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Can a Saliva Test Provide a New Biomarker for MS?
PARIS—A noninvasive test that assesses immunoglobulin (Ig) free light chains in saliva may detect immunopathologic changes in the multiple sclerosis (MS) disease state and evaluate response to treatment, according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. The technique has a specificity of 80% and sensitivity of 89% for diagnosing active MS, said lead author Esther Ganelin-Cohen, MD, PhD, Director of the Neuro-Immunology Clinic at Schneider Children’s Medical Center of Israel, Petach Tikva, Israel, on behalf of her research colleagues.
The complexity of MS requires different biomarkers to evaluate the various aspects of the disease. CSF analysis is commonly used, but the need for lumbar puncture makes CSF tests impractical for monitoring disease activity and response to treatment. In their search for noninvasive diagnostic methods, Dr. Ganelin-Cohen and colleagues hypothesized that Ig free light chain analysis in saliva may help detect immunopathologic changes in patients with MS. This assumption relied on prior reports indicating changes in mucosal immunity in patients with MS, and on a growing body of evidence for a potential diagnostic role of free light chains in MS.
A new technique based on Western blot analysis was developed to study kappa (k) and lambda (λ) free light chain monomers and dimers in saliva. Normal saliva showed high proportion of dimeric free light chains compared to that in the serum. “This finding might be explained by structural peculiarities of Ig in saliva,” Dr. Ganelin-Cohen said. “In contrast to most serum Ig, saliva IgA2 molecules incorporate the dimeric (not monomeric) light chains that may require production of larger amounts of dimeric light chains by the B cells synthesizing IgA2.”
Dr. Ganelin-Cohen and her colleagues compared free light chain monomer and dimer patterns in the saliva of patients with MS with those in healthy subjects. The intensity of the immunoreactive free light chain was measured, and the free light chain indices accounting for the total free light chain level and for monomer/dimer ratios (k monomer/dimer index and λ monomer/dimer index) were computed.
Most patients with active MS showed abnormally high free light chain levels, or a high proportion of monomeric free light chains. The reasons for such pathologic free light chain changes in patients with active MS are not clear, but they might be due to peripheral B lymphocytes penetrating oral mucosa and producing larger amounts of monomeric free light chains. Statistical analysis of these indices showed significant differences not only between patients with active MS (n = 27) and healthy subjects (n = 28), but also between patients with active MS (n = 27) and those in remission (n = 58).
Cut-off values were established to distinguish a healthy state from the pathologic conditions in MS: total free light chain level index = 17, k monomer/dimer index = 4.0, λ monomer/dimer index = 2.4. Most patients with active MS showed free light chain indices above these cut-off values.
The high specificity and sensitivity of the technique for diagnosing active MS enable this test to become a new noninvasive complementary tool to evaluate MS, Dr. Ganelin-Cohen and colleagues concluded.
PARIS—A noninvasive test that assesses immunoglobulin (Ig) free light chains in saliva may detect immunopathologic changes in the multiple sclerosis (MS) disease state and evaluate response to treatment, according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. The technique has a specificity of 80% and sensitivity of 89% for diagnosing active MS, said lead author Esther Ganelin-Cohen, MD, PhD, Director of the Neuro-Immunology Clinic at Schneider Children’s Medical Center of Israel, Petach Tikva, Israel, on behalf of her research colleagues.
The complexity of MS requires different biomarkers to evaluate the various aspects of the disease. CSF analysis is commonly used, but the need for lumbar puncture makes CSF tests impractical for monitoring disease activity and response to treatment. In their search for noninvasive diagnostic methods, Dr. Ganelin-Cohen and colleagues hypothesized that Ig free light chain analysis in saliva may help detect immunopathologic changes in patients with MS. This assumption relied on prior reports indicating changes in mucosal immunity in patients with MS, and on a growing body of evidence for a potential diagnostic role of free light chains in MS.
A new technique based on Western blot analysis was developed to study kappa (k) and lambda (λ) free light chain monomers and dimers in saliva. Normal saliva showed high proportion of dimeric free light chains compared to that in the serum. “This finding might be explained by structural peculiarities of Ig in saliva,” Dr. Ganelin-Cohen said. “In contrast to most serum Ig, saliva IgA2 molecules incorporate the dimeric (not monomeric) light chains that may require production of larger amounts of dimeric light chains by the B cells synthesizing IgA2.”
Dr. Ganelin-Cohen and her colleagues compared free light chain monomer and dimer patterns in the saliva of patients with MS with those in healthy subjects. The intensity of the immunoreactive free light chain was measured, and the free light chain indices accounting for the total free light chain level and for monomer/dimer ratios (k monomer/dimer index and λ monomer/dimer index) were computed.
Most patients with active MS showed abnormally high free light chain levels, or a high proportion of monomeric free light chains. The reasons for such pathologic free light chain changes in patients with active MS are not clear, but they might be due to peripheral B lymphocytes penetrating oral mucosa and producing larger amounts of monomeric free light chains. Statistical analysis of these indices showed significant differences not only between patients with active MS (n = 27) and healthy subjects (n = 28), but also between patients with active MS (n = 27) and those in remission (n = 58).
Cut-off values were established to distinguish a healthy state from the pathologic conditions in MS: total free light chain level index = 17, k monomer/dimer index = 4.0, λ monomer/dimer index = 2.4. Most patients with active MS showed free light chain indices above these cut-off values.
The high specificity and sensitivity of the technique for diagnosing active MS enable this test to become a new noninvasive complementary tool to evaluate MS, Dr. Ganelin-Cohen and colleagues concluded.
PARIS—A noninvasive test that assesses immunoglobulin (Ig) free light chains in saliva may detect immunopathologic changes in the multiple sclerosis (MS) disease state and evaluate response to treatment, according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. The technique has a specificity of 80% and sensitivity of 89% for diagnosing active MS, said lead author Esther Ganelin-Cohen, MD, PhD, Director of the Neuro-Immunology Clinic at Schneider Children’s Medical Center of Israel, Petach Tikva, Israel, on behalf of her research colleagues.
The complexity of MS requires different biomarkers to evaluate the various aspects of the disease. CSF analysis is commonly used, but the need for lumbar puncture makes CSF tests impractical for monitoring disease activity and response to treatment. In their search for noninvasive diagnostic methods, Dr. Ganelin-Cohen and colleagues hypothesized that Ig free light chain analysis in saliva may help detect immunopathologic changes in patients with MS. This assumption relied on prior reports indicating changes in mucosal immunity in patients with MS, and on a growing body of evidence for a potential diagnostic role of free light chains in MS.
A new technique based on Western blot analysis was developed to study kappa (k) and lambda (λ) free light chain monomers and dimers in saliva. Normal saliva showed high proportion of dimeric free light chains compared to that in the serum. “This finding might be explained by structural peculiarities of Ig in saliva,” Dr. Ganelin-Cohen said. “In contrast to most serum Ig, saliva IgA2 molecules incorporate the dimeric (not monomeric) light chains that may require production of larger amounts of dimeric light chains by the B cells synthesizing IgA2.”
Dr. Ganelin-Cohen and her colleagues compared free light chain monomer and dimer patterns in the saliva of patients with MS with those in healthy subjects. The intensity of the immunoreactive free light chain was measured, and the free light chain indices accounting for the total free light chain level and for monomer/dimer ratios (k monomer/dimer index and λ monomer/dimer index) were computed.
Most patients with active MS showed abnormally high free light chain levels, or a high proportion of monomeric free light chains. The reasons for such pathologic free light chain changes in patients with active MS are not clear, but they might be due to peripheral B lymphocytes penetrating oral mucosa and producing larger amounts of monomeric free light chains. Statistical analysis of these indices showed significant differences not only between patients with active MS (n = 27) and healthy subjects (n = 28), but also between patients with active MS (n = 27) and those in remission (n = 58).
Cut-off values were established to distinguish a healthy state from the pathologic conditions in MS: total free light chain level index = 17, k monomer/dimer index = 4.0, λ monomer/dimer index = 2.4. Most patients with active MS showed free light chain indices above these cut-off values.
The high specificity and sensitivity of the technique for diagnosing active MS enable this test to become a new noninvasive complementary tool to evaluate MS, Dr. Ganelin-Cohen and colleagues concluded.
Cancer patients prefer no computer at physician visit
Patients with cancer perceived physicians who did not use a computer as more compassionate, more professional, and better at communication, according to results of a randomized, video-based study presented at the Palliative and Supportive Care in Oncology Symposium.
In addition, the majority of patients said they would prefer having a doctor who communicated face to face (in other words, without aid of a computer) to be their provider, said Ali Haider, MD, of the University of Texas MD Anderson Cancer Center, Houston.
This is one of the few, if not only, studies to evaluate how the presence of a computer affects exam room interactions between physicians and patients, Dr. Haider said in a press conference held during the meeting.
To test the impact of the computer in the exam room, Dr. Haider and his colleagues created four different 3-minute video vignettes featuring two different actors playing physicians in an encounter with a patient. Each actor created one video in which he used a computer and one in which he did not. To minimize potential bias, the videos had identical scripts, and actors were careful to use the same gestures, expressions, and nonverbal communication in each video.
A total of 120 cancer patients were randomized to view two of the videos and fill out validated questionnaires rating their perception of the physician’s compassion, communication skills, and professionalism.
The face-to-face clinical encounter videos were associated with a median compassion score of 9 on a scale of 0-50 where 0 is best and 50 is worst; by comparison, the encounters with computers scored worse, at a median of 20 out of 50 (P = .0003). Likewise, the patients rated the face-to-face encounter videos significantly higher on communication skills (P = .0001) and professionalism (P = .013).
After watching both videos, the patients were asked which encounter they would personally prefer, and 86 (72%) said they liked the face-to-face communication video better.
Actors and patients were all blinded to the purpose of the study, according to the researchers.
Further research is required to confirm these findings in other clinical settings and populations, according to Dr. Haider.
“We believe these results may be different if we choose a younger population, or patients with high computer literacy,” he explained.
While more research may be needed, “face-to-face communication seems quite possibly the preferred route, despite the pressures clinicians have to search and document in the medical record,” said medical oncologist Andrew S. Epstein, MD, of Memorial Sloan Kettering Cancer Center, New York, who was not involved with the study.
“In an age of ubiquitous technology, this study is an important reminder of the need to address the potential for technology to interfere with the patient-physician interface,” said Dr. Epstein, who moderated the press conference from the palliative care symposium, which was cosponsored by AAHPM, ASCO, ASTRO, and MASCC.
Patients with cancer perceived physicians who did not use a computer as more compassionate, more professional, and better at communication, according to results of a randomized, video-based study presented at the Palliative and Supportive Care in Oncology Symposium.
In addition, the majority of patients said they would prefer having a doctor who communicated face to face (in other words, without aid of a computer) to be their provider, said Ali Haider, MD, of the University of Texas MD Anderson Cancer Center, Houston.
This is one of the few, if not only, studies to evaluate how the presence of a computer affects exam room interactions between physicians and patients, Dr. Haider said in a press conference held during the meeting.
To test the impact of the computer in the exam room, Dr. Haider and his colleagues created four different 3-minute video vignettes featuring two different actors playing physicians in an encounter with a patient. Each actor created one video in which he used a computer and one in which he did not. To minimize potential bias, the videos had identical scripts, and actors were careful to use the same gestures, expressions, and nonverbal communication in each video.
A total of 120 cancer patients were randomized to view two of the videos and fill out validated questionnaires rating their perception of the physician’s compassion, communication skills, and professionalism.
The face-to-face clinical encounter videos were associated with a median compassion score of 9 on a scale of 0-50 where 0 is best and 50 is worst; by comparison, the encounters with computers scored worse, at a median of 20 out of 50 (P = .0003). Likewise, the patients rated the face-to-face encounter videos significantly higher on communication skills (P = .0001) and professionalism (P = .013).
After watching both videos, the patients were asked which encounter they would personally prefer, and 86 (72%) said they liked the face-to-face communication video better.
Actors and patients were all blinded to the purpose of the study, according to the researchers.
Further research is required to confirm these findings in other clinical settings and populations, according to Dr. Haider.
“We believe these results may be different if we choose a younger population, or patients with high computer literacy,” he explained.
While more research may be needed, “face-to-face communication seems quite possibly the preferred route, despite the pressures clinicians have to search and document in the medical record,” said medical oncologist Andrew S. Epstein, MD, of Memorial Sloan Kettering Cancer Center, New York, who was not involved with the study.
“In an age of ubiquitous technology, this study is an important reminder of the need to address the potential for technology to interfere with the patient-physician interface,” said Dr. Epstein, who moderated the press conference from the palliative care symposium, which was cosponsored by AAHPM, ASCO, ASTRO, and MASCC.
Patients with cancer perceived physicians who did not use a computer as more compassionate, more professional, and better at communication, according to results of a randomized, video-based study presented at the Palliative and Supportive Care in Oncology Symposium.
In addition, the majority of patients said they would prefer having a doctor who communicated face to face (in other words, without aid of a computer) to be their provider, said Ali Haider, MD, of the University of Texas MD Anderson Cancer Center, Houston.
This is one of the few, if not only, studies to evaluate how the presence of a computer affects exam room interactions between physicians and patients, Dr. Haider said in a press conference held during the meeting.
To test the impact of the computer in the exam room, Dr. Haider and his colleagues created four different 3-minute video vignettes featuring two different actors playing physicians in an encounter with a patient. Each actor created one video in which he used a computer and one in which he did not. To minimize potential bias, the videos had identical scripts, and actors were careful to use the same gestures, expressions, and nonverbal communication in each video.
A total of 120 cancer patients were randomized to view two of the videos and fill out validated questionnaires rating their perception of the physician’s compassion, communication skills, and professionalism.
The face-to-face clinical encounter videos were associated with a median compassion score of 9 on a scale of 0-50 where 0 is best and 50 is worst; by comparison, the encounters with computers scored worse, at a median of 20 out of 50 (P = .0003). Likewise, the patients rated the face-to-face encounter videos significantly higher on communication skills (P = .0001) and professionalism (P = .013).
After watching both videos, the patients were asked which encounter they would personally prefer, and 86 (72%) said they liked the face-to-face communication video better.
Actors and patients were all blinded to the purpose of the study, according to the researchers.
Further research is required to confirm these findings in other clinical settings and populations, according to Dr. Haider.
“We believe these results may be different if we choose a younger population, or patients with high computer literacy,” he explained.
While more research may be needed, “face-to-face communication seems quite possibly the preferred route, despite the pressures clinicians have to search and document in the medical record,” said medical oncologist Andrew S. Epstein, MD, of Memorial Sloan Kettering Cancer Center, New York, who was not involved with the study.
“In an age of ubiquitous technology, this study is an important reminder of the need to address the potential for technology to interfere with the patient-physician interface,” said Dr. Epstein, who moderated the press conference from the palliative care symposium, which was cosponsored by AAHPM, ASCO, ASTRO, and MASCC.
AT PALLONC 2017
Key clinical point: Patients rate physicians who communicate face to face, without using a computer, as more compassionate, more professional, and better at communication.
Major finding: A total of 72% of patients preferred videos in which physicians did not use a computer during the conversation.
Data source: Randomized study including 120 adults who watched two short video vignettes depicting two different physician-patient encounters.
Disclosures: Dr. Haider reported no disclosures. The study was funded by the University of Texas MD Anderson Cancer Center.
Sunburn Purpura
To the Editor:
Chronic UV exposure has been linked to increased skin fragility and the development of purpuric lesions, a benign condition known as actinic purpura and commonly seen in elderly patients. Petechial skin changes acutely following intense sun exposure is a rare phenomenon referred to as sunburn purpura, photolocalized purpura, or solar purpura.
A 19-year-old woman presented with red and purple spots on the pretibial region of both legs extending to the thigh. One week prior to presentation she had a severe sunburn affecting most of the body, which resolved without blistering. Two days later, the spots appeared within the most severely sunburned areas of both legs. The patient reported that the lesions were mildly painful to palpation, but she was more concerned about the appearance. She denied any history of similar skin changes associated with sun exposure. The patient was otherwise healthy and denied any recent illnesses. She noted a history of mild bruising and bleeding with a resulting unremarkable workup by her primary care physician. The only medication taken was etonogestrel-ethinyl estradiol vaginal ring.
The scalp, face, arms, trunk, and legs were examined, and nonpalpable petechial changes were noted on the anterior aspect of the legs (Figure 1), with changes more prominent on the distal aspect of the legs. Mild superficial epidermal exfoliation was noted on both anterior thighs. The area of the lesions was not warm. The lesions were mildly tender to palpation. The remainder of the physical examination was unremarkable.
Given the timing of onset, preceding sun exposure, and the morphologic characteristics of the lesions, sunburn purpura was suspected. A punch biopsy of the anterior aspect of the left thigh was performed to rule out vasculitis. Microscopic examination revealed reactive epidermal changes with mild vascular ectasia and erythrocyte extravasation not associated with appreciable inflammation or evidence of vascular injury (Figure 2). Biopsy exposure to fluorescein-labeled antibodies directed against IgG, IgM, IgA, C3, and polyvalent immunoglobulins (IgG, IgM, and IgA) yielded no immunofluorescence. These biopsy results were consistent with sunburn purpura. Given the patient's normal platelet count, a diagnosis of idiopathic sunburn purpura was made. The patient was informed of the biopsy results and advised that the petechiae should resolve without treatment in 1 to 2 weeks, which occurred.
Sunburn purpura remains a rare phenomenon in which a petechial or purpuric rash develops acutely after intense sun exposure. We prefer the term sunburn purpura because it reflects the acuity of the phenomenon, as opposed to the previous labels solar purpura or photolocalized purpura, which also could suggest causality from chronic sun exposure. It has been proposed that sunburn purpura is a finding associated with a number of conditions rather than a unique entity.1 The following characteristics can be helpful in describing the development of sunburn purpura: delay following UV exposure, gross morphology, histologic findings, and possible associated medical conditions.1 Our case represents an important addition to the literature, as it differs from previously reported cases. Most importantly, the nonspecific biopsy findings and unremarkable laboratory findings associated with our case may represent primary or idiopathic sunburn purpura.
Previously reported cases of sunburn purpura have occurred in patients aged 10 to 66 years. It has been seen following UV exposure, vigorous exercise and high-dose aspirin, or concurrent fluoroquinolone therapy, or in the setting of erythropoietic protoporphyria, idiopathic thrombocytopenic purpura, or polymorphous light eruption.2-8 When performed, histology has revealed capillaritis, solar elastosis, perivascular infiltrate, lymphocytic perivascular infiltrate with dermal edema, or leukocytoclastic vasculitis.1,2,7-9 Our patient did not have a history of erythropoietic protoporphyria, polymorphous light eruption, or idiopathic thrombocytopenic purpura. She had not recently exercised, was not thrombocytopenic, and was not taking antiplatelet medications. She had no recent history of fluoroquinolone use. On histologic examination, our patient's biopsy demonstrated nonspecific petechial changes without signs of chronic UV exposure, dermal edema, vasculitis, lymphocytic infiltrate, or capillaritis.
Idiopathic sunburn purpura should only be diagnosed after other conditions are excluded. When evaluating a patient who presents with new-onset petechial rash following sun exposure, it is important to rule out vasculitis or thrombocytopenia as the cause, which is best achieved through skin biopsy and a platelet count, respectively. If there are no associated symptoms or thrombocytopenia and biopsy shows nonspecific vascular ectasia and erythrocyte extravasation, the physician should consider the diagnosis of idiopathic sunburn (solar or photolocalized) purpura. Along with regular UV protection, the physician should advise that the rash typically resolves without treatment in 1 to 2 weeks.
- Waters AJ, Sandhu DR, Green CM, et al. Solar capillaritis as a cause of solar purpura. Clin Exp Dermatol. 2009;34:E821-E824.
- Latenser BA, Hempstead RW. Exercise-associated solar purpura in an atypical location. Cutis. 1985;35:365-366.
- Rubegni P, Feci L, Pellegrino M, et al. Photolocalized purpura during levofloxacin therapy. Photodermatol Photoimmunol Photomed. 2012;28:105-107.
- Urbina F, Barrios M, Sudy E. Photolocalized purpura during ciprofloxacin therapy. Photodermatol Photoimmunol Photomed. 2006;22:111-112.
- Torinuki W, Miura T. Erythropoietic protoporphyria showing solar purpura. Dermatologica. 1983;167:220-222.
- Leung AK. Purpura associated with exposure to sunlight. J R Soc Med. 1986;79:423-424.
- Kalivas J, Kalivas L. Solar purpura appearing in a patient with polymorphous light eruption. Photodermatol Photoimmunol Photomed. 1995;11:31-32.
- Ros AM. Solar purpura--an unusual manifestation of polymorphous light eruption. Photodermatol. 1988;5:47-48.
- Guarrera M, Parodi A, Rebora A. Solar purpura is not related to polymorphous light eruption. Photodermatol. 1989;6:293-294.
To the Editor:
Chronic UV exposure has been linked to increased skin fragility and the development of purpuric lesions, a benign condition known as actinic purpura and commonly seen in elderly patients. Petechial skin changes acutely following intense sun exposure is a rare phenomenon referred to as sunburn purpura, photolocalized purpura, or solar purpura.
A 19-year-old woman presented with red and purple spots on the pretibial region of both legs extending to the thigh. One week prior to presentation she had a severe sunburn affecting most of the body, which resolved without blistering. Two days later, the spots appeared within the most severely sunburned areas of both legs. The patient reported that the lesions were mildly painful to palpation, but she was more concerned about the appearance. She denied any history of similar skin changes associated with sun exposure. The patient was otherwise healthy and denied any recent illnesses. She noted a history of mild bruising and bleeding with a resulting unremarkable workup by her primary care physician. The only medication taken was etonogestrel-ethinyl estradiol vaginal ring.
The scalp, face, arms, trunk, and legs were examined, and nonpalpable petechial changes were noted on the anterior aspect of the legs (Figure 1), with changes more prominent on the distal aspect of the legs. Mild superficial epidermal exfoliation was noted on both anterior thighs. The area of the lesions was not warm. The lesions were mildly tender to palpation. The remainder of the physical examination was unremarkable.
Given the timing of onset, preceding sun exposure, and the morphologic characteristics of the lesions, sunburn purpura was suspected. A punch biopsy of the anterior aspect of the left thigh was performed to rule out vasculitis. Microscopic examination revealed reactive epidermal changes with mild vascular ectasia and erythrocyte extravasation not associated with appreciable inflammation or evidence of vascular injury (Figure 2). Biopsy exposure to fluorescein-labeled antibodies directed against IgG, IgM, IgA, C3, and polyvalent immunoglobulins (IgG, IgM, and IgA) yielded no immunofluorescence. These biopsy results were consistent with sunburn purpura. Given the patient's normal platelet count, a diagnosis of idiopathic sunburn purpura was made. The patient was informed of the biopsy results and advised that the petechiae should resolve without treatment in 1 to 2 weeks, which occurred.
Sunburn purpura remains a rare phenomenon in which a petechial or purpuric rash develops acutely after intense sun exposure. We prefer the term sunburn purpura because it reflects the acuity of the phenomenon, as opposed to the previous labels solar purpura or photolocalized purpura, which also could suggest causality from chronic sun exposure. It has been proposed that sunburn purpura is a finding associated with a number of conditions rather than a unique entity.1 The following characteristics can be helpful in describing the development of sunburn purpura: delay following UV exposure, gross morphology, histologic findings, and possible associated medical conditions.1 Our case represents an important addition to the literature, as it differs from previously reported cases. Most importantly, the nonspecific biopsy findings and unremarkable laboratory findings associated with our case may represent primary or idiopathic sunburn purpura.
Previously reported cases of sunburn purpura have occurred in patients aged 10 to 66 years. It has been seen following UV exposure, vigorous exercise and high-dose aspirin, or concurrent fluoroquinolone therapy, or in the setting of erythropoietic protoporphyria, idiopathic thrombocytopenic purpura, or polymorphous light eruption.2-8 When performed, histology has revealed capillaritis, solar elastosis, perivascular infiltrate, lymphocytic perivascular infiltrate with dermal edema, or leukocytoclastic vasculitis.1,2,7-9 Our patient did not have a history of erythropoietic protoporphyria, polymorphous light eruption, or idiopathic thrombocytopenic purpura. She had not recently exercised, was not thrombocytopenic, and was not taking antiplatelet medications. She had no recent history of fluoroquinolone use. On histologic examination, our patient's biopsy demonstrated nonspecific petechial changes without signs of chronic UV exposure, dermal edema, vasculitis, lymphocytic infiltrate, or capillaritis.
Idiopathic sunburn purpura should only be diagnosed after other conditions are excluded. When evaluating a patient who presents with new-onset petechial rash following sun exposure, it is important to rule out vasculitis or thrombocytopenia as the cause, which is best achieved through skin biopsy and a platelet count, respectively. If there are no associated symptoms or thrombocytopenia and biopsy shows nonspecific vascular ectasia and erythrocyte extravasation, the physician should consider the diagnosis of idiopathic sunburn (solar or photolocalized) purpura. Along with regular UV protection, the physician should advise that the rash typically resolves without treatment in 1 to 2 weeks.
To the Editor:
Chronic UV exposure has been linked to increased skin fragility and the development of purpuric lesions, a benign condition known as actinic purpura and commonly seen in elderly patients. Petechial skin changes acutely following intense sun exposure is a rare phenomenon referred to as sunburn purpura, photolocalized purpura, or solar purpura.
A 19-year-old woman presented with red and purple spots on the pretibial region of both legs extending to the thigh. One week prior to presentation she had a severe sunburn affecting most of the body, which resolved without blistering. Two days later, the spots appeared within the most severely sunburned areas of both legs. The patient reported that the lesions were mildly painful to palpation, but she was more concerned about the appearance. She denied any history of similar skin changes associated with sun exposure. The patient was otherwise healthy and denied any recent illnesses. She noted a history of mild bruising and bleeding with a resulting unremarkable workup by her primary care physician. The only medication taken was etonogestrel-ethinyl estradiol vaginal ring.
The scalp, face, arms, trunk, and legs were examined, and nonpalpable petechial changes were noted on the anterior aspect of the legs (Figure 1), with changes more prominent on the distal aspect of the legs. Mild superficial epidermal exfoliation was noted on both anterior thighs. The area of the lesions was not warm. The lesions were mildly tender to palpation. The remainder of the physical examination was unremarkable.
Given the timing of onset, preceding sun exposure, and the morphologic characteristics of the lesions, sunburn purpura was suspected. A punch biopsy of the anterior aspect of the left thigh was performed to rule out vasculitis. Microscopic examination revealed reactive epidermal changes with mild vascular ectasia and erythrocyte extravasation not associated with appreciable inflammation or evidence of vascular injury (Figure 2). Biopsy exposure to fluorescein-labeled antibodies directed against IgG, IgM, IgA, C3, and polyvalent immunoglobulins (IgG, IgM, and IgA) yielded no immunofluorescence. These biopsy results were consistent with sunburn purpura. Given the patient's normal platelet count, a diagnosis of idiopathic sunburn purpura was made. The patient was informed of the biopsy results and advised that the petechiae should resolve without treatment in 1 to 2 weeks, which occurred.
Sunburn purpura remains a rare phenomenon in which a petechial or purpuric rash develops acutely after intense sun exposure. We prefer the term sunburn purpura because it reflects the acuity of the phenomenon, as opposed to the previous labels solar purpura or photolocalized purpura, which also could suggest causality from chronic sun exposure. It has been proposed that sunburn purpura is a finding associated with a number of conditions rather than a unique entity.1 The following characteristics can be helpful in describing the development of sunburn purpura: delay following UV exposure, gross morphology, histologic findings, and possible associated medical conditions.1 Our case represents an important addition to the literature, as it differs from previously reported cases. Most importantly, the nonspecific biopsy findings and unremarkable laboratory findings associated with our case may represent primary or idiopathic sunburn purpura.
Previously reported cases of sunburn purpura have occurred in patients aged 10 to 66 years. It has been seen following UV exposure, vigorous exercise and high-dose aspirin, or concurrent fluoroquinolone therapy, or in the setting of erythropoietic protoporphyria, idiopathic thrombocytopenic purpura, or polymorphous light eruption.2-8 When performed, histology has revealed capillaritis, solar elastosis, perivascular infiltrate, lymphocytic perivascular infiltrate with dermal edema, or leukocytoclastic vasculitis.1,2,7-9 Our patient did not have a history of erythropoietic protoporphyria, polymorphous light eruption, or idiopathic thrombocytopenic purpura. She had not recently exercised, was not thrombocytopenic, and was not taking antiplatelet medications. She had no recent history of fluoroquinolone use. On histologic examination, our patient's biopsy demonstrated nonspecific petechial changes without signs of chronic UV exposure, dermal edema, vasculitis, lymphocytic infiltrate, or capillaritis.
Idiopathic sunburn purpura should only be diagnosed after other conditions are excluded. When evaluating a patient who presents with new-onset petechial rash following sun exposure, it is important to rule out vasculitis or thrombocytopenia as the cause, which is best achieved through skin biopsy and a platelet count, respectively. If there are no associated symptoms or thrombocytopenia and biopsy shows nonspecific vascular ectasia and erythrocyte extravasation, the physician should consider the diagnosis of idiopathic sunburn (solar or photolocalized) purpura. Along with regular UV protection, the physician should advise that the rash typically resolves without treatment in 1 to 2 weeks.
- Waters AJ, Sandhu DR, Green CM, et al. Solar capillaritis as a cause of solar purpura. Clin Exp Dermatol. 2009;34:E821-E824.
- Latenser BA, Hempstead RW. Exercise-associated solar purpura in an atypical location. Cutis. 1985;35:365-366.
- Rubegni P, Feci L, Pellegrino M, et al. Photolocalized purpura during levofloxacin therapy. Photodermatol Photoimmunol Photomed. 2012;28:105-107.
- Urbina F, Barrios M, Sudy E. Photolocalized purpura during ciprofloxacin therapy. Photodermatol Photoimmunol Photomed. 2006;22:111-112.
- Torinuki W, Miura T. Erythropoietic protoporphyria showing solar purpura. Dermatologica. 1983;167:220-222.
- Leung AK. Purpura associated with exposure to sunlight. J R Soc Med. 1986;79:423-424.
- Kalivas J, Kalivas L. Solar purpura appearing in a patient with polymorphous light eruption. Photodermatol Photoimmunol Photomed. 1995;11:31-32.
- Ros AM. Solar purpura--an unusual manifestation of polymorphous light eruption. Photodermatol. 1988;5:47-48.
- Guarrera M, Parodi A, Rebora A. Solar purpura is not related to polymorphous light eruption. Photodermatol. 1989;6:293-294.
- Waters AJ, Sandhu DR, Green CM, et al. Solar capillaritis as a cause of solar purpura. Clin Exp Dermatol. 2009;34:E821-E824.
- Latenser BA, Hempstead RW. Exercise-associated solar purpura in an atypical location. Cutis. 1985;35:365-366.
- Rubegni P, Feci L, Pellegrino M, et al. Photolocalized purpura during levofloxacin therapy. Photodermatol Photoimmunol Photomed. 2012;28:105-107.
- Urbina F, Barrios M, Sudy E. Photolocalized purpura during ciprofloxacin therapy. Photodermatol Photoimmunol Photomed. 2006;22:111-112.
- Torinuki W, Miura T. Erythropoietic protoporphyria showing solar purpura. Dermatologica. 1983;167:220-222.
- Leung AK. Purpura associated with exposure to sunlight. J R Soc Med. 1986;79:423-424.
- Kalivas J, Kalivas L. Solar purpura appearing in a patient with polymorphous light eruption. Photodermatol Photoimmunol Photomed. 1995;11:31-32.
- Ros AM. Solar purpura--an unusual manifestation of polymorphous light eruption. Photodermatol. 1988;5:47-48.
- Guarrera M, Parodi A, Rebora A. Solar purpura is not related to polymorphous light eruption. Photodermatol. 1989;6:293-294.
Practice Points
- Petechial skin changes acutely following intense sun exposure is a rare phenomenon referred to as sunburn purpura, photolocalized purpura, or solar purpura.
- Idiopathic sunburn purpura should only be diagnosed after vasculitis and/or thrombocytopenia is ruled out, which is best achieved through skin biopsy and a platelet count, respectively.
- The rash typically resolves without treatment in 1 to 2 weeks; however, a variety of UV protection modalities and education should be offered to the patient.
Naloxone: Difficult conversations about a potential lifesaver
New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.
A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.1
Although much of the research was conducted in outpatient settings, the researchers say several lessons may be translated to the hospital readily. “Patients were really willing to embrace the idea of naloxone when it was framed to be used in a worst-case scenario,” Mr. Mueller said; some providers, for example, compared it to having a fire extinguisher in the house. “I think one patient said, ‘You know, I don’t plan on starting a fire in my kitchen, but it’s good to have there just in case something goes wrong.’ ”
Another important lesson, Mr. Mueller said, is to consider multiple factors that might heighten the overdose risk, such as a change in the prescription or a medical condition like renal failure. Including those considerations in a conversation might help destigmatize the topic and help patients who are concerned that they might be perceived as misusing the medication.
Ideally, opioid-safety interventions should be more patient centered, emphasizing safer home storage to prevent secondary exposures and educating patients fully about the medication’s downsides, she said. “They may have been on them a long time but never been fully informed of the risks,” she said. Among her group’s future research goals, Dr. Binswanger hopes to investigate how best to communicate such risks to patients.
References
1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.
A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.1
Although much of the research was conducted in outpatient settings, the researchers say several lessons may be translated to the hospital readily. “Patients were really willing to embrace the idea of naloxone when it was framed to be used in a worst-case scenario,” Mr. Mueller said; some providers, for example, compared it to having a fire extinguisher in the house. “I think one patient said, ‘You know, I don’t plan on starting a fire in my kitchen, but it’s good to have there just in case something goes wrong.’ ”
Another important lesson, Mr. Mueller said, is to consider multiple factors that might heighten the overdose risk, such as a change in the prescription or a medical condition like renal failure. Including those considerations in a conversation might help destigmatize the topic and help patients who are concerned that they might be perceived as misusing the medication.
Ideally, opioid-safety interventions should be more patient centered, emphasizing safer home storage to prevent secondary exposures and educating patients fully about the medication’s downsides, she said. “They may have been on them a long time but never been fully informed of the risks,” she said. Among her group’s future research goals, Dr. Binswanger hopes to investigate how best to communicate such risks to patients.
References
1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.
A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.1
Although much of the research was conducted in outpatient settings, the researchers say several lessons may be translated to the hospital readily. “Patients were really willing to embrace the idea of naloxone when it was framed to be used in a worst-case scenario,” Mr. Mueller said; some providers, for example, compared it to having a fire extinguisher in the house. “I think one patient said, ‘You know, I don’t plan on starting a fire in my kitchen, but it’s good to have there just in case something goes wrong.’ ”
Another important lesson, Mr. Mueller said, is to consider multiple factors that might heighten the overdose risk, such as a change in the prescription or a medical condition like renal failure. Including those considerations in a conversation might help destigmatize the topic and help patients who are concerned that they might be perceived as misusing the medication.
Ideally, opioid-safety interventions should be more patient centered, emphasizing safer home storage to prevent secondary exposures and educating patients fully about the medication’s downsides, she said. “They may have been on them a long time but never been fully informed of the risks,” she said. Among her group’s future research goals, Dr. Binswanger hopes to investigate how best to communicate such risks to patients.
References
1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
Evidence-backed questions can guide a GERD vs. NERD differential diagnosis
CHICAGO – when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.
“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”
“So generally there is no reason to initially refer older children and teenagers to a gastroenterologist,” Dr. Wershil said. “One of the essential things [you] do is consider all the causes of vomiting that are not GERD. If your first go-to is GERD, you’re going to miss other issues.”
Dr. Wershil reviewed the definitions: Gastroesophageal reflux is passage of gastric contents into the esophagus. GERD, on the other hand, is defined by the troublesome symptoms or complications associated with reflux of gastric material into the esophagus. In contrast, NERD is the presence of reflux symptoms with no evidence of mucosal erosion or mucosal breaks.
Considerations backed by evidence
Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.
He recommended the following five considerations to distinguish GERD from NERD:
- Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
- Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
- Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
- Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
- Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.
“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
The role of diagnostic testing
Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”
An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”
Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”
“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.
He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”
Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.
CHICAGO – when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.
“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”
“So generally there is no reason to initially refer older children and teenagers to a gastroenterologist,” Dr. Wershil said. “One of the essential things [you] do is consider all the causes of vomiting that are not GERD. If your first go-to is GERD, you’re going to miss other issues.”
Dr. Wershil reviewed the definitions: Gastroesophageal reflux is passage of gastric contents into the esophagus. GERD, on the other hand, is defined by the troublesome symptoms or complications associated with reflux of gastric material into the esophagus. In contrast, NERD is the presence of reflux symptoms with no evidence of mucosal erosion or mucosal breaks.
Considerations backed by evidence
Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.
He recommended the following five considerations to distinguish GERD from NERD:
- Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
- Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
- Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
- Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
- Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.
“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
The role of diagnostic testing
Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”
An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”
Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”
“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.
He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”
Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.
CHICAGO – when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.
“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”
“So generally there is no reason to initially refer older children and teenagers to a gastroenterologist,” Dr. Wershil said. “One of the essential things [you] do is consider all the causes of vomiting that are not GERD. If your first go-to is GERD, you’re going to miss other issues.”
Dr. Wershil reviewed the definitions: Gastroesophageal reflux is passage of gastric contents into the esophagus. GERD, on the other hand, is defined by the troublesome symptoms or complications associated with reflux of gastric material into the esophagus. In contrast, NERD is the presence of reflux symptoms with no evidence of mucosal erosion or mucosal breaks.
Considerations backed by evidence
Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.
He recommended the following five considerations to distinguish GERD from NERD:
- Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
- Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
- Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
- Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
- Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.
“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
The role of diagnostic testing
Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”
An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”
Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”
“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.
He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”
Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.
EXPERT ANALYSIS FROM AAP 2017
Rheumatoid arthritis increases risk of COPD hospitalizations
Individuals with rheumatoid arthritis (RA) had an increased risk of hospitalizations from chronic obstructive pulmonary disease (COPD) when compared with the general population in a Canadian retrospective, population-based cohort study.
The risk of COPD hospitalizations was 47% higher in individuals with RA. “This finding emphasizes the need to control inflammation in rheumatoid arthritis, not only to prevent joint damage, but also to prevent complications of systemic inflammation, including the development of comorbidities such as cardiovascular diseases and COPD,” wrote Diane Lacaille, MD, of the University of British Columbia, Vancouver, and her coauthors (Arthritis Care Res. 2017 Oct 19. doi: 10.1002/acr.23410).
Several previous studies have suggested a link between COPD and inflammation, Dr. Lacaille and her colleagues said. Accordingly, they sought to evaluate the risk of COPD hospitalizations in a cohort of 24,625 individuals with RA as compared with 25,396 general population controls randomly selected and matched based on age, sex, and index year. Most subjects in the analysis were female, and the mean age at onset of RA was 57.2 years.
The investigators reported an increased incidence of COPD in individuals with RA, compared with controls, based on an incident rate ratio (IRR) of 1.58 (95% confidence interval, 1.34-1.87) that dropped to 1.47 (95% CI, 1.24-1.74) after adjustment for potential confounders, including comorbidities and health services usage at baseline. The overall incidence rate for COPD was 2.07 per 1,000 patient-years for RA patients and 1.31 per 1,000 patient-years for controls.
When the model was stratified based on sex, COPD hospitalization risk was significantly increased in women (adjusted hazard ratio [HR], 1.61; 95% CI, 1.30-1.98), but not in men (adjusted HR, 1.25; 95% CI, 0.95-1.66), they said.
Data were not available on smoking, the main COPD risk factor, for the patients in this study; however, the increased risk of COPD hospitalizations in the RA group remained significant after modeling for smoking, according to the investigators.
Combined, these results have “notable implications for the clinical care of RA and COPD,” Dr. Lacaille and her coinvestigators said.
Both clinicians and people living with RA “should be aware of the increased risk of developing COPD and be vigilant in watching for early symptoms of COPD, so that appropriate diagnostic tests can be administered at the onset of early symptoms,” they wrote. “Early detection of COPD is essential so that effective treatments can be initiated before irreversible damage to the lungs occurs, to improve long-term outcomes.”
These findings strengthen the conclusions of two previous cross-sectional studies showing an association between RA and COPD prevalence, according to the investigators. In one study, RA patients in Israel who were receiving disease-modifying antirheumatic drugs had double the prevalence of COPD, compared with general population controls, according to authors of that study (Immunol Res. 2013;56[2-3]:261-6). Similarly, U.K. investigators compared 421 RA patients against controls and reported a twofold increase in obstructive pattern on screening spirometry in the RA group (Ann Rheum Dis. 2013;72:1517-23).
The current study from Dr. Lacaille and her coinvestigators was supported by funding from the Canadian Institute for Health Research. The authors reported that they had no financial disclosures, conflicts of interest, or benefits from commercial sources.
Individuals with rheumatoid arthritis (RA) had an increased risk of hospitalizations from chronic obstructive pulmonary disease (COPD) when compared with the general population in a Canadian retrospective, population-based cohort study.
The risk of COPD hospitalizations was 47% higher in individuals with RA. “This finding emphasizes the need to control inflammation in rheumatoid arthritis, not only to prevent joint damage, but also to prevent complications of systemic inflammation, including the development of comorbidities such as cardiovascular diseases and COPD,” wrote Diane Lacaille, MD, of the University of British Columbia, Vancouver, and her coauthors (Arthritis Care Res. 2017 Oct 19. doi: 10.1002/acr.23410).
Several previous studies have suggested a link between COPD and inflammation, Dr. Lacaille and her colleagues said. Accordingly, they sought to evaluate the risk of COPD hospitalizations in a cohort of 24,625 individuals with RA as compared with 25,396 general population controls randomly selected and matched based on age, sex, and index year. Most subjects in the analysis were female, and the mean age at onset of RA was 57.2 years.
The investigators reported an increased incidence of COPD in individuals with RA, compared with controls, based on an incident rate ratio (IRR) of 1.58 (95% confidence interval, 1.34-1.87) that dropped to 1.47 (95% CI, 1.24-1.74) after adjustment for potential confounders, including comorbidities and health services usage at baseline. The overall incidence rate for COPD was 2.07 per 1,000 patient-years for RA patients and 1.31 per 1,000 patient-years for controls.
When the model was stratified based on sex, COPD hospitalization risk was significantly increased in women (adjusted hazard ratio [HR], 1.61; 95% CI, 1.30-1.98), but not in men (adjusted HR, 1.25; 95% CI, 0.95-1.66), they said.
Data were not available on smoking, the main COPD risk factor, for the patients in this study; however, the increased risk of COPD hospitalizations in the RA group remained significant after modeling for smoking, according to the investigators.
Combined, these results have “notable implications for the clinical care of RA and COPD,” Dr. Lacaille and her coinvestigators said.
Both clinicians and people living with RA “should be aware of the increased risk of developing COPD and be vigilant in watching for early symptoms of COPD, so that appropriate diagnostic tests can be administered at the onset of early symptoms,” they wrote. “Early detection of COPD is essential so that effective treatments can be initiated before irreversible damage to the lungs occurs, to improve long-term outcomes.”
These findings strengthen the conclusions of two previous cross-sectional studies showing an association between RA and COPD prevalence, according to the investigators. In one study, RA patients in Israel who were receiving disease-modifying antirheumatic drugs had double the prevalence of COPD, compared with general population controls, according to authors of that study (Immunol Res. 2013;56[2-3]:261-6). Similarly, U.K. investigators compared 421 RA patients against controls and reported a twofold increase in obstructive pattern on screening spirometry in the RA group (Ann Rheum Dis. 2013;72:1517-23).
The current study from Dr. Lacaille and her coinvestigators was supported by funding from the Canadian Institute for Health Research. The authors reported that they had no financial disclosures, conflicts of interest, or benefits from commercial sources.
Individuals with rheumatoid arthritis (RA) had an increased risk of hospitalizations from chronic obstructive pulmonary disease (COPD) when compared with the general population in a Canadian retrospective, population-based cohort study.
The risk of COPD hospitalizations was 47% higher in individuals with RA. “This finding emphasizes the need to control inflammation in rheumatoid arthritis, not only to prevent joint damage, but also to prevent complications of systemic inflammation, including the development of comorbidities such as cardiovascular diseases and COPD,” wrote Diane Lacaille, MD, of the University of British Columbia, Vancouver, and her coauthors (Arthritis Care Res. 2017 Oct 19. doi: 10.1002/acr.23410).
Several previous studies have suggested a link between COPD and inflammation, Dr. Lacaille and her colleagues said. Accordingly, they sought to evaluate the risk of COPD hospitalizations in a cohort of 24,625 individuals with RA as compared with 25,396 general population controls randomly selected and matched based on age, sex, and index year. Most subjects in the analysis were female, and the mean age at onset of RA was 57.2 years.
The investigators reported an increased incidence of COPD in individuals with RA, compared with controls, based on an incident rate ratio (IRR) of 1.58 (95% confidence interval, 1.34-1.87) that dropped to 1.47 (95% CI, 1.24-1.74) after adjustment for potential confounders, including comorbidities and health services usage at baseline. The overall incidence rate for COPD was 2.07 per 1,000 patient-years for RA patients and 1.31 per 1,000 patient-years for controls.
When the model was stratified based on sex, COPD hospitalization risk was significantly increased in women (adjusted hazard ratio [HR], 1.61; 95% CI, 1.30-1.98), but not in men (adjusted HR, 1.25; 95% CI, 0.95-1.66), they said.
Data were not available on smoking, the main COPD risk factor, for the patients in this study; however, the increased risk of COPD hospitalizations in the RA group remained significant after modeling for smoking, according to the investigators.
Combined, these results have “notable implications for the clinical care of RA and COPD,” Dr. Lacaille and her coinvestigators said.
Both clinicians and people living with RA “should be aware of the increased risk of developing COPD and be vigilant in watching for early symptoms of COPD, so that appropriate diagnostic tests can be administered at the onset of early symptoms,” they wrote. “Early detection of COPD is essential so that effective treatments can be initiated before irreversible damage to the lungs occurs, to improve long-term outcomes.”
These findings strengthen the conclusions of two previous cross-sectional studies showing an association between RA and COPD prevalence, according to the investigators. In one study, RA patients in Israel who were receiving disease-modifying antirheumatic drugs had double the prevalence of COPD, compared with general population controls, according to authors of that study (Immunol Res. 2013;56[2-3]:261-6). Similarly, U.K. investigators compared 421 RA patients against controls and reported a twofold increase in obstructive pattern on screening spirometry in the RA group (Ann Rheum Dis. 2013;72:1517-23).
The current study from Dr. Lacaille and her coinvestigators was supported by funding from the Canadian Institute for Health Research. The authors reported that they had no financial disclosures, conflicts of interest, or benefits from commercial sources.
FROM Arthritis Care AND Research
Key clinical point:
Major finding: The risk of COPD hospitalizations was 47% higher in individuals with rheumatoid arthritis (adjusted hazard ratio, 1.47; 95% confidence interval, 1.34-1.87).
Data source: A retrospective cohort study including approximately 25,000 RA patients seen in British Columbia and a roughly equal number of controls.
Disclosures: The Canadian Institute for Health Research provided funding for the study. The authors reported that they had no financial disclosures, conflicts of interest, or benefits from commercial sources.
A ‘game changer’ for pediatric HIV
In memory of Anne Marie Regan, CPNP, senior research coordinator, Pediatric HIV Program, Boston City Hospital
Our first child with perinatal HIV presented in 1985 at age 4 weeks with failure to thrive, vomiting, diarrhea, and thrush. Over the next several years, the number of HIV-infected infants grew exponentially, and by 1991, we were caring for more than 50 infants and children at Boston City Hospital.
Antiretrovirals were marginally effective for HIV-infected infants and children at this time. Subsequently, we embarked on a national effort to prevent vertical transmission. We participated first in the study of pharmacokinetics of zidovudine (AZT) in newborns. We enrolled patients in ACTG 076 to test the hypothesis that treatment with AZT during pregnancy and labor, and in the infant, would reduce the risk of vertical transmission. Fifty U.S. and nine French sites enrolled 473 women between April 1991 and December 20, 1993. The results were spectacular; 8 of 100 infants in the AZT treatment group, compared with 25 out of 100 infants in the control group, developed HIV. By 1995, HIV testing was offered to all women at Boston Medical Center (formerly Boston City Hospital), and the promise of prevention of vertical transmission was reaching fruition. Between 1996 and 2016, approximately 500 HIV-infected women delivered at Boston Medical Center with vertical transmission identified in only 6 (1.2%) infants; without ACTG 076, we would have expected 125! In 2013, the Centers for Disease Control and Prevention reported that 70% of pregnant HIV-infected women received the complete 076 regimen, and 93% of mothers or infants received some part of the regimen. In 1992, 900 HIV-infected infants were diagnosed in the United States, and as many as 2,000 newborns were estimated to have been born infected with HIV; in 2015, 86 vertical transmissions were identified. This was, and remains, a remarkable accomplishment.
Dr. Pelton is chief of pediatric infectious diseases and coordinator of the maternal-child HIV program at Boston Medical Center. Ms. Moloney is a certified pediatric nurse practitioner in the division of pediatric infectious diseases. Dr. Pelton said he had no relevant financial disclosures, and Ms. Moloney is a speaker (on vaccines) for Sanofi Pasteur. Email them at [email protected].
In memory of Anne Marie Regan, CPNP, senior research coordinator, Pediatric HIV Program, Boston City Hospital
Our first child with perinatal HIV presented in 1985 at age 4 weeks with failure to thrive, vomiting, diarrhea, and thrush. Over the next several years, the number of HIV-infected infants grew exponentially, and by 1991, we were caring for more than 50 infants and children at Boston City Hospital.
Antiretrovirals were marginally effective for HIV-infected infants and children at this time. Subsequently, we embarked on a national effort to prevent vertical transmission. We participated first in the study of pharmacokinetics of zidovudine (AZT) in newborns. We enrolled patients in ACTG 076 to test the hypothesis that treatment with AZT during pregnancy and labor, and in the infant, would reduce the risk of vertical transmission. Fifty U.S. and nine French sites enrolled 473 women between April 1991 and December 20, 1993. The results were spectacular; 8 of 100 infants in the AZT treatment group, compared with 25 out of 100 infants in the control group, developed HIV. By 1995, HIV testing was offered to all women at Boston Medical Center (formerly Boston City Hospital), and the promise of prevention of vertical transmission was reaching fruition. Between 1996 and 2016, approximately 500 HIV-infected women delivered at Boston Medical Center with vertical transmission identified in only 6 (1.2%) infants; without ACTG 076, we would have expected 125! In 2013, the Centers for Disease Control and Prevention reported that 70% of pregnant HIV-infected women received the complete 076 regimen, and 93% of mothers or infants received some part of the regimen. In 1992, 900 HIV-infected infants were diagnosed in the United States, and as many as 2,000 newborns were estimated to have been born infected with HIV; in 2015, 86 vertical transmissions were identified. This was, and remains, a remarkable accomplishment.
Dr. Pelton is chief of pediatric infectious diseases and coordinator of the maternal-child HIV program at Boston Medical Center. Ms. Moloney is a certified pediatric nurse practitioner in the division of pediatric infectious diseases. Dr. Pelton said he had no relevant financial disclosures, and Ms. Moloney is a speaker (on vaccines) for Sanofi Pasteur. Email them at [email protected].
In memory of Anne Marie Regan, CPNP, senior research coordinator, Pediatric HIV Program, Boston City Hospital
Our first child with perinatal HIV presented in 1985 at age 4 weeks with failure to thrive, vomiting, diarrhea, and thrush. Over the next several years, the number of HIV-infected infants grew exponentially, and by 1991, we were caring for more than 50 infants and children at Boston City Hospital.
Antiretrovirals were marginally effective for HIV-infected infants and children at this time. Subsequently, we embarked on a national effort to prevent vertical transmission. We participated first in the study of pharmacokinetics of zidovudine (AZT) in newborns. We enrolled patients in ACTG 076 to test the hypothesis that treatment with AZT during pregnancy and labor, and in the infant, would reduce the risk of vertical transmission. Fifty U.S. and nine French sites enrolled 473 women between April 1991 and December 20, 1993. The results were spectacular; 8 of 100 infants in the AZT treatment group, compared with 25 out of 100 infants in the control group, developed HIV. By 1995, HIV testing was offered to all women at Boston Medical Center (formerly Boston City Hospital), and the promise of prevention of vertical transmission was reaching fruition. Between 1996 and 2016, approximately 500 HIV-infected women delivered at Boston Medical Center with vertical transmission identified in only 6 (1.2%) infants; without ACTG 076, we would have expected 125! In 2013, the Centers for Disease Control and Prevention reported that 70% of pregnant HIV-infected women received the complete 076 regimen, and 93% of mothers or infants received some part of the regimen. In 1992, 900 HIV-infected infants were diagnosed in the United States, and as many as 2,000 newborns were estimated to have been born infected with HIV; in 2015, 86 vertical transmissions were identified. This was, and remains, a remarkable accomplishment.
Dr. Pelton is chief of pediatric infectious diseases and coordinator of the maternal-child HIV program at Boston Medical Center. Ms. Moloney is a certified pediatric nurse practitioner in the division of pediatric infectious diseases. Dr. Pelton said he had no relevant financial disclosures, and Ms. Moloney is a speaker (on vaccines) for Sanofi Pasteur. Email them at [email protected].
Dermatologists, rheumatologists differ in management of pediatric discoid lupus erythematosus
CHICAGO – With no consensus guidelines, rheumatologists and dermatologists have significant practice-based differences in their treatment of children with discoid lupus erythematosus, according to a survey of the two specialties.
The survey’s results from 57 pediatric dermatologists and 47 pediatric rheumatologists showed a lack of consensus between the two specialties in how to screen for systemic lupus erythematosus (SLE). The two specialties also differed in identification of which features of discoid lupus erythematosus (DLE) might predispose children to developing SLE, and in some therapy choices for DLE.
Although rare in children, DLE may develop into systemic lupus erythematosus in about 25%-30% of pediatric patients, according to Lisa Arkin, MD, who shared the survey results during a poster presentation at the World Congress of Pediatric Dermatology.
Dr. Arkin and her colleagues conducted a Web-based survey to examine differences in DLE treatment practice patterns between pediatric dermatologists and pediatric rheumatologists. They sent the survey to 292 members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA), and to 200 members of the Pediatric Dermatology Research Alliance (PeDRA), and received responses from 44% of the rheumatologists and 56% of the dermatologists. Of those, 57 dermatologists and 47 rheumatologists met inclusion criteria for the study.
More than half of the respondents in each specialty had seen fewer than 10 patients with skin-limited DLE, and fewer than 10 patients with SLE and DLE, over the course of their careers, said Dr. Arkin, director of pediatric dermatology at the University of Wisconsin, Madison.
Consensus was defined by Dr. Arkin and her colleagues as greater than 70% agreement from both specialties, and 2-sided P values less than .05 showed practice differences between rheumatologists and dermatologists.
Clinicians reached a consensus that the presence of either arthritis or nephritis in a pediatric patient with DLE put the patient at high risk for SLE. Arthritis was identified as a high-risk feature by 41 of 57 dermatologists (72%) and 36 of 47 rheumatologists (77%), while nephritis was seen as a high-risk feature by 39 dermatologists (68%) and 37 rheumatologists (79%). However, said Dr. Arkin, “no other features from a list of 30 risk factors including demographics, clinical, or laboratory features achieved consensus.”
In deciding which laboratory studies to order to screen for SLE upon DLE diagnosis, 26 dermatologists (46%) and 38 rheumatologists (81%) choose a full screening panel, according to the survey results. That was a significant between-specialty difference (P less than .001). The full panel consisted of obtaining a complete blood count with differential, testing for renal and hepatic function, obtaining the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and doing urine studies. The panel also included testing for complements, autoantibodies including anti–double-stranded DNA, single-stranded A and B, ribonucleoprotein, anti-Smith, and antiphospholipid antibodies.
However, when individual laboratory studies were examined, several did achieve consensus for baseline screening. Those included the CBC with differential; urinalysis (but not urine protein creatinine), ESR (but not CRP); complement, renal, and hepatic function testing; and most autoantibody testing (but not antiphospholipid antibody testing). Where there were differences in likelihood to order a test, rheumatologists were more likely to order the test than dermatologists.
In deciding on initial treatment, “rheumatologists were more likely to always initiate hydroxychloroquine than dermatologists,” said Dr. Arkin. Of the rheumatologists, 49% always initiated hydroxychloroquine, compared with 14% of the dermatologists (P less than .001).
In contrast, “dermatologists were more likely to always initiate topical therapy than the rheumatologists,” said Dr. Arkin. Topical therapy was always started by 81% of the dermatologists and 33% of the rheumatologists (P less than .001).
Although the specialties differed in whether they always initiated a certain treatment, “hydroxychloroquine achieved consensus as first-line therapy,” Dr. Arkin noted, with 81% of dermatologists and 87% of rheumatologists choosing hydroxychloroquine when the survey asked for a first-line systemic therapy.
There was no consensus about which agents were best for add-on therapy. Of the dermatologists, 32% would sometimes use methotrexate, which was used by 21% of rheumatologists for refractory skin disease. Quinacrine was used as add-on therapy by 21% of dermatologists and 15% of rheumatologists. Rheumatologists were significantly more likely to add dapsone than dermatologists (28% vs. 5%, P = .002).
The survey points to the need to develop consensus guidelines in the treatment of pediatric DLE, said Dr. Arkin. “Knowledge gaps include risk factors for SLE, optimal screening, and therapy,” she explained. “Collection of robust longitudinal data will aid in developing pediatric consensus guidelines for DLE.”
Dr. Arkin had no conflicts of interest.
[email protected]
On Twitter @karioakes
CHICAGO – With no consensus guidelines, rheumatologists and dermatologists have significant practice-based differences in their treatment of children with discoid lupus erythematosus, according to a survey of the two specialties.
The survey’s results from 57 pediatric dermatologists and 47 pediatric rheumatologists showed a lack of consensus between the two specialties in how to screen for systemic lupus erythematosus (SLE). The two specialties also differed in identification of which features of discoid lupus erythematosus (DLE) might predispose children to developing SLE, and in some therapy choices for DLE.
Although rare in children, DLE may develop into systemic lupus erythematosus in about 25%-30% of pediatric patients, according to Lisa Arkin, MD, who shared the survey results during a poster presentation at the World Congress of Pediatric Dermatology.
Dr. Arkin and her colleagues conducted a Web-based survey to examine differences in DLE treatment practice patterns between pediatric dermatologists and pediatric rheumatologists. They sent the survey to 292 members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA), and to 200 members of the Pediatric Dermatology Research Alliance (PeDRA), and received responses from 44% of the rheumatologists and 56% of the dermatologists. Of those, 57 dermatologists and 47 rheumatologists met inclusion criteria for the study.
More than half of the respondents in each specialty had seen fewer than 10 patients with skin-limited DLE, and fewer than 10 patients with SLE and DLE, over the course of their careers, said Dr. Arkin, director of pediatric dermatology at the University of Wisconsin, Madison.
Consensus was defined by Dr. Arkin and her colleagues as greater than 70% agreement from both specialties, and 2-sided P values less than .05 showed practice differences between rheumatologists and dermatologists.
Clinicians reached a consensus that the presence of either arthritis or nephritis in a pediatric patient with DLE put the patient at high risk for SLE. Arthritis was identified as a high-risk feature by 41 of 57 dermatologists (72%) and 36 of 47 rheumatologists (77%), while nephritis was seen as a high-risk feature by 39 dermatologists (68%) and 37 rheumatologists (79%). However, said Dr. Arkin, “no other features from a list of 30 risk factors including demographics, clinical, or laboratory features achieved consensus.”
In deciding which laboratory studies to order to screen for SLE upon DLE diagnosis, 26 dermatologists (46%) and 38 rheumatologists (81%) choose a full screening panel, according to the survey results. That was a significant between-specialty difference (P less than .001). The full panel consisted of obtaining a complete blood count with differential, testing for renal and hepatic function, obtaining the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and doing urine studies. The panel also included testing for complements, autoantibodies including anti–double-stranded DNA, single-stranded A and B, ribonucleoprotein, anti-Smith, and antiphospholipid antibodies.
However, when individual laboratory studies were examined, several did achieve consensus for baseline screening. Those included the CBC with differential; urinalysis (but not urine protein creatinine), ESR (but not CRP); complement, renal, and hepatic function testing; and most autoantibody testing (but not antiphospholipid antibody testing). Where there were differences in likelihood to order a test, rheumatologists were more likely to order the test than dermatologists.
In deciding on initial treatment, “rheumatologists were more likely to always initiate hydroxychloroquine than dermatologists,” said Dr. Arkin. Of the rheumatologists, 49% always initiated hydroxychloroquine, compared with 14% of the dermatologists (P less than .001).
In contrast, “dermatologists were more likely to always initiate topical therapy than the rheumatologists,” said Dr. Arkin. Topical therapy was always started by 81% of the dermatologists and 33% of the rheumatologists (P less than .001).
Although the specialties differed in whether they always initiated a certain treatment, “hydroxychloroquine achieved consensus as first-line therapy,” Dr. Arkin noted, with 81% of dermatologists and 87% of rheumatologists choosing hydroxychloroquine when the survey asked for a first-line systemic therapy.
There was no consensus about which agents were best for add-on therapy. Of the dermatologists, 32% would sometimes use methotrexate, which was used by 21% of rheumatologists for refractory skin disease. Quinacrine was used as add-on therapy by 21% of dermatologists and 15% of rheumatologists. Rheumatologists were significantly more likely to add dapsone than dermatologists (28% vs. 5%, P = .002).
The survey points to the need to develop consensus guidelines in the treatment of pediatric DLE, said Dr. Arkin. “Knowledge gaps include risk factors for SLE, optimal screening, and therapy,” she explained. “Collection of robust longitudinal data will aid in developing pediatric consensus guidelines for DLE.”
Dr. Arkin had no conflicts of interest.
[email protected]
On Twitter @karioakes
CHICAGO – With no consensus guidelines, rheumatologists and dermatologists have significant practice-based differences in their treatment of children with discoid lupus erythematosus, according to a survey of the two specialties.
The survey’s results from 57 pediatric dermatologists and 47 pediatric rheumatologists showed a lack of consensus between the two specialties in how to screen for systemic lupus erythematosus (SLE). The two specialties also differed in identification of which features of discoid lupus erythematosus (DLE) might predispose children to developing SLE, and in some therapy choices for DLE.
Although rare in children, DLE may develop into systemic lupus erythematosus in about 25%-30% of pediatric patients, according to Lisa Arkin, MD, who shared the survey results during a poster presentation at the World Congress of Pediatric Dermatology.
Dr. Arkin and her colleagues conducted a Web-based survey to examine differences in DLE treatment practice patterns between pediatric dermatologists and pediatric rheumatologists. They sent the survey to 292 members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA), and to 200 members of the Pediatric Dermatology Research Alliance (PeDRA), and received responses from 44% of the rheumatologists and 56% of the dermatologists. Of those, 57 dermatologists and 47 rheumatologists met inclusion criteria for the study.
More than half of the respondents in each specialty had seen fewer than 10 patients with skin-limited DLE, and fewer than 10 patients with SLE and DLE, over the course of their careers, said Dr. Arkin, director of pediatric dermatology at the University of Wisconsin, Madison.
Consensus was defined by Dr. Arkin and her colleagues as greater than 70% agreement from both specialties, and 2-sided P values less than .05 showed practice differences between rheumatologists and dermatologists.
Clinicians reached a consensus that the presence of either arthritis or nephritis in a pediatric patient with DLE put the patient at high risk for SLE. Arthritis was identified as a high-risk feature by 41 of 57 dermatologists (72%) and 36 of 47 rheumatologists (77%), while nephritis was seen as a high-risk feature by 39 dermatologists (68%) and 37 rheumatologists (79%). However, said Dr. Arkin, “no other features from a list of 30 risk factors including demographics, clinical, or laboratory features achieved consensus.”
In deciding which laboratory studies to order to screen for SLE upon DLE diagnosis, 26 dermatologists (46%) and 38 rheumatologists (81%) choose a full screening panel, according to the survey results. That was a significant between-specialty difference (P less than .001). The full panel consisted of obtaining a complete blood count with differential, testing for renal and hepatic function, obtaining the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and doing urine studies. The panel also included testing for complements, autoantibodies including anti–double-stranded DNA, single-stranded A and B, ribonucleoprotein, anti-Smith, and antiphospholipid antibodies.
However, when individual laboratory studies were examined, several did achieve consensus for baseline screening. Those included the CBC with differential; urinalysis (but not urine protein creatinine), ESR (but not CRP); complement, renal, and hepatic function testing; and most autoantibody testing (but not antiphospholipid antibody testing). Where there were differences in likelihood to order a test, rheumatologists were more likely to order the test than dermatologists.
In deciding on initial treatment, “rheumatologists were more likely to always initiate hydroxychloroquine than dermatologists,” said Dr. Arkin. Of the rheumatologists, 49% always initiated hydroxychloroquine, compared with 14% of the dermatologists (P less than .001).
In contrast, “dermatologists were more likely to always initiate topical therapy than the rheumatologists,” said Dr. Arkin. Topical therapy was always started by 81% of the dermatologists and 33% of the rheumatologists (P less than .001).
Although the specialties differed in whether they always initiated a certain treatment, “hydroxychloroquine achieved consensus as first-line therapy,” Dr. Arkin noted, with 81% of dermatologists and 87% of rheumatologists choosing hydroxychloroquine when the survey asked for a first-line systemic therapy.
There was no consensus about which agents were best for add-on therapy. Of the dermatologists, 32% would sometimes use methotrexate, which was used by 21% of rheumatologists for refractory skin disease. Quinacrine was used as add-on therapy by 21% of dermatologists and 15% of rheumatologists. Rheumatologists were significantly more likely to add dapsone than dermatologists (28% vs. 5%, P = .002).
The survey points to the need to develop consensus guidelines in the treatment of pediatric DLE, said Dr. Arkin. “Knowledge gaps include risk factors for SLE, optimal screening, and therapy,” she explained. “Collection of robust longitudinal data will aid in developing pediatric consensus guidelines for DLE.”
Dr. Arkin had no conflicts of interest.
[email protected]
On Twitter @karioakes
AT WCPD 2017
Key clinical point:
Major finding: The two specialties reached a consensus in identifying 2 of 30 potential high-risk features for the development of systemic lupus erythematosus.
Data source: Survey results from 57 pediatric dermatologists and 47 pediatric rheumatologists who treat children with DLE.Disclosures: Dr. Arkin had no relevant financial conflicts.
Psychiatric illness, low IQ often co-occur among male inmates
BERLIN – Among inmates in a Mexican federal prison, psychiatric disorders went hand-in-hand with low or extremely low IQ scores, a study showed.
About 86% of the inmates with a mental illness also had an IQ of 67-69. These men were likely to have multiple psychiatric diagnoses compounded by traumatic brain injury and substance dependence. They also were lowest in the hierarchy of organized crime, Isaac S. Carlos, MD, said at the meeting of the World Psychiatric Association.
Outside prison, this combination of mental illness and low intelligence set these men up for manipulation by more intelligent criminals, who used them most frequently as drug mules or henchmen, Dr. Carlos said. Inside, they were still extremely vulnerable to manipulation and abuse by more intelligent inmates who retain their intellectual dominance in the prison social structure.
Dr. Carlos is an attending psychiatrist in a large, maximum security federal prison that houses thousands of men convicted mostly in organized crime rings associated with drug trafficking. About 45% of the country’s federal inmate population overall has been diagnosed with some kind of mental disorder and requires treatment, but there are few options, he said. In Dr. Carlos’s institution, with one psychiatrist, one criminologist, and 20 psychologists to serve more than 5,000 prisoners, there are few opportunities to do rehabilitative therapy, counseling, or any behavioral interventions. Medication is about the best treatment offered, Dr. Carlos said.
He said he is actively trying to establish an integrative care system there. As part of the project, Dr. Carlos and his colleagues looked at the co-occurrence of psychiatric diagnoses and IQ level.
His group comprised 400 inmates who were sent for psychiatric assessment, which included the Wechsler Abbreviated Scale of Intelligence, Second Edition. Each inmate also received a ranking for his role in organized crime: intellectual (administrative leaders and organizers at the top of the hierarchy), technical (responsible for transportation and transactions), or material (executers of the criminal commands from above).
Of the 400 inmates referred, 300 had at least one ICD-10 mental illness diagnosis. These men were a mean of 30 years old with a mean of 10 years of education. About a third of the group had a triple diagnosis of psychosis, dependence on multiple substances, and dissocial personality disorder (which is comparable to antisocial personality disorder in the DSM-5). These inmates also had the lowest IQ measurements.
Other diagnostic combinations included schizoaffective plus dissocial disorder; substance abuse plus psychosis; dependent personality disorder plus dissocial disorder; traumatic brain injury or posttraumatic stress disorder with psychosis; dependent personality plus dissocial disorder; bipolar disorder plus either dissocial disorder or dependent personality; depression plus borderline personality disorder; depression plus narcissistic disorder; depression plus both personality disorder and dependent personality disorder; adjustment disorder plus dissocial disorder; anxiety plus both dependent and personality disorder, with or without narcissistic disorder; and dependent disorder plus either narcissism or borderline personality disorder.
Only one inmate had a high IQ score. This man had a dual diagnosis of depression and narcissism, and an IQ of 129. He was considered an intellectual offender.
The next highest IQ was 77 – the upper limit of a large group of scores in the 70s. Diagnoses included adjustment disorder plus dissocial disorder; posttraumatic stress disorder plus dissocial disorder; bipolar plus dissocial disorder; and depression plus borderline personality disorder. These men largely fell into the “technical” offender category – the middlemen of organized crime.
At the lower end of the IQ scale were the men categorized as “material” offenders. With IQs ranging from 67 to 69, these men frequently had multiple mental illnesses complicated by brain damage and substance abuse. When psychosis occurred, it was always in conjunction with these lower IQ scores. Low scores were common, Dr. Carlos said: In fact, 45% of the cohort had an IQ of 67; 22%, an IQ of 68; and 19%, an IQ of 69.
“It is necessary to understand the psychiatric comorbidities as well as the IQ in order to get better treatment responses,” Dr. Carlos said. “In some other prisons, this is already understood and a part of therapeutic treatment, but we just don’t have this (in the federal prison system). We have to make the people who run these prisons understand this.”
He had no relevant financial disclosure.
[email protected]
On Twitter @alz_gal
BERLIN – Among inmates in a Mexican federal prison, psychiatric disorders went hand-in-hand with low or extremely low IQ scores, a study showed.
About 86% of the inmates with a mental illness also had an IQ of 67-69. These men were likely to have multiple psychiatric diagnoses compounded by traumatic brain injury and substance dependence. They also were lowest in the hierarchy of organized crime, Isaac S. Carlos, MD, said at the meeting of the World Psychiatric Association.
Outside prison, this combination of mental illness and low intelligence set these men up for manipulation by more intelligent criminals, who used them most frequently as drug mules or henchmen, Dr. Carlos said. Inside, they were still extremely vulnerable to manipulation and abuse by more intelligent inmates who retain their intellectual dominance in the prison social structure.
Dr. Carlos is an attending psychiatrist in a large, maximum security federal prison that houses thousands of men convicted mostly in organized crime rings associated with drug trafficking. About 45% of the country’s federal inmate population overall has been diagnosed with some kind of mental disorder and requires treatment, but there are few options, he said. In Dr. Carlos’s institution, with one psychiatrist, one criminologist, and 20 psychologists to serve more than 5,000 prisoners, there are few opportunities to do rehabilitative therapy, counseling, or any behavioral interventions. Medication is about the best treatment offered, Dr. Carlos said.
He said he is actively trying to establish an integrative care system there. As part of the project, Dr. Carlos and his colleagues looked at the co-occurrence of psychiatric diagnoses and IQ level.
His group comprised 400 inmates who were sent for psychiatric assessment, which included the Wechsler Abbreviated Scale of Intelligence, Second Edition. Each inmate also received a ranking for his role in organized crime: intellectual (administrative leaders and organizers at the top of the hierarchy), technical (responsible for transportation and transactions), or material (executers of the criminal commands from above).
Of the 400 inmates referred, 300 had at least one ICD-10 mental illness diagnosis. These men were a mean of 30 years old with a mean of 10 years of education. About a third of the group had a triple diagnosis of psychosis, dependence on multiple substances, and dissocial personality disorder (which is comparable to antisocial personality disorder in the DSM-5). These inmates also had the lowest IQ measurements.
Other diagnostic combinations included schizoaffective plus dissocial disorder; substance abuse plus psychosis; dependent personality disorder plus dissocial disorder; traumatic brain injury or posttraumatic stress disorder with psychosis; dependent personality plus dissocial disorder; bipolar disorder plus either dissocial disorder or dependent personality; depression plus borderline personality disorder; depression plus narcissistic disorder; depression plus both personality disorder and dependent personality disorder; adjustment disorder plus dissocial disorder; anxiety plus both dependent and personality disorder, with or without narcissistic disorder; and dependent disorder plus either narcissism or borderline personality disorder.
Only one inmate had a high IQ score. This man had a dual diagnosis of depression and narcissism, and an IQ of 129. He was considered an intellectual offender.
The next highest IQ was 77 – the upper limit of a large group of scores in the 70s. Diagnoses included adjustment disorder plus dissocial disorder; posttraumatic stress disorder plus dissocial disorder; bipolar plus dissocial disorder; and depression plus borderline personality disorder. These men largely fell into the “technical” offender category – the middlemen of organized crime.
At the lower end of the IQ scale were the men categorized as “material” offenders. With IQs ranging from 67 to 69, these men frequently had multiple mental illnesses complicated by brain damage and substance abuse. When psychosis occurred, it was always in conjunction with these lower IQ scores. Low scores were common, Dr. Carlos said: In fact, 45% of the cohort had an IQ of 67; 22%, an IQ of 68; and 19%, an IQ of 69.
“It is necessary to understand the psychiatric comorbidities as well as the IQ in order to get better treatment responses,” Dr. Carlos said. “In some other prisons, this is already understood and a part of therapeutic treatment, but we just don’t have this (in the federal prison system). We have to make the people who run these prisons understand this.”
He had no relevant financial disclosure.
[email protected]
On Twitter @alz_gal
BERLIN – Among inmates in a Mexican federal prison, psychiatric disorders went hand-in-hand with low or extremely low IQ scores, a study showed.
About 86% of the inmates with a mental illness also had an IQ of 67-69. These men were likely to have multiple psychiatric diagnoses compounded by traumatic brain injury and substance dependence. They also were lowest in the hierarchy of organized crime, Isaac S. Carlos, MD, said at the meeting of the World Psychiatric Association.
Outside prison, this combination of mental illness and low intelligence set these men up for manipulation by more intelligent criminals, who used them most frequently as drug mules or henchmen, Dr. Carlos said. Inside, they were still extremely vulnerable to manipulation and abuse by more intelligent inmates who retain their intellectual dominance in the prison social structure.
Dr. Carlos is an attending psychiatrist in a large, maximum security federal prison that houses thousands of men convicted mostly in organized crime rings associated with drug trafficking. About 45% of the country’s federal inmate population overall has been diagnosed with some kind of mental disorder and requires treatment, but there are few options, he said. In Dr. Carlos’s institution, with one psychiatrist, one criminologist, and 20 psychologists to serve more than 5,000 prisoners, there are few opportunities to do rehabilitative therapy, counseling, or any behavioral interventions. Medication is about the best treatment offered, Dr. Carlos said.
He said he is actively trying to establish an integrative care system there. As part of the project, Dr. Carlos and his colleagues looked at the co-occurrence of psychiatric diagnoses and IQ level.
His group comprised 400 inmates who were sent for psychiatric assessment, which included the Wechsler Abbreviated Scale of Intelligence, Second Edition. Each inmate also received a ranking for his role in organized crime: intellectual (administrative leaders and organizers at the top of the hierarchy), technical (responsible for transportation and transactions), or material (executers of the criminal commands from above).
Of the 400 inmates referred, 300 had at least one ICD-10 mental illness diagnosis. These men were a mean of 30 years old with a mean of 10 years of education. About a third of the group had a triple diagnosis of psychosis, dependence on multiple substances, and dissocial personality disorder (which is comparable to antisocial personality disorder in the DSM-5). These inmates also had the lowest IQ measurements.
Other diagnostic combinations included schizoaffective plus dissocial disorder; substance abuse plus psychosis; dependent personality disorder plus dissocial disorder; traumatic brain injury or posttraumatic stress disorder with psychosis; dependent personality plus dissocial disorder; bipolar disorder plus either dissocial disorder or dependent personality; depression plus borderline personality disorder; depression plus narcissistic disorder; depression plus both personality disorder and dependent personality disorder; adjustment disorder plus dissocial disorder; anxiety plus both dependent and personality disorder, with or without narcissistic disorder; and dependent disorder plus either narcissism or borderline personality disorder.
Only one inmate had a high IQ score. This man had a dual diagnosis of depression and narcissism, and an IQ of 129. He was considered an intellectual offender.
The next highest IQ was 77 – the upper limit of a large group of scores in the 70s. Diagnoses included adjustment disorder plus dissocial disorder; posttraumatic stress disorder plus dissocial disorder; bipolar plus dissocial disorder; and depression plus borderline personality disorder. These men largely fell into the “technical” offender category – the middlemen of organized crime.
At the lower end of the IQ scale were the men categorized as “material” offenders. With IQs ranging from 67 to 69, these men frequently had multiple mental illnesses complicated by brain damage and substance abuse. When psychosis occurred, it was always in conjunction with these lower IQ scores. Low scores were common, Dr. Carlos said: In fact, 45% of the cohort had an IQ of 67; 22%, an IQ of 68; and 19%, an IQ of 69.
“It is necessary to understand the psychiatric comorbidities as well as the IQ in order to get better treatment responses,” Dr. Carlos said. “In some other prisons, this is already understood and a part of therapeutic treatment, but we just don’t have this (in the federal prison system). We have to make the people who run these prisons understand this.”
He had no relevant financial disclosure.
[email protected]
On Twitter @alz_gal
AT WPA 2017
Key clinical point:
Major finding: Almost 90% of inmates in a Mexican federal prison with a mental disorder also had a low or extremely low IQ.
Data source: A prospective study of 400 men; 300 had at least one ICD-10 mental health diagnosis.
Disclosures: Dr. Carlos had no relevant financial disclosures.
#MeToo: Does it help?
I can still hear my mother saying these words: “Sticks and stones will break your bones but names will never hurt you.” It was a call for resilience, in a world that wasn’t always kind, but where the expectation was clear: I was to let insults roll off me.
We live in a different world now, one in which there are divisions between the good and the bad, where children have the right not to be called names by bullies. Our college students want safe spaces where they won’t hear offensive ideologies and trigger warnings if they are to be exposed to anything that may rekindle a past trauma.
If you’ve been following social media, then you might be familiar with the #MeToo topic that traveled after the public was made aware of the despicable, sexually aggressive behavior of acclaimed film executive Harvey Weinstein. Actress Alyssa Milano put out a call on social media: “Suggested by a friend: If all the women who have been sexually harassed or assaulted wrote ‘Me too’ as a status, we might give people a sense of the magnitude of the problem.” Others have noted that in medicine, it might well be that 100% of women have been harassed. The hashtag took off, and millions of people wrote #MeToo on their social media sites, including four female U.S. senators who told their stories.
On my personal Facebook page, I voiced a concern about the #MeToo tag. I noted that there were times when men had said some inappropriate things to me and I’d felt uncomfortable. I went on to write, “I don’t feel I was changed, harmed, or victimized by these uncomfortable advances, and I worry that by turning everyone into a victim of sexual harassment, then we detract from the stories of the women who were raped, molested, and those who were the victims of men who were maliciously taking advantage of a power differential. I don’t think we should dilute the message.” One friend (a woman) responded that if I felt uncomfortable, then I was harassed. Another friend (a man) responded that if I did not feel harmed, then I was not harassed.
With no clear definition, this does lead to the question of whether we might be turning everyone into victims and if that is good for our collective psyches. What we don’t seem to say is that if everyone is a victim of something – if not sexual assault or harassment, then something else – then doesn’t that also make everyone a perpetrator? Cam Newton, for instance, has been an advocate of kneeling to oppose institutional racism and, in terms of his own victimization, I would add that he also is the victim of a sport that now knowingly inflicts permanent and disabling brain damage on healthy young men. And now he is not just a victim, he is also a sexist perpetrator, unworthy of endorsing something as wholesome as yogurt.
Other concerns about the #MeToo campaign have also been expressed on social media. Might those who have been victimized feel pressured to publicly announce their victimization? Might the campaign trigger women to recall troubling events that were safely suppressed? While I would not personally use the terms “victimized,” “triggered,” or “harassed,” to describe myself, I would say that the campaign, like many things I see on social media, left me to think about events I had not considered in many years. That’s not necessarily bad: I like revisiting old memories, but others certainly may not. It does leave us to ask how we can live in a society where we can’t openly address our horrors for fear that the victims might be forced to relive them.
And what do we do about these issues with our patients? As a psychotherapist, I don’t live in a comfortable world. Patients often do and say things that make me personally uneasy, and I never considered the idea that I might be entitled to live without such discomfort. The mandate of psychotherapy for the patient is to talk openly about that which is on his or her mind and for the therapist to provide a safe space for thoughts that might be unacceptable in other settings. Patients talk of behaviors that make me worry for their safety. Some talk of sexual fantasies that are demeaning to others. Others are openly sexist, racist, anti-Semitic, or supportive of political ideologies that I strongly oppose. This can be hard work.
Was my mother right? Or was she dismissive? It was good that I always felt she was in my corner cheering me on. Obviously, it’s not just a saying, but a mindset that gets transmitted, sometimes successfully breeding resilience, and sometimes not. Certainly, I have seen that patients feel helped when I have validated their victimization. I have also seen people reassess their values when I have pointed out alternative ways about thinking about situations. I have not found it particularly helpful to tell people that their wounds are not so bad and others have it worse. While I don’t tell patients that sticks and stones will break their bones and names will never hurt them, I do sometimes gently tell them that I wish I could have them dipped in tin so that they would have stronger armor and so that the insensitive words of others might roll off without injuring them so. And as with all communications in our chaotic world, it’s often not the exact words that matter, but rather the context, the tone, and the intention with which they are said.
Sometimes, there really are clear victims and clear perpetrators, but in our world today, one can be both and the sides can be blurry. We are all trying to negotiate a society where words, spoken or unspoken, well-considered or not, have become weapons. Who gets to be comfortable and protected, we might ask, and who does not? Perhaps, in the end, we are left with the possibility that there are no safe spaces.
With thanks to Dr. Emile Bendit for considering the #MeToo hashtag with me.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The battle over involuntary psychiatric care” (Baltimore: Johns Hopkins University Press, 2016).
I can still hear my mother saying these words: “Sticks and stones will break your bones but names will never hurt you.” It was a call for resilience, in a world that wasn’t always kind, but where the expectation was clear: I was to let insults roll off me.
We live in a different world now, one in which there are divisions between the good and the bad, where children have the right not to be called names by bullies. Our college students want safe spaces where they won’t hear offensive ideologies and trigger warnings if they are to be exposed to anything that may rekindle a past trauma.
If you’ve been following social media, then you might be familiar with the #MeToo topic that traveled after the public was made aware of the despicable, sexually aggressive behavior of acclaimed film executive Harvey Weinstein. Actress Alyssa Milano put out a call on social media: “Suggested by a friend: If all the women who have been sexually harassed or assaulted wrote ‘Me too’ as a status, we might give people a sense of the magnitude of the problem.” Others have noted that in medicine, it might well be that 100% of women have been harassed. The hashtag took off, and millions of people wrote #MeToo on their social media sites, including four female U.S. senators who told their stories.
On my personal Facebook page, I voiced a concern about the #MeToo tag. I noted that there were times when men had said some inappropriate things to me and I’d felt uncomfortable. I went on to write, “I don’t feel I was changed, harmed, or victimized by these uncomfortable advances, and I worry that by turning everyone into a victim of sexual harassment, then we detract from the stories of the women who were raped, molested, and those who were the victims of men who were maliciously taking advantage of a power differential. I don’t think we should dilute the message.” One friend (a woman) responded that if I felt uncomfortable, then I was harassed. Another friend (a man) responded that if I did not feel harmed, then I was not harassed.
With no clear definition, this does lead to the question of whether we might be turning everyone into victims and if that is good for our collective psyches. What we don’t seem to say is that if everyone is a victim of something – if not sexual assault or harassment, then something else – then doesn’t that also make everyone a perpetrator? Cam Newton, for instance, has been an advocate of kneeling to oppose institutional racism and, in terms of his own victimization, I would add that he also is the victim of a sport that now knowingly inflicts permanent and disabling brain damage on healthy young men. And now he is not just a victim, he is also a sexist perpetrator, unworthy of endorsing something as wholesome as yogurt.
Other concerns about the #MeToo campaign have also been expressed on social media. Might those who have been victimized feel pressured to publicly announce their victimization? Might the campaign trigger women to recall troubling events that were safely suppressed? While I would not personally use the terms “victimized,” “triggered,” or “harassed,” to describe myself, I would say that the campaign, like many things I see on social media, left me to think about events I had not considered in many years. That’s not necessarily bad: I like revisiting old memories, but others certainly may not. It does leave us to ask how we can live in a society where we can’t openly address our horrors for fear that the victims might be forced to relive them.
And what do we do about these issues with our patients? As a psychotherapist, I don’t live in a comfortable world. Patients often do and say things that make me personally uneasy, and I never considered the idea that I might be entitled to live without such discomfort. The mandate of psychotherapy for the patient is to talk openly about that which is on his or her mind and for the therapist to provide a safe space for thoughts that might be unacceptable in other settings. Patients talk of behaviors that make me worry for their safety. Some talk of sexual fantasies that are demeaning to others. Others are openly sexist, racist, anti-Semitic, or supportive of political ideologies that I strongly oppose. This can be hard work.
Was my mother right? Or was she dismissive? It was good that I always felt she was in my corner cheering me on. Obviously, it’s not just a saying, but a mindset that gets transmitted, sometimes successfully breeding resilience, and sometimes not. Certainly, I have seen that patients feel helped when I have validated their victimization. I have also seen people reassess their values when I have pointed out alternative ways about thinking about situations. I have not found it particularly helpful to tell people that their wounds are not so bad and others have it worse. While I don’t tell patients that sticks and stones will break their bones and names will never hurt them, I do sometimes gently tell them that I wish I could have them dipped in tin so that they would have stronger armor and so that the insensitive words of others might roll off without injuring them so. And as with all communications in our chaotic world, it’s often not the exact words that matter, but rather the context, the tone, and the intention with which they are said.
Sometimes, there really are clear victims and clear perpetrators, but in our world today, one can be both and the sides can be blurry. We are all trying to negotiate a society where words, spoken or unspoken, well-considered or not, have become weapons. Who gets to be comfortable and protected, we might ask, and who does not? Perhaps, in the end, we are left with the possibility that there are no safe spaces.
With thanks to Dr. Emile Bendit for considering the #MeToo hashtag with me.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The battle over involuntary psychiatric care” (Baltimore: Johns Hopkins University Press, 2016).
I can still hear my mother saying these words: “Sticks and stones will break your bones but names will never hurt you.” It was a call for resilience, in a world that wasn’t always kind, but where the expectation was clear: I was to let insults roll off me.
We live in a different world now, one in which there are divisions between the good and the bad, where children have the right not to be called names by bullies. Our college students want safe spaces where they won’t hear offensive ideologies and trigger warnings if they are to be exposed to anything that may rekindle a past trauma.
If you’ve been following social media, then you might be familiar with the #MeToo topic that traveled after the public was made aware of the despicable, sexually aggressive behavior of acclaimed film executive Harvey Weinstein. Actress Alyssa Milano put out a call on social media: “Suggested by a friend: If all the women who have been sexually harassed or assaulted wrote ‘Me too’ as a status, we might give people a sense of the magnitude of the problem.” Others have noted that in medicine, it might well be that 100% of women have been harassed. The hashtag took off, and millions of people wrote #MeToo on their social media sites, including four female U.S. senators who told their stories.
On my personal Facebook page, I voiced a concern about the #MeToo tag. I noted that there were times when men had said some inappropriate things to me and I’d felt uncomfortable. I went on to write, “I don’t feel I was changed, harmed, or victimized by these uncomfortable advances, and I worry that by turning everyone into a victim of sexual harassment, then we detract from the stories of the women who were raped, molested, and those who were the victims of men who were maliciously taking advantage of a power differential. I don’t think we should dilute the message.” One friend (a woman) responded that if I felt uncomfortable, then I was harassed. Another friend (a man) responded that if I did not feel harmed, then I was not harassed.
With no clear definition, this does lead to the question of whether we might be turning everyone into victims and if that is good for our collective psyches. What we don’t seem to say is that if everyone is a victim of something – if not sexual assault or harassment, then something else – then doesn’t that also make everyone a perpetrator? Cam Newton, for instance, has been an advocate of kneeling to oppose institutional racism and, in terms of his own victimization, I would add that he also is the victim of a sport that now knowingly inflicts permanent and disabling brain damage on healthy young men. And now he is not just a victim, he is also a sexist perpetrator, unworthy of endorsing something as wholesome as yogurt.
Other concerns about the #MeToo campaign have also been expressed on social media. Might those who have been victimized feel pressured to publicly announce their victimization? Might the campaign trigger women to recall troubling events that were safely suppressed? While I would not personally use the terms “victimized,” “triggered,” or “harassed,” to describe myself, I would say that the campaign, like many things I see on social media, left me to think about events I had not considered in many years. That’s not necessarily bad: I like revisiting old memories, but others certainly may not. It does leave us to ask how we can live in a society where we can’t openly address our horrors for fear that the victims might be forced to relive them.
And what do we do about these issues with our patients? As a psychotherapist, I don’t live in a comfortable world. Patients often do and say things that make me personally uneasy, and I never considered the idea that I might be entitled to live without such discomfort. The mandate of psychotherapy for the patient is to talk openly about that which is on his or her mind and for the therapist to provide a safe space for thoughts that might be unacceptable in other settings. Patients talk of behaviors that make me worry for their safety. Some talk of sexual fantasies that are demeaning to others. Others are openly sexist, racist, anti-Semitic, or supportive of political ideologies that I strongly oppose. This can be hard work.
Was my mother right? Or was she dismissive? It was good that I always felt she was in my corner cheering me on. Obviously, it’s not just a saying, but a mindset that gets transmitted, sometimes successfully breeding resilience, and sometimes not. Certainly, I have seen that patients feel helped when I have validated their victimization. I have also seen people reassess their values when I have pointed out alternative ways about thinking about situations. I have not found it particularly helpful to tell people that their wounds are not so bad and others have it worse. While I don’t tell patients that sticks and stones will break their bones and names will never hurt them, I do sometimes gently tell them that I wish I could have them dipped in tin so that they would have stronger armor and so that the insensitive words of others might roll off without injuring them so. And as with all communications in our chaotic world, it’s often not the exact words that matter, but rather the context, the tone, and the intention with which they are said.
Sometimes, there really are clear victims and clear perpetrators, but in our world today, one can be both and the sides can be blurry. We are all trying to negotiate a society where words, spoken or unspoken, well-considered or not, have become weapons. Who gets to be comfortable and protected, we might ask, and who does not? Perhaps, in the end, we are left with the possibility that there are no safe spaces.
With thanks to Dr. Emile Bendit for considering the #MeToo hashtag with me.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The battle over involuntary psychiatric care” (Baltimore: Johns Hopkins University Press, 2016).