What does your patient need to know at the first visit? Does it apply to all patients?

All patients should have a total-body skin examination at least once per year; however, the frequency may change based on a prior history of melanoma or skin cancer, number of nevi or dysplastic nevi, and a family history of melanoma.

Patients should be completely undressed, and all nail polish or artificial nails should be removed prior to the examination. A complete cutaneous examination involves inspecting all skin surfaces, scalp, ocular and oral mucosa, fingernails/toenails, and genitalia if the patient agrees. Melanoma can occur in non–UV-exposed areas and the patient should be educated. Explain the ABCDEs of melanoma diagnosis to all patients and discuss concerns of any new or changing lesions, pigmented or not.

The patient should be made aware that a series of digital images will be taken for any suspicious lesions for possible short-term monitoring. The patient also may be offered full-body photography or 3D body imaging if the number of nevi warrants it.

Different patient populations have different risks for melanoma. Although melanoma predominately afflicts patients with a light skin type, there are certain types of melanoma, such as acral melanoma, that can be more common in darker skin types.

If a patient has a history of cutaneous melanoma, then the site should be checked for any local recurrence as well as palpation of the draining lymph nodes and regional lymph nodes.

I also let patients know that I will be using tools such as dermoscopy and/or reflectance confocal microscopy to better diagnose equivocal lesions before pursuing a biopsy. A biopsy may be done if there is a level of suspicion for atypia.

The use of dermoscopy, digital imaging, and reflectance confocal microscopy has changed the way we can detect, monitor, and evaluate atypical nevi. These tools can augment practice and possibly cut down on the rate of biopsies. They also are great for equivocal lesions or lesions that are in cosmetically sensitive areas. I use these tools in my everyday practice.

How do you keep patients compliant?

Empowering patients to perform self-examinations as well as examinations with his/her partner may help to reinforce monitoring by a dermatologist.

Provide patients with reading materials on self-examination while they wait in the office for your examination.

What do you do if they refuse treatment?

If patients defer a full-body skin examination, then I try to educate them about risks for UV exposure and the risk factors for both melanoma and nonmelanoma skin cancer. I also provide information on self-examinations so they can check at home for any irregularly shaped or changing moles.

What resources do you recommend to patients for more information?

It is important for patients to understand the risk factors for melanoma and the long-term prognosis of melanoma. I direct them to the American Academy of Dermatology’s website (http://www.AAD.org) for education and background about melanoma. Also, the Skin Cancer Foundation has inspiring patient stories (http://www.SkinCancer.org).

What does your patient need to know at the first visit? Does it apply to all patients?

All patients should have a total-body skin examination at least once per year; however, the frequency may change based on a prior history of melanoma or skin cancer, number of nevi or dysplastic nevi, and a family history of melanoma.

Patients should be completely undressed, and all nail polish or artificial nails should be removed prior to the examination. A complete cutaneous examination involves inspecting all skin surfaces, scalp, ocular and oral mucosa, fingernails/toenails, and genitalia if the patient agrees. Melanoma can occur in non–UV-exposed areas and the patient should be educated. Explain the ABCDEs of melanoma diagnosis to all patients and discuss concerns of any new or changing lesions, pigmented or not.

The patient should be made aware that a series of digital images will be taken for any suspicious lesions for possible short-term monitoring. The patient also may be offered full-body photography or 3D body imaging if the number of nevi warrants it.

Different patient populations have different risks for melanoma. Although melanoma predominately afflicts patients with a light skin type, there are certain types of melanoma, such as acral melanoma, that can be more common in darker skin types.

If a patient has a history of cutaneous melanoma, then the site should be checked for any local recurrence as well as palpation of the draining lymph nodes and regional lymph nodes.

I also let patients know that I will be using tools such as dermoscopy and/or reflectance confocal microscopy to better diagnose equivocal lesions before pursuing a biopsy. A biopsy may be done if there is a level of suspicion for atypia.

The use of dermoscopy, digital imaging, and reflectance confocal microscopy has changed the way we can detect, monitor, and evaluate atypical nevi. These tools can augment practice and possibly cut down on the rate of biopsies. They also are great for equivocal lesions or lesions that are in cosmetically sensitive areas. I use these tools in my everyday practice.

How do you keep patients compliant?

Empowering patients to perform self-examinations as well as examinations with his/her partner may help to reinforce monitoring by a dermatologist.

Provide patients with reading materials on self-examination while they wait in the office for your examination.

What do you do if they refuse treatment?

If patients defer a full-body skin examination, then I try to educate them about risks for UV exposure and the risk factors for both melanoma and nonmelanoma skin cancer. I also provide information on self-examinations so they can check at home for any irregularly shaped or changing moles.

What resources do you recommend to patients for more information?

It is important for patients to understand the risk factors for melanoma and the long-term prognosis of melanoma. I direct them to the American Academy of Dermatology’s website (http://www.AAD.org) for education and background about melanoma. Also, the Skin Cancer Foundation has inspiring patient stories (http://www.SkinCancer.org).

What does your patient need to know at the first visit? Does it apply to all patients?

All patients should have a total-body skin examination at least once per year; however, the frequency may change based on a prior history of melanoma or skin cancer, number of nevi or dysplastic nevi, and a family history of melanoma.

Patients should be completely undressed, and all nail polish or artificial nails should be removed prior to the examination. A complete cutaneous examination involves inspecting all skin surfaces, scalp, ocular and oral mucosa, fingernails/toenails, and genitalia if the patient agrees. Melanoma can occur in non–UV-exposed areas and the patient should be educated. Explain the ABCDEs of melanoma diagnosis to all patients and discuss concerns of any new or changing lesions, pigmented or not.

The patient should be made aware that a series of digital images will be taken for any suspicious lesions for possible short-term monitoring. The patient also may be offered full-body photography or 3D body imaging if the number of nevi warrants it.

Different patient populations have different risks for melanoma. Although melanoma predominately afflicts patients with a light skin type, there are certain types of melanoma, such as acral melanoma, that can be more common in darker skin types.

If a patient has a history of cutaneous melanoma, then the site should be checked for any local recurrence as well as palpation of the draining lymph nodes and regional lymph nodes.

I also let patients know that I will be using tools such as dermoscopy and/or reflectance confocal microscopy to better diagnose equivocal lesions before pursuing a biopsy. A biopsy may be done if there is a level of suspicion for atypia.

The use of dermoscopy, digital imaging, and reflectance confocal microscopy has changed the way we can detect, monitor, and evaluate atypical nevi. These tools can augment practice and possibly cut down on the rate of biopsies. They also are great for equivocal lesions or lesions that are in cosmetically sensitive areas. I use these tools in my everyday practice.

How do you keep patients compliant?

Empowering patients to perform self-examinations as well as examinations with his/her partner may help to reinforce monitoring by a dermatologist.

Provide patients with reading materials on self-examination while they wait in the office for your examination.

What do you do if they refuse treatment?

If patients defer a full-body skin examination, then I try to educate them about risks for UV exposure and the risk factors for both melanoma and nonmelanoma skin cancer. I also provide information on self-examinations so they can check at home for any irregularly shaped or changing moles.

What resources do you recommend to patients for more information?

It is important for patients to understand the risk factors for melanoma and the long-term prognosis of melanoma. I direct them to the American Academy of Dermatology’s website (http://www.AAD.org) for education and background about melanoma. Also, the Skin Cancer Foundation has inspiring patient stories (http://www.SkinCancer.org).

CHICAGO – After 2 years of maintenance immunotherapy with rituximab, elderly patients with chronic lymphocytic leukemia had better rates of progression-free survival than did patients in an observation group, based on results of the CLL 2007 SA trial from the French FILO (French Innovative Leukemia Organisation) Group.

The two groups did not significantly differ in overall survival, however, with 92.6% estimated 3-year overall survival in the rituximab group and 87.2% in the observation group. Further, the patients given rituximab had more adverse events, based on data presented by Dr. Caroline Dartigeas of the University Hospital in Tours, France, at the annual meeting of the American Society of Clinical Oncology.

Mary Jo Dales/Frontline Medical News

Given the cost and risk for events with rituximab, the findings raise the question of whether there are any meaningful benefits for maintenance rituximab after induction therapy, Dr. Jonathan W. Friedberg of the University of Rochester, N.Y., who was the discussant of the paper, remarked after the presentation. He asked whether there is any evidence that patients feel better if they’re in remission and, thus, their quality of life is improved.

The study included fit, treatment-naive patients aged 65 years and older with B-cell CLL who lacked del17p. Median patient age was 71.3 years, and two-thirds of the patients were men.

Patients received four cycles of induction therapy with fludarabine, cyclophosphamide, and rituximab on a shortened schedule chosen to reduce the risk of cumulative toxicity. At randomization, patients were stratified for immunoglobulin heavy chain variable (IGHV) status (54.8% of patients had unmutated status) and del11q (21.3% of patients had the deletion). Patients who had complete (25.7% of patients) or partial (62.8% of patients) responses were randomly allocated to either maintenance rituximab (202 patients given 500 mg/m² twice per month for 2 years) or to observation (207 patients). Median follow-up from randomization was 43.6 months.

Median progression-free survival in the rituximab arm was 59.3 months (95% confidence interval, 49.6; not reached), compared with 49 months (95% CI, 40.9-60.5) in the observation group (hazard ratio, 0.597; 95% CI, 0.437-0.814; P = .0011), corresponding to 3-year progression-free survival of 83% and 64.2% in each arm, respectively.

Mary Jo Dales/Frontline Medical News

Estimated overall survival at 3 years was 92.6% with rituximab maintenance and 87.2% in the observation group. Rituximab maintenance significantly improved progression-free survival in patients with and without del11q and in those with unmutated IGHV.

Serious adverse events for hematologic toxicity were seen in 6.9% of rituximab-treated patients and 1.9% of patients in the observation group (P = .027). Serious adverse events for infectious toxicity occurred in 18.8% of rituximab-treated patients and 10.1% of the observation group (P = .036). There were 69 deaths post randomization: 32 in the rituximab-treated group and 37 in the observation group. Secondary cancers, excluding basal cell carcinomas of the skin, occurred in 15.3% of the rituximab arm, including five cases of myelodysplastic syndrome, and in 11.1% of the observation group, including three cases of myelodysplastic syndrome.

Dr. Dartigeas is a consultant to Gilead Sciences and has provided expert testimony for Roche/Genentech. Genentech and Biogen jointly market rituximab (Rituxan).

[email protected]

On Twitter @maryjodales

CHICAGO – After 2 years of maintenance immunotherapy with rituximab, elderly patients with chronic lymphocytic leukemia had better rates of progression-free survival than did patients in an observation group, based on results of the CLL 2007 SA trial from the French FILO (French Innovative Leukemia Organisation) Group.

The two groups did not significantly differ in overall survival, however, with 92.6% estimated 3-year overall survival in the rituximab group and 87.2% in the observation group. Further, the patients given rituximab had more adverse events, based on data presented by Dr. Caroline Dartigeas of the University Hospital in Tours, France, at the annual meeting of the American Society of Clinical Oncology.

Mary Jo Dales/Frontline Medical News

Given the cost and risk for events with rituximab, the findings raise the question of whether there are any meaningful benefits for maintenance rituximab after induction therapy, Dr. Jonathan W. Friedberg of the University of Rochester, N.Y., who was the discussant of the paper, remarked after the presentation. He asked whether there is any evidence that patients feel better if they’re in remission and, thus, their quality of life is improved.

The study included fit, treatment-naive patients aged 65 years and older with B-cell CLL who lacked del17p. Median patient age was 71.3 years, and two-thirds of the patients were men.

Patients received four cycles of induction therapy with fludarabine, cyclophosphamide, and rituximab on a shortened schedule chosen to reduce the risk of cumulative toxicity. At randomization, patients were stratified for immunoglobulin heavy chain variable (IGHV) status (54.8% of patients had unmutated status) and del11q (21.3% of patients had the deletion). Patients who had complete (25.7% of patients) or partial (62.8% of patients) responses were randomly allocated to either maintenance rituximab (202 patients given 500 mg/m² twice per month for 2 years) or to observation (207 patients). Median follow-up from randomization was 43.6 months.

Median progression-free survival in the rituximab arm was 59.3 months (95% confidence interval, 49.6; not reached), compared with 49 months (95% CI, 40.9-60.5) in the observation group (hazard ratio, 0.597; 95% CI, 0.437-0.814; P = .0011), corresponding to 3-year progression-free survival of 83% and 64.2% in each arm, respectively.

Mary Jo Dales/Frontline Medical News

Estimated overall survival at 3 years was 92.6% with rituximab maintenance and 87.2% in the observation group. Rituximab maintenance significantly improved progression-free survival in patients with and without del11q and in those with unmutated IGHV.

Serious adverse events for hematologic toxicity were seen in 6.9% of rituximab-treated patients and 1.9% of patients in the observation group (P = .027). Serious adverse events for infectious toxicity occurred in 18.8% of rituximab-treated patients and 10.1% of the observation group (P = .036). There were 69 deaths post randomization: 32 in the rituximab-treated group and 37 in the observation group. Secondary cancers, excluding basal cell carcinomas of the skin, occurred in 15.3% of the rituximab arm, including five cases of myelodysplastic syndrome, and in 11.1% of the observation group, including three cases of myelodysplastic syndrome.

Dr. Dartigeas is a consultant to Gilead Sciences and has provided expert testimony for Roche/Genentech. Genentech and Biogen jointly market rituximab (Rituxan).

[email protected]

On Twitter @maryjodales

CHICAGO – After 2 years of maintenance immunotherapy with rituximab, elderly patients with chronic lymphocytic leukemia had better rates of progression-free survival than did patients in an observation group, based on results of the CLL 2007 SA trial from the French FILO (French Innovative Leukemia Organisation) Group.

The two groups did not significantly differ in overall survival, however, with 92.6% estimated 3-year overall survival in the rituximab group and 87.2% in the observation group. Further, the patients given rituximab had more adverse events, based on data presented by Dr. Caroline Dartigeas of the University Hospital in Tours, France, at the annual meeting of the American Society of Clinical Oncology.

Mary Jo Dales/Frontline Medical News

Given the cost and risk for events with rituximab, the findings raise the question of whether there are any meaningful benefits for maintenance rituximab after induction therapy, Dr. Jonathan W. Friedberg of the University of Rochester, N.Y., who was the discussant of the paper, remarked after the presentation. He asked whether there is any evidence that patients feel better if they’re in remission and, thus, their quality of life is improved.

The study included fit, treatment-naive patients aged 65 years and older with B-cell CLL who lacked del17p. Median patient age was 71.3 years, and two-thirds of the patients were men.

Patients received four cycles of induction therapy with fludarabine, cyclophosphamide, and rituximab on a shortened schedule chosen to reduce the risk of cumulative toxicity. At randomization, patients were stratified for immunoglobulin heavy chain variable (IGHV) status (54.8% of patients had unmutated status) and del11q (21.3% of patients had the deletion). Patients who had complete (25.7% of patients) or partial (62.8% of patients) responses were randomly allocated to either maintenance rituximab (202 patients given 500 mg/m² twice per month for 2 years) or to observation (207 patients). Median follow-up from randomization was 43.6 months.

Median progression-free survival in the rituximab arm was 59.3 months (95% confidence interval, 49.6; not reached), compared with 49 months (95% CI, 40.9-60.5) in the observation group (hazard ratio, 0.597; 95% CI, 0.437-0.814; P = .0011), corresponding to 3-year progression-free survival of 83% and 64.2% in each arm, respectively.

Mary Jo Dales/Frontline Medical News

Estimated overall survival at 3 years was 92.6% with rituximab maintenance and 87.2% in the observation group. Rituximab maintenance significantly improved progression-free survival in patients with and without del11q and in those with unmutated IGHV.

Serious adverse events for hematologic toxicity were seen in 6.9% of rituximab-treated patients and 1.9% of patients in the observation group (P = .027). Serious adverse events for infectious toxicity occurred in 18.8% of rituximab-treated patients and 10.1% of the observation group (P = .036). There were 69 deaths post randomization: 32 in the rituximab-treated group and 37 in the observation group. Secondary cancers, excluding basal cell carcinomas of the skin, occurred in 15.3% of the rituximab arm, including five cases of myelodysplastic syndrome, and in 11.1% of the observation group, including three cases of myelodysplastic syndrome.

Dr. Dartigeas is a consultant to Gilead Sciences and has provided expert testimony for Roche/Genentech. Genentech and Biogen jointly market rituximab (Rituxan).

[email protected]

On Twitter @maryjodales

SCOTTSDALE, ARIZ. – Wiping out the gut microbiome with antibiotics prevented alopecia areata in a study of mice, providing evidence that the gut microbiome may play a role in alopecia, Dr. James Chen reported at the annual meeting of the Society for Investigative Dermatology.

The finding shows that the bacterial culprits in alopecia “reside in the gut microbiome, and not in the skin,” said Dr. Chen, a postdoctoral research fellow in medical genetics at Columbia University, New York.

Alopecia areata is mediated by autoreactive NKG2D+ CD8+ T cells. Aberrations in the human microbiome underlie several other autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and type I diabetes, Dr. Chen noted. “The gut microbiome also has been linked to skin conditions, such as acne, psoriasis, and atopic dermatitis,” he added. “So we asked, if we deplete this microbiome with an antibiotic cocktail, do we see an effect on alopecia?”

To find out, he and his coinvestigators grafted skin from C3H/Hej mice, which spontaneously develop alopecia, onto healthy younger mice, causing them to develop alopecia 6-10 weeks later. “Strikingly, we found that treating unaffected mice with an oral antibiotic cocktail prior to grafting completely prevented the development of alopecia areata, and this remained true through 15 weeks,” he said. “This is the first evidence that the gut microbiome could be implicated in alopecia, based on the absence of the phenotype that we see in treated mice.”

The researchers also evaluated whether the skin microbiomes of antibiotic-treated and control mice differed, and determined that the skin samples resembled each other in terms of overall bacterial load and bacterial taxonomic clustering patterns. That suggests that the skin microbiome is not involved in alopecia areata, Dr. Chen said.

Finally, the investigators transferred NKG2D+ CD8+ T cells from the cutaneous lymph nodes of alopecic mice to normal mice that had been pretreated with antibiotics. The treated mice had little infiltration of these T cells into the skin, and lower overall T-cell levels than control mice, Dr. Chen reported.

The investigators are now testing combinations of antibiotics and fecal transplants to pinpoint which gut bacteria make mice susceptible to hair loss. Doing so “will have significant implications on both our understanding of alopecia areata susceptibility, as well as actionable therapeutic targets for treatment” in humans, Dr. Chen said.

The study was funded by the National Institutes of Health, the Medical Research Council, the Dermatology Foundation, Locks of Love Foundation, and NYSTEM (New York State Stem Cell Science). Dr. Chen had no financial disclosures.

SCOTTSDALE, ARIZ. – Wiping out the gut microbiome with antibiotics prevented alopecia areata in a study of mice, providing evidence that the gut microbiome may play a role in alopecia, Dr. James Chen reported at the annual meeting of the Society for Investigative Dermatology.

The finding shows that the bacterial culprits in alopecia “reside in the gut microbiome, and not in the skin,” said Dr. Chen, a postdoctoral research fellow in medical genetics at Columbia University, New York.

Alopecia areata is mediated by autoreactive NKG2D+ CD8+ T cells. Aberrations in the human microbiome underlie several other autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and type I diabetes, Dr. Chen noted. “The gut microbiome also has been linked to skin conditions, such as acne, psoriasis, and atopic dermatitis,” he added. “So we asked, if we deplete this microbiome with an antibiotic cocktail, do we see an effect on alopecia?”

To find out, he and his coinvestigators grafted skin from C3H/Hej mice, which spontaneously develop alopecia, onto healthy younger mice, causing them to develop alopecia 6-10 weeks later. “Strikingly, we found that treating unaffected mice with an oral antibiotic cocktail prior to grafting completely prevented the development of alopecia areata, and this remained true through 15 weeks,” he said. “This is the first evidence that the gut microbiome could be implicated in alopecia, based on the absence of the phenotype that we see in treated mice.”

The researchers also evaluated whether the skin microbiomes of antibiotic-treated and control mice differed, and determined that the skin samples resembled each other in terms of overall bacterial load and bacterial taxonomic clustering patterns. That suggests that the skin microbiome is not involved in alopecia areata, Dr. Chen said.

Finally, the investigators transferred NKG2D+ CD8+ T cells from the cutaneous lymph nodes of alopecic mice to normal mice that had been pretreated with antibiotics. The treated mice had little infiltration of these T cells into the skin, and lower overall T-cell levels than control mice, Dr. Chen reported.

The investigators are now testing combinations of antibiotics and fecal transplants to pinpoint which gut bacteria make mice susceptible to hair loss. Doing so “will have significant implications on both our understanding of alopecia areata susceptibility, as well as actionable therapeutic targets for treatment” in humans, Dr. Chen said.

The study was funded by the National Institutes of Health, the Medical Research Council, the Dermatology Foundation, Locks of Love Foundation, and NYSTEM (New York State Stem Cell Science). Dr. Chen had no financial disclosures.

SCOTTSDALE, ARIZ. – Wiping out the gut microbiome with antibiotics prevented alopecia areata in a study of mice, providing evidence that the gut microbiome may play a role in alopecia, Dr. James Chen reported at the annual meeting of the Society for Investigative Dermatology.

The finding shows that the bacterial culprits in alopecia “reside in the gut microbiome, and not in the skin,” said Dr. Chen, a postdoctoral research fellow in medical genetics at Columbia University, New York.

Alopecia areata is mediated by autoreactive NKG2D+ CD8+ T cells. Aberrations in the human microbiome underlie several other autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and type I diabetes, Dr. Chen noted. “The gut microbiome also has been linked to skin conditions, such as acne, psoriasis, and atopic dermatitis,” he added. “So we asked, if we deplete this microbiome with an antibiotic cocktail, do we see an effect on alopecia?”

To find out, he and his coinvestigators grafted skin from C3H/Hej mice, which spontaneously develop alopecia, onto healthy younger mice, causing them to develop alopecia 6-10 weeks later. “Strikingly, we found that treating unaffected mice with an oral antibiotic cocktail prior to grafting completely prevented the development of alopecia areata, and this remained true through 15 weeks,” he said. “This is the first evidence that the gut microbiome could be implicated in alopecia, based on the absence of the phenotype that we see in treated mice.”

The researchers also evaluated whether the skin microbiomes of antibiotic-treated and control mice differed, and determined that the skin samples resembled each other in terms of overall bacterial load and bacterial taxonomic clustering patterns. That suggests that the skin microbiome is not involved in alopecia areata, Dr. Chen said.

Finally, the investigators transferred NKG2D+ CD8+ T cells from the cutaneous lymph nodes of alopecic mice to normal mice that had been pretreated with antibiotics. The treated mice had little infiltration of these T cells into the skin, and lower overall T-cell levels than control mice, Dr. Chen reported.

The investigators are now testing combinations of antibiotics and fecal transplants to pinpoint which gut bacteria make mice susceptible to hair loss. Doing so “will have significant implications on both our understanding of alopecia areata susceptibility, as well as actionable therapeutic targets for treatment” in humans, Dr. Chen said.

The study was funded by the National Institutes of Health, the Medical Research Council, the Dermatology Foundation, Locks of Love Foundation, and NYSTEM (New York State Stem Cell Science). Dr. Chen had no financial disclosures.

NEWPORT BEACH, CALIF. – A combination of propranolol and laser is more effective than propranolol alone for infantile hemangiomas, and rapamycin can improve pulse die laser results for port wine stains.

Meanwhile, lasers hurt, so general anesthesia is in order for children as long as they’re older than 6 months.

Those are just a few of the pearls Dr. Kristen Kelly, a University of California, Irvine, professor of dermatology and surgery, shared at the Summit in Aesthetic Medicine. Dr. Kelly explained the latest developments in an interview at the conference, held by Global Academy for Medical Education.

Global Academy and this news organization are owned the same company.

[email protected]

NEWPORT BEACH, CALIF. – A combination of propranolol and laser is more effective than propranolol alone for infantile hemangiomas, and rapamycin can improve pulse die laser results for port wine stains.

Meanwhile, lasers hurt, so general anesthesia is in order for children as long as they’re older than 6 months.

Those are just a few of the pearls Dr. Kristen Kelly, a University of California, Irvine, professor of dermatology and surgery, shared at the Summit in Aesthetic Medicine. Dr. Kelly explained the latest developments in an interview at the conference, held by Global Academy for Medical Education.

Global Academy and this news organization are owned the same company.

[email protected]

NEWPORT BEACH, CALIF. – A combination of propranolol and laser is more effective than propranolol alone for infantile hemangiomas, and rapamycin can improve pulse die laser results for port wine stains.

Meanwhile, lasers hurt, so general anesthesia is in order for children as long as they’re older than 6 months.

Those are just a few of the pearls Dr. Kristen Kelly, a University of California, Irvine, professor of dermatology and surgery, shared at the Summit in Aesthetic Medicine. Dr. Kelly explained the latest developments in an interview at the conference, held by Global Academy for Medical Education.

Global Academy and this news organization are owned the same company.

[email protected]

Sheep are thought of as nervous animals, a good target for predators. You do not want to be a sheep. Unfortunately, many electronic health record (EHR) programs make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. The use of modifier -25 was previously reviewed in Cutis.¹ Despite the availability of this excellent review, I have found that there is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.

When to Bill for E&M

Based on recent discussions with colleagues in the New York area who have been audited, an easy way to bring on a request for medical records is to report an E&M 100% of the time with a procedure. In these instances, every single E&M was performed on the same visit as a dermatologic procedure, most commonly biopsies(Current Procedural Terminology [CPT] code 11100, 11101) and premalignant destructions (CPT code 17000, 17003, 17004), which is in contrast with typical practitioners who perform an E&M approximately 70% of the time (RUC rationale; American Medical Association RBRVS Data Manager; May 12, 2016). One circumstance involved the reporting of E&M services 100% of the time when performed during the same visit as Mohs micrographic surgery (CPT code 17311–17315), a surprising frequency considering that the typical same day use of a code for this procedure with an E&M in the Medicare population is less than 25%.

According to the National Correct Coding Initiative Policy Manual for Medicare Services, procedures with a global period of 90 days are defined as major surgical procedures,² which only include adjacent tissue transfers and grafts for dermatology. If an E&M is performed on the same date of service as one of these procedures to decide whether to perform the procedure, the E&M can be reported separately using modifier -57. Other preoperative E&M services provided on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not reported separately.²

All other procedures dermatologists perform generally are considered minor, which are defined as having a global period of 0 or 10 days. Because the decision to perform a minor procedure is included in the payment for the procedure, E&M services should not be reported separately from the minor procedure. However, “a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”²

Documentation Guidelines

These guidelines seem straightforward, but as with so much else where the government is involved, the devil is in the details. When making coding decisions, you may consult the documentation guidelines from either 1995³ or 1997,⁴ which are available for download on the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html). The 1995 guidelines are less empiric and offer more flexibility, while the 1997 guidelines rely on number of “bullets” as examination elements.

1995 Guidelines

According to the 1995 documentation guidelines, the levels of E&M services are based on 4 types of examination that are defined as follows: (1) problem focused, a limited examination of the affected body area or organ system; (2) expanded problem focused, a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); (3) detailed, an extended examination of the affected body area(s) and other symptomatic or related organ system(s); and (4) comprehensive, a general multisystem examination or complete examination of a single organ system.³ Detailed history is the fuzziest part of the coding universe. Some insurers take an approach that you need to examine 2 to 7 organ systems and 4 distinct lesions in 4 body areas, which is discussed in audit tools available from some Medicare intermediaries (Advancing the Business of Healthcare forum; April 10, 2014). As a result, the 12-bullet examination from the 1997 documentation guidelines may be more suitable for a new level 3 or established level 4 visit. For a comprehensive examination, the 1995 criteria allow for a complete examination of a single organ system such as the full-body skin examination with the patient completely undressed, which is medically necessary in our melanoma patients.

For purposes of examination, 9 body areas are recognized in the 1995 guidelines,³ along with more than a dozen organ systems of which the skin is of most interest to dermatologists.

According to the 1995 guidelines,³ the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s) and range from focused examinations of single body areas to general multisystem or complete single organ system examinations. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. Although a notation of normal is sufficient, abnormal without elaboration is insufficient, and abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. The medical record for a general multisystem examination should include findings involving approximately 8 or more of the 12 organ systems.

An expanded problem focused examination under the 1995 guidelines could be as simple as “Scar on cancer excision site on left cheek soft and supple. No cervical adenopathy.” There is some confusion regarding detailed examinations, and one consultant went as far as calling the guidelines “vague,”5 while others such as a Medicare intermediary make a quantum leap that if a comprehensive general system examination includes 8 to 12 organ systems, one step below should include 2 to 7 organ systems.6 In essence, the payer makes the rules here.

1997 Guidelines

According to the 1997 documentation guidelines, count bullets that are examination elements, which can be either general or single organ system.⁴ (A table showing the bullets for the examination elements is available from the CMS.⁴) For each type of examination, apply the following: problem focused examination requires 1 to 5 elements identified by a bullet, expanded problem focused examination needs at least 6, detailed examination requires at least 12, and comprehensive examination requires all elements identified by a bullet with documentation of every element in each box with a shaded border and at least 1 element in each box with an unshaded border.⁴ Although you may do more writing when using the 1997 guidelines, you can easily count up bullets and these guidelines are amenable to template examinations on paper and obviously easily coded into EHR software that will do the bullet counting for you.

Unfortunately, this is where a ewe becomes a sheep, ripe for hunting for a number of reasons. First, just because you documented an E&M service does not mean it is medically necessary. Do you really need vital signs for every visit? If you are a meaningful EHR user working on penalty avoidance, you may capture examination data for meaningful use that is not medically necessary but cannot be parsed out by the autocoder in your EHR. As a result, simply do a quick manual audit of your notes to see if you are overcoding, which becomes second nature if you do it often.

The second trap, which brings us back to modifier -25, is when you perform a procedure the same day as your E&M or vice versa. Every procedure we do within the Resource-Based Relative Value Scale contains preservice time, which includes review of materials relevant to the procedure, examination of the area, and all preparation (eg, marking, time out, anesthesia, scrub and drape) before the surgery begins. The detailed vignettes are available to those involved in the Relative Value Scale Update Committee process and to the rest of the world in a subscription product called the RBRVS DataManager Online, which is produced by the American Medical Association. Unfortunately, the American Medical Association is not accepting new subscriptions to this product, as it has decided to outsource most of its coding resources to Optum360, one of the many arms of UnitedHealth Group, and will not have a replacement product until after June 30, 2016.⁷

In essence, if you (and your EHR) are counting bullets and then treating the body area in question, you are double-dipping, as the examination of the area is included in the procedure. So if you are heading toward a CPT 99213-25 with 6 bullets, one of which is on the left arm, and you perform a 0- or 10-day global procedure on that arm, you are down to 5 bullets, which drops your level of examination to problem focused. Remember, you need only 2 of 3—history, examination, and decision making—to be at or above that need for that particular level of reporting. If only one of your history or decision making is at or above the needed level for a 99213, the loss of a single bullet drops you down to a 99212! An audit where a handful of medical records are pulled and a request for money back on the universe of payments the insurer has paid is always unpleasant and you should, if you get a request for same, follow all the rules and timelines outlined by the payer. If you knowingly behaved in a risky fashion, consult a good attorney.

Of course, you may argue that the effort needed for the E&M work for the procedure was above and beyond what is typical for the service, which can be a hard standard to meet. Although the CMS requires a “significant and separately identifiable E&M service” as noted above and a separate diagnosis is not needed, the onus is on you to prove it. It is much easier to have a separate diagnosis that stands on its own, which will probably make an audit less common (unless you do it too often).

Final Thoughts

In summary, document what you do, do what you document, and report what is medically necessary. Keep watch over your EHR to be sure it is not overcoding for you. You do not want to be a ewe!

Sheep are thought of as nervous animals, a good target for predators. You do not want to be a sheep. Unfortunately, many electronic health record (EHR) programs make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. The use of modifier -25 was previously reviewed in Cutis.¹ Despite the availability of this excellent review, I have found that there is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.

When to Bill for E&M

Based on recent discussions with colleagues in the New York area who have been audited, an easy way to bring on a request for medical records is to report an E&M 100% of the time with a procedure. In these instances, every single E&M was performed on the same visit as a dermatologic procedure, most commonly biopsies(Current Procedural Terminology [CPT] code 11100, 11101) and premalignant destructions (CPT code 17000, 17003, 17004), which is in contrast with typical practitioners who perform an E&M approximately 70% of the time (RUC rationale; American Medical Association RBRVS Data Manager; May 12, 2016). One circumstance involved the reporting of E&M services 100% of the time when performed during the same visit as Mohs micrographic surgery (CPT code 17311–17315), a surprising frequency considering that the typical same day use of a code for this procedure with an E&M in the Medicare population is less than 25%.

According to the National Correct Coding Initiative Policy Manual for Medicare Services, procedures with a global period of 90 days are defined as major surgical procedures,² which only include adjacent tissue transfers and grafts for dermatology. If an E&M is performed on the same date of service as one of these procedures to decide whether to perform the procedure, the E&M can be reported separately using modifier -57. Other preoperative E&M services provided on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not reported separately.²

All other procedures dermatologists perform generally are considered minor, which are defined as having a global period of 0 or 10 days. Because the decision to perform a minor procedure is included in the payment for the procedure, E&M services should not be reported separately from the minor procedure. However, “a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”²

Documentation Guidelines

These guidelines seem straightforward, but as with so much else where the government is involved, the devil is in the details. When making coding decisions, you may consult the documentation guidelines from either 1995³ or 1997,⁴ which are available for download on the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html). The 1995 guidelines are less empiric and offer more flexibility, while the 1997 guidelines rely on number of “bullets” as examination elements.

1995 Guidelines

According to the 1995 documentation guidelines, the levels of E&M services are based on 4 types of examination that are defined as follows: (1) problem focused, a limited examination of the affected body area or organ system; (2) expanded problem focused, a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); (3) detailed, an extended examination of the affected body area(s) and other symptomatic or related organ system(s); and (4) comprehensive, a general multisystem examination or complete examination of a single organ system.³ Detailed history is the fuzziest part of the coding universe. Some insurers take an approach that you need to examine 2 to 7 organ systems and 4 distinct lesions in 4 body areas, which is discussed in audit tools available from some Medicare intermediaries (Advancing the Business of Healthcare forum; April 10, 2014). As a result, the 12-bullet examination from the 1997 documentation guidelines may be more suitable for a new level 3 or established level 4 visit. For a comprehensive examination, the 1995 criteria allow for a complete examination of a single organ system such as the full-body skin examination with the patient completely undressed, which is medically necessary in our melanoma patients.

For purposes of examination, 9 body areas are recognized in the 1995 guidelines,³ along with more than a dozen organ systems of which the skin is of most interest to dermatologists.

According to the 1995 guidelines,³ the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s) and range from focused examinations of single body areas to general multisystem or complete single organ system examinations. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. Although a notation of normal is sufficient, abnormal without elaboration is insufficient, and abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. The medical record for a general multisystem examination should include findings involving approximately 8 or more of the 12 organ systems.

An expanded problem focused examination under the 1995 guidelines could be as simple as “Scar on cancer excision site on left cheek soft and supple. No cervical adenopathy.” There is some confusion regarding detailed examinations, and one consultant went as far as calling the guidelines “vague,”5 while others such as a Medicare intermediary make a quantum leap that if a comprehensive general system examination includes 8 to 12 organ systems, one step below should include 2 to 7 organ systems.6 In essence, the payer makes the rules here.

1997 Guidelines

According to the 1997 documentation guidelines, count bullets that are examination elements, which can be either general or single organ system.⁴ (A table showing the bullets for the examination elements is available from the CMS.⁴) For each type of examination, apply the following: problem focused examination requires 1 to 5 elements identified by a bullet, expanded problem focused examination needs at least 6, detailed examination requires at least 12, and comprehensive examination requires all elements identified by a bullet with documentation of every element in each box with a shaded border and at least 1 element in each box with an unshaded border.⁴ Although you may do more writing when using the 1997 guidelines, you can easily count up bullets and these guidelines are amenable to template examinations on paper and obviously easily coded into EHR software that will do the bullet counting for you.

Unfortunately, this is where a ewe becomes a sheep, ripe for hunting for a number of reasons. First, just because you documented an E&M service does not mean it is medically necessary. Do you really need vital signs for every visit? If you are a meaningful EHR user working on penalty avoidance, you may capture examination data for meaningful use that is not medically necessary but cannot be parsed out by the autocoder in your EHR. As a result, simply do a quick manual audit of your notes to see if you are overcoding, which becomes second nature if you do it often.

The second trap, which brings us back to modifier -25, is when you perform a procedure the same day as your E&M or vice versa. Every procedure we do within the Resource-Based Relative Value Scale contains preservice time, which includes review of materials relevant to the procedure, examination of the area, and all preparation (eg, marking, time out, anesthesia, scrub and drape) before the surgery begins. The detailed vignettes are available to those involved in the Relative Value Scale Update Committee process and to the rest of the world in a subscription product called the RBRVS DataManager Online, which is produced by the American Medical Association. Unfortunately, the American Medical Association is not accepting new subscriptions to this product, as it has decided to outsource most of its coding resources to Optum360, one of the many arms of UnitedHealth Group, and will not have a replacement product until after June 30, 2016.⁷

In essence, if you (and your EHR) are counting bullets and then treating the body area in question, you are double-dipping, as the examination of the area is included in the procedure. So if you are heading toward a CPT 99213-25 with 6 bullets, one of which is on the left arm, and you perform a 0- or 10-day global procedure on that arm, you are down to 5 bullets, which drops your level of examination to problem focused. Remember, you need only 2 of 3—history, examination, and decision making—to be at or above that need for that particular level of reporting. If only one of your history or decision making is at or above the needed level for a 99213, the loss of a single bullet drops you down to a 99212! An audit where a handful of medical records are pulled and a request for money back on the universe of payments the insurer has paid is always unpleasant and you should, if you get a request for same, follow all the rules and timelines outlined by the payer. If you knowingly behaved in a risky fashion, consult a good attorney.

Of course, you may argue that the effort needed for the E&M work for the procedure was above and beyond what is typical for the service, which can be a hard standard to meet. Although the CMS requires a “significant and separately identifiable E&M service” as noted above and a separate diagnosis is not needed, the onus is on you to prove it. It is much easier to have a separate diagnosis that stands on its own, which will probably make an audit less common (unless you do it too often).

Final Thoughts

In summary, document what you do, do what you document, and report what is medically necessary. Keep watch over your EHR to be sure it is not overcoding for you. You do not want to be a ewe!

Sheep are thought of as nervous animals, a good target for predators. You do not want to be a sheep. Unfortunately, many electronic health record (EHR) programs make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. The use of modifier -25 was previously reviewed in Cutis.¹ Despite the availability of this excellent review, I have found that there is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.

When to Bill for E&M

Based on recent discussions with colleagues in the New York area who have been audited, an easy way to bring on a request for medical records is to report an E&M 100% of the time with a procedure. In these instances, every single E&M was performed on the same visit as a dermatologic procedure, most commonly biopsies(Current Procedural Terminology [CPT] code 11100, 11101) and premalignant destructions (CPT code 17000, 17003, 17004), which is in contrast with typical practitioners who perform an E&M approximately 70% of the time (RUC rationale; American Medical Association RBRVS Data Manager; May 12, 2016). One circumstance involved the reporting of E&M services 100% of the time when performed during the same visit as Mohs micrographic surgery (CPT code 17311–17315), a surprising frequency considering that the typical same day use of a code for this procedure with an E&M in the Medicare population is less than 25%.

According to the National Correct Coding Initiative Policy Manual for Medicare Services, procedures with a global period of 90 days are defined as major surgical procedures,² which only include adjacent tissue transfers and grafts for dermatology. If an E&M is performed on the same date of service as one of these procedures to decide whether to perform the procedure, the E&M can be reported separately using modifier -57. Other preoperative E&M services provided on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not reported separately.²

All other procedures dermatologists perform generally are considered minor, which are defined as having a global period of 0 or 10 days. Because the decision to perform a minor procedure is included in the payment for the procedure, E&M services should not be reported separately from the minor procedure. However, “a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”²

Documentation Guidelines

These guidelines seem straightforward, but as with so much else where the government is involved, the devil is in the details. When making coding decisions, you may consult the documentation guidelines from either 1995³ or 1997,⁴ which are available for download on the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html). The 1995 guidelines are less empiric and offer more flexibility, while the 1997 guidelines rely on number of “bullets” as examination elements.

1995 Guidelines

According to the 1995 documentation guidelines, the levels of E&M services are based on 4 types of examination that are defined as follows: (1) problem focused, a limited examination of the affected body area or organ system; (2) expanded problem focused, a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); (3) detailed, an extended examination of the affected body area(s) and other symptomatic or related organ system(s); and (4) comprehensive, a general multisystem examination or complete examination of a single organ system.³ Detailed history is the fuzziest part of the coding universe. Some insurers take an approach that you need to examine 2 to 7 organ systems and 4 distinct lesions in 4 body areas, which is discussed in audit tools available from some Medicare intermediaries (Advancing the Business of Healthcare forum; April 10, 2014). As a result, the 12-bullet examination from the 1997 documentation guidelines may be more suitable for a new level 3 or established level 4 visit. For a comprehensive examination, the 1995 criteria allow for a complete examination of a single organ system such as the full-body skin examination with the patient completely undressed, which is medically necessary in our melanoma patients.

For purposes of examination, 9 body areas are recognized in the 1995 guidelines,³ along with more than a dozen organ systems of which the skin is of most interest to dermatologists.

According to the 1995 guidelines,³ the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s) and range from focused examinations of single body areas to general multisystem or complete single organ system examinations. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. Although a notation of normal is sufficient, abnormal without elaboration is insufficient, and abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. The medical record for a general multisystem examination should include findings involving approximately 8 or more of the 12 organ systems.

An expanded problem focused examination under the 1995 guidelines could be as simple as “Scar on cancer excision site on left cheek soft and supple. No cervical adenopathy.” There is some confusion regarding detailed examinations, and one consultant went as far as calling the guidelines “vague,”5 while others such as a Medicare intermediary make a quantum leap that if a comprehensive general system examination includes 8 to 12 organ systems, one step below should include 2 to 7 organ systems.6 In essence, the payer makes the rules here.

1997 Guidelines

According to the 1997 documentation guidelines, count bullets that are examination elements, which can be either general or single organ system.⁴ (A table showing the bullets for the examination elements is available from the CMS.⁴) For each type of examination, apply the following: problem focused examination requires 1 to 5 elements identified by a bullet, expanded problem focused examination needs at least 6, detailed examination requires at least 12, and comprehensive examination requires all elements identified by a bullet with documentation of every element in each box with a shaded border and at least 1 element in each box with an unshaded border.⁴ Although you may do more writing when using the 1997 guidelines, you can easily count up bullets and these guidelines are amenable to template examinations on paper and obviously easily coded into EHR software that will do the bullet counting for you.

Unfortunately, this is where a ewe becomes a sheep, ripe for hunting for a number of reasons. First, just because you documented an E&M service does not mean it is medically necessary. Do you really need vital signs for every visit? If you are a meaningful EHR user working on penalty avoidance, you may capture examination data for meaningful use that is not medically necessary but cannot be parsed out by the autocoder in your EHR. As a result, simply do a quick manual audit of your notes to see if you are overcoding, which becomes second nature if you do it often.

The second trap, which brings us back to modifier -25, is when you perform a procedure the same day as your E&M or vice versa. Every procedure we do within the Resource-Based Relative Value Scale contains preservice time, which includes review of materials relevant to the procedure, examination of the area, and all preparation (eg, marking, time out, anesthesia, scrub and drape) before the surgery begins. The detailed vignettes are available to those involved in the Relative Value Scale Update Committee process and to the rest of the world in a subscription product called the RBRVS DataManager Online, which is produced by the American Medical Association. Unfortunately, the American Medical Association is not accepting new subscriptions to this product, as it has decided to outsource most of its coding resources to Optum360, one of the many arms of UnitedHealth Group, and will not have a replacement product until after June 30, 2016.⁷

In essence, if you (and your EHR) are counting bullets and then treating the body area in question, you are double-dipping, as the examination of the area is included in the procedure. So if you are heading toward a CPT 99213-25 with 6 bullets, one of which is on the left arm, and you perform a 0- or 10-day global procedure on that arm, you are down to 5 bullets, which drops your level of examination to problem focused. Remember, you need only 2 of 3—history, examination, and decision making—to be at or above that need for that particular level of reporting. If only one of your history or decision making is at or above the needed level for a 99213, the loss of a single bullet drops you down to a 99212! An audit where a handful of medical records are pulled and a request for money back on the universe of payments the insurer has paid is always unpleasant and you should, if you get a request for same, follow all the rules and timelines outlined by the payer. If you knowingly behaved in a risky fashion, consult a good attorney.

Of course, you may argue that the effort needed for the E&M work for the procedure was above and beyond what is typical for the service, which can be a hard standard to meet. Although the CMS requires a “significant and separately identifiable E&M service” as noted above and a separate diagnosis is not needed, the onus is on you to prove it. It is much easier to have a separate diagnosis that stands on its own, which will probably make an audit less common (unless you do it too often).

Final Thoughts

In summary, document what you do, do what you document, and report what is medically necessary. Keep watch over your EHR to be sure it is not overcoding for you. You do not want to be a ewe!

SCOTTSDALE, ARIZ. – The Janus kinase (JAK) inhibitor tofacitinib dramatically improved several cases of alopecia areata (AA), although some patients relapsed to worse than baseline after completing treatment in a small open label pilot trial.

“Regrowth was demonstrated in 11 out of 12 patients on tofacitinib. Seven out of 12 patients achieved more than 50% regrowth,” Dr. Shawn Sidharthan reported at the annual meeting of the Society for Investigative Dermatology.

Worldwide, alopecia areata, which is caused by immune-mediated destruction of hair follicles, has a lifetime incidence of about 2% (Clin Cosmet Investig Dermatol. 2015;8:397-403). But there are no Food and Drug Administration–approved treatments for AA. Tofacitinib (Xeljanz), which is approved by the FDA for moderate to severe rheumatoid arthritis in adults, is a JAK1 and JAK3 inhibitor that curbs the interferon-gamma response inflammatory pathway, said Dr. Sidharthan of the department of dermatology and genetics at Columbia University, New York.

Abbassyma/Wikimedia Commons/Public Domain

AA shares the same interferon response pathway, and tofacitinib prevented alopecia in mice and led to hair regrowth in a patient with alopecia universalis, he noted.

The single-arm trial included seven patients with moderate to severe patchy AA and five patients with alopecia totalis or alopecia universalis. Patients were treated for 6 months. They initially received 5 mg tofacitinib orally twice daily, which was increased to 10 mg twice daily to improve response. The investigators evaluated patients based on SALT (Severity of Alopecia Tool) scores and the Alopecia Areata Disease Activity Index (ALADIN), which uses three-dimensional bioinformatics to identify groups of genes linked to alopecia.

Seven of 12 patients experienced at least 50% regrowth, including six patients who only improved on 10 mg tofacitinib twice daily, Dr. Sidharthan said. Three additional patients “had good regrowth, but not 50%,” he reported. Among the two remaining patients, one had full regrowth, but dropped out of the study because of uncontrolled hypertension, and one patient with alopecia universalis had little or no regrowth.

Notably, two patients began shedding hair after stopping tofacitinib during the observation period of the study, and their final SALT scores were worse than baseline, Dr. Sidharthan said.

Laboratory monitoring of the cohort revealed no severe adverse events, but one patient paused treatment because of thrombocytopenia. The patient’s platelet count normalized after 2 weeks off tofacitinib, and remained normal when the dose was gradually increased to 10 mg twice daily. Another patient developed leukocytosis that resolved during the off-treatment observation period. One patient who did not comply with instructions to avoid alcohol had elevated liver function tests and was taken off the study. Two patients experienced self-limiting diarrhea, and one patient developed trace hematuria, Dr. Sidharthan noted.

In the study, ALADIN scores correlated with clinical response, he said.

He and his coinvestigators concluded that the overall results “provide a strong rationale for larger clinical trials using JAK inhibitors in alopecia areata,” he said.

Dr. Sidharthan noted that another oral JAK inhibitor, ruxolitinib (Jakafi), led to nearly full hair regrowth in three patients with alopecia in a Columbia University study (Nat Med. 2014 Sep; 20[9]:1043-9).

The Locks of Love Foundation funded the research. Dr. Sidharthan, a clinical research fellow in dermatology at Columbia, had no disclosures.

SCOTTSDALE, ARIZ. – The Janus kinase (JAK) inhibitor tofacitinib dramatically improved several cases of alopecia areata (AA), although some patients relapsed to worse than baseline after completing treatment in a small open label pilot trial.

“Regrowth was demonstrated in 11 out of 12 patients on tofacitinib. Seven out of 12 patients achieved more than 50% regrowth,” Dr. Shawn Sidharthan reported at the annual meeting of the Society for Investigative Dermatology.

Worldwide, alopecia areata, which is caused by immune-mediated destruction of hair follicles, has a lifetime incidence of about 2% (Clin Cosmet Investig Dermatol. 2015;8:397-403). But there are no Food and Drug Administration–approved treatments for AA. Tofacitinib (Xeljanz), which is approved by the FDA for moderate to severe rheumatoid arthritis in adults, is a JAK1 and JAK3 inhibitor that curbs the interferon-gamma response inflammatory pathway, said Dr. Sidharthan of the department of dermatology and genetics at Columbia University, New York.

Abbassyma/Wikimedia Commons/Public Domain

AA shares the same interferon response pathway, and tofacitinib prevented alopecia in mice and led to hair regrowth in a patient with alopecia universalis, he noted.

The single-arm trial included seven patients with moderate to severe patchy AA and five patients with alopecia totalis or alopecia universalis. Patients were treated for 6 months. They initially received 5 mg tofacitinib orally twice daily, which was increased to 10 mg twice daily to improve response. The investigators evaluated patients based on SALT (Severity of Alopecia Tool) scores and the Alopecia Areata Disease Activity Index (ALADIN), which uses three-dimensional bioinformatics to identify groups of genes linked to alopecia.

Seven of 12 patients experienced at least 50% regrowth, including six patients who only improved on 10 mg tofacitinib twice daily, Dr. Sidharthan said. Three additional patients “had good regrowth, but not 50%,” he reported. Among the two remaining patients, one had full regrowth, but dropped out of the study because of uncontrolled hypertension, and one patient with alopecia universalis had little or no regrowth.

Notably, two patients began shedding hair after stopping tofacitinib during the observation period of the study, and their final SALT scores were worse than baseline, Dr. Sidharthan said.

Laboratory monitoring of the cohort revealed no severe adverse events, but one patient paused treatment because of thrombocytopenia. The patient’s platelet count normalized after 2 weeks off tofacitinib, and remained normal when the dose was gradually increased to 10 mg twice daily. Another patient developed leukocytosis that resolved during the off-treatment observation period. One patient who did not comply with instructions to avoid alcohol had elevated liver function tests and was taken off the study. Two patients experienced self-limiting diarrhea, and one patient developed trace hematuria, Dr. Sidharthan noted.

In the study, ALADIN scores correlated with clinical response, he said.

He and his coinvestigators concluded that the overall results “provide a strong rationale for larger clinical trials using JAK inhibitors in alopecia areata,” he said.

Dr. Sidharthan noted that another oral JAK inhibitor, ruxolitinib (Jakafi), led to nearly full hair regrowth in three patients with alopecia in a Columbia University study (Nat Med. 2014 Sep; 20[9]:1043-9).

The Locks of Love Foundation funded the research. Dr. Sidharthan, a clinical research fellow in dermatology at Columbia, had no disclosures.

SCOTTSDALE, ARIZ. – The Janus kinase (JAK) inhibitor tofacitinib dramatically improved several cases of alopecia areata (AA), although some patients relapsed to worse than baseline after completing treatment in a small open label pilot trial.

“Regrowth was demonstrated in 11 out of 12 patients on tofacitinib. Seven out of 12 patients achieved more than 50% regrowth,” Dr. Shawn Sidharthan reported at the annual meeting of the Society for Investigative Dermatology.

Worldwide, alopecia areata, which is caused by immune-mediated destruction of hair follicles, has a lifetime incidence of about 2% (Clin Cosmet Investig Dermatol. 2015;8:397-403). But there are no Food and Drug Administration–approved treatments for AA. Tofacitinib (Xeljanz), which is approved by the FDA for moderate to severe rheumatoid arthritis in adults, is a JAK1 and JAK3 inhibitor that curbs the interferon-gamma response inflammatory pathway, said Dr. Sidharthan of the department of dermatology and genetics at Columbia University, New York.

Abbassyma/Wikimedia Commons/Public Domain

AA shares the same interferon response pathway, and tofacitinib prevented alopecia in mice and led to hair regrowth in a patient with alopecia universalis, he noted.

The single-arm trial included seven patients with moderate to severe patchy AA and five patients with alopecia totalis or alopecia universalis. Patients were treated for 6 months. They initially received 5 mg tofacitinib orally twice daily, which was increased to 10 mg twice daily to improve response. The investigators evaluated patients based on SALT (Severity of Alopecia Tool) scores and the Alopecia Areata Disease Activity Index (ALADIN), which uses three-dimensional bioinformatics to identify groups of genes linked to alopecia.

Seven of 12 patients experienced at least 50% regrowth, including six patients who only improved on 10 mg tofacitinib twice daily, Dr. Sidharthan said. Three additional patients “had good regrowth, but not 50%,” he reported. Among the two remaining patients, one had full regrowth, but dropped out of the study because of uncontrolled hypertension, and one patient with alopecia universalis had little or no regrowth.

Notably, two patients began shedding hair after stopping tofacitinib during the observation period of the study, and their final SALT scores were worse than baseline, Dr. Sidharthan said.

Laboratory monitoring of the cohort revealed no severe adverse events, but one patient paused treatment because of thrombocytopenia. The patient’s platelet count normalized after 2 weeks off tofacitinib, and remained normal when the dose was gradually increased to 10 mg twice daily. Another patient developed leukocytosis that resolved during the off-treatment observation period. One patient who did not comply with instructions to avoid alcohol had elevated liver function tests and was taken off the study. Two patients experienced self-limiting diarrhea, and one patient developed trace hematuria, Dr. Sidharthan noted.

In the study, ALADIN scores correlated with clinical response, he said.

He and his coinvestigators concluded that the overall results “provide a strong rationale for larger clinical trials using JAK inhibitors in alopecia areata,” he said.

Dr. Sidharthan noted that another oral JAK inhibitor, ruxolitinib (Jakafi), led to nearly full hair regrowth in three patients with alopecia in a Columbia University study (Nat Med. 2014 Sep; 20[9]:1043-9).

The Locks of Love Foundation funded the research. Dr. Sidharthan, a clinical research fellow in dermatology at Columbia, had no disclosures.

Special activities are everywhere today at the Vascular Annual Meeting, including the official welcome and an opening reception, not to mention the opening of the Exhibit Hall.

Activities include:

• The Opening Ceremony, 8 to 8:30 a.m. in Potomac Ballroom A/B.

• The SVS Awards Ceremony, 2:50 to 3 p.m., Potomac Ballroom A/B. Who will receive SVS’ highest honor, the Lifetime Achievement Award? Find out at the ceremony.

• Opening of the Exhibit Hall at 12 p.m. Exhibits will close at 6 p.m.

• The Opening Reception, 5:30 to 6:30 p.m., Exhibit Halls A-C.

• Alumni receptions. Alums from many institutions – Harvard, Yale, UCLA, Montefiore, Cleveland Clinic, Mayo Clinic, Baylor and many others – will catch up with former classmates and other graduates at receptions Thursday evening. The full list can be found in the Mobile App. Only the Baylor reception is off-site; all others are held at the Gaylord National Resort & Convention Center.

Special activities are everywhere today at the Vascular Annual Meeting, including the official welcome and an opening reception, not to mention the opening of the Exhibit Hall.

Activities include:

• The Opening Ceremony, 8 to 8:30 a.m. in Potomac Ballroom A/B.

• The SVS Awards Ceremony, 2:50 to 3 p.m., Potomac Ballroom A/B. Who will receive SVS’ highest honor, the Lifetime Achievement Award? Find out at the ceremony.

• Opening of the Exhibit Hall at 12 p.m. Exhibits will close at 6 p.m.

• The Opening Reception, 5:30 to 6:30 p.m., Exhibit Halls A-C.

• Alumni receptions. Alums from many institutions – Harvard, Yale, UCLA, Montefiore, Cleveland Clinic, Mayo Clinic, Baylor and many others – will catch up with former classmates and other graduates at receptions Thursday evening. The full list can be found in the Mobile App. Only the Baylor reception is off-site; all others are held at the Gaylord National Resort & Convention Center.

Special activities are everywhere today at the Vascular Annual Meeting, including the official welcome and an opening reception, not to mention the opening of the Exhibit Hall.

Activities include:

• The Opening Ceremony, 8 to 8:30 a.m. in Potomac Ballroom A/B.

• The SVS Awards Ceremony, 2:50 to 3 p.m., Potomac Ballroom A/B. Who will receive SVS’ highest honor, the Lifetime Achievement Award? Find out at the ceremony.

• Opening of the Exhibit Hall at 12 p.m. Exhibits will close at 6 p.m.

• The Opening Reception, 5:30 to 6:30 p.m., Exhibit Halls A-C.

• Alumni receptions. Alums from many institutions – Harvard, Yale, UCLA, Montefiore, Cleveland Clinic, Mayo Clinic, Baylor and many others – will catch up with former classmates and other graduates at receptions Thursday evening. The full list can be found in the Mobile App. Only the Baylor reception is off-site; all others are held at the Gaylord National Resort & Convention Center.

Thursday’s lineup includes special lectures and invited speakers, including:

John Homans Lecture, 10 to 10:30 a.m., Potomac Ballroom A/B. Dr. Frank Veith will take “A Look at the Future of Vascular Surgery."

E. Stanley Crawford Critical Issues Forum, Potomac Ballroom A/B, will discuss “In Search of Clarity: SFA-Popliteal Interventions for Claudication.” 

Roy Greenberg Distinguished Lecture, 3 to 3:30 p.m., Potomac Ballroom A/B. Dr. Timothy A. Resch will present a talk on “Aortic Disease – The Quest to Improve Patient Outcomes.”

Thursday’s lineup includes special lectures and invited speakers, including:

John Homans Lecture, 10 to 10:30 a.m., Potomac Ballroom A/B. Dr. Frank Veith will take “A Look at the Future of Vascular Surgery."

E. Stanley Crawford Critical Issues Forum, Potomac Ballroom A/B, will discuss “In Search of Clarity: SFA-Popliteal Interventions for Claudication.” 

Roy Greenberg Distinguished Lecture, 3 to 3:30 p.m., Potomac Ballroom A/B. Dr. Timothy A. Resch will present a talk on “Aortic Disease – The Quest to Improve Patient Outcomes.”

Thursday’s lineup includes special lectures and invited speakers, including:

John Homans Lecture, 10 to 10:30 a.m., Potomac Ballroom A/B. Dr. Frank Veith will take “A Look at the Future of Vascular Surgery."

E. Stanley Crawford Critical Issues Forum, Potomac Ballroom A/B, will discuss “In Search of Clarity: SFA-Popliteal Interventions for Claudication.” 

Roy Greenberg Distinguished Lecture, 3 to 3:30 p.m., Potomac Ballroom A/B. Dr. Timothy A. Resch will present a talk on “Aortic Disease – The Quest to Improve Patient Outcomes.”

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.