For Residents

Figure 1

The FP suspected that this was a nodular basal cell carcinoma (BCC) with pigmentation. The physical exam was suspicious because of the pearly appearance, superficial ulcerations, and presence of telangiectasias with a loss of the normal pore pattern. Dermoscopy gave further evidence for a nodular BCC by revealing arborizing “tree-like” telangiectasias, ulcerations, shiny white areas, and gray-blue globules. Skin cancers often produce their own vascular supply and also ulcerate. The shiny white areas (which are the result of collagen deposition and occur in many skin cancers) are best seen with polarized dermoscopy.

The FP recommended a shave biopsy and performed one immediately after obtaining patient consent. (See the Watch & Learn video on “Shave biopsy.”) Knowing that the BCC would be vascular, the FP injected 1% lidocaine with epinephrine and waited 15 minutes for the epinephrine to work.

After seeing another patient, he performed the shave biopsy with a Dermablade, and used a cotton-tipped applicator to vigorously apply the aluminum chloride to the site. He used a twisting motion and pressure to stop most of the bleeding and then used his electrosurgical instrument—with a sharp tipped electrode—to stop recalcitrant bleeders.

The patient was given a diagnosis of BCC on the follow-up visit. The FP referred the patient for Mohs surgery because of the large size and location of the tumor.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Figure 1

The FP suspected that this was a nodular basal cell carcinoma (BCC) with pigmentation. The physical exam was suspicious because of the pearly appearance, superficial ulcerations, and presence of telangiectasias with a loss of the normal pore pattern. Dermoscopy gave further evidence for a nodular BCC by revealing arborizing “tree-like” telangiectasias, ulcerations, shiny white areas, and gray-blue globules. Skin cancers often produce their own vascular supply and also ulcerate. The shiny white areas (which are the result of collagen deposition and occur in many skin cancers) are best seen with polarized dermoscopy.

The FP recommended a shave biopsy and performed one immediately after obtaining patient consent. (See the Watch & Learn video on “Shave biopsy.”) Knowing that the BCC would be vascular, the FP injected 1% lidocaine with epinephrine and waited 15 minutes for the epinephrine to work.

After seeing another patient, he performed the shave biopsy with a Dermablade, and used a cotton-tipped applicator to vigorously apply the aluminum chloride to the site. He used a twisting motion and pressure to stop most of the bleeding and then used his electrosurgical instrument—with a sharp tipped electrode—to stop recalcitrant bleeders.

The patient was given a diagnosis of BCC on the follow-up visit. The FP referred the patient for Mohs surgery because of the large size and location of the tumor.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Figure 1

The FP suspected that this was a nodular basal cell carcinoma (BCC) with pigmentation. The physical exam was suspicious because of the pearly appearance, superficial ulcerations, and presence of telangiectasias with a loss of the normal pore pattern. Dermoscopy gave further evidence for a nodular BCC by revealing arborizing “tree-like” telangiectasias, ulcerations, shiny white areas, and gray-blue globules. Skin cancers often produce their own vascular supply and also ulcerate. The shiny white areas (which are the result of collagen deposition and occur in many skin cancers) are best seen with polarized dermoscopy.

The FP recommended a shave biopsy and performed one immediately after obtaining patient consent. (See the Watch & Learn video on “Shave biopsy.”) Knowing that the BCC would be vascular, the FP injected 1% lidocaine with epinephrine and waited 15 minutes for the epinephrine to work.

After seeing another patient, he performed the shave biopsy with a Dermablade, and used a cotton-tipped applicator to vigorously apply the aluminum chloride to the site. He used a twisting motion and pressure to stop most of the bleeding and then used his electrosurgical instrument—with a sharp tipped electrode—to stop recalcitrant bleeders.

The patient was given a diagnosis of BCC on the follow-up visit. The FP referred the patient for Mohs surgery because of the large size and location of the tumor.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The rate of burnout among physicians is disturbingly high, and wellness promotion is needed at all levels of training. While rigorous clinical training is necessary to build competence for making life-or-death decisions, training should not cause an indifference toward life or death. Because many physicians experience burnout during residency, we all must commit to wellness, which directly leads to healthier professionals and improved patient care.

Ey et al¹ evaluated the feasibility and application of a wellness program for residents/fellows and faculty in an academic health center over 10 years. They concluded that a comprehensive model of care was viable and well-valued, based on high levels of physician satisfaction with the program. This model, which involves educational outreach, direct care, and consultation, inspired me to reflect on the resident burnout prevention strategies employed by the residency program in which I am currently training.

Even in situations where a formal wellness program does not exist, measures that promote resident well-being can be embedded and easily adapted:

• Education on recognizing the early signs of burnout or establishing a “buddy system” can promote a help-seeking culture and ease the transition into residency.
• Faculty who provide feedback in the “sandwich method” (praise followed by corrective feedback followed by more praise) can help promote self-confidence among residents.
• Process groups and monthly meetings with chief residents present opportunities for professional development and for residents to express concerns.
• Social gatherings that encourage team building and regular interaction among residents, attendings, and family members help build a comforting sense of community.
• A residency program director and faculty who adopt open-door policies and foster personal attention and guidance are also essential.

A recent cross-sectional analysis found that building competence, autonomy, coping mechanisms, adequate sleep, and social relatedness were associated with resident well-being.² Hence, these factors should be integrated within residency training programs.

Residency should be approached as an engagement between colleagues where autonomy and confidence are promoted while residents acquire clinical skills within a wellness-promoting, learning environment. Demanding schedules may limit access to a dedicated wellness program; however, it is essential that a system be established to quickly identify and mitigate burnout. We all strive to be the best in our respective fields, and we must re-evaluate how we achieve excellent training while developing proper skills for future success. As physicians, we are not machines; our humanity connects us with our patients, explains life-changing news, or consoles the bereaved when there is loss of life. We must embrace our humanity and be mindful that physicians experiencing burnout cannot deliver high-quality care. Early detection and prevention strategies during residency training are key.

The rate of burnout among physicians is disturbingly high, and wellness promotion is needed at all levels of training. While rigorous clinical training is necessary to build competence for making life-or-death decisions, training should not cause an indifference toward life or death. Because many physicians experience burnout during residency, we all must commit to wellness, which directly leads to healthier professionals and improved patient care.

Ey et al¹ evaluated the feasibility and application of a wellness program for residents/fellows and faculty in an academic health center over 10 years. They concluded that a comprehensive model of care was viable and well-valued, based on high levels of physician satisfaction with the program. This model, which involves educational outreach, direct care, and consultation, inspired me to reflect on the resident burnout prevention strategies employed by the residency program in which I am currently training.

Even in situations where a formal wellness program does not exist, measures that promote resident well-being can be embedded and easily adapted:

• Education on recognizing the early signs of burnout or establishing a “buddy system” can promote a help-seeking culture and ease the transition into residency.
• Faculty who provide feedback in the “sandwich method” (praise followed by corrective feedback followed by more praise) can help promote self-confidence among residents.
• Process groups and monthly meetings with chief residents present opportunities for professional development and for residents to express concerns.
• Social gatherings that encourage team building and regular interaction among residents, attendings, and family members help build a comforting sense of community.
• A residency program director and faculty who adopt open-door policies and foster personal attention and guidance are also essential.

A recent cross-sectional analysis found that building competence, autonomy, coping mechanisms, adequate sleep, and social relatedness were associated with resident well-being.² Hence, these factors should be integrated within residency training programs.

Residency should be approached as an engagement between colleagues where autonomy and confidence are promoted while residents acquire clinical skills within a wellness-promoting, learning environment. Demanding schedules may limit access to a dedicated wellness program; however, it is essential that a system be established to quickly identify and mitigate burnout. We all strive to be the best in our respective fields, and we must re-evaluate how we achieve excellent training while developing proper skills for future success. As physicians, we are not machines; our humanity connects us with our patients, explains life-changing news, or consoles the bereaved when there is loss of life. We must embrace our humanity and be mindful that physicians experiencing burnout cannot deliver high-quality care. Early detection and prevention strategies during residency training are key.

The rate of burnout among physicians is disturbingly high, and wellness promotion is needed at all levels of training. While rigorous clinical training is necessary to build competence for making life-or-death decisions, training should not cause an indifference toward life or death. Because many physicians experience burnout during residency, we all must commit to wellness, which directly leads to healthier professionals and improved patient care.

Ey et al¹ evaluated the feasibility and application of a wellness program for residents/fellows and faculty in an academic health center over 10 years. They concluded that a comprehensive model of care was viable and well-valued, based on high levels of physician satisfaction with the program. This model, which involves educational outreach, direct care, and consultation, inspired me to reflect on the resident burnout prevention strategies employed by the residency program in which I am currently training.

Even in situations where a formal wellness program does not exist, measures that promote resident well-being can be embedded and easily adapted:

• Education on recognizing the early signs of burnout or establishing a “buddy system” can promote a help-seeking culture and ease the transition into residency.
• Faculty who provide feedback in the “sandwich method” (praise followed by corrective feedback followed by more praise) can help promote self-confidence among residents.
• Process groups and monthly meetings with chief residents present opportunities for professional development and for residents to express concerns.
• Social gatherings that encourage team building and regular interaction among residents, attendings, and family members help build a comforting sense of community.
• A residency program director and faculty who adopt open-door policies and foster personal attention and guidance are also essential.

A recent cross-sectional analysis found that building competence, autonomy, coping mechanisms, adequate sleep, and social relatedness were associated with resident well-being.² Hence, these factors should be integrated within residency training programs.

Residency should be approached as an engagement between colleagues where autonomy and confidence are promoted while residents acquire clinical skills within a wellness-promoting, learning environment. Demanding schedules may limit access to a dedicated wellness program; however, it is essential that a system be established to quickly identify and mitigate burnout. We all strive to be the best in our respective fields, and we must re-evaluate how we achieve excellent training while developing proper skills for future success. As physicians, we are not machines; our humanity connects us with our patients, explains life-changing news, or consoles the bereaved when there is loss of life. We must embrace our humanity and be mindful that physicians experiencing burnout cannot deliver high-quality care. Early detection and prevention strategies during residency training are key.

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

References

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

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

The most useful applications (apps) for health care professionals and students? Medical calculator apps (along with drug reference and disease diagnosis apps), according to surveys of clinicians and students.^1,2 The utility of calculator apps to these groups is not surprising; calculator apps fall in the category of clinical decision-making apps, which also includes decision support systems, clinical treatment guidelines, disease diagnosis aids, differential diagnosis aids, laboratory test ordering, laboratory test interpretation, and medical exams.³ Calculator apps obviously save time as most health care providers have not memorized the many medical formulas and do not have computational speed. I have previously discussed other, more ObGyn-specific calculators, such as due date calculators.^4,5 In this App Review column, however, I would like to highlight 3 general calculator apps: Calculate by QxMD, CliniCalc Medical Calculator, and Medscape. Researchers found all 3 apps 100% accurate and contained the most functions desired by internists.⁶ The apps are available at no cost and include many unique calculators. My colleagues and I actually used Calculate by QxMD to verify calculations in a previous study.⁷

A clinical example for how to apply calculators in practice is as follows: A multiparous patient at term has undergone an unscheduled cesarean delivery for arrest of dilation and intra-amniotic infection. You need to decide if the patient requires anti‑coagulants for deep venous thrombosis (DVT) prophylaxis and her necessary daily dose for gentamicin for postpartum infection prophylaxis. You can use Medscape’s body mass index (BMI) calculator to find out that this patient’s BMI is 45 kg/m² and that DVT prophylaxis is in fact indicated. You also can use QxMD’s ideal body weight calculator to get the patient’s weight and determine the appropriate daily dose for gentamicin.

The TABLE provides more information on the apps, with its inclusions based on a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature used, and important special features).⁷

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

The most useful applications (apps) for health care professionals and students? Medical calculator apps (along with drug reference and disease diagnosis apps), according to surveys of clinicians and students.^1,2 The utility of calculator apps to these groups is not surprising; calculator apps fall in the category of clinical decision-making apps, which also includes decision support systems, clinical treatment guidelines, disease diagnosis aids, differential diagnosis aids, laboratory test ordering, laboratory test interpretation, and medical exams.³ Calculator apps obviously save time as most health care providers have not memorized the many medical formulas and do not have computational speed. I have previously discussed other, more ObGyn-specific calculators, such as due date calculators.^4,5 In this App Review column, however, I would like to highlight 3 general calculator apps: Calculate by QxMD, CliniCalc Medical Calculator, and Medscape. Researchers found all 3 apps 100% accurate and contained the most functions desired by internists.⁶ The apps are available at no cost and include many unique calculators. My colleagues and I actually used Calculate by QxMD to verify calculations in a previous study.⁷

A clinical example for how to apply calculators in practice is as follows: A multiparous patient at term has undergone an unscheduled cesarean delivery for arrest of dilation and intra-amniotic infection. You need to decide if the patient requires anti‑coagulants for deep venous thrombosis (DVT) prophylaxis and her necessary daily dose for gentamicin for postpartum infection prophylaxis. You can use Medscape’s body mass index (BMI) calculator to find out that this patient’s BMI is 45 kg/m² and that DVT prophylaxis is in fact indicated. You also can use QxMD’s ideal body weight calculator to get the patient’s weight and determine the appropriate daily dose for gentamicin.

The TABLE provides more information on the apps, with its inclusions based on a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature used, and important special features).⁷

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

The most useful applications (apps) for health care professionals and students? Medical calculator apps (along with drug reference and disease diagnosis apps), according to surveys of clinicians and students.^1,2 The utility of calculator apps to these groups is not surprising; calculator apps fall in the category of clinical decision-making apps, which also includes decision support systems, clinical treatment guidelines, disease diagnosis aids, differential diagnosis aids, laboratory test ordering, laboratory test interpretation, and medical exams.³ Calculator apps obviously save time as most health care providers have not memorized the many medical formulas and do not have computational speed. I have previously discussed other, more ObGyn-specific calculators, such as due date calculators.^4,5 In this App Review column, however, I would like to highlight 3 general calculator apps: Calculate by QxMD, CliniCalc Medical Calculator, and Medscape. Researchers found all 3 apps 100% accurate and contained the most functions desired by internists.⁶ The apps are available at no cost and include many unique calculators. My colleagues and I actually used Calculate by QxMD to verify calculations in a previous study.⁷

A clinical example for how to apply calculators in practice is as follows: A multiparous patient at term has undergone an unscheduled cesarean delivery for arrest of dilation and intra-amniotic infection. You need to decide if the patient requires anti‑coagulants for deep venous thrombosis (DVT) prophylaxis and her necessary daily dose for gentamicin for postpartum infection prophylaxis. You can use Medscape’s body mass index (BMI) calculator to find out that this patient’s BMI is 45 kg/m² and that DVT prophylaxis is in fact indicated. You also can use QxMD’s ideal body weight calculator to get the patient’s weight and determine the appropriate daily dose for gentamicin.

The TABLE provides more information on the apps, with its inclusions based on a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature used, and important special features).⁷

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

Babies evolved to cry to get their needs met and adults evolved to be aroused by the sound. Perfect match, right? But crying/fussing was rated the No. 1 hardest part of parenting for 0- to 3-year-olds in our data from more than 68,000 parents.

Petro Feketa/iStockphoto

As clinicians, we become amazingly immune to the crying in our offices, but hopefully not to crying as a concern of parents. Our training directs us to look for pathology such as under- or overfeeding, infection, gastroesophageal reflux disease (GERD), volvulus, a hair tourniquet, or an injury as causes of crying. Having ruled these out, the bigger task is making sure that parents learn to read their infants’ crying and find ways to console them. Learning to handle crying can be tense, frustrating, and upsetting for parents, but success is ultimately satisfying and an important part of the reciprocal interaction that builds attachment for both parent and child.

“Developmental crying” is a great term for explaining crying in the first 3 months to families, as it is age related. The acronym PURPLE was created to teach about this normal crying.
 

• “P” is for peak of crying – babies may cry more each week, most in month 2, then less in months 3-5.
• “U” is for unexpected – crying can come and go without explanation.
• “R” is for resists soothing – babies may not stop crying no matter what is tried.
• “P” is for pain-like face – babies appear to be in pain, even if they are not.
• “L” is for long lasting – crying can last 5 hours a day or more.
• “E” is for evening – the baby might cry more in the late afternoon and evening.

The 1- to 2-week visit is a key time to teach parents about the expected upcoming crying and ways to manage it. I lean on the evidence-based steps for soothing, using the 5 S’s described by Harvey Karp, MD, based on the wisdom of T. Berry Brazelton, MD. These include:

• Swaddling in a wrap that constrains arms and legs.
• Side or stomach holding (but not for sleeping).
• Shushing sounds of voice, radio static, fan, air conditioner, or car ride.
• Swinging gently (point out to never shake a baby).
• Sucking on a pacifier, finger, or hand.

Because babies change state slowly and also respond to high caregiver emotion such as anxiety, it is important for parents to take some deep breaths and give each “S” several minutes to have an effect.

Some of our patients will go beyond typical crying to colic, defined as crying for at least 3 hours per day, at least 3 days per week, starting before 3 months post term. While typically easing by age 3 months, colic can in nightmare cases persist to age 1 year. Needless to say, prolonged crying can be an enormous stress for families. Researchers in the Fussy Baby Network consulting on infant crying have found value in a family prescription for REST: Reassurance, Empathy, Support, and Time away. Reassurance that the child is not ill should be provided after a careful history, including asking why parents think the baby is crying, and a physical exam, even if we think we can tell at a glance that the baby is okay. Remember that every parent’s first concern is whether the baby is okay, and crying indicates otherwise. Parents are counting on us for a thorough exam before we reassure them. Exhausted new parents deserve empathy – acknowledgment of how difficult, scary, and maddening it is to not be able to console their newborns.

While friends are saying “You must be so happy!” after a child is born, ambivalence (What have I done to my life?) is very common, but not easy to admit. We can point out that the typical age at which parents report “loving” their infants is actually more like 6 weeks, when they finally smile! To acknowledge ambivalence, I may say, “When you feel like throwing him out the window, it’s okay to lay him in the crib and put on headphones for a few minutes.” Music, meditation, yoga, or exercise are break activities that also can reduce parent stress.

Support for the parents is one of the most important protections for children at all ages, but can’t be assumed. Unfortunately, crying tends to increase beginning at 2 weeks post term, right when the partner returns to work or relatives leave. It is important to ask, “Who is helping you with the baby?” Just having a partner doesn’t mean that person is taking a turn! Fathers may be afraid of holding a baby, or may have no experience and try to defer. We need to encourage fathers in all aspects of care but especially to “find at least one way to console your baby.” Sometimes mothers “rescue” dads too quickly. While mothers may have both more experience with infants and the magic of breastfeeding for consoling, depriving fathers of working through the struggle of managing crying can result in their developing less confidence in caregiving. It also can cause them to miss out on supporting the mother at this delicate time, a chance to profoundly strengthen the partnership.

Taking into account the importance for parents of finding ways to console crying babies, getting some “time away” can be helpful, especially if crying goes on for months. Maybe those friends who asked, “What can I do to help?” could come over for an hour in the evening (peak crying time) to hold the baby. This also can be a chance for parent time together, a newly rare commodity.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Babies evolved to cry to get their needs met and adults evolved to be aroused by the sound. Perfect match, right? But crying/fussing was rated the No. 1 hardest part of parenting for 0- to 3-year-olds in our data from more than 68,000 parents.

Petro Feketa/iStockphoto

As clinicians, we become amazingly immune to the crying in our offices, but hopefully not to crying as a concern of parents. Our training directs us to look for pathology such as under- or overfeeding, infection, gastroesophageal reflux disease (GERD), volvulus, a hair tourniquet, or an injury as causes of crying. Having ruled these out, the bigger task is making sure that parents learn to read their infants’ crying and find ways to console them. Learning to handle crying can be tense, frustrating, and upsetting for parents, but success is ultimately satisfying and an important part of the reciprocal interaction that builds attachment for both parent and child.

“Developmental crying” is a great term for explaining crying in the first 3 months to families, as it is age related. The acronym PURPLE was created to teach about this normal crying.
 

• “P” is for peak of crying – babies may cry more each week, most in month 2, then less in months 3-5.
• “U” is for unexpected – crying can come and go without explanation.
• “R” is for resists soothing – babies may not stop crying no matter what is tried.
• “P” is for pain-like face – babies appear to be in pain, even if they are not.
• “L” is for long lasting – crying can last 5 hours a day or more.
• “E” is for evening – the baby might cry more in the late afternoon and evening.

The 1- to 2-week visit is a key time to teach parents about the expected upcoming crying and ways to manage it. I lean on the evidence-based steps for soothing, using the 5 S’s described by Harvey Karp, MD, based on the wisdom of T. Berry Brazelton, MD. These include:

• Swaddling in a wrap that constrains arms and legs.
• Side or stomach holding (but not for sleeping).
• Shushing sounds of voice, radio static, fan, air conditioner, or car ride.
• Swinging gently (point out to never shake a baby).
• Sucking on a pacifier, finger, or hand.

Because babies change state slowly and also respond to high caregiver emotion such as anxiety, it is important for parents to take some deep breaths and give each “S” several minutes to have an effect.

Some of our patients will go beyond typical crying to colic, defined as crying for at least 3 hours per day, at least 3 days per week, starting before 3 months post term. While typically easing by age 3 months, colic can in nightmare cases persist to age 1 year. Needless to say, prolonged crying can be an enormous stress for families. Researchers in the Fussy Baby Network consulting on infant crying have found value in a family prescription for REST: Reassurance, Empathy, Support, and Time away. Reassurance that the child is not ill should be provided after a careful history, including asking why parents think the baby is crying, and a physical exam, even if we think we can tell at a glance that the baby is okay. Remember that every parent’s first concern is whether the baby is okay, and crying indicates otherwise. Parents are counting on us for a thorough exam before we reassure them. Exhausted new parents deserve empathy – acknowledgment of how difficult, scary, and maddening it is to not be able to console their newborns.

While friends are saying “You must be so happy!” after a child is born, ambivalence (What have I done to my life?) is very common, but not easy to admit. We can point out that the typical age at which parents report “loving” their infants is actually more like 6 weeks, when they finally smile! To acknowledge ambivalence, I may say, “When you feel like throwing him out the window, it’s okay to lay him in the crib and put on headphones for a few minutes.” Music, meditation, yoga, or exercise are break activities that also can reduce parent stress.

Support for the parents is one of the most important protections for children at all ages, but can’t be assumed. Unfortunately, crying tends to increase beginning at 2 weeks post term, right when the partner returns to work or relatives leave. It is important to ask, “Who is helping you with the baby?” Just having a partner doesn’t mean that person is taking a turn! Fathers may be afraid of holding a baby, or may have no experience and try to defer. We need to encourage fathers in all aspects of care but especially to “find at least one way to console your baby.” Sometimes mothers “rescue” dads too quickly. While mothers may have both more experience with infants and the magic of breastfeeding for consoling, depriving fathers of working through the struggle of managing crying can result in their developing less confidence in caregiving. It also can cause them to miss out on supporting the mother at this delicate time, a chance to profoundly strengthen the partnership.

Taking into account the importance for parents of finding ways to console crying babies, getting some “time away” can be helpful, especially if crying goes on for months. Maybe those friends who asked, “What can I do to help?” could come over for an hour in the evening (peak crying time) to hold the baby. This also can be a chance for parent time together, a newly rare commodity.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Babies evolved to cry to get their needs met and adults evolved to be aroused by the sound. Perfect match, right? But crying/fussing was rated the No. 1 hardest part of parenting for 0- to 3-year-olds in our data from more than 68,000 parents.

Petro Feketa/iStockphoto

As clinicians, we become amazingly immune to the crying in our offices, but hopefully not to crying as a concern of parents. Our training directs us to look for pathology such as under- or overfeeding, infection, gastroesophageal reflux disease (GERD), volvulus, a hair tourniquet, or an injury as causes of crying. Having ruled these out, the bigger task is making sure that parents learn to read their infants’ crying and find ways to console them. Learning to handle crying can be tense, frustrating, and upsetting for parents, but success is ultimately satisfying and an important part of the reciprocal interaction that builds attachment for both parent and child.

“Developmental crying” is a great term for explaining crying in the first 3 months to families, as it is age related. The acronym PURPLE was created to teach about this normal crying.
 

• “P” is for peak of crying – babies may cry more each week, most in month 2, then less in months 3-5.
• “U” is for unexpected – crying can come and go without explanation.
• “R” is for resists soothing – babies may not stop crying no matter what is tried.
• “P” is for pain-like face – babies appear to be in pain, even if they are not.
• “L” is for long lasting – crying can last 5 hours a day or more.
• “E” is for evening – the baby might cry more in the late afternoon and evening.

The 1- to 2-week visit is a key time to teach parents about the expected upcoming crying and ways to manage it. I lean on the evidence-based steps for soothing, using the 5 S’s described by Harvey Karp, MD, based on the wisdom of T. Berry Brazelton, MD. These include:

• Swaddling in a wrap that constrains arms and legs.
• Side or stomach holding (but not for sleeping).
• Shushing sounds of voice, radio static, fan, air conditioner, or car ride.
• Swinging gently (point out to never shake a baby).
• Sucking on a pacifier, finger, or hand.

Because babies change state slowly and also respond to high caregiver emotion such as anxiety, it is important for parents to take some deep breaths and give each “S” several minutes to have an effect.

Some of our patients will go beyond typical crying to colic, defined as crying for at least 3 hours per day, at least 3 days per week, starting before 3 months post term. While typically easing by age 3 months, colic can in nightmare cases persist to age 1 year. Needless to say, prolonged crying can be an enormous stress for families. Researchers in the Fussy Baby Network consulting on infant crying have found value in a family prescription for REST: Reassurance, Empathy, Support, and Time away. Reassurance that the child is not ill should be provided after a careful history, including asking why parents think the baby is crying, and a physical exam, even if we think we can tell at a glance that the baby is okay. Remember that every parent’s first concern is whether the baby is okay, and crying indicates otherwise. Parents are counting on us for a thorough exam before we reassure them. Exhausted new parents deserve empathy – acknowledgment of how difficult, scary, and maddening it is to not be able to console their newborns.

While friends are saying “You must be so happy!” after a child is born, ambivalence (What have I done to my life?) is very common, but not easy to admit. We can point out that the typical age at which parents report “loving” their infants is actually more like 6 weeks, when they finally smile! To acknowledge ambivalence, I may say, “When you feel like throwing him out the window, it’s okay to lay him in the crib and put on headphones for a few minutes.” Music, meditation, yoga, or exercise are break activities that also can reduce parent stress.

Support for the parents is one of the most important protections for children at all ages, but can’t be assumed. Unfortunately, crying tends to increase beginning at 2 weeks post term, right when the partner returns to work or relatives leave. It is important to ask, “Who is helping you with the baby?” Just having a partner doesn’t mean that person is taking a turn! Fathers may be afraid of holding a baby, or may have no experience and try to defer. We need to encourage fathers in all aspects of care but especially to “find at least one way to console your baby.” Sometimes mothers “rescue” dads too quickly. While mothers may have both more experience with infants and the magic of breastfeeding for consoling, depriving fathers of working through the struggle of managing crying can result in their developing less confidence in caregiving. It also can cause them to miss out on supporting the mother at this delicate time, a chance to profoundly strengthen the partnership.

Taking into account the importance for parents of finding ways to console crying babies, getting some “time away” can be helpful, especially if crying goes on for months. Maybe those friends who asked, “What can I do to help?” could come over for an hour in the evening (peak crying time) to hold the baby. This also can be a chance for parent time together, a newly rare commodity.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

I think the question was intended as polite, dinner party chit chat ... maybe an attempt by a gracious hostess to make sure everyone was engaged in conversation.

“So what pediatric infectious disease should parents be most worried about?” she asked me.

I’ll admit that a couple of perfectly respectable and noncontroversial possibilities crossed my mind before I answered.

Acute flaccid myelitis? Measles?

When I replied, “gonorrhea,” conversation at the table pretty much stopped.

Let me explain. Acute flaccid myelitis is a polio-like neurologic condition that has been grabbing headlines. Yes, it is concerning that most cases have occurred in children and some affected children are left with long-term deficits. Technically though, AFM is a neurologic rather than an infectious disease. When cases occur, we suspect a viral infection but according to the Centers for Disease Control and Prevention, no pathogen has been consistently identified from the spinal fluid of infected patients. From August 2014 to September 2018, the CDC received information on 368 confirmed cases, so AFM fortunately is still rare.

News reports describe measles outbreaks raging in Europe – more than 41,000 cases so far this year, and 40 deaths – and warn that the United States could be next. But let’s be honest: We have a safe and effective vaccine for measles and outbreaks like this don’t happen when individuals are appropriately immunized. Parents, immunize your children. If you are lucky enough to be traveling to Europe with your baby, remember that MMR vaccine is indicated for 6- to 11-month olds, but it doesn’t count in the 2-dose series.

But gonorrhea?

In 2017, the World Health Organization included Neisseria gonorrhoeae on its list of bacteria that pose the greatest threat to human health and for which new antibiotics are urgently needed. The popular media are calling N. gonorrhoeae one of the new “superbugs.” Globally, patients are being diagnosed with strains of gonorrhea that are resistant to all commonly used antibiotics. As reported during IDWeek 2018 this October, patients also are being diagnosed in the United States.

CDC

Sancta St. Cyr, MD, of the Centers for Disease Control and Prevention, and her colleagues reported data from the Gonococcal Isolate Surveillance Project (GISP) and trends in multidrug resistant (MDR) and extensively-drug resistant (XDR) gonorrhea in the United States. A gonococcal isolate with resistance or elevated minimum inhibitory concentrations (MIC) to greater than or equal to two classes of antimicrobials is classified as MDR and an isolate with elevated MICs to greater than or equal to three classes of antimicrobials is classified as XDR. The MIC is the lowest antimicrobial concentration that inhibits growth of bacteria in the laboratory and rising MICs – evidence that higher levels of an antibiotic are needed to stop bacterial growth – can be an early indicator that resistance is emerging.

More than 150,000 gonococcal isolates were tested between 1987 and 2016. The first isolates with elevated MICs to cephalosporins and macrolides were identified in 1998, and since 2011, MDR resistance rates have hovered around 1%. In 2016, the rate was 1.1%, down from 1.3% in 2011. A single XDR isolate with resistance to fluoroquinolones with elevated MICs to both cephalosporins and macrolides was identified in 2011.

One could look at these data and ask if this is a “glass half full or half empty” situation, but I propose that clinicians and public health officials should not look at these data and be reassured that rates of MDR-gonorrhea remained stable between 2010 and 2016. According to a recent surveillance report released by the CDC, the absolute number of cases of gonorrhea has continued to rise. In 2017, there were 555,608 cases reported in the United States, a 67% increase since 2013. If we assume that rates of resistance in 2017 were similar to those in 2016, that’s more than 5,000 cases of MDR-gonorrhea in a single year.

“That’s bad,” one of my dining companions agreed. “But is gonorrhea really a pediatric issue?”

To answer that question, we just have to look at the numbers. According to the 2017 Youth Risk Behavior Survey, the percentage of high school students who had ever had sex was approximately 40% and about 10% of students had four or more lifetime partners. More than 45% of sexually active students denied the use of a condom during the last sexual intercourse. Certainly, that puts many teenagers at risk for sexually transmitted infections (STIs). Perhaps it shouldn’t be surprising that public health authorities report that half of all new STIs occur in individuals aged 15-24 years. Moreover, 25% of sexually active adolescent girls contract at least one STI.

Gonorrhea is the second most commonly reported notifiable disease in the United States, and according to the CDC, rates of disease in 2017 were highest among adolescents and young adults. In females specifically, the highest rates of gonorrhea were observed among those aged 20-24 years (684.8 cases per 100,000 females) and 15-19 years (557.4 cases per 100,000 females).

It makes sense that pediatricians and parents advocate for making the reduction of gonorrhea transmission rates a public health priority. We also need to recognize that prompt diagnosis and appropriate treatment are critical. Since 2015, dual therapy with ceftriaxone and azithromycin is the only CDC-recommended treatment for gonorrhea.

At that dinner party, my closest friend, who also happens to be a pediatrician, rolled her eyes and shot me look that I’m sure meant, “Nobody really wants to talk about gonorrhea over dessert.” Still, because she is a good friend she said, “So basically you’re saying that millions of teenagers are getting infected with a form of gonorrhea that takes at least two antibiotics to treat, and if this keeps up, we may see kids with untreatable infection. Now that is scary.”

I kept quiet after that but I wanted to mention that in 2017, less than 85% of patients diagnosed with gonorrhea at selected surveillance sites received the recommended treatment with two antibiotics. Patients with inadequately treated gonorrhea are at risk for a host of sequelae. Women can develop pelvic inflammatory disease, abscesses, chronic pelvic pain, and damage of the fallopian tubes that can lead to infertility. Men can develop epididymitis, which occasionally results in infertility. Rarely, N. gonorrhoeae can spread to the blood and cause life-threatening infection. Of course, patients who aren’t treated appropriately may continue to spread the bacteria. Scary? You bet.

For pediatricians who need a refresher course in the treatment of STIs, there are free resources available. The CDC’s 2015 STD Treatment Guidelines are available in a free app; the app contains a nice refresher on taking a sexual history. There also is a print version, wall chart, and pocket guide. Providers also may want to check out the National STD Curriculum offered by the University of Washington STD Prevention Training Center and the University of Washington. Visit https://www.std.uw.edu/.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

I think the question was intended as polite, dinner party chit chat ... maybe an attempt by a gracious hostess to make sure everyone was engaged in conversation.

“So what pediatric infectious disease should parents be most worried about?” she asked me.

I’ll admit that a couple of perfectly respectable and noncontroversial possibilities crossed my mind before I answered.

Acute flaccid myelitis? Measles?

When I replied, “gonorrhea,” conversation at the table pretty much stopped.

Let me explain. Acute flaccid myelitis is a polio-like neurologic condition that has been grabbing headlines. Yes, it is concerning that most cases have occurred in children and some affected children are left with long-term deficits. Technically though, AFM is a neurologic rather than an infectious disease. When cases occur, we suspect a viral infection but according to the Centers for Disease Control and Prevention, no pathogen has been consistently identified from the spinal fluid of infected patients. From August 2014 to September 2018, the CDC received information on 368 confirmed cases, so AFM fortunately is still rare.

News reports describe measles outbreaks raging in Europe – more than 41,000 cases so far this year, and 40 deaths – and warn that the United States could be next. But let’s be honest: We have a safe and effective vaccine for measles and outbreaks like this don’t happen when individuals are appropriately immunized. Parents, immunize your children. If you are lucky enough to be traveling to Europe with your baby, remember that MMR vaccine is indicated for 6- to 11-month olds, but it doesn’t count in the 2-dose series.

But gonorrhea?

In 2017, the World Health Organization included Neisseria gonorrhoeae on its list of bacteria that pose the greatest threat to human health and for which new antibiotics are urgently needed. The popular media are calling N. gonorrhoeae one of the new “superbugs.” Globally, patients are being diagnosed with strains of gonorrhea that are resistant to all commonly used antibiotics. As reported during IDWeek 2018 this October, patients also are being diagnosed in the United States.

CDC

Sancta St. Cyr, MD, of the Centers for Disease Control and Prevention, and her colleagues reported data from the Gonococcal Isolate Surveillance Project (GISP) and trends in multidrug resistant (MDR) and extensively-drug resistant (XDR) gonorrhea in the United States. A gonococcal isolate with resistance or elevated minimum inhibitory concentrations (MIC) to greater than or equal to two classes of antimicrobials is classified as MDR and an isolate with elevated MICs to greater than or equal to three classes of antimicrobials is classified as XDR. The MIC is the lowest antimicrobial concentration that inhibits growth of bacteria in the laboratory and rising MICs – evidence that higher levels of an antibiotic are needed to stop bacterial growth – can be an early indicator that resistance is emerging.

More than 150,000 gonococcal isolates were tested between 1987 and 2016. The first isolates with elevated MICs to cephalosporins and macrolides were identified in 1998, and since 2011, MDR resistance rates have hovered around 1%. In 2016, the rate was 1.1%, down from 1.3% in 2011. A single XDR isolate with resistance to fluoroquinolones with elevated MICs to both cephalosporins and macrolides was identified in 2011.

One could look at these data and ask if this is a “glass half full or half empty” situation, but I propose that clinicians and public health officials should not look at these data and be reassured that rates of MDR-gonorrhea remained stable between 2010 and 2016. According to a recent surveillance report released by the CDC, the absolute number of cases of gonorrhea has continued to rise. In 2017, there were 555,608 cases reported in the United States, a 67% increase since 2013. If we assume that rates of resistance in 2017 were similar to those in 2016, that’s more than 5,000 cases of MDR-gonorrhea in a single year.

“That’s bad,” one of my dining companions agreed. “But is gonorrhea really a pediatric issue?”

To answer that question, we just have to look at the numbers. According to the 2017 Youth Risk Behavior Survey, the percentage of high school students who had ever had sex was approximately 40% and about 10% of students had four or more lifetime partners. More than 45% of sexually active students denied the use of a condom during the last sexual intercourse. Certainly, that puts many teenagers at risk for sexually transmitted infections (STIs). Perhaps it shouldn’t be surprising that public health authorities report that half of all new STIs occur in individuals aged 15-24 years. Moreover, 25% of sexually active adolescent girls contract at least one STI.

Gonorrhea is the second most commonly reported notifiable disease in the United States, and according to the CDC, rates of disease in 2017 were highest among adolescents and young adults. In females specifically, the highest rates of gonorrhea were observed among those aged 20-24 years (684.8 cases per 100,000 females) and 15-19 years (557.4 cases per 100,000 females).

It makes sense that pediatricians and parents advocate for making the reduction of gonorrhea transmission rates a public health priority. We also need to recognize that prompt diagnosis and appropriate treatment are critical. Since 2015, dual therapy with ceftriaxone and azithromycin is the only CDC-recommended treatment for gonorrhea.

At that dinner party, my closest friend, who also happens to be a pediatrician, rolled her eyes and shot me look that I’m sure meant, “Nobody really wants to talk about gonorrhea over dessert.” Still, because she is a good friend she said, “So basically you’re saying that millions of teenagers are getting infected with a form of gonorrhea that takes at least two antibiotics to treat, and if this keeps up, we may see kids with untreatable infection. Now that is scary.”

I kept quiet after that but I wanted to mention that in 2017, less than 85% of patients diagnosed with gonorrhea at selected surveillance sites received the recommended treatment with two antibiotics. Patients with inadequately treated gonorrhea are at risk for a host of sequelae. Women can develop pelvic inflammatory disease, abscesses, chronic pelvic pain, and damage of the fallopian tubes that can lead to infertility. Men can develop epididymitis, which occasionally results in infertility. Rarely, N. gonorrhoeae can spread to the blood and cause life-threatening infection. Of course, patients who aren’t treated appropriately may continue to spread the bacteria. Scary? You bet.

For pediatricians who need a refresher course in the treatment of STIs, there are free resources available. The CDC’s 2015 STD Treatment Guidelines are available in a free app; the app contains a nice refresher on taking a sexual history. There also is a print version, wall chart, and pocket guide. Providers also may want to check out the National STD Curriculum offered by the University of Washington STD Prevention Training Center and the University of Washington. Visit https://www.std.uw.edu/.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

I think the question was intended as polite, dinner party chit chat ... maybe an attempt by a gracious hostess to make sure everyone was engaged in conversation.

“So what pediatric infectious disease should parents be most worried about?” she asked me.

I’ll admit that a couple of perfectly respectable and noncontroversial possibilities crossed my mind before I answered.

Acute flaccid myelitis? Measles?

When I replied, “gonorrhea,” conversation at the table pretty much stopped.

Let me explain. Acute flaccid myelitis is a polio-like neurologic condition that has been grabbing headlines. Yes, it is concerning that most cases have occurred in children and some affected children are left with long-term deficits. Technically though, AFM is a neurologic rather than an infectious disease. When cases occur, we suspect a viral infection but according to the Centers for Disease Control and Prevention, no pathogen has been consistently identified from the spinal fluid of infected patients. From August 2014 to September 2018, the CDC received information on 368 confirmed cases, so AFM fortunately is still rare.

News reports describe measles outbreaks raging in Europe – more than 41,000 cases so far this year, and 40 deaths – and warn that the United States could be next. But let’s be honest: We have a safe and effective vaccine for measles and outbreaks like this don’t happen when individuals are appropriately immunized. Parents, immunize your children. If you are lucky enough to be traveling to Europe with your baby, remember that MMR vaccine is indicated for 6- to 11-month olds, but it doesn’t count in the 2-dose series.

But gonorrhea?

In 2017, the World Health Organization included Neisseria gonorrhoeae on its list of bacteria that pose the greatest threat to human health and for which new antibiotics are urgently needed. The popular media are calling N. gonorrhoeae one of the new “superbugs.” Globally, patients are being diagnosed with strains of gonorrhea that are resistant to all commonly used antibiotics. As reported during IDWeek 2018 this October, patients also are being diagnosed in the United States.

CDC

Sancta St. Cyr, MD, of the Centers for Disease Control and Prevention, and her colleagues reported data from the Gonococcal Isolate Surveillance Project (GISP) and trends in multidrug resistant (MDR) and extensively-drug resistant (XDR) gonorrhea in the United States. A gonococcal isolate with resistance or elevated minimum inhibitory concentrations (MIC) to greater than or equal to two classes of antimicrobials is classified as MDR and an isolate with elevated MICs to greater than or equal to three classes of antimicrobials is classified as XDR. The MIC is the lowest antimicrobial concentration that inhibits growth of bacteria in the laboratory and rising MICs – evidence that higher levels of an antibiotic are needed to stop bacterial growth – can be an early indicator that resistance is emerging.

More than 150,000 gonococcal isolates were tested between 1987 and 2016. The first isolates with elevated MICs to cephalosporins and macrolides were identified in 1998, and since 2011, MDR resistance rates have hovered around 1%. In 2016, the rate was 1.1%, down from 1.3% in 2011. A single XDR isolate with resistance to fluoroquinolones with elevated MICs to both cephalosporins and macrolides was identified in 2011.

One could look at these data and ask if this is a “glass half full or half empty” situation, but I propose that clinicians and public health officials should not look at these data and be reassured that rates of MDR-gonorrhea remained stable between 2010 and 2016. According to a recent surveillance report released by the CDC, the absolute number of cases of gonorrhea has continued to rise. In 2017, there were 555,608 cases reported in the United States, a 67% increase since 2013. If we assume that rates of resistance in 2017 were similar to those in 2016, that’s more than 5,000 cases of MDR-gonorrhea in a single year.

“That’s bad,” one of my dining companions agreed. “But is gonorrhea really a pediatric issue?”

To answer that question, we just have to look at the numbers. According to the 2017 Youth Risk Behavior Survey, the percentage of high school students who had ever had sex was approximately 40% and about 10% of students had four or more lifetime partners. More than 45% of sexually active students denied the use of a condom during the last sexual intercourse. Certainly, that puts many teenagers at risk for sexually transmitted infections (STIs). Perhaps it shouldn’t be surprising that public health authorities report that half of all new STIs occur in individuals aged 15-24 years. Moreover, 25% of sexually active adolescent girls contract at least one STI.

Gonorrhea is the second most commonly reported notifiable disease in the United States, and according to the CDC, rates of disease in 2017 were highest among adolescents and young adults. In females specifically, the highest rates of gonorrhea were observed among those aged 20-24 years (684.8 cases per 100,000 females) and 15-19 years (557.4 cases per 100,000 females).

It makes sense that pediatricians and parents advocate for making the reduction of gonorrhea transmission rates a public health priority. We also need to recognize that prompt diagnosis and appropriate treatment are critical. Since 2015, dual therapy with ceftriaxone and azithromycin is the only CDC-recommended treatment for gonorrhea.

At that dinner party, my closest friend, who also happens to be a pediatrician, rolled her eyes and shot me look that I’m sure meant, “Nobody really wants to talk about gonorrhea over dessert.” Still, because she is a good friend she said, “So basically you’re saying that millions of teenagers are getting infected with a form of gonorrhea that takes at least two antibiotics to treat, and if this keeps up, we may see kids with untreatable infection. Now that is scary.”

I kept quiet after that but I wanted to mention that in 2017, less than 85% of patients diagnosed with gonorrhea at selected surveillance sites received the recommended treatment with two antibiotics. Patients with inadequately treated gonorrhea are at risk for a host of sequelae. Women can develop pelvic inflammatory disease, abscesses, chronic pelvic pain, and damage of the fallopian tubes that can lead to infertility. Men can develop epididymitis, which occasionally results in infertility. Rarely, N. gonorrhoeae can spread to the blood and cause life-threatening infection. Of course, patients who aren’t treated appropriately may continue to spread the bacteria. Scary? You bet.

For pediatricians who need a refresher course in the treatment of STIs, there are free resources available. The CDC’s 2015 STD Treatment Guidelines are available in a free app; the app contains a nice refresher on taking a sexual history. There also is a print version, wall chart, and pocket guide. Providers also may want to check out the National STD Curriculum offered by the University of Washington STD Prevention Training Center and the University of Washington. Visit https://www.std.uw.edu/.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

The FP suspected a basal cell carcinoma (BCC) or squamous cell carcinoma.

Informed consent was obtained, and the FP numbed the area with 1% lidocaine and epinephrine using a 30 gauge needle. The area was exquisitely tender, so a small needle was used and the anesthesia was injected slowly. (It is safe and recommended to use epinephrine for biopsy on or around the nose.) The physician performed a shave biopsy. (See the Watch & Learn video on “Shave biopsy.”)

The biopsy results confirmed an infiltrative BCC. The physician recognized this as a more aggressive BCC and its location at the nasolabial fold suggested that the patient was at an increased risk for recurrence. He communicated these risk factors to the patient, and she accepted a referral for Mohs surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP suspected a basal cell carcinoma (BCC) or squamous cell carcinoma.

Informed consent was obtained, and the FP numbed the area with 1% lidocaine and epinephrine using a 30 gauge needle. The area was exquisitely tender, so a small needle was used and the anesthesia was injected slowly. (It is safe and recommended to use epinephrine for biopsy on or around the nose.) The physician performed a shave biopsy. (See the Watch & Learn video on “Shave biopsy.”)

The biopsy results confirmed an infiltrative BCC. The physician recognized this as a more aggressive BCC and its location at the nasolabial fold suggested that the patient was at an increased risk for recurrence. He communicated these risk factors to the patient, and she accepted a referral for Mohs surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP suspected a basal cell carcinoma (BCC) or squamous cell carcinoma.

Informed consent was obtained, and the FP numbed the area with 1% lidocaine and epinephrine using a 30 gauge needle. The area was exquisitely tender, so a small needle was used and the anesthesia was injected slowly. (It is safe and recommended to use epinephrine for biopsy on or around the nose.) The physician performed a shave biopsy. (See the Watch & Learn video on “Shave biopsy.”)

The biopsy results confirmed an infiltrative BCC. The physician recognized this as a more aggressive BCC and its location at the nasolabial fold suggested that the patient was at an increased risk for recurrence. He communicated these risk factors to the patient, and she accepted a referral for Mohs surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

SAN FRANCISCO – There’s no need to wait for western blot results to differentiate Lyme arthritis from septic arthritis in children, as long as your lab, like many, uses the Liaison Borrelia burgdorferi assay, according to investigators at the University of Minnesota, Minneapolis.

M. Alexander Otto/MDedge News

Acute, isolated monoarthritis presents with a single swollen joint and pain whether it’s due to Lyme disease or infection, so it’s hard to tell them apart. Current guidelines recommend a two-tier approach to diagnose Lyme arthritis, an initial blood screen followed by western blot confirmation. Screening results come back in a few hours, but western blot confirmation can take days.

In the meantime, children are treated presumptively for the more concerning diagnosis – septic arthritis – which means hospitalization, surgical drainage, and IV antibiotics. Those who turn out to have Lyme are exposed to the risks and costs of unnecessary treatment and delays to proper diagnosis and doxycycline.

When “kids come in with a swollen knee, maybe 10% or 15% end up in the hospital being treated for septic arthritis that they never had. I wanted to see if we can diagnose Lyme arthritis more quickly,” said lead investigator Bazak Sharon, MD, a pediatric infectious disease specialist at the university’s Masonic Children’s Hospital.

Masonic and its affiliated health system use the Liaison Borrelia burgdorferi assay (DiaSorin) to screen for Lyme, and a careful parsing of the results seems to solve the problem.

Liaison is a chemiluminescence immunoassay that uses light to measure IgM and IgG antibodies to a B. burgdorferi surface protein in serum samples. Results are reported as relative light units (RLUs); below 0.9 RLUs is negative; 0.9-1.1 is equivocal, and over 1.1 is positive.

It’s where patients fall in the range of positivity that matters when it comes to differentiating Lyme from septic arthritis, Dr. Sharon said at ID Week, an annual scientific meeting on infectious diseases (Clin Vaccine Immunol. 2008 Dec;15[12]:1796-804).

He and his team reviewed 60 cases of acute, isolated monoarthritis culled from more than 700 children who presented with joint complaints from 2011 to 2016; 47 had Lyme arthritis confirmed by western blot; 13 had septic arthritis.

It turned out that “every single patient with a” Liaison value of 9 RLUs or higher was confirmed on western blot for Lyme. “Under 9, there was not a single case of Lyme arthritis,” Dr. Sharon said. Three other patients with acute arthritis also tested positive on the screen, but their RLU values were below 4; two turned out to be trauma related and one was ultimately diagnosed with juvenile idiopathic arthritis. Western blots were negative in all three.

The RLU number reported on the screening test “appears to correlate very well with Lyme arthritis. In an otherwise healthy child presenting with acute joint swelling, utilizing this screening test can confirm clinical suspicion of Lyme arthritis within hours, and prevent the potential harmful interventions accompanying a misdiagnosis of septic arthritis. Just do the screening. If it comes up above 9, you’ve got Lyme arthritis,” and don’t need to wait for western blot results to treat, Dr. Sharon said.

In other words, above 9, treat for Lyme.

The investigators plan to delve further into their results with sensitivity/specificity and other analyses before publishing. Ultimately, “my goal is to have a better diagnosis algorithm for kids who present with acute, isolated monoarthritis,” Dr. Sharon said.

There was no industry funding for the work, and the investigators didn’t have any disclosures.
 

[email protected]

SOURCE: Sharon B et al. 2018 ID Week abstract 286.

SAN FRANCISCO – There’s no need to wait for western blot results to differentiate Lyme arthritis from septic arthritis in children, as long as your lab, like many, uses the Liaison Borrelia burgdorferi assay, according to investigators at the University of Minnesota, Minneapolis.

M. Alexander Otto/MDedge News

Acute, isolated monoarthritis presents with a single swollen joint and pain whether it’s due to Lyme disease or infection, so it’s hard to tell them apart. Current guidelines recommend a two-tier approach to diagnose Lyme arthritis, an initial blood screen followed by western blot confirmation. Screening results come back in a few hours, but western blot confirmation can take days.

In the meantime, children are treated presumptively for the more concerning diagnosis – septic arthritis – which means hospitalization, surgical drainage, and IV antibiotics. Those who turn out to have Lyme are exposed to the risks and costs of unnecessary treatment and delays to proper diagnosis and doxycycline.

When “kids come in with a swollen knee, maybe 10% or 15% end up in the hospital being treated for septic arthritis that they never had. I wanted to see if we can diagnose Lyme arthritis more quickly,” said lead investigator Bazak Sharon, MD, a pediatric infectious disease specialist at the university’s Masonic Children’s Hospital.

Masonic and its affiliated health system use the Liaison Borrelia burgdorferi assay (DiaSorin) to screen for Lyme, and a careful parsing of the results seems to solve the problem.

Liaison is a chemiluminescence immunoassay that uses light to measure IgM and IgG antibodies to a B. burgdorferi surface protein in serum samples. Results are reported as relative light units (RLUs); below 0.9 RLUs is negative; 0.9-1.1 is equivocal, and over 1.1 is positive.

It’s where patients fall in the range of positivity that matters when it comes to differentiating Lyme from septic arthritis, Dr. Sharon said at ID Week, an annual scientific meeting on infectious diseases (Clin Vaccine Immunol. 2008 Dec;15[12]:1796-804).

He and his team reviewed 60 cases of acute, isolated monoarthritis culled from more than 700 children who presented with joint complaints from 2011 to 2016; 47 had Lyme arthritis confirmed by western blot; 13 had septic arthritis.

It turned out that “every single patient with a” Liaison value of 9 RLUs or higher was confirmed on western blot for Lyme. “Under 9, there was not a single case of Lyme arthritis,” Dr. Sharon said. Three other patients with acute arthritis also tested positive on the screen, but their RLU values were below 4; two turned out to be trauma related and one was ultimately diagnosed with juvenile idiopathic arthritis. Western blots were negative in all three.

The RLU number reported on the screening test “appears to correlate very well with Lyme arthritis. In an otherwise healthy child presenting with acute joint swelling, utilizing this screening test can confirm clinical suspicion of Lyme arthritis within hours, and prevent the potential harmful interventions accompanying a misdiagnosis of septic arthritis. Just do the screening. If it comes up above 9, you’ve got Lyme arthritis,” and don’t need to wait for western blot results to treat, Dr. Sharon said.

In other words, above 9, treat for Lyme.

The investigators plan to delve further into their results with sensitivity/specificity and other analyses before publishing. Ultimately, “my goal is to have a better diagnosis algorithm for kids who present with acute, isolated monoarthritis,” Dr. Sharon said.

There was no industry funding for the work, and the investigators didn’t have any disclosures.
 

[email protected]

SOURCE: Sharon B et al. 2018 ID Week abstract 286.

SAN FRANCISCO – There’s no need to wait for western blot results to differentiate Lyme arthritis from septic arthritis in children, as long as your lab, like many, uses the Liaison Borrelia burgdorferi assay, according to investigators at the University of Minnesota, Minneapolis.

M. Alexander Otto/MDedge News

Acute, isolated monoarthritis presents with a single swollen joint and pain whether it’s due to Lyme disease or infection, so it’s hard to tell them apart. Current guidelines recommend a two-tier approach to diagnose Lyme arthritis, an initial blood screen followed by western blot confirmation. Screening results come back in a few hours, but western blot confirmation can take days.

In the meantime, children are treated presumptively for the more concerning diagnosis – septic arthritis – which means hospitalization, surgical drainage, and IV antibiotics. Those who turn out to have Lyme are exposed to the risks and costs of unnecessary treatment and delays to proper diagnosis and doxycycline.

When “kids come in with a swollen knee, maybe 10% or 15% end up in the hospital being treated for septic arthritis that they never had. I wanted to see if we can diagnose Lyme arthritis more quickly,” said lead investigator Bazak Sharon, MD, a pediatric infectious disease specialist at the university’s Masonic Children’s Hospital.

Masonic and its affiliated health system use the Liaison Borrelia burgdorferi assay (DiaSorin) to screen for Lyme, and a careful parsing of the results seems to solve the problem.

Liaison is a chemiluminescence immunoassay that uses light to measure IgM and IgG antibodies to a B. burgdorferi surface protein in serum samples. Results are reported as relative light units (RLUs); below 0.9 RLUs is negative; 0.9-1.1 is equivocal, and over 1.1 is positive.

It’s where patients fall in the range of positivity that matters when it comes to differentiating Lyme from septic arthritis, Dr. Sharon said at ID Week, an annual scientific meeting on infectious diseases (Clin Vaccine Immunol. 2008 Dec;15[12]:1796-804).

He and his team reviewed 60 cases of acute, isolated monoarthritis culled from more than 700 children who presented with joint complaints from 2011 to 2016; 47 had Lyme arthritis confirmed by western blot; 13 had septic arthritis.

It turned out that “every single patient with a” Liaison value of 9 RLUs or higher was confirmed on western blot for Lyme. “Under 9, there was not a single case of Lyme arthritis,” Dr. Sharon said. Three other patients with acute arthritis also tested positive on the screen, but their RLU values were below 4; two turned out to be trauma related and one was ultimately diagnosed with juvenile idiopathic arthritis. Western blots were negative in all three.

The RLU number reported on the screening test “appears to correlate very well with Lyme arthritis. In an otherwise healthy child presenting with acute joint swelling, utilizing this screening test can confirm clinical suspicion of Lyme arthritis within hours, and prevent the potential harmful interventions accompanying a misdiagnosis of septic arthritis. Just do the screening. If it comes up above 9, you’ve got Lyme arthritis,” and don’t need to wait for western blot results to treat, Dr. Sharon said.

In other words, above 9, treat for Lyme.

The investigators plan to delve further into their results with sensitivity/specificity and other analyses before publishing. Ultimately, “my goal is to have a better diagnosis algorithm for kids who present with acute, isolated monoarthritis,” Dr. Sharon said.

There was no industry funding for the work, and the investigators didn’t have any disclosures.
 

[email protected]

SOURCE: Sharon B et al. 2018 ID Week abstract 286.

MONTEREY, CALIF. – Julie C. Harper, MD, likes to warn her patients with acne about an unexpected possible side effect of treatment with isotretinoin. “You may become a dermatologist.”

After all, that’s exactly how Dr. Harper herself was inspired to pursue a career in dermatology. As a teenager, she had acne and was treated with isotretinoin three times. The experience was so influential that she went into dermatology with a specific goal of treating acne.

“I love all of it, and in my practice I treat everything,” said Dr. Harper, “but I have a special interest in helping people with acne be as clear as they can be.” Indeed, she helped found the American Acne and Rosacea Society, which she now serves as president.

Dr. Harper, who practices in Birmingham, Ala., spoke about her approach to acne and rosacea in an interview following one of her presentations at the annual Coastal Dermatology Symposium.

DERMATOLOGY NEWS: What drew you to focus on rosacea in addition to acne?

Dr. Harper: Acne and rosacea are often coupled together because both of them affect the face, and they create red bumps on the skin. But they’re very distinct diagnoses, and their pathogenesis is completely different. My interest in treating rosacea was secondary to acne, but I love to treat them both.

DN: Are they both equally challenging to treat?

Dr. Harper: In some ways, rosacea is more challenging to treat.

With acne, we have a pretty good algorithm for how we treat it. We can end with isotretinoin, which for many people is a cure. But we really don’t have that last step in rosacea.

DN: What are you doing differently with rosacea than you might not have done a few years ago?

Dr. Harper: More combination therapy. The trend is more toward a comprehensive combination approach to treat everything we see in rosacea: Hit this as hard as you can. Hit everything you see. Part of that is because we have some newer drugs like the alpha-adrenergic agonists that work differently than anything we’ve had before.

We have a couple of good combination studies. One study examined ivermectin plus brimonidine (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Those two worked better together if you did not delay the brimonidine for 4 weeks and only used it with the ivermectin for part of the study.


There are also the newer studies that look at doxycycline plus ivermectin and compare it with ivermectin plus placebo. The combination works better, and it works faster (Adv Ther. 2016;33[9]:1481-1501; unpublished clinical trial data on file with Galderma, NCT03075891).

On top of those treatments, we may need to add laser for background redness, or an oral beta-blocker for flushing if the patient still complains of the symptoms.

DN: What’s most challenging to treat in rosacea?

Dr. Harper: The redness and phymatous changes are the hardest. Once you get phymatous changes, you have to do a physical modality.

Most of us think that if we treat rosacea aggressively up front, maybe we can prevent the phymatous changes. Prevention is key, just like prevention of acne scarring is easier than getting rid of scars once you have it.

Other than phyma, it’s the redness. Even the Food and Drug Administration–approved products we have for redness don’t work for flushing. Patients stand up to give up a presentation and “Oh no, here comes a red face.” That’s the hardest part to manage.

DN: How do beta-blockers fare at treating flushing?

Dr. Harper: They can help, but I don’t know that they can knock it out completely.

And we should remember that there are no FDA-approved beta-blockers to treat this. Most of the data we have are small case reports or case series. We don’t have a lot of data.

DN: Is there anything that’s used too much in rosacea?

Dr. Harper: Probably metronidazole. I understand why it’s used. It’s not a bad drug. But we have better drugs now.

I think we use metronidazole whenever things aren’t covered by insurance. And we use it to do too many things. Don’t try to make metronidazole do everything.

Metronidazole is FDA-approved for papules and pustules. It wasn’t ever intended to help with flushing and background erythema, and you’ll need to use something else with it.

DN: What’s coming down the line for rosacea?

Dr. Harper: We’ve got a couple new antibiotics: a new topical antibiotic and another oral antibiotic.

DN: Let’s talk about acne. Do you think isotretinoin is underused?

Dr. Harper: We should be using more of it. Why do we hold this drug hostage from our patients? In many people, it will cure their acne if they take it for just 5-6 months.

Are we worried about inflammatory bowel disease? The most recent studies say that’s not really an association. Are we worried about depression? We’ve had a meta-analysis that suggests if you take all that data, depression – if anything – gets better in people who take isotretinoin (Am J Gastroenterol. 2014 Apr;109[4]:563-9; J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.e9).

We need to take [the risk with pregnancy] seriously. But we need to be putting more people on the drug and giving them the opportunity to be clear.

 

DN: What should be used less in acne?

Dr. Harper: We should use less antibiotics and more of everything else – more hormonal treatments, more isotretinoin, more topical retinoids.

That doesn’t mean no antibiotics. But instead of doing three repetitive courses of antibiotics, do one. If acne recurs, go to isotretinoin. Go to an alternative.

DN: What about spironolactone in acne?

Dr. Harper: It’s a blood pressure medicine, but it’s got an antiandrogenic qualities. It blocks the androgen receptor so it’s like getting the benefits of the birth control pill without the estrogen. It can be very beneficial for acne in women.

Its use increased from 2004 to 2013, and people are getting the hang of it. But when you compare it with the number of antibiotics prescribed, antibiotics are written a whole lot more (J Am Acad Dermatol. 2017 Sep;77[3],456-63.e4).

DN: Is there anything that is especially helpful in treating men?

Dr. Harper: Part of the way that birth control and spironolactone work is by decreasing sebum, and we don’t have anything like that for men. But potentially, there may be a topical antiandrogen product that decreases sebum.

DN: How do you deal with patients who are in a lot of distress because of acne or rosacea?

Dr. Harper: You listen to them and tell them you hear what they’re saying. “I understand that you want to be clear, and I’ll help you do that.”

Listen to why they’re not doing well and why they’re frustrated with what they’ve used. They might say, “I don’t use what you gave me because I don’t like the way it feels.” Or, “the drug that you prescribed is too expensive.”

If they’re really doing everything you said, and they’re not doing well, in both of those conditions it may be time for isotretinoin.

In acne, I’ve never seen it fail. It doesn’t work as predictably in rosacea, but it does pretty well if you do low-dose, intermittent isotretinoin.

DN: Do you ever try treatments that are unexpected for acne and rosacea?

Dr. Harper: If you use the right combination of what we have, and try to target pathogenesis, I don’t think we have to go off the reservation very often. We can get good results with what we have available.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications. Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, La Roche–Posay, and Ortho Pharmaceutical, and has served as an investigator for Bayer.

MONTEREY, CALIF. – Julie C. Harper, MD, likes to warn her patients with acne about an unexpected possible side effect of treatment with isotretinoin. “You may become a dermatologist.”

After all, that’s exactly how Dr. Harper herself was inspired to pursue a career in dermatology. As a teenager, she had acne and was treated with isotretinoin three times. The experience was so influential that she went into dermatology with a specific goal of treating acne.

“I love all of it, and in my practice I treat everything,” said Dr. Harper, “but I have a special interest in helping people with acne be as clear as they can be.” Indeed, she helped found the American Acne and Rosacea Society, which she now serves as president.

Dr. Harper, who practices in Birmingham, Ala., spoke about her approach to acne and rosacea in an interview following one of her presentations at the annual Coastal Dermatology Symposium.

DERMATOLOGY NEWS: What drew you to focus on rosacea in addition to acne?

Dr. Harper: Acne and rosacea are often coupled together because both of them affect the face, and they create red bumps on the skin. But they’re very distinct diagnoses, and their pathogenesis is completely different. My interest in treating rosacea was secondary to acne, but I love to treat them both.

DN: Are they both equally challenging to treat?

Dr. Harper: In some ways, rosacea is more challenging to treat.

With acne, we have a pretty good algorithm for how we treat it. We can end with isotretinoin, which for many people is a cure. But we really don’t have that last step in rosacea.

DN: What are you doing differently with rosacea than you might not have done a few years ago?

Dr. Harper: More combination therapy. The trend is more toward a comprehensive combination approach to treat everything we see in rosacea: Hit this as hard as you can. Hit everything you see. Part of that is because we have some newer drugs like the alpha-adrenergic agonists that work differently than anything we’ve had before.

We have a couple of good combination studies. One study examined ivermectin plus brimonidine (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Those two worked better together if you did not delay the brimonidine for 4 weeks and only used it with the ivermectin for part of the study.


There are also the newer studies that look at doxycycline plus ivermectin and compare it with ivermectin plus placebo. The combination works better, and it works faster (Adv Ther. 2016;33[9]:1481-1501; unpublished clinical trial data on file with Galderma, NCT03075891).

On top of those treatments, we may need to add laser for background redness, or an oral beta-blocker for flushing if the patient still complains of the symptoms.

DN: What’s most challenging to treat in rosacea?

Dr. Harper: The redness and phymatous changes are the hardest. Once you get phymatous changes, you have to do a physical modality.

Most of us think that if we treat rosacea aggressively up front, maybe we can prevent the phymatous changes. Prevention is key, just like prevention of acne scarring is easier than getting rid of scars once you have it.

Other than phyma, it’s the redness. Even the Food and Drug Administration–approved products we have for redness don’t work for flushing. Patients stand up to give up a presentation and “Oh no, here comes a red face.” That’s the hardest part to manage.

DN: How do beta-blockers fare at treating flushing?

Dr. Harper: They can help, but I don’t know that they can knock it out completely.

And we should remember that there are no FDA-approved beta-blockers to treat this. Most of the data we have are small case reports or case series. We don’t have a lot of data.

DN: Is there anything that’s used too much in rosacea?

Dr. Harper: Probably metronidazole. I understand why it’s used. It’s not a bad drug. But we have better drugs now.

I think we use metronidazole whenever things aren’t covered by insurance. And we use it to do too many things. Don’t try to make metronidazole do everything.

Metronidazole is FDA-approved for papules and pustules. It wasn’t ever intended to help with flushing and background erythema, and you’ll need to use something else with it.

DN: What’s coming down the line for rosacea?

Dr. Harper: We’ve got a couple new antibiotics: a new topical antibiotic and another oral antibiotic.

DN: Let’s talk about acne. Do you think isotretinoin is underused?

Dr. Harper: We should be using more of it. Why do we hold this drug hostage from our patients? In many people, it will cure their acne if they take it for just 5-6 months.

Are we worried about inflammatory bowel disease? The most recent studies say that’s not really an association. Are we worried about depression? We’ve had a meta-analysis that suggests if you take all that data, depression – if anything – gets better in people who take isotretinoin (Am J Gastroenterol. 2014 Apr;109[4]:563-9; J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.e9).

We need to take [the risk with pregnancy] seriously. But we need to be putting more people on the drug and giving them the opportunity to be clear.

 

DN: What should be used less in acne?

Dr. Harper: We should use less antibiotics and more of everything else – more hormonal treatments, more isotretinoin, more topical retinoids.

That doesn’t mean no antibiotics. But instead of doing three repetitive courses of antibiotics, do one. If acne recurs, go to isotretinoin. Go to an alternative.

DN: What about spironolactone in acne?

Dr. Harper: It’s a blood pressure medicine, but it’s got an antiandrogenic qualities. It blocks the androgen receptor so it’s like getting the benefits of the birth control pill without the estrogen. It can be very beneficial for acne in women.

Its use increased from 2004 to 2013, and people are getting the hang of it. But when you compare it with the number of antibiotics prescribed, antibiotics are written a whole lot more (J Am Acad Dermatol. 2017 Sep;77[3],456-63.e4).

DN: Is there anything that is especially helpful in treating men?

Dr. Harper: Part of the way that birth control and spironolactone work is by decreasing sebum, and we don’t have anything like that for men. But potentially, there may be a topical antiandrogen product that decreases sebum.

DN: How do you deal with patients who are in a lot of distress because of acne or rosacea?

Dr. Harper: You listen to them and tell them you hear what they’re saying. “I understand that you want to be clear, and I’ll help you do that.”

Listen to why they’re not doing well and why they’re frustrated with what they’ve used. They might say, “I don’t use what you gave me because I don’t like the way it feels.” Or, “the drug that you prescribed is too expensive.”

If they’re really doing everything you said, and they’re not doing well, in both of those conditions it may be time for isotretinoin.

In acne, I’ve never seen it fail. It doesn’t work as predictably in rosacea, but it does pretty well if you do low-dose, intermittent isotretinoin.

DN: Do you ever try treatments that are unexpected for acne and rosacea?

Dr. Harper: If you use the right combination of what we have, and try to target pathogenesis, I don’t think we have to go off the reservation very often. We can get good results with what we have available.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications. Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, La Roche–Posay, and Ortho Pharmaceutical, and has served as an investigator for Bayer.

MONTEREY, CALIF. – Julie C. Harper, MD, likes to warn her patients with acne about an unexpected possible side effect of treatment with isotretinoin. “You may become a dermatologist.”

After all, that’s exactly how Dr. Harper herself was inspired to pursue a career in dermatology. As a teenager, she had acne and was treated with isotretinoin three times. The experience was so influential that she went into dermatology with a specific goal of treating acne.

“I love all of it, and in my practice I treat everything,” said Dr. Harper, “but I have a special interest in helping people with acne be as clear as they can be.” Indeed, she helped found the American Acne and Rosacea Society, which she now serves as president.

Dr. Harper, who practices in Birmingham, Ala., spoke about her approach to acne and rosacea in an interview following one of her presentations at the annual Coastal Dermatology Symposium.

DERMATOLOGY NEWS: What drew you to focus on rosacea in addition to acne?

Dr. Harper: Acne and rosacea are often coupled together because both of them affect the face, and they create red bumps on the skin. But they’re very distinct diagnoses, and their pathogenesis is completely different. My interest in treating rosacea was secondary to acne, but I love to treat them both.

DN: Are they both equally challenging to treat?

Dr. Harper: In some ways, rosacea is more challenging to treat.

With acne, we have a pretty good algorithm for how we treat it. We can end with isotretinoin, which for many people is a cure. But we really don’t have that last step in rosacea.

DN: What are you doing differently with rosacea than you might not have done a few years ago?

Dr. Harper: More combination therapy. The trend is more toward a comprehensive combination approach to treat everything we see in rosacea: Hit this as hard as you can. Hit everything you see. Part of that is because we have some newer drugs like the alpha-adrenergic agonists that work differently than anything we’ve had before.

We have a couple of good combination studies. One study examined ivermectin plus brimonidine (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Those two worked better together if you did not delay the brimonidine for 4 weeks and only used it with the ivermectin for part of the study.


There are also the newer studies that look at doxycycline plus ivermectin and compare it with ivermectin plus placebo. The combination works better, and it works faster (Adv Ther. 2016;33[9]:1481-1501; unpublished clinical trial data on file with Galderma, NCT03075891).

On top of those treatments, we may need to add laser for background redness, or an oral beta-blocker for flushing if the patient still complains of the symptoms.

DN: What’s most challenging to treat in rosacea?

Dr. Harper: The redness and phymatous changes are the hardest. Once you get phymatous changes, you have to do a physical modality.

Most of us think that if we treat rosacea aggressively up front, maybe we can prevent the phymatous changes. Prevention is key, just like prevention of acne scarring is easier than getting rid of scars once you have it.

Other than phyma, it’s the redness. Even the Food and Drug Administration–approved products we have for redness don’t work for flushing. Patients stand up to give up a presentation and “Oh no, here comes a red face.” That’s the hardest part to manage.

DN: How do beta-blockers fare at treating flushing?

Dr. Harper: They can help, but I don’t know that they can knock it out completely.

And we should remember that there are no FDA-approved beta-blockers to treat this. Most of the data we have are small case reports or case series. We don’t have a lot of data.

DN: Is there anything that’s used too much in rosacea?

Dr. Harper: Probably metronidazole. I understand why it’s used. It’s not a bad drug. But we have better drugs now.

I think we use metronidazole whenever things aren’t covered by insurance. And we use it to do too many things. Don’t try to make metronidazole do everything.

Metronidazole is FDA-approved for papules and pustules. It wasn’t ever intended to help with flushing and background erythema, and you’ll need to use something else with it.

DN: What’s coming down the line for rosacea?

Dr. Harper: We’ve got a couple new antibiotics: a new topical antibiotic and another oral antibiotic.

DN: Let’s talk about acne. Do you think isotretinoin is underused?

Dr. Harper: We should be using more of it. Why do we hold this drug hostage from our patients? In many people, it will cure their acne if they take it for just 5-6 months.

Are we worried about inflammatory bowel disease? The most recent studies say that’s not really an association. Are we worried about depression? We’ve had a meta-analysis that suggests if you take all that data, depression – if anything – gets better in people who take isotretinoin (Am J Gastroenterol. 2014 Apr;109[4]:563-9; J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.e9).

We need to take [the risk with pregnancy] seriously. But we need to be putting more people on the drug and giving them the opportunity to be clear.

 

DN: What should be used less in acne?

Dr. Harper: We should use less antibiotics and more of everything else – more hormonal treatments, more isotretinoin, more topical retinoids.

That doesn’t mean no antibiotics. But instead of doing three repetitive courses of antibiotics, do one. If acne recurs, go to isotretinoin. Go to an alternative.

DN: What about spironolactone in acne?

Dr. Harper: It’s a blood pressure medicine, but it’s got an antiandrogenic qualities. It blocks the androgen receptor so it’s like getting the benefits of the birth control pill without the estrogen. It can be very beneficial for acne in women.

Its use increased from 2004 to 2013, and people are getting the hang of it. But when you compare it with the number of antibiotics prescribed, antibiotics are written a whole lot more (J Am Acad Dermatol. 2017 Sep;77[3],456-63.e4).

DN: Is there anything that is especially helpful in treating men?

Dr. Harper: Part of the way that birth control and spironolactone work is by decreasing sebum, and we don’t have anything like that for men. But potentially, there may be a topical antiandrogen product that decreases sebum.

DN: How do you deal with patients who are in a lot of distress because of acne or rosacea?

Dr. Harper: You listen to them and tell them you hear what they’re saying. “I understand that you want to be clear, and I’ll help you do that.”

Listen to why they’re not doing well and why they’re frustrated with what they’ve used. They might say, “I don’t use what you gave me because I don’t like the way it feels.” Or, “the drug that you prescribed is too expensive.”

If they’re really doing everything you said, and they’re not doing well, in both of those conditions it may be time for isotretinoin.

In acne, I’ve never seen it fail. It doesn’t work as predictably in rosacea, but it does pretty well if you do low-dose, intermittent isotretinoin.

DN: Do you ever try treatments that are unexpected for acne and rosacea?

Dr. Harper: If you use the right combination of what we have, and try to target pathogenesis, I don’t think we have to go off the reservation very often. We can get good results with what we have available.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications. Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, La Roche–Posay, and Ortho Pharmaceutical, and has served as an investigator for Bayer.