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Apple pie and ...
How do you feel about apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?
Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life. 
You may never have been asked that question in exactly that way before, but I suspect you have thought about it both professionally and personally. You may have considered the answer as you were deciding if, when, and how you were going to return to work after maternity leave. Or you may have been forced to consider the question in formulating an opinion in a case of contested child custody.
An opinion piece in the Wall Street Journal (“The Politicization of Motherhood,” by James Taranto, Oct. 27, 2017) suggests that how you answer my question about the biological necessity of motherhood will determine your position on one of our nation’s political divides. The article focuses on Erica Komisar, who has written a book in which she lays out evidence from the fields of neuroscience, psychology, and epigenetics supporting her view that a mother is biologically equipped to provide for the emotional development of her child (“Being There: Why Prioritizing Motherhood in the First Three Years Matters,” New York: TarcherPerigee, 2017).
I haven’t read Ms. Komisar’s book, nor am I aware of the studies she cites, but reading the article prompted me to think a bit more deeply regarding how I feel about motherhood. I guess I always have felt that there is something special that a mother can provide her children, particularly during the first 3 years of life. I don’t know whether there is a neurobiological basis for this special something, but if it is missing, the child’s emotional development can suffer. Are there situations where another person(s) can provide a substitute for this special maternal sauce? Of course, but it doesn’t always work as well as the real thing. And not every mother has an adequate amount of that certain maternal something.
As pediatricians, we are faced with two challenges. The first is to help families cope with situations in which that special maternal ingredient is absent or in short supply. Our second challenge is to help mothers who believe there is something special they can offer their children but feel guilty because, for whatever reason, they can’t be there to provide it.
I am interested to hear how you feel about motherhood ... and apple pie.
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.
How do you feel about apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?
Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life.
You may never have been asked that question in exactly that way before, but I suspect you have thought about it both professionally and personally. You may have considered the answer as you were deciding if, when, and how you were going to return to work after maternity leave. Or you may have been forced to consider the question in formulating an opinion in a case of contested child custody.
An opinion piece in the Wall Street Journal (“The Politicization of Motherhood,” by James Taranto, Oct. 27, 2017) suggests that how you answer my question about the biological necessity of motherhood will determine your position on one of our nation’s political divides. The article focuses on Erica Komisar, who has written a book in which she lays out evidence from the fields of neuroscience, psychology, and epigenetics supporting her view that a mother is biologically equipped to provide for the emotional development of her child (“Being There: Why Prioritizing Motherhood in the First Three Years Matters,” New York: TarcherPerigee, 2017).
I haven’t read Ms. Komisar’s book, nor am I aware of the studies she cites, but reading the article prompted me to think a bit more deeply regarding how I feel about motherhood. I guess I always have felt that there is something special that a mother can provide her children, particularly during the first 3 years of life. I don’t know whether there is a neurobiological basis for this special something, but if it is missing, the child’s emotional development can suffer. Are there situations where another person(s) can provide a substitute for this special maternal sauce? Of course, but it doesn’t always work as well as the real thing. And not every mother has an adequate amount of that certain maternal something.
As pediatricians, we are faced with two challenges. The first is to help families cope with situations in which that special maternal ingredient is absent or in short supply. Our second challenge is to help mothers who believe there is something special they can offer their children but feel guilty because, for whatever reason, they can’t be there to provide it.
I am interested to hear how you feel about motherhood ... and apple pie.
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.
How do you feel about apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?
Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life.
You may never have been asked that question in exactly that way before, but I suspect you have thought about it both professionally and personally. You may have considered the answer as you were deciding if, when, and how you were going to return to work after maternity leave. Or you may have been forced to consider the question in formulating an opinion in a case of contested child custody.
An opinion piece in the Wall Street Journal (“The Politicization of Motherhood,” by James Taranto, Oct. 27, 2017) suggests that how you answer my question about the biological necessity of motherhood will determine your position on one of our nation’s political divides. The article focuses on Erica Komisar, who has written a book in which she lays out evidence from the fields of neuroscience, psychology, and epigenetics supporting her view that a mother is biologically equipped to provide for the emotional development of her child (“Being There: Why Prioritizing Motherhood in the First Three Years Matters,” New York: TarcherPerigee, 2017).
I haven’t read Ms. Komisar’s book, nor am I aware of the studies she cites, but reading the article prompted me to think a bit more deeply regarding how I feel about motherhood. I guess I always have felt that there is something special that a mother can provide her children, particularly during the first 3 years of life. I don’t know whether there is a neurobiological basis for this special something, but if it is missing, the child’s emotional development can suffer. Are there situations where another person(s) can provide a substitute for this special maternal sauce? Of course, but it doesn’t always work as well as the real thing. And not every mother has an adequate amount of that certain maternal something.
As pediatricians, we are faced with two challenges. The first is to help families cope with situations in which that special maternal ingredient is absent or in short supply. Our second challenge is to help mothers who believe there is something special they can offer their children but feel guilty because, for whatever reason, they can’t be there to provide it.
I am interested to hear how you feel about motherhood ... and apple pie.
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.
Immunization information systems show progress over recent years
From 2013 to 2016, all U.S. immunization information systems showed progress in bidirectional information exchange with EHRs, said Neil Murthy, MD, and his associates at the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta.
Across all 55 jurisdictions in 49 states and six cities in the United States using immunization information systems (IIS), 106% of U.S. births were registered in IIS in 2016, which is an increase from 102% in 2013; percentages may exceed 100%, because a child who is born in one state but who lives in a different state might be recorded in both IISs.
Bidirectional exchange of data with EHRs is an important part of an IIS. In 2016, 91% of jurisdictions had an IIS that used a platform-independent messaging system that received vaccination histories from providers and returned acknowledgment messages, compared with 87% in 2013, the investigators said.
“Clinical Decision Support (CDS) functionalities enable providers to evaluate the validity of vaccine doses administered to patients and forecast future vaccines that will be needed, based on recommendations developed by the Advisory Committee on Immunization Practices,” Dr. Murthy and his associates said. In 2016, 58% of the 55 jurisdictions sent a vaccine forecast to another system, compared with 31% in 2013.
In 2016, 95% of the 55 jurisdictions gave a “predefined, automatic report on immunization coverage by provider site,” compared with 89% of jurisdictions in 2013.
“IISs are integral components of routine clinical practice and public health surveillance for immunization,” Dr. Murthy and his associates said. “Availability of more complete IIS data also offers many benefits to health care providers and public health practitioners, including consolidating patients’ vaccination histories, identifying undervaccinated subgroups, and forecasting the needs of individual patients for recommended vaccines.”
Read more in Morbidity and Mortality Weekly Report (2017 Nov 3;66[43]:1178-81).
From 2013 to 2016, all U.S. immunization information systems showed progress in bidirectional information exchange with EHRs, said Neil Murthy, MD, and his associates at the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta.
Across all 55 jurisdictions in 49 states and six cities in the United States using immunization information systems (IIS), 106% of U.S. births were registered in IIS in 2016, which is an increase from 102% in 2013; percentages may exceed 100%, because a child who is born in one state but who lives in a different state might be recorded in both IISs.
Bidirectional exchange of data with EHRs is an important part of an IIS. In 2016, 91% of jurisdictions had an IIS that used a platform-independent messaging system that received vaccination histories from providers and returned acknowledgment messages, compared with 87% in 2013, the investigators said.
“Clinical Decision Support (CDS) functionalities enable providers to evaluate the validity of vaccine doses administered to patients and forecast future vaccines that will be needed, based on recommendations developed by the Advisory Committee on Immunization Practices,” Dr. Murthy and his associates said. In 2016, 58% of the 55 jurisdictions sent a vaccine forecast to another system, compared with 31% in 2013.
In 2016, 95% of the 55 jurisdictions gave a “predefined, automatic report on immunization coverage by provider site,” compared with 89% of jurisdictions in 2013.
“IISs are integral components of routine clinical practice and public health surveillance for immunization,” Dr. Murthy and his associates said. “Availability of more complete IIS data also offers many benefits to health care providers and public health practitioners, including consolidating patients’ vaccination histories, identifying undervaccinated subgroups, and forecasting the needs of individual patients for recommended vaccines.”
Read more in Morbidity and Mortality Weekly Report (2017 Nov 3;66[43]:1178-81).
From 2013 to 2016, all U.S. immunization information systems showed progress in bidirectional information exchange with EHRs, said Neil Murthy, MD, and his associates at the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta.
Across all 55 jurisdictions in 49 states and six cities in the United States using immunization information systems (IIS), 106% of U.S. births were registered in IIS in 2016, which is an increase from 102% in 2013; percentages may exceed 100%, because a child who is born in one state but who lives in a different state might be recorded in both IISs.
Bidirectional exchange of data with EHRs is an important part of an IIS. In 2016, 91% of jurisdictions had an IIS that used a platform-independent messaging system that received vaccination histories from providers and returned acknowledgment messages, compared with 87% in 2013, the investigators said.
“Clinical Decision Support (CDS) functionalities enable providers to evaluate the validity of vaccine doses administered to patients and forecast future vaccines that will be needed, based on recommendations developed by the Advisory Committee on Immunization Practices,” Dr. Murthy and his associates said. In 2016, 58% of the 55 jurisdictions sent a vaccine forecast to another system, compared with 31% in 2013.
In 2016, 95% of the 55 jurisdictions gave a “predefined, automatic report on immunization coverage by provider site,” compared with 89% of jurisdictions in 2013.
“IISs are integral components of routine clinical practice and public health surveillance for immunization,” Dr. Murthy and his associates said. “Availability of more complete IIS data also offers many benefits to health care providers and public health practitioners, including consolidating patients’ vaccination histories, identifying undervaccinated subgroups, and forecasting the needs of individual patients for recommended vaccines.”
Read more in Morbidity and Mortality Weekly Report (2017 Nov 3;66[43]:1178-81).
FROM MMWR
Pediatric thyroid nodules: Experienced radiologists best ultrasound risk stratification
VICTORIA, B.C. – Ultrasound risk criteria for adults are no match for the training, skill, and gut instinct of an experienced radiologist when evaluating pediatric thyroid nodules, results of a retrospective cohort study reported at the annual meeting of the American Thyroid Association suggest.
“In 2015, the ATA commissioned a pediatric task force that developed valuable guidelines specific to our pediatric patients. These guidelines recommend performing an FNA [fine-needle aspiration biopsy] in any nodule with a concerning clinical history or a concerning ultrasound feature,” commented first author Ana L. Creo, MD, a pediatric endocrinology fellow at the Mayo Clinic in Rochester, Minn.
She and her colleagues analyzed findings from diagnostic ultrasound in 112 patients aged under 21 years who had 145 thyroid nodules that were ultimately assessed histologically or cytologically.
Results showed that the radiologists’ overall impression and the ATA risk-stratification system for adults had the same high sensitivity, picking up 9 out of 10 malignant cases, she reported. But the radiologists’ overall impression had much higher specificity, correctly classifying 8 out of 10 benign cases, versus about 5 out of 10 for the risk stratification.
“These findings may have implications in trying to avoid unnecessary FNAs, particularly in our population,” Dr. Creo summarized. “Our million dollar question is trying to get in the heads of the radiologists to figure out what really goes into that overall impression. And if we can apply a specific score to that, I think that would be most clinically useful.”
“Based upon these results, further work is needed to determine the usefulness of the adult ATA ultrasound risk stratification in children, moving towards an ultrasound-based stratification system specific to our pediatric patients,” she concluded.
One session cochair, Catherine A. Dinauer, MD, a pediatric endocrinologist and clinician at the Yale Pediatric Thyroid Center, New Haven, Conn., commented, “It seems as though we’re pretty good at picking up which nodules are malignant, but I still feel like so many of the nodules that are benign are suspicious by ultrasound. Trying to tease out what is it about those benign ones may allow us to figure out in which ones we could avoid biopsy. That’s where we see we are not that good at it.”
Nodule attributes that might help in this regard include subtypes of microcalcifications, irregular margins, and position of the nodule in the gland relative to the skin, she proposed.
The other session cochair, Yaron Tomer, MD, chair of the department of medicine and the Anita and Jack Saltz Chair in Diabetes Research at the Montefiore Medical Center, New York, stressed knowing one’s radiologist and questioned the generalizability of the findings.
“You have to know your own radiologist well and how well you can trust them. Probably, the investigators chose some of the top radiologists in their institution and maybe even in the nation, so we have to be careful as to whether this applies to places that don’t have access to such great radiologists,” he commented. “But I think even if the guidelines are not perfect, they are the best we have right now.”
Study details
The investigators studied pediatric patients (mean age, 15.5 years) with thyroid nodules who underwent initial ultrasound at the Mayo Clinic during 1996-2015, had at least a year of follow-up, and for whom histology or cytology results were available. Those with a known genetic tumor syndrome or a history of radiation exposure were excluded.
Two blinded radiologists assessed nodule ultrasound features using the Thyroid Imaging and Reporting Data System (TIRADS) (J Am Coll Radiol. 2015;12[12 Pt A]:1272-9) and then rendered their overall impression: malignant, indeterminate, or benign.
Next, an independent reviewer assigned each nodule an ATA adult risk category (Thyroid. 2016;26:1-133): high, intermediate, low, or very low suspicion.
Finally, both measures were compared against the reference standard of the nodule’s histology or cytology results.
Ultimately, 34% of the patients had malignant nodules, Dr. Creo reported. “This is likely quite a bit elevated from the true prevalence due to our intentional study design requiring follow-up, likely excluding some patients with benign nodules,” she commented.
Patients with benign and malignant nodules did not differ significantly on any of a variety of sociodemographic and clinical factors, such as family history and mode of detection.
For comparison of sensitivity, the investigators combined the ATA risk categories of high and intermediate suspicion and combined the overall radiologists’ impression of malignant and indeterminate. “We felt this best answered the practical clinical question of how many malignant nodules would be missed if FNA was not performed, assuming FNA would typically be performed if the ATA risk stratification was high or intermediate or if the radiologist’s overall impression was malignant or indeterminate,” Dr. Creo explained.
Results here showed that the ATA risk stratification and the radiologists’ overall impression had the same high sensitivity of 90%.
For comparison of specificity, the investigators compared the ATA risk category of high suspicion with the radiologists’ overall impression of malignant.
Results showed that the overall impression had specificity of 80%, whereas the risk category had a specificity of only about 52%. Findings were similar when analyses instead used ATA high suspicion and intermediate suspicion combined.
“The key ultrasound characteristics that drove the diagnosis included having a solid component, calcifications, irregular margins, and hypoechogenicity – all similar to those seen in pediatric studies and similar to those in adult studies as well,” Dr. Creo noted.
Compared with benign nodules, malignant nodules significantly more often had a greater than 75% solid component (84% vs. 64%; P = .01), contained calcifications (60% vs. 18%; P less than .0001), had irregular margins (70% vs. 46%; P = .0073), and were hypoechogenic (74% vs. 51%; P = .0073). Notably, size and presence of halo did not differ significantly.
“Our study adds to previous work in that it had a relatively large pediatric sample size, used strict inclusion criteria with at least a year of follow-up to increase the validity of the diagnosis, and had precise definitions of the ultrasound features,” concluded Dr. Creo, who disclosed that she had no relevant conflicts of interest.
At the same time, the study had limitations, such as its use of a referral population, likely loss to follow-up of some patients with benign nodules, and possible clustering effect. “Lastly, we had the benefit of extremely experienced pediatric radiologists, and their overall diagnostic accuracy may not universally apply across all radiologists,” she said.
VICTORIA, B.C. – Ultrasound risk criteria for adults are no match for the training, skill, and gut instinct of an experienced radiologist when evaluating pediatric thyroid nodules, results of a retrospective cohort study reported at the annual meeting of the American Thyroid Association suggest.
“In 2015, the ATA commissioned a pediatric task force that developed valuable guidelines specific to our pediatric patients. These guidelines recommend performing an FNA [fine-needle aspiration biopsy] in any nodule with a concerning clinical history or a concerning ultrasound feature,” commented first author Ana L. Creo, MD, a pediatric endocrinology fellow at the Mayo Clinic in Rochester, Minn.
She and her colleagues analyzed findings from diagnostic ultrasound in 112 patients aged under 21 years who had 145 thyroid nodules that were ultimately assessed histologically or cytologically.
Results showed that the radiologists’ overall impression and the ATA risk-stratification system for adults had the same high sensitivity, picking up 9 out of 10 malignant cases, she reported. But the radiologists’ overall impression had much higher specificity, correctly classifying 8 out of 10 benign cases, versus about 5 out of 10 for the risk stratification.
“These findings may have implications in trying to avoid unnecessary FNAs, particularly in our population,” Dr. Creo summarized. “Our million dollar question is trying to get in the heads of the radiologists to figure out what really goes into that overall impression. And if we can apply a specific score to that, I think that would be most clinically useful.”
“Based upon these results, further work is needed to determine the usefulness of the adult ATA ultrasound risk stratification in children, moving towards an ultrasound-based stratification system specific to our pediatric patients,” she concluded.
One session cochair, Catherine A. Dinauer, MD, a pediatric endocrinologist and clinician at the Yale Pediatric Thyroid Center, New Haven, Conn., commented, “It seems as though we’re pretty good at picking up which nodules are malignant, but I still feel like so many of the nodules that are benign are suspicious by ultrasound. Trying to tease out what is it about those benign ones may allow us to figure out in which ones we could avoid biopsy. That’s where we see we are not that good at it.”
Nodule attributes that might help in this regard include subtypes of microcalcifications, irregular margins, and position of the nodule in the gland relative to the skin, she proposed.
The other session cochair, Yaron Tomer, MD, chair of the department of medicine and the Anita and Jack Saltz Chair in Diabetes Research at the Montefiore Medical Center, New York, stressed knowing one’s radiologist and questioned the generalizability of the findings.
“You have to know your own radiologist well and how well you can trust them. Probably, the investigators chose some of the top radiologists in their institution and maybe even in the nation, so we have to be careful as to whether this applies to places that don’t have access to such great radiologists,” he commented. “But I think even if the guidelines are not perfect, they are the best we have right now.”
Study details
The investigators studied pediatric patients (mean age, 15.5 years) with thyroid nodules who underwent initial ultrasound at the Mayo Clinic during 1996-2015, had at least a year of follow-up, and for whom histology or cytology results were available. Those with a known genetic tumor syndrome or a history of radiation exposure were excluded.
Two blinded radiologists assessed nodule ultrasound features using the Thyroid Imaging and Reporting Data System (TIRADS) (J Am Coll Radiol. 2015;12[12 Pt A]:1272-9) and then rendered their overall impression: malignant, indeterminate, or benign.
Next, an independent reviewer assigned each nodule an ATA adult risk category (Thyroid. 2016;26:1-133): high, intermediate, low, or very low suspicion.
Finally, both measures were compared against the reference standard of the nodule’s histology or cytology results.
Ultimately, 34% of the patients had malignant nodules, Dr. Creo reported. “This is likely quite a bit elevated from the true prevalence due to our intentional study design requiring follow-up, likely excluding some patients with benign nodules,” she commented.
Patients with benign and malignant nodules did not differ significantly on any of a variety of sociodemographic and clinical factors, such as family history and mode of detection.
For comparison of sensitivity, the investigators combined the ATA risk categories of high and intermediate suspicion and combined the overall radiologists’ impression of malignant and indeterminate. “We felt this best answered the practical clinical question of how many malignant nodules would be missed if FNA was not performed, assuming FNA would typically be performed if the ATA risk stratification was high or intermediate or if the radiologist’s overall impression was malignant or indeterminate,” Dr. Creo explained.
Results here showed that the ATA risk stratification and the radiologists’ overall impression had the same high sensitivity of 90%.
For comparison of specificity, the investigators compared the ATA risk category of high suspicion with the radiologists’ overall impression of malignant.
Results showed that the overall impression had specificity of 80%, whereas the risk category had a specificity of only about 52%. Findings were similar when analyses instead used ATA high suspicion and intermediate suspicion combined.
“The key ultrasound characteristics that drove the diagnosis included having a solid component, calcifications, irregular margins, and hypoechogenicity – all similar to those seen in pediatric studies and similar to those in adult studies as well,” Dr. Creo noted.
Compared with benign nodules, malignant nodules significantly more often had a greater than 75% solid component (84% vs. 64%; P = .01), contained calcifications (60% vs. 18%; P less than .0001), had irregular margins (70% vs. 46%; P = .0073), and were hypoechogenic (74% vs. 51%; P = .0073). Notably, size and presence of halo did not differ significantly.
“Our study adds to previous work in that it had a relatively large pediatric sample size, used strict inclusion criteria with at least a year of follow-up to increase the validity of the diagnosis, and had precise definitions of the ultrasound features,” concluded Dr. Creo, who disclosed that she had no relevant conflicts of interest.
At the same time, the study had limitations, such as its use of a referral population, likely loss to follow-up of some patients with benign nodules, and possible clustering effect. “Lastly, we had the benefit of extremely experienced pediatric radiologists, and their overall diagnostic accuracy may not universally apply across all radiologists,” she said.
VICTORIA, B.C. – Ultrasound risk criteria for adults are no match for the training, skill, and gut instinct of an experienced radiologist when evaluating pediatric thyroid nodules, results of a retrospective cohort study reported at the annual meeting of the American Thyroid Association suggest.
“In 2015, the ATA commissioned a pediatric task force that developed valuable guidelines specific to our pediatric patients. These guidelines recommend performing an FNA [fine-needle aspiration biopsy] in any nodule with a concerning clinical history or a concerning ultrasound feature,” commented first author Ana L. Creo, MD, a pediatric endocrinology fellow at the Mayo Clinic in Rochester, Minn.
She and her colleagues analyzed findings from diagnostic ultrasound in 112 patients aged under 21 years who had 145 thyroid nodules that were ultimately assessed histologically or cytologically.
Results showed that the radiologists’ overall impression and the ATA risk-stratification system for adults had the same high sensitivity, picking up 9 out of 10 malignant cases, she reported. But the radiologists’ overall impression had much higher specificity, correctly classifying 8 out of 10 benign cases, versus about 5 out of 10 for the risk stratification.
“These findings may have implications in trying to avoid unnecessary FNAs, particularly in our population,” Dr. Creo summarized. “Our million dollar question is trying to get in the heads of the radiologists to figure out what really goes into that overall impression. And if we can apply a specific score to that, I think that would be most clinically useful.”
“Based upon these results, further work is needed to determine the usefulness of the adult ATA ultrasound risk stratification in children, moving towards an ultrasound-based stratification system specific to our pediatric patients,” she concluded.
One session cochair, Catherine A. Dinauer, MD, a pediatric endocrinologist and clinician at the Yale Pediatric Thyroid Center, New Haven, Conn., commented, “It seems as though we’re pretty good at picking up which nodules are malignant, but I still feel like so many of the nodules that are benign are suspicious by ultrasound. Trying to tease out what is it about those benign ones may allow us to figure out in which ones we could avoid biopsy. That’s where we see we are not that good at it.”
Nodule attributes that might help in this regard include subtypes of microcalcifications, irregular margins, and position of the nodule in the gland relative to the skin, she proposed.
The other session cochair, Yaron Tomer, MD, chair of the department of medicine and the Anita and Jack Saltz Chair in Diabetes Research at the Montefiore Medical Center, New York, stressed knowing one’s radiologist and questioned the generalizability of the findings.
“You have to know your own radiologist well and how well you can trust them. Probably, the investigators chose some of the top radiologists in their institution and maybe even in the nation, so we have to be careful as to whether this applies to places that don’t have access to such great radiologists,” he commented. “But I think even if the guidelines are not perfect, they are the best we have right now.”
Study details
The investigators studied pediatric patients (mean age, 15.5 years) with thyroid nodules who underwent initial ultrasound at the Mayo Clinic during 1996-2015, had at least a year of follow-up, and for whom histology or cytology results were available. Those with a known genetic tumor syndrome or a history of radiation exposure were excluded.
Two blinded radiologists assessed nodule ultrasound features using the Thyroid Imaging and Reporting Data System (TIRADS) (J Am Coll Radiol. 2015;12[12 Pt A]:1272-9) and then rendered their overall impression: malignant, indeterminate, or benign.
Next, an independent reviewer assigned each nodule an ATA adult risk category (Thyroid. 2016;26:1-133): high, intermediate, low, or very low suspicion.
Finally, both measures were compared against the reference standard of the nodule’s histology or cytology results.
Ultimately, 34% of the patients had malignant nodules, Dr. Creo reported. “This is likely quite a bit elevated from the true prevalence due to our intentional study design requiring follow-up, likely excluding some patients with benign nodules,” she commented.
Patients with benign and malignant nodules did not differ significantly on any of a variety of sociodemographic and clinical factors, such as family history and mode of detection.
For comparison of sensitivity, the investigators combined the ATA risk categories of high and intermediate suspicion and combined the overall radiologists’ impression of malignant and indeterminate. “We felt this best answered the practical clinical question of how many malignant nodules would be missed if FNA was not performed, assuming FNA would typically be performed if the ATA risk stratification was high or intermediate or if the radiologist’s overall impression was malignant or indeterminate,” Dr. Creo explained.
Results here showed that the ATA risk stratification and the radiologists’ overall impression had the same high sensitivity of 90%.
For comparison of specificity, the investigators compared the ATA risk category of high suspicion with the radiologists’ overall impression of malignant.
Results showed that the overall impression had specificity of 80%, whereas the risk category had a specificity of only about 52%. Findings were similar when analyses instead used ATA high suspicion and intermediate suspicion combined.
“The key ultrasound characteristics that drove the diagnosis included having a solid component, calcifications, irregular margins, and hypoechogenicity – all similar to those seen in pediatric studies and similar to those in adult studies as well,” Dr. Creo noted.
Compared with benign nodules, malignant nodules significantly more often had a greater than 75% solid component (84% vs. 64%; P = .01), contained calcifications (60% vs. 18%; P less than .0001), had irregular margins (70% vs. 46%; P = .0073), and were hypoechogenic (74% vs. 51%; P = .0073). Notably, size and presence of halo did not differ significantly.
“Our study adds to previous work in that it had a relatively large pediatric sample size, used strict inclusion criteria with at least a year of follow-up to increase the validity of the diagnosis, and had precise definitions of the ultrasound features,” concluded Dr. Creo, who disclosed that she had no relevant conflicts of interest.
At the same time, the study had limitations, such as its use of a referral population, likely loss to follow-up of some patients with benign nodules, and possible clustering effect. “Lastly, we had the benefit of extremely experienced pediatric radiologists, and their overall diagnostic accuracy may not universally apply across all radiologists,” she said.
AT ATA 2017
Key clinical point:
Major finding: Radiologists’ overall impression and ATA risk stratification had the same good sensitivity (90% for each), but the former had higher specificity (80% vs. 52%).
Data source: A retrospective cohort study of 112 patients younger than 21 who had 145 thyroid nodules.
Disclosures: Dr. Creo disclosed that she had no relevant conflicts of interest.
Teach your adolescent patients about normal menses, so they know when it’s abnormal
CHICAGO – , according to S. Paige Hertweck, MD, chief of gynecology at Norton Children’s Hospital in Louisville, Ky.
“Remember to use the menstrual cycle as a vital sign,” Dr. Hertweck told attendees at the American Academy of Pediatrics annual meeting. “Even within the first year of menarche, most girls have a period at least every 90 days, so work up those who don’t.”
The median age of menarche is 12.4 years, typically beginning within 2-3 years of breast budding at Tanner Stage 4 breast development, she said. By 15 years of age, 98% of girls have begun menstruation.
Girls’ cycles typically last 21-45 days, an average of 32.2 days during their first year of menstruation, with flow for 7 days or less, requiring an average of 3-6 pads and/or tampons per day. Dr. Hertweck recommends you write down these features of normal menstruation so that your patients can tell you when their cycle is abnormal or menses doesn’t return.
“Cycle length is more variable for teens versus women 20-40 years old,” she said. However, “it’s not true that ‘anything goes’ for cycle length” in teens, she added. “Cycles that are consistently outside the range of 21-45 days are statistically uncommon.” Hence the need to evaluate causes of amenorrhea in girls whose cycles exceed 90 days.
Possible causes of amenorrhea include pregnancy, polycystic ovary syndrome, thyroid abnormalities, hyperprolactinemia, primary ovarian insufficiency, or hypogonadal amenorrhea, typically stimulated by the first instance of anorexia, Crohn’s disease, celiac disease, or a gluten intolerance.
Primary amenorrhea
Dr. Hertweck listed five benchmarks that indicate primary amenorrhea requiring evaluation. Those indicators include girls who have no menarche by age 15 years or within 3 years of breast budding, no breast development by age 13 years, or no menses by age 14 years with hirsutism or with a history of excessive exercise or of an eating disorder.
You can start by examining what normal menstruation relies on: an intact central nervous system with a functioning pituitary, an ovarian response, and a normal uterus, cervix, and vagina. You should check the patient’s follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels to assess CNS functioning, and estradiol levels to assess ovarian response. A genital exam with a pelvic ultrasound can reveal any possible defects in the uterus, cervix, or vagina.
The presence of breasts without a uterus indicates normal estrogen production, so the missing uterus could be a congenital defect or result from androgen insensitivity, Dr. Hertweck explained. In those without breasts, gonadal dysgenesis or gonadal enzymatic deficiency may explain no estrogen production. If the patient has both breasts and a uterus, you should rule out pregnancy first and then track CNS changes via FSH, TSH, and prolactin levels.
Premature ovarian insufficiency
Approximately 1% of females experience premature ovarian insufficiency, which can be diagnosed as early as age 14 years and should be suspected in a patient with a uterus but without breasts who has low estradiol levels, CNS failure identified by a high FSH level, and gonadal failure.
Formal diagnosis requires two separate instances of FSH elevation, and chromosomal testing should be done to rule out gonadal dysgenesis. You also should test the serum anti-Müllerian hormone biomarker (readings above 8 are concerning) and look for two possible causes. The FMR1 (Fragile X) premutation carrier status could be a cause, or presence of 21-hydroxylase and/or adrenal antibodies indicate autoimmune polyglandular syndrome.
Catching premature ovarian insufficiency early enough may allow patients to preserve some fertility if they still have oocytes present. Aside from this, girls will need hormone replacement therapy to fulfill developmental emotional and physical needs, such as bone growth and overall health. Despite a history of treating teens with premature ovarian insufficiency like adults, you should follow the practice guidelines specific to adolescents by the American College of Obstetricians and Gynecologists committee opinion statement (Obstet Gynecol. 2014;123:193-7).
Menorrhagia: heavy menstrual bleeding
Even though average blood loss is estimated at 30 mL per period, that number means little in clinical practice because patients cannot measure the actual amount of menses. Better indicators of abnormally greater flow include flow lasting longer than 7 days, finding clots larger than a quarter, changing menstrual products every 1-2 hours, leaking onto clothing such that patients need to take extra clothes to school, and any heavy periods that occur with easy bruising or with a family history of bleeding disorders.
First-line treatment for heavy menstrual bleeding in teens is hormonal contraception, either combination oral contraceptive pills, the transdermal patch, or the intravaginal ring, which can be combined with other therapies.
An alternative for those under age 18 (per Food and Drug Administration labeling) is oral tranexamic acid, found in a crossover trial with an oral contraceptive pill to be just as effective at reducing average blood loss and improving quality of life, but with fewer side effects and better compliance. Before prescribing anything for heavy menstrual bleeding, however, you must consider possible causes and rule some out that require different management.
Aside from pregnancy, one potential cause of menorrhagia is infection such as chlamydia or gonorrhea, which should be considered even in those with a negative sexual history, Dr. Hertweck said. Other possible causes include an immature hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (even with low hemoglobin), malignancy with a hormone-producing tumor, hypothalamic dysfunction (often stimulated by eating disorders, obesity, rapid weight loss, or gluten intolerance), or coagulopathy.
“Teens with menorrhagia may need to be screened for a bleeding disorder,” Dr. Hertweck said. At a minimum, she recommends checking complete blood count, ferritin, and TSH. “The most common bleeding disorders associated with heavy menstrual bleeding include platelet function disorders and von Willebrand.”
Up to half of teen girls with menorrhagia who visit a hematologist or multidisciplinary clinic receive a diagnosis of a bleeding disorder, Dr. Hertweck said. And up to half of those with menorrhagia at menarche may have von Willebrand, as do one in six adolescents who go to the emergency department because of heavy menstrual bleeding.
Von Willebrand syndrome
Von Willebrand syndrome is a deficiency or dysfunction of von Willebrand factor (vWF), a protein with binding sites for platelets, collagen, and factor VIII that “serves as a bridge between platelets and injury sites in vessel walls” and “protects factor VIII from rapid proteolytic degradation,” Dr. Hertweck said. Von Willebrand syndrome is the most common inherited congenital bleeding disorder. Although acquired von Willebrand syndrome is rare, it has grown in incidence among those with complex cardiovascular, hematologic, or immunologic disorders.
“Correct diagnosis is complex and not always straightforward,” Dr. Hertweck said, but “a positive response to questions in four categories is highly sensitive.” They are as follows:
• Menses lasting at least 7 days and interfering with a person’s daily activities.
• “History of treatment for anemia.
• Family history of a diagnosed bleeding disorder.
• History of excessive bleeding after tooth extraction, delivery, miscarriage, or surgery.
Diagnostic assays include platelet concentration of vWF antigen, an activity test of vWF-platelet binding, and factor VIII activity. However, you often need to repeat diagnostic testing because vWF antigens vary according to race, blood type, age, acute phase response, and menstrual cycle timing, Dr. Hertweck said.
“Remember to draw von Willebrand testing only during the first 3 days of the menstrual cycle when estrogen levels are at the nadir,” she said.
Because estrogen increases vWF, treatment for von Willebrand syndrome should be progestin only, either oral pills, medroxyprogesterone acetate (MPA, or Depo-Provera injections), or an etonogestrel implant.
Dr. Hertweck presented several cases of abnormal menstruation and extreme conditions such as severe menorrhagia. Outside of von Willebrand in such patients, possible platelet disorders could include Glanzmann thrombasthenia (a platelet function disorder that is caused by an abnormality in the genes for glycoproteins IIb/IIIa) and platelet storage pool disorder, both of which should be diagnosed by a hematologist.
Dr. Hertweck reported having a research grant from Merck related to contraceptive implants in adolescents.
CHICAGO – , according to S. Paige Hertweck, MD, chief of gynecology at Norton Children’s Hospital in Louisville, Ky.
“Remember to use the menstrual cycle as a vital sign,” Dr. Hertweck told attendees at the American Academy of Pediatrics annual meeting. “Even within the first year of menarche, most girls have a period at least every 90 days, so work up those who don’t.”
The median age of menarche is 12.4 years, typically beginning within 2-3 years of breast budding at Tanner Stage 4 breast development, she said. By 15 years of age, 98% of girls have begun menstruation.
Girls’ cycles typically last 21-45 days, an average of 32.2 days during their first year of menstruation, with flow for 7 days or less, requiring an average of 3-6 pads and/or tampons per day. Dr. Hertweck recommends you write down these features of normal menstruation so that your patients can tell you when their cycle is abnormal or menses doesn’t return.
“Cycle length is more variable for teens versus women 20-40 years old,” she said. However, “it’s not true that ‘anything goes’ for cycle length” in teens, she added. “Cycles that are consistently outside the range of 21-45 days are statistically uncommon.” Hence the need to evaluate causes of amenorrhea in girls whose cycles exceed 90 days.
Possible causes of amenorrhea include pregnancy, polycystic ovary syndrome, thyroid abnormalities, hyperprolactinemia, primary ovarian insufficiency, or hypogonadal amenorrhea, typically stimulated by the first instance of anorexia, Crohn’s disease, celiac disease, or a gluten intolerance.
Primary amenorrhea
Dr. Hertweck listed five benchmarks that indicate primary amenorrhea requiring evaluation. Those indicators include girls who have no menarche by age 15 years or within 3 years of breast budding, no breast development by age 13 years, or no menses by age 14 years with hirsutism or with a history of excessive exercise or of an eating disorder.
You can start by examining what normal menstruation relies on: an intact central nervous system with a functioning pituitary, an ovarian response, and a normal uterus, cervix, and vagina. You should check the patient’s follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels to assess CNS functioning, and estradiol levels to assess ovarian response. A genital exam with a pelvic ultrasound can reveal any possible defects in the uterus, cervix, or vagina.
The presence of breasts without a uterus indicates normal estrogen production, so the missing uterus could be a congenital defect or result from androgen insensitivity, Dr. Hertweck explained. In those without breasts, gonadal dysgenesis or gonadal enzymatic deficiency may explain no estrogen production. If the patient has both breasts and a uterus, you should rule out pregnancy first and then track CNS changes via FSH, TSH, and prolactin levels.
Premature ovarian insufficiency
Approximately 1% of females experience premature ovarian insufficiency, which can be diagnosed as early as age 14 years and should be suspected in a patient with a uterus but without breasts who has low estradiol levels, CNS failure identified by a high FSH level, and gonadal failure.
Formal diagnosis requires two separate instances of FSH elevation, and chromosomal testing should be done to rule out gonadal dysgenesis. You also should test the serum anti-Müllerian hormone biomarker (readings above 8 are concerning) and look for two possible causes. The FMR1 (Fragile X) premutation carrier status could be a cause, or presence of 21-hydroxylase and/or adrenal antibodies indicate autoimmune polyglandular syndrome.
Catching premature ovarian insufficiency early enough may allow patients to preserve some fertility if they still have oocytes present. Aside from this, girls will need hormone replacement therapy to fulfill developmental emotional and physical needs, such as bone growth and overall health. Despite a history of treating teens with premature ovarian insufficiency like adults, you should follow the practice guidelines specific to adolescents by the American College of Obstetricians and Gynecologists committee opinion statement (Obstet Gynecol. 2014;123:193-7).
Menorrhagia: heavy menstrual bleeding
Even though average blood loss is estimated at 30 mL per period, that number means little in clinical practice because patients cannot measure the actual amount of menses. Better indicators of abnormally greater flow include flow lasting longer than 7 days, finding clots larger than a quarter, changing menstrual products every 1-2 hours, leaking onto clothing such that patients need to take extra clothes to school, and any heavy periods that occur with easy bruising or with a family history of bleeding disorders.
First-line treatment for heavy menstrual bleeding in teens is hormonal contraception, either combination oral contraceptive pills, the transdermal patch, or the intravaginal ring, which can be combined with other therapies.
An alternative for those under age 18 (per Food and Drug Administration labeling) is oral tranexamic acid, found in a crossover trial with an oral contraceptive pill to be just as effective at reducing average blood loss and improving quality of life, but with fewer side effects and better compliance. Before prescribing anything for heavy menstrual bleeding, however, you must consider possible causes and rule some out that require different management.
Aside from pregnancy, one potential cause of menorrhagia is infection such as chlamydia or gonorrhea, which should be considered even in those with a negative sexual history, Dr. Hertweck said. Other possible causes include an immature hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (even with low hemoglobin), malignancy with a hormone-producing tumor, hypothalamic dysfunction (often stimulated by eating disorders, obesity, rapid weight loss, or gluten intolerance), or coagulopathy.
“Teens with menorrhagia may need to be screened for a bleeding disorder,” Dr. Hertweck said. At a minimum, she recommends checking complete blood count, ferritin, and TSH. “The most common bleeding disorders associated with heavy menstrual bleeding include platelet function disorders and von Willebrand.”
Up to half of teen girls with menorrhagia who visit a hematologist or multidisciplinary clinic receive a diagnosis of a bleeding disorder, Dr. Hertweck said. And up to half of those with menorrhagia at menarche may have von Willebrand, as do one in six adolescents who go to the emergency department because of heavy menstrual bleeding.
Von Willebrand syndrome
Von Willebrand syndrome is a deficiency or dysfunction of von Willebrand factor (vWF), a protein with binding sites for platelets, collagen, and factor VIII that “serves as a bridge between platelets and injury sites in vessel walls” and “protects factor VIII from rapid proteolytic degradation,” Dr. Hertweck said. Von Willebrand syndrome is the most common inherited congenital bleeding disorder. Although acquired von Willebrand syndrome is rare, it has grown in incidence among those with complex cardiovascular, hematologic, or immunologic disorders.
“Correct diagnosis is complex and not always straightforward,” Dr. Hertweck said, but “a positive response to questions in four categories is highly sensitive.” They are as follows:
• Menses lasting at least 7 days and interfering with a person’s daily activities.
• “History of treatment for anemia.
• Family history of a diagnosed bleeding disorder.
• History of excessive bleeding after tooth extraction, delivery, miscarriage, or surgery.
Diagnostic assays include platelet concentration of vWF antigen, an activity test of vWF-platelet binding, and factor VIII activity. However, you often need to repeat diagnostic testing because vWF antigens vary according to race, blood type, age, acute phase response, and menstrual cycle timing, Dr. Hertweck said.
“Remember to draw von Willebrand testing only during the first 3 days of the menstrual cycle when estrogen levels are at the nadir,” she said.
Because estrogen increases vWF, treatment for von Willebrand syndrome should be progestin only, either oral pills, medroxyprogesterone acetate (MPA, or Depo-Provera injections), or an etonogestrel implant.
Dr. Hertweck presented several cases of abnormal menstruation and extreme conditions such as severe menorrhagia. Outside of von Willebrand in such patients, possible platelet disorders could include Glanzmann thrombasthenia (a platelet function disorder that is caused by an abnormality in the genes for glycoproteins IIb/IIIa) and platelet storage pool disorder, both of which should be diagnosed by a hematologist.
Dr. Hertweck reported having a research grant from Merck related to contraceptive implants in adolescents.
CHICAGO – , according to S. Paige Hertweck, MD, chief of gynecology at Norton Children’s Hospital in Louisville, Ky.
“Remember to use the menstrual cycle as a vital sign,” Dr. Hertweck told attendees at the American Academy of Pediatrics annual meeting. “Even within the first year of menarche, most girls have a period at least every 90 days, so work up those who don’t.”
The median age of menarche is 12.4 years, typically beginning within 2-3 years of breast budding at Tanner Stage 4 breast development, she said. By 15 years of age, 98% of girls have begun menstruation.
Girls’ cycles typically last 21-45 days, an average of 32.2 days during their first year of menstruation, with flow for 7 days or less, requiring an average of 3-6 pads and/or tampons per day. Dr. Hertweck recommends you write down these features of normal menstruation so that your patients can tell you when their cycle is abnormal or menses doesn’t return.
“Cycle length is more variable for teens versus women 20-40 years old,” she said. However, “it’s not true that ‘anything goes’ for cycle length” in teens, she added. “Cycles that are consistently outside the range of 21-45 days are statistically uncommon.” Hence the need to evaluate causes of amenorrhea in girls whose cycles exceed 90 days.
Possible causes of amenorrhea include pregnancy, polycystic ovary syndrome, thyroid abnormalities, hyperprolactinemia, primary ovarian insufficiency, or hypogonadal amenorrhea, typically stimulated by the first instance of anorexia, Crohn’s disease, celiac disease, or a gluten intolerance.
Primary amenorrhea
Dr. Hertweck listed five benchmarks that indicate primary amenorrhea requiring evaluation. Those indicators include girls who have no menarche by age 15 years or within 3 years of breast budding, no breast development by age 13 years, or no menses by age 14 years with hirsutism or with a history of excessive exercise or of an eating disorder.
You can start by examining what normal menstruation relies on: an intact central nervous system with a functioning pituitary, an ovarian response, and a normal uterus, cervix, and vagina. You should check the patient’s follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels to assess CNS functioning, and estradiol levels to assess ovarian response. A genital exam with a pelvic ultrasound can reveal any possible defects in the uterus, cervix, or vagina.
The presence of breasts without a uterus indicates normal estrogen production, so the missing uterus could be a congenital defect or result from androgen insensitivity, Dr. Hertweck explained. In those without breasts, gonadal dysgenesis or gonadal enzymatic deficiency may explain no estrogen production. If the patient has both breasts and a uterus, you should rule out pregnancy first and then track CNS changes via FSH, TSH, and prolactin levels.
Premature ovarian insufficiency
Approximately 1% of females experience premature ovarian insufficiency, which can be diagnosed as early as age 14 years and should be suspected in a patient with a uterus but without breasts who has low estradiol levels, CNS failure identified by a high FSH level, and gonadal failure.
Formal diagnosis requires two separate instances of FSH elevation, and chromosomal testing should be done to rule out gonadal dysgenesis. You also should test the serum anti-Müllerian hormone biomarker (readings above 8 are concerning) and look for two possible causes. The FMR1 (Fragile X) premutation carrier status could be a cause, or presence of 21-hydroxylase and/or adrenal antibodies indicate autoimmune polyglandular syndrome.
Catching premature ovarian insufficiency early enough may allow patients to preserve some fertility if they still have oocytes present. Aside from this, girls will need hormone replacement therapy to fulfill developmental emotional and physical needs, such as bone growth and overall health. Despite a history of treating teens with premature ovarian insufficiency like adults, you should follow the practice guidelines specific to adolescents by the American College of Obstetricians and Gynecologists committee opinion statement (Obstet Gynecol. 2014;123:193-7).
Menorrhagia: heavy menstrual bleeding
Even though average blood loss is estimated at 30 mL per period, that number means little in clinical practice because patients cannot measure the actual amount of menses. Better indicators of abnormally greater flow include flow lasting longer than 7 days, finding clots larger than a quarter, changing menstrual products every 1-2 hours, leaking onto clothing such that patients need to take extra clothes to school, and any heavy periods that occur with easy bruising or with a family history of bleeding disorders.
First-line treatment for heavy menstrual bleeding in teens is hormonal contraception, either combination oral contraceptive pills, the transdermal patch, or the intravaginal ring, which can be combined with other therapies.
An alternative for those under age 18 (per Food and Drug Administration labeling) is oral tranexamic acid, found in a crossover trial with an oral contraceptive pill to be just as effective at reducing average blood loss and improving quality of life, but with fewer side effects and better compliance. Before prescribing anything for heavy menstrual bleeding, however, you must consider possible causes and rule some out that require different management.
Aside from pregnancy, one potential cause of menorrhagia is infection such as chlamydia or gonorrhea, which should be considered even in those with a negative sexual history, Dr. Hertweck said. Other possible causes include an immature hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (even with low hemoglobin), malignancy with a hormone-producing tumor, hypothalamic dysfunction (often stimulated by eating disorders, obesity, rapid weight loss, or gluten intolerance), or coagulopathy.
“Teens with menorrhagia may need to be screened for a bleeding disorder,” Dr. Hertweck said. At a minimum, she recommends checking complete blood count, ferritin, and TSH. “The most common bleeding disorders associated with heavy menstrual bleeding include platelet function disorders and von Willebrand.”
Up to half of teen girls with menorrhagia who visit a hematologist or multidisciplinary clinic receive a diagnosis of a bleeding disorder, Dr. Hertweck said. And up to half of those with menorrhagia at menarche may have von Willebrand, as do one in six adolescents who go to the emergency department because of heavy menstrual bleeding.
Von Willebrand syndrome
Von Willebrand syndrome is a deficiency or dysfunction of von Willebrand factor (vWF), a protein with binding sites for platelets, collagen, and factor VIII that “serves as a bridge between platelets and injury sites in vessel walls” and “protects factor VIII from rapid proteolytic degradation,” Dr. Hertweck said. Von Willebrand syndrome is the most common inherited congenital bleeding disorder. Although acquired von Willebrand syndrome is rare, it has grown in incidence among those with complex cardiovascular, hematologic, or immunologic disorders.
“Correct diagnosis is complex and not always straightforward,” Dr. Hertweck said, but “a positive response to questions in four categories is highly sensitive.” They are as follows:
• Menses lasting at least 7 days and interfering with a person’s daily activities.
• “History of treatment for anemia.
• Family history of a diagnosed bleeding disorder.
• History of excessive bleeding after tooth extraction, delivery, miscarriage, or surgery.
Diagnostic assays include platelet concentration of vWF antigen, an activity test of vWF-platelet binding, and factor VIII activity. However, you often need to repeat diagnostic testing because vWF antigens vary according to race, blood type, age, acute phase response, and menstrual cycle timing, Dr. Hertweck said.
“Remember to draw von Willebrand testing only during the first 3 days of the menstrual cycle when estrogen levels are at the nadir,” she said.
Because estrogen increases vWF, treatment for von Willebrand syndrome should be progestin only, either oral pills, medroxyprogesterone acetate (MPA, or Depo-Provera injections), or an etonogestrel implant.
Dr. Hertweck presented several cases of abnormal menstruation and extreme conditions such as severe menorrhagia. Outside of von Willebrand in such patients, possible platelet disorders could include Glanzmann thrombasthenia (a platelet function disorder that is caused by an abnormality in the genes for glycoproteins IIb/IIIa) and platelet storage pool disorder, both of which should be diagnosed by a hematologist.
Dr. Hertweck reported having a research grant from Merck related to contraceptive implants in adolescents.
EXPERT ANALYSIS FROM AAP 2017
The pediatrician detective and high lead levels
I am not going to tell you about the dangers of lead, as it is well known and publicized, but I will tell you my family’s story with lead.
In 2012, 1 year after my younger daughter was born, I took her for her 1-year checkup. As I would do with any of my pediatric patients at this age, I took her for a lead level check. Never during my residency training or my first few years of practice as a pediatrician have I encountered a positive lead level. So when I opened the lab result sheet, I thought I would be shredding it the next moment. Well, that didn’t happen. It turned out that her lead level was 7 mcg/dL! Not too high, but detectable. The only question that kept on coming back over the next month or so was a big WHY? Why my child? Now my older daughter’s lead level was normal at her 1-year visit. We had just moved into a new house before my youngest daughter was born. I thought, it has to do with the house, and since my 1-year-old was putting everything in her mouth at this stage, then she must be getting the lead that way.
So it was not the house or the wall pipes that were contaminated with lead. It was not our food that we cooked, otherwise my nanny’s daughter would have had a high lead level, as she ate the same food we ate almost daily. Our family did not travel recently. So what was it that my family had or ate that my neighbor or nanny’s child did not?
The answer was thyme. It is an herb that we mix with olive oil and spread on dough – I call it Lebanese pizza. That is one thing that my nanny and her child never ate, but we did. It was a long painful month of investigation, elimination, and anxiety. I called the public health department in Phoenix and they stated that lots of imported spices were contaminated with lead. There were two theories as to why this might happen. The first one is that the spice dealers would add lead to increase the weight of the spices to get more money. The second is that the spice fields were close to factories that used lead in their manufacturing, and somehow the lead would contaminate the nearby fields where the spices grew.
The type of thyme we used was bought in Syria and packaged in Lebanon. It was not the pure organic type that we usually got from our grandparents in our southern Lebanese village. This packaged thyme had lot of nuts added to it to give it more flavor.
The public health department official asked that I send her some samples of all the spices that I had. I packed up to ten different spice bags including the thyme. Two weeks later she called me, stating that the lead level allowable in spices must be less than 10, and that our thyme’s lead level was 900!
We got rid of all the spices, and have never eaten that packaged spice again. My kids’ lead levels dropped nicely afterward and back to normal. That is our story with lead. Now it seems like a mini-detective story and even fun, but the anxiety that I experienced until we figured out the cause was not!
Dr. Faddoul is a private practice pediatrician in La Canada Flintridge, Calif.
I am not going to tell you about the dangers of lead, as it is well known and publicized, but I will tell you my family’s story with lead.
In 2012, 1 year after my younger daughter was born, I took her for her 1-year checkup. As I would do with any of my pediatric patients at this age, I took her for a lead level check. Never during my residency training or my first few years of practice as a pediatrician have I encountered a positive lead level. So when I opened the lab result sheet, I thought I would be shredding it the next moment. Well, that didn’t happen. It turned out that her lead level was 7 mcg/dL! Not too high, but detectable. The only question that kept on coming back over the next month or so was a big WHY? Why my child? Now my older daughter’s lead level was normal at her 1-year visit. We had just moved into a new house before my youngest daughter was born. I thought, it has to do with the house, and since my 1-year-old was putting everything in her mouth at this stage, then she must be getting the lead that way.
So it was not the house or the wall pipes that were contaminated with lead. It was not our food that we cooked, otherwise my nanny’s daughter would have had a high lead level, as she ate the same food we ate almost daily. Our family did not travel recently. So what was it that my family had or ate that my neighbor or nanny’s child did not?
The answer was thyme. It is an herb that we mix with olive oil and spread on dough – I call it Lebanese pizza. That is one thing that my nanny and her child never ate, but we did. It was a long painful month of investigation, elimination, and anxiety. I called the public health department in Phoenix and they stated that lots of imported spices were contaminated with lead. There were two theories as to why this might happen. The first one is that the spice dealers would add lead to increase the weight of the spices to get more money. The second is that the spice fields were close to factories that used lead in their manufacturing, and somehow the lead would contaminate the nearby fields where the spices grew.
The type of thyme we used was bought in Syria and packaged in Lebanon. It was not the pure organic type that we usually got from our grandparents in our southern Lebanese village. This packaged thyme had lot of nuts added to it to give it more flavor.
The public health department official asked that I send her some samples of all the spices that I had. I packed up to ten different spice bags including the thyme. Two weeks later she called me, stating that the lead level allowable in spices must be less than 10, and that our thyme’s lead level was 900!
We got rid of all the spices, and have never eaten that packaged spice again. My kids’ lead levels dropped nicely afterward and back to normal. That is our story with lead. Now it seems like a mini-detective story and even fun, but the anxiety that I experienced until we figured out the cause was not!
Dr. Faddoul is a private practice pediatrician in La Canada Flintridge, Calif.
I am not going to tell you about the dangers of lead, as it is well known and publicized, but I will tell you my family’s story with lead.
In 2012, 1 year after my younger daughter was born, I took her for her 1-year checkup. As I would do with any of my pediatric patients at this age, I took her for a lead level check. Never during my residency training or my first few years of practice as a pediatrician have I encountered a positive lead level. So when I opened the lab result sheet, I thought I would be shredding it the next moment. Well, that didn’t happen. It turned out that her lead level was 7 mcg/dL! Not too high, but detectable. The only question that kept on coming back over the next month or so was a big WHY? Why my child? Now my older daughter’s lead level was normal at her 1-year visit. We had just moved into a new house before my youngest daughter was born. I thought, it has to do with the house, and since my 1-year-old was putting everything in her mouth at this stage, then she must be getting the lead that way.
So it was not the house or the wall pipes that were contaminated with lead. It was not our food that we cooked, otherwise my nanny’s daughter would have had a high lead level, as she ate the same food we ate almost daily. Our family did not travel recently. So what was it that my family had or ate that my neighbor or nanny’s child did not?
The answer was thyme. It is an herb that we mix with olive oil and spread on dough – I call it Lebanese pizza. That is one thing that my nanny and her child never ate, but we did. It was a long painful month of investigation, elimination, and anxiety. I called the public health department in Phoenix and they stated that lots of imported spices were contaminated with lead. There were two theories as to why this might happen. The first one is that the spice dealers would add lead to increase the weight of the spices to get more money. The second is that the spice fields were close to factories that used lead in their manufacturing, and somehow the lead would contaminate the nearby fields where the spices grew.
The type of thyme we used was bought in Syria and packaged in Lebanon. It was not the pure organic type that we usually got from our grandparents in our southern Lebanese village. This packaged thyme had lot of nuts added to it to give it more flavor.
The public health department official asked that I send her some samples of all the spices that I had. I packed up to ten different spice bags including the thyme. Two weeks later she called me, stating that the lead level allowable in spices must be less than 10, and that our thyme’s lead level was 900!
We got rid of all the spices, and have never eaten that packaged spice again. My kids’ lead levels dropped nicely afterward and back to normal. That is our story with lead. Now it seems like a mini-detective story and even fun, but the anxiety that I experienced until we figured out the cause was not!
Dr. Faddoul is a private practice pediatrician in La Canada Flintridge, Calif.
Heart surgery halves in-hospital mortality in trisomy 13 and 18
For infants with trisomy 13 or trisomy 18, congenital heart surgery is associated with a significant decrease in in-hospital mortality, according to results of a large, retrospective, multicenter cohort study.
In-hospital mortality was 45% lower in trisomy 13 patients (P = .003) and 64% lower in trisomy 18 patients (P less than.001) who underwent surgery, data show (Pediatrics 140(5); 2017. doi: https://doi.org/10.1542/peds.2017-0772).
The study, based on records from the 44 participating children’s hospitals represented in the Pediatric Health Information System (PHIS) database, included 1,668 newborns with trisomy 13 or 18 who were admitted within 14 days of birth. Median age at admission was less than 1 day for both groups.
Congenital heart disease was present in 925 out of 1,020 infants with trisomy 18 (91%) and 555 out of 648 with trisomy 13 (86%), the report stated.
For those infants with congenital heart disease, overall mortality was highest during the first hospital admission (63%), investigators wrote. However, for those undergoing congenital heart surgery, multivariate analysis showed decreased in-hospital mortality vs. those who had no surgery for both the trisomy 13 (30% vs. 55%, respectively, P = .003) and the trisomy 18 groups (16% vs. 44%, P less than .001).
This is not only the largest-ever study of trisomy 13 and 18 ever reported, according to the investigators, but also the first to show that higher weight, female sex, and older age at admission are associated with improved survival following congenital heart surgery among these patients. Multiple logistic regression analysis showed significant effects of these risk factors on mortality for both the trisomy 13 and 18 infant subsets, according to Dr. Kosiv and her colleagues.
These findings come at a time when many centers elect not to perform congenital heart surgery in trisomy 13 and 18 patients, the investigators wrote, noting that management is typically limited to medical strategies due to the “markedly short life expectancy” and grave prognosis associated with the condition.
Mortality was markedly decreased, but still considerably higher than what would be expected for congenital heart surgery in the general population, which is an important consideration for families and practitioners who are considering the procedure, investigators said in their report.
Nevertheless, the present findings suggest that “CHS may not be futile, at least not in the short-term, in patients with T13 and T18,” Dr. Kosiv and colleagues wrote. “Additionally, these results suggest that CHS may allow families to be able to take their children home and avoid [them] dying in the hospital.”
The article by Kosiv and colleagues provides “compelling evidence that congenital heart surgery can be considered” in infants with trisomy 13 or 18, according Kathy J. Jenkins, MD, MPH, and Amy E. Roberts, MD in their accompanying editorial. The decision, however, should be made as part of a comprehensive treatment plan, they said.
“In our view, this should only occur when parents are fully informed of the still significant residual infant mortality risk with cardiac surgery … and unavoidable, severe neurocognitive delays,” they wrote in their editorial.
Caregivers helping families make the decision, they added, should be aware that delays in decision-making might make operations impossible or even more risky than they already are.
“The revolution in congenital heart surgery … has now changed the equation for infants with trisomy 18 and 13 just as it did for trisomy 21 in the past,” the authors wrote. “However, numerous factors must be taken into account to optimize decision-making for each infant and family.”
Dr. Jenkins, MD, MPH, and Dr. Roberts, MD are with the Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts. These comments are based on their editorial (Pediatrics 2017. doi: https://doi.org/10.1542/peds.2017-2809). The authors reported no potential conflicts of interest.
The article by Kosiv and colleagues provides “compelling evidence that congenital heart surgery can be considered” in infants with trisomy 13 or 18, according Kathy J. Jenkins, MD, MPH, and Amy E. Roberts, MD in their accompanying editorial. The decision, however, should be made as part of a comprehensive treatment plan, they said.
“In our view, this should only occur when parents are fully informed of the still significant residual infant mortality risk with cardiac surgery … and unavoidable, severe neurocognitive delays,” they wrote in their editorial.
Caregivers helping families make the decision, they added, should be aware that delays in decision-making might make operations impossible or even more risky than they already are.
“The revolution in congenital heart surgery … has now changed the equation for infants with trisomy 18 and 13 just as it did for trisomy 21 in the past,” the authors wrote. “However, numerous factors must be taken into account to optimize decision-making for each infant and family.”
Dr. Jenkins, MD, MPH, and Dr. Roberts, MD are with the Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts. These comments are based on their editorial (Pediatrics 2017. doi: https://doi.org/10.1542/peds.2017-2809). The authors reported no potential conflicts of interest.
The article by Kosiv and colleagues provides “compelling evidence that congenital heart surgery can be considered” in infants with trisomy 13 or 18, according Kathy J. Jenkins, MD, MPH, and Amy E. Roberts, MD in their accompanying editorial. The decision, however, should be made as part of a comprehensive treatment plan, they said.
“In our view, this should only occur when parents are fully informed of the still significant residual infant mortality risk with cardiac surgery … and unavoidable, severe neurocognitive delays,” they wrote in their editorial.
Caregivers helping families make the decision, they added, should be aware that delays in decision-making might make operations impossible or even more risky than they already are.
“The revolution in congenital heart surgery … has now changed the equation for infants with trisomy 18 and 13 just as it did for trisomy 21 in the past,” the authors wrote. “However, numerous factors must be taken into account to optimize decision-making for each infant and family.”
Dr. Jenkins, MD, MPH, and Dr. Roberts, MD are with the Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts. These comments are based on their editorial (Pediatrics 2017. doi: https://doi.org/10.1542/peds.2017-2809). The authors reported no potential conflicts of interest.
For infants with trisomy 13 or trisomy 18, congenital heart surgery is associated with a significant decrease in in-hospital mortality, according to results of a large, retrospective, multicenter cohort study.
In-hospital mortality was 45% lower in trisomy 13 patients (P = .003) and 64% lower in trisomy 18 patients (P less than.001) who underwent surgery, data show (Pediatrics 140(5); 2017. doi: https://doi.org/10.1542/peds.2017-0772).
The study, based on records from the 44 participating children’s hospitals represented in the Pediatric Health Information System (PHIS) database, included 1,668 newborns with trisomy 13 or 18 who were admitted within 14 days of birth. Median age at admission was less than 1 day for both groups.
Congenital heart disease was present in 925 out of 1,020 infants with trisomy 18 (91%) and 555 out of 648 with trisomy 13 (86%), the report stated.
For those infants with congenital heart disease, overall mortality was highest during the first hospital admission (63%), investigators wrote. However, for those undergoing congenital heart surgery, multivariate analysis showed decreased in-hospital mortality vs. those who had no surgery for both the trisomy 13 (30% vs. 55%, respectively, P = .003) and the trisomy 18 groups (16% vs. 44%, P less than .001).
This is not only the largest-ever study of trisomy 13 and 18 ever reported, according to the investigators, but also the first to show that higher weight, female sex, and older age at admission are associated with improved survival following congenital heart surgery among these patients. Multiple logistic regression analysis showed significant effects of these risk factors on mortality for both the trisomy 13 and 18 infant subsets, according to Dr. Kosiv and her colleagues.
These findings come at a time when many centers elect not to perform congenital heart surgery in trisomy 13 and 18 patients, the investigators wrote, noting that management is typically limited to medical strategies due to the “markedly short life expectancy” and grave prognosis associated with the condition.
Mortality was markedly decreased, but still considerably higher than what would be expected for congenital heart surgery in the general population, which is an important consideration for families and practitioners who are considering the procedure, investigators said in their report.
Nevertheless, the present findings suggest that “CHS may not be futile, at least not in the short-term, in patients with T13 and T18,” Dr. Kosiv and colleagues wrote. “Additionally, these results suggest that CHS may allow families to be able to take their children home and avoid [them] dying in the hospital.”
For infants with trisomy 13 or trisomy 18, congenital heart surgery is associated with a significant decrease in in-hospital mortality, according to results of a large, retrospective, multicenter cohort study.
In-hospital mortality was 45% lower in trisomy 13 patients (P = .003) and 64% lower in trisomy 18 patients (P less than.001) who underwent surgery, data show (Pediatrics 140(5); 2017. doi: https://doi.org/10.1542/peds.2017-0772).
The study, based on records from the 44 participating children’s hospitals represented in the Pediatric Health Information System (PHIS) database, included 1,668 newborns with trisomy 13 or 18 who were admitted within 14 days of birth. Median age at admission was less than 1 day for both groups.
Congenital heart disease was present in 925 out of 1,020 infants with trisomy 18 (91%) and 555 out of 648 with trisomy 13 (86%), the report stated.
For those infants with congenital heart disease, overall mortality was highest during the first hospital admission (63%), investigators wrote. However, for those undergoing congenital heart surgery, multivariate analysis showed decreased in-hospital mortality vs. those who had no surgery for both the trisomy 13 (30% vs. 55%, respectively, P = .003) and the trisomy 18 groups (16% vs. 44%, P less than .001).
This is not only the largest-ever study of trisomy 13 and 18 ever reported, according to the investigators, but also the first to show that higher weight, female sex, and older age at admission are associated with improved survival following congenital heart surgery among these patients. Multiple logistic regression analysis showed significant effects of these risk factors on mortality for both the trisomy 13 and 18 infant subsets, according to Dr. Kosiv and her colleagues.
These findings come at a time when many centers elect not to perform congenital heart surgery in trisomy 13 and 18 patients, the investigators wrote, noting that management is typically limited to medical strategies due to the “markedly short life expectancy” and grave prognosis associated with the condition.
Mortality was markedly decreased, but still considerably higher than what would be expected for congenital heart surgery in the general population, which is an important consideration for families and practitioners who are considering the procedure, investigators said in their report.
Nevertheless, the present findings suggest that “CHS may not be futile, at least not in the short-term, in patients with T13 and T18,” Dr. Kosiv and colleagues wrote. “Additionally, these results suggest that CHS may allow families to be able to take their children home and avoid [them] dying in the hospital.”
FROM PEDIATRICS
Key clinical point: Despite many centers choosing not to perform congenital heart surgery in infants with trisomy 13 and trisomy 18, doing so cuts in-hospital mortality by more than half.
Major finding: In-hospital mortality was 45% lower in trisomy 13 patients (P = 0.003) and 64% lower in trisomy 18 patients (P < 0.001) who underwent surgery.
Data source: A large, retrospective, multicenter cohort study of 1,668 newborns with trisomy 13 or 18 admitted within 14 days of birth.
Disclosures: The authors reported no potential conflicts of interest.
Pediatric seclusion and restraint increases with ADHD, decreases with PTSD
NEW ORLEANS – Attention-deficit/hyperactivity disorder and non-suicidal self-harm – cutting and head banging, for instance – strongly predicted longer seclusion and restraint episodes, sometimes past 2 hours, in a review at the University of Missouri, Columbia, pediatric inpatient psychiatric unit.
Meanwhile, children with histories of physical abuse, post-traumatic stress disorder (PTSD), or out-of-home placement were less likely to have multiple seclusion and restraint (SR) episodes during an admission, and had lower numbers of SR events overall. Perhaps hyper-vigilance due to past traumas helped them avoid situations that led to problems. Staff might also have used a lighter touch given the children’s histories.
The investigators reviewed 305 SR episodes from 2011-2014 among 92 children aged 5-18 years old. They plan to expand their study to 2009-2017 and add a prospective arm.
It’s well known that SR, a last-ditch effort to prevent physical harm, traumatizes patients, but research on how to avoid it has mostly focused on adults. The Missouri team wants to change that by identifying the children most at risk, so that something can be done beforehand to prevent it. Maybe extra one-on-one care would help, Dr. Badawy said.
The children in the review were an average of 10.5 years old, and most were admitted for 3-7 days. Fifty-five (60%) had multiple SR episodes, 34 in a single admission and 21 across multiple admissions; 71% of the episodes were in boys, 58% in white children, 27.7% in black children, and the rest in multiracial children. Twenty-one percent of the episodes were in children with intellectual problems. ADHD and oppositional defiant disorder were the most common diagnoses, each diagnosed in more than half of the subjects.
When asked how a 5-year-old child can end up in restraints, Dr. Badawy agreed that bad parenting is a factor. Parents who don’t know any better might escalate normal behavior, and others might simply not care that much about their kids, or have much empathy. “In the 5-10 year-olds, I do think a lot of it is parenting. Neglect is the number one form of abuse,” she said, “and it causes instability in children.”
But parents aren’t always the problem. Dr. Badawy mentioned an “extremely depressed” boy who tried to hang himself again and again, at 8 years old. “His parents were supportive and focused on getting him better,” she said. It’s unknown if anything happened to him when they weren’t around.
If SR is related to children’s own behavior, and if they are able to listen to staff afterward and control it, kids seem able to avoid another episode. Those who have PTSD, or who have been through physical abuse or out-of-home placement, seemed particularly adept in the review.
Avoidance seems less likely, however, when children are set off by other kids.
Sometimes there are clues of impending trouble, like the boy who walked around whistling before he lashed out. Staff at the university quickly learned to swoop in and calm him when they heard the whistling.
The investigators had no industry disclosures.
NEW ORLEANS – Attention-deficit/hyperactivity disorder and non-suicidal self-harm – cutting and head banging, for instance – strongly predicted longer seclusion and restraint episodes, sometimes past 2 hours, in a review at the University of Missouri, Columbia, pediatric inpatient psychiatric unit.
Meanwhile, children with histories of physical abuse, post-traumatic stress disorder (PTSD), or out-of-home placement were less likely to have multiple seclusion and restraint (SR) episodes during an admission, and had lower numbers of SR events overall. Perhaps hyper-vigilance due to past traumas helped them avoid situations that led to problems. Staff might also have used a lighter touch given the children’s histories.
The investigators reviewed 305 SR episodes from 2011-2014 among 92 children aged 5-18 years old. They plan to expand their study to 2009-2017 and add a prospective arm.
It’s well known that SR, a last-ditch effort to prevent physical harm, traumatizes patients, but research on how to avoid it has mostly focused on adults. The Missouri team wants to change that by identifying the children most at risk, so that something can be done beforehand to prevent it. Maybe extra one-on-one care would help, Dr. Badawy said.
The children in the review were an average of 10.5 years old, and most were admitted for 3-7 days. Fifty-five (60%) had multiple SR episodes, 34 in a single admission and 21 across multiple admissions; 71% of the episodes were in boys, 58% in white children, 27.7% in black children, and the rest in multiracial children. Twenty-one percent of the episodes were in children with intellectual problems. ADHD and oppositional defiant disorder were the most common diagnoses, each diagnosed in more than half of the subjects.
When asked how a 5-year-old child can end up in restraints, Dr. Badawy agreed that bad parenting is a factor. Parents who don’t know any better might escalate normal behavior, and others might simply not care that much about their kids, or have much empathy. “In the 5-10 year-olds, I do think a lot of it is parenting. Neglect is the number one form of abuse,” she said, “and it causes instability in children.”
But parents aren’t always the problem. Dr. Badawy mentioned an “extremely depressed” boy who tried to hang himself again and again, at 8 years old. “His parents were supportive and focused on getting him better,” she said. It’s unknown if anything happened to him when they weren’t around.
If SR is related to children’s own behavior, and if they are able to listen to staff afterward and control it, kids seem able to avoid another episode. Those who have PTSD, or who have been through physical abuse or out-of-home placement, seemed particularly adept in the review.
Avoidance seems less likely, however, when children are set off by other kids.
Sometimes there are clues of impending trouble, like the boy who walked around whistling before he lashed out. Staff at the university quickly learned to swoop in and calm him when they heard the whistling.
The investigators had no industry disclosures.
NEW ORLEANS – Attention-deficit/hyperactivity disorder and non-suicidal self-harm – cutting and head banging, for instance – strongly predicted longer seclusion and restraint episodes, sometimes past 2 hours, in a review at the University of Missouri, Columbia, pediatric inpatient psychiatric unit.
Meanwhile, children with histories of physical abuse, post-traumatic stress disorder (PTSD), or out-of-home placement were less likely to have multiple seclusion and restraint (SR) episodes during an admission, and had lower numbers of SR events overall. Perhaps hyper-vigilance due to past traumas helped them avoid situations that led to problems. Staff might also have used a lighter touch given the children’s histories.
The investigators reviewed 305 SR episodes from 2011-2014 among 92 children aged 5-18 years old. They plan to expand their study to 2009-2017 and add a prospective arm.
It’s well known that SR, a last-ditch effort to prevent physical harm, traumatizes patients, but research on how to avoid it has mostly focused on adults. The Missouri team wants to change that by identifying the children most at risk, so that something can be done beforehand to prevent it. Maybe extra one-on-one care would help, Dr. Badawy said.
The children in the review were an average of 10.5 years old, and most were admitted for 3-7 days. Fifty-five (60%) had multiple SR episodes, 34 in a single admission and 21 across multiple admissions; 71% of the episodes were in boys, 58% in white children, 27.7% in black children, and the rest in multiracial children. Twenty-one percent of the episodes were in children with intellectual problems. ADHD and oppositional defiant disorder were the most common diagnoses, each diagnosed in more than half of the subjects.
When asked how a 5-year-old child can end up in restraints, Dr. Badawy agreed that bad parenting is a factor. Parents who don’t know any better might escalate normal behavior, and others might simply not care that much about their kids, or have much empathy. “In the 5-10 year-olds, I do think a lot of it is parenting. Neglect is the number one form of abuse,” she said, “and it causes instability in children.”
But parents aren’t always the problem. Dr. Badawy mentioned an “extremely depressed” boy who tried to hang himself again and again, at 8 years old. “His parents were supportive and focused on getting him better,” she said. It’s unknown if anything happened to him when they weren’t around.
If SR is related to children’s own behavior, and if they are able to listen to staff afterward and control it, kids seem able to avoid another episode. Those who have PTSD, or who have been through physical abuse or out-of-home placement, seemed particularly adept in the review.
Avoidance seems less likely, however, when children are set off by other kids.
Sometimes there are clues of impending trouble, like the boy who walked around whistling before he lashed out. Staff at the university quickly learned to swoop in and calm him when they heard the whistling.
The investigators had no industry disclosures.
AT IPS 2017
Key clinical point:
Major finding: ADHD and non-suicidal self-harm – cutting and head banging – strongly predict longer seclusion and restraint episodes, sometimes past 2 hours.
Data source: A University of Missouri, Columbia, review of 305 seclusion and restraint episodes from 2011-2014 among 92 children aged 5-18 years old.
Disclosures: The investigators had no industry disclosures.
VIDEO: Treating vascular lesions in children
LAS VEGAS – Clinicians should not shy away from light-based treatment of vascular lesions in children, for reasons that include achieving better results when treated early, according to Kristen M. Kelly, MD.
Special considerations include addressing children’s fears. “One of the strategies we use is we have child life specialists who help us” create a friendly and welcoming environment, Dr. Kelly said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. Consequently, “many of our children actually come in, they’re excited about their visit ... and are looking forward to seeing us at the next visit,” she noted.
Which type of anesthesia to use is another important consideration when treating children, said Dr. Kelly of the University of California, Irvine, in Orange. “For a larger procedure ... one definitely could consider general anesthesia,” but there are risks and benefits to general anesthesia in very young children, and options should be discussed with patients and their families, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Clinicians should not shy away from light-based treatment of vascular lesions in children, for reasons that include achieving better results when treated early, according to Kristen M. Kelly, MD.
Special considerations include addressing children’s fears. “One of the strategies we use is we have child life specialists who help us” create a friendly and welcoming environment, Dr. Kelly said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. Consequently, “many of our children actually come in, they’re excited about their visit ... and are looking forward to seeing us at the next visit,” she noted.
Which type of anesthesia to use is another important consideration when treating children, said Dr. Kelly of the University of California, Irvine, in Orange. “For a larger procedure ... one definitely could consider general anesthesia,” but there are risks and benefits to general anesthesia in very young children, and options should be discussed with patients and their families, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Clinicians should not shy away from light-based treatment of vascular lesions in children, for reasons that include achieving better results when treated early, according to Kristen M. Kelly, MD.
Special considerations include addressing children’s fears. “One of the strategies we use is we have child life specialists who help us” create a friendly and welcoming environment, Dr. Kelly said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. Consequently, “many of our children actually come in, they’re excited about their visit ... and are looking forward to seeing us at the next visit,” she noted.
Which type of anesthesia to use is another important consideration when treating children, said Dr. Kelly of the University of California, Irvine, in Orange. “For a larger procedure ... one definitely could consider general anesthesia,” but there are risks and benefits to general anesthesia in very young children, and options should be discussed with patients and their families, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
Use of MenACWY-CRM vaccine in 2- to 10-year-olds raised no safety concerns
, reported Sara Yee Tartof, PhD, of Kaiser Permanente Southern California, Pasadena, and her associates.
The study was undertaken to evaluate the safety of the MenACWY-CRM vaccine in the care of children aged 2-10 years in the real world. The other quadrivalent meningococcal conjugate vaccine, MenACWY-D (Menactra), was not used in this study.
In a retrospective, observational study of 327 children aged 2-10 years when they received the MenACWY-CRM vaccine as part of routine clinical care, there was only one event of interest, which was a child who developed asthma during the 1-year observation period, and that occurred 237 days after vaccination with both the MenACWY-CRM and a typhoid vaccine. “A causal link between the two events is unlikely,” Dr. Tartof and her associates wrote.
Most of the serious medically attended events were considered to be unrelated to MenACWY-CRM vaccination, or symptom onset occurred a long time after vaccination. “The remaining events were pneumonia, bronchitis, cough, febrile convulsion, and vomiting identified within 30 days of vaccination among four children,” the investigators reported. “Pneumonia, bronchitis, and cough were diagnosed in the same child; cough, febrile convulsion, and vomiting were diagnosed separately in the other 3 children.
“It appears that many MenACWY-CRM recipients in our study population received the vaccine because of travel to high-risk areas, possible exposure to meningitis, or as routine vaccinations received early as part of the ACIP-recommended routine vaccination for those 11-12 years old,” Dr. Tartof and her associates wrote.
Read more in the Pediatric Infectious Diseases Journal (2017 Nov 1. doi: 10.1097/INF.0000000000001696).
, reported Sara Yee Tartof, PhD, of Kaiser Permanente Southern California, Pasadena, and her associates.
The study was undertaken to evaluate the safety of the MenACWY-CRM vaccine in the care of children aged 2-10 years in the real world. The other quadrivalent meningococcal conjugate vaccine, MenACWY-D (Menactra), was not used in this study.
In a retrospective, observational study of 327 children aged 2-10 years when they received the MenACWY-CRM vaccine as part of routine clinical care, there was only one event of interest, which was a child who developed asthma during the 1-year observation period, and that occurred 237 days after vaccination with both the MenACWY-CRM and a typhoid vaccine. “A causal link between the two events is unlikely,” Dr. Tartof and her associates wrote.
Most of the serious medically attended events were considered to be unrelated to MenACWY-CRM vaccination, or symptom onset occurred a long time after vaccination. “The remaining events were pneumonia, bronchitis, cough, febrile convulsion, and vomiting identified within 30 days of vaccination among four children,” the investigators reported. “Pneumonia, bronchitis, and cough were diagnosed in the same child; cough, febrile convulsion, and vomiting were diagnosed separately in the other 3 children.
“It appears that many MenACWY-CRM recipients in our study population received the vaccine because of travel to high-risk areas, possible exposure to meningitis, or as routine vaccinations received early as part of the ACIP-recommended routine vaccination for those 11-12 years old,” Dr. Tartof and her associates wrote.
Read more in the Pediatric Infectious Diseases Journal (2017 Nov 1. doi: 10.1097/INF.0000000000001696).
, reported Sara Yee Tartof, PhD, of Kaiser Permanente Southern California, Pasadena, and her associates.
The study was undertaken to evaluate the safety of the MenACWY-CRM vaccine in the care of children aged 2-10 years in the real world. The other quadrivalent meningococcal conjugate vaccine, MenACWY-D (Menactra), was not used in this study.
In a retrospective, observational study of 327 children aged 2-10 years when they received the MenACWY-CRM vaccine as part of routine clinical care, there was only one event of interest, which was a child who developed asthma during the 1-year observation period, and that occurred 237 days after vaccination with both the MenACWY-CRM and a typhoid vaccine. “A causal link between the two events is unlikely,” Dr. Tartof and her associates wrote.
Most of the serious medically attended events were considered to be unrelated to MenACWY-CRM vaccination, or symptom onset occurred a long time after vaccination. “The remaining events were pneumonia, bronchitis, cough, febrile convulsion, and vomiting identified within 30 days of vaccination among four children,” the investigators reported. “Pneumonia, bronchitis, and cough were diagnosed in the same child; cough, febrile convulsion, and vomiting were diagnosed separately in the other 3 children.
“It appears that many MenACWY-CRM recipients in our study population received the vaccine because of travel to high-risk areas, possible exposure to meningitis, or as routine vaccinations received early as part of the ACIP-recommended routine vaccination for those 11-12 years old,” Dr. Tartof and her associates wrote.
Read more in the Pediatric Infectious Diseases Journal (2017 Nov 1. doi: 10.1097/INF.0000000000001696).
FROM PEDIATRIC INFECTIOUS DISEASE JOURNAL
Early diagnosis of tuberous sclerosis may be possible in infants
with an echocardiogram for cardiac rhabdomyomas and a skin examination for hypomelanotic macules, noninvasive tests that do not require sedation, said Peter E. Davis, MD, of Boston Children’s Hospital, and his associates on behalf of the Tuberous Sclerosis Complex Autism Center of Excellence Research Network.
“Early TSC diagnosis in infants opens a window of opportunity to treat before the onset of epilepsy or other neurodevelopmental disorders and allows for close surveillance for sequelae of TSC,” the researchers said. “However, this window may be as small as a few months.”
In two concurrent, prospective, longitudinal, observational studies at five medical centers of 130 infants meeting a genetic or clinical diagnosis of TSC, cardiac rhabdomyomas, and hypomelanotic macules were the most common initial presenting features, occurring in 59% and 39% of infants, respectively; 85% of infants had either or both. In terms of prevalence, hypomelanotic macules and tubers or other cortical dysplasias were the most prevalent TSC features both occurring at 94%, followed by subependymal nodules (SENs) at 90%, and cardiac rhabdomyomas at 82%. Every infant had at least one of these diagnostic criteria, and 61% had all four of them, the investigators reported.
Neuroimaging results were available in 115 infants, of whom 94% had tubers or cortical dysplasias, 90% had SENs, and 89% had both; 6% had subependymal giant cell astrocytomas. Seizure onset occurred in 15% of infants before or when other TSC criteria were recorded, “suggesting that seizure was an initial presenting symptom.” Seizure onset occurred within 3 months after initial presentation in 17% of infants, within 6 months in 39%, and within 12 months in 57%. Ultimately, 57% of the infants had infantile spasms, 55% had focal seizures, and 12% had another seizure type, Dr. Davis and his associates said.
“Early, prospective use of EEGs may enable risk stratification in studies of epilepsy prevention in infants with TSC. The antiepileptic medication vigabatrin is particularly effective in treating infantile spasms in TSC and has mTOR [mechanistic target of the rapamycin]–inhibiting effects. Vigabatrin is currently in clinical trials to determine its efficacy at preventing epilepsy in patients with TSC,” they said, although the drug is not currently recommended for infants. “mTOR inhibitors have been successfully used to treat multiple TSC manifestations and have shown some efficacy as adjunctive treatment of refractory epilepsy,” they wrote, adding that studies are needed “to determine the safety and efficacy of mTOR inhibitors in this age group.”
Read more at Pediatrics. 2017;140(6):e20164040 (doi: 10.1542/peds.2016-4040).
with an echocardiogram for cardiac rhabdomyomas and a skin examination for hypomelanotic macules, noninvasive tests that do not require sedation, said Peter E. Davis, MD, of Boston Children’s Hospital, and his associates on behalf of the Tuberous Sclerosis Complex Autism Center of Excellence Research Network.
“Early TSC diagnosis in infants opens a window of opportunity to treat before the onset of epilepsy or other neurodevelopmental disorders and allows for close surveillance for sequelae of TSC,” the researchers said. “However, this window may be as small as a few months.”
In two concurrent, prospective, longitudinal, observational studies at five medical centers of 130 infants meeting a genetic or clinical diagnosis of TSC, cardiac rhabdomyomas, and hypomelanotic macules were the most common initial presenting features, occurring in 59% and 39% of infants, respectively; 85% of infants had either or both. In terms of prevalence, hypomelanotic macules and tubers or other cortical dysplasias were the most prevalent TSC features both occurring at 94%, followed by subependymal nodules (SENs) at 90%, and cardiac rhabdomyomas at 82%. Every infant had at least one of these diagnostic criteria, and 61% had all four of them, the investigators reported.
Neuroimaging results were available in 115 infants, of whom 94% had tubers or cortical dysplasias, 90% had SENs, and 89% had both; 6% had subependymal giant cell astrocytomas. Seizure onset occurred in 15% of infants before or when other TSC criteria were recorded, “suggesting that seizure was an initial presenting symptom.” Seizure onset occurred within 3 months after initial presentation in 17% of infants, within 6 months in 39%, and within 12 months in 57%. Ultimately, 57% of the infants had infantile spasms, 55% had focal seizures, and 12% had another seizure type, Dr. Davis and his associates said.
“Early, prospective use of EEGs may enable risk stratification in studies of epilepsy prevention in infants with TSC. The antiepileptic medication vigabatrin is particularly effective in treating infantile spasms in TSC and has mTOR [mechanistic target of the rapamycin]–inhibiting effects. Vigabatrin is currently in clinical trials to determine its efficacy at preventing epilepsy in patients with TSC,” they said, although the drug is not currently recommended for infants. “mTOR inhibitors have been successfully used to treat multiple TSC manifestations and have shown some efficacy as adjunctive treatment of refractory epilepsy,” they wrote, adding that studies are needed “to determine the safety and efficacy of mTOR inhibitors in this age group.”
Read more at Pediatrics. 2017;140(6):e20164040 (doi: 10.1542/peds.2016-4040).
with an echocardiogram for cardiac rhabdomyomas and a skin examination for hypomelanotic macules, noninvasive tests that do not require sedation, said Peter E. Davis, MD, of Boston Children’s Hospital, and his associates on behalf of the Tuberous Sclerosis Complex Autism Center of Excellence Research Network.
“Early TSC diagnosis in infants opens a window of opportunity to treat before the onset of epilepsy or other neurodevelopmental disorders and allows for close surveillance for sequelae of TSC,” the researchers said. “However, this window may be as small as a few months.”
In two concurrent, prospective, longitudinal, observational studies at five medical centers of 130 infants meeting a genetic or clinical diagnosis of TSC, cardiac rhabdomyomas, and hypomelanotic macules were the most common initial presenting features, occurring in 59% and 39% of infants, respectively; 85% of infants had either or both. In terms of prevalence, hypomelanotic macules and tubers or other cortical dysplasias were the most prevalent TSC features both occurring at 94%, followed by subependymal nodules (SENs) at 90%, and cardiac rhabdomyomas at 82%. Every infant had at least one of these diagnostic criteria, and 61% had all four of them, the investigators reported.
Neuroimaging results were available in 115 infants, of whom 94% had tubers or cortical dysplasias, 90% had SENs, and 89% had both; 6% had subependymal giant cell astrocytomas. Seizure onset occurred in 15% of infants before or when other TSC criteria were recorded, “suggesting that seizure was an initial presenting symptom.” Seizure onset occurred within 3 months after initial presentation in 17% of infants, within 6 months in 39%, and within 12 months in 57%. Ultimately, 57% of the infants had infantile spasms, 55% had focal seizures, and 12% had another seizure type, Dr. Davis and his associates said.
“Early, prospective use of EEGs may enable risk stratification in studies of epilepsy prevention in infants with TSC. The antiepileptic medication vigabatrin is particularly effective in treating infantile spasms in TSC and has mTOR [mechanistic target of the rapamycin]–inhibiting effects. Vigabatrin is currently in clinical trials to determine its efficacy at preventing epilepsy in patients with TSC,” they said, although the drug is not currently recommended for infants. “mTOR inhibitors have been successfully used to treat multiple TSC manifestations and have shown some efficacy as adjunctive treatment of refractory epilepsy,” they wrote, adding that studies are needed “to determine the safety and efficacy of mTOR inhibitors in this age group.”
Read more at Pediatrics. 2017;140(6):e20164040 (doi: 10.1542/peds.2016-4040).
FROM PEDIATRICS