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 pandemic has forced changes and adaptations within 

. At the surface level, physicians have had to shift to telemedicine and determine which areas within their own practice continue to be viable.

Patients have faced postponement or cancellations (voluntary or not) of consultations and procedures.

In spite of this reality, dermatological care—and the healthcare industry at large—has continued serving and meeting patient needs to the best of their ability.

Furthermore, with a nationwide and global vaccination campaign fully underway, procedures and care practices that have been placed on halt are likely to resume for many clinicians.

Of course, this is a story well-known and often told. 

And yet, how might this past year have looked for a cosmetic dermatologist?

Brad Glick, DO, FAAD, sought this perspective in the latest episode of 

He sat down with Valerie Callender, MD, an internationally recognized dermatologist based in Genn Dale, Maryland, to talk with her about the challenges and shifts within her practice over this past year.

Callender discussed how dermatology and her practice have fared in light of these health measures, which procedures have been most affected by them, and what the outlook is for the future.

She also gave insight into her care practices and strategies, with particular consideration for the needs and expectations of patients of color.

Podcasts

Valerie Callender, MD, draws on her experiences in clinical practice to discuss cosmetic dermatology care practices and the challenges of this past year. 

News

Dermatology

Plaque Psoriasis

Internal Medicine

Valerie Callender, MD: What's New in Cosmetic Dermatology

As a specialist in physician health, I have gained an enormous amount from a long career of looking after medical colleagues. One of the lessons has been humility. What follows is adapted from my new book 

“I have never entirely escaped the view that being a doctor is something of a moral luxury, by which doctors are easily corrupted. We can so easily end up complacent and self-important, feeling ourselves to be more important than our patients.” 

My doctor-patients have taught me humility. Many of them are complex, and they’ve challenged my competency and skills. Some have fired me. Some have threatened to sue or report me to the medical licensing board. Some have taken their lives. With this comes infinite soul searching, and a degree of professional modesty, an acceptance of my limitations. It’s become easier to say: “I don’t know.” And to see my mistakes, to sit with them, and to apologize. One psychiatrist put it crisply: 

“One of the most profound human interactions is the offering and accepting of apologies.”

 (New York: Oxford University Press, 2004) 1.

I do not believe that these realizations or insights into myself are unique to those who treat physicians. They are the trajectory of all clinicians as the years of practice lengthen. No way of proving it, but I would argue that treating physicians has hastened or enhanced a particular kind of humbleness in me. And this has served me well, not just for personal gain, but for my professional growth.

Many of my doctor-patients have mirrored humility in my office, and I have tried hard to capture and emulate their posture. How can you not when you are present at their diminishment, vulnerability, simple humanness, and rawness in their hour of need? Many have been brought to their knees by their battles with alcohol or depression, ugly divorces, dismissal from their jobs, or suspension of their medical license. As they make progress, begin to feel better, understand themselves in more depth and reach a healthy stage of pondering and expansive thinking, some utter statements like this: “I think there’s a silver lining to this nightmare. It’s changed me. I’m a nicer person. Kinder.” I’ve been tempted to blurt out “me too,” but I don’t.

Dr. Norris, a radiologist, came to see me in the throes of leaving her husband, a transplant surgeon. Her children were now on their own and she finally felt emancipated, free to extract herself from a stifling, abusive marriage. She did well for the first six months or so, but she developed a recurrence of a depression that she experienced years earlier after the birth of her second child. She fell fast, nearly attempted suicide, and I had to hospitalize her. But she prevailed, responded nicely to treatment, and was safe to leave after three weeks. I looked after her for about five years.

I want to highlight here what kind of a person she was. Highly accomplished, Dr. Norris headed her department, one of the few women chairs at that time. This came with an international reputation in her field, and accolades and national awards outside of medicine for her pioneering role modeling for women’s achievement. We worked at the same medical center, where she was a household name. When I needed to hospitalize her, I planned to have a colleague look after her at another hospital, respecting her privacy. She would have none of it. She insisted on being treated where we both worked. She allayed any awkwardness in the nursing staff, or anxiety in the medical students or residents, by just being her authentic self. She never pulled rank, and all of the trainees involved in her care marveled at her disposition. She was warm and expressive and full of gratitude for all we did for her.

Dr. Norris’s humility was a gift to me, and one that extended beyond myself. Just after I signed her release and she left the ward to go home, both the medical student and psychiatry resident who assisted me in her care talked about the impression she made on them. They admired what kind of patient she had been—very ill, but not embarrassed to be a doctor-patient on a mental health service. How she bore her illness with fortitude, dignity, and grace. How kind she was toward them. And should they ever be admitted to a psychiatric unit themselves, that remembering her might make the experience of it less burdensome for them.

, is Professor of Clinical Psychiatry and recent past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Health Sciences University in Brooklyn.

He is the author or co-author of eight other books, including

The views expressed in the article represent those of the author, not necessarily those of the publication.

Clinicians and experts interested in responding to this piece, or submitting their own articles to

Articles

A doctor writes on his experiences in treating colleagues in his psychiatry practice, and the humility he's gained from it.

Psychiatry

Lessons Learned from My Doctor-Patients

Food allergy immunotherapy may be heavily influenced by age of initiation.

Investigators from the University of North Carolina School of Medicine 

American Academy of Allergy, Asthma & Immunology (AAAAI) 2021 Virtual Sessions

 last week showing sublingual immunotherapy (SLIT) initiated in children with peanut allergy aged 1-4 years old resulted in significant desensitization to the allergen and sustained unresponsiveness to allergen exposure months after ending once-daily SLIT.

The research, presented by Edwin Kim, MD, MS, builds on previous assessment of SLIT by himself and colleagues which showed the benefit and safety of the 

LEAP Study-informed allergen exposure treatment plan

 in a slightly older pediatric patient population.

With evidence that even younger patients benefit more greatly and for longer, and with the lone regulated peanut immunotherapy 

AR101 (PALFORZIA) being indicated for ages 4-17

, Kim and colleagues are making progress on a promising pathway of research for allergen desensitization.

, Kim discussed the AAAAI 2021 trial results, what may drive earlier immunotherapy response, and what other allergens may be considered for research.

: What were your thoughts on the trial outcomes?

 We're so happy about this, I mean, for multiple reasons. One point I'll make right up front is the ability to go down to this young age, to me, is vitally important. Of course, I think we're trying to promote the LEAP guidelines with early introduction of peanut to try to prevent allergy. And we think that will be successful, but at the same time, we know that there's still going to be kids that are allergic. And I think with the LEAP guidelines, because of that, we're going to start capturing these kids even younger from when they're first diagnosed.

So, to be able to have treatments that we can immediately offer these kids as soon as they are diagnosed, I think is going to be really important for these kids and for their families. Number one, that comes to mind as far as trying to be able to go younger.

Then number two is this kind of hypothesis of the immune systems of these younger kids potentially being more responsive to these treatments is something we've suspected. I feel like our data is small, but seems to support that concept as well. Because our study we published in 2019, that group was on average about age 7. And we saw good effects there. But now that we go down to an average age of 2, those effects are much stronger, where we've got kids routinely eating 4000 milligrams—like 15-16 peanuts without any symptoms at all. And then a bunch of them hanging on to it for at least 3 months without any treatment, which is far stronger than what we saw with the older kids.

I think there's a lot of excitement with our own group that this is real, that this is something that really can become a benefit to these young kids in the future.

What factors do we believe are driving the increased benefit of earlier sublingual immunotherapy initiation in young children? Are there key characteristic differences between the average toddler patient versus a seven-year old?

 It's in hypothesis mode right now as well. But I think a question that I still want to understand, and I think other researchers out there are thinking the same, is trying to separate out whether it's actually chronological age, or is it their IgE level, their peanut-specific testing levels? Because we do know that early on in diagnosis that your IgE level, your skin test levels, are going to likely be on the small side. And then over those first few years of life with the allergy, those numbers, oftentimes will go up until they find their final steady level or whatever you want to call it. That maintenance level.

So, not surprisingly, in our cohort, these young kids, they do have smaller IgE levels. So which one is it? Is it the age? Is it IgE? Is it both? I don't know that we know that answer just yet. But we're hoping to be able to, as we analyze the the lab stuff that we have from this cohort more in-depth, as well as other studies out there looking at the same age group. We're trying to separate that piece out. The idea that those IgE levels and the skin test change a lot in the first year or so goes back to this concept of, is their immune system more moldable? Or is it more willing to change, versus maybe when you're older, your immune system is more set.

I think those are all the thoughts that we have right now. Older kids can respond, there's no doubt about that. I don't want people to get the wrong message that you age out, and you can't get better. But at least our data seems to suggest if you can start earlier, that may give you an a slightly better and a slightly longer-lasting benefit.

What is it particularly about peanut that has made it the most promising prospect for allergen immunotherapy assessment?

 The field sort of just naturally went there, and I think the main reason is that peanut is a very prevalent allergy and the numbers keep going up. But it also tends to be the one that's more severe, it tends to be the one that people don't outgrow. They really hang on to it for life. So, for all those reasons, I think it made sense that peanut is where we started.

But I would guess that more than half of the patients that we see for peanut allergy have other allergies at the same time. And there are plenty of kids out there who are allergic to other things and not peanut. So, this is very much proof that the concept works, that we're not crazy. But I think we very much need to and want to be able to expand this to to the other foods that people can be allergic to—and maybe multiple foods. Not only should we be thinking about can we do SLIT for milk, but we should be thinking can we do SLIT for milk, egg and peanut at the same time.

And there's definitely growing research looking at multiple allergens simultaneously. A lot of work coming out of Stanford is in that area using the the flours in oral immunotherapy. But when thinking about future directions for what we're doing for SLIT, that's very high on the list of how do we get this concept to other foods. I think instinctively, it seems like it should be pretty amenable to multiple foods at the same time. You just mix a bunch of liquids together and go for it. And maybe it's a lot easier than it might be to try to do an adjusted form. So that's very much a direction we want to go.

Younger patients are faring better, and for longer, with sublingual immunotherapy. A leading investigator discusses what more needs to be learned in the burgeoning field.

Allergy

Pediatrics

Family Medicine

Edwin Kim, MD, MS: Uncovering the Factors of Peanut Allergy Immunotherapy

Researchers are pursuing a new way to screen and identify patients who might reject 

A team, led by Rania El Fekih, MD, Renal Division, Transplantation Research Center, Brigham and Women’s Hospital and Children’s Hospital, Harvard Medical School, used urine samples with matched biopsy samples to isolate urinary exosomal mRNAs and developed rejection signatures on the basis of differential gene expression.

Often the traditional biomarkers used to monitor a kidney allograft for rejection are late markers for injury and lack the needed sensitivity and specificity. However, allograft biopsies are invasive, but costly, showing the need for a noninvasive clinical test that can accurately diagnose kidney allograft rejections to improve allograft outcomes.

In urinary exosome, tiny vesicles released into the urine that carry parent cells’ proteins and nucleic acids, reflect the biologic function of the parent cells within the kidney, including immune cells. Urine is stable enough to make them a useful tool for liquid biopsies and a noninvasive diagnostic biomarker for kidney-transplant rejection.

The investigators used 192 of 220 urine samples with matched biopsy samples from 175 patients who underwent a clinically indicated kidney-transplant biopsy.

To assess the performance of the signatures on multiple data subsets, the investigators used cross-validation.

The investigators found an exosomal mRNA signature discriminated between biopsy samples from patients with all-cause rejection and those with no rejection. This yielded an area under the curve (AUC) of 0.93 (95% CI, 0.87-0.98), which was significantly better than the current standard of care (increase in eGFR AUC, 0.57; 95% CI, 0.49-0.65).

In addition, the exosome-based signature’s negative predictive value was 93.3% and its positive predictive value was 86.2%.

While using the same approach, the researchers identified an additional gene signature that discriminated patients with T cell-mediated rejection from those with antibody-mediated rejection (with an AUC of 0.87; 95% CI, 0.76-0.97), with a negative predictive value of 90.6% and positive predictive value of 77.8%.

“Our findings show that mRNA signatures derived from urinary exosomes represent a powerful and noninvasive tool to screen for kidney allograft rejection,” the authors wrote. “This finding has the potential to assist clinicians in therapeutic decision making.”

Despite effort and acknowledgement, new research shows kidney transplantation has not improved much in the last 2 decades for patients with 

In recent decades researchers have extensively researched and promoted different policies to improve access to kidney transplants for patients with end-stage kidney disease. However, there is still wide variation in transplant referral rates existing between different dialysis facilities.

The study included 1.3 million adult patients in which the cumulative four-year WLT was 29.7%. This was unchanged over the course of 5 eras. The preemptive WLT prior to dialysis increased by era from 5.2% in 1997-2000 to 9.8% in 2013-2016.

Discovery and Validation of a Urinary Exosome mRNA Signature for the Diagnosis of Human Kidney Transplant Rejection

Journal of the American Society of Nephrology

Traditional screenings for kidney allograft rejections can be expensive and invasive, highlighting the need for new methods.

Hospital Medicine

Nephrology

Urine Sampling Might Better Forecast Kidney Allograft Rejection

Findings from a new study confirmed the efficacy of terlipressin in adults with cirrhosis and 

Although the vasoconstrictor led to improved renal function, it was nonetheless associated with serious adverse events, including respiratory failure.

The phase 3 CONFIRM trial, led by Florence Wong, MD, Department of Medicine, University of Toronto, evaluated patients with HRS-1, cirrhosis, ascites, and rapidly progressive kidney failure.

The primary outcome sought by the investigators was verified reversal of HRS, which they defined as “2 consecutive serum creatinine measurements of 1.5 mg per deciliter or less at least 2 hours apart and survival without renal-replacement therapy for at least 10 days after the completion of treatment.”

Wong and colleagues randomized a total of 300 patients 2:1 to receive terlipressin or placebo, with a recommended addition of albumin.

Treatment was administered for up to 14 days, and included intravenous administration of 1 mg of either agent over 2 minutes every 5.5-6.5 hours.

“On day 4, patients with a serum creatinine level that had decreased by less than 30% from the baseline level after a minimum of 10 doses of terlipressin or placebo could receive 2 mg every 6 hours, except in those with coronary artery disease, circulatory overload, pulmonary edema, or bronchospasm,” noted the investigators.

As such, of the entire population, verified HRS reversal was identified in 32% of patients in the terlipressin group and 17% in the placebo group (

“With respect to the prespecified secondary end points," the team wrote, "HRS reversal, defined as any serum creatinine level of 1.5 mg per deciliter or less during the first 14 days, was reported in 78 patients (39%) in the terlipressin group and 18 (18%) in the placebo group (

Further, 34% in the terlipressin group and 17% in the placebo experienced HRS reversal without renal-replacement therapy by day 30 (

The investigators also noted that 84 patients in the terlipressin group and 48 patients in the placebo group had systemic inflammatory response syndrome. As such, 37% and 6%, respectively, likewise experienced verified HRS reversal without recurrence by day 30 (

Verified reversal of HRS without recurrence by day 30 occurred in 26% of terlipressin patients and 17% in the placebo group (

Liver transplantation occurred in 23% in the terlipressin group and 29% in the placebo group at day 90; however, death occurred in 51% of terlipressin-users and 45% of placebo-users.

Adverse events, including abdominal pain, nausea, diarrhea, and respiratory failure, were reported more often with terlipressin than placebo.

And finally, death within 90 days due to respiratory disorders occurred in 11% of terlipressin patients and 2% in placebo patients.

“Overall, the results of the CONFIRM Study are in accordance with the data from previous clinical trials that provided evidence that terlipressin improves kidney function in patients with HRS-1,” indicated Wong and team.

Nonetheless, they cautioned use of the drug in patients who are more advanced in liver disease—citing the increased risk for adverse events and death.

Terlipressin plus Albumin for the Treatment of Type 1 Hepatorenal Syndrome

Use of the vasoconstrictor was associated with increased risk for death due to respiratory disorders.

Hepatitis C

Study Confirms Efficacy of Terlipressin for Type 1 Hepatorenal Syndrome

Sleep has increased since the beginning of the pandemic in college students, while social activity has decreased. 

Coronavirus

Infectious Disease

Major Depressive Disorder

Sleep

Depression Increased as Physical Activity Decreased During COVID-19 Pandemic

The approval is based on absolute efficacy data from 3 influenza seasons. 

Influenza

FDA Expands Pediatric Indication for Cell-Based Quadrivalent Flu Vaccine

Exposure to PPIs was associated with a moderate increase in the risk of community-acquired C diff infection, even after treatment discontinuation. 

C Difficile Infection

Gastroenterology

Elevated Risk for C diff with Proton-Pump Inhibitor Use

The indication makes the IL-6 inhibitor the first biologic approved for treating pulmonary function in patients with the rare disease.

Pulmonology

Rare Disease Report®

Rheumatology

FDA Approves Tocilizumab for SSc Interstitial Lung Disease

Risk was greater in children requiring intensive care, those with chronic kidney disease, and older patients.

Ibuprofen Use in Children Linked to Hospital-Acquired Kidney Injury

Genetically-indexed inhibition of TNF-TNFR1 signaling was predicted to reduce the risk of Crohn’s disease and ulcerative colitis, and increased the risk of multiple sclerosis.

Geriatrics

Neurology

Parkinson Disease

TNF Treatment Fails to Prevent or Delay Parkinson Disease in Clinical Trial

Albumin infusions did not result in statistically significant differences in predefined study endpoints.

Albumin Treatment Not Necessarily Better for Cirrhosis Patients

The study underscores the importance of interpreting patient-reported disease severity scores in the context of mental health factors.


Anxiety, Depression Linked to Patient Overestimation of Psoriasis Severity 

More patients also achieved endoscopic and histologic remission in the treatment group compared to the placebo group.

Ulcerative Colitis

ABX464 Results in Clinical Remission for Ulcerative Colitis Patients

Patients ≥65 years using glargine or detemir, rather than NPH insulin, had lower risk of hospitalizations or emergency department visits due to hypoglycemia. 

Latest Clinical News

Valerie Callender, MD: What's New in Cosmetic Dermatology

Lessons Learned from My Doctor-Patients

Edwin Kim, MD, MS: Uncovering the Factors of Peanut Allergy Immunotherapy

Urine Sampling Might Better Forecast Kidney Allograft Rejection

Study Confirms Efficacy of Terlipressin for Type 1 Hepatorenal Syndrome