Commentary

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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.”

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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.”

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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.”

Native to China, India, and Iran, Melia azedarach – also known as Chinaberry (Ku-lian), Pride of China, Indian lilac, Persian lilac, and white cedar – is a large nondeciduous tree now cultivated throughout the world.^1-3 The leaves and fruits of this member of the Meliaceae family have been found to exhibit anthelmintic and antifeedant activity toward insects.⁴ The root bark or dried stem bark of the plant is used in traditional Chinese medicine to treat dermatoses and to expel and repel worms.^5,6M. azedarach has also been used in Ayurveda³; it is known as Bakayn in India and Pakistan, where it has been used in traditional medicine to treat leprosy, scrofula, nausea, vomiting, thirst, and eruptive skin conditions.^3,7

Traditional indications

Cropley and Hasegawa noted in 2007 that M. azedarach was used in the 19th century in the United States primarily as an anthelmintic, but also to treat tinea capitis and to eliminate lice.Further, they noted that the plant, which was widely cultivated in the South, was used, according to the literature of the 1800s, as a diuretic, as well as to promote hair growth, and treat scalp eruptions, fever, and malaria.⁸

A 2006 ethnopharmacologic study by Saikia et al. of medicinal plants used in Assam (Northeast India) to treat skin disorders and for cosmetic purposes revealed that M. azedarach was one of the primary plants used for medicinal purposes, including 18 skin conditions such as acne, burns, carbuncles, abscesses, measles, pediculosis, cellulitis, and prickly heat.⁹

Four years later, in an ethnopharmacologic study of medicinal plants used to treat cutaneous disorders and in folk cosmetics, Abbasi et al. interviewed residents in 30 remote tribal communities in the Northwest Frontier Province of Pakistan, finding that M. azedarach was one of 15 plant species identified as curative for numerous skin diseases, including boils, acne, and scabies.¹⁰

Biologic activity

Various constituents of M. azedarach have been associated with a wide range of biologic activity. The antifungal activity of the plant has been attributed to its hydroxycoumarin content; anti-inflammatory activity to its monoterpenes; bacteriostatic properties to its beta-carboline alkaloids; antiviral effects to its meliacin and meliacarpin; and insecticidal and antifeedant activity to its limonoids, which belong to the tetranortriterpenoid class of compounds.^7,11 Limonoids also are reputed to confer antibacterial, antiviral, and antifungal activities.¹² Recent research suggests the potential of M. azedarach to offer a correspondingly broad impact on various conditions.

Forest & Kim Starr

Anticancer potential

Zhou et al. isolated new ring C-seco limonoids from Brazilian M. azedarach in 2004 and evaluated their cytotoxic activity, finding that two limonoids significantly inhibited HeLa S3 cancer cells.^4,11

In 2009, He et al. extracted water-soluble polysaccharides from the fruit of M. azedarach and assessed their cytotoxic activity against four human cell lines in vitro. They found that the major polysaccharide component exhibited potent cytotoxic activity in the BGC-823 cell line.³ Also that year, Wu et al. isolated three new and multiple known steroids from the leaves of Chinese M. azedarach, finding that two of the newly identified steroids – (20S)-5,24(28)-ergostadiene-3-beta,7-alpha,16-beta,20-tetrol and (20S)-5-ergostene-3-beta,7-alpha,16-beta,20-tetrol – and one of the known ones exerted significant cytotoxic impact in three human cancer cell lines (A-549, H460, U251).¹

Two years later, Wu et al. isolated two new triterpenoids (21,24-cycloeupha-7-ene-3-beta,16beta,21-alpha,25-tetrol and 3-beta-acetoxy-12-beta-hydroxy-eupha-7,24-dien-21,16-beta-olide) and two new steroids (29-hydroperoxy-stigmasta-7,24(28) xi-dien-3-beta-ol and 24-xi-hydroperoxy-24-vinyl-lathosterol) along with several known related substances from M. azedarach bark. Five of the known compounds demonstrated cytotoxic activity against three human cancer cell lines (A-549, H460, HGC27).⁶

More recently, Yuan et al. isolated two limonoids, one triterpenoid, one steroid, and one sesquiterpenoid, as well as nine known limonoids from the bark of M. azedarach. In addition, the investigators observed that seven of the limonoids exhibited significant inhibitory properties against five human tumor cell lines (HL-60, SMM-C7721, A-549, MCF-7, and SW480).⁵

Efficacy against head lice

In 2007, Carpinella et al. investigated in vitro the pediculicidal and ovicidal activity of an M. azedarach extract against Pediculus humanus capitis, noting the increasing resistance of head lice to synthetic drugs. A combination of 20% ripe fruit extract with 10% ripe fruit oil was found to be the most effective in eradicating adult lice (96.5%). The investigators also prepared a formulation of extract and oil at 10% combined with an emulsifier and preservatives that yielded 92.3% mortality of adult lice and complete inhibition of nymph emergence. They concluded that the use of M. azedarach formulations may be a viable and natural way to control head lice.²M. azedarach also has been the key active ingredient in an antimicrobial cream and a preparation to treat tinea pedis.⁷

Topical cream

Saleem et al. reported in 2008 on an herbal cream preparation using a standardized extract of M. azedarach flowers that displayed strong antibacterial activity against cellulitis, pustules, and pyogenic infections, and other conditions in clinical trials in children under the age of 10 years in four different villages in Pakistan. Subjects with bacterial infections anywhere on the body were divided into three groups, one treated with M. azedarach cream, one with placebo (negative control), and one with neomycin (positive control). Each treatment was applied twice daily for 15 days. The investigators observed that the healing effects of M. azedarach were similar to those rendered by neomycin.⁷

Conclusion

Not only has M. azedarach been used in several traditional medical systems, but its uses have consistently included cutaneous indications. Its most convincing modern application may be for head lice, but recent evidence and traditional uses suggest that this versatile plant may indeed warrant a more prominent role in the current dermatologic armamentarium. Future research is needed, and should provide some interesting answers.

References

1. Steroids. 2009 Sep;74(9):761-5.

2. J Am Acad Dermatol. 2007 Feb;56(2):250-6.

3. Fitoterapia. 2009 Oct;80(7):399-403.

4. Chem Pharm Bull (Tokyo). 2005 Oct;53(10):1362-5.

5. Planta Med. 2013 Jan;79(2):163-8.

6. Planta Med. 2011 Jun;77(9):922-8.

7. Phytomedicine. 2008 Apr;15(4):231-6.

8. J Am Acad Dermatol. 2007 Aug;57(2):366-7.

9. J Ethnopharmacol. 2006 Jun 30;106(2):149-57.

10. J Ethnopharmacol. 2010 Mar 24;128(2):322-35.

11. J Nat Prod. 2004 Sep;67(9):1544-7.

12. Chem Biodivers. 2010 Apr;7(4):839-59.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Native to China, India, and Iran, Melia azedarach – also known as Chinaberry (Ku-lian), Pride of China, Indian lilac, Persian lilac, and white cedar – is a large nondeciduous tree now cultivated throughout the world.^1-3 The leaves and fruits of this member of the Meliaceae family have been found to exhibit anthelmintic and antifeedant activity toward insects.⁴ The root bark or dried stem bark of the plant is used in traditional Chinese medicine to treat dermatoses and to expel and repel worms.^5,6M. azedarach has also been used in Ayurveda³; it is known as Bakayn in India and Pakistan, where it has been used in traditional medicine to treat leprosy, scrofula, nausea, vomiting, thirst, and eruptive skin conditions.^3,7

Traditional indications

Cropley and Hasegawa noted in 2007 that M. azedarach was used in the 19th century in the United States primarily as an anthelmintic, but also to treat tinea capitis and to eliminate lice.Further, they noted that the plant, which was widely cultivated in the South, was used, according to the literature of the 1800s, as a diuretic, as well as to promote hair growth, and treat scalp eruptions, fever, and malaria.⁸

A 2006 ethnopharmacologic study by Saikia et al. of medicinal plants used in Assam (Northeast India) to treat skin disorders and for cosmetic purposes revealed that M. azedarach was one of the primary plants used for medicinal purposes, including 18 skin conditions such as acne, burns, carbuncles, abscesses, measles, pediculosis, cellulitis, and prickly heat.⁹

Four years later, in an ethnopharmacologic study of medicinal plants used to treat cutaneous disorders and in folk cosmetics, Abbasi et al. interviewed residents in 30 remote tribal communities in the Northwest Frontier Province of Pakistan, finding that M. azedarach was one of 15 plant species identified as curative for numerous skin diseases, including boils, acne, and scabies.¹⁰

Biologic activity

Various constituents of M. azedarach have been associated with a wide range of biologic activity. The antifungal activity of the plant has been attributed to its hydroxycoumarin content; anti-inflammatory activity to its monoterpenes; bacteriostatic properties to its beta-carboline alkaloids; antiviral effects to its meliacin and meliacarpin; and insecticidal and antifeedant activity to its limonoids, which belong to the tetranortriterpenoid class of compounds.^7,11 Limonoids also are reputed to confer antibacterial, antiviral, and antifungal activities.¹² Recent research suggests the potential of M. azedarach to offer a correspondingly broad impact on various conditions.

Forest & Kim Starr

Anticancer potential

Zhou et al. isolated new ring C-seco limonoids from Brazilian M. azedarach in 2004 and evaluated their cytotoxic activity, finding that two limonoids significantly inhibited HeLa S3 cancer cells.^4,11

In 2009, He et al. extracted water-soluble polysaccharides from the fruit of M. azedarach and assessed their cytotoxic activity against four human cell lines in vitro. They found that the major polysaccharide component exhibited potent cytotoxic activity in the BGC-823 cell line.³ Also that year, Wu et al. isolated three new and multiple known steroids from the leaves of Chinese M. azedarach, finding that two of the newly identified steroids – (20S)-5,24(28)-ergostadiene-3-beta,7-alpha,16-beta,20-tetrol and (20S)-5-ergostene-3-beta,7-alpha,16-beta,20-tetrol – and one of the known ones exerted significant cytotoxic impact in three human cancer cell lines (A-549, H460, U251).¹

Two years later, Wu et al. isolated two new triterpenoids (21,24-cycloeupha-7-ene-3-beta,16beta,21-alpha,25-tetrol and 3-beta-acetoxy-12-beta-hydroxy-eupha-7,24-dien-21,16-beta-olide) and two new steroids (29-hydroperoxy-stigmasta-7,24(28) xi-dien-3-beta-ol and 24-xi-hydroperoxy-24-vinyl-lathosterol) along with several known related substances from M. azedarach bark. Five of the known compounds demonstrated cytotoxic activity against three human cancer cell lines (A-549, H460, HGC27).⁶

More recently, Yuan et al. isolated two limonoids, one triterpenoid, one steroid, and one sesquiterpenoid, as well as nine known limonoids from the bark of M. azedarach. In addition, the investigators observed that seven of the limonoids exhibited significant inhibitory properties against five human tumor cell lines (HL-60, SMM-C7721, A-549, MCF-7, and SW480).⁵

Efficacy against head lice

In 2007, Carpinella et al. investigated in vitro the pediculicidal and ovicidal activity of an M. azedarach extract against Pediculus humanus capitis, noting the increasing resistance of head lice to synthetic drugs. A combination of 20% ripe fruit extract with 10% ripe fruit oil was found to be the most effective in eradicating adult lice (96.5%). The investigators also prepared a formulation of extract and oil at 10% combined with an emulsifier and preservatives that yielded 92.3% mortality of adult lice and complete inhibition of nymph emergence. They concluded that the use of M. azedarach formulations may be a viable and natural way to control head lice.²M. azedarach also has been the key active ingredient in an antimicrobial cream and a preparation to treat tinea pedis.⁷

Topical cream

Saleem et al. reported in 2008 on an herbal cream preparation using a standardized extract of M. azedarach flowers that displayed strong antibacterial activity against cellulitis, pustules, and pyogenic infections, and other conditions in clinical trials in children under the age of 10 years in four different villages in Pakistan. Subjects with bacterial infections anywhere on the body were divided into three groups, one treated with M. azedarach cream, one with placebo (negative control), and one with neomycin (positive control). Each treatment was applied twice daily for 15 days. The investigators observed that the healing effects of M. azedarach were similar to those rendered by neomycin.⁷

Conclusion

Not only has M. azedarach been used in several traditional medical systems, but its uses have consistently included cutaneous indications. Its most convincing modern application may be for head lice, but recent evidence and traditional uses suggest that this versatile plant may indeed warrant a more prominent role in the current dermatologic armamentarium. Future research is needed, and should provide some interesting answers.

References

1. Steroids. 2009 Sep;74(9):761-5.

2. J Am Acad Dermatol. 2007 Feb;56(2):250-6.

3. Fitoterapia. 2009 Oct;80(7):399-403.

4. Chem Pharm Bull (Tokyo). 2005 Oct;53(10):1362-5.

5. Planta Med. 2013 Jan;79(2):163-8.

6. Planta Med. 2011 Jun;77(9):922-8.

7. Phytomedicine. 2008 Apr;15(4):231-6.

8. J Am Acad Dermatol. 2007 Aug;57(2):366-7.

9. J Ethnopharmacol. 2006 Jun 30;106(2):149-57.

10. J Ethnopharmacol. 2010 Mar 24;128(2):322-35.

11. J Nat Prod. 2004 Sep;67(9):1544-7.

12. Chem Biodivers. 2010 Apr;7(4):839-59.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Native to China, India, and Iran, Melia azedarach – also known as Chinaberry (Ku-lian), Pride of China, Indian lilac, Persian lilac, and white cedar – is a large nondeciduous tree now cultivated throughout the world.^1-3 The leaves and fruits of this member of the Meliaceae family have been found to exhibit anthelmintic and antifeedant activity toward insects.⁴ The root bark or dried stem bark of the plant is used in traditional Chinese medicine to treat dermatoses and to expel and repel worms.^5,6M. azedarach has also been used in Ayurveda³; it is known as Bakayn in India and Pakistan, where it has been used in traditional medicine to treat leprosy, scrofula, nausea, vomiting, thirst, and eruptive skin conditions.^3,7

Traditional indications

Cropley and Hasegawa noted in 2007 that M. azedarach was used in the 19th century in the United States primarily as an anthelmintic, but also to treat tinea capitis and to eliminate lice.Further, they noted that the plant, which was widely cultivated in the South, was used, according to the literature of the 1800s, as a diuretic, as well as to promote hair growth, and treat scalp eruptions, fever, and malaria.⁸

A 2006 ethnopharmacologic study by Saikia et al. of medicinal plants used in Assam (Northeast India) to treat skin disorders and for cosmetic purposes revealed that M. azedarach was one of the primary plants used for medicinal purposes, including 18 skin conditions such as acne, burns, carbuncles, abscesses, measles, pediculosis, cellulitis, and prickly heat.⁹

Four years later, in an ethnopharmacologic study of medicinal plants used to treat cutaneous disorders and in folk cosmetics, Abbasi et al. interviewed residents in 30 remote tribal communities in the Northwest Frontier Province of Pakistan, finding that M. azedarach was one of 15 plant species identified as curative for numerous skin diseases, including boils, acne, and scabies.¹⁰

Biologic activity

Various constituents of M. azedarach have been associated with a wide range of biologic activity. The antifungal activity of the plant has been attributed to its hydroxycoumarin content; anti-inflammatory activity to its monoterpenes; bacteriostatic properties to its beta-carboline alkaloids; antiviral effects to its meliacin and meliacarpin; and insecticidal and antifeedant activity to its limonoids, which belong to the tetranortriterpenoid class of compounds.^7,11 Limonoids also are reputed to confer antibacterial, antiviral, and antifungal activities.¹² Recent research suggests the potential of M. azedarach to offer a correspondingly broad impact on various conditions.

Forest & Kim Starr

Anticancer potential

Zhou et al. isolated new ring C-seco limonoids from Brazilian M. azedarach in 2004 and evaluated their cytotoxic activity, finding that two limonoids significantly inhibited HeLa S3 cancer cells.^4,11

In 2009, He et al. extracted water-soluble polysaccharides from the fruit of M. azedarach and assessed their cytotoxic activity against four human cell lines in vitro. They found that the major polysaccharide component exhibited potent cytotoxic activity in the BGC-823 cell line.³ Also that year, Wu et al. isolated three new and multiple known steroids from the leaves of Chinese M. azedarach, finding that two of the newly identified steroids – (20S)-5,24(28)-ergostadiene-3-beta,7-alpha,16-beta,20-tetrol and (20S)-5-ergostene-3-beta,7-alpha,16-beta,20-tetrol – and one of the known ones exerted significant cytotoxic impact in three human cancer cell lines (A-549, H460, U251).¹

Two years later, Wu et al. isolated two new triterpenoids (21,24-cycloeupha-7-ene-3-beta,16beta,21-alpha,25-tetrol and 3-beta-acetoxy-12-beta-hydroxy-eupha-7,24-dien-21,16-beta-olide) and two new steroids (29-hydroperoxy-stigmasta-7,24(28) xi-dien-3-beta-ol and 24-xi-hydroperoxy-24-vinyl-lathosterol) along with several known related substances from M. azedarach bark. Five of the known compounds demonstrated cytotoxic activity against three human cancer cell lines (A-549, H460, HGC27).⁶

More recently, Yuan et al. isolated two limonoids, one triterpenoid, one steroid, and one sesquiterpenoid, as well as nine known limonoids from the bark of M. azedarach. In addition, the investigators observed that seven of the limonoids exhibited significant inhibitory properties against five human tumor cell lines (HL-60, SMM-C7721, A-549, MCF-7, and SW480).⁵

Efficacy against head lice

In 2007, Carpinella et al. investigated in vitro the pediculicidal and ovicidal activity of an M. azedarach extract against Pediculus humanus capitis, noting the increasing resistance of head lice to synthetic drugs. A combination of 20% ripe fruit extract with 10% ripe fruit oil was found to be the most effective in eradicating adult lice (96.5%). The investigators also prepared a formulation of extract and oil at 10% combined with an emulsifier and preservatives that yielded 92.3% mortality of adult lice and complete inhibition of nymph emergence. They concluded that the use of M. azedarach formulations may be a viable and natural way to control head lice.²M. azedarach also has been the key active ingredient in an antimicrobial cream and a preparation to treat tinea pedis.⁷

Topical cream

Saleem et al. reported in 2008 on an herbal cream preparation using a standardized extract of M. azedarach flowers that displayed strong antibacterial activity against cellulitis, pustules, and pyogenic infections, and other conditions in clinical trials in children under the age of 10 years in four different villages in Pakistan. Subjects with bacterial infections anywhere on the body were divided into three groups, one treated with M. azedarach cream, one with placebo (negative control), and one with neomycin (positive control). Each treatment was applied twice daily for 15 days. The investigators observed that the healing effects of M. azedarach were similar to those rendered by neomycin.⁷

Conclusion

Not only has M. azedarach been used in several traditional medical systems, but its uses have consistently included cutaneous indications. Its most convincing modern application may be for head lice, but recent evidence and traditional uses suggest that this versatile plant may indeed warrant a more prominent role in the current dermatologic armamentarium. Future research is needed, and should provide some interesting answers.

References

1. Steroids. 2009 Sep;74(9):761-5.

2. J Am Acad Dermatol. 2007 Feb;56(2):250-6.

3. Fitoterapia. 2009 Oct;80(7):399-403.

4. Chem Pharm Bull (Tokyo). 2005 Oct;53(10):1362-5.

5. Planta Med. 2013 Jan;79(2):163-8.

6. Planta Med. 2011 Jun;77(9):922-8.

7. Phytomedicine. 2008 Apr;15(4):231-6.

8. J Am Acad Dermatol. 2007 Aug;57(2):366-7.

9. J Ethnopharmacol. 2006 Jun 30;106(2):149-57.

10. J Ethnopharmacol. 2010 Mar 24;128(2):322-35.

11. J Nat Prod. 2004 Sep;67(9):1544-7.

12. Chem Biodivers. 2010 Apr;7(4):839-59.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

I am a member of a large primary care group certified as a level 3 patient-centered medical home; we are in the midst of certifying for Meaningful Use Stage 2. Recently, my first patient of the day was a 65-year-old widowed man who used tobacco, had diabetes, hypertension, and elevated lipid levels, and hadn’t seen me in 2 years. He came in for a Medicare Advantage comprehensive physical examination.

To meet all Meaningful Use Stage 2 expectations during his physical exam, I had to:
• check the box to document discussion of body mass index (his was 26 kg/m²),
• check the box for functional status assessment,
• check the box to indicate that his blood pressure was under 140/90 mm Hg (the threshold for a previously diagnosed hypertensive patient),
• generate annual care guides for the “clinically important conditions” of hypertension with diabetes, tobacco use, and hyperlipidemia,
• review the quality information stoplight for lab tests to be ordered,
• remind the patient to complete his annual eye examination,
• identify hierarchical categorical coding to maximize the accurate morbidity determination of my patient and, therefore, funding for our medical group,
• click on the code for annual prostate examination screening,
• click on the code to bill for tobacco cessation counseling, and
• generate a visit summary.

Naturally, all of this was in addition to giving my patient my full, undivided attention, providing him with the opportunity to express his concerns, and then pursuing a careful examination of his health problems.

Documentation expectations, coding, billing, and the like degrade the clinician-patient relationship, and I’m not going to redirect my attention away from the patient’s concerns and toward these activities. I will continue to listen and respect what my patients have to say and engage with them, and not my keyboard. I will strive to identify and meet their health needs.

Click the boxes? Yes, I will click all the right boxes; my livelihood and my medical group’s future success depend on that. But how much congruence will there be between what I “click” and what I “do”? Well …

We are challenged by good intentions but crushingly poor execution—and it’s taking its toll.

H. Andrew Selinger, MD
Bristol, Conn

I am a member of a large primary care group certified as a level 3 patient-centered medical home; we are in the midst of certifying for Meaningful Use Stage 2. Recently, my first patient of the day was a 65-year-old widowed man who used tobacco, had diabetes, hypertension, and elevated lipid levels, and hadn’t seen me in 2 years. He came in for a Medicare Advantage comprehensive physical examination.

To meet all Meaningful Use Stage 2 expectations during his physical exam, I had to:
• check the box to document discussion of body mass index (his was 26 kg/m²),
• check the box for functional status assessment,
• check the box to indicate that his blood pressure was under 140/90 mm Hg (the threshold for a previously diagnosed hypertensive patient),
• generate annual care guides for the “clinically important conditions” of hypertension with diabetes, tobacco use, and hyperlipidemia,
• review the quality information stoplight for lab tests to be ordered,
• remind the patient to complete his annual eye examination,
• identify hierarchical categorical coding to maximize the accurate morbidity determination of my patient and, therefore, funding for our medical group,
• click on the code for annual prostate examination screening,
• click on the code to bill for tobacco cessation counseling, and
• generate a visit summary.

Naturally, all of this was in addition to giving my patient my full, undivided attention, providing him with the opportunity to express his concerns, and then pursuing a careful examination of his health problems.

Documentation expectations, coding, billing, and the like degrade the clinician-patient relationship, and I’m not going to redirect my attention away from the patient’s concerns and toward these activities. I will continue to listen and respect what my patients have to say and engage with them, and not my keyboard. I will strive to identify and meet their health needs.

Click the boxes? Yes, I will click all the right boxes; my livelihood and my medical group’s future success depend on that. But how much congruence will there be between what I “click” and what I “do”? Well …

We are challenged by good intentions but crushingly poor execution—and it’s taking its toll.

H. Andrew Selinger, MD
Bristol, Conn

I am a member of a large primary care group certified as a level 3 patient-centered medical home; we are in the midst of certifying for Meaningful Use Stage 2. Recently, my first patient of the day was a 65-year-old widowed man who used tobacco, had diabetes, hypertension, and elevated lipid levels, and hadn’t seen me in 2 years. He came in for a Medicare Advantage comprehensive physical examination.

To meet all Meaningful Use Stage 2 expectations during his physical exam, I had to:
• check the box to document discussion of body mass index (his was 26 kg/m²),
• check the box for functional status assessment,
• check the box to indicate that his blood pressure was under 140/90 mm Hg (the threshold for a previously diagnosed hypertensive patient),
• generate annual care guides for the “clinically important conditions” of hypertension with diabetes, tobacco use, and hyperlipidemia,
• review the quality information stoplight for lab tests to be ordered,
• remind the patient to complete his annual eye examination,
• identify hierarchical categorical coding to maximize the accurate morbidity determination of my patient and, therefore, funding for our medical group,
• click on the code for annual prostate examination screening,
• click on the code to bill for tobacco cessation counseling, and
• generate a visit summary.

Naturally, all of this was in addition to giving my patient my full, undivided attention, providing him with the opportunity to express his concerns, and then pursuing a careful examination of his health problems.

Documentation expectations, coding, billing, and the like degrade the clinician-patient relationship, and I’m not going to redirect my attention away from the patient’s concerns and toward these activities. I will continue to listen and respect what my patients have to say and engage with them, and not my keyboard. I will strive to identify and meet their health needs.

Click the boxes? Yes, I will click all the right boxes; my livelihood and my medical group’s future success depend on that. But how much congruence will there be between what I “click” and what I “do”? Well …

We are challenged by good intentions but crushingly poor execution—and it’s taking its toll.

H. Andrew Selinger, MD
Bristol, Conn

Like everyone else’s grandmother, mine gave me all kinds of advice while I was growing up. Some tips I still remember.

One came when I was home for Thanksgiving during my first year of medical school. She was frustrated over her recent visit to an internist. He kept ordering more tests but wouldn’t answer questions about what might be causing her symptoms.

She told me that, if I didn’t know what was going on, to just say so. As a patient, she felt that an honest answer was better than silence.

Today, as a doctor, I agree with her. So, while I may still be doing tests to crack the case, I have no problem, when asked what I think is going on, with saying “I don’t know.”

This approach isn’t perfect for everyone. Some docs (and patients) may see it as a sign of incompetence or weakness, thinking that admitting fallibility is a breach of the relationship or that with some tests the doctor becomes omniscient. Of course, that’s far from the truth.

In my experience, patients prefer the honesty of my saying “I don’t know.” I’m not saying I’ll never know, I’m just saying that, at present, I’m still looking for the answer.

Nobody likes being in the dark about their health, but at the same time they don’t want to feel their doctor is keeping a secret from them. By making it clear that I’m not, I’m hoping to keep a strong therapeutic relationship. I promise them that when I know, they’ll know, and that I’m honest when stumped. If I need to refer elsewhere for an answer, I have no problem doing that. Medicine, and neurology in particular, is a complex field. If every diagnosis were a slam-dunk, we wouldn’t need specialists and subspecialists (and even subsubspecialists).

Most people know and understand that, recognize the inherent uncertainty of this job, and know that I don’t know. I promise them that “I don’t know” doesn’t mean I’m done looking, it just means I’m going to keep trying. That’s the best anyone can do. Right, Granny?

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

Like everyone else’s grandmother, mine gave me all kinds of advice while I was growing up. Some tips I still remember.

One came when I was home for Thanksgiving during my first year of medical school. She was frustrated over her recent visit to an internist. He kept ordering more tests but wouldn’t answer questions about what might be causing her symptoms.

She told me that, if I didn’t know what was going on, to just say so. As a patient, she felt that an honest answer was better than silence.

Today, as a doctor, I agree with her. So, while I may still be doing tests to crack the case, I have no problem, when asked what I think is going on, with saying “I don’t know.”

This approach isn’t perfect for everyone. Some docs (and patients) may see it as a sign of incompetence or weakness, thinking that admitting fallibility is a breach of the relationship or that with some tests the doctor becomes omniscient. Of course, that’s far from the truth.

In my experience, patients prefer the honesty of my saying “I don’t know.” I’m not saying I’ll never know, I’m just saying that, at present, I’m still looking for the answer.

Nobody likes being in the dark about their health, but at the same time they don’t want to feel their doctor is keeping a secret from them. By making it clear that I’m not, I’m hoping to keep a strong therapeutic relationship. I promise them that when I know, they’ll know, and that I’m honest when stumped. If I need to refer elsewhere for an answer, I have no problem doing that. Medicine, and neurology in particular, is a complex field. If every diagnosis were a slam-dunk, we wouldn’t need specialists and subspecialists (and even subsubspecialists).

Most people know and understand that, recognize the inherent uncertainty of this job, and know that I don’t know. I promise them that “I don’t know” doesn’t mean I’m done looking, it just means I’m going to keep trying. That’s the best anyone can do. Right, Granny?

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

Like everyone else’s grandmother, mine gave me all kinds of advice while I was growing up. Some tips I still remember.

One came when I was home for Thanksgiving during my first year of medical school. She was frustrated over her recent visit to an internist. He kept ordering more tests but wouldn’t answer questions about what might be causing her symptoms.

She told me that, if I didn’t know what was going on, to just say so. As a patient, she felt that an honest answer was better than silence.

Today, as a doctor, I agree with her. So, while I may still be doing tests to crack the case, I have no problem, when asked what I think is going on, with saying “I don’t know.”

This approach isn’t perfect for everyone. Some docs (and patients) may see it as a sign of incompetence or weakness, thinking that admitting fallibility is a breach of the relationship or that with some tests the doctor becomes omniscient. Of course, that’s far from the truth.

In my experience, patients prefer the honesty of my saying “I don’t know.” I’m not saying I’ll never know, I’m just saying that, at present, I’m still looking for the answer.

Nobody likes being in the dark about their health, but at the same time they don’t want to feel their doctor is keeping a secret from them. By making it clear that I’m not, I’m hoping to keep a strong therapeutic relationship. I promise them that when I know, they’ll know, and that I’m honest when stumped. If I need to refer elsewhere for an answer, I have no problem doing that. Medicine, and neurology in particular, is a complex field. If every diagnosis were a slam-dunk, we wouldn’t need specialists and subspecialists (and even subsubspecialists).

Most people know and understand that, recognize the inherent uncertainty of this job, and know that I don’t know. I promise them that “I don’t know” doesn’t mean I’m done looking, it just means I’m going to keep trying. That’s the best anyone can do. Right, Granny?

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

Isolation in juvenile detention centers persists despite ample data demonstrating the traumatizing consequences to youth who often already have been traumatized. I recently visited a detention center as part of my pediatric residency’s advocacy rotation. There, I learned that youth are kept in isolation for several days, with a vague definition by staff on the limit of “several days.” Multiple words were used for confinement, the most stunning and horrific of which was “segregation” – “He got into a fight and was placed in segregation.” While in isolation or segregation – whatever it is called – mental illness and posttraumatic stress disorder are exacerbated. Youth do not participate in school classes, and they are barred from the daily hour of physical activity. In extreme cases, they go from complete isolation one day to complete freedom the next.

The vibe word in the facility I visited was “evidence-based strategies,” stressed by the new administration. But evidence-based strategies do not include isolation. They include educating staff about the pervasive effects of trauma in children. They include communication interventions, conflict resolution, and the implementation of rewards such as extra visitation, computer time, or the use of an adolescent’s own personal hygiene items or clothing. They include knowledge of the adolescent brain, and how the use of isolation in juvenile centers has led to increased suicide rates in those children.

Lindsay M. Hayes, author of the National Center on Institutions and Alternatives’ 2004 report “Juvenile Suicide in Confinement: A National Study,” wrote: ”Although room confinement remains a staple in most juvenile facilities, it is a sanction that can have deadly consequences. … More than 50% of all youths’ suicides in juvenile facilities occurred while young people were isolated alone in their rooms, and … more than 60% of young people who committed suicide in custody had a history of being held in isolation.”

The United Nations has called on all countries to absolutely prohibit solitary confinement for juveniles, as has the American Academy of Child and Adolescent Psychiatry. Thus, extreme isolation should not be another tool for juvenile detention centers.

Currently, 20 states have banned solitary confinement in juvenile detention facilities. The major barriers are from staff, who state it would remove a tool, put staff in danger, and allow youth to run the facilities. None of these has been shown to be true. Some juvenile detention centers have changed the traditional meaning of isolation – youth will have a minimum of 8 hours away from isolation when confined for a day or longer. “During that 8 hours, they have the opportunity to talk to and be in the company of staff,” said Adam Schwartz, a lawyer for the American Civil Liberties Union of Illinois, whose lawsuit drastically limited solitary confinement practices in Illinois’s juvenile detention centers. The policy also requires that inmates in isolation continue to receive education and mental health services.

There is a human dignity that not even detainees deserve to lose. President Obama has discussed this, as has the 2012 Report of the Attorney General’s National Task Force on Children Exposed to Violence, which concluded: “Nowhere is the damaging impact of incarceration on vulnerable children more obvious than when it involves solitary confinement.” I am writing this article to raise awareness about this underreported problem in hopes that new legislation will lead to change that is in the best interest of our children.

Dr. Raffa is in postgraduate year 2 in her pediatric residency at Vanderbilt Children’s Hospital in Nashville, Tenn.

Isolation in juvenile detention centers persists despite ample data demonstrating the traumatizing consequences to youth who often already have been traumatized. I recently visited a detention center as part of my pediatric residency’s advocacy rotation. There, I learned that youth are kept in isolation for several days, with a vague definition by staff on the limit of “several days.” Multiple words were used for confinement, the most stunning and horrific of which was “segregation” – “He got into a fight and was placed in segregation.” While in isolation or segregation – whatever it is called – mental illness and posttraumatic stress disorder are exacerbated. Youth do not participate in school classes, and they are barred from the daily hour of physical activity. In extreme cases, they go from complete isolation one day to complete freedom the next.

The vibe word in the facility I visited was “evidence-based strategies,” stressed by the new administration. But evidence-based strategies do not include isolation. They include educating staff about the pervasive effects of trauma in children. They include communication interventions, conflict resolution, and the implementation of rewards such as extra visitation, computer time, or the use of an adolescent’s own personal hygiene items or clothing. They include knowledge of the adolescent brain, and how the use of isolation in juvenile centers has led to increased suicide rates in those children.

Lindsay M. Hayes, author of the National Center on Institutions and Alternatives’ 2004 report “Juvenile Suicide in Confinement: A National Study,” wrote: ”Although room confinement remains a staple in most juvenile facilities, it is a sanction that can have deadly consequences. … More than 50% of all youths’ suicides in juvenile facilities occurred while young people were isolated alone in their rooms, and … more than 60% of young people who committed suicide in custody had a history of being held in isolation.”

The United Nations has called on all countries to absolutely prohibit solitary confinement for juveniles, as has the American Academy of Child and Adolescent Psychiatry. Thus, extreme isolation should not be another tool for juvenile detention centers.

Currently, 20 states have banned solitary confinement in juvenile detention facilities. The major barriers are from staff, who state it would remove a tool, put staff in danger, and allow youth to run the facilities. None of these has been shown to be true. Some juvenile detention centers have changed the traditional meaning of isolation – youth will have a minimum of 8 hours away from isolation when confined for a day or longer. “During that 8 hours, they have the opportunity to talk to and be in the company of staff,” said Adam Schwartz, a lawyer for the American Civil Liberties Union of Illinois, whose lawsuit drastically limited solitary confinement practices in Illinois’s juvenile detention centers. The policy also requires that inmates in isolation continue to receive education and mental health services.

There is a human dignity that not even detainees deserve to lose. President Obama has discussed this, as has the 2012 Report of the Attorney General’s National Task Force on Children Exposed to Violence, which concluded: “Nowhere is the damaging impact of incarceration on vulnerable children more obvious than when it involves solitary confinement.” I am writing this article to raise awareness about this underreported problem in hopes that new legislation will lead to change that is in the best interest of our children.

Dr. Raffa is in postgraduate year 2 in her pediatric residency at Vanderbilt Children’s Hospital in Nashville, Tenn.

Isolation in juvenile detention centers persists despite ample data demonstrating the traumatizing consequences to youth who often already have been traumatized. I recently visited a detention center as part of my pediatric residency’s advocacy rotation. There, I learned that youth are kept in isolation for several days, with a vague definition by staff on the limit of “several days.” Multiple words were used for confinement, the most stunning and horrific of which was “segregation” – “He got into a fight and was placed in segregation.” While in isolation or segregation – whatever it is called – mental illness and posttraumatic stress disorder are exacerbated. Youth do not participate in school classes, and they are barred from the daily hour of physical activity. In extreme cases, they go from complete isolation one day to complete freedom the next.

The vibe word in the facility I visited was “evidence-based strategies,” stressed by the new administration. But evidence-based strategies do not include isolation. They include educating staff about the pervasive effects of trauma in children. They include communication interventions, conflict resolution, and the implementation of rewards such as extra visitation, computer time, or the use of an adolescent’s own personal hygiene items or clothing. They include knowledge of the adolescent brain, and how the use of isolation in juvenile centers has led to increased suicide rates in those children.

Lindsay M. Hayes, author of the National Center on Institutions and Alternatives’ 2004 report “Juvenile Suicide in Confinement: A National Study,” wrote: ”Although room confinement remains a staple in most juvenile facilities, it is a sanction that can have deadly consequences. … More than 50% of all youths’ suicides in juvenile facilities occurred while young people were isolated alone in their rooms, and … more than 60% of young people who committed suicide in custody had a history of being held in isolation.”

The United Nations has called on all countries to absolutely prohibit solitary confinement for juveniles, as has the American Academy of Child and Adolescent Psychiatry. Thus, extreme isolation should not be another tool for juvenile detention centers.

Currently, 20 states have banned solitary confinement in juvenile detention facilities. The major barriers are from staff, who state it would remove a tool, put staff in danger, and allow youth to run the facilities. None of these has been shown to be true. Some juvenile detention centers have changed the traditional meaning of isolation – youth will have a minimum of 8 hours away from isolation when confined for a day or longer. “During that 8 hours, they have the opportunity to talk to and be in the company of staff,” said Adam Schwartz, a lawyer for the American Civil Liberties Union of Illinois, whose lawsuit drastically limited solitary confinement practices in Illinois’s juvenile detention centers. The policy also requires that inmates in isolation continue to receive education and mental health services.

There is a human dignity that not even detainees deserve to lose. President Obama has discussed this, as has the 2012 Report of the Attorney General’s National Task Force on Children Exposed to Violence, which concluded: “Nowhere is the damaging impact of incarceration on vulnerable children more obvious than when it involves solitary confinement.” I am writing this article to raise awareness about this underreported problem in hopes that new legislation will lead to change that is in the best interest of our children.

Dr. Raffa is in postgraduate year 2 in her pediatric residency at Vanderbilt Children’s Hospital in Nashville, Tenn.

In 2002, Dr. Bruce B. Lee first described a laparoscopic technique to ablate symptomatic uterine fibroids utilizing radiofrequency under ultrasound guidance. Since this time, several papers have documented the procedure’s feasibility and efficacy, including reduction in menstrual blood loss, fibroid volume decrease, and improvement in quality of life.

In a randomized, prospective, single-center, longitudinal study that compared laparoscopic radiofrequency volumetric thermal ablation (RFVTA) of fibroids with laparoscopic myomectomy, Dr. Sara Y. Brucker and her colleagues concluded that RFVTA resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than did laparoscopic myomectomy (Int J Gynaecol Obstet. 2014 Jun;125[3]:261-5).

More recently, in the literature and at the 2015 American Association of Gynecologic Laparoscopists (AAGL) Global Congress in November, viable, full-term pregnancies have been reported in patients previously treated for symptomatic fibroids via RFVTA (J Reprod Med. 2015 May-Jun;60[5-6]:194-8).

The system for performing RFVTA of symptomatic fibroids – the Acessa System (Halt Medical) – has continued to improve. Earlier this year, Dr. Donald I. Galen described the use of electromagnetic image guidance, which has been cleared by the Food and Drug Administration and incorporated into the Acessa Guidance System. Dr. Galen’s feasibility study showed that the guidance system enhances the ultrasonic image of Acessa’s handpiece to facilitate accurate tip placement during the targeting and ablation of uterine fibroids (Biomed Eng Online. 2015 Oct 15;14:90).

In this edition of the Master Class in Gynecologic Surgery, Dr. Jay M. Berman discusses the use of RFVTA for the treatment of symptomatic uterine fibroids. Dr. Berman is interim chairman of Wayne State University’s department of obstetrics and gynecology and interim specialist in chief for obstetrics and gynecology at the Detroit Medical Center. He served as a principal investigator of the pivotal trial of Acessa and has reported on reproductive outcomes. Dr. Berman has long been interested in alternatives to hysterectomy for fibroid management and has incorporated RFVTA into his armamentarium of therapies.

Dr. Miller is a clinical associate professor at the University of Illinois at Chicago, and a past president of the AAGL and the International Society for Gynecologic Endoscopy (ISGE). He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville and Schaumburg, Ill.; director of minimally invasive gynecologic surgery and the director of the AAGL/Society of Reproductive Surgery fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. Dr. Miller reported that he is a consultant for Halt Medical Inc., which developed the Acessa System.

In 2002, Dr. Bruce B. Lee first described a laparoscopic technique to ablate symptomatic uterine fibroids utilizing radiofrequency under ultrasound guidance. Since this time, several papers have documented the procedure’s feasibility and efficacy, including reduction in menstrual blood loss, fibroid volume decrease, and improvement in quality of life.

In a randomized, prospective, single-center, longitudinal study that compared laparoscopic radiofrequency volumetric thermal ablation (RFVTA) of fibroids with laparoscopic myomectomy, Dr. Sara Y. Brucker and her colleagues concluded that RFVTA resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than did laparoscopic myomectomy (Int J Gynaecol Obstet. 2014 Jun;125[3]:261-5).

More recently, in the literature and at the 2015 American Association of Gynecologic Laparoscopists (AAGL) Global Congress in November, viable, full-term pregnancies have been reported in patients previously treated for symptomatic fibroids via RFVTA (J Reprod Med. 2015 May-Jun;60[5-6]:194-8).

The system for performing RFVTA of symptomatic fibroids – the Acessa System (Halt Medical) – has continued to improve. Earlier this year, Dr. Donald I. Galen described the use of electromagnetic image guidance, which has been cleared by the Food and Drug Administration and incorporated into the Acessa Guidance System. Dr. Galen’s feasibility study showed that the guidance system enhances the ultrasonic image of Acessa’s handpiece to facilitate accurate tip placement during the targeting and ablation of uterine fibroids (Biomed Eng Online. 2015 Oct 15;14:90).

In this edition of the Master Class in Gynecologic Surgery, Dr. Jay M. Berman discusses the use of RFVTA for the treatment of symptomatic uterine fibroids. Dr. Berman is interim chairman of Wayne State University’s department of obstetrics and gynecology and interim specialist in chief for obstetrics and gynecology at the Detroit Medical Center. He served as a principal investigator of the pivotal trial of Acessa and has reported on reproductive outcomes. Dr. Berman has long been interested in alternatives to hysterectomy for fibroid management and has incorporated RFVTA into his armamentarium of therapies.

Dr. Miller is a clinical associate professor at the University of Illinois at Chicago, and a past president of the AAGL and the International Society for Gynecologic Endoscopy (ISGE). He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville and Schaumburg, Ill.; director of minimally invasive gynecologic surgery and the director of the AAGL/Society of Reproductive Surgery fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. Dr. Miller reported that he is a consultant for Halt Medical Inc., which developed the Acessa System.

In 2002, Dr. Bruce B. Lee first described a laparoscopic technique to ablate symptomatic uterine fibroids utilizing radiofrequency under ultrasound guidance. Since this time, several papers have documented the procedure’s feasibility and efficacy, including reduction in menstrual blood loss, fibroid volume decrease, and improvement in quality of life.

In a randomized, prospective, single-center, longitudinal study that compared laparoscopic radiofrequency volumetric thermal ablation (RFVTA) of fibroids with laparoscopic myomectomy, Dr. Sara Y. Brucker and her colleagues concluded that RFVTA resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than did laparoscopic myomectomy (Int J Gynaecol Obstet. 2014 Jun;125[3]:261-5).

More recently, in the literature and at the 2015 American Association of Gynecologic Laparoscopists (AAGL) Global Congress in November, viable, full-term pregnancies have been reported in patients previously treated for symptomatic fibroids via RFVTA (J Reprod Med. 2015 May-Jun;60[5-6]:194-8).

The system for performing RFVTA of symptomatic fibroids – the Acessa System (Halt Medical) – has continued to improve. Earlier this year, Dr. Donald I. Galen described the use of electromagnetic image guidance, which has been cleared by the Food and Drug Administration and incorporated into the Acessa Guidance System. Dr. Galen’s feasibility study showed that the guidance system enhances the ultrasonic image of Acessa’s handpiece to facilitate accurate tip placement during the targeting and ablation of uterine fibroids (Biomed Eng Online. 2015 Oct 15;14:90).

In this edition of the Master Class in Gynecologic Surgery, Dr. Jay M. Berman discusses the use of RFVTA for the treatment of symptomatic uterine fibroids. Dr. Berman is interim chairman of Wayne State University’s department of obstetrics and gynecology and interim specialist in chief for obstetrics and gynecology at the Detroit Medical Center. He served as a principal investigator of the pivotal trial of Acessa and has reported on reproductive outcomes. Dr. Berman has long been interested in alternatives to hysterectomy for fibroid management and has incorporated RFVTA into his armamentarium of therapies.

Dr. Miller is a clinical associate professor at the University of Illinois at Chicago, and a past president of the AAGL and the International Society for Gynecologic Endoscopy (ISGE). He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville and Schaumburg, Ill.; director of minimally invasive gynecologic surgery and the director of the AAGL/Society of Reproductive Surgery fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. Dr. Miller reported that he is a consultant for Halt Medical Inc., which developed the Acessa System.