Opinion

 

Like their cisgender counterparts, transgender and gender nonconforming patients (trans patients) may reach a point in their lives where they want to build their own families. This may be achieved through adoption, alternative insemination with donor sperm, or assisted reproductive treatment with donor sperm or egg, cryopreserved sperm or egg, or surrogacy.¹There are several unique needs of trans patients that extend into obstetrics and may be addressed as early as the first gender transition visit. Obstetricians can provide more equitable care to trans individuals by acknowledging these needs and providing gender-inclusive counseling and guidance.

Stuart Jenner/Thinkstock

The American Society for Reproductive Medicine recommends that medical providers counsel patients about the potential effects of medical transitioning on their fertility prior to the initiation of hormonal or surgical therapies.² Patients should be educated about options for fertility preservation and reproduction since exogenous hormones and gonadectomy impact fertility.³ A referral to a fertility specialist should be placed for patients interested in oocyte or sperm cryopreservation, embryo cryopreservation, or ovarian tissue cryopreservation.²

If a trans patient presents to the obstetrician/gynecologist for preconception counseling after undergoing medical gender transition, they should be offered evidence-based guidance based on an organ inventory (surgical history with documentation of natal sex organs still in situ). A biologic pregnancy may be a fertility option for a patient who has a vagina, uterus, fallopian tubes, and ovaries and is not currently using testosterone. Gender-affirming testosterone therapy suppresses ovulation and causes amenorrhea in most patients, although this is often reversible once the exogenous hormone is discontinued.² When the patient is ovulating on their own or undergoes ovulation induction, conception may be achieved via the same methods used with cisgender couples: Sperm is obtained from a partner or donor, followed by intercourse if the patient is comfortable with this, intrauterine insemination (IUI), or in vitro fertilization (IVF).

Conversely, a trans patient with a penis and testicles who has already undergone medical gender affirmation with estrogen should be counseled that prior exposure to estrogen may have caused irreversible testicular damage, making assisted reproductive treatment more challenging if sperm had not been cryopreserved prior to starting gender-affirming hormone therapy.² If spermatogenesis is successful or sperm was previously cryopreserved, the next step in reproductive counseling for these patients centers on finding gestational carriers and egg donors if the patient does not already have a partner who is willing or able to carry the child. At this point in time, uterine transplantation has not been attempted in a trans patient and therefore is not considered a viable fertility option.

The trans patient who becomes pregnant will encounter physical changes that may trigger underlying gender dysphoria. One study found that transgender men who experience pregnancy exhibited varying degrees of gender dysphoria.⁴ Obstetrician/gynecologists should have an awareness about the possibility of heightened gender dysphoria and sensitively approach prenatal visits by avoiding triggering language or using inappropriate pronouns. Simply asking a trans patient about preferred pronouns and terminology for body parts can be the difference between a negative and positive pregnancy experience. For example, a transman may prefer a different term for vagina/vulva/cervix. This is especially important at the time of delivery, when exams may become more frequent for the patient. However, inclusive prenatal care starts from the first prenatal visit when the patient checks in and continues all the way through the doctor/patient experience. All office staff should be trained to use preferred names and pronouns and gender-neutral restrooms should be easily accessible. Likewise, waiting rooms should include visible support for the LGBTQ (lesbian, gay, bisexual, transgender and queer or questioning) patient population.

The anatomy ultrasound and “gender reveal” during the pregnancy and at the time of delivery can understandably also be a sensitive subject for a pregnant trans patient. Previous cultural practice has been to describe the gender of the fetus at the anatomy ultrasound, when in fact, gender can only be self-determined by an individual many years after birth. What the anatomy ultrasound does convey is the appearance of external genitalia to help predict the assigned sex. As obstetrician/gynecologists who practice evidence-based medicine, we are encouraged to challenge the cultural norm of announcing the gender of the baby at time of ultrasound and at time of birth. We should focus instead on conveying what objective information we do know. After the infant is born, we know the sex they are assigned based on the what external reproductive organs are seen.

In the postpartum period, trans patients who successfully carried a pregnancy may choose to feed their infant with their own human milk. For some trans patients, breastfeeding may be referred to as chestfeeding, since this terminology is more gender neutral. Having prior chest masculinization surgery does not exclude a transmasculine patient from lactating, although milk production may vary. Patients should be counseled that there is limited data on the safety of testosterone use while lactating.¹ We found only one case report of induced lactation in a nonpuerperal transfeminine patient.⁵ In addition to addressing infant feeding concerns, obstetrician/gynecologists should counsel postpartum trans patients about contraceptive options and screen for perinatal mood disorders, especially those patients with a history of mood disorders before pregnancy.

Ultimately, trans patients seeking fertility options and obstetrical care have a right to obtain reliable information and access gender-inclusive treatment from their obstetrician/gynecologists. Each family makeup is unique and should be respected by all health care professionals taking care of the patient. As obstetrician/gynecologists, it is our duty to coordinate and advocate for the equitable care of our trans patients who want to grow their families.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Katie Riddle is an ob.gyn. in Connecticut who is passionate about LGBTQ health care. She recently completed her residency in Ann Arbor, Mich. Dr. Riddle identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joyner and Dr. Riddle said they had no financial disclosures. Email them at obnews@mdedge.com.

References

1. Viloria RP. “Reproductive Health and Obstetric Care in Transgender Patients.” Fenway Health.

2. Amato P. “Fertility options for transgender persons.” University of California, San Francisco Transgender Care and Treatment Guidelines. 2016 Jun 17.

3. Fertil Steril. 2015 Nov. doi: 10.1016/j.fertnstert.2015.08.021.

4. Obstet Gynecol. 2014. doi: 10.1097/AOG.0000000000000540.

5. Transgend Health. 2018 Jan 1. doi: 10.1089/trgh.2017.0044.

 

Like their cisgender counterparts, transgender and gender nonconforming patients (trans patients) may reach a point in their lives where they want to build their own families. This may be achieved through adoption, alternative insemination with donor sperm, or assisted reproductive treatment with donor sperm or egg, cryopreserved sperm or egg, or surrogacy.¹There are several unique needs of trans patients that extend into obstetrics and may be addressed as early as the first gender transition visit. Obstetricians can provide more equitable care to trans individuals by acknowledging these needs and providing gender-inclusive counseling and guidance.

Stuart Jenner/Thinkstock

The American Society for Reproductive Medicine recommends that medical providers counsel patients about the potential effects of medical transitioning on their fertility prior to the initiation of hormonal or surgical therapies.² Patients should be educated about options for fertility preservation and reproduction since exogenous hormones and gonadectomy impact fertility.³ A referral to a fertility specialist should be placed for patients interested in oocyte or sperm cryopreservation, embryo cryopreservation, or ovarian tissue cryopreservation.²

If a trans patient presents to the obstetrician/gynecologist for preconception counseling after undergoing medical gender transition, they should be offered evidence-based guidance based on an organ inventory (surgical history with documentation of natal sex organs still in situ). A biologic pregnancy may be a fertility option for a patient who has a vagina, uterus, fallopian tubes, and ovaries and is not currently using testosterone. Gender-affirming testosterone therapy suppresses ovulation and causes amenorrhea in most patients, although this is often reversible once the exogenous hormone is discontinued.² When the patient is ovulating on their own or undergoes ovulation induction, conception may be achieved via the same methods used with cisgender couples: Sperm is obtained from a partner or donor, followed by intercourse if the patient is comfortable with this, intrauterine insemination (IUI), or in vitro fertilization (IVF).

Conversely, a trans patient with a penis and testicles who has already undergone medical gender affirmation with estrogen should be counseled that prior exposure to estrogen may have caused irreversible testicular damage, making assisted reproductive treatment more challenging if sperm had not been cryopreserved prior to starting gender-affirming hormone therapy.² If spermatogenesis is successful or sperm was previously cryopreserved, the next step in reproductive counseling for these patients centers on finding gestational carriers and egg donors if the patient does not already have a partner who is willing or able to carry the child. At this point in time, uterine transplantation has not been attempted in a trans patient and therefore is not considered a viable fertility option.

The trans patient who becomes pregnant will encounter physical changes that may trigger underlying gender dysphoria. One study found that transgender men who experience pregnancy exhibited varying degrees of gender dysphoria.⁴ Obstetrician/gynecologists should have an awareness about the possibility of heightened gender dysphoria and sensitively approach prenatal visits by avoiding triggering language or using inappropriate pronouns. Simply asking a trans patient about preferred pronouns and terminology for body parts can be the difference between a negative and positive pregnancy experience. For example, a transman may prefer a different term for vagina/vulva/cervix. This is especially important at the time of delivery, when exams may become more frequent for the patient. However, inclusive prenatal care starts from the first prenatal visit when the patient checks in and continues all the way through the doctor/patient experience. All office staff should be trained to use preferred names and pronouns and gender-neutral restrooms should be easily accessible. Likewise, waiting rooms should include visible support for the LGBTQ (lesbian, gay, bisexual, transgender and queer or questioning) patient population.

The anatomy ultrasound and “gender reveal” during the pregnancy and at the time of delivery can understandably also be a sensitive subject for a pregnant trans patient. Previous cultural practice has been to describe the gender of the fetus at the anatomy ultrasound, when in fact, gender can only be self-determined by an individual many years after birth. What the anatomy ultrasound does convey is the appearance of external genitalia to help predict the assigned sex. As obstetrician/gynecologists who practice evidence-based medicine, we are encouraged to challenge the cultural norm of announcing the gender of the baby at time of ultrasound and at time of birth. We should focus instead on conveying what objective information we do know. After the infant is born, we know the sex they are assigned based on the what external reproductive organs are seen.

In the postpartum period, trans patients who successfully carried a pregnancy may choose to feed their infant with their own human milk. For some trans patients, breastfeeding may be referred to as chestfeeding, since this terminology is more gender neutral. Having prior chest masculinization surgery does not exclude a transmasculine patient from lactating, although milk production may vary. Patients should be counseled that there is limited data on the safety of testosterone use while lactating.¹ We found only one case report of induced lactation in a nonpuerperal transfeminine patient.⁵ In addition to addressing infant feeding concerns, obstetrician/gynecologists should counsel postpartum trans patients about contraceptive options and screen for perinatal mood disorders, especially those patients with a history of mood disorders before pregnancy.

Ultimately, trans patients seeking fertility options and obstetrical care have a right to obtain reliable information and access gender-inclusive treatment from their obstetrician/gynecologists. Each family makeup is unique and should be respected by all health care professionals taking care of the patient. As obstetrician/gynecologists, it is our duty to coordinate and advocate for the equitable care of our trans patients who want to grow their families.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Katie Riddle is an ob.gyn. in Connecticut who is passionate about LGBTQ health care. She recently completed her residency in Ann Arbor, Mich. Dr. Riddle identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joyner and Dr. Riddle said they had no financial disclosures. Email them at obnews@mdedge.com.

References

1. Viloria RP. “Reproductive Health and Obstetric Care in Transgender Patients.” Fenway Health.

2. Amato P. “Fertility options for transgender persons.” University of California, San Francisco Transgender Care and Treatment Guidelines. 2016 Jun 17.

3. Fertil Steril. 2015 Nov. doi: 10.1016/j.fertnstert.2015.08.021.

4. Obstet Gynecol. 2014. doi: 10.1097/AOG.0000000000000540.

5. Transgend Health. 2018 Jan 1. doi: 10.1089/trgh.2017.0044.

 

Like their cisgender counterparts, transgender and gender nonconforming patients (trans patients) may reach a point in their lives where they want to build their own families. This may be achieved through adoption, alternative insemination with donor sperm, or assisted reproductive treatment with donor sperm or egg, cryopreserved sperm or egg, or surrogacy.¹There are several unique needs of trans patients that extend into obstetrics and may be addressed as early as the first gender transition visit. Obstetricians can provide more equitable care to trans individuals by acknowledging these needs and providing gender-inclusive counseling and guidance.

Stuart Jenner/Thinkstock

The American Society for Reproductive Medicine recommends that medical providers counsel patients about the potential effects of medical transitioning on their fertility prior to the initiation of hormonal or surgical therapies.² Patients should be educated about options for fertility preservation and reproduction since exogenous hormones and gonadectomy impact fertility.³ A referral to a fertility specialist should be placed for patients interested in oocyte or sperm cryopreservation, embryo cryopreservation, or ovarian tissue cryopreservation.²

If a trans patient presents to the obstetrician/gynecologist for preconception counseling after undergoing medical gender transition, they should be offered evidence-based guidance based on an organ inventory (surgical history with documentation of natal sex organs still in situ). A biologic pregnancy may be a fertility option for a patient who has a vagina, uterus, fallopian tubes, and ovaries and is not currently using testosterone. Gender-affirming testosterone therapy suppresses ovulation and causes amenorrhea in most patients, although this is often reversible once the exogenous hormone is discontinued.² When the patient is ovulating on their own or undergoes ovulation induction, conception may be achieved via the same methods used with cisgender couples: Sperm is obtained from a partner or donor, followed by intercourse if the patient is comfortable with this, intrauterine insemination (IUI), or in vitro fertilization (IVF).

Conversely, a trans patient with a penis and testicles who has already undergone medical gender affirmation with estrogen should be counseled that prior exposure to estrogen may have caused irreversible testicular damage, making assisted reproductive treatment more challenging if sperm had not been cryopreserved prior to starting gender-affirming hormone therapy.² If spermatogenesis is successful or sperm was previously cryopreserved, the next step in reproductive counseling for these patients centers on finding gestational carriers and egg donors if the patient does not already have a partner who is willing or able to carry the child. At this point in time, uterine transplantation has not been attempted in a trans patient and therefore is not considered a viable fertility option.

The trans patient who becomes pregnant will encounter physical changes that may trigger underlying gender dysphoria. One study found that transgender men who experience pregnancy exhibited varying degrees of gender dysphoria.⁴ Obstetrician/gynecologists should have an awareness about the possibility of heightened gender dysphoria and sensitively approach prenatal visits by avoiding triggering language or using inappropriate pronouns. Simply asking a trans patient about preferred pronouns and terminology for body parts can be the difference between a negative and positive pregnancy experience. For example, a transman may prefer a different term for vagina/vulva/cervix. This is especially important at the time of delivery, when exams may become more frequent for the patient. However, inclusive prenatal care starts from the first prenatal visit when the patient checks in and continues all the way through the doctor/patient experience. All office staff should be trained to use preferred names and pronouns and gender-neutral restrooms should be easily accessible. Likewise, waiting rooms should include visible support for the LGBTQ (lesbian, gay, bisexual, transgender and queer or questioning) patient population.

The anatomy ultrasound and “gender reveal” during the pregnancy and at the time of delivery can understandably also be a sensitive subject for a pregnant trans patient. Previous cultural practice has been to describe the gender of the fetus at the anatomy ultrasound, when in fact, gender can only be self-determined by an individual many years after birth. What the anatomy ultrasound does convey is the appearance of external genitalia to help predict the assigned sex. As obstetrician/gynecologists who practice evidence-based medicine, we are encouraged to challenge the cultural norm of announcing the gender of the baby at time of ultrasound and at time of birth. We should focus instead on conveying what objective information we do know. After the infant is born, we know the sex they are assigned based on the what external reproductive organs are seen.

In the postpartum period, trans patients who successfully carried a pregnancy may choose to feed their infant with their own human milk. For some trans patients, breastfeeding may be referred to as chestfeeding, since this terminology is more gender neutral. Having prior chest masculinization surgery does not exclude a transmasculine patient from lactating, although milk production may vary. Patients should be counseled that there is limited data on the safety of testosterone use while lactating.¹ We found only one case report of induced lactation in a nonpuerperal transfeminine patient.⁵ In addition to addressing infant feeding concerns, obstetrician/gynecologists should counsel postpartum trans patients about contraceptive options and screen for perinatal mood disorders, especially those patients with a history of mood disorders before pregnancy.

Ultimately, trans patients seeking fertility options and obstetrical care have a right to obtain reliable information and access gender-inclusive treatment from their obstetrician/gynecologists. Each family makeup is unique and should be respected by all health care professionals taking care of the patient. As obstetrician/gynecologists, it is our duty to coordinate and advocate for the equitable care of our trans patients who want to grow their families.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Katie Riddle is an ob.gyn. in Connecticut who is passionate about LGBTQ health care. She recently completed her residency in Ann Arbor, Mich. Dr. Riddle identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joyner and Dr. Riddle said they had no financial disclosures. Email them at obnews@mdedge.com.

References

1. Viloria RP. “Reproductive Health and Obstetric Care in Transgender Patients.” Fenway Health.

2. Amato P. “Fertility options for transgender persons.” University of California, San Francisco Transgender Care and Treatment Guidelines. 2016 Jun 17.

3. Fertil Steril. 2015 Nov. doi: 10.1016/j.fertnstert.2015.08.021.

4. Obstet Gynecol. 2014. doi: 10.1097/AOG.0000000000000540.

5. Transgend Health. 2018 Jan 1. doi: 10.1089/trgh.2017.0044.

Cannabidiol (CBD) seems to be everywhere now. Since the Farm Bill of 2018 legalizing the cultivation of hemp was signed into law last December, many CBD-based products have hit the market. The advent of potent CBD oil concentrates, nonintoxicating CBD-rich products, and innovative smokeless delivery systems has transformed the therapeutic landscape and changed the public conversation about cannabis. That, and with the surge in legal availability, its use is more commonplace now – even in elderly populations and regions of the country where products thought to be associated with the marijuana plant would have once been considered taboo. A recent Gallup poll found that 14% of Americans say they now use CBD. As the benefits of CBD are demonstrated and perceptions change, having background knowledge of the manufacturing and available data on CBD will be helpful when patients ask about these products for skin care, to provide an evidenced-based approach.

CBD is one of over a hundred phytocannabinoids, which are naturally occurring cannabinoids found in the oily resin of the flower or “bud” (and to a lesser extent the leaves) of the cannabis plant. This is opposed to synthetic cannabinoids, as well as endocannabinoids (cannabinoid receptors found in humans and animals). Both CBD and THC (delta9-tetrahydrocannabinol), another phytocannabinoid, can provide anti-inflammatory and pain-control benefits; the main difference is that THC has psychoactive effects and CBD does not.

Cannabis is a genus of flowering plants in the Cannabaceae family, made up of three primary species: Cannabis sativa, Cannabis indica, and Cannabis ruderalis. CBD can be harvested from either Cannabis sativa or Cannabis indica. People often confuse hemp as equal to Cannabis sativa species and marijuana as equal to Cannabis indica, but neither hemp or marijuana are specific strains or species of cannabis plants, they are broad classifications of cannabis that do not indicate a specific strain.

Hemp, a term used to classify varieties of cannabis that contain trace amounts of THC, has generally been used to describe nonintoxicating cannabis harvested for the industrial use of its derived products, such as textiles, paper, food (hemp seeds), building materials, and skin care. While both “hemp” and “marijuana” can produce high amounts of CBD, CBD products sourced from hemp contain 0.3% THC or less (the legal allowance), while CBD products derived from “marijuana” typically contain 5%-35% THC. Since the 2018 Farm Act legalized the production of hemp in all 50 states, but not marijuana, most CBD nationwide is sourced from hemp. CBD from a marijuana source or a product containing both CBD and over 0.3% THC can only be sold in states where marijuana is legal. At this time, 11 states have legalized marijuana.

Marijuana varieties, grown to maximize the amount or quality of THC, are selectively bred in controlled environments designed to optimize the breed’s characteristics and produce female plants that yield budding flowers. In contrast, because of hemp’s diverse uses, it is grown to maximize its size and yield and is typically grown outdoors and does not require the level of control and attention needed to grow marijuana.

 

While there is some debate about whether CBD derived from hemp or marijuana differs, medical observations to date are that CBD derived from either source has the same mechanism of action; however, whether CBD has more therapeutic benefits in products alone or in combination with THC and other cannabis components remains to be determined. Of note, CBD is also absent in the roots or the seeds of cannabis and hemp. While hemp seeds are a good source of protein and omega-3 fatty acids, companies that claim they derive CBD from hemp stalk, hemp seeds, or hemp seed oil are making false claims because these parts of the plants contain no CBD, no THC, and no known plant cannabinoids.

CBD binds to endocannabinoid receptor CB2, whereas THC binds to both CB1 and CB2. CB1 receptors are primarily found in the central nervous system, affecting neurotransmitters leading to CNS depression, euphoria, psychosis, impaired memory, and increased appetite and have antiemetic effects, whereas CB2 is mostly found in peripheral organs and primarily affects the immune system resulting in decreased pain and anti-inflammatory and antioxidant effects.

The skin has the highest amount and concentration of CB2 receptors in the body. As detailed in Dr. Leslie Baumann’s column “Primer on cannabis for cosmeceuticals” in Dermatology News, June 2019, skin-specific studies indicate that, when applied topically, CBD decreases sebum production and has anti-inflammatory effects. There is also evidence that CBD has antioxidant effects. Therefore, in the correct formulation, CBD may have potential in treating common sometimes debilitating skin conditions such as acne, as well as other inflammatory skin conditions.

For acne, beauty products containing CBD have the potential to help overall complexion and prevent acne scars. Because most degradation of collagen involves inflammation – whether the inflammation is secondary to excessive UV exposure, diet, poor health, or stress – the anti-inflammatory and antioxidant effects also have potential benefit in treating and preventing signs of aging. Of note, the CB2 receptor has also been shown to be upregulated in melanoma and squamous cell carcinoma. In a recent study of keratinocytes irradiated with UVA and UVB light, CBD demonstrated antioxidant activity through nuclear factor erythroid 2–related factor 2 (Nrf2) activation, as well as anti-inflammatory properties as an inhibitor of the nuclear factor NF-kappa-B. Whether topical CBD can effectively prevent or treat cutaneous tumorigenesis is promising, but large scale data are still needed.

So far, the benefits of CBD in beauty products and topical skin formulations for treatment of skin disease are based on preclinical information, and there is a corresponding lack of high-quality randomized, controlled trials that evaluate their effects on skin-specific issues. Now, with the 2018 Farm Act in place, large-scale, randomized, controlled trials with cannabinoids should be able to be performed more easily to demonstrate the dermatologic benefits of this promising compound.

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. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

Resources

Gallup. “14% of Americans Say They Use CBD Products.” https://news.gallup.com/poll/263147/americans-say-cbd-products.aspx.

Project CBD. “What is CBD?” www.projectcbd.org/cbd-101-what-is-cbd.

Palmieri B et al. Clin Ter. 2019 Mar-Apr;170(2):e93-e99.

Jastrząb A et al. Cells. 2019 Aug 3;8(8).

Cannabidiol (CBD) seems to be everywhere now. Since the Farm Bill of 2018 legalizing the cultivation of hemp was signed into law last December, many CBD-based products have hit the market. The advent of potent CBD oil concentrates, nonintoxicating CBD-rich products, and innovative smokeless delivery systems has transformed the therapeutic landscape and changed the public conversation about cannabis. That, and with the surge in legal availability, its use is more commonplace now – even in elderly populations and regions of the country where products thought to be associated with the marijuana plant would have once been considered taboo. A recent Gallup poll found that 14% of Americans say they now use CBD. As the benefits of CBD are demonstrated and perceptions change, having background knowledge of the manufacturing and available data on CBD will be helpful when patients ask about these products for skin care, to provide an evidenced-based approach.

CBD is one of over a hundred phytocannabinoids, which are naturally occurring cannabinoids found in the oily resin of the flower or “bud” (and to a lesser extent the leaves) of the cannabis plant. This is opposed to synthetic cannabinoids, as well as endocannabinoids (cannabinoid receptors found in humans and animals). Both CBD and THC (delta9-tetrahydrocannabinol), another phytocannabinoid, can provide anti-inflammatory and pain-control benefits; the main difference is that THC has psychoactive effects and CBD does not.

Cannabis is a genus of flowering plants in the Cannabaceae family, made up of three primary species: Cannabis sativa, Cannabis indica, and Cannabis ruderalis. CBD can be harvested from either Cannabis sativa or Cannabis indica. People often confuse hemp as equal to Cannabis sativa species and marijuana as equal to Cannabis indica, but neither hemp or marijuana are specific strains or species of cannabis plants, they are broad classifications of cannabis that do not indicate a specific strain.

Hemp, a term used to classify varieties of cannabis that contain trace amounts of THC, has generally been used to describe nonintoxicating cannabis harvested for the industrial use of its derived products, such as textiles, paper, food (hemp seeds), building materials, and skin care. While both “hemp” and “marijuana” can produce high amounts of CBD, CBD products sourced from hemp contain 0.3% THC or less (the legal allowance), while CBD products derived from “marijuana” typically contain 5%-35% THC. Since the 2018 Farm Act legalized the production of hemp in all 50 states, but not marijuana, most CBD nationwide is sourced from hemp. CBD from a marijuana source or a product containing both CBD and over 0.3% THC can only be sold in states where marijuana is legal. At this time, 11 states have legalized marijuana.

Marijuana varieties, grown to maximize the amount or quality of THC, are selectively bred in controlled environments designed to optimize the breed’s characteristics and produce female plants that yield budding flowers. In contrast, because of hemp’s diverse uses, it is grown to maximize its size and yield and is typically grown outdoors and does not require the level of control and attention needed to grow marijuana.

 

While there is some debate about whether CBD derived from hemp or marijuana differs, medical observations to date are that CBD derived from either source has the same mechanism of action; however, whether CBD has more therapeutic benefits in products alone or in combination with THC and other cannabis components remains to be determined. Of note, CBD is also absent in the roots or the seeds of cannabis and hemp. While hemp seeds are a good source of protein and omega-3 fatty acids, companies that claim they derive CBD from hemp stalk, hemp seeds, or hemp seed oil are making false claims because these parts of the plants contain no CBD, no THC, and no known plant cannabinoids.

CBD binds to endocannabinoid receptor CB2, whereas THC binds to both CB1 and CB2. CB1 receptors are primarily found in the central nervous system, affecting neurotransmitters leading to CNS depression, euphoria, psychosis, impaired memory, and increased appetite and have antiemetic effects, whereas CB2 is mostly found in peripheral organs and primarily affects the immune system resulting in decreased pain and anti-inflammatory and antioxidant effects.

The skin has the highest amount and concentration of CB2 receptors in the body. As detailed in Dr. Leslie Baumann’s column “Primer on cannabis for cosmeceuticals” in Dermatology News, June 2019, skin-specific studies indicate that, when applied topically, CBD decreases sebum production and has anti-inflammatory effects. There is also evidence that CBD has antioxidant effects. Therefore, in the correct formulation, CBD may have potential in treating common sometimes debilitating skin conditions such as acne, as well as other inflammatory skin conditions.

For acne, beauty products containing CBD have the potential to help overall complexion and prevent acne scars. Because most degradation of collagen involves inflammation – whether the inflammation is secondary to excessive UV exposure, diet, poor health, or stress – the anti-inflammatory and antioxidant effects also have potential benefit in treating and preventing signs of aging. Of note, the CB2 receptor has also been shown to be upregulated in melanoma and squamous cell carcinoma. In a recent study of keratinocytes irradiated with UVA and UVB light, CBD demonstrated antioxidant activity through nuclear factor erythroid 2–related factor 2 (Nrf2) activation, as well as anti-inflammatory properties as an inhibitor of the nuclear factor NF-kappa-B. Whether topical CBD can effectively prevent or treat cutaneous tumorigenesis is promising, but large scale data are still needed.

So far, the benefits of CBD in beauty products and topical skin formulations for treatment of skin disease are based on preclinical information, and there is a corresponding lack of high-quality randomized, controlled trials that evaluate their effects on skin-specific issues. Now, with the 2018 Farm Act in place, large-scale, randomized, controlled trials with cannabinoids should be able to be performed more easily to demonstrate the dermatologic benefits of this promising compound.

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. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

Resources

Gallup. “14% of Americans Say They Use CBD Products.” https://news.gallup.com/poll/263147/americans-say-cbd-products.aspx.

Project CBD. “What is CBD?” www.projectcbd.org/cbd-101-what-is-cbd.

Palmieri B et al. Clin Ter. 2019 Mar-Apr;170(2):e93-e99.

Jastrząb A et al. Cells. 2019 Aug 3;8(8).

Cannabidiol (CBD) seems to be everywhere now. Since the Farm Bill of 2018 legalizing the cultivation of hemp was signed into law last December, many CBD-based products have hit the market. The advent of potent CBD oil concentrates, nonintoxicating CBD-rich products, and innovative smokeless delivery systems has transformed the therapeutic landscape and changed the public conversation about cannabis. That, and with the surge in legal availability, its use is more commonplace now – even in elderly populations and regions of the country where products thought to be associated with the marijuana plant would have once been considered taboo. A recent Gallup poll found that 14% of Americans say they now use CBD. As the benefits of CBD are demonstrated and perceptions change, having background knowledge of the manufacturing and available data on CBD will be helpful when patients ask about these products for skin care, to provide an evidenced-based approach.

CBD is one of over a hundred phytocannabinoids, which are naturally occurring cannabinoids found in the oily resin of the flower or “bud” (and to a lesser extent the leaves) of the cannabis plant. This is opposed to synthetic cannabinoids, as well as endocannabinoids (cannabinoid receptors found in humans and animals). Both CBD and THC (delta9-tetrahydrocannabinol), another phytocannabinoid, can provide anti-inflammatory and pain-control benefits; the main difference is that THC has psychoactive effects and CBD does not.

Cannabis is a genus of flowering plants in the Cannabaceae family, made up of three primary species: Cannabis sativa, Cannabis indica, and Cannabis ruderalis. CBD can be harvested from either Cannabis sativa or Cannabis indica. People often confuse hemp as equal to Cannabis sativa species and marijuana as equal to Cannabis indica, but neither hemp or marijuana are specific strains or species of cannabis plants, they are broad classifications of cannabis that do not indicate a specific strain.

Hemp, a term used to classify varieties of cannabis that contain trace amounts of THC, has generally been used to describe nonintoxicating cannabis harvested for the industrial use of its derived products, such as textiles, paper, food (hemp seeds), building materials, and skin care. While both “hemp” and “marijuana” can produce high amounts of CBD, CBD products sourced from hemp contain 0.3% THC or less (the legal allowance), while CBD products derived from “marijuana” typically contain 5%-35% THC. Since the 2018 Farm Act legalized the production of hemp in all 50 states, but not marijuana, most CBD nationwide is sourced from hemp. CBD from a marijuana source or a product containing both CBD and over 0.3% THC can only be sold in states where marijuana is legal. At this time, 11 states have legalized marijuana.

Marijuana varieties, grown to maximize the amount or quality of THC, are selectively bred in controlled environments designed to optimize the breed’s characteristics and produce female plants that yield budding flowers. In contrast, because of hemp’s diverse uses, it is grown to maximize its size and yield and is typically grown outdoors and does not require the level of control and attention needed to grow marijuana.

 

While there is some debate about whether CBD derived from hemp or marijuana differs, medical observations to date are that CBD derived from either source has the same mechanism of action; however, whether CBD has more therapeutic benefits in products alone or in combination with THC and other cannabis components remains to be determined. Of note, CBD is also absent in the roots or the seeds of cannabis and hemp. While hemp seeds are a good source of protein and omega-3 fatty acids, companies that claim they derive CBD from hemp stalk, hemp seeds, or hemp seed oil are making false claims because these parts of the plants contain no CBD, no THC, and no known plant cannabinoids.

CBD binds to endocannabinoid receptor CB2, whereas THC binds to both CB1 and CB2. CB1 receptors are primarily found in the central nervous system, affecting neurotransmitters leading to CNS depression, euphoria, psychosis, impaired memory, and increased appetite and have antiemetic effects, whereas CB2 is mostly found in peripheral organs and primarily affects the immune system resulting in decreased pain and anti-inflammatory and antioxidant effects.

The skin has the highest amount and concentration of CB2 receptors in the body. As detailed in Dr. Leslie Baumann’s column “Primer on cannabis for cosmeceuticals” in Dermatology News, June 2019, skin-specific studies indicate that, when applied topically, CBD decreases sebum production and has anti-inflammatory effects. There is also evidence that CBD has antioxidant effects. Therefore, in the correct formulation, CBD may have potential in treating common sometimes debilitating skin conditions such as acne, as well as other inflammatory skin conditions.

For acne, beauty products containing CBD have the potential to help overall complexion and prevent acne scars. Because most degradation of collagen involves inflammation – whether the inflammation is secondary to excessive UV exposure, diet, poor health, or stress – the anti-inflammatory and antioxidant effects also have potential benefit in treating and preventing signs of aging. Of note, the CB2 receptor has also been shown to be upregulated in melanoma and squamous cell carcinoma. In a recent study of keratinocytes irradiated with UVA and UVB light, CBD demonstrated antioxidant activity through nuclear factor erythroid 2–related factor 2 (Nrf2) activation, as well as anti-inflammatory properties as an inhibitor of the nuclear factor NF-kappa-B. Whether topical CBD can effectively prevent or treat cutaneous tumorigenesis is promising, but large scale data are still needed.

So far, the benefits of CBD in beauty products and topical skin formulations for treatment of skin disease are based on preclinical information, and there is a corresponding lack of high-quality randomized, controlled trials that evaluate their effects on skin-specific issues. Now, with the 2018 Farm Act in place, large-scale, randomized, controlled trials with cannabinoids should be able to be performed more easily to demonstrate the dermatologic benefits of this promising compound.

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. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

Resources

Gallup. “14% of Americans Say They Use CBD Products.” https://news.gallup.com/poll/263147/americans-say-cbd-products.aspx.

Project CBD. “What is CBD?” www.projectcbd.org/cbd-101-what-is-cbd.

Palmieri B et al. Clin Ter. 2019 Mar-Apr;170(2):e93-e99.

Jastrząb A et al. Cells. 2019 Aug 3;8(8).

If you are still struggling to understand the ADHD phenomenon and its meteoric rise to prominence over the last 3 or 4 decades, a study published in the September 2019 Pediatrics may help you make sense of why you are spending a large part of your professional day counseling parents and treating children whose lives are disrupted by their impulsivity, distractibility, and inattentiveness (“24-hour movement behaviors and impulsivity.” doi: 10.1542/peds.2019-0187). Researchers at the Children’s Hospital of Eastern Ontario (Canada) Research Institute used data collected over 10 years in 21 sites across the United States on more than 4,500 children aged 8-11 years, looking for possible associations between impulsivity and three factors – sleep duration, screen time, and physical activity.

Goads Agency/Getty Images

They found that children who were exposed to fewer than 2 hours of recreational screen time each day and slept 9-11 hours nightly had significantly reduced scores on a range of impulsivity scores. While participating in at least 60 minutes of vigorous physical activity per day also was associated with less impulsivity, the effect added little to the benefit of the sleep/screen time combination. Although these nonpharmacologic strategies aimed at decreasing impulsivity may not be a cure-all for every child with symptoms that suggest ADHD, the data are compelling.

I hope that the associations these Canadian researchers have unearthed is not news to you. But their observation that 30% of the sample population met none of the recommendations for sleep, screen time, and activity and that only 5% of the sample did suggests that too few of us are delivering the message with sufficient enthusiasm and/or too many parents aren’t taking it seriously.

Over the last several years I have been encouraged to find sleep and screen time limits mentioned in articles on ADHD for both professionals and parents, but these potent contributors to impulsivity and distractibility always seem to be relegated to the oh-by-the-way category at the end of the article after a lengthy discussion of the relative values of medication and cognitive-behavioral therapy. And unfortunately, meeting these behavioral guidelines can be difficult to achieve and cannot be subcontracted out to a therapist or a pharmacist. They require parents to set and enforce limits. Saying no is difficult for all of us, particularly those without much prior experience.

Have you observed the association between inadequate sleep, excessive screen time, and impulsivity? How robustly have you bought into the idea that more sleep and less screen time are, if not THE answers, at least are the two we should start with? Where do your recommendations about screen time, sleep, and physical activity fit into the script when you are talking with parents about their child’s ADHD-ish behaviors? Have you put them in the oh-by-the-way category?

Do you ever say, “I know you may be expecting me to talk about medication at this visit, but I suggest you try setting and enforcing these limits on sleep and screen time for a few months and we will see how things are going”? “And I am going to give you some suggestions on how you can do this, and we will meet again as often as you feel is necessary to ease the process.”

Do you think you have the time to try this approach? Do you feel you have the skills to counsel on sleep and behavior? Do you think you can find someone with the time and experience who shares your priorities about screen time and sleep to do the parental coaching for you? It’s an approach worth considering when you step back and take the longer look at why we are living through this decades-long ADHD phenomenon.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

If you are still struggling to understand the ADHD phenomenon and its meteoric rise to prominence over the last 3 or 4 decades, a study published in the September 2019 Pediatrics may help you make sense of why you are spending a large part of your professional day counseling parents and treating children whose lives are disrupted by their impulsivity, distractibility, and inattentiveness (“24-hour movement behaviors and impulsivity.” doi: 10.1542/peds.2019-0187). Researchers at the Children’s Hospital of Eastern Ontario (Canada) Research Institute used data collected over 10 years in 21 sites across the United States on more than 4,500 children aged 8-11 years, looking for possible associations between impulsivity and three factors – sleep duration, screen time, and physical activity.

Goads Agency/Getty Images

They found that children who were exposed to fewer than 2 hours of recreational screen time each day and slept 9-11 hours nightly had significantly reduced scores on a range of impulsivity scores. While participating in at least 60 minutes of vigorous physical activity per day also was associated with less impulsivity, the effect added little to the benefit of the sleep/screen time combination. Although these nonpharmacologic strategies aimed at decreasing impulsivity may not be a cure-all for every child with symptoms that suggest ADHD, the data are compelling.

I hope that the associations these Canadian researchers have unearthed is not news to you. But their observation that 30% of the sample population met none of the recommendations for sleep, screen time, and activity and that only 5% of the sample did suggests that too few of us are delivering the message with sufficient enthusiasm and/or too many parents aren’t taking it seriously.

Over the last several years I have been encouraged to find sleep and screen time limits mentioned in articles on ADHD for both professionals and parents, but these potent contributors to impulsivity and distractibility always seem to be relegated to the oh-by-the-way category at the end of the article after a lengthy discussion of the relative values of medication and cognitive-behavioral therapy. And unfortunately, meeting these behavioral guidelines can be difficult to achieve and cannot be subcontracted out to a therapist or a pharmacist. They require parents to set and enforce limits. Saying no is difficult for all of us, particularly those without much prior experience.

Have you observed the association between inadequate sleep, excessive screen time, and impulsivity? How robustly have you bought into the idea that more sleep and less screen time are, if not THE answers, at least are the two we should start with? Where do your recommendations about screen time, sleep, and physical activity fit into the script when you are talking with parents about their child’s ADHD-ish behaviors? Have you put them in the oh-by-the-way category?

Do you ever say, “I know you may be expecting me to talk about medication at this visit, but I suggest you try setting and enforcing these limits on sleep and screen time for a few months and we will see how things are going”? “And I am going to give you some suggestions on how you can do this, and we will meet again as often as you feel is necessary to ease the process.”

Do you think you have the time to try this approach? Do you feel you have the skills to counsel on sleep and behavior? Do you think you can find someone with the time and experience who shares your priorities about screen time and sleep to do the parental coaching for you? It’s an approach worth considering when you step back and take the longer look at why we are living through this decades-long ADHD phenomenon.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

If you are still struggling to understand the ADHD phenomenon and its meteoric rise to prominence over the last 3 or 4 decades, a study published in the September 2019 Pediatrics may help you make sense of why you are spending a large part of your professional day counseling parents and treating children whose lives are disrupted by their impulsivity, distractibility, and inattentiveness (“24-hour movement behaviors and impulsivity.” doi: 10.1542/peds.2019-0187). Researchers at the Children’s Hospital of Eastern Ontario (Canada) Research Institute used data collected over 10 years in 21 sites across the United States on more than 4,500 children aged 8-11 years, looking for possible associations between impulsivity and three factors – sleep duration, screen time, and physical activity.

Goads Agency/Getty Images

They found that children who were exposed to fewer than 2 hours of recreational screen time each day and slept 9-11 hours nightly had significantly reduced scores on a range of impulsivity scores. While participating in at least 60 minutes of vigorous physical activity per day also was associated with less impulsivity, the effect added little to the benefit of the sleep/screen time combination. Although these nonpharmacologic strategies aimed at decreasing impulsivity may not be a cure-all for every child with symptoms that suggest ADHD, the data are compelling.

I hope that the associations these Canadian researchers have unearthed is not news to you. But their observation that 30% of the sample population met none of the recommendations for sleep, screen time, and activity and that only 5% of the sample did suggests that too few of us are delivering the message with sufficient enthusiasm and/or too many parents aren’t taking it seriously.

Over the last several years I have been encouraged to find sleep and screen time limits mentioned in articles on ADHD for both professionals and parents, but these potent contributors to impulsivity and distractibility always seem to be relegated to the oh-by-the-way category at the end of the article after a lengthy discussion of the relative values of medication and cognitive-behavioral therapy. And unfortunately, meeting these behavioral guidelines can be difficult to achieve and cannot be subcontracted out to a therapist or a pharmacist. They require parents to set and enforce limits. Saying no is difficult for all of us, particularly those without much prior experience.

Have you observed the association between inadequate sleep, excessive screen time, and impulsivity? How robustly have you bought into the idea that more sleep and less screen time are, if not THE answers, at least are the two we should start with? Where do your recommendations about screen time, sleep, and physical activity fit into the script when you are talking with parents about their child’s ADHD-ish behaviors? Have you put them in the oh-by-the-way category?

Do you ever say, “I know you may be expecting me to talk about medication at this visit, but I suggest you try setting and enforcing these limits on sleep and screen time for a few months and we will see how things are going”? “And I am going to give you some suggestions on how you can do this, and we will meet again as often as you feel is necessary to ease the process.”

Do you think you have the time to try this approach? Do you feel you have the skills to counsel on sleep and behavior? Do you think you can find someone with the time and experience who shares your priorities about screen time and sleep to do the parental coaching for you? It’s an approach worth considering when you step back and take the longer look at why we are living through this decades-long ADHD phenomenon.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

No topic is quite so controversial in psychiatry as outpatient civil commitment.

We all value the right to make our own medical decisions, perhaps even more so when it comes to issues of mental health. The concern, however, is that some patients lack the ability to see that they are ill, and their refusal to participate in treatment leads them to repeated involuntary hospitalizations or to behaviors that result in their incarceration. Mandated care for forensic patients – those who have ended up in the criminal justice system – is not as controversial, but for those who have committed no crime, the legislative struggles can get very heated. Add to that the cost of implementing outpatient civil commitment (OCC), the difficulties in enforcing the orders, the call to include an array of services for participants, the difficulties in ascertaining if these mandates are successful in helping patients live better lives, and the fact that treatment doesn’t always work, then what seems like a simple solution to the problem of noncompliance is actually quite complex.

Maryland is one of four states that does not have OCC. In 2017, it was announced that the city of Baltimore would begin an OCC pilot program. The program, administered by Behavioral Health System Baltimore (BHSB) in partnership with numerous other mental health organizations, has had several fits and starts. The program initially was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), and the grant required the program to serve a minimum of 75 patients. However, it was soon discovered that there were no written regulations, and that began a 1-year delay while regulations were written, including two periods for open public comment. Once set, BHSB needed to let local hospitals know the program existed and solicit referrals.

When it became clear that they would not be able to serve 75 individuals, BHSB elected to give its funding back to SAMHSA, and a second 3-month delay ensued until the state of Maryland picked up the cost. The Baltimore pilot project in OCC is different from other civil commitment programs. The criteria for inclusion are brief: The patient must be aged over 18 years, be a resident of Baltimore, and must have been retained by a judge at a hospital inpatient civil commitment hearing at least two times in the past year because of noncompliance with outpatient treatment. The referral needs to come from the inpatient unit before the patient is discharged, and entails a “settlement agreement” with a judge, typically the same administrative law judge that visits the hospital weekly for the inpatient commitment hearings. A connection is made with the patient prior to discharge from the inpatient facility.

The Baltimore project also differs in many ways from traditional outpatient commitment programs in other states. In this program, the patient is not mandated to treatment. Instead, the patient is required to meet with the program’s peer-recovery specialist. The recovery specialist provides support for the patient after discharge, facilitates engagement in both psychiatric and somatic medical care, and helps with transportation to appointments. Services for each participant continue for 6 months; the initial SAMHSA grant was for $2.8 million for 4 years.

Nicole McGill, the program’s monitor notes: “When people are repeatedly hospitalized, it signals to us that maybe the system hasn’t been doing what it needs to do. For those people, the OCC pilot aims to be the connection to existing services in the community.”

Of the 19 people who have been referred to the program since October 2017, 9 have been accepted. Six of those patients enrolled voluntarily; three were ordered into the program against their will. Of those three, one patient has refused to meet with the peer-recovery specialist. That patient, however, is enrolled with an Assertive Community Treatment and is not someone who is refusing psychiatric treatment. That patient was enlisted with the hope that more engagement might prevent future hospitalizations.

“We didn’t want to create a program that forced people into treatment,” said Adrienne Breidenstine, vice president for policy and communications for BHSB. “Those programs don’t work. If a program participant chooses not to engage in services, the OCC peers will step up their engagement. There are no punitive or legal consequences; they aren’t brought back to the hospital or taken to jail.”

So far, the program has been well received by its clients. Feedback is solicited through the Mental Health Association of Maryland. One client provided a testimonial saying: “I didn’t know there were so many resources out there. They took me to the food co-op and gave me free sheets. I got a fan. They didn’t waste time getting me that. It helped a lot with the heat. They get me to appointments. They helped so much.”

This fall, BHSB is expanding its services; as of Sept. 9, 2019, any Baltimore resident who is currently hospitalized and has been hospitalized at least one other time in the past 12 months will be eligible for the outpatient “commitment” program; there will no longer be a requirement that these inpatient stays involved retention at a civil commitment hearing or that the patient ever had an involuntary status. Patients who have not been committed to the hospital, however, will only be able to enter the program on a voluntary track.

This model of OCC is a bit of a misnomer: Most of the patients are in the program voluntarily, and they are not being required to go to treatment or take medications. It is a way to get a higher level of service to the sickest of patients who have needed repeated hospitalizations without the objections that get raised when patients are mandated to care. Given the distress that involuntary hospitalization causes, it may well be helpful to expand a voluntary offer of services to all patients who are retained at a hearing, even if only once; perhaps the added support could prevent future decompensations.

For now, the program has had a rough beginning, and the expense is hard to justify for so few patients. For advocates who support outpatient commitment, this program does not go far enough, as there is no requirement to take medications and no consequence for refusal to participate. As the criteria for inclusion are loosened to include those who are repeatedly hospitalized on a voluntary basis, it will be interesting to see if hospitalizations can be prevented and if the quality of life can be improved for these patients.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice, and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

 

No topic is quite so controversial in psychiatry as outpatient civil commitment.

We all value the right to make our own medical decisions, perhaps even more so when it comes to issues of mental health. The concern, however, is that some patients lack the ability to see that they are ill, and their refusal to participate in treatment leads them to repeated involuntary hospitalizations or to behaviors that result in their incarceration. Mandated care for forensic patients – those who have ended up in the criminal justice system – is not as controversial, but for those who have committed no crime, the legislative struggles can get very heated. Add to that the cost of implementing outpatient civil commitment (OCC), the difficulties in enforcing the orders, the call to include an array of services for participants, the difficulties in ascertaining if these mandates are successful in helping patients live better lives, and the fact that treatment doesn’t always work, then what seems like a simple solution to the problem of noncompliance is actually quite complex.

Maryland is one of four states that does not have OCC. In 2017, it was announced that the city of Baltimore would begin an OCC pilot program. The program, administered by Behavioral Health System Baltimore (BHSB) in partnership with numerous other mental health organizations, has had several fits and starts. The program initially was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), and the grant required the program to serve a minimum of 75 patients. However, it was soon discovered that there were no written regulations, and that began a 1-year delay while regulations were written, including two periods for open public comment. Once set, BHSB needed to let local hospitals know the program existed and solicit referrals.

When it became clear that they would not be able to serve 75 individuals, BHSB elected to give its funding back to SAMHSA, and a second 3-month delay ensued until the state of Maryland picked up the cost. The Baltimore pilot project in OCC is different from other civil commitment programs. The criteria for inclusion are brief: The patient must be aged over 18 years, be a resident of Baltimore, and must have been retained by a judge at a hospital inpatient civil commitment hearing at least two times in the past year because of noncompliance with outpatient treatment. The referral needs to come from the inpatient unit before the patient is discharged, and entails a “settlement agreement” with a judge, typically the same administrative law judge that visits the hospital weekly for the inpatient commitment hearings. A connection is made with the patient prior to discharge from the inpatient facility.

The Baltimore project also differs in many ways from traditional outpatient commitment programs in other states. In this program, the patient is not mandated to treatment. Instead, the patient is required to meet with the program’s peer-recovery specialist. The recovery specialist provides support for the patient after discharge, facilitates engagement in both psychiatric and somatic medical care, and helps with transportation to appointments. Services for each participant continue for 6 months; the initial SAMHSA grant was for $2.8 million for 4 years.

Nicole McGill, the program’s monitor notes: “When people are repeatedly hospitalized, it signals to us that maybe the system hasn’t been doing what it needs to do. For those people, the OCC pilot aims to be the connection to existing services in the community.”

Of the 19 people who have been referred to the program since October 2017, 9 have been accepted. Six of those patients enrolled voluntarily; three were ordered into the program against their will. Of those three, one patient has refused to meet with the peer-recovery specialist. That patient, however, is enrolled with an Assertive Community Treatment and is not someone who is refusing psychiatric treatment. That patient was enlisted with the hope that more engagement might prevent future hospitalizations.

“We didn’t want to create a program that forced people into treatment,” said Adrienne Breidenstine, vice president for policy and communications for BHSB. “Those programs don’t work. If a program participant chooses not to engage in services, the OCC peers will step up their engagement. There are no punitive or legal consequences; they aren’t brought back to the hospital or taken to jail.”

So far, the program has been well received by its clients. Feedback is solicited through the Mental Health Association of Maryland. One client provided a testimonial saying: “I didn’t know there were so many resources out there. They took me to the food co-op and gave me free sheets. I got a fan. They didn’t waste time getting me that. It helped a lot with the heat. They get me to appointments. They helped so much.”

This fall, BHSB is expanding its services; as of Sept. 9, 2019, any Baltimore resident who is currently hospitalized and has been hospitalized at least one other time in the past 12 months will be eligible for the outpatient “commitment” program; there will no longer be a requirement that these inpatient stays involved retention at a civil commitment hearing or that the patient ever had an involuntary status. Patients who have not been committed to the hospital, however, will only be able to enter the program on a voluntary track.

This model of OCC is a bit of a misnomer: Most of the patients are in the program voluntarily, and they are not being required to go to treatment or take medications. It is a way to get a higher level of service to the sickest of patients who have needed repeated hospitalizations without the objections that get raised when patients are mandated to care. Given the distress that involuntary hospitalization causes, it may well be helpful to expand a voluntary offer of services to all patients who are retained at a hearing, even if only once; perhaps the added support could prevent future decompensations.

For now, the program has had a rough beginning, and the expense is hard to justify for so few patients. For advocates who support outpatient commitment, this program does not go far enough, as there is no requirement to take medications and no consequence for refusal to participate. As the criteria for inclusion are loosened to include those who are repeatedly hospitalized on a voluntary basis, it will be interesting to see if hospitalizations can be prevented and if the quality of life can be improved for these patients.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice, and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

 

No topic is quite so controversial in psychiatry as outpatient civil commitment.

We all value the right to make our own medical decisions, perhaps even more so when it comes to issues of mental health. The concern, however, is that some patients lack the ability to see that they are ill, and their refusal to participate in treatment leads them to repeated involuntary hospitalizations or to behaviors that result in their incarceration. Mandated care for forensic patients – those who have ended up in the criminal justice system – is not as controversial, but for those who have committed no crime, the legislative struggles can get very heated. Add to that the cost of implementing outpatient civil commitment (OCC), the difficulties in enforcing the orders, the call to include an array of services for participants, the difficulties in ascertaining if these mandates are successful in helping patients live better lives, and the fact that treatment doesn’t always work, then what seems like a simple solution to the problem of noncompliance is actually quite complex.

Maryland is one of four states that does not have OCC. In 2017, it was announced that the city of Baltimore would begin an OCC pilot program. The program, administered by Behavioral Health System Baltimore (BHSB) in partnership with numerous other mental health organizations, has had several fits and starts. The program initially was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), and the grant required the program to serve a minimum of 75 patients. However, it was soon discovered that there were no written regulations, and that began a 1-year delay while regulations were written, including two periods for open public comment. Once set, BHSB needed to let local hospitals know the program existed and solicit referrals.

When it became clear that they would not be able to serve 75 individuals, BHSB elected to give its funding back to SAMHSA, and a second 3-month delay ensued until the state of Maryland picked up the cost. The Baltimore pilot project in OCC is different from other civil commitment programs. The criteria for inclusion are brief: The patient must be aged over 18 years, be a resident of Baltimore, and must have been retained by a judge at a hospital inpatient civil commitment hearing at least two times in the past year because of noncompliance with outpatient treatment. The referral needs to come from the inpatient unit before the patient is discharged, and entails a “settlement agreement” with a judge, typically the same administrative law judge that visits the hospital weekly for the inpatient commitment hearings. A connection is made with the patient prior to discharge from the inpatient facility.

The Baltimore project also differs in many ways from traditional outpatient commitment programs in other states. In this program, the patient is not mandated to treatment. Instead, the patient is required to meet with the program’s peer-recovery specialist. The recovery specialist provides support for the patient after discharge, facilitates engagement in both psychiatric and somatic medical care, and helps with transportation to appointments. Services for each participant continue for 6 months; the initial SAMHSA grant was for $2.8 million for 4 years.

Nicole McGill, the program’s monitor notes: “When people are repeatedly hospitalized, it signals to us that maybe the system hasn’t been doing what it needs to do. For those people, the OCC pilot aims to be the connection to existing services in the community.”

Of the 19 people who have been referred to the program since October 2017, 9 have been accepted. Six of those patients enrolled voluntarily; three were ordered into the program against their will. Of those three, one patient has refused to meet with the peer-recovery specialist. That patient, however, is enrolled with an Assertive Community Treatment and is not someone who is refusing psychiatric treatment. That patient was enlisted with the hope that more engagement might prevent future hospitalizations.

“We didn’t want to create a program that forced people into treatment,” said Adrienne Breidenstine, vice president for policy and communications for BHSB. “Those programs don’t work. If a program participant chooses not to engage in services, the OCC peers will step up their engagement. There are no punitive or legal consequences; they aren’t brought back to the hospital or taken to jail.”

So far, the program has been well received by its clients. Feedback is solicited through the Mental Health Association of Maryland. One client provided a testimonial saying: “I didn’t know there were so many resources out there. They took me to the food co-op and gave me free sheets. I got a fan. They didn’t waste time getting me that. It helped a lot with the heat. They get me to appointments. They helped so much.”

This fall, BHSB is expanding its services; as of Sept. 9, 2019, any Baltimore resident who is currently hospitalized and has been hospitalized at least one other time in the past 12 months will be eligible for the outpatient “commitment” program; there will no longer be a requirement that these inpatient stays involved retention at a civil commitment hearing or that the patient ever had an involuntary status. Patients who have not been committed to the hospital, however, will only be able to enter the program on a voluntary track.

This model of OCC is a bit of a misnomer: Most of the patients are in the program voluntarily, and they are not being required to go to treatment or take medications. It is a way to get a higher level of service to the sickest of patients who have needed repeated hospitalizations without the objections that get raised when patients are mandated to care. Given the distress that involuntary hospitalization causes, it may well be helpful to expand a voluntary offer of services to all patients who are retained at a hearing, even if only once; perhaps the added support could prevent future decompensations.

For now, the program has had a rough beginning, and the expense is hard to justify for so few patients. For advocates who support outpatient commitment, this program does not go far enough, as there is no requirement to take medications and no consequence for refusal to participate. As the criteria for inclusion are loosened to include those who are repeatedly hospitalized on a voluntary basis, it will be interesting to see if hospitalizations can be prevented and if the quality of life can be improved for these patients.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice, and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

 

A 54-year-old pharmacist with a history of gout, hypertension, and conjunctivitis presents for evaluation of pink eye in the summer. The morning before coming into the office, he noticed that his right eye was red and inflamed. He self-treated with saline washes and eye drops, but upon awakening the next day, he found his right eye to be crusted shut with surrounding yellow discharge. He has not had any changes to his vision but endorses a somewhat uncomfortable, “gritty” sensation. He reports no recent cough, nasal congestion, or allergies, and he has not been around any sick contacts. His blood pressure is 102/58 mm Hg, pulse is 76 bpm, and body mass index is 27.3 kg/m². His eye exam reveals unilateral conjunctival injections but no hyperemia of the conjunctiva adjacent to the cornea. Mucopurulent discharge was neither found on the undersurface of the eyelid nor emerging from the eye. Which of the following is the best treatment for this patient’s condition?

A) Erythromycin 5 mg/gram ophthalmic ointment.

B) Ofloxacin 0.3% ophthalmic drops.

C) Antihistamine drops.

D) Eye lubricant drops.

E) No treatment necessary.

This patient is an adult presenting with presumed conjunctivitis. Because he is presenting in the summer without observed purulent discharge, his condition is unlikely to be bacterial. This patient does not need treatment, although eye lubricant drops could reduce his discomfort.

Nearly 1% of primary care office visits¹ and 300 million in annual costs² are spent evaluating and treating “pink eye.” After ruling out serious eye disease, clinicians need to determine which cases of suspected conjunctivitis are most likely to be bacterial to allow for judicious use of antibiotic eye drops. This is an important undertaking as most patients assume that antibiotics are needed.

How do we know which history and clinical exam findings to lean on when attempting to categorize conjunctivitis as bacterial or not? If a patient reports purulent discharge, doesn’t that mean it is bacterial? Surprisingly, a systematic review published in 2016 by Narayana and McGee found that a patient’s self-report of “purulent drainage” is diagnostically unhelpful, but if a clinician finds it on exam, the likelihood of a bacterial etiology increases.³

Narayana and McGee analyzed three studies that enrolled a total of 281 patients with presumed conjunctivitis who underwent bacterial cultures. They then determined which findings increased the probability of positive bacterial culture. From strongest to weakest, the best indicators of a bacterial cause were found to be: complete redness of the conjunctival membrane obscuring tarsal vessels (the vessels visible on the inside of everted upper or lower eyelids) (likelihood ratio, 4.6), observed purulent discharge (LR, 3.9), matting of both eyes in the morning (LR, 3.6), and presence during winter/spring months (LR, 1.9). On the other hand, failure to observe a red eye at 20 feet (LR, 0.2), absence of morning gluing of either eye (LR, 0.3), and presentation during summer months (LR, 0.4) all decreased the probability of a bacterial cause. This review and different study by Stenson et al. unfortunately have conflicting evidence regarding whether the following findings are diagnostically helpful: qualities of eye discomfort (such as burning or itching), preauricular adenopathy, conjunctival follicles, and conjunctival papillae.^3,4 Rietveld and colleagues found that a history of conjunctivitis decreased the likelihood of bacterial conjunctivitis.⁵

Ultimately, if the former indicators are kept in mind, primary care clinicians should be able to decrease the prescribing of topical antimicrobials to patients with non-bacterial conjunctivitis.

Pearl: The best indicators of a bacterial cause in patients with presumed conjunctivitis are complete redness of the conjunctival membrane obscuring tarsal vessels, observed purulent discharge, and matting of both eyes in the morning. Presentation during the summer months and having a history of conjunctivitis decreases the likelihood of bacterial conjunctivitis.

Ms. Momany is a fourth-year medical student at University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at that university. Contact Dr. Paauw at imnews@mdedge.com.

References

1. Azari AA and Barney NP. JAMA. 2013 Oct 23; 310(16):1721-9.

2. Smith AF and Waycaster C. BMC Ophthalmol. 2009 Nov 25. doi: 10.1186/1471-2415-9-13.

3) Narayana S and McGee S. Am J Med. 2015;128(11):1220-4.e1.

4) Stenson S et al. Arch Ophthalmol. 1982;100(8):1275-7.

5) Rietveld RP et al. BMJ. 2004 Jul 24;329(7459):206-10.

 

A 54-year-old pharmacist with a history of gout, hypertension, and conjunctivitis presents for evaluation of pink eye in the summer. The morning before coming into the office, he noticed that his right eye was red and inflamed. He self-treated with saline washes and eye drops, but upon awakening the next day, he found his right eye to be crusted shut with surrounding yellow discharge. He has not had any changes to his vision but endorses a somewhat uncomfortable, “gritty” sensation. He reports no recent cough, nasal congestion, or allergies, and he has not been around any sick contacts. His blood pressure is 102/58 mm Hg, pulse is 76 bpm, and body mass index is 27.3 kg/m². His eye exam reveals unilateral conjunctival injections but no hyperemia of the conjunctiva adjacent to the cornea. Mucopurulent discharge was neither found on the undersurface of the eyelid nor emerging from the eye. Which of the following is the best treatment for this patient’s condition?

A) Erythromycin 5 mg/gram ophthalmic ointment.

B) Ofloxacin 0.3% ophthalmic drops.

C) Antihistamine drops.

D) Eye lubricant drops.

E) No treatment necessary.

This patient is an adult presenting with presumed conjunctivitis. Because he is presenting in the summer without observed purulent discharge, his condition is unlikely to be bacterial. This patient does not need treatment, although eye lubricant drops could reduce his discomfort.

Nearly 1% of primary care office visits¹ and 300 million in annual costs² are spent evaluating and treating “pink eye.” After ruling out serious eye disease, clinicians need to determine which cases of suspected conjunctivitis are most likely to be bacterial to allow for judicious use of antibiotic eye drops. This is an important undertaking as most patients assume that antibiotics are needed.

How do we know which history and clinical exam findings to lean on when attempting to categorize conjunctivitis as bacterial or not? If a patient reports purulent discharge, doesn’t that mean it is bacterial? Surprisingly, a systematic review published in 2016 by Narayana and McGee found that a patient’s self-report of “purulent drainage” is diagnostically unhelpful, but if a clinician finds it on exam, the likelihood of a bacterial etiology increases.³

Narayana and McGee analyzed three studies that enrolled a total of 281 patients with presumed conjunctivitis who underwent bacterial cultures. They then determined which findings increased the probability of positive bacterial culture. From strongest to weakest, the best indicators of a bacterial cause were found to be: complete redness of the conjunctival membrane obscuring tarsal vessels (the vessels visible on the inside of everted upper or lower eyelids) (likelihood ratio, 4.6), observed purulent discharge (LR, 3.9), matting of both eyes in the morning (LR, 3.6), and presence during winter/spring months (LR, 1.9). On the other hand, failure to observe a red eye at 20 feet (LR, 0.2), absence of morning gluing of either eye (LR, 0.3), and presentation during summer months (LR, 0.4) all decreased the probability of a bacterial cause. This review and different study by Stenson et al. unfortunately have conflicting evidence regarding whether the following findings are diagnostically helpful: qualities of eye discomfort (such as burning or itching), preauricular adenopathy, conjunctival follicles, and conjunctival papillae.^3,4 Rietveld and colleagues found that a history of conjunctivitis decreased the likelihood of bacterial conjunctivitis.⁵

Ultimately, if the former indicators are kept in mind, primary care clinicians should be able to decrease the prescribing of topical antimicrobials to patients with non-bacterial conjunctivitis.

Pearl: The best indicators of a bacterial cause in patients with presumed conjunctivitis are complete redness of the conjunctival membrane obscuring tarsal vessels, observed purulent discharge, and matting of both eyes in the morning. Presentation during the summer months and having a history of conjunctivitis decreases the likelihood of bacterial conjunctivitis.

Ms. Momany is a fourth-year medical student at University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at that university. Contact Dr. Paauw at imnews@mdedge.com.

References

1. Azari AA and Barney NP. JAMA. 2013 Oct 23; 310(16):1721-9.

2. Smith AF and Waycaster C. BMC Ophthalmol. 2009 Nov 25. doi: 10.1186/1471-2415-9-13.

3) Narayana S and McGee S. Am J Med. 2015;128(11):1220-4.e1.

4) Stenson S et al. Arch Ophthalmol. 1982;100(8):1275-7.

5) Rietveld RP et al. BMJ. 2004 Jul 24;329(7459):206-10.

 

A 54-year-old pharmacist with a history of gout, hypertension, and conjunctivitis presents for evaluation of pink eye in the summer. The morning before coming into the office, he noticed that his right eye was red and inflamed. He self-treated with saline washes and eye drops, but upon awakening the next day, he found his right eye to be crusted shut with surrounding yellow discharge. He has not had any changes to his vision but endorses a somewhat uncomfortable, “gritty” sensation. He reports no recent cough, nasal congestion, or allergies, and he has not been around any sick contacts. His blood pressure is 102/58 mm Hg, pulse is 76 bpm, and body mass index is 27.3 kg/m². His eye exam reveals unilateral conjunctival injections but no hyperemia of the conjunctiva adjacent to the cornea. Mucopurulent discharge was neither found on the undersurface of the eyelid nor emerging from the eye. Which of the following is the best treatment for this patient’s condition?

A) Erythromycin 5 mg/gram ophthalmic ointment.

B) Ofloxacin 0.3% ophthalmic drops.

C) Antihistamine drops.

D) Eye lubricant drops.

E) No treatment necessary.

This patient is an adult presenting with presumed conjunctivitis. Because he is presenting in the summer without observed purulent discharge, his condition is unlikely to be bacterial. This patient does not need treatment, although eye lubricant drops could reduce his discomfort.

Nearly 1% of primary care office visits¹ and 300 million in annual costs² are spent evaluating and treating “pink eye.” After ruling out serious eye disease, clinicians need to determine which cases of suspected conjunctivitis are most likely to be bacterial to allow for judicious use of antibiotic eye drops. This is an important undertaking as most patients assume that antibiotics are needed.

How do we know which history and clinical exam findings to lean on when attempting to categorize conjunctivitis as bacterial or not? If a patient reports purulent discharge, doesn’t that mean it is bacterial? Surprisingly, a systematic review published in 2016 by Narayana and McGee found that a patient’s self-report of “purulent drainage” is diagnostically unhelpful, but if a clinician finds it on exam, the likelihood of a bacterial etiology increases.³

Narayana and McGee analyzed three studies that enrolled a total of 281 patients with presumed conjunctivitis who underwent bacterial cultures. They then determined which findings increased the probability of positive bacterial culture. From strongest to weakest, the best indicators of a bacterial cause were found to be: complete redness of the conjunctival membrane obscuring tarsal vessels (the vessels visible on the inside of everted upper or lower eyelids) (likelihood ratio, 4.6), observed purulent discharge (LR, 3.9), matting of both eyes in the morning (LR, 3.6), and presence during winter/spring months (LR, 1.9). On the other hand, failure to observe a red eye at 20 feet (LR, 0.2), absence of morning gluing of either eye (LR, 0.3), and presentation during summer months (LR, 0.4) all decreased the probability of a bacterial cause. This review and different study by Stenson et al. unfortunately have conflicting evidence regarding whether the following findings are diagnostically helpful: qualities of eye discomfort (such as burning or itching), preauricular adenopathy, conjunctival follicles, and conjunctival papillae.^3,4 Rietveld and colleagues found that a history of conjunctivitis decreased the likelihood of bacterial conjunctivitis.⁵

Ultimately, if the former indicators are kept in mind, primary care clinicians should be able to decrease the prescribing of topical antimicrobials to patients with non-bacterial conjunctivitis.

Pearl: The best indicators of a bacterial cause in patients with presumed conjunctivitis are complete redness of the conjunctival membrane obscuring tarsal vessels, observed purulent discharge, and matting of both eyes in the morning. Presentation during the summer months and having a history of conjunctivitis decreases the likelihood of bacterial conjunctivitis.

Ms. Momany is a fourth-year medical student at University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at that university. Contact Dr. Paauw at imnews@mdedge.com.

References

1. Azari AA and Barney NP. JAMA. 2013 Oct 23; 310(16):1721-9.

2. Smith AF and Waycaster C. BMC Ophthalmol. 2009 Nov 25. doi: 10.1186/1471-2415-9-13.

3) Narayana S and McGee S. Am J Med. 2015;128(11):1220-4.e1.

4) Stenson S et al. Arch Ophthalmol. 1982;100(8):1275-7.

5) Rietveld RP et al. BMJ. 2004 Jul 24;329(7459):206-10.

 

As youth suicides continue to climb nationwide, a growing body of research shows that the deaths are happening at higher rates in rural communities.

Courtesy Dr. Kriechman

In 2017, suicides reached their highest point since 2000, a trend driven by a sharp rise in male suicides and in youth aged 15-19 years, according to an analysis published recently in JAMA (2019 Jun 18. doi: 10.1001/jama.2019.5054). Among youth aged 15-19 years, the suicide rate was 12 per 100,000 in 2017 (18 per 100,000 in males and 5 per 100,000 in females), compared with 8 per 100,000 in 2000, the study found. Across all age groups, the highest suicide rates and greatest rate increases are in rural counties, according to data from the Centers for Disease Control and Prevention (CDC).

Now, a unique initiative in New Mexico is working to combat those alarming trends through an alliance of community leaders that strives to strengthen resilience and build peer support for at-risk youth.

The Alliance-Building for Suicide Prevention & Youth Resilience (ASPYR) program, created by the University of New Mexico (UNM), Albuquerque, focuses on training professionals and advocates within New Mexico communities in a strength-based, youth-directed, collaborative approach for the assessment and treatment of suicidality. A diversity of community members undergo the training, including health and behavioral health care providers, peer support and community support workers, youth and community advocates, educators, and first responders. The initiative also supports and facilitates the development of a communitywide crisis intervention plan that promotes youth safety and resilience.

“ASPYR is unique, in that we actively involve youth to guide our program, versus an adult-only led program,” says Laura Rombach, program manager for ASPYR and a senior program therapist in the department of psychiatry and behavioral sciences at UNM. “Youth offer feedback about our training and ideas about how to best prevent suicide in their schools and communities. New Mexico is underresourced, and individuals living in rural/frontier areas do not always have access to licensed behavioral health providers, so our training is developed for licensed providers as well as peers and paraprofessionals to increase the knowledge of care for individuals experiencing a suicidal crisis.”
 

Rural populations present challenges

The many rural pockets of New Mexico pose numerous obstacles for antisuicide advocates.

Of the 33 counties in New Mexico, six are identified by the Census Bureau as completely “rural,” and an additional six are defined as mostly rural, according to the University of New Mexico Bureau of Business & Economic Research. Even among counties considered “urban” however, a considerable amount of the population lives in rural areas, according to the bureau. San Juan County, for example, which is considered urban by the Census Bureau, had an estimated 34% of residents living in rural areas in 2010.

Poverty adds to the difficulty. In 2017, nearly one in five New Mexicans (20%) lived below the poverty line, and the state had the second-highest rate of children under 18 years living in poverty in the country, according to a report by the New Mexico Department of Workforce Solutions.

“New Mexico is an impoverished state with limited capacity, especially in regards to behavioral health services,” said Avi Kriechman, MD, principal investigator for ASPYR at UNM and a child, adolescent, and family psychiatrist at the university. “It is also challenging to create a truly statewide effort where there is limited public transportation, problematic Internet connection, and other barriers to involving those who live and work in rural and frontier New Mexico.”

Addressing suicide among the many native and Indigenous people in rural New Mexico presents another unique set of challenges, said Mary Roessel, MD, a Santa Fe, N.M.–based psychiatrist who specializes in cultural psychiatry. Native and Indigenous residents often have a general mistrust of outsiders and a stigma against mental illnesses, Dr. Roessel said in an interview.

“One of the problems is being able to identify when a person has attempted suicide in some of these small, private, Pueblo communities because they are very closed,” she said. “At times, we don’t get the information to go in and help them. They’re trying to address or deal with the problem themselves.”

To address the many barriers of rural New Mexico, ASPYR works hard to recognize, identify, and support preexisting community resources that are often neglected in needs assessment and stakeholder identification, Dr. Kriechman said. This can include food banks, church care committees, youth advocacy groups, local caregiving, and spiritual traditions, among others. Frequently, many community caregivers and agencies have not connected or communicated with one another and often are unaware of all they have to offer, he said.

“We try to build capacity through community trainings, which include a widely diverse group of providers, advocates, and supports,” he continued. “Our trainings involve highlighting and building upon local and cultural practices and traditions of healing, caregiving, and support. A significant part of our onsite training involves assembling a representative group of local providers in health care, behavioral health care, peer & community support and advocacy, education, first responders to community crises, and government and nonprofit agencies, then facilitating a community conversation between the panel and training attendees about how best to move forward in a synergistic and systemic manner to support youth safety and resilience.”
 

 

Peers support peers

While ASPYR encompasses elements of other suicide prevention models, two unique cornerstones of the program are its emphasis on resilience and promotion of peer support. The strength-based, youth-directed approach includes creating a youth-directed safety plan, enlisting peers as support and reducing access to lethal means.

Regarding the youth safety plan, Dr. Kriechman explained that, rather than being prescribed and instructed in expert-selected and expert-driven coping skills, youth are offered a menu of options that most speak to their strengths, values, experience, and preferences. Young people also select a peer who, if they wish, accompanies them to sessions, and supports and coaches them at home.

“Peers are often more influential than parents, siblings, family members, and adults regarding youth behavior,” Dr. Kriechman said. “Most often, it is a peer that a youth-at-risk turns to for support, counsel, role models, and understanding. Youth who wish to offer their peers support can quickly be trained to provide early identification of youth at risk, motivational support to seek help, and a ‘warm hand-off’ to community resources.”

In addition, a Youth Advisory Council established as part of the program draws from young people across New Mexico to participate in state and national conferences, and conduct outreach efforts to peers.

ASPYR Youth council member Serenity Gomez, a senior at the Public Academy for Performing Arts in Albuquerque, became interested in ASPYR after volunteering for the American Foundation for Suicide Prevention in 2016. As a youth council member, Ms. Gomez said she helps create projects to raise suicide awareness, whether through posters, stickers, social media, poetry, or songs.

“My experience as a youth council member has really opened my eyes and has made me more motivated to help others,” she said in an interview. “It has also showed me that talking about suicide doesn’t always have to be a slideshow of facts. You can reach people through music, poetry, storytelling, and so much more. Many people are afraid to talk about suicide because it’s such a scary idea, but if we all talk about it and bring more awareness, then we can find the support everyone needs. In ASPYR, specifically, I hope to reach youth and help all youth learn to support each other.”

Since ASPYR launched in 2017, the program has provided both onsite and online trainings to hundreds of New Mexicans, and has helped rural and frontier communities start working on collaborative approaches to promoting youth safety and resilience, Dr. Kriechman said. Following community consultations, numerous rural communities have since formed systems of care to identify, support, and treat youth at risk. In addition to the youth council, an Advisory Community Council has also been established that welcomes any New Mexico resident interested in working on the mission of preventing youth suicide.

The program’s approach of focusing on strengths, rather than deficits, has resonated strongly with community providers with whom the program partners, Dr. Kriechman added. For example, the program shifts from “no-suicide contracts” to safety planning, focusing on reasons for living rather than reasons for dying, and shifting from prescribing coping skills to strengthening preexisting coping skills in young people.

“An ultimate hope for ASPYR is emphasizing that recovery from any of life’s challenges is far more than symptom reduction or agency collaboration,” Dr. Kriechman said. “It is the understanding that a life of value and meaning, the instillation of hope and support for the unique strengths, competencies, skills, and understandings of each individual, is honored, respected, and supported.”

agallegos@mdedge.com

 

As youth suicides continue to climb nationwide, a growing body of research shows that the deaths are happening at higher rates in rural communities.

Courtesy Dr. Kriechman

In 2017, suicides reached their highest point since 2000, a trend driven by a sharp rise in male suicides and in youth aged 15-19 years, according to an analysis published recently in JAMA (2019 Jun 18. doi: 10.1001/jama.2019.5054). Among youth aged 15-19 years, the suicide rate was 12 per 100,000 in 2017 (18 per 100,000 in males and 5 per 100,000 in females), compared with 8 per 100,000 in 2000, the study found. Across all age groups, the highest suicide rates and greatest rate increases are in rural counties, according to data from the Centers for Disease Control and Prevention (CDC).

Now, a unique initiative in New Mexico is working to combat those alarming trends through an alliance of community leaders that strives to strengthen resilience and build peer support for at-risk youth.

The Alliance-Building for Suicide Prevention & Youth Resilience (ASPYR) program, created by the University of New Mexico (UNM), Albuquerque, focuses on training professionals and advocates within New Mexico communities in a strength-based, youth-directed, collaborative approach for the assessment and treatment of suicidality. A diversity of community members undergo the training, including health and behavioral health care providers, peer support and community support workers, youth and community advocates, educators, and first responders. The initiative also supports and facilitates the development of a communitywide crisis intervention plan that promotes youth safety and resilience.

“ASPYR is unique, in that we actively involve youth to guide our program, versus an adult-only led program,” says Laura Rombach, program manager for ASPYR and a senior program therapist in the department of psychiatry and behavioral sciences at UNM. “Youth offer feedback about our training and ideas about how to best prevent suicide in their schools and communities. New Mexico is underresourced, and individuals living in rural/frontier areas do not always have access to licensed behavioral health providers, so our training is developed for licensed providers as well as peers and paraprofessionals to increase the knowledge of care for individuals experiencing a suicidal crisis.”
 

Rural populations present challenges

The many rural pockets of New Mexico pose numerous obstacles for antisuicide advocates.

Of the 33 counties in New Mexico, six are identified by the Census Bureau as completely “rural,” and an additional six are defined as mostly rural, according to the University of New Mexico Bureau of Business & Economic Research. Even among counties considered “urban” however, a considerable amount of the population lives in rural areas, according to the bureau. San Juan County, for example, which is considered urban by the Census Bureau, had an estimated 34% of residents living in rural areas in 2010.

Poverty adds to the difficulty. In 2017, nearly one in five New Mexicans (20%) lived below the poverty line, and the state had the second-highest rate of children under 18 years living in poverty in the country, according to a report by the New Mexico Department of Workforce Solutions.

“New Mexico is an impoverished state with limited capacity, especially in regards to behavioral health services,” said Avi Kriechman, MD, principal investigator for ASPYR at UNM and a child, adolescent, and family psychiatrist at the university. “It is also challenging to create a truly statewide effort where there is limited public transportation, problematic Internet connection, and other barriers to involving those who live and work in rural and frontier New Mexico.”

Addressing suicide among the many native and Indigenous people in rural New Mexico presents another unique set of challenges, said Mary Roessel, MD, a Santa Fe, N.M.–based psychiatrist who specializes in cultural psychiatry. Native and Indigenous residents often have a general mistrust of outsiders and a stigma against mental illnesses, Dr. Roessel said in an interview.

“One of the problems is being able to identify when a person has attempted suicide in some of these small, private, Pueblo communities because they are very closed,” she said. “At times, we don’t get the information to go in and help them. They’re trying to address or deal with the problem themselves.”

To address the many barriers of rural New Mexico, ASPYR works hard to recognize, identify, and support preexisting community resources that are often neglected in needs assessment and stakeholder identification, Dr. Kriechman said. This can include food banks, church care committees, youth advocacy groups, local caregiving, and spiritual traditions, among others. Frequently, many community caregivers and agencies have not connected or communicated with one another and often are unaware of all they have to offer, he said.

“We try to build capacity through community trainings, which include a widely diverse group of providers, advocates, and supports,” he continued. “Our trainings involve highlighting and building upon local and cultural practices and traditions of healing, caregiving, and support. A significant part of our onsite training involves assembling a representative group of local providers in health care, behavioral health care, peer & community support and advocacy, education, first responders to community crises, and government and nonprofit agencies, then facilitating a community conversation between the panel and training attendees about how best to move forward in a synergistic and systemic manner to support youth safety and resilience.”
 

 

Peers support peers

While ASPYR encompasses elements of other suicide prevention models, two unique cornerstones of the program are its emphasis on resilience and promotion of peer support. The strength-based, youth-directed approach includes creating a youth-directed safety plan, enlisting peers as support and reducing access to lethal means.

Regarding the youth safety plan, Dr. Kriechman explained that, rather than being prescribed and instructed in expert-selected and expert-driven coping skills, youth are offered a menu of options that most speak to their strengths, values, experience, and preferences. Young people also select a peer who, if they wish, accompanies them to sessions, and supports and coaches them at home.

“Peers are often more influential than parents, siblings, family members, and adults regarding youth behavior,” Dr. Kriechman said. “Most often, it is a peer that a youth-at-risk turns to for support, counsel, role models, and understanding. Youth who wish to offer their peers support can quickly be trained to provide early identification of youth at risk, motivational support to seek help, and a ‘warm hand-off’ to community resources.”

In addition, a Youth Advisory Council established as part of the program draws from young people across New Mexico to participate in state and national conferences, and conduct outreach efforts to peers.

ASPYR Youth council member Serenity Gomez, a senior at the Public Academy for Performing Arts in Albuquerque, became interested in ASPYR after volunteering for the American Foundation for Suicide Prevention in 2016. As a youth council member, Ms. Gomez said she helps create projects to raise suicide awareness, whether through posters, stickers, social media, poetry, or songs.

“My experience as a youth council member has really opened my eyes and has made me more motivated to help others,” she said in an interview. “It has also showed me that talking about suicide doesn’t always have to be a slideshow of facts. You can reach people through music, poetry, storytelling, and so much more. Many people are afraid to talk about suicide because it’s such a scary idea, but if we all talk about it and bring more awareness, then we can find the support everyone needs. In ASPYR, specifically, I hope to reach youth and help all youth learn to support each other.”

Since ASPYR launched in 2017, the program has provided both onsite and online trainings to hundreds of New Mexicans, and has helped rural and frontier communities start working on collaborative approaches to promoting youth safety and resilience, Dr. Kriechman said. Following community consultations, numerous rural communities have since formed systems of care to identify, support, and treat youth at risk. In addition to the youth council, an Advisory Community Council has also been established that welcomes any New Mexico resident interested in working on the mission of preventing youth suicide.

The program’s approach of focusing on strengths, rather than deficits, has resonated strongly with community providers with whom the program partners, Dr. Kriechman added. For example, the program shifts from “no-suicide contracts” to safety planning, focusing on reasons for living rather than reasons for dying, and shifting from prescribing coping skills to strengthening preexisting coping skills in young people.

“An ultimate hope for ASPYR is emphasizing that recovery from any of life’s challenges is far more than symptom reduction or agency collaboration,” Dr. Kriechman said. “It is the understanding that a life of value and meaning, the instillation of hope and support for the unique strengths, competencies, skills, and understandings of each individual, is honored, respected, and supported.”

agallegos@mdedge.com

 

As youth suicides continue to climb nationwide, a growing body of research shows that the deaths are happening at higher rates in rural communities.

Courtesy Dr. Kriechman

In 2017, suicides reached their highest point since 2000, a trend driven by a sharp rise in male suicides and in youth aged 15-19 years, according to an analysis published recently in JAMA (2019 Jun 18. doi: 10.1001/jama.2019.5054). Among youth aged 15-19 years, the suicide rate was 12 per 100,000 in 2017 (18 per 100,000 in males and 5 per 100,000 in females), compared with 8 per 100,000 in 2000, the study found. Across all age groups, the highest suicide rates and greatest rate increases are in rural counties, according to data from the Centers for Disease Control and Prevention (CDC).

Now, a unique initiative in New Mexico is working to combat those alarming trends through an alliance of community leaders that strives to strengthen resilience and build peer support for at-risk youth.

The Alliance-Building for Suicide Prevention & Youth Resilience (ASPYR) program, created by the University of New Mexico (UNM), Albuquerque, focuses on training professionals and advocates within New Mexico communities in a strength-based, youth-directed, collaborative approach for the assessment and treatment of suicidality. A diversity of community members undergo the training, including health and behavioral health care providers, peer support and community support workers, youth and community advocates, educators, and first responders. The initiative also supports and facilitates the development of a communitywide crisis intervention plan that promotes youth safety and resilience.

“ASPYR is unique, in that we actively involve youth to guide our program, versus an adult-only led program,” says Laura Rombach, program manager for ASPYR and a senior program therapist in the department of psychiatry and behavioral sciences at UNM. “Youth offer feedback about our training and ideas about how to best prevent suicide in their schools and communities. New Mexico is underresourced, and individuals living in rural/frontier areas do not always have access to licensed behavioral health providers, so our training is developed for licensed providers as well as peers and paraprofessionals to increase the knowledge of care for individuals experiencing a suicidal crisis.”
 

Rural populations present challenges

The many rural pockets of New Mexico pose numerous obstacles for antisuicide advocates.

Of the 33 counties in New Mexico, six are identified by the Census Bureau as completely “rural,” and an additional six are defined as mostly rural, according to the University of New Mexico Bureau of Business & Economic Research. Even among counties considered “urban” however, a considerable amount of the population lives in rural areas, according to the bureau. San Juan County, for example, which is considered urban by the Census Bureau, had an estimated 34% of residents living in rural areas in 2010.

Poverty adds to the difficulty. In 2017, nearly one in five New Mexicans (20%) lived below the poverty line, and the state had the second-highest rate of children under 18 years living in poverty in the country, according to a report by the New Mexico Department of Workforce Solutions.

“New Mexico is an impoverished state with limited capacity, especially in regards to behavioral health services,” said Avi Kriechman, MD, principal investigator for ASPYR at UNM and a child, adolescent, and family psychiatrist at the university. “It is also challenging to create a truly statewide effort where there is limited public transportation, problematic Internet connection, and other barriers to involving those who live and work in rural and frontier New Mexico.”

Addressing suicide among the many native and Indigenous people in rural New Mexico presents another unique set of challenges, said Mary Roessel, MD, a Santa Fe, N.M.–based psychiatrist who specializes in cultural psychiatry. Native and Indigenous residents often have a general mistrust of outsiders and a stigma against mental illnesses, Dr. Roessel said in an interview.

“One of the problems is being able to identify when a person has attempted suicide in some of these small, private, Pueblo communities because they are very closed,” she said. “At times, we don’t get the information to go in and help them. They’re trying to address or deal with the problem themselves.”

To address the many barriers of rural New Mexico, ASPYR works hard to recognize, identify, and support preexisting community resources that are often neglected in needs assessment and stakeholder identification, Dr. Kriechman said. This can include food banks, church care committees, youth advocacy groups, local caregiving, and spiritual traditions, among others. Frequently, many community caregivers and agencies have not connected or communicated with one another and often are unaware of all they have to offer, he said.

“We try to build capacity through community trainings, which include a widely diverse group of providers, advocates, and supports,” he continued. “Our trainings involve highlighting and building upon local and cultural practices and traditions of healing, caregiving, and support. A significant part of our onsite training involves assembling a representative group of local providers in health care, behavioral health care, peer & community support and advocacy, education, first responders to community crises, and government and nonprofit agencies, then facilitating a community conversation between the panel and training attendees about how best to move forward in a synergistic and systemic manner to support youth safety and resilience.”
 

 

Peers support peers

While ASPYR encompasses elements of other suicide prevention models, two unique cornerstones of the program are its emphasis on resilience and promotion of peer support. The strength-based, youth-directed approach includes creating a youth-directed safety plan, enlisting peers as support and reducing access to lethal means.

Regarding the youth safety plan, Dr. Kriechman explained that, rather than being prescribed and instructed in expert-selected and expert-driven coping skills, youth are offered a menu of options that most speak to their strengths, values, experience, and preferences. Young people also select a peer who, if they wish, accompanies them to sessions, and supports and coaches them at home.

“Peers are often more influential than parents, siblings, family members, and adults regarding youth behavior,” Dr. Kriechman said. “Most often, it is a peer that a youth-at-risk turns to for support, counsel, role models, and understanding. Youth who wish to offer their peers support can quickly be trained to provide early identification of youth at risk, motivational support to seek help, and a ‘warm hand-off’ to community resources.”

In addition, a Youth Advisory Council established as part of the program draws from young people across New Mexico to participate in state and national conferences, and conduct outreach efforts to peers.

ASPYR Youth council member Serenity Gomez, a senior at the Public Academy for Performing Arts in Albuquerque, became interested in ASPYR after volunteering for the American Foundation for Suicide Prevention in 2016. As a youth council member, Ms. Gomez said she helps create projects to raise suicide awareness, whether through posters, stickers, social media, poetry, or songs.

“My experience as a youth council member has really opened my eyes and has made me more motivated to help others,” she said in an interview. “It has also showed me that talking about suicide doesn’t always have to be a slideshow of facts. You can reach people through music, poetry, storytelling, and so much more. Many people are afraid to talk about suicide because it’s such a scary idea, but if we all talk about it and bring more awareness, then we can find the support everyone needs. In ASPYR, specifically, I hope to reach youth and help all youth learn to support each other.”

Since ASPYR launched in 2017, the program has provided both onsite and online trainings to hundreds of New Mexicans, and has helped rural and frontier communities start working on collaborative approaches to promoting youth safety and resilience, Dr. Kriechman said. Following community consultations, numerous rural communities have since formed systems of care to identify, support, and treat youth at risk. In addition to the youth council, an Advisory Community Council has also been established that welcomes any New Mexico resident interested in working on the mission of preventing youth suicide.

The program’s approach of focusing on strengths, rather than deficits, has resonated strongly with community providers with whom the program partners, Dr. Kriechman added. For example, the program shifts from “no-suicide contracts” to safety planning, focusing on reasons for living rather than reasons for dying, and shifting from prescribing coping skills to strengthening preexisting coping skills in young people.

“An ultimate hope for ASPYR is emphasizing that recovery from any of life’s challenges is far more than symptom reduction or agency collaboration,” Dr. Kriechman said. “It is the understanding that a life of value and meaning, the instillation of hope and support for the unique strengths, competencies, skills, and understandings of each individual, is honored, respected, and supported.”

agallegos@mdedge.com

 

Unreasonable step therapy and prior authorizations, overly expensive generic drugs, opposition to a 5-year Medicare pay freeze, surprise medical billing, and the risks and benefits of sunscreen use for the prevention of skin cancer.

These were just some of the hot button issues that 156 of my fellow dermatologists brought before a record-breaking American Academy of Dermatology Association Legislative Conference in Washington. We also were joined by 49 patients and practice administrators for this terrific meeting filled with classes and speakers. Members of Congress joined us at various sessions and social occasions with good food, fine wine, and great conversations. Radio personality and CNN host Michael Smerconish gave a very funny speech at dinner and had comments about civility in politics. The comradery was excellent and the intellectual food for thought was extraordinary – right up the alley of dermatologists who are also political junkies.

Most congressional representatives are not well versed in health care topics. As a result, we spent a good deal of time on education – speaking to junior staffers who are expected to keep the members of Congress updated on what they need to know about medical and, specifically, dermatologic issues. As many refer to Washington as “the swamp,” you can consider the House members to be the “big gators,” and the staffers the ”little gators.” Taking that analogy further, lobbying (or educating) then logically becomes “gator wrestling.”

Most of the time we met with little gators, although this year we also met with 84 big gators. We took turns telling them true stories based on our patients’ problems with abuses within our health care system. I think these stories are effective. This is your representative government in action!

On the last day of the conference, we made personal calls by state on the hill offices. Some groups, like Ohio, were nine strong! Everyone gets to speak. This year’s meeting was attended by a total of 31 dermatology residents, and the residents from Ohio State and Cleveland Clinic who participated in our state meetings were terrific. In all, we covered 228 offices – 157 Congressional and 71 Senate.

Rep. John Joyce, MD, FAAD (R-PA-13) was on hand and is the first dermatologist elected for a full term to Congress. Anyone at the meeting could have spent all the time they wanted with him discussing our issues. He is most knowledgeable and a great asset for our specialty. Dr. Joyce is recognized as a dermatologist by his fellow representatives, and even by Speaker Nancy Pelosi and President Trump. For 30 years, Dr. Joyce has been a proud member of the American Academy of Dermatology, as is his wife Dr. Alice Joyce, who also is a dermatologist and continues to run their practice, Altoona Dermatology Associates.

Dr. Joyce is a true asset to dermatology. As an individual, I advocate supporting his campaign financially if you get the chance, beyond just what SkinPAC can give him.

In sum, the AADA Legislative Conference is a lot of productive fun. You get to network with all the leaders of the AAD, as well as many of the leaders of the United States. If you donate $5,000 to SkinPAC, they will pay your way to the conference. If you contribute $1,000, you get to go to the high-donor dinner (The same goes for a $50 donation from residents, no typo!). What’s not to like about that? Most dermatologists like a good party. Next year’s meeting is Sept. 13-15, 2020. See you there!
 

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.


 

 

Unreasonable step therapy and prior authorizations, overly expensive generic drugs, opposition to a 5-year Medicare pay freeze, surprise medical billing, and the risks and benefits of sunscreen use for the prevention of skin cancer.

These were just some of the hot button issues that 156 of my fellow dermatologists brought before a record-breaking American Academy of Dermatology Association Legislative Conference in Washington. We also were joined by 49 patients and practice administrators for this terrific meeting filled with classes and speakers. Members of Congress joined us at various sessions and social occasions with good food, fine wine, and great conversations. Radio personality and CNN host Michael Smerconish gave a very funny speech at dinner and had comments about civility in politics. The comradery was excellent and the intellectual food for thought was extraordinary – right up the alley of dermatologists who are also political junkies.

Most congressional representatives are not well versed in health care topics. As a result, we spent a good deal of time on education – speaking to junior staffers who are expected to keep the members of Congress updated on what they need to know about medical and, specifically, dermatologic issues. As many refer to Washington as “the swamp,” you can consider the House members to be the “big gators,” and the staffers the ”little gators.” Taking that analogy further, lobbying (or educating) then logically becomes “gator wrestling.”

Most of the time we met with little gators, although this year we also met with 84 big gators. We took turns telling them true stories based on our patients’ problems with abuses within our health care system. I think these stories are effective. This is your representative government in action!

On the last day of the conference, we made personal calls by state on the hill offices. Some groups, like Ohio, were nine strong! Everyone gets to speak. This year’s meeting was attended by a total of 31 dermatology residents, and the residents from Ohio State and Cleveland Clinic who participated in our state meetings were terrific. In all, we covered 228 offices – 157 Congressional and 71 Senate.

Rep. John Joyce, MD, FAAD (R-PA-13) was on hand and is the first dermatologist elected for a full term to Congress. Anyone at the meeting could have spent all the time they wanted with him discussing our issues. He is most knowledgeable and a great asset for our specialty. Dr. Joyce is recognized as a dermatologist by his fellow representatives, and even by Speaker Nancy Pelosi and President Trump. For 30 years, Dr. Joyce has been a proud member of the American Academy of Dermatology, as is his wife Dr. Alice Joyce, who also is a dermatologist and continues to run their practice, Altoona Dermatology Associates.

Dr. Joyce is a true asset to dermatology. As an individual, I advocate supporting his campaign financially if you get the chance, beyond just what SkinPAC can give him.

In sum, the AADA Legislative Conference is a lot of productive fun. You get to network with all the leaders of the AAD, as well as many of the leaders of the United States. If you donate $5,000 to SkinPAC, they will pay your way to the conference. If you contribute $1,000, you get to go to the high-donor dinner (The same goes for a $50 donation from residents, no typo!). What’s not to like about that? Most dermatologists like a good party. Next year’s meeting is Sept. 13-15, 2020. See you there!
 

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.


 

 

Unreasonable step therapy and prior authorizations, overly expensive generic drugs, opposition to a 5-year Medicare pay freeze, surprise medical billing, and the risks and benefits of sunscreen use for the prevention of skin cancer.

These were just some of the hot button issues that 156 of my fellow dermatologists brought before a record-breaking American Academy of Dermatology Association Legislative Conference in Washington. We also were joined by 49 patients and practice administrators for this terrific meeting filled with classes and speakers. Members of Congress joined us at various sessions and social occasions with good food, fine wine, and great conversations. Radio personality and CNN host Michael Smerconish gave a very funny speech at dinner and had comments about civility in politics. The comradery was excellent and the intellectual food for thought was extraordinary – right up the alley of dermatologists who are also political junkies.

Most congressional representatives are not well versed in health care topics. As a result, we spent a good deal of time on education – speaking to junior staffers who are expected to keep the members of Congress updated on what they need to know about medical and, specifically, dermatologic issues. As many refer to Washington as “the swamp,” you can consider the House members to be the “big gators,” and the staffers the ”little gators.” Taking that analogy further, lobbying (or educating) then logically becomes “gator wrestling.”

Most of the time we met with little gators, although this year we also met with 84 big gators. We took turns telling them true stories based on our patients’ problems with abuses within our health care system. I think these stories are effective. This is your representative government in action!

On the last day of the conference, we made personal calls by state on the hill offices. Some groups, like Ohio, were nine strong! Everyone gets to speak. This year’s meeting was attended by a total of 31 dermatology residents, and the residents from Ohio State and Cleveland Clinic who participated in our state meetings were terrific. In all, we covered 228 offices – 157 Congressional and 71 Senate.

Rep. John Joyce, MD, FAAD (R-PA-13) was on hand and is the first dermatologist elected for a full term to Congress. Anyone at the meeting could have spent all the time they wanted with him discussing our issues. He is most knowledgeable and a great asset for our specialty. Dr. Joyce is recognized as a dermatologist by his fellow representatives, and even by Speaker Nancy Pelosi and President Trump. For 30 years, Dr. Joyce has been a proud member of the American Academy of Dermatology, as is his wife Dr. Alice Joyce, who also is a dermatologist and continues to run their practice, Altoona Dermatology Associates.

Dr. Joyce is a true asset to dermatology. As an individual, I advocate supporting his campaign financially if you get the chance, beyond just what SkinPAC can give him.

In sum, the AADA Legislative Conference is a lot of productive fun. You get to network with all the leaders of the AAD, as well as many of the leaders of the United States. If you donate $5,000 to SkinPAC, they will pay your way to the conference. If you contribute $1,000, you get to go to the high-donor dinner (The same goes for a $50 donation from residents, no typo!). What’s not to like about that? Most dermatologists like a good party. Next year’s meeting is Sept. 13-15, 2020. See you there!
 

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.


 

You are seeing a 9-year-old for her annual health maintenance visit. A quick look at her growth chart easily confirms your first impression that she is obese. How are you going to address the weight that you know, and she probably suspects, is going to make her vulnerable to a myriad of health problems as she gets older?

SolStock/iStock/Getty Image

If she has been your patient since she was in preschool, this is certainly not the first time that her growth chart has been concerning. When did you first start discussing her weight with her parents? What words did you use? What strategies have you suggested? What referrals have you made? Maybe you have already given up and decided to not even “go there” at this visit because your experience with overweight patients has been so disappointing.

In her op ed in the New York Times, Dr. Perri Klass reconsiders these kinds of questions as she reviews an article in the journal Childhood Obesity (“Let’s Not Just Dismiss the Weight Watchers Kurbo App,” by Michelle I. Cardel, PhD, MS, RD, and Elsie M. Taveras, MD, MPH, August 2019) written by a nutrition scientist and a pediatrician who are concerned about a new weight loss app for children recently released by Weight Watchers. (The Checkup, “Helping Children Learn to Eat Well,” The New York Times, Aug. 26, 2019). Although the authors of the journal article question some of the science behind the app, their primary concerns are that the app is aimed at children without a way to guarantee parental involvement, and in their opinion the app also places too much emphasis on weight loss.

Their concerns go right to the heart of what troubles me about managing obesity in children. How should I talk to a child about her weight? What words can I choose without shaming? Maybe I shouldn’t be talking to her at all. When a child is 18 months old, we don’t talk to her about her growth chart. Not because she couldn’t understand, but because the solution rests not with her but with her parents.

At what age does a child’s obesity cease being simply a parenting problem and instead become something the child must solve? Does that point come when we have given up on the parents’ ability to create and maintain an environment that discourages obesity? Is that the point when we begin asking the child to unlearn a complex set of behaviors that have been enabled or at least tolerated and poorly modeled at home?

When we begin to talk to a child about his weight do we begin by telling him that he may not have been a contributor to the problem when it began but from now on he needs to be a major player in its management? Of course we don’t share that reality with an 8-year-old, but sometime during his struggle to manage his weight he will connect the dots.

If you are beginning to suspect that I have built my pediatric career around a scaffolding of parent blaming and shaming you are wrong. I know that there are children who have inherited a suite of genes that make them vulnerable to obesity. And I know that too many children grow up in environments in which their parents are powerless to control the family diet for economic reasons. But I am sure that like me you mutter to yourself and your colleagues about the number of patients you are seeing each day whose growth charts are a clear reflection of less than optimal parenting.

Does all of this mean we throw in the towel and stop trying to help overweight children after they turn 6 years old? Of course not. But, it does mean we must redouble our efforts to help parents manage their children’s diets and activity levels in those first critical preschool years.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

You are seeing a 9-year-old for her annual health maintenance visit. A quick look at her growth chart easily confirms your first impression that she is obese. How are you going to address the weight that you know, and she probably suspects, is going to make her vulnerable to a myriad of health problems as she gets older?

SolStock/iStock/Getty Image

If she has been your patient since she was in preschool, this is certainly not the first time that her growth chart has been concerning. When did you first start discussing her weight with her parents? What words did you use? What strategies have you suggested? What referrals have you made? Maybe you have already given up and decided to not even “go there” at this visit because your experience with overweight patients has been so disappointing.

In her op ed in the New York Times, Dr. Perri Klass reconsiders these kinds of questions as she reviews an article in the journal Childhood Obesity (“Let’s Not Just Dismiss the Weight Watchers Kurbo App,” by Michelle I. Cardel, PhD, MS, RD, and Elsie M. Taveras, MD, MPH, August 2019) written by a nutrition scientist and a pediatrician who are concerned about a new weight loss app for children recently released by Weight Watchers. (The Checkup, “Helping Children Learn to Eat Well,” The New York Times, Aug. 26, 2019). Although the authors of the journal article question some of the science behind the app, their primary concerns are that the app is aimed at children without a way to guarantee parental involvement, and in their opinion the app also places too much emphasis on weight loss.

Their concerns go right to the heart of what troubles me about managing obesity in children. How should I talk to a child about her weight? What words can I choose without shaming? Maybe I shouldn’t be talking to her at all. When a child is 18 months old, we don’t talk to her about her growth chart. Not because she couldn’t understand, but because the solution rests not with her but with her parents.

At what age does a child’s obesity cease being simply a parenting problem and instead become something the child must solve? Does that point come when we have given up on the parents’ ability to create and maintain an environment that discourages obesity? Is that the point when we begin asking the child to unlearn a complex set of behaviors that have been enabled or at least tolerated and poorly modeled at home?

When we begin to talk to a child about his weight do we begin by telling him that he may not have been a contributor to the problem when it began but from now on he needs to be a major player in its management? Of course we don’t share that reality with an 8-year-old, but sometime during his struggle to manage his weight he will connect the dots.

If you are beginning to suspect that I have built my pediatric career around a scaffolding of parent blaming and shaming you are wrong. I know that there are children who have inherited a suite of genes that make them vulnerable to obesity. And I know that too many children grow up in environments in which their parents are powerless to control the family diet for economic reasons. But I am sure that like me you mutter to yourself and your colleagues about the number of patients you are seeing each day whose growth charts are a clear reflection of less than optimal parenting.

Does all of this mean we throw in the towel and stop trying to help overweight children after they turn 6 years old? Of course not. But, it does mean we must redouble our efforts to help parents manage their children’s diets and activity levels in those first critical preschool years.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

You are seeing a 9-year-old for her annual health maintenance visit. A quick look at her growth chart easily confirms your first impression that she is obese. How are you going to address the weight that you know, and she probably suspects, is going to make her vulnerable to a myriad of health problems as she gets older?

SolStock/iStock/Getty Image

If she has been your patient since she was in preschool, this is certainly not the first time that her growth chart has been concerning. When did you first start discussing her weight with her parents? What words did you use? What strategies have you suggested? What referrals have you made? Maybe you have already given up and decided to not even “go there” at this visit because your experience with overweight patients has been so disappointing.

In her op ed in the New York Times, Dr. Perri Klass reconsiders these kinds of questions as she reviews an article in the journal Childhood Obesity (“Let’s Not Just Dismiss the Weight Watchers Kurbo App,” by Michelle I. Cardel, PhD, MS, RD, and Elsie M. Taveras, MD, MPH, August 2019) written by a nutrition scientist and a pediatrician who are concerned about a new weight loss app for children recently released by Weight Watchers. (The Checkup, “Helping Children Learn to Eat Well,” The New York Times, Aug. 26, 2019). Although the authors of the journal article question some of the science behind the app, their primary concerns are that the app is aimed at children without a way to guarantee parental involvement, and in their opinion the app also places too much emphasis on weight loss.

Their concerns go right to the heart of what troubles me about managing obesity in children. How should I talk to a child about her weight? What words can I choose without shaming? Maybe I shouldn’t be talking to her at all. When a child is 18 months old, we don’t talk to her about her growth chart. Not because she couldn’t understand, but because the solution rests not with her but with her parents.

At what age does a child’s obesity cease being simply a parenting problem and instead become something the child must solve? Does that point come when we have given up on the parents’ ability to create and maintain an environment that discourages obesity? Is that the point when we begin asking the child to unlearn a complex set of behaviors that have been enabled or at least tolerated and poorly modeled at home?

When we begin to talk to a child about his weight do we begin by telling him that he may not have been a contributor to the problem when it began but from now on he needs to be a major player in its management? Of course we don’t share that reality with an 8-year-old, but sometime during his struggle to manage his weight he will connect the dots.

If you are beginning to suspect that I have built my pediatric career around a scaffolding of parent blaming and shaming you are wrong. I know that there are children who have inherited a suite of genes that make them vulnerable to obesity. And I know that too many children grow up in environments in which their parents are powerless to control the family diet for economic reasons. But I am sure that like me you mutter to yourself and your colleagues about the number of patients you are seeing each day whose growth charts are a clear reflection of less than optimal parenting.

Does all of this mean we throw in the towel and stop trying to help overweight children after they turn 6 years old? Of course not. But, it does mean we must redouble our efforts to help parents manage their children’s diets and activity levels in those first critical preschool years.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

Evolution is an amazing thing, and its more fascinating aspects are never more apparent than in the endless genetic dance between host and pathogen. And certainly, our fascination with the dance is not merely an intellectual exercise. The evolution of disease is perhaps one of the starkest examples of human misery writ large across the pages of recorded history.

Wikimedia Commons/Public Domain

In particular, the evolution of syphilis from dramatically visible, epidemic terror to silent, endemic, and long-term killer is one of the most striking examples of host-pathogen evolution. It is an example noteworthy not only for the profound transformation that occurred, but for the speed of the change, beginning so fast that it was noticed and detailed by physicians at the time as occurring over less than a human generation rather than centuries.

This very speed of the change makes it relatively certain that it was not the human species that evolved resistance, but rather that the syphilis-causing spirochetes transformed in virulence within almost the blink of an evolutionary eye – an epidemiologic mystery of profound importance to the countless lives involved.

Syphilis was a dramatic new phenomenon in the Old World of the late 15th and early 16th centuries – a hitherto unknown disease of terrible guise and rapid dissemination. It was noted and discussed throughout many of the writings of the time, so much so that one of the first detailed patient accounts in recorded history of the experience of a disease was written in response to a syphilis infection.

In 1498, Tommaso di Silvestro, an Italian notary, described his symptoms in depth: “I remember how I, Ser Tomaso, during the day 27th of April 1498, coming back from the fair in Foligno, started to feel pain in the virga [a contemporary euphemism for penis]. And then the pain grew in intensity. Then in June I started to feel the pains of the French disease. And all my body filled with pustules and crusts. I had pains in the right and left arms, in the entire arm, from the shoulder to the hand, I was filled with pain to the bones and I never found peace. And then I had pains in the right knee and all my body got full of boils, at the back at the front and behind.”

Alessandro Benedetti (1450-1512), a military surgeon and chronicler of the expedition of Charles VIII, wrote in 1497 that sufferers lost hands, feet, eyes, and noses to the disease, such that it made “the entire body so repulsive to look at and causes such great suffering.”Another common characteristic was a foul smell typical of the infected.

Wellcome Library, London. Wellcome Images/Wikimedia Commons/CCA-4.0 International

Careful analysis by historians has shown that, according to records from the time period, 10-15 years after the start of the epidemic in the late 15th century, there was a noticeable decline in disease virulence.

As one historian put it: “Many physicians and contemporary observers noticed the progressive decline in the severity of the disease. Many symptoms were less severe, and the rash, of a reddish color, did not cause itching.” Girolamo Fracastoro writes about some of these transformations, stating that “in the first epidemic periods the pustules were filthier,’ while they were ‘harder and drier’ afterwards.” Similarly, the historian and scholar Bernardino Cirillo dell’Aquila (1500-1575), writing in the 1530s, stated: “This horrible disease in different periods (1494) till the present had different alterations and different effects depending on the complications, and now many people just lose their hair and nothing else.”

As added documentation of the change, the chaplain of the infamous conquistador Hernàn Cortés reported that syphilis was less severe in his time than earlier. He wrote that: “at the beginning this disease was very violent, dirty and indecent; now it is no longer so severe and so indecent.”

The medical literature of the time confirmed that the fever, characteristic of the second stage of the disease, “was less violent, while even the rashes were just a ‘reddening.’ Moreover, the gummy tumors appeared only in a limited number of cases.”

According to another historian, “By the middle of the 16th century, the generation of physicians born between the end of the 15th century and the first decades of the 16th century considered the exceptional virulence manifested by syphilis when it first appeared to be ancient history.”

And Ambroise Paré (1510-1590), a renowned French surgeon, stated: “Today it is much less serious and easier to heal than it was in the past... It is obviously becoming much milder … so that it seems it should disappear in the future.”

Lacking detailed genetic analysis of the changing pathogen, if one were to speculate on why the virulence of syphilis decreased so rapidly, I suggest, in a Just-So story fashion, that one might merely speculate on the evolutionary wisdom of an STD that commonly turned its victims into foul-smelling, scabrous, agonized, and lethargic individuals who lost body parts, including their genitals, according to some reports. None of these outcomes, of course, would be conducive to the natural spread of the disease. In addition, this is a good case for sexual selection as well as early death of the host, which are two main engineers of evolutionary change.

But for whatever reason, the presentation of syphilis changed dramatically over a relatively short period of time, and as the disease was still spreading through a previously unexposed population, a change in pathogenicity rather than host immunity seems the most logical explanation.

As syphilis evolved from its initial onslaught, it showed new and hitherto unseen symptoms, including the aforementioned hair loss, and other manifestations such as tinnitus. Soon it was presenting so many systemic phenotypes similar to the effects of other diseases that Sir William Osler (1849-1919) ultimately proposed that syphilis should be described as the “Great Imitator.”

The evolution of syphilis from epidemic to endemic does not diminish the horrors of those afflicted with active tertiary syphilis, but as the disease transformed, these effects were greatly postponed and occurred less commonly, compared with their relatively rapid onset in an earlier era and in a greater proportion of the infected individuals.

Although still lethal, especially in its congenital form, by the end of the 16th century, syphilis had completed its rapid evolution from a devastating, highly visible plague to the covert disease “so sinful that it could not be discussed by name.” It would remain so until the rise of modern antibiotics finally provided a reliable cure. Active tertiary syphilis remained a severe affliction, but the effects were postponed from their relatively rapid onset in an earlier era and in a greater proportion of the infected individuals.

So, syphilis remains a unique example of host-pathogen evolution, an endemic part of the global human condition, battled by physicians in mostly futile efforts for nearly 500 years, and a disease tracking closely with the rise of modern medicine.

mlesney@mdedge.com

References

Frith J. 2012. Syphilis – Its Early History and Treatment Until Penicillin and the Debate on its Origins. J Military and Veteran’s Health. 20(4):49-58.

Tognoti B. 2009. The Rise and Fall of Syphilis in Renaissance Italy. J Med Humanit. 30(2):99-113.

Mark Lesney is the managing editor of MDedge.com/IDPractioner. He has a PhD in plant virology and a PhD in the history of science, with a focus on the history of biotechnology and medicine. He has served as an adjunct assistant professor of the department of biochemistry and molecular & celluar biology at Georgetown University, Washington, D.C.

Evolution is an amazing thing, and its more fascinating aspects are never more apparent than in the endless genetic dance between host and pathogen. And certainly, our fascination with the dance is not merely an intellectual exercise. The evolution of disease is perhaps one of the starkest examples of human misery writ large across the pages of recorded history.

Wikimedia Commons/Public Domain

In particular, the evolution of syphilis from dramatically visible, epidemic terror to silent, endemic, and long-term killer is one of the most striking examples of host-pathogen evolution. It is an example noteworthy not only for the profound transformation that occurred, but for the speed of the change, beginning so fast that it was noticed and detailed by physicians at the time as occurring over less than a human generation rather than centuries.

This very speed of the change makes it relatively certain that it was not the human species that evolved resistance, but rather that the syphilis-causing spirochetes transformed in virulence within almost the blink of an evolutionary eye – an epidemiologic mystery of profound importance to the countless lives involved.

Syphilis was a dramatic new phenomenon in the Old World of the late 15th and early 16th centuries – a hitherto unknown disease of terrible guise and rapid dissemination. It was noted and discussed throughout many of the writings of the time, so much so that one of the first detailed patient accounts in recorded history of the experience of a disease was written in response to a syphilis infection.

In 1498, Tommaso di Silvestro, an Italian notary, described his symptoms in depth: “I remember how I, Ser Tomaso, during the day 27th of April 1498, coming back from the fair in Foligno, started to feel pain in the virga [a contemporary euphemism for penis]. And then the pain grew in intensity. Then in June I started to feel the pains of the French disease. And all my body filled with pustules and crusts. I had pains in the right and left arms, in the entire arm, from the shoulder to the hand, I was filled with pain to the bones and I never found peace. And then I had pains in the right knee and all my body got full of boils, at the back at the front and behind.”

Alessandro Benedetti (1450-1512), a military surgeon and chronicler of the expedition of Charles VIII, wrote in 1497 that sufferers lost hands, feet, eyes, and noses to the disease, such that it made “the entire body so repulsive to look at and causes such great suffering.”Another common characteristic was a foul smell typical of the infected.

Wellcome Library, London. Wellcome Images/Wikimedia Commons/CCA-4.0 International

Careful analysis by historians has shown that, according to records from the time period, 10-15 years after the start of the epidemic in the late 15th century, there was a noticeable decline in disease virulence.

As one historian put it: “Many physicians and contemporary observers noticed the progressive decline in the severity of the disease. Many symptoms were less severe, and the rash, of a reddish color, did not cause itching.” Girolamo Fracastoro writes about some of these transformations, stating that “in the first epidemic periods the pustules were filthier,’ while they were ‘harder and drier’ afterwards.” Similarly, the historian and scholar Bernardino Cirillo dell’Aquila (1500-1575), writing in the 1530s, stated: “This horrible disease in different periods (1494) till the present had different alterations and different effects depending on the complications, and now many people just lose their hair and nothing else.”

As added documentation of the change, the chaplain of the infamous conquistador Hernàn Cortés reported that syphilis was less severe in his time than earlier. He wrote that: “at the beginning this disease was very violent, dirty and indecent; now it is no longer so severe and so indecent.”

The medical literature of the time confirmed that the fever, characteristic of the second stage of the disease, “was less violent, while even the rashes were just a ‘reddening.’ Moreover, the gummy tumors appeared only in a limited number of cases.”

According to another historian, “By the middle of the 16th century, the generation of physicians born between the end of the 15th century and the first decades of the 16th century considered the exceptional virulence manifested by syphilis when it first appeared to be ancient history.”

And Ambroise Paré (1510-1590), a renowned French surgeon, stated: “Today it is much less serious and easier to heal than it was in the past... It is obviously becoming much milder … so that it seems it should disappear in the future.”

Lacking detailed genetic analysis of the changing pathogen, if one were to speculate on why the virulence of syphilis decreased so rapidly, I suggest, in a Just-So story fashion, that one might merely speculate on the evolutionary wisdom of an STD that commonly turned its victims into foul-smelling, scabrous, agonized, and lethargic individuals who lost body parts, including their genitals, according to some reports. None of these outcomes, of course, would be conducive to the natural spread of the disease. In addition, this is a good case for sexual selection as well as early death of the host, which are two main engineers of evolutionary change.

But for whatever reason, the presentation of syphilis changed dramatically over a relatively short period of time, and as the disease was still spreading through a previously unexposed population, a change in pathogenicity rather than host immunity seems the most logical explanation.

As syphilis evolved from its initial onslaught, it showed new and hitherto unseen symptoms, including the aforementioned hair loss, and other manifestations such as tinnitus. Soon it was presenting so many systemic phenotypes similar to the effects of other diseases that Sir William Osler (1849-1919) ultimately proposed that syphilis should be described as the “Great Imitator.”

The evolution of syphilis from epidemic to endemic does not diminish the horrors of those afflicted with active tertiary syphilis, but as the disease transformed, these effects were greatly postponed and occurred less commonly, compared with their relatively rapid onset in an earlier era and in a greater proportion of the infected individuals.

Although still lethal, especially in its congenital form, by the end of the 16th century, syphilis had completed its rapid evolution from a devastating, highly visible plague to the covert disease “so sinful that it could not be discussed by name.” It would remain so until the rise of modern antibiotics finally provided a reliable cure. Active tertiary syphilis remained a severe affliction, but the effects were postponed from their relatively rapid onset in an earlier era and in a greater proportion of the infected individuals.

So, syphilis remains a unique example of host-pathogen evolution, an endemic part of the global human condition, battled by physicians in mostly futile efforts for nearly 500 years, and a disease tracking closely with the rise of modern medicine.

mlesney@mdedge.com

References

Frith J. 2012. Syphilis – Its Early History and Treatment Until Penicillin and the Debate on its Origins. J Military and Veteran’s Health. 20(4):49-58.

Tognoti B. 2009. The Rise and Fall of Syphilis in Renaissance Italy. J Med Humanit. 30(2):99-113.

Mark Lesney is the managing editor of MDedge.com/IDPractioner. He has a PhD in plant virology and a PhD in the history of science, with a focus on the history of biotechnology and medicine. He has served as an adjunct assistant professor of the department of biochemistry and molecular & celluar biology at Georgetown University, Washington, D.C.

Evolution is an amazing thing, and its more fascinating aspects are never more apparent than in the endless genetic dance between host and pathogen. And certainly, our fascination with the dance is not merely an intellectual exercise. The evolution of disease is perhaps one of the starkest examples of human misery writ large across the pages of recorded history.

Wikimedia Commons/Public Domain

In particular, the evolution of syphilis from dramatically visible, epidemic terror to silent, endemic, and long-term killer is one of the most striking examples of host-pathogen evolution. It is an example noteworthy not only for the profound transformation that occurred, but for the speed of the change, beginning so fast that it was noticed and detailed by physicians at the time as occurring over less than a human generation rather than centuries.

This very speed of the change makes it relatively certain that it was not the human species that evolved resistance, but rather that the syphilis-causing spirochetes transformed in virulence within almost the blink of an evolutionary eye – an epidemiologic mystery of profound importance to the countless lives involved.

Syphilis was a dramatic new phenomenon in the Old World of the late 15th and early 16th centuries – a hitherto unknown disease of terrible guise and rapid dissemination. It was noted and discussed throughout many of the writings of the time, so much so that one of the first detailed patient accounts in recorded history of the experience of a disease was written in response to a syphilis infection.

In 1498, Tommaso di Silvestro, an Italian notary, described his symptoms in depth: “I remember how I, Ser Tomaso, during the day 27th of April 1498, coming back from the fair in Foligno, started to feel pain in the virga [a contemporary euphemism for penis]. And then the pain grew in intensity. Then in June I started to feel the pains of the French disease. And all my body filled with pustules and crusts. I had pains in the right and left arms, in the entire arm, from the shoulder to the hand, I was filled with pain to the bones and I never found peace. And then I had pains in the right knee and all my body got full of boils, at the back at the front and behind.”

Alessandro Benedetti (1450-1512), a military surgeon and chronicler of the expedition of Charles VIII, wrote in 1497 that sufferers lost hands, feet, eyes, and noses to the disease, such that it made “the entire body so repulsive to look at and causes such great suffering.”Another common characteristic was a foul smell typical of the infected.

Wellcome Library, London. Wellcome Images/Wikimedia Commons/CCA-4.0 International

Careful analysis by historians has shown that, according to records from the time period, 10-15 years after the start of the epidemic in the late 15th century, there was a noticeable decline in disease virulence.

As one historian put it: “Many physicians and contemporary observers noticed the progressive decline in the severity of the disease. Many symptoms were less severe, and the rash, of a reddish color, did not cause itching.” Girolamo Fracastoro writes about some of these transformations, stating that “in the first epidemic periods the pustules were filthier,’ while they were ‘harder and drier’ afterwards.” Similarly, the historian and scholar Bernardino Cirillo dell’Aquila (1500-1575), writing in the 1530s, stated: “This horrible disease in different periods (1494) till the present had different alterations and different effects depending on the complications, and now many people just lose their hair and nothing else.”

As added documentation of the change, the chaplain of the infamous conquistador Hernàn Cortés reported that syphilis was less severe in his time than earlier. He wrote that: “at the beginning this disease was very violent, dirty and indecent; now it is no longer so severe and so indecent.”

The medical literature of the time confirmed that the fever, characteristic of the second stage of the disease, “was less violent, while even the rashes were just a ‘reddening.’ Moreover, the gummy tumors appeared only in a limited number of cases.”

According to another historian, “By the middle of the 16th century, the generation of physicians born between the end of the 15th century and the first decades of the 16th century considered the exceptional virulence manifested by syphilis when it first appeared to be ancient history.”

And Ambroise Paré (1510-1590), a renowned French surgeon, stated: “Today it is much less serious and easier to heal than it was in the past... It is obviously becoming much milder … so that it seems it should disappear in the future.”

Lacking detailed genetic analysis of the changing pathogen, if one were to speculate on why the virulence of syphilis decreased so rapidly, I suggest, in a Just-So story fashion, that one might merely speculate on the evolutionary wisdom of an STD that commonly turned its victims into foul-smelling, scabrous, agonized, and lethargic individuals who lost body parts, including their genitals, according to some reports. None of these outcomes, of course, would be conducive to the natural spread of the disease. In addition, this is a good case for sexual selection as well as early death of the host, which are two main engineers of evolutionary change.

But for whatever reason, the presentation of syphilis changed dramatically over a relatively short period of time, and as the disease was still spreading through a previously unexposed population, a change in pathogenicity rather than host immunity seems the most logical explanation.

As syphilis evolved from its initial onslaught, it showed new and hitherto unseen symptoms, including the aforementioned hair loss, and other manifestations such as tinnitus. Soon it was presenting so many systemic phenotypes similar to the effects of other diseases that Sir William Osler (1849-1919) ultimately proposed that syphilis should be described as the “Great Imitator.”

The evolution of syphilis from epidemic to endemic does not diminish the horrors of those afflicted with active tertiary syphilis, but as the disease transformed, these effects were greatly postponed and occurred less commonly, compared with their relatively rapid onset in an earlier era and in a greater proportion of the infected individuals.

Although still lethal, especially in its congenital form, by the end of the 16th century, syphilis had completed its rapid evolution from a devastating, highly visible plague to the covert disease “so sinful that it could not be discussed by name.” It would remain so until the rise of modern antibiotics finally provided a reliable cure. Active tertiary syphilis remained a severe affliction, but the effects were postponed from their relatively rapid onset in an earlier era and in a greater proportion of the infected individuals.

So, syphilis remains a unique example of host-pathogen evolution, an endemic part of the global human condition, battled by physicians in mostly futile efforts for nearly 500 years, and a disease tracking closely with the rise of modern medicine.

mlesney@mdedge.com

References

Frith J. 2012. Syphilis – Its Early History and Treatment Until Penicillin and the Debate on its Origins. J Military and Veteran’s Health. 20(4):49-58.

Tognoti B. 2009. The Rise and Fall of Syphilis in Renaissance Italy. J Med Humanit. 30(2):99-113.

Mark Lesney is the managing editor of MDedge.com/IDPractioner. He has a PhD in plant virology and a PhD in the history of science, with a focus on the history of biotechnology and medicine. He has served as an adjunct assistant professor of the department of biochemistry and molecular & celluar biology at Georgetown University, Washington, D.C.