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Antibiotic choice for acute otitis media 2018
It’s a new year and a new respiratory season so my thoughts turn to the most common infection in pediatrics where an antibiotic might appropriately be prescribed – acute otitis media (AOM). The guidelines of the American Academy of Pediatrics were finalized in 2012 and published in 2013 and based on data that the AAP subcommittee considered. A recommendation emerged for amoxicillin to remain the treatment of choice if an antibiotic was to be prescribed at all, leaving the observation option as a continued consideration under defined clinical circumstances. The oral alternative antibiotics recommended were amoxicillin/clavulanate and cefdinir (Pediatrics. 2013. doi: 10.1542/peds.2012-3488).
Since the AAP subcommittee deliberated, changes have occurred in AOM etiology and the frequency of antibiotic resistance among the common bacteria that cause the infection. Our group in Rochester (N.Y.) continues to be the only site in the United States conducting a prospective assessment of AOM; we hope our data are generalizable to the entire country, but that is not certain. In Rochester, we saw an overall drop in AOM incidence after introduction of Prevnar 7 of about 10%-15% overall and that corresponded reasonably well with the frequency of AOM caused by Streptococcus pneumoniae involving the seven serotypes in the PCV7 vaccine. We then had a rebound in AOM infections, largely caused by serotype 19A, such that the overall incidence of AOM returned back to levels nearly the same as before PCV7 by 2010. With the introduction of Prevnar 13, and the dramatic reduction of serotype 19A nasal colonization – a necessary precursor of AOM – the incidence of AOM overall fell again, and compared with the pre-PCV7 era, I estimate that we are seeing about 20%-25% less AOM today.
In late 2017, we published an article describing the epidemiology of AOM in the PCV era (Pediatrics. 2017 Aug. doi: 10.1542/peds.2017-0181), in which we described changes in otopathogen distribution over time from 1996 through 2016. It showed that by end of 2016, the predominant bacteria causing AOM were Haemophilus influenzae, accounting for 60% of all AOM (52% detected by culture from tympanocentesis and another 8% detected by polymerase chain reaction). Among the H. influenzae from middle ear fluid, beta-lactamase production occurred in 45%. Therefore, according to principles of infectious disease antibiotic efficacy predictions, use of amoxicillin in standard dose or high dose would not eradicate about half of the H. influenzae causing AOM. In the table included in this column, I show calculations of predicted outcomes from amoxicillin, amoxicillin/clavulanate, and cefdinir treatment based on the projected otopathogen mix and resistance frequencies of 2016. Added to the data on H. influenzae I have included results of S. pneumoniae high nonsusceptibility at 5% of strains and beta-lactamase production by Moraxella catarrhalis at 100% of strains. 
Strictly based on in vitro susceptibility and the known otopathogen mix, the calculations show that amoxicillin could result in a maximum cure of 57%, amoxicillin/clavulanate of 99%, and cefdinir of 80% of treated children.
In vitro susceptibility has its limitations. Pharmacodynamic calculations would drop the predicted success of all three antibiotics because suboptimal absorption after oral dosing occurs with amoxicillin and amoxicillin/clavulanate more so than with cefdinir, thereby resulting in lower than predicted levels of antibiotic at the site of infection within the middle ear, whereas the achievable level of cefdinir with recommended dosing sometimes is below the desired in vitro cut point.
To balance that lowered predicted efficacy, each of the otopathogens has an associated “spontaneous cure rate” that is often quoted as being 20% for S. pneumoniae, 50% for H. influenzae, and 80% for M. catarrhalis. However, to be clear, those rates were derived largely from assessments about 5 days after antibiotic treatment was started with ineffective drugs or with placebos and do not account for the true spontaneous clinical cure rate of AOM if assessed in the first few days after onset (when pain and fever are at their peak) nor if assessed 14-30 days later when almost all children have been cured by their immune systems.
The calculations also do not account for overdiagnosis in clinical practice. Indeed, if the child does not have AOM, then the child will have a cure regardless of which antibiotic is selected. Rates of overdiagnosis of AOM have been assessed with various methods and are subject to limitations. But overall the data and most experts agree that overdiagnosis by pediatricians, family physicians, urgent care physicians, nurse practitioners, and physician assistants is in the range of 30%-50%.
Before the reader leaps to the conclusion that I am endorsing any particular antibiotic strictly based on predicted in vitro efficacy, I would state that many considerations must be given to whether to use an antibiotic for AOM, and which antibiotic to use, at what dose, and for what duration. This column is just pointing out a few key up-to-date facts for your consideration.
It’s a new year and a new respiratory season so my thoughts turn to the most common infection in pediatrics where an antibiotic might appropriately be prescribed – acute otitis media (AOM). The guidelines of the American Academy of Pediatrics were finalized in 2012 and published in 2013 and based on data that the AAP subcommittee considered. A recommendation emerged for amoxicillin to remain the treatment of choice if an antibiotic was to be prescribed at all, leaving the observation option as a continued consideration under defined clinical circumstances. The oral alternative antibiotics recommended were amoxicillin/clavulanate and cefdinir (Pediatrics. 2013. doi: 10.1542/peds.2012-3488).
Since the AAP subcommittee deliberated, changes have occurred in AOM etiology and the frequency of antibiotic resistance among the common bacteria that cause the infection. Our group in Rochester (N.Y.) continues to be the only site in the United States conducting a prospective assessment of AOM; we hope our data are generalizable to the entire country, but that is not certain. In Rochester, we saw an overall drop in AOM incidence after introduction of Prevnar 7 of about 10%-15% overall and that corresponded reasonably well with the frequency of AOM caused by Streptococcus pneumoniae involving the seven serotypes in the PCV7 vaccine. We then had a rebound in AOM infections, largely caused by serotype 19A, such that the overall incidence of AOM returned back to levels nearly the same as before PCV7 by 2010. With the introduction of Prevnar 13, and the dramatic reduction of serotype 19A nasal colonization – a necessary precursor of AOM – the incidence of AOM overall fell again, and compared with the pre-PCV7 era, I estimate that we are seeing about 20%-25% less AOM today.
In late 2017, we published an article describing the epidemiology of AOM in the PCV era (Pediatrics. 2017 Aug. doi: 10.1542/peds.2017-0181), in which we described changes in otopathogen distribution over time from 1996 through 2016. It showed that by end of 2016, the predominant bacteria causing AOM were Haemophilus influenzae, accounting for 60% of all AOM (52% detected by culture from tympanocentesis and another 8% detected by polymerase chain reaction). Among the H. influenzae from middle ear fluid, beta-lactamase production occurred in 45%. Therefore, according to principles of infectious disease antibiotic efficacy predictions, use of amoxicillin in standard dose or high dose would not eradicate about half of the H. influenzae causing AOM. In the table included in this column, I show calculations of predicted outcomes from amoxicillin, amoxicillin/clavulanate, and cefdinir treatment based on the projected otopathogen mix and resistance frequencies of 2016. Added to the data on H. influenzae I have included results of S. pneumoniae high nonsusceptibility at 5% of strains and beta-lactamase production by Moraxella catarrhalis at 100% of strains.
Strictly based on in vitro susceptibility and the known otopathogen mix, the calculations show that amoxicillin could result in a maximum cure of 57%, amoxicillin/clavulanate of 99%, and cefdinir of 80% of treated children.
In vitro susceptibility has its limitations. Pharmacodynamic calculations would drop the predicted success of all three antibiotics because suboptimal absorption after oral dosing occurs with amoxicillin and amoxicillin/clavulanate more so than with cefdinir, thereby resulting in lower than predicted levels of antibiotic at the site of infection within the middle ear, whereas the achievable level of cefdinir with recommended dosing sometimes is below the desired in vitro cut point.
To balance that lowered predicted efficacy, each of the otopathogens has an associated “spontaneous cure rate” that is often quoted as being 20% for S. pneumoniae, 50% for H. influenzae, and 80% for M. catarrhalis. However, to be clear, those rates were derived largely from assessments about 5 days after antibiotic treatment was started with ineffective drugs or with placebos and do not account for the true spontaneous clinical cure rate of AOM if assessed in the first few days after onset (when pain and fever are at their peak) nor if assessed 14-30 days later when almost all children have been cured by their immune systems.
The calculations also do not account for overdiagnosis in clinical practice. Indeed, if the child does not have AOM, then the child will have a cure regardless of which antibiotic is selected. Rates of overdiagnosis of AOM have been assessed with various methods and are subject to limitations. But overall the data and most experts agree that overdiagnosis by pediatricians, family physicians, urgent care physicians, nurse practitioners, and physician assistants is in the range of 30%-50%.
Before the reader leaps to the conclusion that I am endorsing any particular antibiotic strictly based on predicted in vitro efficacy, I would state that many considerations must be given to whether to use an antibiotic for AOM, and which antibiotic to use, at what dose, and for what duration. This column is just pointing out a few key up-to-date facts for your consideration.
It’s a new year and a new respiratory season so my thoughts turn to the most common infection in pediatrics where an antibiotic might appropriately be prescribed – acute otitis media (AOM). The guidelines of the American Academy of Pediatrics were finalized in 2012 and published in 2013 and based on data that the AAP subcommittee considered. A recommendation emerged for amoxicillin to remain the treatment of choice if an antibiotic was to be prescribed at all, leaving the observation option as a continued consideration under defined clinical circumstances. The oral alternative antibiotics recommended were amoxicillin/clavulanate and cefdinir (Pediatrics. 2013. doi: 10.1542/peds.2012-3488).
Since the AAP subcommittee deliberated, changes have occurred in AOM etiology and the frequency of antibiotic resistance among the common bacteria that cause the infection. Our group in Rochester (N.Y.) continues to be the only site in the United States conducting a prospective assessment of AOM; we hope our data are generalizable to the entire country, but that is not certain. In Rochester, we saw an overall drop in AOM incidence after introduction of Prevnar 7 of about 10%-15% overall and that corresponded reasonably well with the frequency of AOM caused by Streptococcus pneumoniae involving the seven serotypes in the PCV7 vaccine. We then had a rebound in AOM infections, largely caused by serotype 19A, such that the overall incidence of AOM returned back to levels nearly the same as before PCV7 by 2010. With the introduction of Prevnar 13, and the dramatic reduction of serotype 19A nasal colonization – a necessary precursor of AOM – the incidence of AOM overall fell again, and compared with the pre-PCV7 era, I estimate that we are seeing about 20%-25% less AOM today.
In late 2017, we published an article describing the epidemiology of AOM in the PCV era (Pediatrics. 2017 Aug. doi: 10.1542/peds.2017-0181), in which we described changes in otopathogen distribution over time from 1996 through 2016. It showed that by end of 2016, the predominant bacteria causing AOM were Haemophilus influenzae, accounting for 60% of all AOM (52% detected by culture from tympanocentesis and another 8% detected by polymerase chain reaction). Among the H. influenzae from middle ear fluid, beta-lactamase production occurred in 45%. Therefore, according to principles of infectious disease antibiotic efficacy predictions, use of amoxicillin in standard dose or high dose would not eradicate about half of the H. influenzae causing AOM. In the table included in this column, I show calculations of predicted outcomes from amoxicillin, amoxicillin/clavulanate, and cefdinir treatment based on the projected otopathogen mix and resistance frequencies of 2016. Added to the data on H. influenzae I have included results of S. pneumoniae high nonsusceptibility at 5% of strains and beta-lactamase production by Moraxella catarrhalis at 100% of strains.
Strictly based on in vitro susceptibility and the known otopathogen mix, the calculations show that amoxicillin could result in a maximum cure of 57%, amoxicillin/clavulanate of 99%, and cefdinir of 80% of treated children.
In vitro susceptibility has its limitations. Pharmacodynamic calculations would drop the predicted success of all three antibiotics because suboptimal absorption after oral dosing occurs with amoxicillin and amoxicillin/clavulanate more so than with cefdinir, thereby resulting in lower than predicted levels of antibiotic at the site of infection within the middle ear, whereas the achievable level of cefdinir with recommended dosing sometimes is below the desired in vitro cut point.
To balance that lowered predicted efficacy, each of the otopathogens has an associated “spontaneous cure rate” that is often quoted as being 20% for S. pneumoniae, 50% for H. influenzae, and 80% for M. catarrhalis. However, to be clear, those rates were derived largely from assessments about 5 days after antibiotic treatment was started with ineffective drugs or with placebos and do not account for the true spontaneous clinical cure rate of AOM if assessed in the first few days after onset (when pain and fever are at their peak) nor if assessed 14-30 days later when almost all children have been cured by their immune systems.
The calculations also do not account for overdiagnosis in clinical practice. Indeed, if the child does not have AOM, then the child will have a cure regardless of which antibiotic is selected. Rates of overdiagnosis of AOM have been assessed with various methods and are subject to limitations. But overall the data and most experts agree that overdiagnosis by pediatricians, family physicians, urgent care physicians, nurse practitioners, and physician assistants is in the range of 30%-50%.
Before the reader leaps to the conclusion that I am endorsing any particular antibiotic strictly based on predicted in vitro efficacy, I would state that many considerations must be given to whether to use an antibiotic for AOM, and which antibiotic to use, at what dose, and for what duration. This column is just pointing out a few key up-to-date facts for your consideration.
EHR application doubles hypertension recognition rate
Hypertension discovery in pediatric patients more than doubled for physicians using a clinical decision support (CDS) tool connected to the EHR, results of a study found.
Elyse O. Kharbanda, MD, MPH, a researcher at the HealthPartners Institute, Minneapolis, and her fellow investigators assert that using such a tool will help rectify the trend of underreported hypertension in adolescents, which remains a serious concern despite providers’ routinely taking blood pressure measurements during outpatient visits.
“Among patients with multiple visits, electronic health records should contain sufficient information to diagnose hypertension,” Dr. Kharbanda and her associates reported in their article published in Pediatrics. “However, even when EHRs are configured to display BP percentiles, information on the patterns of BP percentiles over time, previous diagnoses, and medications is not presented in a format that is useful for clinicians.”
With TeenBP, providers are first prompted to take an initial BP reading, as well as height and weight measurements.
If the first measure is above the 95th percentile, the CDS requests an additional reading, which is then averaged with the first. If average of the two is above or within the 95th percentile, the provider is notified and sent a list of recommendations, including a diagnosis of hypertension, lipid screening, and nutrition referral.
The 2-year trial included 522 pediatric patients with incident hypertension; the data were gathered from 20 primary care clinics within one health system between April 2014 and April 2016.
The rate of clinical recognition of patients’ hypertension in the clinics utilizing the CDS tool was more than double the rate seen in the clinics that weren’t (55% and 21%, respectively; P less than .001).
More of the children seen in CDS clinics were referred to dietitians or weight loss programs, compared with those seen in the control clinics (17% and 4%, respectively; P = .001).
Those who used the tool reported high levels of satisfaction, which is likely partly because investigators consulted physicians to help design the application.
“The CDS tool was based on the guidelines for BP management in children and adolescents in effect at the time of the study with local input from clinical and operational leaders within the medical group, and thus it contained the so-called right information,” according to Dr. Kharbanda and her fellow investigators.
Of the 55 physicians who remembered using the tool, 92% thought is was useful in identifying hypertension, 94% considered the CDS a good use of time, and 95% believed is was a useful shared-decision making tool.
When designing TeenBP, investigators tailored the application to the work flow and culture of the health system used for the study, which may limit the generalizability of the findings.
The study was funded by the National Institutes of Health. Dr. Kharbanda and her associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
The rate of children and adolescents with elevated blood pressure going unrecognized is an increasingly concerning issue – one that is complicated because physicians lack a simple, single BP value system. Some have tried to fill the gap, creating simplified tables of BP values or automated displays of BP values in EHRs, but having a table that only takes age and sex into consideration for screening does not cover the complexities needed to identify hypertension.
Previous studies have looked into utilizing a clinical decision support (CDS) application, which has great potential as a digital multitool to improve quality of care, increase efficiency, and reduce medical errors. However, to be an effective CDS, it must fill the “CDS Five Rights” framework. This guideline states that a CDS tool needs to provide: “the right information, to the right people, through the right channels, in the right intervention formats, at the right points in the work flow.”
The TeenBP CDS developed by Kharbanda et al. fulfills these requirements and goes beyond any CDS previously designed. Even so, 45% of children with elevated BP or hypertension were not recognized, emphasizing the need for additional strategies outside of relying on new technology.
Visit summaries should be given to parents with BP readings so that they can monitor their children’s levels, for example.
Recognition of abnormal BP in teens is the first step toward preventing cardiovascular disease as an adult, and hopefully, the development of new tools, including this CDS, will help physicians find those children who have been overlooked.
Ari H. Pollack, MD, MSIM, is a pediatric nephrologist at the Seattle Children’s Hospital and an assistant professor of pediatrics at the University of Washington, Seattle. Joseph T. Flynn, MD, MS, is the division chief of nephrology in prenatal diagnosis and treatment at the Seattle Children’s Hospital and a professor of pediatrics at the same university. Dr. Pollack and Dr. Flynn reported no relevant financial disclosures in their commentary in Pediatrics (2018. doi: 10.1542/peds.2017-3756).
The rate of children and adolescents with elevated blood pressure going unrecognized is an increasingly concerning issue – one that is complicated because physicians lack a simple, single BP value system. Some have tried to fill the gap, creating simplified tables of BP values or automated displays of BP values in EHRs, but having a table that only takes age and sex into consideration for screening does not cover the complexities needed to identify hypertension.
Previous studies have looked into utilizing a clinical decision support (CDS) application, which has great potential as a digital multitool to improve quality of care, increase efficiency, and reduce medical errors. However, to be an effective CDS, it must fill the “CDS Five Rights” framework. This guideline states that a CDS tool needs to provide: “the right information, to the right people, through the right channels, in the right intervention formats, at the right points in the work flow.”
The TeenBP CDS developed by Kharbanda et al. fulfills these requirements and goes beyond any CDS previously designed. Even so, 45% of children with elevated BP or hypertension were not recognized, emphasizing the need for additional strategies outside of relying on new technology.
Visit summaries should be given to parents with BP readings so that they can monitor their children’s levels, for example.
Recognition of abnormal BP in teens is the first step toward preventing cardiovascular disease as an adult, and hopefully, the development of new tools, including this CDS, will help physicians find those children who have been overlooked.
Ari H. Pollack, MD, MSIM, is a pediatric nephrologist at the Seattle Children’s Hospital and an assistant professor of pediatrics at the University of Washington, Seattle. Joseph T. Flynn, MD, MS, is the division chief of nephrology in prenatal diagnosis and treatment at the Seattle Children’s Hospital and a professor of pediatrics at the same university. Dr. Pollack and Dr. Flynn reported no relevant financial disclosures in their commentary in Pediatrics (2018. doi: 10.1542/peds.2017-3756).
The rate of children and adolescents with elevated blood pressure going unrecognized is an increasingly concerning issue – one that is complicated because physicians lack a simple, single BP value system. Some have tried to fill the gap, creating simplified tables of BP values or automated displays of BP values in EHRs, but having a table that only takes age and sex into consideration for screening does not cover the complexities needed to identify hypertension.
Previous studies have looked into utilizing a clinical decision support (CDS) application, which has great potential as a digital multitool to improve quality of care, increase efficiency, and reduce medical errors. However, to be an effective CDS, it must fill the “CDS Five Rights” framework. This guideline states that a CDS tool needs to provide: “the right information, to the right people, through the right channels, in the right intervention formats, at the right points in the work flow.”
The TeenBP CDS developed by Kharbanda et al. fulfills these requirements and goes beyond any CDS previously designed. Even so, 45% of children with elevated BP or hypertension were not recognized, emphasizing the need for additional strategies outside of relying on new technology.
Visit summaries should be given to parents with BP readings so that they can monitor their children’s levels, for example.
Recognition of abnormal BP in teens is the first step toward preventing cardiovascular disease as an adult, and hopefully, the development of new tools, including this CDS, will help physicians find those children who have been overlooked.
Ari H. Pollack, MD, MSIM, is a pediatric nephrologist at the Seattle Children’s Hospital and an assistant professor of pediatrics at the University of Washington, Seattle. Joseph T. Flynn, MD, MS, is the division chief of nephrology in prenatal diagnosis and treatment at the Seattle Children’s Hospital and a professor of pediatrics at the same university. Dr. Pollack and Dr. Flynn reported no relevant financial disclosures in their commentary in Pediatrics (2018. doi: 10.1542/peds.2017-3756).
Hypertension discovery in pediatric patients more than doubled for physicians using a clinical decision support (CDS) tool connected to the EHR, results of a study found.
Elyse O. Kharbanda, MD, MPH, a researcher at the HealthPartners Institute, Minneapolis, and her fellow investigators assert that using such a tool will help rectify the trend of underreported hypertension in adolescents, which remains a serious concern despite providers’ routinely taking blood pressure measurements during outpatient visits.
“Among patients with multiple visits, electronic health records should contain sufficient information to diagnose hypertension,” Dr. Kharbanda and her associates reported in their article published in Pediatrics. “However, even when EHRs are configured to display BP percentiles, information on the patterns of BP percentiles over time, previous diagnoses, and medications is not presented in a format that is useful for clinicians.”
With TeenBP, providers are first prompted to take an initial BP reading, as well as height and weight measurements.
If the first measure is above the 95th percentile, the CDS requests an additional reading, which is then averaged with the first. If average of the two is above or within the 95th percentile, the provider is notified and sent a list of recommendations, including a diagnosis of hypertension, lipid screening, and nutrition referral.
The 2-year trial included 522 pediatric patients with incident hypertension; the data were gathered from 20 primary care clinics within one health system between April 2014 and April 2016.
The rate of clinical recognition of patients’ hypertension in the clinics utilizing the CDS tool was more than double the rate seen in the clinics that weren’t (55% and 21%, respectively; P less than .001).
More of the children seen in CDS clinics were referred to dietitians or weight loss programs, compared with those seen in the control clinics (17% and 4%, respectively; P = .001).
Those who used the tool reported high levels of satisfaction, which is likely partly because investigators consulted physicians to help design the application.
“The CDS tool was based on the guidelines for BP management in children and adolescents in effect at the time of the study with local input from clinical and operational leaders within the medical group, and thus it contained the so-called right information,” according to Dr. Kharbanda and her fellow investigators.
Of the 55 physicians who remembered using the tool, 92% thought is was useful in identifying hypertension, 94% considered the CDS a good use of time, and 95% believed is was a useful shared-decision making tool.
When designing TeenBP, investigators tailored the application to the work flow and culture of the health system used for the study, which may limit the generalizability of the findings.
The study was funded by the National Institutes of Health. Dr. Kharbanda and her associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
Hypertension discovery in pediatric patients more than doubled for physicians using a clinical decision support (CDS) tool connected to the EHR, results of a study found.
Elyse O. Kharbanda, MD, MPH, a researcher at the HealthPartners Institute, Minneapolis, and her fellow investigators assert that using such a tool will help rectify the trend of underreported hypertension in adolescents, which remains a serious concern despite providers’ routinely taking blood pressure measurements during outpatient visits.
“Among patients with multiple visits, electronic health records should contain sufficient information to diagnose hypertension,” Dr. Kharbanda and her associates reported in their article published in Pediatrics. “However, even when EHRs are configured to display BP percentiles, information on the patterns of BP percentiles over time, previous diagnoses, and medications is not presented in a format that is useful for clinicians.”
With TeenBP, providers are first prompted to take an initial BP reading, as well as height and weight measurements.
If the first measure is above the 95th percentile, the CDS requests an additional reading, which is then averaged with the first. If average of the two is above or within the 95th percentile, the provider is notified and sent a list of recommendations, including a diagnosis of hypertension, lipid screening, and nutrition referral.
The 2-year trial included 522 pediatric patients with incident hypertension; the data were gathered from 20 primary care clinics within one health system between April 2014 and April 2016.
The rate of clinical recognition of patients’ hypertension in the clinics utilizing the CDS tool was more than double the rate seen in the clinics that weren’t (55% and 21%, respectively; P less than .001).
More of the children seen in CDS clinics were referred to dietitians or weight loss programs, compared with those seen in the control clinics (17% and 4%, respectively; P = .001).
Those who used the tool reported high levels of satisfaction, which is likely partly because investigators consulted physicians to help design the application.
“The CDS tool was based on the guidelines for BP management in children and adolescents in effect at the time of the study with local input from clinical and operational leaders within the medical group, and thus it contained the so-called right information,” according to Dr. Kharbanda and her fellow investigators.
Of the 55 physicians who remembered using the tool, 92% thought is was useful in identifying hypertension, 94% considered the CDS a good use of time, and 95% believed is was a useful shared-decision making tool.
When designing TeenBP, investigators tailored the application to the work flow and culture of the health system used for the study, which may limit the generalizability of the findings.
The study was funded by the National Institutes of Health. Dr. Kharbanda and her associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
FROM PEDIATRICS
Key clinical point: Using a clinical decision support (CDS) tool doubles the rate of hypertension detection in children.
Major finding: Providers in clinics that used CDS recognized hypertension in 55% of patients, compared with 21% of patients in usual care (P less than .001).
Study details: Cluster-randomized trial of 522 pediatric patients across 20 primary care clinics who received care between April 2014 and April 2016.
Disclosures: The study was funded by the National Institutes of Health. The investigators reported no relevant financial disclosures.
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
Persistent opioid use a risk after surgery in teens and young adults
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
FROM PEDIATRICS
Key clinical point: Especially for females, older teens, and young adults, there’s a risk for persistent postsurgical opioid use.
Major finding: Opioid use persisted for 4.8% of patients undergoing surgery, compared with 0.1% of patients who did not have surgery.
Study details: Retrospective review of claims database including 88,637 adolescent and young adult patients undergoing surgery, and 110,432 controls who did not have surgery.
Disclosures: The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no conflicts of interest. Some of the other investigators received grants from various agencies.
Source: Harbaugh CM et al. Pediatrics. 2018 Jan 1;141(1):e20172439
Journal of Hospital Medicine – Jan. 2018
BACKGROUND: Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children’s hospitals. Despite multiple efforts to improve pediatric-adult health care transitions, little guidance exists for transitioning inpatient care.
OBJECTIVE: This study sought to characterize pediatric-adult inpatient care transitions across general pediatric services at U.S. children’s hospitals.
DESIGN and SETTING: National survey of inpatient general pediatric service leaders at U.S. children’s hospitals from January 2016 to July 2016.
MEASUREMENT: Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having a specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations among institutional characteristics, transition activities, and presence of an inpatient transition initiative.
RESULTS: Of 195 children’s hospitals, 96 responded (49.2% response rate). Transition initiatives were present at 38% of children’s hospitals, more often where there were providers who were trained in both internal medicine and pediatrics or where there were outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer.
CONCLUSION: Relatively few inpatient general pediatric services at U.S. children’s hospitals have leaders or dedicated processes to shepherd transitions to adult-oriented inpatient care. Across institutions, there is wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.
Also in JHM this month
Characterizing hospitalist practice and perceptions of critical care delivery
AUTHORS: Joseph R. Sweigart, MD, FACP, FHM; David Aymond, MD; Alfred Burger, MD, FACP, SFHM; Andy Kelly, MAS, MS; Nick Marzano, Med; Thomas McIlraith, MD, SFHM; Peter Morris, MD; Mark V. Williams, MD, FACP, MHM; and Eric M. Siegal, MD, SFHM, FCCM
Clinical decision making: Observing the smartphone user an observational study in predicting acute surgical patients’ suitability for discharge
AUTHORS: Richard Hoffmann, MBBS; Simon Harley, MBBS; Samuel Ellison, MBBS; and Peter G. Devitt, MBBS, FRACS
BACKGROUND: Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children’s hospitals. Despite multiple efforts to improve pediatric-adult health care transitions, little guidance exists for transitioning inpatient care.
OBJECTIVE: This study sought to characterize pediatric-adult inpatient care transitions across general pediatric services at U.S. children’s hospitals.
DESIGN and SETTING: National survey of inpatient general pediatric service leaders at U.S. children’s hospitals from January 2016 to July 2016.
MEASUREMENT: Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having a specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations among institutional characteristics, transition activities, and presence of an inpatient transition initiative.
RESULTS: Of 195 children’s hospitals, 96 responded (49.2% response rate). Transition initiatives were present at 38% of children’s hospitals, more often where there were providers who were trained in both internal medicine and pediatrics or where there were outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer.
CONCLUSION: Relatively few inpatient general pediatric services at U.S. children’s hospitals have leaders or dedicated processes to shepherd transitions to adult-oriented inpatient care. Across institutions, there is wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.
Also in JHM this month
Characterizing hospitalist practice and perceptions of critical care delivery
AUTHORS: Joseph R. Sweigart, MD, FACP, FHM; David Aymond, MD; Alfred Burger, MD, FACP, SFHM; Andy Kelly, MAS, MS; Nick Marzano, Med; Thomas McIlraith, MD, SFHM; Peter Morris, MD; Mark V. Williams, MD, FACP, MHM; and Eric M. Siegal, MD, SFHM, FCCM
Clinical decision making: Observing the smartphone user an observational study in predicting acute surgical patients’ suitability for discharge
AUTHORS: Richard Hoffmann, MBBS; Simon Harley, MBBS; Samuel Ellison, MBBS; and Peter G. Devitt, MBBS, FRACS
BACKGROUND: Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children’s hospitals. Despite multiple efforts to improve pediatric-adult health care transitions, little guidance exists for transitioning inpatient care.
OBJECTIVE: This study sought to characterize pediatric-adult inpatient care transitions across general pediatric services at U.S. children’s hospitals.
DESIGN and SETTING: National survey of inpatient general pediatric service leaders at U.S. children’s hospitals from January 2016 to July 2016.
MEASUREMENT: Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having a specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations among institutional characteristics, transition activities, and presence of an inpatient transition initiative.
RESULTS: Of 195 children’s hospitals, 96 responded (49.2% response rate). Transition initiatives were present at 38% of children’s hospitals, more often where there were providers who were trained in both internal medicine and pediatrics or where there were outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer.
CONCLUSION: Relatively few inpatient general pediatric services at U.S. children’s hospitals have leaders or dedicated processes to shepherd transitions to adult-oriented inpatient care. Across institutions, there is wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.
Also in JHM this month
Characterizing hospitalist practice and perceptions of critical care delivery
AUTHORS: Joseph R. Sweigart, MD, FACP, FHM; David Aymond, MD; Alfred Burger, MD, FACP, SFHM; Andy Kelly, MAS, MS; Nick Marzano, Med; Thomas McIlraith, MD, SFHM; Peter Morris, MD; Mark V. Williams, MD, FACP, MHM; and Eric M. Siegal, MD, SFHM, FCCM
Clinical decision making: Observing the smartphone user an observational study in predicting acute surgical patients’ suitability for discharge
AUTHORS: Richard Hoffmann, MBBS; Simon Harley, MBBS; Samuel Ellison, MBBS; and Peter G. Devitt, MBBS, FRACS
Yellow-Orange Hairless Plaque on the Scalp
The Diagnosis: Nevus Sebaceous
The patient presented with a typical solitary scalp lesion characteristic of nevus sebaceous (NS). The lesion was present at birth as a flat and smooth hairless plaque; however, over time it became more thickened and noticeable, which prompted the parents to seek medical advice.
Nevus sebaceous, also known as NS of Jadassohn, is a benign congenital hamartoma of the sebaceous gland that usually is present at birth and frequently involves the scalp and/or the face. The classic NS lesion is solitary and appears as a well-circumscribed, waxy, yellow-orange or tan, hairless plaque. Despite the presence of these lesions at birth, they may not be noted until early childhood or rarely until adulthood. Generally, the lesion tends to thicken and become more verrucous and velvety over time, particularly around the time of reaching puberty.1 Clinically, NS lesions vary in size from 1 cm to several centimeters. Lesions initially tend to grow proportionately with the child until puberty when they become notably thicker, greasier, and verrucous or nodular under hormonal influences. The yellow discoloration of the lesion is due to sebaceous gland secretion, and the characteristic color usually becomes less evident with age.
Nevus sebaceous occurs in approximately 0.3% of newborns and tends to be sporadic in nature; however, rare familial forms have been reported.2,3 Nevus sebaceous can present as multiple nevi that tend to be extensive and distributed along the Blaschko lines, and they usually are associated with neurologic, ocular, or skeletal defects. Involvement of the central nervous system frequently is associated with large sebaceous nevi located on the face or scalp. This association has been termed NS syndrome.4 Neurologic abnormalities associated with NS syndrome include seizures, mental retardation, and hemimegalencephaly.5 Ocular findings most communally associated with the syndrome are choristomas and colobomas.6-8
There are several benign and malignant epithelial neoplasms that may develop within sebaceous nevi. Benign tumors include trichoblastoma, syringocystadenoma papilliferum, trichilemmoma, sebaceoma, nodular hidradenoma, and hidrocystoma.1,8,9 Malignant neoplasms include basal cell carcinoma (BCC), apocrine carcinoma, sebaceous carcinoma, and squamous cell carcinoma. The lifetime risk of malignancy in NS is unknown. In an extensive literature review by Moody et al10 of 4923 cases of NS for the development of secondary benign and malignant neoplasms, 16% developed benign tumors while 8% developed malignant tumors such as BCC. However, subsequent studies suggested that the incidence of BCC may have been overestimated due to misinterpretation of trichoblastoma and may be less than 1%.11-13
Usually the diagnosis of NS is made clinically and rarely a biopsy for histopathologic confirmation may be needed when the diagnosis is uncertain. Typically, these histopathologic findings include immature hair follicles, hyperplastic immature sebaceous glands, dilated apocrine glands, and epidermal hyperplasia.9 For patients with suspected NS syndrome, additional neurologic and ophthalmologic evaluations should be performed including neuroimaging studies, skeletal radiography, and analysis of liver and renal function.14
The current standard of care in treating NS is full-thickness excision. However, the decision should be individualized based on patient age, extension and location of the lesion, concerns about the cosmetic appearance, and the risk for malignancy.
The 2 main reasons to excise NS include concern about malignancy and undesirable cosmetic appearance. Once a malignant lesion develops within NS, it generally is agreed that the tumor and the entire nevus should be removed; however, recommendations vary for excising NS prophylactically to decrease the risk for malignant growths. Because the risk for malignant transformation seems to be lower than previously thought, observation can be a reasonable choice for lesions that are not associated with cosmetic concern.12,13
Photodynamic therapy, CO2 laser resurfacing, and dermabrasion have been reported as alternative therapeutic approaches. However, there is a growing concern on how effective these treatment modalities are in completely removing the lesion and whether the risk for recurrence and potential for neoplasm development remains.1,9
This patient was healthy with normal development and growth and no signs of neurologic or ocular involvement. The parents were counseled about the risk for malignancy and the long-term cosmetic appearance of the lesion. They opted for surgical excision of the lesion at 18 months of age.
- Eisen DB, Michael DJ. Sebaceous lesions and their associated syndromes: part I. J Am Acad Dermatol. 2009;61:549-560; quiz 561-562.
- Happle R, König A. Familial naevus sebaceus may be explained by paradominant transmission. Br J Dermatol. 1999;141:377.
- Hughes SM, Wilkerson AE, Winfield HL, et al. Familial nevus sebaceus in dizygotic male twins. J Am Acad Dermatol. 2006;54(2 suppl):S47-S48.
- Sugarman JL. Epidermal nevus syndromes. Semin Cutan Med Surg. 2007;26:221-230.
- Davies D, Rogers M. Review of neurological manifestations in 196 patients with sebaceous naevi. Australas J Dermatol. 2002;43:20-23.
- Trivedi N, Nehete G. Complex limbal choristoma in linear nevus sebaceous syndrome managed with scleral grafting. Indian J Ophthalmol. 2016;64:692-694.
- Nema N, Singh K, Verma A. Complex limbal choristoma in nevus sebaceous syndrome [published online February 14, 2012]. Pediatr Dermatol. 2012;29:227-229.
- Park JM, Kim DS, Kim J, et al. Epibulbar complex choristoma and hemimegalencephaly in linear sebaceous naevus syndrome [published online July 2, 2009]. Clin Exp Dermatol. 2009;34:E686-E689.
- Simi CM, Rajalakshmi T, Correa M. Clinicopathologic analysis of 21 cases of nevus sebaceus: a retrospective study. Indian J Dermatol Venereol Leprol. 2008;74:625-627.
- Moody MN, Landau JM, Goldberg LH. Nevus sebaceous revisited. Pediatr Dermatol. 2012;29:15-23.
- Cribier B, Scrivener Y, Grosshans E. Tumors arising in nevus sebaceus: a study of 596 cases. J Am Acad Dermatol. 2000;42(2 pt 1):263-268.
- Santibanez-Gallerani A, Marshall D, Duarte AM, et al. Should nevus sebaceus of Jadassohn in children be excised? a study of 757 cases, and literature review. J Craniofac Surg. 2003;14:658-660.
- Rosen H, Schmidt B, Lam HP, et al. Management of nevus sebaceous and the risk of basal cell carcinoma: an 18-year review. Pediatr Dermatol. 2009;26:676-681.
- Brandling-Bennett HA, Morel KD. Epidermal nevi. Pediatr Clin North Am. 2010;57:1177-1198.
The Diagnosis: Nevus Sebaceous
The patient presented with a typical solitary scalp lesion characteristic of nevus sebaceous (NS). The lesion was present at birth as a flat and smooth hairless plaque; however, over time it became more thickened and noticeable, which prompted the parents to seek medical advice.
Nevus sebaceous, also known as NS of Jadassohn, is a benign congenital hamartoma of the sebaceous gland that usually is present at birth and frequently involves the scalp and/or the face. The classic NS lesion is solitary and appears as a well-circumscribed, waxy, yellow-orange or tan, hairless plaque. Despite the presence of these lesions at birth, they may not be noted until early childhood or rarely until adulthood. Generally, the lesion tends to thicken and become more verrucous and velvety over time, particularly around the time of reaching puberty.1 Clinically, NS lesions vary in size from 1 cm to several centimeters. Lesions initially tend to grow proportionately with the child until puberty when they become notably thicker, greasier, and verrucous or nodular under hormonal influences. The yellow discoloration of the lesion is due to sebaceous gland secretion, and the characteristic color usually becomes less evident with age.
Nevus sebaceous occurs in approximately 0.3% of newborns and tends to be sporadic in nature; however, rare familial forms have been reported.2,3 Nevus sebaceous can present as multiple nevi that tend to be extensive and distributed along the Blaschko lines, and they usually are associated with neurologic, ocular, or skeletal defects. Involvement of the central nervous system frequently is associated with large sebaceous nevi located on the face or scalp. This association has been termed NS syndrome.4 Neurologic abnormalities associated with NS syndrome include seizures, mental retardation, and hemimegalencephaly.5 Ocular findings most communally associated with the syndrome are choristomas and colobomas.6-8
There are several benign and malignant epithelial neoplasms that may develop within sebaceous nevi. Benign tumors include trichoblastoma, syringocystadenoma papilliferum, trichilemmoma, sebaceoma, nodular hidradenoma, and hidrocystoma.1,8,9 Malignant neoplasms include basal cell carcinoma (BCC), apocrine carcinoma, sebaceous carcinoma, and squamous cell carcinoma. The lifetime risk of malignancy in NS is unknown. In an extensive literature review by Moody et al10 of 4923 cases of NS for the development of secondary benign and malignant neoplasms, 16% developed benign tumors while 8% developed malignant tumors such as BCC. However, subsequent studies suggested that the incidence of BCC may have been overestimated due to misinterpretation of trichoblastoma and may be less than 1%.11-13
Usually the diagnosis of NS is made clinically and rarely a biopsy for histopathologic confirmation may be needed when the diagnosis is uncertain. Typically, these histopathologic findings include immature hair follicles, hyperplastic immature sebaceous glands, dilated apocrine glands, and epidermal hyperplasia.9 For patients with suspected NS syndrome, additional neurologic and ophthalmologic evaluations should be performed including neuroimaging studies, skeletal radiography, and analysis of liver and renal function.14
The current standard of care in treating NS is full-thickness excision. However, the decision should be individualized based on patient age, extension and location of the lesion, concerns about the cosmetic appearance, and the risk for malignancy.
The 2 main reasons to excise NS include concern about malignancy and undesirable cosmetic appearance. Once a malignant lesion develops within NS, it generally is agreed that the tumor and the entire nevus should be removed; however, recommendations vary for excising NS prophylactically to decrease the risk for malignant growths. Because the risk for malignant transformation seems to be lower than previously thought, observation can be a reasonable choice for lesions that are not associated with cosmetic concern.12,13
Photodynamic therapy, CO2 laser resurfacing, and dermabrasion have been reported as alternative therapeutic approaches. However, there is a growing concern on how effective these treatment modalities are in completely removing the lesion and whether the risk for recurrence and potential for neoplasm development remains.1,9
This patient was healthy with normal development and growth and no signs of neurologic or ocular involvement. The parents were counseled about the risk for malignancy and the long-term cosmetic appearance of the lesion. They opted for surgical excision of the lesion at 18 months of age.
The Diagnosis: Nevus Sebaceous
The patient presented with a typical solitary scalp lesion characteristic of nevus sebaceous (NS). The lesion was present at birth as a flat and smooth hairless plaque; however, over time it became more thickened and noticeable, which prompted the parents to seek medical advice.
Nevus sebaceous, also known as NS of Jadassohn, is a benign congenital hamartoma of the sebaceous gland that usually is present at birth and frequently involves the scalp and/or the face. The classic NS lesion is solitary and appears as a well-circumscribed, waxy, yellow-orange or tan, hairless plaque. Despite the presence of these lesions at birth, they may not be noted until early childhood or rarely until adulthood. Generally, the lesion tends to thicken and become more verrucous and velvety over time, particularly around the time of reaching puberty.1 Clinically, NS lesions vary in size from 1 cm to several centimeters. Lesions initially tend to grow proportionately with the child until puberty when they become notably thicker, greasier, and verrucous or nodular under hormonal influences. The yellow discoloration of the lesion is due to sebaceous gland secretion, and the characteristic color usually becomes less evident with age.
Nevus sebaceous occurs in approximately 0.3% of newborns and tends to be sporadic in nature; however, rare familial forms have been reported.2,3 Nevus sebaceous can present as multiple nevi that tend to be extensive and distributed along the Blaschko lines, and they usually are associated with neurologic, ocular, or skeletal defects. Involvement of the central nervous system frequently is associated with large sebaceous nevi located on the face or scalp. This association has been termed NS syndrome.4 Neurologic abnormalities associated with NS syndrome include seizures, mental retardation, and hemimegalencephaly.5 Ocular findings most communally associated with the syndrome are choristomas and colobomas.6-8
There are several benign and malignant epithelial neoplasms that may develop within sebaceous nevi. Benign tumors include trichoblastoma, syringocystadenoma papilliferum, trichilemmoma, sebaceoma, nodular hidradenoma, and hidrocystoma.1,8,9 Malignant neoplasms include basal cell carcinoma (BCC), apocrine carcinoma, sebaceous carcinoma, and squamous cell carcinoma. The lifetime risk of malignancy in NS is unknown. In an extensive literature review by Moody et al10 of 4923 cases of NS for the development of secondary benign and malignant neoplasms, 16% developed benign tumors while 8% developed malignant tumors such as BCC. However, subsequent studies suggested that the incidence of BCC may have been overestimated due to misinterpretation of trichoblastoma and may be less than 1%.11-13
Usually the diagnosis of NS is made clinically and rarely a biopsy for histopathologic confirmation may be needed when the diagnosis is uncertain. Typically, these histopathologic findings include immature hair follicles, hyperplastic immature sebaceous glands, dilated apocrine glands, and epidermal hyperplasia.9 For patients with suspected NS syndrome, additional neurologic and ophthalmologic evaluations should be performed including neuroimaging studies, skeletal radiography, and analysis of liver and renal function.14
The current standard of care in treating NS is full-thickness excision. However, the decision should be individualized based on patient age, extension and location of the lesion, concerns about the cosmetic appearance, and the risk for malignancy.
The 2 main reasons to excise NS include concern about malignancy and undesirable cosmetic appearance. Once a malignant lesion develops within NS, it generally is agreed that the tumor and the entire nevus should be removed; however, recommendations vary for excising NS prophylactically to decrease the risk for malignant growths. Because the risk for malignant transformation seems to be lower than previously thought, observation can be a reasonable choice for lesions that are not associated with cosmetic concern.12,13
Photodynamic therapy, CO2 laser resurfacing, and dermabrasion have been reported as alternative therapeutic approaches. However, there is a growing concern on how effective these treatment modalities are in completely removing the lesion and whether the risk for recurrence and potential for neoplasm development remains.1,9
This patient was healthy with normal development and growth and no signs of neurologic or ocular involvement. The parents were counseled about the risk for malignancy and the long-term cosmetic appearance of the lesion. They opted for surgical excision of the lesion at 18 months of age.
- Eisen DB, Michael DJ. Sebaceous lesions and their associated syndromes: part I. J Am Acad Dermatol. 2009;61:549-560; quiz 561-562.
- Happle R, König A. Familial naevus sebaceus may be explained by paradominant transmission. Br J Dermatol. 1999;141:377.
- Hughes SM, Wilkerson AE, Winfield HL, et al. Familial nevus sebaceus in dizygotic male twins. J Am Acad Dermatol. 2006;54(2 suppl):S47-S48.
- Sugarman JL. Epidermal nevus syndromes. Semin Cutan Med Surg. 2007;26:221-230.
- Davies D, Rogers M. Review of neurological manifestations in 196 patients with sebaceous naevi. Australas J Dermatol. 2002;43:20-23.
- Trivedi N, Nehete G. Complex limbal choristoma in linear nevus sebaceous syndrome managed with scleral grafting. Indian J Ophthalmol. 2016;64:692-694.
- Nema N, Singh K, Verma A. Complex limbal choristoma in nevus sebaceous syndrome [published online February 14, 2012]. Pediatr Dermatol. 2012;29:227-229.
- Park JM, Kim DS, Kim J, et al. Epibulbar complex choristoma and hemimegalencephaly in linear sebaceous naevus syndrome [published online July 2, 2009]. Clin Exp Dermatol. 2009;34:E686-E689.
- Simi CM, Rajalakshmi T, Correa M. Clinicopathologic analysis of 21 cases of nevus sebaceus: a retrospective study. Indian J Dermatol Venereol Leprol. 2008;74:625-627.
- Moody MN, Landau JM, Goldberg LH. Nevus sebaceous revisited. Pediatr Dermatol. 2012;29:15-23.
- Cribier B, Scrivener Y, Grosshans E. Tumors arising in nevus sebaceus: a study of 596 cases. J Am Acad Dermatol. 2000;42(2 pt 1):263-268.
- Santibanez-Gallerani A, Marshall D, Duarte AM, et al. Should nevus sebaceus of Jadassohn in children be excised? a study of 757 cases, and literature review. J Craniofac Surg. 2003;14:658-660.
- Rosen H, Schmidt B, Lam HP, et al. Management of nevus sebaceous and the risk of basal cell carcinoma: an 18-year review. Pediatr Dermatol. 2009;26:676-681.
- Brandling-Bennett HA, Morel KD. Epidermal nevi. Pediatr Clin North Am. 2010;57:1177-1198.
- Eisen DB, Michael DJ. Sebaceous lesions and their associated syndromes: part I. J Am Acad Dermatol. 2009;61:549-560; quiz 561-562.
- Happle R, König A. Familial naevus sebaceus may be explained by paradominant transmission. Br J Dermatol. 1999;141:377.
- Hughes SM, Wilkerson AE, Winfield HL, et al. Familial nevus sebaceus in dizygotic male twins. J Am Acad Dermatol. 2006;54(2 suppl):S47-S48.
- Sugarman JL. Epidermal nevus syndromes. Semin Cutan Med Surg. 2007;26:221-230.
- Davies D, Rogers M. Review of neurological manifestations in 196 patients with sebaceous naevi. Australas J Dermatol. 2002;43:20-23.
- Trivedi N, Nehete G. Complex limbal choristoma in linear nevus sebaceous syndrome managed with scleral grafting. Indian J Ophthalmol. 2016;64:692-694.
- Nema N, Singh K, Verma A. Complex limbal choristoma in nevus sebaceous syndrome [published online February 14, 2012]. Pediatr Dermatol. 2012;29:227-229.
- Park JM, Kim DS, Kim J, et al. Epibulbar complex choristoma and hemimegalencephaly in linear sebaceous naevus syndrome [published online July 2, 2009]. Clin Exp Dermatol. 2009;34:E686-E689.
- Simi CM, Rajalakshmi T, Correa M. Clinicopathologic analysis of 21 cases of nevus sebaceus: a retrospective study. Indian J Dermatol Venereol Leprol. 2008;74:625-627.
- Moody MN, Landau JM, Goldberg LH. Nevus sebaceous revisited. Pediatr Dermatol. 2012;29:15-23.
- Cribier B, Scrivener Y, Grosshans E. Tumors arising in nevus sebaceus: a study of 596 cases. J Am Acad Dermatol. 2000;42(2 pt 1):263-268.
- Santibanez-Gallerani A, Marshall D, Duarte AM, et al. Should nevus sebaceus of Jadassohn in children be excised? a study of 757 cases, and literature review. J Craniofac Surg. 2003;14:658-660.
- Rosen H, Schmidt B, Lam HP, et al. Management of nevus sebaceous and the risk of basal cell carcinoma: an 18-year review. Pediatr Dermatol. 2009;26:676-681.
- Brandling-Bennett HA, Morel KD. Epidermal nevi. Pediatr Clin North Am. 2010;57:1177-1198.
An otherwise healthy 13-month-old boy presented with a well-circumscribed, 3×4-cm, yellow-orange plaque with a verrucous velvety surface on the right side of the posterior scalp. The patient was born at 33 weeks' gestation and had an uneventful perinatal course with a normal head ultrasound at 4 days of age. The lesion had been present since birth and initially was comprised of waxy, yellow-orange, hairless plaques that became more thickened and noticeable over time. The mother recalled that the surface of the plaque initially was flat and smooth but gradually became bumpier and greasier in consistency in the months prior to presentation. The patient was otherwise asymptomatic.
Hungry or what?
“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).
But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.
The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”
While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.
What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.
Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.
There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).
But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.
The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”
While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.
What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.
Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.
There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).
But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.
The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”
While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.
What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.
Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.
There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
Surgery or Medical Management for Refractory Pediatric Epilepsy?
Children and adolescents with drug-resistant epilepsy who undergo surgery appear to have significantly higher rates of seizure freedom and better quality of life and behavior scores at 12 months than those who receive medical therapy alone, according to a study published in the October 26, 2017, issue of the New England Journal of Medicine. Serious anticipated adverse events may occur after surgery, however.
“The improvements that were observed in other cognitive, behavioral, and quality of life scores in the surgery group may have been due to a reduction in the frequency of seizures; conversely, the deterioration in these measures in the medical-therapy group may be attributed to a continuation of seizures,” said Rekha Dwivedi, PhD, a postdoctoral fellow at the All India Institute of Medical Sciences in New Delhi, and colleagues.
Comparing Methods Intended to Improve Outcomes
Children and adolescents with drug-resistant epilepsy have an increased risk of poor long-term intellectual and psychosocial outcomes, along with a poor health-related quality of life. Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but evidence of benefit from randomized trials in this age group is limited.
A meta-analysis of uncontrolled studies comparing seizure outcomes of surgeries in children indicated that 74% of patients with brain lesions and 45% without lesions had become seizure-free at one year of follow-up. In a retrospective analysis involving 142 children and adolescents with drug-resistant epilepsy who had undergone surgery, 79.3% of patients were free from disabling seizures after a mean follow-up of approximately four years.
To investigate the effects of surgery further, Dr. Dwivedi and colleagues performed a single-center trial. They sought to compare epilepsy surgery with continued medical therapy alone in patients on a waiting list for surgery.
Researchers randomized 116 patients age 18 or younger with drug-resistant epilepsy to brain surgery appropriate to the underlying cause of epilepsy, along with appropriate medical therapy, or to medical therapy alone. Patients for whom there was no consensus regarding the location of an epileptic focus, patients who had any other systemic illness, and patients with a history of status epilepticus were excluded.
Participants assigned to the surgery group underwent the procedure within a month after randomization. Those assigned to the medical-therapy group remained on a waiting list. Surgery for these patients was scheduled for one year or longer after randomization. The primary outcome was seizure freedom at 12 months. Secondary outcomes included the Hague Seizure Severity scale score, the Binet–Kamat intelligence quotient or the social quotient on the Vineland Social Maturity Scale, the T score on the Child Behavior Checklist, and the Pediatric Quality of Life Inventory score.
Most of the Surgery Group Became Seizure-Free at 12 Months
Median age was 9 in the surgery group and 10 in the medical-therapy group. In all, 14 patients had temporal lobe resections, 12 patients had resection of a lesion in a lobe other than the temporal lobe, 15 patients had hemispherotomy, 10 patients had a corpus callosotomy, and six patients had a disconnection or resection of hypothalamic hamartoma.
At 12 months, 44 of 57 patients (77%) in the surgery group became seizure-free, compared with four of 59 patients (7%) in the medical-therapy group. Furthermore, 21 patients (37%) in the surgery group were completely seizure-free during the entire 12-month period.
All patients who had undergone temporal lobectomy or hypothalamic hamartoma surgeries were seizure-free at the last follow-up. Of the patients who had undergone extratemporal resection or hemispherotomy, 11 of 12 patients (92%) and 13 of 15 (87%), had complete freedom from seizures, respectively.
Two of 15 patients (13%) in the medical-therapy group who were on the waiting list for a temporal lobectomy were seizure-free at 12 months, along with one of 19 patients (5%) who were on a waiting list for extratemporal resection and one of 16 patients (6%) who were waiting for a corpus callostomy. Patients with a planned hemispherotomy or intervention for hypothalamic hamartoma were not seizure-free at 12 months.
In addition, between-group differences in the change from baseline to 12 months significantly favored surgery with respect to the Hague Seizure Severity scale score, the Child Behavior Checklist, the Pediatric Quality of Life Inventory, and the Vineland Social Maturity Scale, but not the Binet–Kamat intelligence quotient, said the researchers.
Adverse Events and Study Limitations
Serious adverse events occurred in 19 patients (33%) in the surgery group and no patients in the medical-therapy group. Monoparesis occurred in two patients who had undergone temporal lobectomy or resection of parietal focal cortical dysplasia. Hemiparesis occurred in 15 patients who had undergone hemispherotomy. Finally, generalized hypotonia and language deficits occurred in one patient who had undergone frontal lobectomy.
Ten patients in the medical-therapy group had physical injuries associated with seizures (eg, cuts, burns, and fractures). One patient had an adverse event associated with an antiepileptic drug, and autistic features developed in another patient. No deaths occurred in either group.
One study limitation was that patients included in this trial underwent many types of epilepsy surgeries to treat various underlying pathologic causes of seizures. Another limitation was that there was an overrepresentation of hypothalamic hamartomas, compared with some other series, said the researchers.
—Erica Tricarico
Suggested Reading
Dwivedi R, Ramanujam B, Chandra PS, et al. Surgery for drug-resistant epilepsy in children. N Engl J Med. 2017;377(17):1639-1647.
Children and adolescents with drug-resistant epilepsy who undergo surgery appear to have significantly higher rates of seizure freedom and better quality of life and behavior scores at 12 months than those who receive medical therapy alone, according to a study published in the October 26, 2017, issue of the New England Journal of Medicine. Serious anticipated adverse events may occur after surgery, however.
“The improvements that were observed in other cognitive, behavioral, and quality of life scores in the surgery group may have been due to a reduction in the frequency of seizures; conversely, the deterioration in these measures in the medical-therapy group may be attributed to a continuation of seizures,” said Rekha Dwivedi, PhD, a postdoctoral fellow at the All India Institute of Medical Sciences in New Delhi, and colleagues.
Comparing Methods Intended to Improve Outcomes
Children and adolescents with drug-resistant epilepsy have an increased risk of poor long-term intellectual and psychosocial outcomes, along with a poor health-related quality of life. Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but evidence of benefit from randomized trials in this age group is limited.
A meta-analysis of uncontrolled studies comparing seizure outcomes of surgeries in children indicated that 74% of patients with brain lesions and 45% without lesions had become seizure-free at one year of follow-up. In a retrospective analysis involving 142 children and adolescents with drug-resistant epilepsy who had undergone surgery, 79.3% of patients were free from disabling seizures after a mean follow-up of approximately four years.
To investigate the effects of surgery further, Dr. Dwivedi and colleagues performed a single-center trial. They sought to compare epilepsy surgery with continued medical therapy alone in patients on a waiting list for surgery.
Researchers randomized 116 patients age 18 or younger with drug-resistant epilepsy to brain surgery appropriate to the underlying cause of epilepsy, along with appropriate medical therapy, or to medical therapy alone. Patients for whom there was no consensus regarding the location of an epileptic focus, patients who had any other systemic illness, and patients with a history of status epilepticus were excluded.
Participants assigned to the surgery group underwent the procedure within a month after randomization. Those assigned to the medical-therapy group remained on a waiting list. Surgery for these patients was scheduled for one year or longer after randomization. The primary outcome was seizure freedom at 12 months. Secondary outcomes included the Hague Seizure Severity scale score, the Binet–Kamat intelligence quotient or the social quotient on the Vineland Social Maturity Scale, the T score on the Child Behavior Checklist, and the Pediatric Quality of Life Inventory score.
Most of the Surgery Group Became Seizure-Free at 12 Months
Median age was 9 in the surgery group and 10 in the medical-therapy group. In all, 14 patients had temporal lobe resections, 12 patients had resection of a lesion in a lobe other than the temporal lobe, 15 patients had hemispherotomy, 10 patients had a corpus callosotomy, and six patients had a disconnection or resection of hypothalamic hamartoma.
At 12 months, 44 of 57 patients (77%) in the surgery group became seizure-free, compared with four of 59 patients (7%) in the medical-therapy group. Furthermore, 21 patients (37%) in the surgery group were completely seizure-free during the entire 12-month period.
All patients who had undergone temporal lobectomy or hypothalamic hamartoma surgeries were seizure-free at the last follow-up. Of the patients who had undergone extratemporal resection or hemispherotomy, 11 of 12 patients (92%) and 13 of 15 (87%), had complete freedom from seizures, respectively.
Two of 15 patients (13%) in the medical-therapy group who were on the waiting list for a temporal lobectomy were seizure-free at 12 months, along with one of 19 patients (5%) who were on a waiting list for extratemporal resection and one of 16 patients (6%) who were waiting for a corpus callostomy. Patients with a planned hemispherotomy or intervention for hypothalamic hamartoma were not seizure-free at 12 months.
In addition, between-group differences in the change from baseline to 12 months significantly favored surgery with respect to the Hague Seizure Severity scale score, the Child Behavior Checklist, the Pediatric Quality of Life Inventory, and the Vineland Social Maturity Scale, but not the Binet–Kamat intelligence quotient, said the researchers.
Adverse Events and Study Limitations
Serious adverse events occurred in 19 patients (33%) in the surgery group and no patients in the medical-therapy group. Monoparesis occurred in two patients who had undergone temporal lobectomy or resection of parietal focal cortical dysplasia. Hemiparesis occurred in 15 patients who had undergone hemispherotomy. Finally, generalized hypotonia and language deficits occurred in one patient who had undergone frontal lobectomy.
Ten patients in the medical-therapy group had physical injuries associated with seizures (eg, cuts, burns, and fractures). One patient had an adverse event associated with an antiepileptic drug, and autistic features developed in another patient. No deaths occurred in either group.
One study limitation was that patients included in this trial underwent many types of epilepsy surgeries to treat various underlying pathologic causes of seizures. Another limitation was that there was an overrepresentation of hypothalamic hamartomas, compared with some other series, said the researchers.
—Erica Tricarico
Suggested Reading
Dwivedi R, Ramanujam B, Chandra PS, et al. Surgery for drug-resistant epilepsy in children. N Engl J Med. 2017;377(17):1639-1647.
Children and adolescents with drug-resistant epilepsy who undergo surgery appear to have significantly higher rates of seizure freedom and better quality of life and behavior scores at 12 months than those who receive medical therapy alone, according to a study published in the October 26, 2017, issue of the New England Journal of Medicine. Serious anticipated adverse events may occur after surgery, however.
“The improvements that were observed in other cognitive, behavioral, and quality of life scores in the surgery group may have been due to a reduction in the frequency of seizures; conversely, the deterioration in these measures in the medical-therapy group may be attributed to a continuation of seizures,” said Rekha Dwivedi, PhD, a postdoctoral fellow at the All India Institute of Medical Sciences in New Delhi, and colleagues.
Comparing Methods Intended to Improve Outcomes
Children and adolescents with drug-resistant epilepsy have an increased risk of poor long-term intellectual and psychosocial outcomes, along with a poor health-related quality of life. Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but evidence of benefit from randomized trials in this age group is limited.
A meta-analysis of uncontrolled studies comparing seizure outcomes of surgeries in children indicated that 74% of patients with brain lesions and 45% without lesions had become seizure-free at one year of follow-up. In a retrospective analysis involving 142 children and adolescents with drug-resistant epilepsy who had undergone surgery, 79.3% of patients were free from disabling seizures after a mean follow-up of approximately four years.
To investigate the effects of surgery further, Dr. Dwivedi and colleagues performed a single-center trial. They sought to compare epilepsy surgery with continued medical therapy alone in patients on a waiting list for surgery.
Researchers randomized 116 patients age 18 or younger with drug-resistant epilepsy to brain surgery appropriate to the underlying cause of epilepsy, along with appropriate medical therapy, or to medical therapy alone. Patients for whom there was no consensus regarding the location of an epileptic focus, patients who had any other systemic illness, and patients with a history of status epilepticus were excluded.
Participants assigned to the surgery group underwent the procedure within a month after randomization. Those assigned to the medical-therapy group remained on a waiting list. Surgery for these patients was scheduled for one year or longer after randomization. The primary outcome was seizure freedom at 12 months. Secondary outcomes included the Hague Seizure Severity scale score, the Binet–Kamat intelligence quotient or the social quotient on the Vineland Social Maturity Scale, the T score on the Child Behavior Checklist, and the Pediatric Quality of Life Inventory score.
Most of the Surgery Group Became Seizure-Free at 12 Months
Median age was 9 in the surgery group and 10 in the medical-therapy group. In all, 14 patients had temporal lobe resections, 12 patients had resection of a lesion in a lobe other than the temporal lobe, 15 patients had hemispherotomy, 10 patients had a corpus callosotomy, and six patients had a disconnection or resection of hypothalamic hamartoma.
At 12 months, 44 of 57 patients (77%) in the surgery group became seizure-free, compared with four of 59 patients (7%) in the medical-therapy group. Furthermore, 21 patients (37%) in the surgery group were completely seizure-free during the entire 12-month period.
All patients who had undergone temporal lobectomy or hypothalamic hamartoma surgeries were seizure-free at the last follow-up. Of the patients who had undergone extratemporal resection or hemispherotomy, 11 of 12 patients (92%) and 13 of 15 (87%), had complete freedom from seizures, respectively.
Two of 15 patients (13%) in the medical-therapy group who were on the waiting list for a temporal lobectomy were seizure-free at 12 months, along with one of 19 patients (5%) who were on a waiting list for extratemporal resection and one of 16 patients (6%) who were waiting for a corpus callostomy. Patients with a planned hemispherotomy or intervention for hypothalamic hamartoma were not seizure-free at 12 months.
In addition, between-group differences in the change from baseline to 12 months significantly favored surgery with respect to the Hague Seizure Severity scale score, the Child Behavior Checklist, the Pediatric Quality of Life Inventory, and the Vineland Social Maturity Scale, but not the Binet–Kamat intelligence quotient, said the researchers.
Adverse Events and Study Limitations
Serious adverse events occurred in 19 patients (33%) in the surgery group and no patients in the medical-therapy group. Monoparesis occurred in two patients who had undergone temporal lobectomy or resection of parietal focal cortical dysplasia. Hemiparesis occurred in 15 patients who had undergone hemispherotomy. Finally, generalized hypotonia and language deficits occurred in one patient who had undergone frontal lobectomy.
Ten patients in the medical-therapy group had physical injuries associated with seizures (eg, cuts, burns, and fractures). One patient had an adverse event associated with an antiepileptic drug, and autistic features developed in another patient. No deaths occurred in either group.
One study limitation was that patients included in this trial underwent many types of epilepsy surgeries to treat various underlying pathologic causes of seizures. Another limitation was that there was an overrepresentation of hypothalamic hamartomas, compared with some other series, said the researchers.
—Erica Tricarico
Suggested Reading
Dwivedi R, Ramanujam B, Chandra PS, et al. Surgery for drug-resistant epilepsy in children. N Engl J Med. 2017;377(17):1639-1647.
CBT cost effective for depressed teens refusing antidepressants
“In this study, we demonstrate that brief primary care CBT is a cost-effective treatment option for adolescents with depression and likely generates cost savings over 2 years,” said John F. Dickerson, PhD, of Kaiser Permanente Center for Health Research, Portland, Ore., and his associates
Youth randomly assigned to CBT plus TAU had 26.8 more depression-free days (P = .043) and 0.067 more quality-adjusted life-years (P = .043) on average, compared with patients receiving TAU over a 12-month period. Also, patients in the CBT group had fewer hospitalizations, compared with patients in the TAU group (1.1% vs. 8.8% during 12 months, and 4.4% vs. 12.1% during 24 months), reported Dr. Dickerson and his colleagues.
By the end of the 24-month follow-up, average total costs were $2,811 among youth randomly assigned to CBT plus TAU and $7,354 among youth assigned TAU (adjusted to 2008 U.S. dollars).
“Many adolescents with depression choose to not initiate or continue antidepressant therapy, which limits their options for depression treatment,” the investigators said. “In this evaluation, it is demonstrated that brief, primary care–based CBT is a cost-effective option for the treatment of depression among adolescents with depression who decline or quickly discontinue pharmacotherapy.”
Read more at Pediatrics (2018. doi: 10.1542/peds.2017-1969).
“In this study, we demonstrate that brief primary care CBT is a cost-effective treatment option for adolescents with depression and likely generates cost savings over 2 years,” said John F. Dickerson, PhD, of Kaiser Permanente Center for Health Research, Portland, Ore., and his associates
Youth randomly assigned to CBT plus TAU had 26.8 more depression-free days (P = .043) and 0.067 more quality-adjusted life-years (P = .043) on average, compared with patients receiving TAU over a 12-month period. Also, patients in the CBT group had fewer hospitalizations, compared with patients in the TAU group (1.1% vs. 8.8% during 12 months, and 4.4% vs. 12.1% during 24 months), reported Dr. Dickerson and his colleagues.
By the end of the 24-month follow-up, average total costs were $2,811 among youth randomly assigned to CBT plus TAU and $7,354 among youth assigned TAU (adjusted to 2008 U.S. dollars).
“Many adolescents with depression choose to not initiate or continue antidepressant therapy, which limits their options for depression treatment,” the investigators said. “In this evaluation, it is demonstrated that brief, primary care–based CBT is a cost-effective option for the treatment of depression among adolescents with depression who decline or quickly discontinue pharmacotherapy.”
Read more at Pediatrics (2018. doi: 10.1542/peds.2017-1969).
“In this study, we demonstrate that brief primary care CBT is a cost-effective treatment option for adolescents with depression and likely generates cost savings over 2 years,” said John F. Dickerson, PhD, of Kaiser Permanente Center for Health Research, Portland, Ore., and his associates
Youth randomly assigned to CBT plus TAU had 26.8 more depression-free days (P = .043) and 0.067 more quality-adjusted life-years (P = .043) on average, compared with patients receiving TAU over a 12-month period. Also, patients in the CBT group had fewer hospitalizations, compared with patients in the TAU group (1.1% vs. 8.8% during 12 months, and 4.4% vs. 12.1% during 24 months), reported Dr. Dickerson and his colleagues.
By the end of the 24-month follow-up, average total costs were $2,811 among youth randomly assigned to CBT plus TAU and $7,354 among youth assigned TAU (adjusted to 2008 U.S. dollars).
“Many adolescents with depression choose to not initiate or continue antidepressant therapy, which limits their options for depression treatment,” the investigators said. “In this evaluation, it is demonstrated that brief, primary care–based CBT is a cost-effective option for the treatment of depression among adolescents with depression who decline or quickly discontinue pharmacotherapy.”
Read more at Pediatrics (2018. doi: 10.1542/peds.2017-1969).
FROM PEDIATRICS
CAR T-cell therapy on fast track in US, EU
The chimeric antigen receptor (CAR) T-cell therapy tisagenlecleucel (Kymriah, formerly CTL019) is getting fast-tracked in the United States (US) and European Union (EU).
The US Food and Drug Administration (FDA) has accepted for priority review the supplemental biologics license application (sBLA) for tisagenlecleucel for the treatment of adults with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) who are ineligible for, or relapse after, autologous hematopoietic stem cell transplant (auto-HSCT).
Meanwhile, the European Medicines Agency (EMA) has granted accelerated assessment to the marketing authorization application (MAA) for tisagenlecleucel for the treatment of children and young adults with R/R B-cell acute lymphoblastic leukemia (ALL) and for adults with R/R DLBCL who are ineligible for auto-HSCT.
If the sBLA and MAA are approved, tisagenlecleucel will be the first CAR T-cell therapy available for 2 distinct indications in non-Hodgkin lymphoma and B-cell ALL.
Tisagenlecleucel became the first CAR T-cell therapy to receive regulatory approval when it was approved by the FDA in August 2017 for use in patients up to 25 years of age who have B-cell precursor ALL that is refractory or in second or later relapse.
Supporting data
The regulatory applications for tisagenlecleucel in the US and EU are supported by data from the Novartis-sponsored global clinical trial program in children and young adults with R/R B-cell ALL and adults with R/R DLBCL.
Results from the phase 2 JULIET trial served as the basis of the sBLA and MAA for tisagenlecleucel in adults with R/R DLCBL. Data from this trial were presented at the 2017 ASH Annual Meeting in December.
Results from the phase 2 ELIANA study were submitted as part of the MAA for tisagenlecleucel in children and young adults with R/R B-cell ALL. Data from this trial were presented at the 2017 EHA Congress last June.
About priority review, accelerated assessment
The FDA grants priority review to applications for products that may provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.
The FDA’s goal is to take action on a priority review application within 6 months of receiving it, rather than the standard 10 months.
The EMA grants accelerated assessment when a product is expected to be of major public health interest, particularly from the point of view of therapeutic innovation.
Accelerated assessment shortens the review period from 210 days to 150 days. 
The chimeric antigen receptor (CAR) T-cell therapy tisagenlecleucel (Kymriah, formerly CTL019) is getting fast-tracked in the United States (US) and European Union (EU).
The US Food and Drug Administration (FDA) has accepted for priority review the supplemental biologics license application (sBLA) for tisagenlecleucel for the treatment of adults with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) who are ineligible for, or relapse after, autologous hematopoietic stem cell transplant (auto-HSCT).
Meanwhile, the European Medicines Agency (EMA) has granted accelerated assessment to the marketing authorization application (MAA) for tisagenlecleucel for the treatment of children and young adults with R/R B-cell acute lymphoblastic leukemia (ALL) and for adults with R/R DLBCL who are ineligible for auto-HSCT.
If the sBLA and MAA are approved, tisagenlecleucel will be the first CAR T-cell therapy available for 2 distinct indications in non-Hodgkin lymphoma and B-cell ALL.
Tisagenlecleucel became the first CAR T-cell therapy to receive regulatory approval when it was approved by the FDA in August 2017 for use in patients up to 25 years of age who have B-cell precursor ALL that is refractory or in second or later relapse.
Supporting data
The regulatory applications for tisagenlecleucel in the US and EU are supported by data from the Novartis-sponsored global clinical trial program in children and young adults with R/R B-cell ALL and adults with R/R DLBCL.
Results from the phase 2 JULIET trial served as the basis of the sBLA and MAA for tisagenlecleucel in adults with R/R DLCBL. Data from this trial were presented at the 2017 ASH Annual Meeting in December.
Results from the phase 2 ELIANA study were submitted as part of the MAA for tisagenlecleucel in children and young adults with R/R B-cell ALL. Data from this trial were presented at the 2017 EHA Congress last June.
About priority review, accelerated assessment
The FDA grants priority review to applications for products that may provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.
The FDA’s goal is to take action on a priority review application within 6 months of receiving it, rather than the standard 10 months.
The EMA grants accelerated assessment when a product is expected to be of major public health interest, particularly from the point of view of therapeutic innovation.
Accelerated assessment shortens the review period from 210 days to 150 days.
The chimeric antigen receptor (CAR) T-cell therapy tisagenlecleucel (Kymriah, formerly CTL019) is getting fast-tracked in the United States (US) and European Union (EU).
The US Food and Drug Administration (FDA) has accepted for priority review the supplemental biologics license application (sBLA) for tisagenlecleucel for the treatment of adults with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) who are ineligible for, or relapse after, autologous hematopoietic stem cell transplant (auto-HSCT).
Meanwhile, the European Medicines Agency (EMA) has granted accelerated assessment to the marketing authorization application (MAA) for tisagenlecleucel for the treatment of children and young adults with R/R B-cell acute lymphoblastic leukemia (ALL) and for adults with R/R DLBCL who are ineligible for auto-HSCT.
If the sBLA and MAA are approved, tisagenlecleucel will be the first CAR T-cell therapy available for 2 distinct indications in non-Hodgkin lymphoma and B-cell ALL.
Tisagenlecleucel became the first CAR T-cell therapy to receive regulatory approval when it was approved by the FDA in August 2017 for use in patients up to 25 years of age who have B-cell precursor ALL that is refractory or in second or later relapse.
Supporting data
The regulatory applications for tisagenlecleucel in the US and EU are supported by data from the Novartis-sponsored global clinical trial program in children and young adults with R/R B-cell ALL and adults with R/R DLBCL.
Results from the phase 2 JULIET trial served as the basis of the sBLA and MAA for tisagenlecleucel in adults with R/R DLCBL. Data from this trial were presented at the 2017 ASH Annual Meeting in December.
Results from the phase 2 ELIANA study were submitted as part of the MAA for tisagenlecleucel in children and young adults with R/R B-cell ALL. Data from this trial were presented at the 2017 EHA Congress last June.
About priority review, accelerated assessment
The FDA grants priority review to applications for products that may provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.
The FDA’s goal is to take action on a priority review application within 6 months of receiving it, rather than the standard 10 months.
The EMA grants accelerated assessment when a product is expected to be of major public health interest, particularly from the point of view of therapeutic innovation.
Accelerated assessment shortens the review period from 210 days to 150 days.
Atopic march largely attributed to genetic factors
according to a systematic review.
PhD candidate Sabria Khan and her colleagues at the Centre for Epidemiology and Biostatistics at the University of Melbourne said that the atopic march concept “asserts that allergic diseases start in early life with eczema, progress through food allergy, and culminate with hay fever and asthma.”
This systematic review of ten twin and sibling studies looked at known, measured environmental and genetic influences on the associations between the atopic phenotypes of the atopic march.
The studies of asthma and hay fever suggested that the prevalence of having both conditions was high (32%) and that they were more likely to occur together in monozygotic twins than they were in dizygotic twins. Similarly, other studies found a high phenotypic overlap between eczema and asthma and between eczema and hay fever, which was more pronounced in monozygotic twins than in dizygotic twins.
“Asthma is linked to hay fever and eczema through intermediate phenotypes like clinical measures of lung function, physiological measures of airway responsiveness and the biomarker exhaled nitric oxide, all of which are influenced by hereditary factors,” the authors said.
Overall, they concluded that genetic factors account for 75% of eczema cases, 70%-91% of asthma cases, and 72%-84% of hay fever cases, making them all highly heritable diseases.
“Our study found that the contribution of shared environmental factors to the proportion of correlation are very low (from 4% to 18%) and does not explain the familial patterns seen for asthma and hay fever,” they reported. “This finding contradicts various analyses where smoking behavior, indoor-outdoor pollution, and house dust mites were found to be significant risk factor for asthma and hay fever that are shared by siblings.”
The authors commented that preventing the onset of the atopic march, or arresting its development, could have significant public health implications. They suggested that interventions such as oral antihistamines could be introduced either before a child gets eczema or before a child with eczema goes on to develop asthma or hay fever. “Two randomized controlled trials showed moisturizing the skin can prevent mild to moderate eczema, and long-term studies are needed to see whether such intervention will prevent development of asthma and hay fever,” they said.
No conflicts of interest were declared.
SOURCE: Khan SJ et al. Allergy. 2018 Jan;73(1):17-28.
according to a systematic review.
PhD candidate Sabria Khan and her colleagues at the Centre for Epidemiology and Biostatistics at the University of Melbourne said that the atopic march concept “asserts that allergic diseases start in early life with eczema, progress through food allergy, and culminate with hay fever and asthma.”
This systematic review of ten twin and sibling studies looked at known, measured environmental and genetic influences on the associations between the atopic phenotypes of the atopic march.
The studies of asthma and hay fever suggested that the prevalence of having both conditions was high (32%) and that they were more likely to occur together in monozygotic twins than they were in dizygotic twins. Similarly, other studies found a high phenotypic overlap between eczema and asthma and between eczema and hay fever, which was more pronounced in monozygotic twins than in dizygotic twins.
“Asthma is linked to hay fever and eczema through intermediate phenotypes like clinical measures of lung function, physiological measures of airway responsiveness and the biomarker exhaled nitric oxide, all of which are influenced by hereditary factors,” the authors said.
Overall, they concluded that genetic factors account for 75% of eczema cases, 70%-91% of asthma cases, and 72%-84% of hay fever cases, making them all highly heritable diseases.
“Our study found that the contribution of shared environmental factors to the proportion of correlation are very low (from 4% to 18%) and does not explain the familial patterns seen for asthma and hay fever,” they reported. “This finding contradicts various analyses where smoking behavior, indoor-outdoor pollution, and house dust mites were found to be significant risk factor for asthma and hay fever that are shared by siblings.”
The authors commented that preventing the onset of the atopic march, or arresting its development, could have significant public health implications. They suggested that interventions such as oral antihistamines could be introduced either before a child gets eczema or before a child with eczema goes on to develop asthma or hay fever. “Two randomized controlled trials showed moisturizing the skin can prevent mild to moderate eczema, and long-term studies are needed to see whether such intervention will prevent development of asthma and hay fever,” they said.
No conflicts of interest were declared.
SOURCE: Khan SJ et al. Allergy. 2018 Jan;73(1):17-28.
according to a systematic review.
PhD candidate Sabria Khan and her colleagues at the Centre for Epidemiology and Biostatistics at the University of Melbourne said that the atopic march concept “asserts that allergic diseases start in early life with eczema, progress through food allergy, and culminate with hay fever and asthma.”
This systematic review of ten twin and sibling studies looked at known, measured environmental and genetic influences on the associations between the atopic phenotypes of the atopic march.
The studies of asthma and hay fever suggested that the prevalence of having both conditions was high (32%) and that they were more likely to occur together in monozygotic twins than they were in dizygotic twins. Similarly, other studies found a high phenotypic overlap between eczema and asthma and between eczema and hay fever, which was more pronounced in monozygotic twins than in dizygotic twins.
“Asthma is linked to hay fever and eczema through intermediate phenotypes like clinical measures of lung function, physiological measures of airway responsiveness and the biomarker exhaled nitric oxide, all of which are influenced by hereditary factors,” the authors said.
Overall, they concluded that genetic factors account for 75% of eczema cases, 70%-91% of asthma cases, and 72%-84% of hay fever cases, making them all highly heritable diseases.
“Our study found that the contribution of shared environmental factors to the proportion of correlation are very low (from 4% to 18%) and does not explain the familial patterns seen for asthma and hay fever,” they reported. “This finding contradicts various analyses where smoking behavior, indoor-outdoor pollution, and house dust mites were found to be significant risk factor for asthma and hay fever that are shared by siblings.”
The authors commented that preventing the onset of the atopic march, or arresting its development, could have significant public health implications. They suggested that interventions such as oral antihistamines could be introduced either before a child gets eczema or before a child with eczema goes on to develop asthma or hay fever. “Two randomized controlled trials showed moisturizing the skin can prevent mild to moderate eczema, and long-term studies are needed to see whether such intervention will prevent development of asthma and hay fever,” they said.
No conflicts of interest were declared.
SOURCE: Khan SJ et al. Allergy. 2018 Jan;73(1):17-28.
FROM ALLERGY
Key clinical point: Twin and sibling studies suggest that genetics play a far more significant role than environmental factors in the progression of atopic disease in childhood known as the “atopic march.”
Major finding: Genetic factors account for 75% of eczema, 70%-91% of asthma, and 72%-84% of hay fever.
Data source: Systematic review of ten twin and sibling studies.
Disclosures: No conflicts of interest were declared.
Source: Khan SJ et al. Allergy. 2018 Jan;73(1):17-28.