A case series of seven girls with apparent vitiligoid lichen sclerosus supports the possible predisposition of this condition in darker skin types, said Margaret H. Dennin, of the University of Chicago, and her associates.

Vitiligoid lichen sclerosus is a superficial variant of lichen sclerosus (LS), in which the lesion clinically appears to be vitiligo, but histologically is consistent with LS.

Seven dark-skinned girls aged 3-9 years had symptomatic (pruritus, pain, bleeding, constipation) depigmented patches of the vulvar or perianal region; three had purpuric lesions. None of the patients had atrophy or scarring, and they had no depigmentation anywhere else on their bodies. Follow-up was an average 2 years (range 3 months to 4 years).

Treatment with high-potency topical steroids, calcineurin inhibitors, or both resulted in improvement or resolution of their symptoms in all cases, but there was mild or no improvement in the depigmentation. Biopsies were not performed because of the patients’ young age and the location of the lesions, the investigators said.

The term vitiligoid lichen sclerosus was first coined in 1961 by Borda et al. when depigmented patches, as seen in both conditions, constituted the clinical appearance, but lacked the inflammation, atrophy, and sclerosis of typical LS. Histologically, these lesions were like LS, “based on the presence of a thin band of papillary dermal sclerosis,” Ms. Dennin and her associates said. Borda et al. suggested that vitiligoid lichen sclerosus might be limited to dark-skinned people, and recent reports support this. Alternatively, it may be that the depigmentation simply is more obvious on dark-skinned people, and asymptomatic cases go unnoticed on lighter-skinned people, the investigators surmised.

Both vitiligo and LS are autoimmune cutaneous disorders, and they both often affect the anogenital region. The conditions “may be linked through a common autoimmune response from exposed intracellular or altered cell surface antigens on damaged melanocytes,” the investigators said. “Histologic evidence demonstrates that development of vitiligo involves a preceding lichenoid inflammatory reaction that may trigger an autoimmune reaction to melanocytes, decreasing their number. Evolving vitiligo with a lichenoid reaction may result in epitope spreading and the development of LS.”

The study is limited by its retrospective nature, small sample size, and lack of biopsies, the researchers noted. Larger studies are needed to look at the overlap of the conditions, and “understand the true prevalence of vitiligoid lichen sclerosus,” Ms. Dennin and her associates said.

Read more in Pediatric Dermatology (2018. doi: 10.1111/pde.13399).

cnellist@frontlinemedcom.com

A case series of seven girls with apparent vitiligoid lichen sclerosus supports the possible predisposition of this condition in darker skin types, said Margaret H. Dennin, of the University of Chicago, and her associates.

Vitiligoid lichen sclerosus is a superficial variant of lichen sclerosus (LS), in which the lesion clinically appears to be vitiligo, but histologically is consistent with LS.

Seven dark-skinned girls aged 3-9 years had symptomatic (pruritus, pain, bleeding, constipation) depigmented patches of the vulvar or perianal region; three had purpuric lesions. None of the patients had atrophy or scarring, and they had no depigmentation anywhere else on their bodies. Follow-up was an average 2 years (range 3 months to 4 years).

Treatment with high-potency topical steroids, calcineurin inhibitors, or both resulted in improvement or resolution of their symptoms in all cases, but there was mild or no improvement in the depigmentation. Biopsies were not performed because of the patients’ young age and the location of the lesions, the investigators said.

The term vitiligoid lichen sclerosus was first coined in 1961 by Borda et al. when depigmented patches, as seen in both conditions, constituted the clinical appearance, but lacked the inflammation, atrophy, and sclerosis of typical LS. Histologically, these lesions were like LS, “based on the presence of a thin band of papillary dermal sclerosis,” Ms. Dennin and her associates said. Borda et al. suggested that vitiligoid lichen sclerosus might be limited to dark-skinned people, and recent reports support this. Alternatively, it may be that the depigmentation simply is more obvious on dark-skinned people, and asymptomatic cases go unnoticed on lighter-skinned people, the investigators surmised.

Both vitiligo and LS are autoimmune cutaneous disorders, and they both often affect the anogenital region. The conditions “may be linked through a common autoimmune response from exposed intracellular or altered cell surface antigens on damaged melanocytes,” the investigators said. “Histologic evidence demonstrates that development of vitiligo involves a preceding lichenoid inflammatory reaction that may trigger an autoimmune reaction to melanocytes, decreasing their number. Evolving vitiligo with a lichenoid reaction may result in epitope spreading and the development of LS.”

The study is limited by its retrospective nature, small sample size, and lack of biopsies, the researchers noted. Larger studies are needed to look at the overlap of the conditions, and “understand the true prevalence of vitiligoid lichen sclerosus,” Ms. Dennin and her associates said.

Read more in Pediatric Dermatology (2018. doi: 10.1111/pde.13399).

cnellist@frontlinemedcom.com

A case series of seven girls with apparent vitiligoid lichen sclerosus supports the possible predisposition of this condition in darker skin types, said Margaret H. Dennin, of the University of Chicago, and her associates.

Vitiligoid lichen sclerosus is a superficial variant of lichen sclerosus (LS), in which the lesion clinically appears to be vitiligo, but histologically is consistent with LS.

Seven dark-skinned girls aged 3-9 years had symptomatic (pruritus, pain, bleeding, constipation) depigmented patches of the vulvar or perianal region; three had purpuric lesions. None of the patients had atrophy or scarring, and they had no depigmentation anywhere else on their bodies. Follow-up was an average 2 years (range 3 months to 4 years).

Treatment with high-potency topical steroids, calcineurin inhibitors, or both resulted in improvement or resolution of their symptoms in all cases, but there was mild or no improvement in the depigmentation. Biopsies were not performed because of the patients’ young age and the location of the lesions, the investigators said.

The term vitiligoid lichen sclerosus was first coined in 1961 by Borda et al. when depigmented patches, as seen in both conditions, constituted the clinical appearance, but lacked the inflammation, atrophy, and sclerosis of typical LS. Histologically, these lesions were like LS, “based on the presence of a thin band of papillary dermal sclerosis,” Ms. Dennin and her associates said. Borda et al. suggested that vitiligoid lichen sclerosus might be limited to dark-skinned people, and recent reports support this. Alternatively, it may be that the depigmentation simply is more obvious on dark-skinned people, and asymptomatic cases go unnoticed on lighter-skinned people, the investigators surmised.

Both vitiligo and LS are autoimmune cutaneous disorders, and they both often affect the anogenital region. The conditions “may be linked through a common autoimmune response from exposed intracellular or altered cell surface antigens on damaged melanocytes,” the investigators said. “Histologic evidence demonstrates that development of vitiligo involves a preceding lichenoid inflammatory reaction that may trigger an autoimmune reaction to melanocytes, decreasing their number. Evolving vitiligo with a lichenoid reaction may result in epitope spreading and the development of LS.”

The study is limited by its retrospective nature, small sample size, and lack of biopsies, the researchers noted. Larger studies are needed to look at the overlap of the conditions, and “understand the true prevalence of vitiligoid lichen sclerosus,” Ms. Dennin and her associates said.

Read more in Pediatric Dermatology (2018. doi: 10.1111/pde.13399).

cnellist@frontlinemedcom.com

The Diagnosis: Dermatofibroma

On dermoscopy, a central stellate, white, scarlike patch was seen (Figure). On both legs the patient had several additional brown 5- to 7-mm papules with similar dermoscopic features.

Dermatofibromas are common benign fibrosing tumors that appear as firm papules or plaques with variable color, commonly on the legs. Typically, lateral compression of a dermatofibroma causes downward displacement, called a positive dimple sign. On histology, fibroblasts and myofibroblasts can be seen as short intersecting fascicles with variable inflammatory cells and induction of adjacent structure hyperplasia. The etiology of dermatofibromas is unclear, though some are thought to be secondary to trauma or arthropod bites.¹ Because these tumors are benign, the correct diagnosis can avoid unnecessary biopsies or other procedures.

The dermoscopic features of dermatofibromas have been well established.² As perhaps the most easily identified structure, scarlike patches were seen in as many as 92% (22/24) of dermatofibromas in one study by Ferarri et al,³ while pigment networks also are commonly seen.² In our case, given the surrounding dense tattoo deposition, it was difficult to ascertain any pigment network. However, the scarlike central patch was clearly apparent by dermoscopy.

Because dermatofibromas are hypothesized to be secondary to trauma, presumably applying tattoos also may cause dermatofibromas. Limited cases have described dermatofibromas arising in tattoos applied several months to years prior.^4-6 No prior cases utilized dermoscopy. In our case, clinical examination and dermoscopy clearly demonstrated features consistent with a dermatofibroma, and the patient had more characteristic dermatofibromas scattered elsewhere on both legs. The patient was reassured that the lesions were benign and that the depigmentation was likely secondary to the process of dermatofibroma growth. She declined any treatment.

The Diagnosis: Dermatofibroma

On dermoscopy, a central stellate, white, scarlike patch was seen (Figure). On both legs the patient had several additional brown 5- to 7-mm papules with similar dermoscopic features.

Dermatofibromas are common benign fibrosing tumors that appear as firm papules or plaques with variable color, commonly on the legs. Typically, lateral compression of a dermatofibroma causes downward displacement, called a positive dimple sign. On histology, fibroblasts and myofibroblasts can be seen as short intersecting fascicles with variable inflammatory cells and induction of adjacent structure hyperplasia. The etiology of dermatofibromas is unclear, though some are thought to be secondary to trauma or arthropod bites.¹ Because these tumors are benign, the correct diagnosis can avoid unnecessary biopsies or other procedures.

The dermoscopic features of dermatofibromas have been well established.² As perhaps the most easily identified structure, scarlike patches were seen in as many as 92% (22/24) of dermatofibromas in one study by Ferarri et al,³ while pigment networks also are commonly seen.² In our case, given the surrounding dense tattoo deposition, it was difficult to ascertain any pigment network. However, the scarlike central patch was clearly apparent by dermoscopy.

Because dermatofibromas are hypothesized to be secondary to trauma, presumably applying tattoos also may cause dermatofibromas. Limited cases have described dermatofibromas arising in tattoos applied several months to years prior.^4-6 No prior cases utilized dermoscopy. In our case, clinical examination and dermoscopy clearly demonstrated features consistent with a dermatofibroma, and the patient had more characteristic dermatofibromas scattered elsewhere on both legs. The patient was reassured that the lesions were benign and that the depigmentation was likely secondary to the process of dermatofibroma growth. She declined any treatment.

The Diagnosis: Dermatofibroma

On dermoscopy, a central stellate, white, scarlike patch was seen (Figure). On both legs the patient had several additional brown 5- to 7-mm papules with similar dermoscopic features.

Dermatofibromas are common benign fibrosing tumors that appear as firm papules or plaques with variable color, commonly on the legs. Typically, lateral compression of a dermatofibroma causes downward displacement, called a positive dimple sign. On histology, fibroblasts and myofibroblasts can be seen as short intersecting fascicles with variable inflammatory cells and induction of adjacent structure hyperplasia. The etiology of dermatofibromas is unclear, though some are thought to be secondary to trauma or arthropod bites.¹ Because these tumors are benign, the correct diagnosis can avoid unnecessary biopsies or other procedures.

The dermoscopic features of dermatofibromas have been well established.² As perhaps the most easily identified structure, scarlike patches were seen in as many as 92% (22/24) of dermatofibromas in one study by Ferarri et al,³ while pigment networks also are commonly seen.² In our case, given the surrounding dense tattoo deposition, it was difficult to ascertain any pigment network. However, the scarlike central patch was clearly apparent by dermoscopy.

Because dermatofibromas are hypothesized to be secondary to trauma, presumably applying tattoos also may cause dermatofibromas. Limited cases have described dermatofibromas arising in tattoos applied several months to years prior.^4-6 No prior cases utilized dermoscopy. In our case, clinical examination and dermoscopy clearly demonstrated features consistent with a dermatofibroma, and the patient had more characteristic dermatofibromas scattered elsewhere on both legs. The patient was reassured that the lesions were benign and that the depigmentation was likely secondary to the process of dermatofibroma growth. She declined any treatment.

DENVER – Thirty-day transcatheter aortic valve replacement (TAVR) outcomes in real-world clinical practice using the Evolut R self-expanding valve were as good in patients treated for bicuspid disease as for tricuspid disease, according to a retrospective analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) national registry.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

SOURCE: Popma JJ. TCT 2017.

DENVER – Thirty-day transcatheter aortic valve replacement (TAVR) outcomes in real-world clinical practice using the Evolut R self-expanding valve were as good in patients treated for bicuspid disease as for tricuspid disease, according to a retrospective analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) national registry.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

SOURCE: Popma JJ. TCT 2017.

DENVER – Thirty-day transcatheter aortic valve replacement (TAVR) outcomes in real-world clinical practice using the Evolut R self-expanding valve were as good in patients treated for bicuspid disease as for tricuspid disease, according to a retrospective analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) national registry.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

SOURCE: Popma JJ. TCT 2017.

Desmoplastic melanoma, a rare chemotherapy-resistant cutaneous malignancy, appears to be particularly responsive to immunotherapy with inhibitors of programmed death 1 (PD-1) or PD ligand 1 (PD-L1), investigators found.

Of 60 patients with desmoplastic melanoma (DM) treated with pembrolizumab (Keytruda), nivolumab (Opdivo), or an experimental PD-L1 inhibitor (BMS 936559) and followed for a median of 22 months, 42 (70%) had an objective response to immunotherapy, including 19 patients (32%) with a complete response (CR), and 38% with a partial response, reported Antoni Ribas, MD, PhD, of the University of California, Los Angeles, and colleagues.

SOURCE: Ribas A et al. Nature. 2018 Jan 10. doi: 10.1038/nature25187.

Desmoplastic melanoma, a rare chemotherapy-resistant cutaneous malignancy, appears to be particularly responsive to immunotherapy with inhibitors of programmed death 1 (PD-1) or PD ligand 1 (PD-L1), investigators found.

Of 60 patients with desmoplastic melanoma (DM) treated with pembrolizumab (Keytruda), nivolumab (Opdivo), or an experimental PD-L1 inhibitor (BMS 936559) and followed for a median of 22 months, 42 (70%) had an objective response to immunotherapy, including 19 patients (32%) with a complete response (CR), and 38% with a partial response, reported Antoni Ribas, MD, PhD, of the University of California, Los Angeles, and colleagues.

SOURCE: Ribas A et al. Nature. 2018 Jan 10. doi: 10.1038/nature25187.

Desmoplastic melanoma, a rare chemotherapy-resistant cutaneous malignancy, appears to be particularly responsive to immunotherapy with inhibitors of programmed death 1 (PD-1) or PD ligand 1 (PD-L1), investigators found.

Of 60 patients with desmoplastic melanoma (DM) treated with pembrolizumab (Keytruda), nivolumab (Opdivo), or an experimental PD-L1 inhibitor (BMS 936559) and followed for a median of 22 months, 42 (70%) had an objective response to immunotherapy, including 19 patients (32%) with a complete response (CR), and 38% with a partial response, reported Antoni Ribas, MD, PhD, of the University of California, Los Angeles, and colleagues.

SOURCE: Ribas A et al. Nature. 2018 Jan 10. doi: 10.1038/nature25187.

When I came to this country, even before my current residency, I launched my addiction psychiatry career by researching nicotine addiction in schizophrenia patients. Those early experiences gave me a greater understanding of the health concerns and life experiences of people with addictions – and those more likely to develop them.

So imagine my excitement when I first became acquainted with the American Academy of Addiction Psychiatry (AAAP). I first learned about the AAAP, its mission, and activities at the 2017 American Psychiatric Association’s annual meeting in San Diego.

Getting in and involved

After returning to New York, I took those next steps and joined up, which opened the AAAP gates so I could receive its newsletters and submission calls, gain access to resources such as The American Journal on Addictions, survey the various joinable task forces, as well as discover who might be available to me as a mentor as part of the AAAP’s mentor-mentee program.

Sometime during my third-year residency training, I received a member-email advertising the AAAP 28th Annual Meeting and Scientific Symposium, and soon after that, received another email calling for research submissions to be presented there, as well as an invitation to apply for a trainee travel scholarship that would defray the cost for and allow its fellows to attend the meeting in San Diego. That alone was enticing enough to apply. But even more enticing was the opportunity to showcase the addiction work I had been doing during my residency, as well as to meet other members at various levels of the AAAP to determine whether I wanted to become more involved.
 

Pursuing experiences

I did not think twice about applying for the poster presentation and the travel scholarship. The AAAP’s online application forms for both were easy to understand and very well structured, which greatly helped me with filling out and formatting my applications. Taking the initiative toward even these first AAAP offerings brought more positive echoes. I was thrilled when the poster I proposed was accepted, mostly because it would give me the chance to present my recent addiction psych work from a higher platform. A few weeks later, I was thrilled again when I received an AAAP email congratulating me on being awarded the San Diego 28th annual meeting travel scholarship, which would waive the annual membership and conference registration fees, in addition to defraying my travel costs. Pacific breezes, here I come. And there I went. (Thanks to my extremely supportive training director, who first nominated me for the award.)

On the ground at 2017 AAAP

The 28th AAAP annual meeting opened on a balmy December Thursday, and that’s the day I arrived. I attended many addiction workshops and symposiums, which featured premier figures in addiction psychiatry. Of the numerous trainee-specific events I attended, the most informative was the “Fellowship Forum: Exploring the Field of Addiction Psychiatry.” At this forum, I learned the true benefits of doing an addiction psychiatry fellowship, while meeting many of the fellowship program directors of top institutions. Having them all under one “roof” made it easy to compare and contrast the specific training they offered.

Then came what were, for me, major highlights of the AAAP 2017. After I delivered my poster presentation and shared my research, I was able to receive very close, constructive feedback from the field’s most experienced professionals. And, finally, I met my AAAP mentors face to face: Dr. Amy Yule of Harvard Medical School, Boston; Dr. Thomas Penders, of East Carolina University, Greenville, N.C.; and Dr. Cornel Stanciu of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
 

One AAAP trainee’s takeaways

All AAAP trainees, fellows, presenters leave the meeting with their own conclusions, but my biggest takeaways were:

• Regarding barriers to buprenorphine, emerging research supports similar efficacy for long-acting injectable naltrexone.
• Various protocols for rapid implementation of naltrexone are being used, and these allow for smoother transition and shorter “washout” periods.
• We should not overlook the effects of tobacco use in our patient population – and should address it aggressively, regardless of psychiatric comorbidities.
• The cannabinoid CBD receptors that exist on the dopamine pathway strengthen and complicate their relationship with psychosis.
• Telehealth should be seen as a potential solution for the incredible demand for addiction specialists, especially in rural and remote settings. The body of evidence supporting its efficacy is expanding.
• Synthetic cannabinoids are prevalent, and toxidromes exist – yet, trainees are not current on these.

The challenges facing those of us dedicated to fighting addiction have never been greater. I would urge more trainees and psychiatrists to join the AAAP in light of the opioid crisis and the potential fallout tied to marijuana legalization. I am grateful to have the opportunity to join my colleagues in this fight. Becoming part of the AAAP has led to a highly rewarding, career-enriching experience.
 

This article was updated 1/17/17.

Dr. Ahmed is a third-year resident in the department of psychiatry at Nassau University Medical Center, East Meadow, New York. Besides addiction psychiatry, his interests include public social psychiatry, health care policy, health disparities, and mental health stigma. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

When I came to this country, even before my current residency, I launched my addiction psychiatry career by researching nicotine addiction in schizophrenia patients. Those early experiences gave me a greater understanding of the health concerns and life experiences of people with addictions – and those more likely to develop them.

So imagine my excitement when I first became acquainted with the American Academy of Addiction Psychiatry (AAAP). I first learned about the AAAP, its mission, and activities at the 2017 American Psychiatric Association’s annual meeting in San Diego.

Getting in and involved

After returning to New York, I took those next steps and joined up, which opened the AAAP gates so I could receive its newsletters and submission calls, gain access to resources such as The American Journal on Addictions, survey the various joinable task forces, as well as discover who might be available to me as a mentor as part of the AAAP’s mentor-mentee program.

Sometime during my third-year residency training, I received a member-email advertising the AAAP 28th Annual Meeting and Scientific Symposium, and soon after that, received another email calling for research submissions to be presented there, as well as an invitation to apply for a trainee travel scholarship that would defray the cost for and allow its fellows to attend the meeting in San Diego. That alone was enticing enough to apply. But even more enticing was the opportunity to showcase the addiction work I had been doing during my residency, as well as to meet other members at various levels of the AAAP to determine whether I wanted to become more involved.
 

Pursuing experiences

I did not think twice about applying for the poster presentation and the travel scholarship. The AAAP’s online application forms for both were easy to understand and very well structured, which greatly helped me with filling out and formatting my applications. Taking the initiative toward even these first AAAP offerings brought more positive echoes. I was thrilled when the poster I proposed was accepted, mostly because it would give me the chance to present my recent addiction psych work from a higher platform. A few weeks later, I was thrilled again when I received an AAAP email congratulating me on being awarded the San Diego 28th annual meeting travel scholarship, which would waive the annual membership and conference registration fees, in addition to defraying my travel costs. Pacific breezes, here I come. And there I went. (Thanks to my extremely supportive training director, who first nominated me for the award.)

On the ground at 2017 AAAP

The 28th AAAP annual meeting opened on a balmy December Thursday, and that’s the day I arrived. I attended many addiction workshops and symposiums, which featured premier figures in addiction psychiatry. Of the numerous trainee-specific events I attended, the most informative was the “Fellowship Forum: Exploring the Field of Addiction Psychiatry.” At this forum, I learned the true benefits of doing an addiction psychiatry fellowship, while meeting many of the fellowship program directors of top institutions. Having them all under one “roof” made it easy to compare and contrast the specific training they offered.

Then came what were, for me, major highlights of the AAAP 2017. After I delivered my poster presentation and shared my research, I was able to receive very close, constructive feedback from the field’s most experienced professionals. And, finally, I met my AAAP mentors face to face: Dr. Amy Yule of Harvard Medical School, Boston; Dr. Thomas Penders, of East Carolina University, Greenville, N.C.; and Dr. Cornel Stanciu of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
 

One AAAP trainee’s takeaways

All AAAP trainees, fellows, presenters leave the meeting with their own conclusions, but my biggest takeaways were:

• Regarding barriers to buprenorphine, emerging research supports similar efficacy for long-acting injectable naltrexone.
• Various protocols for rapid implementation of naltrexone are being used, and these allow for smoother transition and shorter “washout” periods.
• We should not overlook the effects of tobacco use in our patient population – and should address it aggressively, regardless of psychiatric comorbidities.
• The cannabinoid CBD receptors that exist on the dopamine pathway strengthen and complicate their relationship with psychosis.
• Telehealth should be seen as a potential solution for the incredible demand for addiction specialists, especially in rural and remote settings. The body of evidence supporting its efficacy is expanding.
• Synthetic cannabinoids are prevalent, and toxidromes exist – yet, trainees are not current on these.

The challenges facing those of us dedicated to fighting addiction have never been greater. I would urge more trainees and psychiatrists to join the AAAP in light of the opioid crisis and the potential fallout tied to marijuana legalization. I am grateful to have the opportunity to join my colleagues in this fight. Becoming part of the AAAP has led to a highly rewarding, career-enriching experience.
 

This article was updated 1/17/17.

Dr. Ahmed is a third-year resident in the department of psychiatry at Nassau University Medical Center, East Meadow, New York. Besides addiction psychiatry, his interests include public social psychiatry, health care policy, health disparities, and mental health stigma. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

When I came to this country, even before my current residency, I launched my addiction psychiatry career by researching nicotine addiction in schizophrenia patients. Those early experiences gave me a greater understanding of the health concerns and life experiences of people with addictions – and those more likely to develop them.

So imagine my excitement when I first became acquainted with the American Academy of Addiction Psychiatry (AAAP). I first learned about the AAAP, its mission, and activities at the 2017 American Psychiatric Association’s annual meeting in San Diego.

Getting in and involved

After returning to New York, I took those next steps and joined up, which opened the AAAP gates so I could receive its newsletters and submission calls, gain access to resources such as The American Journal on Addictions, survey the various joinable task forces, as well as discover who might be available to me as a mentor as part of the AAAP’s mentor-mentee program.

Sometime during my third-year residency training, I received a member-email advertising the AAAP 28th Annual Meeting and Scientific Symposium, and soon after that, received another email calling for research submissions to be presented there, as well as an invitation to apply for a trainee travel scholarship that would defray the cost for and allow its fellows to attend the meeting in San Diego. That alone was enticing enough to apply. But even more enticing was the opportunity to showcase the addiction work I had been doing during my residency, as well as to meet other members at various levels of the AAAP to determine whether I wanted to become more involved.
 

Pursuing experiences

I did not think twice about applying for the poster presentation and the travel scholarship. The AAAP’s online application forms for both were easy to understand and very well structured, which greatly helped me with filling out and formatting my applications. Taking the initiative toward even these first AAAP offerings brought more positive echoes. I was thrilled when the poster I proposed was accepted, mostly because it would give me the chance to present my recent addiction psych work from a higher platform. A few weeks later, I was thrilled again when I received an AAAP email congratulating me on being awarded the San Diego 28th annual meeting travel scholarship, which would waive the annual membership and conference registration fees, in addition to defraying my travel costs. Pacific breezes, here I come. And there I went. (Thanks to my extremely supportive training director, who first nominated me for the award.)

On the ground at 2017 AAAP

The 28th AAAP annual meeting opened on a balmy December Thursday, and that’s the day I arrived. I attended many addiction workshops and symposiums, which featured premier figures in addiction psychiatry. Of the numerous trainee-specific events I attended, the most informative was the “Fellowship Forum: Exploring the Field of Addiction Psychiatry.” At this forum, I learned the true benefits of doing an addiction psychiatry fellowship, while meeting many of the fellowship program directors of top institutions. Having them all under one “roof” made it easy to compare and contrast the specific training they offered.

Then came what were, for me, major highlights of the AAAP 2017. After I delivered my poster presentation and shared my research, I was able to receive very close, constructive feedback from the field’s most experienced professionals. And, finally, I met my AAAP mentors face to face: Dr. Amy Yule of Harvard Medical School, Boston; Dr. Thomas Penders, of East Carolina University, Greenville, N.C.; and Dr. Cornel Stanciu of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
 

One AAAP trainee’s takeaways

All AAAP trainees, fellows, presenters leave the meeting with their own conclusions, but my biggest takeaways were:

• Regarding barriers to buprenorphine, emerging research supports similar efficacy for long-acting injectable naltrexone.
• Various protocols for rapid implementation of naltrexone are being used, and these allow for smoother transition and shorter “washout” periods.
• We should not overlook the effects of tobacco use in our patient population – and should address it aggressively, regardless of psychiatric comorbidities.
• The cannabinoid CBD receptors that exist on the dopamine pathway strengthen and complicate their relationship with psychosis.
• Telehealth should be seen as a potential solution for the incredible demand for addiction specialists, especially in rural and remote settings. The body of evidence supporting its efficacy is expanding.
• Synthetic cannabinoids are prevalent, and toxidromes exist – yet, trainees are not current on these.

The challenges facing those of us dedicated to fighting addiction have never been greater. I would urge more trainees and psychiatrists to join the AAAP in light of the opioid crisis and the potential fallout tied to marijuana legalization. I am grateful to have the opportunity to join my colleagues in this fight. Becoming part of the AAAP has led to a highly rewarding, career-enriching experience.
 

This article was updated 1/17/17.

Dr. Ahmed is a third-year resident in the department of psychiatry at Nassau University Medical Center, East Meadow, New York. Besides addiction psychiatry, his interests include public social psychiatry, health care policy, health disparities, and mental health stigma. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

As far as the influenza virus is concerned, the new year started in the same way as the old one ended: with almost half of the states at the highest level of flu activity, according to the Centers for Disease Control and Prevention.

For the week ending Jan. 6, 2018, there were 23 states – including California, Illinois, and Texas – at level 10 on the CDC’s 1-10 scale for influenza-like illness (ILI) activity, which was up from 22 for the last full week of 2017. Joining the 23 states in the “high” range were New Jersey and Ohio at level 9 and Colorado at level 8, the CDC’s influenza division reported Jan. 12.

rfranki@frontlinemedcom.com

As far as the influenza virus is concerned, the new year started in the same way as the old one ended: with almost half of the states at the highest level of flu activity, according to the Centers for Disease Control and Prevention.

For the week ending Jan. 6, 2018, there were 23 states – including California, Illinois, and Texas – at level 10 on the CDC’s 1-10 scale for influenza-like illness (ILI) activity, which was up from 22 for the last full week of 2017. Joining the 23 states in the “high” range were New Jersey and Ohio at level 9 and Colorado at level 8, the CDC’s influenza division reported Jan. 12.

rfranki@frontlinemedcom.com

As far as the influenza virus is concerned, the new year started in the same way as the old one ended: with almost half of the states at the highest level of flu activity, according to the Centers for Disease Control and Prevention.

For the week ending Jan. 6, 2018, there were 23 states – including California, Illinois, and Texas – at level 10 on the CDC’s 1-10 scale for influenza-like illness (ILI) activity, which was up from 22 for the last full week of 2017. Joining the 23 states in the “high” range were New Jersey and Ohio at level 9 and Colorado at level 8, the CDC’s influenza division reported Jan. 12.

rfranki@frontlinemedcom.com

CHICAGO – Vascular surgeons are solidly within the top tier of surgical subspecialists in terms of risk for burnout, Joan M. Anzia, MD, observed at a symposium on vascular surgery sponsored by Northwestern University.

Joining them in this unwelcome company with an elevated rate of lower quality of life are trauma surgeons, urologists, and otolaryngologists, according to the results of a 9-year-old national study of burnout and career satisfaction among American surgeons that has served as a wakeup call for the profession (Ann Surg. 2009 Sep;250[3]:463-71).

Bruce Jancin/Frontline Medical News

Courtesy Mayo Clinic

bjancin@frontlinemedcom.com

CHICAGO – Vascular surgeons are solidly within the top tier of surgical subspecialists in terms of risk for burnout, Joan M. Anzia, MD, observed at a symposium on vascular surgery sponsored by Northwestern University.

Joining them in this unwelcome company with an elevated rate of lower quality of life are trauma surgeons, urologists, and otolaryngologists, according to the results of a 9-year-old national study of burnout and career satisfaction among American surgeons that has served as a wakeup call for the profession (Ann Surg. 2009 Sep;250[3]:463-71).

Bruce Jancin/Frontline Medical News

Courtesy Mayo Clinic

bjancin@frontlinemedcom.com

CHICAGO – Vascular surgeons are solidly within the top tier of surgical subspecialists in terms of risk for burnout, Joan M. Anzia, MD, observed at a symposium on vascular surgery sponsored by Northwestern University.

Joining them in this unwelcome company with an elevated rate of lower quality of life are trauma surgeons, urologists, and otolaryngologists, according to the results of a 9-year-old national study of burnout and career satisfaction among American surgeons that has served as a wakeup call for the profession (Ann Surg. 2009 Sep;250[3]:463-71).

Bruce Jancin/Frontline Medical News

Courtesy Mayo Clinic

bjancin@frontlinemedcom.com

The American Board of Internal Medicine (ABIM) changed its certification policy for bedside procedures over a decade ago.¹ Acquiring manual competence in abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis is no longer an expectation of residency training. ABIM diplomates should “know” these procedures but not necessarily “do” them. Hospitalists, most of whom are themselves ABIM diplomates, are still, however, expected to do them as core competencies,²perhaps because hospitalists are often available off-hours, when roughly half of bedside procedures are performed.³

Hospitalists increasingly perform bedside procedures with ultrasound guidance.⁴ Yet training in ultrasound guidance is significantly varied as well,⁵ simply because point-of-care ultrasound (POCUS) has only recently become widespread.⁶ And though some skills are transferrable from landmark-guided to ultrasound -guided procedures, many are not.^7-10 Furthermore, ultrasound guidance is often not explicitly delineated on the privileging forms used by hospitals,¹¹ even where ultrasound guidance has become standard.¹²

Working Group Formation

In January 2015, the SHM Board of Directors asked the SHM Education Committee to convene the POCUS Task Force. The purpose of the task force was to develop recommendations on ultrasound guidance for bedside procedures. The SHM Education Committee appointed 3 chairs of the task force: 1 senior member of the SHM Education Committee and 2 POCUS experts. The chairs assembled a task force of 31 members that included 5 working groups, a multispecialty peer review group, and a guideline methodologist (supplemental Appendix 1). Invitation was based on members’ past contributions to SHM POCUS-related activities, up-front commitment, and declared conflicts of interest. Working group members self-identified as “hospitalists,” whereas peer reviewers were nonhospitalists but nationally recognized POCUS physician-leaders specializing in emergency medicine, cardiology, critical care medicine, and anesthesiology. Task force membership was vetted by a chair of the SHM POCUS Task Force and the Director of Education before work began. This position statement was authored by the Credentialing Working Group together with the chairs of the other 4 working groups and a guideline methodologist.

Disclosures

Signed disclosure statements of all task force members were reviewed prior to inclusion on the task force (supplemental Appendix 2); no members received honoraria for participation. Industry representatives did not contribute to the development of the guidelines nor to any conference calls or meetings.

Literature Search Strategy

A literature search was conducted by a biomedical librarian. Records from 1979 to January of 2017 were searched in Medline, Embase, CINAHL, Cochrane, and Google Scholar (supplemental Appendix 3). Search limiters were English language and adults. Articles were manually screened to exclude nonhuman or endoscopic ultrasound applications. Final article selection was based on working group consensus.

Draft Pathways

The Credentialing Working Group drafted initial and ongoing certification pathways (Figure 1 and Figure 2). The other 4 working groups from the task force were surveyed about the elements and overall appropriateness of these draft pathways. This survey and its results have already been published.¹² The Credentialing Working Group then revised the certification pathways by using these survey results and codified individual aspects of these pathways into recommendations.

Development of Position Statement

Based on the Grading of Recommendation Assessment Development and Evaluation methodology, all final article selections were initially rated as either low-quality (observational studies) or unclassifiable (expert opinion).¹⁶ These initial ratings were downgraded further because of indirectness, because none of the articles involved the intervention of interest (a credentialing pathway) in a population of interest (hospitalists) measuring the outcomes of interest (patient-level outcomes).¹⁷ Given the universal low-quality evidence ratings, we altered the task force strategy of developing guidelines, which the other 4 working groups are writing, and instead developed a position statement by using consensus gathering in 3 steps.

First, the Credentialing Working Group drafted an initial position statement composed of recommendations for credentialing pathways and other general aspects of credentialing. All final article selections were incorporated as references in a draft of the position statement and compiled in a full-text compendium. Second, feedback was provided by the other 4 task force working groups, the task force peer reviewers, and the SHM Education Committee. Feedback was incorporated by the authors of this statement who were the Credentialing Working Group, the chairs of the other 4 working groups, and a guideline methodologist. Third, final suggestions from all members of the SHM POCUS Task Force and SHM Education Committee were incorporated before final approval by the SHM Board of Directors in September 2017.

A total of 1438 references were identified in the original search. Manual selection led to 101 articles, which were incorporated into the following 4 domains with 16 recommendations.

General Credentialing Process

Basic Cognitive Competence Can Be Certified with Written or Oral Examinations

The ABIM defines cognitive competence as having 3 abilities: “(1) to explain indications, contraindications, patient preparation methods, sterile techniques, pain management, proper techniques for handling specimens and fluids obtained, and test results; (2) to recognize and manage complications; and, (3) to clearly explain to a patient all facets of the procedure necessary to obtain informed consent.”¹ These abilities can be assessed with written or oral examinations that may be integrated into simulation- or patient-based assessments.^18-21

Minimum Thresholds of Experience to Trigger the Timing of a Patient-Based Assessment Should Be Determined by Empirical Methods

Learning curves are highly variable^22-25 and even plateaus may not herald basic competence.²⁶ Expert opinions²⁷ can be used to establish minimum thresholds of experience, but such opinions may paradoxically exceed the current thresholds of experts’ own hospitals.¹² Thus, empirical methods, such as those based on cumulative sum analysis^28-30 or local learning curves,^31,32 are preferred. If such methods are not available, a recent survey of hospitalist experts may provide guidance.¹² Regardless, once established, minimum thresholds are necessary but not sufficient to determine competency (see “Basic manual competence must be certified through patient-based assessments” section).

Hospitalists Should Formally Log All of Their Attempted Procedures, Ideally in an Electronic Medical Record

Simple self-reported numbers of procedures performed often misrepresent actual experience^33,34 and do not include periprocedural complications.^35,36 Thus, hospitalists should report their experience with logs of all attempted procedures, both successful and unsuccessful. Such logs must include information about supervising providers (if applicable) and patient outcomes, including periprocedural adverse events,³⁷ but they must also remain compliant with the Health Insurance Portability and Accountability Act.

Health Information Technology Service Should Routinely Pull Collations of All Attempted Procedures from Comprehensive Electronic Medical Records

Active surveillance may reduce complications by identifying hospitalists who may benefit from further training.³⁸ In order to facilitate active surveillance systems, documentation (such as a procedure note) should be both integrated into an electronic medical record and protocol driven,³⁹ including procedure technique, ultrasound findings, and any safety events (both near misses and adverse events).

Basic Manual Competence Must Be Certified Through Patient-Based Assessments

Multiple interacting factors, including environment, patients, baseline skills, training, experience, and skills decay, affect manual competence. Certifications that are based solely on reaching minimum thresholds of experience, even when accurate, are not valid reflections of manual competence,^15,40-43 and neither are those based on self-perception.⁴⁴ Patient-based assessments are, thus, necessary to ensure manual competence.^45-48

Certification Assessments of Manual Competence Should Combine 2 Types of Structured Instruments: Checklists and Overall Scores

Assessments based on direct observation are more reliable when formally structured.^49,50 Though checklists used in observed structured clinical examinations capture many important manual skills,^51-56 they do not completely reflect a hospitalist’s manual competence;⁵⁷ situations may occur in which a hospitalist meets all the individual items on a checklist but cannot perform an entire procedure with basic competence. Therefore, checklists should be paired with overall scores.^58-61 Both checklists and overall scores ought to be obtained from reliable and valid instruments.

Certification Assessments Should Include Feedback

Assessments without feedback are missed learning opportunities.⁶² Both simulation-⁶³ and patient-based assessments should provide feedback in real time to reinforce effective behaviors and remedy faulty ones.

If Remedial Training is Needed, Simulator-Based Training Can Supplement but Not Replace Patient-Based Training

Supervised simulator-based training allows hospitalists to master basic components of a procedure⁶⁴ (including orientation to equipment, sequence of operations, dexterity, ultrasound anatomy, and real-time guidance technique) while improving both cognitive and manual skills.^42,43,65-71 In addition to their role in basic training (which is outside the scope of this position statement), simulators can be useful for remedial training. To be sufficient for hospitalists who do not pass their patient-based assessments, however, remedial training that begins with simulation must also include patient-based training and assessment.^72-75

Initial Credentialing Process

A Minimum Threshold of Experience Should Be Reached before Patient-Based Assessments are Conducted (Figure 1)

Initial Certification Assessments Should Ideally Begin on Simulators

Simulators allow the assurance of safe manual skills, including proper needle insertion techniques and disposal of sharp objects.^3,79 If simulators are not available, however, then patient-based training and assessments can still be performed under direct observation. Safe performance of ultrasound-guided procedures during patient-based assessments (without preceding simulator-based assessments) is sufficient to certify manual competence.

Ongoing Credentialing

Certification to Perform Ultrasound-Guided Procedures Should Be Routinely Re-Evaluated During Ongoing Credentialing (Figure 2)

Observed Patient-Based Assessments Should Occur When a Periprocedural Safety Event Occurs that is Potentially Caused by “Provider Error”

Safety events include both near misses and adverse events. Information about both is ideally “flagged” and “pushed” to hospitalist group leaders by active surveillance and reporting systems. Once reviewed, if a safety event is considered to potentially have been caused by provider error (including knowledge- and skill-based errors),⁸³ then the provider who performed the procedure should undergo an observed patient-based assessment.

Simulation-Based Practice Can Supplement Patient-Based Experience for Ongoing Credentialing

When hospitalists do not achieve a minimum threshold of patient-based experience since the antecedent certification, simulation-based training can supplement their patient-based experience.⁸⁴ In these cases, however, an observed patient-based assessment must occur. Another consideration is whether or not the privilege should be relinquished because of an infrequent need.

Credentialing Infrastructure

Hospitalists Themselves Should Not Bear the Financial Costs of Developing and Maintaining Training and Certification Programs for Ultrasound-Guided Procedures

Equipment and personnel costs^85,86 commonly impede ultrasound-guided procedure programs.^4,87,88 Hospitalists whose job descriptions include the performance of ultrasound-guided procedures should not be expected to bear the costs of ultrasound machines, image archival software, equipment maintenance, and initial and ongoing training and certification.

Assessors Should Be Unbiased Expert Providers Who Have Demonstrated Mastery in Performance of the Procedure Being Assessed and Regularly Perform It in a Similar Practice Environment

Assessors should be expert providers who regularly perform the ultrasound-guided procedure in a similar practice environment.^9,89-94 For example, providers who are not hospitalists but who are experts in an ultrasound-guided procedure and commonly perform it on the hospital wards would be acceptable assessors. However, a radiologist who only performs that procedure in a fully-staffed interventional radiology suite with fluoroscopy or computed tomography guidance would not be an acceptable assessor. More than 1 assessor may balance idiosyncratic assessments;⁹⁵ but when assessments are well structured, additional assessors are generally not needed.¹⁸Candidate assessors should be vetted by the hospitalist group leader and the hospital privileging committee.

If Intramural Assessors Are Not Available, Extramural Assessors May Be Considered

Intramural assessors are generally preferred because of familiarity with the local practice environment, including the available procedure kits and typical patient characteristics. Nevertheless, extramural assessors^27,77,85,96 may theoretically provide even more valid assessments than intramural ones because extramural assessors are neither influenced by relationships with local hospitalists nor biased by local hospitalists’ skills.^97,98 Remote performance assessment through video recordings⁹⁹ or live-video streaming is another option¹⁰⁰ but is not sufficient unless a room camera is available to simultaneously view probe movement and the ultrasound screen.¹⁰¹ In addition, remote assessment does not allow the assessor to physically assume control of the procedure to either salvage it or perhaps, in some cases, prevent a complication.

There are no high-quality randomized trials in support of a single credentialing pathway over any other.^94,102 The credentialing pathways at the center of this position statement are based on expert opinion. Our methods can be criticized straightaway, therefore, for reliance on the experience and expertise of our working group and task force. Any position statement written without high-quality supportive evidence would be appropriately subject to the same criticism. Without evidence in support of an overall pathway, we codified specific aspects of the pathways into 16 individual recommendations.

Patient-level outcomes do not back these recommendations. Consider, for example, our recommendation that certification assessments be made from structured instruments and not simply from an assessor’s gestalt. Here, the basis is not improved patient-level outcomes from a trial (such as reduced complications or increased procedural success) but improved psychometric performance from reliability studies. The body of evidence for our recommendations is similarly indirect, mostly because the outcomes studied are more proximate and, thus, less meaningful than patient-level outcomes, which are the outcomes of greatest interest but are woefully understudied for clinical competence.^17,97,103

The need for high-quality evidence is most pronounced in distinguishing how recommendations should be modified for various settings. Wide variations in resources and patient-mix will make some recommendations impracticable, meaning that they could not be carried out with available resources. For example, our recommendation that credentialing decisions should ultimately rely on certifications made by assessors during patient-based assessments may not be practicable at small, rural hospitals. Such hospitals may not have access to local assessors, and they may not admit enough patients who need the types of ultrasound-guided procedures for which hospitalists seek certification (especially given the need to coordinate the schedules of patients, procedure-performing hospitalists, and assessors). Collaborative efforts between hospitals for regional certification may be a potential solution to consider. But if recommendations are truly impracticable, the task force recognizes they may need to be modified. Given the low quality of evidence supporting our recommendations, such modifications would be readily defendable, especially if they emerged from collaborative discussions between privileging committees, hospitalist directors, and local experts.

One way for hospitals to implement our recommendations may be to follow a recommendation proposed by the authors of the original hospitalist core competencies over a decade ago: “The presence of a procedural skill in the Core Competencies does not necessarily indicate that every hospitalist will perform or be proficient in that procedure.”¹⁰⁴ In other words, bedside procedures may be delegated to some but not all hospitalists. Such “proceduralists” would have some proportion of their clinical responsibility dedicated to performing procedures. Delineation of this job description must be made locally because it balances 2 hospital-specific characteristics: patients’ needs for procedures against the availability of providers with basic competence to perform them, which includes hospitalists but also emergency medicine physicians, specialists, and interventional radiologists. A salutary benefit for hospitals is that hospitalists who are not proceduralists would not need to undergo certification in basic competence for the bedside procedures they will not be performing.

Regardless of whether some or all hospitalists at a particular hospital are expected to perform bedside procedures, technology may help to improve the practicability of our recommendations. For example, simulators may evolve to replace actual patient-level experience in achieving minimum thresholds. Certification assessments of manual skills may even someday occur entirely on simulators. Real-time high-definition video streaming enhanced with multiple cameras may allow for remote assessments. Until such advances mature, high-quality patient-level data should be sought through additional research to refine our current recommendations.

We hope that these recommendations will improve how basic competence in ultrasound-guided bedside procedures is assessed. Our ultimate goal is to improve how hospitalists perform these procedures. Patient safety is, therefore, considered paramount to cost. Nevertheless, the hospital administrative leaders and privileging committee members on our Task Force concluded that many hospitals have been seeking guidance on credentialing for bedside procedures, and the likely difficulties of implementing our recommendations (including cost) would not be prohibitive at most hospitals, especially given recognition that these recommendations can be tailored to each setting.

Collaborators from SHM POCUS Task Force are Saaid Abdel-Ghani, Michael Blaivas, Dan Brotman, Carolina Candotti, Jagriti Chadha, Joel Cho, Ria Dancel, Ricardo Franco, Richard Hoppmann, Susan Hunt, Venkat Kalidindi, Ketino Kobaidze, Josh Lenchus, Benji Mathews, Satyen Nichani, Vicki Noble, Martin Perez, Nitin Puri, Aliaksei Pustavoitau, Sophia Rodgers, Gerard Salame, Daniel Schnobrich, Kirk Spencer, Vivek Tayal, Jeff Bates, Anjali Bhagra, Kreegan Reierson, Robert Arntfield, Paul Mayo, Loretta Grikis.

Disclosure

Brian P. Lucas received funding from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, and National Center for Translational Science (UL1TR001086). Nilam Soni received funding from the Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative (HX002263-01A1). The contents of this publication do not represent the views of the United States Department of Veterans Affairs or the United States Government.

The American Board of Internal Medicine (ABIM) changed its certification policy for bedside procedures over a decade ago.¹ Acquiring manual competence in abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis is no longer an expectation of residency training. ABIM diplomates should “know” these procedures but not necessarily “do” them. Hospitalists, most of whom are themselves ABIM diplomates, are still, however, expected to do them as core competencies,²perhaps because hospitalists are often available off-hours, when roughly half of bedside procedures are performed.³

Hospitalists increasingly perform bedside procedures with ultrasound guidance.⁴ Yet training in ultrasound guidance is significantly varied as well,⁵ simply because point-of-care ultrasound (POCUS) has only recently become widespread.⁶ And though some skills are transferrable from landmark-guided to ultrasound -guided procedures, many are not.^7-10 Furthermore, ultrasound guidance is often not explicitly delineated on the privileging forms used by hospitals,¹¹ even where ultrasound guidance has become standard.¹²

Working Group Formation

In January 2015, the SHM Board of Directors asked the SHM Education Committee to convene the POCUS Task Force. The purpose of the task force was to develop recommendations on ultrasound guidance for bedside procedures. The SHM Education Committee appointed 3 chairs of the task force: 1 senior member of the SHM Education Committee and 2 POCUS experts. The chairs assembled a task force of 31 members that included 5 working groups, a multispecialty peer review group, and a guideline methodologist (supplemental Appendix 1). Invitation was based on members’ past contributions to SHM POCUS-related activities, up-front commitment, and declared conflicts of interest. Working group members self-identified as “hospitalists,” whereas peer reviewers were nonhospitalists but nationally recognized POCUS physician-leaders specializing in emergency medicine, cardiology, critical care medicine, and anesthesiology. Task force membership was vetted by a chair of the SHM POCUS Task Force and the Director of Education before work began. This position statement was authored by the Credentialing Working Group together with the chairs of the other 4 working groups and a guideline methodologist.

Disclosures

Signed disclosure statements of all task force members were reviewed prior to inclusion on the task force (supplemental Appendix 2); no members received honoraria for participation. Industry representatives did not contribute to the development of the guidelines nor to any conference calls or meetings.

Literature Search Strategy

A literature search was conducted by a biomedical librarian. Records from 1979 to January of 2017 were searched in Medline, Embase, CINAHL, Cochrane, and Google Scholar (supplemental Appendix 3). Search limiters were English language and adults. Articles were manually screened to exclude nonhuman or endoscopic ultrasound applications. Final article selection was based on working group consensus.

Draft Pathways

The Credentialing Working Group drafted initial and ongoing certification pathways (Figure 1 and Figure 2). The other 4 working groups from the task force were surveyed about the elements and overall appropriateness of these draft pathways. This survey and its results have already been published.¹² The Credentialing Working Group then revised the certification pathways by using these survey results and codified individual aspects of these pathways into recommendations.

Development of Position Statement

Based on the Grading of Recommendation Assessment Development and Evaluation methodology, all final article selections were initially rated as either low-quality (observational studies) or unclassifiable (expert opinion).¹⁶ These initial ratings were downgraded further because of indirectness, because none of the articles involved the intervention of interest (a credentialing pathway) in a population of interest (hospitalists) measuring the outcomes of interest (patient-level outcomes).¹⁷ Given the universal low-quality evidence ratings, we altered the task force strategy of developing guidelines, which the other 4 working groups are writing, and instead developed a position statement by using consensus gathering in 3 steps.

First, the Credentialing Working Group drafted an initial position statement composed of recommendations for credentialing pathways and other general aspects of credentialing. All final article selections were incorporated as references in a draft of the position statement and compiled in a full-text compendium. Second, feedback was provided by the other 4 task force working groups, the task force peer reviewers, and the SHM Education Committee. Feedback was incorporated by the authors of this statement who were the Credentialing Working Group, the chairs of the other 4 working groups, and a guideline methodologist. Third, final suggestions from all members of the SHM POCUS Task Force and SHM Education Committee were incorporated before final approval by the SHM Board of Directors in September 2017.

A total of 1438 references were identified in the original search. Manual selection led to 101 articles, which were incorporated into the following 4 domains with 16 recommendations.

General Credentialing Process

Basic Cognitive Competence Can Be Certified with Written or Oral Examinations

The ABIM defines cognitive competence as having 3 abilities: “(1) to explain indications, contraindications, patient preparation methods, sterile techniques, pain management, proper techniques for handling specimens and fluids obtained, and test results; (2) to recognize and manage complications; and, (3) to clearly explain to a patient all facets of the procedure necessary to obtain informed consent.”¹ These abilities can be assessed with written or oral examinations that may be integrated into simulation- or patient-based assessments.^18-21

Minimum Thresholds of Experience to Trigger the Timing of a Patient-Based Assessment Should Be Determined by Empirical Methods

Learning curves are highly variable^22-25 and even plateaus may not herald basic competence.²⁶ Expert opinions²⁷ can be used to establish minimum thresholds of experience, but such opinions may paradoxically exceed the current thresholds of experts’ own hospitals.¹² Thus, empirical methods, such as those based on cumulative sum analysis^28-30 or local learning curves,^31,32 are preferred. If such methods are not available, a recent survey of hospitalist experts may provide guidance.¹² Regardless, once established, minimum thresholds are necessary but not sufficient to determine competency (see “Basic manual competence must be certified through patient-based assessments” section).

Hospitalists Should Formally Log All of Their Attempted Procedures, Ideally in an Electronic Medical Record

Simple self-reported numbers of procedures performed often misrepresent actual experience^33,34 and do not include periprocedural complications.^35,36 Thus, hospitalists should report their experience with logs of all attempted procedures, both successful and unsuccessful. Such logs must include information about supervising providers (if applicable) and patient outcomes, including periprocedural adverse events,³⁷ but they must also remain compliant with the Health Insurance Portability and Accountability Act.

Health Information Technology Service Should Routinely Pull Collations of All Attempted Procedures from Comprehensive Electronic Medical Records

Active surveillance may reduce complications by identifying hospitalists who may benefit from further training.³⁸ In order to facilitate active surveillance systems, documentation (such as a procedure note) should be both integrated into an electronic medical record and protocol driven,³⁹ including procedure technique, ultrasound findings, and any safety events (both near misses and adverse events).

Basic Manual Competence Must Be Certified Through Patient-Based Assessments

Multiple interacting factors, including environment, patients, baseline skills, training, experience, and skills decay, affect manual competence. Certifications that are based solely on reaching minimum thresholds of experience, even when accurate, are not valid reflections of manual competence,^15,40-43 and neither are those based on self-perception.⁴⁴ Patient-based assessments are, thus, necessary to ensure manual competence.^45-48

Certification Assessments of Manual Competence Should Combine 2 Types of Structured Instruments: Checklists and Overall Scores

Assessments based on direct observation are more reliable when formally structured.^49,50 Though checklists used in observed structured clinical examinations capture many important manual skills,^51-56 they do not completely reflect a hospitalist’s manual competence;⁵⁷ situations may occur in which a hospitalist meets all the individual items on a checklist but cannot perform an entire procedure with basic competence. Therefore, checklists should be paired with overall scores.^58-61 Both checklists and overall scores ought to be obtained from reliable and valid instruments.

Certification Assessments Should Include Feedback

Assessments without feedback are missed learning opportunities.⁶² Both simulation-⁶³ and patient-based assessments should provide feedback in real time to reinforce effective behaviors and remedy faulty ones.

If Remedial Training is Needed, Simulator-Based Training Can Supplement but Not Replace Patient-Based Training

Supervised simulator-based training allows hospitalists to master basic components of a procedure⁶⁴ (including orientation to equipment, sequence of operations, dexterity, ultrasound anatomy, and real-time guidance technique) while improving both cognitive and manual skills.^42,43,65-71 In addition to their role in basic training (which is outside the scope of this position statement), simulators can be useful for remedial training. To be sufficient for hospitalists who do not pass their patient-based assessments, however, remedial training that begins with simulation must also include patient-based training and assessment.^72-75

Initial Credentialing Process

A Minimum Threshold of Experience Should Be Reached before Patient-Based Assessments are Conducted (Figure 1)

Initial Certification Assessments Should Ideally Begin on Simulators

Simulators allow the assurance of safe manual skills, including proper needle insertion techniques and disposal of sharp objects.^3,79 If simulators are not available, however, then patient-based training and assessments can still be performed under direct observation. Safe performance of ultrasound-guided procedures during patient-based assessments (without preceding simulator-based assessments) is sufficient to certify manual competence.

Ongoing Credentialing

Certification to Perform Ultrasound-Guided Procedures Should Be Routinely Re-Evaluated During Ongoing Credentialing (Figure 2)

Observed Patient-Based Assessments Should Occur When a Periprocedural Safety Event Occurs that is Potentially Caused by “Provider Error”

Safety events include both near misses and adverse events. Information about both is ideally “flagged” and “pushed” to hospitalist group leaders by active surveillance and reporting systems. Once reviewed, if a safety event is considered to potentially have been caused by provider error (including knowledge- and skill-based errors),⁸³ then the provider who performed the procedure should undergo an observed patient-based assessment.

Simulation-Based Practice Can Supplement Patient-Based Experience for Ongoing Credentialing

When hospitalists do not achieve a minimum threshold of patient-based experience since the antecedent certification, simulation-based training can supplement their patient-based experience.⁸⁴ In these cases, however, an observed patient-based assessment must occur. Another consideration is whether or not the privilege should be relinquished because of an infrequent need.

Credentialing Infrastructure

Hospitalists Themselves Should Not Bear the Financial Costs of Developing and Maintaining Training and Certification Programs for Ultrasound-Guided Procedures

Equipment and personnel costs^85,86 commonly impede ultrasound-guided procedure programs.^4,87,88 Hospitalists whose job descriptions include the performance of ultrasound-guided procedures should not be expected to bear the costs of ultrasound machines, image archival software, equipment maintenance, and initial and ongoing training and certification.

Assessors Should Be Unbiased Expert Providers Who Have Demonstrated Mastery in Performance of the Procedure Being Assessed and Regularly Perform It in a Similar Practice Environment

Assessors should be expert providers who regularly perform the ultrasound-guided procedure in a similar practice environment.^9,89-94 For example, providers who are not hospitalists but who are experts in an ultrasound-guided procedure and commonly perform it on the hospital wards would be acceptable assessors. However, a radiologist who only performs that procedure in a fully-staffed interventional radiology suite with fluoroscopy or computed tomography guidance would not be an acceptable assessor. More than 1 assessor may balance idiosyncratic assessments;⁹⁵ but when assessments are well structured, additional assessors are generally not needed.¹⁸Candidate assessors should be vetted by the hospitalist group leader and the hospital privileging committee.

If Intramural Assessors Are Not Available, Extramural Assessors May Be Considered

Intramural assessors are generally preferred because of familiarity with the local practice environment, including the available procedure kits and typical patient characteristics. Nevertheless, extramural assessors^27,77,85,96 may theoretically provide even more valid assessments than intramural ones because extramural assessors are neither influenced by relationships with local hospitalists nor biased by local hospitalists’ skills.^97,98 Remote performance assessment through video recordings⁹⁹ or live-video streaming is another option¹⁰⁰ but is not sufficient unless a room camera is available to simultaneously view probe movement and the ultrasound screen.¹⁰¹ In addition, remote assessment does not allow the assessor to physically assume control of the procedure to either salvage it or perhaps, in some cases, prevent a complication.

There are no high-quality randomized trials in support of a single credentialing pathway over any other.^94,102 The credentialing pathways at the center of this position statement are based on expert opinion. Our methods can be criticized straightaway, therefore, for reliance on the experience and expertise of our working group and task force. Any position statement written without high-quality supportive evidence would be appropriately subject to the same criticism. Without evidence in support of an overall pathway, we codified specific aspects of the pathways into 16 individual recommendations.

Patient-level outcomes do not back these recommendations. Consider, for example, our recommendation that certification assessments be made from structured instruments and not simply from an assessor’s gestalt. Here, the basis is not improved patient-level outcomes from a trial (such as reduced complications or increased procedural success) but improved psychometric performance from reliability studies. The body of evidence for our recommendations is similarly indirect, mostly because the outcomes studied are more proximate and, thus, less meaningful than patient-level outcomes, which are the outcomes of greatest interest but are woefully understudied for clinical competence.^17,97,103

The need for high-quality evidence is most pronounced in distinguishing how recommendations should be modified for various settings. Wide variations in resources and patient-mix will make some recommendations impracticable, meaning that they could not be carried out with available resources. For example, our recommendation that credentialing decisions should ultimately rely on certifications made by assessors during patient-based assessments may not be practicable at small, rural hospitals. Such hospitals may not have access to local assessors, and they may not admit enough patients who need the types of ultrasound-guided procedures for which hospitalists seek certification (especially given the need to coordinate the schedules of patients, procedure-performing hospitalists, and assessors). Collaborative efforts between hospitals for regional certification may be a potential solution to consider. But if recommendations are truly impracticable, the task force recognizes they may need to be modified. Given the low quality of evidence supporting our recommendations, such modifications would be readily defendable, especially if they emerged from collaborative discussions between privileging committees, hospitalist directors, and local experts.

One way for hospitals to implement our recommendations may be to follow a recommendation proposed by the authors of the original hospitalist core competencies over a decade ago: “The presence of a procedural skill in the Core Competencies does not necessarily indicate that every hospitalist will perform or be proficient in that procedure.”¹⁰⁴ In other words, bedside procedures may be delegated to some but not all hospitalists. Such “proceduralists” would have some proportion of their clinical responsibility dedicated to performing procedures. Delineation of this job description must be made locally because it balances 2 hospital-specific characteristics: patients’ needs for procedures against the availability of providers with basic competence to perform them, which includes hospitalists but also emergency medicine physicians, specialists, and interventional radiologists. A salutary benefit for hospitals is that hospitalists who are not proceduralists would not need to undergo certification in basic competence for the bedside procedures they will not be performing.

Regardless of whether some or all hospitalists at a particular hospital are expected to perform bedside procedures, technology may help to improve the practicability of our recommendations. For example, simulators may evolve to replace actual patient-level experience in achieving minimum thresholds. Certification assessments of manual skills may even someday occur entirely on simulators. Real-time high-definition video streaming enhanced with multiple cameras may allow for remote assessments. Until such advances mature, high-quality patient-level data should be sought through additional research to refine our current recommendations.

We hope that these recommendations will improve how basic competence in ultrasound-guided bedside procedures is assessed. Our ultimate goal is to improve how hospitalists perform these procedures. Patient safety is, therefore, considered paramount to cost. Nevertheless, the hospital administrative leaders and privileging committee members on our Task Force concluded that many hospitals have been seeking guidance on credentialing for bedside procedures, and the likely difficulties of implementing our recommendations (including cost) would not be prohibitive at most hospitals, especially given recognition that these recommendations can be tailored to each setting.

Collaborators from SHM POCUS Task Force are Saaid Abdel-Ghani, Michael Blaivas, Dan Brotman, Carolina Candotti, Jagriti Chadha, Joel Cho, Ria Dancel, Ricardo Franco, Richard Hoppmann, Susan Hunt, Venkat Kalidindi, Ketino Kobaidze, Josh Lenchus, Benji Mathews, Satyen Nichani, Vicki Noble, Martin Perez, Nitin Puri, Aliaksei Pustavoitau, Sophia Rodgers, Gerard Salame, Daniel Schnobrich, Kirk Spencer, Vivek Tayal, Jeff Bates, Anjali Bhagra, Kreegan Reierson, Robert Arntfield, Paul Mayo, Loretta Grikis.

Disclosure

Brian P. Lucas received funding from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, and National Center for Translational Science (UL1TR001086). Nilam Soni received funding from the Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative (HX002263-01A1). The contents of this publication do not represent the views of the United States Department of Veterans Affairs or the United States Government.

The American Board of Internal Medicine (ABIM) changed its certification policy for bedside procedures over a decade ago.¹ Acquiring manual competence in abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis is no longer an expectation of residency training. ABIM diplomates should “know” these procedures but not necessarily “do” them. Hospitalists, most of whom are themselves ABIM diplomates, are still, however, expected to do them as core competencies,²perhaps because hospitalists are often available off-hours, when roughly half of bedside procedures are performed.³

Hospitalists increasingly perform bedside procedures with ultrasound guidance.⁴ Yet training in ultrasound guidance is significantly varied as well,⁵ simply because point-of-care ultrasound (POCUS) has only recently become widespread.⁶ And though some skills are transferrable from landmark-guided to ultrasound -guided procedures, many are not.^7-10 Furthermore, ultrasound guidance is often not explicitly delineated on the privileging forms used by hospitals,¹¹ even where ultrasound guidance has become standard.¹²

Working Group Formation

In January 2015, the SHM Board of Directors asked the SHM Education Committee to convene the POCUS Task Force. The purpose of the task force was to develop recommendations on ultrasound guidance for bedside procedures. The SHM Education Committee appointed 3 chairs of the task force: 1 senior member of the SHM Education Committee and 2 POCUS experts. The chairs assembled a task force of 31 members that included 5 working groups, a multispecialty peer review group, and a guideline methodologist (supplemental Appendix 1). Invitation was based on members’ past contributions to SHM POCUS-related activities, up-front commitment, and declared conflicts of interest. Working group members self-identified as “hospitalists,” whereas peer reviewers were nonhospitalists but nationally recognized POCUS physician-leaders specializing in emergency medicine, cardiology, critical care medicine, and anesthesiology. Task force membership was vetted by a chair of the SHM POCUS Task Force and the Director of Education before work began. This position statement was authored by the Credentialing Working Group together with the chairs of the other 4 working groups and a guideline methodologist.

Disclosures

Signed disclosure statements of all task force members were reviewed prior to inclusion on the task force (supplemental Appendix 2); no members received honoraria for participation. Industry representatives did not contribute to the development of the guidelines nor to any conference calls or meetings.

Literature Search Strategy

A literature search was conducted by a biomedical librarian. Records from 1979 to January of 2017 were searched in Medline, Embase, CINAHL, Cochrane, and Google Scholar (supplemental Appendix 3). Search limiters were English language and adults. Articles were manually screened to exclude nonhuman or endoscopic ultrasound applications. Final article selection was based on working group consensus.

Draft Pathways

The Credentialing Working Group drafted initial and ongoing certification pathways (Figure 1 and Figure 2). The other 4 working groups from the task force were surveyed about the elements and overall appropriateness of these draft pathways. This survey and its results have already been published.¹² The Credentialing Working Group then revised the certification pathways by using these survey results and codified individual aspects of these pathways into recommendations.

Development of Position Statement

Based on the Grading of Recommendation Assessment Development and Evaluation methodology, all final article selections were initially rated as either low-quality (observational studies) or unclassifiable (expert opinion).¹⁶ These initial ratings were downgraded further because of indirectness, because none of the articles involved the intervention of interest (a credentialing pathway) in a population of interest (hospitalists) measuring the outcomes of interest (patient-level outcomes).¹⁷ Given the universal low-quality evidence ratings, we altered the task force strategy of developing guidelines, which the other 4 working groups are writing, and instead developed a position statement by using consensus gathering in 3 steps.

First, the Credentialing Working Group drafted an initial position statement composed of recommendations for credentialing pathways and other general aspects of credentialing. All final article selections were incorporated as references in a draft of the position statement and compiled in a full-text compendium. Second, feedback was provided by the other 4 task force working groups, the task force peer reviewers, and the SHM Education Committee. Feedback was incorporated by the authors of this statement who were the Credentialing Working Group, the chairs of the other 4 working groups, and a guideline methodologist. Third, final suggestions from all members of the SHM POCUS Task Force and SHM Education Committee were incorporated before final approval by the SHM Board of Directors in September 2017.

A total of 1438 references were identified in the original search. Manual selection led to 101 articles, which were incorporated into the following 4 domains with 16 recommendations.

General Credentialing Process

Basic Cognitive Competence Can Be Certified with Written or Oral Examinations

The ABIM defines cognitive competence as having 3 abilities: “(1) to explain indications, contraindications, patient preparation methods, sterile techniques, pain management, proper techniques for handling specimens and fluids obtained, and test results; (2) to recognize and manage complications; and, (3) to clearly explain to a patient all facets of the procedure necessary to obtain informed consent.”¹ These abilities can be assessed with written or oral examinations that may be integrated into simulation- or patient-based assessments.^18-21

Minimum Thresholds of Experience to Trigger the Timing of a Patient-Based Assessment Should Be Determined by Empirical Methods

Learning curves are highly variable^22-25 and even plateaus may not herald basic competence.²⁶ Expert opinions²⁷ can be used to establish minimum thresholds of experience, but such opinions may paradoxically exceed the current thresholds of experts’ own hospitals.¹² Thus, empirical methods, such as those based on cumulative sum analysis^28-30 or local learning curves,^31,32 are preferred. If such methods are not available, a recent survey of hospitalist experts may provide guidance.¹² Regardless, once established, minimum thresholds are necessary but not sufficient to determine competency (see “Basic manual competence must be certified through patient-based assessments” section).

Hospitalists Should Formally Log All of Their Attempted Procedures, Ideally in an Electronic Medical Record

Simple self-reported numbers of procedures performed often misrepresent actual experience^33,34 and do not include periprocedural complications.^35,36 Thus, hospitalists should report their experience with logs of all attempted procedures, both successful and unsuccessful. Such logs must include information about supervising providers (if applicable) and patient outcomes, including periprocedural adverse events,³⁷ but they must also remain compliant with the Health Insurance Portability and Accountability Act.

Health Information Technology Service Should Routinely Pull Collations of All Attempted Procedures from Comprehensive Electronic Medical Records

Active surveillance may reduce complications by identifying hospitalists who may benefit from further training.³⁸ In order to facilitate active surveillance systems, documentation (such as a procedure note) should be both integrated into an electronic medical record and protocol driven,³⁹ including procedure technique, ultrasound findings, and any safety events (both near misses and adverse events).

Basic Manual Competence Must Be Certified Through Patient-Based Assessments

Multiple interacting factors, including environment, patients, baseline skills, training, experience, and skills decay, affect manual competence. Certifications that are based solely on reaching minimum thresholds of experience, even when accurate, are not valid reflections of manual competence,^15,40-43 and neither are those based on self-perception.⁴⁴ Patient-based assessments are, thus, necessary to ensure manual competence.^45-48

Certification Assessments of Manual Competence Should Combine 2 Types of Structured Instruments: Checklists and Overall Scores

Assessments based on direct observation are more reliable when formally structured.^49,50 Though checklists used in observed structured clinical examinations capture many important manual skills,^51-56 they do not completely reflect a hospitalist’s manual competence;⁵⁷ situations may occur in which a hospitalist meets all the individual items on a checklist but cannot perform an entire procedure with basic competence. Therefore, checklists should be paired with overall scores.^58-61 Both checklists and overall scores ought to be obtained from reliable and valid instruments.

Certification Assessments Should Include Feedback

Assessments without feedback are missed learning opportunities.⁶² Both simulation-⁶³ and patient-based assessments should provide feedback in real time to reinforce effective behaviors and remedy faulty ones.

If Remedial Training is Needed, Simulator-Based Training Can Supplement but Not Replace Patient-Based Training

Supervised simulator-based training allows hospitalists to master basic components of a procedure⁶⁴ (including orientation to equipment, sequence of operations, dexterity, ultrasound anatomy, and real-time guidance technique) while improving both cognitive and manual skills.^42,43,65-71 In addition to their role in basic training (which is outside the scope of this position statement), simulators can be useful for remedial training. To be sufficient for hospitalists who do not pass their patient-based assessments, however, remedial training that begins with simulation must also include patient-based training and assessment.^72-75

Initial Credentialing Process

A Minimum Threshold of Experience Should Be Reached before Patient-Based Assessments are Conducted (Figure 1)

Initial Certification Assessments Should Ideally Begin on Simulators

Simulators allow the assurance of safe manual skills, including proper needle insertion techniques and disposal of sharp objects.^3,79 If simulators are not available, however, then patient-based training and assessments can still be performed under direct observation. Safe performance of ultrasound-guided procedures during patient-based assessments (without preceding simulator-based assessments) is sufficient to certify manual competence.

Ongoing Credentialing

Certification to Perform Ultrasound-Guided Procedures Should Be Routinely Re-Evaluated During Ongoing Credentialing (Figure 2)

Observed Patient-Based Assessments Should Occur When a Periprocedural Safety Event Occurs that is Potentially Caused by “Provider Error”

Safety events include both near misses and adverse events. Information about both is ideally “flagged” and “pushed” to hospitalist group leaders by active surveillance and reporting systems. Once reviewed, if a safety event is considered to potentially have been caused by provider error (including knowledge- and skill-based errors),⁸³ then the provider who performed the procedure should undergo an observed patient-based assessment.

Simulation-Based Practice Can Supplement Patient-Based Experience for Ongoing Credentialing

When hospitalists do not achieve a minimum threshold of patient-based experience since the antecedent certification, simulation-based training can supplement their patient-based experience.⁸⁴ In these cases, however, an observed patient-based assessment must occur. Another consideration is whether or not the privilege should be relinquished because of an infrequent need.

Credentialing Infrastructure

Hospitalists Themselves Should Not Bear the Financial Costs of Developing and Maintaining Training and Certification Programs for Ultrasound-Guided Procedures

Equipment and personnel costs^85,86 commonly impede ultrasound-guided procedure programs.^4,87,88 Hospitalists whose job descriptions include the performance of ultrasound-guided procedures should not be expected to bear the costs of ultrasound machines, image archival software, equipment maintenance, and initial and ongoing training and certification.

Assessors Should Be Unbiased Expert Providers Who Have Demonstrated Mastery in Performance of the Procedure Being Assessed and Regularly Perform It in a Similar Practice Environment

Assessors should be expert providers who regularly perform the ultrasound-guided procedure in a similar practice environment.^9,89-94 For example, providers who are not hospitalists but who are experts in an ultrasound-guided procedure and commonly perform it on the hospital wards would be acceptable assessors. However, a radiologist who only performs that procedure in a fully-staffed interventional radiology suite with fluoroscopy or computed tomography guidance would not be an acceptable assessor. More than 1 assessor may balance idiosyncratic assessments;⁹⁵ but when assessments are well structured, additional assessors are generally not needed.¹⁸Candidate assessors should be vetted by the hospitalist group leader and the hospital privileging committee.

If Intramural Assessors Are Not Available, Extramural Assessors May Be Considered

Intramural assessors are generally preferred because of familiarity with the local practice environment, including the available procedure kits and typical patient characteristics. Nevertheless, extramural assessors^27,77,85,96 may theoretically provide even more valid assessments than intramural ones because extramural assessors are neither influenced by relationships with local hospitalists nor biased by local hospitalists’ skills.^97,98 Remote performance assessment through video recordings⁹⁹ or live-video streaming is another option¹⁰⁰ but is not sufficient unless a room camera is available to simultaneously view probe movement and the ultrasound screen.¹⁰¹ In addition, remote assessment does not allow the assessor to physically assume control of the procedure to either salvage it or perhaps, in some cases, prevent a complication.

There are no high-quality randomized trials in support of a single credentialing pathway over any other.^94,102 The credentialing pathways at the center of this position statement are based on expert opinion. Our methods can be criticized straightaway, therefore, for reliance on the experience and expertise of our working group and task force. Any position statement written without high-quality supportive evidence would be appropriately subject to the same criticism. Without evidence in support of an overall pathway, we codified specific aspects of the pathways into 16 individual recommendations.

Patient-level outcomes do not back these recommendations. Consider, for example, our recommendation that certification assessments be made from structured instruments and not simply from an assessor’s gestalt. Here, the basis is not improved patient-level outcomes from a trial (such as reduced complications or increased procedural success) but improved psychometric performance from reliability studies. The body of evidence for our recommendations is similarly indirect, mostly because the outcomes studied are more proximate and, thus, less meaningful than patient-level outcomes, which are the outcomes of greatest interest but are woefully understudied for clinical competence.^17,97,103

The need for high-quality evidence is most pronounced in distinguishing how recommendations should be modified for various settings. Wide variations in resources and patient-mix will make some recommendations impracticable, meaning that they could not be carried out with available resources. For example, our recommendation that credentialing decisions should ultimately rely on certifications made by assessors during patient-based assessments may not be practicable at small, rural hospitals. Such hospitals may not have access to local assessors, and they may not admit enough patients who need the types of ultrasound-guided procedures for which hospitalists seek certification (especially given the need to coordinate the schedules of patients, procedure-performing hospitalists, and assessors). Collaborative efforts between hospitals for regional certification may be a potential solution to consider. But if recommendations are truly impracticable, the task force recognizes they may need to be modified. Given the low quality of evidence supporting our recommendations, such modifications would be readily defendable, especially if they emerged from collaborative discussions between privileging committees, hospitalist directors, and local experts.

One way for hospitals to implement our recommendations may be to follow a recommendation proposed by the authors of the original hospitalist core competencies over a decade ago: “The presence of a procedural skill in the Core Competencies does not necessarily indicate that every hospitalist will perform or be proficient in that procedure.”¹⁰⁴ In other words, bedside procedures may be delegated to some but not all hospitalists. Such “proceduralists” would have some proportion of their clinical responsibility dedicated to performing procedures. Delineation of this job description must be made locally because it balances 2 hospital-specific characteristics: patients’ needs for procedures against the availability of providers with basic competence to perform them, which includes hospitalists but also emergency medicine physicians, specialists, and interventional radiologists. A salutary benefit for hospitals is that hospitalists who are not proceduralists would not need to undergo certification in basic competence for the bedside procedures they will not be performing.

Regardless of whether some or all hospitalists at a particular hospital are expected to perform bedside procedures, technology may help to improve the practicability of our recommendations. For example, simulators may evolve to replace actual patient-level experience in achieving minimum thresholds. Certification assessments of manual skills may even someday occur entirely on simulators. Real-time high-definition video streaming enhanced with multiple cameras may allow for remote assessments. Until such advances mature, high-quality patient-level data should be sought through additional research to refine our current recommendations.

We hope that these recommendations will improve how basic competence in ultrasound-guided bedside procedures is assessed. Our ultimate goal is to improve how hospitalists perform these procedures. Patient safety is, therefore, considered paramount to cost. Nevertheless, the hospital administrative leaders and privileging committee members on our Task Force concluded that many hospitals have been seeking guidance on credentialing for bedside procedures, and the likely difficulties of implementing our recommendations (including cost) would not be prohibitive at most hospitals, especially given recognition that these recommendations can be tailored to each setting.

Collaborators from SHM POCUS Task Force are Saaid Abdel-Ghani, Michael Blaivas, Dan Brotman, Carolina Candotti, Jagriti Chadha, Joel Cho, Ria Dancel, Ricardo Franco, Richard Hoppmann, Susan Hunt, Venkat Kalidindi, Ketino Kobaidze, Josh Lenchus, Benji Mathews, Satyen Nichani, Vicki Noble, Martin Perez, Nitin Puri, Aliaksei Pustavoitau, Sophia Rodgers, Gerard Salame, Daniel Schnobrich, Kirk Spencer, Vivek Tayal, Jeff Bates, Anjali Bhagra, Kreegan Reierson, Robert Arntfield, Paul Mayo, Loretta Grikis.

Disclosure

Brian P. Lucas received funding from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, and National Center for Translational Science (UL1TR001086). Nilam Soni received funding from the Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative (HX002263-01A1). The contents of this publication do not represent the views of the United States Department of Veterans Affairs or the United States Government.

Bariatric surgery has been demonstrated to improve a host of obesity-related comorbidities, but the operation carries a risk of complications, including chronic abdominal pain and ulcers, that should acknowledged by clinicians and understood by patients, a large cohort study has shown.

Gunn Signe Jakobsen, MD, of Vestfold Hospital Trust, Tønsberg, Norway, and her colleagues wrote in an article published in JAMA, “Few studies report long-term complication rates. ... No large-scale clinical practice–based study has compared the long-term association of bariatric surgery and specialized medical obesity treatment with obesity-related somatic and mental comorbidities, nor the irrespective complication rates.”

The investigators compared outcomes from 932 patients who underwent bariatric surgery and 956 who underwent specialized medical treatment that involved either individual or group lifestyle intervention programs. The study population included 1,249 women and 639 men with an average age of 44 years and an average baseline body mass index of 44 kg/m².

The surgery patients were more likely than the medical treatment patients to have hypertension remission (absolute risk 32% vs. 12%, respectively), and less likely to develop new-onset hypertension (absolute risk 4% vs. 12%, respectively). Diabetes remission was significantly higher among surgery patients, compared with medical treatment patients (58% vs. 13%) as was the likelihood of dyslipidemia remission (43% vs. 13%). Surgery patients also were less likely to develop new-onset diabetes or dyslipidemia than the medical treatment patients.

However, more patients who underwent bariatric surgery had low ferritin levels, compared with the medical treatment patients (26% vs. 12%). The surgery patients were significantly more likely than the medical treatment patients to develop new-onset depression (adjusted relative risk, 1.5; 95% confidence interval, 1.4-1.7), anxiety and sleep disorders (aRR, 1.3; 95% CI, 1.2-1.5), and treatment with opioids (aRR, 1.3; 95% CI, 1.2-1.4). In addition, bariatric patients were more likely to have at least one additional gastrointestinal surgical procedure (aRR, 2.0; 95% CI, 1.7-2.4), an operation for intestinal obstruction (aRR, 10.5; 95% CI, 5.1-21.5), abdominal pain (aRR, 1.9; 95% CI, 1.6-2.3), and gastroduodenal ulcers (aRR, 3.4; 95% CI 2.0-5.6).

The study was limited by several factors, including selection bias of younger, heavier patients in the bariatric surgery group, the lack of data on actual weight loss, incomplete laboratory data, and a relatively homogeneous white population, the researchers noted. However, the nearly 100% follow-up over approximately 6 years adds to the strength of the findings, which suggest that “the risk for complications should be considered in the decision-making process,” for obese patients considering bariatric surgery, they said.

Dr. Jakobsen was supported by the Vestfold Hospital Trust, with no financial conflicts to disclose.

SOURCE: Jakobsen G et al. JAMA. 2018 Jan 16;319(3):291-301.

Bariatric surgery has been demonstrated to improve a host of obesity-related comorbidities, but the operation carries a risk of complications, including chronic abdominal pain and ulcers, that should acknowledged by clinicians and understood by patients, a large cohort study has shown.

Gunn Signe Jakobsen, MD, of Vestfold Hospital Trust, Tønsberg, Norway, and her colleagues wrote in an article published in JAMA, “Few studies report long-term complication rates. ... No large-scale clinical practice–based study has compared the long-term association of bariatric surgery and specialized medical obesity treatment with obesity-related somatic and mental comorbidities, nor the irrespective complication rates.”

The investigators compared outcomes from 932 patients who underwent bariatric surgery and 956 who underwent specialized medical treatment that involved either individual or group lifestyle intervention programs. The study population included 1,249 women and 639 men with an average age of 44 years and an average baseline body mass index of 44 kg/m².

The surgery patients were more likely than the medical treatment patients to have hypertension remission (absolute risk 32% vs. 12%, respectively), and less likely to develop new-onset hypertension (absolute risk 4% vs. 12%, respectively). Diabetes remission was significantly higher among surgery patients, compared with medical treatment patients (58% vs. 13%) as was the likelihood of dyslipidemia remission (43% vs. 13%). Surgery patients also were less likely to develop new-onset diabetes or dyslipidemia than the medical treatment patients.

However, more patients who underwent bariatric surgery had low ferritin levels, compared with the medical treatment patients (26% vs. 12%). The surgery patients were significantly more likely than the medical treatment patients to develop new-onset depression (adjusted relative risk, 1.5; 95% confidence interval, 1.4-1.7), anxiety and sleep disorders (aRR, 1.3; 95% CI, 1.2-1.5), and treatment with opioids (aRR, 1.3; 95% CI, 1.2-1.4). In addition, bariatric patients were more likely to have at least one additional gastrointestinal surgical procedure (aRR, 2.0; 95% CI, 1.7-2.4), an operation for intestinal obstruction (aRR, 10.5; 95% CI, 5.1-21.5), abdominal pain (aRR, 1.9; 95% CI, 1.6-2.3), and gastroduodenal ulcers (aRR, 3.4; 95% CI 2.0-5.6).

The study was limited by several factors, including selection bias of younger, heavier patients in the bariatric surgery group, the lack of data on actual weight loss, incomplete laboratory data, and a relatively homogeneous white population, the researchers noted. However, the nearly 100% follow-up over approximately 6 years adds to the strength of the findings, which suggest that “the risk for complications should be considered in the decision-making process,” for obese patients considering bariatric surgery, they said.

Dr. Jakobsen was supported by the Vestfold Hospital Trust, with no financial conflicts to disclose.

SOURCE: Jakobsen G et al. JAMA. 2018 Jan 16;319(3):291-301.

Bariatric surgery has been demonstrated to improve a host of obesity-related comorbidities, but the operation carries a risk of complications, including chronic abdominal pain and ulcers, that should acknowledged by clinicians and understood by patients, a large cohort study has shown.

Gunn Signe Jakobsen, MD, of Vestfold Hospital Trust, Tønsberg, Norway, and her colleagues wrote in an article published in JAMA, “Few studies report long-term complication rates. ... No large-scale clinical practice–based study has compared the long-term association of bariatric surgery and specialized medical obesity treatment with obesity-related somatic and mental comorbidities, nor the irrespective complication rates.”

The investigators compared outcomes from 932 patients who underwent bariatric surgery and 956 who underwent specialized medical treatment that involved either individual or group lifestyle intervention programs. The study population included 1,249 women and 639 men with an average age of 44 years and an average baseline body mass index of 44 kg/m².

The surgery patients were more likely than the medical treatment patients to have hypertension remission (absolute risk 32% vs. 12%, respectively), and less likely to develop new-onset hypertension (absolute risk 4% vs. 12%, respectively). Diabetes remission was significantly higher among surgery patients, compared with medical treatment patients (58% vs. 13%) as was the likelihood of dyslipidemia remission (43% vs. 13%). Surgery patients also were less likely to develop new-onset diabetes or dyslipidemia than the medical treatment patients.

However, more patients who underwent bariatric surgery had low ferritin levels, compared with the medical treatment patients (26% vs. 12%). The surgery patients were significantly more likely than the medical treatment patients to develop new-onset depression (adjusted relative risk, 1.5; 95% confidence interval, 1.4-1.7), anxiety and sleep disorders (aRR, 1.3; 95% CI, 1.2-1.5), and treatment with opioids (aRR, 1.3; 95% CI, 1.2-1.4). In addition, bariatric patients were more likely to have at least one additional gastrointestinal surgical procedure (aRR, 2.0; 95% CI, 1.7-2.4), an operation for intestinal obstruction (aRR, 10.5; 95% CI, 5.1-21.5), abdominal pain (aRR, 1.9; 95% CI, 1.6-2.3), and gastroduodenal ulcers (aRR, 3.4; 95% CI 2.0-5.6).

The study was limited by several factors, including selection bias of younger, heavier patients in the bariatric surgery group, the lack of data on actual weight loss, incomplete laboratory data, and a relatively homogeneous white population, the researchers noted. However, the nearly 100% follow-up over approximately 6 years adds to the strength of the findings, which suggest that “the risk for complications should be considered in the decision-making process,” for obese patients considering bariatric surgery, they said.

Dr. Jakobsen was supported by the Vestfold Hospital Trust, with no financial conflicts to disclose.

SOURCE: Jakobsen G et al. JAMA. 2018 Jan 16;319(3):291-301.

CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.

Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.

A primer on seizures

Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.

You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.

“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”

Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
 

Febrile seizures

About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.

Determining seizure causes

If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?

Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm³ or above 10 PMN/mm³ should not be attributed to a seizure,” she said.

An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
 

Epilepsy management

After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.

Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.

shironosov/iStockphoto

Physical health and learning differences

Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.

Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.

You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.

Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.

Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:

• Education

• Parenting

• Independence (including driving)

• Learning

• Eating (nutrition and bone health)

• Pharmacotherapy (anticonvulsants)

• School

• You (the child’s caretakers).

Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.

CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.

Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.

A primer on seizures

Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.

You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.

“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”

Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
 

Febrile seizures

About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.

Determining seizure causes

If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?

Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm³ or above 10 PMN/mm³ should not be attributed to a seizure,” she said.

An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
 

Epilepsy management

After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.

Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.

shironosov/iStockphoto

Physical health and learning differences

Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.

Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.

You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.

Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.

Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:

• Education

• Parenting

• Independence (including driving)

• Learning

• Eating (nutrition and bone health)

• Pharmacotherapy (anticonvulsants)

• School

• You (the child’s caretakers).

Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.

CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.

Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.

A primer on seizures

Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.

You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.

“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”

Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
 

Febrile seizures

About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.

Determining seizure causes

If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?

Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm³ or above 10 PMN/mm³ should not be attributed to a seizure,” she said.

An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
 

Epilepsy management

After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.

Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.

shironosov/iStockphoto

Physical health and learning differences

Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.

Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.

You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.

Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.

Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:

• Education

• Parenting

• Independence (including driving)

• Learning

• Eating (nutrition and bone health)

• Pharmacotherapy (anticonvulsants)

• School

• You (the child’s caretakers).

Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.