The SVS Executive Committee, at its July retreat, approved the appointment of the chair of the SVS Community Practice Committee (currently Dr. Richard Lynn) as an interim ex officio member of the SVS Executive Committee. As part of the same change, Dr. Lynn also has been appointed to the Nominating Committee.

The SVS Executive Committee, at its July retreat, approved the appointment of the chair of the SVS Community Practice Committee (currently Dr. Richard Lynn) as an interim ex officio member of the SVS Executive Committee. As part of the same change, Dr. Lynn also has been appointed to the Nominating Committee.

The SVS Executive Committee, at its July retreat, approved the appointment of the chair of the SVS Community Practice Committee (currently Dr. Richard Lynn) as an interim ex officio member of the SVS Executive Committee. As part of the same change, Dr. Lynn also has been appointed to the Nominating Committee.

WASHINGTON – A sea change is underway in how major depressive and bipolar disorders are diagnosed and treated.

Historically, the absence of an accurate, comprehensive nosology of depression has led to much suffering and confusion. People with bipolar disorder in particular are either not diagnosed early enough or are not diagnosed with the correct “flavor” of depression, according to Roger S. McIntyre, MD, author of updated treatment guidelines for bipolar depression, and the first-ever treatment guidelines for mixed features in major depressive disorder. “Twenty years ago, we would have described bipolar as episodic breakthroughs of mania and depression, with well intervals in between,” Dr. McIntyre said at Summit in Neurology & Psychiatry. “But now, we’ve really changed our fundamental thinking about bipolar disorder.”

Although reasons for the evolution in thinking are many, one of the strongest currents of change flows from the 2013 publication of the DSM-5, according to Dr. McIntyre, professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at University Health Network in Toronto.

“The DSM-5’s authors took a neo-Kraepelinian view that mood disorders are dimensional,” Dr. McIntyre said in an interview. As a result, there’s been a reversal of what he called the “social construct imposed upon the cosmos of mood disorders by the DSM-III that divided that world into either depression or bipolar disorder.”

This return to thinking of mood disorders as existing on a continuum, as psychiatrist Emil Kraepelin, MD, theorized around the turn of the last century, pivots on the decision to do away with mixed states and to instead add the mixed features specifier.

“The move to mixed features is the necessary bridge between bipolar disease and major depressive disorder,” Dr. McIntyre said in the interview.

Therefore, for a period of time between the 1980 publication of the DSM-III and the DSM-5, “real-world” presentations of subsyndromal, opposite-pole symptoms that are common in major depressive disorder (MDD) and in bipolar disorder were not accounted for.

In practical terms, the addition of mixed features means that a patient with mania who presents with subsyndromal depressive symptoms would be seen, for example, to have mania with mixed features. A patient with a depressive episode who presents with subsyndromal hypomanic symptoms would be seen to have depression with mixed features. Therefore, depression with mixed features can be present not only in MDD, but in both bipolar I and II.

New treatment algorithms

This dimensional approach of assessing mixed features along a continuum could lead to better and earlier diagnosis of bipolar depression and more targeted therapies, according to Dr. McIntyre. What he thinks it won’t do is lead to an overzealousness in the overdiagnosis of bipolar depression.

“That is false. We wouldn’t say we’re not going to diagnose bowel cancer because we hear it’s overdiagnosed. But to get the diagnoses right, what we need is fidelity to diagnostic criteria.”

Enter the state of Florida. As part of its best practices for psychotherapeutic use in adults, Florida is the first state to have published evidence-based guidelines for depression with mixed features. Dr. McIntyre is one of the guidelines’ coauthors.

Antidepressants bad, olanzapine worse

Some changes to treatment algorithms might come as a surprise. Despite being among the most commonly prescribed treatments for bipolar disorder, monotherapy with antidepressants is not approved in the guidelines. “Period,” said Dr. McIntyre. “Many patients do well on antidepressants, but the most common outcome is inefficacy.”

It might be better to combine an antidepressant with an atypical antipsychotic, or a mood stabilizer to avoid treatment-emergent mania, or, more commonly, destabilization in patients who are susceptible to subsyndromal mania, he said.

In addition to mitigating symptoms of a depressive episode, atypicals can help suppress hypomanic symptoms. Dr. McIntyre said this is critical to remember, because patients with these combinations of symptoms are “the very persons who shouldn’t get an antidepressant but are also the ones most likely to be prescribed them,” according to old ways of thinking.

As for maintenance in bipolar disorder, Dr. McIntyre believes the axiom, “What gets you well keeps you well,” is a good rule of thumb when going through the algorithm. “It’s not always true, but it’s almost always true.”

Management of MDD with mixed features includes the introduction of atypicals or mood stabilizers such as lithium or lamotrigine in patients with any prior history of hypomania or mania, something Dr. McIntyre said already is beginning to happen in practice.

Olanzapine monotherapy as a first-line treatment of bipolar disorder initially was “demoted” by Dr. McIntyre and his coauthors in Florida’s bipolar treatment guidelines. In the updated version, the atypical remains a second-line therapy behind lurasidone as the recommended first-line therapy because of olanzapine’s tendency to interfere with metabolic processes. Quetiapine also is a first-line therapy, but with the qualification that it, too, could interfere with metabolic processes. Combination therapy with olanzapine plus fluoxetine is second-line.

“Lurasidone does not have the metabolic changes of quetiapine. It doesn’t make sense to treat mania and then erase 25 years of a person’s life because of weight gain,” Dr. McIntyre said.

The average lifespan of people with bipolar disorder is about 20 years shorter than it is for those without serious mental illness.

Inflammation harms cognition

The changes are indicative of how seriously the field has begun to take metabolic disturbance as an adverse event in serious mental illness. Literature on obesity as a “psycho-toxin” is growing, and Dr. McIntyre is among the pioneers.

One study by Dr. McIntyre and his colleagues, currently in press, explores how obesity-related inflammation disturbs the brain’s dopamine system, resulting in interference with executive function. Because it is well established that people with bipolar disorder are more likely to be obese (J Affect Disord. 2008 Sep;110[1-2]:149-55), they also are more susceptible to cognitive impairment than are people of normal weight, according to Dr. McIntyre.

In a 2013 study, Dr. McIntyre and his colleagues showed that a first episode of mania in a person with obesity creates the same level of cognitive impairment as that found in the brains of normal-weight individuals who have experienced five episodes of mania (Psychological Med. 2014 Feb;44[3]:533-41). “There is something about obesity that is brain toxic,” he said.

Proof of concept of this is that cognitive outcomes for people before bariatric surgery are worse than postsurgery outcomes (Am J Surg. 2014 Jun;207[6]:870-6).

Systemic inflammation elevates levels of C-reactive protein, interleukin-1, and other cytokines, and interferes with insulin signaling; all have deleterious effects on cognition, as well as metabolic health. Those disturbances negatively affect emotional regulation, sleep, appetite, and sex drive, as well as executive function, he said.

“Inflammation is a convergent system, implicated across many brain- and body-based disorders. People with bipolar disorder not only have systemic increases in inflammation, but also neuroinflammation,” Dr. McIntyre said.

Accordingly, controlling inflammation becomes essential to chronic management of depression in general and bipolar in particular since, with each successive episode of untreated mania, patients’ ability to think clearly takes a hit. “Cognitive function is the principal determinant of psychosocial function, of workplace visibility, [and] of quality of life in most patient-reported outcomes,” Dr. McIntyre said.

Cognitive impairment also can lead to a worsening of the ability to balance reward and impulse control, leading to higher rates of substance abuse or other psychiatric comorbidities after onset of bipolar disease; a vicious cycle can ensue.

“As cognitive difficulties rise, comorbidities rise. But also, some of the comorbidities we see are reflections of cognitive impairment,” Dr. McIntyre said. To wit, binge eating disorder and bulimia nervosa are common in people with bipolar disorder (J Affect Disord. 2016 Feb;191:216-2).

Citing a recent scientific statement from the American Heart Association recommending that bipolar disorder and MDD should be considered tier II risk factors for cardiovascular disease among youth, the Florida guidelines urge clinicians to regularly screen patients for cardiometabolic disorders – not only for their medical implications but for their potential to flag emergent psychiatric issues.

Pharmacotherapeutics specifically targeting neuroinflammation are not yet ready for clinical practice, but Dr. McIntyre said other, more conventional therapies are available for bipolar disorder that have anti-inflammatory properties, including selective serotonin reuptake inhibitors and lithium. “Lithium is also anti-amyloid and has an anti-suicide effect. It is a drug I would definitely use as first line.”

Some behavioral therapies also are protective against inflammation and are recommended in the guidelines. Those include attention to sleep hygiene, diet, and exercise. “Social rhythm therapy is underutilized. These patients need their day organized. They need aerobics; they need sleep,” Dr. McIntyre said.

Future is now

Although the “whole-person” approach is still nascent – seeing depression as a collection of what Dr. McIntyre said are alterations in the neural circuitry amounting to a series of “disconnection syndromes” – psychiatry already has entered a new era where disease models are more comprehensive, he said.

This new way of thinking can connect the dots between why, for example, so many people with bipolar depression also have drug and alcohol abuse. It also could help explain why in bipolar there is so much obesity, or why there is so much anxiety, he said. “We’ve moved away from the rather silly, overly simplistic notions that you have too much or too little serotonin. Or that there was too much or too little dopamine causing mania. It made for convenient sound bytes, but it was probably just superstition we were gravitating to.”

The guidelines have been peer reviewed and will be published in the Journal of Clinical Psychiatry later this year, Dr. McIntyre said.

The meeting was held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

Dr. McIntyre disclosed that he has numerous industry relationships, including with AstraZeneca, Eli Lilly, Janssen Ortho, Lundbeck, Pfizer, and Shire.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – A sea change is underway in how major depressive and bipolar disorders are diagnosed and treated.

Historically, the absence of an accurate, comprehensive nosology of depression has led to much suffering and confusion. People with bipolar disorder in particular are either not diagnosed early enough or are not diagnosed with the correct “flavor” of depression, according to Roger S. McIntyre, MD, author of updated treatment guidelines for bipolar depression, and the first-ever treatment guidelines for mixed features in major depressive disorder. “Twenty years ago, we would have described bipolar as episodic breakthroughs of mania and depression, with well intervals in between,” Dr. McIntyre said at Summit in Neurology & Psychiatry. “But now, we’ve really changed our fundamental thinking about bipolar disorder.”

Although reasons for the evolution in thinking are many, one of the strongest currents of change flows from the 2013 publication of the DSM-5, according to Dr. McIntyre, professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at University Health Network in Toronto.

“The DSM-5’s authors took a neo-Kraepelinian view that mood disorders are dimensional,” Dr. McIntyre said in an interview. As a result, there’s been a reversal of what he called the “social construct imposed upon the cosmos of mood disorders by the DSM-III that divided that world into either depression or bipolar disorder.”

This return to thinking of mood disorders as existing on a continuum, as psychiatrist Emil Kraepelin, MD, theorized around the turn of the last century, pivots on the decision to do away with mixed states and to instead add the mixed features specifier.

“The move to mixed features is the necessary bridge between bipolar disease and major depressive disorder,” Dr. McIntyre said in the interview.

Therefore, for a period of time between the 1980 publication of the DSM-III and the DSM-5, “real-world” presentations of subsyndromal, opposite-pole symptoms that are common in major depressive disorder (MDD) and in bipolar disorder were not accounted for.

In practical terms, the addition of mixed features means that a patient with mania who presents with subsyndromal depressive symptoms would be seen, for example, to have mania with mixed features. A patient with a depressive episode who presents with subsyndromal hypomanic symptoms would be seen to have depression with mixed features. Therefore, depression with mixed features can be present not only in MDD, but in both bipolar I and II.

New treatment algorithms

This dimensional approach of assessing mixed features along a continuum could lead to better and earlier diagnosis of bipolar depression and more targeted therapies, according to Dr. McIntyre. What he thinks it won’t do is lead to an overzealousness in the overdiagnosis of bipolar depression.

“That is false. We wouldn’t say we’re not going to diagnose bowel cancer because we hear it’s overdiagnosed. But to get the diagnoses right, what we need is fidelity to diagnostic criteria.”

Enter the state of Florida. As part of its best practices for psychotherapeutic use in adults, Florida is the first state to have published evidence-based guidelines for depression with mixed features. Dr. McIntyre is one of the guidelines’ coauthors.

Antidepressants bad, olanzapine worse

Some changes to treatment algorithms might come as a surprise. Despite being among the most commonly prescribed treatments for bipolar disorder, monotherapy with antidepressants is not approved in the guidelines. “Period,” said Dr. McIntyre. “Many patients do well on antidepressants, but the most common outcome is inefficacy.”

It might be better to combine an antidepressant with an atypical antipsychotic, or a mood stabilizer to avoid treatment-emergent mania, or, more commonly, destabilization in patients who are susceptible to subsyndromal mania, he said.

In addition to mitigating symptoms of a depressive episode, atypicals can help suppress hypomanic symptoms. Dr. McIntyre said this is critical to remember, because patients with these combinations of symptoms are “the very persons who shouldn’t get an antidepressant but are also the ones most likely to be prescribed them,” according to old ways of thinking.

As for maintenance in bipolar disorder, Dr. McIntyre believes the axiom, “What gets you well keeps you well,” is a good rule of thumb when going through the algorithm. “It’s not always true, but it’s almost always true.”

Management of MDD with mixed features includes the introduction of atypicals or mood stabilizers such as lithium or lamotrigine in patients with any prior history of hypomania or mania, something Dr. McIntyre said already is beginning to happen in practice.

Olanzapine monotherapy as a first-line treatment of bipolar disorder initially was “demoted” by Dr. McIntyre and his coauthors in Florida’s bipolar treatment guidelines. In the updated version, the atypical remains a second-line therapy behind lurasidone as the recommended first-line therapy because of olanzapine’s tendency to interfere with metabolic processes. Quetiapine also is a first-line therapy, but with the qualification that it, too, could interfere with metabolic processes. Combination therapy with olanzapine plus fluoxetine is second-line.

“Lurasidone does not have the metabolic changes of quetiapine. It doesn’t make sense to treat mania and then erase 25 years of a person’s life because of weight gain,” Dr. McIntyre said.

The average lifespan of people with bipolar disorder is about 20 years shorter than it is for those without serious mental illness.

Inflammation harms cognition

The changes are indicative of how seriously the field has begun to take metabolic disturbance as an adverse event in serious mental illness. Literature on obesity as a “psycho-toxin” is growing, and Dr. McIntyre is among the pioneers.

One study by Dr. McIntyre and his colleagues, currently in press, explores how obesity-related inflammation disturbs the brain’s dopamine system, resulting in interference with executive function. Because it is well established that people with bipolar disorder are more likely to be obese (J Affect Disord. 2008 Sep;110[1-2]:149-55), they also are more susceptible to cognitive impairment than are people of normal weight, according to Dr. McIntyre.

In a 2013 study, Dr. McIntyre and his colleagues showed that a first episode of mania in a person with obesity creates the same level of cognitive impairment as that found in the brains of normal-weight individuals who have experienced five episodes of mania (Psychological Med. 2014 Feb;44[3]:533-41). “There is something about obesity that is brain toxic,” he said.

Proof of concept of this is that cognitive outcomes for people before bariatric surgery are worse than postsurgery outcomes (Am J Surg. 2014 Jun;207[6]:870-6).

Systemic inflammation elevates levels of C-reactive protein, interleukin-1, and other cytokines, and interferes with insulin signaling; all have deleterious effects on cognition, as well as metabolic health. Those disturbances negatively affect emotional regulation, sleep, appetite, and sex drive, as well as executive function, he said.

“Inflammation is a convergent system, implicated across many brain- and body-based disorders. People with bipolar disorder not only have systemic increases in inflammation, but also neuroinflammation,” Dr. McIntyre said.

Accordingly, controlling inflammation becomes essential to chronic management of depression in general and bipolar in particular since, with each successive episode of untreated mania, patients’ ability to think clearly takes a hit. “Cognitive function is the principal determinant of psychosocial function, of workplace visibility, [and] of quality of life in most patient-reported outcomes,” Dr. McIntyre said.

Cognitive impairment also can lead to a worsening of the ability to balance reward and impulse control, leading to higher rates of substance abuse or other psychiatric comorbidities after onset of bipolar disease; a vicious cycle can ensue.

“As cognitive difficulties rise, comorbidities rise. But also, some of the comorbidities we see are reflections of cognitive impairment,” Dr. McIntyre said. To wit, binge eating disorder and bulimia nervosa are common in people with bipolar disorder (J Affect Disord. 2016 Feb;191:216-2).

Citing a recent scientific statement from the American Heart Association recommending that bipolar disorder and MDD should be considered tier II risk factors for cardiovascular disease among youth, the Florida guidelines urge clinicians to regularly screen patients for cardiometabolic disorders – not only for their medical implications but for their potential to flag emergent psychiatric issues.

Pharmacotherapeutics specifically targeting neuroinflammation are not yet ready for clinical practice, but Dr. McIntyre said other, more conventional therapies are available for bipolar disorder that have anti-inflammatory properties, including selective serotonin reuptake inhibitors and lithium. “Lithium is also anti-amyloid and has an anti-suicide effect. It is a drug I would definitely use as first line.”

Some behavioral therapies also are protective against inflammation and are recommended in the guidelines. Those include attention to sleep hygiene, diet, and exercise. “Social rhythm therapy is underutilized. These patients need their day organized. They need aerobics; they need sleep,” Dr. McIntyre said.

Future is now

Although the “whole-person” approach is still nascent – seeing depression as a collection of what Dr. McIntyre said are alterations in the neural circuitry amounting to a series of “disconnection syndromes” – psychiatry already has entered a new era where disease models are more comprehensive, he said.

This new way of thinking can connect the dots between why, for example, so many people with bipolar depression also have drug and alcohol abuse. It also could help explain why in bipolar there is so much obesity, or why there is so much anxiety, he said. “We’ve moved away from the rather silly, overly simplistic notions that you have too much or too little serotonin. Or that there was too much or too little dopamine causing mania. It made for convenient sound bytes, but it was probably just superstition we were gravitating to.”

The guidelines have been peer reviewed and will be published in the Journal of Clinical Psychiatry later this year, Dr. McIntyre said.

The meeting was held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

Dr. McIntyre disclosed that he has numerous industry relationships, including with AstraZeneca, Eli Lilly, Janssen Ortho, Lundbeck, Pfizer, and Shire.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – A sea change is underway in how major depressive and bipolar disorders are diagnosed and treated.

Historically, the absence of an accurate, comprehensive nosology of depression has led to much suffering and confusion. People with bipolar disorder in particular are either not diagnosed early enough or are not diagnosed with the correct “flavor” of depression, according to Roger S. McIntyre, MD, author of updated treatment guidelines for bipolar depression, and the first-ever treatment guidelines for mixed features in major depressive disorder. “Twenty years ago, we would have described bipolar as episodic breakthroughs of mania and depression, with well intervals in between,” Dr. McIntyre said at Summit in Neurology & Psychiatry. “But now, we’ve really changed our fundamental thinking about bipolar disorder.”

Although reasons for the evolution in thinking are many, one of the strongest currents of change flows from the 2013 publication of the DSM-5, according to Dr. McIntyre, professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at University Health Network in Toronto.

“The DSM-5’s authors took a neo-Kraepelinian view that mood disorders are dimensional,” Dr. McIntyre said in an interview. As a result, there’s been a reversal of what he called the “social construct imposed upon the cosmos of mood disorders by the DSM-III that divided that world into either depression or bipolar disorder.”

This return to thinking of mood disorders as existing on a continuum, as psychiatrist Emil Kraepelin, MD, theorized around the turn of the last century, pivots on the decision to do away with mixed states and to instead add the mixed features specifier.

“The move to mixed features is the necessary bridge between bipolar disease and major depressive disorder,” Dr. McIntyre said in the interview.

Therefore, for a period of time between the 1980 publication of the DSM-III and the DSM-5, “real-world” presentations of subsyndromal, opposite-pole symptoms that are common in major depressive disorder (MDD) and in bipolar disorder were not accounted for.

In practical terms, the addition of mixed features means that a patient with mania who presents with subsyndromal depressive symptoms would be seen, for example, to have mania with mixed features. A patient with a depressive episode who presents with subsyndromal hypomanic symptoms would be seen to have depression with mixed features. Therefore, depression with mixed features can be present not only in MDD, but in both bipolar I and II.

New treatment algorithms

This dimensional approach of assessing mixed features along a continuum could lead to better and earlier diagnosis of bipolar depression and more targeted therapies, according to Dr. McIntyre. What he thinks it won’t do is lead to an overzealousness in the overdiagnosis of bipolar depression.

“That is false. We wouldn’t say we’re not going to diagnose bowel cancer because we hear it’s overdiagnosed. But to get the diagnoses right, what we need is fidelity to diagnostic criteria.”

Enter the state of Florida. As part of its best practices for psychotherapeutic use in adults, Florida is the first state to have published evidence-based guidelines for depression with mixed features. Dr. McIntyre is one of the guidelines’ coauthors.

Antidepressants bad, olanzapine worse

Some changes to treatment algorithms might come as a surprise. Despite being among the most commonly prescribed treatments for bipolar disorder, monotherapy with antidepressants is not approved in the guidelines. “Period,” said Dr. McIntyre. “Many patients do well on antidepressants, but the most common outcome is inefficacy.”

It might be better to combine an antidepressant with an atypical antipsychotic, or a mood stabilizer to avoid treatment-emergent mania, or, more commonly, destabilization in patients who are susceptible to subsyndromal mania, he said.

In addition to mitigating symptoms of a depressive episode, atypicals can help suppress hypomanic symptoms. Dr. McIntyre said this is critical to remember, because patients with these combinations of symptoms are “the very persons who shouldn’t get an antidepressant but are also the ones most likely to be prescribed them,” according to old ways of thinking.

As for maintenance in bipolar disorder, Dr. McIntyre believes the axiom, “What gets you well keeps you well,” is a good rule of thumb when going through the algorithm. “It’s not always true, but it’s almost always true.”

Management of MDD with mixed features includes the introduction of atypicals or mood stabilizers such as lithium or lamotrigine in patients with any prior history of hypomania or mania, something Dr. McIntyre said already is beginning to happen in practice.

Olanzapine monotherapy as a first-line treatment of bipolar disorder initially was “demoted” by Dr. McIntyre and his coauthors in Florida’s bipolar treatment guidelines. In the updated version, the atypical remains a second-line therapy behind lurasidone as the recommended first-line therapy because of olanzapine’s tendency to interfere with metabolic processes. Quetiapine also is a first-line therapy, but with the qualification that it, too, could interfere with metabolic processes. Combination therapy with olanzapine plus fluoxetine is second-line.

“Lurasidone does not have the metabolic changes of quetiapine. It doesn’t make sense to treat mania and then erase 25 years of a person’s life because of weight gain,” Dr. McIntyre said.

The average lifespan of people with bipolar disorder is about 20 years shorter than it is for those without serious mental illness.

Inflammation harms cognition

The changes are indicative of how seriously the field has begun to take metabolic disturbance as an adverse event in serious mental illness. Literature on obesity as a “psycho-toxin” is growing, and Dr. McIntyre is among the pioneers.

One study by Dr. McIntyre and his colleagues, currently in press, explores how obesity-related inflammation disturbs the brain’s dopamine system, resulting in interference with executive function. Because it is well established that people with bipolar disorder are more likely to be obese (J Affect Disord. 2008 Sep;110[1-2]:149-55), they also are more susceptible to cognitive impairment than are people of normal weight, according to Dr. McIntyre.

In a 2013 study, Dr. McIntyre and his colleagues showed that a first episode of mania in a person with obesity creates the same level of cognitive impairment as that found in the brains of normal-weight individuals who have experienced five episodes of mania (Psychological Med. 2014 Feb;44[3]:533-41). “There is something about obesity that is brain toxic,” he said.

Proof of concept of this is that cognitive outcomes for people before bariatric surgery are worse than postsurgery outcomes (Am J Surg. 2014 Jun;207[6]:870-6).

Systemic inflammation elevates levels of C-reactive protein, interleukin-1, and other cytokines, and interferes with insulin signaling; all have deleterious effects on cognition, as well as metabolic health. Those disturbances negatively affect emotional regulation, sleep, appetite, and sex drive, as well as executive function, he said.

“Inflammation is a convergent system, implicated across many brain- and body-based disorders. People with bipolar disorder not only have systemic increases in inflammation, but also neuroinflammation,” Dr. McIntyre said.

Accordingly, controlling inflammation becomes essential to chronic management of depression in general and bipolar in particular since, with each successive episode of untreated mania, patients’ ability to think clearly takes a hit. “Cognitive function is the principal determinant of psychosocial function, of workplace visibility, [and] of quality of life in most patient-reported outcomes,” Dr. McIntyre said.

Cognitive impairment also can lead to a worsening of the ability to balance reward and impulse control, leading to higher rates of substance abuse or other psychiatric comorbidities after onset of bipolar disease; a vicious cycle can ensue.

“As cognitive difficulties rise, comorbidities rise. But also, some of the comorbidities we see are reflections of cognitive impairment,” Dr. McIntyre said. To wit, binge eating disorder and bulimia nervosa are common in people with bipolar disorder (J Affect Disord. 2016 Feb;191:216-2).

Citing a recent scientific statement from the American Heart Association recommending that bipolar disorder and MDD should be considered tier II risk factors for cardiovascular disease among youth, the Florida guidelines urge clinicians to regularly screen patients for cardiometabolic disorders – not only for their medical implications but for their potential to flag emergent psychiatric issues.

Pharmacotherapeutics specifically targeting neuroinflammation are not yet ready for clinical practice, but Dr. McIntyre said other, more conventional therapies are available for bipolar disorder that have anti-inflammatory properties, including selective serotonin reuptake inhibitors and lithium. “Lithium is also anti-amyloid and has an anti-suicide effect. It is a drug I would definitely use as first line.”

Some behavioral therapies also are protective against inflammation and are recommended in the guidelines. Those include attention to sleep hygiene, diet, and exercise. “Social rhythm therapy is underutilized. These patients need their day organized. They need aerobics; they need sleep,” Dr. McIntyre said.

Future is now

Although the “whole-person” approach is still nascent – seeing depression as a collection of what Dr. McIntyre said are alterations in the neural circuitry amounting to a series of “disconnection syndromes” – psychiatry already has entered a new era where disease models are more comprehensive, he said.

This new way of thinking can connect the dots between why, for example, so many people with bipolar depression also have drug and alcohol abuse. It also could help explain why in bipolar there is so much obesity, or why there is so much anxiety, he said. “We’ve moved away from the rather silly, overly simplistic notions that you have too much or too little serotonin. Or that there was too much or too little dopamine causing mania. It made for convenient sound bytes, but it was probably just superstition we were gravitating to.”

The guidelines have been peer reviewed and will be published in the Journal of Clinical Psychiatry later this year, Dr. McIntyre said.

The meeting was held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

Dr. McIntyre disclosed that he has numerous industry relationships, including with AstraZeneca, Eli Lilly, Janssen Ortho, Lundbeck, Pfizer, and Shire.

[email protected]

On Twitter @whitneymcknight

Live attenuated influenza vaccine (LAIV) was no more effective than inactivated influenza vaccine (IIV) in small, compact, rural communities, according to Mark Loeb, MD, and his associates.

For the study, vaccinations were given to children aged 36 months to 15 years living in Hutterite colonies in Canada. Hutterite colonies are isolated, their residents live communally, and influenza is prevalent, making them suited for this cluster randomized trial.

Of the 1,186 children included in the study, mean coverage was 76.7% in the LAIV group, compared with 72.4% in the IIV group. Incidence of influenza was 5.3% in the LAIV group and 5.2% in the IIV group. Compared to IIV, the hazard ratio for LAIV for influenza A or B was 1.03.

Children vaccinated with LAIV were at a higher risk for influenza A (hazard ratio, 1.62), but were at lower risk for influenza B (HR, 0.66). Influenza attack rates were similar in children younger and older than 6 years old. Adverse reactions were more likely in the IIV group than in the LAIV group, but no serious adverse events were reported.

“Although influenza transmission networks in Hutterite communities may differ from that in other communities, there are no data to confirm this. In fact, there may be more variability in social networks between urban and rural communities – or even among various urban communities – than between Hutterite and other (rural) communities. Even if variability exists, if a clear benefit of LAIV over IIV in reducing influenza-associated illness cannot be detected in this setting it is unlikely to be seen in other communities,” the investigators noted.

Find the full study in Annals of Internal Medicine (doi: 10.7326/M16-0513).

[email protected]

Live attenuated influenza vaccine (LAIV) was no more effective than inactivated influenza vaccine (IIV) in small, compact, rural communities, according to Mark Loeb, MD, and his associates.

For the study, vaccinations were given to children aged 36 months to 15 years living in Hutterite colonies in Canada. Hutterite colonies are isolated, their residents live communally, and influenza is prevalent, making them suited for this cluster randomized trial.

Of the 1,186 children included in the study, mean coverage was 76.7% in the LAIV group, compared with 72.4% in the IIV group. Incidence of influenza was 5.3% in the LAIV group and 5.2% in the IIV group. Compared to IIV, the hazard ratio for LAIV for influenza A or B was 1.03.

Children vaccinated with LAIV were at a higher risk for influenza A (hazard ratio, 1.62), but were at lower risk for influenza B (HR, 0.66). Influenza attack rates were similar in children younger and older than 6 years old. Adverse reactions were more likely in the IIV group than in the LAIV group, but no serious adverse events were reported.

“Although influenza transmission networks in Hutterite communities may differ from that in other communities, there are no data to confirm this. In fact, there may be more variability in social networks between urban and rural communities – or even among various urban communities – than between Hutterite and other (rural) communities. Even if variability exists, if a clear benefit of LAIV over IIV in reducing influenza-associated illness cannot be detected in this setting it is unlikely to be seen in other communities,” the investigators noted.

Find the full study in Annals of Internal Medicine (doi: 10.7326/M16-0513).

[email protected]

Live attenuated influenza vaccine (LAIV) was no more effective than inactivated influenza vaccine (IIV) in small, compact, rural communities, according to Mark Loeb, MD, and his associates.

For the study, vaccinations were given to children aged 36 months to 15 years living in Hutterite colonies in Canada. Hutterite colonies are isolated, their residents live communally, and influenza is prevalent, making them suited for this cluster randomized trial.

Of the 1,186 children included in the study, mean coverage was 76.7% in the LAIV group, compared with 72.4% in the IIV group. Incidence of influenza was 5.3% in the LAIV group and 5.2% in the IIV group. Compared to IIV, the hazard ratio for LAIV for influenza A or B was 1.03.

Children vaccinated with LAIV were at a higher risk for influenza A (hazard ratio, 1.62), but were at lower risk for influenza B (HR, 0.66). Influenza attack rates were similar in children younger and older than 6 years old. Adverse reactions were more likely in the IIV group than in the LAIV group, but no serious adverse events were reported.

“Although influenza transmission networks in Hutterite communities may differ from that in other communities, there are no data to confirm this. In fact, there may be more variability in social networks between urban and rural communities – or even among various urban communities – than between Hutterite and other (rural) communities. Even if variability exists, if a clear benefit of LAIV over IIV in reducing influenza-associated illness cannot be detected in this setting it is unlikely to be seen in other communities,” the investigators noted.

Find the full study in Annals of Internal Medicine (doi: 10.7326/M16-0513).

[email protected]

Myth: Psoriasis Cannot Be Treated

At the Summer Meeting of the American Academy of Dermatology in Boston, Massachusetts (July 28-31, 2016), Dr. Alexa Kimball presented on dermatology research advances at the plenary session and referenced the revolution in psoriasis treatment that has been experienced in the last several years, noting that dermatologists previously were relegated to treating patients with tar treatments. Today, many options for the treatment of psoriasis exist, though the disease is not curable.

According to the Mayo Clinic, psoriasis treatment is aimed at stopping the skin cells from growing so quickly, which reduces inflammation and plaque formation, and removing scales and smoothing skin. It is important for patients to understand the different treatment options so that they are aware that a variety of therapies may be tried until the right regimen with the fewest potential side effects is found. Options include:

• Biologics: given by injection or intravenous infusion for moderate to severe psoriasis that has not responded to other treatments

• Experimental medications: new medications undergoing clinical trials

• Oral treatments: inhibit specific molecules associated with inflammation and can be taken by mouth rather than injection or infusion (eg, retinoids, methotrexate, cyclosporine)

• Phototherapy or other light therapy: involves exposing the skin to UV light on a regular basis and under medical supervision (eg, UVB phototherapy, narrowband UVB therapy, psoralen plus UVA, excimer laser)

• Systemics: given orally or by injection and work throughout the body for moderate to severe psoriasis

• Topicals: applied to the skin and typically used for mild to moderate psoriasis (eg, topical corticosteroids, vitamin D analogues, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, coal tar, moisturizers)

In a 2014 analysis of data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey of the National Center for Health Statistics, the frequency of phototherapy treatments for psoriasis significantly decreased from 1993 to 2010 (P<.001), while the frequency of biologics significantly increased, becoming the most frequently used treatment from 2008 to 2010 (P<.0001).

However, psoriasis has been noted to be undertreated. A 2007 survey of 1657 psoriasis patients (28% with severe disease and 41% with moderate disease) from the National Psoriasis Foundation contact database indicated that 39% of respondents with severe psoriasis and 37% with moderate psoriasis were not currently receiving any treatment. Among those receiving treatment, only 43% with severe psoriasis received either traditional systemic therapy, biologic therapy, or phototherapy.

Access to care and cost of treatment are some of the reasons why psoriasis may go untreated. In 2013 the National Psoriasis Foundation reported results of a survey of 5600 patients with psoriasis and psoriatic arthritis, which revealed that patients did not see a specialist (ie, dermatologist, rheumatologist) to treat their disease because they had given up on treatment (28%), it was too expensive (21%), or it was too much of a hassle (11%). Although approximately 91% of patients were covered by medical insurance, the majority spent more than $2500 per year in out-of-pocket costs for their disease.

Patient satisfaction with treatment also is a concern. A 2002 National Psoriasis Foundation survey reported that 33% of patients are unsatisfied with current treatments and 78% do not use more aggressive therapies to treat their disease because of their side effects and lack of effectiveness. The advent of biologic therapies and new oral treatments has afforded psoriasis patients the opportunity to have a frank discussion with their health care provider if they are not satisfied with treatment or are not seeing the type of improvement that would make a substantial impact on their quality of life. Additionally, over time skin may become resistant to various treatments. Therefore, open communication with psoriasis patients is key.

Expert Commentary

We are in the midst of a second revolution in the treatment of psoriasis. We have multiple new biologic and oral agents available for the treatment of this condition. In addition, there are a large number of treatments currently in development. Not only can psoriasis be treated, it can be treated highly effectively and safely.

—Jeffrey M. Weinberg, MD (New York, New York)

Myth: Psoriasis Cannot Be Treated

At the Summer Meeting of the American Academy of Dermatology in Boston, Massachusetts (July 28-31, 2016), Dr. Alexa Kimball presented on dermatology research advances at the plenary session and referenced the revolution in psoriasis treatment that has been experienced in the last several years, noting that dermatologists previously were relegated to treating patients with tar treatments. Today, many options for the treatment of psoriasis exist, though the disease is not curable.

According to the Mayo Clinic, psoriasis treatment is aimed at stopping the skin cells from growing so quickly, which reduces inflammation and plaque formation, and removing scales and smoothing skin. It is important for patients to understand the different treatment options so that they are aware that a variety of therapies may be tried until the right regimen with the fewest potential side effects is found. Options include:

• Biologics: given by injection or intravenous infusion for moderate to severe psoriasis that has not responded to other treatments

• Experimental medications: new medications undergoing clinical trials

• Oral treatments: inhibit specific molecules associated with inflammation and can be taken by mouth rather than injection or infusion (eg, retinoids, methotrexate, cyclosporine)

• Phototherapy or other light therapy: involves exposing the skin to UV light on a regular basis and under medical supervision (eg, UVB phototherapy, narrowband UVB therapy, psoralen plus UVA, excimer laser)

• Systemics: given orally or by injection and work throughout the body for moderate to severe psoriasis

• Topicals: applied to the skin and typically used for mild to moderate psoriasis (eg, topical corticosteroids, vitamin D analogues, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, coal tar, moisturizers)

In a 2014 analysis of data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey of the National Center for Health Statistics, the frequency of phototherapy treatments for psoriasis significantly decreased from 1993 to 2010 (P<.001), while the frequency of biologics significantly increased, becoming the most frequently used treatment from 2008 to 2010 (P<.0001).

However, psoriasis has been noted to be undertreated. A 2007 survey of 1657 psoriasis patients (28% with severe disease and 41% with moderate disease) from the National Psoriasis Foundation contact database indicated that 39% of respondents with severe psoriasis and 37% with moderate psoriasis were not currently receiving any treatment. Among those receiving treatment, only 43% with severe psoriasis received either traditional systemic therapy, biologic therapy, or phototherapy.

Access to care and cost of treatment are some of the reasons why psoriasis may go untreated. In 2013 the National Psoriasis Foundation reported results of a survey of 5600 patients with psoriasis and psoriatic arthritis, which revealed that patients did not see a specialist (ie, dermatologist, rheumatologist) to treat their disease because they had given up on treatment (28%), it was too expensive (21%), or it was too much of a hassle (11%). Although approximately 91% of patients were covered by medical insurance, the majority spent more than $2500 per year in out-of-pocket costs for their disease.

Patient satisfaction with treatment also is a concern. A 2002 National Psoriasis Foundation survey reported that 33% of patients are unsatisfied with current treatments and 78% do not use more aggressive therapies to treat their disease because of their side effects and lack of effectiveness. The advent of biologic therapies and new oral treatments has afforded psoriasis patients the opportunity to have a frank discussion with their health care provider if they are not satisfied with treatment or are not seeing the type of improvement that would make a substantial impact on their quality of life. Additionally, over time skin may become resistant to various treatments. Therefore, open communication with psoriasis patients is key.

Expert Commentary

We are in the midst of a second revolution in the treatment of psoriasis. We have multiple new biologic and oral agents available for the treatment of this condition. In addition, there are a large number of treatments currently in development. Not only can psoriasis be treated, it can be treated highly effectively and safely.

—Jeffrey M. Weinberg, MD (New York, New York)

Myth: Psoriasis Cannot Be Treated

At the Summer Meeting of the American Academy of Dermatology in Boston, Massachusetts (July 28-31, 2016), Dr. Alexa Kimball presented on dermatology research advances at the plenary session and referenced the revolution in psoriasis treatment that has been experienced in the last several years, noting that dermatologists previously were relegated to treating patients with tar treatments. Today, many options for the treatment of psoriasis exist, though the disease is not curable.

According to the Mayo Clinic, psoriasis treatment is aimed at stopping the skin cells from growing so quickly, which reduces inflammation and plaque formation, and removing scales and smoothing skin. It is important for patients to understand the different treatment options so that they are aware that a variety of therapies may be tried until the right regimen with the fewest potential side effects is found. Options include:

• Biologics: given by injection or intravenous infusion for moderate to severe psoriasis that has not responded to other treatments

• Experimental medications: new medications undergoing clinical trials

• Oral treatments: inhibit specific molecules associated with inflammation and can be taken by mouth rather than injection or infusion (eg, retinoids, methotrexate, cyclosporine)

• Phototherapy or other light therapy: involves exposing the skin to UV light on a regular basis and under medical supervision (eg, UVB phototherapy, narrowband UVB therapy, psoralen plus UVA, excimer laser)

• Systemics: given orally or by injection and work throughout the body for moderate to severe psoriasis

• Topicals: applied to the skin and typically used for mild to moderate psoriasis (eg, topical corticosteroids, vitamin D analogues, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, coal tar, moisturizers)

In a 2014 analysis of data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey of the National Center for Health Statistics, the frequency of phototherapy treatments for psoriasis significantly decreased from 1993 to 2010 (P<.001), while the frequency of biologics significantly increased, becoming the most frequently used treatment from 2008 to 2010 (P<.0001).

However, psoriasis has been noted to be undertreated. A 2007 survey of 1657 psoriasis patients (28% with severe disease and 41% with moderate disease) from the National Psoriasis Foundation contact database indicated that 39% of respondents with severe psoriasis and 37% with moderate psoriasis were not currently receiving any treatment. Among those receiving treatment, only 43% with severe psoriasis received either traditional systemic therapy, biologic therapy, or phototherapy.

Access to care and cost of treatment are some of the reasons why psoriasis may go untreated. In 2013 the National Psoriasis Foundation reported results of a survey of 5600 patients with psoriasis and psoriatic arthritis, which revealed that patients did not see a specialist (ie, dermatologist, rheumatologist) to treat their disease because they had given up on treatment (28%), it was too expensive (21%), or it was too much of a hassle (11%). Although approximately 91% of patients were covered by medical insurance, the majority spent more than $2500 per year in out-of-pocket costs for their disease.

Patient satisfaction with treatment also is a concern. A 2002 National Psoriasis Foundation survey reported that 33% of patients are unsatisfied with current treatments and 78% do not use more aggressive therapies to treat their disease because of their side effects and lack of effectiveness. The advent of biologic therapies and new oral treatments has afforded psoriasis patients the opportunity to have a frank discussion with their health care provider if they are not satisfied with treatment or are not seeing the type of improvement that would make a substantial impact on their quality of life. Additionally, over time skin may become resistant to various treatments. Therefore, open communication with psoriasis patients is key.

Expert Commentary

We are in the midst of a second revolution in the treatment of psoriasis. We have multiple new biologic and oral agents available for the treatment of this condition. In addition, there are a large number of treatments currently in development. Not only can psoriasis be treated, it can be treated highly effectively and safely.

—Jeffrey M. Weinberg, MD (New York, New York)

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.

Lasers

In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.^1,2 Ablative resurfacing lasers such as the CO₂ laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.^1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.³ With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.^1-3

Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.^1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.³ When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.^1-3 Some tattoo inks may paradoxically darken when treated with lasers.³ A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.^2,3

Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.^1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.^1-3 For all laser procedures, strict sun protection is advised before and after the procedure.

Chemical Peels

Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).⁴ Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.^4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.^4,5 Strict sun protection should be advised both before and after a chemical peel.

While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.⁴ Glycolic acid and SA are known to be safer for patients with skin of color.^4,5

Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.⁴ Skin of color may benefit from hydroquinone used before and after a chemical peel.⁵ At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.⁴ Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.

Final Thoughts

For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.

Lasers

In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.^1,2 Ablative resurfacing lasers such as the CO₂ laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.^1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.³ With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.^1-3

Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.^1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.³ When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.^1-3 Some tattoo inks may paradoxically darken when treated with lasers.³ A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.^2,3

Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.^1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.^1-3 For all laser procedures, strict sun protection is advised before and after the procedure.

Chemical Peels

Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).⁴ Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.^4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.^4,5 Strict sun protection should be advised both before and after a chemical peel.

While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.⁴ Glycolic acid and SA are known to be safer for patients with skin of color.^4,5

Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.⁴ Skin of color may benefit from hydroquinone used before and after a chemical peel.⁵ At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.⁴ Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.

Final Thoughts

For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.

Lasers

In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.^1,2 Ablative resurfacing lasers such as the CO₂ laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.^1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.³ With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.^1-3

Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.^1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.³ When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.^1-3 Some tattoo inks may paradoxically darken when treated with lasers.³ A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.^2,3

Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.^1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.^1-3 For all laser procedures, strict sun protection is advised before and after the procedure.

Chemical Peels

Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).⁴ Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.^4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.^4,5 Strict sun protection should be advised both before and after a chemical peel.

While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.⁴ Glycolic acid and SA are known to be safer for patients with skin of color.^4,5

Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.⁴ Skin of color may benefit from hydroquinone used before and after a chemical peel.⁵ At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.⁴ Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.

Final Thoughts

For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

HIPPA Identifiers

To maintain patient privacy when specific cases are referenced in an online or printed publication, HIPPA includes a list of 18 items that can identify an individual. These “HIPPA Identifiers,” listed below, must be omitted from any online medical discussions.7

1. Names
2. Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
3. Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers including license plate numbers and VINs
13. Device identifiers and serial numbers
14. URLs
15. IP addresses
16. Biometric identifiers, including finger and voice prints
17. Full face (or any comparable image) photographs
18. Any other unique identifying number, characteristic, or code

How Hospitalists Can Use Social Media to Improve Their Institution’s Care

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company that advises physicians about online promotion, sees social media as an opportunity for hospitalists to benefit their hospital in a number of ways.

“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”

According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.

Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH

—Maybelle Cowan-Lincoln

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

HIPPA Identifiers

To maintain patient privacy when specific cases are referenced in an online or printed publication, HIPPA includes a list of 18 items that can identify an individual. These “HIPPA Identifiers,” listed below, must be omitted from any online medical discussions.7

1. Names
2. Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
3. Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers including license plate numbers and VINs
13. Device identifiers and serial numbers
14. URLs
15. IP addresses
16. Biometric identifiers, including finger and voice prints
17. Full face (or any comparable image) photographs
18. Any other unique identifying number, characteristic, or code

How Hospitalists Can Use Social Media to Improve Their Institution’s Care

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company that advises physicians about online promotion, sees social media as an opportunity for hospitalists to benefit their hospital in a number of ways.

“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”

According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.

Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH

—Maybelle Cowan-Lincoln

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

HIPPA Identifiers

To maintain patient privacy when specific cases are referenced in an online or printed publication, HIPPA includes a list of 18 items that can identify an individual. These “HIPPA Identifiers,” listed below, must be omitted from any online medical discussions.7

1. Names
2. Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
3. Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers including license plate numbers and VINs
13. Device identifiers and serial numbers
14. URLs
15. IP addresses
16. Biometric identifiers, including finger and voice prints
17. Full face (or any comparable image) photographs
18. Any other unique identifying number, characteristic, or code

How Hospitalists Can Use Social Media to Improve Their Institution’s Care

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company that advises physicians about online promotion, sees social media as an opportunity for hospitalists to benefit their hospital in a number of ways.

“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”

According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.

Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH

—Maybelle Cowan-Lincoln

HHS Secretary Sylvia M. Burwell

The United States Department of Health and Human Services (HHS) has declared a public health emergency for Puerto Rico due to the Zika virus outbreak.

The declaration allows the federal government to provide support to the government of Puerto Rico to address the outbreak.

“This administration is committed to meeting the Zika outbreak in Puerto Rico with the necessary urgency,” said HHS Secretary Sylvia M. Burwell.

“This emergency declaration allows us to provide additional support to the Puerto Rican government and reminds us of the importance of pregnant women, women of child-bearing age, and their partners taking additional steps to protect themselves and their families from Zika.”

Through the public health emergency declaration, the government of Puerto Rico can:

• Apply for funding to hire and train unemployed workers to assist in vector control and outreach and education efforts through the US Department of Labor’s National Dislocated Worker Grant program
• Request the temporary reassignment of local public health department or agency personnel who are funded through Public Health Service Act programs in Puerto Rico to assist in the Zika response.

“The declaration made by HHS, which grants access to certain funds, is another example of collaboration between the federal government and the government of Puerto Rico,” said Alejandro García Padilla, governor of the Commonwealth of Puerto Rico.

In April, the HHS awarded $5 million to Puerto Rico health centers to fight the spread of the Zika virus. In March, the HHS shipped blood products to the island in response to the Zika outbreak.

Earlier this month, the US Centers for Disease Control and Prevention (CDC) awarded $16 million to US states and territories, including Puerto Rico, to fight the Zika virus. In July, the CDC awarded $25 million to US states, cities, and territories for the same purpose.

According to the Puerto Rico Department of Health, as of August 12, there have been 10,690 laboratory-confirmed cases of Zika in Puerto Rico, which includes 1035 pregnant women.

The actual number of people infected with Zika may be higher because most people with Zika infections have no symptoms and might not seek testing.

HHS Secretary Sylvia M. Burwell

The United States Department of Health and Human Services (HHS) has declared a public health emergency for Puerto Rico due to the Zika virus outbreak.

The declaration allows the federal government to provide support to the government of Puerto Rico to address the outbreak.

“This administration is committed to meeting the Zika outbreak in Puerto Rico with the necessary urgency,” said HHS Secretary Sylvia M. Burwell.

“This emergency declaration allows us to provide additional support to the Puerto Rican government and reminds us of the importance of pregnant women, women of child-bearing age, and their partners taking additional steps to protect themselves and their families from Zika.”

Through the public health emergency declaration, the government of Puerto Rico can:

• Apply for funding to hire and train unemployed workers to assist in vector control and outreach and education efforts through the US Department of Labor’s National Dislocated Worker Grant program
• Request the temporary reassignment of local public health department or agency personnel who are funded through Public Health Service Act programs in Puerto Rico to assist in the Zika response.

“The declaration made by HHS, which grants access to certain funds, is another example of collaboration between the federal government and the government of Puerto Rico,” said Alejandro García Padilla, governor of the Commonwealth of Puerto Rico.

In April, the HHS awarded $5 million to Puerto Rico health centers to fight the spread of the Zika virus. In March, the HHS shipped blood products to the island in response to the Zika outbreak.

Earlier this month, the US Centers for Disease Control and Prevention (CDC) awarded $16 million to US states and territories, including Puerto Rico, to fight the Zika virus. In July, the CDC awarded $25 million to US states, cities, and territories for the same purpose.

According to the Puerto Rico Department of Health, as of August 12, there have been 10,690 laboratory-confirmed cases of Zika in Puerto Rico, which includes 1035 pregnant women.

The actual number of people infected with Zika may be higher because most people with Zika infections have no symptoms and might not seek testing.

HHS Secretary Sylvia M. Burwell

The United States Department of Health and Human Services (HHS) has declared a public health emergency for Puerto Rico due to the Zika virus outbreak.

The declaration allows the federal government to provide support to the government of Puerto Rico to address the outbreak.

“This administration is committed to meeting the Zika outbreak in Puerto Rico with the necessary urgency,” said HHS Secretary Sylvia M. Burwell.

“This emergency declaration allows us to provide additional support to the Puerto Rican government and reminds us of the importance of pregnant women, women of child-bearing age, and their partners taking additional steps to protect themselves and their families from Zika.”

Through the public health emergency declaration, the government of Puerto Rico can:

• Apply for funding to hire and train unemployed workers to assist in vector control and outreach and education efforts through the US Department of Labor’s National Dislocated Worker Grant program
• Request the temporary reassignment of local public health department or agency personnel who are funded through Public Health Service Act programs in Puerto Rico to assist in the Zika response.

“The declaration made by HHS, which grants access to certain funds, is another example of collaboration between the federal government and the government of Puerto Rico,” said Alejandro García Padilla, governor of the Commonwealth of Puerto Rico.

In April, the HHS awarded $5 million to Puerto Rico health centers to fight the spread of the Zika virus. In March, the HHS shipped blood products to the island in response to the Zika outbreak.

Earlier this month, the US Centers for Disease Control and Prevention (CDC) awarded $16 million to US states and territories, including Puerto Rico, to fight the Zika virus. In July, the CDC awarded $25 million to US states, cities, and territories for the same purpose.

According to the Puerto Rico Department of Health, as of August 12, there have been 10,690 laboratory-confirmed cases of Zika in Puerto Rico, which includes 1035 pregnant women.

The actual number of people infected with Zika may be higher because most people with Zika infections have no symptoms and might not seek testing.

Micrograph showing CLL

New research explains how an inherited genetic variant associated with an increased risk of chronic lymphocytic leukemia (CLL) helps cancer cells survive.

Previous research showed that DNA variations at 15q15.1 are linked with an increased risk of CLL.

With the current study, researchers believe they have identified the causal variant at 15q15.1 and determined the mechanism by which it influences tumorigenesis.

Richard Houlston, MD, PhD, of The Institute of Cancer Research in London, UK, and his colleagues conducted this research and detailed the results in Cell Reports.

The researchers said the single nucleotide polymorphism rs539846 underlies the 15q15.1 CLL risk locus.

And the rs539846-A risk allele interferes with BCL-2 modifying factor (BMF), which normally works to produce pro-apoptotic signals.

This interference makes it harder for the protein RELA to “flip on” the activity of BMF and reduces levels of the pro-apoptotic signals, allowing CLL cells to sidestep self-destruction.

“Although many significant risk variants for this type of leukemia have been identified, the biological mechanisms through which these variants affect leukemia development have been less well studied,” Dr Houlston said.

“This study highlights the importance of cell-death-inducing proteins such as BMF in controlling CLL development and could help in the design of new drugs to treat this disease.”

In addition, Dr Houlston and his colleagues said their findings complement work from phase 1 and phase 2 trials of venetoclax (formerly ABT-199) in CLL.

The trials suggested that venetoclax mimics pro-apoptotic proteins by targeting the pro-survival BCL-2 pathway. In this way, the drug can produce anticancer effects in CLL patients.

Dr Houlston and his colleagues believe their discovery could provide important insight into how venetoclax and similar drugs work, which could optimize the drugs’ use.

Micrograph showing CLL

New research explains how an inherited genetic variant associated with an increased risk of chronic lymphocytic leukemia (CLL) helps cancer cells survive.

Previous research showed that DNA variations at 15q15.1 are linked with an increased risk of CLL.

With the current study, researchers believe they have identified the causal variant at 15q15.1 and determined the mechanism by which it influences tumorigenesis.

Richard Houlston, MD, PhD, of The Institute of Cancer Research in London, UK, and his colleagues conducted this research and detailed the results in Cell Reports.

The researchers said the single nucleotide polymorphism rs539846 underlies the 15q15.1 CLL risk locus.

And the rs539846-A risk allele interferes with BCL-2 modifying factor (BMF), which normally works to produce pro-apoptotic signals.

This interference makes it harder for the protein RELA to “flip on” the activity of BMF and reduces levels of the pro-apoptotic signals, allowing CLL cells to sidestep self-destruction.

“Although many significant risk variants for this type of leukemia have been identified, the biological mechanisms through which these variants affect leukemia development have been less well studied,” Dr Houlston said.

“This study highlights the importance of cell-death-inducing proteins such as BMF in controlling CLL development and could help in the design of new drugs to treat this disease.”

In addition, Dr Houlston and his colleagues said their findings complement work from phase 1 and phase 2 trials of venetoclax (formerly ABT-199) in CLL.

The trials suggested that venetoclax mimics pro-apoptotic proteins by targeting the pro-survival BCL-2 pathway. In this way, the drug can produce anticancer effects in CLL patients.

Dr Houlston and his colleagues believe their discovery could provide important insight into how venetoclax and similar drugs work, which could optimize the drugs’ use.

Micrograph showing CLL

New research explains how an inherited genetic variant associated with an increased risk of chronic lymphocytic leukemia (CLL) helps cancer cells survive.

Previous research showed that DNA variations at 15q15.1 are linked with an increased risk of CLL.

With the current study, researchers believe they have identified the causal variant at 15q15.1 and determined the mechanism by which it influences tumorigenesis.

Richard Houlston, MD, PhD, of The Institute of Cancer Research in London, UK, and his colleagues conducted this research and detailed the results in Cell Reports.

The researchers said the single nucleotide polymorphism rs539846 underlies the 15q15.1 CLL risk locus.

And the rs539846-A risk allele interferes with BCL-2 modifying factor (BMF), which normally works to produce pro-apoptotic signals.

This interference makes it harder for the protein RELA to “flip on” the activity of BMF and reduces levels of the pro-apoptotic signals, allowing CLL cells to sidestep self-destruction.

“Although many significant risk variants for this type of leukemia have been identified, the biological mechanisms through which these variants affect leukemia development have been less well studied,” Dr Houlston said.

“This study highlights the importance of cell-death-inducing proteins such as BMF in controlling CLL development and could help in the design of new drugs to treat this disease.”

In addition, Dr Houlston and his colleagues said their findings complement work from phase 1 and phase 2 trials of venetoclax (formerly ABT-199) in CLL.

The trials suggested that venetoclax mimics pro-apoptotic proteins by targeting the pro-survival BCL-2 pathway. In this way, the drug can produce anticancer effects in CLL patients.

Dr Houlston and his colleagues believe their discovery could provide important insight into how venetoclax and similar drugs work, which could optimize the drugs’ use.

Topical timolol maleate acts as an effective alternate to oral propranolol for treatment of certain infantile hemangiomas (IHs), based on data from a retrospective study of 731 children. The findings were published online August 15 in Pediatrics.

“Superficial, relatively thin IHs, regardless of pretreatment surface or body site, are likely to respond reasonably well to several months of treatment with modest, but definite improvements in color and size,” wrote Katherine Püttgen, MD, of Johns Hopkins University in Baltimore, Md., and colleagues in the Hemangioma Investigator Group (Pediatrics 2016;138:e20160355 [doi: 10.1052/peds.2016-0355]).

Courtesy CDC/Richard S. Hibbets

Although topical timolol maleate (TTM) has been used off label to treat infantile hemangiomas since 2010, “there is very limited information regarding off-label safety and pharmacokinetic data when used on hemangioma-affected skin,” the researchers noted.

The researchers reviewed data from 731 children treated at nine pediatric centers in the United States. Patients were treated for at least 30 days; the average treatment duration was 9 months. Most of the children (41%) began treatment between ages 0 and 3 months, and 86% were treatment naïve.

About 85% of the children received TTM 0.5% GFS (gel-forming solution), with parents instructed to apply 1 drop twice daily to the IH; 15% were prescribed 4 drops or more of TTM daily. Treatment response was assessed based on visual analog scales for color (VAS-C) and for size, extent, and volume (VAS-SEV).

Overall, 70% of children showed improvement of at least 10% from baseline on the VAS-C after 1-3 months of treatment, and 92% showed meaningful improvement from baseline after 6-9 months of treatment. VAS-SEV scores improved at least 10% from baseline in 39% of children after 1-3 months and meaningful improvement in 76% after 6-9 months.

Independent predictors of treatment success included longer treatment time and thinner, superficial IH at baseline.

Adverse events were observed in 3% of the patients, approximately half of which were reports of scaly skin. No patients discontinued the study because of adverse events, and no cardiovascular adverse events were reported.

The results were limited by several factors including the lack of controls and the retrospective nature of the study, the researchers noted. In addition, they cautioned against the use of However, the findings suggest that “TTM can be recommended as an initial, and often sole, treatment modality for many relatively superficial His without aggressive growth or threat of functional impairment,” they said. However, the researchers cautioned against TTM in cases of ulcerated IHs because of the potential for increased drug absorption.

Dr. Püttgen and several coauthors disclosed serving as consultants to Pierre Fabre.

Topical timolol maleate acts as an effective alternate to oral propranolol for treatment of certain infantile hemangiomas (IHs), based on data from a retrospective study of 731 children. The findings were published online August 15 in Pediatrics.

“Superficial, relatively thin IHs, regardless of pretreatment surface or body site, are likely to respond reasonably well to several months of treatment with modest, but definite improvements in color and size,” wrote Katherine Püttgen, MD, of Johns Hopkins University in Baltimore, Md., and colleagues in the Hemangioma Investigator Group (Pediatrics 2016;138:e20160355 [doi: 10.1052/peds.2016-0355]).

Courtesy CDC/Richard S. Hibbets

Although topical timolol maleate (TTM) has been used off label to treat infantile hemangiomas since 2010, “there is very limited information regarding off-label safety and pharmacokinetic data when used on hemangioma-affected skin,” the researchers noted.

The researchers reviewed data from 731 children treated at nine pediatric centers in the United States. Patients were treated for at least 30 days; the average treatment duration was 9 months. Most of the children (41%) began treatment between ages 0 and 3 months, and 86% were treatment naïve.

About 85% of the children received TTM 0.5% GFS (gel-forming solution), with parents instructed to apply 1 drop twice daily to the IH; 15% were prescribed 4 drops or more of TTM daily. Treatment response was assessed based on visual analog scales for color (VAS-C) and for size, extent, and volume (VAS-SEV).

Overall, 70% of children showed improvement of at least 10% from baseline on the VAS-C after 1-3 months of treatment, and 92% showed meaningful improvement from baseline after 6-9 months of treatment. VAS-SEV scores improved at least 10% from baseline in 39% of children after 1-3 months and meaningful improvement in 76% after 6-9 months.

Independent predictors of treatment success included longer treatment time and thinner, superficial IH at baseline.

Adverse events were observed in 3% of the patients, approximately half of which were reports of scaly skin. No patients discontinued the study because of adverse events, and no cardiovascular adverse events were reported.

The results were limited by several factors including the lack of controls and the retrospective nature of the study, the researchers noted. In addition, they cautioned against the use of However, the findings suggest that “TTM can be recommended as an initial, and often sole, treatment modality for many relatively superficial His without aggressive growth or threat of functional impairment,” they said. However, the researchers cautioned against TTM in cases of ulcerated IHs because of the potential for increased drug absorption.

Dr. Püttgen and several coauthors disclosed serving as consultants to Pierre Fabre.

Topical timolol maleate acts as an effective alternate to oral propranolol for treatment of certain infantile hemangiomas (IHs), based on data from a retrospective study of 731 children. The findings were published online August 15 in Pediatrics.

“Superficial, relatively thin IHs, regardless of pretreatment surface or body site, are likely to respond reasonably well to several months of treatment with modest, but definite improvements in color and size,” wrote Katherine Püttgen, MD, of Johns Hopkins University in Baltimore, Md., and colleagues in the Hemangioma Investigator Group (Pediatrics 2016;138:e20160355 [doi: 10.1052/peds.2016-0355]).

Courtesy CDC/Richard S. Hibbets

Although topical timolol maleate (TTM) has been used off label to treat infantile hemangiomas since 2010, “there is very limited information regarding off-label safety and pharmacokinetic data when used on hemangioma-affected skin,” the researchers noted.

The researchers reviewed data from 731 children treated at nine pediatric centers in the United States. Patients were treated for at least 30 days; the average treatment duration was 9 months. Most of the children (41%) began treatment between ages 0 and 3 months, and 86% were treatment naïve.

About 85% of the children received TTM 0.5% GFS (gel-forming solution), with parents instructed to apply 1 drop twice daily to the IH; 15% were prescribed 4 drops or more of TTM daily. Treatment response was assessed based on visual analog scales for color (VAS-C) and for size, extent, and volume (VAS-SEV).

Overall, 70% of children showed improvement of at least 10% from baseline on the VAS-C after 1-3 months of treatment, and 92% showed meaningful improvement from baseline after 6-9 months of treatment. VAS-SEV scores improved at least 10% from baseline in 39% of children after 1-3 months and meaningful improvement in 76% after 6-9 months.

Independent predictors of treatment success included longer treatment time and thinner, superficial IH at baseline.

Adverse events were observed in 3% of the patients, approximately half of which were reports of scaly skin. No patients discontinued the study because of adverse events, and no cardiovascular adverse events were reported.

The results were limited by several factors including the lack of controls and the retrospective nature of the study, the researchers noted. In addition, they cautioned against the use of However, the findings suggest that “TTM can be recommended as an initial, and often sole, treatment modality for many relatively superficial His without aggressive growth or threat of functional impairment,” they said. However, the researchers cautioned against TTM in cases of ulcerated IHs because of the potential for increased drug absorption.

Dr. Püttgen and several coauthors disclosed serving as consultants to Pierre Fabre.

NATIONAL HARBOR, MD – “Specialties are like species,” said Frank J. Veith, MD, “they must evolve or go extinct.”

Dr. Veith of the New York University Langone Medical Center made this comparison in his 2016 Homans Lecture on the topic of “The future of vascular surgery,” at this year’s annual meeting hosted by the Society for Vascular Surgery.

©Martin Allred

Dr. Veith reviewed the history of vascular surgery, touched on its present status, and speculated on its potentially bright future. The vascular specialty has evolved dramatically over the past decades, especially in the area of embracing the endovascular revolution, said Dr. Veith, with that revolution putting vascular surgery at the forefront of research to develop new techniques.

His witnessing such innovations as those developed by Dr. Juan Parodi, and being a part of the early history of endovascular surgery, convinced Dr. Veith of its long-term importance to the development and survival of the specialty.

In his 1996 SVS Presidential Address, he predicted that 40%-70% of the open operations being done then would be replaced by endovascular procedures. “Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them.” Dr. Veith added that, although his recommendation was not greeted with open arms by everyone, endovascular techniques moved forward.

In fact, “vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care,” he said.

Dr. Veith pointed out that a wide variety of conditions are now amenable to endovascular treatment, although some, including carotid disease, remain controversial. He listed examples of those conditions that he felt were still best treated with open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu’s lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower-extremity lesion, some carotid lesions, and some failed endovascular treatments.

“Our specialty has embraced the endovascular revolution and become endocompetent,” he said. “It is why vascular surgery is doing as well as it is today.” He added. “Vascular surgery is presently an exciting, vibrant specialty in the United States.”

Dr. Veith noted, “Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart – whether that treatment be medical, endovascular, or open. There are abundant numbers of patients who require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.”

However, despite the fact vascular surgery is an exciting and vibrant specialty, and the best for treating vascular disease outside of the heart and the brain, the vascular specialty has significant problems competing with other specialties, he said.

He blamed in part the size and structure of the specialty, in particular with regard to its competition.

“Vascular surgery competes, as it always has, with general and cardiac surgeons. However, general surgeons have become less competitive, but cardiac surgeons have become more in need of work, and thus more active beyond the heart and thoracic aorta – as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology.”

He outlined a number of major challenges these other disciplines create, in part, because of the DRG/RVU/dollar orientation of institutions, and the fact that most institutions still consider vascular surgery a subspecialty of general or cardiac surgery, or a subordinate part of a Heart & Vascular Center, with administrative control of these centers rarely in the hands of vascular surgeons. Moreover, when institutional resources – like angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon – or worse a cardiologist,” he added.

He stated that these conditions limit vascular surgery’s ability to get its fair share of institutional resources.

“The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive,” he stated.

“To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions,” Dr. Veith advised.

In discussing the technological future, Dr. Veith said that by 2026, 75%-95% of all vascular cases requiring more than medical therapy will be treated endovascularly, with perhaps 5% in a hybrid fashion (open plus endovascular), and between 5% and 15% being treated fully by open surgery. This shift away from open surgery is and will continue to cause challenges in training and patient access to open treatment.

He asked the question: How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them?

“One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training,” he answered.

But the technological future he painted was bright. Not only was the future likely to be filled with new advances in medical therapy, but he also highlighted computer-assisted 3-D–device navigational tools to aid endovascular treatment; advances in robotic guidance to decrease radiation exposure and facilitate device placement; computer-enhanced simulation to improve training and, when patient specific, to allow procedure planning and rehearsal; and even 3-D printed modeling of lesions and blood vessels.

He predicted that the endovascular problems of intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds – once the best way of getting the best drug to the proper location is found – and that computer-enabled remote monitoring of flows within grafts and stents, perhaps using miniaturized piezoelectric sensors, will allow corrective treatment before occlusion occurs.

Dr. Veith stated that, in his view, to take its proper place, vascular surgery should rise above its subspecialty status in the shadow of general surgery and in its competition with cardiology.

This “will help vascular surgery to flourish and be recognized as the main specialty devoted to patients with noncardiac vascular diseases. Vascular surgery can then fulfill its potential for a brighter future. More importantly, patients and society will be the ultimate beneficiaries,” he concluded.

Dr. Veith reported that he had no conflicts to disclose with regard to his remarks.

[email protected]

On Twitter @VascularTweets

NATIONAL HARBOR, MD – “Specialties are like species,” said Frank J. Veith, MD, “they must evolve or go extinct.”

Dr. Veith of the New York University Langone Medical Center made this comparison in his 2016 Homans Lecture on the topic of “The future of vascular surgery,” at this year’s annual meeting hosted by the Society for Vascular Surgery.

©Martin Allred

Dr. Veith reviewed the history of vascular surgery, touched on its present status, and speculated on its potentially bright future. The vascular specialty has evolved dramatically over the past decades, especially in the area of embracing the endovascular revolution, said Dr. Veith, with that revolution putting vascular surgery at the forefront of research to develop new techniques.

His witnessing such innovations as those developed by Dr. Juan Parodi, and being a part of the early history of endovascular surgery, convinced Dr. Veith of its long-term importance to the development and survival of the specialty.

In his 1996 SVS Presidential Address, he predicted that 40%-70% of the open operations being done then would be replaced by endovascular procedures. “Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them.” Dr. Veith added that, although his recommendation was not greeted with open arms by everyone, endovascular techniques moved forward.

In fact, “vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care,” he said.

Dr. Veith pointed out that a wide variety of conditions are now amenable to endovascular treatment, although some, including carotid disease, remain controversial. He listed examples of those conditions that he felt were still best treated with open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu’s lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower-extremity lesion, some carotid lesions, and some failed endovascular treatments.

“Our specialty has embraced the endovascular revolution and become endocompetent,” he said. “It is why vascular surgery is doing as well as it is today.” He added. “Vascular surgery is presently an exciting, vibrant specialty in the United States.”

Dr. Veith noted, “Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart – whether that treatment be medical, endovascular, or open. There are abundant numbers of patients who require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.”

However, despite the fact vascular surgery is an exciting and vibrant specialty, and the best for treating vascular disease outside of the heart and the brain, the vascular specialty has significant problems competing with other specialties, he said.

He blamed in part the size and structure of the specialty, in particular with regard to its competition.

“Vascular surgery competes, as it always has, with general and cardiac surgeons. However, general surgeons have become less competitive, but cardiac surgeons have become more in need of work, and thus more active beyond the heart and thoracic aorta – as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology.”

He outlined a number of major challenges these other disciplines create, in part, because of the DRG/RVU/dollar orientation of institutions, and the fact that most institutions still consider vascular surgery a subspecialty of general or cardiac surgery, or a subordinate part of a Heart & Vascular Center, with administrative control of these centers rarely in the hands of vascular surgeons. Moreover, when institutional resources – like angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon – or worse a cardiologist,” he added.

He stated that these conditions limit vascular surgery’s ability to get its fair share of institutional resources.

“The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive,” he stated.

“To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions,” Dr. Veith advised.

In discussing the technological future, Dr. Veith said that by 2026, 75%-95% of all vascular cases requiring more than medical therapy will be treated endovascularly, with perhaps 5% in a hybrid fashion (open plus endovascular), and between 5% and 15% being treated fully by open surgery. This shift away from open surgery is and will continue to cause challenges in training and patient access to open treatment.

He asked the question: How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them?

“One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training,” he answered.

But the technological future he painted was bright. Not only was the future likely to be filled with new advances in medical therapy, but he also highlighted computer-assisted 3-D–device navigational tools to aid endovascular treatment; advances in robotic guidance to decrease radiation exposure and facilitate device placement; computer-enhanced simulation to improve training and, when patient specific, to allow procedure planning and rehearsal; and even 3-D printed modeling of lesions and blood vessels.

He predicted that the endovascular problems of intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds – once the best way of getting the best drug to the proper location is found – and that computer-enabled remote monitoring of flows within grafts and stents, perhaps using miniaturized piezoelectric sensors, will allow corrective treatment before occlusion occurs.

Dr. Veith stated that, in his view, to take its proper place, vascular surgery should rise above its subspecialty status in the shadow of general surgery and in its competition with cardiology.

This “will help vascular surgery to flourish and be recognized as the main specialty devoted to patients with noncardiac vascular diseases. Vascular surgery can then fulfill its potential for a brighter future. More importantly, patients and society will be the ultimate beneficiaries,” he concluded.

Dr. Veith reported that he had no conflicts to disclose with regard to his remarks.

[email protected]

On Twitter @VascularTweets

NATIONAL HARBOR, MD – “Specialties are like species,” said Frank J. Veith, MD, “they must evolve or go extinct.”

Dr. Veith of the New York University Langone Medical Center made this comparison in his 2016 Homans Lecture on the topic of “The future of vascular surgery,” at this year’s annual meeting hosted by the Society for Vascular Surgery.

©Martin Allred

Dr. Veith reviewed the history of vascular surgery, touched on its present status, and speculated on its potentially bright future. The vascular specialty has evolved dramatically over the past decades, especially in the area of embracing the endovascular revolution, said Dr. Veith, with that revolution putting vascular surgery at the forefront of research to develop new techniques.

His witnessing such innovations as those developed by Dr. Juan Parodi, and being a part of the early history of endovascular surgery, convinced Dr. Veith of its long-term importance to the development and survival of the specialty.

In his 1996 SVS Presidential Address, he predicted that 40%-70% of the open operations being done then would be replaced by endovascular procedures. “Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them.” Dr. Veith added that, although his recommendation was not greeted with open arms by everyone, endovascular techniques moved forward.

In fact, “vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care,” he said.

Dr. Veith pointed out that a wide variety of conditions are now amenable to endovascular treatment, although some, including carotid disease, remain controversial. He listed examples of those conditions that he felt were still best treated with open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu’s lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower-extremity lesion, some carotid lesions, and some failed endovascular treatments.

“Our specialty has embraced the endovascular revolution and become endocompetent,” he said. “It is why vascular surgery is doing as well as it is today.” He added. “Vascular surgery is presently an exciting, vibrant specialty in the United States.”

Dr. Veith noted, “Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart – whether that treatment be medical, endovascular, or open. There are abundant numbers of patients who require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.”

However, despite the fact vascular surgery is an exciting and vibrant specialty, and the best for treating vascular disease outside of the heart and the brain, the vascular specialty has significant problems competing with other specialties, he said.

He blamed in part the size and structure of the specialty, in particular with regard to its competition.

“Vascular surgery competes, as it always has, with general and cardiac surgeons. However, general surgeons have become less competitive, but cardiac surgeons have become more in need of work, and thus more active beyond the heart and thoracic aorta – as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology.”

He outlined a number of major challenges these other disciplines create, in part, because of the DRG/RVU/dollar orientation of institutions, and the fact that most institutions still consider vascular surgery a subspecialty of general or cardiac surgery, or a subordinate part of a Heart & Vascular Center, with administrative control of these centers rarely in the hands of vascular surgeons. Moreover, when institutional resources – like angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon – or worse a cardiologist,” he added.

He stated that these conditions limit vascular surgery’s ability to get its fair share of institutional resources.

“The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive,” he stated.

“To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions,” Dr. Veith advised.

In discussing the technological future, Dr. Veith said that by 2026, 75%-95% of all vascular cases requiring more than medical therapy will be treated endovascularly, with perhaps 5% in a hybrid fashion (open plus endovascular), and between 5% and 15% being treated fully by open surgery. This shift away from open surgery is and will continue to cause challenges in training and patient access to open treatment.

He asked the question: How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them?

“One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training,” he answered.

But the technological future he painted was bright. Not only was the future likely to be filled with new advances in medical therapy, but he also highlighted computer-assisted 3-D–device navigational tools to aid endovascular treatment; advances in robotic guidance to decrease radiation exposure and facilitate device placement; computer-enhanced simulation to improve training and, when patient specific, to allow procedure planning and rehearsal; and even 3-D printed modeling of lesions and blood vessels.

He predicted that the endovascular problems of intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds – once the best way of getting the best drug to the proper location is found – and that computer-enabled remote monitoring of flows within grafts and stents, perhaps using miniaturized piezoelectric sensors, will allow corrective treatment before occlusion occurs.

Dr. Veith stated that, in his view, to take its proper place, vascular surgery should rise above its subspecialty status in the shadow of general surgery and in its competition with cardiology.

This “will help vascular surgery to flourish and be recognized as the main specialty devoted to patients with noncardiac vascular diseases. Vascular surgery can then fulfill its potential for a brighter future. More importantly, patients and society will be the ultimate beneficiaries,” he concluded.

Dr. Veith reported that he had no conflicts to disclose with regard to his remarks.

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