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Dermatological News Dermatological News Document Transcript

  • Dermatological News Spring 2005 Edited by Lorie Gottwald, M.D. Ohio Dermatological Association, Inc. Founded 1984 A Message From the President Political issues took the forefront this spring at both the State and National level. Select physicians had the opportunity to travel to Washington, DC to lobby on behalf of medicine in general and Dermatology in specific. Under the guidance of the American Academy of Dermatology Association, individuals from states across the nation met with their respective Senators and Representatives to endorse: **A Halt to Drastic Medicare Physician Pay Cuts **Medical Liability Reform **Federal Skin Disease Research Funding As a representative for Ohio, I was able to appreciate the incredible research, preparation and organization of the AAD and AADA in their efforts to protect the interests of their constituents and the specialty of Dermatology. The AAD/AADA websites have full information and position statements regarding their positions on the above issues, and are well worth the read. Locally, ODA delegate to the Ohio State Medical Board Joe Hazel, MD has given a summary of events to watch for on the State level; please see his article. It’s clear the current atmosphere of decreasing reimbursement, rising practice costs and increasing legislation argue for strong actions to be taken by physicians. The ODA will continue to provide a watchful eye, and strongly encourages all individuals to support local and national political action committees and to contact their local and state representatives to voice these concerns . . .the time to act is before it’s too late! Lorie Gottwald, M.D. President Ohio Dermatological Association Page 1 of 11
  • Insurance Watch The ODA received notification that certain malpractice carriers in the state are increasing malpractice premiums by up to $15,000 if Botulinum toxin is used in office for cosmetic treatments. For the practitioner who offers this service as a small part of their practice and/or as a courtesy service to assure complete local care, this will prove unaffordable. The ODA needs to know if you have been affected by such a premium change, and how this will impact on you and your patients. Please contact your regional ODA representative—check out the website—or Lorie Gottwald, MD at lgottwald@mco.edu, with any information or concerns. Malpractice Update Dr. Joe Hazel Ohio Medical Malpractice Commission Releases Final Report Two years after being created under S.B. 281, the Ohio Medical Malpractice Commission released its final report detailing its findings and recommendations on the medical liability crisis in Ohio. The report largely supports the OSMA's statements over the past two years and refutes comments made by the Ohio Academy of Trial Lawyers. "We are pleased the Commission's report confirms what physicians have known all along: that Ohio's medical liability crisis is real, and that Ohio's patient population is being impacted, with significant reduction in patient services already having occurred," said Steve Combs, MD, OSMA president. According to the Commission report: • Rising medical liability insurance premiums have affected physician behavior and a significant reduction in patient services has occurred; • Ohio's medical liability reforms are beginning to stabilize the medical liability insurance market and are giving insurers confidence to continue or begin service in Ohio. In 2002, the average rate increase was 32%. This year, the average increase will be less than 8%; • The cost of defending and settling claims drove increases in premiums; and • Ohio should pursue a statewide, anonymous, voluntary & non-punitive medical error reporting system that focuses on "systems" within healthcare delivery and recognizes that an adverse event may be caused by a failure in the system and not a personal error. Some of the Commission's recommendations include: • Ohio should retain the provisions in Senate Bill 281 (2002); • Upon OSMA's recommendation, "investigate the economic implications of the Medical Liability Underwriting Association providing 'tail' coverage if the original insurer becomes insolvent or stopped doing business in the state." • All medical liability carriers should be required to justify their rates annually, regardless of whether the carrier is seeking a premium increase; • Investigate programs that forgive educational loans for physicians who remain in Ohio; • Investigate the regulation of captives in Ohio; The Commission report will be distributed to all members of the Ohio General Assembly. Any further action must be taken by the General Assembly. Page 2 of 11
  • Joint Regulatory Statement Update The Ohio State Medical Board and the Ohio State Board of Cosmetology have been working together to provide a Joint Regulatory Statement Regarding the Provision of Esthetic, Cosmetology and Related Services. While the Medical Board had tentatively approved a draft of this statement as presented in the last newsletter and website, the Cosmetology Board has questioned some of the language/definitions contained therein. Thus, the Joint Regulatory Statement awaits approval; notification regarding its final passage and form will be available as soon as the ODA becomes aware. Reminder—Office-Based Sedation The ODA would like to remind all physicians who use moderate sedation in their offices that they must be accredited by July 1, 2005. The State Medical Board of Ohio adopted rules concerning office-based surgery that were effective January 1, 2004. Rule 4731-25-07, Ohio Administrative Code, requires accreditation of the office setting by one of four named groups. Physicians who were performing office-based surgery in an office setting that was not accredited prior to the effective date of the rules were given eighteen months in which to apply for accreditation and an additional eighteen month following application to achieve accreditation. If you perform procedures or surgery in your office using moderate sedation/analgesia or anesthesia services, and you are not licensed by the Ohio Department of Health as an ambulatory surgical facility, these rules most likely apply to you. The deadline for applying for accreditation of the office-based setting is July 1, 2005. Application must be made to one of the four accrediting bodies recognized in the rule by that date in order to perform office-based surgeries. The four groups recognized are: The American Association for Accreditation of Ambulatory Surgery Facilities, Inc (AAAASF—www.AAAASF.org) The Accreditation Association for Ambulatory Health Care, Inc (AAAHC— www.AAAHC.org) The Healthcare Facilities Accreditation Program of the American Osteopathic Association (HFAP—doonline.org) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO— www.jcaho.org Thanks to Donald Mottley, Esq for assisting the ODA with these updates Dumb Insurance Policy of the Season Submitted by Robert Brodell, M.D. Medicaid will not cover a retinoid for the treatment of acne for age 23 and over unless the patient has failed on two other formulary acne products. Most dermatologists would agree that the patient will get better faster if using systemic antibiotics and/or topical antibiotics plus a retinoid to unclog pores. When the patient improves on antibiotic medication alone and this is stopped, the acne usually promptly recurs; thus necessitating the patient to continue antibiotic therapy for the long term and increasing the cost to the insurance company. Please feel free to submit your “Dumb Insurance Policy of the Season! Page 3 of 11
  • A Dermatologic Diary Walter B. Shelley, M.D. and E. Dorinda Shelley, M.D. Meeting Excellent advice from Dr. Ira L. Skolnik (Concord, MA), a pediatric dermatologist, at the January Noah Worcester meeting in Florida: Always make eye contact with the infant, child, or teenager. This involves keeping yourself at eye level with the child, and may require squatting down. Greet the child first, perhaps with a “High-five” sign. Later, the parent. Have the child give the history first (if over 5 or 6 years old). Be a good listener. Sit down. Unclothe only the necessary area. Use small, understandable words. Don’t ambush the child. If possible, perform any procedure at a separate visit. Rehearse the procedure ahead of time to alleviate fear. Don’t let the child see or hear the instruments (avoid clanging). Sedate child with Benadryl, Atarax, a benzodiazepine, or acetaminophen with codeine. Test beforehand to avoid a hyperactivity reaction. Apply EMLA or LMX 30-60 minutes prior to surgery. Before injection, apply pressure with finger. Distract child – have parents sing with child or play with favorite toy. Remember that teenagers want to be treated as adults. Speak directly to them and explain why a problem needs to be treated. If under 18, need informed parental consent signed for procedures. Schedule frequent follow-up visits. Talk to both parents in examining room. Have them repeat instructions. Give handout on instructions. Block off extra time for rare conditions. Refer parents to support groups and specialists. At the Michigan Dermatological Society on April 6, 2005, the Arthur C. Curtis Lecture was given by Jonathan NWN Barker, M.D., FRCP, Professor and Chair of Dermatology, St. Johns Institute of Dermatology, St. Thomas Hospital in London. In 1989 the old St. Johns Hospital for skin diseases (founded 1863 in Soho) moved to its present location across the Thames River from Parliament. They have 60,000 out- patient visits (60% tertiary care) and 250 inpatients per year. In their Severe Psoriasis Clinic they see 250 new patients per year, of whom 10-25% have arthritis. Methotrexate is their gold standard of treatment, for both skin and joints, given with folic acid supplementation. Use 2.5mg/wk in the elderly. They don’t do liver biopsies routinely (only if indicated) or check LFT’s too often. Many of their patients have taken methotrexate for many years (up to 40) with no problems. In his opinion, hepatic fibrosis is most often caused by steatosis associated with obesity, a major USA problem. Other treatments they like include: cyclosporin A for a “quick fix” short term, used intermittently; narrowband UVB or bath PUVA for phototherapy, with traditional PUVA used only rarely due to risk of skin cancer; hydroxyurea helps 50% of plaque- type psoriasis, well-tolerated by the elderly; fumaric acid esters (1st line treatment in Germany, helps 50% of patients). And the new biologics? They are often effective and help prevent joint destruction, but are very expensive and don’t always work, so are not used commonly. Page 4 of 11
  • Scanning the Literature Do you have a patient with a puzzling dermatitis? It could be due to food sensitivity. A simple entry point is a single patch test to Balsam of Peru. If it is positive, your patient may be sensitive to oranges, chocolate or Coca Cola (Dermatologic Therapy 2004;17:264). Rapamycin (sirolimus), an immunosuppressive drug, completely cleared the lesions of Kaposi’s sarcoma within three months. Might it work topically? (NEJM 2005;March 31) Bosentan, an endothelial-receptor antagonist, proved effective for a 50-year-old man with severe digital ulceration from progressive systemic sclerosus. After two weeks (dosage 62.5mg bid) the ulcers were healing and pain had lessened, and after four months he was virtually cleared (Ann Int Med 2005;142:802). Botox® injections for palmar hyperhidrosis are so painful they require a nerve block. It was exciting to see this can be avoided by delivering the Botox® by iontophoresis (Br J Dermatol 2004:151-1093). Therapy can be a marvelous diagnostic tool. A scaling fissured growth on the right index finger had persisted 6 years following injury with a sewing needle, with no diagnosis established. Antitubercular therapy (rifampicin, isonicotinic acid and ethambutol) was curative. It was a case of tuberculosis verrucosa cutis where no organism could be found on biopsy (Internat J Dermatol 2005;44:220). Epidermal desquamation is virtually ignored, but this classic review documents how scales protect us from microbial invasion and how they shed toxins. They are the hand-maidens of excretion (J Dermatol Science 2004;31:131). Readers of Science were treated to a full color sketch of skin showing how the epidermis is anchored to the dermis by fibrils of Collagen VII, produced by keratinocytes. Mutations in Collagen VII cause dystrophic epidermolysis bullosa. If mutations result in retention of a crucial fragment of this collagen, malignant squamous cell epithelioma develops (Science 2005 March 18;307:17-27). In the lab scientists are making a giant stride in gene therapy. They can chop RNA into pieces (small interfering RNA, i.e. si RNA), which conglomerates with protein to make up RNAi machinery (RSC complex). Before you yawn, you should gasp, since this RSC complex is a magic bullet that can specifically destroy any mRNA with a complementary sequence. Out go the bad guys, without disturbing a single good guy! (Stanford Medicine, Winter 2005;p.14) Now you can take sharp close-up digital photos 1.2 inches from your patient’s skin lesion. This 8 mega pixel Nikon® Coolpix 8800 camera ($725) also allows you to take movies of the birth of a sweat droplet or the dynamics of wrinkling. Or you can record 60 seconds of a louse’s wandering in Pubic Land (New York Times, February 24, 2005;p. E1) To see flowers the way bees do, without our lens filter for ultraviolet rays, or the way we would see if aphakic, go to www.naturfotograf.com Don’t sell stock to pay for your child’s college education. Give it to him outright. When he sells it, the tax will be only 5%. Note you must have owned the stock for more than one year. You and your spouse can give a total of $22,000 each year gift tax free (Smart Money, March 2005; p. 65). Page 5 of 11
  • In 1989 Stephen Fodor and associates invented the DNA microarray, which today gives researchers the ability to analyze expression from tens of thousands of different genes simultaneously. Using the GeneChip® arrays (Affmetrix, Santa Clara CA) investigators can look at the entire genome at one time, comparing disease states with the normal. Furthermore, they can identify drugs that disrupt expression of the disease genes. It is an exciting time for personalized drug therapy (Am Biotech Lab 2005;23:34). The Intel Science Talent Search First Prize went to a 17-year-old, David Nye, for designing a fluorescent nanocrystal sensor that detects neurotoxins. Nanotechnology is our future (Science 2005;307:1869). When Alexander Fleming discovered penicillin in 1928, his mold, Penicillium notatum, produced only trace amounts. For commercial production of penicillin, the pharmaceutical companies utilized Penicillium. chrysogenum which churns out a thousand times more than the original mold. A single genetic mutation now explains this phenomenal production of penicillin. Both molds produce the same precursor acid, but a gene defect in P. chrysogenum prevents conversion to anything but penicillin (Science 2005;307:1867). Do you want to graph or statistically analyze thousands of values from your clinical observations, or do you want to display images of your skin lesions? Then IGOR Pro 5 is your invaluable associate (Phone 503-620-3001). There are over 700 species of micro-organisms in your patient’s mouth. The best known is Streptococcus mutans, which colonizes every tooth of almost every child, and generates lactic acid that erodes enamel. Ninety-two species live on the tongue and half dozen account for halitosis. Now the plan is to colonize the mouth with genetically altered S. mutans incapable of generating lactic acid. Yes, sweet smelling organisms for the tongue are on the way (Science 2005;307:1901). For a wonderfully detailed introspective essay on physicians’ incomes, read the account of Atul Gawande, a young doctor being recruited by a clinic in Boston (New Yorker, April 4, 2005;p. 44). We get about 20 mail order catalogues a week. We think a shrewd marketer should send them to our clinic for patients to peruse. The Hammacher Schlemmer Catalogue (Spring supplement 2005) describes the only FDA-cleared device for motion sickness. Worn like a wrist watch, it transmits gentle electrical signals (five settings) that convince the brain that all is perfectly steady. Cost $99.95. As a physiologist WBS sees this unit being far more effective in an ear plug. Personal Communication A letter from Dr. Levon Zenian in Syria describes a 60-year-old patient with severe progressive hair loss unresponsive to treatment with biotin or zinc. Cure came when he eliminated the olive oil (2oz/day) from his diet. 2-23-05. E. William Rosenberg, M.D. taught us that the sunscreen, Coppertone®, prevents sunburn even when applied immediately after sun exposure. Page 6 of 11
  • Word Origins from Greek Gill: Lip. Mesopotamia: Between-rivers, i.e. the Tigris and Euphrates of Iraq. Hippopotamus: Horse in river. Cynosure: Dog’s tail, refers to the North Star of the Ursa Minor Constallation Medicine: Preserving the Passion in the 21st Century, Second Edition 2004, by Phil Manning and Lois De Bakey. This little paperback will push the Refresh button on your brain. As bedside reading, it will help you sleep better and wake up smarter. Historical Tales of Toledo By Clint Mauch – available from the Toledo Rotary Club; 419-241-7060 Each story holds your attention. In sum, it is a rare treasure with great photographs. A Short History of Nearly Everything By Bill Bryson 2003 An enchanting story of the universe, our planet, and the lives on it. He makes facts read like fiction, telling personal stories of their origin. Want to actually see particles from the beginning of time? Turn on your television to any channel it does not receive. One percent of the dancing flashes on your screen are actual particles from the birth of the universe, traces of the Big Bang Explosion still being seen billions of years later. Overheard An elderly woman in a nursing home complained about her exercise bike, “I don’t understand why I have to ride this. It doesn’t go anywhere!” Persuasion is an art. We like the story of the man who was unhappy when his wife had her hair cut short. Instead of an ineffectual, “I like it better long,” he simply said, “Amazing, how short hair makes your nose so prominent.” We often get 2 copies of things dermatologic, including journals. Why does EDS insist on keeping both copies? Because, it doubles our chances of being able to find what we’re looking for! Page 7 of 11
  • Horse Sense Craig G. Burkhart, MPH, M.D. Greetings! Hopefully everyone is reading their ODA newsletters. Let us check the headlines for this issue. Contact Urticaria from Mars!! Did you see that recent case of intermittent lip swelling and itching from biting open the wrapper of a Mars chocolate candy bar (Clinical and Experimental Dermatology 2005;30:187-193). The manufacturer confirmed that they had used natural rubber latex in their cold-sealed wrapper. Such is also the case with Kit Kat. Thus, latex-sensitive patients must avoid biting open the wrapper of certain candy bars until the manufacturers can develop a satisfactory latex-free synthetic coldsealant for their products. Check your condoms for carcinogens In the March issue of Molecular Nutrition and Food Research, Kathi Ellendt reported that balloons and condoms that come in contact with body fluids discharge nitrosamines as by-products of the vulcanizing process used to strengthen rubber elasticity. Nitrosamines are suspected of being human carcinogens. Indeed, some countries have strict nitrosamine concentration levels allowed for baby-bottle nipples and other infant products in place. If patients ask, the researchers immersed unrolled condoms for one hour in a solution resembling human sweat. Nitrosamine levels of up to 660 micrograms per kilogram of condom were quantitated. Possibly patients using condoms should be instructed to use such ornaments for less than one hour per usage. Light might not be all bad The American Psychiatric Association commissioned research on use of bright lights for pathologic depression. The American Journal of Psychiatry in April suggests that light is about as effective as antidepressant drugs for psychiatric mood problems. Light is best administered early in the morning for 30 minutes to one hour. No new news Staying with depression, J. Douglas Bremner from Emory studied positron emission tomography (PET) scans on a group of 28 people with acne has stated that isotretinoin showed decreased activity in the orbitofrontal cortex, the brain region that controls mood and social interactions. Patients on antibiotics did not have these alterations. This data still has not been published. I have been flattered that one of our Ohio colleagues has asked me to review one of the topics which I have previously addressed in the literature, namely blastomycosis. Page 8 of 11
  • A Non-Textbook, Non-Invasive Diagnostic Test for Pulmonary Deep Fungal Infections Although the medicine focuses on high technological, expensive, state-of-the-art methods to diagnose systemic fungal diseases, I would like more consideration of a non-textbook, non-invasive test. Fungal infections are acquired primarily by inhalation and spread via lymphohematogenous dissemination can be found in various organs such as the lungs, liver, spleen, and central nervous system. Serological tests are often not positive requiring diagnosis by such pulmonary procedures as bronchial lavage, bronchoscopic brushing and bronchoscopic needle aspiration, video-assisted thoracic surgery and thoracotomy. I have suggested that examination of one’s excreta may be all that is necessary.1 Inasmuch as patients with pulmonary deep mycoses cough and swallow their sputum, there are now three articles suggesting that stool cultures may be a viable, yet dirty, method to confirm a diagnosis of pulmonary fungal disease.1-3 I query whether this patient-friendly diagnostic ‘procedure’ for deep mycoses may be overlooked by the writers of medical textbooks and our procedure-oriented physicians and surgeons. 1. Burkhart CN, Burkhart CG. Stool cultures to prove blastomycosis. J Am Acad Dermatol 2004;50:486-7. 2. Baumgardner DJ, Paretsky DP. Identification of Blastomyces dermatitidis in the stool of a dog with acute pulmonary blastomycosis. J Med Vet Mycol 1997;35:4419-21. 3. Witorsch P, Utz. North American blastomycosis: a study of 40 patients. Medicine (Baltimore) 1968;47:169-200. Congratulations to Brodell Medical! Bob Brodell, MD and his medical staff deserve acknowledgement for their significant contributions to the American Cancer Society Relay for Life. Brodell Medical raised an impressive $56,476 dollars to “Focus on a Cure,” topping their friendly rival/ “arch nemesis” Antenucci Plumbing by $35! Dr. Brodell—also known as “Dr. Bob”—received further accolades as he became one of only five individuals inducted into the National Relay for Life Hall of Fame. The Ohio Dermatological Association is extremely grateful to Dr. Brodell for establishing such a strong relationship with the American Cancer Society, benefiting both organizations through the promotion of skin cancer awareness and charing of critical resources. Please watch for the announcement of Dr. Brodell’s Summer CME program, as the ODA/ACS partner ship continues! Know of an amazing Dermatologist or practitioner that deserves recognition? Want to get involved in Relay for Life or other ACS activities? Contact us through the ODA website or via your regional representative! Page 9 of 11
  • Do you know a Dermatologist in Ohio who is not a member of the ODA? A membership application can be downloaded from the website www.ohderm.org or contact our Executive Director, Cynthia Bartunek. cell/VM: 330.720.3847 Fax: 330.392.5870 OdaExec@neo.rr.com Have an Idea? ODA Welcomes Newsletter Suggestions Please send newsletter articles, information, suggestions and comments to the Editor, Lorie Gottwald, M.D. via e-mail at lgottwald@meduohio.edu for publication. Page 10 of 11
  • Mark Your Calendars! 2005 Ohio Dermatological Association Annual Meeting Hilton Columbus at Easton Town Center Friday, October 14th – Sunday, October 16th Online reservations at www.hilton.com Code word is DRM. Registration information will be sent in August The Summer CME is scheduled for Saturday September 10, 2005 at the "beautiful Avalon Inn" , Warren, Ohio Page 11 of 11