Commentary

Every cancer diagnosis starts out as anything but. That’s what I was thinking when I met Sue Marcus (not her real name) in the emergency department one Friday afternoon.

“You know,” she said in a matter of fact manner. “I think I might have the flu.”

“Yes,” I said. “You might.”

“I was in Vegas a week ago, and the person next to me was sick.”

“It’s definitely possible. That’s one of the things we’ll test for.”

“I mean ... what else can it be?”

I had information Sue didn’t yet. All her blood counts were disturbingly low. On top of that, the lab had picked up several atypical appearing cells. They could be reactive, in the setting of infection, or they could be blasts – a new diagnosis of leukemia.

I paused.

“I’m going to say this now, so you know what we are looking for. There’s a lot more information we still need.”

“But?”

“But, another possibility is that it is cancer.”

“Cancer?”

“Leukemia, maybe.”

I explained the next steps. We would have flow cytometry by that night, but it’s not a perfect test. We were limited, actually, by logistics. It was a Friday night. We would do a bone marrow biopsy on Monday. It would be several days before we’d know with certainty.

That evening, the hematology fellow and I looked at the slide under the microscope. We agreed with the lab.

“That’s a blast, isn’t it?”

“Yes, I think it is.”

But they were not completely classic, and they were sporadic. It wasn’t enough to say for sure. Meanwhile, Sue, understandably, wanted answers.

“What did you see? Is it cancer, or not?”

There was flow cytometry that night, showing an abnormal population of cells. And then, finally, there was a bone marrow biopsy clinching the diagnosis.

We explained what the path ahead looked like: Hospitalization for a month. Chemotherapy, then a repeat bone marrow biopsy to look for response. Then more chemotherapy. Chances of remission. Long-term implications.

As we gathered more information, Sue’s questions evolved.

“Is it curable?”

“Can I go back to work?”

And one day, a week into treatment, she asked, “Am I going to die?”

Over my last 3 years as an internal medicine resident, I’ve been humbled by how often patients turned to me for answers to some of the most difficult questions I could imagine. Sometimes, the questions seemed purely factual, but often, they took a more existential bent: How should I spend my last months? What should I do now? Patients have asked me if they are going to die, along with when, how, and even why.

I’ve wrestled with how to communicate candidly, treading a delicate balance between being as up-front as possible while also recognizing the uncertainty inherent in predicting. I’ve struggled with walking the tightrope of delivering bad news while also emphasizing compassion and support.

I chose hematology and oncology in part because of the gravity of these interactions. I enjoy being a primary doctor for a complex, sick, patient population who are grappling with physically and emotionally challenging illness. I value longitudinal relationships with patients I know well. I found the medicine of hematology and oncology interdisciplinary, the details high stakes, and the big questions always at play. If it was meaningful work I sought, cancer became the ultimate question that mattered.

The changing landscape of cancer care is making these conversations substantially more difficult. A central tenet of medicine is truthfulness: setting the stage for what is going on and what to anticipate. It’s explaining the nuances of the upcoming treatment options, while also addressing what a person’s life may look like down the road. It’s understanding what matters most to a patient, understanding what therapeutic choices we can offer – and then trying to reconcile them, as best as we can.

This has always been hard. But it’s getting harder. The options we have to treat cancer are expanding rapidly as immunotherapy competes with the basics of chemotherapy, radiation, and surgery. We work alongside researchers looking to change the paradigm, collecting information on outcomes and side effects as we go along. We are learning and we are applying what we learn – in real time – on real people willing to try.

How can we speak honestly about a prognosis when our data are limited and our tools are in continuous flux? How can we prepare someone for what lies ahead when we are still trying to grasp what today looks like?

All the while, medical uncertainties are amplified by a complex system with many moving parts. It’s a system in which some patients cannot afford care, in which insurance companies may deny necessary treatment, and where families may come together or fall apart in the face of incredible adversity. There are factors outside the scope of pure medicine that make the path ahead all the hazier and navigating it all the more challenging.

In July, I began my hematology and oncology fellowship. I am caring for patients with a range of cancers, and all of that goes along with the weight of those diagnoses. Learning the most up-to-date management in a constantly evolving landscape will be an ongoing skill. That my patients allow me into their most vulnerable moments – and trust me with them – is a gift.

For patients like Sue, there sometimes remain more questions than answers. She recently underwent her third round of chemotherapy and endured multiple blood clots. With her insurance covering only limited interventions, she is deciding what to focus on and where to receive her care. Her story, like many others, continues to be written.

I am deeply aware of the difficulties that are a part of the world of cancer – and the heartbreak. How can we hold up scans triumphantly showing no recurrence in some patients while others suffer one failed treatment after another? When should we push for more therapy and when should we shift our efforts toward comfort? What should we prioritize – medically and personally – if time is limited?

These questions are hard, but I cannot think of any that are more meaningful.

This is a column about patients and uncertainty as I pursue my hematology and oncology fellowship and grapple with these questions. I look forward to sharing them with you each month.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Every cancer diagnosis starts out as anything but. That’s what I was thinking when I met Sue Marcus (not her real name) in the emergency department one Friday afternoon.

“You know,” she said in a matter of fact manner. “I think I might have the flu.”

“Yes,” I said. “You might.”

“I was in Vegas a week ago, and the person next to me was sick.”

“It’s definitely possible. That’s one of the things we’ll test for.”

“I mean ... what else can it be?”

I had information Sue didn’t yet. All her blood counts were disturbingly low. On top of that, the lab had picked up several atypical appearing cells. They could be reactive, in the setting of infection, or they could be blasts – a new diagnosis of leukemia.

I paused.

“I’m going to say this now, so you know what we are looking for. There’s a lot more information we still need.”

“But?”

“But, another possibility is that it is cancer.”

“Cancer?”

“Leukemia, maybe.”

I explained the next steps. We would have flow cytometry by that night, but it’s not a perfect test. We were limited, actually, by logistics. It was a Friday night. We would do a bone marrow biopsy on Monday. It would be several days before we’d know with certainty.

That evening, the hematology fellow and I looked at the slide under the microscope. We agreed with the lab.

“That’s a blast, isn’t it?”

“Yes, I think it is.”

But they were not completely classic, and they were sporadic. It wasn’t enough to say for sure. Meanwhile, Sue, understandably, wanted answers.

“What did you see? Is it cancer, or not?”

There was flow cytometry that night, showing an abnormal population of cells. And then, finally, there was a bone marrow biopsy clinching the diagnosis.

We explained what the path ahead looked like: Hospitalization for a month. Chemotherapy, then a repeat bone marrow biopsy to look for response. Then more chemotherapy. Chances of remission. Long-term implications.

As we gathered more information, Sue’s questions evolved.

“Is it curable?”

“Can I go back to work?”

And one day, a week into treatment, she asked, “Am I going to die?”

Over my last 3 years as an internal medicine resident, I’ve been humbled by how often patients turned to me for answers to some of the most difficult questions I could imagine. Sometimes, the questions seemed purely factual, but often, they took a more existential bent: How should I spend my last months? What should I do now? Patients have asked me if they are going to die, along with when, how, and even why.

I’ve wrestled with how to communicate candidly, treading a delicate balance between being as up-front as possible while also recognizing the uncertainty inherent in predicting. I’ve struggled with walking the tightrope of delivering bad news while also emphasizing compassion and support.

I chose hematology and oncology in part because of the gravity of these interactions. I enjoy being a primary doctor for a complex, sick, patient population who are grappling with physically and emotionally challenging illness. I value longitudinal relationships with patients I know well. I found the medicine of hematology and oncology interdisciplinary, the details high stakes, and the big questions always at play. If it was meaningful work I sought, cancer became the ultimate question that mattered.

The changing landscape of cancer care is making these conversations substantially more difficult. A central tenet of medicine is truthfulness: setting the stage for what is going on and what to anticipate. It’s explaining the nuances of the upcoming treatment options, while also addressing what a person’s life may look like down the road. It’s understanding what matters most to a patient, understanding what therapeutic choices we can offer – and then trying to reconcile them, as best as we can.

This has always been hard. But it’s getting harder. The options we have to treat cancer are expanding rapidly as immunotherapy competes with the basics of chemotherapy, radiation, and surgery. We work alongside researchers looking to change the paradigm, collecting information on outcomes and side effects as we go along. We are learning and we are applying what we learn – in real time – on real people willing to try.

How can we speak honestly about a prognosis when our data are limited and our tools are in continuous flux? How can we prepare someone for what lies ahead when we are still trying to grasp what today looks like?

All the while, medical uncertainties are amplified by a complex system with many moving parts. It’s a system in which some patients cannot afford care, in which insurance companies may deny necessary treatment, and where families may come together or fall apart in the face of incredible adversity. There are factors outside the scope of pure medicine that make the path ahead all the hazier and navigating it all the more challenging.

In July, I began my hematology and oncology fellowship. I am caring for patients with a range of cancers, and all of that goes along with the weight of those diagnoses. Learning the most up-to-date management in a constantly evolving landscape will be an ongoing skill. That my patients allow me into their most vulnerable moments – and trust me with them – is a gift.

For patients like Sue, there sometimes remain more questions than answers. She recently underwent her third round of chemotherapy and endured multiple blood clots. With her insurance covering only limited interventions, she is deciding what to focus on and where to receive her care. Her story, like many others, continues to be written.

I am deeply aware of the difficulties that are a part of the world of cancer – and the heartbreak. How can we hold up scans triumphantly showing no recurrence in some patients while others suffer one failed treatment after another? When should we push for more therapy and when should we shift our efforts toward comfort? What should we prioritize – medically and personally – if time is limited?

These questions are hard, but I cannot think of any that are more meaningful.

This is a column about patients and uncertainty as I pursue my hematology and oncology fellowship and grapple with these questions. I look forward to sharing them with you each month.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Every cancer diagnosis starts out as anything but. That’s what I was thinking when I met Sue Marcus (not her real name) in the emergency department one Friday afternoon.

“You know,” she said in a matter of fact manner. “I think I might have the flu.”

“Yes,” I said. “You might.”

“I was in Vegas a week ago, and the person next to me was sick.”

“It’s definitely possible. That’s one of the things we’ll test for.”

“I mean ... what else can it be?”

I had information Sue didn’t yet. All her blood counts were disturbingly low. On top of that, the lab had picked up several atypical appearing cells. They could be reactive, in the setting of infection, or they could be blasts – a new diagnosis of leukemia.

I paused.

“I’m going to say this now, so you know what we are looking for. There’s a lot more information we still need.”

“But?”

“But, another possibility is that it is cancer.”

“Cancer?”

“Leukemia, maybe.”

I explained the next steps. We would have flow cytometry by that night, but it’s not a perfect test. We were limited, actually, by logistics. It was a Friday night. We would do a bone marrow biopsy on Monday. It would be several days before we’d know with certainty.

That evening, the hematology fellow and I looked at the slide under the microscope. We agreed with the lab.

“That’s a blast, isn’t it?”

“Yes, I think it is.”

But they were not completely classic, and they were sporadic. It wasn’t enough to say for sure. Meanwhile, Sue, understandably, wanted answers.

“What did you see? Is it cancer, or not?”

There was flow cytometry that night, showing an abnormal population of cells. And then, finally, there was a bone marrow biopsy clinching the diagnosis.

We explained what the path ahead looked like: Hospitalization for a month. Chemotherapy, then a repeat bone marrow biopsy to look for response. Then more chemotherapy. Chances of remission. Long-term implications.

As we gathered more information, Sue’s questions evolved.

“Is it curable?”

“Can I go back to work?”

And one day, a week into treatment, she asked, “Am I going to die?”

Over my last 3 years as an internal medicine resident, I’ve been humbled by how often patients turned to me for answers to some of the most difficult questions I could imagine. Sometimes, the questions seemed purely factual, but often, they took a more existential bent: How should I spend my last months? What should I do now? Patients have asked me if they are going to die, along with when, how, and even why.

I’ve wrestled with how to communicate candidly, treading a delicate balance between being as up-front as possible while also recognizing the uncertainty inherent in predicting. I’ve struggled with walking the tightrope of delivering bad news while also emphasizing compassion and support.

I chose hematology and oncology in part because of the gravity of these interactions. I enjoy being a primary doctor for a complex, sick, patient population who are grappling with physically and emotionally challenging illness. I value longitudinal relationships with patients I know well. I found the medicine of hematology and oncology interdisciplinary, the details high stakes, and the big questions always at play. If it was meaningful work I sought, cancer became the ultimate question that mattered.

The changing landscape of cancer care is making these conversations substantially more difficult. A central tenet of medicine is truthfulness: setting the stage for what is going on and what to anticipate. It’s explaining the nuances of the upcoming treatment options, while also addressing what a person’s life may look like down the road. It’s understanding what matters most to a patient, understanding what therapeutic choices we can offer – and then trying to reconcile them, as best as we can.

This has always been hard. But it’s getting harder. The options we have to treat cancer are expanding rapidly as immunotherapy competes with the basics of chemotherapy, radiation, and surgery. We work alongside researchers looking to change the paradigm, collecting information on outcomes and side effects as we go along. We are learning and we are applying what we learn – in real time – on real people willing to try.

How can we speak honestly about a prognosis when our data are limited and our tools are in continuous flux? How can we prepare someone for what lies ahead when we are still trying to grasp what today looks like?

All the while, medical uncertainties are amplified by a complex system with many moving parts. It’s a system in which some patients cannot afford care, in which insurance companies may deny necessary treatment, and where families may come together or fall apart in the face of incredible adversity. There are factors outside the scope of pure medicine that make the path ahead all the hazier and navigating it all the more challenging.

In July, I began my hematology and oncology fellowship. I am caring for patients with a range of cancers, and all of that goes along with the weight of those diagnoses. Learning the most up-to-date management in a constantly evolving landscape will be an ongoing skill. That my patients allow me into their most vulnerable moments – and trust me with them – is a gift.

For patients like Sue, there sometimes remain more questions than answers. She recently underwent her third round of chemotherapy and endured multiple blood clots. With her insurance covering only limited interventions, she is deciding what to focus on and where to receive her care. Her story, like many others, continues to be written.

I am deeply aware of the difficulties that are a part of the world of cancer – and the heartbreak. How can we hold up scans triumphantly showing no recurrence in some patients while others suffer one failed treatment after another? When should we push for more therapy and when should we shift our efforts toward comfort? What should we prioritize – medically and personally – if time is limited?

These questions are hard, but I cannot think of any that are more meaningful.

This is a column about patients and uncertainty as I pursue my hematology and oncology fellowship and grapple with these questions. I look forward to sharing them with you each month.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

I read “Up In Arms About Gun Violence” in the May/June issue of Clinician Reviews with great interest. My response is drawn from research, professional experience, and three particularly formative experiences:

• The birth of a child with learning and behavioral differences requiring an individualized education program and temporary placement in an alternative school.
• Co-leading a parent workshop for my clinical Capstone project.
• A nonclinical position at a public alternative school for children with emotional and behavioral disorders.

In nursing, as in all human services, we strive to be holistic, drawing from science, research, ethics, human development, sociology, anthropology, etc, to function in our roles. Many in nursing have come to value and function well in multidisciplinary teams for the management of individuals with complex needs.

What I have learned in my life—a fact supported by my professional preparation—is that the cycle of poverty, poor health, and quality of life are greatly influenced by education. During my pediatrics rotation and clinical, I learned you must consider family to be the vehicle by which the child may benefit from your clinical services. Therefore, you must reach beyond your setting in an effective and consistent way to engage, connect the home, and then follow up for response. My colleagues are aware of the need to document and the processes currently available for health, social service, and school professionals to report concerns. Too often, obstacles and other influences stand in the way of our ethical duty as professionals; we must find a way to overcome them, both individually and as a group.

We have processes for adolescents aging out of foster care and the developmentally delayed transitioning to sheltered work; can these be expanded?

My experience in a public school district’s alternative school for children in grades 6-12 opened my eyes to the need for the public to understand how these schools function. I likened these schools to the intensive care unit in the acute care setting. Smaller population, high needs, high cost, and dedicated staff but high burnout and turnover. Children in my school came from foster care or struggling homes and often had experienced trauma. Underfunded school districts cut nurses and social workers, cannot attract professional support staff, and choose to distribute money and efforts on the general population in neighborhood schools.

My “professional health care” mindset was embedded in an environment of wounded children, amazing educators, and support staff; powerless to do our best, we held on. But it is not enough to just hold on, sequestering at-risk children out of sight. We can do better.

Continue to: Some ideas to turn this belief into reality

Some ideas to turn this belief into reality:

1. Create position statements and recommendations for our licensing and professional certifying bodies to share with their membership.
2. Include mandates for communicating those recommendations during certification and relicensing.
3. Employ district staff or contracted consulting medical and psychologic evaluators for review of public school students with health and behavioral diagnoses.
4. Partner better with schools from the community health, pediatrician, behavioral health, and primary care settings. Kennedy Krieger Institute has partnered with schools in Baltimore—can this be replicated elsewhere?
5. Every child enters school with a need for health clearance and a “Guardian Permission Contact Card.” Perhaps we can expand this to develop a process for results of routine assessments to be shared, for the safety and welfare of the child.
6. Teach individuals to cope effectively with the anxiety and distress fed by constant exposure to the Internet and social media. This can—and should—be done through multiple venues: religious and social groups and the workplace.
7. Inform the public with PowerPoint presentations and seminars, advertising what to look for and where to get help for concerning behaviors; again, this can be done through multiple portals. This, I believe, may also help defuse tensions between parents and schools surrounding children with health and educational differences.
8. Have professional health associations deliver a cohesive message to our legislators for gun control, funding for research, and mental and public health.

Dr. Onieal, you are correct in saying that this epidemic of mass shootings is a public health issue. It is a threat as serious as HIV, cancer, lead poisoning, hypertension, and diabetes. We must find a way to stop this epidemic.

Diane Page, RN, MSN, ARNP-C
Sanford, FL

I read “Up In Arms About Gun Violence” in the May/June issue of Clinician Reviews with great interest. My response is drawn from research, professional experience, and three particularly formative experiences:

• The birth of a child with learning and behavioral differences requiring an individualized education program and temporary placement in an alternative school.
• Co-leading a parent workshop for my clinical Capstone project.
• A nonclinical position at a public alternative school for children with emotional and behavioral disorders.

In nursing, as in all human services, we strive to be holistic, drawing from science, research, ethics, human development, sociology, anthropology, etc, to function in our roles. Many in nursing have come to value and function well in multidisciplinary teams for the management of individuals with complex needs.

What I have learned in my life—a fact supported by my professional preparation—is that the cycle of poverty, poor health, and quality of life are greatly influenced by education. During my pediatrics rotation and clinical, I learned you must consider family to be the vehicle by which the child may benefit from your clinical services. Therefore, you must reach beyond your setting in an effective and consistent way to engage, connect the home, and then follow up for response. My colleagues are aware of the need to document and the processes currently available for health, social service, and school professionals to report concerns. Too often, obstacles and other influences stand in the way of our ethical duty as professionals; we must find a way to overcome them, both individually and as a group.

We have processes for adolescents aging out of foster care and the developmentally delayed transitioning to sheltered work; can these be expanded?

My experience in a public school district’s alternative school for children in grades 6-12 opened my eyes to the need for the public to understand how these schools function. I likened these schools to the intensive care unit in the acute care setting. Smaller population, high needs, high cost, and dedicated staff but high burnout and turnover. Children in my school came from foster care or struggling homes and often had experienced trauma. Underfunded school districts cut nurses and social workers, cannot attract professional support staff, and choose to distribute money and efforts on the general population in neighborhood schools.

My “professional health care” mindset was embedded in an environment of wounded children, amazing educators, and support staff; powerless to do our best, we held on. But it is not enough to just hold on, sequestering at-risk children out of sight. We can do better.

Continue to: Some ideas to turn this belief into reality

Some ideas to turn this belief into reality:

1. Create position statements and recommendations for our licensing and professional certifying bodies to share with their membership.
2. Include mandates for communicating those recommendations during certification and relicensing.
3. Employ district staff or contracted consulting medical and psychologic evaluators for review of public school students with health and behavioral diagnoses.
4. Partner better with schools from the community health, pediatrician, behavioral health, and primary care settings. Kennedy Krieger Institute has partnered with schools in Baltimore—can this be replicated elsewhere?
5. Every child enters school with a need for health clearance and a “Guardian Permission Contact Card.” Perhaps we can expand this to develop a process for results of routine assessments to be shared, for the safety and welfare of the child.
6. Teach individuals to cope effectively with the anxiety and distress fed by constant exposure to the Internet and social media. This can—and should—be done through multiple venues: religious and social groups and the workplace.
7. Inform the public with PowerPoint presentations and seminars, advertising what to look for and where to get help for concerning behaviors; again, this can be done through multiple portals. This, I believe, may also help defuse tensions between parents and schools surrounding children with health and educational differences.
8. Have professional health associations deliver a cohesive message to our legislators for gun control, funding for research, and mental and public health.

Dr. Onieal, you are correct in saying that this epidemic of mass shootings is a public health issue. It is a threat as serious as HIV, cancer, lead poisoning, hypertension, and diabetes. We must find a way to stop this epidemic.

Diane Page, RN, MSN, ARNP-C
Sanford, FL

I read “Up In Arms About Gun Violence” in the May/June issue of Clinician Reviews with great interest. My response is drawn from research, professional experience, and three particularly formative experiences:

• The birth of a child with learning and behavioral differences requiring an individualized education program and temporary placement in an alternative school.
• Co-leading a parent workshop for my clinical Capstone project.
• A nonclinical position at a public alternative school for children with emotional and behavioral disorders.

In nursing, as in all human services, we strive to be holistic, drawing from science, research, ethics, human development, sociology, anthropology, etc, to function in our roles. Many in nursing have come to value and function well in multidisciplinary teams for the management of individuals with complex needs.

What I have learned in my life—a fact supported by my professional preparation—is that the cycle of poverty, poor health, and quality of life are greatly influenced by education. During my pediatrics rotation and clinical, I learned you must consider family to be the vehicle by which the child may benefit from your clinical services. Therefore, you must reach beyond your setting in an effective and consistent way to engage, connect the home, and then follow up for response. My colleagues are aware of the need to document and the processes currently available for health, social service, and school professionals to report concerns. Too often, obstacles and other influences stand in the way of our ethical duty as professionals; we must find a way to overcome them, both individually and as a group.

We have processes for adolescents aging out of foster care and the developmentally delayed transitioning to sheltered work; can these be expanded?

My experience in a public school district’s alternative school for children in grades 6-12 opened my eyes to the need for the public to understand how these schools function. I likened these schools to the intensive care unit in the acute care setting. Smaller population, high needs, high cost, and dedicated staff but high burnout and turnover. Children in my school came from foster care or struggling homes and often had experienced trauma. Underfunded school districts cut nurses and social workers, cannot attract professional support staff, and choose to distribute money and efforts on the general population in neighborhood schools.

My “professional health care” mindset was embedded in an environment of wounded children, amazing educators, and support staff; powerless to do our best, we held on. But it is not enough to just hold on, sequestering at-risk children out of sight. We can do better.

Continue to: Some ideas to turn this belief into reality

Some ideas to turn this belief into reality:

1. Create position statements and recommendations for our licensing and professional certifying bodies to share with their membership.
2. Include mandates for communicating those recommendations during certification and relicensing.
3. Employ district staff or contracted consulting medical and psychologic evaluators for review of public school students with health and behavioral diagnoses.
4. Partner better with schools from the community health, pediatrician, behavioral health, and primary care settings. Kennedy Krieger Institute has partnered with schools in Baltimore—can this be replicated elsewhere?
5. Every child enters school with a need for health clearance and a “Guardian Permission Contact Card.” Perhaps we can expand this to develop a process for results of routine assessments to be shared, for the safety and welfare of the child.
6. Teach individuals to cope effectively with the anxiety and distress fed by constant exposure to the Internet and social media. This can—and should—be done through multiple venues: religious and social groups and the workplace.
7. Inform the public with PowerPoint presentations and seminars, advertising what to look for and where to get help for concerning behaviors; again, this can be done through multiple portals. This, I believe, may also help defuse tensions between parents and schools surrounding children with health and educational differences.
8. Have professional health associations deliver a cohesive message to our legislators for gun control, funding for research, and mental and public health.

Dr. Onieal, you are correct in saying that this epidemic of mass shootings is a public health issue. It is a threat as serious as HIV, cancer, lead poisoning, hypertension, and diabetes. We must find a way to stop this epidemic.

Diane Page, RN, MSN, ARNP-C
Sanford, FL

The U.S. Preventive Services Task Force commissioned a systematic evidence review of 168 fair-good quality articles to examine newer evidence on screening for and treatment of osteoporotic fracture in women and men and update its 2011 guideline. They found convincing evidence that bone measurement tests and clinical risk assessment tools are accurate for predicting osteoporotic fractures in women. For postmenopausal women older than 65 years and those younger than 65 years with increased risk of osteoporosis, USPSTF found convincing evidence that screening can detect osteoporosis and that treatment can provide at least a moderate benefit in preventing fractures (grade B). For men, they report inadequate evidence on the benefits and harms of screening for osteoporosis to reduce the risk of fractures (I statement).

Importance

Osteoporosis leads to increased bone fragility and risk of fractures, specifically hip fractures, that are associated with limitations in ambulation, chronic pain, disability and loss of independence, and decreased quality of life: 21%-30% of those who suffer hip fractures die within 1 year. Osteoporosis is usually asymptomatic until a fracture occurs, thus preventing fractures is the main goal of an osteoporosis screening strategy. With the increasing life expectancy of the U.S. population, the potential preventable burden is likely to increase in future years.

Screening tests

The most commonly used test is central dual energy x-ray absorptiometry (DXA), which provides measurement of bone mineral density (BMD) of the hip and lumbar spine. Most treatment guidelines already use central DXA BMD to define osteoporosis and the threshold at which to start drug therapies for prevention. Other lower-cost and more accessible alternatives include peripheral DXA, which measures BMD at lower forearm and heel, and quantitative ultrasound (QUS), which also evaluates peripheral sites like the calcaneus. QUS does not measure BMD. USPSTF found that the harms associated with screening were small (mainly radiation exposure from DXA and opportunity costs).

Population and risk assessment

The review included adults older than 40 years of age, mostly postmenopausal women, without a history of previous low-trauma fractures, without conditions or medications that may cause secondary osteoporosis, and without increased risk of falls.

Patients at increased risk of osteoporotic fractures include those with parental history of hip fractures, low body weight, excessive alcohol consumption, and smokers. For postmenopausal women younger than 65 years of age with at least one risk factor, a reasonable approach to determine who should be screened with BMD is to use one of the various clinical risk assessment tools available. The most frequently studied tools in women are the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), Osteoporosis Self-Assessment Tool (OST), and Simple Calculated Osteoporosis Risk Estimation (SCORE). The Fracture Risk Assessment (FRAX) tool calculates the 10-year risk of a major osteoporotic fracture (MOF) using clinical risk factors. For example, one approach is to perform BMD in women younger than 65 years with a FRAX risk greater than 8.4% (the FRAX risk of a 65-year-old woman of mean height and weight without major risk factors).

In men, the prevalence of osteoporosis (4.3%) is generally lower than in women (15.4%). In the absence of other risk factors, it is not till age 80 that the prevalence of osteoporosis in white men starts to reach that of a 65-year-old white woman. While men have similar risk factors as women described above, men with hypogonadism, history of cerebrovascular accident, and history of diabetes are also at increased risk of fracture.
 

Preventative measures to reduce osteoporotic fractures

Approved drug therapies. The majority of studies were conducted in postmenopausal women. Bisphosphonates, most commonly used and studied, significantly reduced vertebral and nonvertebral fractures but not hip fractures (possibly because of underpowered studies). Raloxifene and parathyroid hormone reduced vertebral fractures but not nonvertebral fractures. Denosumab significantly reduced all three types of fractures. A 2011 review identified that estrogen reduced vertebral fractures, but no new studies were identified for the current review. Data from the Women’s Health Initiative show that women receiving estrogen with or without progesterone had an elevated risk of stroke, venous thromboembolism, and gallbladder disease; their risk for urinary incontinence was increased during the first year of follow-up. In addition, women receiving estrogen plus progestin had a higher risk of invasive breast cancer, coronary heart disease, and probable dementia. The risk of serious adverse events, upper-gastrointestinal events, or cardiovascular events associated with the most common class of medications used, bisphosphonates, is small. Evidence on the effectiveness of medications to treat osteoporosis in men is lacking (only two studies conducted).

Exercise. Engagement in 120-300 minutes of weekly moderate-intensity aerobic activity can reduce the risk of hip fractures, and performance of weekly balance and muscle-strengthening activities can help prevent falls in older adults.

Supplements. In a separate recommendation, USPSTF recommends against daily supplementation with less than 400 IU of vitamin D and less than 1,000 mg of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. They found insufficient evidence on supplementation with higher doses of vitamin D and calcium in postmenopausal women, or at any dose in men and premenopausal women.
 

Recommendations from others

The National Osteoporosis Foundation and the International Society for Clinical Densitometry recommend BMD testing in all women older than 65 years, all men over 70 years, postmenopausal women younger than 65 years, and men aged 50-69 years with increased risk factors. The American Academy of Family Physicians recommends against DXA screening in women younger than 65 years and men younger than 70 years with no risk factors.
 

The bottom line

For all women older than 65 years and postmenopausal women younger than 65 years who are at increased risk, screen for and treat osteoporosis to prevent fractures. For men, there is insufficient evidence to screen.

Dr. Shrestha is a second-year resident in the Family Medicine Residency Program at Abington (Pa.) - Jefferson Health. 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. U.S. Preventative Services Task Force. JAMA. 2018 Jun 26;319(24):2521-31.

2. U.S. Preventative Services Task Force. JAMA. 2018 Jun 26;319(24):2532-51.
 

The U.S. Preventive Services Task Force commissioned a systematic evidence review of 168 fair-good quality articles to examine newer evidence on screening for and treatment of osteoporotic fracture in women and men and update its 2011 guideline. They found convincing evidence that bone measurement tests and clinical risk assessment tools are accurate for predicting osteoporotic fractures in women. For postmenopausal women older than 65 years and those younger than 65 years with increased risk of osteoporosis, USPSTF found convincing evidence that screening can detect osteoporosis and that treatment can provide at least a moderate benefit in preventing fractures (grade B). For men, they report inadequate evidence on the benefits and harms of screening for osteoporosis to reduce the risk of fractures (I statement).

Importance

Osteoporosis leads to increased bone fragility and risk of fractures, specifically hip fractures, that are associated with limitations in ambulation, chronic pain, disability and loss of independence, and decreased quality of life: 21%-30% of those who suffer hip fractures die within 1 year. Osteoporosis is usually asymptomatic until a fracture occurs, thus preventing fractures is the main goal of an osteoporosis screening strategy. With the increasing life expectancy of the U.S. population, the potential preventable burden is likely to increase in future years.

Screening tests

The most commonly used test is central dual energy x-ray absorptiometry (DXA), which provides measurement of bone mineral density (BMD) of the hip and lumbar spine. Most treatment guidelines already use central DXA BMD to define osteoporosis and the threshold at which to start drug therapies for prevention. Other lower-cost and more accessible alternatives include peripheral DXA, which measures BMD at lower forearm and heel, and quantitative ultrasound (QUS), which also evaluates peripheral sites like the calcaneus. QUS does not measure BMD. USPSTF found that the harms associated with screening were small (mainly radiation exposure from DXA and opportunity costs).

Population and risk assessment

The review included adults older than 40 years of age, mostly postmenopausal women, without a history of previous low-trauma fractures, without conditions or medications that may cause secondary osteoporosis, and without increased risk of falls.

Patients at increased risk of osteoporotic fractures include those with parental history of hip fractures, low body weight, excessive alcohol consumption, and smokers. For postmenopausal women younger than 65 years of age with at least one risk factor, a reasonable approach to determine who should be screened with BMD is to use one of the various clinical risk assessment tools available. The most frequently studied tools in women are the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), Osteoporosis Self-Assessment Tool (OST), and Simple Calculated Osteoporosis Risk Estimation (SCORE). The Fracture Risk Assessment (FRAX) tool calculates the 10-year risk of a major osteoporotic fracture (MOF) using clinical risk factors. For example, one approach is to perform BMD in women younger than 65 years with a FRAX risk greater than 8.4% (the FRAX risk of a 65-year-old woman of mean height and weight without major risk factors).

In men, the prevalence of osteoporosis (4.3%) is generally lower than in women (15.4%). In the absence of other risk factors, it is not till age 80 that the prevalence of osteoporosis in white men starts to reach that of a 65-year-old white woman. While men have similar risk factors as women described above, men with hypogonadism, history of cerebrovascular accident, and history of diabetes are also at increased risk of fracture.
 

Preventative measures to reduce osteoporotic fractures

Approved drug therapies. The majority of studies were conducted in postmenopausal women. Bisphosphonates, most commonly used and studied, significantly reduced vertebral and nonvertebral fractures but not hip fractures (possibly because of underpowered studies). Raloxifene and parathyroid hormone reduced vertebral fractures but not nonvertebral fractures. Denosumab significantly reduced all three types of fractures. A 2011 review identified that estrogen reduced vertebral fractures, but no new studies were identified for the current review. Data from the Women’s Health Initiative show that women receiving estrogen with or without progesterone had an elevated risk of stroke, venous thromboembolism, and gallbladder disease; their risk for urinary incontinence was increased during the first year of follow-up. In addition, women receiving estrogen plus progestin had a higher risk of invasive breast cancer, coronary heart disease, and probable dementia. The risk of serious adverse events, upper-gastrointestinal events, or cardiovascular events associated with the most common class of medications used, bisphosphonates, is small. Evidence on the effectiveness of medications to treat osteoporosis in men is lacking (only two studies conducted).

Exercise. Engagement in 120-300 minutes of weekly moderate-intensity aerobic activity can reduce the risk of hip fractures, and performance of weekly balance and muscle-strengthening activities can help prevent falls in older adults.

Supplements. In a separate recommendation, USPSTF recommends against daily supplementation with less than 400 IU of vitamin D and less than 1,000 mg of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. They found insufficient evidence on supplementation with higher doses of vitamin D and calcium in postmenopausal women, or at any dose in men and premenopausal women.
 

Recommendations from others

The National Osteoporosis Foundation and the International Society for Clinical Densitometry recommend BMD testing in all women older than 65 years, all men over 70 years, postmenopausal women younger than 65 years, and men aged 50-69 years with increased risk factors. The American Academy of Family Physicians recommends against DXA screening in women younger than 65 years and men younger than 70 years with no risk factors.
 

The bottom line

For all women older than 65 years and postmenopausal women younger than 65 years who are at increased risk, screen for and treat osteoporosis to prevent fractures. For men, there is insufficient evidence to screen.

Dr. Shrestha is a second-year resident in the Family Medicine Residency Program at Abington (Pa.) - Jefferson Health. 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. U.S. Preventative Services Task Force. JAMA. 2018 Jun 26;319(24):2521-31.

2. U.S. Preventative Services Task Force. JAMA. 2018 Jun 26;319(24):2532-51.
 

The U.S. Preventive Services Task Force commissioned a systematic evidence review of 168 fair-good quality articles to examine newer evidence on screening for and treatment of osteoporotic fracture in women and men and update its 2011 guideline. They found convincing evidence that bone measurement tests and clinical risk assessment tools are accurate for predicting osteoporotic fractures in women. For postmenopausal women older than 65 years and those younger than 65 years with increased risk of osteoporosis, USPSTF found convincing evidence that screening can detect osteoporosis and that treatment can provide at least a moderate benefit in preventing fractures (grade B). For men, they report inadequate evidence on the benefits and harms of screening for osteoporosis to reduce the risk of fractures (I statement).

Importance

Osteoporosis leads to increased bone fragility and risk of fractures, specifically hip fractures, that are associated with limitations in ambulation, chronic pain, disability and loss of independence, and decreased quality of life: 21%-30% of those who suffer hip fractures die within 1 year. Osteoporosis is usually asymptomatic until a fracture occurs, thus preventing fractures is the main goal of an osteoporosis screening strategy. With the increasing life expectancy of the U.S. population, the potential preventable burden is likely to increase in future years.

Screening tests

The most commonly used test is central dual energy x-ray absorptiometry (DXA), which provides measurement of bone mineral density (BMD) of the hip and lumbar spine. Most treatment guidelines already use central DXA BMD to define osteoporosis and the threshold at which to start drug therapies for prevention. Other lower-cost and more accessible alternatives include peripheral DXA, which measures BMD at lower forearm and heel, and quantitative ultrasound (QUS), which also evaluates peripheral sites like the calcaneus. QUS does not measure BMD. USPSTF found that the harms associated with screening were small (mainly radiation exposure from DXA and opportunity costs).

Population and risk assessment

The review included adults older than 40 years of age, mostly postmenopausal women, without a history of previous low-trauma fractures, without conditions or medications that may cause secondary osteoporosis, and without increased risk of falls.

Patients at increased risk of osteoporotic fractures include those with parental history of hip fractures, low body weight, excessive alcohol consumption, and smokers. For postmenopausal women younger than 65 years of age with at least one risk factor, a reasonable approach to determine who should be screened with BMD is to use one of the various clinical risk assessment tools available. The most frequently studied tools in women are the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), Osteoporosis Self-Assessment Tool (OST), and Simple Calculated Osteoporosis Risk Estimation (SCORE). The Fracture Risk Assessment (FRAX) tool calculates the 10-year risk of a major osteoporotic fracture (MOF) using clinical risk factors. For example, one approach is to perform BMD in women younger than 65 years with a FRAX risk greater than 8.4% (the FRAX risk of a 65-year-old woman of mean height and weight without major risk factors).

In men, the prevalence of osteoporosis (4.3%) is generally lower than in women (15.4%). In the absence of other risk factors, it is not till age 80 that the prevalence of osteoporosis in white men starts to reach that of a 65-year-old white woman. While men have similar risk factors as women described above, men with hypogonadism, history of cerebrovascular accident, and history of diabetes are also at increased risk of fracture.
 

Preventative measures to reduce osteoporotic fractures

Approved drug therapies. The majority of studies were conducted in postmenopausal women. Bisphosphonates, most commonly used and studied, significantly reduced vertebral and nonvertebral fractures but not hip fractures (possibly because of underpowered studies). Raloxifene and parathyroid hormone reduced vertebral fractures but not nonvertebral fractures. Denosumab significantly reduced all three types of fractures. A 2011 review identified that estrogen reduced vertebral fractures, but no new studies were identified for the current review. Data from the Women’s Health Initiative show that women receiving estrogen with or without progesterone had an elevated risk of stroke, venous thromboembolism, and gallbladder disease; their risk for urinary incontinence was increased during the first year of follow-up. In addition, women receiving estrogen plus progestin had a higher risk of invasive breast cancer, coronary heart disease, and probable dementia. The risk of serious adverse events, upper-gastrointestinal events, or cardiovascular events associated with the most common class of medications used, bisphosphonates, is small. Evidence on the effectiveness of medications to treat osteoporosis in men is lacking (only two studies conducted).

Exercise. Engagement in 120-300 minutes of weekly moderate-intensity aerobic activity can reduce the risk of hip fractures, and performance of weekly balance and muscle-strengthening activities can help prevent falls in older adults.

Supplements. In a separate recommendation, USPSTF recommends against daily supplementation with less than 400 IU of vitamin D and less than 1,000 mg of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. They found insufficient evidence on supplementation with higher doses of vitamin D and calcium in postmenopausal women, or at any dose in men and premenopausal women.
 

Recommendations from others

The National Osteoporosis Foundation and the International Society for Clinical Densitometry recommend BMD testing in all women older than 65 years, all men over 70 years, postmenopausal women younger than 65 years, and men aged 50-69 years with increased risk factors. The American Academy of Family Physicians recommends against DXA screening in women younger than 65 years and men younger than 70 years with no risk factors.
 

The bottom line

For all women older than 65 years and postmenopausal women younger than 65 years who are at increased risk, screen for and treat osteoporosis to prevent fractures. For men, there is insufficient evidence to screen.

Dr. Shrestha is a second-year resident in the Family Medicine Residency Program at Abington (Pa.) - Jefferson Health. 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. U.S. Preventative Services Task Force. JAMA. 2018 Jun 26;319(24):2521-31.

2. U.S. Preventative Services Task Force. JAMA. 2018 Jun 26;319(24):2532-51.
 

Summer is often a time when we can take a break from our usual frenetic schedules. It is a time to catch up on nonurgent reading. I just completed 3 books of interest, including Bad Blood, by John Carreyrou, What the Eyes Don’t See, by Mona Hanna-Attisha, and Overcharged, by Charles Silver and David Hyman.

The common thread among them is their focus on the interplay among American medicine, politics, money, and denial of science. Carreyrou is a Wall Street Journal investigative reporter who describes the spectacular rise and ignominious fall of Theranos, a privately held company in the business of blood testing and diagnostics. Theranos claimed to have a secret process enabling them to run over 200 diagnostic blood tests on blood derived from a finger prick. At its peak, the company was valued at $10 billion but their secret process proved to be false science. They are now subject to multiple lawsuits and their leaders are under criminal investigation.

Dr. Attisha’s book describes the decisions made by Michigan political and administrative leaders that resulted in high levels of lead in Flint’s water supply. Dr. Attisha is a pediatrician in Flint who documented elevated lead levels in her small patients. When she tried to bring this to public attention, her data was met with enormous backlash by leaders who tried to deny facts and discredit her personally. Neurological damage from childhood lead poisoning is not reversible.

Hyman and Silver’s book (published by the Cato Institute) asserts that politics, third-party payers, and the health care industry, together, have devised a system of wealth transfer from taxpayers to health care providers. It provides examples where this system (that separates payment from health value) does real harm to individual people and the nation. Reading this book makes us think about who should hold the assets from which first-dollar medical payments derive. It reminded me of the famous saying by James Madison, “If all men were angels, there would be no need for government.”

In some circles, science, data, and the scientific method are not valued. In the end, as these books point out, everyone can be entitled to their opinion, but no one has the power to alter facts.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Summer is often a time when we can take a break from our usual frenetic schedules. It is a time to catch up on nonurgent reading. I just completed 3 books of interest, including Bad Blood, by John Carreyrou, What the Eyes Don’t See, by Mona Hanna-Attisha, and Overcharged, by Charles Silver and David Hyman.

The common thread among them is their focus on the interplay among American medicine, politics, money, and denial of science. Carreyrou is a Wall Street Journal investigative reporter who describes the spectacular rise and ignominious fall of Theranos, a privately held company in the business of blood testing and diagnostics. Theranos claimed to have a secret process enabling them to run over 200 diagnostic blood tests on blood derived from a finger prick. At its peak, the company was valued at $10 billion but their secret process proved to be false science. They are now subject to multiple lawsuits and their leaders are under criminal investigation.

Dr. Attisha’s book describes the decisions made by Michigan political and administrative leaders that resulted in high levels of lead in Flint’s water supply. Dr. Attisha is a pediatrician in Flint who documented elevated lead levels in her small patients. When she tried to bring this to public attention, her data was met with enormous backlash by leaders who tried to deny facts and discredit her personally. Neurological damage from childhood lead poisoning is not reversible.

Hyman and Silver’s book (published by the Cato Institute) asserts that politics, third-party payers, and the health care industry, together, have devised a system of wealth transfer from taxpayers to health care providers. It provides examples where this system (that separates payment from health value) does real harm to individual people and the nation. Reading this book makes us think about who should hold the assets from which first-dollar medical payments derive. It reminded me of the famous saying by James Madison, “If all men were angels, there would be no need for government.”

In some circles, science, data, and the scientific method are not valued. In the end, as these books point out, everyone can be entitled to their opinion, but no one has the power to alter facts.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Summer is often a time when we can take a break from our usual frenetic schedules. It is a time to catch up on nonurgent reading. I just completed 3 books of interest, including Bad Blood, by John Carreyrou, What the Eyes Don’t See, by Mona Hanna-Attisha, and Overcharged, by Charles Silver and David Hyman.

The common thread among them is their focus on the interplay among American medicine, politics, money, and denial of science. Carreyrou is a Wall Street Journal investigative reporter who describes the spectacular rise and ignominious fall of Theranos, a privately held company in the business of blood testing and diagnostics. Theranos claimed to have a secret process enabling them to run over 200 diagnostic blood tests on blood derived from a finger prick. At its peak, the company was valued at $10 billion but their secret process proved to be false science. They are now subject to multiple lawsuits and their leaders are under criminal investigation.

Dr. Attisha’s book describes the decisions made by Michigan political and administrative leaders that resulted in high levels of lead in Flint’s water supply. Dr. Attisha is a pediatrician in Flint who documented elevated lead levels in her small patients. When she tried to bring this to public attention, her data was met with enormous backlash by leaders who tried to deny facts and discredit her personally. Neurological damage from childhood lead poisoning is not reversible.

Hyman and Silver’s book (published by the Cato Institute) asserts that politics, third-party payers, and the health care industry, together, have devised a system of wealth transfer from taxpayers to health care providers. It provides examples where this system (that separates payment from health value) does real harm to individual people and the nation. Reading this book makes us think about who should hold the assets from which first-dollar medical payments derive. It reminded me of the famous saying by James Madison, “If all men were angels, there would be no need for government.”

In some circles, science, data, and the scientific method are not valued. In the end, as these books point out, everyone can be entitled to their opinion, but no one has the power to alter facts.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Cervical screening recommendations do not cover all circumstances

Starting cervical cancer screening at age 21 does not necessarily take into account the fact that we are seeing youngsters initiating sexual activity as young as age 9. We obviously see pregnancies early as well. Waiting to screen until age 21, therefore, may cause us to miss the development of high-grade lesions and cervical cancer. As you know, cases in the literature report instances of invasive cancer with first Pap test at age 21. Also, human papillomavirus (HPV) is spread by sexual activity, with the squamous columnar junction more susceptible to infection at a young age.

Recommendations regarding cervical cancer screening for older women also should take into account new sexual partners. Currently, both men and women are living longer and are remarrying or are sexually active with multiple partners. The fact that older women are desiring hormone replacement for vaginal lubrication and dyspareunia shows that they are sexually active even in their late 70s. I believe that the incidence of HPV infection to cervical, vaginal, and vulvar tissue will be increasing as a result.

In an age in which primary care physicians do not have time to perform Pap tests or vaginal, cervical, and vulvar exams because they are overwhelmed with keeping up with patients’ major medical issues is a misunderstanding regarding current recommendations for Pap test screening.

Elizabeth Reinoehl-McClaskey, DO
Onley, Virginia

Dr. Einstein responds

Sexual behavior can start early, but this does not lead to cancer. When we screen, we are looking for cancer, not HPV infection, which is quite common in women and men younger than age 21. Also, one might question whether current screening techniques pick up early-onset tumors. Regarding older women, sexual activity and the rate of older women getting cervical cancer should be considered in future guidelines.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Cervical screening recommendations do not cover all circumstances

Starting cervical cancer screening at age 21 does not necessarily take into account the fact that we are seeing youngsters initiating sexual activity as young as age 9. We obviously see pregnancies early as well. Waiting to screen until age 21, therefore, may cause us to miss the development of high-grade lesions and cervical cancer. As you know, cases in the literature report instances of invasive cancer with first Pap test at age 21. Also, human papillomavirus (HPV) is spread by sexual activity, with the squamous columnar junction more susceptible to infection at a young age.

Recommendations regarding cervical cancer screening for older women also should take into account new sexual partners. Currently, both men and women are living longer and are remarrying or are sexually active with multiple partners. The fact that older women are desiring hormone replacement for vaginal lubrication and dyspareunia shows that they are sexually active even in their late 70s. I believe that the incidence of HPV infection to cervical, vaginal, and vulvar tissue will be increasing as a result.

In an age in which primary care physicians do not have time to perform Pap tests or vaginal, cervical, and vulvar exams because they are overwhelmed with keeping up with patients’ major medical issues is a misunderstanding regarding current recommendations for Pap test screening.

Elizabeth Reinoehl-McClaskey, DO
Onley, Virginia

Dr. Einstein responds

Sexual behavior can start early, but this does not lead to cancer. When we screen, we are looking for cancer, not HPV infection, which is quite common in women and men younger than age 21. Also, one might question whether current screening techniques pick up early-onset tumors. Regarding older women, sexual activity and the rate of older women getting cervical cancer should be considered in future guidelines.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Cervical screening recommendations do not cover all circumstances

Starting cervical cancer screening at age 21 does not necessarily take into account the fact that we are seeing youngsters initiating sexual activity as young as age 9. We obviously see pregnancies early as well. Waiting to screen until age 21, therefore, may cause us to miss the development of high-grade lesions and cervical cancer. As you know, cases in the literature report instances of invasive cancer with first Pap test at age 21. Also, human papillomavirus (HPV) is spread by sexual activity, with the squamous columnar junction more susceptible to infection at a young age.

Recommendations regarding cervical cancer screening for older women also should take into account new sexual partners. Currently, both men and women are living longer and are remarrying or are sexually active with multiple partners. The fact that older women are desiring hormone replacement for vaginal lubrication and dyspareunia shows that they are sexually active even in their late 70s. I believe that the incidence of HPV infection to cervical, vaginal, and vulvar tissue will be increasing as a result.

In an age in which primary care physicians do not have time to perform Pap tests or vaginal, cervical, and vulvar exams because they are overwhelmed with keeping up with patients’ major medical issues is a misunderstanding regarding current recommendations for Pap test screening.

Elizabeth Reinoehl-McClaskey, DO
Onley, Virginia

Dr. Einstein responds

Sexual behavior can start early, but this does not lead to cancer. When we screen, we are looking for cancer, not HPV infection, which is quite common in women and men younger than age 21. Also, one might question whether current screening techniques pick up early-onset tumors. Regarding older women, sexual activity and the rate of older women getting cervical cancer should be considered in future guidelines.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Midwife-physician alliance benefits women

I want to thank Dr. Barbieri for the introduction to his April editorial in which he states that the “trusted nurse midwife asks you to consult on her patient.” Where I practice (in a large suburb of Kansas with a hospital where more than 5,000 babies are delivered yearly), there is a serious lack of midwives and an even greater lack of physicians to support them. As the co-owner of an independently owned nurse-midwife practice, after losing our collaborating physician, we were unable to secure collaboration from any other group, despite our cesarean delivery rate of 5%, vaginal birth after cesarean success rate of 87%, and chorioamnionitis rate of 0%. Please continue to educate your readers on the benefit to women when all obstetric providers work together.

Julie Gorenc, CNM
Lenexa, Kansas

Dr. Barbieri responds

I thank Ms. Gorenc for her support of OBG Management and share her concern about optimizing obstetric care. Given the pending shortage of clinicians, we will need all experienced clinicians to work together to ensure access to high-quality obstetric care. My observation is that many obstetricians are concerned about liability issues that can be associated with coverage of other clinicians, including nurse midwives. The quality of obstetric care and collaboration would be enhanced if our medical tort system could evolve to a “just culture,” ending the “blame and shame” associated with tort litigation.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Midwife-physician alliance benefits women

I want to thank Dr. Barbieri for the introduction to his April editorial in which he states that the “trusted nurse midwife asks you to consult on her patient.” Where I practice (in a large suburb of Kansas with a hospital where more than 5,000 babies are delivered yearly), there is a serious lack of midwives and an even greater lack of physicians to support them. As the co-owner of an independently owned nurse-midwife practice, after losing our collaborating physician, we were unable to secure collaboration from any other group, despite our cesarean delivery rate of 5%, vaginal birth after cesarean success rate of 87%, and chorioamnionitis rate of 0%. Please continue to educate your readers on the benefit to women when all obstetric providers work together.

Julie Gorenc, CNM
Lenexa, Kansas

Dr. Barbieri responds

I thank Ms. Gorenc for her support of OBG Management and share her concern about optimizing obstetric care. Given the pending shortage of clinicians, we will need all experienced clinicians to work together to ensure access to high-quality obstetric care. My observation is that many obstetricians are concerned about liability issues that can be associated with coverage of other clinicians, including nurse midwives. The quality of obstetric care and collaboration would be enhanced if our medical tort system could evolve to a “just culture,” ending the “blame and shame” associated with tort litigation.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Midwife-physician alliance benefits women

I want to thank Dr. Barbieri for the introduction to his April editorial in which he states that the “trusted nurse midwife asks you to consult on her patient.” Where I practice (in a large suburb of Kansas with a hospital where more than 5,000 babies are delivered yearly), there is a serious lack of midwives and an even greater lack of physicians to support them. As the co-owner of an independently owned nurse-midwife practice, after losing our collaborating physician, we were unable to secure collaboration from any other group, despite our cesarean delivery rate of 5%, vaginal birth after cesarean success rate of 87%, and chorioamnionitis rate of 0%. Please continue to educate your readers on the benefit to women when all obstetric providers work together.

Julie Gorenc, CNM
Lenexa, Kansas

Dr. Barbieri responds

I thank Ms. Gorenc for her support of OBG Management and share her concern about optimizing obstetric care. Given the pending shortage of clinicians, we will need all experienced clinicians to work together to ensure access to high-quality obstetric care. My observation is that many obstetricians are concerned about liability issues that can be associated with coverage of other clinicians, including nurse midwives. The quality of obstetric care and collaboration would be enhanced if our medical tort system could evolve to a “just culture,” ending the “blame and shame” associated with tort litigation.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Diagnostics company asserts medical and pathology groups prefer cotesting for cervical cancer screening

We are concerned about Dr. Wright’s March 2018 gynecologic cancer coverage of US Preventive Services Task Force (USPSTF) screening guidelines for cervical cancer.

The article suggests that draft USPSTF cervical cancer guidelines issued in September 2017 are final when in fact that is not the case. The USPSTF issued draft guidelines in late 2017, butfinal publication is pending USPSTFrevisions in response to submitted public comments. This means that, for now, existing USPSTF guidelines remain in place, and these guidelines clearly recommend cotesting (high-risk HPV and cytology/Pap) in women 30 to 65 years of age every 5 years as an appropriate screening modality, in alignment with the American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, and the American Cancer Society, among others.

It is also notable that the proposed USPSTF guidelines have been met with sharp resistance. ACOG, as well as several organizations, including the American Society of Clinical Pathology, American Society of Cytopathology, the American Society for Cytotechnology, the College of American Pathologists, the International Academy of Cytology, and the Papanicolaou Society of Cytopathology, cite concerns with the proposed USPSTF guidelines and continue to argue in favor of cotesting in women 30 to 65 years of age.^1,2

We also fear that Dr. Wright may have provided data out of context. For instance, he notes that the USPSTF, in its draft guidelines, found that cotesting increased the number of follow-up tests but did not increase detection of CIN3+ in a decision model. Yet, the USPSTF analysis overrelied on research from European populations (not representative of the US cervical cancer experience) and excluded peer-reviewed data of women in the United States, which clearly shows that HPV-Pap together catches more cervical cancers than either Pap or HPV alone.³

D.P. Alagia, MD, and Harvey W. Kaufman, MD, MBA
Quest Diagnostics
Madison, New Jersey

Dr. Wright responds

I thank Drs. Alagia and Kaufman for their interest in the work and their comments regarding the USPSTF cervical cancer guidelines. As stated in the article, the USPSTF recommendations are currently in draft form and subject to revision based on public comment. The guidelines are a synthesis of best available evidence and are meant to weigh the benefits and harms of various cervical cancer screening strategies. The recommendations are based in part on simulation modeling that incorporates available evidence and projects the long-term effects of multiple rounds of screening. While the decision models incorporated a large amount of data and were robust in a variety of sensitivity analyses, as with all decision analyses, they are limited by the underlying assumptions utilized in the model. Over the last 2 decades, screening practices for cervical cancer have dramatically shifted. Highlighting the USPSTF draft guidelines was meant to raise awareness among clinicians and policy makers of the evolving role of high-risk HPV testing, either alone or in combination with cytology, as a screening modality for cervical cancer.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Diagnostics company asserts medical and pathology groups prefer cotesting for cervical cancer screening

We are concerned about Dr. Wright’s March 2018 gynecologic cancer coverage of US Preventive Services Task Force (USPSTF) screening guidelines for cervical cancer.

The article suggests that draft USPSTF cervical cancer guidelines issued in September 2017 are final when in fact that is not the case. The USPSTF issued draft guidelines in late 2017, butfinal publication is pending USPSTFrevisions in response to submitted public comments. This means that, for now, existing USPSTF guidelines remain in place, and these guidelines clearly recommend cotesting (high-risk HPV and cytology/Pap) in women 30 to 65 years of age every 5 years as an appropriate screening modality, in alignment with the American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, and the American Cancer Society, among others.

It is also notable that the proposed USPSTF guidelines have been met with sharp resistance. ACOG, as well as several organizations, including the American Society of Clinical Pathology, American Society of Cytopathology, the American Society for Cytotechnology, the College of American Pathologists, the International Academy of Cytology, and the Papanicolaou Society of Cytopathology, cite concerns with the proposed USPSTF guidelines and continue to argue in favor of cotesting in women 30 to 65 years of age.^1,2

We also fear that Dr. Wright may have provided data out of context. For instance, he notes that the USPSTF, in its draft guidelines, found that cotesting increased the number of follow-up tests but did not increase detection of CIN3+ in a decision model. Yet, the USPSTF analysis overrelied on research from European populations (not representative of the US cervical cancer experience) and excluded peer-reviewed data of women in the United States, which clearly shows that HPV-Pap together catches more cervical cancers than either Pap or HPV alone.³

D.P. Alagia, MD, and Harvey W. Kaufman, MD, MBA
Quest Diagnostics
Madison, New Jersey

Dr. Wright responds

I thank Drs. Alagia and Kaufman for their interest in the work and their comments regarding the USPSTF cervical cancer guidelines. As stated in the article, the USPSTF recommendations are currently in draft form and subject to revision based on public comment. The guidelines are a synthesis of best available evidence and are meant to weigh the benefits and harms of various cervical cancer screening strategies. The recommendations are based in part on simulation modeling that incorporates available evidence and projects the long-term effects of multiple rounds of screening. While the decision models incorporated a large amount of data and were robust in a variety of sensitivity analyses, as with all decision analyses, they are limited by the underlying assumptions utilized in the model. Over the last 2 decades, screening practices for cervical cancer have dramatically shifted. Highlighting the USPSTF draft guidelines was meant to raise awareness among clinicians and policy makers of the evolving role of high-risk HPV testing, either alone or in combination with cytology, as a screening modality for cervical cancer.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Diagnostics company asserts medical and pathology groups prefer cotesting for cervical cancer screening

We are concerned about Dr. Wright’s March 2018 gynecologic cancer coverage of US Preventive Services Task Force (USPSTF) screening guidelines for cervical cancer.

The article suggests that draft USPSTF cervical cancer guidelines issued in September 2017 are final when in fact that is not the case. The USPSTF issued draft guidelines in late 2017, butfinal publication is pending USPSTFrevisions in response to submitted public comments. This means that, for now, existing USPSTF guidelines remain in place, and these guidelines clearly recommend cotesting (high-risk HPV and cytology/Pap) in women 30 to 65 years of age every 5 years as an appropriate screening modality, in alignment with the American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, and the American Cancer Society, among others.

It is also notable that the proposed USPSTF guidelines have been met with sharp resistance. ACOG, as well as several organizations, including the American Society of Clinical Pathology, American Society of Cytopathology, the American Society for Cytotechnology, the College of American Pathologists, the International Academy of Cytology, and the Papanicolaou Society of Cytopathology, cite concerns with the proposed USPSTF guidelines and continue to argue in favor of cotesting in women 30 to 65 years of age.^1,2

We also fear that Dr. Wright may have provided data out of context. For instance, he notes that the USPSTF, in its draft guidelines, found that cotesting increased the number of follow-up tests but did not increase detection of CIN3+ in a decision model. Yet, the USPSTF analysis overrelied on research from European populations (not representative of the US cervical cancer experience) and excluded peer-reviewed data of women in the United States, which clearly shows that HPV-Pap together catches more cervical cancers than either Pap or HPV alone.³

D.P. Alagia, MD, and Harvey W. Kaufman, MD, MBA
Quest Diagnostics
Madison, New Jersey

Dr. Wright responds

I thank Drs. Alagia and Kaufman for their interest in the work and their comments regarding the USPSTF cervical cancer guidelines. As stated in the article, the USPSTF recommendations are currently in draft form and subject to revision based on public comment. The guidelines are a synthesis of best available evidence and are meant to weigh the benefits and harms of various cervical cancer screening strategies. The recommendations are based in part on simulation modeling that incorporates available evidence and projects the long-term effects of multiple rounds of screening. While the decision models incorporated a large amount of data and were robust in a variety of sensitivity analyses, as with all decision analyses, they are limited by the underlying assumptions utilized in the model. Over the last 2 decades, screening practices for cervical cancer have dramatically shifted. Highlighting the USPSTF draft guidelines was meant to raise awareness among clinicians and policy makers of the evolving role of high-risk HPV testing, either alone or in combination with cytology, as a screening modality for cervical cancer.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

Recently, a medical consulting group published, “The disruption of primary care: How customer-obsessed companies are changing everything.”¹ The essay paints a not-too-rosy picture for the future of traditional family medicine in our Internet-dominated, immediate-gratification-seeking society. They contend:

“The future of primary care extends far beyond the physician’s office to pharmacies, supermarkets and retail clinics including CVS, Walgreens, Target and CityMD, as well as virtual care companies such as MDLive and Amwell. Increasingly, Internet and technology companies like Amazon, Google and Apple are showing signs of getting into the healthcare services and information arena. … These formidable customer-centric companies are primed to become preferred alternative providers of health information and low-acuity services, while lowering the price point of primary care services.”

I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care.

While it is an interesting piece, I remain bullish on family medicine and believe the future remains bright for those who practice high-quality primary care. Why?

1. Cost efficacy. For common medical conditions, family physicians (FPs) are much more cost-effective than specialty or emergency department care. For example, a young man recently hit his thumb and had a subungual hematoma. He visited an orthopedic physician’s office, where the physician ordered an unnecessary x-ray and sent him home without draining the hematoma. The cost was more than $300. The patient was referred to our office where, later that day, we drained the hematoma with a hypodermic needle at a cost of $90. We all have similar stories of expensive but ineffective care.

2. Immediate care. Many family medicine groups have responded to the demand for immediate care with extended hours, assigning a doctor of the day, and/or having an open-access schedule that allows for a sufficient number of same-day appointments. Many FPs are now available for “virtual visits,” since Web portals for electronic medical records have been become easy to use for secure communication. In addition, many FPs have developed e-consult services to streamline specialist consultations. At the Cleveland Clinic, an FP leads the primary care telemedicine program.

3. A future that is not mutually exclusive. The authors contend that the future will be a matrix of health care services available via the Internet like the Amazon model. I see that model as fully compatible with excellent family medicine. In such a model, a skilled FP and staff provide timely acute care and chronic disease management; they connect patients to other health-related services and high-quality health care information; and they guide patients through our increasingly complex medical system. Isn’t that what we’re already doing?

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

Laboratory work revealed a normal CBC and differential, an elevated C-reactive protein (CRP) and sedimentation rate (ESR), negative antistreptolysin O (ASO) titers, negative pregnancy test, a normal urinalysis, and negative blood, throat, and urine cultures. A chest x-ray also was negative as well as angiotensin-converting enzyme (ACE) levels. Tuberculosis interferon-gamma release essay was negative.

The patient was diagnosed with erythema nodosum (EN), based on physical exam and history of the lesions. In her particular case, infectious causes including streptococcus infection, tuberculosis, and coccidioidomycosis were ruled out. There were no x-ray findings that suggested sarcoidosis and her ACE level was within normal limits. The pregnancy test also was negative. Given her recent start on OCs, this was thought to be the cause of the lesions.

She was treated with elevation, compression stockings, and NSAIDs and discontinuation of OCs. The lesions resolved after 6 weeks leaving bruiselike patches (erythema contusiformis).

EN is a delayed-type hypersensitivity reaction, causing inflammation on the fat (panniculitis) most commonly on the shins, but it can also occur on the arms, face, neck, and thighs. It is the most common type of panniculitis and is usually seen more often in women from the second to fourth decade of life. Erythematous tender nodules in crops commonly located on the shins are the characteristic physical finding. Systemic symptoms can occur including fever, malaise, and joint pain. The lesions usually last up to 6-8 weeks and may leave bruiselike patches or postinflammatory hyperpigmentation that can take months to improve.¹

The diagnosis of EN usually is made by physical examination and natural history. In unusual severe cases or lesions in atypical locations, a skin biopsy is indicated. Histologic examination of one of the lesions reveals a septal panniculitis without vasculitis. Miescher’s radial granulomas (grouped macrophages around neutrophils or septa-like spaces) often are present and are a characteristic feature of EN.

EN can be triggered by different types of infections such as streptococcus, mycoplasma, tuberculosis, or bacterial gastroenteritis; medications such as OCs, sulfonamides, iodides, penicillin, or bromides; medical conditions that include inflammatory bowel disease, pregnancy, or sarcoidosis; or neutrophilic dermatosis and malignancy such as leukemia and Hodgkin disease.^2,3 A third of the cases are idiopathic. In children, streptococcal infections are responsible for most cases of EN.⁴

Recommended work-up to investigate possible triggers includes a CBC with differential, sedimentation rate, CRP, ASO titers or anti-DNase B titers, tuberculin skin test or interferon-gamma TB test and a chest X ray. If there are any other symptoms, physical signs, or risk factors are present for the other not so common causes, further ancillary testing may be warranted.

Erythematous nodules and papules on the shin in children are commonly caused by arthropod bites also known as papular urticaria. These lesions are pruritic rather than tender and usually respond to topical corticosteroids and oral antihistamines. Subcutaneous bacterial, fungal, or atypical mycobacterial infections can present with tender nodules that can ulcerate and drain on the shins, feet, or any other body part. These patients may have a history of immunodeficiency and usually systemic symptoms of infection are present. Cutaneous polyarteritis nodosa (PAN) also can present with tender nodules on the legs but these lesions usually necrose and ulcerate and may be associated with livedo racemosa, a transient or persistent, blotchy, reddish-blue to purple, netlike cyanotic pattern. On pathology, PAN presents with necrotizing medium vessel vasculitis. Malignant nodules also can occur on the shin. Pathology will show atypical cells. Other forms of panniculitis, such as erythema induratum and pancreatic panniculitis, can present with tender nodules but these lesions usually occur on the calves and ulcerate.

Management of EN starts with treating the underlying infection or stopping the causative medication. Initial measures include bed rest, leg elevation, compression bandages, and NSAIDs. Potassium iodide is a very effective therapy as it may control the symptoms within 24 hours. When there is no response to the above, or the patient has severe symptoms, a short course of systemic glucocorticoids can be started. Other medications for recalcitrant or recurrent lesions include colchicine, dapsone, or hydroxychloroquine.
 

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.

References

1. Panniculitis, in “Dermatology,” 3rd ed. (Philadelphia: Elsevier Saunders, 2012, p. 1641).

2. Arthritis Rheum. 2000 Mar;43(3):584-92.

3. J Clin Oncol. 2007 Sep 1;25(25):4011-2.

4. Turk J Pediatr. 2014 Mar-Apr;56(2):144-9.

Laboratory work revealed a normal CBC and differential, an elevated C-reactive protein (CRP) and sedimentation rate (ESR), negative antistreptolysin O (ASO) titers, negative pregnancy test, a normal urinalysis, and negative blood, throat, and urine cultures. A chest x-ray also was negative as well as angiotensin-converting enzyme (ACE) levels. Tuberculosis interferon-gamma release essay was negative.

The patient was diagnosed with erythema nodosum (EN), based on physical exam and history of the lesions. In her particular case, infectious causes including streptococcus infection, tuberculosis, and coccidioidomycosis were ruled out. There were no x-ray findings that suggested sarcoidosis and her ACE level was within normal limits. The pregnancy test also was negative. Given her recent start on OCs, this was thought to be the cause of the lesions.

She was treated with elevation, compression stockings, and NSAIDs and discontinuation of OCs. The lesions resolved after 6 weeks leaving bruiselike patches (erythema contusiformis).

EN is a delayed-type hypersensitivity reaction, causing inflammation on the fat (panniculitis) most commonly on the shins, but it can also occur on the arms, face, neck, and thighs. It is the most common type of panniculitis and is usually seen more often in women from the second to fourth decade of life. Erythematous tender nodules in crops commonly located on the shins are the characteristic physical finding. Systemic symptoms can occur including fever, malaise, and joint pain. The lesions usually last up to 6-8 weeks and may leave bruiselike patches or postinflammatory hyperpigmentation that can take months to improve.¹

The diagnosis of EN usually is made by physical examination and natural history. In unusual severe cases or lesions in atypical locations, a skin biopsy is indicated. Histologic examination of one of the lesions reveals a septal panniculitis without vasculitis. Miescher’s radial granulomas (grouped macrophages around neutrophils or septa-like spaces) often are present and are a characteristic feature of EN.

EN can be triggered by different types of infections such as streptococcus, mycoplasma, tuberculosis, or bacterial gastroenteritis; medications such as OCs, sulfonamides, iodides, penicillin, or bromides; medical conditions that include inflammatory bowel disease, pregnancy, or sarcoidosis; or neutrophilic dermatosis and malignancy such as leukemia and Hodgkin disease.^2,3 A third of the cases are idiopathic. In children, streptococcal infections are responsible for most cases of EN.⁴

Recommended work-up to investigate possible triggers includes a CBC with differential, sedimentation rate, CRP, ASO titers or anti-DNase B titers, tuberculin skin test or interferon-gamma TB test and a chest X ray. If there are any other symptoms, physical signs, or risk factors are present for the other not so common causes, further ancillary testing may be warranted.

Erythematous nodules and papules on the shin in children are commonly caused by arthropod bites also known as papular urticaria. These lesions are pruritic rather than tender and usually respond to topical corticosteroids and oral antihistamines. Subcutaneous bacterial, fungal, or atypical mycobacterial infections can present with tender nodules that can ulcerate and drain on the shins, feet, or any other body part. These patients may have a history of immunodeficiency and usually systemic symptoms of infection are present. Cutaneous polyarteritis nodosa (PAN) also can present with tender nodules on the legs but these lesions usually necrose and ulcerate and may be associated with livedo racemosa, a transient or persistent, blotchy, reddish-blue to purple, netlike cyanotic pattern. On pathology, PAN presents with necrotizing medium vessel vasculitis. Malignant nodules also can occur on the shin. Pathology will show atypical cells. Other forms of panniculitis, such as erythema induratum and pancreatic panniculitis, can present with tender nodules but these lesions usually occur on the calves and ulcerate.

Management of EN starts with treating the underlying infection or stopping the causative medication. Initial measures include bed rest, leg elevation, compression bandages, and NSAIDs. Potassium iodide is a very effective therapy as it may control the symptoms within 24 hours. When there is no response to the above, or the patient has severe symptoms, a short course of systemic glucocorticoids can be started. Other medications for recalcitrant or recurrent lesions include colchicine, dapsone, or hydroxychloroquine.
 

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.

References

1. Panniculitis, in “Dermatology,” 3rd ed. (Philadelphia: Elsevier Saunders, 2012, p. 1641).

2. Arthritis Rheum. 2000 Mar;43(3):584-92.

3. J Clin Oncol. 2007 Sep 1;25(25):4011-2.

4. Turk J Pediatr. 2014 Mar-Apr;56(2):144-9.

Laboratory work revealed a normal CBC and differential, an elevated C-reactive protein (CRP) and sedimentation rate (ESR), negative antistreptolysin O (ASO) titers, negative pregnancy test, a normal urinalysis, and negative blood, throat, and urine cultures. A chest x-ray also was negative as well as angiotensin-converting enzyme (ACE) levels. Tuberculosis interferon-gamma release essay was negative.

The patient was diagnosed with erythema nodosum (EN), based on physical exam and history of the lesions. In her particular case, infectious causes including streptococcus infection, tuberculosis, and coccidioidomycosis were ruled out. There were no x-ray findings that suggested sarcoidosis and her ACE level was within normal limits. The pregnancy test also was negative. Given her recent start on OCs, this was thought to be the cause of the lesions.

She was treated with elevation, compression stockings, and NSAIDs and discontinuation of OCs. The lesions resolved after 6 weeks leaving bruiselike patches (erythema contusiformis).

EN is a delayed-type hypersensitivity reaction, causing inflammation on the fat (panniculitis) most commonly on the shins, but it can also occur on the arms, face, neck, and thighs. It is the most common type of panniculitis and is usually seen more often in women from the second to fourth decade of life. Erythematous tender nodules in crops commonly located on the shins are the characteristic physical finding. Systemic symptoms can occur including fever, malaise, and joint pain. The lesions usually last up to 6-8 weeks and may leave bruiselike patches or postinflammatory hyperpigmentation that can take months to improve.¹

The diagnosis of EN usually is made by physical examination and natural history. In unusual severe cases or lesions in atypical locations, a skin biopsy is indicated. Histologic examination of one of the lesions reveals a septal panniculitis without vasculitis. Miescher’s radial granulomas (grouped macrophages around neutrophils or septa-like spaces) often are present and are a characteristic feature of EN.

EN can be triggered by different types of infections such as streptococcus, mycoplasma, tuberculosis, or bacterial gastroenteritis; medications such as OCs, sulfonamides, iodides, penicillin, or bromides; medical conditions that include inflammatory bowel disease, pregnancy, or sarcoidosis; or neutrophilic dermatosis and malignancy such as leukemia and Hodgkin disease.^2,3 A third of the cases are idiopathic. In children, streptococcal infections are responsible for most cases of EN.⁴

Recommended work-up to investigate possible triggers includes a CBC with differential, sedimentation rate, CRP, ASO titers or anti-DNase B titers, tuberculin skin test or interferon-gamma TB test and a chest X ray. If there are any other symptoms, physical signs, or risk factors are present for the other not so common causes, further ancillary testing may be warranted.

Erythematous nodules and papules on the shin in children are commonly caused by arthropod bites also known as papular urticaria. These lesions are pruritic rather than tender and usually respond to topical corticosteroids and oral antihistamines. Subcutaneous bacterial, fungal, or atypical mycobacterial infections can present with tender nodules that can ulcerate and drain on the shins, feet, or any other body part. These patients may have a history of immunodeficiency and usually systemic symptoms of infection are present. Cutaneous polyarteritis nodosa (PAN) also can present with tender nodules on the legs but these lesions usually necrose and ulcerate and may be associated with livedo racemosa, a transient or persistent, blotchy, reddish-blue to purple, netlike cyanotic pattern. On pathology, PAN presents with necrotizing medium vessel vasculitis. Malignant nodules also can occur on the shin. Pathology will show atypical cells. Other forms of panniculitis, such as erythema induratum and pancreatic panniculitis, can present with tender nodules but these lesions usually occur on the calves and ulcerate.

Management of EN starts with treating the underlying infection or stopping the causative medication. Initial measures include bed rest, leg elevation, compression bandages, and NSAIDs. Potassium iodide is a very effective therapy as it may control the symptoms within 24 hours. When there is no response to the above, or the patient has severe symptoms, a short course of systemic glucocorticoids can be started. Other medications for recalcitrant or recurrent lesions include colchicine, dapsone, or hydroxychloroquine.
 

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.

References

1. Panniculitis, in “Dermatology,” 3rd ed. (Philadelphia: Elsevier Saunders, 2012, p. 1641).

2. Arthritis Rheum. 2000 Mar;43(3):584-92.

3. J Clin Oncol. 2007 Sep 1;25(25):4011-2.

4. Turk J Pediatr. 2014 Mar-Apr;56(2):144-9.