User login
MDedge conference coverage features onsite reporting of the latest study results and expert perspectives from leading researchers.
Screening gaps miss childhood heart problems
People with a rare genetic condition that causes extremely elevated levels of low-density lipoprotein cholesterol (LDL-C) may miss out on decades of treatment because of a lack of lipid screening in childhood, researchers reported at the annual meeting of the American Academy of Pediatrics.
The condition, homozygous familial hypercholesterolemia (FH), raises the risk for atherosclerotic cardiovascular disease (ASCVD) as early as the first decade of life.
Routine screening for FH is uncommon, however, the researchers said. Lack of familiarity with guidelines and limited access to lipid specialists have been cited as possible reasons for inconsistent screening practices.
“These findings and recent improvement in lipid lowering therapies make a compelling case for rigorous compliance with AAP’s guidelines on lipid screening for children with a family history of FH or ASCVD at age 2,” study coauthor Mary P. McGowan, MD, chief medical officer of the Family Heart Foundation, said in a statement about the new study.
Early consequences
To characterize patients with homozygous FH, Dr. McGowan and her colleagues examined data from 67 participants in the CASCADE-FH registry. The Family Heart Foundation created the registry in 2013, and 40 medical centers in the United States contribute data to the repository. The researchers had access to data about patients with homozygous FH from 20 centers in the registry.
Dr. McGowan’s group compared 16 patients with homozygous FH who enrolled in the registry when they were children and 51 patients who were adults at the time of their enrollment.
Patients enrolled as children had a median age at diagnosis of 2 years (interquartile range [IQR], 2-3.5), whereas patients enrolled as adults had a median age at diagnosis of 12.6 years (IQR, 4.1-26.5).
The median untreated level of LDL-C in those enrolled as children was 776 mg/dL (IQR, 704-892). Among those enrolled as adults, it was 533 mg/dL (IQR, 467-702).
Approximately 19% of those enrolled as children had evidence of aortic valve stenosis, and 43.8% had evidence of ASCVD. The median age at onset of ASCVD was 8.9 years. One child was diagnosed with ASCVD at age 2 years and underwent liver transplant at age 4 years. Another was diagnosed with the condition at age 3 years and underwent liver transplant at age 8 years. Two children underwent coronary artery bypass grafting at ages 6 years and 14 years. Five participants underwent liver transplant before age 18 years.
About 56% of participants who enrolled as children had xanthomas, or fat deposits in tendons, and none had corneal arcus — a gray-white line of fat deposits around the edge of the cornea, both of which can indicate homozygous FH in children.
Treatment reduced LDL-C substantially, but only 25% of children achieved goal levels of cholesterol, the researchers reported. Patients who received more lipid-lowering therapies had a better chance of reaching their target levels, they found.
The data raise “the possibility that only children with the most severe phenotypes are diagnosed before adulthood,” the researchers said.
Clinical diagnosis of homozygous FH can be based on LDL-C levels, family history, and the presence of xanthomas, the researchers noted. Many children do not have physical findings, however, and a lipid panel or genetic testing may be necessary.
“There is a clear need to implement universal screening” to identify all children with homozygous FH and heterozygous FH, a less severe and more common form of FH, Dr. McGowan said.
Possible missed cases
As many as 1 in 250 people may have heterozygous FH, and 1 in 300,000 people may have homozygous FH, according to estimates. Patients with homozygous FH have two FH genes, one from each parent. In patients with homozygous FH, levels of LDL-C levels typically range between 400 and 1,000 mg/dL without treatment, which is four to 10 times higher than normal concentrations of the blood fat, according to the Family Heart Foundation.
“This study adds to a growing body of literature – including our own work – demonstrating that recommended universal screening occurs in barely 1 in 5 children. This means some patients are not being recognized as having treatable diseases,” said Justin H. Berger, MD, PhD, a pediatric cardiologist at Children’s Hospital of Philadelphia.
Even among children who are at the highest risk for early onset adult-type heart disease, only a quarter to two-thirds receive recommended screening, said Dr. Berger, who was not a member of the study team.
While Dr. Berger advocates universal lipid screening, improving screening rates in practice probably isn’t as simple as telling clinicians to screen more, he said. “Increasing testing will increase health care spending and the burden on busy primary care providers without addressing who will subsequently evaluate and manage children with abnormal lipid screening results,” Dr. Berger said.
Instead, clinicians may want to focus on screening patients who are at risk, which “could have dramatic benefits for their life-long cardiovascular health,” he said.
Dr. McGowan disclosed ties to Abbott and Regeneron, and her coauthors disclosed ties to Esperion Therapeutics and research funding from Regeneron and REGENXBIO. Dr. Berger disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
People with a rare genetic condition that causes extremely elevated levels of low-density lipoprotein cholesterol (LDL-C) may miss out on decades of treatment because of a lack of lipid screening in childhood, researchers reported at the annual meeting of the American Academy of Pediatrics.
The condition, homozygous familial hypercholesterolemia (FH), raises the risk for atherosclerotic cardiovascular disease (ASCVD) as early as the first decade of life.
Routine screening for FH is uncommon, however, the researchers said. Lack of familiarity with guidelines and limited access to lipid specialists have been cited as possible reasons for inconsistent screening practices.
“These findings and recent improvement in lipid lowering therapies make a compelling case for rigorous compliance with AAP’s guidelines on lipid screening for children with a family history of FH or ASCVD at age 2,” study coauthor Mary P. McGowan, MD, chief medical officer of the Family Heart Foundation, said in a statement about the new study.
Early consequences
To characterize patients with homozygous FH, Dr. McGowan and her colleagues examined data from 67 participants in the CASCADE-FH registry. The Family Heart Foundation created the registry in 2013, and 40 medical centers in the United States contribute data to the repository. The researchers had access to data about patients with homozygous FH from 20 centers in the registry.
Dr. McGowan’s group compared 16 patients with homozygous FH who enrolled in the registry when they were children and 51 patients who were adults at the time of their enrollment.
Patients enrolled as children had a median age at diagnosis of 2 years (interquartile range [IQR], 2-3.5), whereas patients enrolled as adults had a median age at diagnosis of 12.6 years (IQR, 4.1-26.5).
The median untreated level of LDL-C in those enrolled as children was 776 mg/dL (IQR, 704-892). Among those enrolled as adults, it was 533 mg/dL (IQR, 467-702).
Approximately 19% of those enrolled as children had evidence of aortic valve stenosis, and 43.8% had evidence of ASCVD. The median age at onset of ASCVD was 8.9 years. One child was diagnosed with ASCVD at age 2 years and underwent liver transplant at age 4 years. Another was diagnosed with the condition at age 3 years and underwent liver transplant at age 8 years. Two children underwent coronary artery bypass grafting at ages 6 years and 14 years. Five participants underwent liver transplant before age 18 years.
About 56% of participants who enrolled as children had xanthomas, or fat deposits in tendons, and none had corneal arcus — a gray-white line of fat deposits around the edge of the cornea, both of which can indicate homozygous FH in children.
Treatment reduced LDL-C substantially, but only 25% of children achieved goal levels of cholesterol, the researchers reported. Patients who received more lipid-lowering therapies had a better chance of reaching their target levels, they found.
The data raise “the possibility that only children with the most severe phenotypes are diagnosed before adulthood,” the researchers said.
Clinical diagnosis of homozygous FH can be based on LDL-C levels, family history, and the presence of xanthomas, the researchers noted. Many children do not have physical findings, however, and a lipid panel or genetic testing may be necessary.
“There is a clear need to implement universal screening” to identify all children with homozygous FH and heterozygous FH, a less severe and more common form of FH, Dr. McGowan said.
Possible missed cases
As many as 1 in 250 people may have heterozygous FH, and 1 in 300,000 people may have homozygous FH, according to estimates. Patients with homozygous FH have two FH genes, one from each parent. In patients with homozygous FH, levels of LDL-C levels typically range between 400 and 1,000 mg/dL without treatment, which is four to 10 times higher than normal concentrations of the blood fat, according to the Family Heart Foundation.
“This study adds to a growing body of literature – including our own work – demonstrating that recommended universal screening occurs in barely 1 in 5 children. This means some patients are not being recognized as having treatable diseases,” said Justin H. Berger, MD, PhD, a pediatric cardiologist at Children’s Hospital of Philadelphia.
Even among children who are at the highest risk for early onset adult-type heart disease, only a quarter to two-thirds receive recommended screening, said Dr. Berger, who was not a member of the study team.
While Dr. Berger advocates universal lipid screening, improving screening rates in practice probably isn’t as simple as telling clinicians to screen more, he said. “Increasing testing will increase health care spending and the burden on busy primary care providers without addressing who will subsequently evaluate and manage children with abnormal lipid screening results,” Dr. Berger said.
Instead, clinicians may want to focus on screening patients who are at risk, which “could have dramatic benefits for their life-long cardiovascular health,” he said.
Dr. McGowan disclosed ties to Abbott and Regeneron, and her coauthors disclosed ties to Esperion Therapeutics and research funding from Regeneron and REGENXBIO. Dr. Berger disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
People with a rare genetic condition that causes extremely elevated levels of low-density lipoprotein cholesterol (LDL-C) may miss out on decades of treatment because of a lack of lipid screening in childhood, researchers reported at the annual meeting of the American Academy of Pediatrics.
The condition, homozygous familial hypercholesterolemia (FH), raises the risk for atherosclerotic cardiovascular disease (ASCVD) as early as the first decade of life.
Routine screening for FH is uncommon, however, the researchers said. Lack of familiarity with guidelines and limited access to lipid specialists have been cited as possible reasons for inconsistent screening practices.
“These findings and recent improvement in lipid lowering therapies make a compelling case for rigorous compliance with AAP’s guidelines on lipid screening for children with a family history of FH or ASCVD at age 2,” study coauthor Mary P. McGowan, MD, chief medical officer of the Family Heart Foundation, said in a statement about the new study.
Early consequences
To characterize patients with homozygous FH, Dr. McGowan and her colleagues examined data from 67 participants in the CASCADE-FH registry. The Family Heart Foundation created the registry in 2013, and 40 medical centers in the United States contribute data to the repository. The researchers had access to data about patients with homozygous FH from 20 centers in the registry.
Dr. McGowan’s group compared 16 patients with homozygous FH who enrolled in the registry when they were children and 51 patients who were adults at the time of their enrollment.
Patients enrolled as children had a median age at diagnosis of 2 years (interquartile range [IQR], 2-3.5), whereas patients enrolled as adults had a median age at diagnosis of 12.6 years (IQR, 4.1-26.5).
The median untreated level of LDL-C in those enrolled as children was 776 mg/dL (IQR, 704-892). Among those enrolled as adults, it was 533 mg/dL (IQR, 467-702).
Approximately 19% of those enrolled as children had evidence of aortic valve stenosis, and 43.8% had evidence of ASCVD. The median age at onset of ASCVD was 8.9 years. One child was diagnosed with ASCVD at age 2 years and underwent liver transplant at age 4 years. Another was diagnosed with the condition at age 3 years and underwent liver transplant at age 8 years. Two children underwent coronary artery bypass grafting at ages 6 years and 14 years. Five participants underwent liver transplant before age 18 years.
About 56% of participants who enrolled as children had xanthomas, or fat deposits in tendons, and none had corneal arcus — a gray-white line of fat deposits around the edge of the cornea, both of which can indicate homozygous FH in children.
Treatment reduced LDL-C substantially, but only 25% of children achieved goal levels of cholesterol, the researchers reported. Patients who received more lipid-lowering therapies had a better chance of reaching their target levels, they found.
The data raise “the possibility that only children with the most severe phenotypes are diagnosed before adulthood,” the researchers said.
Clinical diagnosis of homozygous FH can be based on LDL-C levels, family history, and the presence of xanthomas, the researchers noted. Many children do not have physical findings, however, and a lipid panel or genetic testing may be necessary.
“There is a clear need to implement universal screening” to identify all children with homozygous FH and heterozygous FH, a less severe and more common form of FH, Dr. McGowan said.
Possible missed cases
As many as 1 in 250 people may have heterozygous FH, and 1 in 300,000 people may have homozygous FH, according to estimates. Patients with homozygous FH have two FH genes, one from each parent. In patients with homozygous FH, levels of LDL-C levels typically range between 400 and 1,000 mg/dL without treatment, which is four to 10 times higher than normal concentrations of the blood fat, according to the Family Heart Foundation.
“This study adds to a growing body of literature – including our own work – demonstrating that recommended universal screening occurs in barely 1 in 5 children. This means some patients are not being recognized as having treatable diseases,” said Justin H. Berger, MD, PhD, a pediatric cardiologist at Children’s Hospital of Philadelphia.
Even among children who are at the highest risk for early onset adult-type heart disease, only a quarter to two-thirds receive recommended screening, said Dr. Berger, who was not a member of the study team.
While Dr. Berger advocates universal lipid screening, improving screening rates in practice probably isn’t as simple as telling clinicians to screen more, he said. “Increasing testing will increase health care spending and the burden on busy primary care providers without addressing who will subsequently evaluate and manage children with abnormal lipid screening results,” Dr. Berger said.
Instead, clinicians may want to focus on screening patients who are at risk, which “could have dramatic benefits for their life-long cardiovascular health,” he said.
Dr. McGowan disclosed ties to Abbott and Regeneron, and her coauthors disclosed ties to Esperion Therapeutics and research funding from Regeneron and REGENXBIO. Dr. Berger disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM AAP 2022
Sleep kits help foster children manage effects of trauma
A stuffed animal, aromatherapy, a night light. A kit containing these and other items can help children in foster care who have experienced trauma sleep more soundly, a critical step in helping them cope with their emotional distress.
In a new study, researchers at the Children’s Hospital of Philadelphia reported that sleep kits specially tailored to foster children appeared to be helpful in most cases. The kits can be distributed by pediatricians in the office or clinic setting.
“Children who have experienced trauma can have issues with behavior, it can impact their school, and they have difficulties sleeping,” said Kristine Fortin, MD, MPH, director of the fostering health program at Safe Place: Center for Child Protection and Health at CHOP. “I thought, what could a pediatrician do in the office in one visit to help children with sleep?”
Dr. Fortin and colleagues designed sleep kits for both younger children and adolescents.
The version for teenagers contained a sound machine, aromatherapy spray, and a sleep mask. The kits for younger children contained matching stuffed toys to share with someone they felt connected to, and a rechargeable night-light. All kits included written materials about sleep hygiene, a journal, and directions for downloading a free age-appropriate relaxation app for belly breathing or a PTSD Coach app from the Department of Veterans Affairs to manage symptoms of trauma.
In a pilot study presented at the annual meeting of the American Academy of Pediatrics, Dr. Fortin and colleagues surveyed caregivers in foster homes about their use of the kits.
Of the 20 foster parents who responded to the survey, 11 said the kits helped “very much,” 5 others reported they helped “somewhat,” another 2 reported no improvements in sleep, and 2 said they didn’t know the effect. The children for whom results were unknown moved from the home without the sleep kit or had difficulties communicating with the foster parents, resulting in incomplete assessment, according to the researchers.
Night-lights were used most in the kits, followed by the stuffed toys, sound machines, and sleep journals.
Dr. Fortin said existing resources like sleep therapy or medication can be costly or difficult to find, and many pediatricians don’t have enough time during wellness visits to address symptoms like sleep deprivation. She said the sleep kits could be an alternative to other forms of sleep therapy. “If these sleep kits were effective, and could really help them sleep, then maybe less children would need something like medication.”
Dr. Fortin said the kits her group has designed are tailored specifically for children with symptoms of trauma, or with difficult emotions associated with foster care.
“We’ve tried to design something that can be really practical and easy to use in a pediatric visit, where there’s a lot of written information that can be discussed with the child and their family,” Dr. Fortin said.
She added that she would like to see clinicians give out the sleep kits during in-office visits.
“These sleep issues are common in foster children,” she said. “We felt it was important to do an intervention.”
Kristina Lenker, PhD, a sleep psychologist at Penn State Health, Hershey, said children in foster care often struggle with falling or staying asleep, an inability to sleep alone, nightmares, and bed wetting.
“Sleep kits can be particularly helpful for these children, given how they can help caregivers to provide a safe sleep environment and predictable routine, and send messages of safety and comfort at bedtime, with tangible objects, and enable children to feel a sense of control,” she said.
Charitable organizations like Pajama Program and Sleeping Children Around the World provide sleep kits to children from underserved backgrounds. But Candice Alfano, PhD, director of the University of Houston’s Sleep and Anxiety Center of Houston, said the CHOP kits are the first to specifically target sleeping difficulties in foster children.
“Sleep is a largely neglected yet essential area of health, development, and well-being in this highly-vulnerable population of youth, so I am very excited to see this work being done,” Dr. Alfano said in an interview.
Dr. Fortin and Dr. Lenker reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A stuffed animal, aromatherapy, a night light. A kit containing these and other items can help children in foster care who have experienced trauma sleep more soundly, a critical step in helping them cope with their emotional distress.
In a new study, researchers at the Children’s Hospital of Philadelphia reported that sleep kits specially tailored to foster children appeared to be helpful in most cases. The kits can be distributed by pediatricians in the office or clinic setting.
“Children who have experienced trauma can have issues with behavior, it can impact their school, and they have difficulties sleeping,” said Kristine Fortin, MD, MPH, director of the fostering health program at Safe Place: Center for Child Protection and Health at CHOP. “I thought, what could a pediatrician do in the office in one visit to help children with sleep?”
Dr. Fortin and colleagues designed sleep kits for both younger children and adolescents.
The version for teenagers contained a sound machine, aromatherapy spray, and a sleep mask. The kits for younger children contained matching stuffed toys to share with someone they felt connected to, and a rechargeable night-light. All kits included written materials about sleep hygiene, a journal, and directions for downloading a free age-appropriate relaxation app for belly breathing or a PTSD Coach app from the Department of Veterans Affairs to manage symptoms of trauma.
In a pilot study presented at the annual meeting of the American Academy of Pediatrics, Dr. Fortin and colleagues surveyed caregivers in foster homes about their use of the kits.
Of the 20 foster parents who responded to the survey, 11 said the kits helped “very much,” 5 others reported they helped “somewhat,” another 2 reported no improvements in sleep, and 2 said they didn’t know the effect. The children for whom results were unknown moved from the home without the sleep kit or had difficulties communicating with the foster parents, resulting in incomplete assessment, according to the researchers.
Night-lights were used most in the kits, followed by the stuffed toys, sound machines, and sleep journals.
Dr. Fortin said existing resources like sleep therapy or medication can be costly or difficult to find, and many pediatricians don’t have enough time during wellness visits to address symptoms like sleep deprivation. She said the sleep kits could be an alternative to other forms of sleep therapy. “If these sleep kits were effective, and could really help them sleep, then maybe less children would need something like medication.”
Dr. Fortin said the kits her group has designed are tailored specifically for children with symptoms of trauma, or with difficult emotions associated with foster care.
“We’ve tried to design something that can be really practical and easy to use in a pediatric visit, where there’s a lot of written information that can be discussed with the child and their family,” Dr. Fortin said.
She added that she would like to see clinicians give out the sleep kits during in-office visits.
“These sleep issues are common in foster children,” she said. “We felt it was important to do an intervention.”
Kristina Lenker, PhD, a sleep psychologist at Penn State Health, Hershey, said children in foster care often struggle with falling or staying asleep, an inability to sleep alone, nightmares, and bed wetting.
“Sleep kits can be particularly helpful for these children, given how they can help caregivers to provide a safe sleep environment and predictable routine, and send messages of safety and comfort at bedtime, with tangible objects, and enable children to feel a sense of control,” she said.
Charitable organizations like Pajama Program and Sleeping Children Around the World provide sleep kits to children from underserved backgrounds. But Candice Alfano, PhD, director of the University of Houston’s Sleep and Anxiety Center of Houston, said the CHOP kits are the first to specifically target sleeping difficulties in foster children.
“Sleep is a largely neglected yet essential area of health, development, and well-being in this highly-vulnerable population of youth, so I am very excited to see this work being done,” Dr. Alfano said in an interview.
Dr. Fortin and Dr. Lenker reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A stuffed animal, aromatherapy, a night light. A kit containing these and other items can help children in foster care who have experienced trauma sleep more soundly, a critical step in helping them cope with their emotional distress.
In a new study, researchers at the Children’s Hospital of Philadelphia reported that sleep kits specially tailored to foster children appeared to be helpful in most cases. The kits can be distributed by pediatricians in the office or clinic setting.
“Children who have experienced trauma can have issues with behavior, it can impact their school, and they have difficulties sleeping,” said Kristine Fortin, MD, MPH, director of the fostering health program at Safe Place: Center for Child Protection and Health at CHOP. “I thought, what could a pediatrician do in the office in one visit to help children with sleep?”
Dr. Fortin and colleagues designed sleep kits for both younger children and adolescents.
The version for teenagers contained a sound machine, aromatherapy spray, and a sleep mask. The kits for younger children contained matching stuffed toys to share with someone they felt connected to, and a rechargeable night-light. All kits included written materials about sleep hygiene, a journal, and directions for downloading a free age-appropriate relaxation app for belly breathing or a PTSD Coach app from the Department of Veterans Affairs to manage symptoms of trauma.
In a pilot study presented at the annual meeting of the American Academy of Pediatrics, Dr. Fortin and colleagues surveyed caregivers in foster homes about their use of the kits.
Of the 20 foster parents who responded to the survey, 11 said the kits helped “very much,” 5 others reported they helped “somewhat,” another 2 reported no improvements in sleep, and 2 said they didn’t know the effect. The children for whom results were unknown moved from the home without the sleep kit or had difficulties communicating with the foster parents, resulting in incomplete assessment, according to the researchers.
Night-lights were used most in the kits, followed by the stuffed toys, sound machines, and sleep journals.
Dr. Fortin said existing resources like sleep therapy or medication can be costly or difficult to find, and many pediatricians don’t have enough time during wellness visits to address symptoms like sleep deprivation. She said the sleep kits could be an alternative to other forms of sleep therapy. “If these sleep kits were effective, and could really help them sleep, then maybe less children would need something like medication.”
Dr. Fortin said the kits her group has designed are tailored specifically for children with symptoms of trauma, or with difficult emotions associated with foster care.
“We’ve tried to design something that can be really practical and easy to use in a pediatric visit, where there’s a lot of written information that can be discussed with the child and their family,” Dr. Fortin said.
She added that she would like to see clinicians give out the sleep kits during in-office visits.
“These sleep issues are common in foster children,” she said. “We felt it was important to do an intervention.”
Kristina Lenker, PhD, a sleep psychologist at Penn State Health, Hershey, said children in foster care often struggle with falling or staying asleep, an inability to sleep alone, nightmares, and bed wetting.
“Sleep kits can be particularly helpful for these children, given how they can help caregivers to provide a safe sleep environment and predictable routine, and send messages of safety and comfort at bedtime, with tangible objects, and enable children to feel a sense of control,” she said.
Charitable organizations like Pajama Program and Sleeping Children Around the World provide sleep kits to children from underserved backgrounds. But Candice Alfano, PhD, director of the University of Houston’s Sleep and Anxiety Center of Houston, said the CHOP kits are the first to specifically target sleeping difficulties in foster children.
“Sleep is a largely neglected yet essential area of health, development, and well-being in this highly-vulnerable population of youth, so I am very excited to see this work being done,” Dr. Alfano said in an interview.
Dr. Fortin and Dr. Lenker reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM AAP 2022
Cerebral palsy: Video clues suggest dystonia
CINCINNATI – Dystonia is a frequent complication seen in cerebral palsy, but it often goes undiagnosed. Using a unique video analysis, researchers have identified some movement features that have the potential to simplify diagnosis.
“[We have] previously demonstrated that by the age of 5 years, only 30% of children seen in a clinical setting have had their predominant motor phenotype identified, including dystonia. This helps demonstrate a broad diagnostic gap and the need for novel solutions,” said Laura Gilbert, DO, during her presentation of the results at the 2022 annual meeting of the Child Neurology Society.
Diagnosis of dystonia is challenging because of its clinical variability, and diagnostic tools often require a trained physician, which limits access to diagnoses. Expert clinician consensus therefore remains the gold standard for diagnosis of dystonia.
Another clinical need is that specific features of dystonia have not been well described in the upper extremities, and the research suggests there could be differences in brain injuries contributing to dystonia in the two domains.
The researchers set out to discover expert-identified features of patient videos that could be used to allow nonexperts to make a diagnosis of dystonia.
The researchers analyzed 26 videos with upper extremity exam maneuvers performed on children with periventricular leukomalacia at St. Louis Children’s Hospital Cerebral Palsy Center from 2005 to 2018. Among the study cohort, 65% of patients were male, 77% were White, and 11% were Black; 24% of patients were Gross Motor Function Classification Scale I, 24% were GMFCS II, 24% were GMFCS III, 16% were GMFCS IV, and 12% were GMFCS V. A total of 12% of patients were older than 20, 11% were aged 15-20, 38% were aged 10-15, 31% were aged 5-10, and 8% were age 5 or younger.
Video clues aid diagnosis
Three pediatric movement disorder specialists independently reviewed each video and assessed severity of dystonia. They then met over Zoom to reach a diagnostic consensus for each case.
The research team performed a content analysis of the experts’ discussions and identified specific statement fragments. The frequency of these fragments was then linked to severity of dystonia.
A total of 45% of the statement fragments referenced movement codes, which in turn comprised five content areas: 33% referenced a body part, 24% focused on laterality, 22% described movement features, 18% an action, and 3% described exam maneuvers. Examples included shoulder as a body part, flexion as an action descriptor, brisk as a movement feature, unilateral, and finger-nose-finger for exam maneuver.
With increasing dystonia severity, the shoulder was more often cited and hand was cited less often. Mirror movements, defined as involuntary, contralateral movements that are similar to the voluntary action, occurred more often in patients with no dystonia or only mild dystonia. Variability of movement over time, which is a distinguishing feature found in lower extremities, was not significantly associated with dystonia severity.
Within the category of exam maneuver, hand opening and closing was the most commonly cited, and it was cited more frequently among individuals with mild dystonia (70% vs. about 10% for both no dystonia and moderate to severe dystonia; P < .005).
“So how can we adopt this clinically? First, we can add in a very brief exam maneuver of hand opening and closing that can help assess for mild dystonia. Shoulder involvement may suggest more severe dystonia, and we must recognize the dystonia features seem to differ by body region and the triggering task. Overall, to help improve dystonia diagnosis, we must continue to work towards understanding these salient features to fully grasp the breadth of dystonia manifestations in people with [cerebral palsy],” said Dr. Gilbert, who is a pediatric movements disorder fellow at Washington University in St. Louis.
Key features help determine dystonia severity
The study is particularly interesting for its different findings in upper extremities versus lower extremities, according to Keith Coffman, MD, who comoderated the session where the study was presented. “That same group showed that there are very clear differences in lower-extremity function, but when they looked at upper extremity, there really weren’t robust differences. What it may show is that the features of cerebral palsy regarding dystonia may be very dependent on what type of injury you have to your brain. Because when you think about where the motor fibers that provide leg function, they live along the medial walls of the brain right along the midline, whereas the representation of the hand and arm are more out on the lateral side of the brain. So it may be that those regional anatomy differences and where the injury occurred could be at the baseline of why they had such differences in motor function,” said Dr. Coffman, who is a professor of pediatrics at University of Missouri–Kansas City and director of the movement disorders program at Children’s Mercy Hospital, also in Kansas City, Mo.
He suggested that the researchers might also do kinematic analysis of the videos to make predictions using quantitative differences in movement.
The research has the potential to improve dystonia diagnosis, according to comoderator Marc Patterson, MD, professor of neurology, pediatrics, and medical genetics at Mayo Clinic in Rochester, Minn. “I think they really pointed to some key features that can help clinicians distinguish [dystonia severity]. Something like the speed of opening and closing the hands [is a] fairly simple thing. That was to me the chief value of that study,” Dr. Patterson said.
Dr. Gilbert reported no relevant disclosures.
CINCINNATI – Dystonia is a frequent complication seen in cerebral palsy, but it often goes undiagnosed. Using a unique video analysis, researchers have identified some movement features that have the potential to simplify diagnosis.
“[We have] previously demonstrated that by the age of 5 years, only 30% of children seen in a clinical setting have had their predominant motor phenotype identified, including dystonia. This helps demonstrate a broad diagnostic gap and the need for novel solutions,” said Laura Gilbert, DO, during her presentation of the results at the 2022 annual meeting of the Child Neurology Society.
Diagnosis of dystonia is challenging because of its clinical variability, and diagnostic tools often require a trained physician, which limits access to diagnoses. Expert clinician consensus therefore remains the gold standard for diagnosis of dystonia.
Another clinical need is that specific features of dystonia have not been well described in the upper extremities, and the research suggests there could be differences in brain injuries contributing to dystonia in the two domains.
The researchers set out to discover expert-identified features of patient videos that could be used to allow nonexperts to make a diagnosis of dystonia.
The researchers analyzed 26 videos with upper extremity exam maneuvers performed on children with periventricular leukomalacia at St. Louis Children’s Hospital Cerebral Palsy Center from 2005 to 2018. Among the study cohort, 65% of patients were male, 77% were White, and 11% were Black; 24% of patients were Gross Motor Function Classification Scale I, 24% were GMFCS II, 24% were GMFCS III, 16% were GMFCS IV, and 12% were GMFCS V. A total of 12% of patients were older than 20, 11% were aged 15-20, 38% were aged 10-15, 31% were aged 5-10, and 8% were age 5 or younger.
Video clues aid diagnosis
Three pediatric movement disorder specialists independently reviewed each video and assessed severity of dystonia. They then met over Zoom to reach a diagnostic consensus for each case.
The research team performed a content analysis of the experts’ discussions and identified specific statement fragments. The frequency of these fragments was then linked to severity of dystonia.
A total of 45% of the statement fragments referenced movement codes, which in turn comprised five content areas: 33% referenced a body part, 24% focused on laterality, 22% described movement features, 18% an action, and 3% described exam maneuvers. Examples included shoulder as a body part, flexion as an action descriptor, brisk as a movement feature, unilateral, and finger-nose-finger for exam maneuver.
With increasing dystonia severity, the shoulder was more often cited and hand was cited less often. Mirror movements, defined as involuntary, contralateral movements that are similar to the voluntary action, occurred more often in patients with no dystonia or only mild dystonia. Variability of movement over time, which is a distinguishing feature found in lower extremities, was not significantly associated with dystonia severity.
Within the category of exam maneuver, hand opening and closing was the most commonly cited, and it was cited more frequently among individuals with mild dystonia (70% vs. about 10% for both no dystonia and moderate to severe dystonia; P < .005).
“So how can we adopt this clinically? First, we can add in a very brief exam maneuver of hand opening and closing that can help assess for mild dystonia. Shoulder involvement may suggest more severe dystonia, and we must recognize the dystonia features seem to differ by body region and the triggering task. Overall, to help improve dystonia diagnosis, we must continue to work towards understanding these salient features to fully grasp the breadth of dystonia manifestations in people with [cerebral palsy],” said Dr. Gilbert, who is a pediatric movements disorder fellow at Washington University in St. Louis.
Key features help determine dystonia severity
The study is particularly interesting for its different findings in upper extremities versus lower extremities, according to Keith Coffman, MD, who comoderated the session where the study was presented. “That same group showed that there are very clear differences in lower-extremity function, but when they looked at upper extremity, there really weren’t robust differences. What it may show is that the features of cerebral palsy regarding dystonia may be very dependent on what type of injury you have to your brain. Because when you think about where the motor fibers that provide leg function, they live along the medial walls of the brain right along the midline, whereas the representation of the hand and arm are more out on the lateral side of the brain. So it may be that those regional anatomy differences and where the injury occurred could be at the baseline of why they had such differences in motor function,” said Dr. Coffman, who is a professor of pediatrics at University of Missouri–Kansas City and director of the movement disorders program at Children’s Mercy Hospital, also in Kansas City, Mo.
He suggested that the researchers might also do kinematic analysis of the videos to make predictions using quantitative differences in movement.
The research has the potential to improve dystonia diagnosis, according to comoderator Marc Patterson, MD, professor of neurology, pediatrics, and medical genetics at Mayo Clinic in Rochester, Minn. “I think they really pointed to some key features that can help clinicians distinguish [dystonia severity]. Something like the speed of opening and closing the hands [is a] fairly simple thing. That was to me the chief value of that study,” Dr. Patterson said.
Dr. Gilbert reported no relevant disclosures.
CINCINNATI – Dystonia is a frequent complication seen in cerebral palsy, but it often goes undiagnosed. Using a unique video analysis, researchers have identified some movement features that have the potential to simplify diagnosis.
“[We have] previously demonstrated that by the age of 5 years, only 30% of children seen in a clinical setting have had their predominant motor phenotype identified, including dystonia. This helps demonstrate a broad diagnostic gap and the need for novel solutions,” said Laura Gilbert, DO, during her presentation of the results at the 2022 annual meeting of the Child Neurology Society.
Diagnosis of dystonia is challenging because of its clinical variability, and diagnostic tools often require a trained physician, which limits access to diagnoses. Expert clinician consensus therefore remains the gold standard for diagnosis of dystonia.
Another clinical need is that specific features of dystonia have not been well described in the upper extremities, and the research suggests there could be differences in brain injuries contributing to dystonia in the two domains.
The researchers set out to discover expert-identified features of patient videos that could be used to allow nonexperts to make a diagnosis of dystonia.
The researchers analyzed 26 videos with upper extremity exam maneuvers performed on children with periventricular leukomalacia at St. Louis Children’s Hospital Cerebral Palsy Center from 2005 to 2018. Among the study cohort, 65% of patients were male, 77% were White, and 11% were Black; 24% of patients were Gross Motor Function Classification Scale I, 24% were GMFCS II, 24% were GMFCS III, 16% were GMFCS IV, and 12% were GMFCS V. A total of 12% of patients were older than 20, 11% were aged 15-20, 38% were aged 10-15, 31% were aged 5-10, and 8% were age 5 or younger.
Video clues aid diagnosis
Three pediatric movement disorder specialists independently reviewed each video and assessed severity of dystonia. They then met over Zoom to reach a diagnostic consensus for each case.
The research team performed a content analysis of the experts’ discussions and identified specific statement fragments. The frequency of these fragments was then linked to severity of dystonia.
A total of 45% of the statement fragments referenced movement codes, which in turn comprised five content areas: 33% referenced a body part, 24% focused on laterality, 22% described movement features, 18% an action, and 3% described exam maneuvers. Examples included shoulder as a body part, flexion as an action descriptor, brisk as a movement feature, unilateral, and finger-nose-finger for exam maneuver.
With increasing dystonia severity, the shoulder was more often cited and hand was cited less often. Mirror movements, defined as involuntary, contralateral movements that are similar to the voluntary action, occurred more often in patients with no dystonia or only mild dystonia. Variability of movement over time, which is a distinguishing feature found in lower extremities, was not significantly associated with dystonia severity.
Within the category of exam maneuver, hand opening and closing was the most commonly cited, and it was cited more frequently among individuals with mild dystonia (70% vs. about 10% for both no dystonia and moderate to severe dystonia; P < .005).
“So how can we adopt this clinically? First, we can add in a very brief exam maneuver of hand opening and closing that can help assess for mild dystonia. Shoulder involvement may suggest more severe dystonia, and we must recognize the dystonia features seem to differ by body region and the triggering task. Overall, to help improve dystonia diagnosis, we must continue to work towards understanding these salient features to fully grasp the breadth of dystonia manifestations in people with [cerebral palsy],” said Dr. Gilbert, who is a pediatric movements disorder fellow at Washington University in St. Louis.
Key features help determine dystonia severity
The study is particularly interesting for its different findings in upper extremities versus lower extremities, according to Keith Coffman, MD, who comoderated the session where the study was presented. “That same group showed that there are very clear differences in lower-extremity function, but when they looked at upper extremity, there really weren’t robust differences. What it may show is that the features of cerebral palsy regarding dystonia may be very dependent on what type of injury you have to your brain. Because when you think about where the motor fibers that provide leg function, they live along the medial walls of the brain right along the midline, whereas the representation of the hand and arm are more out on the lateral side of the brain. So it may be that those regional anatomy differences and where the injury occurred could be at the baseline of why they had such differences in motor function,” said Dr. Coffman, who is a professor of pediatrics at University of Missouri–Kansas City and director of the movement disorders program at Children’s Mercy Hospital, also in Kansas City, Mo.
He suggested that the researchers might also do kinematic analysis of the videos to make predictions using quantitative differences in movement.
The research has the potential to improve dystonia diagnosis, according to comoderator Marc Patterson, MD, professor of neurology, pediatrics, and medical genetics at Mayo Clinic in Rochester, Minn. “I think they really pointed to some key features that can help clinicians distinguish [dystonia severity]. Something like the speed of opening and closing the hands [is a] fairly simple thing. That was to me the chief value of that study,” Dr. Patterson said.
Dr. Gilbert reported no relevant disclosures.
AT CNS 2022
One-third of pancreatic cancer diagnoses missed on scans
say United Kingdom researchers who report a novel analysis.
The study set out to identify the incidence and root causes of missed pancreatic cancer diagnoses on CT and MRI scans, the investigators explained at the United European Gastroenterology Week 2022.
The team studied 600 pancreatic cancer cases, including 46 cases (7.7%) categorized as postimaging pancreatic cancer (PIPC) – cases not detected on imaging performed 3-18 months prior to diagnosis.
They also reviewed 46 CT scans and 4 MRI scans performed in PIPC patients.
The detailed analysis showed that 36% of cases of PIPC were potentially avoidable, reported first author Nosheen Umar, MD, a gastroenterology research fellow at the University of Birmingham (England).
In 10% of PIPC patients, imaging signs associated with pancreatic cancer, such as dilated bile or pancreatic ducts, were not recognized as such and were not investigated further. In 26% of scans, the signs of a mass lesion were not picked up by the radiologist.
The findings are notable as the time window for curative PC surgery is often short, and missing the diagnosis on cross-sectional imaging can result in worse clinical outcomes for patients already dealing with a challenging cancer that has generally poor outcomes, Dr. Umar said in an interview.
In fact, pancreatic cancer has the lowest survival rate of all cancers in Europe, the UEG noted in a press release. Life expectancy at the time of diagnosis is just 4.6 months, and 5-year survival is less than 10%, Dr. Umar said.
Pancreatic cancer causes 95,000 deaths in the European Union each year, the UEG noted, adding that by 2035 the number of cases is predicted to rise by almost 40%.
Details of missed imaging signs
The aim of this study was to establish the most plausible explanations for missed imaging signs of PC, Dr. Umar explained, adding that early diagnosis is vitally important for offering patients the best chance of survival.
Cases analyzed for the study were identified from electronic medical records of adults diagnosed with PC between 2016 and 2021 at two National Health Service providers. An algorithm was developed to categorize PIPC and assess potential causes of the missed diagnoses.
The PIPC cases were categorized by type:
- Type 1 – A focal lesion on previous imaging reported in the same pancreatic segment as PIPC (0% of cases)
- Type 2 – Imaging changes that can be associated with PC reported on previous imaging (20% of cases)
- Type 3 – No lesion or imaging changes that can be associated with PC reported on previous imaging in the same pancreatic segment as PIPC, but lesion or imaging changes noted on review after PIPC diagnosis (26% of cases)
- Type 4 – No lesion or imaging changes that can be associated with PC reported on previous imaging in the same pancreatic segment as PIPC and no lesion or imaging changes on review after PIPC diagnosis (54% of cases)
“We hope this study will raise awareness of the issue of postimaging pancreatic cancer and common reasons why pancreatic cancer can be initially missed,” Dr. Umar stated in the UEG press release. “This will help to standardize future studies of this issue and guide quality improvement efforts so we can increase the likelihood of an early diagnosis of pancreatic cancer, increase the chances of patient survival and, ultimately, save lives.”
The authors reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
say United Kingdom researchers who report a novel analysis.
The study set out to identify the incidence and root causes of missed pancreatic cancer diagnoses on CT and MRI scans, the investigators explained at the United European Gastroenterology Week 2022.
The team studied 600 pancreatic cancer cases, including 46 cases (7.7%) categorized as postimaging pancreatic cancer (PIPC) – cases not detected on imaging performed 3-18 months prior to diagnosis.
They also reviewed 46 CT scans and 4 MRI scans performed in PIPC patients.
The detailed analysis showed that 36% of cases of PIPC were potentially avoidable, reported first author Nosheen Umar, MD, a gastroenterology research fellow at the University of Birmingham (England).
In 10% of PIPC patients, imaging signs associated with pancreatic cancer, such as dilated bile or pancreatic ducts, were not recognized as such and were not investigated further. In 26% of scans, the signs of a mass lesion were not picked up by the radiologist.
The findings are notable as the time window for curative PC surgery is often short, and missing the diagnosis on cross-sectional imaging can result in worse clinical outcomes for patients already dealing with a challenging cancer that has generally poor outcomes, Dr. Umar said in an interview.
In fact, pancreatic cancer has the lowest survival rate of all cancers in Europe, the UEG noted in a press release. Life expectancy at the time of diagnosis is just 4.6 months, and 5-year survival is less than 10%, Dr. Umar said.
Pancreatic cancer causes 95,000 deaths in the European Union each year, the UEG noted, adding that by 2035 the number of cases is predicted to rise by almost 40%.
Details of missed imaging signs
The aim of this study was to establish the most plausible explanations for missed imaging signs of PC, Dr. Umar explained, adding that early diagnosis is vitally important for offering patients the best chance of survival.
Cases analyzed for the study were identified from electronic medical records of adults diagnosed with PC between 2016 and 2021 at two National Health Service providers. An algorithm was developed to categorize PIPC and assess potential causes of the missed diagnoses.
The PIPC cases were categorized by type:
- Type 1 – A focal lesion on previous imaging reported in the same pancreatic segment as PIPC (0% of cases)
- Type 2 – Imaging changes that can be associated with PC reported on previous imaging (20% of cases)
- Type 3 – No lesion or imaging changes that can be associated with PC reported on previous imaging in the same pancreatic segment as PIPC, but lesion or imaging changes noted on review after PIPC diagnosis (26% of cases)
- Type 4 – No lesion or imaging changes that can be associated with PC reported on previous imaging in the same pancreatic segment as PIPC and no lesion or imaging changes on review after PIPC diagnosis (54% of cases)
“We hope this study will raise awareness of the issue of postimaging pancreatic cancer and common reasons why pancreatic cancer can be initially missed,” Dr. Umar stated in the UEG press release. “This will help to standardize future studies of this issue and guide quality improvement efforts so we can increase the likelihood of an early diagnosis of pancreatic cancer, increase the chances of patient survival and, ultimately, save lives.”
The authors reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
say United Kingdom researchers who report a novel analysis.
The study set out to identify the incidence and root causes of missed pancreatic cancer diagnoses on CT and MRI scans, the investigators explained at the United European Gastroenterology Week 2022.
The team studied 600 pancreatic cancer cases, including 46 cases (7.7%) categorized as postimaging pancreatic cancer (PIPC) – cases not detected on imaging performed 3-18 months prior to diagnosis.
They also reviewed 46 CT scans and 4 MRI scans performed in PIPC patients.
The detailed analysis showed that 36% of cases of PIPC were potentially avoidable, reported first author Nosheen Umar, MD, a gastroenterology research fellow at the University of Birmingham (England).
In 10% of PIPC patients, imaging signs associated with pancreatic cancer, such as dilated bile or pancreatic ducts, were not recognized as such and were not investigated further. In 26% of scans, the signs of a mass lesion were not picked up by the radiologist.
The findings are notable as the time window for curative PC surgery is often short, and missing the diagnosis on cross-sectional imaging can result in worse clinical outcomes for patients already dealing with a challenging cancer that has generally poor outcomes, Dr. Umar said in an interview.
In fact, pancreatic cancer has the lowest survival rate of all cancers in Europe, the UEG noted in a press release. Life expectancy at the time of diagnosis is just 4.6 months, and 5-year survival is less than 10%, Dr. Umar said.
Pancreatic cancer causes 95,000 deaths in the European Union each year, the UEG noted, adding that by 2035 the number of cases is predicted to rise by almost 40%.
Details of missed imaging signs
The aim of this study was to establish the most plausible explanations for missed imaging signs of PC, Dr. Umar explained, adding that early diagnosis is vitally important for offering patients the best chance of survival.
Cases analyzed for the study were identified from electronic medical records of adults diagnosed with PC between 2016 and 2021 at two National Health Service providers. An algorithm was developed to categorize PIPC and assess potential causes of the missed diagnoses.
The PIPC cases were categorized by type:
- Type 1 – A focal lesion on previous imaging reported in the same pancreatic segment as PIPC (0% of cases)
- Type 2 – Imaging changes that can be associated with PC reported on previous imaging (20% of cases)
- Type 3 – No lesion or imaging changes that can be associated with PC reported on previous imaging in the same pancreatic segment as PIPC, but lesion or imaging changes noted on review after PIPC diagnosis (26% of cases)
- Type 4 – No lesion or imaging changes that can be associated with PC reported on previous imaging in the same pancreatic segment as PIPC and no lesion or imaging changes on review after PIPC diagnosis (54% of cases)
“We hope this study will raise awareness of the issue of postimaging pancreatic cancer and common reasons why pancreatic cancer can be initially missed,” Dr. Umar stated in the UEG press release. “This will help to standardize future studies of this issue and guide quality improvement efforts so we can increase the likelihood of an early diagnosis of pancreatic cancer, increase the chances of patient survival and, ultimately, save lives.”
The authors reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Hospitalizations for VAP rose prior to pandemic
Health care–associated infections are a significant burden, and “ventilator associated-pneumonia is a contributor to that,” said Namratha S. Meda, MBBS, in a presentation at the annual meeting of the American College of Chest Physicians.
VAP can affect length of stay and other costs, but factors related to VAP hospitalization have not been well studied, said Dr. Meda, of Medstar Health/Georgetown University Hospital, Washington.
To examine trends in hospitalization for VAP, Dr. Meda and colleagues reviewed data from the National Inpatient Sample from January 2013 to December 2019. The study population included adult patients with VAP as a primary or secondary diagnosis based on ICD-9 or ICD-10 codes.
Overall, the trend in hospitalizations showed a consistent increase, said Dr. Meda.
The researchers identified 128,025 adult hospitalizations with VAP during the study period, with an increase from 50 VAP cases per 100,000 hospitalizations in 2013 to 75 cases per 100,000 hospitalizations in 2019.
A total of 42,120 hospitalizations were associated with tracheostomy, ventilator dependence, or both. Hospitalizations in these categories increased by 80% during the study period, from 15 cases per 100,000 hospitalizations in 2013 to 27 cases per 100,000 hospitalizations in 2019.
The median cost for each hospitalization was $83,311, and showed a 2.9% increase from 2013 to 2019. The estimated annual cost of VAP hospitalizations was approximately $2.8 billion in 2019, Dr. Meda emphasized. However, all-cause hospital mortality remained unchanged over the study period, at approximately 20%.
The mean age of the hospitalized VAP patients was 58 years across all VAP-related hospitalizations, and 36.5% were women. More than half (58%) were White, 21% were Black, and 12% were Hispanic.
The researchers noted some sex and racial disparities; the median age was lower for Black and Hispanic patients, compared with White patients, but all-cause mortality was lower. Men had a significantly longer median length of stay, compared with women (21 days vs. 19 days), and higher median costs ($87,981 vs. $74,889) with a P <.001 for both, but the all-cause in-hospital mortality was not significantly different between sexes.
The steady increase in hospitalization for VAP without a significant change in all-cause mortality, might be driven by hospitals with higher levels of tracheostomy and ventilator dependence, but more research is needed, Dr. Meda noted.
The study was limited by the observational design, which allowed the researchers to report an association, but not causality, said Dr. Meda. However, the results reflect the ongoing financial burden of VAP on the health care system, although “it would be interesting to see how the trend might change if we just looked at the clinical definition versus billing data,” she noted.
The study did not include data since the advent of COVID-19, but COVID is likely to drive the trend of increasing VAP hospitalization higher, Dr. Meda added.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Health care–associated infections are a significant burden, and “ventilator associated-pneumonia is a contributor to that,” said Namratha S. Meda, MBBS, in a presentation at the annual meeting of the American College of Chest Physicians.
VAP can affect length of stay and other costs, but factors related to VAP hospitalization have not been well studied, said Dr. Meda, of Medstar Health/Georgetown University Hospital, Washington.
To examine trends in hospitalization for VAP, Dr. Meda and colleagues reviewed data from the National Inpatient Sample from January 2013 to December 2019. The study population included adult patients with VAP as a primary or secondary diagnosis based on ICD-9 or ICD-10 codes.
Overall, the trend in hospitalizations showed a consistent increase, said Dr. Meda.
The researchers identified 128,025 adult hospitalizations with VAP during the study period, with an increase from 50 VAP cases per 100,000 hospitalizations in 2013 to 75 cases per 100,000 hospitalizations in 2019.
A total of 42,120 hospitalizations were associated with tracheostomy, ventilator dependence, or both. Hospitalizations in these categories increased by 80% during the study period, from 15 cases per 100,000 hospitalizations in 2013 to 27 cases per 100,000 hospitalizations in 2019.
The median cost for each hospitalization was $83,311, and showed a 2.9% increase from 2013 to 2019. The estimated annual cost of VAP hospitalizations was approximately $2.8 billion in 2019, Dr. Meda emphasized. However, all-cause hospital mortality remained unchanged over the study period, at approximately 20%.
The mean age of the hospitalized VAP patients was 58 years across all VAP-related hospitalizations, and 36.5% were women. More than half (58%) were White, 21% were Black, and 12% were Hispanic.
The researchers noted some sex and racial disparities; the median age was lower for Black and Hispanic patients, compared with White patients, but all-cause mortality was lower. Men had a significantly longer median length of stay, compared with women (21 days vs. 19 days), and higher median costs ($87,981 vs. $74,889) with a P <.001 for both, but the all-cause in-hospital mortality was not significantly different between sexes.
The steady increase in hospitalization for VAP without a significant change in all-cause mortality, might be driven by hospitals with higher levels of tracheostomy and ventilator dependence, but more research is needed, Dr. Meda noted.
The study was limited by the observational design, which allowed the researchers to report an association, but not causality, said Dr. Meda. However, the results reflect the ongoing financial burden of VAP on the health care system, although “it would be interesting to see how the trend might change if we just looked at the clinical definition versus billing data,” she noted.
The study did not include data since the advent of COVID-19, but COVID is likely to drive the trend of increasing VAP hospitalization higher, Dr. Meda added.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Health care–associated infections are a significant burden, and “ventilator associated-pneumonia is a contributor to that,” said Namratha S. Meda, MBBS, in a presentation at the annual meeting of the American College of Chest Physicians.
VAP can affect length of stay and other costs, but factors related to VAP hospitalization have not been well studied, said Dr. Meda, of Medstar Health/Georgetown University Hospital, Washington.
To examine trends in hospitalization for VAP, Dr. Meda and colleagues reviewed data from the National Inpatient Sample from January 2013 to December 2019. The study population included adult patients with VAP as a primary or secondary diagnosis based on ICD-9 or ICD-10 codes.
Overall, the trend in hospitalizations showed a consistent increase, said Dr. Meda.
The researchers identified 128,025 adult hospitalizations with VAP during the study period, with an increase from 50 VAP cases per 100,000 hospitalizations in 2013 to 75 cases per 100,000 hospitalizations in 2019.
A total of 42,120 hospitalizations were associated with tracheostomy, ventilator dependence, or both. Hospitalizations in these categories increased by 80% during the study period, from 15 cases per 100,000 hospitalizations in 2013 to 27 cases per 100,000 hospitalizations in 2019.
The median cost for each hospitalization was $83,311, and showed a 2.9% increase from 2013 to 2019. The estimated annual cost of VAP hospitalizations was approximately $2.8 billion in 2019, Dr. Meda emphasized. However, all-cause hospital mortality remained unchanged over the study period, at approximately 20%.
The mean age of the hospitalized VAP patients was 58 years across all VAP-related hospitalizations, and 36.5% were women. More than half (58%) were White, 21% were Black, and 12% were Hispanic.
The researchers noted some sex and racial disparities; the median age was lower for Black and Hispanic patients, compared with White patients, but all-cause mortality was lower. Men had a significantly longer median length of stay, compared with women (21 days vs. 19 days), and higher median costs ($87,981 vs. $74,889) with a P <.001 for both, but the all-cause in-hospital mortality was not significantly different between sexes.
The steady increase in hospitalization for VAP without a significant change in all-cause mortality, might be driven by hospitals with higher levels of tracheostomy and ventilator dependence, but more research is needed, Dr. Meda noted.
The study was limited by the observational design, which allowed the researchers to report an association, but not causality, said Dr. Meda. However, the results reflect the ongoing financial burden of VAP on the health care system, although “it would be interesting to see how the trend might change if we just looked at the clinical definition versus billing data,” she noted.
The study did not include data since the advent of COVID-19, but COVID is likely to drive the trend of increasing VAP hospitalization higher, Dr. Meda added.
The study received no outside funding. The researchers had no financial conflicts to disclose.
FROM CHEST 2022
Sepsis transition program may lower mortality in patients discharged to post-acute care
Sepsis survivors discharged to post-acute care facilities are at high risk for mortality and hospital readmission, according to Nicholas Colucciello, MD, and few interventions have been shown to reduce these adverse outcomes.
Dr. Colucciello and colleagues compared the effects of a Sepsis Transition And Recovery (STAR) program versus Usual Care (UC) alone on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care.
In a study presented at the annual meeting of the American College of Chest Physicians (CHEST), Dr. Colucciello, a primary care physician in Toledo, Ohio, presented data suggesting that
Study of IMPACTS
The study was a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial, focusing only on those patients who were discharged to a post-acute care facility. IMPACTS evaluated the effectiveness of STAR, a post-sepsis transition program using nurse navigators to deliver best-practice post-sepsis care during and after hospitalization, Dr. Colucciello said. The interventions included comorbidity monitoring, medication review, evaluation for new impairments/symptoms, and goals of care assessment.
“Over one-third of sepsis survivors are discharged to post-acute care as they are not stable enough to go home,” said Dr. Colucciello, and among these patients there is a high risk for mortality and hospital readmission.
Dr. Colucciello and his colleagues randomly assigned patients hospitalized with sepsis and deemed high risk for post-discharge readmission or mortality to either STAR or usual care. The primary outcome was a composite of 30-day readmission and mortality, which was assessed from the electronic health record and social security death master file.
Of the 175 (21%) IMPACTS patients discharged to post-acute care facilities, 143 (82%) were sent to skilled nursing facilities, and 12 (7%) were sent to long-term acute care hospitals. The remaining 20 patients (11%) were sent to inpatient rehabilitation. A total of 88 of these patients received the STAR intervention and 87 received usual care.
Suggestive results
The study showed that the composite primary endpoint occurred in 26 (30.6%) patients in the usual care group versus 18 (20.7%) patients in the STAR group, for a risk difference of –9.9% (95% CI, –22.9 to 3.1), according to Dr. Colucciello. As individual factors, 30-day all-cause mortality was 8.2% in the UC group, compared with 5.8% in the STAR group, for a risk difference of –2.5% (95% CI, –10.1 to 5.0) and the 30-day all-cause readmission was 27.1% in the UC group, compared with 17.2% in the STAR program, for a risk difference of –9.8% (95% CI, –22.2 to 2.5). On average, patients receiving UC experienced 26.5 hospital-free days, compared with 27.4 hospital-free days in the STAR group, he added.
The biggest limitation of the study was the fact that it was underpowered to detect statistically significant differences, despite the suggestive results, said Dr. Colucciello. However, he added: “This secondary analysis of the IMPACTS randomized trial found that the STAR intervention may decrease 30-day mortality and readmission rates among sepsis patients discharged to a post-acute care facility,” he concluded.
Dr. Colucciello and colleagues report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Sepsis survivors discharged to post-acute care facilities are at high risk for mortality and hospital readmission, according to Nicholas Colucciello, MD, and few interventions have been shown to reduce these adverse outcomes.
Dr. Colucciello and colleagues compared the effects of a Sepsis Transition And Recovery (STAR) program versus Usual Care (UC) alone on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care.
In a study presented at the annual meeting of the American College of Chest Physicians (CHEST), Dr. Colucciello, a primary care physician in Toledo, Ohio, presented data suggesting that
Study of IMPACTS
The study was a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial, focusing only on those patients who were discharged to a post-acute care facility. IMPACTS evaluated the effectiveness of STAR, a post-sepsis transition program using nurse navigators to deliver best-practice post-sepsis care during and after hospitalization, Dr. Colucciello said. The interventions included comorbidity monitoring, medication review, evaluation for new impairments/symptoms, and goals of care assessment.
“Over one-third of sepsis survivors are discharged to post-acute care as they are not stable enough to go home,” said Dr. Colucciello, and among these patients there is a high risk for mortality and hospital readmission.
Dr. Colucciello and his colleagues randomly assigned patients hospitalized with sepsis and deemed high risk for post-discharge readmission or mortality to either STAR or usual care. The primary outcome was a composite of 30-day readmission and mortality, which was assessed from the electronic health record and social security death master file.
Of the 175 (21%) IMPACTS patients discharged to post-acute care facilities, 143 (82%) were sent to skilled nursing facilities, and 12 (7%) were sent to long-term acute care hospitals. The remaining 20 patients (11%) were sent to inpatient rehabilitation. A total of 88 of these patients received the STAR intervention and 87 received usual care.
Suggestive results
The study showed that the composite primary endpoint occurred in 26 (30.6%) patients in the usual care group versus 18 (20.7%) patients in the STAR group, for a risk difference of –9.9% (95% CI, –22.9 to 3.1), according to Dr. Colucciello. As individual factors, 30-day all-cause mortality was 8.2% in the UC group, compared with 5.8% in the STAR group, for a risk difference of –2.5% (95% CI, –10.1 to 5.0) and the 30-day all-cause readmission was 27.1% in the UC group, compared with 17.2% in the STAR program, for a risk difference of –9.8% (95% CI, –22.2 to 2.5). On average, patients receiving UC experienced 26.5 hospital-free days, compared with 27.4 hospital-free days in the STAR group, he added.
The biggest limitation of the study was the fact that it was underpowered to detect statistically significant differences, despite the suggestive results, said Dr. Colucciello. However, he added: “This secondary analysis of the IMPACTS randomized trial found that the STAR intervention may decrease 30-day mortality and readmission rates among sepsis patients discharged to a post-acute care facility,” he concluded.
Dr. Colucciello and colleagues report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Sepsis survivors discharged to post-acute care facilities are at high risk for mortality and hospital readmission, according to Nicholas Colucciello, MD, and few interventions have been shown to reduce these adverse outcomes.
Dr. Colucciello and colleagues compared the effects of a Sepsis Transition And Recovery (STAR) program versus Usual Care (UC) alone on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care.
In a study presented at the annual meeting of the American College of Chest Physicians (CHEST), Dr. Colucciello, a primary care physician in Toledo, Ohio, presented data suggesting that
Study of IMPACTS
The study was a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial, focusing only on those patients who were discharged to a post-acute care facility. IMPACTS evaluated the effectiveness of STAR, a post-sepsis transition program using nurse navigators to deliver best-practice post-sepsis care during and after hospitalization, Dr. Colucciello said. The interventions included comorbidity monitoring, medication review, evaluation for new impairments/symptoms, and goals of care assessment.
“Over one-third of sepsis survivors are discharged to post-acute care as they are not stable enough to go home,” said Dr. Colucciello, and among these patients there is a high risk for mortality and hospital readmission.
Dr. Colucciello and his colleagues randomly assigned patients hospitalized with sepsis and deemed high risk for post-discharge readmission or mortality to either STAR or usual care. The primary outcome was a composite of 30-day readmission and mortality, which was assessed from the electronic health record and social security death master file.
Of the 175 (21%) IMPACTS patients discharged to post-acute care facilities, 143 (82%) were sent to skilled nursing facilities, and 12 (7%) were sent to long-term acute care hospitals. The remaining 20 patients (11%) were sent to inpatient rehabilitation. A total of 88 of these patients received the STAR intervention and 87 received usual care.
Suggestive results
The study showed that the composite primary endpoint occurred in 26 (30.6%) patients in the usual care group versus 18 (20.7%) patients in the STAR group, for a risk difference of –9.9% (95% CI, –22.9 to 3.1), according to Dr. Colucciello. As individual factors, 30-day all-cause mortality was 8.2% in the UC group, compared with 5.8% in the STAR group, for a risk difference of –2.5% (95% CI, –10.1 to 5.0) and the 30-day all-cause readmission was 27.1% in the UC group, compared with 17.2% in the STAR program, for a risk difference of –9.8% (95% CI, –22.2 to 2.5). On average, patients receiving UC experienced 26.5 hospital-free days, compared with 27.4 hospital-free days in the STAR group, he added.
The biggest limitation of the study was the fact that it was underpowered to detect statistically significant differences, despite the suggestive results, said Dr. Colucciello. However, he added: “This secondary analysis of the IMPACTS randomized trial found that the STAR intervention may decrease 30-day mortality and readmission rates among sepsis patients discharged to a post-acute care facility,” he concluded.
Dr. Colucciello and colleagues report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM CHEST 2022
Sepsis predictor tool falls short in emergency setting
Use of a sepsis predictor made little difference in time to antibiotic administration for septic patients in the emergency department, based on data from more than 200 patients.
“One of the big problems with sepsis is the lack of current tools for early and accurate diagnoses,” said Daniel Burgin, MD, an internal medicine resident at Louisiana State University, Baton Rouge, in a presentation at the annual meeting of the American College of Chest Physicians.
The EPIC Sepsis Model (ESM) was designed to help facilitate earlier detection of sepsis and speed time to the start of antibiotics, but its effectiveness has not been well studied, Dr. Burgin said.
In Dr. Burgin’s facility, the ESM is mainly driven by systemic inflammatory response syndrome (SIRS) and blood pressure and is calculated every 15 minutes; the system triggers a best-practice advisory if needed, with an alert that sepsis may be suspected.
To assess the impact of ESM on time to antibiotics, Dr. Burgin and colleagues reviewed data from 226 adult patients who presented to a single emergency department between February 2019 and June 2019. All patients presented with at least two criteria for SIRS. An ESM threshold of 6 was designed to trigger a set of orders to guide providers on a treatment plan that included antibiotics.
The researchers compared times to the ordering and the administration of antibiotics for patients with ESM scores of 6 or higher vs. less than 6 within 6 hours of triage in the ED. A total of 109 patients (48.2%) received antibiotics in the ED. Of these, 71 (74.5%) had ESM less than 6 and 38 (40.6%) had ESM of 6 or higher. The times from triage to antibiotics ordered and administered was significantly less in patients with ESM of 6 or higher (90.5 minutes vs. 131.5 minutes; 136 minutes vs. 186 minutes, respectively; P = .011 for both).
A total of 188 patients were evaluated for infection, and 86 met Sepsis-2 criteria based on physician chart review. These patients were significantly more likely than those not meeting the Sepsis-2 criteria to receive antibiotics in the ED (76.7% vs. 22.8%; P <.001).
Another 21 patients met criteria for Sepsis-3 based on a physician panel. Although all 21 received antibiotics, 5 did not receive them within 6 hours of triage in the ED, Dr. Burgin said. The median times to ordering and administration of antibiotics for Sepsis-3 patients with an ESM of 6 or higher were –5 and 38.5 (interquartile range), respectively.
“We hope that the ESM would prompt providers to start the order [for antibiotics],” Dr. Burgin said in his presentation. However, the researchers found no consistent patterns, and in many cases the ESM alerts occurred after the orders had been initiated, he noted.
The study findings were limited by the use of data from a single center; the implementation of the EPIC tool is hospital specific, said Dr. Burgin. However, the results suggest that he said.
“While this research proved useful in assessing the impact of ESM on time to antibiotics, more research is needed to understand how to operationalize predictive analytics,” Dr. Burgin said of the study findings. “The goal is to find the balance between early identification of sepsis and timely antimicrobial therapy and the potential harm of overalerting treatment teams.”
The study was supported in part by Cytovale, a sepsis diagnostics company. Several coauthors disclosed financial relationships with Cytovale. Dr. Burgin reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Use of a sepsis predictor made little difference in time to antibiotic administration for septic patients in the emergency department, based on data from more than 200 patients.
“One of the big problems with sepsis is the lack of current tools for early and accurate diagnoses,” said Daniel Burgin, MD, an internal medicine resident at Louisiana State University, Baton Rouge, in a presentation at the annual meeting of the American College of Chest Physicians.
The EPIC Sepsis Model (ESM) was designed to help facilitate earlier detection of sepsis and speed time to the start of antibiotics, but its effectiveness has not been well studied, Dr. Burgin said.
In Dr. Burgin’s facility, the ESM is mainly driven by systemic inflammatory response syndrome (SIRS) and blood pressure and is calculated every 15 minutes; the system triggers a best-practice advisory if needed, with an alert that sepsis may be suspected.
To assess the impact of ESM on time to antibiotics, Dr. Burgin and colleagues reviewed data from 226 adult patients who presented to a single emergency department between February 2019 and June 2019. All patients presented with at least two criteria for SIRS. An ESM threshold of 6 was designed to trigger a set of orders to guide providers on a treatment plan that included antibiotics.
The researchers compared times to the ordering and the administration of antibiotics for patients with ESM scores of 6 or higher vs. less than 6 within 6 hours of triage in the ED. A total of 109 patients (48.2%) received antibiotics in the ED. Of these, 71 (74.5%) had ESM less than 6 and 38 (40.6%) had ESM of 6 or higher. The times from triage to antibiotics ordered and administered was significantly less in patients with ESM of 6 or higher (90.5 minutes vs. 131.5 minutes; 136 minutes vs. 186 minutes, respectively; P = .011 for both).
A total of 188 patients were evaluated for infection, and 86 met Sepsis-2 criteria based on physician chart review. These patients were significantly more likely than those not meeting the Sepsis-2 criteria to receive antibiotics in the ED (76.7% vs. 22.8%; P <.001).
Another 21 patients met criteria for Sepsis-3 based on a physician panel. Although all 21 received antibiotics, 5 did not receive them within 6 hours of triage in the ED, Dr. Burgin said. The median times to ordering and administration of antibiotics for Sepsis-3 patients with an ESM of 6 or higher were –5 and 38.5 (interquartile range), respectively.
“We hope that the ESM would prompt providers to start the order [for antibiotics],” Dr. Burgin said in his presentation. However, the researchers found no consistent patterns, and in many cases the ESM alerts occurred after the orders had been initiated, he noted.
The study findings were limited by the use of data from a single center; the implementation of the EPIC tool is hospital specific, said Dr. Burgin. However, the results suggest that he said.
“While this research proved useful in assessing the impact of ESM on time to antibiotics, more research is needed to understand how to operationalize predictive analytics,” Dr. Burgin said of the study findings. “The goal is to find the balance between early identification of sepsis and timely antimicrobial therapy and the potential harm of overalerting treatment teams.”
The study was supported in part by Cytovale, a sepsis diagnostics company. Several coauthors disclosed financial relationships with Cytovale. Dr. Burgin reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Use of a sepsis predictor made little difference in time to antibiotic administration for septic patients in the emergency department, based on data from more than 200 patients.
“One of the big problems with sepsis is the lack of current tools for early and accurate diagnoses,” said Daniel Burgin, MD, an internal medicine resident at Louisiana State University, Baton Rouge, in a presentation at the annual meeting of the American College of Chest Physicians.
The EPIC Sepsis Model (ESM) was designed to help facilitate earlier detection of sepsis and speed time to the start of antibiotics, but its effectiveness has not been well studied, Dr. Burgin said.
In Dr. Burgin’s facility, the ESM is mainly driven by systemic inflammatory response syndrome (SIRS) and blood pressure and is calculated every 15 minutes; the system triggers a best-practice advisory if needed, with an alert that sepsis may be suspected.
To assess the impact of ESM on time to antibiotics, Dr. Burgin and colleagues reviewed data from 226 adult patients who presented to a single emergency department between February 2019 and June 2019. All patients presented with at least two criteria for SIRS. An ESM threshold of 6 was designed to trigger a set of orders to guide providers on a treatment plan that included antibiotics.
The researchers compared times to the ordering and the administration of antibiotics for patients with ESM scores of 6 or higher vs. less than 6 within 6 hours of triage in the ED. A total of 109 patients (48.2%) received antibiotics in the ED. Of these, 71 (74.5%) had ESM less than 6 and 38 (40.6%) had ESM of 6 or higher. The times from triage to antibiotics ordered and administered was significantly less in patients with ESM of 6 or higher (90.5 minutes vs. 131.5 minutes; 136 minutes vs. 186 minutes, respectively; P = .011 for both).
A total of 188 patients were evaluated for infection, and 86 met Sepsis-2 criteria based on physician chart review. These patients were significantly more likely than those not meeting the Sepsis-2 criteria to receive antibiotics in the ED (76.7% vs. 22.8%; P <.001).
Another 21 patients met criteria for Sepsis-3 based on a physician panel. Although all 21 received antibiotics, 5 did not receive them within 6 hours of triage in the ED, Dr. Burgin said. The median times to ordering and administration of antibiotics for Sepsis-3 patients with an ESM of 6 or higher were –5 and 38.5 (interquartile range), respectively.
“We hope that the ESM would prompt providers to start the order [for antibiotics],” Dr. Burgin said in his presentation. However, the researchers found no consistent patterns, and in many cases the ESM alerts occurred after the orders had been initiated, he noted.
The study findings were limited by the use of data from a single center; the implementation of the EPIC tool is hospital specific, said Dr. Burgin. However, the results suggest that he said.
“While this research proved useful in assessing the impact of ESM on time to antibiotics, more research is needed to understand how to operationalize predictive analytics,” Dr. Burgin said of the study findings. “The goal is to find the balance between early identification of sepsis and timely antimicrobial therapy and the potential harm of overalerting treatment teams.”
The study was supported in part by Cytovale, a sepsis diagnostics company. Several coauthors disclosed financial relationships with Cytovale. Dr. Burgin reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM CHEST 2022
Most pediatric myocarditis caused by viruses
ANAHEIM – A wide range of factors can cause myocarditis; most often viral infections cause myocarditis in children and teens, according to Ryan Butts, MD, medical director of the pediatric advanced cardiac care program at the University of Texas Southwestern Medical Center and Children’s Health of Texas.
Dr. Butts provided an overview of what pediatricians and other clinicians caring for children and teens should know about myocarditis at the annual meeting of the American Academy of Pediatrics.
The important new things that attendees may want to take away from this for their practice are improved recognition and diagnostic workup for acute viral myocarditis, making sure cardiology follow-up occurs after an admission for the condition, enhanced evaluation of the child before they return to competitive sports, and the availability of written or verbal education for patients relating to COVID vaccine–associated myocarditis, Dr. Butts said.
He also provided a set of key takeaways:
- Myocarditis is rare.
- The most common viruses causing myocarditis are always changing.
- Myocarditis is most common in infants and teenagers but it has different clinical patterns in each population.
- MRI is becoming the diagnostic tool of choice.
- IVIG frequently is used but good evidence for the therapy is lacking.
- Patients may go home on cardiac medications but have good long-term outcomes.
- Patients must have a 6-month restriction on competitive sports after diagnosis.
Frank Han, MD, a pediatric cardiologist at OSF Medical Center and Children’s Hospital of Illinois in Peoria, said he found the most helpful parts of Dr. Butts’ presentation to be the diagnosis and triage of myocarditis in the major age groups.
“Myocarditis can have variable presentations, and its cause may influence how the myocarditis behaves,” Dr. Han said. Pediatric cardiologists, he said, are uniquely positioned to triage and diagnose myocarditis.
Epidemiology and presentation
Just 0.05% of admissions from 28.6 million U.S. pediatric ED visits every year are for myocarditis, Dr. Butts said. While viruses are the most common cause of myocarditis, bacterial infections and noninfectious causes, including hypersensitivity reactions, systemic disorders, and toxic substances, can also cause the condition. The dominant viruses causing myocarditis have shifted over the years as well. Coxsackie B was the most common cause in the 1980s, but adenovirus became more common in the 1990s and parvovirus B19 in the 2000s. Why some kids develop myocarditis while others don’t is unclear, but the host-immune response to the virus likely plays an important role.
Research has shown two substantial spikes in the incidence of myocarditis children: infants under 2 years old and teens aged 14-19. Although myocarditis refers to any inflammation of myocardium not caused by ischemia, the signs, symptoms, and lab results vary according to patient’s age group. The only constant is that diaphoresis is rare across all ages.
Infants are more likely to show respiratory distress (68%) and an enlarged liver (40%) but can also present with gastrointestinal symptoms (24%). Vomiting without fever or diarrhea should arouse clinical suspicion of myocarditis in infants, although fever and diarrhea can occur.
In young children, who have the lowest incidence, fatigue presents in about one-third, with 20% presenting with chest pain and 20% with hepatomegaly. The most common symptom in teens by far (80%) is chest pain. About one-third also have respiratory distress but gastrointestinal symptoms are less common (20%).
When should a clinician suspect myocarditis in a teen presenting with chest pain? “If the chest pain is reproducible and if you can localize it, they don’t need further evaluation,” Dr. Butts said. “After that, it’s a lot about the history.”
In terms of lab results, ventricular function measured by brain natriuretic peptide is significantly depressed in infants and young children but often near normal in teens. Inflammatory markers (C-reactive protein) tend to be low in infants but elevated in young children and teens. And troponin levels, denoting myocardial injury, are minimal in infants and young children but elevated in teens. Median ejection fraction on echocardiograms, about 55% in normal hearts, will often be low in infants and young children, around 30%-33%, but is near normal (54%) in teens.
Diagnosis and management
Cardiac MRI increasingly has been replacing endomyocardial biopsy for diagnosis, with MRI exceeding biopsy use between 2009 and 2010, Dr. Butts said. The advantage of endomyocardial biopsy is that it’s specific, if not very sensitive. The test is invasive, however, requiring sedation and carrying the risk of tricuspid injury. The most common finding on cardiac MRI is late gadolinium enhancement (80%) while early gadolinium enhancement is less common (55%).
Although Dr. Butts mentioned the Dallas diagnostic criteria from 1987, he advocated for the more recent Lake Louise Criteria, which require clinical suspicion of myocarditis and at least two of three findings on MRI: T2-weighted myocardial abnormalities, T1 early or late gadolinium enhancement, or regional wall motion abnormalities or evidence of pericarditis
Point-of-care ultrasound can be useful for detecting myocarditis, but its success depends on whether the user can pick up on the subtle changes in ventricular function. “Just because someone has a point-of-care ultrasound that’s normal or thought to be normal, it shouldn’t rule out the diagnosis,” he said.
Learning the etiology of viral myocarditis often is difficult, and etiology doesn’t affect management of the condition, Dr. Butts said. Even in cases of myocarditis confirmed by biopsy, the virus may be identified in only about 60%-70% of cases with myocardial polymerase chain reaction. In clinical cases, the virus can be determined only about 25%-30% of the time with serum PCR.
Prognosis is usually good, with 80%-90% of children and teens going home transplant free despite most arriving critically ill and 50%-80% initially being admitted to ICU. Two-thirds of those discharged go home with heart failure medications, but only one in six are readmitted within a year.
The strongest risk factors for poor prognosis are younger age and being critically ill at presentation but other risk factors include female sex, poor ventricular function, poor perfusion on exam, increased dilation on echocardiogram, and a need for ECMO or inotropes or mechanical ventilation.
That said, Dr. Butts cautioned attendees not to ignore normal function. In one study of 171 patients, among 75 who presented with normal function, 15% went home with inotropes, 12% required mechanical ventilation, 9% had arrhythmia, and 5% needed extracorporeal membrane oxygenation.
A big question in treatment is whether to give IVIG or not and the evidence is murky, Dr. Butts said. He reviewed a couple studies on IVIG, including one that suggested better ventricular functional recovery with the treatment but those who received IVIG were also more likely to be on an ACE inhibitor.
“Was it the ACE inhibitor or was it IVIG? We don’t know,” he said. Different cardiologists may give different opinions on IVIG. “It has nothing to do with the actual evidence behind it.”
IVIG has drawbacks: It’s very expensive and it involves risks that include serum sickness and interstitial nephritis.
“Pediatricians typically aren’t going to directly decide on giving or not giving IVIG,” Dr. Han said. “Typically, the ultimate choice comes from a group discussion between the hospital cardiologist – perhaps the hospitalist pediatrician if they are involved – and the family. We acknowledge the ambiguity of the evidence and decide based upon the severity of the initial disease process.”
Return to competitive sports; Follow-up critical
Experts are much more confident, however, about when teens admitted with viral myocarditis can return to competitive sports. But Dr. Butts said he suspects the guidelines for these children aren’t followed as closely as they should be. The American Heart Association recommends waiting 6 months after discharge and ensuring the athlete has a normal echocardiogram, Holter monitoring, and stress test.
“It’s incredibly important to have them come back and see the cardiologist 6 months after admission,” Dr. Butts said. “The only patient I’ve ever had who died 6-7 months post myocarditis is somebody who, during their stress test, had increasing ventricular ectopy. I told him not to do sports. He didn’t listen to me and unfortunately passed away – I’m assuming from arrhythmia.”
COVID and vaccine-associated myocarditis
Vaccine-associated myocarditis is substantially milder than viral myocarditis, Dr. Butts said. A small study from a single center in Atlanta found that ejection fraction at admission was normal, around 56%, in those with vaccine-associated myocarditis, compared with 45% with non-COVID viral myocarditis and 50% with multisystem inflammatory syndrome in children or myocarditis from COVID-19. All patients with vaccine-associated myocarditis had normal function at discharge, compared with 73% of those with viral myocarditis and 93% with COVID-associated myocarditis.
While 22% of those with vaccine-associated myocarditis were admitted to the ICU, twice as many (40%) with viral myocarditis were, and three times as many (68%) with COVID-associated myocarditis ended up in intensive care.
Dr. Butts also noted a Morbidity and Mortality Weekly Report from the Centers of Disease Control and Prevention that found teen boys had two to six times greater risk of heart complications after COVID-19 infection than after COVID vaccination.
In terms of direct comparisons, vaccine-related myocarditis occurred about 12-18 times per 100,000 doses for boys ages 5-11 years, compared with cardiac involvement in 93-133 cases out of 100,000 COVID-19 infections. Boys aged 12-17 years experienced 12-21 cases of myocarditis per 100,000 doses of the vaccine, compared with cardiac involvement in 50-64 out of 100,000 infections.
The bottom line, Dr. Butts said, is that cardiac involvement in MIS-C is common, but typically improves by discharge. “Vaccine-associated myocarditis is a mild clinical syndrome that has a very short duration, and, in my opinion, should never lead us to ever advise anybody not to get the vaccine. I’ve had many patients, even patients in their first year post transplant, who have gotten the COVID-19 vaccine and were just fine.”
Dr. Butts acknowledged that talking with families about the risk of myocarditis with the vaccine is challenging. He often starts these conversations by sharing the statistics, but he said relatable stories are the key. He will also relate the statistics to something the parents and teen will understand, whether it’s sports or another comparison. He does recommend that teens who develop vaccine-associated myocarditis complete the series and get the booster. Their chances of developing myocarditis again are extremely low, whereas “the likelihood of them being really ill from COVID-19 is much, much higher.”
Dr. Butts and Dr. Han had no disclosures. The presentation involved no external funding.
ANAHEIM – A wide range of factors can cause myocarditis; most often viral infections cause myocarditis in children and teens, according to Ryan Butts, MD, medical director of the pediatric advanced cardiac care program at the University of Texas Southwestern Medical Center and Children’s Health of Texas.
Dr. Butts provided an overview of what pediatricians and other clinicians caring for children and teens should know about myocarditis at the annual meeting of the American Academy of Pediatrics.
The important new things that attendees may want to take away from this for their practice are improved recognition and diagnostic workup for acute viral myocarditis, making sure cardiology follow-up occurs after an admission for the condition, enhanced evaluation of the child before they return to competitive sports, and the availability of written or verbal education for patients relating to COVID vaccine–associated myocarditis, Dr. Butts said.
He also provided a set of key takeaways:
- Myocarditis is rare.
- The most common viruses causing myocarditis are always changing.
- Myocarditis is most common in infants and teenagers but it has different clinical patterns in each population.
- MRI is becoming the diagnostic tool of choice.
- IVIG frequently is used but good evidence for the therapy is lacking.
- Patients may go home on cardiac medications but have good long-term outcomes.
- Patients must have a 6-month restriction on competitive sports after diagnosis.
Frank Han, MD, a pediatric cardiologist at OSF Medical Center and Children’s Hospital of Illinois in Peoria, said he found the most helpful parts of Dr. Butts’ presentation to be the diagnosis and triage of myocarditis in the major age groups.
“Myocarditis can have variable presentations, and its cause may influence how the myocarditis behaves,” Dr. Han said. Pediatric cardiologists, he said, are uniquely positioned to triage and diagnose myocarditis.
Epidemiology and presentation
Just 0.05% of admissions from 28.6 million U.S. pediatric ED visits every year are for myocarditis, Dr. Butts said. While viruses are the most common cause of myocarditis, bacterial infections and noninfectious causes, including hypersensitivity reactions, systemic disorders, and toxic substances, can also cause the condition. The dominant viruses causing myocarditis have shifted over the years as well. Coxsackie B was the most common cause in the 1980s, but adenovirus became more common in the 1990s and parvovirus B19 in the 2000s. Why some kids develop myocarditis while others don’t is unclear, but the host-immune response to the virus likely plays an important role.
Research has shown two substantial spikes in the incidence of myocarditis children: infants under 2 years old and teens aged 14-19. Although myocarditis refers to any inflammation of myocardium not caused by ischemia, the signs, symptoms, and lab results vary according to patient’s age group. The only constant is that diaphoresis is rare across all ages.
Infants are more likely to show respiratory distress (68%) and an enlarged liver (40%) but can also present with gastrointestinal symptoms (24%). Vomiting without fever or diarrhea should arouse clinical suspicion of myocarditis in infants, although fever and diarrhea can occur.
In young children, who have the lowest incidence, fatigue presents in about one-third, with 20% presenting with chest pain and 20% with hepatomegaly. The most common symptom in teens by far (80%) is chest pain. About one-third also have respiratory distress but gastrointestinal symptoms are less common (20%).
When should a clinician suspect myocarditis in a teen presenting with chest pain? “If the chest pain is reproducible and if you can localize it, they don’t need further evaluation,” Dr. Butts said. “After that, it’s a lot about the history.”
In terms of lab results, ventricular function measured by brain natriuretic peptide is significantly depressed in infants and young children but often near normal in teens. Inflammatory markers (C-reactive protein) tend to be low in infants but elevated in young children and teens. And troponin levels, denoting myocardial injury, are minimal in infants and young children but elevated in teens. Median ejection fraction on echocardiograms, about 55% in normal hearts, will often be low in infants and young children, around 30%-33%, but is near normal (54%) in teens.
Diagnosis and management
Cardiac MRI increasingly has been replacing endomyocardial biopsy for diagnosis, with MRI exceeding biopsy use between 2009 and 2010, Dr. Butts said. The advantage of endomyocardial biopsy is that it’s specific, if not very sensitive. The test is invasive, however, requiring sedation and carrying the risk of tricuspid injury. The most common finding on cardiac MRI is late gadolinium enhancement (80%) while early gadolinium enhancement is less common (55%).
Although Dr. Butts mentioned the Dallas diagnostic criteria from 1987, he advocated for the more recent Lake Louise Criteria, which require clinical suspicion of myocarditis and at least two of three findings on MRI: T2-weighted myocardial abnormalities, T1 early or late gadolinium enhancement, or regional wall motion abnormalities or evidence of pericarditis
Point-of-care ultrasound can be useful for detecting myocarditis, but its success depends on whether the user can pick up on the subtle changes in ventricular function. “Just because someone has a point-of-care ultrasound that’s normal or thought to be normal, it shouldn’t rule out the diagnosis,” he said.
Learning the etiology of viral myocarditis often is difficult, and etiology doesn’t affect management of the condition, Dr. Butts said. Even in cases of myocarditis confirmed by biopsy, the virus may be identified in only about 60%-70% of cases with myocardial polymerase chain reaction. In clinical cases, the virus can be determined only about 25%-30% of the time with serum PCR.
Prognosis is usually good, with 80%-90% of children and teens going home transplant free despite most arriving critically ill and 50%-80% initially being admitted to ICU. Two-thirds of those discharged go home with heart failure medications, but only one in six are readmitted within a year.
The strongest risk factors for poor prognosis are younger age and being critically ill at presentation but other risk factors include female sex, poor ventricular function, poor perfusion on exam, increased dilation on echocardiogram, and a need for ECMO or inotropes or mechanical ventilation.
That said, Dr. Butts cautioned attendees not to ignore normal function. In one study of 171 patients, among 75 who presented with normal function, 15% went home with inotropes, 12% required mechanical ventilation, 9% had arrhythmia, and 5% needed extracorporeal membrane oxygenation.
A big question in treatment is whether to give IVIG or not and the evidence is murky, Dr. Butts said. He reviewed a couple studies on IVIG, including one that suggested better ventricular functional recovery with the treatment but those who received IVIG were also more likely to be on an ACE inhibitor.
“Was it the ACE inhibitor or was it IVIG? We don’t know,” he said. Different cardiologists may give different opinions on IVIG. “It has nothing to do with the actual evidence behind it.”
IVIG has drawbacks: It’s very expensive and it involves risks that include serum sickness and interstitial nephritis.
“Pediatricians typically aren’t going to directly decide on giving or not giving IVIG,” Dr. Han said. “Typically, the ultimate choice comes from a group discussion between the hospital cardiologist – perhaps the hospitalist pediatrician if they are involved – and the family. We acknowledge the ambiguity of the evidence and decide based upon the severity of the initial disease process.”
Return to competitive sports; Follow-up critical
Experts are much more confident, however, about when teens admitted with viral myocarditis can return to competitive sports. But Dr. Butts said he suspects the guidelines for these children aren’t followed as closely as they should be. The American Heart Association recommends waiting 6 months after discharge and ensuring the athlete has a normal echocardiogram, Holter monitoring, and stress test.
“It’s incredibly important to have them come back and see the cardiologist 6 months after admission,” Dr. Butts said. “The only patient I’ve ever had who died 6-7 months post myocarditis is somebody who, during their stress test, had increasing ventricular ectopy. I told him not to do sports. He didn’t listen to me and unfortunately passed away – I’m assuming from arrhythmia.”
COVID and vaccine-associated myocarditis
Vaccine-associated myocarditis is substantially milder than viral myocarditis, Dr. Butts said. A small study from a single center in Atlanta found that ejection fraction at admission was normal, around 56%, in those with vaccine-associated myocarditis, compared with 45% with non-COVID viral myocarditis and 50% with multisystem inflammatory syndrome in children or myocarditis from COVID-19. All patients with vaccine-associated myocarditis had normal function at discharge, compared with 73% of those with viral myocarditis and 93% with COVID-associated myocarditis.
While 22% of those with vaccine-associated myocarditis were admitted to the ICU, twice as many (40%) with viral myocarditis were, and three times as many (68%) with COVID-associated myocarditis ended up in intensive care.
Dr. Butts also noted a Morbidity and Mortality Weekly Report from the Centers of Disease Control and Prevention that found teen boys had two to six times greater risk of heart complications after COVID-19 infection than after COVID vaccination.
In terms of direct comparisons, vaccine-related myocarditis occurred about 12-18 times per 100,000 doses for boys ages 5-11 years, compared with cardiac involvement in 93-133 cases out of 100,000 COVID-19 infections. Boys aged 12-17 years experienced 12-21 cases of myocarditis per 100,000 doses of the vaccine, compared with cardiac involvement in 50-64 out of 100,000 infections.
The bottom line, Dr. Butts said, is that cardiac involvement in MIS-C is common, but typically improves by discharge. “Vaccine-associated myocarditis is a mild clinical syndrome that has a very short duration, and, in my opinion, should never lead us to ever advise anybody not to get the vaccine. I’ve had many patients, even patients in their first year post transplant, who have gotten the COVID-19 vaccine and were just fine.”
Dr. Butts acknowledged that talking with families about the risk of myocarditis with the vaccine is challenging. He often starts these conversations by sharing the statistics, but he said relatable stories are the key. He will also relate the statistics to something the parents and teen will understand, whether it’s sports or another comparison. He does recommend that teens who develop vaccine-associated myocarditis complete the series and get the booster. Their chances of developing myocarditis again are extremely low, whereas “the likelihood of them being really ill from COVID-19 is much, much higher.”
Dr. Butts and Dr. Han had no disclosures. The presentation involved no external funding.
ANAHEIM – A wide range of factors can cause myocarditis; most often viral infections cause myocarditis in children and teens, according to Ryan Butts, MD, medical director of the pediatric advanced cardiac care program at the University of Texas Southwestern Medical Center and Children’s Health of Texas.
Dr. Butts provided an overview of what pediatricians and other clinicians caring for children and teens should know about myocarditis at the annual meeting of the American Academy of Pediatrics.
The important new things that attendees may want to take away from this for their practice are improved recognition and diagnostic workup for acute viral myocarditis, making sure cardiology follow-up occurs after an admission for the condition, enhanced evaluation of the child before they return to competitive sports, and the availability of written or verbal education for patients relating to COVID vaccine–associated myocarditis, Dr. Butts said.
He also provided a set of key takeaways:
- Myocarditis is rare.
- The most common viruses causing myocarditis are always changing.
- Myocarditis is most common in infants and teenagers but it has different clinical patterns in each population.
- MRI is becoming the diagnostic tool of choice.
- IVIG frequently is used but good evidence for the therapy is lacking.
- Patients may go home on cardiac medications but have good long-term outcomes.
- Patients must have a 6-month restriction on competitive sports after diagnosis.
Frank Han, MD, a pediatric cardiologist at OSF Medical Center and Children’s Hospital of Illinois in Peoria, said he found the most helpful parts of Dr. Butts’ presentation to be the diagnosis and triage of myocarditis in the major age groups.
“Myocarditis can have variable presentations, and its cause may influence how the myocarditis behaves,” Dr. Han said. Pediatric cardiologists, he said, are uniquely positioned to triage and diagnose myocarditis.
Epidemiology and presentation
Just 0.05% of admissions from 28.6 million U.S. pediatric ED visits every year are for myocarditis, Dr. Butts said. While viruses are the most common cause of myocarditis, bacterial infections and noninfectious causes, including hypersensitivity reactions, systemic disorders, and toxic substances, can also cause the condition. The dominant viruses causing myocarditis have shifted over the years as well. Coxsackie B was the most common cause in the 1980s, but adenovirus became more common in the 1990s and parvovirus B19 in the 2000s. Why some kids develop myocarditis while others don’t is unclear, but the host-immune response to the virus likely plays an important role.
Research has shown two substantial spikes in the incidence of myocarditis children: infants under 2 years old and teens aged 14-19. Although myocarditis refers to any inflammation of myocardium not caused by ischemia, the signs, symptoms, and lab results vary according to patient’s age group. The only constant is that diaphoresis is rare across all ages.
Infants are more likely to show respiratory distress (68%) and an enlarged liver (40%) but can also present with gastrointestinal symptoms (24%). Vomiting without fever or diarrhea should arouse clinical suspicion of myocarditis in infants, although fever and diarrhea can occur.
In young children, who have the lowest incidence, fatigue presents in about one-third, with 20% presenting with chest pain and 20% with hepatomegaly. The most common symptom in teens by far (80%) is chest pain. About one-third also have respiratory distress but gastrointestinal symptoms are less common (20%).
When should a clinician suspect myocarditis in a teen presenting with chest pain? “If the chest pain is reproducible and if you can localize it, they don’t need further evaluation,” Dr. Butts said. “After that, it’s a lot about the history.”
In terms of lab results, ventricular function measured by brain natriuretic peptide is significantly depressed in infants and young children but often near normal in teens. Inflammatory markers (C-reactive protein) tend to be low in infants but elevated in young children and teens. And troponin levels, denoting myocardial injury, are minimal in infants and young children but elevated in teens. Median ejection fraction on echocardiograms, about 55% in normal hearts, will often be low in infants and young children, around 30%-33%, but is near normal (54%) in teens.
Diagnosis and management
Cardiac MRI increasingly has been replacing endomyocardial biopsy for diagnosis, with MRI exceeding biopsy use between 2009 and 2010, Dr. Butts said. The advantage of endomyocardial biopsy is that it’s specific, if not very sensitive. The test is invasive, however, requiring sedation and carrying the risk of tricuspid injury. The most common finding on cardiac MRI is late gadolinium enhancement (80%) while early gadolinium enhancement is less common (55%).
Although Dr. Butts mentioned the Dallas diagnostic criteria from 1987, he advocated for the more recent Lake Louise Criteria, which require clinical suspicion of myocarditis and at least two of three findings on MRI: T2-weighted myocardial abnormalities, T1 early or late gadolinium enhancement, or regional wall motion abnormalities or evidence of pericarditis
Point-of-care ultrasound can be useful for detecting myocarditis, but its success depends on whether the user can pick up on the subtle changes in ventricular function. “Just because someone has a point-of-care ultrasound that’s normal or thought to be normal, it shouldn’t rule out the diagnosis,” he said.
Learning the etiology of viral myocarditis often is difficult, and etiology doesn’t affect management of the condition, Dr. Butts said. Even in cases of myocarditis confirmed by biopsy, the virus may be identified in only about 60%-70% of cases with myocardial polymerase chain reaction. In clinical cases, the virus can be determined only about 25%-30% of the time with serum PCR.
Prognosis is usually good, with 80%-90% of children and teens going home transplant free despite most arriving critically ill and 50%-80% initially being admitted to ICU. Two-thirds of those discharged go home with heart failure medications, but only one in six are readmitted within a year.
The strongest risk factors for poor prognosis are younger age and being critically ill at presentation but other risk factors include female sex, poor ventricular function, poor perfusion on exam, increased dilation on echocardiogram, and a need for ECMO or inotropes or mechanical ventilation.
That said, Dr. Butts cautioned attendees not to ignore normal function. In one study of 171 patients, among 75 who presented with normal function, 15% went home with inotropes, 12% required mechanical ventilation, 9% had arrhythmia, and 5% needed extracorporeal membrane oxygenation.
A big question in treatment is whether to give IVIG or not and the evidence is murky, Dr. Butts said. He reviewed a couple studies on IVIG, including one that suggested better ventricular functional recovery with the treatment but those who received IVIG were also more likely to be on an ACE inhibitor.
“Was it the ACE inhibitor or was it IVIG? We don’t know,” he said. Different cardiologists may give different opinions on IVIG. “It has nothing to do with the actual evidence behind it.”
IVIG has drawbacks: It’s very expensive and it involves risks that include serum sickness and interstitial nephritis.
“Pediatricians typically aren’t going to directly decide on giving or not giving IVIG,” Dr. Han said. “Typically, the ultimate choice comes from a group discussion between the hospital cardiologist – perhaps the hospitalist pediatrician if they are involved – and the family. We acknowledge the ambiguity of the evidence and decide based upon the severity of the initial disease process.”
Return to competitive sports; Follow-up critical
Experts are much more confident, however, about when teens admitted with viral myocarditis can return to competitive sports. But Dr. Butts said he suspects the guidelines for these children aren’t followed as closely as they should be. The American Heart Association recommends waiting 6 months after discharge and ensuring the athlete has a normal echocardiogram, Holter monitoring, and stress test.
“It’s incredibly important to have them come back and see the cardiologist 6 months after admission,” Dr. Butts said. “The only patient I’ve ever had who died 6-7 months post myocarditis is somebody who, during their stress test, had increasing ventricular ectopy. I told him not to do sports. He didn’t listen to me and unfortunately passed away – I’m assuming from arrhythmia.”
COVID and vaccine-associated myocarditis
Vaccine-associated myocarditis is substantially milder than viral myocarditis, Dr. Butts said. A small study from a single center in Atlanta found that ejection fraction at admission was normal, around 56%, in those with vaccine-associated myocarditis, compared with 45% with non-COVID viral myocarditis and 50% with multisystem inflammatory syndrome in children or myocarditis from COVID-19. All patients with vaccine-associated myocarditis had normal function at discharge, compared with 73% of those with viral myocarditis and 93% with COVID-associated myocarditis.
While 22% of those with vaccine-associated myocarditis were admitted to the ICU, twice as many (40%) with viral myocarditis were, and three times as many (68%) with COVID-associated myocarditis ended up in intensive care.
Dr. Butts also noted a Morbidity and Mortality Weekly Report from the Centers of Disease Control and Prevention that found teen boys had two to six times greater risk of heart complications after COVID-19 infection than after COVID vaccination.
In terms of direct comparisons, vaccine-related myocarditis occurred about 12-18 times per 100,000 doses for boys ages 5-11 years, compared with cardiac involvement in 93-133 cases out of 100,000 COVID-19 infections. Boys aged 12-17 years experienced 12-21 cases of myocarditis per 100,000 doses of the vaccine, compared with cardiac involvement in 50-64 out of 100,000 infections.
The bottom line, Dr. Butts said, is that cardiac involvement in MIS-C is common, but typically improves by discharge. “Vaccine-associated myocarditis is a mild clinical syndrome that has a very short duration, and, in my opinion, should never lead us to ever advise anybody not to get the vaccine. I’ve had many patients, even patients in their first year post transplant, who have gotten the COVID-19 vaccine and were just fine.”
Dr. Butts acknowledged that talking with families about the risk of myocarditis with the vaccine is challenging. He often starts these conversations by sharing the statistics, but he said relatable stories are the key. He will also relate the statistics to something the parents and teen will understand, whether it’s sports or another comparison. He does recommend that teens who develop vaccine-associated myocarditis complete the series and get the booster. Their chances of developing myocarditis again are extremely low, whereas “the likelihood of them being really ill from COVID-19 is much, much higher.”
Dr. Butts and Dr. Han had no disclosures. The presentation involved no external funding.
AT AAP 2022
Novel stepwise method found to benefit patients with severe rhinophyma
DENVER –
Rhinophyma occurs primarily in the sixth and seventh decades of life and is marked by facial hypertrophy that leads to tumor-like growth, inflammation, fibrosis, and loss of the cosmetic nasal subunits. “When it becomes severe it leads to a degree of embarrassment as well,” one of the study authors, Patricia Richey, MD, said during an oral abstract session at the annual meeting of the American Society for Dermatologic Surgery. “We found that our method has been efficacious, but most often, and more importantly, leads to an improvement in the patient’s quality of life.”
To date, clinicians have used fully ablative lasers to treat varying degrees of rhinophyma but at a cost of prolonged healing time and higher rates of scarring and pigment or textural changes. However, not all dermatologists use full-field ablative lasers in their practices.
“Fractionated ablative lasers have been used in the past for mild to moderate rhinophyma, but they cannot ablate to 100% density, which would be necessary to debulk the marked hypertrophy present in our patients,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “That’s why we added a surgical component.”
She and colleague Mathew M. Avram, MD, JD, developed a three-step method for treating severe rhinophyma that they performed on three elderly patients. Step 1 is the surgical debulk. Following infiltration of local anesthesia, a razor blade or 15-blade is used to excise the most prominent lobules of hypertrophied sebaceous tissue down to the fibrofatty layer of the nose as a partial thickness excision that does not reach the level of the perichondrium or cartilage. “Hemostasis is achieved with electrocoagulation and application of petrolatum ointment, followed by a pressure dressing,” Dr. Richey said. “The location of the debulk varies by patient.”
Step 2 involves fractionated ablative laser treatment 4 weeks later with either the CO2 or erbium:YAG (Er:YAG) 2,940-nm laser. According to Dr. Richey, the typical setting for the fractionated CO2 is a fluence of 70mJ/cm2 and a high density, performing six out of four passes with 60 seconds between each pass, “though these settings may vary based on the patient presentation,” she said.
The treatment level ranges from 5 (14% density) to 10 (70% density, for the most severe cases). Meanwhile, a representative setting for the ablative fractionated Er:YAG 2,940-nm laser is 250 mcm, no coagulation, 5.5% density, and one pass. “If a second surgical debulk is performed on the same day as ablative laser treatment, the sites of shave removal are typically avoided with the laser,” she said. If a certain portion of the nose has recently healed following surgical debulk 4 weeks prior, they may perform only two passes in this region.
In an interview, Dr. Avram, who directs the MGH Dermatology Laser and Cosmetic Center, characterized the staged method as providing “transformative change to severe, cosmetically disfiguring rhinophyma. The ablative fractional laser provides more fine-tuned contouring.”
The three patients studied had an average of three to four monthly treatments. “There is typically a great deal of improvement by the second treatment,” Dr. Richey said. Add-on treatments may include low voltage electrodessication at 1.8 watts for patients with well-demarcated papules of sebaceous hyperplasia, and a vascular laser such as the pulsed dye laser if telangiectasias are present.
One limitation of the stepwise method, she said, is that the surgical debulk typically results in a scar, “but it’s rarely noticeable if carefully performed, likely due to fractionated ablative use during the scar remodeling period. It’s important to set expectations with your patient at the initial consult. We always discuss treatment goals and that while we aim achieve the most desirable outcome possible, we’re never going to get them back to having a completely normal nose. They’re always going to have some mild or moderate rhinophymatous changes present.”
Vincent Richer, MD, a Vancouver-based medical and cosmetic dermatologist who was asked to comment on these results, characterized the stepwise method as promising. “Though more treatments are required, the easier recovery, safe outcomes in the case presented and excellent cosmetic result made it an interesting alternative when fully ablative resurfacing is daunting, either for patients or physicians involved,” he said in an interview.
The researchers reported having no relevant disclosures. Dr. Richer disclosed that he performs clinical trials for AbbVie/Allergan, Galderma, Leo Pharma, Pfizer, and is a member of advisory board for Bausch, Celgene, Eli Lilly, Galderma, Janssen, Johnson & Johnson, Leo Pharma, L’Oréal, and Sanofi. He is also a consultant to AbbVie/Allergan, Bausch, Celgene, Eli Lilly, Galderma, Janssen, Johnson & Johnson, Leo Pharma, L’Oréal, Merz, and Sanofi.
DENVER –
Rhinophyma occurs primarily in the sixth and seventh decades of life and is marked by facial hypertrophy that leads to tumor-like growth, inflammation, fibrosis, and loss of the cosmetic nasal subunits. “When it becomes severe it leads to a degree of embarrassment as well,” one of the study authors, Patricia Richey, MD, said during an oral abstract session at the annual meeting of the American Society for Dermatologic Surgery. “We found that our method has been efficacious, but most often, and more importantly, leads to an improvement in the patient’s quality of life.”
To date, clinicians have used fully ablative lasers to treat varying degrees of rhinophyma but at a cost of prolonged healing time and higher rates of scarring and pigment or textural changes. However, not all dermatologists use full-field ablative lasers in their practices.
“Fractionated ablative lasers have been used in the past for mild to moderate rhinophyma, but they cannot ablate to 100% density, which would be necessary to debulk the marked hypertrophy present in our patients,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “That’s why we added a surgical component.”
She and colleague Mathew M. Avram, MD, JD, developed a three-step method for treating severe rhinophyma that they performed on three elderly patients. Step 1 is the surgical debulk. Following infiltration of local anesthesia, a razor blade or 15-blade is used to excise the most prominent lobules of hypertrophied sebaceous tissue down to the fibrofatty layer of the nose as a partial thickness excision that does not reach the level of the perichondrium or cartilage. “Hemostasis is achieved with electrocoagulation and application of petrolatum ointment, followed by a pressure dressing,” Dr. Richey said. “The location of the debulk varies by patient.”
Step 2 involves fractionated ablative laser treatment 4 weeks later with either the CO2 or erbium:YAG (Er:YAG) 2,940-nm laser. According to Dr. Richey, the typical setting for the fractionated CO2 is a fluence of 70mJ/cm2 and a high density, performing six out of four passes with 60 seconds between each pass, “though these settings may vary based on the patient presentation,” she said.
The treatment level ranges from 5 (14% density) to 10 (70% density, for the most severe cases). Meanwhile, a representative setting for the ablative fractionated Er:YAG 2,940-nm laser is 250 mcm, no coagulation, 5.5% density, and one pass. “If a second surgical debulk is performed on the same day as ablative laser treatment, the sites of shave removal are typically avoided with the laser,” she said. If a certain portion of the nose has recently healed following surgical debulk 4 weeks prior, they may perform only two passes in this region.
In an interview, Dr. Avram, who directs the MGH Dermatology Laser and Cosmetic Center, characterized the staged method as providing “transformative change to severe, cosmetically disfiguring rhinophyma. The ablative fractional laser provides more fine-tuned contouring.”
The three patients studied had an average of three to four monthly treatments. “There is typically a great deal of improvement by the second treatment,” Dr. Richey said. Add-on treatments may include low voltage electrodessication at 1.8 watts for patients with well-demarcated papules of sebaceous hyperplasia, and a vascular laser such as the pulsed dye laser if telangiectasias are present.
One limitation of the stepwise method, she said, is that the surgical debulk typically results in a scar, “but it’s rarely noticeable if carefully performed, likely due to fractionated ablative use during the scar remodeling period. It’s important to set expectations with your patient at the initial consult. We always discuss treatment goals and that while we aim achieve the most desirable outcome possible, we’re never going to get them back to having a completely normal nose. They’re always going to have some mild or moderate rhinophymatous changes present.”
Vincent Richer, MD, a Vancouver-based medical and cosmetic dermatologist who was asked to comment on these results, characterized the stepwise method as promising. “Though more treatments are required, the easier recovery, safe outcomes in the case presented and excellent cosmetic result made it an interesting alternative when fully ablative resurfacing is daunting, either for patients or physicians involved,” he said in an interview.
The researchers reported having no relevant disclosures. Dr. Richer disclosed that he performs clinical trials for AbbVie/Allergan, Galderma, Leo Pharma, Pfizer, and is a member of advisory board for Bausch, Celgene, Eli Lilly, Galderma, Janssen, Johnson & Johnson, Leo Pharma, L’Oréal, and Sanofi. He is also a consultant to AbbVie/Allergan, Bausch, Celgene, Eli Lilly, Galderma, Janssen, Johnson & Johnson, Leo Pharma, L’Oréal, Merz, and Sanofi.
DENVER –
Rhinophyma occurs primarily in the sixth and seventh decades of life and is marked by facial hypertrophy that leads to tumor-like growth, inflammation, fibrosis, and loss of the cosmetic nasal subunits. “When it becomes severe it leads to a degree of embarrassment as well,” one of the study authors, Patricia Richey, MD, said during an oral abstract session at the annual meeting of the American Society for Dermatologic Surgery. “We found that our method has been efficacious, but most often, and more importantly, leads to an improvement in the patient’s quality of life.”
To date, clinicians have used fully ablative lasers to treat varying degrees of rhinophyma but at a cost of prolonged healing time and higher rates of scarring and pigment or textural changes. However, not all dermatologists use full-field ablative lasers in their practices.
“Fractionated ablative lasers have been used in the past for mild to moderate rhinophyma, but they cannot ablate to 100% density, which would be necessary to debulk the marked hypertrophy present in our patients,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “That’s why we added a surgical component.”
She and colleague Mathew M. Avram, MD, JD, developed a three-step method for treating severe rhinophyma that they performed on three elderly patients. Step 1 is the surgical debulk. Following infiltration of local anesthesia, a razor blade or 15-blade is used to excise the most prominent lobules of hypertrophied sebaceous tissue down to the fibrofatty layer of the nose as a partial thickness excision that does not reach the level of the perichondrium or cartilage. “Hemostasis is achieved with electrocoagulation and application of petrolatum ointment, followed by a pressure dressing,” Dr. Richey said. “The location of the debulk varies by patient.”
Step 2 involves fractionated ablative laser treatment 4 weeks later with either the CO2 or erbium:YAG (Er:YAG) 2,940-nm laser. According to Dr. Richey, the typical setting for the fractionated CO2 is a fluence of 70mJ/cm2 and a high density, performing six out of four passes with 60 seconds between each pass, “though these settings may vary based on the patient presentation,” she said.
The treatment level ranges from 5 (14% density) to 10 (70% density, for the most severe cases). Meanwhile, a representative setting for the ablative fractionated Er:YAG 2,940-nm laser is 250 mcm, no coagulation, 5.5% density, and one pass. “If a second surgical debulk is performed on the same day as ablative laser treatment, the sites of shave removal are typically avoided with the laser,” she said. If a certain portion of the nose has recently healed following surgical debulk 4 weeks prior, they may perform only two passes in this region.
In an interview, Dr. Avram, who directs the MGH Dermatology Laser and Cosmetic Center, characterized the staged method as providing “transformative change to severe, cosmetically disfiguring rhinophyma. The ablative fractional laser provides more fine-tuned contouring.”
The three patients studied had an average of three to four monthly treatments. “There is typically a great deal of improvement by the second treatment,” Dr. Richey said. Add-on treatments may include low voltage electrodessication at 1.8 watts for patients with well-demarcated papules of sebaceous hyperplasia, and a vascular laser such as the pulsed dye laser if telangiectasias are present.
One limitation of the stepwise method, she said, is that the surgical debulk typically results in a scar, “but it’s rarely noticeable if carefully performed, likely due to fractionated ablative use during the scar remodeling period. It’s important to set expectations with your patient at the initial consult. We always discuss treatment goals and that while we aim achieve the most desirable outcome possible, we’re never going to get them back to having a completely normal nose. They’re always going to have some mild or moderate rhinophymatous changes present.”
Vincent Richer, MD, a Vancouver-based medical and cosmetic dermatologist who was asked to comment on these results, characterized the stepwise method as promising. “Though more treatments are required, the easier recovery, safe outcomes in the case presented and excellent cosmetic result made it an interesting alternative when fully ablative resurfacing is daunting, either for patients or physicians involved,” he said in an interview.
The researchers reported having no relevant disclosures. Dr. Richer disclosed that he performs clinical trials for AbbVie/Allergan, Galderma, Leo Pharma, Pfizer, and is a member of advisory board for Bausch, Celgene, Eli Lilly, Galderma, Janssen, Johnson & Johnson, Leo Pharma, L’Oréal, and Sanofi. He is also a consultant to AbbVie/Allergan, Bausch, Celgene, Eli Lilly, Galderma, Janssen, Johnson & Johnson, Leo Pharma, L’Oréal, Merz, and Sanofi.
AT ASDS 2022
Pediatric faculty salaries have substantial racial, ethnic, gender disparities
ANAHEIM, CALIF. – Black and Hispanic pediatric faculty earn less than their White counterparts regardless of rank and degree, according to a study presented at the American Academy of Pediatrics National Conference.
“Our results demonstrated broad disparities in compensation by both gender and race/ethnicity,” Kimberly Montez, MD, MPH, of the department of pediatrics at Wake Forest University, Winston-Salem, N.C., told attendees.
Arghavan Salles, MD, PhD, of Stanford (Calif.) University and a senior research scholar at the Clayman Institute for Gender Research, also in Stanford, was not involved in this study but conducts similar research and was unsurprised by these findings.
“It may surprise some people that these gender-based disparities persist in pediatrics, given it is a female-dominated specialty,” Dr. Salles said in an interview. “However, we see the same pattern in other female-dominated medical fields, such as obstetrics and gynecology and nursing.”
Dr. Montez, also the associate director of Wake Forest’s Maya Angelou Center for Health Equity and the associate editor for Diversity, Equity, Inclusion and Justice at the journal Pediatrics, told attendees that it’s important for academic medical centers to “identify, acknowledge, and address inequities in compensation models, including conducting transparent salary audits, standardizing new hire compensation benchmarks, and automatic review of salary outliers.”
Among the barriers to advancement that exist in academic medicine for individuals underrepresented in medicine are “racism, bias, discrimination, lack of mentorship, and the minority tax – extra responsibilities placed on individuals in the name of diversity,” Dr. Montez said. She drew attention to an article she coauthored in Pediatrics in August that highlighted how historically underrepresented individuals’ representation declined as rank increased and how the diversity of faculty pediatricians does not reflect that of the U.S. population.
Dr. Salles elaborated on the “minority tax” Dr. Montez referenced.
Faculty who are underrepresented in medicine “unfairly bear the majority of the responsibility to mentor [underrepresented] trainees and are more likely to be asked to serve in diversity, equity, and inclusion roles,” Dr. Salles said. “This work is too often uncompensated and undervalued, thereby affecting compensation.” This work also plays a role in gender salary disparities since women, especially women of color, are more likely to take on these roles, Dr. Salles added.
In this study, Dr. Montez and her colleagues aimed to investigate the differences in pediatric faculty salaries by race, ethnicity, and rank and then assess the association of median salary with race/ethnicity after adjustment for degree, rank, and gender. They conducted a cross-sectional study relying on 2020-2021 pediatric faculty median compensation data from the Association of American Medical Colleges annual Medical School Faculty Salary Survey report. The report had a response rate greater than 98% from the 152 medical schools queried.
For both the AAMC report and this study, individuals underrepresented in medicine included those who are African American/Black, Hispanic, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander.
The survey included data on 26,548 pediatric faculty, 58% of whom were women, with a median salary of $216,289. Two-thirds of these faculty (67.2%) were White, 4.5% were Hispanic, and 4.4% were Black. Half (50%) were assistant professors, 25% were associate professors, and 17% were professors.
”Women were overly represented among instructors and assistant professors, while men were overly represented [among] associate professors, professors, chiefs, and chairs,” the authors reported. “Men consistently had higher median salaries among all ranks and races/ethnicities.”
For positions of associate professor, professor, chief, and chair, representation of those underrepresented in medicine decreased compared with their overall percentage, but the trend was the opposite for White faculty, who were overrepresented in higher positions relative to their overall percentage. Those with the lowest median salary across all ranks and races/ethnicities were Hispanic women.
Median salaries for those underrepresented in medicine were lower than salaries of White faculty even after adjustment for degree. Black, Hispanic, and American Indian or Alaska Native faculty also had lower median salaries than White faculty after adjusting for rank, but Asian faculty and those who self-identified as “other” race/ethnicity had slightly higher median salaries than White faculty.
Though the findings were not surprising overall, Dr. Montez did note a couple unexpected findings: Hispanic women earn the least across all ranks and Black men earn the most at the associate and professor levels – though Black men also represent a very tiny percentage of individuals at those ranks in the first place.
Dr. Salles noted that the gender wage gap appears widest for Hispanic physicians, compared with White or Black physicians. “It’s important to keep in mind, though, that due to structural racism, implicit bias, and many other factors, there are very few Black and Hispanic full professors of medicine,” Dr. Salles said.
“Gender bias, sexism, and misogyny” are among the many factors that contribute to the gender pay gap,” Dr. Salles said, and ”the work of women is not valued in the same way as the work of men.”
She pointed to past research showing that CVs with male names at the top are judged as better than those with female names at the top.
”Similarly, it will be judged as being better if the name is Emily or Greg rather than Lakisha or Jamal,” Dr. Salles said. “These findings suggest we evaluate people’s work through the lens of who we think they are and we automatically judge women and other marginalized people to be less worthy.”
Dr. Montez agreed that discrimination is the most likely reason for the salary disparities between men and women and also noted additional factors.
“Women are more likely to shoulder the household and childcare responsibilities as compared to men and they may accept a lower salary for other benefits, such as flexible work hours [and] onsite childcare,” Dr. Montez said. In addition, she said, since most chairs in academic pediatrics are men, new women faculty may not feel able to negotiate higher salaries, or may feel different pressures than men.
Dr. Salles emphasized the importance of not blaming women for not negotiating enough since “women pay a social penalty when they do negotiate.” This problem is likely compounded for women of color, she added. “Offering equitable packages to begin with, rather than requiring applicants to negotiate, would be more equitable.”
Because the AAMC report data was disaggregated, it’s not possible to identify trends by institution, Dr. Montez said, but the August article specifically recommends “that future data be institution specific, and provide race, ethnicity, sex, and rank information, including hiring and promotion details,” including salary information.
In fact, a publicly available, institution-specific equity dashboard would be a “minimum starting point” for tracking and addressing disparities as well as the effect of any interventions, Dr. Montez said. She noted other potential policies that could ameliorate disparities.
“Given that caregiving responsibilities for women often lead to fewer hours worked, work interruptions, and less opportunity for advancement, restructuring jobs with more flexible work schedules without pay reduction and not limiting advancement based on part-time status could be considered,” Dr. Montez said. ”For promotion, given that individuals [underrepresented in medicine] often shoulder the minority tax, institutions should develop promotion criteria to account for this academic credit. Institutions could also implement an annual salary-monitoring system with corrections, should it reveal disparities.”
Dr. Salles consults for Intuitive Surgical and the Intuitive Foundation, but neither of these are related to diversity, equity, and inclusion. Dr. Montez had no disclosures. The study involved no external funding.
ANAHEIM, CALIF. – Black and Hispanic pediatric faculty earn less than their White counterparts regardless of rank and degree, according to a study presented at the American Academy of Pediatrics National Conference.
“Our results demonstrated broad disparities in compensation by both gender and race/ethnicity,” Kimberly Montez, MD, MPH, of the department of pediatrics at Wake Forest University, Winston-Salem, N.C., told attendees.
Arghavan Salles, MD, PhD, of Stanford (Calif.) University and a senior research scholar at the Clayman Institute for Gender Research, also in Stanford, was not involved in this study but conducts similar research and was unsurprised by these findings.
“It may surprise some people that these gender-based disparities persist in pediatrics, given it is a female-dominated specialty,” Dr. Salles said in an interview. “However, we see the same pattern in other female-dominated medical fields, such as obstetrics and gynecology and nursing.”
Dr. Montez, also the associate director of Wake Forest’s Maya Angelou Center for Health Equity and the associate editor for Diversity, Equity, Inclusion and Justice at the journal Pediatrics, told attendees that it’s important for academic medical centers to “identify, acknowledge, and address inequities in compensation models, including conducting transparent salary audits, standardizing new hire compensation benchmarks, and automatic review of salary outliers.”
Among the barriers to advancement that exist in academic medicine for individuals underrepresented in medicine are “racism, bias, discrimination, lack of mentorship, and the minority tax – extra responsibilities placed on individuals in the name of diversity,” Dr. Montez said. She drew attention to an article she coauthored in Pediatrics in August that highlighted how historically underrepresented individuals’ representation declined as rank increased and how the diversity of faculty pediatricians does not reflect that of the U.S. population.
Dr. Salles elaborated on the “minority tax” Dr. Montez referenced.
Faculty who are underrepresented in medicine “unfairly bear the majority of the responsibility to mentor [underrepresented] trainees and are more likely to be asked to serve in diversity, equity, and inclusion roles,” Dr. Salles said. “This work is too often uncompensated and undervalued, thereby affecting compensation.” This work also plays a role in gender salary disparities since women, especially women of color, are more likely to take on these roles, Dr. Salles added.
In this study, Dr. Montez and her colleagues aimed to investigate the differences in pediatric faculty salaries by race, ethnicity, and rank and then assess the association of median salary with race/ethnicity after adjustment for degree, rank, and gender. They conducted a cross-sectional study relying on 2020-2021 pediatric faculty median compensation data from the Association of American Medical Colleges annual Medical School Faculty Salary Survey report. The report had a response rate greater than 98% from the 152 medical schools queried.
For both the AAMC report and this study, individuals underrepresented in medicine included those who are African American/Black, Hispanic, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander.
The survey included data on 26,548 pediatric faculty, 58% of whom were women, with a median salary of $216,289. Two-thirds of these faculty (67.2%) were White, 4.5% were Hispanic, and 4.4% were Black. Half (50%) were assistant professors, 25% were associate professors, and 17% were professors.
”Women were overly represented among instructors and assistant professors, while men were overly represented [among] associate professors, professors, chiefs, and chairs,” the authors reported. “Men consistently had higher median salaries among all ranks and races/ethnicities.”
For positions of associate professor, professor, chief, and chair, representation of those underrepresented in medicine decreased compared with their overall percentage, but the trend was the opposite for White faculty, who were overrepresented in higher positions relative to their overall percentage. Those with the lowest median salary across all ranks and races/ethnicities were Hispanic women.
Median salaries for those underrepresented in medicine were lower than salaries of White faculty even after adjustment for degree. Black, Hispanic, and American Indian or Alaska Native faculty also had lower median salaries than White faculty after adjusting for rank, but Asian faculty and those who self-identified as “other” race/ethnicity had slightly higher median salaries than White faculty.
Though the findings were not surprising overall, Dr. Montez did note a couple unexpected findings: Hispanic women earn the least across all ranks and Black men earn the most at the associate and professor levels – though Black men also represent a very tiny percentage of individuals at those ranks in the first place.
Dr. Salles noted that the gender wage gap appears widest for Hispanic physicians, compared with White or Black physicians. “It’s important to keep in mind, though, that due to structural racism, implicit bias, and many other factors, there are very few Black and Hispanic full professors of medicine,” Dr. Salles said.
“Gender bias, sexism, and misogyny” are among the many factors that contribute to the gender pay gap,” Dr. Salles said, and ”the work of women is not valued in the same way as the work of men.”
She pointed to past research showing that CVs with male names at the top are judged as better than those with female names at the top.
”Similarly, it will be judged as being better if the name is Emily or Greg rather than Lakisha or Jamal,” Dr. Salles said. “These findings suggest we evaluate people’s work through the lens of who we think they are and we automatically judge women and other marginalized people to be less worthy.”
Dr. Montez agreed that discrimination is the most likely reason for the salary disparities between men and women and also noted additional factors.
“Women are more likely to shoulder the household and childcare responsibilities as compared to men and they may accept a lower salary for other benefits, such as flexible work hours [and] onsite childcare,” Dr. Montez said. In addition, she said, since most chairs in academic pediatrics are men, new women faculty may not feel able to negotiate higher salaries, or may feel different pressures than men.
Dr. Salles emphasized the importance of not blaming women for not negotiating enough since “women pay a social penalty when they do negotiate.” This problem is likely compounded for women of color, she added. “Offering equitable packages to begin with, rather than requiring applicants to negotiate, would be more equitable.”
Because the AAMC report data was disaggregated, it’s not possible to identify trends by institution, Dr. Montez said, but the August article specifically recommends “that future data be institution specific, and provide race, ethnicity, sex, and rank information, including hiring and promotion details,” including salary information.
In fact, a publicly available, institution-specific equity dashboard would be a “minimum starting point” for tracking and addressing disparities as well as the effect of any interventions, Dr. Montez said. She noted other potential policies that could ameliorate disparities.
“Given that caregiving responsibilities for women often lead to fewer hours worked, work interruptions, and less opportunity for advancement, restructuring jobs with more flexible work schedules without pay reduction and not limiting advancement based on part-time status could be considered,” Dr. Montez said. ”For promotion, given that individuals [underrepresented in medicine] often shoulder the minority tax, institutions should develop promotion criteria to account for this academic credit. Institutions could also implement an annual salary-monitoring system with corrections, should it reveal disparities.”
Dr. Salles consults for Intuitive Surgical and the Intuitive Foundation, but neither of these are related to diversity, equity, and inclusion. Dr. Montez had no disclosures. The study involved no external funding.
ANAHEIM, CALIF. – Black and Hispanic pediatric faculty earn less than their White counterparts regardless of rank and degree, according to a study presented at the American Academy of Pediatrics National Conference.
“Our results demonstrated broad disparities in compensation by both gender and race/ethnicity,” Kimberly Montez, MD, MPH, of the department of pediatrics at Wake Forest University, Winston-Salem, N.C., told attendees.
Arghavan Salles, MD, PhD, of Stanford (Calif.) University and a senior research scholar at the Clayman Institute for Gender Research, also in Stanford, was not involved in this study but conducts similar research and was unsurprised by these findings.
“It may surprise some people that these gender-based disparities persist in pediatrics, given it is a female-dominated specialty,” Dr. Salles said in an interview. “However, we see the same pattern in other female-dominated medical fields, such as obstetrics and gynecology and nursing.”
Dr. Montez, also the associate director of Wake Forest’s Maya Angelou Center for Health Equity and the associate editor for Diversity, Equity, Inclusion and Justice at the journal Pediatrics, told attendees that it’s important for academic medical centers to “identify, acknowledge, and address inequities in compensation models, including conducting transparent salary audits, standardizing new hire compensation benchmarks, and automatic review of salary outliers.”
Among the barriers to advancement that exist in academic medicine for individuals underrepresented in medicine are “racism, bias, discrimination, lack of mentorship, and the minority tax – extra responsibilities placed on individuals in the name of diversity,” Dr. Montez said. She drew attention to an article she coauthored in Pediatrics in August that highlighted how historically underrepresented individuals’ representation declined as rank increased and how the diversity of faculty pediatricians does not reflect that of the U.S. population.
Dr. Salles elaborated on the “minority tax” Dr. Montez referenced.
Faculty who are underrepresented in medicine “unfairly bear the majority of the responsibility to mentor [underrepresented] trainees and are more likely to be asked to serve in diversity, equity, and inclusion roles,” Dr. Salles said. “This work is too often uncompensated and undervalued, thereby affecting compensation.” This work also plays a role in gender salary disparities since women, especially women of color, are more likely to take on these roles, Dr. Salles added.
In this study, Dr. Montez and her colleagues aimed to investigate the differences in pediatric faculty salaries by race, ethnicity, and rank and then assess the association of median salary with race/ethnicity after adjustment for degree, rank, and gender. They conducted a cross-sectional study relying on 2020-2021 pediatric faculty median compensation data from the Association of American Medical Colleges annual Medical School Faculty Salary Survey report. The report had a response rate greater than 98% from the 152 medical schools queried.
For both the AAMC report and this study, individuals underrepresented in medicine included those who are African American/Black, Hispanic, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander.
The survey included data on 26,548 pediatric faculty, 58% of whom were women, with a median salary of $216,289. Two-thirds of these faculty (67.2%) were White, 4.5% were Hispanic, and 4.4% were Black. Half (50%) were assistant professors, 25% were associate professors, and 17% were professors.
”Women were overly represented among instructors and assistant professors, while men were overly represented [among] associate professors, professors, chiefs, and chairs,” the authors reported. “Men consistently had higher median salaries among all ranks and races/ethnicities.”
For positions of associate professor, professor, chief, and chair, representation of those underrepresented in medicine decreased compared with their overall percentage, but the trend was the opposite for White faculty, who were overrepresented in higher positions relative to their overall percentage. Those with the lowest median salary across all ranks and races/ethnicities were Hispanic women.
Median salaries for those underrepresented in medicine were lower than salaries of White faculty even after adjustment for degree. Black, Hispanic, and American Indian or Alaska Native faculty also had lower median salaries than White faculty after adjusting for rank, but Asian faculty and those who self-identified as “other” race/ethnicity had slightly higher median salaries than White faculty.
Though the findings were not surprising overall, Dr. Montez did note a couple unexpected findings: Hispanic women earn the least across all ranks and Black men earn the most at the associate and professor levels – though Black men also represent a very tiny percentage of individuals at those ranks in the first place.
Dr. Salles noted that the gender wage gap appears widest for Hispanic physicians, compared with White or Black physicians. “It’s important to keep in mind, though, that due to structural racism, implicit bias, and many other factors, there are very few Black and Hispanic full professors of medicine,” Dr. Salles said.
“Gender bias, sexism, and misogyny” are among the many factors that contribute to the gender pay gap,” Dr. Salles said, and ”the work of women is not valued in the same way as the work of men.”
She pointed to past research showing that CVs with male names at the top are judged as better than those with female names at the top.
”Similarly, it will be judged as being better if the name is Emily or Greg rather than Lakisha or Jamal,” Dr. Salles said. “These findings suggest we evaluate people’s work through the lens of who we think they are and we automatically judge women and other marginalized people to be less worthy.”
Dr. Montez agreed that discrimination is the most likely reason for the salary disparities between men and women and also noted additional factors.
“Women are more likely to shoulder the household and childcare responsibilities as compared to men and they may accept a lower salary for other benefits, such as flexible work hours [and] onsite childcare,” Dr. Montez said. In addition, she said, since most chairs in academic pediatrics are men, new women faculty may not feel able to negotiate higher salaries, or may feel different pressures than men.
Dr. Salles emphasized the importance of not blaming women for not negotiating enough since “women pay a social penalty when they do negotiate.” This problem is likely compounded for women of color, she added. “Offering equitable packages to begin with, rather than requiring applicants to negotiate, would be more equitable.”
Because the AAMC report data was disaggregated, it’s not possible to identify trends by institution, Dr. Montez said, but the August article specifically recommends “that future data be institution specific, and provide race, ethnicity, sex, and rank information, including hiring and promotion details,” including salary information.
In fact, a publicly available, institution-specific equity dashboard would be a “minimum starting point” for tracking and addressing disparities as well as the effect of any interventions, Dr. Montez said. She noted other potential policies that could ameliorate disparities.
“Given that caregiving responsibilities for women often lead to fewer hours worked, work interruptions, and less opportunity for advancement, restructuring jobs with more flexible work schedules without pay reduction and not limiting advancement based on part-time status could be considered,” Dr. Montez said. ”For promotion, given that individuals [underrepresented in medicine] often shoulder the minority tax, institutions should develop promotion criteria to account for this academic credit. Institutions could also implement an annual salary-monitoring system with corrections, should it reveal disparities.”
Dr. Salles consults for Intuitive Surgical and the Intuitive Foundation, but neither of these are related to diversity, equity, and inclusion. Dr. Montez had no disclosures. The study involved no external funding.
AT AAP 2022
