CASE: Stage 2 prolapse to the hymenal ring

A 54-year-old Para 3 woman presents with stage 2 prolapse to the hymenal ring. The prolapse predominantly involves the anterior vagina, with her cervix prolapsing to 2 cm within the hymenal ring. The patient is bothered by the bulge and stress urinary leakage. She does not want to use a pessary and prefers to have definitive surgical correction, including hysterectomy.

The first surgeon she consulted recommended a vaginal hysterectomy, anterior colporrhaphy, anterior synthetic mesh vaginal colpopexy, and synthetic midurethral sling. The patient was concerned about mesh placement for prolapse and the sling after seeing ads on the Internet about vaginal mesh. She presents for a second opinion about surgical alternatives.

Stop routinely offering synthetic vaginal mesh for prolapse

Advantages to the use of synthetic vaginal mesh include improved subjective and objective cure rates for prolapse (especially for the anterior compartment) and fewer repeat surgeries for recurrent prolapse. However, disadvantages include:

• mesh exposure and extrusion through the vaginal epithelium
• overall higher reoperation for mesh-related complications and de novo stress urinary incontinence.¹

Synthetic vaginal mesh should be reserved for special situations. Currently, experts agree that synthetic vaginal mesh is appropriate in cases of recurrent prolapse, advanced-stage prolapse, collagen deficiency, or in cases with relative contraindications to longer endoscopic or abdominal surgery, such as medical comorbidities or adhesions.^2,3 Other indications for synthetic vaginal mesh include vaginal hysteropexy procedures.

Mesh is likely not necessary in:

• primary repairs
• prolapse < POPQ (pelvic organ prolapse quantification system) stage 2
• posterior prolapse
• patients with chronic pelvic pain.

Start offering, learning, and mastering native tissue repairs

For the patient in the opening case, who has symptomatic stage 2 uterovaginal prolapse and stress urinary incontinence, surgery, including a transvaginal hysterectomy, anterior colporrhaphy, uterosacral ligament suspension, and synthetic midurethral sling, is a reasonable alternative and has a high subjective and objective cure rate—81.2% rate for anterior prolapse and 98.3% rate for apical prolapse. Better outcomes are noted with stage 2 compared with stage 3 prolapse (92.4% vs 66.8%, respectively).⁴

Final note

If you are offering selective transvaginal synthetic mesh for prolapse repairs:

• Undergo training specific to each device.
• Track your outcomes—including objective, subjective, quality of life, and reoperation for complications and recurrence.
• Enroll in the national pelvic floor disorders registry, which is scheduled to debut in Fall 2013.

We want to hear from you! Tell us what you think.

CASE: Stage 2 prolapse to the hymenal ring

A 54-year-old Para 3 woman presents with stage 2 prolapse to the hymenal ring. The prolapse predominantly involves the anterior vagina, with her cervix prolapsing to 2 cm within the hymenal ring. The patient is bothered by the bulge and stress urinary leakage. She does not want to use a pessary and prefers to have definitive surgical correction, including hysterectomy.

The first surgeon she consulted recommended a vaginal hysterectomy, anterior colporrhaphy, anterior synthetic mesh vaginal colpopexy, and synthetic midurethral sling. The patient was concerned about mesh placement for prolapse and the sling after seeing ads on the Internet about vaginal mesh. She presents for a second opinion about surgical alternatives.

Stop routinely offering synthetic vaginal mesh for prolapse

Advantages to the use of synthetic vaginal mesh include improved subjective and objective cure rates for prolapse (especially for the anterior compartment) and fewer repeat surgeries for recurrent prolapse. However, disadvantages include:

• mesh exposure and extrusion through the vaginal epithelium
• overall higher reoperation for mesh-related complications and de novo stress urinary incontinence.¹

Synthetic vaginal mesh should be reserved for special situations. Currently, experts agree that synthetic vaginal mesh is appropriate in cases of recurrent prolapse, advanced-stage prolapse, collagen deficiency, or in cases with relative contraindications to longer endoscopic or abdominal surgery, such as medical comorbidities or adhesions.^2,3 Other indications for synthetic vaginal mesh include vaginal hysteropexy procedures.

Mesh is likely not necessary in:

• primary repairs
• prolapse < POPQ (pelvic organ prolapse quantification system) stage 2
• posterior prolapse
• patients with chronic pelvic pain.

Start offering, learning, and mastering native tissue repairs

For the patient in the opening case, who has symptomatic stage 2 uterovaginal prolapse and stress urinary incontinence, surgery, including a transvaginal hysterectomy, anterior colporrhaphy, uterosacral ligament suspension, and synthetic midurethral sling, is a reasonable alternative and has a high subjective and objective cure rate—81.2% rate for anterior prolapse and 98.3% rate for apical prolapse. Better outcomes are noted with stage 2 compared with stage 3 prolapse (92.4% vs 66.8%, respectively).⁴

Final note

If you are offering selective transvaginal synthetic mesh for prolapse repairs:

• Undergo training specific to each device.
• Track your outcomes—including objective, subjective, quality of life, and reoperation for complications and recurrence.
• Enroll in the national pelvic floor disorders registry, which is scheduled to debut in Fall 2013.

We want to hear from you! Tell us what you think.

CASE: Stage 2 prolapse to the hymenal ring

A 54-year-old Para 3 woman presents with stage 2 prolapse to the hymenal ring. The prolapse predominantly involves the anterior vagina, with her cervix prolapsing to 2 cm within the hymenal ring. The patient is bothered by the bulge and stress urinary leakage. She does not want to use a pessary and prefers to have definitive surgical correction, including hysterectomy.

The first surgeon she consulted recommended a vaginal hysterectomy, anterior colporrhaphy, anterior synthetic mesh vaginal colpopexy, and synthetic midurethral sling. The patient was concerned about mesh placement for prolapse and the sling after seeing ads on the Internet about vaginal mesh. She presents for a second opinion about surgical alternatives.

Stop routinely offering synthetic vaginal mesh for prolapse

Advantages to the use of synthetic vaginal mesh include improved subjective and objective cure rates for prolapse (especially for the anterior compartment) and fewer repeat surgeries for recurrent prolapse. However, disadvantages include:

• mesh exposure and extrusion through the vaginal epithelium
• overall higher reoperation for mesh-related complications and de novo stress urinary incontinence.¹

Synthetic vaginal mesh should be reserved for special situations. Currently, experts agree that synthetic vaginal mesh is appropriate in cases of recurrent prolapse, advanced-stage prolapse, collagen deficiency, or in cases with relative contraindications to longer endoscopic or abdominal surgery, such as medical comorbidities or adhesions.^2,3 Other indications for synthetic vaginal mesh include vaginal hysteropexy procedures.

Mesh is likely not necessary in:

• primary repairs
• prolapse < POPQ (pelvic organ prolapse quantification system) stage 2
• posterior prolapse
• patients with chronic pelvic pain.

Start offering, learning, and mastering native tissue repairs

For the patient in the opening case, who has symptomatic stage 2 uterovaginal prolapse and stress urinary incontinence, surgery, including a transvaginal hysterectomy, anterior colporrhaphy, uterosacral ligament suspension, and synthetic midurethral sling, is a reasonable alternative and has a high subjective and objective cure rate—81.2% rate for anterior prolapse and 98.3% rate for apical prolapse. Better outcomes are noted with stage 2 compared with stage 3 prolapse (92.4% vs 66.8%, respectively).⁴

Final note

If you are offering selective transvaginal synthetic mesh for prolapse repairs:

• Undergo training specific to each device.
• Track your outcomes—including objective, subjective, quality of life, and reoperation for complications and recurrence.
• Enroll in the national pelvic floor disorders registry, which is scheduled to debut in Fall 2013.

We want to hear from you! Tell us what you think.

• Michele Jonsson Funk, PhD, and colleagues from University of North Carolina (UNC) at Chapel Hill concluded that using vaginal mesh versus native tissue for anterior prolapse repair is associated with 5-year increased risk of any repeat surgery, especially surgery for mesh removal.¹
  
• Shunaha Kim-Fine, MD, and colleagues from Mayo Clinic, Rochester, Minnesota, believe that traditional native tissue repair is the best procedure for most women undergoing vaginal POP repair.²
  

UNC study details

Investigators from the Gillings School of Global Public Health at UNC studied health-care claims from 2005 to 2010. They identified women who, after undergoing anterior wall prolapse repair, experienced repeat surgery for recurrent prolapse or mesh removal. Of the initial 27,809 anterior prolapse surgeries, 6,871 (24.7%) included the use of vaginal mesh.¹

5-year risk of repeat surgery. The authors determined that¹:

• the 5-year cumulative risk of any repeat surgery was significantly higher with the use of vaginal mesh than with the use of native tissue (15.2% vs 9.8%, respectively; P .0001 with a risk of mesh revision or removal>
• the 5-year risk for recurrent prolapse surgery between both groups was comparable (10.4% vs 9.3%, P = .70).
  

Mayo Clinic study details

Researchers from Female Pelvic Medicine and Reconstructive Surgery, Division of Gynecologic Surgery at Mayo Clinic reviewed the literature and compared vaginal native tissue repair with vaginal mesh–augmented repair of pelvic organ prolapse. Their report was published online ahead of print on January 17, 2013, in Current Bladder Dysfunction Reports.

The authors discuss POP; the procedures available to treat symptomatic POP; the Public Heath Notifications issued in 2008 and 2011 from U.S. Food and Drug Administration (FDA) regarding the use of transvaginal mesh in POP repair; and success, failure, and complication rates from both techniques.²

“Given the lack of robust and long-term data in these relatively new procedures for [mesh-augmentation] repair, we agree with the caution and prudence communication in the recent FDA warning,” state the authors.² However, a caveat is offered that native tissue repair must utilize best principles of surgical technique and incorporate a multicompartment repair to achieve optimal outcome. The authors strongly advise that appropriate surgical technique, obtained only through adequate surgical training, can be improved for both repair procedures.²

Risks and complications from mesh. Mesh introduces unique risks related to the mesh itself, including mesh erosion, and complications, including new onset pain and dyspareunia following mesh-augmented repair. Complications are possibly related to the intrinsic properties of the mesh, (ie, shrinkage); to the patient (ie, scarring); or to the operative technique (ie, the placement/location of the mesh and increased tension on the mesh). The authors conclude that additional studies are needed, given the lack of robust and long-term data on mesh-augmentation repair of POP.²

“The evidence thus far has not shown that the benefits of mesh outweigh the added risks in vaginal prolapse repairs,” write the authors.² Therefore, although patient-centered success rates for both techniques of POP repair are equivalent, the authors conclude: “there does not appear to be a clear advantage of mesh augmentation repair over native tissue in terms of anatomic success.”²

To access the Jonsson Funk abstract, click here.

To access the Kim-Fine abstract, click here.

We want to hear from you! Tell us what you think.

• Michele Jonsson Funk, PhD, and colleagues from University of North Carolina (UNC) at Chapel Hill concluded that using vaginal mesh versus native tissue for anterior prolapse repair is associated with 5-year increased risk of any repeat surgery, especially surgery for mesh removal.¹
  
• Shunaha Kim-Fine, MD, and colleagues from Mayo Clinic, Rochester, Minnesota, believe that traditional native tissue repair is the best procedure for most women undergoing vaginal POP repair.²
  

UNC study details

Investigators from the Gillings School of Global Public Health at UNC studied health-care claims from 2005 to 2010. They identified women who, after undergoing anterior wall prolapse repair, experienced repeat surgery for recurrent prolapse or mesh removal. Of the initial 27,809 anterior prolapse surgeries, 6,871 (24.7%) included the use of vaginal mesh.¹

5-year risk of repeat surgery. The authors determined that¹:

• the 5-year cumulative risk of any repeat surgery was significantly higher with the use of vaginal mesh than with the use of native tissue (15.2% vs 9.8%, respectively; P .0001 with a risk of mesh revision or removal>
• the 5-year risk for recurrent prolapse surgery between both groups was comparable (10.4% vs 9.3%, P = .70).
  

Mayo Clinic study details

Researchers from Female Pelvic Medicine and Reconstructive Surgery, Division of Gynecologic Surgery at Mayo Clinic reviewed the literature and compared vaginal native tissue repair with vaginal mesh–augmented repair of pelvic organ prolapse. Their report was published online ahead of print on January 17, 2013, in Current Bladder Dysfunction Reports.

The authors discuss POP; the procedures available to treat symptomatic POP; the Public Heath Notifications issued in 2008 and 2011 from U.S. Food and Drug Administration (FDA) regarding the use of transvaginal mesh in POP repair; and success, failure, and complication rates from both techniques.²

“Given the lack of robust and long-term data in these relatively new procedures for [mesh-augmentation] repair, we agree with the caution and prudence communication in the recent FDA warning,” state the authors.² However, a caveat is offered that native tissue repair must utilize best principles of surgical technique and incorporate a multicompartment repair to achieve optimal outcome. The authors strongly advise that appropriate surgical technique, obtained only through adequate surgical training, can be improved for both repair procedures.²

Risks and complications from mesh. Mesh introduces unique risks related to the mesh itself, including mesh erosion, and complications, including new onset pain and dyspareunia following mesh-augmented repair. Complications are possibly related to the intrinsic properties of the mesh, (ie, shrinkage); to the patient (ie, scarring); or to the operative technique (ie, the placement/location of the mesh and increased tension on the mesh). The authors conclude that additional studies are needed, given the lack of robust and long-term data on mesh-augmentation repair of POP.²

“The evidence thus far has not shown that the benefits of mesh outweigh the added risks in vaginal prolapse repairs,” write the authors.² Therefore, although patient-centered success rates for both techniques of POP repair are equivalent, the authors conclude: “there does not appear to be a clear advantage of mesh augmentation repair over native tissue in terms of anatomic success.”²

To access the Jonsson Funk abstract, click here.

To access the Kim-Fine abstract, click here.

We want to hear from you! Tell us what you think.

• Michele Jonsson Funk, PhD, and colleagues from University of North Carolina (UNC) at Chapel Hill concluded that using vaginal mesh versus native tissue for anterior prolapse repair is associated with 5-year increased risk of any repeat surgery, especially surgery for mesh removal.¹
  
• Shunaha Kim-Fine, MD, and colleagues from Mayo Clinic, Rochester, Minnesota, believe that traditional native tissue repair is the best procedure for most women undergoing vaginal POP repair.²
  

UNC study details

Investigators from the Gillings School of Global Public Health at UNC studied health-care claims from 2005 to 2010. They identified women who, after undergoing anterior wall prolapse repair, experienced repeat surgery for recurrent prolapse or mesh removal. Of the initial 27,809 anterior prolapse surgeries, 6,871 (24.7%) included the use of vaginal mesh.¹

5-year risk of repeat surgery. The authors determined that¹:

• the 5-year cumulative risk of any repeat surgery was significantly higher with the use of vaginal mesh than with the use of native tissue (15.2% vs 9.8%, respectively; P .0001 with a risk of mesh revision or removal>
• the 5-year risk for recurrent prolapse surgery between both groups was comparable (10.4% vs 9.3%, P = .70).
  

Mayo Clinic study details

Researchers from Female Pelvic Medicine and Reconstructive Surgery, Division of Gynecologic Surgery at Mayo Clinic reviewed the literature and compared vaginal native tissue repair with vaginal mesh–augmented repair of pelvic organ prolapse. Their report was published online ahead of print on January 17, 2013, in Current Bladder Dysfunction Reports.

The authors discuss POP; the procedures available to treat symptomatic POP; the Public Heath Notifications issued in 2008 and 2011 from U.S. Food and Drug Administration (FDA) regarding the use of transvaginal mesh in POP repair; and success, failure, and complication rates from both techniques.²

“Given the lack of robust and long-term data in these relatively new procedures for [mesh-augmentation] repair, we agree with the caution and prudence communication in the recent FDA warning,” state the authors.² However, a caveat is offered that native tissue repair must utilize best principles of surgical technique and incorporate a multicompartment repair to achieve optimal outcome. The authors strongly advise that appropriate surgical technique, obtained only through adequate surgical training, can be improved for both repair procedures.²

Risks and complications from mesh. Mesh introduces unique risks related to the mesh itself, including mesh erosion, and complications, including new onset pain and dyspareunia following mesh-augmented repair. Complications are possibly related to the intrinsic properties of the mesh, (ie, shrinkage); to the patient (ie, scarring); or to the operative technique (ie, the placement/location of the mesh and increased tension on the mesh). The authors conclude that additional studies are needed, given the lack of robust and long-term data on mesh-augmentation repair of POP.²

“The evidence thus far has not shown that the benefits of mesh outweigh the added risks in vaginal prolapse repairs,” write the authors.² Therefore, although patient-centered success rates for both techniques of POP repair are equivalent, the authors conclude: “there does not appear to be a clear advantage of mesh augmentation repair over native tissue in terms of anatomic success.”²

To access the Jonsson Funk abstract, click here.

To access the Kim-Fine abstract, click here.

We want to hear from you! Tell us what you think.

CASE Angela D, a 34-year-old patient, has asthma with recurrent exacerbations. She uses a low-dose inhaled corticosteroid (ICS) daily and an albuterol inhaler, as needed, for shortness of breath or wheezing. She also has allergic rhinitis, for which she uses nasal fluticasone. Yet despite this regimen, Ms. D reports she still experiences wheezing, chest tightness, and shortness of breath 3 to 4 times a week and is awak-ened by coughing at least twice a week. In the past 6 months, she has had one emergency department (ED) visit and completed 2 courses of oral steroids.

Ms. D has gained weight since her last visit 3 months ago; her body mass index has gone from 27.5 to 29 kg/m². And, while she has always been somewhat anxious, Ms. D notes that her anxiety has gotten progressively worse, as well.

About 25 million Americans—approximately one in 12—suffer from asthma¹ and, despite improvements in asthma guidelines and treatment in the last 20 years,² many still struggle with uncontrolled symptoms.³ The consequences can be severe.

Suboptimal control of asthma is associated with a significant decrease in quality of life, a greater likelihood of absence from work or school, and an increased risk for life-threatening events, trips to the ED, hospital admissions, and death.¹ A multifaceted approach, including regular assessment, aggressive medication management, and attention to comorbidities, is needed to alleviate the suffering of patients with persistent asthma. This evidence-based review can help you provide such broad-based treatment.

Diagnosis and classification go hand in hand

The cornerstones of asthma management are accurate diagnosis and assessment of disease severity, based on both qualitative and quantitative measures. Start with a patient history, eliciting information about symptoms, triggers, risk factors, and most importantly, how often symptoms occur. Classic high-pitched wheezing sounds during exhalation, a cough that often worsens at night, shortness of breath, and chest tightness should raise suspicion for an asthma diagnosis.² But frequency (and timing) of symptoms and exacerbations, as well as changes in the patient’s ability to function normally, help to determine whether asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent (TABLE).²

TABLE
Classifying asthma severity²

Because asthma treatment should be based on its classification, an accurate assessment of disease severity is especially important for patients like Ms. D, who have been treated for asthma but continue to have unresolved symptoms. Keep in mind that asthma classification should be based on the worst symptom a patient has, not necessarily the symptom that occurs most frequently. Thus, a patient who has daytime symptoms requiring use of a rescue inhaler 2 to 3 times a week but is awakened at night with shortness of breath 2 times a week would receive a diagnosis of moderate persistent asthma on the basis of the night-time symptoms.

In assessing asthma severity, it is also important to ask specifically about recent events, including ED visits, hospitalizations, and intubations. This information, as well as answers to questions about smoking status, mental health problems, quality of life, and treatment compliance—and whether the patient can afford to purchase the asthma medications you’ve prescribed—can be used to assess the likelihood of poor outcomes.²

Factor in spirometry findings
History and physical examination alone cannot adequately diagnose and classify asthma severity.^4,5 Spirometry, a reimbursable office test that can be administered by trained staff members, can be beneficial for any patient older than 5 years for whom a diagnosis of asthma is being considered or disease severity being determined.² Other objective measures, such as the Mini Asthma Quality of Life questionnaire (http://erj.ersjournals.com/content/14/1/32.full.pdf+html) and peak expiratory flow measurement, may be helpful, as well.^2,6

Spirometry measures forced expiratory volume in one second (FEV₁) and forced vital capacity (FVC) and calculates the FEV₁/FVC ratio. Reference spirometry values vary according to patient characteristics, such as age, height, sex, and race, as well as the positioning of the patient during the test.⁷ (A seated position is optimal to reduce the risk of falls as a result of the light-headedness some patients may experience.) The American Thoracic Society provides a set of criteria (available at http://www.gp-training.net/protocol/respiratory/copd/spirometry.htm) that should be considered in interpreting test results.⁸

The 3 main spirometry patterns you’ll see are:

• Normal (FEV₁ >80% predicted; FVC >80% predicted; FEV₁/FVC >70%)
• Obstructive (FEV₁ <80% predicted; FVC normal or mildly reduced; FEV₁/FVC <70%)
• Restrictive (FEV₁ normal or mildly reduced; FVC <80% predicted; FEV₁/FVC >70%).

Because asthma is a chronic disease with fluctuating symptomatology and severity, spirometry testing should be repeated and results compared on several occasions as a guide to treatment.⁹ When an obstructive pattern is found, the patient should receive a bronchodilator treatment, then undergo spirometry 15 to 20 minutes later to determine reversibility. A reversible obstructive pattern, defined as an increase in FEV₁ by 12% (≥200 mL), is consistent with an asthma diagnosis. If spirometry results are consistently normal but a high clinical suspicion for obstructive disease remains, the patient should be evaluated with a methacholine or histamine challenge test to definitively rule out asthma.¹⁰

Rule out asthma mimics. Many medical conditions can mimic symptoms of asthma and result in misdiagnosis or incorrect severity classification and unnecessary treatment. Patients should be evaluated for alternate or coexisting pulmonary conditions, including restrictive lung disease, vocal cord dysfunction, cough-variant asthma, malignancy, and allergies. For a patient whose asthma diagnosis is in doubt or who has a restrictive pattern on spirometry, additional evaluation based on signs and symptoms may require comprehensive pulmonary function testing, chest x-ray, bronchoscopy, laryngoscopy, computed tomography, and/or allergy testing.²

Peak expiratory flow (PEF). While measuring PEF should not replace spirometry or formal pulmonary function testing, it can be helpful for evaluating disease severity and monitoring treatment. Patients should use their own peak flow meters, and results compared with their personal best measurements. An improvement of 60 L/min or >20% after treatment with a bronchodilator is suggestive of asthma.⁹ There are a number of free or low-cost apps that patients can use to track their PEF measurements and response to treatment, such as Asthma MD, Huff and Puff (for children), and the Peak Flow Calculator.^11-13

An evidence-based approach to asthma treatment

The first step in treating newly diagnosed asthma is to advise the patient to avoid known triggers, such as allergens, stressors, and particular odors or activities, to the extent possible, and, most importantly, to avoid exposure to smoke. If the patient smokes—cigarettes, marijuana, hookah, or pipe—stress the importance of quitting and living in a home that is smoke free. The link between asthma exacerbations and cockroaches is also well documented, particularly affecting those in urban areas. Avoidance of cockroaches and their droppings is critical, and may require the use of pest control services.^14,15

A general principle of asthma management is to treat it aggressively initially to help the patient achieve quick control, then gradually cut back to the fewest medications and lowest effective doses required to maintain control.² The National Heart, Lung, and Blood Institute (NHLBI)’s 2007 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (FIGURE)² call for a stepwise approach.

Short-acting beta-agonists (SABAs) and ICS—first-line asthma therapy—have minimal risks or adverse effects. SABAs help reverse acute shortness of breath and wheezing, and ICS can reduce the frequency of exacerbations.²

FIGURE
Stepwise approach to asthma management for patients ≥12 years

*Consult with an asthma specialist if Step 4 care or higher is required; consider consultation at Step 3.
^†Consider subcutaneous allergen immunotherapy for patients with allergic asthma.
ICS, inhaled corticosteroid; LABA, long-acting beta-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting beta-agonist.
Adapted from: National Asthma Education and Prevention Program. J Allergy Clin Immunol. 2007.²

Second-line therapy is less clearcut
There are several options for patients whose symptoms are not well controlled with first-line treatment: (1) Add a long-acting beta-agonist (LABA); (2) add a leukotriene receptor antagonist (LTRA); or (3) increase the ICS dose, the most straightforward approach.

A dose increase avoids both the additional risk of adverse drug reactions and the added cost associated with another medication. But the easiest solution is not necessarily the best. Consider the evidence detailed below, which includes findings from studies published after the NHLBI’s guidelines.

The research on LABAs
LABAs have been widely used as adjunctive therapy for adults with asthma. However, a 2006 study raised safety concerns.¹⁶

The Salmeterol Multicenter Asthma Research Trial (SMART) compared the safety of the LABA salmeterol with a placebo added to usual asthma care over a 28-week treatment period. Overall, the primary composite end point—the number of respiratory-related deaths or life-threatening events—was low, and not statistically significant for salmeterol (50 vs 36; relative risk [RR]=1.40; 95% confidence interval [CI], 0.91-2.14).¹⁶ However, individual outcomes—respiratory-related deaths, asthma-related deaths, and asthma-related deaths or life-threatening episodes—were significantly more likely in the salmeterol group compared with the placebo group. In subgroup analysis, African American patients were found to be at greatest risk.¹⁶

It is hard to draw general conclusions from these data because the study was terminated early and poor outcomes were limited to a particular study year. Nonetheless, many physicians remain wary of LABAs as adjunctive therapy because of these findings and the media publicity they generated.

A 2010 Cochrane review provided additional data on the safety and efficacy of the combination of a LABA and ICS compared with a higher dose of ICS.¹⁷ The review, which included 48 randomized controlled trials, found that combination therapy had a lower risk of exacerbations for which oral corticosteroids were required than a higher dose of ICS (RR=0.88; 95% CI, 0.78-0.98; P=.02). The median number needed to treat (NNT) was 73. No significant difference in the risk of overall adverse events (RR=0.99; 95% CI, 0.95-1.03) was found, but there was an increase in the risk of tremor (RR=1.84; 95% CI, 1.20-2.82) and a decrease in risk for oral thrush (RR=0.58; 95% CI, 0.40-0.86) in the combination therapy group.

While the Cochrane review did not show a combination of LABA and ICS to be less safe overall than higher doses of ICS alone, the findings were less favorable for children and patients with higher baseline lung function, in circumstances in which the combination therapy was taken for a longer duration, and when the LABA being studied was formoterol.¹⁷

Overall, it is when a LABA is delivered via separate inhaler that adverse outcomes have been reported. Findings have been positive when the LABA is combined with ICS, and this combination is recommended as maintenance therapy for moderate to severe asthma.

Two new studies, published in March 2013, reported successful use of a LABA-ICS combination not only for maintenance via scheduled dosing, but also for early phases of exacerbation via extra dosing—an approach called Single inhaler Maintenance and Reliever Therapy (SMART).^18,19 In both studies, SMART resulted in less excessive use of SABAs and less need for oral steroids, fewer hospitalizations for asthma, and fewer cases of progression to a full-blown exacerbation.

The takeaway: LABAs should be reserved for use as an adjunct to ICS in adults with poor baseline pulmonary function tests or severe asthma, and delivered as a combination product with ICS, not as a separate inhaled medication. SMART is a safe and effective means of administering LABA-ICS therapy for some patients at risk for frequent severe exacerbations.

When to consider LTRAs
LTRAs can be valuable medications in asthma management and there are extensive data on their use, particularly in the treatment of children with asthma. A Cochrane review published in 2012, however, supported current guideline recommendations, finding that as monotherapy, ICS are superior to LTRAs.²⁰

When LTRAs as an adjunctive therapy to ICS were compared with ICS monotherapy, researchers found a modest improvement in PEF (weighted mean difference [WMD] =7.7 L/min; 95% CI, 3.6-11.8) in the group receiving combination therapy and a decrease in the need for a SABA as rescue therapy (WMD=1 puff/week; 95% CI, 0.5-2.0).²¹ There was no significant reduction in the risk of exacerbations requiring systemic steroids (RR=0.64; 95% CI, 0.38-1.07).

LABAs and LTRAs go head to head. A 2010 Cochrane review compared the efficacy and safety of a daily LABA vs a LTRA as add-on therapy for patients whose asthma was not well controlled with ICS monotherapy.²² The LABA/ICS combination was significantly better at reducing the risk of exacerbations requiring systemic corticosteroids than monotherapy with either a LTRA or ICS, reducing the risk from 11% to 9% (RR=0.83; 95% CI, 0.71-0.97). The NNT to prevent one exacerbation over 48 weeks was 38 (95% CI, 22-244).²²

The safety of LABAs continues to be a concern, however, as serious adverse events were more common in the LABA group. The number needed to harm (NNH) with LABA therapy vs LTRA over 48 weeks was 78; 95% CI, 33 to infinity.²² (The width of the CI indicates that while harm is possible in as few as 33 patients, it is also possible that an infinite number of patients would need to be treated for one individual to incur harm.) Overall, the evidence suggests that LABAs are superior add-on therapy to ICS for the treatment of uncontrolled asthma compared with LTRAs, but their use nonetheless requires caution and close monitoring in African American and pediatric patients.¹⁷

Is there a role for a long-acting anticholinergic inhaler?

Long-acting anticholinergic medication (LAAM)—tiotropium is the only drug in this class on the market, but there are others in clinical trials—is the mainstay of therapy for chronic obstructive pulmonary disease. This drug class was not widely available or studied as an asthma treatment when the NHLBI guidelines were drafted.

A 2010 study of tiotropium challenged the notion that there is no place for LAAMs in asthma therapy. Using a 3-way crossover design, the study compared the addition of tiotropium to ICS with a double dose of ICS or a LABA/ICS combination.²³

The results suggest that LAAMs could be useful in treating uncontrolled asthma. Compared with the double dose of ICS, the tiotropium/ICS combination increased PEF by a mean difference of 25.8 L/min (P<.001) and resulted in a statistically significant improvement in the proportion of asthma control days, FEV₁, and daily symptom scores.²³ As an adjunctive treatment to ICS, tiotropium was not inferior to a LABA.

CASE After a detailed history, physical exam, and diagnostic testing, Ms. D was given a diagnosis of moderate persistent asthma. We recognized the need to step up her treatment. Prior to making any changes in her medication regimen, however, our team, which included a clinical pharmacist, observed her use of inhaled medications and verified that she was using the inhaler properly. We then initiated combination therapy, pairing a LABA and ICS.

Comorbidities complicate asthma management

Asthma management is often complicated by other uncontrolled coexisting medical problems. Common comorbidities that can affect asthma severity include allergic rhinitis, chronic sinusitis, gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea (OSA), mental health disorders, tobacco use, and hormonal disturbances.²

Allergic rhinitis. Allergic rhinitis has been associated with worse asthma control and a negative impact on quality of life, and the upper airway inflammation associated with it should be treated.²⁴

Antihistamines and nasal steroids are the most effective medical management. Some patients with allergic rhinitis benefit from blood or skin allergy testing for confirmation or to aid in avoidance. Referral to an allergist may be necessary if symptoms are recalcitrant, a food allergy is in question, or the diagnosis is unclear.

GERD. Compared with the general population, patients with asthma have a much higher risk of GERD, although it is not always symptomatic. While results are inconsistent and difficult to predict, treating symptomatic GERD with acid-blocking medications can result in better asthma control for some patients. However, proton pump inhibitors should not be used to treat asthma symptoms in patients with asymptomatic GERD.^25,26

Obesity and OSA. Weight loss can significantly improve asthma control, decrease medication use, and improve quality of life.^27,28 Obese patients are less likely to respond to treatment with ICS.² Weight loss also benefits those who suffer from OSA, which may contribute to airway hyperresponsiveness.²⁹

Mental health disorders. Compared with the general population, patients with asthma are more likely to have depression, anxiety, and panic disorders.³⁰ Diagnosis and treatment of these comorbid conditions can lead to better asthma management, increased medication adherence, decreased health care utilization—including fewer ED visits and hospitalizations—and a better quality of life.³⁰

CASE We also addressed our patient’s comorbidities—weight gain, allergic rhinitis, and anxiety. The allergic rhinitis was already well-controlled with a nasal steroid, but we suspected a relationship between Ms. D’s weight gain and increasing anxiety associated with some recent life events. We suggested she see a counselor, and she agreed.

When the patient returned in 12 weeks, she reported that she hardly needed her rescue inhaler anymore and that she was managing her anxiety more effectively. She also told us that she had begun a low-fat dietary regimen, and we confirmed that she had already lost 5 pounds.

CORRESPONDENCE 
Stephen A. Wilson, MD, MPH, FAAFP, UPMC St. Margaret, 815 Freeport Road, Pittsburgh, PA 15215; [email protected]

CASE Angela D, a 34-year-old patient, has asthma with recurrent exacerbations. She uses a low-dose inhaled corticosteroid (ICS) daily and an albuterol inhaler, as needed, for shortness of breath or wheezing. She also has allergic rhinitis, for which she uses nasal fluticasone. Yet despite this regimen, Ms. D reports she still experiences wheezing, chest tightness, and shortness of breath 3 to 4 times a week and is awak-ened by coughing at least twice a week. In the past 6 months, she has had one emergency department (ED) visit and completed 2 courses of oral steroids.

Ms. D has gained weight since her last visit 3 months ago; her body mass index has gone from 27.5 to 29 kg/m². And, while she has always been somewhat anxious, Ms. D notes that her anxiety has gotten progressively worse, as well.

About 25 million Americans—approximately one in 12—suffer from asthma¹ and, despite improvements in asthma guidelines and treatment in the last 20 years,² many still struggle with uncontrolled symptoms.³ The consequences can be severe.

Suboptimal control of asthma is associated with a significant decrease in quality of life, a greater likelihood of absence from work or school, and an increased risk for life-threatening events, trips to the ED, hospital admissions, and death.¹ A multifaceted approach, including regular assessment, aggressive medication management, and attention to comorbidities, is needed to alleviate the suffering of patients with persistent asthma. This evidence-based review can help you provide such broad-based treatment.

Diagnosis and classification go hand in hand

The cornerstones of asthma management are accurate diagnosis and assessment of disease severity, based on both qualitative and quantitative measures. Start with a patient history, eliciting information about symptoms, triggers, risk factors, and most importantly, how often symptoms occur. Classic high-pitched wheezing sounds during exhalation, a cough that often worsens at night, shortness of breath, and chest tightness should raise suspicion for an asthma diagnosis.² But frequency (and timing) of symptoms and exacerbations, as well as changes in the patient’s ability to function normally, help to determine whether asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent (TABLE).²

TABLE
Classifying asthma severity²

Because asthma treatment should be based on its classification, an accurate assessment of disease severity is especially important for patients like Ms. D, who have been treated for asthma but continue to have unresolved symptoms. Keep in mind that asthma classification should be based on the worst symptom a patient has, not necessarily the symptom that occurs most frequently. Thus, a patient who has daytime symptoms requiring use of a rescue inhaler 2 to 3 times a week but is awakened at night with shortness of breath 2 times a week would receive a diagnosis of moderate persistent asthma on the basis of the night-time symptoms.

In assessing asthma severity, it is also important to ask specifically about recent events, including ED visits, hospitalizations, and intubations. This information, as well as answers to questions about smoking status, mental health problems, quality of life, and treatment compliance—and whether the patient can afford to purchase the asthma medications you’ve prescribed—can be used to assess the likelihood of poor outcomes.²

Factor in spirometry findings
History and physical examination alone cannot adequately diagnose and classify asthma severity.^4,5 Spirometry, a reimbursable office test that can be administered by trained staff members, can be beneficial for any patient older than 5 years for whom a diagnosis of asthma is being considered or disease severity being determined.² Other objective measures, such as the Mini Asthma Quality of Life questionnaire (http://erj.ersjournals.com/content/14/1/32.full.pdf+html) and peak expiratory flow measurement, may be helpful, as well.^2,6

Spirometry measures forced expiratory volume in one second (FEV₁) and forced vital capacity (FVC) and calculates the FEV₁/FVC ratio. Reference spirometry values vary according to patient characteristics, such as age, height, sex, and race, as well as the positioning of the patient during the test.⁷ (A seated position is optimal to reduce the risk of falls as a result of the light-headedness some patients may experience.) The American Thoracic Society provides a set of criteria (available at http://www.gp-training.net/protocol/respiratory/copd/spirometry.htm) that should be considered in interpreting test results.⁸

The 3 main spirometry patterns you’ll see are:

• Normal (FEV₁ >80% predicted; FVC >80% predicted; FEV₁/FVC >70%)
• Obstructive (FEV₁ <80% predicted; FVC normal or mildly reduced; FEV₁/FVC <70%)
• Restrictive (FEV₁ normal or mildly reduced; FVC <80% predicted; FEV₁/FVC >70%).

Because asthma is a chronic disease with fluctuating symptomatology and severity, spirometry testing should be repeated and results compared on several occasions as a guide to treatment.⁹ When an obstructive pattern is found, the patient should receive a bronchodilator treatment, then undergo spirometry 15 to 20 minutes later to determine reversibility. A reversible obstructive pattern, defined as an increase in FEV₁ by 12% (≥200 mL), is consistent with an asthma diagnosis. If spirometry results are consistently normal but a high clinical suspicion for obstructive disease remains, the patient should be evaluated with a methacholine or histamine challenge test to definitively rule out asthma.¹⁰

Rule out asthma mimics. Many medical conditions can mimic symptoms of asthma and result in misdiagnosis or incorrect severity classification and unnecessary treatment. Patients should be evaluated for alternate or coexisting pulmonary conditions, including restrictive lung disease, vocal cord dysfunction, cough-variant asthma, malignancy, and allergies. For a patient whose asthma diagnosis is in doubt or who has a restrictive pattern on spirometry, additional evaluation based on signs and symptoms may require comprehensive pulmonary function testing, chest x-ray, bronchoscopy, laryngoscopy, computed tomography, and/or allergy testing.²

Peak expiratory flow (PEF). While measuring PEF should not replace spirometry or formal pulmonary function testing, it can be helpful for evaluating disease severity and monitoring treatment. Patients should use their own peak flow meters, and results compared with their personal best measurements. An improvement of 60 L/min or >20% after treatment with a bronchodilator is suggestive of asthma.⁹ There are a number of free or low-cost apps that patients can use to track their PEF measurements and response to treatment, such as Asthma MD, Huff and Puff (for children), and the Peak Flow Calculator.^11-13

An evidence-based approach to asthma treatment

The first step in treating newly diagnosed asthma is to advise the patient to avoid known triggers, such as allergens, stressors, and particular odors or activities, to the extent possible, and, most importantly, to avoid exposure to smoke. If the patient smokes—cigarettes, marijuana, hookah, or pipe—stress the importance of quitting and living in a home that is smoke free. The link between asthma exacerbations and cockroaches is also well documented, particularly affecting those in urban areas. Avoidance of cockroaches and their droppings is critical, and may require the use of pest control services.^14,15

A general principle of asthma management is to treat it aggressively initially to help the patient achieve quick control, then gradually cut back to the fewest medications and lowest effective doses required to maintain control.² The National Heart, Lung, and Blood Institute (NHLBI)’s 2007 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (FIGURE)² call for a stepwise approach.

Short-acting beta-agonists (SABAs) and ICS—first-line asthma therapy—have minimal risks or adverse effects. SABAs help reverse acute shortness of breath and wheezing, and ICS can reduce the frequency of exacerbations.²

FIGURE
Stepwise approach to asthma management for patients ≥12 years

*Consult with an asthma specialist if Step 4 care or higher is required; consider consultation at Step 3.
^†Consider subcutaneous allergen immunotherapy for patients with allergic asthma.
ICS, inhaled corticosteroid; LABA, long-acting beta-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting beta-agonist.
Adapted from: National Asthma Education and Prevention Program. J Allergy Clin Immunol. 2007.²

Second-line therapy is less clearcut
There are several options for patients whose symptoms are not well controlled with first-line treatment: (1) Add a long-acting beta-agonist (LABA); (2) add a leukotriene receptor antagonist (LTRA); or (3) increase the ICS dose, the most straightforward approach.

A dose increase avoids both the additional risk of adverse drug reactions and the added cost associated with another medication. But the easiest solution is not necessarily the best. Consider the evidence detailed below, which includes findings from studies published after the NHLBI’s guidelines.

The research on LABAs
LABAs have been widely used as adjunctive therapy for adults with asthma. However, a 2006 study raised safety concerns.¹⁶

The Salmeterol Multicenter Asthma Research Trial (SMART) compared the safety of the LABA salmeterol with a placebo added to usual asthma care over a 28-week treatment period. Overall, the primary composite end point—the number of respiratory-related deaths or life-threatening events—was low, and not statistically significant for salmeterol (50 vs 36; relative risk [RR]=1.40; 95% confidence interval [CI], 0.91-2.14).¹⁶ However, individual outcomes—respiratory-related deaths, asthma-related deaths, and asthma-related deaths or life-threatening episodes—were significantly more likely in the salmeterol group compared with the placebo group. In subgroup analysis, African American patients were found to be at greatest risk.¹⁶

It is hard to draw general conclusions from these data because the study was terminated early and poor outcomes were limited to a particular study year. Nonetheless, many physicians remain wary of LABAs as adjunctive therapy because of these findings and the media publicity they generated.

A 2010 Cochrane review provided additional data on the safety and efficacy of the combination of a LABA and ICS compared with a higher dose of ICS.¹⁷ The review, which included 48 randomized controlled trials, found that combination therapy had a lower risk of exacerbations for which oral corticosteroids were required than a higher dose of ICS (RR=0.88; 95% CI, 0.78-0.98; P=.02). The median number needed to treat (NNT) was 73. No significant difference in the risk of overall adverse events (RR=0.99; 95% CI, 0.95-1.03) was found, but there was an increase in the risk of tremor (RR=1.84; 95% CI, 1.20-2.82) and a decrease in risk for oral thrush (RR=0.58; 95% CI, 0.40-0.86) in the combination therapy group.

While the Cochrane review did not show a combination of LABA and ICS to be less safe overall than higher doses of ICS alone, the findings were less favorable for children and patients with higher baseline lung function, in circumstances in which the combination therapy was taken for a longer duration, and when the LABA being studied was formoterol.¹⁷

Overall, it is when a LABA is delivered via separate inhaler that adverse outcomes have been reported. Findings have been positive when the LABA is combined with ICS, and this combination is recommended as maintenance therapy for moderate to severe asthma.

Two new studies, published in March 2013, reported successful use of a LABA-ICS combination not only for maintenance via scheduled dosing, but also for early phases of exacerbation via extra dosing—an approach called Single inhaler Maintenance and Reliever Therapy (SMART).^18,19 In both studies, SMART resulted in less excessive use of SABAs and less need for oral steroids, fewer hospitalizations for asthma, and fewer cases of progression to a full-blown exacerbation.

The takeaway: LABAs should be reserved for use as an adjunct to ICS in adults with poor baseline pulmonary function tests or severe asthma, and delivered as a combination product with ICS, not as a separate inhaled medication. SMART is a safe and effective means of administering LABA-ICS therapy for some patients at risk for frequent severe exacerbations.

When to consider LTRAs
LTRAs can be valuable medications in asthma management and there are extensive data on their use, particularly in the treatment of children with asthma. A Cochrane review published in 2012, however, supported current guideline recommendations, finding that as monotherapy, ICS are superior to LTRAs.²⁰

When LTRAs as an adjunctive therapy to ICS were compared with ICS monotherapy, researchers found a modest improvement in PEF (weighted mean difference [WMD] =7.7 L/min; 95% CI, 3.6-11.8) in the group receiving combination therapy and a decrease in the need for a SABA as rescue therapy (WMD=1 puff/week; 95% CI, 0.5-2.0).²¹ There was no significant reduction in the risk of exacerbations requiring systemic steroids (RR=0.64; 95% CI, 0.38-1.07).

LABAs and LTRAs go head to head. A 2010 Cochrane review compared the efficacy and safety of a daily LABA vs a LTRA as add-on therapy for patients whose asthma was not well controlled with ICS monotherapy.²² The LABA/ICS combination was significantly better at reducing the risk of exacerbations requiring systemic corticosteroids than monotherapy with either a LTRA or ICS, reducing the risk from 11% to 9% (RR=0.83; 95% CI, 0.71-0.97). The NNT to prevent one exacerbation over 48 weeks was 38 (95% CI, 22-244).²²

The safety of LABAs continues to be a concern, however, as serious adverse events were more common in the LABA group. The number needed to harm (NNH) with LABA therapy vs LTRA over 48 weeks was 78; 95% CI, 33 to infinity.²² (The width of the CI indicates that while harm is possible in as few as 33 patients, it is also possible that an infinite number of patients would need to be treated for one individual to incur harm.) Overall, the evidence suggests that LABAs are superior add-on therapy to ICS for the treatment of uncontrolled asthma compared with LTRAs, but their use nonetheless requires caution and close monitoring in African American and pediatric patients.¹⁷

Is there a role for a long-acting anticholinergic inhaler?

Long-acting anticholinergic medication (LAAM)—tiotropium is the only drug in this class on the market, but there are others in clinical trials—is the mainstay of therapy for chronic obstructive pulmonary disease. This drug class was not widely available or studied as an asthma treatment when the NHLBI guidelines were drafted.

A 2010 study of tiotropium challenged the notion that there is no place for LAAMs in asthma therapy. Using a 3-way crossover design, the study compared the addition of tiotropium to ICS with a double dose of ICS or a LABA/ICS combination.²³

The results suggest that LAAMs could be useful in treating uncontrolled asthma. Compared with the double dose of ICS, the tiotropium/ICS combination increased PEF by a mean difference of 25.8 L/min (P<.001) and resulted in a statistically significant improvement in the proportion of asthma control days, FEV₁, and daily symptom scores.²³ As an adjunctive treatment to ICS, tiotropium was not inferior to a LABA.

CASE After a detailed history, physical exam, and diagnostic testing, Ms. D was given a diagnosis of moderate persistent asthma. We recognized the need to step up her treatment. Prior to making any changes in her medication regimen, however, our team, which included a clinical pharmacist, observed her use of inhaled medications and verified that she was using the inhaler properly. We then initiated combination therapy, pairing a LABA and ICS.

Comorbidities complicate asthma management

Asthma management is often complicated by other uncontrolled coexisting medical problems. Common comorbidities that can affect asthma severity include allergic rhinitis, chronic sinusitis, gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea (OSA), mental health disorders, tobacco use, and hormonal disturbances.²

Allergic rhinitis. Allergic rhinitis has been associated with worse asthma control and a negative impact on quality of life, and the upper airway inflammation associated with it should be treated.²⁴

Antihistamines and nasal steroids are the most effective medical management. Some patients with allergic rhinitis benefit from blood or skin allergy testing for confirmation or to aid in avoidance. Referral to an allergist may be necessary if symptoms are recalcitrant, a food allergy is in question, or the diagnosis is unclear.

GERD. Compared with the general population, patients with asthma have a much higher risk of GERD, although it is not always symptomatic. While results are inconsistent and difficult to predict, treating symptomatic GERD with acid-blocking medications can result in better asthma control for some patients. However, proton pump inhibitors should not be used to treat asthma symptoms in patients with asymptomatic GERD.^25,26

Obesity and OSA. Weight loss can significantly improve asthma control, decrease medication use, and improve quality of life.^27,28 Obese patients are less likely to respond to treatment with ICS.² Weight loss also benefits those who suffer from OSA, which may contribute to airway hyperresponsiveness.²⁹

Mental health disorders. Compared with the general population, patients with asthma are more likely to have depression, anxiety, and panic disorders.³⁰ Diagnosis and treatment of these comorbid conditions can lead to better asthma management, increased medication adherence, decreased health care utilization—including fewer ED visits and hospitalizations—and a better quality of life.³⁰

CASE We also addressed our patient’s comorbidities—weight gain, allergic rhinitis, and anxiety. The allergic rhinitis was already well-controlled with a nasal steroid, but we suspected a relationship between Ms. D’s weight gain and increasing anxiety associated with some recent life events. We suggested she see a counselor, and she agreed.

When the patient returned in 12 weeks, she reported that she hardly needed her rescue inhaler anymore and that she was managing her anxiety more effectively. She also told us that she had begun a low-fat dietary regimen, and we confirmed that she had already lost 5 pounds.

CORRESPONDENCE 
Stephen A. Wilson, MD, MPH, FAAFP, UPMC St. Margaret, 815 Freeport Road, Pittsburgh, PA 15215; [email protected]

CASE Angela D, a 34-year-old patient, has asthma with recurrent exacerbations. She uses a low-dose inhaled corticosteroid (ICS) daily and an albuterol inhaler, as needed, for shortness of breath or wheezing. She also has allergic rhinitis, for which she uses nasal fluticasone. Yet despite this regimen, Ms. D reports she still experiences wheezing, chest tightness, and shortness of breath 3 to 4 times a week and is awak-ened by coughing at least twice a week. In the past 6 months, she has had one emergency department (ED) visit and completed 2 courses of oral steroids.

Ms. D has gained weight since her last visit 3 months ago; her body mass index has gone from 27.5 to 29 kg/m². And, while she has always been somewhat anxious, Ms. D notes that her anxiety has gotten progressively worse, as well.

About 25 million Americans—approximately one in 12—suffer from asthma¹ and, despite improvements in asthma guidelines and treatment in the last 20 years,² many still struggle with uncontrolled symptoms.³ The consequences can be severe.

Suboptimal control of asthma is associated with a significant decrease in quality of life, a greater likelihood of absence from work or school, and an increased risk for life-threatening events, trips to the ED, hospital admissions, and death.¹ A multifaceted approach, including regular assessment, aggressive medication management, and attention to comorbidities, is needed to alleviate the suffering of patients with persistent asthma. This evidence-based review can help you provide such broad-based treatment.

Diagnosis and classification go hand in hand

The cornerstones of asthma management are accurate diagnosis and assessment of disease severity, based on both qualitative and quantitative measures. Start with a patient history, eliciting information about symptoms, triggers, risk factors, and most importantly, how often symptoms occur. Classic high-pitched wheezing sounds during exhalation, a cough that often worsens at night, shortness of breath, and chest tightness should raise suspicion for an asthma diagnosis.² But frequency (and timing) of symptoms and exacerbations, as well as changes in the patient’s ability to function normally, help to determine whether asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent (TABLE).²

TABLE
Classifying asthma severity²

Because asthma treatment should be based on its classification, an accurate assessment of disease severity is especially important for patients like Ms. D, who have been treated for asthma but continue to have unresolved symptoms. Keep in mind that asthma classification should be based on the worst symptom a patient has, not necessarily the symptom that occurs most frequently. Thus, a patient who has daytime symptoms requiring use of a rescue inhaler 2 to 3 times a week but is awakened at night with shortness of breath 2 times a week would receive a diagnosis of moderate persistent asthma on the basis of the night-time symptoms.

In assessing asthma severity, it is also important to ask specifically about recent events, including ED visits, hospitalizations, and intubations. This information, as well as answers to questions about smoking status, mental health problems, quality of life, and treatment compliance—and whether the patient can afford to purchase the asthma medications you’ve prescribed—can be used to assess the likelihood of poor outcomes.²

Factor in spirometry findings
History and physical examination alone cannot adequately diagnose and classify asthma severity.^4,5 Spirometry, a reimbursable office test that can be administered by trained staff members, can be beneficial for any patient older than 5 years for whom a diagnosis of asthma is being considered or disease severity being determined.² Other objective measures, such as the Mini Asthma Quality of Life questionnaire (http://erj.ersjournals.com/content/14/1/32.full.pdf+html) and peak expiratory flow measurement, may be helpful, as well.^2,6

Spirometry measures forced expiratory volume in one second (FEV₁) and forced vital capacity (FVC) and calculates the FEV₁/FVC ratio. Reference spirometry values vary according to patient characteristics, such as age, height, sex, and race, as well as the positioning of the patient during the test.⁷ (A seated position is optimal to reduce the risk of falls as a result of the light-headedness some patients may experience.) The American Thoracic Society provides a set of criteria (available at http://www.gp-training.net/protocol/respiratory/copd/spirometry.htm) that should be considered in interpreting test results.⁸

The 3 main spirometry patterns you’ll see are:

• Normal (FEV₁ >80% predicted; FVC >80% predicted; FEV₁/FVC >70%)
• Obstructive (FEV₁ <80% predicted; FVC normal or mildly reduced; FEV₁/FVC <70%)
• Restrictive (FEV₁ normal or mildly reduced; FVC <80% predicted; FEV₁/FVC >70%).

Because asthma is a chronic disease with fluctuating symptomatology and severity, spirometry testing should be repeated and results compared on several occasions as a guide to treatment.⁹ When an obstructive pattern is found, the patient should receive a bronchodilator treatment, then undergo spirometry 15 to 20 minutes later to determine reversibility. A reversible obstructive pattern, defined as an increase in FEV₁ by 12% (≥200 mL), is consistent with an asthma diagnosis. If spirometry results are consistently normal but a high clinical suspicion for obstructive disease remains, the patient should be evaluated with a methacholine or histamine challenge test to definitively rule out asthma.¹⁰

Rule out asthma mimics. Many medical conditions can mimic symptoms of asthma and result in misdiagnosis or incorrect severity classification and unnecessary treatment. Patients should be evaluated for alternate or coexisting pulmonary conditions, including restrictive lung disease, vocal cord dysfunction, cough-variant asthma, malignancy, and allergies. For a patient whose asthma diagnosis is in doubt or who has a restrictive pattern on spirometry, additional evaluation based on signs and symptoms may require comprehensive pulmonary function testing, chest x-ray, bronchoscopy, laryngoscopy, computed tomography, and/or allergy testing.²

Peak expiratory flow (PEF). While measuring PEF should not replace spirometry or formal pulmonary function testing, it can be helpful for evaluating disease severity and monitoring treatment. Patients should use their own peak flow meters, and results compared with their personal best measurements. An improvement of 60 L/min or >20% after treatment with a bronchodilator is suggestive of asthma.⁹ There are a number of free or low-cost apps that patients can use to track their PEF measurements and response to treatment, such as Asthma MD, Huff and Puff (for children), and the Peak Flow Calculator.^11-13

An evidence-based approach to asthma treatment

The first step in treating newly diagnosed asthma is to advise the patient to avoid known triggers, such as allergens, stressors, and particular odors or activities, to the extent possible, and, most importantly, to avoid exposure to smoke. If the patient smokes—cigarettes, marijuana, hookah, or pipe—stress the importance of quitting and living in a home that is smoke free. The link between asthma exacerbations and cockroaches is also well documented, particularly affecting those in urban areas. Avoidance of cockroaches and their droppings is critical, and may require the use of pest control services.^14,15

A general principle of asthma management is to treat it aggressively initially to help the patient achieve quick control, then gradually cut back to the fewest medications and lowest effective doses required to maintain control.² The National Heart, Lung, and Blood Institute (NHLBI)’s 2007 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (FIGURE)² call for a stepwise approach.

Short-acting beta-agonists (SABAs) and ICS—first-line asthma therapy—have minimal risks or adverse effects. SABAs help reverse acute shortness of breath and wheezing, and ICS can reduce the frequency of exacerbations.²

FIGURE
Stepwise approach to asthma management for patients ≥12 years

*Consult with an asthma specialist if Step 4 care or higher is required; consider consultation at Step 3.
^†Consider subcutaneous allergen immunotherapy for patients with allergic asthma.
ICS, inhaled corticosteroid; LABA, long-acting beta-agonist; LTRA, leukotriene receptor agonist; SABA, short-acting beta-agonist.
Adapted from: National Asthma Education and Prevention Program. J Allergy Clin Immunol. 2007.²

Second-line therapy is less clearcut
There are several options for patients whose symptoms are not well controlled with first-line treatment: (1) Add a long-acting beta-agonist (LABA); (2) add a leukotriene receptor antagonist (LTRA); or (3) increase the ICS dose, the most straightforward approach.

A dose increase avoids both the additional risk of adverse drug reactions and the added cost associated with another medication. But the easiest solution is not necessarily the best. Consider the evidence detailed below, which includes findings from studies published after the NHLBI’s guidelines.

The research on LABAs
LABAs have been widely used as adjunctive therapy for adults with asthma. However, a 2006 study raised safety concerns.¹⁶

The Salmeterol Multicenter Asthma Research Trial (SMART) compared the safety of the LABA salmeterol with a placebo added to usual asthma care over a 28-week treatment period. Overall, the primary composite end point—the number of respiratory-related deaths or life-threatening events—was low, and not statistically significant for salmeterol (50 vs 36; relative risk [RR]=1.40; 95% confidence interval [CI], 0.91-2.14).¹⁶ However, individual outcomes—respiratory-related deaths, asthma-related deaths, and asthma-related deaths or life-threatening episodes—were significantly more likely in the salmeterol group compared with the placebo group. In subgroup analysis, African American patients were found to be at greatest risk.¹⁶

It is hard to draw general conclusions from these data because the study was terminated early and poor outcomes were limited to a particular study year. Nonetheless, many physicians remain wary of LABAs as adjunctive therapy because of these findings and the media publicity they generated.

A 2010 Cochrane review provided additional data on the safety and efficacy of the combination of a LABA and ICS compared with a higher dose of ICS.¹⁷ The review, which included 48 randomized controlled trials, found that combination therapy had a lower risk of exacerbations for which oral corticosteroids were required than a higher dose of ICS (RR=0.88; 95% CI, 0.78-0.98; P=.02). The median number needed to treat (NNT) was 73. No significant difference in the risk of overall adverse events (RR=0.99; 95% CI, 0.95-1.03) was found, but there was an increase in the risk of tremor (RR=1.84; 95% CI, 1.20-2.82) and a decrease in risk for oral thrush (RR=0.58; 95% CI, 0.40-0.86) in the combination therapy group.

While the Cochrane review did not show a combination of LABA and ICS to be less safe overall than higher doses of ICS alone, the findings were less favorable for children and patients with higher baseline lung function, in circumstances in which the combination therapy was taken for a longer duration, and when the LABA being studied was formoterol.¹⁷

Overall, it is when a LABA is delivered via separate inhaler that adverse outcomes have been reported. Findings have been positive when the LABA is combined with ICS, and this combination is recommended as maintenance therapy for moderate to severe asthma.

Two new studies, published in March 2013, reported successful use of a LABA-ICS combination not only for maintenance via scheduled dosing, but also for early phases of exacerbation via extra dosing—an approach called Single inhaler Maintenance and Reliever Therapy (SMART).^18,19 In both studies, SMART resulted in less excessive use of SABAs and less need for oral steroids, fewer hospitalizations for asthma, and fewer cases of progression to a full-blown exacerbation.

The takeaway: LABAs should be reserved for use as an adjunct to ICS in adults with poor baseline pulmonary function tests or severe asthma, and delivered as a combination product with ICS, not as a separate inhaled medication. SMART is a safe and effective means of administering LABA-ICS therapy for some patients at risk for frequent severe exacerbations.

When to consider LTRAs
LTRAs can be valuable medications in asthma management and there are extensive data on their use, particularly in the treatment of children with asthma. A Cochrane review published in 2012, however, supported current guideline recommendations, finding that as monotherapy, ICS are superior to LTRAs.²⁰

When LTRAs as an adjunctive therapy to ICS were compared with ICS monotherapy, researchers found a modest improvement in PEF (weighted mean difference [WMD] =7.7 L/min; 95% CI, 3.6-11.8) in the group receiving combination therapy and a decrease in the need for a SABA as rescue therapy (WMD=1 puff/week; 95% CI, 0.5-2.0).²¹ There was no significant reduction in the risk of exacerbations requiring systemic steroids (RR=0.64; 95% CI, 0.38-1.07).

LABAs and LTRAs go head to head. A 2010 Cochrane review compared the efficacy and safety of a daily LABA vs a LTRA as add-on therapy for patients whose asthma was not well controlled with ICS monotherapy.²² The LABA/ICS combination was significantly better at reducing the risk of exacerbations requiring systemic corticosteroids than monotherapy with either a LTRA or ICS, reducing the risk from 11% to 9% (RR=0.83; 95% CI, 0.71-0.97). The NNT to prevent one exacerbation over 48 weeks was 38 (95% CI, 22-244).²²

The safety of LABAs continues to be a concern, however, as serious adverse events were more common in the LABA group. The number needed to harm (NNH) with LABA therapy vs LTRA over 48 weeks was 78; 95% CI, 33 to infinity.²² (The width of the CI indicates that while harm is possible in as few as 33 patients, it is also possible that an infinite number of patients would need to be treated for one individual to incur harm.) Overall, the evidence suggests that LABAs are superior add-on therapy to ICS for the treatment of uncontrolled asthma compared with LTRAs, but their use nonetheless requires caution and close monitoring in African American and pediatric patients.¹⁷

Is there a role for a long-acting anticholinergic inhaler?

Long-acting anticholinergic medication (LAAM)—tiotropium is the only drug in this class on the market, but there are others in clinical trials—is the mainstay of therapy for chronic obstructive pulmonary disease. This drug class was not widely available or studied as an asthma treatment when the NHLBI guidelines were drafted.

A 2010 study of tiotropium challenged the notion that there is no place for LAAMs in asthma therapy. Using a 3-way crossover design, the study compared the addition of tiotropium to ICS with a double dose of ICS or a LABA/ICS combination.²³

The results suggest that LAAMs could be useful in treating uncontrolled asthma. Compared with the double dose of ICS, the tiotropium/ICS combination increased PEF by a mean difference of 25.8 L/min (P<.001) and resulted in a statistically significant improvement in the proportion of asthma control days, FEV₁, and daily symptom scores.²³ As an adjunctive treatment to ICS, tiotropium was not inferior to a LABA.

CASE After a detailed history, physical exam, and diagnostic testing, Ms. D was given a diagnosis of moderate persistent asthma. We recognized the need to step up her treatment. Prior to making any changes in her medication regimen, however, our team, which included a clinical pharmacist, observed her use of inhaled medications and verified that she was using the inhaler properly. We then initiated combination therapy, pairing a LABA and ICS.

Comorbidities complicate asthma management

Asthma management is often complicated by other uncontrolled coexisting medical problems. Common comorbidities that can affect asthma severity include allergic rhinitis, chronic sinusitis, gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea (OSA), mental health disorders, tobacco use, and hormonal disturbances.²

Allergic rhinitis. Allergic rhinitis has been associated with worse asthma control and a negative impact on quality of life, and the upper airway inflammation associated with it should be treated.²⁴

Antihistamines and nasal steroids are the most effective medical management. Some patients with allergic rhinitis benefit from blood or skin allergy testing for confirmation or to aid in avoidance. Referral to an allergist may be necessary if symptoms are recalcitrant, a food allergy is in question, or the diagnosis is unclear.

GERD. Compared with the general population, patients with asthma have a much higher risk of GERD, although it is not always symptomatic. While results are inconsistent and difficult to predict, treating symptomatic GERD with acid-blocking medications can result in better asthma control for some patients. However, proton pump inhibitors should not be used to treat asthma symptoms in patients with asymptomatic GERD.^25,26

Obesity and OSA. Weight loss can significantly improve asthma control, decrease medication use, and improve quality of life.^27,28 Obese patients are less likely to respond to treatment with ICS.² Weight loss also benefits those who suffer from OSA, which may contribute to airway hyperresponsiveness.²⁹

Mental health disorders. Compared with the general population, patients with asthma are more likely to have depression, anxiety, and panic disorders.³⁰ Diagnosis and treatment of these comorbid conditions can lead to better asthma management, increased medication adherence, decreased health care utilization—including fewer ED visits and hospitalizations—and a better quality of life.³⁰

CASE We also addressed our patient’s comorbidities—weight gain, allergic rhinitis, and anxiety. The allergic rhinitis was already well-controlled with a nasal steroid, but we suspected a relationship between Ms. D’s weight gain and increasing anxiety associated with some recent life events. We suggested she see a counselor, and she agreed.

When the patient returned in 12 weeks, she reported that she hardly needed her rescue inhaler anymore and that she was managing her anxiety more effectively. She also told us that she had begun a low-fat dietary regimen, and we confirmed that she had already lost 5 pounds.

CORRESPONDENCE 
Stephen A. Wilson, MD, MPH, FAAFP, UPMC St. Margaret, 815 Freeport Road, Pittsburgh, PA 15215; [email protected]

Baseball players and other athletes who spend much of their time throwing a ball risk a variety of shoulder injuries because the repetitive motion causes repeated microtraumatic stress in the area. Injuries result from overuse of the muscles involved, improper technique—or both.

The review that follows will help you zero in on the correct diagnosis and identify the treatment that’s best for your patient.

First step: Cover these points in the history

In order to gather a detailed history of a patient with shoulder pain, you’ll want to do the following:

Ask about the location of the pain. Anterior shoulder pain is associated with subluxation, multidirectional instability, subacromial bursitis, and injury to the biceps, supraspinatus or subscapularis.¹ Posterior shoulder pain has been linked to infraspinatus injuries.

Assess the severity of the pain. Ask patients: “On a scale of one to 10, where 10 is the worst pain you have ever felt, how would you rate the pain you are feeling?”

Pinpoint the timing of the pain. Determine the phase of the throwing process that reproduces the primary symptoms. The 6 phases are wind up, early cocking, late cocking, acceleration, deceleration, and follow-through (FIGURE 1). So if, for instance, the patient tells you that his arm “went dead” during the late cocking, or early acceleration phase, it should prompt you to suspect subluxation.²

Videos

See how the Neer’s and Hawkin’s tests are done

Christopher Faubel, MD, Thepainsource.com

 

 

 Neer’s Impingement test

 

 

Hawkins test

FIGURE 1
The 6 phases of throwing

Ascertain the nature of the patient’s pain after activity. Does the patient experience the pain at night? If he answers Yes, you’ll want to consider the possibility of a rotator cuff tear.

Ask these targeted questions:

• When you raise your arm, do you feel a pinching pain in your shoulder? This may suggest the presence of impingement.
• Is your shoulder “catching” or “locking up”? If so, consider a labral tear or loose body, eg, a piece of cartilage or bone floating around in the joint.
• Does your shoulder feel like it is coming out of its socket—either partially or completely? This suggests shoulder instability.
• Is it difficult for you to reach behind your back, or do you have shoulder pain when you try to do this? This may indicate glenohumeral internal rotation deficit.
• Do you feel like you are throwing the ball slower, or with less accuracy? This may be an indication that there is something wrong with the rotator cuff muscles, the innervation around the shoulders, or the labrum that partly holds the shoulder together. Sometimes, a tear of the labrum presents simply as a “loss of power” in throwing, as defined by the athlete who is used to throwing the ball faster or farther.

Diagnoses to consider

Based on the patient’s history and responses to your questions, you’ll likely consider one of the following diagnoses as part of the differential.

External or internal impingement syndromes
What you’ll see. External or “subacromial” impingement syndrome results from compression of the rotator cuff between the coracoacromial arch and the humeral head. A sloping or hooked acromion or osteophyte may contribute to the syndrome.³ Neer’s and Hawkin’s tests are often positive, and there may be pain with the arc of motion. (For more on these and the other tests mentioned here, see “Athlete has shoulder problems? Consider these tests”.)

Internal impingement results from pinching of the rotator cuff between the posterosuperior labrum and the greater tuberosity. The pain usually occurs with repetitive maximal shoulder internal rotation and abduction, which leads to cumulative microtrauma and eventual articular-sided rotator cuff pathology.⁴ The patient will complain of pain with shoulder internal rotation and abduction. Neer’s and Hawkin’s tests are helpful in detecting internal impingement.

Shoulder girdle fatigue from lack of conditioning and overthrowing—or the tight posterior capsule often seen in throwing athletes—may also contribute to the disorder.⁴

Treatment. Proper management involves relative rest from overhead activities, and an individualized rehabilitation program that includes dynamic stretching/strengthening through the rotator cuff, posterior capsule, and scapular stabilizers. Injecting a corticosteroid-analgesic solution into the subacromial space may help you arrive at a diagnosis and also offers symptomatic relief.^1,3 Consider bursectomy, arthroscopic acromioplasty, capsulotomy and/or debridement for recalcitrant cases.^4,5

Shoulder labrum pathology
What you’ll see. Overhead-throwing athletes are at risk of labral tears. The externally rotated, abducted arm of a thrower causes posterior rotation of the biceps anchor, peeling the biceps from its superior labrum attachment,⁶ a superior labrum anterior and posterior (SLAP) tear, or a type II tear from anterior to posterior. SLAP tears may lead to shoulder catching and locking. The patient may complain of vague shoulder pain,⁷ which is worse in the late cocking phase. O’Brien’s test will be positive.

Magnetic resonance imaging (MRI) with arthrogram can reveal a labral tear. Consider ordering an MRI when the athlete’s pain is accompanied by mechanical symptoms, such as locking, catching, or instability, or if the shoulder signs and symptoms do not appear to be responding to appropriate physical therapy interventions after a period of time—usually 4 to 6 weeks.

Treatment. For small tears, conservative management includes relative rest and physical therapy.³ Depending on the tear morphology, consider arthroscopic labral debridement or repair if conservative measures fail. The literature offers mixed conclusions on the benefits of surgery, with varying rates of full return to play.^8-10

Shoulder instability
What you’ll see. Instability in throwing athletes is multifactorial, and rarely due to an isolated shoulder structure injury.¹¹ Patients will complain that their shoulder feels as if it is going to come out of its socket, even when they are not throwing. To help detect instability, look for the sulcus sign, and do a load and shift test and an apprehension-relocation test.

Two categories of injury. Instability injuries fall into 2 primary categories: TUBS (Traumatic, Unilateral, associated with Bankart lesion, treated with Surgery) and AMBRI (Atraumatic, Multidirectional, Bilateral, treated with Rehabilitation, Inferior capsular shift).

As its name makes clear, TUBS is associated with a Bankart lesion (an avulsion of the anteroinferior glenoid labrum to its attachment to the humerus). Shoulder x-rays, including outlet, axillary lateral, and anteroposterior views,³ may reveal a bony Bankart lesion. You may also see a Hill-Sachs lesion here, which is noted on the humeral posterolateral head as a depression in the bony cortex.

AMBRI is more common than TUBS in throwers. Athletes often gain a competitive edge by increasing external rotation. However, when overdone, this results in the excessive laxity seen in AMBRI. While rare, acute traumatic dislocation can occur in those with AMBRI-type instability.

Treatment. Scapular stabilization exercises, dynamic rotator cuff strengthening, relative rest, and a short course (7-10 days) of nonsteroidal anti-inflammatory drugs are the mainstays of shoulder instability treatment in the throwing athlete.^1,3 A throwing program may be started when the athlete is asymptomatic and has rested. You may also need to prescribe a longer rest period of 4 to 6 weeks if the symptoms return after commencing activity. For recalcitrant cases, consider surgery (via open or arthroscopic approaches⁶) to treat the associated underlying pathology.

Glenohumeral internal rotation deficit
What you’ll see. Posterior capsular contracture, common in the throwing athlete’s shoulder, causes decreased internal rotation and posterior shift of the total arc of glenohumeral motion.³ The patient may complain of decreased ability to reach backwards or pain when attempting to do so.

The anterior aspect of the shoulder’s capsule also lengthens, allowing anterior capsular laxity that causes additional problems, including internal impingement, SLAP tears, articular-sided, partial-thickness rotator cuff tears, and posterosuperior rotator cuff impingement. The risk for this cascade of complications increases in patients with throwing-shoulder internal rotation deficits ≥25° compared with the nonthrowing side, and a total arc of motion <180°.¹²

Treatment. Stretching the tight posterior capsule using the sleeper stretch (FIGURE 2) or the cross-body stretch (FIGURE 3) has proven very successful, with 90% of athletes seeing their symptoms resolve within 2 weeks.^13,14 If conservative treatment is ineffective, consider selective arthroscopic capsular release of the posterior inferior glenohumeral ligament.

FIGURE 2
The sleeper stretch

FIGURE 3
The cross-body stretch

Rotator cuff tears
What you’ll see. Partial-thickness, articular-sided tears of the supraspinatus, infraspinatus, or both—found posterosuperiorly at the posterior rotator interval—are common in throwing athletes. The patient may complain of weakness when trying to do overhead tasks or movements requiring shoulder abduction. The supraspinatus is usually the muscle affected, and so testing of this muscle with the “empty can test” will show pain with weakness if there is a tear. However, full-thickness rotator cuff tears are rare;³ consider a diagnosis of instability or a partial tear in such cases. An MRI can reveal a rotator cuff tear. In fact, the imaging may be necessary for any suspicion of a tear in an athlete.

Treatment. Recommend strengthening exercises to patients before considering surgery. Nonoperative treatment is preferred, and should be given a fair trial before surgery; studies have not consistently supported the operative approach to rotator cuff tears.^5,15 However, if conservative management fails, arthroscopic debridement of torn tissues is recommended over open procedures.³

Scapular dyskinesis and “SICK syndrome”
What you’ll see. Poor development of, or fatigue in, the scapular stabilizers leads to scapular dyskinesis (poor scapular control and motion). Scapulothoracic dyskinesis can progress to an overuse muscular fatigue syndrome called the “SICK syndrome” (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement).¹⁶ The most common symptoms include anterior shoulder pain, posterior/superior scapular pain with or without radiation,¹⁶ and a “dead arm” sensation. If not treated, this can result in rotator cuff lesions, impingement, and labral pathology.

Treatment. Both treatment and prevention are dependent on the proper biomechanics to retract and rotate the scapula correctly during throwing.¹ Strengthening the scapular stabilizers and stretching tight posterior structures help to promote proper biomechanics, and enable a successful return to throwing.¹⁴

Help patients prevent injuries in the first place

To reduce the risk of shoulder injuries, athletes need to maintain an appropriate “thrower’s motion” at the glenohumeral joint.¹⁷ Overhead throwing athletes often exhibit excessive external rotation in their dominant shoulders,¹⁸ while internal rotation is reduced.¹⁹

Frequent gentle stretching may help maintain equal total motion in both the throwing shoulder and the nondominant shoulder. However, warn patients to avoid overaggressive stretching to gain mobility; the goal should be to maintain mobility.¹⁷

Strengthening of the entire upper extremity (shoulder, scapula, elbow, and wrist) is essential. While the individual needs of each athlete must be addressed, electromyographic studies of the throwing motion suggest that stretching, strengthening, and retraining of the muscles that allow the shoulders to rotate upwards and backwards help the shoulder blade keep close to the rib cage at the back. These are the most important initial steps in rehabilitating shoulder injuries in a throwing athlete.

Prevention and treatment programs for the throwing athlete should always incorporate dynamic stabilization and neuromuscular control.¹⁷ Additionally, the transfer of kinetic energy, as well as proximal stability with distal mobility of the upper extremity, are enhanced by core stabilization drills, including planks and side planks, as well as lower body training. As such, core strengthening is a very important component of injury prevention exercise regimens for throwing athletes.

Lastly, throwing programs incorporating maximum pitch counts per day, rest days, and gentle throwing are key to injury prevention. Direct young throwing athletes and their parents to resources such as http://pediatrics.aappublications.org/content/129/3/e842.full.pdf+html. (Tell them to see the recommendations at the end of the document.) Keep in mind, however, that there are no clear recommendations for college and professional pitching.

Young athletes. It is important to note that athletes with immature skeletons are at particular risk of injury due to the relative weakness of the open growth plate and the development of muscle imbalance. It is essential to appropriately apply the principles discussed here to young athletes to prevent injury.

CORRESPONDENCE 
George Guntur A. Pujalte, MD, Penn State Milton S. Hershey Medical Center, 500 Hershey Center Drive, Hershey, PA 17033; [email protected]

Baseball players and other athletes who spend much of their time throwing a ball risk a variety of shoulder injuries because the repetitive motion causes repeated microtraumatic stress in the area. Injuries result from overuse of the muscles involved, improper technique—or both.

The review that follows will help you zero in on the correct diagnosis and identify the treatment that’s best for your patient.

First step: Cover these points in the history

In order to gather a detailed history of a patient with shoulder pain, you’ll want to do the following:

Ask about the location of the pain. Anterior shoulder pain is associated with subluxation, multidirectional instability, subacromial bursitis, and injury to the biceps, supraspinatus or subscapularis.¹ Posterior shoulder pain has been linked to infraspinatus injuries.

Assess the severity of the pain. Ask patients: “On a scale of one to 10, where 10 is the worst pain you have ever felt, how would you rate the pain you are feeling?”

Pinpoint the timing of the pain. Determine the phase of the throwing process that reproduces the primary symptoms. The 6 phases are wind up, early cocking, late cocking, acceleration, deceleration, and follow-through (FIGURE 1). So if, for instance, the patient tells you that his arm “went dead” during the late cocking, or early acceleration phase, it should prompt you to suspect subluxation.²

Videos

See how the Neer’s and Hawkin’s tests are done

Christopher Faubel, MD, Thepainsource.com

 

 

 Neer’s Impingement test

 

 

Hawkins test

FIGURE 1
The 6 phases of throwing

Ascertain the nature of the patient’s pain after activity. Does the patient experience the pain at night? If he answers Yes, you’ll want to consider the possibility of a rotator cuff tear.

Ask these targeted questions:

• When you raise your arm, do you feel a pinching pain in your shoulder? This may suggest the presence of impingement.
• Is your shoulder “catching” or “locking up”? If so, consider a labral tear or loose body, eg, a piece of cartilage or bone floating around in the joint.
• Does your shoulder feel like it is coming out of its socket—either partially or completely? This suggests shoulder instability.
• Is it difficult for you to reach behind your back, or do you have shoulder pain when you try to do this? This may indicate glenohumeral internal rotation deficit.
• Do you feel like you are throwing the ball slower, or with less accuracy? This may be an indication that there is something wrong with the rotator cuff muscles, the innervation around the shoulders, or the labrum that partly holds the shoulder together. Sometimes, a tear of the labrum presents simply as a “loss of power” in throwing, as defined by the athlete who is used to throwing the ball faster or farther.

Diagnoses to consider

Based on the patient’s history and responses to your questions, you’ll likely consider one of the following diagnoses as part of the differential.

External or internal impingement syndromes
What you’ll see. External or “subacromial” impingement syndrome results from compression of the rotator cuff between the coracoacromial arch and the humeral head. A sloping or hooked acromion or osteophyte may contribute to the syndrome.³ Neer’s and Hawkin’s tests are often positive, and there may be pain with the arc of motion. (For more on these and the other tests mentioned here, see “Athlete has shoulder problems? Consider these tests”.)

Internal impingement results from pinching of the rotator cuff between the posterosuperior labrum and the greater tuberosity. The pain usually occurs with repetitive maximal shoulder internal rotation and abduction, which leads to cumulative microtrauma and eventual articular-sided rotator cuff pathology.⁴ The patient will complain of pain with shoulder internal rotation and abduction. Neer’s and Hawkin’s tests are helpful in detecting internal impingement.

Shoulder girdle fatigue from lack of conditioning and overthrowing—or the tight posterior capsule often seen in throwing athletes—may also contribute to the disorder.⁴

Treatment. Proper management involves relative rest from overhead activities, and an individualized rehabilitation program that includes dynamic stretching/strengthening through the rotator cuff, posterior capsule, and scapular stabilizers. Injecting a corticosteroid-analgesic solution into the subacromial space may help you arrive at a diagnosis and also offers symptomatic relief.^1,3 Consider bursectomy, arthroscopic acromioplasty, capsulotomy and/or debridement for recalcitrant cases.^4,5

Shoulder labrum pathology
What you’ll see. Overhead-throwing athletes are at risk of labral tears. The externally rotated, abducted arm of a thrower causes posterior rotation of the biceps anchor, peeling the biceps from its superior labrum attachment,⁶ a superior labrum anterior and posterior (SLAP) tear, or a type II tear from anterior to posterior. SLAP tears may lead to shoulder catching and locking. The patient may complain of vague shoulder pain,⁷ which is worse in the late cocking phase. O’Brien’s test will be positive.

Magnetic resonance imaging (MRI) with arthrogram can reveal a labral tear. Consider ordering an MRI when the athlete’s pain is accompanied by mechanical symptoms, such as locking, catching, or instability, or if the shoulder signs and symptoms do not appear to be responding to appropriate physical therapy interventions after a period of time—usually 4 to 6 weeks.

Treatment. For small tears, conservative management includes relative rest and physical therapy.³ Depending on the tear morphology, consider arthroscopic labral debridement or repair if conservative measures fail. The literature offers mixed conclusions on the benefits of surgery, with varying rates of full return to play.^8-10

Shoulder instability
What you’ll see. Instability in throwing athletes is multifactorial, and rarely due to an isolated shoulder structure injury.¹¹ Patients will complain that their shoulder feels as if it is going to come out of its socket, even when they are not throwing. To help detect instability, look for the sulcus sign, and do a load and shift test and an apprehension-relocation test.

Two categories of injury. Instability injuries fall into 2 primary categories: TUBS (Traumatic, Unilateral, associated with Bankart lesion, treated with Surgery) and AMBRI (Atraumatic, Multidirectional, Bilateral, treated with Rehabilitation, Inferior capsular shift).

As its name makes clear, TUBS is associated with a Bankart lesion (an avulsion of the anteroinferior glenoid labrum to its attachment to the humerus). Shoulder x-rays, including outlet, axillary lateral, and anteroposterior views,³ may reveal a bony Bankart lesion. You may also see a Hill-Sachs lesion here, which is noted on the humeral posterolateral head as a depression in the bony cortex.

AMBRI is more common than TUBS in throwers. Athletes often gain a competitive edge by increasing external rotation. However, when overdone, this results in the excessive laxity seen in AMBRI. While rare, acute traumatic dislocation can occur in those with AMBRI-type instability.

Treatment. Scapular stabilization exercises, dynamic rotator cuff strengthening, relative rest, and a short course (7-10 days) of nonsteroidal anti-inflammatory drugs are the mainstays of shoulder instability treatment in the throwing athlete.^1,3 A throwing program may be started when the athlete is asymptomatic and has rested. You may also need to prescribe a longer rest period of 4 to 6 weeks if the symptoms return after commencing activity. For recalcitrant cases, consider surgery (via open or arthroscopic approaches⁶) to treat the associated underlying pathology.

Glenohumeral internal rotation deficit
What you’ll see. Posterior capsular contracture, common in the throwing athlete’s shoulder, causes decreased internal rotation and posterior shift of the total arc of glenohumeral motion.³ The patient may complain of decreased ability to reach backwards or pain when attempting to do so.

The anterior aspect of the shoulder’s capsule also lengthens, allowing anterior capsular laxity that causes additional problems, including internal impingement, SLAP tears, articular-sided, partial-thickness rotator cuff tears, and posterosuperior rotator cuff impingement. The risk for this cascade of complications increases in patients with throwing-shoulder internal rotation deficits ≥25° compared with the nonthrowing side, and a total arc of motion <180°.¹²

Treatment. Stretching the tight posterior capsule using the sleeper stretch (FIGURE 2) or the cross-body stretch (FIGURE 3) has proven very successful, with 90% of athletes seeing their symptoms resolve within 2 weeks.^13,14 If conservative treatment is ineffective, consider selective arthroscopic capsular release of the posterior inferior glenohumeral ligament.

FIGURE 2
The sleeper stretch

FIGURE 3
The cross-body stretch

Rotator cuff tears
What you’ll see. Partial-thickness, articular-sided tears of the supraspinatus, infraspinatus, or both—found posterosuperiorly at the posterior rotator interval—are common in throwing athletes. The patient may complain of weakness when trying to do overhead tasks or movements requiring shoulder abduction. The supraspinatus is usually the muscle affected, and so testing of this muscle with the “empty can test” will show pain with weakness if there is a tear. However, full-thickness rotator cuff tears are rare;³ consider a diagnosis of instability or a partial tear in such cases. An MRI can reveal a rotator cuff tear. In fact, the imaging may be necessary for any suspicion of a tear in an athlete.

Treatment. Recommend strengthening exercises to patients before considering surgery. Nonoperative treatment is preferred, and should be given a fair trial before surgery; studies have not consistently supported the operative approach to rotator cuff tears.^5,15 However, if conservative management fails, arthroscopic debridement of torn tissues is recommended over open procedures.³

Scapular dyskinesis and “SICK syndrome”
What you’ll see. Poor development of, or fatigue in, the scapular stabilizers leads to scapular dyskinesis (poor scapular control and motion). Scapulothoracic dyskinesis can progress to an overuse muscular fatigue syndrome called the “SICK syndrome” (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement).¹⁶ The most common symptoms include anterior shoulder pain, posterior/superior scapular pain with or without radiation,¹⁶ and a “dead arm” sensation. If not treated, this can result in rotator cuff lesions, impingement, and labral pathology.

Treatment. Both treatment and prevention are dependent on the proper biomechanics to retract and rotate the scapula correctly during throwing.¹ Strengthening the scapular stabilizers and stretching tight posterior structures help to promote proper biomechanics, and enable a successful return to throwing.¹⁴

Help patients prevent injuries in the first place

To reduce the risk of shoulder injuries, athletes need to maintain an appropriate “thrower’s motion” at the glenohumeral joint.¹⁷ Overhead throwing athletes often exhibit excessive external rotation in their dominant shoulders,¹⁸ while internal rotation is reduced.¹⁹

Frequent gentle stretching may help maintain equal total motion in both the throwing shoulder and the nondominant shoulder. However, warn patients to avoid overaggressive stretching to gain mobility; the goal should be to maintain mobility.¹⁷

Strengthening of the entire upper extremity (shoulder, scapula, elbow, and wrist) is essential. While the individual needs of each athlete must be addressed, electromyographic studies of the throwing motion suggest that stretching, strengthening, and retraining of the muscles that allow the shoulders to rotate upwards and backwards help the shoulder blade keep close to the rib cage at the back. These are the most important initial steps in rehabilitating shoulder injuries in a throwing athlete.

Prevention and treatment programs for the throwing athlete should always incorporate dynamic stabilization and neuromuscular control.¹⁷ Additionally, the transfer of kinetic energy, as well as proximal stability with distal mobility of the upper extremity, are enhanced by core stabilization drills, including planks and side planks, as well as lower body training. As such, core strengthening is a very important component of injury prevention exercise regimens for throwing athletes.

Lastly, throwing programs incorporating maximum pitch counts per day, rest days, and gentle throwing are key to injury prevention. Direct young throwing athletes and their parents to resources such as http://pediatrics.aappublications.org/content/129/3/e842.full.pdf+html. (Tell them to see the recommendations at the end of the document.) Keep in mind, however, that there are no clear recommendations for college and professional pitching.

Young athletes. It is important to note that athletes with immature skeletons are at particular risk of injury due to the relative weakness of the open growth plate and the development of muscle imbalance. It is essential to appropriately apply the principles discussed here to young athletes to prevent injury.

CORRESPONDENCE 
George Guntur A. Pujalte, MD, Penn State Milton S. Hershey Medical Center, 500 Hershey Center Drive, Hershey, PA 17033; [email protected]

Baseball players and other athletes who spend much of their time throwing a ball risk a variety of shoulder injuries because the repetitive motion causes repeated microtraumatic stress in the area. Injuries result from overuse of the muscles involved, improper technique—or both.

The review that follows will help you zero in on the correct diagnosis and identify the treatment that’s best for your patient.

First step: Cover these points in the history

In order to gather a detailed history of a patient with shoulder pain, you’ll want to do the following:

Ask about the location of the pain. Anterior shoulder pain is associated with subluxation, multidirectional instability, subacromial bursitis, and injury to the biceps, supraspinatus or subscapularis.¹ Posterior shoulder pain has been linked to infraspinatus injuries.

Assess the severity of the pain. Ask patients: “On a scale of one to 10, where 10 is the worst pain you have ever felt, how would you rate the pain you are feeling?”

Pinpoint the timing of the pain. Determine the phase of the throwing process that reproduces the primary symptoms. The 6 phases are wind up, early cocking, late cocking, acceleration, deceleration, and follow-through (FIGURE 1). So if, for instance, the patient tells you that his arm “went dead” during the late cocking, or early acceleration phase, it should prompt you to suspect subluxation.²

Videos

See how the Neer’s and Hawkin’s tests are done

Christopher Faubel, MD, Thepainsource.com

 

 

 Neer’s Impingement test

 

 

Hawkins test

FIGURE 1
The 6 phases of throwing

Ascertain the nature of the patient’s pain after activity. Does the patient experience the pain at night? If he answers Yes, you’ll want to consider the possibility of a rotator cuff tear.

Ask these targeted questions:

• When you raise your arm, do you feel a pinching pain in your shoulder? This may suggest the presence of impingement.
• Is your shoulder “catching” or “locking up”? If so, consider a labral tear or loose body, eg, a piece of cartilage or bone floating around in the joint.
• Does your shoulder feel like it is coming out of its socket—either partially or completely? This suggests shoulder instability.
• Is it difficult for you to reach behind your back, or do you have shoulder pain when you try to do this? This may indicate glenohumeral internal rotation deficit.
• Do you feel like you are throwing the ball slower, or with less accuracy? This may be an indication that there is something wrong with the rotator cuff muscles, the innervation around the shoulders, or the labrum that partly holds the shoulder together. Sometimes, a tear of the labrum presents simply as a “loss of power” in throwing, as defined by the athlete who is used to throwing the ball faster or farther.

Diagnoses to consider

Based on the patient’s history and responses to your questions, you’ll likely consider one of the following diagnoses as part of the differential.

External or internal impingement syndromes
What you’ll see. External or “subacromial” impingement syndrome results from compression of the rotator cuff between the coracoacromial arch and the humeral head. A sloping or hooked acromion or osteophyte may contribute to the syndrome.³ Neer’s and Hawkin’s tests are often positive, and there may be pain with the arc of motion. (For more on these and the other tests mentioned here, see “Athlete has shoulder problems? Consider these tests”.)

Internal impingement results from pinching of the rotator cuff between the posterosuperior labrum and the greater tuberosity. The pain usually occurs with repetitive maximal shoulder internal rotation and abduction, which leads to cumulative microtrauma and eventual articular-sided rotator cuff pathology.⁴ The patient will complain of pain with shoulder internal rotation and abduction. Neer’s and Hawkin’s tests are helpful in detecting internal impingement.

Shoulder girdle fatigue from lack of conditioning and overthrowing—or the tight posterior capsule often seen in throwing athletes—may also contribute to the disorder.⁴

Treatment. Proper management involves relative rest from overhead activities, and an individualized rehabilitation program that includes dynamic stretching/strengthening through the rotator cuff, posterior capsule, and scapular stabilizers. Injecting a corticosteroid-analgesic solution into the subacromial space may help you arrive at a diagnosis and also offers symptomatic relief.^1,3 Consider bursectomy, arthroscopic acromioplasty, capsulotomy and/or debridement for recalcitrant cases.^4,5

Shoulder labrum pathology
What you’ll see. Overhead-throwing athletes are at risk of labral tears. The externally rotated, abducted arm of a thrower causes posterior rotation of the biceps anchor, peeling the biceps from its superior labrum attachment,⁶ a superior labrum anterior and posterior (SLAP) tear, or a type II tear from anterior to posterior. SLAP tears may lead to shoulder catching and locking. The patient may complain of vague shoulder pain,⁷ which is worse in the late cocking phase. O’Brien’s test will be positive.

Magnetic resonance imaging (MRI) with arthrogram can reveal a labral tear. Consider ordering an MRI when the athlete’s pain is accompanied by mechanical symptoms, such as locking, catching, or instability, or if the shoulder signs and symptoms do not appear to be responding to appropriate physical therapy interventions after a period of time—usually 4 to 6 weeks.

Treatment. For small tears, conservative management includes relative rest and physical therapy.³ Depending on the tear morphology, consider arthroscopic labral debridement or repair if conservative measures fail. The literature offers mixed conclusions on the benefits of surgery, with varying rates of full return to play.^8-10

Shoulder instability
What you’ll see. Instability in throwing athletes is multifactorial, and rarely due to an isolated shoulder structure injury.¹¹ Patients will complain that their shoulder feels as if it is going to come out of its socket, even when they are not throwing. To help detect instability, look for the sulcus sign, and do a load and shift test and an apprehension-relocation test.

Two categories of injury. Instability injuries fall into 2 primary categories: TUBS (Traumatic, Unilateral, associated with Bankart lesion, treated with Surgery) and AMBRI (Atraumatic, Multidirectional, Bilateral, treated with Rehabilitation, Inferior capsular shift).

As its name makes clear, TUBS is associated with a Bankart lesion (an avulsion of the anteroinferior glenoid labrum to its attachment to the humerus). Shoulder x-rays, including outlet, axillary lateral, and anteroposterior views,³ may reveal a bony Bankart lesion. You may also see a Hill-Sachs lesion here, which is noted on the humeral posterolateral head as a depression in the bony cortex.

AMBRI is more common than TUBS in throwers. Athletes often gain a competitive edge by increasing external rotation. However, when overdone, this results in the excessive laxity seen in AMBRI. While rare, acute traumatic dislocation can occur in those with AMBRI-type instability.

Treatment. Scapular stabilization exercises, dynamic rotator cuff strengthening, relative rest, and a short course (7-10 days) of nonsteroidal anti-inflammatory drugs are the mainstays of shoulder instability treatment in the throwing athlete.^1,3 A throwing program may be started when the athlete is asymptomatic and has rested. You may also need to prescribe a longer rest period of 4 to 6 weeks if the symptoms return after commencing activity. For recalcitrant cases, consider surgery (via open or arthroscopic approaches⁶) to treat the associated underlying pathology.

Glenohumeral internal rotation deficit
What you’ll see. Posterior capsular contracture, common in the throwing athlete’s shoulder, causes decreased internal rotation and posterior shift of the total arc of glenohumeral motion.³ The patient may complain of decreased ability to reach backwards or pain when attempting to do so.

The anterior aspect of the shoulder’s capsule also lengthens, allowing anterior capsular laxity that causes additional problems, including internal impingement, SLAP tears, articular-sided, partial-thickness rotator cuff tears, and posterosuperior rotator cuff impingement. The risk for this cascade of complications increases in patients with throwing-shoulder internal rotation deficits ≥25° compared with the nonthrowing side, and a total arc of motion <180°.¹²

Treatment. Stretching the tight posterior capsule using the sleeper stretch (FIGURE 2) or the cross-body stretch (FIGURE 3) has proven very successful, with 90% of athletes seeing their symptoms resolve within 2 weeks.^13,14 If conservative treatment is ineffective, consider selective arthroscopic capsular release of the posterior inferior glenohumeral ligament.

FIGURE 2
The sleeper stretch

FIGURE 3
The cross-body stretch

Rotator cuff tears
What you’ll see. Partial-thickness, articular-sided tears of the supraspinatus, infraspinatus, or both—found posterosuperiorly at the posterior rotator interval—are common in throwing athletes. The patient may complain of weakness when trying to do overhead tasks or movements requiring shoulder abduction. The supraspinatus is usually the muscle affected, and so testing of this muscle with the “empty can test” will show pain with weakness if there is a tear. However, full-thickness rotator cuff tears are rare;³ consider a diagnosis of instability or a partial tear in such cases. An MRI can reveal a rotator cuff tear. In fact, the imaging may be necessary for any suspicion of a tear in an athlete.

Treatment. Recommend strengthening exercises to patients before considering surgery. Nonoperative treatment is preferred, and should be given a fair trial before surgery; studies have not consistently supported the operative approach to rotator cuff tears.^5,15 However, if conservative management fails, arthroscopic debridement of torn tissues is recommended over open procedures.³

Scapular dyskinesis and “SICK syndrome”
What you’ll see. Poor development of, or fatigue in, the scapular stabilizers leads to scapular dyskinesis (poor scapular control and motion). Scapulothoracic dyskinesis can progress to an overuse muscular fatigue syndrome called the “SICK syndrome” (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement).¹⁶ The most common symptoms include anterior shoulder pain, posterior/superior scapular pain with or without radiation,¹⁶ and a “dead arm” sensation. If not treated, this can result in rotator cuff lesions, impingement, and labral pathology.

Treatment. Both treatment and prevention are dependent on the proper biomechanics to retract and rotate the scapula correctly during throwing.¹ Strengthening the scapular stabilizers and stretching tight posterior structures help to promote proper biomechanics, and enable a successful return to throwing.¹⁴

Help patients prevent injuries in the first place

To reduce the risk of shoulder injuries, athletes need to maintain an appropriate “thrower’s motion” at the glenohumeral joint.¹⁷ Overhead throwing athletes often exhibit excessive external rotation in their dominant shoulders,¹⁸ while internal rotation is reduced.¹⁹

Frequent gentle stretching may help maintain equal total motion in both the throwing shoulder and the nondominant shoulder. However, warn patients to avoid overaggressive stretching to gain mobility; the goal should be to maintain mobility.¹⁷

Strengthening of the entire upper extremity (shoulder, scapula, elbow, and wrist) is essential. While the individual needs of each athlete must be addressed, electromyographic studies of the throwing motion suggest that stretching, strengthening, and retraining of the muscles that allow the shoulders to rotate upwards and backwards help the shoulder blade keep close to the rib cage at the back. These are the most important initial steps in rehabilitating shoulder injuries in a throwing athlete.

Prevention and treatment programs for the throwing athlete should always incorporate dynamic stabilization and neuromuscular control.¹⁷ Additionally, the transfer of kinetic energy, as well as proximal stability with distal mobility of the upper extremity, are enhanced by core stabilization drills, including planks and side planks, as well as lower body training. As such, core strengthening is a very important component of injury prevention exercise regimens for throwing athletes.

Lastly, throwing programs incorporating maximum pitch counts per day, rest days, and gentle throwing are key to injury prevention. Direct young throwing athletes and their parents to resources such as http://pediatrics.aappublications.org/content/129/3/e842.full.pdf+html. (Tell them to see the recommendations at the end of the document.) Keep in mind, however, that there are no clear recommendations for college and professional pitching.

Young athletes. It is important to note that athletes with immature skeletons are at particular risk of injury due to the relative weakness of the open growth plate and the development of muscle imbalance. It is essential to appropriately apply the principles discussed here to young athletes to prevent injury.

CORRESPONDENCE 
George Guntur A. Pujalte, MD, Penn State Milton S. Hershey Medical Center, 500 Hershey Center Drive, Hershey, PA 17033; [email protected]

A survey from the National Institute of Child Health and Human Development estimated that 20% of 6th through 10th graders admitted to bullying their classmates.¹ In addition to an increased risk for personal injury, bullied children are more likely to report low self-esteem and emotional problems² and often experience loneliness.¹ In contrast, children who bully suffer in their school performance¹ and are more likely to engage in drug use³ and violence⁴ later in life. Child psychiatrists often see both bullies and their victims.

Evidence-based recommendations are available to help educators improve the school climate⁵ and identify children who are at an increased risk for bullying,⁶ but research supporting specific clinical strategies for managing a child who bullies is limited. Establishing rapport and engaging a bully often is challenging; these difficulties further complicate assessment and successful management of such children.

We present the mnemonic MEAN to help clinicians assess and understand children who bully.

Model. Discuss, demonstrate, and practice models of alternative social skills and behaviors, including active listening, being open to others’ views, accepting failure, controlling impulses, developing problem-solving techniques, and treating others with respect.

Empathize. Encourage children who bully to explore their feelings about themselves—which may uncover poor self-esteem, anger, or guilt—and acknowledge the hurt they cause others by bullying. Focusing on the pain they inflict on others in the context of personal experiences of pain that likely is driving their aggression may enable bullies to empathize with their victims.

Assess. Help the bully assess the costs and benefits of his or her behavior. Point out what the bully stands to gain from ending his or her aggressive behavior, which likely already has resulted in lost recesses, after school detentions, missed sports practices, and the loss of privileges at home. Most importantly, assess and treat any underlying psychopathology, including mood and anxiety disorders.

Nurture. Aid the bully in identifying his or her prosocial strengths to build self-esteem and thereby reduce the need to commit aggressive acts as a means of gaining a sense of control or personal security. Disarm the child with your genuine concern for his or her well-being.

Using these psychotherapeutic techniques may enhance establishing rapport with a child who bullies and may improve outcomes.

Disclosures

Dr. Kepple reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Madaan receives grant or research support from Eli Lilly and Company, Forest Pharmaceuticals, Merck, Otsuka, Pfizer Inc., and Shire.

A survey from the National Institute of Child Health and Human Development estimated that 20% of 6th through 10th graders admitted to bullying their classmates.¹ In addition to an increased risk for personal injury, bullied children are more likely to report low self-esteem and emotional problems² and often experience loneliness.¹ In contrast, children who bully suffer in their school performance¹ and are more likely to engage in drug use³ and violence⁴ later in life. Child psychiatrists often see both bullies and their victims.

Evidence-based recommendations are available to help educators improve the school climate⁵ and identify children who are at an increased risk for bullying,⁶ but research supporting specific clinical strategies for managing a child who bullies is limited. Establishing rapport and engaging a bully often is challenging; these difficulties further complicate assessment and successful management of such children.

We present the mnemonic MEAN to help clinicians assess and understand children who bully.

Model. Discuss, demonstrate, and practice models of alternative social skills and behaviors, including active listening, being open to others’ views, accepting failure, controlling impulses, developing problem-solving techniques, and treating others with respect.

Empathize. Encourage children who bully to explore their feelings about themselves—which may uncover poor self-esteem, anger, or guilt—and acknowledge the hurt they cause others by bullying. Focusing on the pain they inflict on others in the context of personal experiences of pain that likely is driving their aggression may enable bullies to empathize with their victims.

Assess. Help the bully assess the costs and benefits of his or her behavior. Point out what the bully stands to gain from ending his or her aggressive behavior, which likely already has resulted in lost recesses, after school detentions, missed sports practices, and the loss of privileges at home. Most importantly, assess and treat any underlying psychopathology, including mood and anxiety disorders.

Nurture. Aid the bully in identifying his or her prosocial strengths to build self-esteem and thereby reduce the need to commit aggressive acts as a means of gaining a sense of control or personal security. Disarm the child with your genuine concern for his or her well-being.

Using these psychotherapeutic techniques may enhance establishing rapport with a child who bullies and may improve outcomes.

Disclosures

Dr. Kepple reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Madaan receives grant or research support from Eli Lilly and Company, Forest Pharmaceuticals, Merck, Otsuka, Pfizer Inc., and Shire.

A survey from the National Institute of Child Health and Human Development estimated that 20% of 6th through 10th graders admitted to bullying their classmates.¹ In addition to an increased risk for personal injury, bullied children are more likely to report low self-esteem and emotional problems² and often experience loneliness.¹ In contrast, children who bully suffer in their school performance¹ and are more likely to engage in drug use³ and violence⁴ later in life. Child psychiatrists often see both bullies and their victims.

Evidence-based recommendations are available to help educators improve the school climate⁵ and identify children who are at an increased risk for bullying,⁶ but research supporting specific clinical strategies for managing a child who bullies is limited. Establishing rapport and engaging a bully often is challenging; these difficulties further complicate assessment and successful management of such children.

We present the mnemonic MEAN to help clinicians assess and understand children who bully.

Model. Discuss, demonstrate, and practice models of alternative social skills and behaviors, including active listening, being open to others’ views, accepting failure, controlling impulses, developing problem-solving techniques, and treating others with respect.

Empathize. Encourage children who bully to explore their feelings about themselves—which may uncover poor self-esteem, anger, or guilt—and acknowledge the hurt they cause others by bullying. Focusing on the pain they inflict on others in the context of personal experiences of pain that likely is driving their aggression may enable bullies to empathize with their victims.

Assess. Help the bully assess the costs and benefits of his or her behavior. Point out what the bully stands to gain from ending his or her aggressive behavior, which likely already has resulted in lost recesses, after school detentions, missed sports practices, and the loss of privileges at home. Most importantly, assess and treat any underlying psychopathology, including mood and anxiety disorders.

Nurture. Aid the bully in identifying his or her prosocial strengths to build self-esteem and thereby reduce the need to commit aggressive acts as a means of gaining a sense of control or personal security. Disarm the child with your genuine concern for his or her well-being.

Using these psychotherapeutic techniques may enhance establishing rapport with a child who bullies and may improve outcomes.

Disclosures

Dr. Kepple reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Madaan receives grant or research support from Eli Lilly and Company, Forest Pharmaceuticals, Merck, Otsuka, Pfizer Inc., and Shire.

In the aftermath of a school shooting, parents and teachers may seek a psychiatrist’s advice on how to best discuss these incidents with children. We offer guidelines on what to tell concerned parents, educators, and other adults who may interact with children affected by a school shooting.

6 tips for interacting with children

1. Talk about the event. Instruct adults to ask children to share their feelings about the incident and to show genuine interest in listening to the child’s thoughts and point of view. Adults shouldn’t pretend the event hasn’t occurred or isn’t serious. Children may be more worried if they think adults are too afraid to tell them what is happening. It is important to gently correct any misinformation older students may have received via social media.¹

2. Reinforce that home is a safe haven. Overwhelming emotions and uncertainty can bring about a sense of insecurity in children. Children may come home seeking a safe environment. Advise parents to plan a night where family members participate in a favorite family activity.¹ Tell parents to remind their children that trust-worthy adults—parents, emergency workers, police, firefighters, doctors, and the military—are helping provide safety, comfort, and support.²

3. Limit television time. If children are exposed to the news, parents should watch it with them briefly, but avoid letting children rewatch the same event repetitively. Constant exposure to the event may heighten a child’s anxiety and fears.

4. Maintain a normal routine. Tell parents they should maintain, as best they can, their normal routine for dinner, homework, chores, and bedtime, but to remain flexible.² Children may have a hard time concentrating on schoolwork or falling asleep. Advise parents to spend extra time reading or playing quiet games with their children, particularly at bedtime. These activities are calming, foster a sense of closeness and security, and reinforce a feeling of normalcy.

5. Encourage emotions. Instruct parents to explain to their children that all feelings are okay and normal, and to let children talk about their feelings and help put them into perspective.¹ Children may need help in expressing these feelings, so be patient. If an incident happened at the child’s school, teachers and administrators may conduct group sessions to help children express their concerns about being back in school.

6. Seek creativity or spirituality. Encourage parents and other adults to provide a creative outlet for children, such as making get well cards or sending letters to the survivors and their families. Writing thank you letters to doctors, nurses, fire-fighters, and police officers also may be comforting.^1,2 Suggest that parents encourage their children to pray or think hopeful thoughts for the victims and their families.

2 tips for interacting with adults

7. Recommend they take care of themselves. Explain to adult caregivers that because children learn by observing, they shouldn’t ignore their own feelings of anxiety, grief, and anger. By expressing their emotions in a productive manner, adults will be better able to support their children. Encourage adults to talk to friends, family, religious leaders, or mental health counselors.

8. Advise adults to be alert for children who may need professional help. Tell them to be vigilant when monitoring a child’s emotional state. Children who may benefit from mental health counseling after a tragedy may exhibit warning signs, such as changes in behavior, appetite, and sleep patterns, which may indicate the child is experiencing grief, anxiety, or discomfort.

Remind adults to be aware of children who are at greater risk for mental health issues, including those who are already struggling with other recent traumatic experiences—past traumatic experiences, personal loss, depression, or other mental illness.¹ Be particularly observant for children who may be at risk of suicide.^1,2 Professional counseling may be needed for a child who is experiencing an emotional reaction that lasts >1 month and is impacting his or her daily functioning.¹

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

In the aftermath of a school shooting, parents and teachers may seek a psychiatrist’s advice on how to best discuss these incidents with children. We offer guidelines on what to tell concerned parents, educators, and other adults who may interact with children affected by a school shooting.

6 tips for interacting with children

1. Talk about the event. Instruct adults to ask children to share their feelings about the incident and to show genuine interest in listening to the child’s thoughts and point of view. Adults shouldn’t pretend the event hasn’t occurred or isn’t serious. Children may be more worried if they think adults are too afraid to tell them what is happening. It is important to gently correct any misinformation older students may have received via social media.¹

2. Reinforce that home is a safe haven. Overwhelming emotions and uncertainty can bring about a sense of insecurity in children. Children may come home seeking a safe environment. Advise parents to plan a night where family members participate in a favorite family activity.¹ Tell parents to remind their children that trust-worthy adults—parents, emergency workers, police, firefighters, doctors, and the military—are helping provide safety, comfort, and support.²

3. Limit television time. If children are exposed to the news, parents should watch it with them briefly, but avoid letting children rewatch the same event repetitively. Constant exposure to the event may heighten a child’s anxiety and fears.

4. Maintain a normal routine. Tell parents they should maintain, as best they can, their normal routine for dinner, homework, chores, and bedtime, but to remain flexible.² Children may have a hard time concentrating on schoolwork or falling asleep. Advise parents to spend extra time reading or playing quiet games with their children, particularly at bedtime. These activities are calming, foster a sense of closeness and security, and reinforce a feeling of normalcy.

5. Encourage emotions. Instruct parents to explain to their children that all feelings are okay and normal, and to let children talk about their feelings and help put them into perspective.¹ Children may need help in expressing these feelings, so be patient. If an incident happened at the child’s school, teachers and administrators may conduct group sessions to help children express their concerns about being back in school.

6. Seek creativity or spirituality. Encourage parents and other adults to provide a creative outlet for children, such as making get well cards or sending letters to the survivors and their families. Writing thank you letters to doctors, nurses, fire-fighters, and police officers also may be comforting.^1,2 Suggest that parents encourage their children to pray or think hopeful thoughts for the victims and their families.

2 tips for interacting with adults

7. Recommend they take care of themselves. Explain to adult caregivers that because children learn by observing, they shouldn’t ignore their own feelings of anxiety, grief, and anger. By expressing their emotions in a productive manner, adults will be better able to support their children. Encourage adults to talk to friends, family, religious leaders, or mental health counselors.

8. Advise adults to be alert for children who may need professional help. Tell them to be vigilant when monitoring a child’s emotional state. Children who may benefit from mental health counseling after a tragedy may exhibit warning signs, such as changes in behavior, appetite, and sleep patterns, which may indicate the child is experiencing grief, anxiety, or discomfort.

Remind adults to be aware of children who are at greater risk for mental health issues, including those who are already struggling with other recent traumatic experiences—past traumatic experiences, personal loss, depression, or other mental illness.¹ Be particularly observant for children who may be at risk of suicide.^1,2 Professional counseling may be needed for a child who is experiencing an emotional reaction that lasts >1 month and is impacting his or her daily functioning.¹

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

In the aftermath of a school shooting, parents and teachers may seek a psychiatrist’s advice on how to best discuss these incidents with children. We offer guidelines on what to tell concerned parents, educators, and other adults who may interact with children affected by a school shooting.

6 tips for interacting with children

1. Talk about the event. Instruct adults to ask children to share their feelings about the incident and to show genuine interest in listening to the child’s thoughts and point of view. Adults shouldn’t pretend the event hasn’t occurred or isn’t serious. Children may be more worried if they think adults are too afraid to tell them what is happening. It is important to gently correct any misinformation older students may have received via social media.¹

2. Reinforce that home is a safe haven. Overwhelming emotions and uncertainty can bring about a sense of insecurity in children. Children may come home seeking a safe environment. Advise parents to plan a night where family members participate in a favorite family activity.¹ Tell parents to remind their children that trust-worthy adults—parents, emergency workers, police, firefighters, doctors, and the military—are helping provide safety, comfort, and support.²

3. Limit television time. If children are exposed to the news, parents should watch it with them briefly, but avoid letting children rewatch the same event repetitively. Constant exposure to the event may heighten a child’s anxiety and fears.

4. Maintain a normal routine. Tell parents they should maintain, as best they can, their normal routine for dinner, homework, chores, and bedtime, but to remain flexible.² Children may have a hard time concentrating on schoolwork or falling asleep. Advise parents to spend extra time reading or playing quiet games with their children, particularly at bedtime. These activities are calming, foster a sense of closeness and security, and reinforce a feeling of normalcy.

5. Encourage emotions. Instruct parents to explain to their children that all feelings are okay and normal, and to let children talk about their feelings and help put them into perspective.¹ Children may need help in expressing these feelings, so be patient. If an incident happened at the child’s school, teachers and administrators may conduct group sessions to help children express their concerns about being back in school.

6. Seek creativity or spirituality. Encourage parents and other adults to provide a creative outlet for children, such as making get well cards or sending letters to the survivors and their families. Writing thank you letters to doctors, nurses, fire-fighters, and police officers also may be comforting.^1,2 Suggest that parents encourage their children to pray or think hopeful thoughts for the victims and their families.

2 tips for interacting with adults

7. Recommend they take care of themselves. Explain to adult caregivers that because children learn by observing, they shouldn’t ignore their own feelings of anxiety, grief, and anger. By expressing their emotions in a productive manner, adults will be better able to support their children. Encourage adults to talk to friends, family, religious leaders, or mental health counselors.

8. Advise adults to be alert for children who may need professional help. Tell them to be vigilant when monitoring a child’s emotional state. Children who may benefit from mental health counseling after a tragedy may exhibit warning signs, such as changes in behavior, appetite, and sleep patterns, which may indicate the child is experiencing grief, anxiety, or discomfort.

Remind adults to be aware of children who are at greater risk for mental health issues, including those who are already struggling with other recent traumatic experiences—past traumatic experiences, personal loss, depression, or other mental illness.¹ Be particularly observant for children who may be at risk of suicide.^1,2 Professional counseling may be needed for a child who is experiencing an emotional reaction that lasts >1 month and is impacting his or her daily functioning.¹

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Lung cancer is the leading cause of cancer-related mortality among men and women in the United States. Non–small-cell lung cancer (NSCLC) accounts for about 85% of all lung cancers. Most patients with NSCLC present with advanced disease and median overall survival in this incurable setting remain dismal. Accumulating evidence suggests that both histology and molecular signature have prognostic and predictive value for NSCLC. Recent advances in the molecular characterization of NSCLC tumors have made individualized treatment approaches feasible. Personalized chemotherapy and targeted biological therapy based on a tumor’s individual biologic and molecular profile can optimize efficacy while minimizing toxicity. Molecular testing for activating mutations in the epidermal growth factor receptor (EGFR) domain and EML4-ALK translocation are routinely used to guide therapeutic decisions. Several new treatments that irreversibly target EGFR family members are in development for patients with NSCLC. Novel EML4-ALK inhibitors such as LDK378 are promising agents with encouraging early efficacy data. KRAS mutations are the most common mutation in adenocarcinomas. Although no agents for this subset of NSCLC have been approved, there are several agents in clinical development, including selumetinib, an MEK inhibitor, that seem promising. A growing body of evidence suggests that NSCLC is subject to immune surveillance. Immunotherapeutic interventions, including vaccine therapy and antigen-independent immunomodulatory strategies, may improve outcomes in NSCLC. In this review, we summarize recent advances in non–small-cell lung cancer, with an emphasis on investigational strategies for individualized treatment.

*Click on the link to the left for a PDF of the full article.

Lung cancer is the leading cause of cancer-related mortality among men and women in the United States. Non–small-cell lung cancer (NSCLC) accounts for about 85% of all lung cancers. Most patients with NSCLC present with advanced disease and median overall survival in this incurable setting remain dismal. Accumulating evidence suggests that both histology and molecular signature have prognostic and predictive value for NSCLC. Recent advances in the molecular characterization of NSCLC tumors have made individualized treatment approaches feasible. Personalized chemotherapy and targeted biological therapy based on a tumor’s individual biologic and molecular profile can optimize efficacy while minimizing toxicity. Molecular testing for activating mutations in the epidermal growth factor receptor (EGFR) domain and EML4-ALK translocation are routinely used to guide therapeutic decisions. Several new treatments that irreversibly target EGFR family members are in development for patients with NSCLC. Novel EML4-ALK inhibitors such as LDK378 are promising agents with encouraging early efficacy data. KRAS mutations are the most common mutation in adenocarcinomas. Although no agents for this subset of NSCLC have been approved, there are several agents in clinical development, including selumetinib, an MEK inhibitor, that seem promising. A growing body of evidence suggests that NSCLC is subject to immune surveillance. Immunotherapeutic interventions, including vaccine therapy and antigen-independent immunomodulatory strategies, may improve outcomes in NSCLC. In this review, we summarize recent advances in non–small-cell lung cancer, with an emphasis on investigational strategies for individualized treatment.

*Click on the link to the left for a PDF of the full article.

Lung cancer is the leading cause of cancer-related mortality among men and women in the United States. Non–small-cell lung cancer (NSCLC) accounts for about 85% of all lung cancers. Most patients with NSCLC present with advanced disease and median overall survival in this incurable setting remain dismal. Accumulating evidence suggests that both histology and molecular signature have prognostic and predictive value for NSCLC. Recent advances in the molecular characterization of NSCLC tumors have made individualized treatment approaches feasible. Personalized chemotherapy and targeted biological therapy based on a tumor’s individual biologic and molecular profile can optimize efficacy while minimizing toxicity. Molecular testing for activating mutations in the epidermal growth factor receptor (EGFR) domain and EML4-ALK translocation are routinely used to guide therapeutic decisions. Several new treatments that irreversibly target EGFR family members are in development for patients with NSCLC. Novel EML4-ALK inhibitors such as LDK378 are promising agents with encouraging early efficacy data. KRAS mutations are the most common mutation in adenocarcinomas. Although no agents for this subset of NSCLC have been approved, there are several agents in clinical development, including selumetinib, an MEK inhibitor, that seem promising. A growing body of evidence suggests that NSCLC is subject to immune surveillance. Immunotherapeutic interventions, including vaccine therapy and antigen-independent immunomodulatory strategies, may improve outcomes in NSCLC. In this review, we summarize recent advances in non–small-cell lung cancer, with an emphasis on investigational strategies for individualized treatment.

*Click on the link to the left for a PDF of the full article.

ANSWER
The correct interpretation includes sinus tachycardia with occasional premature ventricular complexes (PVCs), left atrial enlargement, evidence of a previous inferior MI, and an acute anterior MI. Sinus tachycardia is evidenced by a rate ≥ 100 beats/min and the presence of a P wave for every QRS complex with a constant PR interval. A single PVC is evident (12th beat of the rhythm strips V₁, II, and V₅).

Left atrial enlargement is evidenced by a large P wave in lead II and a biphasic P wave with the terminal portion larger than the initial portion in lead V₁. An old inferior MI is evidenced by the presence of Q waves in leads II, III, and aVF.

An evolving anterior MI is diagnosed by the presence of poor R-wave progression with ST-segment elevations and T-wave inversion in leads V₂, V₃, and V₄. This was subsequently confirmed by clinically significant elevations of serum troponin levels and by cardiac catheterization, which revealed occlusion of the left anterior descending artery distal to the internal mammary artery anastomosis.

ANSWER
The correct interpretation includes sinus tachycardia with occasional premature ventricular complexes (PVCs), left atrial enlargement, evidence of a previous inferior MI, and an acute anterior MI. Sinus tachycardia is evidenced by a rate ≥ 100 beats/min and the presence of a P wave for every QRS complex with a constant PR interval. A single PVC is evident (12th beat of the rhythm strips V₁, II, and V₅).

Left atrial enlargement is evidenced by a large P wave in lead II and a biphasic P wave with the terminal portion larger than the initial portion in lead V₁. An old inferior MI is evidenced by the presence of Q waves in leads II, III, and aVF.

An evolving anterior MI is diagnosed by the presence of poor R-wave progression with ST-segment elevations and T-wave inversion in leads V₂, V₃, and V₄. This was subsequently confirmed by clinically significant elevations of serum troponin levels and by cardiac catheterization, which revealed occlusion of the left anterior descending artery distal to the internal mammary artery anastomosis.

ANSWER
The correct interpretation includes sinus tachycardia with occasional premature ventricular complexes (PVCs), left atrial enlargement, evidence of a previous inferior MI, and an acute anterior MI. Sinus tachycardia is evidenced by a rate ≥ 100 beats/min and the presence of a P wave for every QRS complex with a constant PR interval. A single PVC is evident (12th beat of the rhythm strips V₁, II, and V₅).

Left atrial enlargement is evidenced by a large P wave in lead II and a biphasic P wave with the terminal portion larger than the initial portion in lead V₁. An old inferior MI is evidenced by the presence of Q waves in leads II, III, and aVF.

An evolving anterior MI is diagnosed by the presence of poor R-wave progression with ST-segment elevations and T-wave inversion in leads V₂, V₃, and V₄. This was subsequently confirmed by clinically significant elevations of serum troponin levels and by cardiac catheterization, which revealed occlusion of the left anterior descending artery distal to the internal mammary artery anastomosis.

ANSWER
The most likely diagnosis is psoriasis (choice “d”), which can manifest with localized involvement (see discussion below).

Fungal infection (choice “a”) is unlikely, given the negative results of the KOH prep and total lack of response to treatment for that diagnosis.

Eczema (choice “b”) does not manifest as such thick, adherent scale. If any nail changes were involved, they would likely consist of transverse nail ridges.

A variant of squamous cell carcinoma (SCC; choice “c”)—caused by human papillomavirus (HPV), for example—can produce somewhat similar changes in the skin. But it would be unlikely to lead to nail changes, and it would not be intermittent, as this rash was in apparent response to OTC cream.

DISCUSSION
A punch biopsy is sometimes required to confirm the diagnosis of psoriasis, but this combination of skin and nail changes is quite suggestive of that entity. In this case, the confirmation was made by a different route: The rheumatologist judged that the patient’s arthritis was psoriatic in nature. The arthritis was treated with methotrexate, which soon cleared the skin disease without any help from dermatology.

This case serves to reinforce the possible mind-body role of stress in the genesis of this disease; however, at least 30% of the time, there is a positive family history. It also demonstrates the seemingly contradictory fact that the severity of the psoriasis doesn’t always correlate with the presence or absence of psoriatic arthritis.

Adding to the difficulty of making the diagnosis of psoriasis is the localized distribution of the scales, since it can usually be corroborated by finding lesions in their usual haunts—such as the extensor surfaces of arms, legs, on the trunk, or in the scalp. Cases such as this one force the provider to carefully consider the differential, which includes fungal infection. But the dermatophytes that cause ordinary fungal infections have to come from predictable sources (eg, children, pets, or farm animals), all missing from this patient’s history.

Had the rash been “fixed” (unchanging), the diagnosis of SCC would have to be considered more carefully. Superficial SCC is called Bowen’s disease, which, in cases such as this, is usually caused by HPV, not by the more typical overexposure to UV light. Though superficial, Bowen’s disease can become focally invasive and can even metastasize.

Had this patient not been treated with methotrexate, we would probably have used topical class 1 corticosteroid creams, which would have had a good chance to improve his skin but not his nail. The patient was also counseled regarding the role of stress and increased alcohol intake in the worsening of his disease. His prognosis for skin and joint disease is decent, though he will probably experience recurrences.

ANSWER
The most likely diagnosis is psoriasis (choice “d”), which can manifest with localized involvement (see discussion below).

Fungal infection (choice “a”) is unlikely, given the negative results of the KOH prep and total lack of response to treatment for that diagnosis.

Eczema (choice “b”) does not manifest as such thick, adherent scale. If any nail changes were involved, they would likely consist of transverse nail ridges.

A variant of squamous cell carcinoma (SCC; choice “c”)—caused by human papillomavirus (HPV), for example—can produce somewhat similar changes in the skin. But it would be unlikely to lead to nail changes, and it would not be intermittent, as this rash was in apparent response to OTC cream.

DISCUSSION
A punch biopsy is sometimes required to confirm the diagnosis of psoriasis, but this combination of skin and nail changes is quite suggestive of that entity. In this case, the confirmation was made by a different route: The rheumatologist judged that the patient’s arthritis was psoriatic in nature. The arthritis was treated with methotrexate, which soon cleared the skin disease without any help from dermatology.

This case serves to reinforce the possible mind-body role of stress in the genesis of this disease; however, at least 30% of the time, there is a positive family history. It also demonstrates the seemingly contradictory fact that the severity of the psoriasis doesn’t always correlate with the presence or absence of psoriatic arthritis.

Adding to the difficulty of making the diagnosis of psoriasis is the localized distribution of the scales, since it can usually be corroborated by finding lesions in their usual haunts—such as the extensor surfaces of arms, legs, on the trunk, or in the scalp. Cases such as this one force the provider to carefully consider the differential, which includes fungal infection. But the dermatophytes that cause ordinary fungal infections have to come from predictable sources (eg, children, pets, or farm animals), all missing from this patient’s history.

Had the rash been “fixed” (unchanging), the diagnosis of SCC would have to be considered more carefully. Superficial SCC is called Bowen’s disease, which, in cases such as this, is usually caused by HPV, not by the more typical overexposure to UV light. Though superficial, Bowen’s disease can become focally invasive and can even metastasize.

Had this patient not been treated with methotrexate, we would probably have used topical class 1 corticosteroid creams, which would have had a good chance to improve his skin but not his nail. The patient was also counseled regarding the role of stress and increased alcohol intake in the worsening of his disease. His prognosis for skin and joint disease is decent, though he will probably experience recurrences.

ANSWER
The most likely diagnosis is psoriasis (choice “d”), which can manifest with localized involvement (see discussion below).

Fungal infection (choice “a”) is unlikely, given the negative results of the KOH prep and total lack of response to treatment for that diagnosis.

Eczema (choice “b”) does not manifest as such thick, adherent scale. If any nail changes were involved, they would likely consist of transverse nail ridges.

A variant of squamous cell carcinoma (SCC; choice “c”)—caused by human papillomavirus (HPV), for example—can produce somewhat similar changes in the skin. But it would be unlikely to lead to nail changes, and it would not be intermittent, as this rash was in apparent response to OTC cream.

DISCUSSION
A punch biopsy is sometimes required to confirm the diagnosis of psoriasis, but this combination of skin and nail changes is quite suggestive of that entity. In this case, the confirmation was made by a different route: The rheumatologist judged that the patient’s arthritis was psoriatic in nature. The arthritis was treated with methotrexate, which soon cleared the skin disease without any help from dermatology.

This case serves to reinforce the possible mind-body role of stress in the genesis of this disease; however, at least 30% of the time, there is a positive family history. It also demonstrates the seemingly contradictory fact that the severity of the psoriasis doesn’t always correlate with the presence or absence of psoriatic arthritis.

Adding to the difficulty of making the diagnosis of psoriasis is the localized distribution of the scales, since it can usually be corroborated by finding lesions in their usual haunts—such as the extensor surfaces of arms, legs, on the trunk, or in the scalp. Cases such as this one force the provider to carefully consider the differential, which includes fungal infection. But the dermatophytes that cause ordinary fungal infections have to come from predictable sources (eg, children, pets, or farm animals), all missing from this patient’s history.

Had the rash been “fixed” (unchanging), the diagnosis of SCC would have to be considered more carefully. Superficial SCC is called Bowen’s disease, which, in cases such as this, is usually caused by HPV, not by the more typical overexposure to UV light. Though superficial, Bowen’s disease can become focally invasive and can even metastasize.

Had this patient not been treated with methotrexate, we would probably have used topical class 1 corticosteroid creams, which would have had a good chance to improve his skin but not his nail. The patient was also counseled regarding the role of stress and increased alcohol intake in the worsening of his disease. His prognosis for skin and joint disease is decent, though he will probably experience recurrences.