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Transition to adult epilepsy care done right
Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old young woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications including valproic acid with a previous trial of the ketogenic diet. You receive a report that she has focal epilepsy and is having frequent seizures and last had an MRI at age 2 years. Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.
There is a not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a Transition Tool that is helpful in outlining the steps for a successful transition, and in 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care and they recommend that a written policy be present for all offices.
Talking about transitioning should start as early as 10-12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.
, even if they are still seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.
An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to smooth the transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists). The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And, hopefully, next time, the patient scenario seen above will go more smoothly!
Dr. Felton is an epilepsy specialist at the University of Wisconsin, Madison, and Dr. Kelley is director of the Pediatric Epilepsy Monitoring Unit at Johns Hopkins University, Baltimore. This editorial reflects the content of a presentation given by Dr. Felton and Dr. Kelley at the annual meeting of the American Epilepsy Society in Houston. The authors report no conflict of interest.
Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old young woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications including valproic acid with a previous trial of the ketogenic diet. You receive a report that she has focal epilepsy and is having frequent seizures and last had an MRI at age 2 years. Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.
There is a not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a Transition Tool that is helpful in outlining the steps for a successful transition, and in 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care and they recommend that a written policy be present for all offices.
Talking about transitioning should start as early as 10-12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.
, even if they are still seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.
An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to smooth the transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists). The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And, hopefully, next time, the patient scenario seen above will go more smoothly!
Dr. Felton is an epilepsy specialist at the University of Wisconsin, Madison, and Dr. Kelley is director of the Pediatric Epilepsy Monitoring Unit at Johns Hopkins University, Baltimore. This editorial reflects the content of a presentation given by Dr. Felton and Dr. Kelley at the annual meeting of the American Epilepsy Society in Houston. The authors report no conflict of interest.
Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old young woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications including valproic acid with a previous trial of the ketogenic diet. You receive a report that she has focal epilepsy and is having frequent seizures and last had an MRI at age 2 years. Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.
There is a not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a Transition Tool that is helpful in outlining the steps for a successful transition, and in 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care and they recommend that a written policy be present for all offices.
Talking about transitioning should start as early as 10-12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.
, even if they are still seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.
An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to smooth the transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists). The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And, hopefully, next time, the patient scenario seen above will go more smoothly!
Dr. Felton is an epilepsy specialist at the University of Wisconsin, Madison, and Dr. Kelley is director of the Pediatric Epilepsy Monitoring Unit at Johns Hopkins University, Baltimore. This editorial reflects the content of a presentation given by Dr. Felton and Dr. Kelley at the annual meeting of the American Epilepsy Society in Houston. The authors report no conflict of interest.
Scientific skepticism
Contrary to popular belief, great scientists do not spend their days proving that their new ideas are correct. That is just the romantic portrait of the field that is taught to schoolchildren. The reality is that great scientists do everything they can think of to disprove their theories. They exhaustively consider all other plausible explanations, challenge any potential bias in their methodology, rule out random flukes in the data collection, and refine any error in the data measurement. Only after doing all that, when no other conclusion is possible, do true scientists publish their new theories as truth. Then they await confirmation from their peers.
That is the philosophy behind the modern scientific method. In the hard sciences like chemistry and physics, this paradigm is reinforced because a scientist stakes his or her reputation on every publication. Funding from various government agencies often is controlled by peers in the field. If published work is inaccurate, the likelihood of receiving funding is markedly diminished.
Medicine has a long history of being biased by the belief that its therapies work. Even faith healers who consider themselves scientists will cite repeated examples of personal success as evidence that their approach works. However, they were looking for confirmation. To truly be a scientist, one cannot seek to affirm one’s beliefs. One must to the best of one’s ability seek to disprove them.
In 2016, postmodern voices have challenged the very existence of truth. The falsehoods rampant in politics have spilled over into a distrust of science. This distrust is manifest in vaccine deniers and the debate about climate change. There are a few charlatans and mercenaries in every field who sell their soul and skills to the highest bidder. Science is no exception. These disreputable scientists seek to obfuscate rather than clarify. They have been employed by the tobacco industry, the oil industry, and various groups with agendas other than seeking truth. They, with the help of weak journalism, have tainted the perception of science in the public arena. The uproar has prominent scientists defending the scientific method and arguing for science as the determiner of facts. Sen. Daniel Patrick Moynihan once said, “Everyone is entitled to his own opinion, but not to his own facts.”
In the 19th century, hawking snake oil was big business. In the early 20th century, the ethical drug industry was created in the United States. The Pure Food and Drug Act of 1906 and the Federal Food, Drug, and Cosmetic Act of 1938 empowered the Food and Drug Administration to regulate what has become 25% of U.S. industry. Those regulations demand honest labeling, good manufacturing processes, proof of efficacy, and an assessment of safety. The FDA deals with many stakeholders in the process for approving new drugs. The system is an imperfect balance between getting lifesaving new discoveries to market quickly while avoiding disasters. The most recent news has been the head of the FDA defending the need for proof of effectiveness in addition to proof of safety.
Even after a year in which truth seemed elusive and science hit a low point in prestige, it is still bizarre to me that the government would consider turning the drug industry into one in which proof of effectiveness is not a minimum requirement. That is postmodern thinking run amok. But the root of the problem lies deeper. When scientists stop being skeptics and instead focus on finding something publishable, the temptation is already leading them along the road illuminated by Dante Alighieri.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Contrary to popular belief, great scientists do not spend their days proving that their new ideas are correct. That is just the romantic portrait of the field that is taught to schoolchildren. The reality is that great scientists do everything they can think of to disprove their theories. They exhaustively consider all other plausible explanations, challenge any potential bias in their methodology, rule out random flukes in the data collection, and refine any error in the data measurement. Only after doing all that, when no other conclusion is possible, do true scientists publish their new theories as truth. Then they await confirmation from their peers.
That is the philosophy behind the modern scientific method. In the hard sciences like chemistry and physics, this paradigm is reinforced because a scientist stakes his or her reputation on every publication. Funding from various government agencies often is controlled by peers in the field. If published work is inaccurate, the likelihood of receiving funding is markedly diminished.
Medicine has a long history of being biased by the belief that its therapies work. Even faith healers who consider themselves scientists will cite repeated examples of personal success as evidence that their approach works. However, they were looking for confirmation. To truly be a scientist, one cannot seek to affirm one’s beliefs. One must to the best of one’s ability seek to disprove them.
In 2016, postmodern voices have challenged the very existence of truth. The falsehoods rampant in politics have spilled over into a distrust of science. This distrust is manifest in vaccine deniers and the debate about climate change. There are a few charlatans and mercenaries in every field who sell their soul and skills to the highest bidder. Science is no exception. These disreputable scientists seek to obfuscate rather than clarify. They have been employed by the tobacco industry, the oil industry, and various groups with agendas other than seeking truth. They, with the help of weak journalism, have tainted the perception of science in the public arena. The uproar has prominent scientists defending the scientific method and arguing for science as the determiner of facts. Sen. Daniel Patrick Moynihan once said, “Everyone is entitled to his own opinion, but not to his own facts.”
In the 19th century, hawking snake oil was big business. In the early 20th century, the ethical drug industry was created in the United States. The Pure Food and Drug Act of 1906 and the Federal Food, Drug, and Cosmetic Act of 1938 empowered the Food and Drug Administration to regulate what has become 25% of U.S. industry. Those regulations demand honest labeling, good manufacturing processes, proof of efficacy, and an assessment of safety. The FDA deals with many stakeholders in the process for approving new drugs. The system is an imperfect balance between getting lifesaving new discoveries to market quickly while avoiding disasters. The most recent news has been the head of the FDA defending the need for proof of effectiveness in addition to proof of safety.
Even after a year in which truth seemed elusive and science hit a low point in prestige, it is still bizarre to me that the government would consider turning the drug industry into one in which proof of effectiveness is not a minimum requirement. That is postmodern thinking run amok. But the root of the problem lies deeper. When scientists stop being skeptics and instead focus on finding something publishable, the temptation is already leading them along the road illuminated by Dante Alighieri.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Contrary to popular belief, great scientists do not spend their days proving that their new ideas are correct. That is just the romantic portrait of the field that is taught to schoolchildren. The reality is that great scientists do everything they can think of to disprove their theories. They exhaustively consider all other plausible explanations, challenge any potential bias in their methodology, rule out random flukes in the data collection, and refine any error in the data measurement. Only after doing all that, when no other conclusion is possible, do true scientists publish their new theories as truth. Then they await confirmation from their peers.
That is the philosophy behind the modern scientific method. In the hard sciences like chemistry and physics, this paradigm is reinforced because a scientist stakes his or her reputation on every publication. Funding from various government agencies often is controlled by peers in the field. If published work is inaccurate, the likelihood of receiving funding is markedly diminished.
Medicine has a long history of being biased by the belief that its therapies work. Even faith healers who consider themselves scientists will cite repeated examples of personal success as evidence that their approach works. However, they were looking for confirmation. To truly be a scientist, one cannot seek to affirm one’s beliefs. One must to the best of one’s ability seek to disprove them.
In 2016, postmodern voices have challenged the very existence of truth. The falsehoods rampant in politics have spilled over into a distrust of science. This distrust is manifest in vaccine deniers and the debate about climate change. There are a few charlatans and mercenaries in every field who sell their soul and skills to the highest bidder. Science is no exception. These disreputable scientists seek to obfuscate rather than clarify. They have been employed by the tobacco industry, the oil industry, and various groups with agendas other than seeking truth. They, with the help of weak journalism, have tainted the perception of science in the public arena. The uproar has prominent scientists defending the scientific method and arguing for science as the determiner of facts. Sen. Daniel Patrick Moynihan once said, “Everyone is entitled to his own opinion, but not to his own facts.”
In the 19th century, hawking snake oil was big business. In the early 20th century, the ethical drug industry was created in the United States. The Pure Food and Drug Act of 1906 and the Federal Food, Drug, and Cosmetic Act of 1938 empowered the Food and Drug Administration to regulate what has become 25% of U.S. industry. Those regulations demand honest labeling, good manufacturing processes, proof of efficacy, and an assessment of safety. The FDA deals with many stakeholders in the process for approving new drugs. The system is an imperfect balance between getting lifesaving new discoveries to market quickly while avoiding disasters. The most recent news has been the head of the FDA defending the need for proof of effectiveness in addition to proof of safety.
Even after a year in which truth seemed elusive and science hit a low point in prestige, it is still bizarre to me that the government would consider turning the drug industry into one in which proof of effectiveness is not a minimum requirement. That is postmodern thinking run amok. But the root of the problem lies deeper. When scientists stop being skeptics and instead focus on finding something publishable, the temptation is already leading them along the road illuminated by Dante Alighieri.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.
Hip Arthroscopy
Editor’s Note: AJO is fortunate to have Shane Nho, one of the nation’s leading hip arthroscopists, as our Deputy Editor-in-Chief. He has compiled an outstanding update for all orthopedic surgeons who see hip patients. It’s my pleasure to turn this issue over to him. On a side note, we’ve added a new feature for our speed readers. From now on, all articles published in AJO will feature a “Take-Home Points” text box. These points represent the most important items that the authors wish to convey from their article. Please enjoy this month’s issue and keep the feedback coming. We are striving to continuously improve AJO and make it your go-to journal for practical information that you can apply directly to your practice.
—Bryan T. Hanypsiak, MD
Hip arthroscopy has been evolving over the past 2 decades as our techniques have been refined and our clinical outcomes have been reported. We have reached a point in our field to look back at the progress that has been made while also providing our readers with the most up-to-date information on diagnosis, imaging studies, and decision making for appropriate treatment.
Trofa and colleagues provide an excellent overview on intra- and extra-articular pathology of the hip and pelvis in their article, “Mastering the Physical Examination of the Athlete’s Hip”. The authors review common injuries in the athlete and provide physical examination tests to differentiate between adductor strain, athletic pubalgia, osteitis pubis, and femoroacetabular impingement (FAI). Also in this issue, Lewis and colleagues provide a comprehensive review of imaging studies in the “Imaging for Nonarthritic Hip Pathology”. The authors review the most common radiographic measurements to detect FAI as well as describe the role of computed tomography and magnetic resonance imaging.
The mastery of hip arthroscopy for the treatment of FAI has a steep learning curve and the techniques have evolved along with our understanding of the importance of the labrum and capsule. We are fortunate to have an article provided by one of the pioneers in the field, Dr. Marc J. Philippon, describing his role in advancing the field in the article “Treatment of FAI: Labrum, Cartilage, Osseous Deformity, and Capsule”. Kollmorgen and Mather provide the most up-to-date techniques for labrum repair and reconstruction. Friel and colleagues report on capsular repair and plication using the T-capsulotomy and the extensile interportal capsulotomy.
We also have the opportunity to read about a number of clinical studies describing the experiences of multi-center studies and epidemiologic studies on large volumes of data. The ANCHOR group provides a summary of the experiences of some of the most renowned hip surgeons in North America as the treatment of FAI evolved from an open approach to an all-arthroscopic approach. The MASH group is a large multi-center group of hip arthroscopists in the United States who describe their current indications for surgical treatment of FAI.
On AmJOrthopedics.com, Matsuda and colleagues describe the outcomes of borderline dysplasia patients compared to normal controls across multiple centers. Anthony and colleagues report on the complication rates using the National Surgical Quality Improvement Program database.
I believe that our Hip Arthroscopy issue will not disappoint you. It is a comprehensive review of the state-of-the-art in hip arthroscopy from physical examination to current surgical techniques to clinical outcomes from large databases for the treatment of FAI. After reviewing this issue, you will be equipped with the most up-to-date information on the treatment of nonarthritic hip disease.
Am J Orthop. 2017;46(1):8. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Editor’s Note: AJO is fortunate to have Shane Nho, one of the nation’s leading hip arthroscopists, as our Deputy Editor-in-Chief. He has compiled an outstanding update for all orthopedic surgeons who see hip patients. It’s my pleasure to turn this issue over to him. On a side note, we’ve added a new feature for our speed readers. From now on, all articles published in AJO will feature a “Take-Home Points” text box. These points represent the most important items that the authors wish to convey from their article. Please enjoy this month’s issue and keep the feedback coming. We are striving to continuously improve AJO and make it your go-to journal for practical information that you can apply directly to your practice.
—Bryan T. Hanypsiak, MD
Hip arthroscopy has been evolving over the past 2 decades as our techniques have been refined and our clinical outcomes have been reported. We have reached a point in our field to look back at the progress that has been made while also providing our readers with the most up-to-date information on diagnosis, imaging studies, and decision making for appropriate treatment.
Trofa and colleagues provide an excellent overview on intra- and extra-articular pathology of the hip and pelvis in their article, “Mastering the Physical Examination of the Athlete’s Hip”. The authors review common injuries in the athlete and provide physical examination tests to differentiate between adductor strain, athletic pubalgia, osteitis pubis, and femoroacetabular impingement (FAI). Also in this issue, Lewis and colleagues provide a comprehensive review of imaging studies in the “Imaging for Nonarthritic Hip Pathology”. The authors review the most common radiographic measurements to detect FAI as well as describe the role of computed tomography and magnetic resonance imaging.
The mastery of hip arthroscopy for the treatment of FAI has a steep learning curve and the techniques have evolved along with our understanding of the importance of the labrum and capsule. We are fortunate to have an article provided by one of the pioneers in the field, Dr. Marc J. Philippon, describing his role in advancing the field in the article “Treatment of FAI: Labrum, Cartilage, Osseous Deformity, and Capsule”. Kollmorgen and Mather provide the most up-to-date techniques for labrum repair and reconstruction. Friel and colleagues report on capsular repair and plication using the T-capsulotomy and the extensile interportal capsulotomy.
We also have the opportunity to read about a number of clinical studies describing the experiences of multi-center studies and epidemiologic studies on large volumes of data. The ANCHOR group provides a summary of the experiences of some of the most renowned hip surgeons in North America as the treatment of FAI evolved from an open approach to an all-arthroscopic approach. The MASH group is a large multi-center group of hip arthroscopists in the United States who describe their current indications for surgical treatment of FAI.
On AmJOrthopedics.com, Matsuda and colleagues describe the outcomes of borderline dysplasia patients compared to normal controls across multiple centers. Anthony and colleagues report on the complication rates using the National Surgical Quality Improvement Program database.
I believe that our Hip Arthroscopy issue will not disappoint you. It is a comprehensive review of the state-of-the-art in hip arthroscopy from physical examination to current surgical techniques to clinical outcomes from large databases for the treatment of FAI. After reviewing this issue, you will be equipped with the most up-to-date information on the treatment of nonarthritic hip disease.
Am J Orthop. 2017;46(1):8. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Editor’s Note: AJO is fortunate to have Shane Nho, one of the nation’s leading hip arthroscopists, as our Deputy Editor-in-Chief. He has compiled an outstanding update for all orthopedic surgeons who see hip patients. It’s my pleasure to turn this issue over to him. On a side note, we’ve added a new feature for our speed readers. From now on, all articles published in AJO will feature a “Take-Home Points” text box. These points represent the most important items that the authors wish to convey from their article. Please enjoy this month’s issue and keep the feedback coming. We are striving to continuously improve AJO and make it your go-to journal for practical information that you can apply directly to your practice.
—Bryan T. Hanypsiak, MD
Hip arthroscopy has been evolving over the past 2 decades as our techniques have been refined and our clinical outcomes have been reported. We have reached a point in our field to look back at the progress that has been made while also providing our readers with the most up-to-date information on diagnosis, imaging studies, and decision making for appropriate treatment.
Trofa and colleagues provide an excellent overview on intra- and extra-articular pathology of the hip and pelvis in their article, “Mastering the Physical Examination of the Athlete’s Hip”. The authors review common injuries in the athlete and provide physical examination tests to differentiate between adductor strain, athletic pubalgia, osteitis pubis, and femoroacetabular impingement (FAI). Also in this issue, Lewis and colleagues provide a comprehensive review of imaging studies in the “Imaging for Nonarthritic Hip Pathology”. The authors review the most common radiographic measurements to detect FAI as well as describe the role of computed tomography and magnetic resonance imaging.
The mastery of hip arthroscopy for the treatment of FAI has a steep learning curve and the techniques have evolved along with our understanding of the importance of the labrum and capsule. We are fortunate to have an article provided by one of the pioneers in the field, Dr. Marc J. Philippon, describing his role in advancing the field in the article “Treatment of FAI: Labrum, Cartilage, Osseous Deformity, and Capsule”. Kollmorgen and Mather provide the most up-to-date techniques for labrum repair and reconstruction. Friel and colleagues report on capsular repair and plication using the T-capsulotomy and the extensile interportal capsulotomy.
We also have the opportunity to read about a number of clinical studies describing the experiences of multi-center studies and epidemiologic studies on large volumes of data. The ANCHOR group provides a summary of the experiences of some of the most renowned hip surgeons in North America as the treatment of FAI evolved from an open approach to an all-arthroscopic approach. The MASH group is a large multi-center group of hip arthroscopists in the United States who describe their current indications for surgical treatment of FAI.
On AmJOrthopedics.com, Matsuda and colleagues describe the outcomes of borderline dysplasia patients compared to normal controls across multiple centers. Anthony and colleagues report on the complication rates using the National Surgical Quality Improvement Program database.
I believe that our Hip Arthroscopy issue will not disappoint you. It is a comprehensive review of the state-of-the-art in hip arthroscopy from physical examination to current surgical techniques to clinical outcomes from large databases for the treatment of FAI. After reviewing this issue, you will be equipped with the most up-to-date information on the treatment of nonarthritic hip disease.
Am J Orthop. 2017;46(1):8. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Clinicians Should Retain the Ability to Choose a Pathologist
As employers search for ways to reduce the cost of providing health care to their employees, there is a growing trend toward narrowed provider networks and exclusive laboratory contracts. In the case of clinical pathology, some of these choices make sense from the employer’s perspective. A complete blood cell count or comprehensive metabolic panel is done on a machine and the result is much the same regardless of the laboratory. So why not have all laboratory tests performed by the lowest bidder?
Laboratories vary in quality and anatomic pathology services are different from blood tests. Each slide must be interpreted by a physician and skill in the interpretation of skin specimens varies widely. Dermatopathology was one of the first subspecialties to be recognized within pathology, as it requires a high level of expertise. Clinicopathological correlation often is key to the accurate interpretation of a specimen. The stakes are high, and a delay in diagnosis of melanoma remains one of the most serious errors in medicine and one of the most common causes for litigation in dermatology.
The accurate interpretation of skin biopsy specimens becomes especially difficult when inadequate or misleading clinical information accompanies the specimen. A study of 589 biopsies submitted by primary care physicians and reported by general pathologists demonstrated a 6.5% error rate. False-negative errors were the most common, but false-positives also were observed.1 A study of pigmented lesions referred to the University of California, San Francisco, demonstrated a discordance rate of 14.3%.2 The degree of discordance would be expected to vary based on the range of diagnoses included in each study.
Board-certified dermatopathologists have varying areas of expertise and there is notable subjectivity in the interpretation of biopsy specimens. In the case of problematic pigmented lesions such as atypical Spitz nevi, there can be low interobserver agreement even among the experts in categorizing lesions as malignant versus nonmalignant (κ=0.30).3 The low concordance among expert dermatopathologists demonstrates that light microscopic features alone often are inadequate for diagnosis. Advanced studies, including immunohistochemical stains, can help to clarify the diagnosis. In the case of atypical Spitz tumors, the contribution of special stains to the final diagnosis is statistically similar to that of hematoxylin and eosin sections and age, suggesting that nothing alone is sufficiently reliable to establish a definitive diagnosis in every case.4 Although helpful, these studies are costly, and savings obtained by sending cases to the lowest bidder can evaporate quickly. Costs are higher when factoring in molecular studies, which can run upwards of $3000 per slide; the cost of litigation related to incorrect diagnoses; or the human costs of an incorrect diagnosis.
As a group, dermatopathologists are highly skilled in the interpretation of skin specimens, but challenging lesions are common in the routine practice of dermatopathology. A study of 1249 pigmented melanocytic lesions demonstrated substantial agreement among expert dermatopathologists for less problematic lesions, though agreement was greater for patients 40 years and older (κ=0.67) than for younger patients (κ=0.49). Agreement was lower for patients with atypical mole syndrome (κ=0.31).5 These discrepancies occur despite the fact that there is good interobserver reproducibility for grading of individual histological features such as asymmetry, circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, symmetrical melanin, deep melanin, cytological atypia, mitoses, dermal lymphocytic infiltrate, and necrosis.6 These results indicate that accurate diagnoses cannot be reliably established simply by grading a list of histological features. Accurate diagnosis requires complex pattern recognition and integration of findings. Conflicting criteria often are present and an accurate interpretation requires considerable judgment as to which features are significant and which are not.
Separation of sebaceous adenoma, sebaceoma, and well-differentiated sebaceous carcinoma is another challenging area, and interobserver consensus can be as low as 11%,7 which suggests notable subjectivity in the criteria for diagnosis of nonmelanocytic tumors and emphasizes the importance of communication between the dermatopathologist and clinician when determining how to manage an ambiguous lesion. The interpretation of inflammatory skin diseases, alopecia, and lymphoid proliferations also can be problematic, and expert consultation often is required.
All dermatologists receive substantial training in dermatopathology, which puts them in an excellent position to interpret ambiguous findings in the context of the clinical presentation. Sometimes the dermatologist who has seen the clinical presentation can be in the best position to make the diagnosis. All clinicians must be wary of bias and an objective set of eyes often can be helpful. Communication is crucial to ensure appropriate care for each patient, and policies that restrict the choice of pathologist can be damaging.
- Trotter MJ, Bruecks AK. Interpretation of skin biopsies by general pathologists: diagnostic discrepancy rate measured by blinded review. Arch Pathol Lab Med. 2003;127:1489-1492.
- Shoo BA, Sagebiel RW, Kashani-Sabet M. Discordance in the histopathologic diagnosis of melanoma at a melanoma referral center [published online March 19, 2010]. J Am Acad Dermatol. 2010;62:751-756.
- Gerami P, Busam K, Cochran A, et al. Histomorphologic assessment and interobserver diagnostic reproducibility of atypical spitzoid melanocytic neoplasms with long-term follow-up. Am J Surg Pathol. 2014;38:934-940.
- Puri PK, Ferringer TC, Tyler WB, et al. Statistical analysis of the concordance of immunohistochemical stains with the final diagnosis in spitzoid neoplasms. Am J Dermatopathol. 2011;33:72-77.
- Braun RP, Gutkowicz-Krusin D, Rabinovitz H, et al. Agreement of dermatopathologists in the evaluation of clinically difficult melanocytic lesions: how golden is the ‘gold standard’? Dermatology. 2012;224:51-58.
- Urso C, Rongioletti F, Innocenzi D, et al. Interobserver reproducibility of histological features in cutaneous malignant melanoma. J Clin Pathol. 2005;58:1194-1198.
- Harvey NT, Budgeon CA, Leecy T, et al. Interobserver variability in the diagnosis of circumscribed sebaceous neoplasms of the skin. Pathology. 2013;45:581-586.
As employers search for ways to reduce the cost of providing health care to their employees, there is a growing trend toward narrowed provider networks and exclusive laboratory contracts. In the case of clinical pathology, some of these choices make sense from the employer’s perspective. A complete blood cell count or comprehensive metabolic panel is done on a machine and the result is much the same regardless of the laboratory. So why not have all laboratory tests performed by the lowest bidder?
Laboratories vary in quality and anatomic pathology services are different from blood tests. Each slide must be interpreted by a physician and skill in the interpretation of skin specimens varies widely. Dermatopathology was one of the first subspecialties to be recognized within pathology, as it requires a high level of expertise. Clinicopathological correlation often is key to the accurate interpretation of a specimen. The stakes are high, and a delay in diagnosis of melanoma remains one of the most serious errors in medicine and one of the most common causes for litigation in dermatology.
The accurate interpretation of skin biopsy specimens becomes especially difficult when inadequate or misleading clinical information accompanies the specimen. A study of 589 biopsies submitted by primary care physicians and reported by general pathologists demonstrated a 6.5% error rate. False-negative errors were the most common, but false-positives also were observed.1 A study of pigmented lesions referred to the University of California, San Francisco, demonstrated a discordance rate of 14.3%.2 The degree of discordance would be expected to vary based on the range of diagnoses included in each study.
Board-certified dermatopathologists have varying areas of expertise and there is notable subjectivity in the interpretation of biopsy specimens. In the case of problematic pigmented lesions such as atypical Spitz nevi, there can be low interobserver agreement even among the experts in categorizing lesions as malignant versus nonmalignant (κ=0.30).3 The low concordance among expert dermatopathologists demonstrates that light microscopic features alone often are inadequate for diagnosis. Advanced studies, including immunohistochemical stains, can help to clarify the diagnosis. In the case of atypical Spitz tumors, the contribution of special stains to the final diagnosis is statistically similar to that of hematoxylin and eosin sections and age, suggesting that nothing alone is sufficiently reliable to establish a definitive diagnosis in every case.4 Although helpful, these studies are costly, and savings obtained by sending cases to the lowest bidder can evaporate quickly. Costs are higher when factoring in molecular studies, which can run upwards of $3000 per slide; the cost of litigation related to incorrect diagnoses; or the human costs of an incorrect diagnosis.
As a group, dermatopathologists are highly skilled in the interpretation of skin specimens, but challenging lesions are common in the routine practice of dermatopathology. A study of 1249 pigmented melanocytic lesions demonstrated substantial agreement among expert dermatopathologists for less problematic lesions, though agreement was greater for patients 40 years and older (κ=0.67) than for younger patients (κ=0.49). Agreement was lower for patients with atypical mole syndrome (κ=0.31).5 These discrepancies occur despite the fact that there is good interobserver reproducibility for grading of individual histological features such as asymmetry, circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, symmetrical melanin, deep melanin, cytological atypia, mitoses, dermal lymphocytic infiltrate, and necrosis.6 These results indicate that accurate diagnoses cannot be reliably established simply by grading a list of histological features. Accurate diagnosis requires complex pattern recognition and integration of findings. Conflicting criteria often are present and an accurate interpretation requires considerable judgment as to which features are significant and which are not.
Separation of sebaceous adenoma, sebaceoma, and well-differentiated sebaceous carcinoma is another challenging area, and interobserver consensus can be as low as 11%,7 which suggests notable subjectivity in the criteria for diagnosis of nonmelanocytic tumors and emphasizes the importance of communication between the dermatopathologist and clinician when determining how to manage an ambiguous lesion. The interpretation of inflammatory skin diseases, alopecia, and lymphoid proliferations also can be problematic, and expert consultation often is required.
All dermatologists receive substantial training in dermatopathology, which puts them in an excellent position to interpret ambiguous findings in the context of the clinical presentation. Sometimes the dermatologist who has seen the clinical presentation can be in the best position to make the diagnosis. All clinicians must be wary of bias and an objective set of eyes often can be helpful. Communication is crucial to ensure appropriate care for each patient, and policies that restrict the choice of pathologist can be damaging.
As employers search for ways to reduce the cost of providing health care to their employees, there is a growing trend toward narrowed provider networks and exclusive laboratory contracts. In the case of clinical pathology, some of these choices make sense from the employer’s perspective. A complete blood cell count or comprehensive metabolic panel is done on a machine and the result is much the same regardless of the laboratory. So why not have all laboratory tests performed by the lowest bidder?
Laboratories vary in quality and anatomic pathology services are different from blood tests. Each slide must be interpreted by a physician and skill in the interpretation of skin specimens varies widely. Dermatopathology was one of the first subspecialties to be recognized within pathology, as it requires a high level of expertise. Clinicopathological correlation often is key to the accurate interpretation of a specimen. The stakes are high, and a delay in diagnosis of melanoma remains one of the most serious errors in medicine and one of the most common causes for litigation in dermatology.
The accurate interpretation of skin biopsy specimens becomes especially difficult when inadequate or misleading clinical information accompanies the specimen. A study of 589 biopsies submitted by primary care physicians and reported by general pathologists demonstrated a 6.5% error rate. False-negative errors were the most common, but false-positives also were observed.1 A study of pigmented lesions referred to the University of California, San Francisco, demonstrated a discordance rate of 14.3%.2 The degree of discordance would be expected to vary based on the range of diagnoses included in each study.
Board-certified dermatopathologists have varying areas of expertise and there is notable subjectivity in the interpretation of biopsy specimens. In the case of problematic pigmented lesions such as atypical Spitz nevi, there can be low interobserver agreement even among the experts in categorizing lesions as malignant versus nonmalignant (κ=0.30).3 The low concordance among expert dermatopathologists demonstrates that light microscopic features alone often are inadequate for diagnosis. Advanced studies, including immunohistochemical stains, can help to clarify the diagnosis. In the case of atypical Spitz tumors, the contribution of special stains to the final diagnosis is statistically similar to that of hematoxylin and eosin sections and age, suggesting that nothing alone is sufficiently reliable to establish a definitive diagnosis in every case.4 Although helpful, these studies are costly, and savings obtained by sending cases to the lowest bidder can evaporate quickly. Costs are higher when factoring in molecular studies, which can run upwards of $3000 per slide; the cost of litigation related to incorrect diagnoses; or the human costs of an incorrect diagnosis.
As a group, dermatopathologists are highly skilled in the interpretation of skin specimens, but challenging lesions are common in the routine practice of dermatopathology. A study of 1249 pigmented melanocytic lesions demonstrated substantial agreement among expert dermatopathologists for less problematic lesions, though agreement was greater for patients 40 years and older (κ=0.67) than for younger patients (κ=0.49). Agreement was lower for patients with atypical mole syndrome (κ=0.31).5 These discrepancies occur despite the fact that there is good interobserver reproducibility for grading of individual histological features such as asymmetry, circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, symmetrical melanin, deep melanin, cytological atypia, mitoses, dermal lymphocytic infiltrate, and necrosis.6 These results indicate that accurate diagnoses cannot be reliably established simply by grading a list of histological features. Accurate diagnosis requires complex pattern recognition and integration of findings. Conflicting criteria often are present and an accurate interpretation requires considerable judgment as to which features are significant and which are not.
Separation of sebaceous adenoma, sebaceoma, and well-differentiated sebaceous carcinoma is another challenging area, and interobserver consensus can be as low as 11%,7 which suggests notable subjectivity in the criteria for diagnosis of nonmelanocytic tumors and emphasizes the importance of communication between the dermatopathologist and clinician when determining how to manage an ambiguous lesion. The interpretation of inflammatory skin diseases, alopecia, and lymphoid proliferations also can be problematic, and expert consultation often is required.
All dermatologists receive substantial training in dermatopathology, which puts them in an excellent position to interpret ambiguous findings in the context of the clinical presentation. Sometimes the dermatologist who has seen the clinical presentation can be in the best position to make the diagnosis. All clinicians must be wary of bias and an objective set of eyes often can be helpful. Communication is crucial to ensure appropriate care for each patient, and policies that restrict the choice of pathologist can be damaging.
- Trotter MJ, Bruecks AK. Interpretation of skin biopsies by general pathologists: diagnostic discrepancy rate measured by blinded review. Arch Pathol Lab Med. 2003;127:1489-1492.
- Shoo BA, Sagebiel RW, Kashani-Sabet M. Discordance in the histopathologic diagnosis of melanoma at a melanoma referral center [published online March 19, 2010]. J Am Acad Dermatol. 2010;62:751-756.
- Gerami P, Busam K, Cochran A, et al. Histomorphologic assessment and interobserver diagnostic reproducibility of atypical spitzoid melanocytic neoplasms with long-term follow-up. Am J Surg Pathol. 2014;38:934-940.
- Puri PK, Ferringer TC, Tyler WB, et al. Statistical analysis of the concordance of immunohistochemical stains with the final diagnosis in spitzoid neoplasms. Am J Dermatopathol. 2011;33:72-77.
- Braun RP, Gutkowicz-Krusin D, Rabinovitz H, et al. Agreement of dermatopathologists in the evaluation of clinically difficult melanocytic lesions: how golden is the ‘gold standard’? Dermatology. 2012;224:51-58.
- Urso C, Rongioletti F, Innocenzi D, et al. Interobserver reproducibility of histological features in cutaneous malignant melanoma. J Clin Pathol. 2005;58:1194-1198.
- Harvey NT, Budgeon CA, Leecy T, et al. Interobserver variability in the diagnosis of circumscribed sebaceous neoplasms of the skin. Pathology. 2013;45:581-586.
- Trotter MJ, Bruecks AK. Interpretation of skin biopsies by general pathologists: diagnostic discrepancy rate measured by blinded review. Arch Pathol Lab Med. 2003;127:1489-1492.
- Shoo BA, Sagebiel RW, Kashani-Sabet M. Discordance in the histopathologic diagnosis of melanoma at a melanoma referral center [published online March 19, 2010]. J Am Acad Dermatol. 2010;62:751-756.
- Gerami P, Busam K, Cochran A, et al. Histomorphologic assessment and interobserver diagnostic reproducibility of atypical spitzoid melanocytic neoplasms with long-term follow-up. Am J Surg Pathol. 2014;38:934-940.
- Puri PK, Ferringer TC, Tyler WB, et al. Statistical analysis of the concordance of immunohistochemical stains with the final diagnosis in spitzoid neoplasms. Am J Dermatopathol. 2011;33:72-77.
- Braun RP, Gutkowicz-Krusin D, Rabinovitz H, et al. Agreement of dermatopathologists in the evaluation of clinically difficult melanocytic lesions: how golden is the ‘gold standard’? Dermatology. 2012;224:51-58.
- Urso C, Rongioletti F, Innocenzi D, et al. Interobserver reproducibility of histological features in cutaneous malignant melanoma. J Clin Pathol. 2005;58:1194-1198.
- Harvey NT, Budgeon CA, Leecy T, et al. Interobserver variability in the diagnosis of circumscribed sebaceous neoplasms of the skin. Pathology. 2013;45:581-586.
French psychiatrist condemned for society’s deficiency
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
Pain Management: How About Holistic?
I recently received the letter and instruction card for prescribing narcotic analgesics from US Surgeon General Vice Admiral Vivek H. Murthy, MD, MBA. While I agree in principle with the movement to improve pain management, I feel there is a lot being overlooked in this crusade and would like to suggest alternative evidence-based methods that don’t involve prescription narcotics.
I have extensive training in energy therapy, guided imagery, and ozonotherapy. Healing touch is one well-researched energy therapy that has been shown to reduce pain. I have performed and published research demonstrating its efficacy (see http://healingbeyondborders.org/index.php/research-integrative-health/research); patients’ functional abilities improve, and they are able to decrease or eliminate use of pain medication. Providers from many disciplines, including MDs, DOs, NPs, and DCs, practice healing touch. Training for healing touch is available worldwide. The certification process is similar to masters-level education, including both classroom and hands-on clinical practice experience. My practice uses healing touch for patients, and I teach classes using the international curriculum.
In addition to the research published on the efficacy of guided imagery (another method of pain relief therapy), I have personally witnessed and been part of several successful examples in my clinical practice. In the burn unit, Dr. Jean Achterberg Lawlis and I used guided imagery to relieve pain in patients with third- and fourth-degree burns over 70% or more of their body. We performed tanking and dressing changes without narcotic pain medications; patients were comfortable during treatment and slept peacefully after. In another instance, a 23-year-old man presented with major chest and spine injuries after a motorcycle accident. Morphine (100 mg IV) did nothing to relieve his pain. But guided imagery of racing his stock car around a racetrack eliminated any need for narcotics during dressing changes. I’ve also worked with women prenatally, teaching guided imagery for smooth, successful deliveries without pain medications or epidural.
Ozonotherapy has an extensive international evidence base, and many studies show that it relieves pain without the need for narcotics (see http://aaot.us/?page=Literature). I have seen many cases of chronic pain relieved by major autohemolytic therapy and prolozone injection therapies. Here, too, patients are able to decrease and eventually stop their narcotic medications. Some patients are able to avoid joint replacement surgery, achieving improved function and comfort without the adverse effects of steroids.
An effective way to release muscle tension and relieve pain from injury (eg, low back pain, plantar fasciitis, whiplash, carpal tunnel) is through massage therapy. Providers who refer patients to massage practitioners can avoid narcotic medication prescriptions by addressing the problem that is causing the pain. Chiropractic care is a standard care for low back pain; it can also resolve problems that cause migraines, trigeminal neuralgia, and Bell’s palsy without narcotics, steroids, or the sedating muscle relaxants and seizure medications. Yet several veterans in my community were denied chiropractic care until they had tried narcotics and physical therapy (which involved a four-hour roundtrip car ride, no less). Oh, and in the meantime, they were prescribed an additional narcotic!
By focusing only on narcotics, we miss out on other options to treat pain. If we overlook the full range of evidence, then the “evidence-based” mantra isn’t truthful, nor is it useful. To follow the pledge to “do no harm,” we must treat the causes of pain. Of the Surgeon General, I request: Please don’t just send us a teaching card on how to prescribe narcotics. Get providers involved in seeking continuing education credits in therapies that help us avoid prescribing them in the first place.
Susan Peck, PhD, GNP-BC, APNP, FAAO, APT, CHTP/I
Eau Claire, WI
I recently received the letter and instruction card for prescribing narcotic analgesics from US Surgeon General Vice Admiral Vivek H. Murthy, MD, MBA. While I agree in principle with the movement to improve pain management, I feel there is a lot being overlooked in this crusade and would like to suggest alternative evidence-based methods that don’t involve prescription narcotics.
I have extensive training in energy therapy, guided imagery, and ozonotherapy. Healing touch is one well-researched energy therapy that has been shown to reduce pain. I have performed and published research demonstrating its efficacy (see http://healingbeyondborders.org/index.php/research-integrative-health/research); patients’ functional abilities improve, and they are able to decrease or eliminate use of pain medication. Providers from many disciplines, including MDs, DOs, NPs, and DCs, practice healing touch. Training for healing touch is available worldwide. The certification process is similar to masters-level education, including both classroom and hands-on clinical practice experience. My practice uses healing touch for patients, and I teach classes using the international curriculum.
In addition to the research published on the efficacy of guided imagery (another method of pain relief therapy), I have personally witnessed and been part of several successful examples in my clinical practice. In the burn unit, Dr. Jean Achterberg Lawlis and I used guided imagery to relieve pain in patients with third- and fourth-degree burns over 70% or more of their body. We performed tanking and dressing changes without narcotic pain medications; patients were comfortable during treatment and slept peacefully after. In another instance, a 23-year-old man presented with major chest and spine injuries after a motorcycle accident. Morphine (100 mg IV) did nothing to relieve his pain. But guided imagery of racing his stock car around a racetrack eliminated any need for narcotics during dressing changes. I’ve also worked with women prenatally, teaching guided imagery for smooth, successful deliveries without pain medications or epidural.
Ozonotherapy has an extensive international evidence base, and many studies show that it relieves pain without the need for narcotics (see http://aaot.us/?page=Literature). I have seen many cases of chronic pain relieved by major autohemolytic therapy and prolozone injection therapies. Here, too, patients are able to decrease and eventually stop their narcotic medications. Some patients are able to avoid joint replacement surgery, achieving improved function and comfort without the adverse effects of steroids.
An effective way to release muscle tension and relieve pain from injury (eg, low back pain, plantar fasciitis, whiplash, carpal tunnel) is through massage therapy. Providers who refer patients to massage practitioners can avoid narcotic medication prescriptions by addressing the problem that is causing the pain. Chiropractic care is a standard care for low back pain; it can also resolve problems that cause migraines, trigeminal neuralgia, and Bell’s palsy without narcotics, steroids, or the sedating muscle relaxants and seizure medications. Yet several veterans in my community were denied chiropractic care until they had tried narcotics and physical therapy (which involved a four-hour roundtrip car ride, no less). Oh, and in the meantime, they were prescribed an additional narcotic!
By focusing only on narcotics, we miss out on other options to treat pain. If we overlook the full range of evidence, then the “evidence-based” mantra isn’t truthful, nor is it useful. To follow the pledge to “do no harm,” we must treat the causes of pain. Of the Surgeon General, I request: Please don’t just send us a teaching card on how to prescribe narcotics. Get providers involved in seeking continuing education credits in therapies that help us avoid prescribing them in the first place.
Susan Peck, PhD, GNP-BC, APNP, FAAO, APT, CHTP/I
Eau Claire, WI
I recently received the letter and instruction card for prescribing narcotic analgesics from US Surgeon General Vice Admiral Vivek H. Murthy, MD, MBA. While I agree in principle with the movement to improve pain management, I feel there is a lot being overlooked in this crusade and would like to suggest alternative evidence-based methods that don’t involve prescription narcotics.
I have extensive training in energy therapy, guided imagery, and ozonotherapy. Healing touch is one well-researched energy therapy that has been shown to reduce pain. I have performed and published research demonstrating its efficacy (see http://healingbeyondborders.org/index.php/research-integrative-health/research); patients’ functional abilities improve, and they are able to decrease or eliminate use of pain medication. Providers from many disciplines, including MDs, DOs, NPs, and DCs, practice healing touch. Training for healing touch is available worldwide. The certification process is similar to masters-level education, including both classroom and hands-on clinical practice experience. My practice uses healing touch for patients, and I teach classes using the international curriculum.
In addition to the research published on the efficacy of guided imagery (another method of pain relief therapy), I have personally witnessed and been part of several successful examples in my clinical practice. In the burn unit, Dr. Jean Achterberg Lawlis and I used guided imagery to relieve pain in patients with third- and fourth-degree burns over 70% or more of their body. We performed tanking and dressing changes without narcotic pain medications; patients were comfortable during treatment and slept peacefully after. In another instance, a 23-year-old man presented with major chest and spine injuries after a motorcycle accident. Morphine (100 mg IV) did nothing to relieve his pain. But guided imagery of racing his stock car around a racetrack eliminated any need for narcotics during dressing changes. I’ve also worked with women prenatally, teaching guided imagery for smooth, successful deliveries without pain medications or epidural.
Ozonotherapy has an extensive international evidence base, and many studies show that it relieves pain without the need for narcotics (see http://aaot.us/?page=Literature). I have seen many cases of chronic pain relieved by major autohemolytic therapy and prolozone injection therapies. Here, too, patients are able to decrease and eventually stop their narcotic medications. Some patients are able to avoid joint replacement surgery, achieving improved function and comfort without the adverse effects of steroids.
An effective way to release muscle tension and relieve pain from injury (eg, low back pain, plantar fasciitis, whiplash, carpal tunnel) is through massage therapy. Providers who refer patients to massage practitioners can avoid narcotic medication prescriptions by addressing the problem that is causing the pain. Chiropractic care is a standard care for low back pain; it can also resolve problems that cause migraines, trigeminal neuralgia, and Bell’s palsy without narcotics, steroids, or the sedating muscle relaxants and seizure medications. Yet several veterans in my community were denied chiropractic care until they had tried narcotics and physical therapy (which involved a four-hour roundtrip car ride, no less). Oh, and in the meantime, they were prescribed an additional narcotic!
By focusing only on narcotics, we miss out on other options to treat pain. If we overlook the full range of evidence, then the “evidence-based” mantra isn’t truthful, nor is it useful. To follow the pledge to “do no harm,” we must treat the causes of pain. Of the Surgeon General, I request: Please don’t just send us a teaching card on how to prescribe narcotics. Get providers involved in seeking continuing education credits in therapies that help us avoid prescribing them in the first place.
Susan Peck, PhD, GNP-BC, APNP, FAAO, APT, CHTP/I
Eau Claire, WI
Staring down the opioid epidemic
Nearly 80 people die every day in America from an opioid overdose.1 At the same time, sales of prescription painkillers have increased 4-fold since 1999.2 My own medical assistant was given an unsolicited prescription for 40 oxycodone after a wisdom tooth extraction.
Meanwhile, about 80% of the country’s 2 million opioid-dependent patients are not receiving the treatment they need.3,4 In Vermont, for example, more than 500 patients are on waiting lists to receive buprenorphine (the partial opioid agonist used to treat opioid addiction)—a wait that for many of them will last for more than a year and may cost them their life.5
Buprenorphine makes good sense. Fortunately, buprenorphine can reverse opioid cravings within minutes. Medication-assisted treatment with buprenorphine derivatives allows patients to lead normal, productive, and stable lives. Every dollar invested in treating opioid addiction saves society $7 in drug-related crime and criminal justice costs.6 In addition, 50% to 80% of opioid-dependent patients remain opioid-free for 12 months while taking buprenorphine.7
Steps we can take. As family physicians (FPs), we are frequently overwhelmed by regulatory concerns, overhead expenses, and providing meaningful use data to third-party payers. And we sometimes take the easy route of simply prescribing or refilling scheduled drugs. Instead, we should educate ourselves and our patients about alternative therapeutic interventions for pain control and addiction.
To that end, I encourage all FPs to take the 8-hour online course provided by the American Society of Addiction Medicine to obtain a US Drug Enforcement Administration waiver for prescribing buprenorphine (available at: http://www.asam.org/education/live-online-cme/buprenorphine-course). It costs less than $200 and successful completion of this CME program allows FPs to deliver office-based opioid dependency interventions as per the Drug Addiction Treatment Act of 2000.
Right now, monthly patient censuses indicate that there are about 3234 buprenorphine prescribers providing care for 245,016 opioid-dependent patients, and fewer than 20% of those prescribers are FPs.8 We need to change that. We have an opportunity to invest in the future of these high-risk patients. Let’s not let them down.
1. Democratic staff of the senate committee on finance. Dying waiting for treatment: the opioid use disorder treatment gap and the need for funding. October 10, 2016. Available at: https://www.finance.senate.gov/imo/media/doc/101116%20Opioid%20Treatment%20Gap%20Report%20Final.pdf. Accessed December 14, 2016.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.
3. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States. JAMA. 2015;314:1515-1517.
4. Substance Abuse and Mental Health Services Administration. Opioids. Available at: https://www.samhsa.gov/atod/opioids. Accessed December 14, 2016.
5. Vestal C. Waiting lists grow for medicine to fight opioid addiction. Stateline. February 11, 2016. Available at: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/02/11/waiting-lists-grow-for-medicine-to-fight-opioid-addiction. Accessed December 14, 2016.
6. National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (third edition). Is drug addiction treatment worth its cost? Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost. Accessed December 14, 2016.
7. Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci. 2007; 9:455-470.
8. Stein BD, Sorbero MJ, Dick AW, et al. Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment. JAMA. 2016;316:1211-1212.
Unger Primary Care Concierge Medical Group, Rancho Cucamonga, Calif. Dr. Unger is a member of JFP’s editorial board. He reported no potential conflict of interest relevant to this article.
Unger Primary Care Concierge Medical Group, Rancho Cucamonga, Calif. Dr. Unger is a member of JFP’s editorial board. He reported no potential conflict of interest relevant to this article.
Unger Primary Care Concierge Medical Group, Rancho Cucamonga, Calif. Dr. Unger is a member of JFP’s editorial board. He reported no potential conflict of interest relevant to this article.
Nearly 80 people die every day in America from an opioid overdose.1 At the same time, sales of prescription painkillers have increased 4-fold since 1999.2 My own medical assistant was given an unsolicited prescription for 40 oxycodone after a wisdom tooth extraction.
Meanwhile, about 80% of the country’s 2 million opioid-dependent patients are not receiving the treatment they need.3,4 In Vermont, for example, more than 500 patients are on waiting lists to receive buprenorphine (the partial opioid agonist used to treat opioid addiction)—a wait that for many of them will last for more than a year and may cost them their life.5
Buprenorphine makes good sense. Fortunately, buprenorphine can reverse opioid cravings within minutes. Medication-assisted treatment with buprenorphine derivatives allows patients to lead normal, productive, and stable lives. Every dollar invested in treating opioid addiction saves society $7 in drug-related crime and criminal justice costs.6 In addition, 50% to 80% of opioid-dependent patients remain opioid-free for 12 months while taking buprenorphine.7
Steps we can take. As family physicians (FPs), we are frequently overwhelmed by regulatory concerns, overhead expenses, and providing meaningful use data to third-party payers. And we sometimes take the easy route of simply prescribing or refilling scheduled drugs. Instead, we should educate ourselves and our patients about alternative therapeutic interventions for pain control and addiction.
To that end, I encourage all FPs to take the 8-hour online course provided by the American Society of Addiction Medicine to obtain a US Drug Enforcement Administration waiver for prescribing buprenorphine (available at: http://www.asam.org/education/live-online-cme/buprenorphine-course). It costs less than $200 and successful completion of this CME program allows FPs to deliver office-based opioid dependency interventions as per the Drug Addiction Treatment Act of 2000.
Right now, monthly patient censuses indicate that there are about 3234 buprenorphine prescribers providing care for 245,016 opioid-dependent patients, and fewer than 20% of those prescribers are FPs.8 We need to change that. We have an opportunity to invest in the future of these high-risk patients. Let’s not let them down.
Nearly 80 people die every day in America from an opioid overdose.1 At the same time, sales of prescription painkillers have increased 4-fold since 1999.2 My own medical assistant was given an unsolicited prescription for 40 oxycodone after a wisdom tooth extraction.
Meanwhile, about 80% of the country’s 2 million opioid-dependent patients are not receiving the treatment they need.3,4 In Vermont, for example, more than 500 patients are on waiting lists to receive buprenorphine (the partial opioid agonist used to treat opioid addiction)—a wait that for many of them will last for more than a year and may cost them their life.5
Buprenorphine makes good sense. Fortunately, buprenorphine can reverse opioid cravings within minutes. Medication-assisted treatment with buprenorphine derivatives allows patients to lead normal, productive, and stable lives. Every dollar invested in treating opioid addiction saves society $7 in drug-related crime and criminal justice costs.6 In addition, 50% to 80% of opioid-dependent patients remain opioid-free for 12 months while taking buprenorphine.7
Steps we can take. As family physicians (FPs), we are frequently overwhelmed by regulatory concerns, overhead expenses, and providing meaningful use data to third-party payers. And we sometimes take the easy route of simply prescribing or refilling scheduled drugs. Instead, we should educate ourselves and our patients about alternative therapeutic interventions for pain control and addiction.
To that end, I encourage all FPs to take the 8-hour online course provided by the American Society of Addiction Medicine to obtain a US Drug Enforcement Administration waiver for prescribing buprenorphine (available at: http://www.asam.org/education/live-online-cme/buprenorphine-course). It costs less than $200 and successful completion of this CME program allows FPs to deliver office-based opioid dependency interventions as per the Drug Addiction Treatment Act of 2000.
Right now, monthly patient censuses indicate that there are about 3234 buprenorphine prescribers providing care for 245,016 opioid-dependent patients, and fewer than 20% of those prescribers are FPs.8 We need to change that. We have an opportunity to invest in the future of these high-risk patients. Let’s not let them down.
1. Democratic staff of the senate committee on finance. Dying waiting for treatment: the opioid use disorder treatment gap and the need for funding. October 10, 2016. Available at: https://www.finance.senate.gov/imo/media/doc/101116%20Opioid%20Treatment%20Gap%20Report%20Final.pdf. Accessed December 14, 2016.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.
3. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States. JAMA. 2015;314:1515-1517.
4. Substance Abuse and Mental Health Services Administration. Opioids. Available at: https://www.samhsa.gov/atod/opioids. Accessed December 14, 2016.
5. Vestal C. Waiting lists grow for medicine to fight opioid addiction. Stateline. February 11, 2016. Available at: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/02/11/waiting-lists-grow-for-medicine-to-fight-opioid-addiction. Accessed December 14, 2016.
6. National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (third edition). Is drug addiction treatment worth its cost? Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost. Accessed December 14, 2016.
7. Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci. 2007; 9:455-470.
8. Stein BD, Sorbero MJ, Dick AW, et al. Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment. JAMA. 2016;316:1211-1212.
1. Democratic staff of the senate committee on finance. Dying waiting for treatment: the opioid use disorder treatment gap and the need for funding. October 10, 2016. Available at: https://www.finance.senate.gov/imo/media/doc/101116%20Opioid%20Treatment%20Gap%20Report%20Final.pdf. Accessed December 14, 2016.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.
3. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States. JAMA. 2015;314:1515-1517.
4. Substance Abuse and Mental Health Services Administration. Opioids. Available at: https://www.samhsa.gov/atod/opioids. Accessed December 14, 2016.
5. Vestal C. Waiting lists grow for medicine to fight opioid addiction. Stateline. February 11, 2016. Available at: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/02/11/waiting-lists-grow-for-medicine-to-fight-opioid-addiction. Accessed December 14, 2016.
6. National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (third edition). Is drug addiction treatment worth its cost? Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost. Accessed December 14, 2016.
7. Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci. 2007; 9:455-470.
8. Stein BD, Sorbero MJ, Dick AW, et al. Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment. JAMA. 2016;316:1211-1212.
Revisiting delirious mania; Correcting an error
Revisiting delirious mania
After treating a young woman with delirious mania, we were compelled to comment on the case report “Confused and nearly naked after going on spending sprees” (Cases That Test Your Skills,
A young woman with bipolar I disorder and mild intellectual disability was brought to our inpatient psychiatric unit after she disappeared from her home. Her family reported she was not compliant with her medications, and she recently showed deterioration marked by bizarre and violent behaviors for the previous month.
Although her presentation was consistent with earlier manic episodes, additional behaviors indicated an increase in severity. The patient was only oriented to name, was disrobing, had urinary and fecal incontinence, and showed purposeless hyperactivity such as continuously dancing in circles.
Because we thought she was experiencing a severe exacerbation of bipolar disorder, the patient was started on 4 different antipsychotic trials (typical and atypical) and 2 mood stabilizers, all of which did not produce adequate response. Even after augmentation with nightly long-acting benzodiazepines, the patient’s symptoms remained unchanged.
The patient received a diagnosis of delirious mania, with the underlying mechanism being severe catatonia. A literature search revealed electroconvulsive therapy (ECT) and benzodiazepines as first-line treatments, and discouraged use of typical antipsychotics because of an increased risk of neuroleptic malignant syndrome and malignant delirious mania.1 Because ECT was not available at our facility, we initiated benzodiazepines,
We agree it is prudent to rule out any medical illnesses that could cause delirium. Interestingly, in our patient a head CT revealed small calcifications suggestive of cysticercosis, which have been seen on imaging since age 13. We suggest that this finding contributed to her disinhibition, prolonged her recovery, and could explain why she did not respond adequately to medications.
Diagnosing and treating delirious mania in our patient was challenging. As mentioned by Davis et al, there is no classification of delirious mania in DSM-5. In addition, there are no large-scale studies to educate psychiatrists about the prevalence and appropriate treatment of this disorder.
Our treatment approach differed from that of Davis et al in that we chose scheduled benzodiazepines rather than antipsychotics to target the patient’s catatonia. However, both patients improved, prompting us to further question the mechanism behind this presentation.
We encourage the addition of delirious mania to the next edition of DSM. Without classification and establishment of this diagnosis, psychiatrists are unlikely to consider this serious and potentially fatal syndrome. Delirious mania is mysterious and rare and its inner workings are not fully elucidated.
Sabina Bera, MD MSc
PGY-2 Psychiatry Resident
Mohammed Molla, MD, DFAPA
Interim Joint Chair and Program Director
University of California Los Angeles-Kern
Psychiatry Training Program
Bakersfield, California
Reference
1. Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute setting. J Psychiatr Pract. 2013;19(1):15-28.
Correcting an error
In his informative guest editorial "
David A. Gorelick, MD, PhD
Professor of Psychiatry
Maryland Psychiatric Research Center
University of Maryland
Baltimore, Maryland
Revisiting delirious mania
After treating a young woman with delirious mania, we were compelled to comment on the case report “Confused and nearly naked after going on spending sprees” (Cases That Test Your Skills,
A young woman with bipolar I disorder and mild intellectual disability was brought to our inpatient psychiatric unit after she disappeared from her home. Her family reported she was not compliant with her medications, and she recently showed deterioration marked by bizarre and violent behaviors for the previous month.
Although her presentation was consistent with earlier manic episodes, additional behaviors indicated an increase in severity. The patient was only oriented to name, was disrobing, had urinary and fecal incontinence, and showed purposeless hyperactivity such as continuously dancing in circles.
Because we thought she was experiencing a severe exacerbation of bipolar disorder, the patient was started on 4 different antipsychotic trials (typical and atypical) and 2 mood stabilizers, all of which did not produce adequate response. Even after augmentation with nightly long-acting benzodiazepines, the patient’s symptoms remained unchanged.
The patient received a diagnosis of delirious mania, with the underlying mechanism being severe catatonia. A literature search revealed electroconvulsive therapy (ECT) and benzodiazepines as first-line treatments, and discouraged use of typical antipsychotics because of an increased risk of neuroleptic malignant syndrome and malignant delirious mania.1 Because ECT was not available at our facility, we initiated benzodiazepines,
We agree it is prudent to rule out any medical illnesses that could cause delirium. Interestingly, in our patient a head CT revealed small calcifications suggestive of cysticercosis, which have been seen on imaging since age 13. We suggest that this finding contributed to her disinhibition, prolonged her recovery, and could explain why she did not respond adequately to medications.
Diagnosing and treating delirious mania in our patient was challenging. As mentioned by Davis et al, there is no classification of delirious mania in DSM-5. In addition, there are no large-scale studies to educate psychiatrists about the prevalence and appropriate treatment of this disorder.
Our treatment approach differed from that of Davis et al in that we chose scheduled benzodiazepines rather than antipsychotics to target the patient’s catatonia. However, both patients improved, prompting us to further question the mechanism behind this presentation.
We encourage the addition of delirious mania to the next edition of DSM. Without classification and establishment of this diagnosis, psychiatrists are unlikely to consider this serious and potentially fatal syndrome. Delirious mania is mysterious and rare and its inner workings are not fully elucidated.
Sabina Bera, MD MSc
PGY-2 Psychiatry Resident
Mohammed Molla, MD, DFAPA
Interim Joint Chair and Program Director
University of California Los Angeles-Kern
Psychiatry Training Program
Bakersfield, California
Reference
1. Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute setting. J Psychiatr Pract. 2013;19(1):15-28.
Correcting an error
In his informative guest editorial "
David A. Gorelick, MD, PhD
Professor of Psychiatry
Maryland Psychiatric Research Center
University of Maryland
Baltimore, Maryland
Revisiting delirious mania
After treating a young woman with delirious mania, we were compelled to comment on the case report “Confused and nearly naked after going on spending sprees” (Cases That Test Your Skills,
A young woman with bipolar I disorder and mild intellectual disability was brought to our inpatient psychiatric unit after she disappeared from her home. Her family reported she was not compliant with her medications, and she recently showed deterioration marked by bizarre and violent behaviors for the previous month.
Although her presentation was consistent with earlier manic episodes, additional behaviors indicated an increase in severity. The patient was only oriented to name, was disrobing, had urinary and fecal incontinence, and showed purposeless hyperactivity such as continuously dancing in circles.
Because we thought she was experiencing a severe exacerbation of bipolar disorder, the patient was started on 4 different antipsychotic trials (typical and atypical) and 2 mood stabilizers, all of which did not produce adequate response. Even after augmentation with nightly long-acting benzodiazepines, the patient’s symptoms remained unchanged.
The patient received a diagnosis of delirious mania, with the underlying mechanism being severe catatonia. A literature search revealed electroconvulsive therapy (ECT) and benzodiazepines as first-line treatments, and discouraged use of typical antipsychotics because of an increased risk of neuroleptic malignant syndrome and malignant delirious mania.1 Because ECT was not available at our facility, we initiated benzodiazepines,
We agree it is prudent to rule out any medical illnesses that could cause delirium. Interestingly, in our patient a head CT revealed small calcifications suggestive of cysticercosis, which have been seen on imaging since age 13. We suggest that this finding contributed to her disinhibition, prolonged her recovery, and could explain why she did not respond adequately to medications.
Diagnosing and treating delirious mania in our patient was challenging. As mentioned by Davis et al, there is no classification of delirious mania in DSM-5. In addition, there are no large-scale studies to educate psychiatrists about the prevalence and appropriate treatment of this disorder.
Our treatment approach differed from that of Davis et al in that we chose scheduled benzodiazepines rather than antipsychotics to target the patient’s catatonia. However, both patients improved, prompting us to further question the mechanism behind this presentation.
We encourage the addition of delirious mania to the next edition of DSM. Without classification and establishment of this diagnosis, psychiatrists are unlikely to consider this serious and potentially fatal syndrome. Delirious mania is mysterious and rare and its inner workings are not fully elucidated.
Sabina Bera, MD MSc
PGY-2 Psychiatry Resident
Mohammed Molla, MD, DFAPA
Interim Joint Chair and Program Director
University of California Los Angeles-Kern
Psychiatry Training Program
Bakersfield, California
Reference
1. Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute setting. J Psychiatr Pract. 2013;19(1):15-28.
Correcting an error
In his informative guest editorial "
David A. Gorelick, MD, PhD
Professor of Psychiatry
Maryland Psychiatric Research Center
University of Maryland
Baltimore, Maryland
