Commentary

The article, “Bone disease in patients with kidney disease: A tricky interplay” (J Fam Pract. 2016;65:606-612), incorrectly stated: “Elevations of both fibroblast growth factor 23 (FGF23) and parathyroid hormone (PTH) lead to hyperphosphatemia and hypocalcemia because of decreased urinary excretion of phosphorus.” In fact, FGF23 normally acts to lower blood phosphate levels. Furthermore, an elevated phosphorus level causes an increase in serum calcium levels and not hypocalcemia. This sentence, and the 2 that followed it, should have read:

“Elevations of FGF23 lower blood phosphate levels by inhibiting phosphate reabsorption in the kidneys, thus increasing urinary excretion of phosphorus. Secondary hyperparathyroidism, driven by hypocalcemia, responds to normalize serum calcium levels by increasing the number and size of osteoclasts actively breaking down bone matrix. This increased level of bone breakdown escalates fracture risk.”

This information has been corrected in the online version of the article.

The article, “Bone disease in patients with kidney disease: A tricky interplay” (J Fam Pract. 2016;65:606-612), incorrectly stated: “Elevations of both fibroblast growth factor 23 (FGF23) and parathyroid hormone (PTH) lead to hyperphosphatemia and hypocalcemia because of decreased urinary excretion of phosphorus.” In fact, FGF23 normally acts to lower blood phosphate levels. Furthermore, an elevated phosphorus level causes an increase in serum calcium levels and not hypocalcemia. This sentence, and the 2 that followed it, should have read:

“Elevations of FGF23 lower blood phosphate levels by inhibiting phosphate reabsorption in the kidneys, thus increasing urinary excretion of phosphorus. Secondary hyperparathyroidism, driven by hypocalcemia, responds to normalize serum calcium levels by increasing the number and size of osteoclasts actively breaking down bone matrix. This increased level of bone breakdown escalates fracture risk.”

This information has been corrected in the online version of the article.

The article, “Bone disease in patients with kidney disease: A tricky interplay” (J Fam Pract. 2016;65:606-612), incorrectly stated: “Elevations of both fibroblast growth factor 23 (FGF23) and parathyroid hormone (PTH) lead to hyperphosphatemia and hypocalcemia because of decreased urinary excretion of phosphorus.” In fact, FGF23 normally acts to lower blood phosphate levels. Furthermore, an elevated phosphorus level causes an increase in serum calcium levels and not hypocalcemia. This sentence, and the 2 that followed it, should have read:

“Elevations of FGF23 lower blood phosphate levels by inhibiting phosphate reabsorption in the kidneys, thus increasing urinary excretion of phosphorus. Secondary hyperparathyroidism, driven by hypocalcemia, responds to normalize serum calcium levels by increasing the number and size of osteoclasts actively breaking down bone matrix. This increased level of bone breakdown escalates fracture risk.”

This information has been corrected in the online version of the article.

Since Florida has seen several new cases of local mosquito-borne infection, controlling and preventing Zika infection has great urgency. Zika virus involves an arthropod-borne infection transmitted by Aedes aegypti and Aedes albopictus mosquitoes. Other modes of transmission include the maternal-fetal route, any sexual contact, blood transfusions, organ or tissue transplantation, and laboratory exposure.¹

The first case of Zika infection in the United States and its territories occurred through international travel. According to the Centers for Disease Control and Prevention, as of October 12, 2016, there were 3807 travel-associated cases of Zika infection in the United States and 84 instances in its territories.² As for local transmission, there were 128 people evidencing a Zika infection in the United States and 25,871 in US territories.² Regions between Texas and Florida are at high risk because Aedes mosquitoes primarily inhabit the gulf coast.³ Many cases have occurred despite repellent use and eradication efforts, possibly due to resistance acquired by these mosquitoes.¹

Control measures include using insect repellents, aerial spraying of insecticides, eliminating mosquito breeding sites, covering water tanks, and using mosquito nets or door and window screens. Infection during pregnancy is the greatest concern because of congenital anomalies (including microcephaly) that negatively affect brain development.⁴

Before a possible conception or any sexual contact, women exposed to Zika—with or without symptoms—must wait at least 8 weeks; men with or without symptoms should abstain for 6 months.⁴ Individuals should avoid traveling to areas with Zika infestation, wear long-sleeved clothing treated with permethrin, and minimize outside exposure, especially in evening hours.⁴

The World Health Organization is utilizing genetically modified mosquitoes to diminish Aedes populations; trials conducted in affected areas of Brazil revealed that the number of Aedes mosquitoes was reduced by 90%.⁵ This method of mosquito control is currently being studied in the United States.⁶ Vaccinations to prevent Zika infection are also under investigation.

Physicians should educate patients regarding the clinical manifestations and complications of Zika virus infection; people need to know that the Zika virus can be sexually transmitted. Doctors should also counsel patients to curtail travel to areas that have Zika infestations, or to at least wear protective clothing while in such areas to minimize mosquito bite risk. Educating travelers about appropriate postponement of sexual contact after any exposure to the Zika virus is also essential.⁴

Hema Madhuri Mekala, MD
Priyanga Jayakumar, MD
Rajashekar Reddy Yeruva, MD
Steven Lippmann, MD
Louisville, KY

Since Florida has seen several new cases of local mosquito-borne infection, controlling and preventing Zika infection has great urgency. Zika virus involves an arthropod-borne infection transmitted by Aedes aegypti and Aedes albopictus mosquitoes. Other modes of transmission include the maternal-fetal route, any sexual contact, blood transfusions, organ or tissue transplantation, and laboratory exposure.¹

The first case of Zika infection in the United States and its territories occurred through international travel. According to the Centers for Disease Control and Prevention, as of October 12, 2016, there were 3807 travel-associated cases of Zika infection in the United States and 84 instances in its territories.² As for local transmission, there were 128 people evidencing a Zika infection in the United States and 25,871 in US territories.² Regions between Texas and Florida are at high risk because Aedes mosquitoes primarily inhabit the gulf coast.³ Many cases have occurred despite repellent use and eradication efforts, possibly due to resistance acquired by these mosquitoes.¹

Control measures include using insect repellents, aerial spraying of insecticides, eliminating mosquito breeding sites, covering water tanks, and using mosquito nets or door and window screens. Infection during pregnancy is the greatest concern because of congenital anomalies (including microcephaly) that negatively affect brain development.⁴

Before a possible conception or any sexual contact, women exposed to Zika—with or without symptoms—must wait at least 8 weeks; men with or without symptoms should abstain for 6 months.⁴ Individuals should avoid traveling to areas with Zika infestation, wear long-sleeved clothing treated with permethrin, and minimize outside exposure, especially in evening hours.⁴

The World Health Organization is utilizing genetically modified mosquitoes to diminish Aedes populations; trials conducted in affected areas of Brazil revealed that the number of Aedes mosquitoes was reduced by 90%.⁵ This method of mosquito control is currently being studied in the United States.⁶ Vaccinations to prevent Zika infection are also under investigation.

Physicians should educate patients regarding the clinical manifestations and complications of Zika virus infection; people need to know that the Zika virus can be sexually transmitted. Doctors should also counsel patients to curtail travel to areas that have Zika infestations, or to at least wear protective clothing while in such areas to minimize mosquito bite risk. Educating travelers about appropriate postponement of sexual contact after any exposure to the Zika virus is also essential.⁴

Hema Madhuri Mekala, MD
Priyanga Jayakumar, MD
Rajashekar Reddy Yeruva, MD
Steven Lippmann, MD
Louisville, KY

Since Florida has seen several new cases of local mosquito-borne infection, controlling and preventing Zika infection has great urgency. Zika virus involves an arthropod-borne infection transmitted by Aedes aegypti and Aedes albopictus mosquitoes. Other modes of transmission include the maternal-fetal route, any sexual contact, blood transfusions, organ or tissue transplantation, and laboratory exposure.¹

The first case of Zika infection in the United States and its territories occurred through international travel. According to the Centers for Disease Control and Prevention, as of October 12, 2016, there were 3807 travel-associated cases of Zika infection in the United States and 84 instances in its territories.² As for local transmission, there were 128 people evidencing a Zika infection in the United States and 25,871 in US territories.² Regions between Texas and Florida are at high risk because Aedes mosquitoes primarily inhabit the gulf coast.³ Many cases have occurred despite repellent use and eradication efforts, possibly due to resistance acquired by these mosquitoes.¹

Control measures include using insect repellents, aerial spraying of insecticides, eliminating mosquito breeding sites, covering water tanks, and using mosquito nets or door and window screens. Infection during pregnancy is the greatest concern because of congenital anomalies (including microcephaly) that negatively affect brain development.⁴

Before a possible conception or any sexual contact, women exposed to Zika—with or without symptoms—must wait at least 8 weeks; men with or without symptoms should abstain for 6 months.⁴ Individuals should avoid traveling to areas with Zika infestation, wear long-sleeved clothing treated with permethrin, and minimize outside exposure, especially in evening hours.⁴

The World Health Organization is utilizing genetically modified mosquitoes to diminish Aedes populations; trials conducted in affected areas of Brazil revealed that the number of Aedes mosquitoes was reduced by 90%.⁵ This method of mosquito control is currently being studied in the United States.⁶ Vaccinations to prevent Zika infection are also under investigation.

Physicians should educate patients regarding the clinical manifestations and complications of Zika virus infection; people need to know that the Zika virus can be sexually transmitted. Doctors should also counsel patients to curtail travel to areas that have Zika infestations, or to at least wear protective clothing while in such areas to minimize mosquito bite risk. Educating travelers about appropriate postponement of sexual contact after any exposure to the Zika virus is also essential.⁴

Hema Madhuri Mekala, MD
Priyanga Jayakumar, MD
Rajashekar Reddy Yeruva, MD
Steven Lippmann, MD
Louisville, KY

One of my brothers has adult onset bipolar disorder. As luck would have it, he also has type 2 diabetes mellitus. He struggles constantly with blood sugar control since he needs to take 2 psychotropic medications, both of which cause weight gain.

I mistakenly told a patient that her beta-blocker wasn't interfering with her weight loss.His situation has prompted me to think about the responsibility we have as we care, and advocate, for our patients with major mental illness who require these effective medications. At a minimum, we must be knowledgeable about the adverse metabolic effects of these drugs, avoid prescribing them when possible, and advocate for dose reductions when feasible. Knowing, for example, that these drugs fall on a spectrum, with haloperidol causing the least weight gain and olanzapine causing the most, is important.¹

An eye-opener. The article by Saunders in this issue provides advice on avoiding medications that commonly cause weight gain when prescribing for overweight or obese patients with diabetes, hypertension, and/or depression. I was unaware that some of the drugs on the list contribute to the problem. For example, I saw a new patient last week who has hypertension and is obese; she has been taking the beta-blocker metoprolol for the past 8 years. She has tried unsuccessfully to lose weight. She asked me if the metoprolol could be interfering with weight loss, and I mistakenly told her “No.” Thankfully, we decided to discontinue it anyway. I will admit to her my knowledge gap when I see her next month for follow-up. Errors are great teachers, especially when no harm is done.

The scope of the Saunders article is not meant to be comprehensive, since it focuses on medications for diabetes, hypertension, and depression. I think all of us are aware of the weight gain associated with other commonly prescribed drugs, such as systemic corticosteroids and long-acting progesterone for contraception. Thankfully, combination oral contraceptives do not appear to be associated with weight gain²—answering one of the more common questions I receive from patients about weight and medications.

The bottom line. Avoid prescribing medications that can cause weight gain in overweight and obese patients when possible, use the lowest effective dose when such agents are necessary, and warn patients of this adverse effect so that they can take precautions, such as walking an extra mile a day or giving up that high-calorie latte in the morning.

1. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382:951-962.

2. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;CD003987.

One of my brothers has adult onset bipolar disorder. As luck would have it, he also has type 2 diabetes mellitus. He struggles constantly with blood sugar control since he needs to take 2 psychotropic medications, both of which cause weight gain.

I mistakenly told a patient that her beta-blocker wasn't interfering with her weight loss.His situation has prompted me to think about the responsibility we have as we care, and advocate, for our patients with major mental illness who require these effective medications. At a minimum, we must be knowledgeable about the adverse metabolic effects of these drugs, avoid prescribing them when possible, and advocate for dose reductions when feasible. Knowing, for example, that these drugs fall on a spectrum, with haloperidol causing the least weight gain and olanzapine causing the most, is important.¹

An eye-opener. The article by Saunders in this issue provides advice on avoiding medications that commonly cause weight gain when prescribing for overweight or obese patients with diabetes, hypertension, and/or depression. I was unaware that some of the drugs on the list contribute to the problem. For example, I saw a new patient last week who has hypertension and is obese; she has been taking the beta-blocker metoprolol for the past 8 years. She has tried unsuccessfully to lose weight. She asked me if the metoprolol could be interfering with weight loss, and I mistakenly told her “No.” Thankfully, we decided to discontinue it anyway. I will admit to her my knowledge gap when I see her next month for follow-up. Errors are great teachers, especially when no harm is done.

The scope of the Saunders article is not meant to be comprehensive, since it focuses on medications for diabetes, hypertension, and depression. I think all of us are aware of the weight gain associated with other commonly prescribed drugs, such as systemic corticosteroids and long-acting progesterone for contraception. Thankfully, combination oral contraceptives do not appear to be associated with weight gain²—answering one of the more common questions I receive from patients about weight and medications.

The bottom line. Avoid prescribing medications that can cause weight gain in overweight and obese patients when possible, use the lowest effective dose when such agents are necessary, and warn patients of this adverse effect so that they can take precautions, such as walking an extra mile a day or giving up that high-calorie latte in the morning.

1. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382:951-962.

2. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;CD003987.

One of my brothers has adult onset bipolar disorder. As luck would have it, he also has type 2 diabetes mellitus. He struggles constantly with blood sugar control since he needs to take 2 psychotropic medications, both of which cause weight gain.

I mistakenly told a patient that her beta-blocker wasn't interfering with her weight loss.His situation has prompted me to think about the responsibility we have as we care, and advocate, for our patients with major mental illness who require these effective medications. At a minimum, we must be knowledgeable about the adverse metabolic effects of these drugs, avoid prescribing them when possible, and advocate for dose reductions when feasible. Knowing, for example, that these drugs fall on a spectrum, with haloperidol causing the least weight gain and olanzapine causing the most, is important.¹

An eye-opener. The article by Saunders in this issue provides advice on avoiding medications that commonly cause weight gain when prescribing for overweight or obese patients with diabetes, hypertension, and/or depression. I was unaware that some of the drugs on the list contribute to the problem. For example, I saw a new patient last week who has hypertension and is obese; she has been taking the beta-blocker metoprolol for the past 8 years. She has tried unsuccessfully to lose weight. She asked me if the metoprolol could be interfering with weight loss, and I mistakenly told her “No.” Thankfully, we decided to discontinue it anyway. I will admit to her my knowledge gap when I see her next month for follow-up. Errors are great teachers, especially when no harm is done.

The scope of the Saunders article is not meant to be comprehensive, since it focuses on medications for diabetes, hypertension, and depression. I think all of us are aware of the weight gain associated with other commonly prescribed drugs, such as systemic corticosteroids and long-acting progesterone for contraception. Thankfully, combination oral contraceptives do not appear to be associated with weight gain²—answering one of the more common questions I receive from patients about weight and medications.

The bottom line. Avoid prescribing medications that can cause weight gain in overweight and obese patients when possible, use the lowest effective dose when such agents are necessary, and warn patients of this adverse effect so that they can take precautions, such as walking an extra mile a day or giving up that high-calorie latte in the morning.

1. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382:951-962.

2. Gallo MF, Lopez LM, Grimes DA, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2011;CD003987.

“IN WHICH CLINICAL SITUATIONS CAN THE USE OF THE 52-MG LEVONORGESTREL-RELEASING IUD (MIRENA) AND THE TCU380A COPPER-IUD (PARAGARD) BE EXTENDED?”

ROBERT L. BARBIERI, MD (SEPTEMBER 2016)

Extended-use IUDs and infection risk

For some time now I have been leaving hormonal intrauterine devices (IUDs) in place for 6 to 7 years, until menses returns. In my practice, long-term use of copper-IUDs has been associated with the presence of actinomycosis in the endometrial cavity, although usually without sepsis.

George Haber, MD
Montreal, Canada
 

Suppressing menses, pain with an IUD

I have a number of patients using the 52-mg levonorgestrel-releasing (LNG) IUD (Mirena) for noncontraceptive reasons, especially for reduction or elimination of menstrual flow and/or pain. Many have permanent sterilization in place (tubal sterilization, partner vasectomy) and I tell them we can leave the IUD in as long as they are satisfied with the results, since we are not concerned with pregnancy. Several have continued IUD use well past the 5-year mark.

Alan Smith, MD
Savannah, Georgia
 

LNG-IUD effective for multiple uses

In our practice, we have used the LNG-IUD Mirena off label for over a decade successfully for men-strual suppression in perimenopausal and postmenopausal women effectively for up to 8 years. We often place this device in the uterus after an endometrial ablation. We also offer it extended use as an alternative for menopausal hormone therapy when a progestin is indicated due to the presence of a uterus. Progestin delivery by this IUD is maximized in the endometrium and minimized in the breast and other systemic sites.

John Lenihan Jr, MD
Tacoma, Washington

Dr. Barbieri responds

I thank Dr. Haber for his observations. He notes that users of IUDs may have Actinomyces organisms identified on cervical cytology. These women should be informed of the finding and examined for evidence of active pelvic infection. If the women are asympto-matic and have a normal physical exam, the IUD does not need to be removed and antibiotic treatment is not recommended. If the woman has evidence of pelvic infection, the IUD should be removed and sent for anaerobic culture.

I appreciate that Drs. Smith and Lenihan shared their clinical pearls with readers. Dr. Smith notes that when an LNG-IUD is used to control bleeding in women who are sterilized, there are few concerns about the duration of its contraceptive efficacy, and adequate control of bleeding is a clinically useful end point demonstrating the IUD’s continued efficacy. If bleeding begins to increase after 5 years, the clinician might choose to remove the old device and replace it with a new one. Dr. Lenihan reports his use of the 52-mg LNG-IUD as the progestin in a regimen of menopausal hormone therapy. Of note, there are multiple reports from Finland that use of an LNG-IUD in premenopausal and menopausal women may be associated with an increased risk of breast cancer.^1,2 Conflicting reports from Finland and Germany did not detect an increased risk of breast cancer in women who used an LNG-IUD.^3,4 Clinicians should be aware that when Mirena is used past its approved 5-year time limit, it is an off-label use of the device.

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

“IN WHICH CLINICAL SITUATIONS CAN THE USE OF THE 52-MG LEVONORGESTREL-RELEASING IUD (MIRENA) AND THE TCU380A COPPER-IUD (PARAGARD) BE EXTENDED?”

ROBERT L. BARBIERI, MD (SEPTEMBER 2016)

Extended-use IUDs and infection risk

For some time now I have been leaving hormonal intrauterine devices (IUDs) in place for 6 to 7 years, until menses returns. In my practice, long-term use of copper-IUDs has been associated with the presence of actinomycosis in the endometrial cavity, although usually without sepsis.

George Haber, MD
Montreal, Canada
 

Suppressing menses, pain with an IUD

I have a number of patients using the 52-mg levonorgestrel-releasing (LNG) IUD (Mirena) for noncontraceptive reasons, especially for reduction or elimination of menstrual flow and/or pain. Many have permanent sterilization in place (tubal sterilization, partner vasectomy) and I tell them we can leave the IUD in as long as they are satisfied with the results, since we are not concerned with pregnancy. Several have continued IUD use well past the 5-year mark.

Alan Smith, MD
Savannah, Georgia
 

LNG-IUD effective for multiple uses

In our practice, we have used the LNG-IUD Mirena off label for over a decade successfully for men-strual suppression in perimenopausal and postmenopausal women effectively for up to 8 years. We often place this device in the uterus after an endometrial ablation. We also offer it extended use as an alternative for menopausal hormone therapy when a progestin is indicated due to the presence of a uterus. Progestin delivery by this IUD is maximized in the endometrium and minimized in the breast and other systemic sites.

John Lenihan Jr, MD
Tacoma, Washington

Dr. Barbieri responds

I thank Dr. Haber for his observations. He notes that users of IUDs may have Actinomyces organisms identified on cervical cytology. These women should be informed of the finding and examined for evidence of active pelvic infection. If the women are asympto-matic and have a normal physical exam, the IUD does not need to be removed and antibiotic treatment is not recommended. If the woman has evidence of pelvic infection, the IUD should be removed and sent for anaerobic culture.

I appreciate that Drs. Smith and Lenihan shared their clinical pearls with readers. Dr. Smith notes that when an LNG-IUD is used to control bleeding in women who are sterilized, there are few concerns about the duration of its contraceptive efficacy, and adequate control of bleeding is a clinically useful end point demonstrating the IUD’s continued efficacy. If bleeding begins to increase after 5 years, the clinician might choose to remove the old device and replace it with a new one. Dr. Lenihan reports his use of the 52-mg LNG-IUD as the progestin in a regimen of menopausal hormone therapy. Of note, there are multiple reports from Finland that use of an LNG-IUD in premenopausal and menopausal women may be associated with an increased risk of breast cancer.^1,2 Conflicting reports from Finland and Germany did not detect an increased risk of breast cancer in women who used an LNG-IUD.^3,4 Clinicians should be aware that when Mirena is used past its approved 5-year time limit, it is an off-label use of the device.

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

“IN WHICH CLINICAL SITUATIONS CAN THE USE OF THE 52-MG LEVONORGESTREL-RELEASING IUD (MIRENA) AND THE TCU380A COPPER-IUD (PARAGARD) BE EXTENDED?”

ROBERT L. BARBIERI, MD (SEPTEMBER 2016)

Extended-use IUDs and infection risk

For some time now I have been leaving hormonal intrauterine devices (IUDs) in place for 6 to 7 years, until menses returns. In my practice, long-term use of copper-IUDs has been associated with the presence of actinomycosis in the endometrial cavity, although usually without sepsis.

George Haber, MD
Montreal, Canada
 

Suppressing menses, pain with an IUD

I have a number of patients using the 52-mg levonorgestrel-releasing (LNG) IUD (Mirena) for noncontraceptive reasons, especially for reduction or elimination of menstrual flow and/or pain. Many have permanent sterilization in place (tubal sterilization, partner vasectomy) and I tell them we can leave the IUD in as long as they are satisfied with the results, since we are not concerned with pregnancy. Several have continued IUD use well past the 5-year mark.

Alan Smith, MD
Savannah, Georgia
 

LNG-IUD effective for multiple uses

In our practice, we have used the LNG-IUD Mirena off label for over a decade successfully for men-strual suppression in perimenopausal and postmenopausal women effectively for up to 8 years. We often place this device in the uterus after an endometrial ablation. We also offer it extended use as an alternative for menopausal hormone therapy when a progestin is indicated due to the presence of a uterus. Progestin delivery by this IUD is maximized in the endometrium and minimized in the breast and other systemic sites.

John Lenihan Jr, MD
Tacoma, Washington

Dr. Barbieri responds

I thank Dr. Haber for his observations. He notes that users of IUDs may have Actinomyces organisms identified on cervical cytology. These women should be informed of the finding and examined for evidence of active pelvic infection. If the women are asympto-matic and have a normal physical exam, the IUD does not need to be removed and antibiotic treatment is not recommended. If the woman has evidence of pelvic infection, the IUD should be removed and sent for anaerobic culture.

I appreciate that Drs. Smith and Lenihan shared their clinical pearls with readers. Dr. Smith notes that when an LNG-IUD is used to control bleeding in women who are sterilized, there are few concerns about the duration of its contraceptive efficacy, and adequate control of bleeding is a clinically useful end point demonstrating the IUD’s continued efficacy. If bleeding begins to increase after 5 years, the clinician might choose to remove the old device and replace it with a new one. Dr. Lenihan reports his use of the 52-mg LNG-IUD as the progestin in a regimen of menopausal hormone therapy. Of note, there are multiple reports from Finland that use of an LNG-IUD in premenopausal and menopausal women may be associated with an increased risk of breast cancer.^1,2 Conflicting reports from Finland and Germany did not detect an increased risk of breast cancer in women who used an LNG-IUD.^3,4 Clinicians should be aware that when Mirena is used past its approved 5-year time limit, it is an off-label use of the device.

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

A Google search of “sensory issues in children” reveals more than 20 million results and a wide range of terminology that can be confusing to parents, providers, and youth themselves. Phenomena such as sensory processing disorder, sensory integration disorder, sensory discrimination disorder, and sensory defensiveness are noted, and autism spectrum disorder (ASD) is a label not uncommonly attached to the former terms.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not include a discrete diagnosis to apply to children who have sensory differences, (meaning that they have difficulties regulating sensory input and such difficulties affect their ability to successfully relate to the world around them), but these differences are now part of the diagnostic criteria for ASD. The literature indicates that a majority of youth with ASD demonstrate features of sensory overresponsiveness (JAMA Psychiatry. 2015 Aug;72[8]:778-86), and providers should rightfully be concerned about the possibility of autism in a youngster who is presenting with severe negative responses to auditory, visual, and/or tactile stimuli.

Notably, however, even though sensory problems are considered a feature of autism, they are not pathognomonic for the disorder, and most children with these problems are, in fact, not autistic. Children with deficits in their ability to modulate sensory stimuli can present with a wide range of emotional-behavioral problems, including externalizing behaviors and internalizing symptoms manifesting with anxiety, attention challenges, mood dysregulation, and overall poor adaptive functioning. The relationship between sensory issues (both underresponsiveness and overresponsiveness) and psychopathology is rather complicated as sensory dysfunction can exist independent of a psychiatric disorder, be a significant risk factor for the development of the disorder (J Abnorm Child Psychol. 2009 Nov;37[8]:1077-87), and have symptom overlap with the disorder.

All in all, in spite of this complexity, since the 1960’s (Am J Occup Ther. 1964 Jan-Feb;18:6-11), it’s been clear that sensory dysfunction in children is associated with impairments in development, learning, and self-regulation. Parents of these children experience elevated levels of stress (J Child Fam Stud. 2013 Oct 1;22[7]:912-21), and early identification of sensory differences, psychoeducation, and referral for treatment are critical to minimize these impacts and foster positive outcomes.

Case Summary

In gathering a history and administering the Autism Diagnostic Observation Schedule (ADOS), it became clear that Sarah did not present with the social-communicative impairments that characterize ASD, but she did demonstrate repetitive hand flapping, troubles tolerating large social get-togethers, hypersensitivities, and a vulnerability to getting stuck when attempting to transition between activities. It is not uncommon for Sarah to use “fight-and-flight” reactions when faced with internal or external discomfort. Child Behavior Checklist data revealed multi-informant endorsement of clinical range symptoms across broad-band and narrow-band domains. Additionally, the Sensory Profile–2 yielded elevated scores in categories measuring sensory seeking and sensory sensitivity. The Sensory Profile is a standardized tool that uses caregiver and teacher-completed questionnaires to examine a child’s sensory processing abilities and provide data regarding the effect of such sensory processing on functional performance. Integrating all the available data, our team certainly appreciated Sarah’s profound sensory overresponsiveness, and a diagnosis of an unspecified anxiety disorder was provided along with consideration for attention-deficit/hyperactivity disorder (ADHD) (with teacher input needed to further investigate this possibility). The family history revealed anxiety disorders occurring both maternally and paternally. Additionally, Sarah’s mother’s acknowledged having her own similar sensory issues as a child.

Discussion

Associations among anxiety, sensory overresponsiveness, and ADHD are recognized in the literature (Am J Occup Ther. 2009 Jul-Aug;63[4]:433-40) and have implications for treatment. Furthermore, there is evidence that there is a heritable aspect to sensory processing abnormalities, and tactile defensiveness is associated with fearful temperament and anxiety (J Abnorm Child Psychol. 2006 Jun;34[3]:393-407). In Sarah’s case, her intense behavioral response to ordinary sensory stimuli was striking, and she had not yet been referred for an occupational therapy evaluation, which was the primary recommendation to further assess and understand her complicated sensory profile. As one component of a comprehensive treatment plan, an occupational therapist (www.aota.org), by using evidence-based practices in a sensory-integration framework, could be helpful in addressing Sarah’s range of challenges and promoting positive outcomes related to socialization, behavioral regulation, and attention. Occupational therapists, with assistance from other team members, also could work with Sarah and her family on developing relaxation skills and use exposure and response prevention–oriented intervention strategies to address anxieties. Families, however, should be counseled about the limited data on the use of sensory-based therapies (Pediatrics. 2012 Jun;129[6]:1186-9); the use of parent-management training/family coaching should also be a treatment consideration to help promote overall regulatory functioning in the household.

Clinical pearl

When encountering youth with sensory-related challenges, a clinician’s diagnostic considerations should be more than just thinking about the possibility of an autism spectrum disorder. Symptoms of sensory overresponsiveness are associated with other emotional-behavioral conditions, but also can be seen without co-occurring psychopathology. With the latter, however, providers should be mindful that family-related impairments still may be quite noteworthy (J Am Acad Child Adolesc Psychiatry. 2011 Dec;50[12]:1210-9) and associated behavior problems could be attributed incorrectly to other diagnoses (which may lead to the recommendation of ineffective and inappropriate treatments). Much more research is needed to help develop a robust framework for diagnosing and labeling sensory issues in children and studying the efficacy of available intervention strategies.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic.

A Google search of “sensory issues in children” reveals more than 20 million results and a wide range of terminology that can be confusing to parents, providers, and youth themselves. Phenomena such as sensory processing disorder, sensory integration disorder, sensory discrimination disorder, and sensory defensiveness are noted, and autism spectrum disorder (ASD) is a label not uncommonly attached to the former terms.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not include a discrete diagnosis to apply to children who have sensory differences, (meaning that they have difficulties regulating sensory input and such difficulties affect their ability to successfully relate to the world around them), but these differences are now part of the diagnostic criteria for ASD. The literature indicates that a majority of youth with ASD demonstrate features of sensory overresponsiveness (JAMA Psychiatry. 2015 Aug;72[8]:778-86), and providers should rightfully be concerned about the possibility of autism in a youngster who is presenting with severe negative responses to auditory, visual, and/or tactile stimuli.

Notably, however, even though sensory problems are considered a feature of autism, they are not pathognomonic for the disorder, and most children with these problems are, in fact, not autistic. Children with deficits in their ability to modulate sensory stimuli can present with a wide range of emotional-behavioral problems, including externalizing behaviors and internalizing symptoms manifesting with anxiety, attention challenges, mood dysregulation, and overall poor adaptive functioning. The relationship between sensory issues (both underresponsiveness and overresponsiveness) and psychopathology is rather complicated as sensory dysfunction can exist independent of a psychiatric disorder, be a significant risk factor for the development of the disorder (J Abnorm Child Psychol. 2009 Nov;37[8]:1077-87), and have symptom overlap with the disorder.

All in all, in spite of this complexity, since the 1960’s (Am J Occup Ther. 1964 Jan-Feb;18:6-11), it’s been clear that sensory dysfunction in children is associated with impairments in development, learning, and self-regulation. Parents of these children experience elevated levels of stress (J Child Fam Stud. 2013 Oct 1;22[7]:912-21), and early identification of sensory differences, psychoeducation, and referral for treatment are critical to minimize these impacts and foster positive outcomes.

Case Summary

In gathering a history and administering the Autism Diagnostic Observation Schedule (ADOS), it became clear that Sarah did not present with the social-communicative impairments that characterize ASD, but she did demonstrate repetitive hand flapping, troubles tolerating large social get-togethers, hypersensitivities, and a vulnerability to getting stuck when attempting to transition between activities. It is not uncommon for Sarah to use “fight-and-flight” reactions when faced with internal or external discomfort. Child Behavior Checklist data revealed multi-informant endorsement of clinical range symptoms across broad-band and narrow-band domains. Additionally, the Sensory Profile–2 yielded elevated scores in categories measuring sensory seeking and sensory sensitivity. The Sensory Profile is a standardized tool that uses caregiver and teacher-completed questionnaires to examine a child’s sensory processing abilities and provide data regarding the effect of such sensory processing on functional performance. Integrating all the available data, our team certainly appreciated Sarah’s profound sensory overresponsiveness, and a diagnosis of an unspecified anxiety disorder was provided along with consideration for attention-deficit/hyperactivity disorder (ADHD) (with teacher input needed to further investigate this possibility). The family history revealed anxiety disorders occurring both maternally and paternally. Additionally, Sarah’s mother’s acknowledged having her own similar sensory issues as a child.

Discussion

Associations among anxiety, sensory overresponsiveness, and ADHD are recognized in the literature (Am J Occup Ther. 2009 Jul-Aug;63[4]:433-40) and have implications for treatment. Furthermore, there is evidence that there is a heritable aspect to sensory processing abnormalities, and tactile defensiveness is associated with fearful temperament and anxiety (J Abnorm Child Psychol. 2006 Jun;34[3]:393-407). In Sarah’s case, her intense behavioral response to ordinary sensory stimuli was striking, and she had not yet been referred for an occupational therapy evaluation, which was the primary recommendation to further assess and understand her complicated sensory profile. As one component of a comprehensive treatment plan, an occupational therapist (www.aota.org), by using evidence-based practices in a sensory-integration framework, could be helpful in addressing Sarah’s range of challenges and promoting positive outcomes related to socialization, behavioral regulation, and attention. Occupational therapists, with assistance from other team members, also could work with Sarah and her family on developing relaxation skills and use exposure and response prevention–oriented intervention strategies to address anxieties. Families, however, should be counseled about the limited data on the use of sensory-based therapies (Pediatrics. 2012 Jun;129[6]:1186-9); the use of parent-management training/family coaching should also be a treatment consideration to help promote overall regulatory functioning in the household.

Clinical pearl

When encountering youth with sensory-related challenges, a clinician’s diagnostic considerations should be more than just thinking about the possibility of an autism spectrum disorder. Symptoms of sensory overresponsiveness are associated with other emotional-behavioral conditions, but also can be seen without co-occurring psychopathology. With the latter, however, providers should be mindful that family-related impairments still may be quite noteworthy (J Am Acad Child Adolesc Psychiatry. 2011 Dec;50[12]:1210-9) and associated behavior problems could be attributed incorrectly to other diagnoses (which may lead to the recommendation of ineffective and inappropriate treatments). Much more research is needed to help develop a robust framework for diagnosing and labeling sensory issues in children and studying the efficacy of available intervention strategies.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic.

A Google search of “sensory issues in children” reveals more than 20 million results and a wide range of terminology that can be confusing to parents, providers, and youth themselves. Phenomena such as sensory processing disorder, sensory integration disorder, sensory discrimination disorder, and sensory defensiveness are noted, and autism spectrum disorder (ASD) is a label not uncommonly attached to the former terms.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not include a discrete diagnosis to apply to children who have sensory differences, (meaning that they have difficulties regulating sensory input and such difficulties affect their ability to successfully relate to the world around them), but these differences are now part of the diagnostic criteria for ASD. The literature indicates that a majority of youth with ASD demonstrate features of sensory overresponsiveness (JAMA Psychiatry. 2015 Aug;72[8]:778-86), and providers should rightfully be concerned about the possibility of autism in a youngster who is presenting with severe negative responses to auditory, visual, and/or tactile stimuli.

Notably, however, even though sensory problems are considered a feature of autism, they are not pathognomonic for the disorder, and most children with these problems are, in fact, not autistic. Children with deficits in their ability to modulate sensory stimuli can present with a wide range of emotional-behavioral problems, including externalizing behaviors and internalizing symptoms manifesting with anxiety, attention challenges, mood dysregulation, and overall poor adaptive functioning. The relationship between sensory issues (both underresponsiveness and overresponsiveness) and psychopathology is rather complicated as sensory dysfunction can exist independent of a psychiatric disorder, be a significant risk factor for the development of the disorder (J Abnorm Child Psychol. 2009 Nov;37[8]:1077-87), and have symptom overlap with the disorder.

All in all, in spite of this complexity, since the 1960’s (Am J Occup Ther. 1964 Jan-Feb;18:6-11), it’s been clear that sensory dysfunction in children is associated with impairments in development, learning, and self-regulation. Parents of these children experience elevated levels of stress (J Child Fam Stud. 2013 Oct 1;22[7]:912-21), and early identification of sensory differences, psychoeducation, and referral for treatment are critical to minimize these impacts and foster positive outcomes.

Case Summary

In gathering a history and administering the Autism Diagnostic Observation Schedule (ADOS), it became clear that Sarah did not present with the social-communicative impairments that characterize ASD, but she did demonstrate repetitive hand flapping, troubles tolerating large social get-togethers, hypersensitivities, and a vulnerability to getting stuck when attempting to transition between activities. It is not uncommon for Sarah to use “fight-and-flight” reactions when faced with internal or external discomfort. Child Behavior Checklist data revealed multi-informant endorsement of clinical range symptoms across broad-band and narrow-band domains. Additionally, the Sensory Profile–2 yielded elevated scores in categories measuring sensory seeking and sensory sensitivity. The Sensory Profile is a standardized tool that uses caregiver and teacher-completed questionnaires to examine a child’s sensory processing abilities and provide data regarding the effect of such sensory processing on functional performance. Integrating all the available data, our team certainly appreciated Sarah’s profound sensory overresponsiveness, and a diagnosis of an unspecified anxiety disorder was provided along with consideration for attention-deficit/hyperactivity disorder (ADHD) (with teacher input needed to further investigate this possibility). The family history revealed anxiety disorders occurring both maternally and paternally. Additionally, Sarah’s mother’s acknowledged having her own similar sensory issues as a child.

Discussion

Associations among anxiety, sensory overresponsiveness, and ADHD are recognized in the literature (Am J Occup Ther. 2009 Jul-Aug;63[4]:433-40) and have implications for treatment. Furthermore, there is evidence that there is a heritable aspect to sensory processing abnormalities, and tactile defensiveness is associated with fearful temperament and anxiety (J Abnorm Child Psychol. 2006 Jun;34[3]:393-407). In Sarah’s case, her intense behavioral response to ordinary sensory stimuli was striking, and she had not yet been referred for an occupational therapy evaluation, which was the primary recommendation to further assess and understand her complicated sensory profile. As one component of a comprehensive treatment plan, an occupational therapist (www.aota.org), by using evidence-based practices in a sensory-integration framework, could be helpful in addressing Sarah’s range of challenges and promoting positive outcomes related to socialization, behavioral regulation, and attention. Occupational therapists, with assistance from other team members, also could work with Sarah and her family on developing relaxation skills and use exposure and response prevention–oriented intervention strategies to address anxieties. Families, however, should be counseled about the limited data on the use of sensory-based therapies (Pediatrics. 2012 Jun;129[6]:1186-9); the use of parent-management training/family coaching should also be a treatment consideration to help promote overall regulatory functioning in the household.

Clinical pearl

When encountering youth with sensory-related challenges, a clinician’s diagnostic considerations should be more than just thinking about the possibility of an autism spectrum disorder. Symptoms of sensory overresponsiveness are associated with other emotional-behavioral conditions, but also can be seen without co-occurring psychopathology. With the latter, however, providers should be mindful that family-related impairments still may be quite noteworthy (J Am Acad Child Adolesc Psychiatry. 2011 Dec;50[12]:1210-9) and associated behavior problems could be attributed incorrectly to other diagnoses (which may lead to the recommendation of ineffective and inappropriate treatments). Much more research is needed to help develop a robust framework for diagnosing and labeling sensory issues in children and studying the efficacy of available intervention strategies.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic.

To the Editor:

A recent Cutis article, “Merkel Cell Carcinoma in a Vein Graft Donor Site” (Cutis. 2016;97:364-367), highlighted the localization of a Merkel cell carcinoma (MCC) within a well-healed scar resulting from a vein harvesting procedure performed 18 years prior to presentation. Their discussion focused on factors that may have contributed to the development of the MCC at that specific location. As noted by the authors, this case does not classically fit under the umbrella of a Marjolin ulcer given the stable, well-healed clinical appearance of the scar. We agree and believe it is not secondary to chance either but consistent with Wolf isotopic response.

This concept was originally described by Wyburn-Mason in 1955¹ and later revived by Wolf et al.² Wolf isotopic response describes the development of dermatologic disorders that localize to a site of another distinct and clinically healed skin disorder. Originally, it was reserved for infections, malignancies, and immune conditions restricted to a site of a prior herpetic infection but recently has been expanded to encompass other primary nonherpesvirus-related skin disorders. The pathophysiology behind this phenomenon is unknown but thought to be the interplay of several key elements including immune dysregulation, neural, vascular, and locus minoris resistentiae (ie, a site of lessened resistance).³ Immunosuppression is a known risk factor in the development of MCCs,⁴ thus the proposed local immune dysregulation within a scar may alter the virus-host balance and foster the oncogenic nature of the MCC polyomavirus. A recent article describes another case of an MCC arising within a sternotomy scar,⁵ lending further credibility to a skin vulnerability philosophy. These cases provide further insight into the pathomechanisms involved in the development of this rare and aggressive neoplasm and sheds light on an intriguing dermatologic phenomenon.

To the Editor:

A recent Cutis article, “Merkel Cell Carcinoma in a Vein Graft Donor Site” (Cutis. 2016;97:364-367), highlighted the localization of a Merkel cell carcinoma (MCC) within a well-healed scar resulting from a vein harvesting procedure performed 18 years prior to presentation. Their discussion focused on factors that may have contributed to the development of the MCC at that specific location. As noted by the authors, this case does not classically fit under the umbrella of a Marjolin ulcer given the stable, well-healed clinical appearance of the scar. We agree and believe it is not secondary to chance either but consistent with Wolf isotopic response.

This concept was originally described by Wyburn-Mason in 1955¹ and later revived by Wolf et al.² Wolf isotopic response describes the development of dermatologic disorders that localize to a site of another distinct and clinically healed skin disorder. Originally, it was reserved for infections, malignancies, and immune conditions restricted to a site of a prior herpetic infection but recently has been expanded to encompass other primary nonherpesvirus-related skin disorders. The pathophysiology behind this phenomenon is unknown but thought to be the interplay of several key elements including immune dysregulation, neural, vascular, and locus minoris resistentiae (ie, a site of lessened resistance).³ Immunosuppression is a known risk factor in the development of MCCs,⁴ thus the proposed local immune dysregulation within a scar may alter the virus-host balance and foster the oncogenic nature of the MCC polyomavirus. A recent article describes another case of an MCC arising within a sternotomy scar,⁵ lending further credibility to a skin vulnerability philosophy. These cases provide further insight into the pathomechanisms involved in the development of this rare and aggressive neoplasm and sheds light on an intriguing dermatologic phenomenon.

To the Editor:

A recent Cutis article, “Merkel Cell Carcinoma in a Vein Graft Donor Site” (Cutis. 2016;97:364-367), highlighted the localization of a Merkel cell carcinoma (MCC) within a well-healed scar resulting from a vein harvesting procedure performed 18 years prior to presentation. Their discussion focused on factors that may have contributed to the development of the MCC at that specific location. As noted by the authors, this case does not classically fit under the umbrella of a Marjolin ulcer given the stable, well-healed clinical appearance of the scar. We agree and believe it is not secondary to chance either but consistent with Wolf isotopic response.

This concept was originally described by Wyburn-Mason in 1955¹ and later revived by Wolf et al.² Wolf isotopic response describes the development of dermatologic disorders that localize to a site of another distinct and clinically healed skin disorder. Originally, it was reserved for infections, malignancies, and immune conditions restricted to a site of a prior herpetic infection but recently has been expanded to encompass other primary nonherpesvirus-related skin disorders. The pathophysiology behind this phenomenon is unknown but thought to be the interplay of several key elements including immune dysregulation, neural, vascular, and locus minoris resistentiae (ie, a site of lessened resistance).³ Immunosuppression is a known risk factor in the development of MCCs,⁴ thus the proposed local immune dysregulation within a scar may alter the virus-host balance and foster the oncogenic nature of the MCC polyomavirus. A recent article describes another case of an MCC arising within a sternotomy scar,⁵ lending further credibility to a skin vulnerability philosophy. These cases provide further insight into the pathomechanisms involved in the development of this rare and aggressive neoplasm and sheds light on an intriguing dermatologic phenomenon.

For years, we advocated to repeal the sustainable growth rate (SGR) payment formula. Congress, by passing the MACRA legislation, eliminated SGR but created a new process that links provider reimbursement to value (quality and cost). Value-based reimbursement is here to stay. We now must help CMS devise reasonable linkages that will truly improve patient care, yet keep us in business. MACRA’s final rule is an improvement over the preliminary rule published earlier this spring. Gastroenterologists that plan to practice (and accept Medicare reimbursement) must educate themselves about both the incentive portion (MIPS) and alternative payment models.

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_156.pdf

https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/

https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/

I hope you will take it to heart that we are moving into a new world of care delivery and payment. We need physician leaders and innovators to make sure this works well for our patients and our profession.

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

For years, we advocated to repeal the sustainable growth rate (SGR) payment formula. Congress, by passing the MACRA legislation, eliminated SGR but created a new process that links provider reimbursement to value (quality and cost). Value-based reimbursement is here to stay. We now must help CMS devise reasonable linkages that will truly improve patient care, yet keep us in business. MACRA’s final rule is an improvement over the preliminary rule published earlier this spring. Gastroenterologists that plan to practice (and accept Medicare reimbursement) must educate themselves about both the incentive portion (MIPS) and alternative payment models.

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_156.pdf

https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/

https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/

I hope you will take it to heart that we are moving into a new world of care delivery and payment. We need physician leaders and innovators to make sure this works well for our patients and our profession.

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

For years, we advocated to repeal the sustainable growth rate (SGR) payment formula. Congress, by passing the MACRA legislation, eliminated SGR but created a new process that links provider reimbursement to value (quality and cost). Value-based reimbursement is here to stay. We now must help CMS devise reasonable linkages that will truly improve patient care, yet keep us in business. MACRA’s final rule is an improvement over the preliminary rule published earlier this spring. Gastroenterologists that plan to practice (and accept Medicare reimbursement) must educate themselves about both the incentive portion (MIPS) and alternative payment models.

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_156.pdf

https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/

https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/

I hope you will take it to heart that we are moving into a new world of care delivery and payment. We need physician leaders and innovators to make sure this works well for our patients and our profession.

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

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

The following opinions are my own and not those of the U.S. Department of Defense.

We often lament the shortage of psychiatrists in the United States, but the problem is dire across the globe. According to the World Health Organization, in low- and middle-income countries, 45% of the population lives with less than one psychiatrist per 100,000 citizens.

For many countries, this translates into increased costs for medical care, loss of employee productivity, higher percentages of the population living in poverty, impacts to national security, and an inability to respond to disasters or war. Therefore, significant expansions of mental health approaches need to take place to extend the scope of care beyond traditional therapeutic modalities.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and suicide prevention and peer support programs; worked with Gulf War veterans; and provided individual, group, and family therapy to Vietnam veterans and their families dealing with posttraumatic stress disorder.

The following opinions are my own and not those of the U.S. Department of Defense.

We often lament the shortage of psychiatrists in the United States, but the problem is dire across the globe. According to the World Health Organization, in low- and middle-income countries, 45% of the population lives with less than one psychiatrist per 100,000 citizens.

For many countries, this translates into increased costs for medical care, loss of employee productivity, higher percentages of the population living in poverty, impacts to national security, and an inability to respond to disasters or war. Therefore, significant expansions of mental health approaches need to take place to extend the scope of care beyond traditional therapeutic modalities.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and suicide prevention and peer support programs; worked with Gulf War veterans; and provided individual, group, and family therapy to Vietnam veterans and their families dealing with posttraumatic stress disorder.

The following opinions are my own and not those of the U.S. Department of Defense.

We often lament the shortage of psychiatrists in the United States, but the problem is dire across the globe. According to the World Health Organization, in low- and middle-income countries, 45% of the population lives with less than one psychiatrist per 100,000 citizens.

For many countries, this translates into increased costs for medical care, loss of employee productivity, higher percentages of the population living in poverty, impacts to national security, and an inability to respond to disasters or war. Therefore, significant expansions of mental health approaches need to take place to extend the scope of care beyond traditional therapeutic modalities.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and suicide prevention and peer support programs; worked with Gulf War veterans; and provided individual, group, and family therapy to Vietnam veterans and their families dealing with posttraumatic stress disorder.