Practicing at the top of your license, billing and reimbursement, recruiting and orientation – Those were some of the hot topics discussed by more than 50 attendees of HM17’s Special Interest Forum for nurse practitioners (NPs) and physician assistants (PAs).

“Every year, we are seeing more and more HM groups integrating NPs and PAs into their practice,” said forum moderator Emilie Thornhill, PA-C, a certified PA, who works for Oschner Health in New Orleans, La.

Ms. Thornhill emphasized that a common issue among attendees is restrictive HM policies in dictating the scope of practice for NP/PAs in hospitalist groups.

“That seems to be the thing that is holding us back the most,” she said. “SHM is really going to be the home for these individuals to find the resources they need to address these issues.”

Practicing at the top of your license, billing and reimbursement, recruiting and orientation – Those were some of the hot topics discussed by more than 50 attendees of HM17’s Special Interest Forum for nurse practitioners (NPs) and physician assistants (PAs).

“Every year, we are seeing more and more HM groups integrating NPs and PAs into their practice,” said forum moderator Emilie Thornhill, PA-C, a certified PA, who works for Oschner Health in New Orleans, La.

Ms. Thornhill emphasized that a common issue among attendees is restrictive HM policies in dictating the scope of practice for NP/PAs in hospitalist groups.

“That seems to be the thing that is holding us back the most,” she said. “SHM is really going to be the home for these individuals to find the resources they need to address these issues.”

Practicing at the top of your license, billing and reimbursement, recruiting and orientation – Those were some of the hot topics discussed by more than 50 attendees of HM17’s Special Interest Forum for nurse practitioners (NPs) and physician assistants (PAs).

“Every year, we are seeing more and more HM groups integrating NPs and PAs into their practice,” said forum moderator Emilie Thornhill, PA-C, a certified PA, who works for Oschner Health in New Orleans, La.

Ms. Thornhill emphasized that a common issue among attendees is restrictive HM policies in dictating the scope of practice for NP/PAs in hospitalist groups.

“That seems to be the thing that is holding us back the most,” she said. “SHM is really going to be the home for these individuals to find the resources they need to address these issues.”

Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.

A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.

Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.

The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.

Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.

Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.

Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.

A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.

Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.

The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.

Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.

Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.

Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.

A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.

Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.

The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.

Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.

Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.

Lentigo maligna (LM) and LM melanoma (LMM) represent diagnostic and therapeutic challenges due to their heterogeneous nature and location on cosmetically sensitive areas. Newer ancillary technologies such as reflectance confocal microscopy (RCM) have helped improve diagnosis and management of these challenging lesions.^1,2

Reflectance confocal microscopy is a noninvasive laser system that provides real-time imaging of the epidermis and dermis with cellular resolution and improves diagnostic accuracy of melanocytic lesions.^2,3 Normal melanocytes appear as round bright structures on RCM that are similar in size to surrounding keratinocytes located in the basal layer and regularly distributed around the dermal papillae (junctional nevi) or form regular dense nests in the dermis (intradermal nevi).^4,5 In LM/LMM, there may be widespread infiltration of atypical melanocytes invading hair follicles; large, round, pagetoid melanocytes (larger than surrounding keratinocytes); sheets of large atypical cells at the dermoepidermal junction (DEJ); loss of contour in the dermal papillae; and atypical melanocytes invading the dermal papillae.² Indeed, RCM has good correlation with the degree of histologic atypia and is useful to distinguish between benign nevi, atypical nevi, and melanoma.⁶ By combining lateral mosaics with vertical stacks, RCM allows 3-dimensional approximation of tumor margins and monitoring of nonsurgical therapies.^7,8 The advent of handheld RCM (HRCM) has allowed assessment of large lesions as well as those presenting in difficult locations.⁹ Furthermore, the generation of videomosaics overcomes the limited field of view of traditional RCM and allows for accurate assessment of large lesions.¹⁰

Traditional and handheld RCM have been used to diagnose and map primary LM.^1,2,11 Guitera et al² developed an algorithm using traditional RCM to distinguish benign facial macules and LM. In their training set, they found that when their score resulted in 2 or more points, the sensitivity and specificity to diagnose LM was 85% and 76%, respectively, with an odds ratio of 18.6 for LM. They later applied the algorithm in a test set of 44 benign facial macules and 29 LM and obtained an odds ratio of 60.7 for LM, with sensitivity and specificity rates of 93% and 82%, respectively.² This algorithm also was tested by Menge et al11 using the HRCM. They found 100% sensitivity and 71% specificity for LM when evaluating 63 equivocal facial lesions. Although these results suggest that RCM can accurately distinguish LM from benign lesions in the primary setting, few reports have studied the impact of HRCM in the recurrent setting and its impact in monitoring treatment of LM.^12,13

Herein, we present 5 cases in which HRCM was used to manage complex facial LM/LMM, highlighting its versatility and potential for use in the clinical setting (eTable).

Case Series

Following institutional review board approval, cases of facial LM/LMM presenting for assessment and treatment from January 2014 to December 2015 were retrospectively reviewed. Initially, the clinical margins of the lesions were determined using Wood lamp and/or dermoscopy. Using HRCM, vertical stacks were taken at the 12-, 3-, 6-, and 9-o'clock positions, and videos were captured along the peripheral margins at the DEJ. To create videomosaics, HRCM video frames were extracted and later stitched using a computer algorithm written in a fourth-generation programming language based on prior studies.^10,14 An example HRCM video that was captured and turned into a videomosaic accompanies this article online (http://bit.ly/2oDYS6k). Additional stacks were taken in suspicious areas. We considered an area positive for LM under HRCM when the LM score developed by Guitera et al² was 2 or more. The algorithm scoring includes 2 major criteria--nonedged papillae and round large pagetoid cells--which score 2 points, and 4 minor criteria, including 3 positive criteria--atypical cells at the DEJ, follicular invasion, nucleated cells in the papillae--which each score 1 point, and 1 negative criterion--broadened honeycomb pattern--which scores -1 point.²

RELATED VIDEO: RCM Videomosaic of Melanoma In Situ

Patient 1

An 82-year-old woman was referred to us for management of an LMM on the left side of the forehead (Figure 1A). Handheld RCM from the biopsy site showed large atypical cells in the epidermis, DEJ, and papillary dermis. Superiorly, HRCM showed large dendritic processes but did not reveal LM features in 3 additional clinically worrisome areas. Biopsies showed LMM at the prior biopsy site, LM superiorly, and actinic keratosis in the remaining 3 areas, supporting the HRCM findings. Due to upstaging, the patient was referred for head and neck surgery. To aid in resection, HRCM was performed intraoperatively in a multidisciplinary approach (Figure 1B). Due to the large size of the lesion, surgical margins were taken right outside the HRCM border. Pathology showed LMM extending focally into the margins that were reexcised, achieving clearance.

Patient 2

An 88-year-old woman presented with a slightly pigmented, 2.5×2.3-cm LMM on the left cheek. Because of her age and comorbidities (eg, osteoporosis, deep vein thrombosis in both lower legs requiring anticoagulation therapy, presence of an inferior vena cava filter, bilateral lymphedema of the legs, irritable bowel syndrome, hyperparathyroidism), she was treated with imiquimod cream 5% achieving partial response. The lesion was subsequently excised showing LMM extending to the margins. Not wanting to undergo further surgery, she opted for radiation therapy. Handheld RCM was performed to guide the radiation field, showing pagetoid cells within 1 cm of the scar and clear margins beyond 2 cm. She underwent radiation therapy followed by treatment with imiquimod. On 6-month follow-up, no clinical lesion was apparent, but HRCM showed atypical cells. Biopsies revealed an atypical intraepidermal melanocytic proliferation, but due to patient's comorbidities, close observation was decided.

Patient 3

A 78-year-old man presented with an LMM on the right preauricular area. Handheld RCM demonstrated pleomorphic pagetoid cells along and beyond the clinical margins. Wide excision with sentinel lymph node biopsy was planned, and to aid surgery a confocal map was created (Figure 2). Margins were clear at 1 cm, except inferiorly where they extended to 1.5 cm. Using this preoperative HRCM map, all intraoperative sections were clear. Final pathology confirmed clear margins throughout.

Patient 4

A 62-year-old man presented with hyperpigmentation and bleeding on the left cheek where an LMM was previously removed 8 times over 18 years. Handheld RCM showed pleomorphic cells along the graft border and interestingly within the graft. Ten biopsies were taken, 8 at sites with confocal features that were worrisome for LM (Figures 3A and 3B) and 2 at clinically suspicious sites. The former revealed melanomas (2 that were invasive to 0.3 mm), and the latter revealed solar lentigines. The patient underwent staged excision guided by HRCM (Figure 3C), achieving clear histologic margins except for a focus in the helix. This area was RCM positive but was intentionally not resected due to reconstructive difficulties; imiquimod was indicated in this area.

Patient 5

An 85-year-old woman with 6 prior melanomas over 15 years presented with ill-defined light brown patches on the left cheek at the site where an LM was previously excised 15 years prior. Biopsies showed LM, and due to the patient's age, health, and personal preference to avoid extensive surgery, treatment with imiquimod cream 5% was decided. Over a period of 6 to 12 months, she developed multiple erythematous macules with 2 faintly pigmented areas. Handheld RCM demonstrated atypical cells within the papillae in previously biopsied sites that were rebiopsied, revealing LMM (Breslow depth, 0.2 mm). Staged excision achieved clear margins, but after 8 months HRCM showed LM features. Histology confirmed the diagnosis and imiquimod was reapplied.

Comment

Diagnosis and choice of treatment modality for cases of facial LM is a challenge, and there are a number of factors that may create even more of a clinical dilemma. Surgical excision is the treatment of choice for LM/LMM, and better results are achieved when using histologically controlled surgical procedures such as Mohs micrographic surgery, staged excision, or the "spaghetti technique."^15-17 However, advanced patient age, multiple comorbidities (eg, coronary artery disease, deep vein thrombosis, other conditions requiring anticoagulation therapy), large lesion size in functionally or aesthetically sensitive areas, and indiscriminate borders on photodamaged skin may make surgical excision complicated or not feasible. Additionally, prior treatments to the affected area may further obscure clinical borders, complicating the diagnosis of recurrence/persistence when observed with the naked eye, dermoscopy, or Wood lamp. Because RCM can detect small amounts of melanin and has cellular resolution, it has been suggested as a great diagnostic tool to be combined with dermoscopy when evaluating lightly pigmented/amelanotic facial lesions arising on sun-damaged skin.^18,19 In this case series, we highlighted these difficulties and showed how HRCM can be useful in a variety of scenarios, both pretreatment and posttreatment in complex LM/LMM cases.

Pretreatment Evaluation

Blind mapping biopsies of LM are prone to sample bias and depend greatly on biopsy technique; however, HRCM can guide mapping biopsies by detecting features of LM in vivo with high sensitivity.¹¹ Due to the cosmetically sensitive nature of the lesions, many physicians are discouraged to do multiple mapping biopsies, making it difficult to assess the breadth of the lesion and occult invasion. Multiple studies have shown that occult invasion was not apparent until complete lesion excision was done.^15,20,21 Agarwal-Antal et al²⁰ reported 92 cases of LM, of which 16% (15/92) had unsuspected invasion on final excisional pathology. A long-standing disadvantage of treating LM with nonsurgical modalities has been the inability to detect occult invasion or multifocal invasion within the lesion. As described in patients 1, 4, and 5 in the current case series, utilizing real-time video imaging of the DEJ at the margins and within the lesion has allowed for the detection of deep atypical melanocytes suspicious for perifollicular infiltration and invasion. Knowing the depth of invasion before treatment is essential for not only counseling the patient about disease risk but also for choosing an appropriate treatment modality. Therefore, prospective studies evaluating the performance of RCM to identify invasion are crucial to improve sampling error and avoid unnecessary biopsies.

Surgical Treatment

Although surgery is the first-line treatment option for facial LM, it is not without associated morbidity, and LM is known to have histological subclinical extension, which makes margin assessment difficult. Wide surgical margins on the face are not always possible and become further complicated when trying to maintain adequate functional and cosmetic outcomes. Additionally, the margin for surgical clearance may not be straightforward for facial lesions. Hazan et al¹⁵ showed the mean total surgical margins required for excision of LM and LMM was 7.1 and 10.3 mm, respectively; of the 91 tumors initially diagnosed as LM on biopsy, 16% (15/91) had unsuspected invasion. Guitera et al² reported that the presence of atypical cells within the dermal papillae might be a sign of invasion, which occasionally is not detected histologically due to sampling bias. Handheld RCM offers the advantage of a rapid real-time assessment in areas that may not have been amenable to previous iterations of the device, and it also provides a larger field of view that would be time consuming if performed using conventional RCM. Compared to prior RCM devices that were not handheld, the use of the HRCM does not need to attach a ring to the skin and is less bulky, permitting its use at the bedside of the patient or even intraoperatively.13 In our experience, HRCM has helped to better characterize subclinical spread of LM during the initial consultation and better counsel patients about the extent of the lesion. Handheld RCM also has been used to guide the spaghetti technique in patients with LM/LMM with good correlation between HRCM and histology.²² In our case series, HRCM was used in complex LM/LMM to delineate surgical margins, though in some cases the histologic margins were too close or affected, suggesting HRCM underestimation. Lentigo maligna margin assessment with RCM uses an algorithm that evaluates confocal features in the center of the lesion.^1,2 Therefore, further studies using HRCM should evaluate minor confocal features in the margins as potential markers of positivity to accurately delineate surgical margins.

Nonsurgical Treatment Options

For patients unable or unwilling to pursue surgical treatment, therapies such as imiquimod or radiation have been suggested.^23,24 However, the lack of histological confirmation and possibility for invasive spread has limited these modalities. Lentigo malignas treated with radiation have a 5% recurrence rate, with a median follow-up time of 3 years.²³ Recurrence often can be difficult to detect clinically, as it may manifest as an amelanotic lesion, or postradiation changes can hinder detection. Handheld RCM allows for a cellular-level observation of the irradiated field and can identify radiation-induced changes in LM lesions, including superficial necrosis, apoptotic cells, dilated vessels, and increased inflammatory cells.²⁵ Handheld RCM has previously been used to assess LM treated with radiation and, as in patient 2, can help define the radiation field and detect treatment failure or recurrence.^12,25

Similarly, as described in patient 5, HRCM was utilized to monitor treatment with imiquimod. Many reports use imiquimod for treatment of LM, but application and response vary greatly. Reflectance confocal microscopy has been shown to be useful in monitoring LM treated with imiquimod,⁸ which is important because clinical findings such as inflammation and erythema do not correlate well with response to therapy. Thus, RCM is an appealing noninvasive modality to monitor response to treatment and assess the need for longer treatment duration. Moreover, similar to postradiation changes, treatment with imiquimod may cause an alteration of the clinically apparent pigment. Therefore, it is difficult to assess treatment success by clinical inspection alone. The use of RCM before, during, and after treatment provides a longitudinal assessment of the lesion and has augmented dermatologists' ability to determine treatment success or failure; however, prospective studies evaluating the usefulness of HRCM in the recurrent setting are needed to validate these results.

Limitations

Limitations of this technology include the time needed to image large areas; technology cost; and associated learning curve, which may take from 6 months to 1 year based on our experience. Others have reported the training required for accurate RCM interpretation to be less than that of dermoscopy.²⁶ It has been shown that key RCM diagnostic criteria for lesions including melanoma and basal cell carcinoma are reproducibly recognized among RCM users and that diagnostic accuracy increases with experience.²⁷ These limitations can be overcome with advances in videomosaicing that may streamline the imaging as well as an eventual decrease in cost with greater user adoption and the development of training platforms that enable a faster learning of RCM.²⁸

Conclusion

The use of HRCM can help in the diagnosis and management of facial LMs. Handheld RCM provides longitudinal assessment of LM/LMM that may help determine treatment success or failure and has proven to be useful in detecting the presence of recurrence/persistence in cases that were clinically poorly evident. Moreover, HRCM is a notable ancillary tool, as it can be performed at the bedside of the patient or even intraoperatively and provides a faster approach than conventional RCM in cases where large areas need to be mapped.

In summary, HRCM may eventually be a useful screening tool to guide scouting biopsies to diagnose de novo LM; guide surgical and nonsurgical therapies; and evaluate the presence of recurrence/persistence, especially in large, complex, amelanotic or poorly pigmented lesions. A more standardized use of HRCM in mapping surgical and nonsurgical approaches needs to be evaluated in further studies to provide a fast and reliable complement to histology in such complex cases; therefore, larger studies need to be performed to validate this technique in such complex cases.

Lentigo maligna (LM) and LM melanoma (LMM) represent diagnostic and therapeutic challenges due to their heterogeneous nature and location on cosmetically sensitive areas. Newer ancillary technologies such as reflectance confocal microscopy (RCM) have helped improve diagnosis and management of these challenging lesions.^1,2

Reflectance confocal microscopy is a noninvasive laser system that provides real-time imaging of the epidermis and dermis with cellular resolution and improves diagnostic accuracy of melanocytic lesions.^2,3 Normal melanocytes appear as round bright structures on RCM that are similar in size to surrounding keratinocytes located in the basal layer and regularly distributed around the dermal papillae (junctional nevi) or form regular dense nests in the dermis (intradermal nevi).^4,5 In LM/LMM, there may be widespread infiltration of atypical melanocytes invading hair follicles; large, round, pagetoid melanocytes (larger than surrounding keratinocytes); sheets of large atypical cells at the dermoepidermal junction (DEJ); loss of contour in the dermal papillae; and atypical melanocytes invading the dermal papillae.² Indeed, RCM has good correlation with the degree of histologic atypia and is useful to distinguish between benign nevi, atypical nevi, and melanoma.⁶ By combining lateral mosaics with vertical stacks, RCM allows 3-dimensional approximation of tumor margins and monitoring of nonsurgical therapies.^7,8 The advent of handheld RCM (HRCM) has allowed assessment of large lesions as well as those presenting in difficult locations.⁹ Furthermore, the generation of videomosaics overcomes the limited field of view of traditional RCM and allows for accurate assessment of large lesions.¹⁰

Traditional and handheld RCM have been used to diagnose and map primary LM.^1,2,11 Guitera et al² developed an algorithm using traditional RCM to distinguish benign facial macules and LM. In their training set, they found that when their score resulted in 2 or more points, the sensitivity and specificity to diagnose LM was 85% and 76%, respectively, with an odds ratio of 18.6 for LM. They later applied the algorithm in a test set of 44 benign facial macules and 29 LM and obtained an odds ratio of 60.7 for LM, with sensitivity and specificity rates of 93% and 82%, respectively.² This algorithm also was tested by Menge et al11 using the HRCM. They found 100% sensitivity and 71% specificity for LM when evaluating 63 equivocal facial lesions. Although these results suggest that RCM can accurately distinguish LM from benign lesions in the primary setting, few reports have studied the impact of HRCM in the recurrent setting and its impact in monitoring treatment of LM.^12,13

Herein, we present 5 cases in which HRCM was used to manage complex facial LM/LMM, highlighting its versatility and potential for use in the clinical setting (eTable).

Case Series

Following institutional review board approval, cases of facial LM/LMM presenting for assessment and treatment from January 2014 to December 2015 were retrospectively reviewed. Initially, the clinical margins of the lesions were determined using Wood lamp and/or dermoscopy. Using HRCM, vertical stacks were taken at the 12-, 3-, 6-, and 9-o'clock positions, and videos were captured along the peripheral margins at the DEJ. To create videomosaics, HRCM video frames were extracted and later stitched using a computer algorithm written in a fourth-generation programming language based on prior studies.^10,14 An example HRCM video that was captured and turned into a videomosaic accompanies this article online (http://bit.ly/2oDYS6k). Additional stacks were taken in suspicious areas. We considered an area positive for LM under HRCM when the LM score developed by Guitera et al² was 2 or more. The algorithm scoring includes 2 major criteria--nonedged papillae and round large pagetoid cells--which score 2 points, and 4 minor criteria, including 3 positive criteria--atypical cells at the DEJ, follicular invasion, nucleated cells in the papillae--which each score 1 point, and 1 negative criterion--broadened honeycomb pattern--which scores -1 point.²

RELATED VIDEO: RCM Videomosaic of Melanoma In Situ

Patient 1

An 82-year-old woman was referred to us for management of an LMM on the left side of the forehead (Figure 1A). Handheld RCM from the biopsy site showed large atypical cells in the epidermis, DEJ, and papillary dermis. Superiorly, HRCM showed large dendritic processes but did not reveal LM features in 3 additional clinically worrisome areas. Biopsies showed LMM at the prior biopsy site, LM superiorly, and actinic keratosis in the remaining 3 areas, supporting the HRCM findings. Due to upstaging, the patient was referred for head and neck surgery. To aid in resection, HRCM was performed intraoperatively in a multidisciplinary approach (Figure 1B). Due to the large size of the lesion, surgical margins were taken right outside the HRCM border. Pathology showed LMM extending focally into the margins that were reexcised, achieving clearance.

Patient 2

An 88-year-old woman presented with a slightly pigmented, 2.5×2.3-cm LMM on the left cheek. Because of her age and comorbidities (eg, osteoporosis, deep vein thrombosis in both lower legs requiring anticoagulation therapy, presence of an inferior vena cava filter, bilateral lymphedema of the legs, irritable bowel syndrome, hyperparathyroidism), she was treated with imiquimod cream 5% achieving partial response. The lesion was subsequently excised showing LMM extending to the margins. Not wanting to undergo further surgery, she opted for radiation therapy. Handheld RCM was performed to guide the radiation field, showing pagetoid cells within 1 cm of the scar and clear margins beyond 2 cm. She underwent radiation therapy followed by treatment with imiquimod. On 6-month follow-up, no clinical lesion was apparent, but HRCM showed atypical cells. Biopsies revealed an atypical intraepidermal melanocytic proliferation, but due to patient's comorbidities, close observation was decided.

Patient 3

A 78-year-old man presented with an LMM on the right preauricular area. Handheld RCM demonstrated pleomorphic pagetoid cells along and beyond the clinical margins. Wide excision with sentinel lymph node biopsy was planned, and to aid surgery a confocal map was created (Figure 2). Margins were clear at 1 cm, except inferiorly where they extended to 1.5 cm. Using this preoperative HRCM map, all intraoperative sections were clear. Final pathology confirmed clear margins throughout.

Patient 4

A 62-year-old man presented with hyperpigmentation and bleeding on the left cheek where an LMM was previously removed 8 times over 18 years. Handheld RCM showed pleomorphic cells along the graft border and interestingly within the graft. Ten biopsies were taken, 8 at sites with confocal features that were worrisome for LM (Figures 3A and 3B) and 2 at clinically suspicious sites. The former revealed melanomas (2 that were invasive to 0.3 mm), and the latter revealed solar lentigines. The patient underwent staged excision guided by HRCM (Figure 3C), achieving clear histologic margins except for a focus in the helix. This area was RCM positive but was intentionally not resected due to reconstructive difficulties; imiquimod was indicated in this area.

Patient 5

An 85-year-old woman with 6 prior melanomas over 15 years presented with ill-defined light brown patches on the left cheek at the site where an LM was previously excised 15 years prior. Biopsies showed LM, and due to the patient's age, health, and personal preference to avoid extensive surgery, treatment with imiquimod cream 5% was decided. Over a period of 6 to 12 months, she developed multiple erythematous macules with 2 faintly pigmented areas. Handheld RCM demonstrated atypical cells within the papillae in previously biopsied sites that were rebiopsied, revealing LMM (Breslow depth, 0.2 mm). Staged excision achieved clear margins, but after 8 months HRCM showed LM features. Histology confirmed the diagnosis and imiquimod was reapplied.

Comment

Diagnosis and choice of treatment modality for cases of facial LM is a challenge, and there are a number of factors that may create even more of a clinical dilemma. Surgical excision is the treatment of choice for LM/LMM, and better results are achieved when using histologically controlled surgical procedures such as Mohs micrographic surgery, staged excision, or the "spaghetti technique."^15-17 However, advanced patient age, multiple comorbidities (eg, coronary artery disease, deep vein thrombosis, other conditions requiring anticoagulation therapy), large lesion size in functionally or aesthetically sensitive areas, and indiscriminate borders on photodamaged skin may make surgical excision complicated or not feasible. Additionally, prior treatments to the affected area may further obscure clinical borders, complicating the diagnosis of recurrence/persistence when observed with the naked eye, dermoscopy, or Wood lamp. Because RCM can detect small amounts of melanin and has cellular resolution, it has been suggested as a great diagnostic tool to be combined with dermoscopy when evaluating lightly pigmented/amelanotic facial lesions arising on sun-damaged skin.^18,19 In this case series, we highlighted these difficulties and showed how HRCM can be useful in a variety of scenarios, both pretreatment and posttreatment in complex LM/LMM cases.

Pretreatment Evaluation

Blind mapping biopsies of LM are prone to sample bias and depend greatly on biopsy technique; however, HRCM can guide mapping biopsies by detecting features of LM in vivo with high sensitivity.¹¹ Due to the cosmetically sensitive nature of the lesions, many physicians are discouraged to do multiple mapping biopsies, making it difficult to assess the breadth of the lesion and occult invasion. Multiple studies have shown that occult invasion was not apparent until complete lesion excision was done.^15,20,21 Agarwal-Antal et al²⁰ reported 92 cases of LM, of which 16% (15/92) had unsuspected invasion on final excisional pathology. A long-standing disadvantage of treating LM with nonsurgical modalities has been the inability to detect occult invasion or multifocal invasion within the lesion. As described in patients 1, 4, and 5 in the current case series, utilizing real-time video imaging of the DEJ at the margins and within the lesion has allowed for the detection of deep atypical melanocytes suspicious for perifollicular infiltration and invasion. Knowing the depth of invasion before treatment is essential for not only counseling the patient about disease risk but also for choosing an appropriate treatment modality. Therefore, prospective studies evaluating the performance of RCM to identify invasion are crucial to improve sampling error and avoid unnecessary biopsies.

Surgical Treatment

Although surgery is the first-line treatment option for facial LM, it is not without associated morbidity, and LM is known to have histological subclinical extension, which makes margin assessment difficult. Wide surgical margins on the face are not always possible and become further complicated when trying to maintain adequate functional and cosmetic outcomes. Additionally, the margin for surgical clearance may not be straightforward for facial lesions. Hazan et al¹⁵ showed the mean total surgical margins required for excision of LM and LMM was 7.1 and 10.3 mm, respectively; of the 91 tumors initially diagnosed as LM on biopsy, 16% (15/91) had unsuspected invasion. Guitera et al² reported that the presence of atypical cells within the dermal papillae might be a sign of invasion, which occasionally is not detected histologically due to sampling bias. Handheld RCM offers the advantage of a rapid real-time assessment in areas that may not have been amenable to previous iterations of the device, and it also provides a larger field of view that would be time consuming if performed using conventional RCM. Compared to prior RCM devices that were not handheld, the use of the HRCM does not need to attach a ring to the skin and is less bulky, permitting its use at the bedside of the patient or even intraoperatively.13 In our experience, HRCM has helped to better characterize subclinical spread of LM during the initial consultation and better counsel patients about the extent of the lesion. Handheld RCM also has been used to guide the spaghetti technique in patients with LM/LMM with good correlation between HRCM and histology.²² In our case series, HRCM was used in complex LM/LMM to delineate surgical margins, though in some cases the histologic margins were too close or affected, suggesting HRCM underestimation. Lentigo maligna margin assessment with RCM uses an algorithm that evaluates confocal features in the center of the lesion.^1,2 Therefore, further studies using HRCM should evaluate minor confocal features in the margins as potential markers of positivity to accurately delineate surgical margins.

Nonsurgical Treatment Options

For patients unable or unwilling to pursue surgical treatment, therapies such as imiquimod or radiation have been suggested.^23,24 However, the lack of histological confirmation and possibility for invasive spread has limited these modalities. Lentigo malignas treated with radiation have a 5% recurrence rate, with a median follow-up time of 3 years.²³ Recurrence often can be difficult to detect clinically, as it may manifest as an amelanotic lesion, or postradiation changes can hinder detection. Handheld RCM allows for a cellular-level observation of the irradiated field and can identify radiation-induced changes in LM lesions, including superficial necrosis, apoptotic cells, dilated vessels, and increased inflammatory cells.²⁵ Handheld RCM has previously been used to assess LM treated with radiation and, as in patient 2, can help define the radiation field and detect treatment failure or recurrence.^12,25

Similarly, as described in patient 5, HRCM was utilized to monitor treatment with imiquimod. Many reports use imiquimod for treatment of LM, but application and response vary greatly. Reflectance confocal microscopy has been shown to be useful in monitoring LM treated with imiquimod,⁸ which is important because clinical findings such as inflammation and erythema do not correlate well with response to therapy. Thus, RCM is an appealing noninvasive modality to monitor response to treatment and assess the need for longer treatment duration. Moreover, similar to postradiation changes, treatment with imiquimod may cause an alteration of the clinically apparent pigment. Therefore, it is difficult to assess treatment success by clinical inspection alone. The use of RCM before, during, and after treatment provides a longitudinal assessment of the lesion and has augmented dermatologists' ability to determine treatment success or failure; however, prospective studies evaluating the usefulness of HRCM in the recurrent setting are needed to validate these results.

Limitations

Limitations of this technology include the time needed to image large areas; technology cost; and associated learning curve, which may take from 6 months to 1 year based on our experience. Others have reported the training required for accurate RCM interpretation to be less than that of dermoscopy.²⁶ It has been shown that key RCM diagnostic criteria for lesions including melanoma and basal cell carcinoma are reproducibly recognized among RCM users and that diagnostic accuracy increases with experience.²⁷ These limitations can be overcome with advances in videomosaicing that may streamline the imaging as well as an eventual decrease in cost with greater user adoption and the development of training platforms that enable a faster learning of RCM.²⁸

Conclusion

The use of HRCM can help in the diagnosis and management of facial LMs. Handheld RCM provides longitudinal assessment of LM/LMM that may help determine treatment success or failure and has proven to be useful in detecting the presence of recurrence/persistence in cases that were clinically poorly evident. Moreover, HRCM is a notable ancillary tool, as it can be performed at the bedside of the patient or even intraoperatively and provides a faster approach than conventional RCM in cases where large areas need to be mapped.

In summary, HRCM may eventually be a useful screening tool to guide scouting biopsies to diagnose de novo LM; guide surgical and nonsurgical therapies; and evaluate the presence of recurrence/persistence, especially in large, complex, amelanotic or poorly pigmented lesions. A more standardized use of HRCM in mapping surgical and nonsurgical approaches needs to be evaluated in further studies to provide a fast and reliable complement to histology in such complex cases; therefore, larger studies need to be performed to validate this technique in such complex cases.

Lentigo maligna (LM) and LM melanoma (LMM) represent diagnostic and therapeutic challenges due to their heterogeneous nature and location on cosmetically sensitive areas. Newer ancillary technologies such as reflectance confocal microscopy (RCM) have helped improve diagnosis and management of these challenging lesions.^1,2

Reflectance confocal microscopy is a noninvasive laser system that provides real-time imaging of the epidermis and dermis with cellular resolution and improves diagnostic accuracy of melanocytic lesions.^2,3 Normal melanocytes appear as round bright structures on RCM that are similar in size to surrounding keratinocytes located in the basal layer and regularly distributed around the dermal papillae (junctional nevi) or form regular dense nests in the dermis (intradermal nevi).^4,5 In LM/LMM, there may be widespread infiltration of atypical melanocytes invading hair follicles; large, round, pagetoid melanocytes (larger than surrounding keratinocytes); sheets of large atypical cells at the dermoepidermal junction (DEJ); loss of contour in the dermal papillae; and atypical melanocytes invading the dermal papillae.² Indeed, RCM has good correlation with the degree of histologic atypia and is useful to distinguish between benign nevi, atypical nevi, and melanoma.⁶ By combining lateral mosaics with vertical stacks, RCM allows 3-dimensional approximation of tumor margins and monitoring of nonsurgical therapies.^7,8 The advent of handheld RCM (HRCM) has allowed assessment of large lesions as well as those presenting in difficult locations.⁹ Furthermore, the generation of videomosaics overcomes the limited field of view of traditional RCM and allows for accurate assessment of large lesions.¹⁰

Traditional and handheld RCM have been used to diagnose and map primary LM.^1,2,11 Guitera et al² developed an algorithm using traditional RCM to distinguish benign facial macules and LM. In their training set, they found that when their score resulted in 2 or more points, the sensitivity and specificity to diagnose LM was 85% and 76%, respectively, with an odds ratio of 18.6 for LM. They later applied the algorithm in a test set of 44 benign facial macules and 29 LM and obtained an odds ratio of 60.7 for LM, with sensitivity and specificity rates of 93% and 82%, respectively.² This algorithm also was tested by Menge et al11 using the HRCM. They found 100% sensitivity and 71% specificity for LM when evaluating 63 equivocal facial lesions. Although these results suggest that RCM can accurately distinguish LM from benign lesions in the primary setting, few reports have studied the impact of HRCM in the recurrent setting and its impact in monitoring treatment of LM.^12,13

Herein, we present 5 cases in which HRCM was used to manage complex facial LM/LMM, highlighting its versatility and potential for use in the clinical setting (eTable).

Case Series

Following institutional review board approval, cases of facial LM/LMM presenting for assessment and treatment from January 2014 to December 2015 were retrospectively reviewed. Initially, the clinical margins of the lesions were determined using Wood lamp and/or dermoscopy. Using HRCM, vertical stacks were taken at the 12-, 3-, 6-, and 9-o'clock positions, and videos were captured along the peripheral margins at the DEJ. To create videomosaics, HRCM video frames were extracted and later stitched using a computer algorithm written in a fourth-generation programming language based on prior studies.^10,14 An example HRCM video that was captured and turned into a videomosaic accompanies this article online (http://bit.ly/2oDYS6k). Additional stacks were taken in suspicious areas. We considered an area positive for LM under HRCM when the LM score developed by Guitera et al² was 2 or more. The algorithm scoring includes 2 major criteria--nonedged papillae and round large pagetoid cells--which score 2 points, and 4 minor criteria, including 3 positive criteria--atypical cells at the DEJ, follicular invasion, nucleated cells in the papillae--which each score 1 point, and 1 negative criterion--broadened honeycomb pattern--which scores -1 point.²

RELATED VIDEO: RCM Videomosaic of Melanoma In Situ

Patient 1

An 82-year-old woman was referred to us for management of an LMM on the left side of the forehead (Figure 1A). Handheld RCM from the biopsy site showed large atypical cells in the epidermis, DEJ, and papillary dermis. Superiorly, HRCM showed large dendritic processes but did not reveal LM features in 3 additional clinically worrisome areas. Biopsies showed LMM at the prior biopsy site, LM superiorly, and actinic keratosis in the remaining 3 areas, supporting the HRCM findings. Due to upstaging, the patient was referred for head and neck surgery. To aid in resection, HRCM was performed intraoperatively in a multidisciplinary approach (Figure 1B). Due to the large size of the lesion, surgical margins were taken right outside the HRCM border. Pathology showed LMM extending focally into the margins that were reexcised, achieving clearance.

Patient 2

An 88-year-old woman presented with a slightly pigmented, 2.5×2.3-cm LMM on the left cheek. Because of her age and comorbidities (eg, osteoporosis, deep vein thrombosis in both lower legs requiring anticoagulation therapy, presence of an inferior vena cava filter, bilateral lymphedema of the legs, irritable bowel syndrome, hyperparathyroidism), she was treated with imiquimod cream 5% achieving partial response. The lesion was subsequently excised showing LMM extending to the margins. Not wanting to undergo further surgery, she opted for radiation therapy. Handheld RCM was performed to guide the radiation field, showing pagetoid cells within 1 cm of the scar and clear margins beyond 2 cm. She underwent radiation therapy followed by treatment with imiquimod. On 6-month follow-up, no clinical lesion was apparent, but HRCM showed atypical cells. Biopsies revealed an atypical intraepidermal melanocytic proliferation, but due to patient's comorbidities, close observation was decided.

Patient 3

A 78-year-old man presented with an LMM on the right preauricular area. Handheld RCM demonstrated pleomorphic pagetoid cells along and beyond the clinical margins. Wide excision with sentinel lymph node biopsy was planned, and to aid surgery a confocal map was created (Figure 2). Margins were clear at 1 cm, except inferiorly where they extended to 1.5 cm. Using this preoperative HRCM map, all intraoperative sections were clear. Final pathology confirmed clear margins throughout.

Patient 4

A 62-year-old man presented with hyperpigmentation and bleeding on the left cheek where an LMM was previously removed 8 times over 18 years. Handheld RCM showed pleomorphic cells along the graft border and interestingly within the graft. Ten biopsies were taken, 8 at sites with confocal features that were worrisome for LM (Figures 3A and 3B) and 2 at clinically suspicious sites. The former revealed melanomas (2 that were invasive to 0.3 mm), and the latter revealed solar lentigines. The patient underwent staged excision guided by HRCM (Figure 3C), achieving clear histologic margins except for a focus in the helix. This area was RCM positive but was intentionally not resected due to reconstructive difficulties; imiquimod was indicated in this area.

Patient 5

An 85-year-old woman with 6 prior melanomas over 15 years presented with ill-defined light brown patches on the left cheek at the site where an LM was previously excised 15 years prior. Biopsies showed LM, and due to the patient's age, health, and personal preference to avoid extensive surgery, treatment with imiquimod cream 5% was decided. Over a period of 6 to 12 months, she developed multiple erythematous macules with 2 faintly pigmented areas. Handheld RCM demonstrated atypical cells within the papillae in previously biopsied sites that were rebiopsied, revealing LMM (Breslow depth, 0.2 mm). Staged excision achieved clear margins, but after 8 months HRCM showed LM features. Histology confirmed the diagnosis and imiquimod was reapplied.

Comment

Diagnosis and choice of treatment modality for cases of facial LM is a challenge, and there are a number of factors that may create even more of a clinical dilemma. Surgical excision is the treatment of choice for LM/LMM, and better results are achieved when using histologically controlled surgical procedures such as Mohs micrographic surgery, staged excision, or the "spaghetti technique."^15-17 However, advanced patient age, multiple comorbidities (eg, coronary artery disease, deep vein thrombosis, other conditions requiring anticoagulation therapy), large lesion size in functionally or aesthetically sensitive areas, and indiscriminate borders on photodamaged skin may make surgical excision complicated or not feasible. Additionally, prior treatments to the affected area may further obscure clinical borders, complicating the diagnosis of recurrence/persistence when observed with the naked eye, dermoscopy, or Wood lamp. Because RCM can detect small amounts of melanin and has cellular resolution, it has been suggested as a great diagnostic tool to be combined with dermoscopy when evaluating lightly pigmented/amelanotic facial lesions arising on sun-damaged skin.^18,19 In this case series, we highlighted these difficulties and showed how HRCM can be useful in a variety of scenarios, both pretreatment and posttreatment in complex LM/LMM cases.

Pretreatment Evaluation

Blind mapping biopsies of LM are prone to sample bias and depend greatly on biopsy technique; however, HRCM can guide mapping biopsies by detecting features of LM in vivo with high sensitivity.¹¹ Due to the cosmetically sensitive nature of the lesions, many physicians are discouraged to do multiple mapping biopsies, making it difficult to assess the breadth of the lesion and occult invasion. Multiple studies have shown that occult invasion was not apparent until complete lesion excision was done.^15,20,21 Agarwal-Antal et al²⁰ reported 92 cases of LM, of which 16% (15/92) had unsuspected invasion on final excisional pathology. A long-standing disadvantage of treating LM with nonsurgical modalities has been the inability to detect occult invasion or multifocal invasion within the lesion. As described in patients 1, 4, and 5 in the current case series, utilizing real-time video imaging of the DEJ at the margins and within the lesion has allowed for the detection of deep atypical melanocytes suspicious for perifollicular infiltration and invasion. Knowing the depth of invasion before treatment is essential for not only counseling the patient about disease risk but also for choosing an appropriate treatment modality. Therefore, prospective studies evaluating the performance of RCM to identify invasion are crucial to improve sampling error and avoid unnecessary biopsies.

Surgical Treatment

Although surgery is the first-line treatment option for facial LM, it is not without associated morbidity, and LM is known to have histological subclinical extension, which makes margin assessment difficult. Wide surgical margins on the face are not always possible and become further complicated when trying to maintain adequate functional and cosmetic outcomes. Additionally, the margin for surgical clearance may not be straightforward for facial lesions. Hazan et al¹⁵ showed the mean total surgical margins required for excision of LM and LMM was 7.1 and 10.3 mm, respectively; of the 91 tumors initially diagnosed as LM on biopsy, 16% (15/91) had unsuspected invasion. Guitera et al² reported that the presence of atypical cells within the dermal papillae might be a sign of invasion, which occasionally is not detected histologically due to sampling bias. Handheld RCM offers the advantage of a rapid real-time assessment in areas that may not have been amenable to previous iterations of the device, and it also provides a larger field of view that would be time consuming if performed using conventional RCM. Compared to prior RCM devices that were not handheld, the use of the HRCM does not need to attach a ring to the skin and is less bulky, permitting its use at the bedside of the patient or even intraoperatively.13 In our experience, HRCM has helped to better characterize subclinical spread of LM during the initial consultation and better counsel patients about the extent of the lesion. Handheld RCM also has been used to guide the spaghetti technique in patients with LM/LMM with good correlation between HRCM and histology.²² In our case series, HRCM was used in complex LM/LMM to delineate surgical margins, though in some cases the histologic margins were too close or affected, suggesting HRCM underestimation. Lentigo maligna margin assessment with RCM uses an algorithm that evaluates confocal features in the center of the lesion.^1,2 Therefore, further studies using HRCM should evaluate minor confocal features in the margins as potential markers of positivity to accurately delineate surgical margins.

Nonsurgical Treatment Options

For patients unable or unwilling to pursue surgical treatment, therapies such as imiquimod or radiation have been suggested.^23,24 However, the lack of histological confirmation and possibility for invasive spread has limited these modalities. Lentigo malignas treated with radiation have a 5% recurrence rate, with a median follow-up time of 3 years.²³ Recurrence often can be difficult to detect clinically, as it may manifest as an amelanotic lesion, or postradiation changes can hinder detection. Handheld RCM allows for a cellular-level observation of the irradiated field and can identify radiation-induced changes in LM lesions, including superficial necrosis, apoptotic cells, dilated vessels, and increased inflammatory cells.²⁵ Handheld RCM has previously been used to assess LM treated with radiation and, as in patient 2, can help define the radiation field and detect treatment failure or recurrence.^12,25

Similarly, as described in patient 5, HRCM was utilized to monitor treatment with imiquimod. Many reports use imiquimod for treatment of LM, but application and response vary greatly. Reflectance confocal microscopy has been shown to be useful in monitoring LM treated with imiquimod,⁸ which is important because clinical findings such as inflammation and erythema do not correlate well with response to therapy. Thus, RCM is an appealing noninvasive modality to monitor response to treatment and assess the need for longer treatment duration. Moreover, similar to postradiation changes, treatment with imiquimod may cause an alteration of the clinically apparent pigment. Therefore, it is difficult to assess treatment success by clinical inspection alone. The use of RCM before, during, and after treatment provides a longitudinal assessment of the lesion and has augmented dermatologists' ability to determine treatment success or failure; however, prospective studies evaluating the usefulness of HRCM in the recurrent setting are needed to validate these results.

Limitations

Limitations of this technology include the time needed to image large areas; technology cost; and associated learning curve, which may take from 6 months to 1 year based on our experience. Others have reported the training required for accurate RCM interpretation to be less than that of dermoscopy.²⁶ It has been shown that key RCM diagnostic criteria for lesions including melanoma and basal cell carcinoma are reproducibly recognized among RCM users and that diagnostic accuracy increases with experience.²⁷ These limitations can be overcome with advances in videomosaicing that may streamline the imaging as well as an eventual decrease in cost with greater user adoption and the development of training platforms that enable a faster learning of RCM.²⁸

Conclusion

The use of HRCM can help in the diagnosis and management of facial LMs. Handheld RCM provides longitudinal assessment of LM/LMM that may help determine treatment success or failure and has proven to be useful in detecting the presence of recurrence/persistence in cases that were clinically poorly evident. Moreover, HRCM is a notable ancillary tool, as it can be performed at the bedside of the patient or even intraoperatively and provides a faster approach than conventional RCM in cases where large areas need to be mapped.

In summary, HRCM may eventually be a useful screening tool to guide scouting biopsies to diagnose de novo LM; guide surgical and nonsurgical therapies; and evaluate the presence of recurrence/persistence, especially in large, complex, amelanotic or poorly pigmented lesions. A more standardized use of HRCM in mapping surgical and nonsurgical approaches needs to be evaluated in further studies to provide a fast and reliable complement to histology in such complex cases; therefore, larger studies need to be performed to validate this technique in such complex cases.

A recent executive order by President Trump that aims to overhaul a specialized visa program for foreign workers appears to have more bark than bite, immigration experts say.

The order, published April 21 in the Federal Register, calls upon federal agencies to propose new rules, guidance, and reforms to ensure that H-1B visas are granted only to fill the most highly skilled positions. The H-1B visa program allows U.S. employers to temporarily employ highly skilled foreign workers in specialty occupations; foreign physicians and medical students regularly use the program to practice and train in the United States.

Gage Skidmore/Wikimedia Commons/CC BY-SA 2.0

[email protected]

On Twitter @legal_med

A recent executive order by President Trump that aims to overhaul a specialized visa program for foreign workers appears to have more bark than bite, immigration experts say.

The order, published April 21 in the Federal Register, calls upon federal agencies to propose new rules, guidance, and reforms to ensure that H-1B visas are granted only to fill the most highly skilled positions. The H-1B visa program allows U.S. employers to temporarily employ highly skilled foreign workers in specialty occupations; foreign physicians and medical students regularly use the program to practice and train in the United States.

Gage Skidmore/Wikimedia Commons/CC BY-SA 2.0

[email protected]

On Twitter @legal_med

A recent executive order by President Trump that aims to overhaul a specialized visa program for foreign workers appears to have more bark than bite, immigration experts say.

The order, published April 21 in the Federal Register, calls upon federal agencies to propose new rules, guidance, and reforms to ensure that H-1B visas are granted only to fill the most highly skilled positions. The H-1B visa program allows U.S. employers to temporarily employ highly skilled foreign workers in specialty occupations; foreign physicians and medical students regularly use the program to practice and train in the United States.

Gage Skidmore/Wikimedia Commons/CC BY-SA 2.0

[email protected]

On Twitter @legal_med

Sun exposure and sunburns sustained during childhood are linked to an increased risk for development of skin cancers in adulthood. In infants, the skin is particularly vulnerable and is considered to be at increased risk for UV radiation damage,¹ even as early as the first 6 months of life.² Sun-safe behaviors instituted from a young age may help reduce the risk for future skin cancers.³ To effectively teach parents proper sun-safe practices, it is essential to understand their existing perceptions and behaviors. This study sought to examine differences in infant sun-safety practices during the first 6 months of life among black, Hispanic, and non-Hispanic white (NHW) parents in Miami, Florida.

Methods

Parents presenting to the University of Miami general pediatrics clinic from February 2015 through April 2015 with a child younger than 5 years were administered a 15-item questionnaire that included items on demographics, sun-safety strategies, sunburns and tanning, beliefs and limitations regarding sunscreen, and primary information source regarding sun safety (eg, physician, Internet, media, instincts). Parents were approached by the investigators consecutively for participation in scheduled blocks, with the exception of those who were otherwise engaged in appointment-related tasks (eg, paperwork). The study was approved by the University of Miami Miller School of Medicine institutional review board. The primary objective of this study was to determine the sun protection behaviors that black and Hispanic parents in Miami, Florida, employ in infants younger than 6 months. Secondary objectives included determining if this patient population is at risk for infant sunburns and tanning, beliefs among parents regarding sunscreen's efficacy in the prevention of skin cancers, and limitations of sunscreen use.

All data were analyzed using SAS software version 9.3. Wilcoxon signed rank test, Kruskal-Wallis test, Fisher exact test, and proportional-odds cumulative logit model were used to compare nonparametric data. Parents reporting on the full first 6 months of life (ie, the child was older than 6 months at the time of study completion) were included for analysis of sun-safety strategies. All survey respondents were included for analysis of secondary objectives. Responses from parents of infants of mixed racial and ethnic backgrounds were excluded from applicable subgroup analyses.

Results

Ninety-eight parents were approached for participation in the study; 97 consented to participate and 95 completed the survey. Seventy parents had children who were at least 6 months of age and were included for analysis of the primary objectives (ie, sun-protection strategies in the first 6 months of life). The cohort included 49 Hispanic parents, 26 black parents, and 9 NHW parents; 5 parents indicated their child was of mixed racial and ethnic background. Six respondents indicated another minority group (eg, Native American, Pacific Islander). Eighty-three respondents were mothers, 72 were educated beyond high school, and 14 were Spanish-speaking only. Four reported a known family history of skin cancer.

There were notable differences in application of sunscreen, belief in the efficacy of sunscreen, and primary source of information between parents (Tables 1 and 2). Hispanic parents reported applying sunscreen more consistently than black parents (odds ratio, 4.656; 95% confidence interval, 1.154-18.782; P<.01). Hispanic parents also were more likely than black parents to believe sunscreen is effective in the prevention of skin cancers (odds ratio, 7.499; 95% confidence interval, 1.535-36.620; P<.01). Hispanic parents were more likely to report receiving information regarding sun-safety practices for infants from their pediatrician, whereas NHW parents were more likely to follow their instincts regarding how and if infants should be exposed to the sun (P<.05). No significant differences were found in the reported primary source of information in black versus Hispanic parents or in black versus NHW parents. Three percent (3/95) of respondents reported a sunburn in the infant's first 6 months of life, and 12% (11/95) reported tanning of infants' skin from sun exposure. Tanning was associated with inconsistent shade (P<.01), inconsistent clothing coverage (P<.01), and consistently allowing infants to "develop tolerance to the sun's rays by slowly increasing sun exposure each day" (P<.05).

Comment

The survey results indicated suboptimal sun-protection practices among parents of black and Hispanic infants in Miami. Although the majority of respondents (83% [58/70]) reported keeping their infants in the shade, less than half of parents consistently covered their infants adequately with clothing and hats (40% [28/70] and 43% [30/70], respectively). More alarmingly, one-third of parents reported intentionally increasing their infant's level of sun exposure to develop his/her tolerance to the sun. A minority of parents reported sunburns (3%) and tanning (12%) within the first 6 months of life. Twenty-nine percent of parents (20/70) reported consistently applying sunscreen to their infants who were younger than 6 months despite limited safety data available for this age group.

Although our study included a limited sample size and represents a narrow geographic distribution, these results suggest that shortcomings in current practices in sun protection for black and Hispanic infants younger than 6 months may be a widespread problem. Black and Hispanic patients have a lower incidence of skin cancer, but the diagnosis often is delayed and the mortality is higher when skin cancer does occur.⁴ The common perception among laypeople as well as many health care providers that black and Hispanic individuals are not at risk for skin cancer may limit sun-safety counseling as well as the overall knowledge base of this patient demographic. As demonstrated by the results of this study, there is a need for counseling on sun-safe behaviors from a young age among this population.

Conclusion

This study highlights potential shortcomings in current sun-protection practices for black and Hispanic infants younger than 6 months. Sun-safe behaviors instituted from a young age may help reduce the risk for future skin cancers.³ Additional studies are needed to further define sun-safety behaviors in black and Hispanic children across the United States. Further, additional studies should focus on developing interventions that positively influence sun-safety behaviors in this patient population. 

Sun exposure and sunburns sustained during childhood are linked to an increased risk for development of skin cancers in adulthood. In infants, the skin is particularly vulnerable and is considered to be at increased risk for UV radiation damage,¹ even as early as the first 6 months of life.² Sun-safe behaviors instituted from a young age may help reduce the risk for future skin cancers.³ To effectively teach parents proper sun-safe practices, it is essential to understand their existing perceptions and behaviors. This study sought to examine differences in infant sun-safety practices during the first 6 months of life among black, Hispanic, and non-Hispanic white (NHW) parents in Miami, Florida.

Methods

Parents presenting to the University of Miami general pediatrics clinic from February 2015 through April 2015 with a child younger than 5 years were administered a 15-item questionnaire that included items on demographics, sun-safety strategies, sunburns and tanning, beliefs and limitations regarding sunscreen, and primary information source regarding sun safety (eg, physician, Internet, media, instincts). Parents were approached by the investigators consecutively for participation in scheduled blocks, with the exception of those who were otherwise engaged in appointment-related tasks (eg, paperwork). The study was approved by the University of Miami Miller School of Medicine institutional review board. The primary objective of this study was to determine the sun protection behaviors that black and Hispanic parents in Miami, Florida, employ in infants younger than 6 months. Secondary objectives included determining if this patient population is at risk for infant sunburns and tanning, beliefs among parents regarding sunscreen's efficacy in the prevention of skin cancers, and limitations of sunscreen use.

All data were analyzed using SAS software version 9.3. Wilcoxon signed rank test, Kruskal-Wallis test, Fisher exact test, and proportional-odds cumulative logit model were used to compare nonparametric data. Parents reporting on the full first 6 months of life (ie, the child was older than 6 months at the time of study completion) were included for analysis of sun-safety strategies. All survey respondents were included for analysis of secondary objectives. Responses from parents of infants of mixed racial and ethnic backgrounds were excluded from applicable subgroup analyses.

Results

Ninety-eight parents were approached for participation in the study; 97 consented to participate and 95 completed the survey. Seventy parents had children who were at least 6 months of age and were included for analysis of the primary objectives (ie, sun-protection strategies in the first 6 months of life). The cohort included 49 Hispanic parents, 26 black parents, and 9 NHW parents; 5 parents indicated their child was of mixed racial and ethnic background. Six respondents indicated another minority group (eg, Native American, Pacific Islander). Eighty-three respondents were mothers, 72 were educated beyond high school, and 14 were Spanish-speaking only. Four reported a known family history of skin cancer.

There were notable differences in application of sunscreen, belief in the efficacy of sunscreen, and primary source of information between parents (Tables 1 and 2). Hispanic parents reported applying sunscreen more consistently than black parents (odds ratio, 4.656; 95% confidence interval, 1.154-18.782; P<.01). Hispanic parents also were more likely than black parents to believe sunscreen is effective in the prevention of skin cancers (odds ratio, 7.499; 95% confidence interval, 1.535-36.620; P<.01). Hispanic parents were more likely to report receiving information regarding sun-safety practices for infants from their pediatrician, whereas NHW parents were more likely to follow their instincts regarding how and if infants should be exposed to the sun (P<.05). No significant differences were found in the reported primary source of information in black versus Hispanic parents or in black versus NHW parents. Three percent (3/95) of respondents reported a sunburn in the infant's first 6 months of life, and 12% (11/95) reported tanning of infants' skin from sun exposure. Tanning was associated with inconsistent shade (P<.01), inconsistent clothing coverage (P<.01), and consistently allowing infants to "develop tolerance to the sun's rays by slowly increasing sun exposure each day" (P<.05).

Comment

The survey results indicated suboptimal sun-protection practices among parents of black and Hispanic infants in Miami. Although the majority of respondents (83% [58/70]) reported keeping their infants in the shade, less than half of parents consistently covered their infants adequately with clothing and hats (40% [28/70] and 43% [30/70], respectively). More alarmingly, one-third of parents reported intentionally increasing their infant's level of sun exposure to develop his/her tolerance to the sun. A minority of parents reported sunburns (3%) and tanning (12%) within the first 6 months of life. Twenty-nine percent of parents (20/70) reported consistently applying sunscreen to their infants who were younger than 6 months despite limited safety data available for this age group.

Although our study included a limited sample size and represents a narrow geographic distribution, these results suggest that shortcomings in current practices in sun protection for black and Hispanic infants younger than 6 months may be a widespread problem. Black and Hispanic patients have a lower incidence of skin cancer, but the diagnosis often is delayed and the mortality is higher when skin cancer does occur.⁴ The common perception among laypeople as well as many health care providers that black and Hispanic individuals are not at risk for skin cancer may limit sun-safety counseling as well as the overall knowledge base of this patient demographic. As demonstrated by the results of this study, there is a need for counseling on sun-safe behaviors from a young age among this population.

Conclusion

This study highlights potential shortcomings in current sun-protection practices for black and Hispanic infants younger than 6 months. Sun-safe behaviors instituted from a young age may help reduce the risk for future skin cancers.³ Additional studies are needed to further define sun-safety behaviors in black and Hispanic children across the United States. Further, additional studies should focus on developing interventions that positively influence sun-safety behaviors in this patient population. 

Sun exposure and sunburns sustained during childhood are linked to an increased risk for development of skin cancers in adulthood. In infants, the skin is particularly vulnerable and is considered to be at increased risk for UV radiation damage,¹ even as early as the first 6 months of life.² Sun-safe behaviors instituted from a young age may help reduce the risk for future skin cancers.³ To effectively teach parents proper sun-safe practices, it is essential to understand their existing perceptions and behaviors. This study sought to examine differences in infant sun-safety practices during the first 6 months of life among black, Hispanic, and non-Hispanic white (NHW) parents in Miami, Florida.

Methods

Parents presenting to the University of Miami general pediatrics clinic from February 2015 through April 2015 with a child younger than 5 years were administered a 15-item questionnaire that included items on demographics, sun-safety strategies, sunburns and tanning, beliefs and limitations regarding sunscreen, and primary information source regarding sun safety (eg, physician, Internet, media, instincts). Parents were approached by the investigators consecutively for participation in scheduled blocks, with the exception of those who were otherwise engaged in appointment-related tasks (eg, paperwork). The study was approved by the University of Miami Miller School of Medicine institutional review board. The primary objective of this study was to determine the sun protection behaviors that black and Hispanic parents in Miami, Florida, employ in infants younger than 6 months. Secondary objectives included determining if this patient population is at risk for infant sunburns and tanning, beliefs among parents regarding sunscreen's efficacy in the prevention of skin cancers, and limitations of sunscreen use.

All data were analyzed using SAS software version 9.3. Wilcoxon signed rank test, Kruskal-Wallis test, Fisher exact test, and proportional-odds cumulative logit model were used to compare nonparametric data. Parents reporting on the full first 6 months of life (ie, the child was older than 6 months at the time of study completion) were included for analysis of sun-safety strategies. All survey respondents were included for analysis of secondary objectives. Responses from parents of infants of mixed racial and ethnic backgrounds were excluded from applicable subgroup analyses.

Results

Ninety-eight parents were approached for participation in the study; 97 consented to participate and 95 completed the survey. Seventy parents had children who were at least 6 months of age and were included for analysis of the primary objectives (ie, sun-protection strategies in the first 6 months of life). The cohort included 49 Hispanic parents, 26 black parents, and 9 NHW parents; 5 parents indicated their child was of mixed racial and ethnic background. Six respondents indicated another minority group (eg, Native American, Pacific Islander). Eighty-three respondents were mothers, 72 were educated beyond high school, and 14 were Spanish-speaking only. Four reported a known family history of skin cancer.

There were notable differences in application of sunscreen, belief in the efficacy of sunscreen, and primary source of information between parents (Tables 1 and 2). Hispanic parents reported applying sunscreen more consistently than black parents (odds ratio, 4.656; 95% confidence interval, 1.154-18.782; P<.01). Hispanic parents also were more likely than black parents to believe sunscreen is effective in the prevention of skin cancers (odds ratio, 7.499; 95% confidence interval, 1.535-36.620; P<.01). Hispanic parents were more likely to report receiving information regarding sun-safety practices for infants from their pediatrician, whereas NHW parents were more likely to follow their instincts regarding how and if infants should be exposed to the sun (P<.05). No significant differences were found in the reported primary source of information in black versus Hispanic parents or in black versus NHW parents. Three percent (3/95) of respondents reported a sunburn in the infant's first 6 months of life, and 12% (11/95) reported tanning of infants' skin from sun exposure. Tanning was associated with inconsistent shade (P<.01), inconsistent clothing coverage (P<.01), and consistently allowing infants to "develop tolerance to the sun's rays by slowly increasing sun exposure each day" (P<.05).

Comment

The survey results indicated suboptimal sun-protection practices among parents of black and Hispanic infants in Miami. Although the majority of respondents (83% [58/70]) reported keeping their infants in the shade, less than half of parents consistently covered their infants adequately with clothing and hats (40% [28/70] and 43% [30/70], respectively). More alarmingly, one-third of parents reported intentionally increasing their infant's level of sun exposure to develop his/her tolerance to the sun. A minority of parents reported sunburns (3%) and tanning (12%) within the first 6 months of life. Twenty-nine percent of parents (20/70) reported consistently applying sunscreen to their infants who were younger than 6 months despite limited safety data available for this age group.

Although our study included a limited sample size and represents a narrow geographic distribution, these results suggest that shortcomings in current practices in sun protection for black and Hispanic infants younger than 6 months may be a widespread problem. Black and Hispanic patients have a lower incidence of skin cancer, but the diagnosis often is delayed and the mortality is higher when skin cancer does occur.⁴ The common perception among laypeople as well as many health care providers that black and Hispanic individuals are not at risk for skin cancer may limit sun-safety counseling as well as the overall knowledge base of this patient demographic. As demonstrated by the results of this study, there is a need for counseling on sun-safe behaviors from a young age among this population.

Conclusion

This study highlights potential shortcomings in current sun-protection practices for black and Hispanic infants younger than 6 months. Sun-safe behaviors instituted from a young age may help reduce the risk for future skin cancers.³ Additional studies are needed to further define sun-safety behaviors in black and Hispanic children across the United States. Further, additional studies should focus on developing interventions that positively influence sun-safety behaviors in this patient population. 

It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.

That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.

“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.

To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.

For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.

Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.

Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.

Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”

Dr. Tan had no relevant financial disclosures.

It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.

That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.

“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.

To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.

For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.

Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.

Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.

Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”

Dr. Tan had no relevant financial disclosures.

It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.

That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.

“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.

To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.

For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.

Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.

Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.

Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”

Dr. Tan had no relevant financial disclosures.

In 2015, nearly 2.4 million Americans had an opioid use disorder. Close to 80% did not receive treatment. To help change those numbers, the Substance Abuse and Mental Health Services Administration (SAMHSA) has developed a free mobile application called MATx that supports medication-assisted treatment. The app “empowers health care practitioners to provide effective, evidence-based care for people with opioid use disorder.” Features include the following:

• Information on treatment approaches and medications approved by the FDA for use in treating opioid use disorders;
• A buprenorphine prescribing guide, including information on the Drug Addiction Treatment Act of 2000 waiver process and patient limits;
• Clinical support tools, such as treatment guidelines, ICD-10 coding, and recommendations for working with special populations;
• Access to critical helplines and SAMHSA’s treatment locators.

For more information on the app, visit http://store.samhsa.gov/apps/mat/tools/index.html?WT.ac=PEPAdSpreadWord20161018Prof.

In 2015, nearly 2.4 million Americans had an opioid use disorder. Close to 80% did not receive treatment. To help change those numbers, the Substance Abuse and Mental Health Services Administration (SAMHSA) has developed a free mobile application called MATx that supports medication-assisted treatment. The app “empowers health care practitioners to provide effective, evidence-based care for people with opioid use disorder.” Features include the following:

• Information on treatment approaches and medications approved by the FDA for use in treating opioid use disorders;
• A buprenorphine prescribing guide, including information on the Drug Addiction Treatment Act of 2000 waiver process and patient limits;
• Clinical support tools, such as treatment guidelines, ICD-10 coding, and recommendations for working with special populations;
• Access to critical helplines and SAMHSA’s treatment locators.

For more information on the app, visit http://store.samhsa.gov/apps/mat/tools/index.html?WT.ac=PEPAdSpreadWord20161018Prof.

In 2015, nearly 2.4 million Americans had an opioid use disorder. Close to 80% did not receive treatment. To help change those numbers, the Substance Abuse and Mental Health Services Administration (SAMHSA) has developed a free mobile application called MATx that supports medication-assisted treatment. The app “empowers health care practitioners to provide effective, evidence-based care for people with opioid use disorder.” Features include the following:

• Information on treatment approaches and medications approved by the FDA for use in treating opioid use disorders;
• A buprenorphine prescribing guide, including information on the Drug Addiction Treatment Act of 2000 waiver process and patient limits;
• Clinical support tools, such as treatment guidelines, ICD-10 coding, and recommendations for working with special populations;
• Access to critical helplines and SAMHSA’s treatment locators.

For more information on the app, visit http://store.samhsa.gov/apps/mat/tools/index.html?WT.ac=PEPAdSpreadWord20161018Prof.

Sometimes the final day of a convention is nothing more than the “getaway day.”

But not at HM17. Not this year.

The finale of the 2017 annual meeting is capped off, as has become tradition, by a speech from the dean of hospital medicine: Robert Wachter, MD, MHM. The last time Dr. Wachter gave his address from a Vegas stage, it ended with him in head-to-toe Elton John regalia. While there’s no guarantee of a wardrobe reprisal, the annual address from the man who helped name the specialty promises to entertain and inform, said HM17 course director Lenny Feldman, MD, SFHM.

Sometimes the final day of a convention is nothing more than the “getaway day.”

But not at HM17. Not this year.

The finale of the 2017 annual meeting is capped off, as has become tradition, by a speech from the dean of hospital medicine: Robert Wachter, MD, MHM. The last time Dr. Wachter gave his address from a Vegas stage, it ended with him in head-to-toe Elton John regalia. While there’s no guarantee of a wardrobe reprisal, the annual address from the man who helped name the specialty promises to entertain and inform, said HM17 course director Lenny Feldman, MD, SFHM.

Sometimes the final day of a convention is nothing more than the “getaway day.”

But not at HM17. Not this year.

The finale of the 2017 annual meeting is capped off, as has become tradition, by a speech from the dean of hospital medicine: Robert Wachter, MD, MHM. The last time Dr. Wachter gave his address from a Vegas stage, it ended with him in head-to-toe Elton John regalia. While there’s no guarantee of a wardrobe reprisal, the annual address from the man who helped name the specialty promises to entertain and inform, said HM17 course director Lenny Feldman, MD, SFHM.

Robert M. Wachter, MD, MHM, has given the last plenary address at every SHM annual meeting since 2007. The talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy. Then there was the time when he broke into an Elton John parody.

Where does that point of view come from? Well, as the dean of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli-sci major becomes an academic physician.”

That’s a needed perspective this year, as the level of political upheaval in the United States has added to the tumult in the health care field. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles that doctors face when using electronic health records (EHRs) are among the topics that he will address in his this final discussion.

The defeat of Republicans’ plan to replace the Affordable Care Act (ACA) with the American Health Care Act (AHCA) showed that the divide over health care extends even to intraparty discussions.

“The implosion of the AHCA shows how difficult health reform is and how quickly the ACA became the de facto standard,” Dr. Wachter said. “It is now that status quo that is so difficult to change.”

Dr. Wachter, who famously helped coined the term “hospitalist” in the 1996 New England Journal of Medicine paper that propelled the nascent specialty, said that one big challenge to HM is determining the future of how hospitals get paid – and how they pay their workers (335[7]:514-7).

“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or [if] their payments go way down,” he predicted.

What that means for the daily schedules of hospitalists remains to be seen, but Dr. Wachter doesn’t expect much in the short term.

“The job will be the same,” he said. “Take care of patients well, make them happy, satisfy your bosses and colleagues, and do it for less money. The biggest shift is likely to be that more and more people/systems – doing the same thing – will find that they don’t need as many hospital days, which means that we’ll have fewer patients and fewer hospitals. But we knew that.”

Dr. Wachter is more interested to see what will happen in postacute and other nonhospital facilities, how quickly technology continues to disrupt, and who hospitalists will work for (be it staffing companies, medical groups, or “something new”).

The veteran physician in him says not to get too distracted “by all of the zigs and zags,” he noted, while the political idealist in him says not to ever forget that the “core values and imperatives remain.”

If the past decade of wise words ending SHM’s annual meeting are any indication, Dr. Wachter’s message of trepidation and concern will end on a high note for attendees.

Robert M. Wachter, MD, MHM, has given the last plenary address at every SHM annual meeting since 2007. The talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy. Then there was the time when he broke into an Elton John parody.

Where does that point of view come from? Well, as the dean of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli-sci major becomes an academic physician.”

That’s a needed perspective this year, as the level of political upheaval in the United States has added to the tumult in the health care field. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles that doctors face when using electronic health records (EHRs) are among the topics that he will address in his this final discussion.

The defeat of Republicans’ plan to replace the Affordable Care Act (ACA) with the American Health Care Act (AHCA) showed that the divide over health care extends even to intraparty discussions.

“The implosion of the AHCA shows how difficult health reform is and how quickly the ACA became the de facto standard,” Dr. Wachter said. “It is now that status quo that is so difficult to change.”

Dr. Wachter, who famously helped coined the term “hospitalist” in the 1996 New England Journal of Medicine paper that propelled the nascent specialty, said that one big challenge to HM is determining the future of how hospitals get paid – and how they pay their workers (335[7]:514-7).

“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or [if] their payments go way down,” he predicted.

What that means for the daily schedules of hospitalists remains to be seen, but Dr. Wachter doesn’t expect much in the short term.

“The job will be the same,” he said. “Take care of patients well, make them happy, satisfy your bosses and colleagues, and do it for less money. The biggest shift is likely to be that more and more people/systems – doing the same thing – will find that they don’t need as many hospital days, which means that we’ll have fewer patients and fewer hospitals. But we knew that.”

Dr. Wachter is more interested to see what will happen in postacute and other nonhospital facilities, how quickly technology continues to disrupt, and who hospitalists will work for (be it staffing companies, medical groups, or “something new”).

The veteran physician in him says not to get too distracted “by all of the zigs and zags,” he noted, while the political idealist in him says not to ever forget that the “core values and imperatives remain.”

If the past decade of wise words ending SHM’s annual meeting are any indication, Dr. Wachter’s message of trepidation and concern will end on a high note for attendees.

Robert M. Wachter, MD, MHM, has given the last plenary address at every SHM annual meeting since 2007. The talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy. Then there was the time when he broke into an Elton John parody.

Where does that point of view come from? Well, as the dean of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli-sci major becomes an academic physician.”

That’s a needed perspective this year, as the level of political upheaval in the United States has added to the tumult in the health care field. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles that doctors face when using electronic health records (EHRs) are among the topics that he will address in his this final discussion.

The defeat of Republicans’ plan to replace the Affordable Care Act (ACA) with the American Health Care Act (AHCA) showed that the divide over health care extends even to intraparty discussions.

“The implosion of the AHCA shows how difficult health reform is and how quickly the ACA became the de facto standard,” Dr. Wachter said. “It is now that status quo that is so difficult to change.”

Dr. Wachter, who famously helped coined the term “hospitalist” in the 1996 New England Journal of Medicine paper that propelled the nascent specialty, said that one big challenge to HM is determining the future of how hospitals get paid – and how they pay their workers (335[7]:514-7).

“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or [if] their payments go way down,” he predicted.

What that means for the daily schedules of hospitalists remains to be seen, but Dr. Wachter doesn’t expect much in the short term.

“The job will be the same,” he said. “Take care of patients well, make them happy, satisfy your bosses and colleagues, and do it for less money. The biggest shift is likely to be that more and more people/systems – doing the same thing – will find that they don’t need as many hospital days, which means that we’ll have fewer patients and fewer hospitals. But we knew that.”

Dr. Wachter is more interested to see what will happen in postacute and other nonhospital facilities, how quickly technology continues to disrupt, and who hospitalists will work for (be it staffing companies, medical groups, or “something new”).

The veteran physician in him says not to get too distracted “by all of the zigs and zags,” he noted, while the political idealist in him says not to ever forget that the “core values and imperatives remain.”

If the past decade of wise words ending SHM’s annual meeting are any indication, Dr. Wachter’s message of trepidation and concern will end on a high note for attendees.