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Babesiosis HIV
According to the CDC, the number of reported tickborne diseases more than doubled between 2004-2016 and accounted for > 60% of all reported mosquito-borne, tickborne, and fleaborne disease cases. Which is why it is important to keep an eye out for anyone who has a history of being in a tick-promoting environment. Clinicians from Lehigh Valley Health Network Pocono and Geisinger Commonwealth School of Medicine, both in East Stroudsburg, Pennsylvania, report on a patient whose diagnosis turned on that fact.
The patient, a 71-year-old man, had fever, weakness, headaches, near syncope, and nausea for 4 days. He also had not been eating well.
A complete blood count showed pancytopenia with an excess of band cells, an indicator of inflammation and infection. The patient’s aspartate transaminase levels were elevated. The diagnostic dilemma centered on these findings: Serology tests for HIV 1 and 2 were positive, and a peripheral blood smear showed 0.5% parasitemia consistent with Babesia microti. Both babesiosis and HIV were among the possible diagnoses. Two important factors the clinicians had to consider: The patient had recently been bitten by ticks and was homosexual.
The clinicians note that a variety of infections can lead to false-positive HIV serology, such as malaria, Mycobacterium tuberculosis or Rickettsia species, influenza and hepatitis B vaccinations. Moreover, the Ixodes tick, the same vector that transmits Borrelia burgdorferi, which causes Lyme disease, also transmits B microti. Conversely, HIV infection can exacerbate Lyme disease or babesiosis.
The tests showing B microti were the clincher for the clinicians, who started treatment with fluids, atovaquone, and azithromycin. The patient recovered completely. Repeat HIV serology was negative.
The authors of the report note that babesiosis can be a life-threatening infection in patients with reduced immunity. It is possible that, like malaria and HIV serologies, Babesia and HIV serologies cross-react, the clinicians say. Thus, it is important to screen for both in both infections.
This is the first case, to the clinician’s knowledge, of HIV associated with active babesiosis
According to the CDC, the number of reported tickborne diseases more than doubled between 2004-2016 and accounted for > 60% of all reported mosquito-borne, tickborne, and fleaborne disease cases. Which is why it is important to keep an eye out for anyone who has a history of being in a tick-promoting environment. Clinicians from Lehigh Valley Health Network Pocono and Geisinger Commonwealth School of Medicine, both in East Stroudsburg, Pennsylvania, report on a patient whose diagnosis turned on that fact.
The patient, a 71-year-old man, had fever, weakness, headaches, near syncope, and nausea for 4 days. He also had not been eating well.
A complete blood count showed pancytopenia with an excess of band cells, an indicator of inflammation and infection. The patient’s aspartate transaminase levels were elevated. The diagnostic dilemma centered on these findings: Serology tests for HIV 1 and 2 were positive, and a peripheral blood smear showed 0.5% parasitemia consistent with Babesia microti. Both babesiosis and HIV were among the possible diagnoses. Two important factors the clinicians had to consider: The patient had recently been bitten by ticks and was homosexual.
The clinicians note that a variety of infections can lead to false-positive HIV serology, such as malaria, Mycobacterium tuberculosis or Rickettsia species, influenza and hepatitis B vaccinations. Moreover, the Ixodes tick, the same vector that transmits Borrelia burgdorferi, which causes Lyme disease, also transmits B microti. Conversely, HIV infection can exacerbate Lyme disease or babesiosis.
The tests showing B microti were the clincher for the clinicians, who started treatment with fluids, atovaquone, and azithromycin. The patient recovered completely. Repeat HIV serology was negative.
The authors of the report note that babesiosis can be a life-threatening infection in patients with reduced immunity. It is possible that, like malaria and HIV serologies, Babesia and HIV serologies cross-react, the clinicians say. Thus, it is important to screen for both in both infections.
This is the first case, to the clinician’s knowledge, of HIV associated with active babesiosis
According to the CDC, the number of reported tickborne diseases more than doubled between 2004-2016 and accounted for > 60% of all reported mosquito-borne, tickborne, and fleaborne disease cases. Which is why it is important to keep an eye out for anyone who has a history of being in a tick-promoting environment. Clinicians from Lehigh Valley Health Network Pocono and Geisinger Commonwealth School of Medicine, both in East Stroudsburg, Pennsylvania, report on a patient whose diagnosis turned on that fact.
The patient, a 71-year-old man, had fever, weakness, headaches, near syncope, and nausea for 4 days. He also had not been eating well.
A complete blood count showed pancytopenia with an excess of band cells, an indicator of inflammation and infection. The patient’s aspartate transaminase levels were elevated. The diagnostic dilemma centered on these findings: Serology tests for HIV 1 and 2 were positive, and a peripheral blood smear showed 0.5% parasitemia consistent with Babesia microti. Both babesiosis and HIV were among the possible diagnoses. Two important factors the clinicians had to consider: The patient had recently been bitten by ticks and was homosexual.
The clinicians note that a variety of infections can lead to false-positive HIV serology, such as malaria, Mycobacterium tuberculosis or Rickettsia species, influenza and hepatitis B vaccinations. Moreover, the Ixodes tick, the same vector that transmits Borrelia burgdorferi, which causes Lyme disease, also transmits B microti. Conversely, HIV infection can exacerbate Lyme disease or babesiosis.
The tests showing B microti were the clincher for the clinicians, who started treatment with fluids, atovaquone, and azithromycin. The patient recovered completely. Repeat HIV serology was negative.
The authors of the report note that babesiosis can be a life-threatening infection in patients with reduced immunity. It is possible that, like malaria and HIV serologies, Babesia and HIV serologies cross-react, the clinicians say. Thus, it is important to screen for both in both infections.
This is the first case, to the clinician’s knowledge, of HIV associated with active babesiosis
Lower rates of patient satisfaction may predict readmission
Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?
Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.
Study design: Thematic interview and questionnaire.
Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.
Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.
Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.
Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?
Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.
Study design: Thematic interview and questionnaire.
Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.
Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.
Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.
Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?
Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.
Study design: Thematic interview and questionnaire.
Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.
Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.
Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.
Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Acting up at APA
SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.
We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.
Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.
Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.
The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.
On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.
“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”
A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.
It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.
The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.
Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.
Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. We discussed how improv might be useful in teaching trainees.
“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”
Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”
Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”
I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.
We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.
Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.
Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.
The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.
On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.
“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”
A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.
It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.
The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.
Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.
Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. We discussed how improv might be useful in teaching trainees.
“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”
Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”
Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”
I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.
We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.
Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.
Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.
The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.
On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.
“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”
A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.
It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.
The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.
Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.
Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. We discussed how improv might be useful in teaching trainees.
“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”
Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”
Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”
I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
Multiple Eruptive Syringomas on the Penis
To the Editor:
Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.1 The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.2 However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.3 The clear cell variant has been found to be associated with diabetes mellitus.4 Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.5 We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.
A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.
Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.
Due to the rarity of syringomas on the penis, presentation of these benign eccrine tumors can be commonly mistaken for lichen planus, molluscum contagiosum, genital warts, or bowenoid papulosis.5 The characteristic histopathology of syringomas consists of multiple, small, tadpole or paisley tie–shaped ducts within an eosinophilic stroma. Often, the findings can be histologically confused with desmoplastic trichoepithelioma, morpheaform basal cell carcinoma, and microcystic adnexal carcinoma. Although the histopathology of our patient’s biopsy showed clear cell change, the patient did not report a history of diabetes mellitus, which is a disease that can be associated with the clear cell variant of syringoma. Because syringomas are benign tumors, treatment is not medically necessary unless the lesions are symptomatic. Treatment often is regarded as challenging, as lesions often recur and scarring is a consideration. Possible treatments for removal of the benign papules include surgical excision, electrodesiccation and curettage, shave removal, chemical peels, liquid nitrogen cryotherapy, and CO2 laser vaporization.6
To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.
- Yalisove B, Stolar EEH, Williams CM. Multiple penile papules. syringoma. Arch Dermatol. 1987;123:1391-1396.
- Cohen PR, Tschen JA, Rapini RP. Penile syringoma: reports and review of patients with syringoma located on the penis. J Clin Aesthet Dermatol. 2013;6:38-42.
- Yoshimi N, Kurokawa I, Kakuno A, et al. Case of generalized eruptive clear cell syringoma with diabetes mellitus. J Dermatol. 2012;39:744-745.
- Petersson F, Mjornberg PA, Kazakov DV, et al. Eruptive syringoma of the penis. a report of 2 cases and a review of the literature. Am J Dermatopathol. 2009;31:436-438.
- Wu CY. Multifocal penile syringoma masquerading as genital warts. Clin Exp Dermatol. 2009;34:e290-e291.
- Lipshutz RL, Kantor GR, Vonderheid EC. Multiple penile syringomas mimicking verrucae. Int J Dermatol. 1991;30:69.
To the Editor:
Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.1 The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.2 However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.3 The clear cell variant has been found to be associated with diabetes mellitus.4 Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.5 We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.
A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.
Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.
Due to the rarity of syringomas on the penis, presentation of these benign eccrine tumors can be commonly mistaken for lichen planus, molluscum contagiosum, genital warts, or bowenoid papulosis.5 The characteristic histopathology of syringomas consists of multiple, small, tadpole or paisley tie–shaped ducts within an eosinophilic stroma. Often, the findings can be histologically confused with desmoplastic trichoepithelioma, morpheaform basal cell carcinoma, and microcystic adnexal carcinoma. Although the histopathology of our patient’s biopsy showed clear cell change, the patient did not report a history of diabetes mellitus, which is a disease that can be associated with the clear cell variant of syringoma. Because syringomas are benign tumors, treatment is not medically necessary unless the lesions are symptomatic. Treatment often is regarded as challenging, as lesions often recur and scarring is a consideration. Possible treatments for removal of the benign papules include surgical excision, electrodesiccation and curettage, shave removal, chemical peels, liquid nitrogen cryotherapy, and CO2 laser vaporization.6
To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.
To the Editor:
Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.1 The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.2 However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.3 The clear cell variant has been found to be associated with diabetes mellitus.4 Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.5 We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.
A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.
Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.
Due to the rarity of syringomas on the penis, presentation of these benign eccrine tumors can be commonly mistaken for lichen planus, molluscum contagiosum, genital warts, or bowenoid papulosis.5 The characteristic histopathology of syringomas consists of multiple, small, tadpole or paisley tie–shaped ducts within an eosinophilic stroma. Often, the findings can be histologically confused with desmoplastic trichoepithelioma, morpheaform basal cell carcinoma, and microcystic adnexal carcinoma. Although the histopathology of our patient’s biopsy showed clear cell change, the patient did not report a history of diabetes mellitus, which is a disease that can be associated with the clear cell variant of syringoma. Because syringomas are benign tumors, treatment is not medically necessary unless the lesions are symptomatic. Treatment often is regarded as challenging, as lesions often recur and scarring is a consideration. Possible treatments for removal of the benign papules include surgical excision, electrodesiccation and curettage, shave removal, chemical peels, liquid nitrogen cryotherapy, and CO2 laser vaporization.6
To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.
- Yalisove B, Stolar EEH, Williams CM. Multiple penile papules. syringoma. Arch Dermatol. 1987;123:1391-1396.
- Cohen PR, Tschen JA, Rapini RP. Penile syringoma: reports and review of patients with syringoma located on the penis. J Clin Aesthet Dermatol. 2013;6:38-42.
- Yoshimi N, Kurokawa I, Kakuno A, et al. Case of generalized eruptive clear cell syringoma with diabetes mellitus. J Dermatol. 2012;39:744-745.
- Petersson F, Mjornberg PA, Kazakov DV, et al. Eruptive syringoma of the penis. a report of 2 cases and a review of the literature. Am J Dermatopathol. 2009;31:436-438.
- Wu CY. Multifocal penile syringoma masquerading as genital warts. Clin Exp Dermatol. 2009;34:e290-e291.
- Lipshutz RL, Kantor GR, Vonderheid EC. Multiple penile syringomas mimicking verrucae. Int J Dermatol. 1991;30:69.
- Yalisove B, Stolar EEH, Williams CM. Multiple penile papules. syringoma. Arch Dermatol. 1987;123:1391-1396.
- Cohen PR, Tschen JA, Rapini RP. Penile syringoma: reports and review of patients with syringoma located on the penis. J Clin Aesthet Dermatol. 2013;6:38-42.
- Yoshimi N, Kurokawa I, Kakuno A, et al. Case of generalized eruptive clear cell syringoma with diabetes mellitus. J Dermatol. 2012;39:744-745.
- Petersson F, Mjornberg PA, Kazakov DV, et al. Eruptive syringoma of the penis. a report of 2 cases and a review of the literature. Am J Dermatopathol. 2009;31:436-438.
- Wu CY. Multifocal penile syringoma masquerading as genital warts. Clin Exp Dermatol. 2009;34:e290-e291.
- Lipshutz RL, Kantor GR, Vonderheid EC. Multiple penile syringomas mimicking verrucae. Int J Dermatol. 1991;30:69.
Practice Points
- Penile syringoma can mimic sexually transmitted disease such as condyloma acuminatum or molluscum contagiosum.
- Penile syringomas can be long-standing and require biopsy to differentiate from other conditions.
More empathy for women
At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.
About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.
After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.
Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.
All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.
Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.
At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.
About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.
After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.
Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.
All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.
Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.
At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.
About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.
After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.
Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.
All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.
Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.
HM19: Interprofessional rounds
Better process, outcomes
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
Better process, outcomes
Better process, outcomes
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
What We Don’t Know About Osteoporosis Treatment
A 5-member panel of experts in primary care, geriatrics, and behavioral sciences, among others, convened by the National Institutes of Health (NIH), sought to answer that question. In the Pathways to Prevention (P2P) Workshop: Appropriate Use of Drug Therapies for Osteoporotic Fracture Prevention, the panel discussed the available evidence on long-term drug therapies, in hopes of identifying research gaps and ways to “advance the field.” Then they published a report that summarizes their findings, along with recommendations for “new strengthened research.”
Trials have found 3 to 5 years of ODT is safe and effective, the panel notes, and that some ODTs reduce the incidence of nonvertebral fractures. But those studies have been done mainly in white postmenopausal women. Men, people of other race and ethnicity, residents in facilities, people with advanced and multiple comorbid conditions, and other populations are absent or underrepresented. Thus, estimates on benefits and harms may differ in practice. Moreover, the trial results presented no data on nonfracture patient outcomes or sequelae, such as mobility, hospitalizations, and nursing home placement. The studies also offered limited or no evidence on whether patient characteristics would result in different fracture outcomes.
The panel also noted that few trials extended beyond 5 years, although some observational studies provided “limited evidence” on potential benefits and harms from longer term use. Gaps exist in how to use information on bone biomarkers and other patient characteristics, such as concurrent medication use, that might modify the effects of ODT, the panel concluded.
One of the main issues the panel investigated was how to make sure that the people at highest risk of fracture get the medicine they need. Only about one-third of women at high risk have reported treatment with osteoporosis medication. And among older adults with a hip fracture, only 11% to 13% filled any prescription for osteoporosis medication within 3 months of the fracture.
Information about ODT use and adherence was not included in the systematic evidence review, so the report relies on material provided by the workshop speakers, who say low rates of diagnosis and treatment probably stem from multiple clinician and patient factors. For instance, they said, with regard to clinicians, the problems may be lack of time, knowledge gaps, and lack of appropriate systems in primary care.
The panelists also cited another gap: in communication between clinicians about treatment as patients transition from one setting to another. One solution could be a hospital-based fracture liaison service to coordinate care, they suggest.
Patient factors include perceptions that osteoporosis is a normal part of aging, or that drugs do not work or that they are harmful and risky. Studies about decision making have found that people often overestimate their risk for rare adverse effects (AEs) and underestimate the likelihood of having a fracture.
In their assessment of studies, the workshop panelists found education-based interventions sometimes increase rates of filled prescriptions but not adherence 6 or 10 months down the road. They also found coaching and counseling have been “largely ineffective.”
“We need to identify the reasons why,” the panelists concluded, and made a number of recommendations about how to do the research. For instance, they suggest using a broader array of trial designs, such as innovative platform trials as used in cancer research, where the target of the investigation is the disease and not the drug. Studies also should focus on fracture sequelae, and include diverse populations that “more closely match” the characteristics of people who actually have fractures.
Gaps in knowledge about the uncommon AEs reported with bisphosphonates and other questions mean questions to be answered include which class of drugs should be used first, when treatment should start and how long it should last, and which doses are preferable.
Knowing how to treat can help clinicians and their patients decide whom to treat, the report suggests. Addressing the research gaps will improve the shared decision making needed for answering those questions.
The report was published in Annals of Internal Medicine on April 23, 2019.
A 5-member panel of experts in primary care, geriatrics, and behavioral sciences, among others, convened by the National Institutes of Health (NIH), sought to answer that question. In the Pathways to Prevention (P2P) Workshop: Appropriate Use of Drug Therapies for Osteoporotic Fracture Prevention, the panel discussed the available evidence on long-term drug therapies, in hopes of identifying research gaps and ways to “advance the field.” Then they published a report that summarizes their findings, along with recommendations for “new strengthened research.”
Trials have found 3 to 5 years of ODT is safe and effective, the panel notes, and that some ODTs reduce the incidence of nonvertebral fractures. But those studies have been done mainly in white postmenopausal women. Men, people of other race and ethnicity, residents in facilities, people with advanced and multiple comorbid conditions, and other populations are absent or underrepresented. Thus, estimates on benefits and harms may differ in practice. Moreover, the trial results presented no data on nonfracture patient outcomes or sequelae, such as mobility, hospitalizations, and nursing home placement. The studies also offered limited or no evidence on whether patient characteristics would result in different fracture outcomes.
The panel also noted that few trials extended beyond 5 years, although some observational studies provided “limited evidence” on potential benefits and harms from longer term use. Gaps exist in how to use information on bone biomarkers and other patient characteristics, such as concurrent medication use, that might modify the effects of ODT, the panel concluded.
One of the main issues the panel investigated was how to make sure that the people at highest risk of fracture get the medicine they need. Only about one-third of women at high risk have reported treatment with osteoporosis medication. And among older adults with a hip fracture, only 11% to 13% filled any prescription for osteoporosis medication within 3 months of the fracture.
Information about ODT use and adherence was not included in the systematic evidence review, so the report relies on material provided by the workshop speakers, who say low rates of diagnosis and treatment probably stem from multiple clinician and patient factors. For instance, they said, with regard to clinicians, the problems may be lack of time, knowledge gaps, and lack of appropriate systems in primary care.
The panelists also cited another gap: in communication between clinicians about treatment as patients transition from one setting to another. One solution could be a hospital-based fracture liaison service to coordinate care, they suggest.
Patient factors include perceptions that osteoporosis is a normal part of aging, or that drugs do not work or that they are harmful and risky. Studies about decision making have found that people often overestimate their risk for rare adverse effects (AEs) and underestimate the likelihood of having a fracture.
In their assessment of studies, the workshop panelists found education-based interventions sometimes increase rates of filled prescriptions but not adherence 6 or 10 months down the road. They also found coaching and counseling have been “largely ineffective.”
“We need to identify the reasons why,” the panelists concluded, and made a number of recommendations about how to do the research. For instance, they suggest using a broader array of trial designs, such as innovative platform trials as used in cancer research, where the target of the investigation is the disease and not the drug. Studies also should focus on fracture sequelae, and include diverse populations that “more closely match” the characteristics of people who actually have fractures.
Gaps in knowledge about the uncommon AEs reported with bisphosphonates and other questions mean questions to be answered include which class of drugs should be used first, when treatment should start and how long it should last, and which doses are preferable.
Knowing how to treat can help clinicians and their patients decide whom to treat, the report suggests. Addressing the research gaps will improve the shared decision making needed for answering those questions.
The report was published in Annals of Internal Medicine on April 23, 2019.
A 5-member panel of experts in primary care, geriatrics, and behavioral sciences, among others, convened by the National Institutes of Health (NIH), sought to answer that question. In the Pathways to Prevention (P2P) Workshop: Appropriate Use of Drug Therapies for Osteoporotic Fracture Prevention, the panel discussed the available evidence on long-term drug therapies, in hopes of identifying research gaps and ways to “advance the field.” Then they published a report that summarizes their findings, along with recommendations for “new strengthened research.”
Trials have found 3 to 5 years of ODT is safe and effective, the panel notes, and that some ODTs reduce the incidence of nonvertebral fractures. But those studies have been done mainly in white postmenopausal women. Men, people of other race and ethnicity, residents in facilities, people with advanced and multiple comorbid conditions, and other populations are absent or underrepresented. Thus, estimates on benefits and harms may differ in practice. Moreover, the trial results presented no data on nonfracture patient outcomes or sequelae, such as mobility, hospitalizations, and nursing home placement. The studies also offered limited or no evidence on whether patient characteristics would result in different fracture outcomes.
The panel also noted that few trials extended beyond 5 years, although some observational studies provided “limited evidence” on potential benefits and harms from longer term use. Gaps exist in how to use information on bone biomarkers and other patient characteristics, such as concurrent medication use, that might modify the effects of ODT, the panel concluded.
One of the main issues the panel investigated was how to make sure that the people at highest risk of fracture get the medicine they need. Only about one-third of women at high risk have reported treatment with osteoporosis medication. And among older adults with a hip fracture, only 11% to 13% filled any prescription for osteoporosis medication within 3 months of the fracture.
Information about ODT use and adherence was not included in the systematic evidence review, so the report relies on material provided by the workshop speakers, who say low rates of diagnosis and treatment probably stem from multiple clinician and patient factors. For instance, they said, with regard to clinicians, the problems may be lack of time, knowledge gaps, and lack of appropriate systems in primary care.
The panelists also cited another gap: in communication between clinicians about treatment as patients transition from one setting to another. One solution could be a hospital-based fracture liaison service to coordinate care, they suggest.
Patient factors include perceptions that osteoporosis is a normal part of aging, or that drugs do not work or that they are harmful and risky. Studies about decision making have found that people often overestimate their risk for rare adverse effects (AEs) and underestimate the likelihood of having a fracture.
In their assessment of studies, the workshop panelists found education-based interventions sometimes increase rates of filled prescriptions but not adherence 6 or 10 months down the road. They also found coaching and counseling have been “largely ineffective.”
“We need to identify the reasons why,” the panelists concluded, and made a number of recommendations about how to do the research. For instance, they suggest using a broader array of trial designs, such as innovative platform trials as used in cancer research, where the target of the investigation is the disease and not the drug. Studies also should focus on fracture sequelae, and include diverse populations that “more closely match” the characteristics of people who actually have fractures.
Gaps in knowledge about the uncommon AEs reported with bisphosphonates and other questions mean questions to be answered include which class of drugs should be used first, when treatment should start and how long it should last, and which doses are preferable.
Knowing how to treat can help clinicians and their patients decide whom to treat, the report suggests. Addressing the research gaps will improve the shared decision making needed for answering those questions.
The report was published in Annals of Internal Medicine on April 23, 2019.
Unit-based models of care
A tool for ensuring patient safety
“To me, teamwork is the beauty of our sport, where you have five acting as one. You become selfless.” – Mike Krzyzewski
High-performing teams plan, communicate, reflect, and take action together. Teamwork can transform seemingly impossible tasks into opportunities for people to come together and create value.
The increasing complexity of health care makes team-based care necessary to achieve successful health outcomes for patients. At the Brooklyn (N.Y.) Hospital Center, a 464-bed care center, we transformed the model of care on the medical wards into a geographic, unit-based team model. Here we describe our journey – the successes, the challenges, and the opportunities for growth.
Previous model
In the previous care model on our medical wards, no set structures were in place. Teams would travel to multiple wards throughout the hospital to see the patients they were rounding on. Each floor had its own set of social workers and case managers, therefore a hospital medicine team routinely dealt with more than eight social workers and case managers to address their patients’ needs in a single day.
Multidisciplinary rounds for all medical patients were held at 11 a.m. in a room located a significant distance away from the medical wards. All case managers and social workers would sit in this room from 11 a.m. until noon, and teams would travel to that room to discuss their patients.
Many challenges were identified in this model, including a lack of communication, a de-emphasis on teamwork, and a design that did not take physician workflows into account resulting in low efficiency. Thus, these challenges sparked a desire to create a more effective and team-based methodology of accomplishing excellence in delivery of clinical care. Dr. Pendharkar, having worked primarily in centers with unit-based care, determined that a geographic, unit-based model of care could transform care delivery at the Brooklyn Hospital Center.
Looking ahead
The efforts for transforming the vision of geographic, unit-based teams into a reality started by gathering all stakeholders together to unite for a common mission. Initial meetings were held with all parties including social workers, case managers, residents, nursing staff, bed board and attending physicians in internal medicine, and the emergency department.
The vision of a geographic, unit-based team was shared and explained to all team members. Exercises in LEAN methodology were conducted, including one-piece flow exercises, to highlight the possibilities of what could be accomplished through teamwork. Once support for the vision was in place from all parties, the logistics were addressed.
The biggest challenge to overcome was how to place all of one team’s patients on a singular medical ward. In our hospital, a medical ward holds anywhere from 30 to 33 patients. Each hospital medicine team, of which there are many, typically carries 20-23 patients. We created a blueprint to map out the floor to which each team and attending would be assigned. Next, we partnered with both IT and bed board to design an admission order set that specified the particular geographic location that a team and attending were associated with so that patients could be placed accordingly from the ED.
It was important for the ED doctors, bed board, and the internal medicine residents to understand these changes because all of these parties were involved in the initial admitting process. Dr. Pendharkar and Dr. Malieckal provided all groups with in-person training on how the logistics of the system would unfold. Noon conference lectures were also held to explain the vision to residents.
Over 3 weeks, the first ward we chose to implement our model on slowly accumulated the patients of one team – this was the gradual trickle phase. We then selected a “re-set” date. On the re-set date, it was determined that all patients would go to the team that was assigned to that floor, with the exception of any private attendings’ patients.
On the day before the re-set date, time was spent ensuring that all hand-offs were safe. Dr. Pendharkar and Dr. Malieckal spoke with every intern and team that would be handing off and/or receiving patients as a result of the re-set policy. The goal was to ensure that on that date a ward had close to 100% of its patients belonging to the team/attending that was assigned to that area.
The good
Once we began our geographic, unit-based model, our rounding process was transformed.
Now, our morning rounds were joined by the bedside nurse, case manager, social worker, clinical pharmacy, and nutrition in addition to the core team. The entire team went from room to room on one ward rounding on all 20 to 25 patients back to back, which created an unparalleled level of efficiency and a forum for effective communication lasting throughout the day.
We also added workstations on wheels (WOWS) to the rounding process so that labs, radiology, and more could be reviewed on rounds with the entire team. A standard script was developed so that each patient was introduced to all members of the team, and the care plan was disclosed and highlighted. One patient noted, “I feel so cared for, knowing I have this entire team taking care of me.” We also rounded in the afternoon with the case managers and social workers to follow up tasks that were to be completed that day.
Our first few weeks utilizing the geographic, unit-based model of rounding was largely successful. The residents, now able to round on all of their patients in one location with one case manager and one social worker, noted, “This model of rounding makes my life so much easier, I feel like I can focus on the patient rather than running around. … and I know the social worker and case manager will help me.”
Provider satisfaction had improved, from residents to physicians to nurses, case managers, social workers, and more. Our case manager also noted her satisfaction with the new model, stating that her communication with the medical team was much easier. As the attending, I witnessed firsthand how working together with the team moved care forward much more quickly, compared with the previous model, because of the simple factor of increased ease of communication.
Now all team members were together in the patient room and discussion was much easier. There was less confusion, fewer delays, and better communication – I think unit-based teams can even be described as a lifesaving measure that reduces harm to patients. An additional benefit is the relationship that now developed between doctors, social workers, and case managers – they spent more time together and really got to know one another, creating a feeling of shared success and a deeper drive to help one another succeed.
In our model, 87% of surveyed residents said they felt less burned out in the new geographic, unit-based model of care, and 91% of physicians surveyed said it was easier to talk with team members to coordinate care. Additionally, our HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores saw a drastic increase in many domains. Nursing communication improved by more than 42% on domain 7B; doctor communication improved by more than 31%. Additionally, all other domains saw at least 10% improvement. We are now 5 months out from our initial rollout of the model and continue to see sustained improvements in quality measures.
The bad
The biggest challenges that we are working through with this model are hand-offs and transfer of patients from one team to another. Sometimes, it happens that one team’s patient will wind up on a floor that is the designated floor of another team because of bed availability. We continue to work with bed board to address this issue. We want to minimize transfers and hand-offs to promote continuity and have to balance that with the need for geographic location. With clear communication, hospital collaboration from bed board and safe hand-off methods, this problem can be safely addressed.
Conclusions
The experience of implementing the unit-based team model has been an eye-opening journey. One thing that stands out is that, in an increasingly complex health care system, design thinking is critical.
Design thinking takes into consideration the needs of those who are using a system. In this case, patients and health care workers including doctors, nurses, case managers, and social workers are the end users of the health care system. All parties are utilizing the health care system to optimize patient health. Therefore, we must create systems that are easy to navigate and use by patients and health care workers so that they can ensure the success of patients.
Unit-based teams offer a basic framework to optimize the inpatient system to facilitate better workflow. In our system, it allowed us to optimize communications between health care workers and also between health care workers and patients. It allowed team members to work in close proximity to better share ideas with each other.
We spent a significant amount of time upfront earning the support of all of the disciplines for this effort. We had support from all leaders within the organization and continue to make our case for this model by sharing metrics and holding forums to discuss the process.
Initial data show a marked improvement in many domains of HCAHPS scores. Our frontline staff, including attendings, residents, nursing, case managers, and social workers, also continue to support this effort since it has a positive impact on their workflow and improves their workday quality. One nurse mentioned specifically, “in my 30 years at this hospital I have never seen people work together so well.”
To sustain this effort, we continue to have regular meetings, and there are new features that we would like to add to the program. For example, we are working with our IT group to ensure that each unit-based team will have dashboards available to incorporate real time, actionable data into daily workflows.
We are excited by the potential of our high-performing teams to highlight the patient experience, placing the patient at the center for care, decision making, and rounding. Health care is a team sport, and anytime you build something where all teams are playing together and approaching the finish line as a unit, you will never go wrong!
Dr. Pendharkar is division chief of hospital medicine at the Brooklyn (N.Y.) Hospital Center, medical director of inpatient services and director of quality for the department of medicine at the Brooklyn Hospital Center and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York. Dr. Malieckal is chief resident, internal medicine, at the Brooklyn Hospital Center. Dr. Gasperino is chair, department of medicine; vice president for critical care, perioperative, and hospital medicine; and associate chief medical officer at the Brooklyn Hospital Center.
A tool for ensuring patient safety
A tool for ensuring patient safety
“To me, teamwork is the beauty of our sport, where you have five acting as one. You become selfless.” – Mike Krzyzewski
High-performing teams plan, communicate, reflect, and take action together. Teamwork can transform seemingly impossible tasks into opportunities for people to come together and create value.
The increasing complexity of health care makes team-based care necessary to achieve successful health outcomes for patients. At the Brooklyn (N.Y.) Hospital Center, a 464-bed care center, we transformed the model of care on the medical wards into a geographic, unit-based team model. Here we describe our journey – the successes, the challenges, and the opportunities for growth.
Previous model
In the previous care model on our medical wards, no set structures were in place. Teams would travel to multiple wards throughout the hospital to see the patients they were rounding on. Each floor had its own set of social workers and case managers, therefore a hospital medicine team routinely dealt with more than eight social workers and case managers to address their patients’ needs in a single day.
Multidisciplinary rounds for all medical patients were held at 11 a.m. in a room located a significant distance away from the medical wards. All case managers and social workers would sit in this room from 11 a.m. until noon, and teams would travel to that room to discuss their patients.
Many challenges were identified in this model, including a lack of communication, a de-emphasis on teamwork, and a design that did not take physician workflows into account resulting in low efficiency. Thus, these challenges sparked a desire to create a more effective and team-based methodology of accomplishing excellence in delivery of clinical care. Dr. Pendharkar, having worked primarily in centers with unit-based care, determined that a geographic, unit-based model of care could transform care delivery at the Brooklyn Hospital Center.
Looking ahead
The efforts for transforming the vision of geographic, unit-based teams into a reality started by gathering all stakeholders together to unite for a common mission. Initial meetings were held with all parties including social workers, case managers, residents, nursing staff, bed board and attending physicians in internal medicine, and the emergency department.
The vision of a geographic, unit-based team was shared and explained to all team members. Exercises in LEAN methodology were conducted, including one-piece flow exercises, to highlight the possibilities of what could be accomplished through teamwork. Once support for the vision was in place from all parties, the logistics were addressed.
The biggest challenge to overcome was how to place all of one team’s patients on a singular medical ward. In our hospital, a medical ward holds anywhere from 30 to 33 patients. Each hospital medicine team, of which there are many, typically carries 20-23 patients. We created a blueprint to map out the floor to which each team and attending would be assigned. Next, we partnered with both IT and bed board to design an admission order set that specified the particular geographic location that a team and attending were associated with so that patients could be placed accordingly from the ED.
It was important for the ED doctors, bed board, and the internal medicine residents to understand these changes because all of these parties were involved in the initial admitting process. Dr. Pendharkar and Dr. Malieckal provided all groups with in-person training on how the logistics of the system would unfold. Noon conference lectures were also held to explain the vision to residents.
Over 3 weeks, the first ward we chose to implement our model on slowly accumulated the patients of one team – this was the gradual trickle phase. We then selected a “re-set” date. On the re-set date, it was determined that all patients would go to the team that was assigned to that floor, with the exception of any private attendings’ patients.
On the day before the re-set date, time was spent ensuring that all hand-offs were safe. Dr. Pendharkar and Dr. Malieckal spoke with every intern and team that would be handing off and/or receiving patients as a result of the re-set policy. The goal was to ensure that on that date a ward had close to 100% of its patients belonging to the team/attending that was assigned to that area.
The good
Once we began our geographic, unit-based model, our rounding process was transformed.
Now, our morning rounds were joined by the bedside nurse, case manager, social worker, clinical pharmacy, and nutrition in addition to the core team. The entire team went from room to room on one ward rounding on all 20 to 25 patients back to back, which created an unparalleled level of efficiency and a forum for effective communication lasting throughout the day.
We also added workstations on wheels (WOWS) to the rounding process so that labs, radiology, and more could be reviewed on rounds with the entire team. A standard script was developed so that each patient was introduced to all members of the team, and the care plan was disclosed and highlighted. One patient noted, “I feel so cared for, knowing I have this entire team taking care of me.” We also rounded in the afternoon with the case managers and social workers to follow up tasks that were to be completed that day.
Our first few weeks utilizing the geographic, unit-based model of rounding was largely successful. The residents, now able to round on all of their patients in one location with one case manager and one social worker, noted, “This model of rounding makes my life so much easier, I feel like I can focus on the patient rather than running around. … and I know the social worker and case manager will help me.”
Provider satisfaction had improved, from residents to physicians to nurses, case managers, social workers, and more. Our case manager also noted her satisfaction with the new model, stating that her communication with the medical team was much easier. As the attending, I witnessed firsthand how working together with the team moved care forward much more quickly, compared with the previous model, because of the simple factor of increased ease of communication.
Now all team members were together in the patient room and discussion was much easier. There was less confusion, fewer delays, and better communication – I think unit-based teams can even be described as a lifesaving measure that reduces harm to patients. An additional benefit is the relationship that now developed between doctors, social workers, and case managers – they spent more time together and really got to know one another, creating a feeling of shared success and a deeper drive to help one another succeed.
In our model, 87% of surveyed residents said they felt less burned out in the new geographic, unit-based model of care, and 91% of physicians surveyed said it was easier to talk with team members to coordinate care. Additionally, our HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores saw a drastic increase in many domains. Nursing communication improved by more than 42% on domain 7B; doctor communication improved by more than 31%. Additionally, all other domains saw at least 10% improvement. We are now 5 months out from our initial rollout of the model and continue to see sustained improvements in quality measures.
The bad
The biggest challenges that we are working through with this model are hand-offs and transfer of patients from one team to another. Sometimes, it happens that one team’s patient will wind up on a floor that is the designated floor of another team because of bed availability. We continue to work with bed board to address this issue. We want to minimize transfers and hand-offs to promote continuity and have to balance that with the need for geographic location. With clear communication, hospital collaboration from bed board and safe hand-off methods, this problem can be safely addressed.
Conclusions
The experience of implementing the unit-based team model has been an eye-opening journey. One thing that stands out is that, in an increasingly complex health care system, design thinking is critical.
Design thinking takes into consideration the needs of those who are using a system. In this case, patients and health care workers including doctors, nurses, case managers, and social workers are the end users of the health care system. All parties are utilizing the health care system to optimize patient health. Therefore, we must create systems that are easy to navigate and use by patients and health care workers so that they can ensure the success of patients.
Unit-based teams offer a basic framework to optimize the inpatient system to facilitate better workflow. In our system, it allowed us to optimize communications between health care workers and also between health care workers and patients. It allowed team members to work in close proximity to better share ideas with each other.
We spent a significant amount of time upfront earning the support of all of the disciplines for this effort. We had support from all leaders within the organization and continue to make our case for this model by sharing metrics and holding forums to discuss the process.
Initial data show a marked improvement in many domains of HCAHPS scores. Our frontline staff, including attendings, residents, nursing, case managers, and social workers, also continue to support this effort since it has a positive impact on their workflow and improves their workday quality. One nurse mentioned specifically, “in my 30 years at this hospital I have never seen people work together so well.”
To sustain this effort, we continue to have regular meetings, and there are new features that we would like to add to the program. For example, we are working with our IT group to ensure that each unit-based team will have dashboards available to incorporate real time, actionable data into daily workflows.
We are excited by the potential of our high-performing teams to highlight the patient experience, placing the patient at the center for care, decision making, and rounding. Health care is a team sport, and anytime you build something where all teams are playing together and approaching the finish line as a unit, you will never go wrong!
Dr. Pendharkar is division chief of hospital medicine at the Brooklyn (N.Y.) Hospital Center, medical director of inpatient services and director of quality for the department of medicine at the Brooklyn Hospital Center and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York. Dr. Malieckal is chief resident, internal medicine, at the Brooklyn Hospital Center. Dr. Gasperino is chair, department of medicine; vice president for critical care, perioperative, and hospital medicine; and associate chief medical officer at the Brooklyn Hospital Center.
“To me, teamwork is the beauty of our sport, where you have five acting as one. You become selfless.” – Mike Krzyzewski
High-performing teams plan, communicate, reflect, and take action together. Teamwork can transform seemingly impossible tasks into opportunities for people to come together and create value.
The increasing complexity of health care makes team-based care necessary to achieve successful health outcomes for patients. At the Brooklyn (N.Y.) Hospital Center, a 464-bed care center, we transformed the model of care on the medical wards into a geographic, unit-based team model. Here we describe our journey – the successes, the challenges, and the opportunities for growth.
Previous model
In the previous care model on our medical wards, no set structures were in place. Teams would travel to multiple wards throughout the hospital to see the patients they were rounding on. Each floor had its own set of social workers and case managers, therefore a hospital medicine team routinely dealt with more than eight social workers and case managers to address their patients’ needs in a single day.
Multidisciplinary rounds for all medical patients were held at 11 a.m. in a room located a significant distance away from the medical wards. All case managers and social workers would sit in this room from 11 a.m. until noon, and teams would travel to that room to discuss their patients.
Many challenges were identified in this model, including a lack of communication, a de-emphasis on teamwork, and a design that did not take physician workflows into account resulting in low efficiency. Thus, these challenges sparked a desire to create a more effective and team-based methodology of accomplishing excellence in delivery of clinical care. Dr. Pendharkar, having worked primarily in centers with unit-based care, determined that a geographic, unit-based model of care could transform care delivery at the Brooklyn Hospital Center.
Looking ahead
The efforts for transforming the vision of geographic, unit-based teams into a reality started by gathering all stakeholders together to unite for a common mission. Initial meetings were held with all parties including social workers, case managers, residents, nursing staff, bed board and attending physicians in internal medicine, and the emergency department.
The vision of a geographic, unit-based team was shared and explained to all team members. Exercises in LEAN methodology were conducted, including one-piece flow exercises, to highlight the possibilities of what could be accomplished through teamwork. Once support for the vision was in place from all parties, the logistics were addressed.
The biggest challenge to overcome was how to place all of one team’s patients on a singular medical ward. In our hospital, a medical ward holds anywhere from 30 to 33 patients. Each hospital medicine team, of which there are many, typically carries 20-23 patients. We created a blueprint to map out the floor to which each team and attending would be assigned. Next, we partnered with both IT and bed board to design an admission order set that specified the particular geographic location that a team and attending were associated with so that patients could be placed accordingly from the ED.
It was important for the ED doctors, bed board, and the internal medicine residents to understand these changes because all of these parties were involved in the initial admitting process. Dr. Pendharkar and Dr. Malieckal provided all groups with in-person training on how the logistics of the system would unfold. Noon conference lectures were also held to explain the vision to residents.
Over 3 weeks, the first ward we chose to implement our model on slowly accumulated the patients of one team – this was the gradual trickle phase. We then selected a “re-set” date. On the re-set date, it was determined that all patients would go to the team that was assigned to that floor, with the exception of any private attendings’ patients.
On the day before the re-set date, time was spent ensuring that all hand-offs were safe. Dr. Pendharkar and Dr. Malieckal spoke with every intern and team that would be handing off and/or receiving patients as a result of the re-set policy. The goal was to ensure that on that date a ward had close to 100% of its patients belonging to the team/attending that was assigned to that area.
The good
Once we began our geographic, unit-based model, our rounding process was transformed.
Now, our morning rounds were joined by the bedside nurse, case manager, social worker, clinical pharmacy, and nutrition in addition to the core team. The entire team went from room to room on one ward rounding on all 20 to 25 patients back to back, which created an unparalleled level of efficiency and a forum for effective communication lasting throughout the day.
We also added workstations on wheels (WOWS) to the rounding process so that labs, radiology, and more could be reviewed on rounds with the entire team. A standard script was developed so that each patient was introduced to all members of the team, and the care plan was disclosed and highlighted. One patient noted, “I feel so cared for, knowing I have this entire team taking care of me.” We also rounded in the afternoon with the case managers and social workers to follow up tasks that were to be completed that day.
Our first few weeks utilizing the geographic, unit-based model of rounding was largely successful. The residents, now able to round on all of their patients in one location with one case manager and one social worker, noted, “This model of rounding makes my life so much easier, I feel like I can focus on the patient rather than running around. … and I know the social worker and case manager will help me.”
Provider satisfaction had improved, from residents to physicians to nurses, case managers, social workers, and more. Our case manager also noted her satisfaction with the new model, stating that her communication with the medical team was much easier. As the attending, I witnessed firsthand how working together with the team moved care forward much more quickly, compared with the previous model, because of the simple factor of increased ease of communication.
Now all team members were together in the patient room and discussion was much easier. There was less confusion, fewer delays, and better communication – I think unit-based teams can even be described as a lifesaving measure that reduces harm to patients. An additional benefit is the relationship that now developed between doctors, social workers, and case managers – they spent more time together and really got to know one another, creating a feeling of shared success and a deeper drive to help one another succeed.
In our model, 87% of surveyed residents said they felt less burned out in the new geographic, unit-based model of care, and 91% of physicians surveyed said it was easier to talk with team members to coordinate care. Additionally, our HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores saw a drastic increase in many domains. Nursing communication improved by more than 42% on domain 7B; doctor communication improved by more than 31%. Additionally, all other domains saw at least 10% improvement. We are now 5 months out from our initial rollout of the model and continue to see sustained improvements in quality measures.
The bad
The biggest challenges that we are working through with this model are hand-offs and transfer of patients from one team to another. Sometimes, it happens that one team’s patient will wind up on a floor that is the designated floor of another team because of bed availability. We continue to work with bed board to address this issue. We want to minimize transfers and hand-offs to promote continuity and have to balance that with the need for geographic location. With clear communication, hospital collaboration from bed board and safe hand-off methods, this problem can be safely addressed.
Conclusions
The experience of implementing the unit-based team model has been an eye-opening journey. One thing that stands out is that, in an increasingly complex health care system, design thinking is critical.
Design thinking takes into consideration the needs of those who are using a system. In this case, patients and health care workers including doctors, nurses, case managers, and social workers are the end users of the health care system. All parties are utilizing the health care system to optimize patient health. Therefore, we must create systems that are easy to navigate and use by patients and health care workers so that they can ensure the success of patients.
Unit-based teams offer a basic framework to optimize the inpatient system to facilitate better workflow. In our system, it allowed us to optimize communications between health care workers and also between health care workers and patients. It allowed team members to work in close proximity to better share ideas with each other.
We spent a significant amount of time upfront earning the support of all of the disciplines for this effort. We had support from all leaders within the organization and continue to make our case for this model by sharing metrics and holding forums to discuss the process.
Initial data show a marked improvement in many domains of HCAHPS scores. Our frontline staff, including attendings, residents, nursing, case managers, and social workers, also continue to support this effort since it has a positive impact on their workflow and improves their workday quality. One nurse mentioned specifically, “in my 30 years at this hospital I have never seen people work together so well.”
To sustain this effort, we continue to have regular meetings, and there are new features that we would like to add to the program. For example, we are working with our IT group to ensure that each unit-based team will have dashboards available to incorporate real time, actionable data into daily workflows.
We are excited by the potential of our high-performing teams to highlight the patient experience, placing the patient at the center for care, decision making, and rounding. Health care is a team sport, and anytime you build something where all teams are playing together and approaching the finish line as a unit, you will never go wrong!
Dr. Pendharkar is division chief of hospital medicine at the Brooklyn (N.Y.) Hospital Center, medical director of inpatient services and director of quality for the department of medicine at the Brooklyn Hospital Center and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York. Dr. Malieckal is chief resident, internal medicine, at the Brooklyn Hospital Center. Dr. Gasperino is chair, department of medicine; vice president for critical care, perioperative, and hospital medicine; and associate chief medical officer at the Brooklyn Hospital Center.
Sunscreen ingredients found in bloodstream, but health impact unknown
for sunscreens, in a phase 1 randomized controlled study of 24 healthy volunteers.
In the open-label study, 24 people (mean age 35.5 years) were randomized to one of four commercially available sunscreens (two sprays, one lotion, or one cream formulation); 2 mg of sunscreen per 1 cm2 was applied to 75% of their body surface four times a day for 4 days (described as “maximal use conditions consistent with current sunscreen labeling”), and 30 blood samples were collected over 7 days.
The primary outcome was the maximum plasma concentration of avobenzone, from days 1-7; secondary outcomes were maximum plasma concentrations of sunscreen ingredients oxybenzone, octocrylene, and ecamsule over the same period of time.
All but one participant completed the study. “All four sunscreen active ingredients tested resulted in exposures exceeding 0.5 ng/mL,” reported Murali Matta, PhD, of the FDA’s Center for Drug Evaluation and Research, and coauthors. “The clinical effect of plasma concentrations exceeding 0.5 ng/mL is unknown, necessitating further research,” they added.
According to the study, FDA sunscreen guidance and the proposed rule for over-the-counter sunscreen monograph, nonclinical toxicology studies, such as carcinogenicity and reproductive studies, “may be waived if results of an adequately conducted human pharmacokinetic maximal usage trial show a steady state blood level less than 0.5 ng/mL and an adequately conducted toxicology assessment does not reveal any potential safety concerns.”
The results of this study “do not indicate that individuals should refrain from the use of sunscreen,” the authors concluded, adding that the “systemic absorption of sunscreen ingredients supports the need for further studies to determine the clinical significance of these findings.” The study was published in JAMA.
In an accompanying editorial, former FDA commissioner Robert Califf, MD, professor of cardiology, Duke University, Durham, N.C., and JAMA Dermatology Editor Kanade Shinkai, MD, PhD, of the department of dermatology, University of California, San Francisco, noted that “the demonstration of systemic absorption well above the FDA guideline does not mean these ingredients are unsafe” (JAMA. 2019 May 6. doi: 10.1001/jama.2019.5528). But, they added, the results “raise many important questions about sunscreen and the process by which the sunscreen industry, clinicians, specialty organizations, and regulatory agencies evaluate the benefits and risks of this topical OTC medication. First and foremost, it is essential to determine whether systemic absorption of sunscreen poses risks to human health. Second, the effects of different sunscreen formulations, clinical characteristics (that is, skin type, age, presence of skin diseases that disrupt the skin barrier), physical activity level, and exposure to sun and water on systemic sunscreen levels require further study.”
In a statement, former American Academy of Dermatology President Darrel Rigel, MD, of the department of dermatology, New York University, said that he was concerned that the results were misleading. “We have always known that there is a very small amount of absorption of sunscreens in the bloodstream,” and there are no data that this is a problem, he said, adding: “Tens of millions of people use sunscreens in the U.S. every summer weekend for many years with no incidence. Daily use of a broad-spectrum SPF of at least 30 is the best way to protect yourself from skin cancer. For many people, the chemical formulations cited in the study are the only ones that feel cosmetically elegant enough to wear. Consumers should continue to use their preferred formulation if it means they will actually wear it.”
SOURCE: JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586
It comes as no real surprise that in the wake of the recent FDA proposed rule on sunscreen, which is currently in the “open season” phase for public input, a pilot study supporting said proposal emerges from this very group. We certainly need a watchdog – one that protects us from potentially harmful things in this world. The study presented validates this role. However, let’s not misconstrue what is presented here. In fact, I credit the authors with highlighting a key point in the last sentence of their abstract: These data do not suggest that individuals should refrain from using sunscreen. This paper serves a purpose, which is to support the recommendation to evaluate the potential of these ingredients to penetrate, permeate, and absorb into the systemic circulation. And yes, these data certainly suggest specific filters and formulations can enable systemic absorption, but these findings cannot be correlated to toxicity or pathology.
Let’s critically evaluate what was investigated. The experimental protocol was not exactly realistic, rather, representative of optimal use (2mg/cm2, covering 75% body surface area, four times a day – let’s be real, who actually does that?). The number of those evaluated was low (six per group) and did not account for all skin type and external environments that do play a role in barrier integrity.
While the clinical relevance is unclear, let’s turn to what is not unclear: Ultraviolet radiation causes skin cancer, plain and simple. Therefore, a comprehensive sun protective regimen that includes sunscreen, sun avoidance, and protective clothing is central to prevention. If one is still concerned, there are always mineral sunscreens, zinc and titanium, which the FDA has deemed safe (“generally recognized as safe and effective” or GRASE).
Adam Friedman, MD, is professor and interim chief of dermatology, and director of the supportive oncodermatology clinic, at George Washington University, Washington. He is an advisor and consultant to Aveeno and LaRoche Posay.
It comes as no real surprise that in the wake of the recent FDA proposed rule on sunscreen, which is currently in the “open season” phase for public input, a pilot study supporting said proposal emerges from this very group. We certainly need a watchdog – one that protects us from potentially harmful things in this world. The study presented validates this role. However, let’s not misconstrue what is presented here. In fact, I credit the authors with highlighting a key point in the last sentence of their abstract: These data do not suggest that individuals should refrain from using sunscreen. This paper serves a purpose, which is to support the recommendation to evaluate the potential of these ingredients to penetrate, permeate, and absorb into the systemic circulation. And yes, these data certainly suggest specific filters and formulations can enable systemic absorption, but these findings cannot be correlated to toxicity or pathology.
Let’s critically evaluate what was investigated. The experimental protocol was not exactly realistic, rather, representative of optimal use (2mg/cm2, covering 75% body surface area, four times a day – let’s be real, who actually does that?). The number of those evaluated was low (six per group) and did not account for all skin type and external environments that do play a role in barrier integrity.
While the clinical relevance is unclear, let’s turn to what is not unclear: Ultraviolet radiation causes skin cancer, plain and simple. Therefore, a comprehensive sun protective regimen that includes sunscreen, sun avoidance, and protective clothing is central to prevention. If one is still concerned, there are always mineral sunscreens, zinc and titanium, which the FDA has deemed safe (“generally recognized as safe and effective” or GRASE).
Adam Friedman, MD, is professor and interim chief of dermatology, and director of the supportive oncodermatology clinic, at George Washington University, Washington. He is an advisor and consultant to Aveeno and LaRoche Posay.
It comes as no real surprise that in the wake of the recent FDA proposed rule on sunscreen, which is currently in the “open season” phase for public input, a pilot study supporting said proposal emerges from this very group. We certainly need a watchdog – one that protects us from potentially harmful things in this world. The study presented validates this role. However, let’s not misconstrue what is presented here. In fact, I credit the authors with highlighting a key point in the last sentence of their abstract: These data do not suggest that individuals should refrain from using sunscreen. This paper serves a purpose, which is to support the recommendation to evaluate the potential of these ingredients to penetrate, permeate, and absorb into the systemic circulation. And yes, these data certainly suggest specific filters and formulations can enable systemic absorption, but these findings cannot be correlated to toxicity or pathology.
Let’s critically evaluate what was investigated. The experimental protocol was not exactly realistic, rather, representative of optimal use (2mg/cm2, covering 75% body surface area, four times a day – let’s be real, who actually does that?). The number of those evaluated was low (six per group) and did not account for all skin type and external environments that do play a role in barrier integrity.
While the clinical relevance is unclear, let’s turn to what is not unclear: Ultraviolet radiation causes skin cancer, plain and simple. Therefore, a comprehensive sun protective regimen that includes sunscreen, sun avoidance, and protective clothing is central to prevention. If one is still concerned, there are always mineral sunscreens, zinc and titanium, which the FDA has deemed safe (“generally recognized as safe and effective” or GRASE).
Adam Friedman, MD, is professor and interim chief of dermatology, and director of the supportive oncodermatology clinic, at George Washington University, Washington. He is an advisor and consultant to Aveeno and LaRoche Posay.
for sunscreens, in a phase 1 randomized controlled study of 24 healthy volunteers.
In the open-label study, 24 people (mean age 35.5 years) were randomized to one of four commercially available sunscreens (two sprays, one lotion, or one cream formulation); 2 mg of sunscreen per 1 cm2 was applied to 75% of their body surface four times a day for 4 days (described as “maximal use conditions consistent with current sunscreen labeling”), and 30 blood samples were collected over 7 days.
The primary outcome was the maximum plasma concentration of avobenzone, from days 1-7; secondary outcomes were maximum plasma concentrations of sunscreen ingredients oxybenzone, octocrylene, and ecamsule over the same period of time.
All but one participant completed the study. “All four sunscreen active ingredients tested resulted in exposures exceeding 0.5 ng/mL,” reported Murali Matta, PhD, of the FDA’s Center for Drug Evaluation and Research, and coauthors. “The clinical effect of plasma concentrations exceeding 0.5 ng/mL is unknown, necessitating further research,” they added.
According to the study, FDA sunscreen guidance and the proposed rule for over-the-counter sunscreen monograph, nonclinical toxicology studies, such as carcinogenicity and reproductive studies, “may be waived if results of an adequately conducted human pharmacokinetic maximal usage trial show a steady state blood level less than 0.5 ng/mL and an adequately conducted toxicology assessment does not reveal any potential safety concerns.”
The results of this study “do not indicate that individuals should refrain from the use of sunscreen,” the authors concluded, adding that the “systemic absorption of sunscreen ingredients supports the need for further studies to determine the clinical significance of these findings.” The study was published in JAMA.
In an accompanying editorial, former FDA commissioner Robert Califf, MD, professor of cardiology, Duke University, Durham, N.C., and JAMA Dermatology Editor Kanade Shinkai, MD, PhD, of the department of dermatology, University of California, San Francisco, noted that “the demonstration of systemic absorption well above the FDA guideline does not mean these ingredients are unsafe” (JAMA. 2019 May 6. doi: 10.1001/jama.2019.5528). But, they added, the results “raise many important questions about sunscreen and the process by which the sunscreen industry, clinicians, specialty organizations, and regulatory agencies evaluate the benefits and risks of this topical OTC medication. First and foremost, it is essential to determine whether systemic absorption of sunscreen poses risks to human health. Second, the effects of different sunscreen formulations, clinical characteristics (that is, skin type, age, presence of skin diseases that disrupt the skin barrier), physical activity level, and exposure to sun and water on systemic sunscreen levels require further study.”
In a statement, former American Academy of Dermatology President Darrel Rigel, MD, of the department of dermatology, New York University, said that he was concerned that the results were misleading. “We have always known that there is a very small amount of absorption of sunscreens in the bloodstream,” and there are no data that this is a problem, he said, adding: “Tens of millions of people use sunscreens in the U.S. every summer weekend for many years with no incidence. Daily use of a broad-spectrum SPF of at least 30 is the best way to protect yourself from skin cancer. For many people, the chemical formulations cited in the study are the only ones that feel cosmetically elegant enough to wear. Consumers should continue to use their preferred formulation if it means they will actually wear it.”
SOURCE: JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586
for sunscreens, in a phase 1 randomized controlled study of 24 healthy volunteers.
In the open-label study, 24 people (mean age 35.5 years) were randomized to one of four commercially available sunscreens (two sprays, one lotion, or one cream formulation); 2 mg of sunscreen per 1 cm2 was applied to 75% of their body surface four times a day for 4 days (described as “maximal use conditions consistent with current sunscreen labeling”), and 30 blood samples were collected over 7 days.
The primary outcome was the maximum plasma concentration of avobenzone, from days 1-7; secondary outcomes were maximum plasma concentrations of sunscreen ingredients oxybenzone, octocrylene, and ecamsule over the same period of time.
All but one participant completed the study. “All four sunscreen active ingredients tested resulted in exposures exceeding 0.5 ng/mL,” reported Murali Matta, PhD, of the FDA’s Center for Drug Evaluation and Research, and coauthors. “The clinical effect of plasma concentrations exceeding 0.5 ng/mL is unknown, necessitating further research,” they added.
According to the study, FDA sunscreen guidance and the proposed rule for over-the-counter sunscreen monograph, nonclinical toxicology studies, such as carcinogenicity and reproductive studies, “may be waived if results of an adequately conducted human pharmacokinetic maximal usage trial show a steady state blood level less than 0.5 ng/mL and an adequately conducted toxicology assessment does not reveal any potential safety concerns.”
The results of this study “do not indicate that individuals should refrain from the use of sunscreen,” the authors concluded, adding that the “systemic absorption of sunscreen ingredients supports the need for further studies to determine the clinical significance of these findings.” The study was published in JAMA.
In an accompanying editorial, former FDA commissioner Robert Califf, MD, professor of cardiology, Duke University, Durham, N.C., and JAMA Dermatology Editor Kanade Shinkai, MD, PhD, of the department of dermatology, University of California, San Francisco, noted that “the demonstration of systemic absorption well above the FDA guideline does not mean these ingredients are unsafe” (JAMA. 2019 May 6. doi: 10.1001/jama.2019.5528). But, they added, the results “raise many important questions about sunscreen and the process by which the sunscreen industry, clinicians, specialty organizations, and regulatory agencies evaluate the benefits and risks of this topical OTC medication. First and foremost, it is essential to determine whether systemic absorption of sunscreen poses risks to human health. Second, the effects of different sunscreen formulations, clinical characteristics (that is, skin type, age, presence of skin diseases that disrupt the skin barrier), physical activity level, and exposure to sun and water on systemic sunscreen levels require further study.”
In a statement, former American Academy of Dermatology President Darrel Rigel, MD, of the department of dermatology, New York University, said that he was concerned that the results were misleading. “We have always known that there is a very small amount of absorption of sunscreens in the bloodstream,” and there are no data that this is a problem, he said, adding: “Tens of millions of people use sunscreens in the U.S. every summer weekend for many years with no incidence. Daily use of a broad-spectrum SPF of at least 30 is the best way to protect yourself from skin cancer. For many people, the chemical formulations cited in the study are the only ones that feel cosmetically elegant enough to wear. Consumers should continue to use their preferred formulation if it means they will actually wear it.”
SOURCE: JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586
FROM JAMA
Adult-Onset Asymmetrical Lipomatosis
To the Editor:
An 85-year-old woman presented with extra growth of subcutaneous fat at the left anterior infradiaphragm that expanded circumferentially to the left back over the last 4 years. Two years prior to the current presentation, the left thigh became visibly thicker than the right. Diffuse subtle lipomatosis affecting the ipsilateral face, neck, arms, calf, and foot was noted at that time. Additionally, the patient had hyperlipidemia, gastroesophageal reflux disease, osteoporosis, and scoliosis, all beginning in her late 60s. She reported no alcohol or tobacco use and was taking rosuvastatin, esomeprazole, calcium, vitamin D, and glucosamine. There was no reported family history of asymmetric growth or bony deformities, and her children were healthy.
On physical examination, the lipomatosis affected the entire left side, most prominently around the abdomen, back, and thighs. The affected side was nontender and nonpruritic; there was no atrophy of the unaffected side (Figure). Maximum thigh circumference was 55.1 cm on the affected side and 52.6 cm on the unaffected side. There were no differences in power, reflex, or sensation between the 2 sides, and no hyperhidrosis or vascular malformations were present. Laboratory investigations, including complete blood cell count, complete metabolic panel, lipids, and thyroid-stimulating and sex hormone panels all were within reference range.
Enzi et al1 reported 2 women who developed asymmetrical lipomatosis between the ages of 13 and 20 years. Acquired asymmetrical lipomatosis should be differentiated from the asymmetrical overgrowth diagnosed in neonates and infants.
Proteus syndrome (PS) is a progressive disease involving a combination of overgrowth in a mosaic distribution, connective tissue and epidermal nevi, ovarian cysts, parotid gland tumor, dysregulated adipose tissue, lymphovascular malformation, and certain facial phenotypes.2,3 The average age of onset is 6 to 18 months, and half of cases present at birth.3,4 Hemihyperplasia-multiple lipomatosis syndrome (HHML) describes a mild and nonprogressive variant that does not satisfy the diagnostic criteria of PS; it typically is diagnosed at birth.5 One case of mild and delayed-onset PS was described in a woman who started developing signs at 15 years of age.6 In comparison, asymmetrical lipomatosis and scoliosis were the only abnormal clinical signs present in our patient, and the lipomatosis developed diffusely, as opposed to the typical mosaic distribution found in PS and HHML. Scoliosis can be found in PS and HHML secondary to hemihypertrophy of vertebra or infiltrative intraspinal lipomatosis.7,8 Our patient’s scoliosis was diagnosed more than 10 years prior to the onset of lipomatosis, likely representing degenerative joint disease.9
Prior reported cases of asymmetrical lipomatosis did not describe treatment.1 Ultrasound-guided or conventional liposuction and lipectomy are mainstream therapies for multiple symmetrical lipomatosis, an acquired lipomatosis typically affecting alcoholics in the fourth decade of life. However, recurrence rates are high for surgical treatment of unencapsulated lipomatosis, likely due to incomplete removal of the adipose tissue.10 Alternative treatments found in case reports, including oral salbutamol, mesotherapy using phosphatidylcholine, and fenofibrate (200 mg/d), require further study.11-13 Our patient was not aesthetically bothered by her lipomatosis; therefore, imaging and treatment options were not pursued. In conclusion, we report a patient with acquired asymmetrical lipomatosis with onset in late adulthood, unique from the existing syndromes of asymmetrical hemihyperplasia.1,14
- Enzi G, Digito M, Enzi GB, et al. Asymmetrical lipomatosis: report of two cases. Postgrad Med J. 1985;61:797-800.
- Biesecker LG, Happle R, Mulliken JB, et al. Proteus syndrome: diagnostic criteria, differential diagnosis, and patient evaluation. Am J Med Genet. 1999;84:389-395.
- Biesecker L. The challenges of Proteus syndrome: diagnosis and management. Eur J Hum Genet. 2006;14:1151-1157.
- Cohen MM Jr. Proteus syndrome: an update. Am J Med Genet C Semin Med Genet. 2005;137C:38-52.
- Biesecker LG, Peters KF, Darling TN, et al. Clinical differentiation between Proteus syndrome and hemihyperplasia: description of a distinct form of hemihyperplasia. Am J Med Genet. 1998;79:311-318.
- Luo S, Feng Y, Zheng Y, et al. Mild and delayed-onset Proteus syndrome. Eur J Dermatol. 2007;17:172-173.
- Takebayashi T, Yamashita T, Yokogushi K, et al. Scoliosis in Proteus syndrome: case report. Spine. 2001;26:E395-E398.
- Schulte TL, Liljenqvist U, Görgens H, et al. Hemihyperplasia-multiple lipomatosis syndrome (HHML): a challenge in spinal care. Acta Orthop Belg. 2008;74:714-719.
- Robin GC, Span Y, Steinberg R, et al. Scoliosis in the elderly: a follow-up study. Spine. 1982;7:355-359.
- Brea-García B, Cameselle-Teijeiro J, Couto-González I, et al. Madelung’s disease: comorbidities, fatty mass distribution, and response to treatment of 22 patients. Aesthet Plast Surg. 2013;37:409-416.
- Hasegawa T, Matsukura T, Ikeda S. Mesotherapy for benign symmetric lipomatosis. Aesthet Plast Surg. 2010;34:153-156.
- Zeitler H, Ulrich-Merzenich G, Richter DF, et al. Multiple benign symmetric lipomatosis—a differential diagnosis of obesity. is there a rationale for fibrate treatment? Obes Surg. 2008;18:1354-1356.
- Leung N, Gaer J, Beggs D, et al. Multiple symmetric lipomatosis (Launois‐Bensaude syndrome): effect of oral salbutamol. Clin Endocrinol. 1987;27:601-606.
- Craiglow BG, Ko CJ, Antaya RJ. Two cases of hemihyperplasia-multiple lipomatosis syndrome and review of asymmetric hemihyperplasia syndromes. Pediatr Dermatol. 2014;31:507-510.
To the Editor:
An 85-year-old woman presented with extra growth of subcutaneous fat at the left anterior infradiaphragm that expanded circumferentially to the left back over the last 4 years. Two years prior to the current presentation, the left thigh became visibly thicker than the right. Diffuse subtle lipomatosis affecting the ipsilateral face, neck, arms, calf, and foot was noted at that time. Additionally, the patient had hyperlipidemia, gastroesophageal reflux disease, osteoporosis, and scoliosis, all beginning in her late 60s. She reported no alcohol or tobacco use and was taking rosuvastatin, esomeprazole, calcium, vitamin D, and glucosamine. There was no reported family history of asymmetric growth or bony deformities, and her children were healthy.
On physical examination, the lipomatosis affected the entire left side, most prominently around the abdomen, back, and thighs. The affected side was nontender and nonpruritic; there was no atrophy of the unaffected side (Figure). Maximum thigh circumference was 55.1 cm on the affected side and 52.6 cm on the unaffected side. There were no differences in power, reflex, or sensation between the 2 sides, and no hyperhidrosis or vascular malformations were present. Laboratory investigations, including complete blood cell count, complete metabolic panel, lipids, and thyroid-stimulating and sex hormone panels all were within reference range.
Enzi et al1 reported 2 women who developed asymmetrical lipomatosis between the ages of 13 and 20 years. Acquired asymmetrical lipomatosis should be differentiated from the asymmetrical overgrowth diagnosed in neonates and infants.
Proteus syndrome (PS) is a progressive disease involving a combination of overgrowth in a mosaic distribution, connective tissue and epidermal nevi, ovarian cysts, parotid gland tumor, dysregulated adipose tissue, lymphovascular malformation, and certain facial phenotypes.2,3 The average age of onset is 6 to 18 months, and half of cases present at birth.3,4 Hemihyperplasia-multiple lipomatosis syndrome (HHML) describes a mild and nonprogressive variant that does not satisfy the diagnostic criteria of PS; it typically is diagnosed at birth.5 One case of mild and delayed-onset PS was described in a woman who started developing signs at 15 years of age.6 In comparison, asymmetrical lipomatosis and scoliosis were the only abnormal clinical signs present in our patient, and the lipomatosis developed diffusely, as opposed to the typical mosaic distribution found in PS and HHML. Scoliosis can be found in PS and HHML secondary to hemihypertrophy of vertebra or infiltrative intraspinal lipomatosis.7,8 Our patient’s scoliosis was diagnosed more than 10 years prior to the onset of lipomatosis, likely representing degenerative joint disease.9
Prior reported cases of asymmetrical lipomatosis did not describe treatment.1 Ultrasound-guided or conventional liposuction and lipectomy are mainstream therapies for multiple symmetrical lipomatosis, an acquired lipomatosis typically affecting alcoholics in the fourth decade of life. However, recurrence rates are high for surgical treatment of unencapsulated lipomatosis, likely due to incomplete removal of the adipose tissue.10 Alternative treatments found in case reports, including oral salbutamol, mesotherapy using phosphatidylcholine, and fenofibrate (200 mg/d), require further study.11-13 Our patient was not aesthetically bothered by her lipomatosis; therefore, imaging and treatment options were not pursued. In conclusion, we report a patient with acquired asymmetrical lipomatosis with onset in late adulthood, unique from the existing syndromes of asymmetrical hemihyperplasia.1,14
To the Editor:
An 85-year-old woman presented with extra growth of subcutaneous fat at the left anterior infradiaphragm that expanded circumferentially to the left back over the last 4 years. Two years prior to the current presentation, the left thigh became visibly thicker than the right. Diffuse subtle lipomatosis affecting the ipsilateral face, neck, arms, calf, and foot was noted at that time. Additionally, the patient had hyperlipidemia, gastroesophageal reflux disease, osteoporosis, and scoliosis, all beginning in her late 60s. She reported no alcohol or tobacco use and was taking rosuvastatin, esomeprazole, calcium, vitamin D, and glucosamine. There was no reported family history of asymmetric growth or bony deformities, and her children were healthy.
On physical examination, the lipomatosis affected the entire left side, most prominently around the abdomen, back, and thighs. The affected side was nontender and nonpruritic; there was no atrophy of the unaffected side (Figure). Maximum thigh circumference was 55.1 cm on the affected side and 52.6 cm on the unaffected side. There were no differences in power, reflex, or sensation between the 2 sides, and no hyperhidrosis or vascular malformations were present. Laboratory investigations, including complete blood cell count, complete metabolic panel, lipids, and thyroid-stimulating and sex hormone panels all were within reference range.
Enzi et al1 reported 2 women who developed asymmetrical lipomatosis between the ages of 13 and 20 years. Acquired asymmetrical lipomatosis should be differentiated from the asymmetrical overgrowth diagnosed in neonates and infants.
Proteus syndrome (PS) is a progressive disease involving a combination of overgrowth in a mosaic distribution, connective tissue and epidermal nevi, ovarian cysts, parotid gland tumor, dysregulated adipose tissue, lymphovascular malformation, and certain facial phenotypes.2,3 The average age of onset is 6 to 18 months, and half of cases present at birth.3,4 Hemihyperplasia-multiple lipomatosis syndrome (HHML) describes a mild and nonprogressive variant that does not satisfy the diagnostic criteria of PS; it typically is diagnosed at birth.5 One case of mild and delayed-onset PS was described in a woman who started developing signs at 15 years of age.6 In comparison, asymmetrical lipomatosis and scoliosis were the only abnormal clinical signs present in our patient, and the lipomatosis developed diffusely, as opposed to the typical mosaic distribution found in PS and HHML. Scoliosis can be found in PS and HHML secondary to hemihypertrophy of vertebra or infiltrative intraspinal lipomatosis.7,8 Our patient’s scoliosis was diagnosed more than 10 years prior to the onset of lipomatosis, likely representing degenerative joint disease.9
Prior reported cases of asymmetrical lipomatosis did not describe treatment.1 Ultrasound-guided or conventional liposuction and lipectomy are mainstream therapies for multiple symmetrical lipomatosis, an acquired lipomatosis typically affecting alcoholics in the fourth decade of life. However, recurrence rates are high for surgical treatment of unencapsulated lipomatosis, likely due to incomplete removal of the adipose tissue.10 Alternative treatments found in case reports, including oral salbutamol, mesotherapy using phosphatidylcholine, and fenofibrate (200 mg/d), require further study.11-13 Our patient was not aesthetically bothered by her lipomatosis; therefore, imaging and treatment options were not pursued. In conclusion, we report a patient with acquired asymmetrical lipomatosis with onset in late adulthood, unique from the existing syndromes of asymmetrical hemihyperplasia.1,14
- Enzi G, Digito M, Enzi GB, et al. Asymmetrical lipomatosis: report of two cases. Postgrad Med J. 1985;61:797-800.
- Biesecker LG, Happle R, Mulliken JB, et al. Proteus syndrome: diagnostic criteria, differential diagnosis, and patient evaluation. Am J Med Genet. 1999;84:389-395.
- Biesecker L. The challenges of Proteus syndrome: diagnosis and management. Eur J Hum Genet. 2006;14:1151-1157.
- Cohen MM Jr. Proteus syndrome: an update. Am J Med Genet C Semin Med Genet. 2005;137C:38-52.
- Biesecker LG, Peters KF, Darling TN, et al. Clinical differentiation between Proteus syndrome and hemihyperplasia: description of a distinct form of hemihyperplasia. Am J Med Genet. 1998;79:311-318.
- Luo S, Feng Y, Zheng Y, et al. Mild and delayed-onset Proteus syndrome. Eur J Dermatol. 2007;17:172-173.
- Takebayashi T, Yamashita T, Yokogushi K, et al. Scoliosis in Proteus syndrome: case report. Spine. 2001;26:E395-E398.
- Schulte TL, Liljenqvist U, Görgens H, et al. Hemihyperplasia-multiple lipomatosis syndrome (HHML): a challenge in spinal care. Acta Orthop Belg. 2008;74:714-719.
- Robin GC, Span Y, Steinberg R, et al. Scoliosis in the elderly: a follow-up study. Spine. 1982;7:355-359.
- Brea-García B, Cameselle-Teijeiro J, Couto-González I, et al. Madelung’s disease: comorbidities, fatty mass distribution, and response to treatment of 22 patients. Aesthet Plast Surg. 2013;37:409-416.
- Hasegawa T, Matsukura T, Ikeda S. Mesotherapy for benign symmetric lipomatosis. Aesthet Plast Surg. 2010;34:153-156.
- Zeitler H, Ulrich-Merzenich G, Richter DF, et al. Multiple benign symmetric lipomatosis—a differential diagnosis of obesity. is there a rationale for fibrate treatment? Obes Surg. 2008;18:1354-1356.
- Leung N, Gaer J, Beggs D, et al. Multiple symmetric lipomatosis (Launois‐Bensaude syndrome): effect of oral salbutamol. Clin Endocrinol. 1987;27:601-606.
- Craiglow BG, Ko CJ, Antaya RJ. Two cases of hemihyperplasia-multiple lipomatosis syndrome and review of asymmetric hemihyperplasia syndromes. Pediatr Dermatol. 2014;31:507-510.
- Enzi G, Digito M, Enzi GB, et al. Asymmetrical lipomatosis: report of two cases. Postgrad Med J. 1985;61:797-800.
- Biesecker LG, Happle R, Mulliken JB, et al. Proteus syndrome: diagnostic criteria, differential diagnosis, and patient evaluation. Am J Med Genet. 1999;84:389-395.
- Biesecker L. The challenges of Proteus syndrome: diagnosis and management. Eur J Hum Genet. 2006;14:1151-1157.
- Cohen MM Jr. Proteus syndrome: an update. Am J Med Genet C Semin Med Genet. 2005;137C:38-52.
- Biesecker LG, Peters KF, Darling TN, et al. Clinical differentiation between Proteus syndrome and hemihyperplasia: description of a distinct form of hemihyperplasia. Am J Med Genet. 1998;79:311-318.
- Luo S, Feng Y, Zheng Y, et al. Mild and delayed-onset Proteus syndrome. Eur J Dermatol. 2007;17:172-173.
- Takebayashi T, Yamashita T, Yokogushi K, et al. Scoliosis in Proteus syndrome: case report. Spine. 2001;26:E395-E398.
- Schulte TL, Liljenqvist U, Görgens H, et al. Hemihyperplasia-multiple lipomatosis syndrome (HHML): a challenge in spinal care. Acta Orthop Belg. 2008;74:714-719.
- Robin GC, Span Y, Steinberg R, et al. Scoliosis in the elderly: a follow-up study. Spine. 1982;7:355-359.
- Brea-García B, Cameselle-Teijeiro J, Couto-González I, et al. Madelung’s disease: comorbidities, fatty mass distribution, and response to treatment of 22 patients. Aesthet Plast Surg. 2013;37:409-416.
- Hasegawa T, Matsukura T, Ikeda S. Mesotherapy for benign symmetric lipomatosis. Aesthet Plast Surg. 2010;34:153-156.
- Zeitler H, Ulrich-Merzenich G, Richter DF, et al. Multiple benign symmetric lipomatosis—a differential diagnosis of obesity. is there a rationale for fibrate treatment? Obes Surg. 2008;18:1354-1356.
- Leung N, Gaer J, Beggs D, et al. Multiple symmetric lipomatosis (Launois‐Bensaude syndrome): effect of oral salbutamol. Clin Endocrinol. 1987;27:601-606.
- Craiglow BG, Ko CJ, Antaya RJ. Two cases of hemihyperplasia-multiple lipomatosis syndrome and review of asymmetric hemihyperplasia syndromes. Pediatr Dermatol. 2014;31:507-510.
Practice Points
- Acquired asymmetrical lipomatosis is a rare condition that can develop at any age; it should be differentiated from existing syndromes of asymmetrical hemihyperplasia.
- Acquired asymmetrical lipomatosis is a clinical diagnosis with no laboratory changes. If the patient is clinically stable and asymptomatic, no further investigation or management is required.
