Mixed Topics

I am a doctor, not an engineer.Dr. McCoy, Star Trek “Mirror, Mirror” episode

Last year in my annual wrap-up, I wrote back-to-back editorials (December 2017 and January 2018) on the worst and best of 2017 from a federal health care perspective, emphasizing ethics or the lack thereof. I featured the altruism of federal health care providers (HCPs) responding to natural disasters and the terrible outcome of seemingly banal moral lapses.

This year the best and worst are one and the same, and I am not sure how it could be otherwise: the Department of Veterans Affairs (VA) and Department of Defense (DoD) electronic health record (EHR) contract with Cerner (North Kansas City, MO). Former VA Secretary David Shulkin, MD, announced the deal in 2017 shortly before his departure, and it was signed under then Acting VA Secretary Robert Wilkie in May of 2018.¹ But the reason the Cerner contract is the most impactful and momentous ethical event of the year is perhaps not what readers expect. Search engines will efficiently unearth plentiful drama with ethical import about the contract. There were conspiracy charges that the shadow regime improperly engineered the selection.² The usual Congressional hearings on the VA leadership mismanagement of the EHR culminated in Sen Jon Tester’s (D-MO) martial declaration in a letter to the newly sworn-in VA Chief Information Officer James Paul Gfrerer that “EHR modernization cannot fail.”³

While all this is obviously important, it is not why the annual awards for ethical and unethical behaviors are bestowed on what is essentially an information technology acquisition. The Cerner contract is chosen because of its enormous potential to change the human practice of health care for good or ill; hence, the dual nomination. This column is not about Cerner qua Cerner but about how the EHR has transformed—or deformed—the humanistic aspects of medical practice.

I am old enough to remember the original transition from paper charts to VistA EHR. As an intern with illegible handwriting, I can remember breathing a sigh of relief when the blue screen appeared for the first time. The commands were cumbersome and the code laborious, but it was a technologic marvel to see the clean, organized progress notes and be able to print your medication list or discharge summary. However, it also was the first stuttering waves of a tsunami that would alter medical practice forever. The human cost of the revolution could be seen almost immediately as older clinicians or those who could not type struggled to complete work that with paper and pen would have been easily accomplished.

For many years there was a steady stream of updates to VistA, including the Computerized Patient Record System (CPRS). For a relatively long time in technology terms, VistA and CPRS were the envy of the medical world, which rushed to catch up. Gradually though, VA fell behind; the wizard IT guys could not patch and fix new versions fast enough, and eventually, like all things created, VistA and CPRS became obsolete.⁴ Attitudes toward this microcosm of the modernization of an aging organization were intense and diverse. Some of us held onto CPRS as though it was a transitional object that we had personalized and became attached to with all its quirks and problems. Others could not wait to get rid of it, believing anything new and streamlined had to be better.

Yet the opposite also is true. EHRs have been, and could be again, incredible time-savers, enabling HCPs to deliver more evidence-based, patient-centered care in a more accurate, integrated, timely, and comprehensive manner. For example, Cerner finally could discover the Holy Grail of VA-DoD interoperability and even—dare we dream—integrate with the community. Yet as science fiction aficionados know, the machine designed to free humankind of drudgery may also end up controlling us.

The other commonplace year-end practice is for ersatz prophets to predict the future. I have no idea whether the Cerner EHR will be good or bad for VA and DoD. According to the insightful critic of medical culture, Atul Gawande, MD, who has examined the practitioner-computer interface, what we must guard against is that it does not replace the practitioner-patient relationship.⁵ The most common complaint I hear from patients in VA mental health care is: “They never listen to me, they just sit there typing.” Similarly, clinicians complain: “I spend all my time looking at a screen not at a patient.” As an ethicist, I cannot tell you how many times the blight of copy and paste has thwarted or damaged a patient’s care. And the direct correlation between medical computing and burnout has been well documented as all health care systems struggle with a doctor shortage particularly in primary care—arguably where computer fatigue hits hardest.⁶

What will decide whether EHR modernization will be a positive or negative development for VA and DoD patients? And is there anything we as federal HCPs can do to tip the scales in favor of the what is best for patients and clinicians? The most encouraging step has already been taken: VA and Cerner have set up EHR Councils composed of 60% practicing VA HCPs to provide the clinical perspective and 40% from VA Central Office to encourage synchronization of the top-down and bottom-up processes.⁷

Many experts have pointed out the inherent tension between how computers and human beings work, which I will simplify as the battle between the 3 S’s and the 3 F’s.⁵ The optimal operation of EHRs requires systems, structure, stability; to function successfully human beings need flexibility, freedom, and fragmentation. VistA had more than 100 versions according to a report from the Federal News Network (FNN), which is a striking example of the challenge EHR modernization faces in bridging the 2 orientations. As former VA Chief Information Officer Roger Baker told FNN, replacing this approach of EHR tinkering with a locked-down commercial system will require “a culture change that is orders of magnitude bigger than expected.”⁸

Think of the 2 domains as a Venn diagram. Where the circles overlap is all the things we and patients want and need in health care: empathic listening, strong enduring relationships, accurate diagnosis, accessibility, personalized treatment, continuity of care, mutual respect, patient safety, room to exercise professional judgment, and the data needed to promote shared decision making. Our contribution and duty are to make that inner circle where we all dwell together as wide and full as possible and the overlap between the 2 outer circles as seamless as human imperfection and artificial intelligence permit.

The Gawande article is titled “Why Doctors Hate Their Computers.” Of course, his piece shows that we also love them. None of the proposed liberations from our EHR domination—be they medical scribes or dictation programs—has solved the problem, probably because they are all technologic and just move the slavery downstream. We have come too far, and medicine is too complex, to go back to the age of paper. If we can no longer do the good work of healing and caring without computers, then we have to learn to live with them as our allies not our enemies. After all, even Dr. McCoy had a tricorder.

I am a doctor, not an engineer.Dr. McCoy, Star Trek “Mirror, Mirror” episode

Last year in my annual wrap-up, I wrote back-to-back editorials (December 2017 and January 2018) on the worst and best of 2017 from a federal health care perspective, emphasizing ethics or the lack thereof. I featured the altruism of federal health care providers (HCPs) responding to natural disasters and the terrible outcome of seemingly banal moral lapses.

This year the best and worst are one and the same, and I am not sure how it could be otherwise: the Department of Veterans Affairs (VA) and Department of Defense (DoD) electronic health record (EHR) contract with Cerner (North Kansas City, MO). Former VA Secretary David Shulkin, MD, announced the deal in 2017 shortly before his departure, and it was signed under then Acting VA Secretary Robert Wilkie in May of 2018.¹ But the reason the Cerner contract is the most impactful and momentous ethical event of the year is perhaps not what readers expect. Search engines will efficiently unearth plentiful drama with ethical import about the contract. There were conspiracy charges that the shadow regime improperly engineered the selection.² The usual Congressional hearings on the VA leadership mismanagement of the EHR culminated in Sen Jon Tester’s (D-MO) martial declaration in a letter to the newly sworn-in VA Chief Information Officer James Paul Gfrerer that “EHR modernization cannot fail.”³

While all this is obviously important, it is not why the annual awards for ethical and unethical behaviors are bestowed on what is essentially an information technology acquisition. The Cerner contract is chosen because of its enormous potential to change the human practice of health care for good or ill; hence, the dual nomination. This column is not about Cerner qua Cerner but about how the EHR has transformed—or deformed—the humanistic aspects of medical practice.

I am old enough to remember the original transition from paper charts to VistA EHR. As an intern with illegible handwriting, I can remember breathing a sigh of relief when the blue screen appeared for the first time. The commands were cumbersome and the code laborious, but it was a technologic marvel to see the clean, organized progress notes and be able to print your medication list or discharge summary. However, it also was the first stuttering waves of a tsunami that would alter medical practice forever. The human cost of the revolution could be seen almost immediately as older clinicians or those who could not type struggled to complete work that with paper and pen would have been easily accomplished.

For many years there was a steady stream of updates to VistA, including the Computerized Patient Record System (CPRS). For a relatively long time in technology terms, VistA and CPRS were the envy of the medical world, which rushed to catch up. Gradually though, VA fell behind; the wizard IT guys could not patch and fix new versions fast enough, and eventually, like all things created, VistA and CPRS became obsolete.⁴ Attitudes toward this microcosm of the modernization of an aging organization were intense and diverse. Some of us held onto CPRS as though it was a transitional object that we had personalized and became attached to with all its quirks and problems. Others could not wait to get rid of it, believing anything new and streamlined had to be better.

Yet the opposite also is true. EHRs have been, and could be again, incredible time-savers, enabling HCPs to deliver more evidence-based, patient-centered care in a more accurate, integrated, timely, and comprehensive manner. For example, Cerner finally could discover the Holy Grail of VA-DoD interoperability and even—dare we dream—integrate with the community. Yet as science fiction aficionados know, the machine designed to free humankind of drudgery may also end up controlling us.

The other commonplace year-end practice is for ersatz prophets to predict the future. I have no idea whether the Cerner EHR will be good or bad for VA and DoD. According to the insightful critic of medical culture, Atul Gawande, MD, who has examined the practitioner-computer interface, what we must guard against is that it does not replace the practitioner-patient relationship.⁵ The most common complaint I hear from patients in VA mental health care is: “They never listen to me, they just sit there typing.” Similarly, clinicians complain: “I spend all my time looking at a screen not at a patient.” As an ethicist, I cannot tell you how many times the blight of copy and paste has thwarted or damaged a patient’s care. And the direct correlation between medical computing and burnout has been well documented as all health care systems struggle with a doctor shortage particularly in primary care—arguably where computer fatigue hits hardest.⁶

What will decide whether EHR modernization will be a positive or negative development for VA and DoD patients? And is there anything we as federal HCPs can do to tip the scales in favor of the what is best for patients and clinicians? The most encouraging step has already been taken: VA and Cerner have set up EHR Councils composed of 60% practicing VA HCPs to provide the clinical perspective and 40% from VA Central Office to encourage synchronization of the top-down and bottom-up processes.⁷

Many experts have pointed out the inherent tension between how computers and human beings work, which I will simplify as the battle between the 3 S’s and the 3 F’s.⁵ The optimal operation of EHRs requires systems, structure, stability; to function successfully human beings need flexibility, freedom, and fragmentation. VistA had more than 100 versions according to a report from the Federal News Network (FNN), which is a striking example of the challenge EHR modernization faces in bridging the 2 orientations. As former VA Chief Information Officer Roger Baker told FNN, replacing this approach of EHR tinkering with a locked-down commercial system will require “a culture change that is orders of magnitude bigger than expected.”⁸

Think of the 2 domains as a Venn diagram. Where the circles overlap is all the things we and patients want and need in health care: empathic listening, strong enduring relationships, accurate diagnosis, accessibility, personalized treatment, continuity of care, mutual respect, patient safety, room to exercise professional judgment, and the data needed to promote shared decision making. Our contribution and duty are to make that inner circle where we all dwell together as wide and full as possible and the overlap between the 2 outer circles as seamless as human imperfection and artificial intelligence permit.

The Gawande article is titled “Why Doctors Hate Their Computers.” Of course, his piece shows that we also love them. None of the proposed liberations from our EHR domination—be they medical scribes or dictation programs—has solved the problem, probably because they are all technologic and just move the slavery downstream. We have come too far, and medicine is too complex, to go back to the age of paper. If we can no longer do the good work of healing and caring without computers, then we have to learn to live with them as our allies not our enemies. After all, even Dr. McCoy had a tricorder.

I am a doctor, not an engineer.Dr. McCoy, Star Trek “Mirror, Mirror” episode

Last year in my annual wrap-up, I wrote back-to-back editorials (December 2017 and January 2018) on the worst and best of 2017 from a federal health care perspective, emphasizing ethics or the lack thereof. I featured the altruism of federal health care providers (HCPs) responding to natural disasters and the terrible outcome of seemingly banal moral lapses.

This year the best and worst are one and the same, and I am not sure how it could be otherwise: the Department of Veterans Affairs (VA) and Department of Defense (DoD) electronic health record (EHR) contract with Cerner (North Kansas City, MO). Former VA Secretary David Shulkin, MD, announced the deal in 2017 shortly before his departure, and it was signed under then Acting VA Secretary Robert Wilkie in May of 2018.¹ But the reason the Cerner contract is the most impactful and momentous ethical event of the year is perhaps not what readers expect. Search engines will efficiently unearth plentiful drama with ethical import about the contract. There were conspiracy charges that the shadow regime improperly engineered the selection.² The usual Congressional hearings on the VA leadership mismanagement of the EHR culminated in Sen Jon Tester’s (D-MO) martial declaration in a letter to the newly sworn-in VA Chief Information Officer James Paul Gfrerer that “EHR modernization cannot fail.”³

While all this is obviously important, it is not why the annual awards for ethical and unethical behaviors are bestowed on what is essentially an information technology acquisition. The Cerner contract is chosen because of its enormous potential to change the human practice of health care for good or ill; hence, the dual nomination. This column is not about Cerner qua Cerner but about how the EHR has transformed—or deformed—the humanistic aspects of medical practice.

I am old enough to remember the original transition from paper charts to VistA EHR. As an intern with illegible handwriting, I can remember breathing a sigh of relief when the blue screen appeared for the first time. The commands were cumbersome and the code laborious, but it was a technologic marvel to see the clean, organized progress notes and be able to print your medication list or discharge summary. However, it also was the first stuttering waves of a tsunami that would alter medical practice forever. The human cost of the revolution could be seen almost immediately as older clinicians or those who could not type struggled to complete work that with paper and pen would have been easily accomplished.

For many years there was a steady stream of updates to VistA, including the Computerized Patient Record System (CPRS). For a relatively long time in technology terms, VistA and CPRS were the envy of the medical world, which rushed to catch up. Gradually though, VA fell behind; the wizard IT guys could not patch and fix new versions fast enough, and eventually, like all things created, VistA and CPRS became obsolete.⁴ Attitudes toward this microcosm of the modernization of an aging organization were intense and diverse. Some of us held onto CPRS as though it was a transitional object that we had personalized and became attached to with all its quirks and problems. Others could not wait to get rid of it, believing anything new and streamlined had to be better.

Yet the opposite also is true. EHRs have been, and could be again, incredible time-savers, enabling HCPs to deliver more evidence-based, patient-centered care in a more accurate, integrated, timely, and comprehensive manner. For example, Cerner finally could discover the Holy Grail of VA-DoD interoperability and even—dare we dream—integrate with the community. Yet as science fiction aficionados know, the machine designed to free humankind of drudgery may also end up controlling us.

The other commonplace year-end practice is for ersatz prophets to predict the future. I have no idea whether the Cerner EHR will be good or bad for VA and DoD. According to the insightful critic of medical culture, Atul Gawande, MD, who has examined the practitioner-computer interface, what we must guard against is that it does not replace the practitioner-patient relationship.⁵ The most common complaint I hear from patients in VA mental health care is: “They never listen to me, they just sit there typing.” Similarly, clinicians complain: “I spend all my time looking at a screen not at a patient.” As an ethicist, I cannot tell you how many times the blight of copy and paste has thwarted or damaged a patient’s care. And the direct correlation between medical computing and burnout has been well documented as all health care systems struggle with a doctor shortage particularly in primary care—arguably where computer fatigue hits hardest.⁶

What will decide whether EHR modernization will be a positive or negative development for VA and DoD patients? And is there anything we as federal HCPs can do to tip the scales in favor of the what is best for patients and clinicians? The most encouraging step has already been taken: VA and Cerner have set up EHR Councils composed of 60% practicing VA HCPs to provide the clinical perspective and 40% from VA Central Office to encourage synchronization of the top-down and bottom-up processes.⁷

Many experts have pointed out the inherent tension between how computers and human beings work, which I will simplify as the battle between the 3 S’s and the 3 F’s.⁵ The optimal operation of EHRs requires systems, structure, stability; to function successfully human beings need flexibility, freedom, and fragmentation. VistA had more than 100 versions according to a report from the Federal News Network (FNN), which is a striking example of the challenge EHR modernization faces in bridging the 2 orientations. As former VA Chief Information Officer Roger Baker told FNN, replacing this approach of EHR tinkering with a locked-down commercial system will require “a culture change that is orders of magnitude bigger than expected.”⁸

Think of the 2 domains as a Venn diagram. Where the circles overlap is all the things we and patients want and need in health care: empathic listening, strong enduring relationships, accurate diagnosis, accessibility, personalized treatment, continuity of care, mutual respect, patient safety, room to exercise professional judgment, and the data needed to promote shared decision making. Our contribution and duty are to make that inner circle where we all dwell together as wide and full as possible and the overlap between the 2 outer circles as seamless as human imperfection and artificial intelligence permit.

The Gawande article is titled “Why Doctors Hate Their Computers.” Of course, his piece shows that we also love them. None of the proposed liberations from our EHR domination—be they medical scribes or dictation programs—has solved the problem, probably because they are all technologic and just move the slavery downstream. We have come too far, and medicine is too complex, to go back to the age of paper. If we can no longer do the good work of healing and caring without computers, then we have to learn to live with them as our allies not our enemies. After all, even Dr. McCoy had a tricorder.

Almost all pregnant women would want information about serious treatable childhood-onset conditions from non-invasive prenatal whole-genome sequencing. Also today, a look at asthma, obesity, and the risk for severe sleep apnea in children, new questions about the role that antinuclear antibodies are playing in systemic lupus erythematosus, and the lifetime cost of tobacco is nearly $2 million per smoker.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

Almost all pregnant women would want information about serious treatable childhood-onset conditions from non-invasive prenatal whole-genome sequencing. Also today, a look at asthma, obesity, and the risk for severe sleep apnea in children, new questions about the role that antinuclear antibodies are playing in systemic lupus erythematosus, and the lifetime cost of tobacco is nearly $2 million per smoker.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

Almost all pregnant women would want information about serious treatable childhood-onset conditions from non-invasive prenatal whole-genome sequencing. Also today, a look at asthma, obesity, and the risk for severe sleep apnea in children, new questions about the role that antinuclear antibodies are playing in systemic lupus erythematosus, and the lifetime cost of tobacco is nearly $2 million per smoker.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

Granuloma annulare (GA) is a granulomatous skin disorder of uncertain etiology. A number of clinical variants exist, most commonly localized annular plaques on the hands or feet, generalized lesions, or subcutaneous nodules in children. Histologically, GA exhibits granulomatous inflammation with either interstitial or palisading lymphocytes and histiocytes with mucin deposition.

Few data exist regarding the epidemiology of GA. Although the pathogenesis of GA is unknown, associations between GA and underlying systemic processes, such as diabetes mellitus, hyperlipidemia, thyroid disease, and human immunodeficiency virus (HIV), have been suggested.

The purpose of this retrospective study was to determine the number of cases of GA seen annually at the Department of Dermatology at the University of Pennsylvania (Philadelphia, Pennsylvania) from 2008 to 2014. Additionally, we reviewed all cases of biopsy-proven GA from 2010 to 2014 and reported the demographics, underlying medical comorbidities, medications, treatments, and outcomes seen in this patient population.

Methods

We identified the number of outpatients presenting with GA annually using PennSeek, a tool developed by the Penn Medicine Data Analytics Center to search electronic medical records (EMRs). We queried the EMR database to determine the number of discrete patients seen at the Department of Dermatology at the University of Pennsylvania annually from 2008 (the year the EMR was established) to 2014. We then used PennSeek to determine the number of patients given a diagnosis of GA annually from 2008 to 2014 based on the International Classification of Diseases, Ninth Revision (ICD-9).

After using PennSeek to identify all patients given the ICD-9 diagnosis of GA from 2008 to 2014, we reviewed the EMRs of these patients to identify cases that were biopsy proven. For the biopsy-proven cases of GA seen at the University of Pennsylvania from 2010 to 2014, we reviewed the EMRs of these patients for clinical characteristics and treatment outcomes. For each case, we recorded the patient’s age, sex, medical comorbidities, GA subtype, and medications.

This study was approved by the University of Pennsylvania’s institutional review board.

Results

On average, the percentage of patients given a diagnosis of GA annually was 0.22% (95% CI, 0.19%-0.24%). A Pearson χ² test was used to determine if any single annual percentage was significantly different from the others. We found a P value of .321, which suggests that the percentage of patients with GA seen annually has been stable from 2008 to 2014 (Figure).

There were 133 cases of biopsy-proven GA that were reviewed for clinical characteristics; of them, 86.5% were female. Thyroid disease was noted in 30.1% of patients, hyperlipidemia in 30.1%, and hematologic malignancies in 3.8%. Type 1 diabetes mellitus was noted in 1.5% of patients. None of the patients were HIV-positive, 1.5% were hepatitis B–positive, and 2.3% were hepatitis C–positive. Of the 133 cases, 64.7% had localized GA and 30.8% had generalized GA. Photosensitive and papular GA were rarer (1.5% and 2.3% of cases, respectively). Use of a selective serotonin reuptake inhibitor (SSRI) was noted in 18.1% of patients; use of a calcium channel blocker was noted in 9.0% (Table 1).

Comment

We attempted to determine the period of prevalence of GA in a tertiary care, university-based referral practice and evaluate disease associations, treatments, and outcomes of patients with biopsy-proven GA. Our calculated period prevalence of GA of 0.22% to 0.27% is consistent with another review, which reported that 0.1% to 0.4% of new patients presenting to a dermatology practice were given a diagnosis of GA.¹ More than 85% of the cases we reviewed were seen in females, a finding that is more heavily skewed compared to prior reports that have suggested a female to male ratio of approximately 1:1 to 2:1.^1-7 Our findings suggest that GA is a female-predominant condition, or women may be more likely to seek evaluation for the condition.

More than 95% of the cases we reviewed were localized (64.7%) or generalized (30.8%) GA, making these variants the most common forms of GA, which is consistent with prior reports.^1-3,8,9 Other varieties of GA—drug induced, patch, perforating, photosensitive, palmar, and papular—appear rare. Because this study was conducted at an adult hospital, subcutaneous GA, which often is seen in children, may be underrepresented. As a retrospective chart review, it is possible that documentation is insufficient to capture each rare variant.

At 1.5%, the prevalence of type 1 diabetes mellitus in our patients is slightly higher than the national average of 0.3%.²⁵ However, based on a Fisher exact test of analysis of proportions, this difference is not statistically significant (P=.106).

At 1.5% and 2.3%, the prevalence of hepatitis B and hepatitis C, respectively, in our patients is slightly higher than the national average of 0.5% and 1%, respectively.²⁶ However, based on a Fisher exact test of analysis of proportions, these differences are not statistically significant (P=.142 and P=.146, respectively).

Given the high prevalence of hyperlipidemia in the United States (31.7%), this disease is not overrepresented in our sample (30.1%), though others have suggested there may be a connection.^27,28 Based on a Fisher exact test, this difference of proportions is not statistically significant (P=.780).

Selective serotonin reuptake inhibitor use is common in the United States; approximately 11% of Americans older than 12 years use an SSRI.²⁹ At 18.1%, the use of SSRIs in our patient group was statistically significantly higher than the national average (Fisher exact test, P=.017), suggesting a possible association between SSRI use and development of GA, warranting further investigation.

The use of calcium channel blockers, interferon, and tumor necrosis factor inhibitors was not significantly associated with GA in our series.

GA Therapy
The most commonly used treatments for GA in our study were topical steroids and intralesional triamcinolone, followed by hydroxychloroquine; all treatments employed exhibited a widely variable response. Assessing treatment response via retrospective chart review is challenging and response rates may not be accurately captured.

Study Limitations
Our study had several limitations. In calculating the period prevalence of GA, our query was limited by the number of years that the EMR has been in place. The number of cases we reviewed for clinical characteristics was limited to 133, as many cases with the ICD-9 diagnosis of GA were not biopsy proven and therefore were not included in our review. Many of the cases we reviewed were lost to follow-up, which prevented us from determining treatment outcomes.

Another weakness of our study was that our query did not provide an estimate of incidence or prevalence of GA overall, as this analysis was not a population-based study. The power of our study was limited by the number of cases of GA seen annually and the number of patients lost to follow-up. Additionally, our study population may only be generalizable to other large academic centers.

Conclusion

This study further solidifies our understanding of the epidemiology of GA and diseases that can be associated with GA. We identified a higher female to male ratio than previous reports, and consistent with prior reports, we noted potential associations with conditions such as thyroid disease and hyperlipidemia. Our population demonstrated higher rates of SSRI use than expected, warranting further investigation. Dermatologists should be aware of potential disease associations with GA, but as a whole we need better data and larger studies to determine the appropriate evaluation and treatment for patients with GA.

Granuloma annulare (GA) is a granulomatous skin disorder of uncertain etiology. A number of clinical variants exist, most commonly localized annular plaques on the hands or feet, generalized lesions, or subcutaneous nodules in children. Histologically, GA exhibits granulomatous inflammation with either interstitial or palisading lymphocytes and histiocytes with mucin deposition.

Few data exist regarding the epidemiology of GA. Although the pathogenesis of GA is unknown, associations between GA and underlying systemic processes, such as diabetes mellitus, hyperlipidemia, thyroid disease, and human immunodeficiency virus (HIV), have been suggested.

The purpose of this retrospective study was to determine the number of cases of GA seen annually at the Department of Dermatology at the University of Pennsylvania (Philadelphia, Pennsylvania) from 2008 to 2014. Additionally, we reviewed all cases of biopsy-proven GA from 2010 to 2014 and reported the demographics, underlying medical comorbidities, medications, treatments, and outcomes seen in this patient population.

Methods

We identified the number of outpatients presenting with GA annually using PennSeek, a tool developed by the Penn Medicine Data Analytics Center to search electronic medical records (EMRs). We queried the EMR database to determine the number of discrete patients seen at the Department of Dermatology at the University of Pennsylvania annually from 2008 (the year the EMR was established) to 2014. We then used PennSeek to determine the number of patients given a diagnosis of GA annually from 2008 to 2014 based on the International Classification of Diseases, Ninth Revision (ICD-9).

After using PennSeek to identify all patients given the ICD-9 diagnosis of GA from 2008 to 2014, we reviewed the EMRs of these patients to identify cases that were biopsy proven. For the biopsy-proven cases of GA seen at the University of Pennsylvania from 2010 to 2014, we reviewed the EMRs of these patients for clinical characteristics and treatment outcomes. For each case, we recorded the patient’s age, sex, medical comorbidities, GA subtype, and medications.

This study was approved by the University of Pennsylvania’s institutional review board.

Results

On average, the percentage of patients given a diagnosis of GA annually was 0.22% (95% CI, 0.19%-0.24%). A Pearson χ² test was used to determine if any single annual percentage was significantly different from the others. We found a P value of .321, which suggests that the percentage of patients with GA seen annually has been stable from 2008 to 2014 (Figure).

There were 133 cases of biopsy-proven GA that were reviewed for clinical characteristics; of them, 86.5% were female. Thyroid disease was noted in 30.1% of patients, hyperlipidemia in 30.1%, and hematologic malignancies in 3.8%. Type 1 diabetes mellitus was noted in 1.5% of patients. None of the patients were HIV-positive, 1.5% were hepatitis B–positive, and 2.3% were hepatitis C–positive. Of the 133 cases, 64.7% had localized GA and 30.8% had generalized GA. Photosensitive and papular GA were rarer (1.5% and 2.3% of cases, respectively). Use of a selective serotonin reuptake inhibitor (SSRI) was noted in 18.1% of patients; use of a calcium channel blocker was noted in 9.0% (Table 1).

Comment

We attempted to determine the period of prevalence of GA in a tertiary care, university-based referral practice and evaluate disease associations, treatments, and outcomes of patients with biopsy-proven GA. Our calculated period prevalence of GA of 0.22% to 0.27% is consistent with another review, which reported that 0.1% to 0.4% of new patients presenting to a dermatology practice were given a diagnosis of GA.¹ More than 85% of the cases we reviewed were seen in females, a finding that is more heavily skewed compared to prior reports that have suggested a female to male ratio of approximately 1:1 to 2:1.^1-7 Our findings suggest that GA is a female-predominant condition, or women may be more likely to seek evaluation for the condition.

More than 95% of the cases we reviewed were localized (64.7%) or generalized (30.8%) GA, making these variants the most common forms of GA, which is consistent with prior reports.^1-3,8,9 Other varieties of GA—drug induced, patch, perforating, photosensitive, palmar, and papular—appear rare. Because this study was conducted at an adult hospital, subcutaneous GA, which often is seen in children, may be underrepresented. As a retrospective chart review, it is possible that documentation is insufficient to capture each rare variant.

At 1.5%, the prevalence of type 1 diabetes mellitus in our patients is slightly higher than the national average of 0.3%.²⁵ However, based on a Fisher exact test of analysis of proportions, this difference is not statistically significant (P=.106).

At 1.5% and 2.3%, the prevalence of hepatitis B and hepatitis C, respectively, in our patients is slightly higher than the national average of 0.5% and 1%, respectively.²⁶ However, based on a Fisher exact test of analysis of proportions, these differences are not statistically significant (P=.142 and P=.146, respectively).

Given the high prevalence of hyperlipidemia in the United States (31.7%), this disease is not overrepresented in our sample (30.1%), though others have suggested there may be a connection.^27,28 Based on a Fisher exact test, this difference of proportions is not statistically significant (P=.780).

Selective serotonin reuptake inhibitor use is common in the United States; approximately 11% of Americans older than 12 years use an SSRI.²⁹ At 18.1%, the use of SSRIs in our patient group was statistically significantly higher than the national average (Fisher exact test, P=.017), suggesting a possible association between SSRI use and development of GA, warranting further investigation.

The use of calcium channel blockers, interferon, and tumor necrosis factor inhibitors was not significantly associated with GA in our series.

GA Therapy
The most commonly used treatments for GA in our study were topical steroids and intralesional triamcinolone, followed by hydroxychloroquine; all treatments employed exhibited a widely variable response. Assessing treatment response via retrospective chart review is challenging and response rates may not be accurately captured.

Study Limitations
Our study had several limitations. In calculating the period prevalence of GA, our query was limited by the number of years that the EMR has been in place. The number of cases we reviewed for clinical characteristics was limited to 133, as many cases with the ICD-9 diagnosis of GA were not biopsy proven and therefore were not included in our review. Many of the cases we reviewed were lost to follow-up, which prevented us from determining treatment outcomes.

Another weakness of our study was that our query did not provide an estimate of incidence or prevalence of GA overall, as this analysis was not a population-based study. The power of our study was limited by the number of cases of GA seen annually and the number of patients lost to follow-up. Additionally, our study population may only be generalizable to other large academic centers.

Conclusion

This study further solidifies our understanding of the epidemiology of GA and diseases that can be associated with GA. We identified a higher female to male ratio than previous reports, and consistent with prior reports, we noted potential associations with conditions such as thyroid disease and hyperlipidemia. Our population demonstrated higher rates of SSRI use than expected, warranting further investigation. Dermatologists should be aware of potential disease associations with GA, but as a whole we need better data and larger studies to determine the appropriate evaluation and treatment for patients with GA.

Granuloma annulare (GA) is a granulomatous skin disorder of uncertain etiology. A number of clinical variants exist, most commonly localized annular plaques on the hands or feet, generalized lesions, or subcutaneous nodules in children. Histologically, GA exhibits granulomatous inflammation with either interstitial or palisading lymphocytes and histiocytes with mucin deposition.

Few data exist regarding the epidemiology of GA. Although the pathogenesis of GA is unknown, associations between GA and underlying systemic processes, such as diabetes mellitus, hyperlipidemia, thyroid disease, and human immunodeficiency virus (HIV), have been suggested.

The purpose of this retrospective study was to determine the number of cases of GA seen annually at the Department of Dermatology at the University of Pennsylvania (Philadelphia, Pennsylvania) from 2008 to 2014. Additionally, we reviewed all cases of biopsy-proven GA from 2010 to 2014 and reported the demographics, underlying medical comorbidities, medications, treatments, and outcomes seen in this patient population.

Methods

We identified the number of outpatients presenting with GA annually using PennSeek, a tool developed by the Penn Medicine Data Analytics Center to search electronic medical records (EMRs). We queried the EMR database to determine the number of discrete patients seen at the Department of Dermatology at the University of Pennsylvania annually from 2008 (the year the EMR was established) to 2014. We then used PennSeek to determine the number of patients given a diagnosis of GA annually from 2008 to 2014 based on the International Classification of Diseases, Ninth Revision (ICD-9).

After using PennSeek to identify all patients given the ICD-9 diagnosis of GA from 2008 to 2014, we reviewed the EMRs of these patients to identify cases that were biopsy proven. For the biopsy-proven cases of GA seen at the University of Pennsylvania from 2010 to 2014, we reviewed the EMRs of these patients for clinical characteristics and treatment outcomes. For each case, we recorded the patient’s age, sex, medical comorbidities, GA subtype, and medications.

This study was approved by the University of Pennsylvania’s institutional review board.

Results

On average, the percentage of patients given a diagnosis of GA annually was 0.22% (95% CI, 0.19%-0.24%). A Pearson χ² test was used to determine if any single annual percentage was significantly different from the others. We found a P value of .321, which suggests that the percentage of patients with GA seen annually has been stable from 2008 to 2014 (Figure).

There were 133 cases of biopsy-proven GA that were reviewed for clinical characteristics; of them, 86.5% were female. Thyroid disease was noted in 30.1% of patients, hyperlipidemia in 30.1%, and hematologic malignancies in 3.8%. Type 1 diabetes mellitus was noted in 1.5% of patients. None of the patients were HIV-positive, 1.5% were hepatitis B–positive, and 2.3% were hepatitis C–positive. Of the 133 cases, 64.7% had localized GA and 30.8% had generalized GA. Photosensitive and papular GA were rarer (1.5% and 2.3% of cases, respectively). Use of a selective serotonin reuptake inhibitor (SSRI) was noted in 18.1% of patients; use of a calcium channel blocker was noted in 9.0% (Table 1).

Comment

We attempted to determine the period of prevalence of GA in a tertiary care, university-based referral practice and evaluate disease associations, treatments, and outcomes of patients with biopsy-proven GA. Our calculated period prevalence of GA of 0.22% to 0.27% is consistent with another review, which reported that 0.1% to 0.4% of new patients presenting to a dermatology practice were given a diagnosis of GA.¹ More than 85% of the cases we reviewed were seen in females, a finding that is more heavily skewed compared to prior reports that have suggested a female to male ratio of approximately 1:1 to 2:1.^1-7 Our findings suggest that GA is a female-predominant condition, or women may be more likely to seek evaluation for the condition.

More than 95% of the cases we reviewed were localized (64.7%) or generalized (30.8%) GA, making these variants the most common forms of GA, which is consistent with prior reports.^1-3,8,9 Other varieties of GA—drug induced, patch, perforating, photosensitive, palmar, and papular—appear rare. Because this study was conducted at an adult hospital, subcutaneous GA, which often is seen in children, may be underrepresented. As a retrospective chart review, it is possible that documentation is insufficient to capture each rare variant.

At 1.5%, the prevalence of type 1 diabetes mellitus in our patients is slightly higher than the national average of 0.3%.²⁵ However, based on a Fisher exact test of analysis of proportions, this difference is not statistically significant (P=.106).

At 1.5% and 2.3%, the prevalence of hepatitis B and hepatitis C, respectively, in our patients is slightly higher than the national average of 0.5% and 1%, respectively.²⁶ However, based on a Fisher exact test of analysis of proportions, these differences are not statistically significant (P=.142 and P=.146, respectively).

Given the high prevalence of hyperlipidemia in the United States (31.7%), this disease is not overrepresented in our sample (30.1%), though others have suggested there may be a connection.^27,28 Based on a Fisher exact test, this difference of proportions is not statistically significant (P=.780).

Selective serotonin reuptake inhibitor use is common in the United States; approximately 11% of Americans older than 12 years use an SSRI.²⁹ At 18.1%, the use of SSRIs in our patient group was statistically significantly higher than the national average (Fisher exact test, P=.017), suggesting a possible association between SSRI use and development of GA, warranting further investigation.

The use of calcium channel blockers, interferon, and tumor necrosis factor inhibitors was not significantly associated with GA in our series.

GA Therapy
The most commonly used treatments for GA in our study were topical steroids and intralesional triamcinolone, followed by hydroxychloroquine; all treatments employed exhibited a widely variable response. Assessing treatment response via retrospective chart review is challenging and response rates may not be accurately captured.

Study Limitations
Our study had several limitations. In calculating the period prevalence of GA, our query was limited by the number of years that the EMR has been in place. The number of cases we reviewed for clinical characteristics was limited to 133, as many cases with the ICD-9 diagnosis of GA were not biopsy proven and therefore were not included in our review. Many of the cases we reviewed were lost to follow-up, which prevented us from determining treatment outcomes.

Another weakness of our study was that our query did not provide an estimate of incidence or prevalence of GA overall, as this analysis was not a population-based study. The power of our study was limited by the number of cases of GA seen annually and the number of patients lost to follow-up. Additionally, our study population may only be generalizable to other large academic centers.

Conclusion

This study further solidifies our understanding of the epidemiology of GA and diseases that can be associated with GA. We identified a higher female to male ratio than previous reports, and consistent with prior reports, we noted potential associations with conditions such as thyroid disease and hyperlipidemia. Our population demonstrated higher rates of SSRI use than expected, warranting further investigation. Dermatologists should be aware of potential disease associations with GA, but as a whole we need better data and larger studies to determine the appropriate evaluation and treatment for patients with GA.

Evidence that American football can lead to chronic traumatic encephalopathy (CTE), continues to grow. As a result, some parents are opting to sign their sons up for other sports.

©james boulette/Thinkstock

In the 2017-2018 school year, 6.6% fewer high school athletes participated in tackle football than did 8 years before according to the National Federation of State High School Associations. As the movement away from football continues, a pronounced shift is occurring in the prevalence of young black men in the game.

Many black parents encourage their sons to play football as a way to protect them gang activity. In addition, the sport can be their sole option for securing a college education for their children, an article in the Atlantic said. A recent survey of 50,000 8th-, 10th-, and 12th-grade students found that tackle football is predominantly the domain of black youth.

“This divergence paints a troubling picture of how economic opportunity – or a lack thereof – governs which boys are incentivized to put their body and brain at risk to play. Depending on where families live, and what other options are available to them, they see either a game that is too violent to consider or one that is necessary and important, if risky. Millions of Americans still watch football; NFL ratings were up this season,” Alana Semuels wrote in the article. “That a distinct portion of families won’t let their children play creates a disturbing future for the country’s most popular game.”

“Without a reversal in economic fortunes for poor communities across the country, football could one day become a sport played almost exclusively by black athletes, while still enjoyed by everyone. Black athletes – who already make up the majority of players in the most dangerous on-field positions – would continue to suffer from long-term brain damage, their life cut short by dementia and the scourge of CTE,” she wrote.

Meanwhile, numerous outlets reported that Super Bowl LIII garnered the lowest ratings since 2008.
 

Psychiatric hospital set to close

In both Kansas and Missouri, a shortage in mental health care has become evident, according to an article in the Kansas City Star. And now the Two Rivers Behavioral Health System, a private psychiatric hospital in southeast Kansas City, Mo., is closing its doors. The result will be a loss of 129 jobs and 105 fewer mental health beds in the city.

Patients currently in the facility will be relocated, and their care will continue. But for those who come after, care will now be tougher to find.

Two Rivers, owned by Pennsylvania-based Universal Health Services, treats children and adults. It had 2,347 discharges in 2017 and almost $28 million in revenue but had a net loss of about $3.4 million. The facility has been under scrutiny in the past two decades over its treatment of patients, with accusations about the bolstering of false memories concerning involvements in satanic cults and the treatment of a convicted sex offender who assaulted another patient. The most recent state inspection showed that Two Rivers had failed to provide a safe environment for six patients who were considered suicide risks. The patients had unsupervised access to the nurses’ station, as well as access to pens that could have been used for stabbing and a charging cord that could have been used for strangulation.

In an interview with the Star, Mark Stringer, director of the Missouri Department of Mental Health, said private psychiatric hospitals like Two Rivers are finding it harder to keep functioning, partly because of nursing shortages. Private facilities are not subsidized like state mental hospitals and are unable to secure staff from other facilities.

“There is a general worry about the availability of psychiatric services for people in crisis; there’s just no doubt about that,” Mr. Stringer said. “The loss of beds certainly hurts.”
 

New center offers ‘kind patient care’

In Nashville, Tenn., a new mental illness crisis treatment center is open. The center offers a 24/7 option for those with mental health issues who have run afoul of the law. Instead of incarceration, they can receive treatment, the Tennessean reported.

Estimates are that more than 1 million residents of Tennessee aged 18 years and older have a mental health or substance use disorder. About 25% of those residents having a serious mental health illness.

The new facility includes a crisis walk-in center and a unit where those in the throes of a mental health crisis can seek care. A goal is to get people suffering from an urgent mental illness crisis connected to help faster, especially when they come into contact with police.

“It’s very important to come to a place that’s going to get you help,” Bonnie Kelly said in the article. Ms. Kelly, who reportedly has bipolar disorder, has been arrested several times for disorderly conduct tied to her condition. “It means everything. It is good, kind patient care, rather than just getting you out of the way.”

Aside from benefiting those in need of mental health care, the center will ease the strain on Nashville police, who currently spend more than 5,000 hours each year responding to mental health–related calls. The officers must remain with the person until transfer to a jail or mental health facility is done.

“As a city, we are recognizing that there is a need, and we are investing in that,” East Precinct Commander David Imhof said in the article. “We are helping a population that has had no voice in the past.” Right now, fewer than 60% of patients discharged from state mental health facilities receive any sort of coverage. The result can be cycles of release, arrest, and incarceration.
 

Agency aims to protect patients

The Oregon Health Authority has stepped in to prevent numerous state-funded mental health facilities run by the same contractor from booting out patients with severe mental health problems.

The contractor is Kepro, a Pennsylvania-based company. Since December, the health authority has reversed decisions to release 17 patients, according to an article in the Oregonian. The harder line follows revelations by the newspaper of serious harm to patients who had been released before they were capable of caring for themselves.

Kepro was hired by the health authority and paid $27 million to evaluate the medical needs of mental health patients in Oregon. As part of the evaluation, 215 of 250 patients were deemed unqualified to remain in care.

One was Ruane Oliverio, who has schizophrenia, who was kicked out of a locked facility in Portland last June. Clinicians had warned against her release, insisting that her mental state remained too vulnerable. After being hospitalized multiple times, she was sent to the Oregon State Hospital, the highest and most expensive level of care. She was one of those targeted for release. This decision was reversed, and she continues to receive care.
 

Coalition seeks mental health care for refugees

A new coalition called Matters Involving Neuro-Disorders, or MIND, is trying to help refugees with mental health conditions. The effort is a response to several mental health-related deaths of refugees during 2014-2016, a video produced by the San Diego Union-Tribune said.

“Refugees are brought to this country to help them rebuild their lives,” said Justin Mudekereza, executive director of New Neighbor Relief, a nonprofit organization dedicated to helping refugees adjust to their new lives in the United States. “They have gone through a lot in their countries, then from there, they went to refugee camps, where they spend 15-20 years or more before they got a chance to come to this country.”

Sheila S. Mitra-Sarkar, PhD, of the Institute of Public Urban Affairs at San Diego State University, described the need for a “comprehensive solution” to help refugees adapt to their new society, learn English, find housing and employment, and thrive.

“When I see a patient or someone who seems to have a psychological issue ... I look at everything that goes around them,” said John C. Kuek, PhD, of La Maestra Community Health Centers in San Diego. “I’m looking at the housing issue, the employment issue, and translational issue – meaning they have some family back home and they have a live family here to care for.”

Evidence that American football can lead to chronic traumatic encephalopathy (CTE), continues to grow. As a result, some parents are opting to sign their sons up for other sports.

©james boulette/Thinkstock

In the 2017-2018 school year, 6.6% fewer high school athletes participated in tackle football than did 8 years before according to the National Federation of State High School Associations. As the movement away from football continues, a pronounced shift is occurring in the prevalence of young black men in the game.

Many black parents encourage their sons to play football as a way to protect them gang activity. In addition, the sport can be their sole option for securing a college education for their children, an article in the Atlantic said. A recent survey of 50,000 8th-, 10th-, and 12th-grade students found that tackle football is predominantly the domain of black youth.

“This divergence paints a troubling picture of how economic opportunity – or a lack thereof – governs which boys are incentivized to put their body and brain at risk to play. Depending on where families live, and what other options are available to them, they see either a game that is too violent to consider or one that is necessary and important, if risky. Millions of Americans still watch football; NFL ratings were up this season,” Alana Semuels wrote in the article. “That a distinct portion of families won’t let their children play creates a disturbing future for the country’s most popular game.”

“Without a reversal in economic fortunes for poor communities across the country, football could one day become a sport played almost exclusively by black athletes, while still enjoyed by everyone. Black athletes – who already make up the majority of players in the most dangerous on-field positions – would continue to suffer from long-term brain damage, their life cut short by dementia and the scourge of CTE,” she wrote.

Meanwhile, numerous outlets reported that Super Bowl LIII garnered the lowest ratings since 2008.
 

Psychiatric hospital set to close

In both Kansas and Missouri, a shortage in mental health care has become evident, according to an article in the Kansas City Star. And now the Two Rivers Behavioral Health System, a private psychiatric hospital in southeast Kansas City, Mo., is closing its doors. The result will be a loss of 129 jobs and 105 fewer mental health beds in the city.

Patients currently in the facility will be relocated, and their care will continue. But for those who come after, care will now be tougher to find.

Two Rivers, owned by Pennsylvania-based Universal Health Services, treats children and adults. It had 2,347 discharges in 2017 and almost $28 million in revenue but had a net loss of about $3.4 million. The facility has been under scrutiny in the past two decades over its treatment of patients, with accusations about the bolstering of false memories concerning involvements in satanic cults and the treatment of a convicted sex offender who assaulted another patient. The most recent state inspection showed that Two Rivers had failed to provide a safe environment for six patients who were considered suicide risks. The patients had unsupervised access to the nurses’ station, as well as access to pens that could have been used for stabbing and a charging cord that could have been used for strangulation.

In an interview with the Star, Mark Stringer, director of the Missouri Department of Mental Health, said private psychiatric hospitals like Two Rivers are finding it harder to keep functioning, partly because of nursing shortages. Private facilities are not subsidized like state mental hospitals and are unable to secure staff from other facilities.

“There is a general worry about the availability of psychiatric services for people in crisis; there’s just no doubt about that,” Mr. Stringer said. “The loss of beds certainly hurts.”
 

New center offers ‘kind patient care’

In Nashville, Tenn., a new mental illness crisis treatment center is open. The center offers a 24/7 option for those with mental health issues who have run afoul of the law. Instead of incarceration, they can receive treatment, the Tennessean reported.

Estimates are that more than 1 million residents of Tennessee aged 18 years and older have a mental health or substance use disorder. About 25% of those residents having a serious mental health illness.

The new facility includes a crisis walk-in center and a unit where those in the throes of a mental health crisis can seek care. A goal is to get people suffering from an urgent mental illness crisis connected to help faster, especially when they come into contact with police.

“It’s very important to come to a place that’s going to get you help,” Bonnie Kelly said in the article. Ms. Kelly, who reportedly has bipolar disorder, has been arrested several times for disorderly conduct tied to her condition. “It means everything. It is good, kind patient care, rather than just getting you out of the way.”

Aside from benefiting those in need of mental health care, the center will ease the strain on Nashville police, who currently spend more than 5,000 hours each year responding to mental health–related calls. The officers must remain with the person until transfer to a jail or mental health facility is done.

“As a city, we are recognizing that there is a need, and we are investing in that,” East Precinct Commander David Imhof said in the article. “We are helping a population that has had no voice in the past.” Right now, fewer than 60% of patients discharged from state mental health facilities receive any sort of coverage. The result can be cycles of release, arrest, and incarceration.
 

Agency aims to protect patients

The Oregon Health Authority has stepped in to prevent numerous state-funded mental health facilities run by the same contractor from booting out patients with severe mental health problems.

The contractor is Kepro, a Pennsylvania-based company. Since December, the health authority has reversed decisions to release 17 patients, according to an article in the Oregonian. The harder line follows revelations by the newspaper of serious harm to patients who had been released before they were capable of caring for themselves.

Kepro was hired by the health authority and paid $27 million to evaluate the medical needs of mental health patients in Oregon. As part of the evaluation, 215 of 250 patients were deemed unqualified to remain in care.

One was Ruane Oliverio, who has schizophrenia, who was kicked out of a locked facility in Portland last June. Clinicians had warned against her release, insisting that her mental state remained too vulnerable. After being hospitalized multiple times, she was sent to the Oregon State Hospital, the highest and most expensive level of care. She was one of those targeted for release. This decision was reversed, and she continues to receive care.
 

Coalition seeks mental health care for refugees

A new coalition called Matters Involving Neuro-Disorders, or MIND, is trying to help refugees with mental health conditions. The effort is a response to several mental health-related deaths of refugees during 2014-2016, a video produced by the San Diego Union-Tribune said.

“Refugees are brought to this country to help them rebuild their lives,” said Justin Mudekereza, executive director of New Neighbor Relief, a nonprofit organization dedicated to helping refugees adjust to their new lives in the United States. “They have gone through a lot in their countries, then from there, they went to refugee camps, where they spend 15-20 years or more before they got a chance to come to this country.”

Sheila S. Mitra-Sarkar, PhD, of the Institute of Public Urban Affairs at San Diego State University, described the need for a “comprehensive solution” to help refugees adapt to their new society, learn English, find housing and employment, and thrive.

“When I see a patient or someone who seems to have a psychological issue ... I look at everything that goes around them,” said John C. Kuek, PhD, of La Maestra Community Health Centers in San Diego. “I’m looking at the housing issue, the employment issue, and translational issue – meaning they have some family back home and they have a live family here to care for.”

Evidence that American football can lead to chronic traumatic encephalopathy (CTE), continues to grow. As a result, some parents are opting to sign their sons up for other sports.

©james boulette/Thinkstock

In the 2017-2018 school year, 6.6% fewer high school athletes participated in tackle football than did 8 years before according to the National Federation of State High School Associations. As the movement away from football continues, a pronounced shift is occurring in the prevalence of young black men in the game.

Many black parents encourage their sons to play football as a way to protect them gang activity. In addition, the sport can be their sole option for securing a college education for their children, an article in the Atlantic said. A recent survey of 50,000 8th-, 10th-, and 12th-grade students found that tackle football is predominantly the domain of black youth.

“This divergence paints a troubling picture of how economic opportunity – or a lack thereof – governs which boys are incentivized to put their body and brain at risk to play. Depending on where families live, and what other options are available to them, they see either a game that is too violent to consider or one that is necessary and important, if risky. Millions of Americans still watch football; NFL ratings were up this season,” Alana Semuels wrote in the article. “That a distinct portion of families won’t let their children play creates a disturbing future for the country’s most popular game.”

“Without a reversal in economic fortunes for poor communities across the country, football could one day become a sport played almost exclusively by black athletes, while still enjoyed by everyone. Black athletes – who already make up the majority of players in the most dangerous on-field positions – would continue to suffer from long-term brain damage, their life cut short by dementia and the scourge of CTE,” she wrote.

Meanwhile, numerous outlets reported that Super Bowl LIII garnered the lowest ratings since 2008.
 

Psychiatric hospital set to close

In both Kansas and Missouri, a shortage in mental health care has become evident, according to an article in the Kansas City Star. And now the Two Rivers Behavioral Health System, a private psychiatric hospital in southeast Kansas City, Mo., is closing its doors. The result will be a loss of 129 jobs and 105 fewer mental health beds in the city.

Patients currently in the facility will be relocated, and their care will continue. But for those who come after, care will now be tougher to find.

Two Rivers, owned by Pennsylvania-based Universal Health Services, treats children and adults. It had 2,347 discharges in 2017 and almost $28 million in revenue but had a net loss of about $3.4 million. The facility has been under scrutiny in the past two decades over its treatment of patients, with accusations about the bolstering of false memories concerning involvements in satanic cults and the treatment of a convicted sex offender who assaulted another patient. The most recent state inspection showed that Two Rivers had failed to provide a safe environment for six patients who were considered suicide risks. The patients had unsupervised access to the nurses’ station, as well as access to pens that could have been used for stabbing and a charging cord that could have been used for strangulation.

In an interview with the Star, Mark Stringer, director of the Missouri Department of Mental Health, said private psychiatric hospitals like Two Rivers are finding it harder to keep functioning, partly because of nursing shortages. Private facilities are not subsidized like state mental hospitals and are unable to secure staff from other facilities.

“There is a general worry about the availability of psychiatric services for people in crisis; there’s just no doubt about that,” Mr. Stringer said. “The loss of beds certainly hurts.”
 

New center offers ‘kind patient care’

In Nashville, Tenn., a new mental illness crisis treatment center is open. The center offers a 24/7 option for those with mental health issues who have run afoul of the law. Instead of incarceration, they can receive treatment, the Tennessean reported.

Estimates are that more than 1 million residents of Tennessee aged 18 years and older have a mental health or substance use disorder. About 25% of those residents having a serious mental health illness.

The new facility includes a crisis walk-in center and a unit where those in the throes of a mental health crisis can seek care. A goal is to get people suffering from an urgent mental illness crisis connected to help faster, especially when they come into contact with police.

“It’s very important to come to a place that’s going to get you help,” Bonnie Kelly said in the article. Ms. Kelly, who reportedly has bipolar disorder, has been arrested several times for disorderly conduct tied to her condition. “It means everything. It is good, kind patient care, rather than just getting you out of the way.”

Aside from benefiting those in need of mental health care, the center will ease the strain on Nashville police, who currently spend more than 5,000 hours each year responding to mental health–related calls. The officers must remain with the person until transfer to a jail or mental health facility is done.

“As a city, we are recognizing that there is a need, and we are investing in that,” East Precinct Commander David Imhof said in the article. “We are helping a population that has had no voice in the past.” Right now, fewer than 60% of patients discharged from state mental health facilities receive any sort of coverage. The result can be cycles of release, arrest, and incarceration.
 

Agency aims to protect patients

The Oregon Health Authority has stepped in to prevent numerous state-funded mental health facilities run by the same contractor from booting out patients with severe mental health problems.

The contractor is Kepro, a Pennsylvania-based company. Since December, the health authority has reversed decisions to release 17 patients, according to an article in the Oregonian. The harder line follows revelations by the newspaper of serious harm to patients who had been released before they were capable of caring for themselves.

Kepro was hired by the health authority and paid $27 million to evaluate the medical needs of mental health patients in Oregon. As part of the evaluation, 215 of 250 patients were deemed unqualified to remain in care.

One was Ruane Oliverio, who has schizophrenia, who was kicked out of a locked facility in Portland last June. Clinicians had warned against her release, insisting that her mental state remained too vulnerable. After being hospitalized multiple times, she was sent to the Oregon State Hospital, the highest and most expensive level of care. She was one of those targeted for release. This decision was reversed, and she continues to receive care.
 

Coalition seeks mental health care for refugees

A new coalition called Matters Involving Neuro-Disorders, or MIND, is trying to help refugees with mental health conditions. The effort is a response to several mental health-related deaths of refugees during 2014-2016, a video produced by the San Diego Union-Tribune said.

“Refugees are brought to this country to help them rebuild their lives,” said Justin Mudekereza, executive director of New Neighbor Relief, a nonprofit organization dedicated to helping refugees adjust to their new lives in the United States. “They have gone through a lot in their countries, then from there, they went to refugee camps, where they spend 15-20 years or more before they got a chance to come to this country.”

Sheila S. Mitra-Sarkar, PhD, of the Institute of Public Urban Affairs at San Diego State University, described the need for a “comprehensive solution” to help refugees adapt to their new society, learn English, find housing and employment, and thrive.

“When I see a patient or someone who seems to have a psychological issue ... I look at everything that goes around them,” said John C. Kuek, PhD, of La Maestra Community Health Centers in San Diego. “I’m looking at the housing issue, the employment issue, and translational issue – meaning they have some family back home and they have a live family here to care for.”

CORONADO, CALIF. – Officials at Michigan Medicine have launched an initiative to make optimal health and well-being a norm for its physicians, staff, and learners.

“If you look long and hard at your hospitals, health centers, and medical schools, you would find incidences of depression, near-miss suicide, opioid addiction, substance abuse addictions, and suicide,” Carol R. Bradford, MD, said at the Triological Society’s Combined Sections Meeting. “Another component of this is that we all struggle with our work or learning communities where people don’t take care of each other. People don’t treat each other with respect and civility. Promoting a healthy and civil work environment are essential components of a supportive environment.”

According to Dr. Bradford, executive vice dean for academic affairs at the University of Michigan, Ann Arbor, the complexities and stress of the health care environment compromises the well-being of its workforce with a myriad of time-consuming tasks, including navigating electronic records and ever-populating email inboxes. “We are all connected to devices 24/7, and it has become more and more difficult to maintain a healthy work-life balance,” Dr. Bradford said. “The more accepted term now is integration, because it’s almost impossible to achieve balance. Burnout and other physical and health problems are the result of all of these challenges.”

In late 2017, she and her colleagues used two different validated survey questionnaires to assess the health of Michigan Medicine faculty physicians. They found that about 40% of faculty members in both clinical and basic science departments met criteria for burnout. The top 10 stressors based on the survey were email, clerical activity, time worked outside of regular hours, workload time pressure, work expectations, insufficient time for meaningful activities, in-basket messages, lack of decisional transparency, inadequate compensation, and too many work hours. The top 10 coping strategies were finding meaning in work, using all vacation time, paying attention to healthy/balanced eating, engaging in exercise, seek personal/professional balance, protecting time away from work, protecting sleep time, using a social support network, nurturing spiritual aspects, and engaging in recreation or hobbies.

Results of the survey prompted development of a task force to examine wellness and civility at Michigan Medicine, and to devise strategies and tactics to conquer these challenges. “The goal is to help all human beings who are suffering in our work environment,” said Dr. Bradford, who is also chief academic officer for Michigan Medicine. “What we learned initially is that there is a bit of an overlap. Some lack of wellness is due to a lack of civility, but there are wellness issues and civility issues that are independent of one another.”

Members of the task force formulated several recommendations, the first being to create a Michigan Medicine Wellness Office. Dr. Bradford is currently negotiating with a finalist to serve as its faculty director. She characterized the office as a “hub and spoke” model that will partner with existing entities, including human resources, the office of medical student education, the program in biological sciences, graduate medical education, the office of health equality and inclusion, the office of clinical affairs, and the office of counseling and workplace resilience. “The idea is to create a strategic wellness plan,” said Dr. Bradford, who is also a professor of otolaryngology–head and neck surgery. “One key strategy is to endorse the health and well-being of our faculty, staff, and learners as a core value and cultural norm of Michigan Medicine. In other words, the leadership has to make health and well-being a priority and a value.”

[email protected]

CORONADO, CALIF. – Officials at Michigan Medicine have launched an initiative to make optimal health and well-being a norm for its physicians, staff, and learners.

“If you look long and hard at your hospitals, health centers, and medical schools, you would find incidences of depression, near-miss suicide, opioid addiction, substance abuse addictions, and suicide,” Carol R. Bradford, MD, said at the Triological Society’s Combined Sections Meeting. “Another component of this is that we all struggle with our work or learning communities where people don’t take care of each other. People don’t treat each other with respect and civility. Promoting a healthy and civil work environment are essential components of a supportive environment.”

According to Dr. Bradford, executive vice dean for academic affairs at the University of Michigan, Ann Arbor, the complexities and stress of the health care environment compromises the well-being of its workforce with a myriad of time-consuming tasks, including navigating electronic records and ever-populating email inboxes. “We are all connected to devices 24/7, and it has become more and more difficult to maintain a healthy work-life balance,” Dr. Bradford said. “The more accepted term now is integration, because it’s almost impossible to achieve balance. Burnout and other physical and health problems are the result of all of these challenges.”

In late 2017, she and her colleagues used two different validated survey questionnaires to assess the health of Michigan Medicine faculty physicians. They found that about 40% of faculty members in both clinical and basic science departments met criteria for burnout. The top 10 stressors based on the survey were email, clerical activity, time worked outside of regular hours, workload time pressure, work expectations, insufficient time for meaningful activities, in-basket messages, lack of decisional transparency, inadequate compensation, and too many work hours. The top 10 coping strategies were finding meaning in work, using all vacation time, paying attention to healthy/balanced eating, engaging in exercise, seek personal/professional balance, protecting time away from work, protecting sleep time, using a social support network, nurturing spiritual aspects, and engaging in recreation or hobbies.

Results of the survey prompted development of a task force to examine wellness and civility at Michigan Medicine, and to devise strategies and tactics to conquer these challenges. “The goal is to help all human beings who are suffering in our work environment,” said Dr. Bradford, who is also chief academic officer for Michigan Medicine. “What we learned initially is that there is a bit of an overlap. Some lack of wellness is due to a lack of civility, but there are wellness issues and civility issues that are independent of one another.”

Members of the task force formulated several recommendations, the first being to create a Michigan Medicine Wellness Office. Dr. Bradford is currently negotiating with a finalist to serve as its faculty director. She characterized the office as a “hub and spoke” model that will partner with existing entities, including human resources, the office of medical student education, the program in biological sciences, graduate medical education, the office of health equality and inclusion, the office of clinical affairs, and the office of counseling and workplace resilience. “The idea is to create a strategic wellness plan,” said Dr. Bradford, who is also a professor of otolaryngology–head and neck surgery. “One key strategy is to endorse the health and well-being of our faculty, staff, and learners as a core value and cultural norm of Michigan Medicine. In other words, the leadership has to make health and well-being a priority and a value.”

[email protected]

CORONADO, CALIF. – Officials at Michigan Medicine have launched an initiative to make optimal health and well-being a norm for its physicians, staff, and learners.

“If you look long and hard at your hospitals, health centers, and medical schools, you would find incidences of depression, near-miss suicide, opioid addiction, substance abuse addictions, and suicide,” Carol R. Bradford, MD, said at the Triological Society’s Combined Sections Meeting. “Another component of this is that we all struggle with our work or learning communities where people don’t take care of each other. People don’t treat each other with respect and civility. Promoting a healthy and civil work environment are essential components of a supportive environment.”

According to Dr. Bradford, executive vice dean for academic affairs at the University of Michigan, Ann Arbor, the complexities and stress of the health care environment compromises the well-being of its workforce with a myriad of time-consuming tasks, including navigating electronic records and ever-populating email inboxes. “We are all connected to devices 24/7, and it has become more and more difficult to maintain a healthy work-life balance,” Dr. Bradford said. “The more accepted term now is integration, because it’s almost impossible to achieve balance. Burnout and other physical and health problems are the result of all of these challenges.”

In late 2017, she and her colleagues used two different validated survey questionnaires to assess the health of Michigan Medicine faculty physicians. They found that about 40% of faculty members in both clinical and basic science departments met criteria for burnout. The top 10 stressors based on the survey were email, clerical activity, time worked outside of regular hours, workload time pressure, work expectations, insufficient time for meaningful activities, in-basket messages, lack of decisional transparency, inadequate compensation, and too many work hours. The top 10 coping strategies were finding meaning in work, using all vacation time, paying attention to healthy/balanced eating, engaging in exercise, seek personal/professional balance, protecting time away from work, protecting sleep time, using a social support network, nurturing spiritual aspects, and engaging in recreation or hobbies.

Results of the survey prompted development of a task force to examine wellness and civility at Michigan Medicine, and to devise strategies and tactics to conquer these challenges. “The goal is to help all human beings who are suffering in our work environment,” said Dr. Bradford, who is also chief academic officer for Michigan Medicine. “What we learned initially is that there is a bit of an overlap. Some lack of wellness is due to a lack of civility, but there are wellness issues and civility issues that are independent of one another.”

Members of the task force formulated several recommendations, the first being to create a Michigan Medicine Wellness Office. Dr. Bradford is currently negotiating with a finalist to serve as its faculty director. She characterized the office as a “hub and spoke” model that will partner with existing entities, including human resources, the office of medical student education, the program in biological sciences, graduate medical education, the office of health equality and inclusion, the office of clinical affairs, and the office of counseling and workplace resilience. “The idea is to create a strategic wellness plan,” said Dr. Bradford, who is also a professor of otolaryngology–head and neck surgery. “One key strategy is to endorse the health and well-being of our faculty, staff, and learners as a core value and cultural norm of Michigan Medicine. In other words, the leadership has to make health and well-being a priority and a value.”

[email protected]

Automated office blood pressure readings appear to be more accurate than routine office readings and BP readings in research settings. Also today, a positive fecal immunochemical test should prompt colonoscopy, mild aerobic exercise speeds recovery for sports concussions, and phase 2 studies of the antiamyloid Alzheimer’s drug crenezumab are stopped.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

Automated office blood pressure readings appear to be more accurate than routine office readings and BP readings in research settings. Also today, a positive fecal immunochemical test should prompt colonoscopy, mild aerobic exercise speeds recovery for sports concussions, and phase 2 studies of the antiamyloid Alzheimer’s drug crenezumab are stopped.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

Automated office blood pressure readings appear to be more accurate than routine office readings and BP readings in research settings. Also today, a positive fecal immunochemical test should prompt colonoscopy, mild aerobic exercise speeds recovery for sports concussions, and phase 2 studies of the antiamyloid Alzheimer’s drug crenezumab are stopped.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

A shift in Medicare drug coverage from Part B to Part D might save the government money, but might cost patients. Also today, there’s no single treatment for fibromyalgia, obesity-related cancers are increasing in younger adults, and pregnancy problems predict cardiovascular future.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify

A shift in Medicare drug coverage from Part B to Part D might save the government money, but might cost patients. Also today, there’s no single treatment for fibromyalgia, obesity-related cancers are increasing in younger adults, and pregnancy problems predict cardiovascular future.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify

A shift in Medicare drug coverage from Part B to Part D might save the government money, but might cost patients. Also today, there’s no single treatment for fibromyalgia, obesity-related cancers are increasing in younger adults, and pregnancy problems predict cardiovascular future.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify

David Henry, MD, is the host of Blood & Cancer, the official podcast of MDedge Hematology/Oncology. In this episode, Nick and Dr. Henry discuss advances and excitement in oncology, as well as the opportunities that podcasting provides and tips for dealing with burnout.

Apple Podcasts
Google Podcasts
Spotify

David Henry, MD, is the host of Blood & Cancer, the official podcast of MDedge Hematology/Oncology. In this episode, Nick and Dr. Henry discuss advances and excitement in oncology, as well as the opportunities that podcasting provides and tips for dealing with burnout.

Apple Podcasts
Google Podcasts
Spotify

David Henry, MD, is the host of Blood & Cancer, the official podcast of MDedge Hematology/Oncology. In this episode, Nick and Dr. Henry discuss advances and excitement in oncology, as well as the opportunities that podcasting provides and tips for dealing with burnout.

Apple Podcasts
Google Podcasts
Spotify

To the Editor:

A 50-year-old woman presented with an asymptomatic eruption on the dorsal aspect of the hands, abdomen, and face of 6 months’ duration. The eruption was associated with generalized arthralgia and fatigue. Within several weeks of onset of the cutaneous eruption, the patient developed swelling in the hands as well as worsening arthralgia. She was treated for presumed Lyme borreliosis but reported no improvement in the symptoms. She was then referred to dermatology for further management.

Physical examination revealed red-orange, edematous, monomorphic papulonodules scattered on the nasolabial folds, upper lip, and along the dorsal aspect of the hands and fingers (Figure 1). A brown rippled plaque was present on the left lower abdomen. The oral mucosa and nails were unremarkable. Laboratory studies showed elevated total cholesterol (244 mg/dL [reference range, <200 mg/dL]), low-density lipoproteins (130 mg/dL [reference range, 10–30 mg/dL]), aspartate aminotransferase (140 U/L [reference range, 10–30 U/L]), alanine aminotransferase (110 U/L [reference range, 10–40 U/L]), and total bilirubin (1.5 mg/dL [reference range, 0.3–1.2 mg/dL]). White blood cell count and C-reactive protein levels were within reference range. An antinuclear antibody titer of 1:80 with a homogenous pattern was found, and aldolase levels were elevated. Laboratory investigations for rheumatoid factor, Lyme disease, tuberculosis, hepatitis, and human immunodeficiency virus were negative. A chest radiograph was normal.

Multicentric reticulohistiocytosis typically presents with a severe erosive arthropathy known as arthritis mutilans. Patients display a symmetric polyarthritis that commonly involves the elbows, wrists, and proximal and distal aspects of the interphalangeal joints. Onset and progression can be rapid, and the erosive nature leads to deformities in up to 45% of patients.^2,5,6 Cutaneous findings arise an average of 3 years after the development of arthritis, though one-fifth of patients will initially present with cutaneous findings followed by the development of arthritis at any time.^3,6 Clinical features include flesh-colored to reddish brown or yellow papulonodules that range in size from several millimeters to 2 cm. The lesions most commonly occur on the face (eg, ears, nose, paranasal cheeks), scalp, dorsal and lateral aspects of the hands and fingers, and overlying articular regions of the extremities. Characteristic periungual lesions classically are referred to as coral beads.^4,6 Patients commonly report pruritus that may precede the development of the papules and nodules. Other cutaneous manifestations include xanthelasma, nail changes, and a photodistributed erythematous maculopapular eruption that may mimic dermatomyositis.⁶

Cutaneous findings of MRH can mimic rheumatoid nodules, gout, Gottron papules of dermatomyositis, lipoid proteinosis, sarcoidosis, lepromatous leprosy, granuloma annulare, xanthoma, xanthogranuloma, and fibroxanthoma.^6,7 Histopathologic features may distinguish MRH from such entities. Findings include fairly well-circumscribed aggregates of large multinucleated giant cells with characteristic eosinophilic ground-glass cytoplasm. Histiocytes stain positively for CD68, HAM56, CD11b, and CD14, and variably for factor XIIIa. CD68, which is expressed by monocytes/macrophages, has been universally reported to be the most reliable marker of MRH. Negative staining for S-100 and CD1a supports a non-Langerhans origin for the involved histiocytes. If arthritic symptoms predominate, MRH must be distinguished from rheumatoid and psoriatic arthritis.^6,7

Mucosal involvement occurs in approximately 50% of patients and includes the presence of nodules in the oral, nasal, and pharyngeal mucosae, as well as eye structures.^2,3 Histiocytic infiltration has been documented in the heart, lungs, thyroid, liver, stomach, kidneys, muscle, bone marrow, and urogenital tract. Histiocytes also can invade the cartilage of the ears and nose causing disfigurement and characteristic leonine facies. Pathologic fractures may occur with bone involvement.⁵

Systemic features associated with MRH include hyperlipidemia, diabetes mellitus, thyroid disease, hypergammaglobulinemia, and various autoimmune diseases. Patients less frequently report fever and weight loss.^2,5,6,8 Additionally, a positive tuberculin test occurs in 12% to 50% of patients.⁶ Various autoimmune diseases occur in 6% to 17% of cases including systemic lupus erythematosus, systemic sclerosis, rheumatoid arthritis, dermatomyositis, Sjögren syndrome, and primary biliary cirrhosis.^2,5,6,8 The most clinically salient feature of MRH is its association with malignant conditions, which occur in up to 31% of patients. A variety of cancers have been reported in association with MRH, including breast, cervical, ovarian, stomach, penile, lymphoma, mesothelioma, and melanoma.⁷

The etiology of MRH is unclear. Although onset may precede the development of a malignant condition and regress with treatment, it cannot be considered a true paraneoplastic disorder, as it has no association with a specific cancer and does not typically parallel the disease course.^6,9 Reports of increased levels of inflammatory mediators released from macrophages and endothelial cells, specifically IL-12, IL-1β, IL-6, and tumor necrosis factor α (TNF-α), have been thought to drive the destruction of bone and cartilage.⁶ In particular, TNF-α acts to indirectly induce destruction by stimulating proteolytic activity in macrophages, similar to the pathogenesis of joint damage in rheumatoid arthritis.⁸ Osteoclastic activity may play a role in the pathogenesis of MRH, as multinucleated giant cells in MRH can mature into osteoclasts by receptor activated nuclear factor–κB ligand signaling. In addition, patients treated with bisphosphonates have had decreased lacunar resorption.^2,8

Initial management of MRH should include screening for hyperlipidemia, hypergammaglobulinemia, hyperglycemia, thyroid dysfunction, and autoimmune diseases, as well as age-appropriate cancer screening. Imaging studies should evaluate for the presence of erosive arthritis. There are no well-defined treatment algorithms for MRH due to the rarity of the disease, and recommendations largely rely on case reports. Although spontaneous remission typically occurs within 5 to 10 years, the risk for joint destruction argues for early pharmacologic intervention. Current management includes the use of nonsteroidal anti-inflammatory drugs and various immunosuppressants including oral glucocorticoids, cyclophosphamide, chlorambucil, methotrexate, or azathioprine.² A combination of methotrexate with cyclophosphamide or glucocorticoids also has shown efficacy.¹⁰ Anti–TNF-α agents, such as etanercept, adalimumab, and infliximab, have been used with some success.² Tumor necrosis factor α inhibitors used in combination with oral glucocorticoids and methotrexate may have an increased benefit.^2,9,11 Evidence suggesting that TNF-α plays a role in the destruction of bone and cartilage led to the successful use of infliximab in combination with oral glucocorticoids and methotrexate, which prevented possible development of antibodies to infliximab and increased its efficacy.¹² Bisphosphonate use in combination with glucocorticoids and methotrexate may prevent joint destruction without the serious adverse events associated with anti–TNF-α agents.^2,9,13,14

To the Editor:

A 50-year-old woman presented with an asymptomatic eruption on the dorsal aspect of the hands, abdomen, and face of 6 months’ duration. The eruption was associated with generalized arthralgia and fatigue. Within several weeks of onset of the cutaneous eruption, the patient developed swelling in the hands as well as worsening arthralgia. She was treated for presumed Lyme borreliosis but reported no improvement in the symptoms. She was then referred to dermatology for further management.

Physical examination revealed red-orange, edematous, monomorphic papulonodules scattered on the nasolabial folds, upper lip, and along the dorsal aspect of the hands and fingers (Figure 1). A brown rippled plaque was present on the left lower abdomen. The oral mucosa and nails were unremarkable. Laboratory studies showed elevated total cholesterol (244 mg/dL [reference range, <200 mg/dL]), low-density lipoproteins (130 mg/dL [reference range, 10–30 mg/dL]), aspartate aminotransferase (140 U/L [reference range, 10–30 U/L]), alanine aminotransferase (110 U/L [reference range, 10–40 U/L]), and total bilirubin (1.5 mg/dL [reference range, 0.3–1.2 mg/dL]). White blood cell count and C-reactive protein levels were within reference range. An antinuclear antibody titer of 1:80 with a homogenous pattern was found, and aldolase levels were elevated. Laboratory investigations for rheumatoid factor, Lyme disease, tuberculosis, hepatitis, and human immunodeficiency virus were negative. A chest radiograph was normal.

Multicentric reticulohistiocytosis typically presents with a severe erosive arthropathy known as arthritis mutilans. Patients display a symmetric polyarthritis that commonly involves the elbows, wrists, and proximal and distal aspects of the interphalangeal joints. Onset and progression can be rapid, and the erosive nature leads to deformities in up to 45% of patients.^2,5,6 Cutaneous findings arise an average of 3 years after the development of arthritis, though one-fifth of patients will initially present with cutaneous findings followed by the development of arthritis at any time.^3,6 Clinical features include flesh-colored to reddish brown or yellow papulonodules that range in size from several millimeters to 2 cm. The lesions most commonly occur on the face (eg, ears, nose, paranasal cheeks), scalp, dorsal and lateral aspects of the hands and fingers, and overlying articular regions of the extremities. Characteristic periungual lesions classically are referred to as coral beads.^4,6 Patients commonly report pruritus that may precede the development of the papules and nodules. Other cutaneous manifestations include xanthelasma, nail changes, and a photodistributed erythematous maculopapular eruption that may mimic dermatomyositis.⁶

Cutaneous findings of MRH can mimic rheumatoid nodules, gout, Gottron papules of dermatomyositis, lipoid proteinosis, sarcoidosis, lepromatous leprosy, granuloma annulare, xanthoma, xanthogranuloma, and fibroxanthoma.^6,7 Histopathologic features may distinguish MRH from such entities. Findings include fairly well-circumscribed aggregates of large multinucleated giant cells with characteristic eosinophilic ground-glass cytoplasm. Histiocytes stain positively for CD68, HAM56, CD11b, and CD14, and variably for factor XIIIa. CD68, which is expressed by monocytes/macrophages, has been universally reported to be the most reliable marker of MRH. Negative staining for S-100 and CD1a supports a non-Langerhans origin for the involved histiocytes. If arthritic symptoms predominate, MRH must be distinguished from rheumatoid and psoriatic arthritis.^6,7

Mucosal involvement occurs in approximately 50% of patients and includes the presence of nodules in the oral, nasal, and pharyngeal mucosae, as well as eye structures.^2,3 Histiocytic infiltration has been documented in the heart, lungs, thyroid, liver, stomach, kidneys, muscle, bone marrow, and urogenital tract. Histiocytes also can invade the cartilage of the ears and nose causing disfigurement and characteristic leonine facies. Pathologic fractures may occur with bone involvement.⁵

Systemic features associated with MRH include hyperlipidemia, diabetes mellitus, thyroid disease, hypergammaglobulinemia, and various autoimmune diseases. Patients less frequently report fever and weight loss.^2,5,6,8 Additionally, a positive tuberculin test occurs in 12% to 50% of patients.⁶ Various autoimmune diseases occur in 6% to 17% of cases including systemic lupus erythematosus, systemic sclerosis, rheumatoid arthritis, dermatomyositis, Sjögren syndrome, and primary biliary cirrhosis.^2,5,6,8 The most clinically salient feature of MRH is its association with malignant conditions, which occur in up to 31% of patients. A variety of cancers have been reported in association with MRH, including breast, cervical, ovarian, stomach, penile, lymphoma, mesothelioma, and melanoma.⁷

The etiology of MRH is unclear. Although onset may precede the development of a malignant condition and regress with treatment, it cannot be considered a true paraneoplastic disorder, as it has no association with a specific cancer and does not typically parallel the disease course.^6,9 Reports of increased levels of inflammatory mediators released from macrophages and endothelial cells, specifically IL-12, IL-1β, IL-6, and tumor necrosis factor α (TNF-α), have been thought to drive the destruction of bone and cartilage.⁶ In particular, TNF-α acts to indirectly induce destruction by stimulating proteolytic activity in macrophages, similar to the pathogenesis of joint damage in rheumatoid arthritis.⁸ Osteoclastic activity may play a role in the pathogenesis of MRH, as multinucleated giant cells in MRH can mature into osteoclasts by receptor activated nuclear factor–κB ligand signaling. In addition, patients treated with bisphosphonates have had decreased lacunar resorption.^2,8

Initial management of MRH should include screening for hyperlipidemia, hypergammaglobulinemia, hyperglycemia, thyroid dysfunction, and autoimmune diseases, as well as age-appropriate cancer screening. Imaging studies should evaluate for the presence of erosive arthritis. There are no well-defined treatment algorithms for MRH due to the rarity of the disease, and recommendations largely rely on case reports. Although spontaneous remission typically occurs within 5 to 10 years, the risk for joint destruction argues for early pharmacologic intervention. Current management includes the use of nonsteroidal anti-inflammatory drugs and various immunosuppressants including oral glucocorticoids, cyclophosphamide, chlorambucil, methotrexate, or azathioprine.² A combination of methotrexate with cyclophosphamide or glucocorticoids also has shown efficacy.¹⁰ Anti–TNF-α agents, such as etanercept, adalimumab, and infliximab, have been used with some success.² Tumor necrosis factor α inhibitors used in combination with oral glucocorticoids and methotrexate may have an increased benefit.^2,9,11 Evidence suggesting that TNF-α plays a role in the destruction of bone and cartilage led to the successful use of infliximab in combination with oral glucocorticoids and methotrexate, which prevented possible development of antibodies to infliximab and increased its efficacy.¹² Bisphosphonate use in combination with glucocorticoids and methotrexate may prevent joint destruction without the serious adverse events associated with anti–TNF-α agents.^2,9,13,14

To the Editor:

A 50-year-old woman presented with an asymptomatic eruption on the dorsal aspect of the hands, abdomen, and face of 6 months’ duration. The eruption was associated with generalized arthralgia and fatigue. Within several weeks of onset of the cutaneous eruption, the patient developed swelling in the hands as well as worsening arthralgia. She was treated for presumed Lyme borreliosis but reported no improvement in the symptoms. She was then referred to dermatology for further management.

Physical examination revealed red-orange, edematous, monomorphic papulonodules scattered on the nasolabial folds, upper lip, and along the dorsal aspect of the hands and fingers (Figure 1). A brown rippled plaque was present on the left lower abdomen. The oral mucosa and nails were unremarkable. Laboratory studies showed elevated total cholesterol (244 mg/dL [reference range, <200 mg/dL]), low-density lipoproteins (130 mg/dL [reference range, 10–30 mg/dL]), aspartate aminotransferase (140 U/L [reference range, 10–30 U/L]), alanine aminotransferase (110 U/L [reference range, 10–40 U/L]), and total bilirubin (1.5 mg/dL [reference range, 0.3–1.2 mg/dL]). White blood cell count and C-reactive protein levels were within reference range. An antinuclear antibody titer of 1:80 with a homogenous pattern was found, and aldolase levels were elevated. Laboratory investigations for rheumatoid factor, Lyme disease, tuberculosis, hepatitis, and human immunodeficiency virus were negative. A chest radiograph was normal.

Multicentric reticulohistiocytosis typically presents with a severe erosive arthropathy known as arthritis mutilans. Patients display a symmetric polyarthritis that commonly involves the elbows, wrists, and proximal and distal aspects of the interphalangeal joints. Onset and progression can be rapid, and the erosive nature leads to deformities in up to 45% of patients.^2,5,6 Cutaneous findings arise an average of 3 years after the development of arthritis, though one-fifth of patients will initially present with cutaneous findings followed by the development of arthritis at any time.^3,6 Clinical features include flesh-colored to reddish brown or yellow papulonodules that range in size from several millimeters to 2 cm. The lesions most commonly occur on the face (eg, ears, nose, paranasal cheeks), scalp, dorsal and lateral aspects of the hands and fingers, and overlying articular regions of the extremities. Characteristic periungual lesions classically are referred to as coral beads.^4,6 Patients commonly report pruritus that may precede the development of the papules and nodules. Other cutaneous manifestations include xanthelasma, nail changes, and a photodistributed erythematous maculopapular eruption that may mimic dermatomyositis.⁶

Cutaneous findings of MRH can mimic rheumatoid nodules, gout, Gottron papules of dermatomyositis, lipoid proteinosis, sarcoidosis, lepromatous leprosy, granuloma annulare, xanthoma, xanthogranuloma, and fibroxanthoma.^6,7 Histopathologic features may distinguish MRH from such entities. Findings include fairly well-circumscribed aggregates of large multinucleated giant cells with characteristic eosinophilic ground-glass cytoplasm. Histiocytes stain positively for CD68, HAM56, CD11b, and CD14, and variably for factor XIIIa. CD68, which is expressed by monocytes/macrophages, has been universally reported to be the most reliable marker of MRH. Negative staining for S-100 and CD1a supports a non-Langerhans origin for the involved histiocytes. If arthritic symptoms predominate, MRH must be distinguished from rheumatoid and psoriatic arthritis.^6,7

Mucosal involvement occurs in approximately 50% of patients and includes the presence of nodules in the oral, nasal, and pharyngeal mucosae, as well as eye structures.^2,3 Histiocytic infiltration has been documented in the heart, lungs, thyroid, liver, stomach, kidneys, muscle, bone marrow, and urogenital tract. Histiocytes also can invade the cartilage of the ears and nose causing disfigurement and characteristic leonine facies. Pathologic fractures may occur with bone involvement.⁵

Systemic features associated with MRH include hyperlipidemia, diabetes mellitus, thyroid disease, hypergammaglobulinemia, and various autoimmune diseases. Patients less frequently report fever and weight loss.^2,5,6,8 Additionally, a positive tuberculin test occurs in 12% to 50% of patients.⁶ Various autoimmune diseases occur in 6% to 17% of cases including systemic lupus erythematosus, systemic sclerosis, rheumatoid arthritis, dermatomyositis, Sjögren syndrome, and primary biliary cirrhosis.^2,5,6,8 The most clinically salient feature of MRH is its association with malignant conditions, which occur in up to 31% of patients. A variety of cancers have been reported in association with MRH, including breast, cervical, ovarian, stomach, penile, lymphoma, mesothelioma, and melanoma.⁷

The etiology of MRH is unclear. Although onset may precede the development of a malignant condition and regress with treatment, it cannot be considered a true paraneoplastic disorder, as it has no association with a specific cancer and does not typically parallel the disease course.^6,9 Reports of increased levels of inflammatory mediators released from macrophages and endothelial cells, specifically IL-12, IL-1β, IL-6, and tumor necrosis factor α (TNF-α), have been thought to drive the destruction of bone and cartilage.⁶ In particular, TNF-α acts to indirectly induce destruction by stimulating proteolytic activity in macrophages, similar to the pathogenesis of joint damage in rheumatoid arthritis.⁸ Osteoclastic activity may play a role in the pathogenesis of MRH, as multinucleated giant cells in MRH can mature into osteoclasts by receptor activated nuclear factor–κB ligand signaling. In addition, patients treated with bisphosphonates have had decreased lacunar resorption.^2,8

Initial management of MRH should include screening for hyperlipidemia, hypergammaglobulinemia, hyperglycemia, thyroid dysfunction, and autoimmune diseases, as well as age-appropriate cancer screening. Imaging studies should evaluate for the presence of erosive arthritis. There are no well-defined treatment algorithms for MRH due to the rarity of the disease, and recommendations largely rely on case reports. Although spontaneous remission typically occurs within 5 to 10 years, the risk for joint destruction argues for early pharmacologic intervention. Current management includes the use of nonsteroidal anti-inflammatory drugs and various immunosuppressants including oral glucocorticoids, cyclophosphamide, chlorambucil, methotrexate, or azathioprine.² A combination of methotrexate with cyclophosphamide or glucocorticoids also has shown efficacy.¹⁰ Anti–TNF-α agents, such as etanercept, adalimumab, and infliximab, have been used with some success.² Tumor necrosis factor α inhibitors used in combination with oral glucocorticoids and methotrexate may have an increased benefit.^2,9,11 Evidence suggesting that TNF-α plays a role in the destruction of bone and cartilage led to the successful use of infliximab in combination with oral glucocorticoids and methotrexate, which prevented possible development of antibodies to infliximab and increased its efficacy.¹² Bisphosphonate use in combination with glucocorticoids and methotrexate may prevent joint destruction without the serious adverse events associated with anti–TNF-α agents.^2,9,13,14

TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.

Josve05a/Getty Images

We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.

To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.¹ It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.¹ A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).

A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).

It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.² For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.

As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.³ We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.

There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.⁴Learning the common terminology used by the trans population is a logical first step for physicians seeking to provide more affirming care to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.

1. Lancet. 2016 Jul 23;388(10042):390-400.

2. www.genderbread.org/resource/genderbread-person-v4-0.

3. Obstet Gynecol. 2011 Dec;118(6):1454-8.

4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.

TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.

Josve05a/Getty Images

We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.

To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.¹ It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.¹ A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).

A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).

It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.² For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.

As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.³ We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.

There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.⁴Learning the common terminology used by the trans population is a logical first step for physicians seeking to provide more affirming care to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.

1. Lancet. 2016 Jul 23;388(10042):390-400.

2. www.genderbread.org/resource/genderbread-person-v4-0.

3. Obstet Gynecol. 2011 Dec;118(6):1454-8.

4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.

TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.

Josve05a/Getty Images

We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.

To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.¹ It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.¹ A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).

A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).

It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.² For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.

As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.³ We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.

There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.⁴Learning the common terminology used by the trans population is a logical first step for physicians seeking to provide more affirming care to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.

1. Lancet. 2016 Jul 23;388(10042):390-400.

2. www.genderbread.org/resource/genderbread-person-v4-0.

3. Obstet Gynecol. 2011 Dec;118(6):1454-8.

4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.