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Negative chest x-ray to rule out pediatric pneumonia
, researchers say.
In a paper published in the September issue of Pediatrics, researchers report the results of a prospective cohort study in 683 children – with a median age of 3.1 years – presenting to emergency departments with suspected pneumonia.
Dr. Susan C. Lipsett, from the division of emergency medicine at Boston Children’s Hospital, and co-authors, wrote that the use of chest radiograph to diagnose pneumonia is thought to have limitations such as its inability to distinguish between bacteria and viral infection, and the possible absence of radiographic presentations early in the disease in patients with dehydration.
In this study, 457 (72.8%) of the children had negative chest radiographs. Of these, 44 were clinically diagnosed with pneumonia, despite the radiograph results, and prescribed antibiotics. These children were more likely to have rales or respiratory distress and less likely to have wheezing compared with the children with negative radiographs who were not initially diagnosed with pneumonia.
Among the remaining 411 children with negative radiographs – who were not prescribed antibiotics – five (1.2%) were subsequently diagnosed with pneumonia within 2 weeks of the radiograph. These five children were all under 3 years of age, but none had been treated with intravenous fluids for dehydration. Only one had radiographic findings of pneumonia on a follow-up visit.
Counting the 44 children diagnosed with pneumonia despite the negative x-ray, chest radiography showed a negative predictive value of 89.2% (95% confidence interval, 85.9%-91.9%). Without those children, the negative predictive value was 98.8% (95% CI, 97%-99.6%).
There were also 113 children (16.5%) with positive chest radiographs, and 72 (10.7%) with equivocal radiographs.
The authors said their results showed that most children with negative chest radiograph would recover fully without needing antibiotics, and argued there was a place for chest radiography in the diagnostic process, to rule out bacterial pneumonia.
“Most clinicians caring for children in the outpatient setting rely on clinical signs and symptoms to determine whether to prescribe an antibiotic for the treatment of pneumonia,” they wrote. “However, given recent literature in which the poor reliability and validity of physical examination findings are cited, reliance on physical examination alone may lead to the overdiagnosis of pneumonia.”
They acknowledged that the lack of a universally accepted gold standard for the diagnosis of pneumonia in children was a significant limitation of the research. In addition, the lack of systematic radiographs meant some children who initially had a negative result and recovered without antibiotics may have shown a positive result on a second scan.
No conflicts of interest were declared.
SOURCE: Lipsett S et al. Pediatrics 2018 142(3):e20180236.
While the results of this study offer reassurance that chest radiograph for suspected pneumonia in children has a high negative predictive value, perhaps a more important question is the accuracy of chest radiography at ruling in bacterial pneumonia – its positive predictive value.
There are reasons to suspect that the positive predictive value of chest radiography may not be as high as the negative predictive value found in this study. This is particularly important given that questions have been raised about the utility of antibiotic therapy in treating Mycoplasma pneumonia infection in children.
Leaving out chest radiography altogether in children with a low clinical suspicion for pneumonia would decreased radi-ation use, cost, and perhaps also unnecessary antibiotic prescriptions.
Matthew D. Garber, MD, is from the department of pediatrics at the University of Florida College of Medicine in Jacksonville and Ricardo A. Quinonez, MD, is from the department of pediatrics at the Baylor College of Medicine and Texas Children’s Hospital. These comments are taken from an accompanying editorial (Pediatrics 2018, 142(3): e20182025. https://doi.org/10.1542/peds.2018-2025). No conflicts of interest were declared.
While the results of this study offer reassurance that chest radiograph for suspected pneumonia in children has a high negative predictive value, perhaps a more important question is the accuracy of chest radiography at ruling in bacterial pneumonia – its positive predictive value.
There are reasons to suspect that the positive predictive value of chest radiography may not be as high as the negative predictive value found in this study. This is particularly important given that questions have been raised about the utility of antibiotic therapy in treating Mycoplasma pneumonia infection in children.
Leaving out chest radiography altogether in children with a low clinical suspicion for pneumonia would decreased radi-ation use, cost, and perhaps also unnecessary antibiotic prescriptions.
Matthew D. Garber, MD, is from the department of pediatrics at the University of Florida College of Medicine in Jacksonville and Ricardo A. Quinonez, MD, is from the department of pediatrics at the Baylor College of Medicine and Texas Children’s Hospital. These comments are taken from an accompanying editorial (Pediatrics 2018, 142(3): e20182025. https://doi.org/10.1542/peds.2018-2025). No conflicts of interest were declared.
While the results of this study offer reassurance that chest radiograph for suspected pneumonia in children has a high negative predictive value, perhaps a more important question is the accuracy of chest radiography at ruling in bacterial pneumonia – its positive predictive value.
There are reasons to suspect that the positive predictive value of chest radiography may not be as high as the negative predictive value found in this study. This is particularly important given that questions have been raised about the utility of antibiotic therapy in treating Mycoplasma pneumonia infection in children.
Leaving out chest radiography altogether in children with a low clinical suspicion for pneumonia would decreased radi-ation use, cost, and perhaps also unnecessary antibiotic prescriptions.
Matthew D. Garber, MD, is from the department of pediatrics at the University of Florida College of Medicine in Jacksonville and Ricardo A. Quinonez, MD, is from the department of pediatrics at the Baylor College of Medicine and Texas Children’s Hospital. These comments are taken from an accompanying editorial (Pediatrics 2018, 142(3): e20182025. https://doi.org/10.1542/peds.2018-2025). No conflicts of interest were declared.
, researchers say.
In a paper published in the September issue of Pediatrics, researchers report the results of a prospective cohort study in 683 children – with a median age of 3.1 years – presenting to emergency departments with suspected pneumonia.
Dr. Susan C. Lipsett, from the division of emergency medicine at Boston Children’s Hospital, and co-authors, wrote that the use of chest radiograph to diagnose pneumonia is thought to have limitations such as its inability to distinguish between bacteria and viral infection, and the possible absence of radiographic presentations early in the disease in patients with dehydration.
In this study, 457 (72.8%) of the children had negative chest radiographs. Of these, 44 were clinically diagnosed with pneumonia, despite the radiograph results, and prescribed antibiotics. These children were more likely to have rales or respiratory distress and less likely to have wheezing compared with the children with negative radiographs who were not initially diagnosed with pneumonia.
Among the remaining 411 children with negative radiographs – who were not prescribed antibiotics – five (1.2%) were subsequently diagnosed with pneumonia within 2 weeks of the radiograph. These five children were all under 3 years of age, but none had been treated with intravenous fluids for dehydration. Only one had radiographic findings of pneumonia on a follow-up visit.
Counting the 44 children diagnosed with pneumonia despite the negative x-ray, chest radiography showed a negative predictive value of 89.2% (95% confidence interval, 85.9%-91.9%). Without those children, the negative predictive value was 98.8% (95% CI, 97%-99.6%).
There were also 113 children (16.5%) with positive chest radiographs, and 72 (10.7%) with equivocal radiographs.
The authors said their results showed that most children with negative chest radiograph would recover fully without needing antibiotics, and argued there was a place for chest radiography in the diagnostic process, to rule out bacterial pneumonia.
“Most clinicians caring for children in the outpatient setting rely on clinical signs and symptoms to determine whether to prescribe an antibiotic for the treatment of pneumonia,” they wrote. “However, given recent literature in which the poor reliability and validity of physical examination findings are cited, reliance on physical examination alone may lead to the overdiagnosis of pneumonia.”
They acknowledged that the lack of a universally accepted gold standard for the diagnosis of pneumonia in children was a significant limitation of the research. In addition, the lack of systematic radiographs meant some children who initially had a negative result and recovered without antibiotics may have shown a positive result on a second scan.
No conflicts of interest were declared.
SOURCE: Lipsett S et al. Pediatrics 2018 142(3):e20180236.
, researchers say.
In a paper published in the September issue of Pediatrics, researchers report the results of a prospective cohort study in 683 children – with a median age of 3.1 years – presenting to emergency departments with suspected pneumonia.
Dr. Susan C. Lipsett, from the division of emergency medicine at Boston Children’s Hospital, and co-authors, wrote that the use of chest radiograph to diagnose pneumonia is thought to have limitations such as its inability to distinguish between bacteria and viral infection, and the possible absence of radiographic presentations early in the disease in patients with dehydration.
In this study, 457 (72.8%) of the children had negative chest radiographs. Of these, 44 were clinically diagnosed with pneumonia, despite the radiograph results, and prescribed antibiotics. These children were more likely to have rales or respiratory distress and less likely to have wheezing compared with the children with negative radiographs who were not initially diagnosed with pneumonia.
Among the remaining 411 children with negative radiographs – who were not prescribed antibiotics – five (1.2%) were subsequently diagnosed with pneumonia within 2 weeks of the radiograph. These five children were all under 3 years of age, but none had been treated with intravenous fluids for dehydration. Only one had radiographic findings of pneumonia on a follow-up visit.
Counting the 44 children diagnosed with pneumonia despite the negative x-ray, chest radiography showed a negative predictive value of 89.2% (95% confidence interval, 85.9%-91.9%). Without those children, the negative predictive value was 98.8% (95% CI, 97%-99.6%).
There were also 113 children (16.5%) with positive chest radiographs, and 72 (10.7%) with equivocal radiographs.
The authors said their results showed that most children with negative chest radiograph would recover fully without needing antibiotics, and argued there was a place for chest radiography in the diagnostic process, to rule out bacterial pneumonia.
“Most clinicians caring for children in the outpatient setting rely on clinical signs and symptoms to determine whether to prescribe an antibiotic for the treatment of pneumonia,” they wrote. “However, given recent literature in which the poor reliability and validity of physical examination findings are cited, reliance on physical examination alone may lead to the overdiagnosis of pneumonia.”
They acknowledged that the lack of a universally accepted gold standard for the diagnosis of pneumonia in children was a significant limitation of the research. In addition, the lack of systematic radiographs meant some children who initially had a negative result and recovered without antibiotics may have shown a positive result on a second scan.
No conflicts of interest were declared.
SOURCE: Lipsett S et al. Pediatrics 2018 142(3):e20180236.
FROM PEDIATRICS
Key clinical point: Negative chest radiograph can rule out pneumonia in children.
Major finding: Chest radiograph has a negative predictive value of 89.2% in children with suspected pneumonia.
Study details: Prospective cohort study in 683 children with suspected pneumonia.
Disclosures: No conflicts of interest were declared.
Source: Lipsett S et al. Pediatrics 2018 142(3):e20180236. https://doi.org/10.1542/peds.2018-0236.
Hand, foot, and mouth disease: From self-limited to fatal
Hand, foot, and mouth disease (HFMD) has become a global challenge since its first description in 1957 in New Zealand and Canada. Clinicians readily recognize the characteristic syndrome in young children: fever associated with a papulovesicular rash affecting the palms or soles, or both, usually in spring, summer, or fall. In most cases the disease is self-limited, and brief. However, aseptic meningitis, brainstem encephalitis, acute flaccid paralysis or autonomic nervous system deregulation or cardiorespiratory failure may complicate the clinical course.
HFMD is caused by enterovirus A (formerly called human enterovirus A) which consists of 25 serotypes including multiple coxsackie A viruses, multiple enteroviruses, simian enteroviruses, and baboon enterovirus A13. The clinical spectrum spans from herpangina, characterized by fever and painful mouth ulcers most prominent in the posterior oral cavity (uvula, tonsils, soft plates, and anterior pharyngeal folds), to HFMD with papulovesicular rash on palms and soles with or without mouth ulcers/vesicles.1 In atypical cases, the rash may be maculopapular and may include the buttocks, knees or elbows.
In the United States, the predominant cause is coxsackie A16. However, coxsackie A6 appears to be emerging; often more than one HFMD causing virus is circulating concurrently and clinically indistinguishable. Globally, especially, in Asia, enterovirus 1 is a major cause of HFMD and more often associated with prominent central nervous system involvement. Disease can be sporadic or epidemic. An outbreak is usually defined as two or more cases within a defined geographic area; global epidemics as large as 1.5 million cases (Taiwan, 1998) have been reported, and outbreaks in China involving tens of thousands with multiple deaths have been reported.
In 2015, an outbreak of HFMD occurred during basic military training at Lackland Air Force Base, Bexar County, Texas, due to coxsackie A6.2 The illness was characterized by prodromal symptoms of fever and malaise followed by erosive stomatitis and a rash that began on the palms and soles. The rate of infection among trainees was 4.7% (50 of 1,054 persons).
The differential diagnosis includes aphthous ulcers and herpetic gingivostomatitis.3 Aphthous ulcers are seen more commonly in older children and adolescents, are often recurrent, are not seasonal, and are not associated with rash. Herpes simplex virus gingivostomatitis usually has a febrile prodrome, perioral lesions are frequent in addition to gum and tongue involvement, and gingival bleeding is common. HFMD usually has an incubation period of 3-5 days and fever, malaise, and myalgia prodrome followed by onset of oral and dermatologic manifestations in sequence. The skin rash has features that may overlap with varicella, erythema multiforme (EM) or drug eruption. Varicella usually involves the face before spreading to the extremities, and the lesions are characterized by umbilication and subsequent crusting. EM is characterized by target lesions and drug eruptions are morbilliform or maculopapular. The majority of cases of HFMD are diagnosed clinically; polymerase chain reaction testing is available and best performed on throat or vesicle specimens. Serologic testing for A16 and enterovirus 71 (IgM) is available. Infected patients shed virus for 2-4 weeks and virus is stable in the environment resulting in fecal-oral or oral-oral transmission.
Atypical features of HFMD include occurrence in the winter (outbreak in Alabama in 2011/2012) or an atypical distribution of rash involving the antecubital and popliteal fossae distribution of rash, or “eczema coxsackium” – the accentuation of rash in areas previously affected by atopic dermatitis. Additional features may include nail dystrophies that manifest as Beau lines (deep grooved lines that run from side to side on the fingernail or the toenail) and nail shedding.
A spectrum of neurologic complications has been observed, more frequently with EV71 and more frequently in Asia. The spectrum includes aseptic meningitis and brainstem encephalitis. Progressive cardiopulmonary failure also can be observed in severe cases. The hallmark of severe disease is often presentation with high fever, sweating, mottled skin, and tachycardia. Early signs of CNS involvement include myoclonic jerks, ataxia, and “wandering eyes.”3 Elevated white blood count and/or hyperglycemia may distinguish children with severe disease from benign disease. Anecdotal reports of response to treatment with high-dose methylprednisolone and intravenous immune globulin suggest that the neurologic disease may be an autoimmune phenomenon.
The clinician’s primary role is to accurately diagnose HFMD, provide supportive care for fever and dehydration, and identify those with early signs or laboratory features heralding a more severe course of disease.3 The Centers for Disease Control and Prevention recommends frequent hand washing after toileting and changing diapers, disinfecting surfaces such as toys, avoiding close contact with infected individuals or sharing of personal items for all affected patients. No antiviral treatment is available although improvement following early treatment with acyclovir has been reported anecdotally. Intravenous immunoglobulin has been used in severe cases in Asia with retrospective data analysis suggesting a potential for improvement when administered prior to cardiopulmonary arrest.1
Dr. Pelton is professor of pediatrics and epidemiology at Boston University. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. Cleveland Clinic Journal of Medicine 2014;81(9):537-43.
2. Morbidity and Mortality Weekly Report MMWR. 2016 Jul 8;65(26);678-80.
3. A Guide to clinical management and public health response for hand, foot and mouth disease (HFMD).
Hand, foot, and mouth disease (HFMD) has become a global challenge since its first description in 1957 in New Zealand and Canada. Clinicians readily recognize the characteristic syndrome in young children: fever associated with a papulovesicular rash affecting the palms or soles, or both, usually in spring, summer, or fall. In most cases the disease is self-limited, and brief. However, aseptic meningitis, brainstem encephalitis, acute flaccid paralysis or autonomic nervous system deregulation or cardiorespiratory failure may complicate the clinical course.
HFMD is caused by enterovirus A (formerly called human enterovirus A) which consists of 25 serotypes including multiple coxsackie A viruses, multiple enteroviruses, simian enteroviruses, and baboon enterovirus A13. The clinical spectrum spans from herpangina, characterized by fever and painful mouth ulcers most prominent in the posterior oral cavity (uvula, tonsils, soft plates, and anterior pharyngeal folds), to HFMD with papulovesicular rash on palms and soles with or without mouth ulcers/vesicles.1 In atypical cases, the rash may be maculopapular and may include the buttocks, knees or elbows.
In the United States, the predominant cause is coxsackie A16. However, coxsackie A6 appears to be emerging; often more than one HFMD causing virus is circulating concurrently and clinically indistinguishable. Globally, especially, in Asia, enterovirus 1 is a major cause of HFMD and more often associated with prominent central nervous system involvement. Disease can be sporadic or epidemic. An outbreak is usually defined as two or more cases within a defined geographic area; global epidemics as large as 1.5 million cases (Taiwan, 1998) have been reported, and outbreaks in China involving tens of thousands with multiple deaths have been reported.
In 2015, an outbreak of HFMD occurred during basic military training at Lackland Air Force Base, Bexar County, Texas, due to coxsackie A6.2 The illness was characterized by prodromal symptoms of fever and malaise followed by erosive stomatitis and a rash that began on the palms and soles. The rate of infection among trainees was 4.7% (50 of 1,054 persons).
The differential diagnosis includes aphthous ulcers and herpetic gingivostomatitis.3 Aphthous ulcers are seen more commonly in older children and adolescents, are often recurrent, are not seasonal, and are not associated with rash. Herpes simplex virus gingivostomatitis usually has a febrile prodrome, perioral lesions are frequent in addition to gum and tongue involvement, and gingival bleeding is common. HFMD usually has an incubation period of 3-5 days and fever, malaise, and myalgia prodrome followed by onset of oral and dermatologic manifestations in sequence. The skin rash has features that may overlap with varicella, erythema multiforme (EM) or drug eruption. Varicella usually involves the face before spreading to the extremities, and the lesions are characterized by umbilication and subsequent crusting. EM is characterized by target lesions and drug eruptions are morbilliform or maculopapular. The majority of cases of HFMD are diagnosed clinically; polymerase chain reaction testing is available and best performed on throat or vesicle specimens. Serologic testing for A16 and enterovirus 71 (IgM) is available. Infected patients shed virus for 2-4 weeks and virus is stable in the environment resulting in fecal-oral or oral-oral transmission.
Atypical features of HFMD include occurrence in the winter (outbreak in Alabama in 2011/2012) or an atypical distribution of rash involving the antecubital and popliteal fossae distribution of rash, or “eczema coxsackium” – the accentuation of rash in areas previously affected by atopic dermatitis. Additional features may include nail dystrophies that manifest as Beau lines (deep grooved lines that run from side to side on the fingernail or the toenail) and nail shedding.
A spectrum of neurologic complications has been observed, more frequently with EV71 and more frequently in Asia. The spectrum includes aseptic meningitis and brainstem encephalitis. Progressive cardiopulmonary failure also can be observed in severe cases. The hallmark of severe disease is often presentation with high fever, sweating, mottled skin, and tachycardia. Early signs of CNS involvement include myoclonic jerks, ataxia, and “wandering eyes.”3 Elevated white blood count and/or hyperglycemia may distinguish children with severe disease from benign disease. Anecdotal reports of response to treatment with high-dose methylprednisolone and intravenous immune globulin suggest that the neurologic disease may be an autoimmune phenomenon.
The clinician’s primary role is to accurately diagnose HFMD, provide supportive care for fever and dehydration, and identify those with early signs or laboratory features heralding a more severe course of disease.3 The Centers for Disease Control and Prevention recommends frequent hand washing after toileting and changing diapers, disinfecting surfaces such as toys, avoiding close contact with infected individuals or sharing of personal items for all affected patients. No antiviral treatment is available although improvement following early treatment with acyclovir has been reported anecdotally. Intravenous immunoglobulin has been used in severe cases in Asia with retrospective data analysis suggesting a potential for improvement when administered prior to cardiopulmonary arrest.1
Dr. Pelton is professor of pediatrics and epidemiology at Boston University. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. Cleveland Clinic Journal of Medicine 2014;81(9):537-43.
2. Morbidity and Mortality Weekly Report MMWR. 2016 Jul 8;65(26);678-80.
3. A Guide to clinical management and public health response for hand, foot and mouth disease (HFMD).
Hand, foot, and mouth disease (HFMD) has become a global challenge since its first description in 1957 in New Zealand and Canada. Clinicians readily recognize the characteristic syndrome in young children: fever associated with a papulovesicular rash affecting the palms or soles, or both, usually in spring, summer, or fall. In most cases the disease is self-limited, and brief. However, aseptic meningitis, brainstem encephalitis, acute flaccid paralysis or autonomic nervous system deregulation or cardiorespiratory failure may complicate the clinical course.
HFMD is caused by enterovirus A (formerly called human enterovirus A) which consists of 25 serotypes including multiple coxsackie A viruses, multiple enteroviruses, simian enteroviruses, and baboon enterovirus A13. The clinical spectrum spans from herpangina, characterized by fever and painful mouth ulcers most prominent in the posterior oral cavity (uvula, tonsils, soft plates, and anterior pharyngeal folds), to HFMD with papulovesicular rash on palms and soles with or without mouth ulcers/vesicles.1 In atypical cases, the rash may be maculopapular and may include the buttocks, knees or elbows.
In the United States, the predominant cause is coxsackie A16. However, coxsackie A6 appears to be emerging; often more than one HFMD causing virus is circulating concurrently and clinically indistinguishable. Globally, especially, in Asia, enterovirus 1 is a major cause of HFMD and more often associated with prominent central nervous system involvement. Disease can be sporadic or epidemic. An outbreak is usually defined as two or more cases within a defined geographic area; global epidemics as large as 1.5 million cases (Taiwan, 1998) have been reported, and outbreaks in China involving tens of thousands with multiple deaths have been reported.
In 2015, an outbreak of HFMD occurred during basic military training at Lackland Air Force Base, Bexar County, Texas, due to coxsackie A6.2 The illness was characterized by prodromal symptoms of fever and malaise followed by erosive stomatitis and a rash that began on the palms and soles. The rate of infection among trainees was 4.7% (50 of 1,054 persons).
The differential diagnosis includes aphthous ulcers and herpetic gingivostomatitis.3 Aphthous ulcers are seen more commonly in older children and adolescents, are often recurrent, are not seasonal, and are not associated with rash. Herpes simplex virus gingivostomatitis usually has a febrile prodrome, perioral lesions are frequent in addition to gum and tongue involvement, and gingival bleeding is common. HFMD usually has an incubation period of 3-5 days and fever, malaise, and myalgia prodrome followed by onset of oral and dermatologic manifestations in sequence. The skin rash has features that may overlap with varicella, erythema multiforme (EM) or drug eruption. Varicella usually involves the face before spreading to the extremities, and the lesions are characterized by umbilication and subsequent crusting. EM is characterized by target lesions and drug eruptions are morbilliform or maculopapular. The majority of cases of HFMD are diagnosed clinically; polymerase chain reaction testing is available and best performed on throat or vesicle specimens. Serologic testing for A16 and enterovirus 71 (IgM) is available. Infected patients shed virus for 2-4 weeks and virus is stable in the environment resulting in fecal-oral or oral-oral transmission.
Atypical features of HFMD include occurrence in the winter (outbreak in Alabama in 2011/2012) or an atypical distribution of rash involving the antecubital and popliteal fossae distribution of rash, or “eczema coxsackium” – the accentuation of rash in areas previously affected by atopic dermatitis. Additional features may include nail dystrophies that manifest as Beau lines (deep grooved lines that run from side to side on the fingernail or the toenail) and nail shedding.
A spectrum of neurologic complications has been observed, more frequently with EV71 and more frequently in Asia. The spectrum includes aseptic meningitis and brainstem encephalitis. Progressive cardiopulmonary failure also can be observed in severe cases. The hallmark of severe disease is often presentation with high fever, sweating, mottled skin, and tachycardia. Early signs of CNS involvement include myoclonic jerks, ataxia, and “wandering eyes.”3 Elevated white blood count and/or hyperglycemia may distinguish children with severe disease from benign disease. Anecdotal reports of response to treatment with high-dose methylprednisolone and intravenous immune globulin suggest that the neurologic disease may be an autoimmune phenomenon.
The clinician’s primary role is to accurately diagnose HFMD, provide supportive care for fever and dehydration, and identify those with early signs or laboratory features heralding a more severe course of disease.3 The Centers for Disease Control and Prevention recommends frequent hand washing after toileting and changing diapers, disinfecting surfaces such as toys, avoiding close contact with infected individuals or sharing of personal items for all affected patients. No antiviral treatment is available although improvement following early treatment with acyclovir has been reported anecdotally. Intravenous immunoglobulin has been used in severe cases in Asia with retrospective data analysis suggesting a potential for improvement when administered prior to cardiopulmonary arrest.1
Dr. Pelton is professor of pediatrics and epidemiology at Boston University. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. Cleveland Clinic Journal of Medicine 2014;81(9):537-43.
2. Morbidity and Mortality Weekly Report MMWR. 2016 Jul 8;65(26);678-80.
3. A Guide to clinical management and public health response for hand, foot and mouth disease (HFMD).
RA, JIA may raise risk of preterm delivery
according to a study examining autoimmune disease in pregnancy. Corticosteroid use in any trimester increased that risk from 100%-400%, regardless of how active the arthritis was.
The study found that women with RA had more than double the risk for preterm delivery, compared with a cohort without autoimmune disease (relative risk, 2.09; 95% confidence interval, 1.50-2.91). For women with juvenile idiopathic arthritis (JIA), the relative risk was 1.81 for preterm delivery (95% CI, 1.14-2.89).
The prospective cohort study, part of the Organization of Teratology Information Specialists Autoimmune Disease in Pregnancy Project, enrolled 657 women with RA and 170 women with JIA. The study also included a comparison group of 564 women without autoimmune disease. All of those included in the study were enrolled before 19 weeks’ gestation and delivered live-born infants during 2004-2017.
The study adds to a clinically important area of research that has yielded sometimes conflicting results; clarity has also been impeded by a variety of methodologies. Though several analyses have shown higher risk of preterm delivery in women with RA, not all studies have adjusted for medication use and disease activity, Chelsey F. Smith, MD, and her coauthors wrote in Arthritis Care & Research. Further, how women with JIA fare in pregnancy has not been well studied, they said.
Dr. Smith, a rheumatologist at the University of California, San Diego, and her colleagues included many baseline covariates in their analysis of pregnancy outcomes; these included maternal age and race, socioeconomic status, body mass index, previous adverse pregnancy outcomes, and comorbidities, including autoimmune disease. Adverse pregnancy outcomes during the studied pregnancy were also included as covariates, and deliveries were considered preterm if labor began before 37 weeks’ gestation.
For women with RA, a higher active disease score at any point during pregnancy was associated with a significantly higher risk of preterm delivery, even after adjustment for other potential risk factors, including first-trimester corticosteroid use (adjusted risk ratio, 1.52; 95% CI, 1.06-2.18). The persistence of this association, wrote Dr. Smith and her colleagues, implies “that active disease in RA may contribute to [preterm delivery] independent of medications,” perhaps through the action of proinflammatory cytokines that may stimulate prostaglandins and provoke uterine contractions.
The researchers found, though, that this association between disease activity and risk for preterm birth did not hold true for women with JIA, leaving part of the mystery unsolved.
However, women with both RA and JIA who used corticosteroids in any trimester were more likely to have a preterm delivery, as were women with JIA who used NSAIDs in the first trimester of pregnancy. The use of disease-modifying antirheumatic drugs (DMARDs) and biologics in any trimester did not confer increased risk for preterm delivery in women with either disease state.
There were other differences between the groups: Women with JIA were overall younger, but had more prepregnancy hypertension, which “may have contributed to the elevated incidence of preeclampsia seen in this group,” the investigators wrote. Fever was more common in women with JIA, and had an independent association with preterm delivery, as did first trimester NSAID use in this group alone.
Dr. Smith and her colleagues hypothesized that the relative heterogeneity of the JIA group may mean that disease activity still influenced outcomes.
Among other comorbidities, gestational diabetes (GDM) was more common in the RA group than in the JIA group or the comparison cohort, and was associated with a significantly higher risk for preterm delivery in women with RA, even after accounting for preeclampsia and hypertension in a multivariate analysis.
Dr. Smith and her colleagues pointed out that it was difficult to account for physician behavior in managing pregnancy in these high-risk women. “Additionally, given that women with both RA and GDM are at a particularly high risk for perinatal complications, we can speculate that the obstetricians in this group were perhaps more aggressive about inducing at an earlier gestational age than in other groups, but this information was not available in the dataset.”
Through phone interviews, investigators obtained information about prescription and nonprescription medication use during pregnancy; women were also asked about use of other substances and occupational exposures, infections, and prenatal testing and other medical procedures. Another telephone interview conducted soon after delivery asked about birth outcomes. Abstracted medical record data were used to verify and supplement the interview information.
When looking at treatments used, Dr. Smith and her colleagues grouped autoimmune disease medications into DMARDs, non-DMARD biologic medications, corticosteroids, and NSAIDs.
Disease activity assessment, conducted at intake and at 32 weeks’ gestation, used the Health Assessment Questionnaire, pain scores, and patient global disease activity to calculate a Patient Activity Scale score ranging from 0 to 10. Patients with a score over 3.7 were classified as having high disease activity.
Dr. Smith and her colleagues said that the study’s strengths included its prospective design and robust statistical schema. Also, using data about corticosteroid use and disease activity earlier in pregnancy avoided the inclusion of a reverse causation effect, where systemic inflammatory changes associated with preterm delivery might provoke more disease activity and a consequent boost in corticosteroid use.
However, the researchers said, the overall numbers of participants with preterm delivery was relatively small, and the JIA cohort was small as well.
“Further analyses are necessary to look at other categories of arthritis affecting women of childbearing age, racial disparities in these populations, as well as the influence of disease activity in the later stages of pregnancy on other perinatal factors” that can contribute to preterm delivery, said Dr. Smith and her colleagues.
The collaborative research group that collected data for the study receives research funding from several pharmaceutical companies. None of the authors reported any personal conflicts of interest.
SOURCE: Smith CF et al. Arthritis Care Res. 2018 Aug 21. doi: 10.1002/acr.23730.
according to a study examining autoimmune disease in pregnancy. Corticosteroid use in any trimester increased that risk from 100%-400%, regardless of how active the arthritis was.
The study found that women with RA had more than double the risk for preterm delivery, compared with a cohort without autoimmune disease (relative risk, 2.09; 95% confidence interval, 1.50-2.91). For women with juvenile idiopathic arthritis (JIA), the relative risk was 1.81 for preterm delivery (95% CI, 1.14-2.89).
The prospective cohort study, part of the Organization of Teratology Information Specialists Autoimmune Disease in Pregnancy Project, enrolled 657 women with RA and 170 women with JIA. The study also included a comparison group of 564 women without autoimmune disease. All of those included in the study were enrolled before 19 weeks’ gestation and delivered live-born infants during 2004-2017.
The study adds to a clinically important area of research that has yielded sometimes conflicting results; clarity has also been impeded by a variety of methodologies. Though several analyses have shown higher risk of preterm delivery in women with RA, not all studies have adjusted for medication use and disease activity, Chelsey F. Smith, MD, and her coauthors wrote in Arthritis Care & Research. Further, how women with JIA fare in pregnancy has not been well studied, they said.
Dr. Smith, a rheumatologist at the University of California, San Diego, and her colleagues included many baseline covariates in their analysis of pregnancy outcomes; these included maternal age and race, socioeconomic status, body mass index, previous adverse pregnancy outcomes, and comorbidities, including autoimmune disease. Adverse pregnancy outcomes during the studied pregnancy were also included as covariates, and deliveries were considered preterm if labor began before 37 weeks’ gestation.
For women with RA, a higher active disease score at any point during pregnancy was associated with a significantly higher risk of preterm delivery, even after adjustment for other potential risk factors, including first-trimester corticosteroid use (adjusted risk ratio, 1.52; 95% CI, 1.06-2.18). The persistence of this association, wrote Dr. Smith and her colleagues, implies “that active disease in RA may contribute to [preterm delivery] independent of medications,” perhaps through the action of proinflammatory cytokines that may stimulate prostaglandins and provoke uterine contractions.
The researchers found, though, that this association between disease activity and risk for preterm birth did not hold true for women with JIA, leaving part of the mystery unsolved.
However, women with both RA and JIA who used corticosteroids in any trimester were more likely to have a preterm delivery, as were women with JIA who used NSAIDs in the first trimester of pregnancy. The use of disease-modifying antirheumatic drugs (DMARDs) and biologics in any trimester did not confer increased risk for preterm delivery in women with either disease state.
There were other differences between the groups: Women with JIA were overall younger, but had more prepregnancy hypertension, which “may have contributed to the elevated incidence of preeclampsia seen in this group,” the investigators wrote. Fever was more common in women with JIA, and had an independent association with preterm delivery, as did first trimester NSAID use in this group alone.
Dr. Smith and her colleagues hypothesized that the relative heterogeneity of the JIA group may mean that disease activity still influenced outcomes.
Among other comorbidities, gestational diabetes (GDM) was more common in the RA group than in the JIA group or the comparison cohort, and was associated with a significantly higher risk for preterm delivery in women with RA, even after accounting for preeclampsia and hypertension in a multivariate analysis.
Dr. Smith and her colleagues pointed out that it was difficult to account for physician behavior in managing pregnancy in these high-risk women. “Additionally, given that women with both RA and GDM are at a particularly high risk for perinatal complications, we can speculate that the obstetricians in this group were perhaps more aggressive about inducing at an earlier gestational age than in other groups, but this information was not available in the dataset.”
Through phone interviews, investigators obtained information about prescription and nonprescription medication use during pregnancy; women were also asked about use of other substances and occupational exposures, infections, and prenatal testing and other medical procedures. Another telephone interview conducted soon after delivery asked about birth outcomes. Abstracted medical record data were used to verify and supplement the interview information.
When looking at treatments used, Dr. Smith and her colleagues grouped autoimmune disease medications into DMARDs, non-DMARD biologic medications, corticosteroids, and NSAIDs.
Disease activity assessment, conducted at intake and at 32 weeks’ gestation, used the Health Assessment Questionnaire, pain scores, and patient global disease activity to calculate a Patient Activity Scale score ranging from 0 to 10. Patients with a score over 3.7 were classified as having high disease activity.
Dr. Smith and her colleagues said that the study’s strengths included its prospective design and robust statistical schema. Also, using data about corticosteroid use and disease activity earlier in pregnancy avoided the inclusion of a reverse causation effect, where systemic inflammatory changes associated with preterm delivery might provoke more disease activity and a consequent boost in corticosteroid use.
However, the researchers said, the overall numbers of participants with preterm delivery was relatively small, and the JIA cohort was small as well.
“Further analyses are necessary to look at other categories of arthritis affecting women of childbearing age, racial disparities in these populations, as well as the influence of disease activity in the later stages of pregnancy on other perinatal factors” that can contribute to preterm delivery, said Dr. Smith and her colleagues.
The collaborative research group that collected data for the study receives research funding from several pharmaceutical companies. None of the authors reported any personal conflicts of interest.
SOURCE: Smith CF et al. Arthritis Care Res. 2018 Aug 21. doi: 10.1002/acr.23730.
according to a study examining autoimmune disease in pregnancy. Corticosteroid use in any trimester increased that risk from 100%-400%, regardless of how active the arthritis was.
The study found that women with RA had more than double the risk for preterm delivery, compared with a cohort without autoimmune disease (relative risk, 2.09; 95% confidence interval, 1.50-2.91). For women with juvenile idiopathic arthritis (JIA), the relative risk was 1.81 for preterm delivery (95% CI, 1.14-2.89).
The prospective cohort study, part of the Organization of Teratology Information Specialists Autoimmune Disease in Pregnancy Project, enrolled 657 women with RA and 170 women with JIA. The study also included a comparison group of 564 women without autoimmune disease. All of those included in the study were enrolled before 19 weeks’ gestation and delivered live-born infants during 2004-2017.
The study adds to a clinically important area of research that has yielded sometimes conflicting results; clarity has also been impeded by a variety of methodologies. Though several analyses have shown higher risk of preterm delivery in women with RA, not all studies have adjusted for medication use and disease activity, Chelsey F. Smith, MD, and her coauthors wrote in Arthritis Care & Research. Further, how women with JIA fare in pregnancy has not been well studied, they said.
Dr. Smith, a rheumatologist at the University of California, San Diego, and her colleagues included many baseline covariates in their analysis of pregnancy outcomes; these included maternal age and race, socioeconomic status, body mass index, previous adverse pregnancy outcomes, and comorbidities, including autoimmune disease. Adverse pregnancy outcomes during the studied pregnancy were also included as covariates, and deliveries were considered preterm if labor began before 37 weeks’ gestation.
For women with RA, a higher active disease score at any point during pregnancy was associated with a significantly higher risk of preterm delivery, even after adjustment for other potential risk factors, including first-trimester corticosteroid use (adjusted risk ratio, 1.52; 95% CI, 1.06-2.18). The persistence of this association, wrote Dr. Smith and her colleagues, implies “that active disease in RA may contribute to [preterm delivery] independent of medications,” perhaps through the action of proinflammatory cytokines that may stimulate prostaglandins and provoke uterine contractions.
The researchers found, though, that this association between disease activity and risk for preterm birth did not hold true for women with JIA, leaving part of the mystery unsolved.
However, women with both RA and JIA who used corticosteroids in any trimester were more likely to have a preterm delivery, as were women with JIA who used NSAIDs in the first trimester of pregnancy. The use of disease-modifying antirheumatic drugs (DMARDs) and biologics in any trimester did not confer increased risk for preterm delivery in women with either disease state.
There were other differences between the groups: Women with JIA were overall younger, but had more prepregnancy hypertension, which “may have contributed to the elevated incidence of preeclampsia seen in this group,” the investigators wrote. Fever was more common in women with JIA, and had an independent association with preterm delivery, as did first trimester NSAID use in this group alone.
Dr. Smith and her colleagues hypothesized that the relative heterogeneity of the JIA group may mean that disease activity still influenced outcomes.
Among other comorbidities, gestational diabetes (GDM) was more common in the RA group than in the JIA group or the comparison cohort, and was associated with a significantly higher risk for preterm delivery in women with RA, even after accounting for preeclampsia and hypertension in a multivariate analysis.
Dr. Smith and her colleagues pointed out that it was difficult to account for physician behavior in managing pregnancy in these high-risk women. “Additionally, given that women with both RA and GDM are at a particularly high risk for perinatal complications, we can speculate that the obstetricians in this group were perhaps more aggressive about inducing at an earlier gestational age than in other groups, but this information was not available in the dataset.”
Through phone interviews, investigators obtained information about prescription and nonprescription medication use during pregnancy; women were also asked about use of other substances and occupational exposures, infections, and prenatal testing and other medical procedures. Another telephone interview conducted soon after delivery asked about birth outcomes. Abstracted medical record data were used to verify and supplement the interview information.
When looking at treatments used, Dr. Smith and her colleagues grouped autoimmune disease medications into DMARDs, non-DMARD biologic medications, corticosteroids, and NSAIDs.
Disease activity assessment, conducted at intake and at 32 weeks’ gestation, used the Health Assessment Questionnaire, pain scores, and patient global disease activity to calculate a Patient Activity Scale score ranging from 0 to 10. Patients with a score over 3.7 were classified as having high disease activity.
Dr. Smith and her colleagues said that the study’s strengths included its prospective design and robust statistical schema. Also, using data about corticosteroid use and disease activity earlier in pregnancy avoided the inclusion of a reverse causation effect, where systemic inflammatory changes associated with preterm delivery might provoke more disease activity and a consequent boost in corticosteroid use.
However, the researchers said, the overall numbers of participants with preterm delivery was relatively small, and the JIA cohort was small as well.
“Further analyses are necessary to look at other categories of arthritis affecting women of childbearing age, racial disparities in these populations, as well as the influence of disease activity in the later stages of pregnancy on other perinatal factors” that can contribute to preterm delivery, said Dr. Smith and her colleagues.
The collaborative research group that collected data for the study receives research funding from several pharmaceutical companies. None of the authors reported any personal conflicts of interest.
SOURCE: Smith CF et al. Arthritis Care Res. 2018 Aug 21. doi: 10.1002/acr.23730.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point: The risk of preterm delivery was increased in women with RA and juvenile idiopathic arthritis.
Major finding: The risk ratio for preterm delivery in women with RA was 2.09.
Study details: A prospective cohort study of 657 women with RA, 170 women with juvenile idiopathic arthritis, and 564 women without autoimmune disease.
Disclosures: The study was part of the Organization of Teratology Information Specialists Autoimmune Disease in Pregnancy Project, which receives research funding from several pharmaceutical companies. None of the authors reported any personal conflicts of interest.
Source: Smith CF et al. Arthritis Care Res. 2018 Aug 21. doi: 10.1002/acr.23730.
AAP cautions against marijuana use during pregnancy, breastfeeding
, according to a recent clinical report published in the journal Pediatrics.
“The fact that marijuana is legal in many states may give the impression the drug is harmless during pregnancy, especially with stories swirling on social media about using it for nausea with morning sickness,” Sheryl A. Ryan, MD, FAAP, Chair of the American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention, stated in a press release. “But in fact, this is still a big question. We do not have good safety data on prenatal exposure to marijuana. Based on the limited data that do exist, as pediatricians, we believe there is cause to be concerned about how the drug will impact the long-term development of children.”
The rate of marijuana use is increasing among pregnant women 18 years to 44 years old is increasing, the committee said, with 3.84% of women in 2014 within that age range using marijuana within the past month compared with 2.37% in 2002. Among women who were between 18 years and 25 years old, the rate of marijuana use within the past month was 7.47% in 2014.
The committee also noted research has shown cannabidiol exposure in the short term may impact placental permeability to “pharmacologic agents and recreational substances, potentially placing the fetus at risk from these agents or drugs.” A more well-known substance in marijuana, delta-9-tetrahydrocannabinol (THC) crosses the placental barrier and can appear in fetal blood. Studies have reported any level of marijuana use among pregnant women put the mothers at risk of anemia, while their newborns had an increased risk of low-birth weight and neonatal intensive care unit (NICU) use. Further research has shown impaired mental development, executive function deficits, increased impulsivity and hyperactivity, behavioral problems, depressive symptoms, and greater rates of substance abuse among children exposed to marijuana.
“Many of these effects may not show up right away, but they can impact how well a child can maneuver in the world,” Dr. Ryan stated in the release. “Children’s and teens’ cognitive ability to manage their time and school work might be harmed down the line from marijuana use during their mother’s pregnancy.”
In a related study, Kerri A. Bertrand, MPH, from the department of pediatrics at the University of California in San Diego, Calif., and her colleagues studied cannabinoid concentrations in breastmilk donated to a human milk biorepository. The investigators analyzed 54 samples donated by 50 women who used marijuana while breastfeeding between 2014 and 2017 and determined whether substances such as delta-9-THC, 11-hydroxy-delta-9-tetrahydrocannabinol (11-OH-THC), cannabidiol, and cannabinol were present in breastmilk by performing liquid chromatography mass spectrometry electrospray ionization on the samples.
They found 34 of 54 samples (64%) had detectable delta-9-THC approximately 6 days after marijuana use (median concentration, 9.47 ng/mL; range, 1.01-323 ng/mL), while 5 of 54 samples (9%) had measurable concentrations of 11-OH-THC (range, 1.33-12.80 ng/mL) and 5 of 54 samples (9%) contained measurable cannabidiol (range, 1.32-8.56 ng/mL). Predictors of log delta-9-THC concentrations included number of hours since last use (-0.03; 95% confidence interval, -0.04 to -0.01; P equals .005), the number of times per day marijuana was used (0.51; 95% CI, 0.03-0.99; P equals .039), and the amount of time between sample donation and analysis (0.08; 95% CI, 0.00-0.15; P equals .038), researchers said.
“Because marijuana is the most commonly used recreational drug among breastfeeding women, information regarding risks to breastfeeding infants is urgently needed,” Dr. Bertrand and colleagues wrote in their study.
The authors of the AAP clinical report acknowledge no relevant conflicts of interest. The study by Bertrand and colleagues was supported by the University of California San Diego Center for Better Beginnings, a grant from the National Institutes of Health, and the Gerber Foundation.
SOURCE: Bertrand KA et al. Pediatrics. 2018 Aug 27;doi:10.1542/peds.2018-1076.
The study by Bertrand and colleagues should be commended for being among the first to analyze cannabinoids in breast milk, but there are still very important questions to be answered about marijuana use among women who breast-feed, Sheryl A. Ryan, MD, FAAP, wrote in a related editorial.
Questions remain about why one-third of participants in the study had no detectable cannabinoids in their breast milk, and a frame of reference is needed for the levels that did appear in the study, Dr. Ryan said. Data are also needed on how the cannabinoids “accumulate in the infant, how the infant metabolizes these substances, how quickly they are excreted, whether they accumulate, and thus how long these metabolites remain in the infant,” she said.
Dr. Ryan also questioned what to tell mothers who use marijuana but want to breastfeed their newborns, and noted guidelines from the AAP and the American College of Obstetricians currently recommend avoiding marijuana use entirely while breastfeeding.
“With their study, Bertrand et al. have provided additional and valuable support for those current recommendations. But the picture is incomplete without our understanding of what is happening at the level of those infants exposed to cannabinoid–containing breast milk,” Dr. Ryan said. “Hopefully, the calls for research to answer these important questions will not go unheeded.”
Dr. Ryan is from the Division of Adolescent Medicine and Department of Pediatrics at Penn State Health Children’s Hospital in Hershey, Penn. These comments summarize her editorial in response to Bertrand and colleagues. She reports no relevant conflicts of interest (Ryan SA. Pediatrics. 2018;142[3]:e20181921).
The study by Bertrand and colleagues should be commended for being among the first to analyze cannabinoids in breast milk, but there are still very important questions to be answered about marijuana use among women who breast-feed, Sheryl A. Ryan, MD, FAAP, wrote in a related editorial.
Questions remain about why one-third of participants in the study had no detectable cannabinoids in their breast milk, and a frame of reference is needed for the levels that did appear in the study, Dr. Ryan said. Data are also needed on how the cannabinoids “accumulate in the infant, how the infant metabolizes these substances, how quickly they are excreted, whether they accumulate, and thus how long these metabolites remain in the infant,” she said.
Dr. Ryan also questioned what to tell mothers who use marijuana but want to breastfeed their newborns, and noted guidelines from the AAP and the American College of Obstetricians currently recommend avoiding marijuana use entirely while breastfeeding.
“With their study, Bertrand et al. have provided additional and valuable support for those current recommendations. But the picture is incomplete without our understanding of what is happening at the level of those infants exposed to cannabinoid–containing breast milk,” Dr. Ryan said. “Hopefully, the calls for research to answer these important questions will not go unheeded.”
Dr. Ryan is from the Division of Adolescent Medicine and Department of Pediatrics at Penn State Health Children’s Hospital in Hershey, Penn. These comments summarize her editorial in response to Bertrand and colleagues. She reports no relevant conflicts of interest (Ryan SA. Pediatrics. 2018;142[3]:e20181921).
The study by Bertrand and colleagues should be commended for being among the first to analyze cannabinoids in breast milk, but there are still very important questions to be answered about marijuana use among women who breast-feed, Sheryl A. Ryan, MD, FAAP, wrote in a related editorial.
Questions remain about why one-third of participants in the study had no detectable cannabinoids in their breast milk, and a frame of reference is needed for the levels that did appear in the study, Dr. Ryan said. Data are also needed on how the cannabinoids “accumulate in the infant, how the infant metabolizes these substances, how quickly they are excreted, whether they accumulate, and thus how long these metabolites remain in the infant,” she said.
Dr. Ryan also questioned what to tell mothers who use marijuana but want to breastfeed their newborns, and noted guidelines from the AAP and the American College of Obstetricians currently recommend avoiding marijuana use entirely while breastfeeding.
“With their study, Bertrand et al. have provided additional and valuable support for those current recommendations. But the picture is incomplete without our understanding of what is happening at the level of those infants exposed to cannabinoid–containing breast milk,” Dr. Ryan said. “Hopefully, the calls for research to answer these important questions will not go unheeded.”
Dr. Ryan is from the Division of Adolescent Medicine and Department of Pediatrics at Penn State Health Children’s Hospital in Hershey, Penn. These comments summarize her editorial in response to Bertrand and colleagues. She reports no relevant conflicts of interest (Ryan SA. Pediatrics. 2018;142[3]:e20181921).
, according to a recent clinical report published in the journal Pediatrics.
“The fact that marijuana is legal in many states may give the impression the drug is harmless during pregnancy, especially with stories swirling on social media about using it for nausea with morning sickness,” Sheryl A. Ryan, MD, FAAP, Chair of the American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention, stated in a press release. “But in fact, this is still a big question. We do not have good safety data on prenatal exposure to marijuana. Based on the limited data that do exist, as pediatricians, we believe there is cause to be concerned about how the drug will impact the long-term development of children.”
The rate of marijuana use is increasing among pregnant women 18 years to 44 years old is increasing, the committee said, with 3.84% of women in 2014 within that age range using marijuana within the past month compared with 2.37% in 2002. Among women who were between 18 years and 25 years old, the rate of marijuana use within the past month was 7.47% in 2014.
The committee also noted research has shown cannabidiol exposure in the short term may impact placental permeability to “pharmacologic agents and recreational substances, potentially placing the fetus at risk from these agents or drugs.” A more well-known substance in marijuana, delta-9-tetrahydrocannabinol (THC) crosses the placental barrier and can appear in fetal blood. Studies have reported any level of marijuana use among pregnant women put the mothers at risk of anemia, while their newborns had an increased risk of low-birth weight and neonatal intensive care unit (NICU) use. Further research has shown impaired mental development, executive function deficits, increased impulsivity and hyperactivity, behavioral problems, depressive symptoms, and greater rates of substance abuse among children exposed to marijuana.
“Many of these effects may not show up right away, but they can impact how well a child can maneuver in the world,” Dr. Ryan stated in the release. “Children’s and teens’ cognitive ability to manage their time and school work might be harmed down the line from marijuana use during their mother’s pregnancy.”
In a related study, Kerri A. Bertrand, MPH, from the department of pediatrics at the University of California in San Diego, Calif., and her colleagues studied cannabinoid concentrations in breastmilk donated to a human milk biorepository. The investigators analyzed 54 samples donated by 50 women who used marijuana while breastfeeding between 2014 and 2017 and determined whether substances such as delta-9-THC, 11-hydroxy-delta-9-tetrahydrocannabinol (11-OH-THC), cannabidiol, and cannabinol were present in breastmilk by performing liquid chromatography mass spectrometry electrospray ionization on the samples.
They found 34 of 54 samples (64%) had detectable delta-9-THC approximately 6 days after marijuana use (median concentration, 9.47 ng/mL; range, 1.01-323 ng/mL), while 5 of 54 samples (9%) had measurable concentrations of 11-OH-THC (range, 1.33-12.80 ng/mL) and 5 of 54 samples (9%) contained measurable cannabidiol (range, 1.32-8.56 ng/mL). Predictors of log delta-9-THC concentrations included number of hours since last use (-0.03; 95% confidence interval, -0.04 to -0.01; P equals .005), the number of times per day marijuana was used (0.51; 95% CI, 0.03-0.99; P equals .039), and the amount of time between sample donation and analysis (0.08; 95% CI, 0.00-0.15; P equals .038), researchers said.
“Because marijuana is the most commonly used recreational drug among breastfeeding women, information regarding risks to breastfeeding infants is urgently needed,” Dr. Bertrand and colleagues wrote in their study.
The authors of the AAP clinical report acknowledge no relevant conflicts of interest. The study by Bertrand and colleagues was supported by the University of California San Diego Center for Better Beginnings, a grant from the National Institutes of Health, and the Gerber Foundation.
SOURCE: Bertrand KA et al. Pediatrics. 2018 Aug 27;doi:10.1542/peds.2018-1076.
, according to a recent clinical report published in the journal Pediatrics.
“The fact that marijuana is legal in many states may give the impression the drug is harmless during pregnancy, especially with stories swirling on social media about using it for nausea with morning sickness,” Sheryl A. Ryan, MD, FAAP, Chair of the American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention, stated in a press release. “But in fact, this is still a big question. We do not have good safety data on prenatal exposure to marijuana. Based on the limited data that do exist, as pediatricians, we believe there is cause to be concerned about how the drug will impact the long-term development of children.”
The rate of marijuana use is increasing among pregnant women 18 years to 44 years old is increasing, the committee said, with 3.84% of women in 2014 within that age range using marijuana within the past month compared with 2.37% in 2002. Among women who were between 18 years and 25 years old, the rate of marijuana use within the past month was 7.47% in 2014.
The committee also noted research has shown cannabidiol exposure in the short term may impact placental permeability to “pharmacologic agents and recreational substances, potentially placing the fetus at risk from these agents or drugs.” A more well-known substance in marijuana, delta-9-tetrahydrocannabinol (THC) crosses the placental barrier and can appear in fetal blood. Studies have reported any level of marijuana use among pregnant women put the mothers at risk of anemia, while their newborns had an increased risk of low-birth weight and neonatal intensive care unit (NICU) use. Further research has shown impaired mental development, executive function deficits, increased impulsivity and hyperactivity, behavioral problems, depressive symptoms, and greater rates of substance abuse among children exposed to marijuana.
“Many of these effects may not show up right away, but they can impact how well a child can maneuver in the world,” Dr. Ryan stated in the release. “Children’s and teens’ cognitive ability to manage their time and school work might be harmed down the line from marijuana use during their mother’s pregnancy.”
In a related study, Kerri A. Bertrand, MPH, from the department of pediatrics at the University of California in San Diego, Calif., and her colleagues studied cannabinoid concentrations in breastmilk donated to a human milk biorepository. The investigators analyzed 54 samples donated by 50 women who used marijuana while breastfeeding between 2014 and 2017 and determined whether substances such as delta-9-THC, 11-hydroxy-delta-9-tetrahydrocannabinol (11-OH-THC), cannabidiol, and cannabinol were present in breastmilk by performing liquid chromatography mass spectrometry electrospray ionization on the samples.
They found 34 of 54 samples (64%) had detectable delta-9-THC approximately 6 days after marijuana use (median concentration, 9.47 ng/mL; range, 1.01-323 ng/mL), while 5 of 54 samples (9%) had measurable concentrations of 11-OH-THC (range, 1.33-12.80 ng/mL) and 5 of 54 samples (9%) contained measurable cannabidiol (range, 1.32-8.56 ng/mL). Predictors of log delta-9-THC concentrations included number of hours since last use (-0.03; 95% confidence interval, -0.04 to -0.01; P equals .005), the number of times per day marijuana was used (0.51; 95% CI, 0.03-0.99; P equals .039), and the amount of time between sample donation and analysis (0.08; 95% CI, 0.00-0.15; P equals .038), researchers said.
“Because marijuana is the most commonly used recreational drug among breastfeeding women, information regarding risks to breastfeeding infants is urgently needed,” Dr. Bertrand and colleagues wrote in their study.
The authors of the AAP clinical report acknowledge no relevant conflicts of interest. The study by Bertrand and colleagues was supported by the University of California San Diego Center for Better Beginnings, a grant from the National Institutes of Health, and the Gerber Foundation.
SOURCE: Bertrand KA et al. Pediatrics. 2018 Aug 27;doi:10.1542/peds.2018-1076.
PEDIATRICS
Key clinical point: More studies are needed to analyze the long-term effects marijuana has on mother and child during pregnancy and while breastfeeding.
Major finding: Of women between 18 years and 44 years old, 3.84% used marijuana during pregnancy in 2014 compared with 2.37% in 2002; 64% of samples in Bertrand and colleagues’ study had THC traceable in breastmilk approximately 6 days after marijuana use.
Study details:A clinical report on marijuana use during pregnancy and while breastfeeding, and a study of 50 women who used marijuana while breastfeeding and donated samples to a human milk biorepository.
Disclosures:The authors of the AAP clinical report no relevant conflicts of interest. The study by Bertrand and colleagues was supported by the University of California San Diego Center for Better Beginnings, a grant from the National Institutes of Health, and the Gerber Foundation.
Source: Ryan SA et al. Pediatrics. 2018 Aug 27;doi:10.1542/peds.2018-1889. Bertrand KA et al. Pediatrics. 2018 Aug 27;doi:10.1542/peds.2018-1076.
Russian Twitter bots and trolls amplify vaccine controversy
Russian trolls and bots significantly intensified the polarization of vaccine messaging on Twitter, fostering discord on the social network, according to researchers who analyzed the content of tweets over a 3-year period.
“Bots and trolls are actively involved in the online public health discourse, skewing discussions about vaccination,” wrote David A. Broniatowski, PhD, of George Washington University, Washington, D.C., and his associates.
in the American Journal of Public Health (Am J Public Health. doi: 10.2105/AJPH.2018.304567).
“This is vital knowledge for risk communicators, especially considering that neither members of the public nor algorithmic approaches may be able to easily identify bots, trolls, or cyborgs.”
The researchers conducted two content analyses and one qualitative analysis of tweets from July 2014 to September 2017. Their data set included 1% of all tweets during that time period and a sample of tweets containing vaccine-related keywords.
First they compared rates of vaccine-related tweets between bots and average users, and then they assessed the attitude of these tweets from different account types. Their qualitative case study focused on the use of the hashtag #vaccinateUS which was predominantly used by Russian trolls.
The researchers relied on seven publicly available lists to identify which accounts were bots or trolls and then compared them to randomly selected tweets posted in the same time period.
In their second analysis, the researchers used Botometer, a program created by the Indiana University Network Science Institute (IUNI) and the Center for Complex Networks and Systems Research (CNetS), to categorize tweets as very likely to be human, very likely to be bots, or of uncertain provenance.
Results revealed that Russian trolls, sophisticated bot accounts, and “content polluters” – those that spread malware and unsolicited content – are more likely than average users to tweet about vaccination. Content polluters tweeted more anti-vaccine messages while Russian trolls and sophisticated bots promoted both anti-vaccine and pro-vaccine messages that amplified the polarization (P less than .001).
The higher rate of antivaccine messages from content polluters suggested that antivaccine advocates may have exploited existing bot networks for their messaging.
“These accounts may also use the compelling nature of antivaccine content as clickbait to drive up advertising revenue and expose users to malware,” Dr. Broniatowski and colleagues wrote. “Antivaccine content may increase the risks of infection by both computer and biological viruses.”
The qualitative analysis of the #VaccinateUS hashtag found that 43% were provaccine, 38% were antivaccine and the other 19% were neutral.
“Whereas most non-neutral vaccine-relevant hashtags were clearly identifiable as either provaccine (#vaccineswork, #vaxwithme) or antivaccine (#Vaxxed, #b1less, #CDCWhistleblower), with limited appropriation by the opposing side, #VaccinateUS is unique in that it appears with very polarized messages on both sides,” the researchers reported.
Tweets using the #VaccinateUS hashtags were also more likely to contain grammatical errors, unnatural word choices, and irregular phrasing – but fewer spelling or punctuation errors than average tweets related to vaccines.
“The #VaccinateUS messages are also distinctive in that they contain no links to outside content, rare @mentions of other users, and no images (but occasionally use some emojis),” the researchers found.
Although messages with that hashtag “mirrored” Twitter’s overall vaccine discourse, subtle differences included greater emphasis on “freedom,” “democracy,” and “constitutional rights” than the more common “parental choice” focus of tweets using other vaccine-related hashtags. The conspiracy-theory targets of #VaccinateUS tweets also focused almost entirely on the U.S. government instead of a wide range of conspiracy theories at large, which was more common in other anti-vaccine tweets.
Antivaccine content was densest among accounts, with accounts falling in the middle bot category of uncertainty.
“Although we speculate that this set of accounts contains more sophisticated bots, trolls, and cyborgs, their provenance is ultimately unknown,” the researchers wrote. “Therefore, beyond attempting to prevent bots from spreading messages over social media, public health practitioners should focus on combating the messages themselves while not feeding the trolls.”
The research was funded by the National Institutes of Health. No conflicts of interest were noted.
SOURCE: Broniatowski DA et al. Am J Public Health. 2018 Aug 23. doi: 10.2105/AJPH.2018.304567.
Russian trolls and bots significantly intensified the polarization of vaccine messaging on Twitter, fostering discord on the social network, according to researchers who analyzed the content of tweets over a 3-year period.
“Bots and trolls are actively involved in the online public health discourse, skewing discussions about vaccination,” wrote David A. Broniatowski, PhD, of George Washington University, Washington, D.C., and his associates.
in the American Journal of Public Health (Am J Public Health. doi: 10.2105/AJPH.2018.304567).
“This is vital knowledge for risk communicators, especially considering that neither members of the public nor algorithmic approaches may be able to easily identify bots, trolls, or cyborgs.”
The researchers conducted two content analyses and one qualitative analysis of tweets from July 2014 to September 2017. Their data set included 1% of all tweets during that time period and a sample of tweets containing vaccine-related keywords.
First they compared rates of vaccine-related tweets between bots and average users, and then they assessed the attitude of these tweets from different account types. Their qualitative case study focused on the use of the hashtag #vaccinateUS which was predominantly used by Russian trolls.
The researchers relied on seven publicly available lists to identify which accounts were bots or trolls and then compared them to randomly selected tweets posted in the same time period.
In their second analysis, the researchers used Botometer, a program created by the Indiana University Network Science Institute (IUNI) and the Center for Complex Networks and Systems Research (CNetS), to categorize tweets as very likely to be human, very likely to be bots, or of uncertain provenance.
Results revealed that Russian trolls, sophisticated bot accounts, and “content polluters” – those that spread malware and unsolicited content – are more likely than average users to tweet about vaccination. Content polluters tweeted more anti-vaccine messages while Russian trolls and sophisticated bots promoted both anti-vaccine and pro-vaccine messages that amplified the polarization (P less than .001).
The higher rate of antivaccine messages from content polluters suggested that antivaccine advocates may have exploited existing bot networks for their messaging.
“These accounts may also use the compelling nature of antivaccine content as clickbait to drive up advertising revenue and expose users to malware,” Dr. Broniatowski and colleagues wrote. “Antivaccine content may increase the risks of infection by both computer and biological viruses.”
The qualitative analysis of the #VaccinateUS hashtag found that 43% were provaccine, 38% were antivaccine and the other 19% were neutral.
“Whereas most non-neutral vaccine-relevant hashtags were clearly identifiable as either provaccine (#vaccineswork, #vaxwithme) or antivaccine (#Vaxxed, #b1less, #CDCWhistleblower), with limited appropriation by the opposing side, #VaccinateUS is unique in that it appears with very polarized messages on both sides,” the researchers reported.
Tweets using the #VaccinateUS hashtags were also more likely to contain grammatical errors, unnatural word choices, and irregular phrasing – but fewer spelling or punctuation errors than average tweets related to vaccines.
“The #VaccinateUS messages are also distinctive in that they contain no links to outside content, rare @mentions of other users, and no images (but occasionally use some emojis),” the researchers found.
Although messages with that hashtag “mirrored” Twitter’s overall vaccine discourse, subtle differences included greater emphasis on “freedom,” “democracy,” and “constitutional rights” than the more common “parental choice” focus of tweets using other vaccine-related hashtags. The conspiracy-theory targets of #VaccinateUS tweets also focused almost entirely on the U.S. government instead of a wide range of conspiracy theories at large, which was more common in other anti-vaccine tweets.
Antivaccine content was densest among accounts, with accounts falling in the middle bot category of uncertainty.
“Although we speculate that this set of accounts contains more sophisticated bots, trolls, and cyborgs, their provenance is ultimately unknown,” the researchers wrote. “Therefore, beyond attempting to prevent bots from spreading messages over social media, public health practitioners should focus on combating the messages themselves while not feeding the trolls.”
The research was funded by the National Institutes of Health. No conflicts of interest were noted.
SOURCE: Broniatowski DA et al. Am J Public Health. 2018 Aug 23. doi: 10.2105/AJPH.2018.304567.
Russian trolls and bots significantly intensified the polarization of vaccine messaging on Twitter, fostering discord on the social network, according to researchers who analyzed the content of tweets over a 3-year period.
“Bots and trolls are actively involved in the online public health discourse, skewing discussions about vaccination,” wrote David A. Broniatowski, PhD, of George Washington University, Washington, D.C., and his associates.
in the American Journal of Public Health (Am J Public Health. doi: 10.2105/AJPH.2018.304567).
“This is vital knowledge for risk communicators, especially considering that neither members of the public nor algorithmic approaches may be able to easily identify bots, trolls, or cyborgs.”
The researchers conducted two content analyses and one qualitative analysis of tweets from July 2014 to September 2017. Their data set included 1% of all tweets during that time period and a sample of tweets containing vaccine-related keywords.
First they compared rates of vaccine-related tweets between bots and average users, and then they assessed the attitude of these tweets from different account types. Their qualitative case study focused on the use of the hashtag #vaccinateUS which was predominantly used by Russian trolls.
The researchers relied on seven publicly available lists to identify which accounts were bots or trolls and then compared them to randomly selected tweets posted in the same time period.
In their second analysis, the researchers used Botometer, a program created by the Indiana University Network Science Institute (IUNI) and the Center for Complex Networks and Systems Research (CNetS), to categorize tweets as very likely to be human, very likely to be bots, or of uncertain provenance.
Results revealed that Russian trolls, sophisticated bot accounts, and “content polluters” – those that spread malware and unsolicited content – are more likely than average users to tweet about vaccination. Content polluters tweeted more anti-vaccine messages while Russian trolls and sophisticated bots promoted both anti-vaccine and pro-vaccine messages that amplified the polarization (P less than .001).
The higher rate of antivaccine messages from content polluters suggested that antivaccine advocates may have exploited existing bot networks for their messaging.
“These accounts may also use the compelling nature of antivaccine content as clickbait to drive up advertising revenue and expose users to malware,” Dr. Broniatowski and colleagues wrote. “Antivaccine content may increase the risks of infection by both computer and biological viruses.”
The qualitative analysis of the #VaccinateUS hashtag found that 43% were provaccine, 38% were antivaccine and the other 19% were neutral.
“Whereas most non-neutral vaccine-relevant hashtags were clearly identifiable as either provaccine (#vaccineswork, #vaxwithme) or antivaccine (#Vaxxed, #b1less, #CDCWhistleblower), with limited appropriation by the opposing side, #VaccinateUS is unique in that it appears with very polarized messages on both sides,” the researchers reported.
Tweets using the #VaccinateUS hashtags were also more likely to contain grammatical errors, unnatural word choices, and irregular phrasing – but fewer spelling or punctuation errors than average tweets related to vaccines.
“The #VaccinateUS messages are also distinctive in that they contain no links to outside content, rare @mentions of other users, and no images (but occasionally use some emojis),” the researchers found.
Although messages with that hashtag “mirrored” Twitter’s overall vaccine discourse, subtle differences included greater emphasis on “freedom,” “democracy,” and “constitutional rights” than the more common “parental choice” focus of tweets using other vaccine-related hashtags. The conspiracy-theory targets of #VaccinateUS tweets also focused almost entirely on the U.S. government instead of a wide range of conspiracy theories at large, which was more common in other anti-vaccine tweets.
Antivaccine content was densest among accounts, with accounts falling in the middle bot category of uncertainty.
“Although we speculate that this set of accounts contains more sophisticated bots, trolls, and cyborgs, their provenance is ultimately unknown,” the researchers wrote. “Therefore, beyond attempting to prevent bots from spreading messages over social media, public health practitioners should focus on combating the messages themselves while not feeding the trolls.”
The research was funded by the National Institutes of Health. No conflicts of interest were noted.
SOURCE: Broniatowski DA et al. Am J Public Health. 2018 Aug 23. doi: 10.2105/AJPH.2018.304567.
FROM THE AMERICAN JOURNAL OF PUBLIC HEALTH
Key clinical point: Twitter bots and trolls are polluting social media vaccine discussions.
Major finding: Russian trolls and bots are more likely to amplify polarization of vaccine Twitter messaging while other trolls and bots are more likely to promote anti-vaccine messages and malware.
Study details: The findings are based on three content analyses of vaccine-related Twitter content samples from July 2014 to September 2017.
Disclosures: The research was funded by the National Institutes of Health. No conflicts of interest were noted.
Source: Broniatowski, D et al. Am J Public Health. doi:10.2105/AJPH.2018.304567.
FDA approves Diacomit for Dravet syndrome
The Food and Drug Administration has approved stiripentol (Diacomit) for the treatment of Dravet syndrome in patients aged 2 years and older who are taking clobazam.
Dravet syndrome is a rare form of epilepsy that presents within the first year as febrile seizures and then with other types of seizure later in life. Status epilepticus, a potentially life-threatening medical emergency, is a known risk. Also, developmental and interpersonal difficulties have been associated with this syndrome.
Because there are no clinical data for using stiripentol as monotherapy, it is indicated for use only in conjunction with clobazam. The recommended dosage for stiripentol is 50 mg/kg per day divided into either two or three doses, although the maximum recommended daily dose is 3,000 mg. It is available as either capsules or powder for oral solution, both of which come in either 250-mg or 500-mg forms.
Adverse reactions include somnolence, decreased appetite and weight, neutropenia and thrombocytopenia, tremor, nausea, and suicidal behavior and ideation. Because of the risk of neutropenia and thrombocytopenia, blood counts should be obtained via hematologic testing before starting stiripentol and again every 6 months. Also, as with most antiepileptic drugs, there is a risk of withdrawal symptoms, such as risk of increased seizure frequency and status epilepticus; as such, patients should not discontinue stiripentol without first consulting their health care professional.
Full prescribing information can be found on the FDA website.
The Food and Drug Administration has approved stiripentol (Diacomit) for the treatment of Dravet syndrome in patients aged 2 years and older who are taking clobazam.
Dravet syndrome is a rare form of epilepsy that presents within the first year as febrile seizures and then with other types of seizure later in life. Status epilepticus, a potentially life-threatening medical emergency, is a known risk. Also, developmental and interpersonal difficulties have been associated with this syndrome.
Because there are no clinical data for using stiripentol as monotherapy, it is indicated for use only in conjunction with clobazam. The recommended dosage for stiripentol is 50 mg/kg per day divided into either two or three doses, although the maximum recommended daily dose is 3,000 mg. It is available as either capsules or powder for oral solution, both of which come in either 250-mg or 500-mg forms.
Adverse reactions include somnolence, decreased appetite and weight, neutropenia and thrombocytopenia, tremor, nausea, and suicidal behavior and ideation. Because of the risk of neutropenia and thrombocytopenia, blood counts should be obtained via hematologic testing before starting stiripentol and again every 6 months. Also, as with most antiepileptic drugs, there is a risk of withdrawal symptoms, such as risk of increased seizure frequency and status epilepticus; as such, patients should not discontinue stiripentol without first consulting their health care professional.
Full prescribing information can be found on the FDA website.
The Food and Drug Administration has approved stiripentol (Diacomit) for the treatment of Dravet syndrome in patients aged 2 years and older who are taking clobazam.
Dravet syndrome is a rare form of epilepsy that presents within the first year as febrile seizures and then with other types of seizure later in life. Status epilepticus, a potentially life-threatening medical emergency, is a known risk. Also, developmental and interpersonal difficulties have been associated with this syndrome.
Because there are no clinical data for using stiripentol as monotherapy, it is indicated for use only in conjunction with clobazam. The recommended dosage for stiripentol is 50 mg/kg per day divided into either two or three doses, although the maximum recommended daily dose is 3,000 mg. It is available as either capsules or powder for oral solution, both of which come in either 250-mg or 500-mg forms.
Adverse reactions include somnolence, decreased appetite and weight, neutropenia and thrombocytopenia, tremor, nausea, and suicidal behavior and ideation. Because of the risk of neutropenia and thrombocytopenia, blood counts should be obtained via hematologic testing before starting stiripentol and again every 6 months. Also, as with most antiepileptic drugs, there is a risk of withdrawal symptoms, such as risk of increased seizure frequency and status epilepticus; as such, patients should not discontinue stiripentol without first consulting their health care professional.
Full prescribing information can be found on the FDA website.
Three steps are involved in assessing a vesiculopustular lesion
LAKE TAHOE, CALIF. – Evaluation of an infant with a vesiculopustular lesion entails a pragmatic approach, with three assessment steps, according to pediatric dermatologist Lawrence A. Schachner, MD.
At the annual meeting of the Society for Pediatric Dermatology, Dr. Schachner noted that the differential diagnosis of noninfectious, usually benign neonatal vesiculopustular lesions includes acropustulosis of infancy; eosinophilic pustular folliculitis; erythema toxicum neonatorum; miliaria crystallina, rubra, or profunda; transient neonatal pustular melanosis; and neonatal sucking blisters. Noninfectious lesions that can be potentially serious include acrodermatitis enteropathica, bullous pemphigoid, epidermolysis bullosa, epidermolytic hyperkeratosis, incontinentia pigmenti, Langerhans cell histiocytosis, pemphigus vulgaris, pustular psoriasis, and urticarial pigmentosa.
Step 1 for evaluating vesiculopustular lesions involves drawing out the fluid for bacterial cultures and sensitivity, Gram stains, viral culture and/or serology, said Dr. Schachner, who directs the division of pediatric dermatology at the University of Miami.
Step 2 involves snipping off the lesion’s roof for a potassium hydroxide test to send for dermatopathology or frozen pathology.
Step 3 involves scraping the lesion’s base for viral cytology and cell identification. “If we can see a predominant cell type, that’s where the action is,” said Dr. Schachner, professor of pediatrics at the university. If cytology reveals polymorphic neutrophils, differential diagnoses include transient neonatal pustular melanosis, infantile acropustulosis, bullous impetigo, and pustular psoriasis. If cytology reveals eosinophils, differential diagnoses include eosinophilic pustular folliculitis of infancy, erythema toxicum neonatorum, incontinentia pigmenti, bullous pemphigoid, drug reactions, and arthropod bites. The presence of lymphocytes on cytology, meanwhile, may suggest a differential diagnosis miliaria or acrodermatitis enteropathica.
“When in doubt about the diagnosis, biopsy,” Dr. Schachner said. “This, to me, is a pragmatic approach.”
Dr. Schachner disclosed that he is an investigator for Astellas, Ferndale Labs, Novartis, Organogenesis, Stiefel Laboratories, Berg Pharma, Medimetrics, and Lilly. He is a consultant to Beiersdorf, Lexington, TopMD, Cutanea, Hoth Therapeutics, and Mustela.
dbrunk@mdedge.com
LAKE TAHOE, CALIF. – Evaluation of an infant with a vesiculopustular lesion entails a pragmatic approach, with three assessment steps, according to pediatric dermatologist Lawrence A. Schachner, MD.
At the annual meeting of the Society for Pediatric Dermatology, Dr. Schachner noted that the differential diagnosis of noninfectious, usually benign neonatal vesiculopustular lesions includes acropustulosis of infancy; eosinophilic pustular folliculitis; erythema toxicum neonatorum; miliaria crystallina, rubra, or profunda; transient neonatal pustular melanosis; and neonatal sucking blisters. Noninfectious lesions that can be potentially serious include acrodermatitis enteropathica, bullous pemphigoid, epidermolysis bullosa, epidermolytic hyperkeratosis, incontinentia pigmenti, Langerhans cell histiocytosis, pemphigus vulgaris, pustular psoriasis, and urticarial pigmentosa.
Step 1 for evaluating vesiculopustular lesions involves drawing out the fluid for bacterial cultures and sensitivity, Gram stains, viral culture and/or serology, said Dr. Schachner, who directs the division of pediatric dermatology at the University of Miami.
Step 2 involves snipping off the lesion’s roof for a potassium hydroxide test to send for dermatopathology or frozen pathology.
Step 3 involves scraping the lesion’s base for viral cytology and cell identification. “If we can see a predominant cell type, that’s where the action is,” said Dr. Schachner, professor of pediatrics at the university. If cytology reveals polymorphic neutrophils, differential diagnoses include transient neonatal pustular melanosis, infantile acropustulosis, bullous impetigo, and pustular psoriasis. If cytology reveals eosinophils, differential diagnoses include eosinophilic pustular folliculitis of infancy, erythema toxicum neonatorum, incontinentia pigmenti, bullous pemphigoid, drug reactions, and arthropod bites. The presence of lymphocytes on cytology, meanwhile, may suggest a differential diagnosis miliaria or acrodermatitis enteropathica.
“When in doubt about the diagnosis, biopsy,” Dr. Schachner said. “This, to me, is a pragmatic approach.”
Dr. Schachner disclosed that he is an investigator for Astellas, Ferndale Labs, Novartis, Organogenesis, Stiefel Laboratories, Berg Pharma, Medimetrics, and Lilly. He is a consultant to Beiersdorf, Lexington, TopMD, Cutanea, Hoth Therapeutics, and Mustela.
dbrunk@mdedge.com
LAKE TAHOE, CALIF. – Evaluation of an infant with a vesiculopustular lesion entails a pragmatic approach, with three assessment steps, according to pediatric dermatologist Lawrence A. Schachner, MD.
At the annual meeting of the Society for Pediatric Dermatology, Dr. Schachner noted that the differential diagnosis of noninfectious, usually benign neonatal vesiculopustular lesions includes acropustulosis of infancy; eosinophilic pustular folliculitis; erythema toxicum neonatorum; miliaria crystallina, rubra, or profunda; transient neonatal pustular melanosis; and neonatal sucking blisters. Noninfectious lesions that can be potentially serious include acrodermatitis enteropathica, bullous pemphigoid, epidermolysis bullosa, epidermolytic hyperkeratosis, incontinentia pigmenti, Langerhans cell histiocytosis, pemphigus vulgaris, pustular psoriasis, and urticarial pigmentosa.
Step 1 for evaluating vesiculopustular lesions involves drawing out the fluid for bacterial cultures and sensitivity, Gram stains, viral culture and/or serology, said Dr. Schachner, who directs the division of pediatric dermatology at the University of Miami.
Step 2 involves snipping off the lesion’s roof for a potassium hydroxide test to send for dermatopathology or frozen pathology.
Step 3 involves scraping the lesion’s base for viral cytology and cell identification. “If we can see a predominant cell type, that’s where the action is,” said Dr. Schachner, professor of pediatrics at the university. If cytology reveals polymorphic neutrophils, differential diagnoses include transient neonatal pustular melanosis, infantile acropustulosis, bullous impetigo, and pustular psoriasis. If cytology reveals eosinophils, differential diagnoses include eosinophilic pustular folliculitis of infancy, erythema toxicum neonatorum, incontinentia pigmenti, bullous pemphigoid, drug reactions, and arthropod bites. The presence of lymphocytes on cytology, meanwhile, may suggest a differential diagnosis miliaria or acrodermatitis enteropathica.
“When in doubt about the diagnosis, biopsy,” Dr. Schachner said. “This, to me, is a pragmatic approach.”
Dr. Schachner disclosed that he is an investigator for Astellas, Ferndale Labs, Novartis, Organogenesis, Stiefel Laboratories, Berg Pharma, Medimetrics, and Lilly. He is a consultant to Beiersdorf, Lexington, TopMD, Cutanea, Hoth Therapeutics, and Mustela.
dbrunk@mdedge.com
REPORTING FROM SPD 2018
Oral prednisone is not effective for OME in older children
because many participants had spontaneous resolution of their symptoms, according to results from a randomized, parallel, double-blinded, placebo-controlled trial.
“If effective, a short course of oral steroids for otitis media with effusion would have been appealing as the treatment is generally well tolerated and would avoid more burdensome and expensive interventions such as ventilation tubes or hearing aids,” Nick A. Francis, PhD, of Cardiff University, Wales, and his colleagues wrote in the Lancet.
Dr. Francis and his colleagues enrolled 389 children aged 2-8 years with symptoms of OME from 20 ear, nose, and throat outpatient medical departments into the OSTRICH trial between March 2014 and April 2016, where they were randomized to receive a 7-day course of once daily oral prednisone at 20 mg for children aged 2-5 years and 30 mg for children 6-8 years (total of 200 patients), or placebo (189 patients). Some patients had symptoms of hearing loss from their condition so 183 participants in the oral steroid group and 180 participants in the placebo group underwent a hearing test 4 weeks after treatment.
At 5 weeks, Dr. Francis and his colleagues found that 40% of 183 patients in the oral steroid group and 53% of 180 in the placebo group achieved acceptable hearing after treatment, a small nonsignificant between group difference (absolute difference, 7%; 95% confidence interval, –3 to 17). However, the number needed to treat was 14 to 1, and there was a high number of spontaneous resolutions of symptoms in the study, they said. In addition, there were no between-group differences in adverse events or quality of life.
While they do not recommend routine oral steroids for children in this setting based on limited clinical significance, the investigators suggested oral steroids may be a “reasonable candidate intervention” for treatment of children in other patient populations.
“The high rate of spontaneous resolution identified in this study will support the evidence base informing discussions about watchful waiting in children with hearing loss associated with otitis media with effusion. Given the findings of some benefit from antibiotics for otitis media with effusion in children, and limited trial evidence for a benefit from oral steroids in combination with antibiotics, a rigorous trial of oral steroids combined with antibiotics might be indicated,” Dr. Francis and his colleagues wrote.
The OSTRICH Trial was funded by the National Institute for Health Research Health Technology Assessment program. The authors reported no conflicts of interest.
SOURCE: Francis NA et al. Lancet. 2018 Aug 18. doi: 10.1016/S0140-6736(18)31490-9.
The inclusion criteria for this study were age between 2 and 8 years, which is “generally older” than pediatric patients who develop otitis media with effusion, so the study can apply only to this patient population, Michael E. Pichichero, MD, wrote in a related editorial.
“The pathophysiology of otitis media with effusion and mechanistic work in animal models support the use of systematic steroids for clearing otitis media with effusion,” Dr. Pichichero said. “Given the evidence from trials suggesting that oral steroids alone and in combination with antibiotics help clear otitis media with effusion, the issue remains an open question for children who do not meet the enrollment criteria applied in the current trial.”
Further, he noted that because two-thirds of patients had the condition for a minimum of 12 months were likely to have high viscosity fluid, so-called glue ear, a “temporary opening of the Eustachian tube with 1 week of oral steroids might not have been a fair test.” In addition, pediatric patients with otitis media have a high rate of spontaneous resolution, he said, and noted that Francis et al. addressed the evidence gap with their research.
“Apart from a clear answer about the effect of oral steroids in children aged 2-8 years with prolonged otitis media with effusion, the unique natural history data of otitis media with effusion provided in Francis and colleagues’ study will help inform discussions about whether to opt for grommet surgery or to continue with watchful waiting,” Dr. Pichichero said.
Dr. Pichichero is with the Rochester (N.Y.) General Hospital Research Institute. He reports no relevant conflicts of interest. These comments summarize his editorial on the article by Francis et al. (Lancet. 2018 Aug 18. doi: 10.1016/S0140-6736[18]31862-2 .)
The inclusion criteria for this study were age between 2 and 8 years, which is “generally older” than pediatric patients who develop otitis media with effusion, so the study can apply only to this patient population, Michael E. Pichichero, MD, wrote in a related editorial.
“The pathophysiology of otitis media with effusion and mechanistic work in animal models support the use of systematic steroids for clearing otitis media with effusion,” Dr. Pichichero said. “Given the evidence from trials suggesting that oral steroids alone and in combination with antibiotics help clear otitis media with effusion, the issue remains an open question for children who do not meet the enrollment criteria applied in the current trial.”
Further, he noted that because two-thirds of patients had the condition for a minimum of 12 months were likely to have high viscosity fluid, so-called glue ear, a “temporary opening of the Eustachian tube with 1 week of oral steroids might not have been a fair test.” In addition, pediatric patients with otitis media have a high rate of spontaneous resolution, he said, and noted that Francis et al. addressed the evidence gap with their research.
“Apart from a clear answer about the effect of oral steroids in children aged 2-8 years with prolonged otitis media with effusion, the unique natural history data of otitis media with effusion provided in Francis and colleagues’ study will help inform discussions about whether to opt for grommet surgery or to continue with watchful waiting,” Dr. Pichichero said.
Dr. Pichichero is with the Rochester (N.Y.) General Hospital Research Institute. He reports no relevant conflicts of interest. These comments summarize his editorial on the article by Francis et al. (Lancet. 2018 Aug 18. doi: 10.1016/S0140-6736[18]31862-2 .)
The inclusion criteria for this study were age between 2 and 8 years, which is “generally older” than pediatric patients who develop otitis media with effusion, so the study can apply only to this patient population, Michael E. Pichichero, MD, wrote in a related editorial.
“The pathophysiology of otitis media with effusion and mechanistic work in animal models support the use of systematic steroids for clearing otitis media with effusion,” Dr. Pichichero said. “Given the evidence from trials suggesting that oral steroids alone and in combination with antibiotics help clear otitis media with effusion, the issue remains an open question for children who do not meet the enrollment criteria applied in the current trial.”
Further, he noted that because two-thirds of patients had the condition for a minimum of 12 months were likely to have high viscosity fluid, so-called glue ear, a “temporary opening of the Eustachian tube with 1 week of oral steroids might not have been a fair test.” In addition, pediatric patients with otitis media have a high rate of spontaneous resolution, he said, and noted that Francis et al. addressed the evidence gap with their research.
“Apart from a clear answer about the effect of oral steroids in children aged 2-8 years with prolonged otitis media with effusion, the unique natural history data of otitis media with effusion provided in Francis and colleagues’ study will help inform discussions about whether to opt for grommet surgery or to continue with watchful waiting,” Dr. Pichichero said.
Dr. Pichichero is with the Rochester (N.Y.) General Hospital Research Institute. He reports no relevant conflicts of interest. These comments summarize his editorial on the article by Francis et al. (Lancet. 2018 Aug 18. doi: 10.1016/S0140-6736[18]31862-2 .)
because many participants had spontaneous resolution of their symptoms, according to results from a randomized, parallel, double-blinded, placebo-controlled trial.
“If effective, a short course of oral steroids for otitis media with effusion would have been appealing as the treatment is generally well tolerated and would avoid more burdensome and expensive interventions such as ventilation tubes or hearing aids,” Nick A. Francis, PhD, of Cardiff University, Wales, and his colleagues wrote in the Lancet.
Dr. Francis and his colleagues enrolled 389 children aged 2-8 years with symptoms of OME from 20 ear, nose, and throat outpatient medical departments into the OSTRICH trial between March 2014 and April 2016, where they were randomized to receive a 7-day course of once daily oral prednisone at 20 mg for children aged 2-5 years and 30 mg for children 6-8 years (total of 200 patients), or placebo (189 patients). Some patients had symptoms of hearing loss from their condition so 183 participants in the oral steroid group and 180 participants in the placebo group underwent a hearing test 4 weeks after treatment.
At 5 weeks, Dr. Francis and his colleagues found that 40% of 183 patients in the oral steroid group and 53% of 180 in the placebo group achieved acceptable hearing after treatment, a small nonsignificant between group difference (absolute difference, 7%; 95% confidence interval, –3 to 17). However, the number needed to treat was 14 to 1, and there was a high number of spontaneous resolutions of symptoms in the study, they said. In addition, there were no between-group differences in adverse events or quality of life.
While they do not recommend routine oral steroids for children in this setting based on limited clinical significance, the investigators suggested oral steroids may be a “reasonable candidate intervention” for treatment of children in other patient populations.
“The high rate of spontaneous resolution identified in this study will support the evidence base informing discussions about watchful waiting in children with hearing loss associated with otitis media with effusion. Given the findings of some benefit from antibiotics for otitis media with effusion in children, and limited trial evidence for a benefit from oral steroids in combination with antibiotics, a rigorous trial of oral steroids combined with antibiotics might be indicated,” Dr. Francis and his colleagues wrote.
The OSTRICH Trial was funded by the National Institute for Health Research Health Technology Assessment program. The authors reported no conflicts of interest.
SOURCE: Francis NA et al. Lancet. 2018 Aug 18. doi: 10.1016/S0140-6736(18)31490-9.
because many participants had spontaneous resolution of their symptoms, according to results from a randomized, parallel, double-blinded, placebo-controlled trial.
“If effective, a short course of oral steroids for otitis media with effusion would have been appealing as the treatment is generally well tolerated and would avoid more burdensome and expensive interventions such as ventilation tubes or hearing aids,” Nick A. Francis, PhD, of Cardiff University, Wales, and his colleagues wrote in the Lancet.
Dr. Francis and his colleagues enrolled 389 children aged 2-8 years with symptoms of OME from 20 ear, nose, and throat outpatient medical departments into the OSTRICH trial between March 2014 and April 2016, where they were randomized to receive a 7-day course of once daily oral prednisone at 20 mg for children aged 2-5 years and 30 mg for children 6-8 years (total of 200 patients), or placebo (189 patients). Some patients had symptoms of hearing loss from their condition so 183 participants in the oral steroid group and 180 participants in the placebo group underwent a hearing test 4 weeks after treatment.
At 5 weeks, Dr. Francis and his colleagues found that 40% of 183 patients in the oral steroid group and 53% of 180 in the placebo group achieved acceptable hearing after treatment, a small nonsignificant between group difference (absolute difference, 7%; 95% confidence interval, –3 to 17). However, the number needed to treat was 14 to 1, and there was a high number of spontaneous resolutions of symptoms in the study, they said. In addition, there were no between-group differences in adverse events or quality of life.
While they do not recommend routine oral steroids for children in this setting based on limited clinical significance, the investigators suggested oral steroids may be a “reasonable candidate intervention” for treatment of children in other patient populations.
“The high rate of spontaneous resolution identified in this study will support the evidence base informing discussions about watchful waiting in children with hearing loss associated with otitis media with effusion. Given the findings of some benefit from antibiotics for otitis media with effusion in children, and limited trial evidence for a benefit from oral steroids in combination with antibiotics, a rigorous trial of oral steroids combined with antibiotics might be indicated,” Dr. Francis and his colleagues wrote.
The OSTRICH Trial was funded by the National Institute for Health Research Health Technology Assessment program. The authors reported no conflicts of interest.
SOURCE: Francis NA et al. Lancet. 2018 Aug 18. doi: 10.1016/S0140-6736(18)31490-9.
FROM THE LANCET
Key clinical point: Oral prednisone was well tolerated by children with otitis media with effusion, but there was a high rate of spontaneous resolution in the trial.
Major finding: Acceptable hearing was achieved in 73 of 183 children in the oral steroid group and 59 of 180 children in the placebo group, with a number needed to treat of 14.
Study details: A randomized, parallel, double-blinded, placebo-controlled trial of 389 children aged 2-8 years with symptoms of otitis media with effusion.
Disclosures: The OSTRICH Trial was funded by the National Institute for Health Research Health Technology Assessment program. The authors report no conflicts of interest.
Source: Francis NA et al. Lancet. 2018 Aug 18. doi: 10.1016/S0140-6736(18)31490-9.
The power of connection
Over the past several months, I’ve found myself increasingly reflective on the intersection of culture, relationships, and my professional work with those who have an autism spectrum disorder. Last winter, an adolescent boy treated by myself and other providers died by suicide. Adam (name changed) had been diagnosed with autism as a toddler and had struggled with anxiety and depression for several years; in the office, as he grew into an athletic teenager, Adam spoke more frequently about “not fitting in” with his peers and therapeutic focus was placed on building Adam’s sense of himself and fostering his self-confidence and perceived self-competence. His unexpected death was a tremendous shock, and his loved ones – including the clinical team – desperately searched for answers that could help add some understanding to the heartbreaking event.
Around the time of Adam’s death, I was teaching an undergraduate course about the neuroscience of relationships. The class was learning about the brain in love and the importance of social connectedness in overall health. We discussed the reward pathways, libido, notions of synchrony, the meaning of intimacy, prairie voles, dating trends amongst millennials, attachment principles, Harry Harlow’s work with primates, and the dangers associated with loneliness and isolation. Needless to say, my clinical work and my teaching were marked by similarities in theme, themes involving the importance of connection that were worth attending to – particularly as they have heavily influenced my interest in child and adolescent psychiatry since medical school.
In the spring of 2018, these themes were again revisited in the setting of several events. I attended the annual meeting of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), where Dr. Robert Englander provided an inspiring keynote address on the subject of love as a domain of competence in medical education. He referenced the practice of Metta meditation and how compassion and loving kindness meditation is being studied as a tool for healing and treatment. Certainly, preliminary results from examining the effectiveness of these interventions are promising.1 In June, many of us also were shaken by the deaths of both Kate Spade and Anthony Bourdain, occurring at a time when Centers for Disease Control and Prevention published data indicating rising suicide rates across most of the United States.2
Notably, relationship problems were reported as a major contributor to deaths by suicide. Concurrently, here in Vermont, the 2017 Youth Risk Behavior Survey results were released.Particularly striking were the numbers surrounding the rates of high school LGBT-identified students who thought about suicide (33%) and how they compared to cisgender heterosexual students’ reporting (8%).3 Making sense of these numbers is complicated and many factors appear to be informing the statistics. One can’t help but wonder about the impact of feeling marginalized and isolated on rates of suicide in certain populations. It’s also known that rural Americans have higher suicide rates compared with those living in metropolitan areas, and the lack of social integration and access to mental health care has been examined as a risk factor for these statistics.4,5
As I attempted to search for answers and reconcile national news with my clinical and teaching experiences, I was struck by something that Andrew Solomon eloquently captured in his June 2018 New Yorker article that again touches upon the theme of connection.6 Mr. Solomon writes “modernity is alienating” and about how he receives correspondence from those who struggle with depression. “What is most striking to me is how alone many of them are ... these people are so alone that they are effectively invisible to the rest of us ... many of them describe suicidal feelings,” he noted.
The power of connection in our day-to-day work is undeniable. The influence of human interaction and appreciating one’s unique narrative is a bedrock of clinical care and can unquestionably allow us to better understand individual suffering, deliver optimal care, and combat shame as Hannah Gadsby boldly shared in her recent Netflix comedy special “Nanette.” This shame can drive one to experience earth-shattering depressive episodes and influence thoughts of suicide. “We simply cannot make it on our own,” Ms. Gadsby explains, “we’re humans. We’re to be connected.” Humans are indeed hardwired for connection; isolation and disconnection can lead to significant health problems and are linked with mental health concerns. The former U.S. Surgeon General Vivek H. Murthy, MD, has referred to loneliness as an epidemic, and those with autism may be at increased risk for feeling lonely and isolated.7,8
Synthesizing thoughts about relationships, suicide, loneliness, love, well-being, and autism produces a complicated web of, well, connections. Suicide in the autism population hasn’t been well researched, but one 2016 study revealed sobering numbers about suicide being a leading cause of premature death in people with autism.9 How do these numbers associate with feelings of isolation, wanting to fit in, and troubles talking about emotions – all of which can characterize those with ASD? Data, not surprisingly, support the role of loneliness as a risk factor for the development of depression and suicidal ideation in those with ASD.10 In addition, social-communication challenges, even in the absence of an autism diagnosis, are related to depression and suicidality.11 Another recent study showed a relationship between autistic traits and depression symptoms, an association seemingly linked to being bullied.12 We cannot continue to hold onto the myth that individuals with autism don’t desire relationships and love because it’s these desires and not being able to fulfill them, limited opportunities to engage in meaningful experiences, and feeling different that can lead to negative outcomes.
Talking about suicide is critical in helping to prevent suicide, and there is a need for prevention and screening strategies tailored to specific communities and groups of individuals. How do we go about identifying specific risk factors and address them accordingly, especially in the setting of autism, where risk factors such as behavior change and changes in social interactions can be common features innate to the developmental disorder?
Changes in policy and practice are needed, and all people in crisis deserve supports that appreciate their unique challenges and individual strengths.13 Clinically, being mindful of the consequences of victimization and the power of connectedness and its role in health and well-being is critically important. The Centers for Disease Control and Prevention states that “connectedness is a common thread that weaves together many of the influences of suicidal behavior and has direct relevance for prevention,” and providers should strive to enhance positive connectedness between persons, between individuals, families and community organizations, and among organizations and social institutions.14
Spend time with patients asking about their relationships, desires, and satisfaction with social connections. Ask about loneliness and feelings of rejection while communicating to marginalized individuals that they matter. Finally, appreciate the benefits of safety planning.15 Developing a tailored safety plan with someone who is endorsing suicidal thinking, making follow-up connections (i.e., a telephone call), communicating concern, and instilling hope can save lives.
Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at pdnews@mdedge.com.
References
1. Harv Rev Psychiatry. 2018 Jul/Aug;26(4):201-15.
2. MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):617-24.
3. www.healthvermont.gov/YRBS
4. MMWR Surveill Summ. 2017 Oct;66(18):1-16.
5. JAMA Pediatr. 2015 May;169(5):466-73.
6. “Anthony Bourdain, Kate Spade, and the Preventable Tragedies of Suicide,” By Anthony Solomon, The New Yorker. Jun 8, 2018.
7. “Work and the Loneliness Epidemic,” By Vivek H. Murthy, Harvard Business Review. Sep 28, 2017.
8. Child Dev. 2000 Mar-Apr;71(2):447-56.
9. Br J Psychiatry. 2016 Mar;208(3):232-8.
10. Depress Anxiety. 2018 Jul;35(7):648-57.
11. J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):313-20.
12. JAMA Psychiatry. 2018 Aug 1;75(8):835-43.
13. The Lancet Psychiatry. 2017 Jun;4(6):e11.
14. “Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, www.cdc.gov/injury.
15. JAMA Psychiatry. 2018 Jul 11. doi: 10.1001/jamapsychiatry.2018.1776.
Over the past several months, I’ve found myself increasingly reflective on the intersection of culture, relationships, and my professional work with those who have an autism spectrum disorder. Last winter, an adolescent boy treated by myself and other providers died by suicide. Adam (name changed) had been diagnosed with autism as a toddler and had struggled with anxiety and depression for several years; in the office, as he grew into an athletic teenager, Adam spoke more frequently about “not fitting in” with his peers and therapeutic focus was placed on building Adam’s sense of himself and fostering his self-confidence and perceived self-competence. His unexpected death was a tremendous shock, and his loved ones – including the clinical team – desperately searched for answers that could help add some understanding to the heartbreaking event.
Around the time of Adam’s death, I was teaching an undergraduate course about the neuroscience of relationships. The class was learning about the brain in love and the importance of social connectedness in overall health. We discussed the reward pathways, libido, notions of synchrony, the meaning of intimacy, prairie voles, dating trends amongst millennials, attachment principles, Harry Harlow’s work with primates, and the dangers associated with loneliness and isolation. Needless to say, my clinical work and my teaching were marked by similarities in theme, themes involving the importance of connection that were worth attending to – particularly as they have heavily influenced my interest in child and adolescent psychiatry since medical school.
In the spring of 2018, these themes were again revisited in the setting of several events. I attended the annual meeting of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), where Dr. Robert Englander provided an inspiring keynote address on the subject of love as a domain of competence in medical education. He referenced the practice of Metta meditation and how compassion and loving kindness meditation is being studied as a tool for healing and treatment. Certainly, preliminary results from examining the effectiveness of these interventions are promising.1 In June, many of us also were shaken by the deaths of both Kate Spade and Anthony Bourdain, occurring at a time when Centers for Disease Control and Prevention published data indicating rising suicide rates across most of the United States.2
Notably, relationship problems were reported as a major contributor to deaths by suicide. Concurrently, here in Vermont, the 2017 Youth Risk Behavior Survey results were released.Particularly striking were the numbers surrounding the rates of high school LGBT-identified students who thought about suicide (33%) and how they compared to cisgender heterosexual students’ reporting (8%).3 Making sense of these numbers is complicated and many factors appear to be informing the statistics. One can’t help but wonder about the impact of feeling marginalized and isolated on rates of suicide in certain populations. It’s also known that rural Americans have higher suicide rates compared with those living in metropolitan areas, and the lack of social integration and access to mental health care has been examined as a risk factor for these statistics.4,5
As I attempted to search for answers and reconcile national news with my clinical and teaching experiences, I was struck by something that Andrew Solomon eloquently captured in his June 2018 New Yorker article that again touches upon the theme of connection.6 Mr. Solomon writes “modernity is alienating” and about how he receives correspondence from those who struggle with depression. “What is most striking to me is how alone many of them are ... these people are so alone that they are effectively invisible to the rest of us ... many of them describe suicidal feelings,” he noted.
The power of connection in our day-to-day work is undeniable. The influence of human interaction and appreciating one’s unique narrative is a bedrock of clinical care and can unquestionably allow us to better understand individual suffering, deliver optimal care, and combat shame as Hannah Gadsby boldly shared in her recent Netflix comedy special “Nanette.” This shame can drive one to experience earth-shattering depressive episodes and influence thoughts of suicide. “We simply cannot make it on our own,” Ms. Gadsby explains, “we’re humans. We’re to be connected.” Humans are indeed hardwired for connection; isolation and disconnection can lead to significant health problems and are linked with mental health concerns. The former U.S. Surgeon General Vivek H. Murthy, MD, has referred to loneliness as an epidemic, and those with autism may be at increased risk for feeling lonely and isolated.7,8
Synthesizing thoughts about relationships, suicide, loneliness, love, well-being, and autism produces a complicated web of, well, connections. Suicide in the autism population hasn’t been well researched, but one 2016 study revealed sobering numbers about suicide being a leading cause of premature death in people with autism.9 How do these numbers associate with feelings of isolation, wanting to fit in, and troubles talking about emotions – all of which can characterize those with ASD? Data, not surprisingly, support the role of loneliness as a risk factor for the development of depression and suicidal ideation in those with ASD.10 In addition, social-communication challenges, even in the absence of an autism diagnosis, are related to depression and suicidality.11 Another recent study showed a relationship between autistic traits and depression symptoms, an association seemingly linked to being bullied.12 We cannot continue to hold onto the myth that individuals with autism don’t desire relationships and love because it’s these desires and not being able to fulfill them, limited opportunities to engage in meaningful experiences, and feeling different that can lead to negative outcomes.
Talking about suicide is critical in helping to prevent suicide, and there is a need for prevention and screening strategies tailored to specific communities and groups of individuals. How do we go about identifying specific risk factors and address them accordingly, especially in the setting of autism, where risk factors such as behavior change and changes in social interactions can be common features innate to the developmental disorder?
Changes in policy and practice are needed, and all people in crisis deserve supports that appreciate their unique challenges and individual strengths.13 Clinically, being mindful of the consequences of victimization and the power of connectedness and its role in health and well-being is critically important. The Centers for Disease Control and Prevention states that “connectedness is a common thread that weaves together many of the influences of suicidal behavior and has direct relevance for prevention,” and providers should strive to enhance positive connectedness between persons, between individuals, families and community organizations, and among organizations and social institutions.14
Spend time with patients asking about their relationships, desires, and satisfaction with social connections. Ask about loneliness and feelings of rejection while communicating to marginalized individuals that they matter. Finally, appreciate the benefits of safety planning.15 Developing a tailored safety plan with someone who is endorsing suicidal thinking, making follow-up connections (i.e., a telephone call), communicating concern, and instilling hope can save lives.
Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at pdnews@mdedge.com.
References
1. Harv Rev Psychiatry. 2018 Jul/Aug;26(4):201-15.
2. MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):617-24.
3. www.healthvermont.gov/YRBS
4. MMWR Surveill Summ. 2017 Oct;66(18):1-16.
5. JAMA Pediatr. 2015 May;169(5):466-73.
6. “Anthony Bourdain, Kate Spade, and the Preventable Tragedies of Suicide,” By Anthony Solomon, The New Yorker. Jun 8, 2018.
7. “Work and the Loneliness Epidemic,” By Vivek H. Murthy, Harvard Business Review. Sep 28, 2017.
8. Child Dev. 2000 Mar-Apr;71(2):447-56.
9. Br J Psychiatry. 2016 Mar;208(3):232-8.
10. Depress Anxiety. 2018 Jul;35(7):648-57.
11. J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):313-20.
12. JAMA Psychiatry. 2018 Aug 1;75(8):835-43.
13. The Lancet Psychiatry. 2017 Jun;4(6):e11.
14. “Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, www.cdc.gov/injury.
15. JAMA Psychiatry. 2018 Jul 11. doi: 10.1001/jamapsychiatry.2018.1776.
Over the past several months, I’ve found myself increasingly reflective on the intersection of culture, relationships, and my professional work with those who have an autism spectrum disorder. Last winter, an adolescent boy treated by myself and other providers died by suicide. Adam (name changed) had been diagnosed with autism as a toddler and had struggled with anxiety and depression for several years; in the office, as he grew into an athletic teenager, Adam spoke more frequently about “not fitting in” with his peers and therapeutic focus was placed on building Adam’s sense of himself and fostering his self-confidence and perceived self-competence. His unexpected death was a tremendous shock, and his loved ones – including the clinical team – desperately searched for answers that could help add some understanding to the heartbreaking event.
Around the time of Adam’s death, I was teaching an undergraduate course about the neuroscience of relationships. The class was learning about the brain in love and the importance of social connectedness in overall health. We discussed the reward pathways, libido, notions of synchrony, the meaning of intimacy, prairie voles, dating trends amongst millennials, attachment principles, Harry Harlow’s work with primates, and the dangers associated with loneliness and isolation. Needless to say, my clinical work and my teaching were marked by similarities in theme, themes involving the importance of connection that were worth attending to – particularly as they have heavily influenced my interest in child and adolescent psychiatry since medical school.
In the spring of 2018, these themes were again revisited in the setting of several events. I attended the annual meeting of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), where Dr. Robert Englander provided an inspiring keynote address on the subject of love as a domain of competence in medical education. He referenced the practice of Metta meditation and how compassion and loving kindness meditation is being studied as a tool for healing and treatment. Certainly, preliminary results from examining the effectiveness of these interventions are promising.1 In June, many of us also were shaken by the deaths of both Kate Spade and Anthony Bourdain, occurring at a time when Centers for Disease Control and Prevention published data indicating rising suicide rates across most of the United States.2
Notably, relationship problems were reported as a major contributor to deaths by suicide. Concurrently, here in Vermont, the 2017 Youth Risk Behavior Survey results were released.Particularly striking were the numbers surrounding the rates of high school LGBT-identified students who thought about suicide (33%) and how they compared to cisgender heterosexual students’ reporting (8%).3 Making sense of these numbers is complicated and many factors appear to be informing the statistics. One can’t help but wonder about the impact of feeling marginalized and isolated on rates of suicide in certain populations. It’s also known that rural Americans have higher suicide rates compared with those living in metropolitan areas, and the lack of social integration and access to mental health care has been examined as a risk factor for these statistics.4,5
As I attempted to search for answers and reconcile national news with my clinical and teaching experiences, I was struck by something that Andrew Solomon eloquently captured in his June 2018 New Yorker article that again touches upon the theme of connection.6 Mr. Solomon writes “modernity is alienating” and about how he receives correspondence from those who struggle with depression. “What is most striking to me is how alone many of them are ... these people are so alone that they are effectively invisible to the rest of us ... many of them describe suicidal feelings,” he noted.
The power of connection in our day-to-day work is undeniable. The influence of human interaction and appreciating one’s unique narrative is a bedrock of clinical care and can unquestionably allow us to better understand individual suffering, deliver optimal care, and combat shame as Hannah Gadsby boldly shared in her recent Netflix comedy special “Nanette.” This shame can drive one to experience earth-shattering depressive episodes and influence thoughts of suicide. “We simply cannot make it on our own,” Ms. Gadsby explains, “we’re humans. We’re to be connected.” Humans are indeed hardwired for connection; isolation and disconnection can lead to significant health problems and are linked with mental health concerns. The former U.S. Surgeon General Vivek H. Murthy, MD, has referred to loneliness as an epidemic, and those with autism may be at increased risk for feeling lonely and isolated.7,8
Synthesizing thoughts about relationships, suicide, loneliness, love, well-being, and autism produces a complicated web of, well, connections. Suicide in the autism population hasn’t been well researched, but one 2016 study revealed sobering numbers about suicide being a leading cause of premature death in people with autism.9 How do these numbers associate with feelings of isolation, wanting to fit in, and troubles talking about emotions – all of which can characterize those with ASD? Data, not surprisingly, support the role of loneliness as a risk factor for the development of depression and suicidal ideation in those with ASD.10 In addition, social-communication challenges, even in the absence of an autism diagnosis, are related to depression and suicidality.11 Another recent study showed a relationship between autistic traits and depression symptoms, an association seemingly linked to being bullied.12 We cannot continue to hold onto the myth that individuals with autism don’t desire relationships and love because it’s these desires and not being able to fulfill them, limited opportunities to engage in meaningful experiences, and feeling different that can lead to negative outcomes.
Talking about suicide is critical in helping to prevent suicide, and there is a need for prevention and screening strategies tailored to specific communities and groups of individuals. How do we go about identifying specific risk factors and address them accordingly, especially in the setting of autism, where risk factors such as behavior change and changes in social interactions can be common features innate to the developmental disorder?
Changes in policy and practice are needed, and all people in crisis deserve supports that appreciate their unique challenges and individual strengths.13 Clinically, being mindful of the consequences of victimization and the power of connectedness and its role in health and well-being is critically important. The Centers for Disease Control and Prevention states that “connectedness is a common thread that weaves together many of the influences of suicidal behavior and has direct relevance for prevention,” and providers should strive to enhance positive connectedness between persons, between individuals, families and community organizations, and among organizations and social institutions.14
Spend time with patients asking about their relationships, desires, and satisfaction with social connections. Ask about loneliness and feelings of rejection while communicating to marginalized individuals that they matter. Finally, appreciate the benefits of safety planning.15 Developing a tailored safety plan with someone who is endorsing suicidal thinking, making follow-up connections (i.e., a telephone call), communicating concern, and instilling hope can save lives.
Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at pdnews@mdedge.com.
References
1. Harv Rev Psychiatry. 2018 Jul/Aug;26(4):201-15.
2. MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):617-24.
3. www.healthvermont.gov/YRBS
4. MMWR Surveill Summ. 2017 Oct;66(18):1-16.
5. JAMA Pediatr. 2015 May;169(5):466-73.
6. “Anthony Bourdain, Kate Spade, and the Preventable Tragedies of Suicide,” By Anthony Solomon, The New Yorker. Jun 8, 2018.
7. “Work and the Loneliness Epidemic,” By Vivek H. Murthy, Harvard Business Review. Sep 28, 2017.
8. Child Dev. 2000 Mar-Apr;71(2):447-56.
9. Br J Psychiatry. 2016 Mar;208(3):232-8.
10. Depress Anxiety. 2018 Jul;35(7):648-57.
11. J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):313-20.
12. JAMA Psychiatry. 2018 Aug 1;75(8):835-43.
13. The Lancet Psychiatry. 2017 Jun;4(6):e11.
14. “Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, www.cdc.gov/injury.
15. JAMA Psychiatry. 2018 Jul 11. doi: 10.1001/jamapsychiatry.2018.1776.
Integrated pain program reduced LOS for sickle cell patients
WASHINGTON – Pediatric patients who received interdisciplinary outpatient care for sickle cell disease–related chronic pain experienced a reduction in average length of stay for pain-related hospitalizations, according to an exploratory analysis of patient outcomes at a single center.
Experiences at Children’s Mercy Hospital in Kansas City, Mo., have added to the body of evidence supporting integrative care for sickle cell disease (SCD) pain, Derrick L. Goubeaux, DO, said during an interview at the annual symposium of the Foundation for Sickle Cell Disease Research.
With time, chronic pain can become an overlay on pain from vasoocclusive crises as patients with SCD age, shifting the way that patients and providers think about pain, said Dr. Goubeaux, a pediatric hematology/oncology fellow at Children’s Mercy Hospital in Kansas City.
Using a collaborative approach that pulls in psychologists, social workers, and pain management specialists, the hospital’s multidisciplinary Sickle Cell Integrated Pain Program (SCIPP) seeks to optimize pain control by adding nonpharmacologic measures to medications, he said.
Dr. Goubeaux and his colleagues conducted a retrospective chart review that looked at individuals who received care from, or were referred to, the institution’s SCD program. Included in the study were patients who received care for SCD for at least 2 years before their referral to the SCIPP clinic, so that investigators could compare care for those patients before and after SCIPP clinic integration. The study also included patients who had not yet been integrated into SCIPP clinic care, for comparison.
Though the seven patients who were integrated into the SCIPP clinic did not have fewer hospitalizations than the five who were not referred, average length of stay (LOS) for the SCIPP patients dropped from 11 days to 8 days. Mean LOS also decreased for the non-SCIPP patients, from 7.4 to 5.8 days. The number of admissions per month for both groups increased over the study period, from a mean of 0.41 to 0.84 admissions per month for SCIPP patients, and from 0.27 to 0.43 for non-SCIPP patients.
The patients, who ranged in age from 138 to 253 months, mostly had HbSS SCD, but HbSbeta0, HbSD, and HbSC patients were also included. Four patients in the SCIPP group and two of the non-SCIPP patients were taking hydroxyurea.
Noting that data collection is still in the early stages, Dr. Goubeaux and his collaborators observed that “the LOS has shortened by 3 days in the integrated group, compared to 1.6 days in the [non-SCIPP] group.” They are currently also investigating whether costs per admission and admission-associated opioid use differs for patients integrated into the SCIPP clinic.
Aside from the small number of patients studied, Dr. Goubeaux and his colleagues acknowledged that even non-SCIPP patients are likely to have had pain management and psychology consultations during their inpatient stays – and these consults are conducted by SCIPP-associated providers.
Dr. Goubeaux reported no relevant disclosures or outside sources of funding.
koakes@mdedge.com
WASHINGTON – Pediatric patients who received interdisciplinary outpatient care for sickle cell disease–related chronic pain experienced a reduction in average length of stay for pain-related hospitalizations, according to an exploratory analysis of patient outcomes at a single center.
Experiences at Children’s Mercy Hospital in Kansas City, Mo., have added to the body of evidence supporting integrative care for sickle cell disease (SCD) pain, Derrick L. Goubeaux, DO, said during an interview at the annual symposium of the Foundation for Sickle Cell Disease Research.
With time, chronic pain can become an overlay on pain from vasoocclusive crises as patients with SCD age, shifting the way that patients and providers think about pain, said Dr. Goubeaux, a pediatric hematology/oncology fellow at Children’s Mercy Hospital in Kansas City.
Using a collaborative approach that pulls in psychologists, social workers, and pain management specialists, the hospital’s multidisciplinary Sickle Cell Integrated Pain Program (SCIPP) seeks to optimize pain control by adding nonpharmacologic measures to medications, he said.
Dr. Goubeaux and his colleagues conducted a retrospective chart review that looked at individuals who received care from, or were referred to, the institution’s SCD program. Included in the study were patients who received care for SCD for at least 2 years before their referral to the SCIPP clinic, so that investigators could compare care for those patients before and after SCIPP clinic integration. The study also included patients who had not yet been integrated into SCIPP clinic care, for comparison.
Though the seven patients who were integrated into the SCIPP clinic did not have fewer hospitalizations than the five who were not referred, average length of stay (LOS) for the SCIPP patients dropped from 11 days to 8 days. Mean LOS also decreased for the non-SCIPP patients, from 7.4 to 5.8 days. The number of admissions per month for both groups increased over the study period, from a mean of 0.41 to 0.84 admissions per month for SCIPP patients, and from 0.27 to 0.43 for non-SCIPP patients.
The patients, who ranged in age from 138 to 253 months, mostly had HbSS SCD, but HbSbeta0, HbSD, and HbSC patients were also included. Four patients in the SCIPP group and two of the non-SCIPP patients were taking hydroxyurea.
Noting that data collection is still in the early stages, Dr. Goubeaux and his collaborators observed that “the LOS has shortened by 3 days in the integrated group, compared to 1.6 days in the [non-SCIPP] group.” They are currently also investigating whether costs per admission and admission-associated opioid use differs for patients integrated into the SCIPP clinic.
Aside from the small number of patients studied, Dr. Goubeaux and his colleagues acknowledged that even non-SCIPP patients are likely to have had pain management and psychology consultations during their inpatient stays – and these consults are conducted by SCIPP-associated providers.
Dr. Goubeaux reported no relevant disclosures or outside sources of funding.
koakes@mdedge.com
WASHINGTON – Pediatric patients who received interdisciplinary outpatient care for sickle cell disease–related chronic pain experienced a reduction in average length of stay for pain-related hospitalizations, according to an exploratory analysis of patient outcomes at a single center.
Experiences at Children’s Mercy Hospital in Kansas City, Mo., have added to the body of evidence supporting integrative care for sickle cell disease (SCD) pain, Derrick L. Goubeaux, DO, said during an interview at the annual symposium of the Foundation for Sickle Cell Disease Research.
With time, chronic pain can become an overlay on pain from vasoocclusive crises as patients with SCD age, shifting the way that patients and providers think about pain, said Dr. Goubeaux, a pediatric hematology/oncology fellow at Children’s Mercy Hospital in Kansas City.
Using a collaborative approach that pulls in psychologists, social workers, and pain management specialists, the hospital’s multidisciplinary Sickle Cell Integrated Pain Program (SCIPP) seeks to optimize pain control by adding nonpharmacologic measures to medications, he said.
Dr. Goubeaux and his colleagues conducted a retrospective chart review that looked at individuals who received care from, or were referred to, the institution’s SCD program. Included in the study were patients who received care for SCD for at least 2 years before their referral to the SCIPP clinic, so that investigators could compare care for those patients before and after SCIPP clinic integration. The study also included patients who had not yet been integrated into SCIPP clinic care, for comparison.
Though the seven patients who were integrated into the SCIPP clinic did not have fewer hospitalizations than the five who were not referred, average length of stay (LOS) for the SCIPP patients dropped from 11 days to 8 days. Mean LOS also decreased for the non-SCIPP patients, from 7.4 to 5.8 days. The number of admissions per month for both groups increased over the study period, from a mean of 0.41 to 0.84 admissions per month for SCIPP patients, and from 0.27 to 0.43 for non-SCIPP patients.
The patients, who ranged in age from 138 to 253 months, mostly had HbSS SCD, but HbSbeta0, HbSD, and HbSC patients were also included. Four patients in the SCIPP group and two of the non-SCIPP patients were taking hydroxyurea.
Noting that data collection is still in the early stages, Dr. Goubeaux and his collaborators observed that “the LOS has shortened by 3 days in the integrated group, compared to 1.6 days in the [non-SCIPP] group.” They are currently also investigating whether costs per admission and admission-associated opioid use differs for patients integrated into the SCIPP clinic.
Aside from the small number of patients studied, Dr. Goubeaux and his colleagues acknowledged that even non-SCIPP patients are likely to have had pain management and psychology consultations during their inpatient stays – and these consults are conducted by SCIPP-associated providers.
Dr. Goubeaux reported no relevant disclosures or outside sources of funding.
koakes@mdedge.com
REPORTING FROM FSCDR 2018
Key clinical point:
Major finding: Mean length of stay dropped from 11 days to 8 days after patients were referred to a multidisciplinary care clinic.
Study details: A retrospective chart review of 12 pediatric patients with chronic sickle cell disease-related pain.
Disclosures: The authors reported no conflicts of interest or outside sources of funding.