Category Archives: Pediatrics

Physician narrative on gun control

Posted on by

Recent commentaries offer several physician viewpoints on this problem (NEJM 2013; 368: 397-99, 399-400, 401-403).  For me, the following points were of most interest:

  • 88 Americans died every day from firearm violence in 2011; high-profile events like Sandy Hook, Aurora, Virginia Tech and Columbine are uncommon.
  • In California, background checks are required on all firearm purchases and this has been associated with a 23% reduction in firearm-related crime.  Though, this policy is hampered by neighboring state policies.  In Reno, Nevada, about 1/3rd of the cars at gun shows are from California.
  • In 2010, 6570 deaths in children/young persons (1-24 yrs) were due to gun-related injuries. Gun-related fatalities cause twice as many deaths as cancer, five times as many as heart disease, and fifteen times as many as infections.
  • Suicide attempts with drugs are lethal in <5% whereas 90% involving guns are lethal.
  • The authors advocate for better background checks, a ban on assault weapons, limits on ammunition capacity, and removing restrictions on the collection of public health data regarding gun-related injuries.

In a previous blog about the problem of obesity, I referenced the “issue-attention cycle” problem.  ”This pattern occurs when initial public alarm over the discovery of a problem and optimism about its quick resolution are replaced by the realization that solving the problem will require some public sacrifice and will displace powerful societal interests.”

Despite the high toll exacted by gun violence, will there be enough staying power to work on these incremental steps?

Checklists for Crisis and Daily Care

Posted on by

Not surprisingly, a new study has shown that checklists were associated with improvement in the management of operating-room crisis (NEJM 2013;  368: 246-53).

Many people use a checklist just to go to the grocery store so they don’t forget something important.  In medicine, checklists offer the same opportunity.

In this particular study, 17 operating-room teams participated in 106 simulated surgical crisis scenarios.  When checklists were available, there was better adherence to lifesaving processes: only 6% of steps were missed with checklists compared with 23% when they were unavailable.  Every team performed better when the crisis checklists were available.  Furthermore, 97% of participants reported they would prefer to have a checklist in the event of a crisis.

There were many limitations of this study, particularly the absence of surgeons from most of the simulations (due to difficulty enlisting them as volunteers).  Nevertheless, “experts have long recognized the potential for human fallibility in complex systems…it has been nearly 100 years since the surgeon W. Wayne Babcock called for emergency protocols to be rehearsed and ‘posted on the walls of every operating room.'”

For a pediatric gastroenterologist, the implication of this study is much broader.  It is trying to develop a checklist for every patient.  For a patient with a GI bleed, that checklist may include a supply list for the endoscopy suite, having written instructions for the settings of the cautery equipment, checking the proper PPI dose, and drawing a specific set of labs.  Agreeing to a minimum and not-too-onerous checklist would be worthwhile for almost anybody.  If you have a checklist for any GI condition (or a mobile app), think about adding a comment to this posting. If something is important in day-to-day care of a specific condition, a “hardstop” can be incorporated into electronic records as a reminder.

Related blog entries (mostly guidelines –not really checklists for a few specific conditions):

A much more articulate spokesman for checklists would be Atul Gawande:

Antibiotic resistance: doomed to repeat

Posted on by

“We’re doomed to repeat the past no matter what. That’s what it is to be alive. It’s pretty dense kids who haven’t figured that out by the time they’re ten.” Kurt Vonnegut, Bluebeard

“Those who don’t know history are destined to repeat it.” Edmund Burke

Antibiotic resistance has been occurring for billions of years and will keep on happening (NEJM 2013; 368: 299-301).  This commentary offers a different perspective and indicates that Kurt Vonnegut’s quote is more appropriate for this post.  Some key points:

  • “We live in a bacterial world where we will never be able to stay ahead of the mutation curve.” We will run out of targets to attack microbes.
  • Bacteria “invented” antibiotics billions of years ago, and “resistance is primarily the result of bacterial adaptation to eons of antibiotic exposure.” Thus, even with good antimicrobial stewardship, resistance will still occur.
  • Antibiotic resistance has been identified in bacteria found in underground caves that have been geologically isolated from the planet surface for four million years.
  • In 1945, Alexander Fleming called for stopping the overuse of penicillin to slow the development of resistance.
  • In 2009, three million kilograms of antibiotics were administered to humans and 13 million kilograms to animals.

Possible useful steps: more vaccines to prevent infections, smaller antibiotic clinical trials, use of rapid biomarkers to withhold antibiotics from those without bacterial infections, stopping antibiotics to help livestock growth, better waste-treatment of antibiotics, ‘self-cleaning’ hospital rooms, and better drug delivery to avoid foreign materials in intensive care patients.

Related blog entry:

For the smoking skeptics

Posted on by

How bad is secondhand tobacco smoke (SHS)?  This has been debated.  When I come out of an office room and the entire room smells of smoke, even though no one has smoked in the room, I know this is detrimental.  More proof of this comes from an article which shows that SHS is associated with an increase in the severity of children hospitalized with influenza (J Pediatr 2013; 162: 16-21).

In this study of 117 children, 40% were exposed to SHS.  They had increased need for intensive care (30% vs. 10%), increased intubation (13% vs. 1%), and longer length of stay (LOS) (4 days vs. 2.4 days). In children with chronic conditions, the LOS was 10 vs. 3.5.  After controlling for multiple variables, the authors found that SHS exposure was associated with a 4.7 fold increase in the likelihood of ICU admission and a 70% LOS.

This study had many limitations.  It was a retrospective chart review.  Patients between 2002-2009 were identified initially by the discharge diagnosis of influenza.  Among the 171 charts identified, 117 had a positive influenza culture and adequate data to retrieve.  As a retrospective review, it is possible that screening for smoke exposure was more common in the more severely affected cases.

Additional references:

Advice for doctors after the death of a child

Posted on by

Abraham Lincoln (in a letter to a girl whose father died in the civil war): “It is with deep grief that I learn of the death of your kind and brave father; and especially that it is affecting your young heart beyond what is common in such cases.  In this sad world of ours, sorrow comes to us all; and to the young it comes with bitter agony because it takes them unawares.  The older have learned ever to expect it.”

Fortunately in pediatric care, the death of a child is uncommon.  When it occurs, it can have a devastating effect on the family; a recent article provides a lot of useful advice for this situation (Pediatrics 2012; 130: 1164-69).

Key points:

  • Most parents experience a profound sense of guilt when harm comes to their child even if through no fault of their own.  The duration and intensity vary considerably.
  • Parents invest much of their hopes for the future in their children; this extends to fetuses and infants.
  • Family events may reawaken grief.  In addition, many parents report that their greatest fear is that the child will be forgotten.
  • Even in children with severe disabilities, the parents’ sense of loss is not usually diminished.
  • Peer-support groups can be very helpful (see below).
  • Complicated grief which occurs more often in the setting of previous psychiatric problems often require mental health support.  Previous parent-child troubled relationships may intensify grief as well.
  • Certain types of death like suicide, homicide, or due to drugs/alcohol can contribute to more intense grief.
  • Siblings are often considered ‘the forgotten mourners.’  Grieving parents may not be able to provide adequate support. Sibling issues include ‘survivor guilt’ (especially in the setting of intense sibling rivalry), overprotection, idealization/replacement child, and general issues of sibling grief.
  • Most helpful for pediatricians: provide an opportunity to meet with family members to listen.  “The pediatrician might say, simply ‘I’m so sorry to hear about _____’s death.  What a terrible loss for you and your family.’ Recommends avoiding expressions like “he/she is better off now” which parents may perceive as diminishing the value of the child.

Resources recommended by article:

  1. Compassionate Friends 877-969-0010 –self-help groups
  2. http://www.nationalshare.org –newborn death or stillbirth support
  3. http://www.bereavedparentsusa.org –support for bereaved family members
  4. http://www.survivorsofsuicide.com –support for those who have lost loved ones to suicide

Additional resources/references:

  • Useful Books recommended by previous article (Pediatrics 2000; 105: 445):

“The Fall of Freddie the Leaf” Leo Buscaglia
“When dinosaurs die: a guide to understanding death” Laurie Brown
“Caring for your grieving child” Martha Wakenshaw

  • NEJM 2001; 344: 1162. Suggestions for Writing a Condolence Letter:

There are ways to make the difficult task of writing a condolence letter easier. The letter may describe in detail the extent and depth of the relationship between the physician and the patient, or it may be a much shorter expression of sympathy. Whatever one writes, it is important to avoid superficial attempts to assuage grief, such as, “It was meant to be” or “I know how you feel.” In order to avoid issues of legal liability, the letter should focus on the sadness of death rather than revisit the clinical details of the illness..

One can begin the letter with a direct expression of sorrow about the death, such as “I am writing to send you my condolences on the death of your husband.” In our condolence letters, we try to include a personal memory of the patient and something about the patient’s family or work. Specific references to achievement at work, devotion to family, courage during the illness, or the patient’s character can bring life to the letter. We also state that it was a privilege to have participated in the patient’s care. We point out the comfort the patient received from the family’s love. We conclude the letter with a few words of support to let the family know our thoughts are with them. These suggestions are intended not as a substitute for the expression of genuine thoughts and feelings but as an aid in approaching the task.

Hepcidin for sepsis recognition

Posted on by

While this blog has discussed hepcidin’s essential role in iron homeostasis (see below), it performs well as a marker of sepsis as it is also an acute phase reactant (J Pediatr 2012; 162: 67-71).

Hepcidin is known to contribute to host defense by depriving microbes of access to iron and through direct antimicrobial properties.  In this study, the authors compared the performance of hepcidin to C-reactive protein (CRP) from the serum of 44 infants with late-onset sepsis.  Specimens were obtained in the acute and convalescent periods.

Results:

  • Hepcidin levels were increased 4-fold in infants with sepsis compared without infants who were not septic (P<.0001).  Levels returned to normal following therapy.
  • Hepcidin levels >92.2 ng/mL correctly identified 91% of all infants (PPV 100%, NPV 87%, specificity 100%, sensitivity 76%)
  • Models combining hepcidin with CRP did not perform better than hepcidin alone.
  • Hepcidin values were comparable to CRP, and possibly more useful.  The authors stated that a CRP value of >7.95 mg/dL had a PPV of 89%, NPV 74%, specificity of 96%, and sensitivity of 47%.
  • Hepcidin has been reported to peak at 6 hours after interleukin-6 injection in humans whereas CRP peaks 24-48 hours after an inflammatory stimulus.

Related blog entries:

Colchicine treatment for an orphan disease

Posted on by

In Atlanta, patients with Familial Mediterranean Fever (FMF) do not have a specific specialist and may remain in the care of a pediatric gastroenterologist as a consequence.  Fortunately, when the diagnosis is established, an effective treatment, colchicine, is available (J Pediatr 2012; 161: 1142-6).

Specific pointers in this reference:

  • Often the diagnosis of FMF is a clinical one as 2 mutations (MEFV gene) are found in only 38-72% of patients.
  • Mean age of onset is 1.1 years, but due to diagnostic delays, mean age of treatment is 3.2 years. Early in life, fever attacks may be the only recognizable feature.  Several years later serositis typically develops.
  • Colchicine prophylaxis is recommended for all patients diagnosed with FMF
  • In this 4-year study of 153 patients (all younger than 17 years), 22 (14.4%) developed diarrhea with colcichine and required dose reduction.
  • 18 patients (11.8%) had transient mild increase in transaminases (max ALT 152 IU/L).   One mechanism of liver toxicity for colchicine may be to increase NAFLD.
  • Colcichine dosing in the study: 0.5 mg daily in 11 children (<4 years), 1 mg in 105 patients, 1.5 mg in 19 patients, and 2 mg in 18 patients.
  • Previous recommendations for colchicine dosing in literature were for 0.5 mg for <5 year olds, 1 mg for 5-10 year olds, 1.5 mg for >10 years of age. In this center, most patients receive 1 mg by 2 years of age.
  • In the discussion, the article reviewed the literature showing colchicine seemed to be safe during pregnancy and few adverse effects.

Additional References:

Bystander effect –Genovese syndrome

Posted on by

Genovese syndrome is more commonly called the “bystander effect” (NEJM 2013; 368: 8-9).

“Genovese syndrome” was coined after the brutal stabbing of Catherine Genovese in Queens, NY on March 13, 1964.  What was astonishing was that ~38 people either observed the attacks or heard the victim’s pleas for help and did nothing.  This prompted a large amount of psychological research.  The central factor identified as the reason for the bystander effect was the diffusion of responsibility.

Awareness of the bystander effect is increasingly important in medicine where large teams often are involved in the care of complex patients.  Sometimes it is difficult even to answer “Who is my doctor?”

When many doctors are involved in the care of a patient, it is easy for a passive approach to patient care to develop.  How can this be reversed?

  • Bystanders are far more likely to intervene when they are friends with one another.  Thus, encouraging collegial interactions is important.
  • Understanding that oral communication, even briefly, with the primary care team is crucial.  Written communication is useful for documentation, but important information should be relayed directly.
  • An initiative by the U.S. Agency for Healthcare Research and Quality, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) may be helpful in improving. team-based skills (TeamSTEPPS Home)

Related Links:

Critical drug shortages in U.S.

Posted on by

While the U.S. spends a lot of money on health care, there is little incentive to produce older drugs with small profit margins.  In addition to the financial aspects, there are many other factors involved including the following:  limited number of manufacturers, increased worldwide demand, aging production plants, shortages of materials, stockpiling, and regulatory demands. This is resulting in detrimental outcomes (NEJM 2012; 367: 2461-63).

A specific example is the shortage of mechlorethamine (nitrogen mustard).  Since the 1960s it has been part of a MOPP regimen for Hodgkin’s lymphoma.  For pediatric patients, a modification of this regimen, the Stanford V regimen, has had good success rates for Hodgkin’s lymphoma.

Due to the shortage of mechlorethamine, cyclophosphamide has been substituted into the regimen.  While this substitution was thought to be equally efficacious, a group of investigators from St. Jude/Univ Tennessee, Dana-Farber/Boston Children’s, and Lucile Packard Children’s/Stanford have found that this substitution has resulted in a much lower 2-year event-free survival: 75% with new regimen compared with 88% with previous regimen.  This is despite the fact that patients receiving the newer regimen did not have a more unfavorable treatment profile.

Patients who relapsed had salvage therapy with stem-cell transplantation.  The long-term outcome of the newer regimen group, nevertheless, appears substantially worsened.

This example is not isolated.  Other cancer-drug shortages have included cytarabine, daunorubicin, and methotrexate.  While some of these shortages have been resolved quickly, the frequency of these shortages as well as drugs used for multiple other diseases is alarming.  When physicians and pateints are faced with the prospect of receiving inferior care due to drug shortage, this is extremely “hard to swallow.”