dermatology and increased opportunities within the specialty. The SPD has expanded to a thriving group of collegial pediatric dermatologists now topping 1200 members worldwide.

Although the SPD has strongly influenced practice development in pediatric dermatology, there are fewer than 300 board-certified pediatric dermatologists in the United States and approximately double that number of pediatric dermatology practitioners. The deficiency is glaring based on the national population alone. The US Census Bureau reported 325,719,178 individuals living in the United States (as of July 1, 2017).² With approximately 75 million children in the United States and estimates that 22.8% of the population is younger than 18 years,³ there currently is 1 pediatric dermatologist for every 120,000 children or more.

As if the numbers alone were not adequate, a number of publications have addressed the benefits of pediatric dermatologists in both dermatology and pediatrics training and furthermore in pediatric care. A 2004 survey of dermatology program directors and chairpersons regarding the issue of the pediatric dermatology workforce shortage revealed that 45 of 94 (47.9%) programs employed a pediatric dermatologist and 24 (25.5%) had been looking to hire one for more than a year.⁴ Although more pediatric dermatologists have joined the workforce, it is not surprising that programs with no pediatric dermatologists want them. First, pediatric dermatologists dramatically improve the quality of training with regard to pediatric dermatology education and can increase dermatology residents’ comfort level with children. In a survey of a group of graduating third-year dermatology residents, dermatology residency program directors, and pediatric dermatology fellowship program directors by Nijhawan et al,⁵ residents who were trained in a program with one or more full-time pediatric dermatologists were more likely to feel competent treating children and to feel satisfied with their training program’s pediatric dermatology curriculum than residents without contact with a full-time pediatric dermatologist (50.0% vs 5.9% [P=.002] and 85.3% vs 52.9% [P<.001], respectively). The availability of a pediatric dermatology fellowship further enhanced satisfaction. Residents in programs with no full-time pediatric dermatologist on staff were more likely to be somewhat or extremely dissatisfied with their pediatric dermatology training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (P<.01).⁵

Programs with pediatric dermatologists also offer easy access to a mentor in the field. In a 2010 survey of pediatric dermatologists (published in 2014), Admani et al⁶ reported that 84% (91/109) of respondents (board-certified pediatric dermatologists) cited mentorship as the most important factor influencing their career choice. Exposure to the specialty was noted as a key motivating factor. In my opinion, the actual inclusion of a pediatric dermatology fellowship, whether the position is filled or not, appears to increase the chances of expansion and retention in the field. In the 2014 SPD workforce survey, more than 62% (61/98) of respondents were fellowship trained.⁷ In 2004 there were only 6 pediatric dermatology fellowship training programs. We have come quite far now with 36 fellowships as of August 12, 2018.⁸ The cost of education of course is not simple when pediatric dermatology fellowships are unfunded by the Accreditation Council for Graduate Medical Education; however, it is clear that the initial investment can create ongoing returns in pediatric dermatology.

Furthermore, due to the outpatient burden of skin disease in a pediatrics practice, providing pediatric trainees with contact with a pediatric dermatologist is needed. Prindaville et al⁹ performed a review from 2006 through 2010 of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases, which revealed that 9% of 23 million pediatric visits during this time period were for dermatologic diseases; therefore, knowledge of pediatric dermatology is vital to pediatrician training.

As if there was not enough evidence that pediatric dermatologists are in high demand, SPD pediatric dermatology workforce surveys from the last 5 years, which will soon be updated, show similar indications.^7,10 Fogel and Teng¹¹ showed that 60% of surveyed pediatric dermatologists (N=226) were academic and 81% were salaried. Unlike previous data,¹ the investigators showed that children constituted 79.5% of respondents’ patient populations. The academic practice environment favored by the majority of pediatric dermatologists was associated with seeing fewer patients per week and longer wait times (approximately 60 days for a pediatric dermatologist vs 15 days in other practice environments).¹¹ Therefore, the demand continues to be unmet even in many institutions with pediatric dermatology practitioners in place.

For the medical student or resident seeking a career in pediatric dermatology, it appears that finding and working on projects with mentors likely is the key to stepping in the field. From my own experience, pediatric dermatologists are extremely friendly and open to supporting career development in earnest students. Reach out to potential mentors months before starting desired electives, as you are competing with other students and pediatrics, dermatology, and emergency medicine residents. Joining and attending meetings of the SPD is a great way to find direction in this friendly and collegial field. Additionally, pediatric dermatology sessions at the annual meetings of the American Academy of Dermatology are a wonderful way to experience the excitement of the field. As a pediatric dermatologist in practice for almost 2 decades, I can honestly say that the field is always intellectually stimulating and evolving rapidly through enhanced understanding of disease pathogenesis, genetics, and therapeutics. Helping children and their parents/guardians never gets boring.

The solution to improving the size and accessibility of the pediatric dermatology workforce is not simple and likely starts from the bottom up. More than 75% of pediatric dermatologists favor implementing systems to encourage medical students to pursue a career in pediatric dermatology.⁷ Increasing resident exposure to dedicated pediatric dermatology training time enhances satisfaction.⁵ Increased funding of fellowships can help these students and residents meet their goals. Current fellowship training programs now total 36, but not all approved institutions have been able to support a postgraduate year 5 (PGY-5) or higher fellow, and in my experience some institutions have avoided adding a fellow due to lack of funding internally. The average pediatric dermatologist earns $100,000 less than colleagues who treat adults, which is an impediment to the expansion of the field.¹⁰ This disparity may chase away practitioners, especially those with medical school debt. Debt forgiveness programs, enhanced practice development, and better base pay for pediatric dermatologists could positively impact growth in this specialty. Dermatology and pediatrics training programs need to dedicate more money and developmental support for pediatric dermatologists as a way to invest in the quality of pediatric dermatology education for their trainees. By recognizing the true value of the academic contributions of pediatric dermatologists, dermatology residency programs can invest in producing trainees with greater aplomb and acumen in pediatric dermatology.

When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder

I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.

Superstitions like these are familiar to all of us.

One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.

Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.

Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.

For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.

Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).

These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.

Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.

Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.

Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.

In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.

Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.

During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder

I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.

Superstitions like these are familiar to all of us.

One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.

Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.

Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.

For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.

Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).

These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.

Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.

Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.

Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.

In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.

Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.

During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder

I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.

Superstitions like these are familiar to all of us.

One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.

Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.

Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.

For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.

Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).

These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.

Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.

Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.

Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.

In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.

Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.

During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].