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Vascular occlusion management
The time course and proper management of vascular occlusion attributable to interarterial hyaluronic acid fillers is critical. Albeit a rare complication, off-label uses of HA fillers, lack of proper training of injectors, and lack of clear appropriate guidelines in the management of these complications are some of the causes of delayed treatment and necrotic complications.
There are currently no definitive guidelines for the management of filler-associated cutaneous necrosis as experience with its treatment continues to evolve and be reported. In an attempt to consolidate the published data, as well as to give somewhat of a clear guideline of expectations, a time course and treatment guide has been outlined. The following is a working guideline for management of vascular occlusion attributable to HA fillers based on reports in the literature. This is not a consensus statement, rather it is a consolidation of the anecdotal reports and case studies outlined to help practitioners. It is also not inclusive of all the presentations of vascular occlusion. There are delayed cases of vascular occlusion beginning several days after injection, as well as alternative treatment options that may be considered.
These guidelines also are not for the devastating complication of blindness because of vascular occlusion secondary to fillers. Blindness is beyond the scope of the current article; however, we believe all experienced injectors should have emergency preparations in place and a relationship with an ophthalmologist or other trained surgeons experienced in performing retrobulbar hyaluronidase injections who can be reached in the event of a suspected occlusion. Any symptoms of eye pain, headache, or visual changes need to be immediately treated. Vascular occlusion is an emergency and timing is critical to prevent permanent blindness and facial deformities.
As with all filler injections, risks and complications can happen, and we cannot stress enough the appropriate level of training, as well as expert understanding of anatomy and injection technique, in minimizing potential risks. We encourage regulations and a required level of training to perform these procedures.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
The time course and proper management of vascular occlusion attributable to interarterial hyaluronic acid fillers is critical. Albeit a rare complication, off-label uses of HA fillers, lack of proper training of injectors, and lack of clear appropriate guidelines in the management of these complications are some of the causes of delayed treatment and necrotic complications.
There are currently no definitive guidelines for the management of filler-associated cutaneous necrosis as experience with its treatment continues to evolve and be reported. In an attempt to consolidate the published data, as well as to give somewhat of a clear guideline of expectations, a time course and treatment guide has been outlined. The following is a working guideline for management of vascular occlusion attributable to HA fillers based on reports in the literature. This is not a consensus statement, rather it is a consolidation of the anecdotal reports and case studies outlined to help practitioners. It is also not inclusive of all the presentations of vascular occlusion. There are delayed cases of vascular occlusion beginning several days after injection, as well as alternative treatment options that may be considered.
These guidelines also are not for the devastating complication of blindness because of vascular occlusion secondary to fillers. Blindness is beyond the scope of the current article; however, we believe all experienced injectors should have emergency preparations in place and a relationship with an ophthalmologist or other trained surgeons experienced in performing retrobulbar hyaluronidase injections who can be reached in the event of a suspected occlusion. Any symptoms of eye pain, headache, or visual changes need to be immediately treated. Vascular occlusion is an emergency and timing is critical to prevent permanent blindness and facial deformities.
As with all filler injections, risks and complications can happen, and we cannot stress enough the appropriate level of training, as well as expert understanding of anatomy and injection technique, in minimizing potential risks. We encourage regulations and a required level of training to perform these procedures.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
The time course and proper management of vascular occlusion attributable to interarterial hyaluronic acid fillers is critical. Albeit a rare complication, off-label uses of HA fillers, lack of proper training of injectors, and lack of clear appropriate guidelines in the management of these complications are some of the causes of delayed treatment and necrotic complications.
There are currently no definitive guidelines for the management of filler-associated cutaneous necrosis as experience with its treatment continues to evolve and be reported. In an attempt to consolidate the published data, as well as to give somewhat of a clear guideline of expectations, a time course and treatment guide has been outlined. The following is a working guideline for management of vascular occlusion attributable to HA fillers based on reports in the literature. This is not a consensus statement, rather it is a consolidation of the anecdotal reports and case studies outlined to help practitioners. It is also not inclusive of all the presentations of vascular occlusion. There are delayed cases of vascular occlusion beginning several days after injection, as well as alternative treatment options that may be considered.
These guidelines also are not for the devastating complication of blindness because of vascular occlusion secondary to fillers. Blindness is beyond the scope of the current article; however, we believe all experienced injectors should have emergency preparations in place and a relationship with an ophthalmologist or other trained surgeons experienced in performing retrobulbar hyaluronidase injections who can be reached in the event of a suspected occlusion. Any symptoms of eye pain, headache, or visual changes need to be immediately treated. Vascular occlusion is an emergency and timing is critical to prevent permanent blindness and facial deformities.
As with all filler injections, risks and complications can happen, and we cannot stress enough the appropriate level of training, as well as expert understanding of anatomy and injection technique, in minimizing potential risks. We encourage regulations and a required level of training to perform these procedures.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
My inspiration
Kobe Bryant knew me. Not personally, of course. I never received an autograph or shook his hand. But once in a while if I was up early enough, I’d run into Kobe at the gym in Newport Beach where he and I both worked out. As he did for all his fans at the gym, he’d make eye contact with me and nod hello. He was always focused on his workout – working with a trainer, never with headphones on. In person, he appeared enormous. Unlike most retired professional athletes, he still was in great shape. No doubt he could have suited up in purple and gold, and played against the Clippers that night if needed.
Being from New England, I never was a Laker fan. But I thought, if Kobe can head to the gym after midnight and take a 1,000 shots to prepare for a game, then I could set my alarm for 4 a.m. and take a few dozen more questions from my First Aid books. Head down, “Kryptonite” cranked on my iPod, I wasn’t going to let anyone in that test room outwork me. Neither did he. I put in the time and, like Kobe in the 2002 conference finals against Sacramento, I crushed it.*
When we moved to California, I followed Kobe and the Lakers until he retired. To be clear, I didn’t aspire to be like him, firstly because I’m slightly shorter than Michael Bloomberg, but also because although accomplished, Kobe made some poor choices at times. Indeed, it seems he might have been kinder and more considerate when he was at the top. But in his retirement he looked to be toiling to make reparations, refocusing his prodigious energy and talent for the benefit of others rather than for just for scoring 81 points. His Rolls Royce was there before mine at the gym, and I was there early. He was still getting up early and now preparing to be a great venture capitalist, podcaster, author, and father to his girls.
Watching him carry kettle bells across the floor one morning, I wondered, do people like Kobe Bryant look to others for inspiration? Or are they are born with an endless supply of it? For me, I seemed to push harder and faster when watching idols pass by. Whether it was Kobe or Clayton Christensen (author of “The Innovator’s Dilemma”), Joe Jorizzo, or Barack Obama, I found I could do just a bit more if I had them in mind.
On game days, Kobe spoke of arriving at the arena early, long before anyone. He would use the silent, solo time to reflect on what he needed to do perform that night. I tried this last week, arriving at our clinic early, before any patients or staff. I turned the lights on and took a few minutes to think about what we needed to accomplish that day. I previewed patients on my schedule, searched Up to Date for the latest recommendations on a difficult case. I didn’t know Kobe, but I felt like I did.
When I received the text that Kobe Bryant had died, I was actually working on this column. So I decided to change the topic to write about people who inspire me, ironically inspired by him again. May he rest in peace.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
*This article was updated 2/19/2020.
Kobe Bryant knew me. Not personally, of course. I never received an autograph or shook his hand. But once in a while if I was up early enough, I’d run into Kobe at the gym in Newport Beach where he and I both worked out. As he did for all his fans at the gym, he’d make eye contact with me and nod hello. He was always focused on his workout – working with a trainer, never with headphones on. In person, he appeared enormous. Unlike most retired professional athletes, he still was in great shape. No doubt he could have suited up in purple and gold, and played against the Clippers that night if needed.
Being from New England, I never was a Laker fan. But I thought, if Kobe can head to the gym after midnight and take a 1,000 shots to prepare for a game, then I could set my alarm for 4 a.m. and take a few dozen more questions from my First Aid books. Head down, “Kryptonite” cranked on my iPod, I wasn’t going to let anyone in that test room outwork me. Neither did he. I put in the time and, like Kobe in the 2002 conference finals against Sacramento, I crushed it.*
When we moved to California, I followed Kobe and the Lakers until he retired. To be clear, I didn’t aspire to be like him, firstly because I’m slightly shorter than Michael Bloomberg, but also because although accomplished, Kobe made some poor choices at times. Indeed, it seems he might have been kinder and more considerate when he was at the top. But in his retirement he looked to be toiling to make reparations, refocusing his prodigious energy and talent for the benefit of others rather than for just for scoring 81 points. His Rolls Royce was there before mine at the gym, and I was there early. He was still getting up early and now preparing to be a great venture capitalist, podcaster, author, and father to his girls.
Watching him carry kettle bells across the floor one morning, I wondered, do people like Kobe Bryant look to others for inspiration? Or are they are born with an endless supply of it? For me, I seemed to push harder and faster when watching idols pass by. Whether it was Kobe or Clayton Christensen (author of “The Innovator’s Dilemma”), Joe Jorizzo, or Barack Obama, I found I could do just a bit more if I had them in mind.
On game days, Kobe spoke of arriving at the arena early, long before anyone. He would use the silent, solo time to reflect on what he needed to do perform that night. I tried this last week, arriving at our clinic early, before any patients or staff. I turned the lights on and took a few minutes to think about what we needed to accomplish that day. I previewed patients on my schedule, searched Up to Date for the latest recommendations on a difficult case. I didn’t know Kobe, but I felt like I did.
When I received the text that Kobe Bryant had died, I was actually working on this column. So I decided to change the topic to write about people who inspire me, ironically inspired by him again. May he rest in peace.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
*This article was updated 2/19/2020.
Kobe Bryant knew me. Not personally, of course. I never received an autograph or shook his hand. But once in a while if I was up early enough, I’d run into Kobe at the gym in Newport Beach where he and I both worked out. As he did for all his fans at the gym, he’d make eye contact with me and nod hello. He was always focused on his workout – working with a trainer, never with headphones on. In person, he appeared enormous. Unlike most retired professional athletes, he still was in great shape. No doubt he could have suited up in purple and gold, and played against the Clippers that night if needed.
Being from New England, I never was a Laker fan. But I thought, if Kobe can head to the gym after midnight and take a 1,000 shots to prepare for a game, then I could set my alarm for 4 a.m. and take a few dozen more questions from my First Aid books. Head down, “Kryptonite” cranked on my iPod, I wasn’t going to let anyone in that test room outwork me. Neither did he. I put in the time and, like Kobe in the 2002 conference finals against Sacramento, I crushed it.*
When we moved to California, I followed Kobe and the Lakers until he retired. To be clear, I didn’t aspire to be like him, firstly because I’m slightly shorter than Michael Bloomberg, but also because although accomplished, Kobe made some poor choices at times. Indeed, it seems he might have been kinder and more considerate when he was at the top. But in his retirement he looked to be toiling to make reparations, refocusing his prodigious energy and talent for the benefit of others rather than for just for scoring 81 points. His Rolls Royce was there before mine at the gym, and I was there early. He was still getting up early and now preparing to be a great venture capitalist, podcaster, author, and father to his girls.
Watching him carry kettle bells across the floor one morning, I wondered, do people like Kobe Bryant look to others for inspiration? Or are they are born with an endless supply of it? For me, I seemed to push harder and faster when watching idols pass by. Whether it was Kobe or Clayton Christensen (author of “The Innovator’s Dilemma”), Joe Jorizzo, or Barack Obama, I found I could do just a bit more if I had them in mind.
On game days, Kobe spoke of arriving at the arena early, long before anyone. He would use the silent, solo time to reflect on what he needed to do perform that night. I tried this last week, arriving at our clinic early, before any patients or staff. I turned the lights on and took a few minutes to think about what we needed to accomplish that day. I previewed patients on my schedule, searched Up to Date for the latest recommendations on a difficult case. I didn’t know Kobe, but I felt like I did.
When I received the text that Kobe Bryant had died, I was actually working on this column. So I decided to change the topic to write about people who inspire me, ironically inspired by him again. May he rest in peace.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
*This article was updated 2/19/2020.
Psychopharmacology for aggression? Our field’s ‘nonconsensus’ and the risks
A 13-year-old boy with ADHD, combined type, presents to his family physician with his parents. His parents called for an appointment outside of his routine follow-up care to discuss what they should do to address their son’s new “aggressive behaviors.” He will throw objects when angry, yell, and slam doors at home when he is told to turn off video games. He used to play soccer but doesn’t anymore. He has maintained very good grades and friends. There is not a concern for substance abuse at this time.He speaks in curt sentences during the appointment, and he has his arms crossed or is looking out of the window the entire time.
His parents share in front on him that he has always been a “difficult child” (their words), but they now are struggling to adjust to his aggressive tendencies as he ages. He is growing bigger and angrier. He will not attend therapy and will not see a consultation psychiatrist in the office. A variety of stimulant trials including Ritalin and amphetamine preparations to manage impulsivity in ADHD were ineffective to curb his aggression, and he doesn’t want to take any medication.
They ask, what do we do? They are not worried for their safety but living like this is eroding their quality of life as a family, and the dynamic seems destined to get worse before it gets better.
They wonder, is there a next medication step to manage his aggression?
A family physician presented the above situation to me in my role as a child and adolescent psychiatrist in the medical home. It led us to a fruitful discussion of aggression and what can be done to help families who are all too often in situations like the above, then in your office looking for immediate solutions. The questions are, what can be done with an aggressive child, even and especially without the child’s buy-in to work on that as a problem?
Psychoeducation can go a long way in helping families rethink aggression as a symptom of something deeper, either in the environment or a diagnosis, although we all can empathize with the desire to reconcile the above behavior immediately.
Characterize the aggression
First, it can be helpful to identify a child’s aggression type. There are two types of aggression, reactive and proactive. We most often see reactive aggression in our clinics, which is aggression as a defensive and impulsive response to something in the environment (often limit-setting, as above). Proactive aggression is premeditated and may appear as aggression for aggression’s sake without the emotional drive behind it.
Secondly, it also can be helpful to know that externalizing and internalizing symptoms can represent different sides of the same coin, with the proverbial “coin” as “emotion” and the associated behaviors (throwing objects, in the above example) as the “signs” that there is a complex difficulty in managing painful emotions. Some children (and adults too!) tend to “externalize” strong emotions as aggression or irritability with others, while others “internalize” them by retreating with internal suffering such as “anxiety and depression.” These styles also can be similar among children and their parents.
With those two points in mind, it’s important to consider the diagnosis, which would guide treatment. It’s generally agreed upon that “reactive aggression” is more likely to be related to underlying untreated ADHD, or a depressive or anxiety disorder. This is much more amenable to treatment than aggression related to oppositional defiant disorder or conduct disorder, which are more defined by proactive forms of aggression.
You can pick up on family dynamics that may inadvertently reinforce the same behaviors they so wish to change. In the above example, the parents have clearly identified their son as “the problem.” You can imagine the difficulty of going to school and being a “problem,” and then coming home and feeling the same way. This negative perception can erode a child’s self-esteem over time, which may appear as disengagement or simply not caring in an appointment. It may become harder and harder to engage the child in psychotherapy or even in taking a medication as their only means of resistance to that painful notion about oneself as the “problem.”
It can be useful to begin appointments with “what is going well?” (in the example above, he “has friends and is maintaining grades”) and “what do you like most about your child?” As we all know, positive reinforcement is more powerful than its counterpart. Also problems in a family often are complex, and may involve many family members needing to change to meet their goals, not just the child.
Why you should try behavioral interventions first
Behavioral interventions are the first step always. Parents can do behavioral interventions and change their parenting and family environment through their own behavioral changes – commonly called parent management training. They can assess antecedents of aggression and their own responses, which may contribute or perpetuate a cycle of the aggression – such as giving attention or giving in to fewer limitations to avoid a fight. This small but important point can help protect against a feeling of helplessness that a child will not engage in therapy or skills-building.
In answering the clinician’s question about what to do next, I often feel like the question embedded in this is “what medication is next?” There is a felt pressure to do something “right now” conveyed to a clinician. This drives the impulse to prescribe something immediately – and likely more risky and with less of an evidence base – even before trying the known psychotherapy interventions that have the most evidence to change aggressive tendencies.
In looking deeper into this consultation case, I also found more “food for thought” for one’s thinking about aggression and psychopharmacology in cases like the above: Aggression isn’t an uncomplicated symptom that one can address immediately, and therefore we cannot rely on symptom-specific management to eradicate it. This is similar to prescribing Tylenol to manage a general ache or pain; if the pain persists, we want to know the “whys” of the pain persisting.
Thankfully, there are ways that a parent can better understand behaviors with this philosophy in mind. Applied Behavioral Analysis1 offers some helpful ideas, not only for children with autism spectrum disorder, but that can be applied to one’s understanding of other’s behavior in general. ABA pays attention to antecedents, perpetuating factors, and consequences as well as their interplay in understanding behaviors. You can encourage a family – rather than wanting to “get rid of a problem behavior” – to try to understand it and come up, with help from a psychotherapist or other professional, with a deeper evaluation of the behavior and a specific, collaborative plan.
Most experts see that ADHD, anxiety disorders, depressive disorders, and unrecognized learning disabilities, in sum, are more common underpinnings than not with aggressive children. This also can be confounded by an environment with parents who have those diagnoses untreated as well. Aggression should raise a red flag in our clinics to consider the above even if a family or child simply says aggression is the one issue, and it’s only the child with the issue.
While there have been attempts to find a “spot treatment” for aggression in a medication, medications not only fail to address the underlying issues many times, but have little evidence that support them and may do more harm long term than good.2
Kids need outlets for “normal aggressive drives.” And puberty, as in the case above, is a time of intense emotions of all varieties. In the example above, you may notice that the child is no longer playing soccer, which was likely serving some protective function in many ways for him and as a positive outlet for aggression. In the same way, you may see that kids who are more sedentary or idle (playing unrestricted video games now instead of sports, ) would benefit from revisiting outlets or finding new ones as a family.
Consider medications if the underlying diagnosis merits it
We generally seek to find and treat the underlying diagnosis, if it exists, in the following ways.
If a child has ADHD, as in the case above, you can trial a stimulant or an alpha-adrenergic agent to target impulsivity if that is suspected as the driver of aggression. This may include guanfacine (long-acting Intuniv at night, but I would choose lower dosing such as 0.5 mg to 1 mg at bedtime) to manage ADHD. However, the evidence base that management of ADHD improves aggressive behaviors at all or on their own, is scant. In addition, these medications can represent more harm than good as well, although they are perceived as more innocuous than their antipsychotic counterparts. For example, some patients can begin to have bed-wetting accidents in the evening or become sleepy in classes, which can further erode their sense of self-confidence even if this is clearly attributable to a medication side effect and resolves once the agent is reduced or removed.
In the same way to reorient to diagnosis with children with aggression, you can consider an SSRI for an anxiety disorder or irritable depression. But know that it’s a rare thing for children to say specifically that they are struggling with their emotions, whether they are angry, sad, or nervous and that a deeper dive into this may be warranted. Data by Connor DF et al.3 may indicate anxiety disorders should be highest on one’s differential diagnosis in aggression, followed by consideration for ADHD, which may be a different assumption than one would expect.
Mood stabilizers –lamotrigine (Lamictal), divalproex sodium (Depakote), and lithium – and antipsychotics – aripiprazole (Abilify) and risperidone (Risperdal) – are risky medications and the use of them contradicts the first point, agreed upon by most experts, that diagnosis should drive treatment. One is hardly ever treating a young child for psychosis or bipolar disorder in these circumstances of episodic, reactive aggression. Antipsychotics also carry the notorious risks of metabolic syndrome, among other risks to overall health, which becomes an additive risk over time and potentially into adulthood. I once heard in my child adolescent psychiatry training the haunting phase, “yes, they can ‘work’ quickly but they can work ‘almost too well,’ ” meaning they can sedate or tranquilize an aggressive child when the real goal should be to understand, diagnose, and intervene in ways that see the “big picture” of aggression.
Benzodiazepines generally are avoided in children due to disinhibition and often not even considered, in these circumstances, as they are in adults to manage agitation or aggression, due to this fact.
In many instances in working with families, our role in primary care can be one of illuminating children’s behaviors not just as symptoms to treat, but to understand deeply. This is as true for aggression as it is for anxiety.
Finally, I am reminded of the common question I receive from adult patients in primary care who ask me if anyone has yet made a medication to lose weight that’s safe and effective. Then the counseling commences on our fantasies, from our patients and ourselves, about what medications can do for us and our risks therein.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and assistant professor of psychiatry at the Larner College of Medicine at UVM in Burlington. Email her at pdnews@mdedge.com.
References
1. ABA in the Treatment of Aggressive Behavior Disorder and Lack of Impulse Control.
2. Managing Aggression in Children: A Practical Approach, The Carlat Child Psychiatry Report, May 2010, The Explosive Child.
3. Child Psychiatry Hum Dev. 2006 May;37[1]:1-14.
A 13-year-old boy with ADHD, combined type, presents to his family physician with his parents. His parents called for an appointment outside of his routine follow-up care to discuss what they should do to address their son’s new “aggressive behaviors.” He will throw objects when angry, yell, and slam doors at home when he is told to turn off video games. He used to play soccer but doesn’t anymore. He has maintained very good grades and friends. There is not a concern for substance abuse at this time.He speaks in curt sentences during the appointment, and he has his arms crossed or is looking out of the window the entire time.
His parents share in front on him that he has always been a “difficult child” (their words), but they now are struggling to adjust to his aggressive tendencies as he ages. He is growing bigger and angrier. He will not attend therapy and will not see a consultation psychiatrist in the office. A variety of stimulant trials including Ritalin and amphetamine preparations to manage impulsivity in ADHD were ineffective to curb his aggression, and he doesn’t want to take any medication.
They ask, what do we do? They are not worried for their safety but living like this is eroding their quality of life as a family, and the dynamic seems destined to get worse before it gets better.
They wonder, is there a next medication step to manage his aggression?
A family physician presented the above situation to me in my role as a child and adolescent psychiatrist in the medical home. It led us to a fruitful discussion of aggression and what can be done to help families who are all too often in situations like the above, then in your office looking for immediate solutions. The questions are, what can be done with an aggressive child, even and especially without the child’s buy-in to work on that as a problem?
Psychoeducation can go a long way in helping families rethink aggression as a symptom of something deeper, either in the environment or a diagnosis, although we all can empathize with the desire to reconcile the above behavior immediately.
Characterize the aggression
First, it can be helpful to identify a child’s aggression type. There are two types of aggression, reactive and proactive. We most often see reactive aggression in our clinics, which is aggression as a defensive and impulsive response to something in the environment (often limit-setting, as above). Proactive aggression is premeditated and may appear as aggression for aggression’s sake without the emotional drive behind it.
Secondly, it also can be helpful to know that externalizing and internalizing symptoms can represent different sides of the same coin, with the proverbial “coin” as “emotion” and the associated behaviors (throwing objects, in the above example) as the “signs” that there is a complex difficulty in managing painful emotions. Some children (and adults too!) tend to “externalize” strong emotions as aggression or irritability with others, while others “internalize” them by retreating with internal suffering such as “anxiety and depression.” These styles also can be similar among children and their parents.
With those two points in mind, it’s important to consider the diagnosis, which would guide treatment. It’s generally agreed upon that “reactive aggression” is more likely to be related to underlying untreated ADHD, or a depressive or anxiety disorder. This is much more amenable to treatment than aggression related to oppositional defiant disorder or conduct disorder, which are more defined by proactive forms of aggression.
You can pick up on family dynamics that may inadvertently reinforce the same behaviors they so wish to change. In the above example, the parents have clearly identified their son as “the problem.” You can imagine the difficulty of going to school and being a “problem,” and then coming home and feeling the same way. This negative perception can erode a child’s self-esteem over time, which may appear as disengagement or simply not caring in an appointment. It may become harder and harder to engage the child in psychotherapy or even in taking a medication as their only means of resistance to that painful notion about oneself as the “problem.”
It can be useful to begin appointments with “what is going well?” (in the example above, he “has friends and is maintaining grades”) and “what do you like most about your child?” As we all know, positive reinforcement is more powerful than its counterpart. Also problems in a family often are complex, and may involve many family members needing to change to meet their goals, not just the child.
Why you should try behavioral interventions first
Behavioral interventions are the first step always. Parents can do behavioral interventions and change their parenting and family environment through their own behavioral changes – commonly called parent management training. They can assess antecedents of aggression and their own responses, which may contribute or perpetuate a cycle of the aggression – such as giving attention or giving in to fewer limitations to avoid a fight. This small but important point can help protect against a feeling of helplessness that a child will not engage in therapy or skills-building.
In answering the clinician’s question about what to do next, I often feel like the question embedded in this is “what medication is next?” There is a felt pressure to do something “right now” conveyed to a clinician. This drives the impulse to prescribe something immediately – and likely more risky and with less of an evidence base – even before trying the known psychotherapy interventions that have the most evidence to change aggressive tendencies.
In looking deeper into this consultation case, I also found more “food for thought” for one’s thinking about aggression and psychopharmacology in cases like the above: Aggression isn’t an uncomplicated symptom that one can address immediately, and therefore we cannot rely on symptom-specific management to eradicate it. This is similar to prescribing Tylenol to manage a general ache or pain; if the pain persists, we want to know the “whys” of the pain persisting.
Thankfully, there are ways that a parent can better understand behaviors with this philosophy in mind. Applied Behavioral Analysis1 offers some helpful ideas, not only for children with autism spectrum disorder, but that can be applied to one’s understanding of other’s behavior in general. ABA pays attention to antecedents, perpetuating factors, and consequences as well as their interplay in understanding behaviors. You can encourage a family – rather than wanting to “get rid of a problem behavior” – to try to understand it and come up, with help from a psychotherapist or other professional, with a deeper evaluation of the behavior and a specific, collaborative plan.
Most experts see that ADHD, anxiety disorders, depressive disorders, and unrecognized learning disabilities, in sum, are more common underpinnings than not with aggressive children. This also can be confounded by an environment with parents who have those diagnoses untreated as well. Aggression should raise a red flag in our clinics to consider the above even if a family or child simply says aggression is the one issue, and it’s only the child with the issue.
While there have been attempts to find a “spot treatment” for aggression in a medication, medications not only fail to address the underlying issues many times, but have little evidence that support them and may do more harm long term than good.2
Kids need outlets for “normal aggressive drives.” And puberty, as in the case above, is a time of intense emotions of all varieties. In the example above, you may notice that the child is no longer playing soccer, which was likely serving some protective function in many ways for him and as a positive outlet for aggression. In the same way, you may see that kids who are more sedentary or idle (playing unrestricted video games now instead of sports, ) would benefit from revisiting outlets or finding new ones as a family.
Consider medications if the underlying diagnosis merits it
We generally seek to find and treat the underlying diagnosis, if it exists, in the following ways.
If a child has ADHD, as in the case above, you can trial a stimulant or an alpha-adrenergic agent to target impulsivity if that is suspected as the driver of aggression. This may include guanfacine (long-acting Intuniv at night, but I would choose lower dosing such as 0.5 mg to 1 mg at bedtime) to manage ADHD. However, the evidence base that management of ADHD improves aggressive behaviors at all or on their own, is scant. In addition, these medications can represent more harm than good as well, although they are perceived as more innocuous than their antipsychotic counterparts. For example, some patients can begin to have bed-wetting accidents in the evening or become sleepy in classes, which can further erode their sense of self-confidence even if this is clearly attributable to a medication side effect and resolves once the agent is reduced or removed.
In the same way to reorient to diagnosis with children with aggression, you can consider an SSRI for an anxiety disorder or irritable depression. But know that it’s a rare thing for children to say specifically that they are struggling with their emotions, whether they are angry, sad, or nervous and that a deeper dive into this may be warranted. Data by Connor DF et al.3 may indicate anxiety disorders should be highest on one’s differential diagnosis in aggression, followed by consideration for ADHD, which may be a different assumption than one would expect.
Mood stabilizers –lamotrigine (Lamictal), divalproex sodium (Depakote), and lithium – and antipsychotics – aripiprazole (Abilify) and risperidone (Risperdal) – are risky medications and the use of them contradicts the first point, agreed upon by most experts, that diagnosis should drive treatment. One is hardly ever treating a young child for psychosis or bipolar disorder in these circumstances of episodic, reactive aggression. Antipsychotics also carry the notorious risks of metabolic syndrome, among other risks to overall health, which becomes an additive risk over time and potentially into adulthood. I once heard in my child adolescent psychiatry training the haunting phase, “yes, they can ‘work’ quickly but they can work ‘almost too well,’ ” meaning they can sedate or tranquilize an aggressive child when the real goal should be to understand, diagnose, and intervene in ways that see the “big picture” of aggression.
Benzodiazepines generally are avoided in children due to disinhibition and often not even considered, in these circumstances, as they are in adults to manage agitation or aggression, due to this fact.
In many instances in working with families, our role in primary care can be one of illuminating children’s behaviors not just as symptoms to treat, but to understand deeply. This is as true for aggression as it is for anxiety.
Finally, I am reminded of the common question I receive from adult patients in primary care who ask me if anyone has yet made a medication to lose weight that’s safe and effective. Then the counseling commences on our fantasies, from our patients and ourselves, about what medications can do for us and our risks therein.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and assistant professor of psychiatry at the Larner College of Medicine at UVM in Burlington. Email her at pdnews@mdedge.com.
References
1. ABA in the Treatment of Aggressive Behavior Disorder and Lack of Impulse Control.
2. Managing Aggression in Children: A Practical Approach, The Carlat Child Psychiatry Report, May 2010, The Explosive Child.
3. Child Psychiatry Hum Dev. 2006 May;37[1]:1-14.
A 13-year-old boy with ADHD, combined type, presents to his family physician with his parents. His parents called for an appointment outside of his routine follow-up care to discuss what they should do to address their son’s new “aggressive behaviors.” He will throw objects when angry, yell, and slam doors at home when he is told to turn off video games. He used to play soccer but doesn’t anymore. He has maintained very good grades and friends. There is not a concern for substance abuse at this time.He speaks in curt sentences during the appointment, and he has his arms crossed or is looking out of the window the entire time.
His parents share in front on him that he has always been a “difficult child” (their words), but they now are struggling to adjust to his aggressive tendencies as he ages. He is growing bigger and angrier. He will not attend therapy and will not see a consultation psychiatrist in the office. A variety of stimulant trials including Ritalin and amphetamine preparations to manage impulsivity in ADHD were ineffective to curb his aggression, and he doesn’t want to take any medication.
They ask, what do we do? They are not worried for their safety but living like this is eroding their quality of life as a family, and the dynamic seems destined to get worse before it gets better.
They wonder, is there a next medication step to manage his aggression?
A family physician presented the above situation to me in my role as a child and adolescent psychiatrist in the medical home. It led us to a fruitful discussion of aggression and what can be done to help families who are all too often in situations like the above, then in your office looking for immediate solutions. The questions are, what can be done with an aggressive child, even and especially without the child’s buy-in to work on that as a problem?
Psychoeducation can go a long way in helping families rethink aggression as a symptom of something deeper, either in the environment or a diagnosis, although we all can empathize with the desire to reconcile the above behavior immediately.
Characterize the aggression
First, it can be helpful to identify a child’s aggression type. There are two types of aggression, reactive and proactive. We most often see reactive aggression in our clinics, which is aggression as a defensive and impulsive response to something in the environment (often limit-setting, as above). Proactive aggression is premeditated and may appear as aggression for aggression’s sake without the emotional drive behind it.
Secondly, it also can be helpful to know that externalizing and internalizing symptoms can represent different sides of the same coin, with the proverbial “coin” as “emotion” and the associated behaviors (throwing objects, in the above example) as the “signs” that there is a complex difficulty in managing painful emotions. Some children (and adults too!) tend to “externalize” strong emotions as aggression or irritability with others, while others “internalize” them by retreating with internal suffering such as “anxiety and depression.” These styles also can be similar among children and their parents.
With those two points in mind, it’s important to consider the diagnosis, which would guide treatment. It’s generally agreed upon that “reactive aggression” is more likely to be related to underlying untreated ADHD, or a depressive or anxiety disorder. This is much more amenable to treatment than aggression related to oppositional defiant disorder or conduct disorder, which are more defined by proactive forms of aggression.
You can pick up on family dynamics that may inadvertently reinforce the same behaviors they so wish to change. In the above example, the parents have clearly identified their son as “the problem.” You can imagine the difficulty of going to school and being a “problem,” and then coming home and feeling the same way. This negative perception can erode a child’s self-esteem over time, which may appear as disengagement or simply not caring in an appointment. It may become harder and harder to engage the child in psychotherapy or even in taking a medication as their only means of resistance to that painful notion about oneself as the “problem.”
It can be useful to begin appointments with “what is going well?” (in the example above, he “has friends and is maintaining grades”) and “what do you like most about your child?” As we all know, positive reinforcement is more powerful than its counterpart. Also problems in a family often are complex, and may involve many family members needing to change to meet their goals, not just the child.
Why you should try behavioral interventions first
Behavioral interventions are the first step always. Parents can do behavioral interventions and change their parenting and family environment through their own behavioral changes – commonly called parent management training. They can assess antecedents of aggression and their own responses, which may contribute or perpetuate a cycle of the aggression – such as giving attention or giving in to fewer limitations to avoid a fight. This small but important point can help protect against a feeling of helplessness that a child will not engage in therapy or skills-building.
In answering the clinician’s question about what to do next, I often feel like the question embedded in this is “what medication is next?” There is a felt pressure to do something “right now” conveyed to a clinician. This drives the impulse to prescribe something immediately – and likely more risky and with less of an evidence base – even before trying the known psychotherapy interventions that have the most evidence to change aggressive tendencies.
In looking deeper into this consultation case, I also found more “food for thought” for one’s thinking about aggression and psychopharmacology in cases like the above: Aggression isn’t an uncomplicated symptom that one can address immediately, and therefore we cannot rely on symptom-specific management to eradicate it. This is similar to prescribing Tylenol to manage a general ache or pain; if the pain persists, we want to know the “whys” of the pain persisting.
Thankfully, there are ways that a parent can better understand behaviors with this philosophy in mind. Applied Behavioral Analysis1 offers some helpful ideas, not only for children with autism spectrum disorder, but that can be applied to one’s understanding of other’s behavior in general. ABA pays attention to antecedents, perpetuating factors, and consequences as well as their interplay in understanding behaviors. You can encourage a family – rather than wanting to “get rid of a problem behavior” – to try to understand it and come up, with help from a psychotherapist or other professional, with a deeper evaluation of the behavior and a specific, collaborative plan.
Most experts see that ADHD, anxiety disorders, depressive disorders, and unrecognized learning disabilities, in sum, are more common underpinnings than not with aggressive children. This also can be confounded by an environment with parents who have those diagnoses untreated as well. Aggression should raise a red flag in our clinics to consider the above even if a family or child simply says aggression is the one issue, and it’s only the child with the issue.
While there have been attempts to find a “spot treatment” for aggression in a medication, medications not only fail to address the underlying issues many times, but have little evidence that support them and may do more harm long term than good.2
Kids need outlets for “normal aggressive drives.” And puberty, as in the case above, is a time of intense emotions of all varieties. In the example above, you may notice that the child is no longer playing soccer, which was likely serving some protective function in many ways for him and as a positive outlet for aggression. In the same way, you may see that kids who are more sedentary or idle (playing unrestricted video games now instead of sports, ) would benefit from revisiting outlets or finding new ones as a family.
Consider medications if the underlying diagnosis merits it
We generally seek to find and treat the underlying diagnosis, if it exists, in the following ways.
If a child has ADHD, as in the case above, you can trial a stimulant or an alpha-adrenergic agent to target impulsivity if that is suspected as the driver of aggression. This may include guanfacine (long-acting Intuniv at night, but I would choose lower dosing such as 0.5 mg to 1 mg at bedtime) to manage ADHD. However, the evidence base that management of ADHD improves aggressive behaviors at all or on their own, is scant. In addition, these medications can represent more harm than good as well, although they are perceived as more innocuous than their antipsychotic counterparts. For example, some patients can begin to have bed-wetting accidents in the evening or become sleepy in classes, which can further erode their sense of self-confidence even if this is clearly attributable to a medication side effect and resolves once the agent is reduced or removed.
In the same way to reorient to diagnosis with children with aggression, you can consider an SSRI for an anxiety disorder or irritable depression. But know that it’s a rare thing for children to say specifically that they are struggling with their emotions, whether they are angry, sad, or nervous and that a deeper dive into this may be warranted. Data by Connor DF et al.3 may indicate anxiety disorders should be highest on one’s differential diagnosis in aggression, followed by consideration for ADHD, which may be a different assumption than one would expect.
Mood stabilizers –lamotrigine (Lamictal), divalproex sodium (Depakote), and lithium – and antipsychotics – aripiprazole (Abilify) and risperidone (Risperdal) – are risky medications and the use of them contradicts the first point, agreed upon by most experts, that diagnosis should drive treatment. One is hardly ever treating a young child for psychosis or bipolar disorder in these circumstances of episodic, reactive aggression. Antipsychotics also carry the notorious risks of metabolic syndrome, among other risks to overall health, which becomes an additive risk over time and potentially into adulthood. I once heard in my child adolescent psychiatry training the haunting phase, “yes, they can ‘work’ quickly but they can work ‘almost too well,’ ” meaning they can sedate or tranquilize an aggressive child when the real goal should be to understand, diagnose, and intervene in ways that see the “big picture” of aggression.
Benzodiazepines generally are avoided in children due to disinhibition and often not even considered, in these circumstances, as they are in adults to manage agitation or aggression, due to this fact.
In many instances in working with families, our role in primary care can be one of illuminating children’s behaviors not just as symptoms to treat, but to understand deeply. This is as true for aggression as it is for anxiety.
Finally, I am reminded of the common question I receive from adult patients in primary care who ask me if anyone has yet made a medication to lose weight that’s safe and effective. Then the counseling commences on our fantasies, from our patients and ourselves, about what medications can do for us and our risks therein.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and assistant professor of psychiatry at the Larner College of Medicine at UVM in Burlington. Email her at pdnews@mdedge.com.
References
1. ABA in the Treatment of Aggressive Behavior Disorder and Lack of Impulse Control.
2. Managing Aggression in Children: A Practical Approach, The Carlat Child Psychiatry Report, May 2010, The Explosive Child.
3. Child Psychiatry Hum Dev. 2006 May;37[1]:1-14.
An epidemic of fear and misinformation
As I write this, the 2019 novel coronavirus* continues to spread, exceeding 59,000 cases and 1,300 deaths worldwide. With it spreads fear. In the modern world of social media, misinformation spreads even faster than disease.
The news about a novel and deadly illness crowds out more substantial worries. Humans are not particularly good at assessing risk or responding rationally and consistently to it. Risk is hard to fully define. If you look up “risk” in Merriam Webster’s online dictionary, you get the simple definition of “possibility of loss or injury; peril.” If you look up risk in Wikipedia, you get 12 pages of explanation and 8 more pages of links and references.
People handle risk differently. Some people are more risk adverse than others. Some get a pleasurable thrill from risk, whether a slot machine or a parachute jump. Most people really don’t comprehend small probabilities, with tens of billions of dollars spent annually on U.S. lotteries.
Because 98% of people who get COVID-19 are recovering, this is not an extinction-level event or the zombie apocalypse. It is a major health hazard, and one where morbidity and mortality might be assuaged by an early and effective public health response, including the population’s adoption of good habits such as hand washing, cough etiquette, and staying home when ill.
Three key factors may help reduce the fear factor.
One key factor is accurate communication of health information to the public. This has been severely harmed in the last few years by the promotion of gossip on social media, such as Facebook, within newsfeeds without any vetting, along with a smaller component of deliberate misinformation from untraceable sources. Compare this situation with the decision in May 1988 when Surgeon General C. Everett Koop chose to snail mail a brochure on AIDS to every household in America. It was unprecedented. One element of this communication is the public’s belief that government and health care officials will responsibly and timely convey the information. There are accusations that the Chinese government initially impeded early warnings about COVID-19. Dr. Koop, to his great credit and lifesaving leadership, overcame queasiness within the Reagan administration about issues of morality and taste in discussing some of the HIV information. Alas, no similar leadership occurred in the decade of the 2010s when deaths from the opioid epidemic in the United States skyrocketed to claim more lives annually than car accidents or suicide.
A second factor is the credibility of the scientists. Antivaxxers, climate change deniers, and mercenary scientists have severely damaged that credibility of science, compared with the trust in scientists 50 years ago during the Apollo moon shot.
A third factor is perspective. Poor journalism and clickbait can focus excessively on the rare events as news. Airline crashes make the front page while fatal car accidents, claiming a hundred times more lives annually, don’t even merit a story in local media. Someone wins the lottery weekly but few pay attention to those suffering from gambling debts.
Influenza is killing many times more people than the 2019 novel coronavirus, but the news is focused on cruise ships. In the United States, influenza annually will strike tens of millions, with about 10 per 1,000 hospitalized and 0.5 per 1,000 dying. The novel coronavirus is more lethal. SARS (a coronavirus epidemic in 2003) had 8,000 cases with a mortality rate of 96 per 1,000 while the novel 2019 strain so far is killing about 20 per 1,000. That value may be an overestimate, because there may be a significant fraction of COVID-19 patients with symptoms mild enough that they do not seek medical care and do not get tested and counted.
For perspective, in 1952 the United States reported 50,000 cases of polio (meningitis or paralytic) annually with 3,000 deaths. As many as 95% of cases of poliovirus infection have no or mild symptoms and would not have been reported, so the case fatality rate estimate is skewed. In the 1950s, the United States averaged about 500,000 cases of measles per year, with about 500 deaths annually for a case fatality rate of about 1 per 1,000 in a population that was well nourished with good medical care. In malnourished children without access to modern health care, the case fatality rate can be as high as 100 per 1,000, which is why globally measles killed 142,000 people in 2018, a substantial improvement from 536,000 deaths globally in 2000, but still a leading killer of children worldwide. Vaccines had reduced the annual death toll of polio and measles in the U.S. to zero.
In comparison, in this country the annual incidences are about 70,000 overdose deaths, 50,000 suicides, and 40,000 traffic deaths.
Reassurance is the most common product sold by pediatricians. We look for low-probability, high-impact bad things. Usually we don’t find them and can reassure parents that the child will be okay. Sometimes we spot a higher-risk situation and intervene. My job is to worry professionally so that parents can worry less.
COVID-19 worries me, but irrational people worry me more. The real enemies are fear, disinformation, discrimination, and economic warfare.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
*This article was updated 2/21/2020.
As I write this, the 2019 novel coronavirus* continues to spread, exceeding 59,000 cases and 1,300 deaths worldwide. With it spreads fear. In the modern world of social media, misinformation spreads even faster than disease.
The news about a novel and deadly illness crowds out more substantial worries. Humans are not particularly good at assessing risk or responding rationally and consistently to it. Risk is hard to fully define. If you look up “risk” in Merriam Webster’s online dictionary, you get the simple definition of “possibility of loss or injury; peril.” If you look up risk in Wikipedia, you get 12 pages of explanation and 8 more pages of links and references.
People handle risk differently. Some people are more risk adverse than others. Some get a pleasurable thrill from risk, whether a slot machine or a parachute jump. Most people really don’t comprehend small probabilities, with tens of billions of dollars spent annually on U.S. lotteries.
Because 98% of people who get COVID-19 are recovering, this is not an extinction-level event or the zombie apocalypse. It is a major health hazard, and one where morbidity and mortality might be assuaged by an early and effective public health response, including the population’s adoption of good habits such as hand washing, cough etiquette, and staying home when ill.
Three key factors may help reduce the fear factor.
One key factor is accurate communication of health information to the public. This has been severely harmed in the last few years by the promotion of gossip on social media, such as Facebook, within newsfeeds without any vetting, along with a smaller component of deliberate misinformation from untraceable sources. Compare this situation with the decision in May 1988 when Surgeon General C. Everett Koop chose to snail mail a brochure on AIDS to every household in America. It was unprecedented. One element of this communication is the public’s belief that government and health care officials will responsibly and timely convey the information. There are accusations that the Chinese government initially impeded early warnings about COVID-19. Dr. Koop, to his great credit and lifesaving leadership, overcame queasiness within the Reagan administration about issues of morality and taste in discussing some of the HIV information. Alas, no similar leadership occurred in the decade of the 2010s when deaths from the opioid epidemic in the United States skyrocketed to claim more lives annually than car accidents or suicide.
A second factor is the credibility of the scientists. Antivaxxers, climate change deniers, and mercenary scientists have severely damaged that credibility of science, compared with the trust in scientists 50 years ago during the Apollo moon shot.
A third factor is perspective. Poor journalism and clickbait can focus excessively on the rare events as news. Airline crashes make the front page while fatal car accidents, claiming a hundred times more lives annually, don’t even merit a story in local media. Someone wins the lottery weekly but few pay attention to those suffering from gambling debts.
Influenza is killing many times more people than the 2019 novel coronavirus, but the news is focused on cruise ships. In the United States, influenza annually will strike tens of millions, with about 10 per 1,000 hospitalized and 0.5 per 1,000 dying. The novel coronavirus is more lethal. SARS (a coronavirus epidemic in 2003) had 8,000 cases with a mortality rate of 96 per 1,000 while the novel 2019 strain so far is killing about 20 per 1,000. That value may be an overestimate, because there may be a significant fraction of COVID-19 patients with symptoms mild enough that they do not seek medical care and do not get tested and counted.
For perspective, in 1952 the United States reported 50,000 cases of polio (meningitis or paralytic) annually with 3,000 deaths. As many as 95% of cases of poliovirus infection have no or mild symptoms and would not have been reported, so the case fatality rate estimate is skewed. In the 1950s, the United States averaged about 500,000 cases of measles per year, with about 500 deaths annually for a case fatality rate of about 1 per 1,000 in a population that was well nourished with good medical care. In malnourished children without access to modern health care, the case fatality rate can be as high as 100 per 1,000, which is why globally measles killed 142,000 people in 2018, a substantial improvement from 536,000 deaths globally in 2000, but still a leading killer of children worldwide. Vaccines had reduced the annual death toll of polio and measles in the U.S. to zero.
In comparison, in this country the annual incidences are about 70,000 overdose deaths, 50,000 suicides, and 40,000 traffic deaths.
Reassurance is the most common product sold by pediatricians. We look for low-probability, high-impact bad things. Usually we don’t find them and can reassure parents that the child will be okay. Sometimes we spot a higher-risk situation and intervene. My job is to worry professionally so that parents can worry less.
COVID-19 worries me, but irrational people worry me more. The real enemies are fear, disinformation, discrimination, and economic warfare.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
*This article was updated 2/21/2020.
As I write this, the 2019 novel coronavirus* continues to spread, exceeding 59,000 cases and 1,300 deaths worldwide. With it spreads fear. In the modern world of social media, misinformation spreads even faster than disease.
The news about a novel and deadly illness crowds out more substantial worries. Humans are not particularly good at assessing risk or responding rationally and consistently to it. Risk is hard to fully define. If you look up “risk” in Merriam Webster’s online dictionary, you get the simple definition of “possibility of loss or injury; peril.” If you look up risk in Wikipedia, you get 12 pages of explanation and 8 more pages of links and references.
People handle risk differently. Some people are more risk adverse than others. Some get a pleasurable thrill from risk, whether a slot machine or a parachute jump. Most people really don’t comprehend small probabilities, with tens of billions of dollars spent annually on U.S. lotteries.
Because 98% of people who get COVID-19 are recovering, this is not an extinction-level event or the zombie apocalypse. It is a major health hazard, and one where morbidity and mortality might be assuaged by an early and effective public health response, including the population’s adoption of good habits such as hand washing, cough etiquette, and staying home when ill.
Three key factors may help reduce the fear factor.
One key factor is accurate communication of health information to the public. This has been severely harmed in the last few years by the promotion of gossip on social media, such as Facebook, within newsfeeds without any vetting, along with a smaller component of deliberate misinformation from untraceable sources. Compare this situation with the decision in May 1988 when Surgeon General C. Everett Koop chose to snail mail a brochure on AIDS to every household in America. It was unprecedented. One element of this communication is the public’s belief that government and health care officials will responsibly and timely convey the information. There are accusations that the Chinese government initially impeded early warnings about COVID-19. Dr. Koop, to his great credit and lifesaving leadership, overcame queasiness within the Reagan administration about issues of morality and taste in discussing some of the HIV information. Alas, no similar leadership occurred in the decade of the 2010s when deaths from the opioid epidemic in the United States skyrocketed to claim more lives annually than car accidents or suicide.
A second factor is the credibility of the scientists. Antivaxxers, climate change deniers, and mercenary scientists have severely damaged that credibility of science, compared with the trust in scientists 50 years ago during the Apollo moon shot.
A third factor is perspective. Poor journalism and clickbait can focus excessively on the rare events as news. Airline crashes make the front page while fatal car accidents, claiming a hundred times more lives annually, don’t even merit a story in local media. Someone wins the lottery weekly but few pay attention to those suffering from gambling debts.
Influenza is killing many times more people than the 2019 novel coronavirus, but the news is focused on cruise ships. In the United States, influenza annually will strike tens of millions, with about 10 per 1,000 hospitalized and 0.5 per 1,000 dying. The novel coronavirus is more lethal. SARS (a coronavirus epidemic in 2003) had 8,000 cases with a mortality rate of 96 per 1,000 while the novel 2019 strain so far is killing about 20 per 1,000. That value may be an overestimate, because there may be a significant fraction of COVID-19 patients with symptoms mild enough that they do not seek medical care and do not get tested and counted.
For perspective, in 1952 the United States reported 50,000 cases of polio (meningitis or paralytic) annually with 3,000 deaths. As many as 95% of cases of poliovirus infection have no or mild symptoms and would not have been reported, so the case fatality rate estimate is skewed. In the 1950s, the United States averaged about 500,000 cases of measles per year, with about 500 deaths annually for a case fatality rate of about 1 per 1,000 in a population that was well nourished with good medical care. In malnourished children without access to modern health care, the case fatality rate can be as high as 100 per 1,000, which is why globally measles killed 142,000 people in 2018, a substantial improvement from 536,000 deaths globally in 2000, but still a leading killer of children worldwide. Vaccines had reduced the annual death toll of polio and measles in the U.S. to zero.
In comparison, in this country the annual incidences are about 70,000 overdose deaths, 50,000 suicides, and 40,000 traffic deaths.
Reassurance is the most common product sold by pediatricians. We look for low-probability, high-impact bad things. Usually we don’t find them and can reassure parents that the child will be okay. Sometimes we spot a higher-risk situation and intervene. My job is to worry professionally so that parents can worry less.
COVID-19 worries me, but irrational people worry me more. The real enemies are fear, disinformation, discrimination, and economic warfare.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
*This article was updated 2/21/2020.
An unusual ‘retirement’ option
Whether “retirement” is withdrawing from one’s occupation or from an active working life, it is of utmost importance to not let one’s mind degenerate. Some individuals move on to gathering new intellectual skills by attending new educational courses or meetings, some travel, some become semiprofessional golfers or fishermen, and some find other forms of personal extension. I now serve to develop cost-saving medical programs for county jails in the state of Texas while attempting to improve the overall quality of inmate care.
Initially I was a pediatrician in Houston with special training in allergy and immunology, but because of a medical problem I was forced to abandon my first love – primary pediatrics. My move to a small town at the age of 40 required me to reevaluate my professional life, and I opted to provide care only in my allergy and immunology specialty.
However, living in a small town is different from life in a metropolis, and it was not uncommon for doctors to be asked to assist the community. A number of years ago, our county judge asked if I would help evaluate why our county jail was spending so much money. After several attempts to refuse, I eventually did evaluate the program there, and was flabbergasted by how much money was being wasted. I made some rather simple suggestions as how to correct the problem, but when no primary care doctor stepped forward to implement the changes and run the jail medical program, I became its medical director. When we saved $120,000 the first year, even I was astounded.
While I continued to run my private practice, I did accept other small community’s offers to look into their county jails’ programs. I found that their problems in cost control and quality of health care mirrored those I found in the first jail, and they were easily solvable if the county judge and the local sheriff wanted solutions. I also found that politics makes strange bedfellows, as the saying goes, and often the obvious changes were met with obstruction in one form or another. Nonetheless, I found that I could serve these communities in addition to my individual patients. When it was time for retirement, I continued to have a real desire to make the towns around which I lived and my own community more livable. So
In most things, I found that the same business philosophy and personal medical approach I learned in my pediatrics training and as a private practitioner applied to the jail system. Let me mention some specifics. Using generic medicines was less expensive than using brand names. The diagnoses which patients claimed when they entered jail might or might not be correct, so reevaluating the diagnosis and treatment was appropriate as soon as possible. Hospital and ED visits should be limited to patients’ medically requiring them rather than using the ED as a screening tool.
But I did come to understand that medical care in the county jail is different from medical care outside an incarcerated facility in that sometimes the prisoners had their own reasons for seeking medical care. This was complicated by the fact that often there were critically ill patients presenting to county jails. So carefully established criteria and protocols were an absolute necessity to save lives.
Let me expand on the topic of seeking medical care by the inmate-patients. A relatively small number of these individuals required immediate emergency treatment, without which they could not do well: The diabetic who was not taking his insulin, the out-of-control paranoid schizophrenic who decided he was cured and therefore was unattended, the alcoholic or drug addict who would develop delirium tremens if medications were stopped abruptly. These people had to be identified as quickly as possible and correctly treated. Confounding the problem was the fact that many, and I repeat many, individuals try to use the medical route to manipulate their incarceration environment. I called this the B problem: beds, blankets, barter, buzz, better food, and be out of here. They might claim an illness existed, and often they might believe it did.
A related situation might exist when individuals would demand psychiatric and pain medications, often in large quantities, when they in fact had not taken them for some time in the outside world. Often these patients were addicts, and of course this could create an entire other relationship with the medical team. A third example would be the claim of hypoglycemia so that the prisoner would receive more frequent meals.
One might think that as a pediatrician I was ill prepared to treat adults, and in fact, there was much review of the general medical care needed when I began this program. However, the internists and family physicians in town were glad to assist me whenever I encountered a difficult patient. When hospitalizations were required, the inpatient always was covered by one of the internists on hospital staff. Quite frankly, the doctors seemed pleased to not be dealing with this group of individuals as much as they had in the past.
On a slightly different note, skills honed during my pediatric career were extremely valuable. Children, particularly young children, do not verbally communicate with their parents or their doctor particularly well, so pediatricians are well trained in the skill of observation. The patient who claims a guard hurt his shoulder so badly during an altercation that he cannot move it is found out when he easily whips his arms over his head when asked to remove his shirt. It is not uncommon for an individual to demand antidepressant medications from the medical staff, but when evaluated more thoroughly and for a longer period of time, the patient ends up laughing, even denying any suicidal ideation or any other sign of depression. One also deals with a lot of adolescent behavior from the inmates, such as the individuals who say that unless they don’t get their way (more food) they are not going to take their medications and thus get sicker. That’s Adolescent Medicine 101.
Some of the modalities I utilized in modifying the jail programs will be familiar to every practicing pediatrician. I educate; I teach; I train. Parents of my asthmatic patients had to know what medications to keep handy and when to use them. It is pretty easy to see how that relates to jail medicine. Many patients come into jail with inhalers and with a diagnosis of asthma. Some have the condition, and some do not. By training jail and medical staff how to observe breathing patterns and by performing pulse oximetry, we eliminated a large number of unnecessary ED visits, and we often made the diagnosis of hyperventilation syndrome rather than misdiagnosed asthma.
Jail medicine is a large part of the cost of housing inmates. I did consultation work for a large urban jail, and we saved over $7 million in 1 year. In a medium-sized jail, the cost-savings after a 4-month consultation was over $300,000. This is a lot of money to me, and I suspect is to you, too. Just as in our general communities, we have enough resources to provide medical care and to provide a high level of care for all. However, we cannot waste money by providing inappropriate care or overtesting or overtreating. The medical care must be what treats the disease the patient actually has ... nothing more and nothing less!
If it sounds as if I am cynical about inmate patients, that is not true. However, I am realistic that no one wishes to be in jail. I realize that the medical route is just one that prisoners can and do use to modify their situation. I understand that the medical staff within a jail needs constant education and supervision at first, and with time they become more astute – just like a physician in this arena – at distinguishing the very serious from the mildly serious from malingering. In spite of this, we doctors also can be fooled. However, through constant vigilance and constant education we can get better.
Jail medicine is not for everyone in retirement. Heck, it is not for everyone ever. I found it interesting because it required me to match my diagnostic skills against the diseases and the psychodynamics of individuals who often – not always – made that diagnosis more difficult. Diagnosing illness and curing it – isn’t this why we all went into medicine?
Dr. Yoffe is a retired pediatrician specializing in allergy and immunology who resides in Brenham, Tex. Email him at pdnews@mdedge.com.
This article was updated 2/13/2020.
Whether “retirement” is withdrawing from one’s occupation or from an active working life, it is of utmost importance to not let one’s mind degenerate. Some individuals move on to gathering new intellectual skills by attending new educational courses or meetings, some travel, some become semiprofessional golfers or fishermen, and some find other forms of personal extension. I now serve to develop cost-saving medical programs for county jails in the state of Texas while attempting to improve the overall quality of inmate care.
Initially I was a pediatrician in Houston with special training in allergy and immunology, but because of a medical problem I was forced to abandon my first love – primary pediatrics. My move to a small town at the age of 40 required me to reevaluate my professional life, and I opted to provide care only in my allergy and immunology specialty.
However, living in a small town is different from life in a metropolis, and it was not uncommon for doctors to be asked to assist the community. A number of years ago, our county judge asked if I would help evaluate why our county jail was spending so much money. After several attempts to refuse, I eventually did evaluate the program there, and was flabbergasted by how much money was being wasted. I made some rather simple suggestions as how to correct the problem, but when no primary care doctor stepped forward to implement the changes and run the jail medical program, I became its medical director. When we saved $120,000 the first year, even I was astounded.
While I continued to run my private practice, I did accept other small community’s offers to look into their county jails’ programs. I found that their problems in cost control and quality of health care mirrored those I found in the first jail, and they were easily solvable if the county judge and the local sheriff wanted solutions. I also found that politics makes strange bedfellows, as the saying goes, and often the obvious changes were met with obstruction in one form or another. Nonetheless, I found that I could serve these communities in addition to my individual patients. When it was time for retirement, I continued to have a real desire to make the towns around which I lived and my own community more livable. So
In most things, I found that the same business philosophy and personal medical approach I learned in my pediatrics training and as a private practitioner applied to the jail system. Let me mention some specifics. Using generic medicines was less expensive than using brand names. The diagnoses which patients claimed when they entered jail might or might not be correct, so reevaluating the diagnosis and treatment was appropriate as soon as possible. Hospital and ED visits should be limited to patients’ medically requiring them rather than using the ED as a screening tool.
But I did come to understand that medical care in the county jail is different from medical care outside an incarcerated facility in that sometimes the prisoners had their own reasons for seeking medical care. This was complicated by the fact that often there were critically ill patients presenting to county jails. So carefully established criteria and protocols were an absolute necessity to save lives.
Let me expand on the topic of seeking medical care by the inmate-patients. A relatively small number of these individuals required immediate emergency treatment, without which they could not do well: The diabetic who was not taking his insulin, the out-of-control paranoid schizophrenic who decided he was cured and therefore was unattended, the alcoholic or drug addict who would develop delirium tremens if medications were stopped abruptly. These people had to be identified as quickly as possible and correctly treated. Confounding the problem was the fact that many, and I repeat many, individuals try to use the medical route to manipulate their incarceration environment. I called this the B problem: beds, blankets, barter, buzz, better food, and be out of here. They might claim an illness existed, and often they might believe it did.
A related situation might exist when individuals would demand psychiatric and pain medications, often in large quantities, when they in fact had not taken them for some time in the outside world. Often these patients were addicts, and of course this could create an entire other relationship with the medical team. A third example would be the claim of hypoglycemia so that the prisoner would receive more frequent meals.
One might think that as a pediatrician I was ill prepared to treat adults, and in fact, there was much review of the general medical care needed when I began this program. However, the internists and family physicians in town were glad to assist me whenever I encountered a difficult patient. When hospitalizations were required, the inpatient always was covered by one of the internists on hospital staff. Quite frankly, the doctors seemed pleased to not be dealing with this group of individuals as much as they had in the past.
On a slightly different note, skills honed during my pediatric career were extremely valuable. Children, particularly young children, do not verbally communicate with their parents or their doctor particularly well, so pediatricians are well trained in the skill of observation. The patient who claims a guard hurt his shoulder so badly during an altercation that he cannot move it is found out when he easily whips his arms over his head when asked to remove his shirt. It is not uncommon for an individual to demand antidepressant medications from the medical staff, but when evaluated more thoroughly and for a longer period of time, the patient ends up laughing, even denying any suicidal ideation or any other sign of depression. One also deals with a lot of adolescent behavior from the inmates, such as the individuals who say that unless they don’t get their way (more food) they are not going to take their medications and thus get sicker. That’s Adolescent Medicine 101.
Some of the modalities I utilized in modifying the jail programs will be familiar to every practicing pediatrician. I educate; I teach; I train. Parents of my asthmatic patients had to know what medications to keep handy and when to use them. It is pretty easy to see how that relates to jail medicine. Many patients come into jail with inhalers and with a diagnosis of asthma. Some have the condition, and some do not. By training jail and medical staff how to observe breathing patterns and by performing pulse oximetry, we eliminated a large number of unnecessary ED visits, and we often made the diagnosis of hyperventilation syndrome rather than misdiagnosed asthma.
Jail medicine is a large part of the cost of housing inmates. I did consultation work for a large urban jail, and we saved over $7 million in 1 year. In a medium-sized jail, the cost-savings after a 4-month consultation was over $300,000. This is a lot of money to me, and I suspect is to you, too. Just as in our general communities, we have enough resources to provide medical care and to provide a high level of care for all. However, we cannot waste money by providing inappropriate care or overtesting or overtreating. The medical care must be what treats the disease the patient actually has ... nothing more and nothing less!
If it sounds as if I am cynical about inmate patients, that is not true. However, I am realistic that no one wishes to be in jail. I realize that the medical route is just one that prisoners can and do use to modify their situation. I understand that the medical staff within a jail needs constant education and supervision at first, and with time they become more astute – just like a physician in this arena – at distinguishing the very serious from the mildly serious from malingering. In spite of this, we doctors also can be fooled. However, through constant vigilance and constant education we can get better.
Jail medicine is not for everyone in retirement. Heck, it is not for everyone ever. I found it interesting because it required me to match my diagnostic skills against the diseases and the psychodynamics of individuals who often – not always – made that diagnosis more difficult. Diagnosing illness and curing it – isn’t this why we all went into medicine?
Dr. Yoffe is a retired pediatrician specializing in allergy and immunology who resides in Brenham, Tex. Email him at pdnews@mdedge.com.
This article was updated 2/13/2020.
Whether “retirement” is withdrawing from one’s occupation or from an active working life, it is of utmost importance to not let one’s mind degenerate. Some individuals move on to gathering new intellectual skills by attending new educational courses or meetings, some travel, some become semiprofessional golfers or fishermen, and some find other forms of personal extension. I now serve to develop cost-saving medical programs for county jails in the state of Texas while attempting to improve the overall quality of inmate care.
Initially I was a pediatrician in Houston with special training in allergy and immunology, but because of a medical problem I was forced to abandon my first love – primary pediatrics. My move to a small town at the age of 40 required me to reevaluate my professional life, and I opted to provide care only in my allergy and immunology specialty.
However, living in a small town is different from life in a metropolis, and it was not uncommon for doctors to be asked to assist the community. A number of years ago, our county judge asked if I would help evaluate why our county jail was spending so much money. After several attempts to refuse, I eventually did evaluate the program there, and was flabbergasted by how much money was being wasted. I made some rather simple suggestions as how to correct the problem, but when no primary care doctor stepped forward to implement the changes and run the jail medical program, I became its medical director. When we saved $120,000 the first year, even I was astounded.
While I continued to run my private practice, I did accept other small community’s offers to look into their county jails’ programs. I found that their problems in cost control and quality of health care mirrored those I found in the first jail, and they were easily solvable if the county judge and the local sheriff wanted solutions. I also found that politics makes strange bedfellows, as the saying goes, and often the obvious changes were met with obstruction in one form or another. Nonetheless, I found that I could serve these communities in addition to my individual patients. When it was time for retirement, I continued to have a real desire to make the towns around which I lived and my own community more livable. So
In most things, I found that the same business philosophy and personal medical approach I learned in my pediatrics training and as a private practitioner applied to the jail system. Let me mention some specifics. Using generic medicines was less expensive than using brand names. The diagnoses which patients claimed when they entered jail might or might not be correct, so reevaluating the diagnosis and treatment was appropriate as soon as possible. Hospital and ED visits should be limited to patients’ medically requiring them rather than using the ED as a screening tool.
But I did come to understand that medical care in the county jail is different from medical care outside an incarcerated facility in that sometimes the prisoners had their own reasons for seeking medical care. This was complicated by the fact that often there were critically ill patients presenting to county jails. So carefully established criteria and protocols were an absolute necessity to save lives.
Let me expand on the topic of seeking medical care by the inmate-patients. A relatively small number of these individuals required immediate emergency treatment, without which they could not do well: The diabetic who was not taking his insulin, the out-of-control paranoid schizophrenic who decided he was cured and therefore was unattended, the alcoholic or drug addict who would develop delirium tremens if medications were stopped abruptly. These people had to be identified as quickly as possible and correctly treated. Confounding the problem was the fact that many, and I repeat many, individuals try to use the medical route to manipulate their incarceration environment. I called this the B problem: beds, blankets, barter, buzz, better food, and be out of here. They might claim an illness existed, and often they might believe it did.
A related situation might exist when individuals would demand psychiatric and pain medications, often in large quantities, when they in fact had not taken them for some time in the outside world. Often these patients were addicts, and of course this could create an entire other relationship with the medical team. A third example would be the claim of hypoglycemia so that the prisoner would receive more frequent meals.
One might think that as a pediatrician I was ill prepared to treat adults, and in fact, there was much review of the general medical care needed when I began this program. However, the internists and family physicians in town were glad to assist me whenever I encountered a difficult patient. When hospitalizations were required, the inpatient always was covered by one of the internists on hospital staff. Quite frankly, the doctors seemed pleased to not be dealing with this group of individuals as much as they had in the past.
On a slightly different note, skills honed during my pediatric career were extremely valuable. Children, particularly young children, do not verbally communicate with their parents or their doctor particularly well, so pediatricians are well trained in the skill of observation. The patient who claims a guard hurt his shoulder so badly during an altercation that he cannot move it is found out when he easily whips his arms over his head when asked to remove his shirt. It is not uncommon for an individual to demand antidepressant medications from the medical staff, but when evaluated more thoroughly and for a longer period of time, the patient ends up laughing, even denying any suicidal ideation or any other sign of depression. One also deals with a lot of adolescent behavior from the inmates, such as the individuals who say that unless they don’t get their way (more food) they are not going to take their medications and thus get sicker. That’s Adolescent Medicine 101.
Some of the modalities I utilized in modifying the jail programs will be familiar to every practicing pediatrician. I educate; I teach; I train. Parents of my asthmatic patients had to know what medications to keep handy and when to use them. It is pretty easy to see how that relates to jail medicine. Many patients come into jail with inhalers and with a diagnosis of asthma. Some have the condition, and some do not. By training jail and medical staff how to observe breathing patterns and by performing pulse oximetry, we eliminated a large number of unnecessary ED visits, and we often made the diagnosis of hyperventilation syndrome rather than misdiagnosed asthma.
Jail medicine is a large part of the cost of housing inmates. I did consultation work for a large urban jail, and we saved over $7 million in 1 year. In a medium-sized jail, the cost-savings after a 4-month consultation was over $300,000. This is a lot of money to me, and I suspect is to you, too. Just as in our general communities, we have enough resources to provide medical care and to provide a high level of care for all. However, we cannot waste money by providing inappropriate care or overtesting or overtreating. The medical care must be what treats the disease the patient actually has ... nothing more and nothing less!
If it sounds as if I am cynical about inmate patients, that is not true. However, I am realistic that no one wishes to be in jail. I realize that the medical route is just one that prisoners can and do use to modify their situation. I understand that the medical staff within a jail needs constant education and supervision at first, and with time they become more astute – just like a physician in this arena – at distinguishing the very serious from the mildly serious from malingering. In spite of this, we doctors also can be fooled. However, through constant vigilance and constant education we can get better.
Jail medicine is not for everyone in retirement. Heck, it is not for everyone ever. I found it interesting because it required me to match my diagnostic skills against the diseases and the psychodynamics of individuals who often – not always – made that diagnosis more difficult. Diagnosing illness and curing it – isn’t this why we all went into medicine?
Dr. Yoffe is a retired pediatrician specializing in allergy and immunology who resides in Brenham, Tex. Email him at pdnews@mdedge.com.
This article was updated 2/13/2020.
Cosmeceutical ingredients to use before and after antiaging procedures
Outcomes are improved when proper skincare is practiced before and after any type of dermatologic procedure. This column reviews These are ingredients commonly used before, during, and after procedures.
I will use the first person when I am expressing my personal opinion or experience versus data reported in published studies that I reference.
Ascorbic acid
Ascorbic acid (vitamin C) is an essential cofactor necessary for lysyl hydroxylase and prolyl hydroxylase to produce collagen. Many studies have demonstrated that the use of oral and topical ascorbic acid increases collagen production by fibroblasts.1-3 Several different ascorbic acid products, varying greatly in quality, are available on the market.
Ascorbic acid is very sensitive to light and air exposure and does not penetrate well if not at a pH of 2 or 2.5. There are aqueous and lipophilic formulations. Some are produced from L-ascorbic acid, while others are made from ascorbyl palmitate, or salts such as calcium ascorbate, magnesium ascorbate, magnesium ascorbyl phosphate, sodium ascorbate, and sodium ascorbyl phosphate. Consequently, one must closely evaluate any chosen ascorbic acid preparation and pay close attention to the form used in any studies. I am discussing ascorbic acid in general, but my statements only apply to properly formulated products. Most of the studies I quote used L-ascorbic acid, which is the form studied by the late Sheldon Pinnell, MD, who was an expert on ascorbic acid.
Properly formulated L-ascorbic acid products have a low pH. Unless formulated specifically to deter stinging, these low-pH preparations will sting wounded skin. For this reason, most ascorbic acid preparations should be avoided until the skin has completely re-epithelialized. I prefer using it preprocedure and after the procedure once the skin has re-epithelialized. Alster and West showed that use of ascorbic acid – in an aqueous solution formulated not to sting – after laser resurfacing resulted in a significant decrease in post‐CO2 laser resurfacing erythema by the eighth postoperative week when compared with laser‐irradiated skin that had not received topical vitamin C.4
I prefer using ascorbic acid in patients before and after procedures involving fillers, toxins, skin tightening, and nonablative lasers. In my experience, this improves collagen production. Also, I use ascorbic acid before microneedling, but not during or after. Several case reports have cited allergic granulomatous reactions when ascorbic acid is used during microneedling procedures,5 although these reports did not involve aqueous formulations.
Defensin
Defensins are peptides that play an important role in wound repair. Defensin has exhibited the capacity to activate the leucine-rich repeat-containing G-protein–coupled receptors 5 and 6 (also known as LGR5+ and LGR6+) stem cells.6 This accelerates wound healing by stimulating LGR stem cells to form new keratinocytes that populate the epidermis.7 Using defensins prior to procedures would theoretically speed wound healing, but no studies have been published in this area. Anecdotally, it has been used after microneedling without complication. I have not used defensin in this situation, but when I have asked the audience during lectures, many practitioners have reported using it and found that it accelerates healing.
Growth factors
Growth factors are essential in the skin because they are responsible for immunomodulation, regulation of cell division, wound healing, and tissue generation.1 There are several important growth factor families, including: transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF).2 Because of the numerous different variables that play a role with growth factor function, it is difficult to know exactly which combinations are the most helpful to improve outcomes after procedures. There is some evidence to support the use of FGF, TGF-beta, and EGF, IGF, and PDGF to hasten skin healing.8,9 It is certain that growth factors play an important role in pre- and postprocedure skincare, but we do not yet know which growth factor combinations are the most effective.
Heparan sulfate
Heparan sulfate is a glycosaminoglycan found in the skin. Older cells are less responsive to growth factors than are younger cells; therefore, it is desirable to amplify the growth factor signal in older patients. Heparan sulfate has been shown to contribute to growth factors reaching the receptors on the cell surface and enhancing the cell’s ability to “hear” growth factor signals. Combining growth factors with enhancers such as heparan sulfate, defensins, ascorbic acid, and matrikines can improve outcomes of cosmetic procedures. There are not enough studies yet to substantiate which combinations are the most effective. However, I believe that if you are using a growth factor–containing product after a procedure, you should combine it with heparan sulfate to improve efficacy.
Heparan sulfate is not the same as the blood thinner heparin; however, it may affect clotting factors. It is prudent to stop heparan sulfate the day before a dermal filler procedure because of this theoretical risk. (I have not seen an increase in bruising in patients who use heparan sulfate prior to getting fillers.) I suggest using heparan sulfate–containing products with growth factors 24 hours after injecting fillers to try and enhance collagen synthesis that occurs after hyaluronic acid (HA) filler injections.10
Hyaluronic acid
Hyaluronic acid (HA) is known to increase penetration of drugs, as well as cosmeceutical ingredients.11 For this reason, it is often used before a procedure to increase efficacy of growth factors. Many practitioners report using it during microneedling to help the device glide across the skin. I have not observed or heard of any reports of adverse events from using it during microneedling.
HA has been shown to accelerate wound healing in rats12 and dental procedures.13 For this reason, it is often used after laser resurfacing and microneedling procedures and on sutured and open wounds. HA can vary in chain link and molecular weight and whether or not it is cross linked. These differences affect efficacy and should be taken into consideration when choosing an HA product. Some formulations combine various forms of HA. Because HA may increase bruising because of its effects on fibrin formation,14 I prefer not to use it 2 days prior to or the day of filler injections.15
Hydroxy acids
Pretreating skin with hydroxy acids increases dermal matrix formation,16 promotes collagen synthesis,17 and hastens stratum corneum turnover.18 Although postprocedure healing times after pretreatment with hydroxy acids has not been studied, it is very likely that pretreatment with hydroxy acids speeds healing time by increasing collagen production and cell turnover. West and Alster showed that pretreating skin with hydroxy acids prior to CO2 resurfacing did not affect the incidence of postprocedure hyperpigmentation.19
Matrikines
Matrikines are peptides that occur when extracellular matrix (ECM) macromolecules are partially degraded. These peptides interact with cell surface receptors and activate intracellular signalling pathways to modulate ECM remodeling.20 Matrikines, such as tripeptides and hexapeptides, have been shown to remove damaged collagen and elastin from the ECM.21 It is thought that these matrikines help to prepare the skin for procedures by freeing up space to allow room for newly formed collagen. Using matrikines at least 2 weeks before procedures may precondition the skin to heal faster.22
The tripeptide glycyl-histidyl-lysine (GHK) is a good example of a matrikine. When it forms a complex with copper (II) ions (GHK–Cu) it can stimulate collagen and glycosaminoglycan synthesis23 and increase tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-2, which play a role in wound remodeling.24
A serum that contains tripeptide-1, hexapeptide-12, lactoferrin, and phosphatidyl serine has been shown to speed resolution of bruises and inflammation when applied after procedures. It is believed that these ingredients activate macrophages to clear hemosiderin from the skin.
Retinoids
Derived from vitamin A, the retinoid family includes compounds such as adapalene, retinol, tazarotene, trifarotene, and tretinoin. Retinoids should be used for at least 2-4 weeks prior to procedures to improve outcomes. Multiple studies have cogently revealed that pretreatment with tretinoin accelerates wound healing.25-27 Kligman assessed healing after punch biopsy in the mid-1990s and found that the wounds on arms pretreated with tretinoin cream 0.05%-0.1% were significantly diminished by 35%-37% on days 1 and 4 and 47%-50% reduced on days 6, 8, and 11 as compared with the wounds on untreated arms.28 A tretinoin pretreatment regimen of 2-4 weeks is supported by the preponderance of studies29 because peak epidermal hypertrophy emerges after 7 days of tretinoin application and normalizes after 14 days of continued treatment.30 Such an approach gives the skin time to recover from any retinoid dermatitis before the procedure is performed. Pretreatment with adapalene requires an earlier initiation period and should be introduced 5-6 weeks before procedures because it exhibits a longer half-life.31
Topical retinoids should not be used after a procedure until re-epithelialization is complete. Hung et al. applied 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding in a porcine model, with results revealing that re-epithelialization was accelerated with preprocedure treatment while use after the procedure slowed wound healing.32
Skin care regimen design by procedure type
Procedures can be divided into six main types: nonablative, such as peels, intense pulsed light (IPL), and vascular or pigmented lasers; microneedling or other procedures that cause open channels into the dermis; injectables such as toxins and fillers; ablative, such as CO2, erbium, and fractionated lasers; sutured wounds; and unsutured wounds. Skincare regimens that are prescribed before and after each of these procedures should take into account the Baumann Skin Type, the procedure type, whether it is pre- or postprocedure, and lifestyle issues such as sun exposure. Once the pre- and postprocedure regimen has been designed, patients should be given specific instructions as to which brands, the exact products, and the order in which to apply them.
Conclusion
To ensure the best outcomes from surgical treatments, patient education is a key step. The more that patients know and understand about the ways in which they can prepare for their procedure and treat their skin after the procedure, the better the results. Providers should give this type of information in an easy-to-follow printed instruction sheet because studies show that patients cannot remember most of the oral instructions offered by practitioners. Patients should be encouraged to ask questions during their consultation and procedure and to express any concerns with the practitioner’s office should any arise after they have returned home. These steps help improve patient compliance, satisfaction, and outcomes. Please discuss your opinions and experience with me on LinkedIn. You can also see a lecture on this topic on my website, SkinGuru.com.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), as well as a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. Write to her at dermnews@mdedge.com.
References
1. Murad S et al. Proc Natl Acad Sci U S A. 1981 May;78(5):2879-82.
2. Tajima S, Pinnell SR. J Dermatol Sci. 1996 Mar;11(3):250-3.
3. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
4. Alster TS, West TB. Dermatol Surg. 1998 Mar;24(3):331-4.
5. Soltani-Arabshahi R et al. JAMA Dermatol. 2014 Jan;150(1):68-72.
6. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
7. Hirsch T et al. J Gene Med. 2009 Mar;11(3):220-8.
8. Van Brunt J, Klausner A. Nat Biotechnol. 1988 Jan 1;6:25-30.
9. Lynch SE et al. J Clin Invest. 1989 Aug;84(2):640-6.
10. Wang F et al. Arch Dermatol. 2007 Feb;143(2):155-63.
11. Huang G, Huang H. Drug Deliv. 2018 Nov;25(1):766-72.
12. Celani LM. J Surg Clin Res. 2019 Oct. doi: 10.20398/jscr.v10i2.18825.
13. Yildirim S et al. J Periodontol. 2018 Jan;89(1):36-45.
14. Weigel PH et al. Ciba Found Symp. 1989;143:248-61; discussion 261-4, 281-5.
15. Basora JF et al. Am J Case Rep. 2014 May 9;15:199-202.
16. Okano Yet al. Exp Dermatol. 2003;12 Suppl 2:57-63.
17. Bernstein EF et al. Dermatol Surg. 2001 May;27(5):429-33.
18. Hood HL et al. Food Chem Toxicol. 1999 Nov;37(11):1105-11.
19. West TB, Alster TS. Dermatol Surg. 1999 Jan;25(1):15-7.
20. Maquart FX et al. M. Biochimie. 2005 Mar-Apr;87(3-4):353-60.
21. Pickart L et al. Biomed Res Int. 2015;2015:648108.
22. Widgerow AD et al. Aesthet Surg J. 2019 Apr 8;39 (Supplement 3):S103-11.
23. Maquart FX et al. FEBS Lett. 1988 Oct 10;238(2):343-6.
24. Siméon A et al. J Invest Dermatol. 1999 Jun;112(6):957-64.
25. Vagotis FL, Brundage SR. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
26. Stuzin JM. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
27. Elson ML. J Am Acad Dermatol. 1998 Aug;39:S79-81.
28. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
29. Orringer JS et al. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
30. Kim IH et al. J Korean Med Sci. 1996 Aug;11(4):335-41.
31. Basak PY et al. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
32. Hung VC et al. Arch Dermatol. 1989 Jan;125(1):65-9.
Outcomes are improved when proper skincare is practiced before and after any type of dermatologic procedure. This column reviews These are ingredients commonly used before, during, and after procedures.
I will use the first person when I am expressing my personal opinion or experience versus data reported in published studies that I reference.
Ascorbic acid
Ascorbic acid (vitamin C) is an essential cofactor necessary for lysyl hydroxylase and prolyl hydroxylase to produce collagen. Many studies have demonstrated that the use of oral and topical ascorbic acid increases collagen production by fibroblasts.1-3 Several different ascorbic acid products, varying greatly in quality, are available on the market.
Ascorbic acid is very sensitive to light and air exposure and does not penetrate well if not at a pH of 2 or 2.5. There are aqueous and lipophilic formulations. Some are produced from L-ascorbic acid, while others are made from ascorbyl palmitate, or salts such as calcium ascorbate, magnesium ascorbate, magnesium ascorbyl phosphate, sodium ascorbate, and sodium ascorbyl phosphate. Consequently, one must closely evaluate any chosen ascorbic acid preparation and pay close attention to the form used in any studies. I am discussing ascorbic acid in general, but my statements only apply to properly formulated products. Most of the studies I quote used L-ascorbic acid, which is the form studied by the late Sheldon Pinnell, MD, who was an expert on ascorbic acid.
Properly formulated L-ascorbic acid products have a low pH. Unless formulated specifically to deter stinging, these low-pH preparations will sting wounded skin. For this reason, most ascorbic acid preparations should be avoided until the skin has completely re-epithelialized. I prefer using it preprocedure and after the procedure once the skin has re-epithelialized. Alster and West showed that use of ascorbic acid – in an aqueous solution formulated not to sting – after laser resurfacing resulted in a significant decrease in post‐CO2 laser resurfacing erythema by the eighth postoperative week when compared with laser‐irradiated skin that had not received topical vitamin C.4
I prefer using ascorbic acid in patients before and after procedures involving fillers, toxins, skin tightening, and nonablative lasers. In my experience, this improves collagen production. Also, I use ascorbic acid before microneedling, but not during or after. Several case reports have cited allergic granulomatous reactions when ascorbic acid is used during microneedling procedures,5 although these reports did not involve aqueous formulations.
Defensin
Defensins are peptides that play an important role in wound repair. Defensin has exhibited the capacity to activate the leucine-rich repeat-containing G-protein–coupled receptors 5 and 6 (also known as LGR5+ and LGR6+) stem cells.6 This accelerates wound healing by stimulating LGR stem cells to form new keratinocytes that populate the epidermis.7 Using defensins prior to procedures would theoretically speed wound healing, but no studies have been published in this area. Anecdotally, it has been used after microneedling without complication. I have not used defensin in this situation, but when I have asked the audience during lectures, many practitioners have reported using it and found that it accelerates healing.
Growth factors
Growth factors are essential in the skin because they are responsible for immunomodulation, regulation of cell division, wound healing, and tissue generation.1 There are several important growth factor families, including: transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF).2 Because of the numerous different variables that play a role with growth factor function, it is difficult to know exactly which combinations are the most helpful to improve outcomes after procedures. There is some evidence to support the use of FGF, TGF-beta, and EGF, IGF, and PDGF to hasten skin healing.8,9 It is certain that growth factors play an important role in pre- and postprocedure skincare, but we do not yet know which growth factor combinations are the most effective.
Heparan sulfate
Heparan sulfate is a glycosaminoglycan found in the skin. Older cells are less responsive to growth factors than are younger cells; therefore, it is desirable to amplify the growth factor signal in older patients. Heparan sulfate has been shown to contribute to growth factors reaching the receptors on the cell surface and enhancing the cell’s ability to “hear” growth factor signals. Combining growth factors with enhancers such as heparan sulfate, defensins, ascorbic acid, and matrikines can improve outcomes of cosmetic procedures. There are not enough studies yet to substantiate which combinations are the most effective. However, I believe that if you are using a growth factor–containing product after a procedure, you should combine it with heparan sulfate to improve efficacy.
Heparan sulfate is not the same as the blood thinner heparin; however, it may affect clotting factors. It is prudent to stop heparan sulfate the day before a dermal filler procedure because of this theoretical risk. (I have not seen an increase in bruising in patients who use heparan sulfate prior to getting fillers.) I suggest using heparan sulfate–containing products with growth factors 24 hours after injecting fillers to try and enhance collagen synthesis that occurs after hyaluronic acid (HA) filler injections.10
Hyaluronic acid
Hyaluronic acid (HA) is known to increase penetration of drugs, as well as cosmeceutical ingredients.11 For this reason, it is often used before a procedure to increase efficacy of growth factors. Many practitioners report using it during microneedling to help the device glide across the skin. I have not observed or heard of any reports of adverse events from using it during microneedling.
HA has been shown to accelerate wound healing in rats12 and dental procedures.13 For this reason, it is often used after laser resurfacing and microneedling procedures and on sutured and open wounds. HA can vary in chain link and molecular weight and whether or not it is cross linked. These differences affect efficacy and should be taken into consideration when choosing an HA product. Some formulations combine various forms of HA. Because HA may increase bruising because of its effects on fibrin formation,14 I prefer not to use it 2 days prior to or the day of filler injections.15
Hydroxy acids
Pretreating skin with hydroxy acids increases dermal matrix formation,16 promotes collagen synthesis,17 and hastens stratum corneum turnover.18 Although postprocedure healing times after pretreatment with hydroxy acids has not been studied, it is very likely that pretreatment with hydroxy acids speeds healing time by increasing collagen production and cell turnover. West and Alster showed that pretreating skin with hydroxy acids prior to CO2 resurfacing did not affect the incidence of postprocedure hyperpigmentation.19
Matrikines
Matrikines are peptides that occur when extracellular matrix (ECM) macromolecules are partially degraded. These peptides interact with cell surface receptors and activate intracellular signalling pathways to modulate ECM remodeling.20 Matrikines, such as tripeptides and hexapeptides, have been shown to remove damaged collagen and elastin from the ECM.21 It is thought that these matrikines help to prepare the skin for procedures by freeing up space to allow room for newly formed collagen. Using matrikines at least 2 weeks before procedures may precondition the skin to heal faster.22
The tripeptide glycyl-histidyl-lysine (GHK) is a good example of a matrikine. When it forms a complex with copper (II) ions (GHK–Cu) it can stimulate collagen and glycosaminoglycan synthesis23 and increase tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-2, which play a role in wound remodeling.24
A serum that contains tripeptide-1, hexapeptide-12, lactoferrin, and phosphatidyl serine has been shown to speed resolution of bruises and inflammation when applied after procedures. It is believed that these ingredients activate macrophages to clear hemosiderin from the skin.
Retinoids
Derived from vitamin A, the retinoid family includes compounds such as adapalene, retinol, tazarotene, trifarotene, and tretinoin. Retinoids should be used for at least 2-4 weeks prior to procedures to improve outcomes. Multiple studies have cogently revealed that pretreatment with tretinoin accelerates wound healing.25-27 Kligman assessed healing after punch biopsy in the mid-1990s and found that the wounds on arms pretreated with tretinoin cream 0.05%-0.1% were significantly diminished by 35%-37% on days 1 and 4 and 47%-50% reduced on days 6, 8, and 11 as compared with the wounds on untreated arms.28 A tretinoin pretreatment regimen of 2-4 weeks is supported by the preponderance of studies29 because peak epidermal hypertrophy emerges after 7 days of tretinoin application and normalizes after 14 days of continued treatment.30 Such an approach gives the skin time to recover from any retinoid dermatitis before the procedure is performed. Pretreatment with adapalene requires an earlier initiation period and should be introduced 5-6 weeks before procedures because it exhibits a longer half-life.31
Topical retinoids should not be used after a procedure until re-epithelialization is complete. Hung et al. applied 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding in a porcine model, with results revealing that re-epithelialization was accelerated with preprocedure treatment while use after the procedure slowed wound healing.32
Skin care regimen design by procedure type
Procedures can be divided into six main types: nonablative, such as peels, intense pulsed light (IPL), and vascular or pigmented lasers; microneedling or other procedures that cause open channels into the dermis; injectables such as toxins and fillers; ablative, such as CO2, erbium, and fractionated lasers; sutured wounds; and unsutured wounds. Skincare regimens that are prescribed before and after each of these procedures should take into account the Baumann Skin Type, the procedure type, whether it is pre- or postprocedure, and lifestyle issues such as sun exposure. Once the pre- and postprocedure regimen has been designed, patients should be given specific instructions as to which brands, the exact products, and the order in which to apply them.
Conclusion
To ensure the best outcomes from surgical treatments, patient education is a key step. The more that patients know and understand about the ways in which they can prepare for their procedure and treat their skin after the procedure, the better the results. Providers should give this type of information in an easy-to-follow printed instruction sheet because studies show that patients cannot remember most of the oral instructions offered by practitioners. Patients should be encouraged to ask questions during their consultation and procedure and to express any concerns with the practitioner’s office should any arise after they have returned home. These steps help improve patient compliance, satisfaction, and outcomes. Please discuss your opinions and experience with me on LinkedIn. You can also see a lecture on this topic on my website, SkinGuru.com.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), as well as a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. Write to her at dermnews@mdedge.com.
References
1. Murad S et al. Proc Natl Acad Sci U S A. 1981 May;78(5):2879-82.
2. Tajima S, Pinnell SR. J Dermatol Sci. 1996 Mar;11(3):250-3.
3. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
4. Alster TS, West TB. Dermatol Surg. 1998 Mar;24(3):331-4.
5. Soltani-Arabshahi R et al. JAMA Dermatol. 2014 Jan;150(1):68-72.
6. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
7. Hirsch T et al. J Gene Med. 2009 Mar;11(3):220-8.
8. Van Brunt J, Klausner A. Nat Biotechnol. 1988 Jan 1;6:25-30.
9. Lynch SE et al. J Clin Invest. 1989 Aug;84(2):640-6.
10. Wang F et al. Arch Dermatol. 2007 Feb;143(2):155-63.
11. Huang G, Huang H. Drug Deliv. 2018 Nov;25(1):766-72.
12. Celani LM. J Surg Clin Res. 2019 Oct. doi: 10.20398/jscr.v10i2.18825.
13. Yildirim S et al. J Periodontol. 2018 Jan;89(1):36-45.
14. Weigel PH et al. Ciba Found Symp. 1989;143:248-61; discussion 261-4, 281-5.
15. Basora JF et al. Am J Case Rep. 2014 May 9;15:199-202.
16. Okano Yet al. Exp Dermatol. 2003;12 Suppl 2:57-63.
17. Bernstein EF et al. Dermatol Surg. 2001 May;27(5):429-33.
18. Hood HL et al. Food Chem Toxicol. 1999 Nov;37(11):1105-11.
19. West TB, Alster TS. Dermatol Surg. 1999 Jan;25(1):15-7.
20. Maquart FX et al. M. Biochimie. 2005 Mar-Apr;87(3-4):353-60.
21. Pickart L et al. Biomed Res Int. 2015;2015:648108.
22. Widgerow AD et al. Aesthet Surg J. 2019 Apr 8;39 (Supplement 3):S103-11.
23. Maquart FX et al. FEBS Lett. 1988 Oct 10;238(2):343-6.
24. Siméon A et al. J Invest Dermatol. 1999 Jun;112(6):957-64.
25. Vagotis FL, Brundage SR. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
26. Stuzin JM. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
27. Elson ML. J Am Acad Dermatol. 1998 Aug;39:S79-81.
28. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
29. Orringer JS et al. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
30. Kim IH et al. J Korean Med Sci. 1996 Aug;11(4):335-41.
31. Basak PY et al. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
32. Hung VC et al. Arch Dermatol. 1989 Jan;125(1):65-9.
Outcomes are improved when proper skincare is practiced before and after any type of dermatologic procedure. This column reviews These are ingredients commonly used before, during, and after procedures.
I will use the first person when I am expressing my personal opinion or experience versus data reported in published studies that I reference.
Ascorbic acid
Ascorbic acid (vitamin C) is an essential cofactor necessary for lysyl hydroxylase and prolyl hydroxylase to produce collagen. Many studies have demonstrated that the use of oral and topical ascorbic acid increases collagen production by fibroblasts.1-3 Several different ascorbic acid products, varying greatly in quality, are available on the market.
Ascorbic acid is very sensitive to light and air exposure and does not penetrate well if not at a pH of 2 or 2.5. There are aqueous and lipophilic formulations. Some are produced from L-ascorbic acid, while others are made from ascorbyl palmitate, or salts such as calcium ascorbate, magnesium ascorbate, magnesium ascorbyl phosphate, sodium ascorbate, and sodium ascorbyl phosphate. Consequently, one must closely evaluate any chosen ascorbic acid preparation and pay close attention to the form used in any studies. I am discussing ascorbic acid in general, but my statements only apply to properly formulated products. Most of the studies I quote used L-ascorbic acid, which is the form studied by the late Sheldon Pinnell, MD, who was an expert on ascorbic acid.
Properly formulated L-ascorbic acid products have a low pH. Unless formulated specifically to deter stinging, these low-pH preparations will sting wounded skin. For this reason, most ascorbic acid preparations should be avoided until the skin has completely re-epithelialized. I prefer using it preprocedure and after the procedure once the skin has re-epithelialized. Alster and West showed that use of ascorbic acid – in an aqueous solution formulated not to sting – after laser resurfacing resulted in a significant decrease in post‐CO2 laser resurfacing erythema by the eighth postoperative week when compared with laser‐irradiated skin that had not received topical vitamin C.4
I prefer using ascorbic acid in patients before and after procedures involving fillers, toxins, skin tightening, and nonablative lasers. In my experience, this improves collagen production. Also, I use ascorbic acid before microneedling, but not during or after. Several case reports have cited allergic granulomatous reactions when ascorbic acid is used during microneedling procedures,5 although these reports did not involve aqueous formulations.
Defensin
Defensins are peptides that play an important role in wound repair. Defensin has exhibited the capacity to activate the leucine-rich repeat-containing G-protein–coupled receptors 5 and 6 (also known as LGR5+ and LGR6+) stem cells.6 This accelerates wound healing by stimulating LGR stem cells to form new keratinocytes that populate the epidermis.7 Using defensins prior to procedures would theoretically speed wound healing, but no studies have been published in this area. Anecdotally, it has been used after microneedling without complication. I have not used defensin in this situation, but when I have asked the audience during lectures, many practitioners have reported using it and found that it accelerates healing.
Growth factors
Growth factors are essential in the skin because they are responsible for immunomodulation, regulation of cell division, wound healing, and tissue generation.1 There are several important growth factor families, including: transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF).2 Because of the numerous different variables that play a role with growth factor function, it is difficult to know exactly which combinations are the most helpful to improve outcomes after procedures. There is some evidence to support the use of FGF, TGF-beta, and EGF, IGF, and PDGF to hasten skin healing.8,9 It is certain that growth factors play an important role in pre- and postprocedure skincare, but we do not yet know which growth factor combinations are the most effective.
Heparan sulfate
Heparan sulfate is a glycosaminoglycan found in the skin. Older cells are less responsive to growth factors than are younger cells; therefore, it is desirable to amplify the growth factor signal in older patients. Heparan sulfate has been shown to contribute to growth factors reaching the receptors on the cell surface and enhancing the cell’s ability to “hear” growth factor signals. Combining growth factors with enhancers such as heparan sulfate, defensins, ascorbic acid, and matrikines can improve outcomes of cosmetic procedures. There are not enough studies yet to substantiate which combinations are the most effective. However, I believe that if you are using a growth factor–containing product after a procedure, you should combine it with heparan sulfate to improve efficacy.
Heparan sulfate is not the same as the blood thinner heparin; however, it may affect clotting factors. It is prudent to stop heparan sulfate the day before a dermal filler procedure because of this theoretical risk. (I have not seen an increase in bruising in patients who use heparan sulfate prior to getting fillers.) I suggest using heparan sulfate–containing products with growth factors 24 hours after injecting fillers to try and enhance collagen synthesis that occurs after hyaluronic acid (HA) filler injections.10
Hyaluronic acid
Hyaluronic acid (HA) is known to increase penetration of drugs, as well as cosmeceutical ingredients.11 For this reason, it is often used before a procedure to increase efficacy of growth factors. Many practitioners report using it during microneedling to help the device glide across the skin. I have not observed or heard of any reports of adverse events from using it during microneedling.
HA has been shown to accelerate wound healing in rats12 and dental procedures.13 For this reason, it is often used after laser resurfacing and microneedling procedures and on sutured and open wounds. HA can vary in chain link and molecular weight and whether or not it is cross linked. These differences affect efficacy and should be taken into consideration when choosing an HA product. Some formulations combine various forms of HA. Because HA may increase bruising because of its effects on fibrin formation,14 I prefer not to use it 2 days prior to or the day of filler injections.15
Hydroxy acids
Pretreating skin with hydroxy acids increases dermal matrix formation,16 promotes collagen synthesis,17 and hastens stratum corneum turnover.18 Although postprocedure healing times after pretreatment with hydroxy acids has not been studied, it is very likely that pretreatment with hydroxy acids speeds healing time by increasing collagen production and cell turnover. West and Alster showed that pretreating skin with hydroxy acids prior to CO2 resurfacing did not affect the incidence of postprocedure hyperpigmentation.19
Matrikines
Matrikines are peptides that occur when extracellular matrix (ECM) macromolecules are partially degraded. These peptides interact with cell surface receptors and activate intracellular signalling pathways to modulate ECM remodeling.20 Matrikines, such as tripeptides and hexapeptides, have been shown to remove damaged collagen and elastin from the ECM.21 It is thought that these matrikines help to prepare the skin for procedures by freeing up space to allow room for newly formed collagen. Using matrikines at least 2 weeks before procedures may precondition the skin to heal faster.22
The tripeptide glycyl-histidyl-lysine (GHK) is a good example of a matrikine. When it forms a complex with copper (II) ions (GHK–Cu) it can stimulate collagen and glycosaminoglycan synthesis23 and increase tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-2, which play a role in wound remodeling.24
A serum that contains tripeptide-1, hexapeptide-12, lactoferrin, and phosphatidyl serine has been shown to speed resolution of bruises and inflammation when applied after procedures. It is believed that these ingredients activate macrophages to clear hemosiderin from the skin.
Retinoids
Derived from vitamin A, the retinoid family includes compounds such as adapalene, retinol, tazarotene, trifarotene, and tretinoin. Retinoids should be used for at least 2-4 weeks prior to procedures to improve outcomes. Multiple studies have cogently revealed that pretreatment with tretinoin accelerates wound healing.25-27 Kligman assessed healing after punch biopsy in the mid-1990s and found that the wounds on arms pretreated with tretinoin cream 0.05%-0.1% were significantly diminished by 35%-37% on days 1 and 4 and 47%-50% reduced on days 6, 8, and 11 as compared with the wounds on untreated arms.28 A tretinoin pretreatment regimen of 2-4 weeks is supported by the preponderance of studies29 because peak epidermal hypertrophy emerges after 7 days of tretinoin application and normalizes after 14 days of continued treatment.30 Such an approach gives the skin time to recover from any retinoid dermatitis before the procedure is performed. Pretreatment with adapalene requires an earlier initiation period and should be introduced 5-6 weeks before procedures because it exhibits a longer half-life.31
Topical retinoids should not be used after a procedure until re-epithelialization is complete. Hung et al. applied 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding in a porcine model, with results revealing that re-epithelialization was accelerated with preprocedure treatment while use after the procedure slowed wound healing.32
Skin care regimen design by procedure type
Procedures can be divided into six main types: nonablative, such as peels, intense pulsed light (IPL), and vascular or pigmented lasers; microneedling or other procedures that cause open channels into the dermis; injectables such as toxins and fillers; ablative, such as CO2, erbium, and fractionated lasers; sutured wounds; and unsutured wounds. Skincare regimens that are prescribed before and after each of these procedures should take into account the Baumann Skin Type, the procedure type, whether it is pre- or postprocedure, and lifestyle issues such as sun exposure. Once the pre- and postprocedure regimen has been designed, patients should be given specific instructions as to which brands, the exact products, and the order in which to apply them.
Conclusion
To ensure the best outcomes from surgical treatments, patient education is a key step. The more that patients know and understand about the ways in which they can prepare for their procedure and treat their skin after the procedure, the better the results. Providers should give this type of information in an easy-to-follow printed instruction sheet because studies show that patients cannot remember most of the oral instructions offered by practitioners. Patients should be encouraged to ask questions during their consultation and procedure and to express any concerns with the practitioner’s office should any arise after they have returned home. These steps help improve patient compliance, satisfaction, and outcomes. Please discuss your opinions and experience with me on LinkedIn. You can also see a lecture on this topic on my website, SkinGuru.com.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), as well as a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. Write to her at dermnews@mdedge.com.
References
1. Murad S et al. Proc Natl Acad Sci U S A. 1981 May;78(5):2879-82.
2. Tajima S, Pinnell SR. J Dermatol Sci. 1996 Mar;11(3):250-3.
3. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
4. Alster TS, West TB. Dermatol Surg. 1998 Mar;24(3):331-4.
5. Soltani-Arabshahi R et al. JAMA Dermatol. 2014 Jan;150(1):68-72.
6. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
7. Hirsch T et al. J Gene Med. 2009 Mar;11(3):220-8.
8. Van Brunt J, Klausner A. Nat Biotechnol. 1988 Jan 1;6:25-30.
9. Lynch SE et al. J Clin Invest. 1989 Aug;84(2):640-6.
10. Wang F et al. Arch Dermatol. 2007 Feb;143(2):155-63.
11. Huang G, Huang H. Drug Deliv. 2018 Nov;25(1):766-72.
12. Celani LM. J Surg Clin Res. 2019 Oct. doi: 10.20398/jscr.v10i2.18825.
13. Yildirim S et al. J Periodontol. 2018 Jan;89(1):36-45.
14. Weigel PH et al. Ciba Found Symp. 1989;143:248-61; discussion 261-4, 281-5.
15. Basora JF et al. Am J Case Rep. 2014 May 9;15:199-202.
16. Okano Yet al. Exp Dermatol. 2003;12 Suppl 2:57-63.
17. Bernstein EF et al. Dermatol Surg. 2001 May;27(5):429-33.
18. Hood HL et al. Food Chem Toxicol. 1999 Nov;37(11):1105-11.
19. West TB, Alster TS. Dermatol Surg. 1999 Jan;25(1):15-7.
20. Maquart FX et al. M. Biochimie. 2005 Mar-Apr;87(3-4):353-60.
21. Pickart L et al. Biomed Res Int. 2015;2015:648108.
22. Widgerow AD et al. Aesthet Surg J. 2019 Apr 8;39 (Supplement 3):S103-11.
23. Maquart FX et al. FEBS Lett. 1988 Oct 10;238(2):343-6.
24. Siméon A et al. J Invest Dermatol. 1999 Jun;112(6):957-64.
25. Vagotis FL, Brundage SR. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
26. Stuzin JM. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
27. Elson ML. J Am Acad Dermatol. 1998 Aug;39:S79-81.
28. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
29. Orringer JS et al. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
30. Kim IH et al. J Korean Med Sci. 1996 Aug;11(4):335-41.
31. Basak PY et al. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
32. Hung VC et al. Arch Dermatol. 1989 Jan;125(1):65-9.
2019-nCoV outbreak: A few lessons learned for pediatric practices
In late January, signs were posted in all of the offices in our faculty medical practice building.
Combined with current worldwide health concerns and flu season, we are now asking all patients two questions:
1. Do you have a fever, cough or shortness of breath?
2. Have you traveled to China in the last 2 weeks, or have you had contact with someone who has and who now is sick?
Similar signs appeared in medical offices and EDs across the city. Truth be told, when the signs first went up, some thought it was an overreaction. I practice in a city in the Southeast that is not a port of entry and has no scheduled international passenger flights. Wuhan City, China and the threat of 2019 novel coronavirus (2019-nCoV) seemed very far away.
As the international tally of cases has grown, so have local concerns.
Hopefully, proactive public health measures to care for the few individuals currently infected in the United States and appropriately assessing individuals arriving from mainland China will prevent widespread circulation of 2019-nCoV here. If this is the case, most of us likely will never see a case of the virus. Still, there are important lessons to be learned from current preparedness efforts.
A travel history is important. Several years ago, during the height of concern over the spread of Ebola, the health care systems in which I practice asked everyone about travel to West Africa as soon as they approached the registration desk. In the intervening years, asking about a travel history largely was delegated to providers, and I suspect it largely was driven by patient presentation. Child presenting with 10 days of fever? The clinician likely took a travel history. Child presenting for runny nose, ear ache, or rash? Maybe not. With more consistent screening, we are learning how frequently our patients and their families do travel, and that is helping us expand our differential diagnosis.
We need to practice cough etiquette. Patients who endorse respiratory symptoms as part of 2019 n-CoV screening are handed a mask. Those who have traveled to China in the last 14 days are promptly escorted to an exam room. In truth, we should be following cough etiquette and offering all patients with respiratory symptoms a mask. Heightened awareness of this practice may help prevent the spread of much more common viruses such as influenza. Reliable processes to recognize and rapidly triage patients with an infectious illness are critically important in ambulatory settings, and now we have an opportunity to trial and improve these processes. No one wants a child with measles or chicken pox to sit in the waiting room!
Offices must stock personal protective equipment to comply with standard precautions. The recommended PPE when caring for a patient with 2019 n-CoV includes a gown, gloves, mask (n95 or PAPR if available), and eye protection, such as a face shield or goggles. An initial survey of PPE supplies locally revealed of shortage of PPE for eye protection in some offices. Eye protection should be readily available in pediatric and other primary care offices because it must be used as part of standard precautions during procedures likely to generate droplets of blood or body fluids. Examples of common procedures that require eye protection include swabbing the nasopharynx to obtain a specimen for respiratory virus testing or swabbing the throat to test for group A streptococcus.
We should use diagnostic testing judiciously. Over the last couple of weeks, we’ve had a couple of patients who wanted to be tested for 2019 n-CoV but did not meet person under investigation (PUI) criteria. Public health authorities, who must approve all 2019 n-CoV testing, said no. This is enforced diagnostic stewardship, but it is a reminder that, when a diagnostic test is performed in a person with a low likelihood of disease, there is a risk of a false-positive result. What if we applied this principle to tests we send routinely? We would send fewer urine cultures in patients with normal urinalyses and stop testing infants for Clostridioides difficile.
Frontline providers must partner with public health colleagues during outbreaks. Providers have been instructed to immediately notify local or state health departments when a patient is suspected of having 2019 n-CoV specifically because the PUI criteria are met. This notification was crucial in diagnosing the first cases of 2019 n-CoV in the United States. Nine of the first 11 U.S. cases were in travelers from Wuhan, and according to the Centers for Disease Control and Prevention, eight of these “were identified as a result of patients seeking clinical care for symptoms and clinicians connecting with the appropriate public health systems.” Locally, daytime and after hours phone numbers for the health department have been posted in offices across our health care system. The state health department is hosting well-attended webinars to provide updates and answer questions from clinicians. We may never have a case of 2019 n-CoV in Kentucky, but activities like these build relationships between providers and our colleagues in public health, strengthening infrastructure and the capacity to respond to future outbreaks. I suspect the same is true in many other communities.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
In late January, signs were posted in all of the offices in our faculty medical practice building.
Combined with current worldwide health concerns and flu season, we are now asking all patients two questions:
1. Do you have a fever, cough or shortness of breath?
2. Have you traveled to China in the last 2 weeks, or have you had contact with someone who has and who now is sick?
Similar signs appeared in medical offices and EDs across the city. Truth be told, when the signs first went up, some thought it was an overreaction. I practice in a city in the Southeast that is not a port of entry and has no scheduled international passenger flights. Wuhan City, China and the threat of 2019 novel coronavirus (2019-nCoV) seemed very far away.
As the international tally of cases has grown, so have local concerns.
Hopefully, proactive public health measures to care for the few individuals currently infected in the United States and appropriately assessing individuals arriving from mainland China will prevent widespread circulation of 2019-nCoV here. If this is the case, most of us likely will never see a case of the virus. Still, there are important lessons to be learned from current preparedness efforts.
A travel history is important. Several years ago, during the height of concern over the spread of Ebola, the health care systems in which I practice asked everyone about travel to West Africa as soon as they approached the registration desk. In the intervening years, asking about a travel history largely was delegated to providers, and I suspect it largely was driven by patient presentation. Child presenting with 10 days of fever? The clinician likely took a travel history. Child presenting for runny nose, ear ache, or rash? Maybe not. With more consistent screening, we are learning how frequently our patients and their families do travel, and that is helping us expand our differential diagnosis.
We need to practice cough etiquette. Patients who endorse respiratory symptoms as part of 2019 n-CoV screening are handed a mask. Those who have traveled to China in the last 14 days are promptly escorted to an exam room. In truth, we should be following cough etiquette and offering all patients with respiratory symptoms a mask. Heightened awareness of this practice may help prevent the spread of much more common viruses such as influenza. Reliable processes to recognize and rapidly triage patients with an infectious illness are critically important in ambulatory settings, and now we have an opportunity to trial and improve these processes. No one wants a child with measles or chicken pox to sit in the waiting room!
Offices must stock personal protective equipment to comply with standard precautions. The recommended PPE when caring for a patient with 2019 n-CoV includes a gown, gloves, mask (n95 or PAPR if available), and eye protection, such as a face shield or goggles. An initial survey of PPE supplies locally revealed of shortage of PPE for eye protection in some offices. Eye protection should be readily available in pediatric and other primary care offices because it must be used as part of standard precautions during procedures likely to generate droplets of blood or body fluids. Examples of common procedures that require eye protection include swabbing the nasopharynx to obtain a specimen for respiratory virus testing or swabbing the throat to test for group A streptococcus.
We should use diagnostic testing judiciously. Over the last couple of weeks, we’ve had a couple of patients who wanted to be tested for 2019 n-CoV but did not meet person under investigation (PUI) criteria. Public health authorities, who must approve all 2019 n-CoV testing, said no. This is enforced diagnostic stewardship, but it is a reminder that, when a diagnostic test is performed in a person with a low likelihood of disease, there is a risk of a false-positive result. What if we applied this principle to tests we send routinely? We would send fewer urine cultures in patients with normal urinalyses and stop testing infants for Clostridioides difficile.
Frontline providers must partner with public health colleagues during outbreaks. Providers have been instructed to immediately notify local or state health departments when a patient is suspected of having 2019 n-CoV specifically because the PUI criteria are met. This notification was crucial in diagnosing the first cases of 2019 n-CoV in the United States. Nine of the first 11 U.S. cases were in travelers from Wuhan, and according to the Centers for Disease Control and Prevention, eight of these “were identified as a result of patients seeking clinical care for symptoms and clinicians connecting with the appropriate public health systems.” Locally, daytime and after hours phone numbers for the health department have been posted in offices across our health care system. The state health department is hosting well-attended webinars to provide updates and answer questions from clinicians. We may never have a case of 2019 n-CoV in Kentucky, but activities like these build relationships between providers and our colleagues in public health, strengthening infrastructure and the capacity to respond to future outbreaks. I suspect the same is true in many other communities.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
In late January, signs were posted in all of the offices in our faculty medical practice building.
Combined with current worldwide health concerns and flu season, we are now asking all patients two questions:
1. Do you have a fever, cough or shortness of breath?
2. Have you traveled to China in the last 2 weeks, or have you had contact with someone who has and who now is sick?
Similar signs appeared in medical offices and EDs across the city. Truth be told, when the signs first went up, some thought it was an overreaction. I practice in a city in the Southeast that is not a port of entry and has no scheduled international passenger flights. Wuhan City, China and the threat of 2019 novel coronavirus (2019-nCoV) seemed very far away.
As the international tally of cases has grown, so have local concerns.
Hopefully, proactive public health measures to care for the few individuals currently infected in the United States and appropriately assessing individuals arriving from mainland China will prevent widespread circulation of 2019-nCoV here. If this is the case, most of us likely will never see a case of the virus. Still, there are important lessons to be learned from current preparedness efforts.
A travel history is important. Several years ago, during the height of concern over the spread of Ebola, the health care systems in which I practice asked everyone about travel to West Africa as soon as they approached the registration desk. In the intervening years, asking about a travel history largely was delegated to providers, and I suspect it largely was driven by patient presentation. Child presenting with 10 days of fever? The clinician likely took a travel history. Child presenting for runny nose, ear ache, or rash? Maybe not. With more consistent screening, we are learning how frequently our patients and their families do travel, and that is helping us expand our differential diagnosis.
We need to practice cough etiquette. Patients who endorse respiratory symptoms as part of 2019 n-CoV screening are handed a mask. Those who have traveled to China in the last 14 days are promptly escorted to an exam room. In truth, we should be following cough etiquette and offering all patients with respiratory symptoms a mask. Heightened awareness of this practice may help prevent the spread of much more common viruses such as influenza. Reliable processes to recognize and rapidly triage patients with an infectious illness are critically important in ambulatory settings, and now we have an opportunity to trial and improve these processes. No one wants a child with measles or chicken pox to sit in the waiting room!
Offices must stock personal protective equipment to comply with standard precautions. The recommended PPE when caring for a patient with 2019 n-CoV includes a gown, gloves, mask (n95 or PAPR if available), and eye protection, such as a face shield or goggles. An initial survey of PPE supplies locally revealed of shortage of PPE for eye protection in some offices. Eye protection should be readily available in pediatric and other primary care offices because it must be used as part of standard precautions during procedures likely to generate droplets of blood or body fluids. Examples of common procedures that require eye protection include swabbing the nasopharynx to obtain a specimen for respiratory virus testing or swabbing the throat to test for group A streptococcus.
We should use diagnostic testing judiciously. Over the last couple of weeks, we’ve had a couple of patients who wanted to be tested for 2019 n-CoV but did not meet person under investigation (PUI) criteria. Public health authorities, who must approve all 2019 n-CoV testing, said no. This is enforced diagnostic stewardship, but it is a reminder that, when a diagnostic test is performed in a person with a low likelihood of disease, there is a risk of a false-positive result. What if we applied this principle to tests we send routinely? We would send fewer urine cultures in patients with normal urinalyses and stop testing infants for Clostridioides difficile.
Frontline providers must partner with public health colleagues during outbreaks. Providers have been instructed to immediately notify local or state health departments when a patient is suspected of having 2019 n-CoV specifically because the PUI criteria are met. This notification was crucial in diagnosing the first cases of 2019 n-CoV in the United States. Nine of the first 11 U.S. cases were in travelers from Wuhan, and according to the Centers for Disease Control and Prevention, eight of these “were identified as a result of patients seeking clinical care for symptoms and clinicians connecting with the appropriate public health systems.” Locally, daytime and after hours phone numbers for the health department have been posted in offices across our health care system. The state health department is hosting well-attended webinars to provide updates and answer questions from clinicians. We may never have a case of 2019 n-CoV in Kentucky, but activities like these build relationships between providers and our colleagues in public health, strengthening infrastructure and the capacity to respond to future outbreaks. I suspect the same is true in many other communities.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
Work the program for NP/PAs, and the program will work
A ‘knowledge gap’ in best practices exists
Hospital medicine has been the fastest growing medical specialty since the term “hospitalist” was coined by Bob Wachter, MD, in the famous 1996 New England Journal of Medicine article (doi: 10.1056/NEJM199608153350713). The growth and change within this specialty is also reflected in the changing and migrating target of hospitals and hospital systems as they continue to effectively and safely move from fee-for-service to a payer model that rewards value and improvement in the health of a population – both in and outside of hospital walls.
In a short time, nurse practitioners and physician assistants have become a growing population in the hospital medicine workforce. The 2018 State of Hospital Medicine Report notes a 42% increase in 4 years, and about 75% of hospital medicine groups across the country currently incorporate NP/PAs within a hospital medicine practice. This evolution has occurred in the setting of a looming and well-documented physician shortage, a variety of cost pressures on hospitals that reflect the need for an efficient and cost-effective care delivery model, an increasing NP/PA workforce (the Department of Labor notes increases of 35% and 36% respectively by 2036), and data that indicates similar outcomes, for example, HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems), readmission, and morbidity and mortality in NP/PA-driven care.
This evolution, however, reveals a true knowledge gap in best practices related to integration of these providers. This is impacted by wide variability in the preparation of NPs – they may enter hospitalist practice from a variety of clinical exposures and training, for example, adult gerontology acute care, adult, or even, in some states, family NPs. For PAs, this is reflected in the variety of clinical rotations and pregraduate clinical exposure.
This variability is compounded, too, by the lack of standardization of hospital medicine practices, both with site size and patient acuity, a variety of challenges that drive the need for integration of NP/PA providers, and by-laws that define advanced practice clinical models and function.
In that perspective, it is important to define what constitutes a leading and successful advanced practice provider (APP) integration program. I would suggest:
- A structured and formalized transition-to-practice program for all new graduates and those new to hospital medicine. This program should consist of clinical volume progression, formalized didactic congruent with the Society of Hospital Medicine Core Competencies, and a process for evaluating knowledge and decision making throughout the program and upon completion.
- Development of physician competencies related to APP integration. Physicians are not prepared in their medical school training or residency to understand the differences and similarities of NP/PA providers. These competencies should be required and can best be developed through steady leadership, formalized instruction and accountability for professional teamwork.
- Allowance for NP/PA providers to work at the top of their skills and license. This means utilizing NP/PAs as providers who care for patients – not as scribes or clerical workers. The evolution of the acuity of patients provided for may evolve with the skill set and experience of NP/PAs, but it will evolve – especially if steps 1 and 2 are in place.
- Productivity expectations that reach near physician level of volume. In 2016 State of Hospital Medicine Report data, yearly billable encounters for NP/PAs were within 10% of that of physicians. I think 15% is a reasonable goal.
- Implementation and support of APP administrative leadership structure at the system/site level. This can be as simple as having APPs on the same leadership committees as physician team members, being involved in hiring and training newer physicians and NP/PAs or as broad as having all NP/PAs report to an APP leader. Having an intentional leadership structure that demonstrates and reflects inclusivity and belonging is crucial.
Consistent application of these frameworks will provide a strong infrastructure for successful NP/PA practice.
Ms. Cardin is currently the vice president of advanced practice providers at Sound Physicians and serves on SHM’s board of directors as its secretary. This article appeared initially at the Hospital Leader, the official blog of SHM.
A ‘knowledge gap’ in best practices exists
A ‘knowledge gap’ in best practices exists
Hospital medicine has been the fastest growing medical specialty since the term “hospitalist” was coined by Bob Wachter, MD, in the famous 1996 New England Journal of Medicine article (doi: 10.1056/NEJM199608153350713). The growth and change within this specialty is also reflected in the changing and migrating target of hospitals and hospital systems as they continue to effectively and safely move from fee-for-service to a payer model that rewards value and improvement in the health of a population – both in and outside of hospital walls.
In a short time, nurse practitioners and physician assistants have become a growing population in the hospital medicine workforce. The 2018 State of Hospital Medicine Report notes a 42% increase in 4 years, and about 75% of hospital medicine groups across the country currently incorporate NP/PAs within a hospital medicine practice. This evolution has occurred in the setting of a looming and well-documented physician shortage, a variety of cost pressures on hospitals that reflect the need for an efficient and cost-effective care delivery model, an increasing NP/PA workforce (the Department of Labor notes increases of 35% and 36% respectively by 2036), and data that indicates similar outcomes, for example, HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems), readmission, and morbidity and mortality in NP/PA-driven care.
This evolution, however, reveals a true knowledge gap in best practices related to integration of these providers. This is impacted by wide variability in the preparation of NPs – they may enter hospitalist practice from a variety of clinical exposures and training, for example, adult gerontology acute care, adult, or even, in some states, family NPs. For PAs, this is reflected in the variety of clinical rotations and pregraduate clinical exposure.
This variability is compounded, too, by the lack of standardization of hospital medicine practices, both with site size and patient acuity, a variety of challenges that drive the need for integration of NP/PA providers, and by-laws that define advanced practice clinical models and function.
In that perspective, it is important to define what constitutes a leading and successful advanced practice provider (APP) integration program. I would suggest:
- A structured and formalized transition-to-practice program for all new graduates and those new to hospital medicine. This program should consist of clinical volume progression, formalized didactic congruent with the Society of Hospital Medicine Core Competencies, and a process for evaluating knowledge and decision making throughout the program and upon completion.
- Development of physician competencies related to APP integration. Physicians are not prepared in their medical school training or residency to understand the differences and similarities of NP/PA providers. These competencies should be required and can best be developed through steady leadership, formalized instruction and accountability for professional teamwork.
- Allowance for NP/PA providers to work at the top of their skills and license. This means utilizing NP/PAs as providers who care for patients – not as scribes or clerical workers. The evolution of the acuity of patients provided for may evolve with the skill set and experience of NP/PAs, but it will evolve – especially if steps 1 and 2 are in place.
- Productivity expectations that reach near physician level of volume. In 2016 State of Hospital Medicine Report data, yearly billable encounters for NP/PAs were within 10% of that of physicians. I think 15% is a reasonable goal.
- Implementation and support of APP administrative leadership structure at the system/site level. This can be as simple as having APPs on the same leadership committees as physician team members, being involved in hiring and training newer physicians and NP/PAs or as broad as having all NP/PAs report to an APP leader. Having an intentional leadership structure that demonstrates and reflects inclusivity and belonging is crucial.
Consistent application of these frameworks will provide a strong infrastructure for successful NP/PA practice.
Ms. Cardin is currently the vice president of advanced practice providers at Sound Physicians and serves on SHM’s board of directors as its secretary. This article appeared initially at the Hospital Leader, the official blog of SHM.
Hospital medicine has been the fastest growing medical specialty since the term “hospitalist” was coined by Bob Wachter, MD, in the famous 1996 New England Journal of Medicine article (doi: 10.1056/NEJM199608153350713). The growth and change within this specialty is also reflected in the changing and migrating target of hospitals and hospital systems as they continue to effectively and safely move from fee-for-service to a payer model that rewards value and improvement in the health of a population – both in and outside of hospital walls.
In a short time, nurse practitioners and physician assistants have become a growing population in the hospital medicine workforce. The 2018 State of Hospital Medicine Report notes a 42% increase in 4 years, and about 75% of hospital medicine groups across the country currently incorporate NP/PAs within a hospital medicine practice. This evolution has occurred in the setting of a looming and well-documented physician shortage, a variety of cost pressures on hospitals that reflect the need for an efficient and cost-effective care delivery model, an increasing NP/PA workforce (the Department of Labor notes increases of 35% and 36% respectively by 2036), and data that indicates similar outcomes, for example, HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems), readmission, and morbidity and mortality in NP/PA-driven care.
This evolution, however, reveals a true knowledge gap in best practices related to integration of these providers. This is impacted by wide variability in the preparation of NPs – they may enter hospitalist practice from a variety of clinical exposures and training, for example, adult gerontology acute care, adult, or even, in some states, family NPs. For PAs, this is reflected in the variety of clinical rotations and pregraduate clinical exposure.
This variability is compounded, too, by the lack of standardization of hospital medicine practices, both with site size and patient acuity, a variety of challenges that drive the need for integration of NP/PA providers, and by-laws that define advanced practice clinical models and function.
In that perspective, it is important to define what constitutes a leading and successful advanced practice provider (APP) integration program. I would suggest:
- A structured and formalized transition-to-practice program for all new graduates and those new to hospital medicine. This program should consist of clinical volume progression, formalized didactic congruent with the Society of Hospital Medicine Core Competencies, and a process for evaluating knowledge and decision making throughout the program and upon completion.
- Development of physician competencies related to APP integration. Physicians are not prepared in their medical school training or residency to understand the differences and similarities of NP/PA providers. These competencies should be required and can best be developed through steady leadership, formalized instruction and accountability for professional teamwork.
- Allowance for NP/PA providers to work at the top of their skills and license. This means utilizing NP/PAs as providers who care for patients – not as scribes or clerical workers. The evolution of the acuity of patients provided for may evolve with the skill set and experience of NP/PAs, but it will evolve – especially if steps 1 and 2 are in place.
- Productivity expectations that reach near physician level of volume. In 2016 State of Hospital Medicine Report data, yearly billable encounters for NP/PAs were within 10% of that of physicians. I think 15% is a reasonable goal.
- Implementation and support of APP administrative leadership structure at the system/site level. This can be as simple as having APPs on the same leadership committees as physician team members, being involved in hiring and training newer physicians and NP/PAs or as broad as having all NP/PAs report to an APP leader. Having an intentional leadership structure that demonstrates and reflects inclusivity and belonging is crucial.
Consistent application of these frameworks will provide a strong infrastructure for successful NP/PA practice.
Ms. Cardin is currently the vice president of advanced practice providers at Sound Physicians and serves on SHM’s board of directors as its secretary. This article appeared initially at the Hospital Leader, the official blog of SHM.
Be alert for embezzlement
With myriad complex, high-tech problems facing private practice in this modern era, I am periodically reminded by long-time readers to revisit some of the low-tech issues that will always require our attention.
Few are lower tech (in most cases) and more easily overlooked than theft from within. Embezzlement remains far more common in medical offices than generally assumed – and it often occurs in full view of physicians who think everything is fine. Most embezzlers are not skillful or discreet; their transgressions may go undetected for years, simply because no one suspects it is happening.
Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will prevent or expose the most common forms:
- Make it more difficult. Theft and embezzlement are usually products of opportunity, so minimize those opportunities. No one person should be in charge of the entire bookkeeping process: The person who enters charges should be different from the one who enters payments. The one who writes checks or makes electronic fund transfers should not balance the books, and so on. Internal audits should be done on a regular basis, and all employees should know that. Your accountant can help.
- Reconcile cash receipts daily. Embezzlement does not require sophisticated technology; the most common form is simply taking cash out of the till. In a typical scenario, a patient pays a copay of $15 in cash; the receptionist records the payment as $5, and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the charges, receipts, and cash totals daily.
- Inventory your stock. Cash isn’t the only susceptible commodity. If you sell cosmetics or other products, inventory your stock frequently. And office personnel are not the only potential thieves: Last year, a locum tenens physician down the street conspired with a receptionist to take cash transactions for cosmetic neurotoxins and fillers “off the books” and split the spoils. That office was being ripped off twice; first for the neurotoxin and filler materials themselves, and then for the cash proceeds.
- Separate all accounting duties. Another popular ploy is false invoicing for imaginary supplies. A friend’s experience provides a good example (retold with his permission): His bookkeeper wrote sizable checks to herself, disguising them in the ledger as payments to vendors commonly used by his practice. Since the same employee also balanced the checkbook, she got away with it for years. “It wasn’t at all clever,” he told me, “and I’m embarrassed to admit that it happened to me.” Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check or make the electronic transfer, and a third should match invoices to goods and services received.
- Verify expense reports. False expense reporting is a subset of the fake invoice scam. When an employee asks for reimbursement of expenses, make sure those expenses are real.
- Consider computer safeguards. Computers facilitate a lot of financial chores, but they also consolidate financial data in one place, where it is potentially accessible to anybody, anywhere. Your computer vendor should be aware of this, and there should be safeguards built into your system. Ask about them. If they aren’t there, ask why.
- Hire honest employees. All applicants look great on paper, so check their references; and with their permission, you can run background checks for a few dollars on any of several public information web sites. My columns on hiring are available on the MDedge Dermatology website.
- Look for “red flags.” Examples include employees who refuse to take vacations, because someone else will have do their work or who insist on posting expenses that are a coworker’s responsibility, “just to be nice.” Anyone obviously living beyond his or her means merits suspicion as well.
- Consider bonding your employees. Dishonesty bonds are relatively inexpensive, and provide assurance of some measure of recovery if your safeguards fail. Also, just knowing that your staff is bonded will scare off most dishonest applicants. One effective screen is a question on your employment application: “Would you object to being bonded?”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
With myriad complex, high-tech problems facing private practice in this modern era, I am periodically reminded by long-time readers to revisit some of the low-tech issues that will always require our attention.
Few are lower tech (in most cases) and more easily overlooked than theft from within. Embezzlement remains far more common in medical offices than generally assumed – and it often occurs in full view of physicians who think everything is fine. Most embezzlers are not skillful or discreet; their transgressions may go undetected for years, simply because no one suspects it is happening.
Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will prevent or expose the most common forms:
- Make it more difficult. Theft and embezzlement are usually products of opportunity, so minimize those opportunities. No one person should be in charge of the entire bookkeeping process: The person who enters charges should be different from the one who enters payments. The one who writes checks or makes electronic fund transfers should not balance the books, and so on. Internal audits should be done on a regular basis, and all employees should know that. Your accountant can help.
- Reconcile cash receipts daily. Embezzlement does not require sophisticated technology; the most common form is simply taking cash out of the till. In a typical scenario, a patient pays a copay of $15 in cash; the receptionist records the payment as $5, and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the charges, receipts, and cash totals daily.
- Inventory your stock. Cash isn’t the only susceptible commodity. If you sell cosmetics or other products, inventory your stock frequently. And office personnel are not the only potential thieves: Last year, a locum tenens physician down the street conspired with a receptionist to take cash transactions for cosmetic neurotoxins and fillers “off the books” and split the spoils. That office was being ripped off twice; first for the neurotoxin and filler materials themselves, and then for the cash proceeds.
- Separate all accounting duties. Another popular ploy is false invoicing for imaginary supplies. A friend’s experience provides a good example (retold with his permission): His bookkeeper wrote sizable checks to herself, disguising them in the ledger as payments to vendors commonly used by his practice. Since the same employee also balanced the checkbook, she got away with it for years. “It wasn’t at all clever,” he told me, “and I’m embarrassed to admit that it happened to me.” Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check or make the electronic transfer, and a third should match invoices to goods and services received.
- Verify expense reports. False expense reporting is a subset of the fake invoice scam. When an employee asks for reimbursement of expenses, make sure those expenses are real.
- Consider computer safeguards. Computers facilitate a lot of financial chores, but they also consolidate financial data in one place, where it is potentially accessible to anybody, anywhere. Your computer vendor should be aware of this, and there should be safeguards built into your system. Ask about them. If they aren’t there, ask why.
- Hire honest employees. All applicants look great on paper, so check their references; and with their permission, you can run background checks for a few dollars on any of several public information web sites. My columns on hiring are available on the MDedge Dermatology website.
- Look for “red flags.” Examples include employees who refuse to take vacations, because someone else will have do their work or who insist on posting expenses that are a coworker’s responsibility, “just to be nice.” Anyone obviously living beyond his or her means merits suspicion as well.
- Consider bonding your employees. Dishonesty bonds are relatively inexpensive, and provide assurance of some measure of recovery if your safeguards fail. Also, just knowing that your staff is bonded will scare off most dishonest applicants. One effective screen is a question on your employment application: “Would you object to being bonded?”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
With myriad complex, high-tech problems facing private practice in this modern era, I am periodically reminded by long-time readers to revisit some of the low-tech issues that will always require our attention.
Few are lower tech (in most cases) and more easily overlooked than theft from within. Embezzlement remains far more common in medical offices than generally assumed – and it often occurs in full view of physicians who think everything is fine. Most embezzlers are not skillful or discreet; their transgressions may go undetected for years, simply because no one suspects it is happening.
Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will prevent or expose the most common forms:
- Make it more difficult. Theft and embezzlement are usually products of opportunity, so minimize those opportunities. No one person should be in charge of the entire bookkeeping process: The person who enters charges should be different from the one who enters payments. The one who writes checks or makes electronic fund transfers should not balance the books, and so on. Internal audits should be done on a regular basis, and all employees should know that. Your accountant can help.
- Reconcile cash receipts daily. Embezzlement does not require sophisticated technology; the most common form is simply taking cash out of the till. In a typical scenario, a patient pays a copay of $15 in cash; the receptionist records the payment as $5, and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the charges, receipts, and cash totals daily.
- Inventory your stock. Cash isn’t the only susceptible commodity. If you sell cosmetics or other products, inventory your stock frequently. And office personnel are not the only potential thieves: Last year, a locum tenens physician down the street conspired with a receptionist to take cash transactions for cosmetic neurotoxins and fillers “off the books” and split the spoils. That office was being ripped off twice; first for the neurotoxin and filler materials themselves, and then for the cash proceeds.
- Separate all accounting duties. Another popular ploy is false invoicing for imaginary supplies. A friend’s experience provides a good example (retold with his permission): His bookkeeper wrote sizable checks to herself, disguising them in the ledger as payments to vendors commonly used by his practice. Since the same employee also balanced the checkbook, she got away with it for years. “It wasn’t at all clever,” he told me, “and I’m embarrassed to admit that it happened to me.” Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check or make the electronic transfer, and a third should match invoices to goods and services received.
- Verify expense reports. False expense reporting is a subset of the fake invoice scam. When an employee asks for reimbursement of expenses, make sure those expenses are real.
- Consider computer safeguards. Computers facilitate a lot of financial chores, but they also consolidate financial data in one place, where it is potentially accessible to anybody, anywhere. Your computer vendor should be aware of this, and there should be safeguards built into your system. Ask about them. If they aren’t there, ask why.
- Hire honest employees. All applicants look great on paper, so check their references; and with their permission, you can run background checks for a few dollars on any of several public information web sites. My columns on hiring are available on the MDedge Dermatology website.
- Look for “red flags.” Examples include employees who refuse to take vacations, because someone else will have do their work or who insist on posting expenses that are a coworker’s responsibility, “just to be nice.” Anyone obviously living beyond his or her means merits suspicion as well.
- Consider bonding your employees. Dishonesty bonds are relatively inexpensive, and provide assurance of some measure of recovery if your safeguards fail. Also, just knowing that your staff is bonded will scare off most dishonest applicants. One effective screen is a question on your employment application: “Would you object to being bonded?”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
Helping patients at the end of their lives
My wife thinks I am a little morbid, because I still read the local Sunday newspaper not to catch up on the news, and certainly not for the ads, but mostly to read the obituaries.
All of us have elderly patients, and I am growing old with many of my older patients. Now after treating many thousands of patients whom I have grown to know well, it is not unusual to see an obituary of someone my office staff and I know in the newspaper on a weekly basis.
We send sympathy cards, sometimes I write a personal note to the spouse or family, and several times a year, some of my staff and I will go to the funeral or memorial ceremony.
I usually ask if they died well, comfortably with family, or better yet, suddenly, dropping dead like a stone. This is the unspoken, though usually unrealized, goal of many of us from the world of medicine.
All physicians who have been surrounded by death, some horrible deaths, want to die well. I think it is difficult to do, although my mother came close.
One day when dropping off her best little friend (my 10-year-old daughter), she said “look here, I’ve got a knot in my belly button.” I felt the blood rushing to my head and before I could stop her, she showed me her Sister Mary Joseph nodule, a sign of metastatic internal malignancy. I sat stunned as she looked at me; her eyes showed she already knew my answer.
She lasted at home for 6 weeks, went into hospice, and died 36 hours later.
The last morning before she died, I took my daughter to see her before school. She woke up and called her “sugar” and had her climb into bed with her and snuggle. I got choked up and tearful and started telling her how much I loved her and how sorry I was and how much we would miss her. She looked over at me, and with anger in her voice, told me to be quiet, and explained that death comes to everyone eventually and just to get over it. In retrospect, I understand now that I was not helping her die well.
I am telling this story to bring up a point about professionalism. , this becomes important as the life cycle ends. Aged patients sometimes start blossoming with skin cancers. You must carefully gauge how much “treatment” a patient really needs.
You have a conflict. You get paid to diagnose and treat skin cancers. You must shift roles and become the patient’s protector, and treat the patient as if he or she was your parent. Less, sometimes much less, is often more. Perhaps you only biopsy and treat rapidly growing cancers that endanger crucial structures. You ignore the noninvasive tumors on the trunk and extremities. It is a fine and difficult line to walk.
Patients know they are dying, and at certain stages of grieving will want everything possible done, especially if it is visible. Skin wounds, even from curetting, salves, and cryotherapy, can be painful and sometimes disabling. You must resist unnecessary treatments, temporize if possible, discuss quality time with the patient and the family, and reach a consensus on how aggressive not to be. You must help them die well.
You are not only a healer, but as a master physician you – yes, even you the dermatologist – must also be a helpful guide at the end of life. I am sad to see patients, my old friends, in the newspaper, but feel secretly satisfied if I have spared them unnecessary suffering.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
My wife thinks I am a little morbid, because I still read the local Sunday newspaper not to catch up on the news, and certainly not for the ads, but mostly to read the obituaries.
All of us have elderly patients, and I am growing old with many of my older patients. Now after treating many thousands of patients whom I have grown to know well, it is not unusual to see an obituary of someone my office staff and I know in the newspaper on a weekly basis.
We send sympathy cards, sometimes I write a personal note to the spouse or family, and several times a year, some of my staff and I will go to the funeral or memorial ceremony.
I usually ask if they died well, comfortably with family, or better yet, suddenly, dropping dead like a stone. This is the unspoken, though usually unrealized, goal of many of us from the world of medicine.
All physicians who have been surrounded by death, some horrible deaths, want to die well. I think it is difficult to do, although my mother came close.
One day when dropping off her best little friend (my 10-year-old daughter), she said “look here, I’ve got a knot in my belly button.” I felt the blood rushing to my head and before I could stop her, she showed me her Sister Mary Joseph nodule, a sign of metastatic internal malignancy. I sat stunned as she looked at me; her eyes showed she already knew my answer.
She lasted at home for 6 weeks, went into hospice, and died 36 hours later.
The last morning before she died, I took my daughter to see her before school. She woke up and called her “sugar” and had her climb into bed with her and snuggle. I got choked up and tearful and started telling her how much I loved her and how sorry I was and how much we would miss her. She looked over at me, and with anger in her voice, told me to be quiet, and explained that death comes to everyone eventually and just to get over it. In retrospect, I understand now that I was not helping her die well.
I am telling this story to bring up a point about professionalism. , this becomes important as the life cycle ends. Aged patients sometimes start blossoming with skin cancers. You must carefully gauge how much “treatment” a patient really needs.
You have a conflict. You get paid to diagnose and treat skin cancers. You must shift roles and become the patient’s protector, and treat the patient as if he or she was your parent. Less, sometimes much less, is often more. Perhaps you only biopsy and treat rapidly growing cancers that endanger crucial structures. You ignore the noninvasive tumors on the trunk and extremities. It is a fine and difficult line to walk.
Patients know they are dying, and at certain stages of grieving will want everything possible done, especially if it is visible. Skin wounds, even from curetting, salves, and cryotherapy, can be painful and sometimes disabling. You must resist unnecessary treatments, temporize if possible, discuss quality time with the patient and the family, and reach a consensus on how aggressive not to be. You must help them die well.
You are not only a healer, but as a master physician you – yes, even you the dermatologist – must also be a helpful guide at the end of life. I am sad to see patients, my old friends, in the newspaper, but feel secretly satisfied if I have spared them unnecessary suffering.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
My wife thinks I am a little morbid, because I still read the local Sunday newspaper not to catch up on the news, and certainly not for the ads, but mostly to read the obituaries.
All of us have elderly patients, and I am growing old with many of my older patients. Now after treating many thousands of patients whom I have grown to know well, it is not unusual to see an obituary of someone my office staff and I know in the newspaper on a weekly basis.
We send sympathy cards, sometimes I write a personal note to the spouse or family, and several times a year, some of my staff and I will go to the funeral or memorial ceremony.
I usually ask if they died well, comfortably with family, or better yet, suddenly, dropping dead like a stone. This is the unspoken, though usually unrealized, goal of many of us from the world of medicine.
All physicians who have been surrounded by death, some horrible deaths, want to die well. I think it is difficult to do, although my mother came close.
One day when dropping off her best little friend (my 10-year-old daughter), she said “look here, I’ve got a knot in my belly button.” I felt the blood rushing to my head and before I could stop her, she showed me her Sister Mary Joseph nodule, a sign of metastatic internal malignancy. I sat stunned as she looked at me; her eyes showed she already knew my answer.
She lasted at home for 6 weeks, went into hospice, and died 36 hours later.
The last morning before she died, I took my daughter to see her before school. She woke up and called her “sugar” and had her climb into bed with her and snuggle. I got choked up and tearful and started telling her how much I loved her and how sorry I was and how much we would miss her. She looked over at me, and with anger in her voice, told me to be quiet, and explained that death comes to everyone eventually and just to get over it. In retrospect, I understand now that I was not helping her die well.
I am telling this story to bring up a point about professionalism. , this becomes important as the life cycle ends. Aged patients sometimes start blossoming with skin cancers. You must carefully gauge how much “treatment” a patient really needs.
You have a conflict. You get paid to diagnose and treat skin cancers. You must shift roles and become the patient’s protector, and treat the patient as if he or she was your parent. Less, sometimes much less, is often more. Perhaps you only biopsy and treat rapidly growing cancers that endanger crucial structures. You ignore the noninvasive tumors on the trunk and extremities. It is a fine and difficult line to walk.
Patients know they are dying, and at certain stages of grieving will want everything possible done, especially if it is visible. Skin wounds, even from curetting, salves, and cryotherapy, can be painful and sometimes disabling. You must resist unnecessary treatments, temporize if possible, discuss quality time with the patient and the family, and reach a consensus on how aggressive not to be. You must help them die well.
You are not only a healer, but as a master physician you – yes, even you the dermatologist – must also be a helpful guide at the end of life. I am sad to see patients, my old friends, in the newspaper, but feel secretly satisfied if I have spared them unnecessary suffering.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.