To the Editor:

Vascular lesions associated with melanocytic nevi were first described by Ota et al¹ in 1947 and given the name phacomatosis pigmentovascularis. In 2005, Happle² reclassified phacomatosis pigmentovascularis into 3 well-defined types: (1) phacomatosis cesioflammea: blue spots (caesius means bluish gray in Latin) and nevus flammeus; (2) phacomatosis spilorosea: nevus spilus coexisting with a pale pink telangiectatic nevus; and (3) phacomatosis cesiomarmorata: blue spots and cutis marmorata telangiectatica congenita. In 2011 Joshi et al³ described a case of a 31-year-old woman who had a port-wine stain in association with neurofibromatosis type I (NF-1). We present a case of phacomatosis cesioflammea in association with NF-1.

A 20-year-old woman presented to our outpatient section with a bluish black birthmark on the left side of the face since birth with the onset of multiple painless flesh-colored nodules on the trunk and arms of 1 year’s duration. She reported having occasional pruritus over the nodular lesions. Cutaneous examination showed multiple well-defined café au lait macules (0.5–3.0 cm) with regular margins. Multiple flesh-colored nodules were evident on the upper arms (Figure 1) and trunk. The nodules were firm in consistency and showed buttonholing phenomenon with some of the lesions demonstrating bag-of-worms consistency on palpation. Both palms showed multiple brownish frecklelike macules (Figure 2). A single bluish patch extended from the left ala of the nose to the sideburns. Adjoining the bluish patch was a subtle, ill-defined, nonblanchable red patch extending from the lower margin of the bluish patch to the mandibular ridge (Figure 3). Ocular examination showed melanosis bulbi of the left sclera and a few iris hamartomas (Lisch nodules) in both eyes. A biopsy of the skin nodule was obtained under local anesthesia after obtaining the patient’s informed consent; the specimen was fixed in 10% buffered formalin. A hematoxylin and eosin–stained section showed a well-circumscribed nonencapsulated tumor in the dermis composed of loosely spaced spindle cells and wavy collagenous strands (Figure 4). Routine hemogram and blood biochemistry including urinalysis were within reference range. Radiologic examination of the long bones was unremarkable. Our patient had 3 of 6 criteria defined by the National Institutes of Health for diagnosis of NF-1.⁴ On clinicopathological correlation we made a diagnosis of phacomatosis cesioflammea in association with NF-1. We have reassured the patient about the benign nature of vascular nevus. She was informed that the skin nodules could increase in size during pregnancy and to regularly follow-up with an eye specialist if any visual abnormalities occur.

The term phacomatosis is applied to genetically determined disorders of tissue derived from ectodermal origin (eg, skin, central nervous system, eyes) and commonly includes NF-1, tuberous sclerosis, and von Hippel-Lindau syndrome. Neurofibromatosis type I was first described by German pathologist Friedrich Daniel von Recklinghausen.⁵ Phacomatosis pigmentovascularis has been defined as the association of vascular nevus with a pigmentary nevus. Its pathogenesis can be explained by the twin spotting phenomenon.⁶ Twin spots are paired patches of mutant tissue that differ from each other and from the surrounding normal background skin. They can occur as 2 clinical types: allelic and nonallelic twin spotting. Our patient had nonallelic twin spots for 2 nevoid conditions: vascular (nevus flammeus) and pigmentary (nevus of Ota). Nevus of Ota was distributed in the V2 segment (maxillary nerve) of the fifth cranial nerve along with classical melanosis bulbi, which is considered a characteristic clinical feature of nevus of Ota (nevus cesius).⁷ Nevus flammeus (port-wine stain) is a vascular malformation presenting with flat lesions that persists throughout a patient’s life. The phenomenon of twin spotting, or didymosis (didymos means twin in Greek), has been proposed for co-occurrence of vascular and pigmented nevi.⁸ The association of NF-1 along with phacomatosis cesioflammea (a twin spot) could be explained from mosaicism of tissues derived from neuroectodermal and mesenchymal elements. Neurofibromatosis type I can occur as a mosaic disorder due to either postzygotic germ line or somatic mutations in the NF1 gene located on the proximal long arm of chromosome 17.⁹ Irrespective of the mutational event, a mosaic patient has a mixture of cells, some have normal copies of a particular gene and others have an abnormal copy of the same gene. Somatic mutation can lead to segmental (localized), generalized, or gonadal mosaicism. Somatic mutations occurring early during embryonic development produce generalized mosaicism, and generalized mosaics clinically appear similar to nonmosaic NF-1 cases.^10,11 However, due to a lack of adequate facilities for mutation analysis and financial constraints, we were unable to confirm our case as generalized somatic mosaic for NF1 gene.

Several morphologic abnormalities have been reported with phacomatosis cesioflammea. Wu et al¹² reported a single case of phacomatosis cesioflammea associated with pectus excavatum in a 9-month-old infant. Shields et al¹³ suggested that a thorough ocular examination on a periodic basis is essential to rule out melanoma of ocular tissues in patients with nevus flammeus and ocular melanosis.

Phacomatosis cesioflammea can occur in association with NF-1. The exact incidence of association is not known. The nevoid condition can be treated with appropriate lasers.

To the Editor:

Vascular lesions associated with melanocytic nevi were first described by Ota et al¹ in 1947 and given the name phacomatosis pigmentovascularis. In 2005, Happle² reclassified phacomatosis pigmentovascularis into 3 well-defined types: (1) phacomatosis cesioflammea: blue spots (caesius means bluish gray in Latin) and nevus flammeus; (2) phacomatosis spilorosea: nevus spilus coexisting with a pale pink telangiectatic nevus; and (3) phacomatosis cesiomarmorata: blue spots and cutis marmorata telangiectatica congenita. In 2011 Joshi et al³ described a case of a 31-year-old woman who had a port-wine stain in association with neurofibromatosis type I (NF-1). We present a case of phacomatosis cesioflammea in association with NF-1.

A 20-year-old woman presented to our outpatient section with a bluish black birthmark on the left side of the face since birth with the onset of multiple painless flesh-colored nodules on the trunk and arms of 1 year’s duration. She reported having occasional pruritus over the nodular lesions. Cutaneous examination showed multiple well-defined café au lait macules (0.5–3.0 cm) with regular margins. Multiple flesh-colored nodules were evident on the upper arms (Figure 1) and trunk. The nodules were firm in consistency and showed buttonholing phenomenon with some of the lesions demonstrating bag-of-worms consistency on palpation. Both palms showed multiple brownish frecklelike macules (Figure 2). A single bluish patch extended from the left ala of the nose to the sideburns. Adjoining the bluish patch was a subtle, ill-defined, nonblanchable red patch extending from the lower margin of the bluish patch to the mandibular ridge (Figure 3). Ocular examination showed melanosis bulbi of the left sclera and a few iris hamartomas (Lisch nodules) in both eyes. A biopsy of the skin nodule was obtained under local anesthesia after obtaining the patient’s informed consent; the specimen was fixed in 10% buffered formalin. A hematoxylin and eosin–stained section showed a well-circumscribed nonencapsulated tumor in the dermis composed of loosely spaced spindle cells and wavy collagenous strands (Figure 4). Routine hemogram and blood biochemistry including urinalysis were within reference range. Radiologic examination of the long bones was unremarkable. Our patient had 3 of 6 criteria defined by the National Institutes of Health for diagnosis of NF-1.⁴ On clinicopathological correlation we made a diagnosis of phacomatosis cesioflammea in association with NF-1. We have reassured the patient about the benign nature of vascular nevus. She was informed that the skin nodules could increase in size during pregnancy and to regularly follow-up with an eye specialist if any visual abnormalities occur.

The term phacomatosis is applied to genetically determined disorders of tissue derived from ectodermal origin (eg, skin, central nervous system, eyes) and commonly includes NF-1, tuberous sclerosis, and von Hippel-Lindau syndrome. Neurofibromatosis type I was first described by German pathologist Friedrich Daniel von Recklinghausen.⁵ Phacomatosis pigmentovascularis has been defined as the association of vascular nevus with a pigmentary nevus. Its pathogenesis can be explained by the twin spotting phenomenon.⁶ Twin spots are paired patches of mutant tissue that differ from each other and from the surrounding normal background skin. They can occur as 2 clinical types: allelic and nonallelic twin spotting. Our patient had nonallelic twin spots for 2 nevoid conditions: vascular (nevus flammeus) and pigmentary (nevus of Ota). Nevus of Ota was distributed in the V2 segment (maxillary nerve) of the fifth cranial nerve along with classical melanosis bulbi, which is considered a characteristic clinical feature of nevus of Ota (nevus cesius).⁷ Nevus flammeus (port-wine stain) is a vascular malformation presenting with flat lesions that persists throughout a patient’s life. The phenomenon of twin spotting, or didymosis (didymos means twin in Greek), has been proposed for co-occurrence of vascular and pigmented nevi.⁸ The association of NF-1 along with phacomatosis cesioflammea (a twin spot) could be explained from mosaicism of tissues derived from neuroectodermal and mesenchymal elements. Neurofibromatosis type I can occur as a mosaic disorder due to either postzygotic germ line or somatic mutations in the NF1 gene located on the proximal long arm of chromosome 17.⁹ Irrespective of the mutational event, a mosaic patient has a mixture of cells, some have normal copies of a particular gene and others have an abnormal copy of the same gene. Somatic mutation can lead to segmental (localized), generalized, or gonadal mosaicism. Somatic mutations occurring early during embryonic development produce generalized mosaicism, and generalized mosaics clinically appear similar to nonmosaic NF-1 cases.^10,11 However, due to a lack of adequate facilities for mutation analysis and financial constraints, we were unable to confirm our case as generalized somatic mosaic for NF1 gene.

Several morphologic abnormalities have been reported with phacomatosis cesioflammea. Wu et al¹² reported a single case of phacomatosis cesioflammea associated with pectus excavatum in a 9-month-old infant. Shields et al¹³ suggested that a thorough ocular examination on a periodic basis is essential to rule out melanoma of ocular tissues in patients with nevus flammeus and ocular melanosis.

Phacomatosis cesioflammea can occur in association with NF-1. The exact incidence of association is not known. The nevoid condition can be treated with appropriate lasers.

To the Editor:

Vascular lesions associated with melanocytic nevi were first described by Ota et al¹ in 1947 and given the name phacomatosis pigmentovascularis. In 2005, Happle² reclassified phacomatosis pigmentovascularis into 3 well-defined types: (1) phacomatosis cesioflammea: blue spots (caesius means bluish gray in Latin) and nevus flammeus; (2) phacomatosis spilorosea: nevus spilus coexisting with a pale pink telangiectatic nevus; and (3) phacomatosis cesiomarmorata: blue spots and cutis marmorata telangiectatica congenita. In 2011 Joshi et al³ described a case of a 31-year-old woman who had a port-wine stain in association with neurofibromatosis type I (NF-1). We present a case of phacomatosis cesioflammea in association with NF-1.

A 20-year-old woman presented to our outpatient section with a bluish black birthmark on the left side of the face since birth with the onset of multiple painless flesh-colored nodules on the trunk and arms of 1 year’s duration. She reported having occasional pruritus over the nodular lesions. Cutaneous examination showed multiple well-defined café au lait macules (0.5–3.0 cm) with regular margins. Multiple flesh-colored nodules were evident on the upper arms (Figure 1) and trunk. The nodules were firm in consistency and showed buttonholing phenomenon with some of the lesions demonstrating bag-of-worms consistency on palpation. Both palms showed multiple brownish frecklelike macules (Figure 2). A single bluish patch extended from the left ala of the nose to the sideburns. Adjoining the bluish patch was a subtle, ill-defined, nonblanchable red patch extending from the lower margin of the bluish patch to the mandibular ridge (Figure 3). Ocular examination showed melanosis bulbi of the left sclera and a few iris hamartomas (Lisch nodules) in both eyes. A biopsy of the skin nodule was obtained under local anesthesia after obtaining the patient’s informed consent; the specimen was fixed in 10% buffered formalin. A hematoxylin and eosin–stained section showed a well-circumscribed nonencapsulated tumor in the dermis composed of loosely spaced spindle cells and wavy collagenous strands (Figure 4). Routine hemogram and blood biochemistry including urinalysis were within reference range. Radiologic examination of the long bones was unremarkable. Our patient had 3 of 6 criteria defined by the National Institutes of Health for diagnosis of NF-1.⁴ On clinicopathological correlation we made a diagnosis of phacomatosis cesioflammea in association with NF-1. We have reassured the patient about the benign nature of vascular nevus. She was informed that the skin nodules could increase in size during pregnancy and to regularly follow-up with an eye specialist if any visual abnormalities occur.

The term phacomatosis is applied to genetically determined disorders of tissue derived from ectodermal origin (eg, skin, central nervous system, eyes) and commonly includes NF-1, tuberous sclerosis, and von Hippel-Lindau syndrome. Neurofibromatosis type I was first described by German pathologist Friedrich Daniel von Recklinghausen.⁵ Phacomatosis pigmentovascularis has been defined as the association of vascular nevus with a pigmentary nevus. Its pathogenesis can be explained by the twin spotting phenomenon.⁶ Twin spots are paired patches of mutant tissue that differ from each other and from the surrounding normal background skin. They can occur as 2 clinical types: allelic and nonallelic twin spotting. Our patient had nonallelic twin spots for 2 nevoid conditions: vascular (nevus flammeus) and pigmentary (nevus of Ota). Nevus of Ota was distributed in the V2 segment (maxillary nerve) of the fifth cranial nerve along with classical melanosis bulbi, which is considered a characteristic clinical feature of nevus of Ota (nevus cesius).⁷ Nevus flammeus (port-wine stain) is a vascular malformation presenting with flat lesions that persists throughout a patient’s life. The phenomenon of twin spotting, or didymosis (didymos means twin in Greek), has been proposed for co-occurrence of vascular and pigmented nevi.⁸ The association of NF-1 along with phacomatosis cesioflammea (a twin spot) could be explained from mosaicism of tissues derived from neuroectodermal and mesenchymal elements. Neurofibromatosis type I can occur as a mosaic disorder due to either postzygotic germ line or somatic mutations in the NF1 gene located on the proximal long arm of chromosome 17.⁹ Irrespective of the mutational event, a mosaic patient has a mixture of cells, some have normal copies of a particular gene and others have an abnormal copy of the same gene. Somatic mutation can lead to segmental (localized), generalized, or gonadal mosaicism. Somatic mutations occurring early during embryonic development produce generalized mosaicism, and generalized mosaics clinically appear similar to nonmosaic NF-1 cases.^10,11 However, due to a lack of adequate facilities for mutation analysis and financial constraints, we were unable to confirm our case as generalized somatic mosaic for NF1 gene.

Several morphologic abnormalities have been reported with phacomatosis cesioflammea. Wu et al¹² reported a single case of phacomatosis cesioflammea associated with pectus excavatum in a 9-month-old infant. Shields et al¹³ suggested that a thorough ocular examination on a periodic basis is essential to rule out melanoma of ocular tissues in patients with nevus flammeus and ocular melanosis.

Phacomatosis cesioflammea can occur in association with NF-1. The exact incidence of association is not known. The nevoid condition can be treated with appropriate lasers.

Despite the urging of the United States Preventive Services Task Force and other organizations in 2013, the percentage of baby boomers who underwent testing for hepatitis C (HCV) infection had barely changed 2 years later – from 12.3% in 2013 to 13.8% in 2015.

The numbers are particularly troubling because new and improved antiviral drugs offer cures that could forestall liver cancer, cirrhosis, and other potential complications, with shorter regimens and fewer side effects than older regimens.

Jarun011/Thinkstock

Despite the urging of the United States Preventive Services Task Force and other organizations in 2013, the percentage of baby boomers who underwent testing for hepatitis C (HCV) infection had barely changed 2 years later – from 12.3% in 2013 to 13.8% in 2015.

The numbers are particularly troubling because new and improved antiviral drugs offer cures that could forestall liver cancer, cirrhosis, and other potential complications, with shorter regimens and fewer side effects than older regimens.

Jarun011/Thinkstock

Despite the urging of the United States Preventive Services Task Force and other organizations in 2013, the percentage of baby boomers who underwent testing for hepatitis C (HCV) infection had barely changed 2 years later – from 12.3% in 2013 to 13.8% in 2015.

The numbers are particularly troubling because new and improved antiviral drugs offer cures that could forestall liver cancer, cirrhosis, and other potential complications, with shorter regimens and fewer side effects than older regimens.

Jarun011/Thinkstock

A federal district court judge has blocked health insurer Anthem from acquiring Cigna, ruling the megamerger would violate antitrust laws and stifle competition.

The decision came weeks after another U.S. district court judge barred a merger between health insurance giants Aetna and Humana.

The U.S. Department of Justice praised the latest ruling, calling the decision a victory for patients.

“This merger would have stifled competition, harming consumers by increasing health insurance prices and slowing innovation aimed at lowering the costs of health care,” Acting Assistant Attorney General Brent Snyder said in a statement.

Anthem intends to appeal the decision, said Joseph R. Swedish, Anthem’s chair, president, and chief executive officer. “Anthem is significantly disappointed by the decision, as combining Anthem and Cigna would positively impact the health and well-being of millions of Americans – saving them more than $2 billion in medical costs annually,” Mr. Swedish said in a statement. “If not overturned, the consequences of the decision are far reaching and will hurt American consumers by limiting their access to high-quality affordable care, slowing the industry’s shift to value-based care and improved outcomes for patients, and restricting innovation, which is critical to meeting the evolving needs of health care consumers.”

In a statement, a Cigna official said the company intends to carefully review the opinion and evaluate its options in accordance with the merger agreement.

“Cigna remains focused on helping to improve health care by delivering value to our customers and clients and expanding our business around the world,” the statement said.

The DOJ, 11 states, and the District of Columbia sued Anthem and Cigna in July over their proposed $54 billion consolidation in what would have been the largest merger in history.

The DOJ argued the merger would substantially harm competition and negatively impact the entire insurance industry if allowed to proceed. The consolidation would enhance Anthem’s power to profit at the expense of consumers and the doctors and hospitals who provide their medical care, DOJ attorneys said in their complaint.

Anthem and Cigna argued the proposed acquisition was “procompetitive,” and that the merger would result in efficiencies that would directly benefit consumers via greater access to affordable health care. The benefits of the merger outweigh any alleged anticompetitive effects, according to Anthem.

A trial before Judge Amy Berman Jackson of the U.S. District Court for the District of Columbia ran from November through January.

Judge Berman’s opinion is temporarily under seal to allow parties to review for confidentiality.

The ruling is the second victory for the DOJ in as many weeks. In a Jan. 23 decision, Judge John D. Bates of the U.S. District Court for the District of Columbia denied Aetna’s $37 billion plan to purchase Humana, following a month-long trial that began in early December. Judge Bates ruled the consolidation would violate antitrust laws and reduce competition.

Aetna and Humana did not respond to requests for comment.
 

[email protected]

On Twitter @legal_med

A federal district court judge has blocked health insurer Anthem from acquiring Cigna, ruling the megamerger would violate antitrust laws and stifle competition.

The decision came weeks after another U.S. district court judge barred a merger between health insurance giants Aetna and Humana.

The U.S. Department of Justice praised the latest ruling, calling the decision a victory for patients.

“This merger would have stifled competition, harming consumers by increasing health insurance prices and slowing innovation aimed at lowering the costs of health care,” Acting Assistant Attorney General Brent Snyder said in a statement.

Anthem intends to appeal the decision, said Joseph R. Swedish, Anthem’s chair, president, and chief executive officer. “Anthem is significantly disappointed by the decision, as combining Anthem and Cigna would positively impact the health and well-being of millions of Americans – saving them more than $2 billion in medical costs annually,” Mr. Swedish said in a statement. “If not overturned, the consequences of the decision are far reaching and will hurt American consumers by limiting their access to high-quality affordable care, slowing the industry’s shift to value-based care and improved outcomes for patients, and restricting innovation, which is critical to meeting the evolving needs of health care consumers.”

In a statement, a Cigna official said the company intends to carefully review the opinion and evaluate its options in accordance with the merger agreement.

“Cigna remains focused on helping to improve health care by delivering value to our customers and clients and expanding our business around the world,” the statement said.

The DOJ, 11 states, and the District of Columbia sued Anthem and Cigna in July over their proposed $54 billion consolidation in what would have been the largest merger in history.

The DOJ argued the merger would substantially harm competition and negatively impact the entire insurance industry if allowed to proceed. The consolidation would enhance Anthem’s power to profit at the expense of consumers and the doctors and hospitals who provide their medical care, DOJ attorneys said in their complaint.

Anthem and Cigna argued the proposed acquisition was “procompetitive,” and that the merger would result in efficiencies that would directly benefit consumers via greater access to affordable health care. The benefits of the merger outweigh any alleged anticompetitive effects, according to Anthem.

A trial before Judge Amy Berman Jackson of the U.S. District Court for the District of Columbia ran from November through January.

Judge Berman’s opinion is temporarily under seal to allow parties to review for confidentiality.

The ruling is the second victory for the DOJ in as many weeks. In a Jan. 23 decision, Judge John D. Bates of the U.S. District Court for the District of Columbia denied Aetna’s $37 billion plan to purchase Humana, following a month-long trial that began in early December. Judge Bates ruled the consolidation would violate antitrust laws and reduce competition.

Aetna and Humana did not respond to requests for comment.
 

[email protected]

On Twitter @legal_med

A federal district court judge has blocked health insurer Anthem from acquiring Cigna, ruling the megamerger would violate antitrust laws and stifle competition.

The decision came weeks after another U.S. district court judge barred a merger between health insurance giants Aetna and Humana.

The U.S. Department of Justice praised the latest ruling, calling the decision a victory for patients.

“This merger would have stifled competition, harming consumers by increasing health insurance prices and slowing innovation aimed at lowering the costs of health care,” Acting Assistant Attorney General Brent Snyder said in a statement.

Anthem intends to appeal the decision, said Joseph R. Swedish, Anthem’s chair, president, and chief executive officer. “Anthem is significantly disappointed by the decision, as combining Anthem and Cigna would positively impact the health and well-being of millions of Americans – saving them more than $2 billion in medical costs annually,” Mr. Swedish said in a statement. “If not overturned, the consequences of the decision are far reaching and will hurt American consumers by limiting their access to high-quality affordable care, slowing the industry’s shift to value-based care and improved outcomes for patients, and restricting innovation, which is critical to meeting the evolving needs of health care consumers.”

In a statement, a Cigna official said the company intends to carefully review the opinion and evaluate its options in accordance with the merger agreement.

“Cigna remains focused on helping to improve health care by delivering value to our customers and clients and expanding our business around the world,” the statement said.

The DOJ, 11 states, and the District of Columbia sued Anthem and Cigna in July over their proposed $54 billion consolidation in what would have been the largest merger in history.

The DOJ argued the merger would substantially harm competition and negatively impact the entire insurance industry if allowed to proceed. The consolidation would enhance Anthem’s power to profit at the expense of consumers and the doctors and hospitals who provide their medical care, DOJ attorneys said in their complaint.

Anthem and Cigna argued the proposed acquisition was “procompetitive,” and that the merger would result in efficiencies that would directly benefit consumers via greater access to affordable health care. The benefits of the merger outweigh any alleged anticompetitive effects, according to Anthem.

A trial before Judge Amy Berman Jackson of the U.S. District Court for the District of Columbia ran from November through January.

Judge Berman’s opinion is temporarily under seal to allow parties to review for confidentiality.

The ruling is the second victory for the DOJ in as many weeks. In a Jan. 23 decision, Judge John D. Bates of the U.S. District Court for the District of Columbia denied Aetna’s $37 billion plan to purchase Humana, following a month-long trial that began in early December. Judge Bates ruled the consolidation would violate antitrust laws and reduce competition.

Aetna and Humana did not respond to requests for comment.
 

[email protected]

On Twitter @legal_med

Calling all pediatric hospitalists

Register for Pediatric Hospital Medicine 2017 (PHM17), the premier educational conference for pediatric hospitalists and other clinicians who care for hospitalized children. Re-energize your practice with the latest research, best practices, innovations, and more.

SHM can prepare you for MACRA

Visit www.macraforhm.org for general information and details in the MACRA FAQ and MIPS Tips links.

Don’t miss five new tracks at HM17

• Learn how to avoid diagnostic and therapeutic overuse, and how to move towards the right care for every hospital medicine patient with the High Value Care Track.
• Don’t miss the Clinical Updates Track, which provides evidence-based updates from recent literature published in medicine subspecialty fields and specific topic areas that all hospitalists need to know.
• Accurate and timely diagnosis are the two cornerstones of high-quality patient care. Find out what topics are in the Diagnostic Reasoning Track.
• Learn from experts during the Health Policy Track who will discuss the most current health care policy issues as they impact hospitalists and what we can expect from a new Presidential administration and changes in Congress.
• The Mini Medical Education Track is for hospitalists who are interested in improving their teaching skills.

Learn more about the HM17 schedule and offerings at www.hospitalmedicine2017.org/schedule.
 

Prepare for the entire Focused Practice in Hospital Medicine (FPHM) exam with SPARK ONE

This self-paced study guide engages learners through an open-book format, allowing users to review detailed learning objectives and discussion points and define individual areas of strengths and weaknesses. SHM members Save $150! Learn more at www.hospitalmedicine.org/sparkone.

Improve your treatment of VTE during Blood Clot Awareness Month

March is Blood Clot Awareness Month, and SHM recently introduced a new toolkit and guide surrounding treatment of venous thromboembolism (VTE) in the hospital setting. SHM has a history of providing cutting-edge resources in this space, and Steven B. Deitelzweig, MD, MMM, SFHM, FACP, FACC, system chairman of hospital medicine at Oschner Health System in New Orleans, was integral in editing SHM’s VTE treatment mentored implementation guide and online toolkit.

“SHM has an established track record of implementing evidence-based and guideline-driven learnings successfully, and we continue to see improvement across multiple facilities based on this work with this disease,” Dr. Deitelzweig says. “Whenever possible, I would strongly recommend taking full advantage of SHM’s outstanding programs as they are intensely developed by experts for adoption at hospitals of different sizes, including community and academic centers.”

SHM can help you and your hospital improve treatment of VTE as well – learn how at www.hospitalmedicine.org/vtetreatment.

Share patient experience success stories

Our Patient Experience Committee wants to showcase stories of when care teams or their counterparts in the hospital made a notable shift in a patient’s experience: a special moment or interaction; a successful improvement project; an award for excellence in practice; a memo of commendation; a letter from a patient. Email examples of success to Claudia Stahl at [email protected] by May 11. Submissions can include photos, letters, or videos. SHM will share these moments that “made all the difference” with members on its website via other channels soon to be announced.
 

Brett Radler is SHM’s communications specialist.

Not a member? Know someone who should be? Visit www.joinshm.org to learn about the opportunities we can offer hospital medicine professionals.

Calling all pediatric hospitalists

Register for Pediatric Hospital Medicine 2017 (PHM17), the premier educational conference for pediatric hospitalists and other clinicians who care for hospitalized children. Re-energize your practice with the latest research, best practices, innovations, and more.

SHM can prepare you for MACRA

Visit www.macraforhm.org for general information and details in the MACRA FAQ and MIPS Tips links.

Don’t miss five new tracks at HM17

• Learn how to avoid diagnostic and therapeutic overuse, and how to move towards the right care for every hospital medicine patient with the High Value Care Track.
• Don’t miss the Clinical Updates Track, which provides evidence-based updates from recent literature published in medicine subspecialty fields and specific topic areas that all hospitalists need to know.
• Accurate and timely diagnosis are the two cornerstones of high-quality patient care. Find out what topics are in the Diagnostic Reasoning Track.
• Learn from experts during the Health Policy Track who will discuss the most current health care policy issues as they impact hospitalists and what we can expect from a new Presidential administration and changes in Congress.
• The Mini Medical Education Track is for hospitalists who are interested in improving their teaching skills.

Learn more about the HM17 schedule and offerings at www.hospitalmedicine2017.org/schedule.
 

Prepare for the entire Focused Practice in Hospital Medicine (FPHM) exam with SPARK ONE

This self-paced study guide engages learners through an open-book format, allowing users to review detailed learning objectives and discussion points and define individual areas of strengths and weaknesses. SHM members Save $150! Learn more at www.hospitalmedicine.org/sparkone.

Improve your treatment of VTE during Blood Clot Awareness Month

March is Blood Clot Awareness Month, and SHM recently introduced a new toolkit and guide surrounding treatment of venous thromboembolism (VTE) in the hospital setting. SHM has a history of providing cutting-edge resources in this space, and Steven B. Deitelzweig, MD, MMM, SFHM, FACP, FACC, system chairman of hospital medicine at Oschner Health System in New Orleans, was integral in editing SHM’s VTE treatment mentored implementation guide and online toolkit.

“SHM has an established track record of implementing evidence-based and guideline-driven learnings successfully, and we continue to see improvement across multiple facilities based on this work with this disease,” Dr. Deitelzweig says. “Whenever possible, I would strongly recommend taking full advantage of SHM’s outstanding programs as they are intensely developed by experts for adoption at hospitals of different sizes, including community and academic centers.”

SHM can help you and your hospital improve treatment of VTE as well – learn how at www.hospitalmedicine.org/vtetreatment.

Share patient experience success stories

Our Patient Experience Committee wants to showcase stories of when care teams or their counterparts in the hospital made a notable shift in a patient’s experience: a special moment or interaction; a successful improvement project; an award for excellence in practice; a memo of commendation; a letter from a patient. Email examples of success to Claudia Stahl at [email protected] by May 11. Submissions can include photos, letters, or videos. SHM will share these moments that “made all the difference” with members on its website via other channels soon to be announced.
 

Brett Radler is SHM’s communications specialist.

Not a member? Know someone who should be? Visit www.joinshm.org to learn about the opportunities we can offer hospital medicine professionals.

Calling all pediatric hospitalists

Register for Pediatric Hospital Medicine 2017 (PHM17), the premier educational conference for pediatric hospitalists and other clinicians who care for hospitalized children. Re-energize your practice with the latest research, best practices, innovations, and more.

SHM can prepare you for MACRA

Visit www.macraforhm.org for general information and details in the MACRA FAQ and MIPS Tips links.

Don’t miss five new tracks at HM17

• Learn how to avoid diagnostic and therapeutic overuse, and how to move towards the right care for every hospital medicine patient with the High Value Care Track.
• Don’t miss the Clinical Updates Track, which provides evidence-based updates from recent literature published in medicine subspecialty fields and specific topic areas that all hospitalists need to know.
• Accurate and timely diagnosis are the two cornerstones of high-quality patient care. Find out what topics are in the Diagnostic Reasoning Track.
• Learn from experts during the Health Policy Track who will discuss the most current health care policy issues as they impact hospitalists and what we can expect from a new Presidential administration and changes in Congress.
• The Mini Medical Education Track is for hospitalists who are interested in improving their teaching skills.

Learn more about the HM17 schedule and offerings at www.hospitalmedicine2017.org/schedule.
 

Prepare for the entire Focused Practice in Hospital Medicine (FPHM) exam with SPARK ONE

This self-paced study guide engages learners through an open-book format, allowing users to review detailed learning objectives and discussion points and define individual areas of strengths and weaknesses. SHM members Save $150! Learn more at www.hospitalmedicine.org/sparkone.

Improve your treatment of VTE during Blood Clot Awareness Month

March is Blood Clot Awareness Month, and SHM recently introduced a new toolkit and guide surrounding treatment of venous thromboembolism (VTE) in the hospital setting. SHM has a history of providing cutting-edge resources in this space, and Steven B. Deitelzweig, MD, MMM, SFHM, FACP, FACC, system chairman of hospital medicine at Oschner Health System in New Orleans, was integral in editing SHM’s VTE treatment mentored implementation guide and online toolkit.

“SHM has an established track record of implementing evidence-based and guideline-driven learnings successfully, and we continue to see improvement across multiple facilities based on this work with this disease,” Dr. Deitelzweig says. “Whenever possible, I would strongly recommend taking full advantage of SHM’s outstanding programs as they are intensely developed by experts for adoption at hospitals of different sizes, including community and academic centers.”

SHM can help you and your hospital improve treatment of VTE as well – learn how at www.hospitalmedicine.org/vtetreatment.

Share patient experience success stories

Our Patient Experience Committee wants to showcase stories of when care teams or their counterparts in the hospital made a notable shift in a patient’s experience: a special moment or interaction; a successful improvement project; an award for excellence in practice; a memo of commendation; a letter from a patient. Email examples of success to Claudia Stahl at [email protected] by May 11. Submissions can include photos, letters, or videos. SHM will share these moments that “made all the difference” with members on its website via other channels soon to be announced.
 

Brett Radler is SHM’s communications specialist.

Not a member? Know someone who should be? Visit www.joinshm.org to learn about the opportunities we can offer hospital medicine professionals.

Sparrow Health System in Lansing, Mich., went live with its electronic health record (EHR) system at its main hospital on Dec. 1, 2012. For a year and a half, the system was untapped, innovation-wise. Very few features were turned on, and it sat relatively idle with regard to quality improvement. Hospitalists and others used the EHR, but not ambitiously. Everyone, essentially, used the post-launch period to catch their breath. Some even decided it would be the perfect time to retire, rather than confront the new reality of the EHR.

“It took a good 6 months, probably longer for some, for people to feel comfortable, to start smiling again and really feel like, ‘This isn’t so bad and actually might be working for us,’ ” said Carol Nwelue, MD, medical director of Sparrow’s adult hospitalist service.

• They have hospitalist leaders with a strong interest in IT who like to tinker and refine – and then share the tricks that work with others at their center.
• They belong to EHR-related committees or work at centers with hospitalists with a big presence in those committees.
• They keep their eyes on what other centers are doing with EHRs and use those projects as models for projects at their own centers.
• They are willing to make changes in their own processes, when feasible, so that they can better dovetail with the EHR.
• They keep their lines of communication open with their EHR vendors.
• They attend user meetings to get questions answered and share information and experiences.

At Sparrow, two committees – one nurse-led and one physician-led – guide EHR enhancement. The committees are a place where, yes, doctors can vent about the EHR (the phrase they use is “pain points”), but also a place where they can get constructive feedback. The committees also keep an eye out for EHR projects elsewhere that they might be able to do themselves.

EHR: a CAUTI example

In 2014, Sparrow doctors and nurses wanted to lower their number of catheter-associated urinary tract infections (CAUTI). With the EHR that had gone live 2 years before, they had the data that they needed. They just had to figure out how to turn the data into a workable plan. Ah, if only things were so simple with EHRs. As any health center that has gone through the great transition from paper to digital can attest, having the data only puts you at the foot of the mountain.

But using a program that Texas Health System had developed as a model, Sparrow got its CAUTI program up and running. The new system included not just a placement order, but the discontinuation order, too. Advisories on best practice were built into the work flow, including alerts on when catheters had been in for 48 hours, and metrics were created to track how well the whole thing worked.

Vendor engagement = QI opportunity

Sparrow and many other health systems are motivated to use more of Epic’s features and to innovate through an Epic rewards program that gives rebates for advanced use that can total hundreds of thousands of dollars. That innovation helps Epic problem solve and it can then point to that innovation in its marketing.

Almost all hospitals, and their hospitalists, are using the EHR for such basics as reducing unnecessary testing, medical reconciliation, and to document more accurately, said Eric Helsher, vice president of client success at Epic, whose job is to foster the spread of new and better ways to use the EHR. Most hospitals use the EHR, to at least some degree, for targeted quality improvement (QI) and patient safety programs, he said.

Dr. Palabindala pointed to record-sharing features as a way clinicians can share records within minutes without having to bother with faxing or emailing. Integrating smart-paging into the EHR is another way for doctors to communicate – it may not be as good as a phone call, but it’s less disruptive during a workday, he notes.

Epic is just now rolling out a secure text-messaging system hospitalists and others can use to communicate with one another – the header of the text thread clearly shows the patient it is referencing, Mr. Helsher said. Other EHR uses, such as telemedicine, are being used around the country but are far less widespread. But users are generally becoming more ambitious, he said.

“For the last 5-10 years, we’ve been in such an implementation rush,” Mr. Helsher explained. “ Now, at much more of a macro scale, the mentality has changed to ‘OK, we have these systems, let’s go from the implementation era to the value era.’ ”

Corinne Boudreau, senior marketing manager of physician experience at Meditech, said their sepsis tool has been very popular, while messaging features and shortcut commands for simpler charting are gradually coming into wider use. Meditech also expects their Web-based EHR – designed to give patients access on their mobile devices – will give doctors the mobility they want.

Still, there’s a wide range in how much hospitalists and other doctors are using even the fundamental tools that are available to them.

“I think that between implementation and maximization there is a period of adoption, and I think that that’s where a lot of folks are these days,” she said.

As “physician engagement” has become a buzzword in the industry, Meditech has worked with physician leaders on how to get doctors to absorb the message that the EHR really can help them do their jobs better.

“If you get [doctors] at the right time, you show them how it can make things easier or take time off their workload,” Ms. Boudreau said. “For some physicians that time to get them might be first thing in the morning before they see patients. Another physician might want to do it in the evening. If you hit that evening physician in the morning, you’ve missed that window of opportunity.”

Given the demands on doctors’ time and either an inability or unwillingness to put the time in that’s needed to learn about all functions the EHR can offer, there’s a growing acknowledgment that doctors often can’t simply do this on their own.

“There’s more recognition that this is a project that needs to be resourced,” Ms. Boudreau said. “They’re already strapped for time; to put something additional on top of it needs to be accommodated for. It needs to be resourced in terms of time, it needs to be resourced in terms of compensation. There need to be governance and support of that.”

Early adopters vs. late bloomers

Many hospitalists and HM groups have advanced, but some places have lagged behind, said John Nelson, MD, MHM, a veteran hospitalist, practice management consultant, and longtime columnist with The Hospitalist.

“We find it’s reasonably common to go to a place where they’re still keeping their census in an Excel spreadsheet,” he said. “Last year, we found people who do billing on paper and index cards.”

He said that often, a failure to adopt new EHR functionality isn’t because hospitals and HM groups are avoiding it. He said he sees IT shortcomings as a major blocker.

“They want to use it,” he said. “Inertia might be part of the reason people are failing to fully capture the benefit the EHR could offer, [but] the bigger reason is local IT configurations and support.”

As an example, Dr. Nelson explained that at some of the centers he has worked with the name of the attending physician is not always reflected in the EHR. That’s a big no-no, he said. The problem, he’s sometimes found, isn’t really the EHR, but quirks in the hospital system: The EHR is locked down for that information and can be changed only by a person in the admitting department.

“It would require the hospitalist to call down [to admissions] and get someone else to make that change – and that’s tedious a big headache. They give up and don’t do it anymore,” he said. “Ideally, you’d want to make it so the hospitalists can make the change themselves.”

At his center, Overlake Hospital Medical Center in Bellevue, Wash., a go-to hospitalist is David Chu, MD, who has gone through Epic training and shares tips with colleagues. He is one of a relatively few physicians there who has taken the time to use the drop-down menu feature for putting information into a chart.

That might sound like a fairly basic use for a multimillion-dollar EHR system. But it still can take hours and hours to get it right.

“The way to do it is a little bit of a programmer’s way of looking at things,” Dr. Chu said, noting it involves programming-style language with double colons, commas, and quotations marks.

“For me, I think it took a good 10, 12, 15 hours on my part to get things going,” he said. “It was a good time investment up front to help me on that end, but it’s just hard getting people to want to commit that time, especially if they’re not that savvy with computers.”

His hospitalist colleague, Ryan Chew, MD, is more advanced – he has a taxonomy-like shorthand he uses to give him the right set of basic fields for a given type of case. For someone admitted with pneumonia, he’d want to know certain things all the time. Were they short of breath? Did they have chest pain? What were their vital signs? What about inflammatory markers?

Dr. Chew can get all of those fields to pop up by typing “.rchppneumonia.” The “.” means that a special code is to follow. The “rc” is for Ryan Chew, the “hp” is for history and physical, and “pneumonia,” is the type of case. For cases that require other information to be entered, he can add that as needed.

Hospitalists might try to write shortcut phrases, but unless they have a well-defined system, it won’t be helpful over the long run, he said.

“If you don’t have a good organization system … you’ll never remember it,” Dr. Chew said.

But even he hasn’t created the drop-down menus. He said he just hasn’t been willing to take the time, especially since he feels his own way of doing things seems to be working just fine.

Effort is essential

Expanding the functionalities of the EHR takes effort, no doubt. As a result, some physicians and hospitalist groups have not been open-minded to the idea – and opportunities – of the EHR as a database.

“I think for some people, even still, working with the EHR, it’s become more something they’ve learned to get used to rather than something that they sought to take advantage of, in terms of helping things,” Dr. Chew said. “They’re still working against the EHR a little bit.”

Dr. Palabindala agreed, and said that regardless of resistance or complaint, EHRs work.

“No matter how much we argue, it is proven in multiple studies that EHRs showed increased patient safety and better documentation and better transfer of the data,” he said.

He suggests hospitalists make more of an effort.

“I strongly encourage hospitalists to be part of the every EHR-related committee, including CPOE [computerized physician order entry], analytics, and utilization-review committees,” he said. “Learning about the upgrades and learning about all the possible options, exploring clinical informatics on a regular basis is important. I also encourage [hospitalists] to participate in online, EHR-related surveys to learn more about the EHR utility and what is missing in their home institution.”

He acknowledges that it’s “hard to develop a passion.” Then he put it in terms he thought might resonate: “Think of it like a new version of smart phone. Show the enthusiasm as if you are ready for next version of iPhone or Pixel.” TH

Is hospitalists’ EHR efficiency taken advantage of?

Even though their level of EHR use can be hit or miss, hospitalists tend to be ahead of the game, many agree. But that can come with some drawbacks. They’re often the go-to people everyone else in the hospital relies on to handle the system that some think is too unwieldy to bother with.

“One thing that really distinguishes hospitalists from many other providers, particularly on the inpatient side, is just the frequency with which they use the EHR,” said Eric Helsher of Epic. Many hospitalists are chosen by administrators to test pilot projects for that reason, he adds. “They want to get it out there with a group who they know will have a lot of exposure to the system and may be more willing to make those changes for long-term gain.”

Sometimes that expertise leads to situations that go beyond the hospitalist simply being leaders of change – they’re doing work they were never really intended to do.

John Nelson, MD, MHM, a hospitalist consultant based in Seattle, said hospitalists tell him that a subspecialist might handle a case but will not want to be the attending physician specifically so they don’t have to deal with the EHR. He said the specialist in such cases will say something along the lines of, “You can call me, I’ll help you, and I’ll come by and say hello to the patient and make the care decisions, but I need you to be the attending so you can document in the chart and you can do the med rec because ‘I can’t figure out how to do those buttons right.’ ”

Some will ask hospitalists “for a hand” with a case when really all they want is for the hospitalist to enter information into the system. It’s a tricky situation for the hospitalist, Dr. Nelson said.

“Some will be transparent and say I don’t really have a medical question – I just can’t figure out how to do the med rec and the discharge, so would you do it?” he said, adding the systems issues are largely because of new rounding patterns sparked by HM’s expanding role in-hospital. “I think it meaningfully contributes to what I perceive to be a decline in hospitalist morale in the last 2 or 3 years.”

Tom Collins is a freelance writer in South Florida.

Sparrow Health System in Lansing, Mich., went live with its electronic health record (EHR) system at its main hospital on Dec. 1, 2012. For a year and a half, the system was untapped, innovation-wise. Very few features were turned on, and it sat relatively idle with regard to quality improvement. Hospitalists and others used the EHR, but not ambitiously. Everyone, essentially, used the post-launch period to catch their breath. Some even decided it would be the perfect time to retire, rather than confront the new reality of the EHR.

“It took a good 6 months, probably longer for some, for people to feel comfortable, to start smiling again and really feel like, ‘This isn’t so bad and actually might be working for us,’ ” said Carol Nwelue, MD, medical director of Sparrow’s adult hospitalist service.

• They have hospitalist leaders with a strong interest in IT who like to tinker and refine – and then share the tricks that work with others at their center.
• They belong to EHR-related committees or work at centers with hospitalists with a big presence in those committees.
• They keep their eyes on what other centers are doing with EHRs and use those projects as models for projects at their own centers.
• They are willing to make changes in their own processes, when feasible, so that they can better dovetail with the EHR.
• They keep their lines of communication open with their EHR vendors.
• They attend user meetings to get questions answered and share information and experiences.

At Sparrow, two committees – one nurse-led and one physician-led – guide EHR enhancement. The committees are a place where, yes, doctors can vent about the EHR (the phrase they use is “pain points”), but also a place where they can get constructive feedback. The committees also keep an eye out for EHR projects elsewhere that they might be able to do themselves.

EHR: a CAUTI example

In 2014, Sparrow doctors and nurses wanted to lower their number of catheter-associated urinary tract infections (CAUTI). With the EHR that had gone live 2 years before, they had the data that they needed. They just had to figure out how to turn the data into a workable plan. Ah, if only things were so simple with EHRs. As any health center that has gone through the great transition from paper to digital can attest, having the data only puts you at the foot of the mountain.

But using a program that Texas Health System had developed as a model, Sparrow got its CAUTI program up and running. The new system included not just a placement order, but the discontinuation order, too. Advisories on best practice were built into the work flow, including alerts on when catheters had been in for 48 hours, and metrics were created to track how well the whole thing worked.

Vendor engagement = QI opportunity

Sparrow and many other health systems are motivated to use more of Epic’s features and to innovate through an Epic rewards program that gives rebates for advanced use that can total hundreds of thousands of dollars. That innovation helps Epic problem solve and it can then point to that innovation in its marketing.

Almost all hospitals, and their hospitalists, are using the EHR for such basics as reducing unnecessary testing, medical reconciliation, and to document more accurately, said Eric Helsher, vice president of client success at Epic, whose job is to foster the spread of new and better ways to use the EHR. Most hospitals use the EHR, to at least some degree, for targeted quality improvement (QI) and patient safety programs, he said.

Dr. Palabindala pointed to record-sharing features as a way clinicians can share records within minutes without having to bother with faxing or emailing. Integrating smart-paging into the EHR is another way for doctors to communicate – it may not be as good as a phone call, but it’s less disruptive during a workday, he notes.

Epic is just now rolling out a secure text-messaging system hospitalists and others can use to communicate with one another – the header of the text thread clearly shows the patient it is referencing, Mr. Helsher said. Other EHR uses, such as telemedicine, are being used around the country but are far less widespread. But users are generally becoming more ambitious, he said.

“For the last 5-10 years, we’ve been in such an implementation rush,” Mr. Helsher explained. “ Now, at much more of a macro scale, the mentality has changed to ‘OK, we have these systems, let’s go from the implementation era to the value era.’ ”

Corinne Boudreau, senior marketing manager of physician experience at Meditech, said their sepsis tool has been very popular, while messaging features and shortcut commands for simpler charting are gradually coming into wider use. Meditech also expects their Web-based EHR – designed to give patients access on their mobile devices – will give doctors the mobility they want.

Still, there’s a wide range in how much hospitalists and other doctors are using even the fundamental tools that are available to them.

“I think that between implementation and maximization there is a period of adoption, and I think that that’s where a lot of folks are these days,” she said.

As “physician engagement” has become a buzzword in the industry, Meditech has worked with physician leaders on how to get doctors to absorb the message that the EHR really can help them do their jobs better.

“If you get [doctors] at the right time, you show them how it can make things easier or take time off their workload,” Ms. Boudreau said. “For some physicians that time to get them might be first thing in the morning before they see patients. Another physician might want to do it in the evening. If you hit that evening physician in the morning, you’ve missed that window of opportunity.”

Given the demands on doctors’ time and either an inability or unwillingness to put the time in that’s needed to learn about all functions the EHR can offer, there’s a growing acknowledgment that doctors often can’t simply do this on their own.

“There’s more recognition that this is a project that needs to be resourced,” Ms. Boudreau said. “They’re already strapped for time; to put something additional on top of it needs to be accommodated for. It needs to be resourced in terms of time, it needs to be resourced in terms of compensation. There need to be governance and support of that.”

Early adopters vs. late bloomers

Many hospitalists and HM groups have advanced, but some places have lagged behind, said John Nelson, MD, MHM, a veteran hospitalist, practice management consultant, and longtime columnist with The Hospitalist.

“We find it’s reasonably common to go to a place where they’re still keeping their census in an Excel spreadsheet,” he said. “Last year, we found people who do billing on paper and index cards.”

He said that often, a failure to adopt new EHR functionality isn’t because hospitals and HM groups are avoiding it. He said he sees IT shortcomings as a major blocker.

“They want to use it,” he said. “Inertia might be part of the reason people are failing to fully capture the benefit the EHR could offer, [but] the bigger reason is local IT configurations and support.”

As an example, Dr. Nelson explained that at some of the centers he has worked with the name of the attending physician is not always reflected in the EHR. That’s a big no-no, he said. The problem, he’s sometimes found, isn’t really the EHR, but quirks in the hospital system: The EHR is locked down for that information and can be changed only by a person in the admitting department.

“It would require the hospitalist to call down [to admissions] and get someone else to make that change – and that’s tedious a big headache. They give up and don’t do it anymore,” he said. “Ideally, you’d want to make it so the hospitalists can make the change themselves.”

At his center, Overlake Hospital Medical Center in Bellevue, Wash., a go-to hospitalist is David Chu, MD, who has gone through Epic training and shares tips with colleagues. He is one of a relatively few physicians there who has taken the time to use the drop-down menu feature for putting information into a chart.

That might sound like a fairly basic use for a multimillion-dollar EHR system. But it still can take hours and hours to get it right.

“The way to do it is a little bit of a programmer’s way of looking at things,” Dr. Chu said, noting it involves programming-style language with double colons, commas, and quotations marks.

“For me, I think it took a good 10, 12, 15 hours on my part to get things going,” he said. “It was a good time investment up front to help me on that end, but it’s just hard getting people to want to commit that time, especially if they’re not that savvy with computers.”

His hospitalist colleague, Ryan Chew, MD, is more advanced – he has a taxonomy-like shorthand he uses to give him the right set of basic fields for a given type of case. For someone admitted with pneumonia, he’d want to know certain things all the time. Were they short of breath? Did they have chest pain? What were their vital signs? What about inflammatory markers?

Dr. Chew can get all of those fields to pop up by typing “.rchppneumonia.” The “.” means that a special code is to follow. The “rc” is for Ryan Chew, the “hp” is for history and physical, and “pneumonia,” is the type of case. For cases that require other information to be entered, he can add that as needed.

Hospitalists might try to write shortcut phrases, but unless they have a well-defined system, it won’t be helpful over the long run, he said.

“If you don’t have a good organization system … you’ll never remember it,” Dr. Chew said.

But even he hasn’t created the drop-down menus. He said he just hasn’t been willing to take the time, especially since he feels his own way of doing things seems to be working just fine.

Effort is essential

Expanding the functionalities of the EHR takes effort, no doubt. As a result, some physicians and hospitalist groups have not been open-minded to the idea – and opportunities – of the EHR as a database.

“I think for some people, even still, working with the EHR, it’s become more something they’ve learned to get used to rather than something that they sought to take advantage of, in terms of helping things,” Dr. Chew said. “They’re still working against the EHR a little bit.”

Dr. Palabindala agreed, and said that regardless of resistance or complaint, EHRs work.

“No matter how much we argue, it is proven in multiple studies that EHRs showed increased patient safety and better documentation and better transfer of the data,” he said.

He suggests hospitalists make more of an effort.

“I strongly encourage hospitalists to be part of the every EHR-related committee, including CPOE [computerized physician order entry], analytics, and utilization-review committees,” he said. “Learning about the upgrades and learning about all the possible options, exploring clinical informatics on a regular basis is important. I also encourage [hospitalists] to participate in online, EHR-related surveys to learn more about the EHR utility and what is missing in their home institution.”

He acknowledges that it’s “hard to develop a passion.” Then he put it in terms he thought might resonate: “Think of it like a new version of smart phone. Show the enthusiasm as if you are ready for next version of iPhone or Pixel.” TH

Is hospitalists’ EHR efficiency taken advantage of?

Even though their level of EHR use can be hit or miss, hospitalists tend to be ahead of the game, many agree. But that can come with some drawbacks. They’re often the go-to people everyone else in the hospital relies on to handle the system that some think is too unwieldy to bother with.

“One thing that really distinguishes hospitalists from many other providers, particularly on the inpatient side, is just the frequency with which they use the EHR,” said Eric Helsher of Epic. Many hospitalists are chosen by administrators to test pilot projects for that reason, he adds. “They want to get it out there with a group who they know will have a lot of exposure to the system and may be more willing to make those changes for long-term gain.”

Sometimes that expertise leads to situations that go beyond the hospitalist simply being leaders of change – they’re doing work they were never really intended to do.

John Nelson, MD, MHM, a hospitalist consultant based in Seattle, said hospitalists tell him that a subspecialist might handle a case but will not want to be the attending physician specifically so they don’t have to deal with the EHR. He said the specialist in such cases will say something along the lines of, “You can call me, I’ll help you, and I’ll come by and say hello to the patient and make the care decisions, but I need you to be the attending so you can document in the chart and you can do the med rec because ‘I can’t figure out how to do those buttons right.’ ”

Some will ask hospitalists “for a hand” with a case when really all they want is for the hospitalist to enter information into the system. It’s a tricky situation for the hospitalist, Dr. Nelson said.

“Some will be transparent and say I don’t really have a medical question – I just can’t figure out how to do the med rec and the discharge, so would you do it?” he said, adding the systems issues are largely because of new rounding patterns sparked by HM’s expanding role in-hospital. “I think it meaningfully contributes to what I perceive to be a decline in hospitalist morale in the last 2 or 3 years.”

Tom Collins is a freelance writer in South Florida.

Sparrow Health System in Lansing, Mich., went live with its electronic health record (EHR) system at its main hospital on Dec. 1, 2012. For a year and a half, the system was untapped, innovation-wise. Very few features were turned on, and it sat relatively idle with regard to quality improvement. Hospitalists and others used the EHR, but not ambitiously. Everyone, essentially, used the post-launch period to catch their breath. Some even decided it would be the perfect time to retire, rather than confront the new reality of the EHR.

“It took a good 6 months, probably longer for some, for people to feel comfortable, to start smiling again and really feel like, ‘This isn’t so bad and actually might be working for us,’ ” said Carol Nwelue, MD, medical director of Sparrow’s adult hospitalist service.

• They have hospitalist leaders with a strong interest in IT who like to tinker and refine – and then share the tricks that work with others at their center.
• They belong to EHR-related committees or work at centers with hospitalists with a big presence in those committees.
• They keep their eyes on what other centers are doing with EHRs and use those projects as models for projects at their own centers.
• They are willing to make changes in their own processes, when feasible, so that they can better dovetail with the EHR.
• They keep their lines of communication open with their EHR vendors.
• They attend user meetings to get questions answered and share information and experiences.

At Sparrow, two committees – one nurse-led and one physician-led – guide EHR enhancement. The committees are a place where, yes, doctors can vent about the EHR (the phrase they use is “pain points”), but also a place where they can get constructive feedback. The committees also keep an eye out for EHR projects elsewhere that they might be able to do themselves.

EHR: a CAUTI example

In 2014, Sparrow doctors and nurses wanted to lower their number of catheter-associated urinary tract infections (CAUTI). With the EHR that had gone live 2 years before, they had the data that they needed. They just had to figure out how to turn the data into a workable plan. Ah, if only things were so simple with EHRs. As any health center that has gone through the great transition from paper to digital can attest, having the data only puts you at the foot of the mountain.

But using a program that Texas Health System had developed as a model, Sparrow got its CAUTI program up and running. The new system included not just a placement order, but the discontinuation order, too. Advisories on best practice were built into the work flow, including alerts on when catheters had been in for 48 hours, and metrics were created to track how well the whole thing worked.

Vendor engagement = QI opportunity

Sparrow and many other health systems are motivated to use more of Epic’s features and to innovate through an Epic rewards program that gives rebates for advanced use that can total hundreds of thousands of dollars. That innovation helps Epic problem solve and it can then point to that innovation in its marketing.

Almost all hospitals, and their hospitalists, are using the EHR for such basics as reducing unnecessary testing, medical reconciliation, and to document more accurately, said Eric Helsher, vice president of client success at Epic, whose job is to foster the spread of new and better ways to use the EHR. Most hospitals use the EHR, to at least some degree, for targeted quality improvement (QI) and patient safety programs, he said.

Dr. Palabindala pointed to record-sharing features as a way clinicians can share records within minutes without having to bother with faxing or emailing. Integrating smart-paging into the EHR is another way for doctors to communicate – it may not be as good as a phone call, but it’s less disruptive during a workday, he notes.

Epic is just now rolling out a secure text-messaging system hospitalists and others can use to communicate with one another – the header of the text thread clearly shows the patient it is referencing, Mr. Helsher said. Other EHR uses, such as telemedicine, are being used around the country but are far less widespread. But users are generally becoming more ambitious, he said.

“For the last 5-10 years, we’ve been in such an implementation rush,” Mr. Helsher explained. “ Now, at much more of a macro scale, the mentality has changed to ‘OK, we have these systems, let’s go from the implementation era to the value era.’ ”

Corinne Boudreau, senior marketing manager of physician experience at Meditech, said their sepsis tool has been very popular, while messaging features and shortcut commands for simpler charting are gradually coming into wider use. Meditech also expects their Web-based EHR – designed to give patients access on their mobile devices – will give doctors the mobility they want.

Still, there’s a wide range in how much hospitalists and other doctors are using even the fundamental tools that are available to them.

“I think that between implementation and maximization there is a period of adoption, and I think that that’s where a lot of folks are these days,” she said.

As “physician engagement” has become a buzzword in the industry, Meditech has worked with physician leaders on how to get doctors to absorb the message that the EHR really can help them do their jobs better.

“If you get [doctors] at the right time, you show them how it can make things easier or take time off their workload,” Ms. Boudreau said. “For some physicians that time to get them might be first thing in the morning before they see patients. Another physician might want to do it in the evening. If you hit that evening physician in the morning, you’ve missed that window of opportunity.”

Given the demands on doctors’ time and either an inability or unwillingness to put the time in that’s needed to learn about all functions the EHR can offer, there’s a growing acknowledgment that doctors often can’t simply do this on their own.

“There’s more recognition that this is a project that needs to be resourced,” Ms. Boudreau said. “They’re already strapped for time; to put something additional on top of it needs to be accommodated for. It needs to be resourced in terms of time, it needs to be resourced in terms of compensation. There need to be governance and support of that.”

Early adopters vs. late bloomers

Many hospitalists and HM groups have advanced, but some places have lagged behind, said John Nelson, MD, MHM, a veteran hospitalist, practice management consultant, and longtime columnist with The Hospitalist.

“We find it’s reasonably common to go to a place where they’re still keeping their census in an Excel spreadsheet,” he said. “Last year, we found people who do billing on paper and index cards.”

He said that often, a failure to adopt new EHR functionality isn’t because hospitals and HM groups are avoiding it. He said he sees IT shortcomings as a major blocker.

“They want to use it,” he said. “Inertia might be part of the reason people are failing to fully capture the benefit the EHR could offer, [but] the bigger reason is local IT configurations and support.”

As an example, Dr. Nelson explained that at some of the centers he has worked with the name of the attending physician is not always reflected in the EHR. That’s a big no-no, he said. The problem, he’s sometimes found, isn’t really the EHR, but quirks in the hospital system: The EHR is locked down for that information and can be changed only by a person in the admitting department.

“It would require the hospitalist to call down [to admissions] and get someone else to make that change – and that’s tedious a big headache. They give up and don’t do it anymore,” he said. “Ideally, you’d want to make it so the hospitalists can make the change themselves.”

At his center, Overlake Hospital Medical Center in Bellevue, Wash., a go-to hospitalist is David Chu, MD, who has gone through Epic training and shares tips with colleagues. He is one of a relatively few physicians there who has taken the time to use the drop-down menu feature for putting information into a chart.

That might sound like a fairly basic use for a multimillion-dollar EHR system. But it still can take hours and hours to get it right.

“The way to do it is a little bit of a programmer’s way of looking at things,” Dr. Chu said, noting it involves programming-style language with double colons, commas, and quotations marks.

“For me, I think it took a good 10, 12, 15 hours on my part to get things going,” he said. “It was a good time investment up front to help me on that end, but it’s just hard getting people to want to commit that time, especially if they’re not that savvy with computers.”

His hospitalist colleague, Ryan Chew, MD, is more advanced – he has a taxonomy-like shorthand he uses to give him the right set of basic fields for a given type of case. For someone admitted with pneumonia, he’d want to know certain things all the time. Were they short of breath? Did they have chest pain? What were their vital signs? What about inflammatory markers?

Dr. Chew can get all of those fields to pop up by typing “.rchppneumonia.” The “.” means that a special code is to follow. The “rc” is for Ryan Chew, the “hp” is for history and physical, and “pneumonia,” is the type of case. For cases that require other information to be entered, he can add that as needed.

Hospitalists might try to write shortcut phrases, but unless they have a well-defined system, it won’t be helpful over the long run, he said.

“If you don’t have a good organization system … you’ll never remember it,” Dr. Chew said.

But even he hasn’t created the drop-down menus. He said he just hasn’t been willing to take the time, especially since he feels his own way of doing things seems to be working just fine.

Effort is essential

Expanding the functionalities of the EHR takes effort, no doubt. As a result, some physicians and hospitalist groups have not been open-minded to the idea – and opportunities – of the EHR as a database.

“I think for some people, even still, working with the EHR, it’s become more something they’ve learned to get used to rather than something that they sought to take advantage of, in terms of helping things,” Dr. Chew said. “They’re still working against the EHR a little bit.”

Dr. Palabindala agreed, and said that regardless of resistance or complaint, EHRs work.

“No matter how much we argue, it is proven in multiple studies that EHRs showed increased patient safety and better documentation and better transfer of the data,” he said.

He suggests hospitalists make more of an effort.

“I strongly encourage hospitalists to be part of the every EHR-related committee, including CPOE [computerized physician order entry], analytics, and utilization-review committees,” he said. “Learning about the upgrades and learning about all the possible options, exploring clinical informatics on a regular basis is important. I also encourage [hospitalists] to participate in online, EHR-related surveys to learn more about the EHR utility and what is missing in their home institution.”

He acknowledges that it’s “hard to develop a passion.” Then he put it in terms he thought might resonate: “Think of it like a new version of smart phone. Show the enthusiasm as if you are ready for next version of iPhone or Pixel.” TH

Is hospitalists’ EHR efficiency taken advantage of?

Even though their level of EHR use can be hit or miss, hospitalists tend to be ahead of the game, many agree. But that can come with some drawbacks. They’re often the go-to people everyone else in the hospital relies on to handle the system that some think is too unwieldy to bother with.

“One thing that really distinguishes hospitalists from many other providers, particularly on the inpatient side, is just the frequency with which they use the EHR,” said Eric Helsher of Epic. Many hospitalists are chosen by administrators to test pilot projects for that reason, he adds. “They want to get it out there with a group who they know will have a lot of exposure to the system and may be more willing to make those changes for long-term gain.”

Sometimes that expertise leads to situations that go beyond the hospitalist simply being leaders of change – they’re doing work they were never really intended to do.

John Nelson, MD, MHM, a hospitalist consultant based in Seattle, said hospitalists tell him that a subspecialist might handle a case but will not want to be the attending physician specifically so they don’t have to deal with the EHR. He said the specialist in such cases will say something along the lines of, “You can call me, I’ll help you, and I’ll come by and say hello to the patient and make the care decisions, but I need you to be the attending so you can document in the chart and you can do the med rec because ‘I can’t figure out how to do those buttons right.’ ”

Some will ask hospitalists “for a hand” with a case when really all they want is for the hospitalist to enter information into the system. It’s a tricky situation for the hospitalist, Dr. Nelson said.

“Some will be transparent and say I don’t really have a medical question – I just can’t figure out how to do the med rec and the discharge, so would you do it?” he said, adding the systems issues are largely because of new rounding patterns sparked by HM’s expanding role in-hospital. “I think it meaningfully contributes to what I perceive to be a decline in hospitalist morale in the last 2 or 3 years.”

Tom Collins is a freelance writer in South Florida.

The Diagnosis: Hypertrophic Lupus Erythematosus

Physical examination at initial presentation revealed well-demarcated, 2- to 3-cm plaques with scale distributed most extensively on the elbows and shins with lesser involvement of the chest and abdomen. After treatment with topical steroids, adalimumab, methotrexate, and narrowband UVB phototherapy, new annular, erythematous, and edematous lesions began to appear on the chest and abdomen (Figure 1). These new lesions appeared less hyperkeratotic than the older ones.

Biopsy of a hyperkeratotic lesion from the patient's arm revealed marked hyperkeratosis, parakeratosis, epidermal hyperplasia, focal vacuolar change, solar elastosis, and transepidermal elastotic elimination (Figure 2A). A second biopsy performed on a newer chest lesion revealed interface changes, degeneration of the basal layer, follicular plugging, and dermal mucin (Figure 2B). Serology revealed an antinuclear antibody (ANA) titer of 1:1280 (reference range, <1:40 dilution) and hemoglobin of 11.5 g/dL (reference range, 14.0-17.5 g/dL). On the basis of clinical, histologic, and serologic findings, hypertrophic lupus erythematosus (LE) was diagnosed. The patient was treated with oral prednisone, which resulted in rapid improvement.

Hypertrophic LE is a rare subset of chronic cutaneous lupus first described by Behcet¹ in 1942. Lesions are identified as verrucous keratotic plaques with a characteristic erythematous indurated border.² Patients predominantly are middle-aged women with lesions distributed on sun-exposed areas. Most often, hypertrophic LE is seen in association with the classic lesions of discoid LE; however, patients may present exclusively with the cutaneous manifestations of hypertrophic LE. More rarely, as seen in this case, hypertrophic LE may present in conjunction with systemic features.³ The diagnosis of systemic LE requires 4 of the following criteria be fulfilled: malar rash; discoid rash; photosensitivity; oral ulcers; arthritis; cardiopulmonary serositis; renal involvement; positive ANA titer; and neurologic, hematologic, or immunologic disorders.⁴ Our patient qualified for discoid rash, photosensitivity, cardiopulmonary involvement with mitral valve defects and pulmonary pleuritis, hematologic disorder (anemia), and a positive ANA titer. Furthermore, in patients with only cutaneous discoid LE, serology generally reveals negative or low-titer ANA and negative anti-Ro antibodies.⁵

Hypertrophic LE is characterized histologically by irregular epidermal hyperplasia in association with features of classic cutaneous LE. Distinctive features of cutaneous LE include interface changes, follicular plugging, dermal mucin, and angiocentric lymphocytic inflammation.⁶ Notably, additional biopsies of the less hyperkeratotic lesions on our patient's chest and abdomen were performed, which revealed classic cutaneous LE features (Figure 2B).

Hypertrophic LE has 2 histological variants: lichen planus-like and keratoacanthoma (KA)-like patterns. Most cases are described as lichen planus-like, with a dense bandlike infiltrate in association with irregular epidermal hyperplasia, vacuolar interface changes, and reactive squamous atypia.⁵ In contrast, the less common KA-like lesions consist of a keratinous center with vigorous squamous epithelial proliferation.⁶

Clinically, hypertrophic LE may resemble hypertrophic psoriasis, lichen planus, KA, or squamous cell carcinoma (SCC). Due to the presence of pseudocarcinomatous hyperplasia, the histopathologic differential includes hypertrophic lichen planus, SCC, KA, and deep fungal infections. However, these other diseases lack the classic features of cutaneous LE, which include interface changes, follicular plugging, dermal mucin, and perivascular lymphocytic inflammation. Additionally, transepidermal elastotic elimination (Figure 2A) helps distinguish hypertrophic LE from other diagnoses.⁷ One of the most important tasks is distinguishing hypertrophic LE from SCC. Hypertrophic LE does not typically display eosinophil infiltrates, which differentiates it from SCC and KA. Additionally, studies report that CD123 positivity can be useful.⁶ Positive plasmacytoid dendritic cells are abundant at the dermoepidermal junction in hypertrophic LE, while only single or rare clusters of CD123⁺ cells are seen in SCC.⁸ Also, SCC has been found to arise in long-standing cutaneous LE lesions including both discoid and hypertrophic LE. Therefore, clinical and sometimes histological follow-up is required.

Hypertrophic LE often is challenging to treat and frequently is resistant to antimalarial drugs. The primary goals of treatment involve reducing inflammatory infiltrate and minimizing hyperkeratinization. Topical corticosteroids and calcineurin inhibitors often are inadequate as monotherapy due to reduced penetrance through the thick lesions; however, intralesional corticosteroids may be beneficial in patients with localized disease.⁹ Unfortunately, topical or intralesional treatments are impractical in patients with extensive lesions, as seen in our patient, in which case systemic corticosteroids can be beneficial.

Topical retinoids also have been found to be highly effective.¹⁰ Specifically, retinoids such as acitretin and isotretinoin, in some cases combined with antimalarial drugs, are effective in reducing the keratinization of these lesions. Successful treatment also has been reported with ustekinumab, thalidomide, mycophenolate mofetil, and pulsed dye laser.¹¹ As in other types of cutaneous LE, hyperkeratotic LE is photosensitive; avoidance of prolonged sun exposure should be advised.⁸

The Diagnosis: Hypertrophic Lupus Erythematosus

Physical examination at initial presentation revealed well-demarcated, 2- to 3-cm plaques with scale distributed most extensively on the elbows and shins with lesser involvement of the chest and abdomen. After treatment with topical steroids, adalimumab, methotrexate, and narrowband UVB phototherapy, new annular, erythematous, and edematous lesions began to appear on the chest and abdomen (Figure 1). These new lesions appeared less hyperkeratotic than the older ones.

Biopsy of a hyperkeratotic lesion from the patient's arm revealed marked hyperkeratosis, parakeratosis, epidermal hyperplasia, focal vacuolar change, solar elastosis, and transepidermal elastotic elimination (Figure 2A). A second biopsy performed on a newer chest lesion revealed interface changes, degeneration of the basal layer, follicular plugging, and dermal mucin (Figure 2B). Serology revealed an antinuclear antibody (ANA) titer of 1:1280 (reference range, <1:40 dilution) and hemoglobin of 11.5 g/dL (reference range, 14.0-17.5 g/dL). On the basis of clinical, histologic, and serologic findings, hypertrophic lupus erythematosus (LE) was diagnosed. The patient was treated with oral prednisone, which resulted in rapid improvement.

Hypertrophic LE is a rare subset of chronic cutaneous lupus first described by Behcet¹ in 1942. Lesions are identified as verrucous keratotic plaques with a characteristic erythematous indurated border.² Patients predominantly are middle-aged women with lesions distributed on sun-exposed areas. Most often, hypertrophic LE is seen in association with the classic lesions of discoid LE; however, patients may present exclusively with the cutaneous manifestations of hypertrophic LE. More rarely, as seen in this case, hypertrophic LE may present in conjunction with systemic features.³ The diagnosis of systemic LE requires 4 of the following criteria be fulfilled: malar rash; discoid rash; photosensitivity; oral ulcers; arthritis; cardiopulmonary serositis; renal involvement; positive ANA titer; and neurologic, hematologic, or immunologic disorders.⁴ Our patient qualified for discoid rash, photosensitivity, cardiopulmonary involvement with mitral valve defects and pulmonary pleuritis, hematologic disorder (anemia), and a positive ANA titer. Furthermore, in patients with only cutaneous discoid LE, serology generally reveals negative or low-titer ANA and negative anti-Ro antibodies.⁵

Hypertrophic LE is characterized histologically by irregular epidermal hyperplasia in association with features of classic cutaneous LE. Distinctive features of cutaneous LE include interface changes, follicular plugging, dermal mucin, and angiocentric lymphocytic inflammation.⁶ Notably, additional biopsies of the less hyperkeratotic lesions on our patient's chest and abdomen were performed, which revealed classic cutaneous LE features (Figure 2B).

Hypertrophic LE has 2 histological variants: lichen planus-like and keratoacanthoma (KA)-like patterns. Most cases are described as lichen planus-like, with a dense bandlike infiltrate in association with irregular epidermal hyperplasia, vacuolar interface changes, and reactive squamous atypia.⁵ In contrast, the less common KA-like lesions consist of a keratinous center with vigorous squamous epithelial proliferation.⁶

Clinically, hypertrophic LE may resemble hypertrophic psoriasis, lichen planus, KA, or squamous cell carcinoma (SCC). Due to the presence of pseudocarcinomatous hyperplasia, the histopathologic differential includes hypertrophic lichen planus, SCC, KA, and deep fungal infections. However, these other diseases lack the classic features of cutaneous LE, which include interface changes, follicular plugging, dermal mucin, and perivascular lymphocytic inflammation. Additionally, transepidermal elastotic elimination (Figure 2A) helps distinguish hypertrophic LE from other diagnoses.⁷ One of the most important tasks is distinguishing hypertrophic LE from SCC. Hypertrophic LE does not typically display eosinophil infiltrates, which differentiates it from SCC and KA. Additionally, studies report that CD123 positivity can be useful.⁶ Positive plasmacytoid dendritic cells are abundant at the dermoepidermal junction in hypertrophic LE, while only single or rare clusters of CD123⁺ cells are seen in SCC.⁸ Also, SCC has been found to arise in long-standing cutaneous LE lesions including both discoid and hypertrophic LE. Therefore, clinical and sometimes histological follow-up is required.

Hypertrophic LE often is challenging to treat and frequently is resistant to antimalarial drugs. The primary goals of treatment involve reducing inflammatory infiltrate and minimizing hyperkeratinization. Topical corticosteroids and calcineurin inhibitors often are inadequate as monotherapy due to reduced penetrance through the thick lesions; however, intralesional corticosteroids may be beneficial in patients with localized disease.⁹ Unfortunately, topical or intralesional treatments are impractical in patients with extensive lesions, as seen in our patient, in which case systemic corticosteroids can be beneficial.

Topical retinoids also have been found to be highly effective.¹⁰ Specifically, retinoids such as acitretin and isotretinoin, in some cases combined with antimalarial drugs, are effective in reducing the keratinization of these lesions. Successful treatment also has been reported with ustekinumab, thalidomide, mycophenolate mofetil, and pulsed dye laser.¹¹ As in other types of cutaneous LE, hyperkeratotic LE is photosensitive; avoidance of prolonged sun exposure should be advised.⁸

The Diagnosis: Hypertrophic Lupus Erythematosus

Physical examination at initial presentation revealed well-demarcated, 2- to 3-cm plaques with scale distributed most extensively on the elbows and shins with lesser involvement of the chest and abdomen. After treatment with topical steroids, adalimumab, methotrexate, and narrowband UVB phototherapy, new annular, erythematous, and edematous lesions began to appear on the chest and abdomen (Figure 1). These new lesions appeared less hyperkeratotic than the older ones.

Biopsy of a hyperkeratotic lesion from the patient's arm revealed marked hyperkeratosis, parakeratosis, epidermal hyperplasia, focal vacuolar change, solar elastosis, and transepidermal elastotic elimination (Figure 2A). A second biopsy performed on a newer chest lesion revealed interface changes, degeneration of the basal layer, follicular plugging, and dermal mucin (Figure 2B). Serology revealed an antinuclear antibody (ANA) titer of 1:1280 (reference range, <1:40 dilution) and hemoglobin of 11.5 g/dL (reference range, 14.0-17.5 g/dL). On the basis of clinical, histologic, and serologic findings, hypertrophic lupus erythematosus (LE) was diagnosed. The patient was treated with oral prednisone, which resulted in rapid improvement.

Hypertrophic LE is a rare subset of chronic cutaneous lupus first described by Behcet¹ in 1942. Lesions are identified as verrucous keratotic plaques with a characteristic erythematous indurated border.² Patients predominantly are middle-aged women with lesions distributed on sun-exposed areas. Most often, hypertrophic LE is seen in association with the classic lesions of discoid LE; however, patients may present exclusively with the cutaneous manifestations of hypertrophic LE. More rarely, as seen in this case, hypertrophic LE may present in conjunction with systemic features.³ The diagnosis of systemic LE requires 4 of the following criteria be fulfilled: malar rash; discoid rash; photosensitivity; oral ulcers; arthritis; cardiopulmonary serositis; renal involvement; positive ANA titer; and neurologic, hematologic, or immunologic disorders.⁴ Our patient qualified for discoid rash, photosensitivity, cardiopulmonary involvement with mitral valve defects and pulmonary pleuritis, hematologic disorder (anemia), and a positive ANA titer. Furthermore, in patients with only cutaneous discoid LE, serology generally reveals negative or low-titer ANA and negative anti-Ro antibodies.⁵

Hypertrophic LE is characterized histologically by irregular epidermal hyperplasia in association with features of classic cutaneous LE. Distinctive features of cutaneous LE include interface changes, follicular plugging, dermal mucin, and angiocentric lymphocytic inflammation.⁶ Notably, additional biopsies of the less hyperkeratotic lesions on our patient's chest and abdomen were performed, which revealed classic cutaneous LE features (Figure 2B).

Hypertrophic LE has 2 histological variants: lichen planus-like and keratoacanthoma (KA)-like patterns. Most cases are described as lichen planus-like, with a dense bandlike infiltrate in association with irregular epidermal hyperplasia, vacuolar interface changes, and reactive squamous atypia.⁵ In contrast, the less common KA-like lesions consist of a keratinous center with vigorous squamous epithelial proliferation.⁶

Clinically, hypertrophic LE may resemble hypertrophic psoriasis, lichen planus, KA, or squamous cell carcinoma (SCC). Due to the presence of pseudocarcinomatous hyperplasia, the histopathologic differential includes hypertrophic lichen planus, SCC, KA, and deep fungal infections. However, these other diseases lack the classic features of cutaneous LE, which include interface changes, follicular plugging, dermal mucin, and perivascular lymphocytic inflammation. Additionally, transepidermal elastotic elimination (Figure 2A) helps distinguish hypertrophic LE from other diagnoses.⁷ One of the most important tasks is distinguishing hypertrophic LE from SCC. Hypertrophic LE does not typically display eosinophil infiltrates, which differentiates it from SCC and KA. Additionally, studies report that CD123 positivity can be useful.⁶ Positive plasmacytoid dendritic cells are abundant at the dermoepidermal junction in hypertrophic LE, while only single or rare clusters of CD123⁺ cells are seen in SCC.⁸ Also, SCC has been found to arise in long-standing cutaneous LE lesions including both discoid and hypertrophic LE. Therefore, clinical and sometimes histological follow-up is required.

Hypertrophic LE often is challenging to treat and frequently is resistant to antimalarial drugs. The primary goals of treatment involve reducing inflammatory infiltrate and minimizing hyperkeratinization. Topical corticosteroids and calcineurin inhibitors often are inadequate as monotherapy due to reduced penetrance through the thick lesions; however, intralesional corticosteroids may be beneficial in patients with localized disease.⁹ Unfortunately, topical or intralesional treatments are impractical in patients with extensive lesions, as seen in our patient, in which case systemic corticosteroids can be beneficial.

Topical retinoids also have been found to be highly effective.¹⁰ Specifically, retinoids such as acitretin and isotretinoin, in some cases combined with antimalarial drugs, are effective in reducing the keratinization of these lesions. Successful treatment also has been reported with ustekinumab, thalidomide, mycophenolate mofetil, and pulsed dye laser.¹¹ As in other types of cutaneous LE, hyperkeratotic LE is photosensitive; avoidance of prolonged sun exposure should be advised.⁸

A multi-biomarker disease activity score in patients with longstanding rheumatoid arthritis and low disease activity prior to tapering adalimumab or etanercept did not predict flare-related outcomes in an 18-month, open-label, randomized clinical trial.

These findings seemed “robust and valid, at least in this specific context,” said investigators led by Chantal A. M. Bouman, MD, of Sint Maartenskliniek Nijmegen (the Netherlands), because multiple other outcomes measured in the trial, including discontinuation of biologic and radiographic progression, were not predicted by the multi-biomarker disease activity (MBDA) score, which is derived from an algorithm using a biomarker panel of 12 serum proteins and is marketed under the name Vectra DA.

The researchers sought to determine if measurement of disease activity using biomarkers with the MBDA score has a potential for smaller measurement error, compared with clinical decision making, in predicting the effects of dose tapering of biologic disease-modifying antirheumatic drugs by examining blood samples taken from 171 people with longstanding RA with low disease activity who were participating in the Dutch Dose Reduction Strategies of Subcutaneous TNF inhibitors (DRESS) trial (Rheumatology [Oxford]. 2017 Feb 22. doi: 10.1093/rheumatology/kex003).

The use of biomarkers could potentially overcome some of the drawbacks of the most widely used and extensively validated measure of RA disease activity, the Disease Activity Score in 28 joints (DAS28), which relies on “clinical assessments [that] are subject to interobserver variability, resulting in measurement error and suboptimal precision,” the investigators wrote. “Also, DAS28 can be influenced by factors other than RA disease activity (e.g., OA, [fibromyalgia], or other causes of inflammation, such an infection), resulting in clinical misclassification of disease activity state.”

The randomized DRESS trial investigated the noninferiority of a dose reduction strategy of adalimumab or etanercept (n = 115), compared with usual care (n = 56), on the rate of flare, defined as a DAS28 (using C-reactive protein) increase of more than 1.2 or 0.6 if the current DAS was more than or equal to 3.2. A major flare was one lasting more than 3 months despite treatment intervention.

The baseline MBDA score did not predict successful tapering based on an area under the receiver operating characteristic (AUROC) of 0.53 (95% confidence interval, 0.41-0.66), nor did it predict the discontinuation of either biologic (AUROC = 0.51; 95% CI, 0.36-0.66) or the occurrence of flare (AUROC = 0.50; 95% CI, 0.41-0.59 for both groups combined) or major flare (AUROC = 0.46; 95% CI, 0.32-0.65 for both groups combined).

Although the authors found a borderline positive predictive value of baseline MBDA score for major flare in the usual care group (AUROC = 0.72; 95% CI, 0.56-0.88), they said the finding should be “interpreted cautiously” as multiple testing may have resulted in false-positive findings.

The researchers also discovered that, in contrast to findings from five studies in four cohorts of patients with established or early RA, the MBDA did not predict radiographic progression (AUROC = 0.53 for predicting radiographic progression of more than 0.5 Sharp–van der Heijde points; 95% CI, 0.43-0.63 for both groups combined).

The inability of the MBDA score to predict radiographic outcomes “might be attributable to the low frequency and severity of radiographic progression in our study, with only a small difference in favor of the [usual care] group. It might reflect the strict tight control that was applied to patients who were already in low disease activity or remission,” the investigators suggested.

They also said that, in spite of the findings, the MBDA score may have predictive value in other groups of patients, such as those with early rheumatoid arthritis, higher disease activity, or suboptimal disease control, and suggested that the study’s findings be validated in further studies.

The study received no specific funding. However, one author is an employee of Crescendo Bioscience and reported receiving stock grants from its parent company, Myriad Genetics. Several authors reported relationships with industry.

A multi-biomarker disease activity score in patients with longstanding rheumatoid arthritis and low disease activity prior to tapering adalimumab or etanercept did not predict flare-related outcomes in an 18-month, open-label, randomized clinical trial.

These findings seemed “robust and valid, at least in this specific context,” said investigators led by Chantal A. M. Bouman, MD, of Sint Maartenskliniek Nijmegen (the Netherlands), because multiple other outcomes measured in the trial, including discontinuation of biologic and radiographic progression, were not predicted by the multi-biomarker disease activity (MBDA) score, which is derived from an algorithm using a biomarker panel of 12 serum proteins and is marketed under the name Vectra DA.

The researchers sought to determine if measurement of disease activity using biomarkers with the MBDA score has a potential for smaller measurement error, compared with clinical decision making, in predicting the effects of dose tapering of biologic disease-modifying antirheumatic drugs by examining blood samples taken from 171 people with longstanding RA with low disease activity who were participating in the Dutch Dose Reduction Strategies of Subcutaneous TNF inhibitors (DRESS) trial (Rheumatology [Oxford]. 2017 Feb 22. doi: 10.1093/rheumatology/kex003).

The use of biomarkers could potentially overcome some of the drawbacks of the most widely used and extensively validated measure of RA disease activity, the Disease Activity Score in 28 joints (DAS28), which relies on “clinical assessments [that] are subject to interobserver variability, resulting in measurement error and suboptimal precision,” the investigators wrote. “Also, DAS28 can be influenced by factors other than RA disease activity (e.g., OA, [fibromyalgia], or other causes of inflammation, such an infection), resulting in clinical misclassification of disease activity state.”

The randomized DRESS trial investigated the noninferiority of a dose reduction strategy of adalimumab or etanercept (n = 115), compared with usual care (n = 56), on the rate of flare, defined as a DAS28 (using C-reactive protein) increase of more than 1.2 or 0.6 if the current DAS was more than or equal to 3.2. A major flare was one lasting more than 3 months despite treatment intervention.

The baseline MBDA score did not predict successful tapering based on an area under the receiver operating characteristic (AUROC) of 0.53 (95% confidence interval, 0.41-0.66), nor did it predict the discontinuation of either biologic (AUROC = 0.51; 95% CI, 0.36-0.66) or the occurrence of flare (AUROC = 0.50; 95% CI, 0.41-0.59 for both groups combined) or major flare (AUROC = 0.46; 95% CI, 0.32-0.65 for both groups combined).

Although the authors found a borderline positive predictive value of baseline MBDA score for major flare in the usual care group (AUROC = 0.72; 95% CI, 0.56-0.88), they said the finding should be “interpreted cautiously” as multiple testing may have resulted in false-positive findings.

The researchers also discovered that, in contrast to findings from five studies in four cohorts of patients with established or early RA, the MBDA did not predict radiographic progression (AUROC = 0.53 for predicting radiographic progression of more than 0.5 Sharp–van der Heijde points; 95% CI, 0.43-0.63 for both groups combined).

The inability of the MBDA score to predict radiographic outcomes “might be attributable to the low frequency and severity of radiographic progression in our study, with only a small difference in favor of the [usual care] group. It might reflect the strict tight control that was applied to patients who were already in low disease activity or remission,” the investigators suggested.

They also said that, in spite of the findings, the MBDA score may have predictive value in other groups of patients, such as those with early rheumatoid arthritis, higher disease activity, or suboptimal disease control, and suggested that the study’s findings be validated in further studies.

The study received no specific funding. However, one author is an employee of Crescendo Bioscience and reported receiving stock grants from its parent company, Myriad Genetics. Several authors reported relationships with industry.

A multi-biomarker disease activity score in patients with longstanding rheumatoid arthritis and low disease activity prior to tapering adalimumab or etanercept did not predict flare-related outcomes in an 18-month, open-label, randomized clinical trial.

These findings seemed “robust and valid, at least in this specific context,” said investigators led by Chantal A. M. Bouman, MD, of Sint Maartenskliniek Nijmegen (the Netherlands), because multiple other outcomes measured in the trial, including discontinuation of biologic and radiographic progression, were not predicted by the multi-biomarker disease activity (MBDA) score, which is derived from an algorithm using a biomarker panel of 12 serum proteins and is marketed under the name Vectra DA.

The researchers sought to determine if measurement of disease activity using biomarkers with the MBDA score has a potential for smaller measurement error, compared with clinical decision making, in predicting the effects of dose tapering of biologic disease-modifying antirheumatic drugs by examining blood samples taken from 171 people with longstanding RA with low disease activity who were participating in the Dutch Dose Reduction Strategies of Subcutaneous TNF inhibitors (DRESS) trial (Rheumatology [Oxford]. 2017 Feb 22. doi: 10.1093/rheumatology/kex003).

The use of biomarkers could potentially overcome some of the drawbacks of the most widely used and extensively validated measure of RA disease activity, the Disease Activity Score in 28 joints (DAS28), which relies on “clinical assessments [that] are subject to interobserver variability, resulting in measurement error and suboptimal precision,” the investigators wrote. “Also, DAS28 can be influenced by factors other than RA disease activity (e.g., OA, [fibromyalgia], or other causes of inflammation, such an infection), resulting in clinical misclassification of disease activity state.”

The randomized DRESS trial investigated the noninferiority of a dose reduction strategy of adalimumab or etanercept (n = 115), compared with usual care (n = 56), on the rate of flare, defined as a DAS28 (using C-reactive protein) increase of more than 1.2 or 0.6 if the current DAS was more than or equal to 3.2. A major flare was one lasting more than 3 months despite treatment intervention.

The baseline MBDA score did not predict successful tapering based on an area under the receiver operating characteristic (AUROC) of 0.53 (95% confidence interval, 0.41-0.66), nor did it predict the discontinuation of either biologic (AUROC = 0.51; 95% CI, 0.36-0.66) or the occurrence of flare (AUROC = 0.50; 95% CI, 0.41-0.59 for both groups combined) or major flare (AUROC = 0.46; 95% CI, 0.32-0.65 for both groups combined).

Although the authors found a borderline positive predictive value of baseline MBDA score for major flare in the usual care group (AUROC = 0.72; 95% CI, 0.56-0.88), they said the finding should be “interpreted cautiously” as multiple testing may have resulted in false-positive findings.

The researchers also discovered that, in contrast to findings from five studies in four cohorts of patients with established or early RA, the MBDA did not predict radiographic progression (AUROC = 0.53 for predicting radiographic progression of more than 0.5 Sharp–van der Heijde points; 95% CI, 0.43-0.63 for both groups combined).

The inability of the MBDA score to predict radiographic outcomes “might be attributable to the low frequency and severity of radiographic progression in our study, with only a small difference in favor of the [usual care] group. It might reflect the strict tight control that was applied to patients who were already in low disease activity or remission,” the investigators suggested.

They also said that, in spite of the findings, the MBDA score may have predictive value in other groups of patients, such as those with early rheumatoid arthritis, higher disease activity, or suboptimal disease control, and suggested that the study’s findings be validated in further studies.

The study received no specific funding. However, one author is an employee of Crescendo Bioscience and reported receiving stock grants from its parent company, Myriad Genetics. Several authors reported relationships with industry.

Registration and housing for the 2017 Vascular Annual Meeting are now open. VAM will be held May 31-June 3 in San Diego, with plenaries and exhibits open June 1-3. Register here and make housing reservations here. Already, more than 150 people have registered; look who’s coming here.

Registration and housing for the 2017 Vascular Annual Meeting are now open. VAM will be held May 31-June 3 in San Diego, with plenaries and exhibits open June 1-3. Register here and make housing reservations here. Already, more than 150 people have registered; look who’s coming here.

Registration and housing for the 2017 Vascular Annual Meeting are now open. VAM will be held May 31-June 3 in San Diego, with plenaries and exhibits open June 1-3. Register here and make housing reservations here. Already, more than 150 people have registered; look who’s coming here.

Oct 28 – Nov 1

Toronto, Ontario, Canada

Join us in wonderful Toronto for CHEST 2017, where we’ll connect a global community in clinical chest medicine. Our program will deliver current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats. Take advantage of these opportunities to get involved now:

Submit Abstracts and Case Reports

Submission deadline: March 31

• Fellow Case Reports.
• Medical Student/Resident Case Reports.
• Global Case Reports.
• Clinical Case Puzzlers.

Learn more and submit at chest2017.abstractcentral.com.

Apply for 2017 CHEST Foundation Grants

Application deadline: March 31

The CHEST Foundation has started accepting applications for its clinical research, distinguished scholar, and community service grants. Every year, the CHEST Foundation awards more than a half-million dollars to the next generation of lung health champions.

The grants available are:

• GlaxoSmithKline Distinguished Scholar Research Grant in Respiratory Health: $150,000 over 3 years
• CHEST Foundation Research Grant in Lung Cancer: $50,000-$100,000* over 2 years
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension: $25,000 1-year grant
• CHEST Foundation and Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency: $25,000 1-year grant
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria: $10,000-$30,000* 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism: $30,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis: $30,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease: $50,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health: $10,000 1-year grant
• CHEST Foundation Research Grant in Asthma: $15,000 - $30,000* 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis: $30,000 1-year grant
• Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP: multiple awards up to $15,000 per 1-year grant

*Amount contingent on funding.Apply for grants at chestfoundation.org/grants.

Oct 28 – Nov 1

Toronto, Ontario, Canada

Join us in wonderful Toronto for CHEST 2017, where we’ll connect a global community in clinical chest medicine. Our program will deliver current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats. Take advantage of these opportunities to get involved now:

Submit Abstracts and Case Reports

Submission deadline: March 31

• Fellow Case Reports.
• Medical Student/Resident Case Reports.
• Global Case Reports.
• Clinical Case Puzzlers.

Learn more and submit at chest2017.abstractcentral.com.

Apply for 2017 CHEST Foundation Grants

Application deadline: March 31

The CHEST Foundation has started accepting applications for its clinical research, distinguished scholar, and community service grants. Every year, the CHEST Foundation awards more than a half-million dollars to the next generation of lung health champions.

The grants available are:

• GlaxoSmithKline Distinguished Scholar Research Grant in Respiratory Health: $150,000 over 3 years
• CHEST Foundation Research Grant in Lung Cancer: $50,000-$100,000* over 2 years
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension: $25,000 1-year grant
• CHEST Foundation and Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency: $25,000 1-year grant
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria: $10,000-$30,000* 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism: $30,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis: $30,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease: $50,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health: $10,000 1-year grant
• CHEST Foundation Research Grant in Asthma: $15,000 - $30,000* 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis: $30,000 1-year grant
• Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP: multiple awards up to $15,000 per 1-year grant

*Amount contingent on funding.Apply for grants at chestfoundation.org/grants.

Oct 28 – Nov 1

Toronto, Ontario, Canada

Join us in wonderful Toronto for CHEST 2017, where we’ll connect a global community in clinical chest medicine. Our program will deliver current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats. Take advantage of these opportunities to get involved now:

Submit Abstracts and Case Reports

Submission deadline: March 31

• Fellow Case Reports.
• Medical Student/Resident Case Reports.
• Global Case Reports.
• Clinical Case Puzzlers.

Learn more and submit at chest2017.abstractcentral.com.

Apply for 2017 CHEST Foundation Grants

Application deadline: March 31

The CHEST Foundation has started accepting applications for its clinical research, distinguished scholar, and community service grants. Every year, the CHEST Foundation awards more than a half-million dollars to the next generation of lung health champions.

The grants available are:

• GlaxoSmithKline Distinguished Scholar Research Grant in Respiratory Health: $150,000 over 3 years
• CHEST Foundation Research Grant in Lung Cancer: $50,000-$100,000* over 2 years
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension: $25,000 1-year grant
• CHEST Foundation and Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency: $25,000 1-year grant
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria: $10,000-$30,000* 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism: $30,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis: $30,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease: $50,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health: $10,000 1-year grant
• CHEST Foundation Research Grant in Asthma: $15,000 - $30,000* 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis: $30,000 1-year grant
• Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP: multiple awards up to $15,000 per 1-year grant

*Amount contingent on funding.Apply for grants at chestfoundation.org/grants.

In 2016, Catherine Oberg, MD, was awarded the CHEST Foundation Research Grant in Women’s Lung Health for her project on household air pollution in Ghana. In this recent interview with Dr. Oberg, she describes how she is championing lung health.

How I got involved

In medical school, I was very interested in international medicine and took a trip to Tanzania to do primary care work when I was in my fourth year. I saw firsthand how the people, women especially, sleep, cook, eat, and take care of their children and animals all in one house. I saw how direct smoke exposure from cooking caused symptoms of cough, phlegm, and shortness of breath. I knew this was an area where I could make an impact.

Tackling a leading cause of lung disease

In rural areas around the world, people cook with ineffective fuels, such as animal dung, that cause damaging household air pollution. This is a leading cause of asthma, COPD, and lung cancer worldwide, and it preferentially affects women and children because of their roles in the household. My project focuses on household air pollution with a goal to measure the effectiveness of utilizing a clean burning stove as an intervention.

We have a cohort of women in Ghana and have had randomized clusters using either a liquefied petroleum gas (LPG) clean burning stove or a traditional cook stove for 18 months now. We’re going to look at their lung function, inflammatory markers, and respiratory symptoms and compare the groups to see if the intervention has made a difference.

The impact

Being able to breathe is a function many of us take for granted. The ability to impact something this vital to everyday life is a really exciting and important challenge. It’s an area where I think we can make a big impact.

The future

This project could bring about further research and hopefully provide evidence supporting these types of interventions. The impact could affect millions of people around the world. The CHEST Foundation grant is providing materials that are the foundation of our project. This grant allows us to design better studies in the future, to educate patients in a more effective manner, and to prevent these life-threatening diseases.

The next CHEST Foundation grants cycle is open from February 1 to March 31, 2017. How will you champion lung health? Learn more about foundation grants and how you can apply at https://chest.realmagnet.land/chest-foundation-grants.

In 2016, Catherine Oberg, MD, was awarded the CHEST Foundation Research Grant in Women’s Lung Health for her project on household air pollution in Ghana. In this recent interview with Dr. Oberg, she describes how she is championing lung health.

How I got involved

In medical school, I was very interested in international medicine and took a trip to Tanzania to do primary care work when I was in my fourth year. I saw firsthand how the people, women especially, sleep, cook, eat, and take care of their children and animals all in one house. I saw how direct smoke exposure from cooking caused symptoms of cough, phlegm, and shortness of breath. I knew this was an area where I could make an impact.

Tackling a leading cause of lung disease

In rural areas around the world, people cook with ineffective fuels, such as animal dung, that cause damaging household air pollution. This is a leading cause of asthma, COPD, and lung cancer worldwide, and it preferentially affects women and children because of their roles in the household. My project focuses on household air pollution with a goal to measure the effectiveness of utilizing a clean burning stove as an intervention.

We have a cohort of women in Ghana and have had randomized clusters using either a liquefied petroleum gas (LPG) clean burning stove or a traditional cook stove for 18 months now. We’re going to look at their lung function, inflammatory markers, and respiratory symptoms and compare the groups to see if the intervention has made a difference.

The impact

Being able to breathe is a function many of us take for granted. The ability to impact something this vital to everyday life is a really exciting and important challenge. It’s an area where I think we can make a big impact.

The future

This project could bring about further research and hopefully provide evidence supporting these types of interventions. The impact could affect millions of people around the world. The CHEST Foundation grant is providing materials that are the foundation of our project. This grant allows us to design better studies in the future, to educate patients in a more effective manner, and to prevent these life-threatening diseases.

The next CHEST Foundation grants cycle is open from February 1 to March 31, 2017. How will you champion lung health? Learn more about foundation grants and how you can apply at https://chest.realmagnet.land/chest-foundation-grants.

In 2016, Catherine Oberg, MD, was awarded the CHEST Foundation Research Grant in Women’s Lung Health for her project on household air pollution in Ghana. In this recent interview with Dr. Oberg, she describes how she is championing lung health.

How I got involved

In medical school, I was very interested in international medicine and took a trip to Tanzania to do primary care work when I was in my fourth year. I saw firsthand how the people, women especially, sleep, cook, eat, and take care of their children and animals all in one house. I saw how direct smoke exposure from cooking caused symptoms of cough, phlegm, and shortness of breath. I knew this was an area where I could make an impact.

Tackling a leading cause of lung disease

In rural areas around the world, people cook with ineffective fuels, such as animal dung, that cause damaging household air pollution. This is a leading cause of asthma, COPD, and lung cancer worldwide, and it preferentially affects women and children because of their roles in the household. My project focuses on household air pollution with a goal to measure the effectiveness of utilizing a clean burning stove as an intervention.

We have a cohort of women in Ghana and have had randomized clusters using either a liquefied petroleum gas (LPG) clean burning stove or a traditional cook stove for 18 months now. We’re going to look at their lung function, inflammatory markers, and respiratory symptoms and compare the groups to see if the intervention has made a difference.

The impact

Being able to breathe is a function many of us take for granted. The ability to impact something this vital to everyday life is a really exciting and important challenge. It’s an area where I think we can make a big impact.

The future

This project could bring about further research and hopefully provide evidence supporting these types of interventions. The impact could affect millions of people around the world. The CHEST Foundation grant is providing materials that are the foundation of our project. This grant allows us to design better studies in the future, to educate patients in a more effective manner, and to prevent these life-threatening diseases.

The next CHEST Foundation grants cycle is open from February 1 to March 31, 2017. How will you champion lung health? Learn more about foundation grants and how you can apply at https://chest.realmagnet.land/chest-foundation-grants.