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THE CLINICAL ADVISOR •APRIL 2013

A F O R U M F O R P H Y S I C I A N A S S I S TA N T S

NEWSLINE

■ Make screening personal ■ Asthma drug relieves hives ■ AF and dementia linked ADVISOR FORUM

■ Mix formula as directed ■ Minimize patch reaction ■ Gagless strep test LEGAL ADVISOR

Immunization at school without parental consent

✶ FREE CME COURSES!

■ Dermatology Clinic

TENDER, ATROPHIC ARM LESION PAGE 73

■ Dermatologic Look-Alikes VOLUME 16, NUMBER 4

WHITE PLAQUES ON THE TONGUE PAGE 79 W Where do you rank iin our Salary Survey? F Find out the results coming iin our May issue.

| A P R I L 2 013 | www.ClinicalAdvisor.com

SEXUAL RISK BEHAVIOR IN

OLDER ADULTS Prevalence of HIV (green) and other STDs is on the rise among adults aged 55 years and older.

Download the new app for the iPhone, iPad,and Android— created specifically for nurse practitioners and physician assistants from the publishers of the highest rated journal for these health-care professionals. With the Clinical Advisor app you can: • Take Derm Dx quizzes to learn about difficultto-identify dermatology conditions, and then see how you performed against your peers. • Use medical calculators to do things like assess liver function, convert HbA1C to mean plasma glucose, evaluate BP, determine BMI and more. • Read the latest news about breakthrough treatments, disease outbreaks, drug approvals and recalls, and clinical research.

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Editor Joe Kopcha, editor@clinicaladvisor.com Managing editor Marina Galanakis Senior editor Delicia Yard Web editor Nicole Blazek Contributing editors Bruce D. Askey, MSN, CRNP; Rebecca H. Bryan, APRN, CNP; Eileen F. Campbell, MSN, CRNP; Philip R. Cohen, MD; Deborah L. Cross, MPH, CRNP, ANP-BC; Sharon Dudley-Brown, PhD, FNP-BC; Maria Kidner, DNP, FNP-C; Joan W. Kiely, MSN, CRNP; Debra August King, PhD, PA; Ann W. Latner, JD; Claire B. O’Connell, MPH, PA-C; Kathy Pereira, MSN, FNP-BC; Sherril Sego, FNP, DNP; Julee B. Waldrop, MS, PNP; Kim Zuber, PA-C Art director Andrew Bass Group art director, Haymarket Medical Jennifer Dvoretz Group production manager Kathleen Millea Circulation manager Paul Silver Audience development director John Crewe National accounts manager Alison McCauley, 646.638.6098 alison.mccauley@haymarketmedical.com Group publisher Thomas P. Hennessy, 646.638.6085 tom.hennessy@haymarketmedia.com Editorial director Jeff Forster Vice president, medical magazines and digital products Jim Burke CEO, Haymarket Media, Inc. Lee Maniscalco All correspondence to: The Clinical Advisor 114 West 26th Street, 4th Floor, New York, NY 10001 For advertising sales, call 646.638.6075. For reprints, contact Wright’s Reprints at 877.652.5295. Persons appearing in photographs in “Newsline,” “The Legal Advisor,” and “Clinical Challenge” are not the actual individuals mentioned in the articles.They appear for illustrative purposes only. The Clinical Advisor® (USPS 017-546, ISSN 1524-7317), Volume 16, Number 4, is published 12 times a year, monthly, for $75.00 per year in the United States; $85.00 in Canada; $110.00 for all other foreign, in U.S. dollars, by Haymarket Media, Inc., 114 West 26th Street, 4th Floor, New York, NY 10001. Single copy: $20 U.S.; $30 foreign. www.ClinicalAdvisor.com. To order or update your paid subscription, call 800.436.9269. Periodicals postage rate paid at New York, NY, and additional mailing offices. POSTMASTER: Send all address changes to: The Clinical Advisor, c/o DMDData Inc., 2340 River Road, Des Plaines, IL 60018. Call 800.430.5450 to change your address or make other subscription inquiries. Requests for subscriptions from outside the United States must be accompanied by payment. All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright © 2013.

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6 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

LEVEL

8

CONTENTS APRIL 2013

NEWS AND COMMENT 15

90

73

41

■ A woman presents with tender atrophic plaques on the arm and chest. ■ The hard lesion on a woman’s scalp is marked by complete hair loss within.

Newsline ■ Make cancer screening more personal ■ Asthma drug relieves hives symptoms ■ Chronic pain meds lower testosterone ■ And more

77

Alternative Meds Update Lycopene, primarily found in tomatoes, is valued for its antioxidant activity.

79

CME/CE Dermatologic Look-Alikes Can you differentiate between these white plaques on the tongue?

84

CME/CE Posttest

86

Evidence-Based Medicine

Commentary Personalize cancer screening 15

FEATURES 28

CME/CE Dermatology Clinic

Sexual risk behavior among older adults Societal changes and pharmaceutical advances have led to a rise in sexual activity in this population.

ADVISOR FORUM

CME/CE Vaginal bleeding in the early stages of pregnancy A number of potential causes of bleeding must be considered when deciding what type of management is required.

48

Causes of bleeding in early pregnancy 41

DEPARTMENTS

50

Consultations ■ First steps when treating atrial fibrillation ■ And more Clinical Pearls ■ A little carbonation helps the

54

Derm Dx Read the clinical descriptions, view the images, and make your diagnosis at ClinicalAdvisor.com.

medicine go down ■ And more 50

Your Comments ■ Treating comedones in patients with

64

Legal Advisor A clinician immunizes a child against the H1N1 virus without parental consent.

68

Stat Consult The most recent information on nosocomial pneumonia

MAKING CONTACT

Follow us on Twitter @ClinicalAdvisor

Favre-Racouchot syndrome

New tongue plaques every week 79

Like us on Facebook facebook.com/TheClinicalAdvisor

www.ClinicalAdvisor.com

Visit us on the web ClinicalAdvisor.com

Go mobile with us mobile.ClinicalAdvisor.com

EXCLUSIVE TO THE WEB AT

ClinicalAdvisor.com Web Exclusives

The Waiting Room

CliniAd.com/WyTpbB

Official Blog of The Clinical Advisor

Updated recommendations for sports concussions released The 2012 Zurich Consensus statement on sports concussion offers guidance for concussion evaluation, management and return to play. Most Americans with prediabetes unaware of condition Only about 11% of the estimated 79 million Americans who had prediabetes in 20092010 identified as such. Norovirus leading offender in pediatric gastroenteritis Norovirus far exceeds rotavirus as the leading cause of medically attended acute gastroenteritis in U.S. children.

CliniAd.com/VwgfCl Julee Waldrop, DNP, PNP, FNP State medical boards trying to limit who can be called “Doctor” Advanced practice nurses are unfairly targeted by laws that could make it a felony for nonphysicians to introduce themselves as “Dr.” Robyn Carlisle, MSN, CNM, WHNP The Internet can’t tell if you have cancer Patients should be encouraged to read up on their health, but make sure they are using reputable sources. Sharon M. O’Brien, MPAS, PA-C Treating PTSD in primary care As more military personnel return to the United States with PTSD symptoms, it is time to refresh our knowledge on treating this disorder.

Derm Dx Interact with your peers by viewing the images and offering your diagnosis and comments. CliniAd.com/YDIft3

Cartoon Archive

The Clinical Advisor’s monthly cartoons are now available online as well. CliniAd.com/YcSfHq

MAKING CONTACT

Follow us on Twitter @ClinicalAdvisor

© Roy Delgado

Blue mark on the face and eye A woman presents with a bluish-grey mark that extends from the upper cheek to the forehead and effects the sclera of the eye.

Like us on Facebook facebook.com/TheClinicalAdvisor

12 THE CLINICAL ADVISOR • APRIL 2013 • www.clinicaladvisor.com

Visit us on the web ClinicalAdvisor.com

Go mobile with us mobile.ClinicalAdvisor.com

Newsline A P R I L 2 0 13

Updated acute otitis media guidelines page 23

Atrial fibrillation increases risk for dementia page 23

Long-acting pain meds lower testosterone page 16

© SCIENCE SOURCE / GEOFF TOMPKINSON

Make cancer screening more personal

Mammography is used to detect breast tumors early.

accessed March 15, 2013), interviews with 33 adults aged 63 to 91 years (median age: 76 years) presenting to a senior health center indicated that many of the study participants never discussed stopping screening with their health-care providers or considered stopping on their own, despite the growing recognition that older adults who are unlikely to benefit from cancer screening and would incur risks from the process undergo such testing too frequently. The respondents viewed undergoing screening tests as morally obligatory. Many viewed continued screening as a habit or custom that did not require any decision. Some respondents even noted that they were upset when their physician recommended that they stop undergoing screening.

Percentage of adults who often feel depressed Persons having daily or weekly feelings of depression were categorized as often depressed. Source: CDC, National Health Interview Survey, 2010

15

13.0 10.7

12 Percentage

PATIENTS ARE best equipped to make informed choices about submitting to cancer screening when the discussion with a health-care provider addresses their own personal risk rather than average risks, indicate the results of a Cochrane review (Cochrane Database Syst Rev. 2013;2:CD001865). Adrian G.K. Edwards and colleagues reviewed randomized controlled trials incorporating an intervention with a personalized risk communication element for persons undergoing screening procedures. The 41 studies included 28,700 participants; most of the trials involved screening for colorectal cancer and for breast cancer. Overall, 592 (45.2%) of 1,309 patients who received personalized risk information made informed choices, compared with 229 (20.2%) of 1,135 persons

who received generic risk information. In addition, personalized risk communications appeared to increase patient knowledge and may have improved patient accuracy of risk perception. However, these interventions did not significantly affect patients’ anxiety about being tested. Providing people with personalized risk information resulted in a small increase in number of patients who did undergo a given screening procedure. Older adults may be a particular population for clinicians to target for discussions of informed decision making regarding cancer screening, based on the fi ndings of a study led by Alexia M. Torke, MD. As reported online ahead of print in JAMA Internal Medicine (available at archinte.jamanetwork.com /article.aspx?articleid=1666431;

9

7.7

9.5

10.5

9.9

6.7

9.0 6.0

6.7

6 3 0

Overall

18-44

45-64

65-74

≥75

Age group (yrs)

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 15

Newsline OM A LI ZU M A B ( Xol a i r) may elicit more of a response in patients with chronic idiopathic urticaria (more commonly referred to as hives) than do H1-antihistamines, according to new study findings (N Engl J Med. 2013;368:924-935). A monoclonal antibody, omalizumab is a treatment for severe asthma. It targets immunoglobulin E and affects mastcell and basophil function. The agent has shown efficacy in urticaria patients in phase 2 trials. Recently, a phase 3 randomized, double-blind study evaluated the efficacy and safety of omalizumab in 323 persons, aged 12 to 75 years, with moderate-to-severe chronic idiopathic urticaria who remained symptomatic despite H1-antihistamine therapy.

The patients received three injections of omalizumab 75 mg, 150 mg, or 300 mg, or placebo. Each injection was spaced four weeks apart, and treatment was followed by 16 weeks of observation. The primary efficacy outcome was the change from baseline in a weekly itch-severity score. The scale ranged from 0 to 21, with higher scores indicating more severe itching. The baseline weekly itchseverity score was approximately 14 in all four study groups. At week 12, the mean changes in the weekly itch-severity score from baseline fell by 9.8 points in the 300-mg group, 8.1 points in the 150 mg group, 5.9 points in the 75-mg group, and 5.1 points in the placebo group. Also at 12 weeks, hives were totally eliminated in 53% of the omalizumab

© SCIENCE SOURCE / DR. P. MARAZZI

Asthma drug relieves hives symptoms

Urticaria (shown) is a respose of the body’s immune system.

users, and 44% experienced no further hives or itch. Adverse events occurred with similar frequency in all four groups, and frequency of serious adverse effects was low, but higher in the 300-mg group (6%) than in the placebo (3%), 150-mg (1%), or 75-mg (1%) groups.

MEN TAKING daily longacting opioids were nearly five times more likely to become hypogonadal than were men on short-acting opioids, researchers have found. Although opioids are known to cause low testosterone in men, this is reportedly the first study to show a significant difference in risk between agents that are short-acting (immediate release, taken every four to six hours) and those that are longacting (slow release, taken every eight to 12 hours). Andrea L. Rubinstein, MD, and co-investigators studied 81 men

Long-acting opioids increased the odds of becoming hypogonadal.

who were aged 26 to 79 years (median age: 51 years) seen in a ch ron ic-pa in clinic between January 2009 and June 2010. None of the men had a previous diagnosis of hypogonadism and all had been on a stable daily dose of an opioid for at least three months. Hypogonadism was defined as morning total serum testosterone levels below 250 ng/dL. As Rubinstein’s team detail in an upcoming issue of The Clinical

16 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Journal of Pain, 53% of all the men taking daily opioids were hypogonadal. Of the 46 men receiving long-acting formulations, 34 (74%) were hypogonadal, compared with 12 of 35 men (34%) using short-acting opioids (hydrocodone or oxycodone) exclusively. After controlling for daily dosage and BMI, men on long-acting opioids had 4.78 times greater odds of becoming hypogonadal than did men on the short-acting agents. BMI was also significantly associated with hypogonadism, but daily dose was not.

© THINKSTOCK

Chronic pain meds lower testosterone levels

Newsline

WANING IMMUNITY from diphtheria, tetanus, and pertussis (DTaP) vaccines is likely one reason for a newly discovered steady increase in risk of pertussis in the six years after completion of the five-dose DTaP series. As reported in Pediatrics (available at pediatrics.aappublications. org/content/early/2013/03/06/ peds.2012-1928.long; accessed March 15, 2013), Sara Y. Tartof, PhD, MPH, and colleagues sought to assess the risk of pertussis by time since vaccination in more than 400,000 children in Minnesota and Oregon. Tartof ’s group identified 458 pertussis cases in Minnesota and 89 in Oregon, with incidence rates increasing for each year of the six years of follow-up. Incidence rates in the Minnesota group rose from 15.6/100,000 at year 1 to 138.4/1000,000 at year 6. In the Oregon group, pertussis incidence among the vaccinated children increased from 6.2/100,000 in year 1 to 24.4/100,000 in year 6. “This rise is likely attributable in part to waning immunity from DTaP vaccines,” noted the authors. “Continuing to monitor disease burden and vaccine effectiveness in fully vaccinated children in coming years will be important to assess ongoing risk as additional cohorts vaccinated solely with acellular pertussis vaccines are introduced.”

AF and dementia linked again NEW RESEARCH suggests that atrial fibrillation (AF)—the most common arrhythmia in the United States—is associated with a higher risk for cognitive impairment and dementia, whether or not the person has a history of stroke (Ann Intern Med. 2013;158:338-346). AF and cognitive impairment share three risk factors: heart failure, diabetes, and hypertension. With earlier studies linking AF with an increased risk for cognitive impairment and dementia, investigators analyzed 21 studies examining this association. The results showed AF to be significantly associated with a higher risk for cognitive impairment in persons with first-ever or recurrent stroke and in a broader population including patients with or without a history of stroke. To help determine AF risk, a research team has validated a simple risk-prediction model for women, based on easily obtained patient information. As Brendan

The risk algorithm included age, weight, height, systolic BP, alcohol use, and smoking status.

M. Everett, MD, MPH, and colleagues described in European Heart Journal (avai lable at eurheartj.oxfordjournals.org /content/early/2013/02/13 /eurheartj.eht033.long; accessed March 15, 2013), the model was devised based on 32 possible predictors of AF from the Women’s Health Study (WHS), a cohort of 20,822 women without cardiovascular disease at baseline. After following the women for a median 14.5 years for incident AF, Everett’s group developed the WHS AF risk algorithm, which included terms for age, weight, height, systolic BP, alcohol use, and smoking status. After testing the model in the WHS cohort, the researchers concluded that the new model was significantly better at identifying women at increased risk for AF over the next 10 years than was using a woman’s age alone to determine risk, with the model reassigning nearly one in four women to a more accurate AF risk category. ■

AAP updates acute otitis media advice DON’T DIAGNOSE acute otitis media (AOM) in children with no middle ear effusion based on pneumatic otoscopy and/or tympanometry; do diagnose it in children who present with moderate-to-severe bulging of the tympanic membrane or new onset otorrhea not caused by acute otitis externa; and assess the child for pain, which should be treated if present. These are a few of the recommendations included in the new clinical practice

guideline on this common childhood ear infection, issued by the American Academy of Pediatrics (AAP) (Pediatrics. 2013;131: e964-e999; available at pediatrics .aappublications.org/content/131/3/e964. long, accessed March 15, 2013). The guideline updates the AAP’s 2004 recommendations to primary-care clinicians for the management of uncomplicated AOM in children aged 6 months to 12 years. Unlike the 2004 version, recurrent AOM is addressed.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 23

© CMSP

Pertussis immunity weakens

FEATURE: AYASHA STEWART, MNSC, WHNP-BC, APN, AND SHANNON GRAHAM, MNSC, WHNP-BC, APN

Sexual risk behavior among older adults Societal changes and pharmaceutical advances have led to a rise in sexual activity in this population, and clinicians must adapt to a new reality.

© SCIENCE SOURCE / BIOPHOTO ASSOCIATES / COLORIZATION BY MARY MARTIN

D

ata show that older adults are being treated for a greater number of sexually transmitted diseases (STDs)—especially HIV—than in the past.1 According to recent literature and the CDC, older adults are engaging in more sexual activities despite previous beliefs that such activity declines with age.2 By 2015, the number of people aged 50 years and older living with HIV/AIDS will account for half of all individuals with the disease in the United States. This development is partially attributable to advances in highly active antiretroviral therapy (HAART). Individuals with HIV/AIDS who are taking HAART medications are living longer than those in previous years. However, risky sexual behavior is another reason for this increased incidence of HIV in the older adult population. Health-care providers must be cognizant of this trend and use it to shape their daily clinical practice, namely by routinely assessing and screening for STDs and educating older adults about such STD-protective behaviors as using condoms. Contributing factors

Persons aged 55 years and older represent the highest percentage of those with HIV (green).

28 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

The CDC reported that the highest prevalence rate of HIV diagnoses in 2008 was among persons aged 45 to 54 years. In 2011, the population with the highest percentage of people diagnosed with HIV was among persons aged 55 years and older.2 The reason for the high prevalence of STDs in this population has not been examined fully in the literature. However, a great deal of research data show that older adults are engaging

SEXUAL RISK BEHAVIOR

TABLE 1. Evaluating sexual risk in older adults Normalizing the discussion • I discuss sexual activity with all of my patients because it is an important part of their medical care. Broaching the topic • Tell me about your sex life. • When you say you’ve had sex, what exactly do you mean? • Do you have sex with men, women, or both? Asking about partners • Tell me about the number of sex partners within the past three months. • Where do you meet your partners? • Have you ever gone online to meet partners for sex? • How well do you know your sexual partners? • What do you know about the HIV status of your partners? • How does your partner’s HIV status affect your sexual behavior? • Have you noticed symptoms in your partner that are concerning for you?

two documented trends support the perception of increased sexual activity in older adults and the need for reinforcement of safe-sex practices over the lifespan. For the purposes of this article, sexual risk behavior is defined as “sexual intercourse without condom use with a casual partner, and/or sexual intercourse without condoms with a new main partner with no prior HIV testing.”6 Sexual risk behaviors can result in such negative health outcomes as emotional and social disturbances as well as the transmission of STDs. Since older adults are engaging in riskier sexual behaviors, health-care providers need further education regarding routine assessments of sexuality, risks of STDs, and methods of prevention. Table 1 offers an outline to help evaluate sexual risk in older adults.

Asking about sexual activity

Prevention challenges

• What sexual activities do your sexual partners engage in? • Do you have oral sex? Vaginal sex? Anal sex? • Do you select partners based on HIV status? • Do you ever get drunk or high before you have sex?

The issue of risky sexual behaviors among older adults is multidimensional. Contributing factors include a growing population of older adults, increased longevity, better access to medical care, more availability of treatments for various types of male and female sexual dysfunction, inadequate knowledge and perception of being at risk for STDs, diminished need to protect against unintended pregnancy, and increased societal acceptance and acknowledgment of sexual behaviors in this population. The current population of older adults has been described as “a sexually liberated Baby Boomer generation.”7 A growing rate of older adults without major health impairment is contributing to the improved longevity of this population.8 In one study, older adults who reported poor physical health tended to have a decreased interest in sex.3 Another study examined the results of the 2001 report of the National Advisory Council on Aging, which stated that 92% of survey participants considered sex an important part of life.1 In addition, 75% of those aged 65 to 74 reported being sexually active.1 It is safe to assume that a greater number of older adults in better physical health will result in increased interest in sex. More and more older adults are seeking medical care for such conditions as erectile dysfunction in men and postmenopausal

Asking about prevention methods • What do you do to protect yourself during sex? • Do you use condoms when having sex? How often? With what types of sex? • What has been your experience with using condoms? • What factors/situations get in the way of using condoms? Adapted from Centers for Disease Control and Prevention (CDC); Health Resources and Services Administration; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Incorporating HIV prevention into the medical care of persons living with HIV. Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2003;52(RR-12):1-24. Available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm, accessed March 15, 2013.

in more sexual activity than previously thought.3 In fact, many older adults are continuing sexual activity throughout their lifespan. In a study of 3,005 older adults in the United States, current sexual activity was reported for 73% of those aged 57 to 64 years, 53% of those aged 65 to 74 years, and 26% of those aged 75 to 84 years.4 In addition, the population of individuals older than age 50 years who are single due to divorce or the death of a spouse or significant other is increasing.5 These

For more news, opinion, and clinical features concerning older adults, visit our Geriatrics Information Center at

CliniAd.com/WRiemF. 32 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

SEXUAL RISK BEHAVIOR

atrophic conditions in women. Since the advent of sildenafil (Viagra) in 1998—as well as other phosphodiesterase inhibitors, penile injections, vacuum devices, and prostheses— research has shown an increase in the number of men continuing intercourse into their 80s.3 Topical vaginal estrogens and testosterone for vulvovaginal atrophy have led to fewer sexual pain and lubrication issues for many postmenopausal women.3 Since postmenopausal women do not have to worry about unintended pregnancy, they may choose to engage in unprotected intercourse, putting themselves at higher risk for STDs.9 A 2003 study determined that the perception of risk for STDs among older adults is minimal compared with that of adolescents and young adults.7 Older adults were less likely than younger adults to know how HIV is transmitted and were less knowledgeable about HIV disease progression. A 2008 study assessed for knowledge of STD risk in 165 educated men and women older than age 50 years: A total of 92% of study participants agreed that condoms prevented STDs and AIDS, indicating some level of knowledge of the connection between prevention of STDs and AIDS, but only 13.3% always wore condoms with intercourse.9 Despite the fact that data are limited regarding late-in-life sexuality (especially in assisted-living and nursing homes), a 2011 study of older people in care homes found that these adults do not lose interest in sex but feel limited by staff attitudes and other physical or environmental constraints.10 This increases the likelihood that any sexual activity among these individuals will be unprotected. Societal changes

Overall, society’s view of sexuality in older adults has evolved, primarily in terms of the attitude and perception regarding the importance of sexual health in this population. Sexuality contributes to such health benefits in older adults as improved mental health, decreased stress levels, and decreased feelings of loneliness.8 One only has to turn on the television to observe the shift in society’s perception and acceptance of sexuality in older adults. The media portray older adults as vibrant and sexual beings in the advertising of various products. Such common phrases as, “50 is the new 30” show that the general public is embracing older age and sexuality. Approximately 20% of online daters are from the Baby Boom generation.5 However, even though sexual activity in older adults is more widely accepted, it should be remembered that risky sexual encounters involving unprotected sex (i.e., without a condom) may result in STDs.

POLL POSITION

Do you screen patients older than age 50 years for sexually transmitted diseases? n=240

32%

Yes No

68%

For more polls, visit CliniAd.com/10TDwDb.

TABLE 2.The PLISSIT model Obtaining Permission from the client to initiate sexual discussion Providing the client with Limited Information needed to function sexually Giving Specific Suggestions for the individual to proceed with sexual relations Providing Intensive Therapy surrounding the issues of sexuality for that client

The need for education

Sexuality has positive effects on general well-being and mental health, and pleasure is necessary to maintain this state of well-being, even in the aging population.8 Sexual activity in older adults improves quality of life, but some individuals are hindered by disabilities and/or illness.11 Even so, older adults continue to engage in unprotected intercourse or other risky sexual activity and perceive the risk of acquiring an STD as minimal. Regardless of the knowledge of increased sexual activity, clinicians provide older patients little education regarding safe-sex practices.7 Efforts to increase awareness of the risks of unprotected intercourse should focus on the development and implementation of educational materials geared toward older adults in clinics, assisted-living facilities, and nursing homes. A similar educational effort must be made to educate health-care providers regarding safe-sex practices and the risk of STD transmission in older adults.8,9 Developed in 1976, the PLISSIT model (Table 2) is a sexual-assessment tool that can be used in a variety of clinical settings and may be particularly useful when addressing older adults.12 The simplicity of this model allows a wide variety of questions to be individualized to the patient and his or her particular situation.

34 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Continues on page 38

SEXUAL RISK BEHAVIOR

Older adults continue to engage in unprotected intercourse or other risky sexual activity and perceive the risk of acquiring an STD as minimal. A recurring theme found throughout the literature is that health-care providers tend to avoid asking older patients about sexual health. Compounding matters is the fact that older health-care providers are the least likely to discuss sexuality at all.13 Clinical and societal perceptions have continued under the assumption that older adults have health problems that hinder sexual activity. Older adults also may present with symptoms that the clinician may associate with common pathologic changes attributable to aging or to conditions common in this population (e.g., fatigue, weight loss, and mental confusion). For these reasons, clinicians often dismiss early signs and symptoms of STDs and HIV in older adults.7 Older adults must be counseled on the risks and consequences of unprotected sex. Similarly, health-care providers caring for older adults must be educated regarding clinical perception of the likelihood of STD susceptibility in this population. The prevalence of HIV and STDs among older adults has risen steadily over the past 12 years. Despite societal perceptions of older adults being less interested in sexual activity as they age, many are currently sexually active and engaging in high-risk sexual encounters. To confront this new reality, health-care providers should begin conducting complete sexuality assessments of their older patients and screening these patients for STDs in their daily practice. ■

5. Jeffers LA, DiBartolo MC. Raising health care provider awareness of sexually transmitted disease in patients over age 50. Medsurg Nurs. 2011;206:285-289. 6. Brodbeck J, Vilén UL, Bachmann M, et al. Sexual risk behavior in emerging adults: gender-specific effects of hedonism, psychosocial distress, and sociocognitive variables in a 5-year longitudinal study. AIDS Educ Prev. 2010;22:148-159. 7. Maes CA, Louis M. Knowledge of AIDS, perceived risk of AIDS, and at-risk sexual behaviors among older adults. J Am Acad Nurse Pract. 2003;15:509-516. 8. Bitzer J, Platano G, Tschudin S, Alder J. Sexual counseling in elderly couples. J Sex Med. 2008;5:2027-2043. 9. Olivi M, Santana RG, Mathias TA. Behavior, knowledge and perception of risks about sexually transmitted diseases in a group of people over 50 years old. Rev Lat Am Enfermagem. 2008;16:679-685. 10. Elias J, Ryan A. A review and commentary on the factors that influence expressions of sexuality by older people in care homes. J Clin Nurs. 2011;20:1668-1676. 11. Wallace MA. Assessment of sexual health in older adults. Am J Nurs. 2008;108:52-60. 12. Annon J. The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems. J Sex Educ Ther. 1976;2:1-15. 13. Hellwig, JP. Birth trends. Nurs Womens Health. 2012;16:192-197. All electronic documents accessed March 15, 2013.

© The New Yorker Collection 2013 from cartoonbank.com. All Rights Reserved.

Ms. Stewart is a clinical assistant professor and coordinator for the WHNP specialty program at the University of Arkansas for Medical Sciences College of Nursing, Little Rock, where Ms. Graham is a clinical instructor. References 1. Illa L, Brickman A, Saint-Jean G, et al. Sexual risk behaviors in late middle age and older HIV seropositive adults. AIDS Behav. 2008;12:935-942. 2. Centers for Disease Control and Prevention. Diagnoses of HIV infection among adults aged 50 years and older in the United States and dependent areas, 2007–2010. Available at www.cdc.gov/hiv/surveillance/resources /reports/2010supp_vol18no3/index.htm. 3. Taylor A, Gosney MA. Sexuality in older age: essential considerations for healthcare professionals. Age Ageing. 2011;40:538-543. Available at ageing .oxfordjournals.org/content/40/5/538.long. 4. Lindau ST, Schumm LP, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357:762-74. Available at www.ncbi.nlm.nih.gov/pmc/articles /PMC2426743/.

38 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

“I take it this means the barbeque is ready.”

CME CE

PROGRAM OUTLINE APRIL 2013

0.5 CREDITS

Page 41 FEATURE Vaginal bleeding in the early stages of pregnancy Kimberly D. Walker, MPA, PA-C; Kathy Dexter, MLS, MHA, MPA, PA-C; and Bonnie A. Dadig, EdD, PA-C Kimberly D.Walker, MPA, PA-C; Kathy Dexter, MLS, MHA, MPA, PA-C; and Bonnie A. Dadig, EdD, PA-C have no relationships to disclose relating to the content of this article.

■ LEARNING OBJECTIVES: • Identify the most common cause of fetal demise and subsequent spontaneous abortion. • Name the condition reported by approximately 75% of women with confirmed ectopic pregnancy (EP). • List the diagnostic test most frequently used to diagnose EP. • Explain the management options for a woman with an unruptured EP. 0.5 CREDITS

Page 73 DERMATOLOGY CLINIC Tender, atrophic plaque on the arm and chest Rachel E. Chikowski and Julia R. Nunley, MD Rachel E. Chikowski and Julia R. Nunley, MD, have no relationships to disclose relating to the content of this article.

Firm, indurated scalp lesion with hair loss Esther Stern, NP Esther Stern, NP, has no relationships to disclose relating to the content of this article.

■ LEARNING OBJECTIVES: • To identify and diagnose dermatologic conditions and review up-to-date treatment.

Page 79 DERMATOLOGIC LOOK-ALIKES White plaques on the tongue Kerri Robbins, MD, and Damjan Jutric Kerri Robbins, MD, and Damjan Jutric, has no relationships to disclose relating to the content of this article.

■ LEARNING OBJECTIVE: • To distinguish and properly treat dermatologic conditions with similar presentations.

Page 84 POSTTEST This program has been reviewed and is approved for a maximum of 1 hour of AAPA Category I CME credit by the Physician Assistant Review Panel. Approval is valid for one year from the issue date of April 2013. Participants may submit the self-assessment at any time during that period. This program was planned in accordance with AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs. Nurse Practitioner Associates for Continuing Education (NPACE) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. NPACE designates this educational activity for a maximum of 1 contact hour of credit. Participants should only claim credit commensurate with the extent of their participation in the activity.

40 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

■ LEARNING OBJECTIVES :

CME CE FEATURE

• Identify the most common cause of fetal demise and subsequent spontaneous abortion. • Name the condition reported by approximately 75% of women with ectopic pregnancy (EP). • List the diagnostic test most frequently used to diagnose EP. • Explain the management options for a woman with an unruptured EP. ■ COMPLETE THE POSTTEST: Page 84 ■ ADDITIONAL CME/CE: Pages 73, 79 Turn to page 40 for additional information on this month’s CME/CE courses.

KIMBERLY D. WALKER, MPA, PA-C; KATHY DEXTER, MLS, MHA, MPA, PA-C; AND BONNIE A. DADIG, EDD, PA-C

Vaginal bleeding in the early stages of pregnancy A number of potential causes of vaginal bleeding in early pregnancy must be considered when deciding what type of management is required.

U

p to 25% of all women in the early stages of pregnancy will experience vaginal bleeding or spotting. Even more sobering, half of those women will go on to experience intrauterine fetal demise prior to the 20th week.1 To reduce morbidity and mortality, the astute practitioner should be able to assess and manage effectively a patient with vaginal bleeding in the first half of her pregnancy.

© SCIENCE SOURCE / BIOPHOTO ASSOCIATES

Causes

In an ectopic pregnancy, the embryo (shown) implants outside the uterine cavity.

Appropriate assessment and management of the patient requires an understanding of the differential diagnoses of vaginal bleeding in early pregnancy (Table 1). Fifty percent of early-pregnancy bleeds—defined as bleeding at <20 weeks’ gestation—occur in viable intrauterine pregnancies (IUPs). A total of 30% to 50% of early-pregnancy bleeds indicate fetal demise; 7% of these are attributable to ectopic pregnancy (EP) and fewer than 1% are caused by trophoblastic disease and/or lesions of the cervix/vagina.2 Chromosomal abnormalities are the most common cause of fetal demise and subsequent spontaneous www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 41

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CME CE

EARLY-PREGNANCY BLEEDING

The patient will present with vaginal bleeding and mild-to-moderate subrapubic or midline lower abdominal pain that may radiate to the lower back. abortion. Other causes include infection, reproductive tract abnormalities, toxin exposure and endocrine/autoimmune disease.2,3 Spontaneous abortions can be divided into four types: (1) complete (all products of conception [POC] have passed out of the uterus); (2) incomplete (some POC have passed through a dilated cervix); (3) inevitable (bleeding is present with a dilated cervix with or without POC); and (4) septic (an incomplete spontaneous abortion accompanied by infection).1 A threatened abortion is defined as any vaginal bleeding that occurs in early pregnancy with an embryo/fetus present in the uterus, detectable cardiac activity, and a closed cervical os. In a missed abortion, the embryo/fetus is larger than 5 mm and without heart tones, and the POC are retained.1 An EP is a conceptus that implants outside of the uterus.1 EP is the most common cause of pregnancy-associated death in early pregnancy,4 constituting 6% of all maternal deaths annually.1 The diagnosis of EP is missed at initial presentation an estimated 12% of the time.2 Gestational trophoblastic disease (also known as molar pregnancy or hydatidiform mole) is a potentially malignant condition in which the placenta develops without an embryo.5 In an anembryonic pregnancy (also known as a blighted ovum), the gestational sac is larger than 18 mm in size but does not contain embryonic or fetal tissue. A subchorionic hemorrhage (blood between the chorion and the uterine wall) may produce early pregnancy bleeding but does not necessarily result in the termination of the pregnancy.1 History and presentation

Understanding the factors that put a woman at a higher risk for spontaneous abortion is important when taking the patient’s history. These factors include endocrine disorders; genetic aneuploidy (abnormal number of chromosomes); such immunologic disorders as systemic lupus erythematosus; such infections as gonorrhea, chlamydia, syphilis, and herpes; chemical exposure; radiation exposure; and uterine abnormalities.1 Usually, the patient will present with vaginal bleeding and mild-to-moderate subrapubic or midline lower abdominal pain that may radiate to the lower back.6 The clinician should ask about prior confirmation of pregnancy, last known menstrual period, when the bleeding began, quantity and character of bleeding, and current medications (ovulation agents put a woman at risk for a heterotopic pregnancy, which is an IUP and an EP simultaneously).7

Ask whether the patient has experienced any trauma. Are nausea, vomiting, syncope, fever or cramping associated with the bleeding? Carefully review the woman’s obstetric history, exposure to sexually transmitted infections (STIs), and potential bleeding disorders. In EP, no set constellation of findings confirms or excludes the diagnosis. In fact, clinicians cannot reliably exclude the diagnosis of EP on the basis of history and physical exam findings alone. However, a patient who describes the abdominal pain as “sharp” and denies recent passage of tissue is more likely to have an EP than the patient without these findings. A study found that the frequency of EP in women presenting with a positive ␤-human chorionic gonadotropin (hCG), moderate-to-severe abdominal pain, and no history of tissue passage was 25%.8 Approximately 75% of women with confirmed EP will report a history of amenorrhea.5 Factors that increase a woman’s risk for EP include an intrauterine device currently in place, a history of previous EP, in utero exposure to diethylstilbestrol, genital infection, prior tubal surgery, in vitro fertilization, infertility, and smoking.1 The clinician should suspect an anembryonic pregnancy if the woman reports that her pregnancy symptoms have regressed.A transvaginal ultrasound (TVUS) should be performed to confirm the presence of the fetal heartbeat.1 Trophoblastic disease will present with hyperemesis, irregular and/or heavy bleeding, and vaginal pain in the first half of the pregnancy.2,5 Physical examination

The physical exam of a woman with early-pregnancy bleeding will be focused on the abdominal/pelvic area. If the woman presents with fever in the presence of adnexal/peritoneal symptoms and such signs as rebound tenderness, rigidity and/or guarding, consider a diagnosis of septic abortion. Hypotension, absent or diminished bowel sounds, abdominal distension, and shoulder pain on the ipsilateral side could signify a ruptured EP.1 The pelvic and abdominal examination will often yield inconclusive findings, making ultrasound and quantitative ␤-hCG the diagnostic tests of choice. The physical exam is particularly important if there is no access to ultrasound or ␤-hCG or if the results of either are inconclusive. Physical findings that indicate a viable IUP include minimal cervical and abdominal tenderness, benign adnexa, a closed os, and absence of POC. Because these findings may also be present in a nonviable pregnancy, the diagnosis of a normal pregnancy should be made primarily through ultrasonography.2

42 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Identification of an embryo/fetus with cardiac activity located outside of the uterus is conclusive evidence of an ectopic pregnancy. The size and position of the uterus should be assessed for size-date discrepancy.1,3 Molar pregnancies will present with a uterus larger than gestational dates would suggest; in women with an excluded IUP, a uterus size smaller than what would be expected at 8 weeks’ gestation may point to EP.2,8 The bimanual exam may reveal masses and cervical motion tenderness, leading the clinician to consider EP, but these findings are not definitive.1,8 The classic EP triad of pain, vaginal bleeding, and adnexal mass is nonspecific and is interestingly more often associated with a diagnosis of miscarriage. Literature states that the pelvic-exam findings in diagnosing an EP are unreliable in isolation.2 The speculum exam may identify such nonobstetric causes of bleeding as polyps, STI, cancer, or trauma.1 Any tissue in the os indicates a dilated cervix. Inevitable, incomplete, and/or septic, spontaneous abortions are in the differential if the os is dilated. Threatened, complete, embryonic demise, and/or septic abortions are included in the differential if the os is closed.6 The speculum exam also allows the practitioner to quantify the amount of blood present and remove any POC. Many women who eventually miscarry have inconclusive physical exam findings. For example, a dilated os is found in only 24% of women who go on to miscarry, and the finding of POC on speculum exam is present in only 13% of women who go on to miscarry.2 To summarize, the findings needed to diagnose spontaneous abortion or EP are not obtained by the physical exam, but by ultrasound and ␤-hCG levels.2,8 Diagnostic workup

The diagnostic workup of a women presenting with early pregnancy bleeding includes a complete blood count, WBC count with differential to rule out infection, urinalysis to rule out urinary tract infection, gonorrhea/chlamydia swab, Rh-type blood test, qualitative ␤-hCG test, quantitative ␤-hCG test, TVUS, and serum progesterone levels.1,3,9 Currently, the TVUS and the quantitative ␤-hCG are considered first-line for diagnosis in early-pregnancy bleeding.2 Data show that 91% of EPs are diagnosed with TVUS,10 which is preferred over transabdominal ultrasound because of increased sensitivity.1 Confirmation of a viable IUP is achieved by visualization of the yolk sac by TVUS five to six weeks after the start of the last menstrual period, or when ␤-hCG levels are between 1,500-2,000 mIU/mL.1,3 This range is referred to as the

discriminatory zone. If ␤-hCG levels are too low, serial ␤-hCG levels may be taken every 48 hours (doubling time) until the discriminatory zone is reached. At that point, the TVUS would prove effective in assessing for IUP.3 Findings of a normally progressing IUP include a normal gestational sac consisting of a central blastocyst surrounded by a double ring of echogenic chorionic villi and decidua. Visualization of this structure and absence of a pseudogestational sac rules out an EP. Cardiac activity is noted when the crownrump length is >5 mm (around 10 to 11 weeks’ gestation).1 The presence of a detectable heartbeat decreases the risk of pregnancy loss by 10%,3 and the absence of the above findings allows the clinician to identify failure of the pregnancy.1 All women presenting with signs and symptoms suggestive of EP should have an ultrasound, regardless of specific findings in the history and physical examination, as the specificity of the TVUS in detecting IUP is around 98%, with greater than 90% sensitivity.8,11 When an IUP is verified, the EP is ruled out, but care must be taken not to miss a heterotopic pregnancy.11 An adnexal mass or free fluid in the pelvis is an EP until proven otherwise. Identification of an embryo/fetus with cardiac activity located outside of the uterus is conclusive evidence of an EP. If an intrauterine embryo/fetus without cardiac activity is identified and there is tissue and/or cervical os dilation, fetal demise has most likely taken place. Pathologic examination of tissue from the cervical os in a suspected inevitable spontaneous abortion should show chorionic villi. Lack of fetal heartbeat by 10 to 11 weeks’ gestation in the absence of fetal tissue within the gestational sac signifies an anembryonic pregnancy. Gestational trophoblastic disease presents with classic “snowstorm” appearance of material within the uterine space. Subchorionic hemorrhage may be present in a normally progressing pregnancy, but once hemorrhage is identified, verification of heartbeat is necessary.1 A serum progesterone level >25 ng/mL suggests a viable IUP.5 High serum progesterone levels will rule out an EP, but predictive value depends on the serum ␤-hCG levels.8 Serum progesterone levels are less helpful when ␤-hCG levels are <2,000 IU/L and within the first four weeks of gestation. A ␤-hCG level >2,000 IU/L and a serum progesterone level >22 ng/mL together confer greater than 30% specificity for ruling out an EP. The best role for serum progesterone is in identifying women at low risk for EP when paired with ␤-hCG levels.4 Continues on page 46

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 43

CME CE

EARLY-PREGNANCY BLEEDING

TABLE 1. Differential diagnosis of early-pregnancy vaginal bleeding Differential diagnosis

Definition

Additional history

Spontaneous abortion (subtypes below)

Pregnancy loss at <20 weeks’ gestation

Endocrine disorders, genetic aneuploidy, immunologic disorders, infection, chemical/radiation exposure, uterine abnormalities

Complete spontaneous abortion

All products of conception (POC) evacuated from uterus

Endocrine disorders, genetic aneuploidy, immunologic disorders, infection, chemical/radiation exposure, uterine abnormalities

Physical examination

Diagnostic tests

Management

Transvaginal ultrasound (TVUS): embryonic/fetal tissue without heart tones

␤-hCG ratio <0.87 reliably predicts that the pregnancy will resolve spontaneously without intervention

␤-human chorionic gonadotropin (␤-hCG): doubling rate <80% to 100% every 48 hours (failing intrauterine pregnancy [IUP]); deemed nonviable if <53% Closed os

Expectant: observation, IV fluids; discharge home with obstetric (OB) follow-up and instructions to include no intercourse, bed rest, and return if bleeding worsens; repeat TVUS one week after initial presentation Medical: misoprostol (Cytotec) with follow-up appointment Surgical: dilation and curettage (D&C)

Incomplete spontaneous abortion

Some POC passed through dilated cervix

Endocrine disorders, genetic aneuploidy, immunologic disorders, infection, chemical/radiation exposure, uterine abnormalities

Open os with or without POC

Expectant (90% effective): observation, IV fluids, discharge home with OB follow-up and instructions to include no intercourse, bed rest, and return if bleeding worsens; repeat TVUS one week after initial presentation Medical: misoprostol with follow-up appointment Surgical: D&C

Inevitable spontaneous abortion

Bleeding and a dilated cervix with or without POC

Endocrine disorders, genetic aneuploidy, immunologic disorders, infection, chemical/radiation exposure, uterine abnormalities

Open os with or without POC

Pathologic examination of POC: chorionic villi observed

Expectant: observation, IV fluids, discharge home with OB follow-up and instructions to include no intercourse, bed rest, and return if bleeding worsens; repeat TVUS one week after initial presentation Medical: misoprostol with follow-up appointment Surgical: D&C

Septic spontaneous abortion

Incomplete spontaneous abortion plus infection

Threatened abortion

Confirmed IUP, bleeding, cardiac activity, and closed os at <20 weeks’ gestation

Peritoneal symptoms, fever

Peritoneal/adnexal signs, fever with or without dilated cervix and POC Closed os

Urgent antibiotic administration, uterine evacuation, and OB/GYN consult

TVUS: confirmed heart tones

44 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Expectant: observation, IV fluids, discharge home with OB follow-up and instructions to include no intercourse, bed rest, and return if bleeding worsens; serial TVUS in place of serial ␤-hCG levels

Differential diagnosis

Definition

Missed abortion

Embryo/fetus >5 mm, no heart tones, retained POC

Additional history

Physical examination

Diagnostic tests

Management

Closed os

TVUS: intrauterine embryonic/fetal tissue without heart tones; ␤-hCG increase <53%

Expectant: observation, IV fluids, discharge home with OB follow-up and instructions to include no intercourse, bed rest, and return if bleeding worsens; repeat TVUS one week after initial presentation Medical: misoprostol with follow-up appointment Surgical: D&C or uterine aspiration

Ectopic pregnancy (EP)

A conceptus outside the uterus

Severe, sharp, unilateral, or bilateral adnexal pain; no passage of POC; amenorrhea; intrauterine device in place; history of EP; in utero exposure to diethylstilbestrol; genital infection; tubal surgery; in vitro fertilization; infertility; smoking

Ruptured EP: hypotension, absent/ diminished bowel sounds, abdominal distension, hemodynamically unstable, ipsilateral shoulder pain

TVUS: adnexal mass, free fluid in pelvis, cardiac activity detected outside of uterus, pseudogestational sac

Unruptured EP: uterus <8 weeks’ gestational size, cervical motion tenderness, adnexal mass

␤-hCG: doubling rate <80% to 100% every 48 hours

Uterus larger than gestational dates would suggest

TVUS: classic snowstorm appearance within uterine cavity

Surgery and close follow-up, urine ␤-hCG four to six weeks after pregnancy loss

TVUS: lack of heart tones by 10 to 11 weeks’ gestation and no tissue within gestational sac

Medical: misoprostol with follow-up appointment

TVUS: blood between chorion and uterine wall; cardiac activity confirmed

Expectant management

TVUS: yolk sac by 5 to 6 weeks’ gestation, central blastocyst with chorionic villi and decidua, cardiac activity by 10 to 11 weeks’ gestation with crown-rump length >5 mm

Expectant management

Gestational trophoblastic disease

Placental development without embryo

Hyperemesis, irregular and/or heavy bleeding, vaginal pain at <20 weeks’ gestation

Anembryonic pregnancy

Gestational sac >18 mm but no embryonic/ fetal tissue

Regression of pregnancy symptoms

Subchorionic hemorrhage

Blood between chorion and uterine wall

Benign bleed of viable IUP

50% of all earlypregnancy bleeds

Minimal cervical/ abdominal tenderness, benign adnexa, closed os, absence of POC, nonobstetric causes (e.g., polyps, sexually transmitted infection, vaginal trauma, cancer)

Progesterone: rule out EP with ␤-hCG values >2,000 IU/L and progesterone >22 ng/mL

Ruptured EP: IV fluids, monitor, oxygen, admission, open surgery Expectant: declining ␤-hCG values <1,000 mIU/mL, follow serial ␤-hCG levels to nonpregnant values Medical: methotrexate (Abitrexate, Folex, Mexate) if unruptured EP <3.5 cm, stable vitals, no fetal heartbeat, and ␤-hCG <15,000 mIU/mL Surgical: immediate hospitalization and stabilization if unruptured EP with ␤-hCG >15,000 mIU/mL

Surgical: D&C or uterine aspiration

Progesterone: >25 ng/mL

␤-hCG: 80% to 100% increase every 48 hours until 8 to 10 weeks’ gestation Continues on page 46

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 45

CME CE

EARLY-PREGNANCY BLEEDING

Ectopic pregnancy is an emergent diagnosis that must be rapidly ruled out in all women presenting with abdominal pain and early-pregnancy bleeding. Increasing ␤-hCG serum levels are the first definitive marker of pregnancy, and levels begin to increase approximately eight days after conception.1 A ␤-hCG level <5 mIU/mL is negative for pregnancy, and a level >25 mIU/mL is positive.12 ␤-hCG levels should predictably increase 80% to 100% every 48 hours until the eighth or 10th week of a healthy pregnancy, at which time it peaks, usually at around 100,000 U/mL.1,6 If levels are too low, a failing IUP or an EP should be suspected, and if levels are too high, the possibility of gestational trophoblastic disease should be investigated. An increase <53% deems the pregnancy nonviable.1 Management

The management of early-pregnancy bleeding includes expectant (watchful waiting), medical, and surgical approaches.1 No interventional methods have been proven to prevent spontaneous abortion.3 There is evidence to support the administration of RhoGam (50 µg of anti-D immune globulin) to Rh-negative patients at <12 weeks’ gestation presenting with any bleeding.3 The hemodynamically unstable patient presenting to the emergency department should be given IV fluids and oxygen and admitted to the hospital.6 EP is an emergent diagnosis that must be rapidly ruled out in all women presenting with abdominal pain and early-pregnancy bleeding.11 Early detection of EP allows for conservative, nonsurgical treatment and conservation of the fallopian tubes.2 Expectant management is recommended in patients diagnosed with an EP and declining ␤-hCG values <1,000 mIU/mL.1 Medical management with methotrexate (Abitrexate, Folex, Mexate) is the best option for a stable patient with an unruptured EP measuring <3.5 cm, no detectable fetal heartbeat on ultrasound, and a ␤-hCG <15,000 mIU/mL. A patient with an unruptured EP and ␤-hCG levels >15,000 mIU/mL requies immediate hospitalization, stabilization, and surgical intervention.1,5 The management of a ruptured EP entails hospitalization, stabilization, and open surgery.1 Stable patients presenting with threatened, inevitable, complete, or missed abortions and minimal bleeding may only require observation and IV fluids5 and may be discharged home with an obstetrics follow-up and instructions to abstain from intercourse, observe bed rest, and return if bleeding worsens.6 In the setting of incomplete abortion, watchful waiting is 90% effective.3 In a pregnancy of unknown location—defined as a pregnancy too early to be visualized, a positive pregnancy test, and no POC—a ␤-hCG ratio (levels measured at zero

and 48 hours later) of <0.87 reliably predicts that the pregnancy will resolve spontaneously with no intervention.10 If history, physical exam, and diagnostic test findings point to a pregnancy loss of a previously confirmed pregnancy, expectant management should entail a repeat TVUS one week after initial presentation to confirm complete passage of tissue.1,3 An 80% drop in ␤-hCG levels one week after complete evacuation of tissue also confirms termination. However, if the IUP was never confirmed, continue to follow serial ␤-hCG levels to nonpregnant values to rule out EP. High fever, heavy bleeding, pelvic pain, and general malaise may indicate retained tissue or endometritis.3 Infection may be found more commonly with medical management,13 but expectant management is more likely to result in poorer outcome with embryonic demise and anembryonic pregnancy than in spontaneous abortion.1 Dilation and curettage (D&C) is the treatment of choice after spontaneous abortion or in a missed abortion or anembryonic pregnancy, but some evidence indicates that watchful waiting or treatment with the prostaglandin analogue misoprostol (Cytotec) may be safer, equally effective, and psychologically gentler.1,3 However, the FDA has not approved misoprostol for the management of miscarriage, and clinical discretion must be used.1 Misoprostol will typically result in cramping and bleeding within two to six hours of initiation. Nonsteroidal anti-inflammatory and narcotic/acetaminophen pretreatment is helpful in managing discomfort, fever, and chills. Regardless of the treatment used, a follow-up appointment is necessary for these women.3 Uterine aspiration may be more effective than, and a viable alternative to, D&C in women with anembryonic gestation and embryonic demise. Uterine aspiration was found to be as safe as D&C, quicker to perform, more cost-effective, and amenable to use in the primary-care setting, but should only be used urgently if the woman is experiencing brisk bleeding or prolonged bleeding with a subsequent drop in hemoglobin, or is showing signs of infection.3 If fetal cardiac activity is identified, as seen in a threatened abortion, the best management involves serial TVUS in place of ␤-hCG levels.1 A septic abortion is an urgent diagnosis, and treatment requires antibiotic administration, obstetrics/gynecology consultation, and evacuation of the uterine cavity.1,6 Surgery and careful follow-up is the only method of management for the molar pregnancy (hydatidiform mole). A urine ␤-hCG four to six weeks after the pregnancy loss will confirm that there is no persistent disease.1

46 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

The importance of taking an appropriate history that includes asking about character, distribution, and severity of pain cannot be overstated. Ultimately, all management options for early pregnancy loss are safe, effective, and will not affect future fertility, so the specific management choice should rest with the patient.3

5. Roppolo LP, Davis D, and Kelly SP, eds. Emergency Medicine Handbook: Critical Concepts for Clinical Practice, 1st ed. Philadelphia, Pa.: Mosby, Inc.;2006:905-909. 6. Copland B. Vaginal bleeding in the first trimester. In: Mick NW, Peters

Follow-up

JR, Egan D, et al. Emergency Medicine, 2nd ed. Philadelphia, Pa.: Lippincott

Follow-up with a woman who has experienced a failed pregnancy should include addressing issues of contraception, future fertility/pregnancy, and the emotional impact of pregnancy loss. Any method of contraception is acceptable immediately after a failed pregnancy, and there is no ideal interpregnancy interval.1 A woman’s menstrual cycle should resume four to six weeks after the resolution of the loss.9 Given the numerous causes of early-pregnancy vaginal bleeding, the practitioner must employ sound clinical and diagnostic skills in the assessment, workup, and management of the patient. The importance of taking an appropriate history that includes asking about character, distribution, and severity of pain cannot be overstated. A thorough physical exam, appreciating cervical-motion tenderness, a dilated cervical os, or abdominal rigidity will aid in arriving at the correct diagnosis. The appropriate use of a TVUS and the quantitative ␤-hCG is also essential. Finally, the practitioner must take into consideration all clinical findings to reach a correct diagnosis and work with the patient to mutually decide on expectant, medical, or surgical management, leading to a reduction in morbidity and mortality. ■

Williams & Wilkins; 2005:140-142. 7. Hessert MJ, Juliano M. Fetal loss in symptomatic first-trimester pregnancy with documented yolk sac intrauterine pregnancy. Am J Emerg Med. 2012;30:399-404. 8. Dart RG, Kaplan B, Varaklis K. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med. 1999;33:283-290. 9. PubMed Health. Miscarriage. Available at www.ncbi.nlm.nih.gov/ pubmedhealth/PMH0002458/. 10. Condous G, Kirk E, Van Calster B, et al. Failing pregnancies of unknown location: a prospective evaluation of the human chorionic gonadotrophin ratio. BJOG. 2006;113:521-527. 11. McRae A, Murray H, Edmonds M. Diagnostic accuracy and clinical utility of emergency department targeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematic review. CJEM. 2009;11:355-364. Available at www.cjem-online.ca/v11/n4/p355. 12. American Pregnancy Association. Human chorionic gonadotropin (hCG); the pregnancy hormone. Available at americanpregnancy.org/duringpregnancy/hcglevels.html. 13. Shelley JM, Healy D, Grover S. A randomised trial of surgical, medical and expectant management of first trimester spontaneous miscarriage. Aust N Z J Obstet Gynaecol. 2005;45:122-127. All electronic documents accessed March 15, 2013.

References 1. Deutchman M, Tubay AT, Turok D. First trimester bleeding. Am Fam Physician. 2009;79:985-994. Available at www.aafp.org/afp/2009/0601/p985.html. 2. Isoardi K. Review article: the use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding. Emerg Med Australas. 2009;21:440-448. 3. Prine LW, MacNaughton H. Office management of early pregnancy loss. Am Fam Physician. 2011;84:75-82. Available at www.aafp.org/ afp/2011/0701/p75.html. 4. Buckley RG, King KJ, Disney JD, et al. Serum progesterone testing to predict ectopic pregnancy in symptomatic first-trimester patients. Ann Emerg Med. 2000;36:95-100.

“On the other hand, a zombie plague might be just what social security needs. ”

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© The New Yorker Collection 2013 from cartoonbank.com. All Rights Reserved.

Ms. Walker is a physician assistant in the emergency department at Gwinnett Medical Center in Lawrenceville, Ga. Ms. Dexter is an assistant professor and the clinical director of the physician assistant department at Georgia Regents University in Augusta, Ga., where Dr. Dadig is associate professor and chair.

Advisor Forum These are letters from practitioners around the country who want to share their clinical problems and successes, observations, and pearls with their colleagues. Responding consultants are identified below. We invite you to participate.

Inside the Forum APRIL 2013

Consultations First steps when treating atrial fibrillation . . . . . . . . . . . . . . .48 When mixing formula, prepare only as directed . . . . . . . . . . .49 Dietary adjustments to control Hashimoto disease . . . . . . . . . . . . . .49 Nonsexually transmitted trichomoniasis . . . . . . . . . . . . . . . . .49

Clinical Pearls A little carbonation helps the medicine go down . . . . . . . . . . . . . .50 Minimize reaction to transdermal patch . . . . . . . . . . . . . .50 No more gagging during strep test . . .50

Your Comments

Send us your letters with questions and comments to: Advisor Forum, The Clinical Advisor, 114 West 26th Street, 4th Floor, New York, NY 10001. You may also fax (646) 638-6117, or contact us by e-mail at letters@ clinicaladvisor.com. If you are writing in response to a published letter, please indicate so by including the number in parentheses at the end of each item. Letters are edited for length and clarity. The Clinical Advisor’s policy is to print the author’s name with the letter. No anonymous contributions will be accepted.

Treating comedones in patients with Favre-Racouchot syndrome . . . .50

CONSULTATIONS FIRST STEPS WHEN TREATING ATRIAL FIBRILLATION In a patient who has had his or her first onset of atrial fibrillation (AF), would you advise medication, ablation, or rate control? The individual has normal BP and does not have an enlarged heart.—MING LIN, ANP-BC, New York City Rate control is an excellent starting point. AF is the most common arrhythmia a primary-care clinician faces, and there is a vast array of treatment options available. First is the individual assessment that addresses the patient’s symptoms, which range from none to pre-syncope and profound shortness of breath/fatigue. Second is the structure of the heart (left atrial dilation, ejection fraction). Third is the setting in which the AF occurred (surgery, stress, electrolyte imbalance, acute coronary syndrome or MI, thyroid, infection, random). No therapy has been proven superior to another in a general sense, but a slow start is usually best. A simple plan includes anticoagulation (a must) and beta-blocker control with metoprolol (Lopressor, Toprol) or nebivolol (Bystolic), both of which can be used in patients with diabetes and metabolic syndrome. Reserve non-dihydropyridine calcium-channel blockers for individuals who cannot tolerate beta blockade and have normal ejection fractions. Patients with atrial flutter should have an electrophysiology consult, as ablation is indicated, but AF patients that are not highly symptomatic can be treated medically. Save anti-arrhythmics for highly symptomatic patients or those who fail

OUR CONSULTANTS

Rebecca H. Bryan, APRN, CNP,

Eileen Campbell, MSN, CRNP,

Philip R. Cohen, MD,

is a lecturer in the Family Health NP Program, University of Pennsylvania School of Nursing, Philadelphia.

is associate program director, Family Health NP Program, University of Pennsylvania School of Nursing, Philadelphia.

is clinical associate professor of dermatology, University of Texas Medical Center, Houston.

48 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Deborah L. Cross, MPH, CRNP, ANP-BC, is associate program

director, Gerontology NP Program, University of Pennsylvania School of Nursing, Philadelphia.

Maria Kidner, DNP, FNP-C,

is a nurse practitioner with Cheyenne Cardiology Associates in Cheyenne, Wyo.

on rate control, and refer those patients to cardiology or electrophysiology. In addition, consider cardioversion either after transesophageal echocardiogram or after four weeks of therapeutic anticoagulation. All AF patients need anticoagulation and require an echocardiogram, stress test, and labs (electrolytes and thyroid) in the initial workup. Comprehensive guidelines for the management of patients with AF were released in 2006 (Circulation. 2006;114:e257-354, available at circ.ahajournals.org/content/114/7/e257.long, accessed March 15, 2013).—Maria Kidner, DNP, FNP-C (174-1)

WHEN MIXING FORMULA, PREPARE ONLY AS DIRECTED How precisely must one follow the manufacturer’s directions with regard to the amount of powder and water used in preparing infant formula? If mixed incorrectly, will there be an imbalance in the electrolytes?—CARLA HIGBEE, FNP-C, Long Beach, Calif. Electrolyte imbalance can occur in infants who are fed formula that has been incorrectly mixed. Moreover, hypernatremia can result from formula mixed too thickly. The resulting concentration of sodium is too much for the kidneys to handle, and it is excreted along with water, leading to dangerous dehydration. Mixing the formula with too much water in an effort to save money can lead to failure to thrive and all the problems that entails. To get an infant to gain weight, use less water when mixing formula to increase the calories per ounce, but only up to a certain extent.—Julee B. Waldrop, DNP (174-2)

DIETARY ADJUSTMENTS TO CONTROL HASHIMOTO DISEASE A woman reports eliminating coffee, sugar, soy, milk, wheat, and various gluten-containing products from her diet has

helped control her Hashimoto disease. She no longer has any symptoms, and her labs are all within normal limits. Do any studies support her claims?—KATHLEEN DUPONG, PA-C, Santa Barbara, Calif. Several case studies have provided evidence to support a relationship among autoimmune disorders, including thyroid disease, celiac disease, rheumatologic disorders, and diabetes mellitus. There is strong evidence indicating autoimmune phenomena as the pathogenesis of Hashimoto disease and celiac disease. Individuals with celiac disease are four times more likely to develop autoimmune thyroid disease than those without celiac disease. It is recommended that clinicians screen patients with Hashimoto disease for celiac disease and vice versa (World J. Gastroenterol. 2007;13:1715-1722; available at www. wjgnet.com/1007-9327/full/v13/i11/1715.htm, accessed March 15, 2013).—Claire Babcock O’Connell, MPH, PA-C (174-3)

NONSEXUALLY TRANSMITTED TRICHOMONIASIS I recently treated an elderly woman for trichomoniasis. She has never had a problem with vaginal discharge and has not been sexually active for 16 years. I have heard that some elderly women can have this condition without ever having had intercourse. It has always been my understanding that trichomoniasis is a sexually transmitted disease (STD).— DONNA VOGT, NP, Hamburg, N.Y. The CDC considers trichomoniasis the most common curable STD. Nearly 10% of all healthy women in the United States have evidence of Trichomonas vaginalis. While the parasite is usually passed from an infected person to an uninfected person during sex, fomite transmission is not inconceivable. Inform the patient that long-term chronic infection is entirely possible. Assure her that she will be fine

Debra August King, PHD, PA,

Mary Newberry, CNM, MSN

Claire O’Connell, MPH, PA-C,

Sherril Sego, FNP-C, DNP,

Julee B.Waldrop, DNP,

is senior physician assistant at New York-Presbyterian Hospital, New York City.

provides well-woman gynecologic care as a midwife with Prima Medical Group, Greenbrae, Calif.

teaches in the PA Program at the New Jersey Medical School and Rutgers University, Piscataway, N.J.

is a primary-care nurse practitioner at the Department of Veterans Affairs Medical Center in Kansas City, Mo.

is associate professor at the University of Central Florida (UCF), and practices pediatrics at the UCF Health Center.

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 49

Advisor Forum and there is no need for guilt or remorse. Treatment should be carried out as for any other Trichomonas infection (i.e., a single dose of metronidazole [Flagyl] or tinidazole [Tindamax]).—Sherril Sego, FNP-C, DNP (174-4)

CLINICAL PEARLS A LITTLE CARBONATION HELPS THE MEDICINE GO DOWN Some children may balk at taking an oral medication that has a strange taste (e.g., prednisone). Encourage the child’s parent or caregiver to mask the taste of the medication with a bit of soda water or seltzer.—AMANDA TINI, APRN, CPNP, East Windsor, Conn. (174-5)

MINIMIZE REACTION TO TRANSDERMAL PATCH If a patient has a mild reaction to the adhesive on a transdermal patch, spray a light amount of triamcinolone to the area prior to application. Be sure to allow the spray to dry completely before placing the patch.—ROD LUTES, PA-C, Great Falls, Mont. (174-6)

“Thanks, kid, but I don’t need a trusty sidekick.”

YOUR COMMENTS The following comment was written in response to our monthly dermatology quiz, Derm Dx. To view this case and others like it, visit CliniAd.com/10KIbCF.

TREATING COMEDONES IN PATIENTS WITH FAVRE-RACOUCHOT SYNDROME An OTC salicylic cleanser (especially a 3% shampoo left on the skin overnight) greatly reduces the blackheads associated with Favre-Racouchot syndrome (“Wrinkly, yellow skin and blackheads,” available at CliniAd.com/11fNr65). This is a particularly useful treatment option since Medicare will not cover removal of the cysts and comedones.—ANNE CARLISLE, CRNP, DCNP, Redding, Calif. (174-8) ■ 50 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

© The New Yorker Collection 2013 from cartoonbank.com. All Rights Reserved.

NO MORE GAGGING DURING STREP TEST To stifle the gag reflex while performing a strep test, start at the superior tonsillar pillar next to the uvula and swipe downward.—EUGENIA ZAWADZKI, PA-C, LaPorte, Ind. (174-7)

Derm Dx

EXCLUSIVE TO THE WEB

INTERACT WITH YOUR PEERS by viewing the images and offering your diagnosis and comments. To post your answer, obtain more clues, or view similar cases, visit CliniAd.com/KIbCF. Learn more about diagnosing and treating these conditions, and see how you compare with your fellow colleagues.

Painful and ulcerated purple scars on both ankles A woman, aged 50 years, with no significant medical history presents complaining of purplish lesions on her bilateral medial ankles. The lesions are painful and have ulcerated. WHAT IS YOUR DIAGNOSIS?

• • • •

Livedoid vasculopathy Raynaud’s disease Waldenström hyperglobulinemic purpura Lichen planus

● See the full case at CliniAd.com/YryM20.

Mouth rash and painful skin blisters A Hispanic man, aged 60 years, complains of 12 months of painful blisters and erosions on his mouth and skin. A punch biopsy of one blister demonstrates the epidermis split immediately above the basal layer. WHAT IS YOUR DIAGNOSIS?

• • • •

Pemphigus foliaceus Pemphigus vulgaris Benign familial pemphigus Bullous pemphigoid

● See the full case at CliniAd.com/Xdn9ve.

Have you missed any recent Derm Dx cases? Go to CliniAd.com/10KIbCF for a complete archive of past quizzes as well as additional images of last month’s other cases. Hair loss in a teen girl

54 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Hypopigmented arm patch

8.5”

11”

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11”

8.5”

11”

8.5”

11”

8.5”

11”

8.5”

11”

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11”

XARELTO® (rivaroxaban) tablets

OVERDOSAGE: Overdose of XARELTO may lead to hemorrhage. Discontinue XARELTO and initiate appropriate therapy if bleeding complications associated with overdosage occur. A specific antidote for rivaroxaban is not available. Rivaroxaban systemic exposure is not further increased at single doses >50 mg due to limited absorption. The use of activated charcoal to reduce absorption in case of XARELTO overdose may be considered. Due to the high plasma protein binding, rivaroxaban is not expected to be dialyzable [see Warnings and Precautions and Clinical Pharmacology (12.3) in full Prescribing Information]. Active Ingredient Made in Germany Finished Product Manufactured by: Janssen Ortho, LLC Gurabo, PR 00778 Manufactured for: Janssen Pharmaceuticals, Inc. Titusville, NJ 08560 Licensed from: Bayer HealthCare AG 51368 Leverkusen, Germany © Janssen Pharmaceuticals, Inc. 2011 10185204 K02X121070BBM

“No, now all of our pillaging is done electronically from a centralized office.”

“I’ve spent so much time with family that I’ve started to lose sight of what really matters.” © The New Yorker Collection 2013 from cartoonbank.com. All Rights Reserved.

adverse reactions in nursing infants from rivaroxaban, a decision should be made whether to discontinue nursing or discontinue XARELTO, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness in pediatric patients have not been established. Geriatric Use: Of the total number of patients in the RECORD 1-3 clinical studies evaluating XARELTO, about 54% were 65 years and over, while about 15% were >75 years. In ROCKET AF, approximately 77% were 65 years and over and about 38% were >75 years. In the EINSTEIN DVT, PE and Extension clinical studies approximately 37% were 65  years and over and about 16% were >75  years. In clinical trials the efficacy of XARELTO in the elderly (65  years or older) was similar to that seen in patients younger than 65  years. Both thrombotic and bleeding event rates were higher in these older patients, but the risk-benefit profile was favorable in all age groups [see Clinical Pharmacology (12.3) and Clinical Studies (14) in full Prescribing Information]. Females of Reproductive Potential: Females of reproductive potential requiring anticoagulation should discuss pregnancy planning with their physician. Renal Impairment: In a pharmacokinetic study, compared to healthy subjects with normal creatinine clearance, rivaroxaban exposure increased by approximately 44 to 64% in subjects with renal impairment. Increases in pharmacodynamic effects were also observed [see Clinical Pharmacology (12.3) in full Prescribing Information]. Nonvalvular Atrial Fibrillation: In the ROCKET AF trial, patients with CrCl 30  to 50  mL/min were administered XARELTO 15  mg once daily resulting in serum concentrations of rivaroxaban and clinical outcomes similar to those in patients with better renal function administered XARELTO 20 mg once daily. Patients with CrCl 15  to  30 mL/min were not studied, but administration of XARELTO 15  mg once daily is also expected to result in serum concentrations of rivaroxaban similar to those in patients with normal renal function [see Dosage and Administration (2.3) in full Prescribing Information]. Treatment of DVT and/or PE, and Reduction in the Risk of Recurrence of DVT and of PE: In the EINSTEIN trials, patients with CrCl values <30  mL/min at screening were excluded from the studies. Avoid the use of XARELTO in patients with CrCl <30 mL/min. Prophylaxis of DVT Following Hip or Knee Replacement Surgery: The combined analysis of the RECORD 1-3 clinical efficacy studies did not show an increase in bleeding risk for patients with CrCl 30 to 50  mL/min and reported a possible increase in total venous thromboemboli in this population. Observe closely and promptly evaluate any signs or symptoms of blood loss in patients with CrCl 30 to 50 mL/min. Avoid the use of XARELTO in patients with CrCl <30 mL/min. Hepatic Impairment: In a pharmacokinetic study, compared to healthy subjects with normal liver function, AUC increases of 127% were observed in subjects with moderate hepatic impairment (Child-Pugh B). The safety or PK of XARELTO in patients with severe hepatic impairment (Child-Pugh C) has not been evaluated [see Clinical Pharmacology (12.3) in full Prescribing Information]. Avoid the use of XARELTO in patients with moderate (Child-Pugh B) and severe (Child-Pugh C) hepatic impairment or with any hepatic disease associated with coagulopathy.

LEGAL ADVISOR CASE

Swine flu crisis stirs debate

BY ANN W. LATNER, JD

Ms. P, aged 41 years, was a nurse practitioner working for the public-health department in a mid-sized county in a northeastern state. In 2009, she had been working at her current job for five years, and found her responsibilities to be an interesting mix of public-health initiatives. That fall, a serious outbreak of the H1N1 influenza (swine flu) virus began surfacing. In response to the spate of H1N1 occurrences, the Secretary of Health and Human Services, pursuant to the federal Public Readiness and Emergency Preparedness (PREP) Act, declared that a public-health emergency existed and recommended administration of the antiviral vaccination peramivir. In response to the Secretary’s declaration, the governor of the state issued an executive order authorizing state and local health departments to establish immunization programs to facilitate the timely distribution and administration of the H1N1 vaccine. The public-health department for which Ms. P worked sprang into action. Various immunization clinics—from schools to senior centers—were

©THNIKSTOCK

In response to a federal initiative, a school clinician immunizes a child—but without parental consent.

The mother of one of the children who was immunized was very angry that her daughter had been given the vaccine.

64 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

set up, and all the public-health nurses were sent out to staff the clinics. Ms. P was assigned to run a clinic operating out of an elementary school. Notices and consent forms were sent to parents in the days leading up to the immunization. Ms. P spent almost a full school week in the health office immunizing a steady stream of children who were brought to the infirmary by their teachers. It was exhausting work, but Ms. P was glad to have had a role in protecting children from the potentially fatal virus. One week later, however, Ms. P received a call from the school’s nurse, with whom she had become friendly during the time they worked together. The school nurse wanted to warn Ms. P that the mother of one of the kindergarten children who had been immunized was very angry that her daughter received the vaccine. Continues on page 67

Cases presented are based on actual occurrences. Names of participants and details have been changed. Cases are informational only; no specific legal advice is intended. Persons pictured are not the actual individuals mentioned in the article.

LEGAL ADVISOR “Apparently, Mrs. L [the child’s mother] never returned the consent form,” explained the school nurse. “She thought that by not submitting a consent she was preventing her child from being vaccinated. This woman doesn’t believe in vaccinations, and is extremely upset that her child was inoculated without her consent. I don’t think we’ve heard the last about this.” The school nurse was right. Within the month, Mrs. L sued the public-health department and Ms. P. The administration of the public-health department met with a malpractice attorney to discuss the situation. “Mrs. L is alleging that the administration of the vaccination without consent constituted negligence and resulted in a battery on her daughter,” said the attorney. Before Ms. P could protest, the attorney continued. “Normally,

The court concluded that the plaintiff’s state law claims for negligence and battery were preempted by the PREP act. she might have a case. However, we’re in the midst of a public-health crisis declared by the Secretary of Health and Human Services. I am going to file a motion to have this case dismissed on the grounds that the state has no jurisdiction since a federal public-health emergency was declared. The federal law should preempt the state law, and we should be able to make this case go away.” Ms. P and her employers were relieved, but the relief was short-lived. The attorney soon notified the public-health department that the state court had decided that the federal PREP Act does not extend to situations in which a drug is administered without consent. “I’m sorry,” said the attorney. “However, we can and will appeal.” The attorney filed an appeal that hinged on just one issue: does the federal PREP Act preempt state law claims for negligence and battery? The appeals court held the federal emergency act does preempt state law, even when a vaccine is given without consent, and the case was dismissed. Legal background

In its decision, the appellate court considered the intent of Congress in enacting the federal law. The court cited language in the PREP Act that specifically provided liability protections for pandemic countermeasures taken

by “covered persons” (in this case, clinicians). The Act specifi cally provides that “a covered person shall be immune from suit and liability under Federal and State law with respect to all claims for loss caused by, arising out of, relating to, or resulting from the administration to an individual of a covered countermeasure” pursuant to a declaration of, among other things, a public-health emergency. Although the child’s mother argued that administering a vaccination without consent voids any and all immunity under the law, the court did not agree. In fact, the court concluded that it was the intent of Congress to preempt all state law tort claims arising from the administration of immunizations—even when there was a failure to obtain consent. The court specifically noted that Congress had created an alternative administrative remedy—called the Countermeasures Injury Compensation Program—to compensate people injured by countermeasures taken in response to the declaration of a public-health emergency. In addition, said the court, a person who suffered death or serious physical injury caused by willful misconduct of a clinician would still have a cause of action in federal court. The court was not persuaded by Mrs. L’s arguments that Congress would not have intended to protect such a radical action as immunizing someone without consent. “It is not our role to speculate upon congressional judgments,” wrote the presiding judge in the court’s decision. “Rather, we must presume that Congress fully understood that errors in administering a vaccination program may have physical as well as emotional consequences, and determined that such potential tort liability must give way to the need to promptly and efficiently respond to a pandemic or other public-health emergency.” The court concluded that the plaintiff ’s state law claims for negligence and battery were preempted by the PREP act, and that the state court had no jurisdiction over the matter. Protecting yourself

This was an unusual case, although it may be one that we see more often as new strains of influenza threaten our population. Ms. P was not liable because she had acted in accordance with a federal act, and that act trumped state law. However, it is important to remember that under normal circumstances Ms. P could have faced a lawsuit, and potential liability, for vaccinating a child without the parent’s consent. If you work with children or in a school, remember that parental consent is always necessary, except in the most extreme of circumstances. ■

www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 67

Stat Consult

A quick review of common conditions, using the best global evidence

Description

Nosocomial pneumonia BY ALAN DRABKIN, MD

Dr. Drabkin is a clinical editor for DynaMed (www.ebscohost.com/ dynamed), a database of comprehensive updated summaries covering more than 3,200 clinical topics, and Assistant Clinical Professor of Population Medicine at Harvard Medical School.

• Hospital-acquired pneumonia is pneumonia that occurs >48 hours after admission in a nonintubated patient. • Ventilator-associated pneumonia is pneumonia that occurs >48 hours after endotracheal intubation. Incidence/prevalence

• Second most common nosocomial infection in the United States • Five to 10 patients per 1,000 hospital admissions Causes

• Bacterial — Klebsiella, Enterobacter, Serratia — Pseudomonas aeruginosa — Acinetobacter — Stenotrophomonas maltophilia — Burkholderia cepacia — Staphylococcus aureus — Haemophilus influenzae — Streptococcus pneumoniae — Legionella pneumophila • Fungal (Candida, Aspergillus) • Viral (influenza, parainfluenza, adenovirus, respiratory syncytial virus) Pathogenesis

• Oropharyngeal secretion aspiration

© SCIENCE SOURCE / STEVE GSCHMEISSNER

Likely risk factors

Streptococcus pneumoniae (blue) is one of the most common causes of hospital-acquired infections.

• Disturbed cough reflex, ciliary function, or immunity • Atelectasis, excessive sedation, antibiotics, old age • Nasogastric intubation, elevated gastric pH, large gastric volumes • Endotracheal intubation Possible risk factors

• Recent history of nosocomial pneumonia (<6 months) Continues on page 70

68 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Stat Consult • Oxygen therapy • Ranitidine

• Signs of infection • Decreased oxygenation • Unexplained hemodynamic instability

— Arterial oxygen saturation or arterial blood gas — Complete blood count, electrolytes, renal, liver function tests — Blood cultures — Sampling of lower-respiratory-tract secretions (LRTS) ■ Methods » Endotracheal aspirate » Bronchoalveolar lavage » Protected specimen brush ■ Evaluation » Gram stain » Cultures — Bronchoscopic bacteriologic strategy — Diagnostic thoracentesis if large effusion • If patients are not responding to initial empiric therapy, considerations include — Repeat sampling of LRTS — Change vascular-access catheters — Culture blood, catheter line tips, urine — Other radiologic procedures — Open lung biopsy

Lungs

Imaging studies

• Rales or bronchial breath sounds

• CXR (posteroanterior, lateral, decubitus) • Ultrasound • CT scan (chest, sinus, abdomen)

Factors not associated with increased risk

• Diabetes mellitus Complications

• Higher mortality • Longer hospital stays • Higher rate of malnutrition than community-acquired pneumonia History

• New-onset fever, purulent sputum, or increased cough • Dyspnea or tachypnea • Altered mental status in patients aged 70 years or older General symptoms

Making the diagnosis

• American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) recommendations — New or progressive lung infi ltrate on chest x-ray (CXR) plus two or more of: ■ Fever >38ºC (100.4ºF) ■ Leukocytosis or leukopenia ■ Purulent secretions — If acute respiratory distress syndrome present, suspect and test for nosocomial pneumonia if ■ Any one of above criteria ■ Unexplained hemodynamic instability ■ Deterioration of blood gases during ventilation Rule out • Community-acquired pneumonia • Extrapulmonary infection • Tracheobronchitis • Other pulmonary conditions • Heart failure ATS/IDSA testing overview

• Initial testing — CXR

Other diagnostic testing

• Consider nonbronchoscopic (quantitative) sampling if bronchoscopy not immediately available • Semiquantitative tracheal aspirate not as reliable as quantitative cultures • No sampling technique performed any better than clinical criteria alone • Biomarkers may be useful Empiric antibiotic therapy

• Begin empiric IV therapy immediately if high probability of pneumonia or evidence of sepsis, regardless of LRTS microscopy results • Switch to oral or enteral therapy if good clinical response and functioning intestinal tract • Antibiotic selection — Based on risk assessment for multidrug resistance (MDR) pathogens — Determined by local microbiology (including drug resistance), cost, availability and formulary restrictions

70 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

Continues on page 72

Top Reasons to Attend the

2013 AANP 28th National Conference! June 19 – 23, 2013 in Las Vegas

Largest National Conference for NPs of all Specialties 1. Approximately 350 concurrent sessions throughout the conference focusing on diversity of the NP profession as well as approximately 40 skill enhancement workshops throughout the conference. The conference features expert faculty addressing educational and professional needs of the novice to the advanced NP in nine featured tracks. Evening with Larry King 2. Be a part of a historical NP event as renowned TV talk-show host Larry King interviews NP legendary leaders about their lives, their careers and their thoughts about the future of the NP role. Location Location Location 3. The Conference Hotel, The Venetian and The Palazzo, offers first-class accommodations. Keynote Address by Dr. Donna Shalala and Dr. Barbara Safriet 4. Dr. Shalala will share her insight into the Institute of Medicine (IOM) Report. Dr. Safriet will discuss regulation and legislation. Bon Appétit 5. Few cities in the world can boast about the wide array of dining options available, from all-you-can-eat buffets to some of the finest restaurants in the world. Las Vegas has options for every culinary taste. Continuing Education 6. Up to 42 contact hours of continuing education (CE) will be offered at the 28th National Conference. This program is pending approval for CE and pharmacology credit by the AANP Accreditation Program.

Networking 7. Visit with friends and make new acquaintances at the conference. Join us as we shape the future and celebrate the past. Explore the Exhibit Hall 8. In addition to 270 exhibits with up-to-date information on available products and services, be sure to visit the AANP Boutique to get your “new” AANP branded apparel and specialty items. The Market Place is where you can get personal interest items such as jewelry and other products. Industry Supported/Sponsored Events 9. Registered attendees may receive complimentary access, on a first-come first-serve basis, to a limited number of educational presentations with food service by attending the CE symposia and non-CE product theaters. On-Line Conversation 10. AANP shares the latest NP news through social media and we want to hear from you. Get involved today at LinkedIn, Facebook, Twitter, YouTube, ENP Network and Generation NP. National conference is the perfect venue to integrate social media into your professional life. Experience Vegas Attractions 11. The city houses numerous performance venues, spas, clubs and even kid-friendly attractions. Take a gondola ride at The Venetian, check out the view atop Paris’ Eiffel Tower or enjoy the fantastic fountain show at the Bellagio. Be sure to swing by the Freemont Street Experience in downtown Vegas, a five-block pedestrian walkway that hosts free concerts and performances throughout the week.

Additional Workshops Offered June 18, 2013

There are so many reasons to attend – register today at http://www.aanp.org/conferences and receive housing information on your conference registration receipt.

Stat Consult Other management • Deep vein thrombosis prophylaxis Follow-up

• ATS/IDSA recommendations — After 48 to 72 hours, assess clinical response with serial evaluations. — Make changes to empiric therapy based on clinical and microbiologic data. — Narrow therapy to most focused regimen possible using culture data. — In nonresponding patients, evaluate for ■ Noninfectious mimics of pneumonia ■ Unsuspected or drug-resistant organisms ■ Extrapulmonary sites of infection ■ Complications of pneumonia (empyema, abscess) Prognosis

• Better prognosis if onset is fewer than four days after admission. • Increased morbidity and mortality if onset five or more days after admission. • Decrease in procalcitonin or C-reactive protein (CRP) level over four days is associated with increased survival. • Elevated interleukin levels predicted development of septic shock Screening

• Daily CRP measurements might be effective in detection. • Daily routine CXRs appear to have low yield in intensive care unit. ■

72 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com

© The New Yorker Collection 2013 from cartoonbank.com. All Rights Reserved.

— If recent antibiotic therapy, use drug from different antibiotic class when possible — If MDR risk low/absent ■ Cover for » S. pneumoniae » H. influenzae » Methicillin-sensitive S. aureus » Antibiotic-sensitive enteric gram-negative bacteria, including − Escherichia coli − K. pneumoniae − Enterobacter species − Proteus species − Serratia marcescens ■ Empiric mono-antibiotic therapy may be as effective as combination antibiotic therapy for suspected ventilator-associated pneumonia ■ Monotherapy options − Ceftriaxone (Rocephin) − Levofloxacin (Levaquin) − Moxifloxacin (Avelox) − Ciprofloxacin (Cipro, Proquin) − Ampicillin/sulbactam (Unasyn) − Ertapenem (Invanz) — If MDR risk high ■ Cover for » P. aeruginosa » K. pneumoniae » Acinetobacter species » Methicillin-resistant S. aureus (MRSA) » L. pneumophila » Local nosocomial pathogens ■ Dual or triple therapy recommended » One of − Cefepime (Maxipime) − Ceftazidime − Imipenem − Meropenem (Merrem) − Piperacillin-tazobactam (Zosyn) » Plus one of − Ciprofloxacin − Levofloxacin − Amikacin (Amikin) − Gentamicin (Garamycin) − Tobramycin » If MRSA risk or high incidence locally, add one of − Linezolid (Zyvox) − Vancomycin (Vancocin)

CME CE

Dermatology Clinic ■ LEARNING OBJECTIVES: To identify and diagnose dermatologic conditions and review up-to-date treatment. ■ COMPLETE THE POSTTEST: Page 84

■ ADDITIONAL CME/CE: Pages 41, 79

Turn to page 40 for additional information on this month’s CME/CE courses.

CASE #1

Tender, atrophic plaque on the arm and chest RACHEL E. CHIKOWSKI AND JULIA R. NUNLEY, MD

A black woman, aged 37 years and previously diagnosed with systemic lupus erythematosus (SLE), presented with painful lesions on her right arm of four months’ duration. Review of symptoms was remarkable for photosensitivity and joint pain. Physical exam showed an atrophic tender plaque with overlying depigmentation on her right arm with similar lesions on her forearm and chest. An antinuclear antibody (ANA) test was positive, but anti-doublestranded DNA (dsDNA), anti-Sjögren’s syndrome A (SS-A), and anti-SS-B tests were negative. What is your diagnosis? Turn to page 74

CASE #2

Firm, indurated scalp lesion with hair loss ESTHER STERN, NP

A woman, aged 28 years, complained of a hard lesion on her scalp that her hairdresser had recently noticed. The woman did not know how long the lesion had been there and whether it was growing or stable in size. Intermittent pruritus was the only symptom experienced. The patient was otherwise healthy and took no medication other than prenatal vitamins. Physical exam revealed a 5-cm ivory-white and indurated patch on the vertex of the scalp with a complete loss of hair follicles within. Dermoscopy revealed perifollicular erythema at the margins of the lesion. Examination of the skin, mucosa, and nails was otherwise clear. What is your diagnosis? Turn to page 75 www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • APRIL 2013 73

CME CE

CASE #1

Dermatology Clinic

Lupus profundus

Histopathologic examination of an incisional biopsy from the woman’s arm lesion revealed an inf lammatory infi ltrate of the subcutis in a lobular pattern with moderate hyalinization and calcification. The diagnosis of lupus erythematosus profudus (LEP), also known as lupus panniculitis, was made based on the clinical and histologic findings. LEP, a rare variant in the clinical spectrum of lupus erythematosus (LE), accounts for 1% to 3% of all LE cases, and involves inflammation of subcutaneous fat.1,2 Kaposi first described the condition in 1883 as subcutaneous nodules in patients with SLE.3 Irgang coined the term LEP in 1940 and suggested that LEP was a unique skin finding in LE.4 LEP is now believed to represent a distinct variant of LE, as it may occur in the setting of SLE, in association with such other cutaneous forms of LE as discoid LE (DLE); in conjunction with other autoimmune processes; or, rarely, as an isolated skin finding without an underlying condition.5 According to Wu et al., the incidence of LEP is 2% to 10% in SLE patients and 33% to 70% in DLE patients. Women aged 30 to 60 years are most commonly affected, although LEP has been described in children.2 Recent data suggest that the presence of LEP in a patient with SLE may be predictive of a less severe course.3,6 Lesions of LEP commonly present as indurated and firm, tender, or asymptomatic nodules. At times, the lesions develop as sharply defi ned plaques that arise in crops or appear singly.5 The overlying epidermis is frequently normal in appearance; however, fi ndings of DLE with erythema, atrophy, scaling, ulcerations, follicular plugging, or telangiectasias may be present.5,7 In adults, lesions have a predilection for the proximal upper extremities; the face is more commonly affected in children.7,8 Other frequently affected sites in all patients include the buttocks, chest, breasts, and scalp.5,8 Lesions on the legs are unusual and a useful clinical clue that helps distinguish LEP from other forms of panniculitis.5 Healing of lesions can occur spontaneously or after treatment and often results in atrophic, depressed, and disfiguring scars.5 The pathophysiology of LEP is poorly understood; however, immune complex deposition, as well as T-cell mediated infl ammation, have been implicated.6 Some

studies suggest that LEP is associated with previous trauma and/or injections.9 The differential diagnosis of LEP includes a variety of panniculitides and conditions that affect the deep dermis, such as erythema nodosum, erythema induratum, lupus tumidus, thrombophlebitis, cold panniculitis, deep morphea, and pancreatic fat necrosis.5 In addition, DLE, WeberChristian disease, Jessner’s lymphocytic infi ltrate, sarcoidosis, dermatomyositis, and subcutaneous panniculitis-like T-cell lymphoma (SPTL) can each be clinically confused with LEP. The diagnosis of LEP is made based on clinicalpathologic correlation because there is no pathognomonic clinical, pathologic, or laboratory fi nding diagnostic for LEP. SPTL is the most significant of the diagnoses to correctly identify. Although SPTL usually has more systemic symptoms, the pathologic findings may be identical to those of LEP.7 Immunohistochemistry and molecular studies may be necessary to distinguish the two conditions.9 For diagnosis, adequate subcutaneous tissue must be obtained and submitted for histologic evaluation.10 A punch biopsy is readily obtainable in most office settings and may provide an appropriate specimen. However, the size of the specimen obtained is limited with a punch biopsy, and the amount of fat removed for analysis may not be sufficient. An incisional biopsy allows more subcutaneous tissue to be removed for study and thus may be preferable.10 Serologic studies have little role in the diagnosis of LEP because such studies are frequently normal and, even when abnormal, offer too little consistency to be of diagnostic value.7 Elevated ANA, anti-dsDNA, and rheumatoid factor titers have been described; other reported abnormalities include lymphopenia, anemia, transaminitis, and low complement levels, as well as elevated C-reactive protein and sedimentation.5-7 A deficiency in complement C4 has been repeatedly reported and may be of some significance.7 LEP exhibits a chronic and relapsing course and is often difficult to treat.1 The morbidity of the condition is attributable to lesional pain and disfigurement, both of which can be significant.6 Treatment is effective only if implemented during the active, inflammatory phase of the disease; it is ineffective after scarring and atrophy have occurred.1 While there are currently no FDA-approved medications to treat LEP, there are treatment regimens supported by evidence-based medicine.1 Although the role of UV light in exacerbating the disease is controversial, patients should be advised to routinely use a broad-spectrum sunscreen.8 Topical steroids can be tried alone or in combination with other modalities, but the depth

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of the inflammation may render topical therapy ineffective.11 Intralesional corticosteroids may provide some benefit in limited disease but may result in worsening of cutaneous atrophy or lesional ulceration.1,5-7 Systemic corticosteroids may be highly effective for some patients, but adverse effects limit long term use;5,6 these medications should be reserved for either widespread or resistant disease.12 Such antimalarial medications as hydroxychloroquine 200-400 mg/day and chloroquine 250-500 mg/day, used either alone or in combination with quinacrine 100 mg/day, may be considered first-line systemic therapy for the treatment of LEP.1 The initial course should be between six and 12 weeks; if a response is seen, chronic therapy could be considered.1 Individuals who smoke will not experience the same positive response as that seen in nonsmokers.5,8,12 Although the risk of retinal toxicity is low, all patients receiving an antimalarial medication should be followed by an ophthalmologist. While potentially more effective than antimalarial therapy, thalidomide 50-300 mg/day is considered a second-tier option because of such potential side effects as teratogenicity and neuropathy.1,5 This medication should be reserved for recalcitrant cases and never used in a patient who could become pregnant. A variety of immunosuppressive medications have been used in severe and recalcitrant cases, but results are inconsistent.5,6 Medications with variably reported success include azathioprine, mycophenolate mofetil, methotrexate, cyclophosphamide, cyclosporine, and rituximab.1,5,8 Espírito et al. described two cases of recalcitrant LEP that responded to IV immunoglobulin.6 Cosmetic and reconstructive options available to patients severely affected by disfigurement include various lasers, fi llers, and autologous fat transfer;1 however, these treatments may exacerbate the disease process and should be used cautiously.5 The woman described in this case was treated with hydroxychloroquine 200 mg b.i.d. for three months. The induration and tenderness of the arm lesion resolved during this time. Unfortunately, the atrophy and color loss did not improve. Ms. Chikowski is a third-year medical student at Medical College of Virginia Hospitals, Virginia Commonwealth University, in Richmond, where Dr. Nunley is professor of dermatology. References 1. Hansen CB, Callen JP. Connective tissue panniculitis: lupus panniculitis, dermatomyositis, morphea/scleroderma. Dermatol Ther. 2010;23:341-349.

2. Khoury T, Arayssi T, Kibbi AG, Ghosn S. Extensive fat necrosis with lipomembranous changes and calcification in lupus erythematosus panniculitis is not necessarily associated with systemic lupus erythematosus. Am J Dermatopathol. 2010;32:742-743. 3. Wu CY, Chiang CP. Clinicopathologic challenge: multiple tender lesions on both upper extremities and the back. Int J Dermatol. 2010;49:380-381. 4. Irgang S. Lupus erythematosus profundus. Arch Dermatol Syphilol. 1940;42:97–102. 5. Fraga J, García-Díez A. Lupus erythematosus panniculitis. Dermatol Clin. 2008;26:453-463. 6. Espírito Santo J, Gomes MF, Gomes MJ, et al. Intravenous immunoglobulin in lupus panniculitis. Clin Rev Allergy Immunol. 2010;38:307-318. 7. Weingartner JS, Zedek DC, Burkhart CN, Morrell DS. Lupus erythematosus panniculitis in children: report of three cases and review of previously reported cases. Pediatr Dermatol. 2012;29:169-176. 8. Guissa VR, Trudes G, Jesus AA, et al. Lupus erythematosus panniculitis in children and adolescents. Acta Reumatol Port. 2012;37:82-85. 9. Park HS, Choi JW, Kim BK, Cho KH. Lupus erythematosus panniculitis: clinicopathological, immunophenotypic, and molecular studies. Am J Dermatopathol. 2010;32:24-30. 10. Rose C, Leverkus M, Fleischer M, Shimanovich I. Histopathology of panniculitis—aspects of biopsy techniques and difficulties in diagnosis. J Dtsch Dermatol Ges. 2012;106:421-425. 11. Tsuzaka S, Ishiguro N, Akashi R, Kawashima M. A case of lupus erythematosus profundus with multiple arc-shaped erythematous plaques on the scalp and a review of the literature. Lupus. 2012;21:662-665. 12. Koley S, Sarkar J, Choudhary SV, et al. Lupus erythematosus panniculitis: a case report. J Pakistan Assoc Dermatologists. 2011;21:118-121.

CASE #2

Lichen planopilaris

Lichen planopilaris (LPP), also called follicular lichen planus or lichen follicularis, is a subtype of lichen planus. The condition, first described in 1895, is a cutaneous disorder selectively affecting the follicles of the scalp, causing a scarring and irreversible alopecia. Although LPP is a rare condition overall, it is one of the most common causes of cicatricial alopecia. The three subtypes of LPP are classic LPP, frontal fibrosing alopecia, and Graham-Little-Piccardi-Lasseur syndrome (GLPLS). Classic LPP presents with perifollicular erythema and progressive scarring, often on the central scalp. Frontal

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CME CE

Dermatology Clinic

fibrosing alopecia is seen most commonly in older women and features a bandlike pattern of alopecia in the frontal and temporal regions only. GLPLS includes cicatricial alopecia of the scalp, noncicatricial alopecia of the axillary and pubic hair, and keratosis pilaris of the skin of the trunk and extremities. Women tend to be afflicted with LPP more often than do men. Median age of onset is 40 to 60 years. Physical exam findings include perifollicular erythema and scaling of the scalp with acuminate keratotic plugs. As the inflammation resolves, it is replaced with a smooth, white, atrophic patch with a complete loss of hair follicles within. A perifollicular violaceous erythema is present at the periphery of these lesions, indicating continued progression of the disease. Disease activity may be centralized or multifocal with smaller scattered patches that eventually coalesce into a larger area of alopecia. Dermoscopy is a useful tool for clinically observing the lack of follicular orifices and the perifollicular erythema. In addition, false peripilar cysts may be observed on the hair shaft.1 Most individuals present in great distress over sudden hair loss. Scalp itching, burning, tenderness, or discomfort may also be reported. It is estimated that 7% to 27% of patients with LP have evidence of oral involvement with lacy white lesions on the buccal mucosa, while 20% to 40%

Treatment can be challenging, particularly since lichen planopilaris tends to be slowly progressive and relapses are common. have evidence of cutaneous involvement with the classic polygonal flat-topped papules.2 The pathophysiology of LPP is unclear, but an autoimmune etiology is thought to play a role. Rarely, LPP may be triggered by a pharmacologic agent.1 Histopathologic examination is often necessary to make an accurate diagnosis. Biopsy of active disease tissue will show an inflammatory cell infiltrate surrounding the infundibula of the hair follicles. Cytoid bodies may fi ll the remnants of the fibrous tract. Direct immunofluorescence (DIF) testing is often negative, or rarely it may reveal shaggy linear fibrin and cytoid bodies at the dermo-epidermal junction. To identify active disease, the biopsy must be performed on the perimeter of the affected area. Biopsy specimens from the center atrophic area of alopecia will be nondiagnostic and reveal scar tissue. A 4-mm punch should be the minimum-size biopsy performed.

Differential diagnoses include seborrheic dermatitis and alopecia areata at the very initial stages of the disease when the scarring is not yet obvious. In later stages of the disease, LPP must be differentiated from discoid lupus erythematosus, central centrifugal cicatricial alopecia, and folliculitis decalvans. Biopsy and DIF testing will help distinguish these conditions from LPP. Treatment of LPP can be challenging, particularly since the disease tends to be slowly progressive and relapses are common. Although there are no known cures or treatments to reverse the hair loss associated with LPP, treatments are beneficial in slowing disease progress. Such high-potency topical steroids as clobetasol applied twice a day and then tapered down, or intralesional corticosteroid injections administered monthly, are the mainstays of treatment. Recently, the role of oral tetracycline has been reviewed.3 Oral retinoids have also been shown to be effective. Endstage treatment of inactive disease may include hair transplants and scalp reduction. The clinician must be aware of the potentially severe psychological distress caused by LPP. Referral to a local or national alopecia organization can help patients contact others suffering from the same disease. In addition, patients may benefit from referral to a medical wig specialist. Two 4-mm punch biopsies confirmed the diagnosis of LPP in the woman in this case. She was started on twicedaily clobetasol topical solution for four weeks and then tapered down to daily clobetasol for another four weeks. Her scalp was noted to have a dramatic decrease in peripheral erythema, and the patch of alopecia was stable in size. The long-term treatment goal was to slowly and continuously decrease the topical steroid solution while preventing a relapse in disease activity. ■ Ms. Stern is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J. References 1. Assouly P, Reygagne P. Lichen planopilaris: update on diagnosis and treatment. Semin Cutan Med Surg. 2009;28:3-10. 2. James WD, Berger TG, Elston DM. Pityriasis rosea, pityriasis rubra pilaris, and other papulosquamous and hyperkeratotic disease. In: Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, Pa.: SaundersElsevier; 2011:223. 3. Cevasco NC, Bergfeld WF, Remzi BK, de Knott HR. A case-series of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment. J Am Acad Dermatol. 2007;57:47-53.

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ALTERNATIVE MEDS UPDATE What you should know about the herbs and supplements patients use By Sherril Sego, FNP-C, DNP. Ms. Sego is a staff clinician at the VA Hospital in Kansas City, Mo., where she practices adult medicine and women’s health. She also teaches at the nursing schools of the University of Missouri and the University of Kansas.

Lycopene

© THINKSTOCK

Lycopene is one of many popular nutrients that occur abundantly in nature. Often thought of as the tomato (Lycopersicon esculentum) vitamin, lycopene is largely linked to fruits and vegetables with a red coloring, with tomatoes having the richest content of this nutrient.1 Lycopene is a potent antioxidant with an oxygen radical absorbance capacity (ORAC) rating of 6,000 micromoles TE/g.2 Like many antioxidants, lycopene is synthesized only in plants, not animals. Surveys of typical U.S. diets indicate that approximately 85% of lycopene consumption in the United States is from tomatoes and tomato products.3

Background In its role as an antioxidant, lycopene’s oxidative protection has been targeted as a potential anticarcinogen.4 The secret to the tomato is the presence of an enzyme, lycopene cyclase, that converts lycopene into beta carotene, which is also a potent antioxidant.5 Lycopene is extremely attractive as a nutritional substance for a variety of other reasons as well: In addition to its antioxidant activity and its ready availability, lycopene is also being studied for its antiproliferative effect.6 The antioxidant is thought to prevent cell damage by protecting other critical biomarkers, including DNA, proteins, and lipids.3

Science Research has been focused on lycopene and its potential as a mitigating agent for cardiovascular disease (CVD) and cancer (especially prostate cancer). Researchers project that at least 30% of cancer mortality in the United States could be avoided

with dietary modifications.7 The overall mechanisms of action for lycopene are that it decreases oxidative stress and cellular apoptosis. Physiologically, these actions reduce, or block, harmful mechanisms such as intimal inflammation in arterial walls, oxidative cell damage in lungs, and neoplastic cell formation.5 Lycopene is frequently studied as an agent for reducing prostate cancer incidence and slowing prostate cancer growth. In prostate cells, lycopene inhibits androgen receptor expression, which then leads to a reduction of prostate cancer cell proliferation.8 A review of 20 clinical trials evaluated the impact of tomato/ lycopene dietary intake on the incidence of prostate cancer. Data supported a 25% to 30% decrease in the occurrence of the disease.9 However, there are always conflicting or equivocal findings, and the lycopene-prostate cancer link is not exempt from such ambiguity. In the past 10 years, multiple clinical trials have failed to show a significant impact of the amount of dietary lycopene intake on the incidence of prostate cancer.10 Continues on page 78

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ALTERNATIVE MEDS UPDATE Lycopene also holds promise in preventing CVD and cerebrovascular disease attributable to atherosclerotic damage. A study of more than 1,000 middle-aged men followed for more than 10 years examined the association between serum lycopene levels and end-point occurrence of ischemic stroke.11 The results indicated an average risk reduction of more than 55% in the cohort.11 As part of a larger clinical trial, researchers focused on the impact of dietary lycopene on CVD in women.6 Nearly 29,000 middle-aged and elderly women from the ongoing Women’s Health Study, were followed for approximately five years until death or diagnosis of cancer or CVD.6 Women with serum lycopene levels in the upper three quartiles experienced a 50% cardiovascular risk reduction compared with women with low lycopene levels.6 In another study, investigators monitored the thickness of the carotid intimal layers of more than 1,000 middle-aged men for more than four years.12 The initial research hypothesis stating the assumption that high serum lycopene levels correlated with a reduction in intimal-wall thickening was supported.Across all levels of serum lycopene measurements, a linear reduction in carotid intimalwall thickening correlated with an equivalent decrease in risk of cardiovascular events.12

So, feel free to write your next prescription for the tomato vitamin. ■ References 1. Rao AV, Rao LG. Carotenoids and human health. Pharmacol Res. 2007;55:207-216. 2. Agricultural research page. United States Department of Agriculture website. Available at www.ars.usda.gov/research/publications/publications .htm?seq_no_115=221173. 3. Basu A, Imrhan V. Tomatoes versus lycopene in oxidative stress and carcinogenesis: conclusions from clinical trials. Eur J Clin Nutr. 2007;61:295-303. Available at www

Lycopene shows promise in preventing cardiovascular disease.

Lycopene is frequently studied in regard to reduction of prostate cancer incidence and the slowing of prostate Safety, how supplied, cost, and dose cancer growth.

.nature.com/ejcn/journal/v61/n3/full/1602510a.html. 4. Mayo Clinic. Lycopene. Available at www.mayoclinic .com/health/lycopene/NS_patient-lycopene. 5. Heber D, Lu QY. Overview of mechanisms of action of lycopene. Exp Biol Med. 2002;227:920-923. Available at ebm.rsmjournals.com/content/227/10/920.long. 6. Sesso HD, Buring JE, Norkus EP, Gaziano JM. Plasma lycopene, other carotenoids, and retinol and the risk of cardiovascular disease in women. Am J Clin Nutr. 2004;79:47-53. Available at ajcn.nutrition.org/content/79/1/47.long. 7. Khan N, Afaq F, Muktar H. Cancer chemoprevention through dietary antioxidants: progress and promise. Antioxid Redox Signal. 2008;10:475-510. 8. National Cancer Institute. Prostate cancer, nutrition, and dietary supplements. Available at www.cancer.gov /cancertopics/pdq/cam/prostatesupplements /healthprofessional/page1/AllPages. 9. Kirsh VA, Mayne ST, Peters U, et al. A prospective study of lycopene and tomato product intake and risk of prostate cancer. Cancer Epidemiol Biomarkers Prev. 2006;15:92-98. Available at cebp.aacrjournals.org/content/15/1/92.long. 10. American Cancer Society. Lycopene. Available at www.cancer.org/treatment/treatments andsideeffects/ complementaryandalternativemedicine/dietandnutrition/ lycopene. 11. Karppi J, Laukkanen JA, Sivenius J, et al. Serum lycopene decreases the risk of stroke in men: a population-based follow-up study. Neurology. 2012;79:1540-1547. 12. Rissanen TH, Voutilainen S, Nyyssönen K, et al. Serum

Summary

lycopene concentrations and carotid atherosclerosis: The

Health-care professionals can recommend lycopene supplement (or lycopene-rich food) without reservation. A daily diet abundant in this compound will contribute toward a healthy lifestyle.

Clin Nutr. 2003;77:133-138. Available at ajcn.nutrition.org/

Kuopio Ischemic Heart Disease Risk Factor Study. Am J

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content/77/1/133.long. All electronic documents accessed on March 15, 2013.

© SCIENCE SOURCE / BIOPHOTO ASSOCIATES

Allergy to tomatoes or tomato products poses a safety risk for lycopene use. Depending on the level of hypersensitivity, reactions range from a mild response to severe anaphylaxis. Aside from being present in natural food products, lycopene is available in supplement form—usually tablets or capsules. Depending on the brand, manufacturer, and strength, lycopene cost $20 to $30 for a onemonth supply. The suggested dose for an adult ranges from 2 mg to 30 mg per day.2

CME CE

Dermatologic Look-Alikes ■ LEARNING OBJECTIVE: To distinguish and properly treat dermatologic conditions with similar presentations. ■ COMPLETE THE POSTTEST: Page 84

■ ADDITIONAL CME/CE: Pages 41, 73

Turn to page 40 for additional information on this month’s CME/CE courses.

White plaques on the tongue KERRI ROBBINS, MD, AND DAMJAN JUTRIC

CASE #1

CASE #2

A white man, aged 33 years, presented with lesions on his tongue that had been present for three months. The lesions began as white plaques that enlarged and developed a central erythematous atrophic area. The lesions seemed to heal and develop in new areas on his tongue every week. No pain, pruritus, or taste disturbance was reported. History was significant for guttate psoriasis. Review of systems was otherwise negative. On physical exam, annular white plaques surrounding erythematous atrophic papillae were appreciated on the dorsal tip of the tongue.

A Hispanic man, aged 28 years, presented with complaints of a white tongue for two months. The plaque was asymptomatic and slowly enlarging. Scraping the lesion at home with a toothbrush only caused bleeding. The man had a history of asthma for which he was using an inhaled corticosteroid. Review of systems was otherwise negative. Adherent white plaques were noted on the dorsal tongue and buccal mucosa. A shallow crusted erosion was also noted on the middle of the lower lip. The remainder of the examination was within normal limits.

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CME CE

CASE #1

Dermatologic Look-Alikes

Geographic tongue

Geog raphic tong ue is a benign clinical condition that occurs in approximately 1% to 3% of the population.1 The disorder is also known as benign migratory glossitis, glossitis areata migrans, stomatitis areata migrans, and benign migratory stomatitis. Geographic tongue appears to affect both sexes equally, although some studies have shown a 2:1 female-to-male ratio.1 The condition does not discriminate between races. However, adults tend to suffer from the disorder more than do children. Although geographic tongue has been documented for many years, not much is known about the history or pathogenesis of the disorder. It is believed to have a polygenic mode of inheritance due to its prevalence and clustering within families. A Brazilian study concluded that geographic tongue is associated with the human leukocyte

Generally, no treatment is necessary because the lesions of geographic tongue are benign and typically asymptomatic. antigen (HLA) group HLA-Cw6.2 This is the same HLA group found in many patients who suffer from psoriasis. Other reports have shown that in psoriatic patients, 10% had coexisting geographic tongue, whereas only 2.5% of age-matched and sex-matched subjects were affected by the disorder.3 Whether this means that geographic tongue is a representation of oral psoriasis or that geographic tongue is a distinct entity that occurs more commonly in those with psoriasis is open to debate. Geographic tongue has also been noted to occur with higher frequency in patients with fissured tongue and atopic dermatitis. The plaques associated with the disorder are most commonly found on the anterior two-thirds of the dorsal tongue. The tip and lateral borders are the areas within this region that generally have the highest concentration of lesions. Rarely, the plaques will develop on such other oral mucosal sites as the buccal mucosa, labial mucosa, and soft palate. Even in these instances, the tongue is almost

invariably involved. The lesions start as a small white patch that enlarges centrifugally and develops a central erythematous atrophic zone. The central erythematous region is the result of atrophic fi liform papillae. The atrophic areas are at least partly surrounded by an elevated yellowish-white serpiginous or scalloped border. Patients are often unaware of the disorder until the lesions are found on routine oral examination. Those who do notice the migratory plaques often report a history of the lesions healing within a few days or weeks with the development of new lesions in a different area. Geographic tongue is usually an asymptomatic disorder. Some patients experience a burning sensation or sensitivity to hot and/or spicy foods. In very rare instances, these burning sensations will be severe or constant enough to cause a change in lifestyle and diet. Geographic tongue can usually be diagnosed clinically. If a biopsy is needed, the specimen should be obtained from the peripheral portion of the lesion. Histologically, geographic tongue is described as a psoriasiform mucositis because many of the features resemble cutaneous psoriasis. Classic features include hyperparakeratosis, acanthosis, elongated epithelial rete ridges, and spongiosis. Munro microabscesses—collections of neutrophils within the epithelium—may also be observed. The neutrophilic involvement may be so intense that it is thought by some to be responsible for the destruction and atrophy of the superficial epithelium. Erythroplakia, leukoplakia, and oral candidiasis should be considered in the differential diagnosis. A yellowishwhite serpiginous or annular border surrounding an erythematous atrophic region is a classic clinical feature for geographic tongue and should prevent confusion. A cutaneous examination to look for psoriasis may also help to clinch the diagnosis. Erythroplakia is predominantly a disease of middle-aged to older adults, and lesions most commonly affect the tongue, soft palate, and floor of the mouth. Multiple lesions may be present and appear as welldemarcated erythematous patches or plaques. Leukoplakia (adherent white keratotic plaques) may surround areas of erythroplakia (erythroleukoplakia) or be an isolated finding. White plaques that resemble cottage cheese characterize oral pseudomembranous candidiasis. Erythematous candidiasis presents as erythematous patches on the tongue that have lost the fi liform papillae. White flecks may be seen surrounding the erythematous atrophic areas but are not a major component. Generally, no treatment is necessary because the lesions of geographic tongue are benign in nature and typically asymptomatic. Patient reassurance usually is all that is

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needed. In patients experiencing discomfort and pain, consider advising avoidance of spicy foods, gentle brushing of the tongue, and avoidance of harsh mouthwashes. The latter may be replaced with a soothing saline rinse. Besides altering oral-health habits, patients may use such topical corticosteroids as fluocinonide or betamethasone gel, which can provide relief when applied directly to the lesions as a thin film several times per day. Recently, topical tacrolimus 0.1% ointment has been used successfully for treatment of symptomatic geographic tongue.4 Given that the lesions in this case were asymptomatic, no treatment was given. The man was reassured that geographic tongue is a benign disorder.

CASE #2

Oral candidiasis

Oral candidiasis, also known as thrush, was first described in 1838 by French pediatrician Francois Valleix. It is considered the most common oral fungal infection and is typically caused by the yeastlike fungal organism, Candida albicans. Other members of the Candida genus, such as C. tropicalis, C. krusei, C. parapsilosis, and C. guilliermondii, may also be found in the oral cavity but rarely cause the disorder. No racial or gender predisposition has been found. Dimorphic in nature, C. albicans can exist in either hyphal form or yeast form. The hyphal form is usually associated with invasion of the host, whereas the yeast form is relatively harmless. Candida albicans may be a component of the normal oral microflora in approximately 30% to 50% of individuals.5 Most of these patients will carry the organism without any clinical evidence of infection. The disease most commonly occurs in neonates and infants, patients with a history of broad-spectrum antibiotic or corticosteroid use, those afflicted with xerostomia, and the immunosuppressed (e.g., the elderly or individuals debilitated by diabetes mellitus or HIV).6 Infants are very susceptible, with approximately 37% developing the infection before the first month of life. Oral candidiasis exhibits a wide spectrum of clinical manifestations, including pseudomembranous, erythematous, chronic hyperplastic, and mucocutaneous. Clinically, adherent white plaques that resemble cottage cheese or

curdled milk characterize pseudomembranous candidiasis. The lesions are most commonly seen affecting the buccal mucosa, palate, gingiva, pharynx, and/or dorsal tongue. The white plaques consist of yeast, masses of hyphae, desquamated epithelial cells, and debris. Scraping the plaques with a tongue blade or rubbing them with gauze can remove the lesions. The underlying mucosa may be normal or erythematous and often bleeds. Erythematous candidiasis, the most common form of oral candidiasis, includes such entities as acute atrophic candidiasis, median rhomboid glossitis, chronic multifocal candidiasis, angular cheilitis, and denture stomatitis. The classic lesions of erythematous candidiasis result in the loss of fi liform papillae on the dorsal tongue, leading to an atrophic erythematous patch or plaque. Chronic hyperplastic candidiasis is the least common form, and these plaques cannot be removed by scraping. Lesions of chronic hyperplastic candidiasis are usually located on the anterior buccal mucosa and are clinically indistinguishable from leukoplakia. Chronic mucocutaneous candidiasis is an immunologic disorder characterized by candida infections of the mouth, nails, skin, and other mucosal surfaces. The histologic picture varies depending on which clinical form of the infection is being evaluated. Most commonly, parakeratosis is seen in conjunction with elongation of the epithelial rete ridges. Neutrophilic microabscesses are often identified in the corneal and spinous layers. Chronic inflammation of the underlying connective tissue may be seen in longstanding Candida infections. Hyphae are found embedded within the parakeratin layer and rarely invade the underlying epithelium unless the patient is severely immunocompromised. Hyphae, pseudohyphae (essentially elongated yeast cells), and yeast can readily be identified on staining with the periodic acid-Schiff (PAS) method. Fungal-cell walls contain an abundance of carbohydrates, the target of PAS staining. A 10% to 20% KOH preparation may be used to rapidly evaluate patients for the presence of fungal organisms. A culture can definitively identify the organism and is obtained by rubbing a sterile cotton swab over the lesion and streaking it on a Sabouraud agar slant. Within two to three days of incubation at room temperature, a creamy smooth-surfaced growth of C. albicans will appear. Depending on the clinical subtype, the differential diagnosis may include leukoplakia, geographic tongue, hairy tongue, contact stomatitis, chemical burns, syphilis, lichen planus, erythroplakia, and aphthous stomatitis. There are a variety of treatment options for patients with oral candidiasis. Nystatin is the most popular treatment and

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has been in use since the 1950s. This medication is available as both a suspension and a pastille (lozenge). Nystatin oral suspension is generally taken four times a day and is held in the mouth for as long as possible before the patient swallows or expectorates. Alternatively, one or two pastilles (200,000– 400,000 units) may be dissolved slowly in the mouth, four to five times a day, for 10 to 14 days. Nystatin has a bitter taste, which may lead to low patient compliance. Clotrimazole is available as a pleasant-tasting lozenge and produces few side effects. Patients are instructed to dissolve one lozenge (10 mg) slowly in the mouth, five times a day for 10 to 14 days. Patients requiring systemic therapy are usually treated with fluconazole or itraconazole.7 The overall prognosis for individuals with oral candidiasis is excellent. Treatment with appropriate antifungals leads to rapid resolution. If the lesion does not respond appropriately to antifungal therapy, a biopsy should be performed to rule out such underlying disorders as squamous cell carcinoma or lichen planus. A workup for underlying immunosuppression should also be considered. The patient in this case was treated with nystatin pastilles for two weeks with complete resolution. ■

“And just what are you planning to do with your stupid trans-dimensional one-way escape pod?”

Dr. Robbins is a resident in the Department of Dermatology at Baylor College of Medicine in Houston. Mr. Jutric is a second-year dental student at The University of Texas School of Dentistry, also in Houston. References 1. Neville BW, Damm DD, Allen CM, et al. Oral and Maxillofacial Pathology, 3rd ed. Philadelphia, Pa.: WB Saunders; 2008:779-781. riasis and benign migratory glossitis are associated with HLA-Cw6. Br J Dermatol. 1996 Sep;135(3):368-70. 3. Morris LF, Phillips CM, Binnie WH, et al. Oral lesions in patients with psoriasis: a controlled study. Cutis. 1992;49:339-344. 4. Ishibashi M, Tojo G, Watanabe M, et al. Geographic tongue treated with topical tacrolimus. J Dermatol Case Rep. 2010;4:57-59. Available at www. ncbi.nlm.nih.gov/pmc/articles/PMC3157822/. 5. Arendorf TM, Walker DM. The prevalence and intra-oral distribution of Candida albicans in man. Arch Oral Biol. 1980;25:1-10. 6. Merenstein D, Hu H, Wang C, et al. Colonization by Candida species of the oral and vaginal mucosa in HIV-infected and noninfected women. AIDS Res Hum Retroviruses. 2013;29:30-34. 7. Allen CM. Diagnosing and managing oral candidiasis. J Am Dent Assoc. 1992;123:77-82. All electronic documents accessed March 15, 2013.

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“I have to tell you, I got a totally different diagnosis from someon named PookyPoo on medi-answer.com.”

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2. Gonzaga HF, Torres EA, Alchorne MM, Gerbase-Delima M. Both pso-

CE

POSTTEST Expiration date: April 2014

Nurse Practitioner Associates for Continuing Education (NPACE) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Nurse Practitioner Associates for Continuing Education designates this educational activity for a maximum of 1.0 contact hours of credit. Participants should only claim credit commensurate with the extent of their participation in the activity. Posttests must be completed and submitted online. NPs may register at no charge at www.myCME.com.You must receive a score of 70% or better on each test taken to obtain credit.

CREDITS: 0.5

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Feature

Dermatology Clinic

Dermatologic Look-Alikes

page 41

page 73

page 79

Vaginal bleeding in the early stages of pregnancy

Case #1: Lupus erythematosus profundus

1. What is the most common cause of fetal demise and subsequent spontaneous abortion? a. Reproductive tract abnormalities b. Toxin exposure c. Chromosomal abnormalities d. Infection 2. Approximately 75% of women with confirmed ectopic pregnancy (EP) will report a history of a. Midline abdominal pain b. Amenorrhea c. Hyperemesis d. High fever 3. EP is most frequently diagnosed with a. Serum progesterone level b. Qualitative ß-hCG c. Transabdominal ultrasound d. Transvaginal ultrasound 4. What is the best option for a stable patient with an unruptured EP measuring <3.5 cm, no detectable fetal heartbeat on ultrasound, and ß-hCG <15,000 mIU/mL? a. Observation and IV fluids b. Methotrexate (Abitrexate, Folex, Mexate) c. Misoprostol d. Open surgery

Case #1: Geographic tongue 1. Geographic tongue occurs with higher frequency in patients who have 1. How does lupus erythematosus a. Atopic dermatitis profundus (LEP) commonly present? b. Pityriasis rosea a. Discrete umbilicated papules c. Psoriasis b. Indurated and firm, tender, or d. Dyshidrosis asymptomatic nodules c. Flat-topped violaceous papules 2. What is a classic clinical feature of d. Solid, firm, thick plaques geographic tongue? a. White plaques that resemble 2. What is considered first-line cottage cheese treatment of LEP? b. Multiple demarcated erythematous a. Cyclosporine patches b. Cyclophosphamide c. Yellow-white serpiginous border c. Hydroxychloroquine around atrophic region d. Azathioprine d. Adherent white keratotic plaques Case #2: Lichen planopilaris Case #2: Oral candidiasis 3. Approximately 20% to 40% of 3. Candida albicans affects patients with patients with lichen planopilaris a. Xerostomia (LPP) have evidence of involvement b. Immunosuppression in what area? c. Broad-spectrum antibiotic use a. Skin d. All of the above b. Mouth c. Upper extremities 4. What is a feature of chronic d. Face hyperplastic candidiasis? a. Most often appears on the pharynx 4. What is a mainstay of b. Plaques cannot be scraped off treatment for LPP? c. Mucosa is friable and bleeds easily a. UV phototherapy d. Loss of piliform papillae on the b. Electrodessication dorsal tongue c. Cryosurgery d. Intralesional corticosteroids

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CME

POSTTEST Expiration date: April 2014

This program has been reviewed and is approved for a maximum of 1 hour of AAPA Category I CME credit by the Physician Assistant Review Panel. Approval is valid for one year from the issue date of April 2013. Participants may submit the self-assessment at any time during that period. This program was planned in accordance with AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs. Posttests must be completed and submitted online. PAs may register at no charge at www.myCME.com. To obtain 1.0 hour of AAPA Category I CME credit, you must receive a score of 70% or better on each test taken. CREDITS: 0.5

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Feature

Dermatology Clinic

Dermatologic Look-Alikes

page 41

page 73

page 79

Vaginal bleeding in the early stages of pregnancy

Case #1: Lupus erythematosus profundus

1. What is the most common cause of fetal demise and subsequent spontaneous abortion? a. Reproductive tract abnormalities b. Toxin exposure c. Chromosomal abnormalities d. Infection 2. Approximately 75% of women with confirmed ectopic pregnancy (EP) will report a history of a. Midline abdominal pain b. Amenorrhea c. Hyperemesis d. High fever 3. EP is most frequently diagnosed with a. Serum progesterone level b. Qualitative ß-hCG c. Transabdominal ultrasound d. Transvaginal ultrasound 4. What is the best option for a stable patient with an unruptured EP measuring <3.5 cm, no detectable fetal heartbeat on ultrasound, and ß-hCG <15,000 mIU/mL? a. Observation and IV fluids b. Methotrexate (Abitrexate, Folex, Mexate) c. Misoprostol d. Open surgery

Case #1: Geographic tongue 1. Geographic tongue occurs with higher frequency in patients who have 1. How does lupus erythematosus a. Atopic dermatitis profundus (LEP) commonly present? b. Pityriasis rosea a. Discrete umbilicated papules c. Psoriasis b. Indurated and firm, tender, or d. Dyshidrosis asymptomatic nodules c. Flat-topped violaceous papules 2. What is a classic clinical feature of geod. Solid, firm, thick plaques graphic tongue? a. White plaques that resemble 2. What is considered first-line cottage cheese treatment of LEP? b. Multiple demarcated erythematous a. Cyclosporine patches b. Cyclophosphamide c. Yellow-white serpiginous border c. Hydroxychloroquine around atrophic region d. Azathioprine d. Adherent white keratotic plaques Case #2: Lichen planopilaris Case #2: Oral candidiasis 3. Approximately 20% to 40% of 3. Candida albicans affects patients with patients with lichen planopilaris a. Xerostomia (LPP) have evidence of involvement b. Immunosuppression in what area? c. Broad-spectrum antibiotic use a. Skin d. All of the above b. Mouth c. Upper extremities 4. What is a feature of chronic d. Face hyperplastic candidiasis? a. Most often appears on the pharynx 4. What is a mainstay of b. Plaques cannot be scraped off treatment for LPP? c. Mucosa is friable and bleeds easily a. UV phototherapy d. Loss of piliform papillae on the b. Electrodessication dorsal tongue c. Cryosurgery d. Intralesional corticosteroids

TO TAKE THE POSTTEST please go to CliniAd.com/16fE8Tu

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^V ‡** ]ʘV°ÊÓä£ÎÊÊUÊÊ / ‡ä£xÈ

Evidence-Based Medicine This department uses the best available scientific findings to offer practice guidance on a wide range of conditions seen in primary care.The author, Alan Ehrlich, MD, is a deputy editor for DynaMed, Ipswich, Mass., and assistant clinical professor in Family Medicine, University of Massachusetts Medical School in Worcester. DynaMed (www.ebscohost.com/dynamed/) is a database that provides evidence-based information on more than 3,200 clinical topics and is updated daily through systematic surveillance covering more than 500 journals.The most important evidence identified is summarized here.

HIGH-SENSITIVITY CARDIAC TROPONIN T MEASURED TWICE ONE HOUR APART CAN DIAGNOSE AND RULE OUT MI IN MOST PATIENTS WITH CHEST PAIN Level 1: Likely reliable evidence Cardiac troponin is an important marker of cardiac injury and necrosis that has become increasingly useful in the diagnosis of acute MI. While older-generation troponin assays could require serial measurements over several hours to provide informative results, newer high-sensitivity troponin tests have shown promise in reducing the time to diagnosis. A recent cohort study derived and validated a clinical algorithm for early diagnosis of acute MI using a high-sensitivity cardiac troponin T (hs-cTnT) assay in the emergency department (Arch Intern Med. 2012;172:1211-1218). A total of 872 patients (median age 64 years) presenting with chest pain were randomly divided into derivation and validation cohorts (436 patients each). Patients with ST-segment elevation myocardial infarction or terminal kidney failure requiring dialysis were excluded prior to randomization.All patients had hs-cTnT assays at presentation and at one hour. Patients also had complete clinical assessment including history, physical examination, 12-lead electrocardiography, continuous electrocardiography monitoring, pulse oximetry, standard blood tests, and chest radiography and additional hs-cTnT assays at two, three, and six hours after presentation.The reference standard for acute MI diagnosis was adjudication by two independent cardiologists using all available medical records to 60-day follow-up. A two-part clinical algorithm was developed in the derivation cohort to diagnose or rule out acute MI using the baseline and one-hour troponin tests. Acute MI is ruled out if the baseline hs-cTnT level

In subgroup analyses, [omega-3] supplementation had no significant effect on CV mortality in either the insulin-glargine or standard-care groups.

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is <12 ng/L AND the absolute change in hs-cTnT level within one hour is <3 ng/L.Acute MI is diagnosed if the baseline hs-cTnT level is ≥52 ng/L or the absolute change in hs-cTnT level within one hour is ≥5 ng/L. Patients meeting neither set of criteria fall into the “observation zone,” requiring continued observation and additional testing. The incidence of acute MI in the validation cohort was 17%.The algorithm classified 77% of the group: acute MI was diagnosed in 17% and ruled out in 60%.The remaining 101 patients fell into the observation zone (eight of these patients received a final diagnosis of acute MI). For diagnosing acute MI, the algorithm had 97% specificity and 84% positive predictive value. For ruling out MI, it had 100% sensitivity and 100% negative predictive value. In overall analysis of both cohorts, 30-day survival was 99.8% in patients with MI ruled out, 98.6% in patients in the observation zone, and 95.3% in patients with MI ruled in (p <0.001 for trend).

OMEGA-3 FATTY ACID SUPPLEMENTATION DOES NOT REDUCE MORTALITY OR CARDIOVASCULAR EVENTS IN PATIENTS WITH OR AT HIGH RISK OF DIABETES Level 1: Likely reliable evidence Evidence for the effect of omega-3 fatty acids on cardiovascular (CV) risk has been inconsistent. While some systematic reviews have found little or no evidence that dietary or supplementary The quality of the evidence supporting each item is rated from Level 1 (highest) to Level 3 (lowest). Absolute risk reductions are presented as the number needed to treat (NNT) for one patient to benefit. Absolute risk increases are presented as the number needed to harm (NNH).

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BARIATRIC SURGERY MAY REDUCE DEVELOPMENT OF TYPE 2 DIABETES IN OBESE PATIENTS Level 3: Lacking direct evidence Results of a randomized trial reported earlier this year suggested that bariatric surgery may induce remission of type 2 diabetes in obese patients (N Engl J Med. 2012;366:1577-1585). A new analysis of data from the ongoing Swedish Obese Subjects (SOS) cohort study investigated the relation between bariatric surgery and prevention of type 2 diabetes (N Engl J Med. 2012;367:695-704). From a cohort of 4,047 obese patients (BMI ≥34 in men and ≥38 in women) with up to 15 years of follow-up, a group of 1,658 patients who had bariatric surgery were compared to 1,771 matched controls who did not have surgery.All patients were without diabetes at baseline. In the surgery group, 19% had banding, 69% had vertical banded gastroplasty, and 12% had gastric bypass. The controls received usual care, which ranged from no treatment to advanced lifestyle modification

Data from a nonrandomized, prospective, controlled study show that gastric bypass surgery may induce remission of type 2 diabetes.

interventions. Matching was based on mean group characteristics for the entire SOS cohort using 18 demographic, anthropometric, and psychosocial variables. Significant baseline differences between the groups included higher BMI, BP, total cholesterol, and daily caloric intake in the surgery group (p <0.001 for each). During median 10 years’ follow-up, new-onset diabetes developed in 110 patients in the surgery group and in 392 controls. The overall incidence rates per 1,000 person-years were 6.8 with surgery vs. 28.4 without surgery (p <0.001, NNT 5 for 10 years). In a subgroup of 591 patients with impaired fasting glucose at baseline, the incidence rates were 14.8 with surgery vs. 91 without surgery (p <0.001, NNT 2 for 10 years). ■

“Everybody else’s problems are better than mine.”

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omega-3 fatty acid intake alters the risk of death or CV events in primary or secondary prevention (Cochrane Database Syst Rev. 2004;4:CD003177; Arch Intern Med. 2012;172:686-694), others have shown some benefit against cardiac mortality (BMJ. 2008;337:a2931; Ann Med. 2009;41:301-310). The recently reported ORIGIN trial examined the effects of supplementation in 12,611 patients with impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes (N Engl J Med. 2012;367:309-318). Patients older than age 50 years (mean age 64 years, 88% with diabetes) were randomized to omega-3 fatty acids 1 g orally once daily (Omacor capsule, sold in the United States as Lovaza) vs. placebo. All patients had preexisting CV disease (MI, stroke, or revascularization in 59%) or CV risk factors at baseline. Patients were also randomized to open-label insulin glargine vs. standard care (with results reported in a companion publication).These groups were pooled for the primary analysis of the effects of omega-3 supplementation. At median follow-up of 6.2 years, there were no significant differences between groups in CV mortality (9.1% vs. 9.3%) or all-cause mortality (15.1% vs. 15.4%). There were also no significant differences in fatal and nonfatal MI, fatal and nonfatal stroke, heart failure–related hospitalization, or revascularization procedures. Omega-3 supplementation was associated with significant reduction in triglyceride levels (p <0.001), but had no significant effect on other lipid levels. In subgroup analyses, supplementation had no significant effect on CV mortality in either the insulin-glargine or the standard-care group.

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Evidence-Based Medicine

COMMENTARY Chad R. Stough, MPAS, PA-C, works as a physician assistant at West Atlanta Pediatrics in Dallas, Ga.

Obesity: addressing the issue head-on One of the toughest topics to raise with a patient is weight, but it is now becoming more critical than ever to bring up the subject during a patient encounter. We all know from a medical standpoint about the obesity crisis in America in both the adult and pediatric populations. The bottom line is that obesity is killing us; we see the secondary effects of this condition across all fields of medicine. One can see how significant the issue is by typing into Google the word “obesity”: You get tens of millions of results. Clearly, this is not an issue we can avoid discussing with our patients.

You do not have to spend an hour mapping out meal plans with patients. Just give them some guidance.

We clinicians do not always have the time to address weight in a short office visit with a patient, but what we can do is at least have a list of nutritionists, a handout of a healthy lifestyle plan, patient-education forms explaining a well-balanced diet, and other such materials ready to pass along to the person. If there is a weight-loss program that you like and that you know works—one that promotes a sensible diet—then have available the phone number, an informational pamphlet, or an outline of the program to hand to the patient. That way, you have something that you can at least physically give to the person. As clinicians we have to remember that we are the health-care advocates for these individuals, and we cannot sweep this crucial issue under the rug. You do not have to spend an hour trying to map out meal plans with patients, but by simply giving them some guidance and letting them know that obesity will harm their health, you encourage them to make a choice to live a healthier lifestyle. Just telling the patient to go and lose weight rarely works if there is not some guidance behind the comment. When patients leave at the end of the appointment with something tangible they are much more likely to follow through with the suggestion. We have to remember that even if the patient is in the office for another reason, we cannot

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avoid addressing his or her weight and lifestyle if these are issues that may be impeding the person’s health. The patient may be coming in because of an ear infection now, but next time it could be chest pain or worse in the emergency room. Take advantage of educating the patient in the office, even if you can’t do much more than encourage him or her to flip through the patient-education materials you have provided. Keep in mind how busy everyone is and what information a patient may actually retain after the office visit. Make sure to write down at least some of the guidance for the patient so that he or she can remember your discussion. These are not fun conversations to have, but when patients come back for a follow-up visit and their weight is down, their mood is better, their blood pressure is lower, and their knees do not hurt as much, they will feel great—and so will you. Your patients will forget about the otitis media for which you were treating them, but will thank you for the nutritionist’s phone number or the patient-education handouts you gave them. Do not be afraid to bring up the topic of obesity with your patients. The fact is, America’s health depends on us addressing the issue headon. As the late former surgeon general C. Everett Koop, MD, once said, “You can’t talk of the dangers of snake poisoning and not mention snakes.” ■


April 2013 Clinical Advisor