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■ Genetic screening ■ Insomnia guideline ■ Abnormal liver chemistries CLINICAL CHALLENGE

An unusual, round, solid pelvic mass in a woman LEGAL ADVISOR

Failure to follow up leads to a delayed diagnosis of cancer

n Dermatologic Look-Alikes




n Feature



APRIL 2 017



NERVE PAIN Compression in the right subclavian artery, leading to a reduction in blood flow in thoracic outlet syndrome.

Editor Colby Stong, Senior editor Sandhya George Associate editor Lauren Grygotis Assistant editor Madeline Morr Contributing editors Mark P. Brady, PA-C; Philip R. Cohen, MD; Deborah L. Cross, MPH, CRNP, ANP; Sharon Dudley-Brown, PhD, FNP; Abimbola Farinde, PharmD; Laura A. Foster, CRNP, FNP; Abby A. Jacobson, PA; Maria Kidner, DNP, FNP; Joan W. Kiely, MSN, CRNP; Debra August King, PhD, PA; Ann W. Latner, JD; Mary Newberry, CNM, MSN; Claire Babcock O’Connell, MPH, PA; Kathy Pereira, DNP, FNP; Sherril Sego, DNP, FNP; Ann Walsh, PA-C, SCT(ASCP); Kim Zuber, PA-C Production editor Kim Daigneau Group art director, Haymarket Medical Jennifer Dvoretz Production manager Krassi Varbanov Circulation manager Paul Silver National accounts manager Alison McCauley, 973.224.6414 alison.mccauley @ Publisher Kathleen Hiltz, 201.774.1078 Editorial director Kathleen Walsh Tulley Senior vice president, digital products and medical magazines Jim Burke, RPh CEO, Haymarket Media, Inc. Lee Maniscalco All correspondence to: The Clinical Advisor 275 7th Avenue, 10th Floor, New York, NY 10001 For advertising sales, call 646.638.6085. 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 20, 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., 275 7th Avenue, 10th Floor, New York, NY 10001. Single copy: $20 U.S.; $30 foreign. 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 address change to DMD Data Inc., 10255 W. Higgins Rd, Suite 280, Rosemont, IL 60018. Subscription inquiries: 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 © 2017

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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.


It cannot be beat.—TERRI JORDAN, ARNP, Daytona Beach, Fla. (202-2)

NEUTROPHILS AND LYMPHOCYTES In interpreting a complete blood count with differential, anytime the neutrophils and lymphocytes are numerically close, it is a viral cause; when the neutrophils and lymphocytes are numerically distant, it is a bacterial cause. This is very helpful in determining treatment.—DONNA CARTER, FNP-C, Scottsburg, Ind. (202-1) GENERIC “CAINE” IS EFFECTIVE FOR WOUND CARE For pain relief, most pharmacies offer a “caine” at 2-510%, and basically nothing higher, for between $5 and $30 per tube. I work in wound care and use Walmart’s

INTRA-ARTICULAR INJECTIONS FOR SEVERE OSTEOARTHRITIS Patients with severe osteoarthritis in the knees seem to do better with intra-articular injections if you have them sit up and dangle their legs off the examination table and distract the knee slightly when administering the injection.—ROSEMARY LEDBETTER, PhD, PA, Troy, Ill. (202-3)

YOUR COMMENTS SLIPPED CAPITAL FEMORAL EPIPHYSIS IN OBESE ADOLESCENTS I just read the CME/CE article by Marilou Shreve, DNP, APRN, entitled, “Assessing and treating pediatric obesity” [ June 2015]. I was concerned regarding the oversight of a critical issue in obese adolescents: the increased risk of slipped capital femoral epiphysis (SCFE). This was not addressed in the article. The case study (p. 55) gave incomplete advice regarding the evaluation of an obese adolescent male with knee pain. The most common etiology of the insidious onset of knee pain in children is the hip, due to referred pain from the

Equate brand—vagicaine 20% benzocaine. When using this before debriding a wound, give it three minutes to sedate the nerves, then perform the procedure. I get good results, as patients say. It relieves pain and burning for $1.88.

Advisor F

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 contact us by e-mail at editor@ 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.


These are lette and successe rs from practitioners s, observat around the below. We ions, and country who OUR CONSULTANTS pearls with invite you want to shar to participa their colle e their clinic agues. Resp te. al problems onding cons ultants are identified CON SULTAT IONS

TREATM ENT FOR INFECT URINAR ION SGLT2 REC MALE CHI S IN THE UNC Y TRACT IRCUMCI LD FOR DIA EPTOR BLOCKE If a male SED child conti Deborah L. Cross, MPH, CRNP, Laura A.BET Foster,ES CRNP, FNP, Abby A. Jacobson, PA-C, RS Abimbola Farinde, PhD, PharmD, With the nues toassociate ANP-BC, is practices family medicine is a physician assistant is a professor redevprogram adven t ofPrimary circu SGLT2 recep at Delaware Valley urinaryattract director, Gerontology NP elop Program, mcisi Columbia Southern moda litywith Palmetto on be perfo for type tor infecPhysicians Dermatology University of Pennsylvania School blockersGroup University 2 diabe rmed? regarding inCare as a treatm in Wilmington, Del. in Orange Beach, Ala. useCharleston, S.C. tes, is there ent urology is of Nursing, Philadelphia. any evide NATHAN in patients with to protect the is well advise nce or data type 1 diabe GARDNE d tes mellitus?— R, PA-C, continues to to recommend a circum upper tracts, the kidne CPAAPA, ys. develo cision It p recurr•ent 44 THE ADVISOR AUGUST 2015 •on Castleton, severaCLINICAL l consideration urinary tract the male child who As it currently stands N.Y. , SGLT2 s that infections. for glycemic impede the receptor blocke There are control in ability to cleansenter into this decisio rs are FDA adults with n. Poor hygien should the e and quell -approved child have e may appro diet and exercise, but with type 2 diabetes phimosis, simpl infection potential. appropriate the in ved conjun FDA for use in patien Moreover, AdvisorForum_CA0815.indd urine 44 9/29/15ction 2:38 PM e cathet culture can ts with type has stated that they ketoacidosi steroid cream be a challenge. erization to obtain s, or those are not may tempo an FAR with severe 1 diabetes, patients with Having a short tion of the rarily solve renal functi diabetic steroid the trial of informINDE, PhD, Pharm these issues tenden , though after for infection D (See bottom on.—ABIMBOL ation about once again.—C cy redevelops, placin cessaA Dr. Farinde.) of this page Milwaukee g (203-2) for more , Wis. (203- OLEEN ROSEN, the child at risk 1) DNP, FNP -C, CLI Philip R. Cohen, MD,

is clinicaltions associate professor , shou ld of dermatology, University a of Texas Medical Center, The focus of Houston.


Send us your letter Advisor Forum, The s with questions New York, and comm Clinical Advisor ents to: , 114 clinicaladvisoNY 10001. You may contacWest 26th Street , please If you are writing in t us by e-mail at 4th Floor, each item. e so by including response editor@ to a the Letters are policy is edited for number in parent published letter, to heses at length and contribution print the author ’s name with clarity. The Clinicathe end of s will be accepted. l Advisor the letter. No anonym ’s ous

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VAGINA L RESULT DISCHARGE AND ING FRO If a female M TAMPON ODOR patient has USE a ask if she uses tamp history of vaginal disch ons. If she the pelvic arge with says “yes,” exam when cond odor, that you woul , do not enter ucting the rotating of d to take a pap smea vagina in the same the specu way r. Instead, the cervix. lum Most retain from side to side start shallow until reach ed tampons ing are lodge d in the fold

Philip R.

Cohen, MD, is clinical associa te profess of dermat or ology, of Texas MedicaUniversity l Center, Houston.

SEND TO The Clinical Advisor 275 7th Avenue, 10th floor New York, NY 10001


Deborah L. Cross, MPH, ANP-B

CRNP, C, is associa te program director, Geronto logy NP Program University of Pennsyl vania School , of Nursing , Philadelphia.





MBER 2015

Abimbo la Farinde

, PhD,

is a profess PharmD, or at Columb ia Souther n Univers in Orange ity Beach, Ala.

• www.Clinic



Laura A.


practices familyCRNP, FNP, with Palmett medicine o Primary Care Physicia ns in Charles ton, S.C.

Abby A.


is a physicia n, PA-C, n at Delawa assistant re Dermatology Valley in Wilmington,Group Del.

.indd 62


2:44 PM






Information technology for diabetes care A study of one tracking system’s effect finds improvement in the management of diabetes.

0 2

CME/CE Implementing lifestyle


CME/CE Feature posttest

■■ACOG recommends genetic

screening in all women before and during pregnancy ■■Pharmacologic treatment of insomnia: a new clinical practice guideline from the American Academy of Sleep Medicine ■■Managing diabetic retinopathy: a position statement from the American Diabetes Association ■■Evaluating abnormal liver chemistries: a clinical guideline from the American College of Gastroenterology ■■Evidence lacking for routine pelvic exams, per USPSTF

Insomnia: a new clinical practice guideline 13


36 Conference Roundup: American Academy of Pain Medicine ■■Perioperative care for acute pain management ■■Radiofrequency treatment effective for refractory chronic joint pain ■■CDC’s opioid guideline prompts clinician concerns


Web Roundup A summary of our most recent opinion, news, and multimedia content from Dermatology Clinic n Painful diamond-shaped tongue

lesion in elderly man n An extremely itchy rash on the arms following yardwork

A suspicious mole and delayed diagnosis 51



Dermatologic Look-Alikes Pruritic patches and plaques

Continues on page 6

16 Thoracic outlet syndrome: A review The condition has one fundamental pathophysiology but multiple distinct clinical presentations, including neurogenic, venous, and arterial.


interventions for obesity Part 2 of a three-part series on issues regarding obesity management.

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An unusual pelvic mass in a woman 53

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Legal Advisor A suspicious mole. A clinician’s failure to follow up on a patient’s mole results in a delayed diagnosis of cancer.


Clinical Challenge An unusual pelvic mass in a 43-year-old woman


Your Comments ■ Preventing chronic diseases with lifestyle changes ■ The origin of AIDS and debating the Patient Zero theory


Clinical Pearls ■ Magnesium for patients taking opioids for pain

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Screening for spontaneous preterm birth has low predictive accuracy Using measurements of vaginal fetal fibronectin levels and cervical length did not indicate spontaneous preterm birth among first-time pregnant women. First-year residents will be able to work 24-hour shifts The Accreditation Council for Graduate Medical Education announces that residency programs can increase shift hours for firstyear residents from 16 to 24 hours. Nearly half of all cardiometabolic deaths linked to poor diet Suboptimal intake of 10 specific dietary factors is associated with a substantial proportion of deaths due to heart disease, stroke, or type 2 diabetes.

Nonallergic rhinitis: What clinicians should know Nonallergic rhinitis is a form of rhinitis that does not involve the immune system and often has an unknown etiology. Read more about the symptoms, triggers, risk factors, and complications of nonallergic rhinitis. Click through the slideshow here:

Antithrombotic drug use is associated with a higher risk of subdural hematoma A study published in JAMA found that a higher incidence of subdural hematomas is associated with the increased use of antithrombotic drugs, particularly vitamin K antagonists among older patients. Watch the video here:

The Waiting Room Official Blog of The Clinical Advisor

Sepsis risk calculator helps decrease antibiotic use in infants Data presented at NAPNAP show that an early-onset sepsis calculator can decrease the number of infants who received a sepsis work-up and prophylactic antibiotics. High school seniors improve HPV knowledge after 30-minute lecture Students improved their basic knowledge of HPV and understood the benefits of the HPV vaccine after a session with an NP. Insulin initiation in primary care improves HbA1c levels The Stepping Up model of care produced a significant improvement in HbA1c among adults with type 2 diabetes.


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Jillian Knowles, MMS, PA-C When the PA becomes the patient A physician assistant’s stay in the hospital provides a new perspective of a patient’s experience in the emergency department. Sharon M. O’Brien, MPAS, PA-C Managing headaches in patients with sleep disorders Some well-known sleep disorders are associated with headaches, including sleep apnea and parasomnias. Jim Anderson, MPAS, PA-C, DFAAPA When a young friend overdoses Experiencing the loss of a friend brings a new perspective to working with patients in addiction medicine.

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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 Learn more about diagnosing and treating these conditions, and see how you compare with your fellow colleagues.

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Avascular necrosis of the hip A 27-year-old woman presents with lower back and left hip pain that has been present for several years. The patient consulted a spine specialist, who diagnosed a lumbar spine strain. The woman underwent several months of physical therapy and received trigger-point injections, without relief. She started seeing a different physical therapist, who recommended hip radiographs. WHAT IS THE NEXT BEST TEST TO ORDER?

• Anteroposterior and lateral radiographs of the right hip • Magnetic resonance imaging of the left hip • Computed tomography of the left hip ● See the full case at

Derm Dx Geometrically arranged furrows on the neck An 80-year-old fair-skinned man requests treatment for scattered hyperkeratotic patches on his face and hands, which have been diagnosed clinically as actinic keratoses. On examination, geometrically arranged furrows are found on the patient’s posterior neck. CAN YOU DIAGNOSE THIS CONDITION?

• Anetoderma • Cutis rhomboidalis nuchae • Scleroderma • Sclerederma adultorum ● See the full case at • THE CLINICAL ADVISOR • APRIL 2017 9

Newsline A P R I L 2 017

Pharmacologic treatment of insomnia page 14

Abnormal liver chemistries: a new guideline page 15

How beneficial are pelvic exams in women? page 15

THE AMERICAN College of Obstetricians and Gynecologists (ACOG) has issued recommendations for expanded carrier screening for genetic disorders in all women during and before pregnancy, as published in Obstetrics & Gynecology. According to the guidelines, issued in two separate Committee Opinion statements, screening before pregnancy is preferable because it offers the most complete range of reproductive options, and increased knowledge of potential genetic outcomes allows individuals to make informed decisions and plans around pregnancy based on personal values. A summary of ACOG’s recommendations is as follows: • Ethnic-specific, pan-ethnic, and expanded carrier screening are acceptable strategies for pre-pregnancy and prenatal carrier screening. Each obstetrician–gynecologist or other healthcare provider or practice should establish a standard approach that is consistently offered to and discussed with each patient, ideally before pregnancy. After counseling, a patient may decline any or all carrier screening. • If a patient requests that a screen ing strateg y other than the one used by the

obstetrician–gynecologist or other healthcare provider, the requested test should be made available to her after counseling on its limitations, benefits, and alternatives. • All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis and spinal muscular atrophy, as well as a complete blood count and screening for thalassemias and hemoglobinopathies. Fragile X premutation carrier screening is recommended for women with a family history of fragile X– related disorders or intellectual disability suggestive of fragile X syndrome, or women with a personal history of ovarian insufficiency. • Couples with consanguinity should be offered genetic counseling to discuss the increased risk of recessive conditions being expressed in their offspring and the limitations and benefits of carrier screening. • Carrier screening will not identify all individuals who are at risk of the screened conditions. Patients should be counseled regarding residual risk with any test result. • Prenatal carrier screening does


ACOG recommends genetic screening in all women before pregnancy Genetic screening before pregnancy provides patients with a wider range of options.

not replace newborn screening, nor does newborn screening diminish the potential benefit of prenatal carrier screening. • If a woman is found to be a carrier for a specific condition, her reproductive partner should be offered screening to provide accurate genetic counseling for the couple with regard to the risk of having an affected child. Additional genetic counseling should be provided to discuss the specific condition, residual risk, and options for prenatal testing. • If a carrier couple (ie, carriers for the same condition) is identified before pregnancy, genetic counseling is encouraged so that reproductive options (eg, donor gametes, pre-implantation genetic diagnosis, prenatal diagnosis) can be discussed. • Individuals with a family history of a genetic disorder may benefit from the identification of the specific familial mutation or mutations rather than carrier screening. Knowledge of the specific familial mutation may allow for more specific and rapid prenatal diagnosis. • THE CLINICAL ADVISOR • APRIL 2017 13

Newsline Pharmacologic treatment of insomnia: a new guideline A NEW CLINICAL practice guideline for the pharmacologic treatment of insomnia in adults has been released by the American Academy of Sleep Medicine. The recommendations, which were published in the Journal of Clinical Sleep Medicine, include suggestions for FDA-approved drugs for insomnia, as well as for drugs that are frequently used to treat patients with insomnia but are not FDA-approved for this condition. The recommendations for clinicians include the following: • Use suvorexant as a treatment for sleep maintenance insomnia (vs no treatment) in adults. • Use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia (vs no treatment) in adults. • Use zaleplon as a treatment for sleep onset insomnia (vs no treatment) in adults. • Use zolpidem as a treatment for sleep onset and sleep

The AASM issues a new guideline for treating patients with insomnia.

maintenance insomnia (compared with no treatment) in adults. • Use triazolam as a treatment for sleep onset insomnia (vs no treatment) in adults. • Use temazepam as a treatment for sleep onset and sleep maintenance insomnia (vs no treatment) in adults. • Use ramelteon as a treatment for sleep onset insomnia (vs no treatment) in adults.

• Use doxepin as a treatment for sleep maintenance insomnia (vs no treatment) in adults. • Do not use trazodone as a treatment for sleep onset or sleep maintenance insomnia (vs no treatment) in adults. • Do not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia (vs no treatment) in adults. • Do not use diphenhydramine as a treatment for sleep onset and sleep maintenance insomnia (vs no treatment) in adults. • Do not use melatonin as a treatment for sleep onset or sleep maintenance insomnia (vs no treatment) in adults. • Do not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia (vs no treatment) in adults. • Do not use valerian as a treatment for sleep onset or sleep maintenance insomnia (vs no treatment) in adults.

THE AMERICAN Diabetes Association has issued a position statement for managing patients with diabetic retinopathy, as published in Diabetes Care. The statement includes the following recommendations: • Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. • Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy.

• Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. • Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of diabetes diagnosis. • If there is no evidence of retinopathy for one or more annual eye exams, then exams every 2


Optimizing glycemic control can slow the progression of diabetic retinopathy.

years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations for patients for type 1 or type 2 diabetes should be repeated at least annually by an ophthalmologist or optometrist. • Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy.


Managing diabetic retinopathy: an ADA position statement

A CLINICAL practice guideline regarding the evaluation of abnormal liver chemistries has been published by the American College of Gastroenterology (ACG) in the American Journal of Gastroenterology. The recommendations include the following: • Clinicians should repeat the lab panel or perform a clarifying test before the initiation of evaluation of abnormal liver chemistries. • Testing for chronic hepatitis C virus (HCV) is conducted with anti-HCV, and confirmation is performed with HCV-RNA by nucleic acid testing. Acute HCV testing is with anti-HCV and HCV-RNA by nucleic acid. • Testing for chronic hepatitis B is conducted with hepatitis B surface antigen testing, and acute hepatitis B is conducted with hepatitis B surface antigen and immunoglobulin M antihepatitis B core antigen. • Patients presenting with acute hepatitis and possible fecal-oral

exposure should be tested for acute hepatitis A. Testing for acute hepatitis E should also be considered for patients returning from endemic areas and whose tests for acute hepatitis A, B, and C are negative. • Patients who have elevated BMI and other symptoms of metabolic syndrome, including diabetes, obesity, hyperlipidemia, and hypertension, should undergo screening for nonalcoholic fatty liver disease. • Women who consume more than 140 g per week of alcohol, and men who consume more than 210 g, who present with aspartate aminotransferase (AST)>ALT may be at risk for alcoholic liver disease and should be counseled for alcohol cessation. • Patients who have abnormal liver chemistries without acute hepatitis should undergo testing for hereditary hemochromatosis with an iron level, transferring saturation, and serum ferritin. Patients with transferrin


Evaluating abnormal liver chemistries: a clinical guideline

Liver chemistries, including ALT and AST, are markers of liver injury.

saturation ≥45% or elevated serum ferritin should receive hereditary hemochromatosis gene mutation analysis. • Patients with abnormal AST and ALT levels should undergo testing for autoimmune liver disease, particularly if they have another autoimmune condition. • Patients with persistently elevated AST and ALT levels should undergo screening for alpha-1 anti-trypsin deficiency with alpha-1 anti-trypsin phenotype.

Evidence lacking for routine pelvic exams, per USPSTF CURRENT EVIDENCE is insufficient to assess the benefits and harms of pelvic examination screening in asymptomatic, nonpregnant adult women, according to a USPSTF recommendation statement published in JAMA. The task force commissioned a systematic review to analyze all evidence regarding screening pelvic examinations in asymptomatic, nonpregnant adult women aged 18

USPSTF finds inadequate evidence for pelvic exam screening.

years and older. The review focused on asymptomatic gynecologic conditions that are commonly identified as reasons for conducting the screening pelvic examination, conditions for which the detection of early-stage disease in asymptomatic patients is biologically and clinically plausible, and conditions for which another method of screening is not already addressed by a current USPSTF recommendation.

The USPSTF concluded that “the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women. This statement does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Papanicolaou smear, screening for gonorrhea and chlamydia).” n • THE CLINICAL ADVISOR • APRIL 2017 15



Thoracic outlet syndrome: A review The condition has one fundamental pathophysiology but multiple distinct clinical presentations, including neurogenic, venous, and arterial.


An angiogram of the right subclavian artery in thoracic outlet syndrome.


nce a poorly understood and heavily debated disease within cardiovascular medicine, thoracic outlet syndrome (TOS) has recently been recognized as a more common syndrome than previously thought.1 The condition has many presentations, including vascular and neurogenic, but it is hypothesized that the common pathophysiology of TOS is due to a narrowing of the thoracic outlet. The thoracic outlet is defined by an area through which the subclavian vein, subclavian artery, and brachial plexus all emerge as a neurovascular bundle. Anatomically, the outlet is defined superiorly and inferiorly by the clavicle and first rib, respectively; this area is called the costoclavicular space. The subclavian artery and brachial plexus emerge between the anterior and posterior scalene muscles, and the subclavian vein runs anterior to the anterior scalene muscles into the outlet from which they all continue distally into the arm. There are numerous conditions that can lead to a narrowing of this space, including congenital bone and muscle anomalies, repetitive trauma, stress, depression, and poor posture.1 One study showed that 29% of patients with TOS have bone anomalies.2 Another study found that 43% of patients who received surgical correction for their TOS had an anomaly of scalene muscle development and/or muscle insertion, whereas only 8.5% had an anomalous cervical rib.3 Subacute upper extremity presentations

TOS is further subdivided into neurogenic, venous, and arterial subtypes, dependent on 16 THE CLINICAL ADVISOR • APRIL 2017 •

which structures become impinged within the outlet. The neurogenic type (nTOS) is the most common, and presents in approximately 95% of patients diagnosed with TOS. The venous subtype (vTOS) is present in 3% to 5% of patients. The arterial subtype (aTOS) is the most rare, comprising only 1% to 2% of presentations of those with TOS.1 Although the different types share a common pathophysiology of a narrowed outlet space, their clinical presentations differ widely and should be considered in unilateral presentations of subacute upper extremity complaints in primary care offices. The following section discusses nTOS, vTOS, and aTOS, and their diagnosis and clinical management. Neurogenic TOS

Some physicians further subdivide patients with nTOS based on where the brachial plexus becomes impinged.4 Those who advocate this philosophy distinguish impingement between the scalene muscles as an upper thoracic syndrome—also called cervical outlet syndrome—and impingement between the first rib and clavicle as a true thoracic outlet syndrome.5 Patients with nTOS most commonly present with symptoms of intermittent pain, numbness, and tingling on the ipsilateral side that are distributed in the arms, hands, and fingers. Cervical nTOS has a distribution between C5 and C7, whereas true nTOS has a distribution between C8 and T1.4,5 With regard to what causes nTOS, one study showed that 50% of patients with nTOS have a history of repetitive trauma to the shoulder area, which is hypothesized to result in inflammatory changes and narrowing of the thoracic outlet.1 Even though nTOS is the most common subtype of TOS, the clinical evaluation for patients presenting with nTOS is the most poorly correlated of the three subtypes. However, there are two tests that can raise suspicion for TOS: the elevated arm stress test (EAST) and a lidocaine scalene block test. A patient who presents with symptoms of TOS and a history of repetitive trauma to the shoulder should have an EAST examination to evaluate for nTOS. The EAST examination is performed by having the patient abduct the shoulder to 90° with the elbow flexed to 90° and then place his or her hands facing forward while opening and closing the hands for 3 minutes. A positive test result occurs when the observer sees a decrease in the ability to open and close the hand or a lowering of the patient’s arm with increased time in opening and closing the hand.1 The test is not very specific; however, with a thorough patient history, the test result may support further evaluation for nTOS.

One test that has historically been helpful in diagnosis of nTOS is the lidocaine scalene block test. With imaging guidance, the anterior scalene is injected with lidocaine; in patients with nTOS, a decrease to near resolution of symptoms for up to 4 hours is observed. The lidocaine block test has had a positive predictive value of 90% for success in patients receiving further treatment.6 Initial management for nTOS patients is nonoperative and consists of physical therapy and lifestyle modifications. Successful modifications include avoidance of aggravating behaviors, ergonomic modifications, and selective use of some pharmacologic agents, including nonsteroidal antiinflammatory drugs, antidepressants, and muscle relaxants, with 60% to 70% of patients reporting resolution of symptoms.1 If 8 to 12 weeks of nonoperative management fails, patients may subsequently need to seek referral for surgical management options. Venous TOS

vTOS is due to the impingement of the subclavian vein with resulting thrombosis. Hughes7 describes this “effort thrombosis,” or Paget-Schroetter syndrome, as axillarysubclavian vein thrombosis associated with strenuous and repetitive activity of the upper extremities.8 These patients have been shown to have a correlation with a multitude of underlying aggravating factors, including trauma, repetitive motion, and (although rare), a history of hypercoagulability.1 Trauma to the subclavian vein results in damage to the intima musculature that perpetuates thrombus formation; it is usually seen in younger and more active patients with an association of reported repetitive trauma to the shoulder


Which of the following is the most frequently presenting cause of thoracic outlet syndrome among your patients? n=1,224

■ Bone/muscle anomalies

60.05% 6.78%

■ Repetitive trauma ■ Other


For more polls, visit • THE CLINICAL ADVISOR • APRIL 2017 17


The venous subtype of thoracic outlet syndrome occurs due to impingement of the subclavian vein with resulting thrombosis. region. Patients present with an acute or chronic onset of unilateral upper extremity swelling with red-purple discoloration and pain. Some patients report a chronic feeling of heaviness in the extremity.7 Diagnosis of vTOS is made by a combination of clinical presentation and noninvasive studies. A duplex ultrasound of the subclavian vein in both the resting position and with the arm abducted to 90° is used. Results suggestive of vTOS are Doppler waveforms of both the subclavian and axillary veins showing significant decrease in vein velocity. Treatment of vTOS is subjective to the treating physician’s preference. Nonoperative management of vTOS involves thrombolytic therapy or heparinization, whereas surgical management with thrombectomy and simultaneous first rib resection is another possibility.9,10 Operative management—thoracic outlet decompression—should be performed in symptomatic patients. Arterial TOS

aTOS is the most infrequently seen subtype of thoracic outlet syndrome and is hypothesized to be due to recurrent friction

of the subclavian artery with resultant fibrosis and subsequent stenosis of the subclavian artery. Arterial stenosis, as well as poststenotic aneurysms, may result in arterial thrombosis that can present with symptoms of decreased blood flow to the extremity. Chronically, the patient may complain of claudication or pain of the extremity with activity that subsides with rest. If emboli form, break off, and travel distally, patients may present with subacute focal symptoms such as an individual digit with decreased pallor.11 The most dangerous presentation is in patients who acutely form a completely thrombosed subclavian artery, resulting in decreased blood flow to the upper extremity. Of those patients with congenital bony abnormalities, the highest correlation was with patients diagnosed with aTOS.2 Similar to evaluation of vTOS, patients are best evaluated with Doppler waveforms of the subclavian and axillary arteries. In contrast to the Doppler study results found in patients with vTOS, patients with aTOS show increased velocity with stenosis of the artery, and absent velocities in cases of complete occlusion. Patients with aTOS have

Comparison of the neurogenic, venous, and arterial subtypes of thoracic outlet syndrome SIGNS AND SYMPTOMS





Unilateral, intermittent • Pain • Numbness • Tingling

Unilateral, acute or chronic • Swelling • Limb discoloration • Pain • Heaviness

Unilateral, chronic • Claudication • Pain with activity

History • Repetitive trauma

History • Repetitive trauma • Hypercoagulability

History • Bony abnormalities on previous chest radiograph

Physical examination • Duplex ultrasound: decrease in blood velocity

Physical examination • Duplex ultrasound: increase in blood velocity

Nonoperative • Thrombolytics

Nonoperative • Chest radiograph, if not previously completed

• Physical examination • EAST examination • Lidocaine scalene block test


Nonoperative • Physical therapy • Avoidance • NSAIDs, muscle relaxants, antidepressants

Operative • Thrombectomy • First rib resection

Operative Surgical decompression

Subacute • Decreased pallor

Operative • First rib resection • Aneurysm repair

aTOS, thoracic outlet syndrome, arterial subtype; EAST, elevated arm stress test; NSAID, nonsteroidal anti-inflammatory drug; nTOS, thoracic outlet syndrome, neurogenic subtype; vTOS, thoracic outlet syndrome, venous subtype


Surgical approaches, including transaxillary, supraclavicular, and combined, should be considered if conservative management fails. increased correlation with bony abnormalities compared with those with vTOS; as a result, patients with suspected aTOS should also receive a chest radiograph. As in patients with vTOS, thoracic outlet decompression should be performed in symptomatic patients. Published September 12, 2011. Accessed February 16, 2017. 5. Ranney D. Thoracic outlet: an anatomical redefinition that makes clinical sense. Clin Anat. 1996;9:50-52. 6. Torriani M, Gupta R, Donahue DM. Sonographically guided anesthetic

Surgical management of TOS

injection of anterior scalene muscle for investigation of neurogenic

After conservative management for each subtype of TOS fails, surgical management should be considered. Surgical approaches include the transaxillary approach, the supraclavicular approach, and the combined approach. The transaxillary approach decompresses TOS by resecting the first rib. The supraclavicular approach is performed with anterior and middle scalenectomies with or without first rib resection. Both have been reported to have success rates between 75% and 99%; to date, no randomized clinical trial have been done to compare the two.12 In the combined approach, anterior and middle scalenectomies are done via the supraclavicular approach, and a first rib resection is done via the transaxillary approach. It has been reported that the combined approach improves long-term results and decreases recurrence rates.13 Complications of surgical procedures in these cases include injury to major neurovascular structures, which can be avoided with careful manipulation of structures and proximal control; supraclavicular nerve palsy, resulting in sensory deficit; phrenic nerve palsy, resulting in respiratory compromise; arterial or venous injury, resulting in bleeding or hemothorax; and thoracic duct injury, resulting in a chylous effusion. ■

thoracic outlet syndrome. Skeletal Radiol. 2009;38:1083-1087.

Virginia Bailey, BA, is a medical student at the McGovern Medical School of the University of Texas; Justin Cardenas, BS, is a medical student at Baylor College of Medicine; and Maura Holcomb, MD, is a practicing dermatologist in Houston. References

7. Hughes ES. Venous obstruction in the upper extremity; Paget-Schroetter’s syndrome; a review of 320 cases. Surg Gynecol Obstet. 1949;88:89-127. 8. Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-Schroetter syndrome. Review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11:358-362. 9. Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. Circulation. 2002;106:1874-1880. 10. Drapanas T, Curran WL. Thrombectomy in the treatment of “effort” thrombosis of the axillary and subclavian veins. J Trauma. 1966;6:107-119. 11. Azizzadeh A, Thompson RW. Clinical presentation and patient evaluation in aTOS. In: Illig KA, Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI, eds. Thoracic Outlet Syndrome. London, UK: Springer-Verlag; 2013:551-556. 12. Bharat A, Mackinnon SE, Patterson GA. Supraclavicular approach for thoracic outlet syndrome. In: Sugarbaker D, Bueno R, Colson Y, Jaklitsch M, Krasna M, Mentzer S, eds. Adult Chest Surgery. 2nd ed. New York, NY: McGraw-Hill; 2015:chap 142. 13. Cinà C, Whiteacre L, Edwards R, Maggisano R. Treatment of thoracic outlet syndrome with combined scalenectomy and transaxillary first rib resection. Cardiovasc Surg. 1994;2:514-518.

Do you have a

Clinical Pearl

that you would like to share with your colleagues?

1. Freischlag J, Orion K. Understanding thoracic outlet syndrome. Scientifica (Cairo). 2014;2014:248163. 2. Weber AE, Criado E. Relevance of bone anomalies in patients with thoracic outlet syndrome. Ann Vasc Surg. 2014;28:924-932. 3. Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg. 1992;16:534-542.

Please submit your pearl to:

4. Pauliukas P. Thoracic outlet syndrome: anatomy, symptoms, diagnostic evaluation, and surgical treatment. Slideshare website. • THE CLINICAL ADVISOR • APRIL 2017 19


n LEARNING OBJECTIVES After completing the activity, the participant should be better able to: • Describe the components of a multimodal obesity treatment plan that not only reduces body weight but also improves health outcomes • Implement shared decision-making and motivational interviewing strategies when treating patients with obesity n COMPLETE THE POSTTEST: Page 28


This activity is supported by an educational grant from Novo Nordisk and is a result of a collaborative effort between Haymarket Medical Education, Global Education Group, and the American Society of Endocrinology Physician Assistants (ASEPA). Release Date: April 15, 2017 Expiration Date: April 14, 2018 Estimated time to complete the educational activity: 1 hour Target Audience: This activity has been designed to meet the educational needs of Physician Assistants, Nurse Practitioners, and Dieticians. Faculty Angela Golden, DNP, FNP-C, FAANP Family Nurse Practitioner NP from Home, LLC Munds Park, AZ Accreditation Statements Physician Credit: Haymarket Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Credit Designation: HME designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. For Registered Dietitians/Registered Dietetic Technicians The following activity has been approved by the ACCME, whose approval is recognized by the Commission on Dietetic Registration and, as such, RDs/DTRs will be able to receive 1.00 CPEU. Nursing Credit: Global Education Group is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Credit Designation: This educational activity for 1.00 contact hours is provided by Global Education Group. Nurses should claim only the credit commensurate with the extent of their participation in the activity. This activity is jointly provided by Global Education Group and Haymarket for ANCC credit. Disclosure Policy In accordance with the ACCME Standards for Commercial Support, HME and Global Education require that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. HME and Global Education resolve all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational activities.

The faculty reported the following financial relationships with commercial interests whose products or services may be mentioned in this CME/CE activity. Disclosures Angela Golden, DNP, FNP-C, FAANP is on the speakers’ bureau of and is a consultant to Novo Nordisk, and is on the speakers’ bureau of Orexigen. Staff/Planners’ Disclosures Haymarket Medical Education staff involved in the planning and content review of this activity have no relevant financial relationships to disclose. CME Reviewer, Priya Wanchoo, MD, has no relevant financial relationships to disclose. Global Education Group staff, Ashley Marostica, RN, MS, Andrea Funk, and Lindsay Borvansky, have no relevant financial relationships to disclose. Disclosure of Unlabeled Use: This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. HME and Global Education Group do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Method of Participation: To obtain credit, a score of 70% or better on the post-test is required. This activity is offered at no cost to participants. Please proceed with the activity until you have successfully completed this program, answered all test questions, completed the post-test and evaluation, and have received a digital copy of your credit certificate. Your online certificate will be saved on myCME within your Profile/Exam History, which you can access at any time. Disclaimer: The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of Novo Nordisk, Global Education Group, and Haymarket Medical Education. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. If you have any questions relating to the accreditation of this activity, please contact



Implementing lifestyle interventions for obesity All patients with obesity should be counseled on lifestyle and behavioral modifications to improve patient outcomes and weight-related comorbidities.



Regular face-to-face sessions with patients with obesity are impor­tant to assess progress and support long-term lifestyle changes.

vidence-based guidelines state that obesity is a disease that requires treatment,1,2 starting with comprehensive lifestyle changes that incorporate a reduced-calorie eating plan, increased physical activity, and behavior changes that reinforce eating fewer calories and make it easier to be more active.1-4 Regular face-to-face sessions with patients are important to assess progress, adjust plans, and support long-term lifestyle changes.1,2 The US Preventive Services Task Force recommends that all patients with a body mass index (BMI) of ≥30 kg/m 2 receive intensive, multicomponent lifestyle counseling sessions to facilitate lifestyle change.5 Lifestyle counseling can take place in the primary care clinician’s office or by referral to another practitioner or skilled professional, or commercial program. Despite obesity treatment recommendations, however, lifestyle counseling rates among primary care clinicians are low.6,7 Reasons for this include the fact that healthcare providers may not recognize the complications associated with obesity (ie, they regard obesity as a nonmedical issue). They also may be unaware of the extent to which obesity negatively impacts psychosocial functioning and quality of life, lack consistency in their approach to treatment, lack confidence in their ability to treat obesity, and/or have a weight bias. 8,9 Additionally, there are many barriers to clinicianinitiated lifestyle counseling, including time constraints, lack of resources, competing demands, and limited training.10 • THE CLINICAL ADVISOR • APRIL 2017 21



Clinician attitudes toward patients with obesity can affect the quality of care, including language used in discussing weight, and clini­cian perceptions about treatment efficacy. To help clinicians improve the care they provide to their patients with obesity, this activity will outline the steps and strategies for initiating appropriate lifestyle changes, describe motivational interviewing strategies to empower the patient to make lifestyle changes, and provide the primary care clinician with resources for implementing effective lifestyle changes. ■ Case Study

Aaron B. is a 65-year-old male patient who has been coming to your practice regularly for the last 2 years. He weighs 220 lb (an increase of 15 lb in the past year), and his BMI is 32 kg/m 2. He has a history of hyperlipidemia, which is being treated with a statin. He recently developed symptoms of heartburn, resulting in a return of his previous diagnosis of gastroesophageal reflux disease (GERD). Aaron says that he read that losing weight might help with his GERD symptoms. He is recently retired and wants to spend more time with his young grandchildren but says that he has a difficult time getting up from the floor and keeping up with them on walks. He says he would like to lose weight but that he does not know where to start. Initial steps in promoting lifestyle interventions for obesity

To help patients with obesity begin to make healthy changes, effective communication that develops and reinforces patient trust is critical. The first step in building patient trust in the clinic is recognizing weight bias among clinicians and staff.10,11 Many weight-bias assessments are available to help clinicians identify practices that promote weight stigmatization and discrimination (Figure 1).12

Implicit Association Test – Weight Other Weight-bias Measures Bias.pdf Weight-bias Toolkit

FIGURE 1. Weight bias measures and tools

Weight bias or stigma is defined as placing a lower social value on individuals with overweight or obesity.10 Weight bias exists at a similar rate among clinicians and the general public, and affects patients as well as clinicians.10,13 Among patients, weight bias can include failure to recognize that they have obesity, contribute to a sense that they are caught in an endless loop of failure (previous unsuccessful weight-loss attempts) and a sense of personal failure (internalizing obesity as their own fault), and create a lack of motivation to treat obesity.4,9,10,12 Common clinician stereotypes about patients with obesity are that they are unlikely to be compliant with treatment recommendations, and/or are lazy, undisciplined, and weak-willed.9,10 Clinician attitudes toward patients can also affect the quality of care, including time spent with patients, language used in discussing patient weight, and clinician perceptions about treatment efficacy.10,11 Furthermore, patients are aware of weight bias among clinicians. Many patients report receiving negative or inappropriate comments from clinicians and other health professionals about their weight and report that clinicians are a common source of weight stigma.11 Patients who experience weight bias are less likely to receive preventive care, such as screenings.11 ■ Case Study, continued

The clinician asks Aaron if he feels ready to start treating his chronic disease of obesity; Aaron says that he is. When asked if he had received advice on obesity treatment from his previous clinician, Aaron recalls that during a routine physical several years ago, his former healthcare provider noted his weight and told him he needed to “cut down on junk food” and “try to shape up a bit.” The clinician did not offer any additional specific advice for losing weight and did not explain the health risks of obesity. Aaron said that he was “too ashamed” to ask for weight-loss advice, and said he felt that his clinician was judging him for “letting himself go.” The approach to communication with a patient with obesity should be based on respect, use of appropriate vocabulary, and using a simple nonjudgmental approach to problem solving. By focusing on improving patient health rather than weight loss, clinicians can change the conversation and increase patient motivation. Language plays a critical role in discussing obesity treatment with patients because it can convey weight bias and influence patient motivation to engage in lifestyle changes.14


Motivational interviewing is a collaborative, patient-centered technique to strengthen motivation and encourage lifestyle changes. Certain language (ie, fat, fatness, morbidly obese, obese people) is perceived negatively by patients. People-first language (ie, people with obesity) is preferred by patients, as are the terms “physical activity” and “healthy eating.”14,15 Using people-first language can affect attitude and behavior and is encouraged by many organizations and required for publications in many reputable medical journals.16,17 In addition, consider weight bias in the clinic environment15: Are there large sturdy chairs and exam tables? Are blood pressure cuffs large enough? Do scales accommodate patients of high body weight, and are they located in a private setting? Checklists are available to assist clinicians in creating an office environment that is comfortable for diverse body sizes. Strategies for motivational interviewing

Many patients are ambivalent about initiating changes in long-standing behaviors because this may be perceived as difficult, depriving, and uncomfortable.18 Clinician understanding of these concerns and support in the effort required for making substantial long-term changes are essential to patient success. Motivational interviewing is a collaborative, patient-centered form of guiding to elicit and strengthen motivation to change.19,20 This technique focuses on fostering patient trust by building a relationship based on empathy, understanding, and support, thereby motivating patients to initiate and sustain the lifestyle changes that treat obesity. One common strategy for motivational interviewing consists of the 5A framework (Figure 2).21 Originally developed for smoking cessation, the 5As consist of a comprehensive strategy that includes evaluating patient health status, creating a treatment plan, and providing support for lifestyle changes. Clinician use of the 5As for obesity counseling is associated with higher odds of patient motivation to lose weight, intention to eat healthier, and intention to increase


• Seek permission from the patient to talk about weight.

their activity.22 Many clinicians already Ask and Advise patients about treating obesity; however, Assessing, Agreeing, and Assisting are important for gaining more information about the individual patient and can contribute to patient motivation and intentions to change behavior for better health in the treatment of obesity.22,23 Furthermore, patients whose clinicians arranged for a follow-up visit were more likely to lose weight in the next 3 months.23 Other frameworks for motivational interviewing include the OARS strategy and Elicit-Provide-Elicit.19 The OARS strategy consists of asking Open-ended questions (How do you feel about your health right now?), Affirming the patient’s strengths, successes, and positive behaviors, using Reflective listening to respond thoughtfully and encourage further discussion, and making Summary statements that help clarify the patient’s point of view. Elicit-ProvideElicit is a discussion strategy that refers to asking what the patient already knows about a topic, providing information on any knowledge gaps, and eliciting any new insight from the patient. Baseline assessment

Using motivational interviewing strategies, one of the primary goals of the first patient visit is to gain a comprehensive personalized baseline assessment of the patient.4,24 This should include identif ied causes and contributors to obesity and barriers to treatment of obesity.24 Common general themes include impaired mobility, lack of time/venues for physical activity, depression or chronic illness, lack of clarity on how to make changes, and lack of support or motivation from friends and family. Second, identify any obesity-related health complications (Figure 3) and prescribe treatment or refer the patient for additional treatment. Third, identify specific quality of

Assess Advise Agree Assist

• Determine health status, effects of weight on psychosocial factors, and causes of obesity.

• Ask permission to offer a clinical management plan.

• Obtain patient agreement about the treatment plan.

• Assist patients with identifying and seeking out credible obesity treatment resources.

FIGURE 2. The 5A Framework • THE CLINICAL ADVISOR • APRIL 2017 23



As little as 3% weight loss can improve a patient’s glycemic control and triglycer­ides, as well as reduce his or her risk of developing type 2 diabetes. life goals that the patient would like to address as part of his or her obesity treatment. Examples include: going for walks or hikes with family or friends, completing a 5K, going to an amusement park and enjoying the activities, or dancing with a significant other at a wedding. Finally, it is important to set patient expectations for obesity treatment including weight loss. Many patients desire to achieve at least 32% or far greater weight loss.25,26 Describe the many health benefits of 5% to 10% weight loss24,27 to set patient expectations and maintain focus on improving patient health and quality of life. As little as Cardiometabolic • Congestive heart failure and cor pulmonale • Varicose veins • Thromboembolic events • Hypertension • Hyperlipidemia • Diabetes • Metabolic syndrome • NAFLD • Stroke

Pulmonary • Dyspnea • Obstructive sleep apnea • Hypoventilation/Pickwickian syndrome • Asthma

Musculoskeletal • Immobility • Osteoarthritis • Low back pain • Knee/hip pain • Myalgias • Impaired balance

Other • Pseudotumor cerebri • Nerve entrapment • Cancer • Daytime sleepiness • Gallbladder disease • Chronic kidney disease • PCOS

Gastrointestinal • GERD • Hernias • Constipation

Psychosocial • Anxiety • Depression • Low self-esteem • Social isolation • Eating disorders • Body image dissatisfaction • Diminished sex drive • Impaired intimacy and sexual relationships • Decreased work productivity • Increased work absenteeism

3% weight loss can improve glycemic control, triglycerides, and reduce the risk of developing type 2 diabetes, while weight loss of 5% to 10% further improves glycemic control, HDL and LDL cholesterol, blood pressure, liver function, functional limitations, chronic pain, and the need for related medications.1 The Diabetes Prevention Program Research Group found that moderate lifestyle intervention that led to 7% weight loss decreased the progression to type 2 diabetes by 58%.28 Furthermore, every 1 kg of weight loss was associated with a 16% reduced risk of developing diabetes.29

Integument • Stretch marks • Stasis pigmentation • Venous stasis ulcers • Cellulitis • Skin tags • Intertrigo • Carbuncles

Biases • Society • Family • Workplace • Harassment • Bullying

Negative Perceptions • Unmotivated • Weak-willed • Less intelligent • Less attractive • Unsuccessful • Overindulgent • Lazy

GERD, gastroesophageal reflux disease; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome. Adapted from the Obesity Algorithm, presented by the Obesity Medicine Association (2016-2017).4

FIGURE 3. Common obesity-related complications


Lifestyle programs for obesity prescribe reducing daily caloric intake by any number of dietary plans and increasing physical activity. ■ Case Study, continued

The clinician reassures Aaron that engaging in obesity treatment is important for his health and quality of life, and can help him address other personal goals. The clinician discusses Aaron’s complete medical history, including any previous weight-loss attempts. The clinician then helps Aaron identify specific obesity treatment lifestyle goals; Aaron says that in addition to losing weight and improving his GERD symptoms and lipid levels, he would like to be able to go for longer walks with his grandchildren and keep up with them on these outings. The clinician prescribes famotidine 10 mg twice daily with lifestyle and dietary modifications for Aaron’s GERD symptoms. He discusses the potential benefits of losing even 5% to 10% of body weight, and especially how they relate to Aaron’s goals. Aaron and his healthcare provider discuss an appropriate goal for weight loss; together, they agree that a 10% decrease in body weight (22 lb) over 1 year is an attainable goal for Aaron. Short-term goals will be 7 lb in the next 3 months and 6% (13 lb) at 6 months. Aaron says he is excited to begin, and asks what specific changes he should start making to ensure he meets his weight-loss goals.

programs can assist patients with making and adhering to lifestyle changes. Dietary changes generally focus on identifying daily caloric intake and then reducing caloric intake by 500 kcal/ day.32 Use of meal replacement shakes or bars was significantly associated with weight loss at 1 year in the Look AHEAD study. 33 Other strategies for reducing caloric intake are learning about and understanding hunger, learning about portions (eating smaller portions and eating slower), and how to use these strategies when eating out. Dietary advice should be culturally specific and address patient eating preferences. Create goals for increasing physical activity to 150 minutes per week; the term “exercise” can have negative connotations.1 Physical activity can consist of endurance training (ie, walking, biking, performed as continuous 20- to

Obesity Action Coalition: People-First Language Obesity Action Coalition: Weight Bias and Stigma

Lifestyle change for treating obesity

Generally, lifestyle programs prescribe reducing daily caloric intake (by an estimated 500 kcal/day or adjusted for the individual) by any number of dietary plans and increasing physical activity.1,3,4,30 Additionally, a behavioral program consisting of 14 or more face-to-face sessions in the first 6 months is recommended. Sessions should then be administered on a regular basis to support weight loss and weight maintenance. Since CMS began reimbursing obesity counseling in primary care in 2011, clinicians can be reimbursed for up to 22 15-minute visits over the course of a year (reimbursement in the second half of the year is contingent on patients achieving at least 3 kg of weight loss). 31 Sessions should evaluate progress and provide patients with strategies to reduce calorie consumption and increase activity and may use methods such as selfmonitoring of food intake, physical activity, body weight, and weight-related goals. 24 If face-to-face sessions are not feasible, other support programs, including commercially available diet programs and electronic/Internet

Stop Obesity Alliance: Why Weight? NIH/NIDDK, Talking Tips for Primary Care Providers Checklist for Assessing the Office Environment Checklist.pdf BMIQ Professional Program

American Board of Obesity Medicine

FIGURE 4. Resources for providers • THE CLINICAL ADVISOR • APRIL 2017 25



60-minute sessions or in several short 10-minute bouts, if needed), resistance training (isometric, weights), and flexibility training (stretching, modified yoga).4,34 Clinicians can assist the patient with identifying opportunities for physical activity that are appropriate for the individual and adjusting intensity.35 It is important to assess the patient’s current capabilities and move forward in activities as the patient is able. Activity is important for maintenance. Behavioral intervention refers to any technique that improves patient adherence to dietary and physical activity goals. Behavioral goals should be tailored to the individual and can include specific goals of what the patient will do, when, where, and for how long. General types of behavioral modification include limiting screen time, joining support groups, and engaging family members in lifestyle changes. Self-monitoring is one of the most important components of behavioral intervention and is associated with short- and long-term weight loss. 32 Clinicians can positively influence patient motivation and adherence by providing patients with specific advice (eg, food and activity plans, creating SMART (Specific, Measurable, Attainable, Realistic, Time-Based) goals, regular follow-up and accountability, reviewing performance and goal achievement, and demonstrating interest.4 There are many tools to assist clinicians in helping their patients comply with an obesity treatment plan by providing specific regular follow-up (Figure 5). Examples include commercial dietary/nutrition meal plans, comprehensive programs (Weight Watchers, Jenny Craig), activity

The YMCA Diabetes Prevention Program

Apps for Tracking Activity and Food Intake top-iphone-android-apps#1

trackers, group classes/sessions, exercise buddies, local programs and support, health coaches, phone and tablet apps, and online intensive behavioral therapy programs. ■ Case Study, continued

Aaron and his clinician work on outlining specif ic behavioral changes to help Aaron reach his weight-loss goal. He agrees to begin keeping a food journal on his tablet to better understand his food habits and track his caloric intake; it is decided that a daily reduction of 500 kcal would be most effective in helping Aaron to reach his weight-loss goals. In addition, he also likes the idea of tracking his steps and will work up to a daily goal of 10,000 steps each day by increasing his steps by 1000 steps per week. The clinician tells Aaron that regular follow-up visits will be critical to the success of his weight-loss journey; the first follow-up visit is scheduled for 1 week from today. At this visit, Aaron and his clinician will review his food and activity journal to determine his daily caloric intake and create a 500 kcal deficit goal, as well as review his physical activity. They will also discuss how he can change his behavior to help him meet these goals, and identify and address any barriers that Aaron encounters. Follow-up visits will continue at regular intervals. As Aaron progresses, changes will be made to his eating plan, activity routine, and/or other behaviors. Conclusion

Primary care clinicians play a pivotal role in identifying and treating patients with obesity and obesity complications. By screening patients for obesity, identifying patients who are ready for change, and initiating lifestyle changes, they can improve long-term health and quality of life. Many patients may also need medication as part of their obesity treatment plan and/or bariatric surgery referral. Guidelines are available for further information. n References 1. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/ TOS guideline for the management of overweight and obesity in adults: a repor t of the American College of

Pack Health - Personalized Service That Helps People With Chronic Conditions

Cardiology/ American Hear t Association Task Force on Practice


Guidelines and The Obesity Society. Circulation. 2. Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice

FIGURE 5. Resources for patients

Guideline. J Clin Endocrinol Metab. 2015:jc20143415.


3. Ryan D, Heaner M. Guidelines for managing overweight and

21. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical

obesity in adults. Preface to the full report. Obesity.

review: modified 5 As: minimal intervention for obesity counseling

2014;22(suppl 2):S1-S3.

in primary care. Can Fam Physician. 2013;59:27-31.

4. Obesity Algorithm, presented by the Obesity Medicine Association.

22. Jay M, Gillespie C, Schlair S, et al. Physicians’ use of the 5As

2016-2017. Accessed February 6, 2017.

in counseling obese patients: is the quality of counseling associated

5. Moyer VA, Force USPST. Screening for and management of obesity

with patients’ motivation and intention to lose weight?

in adults: U.S. Preventive Services Task Force recommendation

BMC Health Serv Res. 2010;10:159.

statement. Ann Intern Med. 2012;157:373-378.

23. Alexander SC, Cox ME, Boling Turer CL, et al. Do the five A’s

6. Kraschnewski JL, Sciamanna CN, Pollak KI, et al. The epidemiology

work when physicians counsel about weight loss? Fam Med.

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positive deviance. Int J Obesity. 2013;37:751-753.

24. Kushner RF, Ryan DH. Assessment and lifestyle management

7. Kraschnewski JL, Sciamanna CN, Stuckey HL, et al. A silent

of patients with obesity: clinical recommendations from systematic

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reviews. JAMA. 2014;312:943-952.

counseling. Med Care. 2013;51:186-192.

25. Foster GD, Wadden TA, Vogt RA, Brewer G. What is a

8. Gunther S, Guo F, Sinfield P, et al. Barriers and enablers to

reasonable weight loss? Patients’ expectations and evaluations

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in implementation activities. Qual Prim Care. 2012;20:93-103.


9. Mauro M, Taylor V, Wharton S, Sharma AM. Barriers to obesity

26. Linne Y, Hemmingsson E, Adolfsson B, et al. Patient

treatment. Eur J Intern Med. 2008;19:173-180.

expectations of obesity treatment—the experience from

10. Phelan SM, Burgess DJ, Yeazel MW, et al. Impact of weight bias

a day-care unit. Int J Obes Relat Metabol Disorder.

and stigma on quality of care and outcomes for patients with obesity.


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27. Expert panel report: guidelines (2013) for the management

11. Puhl RM, Heuer CA. The stigma of obesity: a review and update.

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12. DePierre JA, Puhl RM. Experiences of weight stigmatization:

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a review of self-report assessment measures. Obes Facts.

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or metformin. N Engl J Med. 2002;346:393-403.

13. Sabin JA, Marini M, Nosek BA. Implicit and explicit anti-fat bias

29. Hamman RF, Wing RR, Edelstein SL, et al. Effect of weight

among a large sample of medical doctors by BMI, race/ethnicity and

loss with lifestyle intervention on risk of diabetes. Diabetes Care.

gender. PLoS One. 2012;7:e48448.


14. Puhl R, Peterson JL, Luedicke J. Motivating or stigmatizing? Public

30. Bray GA, Fruhbeck G, Ryan DH, Wilding JP. Management

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32. Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle

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33. Wadden TA, West DS, Neiberg RH, et al. One-year weight

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2011;364:1218-1229. • THE CLINICAL ADVISOR • APRIL 2017 27


POST-TEST Expiration date: April 14, 2018

Credit Designation: HME is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. HME designates this educational activity for a maximum of 1.0 AMA PRA Category l Credit™. The following activity has been approved by the AACME, whose approval is recognized by the Commission on Dietetic Registration and, as such, RDs/ DTRs will be able to receive 1.0 CPEU. Global Education Group is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This educational activity for 1.0 contact hours is provided by Global Education Group. Participants should only claim credit commensurate with the extent of their participation in the activity. A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better. Posttest must be completed and submitted online. Please go to

CREDITS: 1.00 | Implementing Lifestyle Interventions for Obesity 1. Which of the following statements is true? a. Weight bias, or stigma, is defined as refusing to treat patients with overweight or obesity. b. Weight bias is more prevalent among the general public than among healthcare clinicians. c. Clinician attitudes toward patients have little impact on quality of care relative to obesity treatment. d. Patients who experience weight bias are less likely to receive preventive care. 2. Use of the “5As” for obesity counseling: a. Is associated with higher odds of patient motivation to engage in recommended lifestyle interventions for obesity. b. Is more useful for smoking cessation than for obesity. c. Is more effective when done by endocrinologists than primary care providers. d. Requires at least 5 office visits to be performed effectively. 3. When using motivational interviewing strategies for obesity, one of the primary goals of the first patient visit is to: a. Impress on the patient the health risks of overweight and obesity. b. Set quality of life goals for treatment. c. Encourage the patient to use weight-loss medications, as they are more effective than lifestyle interventions in most cases. d. All of the above. 4. Behavioral goals for obesity treatment: a. Should be tailored to the individual. b. Should not include specific goals. c. Should include specific goals of what the patient will do. d. Both a and c. e. None of the above. 5. Data show that as little as ___ weight loss can improve glycemic control, triglycerides, and reduce the risk for developing type 2 diabetes. a. 3% b. 5% c. 10% d. 15% 6. The components of a comprehensive obesity treatment plan include: a. Reducing daily caloric intake by an estimated 700 kcal by any number of dietary plans and increasing physical activity. b. A behavioral program consisting of 14 or more face-to-face sessions with the clinician in the first 6 months. c. At least 200 minutes per week of moderate to vigorous exercise. d. Implementing a very-low-calorie diet (~500 kcal/day) for 2 weeks to jumpstart weight loss.

7. As part of an obesity management plan, which of the following strategies is recommended? a. Incorporating running or jogging for at least 30 minutes per day. b. Creating goals for increasing physical activity to 150 minutes per week. c. Completing 90 minutes of training most days of the week. d. Performing mostly aerobic exercises rather than strength-training, as these activities are associated with greater weight loss. 8. Traci D. is a 29-year-old female patient who has been coming to your practice regularly for the last 10 years. She gave birth to her first child 1 year ago. Prior to her pregnancy, Traci was overweight at 5 ft 4 in and 160 lb (body mass index [BMI] = 27.5 kg/m2). During her pregnancy, she gained approximately 30 lb. Following the birth of her daughter, Traci initially lost 15 lb, but over the past year, she gained approximately an additional 20 lb. At today’s visit, she weighs 189 lb, and now has a BMI of 32.4 kg/m. 2 She is otherwise in good health, with no significant health comorbidities. However, she says she is “very upset” by her weight gain and would like to try to lose weight. Which of the following strategies would be appropriate? a. Agree with Traci that she should try to lose weight, but caution her that the majority of patients who lose weight will eventually gain most of it back. b. Review with Traci the myriad health risks associated with obesity. c. Work with Traci to identify some of the causes and contributors to her obesity as well as potential barriers to treatment. d. Refer Traci to a bariatric surgery consultation, as surgery is the most effective treatment for obesity. 9. As a next step, the clinician should: a. Recommend that Traci lose at least 25% of her body weight to ameliorate any potential health risks. b. Help Traci identify her goals for weight loss. c. Suggest that Traci join a gym if she does not already belong to one, and aim to attend at least 60 minutes per day, 3 days per week. d. Recommend that Traci enroll in a commercial diet plan, as recent data show they are more effective at promoting weight loss over the long term. 10. Traci asks the clinician which diet would be best to help her meet her weight-loss goals. Which of the following is an appropriate answer? a. Track daily caloric intake and then reduce caloric intake by 250 kcal/day. b. Track daily caloric intake and then reduce caloric intake by 500 kcal/day. c. Implement a low-fat diet without counting calories. d. Tell Traci that caloric intake is not as important to weight loss as is physical activity.

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3/8/17 12:52 PM


Information technology for diabetes care A study of one tracking system’s effect finds improvement in the management of patients with diabetes.


A tracking system can tailor care and boost self-management in patients with diabetes.



iabetes mellitus is a prevalent chronic disease that affects 28.9 million American adults. Diagnosed cases of diabetes were responsible for $245 billion in total costs in the United States in 2012, $176 billion in direct medical costs, and $69 billion in indirect costs of disability, time lost from work, and premature mortality.1 Undiagnosed cases of diabetes, prediabetes, and gestational diabetes add to these costs.1 The annual healthcare costs of patients who have diabetes with macrovascular comorbidities are statistically significantly higher, with costs of lost productivity reaching $2388 annually per patient.2 Among adults, type 2 diabetes accounts for approximately 90% to 95% of all diagnosed cases of diabetes.3 Type 2 diabetes is associated with older age, obesity, a family history of diabetes, a history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ ethnicity.3 In the battle against this widespread and expensive disease, communication between primary care providers and patients is key. Information technology (IT) can be used by providers as a practice intervention to enhance communication with patients with diabetes and so enable them to improve their self-management. Specifically, a tracking system can serve as a visual tool for both providers and patients. This article discusses the use of one tracking mechanism for diabetes management that helps to control the confounding factors that may affect outcomes. This tracking

system—the Chronic Disease Electronic Management System (CDEMS)—was selected because it tailors care and fosters self-management principles to achieve patient participation and diabetic control. Active patient participation

Diabetes, like other chronic illnesses, is very complex and derives from much more than biological mechanisms alone. In a meta-analysis of articles on type 2 diabetes and psychological and behavioral factors among patients that affect care, Cobden et al4 found that “medication adherence, persistence, treatment satisfaction, patient preferences, and psychological well-being are interrelated; well-studied; and directly or indirectly affect clinical outcomes, health events, resource use, and costs, notably in real-world settings” (p. 143). Their findings illustrate the importance of a patient’s participation in care. Education or training in self-management is a key step in improving health outcomes and quality of life. It focuses on self-care behaviors, such as maintaining healthful eating habits, being active, and monitoring blood sugar. This training is a collaborative process in which primary care providers help people with or at risk for diabetes gain the knowledge and problem-solving and coping skills needed to self-manage the disease and its related conditions successfully. Patients with diabetes benefit from self-monitoring, decision making that is based on the results of monitoring, and informed interactions with healthcare providers.5 Tailoring interventions with patients has been extensively used to improve health behaviors by encouraging good dietary and physical habits, weight loss, and smoking cessation, but it has not yet been shown to improve the self-management behaviors of patients with chronic conditions such as diabetes.6 IT and diabetes

IT is increasingly being included in the management of diabetes. Yet, few studies have shown that IT improves diabetes outcomes. In their systematic review of studies using HbA1C level as their primary outcome measure, Costa et al7 concluded that the results of IT-based interventions for diabetes management may have been confounded by other factors that influenced outcome, such as variations in sample characteristics, providers’ level of computer literacy and experience, IT method of delivery, and patients’ knowledge of diabetes. Therefore, they recommended that confounding variables be acknowledged and controlled as possible and that outcome measures be used that are relevant to the population under study.

Chronic disease electronic management system

The tracking system used in this project was the Chronic Disease Electronic Management System (CDEMS), based on the Chronic Care Model. CDEMS is a software application that was developed by the Washington State Diabetes Prevention and Control Program in 2002. This application is a Microsoft Access database designed to assist medical providers in tracking the care and outcomes of patients with chronic health conditions. CDEMS is precoded to track diabetes, asthma, and adult preventive health but can be customized to define measures for monitoring other chronic conditions. Multiple items may be tracked, including demographic data, laboratory test results, medications, and preventive health interventions. Patient data are entered into the CDEMS at the time of a patient interaction. From the program, graphs of patient trends for key indicators help both patients and TABLE 1. Demographic data of patients: nurse practitioner clinic vs statewide clinics

Demographic data

Patients in nurse practitioner clinic (N = 56), n (%)

Patients in statewide clinics (N = 6949), n (%)

Gender  Male

21 (37.5)

3273 (47.1)


34 (60.7)

3613 (51.99)

1 (1.8)

63 (0.91)

0 (0)

119 (1.71)


6 (10.7)

1051 (15.12)


12 (21.4)

1451 (20.88)


12 (21.4)

1893 (27.24)


25 (44.6)

2435 (35.04)


0 (0)

262 (3.77)

  Native American

0 (0)

26 (0.37)

56 (100)

3826 (55.06)


0 (0)

51 (0.73)


0 (0)

741 (10.66)


0 (0)

20 (0.29)


0 (0)

2023 (29.11)

  Not provided Age group, y  <25




TABLE 2. Clinical data of patients: nurse practitioner clinic vs statewide clinics

Clinical data

Patients in nurse practitioner clinic (N = 56), n (%)

Patients in statewide clinics (N = 6949), n (%)

Type of diabetes   Type 1

2 (3.6)

639 (9.2)

  Type 2

54 (96.4)

6319 (90.93)

  <130 and <80

13 (23.2)

1128 (16.23)

  >130 and/or >80

34 (60.7)

Missing BP: 3638 (52.35)

Systolic and diastolic BP, mmHg

BMI  ≤24.9

8 (14.3)

741 (10.66)


7 (12.5)

1426 (20.52)


11 (19.6)

1512 (21.76)


7 (12.5)

980 (14.1)


14 (25.0)

1086 (15.63)

Current tobacco use

12 (21.4)

601 (8.65)



Average LDL cholesterol level, mg/dL



Average HDL cholesterol level, mg/dL



Average triglyceride level, mg/dL



Average total cholesterol level, mg/dL



Average HbA1C, % of total Hb

their medical providers to improve long-term outcomes. CDEMS is used in practice in two ways: 1) to describe the characteristics and outcomes of an individual provider’s group of patients with diabetes and 2) at the level of individual patients, to graph personal data so that it can be used for self-management, education, and support. The effectiveness of this ongoing tracking system for patients with diabetes was evaluated during a 1-year period. Selected outcomes for diabetes in a rural nurse practitioner (NP)–managed clinic were compared with data from statewide clinics for the same outcomes. The purpose of comparing NP data with statewide data was to examine the overall effectiveness and consistency of diabetic care provided by the NP clinic while using the CDEMS. Demographic and clinical data

It is estimated that there are 272,309 people with diabetes in the state of Kansas, including 69,000 persons with undiagnosed diabetes.8 Demographic data were collected from 56 patients seen in the NP clinic and compared with demographic data from 6949 patients with diabetes tracked throughout the state. The results of the comparison are presented in Table 1. Most of the patients seen in both the NP clinic and the statewide clinics were female, white, and aged older than 65 years. In addition, clinical data were gathered for each diabetes-related appointment at the NP clinic and entered into the CDEMS database. A comparison of the clinical data from the NP clinic with the clinical data from the statewide clinics data is presented in Table 2. Analysis of clinical data

Patients with associated health condition Hypertension

46 (82.1)

3273 (47.1)


48 (85.7)

2722 (39.17)

BMI, body mass index; BP, blood pressure; HbA1C, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein

About 80 clinics reported data across the state. The data for HbA1C levels, lipid profiles, blood pressure, body mass index, and demographic characteristics were accurately recorded in all the clinics. The statewide data for tobacco use and associated health conditions appeared to be inconsistently recorded. This variability between the data for the NP clinic and the data for the statewide clinics is thought to be the result of inconsistencies in recording the data. Therefore, the analysis of the data focuses primarily on the accurately recorded parameters. The average HbA1C value from the NP clinic (7.1) is lower than the average statewide value (7.4). This difference may reflect the consistent management of a smaller group of patients with diabetes and care provided by one provider in a personalized setting within a small rural community. Patients were well-known to the NP, and frequent follow-up led to better compliance. The statewide data reflect a broader, more


heterogeneous population with diverse ethnic backgrounds and greater variance in other risk factors. The average lipid profile values were similar for the NP clinic and the statewide clinics, except for the triglyceride value. The average triglyceride value of the patients in the NP clinic was markedly elevated at 423.4 mg/dL, whereas the average value for the patients in the statewide clinics was 186 mg/dL. This is believed to reflect the high percentage of patients in the NP clinic with a BMI of 40 or higher. The exact cause of the elevated BMI and triglyceride values is unknown but is believed to be related to the dietary intake and other lifestyle patterns of a rural, low-income population. There is a correlation between a high BMI and a high plasma triglyceride level.9 A comparison of blood pressure values between the NP clinic and the statewide clinics showed a higher percentage of patients with elevated blood pressure in the NP clinic. Data are missing for a large number of patients in the statewide clinics and therefore, a comparison cannot be made. Even though the statewide data for tobacco use were inconsistently reported, 21.4% of the patients in the NP clinic reported smoking. According to data from the Centers for Disease Control and Prevention, 22% of adults in Kansas are currently cigarette smokers, and Kansas ranks 31st among the states for tobacco use.10 This indicates a high-risk lifestyle for patients throughout Kansas and the patients in the rural NP clinic. Discussion

The use of electronic medical records can be tailored to track diabetes care. A study by Cebul et al11 of 27,207 adults with

diabetes at 46 practice sites compared the efficacy of paper tracking with that of electronic medical records for achieving the standards of diabetes care and found that electronic medical records were associated with a greater improvement of outcomes in diabetes care. Numerous patient-centered products for tracking diabetes exist, some free and some for purchase. A list of commercially available products is available at Although these may be useful for motivated patients, a provider–patient tracking system enhances patient counseling and improves outcomes. CDEMS promotes the elements of decision support and self-management support in the care of patients with chronic disease. The system provides a foundation for an informed, activated patient to interact with a prepared, proactive practice team. This article demonstrates the unique nature of a community of patients and the capability of a tracking system to focus interventions for the specific needs of a population. NPs are tasked with providing patients with diabetes meaningful criteria for use, such as the HbA1C level and other outcome factors. A tracking system is a powerful tool for aiding individual patients with diabetes to self-manage their disease and for monitoring the standards of diabetes care. n Karen Hayes, PhD, APRN, FNP-BC, ACNP-BC, and Alicia Huckstadt, PhD, APRN, FNP-BC, GNP-BC, are affiliated with the School of Nursing at Wichita State University in Kansas. Dr. Hayes is also a family nurse practitioner with Lake Regional Health System in Osage Beach, Missouri.

Case example One patient’s case in the nurse practitioner (NP) clinic illustrates how diabetes varies among patients. Mrs H is a 71-yearold retired woman who self-manages her diabetes with the assistance of the Chronic Disease Electronic Management System (CDEMS). She uses basal insulin at night and 10 mg of glipizide XL (extended release) during the day to maintain her fasting glucose level between 100 and 127 mg/dL. Her data were first entered into the tracking system in 2009. Mrs H’s CDEMS report demonstrates the practical use of a tracking system. On May 6, 2011, at a clinic visit after a 5-month interval, Mrs H could see that her HbA1C level was elevated at 9.0% of total hemoglobin. In addition, her total

cholesterol level was elevated at 219 mg/dL, and her highdensity lipoprotein (HDL) level was low at 19 mg/dL. With the help of her NP, Mrs H was able to use this information to adjust her insulin dosing and diet and bring her laboratory values under better control at the next visit. The patient’s printed report also contains recommendations for the treatment of diabetes, with documentation of when the standard was last addressed. This information helped Mrs H focus on her personalized treatment plan when the report was reviewed with the NP. Mrs H takes her CDEMS report home and uses it to stay focused on her goals and progress. She still struggles to meet her HbA1C and weight goals and is currently working with the NP to improve the self-management of her condition. • THE CLINICAL ADVISOR • APRIL 2017 33

Writers’ Guidelines The Clinical Advisor welcomes submissions from its readers. Writing for us is an opportunity to share your knowledge and experience with your colleagues — and to collect a fee in the bargain! We pay an honorarium for every submission we accept. We’ll be glad to work with you to develop your ideas into compelling articles. As for length, that depends on which kind of article you submit. CLINICAL FEATURES update our readers on the latest information about conditions seen in everyday practice. Running approximately 2,500 to 5,000 words, including the references, features can be written either as regular narratives or as a series of questions and answers. Topics should be selected with the busy primary-care clinician in mind; specialists should review specialty topics from the primary-care point of view. If at all possible, articles should be accompanied by clinical photos. Charts, tables, and algorithms are also encouraged. Please include your title and affiliation. CLINICAL CHALLENGE is our popular department comprising histories of difficult cases. Each case is presented as a step-by-step, chronological account, revealing the author’s thought processes along the way. It is divided into sections in this order: the patient presentation; the patient history; the twists and turns eventually leading to a diagnosis; the treatment and outcome; and a discussion of the lessons learned or of the condition in general. The length should be about 1,500 words, and accompanying images are encouraged. Please include your title and affiliation. DERMATOLOGY CLINIC is a department that presents photos of actual cases and asks readers to identify the condition. Each case opens with one or two color photos and a 75-to-100-word description of the patient presentation, without giving away the diagnosis. This is followed by a 750-to-1,000-word summary that includes a fuller description of the ailment, an explanation of how the correct diagnosis was reached, a general review of the condition along with a differential diagnosis, and a description of the patient’s treatment and outcome. Topics must be approved by the editor prior to submission. Please include your title and affiliation. COMMENTARY is our guest editorial page. It gives you the opportunity to sound off on an issue of importance to your colleagues nationwide. A typical Commentary runs about 600 words in length. Please include your title and affiliation. To discuss your editorial ideas, contact us by phone at 646.638.6078; by e-mail to; or by mail to The Clinical Advisor, 275 7th Avenue, 10th Floor, New York, NY 10001.

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The Chronic Disease Electronic Management System was supported by the Diabetes Quality of Care Project, funded by the Kansas Department of Health and Environment. References 1. Centers for Disease Control and Prevention. National diabetes statistics report: Estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014. http:// pdf. Accessed March 2, 2017. 2. Fu AZ, Qui Y, Radican L, Wells, BJ. Health care and productivity costs associated with diabetic patients with macrovascular comorbid conditions. Diabetes Care. 2009;32:2187-2192. 3. Centers for Disease Control and Prevention. Diabetes report card

“Sorry I’m late. It took me forever to find this place.”

2014. Atlanta, GA: US Department of Health and Human Services; 2015. Accessed March 2, 2017. 4. Cobden DS, Niessen LW, Barr CE, Rutten FF, Redekop WK. Relationships among self-management, patient perceptions of care, and health economic outcomes for decision-making and ­clinical practice in type 2 diabetes. Value Health. 2010;13:138-147. doi: 10.1111/j.1524-4733.2009.00587.x 5. Stetson B, Schlundt D, Peyrot M, et al. Monitoring in diabetes selfManag. 2011;14:189-197. doi: 10.1089/pop.2010.0030 6. Radhakrishnan K. The efficacy of tailored interventions for selfmanagement outcomes of type 2 diabetes, hypertension or heart disease: a systematic review. J Adv Nurs. 2012;68:496-510. doi: 10.1111/j.1365-2648.2011.05860.x 7. Costa BM, Fitzgerald KJ, Jones KM, Dunning AMT. Effectiveness of IT-based diabetes management interventions: a review of the literature. BMC Fam Pract. 2009;10:72. doi: 1186/1471-2296-10-72. 8. American Diabetes Association. The burden of diabetes in Kansas. pdf. Accessed March 2, 2017. 9. McAdams MA, Van Dam RM, Hu FB. Comparison of self-reported and measured BMI as correlates of disease markers in US adults. Obesity. 2007;15:188-196. 10. Centers for Disease Control and Prevention. Smoking & tobacco use. Kansas. highlights/2012/states/kansas/index.htm. Reviewed December 9, 2014. Accessed March 2, 2017. 11. Cebul RD, Love TE, Jain AK, Hebert CJ. Electronic health records and quality of diabetes care. N Engl J Med. 2011;365:825-833. doi: 10.1056/ NEJMsa1102519 12. Diabetes software. diabetes-technology/diabetes-software. Accessed March 2, 2017.


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Top: © The New Yorker Collection 2017 from All Rights Reserved. Middle, bottom: © Harley Schwadron.

management: issue and recommendation for improvement. Popul Health

Conference Roundup American Academy of Pain Medicine 2017 Annual Meeting Orlando

PERIOPERATIVE CARE FOR ACUTE PAIN MANAGEMENT Perioperative surgical homes and Enhanced Recovery After Surgery (ERAS) protocols can improve postoperative outcomes in patients with chronic opioid use, according to David Edwards, MD, PhD, from Vanderbilt University. Patients with chronic pain who are hospitalized have a higher risk of morbidity and mortality, longer lengths of stay, and more frequent readmissions than patients without chronic pain. Among patients who are hospitalized, pre-admission opioid use is common; in one study, 13% of inpatients at Massachusetts General Hospital reported taking opioids prior to admission. Preoperative chronic opioid use is associated with an increased risk for adverse events and poor outcomes. Opioid-tolerant patients have 20% longer lengths of stay and up to 3 times the rate of readmissions compared with patients without opioid tolerance. Preoperative opioid use is linked to greater disability, lower quality of life, and higher mortality in the postoperative period. “There are many goals of care for surgical patients that can only be met by: 1) working as a team with our colleagues; and 2) implementing evidence-based practice along the entire care continuum,” Dr Edwards said in an interview. “This is what the perioperative surgical home and ERAS pathways of care help us do.” A key element of the perioperative surgical home model includes reducing risk factors for poor outcomes by implementing behavioral changes during the preoperative period. For patients who are chronic opioid users, preoperative measures may include addressing anxiety or reducing opioid dose, which may lead to better

Perioperative surgical homes and Enhanced Recovery After Surgery protocols may significantly reduce the need for opioids.


postoperative outcomes. Comprehensive teambased and coordinated care may be achieved by engaging providers, from nurses to surgeons to the anesthesiologists, in the preoperative stage through the time of discharge. ERAS protocols embody the concepts of the perioperative surgical home and promote early postsurgical recovery by implementing evidence-based best practices. Essential components of ERAS protocols include optimizing preoperative care, using nonopioid analgesics to treat pain, and—if opioids are needed—controlling escalation of opioids to minimize risk. ERAS protocols have been shown to decrease lengths of stay and postsurgical complication rates by up to 30%. “An important outcome for patients is to limit the risks associated with opioids,” Dr Edwards said. “Perioperative surgical homes and ERAS protocols drastically reduce the need for opioids.”

RADIOFREQUENCY TREATMENT EFFECTIVE FOR REFRACTORY CHRONIC JOINT PAIN Radiofrequency treatment (RFT) is an effective option for treating refractory chronic knee, hip, and shoulder joint pain, reported Michael Jacobs, MD, MPH, from the Walter Reed National Military Medical Center. Symptomatic knee osteoarthritis (OA) is one of the top 5 leading causes of disability, affecting 5% to 12% of adults in the United States. The prevalence of hip OA is as high as 9% in adults aged 45 years and older. Chronic shoulder pain, which accounts for 16% of all musculoskeletal pain, is the third most common site of musculoskeletal pain. RFT disrupts pain signal transmission by destroying nerves through thermal ablation


and has been used for trigeminal neuralgia, spinal pain, and cancer pain. Evidence from numerous small, randomized controlled trials supports the use of RFT in treating extremity joint pain. RFT is indicated for chronic intra-articular joint pain due to causes such as OA and vascular necrosis, but not for isolated extra-articular etiologies such as tendinitis or iliotibial band syndrome. In addition, RFT should only be considered in patients whose pain is not satisfactorily controlled with conservative therapy, which includes risk factor modification, physical therapy, medications, and injections. Patients must also be ineligible for surgical intervention and pass a nerve block test that suggests a higher likelihood of responding to RFT. Dr Jacobs discussed the relevant anatomy and RFT techniques for treating the knee, hip, and shoulder joints. Due to the proximity of arteries to the nerves targeted by RFT, arterial injury is a potential adverse event for RFT, but no cases have been reported to date for RFT treatment of knee joint pain. A case series of 17 patients undergoing RFT for hip joint pain exhibited improvement in pain and function at 6 months despite the occurrence of 3 hematomas. Water-cooled RFT is similar to RFT but is able to create a larger neural lesion at lower temperatures to increase the likelihood of producing denervation. Support for cooled RFT for knee joint pain consists of case study data, although a randomized clinical trial has been submitted for publication. RFT is also being considered in patients treated with joint replacement surgery, a sizeable proportion of whom develop chronic pain. Limited data support the use of RFT and cooled RFT in this population.

Symptomatic knee osteoarthritis is one of the top 5 leading causes of disability, affecting 5% to 12% of adults in the United States.

Several aspects of RFT require further study, including evaluation of adverse events related to RFT and the efficacy of RFT after total joint replacement. Comparing RFT techniques—such as conventional, pulsed, and cooled—and determining whether RFT is effective for treating pain in other joints are additional directions for future investigation.

CDC’S OPIOID GUIDELINE PROMPTS CLINICIAN CONCERNS Jeffrey Fudin, PharmD, DAAPM, FCCP, FASHP, adjunct associate professor at Western New England University College of Pharmacy, highlighted his concerns regarding the CDC’s guideline for prescribing opioids for chronic pain. This guideline, consisting of 12 recommendations, was issued in June 2016. According to Dr Fudin, despite the fact that the recommendations were based on either case series or expert opinion, they were assigned a grade A recommendation, a grading that usually requires a minimum of 2 class I studies. Dr Fudin cited a study published in January 2016, which states: “For reasons that are unclear, the notion has become entrenched that 100 or 120 mg per day of morphine equivalent is a ‘high dose’ of opioids and is associated with an inflection point of risk for overdose, despite varying definitions of how daily dose is calculated.” This study examined data from more than 2 million patients for a one-year period in North Carolina, which uses a controlled substances prescription monitoring program. Of those patients, 478 died from overdose, or 0.022% of overdose-related deaths per year. In addition, 80% of those deaths occurred in patients who had been co-prescribed opioids and benzodiazepines. “That’s one CDC guideline I’ll go along with,” remarked Dr Fudin, referring to guideline #3, which points to the “increased risks for respiratory depression when opioids are taken with benzodiazepines, other sedatives, alcohol, illicit drugs such as heroin, or other opioids.” Patients in this group had rates of death from overdose 10 times higher than in patients not taking benzodiazepines concurrently. This study, according to Dr Fudin, contributed to the negative perception of opioids. “Not all opioids are created equal, so that if one opioid does not work, there may be other options,” commented Dr Fudin. In addition, “[patients] may tolerate and/or respond to one opioid better than to the others.” n

These articles were originally published on • THE CLINICAL ADVISOR • APRIL 2016 37

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.

YOUR COMMENTS PREVENTING CHRONIC DISEASES WITH LIFESTYLE CHANGES I believe 100 percent in lifestyle changes for people who are facing preventable diseases such as diabetes, hypertension, coronary artery disease, inflammatory diseases (inflammation is the cornerstone behind almost all chronic diseases), rashes, fatty liver disease, etc. My first-line treatment regimen is a low-carbohydrate lifestyle. If patients are not currently being medicated and their current situation warrants not needing medication at the time of their visit, this is a great opportunity to get them onboard with this plan. But sometimes patients need pharmacotherapy as a bridge to wellness. And some patients insist on being on a medication, but I still emphasize that drugs should be regarded as a short-term approach in mitigating and alleviating their symptoms. Depending on the patient, I always start slowly and stress that this has to become Send us your letters with questions and comments to: Advisor Forum, The Clinical Advisor, 275 7th Avenue, 10th Floor, New York, NY 10001.You may contact us by e-mail at 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.

a lifestyle. This is not going to change overnight, nor are results an instant download. In our current environment of instant gratification and all things available on an App, I try to reorient my patients’ thoughts so that they see their current deteriorated health situation is the byproduct of years of miseducation on food and living, and they have to re-educate themselves and eschew the antiquated dogma of the food pyramid way of thinking. I use scholarship work from titans in the field, such as Gary Taubes, William Davies, Sally Fallon, Mary Enig, Stephen D. Phinney, Jeff Volek, and Ronald M. Krauss, to name a few, and I recommend the Atkins diet if they are not as literate, mainly because most people have heard of the Atkins diet and it is familiar and user-friendly. If they have a higher level of sophistication, I include with the Atkins diet a reduced grain/grain-free approach. I try my best to get them to see the benefits of grass-fed meats and pasture/free-range poultry. But I also understand the financial constraints that this may have. I refer many of my patients with diabetes type 1 and 2 to Richard K. Bernstein, the diabetologist who has done fantastic work with successful outcomes in this patent population. I mention these people because it is important that we all support each other in this battle against mainstream practices that are failing and/or exacerbating the problem. And I feel it is my duty to get the word out that the low-carbohydrate lifestyle is not a fad/new phenomenon; it is an excellent


Philip R. Cohen, MD,

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

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

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

Abimbola Farinde, PhD, PharmD,

is a professor at Columbia Southern University in Orange Beach, Ala.


Laura A. Foster, CRNP, FNP,

Abby A. Jacobson, MS, PA-C,

practices family medicine with Palmetto Primary Care Physicians in Charleston, S.C.

is an assistant professor at Thomas Jefferson University and a dermatology PA at Family Dermatology of Reading, Pa.

alternative to medication. And more so, the low-carbohydrate lifestyle is corroborated by well-educated and thoroughly researched individuals. I tell my patients that this research and guidance are readily available in many forms and outlets for them to access. It would be great if as a collective, farmers of grass-fed/ free-range animal stock could work with communities to help make their meats more accessible to people on limited incomes. I think most people either do not know that there are grain-free options available to them or they feel it is out of their economic reach. I do what I can to help provide my patients with local and/or online free-range/grass-fed resources, but it remains difficult. If anyone has any suggestions and or recommendations, please share. There are many more scholars and practitioners whom I wanted to mention who are doing great work in the lowcarbohydrate world, but due to time and space constraints, I limited them to a few. — CHERIEE SLOBODSKY, MPH, PA-C, Stamford, Conn. (222-1)

THE ORIGIN OF AIDS AND DEBATING THE PATIENT ZERO THEORY Worobey and colleagues describe the genetic diversity of HIV infection in the United States and use the increasing diversity to pinpoint the spread of AIDS from New York to the greater US [“HIV’s newly traced origins in US discredit Patient Zero theory,”]. Importantly, they comprehensively reject “Patient Zero” as the founding infective patient and thus correct the mistaken historical record following Shilts. Nevertheless, Worobey et al maintain that HIV entered the US via Haiti, where it arrived from Africa. There is good reason to believe the Africa-Haiti-USA historical narrative is as incorrect as the narrative around

Debra August King, PhD, PA,

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

Mary Newberry, CNM, MSN,

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

Patient Zero. The evidence suggests that HIV might have spread from the US to the rest of the world. For example, 10% to 24% of the first AIDS patients in Haiti had visited the US or Europe, but none had visited Africa. Of those who had never left Haiti, many were infected by tourists from the US and Europe. Worobey et al argue that patient H6 first brought HIV to the US in 1981, but that misses the possibility that HIV had already arrived in Haiti from the US. Throughout the world, early in the epidemic, the greatest risk factor for contracting AIDS was sexual contact with a gay man from the US. This finding was consistent among incipient AIDS populations throughout Denmark, the United Kingdom, France, West Germany, and South Africa, as well as in the Caribbean. A substantial portion of the first AIDS patients in all these locations were gay men who had homosexual contact with a man from the US, such homosexual contact occurring either inside or outside the US. In sum, the bulk of the epidemiologic evidence points to the migration of HIV from New York City throughout the US, which Worobey et al describe, but also to the rest of the world, which Worobey et al miss. — CHRIS JENNINGS, Boston (222-2)

CLINICAL PEARLS MAGNESIUM FOR PATIENTS TAKING OPIOIDS FOR PAIN Magnesium 500 mg 1 to 2 PO per day, depending on weight, helps keep a patient who is taking opioids from the need to increase his or her dosage due to tolerance. This was a clinical pearl passed on from a pain physician that seemed to work with my former patients. — KAREN DECKER BROWN, APRN-retired, Anchorage (222-3) n

Claire O’Connell, MPH, PA-C,

an associate professor at the Rutgers University Physician Assistant Program, Piscataway, N.J.


Katherine Pereira, DNP, FNP,

is assistant professor, Duke University School of Nursing, Durham, N.C.

Sherril Sego, FNP-C, DNP,

is an independent consultant in Kansas City, Mo. • THE CLINICAL ADVISOR • APRIL 2017 39

Dermatology Clinic CASE #1

Painful diamondshaped tongue lesion in elderly man HELENA A. JENKINSON, BS, AND SARAH S. PINNEY, MD

A 62-year-old white man with a past medical history of latent tuberculosis, vitiligo, and psoriasis presents for follow-up for treatment of psoriasis. The patient’s psoriasis has proven refractory to numerous treatments over the years, so he began treatment with secukinumab, a monoclonal antibody against interleukin-17A. After 2 months of therapy, the patient reports new-onset tongue pain. Physical examination demonstrates an erythematous, edematous, diamond-shaped plaque on the posterior dorsum of the patient’s tongue. What is your diagnosis? Turn to page 44.


An extremely itchy rash on the arms following yardwork ESTHER STERN, NP

A 34-year-old man presents with an itchy rash, primarily on his arms, but also, to a lesser extent, on his face. He denies any fever or malaise, and his medical history is unremarkable. He does not take any medications and notes that he spent the previous weekend doing yardwork on his property, and the rash appeared 4 days later. Physical examination reveals several linear arrangements of papulovesicles on the dorsal and ventral aspects of his forearms with surrounding erythema. What is your diagnosis? Turn to page 45. • THE CLINICAL ADVISOR • APRIL 2017 41

Dermatology Clinic CASE #1

Median rhomboid glossitis

Median rhomboid glossitis (MRG), also known as central papillary atrophy and posterior midline atrophic candidiasis, refers to well-demarcated regions of depapillation on the dorsal tongue, typically occurring midline, anterior to the foramen cecum. Although general ly asymptomatic, patients with MRG may present with pain or pruritus. MRG may also involve a similar erythematous lesion, known as a “kissing lesion,” on the overlying palate, where it comes in contact with the tongue.1 The condition was once believed to be caused by failure of the lateral processes to properly fuse over the tuberculum impar of the tongue during embryogenesis, resulting in a region prone to Candida infection. However, authors today more commonly ascribe the lesions to Candida albicans infection alone.2,3 MRG occurs in an estimated 0.01% to 1.0% of the adult population; the condition affects three times more men than women.3,4 Incidence is increased in patients with diabetes

Topical antifungal agents, such as nystatin suspensions or clotrimazole troches, may be used for treating symptomatic lesions. and those who are immunosuppressed, as well as patients on broad-spectrum antibiotics.1,3 Association of MRG with other risk factors for oral candidiasis, including smoking and use of dentures, has been disputed.1,5 The diagnosis of MRG is typically made based upon clinical appearance of lesions.2 Presence of a Candida species may be confirmed by scraping or culture, however Candida is present as part of the normal oral flora in up to 50% of people.2,4 Biopsy may be useful in cases of ambiguous morphology. Histopathology of MRG demonstrates inflammation with overlying atrophic to hypertrophic squamous epithelium, as well as loss of fungiform and filiform papillae. Candidal hyphae are frequently visible in hematoxylin and eosin stained sections, but they are typically better visualized with a fungal stain.2 Asymptomatic cases of MRG may be merely observed, with no treatment required.6 In addition to MRG, the

differential diagnosis for lesions of the tongue includes such conditions as geographic tongue, lichen planus, lingua plicata, squamous cell carcinoma, and secondary syphilis (Table).1,4,7,8 Topical antifungal agents, such as nystatin suspensions or clotrimazole troches, may be used for the treatment of symptomatic lesions.4 Persistent symptomatic lesions or those that are otherwise suspicious should be biopsied to exclude possible diagnosis of carcinoma.6 Presentation of MRG with “kissing lesions” on the overlying palate may indicate an underlying immunodeficiency and human immunodeficiency virus testing may be considered in such patients.4 Use of secukinumab, a drug approved by the US Food and Drug Administration in January 2015 for the treatment of moderate to severe plaque psoriasis, has been associated with increased frequency of Candida infections, including those Table. Differential diagnosis of tongue lesions1,4,7,8 Condition


Geographic tongue

Geographic tongue, also known as benign migratory glossitis, refers to development of smooth, erythematous lesions caused by loss of filiform papillae; such lesions may occur anywhere on the dorsum or lateral surfaces of the tongue and are often surrounded by white borders; lesions are often recurrent, and may change shape, color, and location over time

Lichen planus

Oral lichen planus may present with either "reticular" or "erosive" manifestations; reticular lichen planus presents with a white, lacy pattern of striations (Wickham striae), whereas erosive lichen planus involves erythema and ulceration of the mucosa

Lingua plicata

Lingua plicata, also known as “fissured tongue” and “scrotal tongue,” is a benign condition characterized by the presence of anteroposteriorly oriented fissures on the dorsal and lateral surfaces of the tongue

Secondary syphilis

Oral lesions of secondary syphilis may be variable in presentation, involving features such as ulcers, plaques, and pharyngitis; one characteristic lesion associated with secondary syphilis is the "mucous patch," a plaque covered by a white pseudomembrane and surrounded by erythema; mucous patches may coalesce in a linear pattern to form so-called "snail track" ulcers

Squamous cell carci- Lesions of oral squamous cell carcinoma typically noma present with regions of thickening overlying a white or erythematous base; such lesions may develop nodularity or ulceration with time


of the skin, oropharynx, and esophagus.9 Secukinumab is a human monoclonal antibody that binds to and neutralizes interleukin (IL)-17A. IL-17A is a cytokine produced by Th17 cells that promotes a neutrophil-dominant inflammatory response that is protective against numerous bacterial and fungal pathogens, including Candida albicans.10 The fact that increased activity of Th17 cells and elevated levels of IL-17A have also in recent years been linked to numerous chronic inflammatory conditions, including psoriasis, asthma, multiple sclerosis, and rheumatoid arthritis, has made it a promising target for therapies.9 The use of secukinumab is the most likely cause of development of MRG in this patient, based upon timing of lesion occurrence, the known association between the drug and Candida infection, and the lack of other known risk factors for this patient. The patient was treated with 10-mg clotrimazole troches three times daily with complete resolution after 2 to 3 weeks. Helena Jenkinson, BS, is a medical student and Sarah Pinney, MD, is an assistant dermatology professor at the McGovern Medical School of the University of Texas at Houston. References 1. Goregen M, Miloglu O, Buyukkurt MC, Caglayan F, Aktas AE. Median rhomboid glossitis: a clinical and microbiological study. Eur J Dent. 2011;5:367-372. 2. Nelson BL, Thompson L. Median rhomboid glossitis. Ear Nose Throat J. 2007;86:600-601. 3. Joseph BK, Savage NW. Tongue pathology. Clin Dermatol. 2000;18:613-618. 4. Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81:627-634. 5. Arendorf TM, Walker DM. Tobacco smoking and denture wearing as local aetiological factors in median rhomboid glossitis. Int J Oral Surg. 1984;13:411-415. 6. Mueller DT, Callanan VP. Congenital malformations of the oral cavity. Otolaryngol Clin North Am. 2007;40:141-160. 7. Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002;113:751-755. 8. Bruce AJ, Rogers RS 3rd. Oral manifestations of sexually transmitted diseases. Clin Dermatol. 2004;22:520-527. 9. Mease PJ, McInnes IB, Kirkham B, et al; FUTURE 1 Study Group. Secukinumab inhibition of interleukin-17A in patients with psoriatic arthritis. N Engl J Med. 2015;373:1329-1339. 10. Miossec P, Korn T, Kuchroo VK. Interleukin-17 and type 17 helper T cells. N Engl J Med. 2009;361:888-898.


Toxicodendron dermatitis

Toxicodendron dermatitis, also known as Rhus dermatitis, is an allergic contact dermatitis resulting from exposure to urushiol, a resin found on the Toxicodendron family of plants. The most popular of these plants include poison ivy, poison oak, and poison sumac. The acute dermatitis, a type IV delayed hypersensitivity reaction, occurs after contact with the plant oil. Unless the allergen is immediately and thoroughly rinsed off, it can spread via contact from the original area of exposure to other parts of the skin. Toxicodendron exposure is a leading cause of allergic contact dermatitis in the United States.1 It is estimated that 50% to 70% of the population is susceptible to the reaction via casual contact with the plant. Of note, urushiol is also found in mangoes,2 Japanese lacquer trees, and cashews,3 and it can cause a similar rash in sensitive patients. The rash of toxicodendron dermatitis presents with erythema, papules, vesicles, and (sometimes) bullae, most notably in a linear distribution. The linear distribution results from the patient sweeping against the plant, as well as the spread of the resin from scratching. Exposed skin, such as on the arms and legs, is most notably involved. Papules are often in seen in interdigital webbing, on the wrists, and on the backs of the fingers. However, touching contaminated fingers to the face and groin transfers the resin and causes the characteristic vesicles to appear in those areas as well. Sometimes, black dots are seen within the rash; these represent black lacquer deposits resulting from the oxidized sap binding to the stratum corneum.4 Uncommonly, if the leaves of these plants are burned and the smoke is inhaled, a systemic reaction may occur in the airways and lungs. A facial dermatitis with numerous small vesicles and swelling will likely also appear. Intense itching is usually the first reported symptom. The rash typically starts 1 to 3 days after the initial exposure, although it can be as soon as 8 hours later in highly sensitized individuals. New lesions can continue to appear up to 1 week later. Diagnosis of toxicodendron dermatitis is clinical and laboratory testing is not necessary. Patch testing for the allergen urushiol is not recommended, as it can induce a sensitivity in an otherwise nonsensitized individual. Other conditions that cause vesicles and should be considered in the differential â&#x20AC;˘ THE CLINICAL ADVISOR â&#x20AC;˘ APRIL 2017 45

Dermatology Clinic diagnosis include bullous impetigo, non–plant-contact ­dermatitis, herpes virus, shingles, and phytophotodermatitis. Avoidance of the offending plant is the best prevention. If exposure to the plant is anticipated, wearing long sleeves, long pants tucked into footwear, and vinyl gloves can effectively act as a barrier. Urushiol binds to the lipid membranes of the cells within 10 to 20 minutes. Therefore, washing the skin thoroughly with soap and water within 20 minutes of exposure can eliminate or minimize the reaction. In addition, all exposed clothing and shoes should also be washed, as the urushiol oil can remain on inanimate objects for extended periods of time. Unless contraindicated, systemic corticosteroids such as oral prednisone are the most effective treatment in severe cases. The 1-week taper standard steroid dose packs, although convenient, are not ideal, as treatment is usually required for a full 2 to 3 weeks. Shorter treatment times are associated with higher rates of relapse of the dermatitis and pruritus. In milder cases, topical medium- to highpotency corticosteroids may be sufficient. Untreated, most cases resolve spontaneously within 3 weeks. Over-the-counter calamine lotion can be soothing for many patients. Oatmeal baths and cool compresses may also provide quick short-term relief. Patients should be educated, however, to avoid antihistamine ointments and topical anesthetic ointments,5 as these have the potential for further sensitization. The patient in our case was treated with 60 mg of prednisone daily for 1 week, followed by 40 mg daily for 1 week, and finally 20 mg daily for 1 week. At the 4-week follow-up, he reported complete resolution of the rash and resolution of the itching with no signs of recurrence. n Esther Stern, NP, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J. References 1. Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 4th ed. Philadelphia, PA: Elsevier Saunders; 2011. 2. Catalano PN. Mango sap and poison ivy dermatitis. J Am Acad Dermatol. 1984;10:522. 3. Marks JG Jr, DeMelfi T, McCarthy MA, et al. Dermatitis from cashew nuts. J Am Acad Dermatol. 1984;10:627-631. 4. Mallory SB, Miller OF, Tyler WB. Toxicodendron radicans ­dermatitis with black lacquer deposit on the skin. J Am Acad Dermatol. 1982;6:363-368. 5. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, PA: Saunders-Elsevier; 2011.

“That was my first husband — he was a louse.”


Top, middle: © The New Yorker Collection 2017 from All Rights Reserved. Bottom: © Harley Schwadron

“Ninety-six kids? Well, you look amazing.”

Dermatologic Look-Alikes Pruritic patches and plaques AARON FONG, BA, AND RANA MAYS, MD



A 32-year-old woman presents with what a primary care physician believed was a “fungal infection” on both knees. The infection had been present there for 3 months. She denies any other affected areas; however, she admits to having had a similar rash in the past, behind her knees and on her arms. She has been treating the area with over-the-counter antifungal creams twice daily with little improvement. Her past medical history is significant for insulin-dependent diabetes and possible eczema as a child, for which she was treated with topical steroids. She denies any new medications or product changes in her skin care routine. She admits to having overly dry skin in the past few months and significant pruritus with the lesions.

A 63-year-old man presents with an itchy intermittent rash on his chest and back for several months. Of note, he has a history of eczema in the past that was treated with topical steroids. He admits to recent increased sun exposure and several changes in medications, including the initiation of metformin for newly diagnosed type 2 diabetes. In addition to the diabetes, his medical history is significant for hypertension, hyperlipidemia, and hypothyroidism. The patient says that the current rash has worsened. He has been self-treating with diphenhydramine and over-the-counter calamine lotion. On examination, the patient is found to have scaly, thin, erythematous patches and plaques. • THE CLINICAL ADVISOR • APRIL 2017 47

Dermatologic Look-Alikes CASE #1

Atopic dermatitis

Atopic dermatitis (eczema) is a chronic, pruritic condition primarily affecting infants and children. The hallmark manifestation of atopic dermatitis is dry skin and pruritus, but it can present in many ways depending on the patientâ&#x20AC;&#x2122;s age and the duration of the disease. In acute atopic dermatitis, erythematous vesicles and papules with exudates and crusting are present. Patients with subacute and chronic eczema present with dry and scaly papules with overlying excoriations. Skin thickening with hyperlinearity (lichenification) due to scratching is commonly seen in chronic cases. Postinflammatory hyperpigmentation or hypopigmentation can also be seen. Lesions at different stages of healing and acuity are often seen at the same time. The distribution of lesions is commonly seen in the flexural surfaces of the extremities. In infants, the rash typically occurs on the face, scalp, and torso. The cause of atopic dermatitis is still not fully understood, although a number of genetic and environmental factors have been identified. Loss of function mutations in the filaggrin gene (FLG) causes a defect in the skin barrier and is associated with a high risk of atopic dermatitis.1,2 Serine protease inhibitor Kazal-type 5 (SPINK5), a gene that encodes for a protease responsible for proper filaggrin formation, has also been associated with increased risk of eczema.3 Other loci, including 5q31 (KIF3A), 11q13 (OVOL1), and 19p13 (ADAMTS10/ACTL9), have also been associated with increased risk of atopic dermatitis.4 Family history of atopic diseases (eczema, asthma, and allergic rhinitis) is a major risk factor of atopic dermatitis. Family history of atopy is positive in approximately 70% of patients who develop atopic dermatitis. This risk increases if one or both parents have a history of atopy.5 Increased immunoglobulin E (IgE) levels are found in about 80% of patients with atopic dermatitis. Levels tend to increase with increased disease severity, but some patients with severe eczema can have normal serum levels of IgE.6 Atopic dermatitis affects approximately 11% of children in the United States.7 However, the incidence of atopic dermatitis has increased over the past 20 years internationally.8 In adults, data on prevalence are limited, but it affects less than 1% of adults.5 Most cases of atopic dermatitis start before age 5 years,

and 85% of cases begin before age 1 year. Data also suggest a slightly higher prevalence in girls and women (1.3:1 ratio).9 Common complications are secondary infections due to bacteria or viruses. Patients with atopic dermatitis are more susceptible to infections due to a defective skin barrier. Impetigo, or superinfections of lesions by Staphylococcus aureus, is common, as most patients are colonized. Secondary infection by herpes simplex virus, also called eczema herpeticum, is a rarer complication, occurring in less than 3% of patients with atopic dermatitis.10 Differential diagnosis for atopic dermatitis includes contact dermatitis, seborrheic dermatitis, and psoriasis. Distribution and shape of lesions, along with a careful patient history, can help differentiate atopic dermatitis from contact dermatitis. Clinicians should ask patients about any new products they may be using, or exposure to other common irritants such as poison ivy. Seborrheic dermatitis is differentiated from eczema by its characteristic greasy scale, as well as its distribution, which is commonly on the scalp, nose, chin, and forehead. Psoriasis can resemble atopic dermatitis but is commonly found on extensor surfaces, such as elbows and

The differential diagnosis for atopic dermatitis includes contact dermatitis, seborrheic dermatitis, and psoriasis. knees, compared with atopic dermatitis, which appears on the flexural surfaces. Silvery scale is also characteristic of psoriasis. Mycosis fungoides can also be considered in cases in which atopic dermatitis does not respond to treatment. Treatment of atopic dermatitis depends on the severity and chronicity of the disease. Goals primarily aim to manage symptoms of pruritus, prevent outbreaks and exacerbations, and reduce therapeutic side effects. All patients should avoid triggers and factors that worsen or exacerbate the disease. Some exacerbating factors include xerosis (dry skin), long, hot baths, high stress, and low humidity.11 In patients with mild to moderate disease, emollients and low- to mid-potency topical steroids are the cornerstones of treatment. The strength of steroid should be chosen based on severity, age of the patient, and body surface area involvement. Mid- to high-potency corticosteroids should be avoided on the face, axilla, and groin due to lower skin thickness in those regions. Emollients should be used liberally to retain moisture.12

48 THE CLINICAL ADVISOR â&#x20AC;˘ APRIL 2017 â&#x20AC;˘

Topical calcineurin inhibitors, such as tacrolimus ointment, are a good option to consider when there is concern about skin atrophy or other side effects of corticosteroids. In acute exacerbations, short-term use of oral prednisone can sometimes reduce the duration of or abort these exacerbations. Topical antibiotics are used for patients with impetiginization. In cases of severe atopic dermatitis refractory to topical treatment, ultraviolet (UV) light therapy is helpful in adults. Psoralen plus UVA (PUVA) radiation, broadband UVA, broadband UVB, combined UVA and UVB, narrow-band UVB, and UVA1 have all been used with varying levels of success.13-16 In our case, treatment with triamcinolone 0.1% ointment, applied twice daily to the affected areas, was initiated for atopic dermatitis. In 2 weeks, the lesions resolved with subsequent mild postinflammatory hyperpigmentation.


Dermal hypersensitivity

Dermal hypersensitivity, also known as urticarial dermatitis, hypersensitivity dermatitis, or hypersensitivity urticarial reaction, is an extremely pruritic, chronic rash that resembles urticaria but lasts longer than 24 hours. It is characterized by erythematous papules that coalesce into plaques. Areas can appear urticarial or eczematous. The epidemiology of dermal hypersensitivity is not fully known. It appears to be more prevalent in patients aged

50 years or older. There have been more reported cases in girls and women than in boys and men.17 The differential diagnosis includes scabies, allergic contact dermatitis, drug hypersensitivity reaction, and prodromal bullous pemphigoid. The diagnosis is often of exclusion because the rash is usually nonspecific. A careful medical history and list of medications from the patient is important to rule out contact dermatitis and drug reactions. In the early stages of bullous pemphigoid, lesions can appear urticarial, resembling dermal hypersensitivity. These lesions last several weeks or even months. Distinguishing features of prodromal bullous pemphigoid from urticarial dermatitis are the presence of vesicles and eosinophilic spongiosis on histology. Histologically, bullous pemphigoid typically has eosinophilic spongiosis with a deeper dermal perivascular lymphocytic and eosinophilic infiltrate in comparison with dermal hypersensitivity. Direct immunofluorescence and serologic testing for basement membrane antigens BP180 and BP230 can confirm the diagnosis of bullous pemphigoid.18 Scabies can be confused with dermal hypersensitivity due to similar clinical and histologic presentations. Both are intensely pruritic, with scattered erythematous papules and plaques. Scabies is characterized more by significant scaling, as well as involvement of the hands, feet, and genitalia (in boys and men). Histologically, dermal hypersensitivity is a commonly used dermatopathology term. It is characterized pathologically by perivascular lymphocytic infiltrates with eosinophils in papillary and upper reticular dermis. There is usually no to minimal epidermal involvement, with occasional spongiosis. First-line treatment for dermal hypersensitivity includes topical corticosteroids and antihistamines. Ultraviolet

Comparison of atopic dermatitis and dermal hypersensitivity Atopic dermatitis

Dermal hypersensitivity

Dermatologic presentation

Thickened, scaly, erythematous papules and plaques

Erythematous papules and plaques resembling urticarial


Atopy, elevated immunoglobulin E, family history, filaggrin mutation




Characteristic locations

Antecubital fossa, popliteal fossa, face, neck, extremities

Trunk, extremities; spares palms, soles, face


Clinical, based on history and physical examination

Diagnosis of exclusion; rule out drug reaction, scabies, contact dermatitis


Topical steroids, antihistamines, tacrolimus

Topical steroids and antihistamines often ineffective; consider systemic corticosteroids and immunosuppressive agents such as mycophenolate or azathioprine â&#x20AC;˘ THE CLINICAL ADVISOR â&#x20AC;˘ APRIL 2017 49

Dermatologic Look-Alikes (UV) B phototherapy is another option for more severe or refractory cases. However, many cases are refractory to these initial treatment modalities. Systemic corticosteroids or other immunosuppressive agents, such as mycophenolate, have been beneficial in these cases.19 In our patient, we performed a 4-mm punch biopsy, which was consistent with a dermal hypersensitivity reaction. The patient was instructed to take hydroxyzine, 25 mg at bedtime, and to apply clobetasol 0.05% ointment twice daily to affected areas. After 2 weeks of this treatment, the lesions had improved significantly. ■

11. Ellis C, Luger T, Abeck D, et al; ICCAD II Faculty. International Consensus Conference on Atopic Dermatitis II (ICCAD II): clinical update and current treatment strategies. Br J Dermatol. 2003;148(suppl 63):3-10. 12. Sidbury R, Davis DM, Cohen DE, et al; American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71:327-349. 13. Jekler J, Larkö O. Combined UVA-UVB versus UVB phototherapy for atopic dermatitis: a paired-comparison study. J Am Acad Dermatol. 1990;22:49-53. 14. Reynolds NJ, Franklin V, Gray JC, Diffey BL, Farr PM. Narrow-band

Aaron Fong, BA, is a medical student and Rana Mays, MD, is a dermatology resident at Baylor College of Medicine in Houston.

ultraviolet B and broad-band ultraviolet A phototherapy in adult atopic eczema: a randomised controlled trial. 3. 2001;357:2012-2016. 15. Taylor K, Swan DJ, Affleck A, Flohr C, Reynolds NJ; UK TREND


and UK DCTN. Treatment of moderate-to-severe atopic eczema

1. Sandilands A, Sutherland C, Irvine AD, McLean WH. Filaggrin in

in adults within the UK: results of a national survey of dermatologists.

the frontline: role in skin barrier function and disease. J Cell Sci.

Br J Dermatol. 2016 Dec 11. doi: 10.1111/bjd.15235 [Epub ahead of print]

2009;122(Pt 9):1285-1294.

16. Fernández-Guarino M, Aboin-Gonzalez S, Barchino L, Velazquez D,

2. Kypriotou M, Huber M, Hohl D. The human epidermal differentiation

Arsuaga C, Lázaro P. Treatment of moderate and severe adult

complex: cornified envelope precursors, S100 proteins and the ‘fused

chronic atopic dermatitis with narrow-band UVB and the combina-

genes’ family. Exp Dermatol. 2012;21:643-649.

tion of narrow-band UVB/UVA phototherapy. Dermatol Ther.

3. Zhao LP, Di Z, Zhang L, et al. Association of SPINK5 gene polymor-


phisms with atopic dermatitis in northeast china. J Eur Acad Dermatol

17. Banan P, Butler G, Wu J. Retrospective chart review in a cohort of

Venereol. 2012;26:572-577.

patients with urticarial dermatitis. Australas J Dermatol. 2014;55:137-139.

4. Paternoster L, Standl M, Chen CM, et al. Meta-analysis of genome-wide

18. Fung MA. The clinical and histopathologic spectrum of “dermal

association studies identifies three new risk loci for atopic dermatitis.

hypersensitivity reactions,” a nonspecific histologic diagnosis that is

Nat Genet. 2011;44:187-192.

not very useful in clinical practice, and the concept of a “dermal

5. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the

hypersensitivity reaction pattern”. J Am Acad Dermatol. 2002;47:898-907.

management of atopic dermatitis: section 1. Diagnosis and assessment of

19. Kossard S, Hamann I, Wilkinson B. Defining urticarial dermatitis:

atopic dermatitis. J Am Acad Dermatol. 2014;70:338-351.

a subset of dermal hypersensitivity reaction pattern. Arch Dermatol.

6. Dhar S, Malakar R, Chattopadhyay S, Dhar S, Banerjee R, Ghosh A.


Correlation of the severity of atopic dermatitis with absolute eosinophil counts in peripheral blood and serum IgE levels. Indian J Dermatol Venereol Leprol. 2005;71:246-249. 7. Shaw TE, Currie GP, Koudelka CW, Simpson EL. Eczema prevalence in the united states: data from the 2003 National Survey of Children’s Health. J Invest Dermatol. 2011;131:67-73. 8. Deckers IA, McLean S, Linssen S, Mommers M, van Schayck CP, Sheikh A. Investigating international time trends in the incidence and prevalence of atopic eczema 1990-2010: a systematic review of epidemiological studies. PLoS One. 2012;7:e39803. 9. Mortz CG, Andersen KE, Dellgren C, Barington T, Bindslev-Jensen C.

Do you have a

Clinical Pearl

that you would like to share with your colleagues?

Atopic dermatitis from adolescence to adulthood in the TOACS cohort: prevalence, persistence, and comorbidities. Allergy. 2015;70:836-845. 10. Leung DY. Why is eczema herpeticum unexpectedly rare? Antiviral Res. 2013;98:153-157.


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A suspicious mole


A clinician’s failure to follow up on a patient’s mole results in a delayed diagnosis of cancer.


Mr N, aged 42 years, was a nurse practitioner who worked in a small primary care practice with two physicians and a physician assistant. When he started with the practice, five years earlier, he only saw existing patients of the physicians. However, over the last two years, and with the support of his supervising physician, he had been seeing his own patients and patients new to the practice. One such patient was Mr P, aged 34 years. The patient had recently moved to town and had picked Mr N’s practice to provide his primary care. His first appointment was in January, when he saw Mr N for his first regular checkup. The patient had not been seen for a regular physical examination in several years. “You know how it is,” he said to Mr N. “I’ve been so busy with work, and then they relocated me here. My wife and I had to get our new place set up, and we have a toddler, so everything takes longer than you expect….  Anyway … we’re hoping to try for another baby soon and my wife said I really needed to find a local healthcare provider … so here I am.”

Melanoma is treatable and has a high survival rate. However, once it metastasizes to other areas of the body, patients’ survival rate declines.

Mr P was fit and athletic. He told Mr N that he stayed in shape by playing tennis and running. His blood pressure was normal. He denied smoking cigarettes or using recreational drugs, and he said he only drank socially on weekends. The patient was in good health, and both his parents were alive. At the end of the exam, Mr N asked the patient if he had any questions. “Well, yes,” the patient said. “I’ve got this little mole on the back of my calf that I’ve had for as long as I can remember, but I noticed that it seems to be changing. I’ve read that it’s important to tell your healthcare provider if you see something like that.” “You’re absolutely right,” said Mr. N, as he bent to examine the small mole. “But I don’t think you have to worry about this one. I’m not concerned about it. But if the appearance bothers you, I recommend you return in 6 months and 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. • THE CLINICAL ADVISOR • APRIL 2017 51

LEGAL ADVISOR we can remove it for cosmetic reasons.” Mr N noted in the patient’s file that the mole was about 1 cm × 1 cm in size, and that it appeared to be a hemangioma or dermatofibroma, which are both benign. The patient thanked him and left the office. Over the next 5 months, the mole on the patient’s calf continued to change, and he came into the practice to have it looked at again. Mr N was off that day, and the patient saw one of the physicians instead. The physician, upon seeing the mole, immediately sent the patient to a surgeon for a consultation and biopsy. The surgeon removed the mole and sent it for analysis, which revealed ulcerating melanoma with downward growth, Clark Level IV. The following month, wide excision and lymph node dissection were performed revealing clear margins and no involvement of lymph nodes.

About 2.1% of men and women will be diagnosed with melanoma at some point in their lifetime, according to the NCI. The patient came in for follow-up visits every 4 months, however 18 months after removal of the mole, a mass was found in his liver. The mass was biopsied and diagnosed to be metastatic spread of the melanoma. The patient died 2 months later, at the age of 36. He left behind a pregnant wife and 3-year-old daughter. Mr P’s son was born 2 months after his death. Mr P’s devastated widow sought the counsel of a plaintiff’s attorney. “If that first practitioner had only taken my husband’s mole seriously, maybe he would be alive today,” she said tearfully. The attorney took on the case and filed a wrongful death lawsuit against Mr N and his practice, alleging that Mr N’s failure to biopsy the suspicious mole resulted in a delayed diagnosis of malignant melanoma causing the patient’s death. Mr N and his practice were informed of the lawsuit and met with their own defense attorney provided by their medical malpractice insurance. Over the next several months, the plaintiff’s attorney retained several experts who were prepared to testify that the standard of care required a biopsy or referral to a surgeon for evaluation of any atypical lesion and that recommending a 6-month wait was substandard and allowed × lesion to progress and continue its downward growth, thereby negatively affecting the patient’s prognosis and chance of a cure. Meanwhile, the defense attorney’s experts were preparing to testify that it was within the accepted standard of care to

watch a lesion for 6 months to see if the appearance changed, since it did not have the appearance of a melanoma when it was first examined. The defense experts were also prepared to testify that the melanoma had already metastasized at the time that Mr N examined the patient and that a diagnosis at that time would not have changed the unfortunate outcome. A month prior to trial, the case settled out of court for $1 million. Legal background

It may seem odd that the defense experts were preparing two defenses that almost seemed contradictory, but it is quite common. The defense’s argument here was 1) we did not do anything wrong (because it was within the standard of care to monitor this mole for 6 months since it did not appear to be melanoma), and 2) even assuming we should have sent the patient for a biopsy when he first came into the office, that would not have changed the final outcome because the melanoma had already metastasized by then and an earlier diagnosis would not have made a difference. Frequently, defense attorneys offer multiple defenses, which in some cases may seem to conflict—as in “We didn’t do anything wrong, but even if we did, it wouldn’t have changed the outcome.” The reason is that without the element of causation—showing that an act or omission by the healthcare provider resulted in the bad outcome for the patient—a medical malpractice case will fail. So defense attorneys often will add the defense of “it was already too late,” as they intended to do in this case. Protecting yourself

If a patient self-reports a mole that has changed appearance, it is wise to refer the patient for a biopsy or to a surgeon or dermatologist for further workup. Assuming that, because a patient is young and healthy, it is unlikely to be melanoma is a very dangerous and mistaken assumption. According to the National Cancer Institute, approximately 2.1% of men and women will be diagnosed with melanoma at some time in their lifetime. In 2016, there were more than 76,000 new cases of melanoma reported. Melanoma is more common in white men than any other group. While localized melanoma is very treatable and has a high survival rate, once it has metastasized to other areas of the body, the survival rate drops dramatically. Having a skin lesion examined early offers the best chance of avoiding a bad outcome, for your patient and yourself. n Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.


Clinical Challenge An unusual pelvic mass in a 43-year-old woman SHERRIL SEGO, FNP-C, DNP

A woman who is in generally good health presents with a visibly enlarged abdomen with left-sided dominance and increased pelvic pressure that had worsened.

Sally presented to her primary care provider with a complaint of increased girth and pelvic pressure that had worsened during the previous 3 months.


HISTORY Sally, a 43-year-old Caucasian, was in generally good health. She had successfully quit smoking about 2 years before her visit after a 30 pack-year history and currently worked full time as a massage therapist. Her history was significant for a lumbar laminectomy 15 years ago and a recent laparoscopic umbilical hernia repair. She had given birth to 2 children by uncomplicated vaginal deliveries 15 and 18 years ago. She was taking no medications and had no known allergies. Since her laparoscopic hernia repair, Sally continued to complain of feeling bloated. She also had begun noticing constipation, which was an unusual problem for her. She denied pain but stated that her abdomen just felt “uncomfortable.” At the same time, she had found that several pairs of her jeans and slacks were too tight around her abdomen, and she had an increased sensation of pelvic pressure, along with urinary frequency. Sally still had regular menses and was sexually active with her husband, but she had a bilateral tubal ligation after her last child was born. She was current on her cervical cancer screenings with no history of atypia. Her symptoms became so pervasive and interfering with her daily life that she sought care from her primary care provider.


Ultrasound revealed a 14-cm round, smooth, solid, nonseptate mass.

Sally presented to the office in apparently perfect health. Her skin was clear and supple, with no blemishes or rash. Her hair was soft, shiny, and without breakage or signs of hair loss. Neurologically, her gait was normal, her speech was intact and appropriate, and her pupils were equal, round, and reactive to light. A heart examination was normal with a pulse of 79 beats per minute in a normal sinus rhythm without • THE CLINICAL ADVISOR • APRIL 2017 53

Clinical Challenge murmurs. Her lungs were clear with a respiratory rate of 18 breaths per minute. Her blood pressure was 128/60 mm Hg, and her weight was 167 pounds. On examination, her abdomen was visibly enlarged with an obvious left-sided dominance. A bimanual pelvic examination further revealed a large, smooth, left lower quadrant adnexal enlargement. The mass was nontender, firm, and not ballotable. No notation of cervical motion tenderness or discharge was observed. A rectovaginal examination confirmed these findings.

LABORATORY TESTS AND IMAGING An ultrasound was subsequently obtained with external and transvaginal views. That report revealed a 14-cm round, smooth, solid, nonseptate mass that totally obscured the left ovary. A noncontrast CT scan did not show any other irregularity or invasive growth such as increased vascularization or adenopathy. Her laboratory workup showed a normal complete blood count with differential. The CA-125 (cancer antigen), which is a protein believed to be a tumor biomarker found in greater concentration in tumor cells than in other cells of the body, was 15 U/mL, which was within normal limits (0 to 35 U/mL). Vaginal swab cultures were negative for sexually transmitted infections. Her ECG and chest X-ray were also normal.

TREATMENT COURSE AND DEFINITIVE DIAGNOSIS Sally was subsequently scheduled for surgical removal of the large ovarian mass. Dermoid cysts are often removed laparoscopically, but due to the size of this mass, an open procedure was required using a Pfannenstiel incision. A 14.2cm, 502-gram smooth growth was removed and sent intact to pathology. Pathologic examination revealed clumping fragments of hair and teeth surrounded by a large amount of mucoid tissue that was diagnostic of a teratoma, or dermoid cyst. Microscopic examination of multiple tissue fragments verified that the mass was negative for any malignancy. Final pathology diagnosis was a cystic teratoma, also known as a dermoid cyst or germ cell tumor.

DISCUSSION Clinical feature and epidemiology. Given Sally’s age and otherwise unremarkable history, the differential diagnosis of any pelvic mass includes endometrioma, tubo-ovarian abscess, pedunculated uterine fibroid, hydrosalpinx, ectopic pregnancy, renal pelvic cyst, and peritoneal cyst.

Any such adnexal mass requires definitive evaluation. Often, the speed of onset, level of pain, and vital signs direct the initial workup. The following masses pose the most concern: • Those that have a complex internal structure on imaging • Those that have solid components • Those that are associated with pain • Masses in prepubescent or postmenopausal women • Large cysts, typically defined as those unilocular cysts greater than 10 cm, have been monitored with the watchful waiting approach. Any complex cyst in a postmenopausal woman should be regarded with increased suspicion, regardless of size. Cystic teratoma is the most common ovarian tumor, accounting for up 10% to 20% of all ovarian tumors.1 These most frequently occur in females aged 15 to 40 years, which are the primary reproductive years.2 Of special note, at least 50% of cancerous adnexal neoplasms in adolescent females are mature cystic teratomas that become malignant.3 A dermoid cyst of the ovaries develops from a totipotential cell, which is a primary oocyte that retains the capability to form all kinds of body tissues. A dermoid cyst is so-named because it has cell walls that are the same as those of the outer skin. These encapsulated tumors are frequently composed of complex structures formed from 1 or more of the 3 germ cell dermal layers. They may be organized with welldifferentiated ecto- and meso-dermal tissues surrounding endodermal structures or very disorganized. They may also comprise tissues normally present in layers of skin, including hair follicles, sebaceous or skin oil, and sweat glands. These tissues and glands continue to secrete their normal substances, which collect inside the cyst, causing it to enlarge and grow. Consequently, structures such as hair, teeth, or bones may be found inside these cysts. Smaller teratomas are often found incidentally during routine pelvic examinations. Because of the often bizarre appearance of the contents of these cysts, their name, teratoma, is derived from the Greek “teras,” meaning monster. Although typically unilateral, documentation of bilaterally occurring tumors indicates an 8% to 14% occurrence. The overall course of discovery and removal of these tumors is usually uneventful. Even in the rare cases of malignant transformation, surgical resection alone has usually been proven to be successful in disease eradication due to their encapsulated structure.3 Complications. The main complication arising from an ovarian dermoid cyst, occurring in 3% to 11% of patients, is torsion.4 Though somewhat counterintuitive, statistics show that the risk of torsion increases with the size of the structure. Spontaneous rupture is also a potentially life-threatening complication with a reported incidence of 1% to 2.5%. Rupture,


by nature, occurs abruptly and leads to hemorrhagic shock and peritonitis. Although these tumors are usually benign, they can undergo transformation to malignancy. This is most common in tumors with predominantly squamous components and is only found in 0.2 to 2.0% of cases. When the dermoid cyst is malignant, a squamous cell carcinoma is the usual cell type.

CONCLUSION AND FOLLOW-UP Sally had an uneventful postoperative course with complete recovery in 6 weeks. Her nagging discomfort and complaints of abdominal enlargement and change in bowel habits were completely resolved. She was released to return to her normal lifestyle following her surgical discharge. ■ Sherril Sego, FNP-C, DNP, is an independent consultant in Kansas City, Mo.

“Short day at school. The computers are down.”

References 1. Hamilton CA. (2012). Cystic teratoma. Available at: http://emedicine. 2. Kim MJ, Kim NY, Lee DY, Yoon BK, Choi D. Clinical characteristics of ovarian teratoma: Age-focused retrospective analysis of 580 cases. Am J Obstet Gynecol. 2011;205(1):32.e1-4. with malignant transformation: experiences of the cooperative GPOH protocols MAKEI 83/86/89/96. Klin Padiatr. 2006;218(6):303-308. 4. Benjapibal M, Boriboonhirunsarn D, Suphanit I, Sangkarat S. Benign cystic teratoma of the ovary: a review of 608 patients. J Med Assoc Thai. 2000;83(9):1016-1020.

The Clinical Advisor

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“Follow the colorfully decorated eggs.” • THE CLINICAL ADVISOR • APRIL 2017 55

Top, bottom: © The New Yorker Collection 2017 from All Rights Reserved. Center: © Harley Schwadron

3. Biskup W, Calaminus G, Schneider DT, Leuschner I, Göbel U. Teratoma

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