Many breakthroughs have been achieved through gastroenterological and hepatological research over the past century, forming the basis of the modern medical practice. As the charitable arm of the American Gastroenterological Association (AGA), the AGA Research Foundation contributes to this tradition of discovery by providing a key source of funding at a critical juncture in a young researcher’s career.

“The Research Scholar Award will have a pivotal effect on my future career,” said Michael Dougan, MD, PhD, Massachusetts General Hospital, Boston, 2017 Research Scholar Award recipient. “This award enables me to establish my own research infrastructure, and lay the experimental foundations for my future work as a clinician‐scientist striving to understand the complex interplay between the immune system, metabolism, and cancer.”

[email protected]

Many breakthroughs have been achieved through gastroenterological and hepatological research over the past century, forming the basis of the modern medical practice. As the charitable arm of the American Gastroenterological Association (AGA), the AGA Research Foundation contributes to this tradition of discovery by providing a key source of funding at a critical juncture in a young researcher’s career.

“The Research Scholar Award will have a pivotal effect on my future career,” said Michael Dougan, MD, PhD, Massachusetts General Hospital, Boston, 2017 Research Scholar Award recipient. “This award enables me to establish my own research infrastructure, and lay the experimental foundations for my future work as a clinician‐scientist striving to understand the complex interplay between the immune system, metabolism, and cancer.”

[email protected]

Many breakthroughs have been achieved through gastroenterological and hepatological research over the past century, forming the basis of the modern medical practice. As the charitable arm of the American Gastroenterological Association (AGA), the AGA Research Foundation contributes to this tradition of discovery by providing a key source of funding at a critical juncture in a young researcher’s career.

“The Research Scholar Award will have a pivotal effect on my future career,” said Michael Dougan, MD, PhD, Massachusetts General Hospital, Boston, 2017 Research Scholar Award recipient. “This award enables me to establish my own research infrastructure, and lay the experimental foundations for my future work as a clinician‐scientist striving to understand the complex interplay between the immune system, metabolism, and cancer.”

[email protected]

BY AYAN KUSARI AND CATALINA MATIZ, MD

The patient was diagnosed with eruptive vellus hair cysts (EVHC). Treatment with a keratolytic, such as 12% lactic acid cream, was recommended. Hydrocortisone 2.5% once daily as needed also was recommended to treat the patient’s itch.

EVHC are benign middermal cysts characterized by epidermoid keratinization of the cyst wall, as well as lamellar keratin and vellus hairs within the cyst.¹ The term “eruptive vellus hair cysts” was first used to describe a longstanding hyperpigmented, monomorphous papular eruption in two children by Esterly, Fretzin, and Pinkus in 1977.² Clinically, EVHC present as 1- to 3-mm follicular, dome-shaped papules that are often skin-colored but also have been described as being brown, gray, green or black colored.^3,4 They appear suddenly and sometimes are associated with mild tenderness and pruritus.^1,5 EVHC most commonly present on the anterior chest but also can present on the upper and lower extremities, face, neck, axillae, and buttocks.⁴

Furthermore, although spontaneous resolution is possible through transepidermal elimination of cyst products, cases may persist for years in the absence of treatment.¹

Accurate diagnosis of eruptive vellus hair cysts is important to guide therapy.

Keratosis pilaris consists of follicular-based papules with variable erythema.⁴ It may be widespread – including over the anterior chest – but is most commonly seen on the cheeks, extensor surfaces of proximal upper extremities, and the anterior thighs.⁴ It is related to excessive keratinization, which leads to formation of horny plugs within hair-follicle orifices.¹

Steatocystoma multiplex is typically characterized by firm, yellow-to-flesh–colored dermal cysts ranging from a few millimeters to 1 cm in size.¹ They are sometimes clinically hard to distinguish from EVHC, and both are associated with keratin 17 gene mutations and type 2 pachyonychia congenita.¹ Nonetheless, this patient’s lesions did not have any features – such as size or drainage – that would point toward steatocystoma multiplex or other skin findings suggestive of pachyonychia congenita.

Superficial folliculitis, also known as Bockhart’s impetigo, is an infection of the follicular ostium and typically presents with perifollicular pustules on an erythematous base that may be painful or pruritic and can occur throughout the corpus, including the anterior trunk.¹

Acne vulgaris is a very common disease that involves the pilosebaceous unit and occurs most frequently on the face, back, upper arms, and chest. However, it is characterized by open and closed comedones, papules, and pustules and, in severe cases, nodules and cysts that may leave postinflammatory hyperpigmentation and scarring. Tiny, hyperpigmented, dome-shaped macules occurring exclusively on the chest would not be characteristic.

Patients with hypohidrotic ectodermal dysplasia, also known as Christ-Siemens-Touraine syndrome, can present with EVHC. This condition is characterized by a triad of fair, sparse short hair; hyperthermia related to decreased sweating; and missing teeth.⁴ Although EVHC have been reported in association with hypohidrotic ectodermal dysplasia, this patient does not have any of the dysmorphic features associated with this syndrome.¹¹

Patients with pachyonychia congenita (type 2) also may have EVHC as part of their presentation, but this patient does not have nail dystrophy, focal palmoplantar keratoderma, follicular keratoses, or multiple steatocysts which also are features of this condition.⁴

Treatment may be offered to patients who are distressed by the lesions or seek cosmesis. A 2012 review of 220 cases of EVHC found that topical retinoic acid, incision/excision, CO2 laser, erbium:yttrium-aluminum-garnet laser, needle evacuation, dermabrasion, and 10% urea cream were each associated with successful treatment in multiple cases.³

Forty years have passed since EVHC was identified as a distinct disease entity. Despite this, eruptive vellus hair cysts remains somewhat understudied, and further research is needed to determine an ideal treatment algorithm for patients with this condition. Our approach was to attempt noninvasive keratolytic therapy before considering retinoids or surgical options; we also recommended steroid treatment for symptom relief. Providers should keep EVHC in the differential for eruptions consisting of tiny papules so that appropriate treatment may be offered.

Dr. Matiz is a pediatric dermatologist at Rady Children’s Hospital, San Diego, and an assistant clinical professor in the department of pediatric and adolescent dermatology at the University of California, San Diego. Mr. Kusari is a medical student at the University of California, San Diego. Dr. Matiz and Mr. Kusari said they had no relevant financial disclosures.

Email them at [email protected].

References

1. “Dermatology.” 3rd ed. (Philadelphia: Saunders, 2012).

2. Arch Dermatol. 1977 Apr;113(4):500-3.

3. Am J Clin Dermatol. 2012 Feb 1;13(1):19-28.

4. “Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence.” 4th ed. (Philadelphia: Saunders, 2011).

5. Indian Dermatol Online J. 2013 Jul;4(3):213-5.

6. J Am Acad Dermatol. 1980 Oct;3(4):425-9.

7. Am J Dermatopathol. 1997 Jun;19(3):250-3.

8. Hum Mol Genet. 1998 Jul;7(7):1143-8.

9. Dermatology. 1998;196(4):392-6.

10. Arch Dermatol. 1986 Feb;122(2):141.

11. Int J Dermatol. 2001 Jun;40(6):401-2.

BY AYAN KUSARI AND CATALINA MATIZ, MD

The patient was diagnosed with eruptive vellus hair cysts (EVHC). Treatment with a keratolytic, such as 12% lactic acid cream, was recommended. Hydrocortisone 2.5% once daily as needed also was recommended to treat the patient’s itch.

EVHC are benign middermal cysts characterized by epidermoid keratinization of the cyst wall, as well as lamellar keratin and vellus hairs within the cyst.¹ The term “eruptive vellus hair cysts” was first used to describe a longstanding hyperpigmented, monomorphous papular eruption in two children by Esterly, Fretzin, and Pinkus in 1977.² Clinically, EVHC present as 1- to 3-mm follicular, dome-shaped papules that are often skin-colored but also have been described as being brown, gray, green or black colored.^3,4 They appear suddenly and sometimes are associated with mild tenderness and pruritus.^1,5 EVHC most commonly present on the anterior chest but also can present on the upper and lower extremities, face, neck, axillae, and buttocks.⁴

Furthermore, although spontaneous resolution is possible through transepidermal elimination of cyst products, cases may persist for years in the absence of treatment.¹

Accurate diagnosis of eruptive vellus hair cysts is important to guide therapy.

Keratosis pilaris consists of follicular-based papules with variable erythema.⁴ It may be widespread – including over the anterior chest – but is most commonly seen on the cheeks, extensor surfaces of proximal upper extremities, and the anterior thighs.⁴ It is related to excessive keratinization, which leads to formation of horny plugs within hair-follicle orifices.¹

Steatocystoma multiplex is typically characterized by firm, yellow-to-flesh–colored dermal cysts ranging from a few millimeters to 1 cm in size.¹ They are sometimes clinically hard to distinguish from EVHC, and both are associated with keratin 17 gene mutations and type 2 pachyonychia congenita.¹ Nonetheless, this patient’s lesions did not have any features – such as size or drainage – that would point toward steatocystoma multiplex or other skin findings suggestive of pachyonychia congenita.

Superficial folliculitis, also known as Bockhart’s impetigo, is an infection of the follicular ostium and typically presents with perifollicular pustules on an erythematous base that may be painful or pruritic and can occur throughout the corpus, including the anterior trunk.¹

Acne vulgaris is a very common disease that involves the pilosebaceous unit and occurs most frequently on the face, back, upper arms, and chest. However, it is characterized by open and closed comedones, papules, and pustules and, in severe cases, nodules and cysts that may leave postinflammatory hyperpigmentation and scarring. Tiny, hyperpigmented, dome-shaped macules occurring exclusively on the chest would not be characteristic.

Patients with hypohidrotic ectodermal dysplasia, also known as Christ-Siemens-Touraine syndrome, can present with EVHC. This condition is characterized by a triad of fair, sparse short hair; hyperthermia related to decreased sweating; and missing teeth.⁴ Although EVHC have been reported in association with hypohidrotic ectodermal dysplasia, this patient does not have any of the dysmorphic features associated with this syndrome.¹¹

Patients with pachyonychia congenita (type 2) also may have EVHC as part of their presentation, but this patient does not have nail dystrophy, focal palmoplantar keratoderma, follicular keratoses, or multiple steatocysts which also are features of this condition.⁴

Treatment may be offered to patients who are distressed by the lesions or seek cosmesis. A 2012 review of 220 cases of EVHC found that topical retinoic acid, incision/excision, CO2 laser, erbium:yttrium-aluminum-garnet laser, needle evacuation, dermabrasion, and 10% urea cream were each associated with successful treatment in multiple cases.³

Forty years have passed since EVHC was identified as a distinct disease entity. Despite this, eruptive vellus hair cysts remains somewhat understudied, and further research is needed to determine an ideal treatment algorithm for patients with this condition. Our approach was to attempt noninvasive keratolytic therapy before considering retinoids or surgical options; we also recommended steroid treatment for symptom relief. Providers should keep EVHC in the differential for eruptions consisting of tiny papules so that appropriate treatment may be offered.

Dr. Matiz is a pediatric dermatologist at Rady Children’s Hospital, San Diego, and an assistant clinical professor in the department of pediatric and adolescent dermatology at the University of California, San Diego. Mr. Kusari is a medical student at the University of California, San Diego. Dr. Matiz and Mr. Kusari said they had no relevant financial disclosures.

Email them at [email protected].

References

1. “Dermatology.” 3rd ed. (Philadelphia: Saunders, 2012).

2. Arch Dermatol. 1977 Apr;113(4):500-3.

3. Am J Clin Dermatol. 2012 Feb 1;13(1):19-28.

4. “Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence.” 4th ed. (Philadelphia: Saunders, 2011).

5. Indian Dermatol Online J. 2013 Jul;4(3):213-5.

6. J Am Acad Dermatol. 1980 Oct;3(4):425-9.

7. Am J Dermatopathol. 1997 Jun;19(3):250-3.

8. Hum Mol Genet. 1998 Jul;7(7):1143-8.

9. Dermatology. 1998;196(4):392-6.

10. Arch Dermatol. 1986 Feb;122(2):141.

11. Int J Dermatol. 2001 Jun;40(6):401-2.

BY AYAN KUSARI AND CATALINA MATIZ, MD

The patient was diagnosed with eruptive vellus hair cysts (EVHC). Treatment with a keratolytic, such as 12% lactic acid cream, was recommended. Hydrocortisone 2.5% once daily as needed also was recommended to treat the patient’s itch.

EVHC are benign middermal cysts characterized by epidermoid keratinization of the cyst wall, as well as lamellar keratin and vellus hairs within the cyst.¹ The term “eruptive vellus hair cysts” was first used to describe a longstanding hyperpigmented, monomorphous papular eruption in two children by Esterly, Fretzin, and Pinkus in 1977.² Clinically, EVHC present as 1- to 3-mm follicular, dome-shaped papules that are often skin-colored but also have been described as being brown, gray, green or black colored.^3,4 They appear suddenly and sometimes are associated with mild tenderness and pruritus.^1,5 EVHC most commonly present on the anterior chest but also can present on the upper and lower extremities, face, neck, axillae, and buttocks.⁴

Furthermore, although spontaneous resolution is possible through transepidermal elimination of cyst products, cases may persist for years in the absence of treatment.¹

Accurate diagnosis of eruptive vellus hair cysts is important to guide therapy.

Keratosis pilaris consists of follicular-based papules with variable erythema.⁴ It may be widespread – including over the anterior chest – but is most commonly seen on the cheeks, extensor surfaces of proximal upper extremities, and the anterior thighs.⁴ It is related to excessive keratinization, which leads to formation of horny plugs within hair-follicle orifices.¹

Steatocystoma multiplex is typically characterized by firm, yellow-to-flesh–colored dermal cysts ranging from a few millimeters to 1 cm in size.¹ They are sometimes clinically hard to distinguish from EVHC, and both are associated with keratin 17 gene mutations and type 2 pachyonychia congenita.¹ Nonetheless, this patient’s lesions did not have any features – such as size or drainage – that would point toward steatocystoma multiplex or other skin findings suggestive of pachyonychia congenita.

Superficial folliculitis, also known as Bockhart’s impetigo, is an infection of the follicular ostium and typically presents with perifollicular pustules on an erythematous base that may be painful or pruritic and can occur throughout the corpus, including the anterior trunk.¹

Acne vulgaris is a very common disease that involves the pilosebaceous unit and occurs most frequently on the face, back, upper arms, and chest. However, it is characterized by open and closed comedones, papules, and pustules and, in severe cases, nodules and cysts that may leave postinflammatory hyperpigmentation and scarring. Tiny, hyperpigmented, dome-shaped macules occurring exclusively on the chest would not be characteristic.

Patients with hypohidrotic ectodermal dysplasia, also known as Christ-Siemens-Touraine syndrome, can present with EVHC. This condition is characterized by a triad of fair, sparse short hair; hyperthermia related to decreased sweating; and missing teeth.⁴ Although EVHC have been reported in association with hypohidrotic ectodermal dysplasia, this patient does not have any of the dysmorphic features associated with this syndrome.¹¹

Patients with pachyonychia congenita (type 2) also may have EVHC as part of their presentation, but this patient does not have nail dystrophy, focal palmoplantar keratoderma, follicular keratoses, or multiple steatocysts which also are features of this condition.⁴

Treatment may be offered to patients who are distressed by the lesions or seek cosmesis. A 2012 review of 220 cases of EVHC found that topical retinoic acid, incision/excision, CO2 laser, erbium:yttrium-aluminum-garnet laser, needle evacuation, dermabrasion, and 10% urea cream were each associated with successful treatment in multiple cases.³

Forty years have passed since EVHC was identified as a distinct disease entity. Despite this, eruptive vellus hair cysts remains somewhat understudied, and further research is needed to determine an ideal treatment algorithm for patients with this condition. Our approach was to attempt noninvasive keratolytic therapy before considering retinoids or surgical options; we also recommended steroid treatment for symptom relief. Providers should keep EVHC in the differential for eruptions consisting of tiny papules so that appropriate treatment may be offered.

Dr. Matiz is a pediatric dermatologist at Rady Children’s Hospital, San Diego, and an assistant clinical professor in the department of pediatric and adolescent dermatology at the University of California, San Diego. Mr. Kusari is a medical student at the University of California, San Diego. Dr. Matiz and Mr. Kusari said they had no relevant financial disclosures.

Email them at [email protected].

References

1. “Dermatology.” 3rd ed. (Philadelphia: Saunders, 2012).

2. Arch Dermatol. 1977 Apr;113(4):500-3.

3. Am J Clin Dermatol. 2012 Feb 1;13(1):19-28.

4. “Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence.” 4th ed. (Philadelphia: Saunders, 2011).

5. Indian Dermatol Online J. 2013 Jul;4(3):213-5.

6. J Am Acad Dermatol. 1980 Oct;3(4):425-9.

7. Am J Dermatopathol. 1997 Jun;19(3):250-3.

8. Hum Mol Genet. 1998 Jul;7(7):1143-8.

9. Dermatology. 1998;196(4):392-6.

10. Arch Dermatol. 1986 Feb;122(2):141.

11. Int J Dermatol. 2001 Jun;40(6):401-2.

CMS released the Medicare Inpatient Prospective Payment System (IPPS) final rule, which affects hospital payments and includes provisions for ambulatory surgery centers (ASCs) and physician payments.

Thanks to the AGA members who submitted comments to the proposed rule, CMS withdrew plans to publicly post facility accreditation reviews and correction plans. Below is a summary of AGA’s position and where CMS landed on each issue.
 

1. Public display of final accreditation surveys and plans of correction.

Summary of AGA position – AGA urged CMS to withdraw its proposal making ASC accreditation surveys open to the public. To support shared transparency objectives, AGA recommended that if CMS were to finalize its proposal, the agency should first develop standards and a framework that considers both violation severity and scope.

CMS final rule – After consideration of the public comments received, CMS will not make ASC accreditation surveys open to the public. CMS was concerned that the suggestion to have accrediting organizations post their survey reports would appear as if it was attempting to circumvent current law, which prohibits CMS from disclosing survey reports or compelling the accrediting organizations to disclose the reports themselves.
 

2. EHR Incentive Program certification requirements for payment year 2018.

Summary of AGA position – AGA supported increased flexibility for 2018 and urged CMS to allow use of EHR technology certified to the 2014 software edition OR the 2015 software edition for the 2018 EHR Incentive Program.

CMS final rule – CMS will allow health care providers to use either 2014 or 2015 CEHRT or a combination of 2014 and 2015 CEHRT for the 2018 EHR Incentive Program.
 

3. Exception for ASC-based physicians under the EHR Incentive Program for payment years 2017 and 2018.

Summary of AGA position – AGA encouraged CMS to define ASC-based as a physician or other eligible professional who provides more than 50% of Medicare billed services in an ASC. AGA was concerned that implementing a higher threshold would leave certain physicians exposed to payment penalties, because the meaningful use requirement is set at 50% or more.

CMS final rule – Unfortunately, CMS set the definition of “ASC-based” as those who provide 75% of all services in an ASC, based on previous statutory definitions.

Policy changes are effective on Oct. 1, 2017, and changes to the 2017 and 2018 EHR Incentive Program apply immediately to the 2015 and 2016 reporting period, and provide relief that will impact 2017 and 2018 payments.
 

[email protected]

CMS released the Medicare Inpatient Prospective Payment System (IPPS) final rule, which affects hospital payments and includes provisions for ambulatory surgery centers (ASCs) and physician payments.

Thanks to the AGA members who submitted comments to the proposed rule, CMS withdrew plans to publicly post facility accreditation reviews and correction plans. Below is a summary of AGA’s position and where CMS landed on each issue.
 

1. Public display of final accreditation surveys and plans of correction.

Summary of AGA position – AGA urged CMS to withdraw its proposal making ASC accreditation surveys open to the public. To support shared transparency objectives, AGA recommended that if CMS were to finalize its proposal, the agency should first develop standards and a framework that considers both violation severity and scope.

CMS final rule – After consideration of the public comments received, CMS will not make ASC accreditation surveys open to the public. CMS was concerned that the suggestion to have accrediting organizations post their survey reports would appear as if it was attempting to circumvent current law, which prohibits CMS from disclosing survey reports or compelling the accrediting organizations to disclose the reports themselves.
 

2. EHR Incentive Program certification requirements for payment year 2018.

Summary of AGA position – AGA supported increased flexibility for 2018 and urged CMS to allow use of EHR technology certified to the 2014 software edition OR the 2015 software edition for the 2018 EHR Incentive Program.

CMS final rule – CMS will allow health care providers to use either 2014 or 2015 CEHRT or a combination of 2014 and 2015 CEHRT for the 2018 EHR Incentive Program.
 

3. Exception for ASC-based physicians under the EHR Incentive Program for payment years 2017 and 2018.

Summary of AGA position – AGA encouraged CMS to define ASC-based as a physician or other eligible professional who provides more than 50% of Medicare billed services in an ASC. AGA was concerned that implementing a higher threshold would leave certain physicians exposed to payment penalties, because the meaningful use requirement is set at 50% or more.

CMS final rule – Unfortunately, CMS set the definition of “ASC-based” as those who provide 75% of all services in an ASC, based on previous statutory definitions.

Policy changes are effective on Oct. 1, 2017, and changes to the 2017 and 2018 EHR Incentive Program apply immediately to the 2015 and 2016 reporting period, and provide relief that will impact 2017 and 2018 payments.
 

[email protected]

CMS released the Medicare Inpatient Prospective Payment System (IPPS) final rule, which affects hospital payments and includes provisions for ambulatory surgery centers (ASCs) and physician payments.

Thanks to the AGA members who submitted comments to the proposed rule, CMS withdrew plans to publicly post facility accreditation reviews and correction plans. Below is a summary of AGA’s position and where CMS landed on each issue.
 

1. Public display of final accreditation surveys and plans of correction.

Summary of AGA position – AGA urged CMS to withdraw its proposal making ASC accreditation surveys open to the public. To support shared transparency objectives, AGA recommended that if CMS were to finalize its proposal, the agency should first develop standards and a framework that considers both violation severity and scope.

CMS final rule – After consideration of the public comments received, CMS will not make ASC accreditation surveys open to the public. CMS was concerned that the suggestion to have accrediting organizations post their survey reports would appear as if it was attempting to circumvent current law, which prohibits CMS from disclosing survey reports or compelling the accrediting organizations to disclose the reports themselves.
 

2. EHR Incentive Program certification requirements for payment year 2018.

Summary of AGA position – AGA supported increased flexibility for 2018 and urged CMS to allow use of EHR technology certified to the 2014 software edition OR the 2015 software edition for the 2018 EHR Incentive Program.

CMS final rule – CMS will allow health care providers to use either 2014 or 2015 CEHRT or a combination of 2014 and 2015 CEHRT for the 2018 EHR Incentive Program.
 

3. Exception for ASC-based physicians under the EHR Incentive Program for payment years 2017 and 2018.

Summary of AGA position – AGA encouraged CMS to define ASC-based as a physician or other eligible professional who provides more than 50% of Medicare billed services in an ASC. AGA was concerned that implementing a higher threshold would leave certain physicians exposed to payment penalties, because the meaningful use requirement is set at 50% or more.

CMS final rule – Unfortunately, CMS set the definition of “ASC-based” as those who provide 75% of all services in an ASC, based on previous statutory definitions.

Policy changes are effective on Oct. 1, 2017, and changes to the 2017 and 2018 EHR Incentive Program apply immediately to the 2015 and 2016 reporting period, and provide relief that will impact 2017 and 2018 payments.
 

[email protected]

Following the stressful divorce of her parents, this 8-year-old girl’s hair began to fall out, prompting her referral to dermatology. Along with the hair loss, she has mild itching and burning in the area.

The child has a history of several atopic phenomena, including seasonal allergies, asthma, and eczema—all of which are replete in her family’s history.

EXAMINATION
The child is in no distress and is quite willing to show the affected area—a sizeable (10 x 8 cm), roughly round area of complete hair loss involving the nuchal periphery of her scalp. Fortunately, the area is covered by longer hair that drapes down.

No epidermal changes (ie, redness, scaling, edema) are seen, and no nodes are palpable in the area. Her arms, brows, and lashes appear normal after careful examination.

What is the diagnosis?

However, the real significance of ophiasis is its uncertain prognosis. For this patient, the extent and type of hair loss, her young age, and her atopic history all predict a poor prognosis. The hair loss is likely to be slow to resolve, if it does at all. It could progress to loss of all scalp hair (alopecia totalis) or every hair on her body (alopecia universalis).

Compounding the problem is the fact that no good treatment exists for this autoimmune disease, which affects those with genetic predisposition. Topical steroid application or intralesional steroid injections (3 to 5 mg/cc triamcinolone suspension) can promote the growth of a few hairs, but neither have an effect on the ultimate outcome. There have been reports of benefit from injectable biologics and oral antimalarials, but these medications have not been approved for use in AA.

Histopathologic studies with special stains show a lymphocytic infiltrate surrounding the hair follicle that prevents the growth of new hairs. Glucocorticoids (eg, prednisone) resolve this and allow new hair growth, but the treatment must be continued for months with unjustifiable adverse effects. Even then, full resolution must come on its own.

This patient was treated with a month-long course of topical triamcinolone 0.1% cream. But as stated above, her prognosis is somewhat guarded.

TAKE-HOME LEARNING POINTS

• Alopecia areata (AA) is an autoimmune process and a common cause of localized hair loss.
• This hair loss is usually acute, complete, and round, and is often seen in multiple patches.
• Of the many forms of AA, this one (ophiasis) has a less certain prognosis, worsened by youth, atopy, and lesion size.
• While ordinary AA resolves on its own in most cases, ophiasis can progress into total loss of scalp hair (alopecia totalis) or loss of all body hair (alopecia universalis).

Following the stressful divorce of her parents, this 8-year-old girl’s hair began to fall out, prompting her referral to dermatology. Along with the hair loss, she has mild itching and burning in the area.

The child has a history of several atopic phenomena, including seasonal allergies, asthma, and eczema—all of which are replete in her family’s history.

EXAMINATION
The child is in no distress and is quite willing to show the affected area—a sizeable (10 x 8 cm), roughly round area of complete hair loss involving the nuchal periphery of her scalp. Fortunately, the area is covered by longer hair that drapes down.

No epidermal changes (ie, redness, scaling, edema) are seen, and no nodes are palpable in the area. Her arms, brows, and lashes appear normal after careful examination.

What is the diagnosis?

However, the real significance of ophiasis is its uncertain prognosis. For this patient, the extent and type of hair loss, her young age, and her atopic history all predict a poor prognosis. The hair loss is likely to be slow to resolve, if it does at all. It could progress to loss of all scalp hair (alopecia totalis) or every hair on her body (alopecia universalis).

Compounding the problem is the fact that no good treatment exists for this autoimmune disease, which affects those with genetic predisposition. Topical steroid application or intralesional steroid injections (3 to 5 mg/cc triamcinolone suspension) can promote the growth of a few hairs, but neither have an effect on the ultimate outcome. There have been reports of benefit from injectable biologics and oral antimalarials, but these medications have not been approved for use in AA.

Histopathologic studies with special stains show a lymphocytic infiltrate surrounding the hair follicle that prevents the growth of new hairs. Glucocorticoids (eg, prednisone) resolve this and allow new hair growth, but the treatment must be continued for months with unjustifiable adverse effects. Even then, full resolution must come on its own.

This patient was treated with a month-long course of topical triamcinolone 0.1% cream. But as stated above, her prognosis is somewhat guarded.

TAKE-HOME LEARNING POINTS

• Alopecia areata (AA) is an autoimmune process and a common cause of localized hair loss.
• This hair loss is usually acute, complete, and round, and is often seen in multiple patches.
• Of the many forms of AA, this one (ophiasis) has a less certain prognosis, worsened by youth, atopy, and lesion size.
• While ordinary AA resolves on its own in most cases, ophiasis can progress into total loss of scalp hair (alopecia totalis) or loss of all body hair (alopecia universalis).

Following the stressful divorce of her parents, this 8-year-old girl’s hair began to fall out, prompting her referral to dermatology. Along with the hair loss, she has mild itching and burning in the area.

The child has a history of several atopic phenomena, including seasonal allergies, asthma, and eczema—all of which are replete in her family’s history.

EXAMINATION
The child is in no distress and is quite willing to show the affected area—a sizeable (10 x 8 cm), roughly round area of complete hair loss involving the nuchal periphery of her scalp. Fortunately, the area is covered by longer hair that drapes down.

No epidermal changes (ie, redness, scaling, edema) are seen, and no nodes are palpable in the area. Her arms, brows, and lashes appear normal after careful examination.

What is the diagnosis?

However, the real significance of ophiasis is its uncertain prognosis. For this patient, the extent and type of hair loss, her young age, and her atopic history all predict a poor prognosis. The hair loss is likely to be slow to resolve, if it does at all. It could progress to loss of all scalp hair (alopecia totalis) or every hair on her body (alopecia universalis).

Compounding the problem is the fact that no good treatment exists for this autoimmune disease, which affects those with genetic predisposition. Topical steroid application or intralesional steroid injections (3 to 5 mg/cc triamcinolone suspension) can promote the growth of a few hairs, but neither have an effect on the ultimate outcome. There have been reports of benefit from injectable biologics and oral antimalarials, but these medications have not been approved for use in AA.

Histopathologic studies with special stains show a lymphocytic infiltrate surrounding the hair follicle that prevents the growth of new hairs. Glucocorticoids (eg, prednisone) resolve this and allow new hair growth, but the treatment must be continued for months with unjustifiable adverse effects. Even then, full resolution must come on its own.

This patient was treated with a month-long course of topical triamcinolone 0.1% cream. But as stated above, her prognosis is somewhat guarded.

TAKE-HOME LEARNING POINTS

• Alopecia areata (AA) is an autoimmune process and a common cause of localized hair loss.
• This hair loss is usually acute, complete, and round, and is often seen in multiple patches.
• Of the many forms of AA, this one (ophiasis) has a less certain prognosis, worsened by youth, atopy, and lesion size.
• While ordinary AA resolves on its own in most cases, ophiasis can progress into total loss of scalp hair (alopecia totalis) or loss of all body hair (alopecia universalis).

SAN FRANCISCO – Blistering diseases are easily misdiagnosed and may resemble psoriasis or other conditions, but a routine histology and clinical examination aren’t sufficient diagnostic starting points.

“You have to have some kind of immunological test,” according to Peter Marinkovich, MD. “Pathologists will try to give you as much information as they can on the routine histology, but don’t use that as a diagnostic.”

If not properly identified, autoimmune blistering diseases can lead to chronic overexposure to steroids and resultant side effects without addressing the underlying problem, said Dr. Marinkovich of the department of dermatology at Stanford (Calif.) University.

Dr. Marinkovich gave one example of a patient who had been diagnosed with bullous pemphigoid several years before, and who was becoming Cushingoid as a result of steroids. But the diagnosis was made on the basis of histopathology and clinical appearance alone.

“Nobody had done the immunofluorescence test,” he explained at the annual meeting of the Pacific Dermatologic Association. “I did it, and it turned out she had linear IgA disease. The patient went through 2 years of toxicity just because nobody had done the immunofluorescence test.” Instead, the patient improved when placed on dapsone, which is much less toxic than prednisone.

Direct/indirect immunofluorescence is the highest-yield test for patients with blistering disease. “It’s the best way, I believe, to make the diagnosis,” Dr. Marinkovich said. If that test isn’t available, serum taken during an active phase can also be used. But serum samples can turn up false negatives, so dermatologists should consider collecting and testing serum samples several times.

Another useful tool is salt-split skin analysis, which will demarcate antigens to the roof or floor of the blister. Specifically, it helps distinguish bullous pemphigoid and epidermolysis bullosa acquisita.

In the future, Dr. Marinkovich said, ELISA (enzyme-linked immunosorbent assay) testing will have greater importance for diagnosis and disease monitoring, not just for pemphigus but for subepidermal bullous disorders as well.

Autoimmune blistering diseases do respond to prednisone treatment, although not as well as some other conditions. However, symptom improvement can mask the true cause of the disease.

“It’s easy for physicians to give steroids, and the patients will be happy for the time being; but that doesn’t solve the problem in the long term,” Dr. Marinkovich cautioned. “These are chronic conditions, and the patient will continue to require prednisone, and they’ll get more and more side effects, which could have been avoided if someone had done a more thorough investigation.”

Topical agents such as tetracycline, niacinamide, and topical steroids are more useful in pemphigoid than for pemphigus, because pemphigoid involves local immune factors that the agents can target, while pemphigus can be driven by antibodies alone, which are not as responsive to these treatments.

When systemic therapies are necessary, prednisone is a useful tool, but aim for the lowest possible dose, he said. Reducing prednisone dose is challenging in and of itself. Dropping the dose too quickly can lead to more long-term exposure, because a steep drop can lead to a rebound in the disease, which leads to a higher dose.

“The patient is on this roller coaster ride, up and down, up and down, and that alone can ramp up disease activity,” said Dr. Marinkovich. “Lowering steroid more steadily is a better way to go. This calms the disease down by itself.”

When steroids can’t be completely tapered, which is almost always the case in pemphigus and common in pemphigoid, add steroid-sparing agents such as mycophenolate and azathioprine.

If the steroid-sparing agents don’t get patients down to 10 mg/day prednisone or below, then consider using rituximab and intravenous IgG.

In Europe, physicians are using rituximab earlier in the course of disease, a strategy that appeared effective in a study published in the Lancet (2017 May 20;389[10083]:2031-40). “The evidence suggests to me that earlier use of rituximab tends to reduce the total amount of steroids that the patients are using and has the potential to reduce the duration of the disease,” Dr. Marinkovich said. “That’s a trend that will be going on in the next couple of years here in the United States.”

Dr. Marinkovich is an investigator on a clinical trial funded by Syntimmune.

SAN FRANCISCO – Blistering diseases are easily misdiagnosed and may resemble psoriasis or other conditions, but a routine histology and clinical examination aren’t sufficient diagnostic starting points.

“You have to have some kind of immunological test,” according to Peter Marinkovich, MD. “Pathologists will try to give you as much information as they can on the routine histology, but don’t use that as a diagnostic.”

If not properly identified, autoimmune blistering diseases can lead to chronic overexposure to steroids and resultant side effects without addressing the underlying problem, said Dr. Marinkovich of the department of dermatology at Stanford (Calif.) University.

Dr. Marinkovich gave one example of a patient who had been diagnosed with bullous pemphigoid several years before, and who was becoming Cushingoid as a result of steroids. But the diagnosis was made on the basis of histopathology and clinical appearance alone.

“Nobody had done the immunofluorescence test,” he explained at the annual meeting of the Pacific Dermatologic Association. “I did it, and it turned out she had linear IgA disease. The patient went through 2 years of toxicity just because nobody had done the immunofluorescence test.” Instead, the patient improved when placed on dapsone, which is much less toxic than prednisone.

Direct/indirect immunofluorescence is the highest-yield test for patients with blistering disease. “It’s the best way, I believe, to make the diagnosis,” Dr. Marinkovich said. If that test isn’t available, serum taken during an active phase can also be used. But serum samples can turn up false negatives, so dermatologists should consider collecting and testing serum samples several times.

Another useful tool is salt-split skin analysis, which will demarcate antigens to the roof or floor of the blister. Specifically, it helps distinguish bullous pemphigoid and epidermolysis bullosa acquisita.

In the future, Dr. Marinkovich said, ELISA (enzyme-linked immunosorbent assay) testing will have greater importance for diagnosis and disease monitoring, not just for pemphigus but for subepidermal bullous disorders as well.

Autoimmune blistering diseases do respond to prednisone treatment, although not as well as some other conditions. However, symptom improvement can mask the true cause of the disease.

“It’s easy for physicians to give steroids, and the patients will be happy for the time being; but that doesn’t solve the problem in the long term,” Dr. Marinkovich cautioned. “These are chronic conditions, and the patient will continue to require prednisone, and they’ll get more and more side effects, which could have been avoided if someone had done a more thorough investigation.”

Topical agents such as tetracycline, niacinamide, and topical steroids are more useful in pemphigoid than for pemphigus, because pemphigoid involves local immune factors that the agents can target, while pemphigus can be driven by antibodies alone, which are not as responsive to these treatments.

When systemic therapies are necessary, prednisone is a useful tool, but aim for the lowest possible dose, he said. Reducing prednisone dose is challenging in and of itself. Dropping the dose too quickly can lead to more long-term exposure, because a steep drop can lead to a rebound in the disease, which leads to a higher dose.

“The patient is on this roller coaster ride, up and down, up and down, and that alone can ramp up disease activity,” said Dr. Marinkovich. “Lowering steroid more steadily is a better way to go. This calms the disease down by itself.”

When steroids can’t be completely tapered, which is almost always the case in pemphigus and common in pemphigoid, add steroid-sparing agents such as mycophenolate and azathioprine.

If the steroid-sparing agents don’t get patients down to 10 mg/day prednisone or below, then consider using rituximab and intravenous IgG.

In Europe, physicians are using rituximab earlier in the course of disease, a strategy that appeared effective in a study published in the Lancet (2017 May 20;389[10083]:2031-40). “The evidence suggests to me that earlier use of rituximab tends to reduce the total amount of steroids that the patients are using and has the potential to reduce the duration of the disease,” Dr. Marinkovich said. “That’s a trend that will be going on in the next couple of years here in the United States.”

Dr. Marinkovich is an investigator on a clinical trial funded by Syntimmune.

SAN FRANCISCO – Blistering diseases are easily misdiagnosed and may resemble psoriasis or other conditions, but a routine histology and clinical examination aren’t sufficient diagnostic starting points.

“You have to have some kind of immunological test,” according to Peter Marinkovich, MD. “Pathologists will try to give you as much information as they can on the routine histology, but don’t use that as a diagnostic.”

If not properly identified, autoimmune blistering diseases can lead to chronic overexposure to steroids and resultant side effects without addressing the underlying problem, said Dr. Marinkovich of the department of dermatology at Stanford (Calif.) University.

Dr. Marinkovich gave one example of a patient who had been diagnosed with bullous pemphigoid several years before, and who was becoming Cushingoid as a result of steroids. But the diagnosis was made on the basis of histopathology and clinical appearance alone.

“Nobody had done the immunofluorescence test,” he explained at the annual meeting of the Pacific Dermatologic Association. “I did it, and it turned out she had linear IgA disease. The patient went through 2 years of toxicity just because nobody had done the immunofluorescence test.” Instead, the patient improved when placed on dapsone, which is much less toxic than prednisone.

Direct/indirect immunofluorescence is the highest-yield test for patients with blistering disease. “It’s the best way, I believe, to make the diagnosis,” Dr. Marinkovich said. If that test isn’t available, serum taken during an active phase can also be used. But serum samples can turn up false negatives, so dermatologists should consider collecting and testing serum samples several times.

Another useful tool is salt-split skin analysis, which will demarcate antigens to the roof or floor of the blister. Specifically, it helps distinguish bullous pemphigoid and epidermolysis bullosa acquisita.

In the future, Dr. Marinkovich said, ELISA (enzyme-linked immunosorbent assay) testing will have greater importance for diagnosis and disease monitoring, not just for pemphigus but for subepidermal bullous disorders as well.

Autoimmune blistering diseases do respond to prednisone treatment, although not as well as some other conditions. However, symptom improvement can mask the true cause of the disease.

“It’s easy for physicians to give steroids, and the patients will be happy for the time being; but that doesn’t solve the problem in the long term,” Dr. Marinkovich cautioned. “These are chronic conditions, and the patient will continue to require prednisone, and they’ll get more and more side effects, which could have been avoided if someone had done a more thorough investigation.”

Topical agents such as tetracycline, niacinamide, and topical steroids are more useful in pemphigoid than for pemphigus, because pemphigoid involves local immune factors that the agents can target, while pemphigus can be driven by antibodies alone, which are not as responsive to these treatments.

When systemic therapies are necessary, prednisone is a useful tool, but aim for the lowest possible dose, he said. Reducing prednisone dose is challenging in and of itself. Dropping the dose too quickly can lead to more long-term exposure, because a steep drop can lead to a rebound in the disease, which leads to a higher dose.

“The patient is on this roller coaster ride, up and down, up and down, and that alone can ramp up disease activity,” said Dr. Marinkovich. “Lowering steroid more steadily is a better way to go. This calms the disease down by itself.”

When steroids can’t be completely tapered, which is almost always the case in pemphigus and common in pemphigoid, add steroid-sparing agents such as mycophenolate and azathioprine.

If the steroid-sparing agents don’t get patients down to 10 mg/day prednisone or below, then consider using rituximab and intravenous IgG.

In Europe, physicians are using rituximab earlier in the course of disease, a strategy that appeared effective in a study published in the Lancet (2017 May 20;389[10083]:2031-40). “The evidence suggests to me that earlier use of rituximab tends to reduce the total amount of steroids that the patients are using and has the potential to reduce the duration of the disease,” Dr. Marinkovich said. “That’s a trend that will be going on in the next couple of years here in the United States.”

Dr. Marinkovich is an investigator on a clinical trial funded by Syntimmune.

The major improvement in survival that patients with systemic lupus erythematosus (SLE) have experienced from 1950 to the mid-1990s has plateaued ever since, reported Maria Tektonidou, MD, and her colleagues. The study was published in Annals of the Rheumatic Diseases.

Dr. Tektonidou of National and Kapodistrian University of Athens and her coauthors at the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases performed a meta-analysis on studies examining survival in adult and pediatric SLE patients from the 1950s to the mid-1990s. Ultimately, they analyzed 125 adult studies, including 82 from high-income countries and 43 from low- to middle-income countries (LMIC), and 51 pediatric studies, of which 33 were from high-income countries and 18 from LMIC.

In adult studies, researchers found that both high-income and LMIC experienced gradual increases in survival from the 1950s to mid-1990s. After this period of time, the survival estimates stabilized. “In 2008–2016, the 5-year, 10-year, and 15-year survival estimates in high-income countries were 0.95 (95% credible interval, 0.94 to 0.96), 0.89 (0.88 to 0.90) and 0.82 (0.81 to 0.83), respectively” (Ann Rheum Dis. 2017 Aug 9. doi: 10.1136/annrheumdis-2017-211663).

Although there were no data for LMIC prior to 1970, researchers identified survival trends similar to those in high-income countries in more recent years. Over the same time period between 2008 and 2016, “the 5-year, 10-year, and 15-year survival estimates in LMIC were 0.92 (0.91 to 0.93), 0.85 (0.84 to 0.87) and 0.79 (0.78 to 0.81), respectively,” according to the report.

Unlike the steady improvement seen over a 40-year period with adult studies, pediatric SLE patients in high-income countries experienced dramatic increases in survival rates from the 1960s to the 1970s, followed by slower increases in survival rates. The researchers reported that between 2008 and 2016,“the 5-year and 10-year survival estimates from high-income countries were 0.99 (0.98 to 1.00) and 0.97 (0.96 to 0.98), respectively.”

LMIC had significantly worse survival in pediatric SLE patients than did their wealthy counterparts. “Survival persistently lagged [behind] that of high-income countries” between 1980 and 2000. Dr. Tektonidou and her associates found that “5-year and 10-year survival estimates from LMIC were 0.85 (0.83 to 0.88) and 0.79 (0.76 to 0.82), respectively.” Due to the small number of studies reporting 15-year survival rates, this time point was not included in the pediatric analysis.

The researchers also analyzed the cause of death for adult and pediatric SLE patients in both high-income countries and LMIC. High-income countries showed lower rates of SLE-associated deaths over time in adults, although infection-related deaths increased in adults in both high-income countries and LMIC. There were not enough studies and data to assess cause of death in pediatric studies in high-income countries, but pediatric patients in LMIC had an upward trend in SLE-associated deaths.

The Intramural Research Program of the National Institute of Arthritis and Musculoskeletal and Skin Diseases supported the study. The researchers reported having no relevant financial disclosures.

[email protected]

The major improvement in survival that patients with systemic lupus erythematosus (SLE) have experienced from 1950 to the mid-1990s has plateaued ever since, reported Maria Tektonidou, MD, and her colleagues. The study was published in Annals of the Rheumatic Diseases.

Dr. Tektonidou of National and Kapodistrian University of Athens and her coauthors at the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases performed a meta-analysis on studies examining survival in adult and pediatric SLE patients from the 1950s to the mid-1990s. Ultimately, they analyzed 125 adult studies, including 82 from high-income countries and 43 from low- to middle-income countries (LMIC), and 51 pediatric studies, of which 33 were from high-income countries and 18 from LMIC.

In adult studies, researchers found that both high-income and LMIC experienced gradual increases in survival from the 1950s to mid-1990s. After this period of time, the survival estimates stabilized. “In 2008–2016, the 5-year, 10-year, and 15-year survival estimates in high-income countries were 0.95 (95% credible interval, 0.94 to 0.96), 0.89 (0.88 to 0.90) and 0.82 (0.81 to 0.83), respectively” (Ann Rheum Dis. 2017 Aug 9. doi: 10.1136/annrheumdis-2017-211663).

Although there were no data for LMIC prior to 1970, researchers identified survival trends similar to those in high-income countries in more recent years. Over the same time period between 2008 and 2016, “the 5-year, 10-year, and 15-year survival estimates in LMIC were 0.92 (0.91 to 0.93), 0.85 (0.84 to 0.87) and 0.79 (0.78 to 0.81), respectively,” according to the report.

Unlike the steady improvement seen over a 40-year period with adult studies, pediatric SLE patients in high-income countries experienced dramatic increases in survival rates from the 1960s to the 1970s, followed by slower increases in survival rates. The researchers reported that between 2008 and 2016,“the 5-year and 10-year survival estimates from high-income countries were 0.99 (0.98 to 1.00) and 0.97 (0.96 to 0.98), respectively.”

LMIC had significantly worse survival in pediatric SLE patients than did their wealthy counterparts. “Survival persistently lagged [behind] that of high-income countries” between 1980 and 2000. Dr. Tektonidou and her associates found that “5-year and 10-year survival estimates from LMIC were 0.85 (0.83 to 0.88) and 0.79 (0.76 to 0.82), respectively.” Due to the small number of studies reporting 15-year survival rates, this time point was not included in the pediatric analysis.

The researchers also analyzed the cause of death for adult and pediatric SLE patients in both high-income countries and LMIC. High-income countries showed lower rates of SLE-associated deaths over time in adults, although infection-related deaths increased in adults in both high-income countries and LMIC. There were not enough studies and data to assess cause of death in pediatric studies in high-income countries, but pediatric patients in LMIC had an upward trend in SLE-associated deaths.

The Intramural Research Program of the National Institute of Arthritis and Musculoskeletal and Skin Diseases supported the study. The researchers reported having no relevant financial disclosures.

[email protected]

The major improvement in survival that patients with systemic lupus erythematosus (SLE) have experienced from 1950 to the mid-1990s has plateaued ever since, reported Maria Tektonidou, MD, and her colleagues. The study was published in Annals of the Rheumatic Diseases.

Dr. Tektonidou of National and Kapodistrian University of Athens and her coauthors at the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases performed a meta-analysis on studies examining survival in adult and pediatric SLE patients from the 1950s to the mid-1990s. Ultimately, they analyzed 125 adult studies, including 82 from high-income countries and 43 from low- to middle-income countries (LMIC), and 51 pediatric studies, of which 33 were from high-income countries and 18 from LMIC.

In adult studies, researchers found that both high-income and LMIC experienced gradual increases in survival from the 1950s to mid-1990s. After this period of time, the survival estimates stabilized. “In 2008–2016, the 5-year, 10-year, and 15-year survival estimates in high-income countries were 0.95 (95% credible interval, 0.94 to 0.96), 0.89 (0.88 to 0.90) and 0.82 (0.81 to 0.83), respectively” (Ann Rheum Dis. 2017 Aug 9. doi: 10.1136/annrheumdis-2017-211663).

Although there were no data for LMIC prior to 1970, researchers identified survival trends similar to those in high-income countries in more recent years. Over the same time period between 2008 and 2016, “the 5-year, 10-year, and 15-year survival estimates in LMIC were 0.92 (0.91 to 0.93), 0.85 (0.84 to 0.87) and 0.79 (0.78 to 0.81), respectively,” according to the report.

Unlike the steady improvement seen over a 40-year period with adult studies, pediatric SLE patients in high-income countries experienced dramatic increases in survival rates from the 1960s to the 1970s, followed by slower increases in survival rates. The researchers reported that between 2008 and 2016,“the 5-year and 10-year survival estimates from high-income countries were 0.99 (0.98 to 1.00) and 0.97 (0.96 to 0.98), respectively.”

LMIC had significantly worse survival in pediatric SLE patients than did their wealthy counterparts. “Survival persistently lagged [behind] that of high-income countries” between 1980 and 2000. Dr. Tektonidou and her associates found that “5-year and 10-year survival estimates from LMIC were 0.85 (0.83 to 0.88) and 0.79 (0.76 to 0.82), respectively.” Due to the small number of studies reporting 15-year survival rates, this time point was not included in the pediatric analysis.

The researchers also analyzed the cause of death for adult and pediatric SLE patients in both high-income countries and LMIC. High-income countries showed lower rates of SLE-associated deaths over time in adults, although infection-related deaths increased in adults in both high-income countries and LMIC. There were not enough studies and data to assess cause of death in pediatric studies in high-income countries, but pediatric patients in LMIC had an upward trend in SLE-associated deaths.

The Intramural Research Program of the National Institute of Arthritis and Musculoskeletal and Skin Diseases supported the study. The researchers reported having no relevant financial disclosures.

[email protected]

Current and former smokers were significantly more likely to have psoriasis than were nonsmokers in an analysis of the Korean National Health Insurance database.

Multivariate analyses produced adjusted incidence rates of 1.14 for current smokers (n = 132,566) and 1.11 for former smokers (n = 47,477), compared with nonsmokers (n = 320,435), indicating “that smoking status is an independent potential risk factor for psoriasis,” reported Eun Joo Lee, PhD, of the National Health Insurance Service in Wonjusi, South Korea, and associates (J Am Acad Dermatol. 2017;77[3]:573-5).

[email protected]

Current and former smokers were significantly more likely to have psoriasis than were nonsmokers in an analysis of the Korean National Health Insurance database.

Multivariate analyses produced adjusted incidence rates of 1.14 for current smokers (n = 132,566) and 1.11 for former smokers (n = 47,477), compared with nonsmokers (n = 320,435), indicating “that smoking status is an independent potential risk factor for psoriasis,” reported Eun Joo Lee, PhD, of the National Health Insurance Service in Wonjusi, South Korea, and associates (J Am Acad Dermatol. 2017;77[3]:573-5).

[email protected]

Current and former smokers were significantly more likely to have psoriasis than were nonsmokers in an analysis of the Korean National Health Insurance database.

Multivariate analyses produced adjusted incidence rates of 1.14 for current smokers (n = 132,566) and 1.11 for former smokers (n = 47,477), compared with nonsmokers (n = 320,435), indicating “that smoking status is an independent potential risk factor for psoriasis,” reported Eun Joo Lee, PhD, of the National Health Insurance Service in Wonjusi, South Korea, and associates (J Am Acad Dermatol. 2017;77[3]:573-5).

[email protected]

As someone less than 1 year into practice, I believe mentorship is one of the most critical essentials as a trainee and a junior attending. I have been privileged to have excellent mentors throughout my training and now, in my first job. A lot of this is luck, but I also have always put mentorship at the top of my list when looking for fellowships and jobs. In fact, part of the reason I took the job I currently have is because the contract clearly stated who my clinical and academic mentors would be. This showed the department’s dedication to grooming junior staff appropriately. Below is my take on how to find mentors.

Have multiple mentors

It’s good to have multiple mentors, each of whom can provide a different kind of mentorship. For junior faculty, key areas of mentorship include:

• Building clinical volume.
• Establishing your reputation as a safe and competent clinician/surgeon.
• Designing your academic/research career.
• Planning your overall career.
• Solving any political/administrative issues.

Currently, my division chief is my clinical/general mentor, from whom I seek clinical advice, political advice should I find myself in a tough situation as a junior attending, and personal advice, as well. We meet monthly to go over various things including clinical/research projects and any clinical issues. I have an academic mentor, who is a basic scientist; we review research ideas together. He reads over and critiques my grants, and he picks apart my presentations. I also have a very senior mentor, a retired thoracic surgeon, whom I seek when I have a challenging case; it is crucial to identify a senior surgeon who has an abundance of experience so you can pick his or her brain – a true resource. This is in addition to the mentors I have from my training, with whom I am still in contact. I think it is important to have mentors outside of your current work for certain situations.
 

Mentors do not have to be in your discipline

It’s useful to have mentors from different fields. As I stated above, my academic mentor is a basic scientist. I am a thoracic surgeon, but I consider my general surgery residency chair, who is an accomplished surgical oncologist, and my residency program director, a general surgeon, to be two of my important mentors. I think it’s a good idea to have someone outside of your discipline as your mentor, even someone in a nonsurgical discipline, as long as she or he provides what you need, such as general career decisions and research mentorship. Having people from different disciplines adds more perspective and depth. For women, female mentors may provide input on career decisions at different life stages.

Do your homework about your would-be mentors

When deciding among different jobs, I did as much homework as possible in researching my would-be clinical mentors, who in most cases are also your senior partners. This included speaking with other junior faculty members within the division, people who had worked with the person in the past, and current mentors who may know them. In my mind, I found the most valuable resources to be people who had worked in the past with potential new mentors or senior partners. They can provide unbiased, sometimes negative, opinions that others might be less willing to provide. In fact, I probably spent more time trying to understand to the negative comments, since this provided valuable information, too.

I always asked questions specific to the mentorship. Were they around to help you in the OR when needed, or was it more of a verbal “I’ll be around”? Were they good about giving the juniors clinical volume and sharing OR time? Did you feel like you grew under his or her mentorship?

In conclusion, my advice about mentorship is to have multiple mentors, each for different purposes. For those looking for fellowships and jobs, learning all you can about your would-be mentors goes a long way toward ensuring an ideal position.

Dr. Suzuki is a general thoracic surgeon at Boston Medical Center.

As someone less than 1 year into practice, I believe mentorship is one of the most critical essentials as a trainee and a junior attending. I have been privileged to have excellent mentors throughout my training and now, in my first job. A lot of this is luck, but I also have always put mentorship at the top of my list when looking for fellowships and jobs. In fact, part of the reason I took the job I currently have is because the contract clearly stated who my clinical and academic mentors would be. This showed the department’s dedication to grooming junior staff appropriately. Below is my take on how to find mentors.

Have multiple mentors

It’s good to have multiple mentors, each of whom can provide a different kind of mentorship. For junior faculty, key areas of mentorship include:

• Building clinical volume.
• Establishing your reputation as a safe and competent clinician/surgeon.
• Designing your academic/research career.
• Planning your overall career.
• Solving any political/administrative issues.

Currently, my division chief is my clinical/general mentor, from whom I seek clinical advice, political advice should I find myself in a tough situation as a junior attending, and personal advice, as well. We meet monthly to go over various things including clinical/research projects and any clinical issues. I have an academic mentor, who is a basic scientist; we review research ideas together. He reads over and critiques my grants, and he picks apart my presentations. I also have a very senior mentor, a retired thoracic surgeon, whom I seek when I have a challenging case; it is crucial to identify a senior surgeon who has an abundance of experience so you can pick his or her brain – a true resource. This is in addition to the mentors I have from my training, with whom I am still in contact. I think it is important to have mentors outside of your current work for certain situations.
 

Mentors do not have to be in your discipline

It’s useful to have mentors from different fields. As I stated above, my academic mentor is a basic scientist. I am a thoracic surgeon, but I consider my general surgery residency chair, who is an accomplished surgical oncologist, and my residency program director, a general surgeon, to be two of my important mentors. I think it’s a good idea to have someone outside of your discipline as your mentor, even someone in a nonsurgical discipline, as long as she or he provides what you need, such as general career decisions and research mentorship. Having people from different disciplines adds more perspective and depth. For women, female mentors may provide input on career decisions at different life stages.

Do your homework about your would-be mentors

When deciding among different jobs, I did as much homework as possible in researching my would-be clinical mentors, who in most cases are also your senior partners. This included speaking with other junior faculty members within the division, people who had worked with the person in the past, and current mentors who may know them. In my mind, I found the most valuable resources to be people who had worked in the past with potential new mentors or senior partners. They can provide unbiased, sometimes negative, opinions that others might be less willing to provide. In fact, I probably spent more time trying to understand to the negative comments, since this provided valuable information, too.

I always asked questions specific to the mentorship. Were they around to help you in the OR when needed, or was it more of a verbal “I’ll be around”? Were they good about giving the juniors clinical volume and sharing OR time? Did you feel like you grew under his or her mentorship?

In conclusion, my advice about mentorship is to have multiple mentors, each for different purposes. For those looking for fellowships and jobs, learning all you can about your would-be mentors goes a long way toward ensuring an ideal position.

Dr. Suzuki is a general thoracic surgeon at Boston Medical Center.

As someone less than 1 year into practice, I believe mentorship is one of the most critical essentials as a trainee and a junior attending. I have been privileged to have excellent mentors throughout my training and now, in my first job. A lot of this is luck, but I also have always put mentorship at the top of my list when looking for fellowships and jobs. In fact, part of the reason I took the job I currently have is because the contract clearly stated who my clinical and academic mentors would be. This showed the department’s dedication to grooming junior staff appropriately. Below is my take on how to find mentors.

Have multiple mentors

It’s good to have multiple mentors, each of whom can provide a different kind of mentorship. For junior faculty, key areas of mentorship include:

• Building clinical volume.
• Establishing your reputation as a safe and competent clinician/surgeon.
• Designing your academic/research career.
• Planning your overall career.
• Solving any political/administrative issues.

Currently, my division chief is my clinical/general mentor, from whom I seek clinical advice, political advice should I find myself in a tough situation as a junior attending, and personal advice, as well. We meet monthly to go over various things including clinical/research projects and any clinical issues. I have an academic mentor, who is a basic scientist; we review research ideas together. He reads over and critiques my grants, and he picks apart my presentations. I also have a very senior mentor, a retired thoracic surgeon, whom I seek when I have a challenging case; it is crucial to identify a senior surgeon who has an abundance of experience so you can pick his or her brain – a true resource. This is in addition to the mentors I have from my training, with whom I am still in contact. I think it is important to have mentors outside of your current work for certain situations.
 

Mentors do not have to be in your discipline

It’s useful to have mentors from different fields. As I stated above, my academic mentor is a basic scientist. I am a thoracic surgeon, but I consider my general surgery residency chair, who is an accomplished surgical oncologist, and my residency program director, a general surgeon, to be two of my important mentors. I think it’s a good idea to have someone outside of your discipline as your mentor, even someone in a nonsurgical discipline, as long as she or he provides what you need, such as general career decisions and research mentorship. Having people from different disciplines adds more perspective and depth. For women, female mentors may provide input on career decisions at different life stages.

Do your homework about your would-be mentors

When deciding among different jobs, I did as much homework as possible in researching my would-be clinical mentors, who in most cases are also your senior partners. This included speaking with other junior faculty members within the division, people who had worked with the person in the past, and current mentors who may know them. In my mind, I found the most valuable resources to be people who had worked in the past with potential new mentors or senior partners. They can provide unbiased, sometimes negative, opinions that others might be less willing to provide. In fact, I probably spent more time trying to understand to the negative comments, since this provided valuable information, too.

I always asked questions specific to the mentorship. Were they around to help you in the OR when needed, or was it more of a verbal “I’ll be around”? Were they good about giving the juniors clinical volume and sharing OR time? Did you feel like you grew under his or her mentorship?

In conclusion, my advice about mentorship is to have multiple mentors, each for different purposes. For those looking for fellowships and jobs, learning all you can about your would-be mentors goes a long way toward ensuring an ideal position.

Dr. Suzuki is a general thoracic surgeon at Boston Medical Center.

The vast majority of us did not end up where we are today by saying “no” to opportunities throughout medical school, surgical training and now early in our clinical practice. In fact, many of us likely said “yes” to just about everything that came our way, and this was reasonable as the number of opportunities was manageable. As you move along your career as a cardiothoracic surgeon, the opportunities increase, especially if you consistently turn in a high performance.

Dr. Brown is a general thoracic surgeon at UC Davis Medical Center, Calif.

The vast majority of us did not end up where we are today by saying “no” to opportunities throughout medical school, surgical training and now early in our clinical practice. In fact, many of us likely said “yes” to just about everything that came our way, and this was reasonable as the number of opportunities was manageable. As you move along your career as a cardiothoracic surgeon, the opportunities increase, especially if you consistently turn in a high performance.

Dr. Brown is a general thoracic surgeon at UC Davis Medical Center, Calif.

The vast majority of us did not end up where we are today by saying “no” to opportunities throughout medical school, surgical training and now early in our clinical practice. In fact, many of us likely said “yes” to just about everything that came our way, and this was reasonable as the number of opportunities was manageable. As you move along your career as a cardiothoracic surgeon, the opportunities increase, especially if you consistently turn in a high performance.

Dr. Brown is a general thoracic surgeon at UC Davis Medical Center, Calif.

As the VA Precision Oncology Program (POP) matures, it is working to ensure that all veterans have access to appropriate therapies no matter the location. At the Association of VA Hematology and Oncology (AVAHO) meeting in Denver, Colorado, Michael Kelley, director of the VA National Program for Medical Oncology outlined the latest POP updates and strongly encouraged VA oncologists to take advantage of its resources.

 According to Kelley, gene panel testing for many tumor types is now available through the POP program. Importantly, POP will pay for the testing. Currently POP is focused on next generation sequencing (NGS) tissue testing and ctDNA (circulating tumor DNA) liquid biopsy for solid tumors. A NGS panel for hematologic malignancies will be available soon. Kelley strongly encouraged facilities that are not currently using POP for NGS testing to reach out to Jill Duffy, director of oncology operations.

 Related: Evaluation of Oncologic Pharmacotherapy and Implementation of a Pharmacist-Managed Monitoring Protocol at a Community-Based Outpatient Clinic

 According to Kelley, POP is moving forward with additional programs to improve oncology care. The POP is developing a national interfacility consult program. It also is developing a “smart” oncology notes template. Other initiatives underway include a patient dashboard, patient tracker, quality metrics, and an end-of-life quality assessment dashboard.

Kelley noted that POP also is working to increase access to clinical trials. The VA has partnered with the National Cancer Institute (NCI) on NAVIGATE to get more VA patients involved in NCI trials. The NAVIGATE program is expected to kick off soon and be up and running in 2018. Grant Huang, acting director for the Cooperative Studies Program in the Office of Research & Development has been helping to lead that initiative.

Related: Implementation of a Precision Oncology Program as an Exemplar of a Learning Health Care System in the VA

The VA also is moving forward with precision oncology as part of the Applied Proteogennomics Organizational Learning and Outcomes (APOLLO) Consortium. The APOLLO program, which emerged out of the Cancer Moonshot, brings together the VA, DoD, and NCI. The DoD is combining genomic and proteomic “to create the nation’s first system in which cancer patients are routinely screened for genomic abnormalities and proteomic information to match their tumor types to targeted therapies.”

As the VA Precision Oncology Program (POP) matures, it is working to ensure that all veterans have access to appropriate therapies no matter the location. At the Association of VA Hematology and Oncology (AVAHO) meeting in Denver, Colorado, Michael Kelley, director of the VA National Program for Medical Oncology outlined the latest POP updates and strongly encouraged VA oncologists to take advantage of its resources.

 According to Kelley, gene panel testing for many tumor types is now available through the POP program. Importantly, POP will pay for the testing. Currently POP is focused on next generation sequencing (NGS) tissue testing and ctDNA (circulating tumor DNA) liquid biopsy for solid tumors. A NGS panel for hematologic malignancies will be available soon. Kelley strongly encouraged facilities that are not currently using POP for NGS testing to reach out to Jill Duffy, director of oncology operations.

 Related: Evaluation of Oncologic Pharmacotherapy and Implementation of a Pharmacist-Managed Monitoring Protocol at a Community-Based Outpatient Clinic

 According to Kelley, POP is moving forward with additional programs to improve oncology care. The POP is developing a national interfacility consult program. It also is developing a “smart” oncology notes template. Other initiatives underway include a patient dashboard, patient tracker, quality metrics, and an end-of-life quality assessment dashboard.

Kelley noted that POP also is working to increase access to clinical trials. The VA has partnered with the National Cancer Institute (NCI) on NAVIGATE to get more VA patients involved in NCI trials. The NAVIGATE program is expected to kick off soon and be up and running in 2018. Grant Huang, acting director for the Cooperative Studies Program in the Office of Research & Development has been helping to lead that initiative.

Related: Implementation of a Precision Oncology Program as an Exemplar of a Learning Health Care System in the VA

The VA also is moving forward with precision oncology as part of the Applied Proteogennomics Organizational Learning and Outcomes (APOLLO) Consortium. The APOLLO program, which emerged out of the Cancer Moonshot, brings together the VA, DoD, and NCI. The DoD is combining genomic and proteomic “to create the nation’s first system in which cancer patients are routinely screened for genomic abnormalities and proteomic information to match their tumor types to targeted therapies.”

As the VA Precision Oncology Program (POP) matures, it is working to ensure that all veterans have access to appropriate therapies no matter the location. At the Association of VA Hematology and Oncology (AVAHO) meeting in Denver, Colorado, Michael Kelley, director of the VA National Program for Medical Oncology outlined the latest POP updates and strongly encouraged VA oncologists to take advantage of its resources.

 According to Kelley, gene panel testing for many tumor types is now available through the POP program. Importantly, POP will pay for the testing. Currently POP is focused on next generation sequencing (NGS) tissue testing and ctDNA (circulating tumor DNA) liquid biopsy for solid tumors. A NGS panel for hematologic malignancies will be available soon. Kelley strongly encouraged facilities that are not currently using POP for NGS testing to reach out to Jill Duffy, director of oncology operations.

 Related: Evaluation of Oncologic Pharmacotherapy and Implementation of a Pharmacist-Managed Monitoring Protocol at a Community-Based Outpatient Clinic

 According to Kelley, POP is moving forward with additional programs to improve oncology care. The POP is developing a national interfacility consult program. It also is developing a “smart” oncology notes template. Other initiatives underway include a patient dashboard, patient tracker, quality metrics, and an end-of-life quality assessment dashboard.

Kelley noted that POP also is working to increase access to clinical trials. The VA has partnered with the National Cancer Institute (NCI) on NAVIGATE to get more VA patients involved in NCI trials. The NAVIGATE program is expected to kick off soon and be up and running in 2018. Grant Huang, acting director for the Cooperative Studies Program in the Office of Research & Development has been helping to lead that initiative.

Related: Implementation of a Precision Oncology Program as an Exemplar of a Learning Health Care System in the VA

The VA also is moving forward with precision oncology as part of the Applied Proteogennomics Organizational Learning and Outcomes (APOLLO) Consortium. The APOLLO program, which emerged out of the Cancer Moonshot, brings together the VA, DoD, and NCI. The DoD is combining genomic and proteomic “to create the nation’s first system in which cancer patients are routinely screened for genomic abnormalities and proteomic information to match their tumor types to targeted therapies.”