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Dermatology atlas will profile disease in all skin types
An atlas that displays the unique nuances between different skin types across the spectrum of dermatologic disease is scheduled for release this coming winter.
Available as an e-book or physical text, Dermatologists need to know what skin diseases look like on all types of skin, said Adam Friedman, MD, who is developing this e-book with Misty Eleryan, MD, MS.
From the SARS-CoV-2 pandemic, multiple nonviral pandemics have rapidly emerged, “most notably the persistent and well-masked racism that maintains disparities in all facets of life, from economics to health care,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview.
In dermatology, “clear disparities in workforce representation and trainee/practitioner education have become more apparent than ever before,” he added.
The project is a collaboration of George Washington University and education publishers Sanova Works and Educational Testing & Assessment Systems.
As a person of color who recently completed her residency in dermatology at George Washington University, Dr. Eleryan had noticed a lack of diversity in photos of common dermatoses. This can contribute to misdiagnoses and delays in treatment in patients of color, Dr. Eleryan, who is now a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, said in an interview.
“We recognized the gap, which is the lack of diversity/variation of skin tones in our dermatology textbooks and atlases,” she added.
The project was several years in the making, Dr. Friedman said. To do this right, “you need resources, funding, and a collaborative and galvanized team of experts.” That involved coordinating with several medical publishers and amassing a team of medical photographers and an expert panel that will assist in evaluating and securing difficult-to-access clinical images.
The atlas is one of several initiatives in the dermatology field to address racial disparities in patient care.
Noticing similar information gaps about clinical presentations in darker skin, a medical student in the United Kingdom, Malone Mukwende, created “Mind the Gap,” a handbook that presents side-by-side images of diseases and illnesses in light and dark skin. This project “highlights how far behind we are, that a medical student with minimal dermatology exposure and experience not only recognized the need but was ready to do something about it,” Dr. Friedman noted.
Others in the field have spotlighted disparities in the medical literature. The SARS-CoV-2 pandemic has especially brought this out, Graeme M. Lipper, MD wrote in a recent editorial for this news organization.
He referred to a literature review of 46 articles describing COVID-19–associated skin manifestations, which included mostly (92%) images in patients with skin types I-III (92%) and none in patients with skin types V or VI.
“These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin,” added Dr. Lipper, an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital.
For now, Dr. Friedman said that the atlas won’t contain a specific section on COVID-19 skin manifestations, although viral-associated skin reactions like morbilliform eruptions, urticaria, and retiform purpura will be displayed. Overall, the atlas will address 60-70 skin conditions.
Physicians who fail to educate themselves on the variations of skin conditions in all skin types may potentially harm patients of color, Dr. Eleryan said. As Dr. Lipper noted in his editorial, nearly half of all dermatologists feel they haven’t had adequate exposure to diseases in skin of color.
“Our atlas will fill that void and hopefully assist in closing the gap in health disparities among patients of color, who are often misdiagnosed or rendered diagnoses very late in the disease process,” Dr. Eleryan said.
An atlas that displays the unique nuances between different skin types across the spectrum of dermatologic disease is scheduled for release this coming winter.
Available as an e-book or physical text, Dermatologists need to know what skin diseases look like on all types of skin, said Adam Friedman, MD, who is developing this e-book with Misty Eleryan, MD, MS.
From the SARS-CoV-2 pandemic, multiple nonviral pandemics have rapidly emerged, “most notably the persistent and well-masked racism that maintains disparities in all facets of life, from economics to health care,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview.
In dermatology, “clear disparities in workforce representation and trainee/practitioner education have become more apparent than ever before,” he added.
The project is a collaboration of George Washington University and education publishers Sanova Works and Educational Testing & Assessment Systems.
As a person of color who recently completed her residency in dermatology at George Washington University, Dr. Eleryan had noticed a lack of diversity in photos of common dermatoses. This can contribute to misdiagnoses and delays in treatment in patients of color, Dr. Eleryan, who is now a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, said in an interview.
“We recognized the gap, which is the lack of diversity/variation of skin tones in our dermatology textbooks and atlases,” she added.
The project was several years in the making, Dr. Friedman said. To do this right, “you need resources, funding, and a collaborative and galvanized team of experts.” That involved coordinating with several medical publishers and amassing a team of medical photographers and an expert panel that will assist in evaluating and securing difficult-to-access clinical images.
The atlas is one of several initiatives in the dermatology field to address racial disparities in patient care.
Noticing similar information gaps about clinical presentations in darker skin, a medical student in the United Kingdom, Malone Mukwende, created “Mind the Gap,” a handbook that presents side-by-side images of diseases and illnesses in light and dark skin. This project “highlights how far behind we are, that a medical student with minimal dermatology exposure and experience not only recognized the need but was ready to do something about it,” Dr. Friedman noted.
Others in the field have spotlighted disparities in the medical literature. The SARS-CoV-2 pandemic has especially brought this out, Graeme M. Lipper, MD wrote in a recent editorial for this news organization.
He referred to a literature review of 46 articles describing COVID-19–associated skin manifestations, which included mostly (92%) images in patients with skin types I-III (92%) and none in patients with skin types V or VI.
“These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin,” added Dr. Lipper, an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital.
For now, Dr. Friedman said that the atlas won’t contain a specific section on COVID-19 skin manifestations, although viral-associated skin reactions like morbilliform eruptions, urticaria, and retiform purpura will be displayed. Overall, the atlas will address 60-70 skin conditions.
Physicians who fail to educate themselves on the variations of skin conditions in all skin types may potentially harm patients of color, Dr. Eleryan said. As Dr. Lipper noted in his editorial, nearly half of all dermatologists feel they haven’t had adequate exposure to diseases in skin of color.
“Our atlas will fill that void and hopefully assist in closing the gap in health disparities among patients of color, who are often misdiagnosed or rendered diagnoses very late in the disease process,” Dr. Eleryan said.
An atlas that displays the unique nuances between different skin types across the spectrum of dermatologic disease is scheduled for release this coming winter.
Available as an e-book or physical text, Dermatologists need to know what skin diseases look like on all types of skin, said Adam Friedman, MD, who is developing this e-book with Misty Eleryan, MD, MS.
From the SARS-CoV-2 pandemic, multiple nonviral pandemics have rapidly emerged, “most notably the persistent and well-masked racism that maintains disparities in all facets of life, from economics to health care,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview.
In dermatology, “clear disparities in workforce representation and trainee/practitioner education have become more apparent than ever before,” he added.
The project is a collaboration of George Washington University and education publishers Sanova Works and Educational Testing & Assessment Systems.
As a person of color who recently completed her residency in dermatology at George Washington University, Dr. Eleryan had noticed a lack of diversity in photos of common dermatoses. This can contribute to misdiagnoses and delays in treatment in patients of color, Dr. Eleryan, who is now a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, said in an interview.
“We recognized the gap, which is the lack of diversity/variation of skin tones in our dermatology textbooks and atlases,” she added.
The project was several years in the making, Dr. Friedman said. To do this right, “you need resources, funding, and a collaborative and galvanized team of experts.” That involved coordinating with several medical publishers and amassing a team of medical photographers and an expert panel that will assist in evaluating and securing difficult-to-access clinical images.
The atlas is one of several initiatives in the dermatology field to address racial disparities in patient care.
Noticing similar information gaps about clinical presentations in darker skin, a medical student in the United Kingdom, Malone Mukwende, created “Mind the Gap,” a handbook that presents side-by-side images of diseases and illnesses in light and dark skin. This project “highlights how far behind we are, that a medical student with minimal dermatology exposure and experience not only recognized the need but was ready to do something about it,” Dr. Friedman noted.
Others in the field have spotlighted disparities in the medical literature. The SARS-CoV-2 pandemic has especially brought this out, Graeme M. Lipper, MD wrote in a recent editorial for this news organization.
He referred to a literature review of 46 articles describing COVID-19–associated skin manifestations, which included mostly (92%) images in patients with skin types I-III (92%) and none in patients with skin types V or VI.
“These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin,” added Dr. Lipper, an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital.
For now, Dr. Friedman said that the atlas won’t contain a specific section on COVID-19 skin manifestations, although viral-associated skin reactions like morbilliform eruptions, urticaria, and retiform purpura will be displayed. Overall, the atlas will address 60-70 skin conditions.
Physicians who fail to educate themselves on the variations of skin conditions in all skin types may potentially harm patients of color, Dr. Eleryan said. As Dr. Lipper noted in his editorial, nearly half of all dermatologists feel they haven’t had adequate exposure to diseases in skin of color.
“Our atlas will fill that void and hopefully assist in closing the gap in health disparities among patients of color, who are often misdiagnosed or rendered diagnoses very late in the disease process,” Dr. Eleryan said.
Rapid establishment of therapeutic protocols during the pandemic
Summary
Evidence on emerging therapeutics and the treatment of COVID-19 and its complications has been incomplete, often contradictory, and rapidly changing. The brisk development of effective strategies aimed at identifying, isolating, and treating this disease requires an equally fluid response. At Dell Seton Medical Center, a safety-net hospital that serves Austin in central Texas, our hospitalists have led the formation of numerous collaborative work groups to address the appropriate triage, management, and operational processes during the COVID-19 evolving pandemic.
We created a hospitalist-led COVID Therapeutics and Informatics Committee composed of specialists (infectious disease, pulmonary and critical care, hematology/oncology, neurology), pharmacy, nursing leadership, and the hospital chief medical officer). This committee was formed to evaluate and reach consensus regarding therapeutic interventions in order to ensure appropriate and timely evidence-based treatment. The goal was to limit practice variation and create a shared mental model to deliver consistent value-based care without increasing complexity. We discuss how evidence was evaluated in an interprofessional setting, focusing on not just the quality of data, but its application in an environment of uncertainty and resource scarcity.
We review the use of electronic communication platforms to facilitate direct and rapid communication among interprofessional providers and hospital leadership. We also discuss the development of creative workarounds to build protocols into the electronic medical record to implement new therapeutic interventions in real time.
This approach allows the rapid establishment and adoption of therapeutic protocols based on expert and consensus opinion in the absence of comprehensive national guidelines. This model may also be adopted for other complex disease states that require coordinated interprofessional interventions and frequent revisions to the standard of care.
Key takeaways
1. Protocols improve care by creating a shared framework for approaching complex diseases and open communication within teams to personalize care.
2. Rapidly appraising evidence requires equipoise, thoughtful interpretation of retrospective data, and applying that specifically to a hospital’s local context.
3. Guidelines are best utilized when they are built into clinical care through Standardized Order Sets and disseminated in multiple modalities that reach their audience just in time.
4. The perfect can’t be the enemy of the good.
Protocolized care in progress: Rapid appraisal of evidence and standardization of practice in a pandemic
Live Q&A: Tuesday, Aug. 11, 1:00-2:00 p.m.
Dr. Brode and Dr. Busch are assistant professors in the department of internal medicine at Dell Medical School, University of Texas, Austin.
Summary
Evidence on emerging therapeutics and the treatment of COVID-19 and its complications has been incomplete, often contradictory, and rapidly changing. The brisk development of effective strategies aimed at identifying, isolating, and treating this disease requires an equally fluid response. At Dell Seton Medical Center, a safety-net hospital that serves Austin in central Texas, our hospitalists have led the formation of numerous collaborative work groups to address the appropriate triage, management, and operational processes during the COVID-19 evolving pandemic.
We created a hospitalist-led COVID Therapeutics and Informatics Committee composed of specialists (infectious disease, pulmonary and critical care, hematology/oncology, neurology), pharmacy, nursing leadership, and the hospital chief medical officer). This committee was formed to evaluate and reach consensus regarding therapeutic interventions in order to ensure appropriate and timely evidence-based treatment. The goal was to limit practice variation and create a shared mental model to deliver consistent value-based care without increasing complexity. We discuss how evidence was evaluated in an interprofessional setting, focusing on not just the quality of data, but its application in an environment of uncertainty and resource scarcity.
We review the use of electronic communication platforms to facilitate direct and rapid communication among interprofessional providers and hospital leadership. We also discuss the development of creative workarounds to build protocols into the electronic medical record to implement new therapeutic interventions in real time.
This approach allows the rapid establishment and adoption of therapeutic protocols based on expert and consensus opinion in the absence of comprehensive national guidelines. This model may also be adopted for other complex disease states that require coordinated interprofessional interventions and frequent revisions to the standard of care.
Key takeaways
1. Protocols improve care by creating a shared framework for approaching complex diseases and open communication within teams to personalize care.
2. Rapidly appraising evidence requires equipoise, thoughtful interpretation of retrospective data, and applying that specifically to a hospital’s local context.
3. Guidelines are best utilized when they are built into clinical care through Standardized Order Sets and disseminated in multiple modalities that reach their audience just in time.
4. The perfect can’t be the enemy of the good.
Protocolized care in progress: Rapid appraisal of evidence and standardization of practice in a pandemic
Live Q&A: Tuesday, Aug. 11, 1:00-2:00 p.m.
Dr. Brode and Dr. Busch are assistant professors in the department of internal medicine at Dell Medical School, University of Texas, Austin.
Summary
Evidence on emerging therapeutics and the treatment of COVID-19 and its complications has been incomplete, often contradictory, and rapidly changing. The brisk development of effective strategies aimed at identifying, isolating, and treating this disease requires an equally fluid response. At Dell Seton Medical Center, a safety-net hospital that serves Austin in central Texas, our hospitalists have led the formation of numerous collaborative work groups to address the appropriate triage, management, and operational processes during the COVID-19 evolving pandemic.
We created a hospitalist-led COVID Therapeutics and Informatics Committee composed of specialists (infectious disease, pulmonary and critical care, hematology/oncology, neurology), pharmacy, nursing leadership, and the hospital chief medical officer). This committee was formed to evaluate and reach consensus regarding therapeutic interventions in order to ensure appropriate and timely evidence-based treatment. The goal was to limit practice variation and create a shared mental model to deliver consistent value-based care without increasing complexity. We discuss how evidence was evaluated in an interprofessional setting, focusing on not just the quality of data, but its application in an environment of uncertainty and resource scarcity.
We review the use of electronic communication platforms to facilitate direct and rapid communication among interprofessional providers and hospital leadership. We also discuss the development of creative workarounds to build protocols into the electronic medical record to implement new therapeutic interventions in real time.
This approach allows the rapid establishment and adoption of therapeutic protocols based on expert and consensus opinion in the absence of comprehensive national guidelines. This model may also be adopted for other complex disease states that require coordinated interprofessional interventions and frequent revisions to the standard of care.
Key takeaways
1. Protocols improve care by creating a shared framework for approaching complex diseases and open communication within teams to personalize care.
2. Rapidly appraising evidence requires equipoise, thoughtful interpretation of retrospective data, and applying that specifically to a hospital’s local context.
3. Guidelines are best utilized when they are built into clinical care through Standardized Order Sets and disseminated in multiple modalities that reach their audience just in time.
4. The perfect can’t be the enemy of the good.
Protocolized care in progress: Rapid appraisal of evidence and standardization of practice in a pandemic
Live Q&A: Tuesday, Aug. 11, 1:00-2:00 p.m.
Dr. Brode and Dr. Busch are assistant professors in the department of internal medicine at Dell Medical School, University of Texas, Austin.
HM20 Virtual Product Theater: Aug. 12
Aug. 12, 2020. 12:00 p.m. to 1:00 p.m. ET
Clinical Insights in VTE: Treatment and Risk Reduction Through Prophylaxis
Speaker: Michael S. Oleksyk, MD, FACP, CPE, CMPE
Clinical assistant professor, Florida State University, Pensacola
Hospitalist & palliative care physician, Baptist Hospital, Pensacola.
Program description:
This lecture will discuss venous thromboembolism prophylaxis, as well as treatment options for patients with deep vein thrombosis and/or pulmonary embolism, and how these treatment options may reduce the risk of recurrent thrombotic events.
Sponsored by Janssen Pharmaceuticals Inc.
Aug. 12, 2020. 12:00 p.m. to 1:00 p.m. ET
Clinical Insights in VTE: Treatment and Risk Reduction Through Prophylaxis
Speaker: Michael S. Oleksyk, MD, FACP, CPE, CMPE
Clinical assistant professor, Florida State University, Pensacola
Hospitalist & palliative care physician, Baptist Hospital, Pensacola.
Program description:
This lecture will discuss venous thromboembolism prophylaxis, as well as treatment options for patients with deep vein thrombosis and/or pulmonary embolism, and how these treatment options may reduce the risk of recurrent thrombotic events.
Sponsored by Janssen Pharmaceuticals Inc.
Aug. 12, 2020. 12:00 p.m. to 1:00 p.m. ET
Clinical Insights in VTE: Treatment and Risk Reduction Through Prophylaxis
Speaker: Michael S. Oleksyk, MD, FACP, CPE, CMPE
Clinical assistant professor, Florida State University, Pensacola
Hospitalist & palliative care physician, Baptist Hospital, Pensacola.
Program description:
This lecture will discuss venous thromboembolism prophylaxis, as well as treatment options for patients with deep vein thrombosis and/or pulmonary embolism, and how these treatment options may reduce the risk of recurrent thrombotic events.
Sponsored by Janssen Pharmaceuticals Inc.
Risk Factors and Management of Skin Cancer Among Active-Duty Servicemembers and Veterans
Melanoma Risk for Servicemembers
Dr. Dunn: Active-duty jobs are quite diverse. We have had almost every civilian occupation category—everything from clerical to food service to outdoor construction workers. Federal service and active-duty military service could lead to assignments that involve high sunlight exposure and subsequently higher risk for melanoma and nonmelanoma skin cancer.
Dr. Miller: I found 2 articles on the topic. The first published in June 2018 reviewed melanoma and nonmelanoma skin cancers in the military.1 Riemenschneider and colleagues1 looked at 9 studies. Statistically, there was increased risk of melanoma associated with service and/or prisoner-of-war status. In World War II, they found tropical environments had the highest risk. And the highest rates were in the US Air Force.
The other article provided US Department of Defense data on skin cancer incidence rates, incidence rates of malignant melanoma in relation to years of military service overall, and the rates for differing military occupational groups.2 The researchers demonstrated that fixed-wing pilots and crew members had the highest rates of developing melanoma. The general trend was that the incidence rate was exponentially higher with more missions flown in relation to years of active service, which I thought was rather interesting.
For other occupational categories, the rate increase was not as great as those involved in aviation. Yes, it’s probably related to exposure. Flying at 40,000 feet on a transcontinental airplane trip is equivalent to the radiation dosage of a chest X-ray. Given all the training time and operational flying for the Air Force, it is anticipated that that mutagenic radiation would increase rates. An aircraft does not offer a lot of protection, especially in the cockpit.
We just had the anniversary of the Apollo 11 mission. Those astronauts received the equivalent of about 40 chest X-rays going to the moon and back. Exposure to UV and at higher altitudes cosmic radiation explains why we would see that more in Air Force personnel.
Dr. Bandino: At high altitude there is less ozone protecting you, although the shielding in a cockpit is better in modern aircraft. As an Air Force member, that was one of the first things I thought about was that an aviator has increased skin cancer risk. But it’s apt to think of military service in general as an occupational risk because there are so many contingency operations and deployments. Regarding sun exposure, sunscreen is provided nowadays and there is more sun awareness, but there is still a stigma and reluctance to apply the sunscreen. It leaves people’s skin feeling greasy, which is not ideal when one has to handle a firearm. It can also get in someone’s eyes and affect vision and performance during combat operations. In other words, there are many reasons that would reduce the desire to wear sunscreen and therefore increase exposure to the elements.
A great current example is coronavirus disease 2019 (COVID-19) operations. Although I’m a dermatologist and typically work inside, I’ve been tasked to run a COVID-19 screening tent in the middle of a field in San Antonio, and thus I’ve got to make sure I take my sunscreen out there every day. The general population may not have that variability in their work cycle and sudden change in occupational UV exposure.
Dr. Miller: I was deployed in a combat zone for operations Desert Shield and Desert Storm. I was with the 2nd Armored Division of the US Army deployed to the desert. There really wasn’t an emphasis on photoprotection. It’s just the logistics. The commanders have a lot more important things to think about, and that’s something, usually, that doesn’t get a high priority. The US military is deploying to more places near the equator, so from an operational sense, there’s probably something to brief the commanders about in terms of the long-term consequences of radiation exposure for military servicemembers.
Dr. Dunn: If you look at deployments over the past 2 decades, we have been putting tens of thousands of individuals in high UV exposure regions. Then you have to look at the long-term consequence of the increased incidence of skin cancer in those individuals. What is the cost of that when it comes to treatment of precancerous lesions and skin cancer throughout a life expectancy of 80-plus years?
Dr. Bandino: With most skin cancers there is such long lag time between exposures and development. I wish there were some better data and research out there that really showed whether military service truly is an independent risk factor or if it’s just specific occupation types within the military. I have family members who both work in contracting services and had served in the military. Would their skin cancer risk be the same as others who are doing similar jobs without the military service?
Dr. Dunn: I have had county employees present for skin cancer surgery and with them comes a form that relates to disability. For groundskeepers or police, we assumed that skin cancer is occupation related due to the patient’s increased sun exposure. Their cancers may be unrelated to their actual years of service, but it seems that many light-skinned individuals in the military are going to develop basal cell and squamous cell skin cancer in the coming decades, which likely is going to be attributed to their years of federal service, even though they may have had other significant recreational exposure outside of work. So, my gut feeling is that we are going to see skin cancer as a disability tied to federal service, which is going to cost us.
Dr. Logemann: Yes, I think there are always going to be confounders—what if the servicemembers used tanning beds, or they were avid surfers? It’s going to be difficult to always parse that out.
Dr. Miller: In talking about melanoma, you really have to parse out the subsets. Is it melanoma in situ, is it superficial, is it acral, is it nodular? They all have different initiation events.
Nodular melanomas probably don’t need UV light to initiate a tumor. Another risk factor is having more than 100 moles or many atypical moles, which puts that person in a higher risk category. Perhaps when soldiers, airmen, and navy personnel get inducted, they should be screened for their mole population because that is a risk factor for developing melanoma, and then we can intervene a little bit and have them watch their UV exposure.
Dr. Jarell: You can’t overstate the importance of how heterogeneous melanoma is as a disease. While there are clearly some types of melanoma that are caused by UV radiation, there are also many types that aren’t. We don’t understand why someone gets melanoma on the inner thigh, bottom of the foot, top of the sole, inside the mouth, or in the genital region—these aren’t places of high sun exposure.
Lentigo maligna, as an example, is clearly caused by UV radiation in most cases. But there are so many other different types of melanoma that you can’t just attribute to UV radiation, and so you get into this whole other discussion as to why people are getting melanoma—military or not.
Dr. Bandino: When volunteering for military service, there’s the DoDMERB (Department of Defense Medical Examination Review Board) system that screens individuals for medical issues incompatible with military service such as severe psoriasis or atopic dermatitis. But to my knowledge, the DoDMERB process focuses more on current or past issues and does little to investigate for future risk of disease. A cutaneous example would be assessing quantity of dysplastic nevi, Fitzpatrick scale 1 phenotype, and family history of melanoma to determine risk of developing melanoma in someone who may have more UV exposure during their military service than a civilian. This dermatological future risk assessment was certainly not something I was trained to do as a flight surgeon when performing basic trainee flight physicals prior to becoming a dermatologist.
Dr. Jarell: I am a little bit hard-pressed to generalize the military as high occupational risk for melanoma. There are clearly other professions—landscapers, fishermen—that are probably at much higher risk than, say, your general military all-comers. Us physicians in the military were probably not at increased risk compared to other physicians in the United States. We have to be careful not to go down a slippery slope and designate all MOSs (military occupational specialties) as at increased risk for skin cancer, in particular melanoma. Nonmelanoma skin cancer, such as basal cell and squamous cell carcinoma, is clearly related to the proportional amount of UV exposure. But melanoma is quite a diverse cancer that has many, many disparate etiologies.
Dr. Dunn: The entry physical into the military is an opportunity to make an impact on the number of nonmelanoma skin cancers that would arise in that population. There is an educational opportunity to tell inductees that nonmelanoma skin cancer is going to occur on convex surfaces of the sun-exposed skin—nose, ears, forehead, chin, tops of the shoulders. If offered sun protection for those areas and you stretch the potential impact of that information over tens of thousands of military members over decades, you might actually come up with a big number of people that not only decreases their morbidity but also dramatically decreased the cost to the system as a whole.
Dr. Jarell: You also have to factor in ethnicity and the role it plays in someone’s likelihood to get skin cancer—melanoma or nonmelanoma skin cancer. Darker-skinned people are at certainly decreased risk for different types of skin cancers.
Dr. Dunn: Yes, that would have to be part of the education and should be. If you have light skin and freckles, then you’re at much higher risk for nonmelanoma skin cancer and need to know the high-risk areas that can be protected by sunblock and clothing.
Dr. Logemann: One thing that might be a little bit unique in the military is that you’re living in San Antonio one minute, and then the next minute you’re over in Afghanistan with a different climate and different environment. When you’re deployed overseas, you might have a little bit less control over your situation; you might not have a lot of sunscreen in a field hospital in Afghanistan. Whereas if you were just living in San Antonio, you could go down to the store and buy it.
Dr. Miller: Is sunblock now encouraged or available to individuals in deployment situations or training situations where they’re going to have prolonged sun exposure every day? Is it part of the regimen, just like carrying extra water because of the risk for dehydration?
Dr. Logemann: To the best of my knowledge, it is not always included in your normal rations or uniform and it may be up to the servicemember to procure sunscreen.
Dr. Bandino: There have been improvements, and usually you at least have access to sunscreen. In many deployed locations, for example, you have the equivalent of a small PX (post exchange) or BX (base exchange), where they have a variety of products for sale from toothbrushes to flip-flops, and now also sunscreen. Of course, the type and quality of the sunscreen may not be that great. It’s likely going to be basic SPF (sun protection factor) 15 or 30 in small tubes. As a recent example, I participated in a humanitarian medical exercise in South America last summer and was actually issued sunscreen combined with DEET, which is great but it was only SPF 30. The combination product is a good idea for tropical locations, but in addition to people just not wanting to wear it, the DEET combination tends to burn and sting a little bit more; you can get a heat sensation from the DEET; and the DEET can damage plastic surfaces, which may not be ideal for deployed equipment.
The other problem is quantity. We all learned in residency the appropriate sunscreen quantity of at least 1 fl oz for the average adult body, and that’s what we counsel our patients on, but what they issued me was 1 small 2- to 3-fl oz tube. It fit in the palm of my hand, and that was my sunscreen for the trip.
So, I do think, even though there have been some improvements, much of sun protection will still fall on the individual servicemember. And, as mentioned, depending on your ethnicity, some people may need it more than others. But it is an area where there probably could be continued improvements.
Dr. Logemann: In addition to sunscreen, I think that maybe we should be taking into consideration some simple measures. For example, is it necessary for people to stand out in formation at 2
Dr. Dunn: I think we all kind of agree that the military service is diverse and that many of the subcategories of occupations within the military lead to increased sun exposure by mandate. We advise sun protection by physical barriers and sunblock.
Diagnosis of Skin Cancer Via Telemedicine
Dr. Dunn: I have friends who remain in the VA (US Department of Veterans Affairs) system, and they are involved with telemedicine in dermatology, which can reduce waiting time and increase the number of patients seen by the dermatologist. In-person and teledermatology visits now are available to servicemembers on active duty and retirees.
Dr. Bandino: At our residency program (San Antonio Uniformed Services Health Education Consortium), we’ve had asynchronous teledermatology for over a decade, even before I was a resident. We provide it primarily as a service for patients at small bases without access to dermatology. Some bases also use it as part of their prescreening process prior to authorizing an in-person dermatology consultation.
Certainly, with the coronavirus pandemic, civilian dermatology is seeing a boom in the teledermatology world that had been slowly increasing in popularity for the last few years. In our residency program, teledermatology has traditionally been just for active-duty servicemembers or their dependents, but now due to the coronavirus pandemic, our teledermatology services have significantly expanded to include adding synchronous capability. We have patients take pictures before their virtual appointment and/or FaceTime during the appointment. Even after the pandemic, there will likely be more integration of synchronous teledermatology going forward as we’re seeing some of the value. Of course, I’m sure we would all agree that accurate diagnosis of pigmented lesions can be very challenging with teledermatology, not to mention other diagnostic limitations. But I think there is still utility and it should only get better with time as technology improves. So, I’m hopeful that we can incorporate more of it in the military.
Dr. Logemann: I’m definitely aware that we have different telehealth opportunities available, even using some newer modalities that are command approved in recent weeks. My experience has been for more complicated dermatology, so people are in remote locations, and they’re being seen by a nondermatologist, and they have questions about how to approach management. But I’m not aware of telemedicine as a screening tool for skin cancer in the military or among my civilian colleagues. I would hope that it could be someday because we’re developing these total-body photography machines as well. It could be a way for a nondermatologist who identifies a lesion to have it triaged by a dermatologist. To say, “Oh yeah, that looks like a melanoma. They need to get in sooner vs later,” but not on a large-scale sort of screening modality.
Dr. Bandino: In my recent experience, it has definitely been a helpful triage tool. In the military, this form of triage can be particularly helpful if someone is overseas to determine whether he/she needs to evacuated and evaluated in-person right away.
Dr. Jarell: It’s been useful in looking at benign things. People have shown me in the past few weeks a lot of seborrheic keratoses and a lot of benign dermal nevus-type things, and I say, “Don’t worry about that.” And you can tell if the resolution is good enough. But a lot of people have shown me things in the past few weeks that have clearly been basal cell carcinoma, which we can probably let that ride out for a few more weeks, but I’m not sure if maybe somebody has an amelanotic melanoma. Maybe you need to come in and get that biopsied ASAP. Or something that looks like a melanoma. The patient should probably come in and get that biopsied.
Dr. Miller: I think we can rely on teledermatology. It’s all predicated on the resolution because we’re all trained in pattern recognition. I think it’s very useful to screen for things that look clinically benign. We have to understand that most dermatology is practiced by nondermatologists in the United States, and many studies show that their diagnostic accuracy is 20%, at best maybe 50%. So, they do need to reach out to a dermatologist and perhaps get some guidance on what to do. I think it could be a very useful tool if used appropriately.
Dr. Dunn: If used appropriately, teledermatology could function in a couple of ways. One, it could allow us to declare lesions to be wholly benign, and only should a lesion change would it need attention. The second is that it would allow us to accelerate the process of getting a patient to us—physically in front of us—for a biopsy if a suspicious lesion is seen. A by-product of that process would be that if patients who have wholly benign, nonworrisome lesions could be screened by telemedicine, then physical appointments where a patient is in front of the doctor would be more open. In other words, let’s say if 25% of all lesional visits could be declared benign via telemedicine that would allow dermatology to preserve its face-to-face appointments for patients who are more likely to have cancer and require procedures like skin biopsy.
Love it or hate it, I think we’re getting it no matter what now. Telemedicine creeped along forever and within 6 weeks it’s become ubiquitous. It’s phenomenal how fast we had to adapt to a system or perish in private practice. Sometimes these episodes that we go through have good consequences as well as bad consequences. Telemedicine probably has been needed for a long time and the insurers were not covering it very well, but suddenly a stay-at-home mandate has unveiled valuable technology—something that we probably should have been able to use more and be adequately reimbursed.
Surgical Treatment of Skin Cancer
Dr. Dunn: Treatment historically has been surgical for nonmelanoma and melanoma skin cancers. Some radiation devices have gained popularity again in the past decade or so, but excisional surgery remains the standard treatment for skin cancer. Nonmelanoma skin cancers almost all are probably treated surgically still, with a small percentage treated with superficial radiation.
Access to care is important to discuss. Are Mohs surgeons readily available, or are plastic surgeons, general surgeons, or vascular surgeons in the federal system contributing to the care of skin cancer? Are they doing excisional surgery after biopsies are done? Are they doing excisional biopsies with the intent of cure?
Dr. Logemann: For active duty, I don’t see any issues getting access to the medical center for Mohs micrographic surgery. Sometimes, if we have a lot of volume, some patients may get deferred to the network, but in my experience, it would not typically be an active-duty servicemember. An active-duty servicemember would get care rendered at one of the medical centers for Mohs surgery. Typically the active-duty–aged population isn’t getting much skin cancer. It certainly does happen, but most of the skin cancers frequently that are treated at medical centers are not infrequently retirees.
Dr. Bandino: Because of our residency program, we are required to have Mohs surgery capability to be ACGME (Accreditation Council for Graduate Medical Education) accredited. We typically have 3 Mohs surgeons, so we never have a problem with access.
In the military, I just refer cases to our Mohs surgeons and everything is taken care of in-house. In fact, this is an area where we may even have better access than the civilian world because there are no insurance hurdles or significant delay in care since our Mohs surgeons aren’t typically booked up for 3 to 4 months like many civilian Mohs surgeons. This is especially true for complex cases since we provide hospital-based care with all specialty services under the same umbrella. So, for example, if the Mohs surgeons have an extensive and complex case requiring multidisciplinary care such as ENT (ear, nose, and throat), facial plastics, or radiation-oncology, they’re all in-house with no insurance issues to navigate. This of course is not usual for most military bases and is only capable at bases attached to a large medical center. There are some similar scenarios in the civilian world with university medical centers and managed care organizations, but we may still have a slight advantage in accessibility and cost.
Dr. Dunn: There are guidelines from the National Comprehensive Cancer Network as to how to treat nonmelanoma and melanoma skin cancer. Almost all of them are surgical and almost all of them are safe, outpatient, local anesthetic procedures with a high cure rate. The vast majority of melanoma and nonmelanoma skin cancers can be handled safely and effectively with minimal morbidity and almost no known mortalities from the treatments themselves. Some of the cancers have been identified as high risk for metastasis and mortality, but they’re relatively uncommon still. The good news about skin cancer is that the risk of death remains very small.
- Riemenschneider K, Liu J, Powers JG. Skin cancer in the military: a systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel.J Am Acad Dermatol. 2018;78:1185-1192.
- Brundage JF, Williams VF, Stahlman S, et al. Incidence rates of malignant melanoma in relation to years of military service, overall and in selected military occupational groups, active component, U.S. Armed Forces, 2001-2015. MSMR. 2017;24:8-14.
Melanoma Risk for Servicemembers
Dr. Dunn: Active-duty jobs are quite diverse. We have had almost every civilian occupation category—everything from clerical to food service to outdoor construction workers. Federal service and active-duty military service could lead to assignments that involve high sunlight exposure and subsequently higher risk for melanoma and nonmelanoma skin cancer.
Dr. Miller: I found 2 articles on the topic. The first published in June 2018 reviewed melanoma and nonmelanoma skin cancers in the military.1 Riemenschneider and colleagues1 looked at 9 studies. Statistically, there was increased risk of melanoma associated with service and/or prisoner-of-war status. In World War II, they found tropical environments had the highest risk. And the highest rates were in the US Air Force.
The other article provided US Department of Defense data on skin cancer incidence rates, incidence rates of malignant melanoma in relation to years of military service overall, and the rates for differing military occupational groups.2 The researchers demonstrated that fixed-wing pilots and crew members had the highest rates of developing melanoma. The general trend was that the incidence rate was exponentially higher with more missions flown in relation to years of active service, which I thought was rather interesting.
For other occupational categories, the rate increase was not as great as those involved in aviation. Yes, it’s probably related to exposure. Flying at 40,000 feet on a transcontinental airplane trip is equivalent to the radiation dosage of a chest X-ray. Given all the training time and operational flying for the Air Force, it is anticipated that that mutagenic radiation would increase rates. An aircraft does not offer a lot of protection, especially in the cockpit.
We just had the anniversary of the Apollo 11 mission. Those astronauts received the equivalent of about 40 chest X-rays going to the moon and back. Exposure to UV and at higher altitudes cosmic radiation explains why we would see that more in Air Force personnel.
Dr. Bandino: At high altitude there is less ozone protecting you, although the shielding in a cockpit is better in modern aircraft. As an Air Force member, that was one of the first things I thought about was that an aviator has increased skin cancer risk. But it’s apt to think of military service in general as an occupational risk because there are so many contingency operations and deployments. Regarding sun exposure, sunscreen is provided nowadays and there is more sun awareness, but there is still a stigma and reluctance to apply the sunscreen. It leaves people’s skin feeling greasy, which is not ideal when one has to handle a firearm. It can also get in someone’s eyes and affect vision and performance during combat operations. In other words, there are many reasons that would reduce the desire to wear sunscreen and therefore increase exposure to the elements.
A great current example is coronavirus disease 2019 (COVID-19) operations. Although I’m a dermatologist and typically work inside, I’ve been tasked to run a COVID-19 screening tent in the middle of a field in San Antonio, and thus I’ve got to make sure I take my sunscreen out there every day. The general population may not have that variability in their work cycle and sudden change in occupational UV exposure.
Dr. Miller: I was deployed in a combat zone for operations Desert Shield and Desert Storm. I was with the 2nd Armored Division of the US Army deployed to the desert. There really wasn’t an emphasis on photoprotection. It’s just the logistics. The commanders have a lot more important things to think about, and that’s something, usually, that doesn’t get a high priority. The US military is deploying to more places near the equator, so from an operational sense, there’s probably something to brief the commanders about in terms of the long-term consequences of radiation exposure for military servicemembers.
Dr. Dunn: If you look at deployments over the past 2 decades, we have been putting tens of thousands of individuals in high UV exposure regions. Then you have to look at the long-term consequence of the increased incidence of skin cancer in those individuals. What is the cost of that when it comes to treatment of precancerous lesions and skin cancer throughout a life expectancy of 80-plus years?
Dr. Bandino: With most skin cancers there is such long lag time between exposures and development. I wish there were some better data and research out there that really showed whether military service truly is an independent risk factor or if it’s just specific occupation types within the military. I have family members who both work in contracting services and had served in the military. Would their skin cancer risk be the same as others who are doing similar jobs without the military service?
Dr. Dunn: I have had county employees present for skin cancer surgery and with them comes a form that relates to disability. For groundskeepers or police, we assumed that skin cancer is occupation related due to the patient’s increased sun exposure. Their cancers may be unrelated to their actual years of service, but it seems that many light-skinned individuals in the military are going to develop basal cell and squamous cell skin cancer in the coming decades, which likely is going to be attributed to their years of federal service, even though they may have had other significant recreational exposure outside of work. So, my gut feeling is that we are going to see skin cancer as a disability tied to federal service, which is going to cost us.
Dr. Logemann: Yes, I think there are always going to be confounders—what if the servicemembers used tanning beds, or they were avid surfers? It’s going to be difficult to always parse that out.
Dr. Miller: In talking about melanoma, you really have to parse out the subsets. Is it melanoma in situ, is it superficial, is it acral, is it nodular? They all have different initiation events.
Nodular melanomas probably don’t need UV light to initiate a tumor. Another risk factor is having more than 100 moles or many atypical moles, which puts that person in a higher risk category. Perhaps when soldiers, airmen, and navy personnel get inducted, they should be screened for their mole population because that is a risk factor for developing melanoma, and then we can intervene a little bit and have them watch their UV exposure.
Dr. Jarell: You can’t overstate the importance of how heterogeneous melanoma is as a disease. While there are clearly some types of melanoma that are caused by UV radiation, there are also many types that aren’t. We don’t understand why someone gets melanoma on the inner thigh, bottom of the foot, top of the sole, inside the mouth, or in the genital region—these aren’t places of high sun exposure.
Lentigo maligna, as an example, is clearly caused by UV radiation in most cases. But there are so many other different types of melanoma that you can’t just attribute to UV radiation, and so you get into this whole other discussion as to why people are getting melanoma—military or not.
Dr. Bandino: When volunteering for military service, there’s the DoDMERB (Department of Defense Medical Examination Review Board) system that screens individuals for medical issues incompatible with military service such as severe psoriasis or atopic dermatitis. But to my knowledge, the DoDMERB process focuses more on current or past issues and does little to investigate for future risk of disease. A cutaneous example would be assessing quantity of dysplastic nevi, Fitzpatrick scale 1 phenotype, and family history of melanoma to determine risk of developing melanoma in someone who may have more UV exposure during their military service than a civilian. This dermatological future risk assessment was certainly not something I was trained to do as a flight surgeon when performing basic trainee flight physicals prior to becoming a dermatologist.
Dr. Jarell: I am a little bit hard-pressed to generalize the military as high occupational risk for melanoma. There are clearly other professions—landscapers, fishermen—that are probably at much higher risk than, say, your general military all-comers. Us physicians in the military were probably not at increased risk compared to other physicians in the United States. We have to be careful not to go down a slippery slope and designate all MOSs (military occupational specialties) as at increased risk for skin cancer, in particular melanoma. Nonmelanoma skin cancer, such as basal cell and squamous cell carcinoma, is clearly related to the proportional amount of UV exposure. But melanoma is quite a diverse cancer that has many, many disparate etiologies.
Dr. Dunn: The entry physical into the military is an opportunity to make an impact on the number of nonmelanoma skin cancers that would arise in that population. There is an educational opportunity to tell inductees that nonmelanoma skin cancer is going to occur on convex surfaces of the sun-exposed skin—nose, ears, forehead, chin, tops of the shoulders. If offered sun protection for those areas and you stretch the potential impact of that information over tens of thousands of military members over decades, you might actually come up with a big number of people that not only decreases their morbidity but also dramatically decreased the cost to the system as a whole.
Dr. Jarell: You also have to factor in ethnicity and the role it plays in someone’s likelihood to get skin cancer—melanoma or nonmelanoma skin cancer. Darker-skinned people are at certainly decreased risk for different types of skin cancers.
Dr. Dunn: Yes, that would have to be part of the education and should be. If you have light skin and freckles, then you’re at much higher risk for nonmelanoma skin cancer and need to know the high-risk areas that can be protected by sunblock and clothing.
Dr. Logemann: One thing that might be a little bit unique in the military is that you’re living in San Antonio one minute, and then the next minute you’re over in Afghanistan with a different climate and different environment. When you’re deployed overseas, you might have a little bit less control over your situation; you might not have a lot of sunscreen in a field hospital in Afghanistan. Whereas if you were just living in San Antonio, you could go down to the store and buy it.
Dr. Miller: Is sunblock now encouraged or available to individuals in deployment situations or training situations where they’re going to have prolonged sun exposure every day? Is it part of the regimen, just like carrying extra water because of the risk for dehydration?
Dr. Logemann: To the best of my knowledge, it is not always included in your normal rations or uniform and it may be up to the servicemember to procure sunscreen.
Dr. Bandino: There have been improvements, and usually you at least have access to sunscreen. In many deployed locations, for example, you have the equivalent of a small PX (post exchange) or BX (base exchange), where they have a variety of products for sale from toothbrushes to flip-flops, and now also sunscreen. Of course, the type and quality of the sunscreen may not be that great. It’s likely going to be basic SPF (sun protection factor) 15 or 30 in small tubes. As a recent example, I participated in a humanitarian medical exercise in South America last summer and was actually issued sunscreen combined with DEET, which is great but it was only SPF 30. The combination product is a good idea for tropical locations, but in addition to people just not wanting to wear it, the DEET combination tends to burn and sting a little bit more; you can get a heat sensation from the DEET; and the DEET can damage plastic surfaces, which may not be ideal for deployed equipment.
The other problem is quantity. We all learned in residency the appropriate sunscreen quantity of at least 1 fl oz for the average adult body, and that’s what we counsel our patients on, but what they issued me was 1 small 2- to 3-fl oz tube. It fit in the palm of my hand, and that was my sunscreen for the trip.
So, I do think, even though there have been some improvements, much of sun protection will still fall on the individual servicemember. And, as mentioned, depending on your ethnicity, some people may need it more than others. But it is an area where there probably could be continued improvements.
Dr. Logemann: In addition to sunscreen, I think that maybe we should be taking into consideration some simple measures. For example, is it necessary for people to stand out in formation at 2
Dr. Dunn: I think we all kind of agree that the military service is diverse and that many of the subcategories of occupations within the military lead to increased sun exposure by mandate. We advise sun protection by physical barriers and sunblock.
Diagnosis of Skin Cancer Via Telemedicine
Dr. Dunn: I have friends who remain in the VA (US Department of Veterans Affairs) system, and they are involved with telemedicine in dermatology, which can reduce waiting time and increase the number of patients seen by the dermatologist. In-person and teledermatology visits now are available to servicemembers on active duty and retirees.
Dr. Bandino: At our residency program (San Antonio Uniformed Services Health Education Consortium), we’ve had asynchronous teledermatology for over a decade, even before I was a resident. We provide it primarily as a service for patients at small bases without access to dermatology. Some bases also use it as part of their prescreening process prior to authorizing an in-person dermatology consultation.
Certainly, with the coronavirus pandemic, civilian dermatology is seeing a boom in the teledermatology world that had been slowly increasing in popularity for the last few years. In our residency program, teledermatology has traditionally been just for active-duty servicemembers or their dependents, but now due to the coronavirus pandemic, our teledermatology services have significantly expanded to include adding synchronous capability. We have patients take pictures before their virtual appointment and/or FaceTime during the appointment. Even after the pandemic, there will likely be more integration of synchronous teledermatology going forward as we’re seeing some of the value. Of course, I’m sure we would all agree that accurate diagnosis of pigmented lesions can be very challenging with teledermatology, not to mention other diagnostic limitations. But I think there is still utility and it should only get better with time as technology improves. So, I’m hopeful that we can incorporate more of it in the military.
Dr. Logemann: I’m definitely aware that we have different telehealth opportunities available, even using some newer modalities that are command approved in recent weeks. My experience has been for more complicated dermatology, so people are in remote locations, and they’re being seen by a nondermatologist, and they have questions about how to approach management. But I’m not aware of telemedicine as a screening tool for skin cancer in the military or among my civilian colleagues. I would hope that it could be someday because we’re developing these total-body photography machines as well. It could be a way for a nondermatologist who identifies a lesion to have it triaged by a dermatologist. To say, “Oh yeah, that looks like a melanoma. They need to get in sooner vs later,” but not on a large-scale sort of screening modality.
Dr. Bandino: In my recent experience, it has definitely been a helpful triage tool. In the military, this form of triage can be particularly helpful if someone is overseas to determine whether he/she needs to evacuated and evaluated in-person right away.
Dr. Jarell: It’s been useful in looking at benign things. People have shown me in the past few weeks a lot of seborrheic keratoses and a lot of benign dermal nevus-type things, and I say, “Don’t worry about that.” And you can tell if the resolution is good enough. But a lot of people have shown me things in the past few weeks that have clearly been basal cell carcinoma, which we can probably let that ride out for a few more weeks, but I’m not sure if maybe somebody has an amelanotic melanoma. Maybe you need to come in and get that biopsied ASAP. Or something that looks like a melanoma. The patient should probably come in and get that biopsied.
Dr. Miller: I think we can rely on teledermatology. It’s all predicated on the resolution because we’re all trained in pattern recognition. I think it’s very useful to screen for things that look clinically benign. We have to understand that most dermatology is practiced by nondermatologists in the United States, and many studies show that their diagnostic accuracy is 20%, at best maybe 50%. So, they do need to reach out to a dermatologist and perhaps get some guidance on what to do. I think it could be a very useful tool if used appropriately.
Dr. Dunn: If used appropriately, teledermatology could function in a couple of ways. One, it could allow us to declare lesions to be wholly benign, and only should a lesion change would it need attention. The second is that it would allow us to accelerate the process of getting a patient to us—physically in front of us—for a biopsy if a suspicious lesion is seen. A by-product of that process would be that if patients who have wholly benign, nonworrisome lesions could be screened by telemedicine, then physical appointments where a patient is in front of the doctor would be more open. In other words, let’s say if 25% of all lesional visits could be declared benign via telemedicine that would allow dermatology to preserve its face-to-face appointments for patients who are more likely to have cancer and require procedures like skin biopsy.
Love it or hate it, I think we’re getting it no matter what now. Telemedicine creeped along forever and within 6 weeks it’s become ubiquitous. It’s phenomenal how fast we had to adapt to a system or perish in private practice. Sometimes these episodes that we go through have good consequences as well as bad consequences. Telemedicine probably has been needed for a long time and the insurers were not covering it very well, but suddenly a stay-at-home mandate has unveiled valuable technology—something that we probably should have been able to use more and be adequately reimbursed.
Surgical Treatment of Skin Cancer
Dr. Dunn: Treatment historically has been surgical for nonmelanoma and melanoma skin cancers. Some radiation devices have gained popularity again in the past decade or so, but excisional surgery remains the standard treatment for skin cancer. Nonmelanoma skin cancers almost all are probably treated surgically still, with a small percentage treated with superficial radiation.
Access to care is important to discuss. Are Mohs surgeons readily available, or are plastic surgeons, general surgeons, or vascular surgeons in the federal system contributing to the care of skin cancer? Are they doing excisional surgery after biopsies are done? Are they doing excisional biopsies with the intent of cure?
Dr. Logemann: For active duty, I don’t see any issues getting access to the medical center for Mohs micrographic surgery. Sometimes, if we have a lot of volume, some patients may get deferred to the network, but in my experience, it would not typically be an active-duty servicemember. An active-duty servicemember would get care rendered at one of the medical centers for Mohs surgery. Typically the active-duty–aged population isn’t getting much skin cancer. It certainly does happen, but most of the skin cancers frequently that are treated at medical centers are not infrequently retirees.
Dr. Bandino: Because of our residency program, we are required to have Mohs surgery capability to be ACGME (Accreditation Council for Graduate Medical Education) accredited. We typically have 3 Mohs surgeons, so we never have a problem with access.
In the military, I just refer cases to our Mohs surgeons and everything is taken care of in-house. In fact, this is an area where we may even have better access than the civilian world because there are no insurance hurdles or significant delay in care since our Mohs surgeons aren’t typically booked up for 3 to 4 months like many civilian Mohs surgeons. This is especially true for complex cases since we provide hospital-based care with all specialty services under the same umbrella. So, for example, if the Mohs surgeons have an extensive and complex case requiring multidisciplinary care such as ENT (ear, nose, and throat), facial plastics, or radiation-oncology, they’re all in-house with no insurance issues to navigate. This of course is not usual for most military bases and is only capable at bases attached to a large medical center. There are some similar scenarios in the civilian world with university medical centers and managed care organizations, but we may still have a slight advantage in accessibility and cost.
Dr. Dunn: There are guidelines from the National Comprehensive Cancer Network as to how to treat nonmelanoma and melanoma skin cancer. Almost all of them are surgical and almost all of them are safe, outpatient, local anesthetic procedures with a high cure rate. The vast majority of melanoma and nonmelanoma skin cancers can be handled safely and effectively with minimal morbidity and almost no known mortalities from the treatments themselves. Some of the cancers have been identified as high risk for metastasis and mortality, but they’re relatively uncommon still. The good news about skin cancer is that the risk of death remains very small.
Melanoma Risk for Servicemembers
Dr. Dunn: Active-duty jobs are quite diverse. We have had almost every civilian occupation category—everything from clerical to food service to outdoor construction workers. Federal service and active-duty military service could lead to assignments that involve high sunlight exposure and subsequently higher risk for melanoma and nonmelanoma skin cancer.
Dr. Miller: I found 2 articles on the topic. The first published in June 2018 reviewed melanoma and nonmelanoma skin cancers in the military.1 Riemenschneider and colleagues1 looked at 9 studies. Statistically, there was increased risk of melanoma associated with service and/or prisoner-of-war status. In World War II, they found tropical environments had the highest risk. And the highest rates were in the US Air Force.
The other article provided US Department of Defense data on skin cancer incidence rates, incidence rates of malignant melanoma in relation to years of military service overall, and the rates for differing military occupational groups.2 The researchers demonstrated that fixed-wing pilots and crew members had the highest rates of developing melanoma. The general trend was that the incidence rate was exponentially higher with more missions flown in relation to years of active service, which I thought was rather interesting.
For other occupational categories, the rate increase was not as great as those involved in aviation. Yes, it’s probably related to exposure. Flying at 40,000 feet on a transcontinental airplane trip is equivalent to the radiation dosage of a chest X-ray. Given all the training time and operational flying for the Air Force, it is anticipated that that mutagenic radiation would increase rates. An aircraft does not offer a lot of protection, especially in the cockpit.
We just had the anniversary of the Apollo 11 mission. Those astronauts received the equivalent of about 40 chest X-rays going to the moon and back. Exposure to UV and at higher altitudes cosmic radiation explains why we would see that more in Air Force personnel.
Dr. Bandino: At high altitude there is less ozone protecting you, although the shielding in a cockpit is better in modern aircraft. As an Air Force member, that was one of the first things I thought about was that an aviator has increased skin cancer risk. But it’s apt to think of military service in general as an occupational risk because there are so many contingency operations and deployments. Regarding sun exposure, sunscreen is provided nowadays and there is more sun awareness, but there is still a stigma and reluctance to apply the sunscreen. It leaves people’s skin feeling greasy, which is not ideal when one has to handle a firearm. It can also get in someone’s eyes and affect vision and performance during combat operations. In other words, there are many reasons that would reduce the desire to wear sunscreen and therefore increase exposure to the elements.
A great current example is coronavirus disease 2019 (COVID-19) operations. Although I’m a dermatologist and typically work inside, I’ve been tasked to run a COVID-19 screening tent in the middle of a field in San Antonio, and thus I’ve got to make sure I take my sunscreen out there every day. The general population may not have that variability in their work cycle and sudden change in occupational UV exposure.
Dr. Miller: I was deployed in a combat zone for operations Desert Shield and Desert Storm. I was with the 2nd Armored Division of the US Army deployed to the desert. There really wasn’t an emphasis on photoprotection. It’s just the logistics. The commanders have a lot more important things to think about, and that’s something, usually, that doesn’t get a high priority. The US military is deploying to more places near the equator, so from an operational sense, there’s probably something to brief the commanders about in terms of the long-term consequences of radiation exposure for military servicemembers.
Dr. Dunn: If you look at deployments over the past 2 decades, we have been putting tens of thousands of individuals in high UV exposure regions. Then you have to look at the long-term consequence of the increased incidence of skin cancer in those individuals. What is the cost of that when it comes to treatment of precancerous lesions and skin cancer throughout a life expectancy of 80-plus years?
Dr. Bandino: With most skin cancers there is such long lag time between exposures and development. I wish there were some better data and research out there that really showed whether military service truly is an independent risk factor or if it’s just specific occupation types within the military. I have family members who both work in contracting services and had served in the military. Would their skin cancer risk be the same as others who are doing similar jobs without the military service?
Dr. Dunn: I have had county employees present for skin cancer surgery and with them comes a form that relates to disability. For groundskeepers or police, we assumed that skin cancer is occupation related due to the patient’s increased sun exposure. Their cancers may be unrelated to their actual years of service, but it seems that many light-skinned individuals in the military are going to develop basal cell and squamous cell skin cancer in the coming decades, which likely is going to be attributed to their years of federal service, even though they may have had other significant recreational exposure outside of work. So, my gut feeling is that we are going to see skin cancer as a disability tied to federal service, which is going to cost us.
Dr. Logemann: Yes, I think there are always going to be confounders—what if the servicemembers used tanning beds, or they were avid surfers? It’s going to be difficult to always parse that out.
Dr. Miller: In talking about melanoma, you really have to parse out the subsets. Is it melanoma in situ, is it superficial, is it acral, is it nodular? They all have different initiation events.
Nodular melanomas probably don’t need UV light to initiate a tumor. Another risk factor is having more than 100 moles or many atypical moles, which puts that person in a higher risk category. Perhaps when soldiers, airmen, and navy personnel get inducted, they should be screened for their mole population because that is a risk factor for developing melanoma, and then we can intervene a little bit and have them watch their UV exposure.
Dr. Jarell: You can’t overstate the importance of how heterogeneous melanoma is as a disease. While there are clearly some types of melanoma that are caused by UV radiation, there are also many types that aren’t. We don’t understand why someone gets melanoma on the inner thigh, bottom of the foot, top of the sole, inside the mouth, or in the genital region—these aren’t places of high sun exposure.
Lentigo maligna, as an example, is clearly caused by UV radiation in most cases. But there are so many other different types of melanoma that you can’t just attribute to UV radiation, and so you get into this whole other discussion as to why people are getting melanoma—military or not.
Dr. Bandino: When volunteering for military service, there’s the DoDMERB (Department of Defense Medical Examination Review Board) system that screens individuals for medical issues incompatible with military service such as severe psoriasis or atopic dermatitis. But to my knowledge, the DoDMERB process focuses more on current or past issues and does little to investigate for future risk of disease. A cutaneous example would be assessing quantity of dysplastic nevi, Fitzpatrick scale 1 phenotype, and family history of melanoma to determine risk of developing melanoma in someone who may have more UV exposure during their military service than a civilian. This dermatological future risk assessment was certainly not something I was trained to do as a flight surgeon when performing basic trainee flight physicals prior to becoming a dermatologist.
Dr. Jarell: I am a little bit hard-pressed to generalize the military as high occupational risk for melanoma. There are clearly other professions—landscapers, fishermen—that are probably at much higher risk than, say, your general military all-comers. Us physicians in the military were probably not at increased risk compared to other physicians in the United States. We have to be careful not to go down a slippery slope and designate all MOSs (military occupational specialties) as at increased risk for skin cancer, in particular melanoma. Nonmelanoma skin cancer, such as basal cell and squamous cell carcinoma, is clearly related to the proportional amount of UV exposure. But melanoma is quite a diverse cancer that has many, many disparate etiologies.
Dr. Dunn: The entry physical into the military is an opportunity to make an impact on the number of nonmelanoma skin cancers that would arise in that population. There is an educational opportunity to tell inductees that nonmelanoma skin cancer is going to occur on convex surfaces of the sun-exposed skin—nose, ears, forehead, chin, tops of the shoulders. If offered sun protection for those areas and you stretch the potential impact of that information over tens of thousands of military members over decades, you might actually come up with a big number of people that not only decreases their morbidity but also dramatically decreased the cost to the system as a whole.
Dr. Jarell: You also have to factor in ethnicity and the role it plays in someone’s likelihood to get skin cancer—melanoma or nonmelanoma skin cancer. Darker-skinned people are at certainly decreased risk for different types of skin cancers.
Dr. Dunn: Yes, that would have to be part of the education and should be. If you have light skin and freckles, then you’re at much higher risk for nonmelanoma skin cancer and need to know the high-risk areas that can be protected by sunblock and clothing.
Dr. Logemann: One thing that might be a little bit unique in the military is that you’re living in San Antonio one minute, and then the next minute you’re over in Afghanistan with a different climate and different environment. When you’re deployed overseas, you might have a little bit less control over your situation; you might not have a lot of sunscreen in a field hospital in Afghanistan. Whereas if you were just living in San Antonio, you could go down to the store and buy it.
Dr. Miller: Is sunblock now encouraged or available to individuals in deployment situations or training situations where they’re going to have prolonged sun exposure every day? Is it part of the regimen, just like carrying extra water because of the risk for dehydration?
Dr. Logemann: To the best of my knowledge, it is not always included in your normal rations or uniform and it may be up to the servicemember to procure sunscreen.
Dr. Bandino: There have been improvements, and usually you at least have access to sunscreen. In many deployed locations, for example, you have the equivalent of a small PX (post exchange) or BX (base exchange), where they have a variety of products for sale from toothbrushes to flip-flops, and now also sunscreen. Of course, the type and quality of the sunscreen may not be that great. It’s likely going to be basic SPF (sun protection factor) 15 or 30 in small tubes. As a recent example, I participated in a humanitarian medical exercise in South America last summer and was actually issued sunscreen combined with DEET, which is great but it was only SPF 30. The combination product is a good idea for tropical locations, but in addition to people just not wanting to wear it, the DEET combination tends to burn and sting a little bit more; you can get a heat sensation from the DEET; and the DEET can damage plastic surfaces, which may not be ideal for deployed equipment.
The other problem is quantity. We all learned in residency the appropriate sunscreen quantity of at least 1 fl oz for the average adult body, and that’s what we counsel our patients on, but what they issued me was 1 small 2- to 3-fl oz tube. It fit in the palm of my hand, and that was my sunscreen for the trip.
So, I do think, even though there have been some improvements, much of sun protection will still fall on the individual servicemember. And, as mentioned, depending on your ethnicity, some people may need it more than others. But it is an area where there probably could be continued improvements.
Dr. Logemann: In addition to sunscreen, I think that maybe we should be taking into consideration some simple measures. For example, is it necessary for people to stand out in formation at 2
Dr. Dunn: I think we all kind of agree that the military service is diverse and that many of the subcategories of occupations within the military lead to increased sun exposure by mandate. We advise sun protection by physical barriers and sunblock.
Diagnosis of Skin Cancer Via Telemedicine
Dr. Dunn: I have friends who remain in the VA (US Department of Veterans Affairs) system, and they are involved with telemedicine in dermatology, which can reduce waiting time and increase the number of patients seen by the dermatologist. In-person and teledermatology visits now are available to servicemembers on active duty and retirees.
Dr. Bandino: At our residency program (San Antonio Uniformed Services Health Education Consortium), we’ve had asynchronous teledermatology for over a decade, even before I was a resident. We provide it primarily as a service for patients at small bases without access to dermatology. Some bases also use it as part of their prescreening process prior to authorizing an in-person dermatology consultation.
Certainly, with the coronavirus pandemic, civilian dermatology is seeing a boom in the teledermatology world that had been slowly increasing in popularity for the last few years. In our residency program, teledermatology has traditionally been just for active-duty servicemembers or their dependents, but now due to the coronavirus pandemic, our teledermatology services have significantly expanded to include adding synchronous capability. We have patients take pictures before their virtual appointment and/or FaceTime during the appointment. Even after the pandemic, there will likely be more integration of synchronous teledermatology going forward as we’re seeing some of the value. Of course, I’m sure we would all agree that accurate diagnosis of pigmented lesions can be very challenging with teledermatology, not to mention other diagnostic limitations. But I think there is still utility and it should only get better with time as technology improves. So, I’m hopeful that we can incorporate more of it in the military.
Dr. Logemann: I’m definitely aware that we have different telehealth opportunities available, even using some newer modalities that are command approved in recent weeks. My experience has been for more complicated dermatology, so people are in remote locations, and they’re being seen by a nondermatologist, and they have questions about how to approach management. But I’m not aware of telemedicine as a screening tool for skin cancer in the military or among my civilian colleagues. I would hope that it could be someday because we’re developing these total-body photography machines as well. It could be a way for a nondermatologist who identifies a lesion to have it triaged by a dermatologist. To say, “Oh yeah, that looks like a melanoma. They need to get in sooner vs later,” but not on a large-scale sort of screening modality.
Dr. Bandino: In my recent experience, it has definitely been a helpful triage tool. In the military, this form of triage can be particularly helpful if someone is overseas to determine whether he/she needs to evacuated and evaluated in-person right away.
Dr. Jarell: It’s been useful in looking at benign things. People have shown me in the past few weeks a lot of seborrheic keratoses and a lot of benign dermal nevus-type things, and I say, “Don’t worry about that.” And you can tell if the resolution is good enough. But a lot of people have shown me things in the past few weeks that have clearly been basal cell carcinoma, which we can probably let that ride out for a few more weeks, but I’m not sure if maybe somebody has an amelanotic melanoma. Maybe you need to come in and get that biopsied ASAP. Or something that looks like a melanoma. The patient should probably come in and get that biopsied.
Dr. Miller: I think we can rely on teledermatology. It’s all predicated on the resolution because we’re all trained in pattern recognition. I think it’s very useful to screen for things that look clinically benign. We have to understand that most dermatology is practiced by nondermatologists in the United States, and many studies show that their diagnostic accuracy is 20%, at best maybe 50%. So, they do need to reach out to a dermatologist and perhaps get some guidance on what to do. I think it could be a very useful tool if used appropriately.
Dr. Dunn: If used appropriately, teledermatology could function in a couple of ways. One, it could allow us to declare lesions to be wholly benign, and only should a lesion change would it need attention. The second is that it would allow us to accelerate the process of getting a patient to us—physically in front of us—for a biopsy if a suspicious lesion is seen. A by-product of that process would be that if patients who have wholly benign, nonworrisome lesions could be screened by telemedicine, then physical appointments where a patient is in front of the doctor would be more open. In other words, let’s say if 25% of all lesional visits could be declared benign via telemedicine that would allow dermatology to preserve its face-to-face appointments for patients who are more likely to have cancer and require procedures like skin biopsy.
Love it or hate it, I think we’re getting it no matter what now. Telemedicine creeped along forever and within 6 weeks it’s become ubiquitous. It’s phenomenal how fast we had to adapt to a system or perish in private practice. Sometimes these episodes that we go through have good consequences as well as bad consequences. Telemedicine probably has been needed for a long time and the insurers were not covering it very well, but suddenly a stay-at-home mandate has unveiled valuable technology—something that we probably should have been able to use more and be adequately reimbursed.
Surgical Treatment of Skin Cancer
Dr. Dunn: Treatment historically has been surgical for nonmelanoma and melanoma skin cancers. Some radiation devices have gained popularity again in the past decade or so, but excisional surgery remains the standard treatment for skin cancer. Nonmelanoma skin cancers almost all are probably treated surgically still, with a small percentage treated with superficial radiation.
Access to care is important to discuss. Are Mohs surgeons readily available, or are plastic surgeons, general surgeons, or vascular surgeons in the federal system contributing to the care of skin cancer? Are they doing excisional surgery after biopsies are done? Are they doing excisional biopsies with the intent of cure?
Dr. Logemann: For active duty, I don’t see any issues getting access to the medical center for Mohs micrographic surgery. Sometimes, if we have a lot of volume, some patients may get deferred to the network, but in my experience, it would not typically be an active-duty servicemember. An active-duty servicemember would get care rendered at one of the medical centers for Mohs surgery. Typically the active-duty–aged population isn’t getting much skin cancer. It certainly does happen, but most of the skin cancers frequently that are treated at medical centers are not infrequently retirees.
Dr. Bandino: Because of our residency program, we are required to have Mohs surgery capability to be ACGME (Accreditation Council for Graduate Medical Education) accredited. We typically have 3 Mohs surgeons, so we never have a problem with access.
In the military, I just refer cases to our Mohs surgeons and everything is taken care of in-house. In fact, this is an area where we may even have better access than the civilian world because there are no insurance hurdles or significant delay in care since our Mohs surgeons aren’t typically booked up for 3 to 4 months like many civilian Mohs surgeons. This is especially true for complex cases since we provide hospital-based care with all specialty services under the same umbrella. So, for example, if the Mohs surgeons have an extensive and complex case requiring multidisciplinary care such as ENT (ear, nose, and throat), facial plastics, or radiation-oncology, they’re all in-house with no insurance issues to navigate. This of course is not usual for most military bases and is only capable at bases attached to a large medical center. There are some similar scenarios in the civilian world with university medical centers and managed care organizations, but we may still have a slight advantage in accessibility and cost.
Dr. Dunn: There are guidelines from the National Comprehensive Cancer Network as to how to treat nonmelanoma and melanoma skin cancer. Almost all of them are surgical and almost all of them are safe, outpatient, local anesthetic procedures with a high cure rate. The vast majority of melanoma and nonmelanoma skin cancers can be handled safely and effectively with minimal morbidity and almost no known mortalities from the treatments themselves. Some of the cancers have been identified as high risk for metastasis and mortality, but they’re relatively uncommon still. The good news about skin cancer is that the risk of death remains very small.
- Riemenschneider K, Liu J, Powers JG. Skin cancer in the military: a systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel.J Am Acad Dermatol. 2018;78:1185-1192.
- Brundage JF, Williams VF, Stahlman S, et al. Incidence rates of malignant melanoma in relation to years of military service, overall and in selected military occupational groups, active component, U.S. Armed Forces, 2001-2015. MSMR. 2017;24:8-14.
- Riemenschneider K, Liu J, Powers JG. Skin cancer in the military: a systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel.J Am Acad Dermatol. 2018;78:1185-1192.
- Brundage JF, Williams VF, Stahlman S, et al. Incidence rates of malignant melanoma in relation to years of military service, overall and in selected military occupational groups, active component, U.S. Armed Forces, 2001-2015. MSMR. 2017;24:8-14.
Appendix may be common site of endometriosis
Among women who have a coincidental appendectomy during surgery for chronic pelvic pain or endometriosis, about 15% have appendiceal endometriosis confirmed by pathological examination, according to a study.
“In the women with appendiceal endometriosis, only 26% had an appendix that looked abnormal,” said Whitney T. Ross, MD, of the department of obstetrics and gynecology at Penn State Health, Hershey.
The results, presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons, indicate that “appendiceal endometriosis is common in women receiving surgery for chronic pelvic pain or endometriosis,” she said. “This study and multiple other studies have also demonstrated that coincidental appendectomy is safe.”
The long-term impact of coincidental appendectomy and its effect on quality of life are not known, however, which may make it difficult to weigh the costs and benefits of the procedure, Dr. Ross said. “It is important to talk to patients about this procedure and determine which approach is the right approach for your institution.”
The study of 609 coincidental appendectomies did not include patients with retrocecal appendices, which may confound the true rate of appendiceal endometriosis, commented Saifuddin T. Mama, MD, MPH, of Rowan University, Camden, N.J.
When the investigators started the study, they were not sure of the risks and benefits of the procedure in patients with retrocecal appendices. An anecdotal report from another research group suggests that outcomes with retrocecal appendices may not be significantly different. “But that is certainly an important question and one that we would like to address in a future prospective study,” Dr. Ross said.
Surgeons have debated the role of coincidental appendectomy during gynecologic surgery. Concerns about safety and questions about the prevalence of appendiceal pathology are reasons that coincidental appendectomy has not been more widely adopted. On the other hand, the procedure may benefit patients and aid diagnosis.
To evaluate the role of coincidental appendectomy in the surgical excision of endometriosis, Dr. Ross and colleagues analyzed data from consecutive coincidental appendectomies performed at one institution between 2013 and 2019. They identified cases in a prospectively maintained surgical database to assess safety and the prevalence of appendiceal pathology.
The indication for surgery was chronic pelvic pain but no visualized endometriosis for 42 patients, stage I-II endometriosis for 388 patients, and stage III-IV endometriosis for 179 patients.
Surgeries included laparoscopic hysterectomy (77.5%), operative laparoscopy (19.9%), and laparoscopic trachelectomy (2.6%). Pathological analysis of the appendices identified endometriosis in 14.9%, malignancy in 0.7%, polyps in 0.5%, and appendicitis in 0.3%.
Among women with chronic pelvic pain but no visualized endometriosis, 2.4% had appendiceal endometriosis. Among those with stage I-II endometriosis, 7% had appendiceal endometriosis, and in patients with stage III-IV endometriosis, the rate of appendiceal endometriosis was 35.2%.
In about 6% of patients with appendiceal endometriosis, the appendix was the only site of pathologically confirmed endometriosis.
Compared with chronic pelvic pain, stage III-IV endometriosis was associated with a significantly increased risk of appendiceal endometriosis (odds ratio, 22.2). The likelihood of appendiceal endometriosis also increased when the appendix looked abnormal (odds ratio, 6.5).
The probability of diagnosing appendiceal endometriosis also increases with the number of other locations of confirmed endometriosis.
“Our surgical decision making is based off of intraoperative findings. However, the final gold-standard diagnosis can’t take place until the pathologic specimen is analyzed,” she said. “We also know that there is a significant discordance, as high as 50%, in early-stage endometriosis between visual inspection and pathology findings.”
There were no complications related to the performance of a coincidental appendectomy during surgery or in the 12 weeks after.
Dr. Ross outlined surgeons’ three main options for performing coincidental appendectomy in patients undergoing surgery for chronic pelvic pain or endometriosis: universal coincidental appendectomy, targeted appendectomy based on operative findings, and performing the procedure based on the appearance of the appendix.
Basing the decision on appearance “is going to miss a lot of appendiceal endometriosis,” Dr. Ross said. In the present study, 67 of the 91 cases, about 74%, would have been missed.
Dr. Ross and Dr. Mama had no relevant financial disclosures. The study coauthors disclosed ties to Titan Medical, Merck, and AbbVie.
SOURCE: Ross WT et al. SGS 2020, Abstract 14.
Among women who have a coincidental appendectomy during surgery for chronic pelvic pain or endometriosis, about 15% have appendiceal endometriosis confirmed by pathological examination, according to a study.
“In the women with appendiceal endometriosis, only 26% had an appendix that looked abnormal,” said Whitney T. Ross, MD, of the department of obstetrics and gynecology at Penn State Health, Hershey.
The results, presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons, indicate that “appendiceal endometriosis is common in women receiving surgery for chronic pelvic pain or endometriosis,” she said. “This study and multiple other studies have also demonstrated that coincidental appendectomy is safe.”
The long-term impact of coincidental appendectomy and its effect on quality of life are not known, however, which may make it difficult to weigh the costs and benefits of the procedure, Dr. Ross said. “It is important to talk to patients about this procedure and determine which approach is the right approach for your institution.”
The study of 609 coincidental appendectomies did not include patients with retrocecal appendices, which may confound the true rate of appendiceal endometriosis, commented Saifuddin T. Mama, MD, MPH, of Rowan University, Camden, N.J.
When the investigators started the study, they were not sure of the risks and benefits of the procedure in patients with retrocecal appendices. An anecdotal report from another research group suggests that outcomes with retrocecal appendices may not be significantly different. “But that is certainly an important question and one that we would like to address in a future prospective study,” Dr. Ross said.
Surgeons have debated the role of coincidental appendectomy during gynecologic surgery. Concerns about safety and questions about the prevalence of appendiceal pathology are reasons that coincidental appendectomy has not been more widely adopted. On the other hand, the procedure may benefit patients and aid diagnosis.
To evaluate the role of coincidental appendectomy in the surgical excision of endometriosis, Dr. Ross and colleagues analyzed data from consecutive coincidental appendectomies performed at one institution between 2013 and 2019. They identified cases in a prospectively maintained surgical database to assess safety and the prevalence of appendiceal pathology.
The indication for surgery was chronic pelvic pain but no visualized endometriosis for 42 patients, stage I-II endometriosis for 388 patients, and stage III-IV endometriosis for 179 patients.
Surgeries included laparoscopic hysterectomy (77.5%), operative laparoscopy (19.9%), and laparoscopic trachelectomy (2.6%). Pathological analysis of the appendices identified endometriosis in 14.9%, malignancy in 0.7%, polyps in 0.5%, and appendicitis in 0.3%.
Among women with chronic pelvic pain but no visualized endometriosis, 2.4% had appendiceal endometriosis. Among those with stage I-II endometriosis, 7% had appendiceal endometriosis, and in patients with stage III-IV endometriosis, the rate of appendiceal endometriosis was 35.2%.
In about 6% of patients with appendiceal endometriosis, the appendix was the only site of pathologically confirmed endometriosis.
Compared with chronic pelvic pain, stage III-IV endometriosis was associated with a significantly increased risk of appendiceal endometriosis (odds ratio, 22.2). The likelihood of appendiceal endometriosis also increased when the appendix looked abnormal (odds ratio, 6.5).
The probability of diagnosing appendiceal endometriosis also increases with the number of other locations of confirmed endometriosis.
“Our surgical decision making is based off of intraoperative findings. However, the final gold-standard diagnosis can’t take place until the pathologic specimen is analyzed,” she said. “We also know that there is a significant discordance, as high as 50%, in early-stage endometriosis between visual inspection and pathology findings.”
There were no complications related to the performance of a coincidental appendectomy during surgery or in the 12 weeks after.
Dr. Ross outlined surgeons’ three main options for performing coincidental appendectomy in patients undergoing surgery for chronic pelvic pain or endometriosis: universal coincidental appendectomy, targeted appendectomy based on operative findings, and performing the procedure based on the appearance of the appendix.
Basing the decision on appearance “is going to miss a lot of appendiceal endometriosis,” Dr. Ross said. In the present study, 67 of the 91 cases, about 74%, would have been missed.
Dr. Ross and Dr. Mama had no relevant financial disclosures. The study coauthors disclosed ties to Titan Medical, Merck, and AbbVie.
SOURCE: Ross WT et al. SGS 2020, Abstract 14.
Among women who have a coincidental appendectomy during surgery for chronic pelvic pain or endometriosis, about 15% have appendiceal endometriosis confirmed by pathological examination, according to a study.
“In the women with appendiceal endometriosis, only 26% had an appendix that looked abnormal,” said Whitney T. Ross, MD, of the department of obstetrics and gynecology at Penn State Health, Hershey.
The results, presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons, indicate that “appendiceal endometriosis is common in women receiving surgery for chronic pelvic pain or endometriosis,” she said. “This study and multiple other studies have also demonstrated that coincidental appendectomy is safe.”
The long-term impact of coincidental appendectomy and its effect on quality of life are not known, however, which may make it difficult to weigh the costs and benefits of the procedure, Dr. Ross said. “It is important to talk to patients about this procedure and determine which approach is the right approach for your institution.”
The study of 609 coincidental appendectomies did not include patients with retrocecal appendices, which may confound the true rate of appendiceal endometriosis, commented Saifuddin T. Mama, MD, MPH, of Rowan University, Camden, N.J.
When the investigators started the study, they were not sure of the risks and benefits of the procedure in patients with retrocecal appendices. An anecdotal report from another research group suggests that outcomes with retrocecal appendices may not be significantly different. “But that is certainly an important question and one that we would like to address in a future prospective study,” Dr. Ross said.
Surgeons have debated the role of coincidental appendectomy during gynecologic surgery. Concerns about safety and questions about the prevalence of appendiceal pathology are reasons that coincidental appendectomy has not been more widely adopted. On the other hand, the procedure may benefit patients and aid diagnosis.
To evaluate the role of coincidental appendectomy in the surgical excision of endometriosis, Dr. Ross and colleagues analyzed data from consecutive coincidental appendectomies performed at one institution between 2013 and 2019. They identified cases in a prospectively maintained surgical database to assess safety and the prevalence of appendiceal pathology.
The indication for surgery was chronic pelvic pain but no visualized endometriosis for 42 patients, stage I-II endometriosis for 388 patients, and stage III-IV endometriosis for 179 patients.
Surgeries included laparoscopic hysterectomy (77.5%), operative laparoscopy (19.9%), and laparoscopic trachelectomy (2.6%). Pathological analysis of the appendices identified endometriosis in 14.9%, malignancy in 0.7%, polyps in 0.5%, and appendicitis in 0.3%.
Among women with chronic pelvic pain but no visualized endometriosis, 2.4% had appendiceal endometriosis. Among those with stage I-II endometriosis, 7% had appendiceal endometriosis, and in patients with stage III-IV endometriosis, the rate of appendiceal endometriosis was 35.2%.
In about 6% of patients with appendiceal endometriosis, the appendix was the only site of pathologically confirmed endometriosis.
Compared with chronic pelvic pain, stage III-IV endometriosis was associated with a significantly increased risk of appendiceal endometriosis (odds ratio, 22.2). The likelihood of appendiceal endometriosis also increased when the appendix looked abnormal (odds ratio, 6.5).
The probability of diagnosing appendiceal endometriosis also increases with the number of other locations of confirmed endometriosis.
“Our surgical decision making is based off of intraoperative findings. However, the final gold-standard diagnosis can’t take place until the pathologic specimen is analyzed,” she said. “We also know that there is a significant discordance, as high as 50%, in early-stage endometriosis between visual inspection and pathology findings.”
There were no complications related to the performance of a coincidental appendectomy during surgery or in the 12 weeks after.
Dr. Ross outlined surgeons’ three main options for performing coincidental appendectomy in patients undergoing surgery for chronic pelvic pain or endometriosis: universal coincidental appendectomy, targeted appendectomy based on operative findings, and performing the procedure based on the appearance of the appendix.
Basing the decision on appearance “is going to miss a lot of appendiceal endometriosis,” Dr. Ross said. In the present study, 67 of the 91 cases, about 74%, would have been missed.
Dr. Ross and Dr. Mama had no relevant financial disclosures. The study coauthors disclosed ties to Titan Medical, Merck, and AbbVie.
SOURCE: Ross WT et al. SGS 2020, Abstract 14.
FROM SGS 2020
Cutaneous clues linked to COVID-19 coagulation risk
, new evidence suggests.
Researchers at Weill Cornell Medicine NewYork–Presbyterian Medical Center in New York linked livedoid and purpuric skin eruptions to a greater likelihood for occlusive vascular disease associated with SARS-CoV-2 infection in a small case series.
These skin signs could augment coagulation assays in this patient population. “Physicians should consider a hematology consult for potential anticoagulation in patients with these skin presentations and severe COVID-19,” senior author Joanna Harp, MD, said in an interview.
“Physicians should also consider D-dimer, fibrinogen, coagulation studies, and a skin biopsy given that there are other diagnoses on the differential as well.”
The research letter was published online on Aug. 5 in JAMA Dermatology.
The findings build on multiple previous reports of skin manifestations associated with COVID-19, including a study of 375 patients in Spain. Among people with suspected or confirmed SARS-CoV-2 infection, senior author of the Spanish research, Ignacio Garcia-Doval, MD, PhD, also observed livedoid and necrotic skin eruptions more commonly in severe disease.
“I think that this case series [from Harp and colleagues] confirms the findings of our previous paper – that patients with livedoid or necrotic lesions have a worse prognosis, as these are markers of vascular occlusion,” he said in an interview.
Dr. Harp and colleagues reported their observations with four patients aged 40-80 years. Each had severe COVID-19 with acute respiratory distress syndrome and required intubation. Treating clinicians requested a dermatology consult to assess acral fixed livedo racemosa and retiform purpura presentations.
D-dimer levels exceeded 3 mcg/mL in each case. All four patients had a suspected pulmonary embolism within 1-5 days of the dermatologic findings. Prophylactic anticoagulation at admission was changed to therapeutic anticoagulation because of increasing D-dimer levels and the suspected thrombotic events.
“I think that the paper is interesting because it shows the associated histopathological findings and has important clinical implications due to the association with pulmonary embolism,” said Dr. Garcia-Doval, a researcher at the Spanish Academy of Dermatology in Madrid. “These patients should probably be anticoagulated.”
Skin biopsy results
Punch biopsies revealed pauci-inflammatory thrombogenic vasculopathy involving capillaries, venules, arterioles, or small arteries.
Livedo racemosa skin findings point to partial occlusion of cutaneous blood vessels, whereas retiform purpura indicate full occlusion of cutaneous blood vessels.
An inability to confirm the exact timing of the onset of the skin rash was a limitation of the study.
“The findings suggest that clinicians caring for patients with COVID-19 should be aware of livedoid and purpuric rashes as potential manifestations of an underlying hypercoagulable state,” the authors noted. “If these skin findings are identified, a skin biopsy should be considered because the result may guide anticoagulation management.”
Observations during an outbreak
The researchers observed these cases between March 13 and April 3, during the peak of the COVID-19 outbreak in New York.
“We did see additional cases since our study period. However, it has decreased significantly with the falling number of COVID-19 cases in the city,” said Dr. Harp, a dermatologist at NewYork–Presbyterian.
Another contributing factor in the drop in cases was “implementation of earlier, more aggressive anticoagulation in many of these patients at our institution,” she added.
The investigators plan to continue the research. “We are working on a more formalized study,” lead author Caren Droesch, MD, said in an interview.
“But given very low patient numbers in our area we have not started recruiting patients,” said Dr. Droesch, a resident at Weill Cornell Medicine and NewYork–Presbyterian at the time of the study. She is now a dermatologist at Mass General Brigham in Wellesley, Mass.
Consider a dermatology consult
“This is a small case series of four patients, but mirrors what we have seen at our institution and what others have reported about individual patients around the world,” Anthony Fernandez, MD, PhD, a dermatologist at Cleveland Clinic, said in an interview. “The skin, like many other organ systems, can be affected by thrombotic events within the setting of COVID-19 disease.”
As in the current study, Dr. Fernandez observed skin manifestations in people with severe COVID-19 with elevated D-dimer levels. These patients typically require mechanical ventilation in the intensive care unit, he added.
“As these authors point out, it is important for all clinicians caring for COVID-19 patients to look for these rashes,” said Dr. Fernandez, who coauthored a report on skin manifestations in this patient population. “We also agree that clinicians should have a low threshold for consulting dermatology. A skin biopsy is minimally invasive and can be important in confirming or refuting that such rashes are truly reflective of thrombotic vasculopathy.”
Dr. Harp, Dr. Droesch and Dr. Garcia-Doval have disclosed no relevant financial relationships. Dr. Fernandez received funding from the Clinical and Translational Science Collaborative at Case Western Reserve University to study skin manifestations of COVID-19.
A version of this article originally appeared on Medscape.com.
, new evidence suggests.
Researchers at Weill Cornell Medicine NewYork–Presbyterian Medical Center in New York linked livedoid and purpuric skin eruptions to a greater likelihood for occlusive vascular disease associated with SARS-CoV-2 infection in a small case series.
These skin signs could augment coagulation assays in this patient population. “Physicians should consider a hematology consult for potential anticoagulation in patients with these skin presentations and severe COVID-19,” senior author Joanna Harp, MD, said in an interview.
“Physicians should also consider D-dimer, fibrinogen, coagulation studies, and a skin biopsy given that there are other diagnoses on the differential as well.”
The research letter was published online on Aug. 5 in JAMA Dermatology.
The findings build on multiple previous reports of skin manifestations associated with COVID-19, including a study of 375 patients in Spain. Among people with suspected or confirmed SARS-CoV-2 infection, senior author of the Spanish research, Ignacio Garcia-Doval, MD, PhD, also observed livedoid and necrotic skin eruptions more commonly in severe disease.
“I think that this case series [from Harp and colleagues] confirms the findings of our previous paper – that patients with livedoid or necrotic lesions have a worse prognosis, as these are markers of vascular occlusion,” he said in an interview.
Dr. Harp and colleagues reported their observations with four patients aged 40-80 years. Each had severe COVID-19 with acute respiratory distress syndrome and required intubation. Treating clinicians requested a dermatology consult to assess acral fixed livedo racemosa and retiform purpura presentations.
D-dimer levels exceeded 3 mcg/mL in each case. All four patients had a suspected pulmonary embolism within 1-5 days of the dermatologic findings. Prophylactic anticoagulation at admission was changed to therapeutic anticoagulation because of increasing D-dimer levels and the suspected thrombotic events.
“I think that the paper is interesting because it shows the associated histopathological findings and has important clinical implications due to the association with pulmonary embolism,” said Dr. Garcia-Doval, a researcher at the Spanish Academy of Dermatology in Madrid. “These patients should probably be anticoagulated.”
Skin biopsy results
Punch biopsies revealed pauci-inflammatory thrombogenic vasculopathy involving capillaries, venules, arterioles, or small arteries.
Livedo racemosa skin findings point to partial occlusion of cutaneous blood vessels, whereas retiform purpura indicate full occlusion of cutaneous blood vessels.
An inability to confirm the exact timing of the onset of the skin rash was a limitation of the study.
“The findings suggest that clinicians caring for patients with COVID-19 should be aware of livedoid and purpuric rashes as potential manifestations of an underlying hypercoagulable state,” the authors noted. “If these skin findings are identified, a skin biopsy should be considered because the result may guide anticoagulation management.”
Observations during an outbreak
The researchers observed these cases between March 13 and April 3, during the peak of the COVID-19 outbreak in New York.
“We did see additional cases since our study period. However, it has decreased significantly with the falling number of COVID-19 cases in the city,” said Dr. Harp, a dermatologist at NewYork–Presbyterian.
Another contributing factor in the drop in cases was “implementation of earlier, more aggressive anticoagulation in many of these patients at our institution,” she added.
The investigators plan to continue the research. “We are working on a more formalized study,” lead author Caren Droesch, MD, said in an interview.
“But given very low patient numbers in our area we have not started recruiting patients,” said Dr. Droesch, a resident at Weill Cornell Medicine and NewYork–Presbyterian at the time of the study. She is now a dermatologist at Mass General Brigham in Wellesley, Mass.
Consider a dermatology consult
“This is a small case series of four patients, but mirrors what we have seen at our institution and what others have reported about individual patients around the world,” Anthony Fernandez, MD, PhD, a dermatologist at Cleveland Clinic, said in an interview. “The skin, like many other organ systems, can be affected by thrombotic events within the setting of COVID-19 disease.”
As in the current study, Dr. Fernandez observed skin manifestations in people with severe COVID-19 with elevated D-dimer levels. These patients typically require mechanical ventilation in the intensive care unit, he added.
“As these authors point out, it is important for all clinicians caring for COVID-19 patients to look for these rashes,” said Dr. Fernandez, who coauthored a report on skin manifestations in this patient population. “We also agree that clinicians should have a low threshold for consulting dermatology. A skin biopsy is minimally invasive and can be important in confirming or refuting that such rashes are truly reflective of thrombotic vasculopathy.”
Dr. Harp, Dr. Droesch and Dr. Garcia-Doval have disclosed no relevant financial relationships. Dr. Fernandez received funding from the Clinical and Translational Science Collaborative at Case Western Reserve University to study skin manifestations of COVID-19.
A version of this article originally appeared on Medscape.com.
, new evidence suggests.
Researchers at Weill Cornell Medicine NewYork–Presbyterian Medical Center in New York linked livedoid and purpuric skin eruptions to a greater likelihood for occlusive vascular disease associated with SARS-CoV-2 infection in a small case series.
These skin signs could augment coagulation assays in this patient population. “Physicians should consider a hematology consult for potential anticoagulation in patients with these skin presentations and severe COVID-19,” senior author Joanna Harp, MD, said in an interview.
“Physicians should also consider D-dimer, fibrinogen, coagulation studies, and a skin biopsy given that there are other diagnoses on the differential as well.”
The research letter was published online on Aug. 5 in JAMA Dermatology.
The findings build on multiple previous reports of skin manifestations associated with COVID-19, including a study of 375 patients in Spain. Among people with suspected or confirmed SARS-CoV-2 infection, senior author of the Spanish research, Ignacio Garcia-Doval, MD, PhD, also observed livedoid and necrotic skin eruptions more commonly in severe disease.
“I think that this case series [from Harp and colleagues] confirms the findings of our previous paper – that patients with livedoid or necrotic lesions have a worse prognosis, as these are markers of vascular occlusion,” he said in an interview.
Dr. Harp and colleagues reported their observations with four patients aged 40-80 years. Each had severe COVID-19 with acute respiratory distress syndrome and required intubation. Treating clinicians requested a dermatology consult to assess acral fixed livedo racemosa and retiform purpura presentations.
D-dimer levels exceeded 3 mcg/mL in each case. All four patients had a suspected pulmonary embolism within 1-5 days of the dermatologic findings. Prophylactic anticoagulation at admission was changed to therapeutic anticoagulation because of increasing D-dimer levels and the suspected thrombotic events.
“I think that the paper is interesting because it shows the associated histopathological findings and has important clinical implications due to the association with pulmonary embolism,” said Dr. Garcia-Doval, a researcher at the Spanish Academy of Dermatology in Madrid. “These patients should probably be anticoagulated.”
Skin biopsy results
Punch biopsies revealed pauci-inflammatory thrombogenic vasculopathy involving capillaries, venules, arterioles, or small arteries.
Livedo racemosa skin findings point to partial occlusion of cutaneous blood vessels, whereas retiform purpura indicate full occlusion of cutaneous blood vessels.
An inability to confirm the exact timing of the onset of the skin rash was a limitation of the study.
“The findings suggest that clinicians caring for patients with COVID-19 should be aware of livedoid and purpuric rashes as potential manifestations of an underlying hypercoagulable state,” the authors noted. “If these skin findings are identified, a skin biopsy should be considered because the result may guide anticoagulation management.”
Observations during an outbreak
The researchers observed these cases between March 13 and April 3, during the peak of the COVID-19 outbreak in New York.
“We did see additional cases since our study period. However, it has decreased significantly with the falling number of COVID-19 cases in the city,” said Dr. Harp, a dermatologist at NewYork–Presbyterian.
Another contributing factor in the drop in cases was “implementation of earlier, more aggressive anticoagulation in many of these patients at our institution,” she added.
The investigators plan to continue the research. “We are working on a more formalized study,” lead author Caren Droesch, MD, said in an interview.
“But given very low patient numbers in our area we have not started recruiting patients,” said Dr. Droesch, a resident at Weill Cornell Medicine and NewYork–Presbyterian at the time of the study. She is now a dermatologist at Mass General Brigham in Wellesley, Mass.
Consider a dermatology consult
“This is a small case series of four patients, but mirrors what we have seen at our institution and what others have reported about individual patients around the world,” Anthony Fernandez, MD, PhD, a dermatologist at Cleveland Clinic, said in an interview. “The skin, like many other organ systems, can be affected by thrombotic events within the setting of COVID-19 disease.”
As in the current study, Dr. Fernandez observed skin manifestations in people with severe COVID-19 with elevated D-dimer levels. These patients typically require mechanical ventilation in the intensive care unit, he added.
“As these authors point out, it is important for all clinicians caring for COVID-19 patients to look for these rashes,” said Dr. Fernandez, who coauthored a report on skin manifestations in this patient population. “We also agree that clinicians should have a low threshold for consulting dermatology. A skin biopsy is minimally invasive and can be important in confirming or refuting that such rashes are truly reflective of thrombotic vasculopathy.”
Dr. Harp, Dr. Droesch and Dr. Garcia-Doval have disclosed no relevant financial relationships. Dr. Fernandez received funding from the Clinical and Translational Science Collaborative at Case Western Reserve University to study skin manifestations of COVID-19.
A version of this article originally appeared on Medscape.com.
FROM JAMA DERMATOLOGY
Inpatient pain management in the era of the opioid epidemic
Hospitalists continue to face challenges balancing appropriate management of acute pain in the inpatient setting with responsible opioid prescribing, particularly with the number of inpatients suffering from both pain and substance use disorders continuing to increase nationwide.
During my virtual session, “Inpatient Management in the Era of the Opioid Epidemic,” I will cover best practices on how to balance appropriate management of acute pain with responsible opioid prescribing and will examine which nonopioid analgesics and nonpharmacologic treatments have been demonstrated to be effective for management of acute pain in hospitalized patients, specifically risk-mitigation strategies designed to increase the number of patients to whom we can safely prescribe nonsteroidal anti-inflammatory agents.
Additionally, I will cover best practices in treating the hospitalized patient with chronic pain on long-term opioid therapy and managing acute pain in hospitalized patients with opioid use disorder. Real world patient scenarios will be the basis of the session.
Key points to be covered include the following:
- Tips for effective patient communication around pain management in the hospital.
- Responsible opioid prescribing in opioid naive patients, including time of discharge.
- Risk-mitigation strategies for use of NSAID medications for acute pain, including expanded use in patients with risk of GI complications, cardiovascular complications, and chronic kidney disease.
- Review of effective and available nonopioid and nonpharmacologic treatments for acute pain.
- Best practices in managing acute pain in patients with active opioid use disorder.
- Best practices in managing acute pain in patients with opioid use disorder who are treated with opioid agonists.
- Treatment of opioid use disorder in the hospital setting.
Inpatient management in the era of the opioid epidemic
Live Q&A: Wednesday, August 19, 1:00-2:00 p.m. ET
Dr. Vettese is associate professor in the Division of General Medicine and Geriatrics at Emory University School of Medicine.
Hospitalists continue to face challenges balancing appropriate management of acute pain in the inpatient setting with responsible opioid prescribing, particularly with the number of inpatients suffering from both pain and substance use disorders continuing to increase nationwide.
During my virtual session, “Inpatient Management in the Era of the Opioid Epidemic,” I will cover best practices on how to balance appropriate management of acute pain with responsible opioid prescribing and will examine which nonopioid analgesics and nonpharmacologic treatments have been demonstrated to be effective for management of acute pain in hospitalized patients, specifically risk-mitigation strategies designed to increase the number of patients to whom we can safely prescribe nonsteroidal anti-inflammatory agents.
Additionally, I will cover best practices in treating the hospitalized patient with chronic pain on long-term opioid therapy and managing acute pain in hospitalized patients with opioid use disorder. Real world patient scenarios will be the basis of the session.
Key points to be covered include the following:
- Tips for effective patient communication around pain management in the hospital.
- Responsible opioid prescribing in opioid naive patients, including time of discharge.
- Risk-mitigation strategies for use of NSAID medications for acute pain, including expanded use in patients with risk of GI complications, cardiovascular complications, and chronic kidney disease.
- Review of effective and available nonopioid and nonpharmacologic treatments for acute pain.
- Best practices in managing acute pain in patients with active opioid use disorder.
- Best practices in managing acute pain in patients with opioid use disorder who are treated with opioid agonists.
- Treatment of opioid use disorder in the hospital setting.
Inpatient management in the era of the opioid epidemic
Live Q&A: Wednesday, August 19, 1:00-2:00 p.m. ET
Dr. Vettese is associate professor in the Division of General Medicine and Geriatrics at Emory University School of Medicine.
Hospitalists continue to face challenges balancing appropriate management of acute pain in the inpatient setting with responsible opioid prescribing, particularly with the number of inpatients suffering from both pain and substance use disorders continuing to increase nationwide.
During my virtual session, “Inpatient Management in the Era of the Opioid Epidemic,” I will cover best practices on how to balance appropriate management of acute pain with responsible opioid prescribing and will examine which nonopioid analgesics and nonpharmacologic treatments have been demonstrated to be effective for management of acute pain in hospitalized patients, specifically risk-mitigation strategies designed to increase the number of patients to whom we can safely prescribe nonsteroidal anti-inflammatory agents.
Additionally, I will cover best practices in treating the hospitalized patient with chronic pain on long-term opioid therapy and managing acute pain in hospitalized patients with opioid use disorder. Real world patient scenarios will be the basis of the session.
Key points to be covered include the following:
- Tips for effective patient communication around pain management in the hospital.
- Responsible opioid prescribing in opioid naive patients, including time of discharge.
- Risk-mitigation strategies for use of NSAID medications for acute pain, including expanded use in patients with risk of GI complications, cardiovascular complications, and chronic kidney disease.
- Review of effective and available nonopioid and nonpharmacologic treatments for acute pain.
- Best practices in managing acute pain in patients with active opioid use disorder.
- Best practices in managing acute pain in patients with opioid use disorder who are treated with opioid agonists.
- Treatment of opioid use disorder in the hospital setting.
Inpatient management in the era of the opioid epidemic
Live Q&A: Wednesday, August 19, 1:00-2:00 p.m. ET
Dr. Vettese is associate professor in the Division of General Medicine and Geriatrics at Emory University School of Medicine.
Welcome to HM20 Virtual
Welcome to the HM20 virtual conference! We’re glad to have you join us to virtually experience sessions from our most popular SHM annual conference tracks including Rapid Fire, Clinical Updates, and High-Value Care! We also have added some new timely topics given our current times that you won’t want to miss. We encourage you to engage with the larger community via social media at #HM20Virtual.
HM20 in San Diego, scheduled originally for April 2020, was trending to be the highest in-person attended SHM annual conference with a fantastic line-up of offerings. Unfortunately, then came our pandemic, or pandemics. In mid-March, the Society of Hospital Medicine board of directors concluded that it was impossible for SHM to move forward with Hospital Medicine 2020 in San Diego because of the continued spread of COVID-19. Canceling the in-person conference during this unprecedented time was the right thing to do. I have valued the SHM leadership team and the larger SHM community for their support in being even more engaged on the front lines and with each other across our world during this time.
The COVID-19 pandemic has created a systemic challenge for health care systems across the nation. As hospitalists continue to be on the front lines of care and also innovations, organizations have leveraged telemedicine to support their patients, protect their clinicians, and conserve scarce resources. It is hospital medicine that has been on the front lines of change and adaptations and have led in this pandemic in many organizations across the nation and the world.
Unfortunately, known health disparities have also been amplified and there came an acute worsening of the chronic issues in this nation. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home. Armaud Arbery was shot and killed by armed neighbors while running through a neighborhood in Brunswick, Ga. Then on May 25, 5 miles from where I call home here in the Twin Cities in Minnesota, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after police kneeled on his neck for over 8 minutes. This pandemic has also shaken up the status quo and laid bare a lot of our country’s long and deep-seated issues – from massive economic inequities to ongoing racial disparities to immigration concerns. It’s woken a lot of our valued hospitalists to the fact that the old ways of doing things just don’t work.
I’m grateful our society has taken steps to speak into these timely topics, and to share via publications, Twitter chats, advocacy items, and more! I want to encourage all of us to use the immense network of our hospitalist communities to comfort each other, learn, grow, and engage. We have not achieved big changes by ourselves. We’ve created valued offerings and innovative changes, and we’ve led on the front lines, in policies and procedures, by doing it together. Meaningful change requires allies in a common cause. We stand with our black and brown brothers and sisters who are particularly attuned to injustice, inequality, and struggle. We in hospital medicine stand up with many others who are struggling, our African American, Latin American, Native American, immigrant, LGBTQ+ communities. This intersection of the crisis of the COVID-19 pandemic and the racism pandemic have led us to a pivotal point in the arc of change and justice. I invite you to comfort each other, learn from each other, and act together in this community. To this end we have included timely resources in our HM20 virtual offering on these topics.
This year has been a big transition year. Not only did 2020 usher in a new decade, along with COVID-19 and our double pandemic, SHM has also had important transitions within its senior leadership. We say farewell to Larry Wellikson, MD, who has been at the helm of SHM since the beginning. On behalf of this annual conference, we want to celebrate and thank you, Larry, for your years of dedication and service to SHM. You have taken the specialty of hospital medicine and created a movement in SHM, where the entire hospital medicine team may gather under a bigger tent for education, community, and for the betterment of care for our patients.
We extend a welcome to Eric Howell, MD, who succeeds Dr. Wellikson as SHM’s CEO. We also welcome Danielle Scheurer, MD, as the new SHM president, succeeding the great leadership offered this past year by Christopher Frost, MD. In addition, Jerome C. Siy, MD, was voted president-elect, Dr. Rachel Thompson, MD, was elected treasurer, Kris Rehm, MD, was voted secretary, and Darlene Tad-y, MD, was elected to the board of directors. We welcome these new officers.
HM20 Virtual will consist of prerecorded on-demand sessions that can be viewed at your convenience as well as live Q&A and attendee networking that will take place during specific dates/times. A few of the top-rated sessions from our historically popular tracks include: Update in Clinical Practice Guidelines, Antibiotics Made Ridiculously Simple, Getting to Know Oncology Emergencies, Inpatient Pain Management in the Era of the Opioid Epidemic, Updates in Heart Failure, and Hyponatremia: Don’t Drink the Water. Additionally, we have some of our perennial favorites including the Update in Hospital Medicine and Top Pediatric Articles of 2019. There will be COVID-19 specific content from expertise throughout the nation focusing on care pathways, clinical updates, telemedicine, point-of-care ultrasound, and more! To view the HM20 Virtual Opening Session and discover what you can expect in this educational experience, click here.
The Journal of Hospital Medicine has had a large presence in our meetings for many years. We are grateful for Samir Shah, MD, and his leadership during this double pandemic, for identifying areas where we can advance the field responsibly in the face of relatively limited evidence, and rapidly evolving news. As part of his commitment, all JHM articles related to COVID-19 and published during the pandemic are open access. A pre-COVID goal that has been realized during the pandemic was to bring more of the journal into our annual conference and the conference contents into the journal. We are proud to say this has been a great collaboration, particularly during this pandemic, and much thanks to Dr. Shah’s leadership for highlighting timely pieces. Kimberly Manning, MD, had an especially powerful piece on the topic of racism and our double pandemic, and she is a featured speaker during our HM20 Virtual offering, under the same title as her article: “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Additionally, Manpreet Malik, MD, and I will be copresenting on a timely topic about the “Immigrant Hospitalist during COVID-19.”
Aside from these sessions for HM20 Virtual, the real can’t miss(es) for the conference are the Research, Innovations, and Clinical Vignette (RIV) posters sessions. I am grateful for the leadership of Stephanie Mueller, MD, who served as chair for this year’s RIV. This unique year has led to the hosting of a virtual poster competition with judging and the opening of a virtual gallery. We are so pleased to be able to share and highlight the work of many of learners and staff hospitalists! I love that a hospitalist on one side of the country can help provide pearls on a case, an innovation, or a research idea that can help improve diagnosis for a patient at the other side of the country. Keep an eye on SHM’s social media and the presentation by Dr. Mueller for announcements of the winners.
A favorite reason many of us attend the annual conference is for the people and community. We wanted to keep this value as we shifted to a virtual offering. Networking will occur through a variety of offerings including Simulive sessions and Special Interest Forums. Simulive sessions will run for 3 weeks from August 11 to August 27. For those of you new to the term, Simulive may sound like a made-up word, but it is an actual amalgamation of a prerecorded webinar and a live interaction (simulated + live = Simulive). Simulive allows the faculty to sit in on their prerecorded session and interact with the audience via the chat feature during the live scheduled recording and spend time afterwards for a live Q&A from the audience.
There will also be over 20 Special Interest Forums hosted in the evenings after these Simulive sessions have concluded to give you a chance to connect with individuals, share experiences, and have meaningful discussions that can directly impact your practice. Samples of the forums include: Diversity and Inclusion, Rural Hospital Medicine, Pediatrics, NP/PA, Perioperative and Comanagement, Health Information Technology, and Point of Care Ultrasound! Take a look at the HM20 registration page for further information. You will receive direct information on how to attend. We encourage you to join!
HM20 also features a virtual 5K! Whether you run on a treadmill or jog in your neighborhood or local park, you can participate in HM20’s Virtual Fun Run or Walk. To participate, simply run your 5K during the weeks of HM20 Virtual and when you’re done, fill out our form to log your time. We encourage you to post a picture on social media as well with #HM20Virtual. You’ll also receive a certificate of completion at the close of HM20 Virtual.
All HM20 Virtual sessions will be available as on-demand after August 31. HM20 virtual offers more than 60 CME hours and over 35 MOC hours that you can claim at your convenience! That’s the most amount of CME and MOC ever offered at SHM for an event! This conference would not be possible without the tireless and relentless effort of SHM staff and leadership, our terrific speakers and faculty, and all the volunteer committee members of SHM. A huge thanks to the Annual Conference Committee who had the charge to develop the content for the Annual Conference, including topics, speakers, and learning objectives. I am grateful to have had the opportunity to serve on this committee for the past 7 years and to lead HM20 this year. Thanks to Brittany Evans, Hayleigh Lawrence, and Michelle Kann for their valued support this past year from an SHM staff perspective; to my assistant course director, Dan Steinberg, MD; and to the immediate past course director, Dustin Smith, MD, for their support.
Once again, we are excited to have you join, and we hope this conference elevates your education in hospital medicine, advances your career, stimulates innovative thinking, and provides you with enduring networking opportunities. We sincerely thank you for attending HM20 Virtual. Welcome!
Dr. Mathews is chief of hospital medicine at Regions Hospital, HealthPartners in St. Paul, Minn., an associate professor at the University of Minnesota, Minneapolis, and course director of HM20.
Welcome to the HM20 virtual conference! We’re glad to have you join us to virtually experience sessions from our most popular SHM annual conference tracks including Rapid Fire, Clinical Updates, and High-Value Care! We also have added some new timely topics given our current times that you won’t want to miss. We encourage you to engage with the larger community via social media at #HM20Virtual.
HM20 in San Diego, scheduled originally for April 2020, was trending to be the highest in-person attended SHM annual conference with a fantastic line-up of offerings. Unfortunately, then came our pandemic, or pandemics. In mid-March, the Society of Hospital Medicine board of directors concluded that it was impossible for SHM to move forward with Hospital Medicine 2020 in San Diego because of the continued spread of COVID-19. Canceling the in-person conference during this unprecedented time was the right thing to do. I have valued the SHM leadership team and the larger SHM community for their support in being even more engaged on the front lines and with each other across our world during this time.
The COVID-19 pandemic has created a systemic challenge for health care systems across the nation. As hospitalists continue to be on the front lines of care and also innovations, organizations have leveraged telemedicine to support their patients, protect their clinicians, and conserve scarce resources. It is hospital medicine that has been on the front lines of change and adaptations and have led in this pandemic in many organizations across the nation and the world.
Unfortunately, known health disparities have also been amplified and there came an acute worsening of the chronic issues in this nation. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home. Armaud Arbery was shot and killed by armed neighbors while running through a neighborhood in Brunswick, Ga. Then on May 25, 5 miles from where I call home here in the Twin Cities in Minnesota, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after police kneeled on his neck for over 8 minutes. This pandemic has also shaken up the status quo and laid bare a lot of our country’s long and deep-seated issues – from massive economic inequities to ongoing racial disparities to immigration concerns. It’s woken a lot of our valued hospitalists to the fact that the old ways of doing things just don’t work.
I’m grateful our society has taken steps to speak into these timely topics, and to share via publications, Twitter chats, advocacy items, and more! I want to encourage all of us to use the immense network of our hospitalist communities to comfort each other, learn, grow, and engage. We have not achieved big changes by ourselves. We’ve created valued offerings and innovative changes, and we’ve led on the front lines, in policies and procedures, by doing it together. Meaningful change requires allies in a common cause. We stand with our black and brown brothers and sisters who are particularly attuned to injustice, inequality, and struggle. We in hospital medicine stand up with many others who are struggling, our African American, Latin American, Native American, immigrant, LGBTQ+ communities. This intersection of the crisis of the COVID-19 pandemic and the racism pandemic have led us to a pivotal point in the arc of change and justice. I invite you to comfort each other, learn from each other, and act together in this community. To this end we have included timely resources in our HM20 virtual offering on these topics.
This year has been a big transition year. Not only did 2020 usher in a new decade, along with COVID-19 and our double pandemic, SHM has also had important transitions within its senior leadership. We say farewell to Larry Wellikson, MD, who has been at the helm of SHM since the beginning. On behalf of this annual conference, we want to celebrate and thank you, Larry, for your years of dedication and service to SHM. You have taken the specialty of hospital medicine and created a movement in SHM, where the entire hospital medicine team may gather under a bigger tent for education, community, and for the betterment of care for our patients.
We extend a welcome to Eric Howell, MD, who succeeds Dr. Wellikson as SHM’s CEO. We also welcome Danielle Scheurer, MD, as the new SHM president, succeeding the great leadership offered this past year by Christopher Frost, MD. In addition, Jerome C. Siy, MD, was voted president-elect, Dr. Rachel Thompson, MD, was elected treasurer, Kris Rehm, MD, was voted secretary, and Darlene Tad-y, MD, was elected to the board of directors. We welcome these new officers.
HM20 Virtual will consist of prerecorded on-demand sessions that can be viewed at your convenience as well as live Q&A and attendee networking that will take place during specific dates/times. A few of the top-rated sessions from our historically popular tracks include: Update in Clinical Practice Guidelines, Antibiotics Made Ridiculously Simple, Getting to Know Oncology Emergencies, Inpatient Pain Management in the Era of the Opioid Epidemic, Updates in Heart Failure, and Hyponatremia: Don’t Drink the Water. Additionally, we have some of our perennial favorites including the Update in Hospital Medicine and Top Pediatric Articles of 2019. There will be COVID-19 specific content from expertise throughout the nation focusing on care pathways, clinical updates, telemedicine, point-of-care ultrasound, and more! To view the HM20 Virtual Opening Session and discover what you can expect in this educational experience, click here.
The Journal of Hospital Medicine has had a large presence in our meetings for many years. We are grateful for Samir Shah, MD, and his leadership during this double pandemic, for identifying areas where we can advance the field responsibly in the face of relatively limited evidence, and rapidly evolving news. As part of his commitment, all JHM articles related to COVID-19 and published during the pandemic are open access. A pre-COVID goal that has been realized during the pandemic was to bring more of the journal into our annual conference and the conference contents into the journal. We are proud to say this has been a great collaboration, particularly during this pandemic, and much thanks to Dr. Shah’s leadership for highlighting timely pieces. Kimberly Manning, MD, had an especially powerful piece on the topic of racism and our double pandemic, and she is a featured speaker during our HM20 Virtual offering, under the same title as her article: “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Additionally, Manpreet Malik, MD, and I will be copresenting on a timely topic about the “Immigrant Hospitalist during COVID-19.”
Aside from these sessions for HM20 Virtual, the real can’t miss(es) for the conference are the Research, Innovations, and Clinical Vignette (RIV) posters sessions. I am grateful for the leadership of Stephanie Mueller, MD, who served as chair for this year’s RIV. This unique year has led to the hosting of a virtual poster competition with judging and the opening of a virtual gallery. We are so pleased to be able to share and highlight the work of many of learners and staff hospitalists! I love that a hospitalist on one side of the country can help provide pearls on a case, an innovation, or a research idea that can help improve diagnosis for a patient at the other side of the country. Keep an eye on SHM’s social media and the presentation by Dr. Mueller for announcements of the winners.
A favorite reason many of us attend the annual conference is for the people and community. We wanted to keep this value as we shifted to a virtual offering. Networking will occur through a variety of offerings including Simulive sessions and Special Interest Forums. Simulive sessions will run for 3 weeks from August 11 to August 27. For those of you new to the term, Simulive may sound like a made-up word, but it is an actual amalgamation of a prerecorded webinar and a live interaction (simulated + live = Simulive). Simulive allows the faculty to sit in on their prerecorded session and interact with the audience via the chat feature during the live scheduled recording and spend time afterwards for a live Q&A from the audience.
There will also be over 20 Special Interest Forums hosted in the evenings after these Simulive sessions have concluded to give you a chance to connect with individuals, share experiences, and have meaningful discussions that can directly impact your practice. Samples of the forums include: Diversity and Inclusion, Rural Hospital Medicine, Pediatrics, NP/PA, Perioperative and Comanagement, Health Information Technology, and Point of Care Ultrasound! Take a look at the HM20 registration page for further information. You will receive direct information on how to attend. We encourage you to join!
HM20 also features a virtual 5K! Whether you run on a treadmill or jog in your neighborhood or local park, you can participate in HM20’s Virtual Fun Run or Walk. To participate, simply run your 5K during the weeks of HM20 Virtual and when you’re done, fill out our form to log your time. We encourage you to post a picture on social media as well with #HM20Virtual. You’ll also receive a certificate of completion at the close of HM20 Virtual.
All HM20 Virtual sessions will be available as on-demand after August 31. HM20 virtual offers more than 60 CME hours and over 35 MOC hours that you can claim at your convenience! That’s the most amount of CME and MOC ever offered at SHM for an event! This conference would not be possible without the tireless and relentless effort of SHM staff and leadership, our terrific speakers and faculty, and all the volunteer committee members of SHM. A huge thanks to the Annual Conference Committee who had the charge to develop the content for the Annual Conference, including topics, speakers, and learning objectives. I am grateful to have had the opportunity to serve on this committee for the past 7 years and to lead HM20 this year. Thanks to Brittany Evans, Hayleigh Lawrence, and Michelle Kann for their valued support this past year from an SHM staff perspective; to my assistant course director, Dan Steinberg, MD; and to the immediate past course director, Dustin Smith, MD, for their support.
Once again, we are excited to have you join, and we hope this conference elevates your education in hospital medicine, advances your career, stimulates innovative thinking, and provides you with enduring networking opportunities. We sincerely thank you for attending HM20 Virtual. Welcome!
Dr. Mathews is chief of hospital medicine at Regions Hospital, HealthPartners in St. Paul, Minn., an associate professor at the University of Minnesota, Minneapolis, and course director of HM20.
Welcome to the HM20 virtual conference! We’re glad to have you join us to virtually experience sessions from our most popular SHM annual conference tracks including Rapid Fire, Clinical Updates, and High-Value Care! We also have added some new timely topics given our current times that you won’t want to miss. We encourage you to engage with the larger community via social media at #HM20Virtual.
HM20 in San Diego, scheduled originally for April 2020, was trending to be the highest in-person attended SHM annual conference with a fantastic line-up of offerings. Unfortunately, then came our pandemic, or pandemics. In mid-March, the Society of Hospital Medicine board of directors concluded that it was impossible for SHM to move forward with Hospital Medicine 2020 in San Diego because of the continued spread of COVID-19. Canceling the in-person conference during this unprecedented time was the right thing to do. I have valued the SHM leadership team and the larger SHM community for their support in being even more engaged on the front lines and with each other across our world during this time.
The COVID-19 pandemic has created a systemic challenge for health care systems across the nation. As hospitalists continue to be on the front lines of care and also innovations, organizations have leveraged telemedicine to support their patients, protect their clinicians, and conserve scarce resources. It is hospital medicine that has been on the front lines of change and adaptations and have led in this pandemic in many organizations across the nation and the world.
Unfortunately, known health disparities have also been amplified and there came an acute worsening of the chronic issues in this nation. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home. Armaud Arbery was shot and killed by armed neighbors while running through a neighborhood in Brunswick, Ga. Then on May 25, 5 miles from where I call home here in the Twin Cities in Minnesota, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after police kneeled on his neck for over 8 minutes. This pandemic has also shaken up the status quo and laid bare a lot of our country’s long and deep-seated issues – from massive economic inequities to ongoing racial disparities to immigration concerns. It’s woken a lot of our valued hospitalists to the fact that the old ways of doing things just don’t work.
I’m grateful our society has taken steps to speak into these timely topics, and to share via publications, Twitter chats, advocacy items, and more! I want to encourage all of us to use the immense network of our hospitalist communities to comfort each other, learn, grow, and engage. We have not achieved big changes by ourselves. We’ve created valued offerings and innovative changes, and we’ve led on the front lines, in policies and procedures, by doing it together. Meaningful change requires allies in a common cause. We stand with our black and brown brothers and sisters who are particularly attuned to injustice, inequality, and struggle. We in hospital medicine stand up with many others who are struggling, our African American, Latin American, Native American, immigrant, LGBTQ+ communities. This intersection of the crisis of the COVID-19 pandemic and the racism pandemic have led us to a pivotal point in the arc of change and justice. I invite you to comfort each other, learn from each other, and act together in this community. To this end we have included timely resources in our HM20 virtual offering on these topics.
This year has been a big transition year. Not only did 2020 usher in a new decade, along with COVID-19 and our double pandemic, SHM has also had important transitions within its senior leadership. We say farewell to Larry Wellikson, MD, who has been at the helm of SHM since the beginning. On behalf of this annual conference, we want to celebrate and thank you, Larry, for your years of dedication and service to SHM. You have taken the specialty of hospital medicine and created a movement in SHM, where the entire hospital medicine team may gather under a bigger tent for education, community, and for the betterment of care for our patients.
We extend a welcome to Eric Howell, MD, who succeeds Dr. Wellikson as SHM’s CEO. We also welcome Danielle Scheurer, MD, as the new SHM president, succeeding the great leadership offered this past year by Christopher Frost, MD. In addition, Jerome C. Siy, MD, was voted president-elect, Dr. Rachel Thompson, MD, was elected treasurer, Kris Rehm, MD, was voted secretary, and Darlene Tad-y, MD, was elected to the board of directors. We welcome these new officers.
HM20 Virtual will consist of prerecorded on-demand sessions that can be viewed at your convenience as well as live Q&A and attendee networking that will take place during specific dates/times. A few of the top-rated sessions from our historically popular tracks include: Update in Clinical Practice Guidelines, Antibiotics Made Ridiculously Simple, Getting to Know Oncology Emergencies, Inpatient Pain Management in the Era of the Opioid Epidemic, Updates in Heart Failure, and Hyponatremia: Don’t Drink the Water. Additionally, we have some of our perennial favorites including the Update in Hospital Medicine and Top Pediatric Articles of 2019. There will be COVID-19 specific content from expertise throughout the nation focusing on care pathways, clinical updates, telemedicine, point-of-care ultrasound, and more! To view the HM20 Virtual Opening Session and discover what you can expect in this educational experience, click here.
The Journal of Hospital Medicine has had a large presence in our meetings for many years. We are grateful for Samir Shah, MD, and his leadership during this double pandemic, for identifying areas where we can advance the field responsibly in the face of relatively limited evidence, and rapidly evolving news. As part of his commitment, all JHM articles related to COVID-19 and published during the pandemic are open access. A pre-COVID goal that has been realized during the pandemic was to bring more of the journal into our annual conference and the conference contents into the journal. We are proud to say this has been a great collaboration, particularly during this pandemic, and much thanks to Dr. Shah’s leadership for highlighting timely pieces. Kimberly Manning, MD, had an especially powerful piece on the topic of racism and our double pandemic, and she is a featured speaker during our HM20 Virtual offering, under the same title as her article: “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Additionally, Manpreet Malik, MD, and I will be copresenting on a timely topic about the “Immigrant Hospitalist during COVID-19.”
Aside from these sessions for HM20 Virtual, the real can’t miss(es) for the conference are the Research, Innovations, and Clinical Vignette (RIV) posters sessions. I am grateful for the leadership of Stephanie Mueller, MD, who served as chair for this year’s RIV. This unique year has led to the hosting of a virtual poster competition with judging and the opening of a virtual gallery. We are so pleased to be able to share and highlight the work of many of learners and staff hospitalists! I love that a hospitalist on one side of the country can help provide pearls on a case, an innovation, or a research idea that can help improve diagnosis for a patient at the other side of the country. Keep an eye on SHM’s social media and the presentation by Dr. Mueller for announcements of the winners.
A favorite reason many of us attend the annual conference is for the people and community. We wanted to keep this value as we shifted to a virtual offering. Networking will occur through a variety of offerings including Simulive sessions and Special Interest Forums. Simulive sessions will run for 3 weeks from August 11 to August 27. For those of you new to the term, Simulive may sound like a made-up word, but it is an actual amalgamation of a prerecorded webinar and a live interaction (simulated + live = Simulive). Simulive allows the faculty to sit in on their prerecorded session and interact with the audience via the chat feature during the live scheduled recording and spend time afterwards for a live Q&A from the audience.
There will also be over 20 Special Interest Forums hosted in the evenings after these Simulive sessions have concluded to give you a chance to connect with individuals, share experiences, and have meaningful discussions that can directly impact your practice. Samples of the forums include: Diversity and Inclusion, Rural Hospital Medicine, Pediatrics, NP/PA, Perioperative and Comanagement, Health Information Technology, and Point of Care Ultrasound! Take a look at the HM20 registration page for further information. You will receive direct information on how to attend. We encourage you to join!
HM20 also features a virtual 5K! Whether you run on a treadmill or jog in your neighborhood or local park, you can participate in HM20’s Virtual Fun Run or Walk. To participate, simply run your 5K during the weeks of HM20 Virtual and when you’re done, fill out our form to log your time. We encourage you to post a picture on social media as well with #HM20Virtual. You’ll also receive a certificate of completion at the close of HM20 Virtual.
All HM20 Virtual sessions will be available as on-demand after August 31. HM20 virtual offers more than 60 CME hours and over 35 MOC hours that you can claim at your convenience! That’s the most amount of CME and MOC ever offered at SHM for an event! This conference would not be possible without the tireless and relentless effort of SHM staff and leadership, our terrific speakers and faculty, and all the volunteer committee members of SHM. A huge thanks to the Annual Conference Committee who had the charge to develop the content for the Annual Conference, including topics, speakers, and learning objectives. I am grateful to have had the opportunity to serve on this committee for the past 7 years and to lead HM20 this year. Thanks to Brittany Evans, Hayleigh Lawrence, and Michelle Kann for their valued support this past year from an SHM staff perspective; to my assistant course director, Dan Steinberg, MD; and to the immediate past course director, Dustin Smith, MD, for their support.
Once again, we are excited to have you join, and we hope this conference elevates your education in hospital medicine, advances your career, stimulates innovative thinking, and provides you with enduring networking opportunities. We sincerely thank you for attending HM20 Virtual. Welcome!
Dr. Mathews is chief of hospital medicine at Regions Hospital, HealthPartners in St. Paul, Minn., an associate professor at the University of Minnesota, Minneapolis, and course director of HM20.
Cognitive impairment in 9/11 responders tied to brain atrophy
, suggest results from the first structural neuroimaging study conducted in this population. The study clarifies that a neurodegenerative condition is present in first responders who experience cognitive impairment in midlife, which “is incredibly important to know,” said lead author Sean Clouston, PhD, of Stony Brook (N.Y.) University.
The findings were presented at the virtual annual meeting of the Alzheimer’s Association International Conference and were published online in Alzheimer’s and Dementia: Diagnosis, Assessment and Disease Monitoring.
Brain atrophy in midlife
During the 9/11 attack and in its aftermath, WTC responders were exposed to a range of inhaled neurotoxicants, as well as extreme psychosocial stressors. A growing number of WTC responders who are now in their 50s and early 60s are experiencing early cognitive impairment.
Using MRI, the investigators examined cortical thickness (CTX), a surrogate marker for neurodegeneration, in 99 mostly male WTC responders; 48 had cognitive impairment, and 51 did not. The age range of the participants was 45 to 65 years, a range during which cortical atrophy is uncommon in the general population, the researchers noted.
Compared with cognitively normal responders, those with cognitive impairment were found to have reductions in CTX across the whole brain and across 21 of 34 cortical regions, including frontal, temporal, and occipital lobes.
In both cognitively impaired and cognitively unimpaired WTC responders, CTX was reduced in the entorhinal and temporal cortices compared with normative data, but reductions were greater with cognitive impairment. Posttraumatic distress disorder (PTSD) status was not predictive of a reduction in CTX across groups.
Dr. Clouston said the level of reduction in CTX in many responders is similar to that commonly found in patients with dementia and may reflect early-stage dementia occurring in midlife.
Limitations of the study include the small sample size, the cross-sectional design, the unique nature of the exposure, and a lack of a non-WTC external control group.
‘Illuminating’ study
Keith N. Fargo, PhD, director of scientific engagement for the Alzheimer’s Association, called the findings “interesting and illuminating” but cautioned that it is not possible to show cause and effect with this type of study.
“We also don’t know when cortical thinning might have started or how quickly it might be progressing,” Dr. Fargo said in an interview.
He noted that the pattern of cortical thinning is “somewhat consistent with what we see among people who live with high levels of air pollution, which is an emerging risk factor for Alzheimer’s disease and other dementias.”
The Lancet Commission on Dementia Prevention, Intervention, and Care added air pollution to its list of modifiable risk factors for dementia, which was recently updated.
Clinicians “need to be aware that their middle-aged 9/11 first responders are at a higher risk level for cognitive impairment, as well as PTSD and depression,” Dr. Fargo said.
The study was funded by the Centers for Disease Control and Prevention and the National Institute on Aging. Dr. Clouston and Dr. Fargo have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
, suggest results from the first structural neuroimaging study conducted in this population. The study clarifies that a neurodegenerative condition is present in first responders who experience cognitive impairment in midlife, which “is incredibly important to know,” said lead author Sean Clouston, PhD, of Stony Brook (N.Y.) University.
The findings were presented at the virtual annual meeting of the Alzheimer’s Association International Conference and were published online in Alzheimer’s and Dementia: Diagnosis, Assessment and Disease Monitoring.
Brain atrophy in midlife
During the 9/11 attack and in its aftermath, WTC responders were exposed to a range of inhaled neurotoxicants, as well as extreme psychosocial stressors. A growing number of WTC responders who are now in their 50s and early 60s are experiencing early cognitive impairment.
Using MRI, the investigators examined cortical thickness (CTX), a surrogate marker for neurodegeneration, in 99 mostly male WTC responders; 48 had cognitive impairment, and 51 did not. The age range of the participants was 45 to 65 years, a range during which cortical atrophy is uncommon in the general population, the researchers noted.
Compared with cognitively normal responders, those with cognitive impairment were found to have reductions in CTX across the whole brain and across 21 of 34 cortical regions, including frontal, temporal, and occipital lobes.
In both cognitively impaired and cognitively unimpaired WTC responders, CTX was reduced in the entorhinal and temporal cortices compared with normative data, but reductions were greater with cognitive impairment. Posttraumatic distress disorder (PTSD) status was not predictive of a reduction in CTX across groups.
Dr. Clouston said the level of reduction in CTX in many responders is similar to that commonly found in patients with dementia and may reflect early-stage dementia occurring in midlife.
Limitations of the study include the small sample size, the cross-sectional design, the unique nature of the exposure, and a lack of a non-WTC external control group.
‘Illuminating’ study
Keith N. Fargo, PhD, director of scientific engagement for the Alzheimer’s Association, called the findings “interesting and illuminating” but cautioned that it is not possible to show cause and effect with this type of study.
“We also don’t know when cortical thinning might have started or how quickly it might be progressing,” Dr. Fargo said in an interview.
He noted that the pattern of cortical thinning is “somewhat consistent with what we see among people who live with high levels of air pollution, which is an emerging risk factor for Alzheimer’s disease and other dementias.”
The Lancet Commission on Dementia Prevention, Intervention, and Care added air pollution to its list of modifiable risk factors for dementia, which was recently updated.
Clinicians “need to be aware that their middle-aged 9/11 first responders are at a higher risk level for cognitive impairment, as well as PTSD and depression,” Dr. Fargo said.
The study was funded by the Centers for Disease Control and Prevention and the National Institute on Aging. Dr. Clouston and Dr. Fargo have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
, suggest results from the first structural neuroimaging study conducted in this population. The study clarifies that a neurodegenerative condition is present in first responders who experience cognitive impairment in midlife, which “is incredibly important to know,” said lead author Sean Clouston, PhD, of Stony Brook (N.Y.) University.
The findings were presented at the virtual annual meeting of the Alzheimer’s Association International Conference and were published online in Alzheimer’s and Dementia: Diagnosis, Assessment and Disease Monitoring.
Brain atrophy in midlife
During the 9/11 attack and in its aftermath, WTC responders were exposed to a range of inhaled neurotoxicants, as well as extreme psychosocial stressors. A growing number of WTC responders who are now in their 50s and early 60s are experiencing early cognitive impairment.
Using MRI, the investigators examined cortical thickness (CTX), a surrogate marker for neurodegeneration, in 99 mostly male WTC responders; 48 had cognitive impairment, and 51 did not. The age range of the participants was 45 to 65 years, a range during which cortical atrophy is uncommon in the general population, the researchers noted.
Compared with cognitively normal responders, those with cognitive impairment were found to have reductions in CTX across the whole brain and across 21 of 34 cortical regions, including frontal, temporal, and occipital lobes.
In both cognitively impaired and cognitively unimpaired WTC responders, CTX was reduced in the entorhinal and temporal cortices compared with normative data, but reductions were greater with cognitive impairment. Posttraumatic distress disorder (PTSD) status was not predictive of a reduction in CTX across groups.
Dr. Clouston said the level of reduction in CTX in many responders is similar to that commonly found in patients with dementia and may reflect early-stage dementia occurring in midlife.
Limitations of the study include the small sample size, the cross-sectional design, the unique nature of the exposure, and a lack of a non-WTC external control group.
‘Illuminating’ study
Keith N. Fargo, PhD, director of scientific engagement for the Alzheimer’s Association, called the findings “interesting and illuminating” but cautioned that it is not possible to show cause and effect with this type of study.
“We also don’t know when cortical thinning might have started or how quickly it might be progressing,” Dr. Fargo said in an interview.
He noted that the pattern of cortical thinning is “somewhat consistent with what we see among people who live with high levels of air pollution, which is an emerging risk factor for Alzheimer’s disease and other dementias.”
The Lancet Commission on Dementia Prevention, Intervention, and Care added air pollution to its list of modifiable risk factors for dementia, which was recently updated.
Clinicians “need to be aware that their middle-aged 9/11 first responders are at a higher risk level for cognitive impairment, as well as PTSD and depression,” Dr. Fargo said.
The study was funded by the Centers for Disease Control and Prevention and the National Institute on Aging. Dr. Clouston and Dr. Fargo have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
From AAIC 2020
Patent foramen ovale linked with increased risk of ischemic stroke in PE
Background: Studies have demonstrated the increased risk for ischemic stroke in patients diagnosed with acute PE, and data support the mechanism of paradoxical embolism via PFO. However, the frequency of this phenomenon is unknown and the strength of the association between PFO and ischemic stroke in patients with PE is unclear.
Study design: Prospective cohort study.
Setting: Four French hospitals.
Synopsis: 315 patients aged 18 years and older presenting with acute symptomatic PE were evaluated at the time of diagnosis for PFO with contrast transthoracic echocardiography and for ischemic stroke with cerebral magnetic resonance imaging. The overall frequency of ischemic stroke at the time of PE diagnosis was high (7.6%), and was nearly four times higher in the PFO group than the non-PFO group (21.4% vs. 5.5%; difference in proportions, 15.9 percentage points; 95% confidence interval, 4.7-30.7).
This study adds to the growing body of data which supports the association of ischemic stroke with PFO and PE. Given the moderate indication for indefinite anticoagulation in patients at high risk for recurrent PE and stroke, there may be a role for screening for PFO in patients with acute PE so that they can be appropriately risk stratified.
Bottom line: The presence of ischemic stroke in patients with acute pulmonary embolism is high, and there is a strong association with PFO.
Citation: Le Moigne E et al. Patent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism: A Prospective Cohort Study. Ann Intern Med. 2019;170:756-63.
Dr. McIntyre is a hospitalist at Ochsner Health System, New Orleans.
Background: Studies have demonstrated the increased risk for ischemic stroke in patients diagnosed with acute PE, and data support the mechanism of paradoxical embolism via PFO. However, the frequency of this phenomenon is unknown and the strength of the association between PFO and ischemic stroke in patients with PE is unclear.
Study design: Prospective cohort study.
Setting: Four French hospitals.
Synopsis: 315 patients aged 18 years and older presenting with acute symptomatic PE were evaluated at the time of diagnosis for PFO with contrast transthoracic echocardiography and for ischemic stroke with cerebral magnetic resonance imaging. The overall frequency of ischemic stroke at the time of PE diagnosis was high (7.6%), and was nearly four times higher in the PFO group than the non-PFO group (21.4% vs. 5.5%; difference in proportions, 15.9 percentage points; 95% confidence interval, 4.7-30.7).
This study adds to the growing body of data which supports the association of ischemic stroke with PFO and PE. Given the moderate indication for indefinite anticoagulation in patients at high risk for recurrent PE and stroke, there may be a role for screening for PFO in patients with acute PE so that they can be appropriately risk stratified.
Bottom line: The presence of ischemic stroke in patients with acute pulmonary embolism is high, and there is a strong association with PFO.
Citation: Le Moigne E et al. Patent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism: A Prospective Cohort Study. Ann Intern Med. 2019;170:756-63.
Dr. McIntyre is a hospitalist at Ochsner Health System, New Orleans.
Background: Studies have demonstrated the increased risk for ischemic stroke in patients diagnosed with acute PE, and data support the mechanism of paradoxical embolism via PFO. However, the frequency of this phenomenon is unknown and the strength of the association between PFO and ischemic stroke in patients with PE is unclear.
Study design: Prospective cohort study.
Setting: Four French hospitals.
Synopsis: 315 patients aged 18 years and older presenting with acute symptomatic PE were evaluated at the time of diagnosis for PFO with contrast transthoracic echocardiography and for ischemic stroke with cerebral magnetic resonance imaging. The overall frequency of ischemic stroke at the time of PE diagnosis was high (7.6%), and was nearly four times higher in the PFO group than the non-PFO group (21.4% vs. 5.5%; difference in proportions, 15.9 percentage points; 95% confidence interval, 4.7-30.7).
This study adds to the growing body of data which supports the association of ischemic stroke with PFO and PE. Given the moderate indication for indefinite anticoagulation in patients at high risk for recurrent PE and stroke, there may be a role for screening for PFO in patients with acute PE so that they can be appropriately risk stratified.
Bottom line: The presence of ischemic stroke in patients with acute pulmonary embolism is high, and there is a strong association with PFO.
Citation: Le Moigne E et al. Patent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism: A Prospective Cohort Study. Ann Intern Med. 2019;170:756-63.
Dr. McIntyre is a hospitalist at Ochsner Health System, New Orleans.