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Does ‘skeletal age’ describe fracture impact on mortality?
Thach Tran, MD, and colleagues introduced the concept of “skeletal age” in a recently published paper that aims to incorporate the impact of fragility, or low trauma, fractures – which can occur in patients with osteoporosis – on mortality risk.
They defined “skeletal age” as the age of the skeleton following a fragility fracture. This is calculated as the chronological age of the individual plus the number of years of “life lost” as a consequence of the specific fracture.
The risk for premature death following fragility fractures is concerning, with 22%-58% of patients with hip fracture dying within a year (Brauer et al.; Rapp et al.). Thus, it’s important to treat osteoporosis in a timely fashion to reduce the risk for such fractures and the excess mortality risk associated with them.
Implementation and uptake of such treatment, however, either before or after a fragility fracture, is far from optimal (Solomon et al). This may be because patients don’t fully understand the consequence of such a fracture, and outcomes measures currently in use (such as relative risk or hazard of mortality) are difficult to communicate to patients.
In the recent paper by Dr. Tran and colleagues, the authors examined the association between fractures and mortality based on sex, age, associated comorbidities, and fracture site. They pooled this information to create a “skeletal age” for each fracture site, using data from the Danish National Hospital Discharge Registry, which documents fractures and related mortality for all Danish people.
They examined mortality over a period of at least 2 years following a fragility fracture in individuals aged 50 or older, and reported that occurrence of any fragility fracture is associated with a 30%-45% increased risk for death, with the highest risk noted for hip and femur fractures (twofold increase). Fractures of the pelvis, vertebrae, humerus, ribs, clavicle, and lower leg were also associated with increased mortality risk, but no increase was seen with fractures of the forearm, knee, ankle, hand, or foot.
The number of years of life lost at any age depending on the fracture site is represented as a linear graph of skeletal age for any chronological age, for specific fracture sites, separated by sex.
For example, the skeletal age of a 50-year-old man who has a hip fracture is 57 years (7 years of life lost as a consequence of the fracture), while that for a 70-year-old man with the same fracture is 75 years (5 years of life lost because of the fracture). Similarly, the skeletal age of a 50-year-old man with a fracture of the pelvis, femur, vertebrae, and humerus is 55 years (5 years of life lost). Fractures of the lower leg, humerus, and clavicle lead to fewer lost years of life.
The authors are to be commended for creating a simple strategy to quantify mortality risk following low-impact or fragility fractures in older individuals; this could enable providers to communicate the importance of osteoporosis treatment more effectively to patients on the basis of their skeletal age, and for patients to better understand this information.
The study design appears reasonably robust as the authors considered many factors that might affect mortality risk, such as sex, age, and comorbidities, and the results are based on information from a very large number of people – 1.6 million.
However, there’s a major issue with the concept of “skeletal age” as proposed by Dr. Tran and colleagues. The term is already in use and defines the maturity of bones in children and adolescents, also called “bone age” (Greulich and Pyle 1959; Skeletal Age, Radiology Key). This is a real oversight and could cause confusion in interpreting “skeletal age.”
Skeletal age as currently defined in children and adolescents is influenced by chronological age, exposure to certain hormones, nutritional deficiencies, and systemic diseases, and is a predictor of adult height based on the skeletal age and current height. This concept is completely different from that being proposed by the authors in this paper. Dr. Tran and colleagues (and the reviewers of this paper) are probably not familiar with the use of the terminology in youth, which is a major oversight; they should consider changing the terminology given this overlap.
Further, fragility fractures can occur from osteoporosis at any age, and this study doesn’t provide information regarding years of life lost from occurrence of fragility fractures at younger ages, or the age at which mortality risk starts to increase (as the study was performed only in those aged 50 or older).
While the study takes into account general comorbidities in developing the model to define years of life lost, it doesn’t account for other factors that can influence fracture risk, such as lifestyle factors, activity level, and genetic risk (family history of osteoporosis, for example). Of note, the impact of additional fractures isn’t considered either and should be factored into future investigations.
Overall, the study is robust and important and provides valuable information regarding mortality risk from a fragility fracture in older people. However, there are some flaws that need to be considered and addressed, the most serious of which is that the term “skeletal age” has been in existence for decades, applied to a much younger age group, and its implications are completely different from those being proposed by the authors here.
A version of this article first appeared on Medscape.com.
Thach Tran, MD, and colleagues introduced the concept of “skeletal age” in a recently published paper that aims to incorporate the impact of fragility, or low trauma, fractures – which can occur in patients with osteoporosis – on mortality risk.
They defined “skeletal age” as the age of the skeleton following a fragility fracture. This is calculated as the chronological age of the individual plus the number of years of “life lost” as a consequence of the specific fracture.
The risk for premature death following fragility fractures is concerning, with 22%-58% of patients with hip fracture dying within a year (Brauer et al.; Rapp et al.). Thus, it’s important to treat osteoporosis in a timely fashion to reduce the risk for such fractures and the excess mortality risk associated with them.
Implementation and uptake of such treatment, however, either before or after a fragility fracture, is far from optimal (Solomon et al). This may be because patients don’t fully understand the consequence of such a fracture, and outcomes measures currently in use (such as relative risk or hazard of mortality) are difficult to communicate to patients.
In the recent paper by Dr. Tran and colleagues, the authors examined the association between fractures and mortality based on sex, age, associated comorbidities, and fracture site. They pooled this information to create a “skeletal age” for each fracture site, using data from the Danish National Hospital Discharge Registry, which documents fractures and related mortality for all Danish people.
They examined mortality over a period of at least 2 years following a fragility fracture in individuals aged 50 or older, and reported that occurrence of any fragility fracture is associated with a 30%-45% increased risk for death, with the highest risk noted for hip and femur fractures (twofold increase). Fractures of the pelvis, vertebrae, humerus, ribs, clavicle, and lower leg were also associated with increased mortality risk, but no increase was seen with fractures of the forearm, knee, ankle, hand, or foot.
The number of years of life lost at any age depending on the fracture site is represented as a linear graph of skeletal age for any chronological age, for specific fracture sites, separated by sex.
For example, the skeletal age of a 50-year-old man who has a hip fracture is 57 years (7 years of life lost as a consequence of the fracture), while that for a 70-year-old man with the same fracture is 75 years (5 years of life lost because of the fracture). Similarly, the skeletal age of a 50-year-old man with a fracture of the pelvis, femur, vertebrae, and humerus is 55 years (5 years of life lost). Fractures of the lower leg, humerus, and clavicle lead to fewer lost years of life.
The authors are to be commended for creating a simple strategy to quantify mortality risk following low-impact or fragility fractures in older individuals; this could enable providers to communicate the importance of osteoporosis treatment more effectively to patients on the basis of their skeletal age, and for patients to better understand this information.
The study design appears reasonably robust as the authors considered many factors that might affect mortality risk, such as sex, age, and comorbidities, and the results are based on information from a very large number of people – 1.6 million.
However, there’s a major issue with the concept of “skeletal age” as proposed by Dr. Tran and colleagues. The term is already in use and defines the maturity of bones in children and adolescents, also called “bone age” (Greulich and Pyle 1959; Skeletal Age, Radiology Key). This is a real oversight and could cause confusion in interpreting “skeletal age.”
Skeletal age as currently defined in children and adolescents is influenced by chronological age, exposure to certain hormones, nutritional deficiencies, and systemic diseases, and is a predictor of adult height based on the skeletal age and current height. This concept is completely different from that being proposed by the authors in this paper. Dr. Tran and colleagues (and the reviewers of this paper) are probably not familiar with the use of the terminology in youth, which is a major oversight; they should consider changing the terminology given this overlap.
Further, fragility fractures can occur from osteoporosis at any age, and this study doesn’t provide information regarding years of life lost from occurrence of fragility fractures at younger ages, or the age at which mortality risk starts to increase (as the study was performed only in those aged 50 or older).
While the study takes into account general comorbidities in developing the model to define years of life lost, it doesn’t account for other factors that can influence fracture risk, such as lifestyle factors, activity level, and genetic risk (family history of osteoporosis, for example). Of note, the impact of additional fractures isn’t considered either and should be factored into future investigations.
Overall, the study is robust and important and provides valuable information regarding mortality risk from a fragility fracture in older people. However, there are some flaws that need to be considered and addressed, the most serious of which is that the term “skeletal age” has been in existence for decades, applied to a much younger age group, and its implications are completely different from those being proposed by the authors here.
A version of this article first appeared on Medscape.com.
Thach Tran, MD, and colleagues introduced the concept of “skeletal age” in a recently published paper that aims to incorporate the impact of fragility, or low trauma, fractures – which can occur in patients with osteoporosis – on mortality risk.
They defined “skeletal age” as the age of the skeleton following a fragility fracture. This is calculated as the chronological age of the individual plus the number of years of “life lost” as a consequence of the specific fracture.
The risk for premature death following fragility fractures is concerning, with 22%-58% of patients with hip fracture dying within a year (Brauer et al.; Rapp et al.). Thus, it’s important to treat osteoporosis in a timely fashion to reduce the risk for such fractures and the excess mortality risk associated with them.
Implementation and uptake of such treatment, however, either before or after a fragility fracture, is far from optimal (Solomon et al). This may be because patients don’t fully understand the consequence of such a fracture, and outcomes measures currently in use (such as relative risk or hazard of mortality) are difficult to communicate to patients.
In the recent paper by Dr. Tran and colleagues, the authors examined the association between fractures and mortality based on sex, age, associated comorbidities, and fracture site. They pooled this information to create a “skeletal age” for each fracture site, using data from the Danish National Hospital Discharge Registry, which documents fractures and related mortality for all Danish people.
They examined mortality over a period of at least 2 years following a fragility fracture in individuals aged 50 or older, and reported that occurrence of any fragility fracture is associated with a 30%-45% increased risk for death, with the highest risk noted for hip and femur fractures (twofold increase). Fractures of the pelvis, vertebrae, humerus, ribs, clavicle, and lower leg were also associated with increased mortality risk, but no increase was seen with fractures of the forearm, knee, ankle, hand, or foot.
The number of years of life lost at any age depending on the fracture site is represented as a linear graph of skeletal age for any chronological age, for specific fracture sites, separated by sex.
For example, the skeletal age of a 50-year-old man who has a hip fracture is 57 years (7 years of life lost as a consequence of the fracture), while that for a 70-year-old man with the same fracture is 75 years (5 years of life lost because of the fracture). Similarly, the skeletal age of a 50-year-old man with a fracture of the pelvis, femur, vertebrae, and humerus is 55 years (5 years of life lost). Fractures of the lower leg, humerus, and clavicle lead to fewer lost years of life.
The authors are to be commended for creating a simple strategy to quantify mortality risk following low-impact or fragility fractures in older individuals; this could enable providers to communicate the importance of osteoporosis treatment more effectively to patients on the basis of their skeletal age, and for patients to better understand this information.
The study design appears reasonably robust as the authors considered many factors that might affect mortality risk, such as sex, age, and comorbidities, and the results are based on information from a very large number of people – 1.6 million.
However, there’s a major issue with the concept of “skeletal age” as proposed by Dr. Tran and colleagues. The term is already in use and defines the maturity of bones in children and adolescents, also called “bone age” (Greulich and Pyle 1959; Skeletal Age, Radiology Key). This is a real oversight and could cause confusion in interpreting “skeletal age.”
Skeletal age as currently defined in children and adolescents is influenced by chronological age, exposure to certain hormones, nutritional deficiencies, and systemic diseases, and is a predictor of adult height based on the skeletal age and current height. This concept is completely different from that being proposed by the authors in this paper. Dr. Tran and colleagues (and the reviewers of this paper) are probably not familiar with the use of the terminology in youth, which is a major oversight; they should consider changing the terminology given this overlap.
Further, fragility fractures can occur from osteoporosis at any age, and this study doesn’t provide information regarding years of life lost from occurrence of fragility fractures at younger ages, or the age at which mortality risk starts to increase (as the study was performed only in those aged 50 or older).
While the study takes into account general comorbidities in developing the model to define years of life lost, it doesn’t account for other factors that can influence fracture risk, such as lifestyle factors, activity level, and genetic risk (family history of osteoporosis, for example). Of note, the impact of additional fractures isn’t considered either and should be factored into future investigations.
Overall, the study is robust and important and provides valuable information regarding mortality risk from a fragility fracture in older people. However, there are some flaws that need to be considered and addressed, the most serious of which is that the term “skeletal age” has been in existence for decades, applied to a much younger age group, and its implications are completely different from those being proposed by the authors here.
A version of this article first appeared on Medscape.com.
DDW 2023: Common GI conditions in primary care
This transcript has been edited for clarity.
Hello and welcome. I am Vivek Kaul, MD, from the University of Rochester (N.Y.) Medical Center. It gives me great pleasure, once again, to collaborate with WebMD and Medscape to present this video capsule.
This time, we have picked the best GI and GI surgery papers from the recently concluded Digestive Disease Week 2023 international meeting in Chicago. For this edition of the Medscape GI/Primary Care video capsule, I thought it would be nice to present a couple of GI surgical papers that have major impact on common GI conditions seen in primary care.
This first paper in the GI surgery realm is “Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study.” This comes to us from the Mayo Clinic in Rochester, Minn.
This was a retrospective study of 329 patients who had type 2 diabetes, who underwent either Roux-en-Y gastric bypass (two-thirds of them) or a surgical sleeve gastrectomy (about one third of them). The mean follow-up was about 6 years. Type 2 diabetes remission was seen in about half of them in this long-term follow-up.
There were significant improvements in hemoglobin A1c, fasting blood glucose, diabetes, and, of course, weight loss – and all were statistically significant. The type of surgery did not seem to make any difference. Both groups really benefited from this.
The take-home point of this study is that patients who have a high BMI and metabolic syndrome, whether they undergo Roux-en-Y gastric bypass or sleeve gastrectomy, should expect to see long-term, durable, positive impact on their diabetes, as well as weight loss, of course, and all the metrics for blood glucose and hemodynamics.
This is an important study and helps us in counseling patients appropriately when they present for selection for these types of surgeries in the appropriate clinical context.
The next paper in the surgical realm is from the University of Padova (Italy), which is “Antireflux Surgery’s Lifespan: 20 Years After Laparoscopic Fundoplication.” This is a prospective study of 137 patients who underwent laparoscopic fundoplication for the management of gastroesophageal reflux disease (n = 107) or a large hiatal hernia (n = 30).
The median follow-up in this study was 22 years, which is among the longest I’ve seen in recent years for any study. A very small percentage of patients underwent revision surgery, which speaks to the skill set and careful selection of the patient cohort.
Only nine patients of 137 had repeat surgeries. Positive outcomes, on the other hand, were seen in the vast majority of patients with reflux, at 84%, and still, two thirds of patients with hiatal hernia had positive outcomes over the long term.
Failure-free survival was much higher for the gastroesophageal reflux cohort, as expected, compared with the hiatal hernia cohort. Patient satisfaction after two decades was almost 90% both for reflux and for hiatal hernia, which is quite a significant milestone.
The take-home point from this study is that laparoscopic fundoplication is quite durable, with success rates approaching 90%, even 2 decades after the surgical intervention. This is quite an important data point for us to discuss with patients when they present with a question around surgery for these indications. Although, as we know well in the era of PPI therapy, surgical indications are definitely reduced, compared with 20 years ago.
The next paper in this group is related to another very important clinical entity, which is acute pancreatitis and the question of pancreatic cancer in those patients who present with acute pancreatitis.
Our previous work in this realm, published a couple of years ago, suggested that about 3% of patients who come to the hospital with acute pancreatitis may harbor pancreatic malignancy, which can be picked up if we do a diligent follow-up with cross-sectional imaging and endoscopic ultrasound.
This paper talks about acute pancreatitis and the modeling of risk in terms of prediction for early cancer. This study was conducted at the University of Pennsylvania and basically speaks to a clinical prediction model to assess the risk for pancreatic cancer after acute pancreatitis diagnosis.
As we know, the risk for pancreatic cancer is highest within 2 years of the initial presentation of acute pancreatitis, especially if the etiology of that pancreatitis was unclear. In this clinical prediction model, as shown on this slide, a variety of demographic and clinical criteria were used, all of which are easily accessible to us in GI and in primary care to calculate the modeling risk.
A large number of patients were used to apply this model: 51,613 patients. The mean age was 62%, the overwhelming majority were male, and half were Caucasian. Using this clinical prediction model, a 2-year incidence of pancreatic ductal adenocarcinoma was calculated to be 1.6% for an absolute number of 800 cases.
Nearly 50% were discovered after 3 months. There was a positive association with pancreatic cystic disease in these patients, which makes sense in terms of their preneoplastic potential.
The take-home point from this study is that readily available demographic and clinical criteria may be useful in helping us predict diagnosis of early pancreatic cancer in a subset of patients who present with acute pancreatitis, and in my opinion, particularly those who present with pancreatitis for which we cannot explain the etiology.
The next paper we have refers to a very common problem, which is Helicobacter pylori infection. This is almost an endemic problem in the Far East and in the third world, but also an increasing problem in the United States.
This particular study comes to us from Taiwan and is looking at different treatment strategies for H. pylori infection. In Taiwan and the Far East, it has been proposed that high acid content in the food might be interfering with efficacy rates. The consideration for antibiotic resistance may be an issue as well. That’s in the background of this paper.
This paper is titled “Enhanced Efficacy of Combined Bismuth and High-Dose Dual Therapy versus High-Dose Dual Therapy Alone or Quadruple Therapy for First-Line H pylori Eradication.” This was an interim report from a large multicenter, randomized controlled trial and included 436 patients with H. pylori infection.
Each patient had biopsies with H. pylori cultures, and they were randomized to one of three regimens as listed here. They received high-dose dual therapy or bismuth along with high-dose dual therapy – so, triple therapy – or they received the amoxicillin-based bismuth and quadruple-therapy regimen. Breath tests were used to check for eradication at the end of the treatment period.
In terms of the results from this study, it’s very clear that the bismuth-based regimen, which is listed here in the middle column, had the highest treatment efficacy rates and moderate adverse event rates when compared with the other two arms.
Reduced eradication in the dual-therapy arm was seen probably due to increased acid food intake. Reduced eradication in the quadruple-therapy arm was likely associated with antibiotic resistance and also with poor compliance, which is understandable when you have more medications to take compared with the group that has fewer medications to take.
The take-home point from this study was that the addition of bismuth might be the silver bullet when you add that to the dual-therapy regimen in difficult cases of H pylori infection. More to come on this, and certainly of relevance to us here as we tackle more and more cases of H. pylori infection stateside.
Last but not least, GI and primary care discussions can never be complete without a discussion on colorectal cancer screening. As the NordICC trial has shown us, it’s not the issue with the screening modality but more about patients’ acceptance of screening, particularly invasive screening.
This paper looked at different strategies and tried to figure out which strategy would be most attractive to bring more people in for screening. This is a large, randomized controlled trial with good distribution of patient populations with approximately half female, half White, and a mean age around 48 years, with more than 20,000 patients.
One of four screening strategies was used. Patients were invited for a fecal immunochemical test, a colonoscopy, or they were invited to choose between a FIT test and a colonoscopy. The final group was mailed a FIT test kit as an outreach mechanism.
Invitations were sent via electronic patient portals, which are very common nowadays, and via the United States Postal Service. Text-message reminders were sent a couple of weeks later. The primary outcome of this study was to look at any colorectal cancer completion rate at 26 weeks.
The results of the study were quite interesting. Screening completion rates were relatively low at 18%. It was interesting to note that the highest screening rates were seen with those who had the FIT test mailed to them, whereas each of the other three groups that had only invitations sent to them had relatively lower screening compliance rates.
The lowest participation was in the colonoscopy invitation group, I suspect due to the invasive nature of the procedure and the patients’ perception of that. When patients were offered a choice, they were more likely to be compliant with screening. In the end, more patients chose colonoscopy as their screening test of choice compared with FIT testing.
The take-home point from this study is that directly sending test kits as an outreach might be more effective than simply inviting subjects to be screened. From those who do respond to be screened, more patients would choose colonoscopy, compared with the FIT test.
With that, I come to the end of this video capsule summary for the Best of GI for Primary Care from DDW 2023. We covered a variety of topics, ranging from pancreatitis to H pylori to colon cancer screening and a couple of GI surgical interventions with long-term outcomes that are very favorable.
Dr. Kaul disclosed conflicts of interest with AMBU, Cook Medical, CDS, CDX,Steris, and Motus GI.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hello and welcome. I am Vivek Kaul, MD, from the University of Rochester (N.Y.) Medical Center. It gives me great pleasure, once again, to collaborate with WebMD and Medscape to present this video capsule.
This time, we have picked the best GI and GI surgery papers from the recently concluded Digestive Disease Week 2023 international meeting in Chicago. For this edition of the Medscape GI/Primary Care video capsule, I thought it would be nice to present a couple of GI surgical papers that have major impact on common GI conditions seen in primary care.
This first paper in the GI surgery realm is “Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study.” This comes to us from the Mayo Clinic in Rochester, Minn.
This was a retrospective study of 329 patients who had type 2 diabetes, who underwent either Roux-en-Y gastric bypass (two-thirds of them) or a surgical sleeve gastrectomy (about one third of them). The mean follow-up was about 6 years. Type 2 diabetes remission was seen in about half of them in this long-term follow-up.
There were significant improvements in hemoglobin A1c, fasting blood glucose, diabetes, and, of course, weight loss – and all were statistically significant. The type of surgery did not seem to make any difference. Both groups really benefited from this.
The take-home point of this study is that patients who have a high BMI and metabolic syndrome, whether they undergo Roux-en-Y gastric bypass or sleeve gastrectomy, should expect to see long-term, durable, positive impact on their diabetes, as well as weight loss, of course, and all the metrics for blood glucose and hemodynamics.
This is an important study and helps us in counseling patients appropriately when they present for selection for these types of surgeries in the appropriate clinical context.
The next paper in the surgical realm is from the University of Padova (Italy), which is “Antireflux Surgery’s Lifespan: 20 Years After Laparoscopic Fundoplication.” This is a prospective study of 137 patients who underwent laparoscopic fundoplication for the management of gastroesophageal reflux disease (n = 107) or a large hiatal hernia (n = 30).
The median follow-up in this study was 22 years, which is among the longest I’ve seen in recent years for any study. A very small percentage of patients underwent revision surgery, which speaks to the skill set and careful selection of the patient cohort.
Only nine patients of 137 had repeat surgeries. Positive outcomes, on the other hand, were seen in the vast majority of patients with reflux, at 84%, and still, two thirds of patients with hiatal hernia had positive outcomes over the long term.
Failure-free survival was much higher for the gastroesophageal reflux cohort, as expected, compared with the hiatal hernia cohort. Patient satisfaction after two decades was almost 90% both for reflux and for hiatal hernia, which is quite a significant milestone.
The take-home point from this study is that laparoscopic fundoplication is quite durable, with success rates approaching 90%, even 2 decades after the surgical intervention. This is quite an important data point for us to discuss with patients when they present with a question around surgery for these indications. Although, as we know well in the era of PPI therapy, surgical indications are definitely reduced, compared with 20 years ago.
The next paper in this group is related to another very important clinical entity, which is acute pancreatitis and the question of pancreatic cancer in those patients who present with acute pancreatitis.
Our previous work in this realm, published a couple of years ago, suggested that about 3% of patients who come to the hospital with acute pancreatitis may harbor pancreatic malignancy, which can be picked up if we do a diligent follow-up with cross-sectional imaging and endoscopic ultrasound.
This paper talks about acute pancreatitis and the modeling of risk in terms of prediction for early cancer. This study was conducted at the University of Pennsylvania and basically speaks to a clinical prediction model to assess the risk for pancreatic cancer after acute pancreatitis diagnosis.
As we know, the risk for pancreatic cancer is highest within 2 years of the initial presentation of acute pancreatitis, especially if the etiology of that pancreatitis was unclear. In this clinical prediction model, as shown on this slide, a variety of demographic and clinical criteria were used, all of which are easily accessible to us in GI and in primary care to calculate the modeling risk.
A large number of patients were used to apply this model: 51,613 patients. The mean age was 62%, the overwhelming majority were male, and half were Caucasian. Using this clinical prediction model, a 2-year incidence of pancreatic ductal adenocarcinoma was calculated to be 1.6% for an absolute number of 800 cases.
Nearly 50% were discovered after 3 months. There was a positive association with pancreatic cystic disease in these patients, which makes sense in terms of their preneoplastic potential.
The take-home point from this study is that readily available demographic and clinical criteria may be useful in helping us predict diagnosis of early pancreatic cancer in a subset of patients who present with acute pancreatitis, and in my opinion, particularly those who present with pancreatitis for which we cannot explain the etiology.
The next paper we have refers to a very common problem, which is Helicobacter pylori infection. This is almost an endemic problem in the Far East and in the third world, but also an increasing problem in the United States.
This particular study comes to us from Taiwan and is looking at different treatment strategies for H. pylori infection. In Taiwan and the Far East, it has been proposed that high acid content in the food might be interfering with efficacy rates. The consideration for antibiotic resistance may be an issue as well. That’s in the background of this paper.
This paper is titled “Enhanced Efficacy of Combined Bismuth and High-Dose Dual Therapy versus High-Dose Dual Therapy Alone or Quadruple Therapy for First-Line H pylori Eradication.” This was an interim report from a large multicenter, randomized controlled trial and included 436 patients with H. pylori infection.
Each patient had biopsies with H. pylori cultures, and they were randomized to one of three regimens as listed here. They received high-dose dual therapy or bismuth along with high-dose dual therapy – so, triple therapy – or they received the amoxicillin-based bismuth and quadruple-therapy regimen. Breath tests were used to check for eradication at the end of the treatment period.
In terms of the results from this study, it’s very clear that the bismuth-based regimen, which is listed here in the middle column, had the highest treatment efficacy rates and moderate adverse event rates when compared with the other two arms.
Reduced eradication in the dual-therapy arm was seen probably due to increased acid food intake. Reduced eradication in the quadruple-therapy arm was likely associated with antibiotic resistance and also with poor compliance, which is understandable when you have more medications to take compared with the group that has fewer medications to take.
The take-home point from this study was that the addition of bismuth might be the silver bullet when you add that to the dual-therapy regimen in difficult cases of H pylori infection. More to come on this, and certainly of relevance to us here as we tackle more and more cases of H. pylori infection stateside.
Last but not least, GI and primary care discussions can never be complete without a discussion on colorectal cancer screening. As the NordICC trial has shown us, it’s not the issue with the screening modality but more about patients’ acceptance of screening, particularly invasive screening.
This paper looked at different strategies and tried to figure out which strategy would be most attractive to bring more people in for screening. This is a large, randomized controlled trial with good distribution of patient populations with approximately half female, half White, and a mean age around 48 years, with more than 20,000 patients.
One of four screening strategies was used. Patients were invited for a fecal immunochemical test, a colonoscopy, or they were invited to choose between a FIT test and a colonoscopy. The final group was mailed a FIT test kit as an outreach mechanism.
Invitations were sent via electronic patient portals, which are very common nowadays, and via the United States Postal Service. Text-message reminders were sent a couple of weeks later. The primary outcome of this study was to look at any colorectal cancer completion rate at 26 weeks.
The results of the study were quite interesting. Screening completion rates were relatively low at 18%. It was interesting to note that the highest screening rates were seen with those who had the FIT test mailed to them, whereas each of the other three groups that had only invitations sent to them had relatively lower screening compliance rates.
The lowest participation was in the colonoscopy invitation group, I suspect due to the invasive nature of the procedure and the patients’ perception of that. When patients were offered a choice, they were more likely to be compliant with screening. In the end, more patients chose colonoscopy as their screening test of choice compared with FIT testing.
The take-home point from this study is that directly sending test kits as an outreach might be more effective than simply inviting subjects to be screened. From those who do respond to be screened, more patients would choose colonoscopy, compared with the FIT test.
With that, I come to the end of this video capsule summary for the Best of GI for Primary Care from DDW 2023. We covered a variety of topics, ranging from pancreatitis to H pylori to colon cancer screening and a couple of GI surgical interventions with long-term outcomes that are very favorable.
Dr. Kaul disclosed conflicts of interest with AMBU, Cook Medical, CDS, CDX,Steris, and Motus GI.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hello and welcome. I am Vivek Kaul, MD, from the University of Rochester (N.Y.) Medical Center. It gives me great pleasure, once again, to collaborate with WebMD and Medscape to present this video capsule.
This time, we have picked the best GI and GI surgery papers from the recently concluded Digestive Disease Week 2023 international meeting in Chicago. For this edition of the Medscape GI/Primary Care video capsule, I thought it would be nice to present a couple of GI surgical papers that have major impact on common GI conditions seen in primary care.
This first paper in the GI surgery realm is “Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study.” This comes to us from the Mayo Clinic in Rochester, Minn.
This was a retrospective study of 329 patients who had type 2 diabetes, who underwent either Roux-en-Y gastric bypass (two-thirds of them) or a surgical sleeve gastrectomy (about one third of them). The mean follow-up was about 6 years. Type 2 diabetes remission was seen in about half of them in this long-term follow-up.
There were significant improvements in hemoglobin A1c, fasting blood glucose, diabetes, and, of course, weight loss – and all were statistically significant. The type of surgery did not seem to make any difference. Both groups really benefited from this.
The take-home point of this study is that patients who have a high BMI and metabolic syndrome, whether they undergo Roux-en-Y gastric bypass or sleeve gastrectomy, should expect to see long-term, durable, positive impact on their diabetes, as well as weight loss, of course, and all the metrics for blood glucose and hemodynamics.
This is an important study and helps us in counseling patients appropriately when they present for selection for these types of surgeries in the appropriate clinical context.
The next paper in the surgical realm is from the University of Padova (Italy), which is “Antireflux Surgery’s Lifespan: 20 Years After Laparoscopic Fundoplication.” This is a prospective study of 137 patients who underwent laparoscopic fundoplication for the management of gastroesophageal reflux disease (n = 107) or a large hiatal hernia (n = 30).
The median follow-up in this study was 22 years, which is among the longest I’ve seen in recent years for any study. A very small percentage of patients underwent revision surgery, which speaks to the skill set and careful selection of the patient cohort.
Only nine patients of 137 had repeat surgeries. Positive outcomes, on the other hand, were seen in the vast majority of patients with reflux, at 84%, and still, two thirds of patients with hiatal hernia had positive outcomes over the long term.
Failure-free survival was much higher for the gastroesophageal reflux cohort, as expected, compared with the hiatal hernia cohort. Patient satisfaction after two decades was almost 90% both for reflux and for hiatal hernia, which is quite a significant milestone.
The take-home point from this study is that laparoscopic fundoplication is quite durable, with success rates approaching 90%, even 2 decades after the surgical intervention. This is quite an important data point for us to discuss with patients when they present with a question around surgery for these indications. Although, as we know well in the era of PPI therapy, surgical indications are definitely reduced, compared with 20 years ago.
The next paper in this group is related to another very important clinical entity, which is acute pancreatitis and the question of pancreatic cancer in those patients who present with acute pancreatitis.
Our previous work in this realm, published a couple of years ago, suggested that about 3% of patients who come to the hospital with acute pancreatitis may harbor pancreatic malignancy, which can be picked up if we do a diligent follow-up with cross-sectional imaging and endoscopic ultrasound.
This paper talks about acute pancreatitis and the modeling of risk in terms of prediction for early cancer. This study was conducted at the University of Pennsylvania and basically speaks to a clinical prediction model to assess the risk for pancreatic cancer after acute pancreatitis diagnosis.
As we know, the risk for pancreatic cancer is highest within 2 years of the initial presentation of acute pancreatitis, especially if the etiology of that pancreatitis was unclear. In this clinical prediction model, as shown on this slide, a variety of demographic and clinical criteria were used, all of which are easily accessible to us in GI and in primary care to calculate the modeling risk.
A large number of patients were used to apply this model: 51,613 patients. The mean age was 62%, the overwhelming majority were male, and half were Caucasian. Using this clinical prediction model, a 2-year incidence of pancreatic ductal adenocarcinoma was calculated to be 1.6% for an absolute number of 800 cases.
Nearly 50% were discovered after 3 months. There was a positive association with pancreatic cystic disease in these patients, which makes sense in terms of their preneoplastic potential.
The take-home point from this study is that readily available demographic and clinical criteria may be useful in helping us predict diagnosis of early pancreatic cancer in a subset of patients who present with acute pancreatitis, and in my opinion, particularly those who present with pancreatitis for which we cannot explain the etiology.
The next paper we have refers to a very common problem, which is Helicobacter pylori infection. This is almost an endemic problem in the Far East and in the third world, but also an increasing problem in the United States.
This particular study comes to us from Taiwan and is looking at different treatment strategies for H. pylori infection. In Taiwan and the Far East, it has been proposed that high acid content in the food might be interfering with efficacy rates. The consideration for antibiotic resistance may be an issue as well. That’s in the background of this paper.
This paper is titled “Enhanced Efficacy of Combined Bismuth and High-Dose Dual Therapy versus High-Dose Dual Therapy Alone or Quadruple Therapy for First-Line H pylori Eradication.” This was an interim report from a large multicenter, randomized controlled trial and included 436 patients with H. pylori infection.
Each patient had biopsies with H. pylori cultures, and they were randomized to one of three regimens as listed here. They received high-dose dual therapy or bismuth along with high-dose dual therapy – so, triple therapy – or they received the amoxicillin-based bismuth and quadruple-therapy regimen. Breath tests were used to check for eradication at the end of the treatment period.
In terms of the results from this study, it’s very clear that the bismuth-based regimen, which is listed here in the middle column, had the highest treatment efficacy rates and moderate adverse event rates when compared with the other two arms.
Reduced eradication in the dual-therapy arm was seen probably due to increased acid food intake. Reduced eradication in the quadruple-therapy arm was likely associated with antibiotic resistance and also with poor compliance, which is understandable when you have more medications to take compared with the group that has fewer medications to take.
The take-home point from this study was that the addition of bismuth might be the silver bullet when you add that to the dual-therapy regimen in difficult cases of H pylori infection. More to come on this, and certainly of relevance to us here as we tackle more and more cases of H. pylori infection stateside.
Last but not least, GI and primary care discussions can never be complete without a discussion on colorectal cancer screening. As the NordICC trial has shown us, it’s not the issue with the screening modality but more about patients’ acceptance of screening, particularly invasive screening.
This paper looked at different strategies and tried to figure out which strategy would be most attractive to bring more people in for screening. This is a large, randomized controlled trial with good distribution of patient populations with approximately half female, half White, and a mean age around 48 years, with more than 20,000 patients.
One of four screening strategies was used. Patients were invited for a fecal immunochemical test, a colonoscopy, or they were invited to choose between a FIT test and a colonoscopy. The final group was mailed a FIT test kit as an outreach mechanism.
Invitations were sent via electronic patient portals, which are very common nowadays, and via the United States Postal Service. Text-message reminders were sent a couple of weeks later. The primary outcome of this study was to look at any colorectal cancer completion rate at 26 weeks.
The results of the study were quite interesting. Screening completion rates were relatively low at 18%. It was interesting to note that the highest screening rates were seen with those who had the FIT test mailed to them, whereas each of the other three groups that had only invitations sent to them had relatively lower screening compliance rates.
The lowest participation was in the colonoscopy invitation group, I suspect due to the invasive nature of the procedure and the patients’ perception of that. When patients were offered a choice, they were more likely to be compliant with screening. In the end, more patients chose colonoscopy as their screening test of choice compared with FIT testing.
The take-home point from this study is that directly sending test kits as an outreach might be more effective than simply inviting subjects to be screened. From those who do respond to be screened, more patients would choose colonoscopy, compared with the FIT test.
With that, I come to the end of this video capsule summary for the Best of GI for Primary Care from DDW 2023. We covered a variety of topics, ranging from pancreatitis to H pylori to colon cancer screening and a couple of GI surgical interventions with long-term outcomes that are very favorable.
Dr. Kaul disclosed conflicts of interest with AMBU, Cook Medical, CDS, CDX,Steris, and Motus GI.
A version of this article first appeared on Medscape.com.
Ruptured aneurysm turns MD couple into doctor-patient
Dr. Taylor Delgado: It was Saturday night, and we had just gone to bed. Suddenly, Ali sat up, and screamed, “My head!” She then became nonresponsive and had a seizure. I was in disbelief, but I also knew exactly what was happening. I called 911: “My wife is having a head bleed. I need an ambulance.” It was a bad connection, and they could barely understand me.
As I tried to carry Ali downstairs, she vomited. She still had rubber bands in her mouth from the jaw fracture that was a result of her accident just a month ago. I knew she needed an airway.
I grabbed a tracheostomy tube, but the opening over her trachea put in for the accident had since closed. I tried to push the tube through her neck, but it hurt her; her eyes opened.
I thought to myself: Maybe she doesn’t need it. This can wait until she gets to the hospital. I can’t do this to her. But she vomited again, and I knew what I had to do.
We were at the top of our stairs. I didn’t have a blade or any other equipment, just the tracheostomy tube with the dilator. I pushed hard, and she started fighting me. I had to hold her hands away with one arm. The tube popped in and she stared back at me in pain and fear.
I finally got her downstairs and called medical control at University Hospital of Cincinnati. I was able to speak with one of the attendings: “Ali’s aneurysm ruptured, and she just had a seizure. She has a GCS of 11 or 12. I replaced her tracheostomy tube. We’ll be there shortly.”
When I heard sirens come down our street, I carried Ali outside, but the sirens were from a firetruck. They likely assumed someone had fallen and had a head laceration. It was beyond deflating. I yelled incredulously: “We need an ambulance here now!”
When the ambulance finally arrived, they tried to tell me that I could not ride with them. Or if I did, I would have to sit up front. After arguing back and forth for a few seconds, I finally demanded: “This is medical control. This is MD-88, and this is my patient. I’m sitting in back with you. She needs four Zofran and two midazolam IV now.”
One month earlier ...
Dr. Alison Delgado: Taylor and I were both 4 months into our second year of residency, and we had been married for 5 months. I was a pediatric resident at Cincinnati Children’s Hospital. She was an emergency medicine resident at the University Hospital. I was having my first day off in a couple weeks, and she was working a shift in the emergency department. She was also a part of the flight crew that day. Second-year residents would go out to the scenes of accidents or to other hospitals to transport the patient back to their Level I trauma center via helicopter. The resident was the physician and considered the leader on these flights.
That afternoon, I went for a bicycle ride. About three-quarters of the way through my ride, I was struck by a car.
The EMS crew got to me fairly quickly. They intubated me at the scene and got me to the closest hospital. Immediately, the hospital realized my case was outside the scope of their care. They contacted University Hospital requesting that their flight crew come to transport me.
Dr. Taylor Delgado: At around 5:30 p.m. the day of my shift, the tones went out on the radio: “AirCare 1 and Pod Doc, you are requested for interhospital transfer, 27-year-old Jane Doe, GCS 5.” That was the only information given.
When we landed at the hospital, I walked in with my nurse. I was listening to the doctor’s report and doing my once over. The patient was a little bit bradycardic, heart rate in the 40s or 50s. Blood pressure was normal if not a little bit elevated. There was obvious facial trauma. The endotracheal tube in place.
She was covered with a blanket, but some of her clothing was visible. Suddenly, I recognized it. It was our cycling team’s kit. I thought, please don’t let it be Ali.
My flight nurse went out and called back to dispatch. “This is my doc’s wife. Dispatch the second helicopter!” She had to repeat herself a few times before they understood what was happening.
As Ali’s spouse, I couldn’t be the flight doctor. I didn’t care. I called medical control myself and told them: “This is Ali. We have to fly her. She has a head injury.” They said: “You can’t fly her.” I said: “We can’t delay her care. I have to fly her.” They said: “No, you can’t fly her.” I broke down. Devastated.
I went back into the room and looked at Ali. Her heart rate was dropping. My flight nurse was in the trauma bay with the emergency physician. We realized definitive care was being delayed because of my presence, which was an awful feeling to have. I think at that point we realized, you do nothing, or you act. So, we acted.
I told my flight nurse: “Let’s give her atropine to increase her heart rate.” I asked about sedation, and she hadn’t had anything. I spurted off some doses: “a hundred of fentanyl and five of midazolam.” My flight nurse actually administered smaller doses. She thought it was a bit aggressive, and she was correct. I was trying to maintain composure, but it was hard.
The emergency medicine physician volunteered to fly with her, so I called back medical control in desperation: “This doctor’s willing to fly. Let him take her.”
They told me apologetically, knowing my agony, that he was not trained to fly and therefore could not do so. I sat down in the ambulance bay crying, waiting for the second helicopter to arrive.
When we got Ali onto AirCare 2, my nurse then told me I couldn’t fly with her. I said, “I’m flying with her.” She said, “no, it’s not safe.” I said, “I’m not leaving her. I’ll sit in the front. What do you think I’m going to do? Jump out of the helicopter?” I think they realized there was no other option that I would agree to. I rode up front.
It was the fastest flight to the trauma center that I had ever experienced. They did a hot offload, meaning they didn’t even shut down the blades. We got her to the trauma center. And then it was a whole other layer of chaos.
Dr. Alison Delgado: Taylor’s presence may have delayed my transfer, but the University emergency department was prepped and waiting for me. Radiology was on hold, surgery and neurosurgery were there waiting. Everyone was in the trauma bay.
Dr. Taylor Delgado: My younger sister was a social worker in that emergency department, and she was on shift. She and my residency director went to CT with Ali. As the images from Ali’s CT scan showed up on the screens, everyone in the room gasped. She had a nonsurvivable head injury.
The AirCare 2 doctor collapsed into our director’s arms and cried: “She’s going to die tonight.” He responded: “I know. But we’ve got work to do.” Then he asked my sister how close she was with me. She told him we were extremely close. “Good, because we have to break the news that she’s going to die tonight.”
But the doctor never told me. I was in the consultation room. He came in and told me that she had a lot of bleeding around the brain, but he couldn’t find the words to tell me the true severity. He didn’t have to.
Dr. Alison Delgado: I was in a coma for 5 days. Shift by shift, they were amazed that I was still there. I had a broken jaw, broken vertebrae in my spine, a broken clavicle and sternum and contusions to my heart and lungs. I was later found to have a dissection of my carotid artery as well as an aneurysm to the carotid artery. These were both caused by the accident.
My jaw was wired shut and a tracheostomy was placed. They coiled the aneurysm and put a stent in the dissection. I was placed on dual antiplatelet therapy to prevent stent thrombosis.
When I initially woke from the coma during my hospital stay, I could not speak, but I remember being told why I was there. My first two thoughts were: Was it my fault? and I need to get back to work.
Two and a half weeks later, I was stable enough to go to an in-patient rehab facility.
I was very motivated. I made a lot of good progress, because Taylor was there with me. We looked through pictures, trying to jog my memory and help with my vocabulary. I’d look at a bird and know this is a flying animal but couldn’t think of the word bird. I couldn’t remember my mom’s name.
Dr. Taylor Delgado: She was becoming more fluent with her speech each day. Her right arm was working more normally. We started going on walks outside. Within 14 days she was discharged home.
When we left the rehab facility, I took a couple extra tracheostomy tubes and supplies, because I didn’t know how long Ali would have her trach. The emergency medicine person in me just thought, always have these things on hand.
A few days later, her ENT doctor decannulated her tracheostomy tube. In our minds, we were done.
The next night, she had the intracranial hemorrhage.
Return to the hospital ...
Dr. Taylor Delgado: The aneurysm they had coiled had ruptured. Ali had a recurrent subarachnoid hemorrhage and an intracranial hemorrhage, and she was still bleeding. So, they took her to IR to try to embolize it and accomplished as much as they possibly could.
She had hydrocephalus, the ventricles in her brain were enlarged. Normally, they would put in a drain, but they couldn’t because she was on aspirin and Plavix (clopidogrel). That would risk her having a bleed around that insertion site, which would cause a brain hemorrhage.
Dr. Alison Delgado: I was like a ticking time bomb. We knew I would have to have surgery as soon as possible to open my skull and clip the aneurysm. But I had to be on the Plavix and aspirin for at least 6 weeks before it would be considered safe to discontinue them. It was another 3 weeks before they could proceed with the surgery.
The second hospitalization was scarier than the first, because I was much more aware. I knew that I might not be able to return to my residency and do the thing I had dreamed of doing. There were risks of me becoming blind or paralyzed during the surgery. I might not even leave the hospital.
Dr. Taylor Delgado: It was mid-December by then, and my dad asked her, “Ali, what do you want for Christmas?” She looked at him deadpan and said, “normal brain.”
Dr. Alison Delgado: The surgery was successful. I went home a few days later. But I’d lost everything I had gained in rehabilitation. My speech was back to square one.
None of the doctors really expected me to go back to work. But from my standpoint, I thought, I could have died the day I was hit. I could have died when the aneurysm ruptured, or at any point along the way. But I’m here and I’m going back to work.
Dr. Taylor Delgado: In January, I went back to work and I had to fly on the helicopter. They were worried about how I would react. My flight director flew with me on my first shift. Our first flight was an inter-facility STEMI transfer. No big deal. The second one was a car accident outside of Batesville, Ind. We were in the back of the ambulance, and I looked at this woman. She was 27 years old, thin, with long hair. She looked exactly like Ali.
Ali flashed into my mind, and I was like, nope. Ali’s at home. She’s fine. This person is right here, right now. Do what you do. I intubated her in the helicopter. We gave her hypertonic saline. I started a blood transfusion. Afterward, my flight director came up to me and said: “You’re released back to full duty. That was the hardest test you could possibly have on your first day back flying, and you nailed it.”
Dr. Alison Delgado: I finished my residency in December of 2012 and passed my pediatric board exam on the first try, almost exactly 3 years after my accident.
The spring before I started medical school in 2005, I had won the Cincinnati Flying Pig marathon. In 2011, a few months after my accident, they invited us to be the starters of the race. When we stood at the starting line, I decided right then I was going to run this marathon again the next year. In spring 2012, I returned and finished in fourth place, beating my previous winning time by two minutes.
I have a different level of empathy for my patients now. I know what it’s like to be scared. I know what it’s like to not know if you’re going to leave the hospital. I’ve lived that. The process of writing my book was also cathartic for me. I told my story to try to give people hope.
Dr. Taylor Delgado: I have a tattoo on my wrist showing the date of Ali’s accident. The idea was to remind myself of what we’ve come through and everyone who went above and beyond. To show gratitude to them and remember everything that they did for us. It’s also to remember that every patient I see is somebody else’s Alison.
A version of this article first appeared on Medscape.com.
Dr. Taylor Delgado: It was Saturday night, and we had just gone to bed. Suddenly, Ali sat up, and screamed, “My head!” She then became nonresponsive and had a seizure. I was in disbelief, but I also knew exactly what was happening. I called 911: “My wife is having a head bleed. I need an ambulance.” It was a bad connection, and they could barely understand me.
As I tried to carry Ali downstairs, she vomited. She still had rubber bands in her mouth from the jaw fracture that was a result of her accident just a month ago. I knew she needed an airway.
I grabbed a tracheostomy tube, but the opening over her trachea put in for the accident had since closed. I tried to push the tube through her neck, but it hurt her; her eyes opened.
I thought to myself: Maybe she doesn’t need it. This can wait until she gets to the hospital. I can’t do this to her. But she vomited again, and I knew what I had to do.
We were at the top of our stairs. I didn’t have a blade or any other equipment, just the tracheostomy tube with the dilator. I pushed hard, and she started fighting me. I had to hold her hands away with one arm. The tube popped in and she stared back at me in pain and fear.
I finally got her downstairs and called medical control at University Hospital of Cincinnati. I was able to speak with one of the attendings: “Ali’s aneurysm ruptured, and she just had a seizure. She has a GCS of 11 or 12. I replaced her tracheostomy tube. We’ll be there shortly.”
When I heard sirens come down our street, I carried Ali outside, but the sirens were from a firetruck. They likely assumed someone had fallen and had a head laceration. It was beyond deflating. I yelled incredulously: “We need an ambulance here now!”
When the ambulance finally arrived, they tried to tell me that I could not ride with them. Or if I did, I would have to sit up front. After arguing back and forth for a few seconds, I finally demanded: “This is medical control. This is MD-88, and this is my patient. I’m sitting in back with you. She needs four Zofran and two midazolam IV now.”
One month earlier ...
Dr. Alison Delgado: Taylor and I were both 4 months into our second year of residency, and we had been married for 5 months. I was a pediatric resident at Cincinnati Children’s Hospital. She was an emergency medicine resident at the University Hospital. I was having my first day off in a couple weeks, and she was working a shift in the emergency department. She was also a part of the flight crew that day. Second-year residents would go out to the scenes of accidents or to other hospitals to transport the patient back to their Level I trauma center via helicopter. The resident was the physician and considered the leader on these flights.
That afternoon, I went for a bicycle ride. About three-quarters of the way through my ride, I was struck by a car.
The EMS crew got to me fairly quickly. They intubated me at the scene and got me to the closest hospital. Immediately, the hospital realized my case was outside the scope of their care. They contacted University Hospital requesting that their flight crew come to transport me.
Dr. Taylor Delgado: At around 5:30 p.m. the day of my shift, the tones went out on the radio: “AirCare 1 and Pod Doc, you are requested for interhospital transfer, 27-year-old Jane Doe, GCS 5.” That was the only information given.
When we landed at the hospital, I walked in with my nurse. I was listening to the doctor’s report and doing my once over. The patient was a little bit bradycardic, heart rate in the 40s or 50s. Blood pressure was normal if not a little bit elevated. There was obvious facial trauma. The endotracheal tube in place.
She was covered with a blanket, but some of her clothing was visible. Suddenly, I recognized it. It was our cycling team’s kit. I thought, please don’t let it be Ali.
My flight nurse went out and called back to dispatch. “This is my doc’s wife. Dispatch the second helicopter!” She had to repeat herself a few times before they understood what was happening.
As Ali’s spouse, I couldn’t be the flight doctor. I didn’t care. I called medical control myself and told them: “This is Ali. We have to fly her. She has a head injury.” They said: “You can’t fly her.” I said: “We can’t delay her care. I have to fly her.” They said: “No, you can’t fly her.” I broke down. Devastated.
I went back into the room and looked at Ali. Her heart rate was dropping. My flight nurse was in the trauma bay with the emergency physician. We realized definitive care was being delayed because of my presence, which was an awful feeling to have. I think at that point we realized, you do nothing, or you act. So, we acted.
I told my flight nurse: “Let’s give her atropine to increase her heart rate.” I asked about sedation, and she hadn’t had anything. I spurted off some doses: “a hundred of fentanyl and five of midazolam.” My flight nurse actually administered smaller doses. She thought it was a bit aggressive, and she was correct. I was trying to maintain composure, but it was hard.
The emergency medicine physician volunteered to fly with her, so I called back medical control in desperation: “This doctor’s willing to fly. Let him take her.”
They told me apologetically, knowing my agony, that he was not trained to fly and therefore could not do so. I sat down in the ambulance bay crying, waiting for the second helicopter to arrive.
When we got Ali onto AirCare 2, my nurse then told me I couldn’t fly with her. I said, “I’m flying with her.” She said, “no, it’s not safe.” I said, “I’m not leaving her. I’ll sit in the front. What do you think I’m going to do? Jump out of the helicopter?” I think they realized there was no other option that I would agree to. I rode up front.
It was the fastest flight to the trauma center that I had ever experienced. They did a hot offload, meaning they didn’t even shut down the blades. We got her to the trauma center. And then it was a whole other layer of chaos.
Dr. Alison Delgado: Taylor’s presence may have delayed my transfer, but the University emergency department was prepped and waiting for me. Radiology was on hold, surgery and neurosurgery were there waiting. Everyone was in the trauma bay.
Dr. Taylor Delgado: My younger sister was a social worker in that emergency department, and she was on shift. She and my residency director went to CT with Ali. As the images from Ali’s CT scan showed up on the screens, everyone in the room gasped. She had a nonsurvivable head injury.
The AirCare 2 doctor collapsed into our director’s arms and cried: “She’s going to die tonight.” He responded: “I know. But we’ve got work to do.” Then he asked my sister how close she was with me. She told him we were extremely close. “Good, because we have to break the news that she’s going to die tonight.”
But the doctor never told me. I was in the consultation room. He came in and told me that she had a lot of bleeding around the brain, but he couldn’t find the words to tell me the true severity. He didn’t have to.
Dr. Alison Delgado: I was in a coma for 5 days. Shift by shift, they were amazed that I was still there. I had a broken jaw, broken vertebrae in my spine, a broken clavicle and sternum and contusions to my heart and lungs. I was later found to have a dissection of my carotid artery as well as an aneurysm to the carotid artery. These were both caused by the accident.
My jaw was wired shut and a tracheostomy was placed. They coiled the aneurysm and put a stent in the dissection. I was placed on dual antiplatelet therapy to prevent stent thrombosis.
When I initially woke from the coma during my hospital stay, I could not speak, but I remember being told why I was there. My first two thoughts were: Was it my fault? and I need to get back to work.
Two and a half weeks later, I was stable enough to go to an in-patient rehab facility.
I was very motivated. I made a lot of good progress, because Taylor was there with me. We looked through pictures, trying to jog my memory and help with my vocabulary. I’d look at a bird and know this is a flying animal but couldn’t think of the word bird. I couldn’t remember my mom’s name.
Dr. Taylor Delgado: She was becoming more fluent with her speech each day. Her right arm was working more normally. We started going on walks outside. Within 14 days she was discharged home.
When we left the rehab facility, I took a couple extra tracheostomy tubes and supplies, because I didn’t know how long Ali would have her trach. The emergency medicine person in me just thought, always have these things on hand.
A few days later, her ENT doctor decannulated her tracheostomy tube. In our minds, we were done.
The next night, she had the intracranial hemorrhage.
Return to the hospital ...
Dr. Taylor Delgado: The aneurysm they had coiled had ruptured. Ali had a recurrent subarachnoid hemorrhage and an intracranial hemorrhage, and she was still bleeding. So, they took her to IR to try to embolize it and accomplished as much as they possibly could.
She had hydrocephalus, the ventricles in her brain were enlarged. Normally, they would put in a drain, but they couldn’t because she was on aspirin and Plavix (clopidogrel). That would risk her having a bleed around that insertion site, which would cause a brain hemorrhage.
Dr. Alison Delgado: I was like a ticking time bomb. We knew I would have to have surgery as soon as possible to open my skull and clip the aneurysm. But I had to be on the Plavix and aspirin for at least 6 weeks before it would be considered safe to discontinue them. It was another 3 weeks before they could proceed with the surgery.
The second hospitalization was scarier than the first, because I was much more aware. I knew that I might not be able to return to my residency and do the thing I had dreamed of doing. There were risks of me becoming blind or paralyzed during the surgery. I might not even leave the hospital.
Dr. Taylor Delgado: It was mid-December by then, and my dad asked her, “Ali, what do you want for Christmas?” She looked at him deadpan and said, “normal brain.”
Dr. Alison Delgado: The surgery was successful. I went home a few days later. But I’d lost everything I had gained in rehabilitation. My speech was back to square one.
None of the doctors really expected me to go back to work. But from my standpoint, I thought, I could have died the day I was hit. I could have died when the aneurysm ruptured, or at any point along the way. But I’m here and I’m going back to work.
Dr. Taylor Delgado: In January, I went back to work and I had to fly on the helicopter. They were worried about how I would react. My flight director flew with me on my first shift. Our first flight was an inter-facility STEMI transfer. No big deal. The second one was a car accident outside of Batesville, Ind. We were in the back of the ambulance, and I looked at this woman. She was 27 years old, thin, with long hair. She looked exactly like Ali.
Ali flashed into my mind, and I was like, nope. Ali’s at home. She’s fine. This person is right here, right now. Do what you do. I intubated her in the helicopter. We gave her hypertonic saline. I started a blood transfusion. Afterward, my flight director came up to me and said: “You’re released back to full duty. That was the hardest test you could possibly have on your first day back flying, and you nailed it.”
Dr. Alison Delgado: I finished my residency in December of 2012 and passed my pediatric board exam on the first try, almost exactly 3 years after my accident.
The spring before I started medical school in 2005, I had won the Cincinnati Flying Pig marathon. In 2011, a few months after my accident, they invited us to be the starters of the race. When we stood at the starting line, I decided right then I was going to run this marathon again the next year. In spring 2012, I returned and finished in fourth place, beating my previous winning time by two minutes.
I have a different level of empathy for my patients now. I know what it’s like to be scared. I know what it’s like to not know if you’re going to leave the hospital. I’ve lived that. The process of writing my book was also cathartic for me. I told my story to try to give people hope.
Dr. Taylor Delgado: I have a tattoo on my wrist showing the date of Ali’s accident. The idea was to remind myself of what we’ve come through and everyone who went above and beyond. To show gratitude to them and remember everything that they did for us. It’s also to remember that every patient I see is somebody else’s Alison.
A version of this article first appeared on Medscape.com.
Dr. Taylor Delgado: It was Saturday night, and we had just gone to bed. Suddenly, Ali sat up, and screamed, “My head!” She then became nonresponsive and had a seizure. I was in disbelief, but I also knew exactly what was happening. I called 911: “My wife is having a head bleed. I need an ambulance.” It was a bad connection, and they could barely understand me.
As I tried to carry Ali downstairs, she vomited. She still had rubber bands in her mouth from the jaw fracture that was a result of her accident just a month ago. I knew she needed an airway.
I grabbed a tracheostomy tube, but the opening over her trachea put in for the accident had since closed. I tried to push the tube through her neck, but it hurt her; her eyes opened.
I thought to myself: Maybe she doesn’t need it. This can wait until she gets to the hospital. I can’t do this to her. But she vomited again, and I knew what I had to do.
We were at the top of our stairs. I didn’t have a blade or any other equipment, just the tracheostomy tube with the dilator. I pushed hard, and she started fighting me. I had to hold her hands away with one arm. The tube popped in and she stared back at me in pain and fear.
I finally got her downstairs and called medical control at University Hospital of Cincinnati. I was able to speak with one of the attendings: “Ali’s aneurysm ruptured, and she just had a seizure. She has a GCS of 11 or 12. I replaced her tracheostomy tube. We’ll be there shortly.”
When I heard sirens come down our street, I carried Ali outside, but the sirens were from a firetruck. They likely assumed someone had fallen and had a head laceration. It was beyond deflating. I yelled incredulously: “We need an ambulance here now!”
When the ambulance finally arrived, they tried to tell me that I could not ride with them. Or if I did, I would have to sit up front. After arguing back and forth for a few seconds, I finally demanded: “This is medical control. This is MD-88, and this is my patient. I’m sitting in back with you. She needs four Zofran and two midazolam IV now.”
One month earlier ...
Dr. Alison Delgado: Taylor and I were both 4 months into our second year of residency, and we had been married for 5 months. I was a pediatric resident at Cincinnati Children’s Hospital. She was an emergency medicine resident at the University Hospital. I was having my first day off in a couple weeks, and she was working a shift in the emergency department. She was also a part of the flight crew that day. Second-year residents would go out to the scenes of accidents or to other hospitals to transport the patient back to their Level I trauma center via helicopter. The resident was the physician and considered the leader on these flights.
That afternoon, I went for a bicycle ride. About three-quarters of the way through my ride, I was struck by a car.
The EMS crew got to me fairly quickly. They intubated me at the scene and got me to the closest hospital. Immediately, the hospital realized my case was outside the scope of their care. They contacted University Hospital requesting that their flight crew come to transport me.
Dr. Taylor Delgado: At around 5:30 p.m. the day of my shift, the tones went out on the radio: “AirCare 1 and Pod Doc, you are requested for interhospital transfer, 27-year-old Jane Doe, GCS 5.” That was the only information given.
When we landed at the hospital, I walked in with my nurse. I was listening to the doctor’s report and doing my once over. The patient was a little bit bradycardic, heart rate in the 40s or 50s. Blood pressure was normal if not a little bit elevated. There was obvious facial trauma. The endotracheal tube in place.
She was covered with a blanket, but some of her clothing was visible. Suddenly, I recognized it. It was our cycling team’s kit. I thought, please don’t let it be Ali.
My flight nurse went out and called back to dispatch. “This is my doc’s wife. Dispatch the second helicopter!” She had to repeat herself a few times before they understood what was happening.
As Ali’s spouse, I couldn’t be the flight doctor. I didn’t care. I called medical control myself and told them: “This is Ali. We have to fly her. She has a head injury.” They said: “You can’t fly her.” I said: “We can’t delay her care. I have to fly her.” They said: “No, you can’t fly her.” I broke down. Devastated.
I went back into the room and looked at Ali. Her heart rate was dropping. My flight nurse was in the trauma bay with the emergency physician. We realized definitive care was being delayed because of my presence, which was an awful feeling to have. I think at that point we realized, you do nothing, or you act. So, we acted.
I told my flight nurse: “Let’s give her atropine to increase her heart rate.” I asked about sedation, and she hadn’t had anything. I spurted off some doses: “a hundred of fentanyl and five of midazolam.” My flight nurse actually administered smaller doses. She thought it was a bit aggressive, and she was correct. I was trying to maintain composure, but it was hard.
The emergency medicine physician volunteered to fly with her, so I called back medical control in desperation: “This doctor’s willing to fly. Let him take her.”
They told me apologetically, knowing my agony, that he was not trained to fly and therefore could not do so. I sat down in the ambulance bay crying, waiting for the second helicopter to arrive.
When we got Ali onto AirCare 2, my nurse then told me I couldn’t fly with her. I said, “I’m flying with her.” She said, “no, it’s not safe.” I said, “I’m not leaving her. I’ll sit in the front. What do you think I’m going to do? Jump out of the helicopter?” I think they realized there was no other option that I would agree to. I rode up front.
It was the fastest flight to the trauma center that I had ever experienced. They did a hot offload, meaning they didn’t even shut down the blades. We got her to the trauma center. And then it was a whole other layer of chaos.
Dr. Alison Delgado: Taylor’s presence may have delayed my transfer, but the University emergency department was prepped and waiting for me. Radiology was on hold, surgery and neurosurgery were there waiting. Everyone was in the trauma bay.
Dr. Taylor Delgado: My younger sister was a social worker in that emergency department, and she was on shift. She and my residency director went to CT with Ali. As the images from Ali’s CT scan showed up on the screens, everyone in the room gasped. She had a nonsurvivable head injury.
The AirCare 2 doctor collapsed into our director’s arms and cried: “She’s going to die tonight.” He responded: “I know. But we’ve got work to do.” Then he asked my sister how close she was with me. She told him we were extremely close. “Good, because we have to break the news that she’s going to die tonight.”
But the doctor never told me. I was in the consultation room. He came in and told me that she had a lot of bleeding around the brain, but he couldn’t find the words to tell me the true severity. He didn’t have to.
Dr. Alison Delgado: I was in a coma for 5 days. Shift by shift, they were amazed that I was still there. I had a broken jaw, broken vertebrae in my spine, a broken clavicle and sternum and contusions to my heart and lungs. I was later found to have a dissection of my carotid artery as well as an aneurysm to the carotid artery. These were both caused by the accident.
My jaw was wired shut and a tracheostomy was placed. They coiled the aneurysm and put a stent in the dissection. I was placed on dual antiplatelet therapy to prevent stent thrombosis.
When I initially woke from the coma during my hospital stay, I could not speak, but I remember being told why I was there. My first two thoughts were: Was it my fault? and I need to get back to work.
Two and a half weeks later, I was stable enough to go to an in-patient rehab facility.
I was very motivated. I made a lot of good progress, because Taylor was there with me. We looked through pictures, trying to jog my memory and help with my vocabulary. I’d look at a bird and know this is a flying animal but couldn’t think of the word bird. I couldn’t remember my mom’s name.
Dr. Taylor Delgado: She was becoming more fluent with her speech each day. Her right arm was working more normally. We started going on walks outside. Within 14 days she was discharged home.
When we left the rehab facility, I took a couple extra tracheostomy tubes and supplies, because I didn’t know how long Ali would have her trach. The emergency medicine person in me just thought, always have these things on hand.
A few days later, her ENT doctor decannulated her tracheostomy tube. In our minds, we were done.
The next night, she had the intracranial hemorrhage.
Return to the hospital ...
Dr. Taylor Delgado: The aneurysm they had coiled had ruptured. Ali had a recurrent subarachnoid hemorrhage and an intracranial hemorrhage, and she was still bleeding. So, they took her to IR to try to embolize it and accomplished as much as they possibly could.
She had hydrocephalus, the ventricles in her brain were enlarged. Normally, they would put in a drain, but they couldn’t because she was on aspirin and Plavix (clopidogrel). That would risk her having a bleed around that insertion site, which would cause a brain hemorrhage.
Dr. Alison Delgado: I was like a ticking time bomb. We knew I would have to have surgery as soon as possible to open my skull and clip the aneurysm. But I had to be on the Plavix and aspirin for at least 6 weeks before it would be considered safe to discontinue them. It was another 3 weeks before they could proceed with the surgery.
The second hospitalization was scarier than the first, because I was much more aware. I knew that I might not be able to return to my residency and do the thing I had dreamed of doing. There were risks of me becoming blind or paralyzed during the surgery. I might not even leave the hospital.
Dr. Taylor Delgado: It was mid-December by then, and my dad asked her, “Ali, what do you want for Christmas?” She looked at him deadpan and said, “normal brain.”
Dr. Alison Delgado: The surgery was successful. I went home a few days later. But I’d lost everything I had gained in rehabilitation. My speech was back to square one.
None of the doctors really expected me to go back to work. But from my standpoint, I thought, I could have died the day I was hit. I could have died when the aneurysm ruptured, or at any point along the way. But I’m here and I’m going back to work.
Dr. Taylor Delgado: In January, I went back to work and I had to fly on the helicopter. They were worried about how I would react. My flight director flew with me on my first shift. Our first flight was an inter-facility STEMI transfer. No big deal. The second one was a car accident outside of Batesville, Ind. We were in the back of the ambulance, and I looked at this woman. She was 27 years old, thin, with long hair. She looked exactly like Ali.
Ali flashed into my mind, and I was like, nope. Ali’s at home. She’s fine. This person is right here, right now. Do what you do. I intubated her in the helicopter. We gave her hypertonic saline. I started a blood transfusion. Afterward, my flight director came up to me and said: “You’re released back to full duty. That was the hardest test you could possibly have on your first day back flying, and you nailed it.”
Dr. Alison Delgado: I finished my residency in December of 2012 and passed my pediatric board exam on the first try, almost exactly 3 years after my accident.
The spring before I started medical school in 2005, I had won the Cincinnati Flying Pig marathon. In 2011, a few months after my accident, they invited us to be the starters of the race. When we stood at the starting line, I decided right then I was going to run this marathon again the next year. In spring 2012, I returned and finished in fourth place, beating my previous winning time by two minutes.
I have a different level of empathy for my patients now. I know what it’s like to be scared. I know what it’s like to not know if you’re going to leave the hospital. I’ve lived that. The process of writing my book was also cathartic for me. I told my story to try to give people hope.
Dr. Taylor Delgado: I have a tattoo on my wrist showing the date of Ali’s accident. The idea was to remind myself of what we’ve come through and everyone who went above and beyond. To show gratitude to them and remember everything that they did for us. It’s also to remember that every patient I see is somebody else’s Alison.
A version of this article first appeared on Medscape.com.
Should you dismiss a difficult patient?
Some patients continually cancel their appointments, ignore your medical directions, treat your staff rudely, or send you harassing emails.
Do you have to tolerate their behavior?
No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading doctors about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members or physicians, or any criminal behavior in the office, experts say.
But even if a reason seems legitimate, that doesn’t make it legal. Doctors should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises doctors about terminating patients.
Ms. Adler said.
Terminating patients for an “illegal” reason such as discrimination based on race or gender or sexual orientation – even if couched as a legitimate patient issue – could open the practice to a lawsuit, Ms. Adler said.
Doctors also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can’t be resolved, doctors should ensure that there’s continuity of care when patients change physicians, said Ms. Adler.
About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices. The most common reasons were legitimate: a patient was “extremely disruptive and/or behaved inappropriately toward clinicians or staff”; a patient had “violated chronic pain and controlled substance policies”; and a patient had “repeatedly missed appointments.”
Jacqui O’Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, said she has dismissed about 15 of 3,000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it.
She also gives patients a warning: If the unacceptable behavior continues, it will lead to their dismissal.
When patients cross a line
Dr. O’Kane warned an elderly man who used the N-word with her that she wouldn’t tolerate that language in her office. Then, when he later called her front office employee the N-word, she decided to dismiss him.
“I said, ‘That’s it, you can’t say that to someone in this office. I already told you once, and you did it again. I’m sorry, you have to find another doctor,’ ” said Dr. O’Kane.
Another patient crossed a line when she missed four appointments, refused to come in, and kept sending Dr. O’Kane long messages on MyChart demanding medications and advice. One message was fairly obtrusive: “If you don’t give me something stronger for my nerves TODAY, I am going to LOSE MY MIND!!!” Dr. O’Kane said the patient wrote.
“I then told her that’s not how I run my practice and that she needed to find someone else.”
Another common reason doctors dismiss patients is for nonpayment, says Ms. Adler.
Recently, however, some patients have also begun demanding their money back from doctors for services already received and billed because they were unhappy about something that occurred at the doctor’s office, said Ms. Adler.
“I advise doctors to respond: ‘We disagree that you didn’t get the service, but we will give you your money back, and we’re also terminating you from our practice.’ At that point, the doctor-patient relationship has become impossible,” said Ms. Adler.
How to dismiss difficult patients ethically and legally
According to the AMA’s Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient if further treatment is medically indicated without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.
Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state’s Medical Practice Act, said Ms. Adler.
Doctors can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.
1. Create written policies. Medical practices can describe the rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. “When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn’t been compliant,” said Ms. Adler.
She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.
2. Document any consistent problems you’re having with a patient. When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if and when you decided to terminate the patient.
3. Meet with the patient to discuss the problem. “Talking and meeting with a patient also allows the physician to assess whether there’s another issue. For example, is there a mental health concern? Is there a financial reason for nonpayment or no-shows? There are multiple benefits to finding out what the problem is,” said Ms. Adler.
Once you’ve decided to terminate a patient, here’s what you should do:
4. Allow enough time for the patient to find alternative care. Ms. Adler recommends giving patients 30 days’ notice and that physicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.
“It’s important to consider the patient’s context – if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer – at least until they finish their treatment,” said Ms. Adler. Also, states may have their own requirements about minimum notice periods, she said.
5. Provide patients with written notice that you intend to terminate their care. Ms. Adler recommends that each letter be tailored to the patient’s specific circumstances. “You could spell out a patient’s history of noncompliance or nonpayment or inappropriate conduct because it’s been documented and the patient is already aware of it from a previous discussion,” she said.
Ms. Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient’s lawyer. Some lawyers will draft the termination letters, she said.
6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new physician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location.
The letter should also state that the doctor will provide emergency care during the 30 days. Ms. Adler also recommends sending the notice by certified mail.
Dr. O’Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don’t have many other options for health care. She also has developed a reputation for being willing to take on difficult patients that other physicians didn’t want to deal with, she said.
She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications.
“The patient may say, ‘I had to choose between paying for medications and putting food on the table,’ ” said Dr. O’Kane.
A version of this article first appeared on Medscape.com.
Some patients continually cancel their appointments, ignore your medical directions, treat your staff rudely, or send you harassing emails.
Do you have to tolerate their behavior?
No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading doctors about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members or physicians, or any criminal behavior in the office, experts say.
But even if a reason seems legitimate, that doesn’t make it legal. Doctors should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises doctors about terminating patients.
Ms. Adler said.
Terminating patients for an “illegal” reason such as discrimination based on race or gender or sexual orientation – even if couched as a legitimate patient issue – could open the practice to a lawsuit, Ms. Adler said.
Doctors also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can’t be resolved, doctors should ensure that there’s continuity of care when patients change physicians, said Ms. Adler.
About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices. The most common reasons were legitimate: a patient was “extremely disruptive and/or behaved inappropriately toward clinicians or staff”; a patient had “violated chronic pain and controlled substance policies”; and a patient had “repeatedly missed appointments.”
Jacqui O’Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, said she has dismissed about 15 of 3,000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it.
She also gives patients a warning: If the unacceptable behavior continues, it will lead to their dismissal.
When patients cross a line
Dr. O’Kane warned an elderly man who used the N-word with her that she wouldn’t tolerate that language in her office. Then, when he later called her front office employee the N-word, she decided to dismiss him.
“I said, ‘That’s it, you can’t say that to someone in this office. I already told you once, and you did it again. I’m sorry, you have to find another doctor,’ ” said Dr. O’Kane.
Another patient crossed a line when she missed four appointments, refused to come in, and kept sending Dr. O’Kane long messages on MyChart demanding medications and advice. One message was fairly obtrusive: “If you don’t give me something stronger for my nerves TODAY, I am going to LOSE MY MIND!!!” Dr. O’Kane said the patient wrote.
“I then told her that’s not how I run my practice and that she needed to find someone else.”
Another common reason doctors dismiss patients is for nonpayment, says Ms. Adler.
Recently, however, some patients have also begun demanding their money back from doctors for services already received and billed because they were unhappy about something that occurred at the doctor’s office, said Ms. Adler.
“I advise doctors to respond: ‘We disagree that you didn’t get the service, but we will give you your money back, and we’re also terminating you from our practice.’ At that point, the doctor-patient relationship has become impossible,” said Ms. Adler.
How to dismiss difficult patients ethically and legally
According to the AMA’s Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient if further treatment is medically indicated without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.
Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state’s Medical Practice Act, said Ms. Adler.
Doctors can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.
1. Create written policies. Medical practices can describe the rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. “When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn’t been compliant,” said Ms. Adler.
She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.
2. Document any consistent problems you’re having with a patient. When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if and when you decided to terminate the patient.
3. Meet with the patient to discuss the problem. “Talking and meeting with a patient also allows the physician to assess whether there’s another issue. For example, is there a mental health concern? Is there a financial reason for nonpayment or no-shows? There are multiple benefits to finding out what the problem is,” said Ms. Adler.
Once you’ve decided to terminate a patient, here’s what you should do:
4. Allow enough time for the patient to find alternative care. Ms. Adler recommends giving patients 30 days’ notice and that physicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.
“It’s important to consider the patient’s context – if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer – at least until they finish their treatment,” said Ms. Adler. Also, states may have their own requirements about minimum notice periods, she said.
5. Provide patients with written notice that you intend to terminate their care. Ms. Adler recommends that each letter be tailored to the patient’s specific circumstances. “You could spell out a patient’s history of noncompliance or nonpayment or inappropriate conduct because it’s been documented and the patient is already aware of it from a previous discussion,” she said.
Ms. Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient’s lawyer. Some lawyers will draft the termination letters, she said.
6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new physician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location.
The letter should also state that the doctor will provide emergency care during the 30 days. Ms. Adler also recommends sending the notice by certified mail.
Dr. O’Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don’t have many other options for health care. She also has developed a reputation for being willing to take on difficult patients that other physicians didn’t want to deal with, she said.
She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications.
“The patient may say, ‘I had to choose between paying for medications and putting food on the table,’ ” said Dr. O’Kane.
A version of this article first appeared on Medscape.com.
Some patients continually cancel their appointments, ignore your medical directions, treat your staff rudely, or send you harassing emails.
Do you have to tolerate their behavior?
No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading doctors about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members or physicians, or any criminal behavior in the office, experts say.
But even if a reason seems legitimate, that doesn’t make it legal. Doctors should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises doctors about terminating patients.
Ms. Adler said.
Terminating patients for an “illegal” reason such as discrimination based on race or gender or sexual orientation – even if couched as a legitimate patient issue – could open the practice to a lawsuit, Ms. Adler said.
Doctors also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can’t be resolved, doctors should ensure that there’s continuity of care when patients change physicians, said Ms. Adler.
About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices. The most common reasons were legitimate: a patient was “extremely disruptive and/or behaved inappropriately toward clinicians or staff”; a patient had “violated chronic pain and controlled substance policies”; and a patient had “repeatedly missed appointments.”
Jacqui O’Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, said she has dismissed about 15 of 3,000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it.
She also gives patients a warning: If the unacceptable behavior continues, it will lead to their dismissal.
When patients cross a line
Dr. O’Kane warned an elderly man who used the N-word with her that she wouldn’t tolerate that language in her office. Then, when he later called her front office employee the N-word, she decided to dismiss him.
“I said, ‘That’s it, you can’t say that to someone in this office. I already told you once, and you did it again. I’m sorry, you have to find another doctor,’ ” said Dr. O’Kane.
Another patient crossed a line when she missed four appointments, refused to come in, and kept sending Dr. O’Kane long messages on MyChart demanding medications and advice. One message was fairly obtrusive: “If you don’t give me something stronger for my nerves TODAY, I am going to LOSE MY MIND!!!” Dr. O’Kane said the patient wrote.
“I then told her that’s not how I run my practice and that she needed to find someone else.”
Another common reason doctors dismiss patients is for nonpayment, says Ms. Adler.
Recently, however, some patients have also begun demanding their money back from doctors for services already received and billed because they were unhappy about something that occurred at the doctor’s office, said Ms. Adler.
“I advise doctors to respond: ‘We disagree that you didn’t get the service, but we will give you your money back, and we’re also terminating you from our practice.’ At that point, the doctor-patient relationship has become impossible,” said Ms. Adler.
How to dismiss difficult patients ethically and legally
According to the AMA’s Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient if further treatment is medically indicated without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.
Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state’s Medical Practice Act, said Ms. Adler.
Doctors can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.
1. Create written policies. Medical practices can describe the rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. “When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn’t been compliant,” said Ms. Adler.
She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.
2. Document any consistent problems you’re having with a patient. When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if and when you decided to terminate the patient.
3. Meet with the patient to discuss the problem. “Talking and meeting with a patient also allows the physician to assess whether there’s another issue. For example, is there a mental health concern? Is there a financial reason for nonpayment or no-shows? There are multiple benefits to finding out what the problem is,” said Ms. Adler.
Once you’ve decided to terminate a patient, here’s what you should do:
4. Allow enough time for the patient to find alternative care. Ms. Adler recommends giving patients 30 days’ notice and that physicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.
“It’s important to consider the patient’s context – if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer – at least until they finish their treatment,” said Ms. Adler. Also, states may have their own requirements about minimum notice periods, she said.
5. Provide patients with written notice that you intend to terminate their care. Ms. Adler recommends that each letter be tailored to the patient’s specific circumstances. “You could spell out a patient’s history of noncompliance or nonpayment or inappropriate conduct because it’s been documented and the patient is already aware of it from a previous discussion,” she said.
Ms. Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient’s lawyer. Some lawyers will draft the termination letters, she said.
6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new physician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location.
The letter should also state that the doctor will provide emergency care during the 30 days. Ms. Adler also recommends sending the notice by certified mail.
Dr. O’Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don’t have many other options for health care. She also has developed a reputation for being willing to take on difficult patients that other physicians didn’t want to deal with, she said.
She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications.
“The patient may say, ‘I had to choose between paying for medications and putting food on the table,’ ” said Dr. O’Kane.
A version of this article first appeared on Medscape.com.
How not to establish rapport with your patient
1. Stride confidently into the room to greet your 84-year-old female patient.
2. Introduce yourself saying, “Hi, I’m Dr. Jeff Benabio.”
3. Extend your clenched fist toward her chest and wait for her to reciprocate.
4. Smile awkwardly behind your mask while you wait.
5. Advise that you are doing a fist bump instead of a handshake to prevent the spread of viruses.
6. Wait.
7. Explain that she can bump, also known as “dap,” you back by extending her clenched fist and bumping into yours.
8. Wait a bit more.
9. Lower your fist and pat her on the shoulder with your left hand. Do so gently so it doesn’t seem like you just did a quick right jab followed by a left hook.
10. Sit down diffidently and pray that you can help her so this office visit is not an utter disaster.
It seemed a good idea for 2020: Let’s stop shaking hands while we wait out this viral apocalypse. Sensible, but entering a patient room and just sitting down didn’t work. It felt cold, impolite – this isn’t the DMV. In medicine, a complete stranger has to trust us to get naked, tell intimate secrets, even be stuck by needles all within minutes of meeting. We needed a trust-building substitute greeting.
There was the Muslim hand-on-my-heart greeting. Or the Hindu “namaste” or Buddhist “amituofo” folded hands. Or perhaps the paternalistic shoulder pat? I went with the fist bump. With some of my partner docs, my old MBA squad, my neighbor, the fist bump felt natural, reciprocated without hesitation. But it fails with many patients. To understand why, it’s helpful to know the history of the fist bump, also known as the dap.
Dap is an acronym for Dignity And Pride. It’s a variation of a handshake that originated among Black soldiers in the Vietnam war as a means of showing fraternity and establishing connectedness. In Vietnam, 30% of the combat battalions were Black. Marginalized in the military and at home, they created a greeting that was meaningful and unique. The dap was a series of shakes, bumps, slaps, and hugs that was symbolic. It was a means of showing respect and humility, that no one is above others, that I’ve got your back and you’ve got mine. It was a powerful recognition of humanity and effective means of personal connection. It spread from the Black community to the general population and it exists still today. The choreographed pregame handshake you see so many NBA players engage in is a descendant of the dap. Like many rituals, it reinforces bonds with those who are your people, your team, those you trust.
The more generalized version is the simple fist bump. It is widely used, notably by President Obama, and in the appropriate circumstance, will almost always be reciprocated. But it doesn’t work well to create trust with a stranger. With a patient for example, you are not showing them respect for some accomplishment. Nor are we connecting with them as a member of your team. Unless this is a patient whom you’ve seen many times before, a fist bump attempt might be met with “are you serious?” In fact, a survey done in 2016 asking infectious disease professionals what they thought of fist bumps as a greeting, very few replied it was a good idea. Most felt it was unprofessional. Not to mention that a fist bump does not symbolize an agreement in the way that a handshake does (and has done since at least the 9th century BC).
With COVID waning and masks doffed, I’ve found myself back to handshaking. Yes, I sanitize before and after, another ritual that has symbolic as well as practical significance. I get fewer sideways glances from my geriatric patients for sure. But I do still offer a little dap for my liquid nitrogen–survivor kids and for the occasional fellow Gen Xer. “Wonder Twin powers, activate!”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]
1. Stride confidently into the room to greet your 84-year-old female patient.
2. Introduce yourself saying, “Hi, I’m Dr. Jeff Benabio.”
3. Extend your clenched fist toward her chest and wait for her to reciprocate.
4. Smile awkwardly behind your mask while you wait.
5. Advise that you are doing a fist bump instead of a handshake to prevent the spread of viruses.
6. Wait.
7. Explain that she can bump, also known as “dap,” you back by extending her clenched fist and bumping into yours.
8. Wait a bit more.
9. Lower your fist and pat her on the shoulder with your left hand. Do so gently so it doesn’t seem like you just did a quick right jab followed by a left hook.
10. Sit down diffidently and pray that you can help her so this office visit is not an utter disaster.
It seemed a good idea for 2020: Let’s stop shaking hands while we wait out this viral apocalypse. Sensible, but entering a patient room and just sitting down didn’t work. It felt cold, impolite – this isn’t the DMV. In medicine, a complete stranger has to trust us to get naked, tell intimate secrets, even be stuck by needles all within minutes of meeting. We needed a trust-building substitute greeting.
There was the Muslim hand-on-my-heart greeting. Or the Hindu “namaste” or Buddhist “amituofo” folded hands. Or perhaps the paternalistic shoulder pat? I went with the fist bump. With some of my partner docs, my old MBA squad, my neighbor, the fist bump felt natural, reciprocated without hesitation. But it fails with many patients. To understand why, it’s helpful to know the history of the fist bump, also known as the dap.
Dap is an acronym for Dignity And Pride. It’s a variation of a handshake that originated among Black soldiers in the Vietnam war as a means of showing fraternity and establishing connectedness. In Vietnam, 30% of the combat battalions were Black. Marginalized in the military and at home, they created a greeting that was meaningful and unique. The dap was a series of shakes, bumps, slaps, and hugs that was symbolic. It was a means of showing respect and humility, that no one is above others, that I’ve got your back and you’ve got mine. It was a powerful recognition of humanity and effective means of personal connection. It spread from the Black community to the general population and it exists still today. The choreographed pregame handshake you see so many NBA players engage in is a descendant of the dap. Like many rituals, it reinforces bonds with those who are your people, your team, those you trust.
The more generalized version is the simple fist bump. It is widely used, notably by President Obama, and in the appropriate circumstance, will almost always be reciprocated. But it doesn’t work well to create trust with a stranger. With a patient for example, you are not showing them respect for some accomplishment. Nor are we connecting with them as a member of your team. Unless this is a patient whom you’ve seen many times before, a fist bump attempt might be met with “are you serious?” In fact, a survey done in 2016 asking infectious disease professionals what they thought of fist bumps as a greeting, very few replied it was a good idea. Most felt it was unprofessional. Not to mention that a fist bump does not symbolize an agreement in the way that a handshake does (and has done since at least the 9th century BC).
With COVID waning and masks doffed, I’ve found myself back to handshaking. Yes, I sanitize before and after, another ritual that has symbolic as well as practical significance. I get fewer sideways glances from my geriatric patients for sure. But I do still offer a little dap for my liquid nitrogen–survivor kids and for the occasional fellow Gen Xer. “Wonder Twin powers, activate!”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]
1. Stride confidently into the room to greet your 84-year-old female patient.
2. Introduce yourself saying, “Hi, I’m Dr. Jeff Benabio.”
3. Extend your clenched fist toward her chest and wait for her to reciprocate.
4. Smile awkwardly behind your mask while you wait.
5. Advise that you are doing a fist bump instead of a handshake to prevent the spread of viruses.
6. Wait.
7. Explain that she can bump, also known as “dap,” you back by extending her clenched fist and bumping into yours.
8. Wait a bit more.
9. Lower your fist and pat her on the shoulder with your left hand. Do so gently so it doesn’t seem like you just did a quick right jab followed by a left hook.
10. Sit down diffidently and pray that you can help her so this office visit is not an utter disaster.
It seemed a good idea for 2020: Let’s stop shaking hands while we wait out this viral apocalypse. Sensible, but entering a patient room and just sitting down didn’t work. It felt cold, impolite – this isn’t the DMV. In medicine, a complete stranger has to trust us to get naked, tell intimate secrets, even be stuck by needles all within minutes of meeting. We needed a trust-building substitute greeting.
There was the Muslim hand-on-my-heart greeting. Or the Hindu “namaste” or Buddhist “amituofo” folded hands. Or perhaps the paternalistic shoulder pat? I went with the fist bump. With some of my partner docs, my old MBA squad, my neighbor, the fist bump felt natural, reciprocated without hesitation. But it fails with many patients. To understand why, it’s helpful to know the history of the fist bump, also known as the dap.
Dap is an acronym for Dignity And Pride. It’s a variation of a handshake that originated among Black soldiers in the Vietnam war as a means of showing fraternity and establishing connectedness. In Vietnam, 30% of the combat battalions were Black. Marginalized in the military and at home, they created a greeting that was meaningful and unique. The dap was a series of shakes, bumps, slaps, and hugs that was symbolic. It was a means of showing respect and humility, that no one is above others, that I’ve got your back and you’ve got mine. It was a powerful recognition of humanity and effective means of personal connection. It spread from the Black community to the general population and it exists still today. The choreographed pregame handshake you see so many NBA players engage in is a descendant of the dap. Like many rituals, it reinforces bonds with those who are your people, your team, those you trust.
The more generalized version is the simple fist bump. It is widely used, notably by President Obama, and in the appropriate circumstance, will almost always be reciprocated. But it doesn’t work well to create trust with a stranger. With a patient for example, you are not showing them respect for some accomplishment. Nor are we connecting with them as a member of your team. Unless this is a patient whom you’ve seen many times before, a fist bump attempt might be met with “are you serious?” In fact, a survey done in 2016 asking infectious disease professionals what they thought of fist bumps as a greeting, very few replied it was a good idea. Most felt it was unprofessional. Not to mention that a fist bump does not symbolize an agreement in the way that a handshake does (and has done since at least the 9th century BC).
With COVID waning and masks doffed, I’ve found myself back to handshaking. Yes, I sanitize before and after, another ritual that has symbolic as well as practical significance. I get fewer sideways glances from my geriatric patients for sure. But I do still offer a little dap for my liquid nitrogen–survivor kids and for the occasional fellow Gen Xer. “Wonder Twin powers, activate!”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]
Should you have a chaperone in the exam room? Many say yes
This transcript has been edited for clarity.
I’m Art Caplan, PhD. I’m at the division of medical ethics at NYU’s Grossman School of Medicine.
, such as breasts, genitalia, and the perianal area.
In some institutions, there has been a movement toward saying a chaperone must be present, that it’s mandatory. I know that is true at Yale’s health care centers and clinics. Others do so when the patient requests it. An interesting situation sometimes occurs when the hospital or the clinic requires a chaperone but the patient says, “I don’t want a chaperone. I want my privacy. I want the gynecologist or the urologist only. I don’t want anyone else to be seeing me. I’m not comfortable with anyone other than the doctor in the room.”
Complicating this issue of when is a chaperone appropriate and when can it be refused, if ever, is the fact that the role of chaperone is ill defined. For example, there isn’t really agreement on who can be a chaperone. Could it be a medical student? Could it be a nurse? Could it be another doctor? Should it be someone who at least has finished nursing school or medical school? Can it be a patient representative? There are no standards about who can play the role.
Should the chaperone be available to be seen when they’re in the room? Should they stay behind a curtain or somewhere where they’re not, so to speak, intrusive into what’s going on in the exam room? Do they sit in a chair? Do they stand? How do they behave, if you will? There’s no agreement.
There’s still no agreement on the training that a chaperone should have. Do we charge them with trying to represent what’s going on with the patient or trying to protect the doctor against any accusations that are ill founded about inappropriate conduct? Are they supposed to do both? How do they obtain consent, if they do, from the patient undergoing an examination in a sensitive part of their body or one that they’re sensitive about?
This area really requires some hard thinking if you’re considering having chaperones present. I think there are some online courses that offer some training. I haven’t looked at them, but they might be worth a look to see if they make you more comfortable about getting a chaperone oriented. I think it’s probably important to set a policy saying a chaperone must always be present for these kinds of examinations and list them, or one can be requested no matter what is going on in terms of the kind of exam being conducted.
There needs to be some statement saying that you have permission to either accept them or refuse them – or you don’t. Should they always be present, for example, with patients who are minors, adolescents or children? Does that extend that far out where a guardian, parent, or someone has to give permission?
In this area, I think we can all understand why chaperones have come to the fore, including allegations of misconduct and inappropriate touching, and considering comfort levels of patients to just put them more at ease. It’s obvious that we haven’t, as a nation or a medical profession, thought it through to the degree to which we have to.
I’m certainly not anti-chaperone, and I believe that if patients are more comfortable having one present, or a doctor is more comfortable having one present, or if we all agree that there are certain patients – kids – where certain types of examinations require or ought to expect the chaperone to be present, that’s wonderful.
We’ve got to lay out the rights of the doctors. We’ve got to lay out the rights of the institutions. We’ve got to lay out the rights of the patients. We should agree on who these people are. We should agree on how they’re trained.
We’ve got some work ahead of us if we’re going to have chaperones become a standard part of the medical examination.
Dr. Kaplan reported conflicts of interest with the Franklin Institute, Tengion, Biogen Idec, Johnson & Johnson, and PriCara.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
I’m Art Caplan, PhD. I’m at the division of medical ethics at NYU’s Grossman School of Medicine.
, such as breasts, genitalia, and the perianal area.
In some institutions, there has been a movement toward saying a chaperone must be present, that it’s mandatory. I know that is true at Yale’s health care centers and clinics. Others do so when the patient requests it. An interesting situation sometimes occurs when the hospital or the clinic requires a chaperone but the patient says, “I don’t want a chaperone. I want my privacy. I want the gynecologist or the urologist only. I don’t want anyone else to be seeing me. I’m not comfortable with anyone other than the doctor in the room.”
Complicating this issue of when is a chaperone appropriate and when can it be refused, if ever, is the fact that the role of chaperone is ill defined. For example, there isn’t really agreement on who can be a chaperone. Could it be a medical student? Could it be a nurse? Could it be another doctor? Should it be someone who at least has finished nursing school or medical school? Can it be a patient representative? There are no standards about who can play the role.
Should the chaperone be available to be seen when they’re in the room? Should they stay behind a curtain or somewhere where they’re not, so to speak, intrusive into what’s going on in the exam room? Do they sit in a chair? Do they stand? How do they behave, if you will? There’s no agreement.
There’s still no agreement on the training that a chaperone should have. Do we charge them with trying to represent what’s going on with the patient or trying to protect the doctor against any accusations that are ill founded about inappropriate conduct? Are they supposed to do both? How do they obtain consent, if they do, from the patient undergoing an examination in a sensitive part of their body or one that they’re sensitive about?
This area really requires some hard thinking if you’re considering having chaperones present. I think there are some online courses that offer some training. I haven’t looked at them, but they might be worth a look to see if they make you more comfortable about getting a chaperone oriented. I think it’s probably important to set a policy saying a chaperone must always be present for these kinds of examinations and list them, or one can be requested no matter what is going on in terms of the kind of exam being conducted.
There needs to be some statement saying that you have permission to either accept them or refuse them – or you don’t. Should they always be present, for example, with patients who are minors, adolescents or children? Does that extend that far out where a guardian, parent, or someone has to give permission?
In this area, I think we can all understand why chaperones have come to the fore, including allegations of misconduct and inappropriate touching, and considering comfort levels of patients to just put them more at ease. It’s obvious that we haven’t, as a nation or a medical profession, thought it through to the degree to which we have to.
I’m certainly not anti-chaperone, and I believe that if patients are more comfortable having one present, or a doctor is more comfortable having one present, or if we all agree that there are certain patients – kids – where certain types of examinations require or ought to expect the chaperone to be present, that’s wonderful.
We’ve got to lay out the rights of the doctors. We’ve got to lay out the rights of the institutions. We’ve got to lay out the rights of the patients. We should agree on who these people are. We should agree on how they’re trained.
We’ve got some work ahead of us if we’re going to have chaperones become a standard part of the medical examination.
Dr. Kaplan reported conflicts of interest with the Franklin Institute, Tengion, Biogen Idec, Johnson & Johnson, and PriCara.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
I’m Art Caplan, PhD. I’m at the division of medical ethics at NYU’s Grossman School of Medicine.
, such as breasts, genitalia, and the perianal area.
In some institutions, there has been a movement toward saying a chaperone must be present, that it’s mandatory. I know that is true at Yale’s health care centers and clinics. Others do so when the patient requests it. An interesting situation sometimes occurs when the hospital or the clinic requires a chaperone but the patient says, “I don’t want a chaperone. I want my privacy. I want the gynecologist or the urologist only. I don’t want anyone else to be seeing me. I’m not comfortable with anyone other than the doctor in the room.”
Complicating this issue of when is a chaperone appropriate and when can it be refused, if ever, is the fact that the role of chaperone is ill defined. For example, there isn’t really agreement on who can be a chaperone. Could it be a medical student? Could it be a nurse? Could it be another doctor? Should it be someone who at least has finished nursing school or medical school? Can it be a patient representative? There are no standards about who can play the role.
Should the chaperone be available to be seen when they’re in the room? Should they stay behind a curtain or somewhere where they’re not, so to speak, intrusive into what’s going on in the exam room? Do they sit in a chair? Do they stand? How do they behave, if you will? There’s no agreement.
There’s still no agreement on the training that a chaperone should have. Do we charge them with trying to represent what’s going on with the patient or trying to protect the doctor against any accusations that are ill founded about inappropriate conduct? Are they supposed to do both? How do they obtain consent, if they do, from the patient undergoing an examination in a sensitive part of their body or one that they’re sensitive about?
This area really requires some hard thinking if you’re considering having chaperones present. I think there are some online courses that offer some training. I haven’t looked at them, but they might be worth a look to see if they make you more comfortable about getting a chaperone oriented. I think it’s probably important to set a policy saying a chaperone must always be present for these kinds of examinations and list them, or one can be requested no matter what is going on in terms of the kind of exam being conducted.
There needs to be some statement saying that you have permission to either accept them or refuse them – or you don’t. Should they always be present, for example, with patients who are minors, adolescents or children? Does that extend that far out where a guardian, parent, or someone has to give permission?
In this area, I think we can all understand why chaperones have come to the fore, including allegations of misconduct and inappropriate touching, and considering comfort levels of patients to just put them more at ease. It’s obvious that we haven’t, as a nation or a medical profession, thought it through to the degree to which we have to.
I’m certainly not anti-chaperone, and I believe that if patients are more comfortable having one present, or a doctor is more comfortable having one present, or if we all agree that there are certain patients – kids – where certain types of examinations require or ought to expect the chaperone to be present, that’s wonderful.
We’ve got to lay out the rights of the doctors. We’ve got to lay out the rights of the institutions. We’ve got to lay out the rights of the patients. We should agree on who these people are. We should agree on how they’re trained.
We’ve got some work ahead of us if we’re going to have chaperones become a standard part of the medical examination.
Dr. Kaplan reported conflicts of interest with the Franklin Institute, Tengion, Biogen Idec, Johnson & Johnson, and PriCara.
A version of this article first appeared on Medscape.com.
Book review: “Sexual Citizens”
The Sexual Health Initiative to Foster Transformation (SHIFT)1 is a landmark study about sexual assault at college, which has generated 20 scientific articles and several chapters in books, but unfortunately, has not made its way into the psychiatric literature.
“Sexual Citizens: Sex, Power and Assault on Campus,” by Jennifer Hirsch and Shamus Khan, (available in audio book and paperback) was written as a follow up to the SHIFT study, so the rest of us can absorb the findings.2 This mixed-methods study included a survey of over 1,600 students aged 18-29 from Columbia University and Barnard College regarding their relationships and sexual histories, including assault. Data were collected using daily diaries, focus groups, and hundreds of hours of field work observation by young researchers. One- to 3-hour in-depth interviews exploring sexual experiences on campus were conducted with 151 students. These interviews are the focus of the book. It is a well-written, provocative story brimming with insights for those of us who lack the time to scour social science literature.
“Sexual Citizens” and the SHIFT study confirmed much of what we know. Sexual assault is common and has enduring effects. The study found that 36% of women and 15% of men had experienced unwanted, nonconsensual sexual contact by senior year. Twenty percent of women and 6% of men were rape survivors. Freshman, LGBTQ, and minority students were found at highest risk of assault. SHIFT reaffirmed that abstinence-only education is not a protective factor against college sexual assault, but neither was knowledge of affirmative consent (the practice of “ongoing and explicit” checking-in with partners) which few students ever employed. Encouragingly, students taught refusal skills were less likely to experience sexual assault.
Many of the book’s valuable lessons fall under the umbrella of failures of language and communication. For example, after drinking, they went to his room. She was expecting a social interaction, but with no other place to sit, they sat on his bed where she was coaxed or pressured into a sexual encounter. Afterward, she leaves, and it is never discussed again. One partner desires emotional intimacy, and the other, bragging rights in the fraternity or at the girls’ weekly brunch. Numerous personal stories like these, though at times heart wrenching, provide perspective on the barriers to addressing assault.
Subjects relayed experiences of assault by strangers or friends, and some provided details of their own actions as perpetrators. Stumbling around words and emotions, an avoidance of explicit language stemmed from shame, a fear of personal responsibility, the desire to maintain social cohesion, and concern for potential consequences for the perpetrator. Many subjects were resistant to calling nonconsensual sexual activity rape or even assault. Some who had perpetrated were unaware their behavior may have been experienced as assault, with recognition of this fact dawning during interviews.
This apparent limitation in self-reflective capacity may be in part due to the conceptualization of what assault is. Focus groups identified a discernible difference in how men and women understood assaults, with men believing rapes looked like a woman fighting back and screaming for help ... which is rarely what happens.
Notably absent among the interviewed are any flagrant perpetrators. The methodology section theorizes that individuals who intentionally harmed their peers were unlikely to choose to participate in this study. In addition, the characterization of assailants as “sociopathic predators” is based in a history of racialized imagery that leads us astray from the truth about campus sexual assault. Most assaults do not involve force, and SHIFT data showed 75% of victims knew their assailants. Ultimately, a major aim of the research was to study assault alongside healthy sex to “understand those pivotal moments when encounters change from being sex, to being assault.” Doing this requires understanding the where, how, and why students have sex, a more complicated undertaking than we may think.
In discussing their sexual lives, subjects frequently noted they did not have space to talk about their assaults. Though 81% of students discussed their experiences with someone, friend groups were often overburdened with stories, which minimized the victim’s experience. Furthermore, most had not sought help from the student counseling centers. Students navigating this complex field were frequently doing so in isolation. SHIFT found subjects to be eager to participate; they would often express thankfulness, and a sense of freedom in sharing with researchers. Commonly, students expressly did not want retribution for perpetrators, but simply a place to be heard without challenge. The current legal system precludes that possibility, leaving individuals without the option to confront perpetrators, and perpetrators often not knowing the extent of the damage they caused.
Where can psychiatrists have an impact right now? “Sexual Citizens” identifies four key areas for intervention to work toward a world with less sexual assault. These are:
- Improving diversity, inequality, and power distortions.
- Education about sex and sexual assault.
- Substance use.
- Mental health.
Substance use and mental health are especially relevant for psychiatrists (That substance use contributes to sexual assault is known by approximately ... everybody!). Unwanted sexual contact prior to college (20% of students) increased the odds of experiencing assault during college. Harm reduction strategies should be introduced before college, according to the SHIFT research, particularly in skills-based training on how to say “No” to unwanted sex. Psychiatrists are likely used to asking brief history questions related to sexual assault and rape. “Sexual Citizens” highlights the inadequacy of this blunt language and guides the reader toward a refined knowledge of the language needed to address sexual assault.
Dr. Whisler is a child and adolescent psychiatry fellow at the Stanford (Calif.) University. Dr. Higgins is affiliate associate professor of psychiatry and family medicine at the Medical University of South Carolina, Charleston.
References
1. Hirsch JS et al. Social dimensions of sexual consent among cisgender heterosexual college students: Insights from ethnographic research. J Adolesc Health. 2019 Jan;64(1):26-35. doi: 10.1016/j.jadohealth.2018.06.011.
2. Hirsch JS and Khan S. Sexual citizens: Sex, power, and assault on campus. New York: W.W. Norton & Company, 2020.
The Sexual Health Initiative to Foster Transformation (SHIFT)1 is a landmark study about sexual assault at college, which has generated 20 scientific articles and several chapters in books, but unfortunately, has not made its way into the psychiatric literature.
“Sexual Citizens: Sex, Power and Assault on Campus,” by Jennifer Hirsch and Shamus Khan, (available in audio book and paperback) was written as a follow up to the SHIFT study, so the rest of us can absorb the findings.2 This mixed-methods study included a survey of over 1,600 students aged 18-29 from Columbia University and Barnard College regarding their relationships and sexual histories, including assault. Data were collected using daily diaries, focus groups, and hundreds of hours of field work observation by young researchers. One- to 3-hour in-depth interviews exploring sexual experiences on campus were conducted with 151 students. These interviews are the focus of the book. It is a well-written, provocative story brimming with insights for those of us who lack the time to scour social science literature.
“Sexual Citizens” and the SHIFT study confirmed much of what we know. Sexual assault is common and has enduring effects. The study found that 36% of women and 15% of men had experienced unwanted, nonconsensual sexual contact by senior year. Twenty percent of women and 6% of men were rape survivors. Freshman, LGBTQ, and minority students were found at highest risk of assault. SHIFT reaffirmed that abstinence-only education is not a protective factor against college sexual assault, but neither was knowledge of affirmative consent (the practice of “ongoing and explicit” checking-in with partners) which few students ever employed. Encouragingly, students taught refusal skills were less likely to experience sexual assault.
Many of the book’s valuable lessons fall under the umbrella of failures of language and communication. For example, after drinking, they went to his room. She was expecting a social interaction, but with no other place to sit, they sat on his bed where she was coaxed or pressured into a sexual encounter. Afterward, she leaves, and it is never discussed again. One partner desires emotional intimacy, and the other, bragging rights in the fraternity or at the girls’ weekly brunch. Numerous personal stories like these, though at times heart wrenching, provide perspective on the barriers to addressing assault.
Subjects relayed experiences of assault by strangers or friends, and some provided details of their own actions as perpetrators. Stumbling around words and emotions, an avoidance of explicit language stemmed from shame, a fear of personal responsibility, the desire to maintain social cohesion, and concern for potential consequences for the perpetrator. Many subjects were resistant to calling nonconsensual sexual activity rape or even assault. Some who had perpetrated were unaware their behavior may have been experienced as assault, with recognition of this fact dawning during interviews.
This apparent limitation in self-reflective capacity may be in part due to the conceptualization of what assault is. Focus groups identified a discernible difference in how men and women understood assaults, with men believing rapes looked like a woman fighting back and screaming for help ... which is rarely what happens.
Notably absent among the interviewed are any flagrant perpetrators. The methodology section theorizes that individuals who intentionally harmed their peers were unlikely to choose to participate in this study. In addition, the characterization of assailants as “sociopathic predators” is based in a history of racialized imagery that leads us astray from the truth about campus sexual assault. Most assaults do not involve force, and SHIFT data showed 75% of victims knew their assailants. Ultimately, a major aim of the research was to study assault alongside healthy sex to “understand those pivotal moments when encounters change from being sex, to being assault.” Doing this requires understanding the where, how, and why students have sex, a more complicated undertaking than we may think.
In discussing their sexual lives, subjects frequently noted they did not have space to talk about their assaults. Though 81% of students discussed their experiences with someone, friend groups were often overburdened with stories, which minimized the victim’s experience. Furthermore, most had not sought help from the student counseling centers. Students navigating this complex field were frequently doing so in isolation. SHIFT found subjects to be eager to participate; they would often express thankfulness, and a sense of freedom in sharing with researchers. Commonly, students expressly did not want retribution for perpetrators, but simply a place to be heard without challenge. The current legal system precludes that possibility, leaving individuals without the option to confront perpetrators, and perpetrators often not knowing the extent of the damage they caused.
Where can psychiatrists have an impact right now? “Sexual Citizens” identifies four key areas for intervention to work toward a world with less sexual assault. These are:
- Improving diversity, inequality, and power distortions.
- Education about sex and sexual assault.
- Substance use.
- Mental health.
Substance use and mental health are especially relevant for psychiatrists (That substance use contributes to sexual assault is known by approximately ... everybody!). Unwanted sexual contact prior to college (20% of students) increased the odds of experiencing assault during college. Harm reduction strategies should be introduced before college, according to the SHIFT research, particularly in skills-based training on how to say “No” to unwanted sex. Psychiatrists are likely used to asking brief history questions related to sexual assault and rape. “Sexual Citizens” highlights the inadequacy of this blunt language and guides the reader toward a refined knowledge of the language needed to address sexual assault.
Dr. Whisler is a child and adolescent psychiatry fellow at the Stanford (Calif.) University. Dr. Higgins is affiliate associate professor of psychiatry and family medicine at the Medical University of South Carolina, Charleston.
References
1. Hirsch JS et al. Social dimensions of sexual consent among cisgender heterosexual college students: Insights from ethnographic research. J Adolesc Health. 2019 Jan;64(1):26-35. doi: 10.1016/j.jadohealth.2018.06.011.
2. Hirsch JS and Khan S. Sexual citizens: Sex, power, and assault on campus. New York: W.W. Norton & Company, 2020.
The Sexual Health Initiative to Foster Transformation (SHIFT)1 is a landmark study about sexual assault at college, which has generated 20 scientific articles and several chapters in books, but unfortunately, has not made its way into the psychiatric literature.
“Sexual Citizens: Sex, Power and Assault on Campus,” by Jennifer Hirsch and Shamus Khan, (available in audio book and paperback) was written as a follow up to the SHIFT study, so the rest of us can absorb the findings.2 This mixed-methods study included a survey of over 1,600 students aged 18-29 from Columbia University and Barnard College regarding their relationships and sexual histories, including assault. Data were collected using daily diaries, focus groups, and hundreds of hours of field work observation by young researchers. One- to 3-hour in-depth interviews exploring sexual experiences on campus were conducted with 151 students. These interviews are the focus of the book. It is a well-written, provocative story brimming with insights for those of us who lack the time to scour social science literature.
“Sexual Citizens” and the SHIFT study confirmed much of what we know. Sexual assault is common and has enduring effects. The study found that 36% of women and 15% of men had experienced unwanted, nonconsensual sexual contact by senior year. Twenty percent of women and 6% of men were rape survivors. Freshman, LGBTQ, and minority students were found at highest risk of assault. SHIFT reaffirmed that abstinence-only education is not a protective factor against college sexual assault, but neither was knowledge of affirmative consent (the practice of “ongoing and explicit” checking-in with partners) which few students ever employed. Encouragingly, students taught refusal skills were less likely to experience sexual assault.
Many of the book’s valuable lessons fall under the umbrella of failures of language and communication. For example, after drinking, they went to his room. She was expecting a social interaction, but with no other place to sit, they sat on his bed where she was coaxed or pressured into a sexual encounter. Afterward, she leaves, and it is never discussed again. One partner desires emotional intimacy, and the other, bragging rights in the fraternity or at the girls’ weekly brunch. Numerous personal stories like these, though at times heart wrenching, provide perspective on the barriers to addressing assault.
Subjects relayed experiences of assault by strangers or friends, and some provided details of their own actions as perpetrators. Stumbling around words and emotions, an avoidance of explicit language stemmed from shame, a fear of personal responsibility, the desire to maintain social cohesion, and concern for potential consequences for the perpetrator. Many subjects were resistant to calling nonconsensual sexual activity rape or even assault. Some who had perpetrated were unaware their behavior may have been experienced as assault, with recognition of this fact dawning during interviews.
This apparent limitation in self-reflective capacity may be in part due to the conceptualization of what assault is. Focus groups identified a discernible difference in how men and women understood assaults, with men believing rapes looked like a woman fighting back and screaming for help ... which is rarely what happens.
Notably absent among the interviewed are any flagrant perpetrators. The methodology section theorizes that individuals who intentionally harmed their peers were unlikely to choose to participate in this study. In addition, the characterization of assailants as “sociopathic predators” is based in a history of racialized imagery that leads us astray from the truth about campus sexual assault. Most assaults do not involve force, and SHIFT data showed 75% of victims knew their assailants. Ultimately, a major aim of the research was to study assault alongside healthy sex to “understand those pivotal moments when encounters change from being sex, to being assault.” Doing this requires understanding the where, how, and why students have sex, a more complicated undertaking than we may think.
In discussing their sexual lives, subjects frequently noted they did not have space to talk about their assaults. Though 81% of students discussed their experiences with someone, friend groups were often overburdened with stories, which minimized the victim’s experience. Furthermore, most had not sought help from the student counseling centers. Students navigating this complex field were frequently doing so in isolation. SHIFT found subjects to be eager to participate; they would often express thankfulness, and a sense of freedom in sharing with researchers. Commonly, students expressly did not want retribution for perpetrators, but simply a place to be heard without challenge. The current legal system precludes that possibility, leaving individuals without the option to confront perpetrators, and perpetrators often not knowing the extent of the damage they caused.
Where can psychiatrists have an impact right now? “Sexual Citizens” identifies four key areas for intervention to work toward a world with less sexual assault. These are:
- Improving diversity, inequality, and power distortions.
- Education about sex and sexual assault.
- Substance use.
- Mental health.
Substance use and mental health are especially relevant for psychiatrists (That substance use contributes to sexual assault is known by approximately ... everybody!). Unwanted sexual contact prior to college (20% of students) increased the odds of experiencing assault during college. Harm reduction strategies should be introduced before college, according to the SHIFT research, particularly in skills-based training on how to say “No” to unwanted sex. Psychiatrists are likely used to asking brief history questions related to sexual assault and rape. “Sexual Citizens” highlights the inadequacy of this blunt language and guides the reader toward a refined knowledge of the language needed to address sexual assault.
Dr. Whisler is a child and adolescent psychiatry fellow at the Stanford (Calif.) University. Dr. Higgins is affiliate associate professor of psychiatry and family medicine at the Medical University of South Carolina, Charleston.
References
1. Hirsch JS et al. Social dimensions of sexual consent among cisgender heterosexual college students: Insights from ethnographic research. J Adolesc Health. 2019 Jan;64(1):26-35. doi: 10.1016/j.jadohealth.2018.06.011.
2. Hirsch JS and Khan S. Sexual citizens: Sex, power, and assault on campus. New York: W.W. Norton & Company, 2020.
A 63-year-old male presented for evaluation of worsening genital lesions and associated swelling
.1 Clinically, ENV presents as verrucous, hyperkeratotic, cobblestone-like patches, plaques, and nodules with associated nonpitting edema of the affected body area.1 Secondary bacterial infections are common and often worsen the clinical course. The etiology of ENV involves chronic lymphatic obstruction and venous insufficiency, with additional risk factors including obesity, chronic lymphedema, bacterial infection, surgery or trauma, neoplasia, radiation, congestive heart failure, or scleroderma.2,3 While most commonly presenting on the lower extremities, cases have been reported involving the abdomen, sacrum, ears, buttocks, and penoscrotal area.1,2
Regardless of location, the pathogenesis of ENV remains the same. Chronic lymphatic obstruction results in accumulation and lymphostasis of protein-rich dermal fluid, which subsequently precipitates fibroblast proliferation and activation, suppression of the local immune response and development of recurrent lymphangitis, chronic inflammation, and potential secondary bacterial infection.2,4
There is no standard of care for the treatment and management of ENV and recurrence is common. Interventions often involve those used for chronic lymphedema – including leg elevation, compression stockings or devices, skin hygiene, and lymphatic pumping.2,3 Medical management with topical and oral retinoids has been reported, as well as emphasis on weight loss and infection control.1,4 Surgical intervention is often reserved for refractory cases that fail to respond to more conservative management, or severe presentations resulting in extensive functional and aesthetic impairment. Less commonly reported treatment modalities include lymphaticovenular anastomosis and ablative carbon dioxide laser use, although this latter intervention demonstrated minimal improvement in this patient.5,6
Penoscrotal ENV is a rare form of ENV affecting the genital region of males, often resulting in significant disfigurement, functional impairment, and psychosocial distress. Penoscrotal elephantiasis can be idiopathic, due to filarial infections, scleroinflammatory stricture of the urethra, Chlamydia trachomatis infection, and lymphostasis secondary to chronic inflammatory conditions such as streptococcal infections, radiotherapy, surgery, chronic venous stasis, or Kaposi sarcoma.7
In addition, hidradenitis suppurativa (HS) has been documented multiple times in the literature in association with the development of ENV, detailing lymphatic scarring secondary to chronic inguinal HS as the main pathogenic factor.8,9
Surgery is the mainstay of treatment for penoscrotal ENV, which not only improves functionality and cosmesis, but also aids in prevention of rare malignant sequelae, such as lymphangiosarcoma.10 Such interventions can involve lymphangioplasty to aid in lymphatic drainage or excision of the mass and subcutaneous tissue with full-thickness skin grafting for reconstruction.7 Collaboration between urology, plastic surgery, and dermatology is often essential to obtain adequate care with satisfactory outcomes and minimal recurrence for patients with this uncommon condition.
This case and photo were submitted by Marlee Hill, a medical student at the University of Oklahoma, Oklahoma City; and Michael Franzetti, MD, and Jeffrey McBride, MD, department of dermatology, University of Oklahoma Health Sciences Center. The column was edited by Donna Bilu Martin, MD.
Dr. Donna Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to d[email protected].
References
1. Hadian Y et al. Dermatol Online J. 2019 Dec 15;25(12):13030/qt6rn1s8ff.
2. Judge N and Kilic A. J Dermatol Case Rep. 2016 Nov 13;10(2):32-4.
3. Dean SM et al. J Am Acad Dermatol. 2011 Jun;64(6):1104-10.
4. Sisto K and Khachemoune A. Am J Clin Dermatol. 2008;9(3):141-6.
5. Motegi S et al. Dermatology. 2007;215(2):147-51.
6. Robinson CG et al. J Cutan Med Surg. 2018;22(6):611-3.
7. Koualla S et al. Ann Chir Plast Esthet. 2023 Apr 10;S0294-1260(23)00035-3.
8. Lelonek E et al. Acta Derm Venereol. 2021 Feb 11;101(2):adv00389.
9. Good LM et al. J Am Acad Dermatol. 2011 May;64(5):993-4.
10. Cerri A et al. Eur J Dermatol. 1998 Oct-Nov;8(7):511-4.
.1 Clinically, ENV presents as verrucous, hyperkeratotic, cobblestone-like patches, plaques, and nodules with associated nonpitting edema of the affected body area.1 Secondary bacterial infections are common and often worsen the clinical course. The etiology of ENV involves chronic lymphatic obstruction and venous insufficiency, with additional risk factors including obesity, chronic lymphedema, bacterial infection, surgery or trauma, neoplasia, radiation, congestive heart failure, or scleroderma.2,3 While most commonly presenting on the lower extremities, cases have been reported involving the abdomen, sacrum, ears, buttocks, and penoscrotal area.1,2
Regardless of location, the pathogenesis of ENV remains the same. Chronic lymphatic obstruction results in accumulation and lymphostasis of protein-rich dermal fluid, which subsequently precipitates fibroblast proliferation and activation, suppression of the local immune response and development of recurrent lymphangitis, chronic inflammation, and potential secondary bacterial infection.2,4
There is no standard of care for the treatment and management of ENV and recurrence is common. Interventions often involve those used for chronic lymphedema – including leg elevation, compression stockings or devices, skin hygiene, and lymphatic pumping.2,3 Medical management with topical and oral retinoids has been reported, as well as emphasis on weight loss and infection control.1,4 Surgical intervention is often reserved for refractory cases that fail to respond to more conservative management, or severe presentations resulting in extensive functional and aesthetic impairment. Less commonly reported treatment modalities include lymphaticovenular anastomosis and ablative carbon dioxide laser use, although this latter intervention demonstrated minimal improvement in this patient.5,6
Penoscrotal ENV is a rare form of ENV affecting the genital region of males, often resulting in significant disfigurement, functional impairment, and psychosocial distress. Penoscrotal elephantiasis can be idiopathic, due to filarial infections, scleroinflammatory stricture of the urethra, Chlamydia trachomatis infection, and lymphostasis secondary to chronic inflammatory conditions such as streptococcal infections, radiotherapy, surgery, chronic venous stasis, or Kaposi sarcoma.7
In addition, hidradenitis suppurativa (HS) has been documented multiple times in the literature in association with the development of ENV, detailing lymphatic scarring secondary to chronic inguinal HS as the main pathogenic factor.8,9
Surgery is the mainstay of treatment for penoscrotal ENV, which not only improves functionality and cosmesis, but also aids in prevention of rare malignant sequelae, such as lymphangiosarcoma.10 Such interventions can involve lymphangioplasty to aid in lymphatic drainage or excision of the mass and subcutaneous tissue with full-thickness skin grafting for reconstruction.7 Collaboration between urology, plastic surgery, and dermatology is often essential to obtain adequate care with satisfactory outcomes and minimal recurrence for patients with this uncommon condition.
This case and photo were submitted by Marlee Hill, a medical student at the University of Oklahoma, Oklahoma City; and Michael Franzetti, MD, and Jeffrey McBride, MD, department of dermatology, University of Oklahoma Health Sciences Center. The column was edited by Donna Bilu Martin, MD.
Dr. Donna Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to d[email protected].
References
1. Hadian Y et al. Dermatol Online J. 2019 Dec 15;25(12):13030/qt6rn1s8ff.
2. Judge N and Kilic A. J Dermatol Case Rep. 2016 Nov 13;10(2):32-4.
3. Dean SM et al. J Am Acad Dermatol. 2011 Jun;64(6):1104-10.
4. Sisto K and Khachemoune A. Am J Clin Dermatol. 2008;9(3):141-6.
5. Motegi S et al. Dermatology. 2007;215(2):147-51.
6. Robinson CG et al. J Cutan Med Surg. 2018;22(6):611-3.
7. Koualla S et al. Ann Chir Plast Esthet. 2023 Apr 10;S0294-1260(23)00035-3.
8. Lelonek E et al. Acta Derm Venereol. 2021 Feb 11;101(2):adv00389.
9. Good LM et al. J Am Acad Dermatol. 2011 May;64(5):993-4.
10. Cerri A et al. Eur J Dermatol. 1998 Oct-Nov;8(7):511-4.
.1 Clinically, ENV presents as verrucous, hyperkeratotic, cobblestone-like patches, plaques, and nodules with associated nonpitting edema of the affected body area.1 Secondary bacterial infections are common and often worsen the clinical course. The etiology of ENV involves chronic lymphatic obstruction and venous insufficiency, with additional risk factors including obesity, chronic lymphedema, bacterial infection, surgery or trauma, neoplasia, radiation, congestive heart failure, or scleroderma.2,3 While most commonly presenting on the lower extremities, cases have been reported involving the abdomen, sacrum, ears, buttocks, and penoscrotal area.1,2
Regardless of location, the pathogenesis of ENV remains the same. Chronic lymphatic obstruction results in accumulation and lymphostasis of protein-rich dermal fluid, which subsequently precipitates fibroblast proliferation and activation, suppression of the local immune response and development of recurrent lymphangitis, chronic inflammation, and potential secondary bacterial infection.2,4
There is no standard of care for the treatment and management of ENV and recurrence is common. Interventions often involve those used for chronic lymphedema – including leg elevation, compression stockings or devices, skin hygiene, and lymphatic pumping.2,3 Medical management with topical and oral retinoids has been reported, as well as emphasis on weight loss and infection control.1,4 Surgical intervention is often reserved for refractory cases that fail to respond to more conservative management, or severe presentations resulting in extensive functional and aesthetic impairment. Less commonly reported treatment modalities include lymphaticovenular anastomosis and ablative carbon dioxide laser use, although this latter intervention demonstrated minimal improvement in this patient.5,6
Penoscrotal ENV is a rare form of ENV affecting the genital region of males, often resulting in significant disfigurement, functional impairment, and psychosocial distress. Penoscrotal elephantiasis can be idiopathic, due to filarial infections, scleroinflammatory stricture of the urethra, Chlamydia trachomatis infection, and lymphostasis secondary to chronic inflammatory conditions such as streptococcal infections, radiotherapy, surgery, chronic venous stasis, or Kaposi sarcoma.7
In addition, hidradenitis suppurativa (HS) has been documented multiple times in the literature in association with the development of ENV, detailing lymphatic scarring secondary to chronic inguinal HS as the main pathogenic factor.8,9
Surgery is the mainstay of treatment for penoscrotal ENV, which not only improves functionality and cosmesis, but also aids in prevention of rare malignant sequelae, such as lymphangiosarcoma.10 Such interventions can involve lymphangioplasty to aid in lymphatic drainage or excision of the mass and subcutaneous tissue with full-thickness skin grafting for reconstruction.7 Collaboration between urology, plastic surgery, and dermatology is often essential to obtain adequate care with satisfactory outcomes and minimal recurrence for patients with this uncommon condition.
This case and photo were submitted by Marlee Hill, a medical student at the University of Oklahoma, Oklahoma City; and Michael Franzetti, MD, and Jeffrey McBride, MD, department of dermatology, University of Oklahoma Health Sciences Center. The column was edited by Donna Bilu Martin, MD.
Dr. Donna Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to d[email protected].
References
1. Hadian Y et al. Dermatol Online J. 2019 Dec 15;25(12):13030/qt6rn1s8ff.
2. Judge N and Kilic A. J Dermatol Case Rep. 2016 Nov 13;10(2):32-4.
3. Dean SM et al. J Am Acad Dermatol. 2011 Jun;64(6):1104-10.
4. Sisto K and Khachemoune A. Am J Clin Dermatol. 2008;9(3):141-6.
5. Motegi S et al. Dermatology. 2007;215(2):147-51.
6. Robinson CG et al. J Cutan Med Surg. 2018;22(6):611-3.
7. Koualla S et al. Ann Chir Plast Esthet. 2023 Apr 10;S0294-1260(23)00035-3.
8. Lelonek E et al. Acta Derm Venereol. 2021 Feb 11;101(2):adv00389.
9. Good LM et al. J Am Acad Dermatol. 2011 May;64(5):993-4.
10. Cerri A et al. Eur J Dermatol. 1998 Oct-Nov;8(7):511-4.
A new nonhormonal option for menopausal hot flashes: What prescribers should know
This transcript has been edited for clarity.
Hello. I am Dr. JoAnn Pinkerton, professor of obstetrics and gynecology at the University of Virginia and a North American Menopause Society–credentialed menopause specialist.
I am excited to tell you about a brand-new, just-approved non-estrogen therapy for treatment of menopausal symptoms. . The manufacturer, Astellas, is expected to make fezolinetant available at pharmacies before the end of this year. This medication binds to and blocks the neurokinin 3 (NK3) receptor, which plays a role in regulating body temperature, leading to a reduction in hot flashes.
For women suffering from frequent moderate to severe hot flashes, fezolinetant is an exciting breakthrough in women’s health as it is a highly effective nonhormonal treatment that reduces hot flashes and improves quality of life.
In two phase 3 clinical trials (Johnson et al. and Lederman et al.), fezolinetant 45 mg reduced the frequency of vasomotor symptoms by about 65%, significantly more than placebo, and similar to the 75% reduction seen with hormone therapy. Fezolinetant’s efficacy becomes evident within 1 week, reducing both frequency and severity of hot flashes.
With respect to side effects, 1%-2% of the menopausal women participating in clinical trials reported adverse events, including headaches, abdominal pain, diarrhea, insomnia, back pain, hot flushes, and reversible elevated hepatic transaminases. Serious adverse events were infrequent.
Subgroup analysis of data presented at ACOG’s 2023 annual meeting noted fezolinetant’s effectiveness among diverse populations, including White or Black race, body mass index of 30 or higher, those younger or older than age 55, smokers, former smokers, and never smokers, in U.S. as well as in European trial participants.
With respect to safety, a 52-week placebo-controlled safety trial confirmed safety for this time period. Adverse effects on the endometrium were neither seen nor expected, as fezolinetant is a centrally acting non–estrogen-containing medication. In addition, no loss of bone density was seen.
Prior trials of neurokinin receptor antagonists suggested the potential for hepatotoxicity. Increases in ALT or AST noted in one of the phase 3 trials of fezolinetant were described as asymptomatic, isolated, intermittent, or transient and returned to baseline during treatment or after discontinuation. However, the FDA placed a warning about liver injury potential. Package labeling recommends baseline liver function tests before starting fezolinetant and at 3, 6, and 9 months. In addition, concomitant use of moderate CYP1A2 inhibitors, including many antidepressants and cimetidine, should be avoided.
As with other recently approved medications, I am concerned that high cost could prevent appropriate candidates from having access.
Until now, the FDA had approved only one nonhormone therapy for vasomotor symptoms, 7.5 mg paroxetine salt. However, neither this formulation nor off-label use of other SSRIs, SNRIs, gabapentinoids, oxybutynin, or clonidine are as effective as hormone therapy or fezolinetant for moderate to severe vasomotor symptoms.
For women with bothersome menopausal hot flashes who can’t or choose not to use hormone therapy, including those with estrogen-sensitive breast or uterine cancers, fezolinetant offers a much-needed, highly effective, safe, nonhormone/non-estrogen option to treat their hot flashes.
The FDA approved it for treating vasomotor symptoms of menopause (hot flashes and night sweats) but it also appears to improve sleep disruption, mood, and quality of life.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hello. I am Dr. JoAnn Pinkerton, professor of obstetrics and gynecology at the University of Virginia and a North American Menopause Society–credentialed menopause specialist.
I am excited to tell you about a brand-new, just-approved non-estrogen therapy for treatment of menopausal symptoms. . The manufacturer, Astellas, is expected to make fezolinetant available at pharmacies before the end of this year. This medication binds to and blocks the neurokinin 3 (NK3) receptor, which plays a role in regulating body temperature, leading to a reduction in hot flashes.
For women suffering from frequent moderate to severe hot flashes, fezolinetant is an exciting breakthrough in women’s health as it is a highly effective nonhormonal treatment that reduces hot flashes and improves quality of life.
In two phase 3 clinical trials (Johnson et al. and Lederman et al.), fezolinetant 45 mg reduced the frequency of vasomotor symptoms by about 65%, significantly more than placebo, and similar to the 75% reduction seen with hormone therapy. Fezolinetant’s efficacy becomes evident within 1 week, reducing both frequency and severity of hot flashes.
With respect to side effects, 1%-2% of the menopausal women participating in clinical trials reported adverse events, including headaches, abdominal pain, diarrhea, insomnia, back pain, hot flushes, and reversible elevated hepatic transaminases. Serious adverse events were infrequent.
Subgroup analysis of data presented at ACOG’s 2023 annual meeting noted fezolinetant’s effectiveness among diverse populations, including White or Black race, body mass index of 30 or higher, those younger or older than age 55, smokers, former smokers, and never smokers, in U.S. as well as in European trial participants.
With respect to safety, a 52-week placebo-controlled safety trial confirmed safety for this time period. Adverse effects on the endometrium were neither seen nor expected, as fezolinetant is a centrally acting non–estrogen-containing medication. In addition, no loss of bone density was seen.
Prior trials of neurokinin receptor antagonists suggested the potential for hepatotoxicity. Increases in ALT or AST noted in one of the phase 3 trials of fezolinetant were described as asymptomatic, isolated, intermittent, or transient and returned to baseline during treatment or after discontinuation. However, the FDA placed a warning about liver injury potential. Package labeling recommends baseline liver function tests before starting fezolinetant and at 3, 6, and 9 months. In addition, concomitant use of moderate CYP1A2 inhibitors, including many antidepressants and cimetidine, should be avoided.
As with other recently approved medications, I am concerned that high cost could prevent appropriate candidates from having access.
Until now, the FDA had approved only one nonhormone therapy for vasomotor symptoms, 7.5 mg paroxetine salt. However, neither this formulation nor off-label use of other SSRIs, SNRIs, gabapentinoids, oxybutynin, or clonidine are as effective as hormone therapy or fezolinetant for moderate to severe vasomotor symptoms.
For women with bothersome menopausal hot flashes who can’t or choose not to use hormone therapy, including those with estrogen-sensitive breast or uterine cancers, fezolinetant offers a much-needed, highly effective, safe, nonhormone/non-estrogen option to treat their hot flashes.
The FDA approved it for treating vasomotor symptoms of menopause (hot flashes and night sweats) but it also appears to improve sleep disruption, mood, and quality of life.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hello. I am Dr. JoAnn Pinkerton, professor of obstetrics and gynecology at the University of Virginia and a North American Menopause Society–credentialed menopause specialist.
I am excited to tell you about a brand-new, just-approved non-estrogen therapy for treatment of menopausal symptoms. . The manufacturer, Astellas, is expected to make fezolinetant available at pharmacies before the end of this year. This medication binds to and blocks the neurokinin 3 (NK3) receptor, which plays a role in regulating body temperature, leading to a reduction in hot flashes.
For women suffering from frequent moderate to severe hot flashes, fezolinetant is an exciting breakthrough in women’s health as it is a highly effective nonhormonal treatment that reduces hot flashes and improves quality of life.
In two phase 3 clinical trials (Johnson et al. and Lederman et al.), fezolinetant 45 mg reduced the frequency of vasomotor symptoms by about 65%, significantly more than placebo, and similar to the 75% reduction seen with hormone therapy. Fezolinetant’s efficacy becomes evident within 1 week, reducing both frequency and severity of hot flashes.
With respect to side effects, 1%-2% of the menopausal women participating in clinical trials reported adverse events, including headaches, abdominal pain, diarrhea, insomnia, back pain, hot flushes, and reversible elevated hepatic transaminases. Serious adverse events were infrequent.
Subgroup analysis of data presented at ACOG’s 2023 annual meeting noted fezolinetant’s effectiveness among diverse populations, including White or Black race, body mass index of 30 or higher, those younger or older than age 55, smokers, former smokers, and never smokers, in U.S. as well as in European trial participants.
With respect to safety, a 52-week placebo-controlled safety trial confirmed safety for this time period. Adverse effects on the endometrium were neither seen nor expected, as fezolinetant is a centrally acting non–estrogen-containing medication. In addition, no loss of bone density was seen.
Prior trials of neurokinin receptor antagonists suggested the potential for hepatotoxicity. Increases in ALT or AST noted in one of the phase 3 trials of fezolinetant were described as asymptomatic, isolated, intermittent, or transient and returned to baseline during treatment or after discontinuation. However, the FDA placed a warning about liver injury potential. Package labeling recommends baseline liver function tests before starting fezolinetant and at 3, 6, and 9 months. In addition, concomitant use of moderate CYP1A2 inhibitors, including many antidepressants and cimetidine, should be avoided.
As with other recently approved medications, I am concerned that high cost could prevent appropriate candidates from having access.
Until now, the FDA had approved only one nonhormone therapy for vasomotor symptoms, 7.5 mg paroxetine salt. However, neither this formulation nor off-label use of other SSRIs, SNRIs, gabapentinoids, oxybutynin, or clonidine are as effective as hormone therapy or fezolinetant for moderate to severe vasomotor symptoms.
For women with bothersome menopausal hot flashes who can’t or choose not to use hormone therapy, including those with estrogen-sensitive breast or uterine cancers, fezolinetant offers a much-needed, highly effective, safe, nonhormone/non-estrogen option to treat their hot flashes.
The FDA approved it for treating vasomotor symptoms of menopause (hot flashes and night sweats) but it also appears to improve sleep disruption, mood, and quality of life.
A version of this article first appeared on Medscape.com.
Are you a physician ... or a vending machine?
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.