Category Archives: Elpern, David J.

Marius Rademaker Hot Spots 2018 Very Low-Dose Isotretinoin

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Very low-dose isotretinoin in mild to moderate papulopustular rosacea; a retrospective review of 52 patients. ABSTRACT BACKGROUND/OBJECTIVES: Rosacea is a chronic inflammatory disorder that affects up to 10% of the population. Standard treatments include topical azelaic acid and metronidazole or systemic tetracyclines. Isotretinoin has generally been restricted to severe disease, often at a dose of 0.5-1.0 mg/kg/day. METHOD: Retrospective review of open-label isotretinoin (initial dose 20 mg/day, with dose adjustments according to response), in patients with mild to moderate papulopustular rosacea. RESULTS: Altogether 52 patients (33 women), mean age 48 years (range 18-86) were treated with isotretinoin over a 5-year period. All patients were commenced on 20-mg isotretinoin/day which was reduced to 10-20 mg once to five times a week (equivalent to 5 mg/day) … Continue reading →

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Metastatic Basal Cell Carcinoma

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Case Presentation Metastatic BCC 2018 Hot Spots in Dermatology Presenters: Marianna F. Karewicz, NP Roman W. Glamb, MD Straub Medical Center Download Fyll Presentation:  Metastatic Basal Cell Abstract Basal Cell Carcinoma (BCC) is deemed as one of the most frequent types of skin cancer. Typically, it is regarded as localized in nature and there is a tendency to view the condition as non-malignant because the tumor rarely metastasizes (Habif, 2016). However, what if the condition became aggressive? If left untreated, BCC has the capability to spread through direct extension, destroying normal tissue and large portions of the body; even penetrating the subcutaneous tissue to bone and/or the brain. This case … Continue reading →

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Illness Narrative – Long Form

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My Illness Narrative: the Autopathography Project (If you want this in a printable form, please email D.J. Elpern djelpern@gmail.com) You may have a complex health problem that doctors have not solved. When you enter the new doctor’s office, a perky young person asks who referred you and then requests your insurance cards. Next, there are numerous forms to fill out. Then, you are seen by an assistant who records your weight, blood pressure, pulse, and even the oxygen saturation from a fingertip. Finally, the physician or his “extender” sees you for 10 – 15 minutes, at least half of which time he is focused on your electronic medical record. After … Continue reading →

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Darkness Visible: A Life of Chaos

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a chaos of hard clay. Byron, Darkness Darkness Visible: A Life in Chaos It takes almost a decade to train a physician: at least seven years for a family practitioner and up to ten for cardiac- and neurosurgeons. We become technically proficient in treating diseases, but are not as adept at treating the illnesses that people present with. How often do we get, or make, the time to really get to know our patients? Physicians are comfortable with disorders that are clear-cut: diabetes, skin cancer, hypertension, and on and on. Yet, there is a subset of humanity with medically unexplained symptoms (MUS). Thirty to 50% of people seen by primary … Continue reading →

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Medical Nemesis: The Expropriation of Health (1975)

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From the Introduction: full notes at:Medical Nemesis Illich Ivan Illich, 1926-2002 (http://en.wikipedia.org/wiki/Ivan_Illich) Introduction: The medical establishment has become a major threat to health.  The disabling impact of professional control over medicine has reached the proportions of an epidemic. Thoughtful public discussion of the iatrogenic [“physician caused”, iatros=physician & genus=birth] pandemic, beginning with an insistence upon demystification of all medical matters, will not be dangerous to the commonweal.  Indeed, what is dangerous is a passive public that has come to rely on superficial medical housecleaning. My argument is that the layman, not the physician, has the potential perspective and effective power to stop the current iatrogenic pandemic. During the last generations … Continue reading →

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Notes on Pathographies

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Notes on Pathographies: An Arabian Nights’ Experience David J. Elpern* * The Skin Clinic, Williamstown, Massachusetts Email          A few years ago, a group of us gathered in the Osler Library at McGill. Osler guided us with his words: The practice of medicine is an art, not a trade: a calling not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with powders or potions, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, the wise upon the foolish… Courage and cheerfulness … Continue reading →

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Sentinel Lymph Node (SLN) Decision Aid

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The question of whether to undergo a SLN biopsy for melanoma is a difficult one.  It is clear that some experts recommend it while others don’t.  If you live in Boston you will be told one thing.  If you live in Montreal you’ll be told another. Where does that leave a patient? In England the National Institute for Clinical Excellence (NICE) provides decision aids for many conditions. Here is their SLN Decision Aid for melanoma.  Please give it thought and discuss it with your dermatologist or surgeon.  The decision is really up to you.  It boils down to “What Matters To You.” Option-Grid-Sentinel-Node-Biopsy-yes-or-no

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Cry the Beloved Specialty

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by David J. Elpern, M.D. presented in shorter form at the Lown Institute Conference, Washington, D.C. April 9. 2018 Every peddler praises his needles. Portuguese proverb In November 2017, the NY Times published an expose about the current state of dermatology.1 It documented bizarre instances of over-diagnosis and over-treatment that are driven by ignorance and greed. Over the past 40 years, I have witnessed these changes in my specialty and am dismayed by the reluctance of my colleagues to address them. This trend began in the early 1980s when the Academy of Dermatology (AAD) assessed its members over 2 million dollars to hire a prominent New York advertising agency to … Continue reading →

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Health Anxiety in Dermatology

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Patients see doctors with varying degrees of concern regarding their health. While some require tests or treatments, a subset has severe health anxiety and cannot be reassured by tests, procedures, or pharmaceuticals but may be helped, at least temporarily, by a sympathetic listening face and reassurance. Hence, we designed a questionnaire to investigate health anxiety in patients recruited from a general dermatology clinic. The study was reported in the International Journal of Dermatology and can be accessed at this pdf: Health Anxiety in Dermatology

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MUDS: In Search of Medically Unexplained Dermatological Symptoms

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MUDS EAJDVby David J. Elpern, M.D. Medically unexplained symptoms (MUS) are relatively well-known in the literature but not discussed in any dermatology journal. A recent book, Is It All In Your Head?: True Stories of Imaginary Illness, by by the neurologist Suzanne O”Sullivan is a readable and accessible resource. While studied in primary care, neurology and rheumatology, our PubMed review found no mention of medically unexplained symptoms in a major dermatology journal. Yet two surveys conducted in my office, each of of 100 consecutive dermatology clinic patients, found that ~ 20% had some form of MUDS. This rate is congruent with the estimated prevalence of MUS.  It appears that MUDS … Continue reading →

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