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Prenatal methadone maintenance linked to poorer child neurodevelopment
SAN FRANCISCO – Infants born to mothers receiving methadone maintenance treatment show poorer-than-average neurodevelopment outcomes, a retrospective study found.
Delays or difficulties in motor abilities appeared first in these children, followed by evidence of cognitive problems in their second year of life, reported Cristina Borradori Tolsa, MD, of University Hospital, Geneva.
“Higher methadone doses during pregnancy can have a detrimental effect on neonatal characteristics and children’s psychomotor development,” Dr. Borradori Tolsa said at the Pediatric Academic Societies meeting. She noted the need for long-term follow-up of children prenatally exposed to methadone maintenance therapy to evaluate their cognitive abilities and school readiness at preschool ages.
Only 38% of the women had exclusively used methadone, while the other 62% had used a variety of substances, including cocaine, alcohol, benzodiazepine, marijuana, and antidepressants. The women had a low average socioeconomic status based on their level of education and the occupations of the children’s fathers.
The researchers drew children’s development data from their scores on the Bayley Scales of Infant Development, Second Edition (BSID-II), at 6 months and 18-24 months. The BSID-II has an average score of 100 and includes a mental development index for language and cognitive development, and a psychomotor development index to assess fine and gross motor skills.
At age 6 months, 75% of the 40 children assessed showed some level of motor skills delay, and 33% had a moderate to severe delay in psychomotor skills. A quarter had no delay at all (a score of at least 85). The average psychomotor score at 6 months was 76, and the average cognitive score was 88. Most of the children (60%) did, however, show mental development within the normal range at 6 months.
By the age of 18-24 months, half of the 36 children assessed showed no motor delays, and half showed no cognitive delays. One in five (20%) showed a moderate to severe psychomotor delay, and 14% showed a moderate to severe mental development delay. Mild delays in mental development occurred in 36% of the toddlers assessed, and 30% showed mild delays in psychomotor skills.
A dose-response effect was seen with mothers’ higher doses of methadone at birth and their children’s psychomotor scores at 6 months. No similar association existed for mental development, and the psychomotor association disappeared by 18-24 months. At this older age, however, 68% of children born to mothers taking a high dose of methadone showed cognitive delays, compared with 29% of children born to mothers on a low dose.
Although no differences were seen in newborns’ average gestational age (an average of 37.8 weeks overall) or birth weight between the high-dose and low-dose methadone groups, infants born to mothers with high doses were more likely to be small for gestational age (P = .01) and to need longer treatment duration for neonatal abstinence syndrome (NAS) (P = .03). Overall, 44% of the newborns were small for gestational age, 28% were born microcephalic, and all but three required pharmacologic treatment for NAS. NAS treatment lasted an average 54 days for the cohort, and the average hospital stay for the babies was 76 days.
The researchers did not report having any external funding or relevant financial disclosures.
SAN FRANCISCO – Infants born to mothers receiving methadone maintenance treatment show poorer-than-average neurodevelopment outcomes, a retrospective study found.
Delays or difficulties in motor abilities appeared first in these children, followed by evidence of cognitive problems in their second year of life, reported Cristina Borradori Tolsa, MD, of University Hospital, Geneva.
“Higher methadone doses during pregnancy can have a detrimental effect on neonatal characteristics and children’s psychomotor development,” Dr. Borradori Tolsa said at the Pediatric Academic Societies meeting. She noted the need for long-term follow-up of children prenatally exposed to methadone maintenance therapy to evaluate their cognitive abilities and school readiness at preschool ages.
Only 38% of the women had exclusively used methadone, while the other 62% had used a variety of substances, including cocaine, alcohol, benzodiazepine, marijuana, and antidepressants. The women had a low average socioeconomic status based on their level of education and the occupations of the children’s fathers.
The researchers drew children’s development data from their scores on the Bayley Scales of Infant Development, Second Edition (BSID-II), at 6 months and 18-24 months. The BSID-II has an average score of 100 and includes a mental development index for language and cognitive development, and a psychomotor development index to assess fine and gross motor skills.
At age 6 months, 75% of the 40 children assessed showed some level of motor skills delay, and 33% had a moderate to severe delay in psychomotor skills. A quarter had no delay at all (a score of at least 85). The average psychomotor score at 6 months was 76, and the average cognitive score was 88. Most of the children (60%) did, however, show mental development within the normal range at 6 months.
By the age of 18-24 months, half of the 36 children assessed showed no motor delays, and half showed no cognitive delays. One in five (20%) showed a moderate to severe psychomotor delay, and 14% showed a moderate to severe mental development delay. Mild delays in mental development occurred in 36% of the toddlers assessed, and 30% showed mild delays in psychomotor skills.
A dose-response effect was seen with mothers’ higher doses of methadone at birth and their children’s psychomotor scores at 6 months. No similar association existed for mental development, and the psychomotor association disappeared by 18-24 months. At this older age, however, 68% of children born to mothers taking a high dose of methadone showed cognitive delays, compared with 29% of children born to mothers on a low dose.
Although no differences were seen in newborns’ average gestational age (an average of 37.8 weeks overall) or birth weight between the high-dose and low-dose methadone groups, infants born to mothers with high doses were more likely to be small for gestational age (P = .01) and to need longer treatment duration for neonatal abstinence syndrome (NAS) (P = .03). Overall, 44% of the newborns were small for gestational age, 28% were born microcephalic, and all but three required pharmacologic treatment for NAS. NAS treatment lasted an average 54 days for the cohort, and the average hospital stay for the babies was 76 days.
The researchers did not report having any external funding or relevant financial disclosures.
SAN FRANCISCO – Infants born to mothers receiving methadone maintenance treatment show poorer-than-average neurodevelopment outcomes, a retrospective study found.
Delays or difficulties in motor abilities appeared first in these children, followed by evidence of cognitive problems in their second year of life, reported Cristina Borradori Tolsa, MD, of University Hospital, Geneva.
“Higher methadone doses during pregnancy can have a detrimental effect on neonatal characteristics and children’s psychomotor development,” Dr. Borradori Tolsa said at the Pediatric Academic Societies meeting. She noted the need for long-term follow-up of children prenatally exposed to methadone maintenance therapy to evaluate their cognitive abilities and school readiness at preschool ages.
Only 38% of the women had exclusively used methadone, while the other 62% had used a variety of substances, including cocaine, alcohol, benzodiazepine, marijuana, and antidepressants. The women had a low average socioeconomic status based on their level of education and the occupations of the children’s fathers.
The researchers drew children’s development data from their scores on the Bayley Scales of Infant Development, Second Edition (BSID-II), at 6 months and 18-24 months. The BSID-II has an average score of 100 and includes a mental development index for language and cognitive development, and a psychomotor development index to assess fine and gross motor skills.
At age 6 months, 75% of the 40 children assessed showed some level of motor skills delay, and 33% had a moderate to severe delay in psychomotor skills. A quarter had no delay at all (a score of at least 85). The average psychomotor score at 6 months was 76, and the average cognitive score was 88. Most of the children (60%) did, however, show mental development within the normal range at 6 months.
By the age of 18-24 months, half of the 36 children assessed showed no motor delays, and half showed no cognitive delays. One in five (20%) showed a moderate to severe psychomotor delay, and 14% showed a moderate to severe mental development delay. Mild delays in mental development occurred in 36% of the toddlers assessed, and 30% showed mild delays in psychomotor skills.
A dose-response effect was seen with mothers’ higher doses of methadone at birth and their children’s psychomotor scores at 6 months. No similar association existed for mental development, and the psychomotor association disappeared by 18-24 months. At this older age, however, 68% of children born to mothers taking a high dose of methadone showed cognitive delays, compared with 29% of children born to mothers on a low dose.
Although no differences were seen in newborns’ average gestational age (an average of 37.8 weeks overall) or birth weight between the high-dose and low-dose methadone groups, infants born to mothers with high doses were more likely to be small for gestational age (P = .01) and to need longer treatment duration for neonatal abstinence syndrome (NAS) (P = .03). Overall, 44% of the newborns were small for gestational age, 28% were born microcephalic, and all but three required pharmacologic treatment for NAS. NAS treatment lasted an average 54 days for the cohort, and the average hospital stay for the babies was 76 days.
The researchers did not report having any external funding or relevant financial disclosures.
AT PAS 17
Key clinical point:
Major finding: Three-fourths of methadone-exposed infants showed psychomotor delays at 6 months, and 50% showed cognitive delays and/or psychomotor delays at 18-24 months.
Data source: A retrospective analysis of neurodevelopment scores of children born to 61 mothers in Geneva who received methadone maintenance therapy during pregnancy.
Disclosures: The researchers did not report having any external funding or relevant financial disclosures.
Teen suicide risk significant among screened nonresponders
SAN FRANCISCO – Teens who answered “no response” for one or more questions during a standard suicide screening in the ED typically have a risk of suicide nearly on par with those who answered “yes” to at least one question, results of a study showed.
“Risk for suicidality was substantial among both groups,” Tricia Hengehold of the University of Cincinnati reported at the Pediatric Academic Societies meeting. “About half of each group fit the medium-risk category, although the yes group had more teens in the high-risk category comparatively.”
In their study, she and her coinvestigators compared all teens who answered yes or no response (NR) to any question on the Ask Suicide-Screening Questions (ASQ). A total of 3,386 adolescents, aged 12-17 years, were screened when each presented to the ED with a complaint other than a psychiatric one. The data came from a preexisting study not initially designed for studying nonresponders.
The majority of teens (93%) answered no to all ASQ questions: 5% answered yes to at least one ASQ question, regardless of other answers, and 2% answered no response on at least one of the ASQ questions, but did not answer yes to any of them.
The average age of participants was 14 years among all response groups, but females were overrepresented in the yes and NR groups: 74% of females answered yes to one of the ASQ questions, compared with just 26% of males. Similarly, 79% of females were classified as nonresponders, vs. 21% of males. In the negative screen group, however, females (54%) and males (46%) were much more evenly represented.
Patients who answered yes or NR also were more likely to have Medicaid or Medicare than commercial insurance or a self-pay arrangement. Within the yes group, 56% had public insurance, and 39% had private insurance. In the NR group, 43% had public insurance, and 53% had private insurance.
Any teens who answered yes or NR should have undergone evaluation by a mental health professional, but those answering yes were more likely to get this evaluation than nonresponders. Nearly all (93%) of those answering yes received the evaluation, compared with 79% of nonresponders. Yet half of the nonresponders who were evaluated were recommended for further follow-up, not far behind the 65% recommended from among the yes group.
A clinically significant risk of suicide existed among 93% of those answering yes and 85% of nonresponders, the investigators found. About a third (33%) of the yes group were classified as high risk – suicidal ideation within the past week or no treatment after a previous attempt – while 16% of the nonresponders were.
“The NR group was more often in an earlier stage of change than the yes group, presenting with a greater percentage of teens in the precontemplation category,” Ms. Hengehold said. The precontemplation category, which included 27% of the NR group and 17% of the yes group, referred to teens who did not believe they would benefit from working with a mental health professional.
The contemplation category referred to teens who said they were still thinking about whether to meet with a mental health professional or that they would seek treatment if their suicidality worsened. This category included 9% of yes responders and 14% of nonresponders.
A higher proportion of yes responders (56%) than nonresponders (41%) had reached the preparation stage, which meant they had agreed to set up treatment or had received a referral within a month after their ED visit. A similar percentage of yes responders and nonresponders were currently in treatment, seeing a mental health professional intermittently, or had successfully received therapy.
“The sociodemographic characteristics of teens that endorse a no response are very similar to those of positive endorsers,” she concluded. She noted the potential importance of including an NR option on suicide-screening instruments.
Although nonresponders had clinically significant mental health concerns that indicated a need for further evaluation, these adolescents were less ready to engage in mental health services than those answering yes.
“This may be important when designing suicide risk interventions for each group,” she reported.
The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
SAN FRANCISCO – Teens who answered “no response” for one or more questions during a standard suicide screening in the ED typically have a risk of suicide nearly on par with those who answered “yes” to at least one question, results of a study showed.
“Risk for suicidality was substantial among both groups,” Tricia Hengehold of the University of Cincinnati reported at the Pediatric Academic Societies meeting. “About half of each group fit the medium-risk category, although the yes group had more teens in the high-risk category comparatively.”
In their study, she and her coinvestigators compared all teens who answered yes or no response (NR) to any question on the Ask Suicide-Screening Questions (ASQ). A total of 3,386 adolescents, aged 12-17 years, were screened when each presented to the ED with a complaint other than a psychiatric one. The data came from a preexisting study not initially designed for studying nonresponders.
The majority of teens (93%) answered no to all ASQ questions: 5% answered yes to at least one ASQ question, regardless of other answers, and 2% answered no response on at least one of the ASQ questions, but did not answer yes to any of them.
The average age of participants was 14 years among all response groups, but females were overrepresented in the yes and NR groups: 74% of females answered yes to one of the ASQ questions, compared with just 26% of males. Similarly, 79% of females were classified as nonresponders, vs. 21% of males. In the negative screen group, however, females (54%) and males (46%) were much more evenly represented.
Patients who answered yes or NR also were more likely to have Medicaid or Medicare than commercial insurance or a self-pay arrangement. Within the yes group, 56% had public insurance, and 39% had private insurance. In the NR group, 43% had public insurance, and 53% had private insurance.
Any teens who answered yes or NR should have undergone evaluation by a mental health professional, but those answering yes were more likely to get this evaluation than nonresponders. Nearly all (93%) of those answering yes received the evaluation, compared with 79% of nonresponders. Yet half of the nonresponders who were evaluated were recommended for further follow-up, not far behind the 65% recommended from among the yes group.
A clinically significant risk of suicide existed among 93% of those answering yes and 85% of nonresponders, the investigators found. About a third (33%) of the yes group were classified as high risk – suicidal ideation within the past week or no treatment after a previous attempt – while 16% of the nonresponders were.
“The NR group was more often in an earlier stage of change than the yes group, presenting with a greater percentage of teens in the precontemplation category,” Ms. Hengehold said. The precontemplation category, which included 27% of the NR group and 17% of the yes group, referred to teens who did not believe they would benefit from working with a mental health professional.
The contemplation category referred to teens who said they were still thinking about whether to meet with a mental health professional or that they would seek treatment if their suicidality worsened. This category included 9% of yes responders and 14% of nonresponders.
A higher proportion of yes responders (56%) than nonresponders (41%) had reached the preparation stage, which meant they had agreed to set up treatment or had received a referral within a month after their ED visit. A similar percentage of yes responders and nonresponders were currently in treatment, seeing a mental health professional intermittently, or had successfully received therapy.
“The sociodemographic characteristics of teens that endorse a no response are very similar to those of positive endorsers,” she concluded. She noted the potential importance of including an NR option on suicide-screening instruments.
Although nonresponders had clinically significant mental health concerns that indicated a need for further evaluation, these adolescents were less ready to engage in mental health services than those answering yes.
“This may be important when designing suicide risk interventions for each group,” she reported.
The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
SAN FRANCISCO – Teens who answered “no response” for one or more questions during a standard suicide screening in the ED typically have a risk of suicide nearly on par with those who answered “yes” to at least one question, results of a study showed.
“Risk for suicidality was substantial among both groups,” Tricia Hengehold of the University of Cincinnati reported at the Pediatric Academic Societies meeting. “About half of each group fit the medium-risk category, although the yes group had more teens in the high-risk category comparatively.”
In their study, she and her coinvestigators compared all teens who answered yes or no response (NR) to any question on the Ask Suicide-Screening Questions (ASQ). A total of 3,386 adolescents, aged 12-17 years, were screened when each presented to the ED with a complaint other than a psychiatric one. The data came from a preexisting study not initially designed for studying nonresponders.
The majority of teens (93%) answered no to all ASQ questions: 5% answered yes to at least one ASQ question, regardless of other answers, and 2% answered no response on at least one of the ASQ questions, but did not answer yes to any of them.
The average age of participants was 14 years among all response groups, but females were overrepresented in the yes and NR groups: 74% of females answered yes to one of the ASQ questions, compared with just 26% of males. Similarly, 79% of females were classified as nonresponders, vs. 21% of males. In the negative screen group, however, females (54%) and males (46%) were much more evenly represented.
Patients who answered yes or NR also were more likely to have Medicaid or Medicare than commercial insurance or a self-pay arrangement. Within the yes group, 56% had public insurance, and 39% had private insurance. In the NR group, 43% had public insurance, and 53% had private insurance.
Any teens who answered yes or NR should have undergone evaluation by a mental health professional, but those answering yes were more likely to get this evaluation than nonresponders. Nearly all (93%) of those answering yes received the evaluation, compared with 79% of nonresponders. Yet half of the nonresponders who were evaluated were recommended for further follow-up, not far behind the 65% recommended from among the yes group.
A clinically significant risk of suicide existed among 93% of those answering yes and 85% of nonresponders, the investigators found. About a third (33%) of the yes group were classified as high risk – suicidal ideation within the past week or no treatment after a previous attempt – while 16% of the nonresponders were.
“The NR group was more often in an earlier stage of change than the yes group, presenting with a greater percentage of teens in the precontemplation category,” Ms. Hengehold said. The precontemplation category, which included 27% of the NR group and 17% of the yes group, referred to teens who did not believe they would benefit from working with a mental health professional.
The contemplation category referred to teens who said they were still thinking about whether to meet with a mental health professional or that they would seek treatment if their suicidality worsened. This category included 9% of yes responders and 14% of nonresponders.
A higher proportion of yes responders (56%) than nonresponders (41%) had reached the preparation stage, which meant they had agreed to set up treatment or had received a referral within a month after their ED visit. A similar percentage of yes responders and nonresponders were currently in treatment, seeing a mental health professional intermittently, or had successfully received therapy.
“The sociodemographic characteristics of teens that endorse a no response are very similar to those of positive endorsers,” she concluded. She noted the potential importance of including an NR option on suicide-screening instruments.
Although nonresponders had clinically significant mental health concerns that indicated a need for further evaluation, these adolescents were less ready to engage in mental health services than those answering yes.
“This may be important when designing suicide risk interventions for each group,” she reported.
The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
AT PAS 17
Key clinical point:
Major finding: Eighty-five percent of teens who were nonresponders on at least one suicide-screening question had a clinically significant risk of suicide, compared with 93% of those answering yes.
Data source: The findings are based on an analysis of responses from 3,386 adolescents screened for suicidality during a nonpsychiatric emergency department visit.
Disclosures: The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
Adoptions increasingly involve special needs, prenatal drug exposures
SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.
“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.
During the initial flood of international adoptions in the 1990s, families sought preadoption consultations, often centering on infectious disease, at an increasing number of adoption clinics. Even with the decline of international adoptions, however, prospective parents still frequently seek information from pediatric providers about children they are considering adopting, whether internationally or domestically.
Prospective parents can receive medical record reviews of children they are considering adopting, provided by adoption agencies or attorneys. Dr. Prock retrospectively reviewed all the preadoptive charts submitted to one adoption clinic during 2 years a decade apart: 63 charts in 2006 and 91 charts in 2016.
Domestic records for both years usually included information about family history, prenatal history, maternal substance abuse history, lab results, and, for newborns, a physical exam. International records, however, generally included only lab results and a physical exam, sometimes with limited information on substance abuse as well, at both time points.
The records reveal just how dramatically referrals have flipped from an international focus to a domestic one in the past decade. International adoption referrals dropped from 84% in 2006 to 29% in 2016 as domestic ones increased from 16% to 71%.
Children with special needs also account for a larger proportion of all adoption referrals today. Just a quarter of international adoption referrals in 2006 involved children with special needs, including cleft lip and/or palate and congenital heart disease, but nearly all international referrals (96%) involved special needs in 2016.
Similarly, domestic adoption referrals in which the child is known to have prenatal exposure to alcohol or drugs doubled from 30% in 2006 to 66% in 2016, driven predominantly by maternal use of marijuana and opiates, Dr. Prock found. It’s important both for providers and for prospective parents to be aware of the higher likelihood that an internationally adopted child will have significant medical and/or developmental needs and that domestically adopted children are more likely to have experienced prenatal drug or alcohol exposures.
“Prospective adoptive parents may benefit from increased understanding of the long-term impact of prenatal substance exposure to marijuana, opiates and other substances,” Dr. Prock said. She also noted the need for prospective parents to be aware of the mental health concerns that can co-occur with substance use even though they may not be reported in preadoptive medical records.
No external funding was used for the research. Dr. Prock had no relevant financial disclosures.
SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.
“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.
During the initial flood of international adoptions in the 1990s, families sought preadoption consultations, often centering on infectious disease, at an increasing number of adoption clinics. Even with the decline of international adoptions, however, prospective parents still frequently seek information from pediatric providers about children they are considering adopting, whether internationally or domestically.
Prospective parents can receive medical record reviews of children they are considering adopting, provided by adoption agencies or attorneys. Dr. Prock retrospectively reviewed all the preadoptive charts submitted to one adoption clinic during 2 years a decade apart: 63 charts in 2006 and 91 charts in 2016.
Domestic records for both years usually included information about family history, prenatal history, maternal substance abuse history, lab results, and, for newborns, a physical exam. International records, however, generally included only lab results and a physical exam, sometimes with limited information on substance abuse as well, at both time points.
The records reveal just how dramatically referrals have flipped from an international focus to a domestic one in the past decade. International adoption referrals dropped from 84% in 2006 to 29% in 2016 as domestic ones increased from 16% to 71%.
Children with special needs also account for a larger proportion of all adoption referrals today. Just a quarter of international adoption referrals in 2006 involved children with special needs, including cleft lip and/or palate and congenital heart disease, but nearly all international referrals (96%) involved special needs in 2016.
Similarly, domestic adoption referrals in which the child is known to have prenatal exposure to alcohol or drugs doubled from 30% in 2006 to 66% in 2016, driven predominantly by maternal use of marijuana and opiates, Dr. Prock found. It’s important both for providers and for prospective parents to be aware of the higher likelihood that an internationally adopted child will have significant medical and/or developmental needs and that domestically adopted children are more likely to have experienced prenatal drug or alcohol exposures.
“Prospective adoptive parents may benefit from increased understanding of the long-term impact of prenatal substance exposure to marijuana, opiates and other substances,” Dr. Prock said. She also noted the need for prospective parents to be aware of the mental health concerns that can co-occur with substance use even though they may not be reported in preadoptive medical records.
No external funding was used for the research. Dr. Prock had no relevant financial disclosures.
SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.
“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.
During the initial flood of international adoptions in the 1990s, families sought preadoption consultations, often centering on infectious disease, at an increasing number of adoption clinics. Even with the decline of international adoptions, however, prospective parents still frequently seek information from pediatric providers about children they are considering adopting, whether internationally or domestically.
Prospective parents can receive medical record reviews of children they are considering adopting, provided by adoption agencies or attorneys. Dr. Prock retrospectively reviewed all the preadoptive charts submitted to one adoption clinic during 2 years a decade apart: 63 charts in 2006 and 91 charts in 2016.
Domestic records for both years usually included information about family history, prenatal history, maternal substance abuse history, lab results, and, for newborns, a physical exam. International records, however, generally included only lab results and a physical exam, sometimes with limited information on substance abuse as well, at both time points.
The records reveal just how dramatically referrals have flipped from an international focus to a domestic one in the past decade. International adoption referrals dropped from 84% in 2006 to 29% in 2016 as domestic ones increased from 16% to 71%.
Children with special needs also account for a larger proportion of all adoption referrals today. Just a quarter of international adoption referrals in 2006 involved children with special needs, including cleft lip and/or palate and congenital heart disease, but nearly all international referrals (96%) involved special needs in 2016.
Similarly, domestic adoption referrals in which the child is known to have prenatal exposure to alcohol or drugs doubled from 30% in 2006 to 66% in 2016, driven predominantly by maternal use of marijuana and opiates, Dr. Prock found. It’s important both for providers and for prospective parents to be aware of the higher likelihood that an internationally adopted child will have significant medical and/or developmental needs and that domestically adopted children are more likely to have experienced prenatal drug or alcohol exposures.
“Prospective adoptive parents may benefit from increased understanding of the long-term impact of prenatal substance exposure to marijuana, opiates and other substances,” Dr. Prock said. She also noted the need for prospective parents to be aware of the mental health concerns that can co-occur with substance use even though they may not be reported in preadoptive medical records.
No external funding was used for the research. Dr. Prock had no relevant financial disclosures.
AT PAS 17
Key clinical point:
Major finding: International adoption referrals with special needs increased from 25% to 96% from 2006 to 2016; domestic referrals with prenatal substance exposure increased from 30% to 66% over the same time period.
Data source: A retrospective review of all preadoptive medical records at a single adoption clinic in 2006 and 2016.
Disclosures: The researchers did not receive external funding. Dr. Prock had no relevant financial disclosures.
More states require coverage of 1-year supplies of contraception
Each semester, Sarah Prager, MD, runs through a familiar yet arduous routine: trying to prescribe a 6- to 12-month supply of oral contraceptives for her college student patients. For those young women who study abroad for one or two semesters, the usual 1-month or 3-month supply won’t be enough.
“I even had two patients who had unplanned pregnancies while studying abroad for this very reason,” said Dr. Prager, associate professor of obstetrics and gynecology at the University of Washington, Seattle. “It’s previously been a real challenge to write the letters, and it takes an absurd amount of time to even fail at getting them 6 months, or to make a plan for them to travel some place to get them.”
This type of policy has been in effect in California since Jan. 1, 2017, and a new study estimates that the measure will save the state nearly $43 million in health care costs while preventing thousands of unintended pregnancies, miscarriages, and abortions (Contraception. 2017 May;95[5]:449-51).
“Awareness of this change in policy will be key in determining how much of an impact it will have,” said Sara McMenamin, PhD, MPH, assistant professor of public health at the University of California, San Diego, and the study’s lead author.
Dr. McMenamin and her colleagues project that 38% of current users of the contraceptive pill, patch, and ring will begin receiving 12-month prescriptions at a time, leading to 15,000 fewer unintended pregnancies, 2,000 fewer miscarriages, and 7,000 fewer abortions every year. Health care costs would be reduced by 0.03%, translating to approximately $42.8 million annually.
There are potential environmental concerns to pill wastage as well, such as keeping it out of river systems and drinking water, Dr. Prager noted.
The California law’s effects will not happen immediately, so there may be a delay in reaching the study’s projections. “These results likely represent an overestimation in the short term, as it will likely take some time to change provider and patient behavior and increase awareness of the new policy,” Dr. McMenamin said.
But the idea is catching on. In 2016, Oregon, Hawaii, Illinois, Maryland, Vermont, and the District of Columbia enacted legislation requiring insurers to cover extended supplies of contraception. Since then, Washington state, Colorado, Virginia, and Nevada have approved similar laws and more than a dozen other states have introduced similar legislation.
Importantly, the effects of this type of coverage cut across demographics, Dr. Prager said.
“I think there’s this perception by many that these are challenges experienced by women who are underresourced or poor or teenagers, and they’re not,” Dr. Prager said. “People are busy, and it’s rare for working adults to have to think about getting to a pharmacy on a regular basis. Contraception is the exception.”
In addition, some women may experience coverage gaps that prevent refills during a job change or other insurance change. Women who travel a lot, for college or work, can have a harder time getting their refills, as well. And women in rural areas may need to drive up to an hour for a pharmacy.
“These are real-life concerns for people of all socioeconomic strata of all ages,” Dr. Prager said. “If you’re off by even a day, then a woman is at risk of pregnancy.”
The California study was supported by the California Health Benefits Review Program. Dr. Prager reported being an unpaid trainer for Nexplanon (Merck).
Each semester, Sarah Prager, MD, runs through a familiar yet arduous routine: trying to prescribe a 6- to 12-month supply of oral contraceptives for her college student patients. For those young women who study abroad for one or two semesters, the usual 1-month or 3-month supply won’t be enough.
“I even had two patients who had unplanned pregnancies while studying abroad for this very reason,” said Dr. Prager, associate professor of obstetrics and gynecology at the University of Washington, Seattle. “It’s previously been a real challenge to write the letters, and it takes an absurd amount of time to even fail at getting them 6 months, or to make a plan for them to travel some place to get them.”
This type of policy has been in effect in California since Jan. 1, 2017, and a new study estimates that the measure will save the state nearly $43 million in health care costs while preventing thousands of unintended pregnancies, miscarriages, and abortions (Contraception. 2017 May;95[5]:449-51).
“Awareness of this change in policy will be key in determining how much of an impact it will have,” said Sara McMenamin, PhD, MPH, assistant professor of public health at the University of California, San Diego, and the study’s lead author.
Dr. McMenamin and her colleagues project that 38% of current users of the contraceptive pill, patch, and ring will begin receiving 12-month prescriptions at a time, leading to 15,000 fewer unintended pregnancies, 2,000 fewer miscarriages, and 7,000 fewer abortions every year. Health care costs would be reduced by 0.03%, translating to approximately $42.8 million annually.
There are potential environmental concerns to pill wastage as well, such as keeping it out of river systems and drinking water, Dr. Prager noted.
The California law’s effects will not happen immediately, so there may be a delay in reaching the study’s projections. “These results likely represent an overestimation in the short term, as it will likely take some time to change provider and patient behavior and increase awareness of the new policy,” Dr. McMenamin said.
But the idea is catching on. In 2016, Oregon, Hawaii, Illinois, Maryland, Vermont, and the District of Columbia enacted legislation requiring insurers to cover extended supplies of contraception. Since then, Washington state, Colorado, Virginia, and Nevada have approved similar laws and more than a dozen other states have introduced similar legislation.
Importantly, the effects of this type of coverage cut across demographics, Dr. Prager said.
“I think there’s this perception by many that these are challenges experienced by women who are underresourced or poor or teenagers, and they’re not,” Dr. Prager said. “People are busy, and it’s rare for working adults to have to think about getting to a pharmacy on a regular basis. Contraception is the exception.”
In addition, some women may experience coverage gaps that prevent refills during a job change or other insurance change. Women who travel a lot, for college or work, can have a harder time getting their refills, as well. And women in rural areas may need to drive up to an hour for a pharmacy.
“These are real-life concerns for people of all socioeconomic strata of all ages,” Dr. Prager said. “If you’re off by even a day, then a woman is at risk of pregnancy.”
The California study was supported by the California Health Benefits Review Program. Dr. Prager reported being an unpaid trainer for Nexplanon (Merck).
Each semester, Sarah Prager, MD, runs through a familiar yet arduous routine: trying to prescribe a 6- to 12-month supply of oral contraceptives for her college student patients. For those young women who study abroad for one or two semesters, the usual 1-month or 3-month supply won’t be enough.
“I even had two patients who had unplanned pregnancies while studying abroad for this very reason,” said Dr. Prager, associate professor of obstetrics and gynecology at the University of Washington, Seattle. “It’s previously been a real challenge to write the letters, and it takes an absurd amount of time to even fail at getting them 6 months, or to make a plan for them to travel some place to get them.”
This type of policy has been in effect in California since Jan. 1, 2017, and a new study estimates that the measure will save the state nearly $43 million in health care costs while preventing thousands of unintended pregnancies, miscarriages, and abortions (Contraception. 2017 May;95[5]:449-51).
“Awareness of this change in policy will be key in determining how much of an impact it will have,” said Sara McMenamin, PhD, MPH, assistant professor of public health at the University of California, San Diego, and the study’s lead author.
Dr. McMenamin and her colleagues project that 38% of current users of the contraceptive pill, patch, and ring will begin receiving 12-month prescriptions at a time, leading to 15,000 fewer unintended pregnancies, 2,000 fewer miscarriages, and 7,000 fewer abortions every year. Health care costs would be reduced by 0.03%, translating to approximately $42.8 million annually.
There are potential environmental concerns to pill wastage as well, such as keeping it out of river systems and drinking water, Dr. Prager noted.
The California law’s effects will not happen immediately, so there may be a delay in reaching the study’s projections. “These results likely represent an overestimation in the short term, as it will likely take some time to change provider and patient behavior and increase awareness of the new policy,” Dr. McMenamin said.
But the idea is catching on. In 2016, Oregon, Hawaii, Illinois, Maryland, Vermont, and the District of Columbia enacted legislation requiring insurers to cover extended supplies of contraception. Since then, Washington state, Colorado, Virginia, and Nevada have approved similar laws and more than a dozen other states have introduced similar legislation.
Importantly, the effects of this type of coverage cut across demographics, Dr. Prager said.
“I think there’s this perception by many that these are challenges experienced by women who are underresourced or poor or teenagers, and they’re not,” Dr. Prager said. “People are busy, and it’s rare for working adults to have to think about getting to a pharmacy on a regular basis. Contraception is the exception.”
In addition, some women may experience coverage gaps that prevent refills during a job change or other insurance change. Women who travel a lot, for college or work, can have a harder time getting their refills, as well. And women in rural areas may need to drive up to an hour for a pharmacy.
“These are real-life concerns for people of all socioeconomic strata of all ages,” Dr. Prager said. “If you’re off by even a day, then a woman is at risk of pregnancy.”
The California study was supported by the California Health Benefits Review Program. Dr. Prager reported being an unpaid trainer for Nexplanon (Merck).
Telemedicine visits after NICU discharge improved care, processes
SAN FRANCISCO – Using telemedicine for a follow-up appointment 1 week after discharge of medically complex infants reduced extra visits or calls to a clinic or emergency department, a recent study found.
The telemedicine visits also helped providers identify ways to improve the neonatal ICU (NICU) discharge process while assessing infants’ home care and answering parents’ questions.
The researchers assessed whether telemedicine visits could ease the transition from neonatal intensive care to home care, respond adequately to caregivers’ needs during that transition, reduce emergency department visits and readmissions, and detect and address any potential problems. The visits also provided an opportunity for feedback on caregivers’ experiences during discharge.
The 92 patients all were medically complex infants who went home with respiratory or feeding equipment, surgical sites and/or complex medication administration. For example, 28 infants had been sent home with a nasogastric tube, 13 had a gastrostomy tube, and 13 had an apnea monitor. Overall, participants had been discharged with an average 2.3 medications and 4.8 scheduled subspecialty follow-up appointments.
The most common conditions among the participants were gastrointestinal disease, neurologic disease, and congenital diaphragmatic hernia or lung lesions. Other conditions included omphalocele, genetic disorders, tracheoesophageal fistula or esophageal atresia and chronic lung disease, or another respiratory disease, Dr. Brant reported at the Pediatric Academic Societies meeting.
Families could enroll in the study only if they had a smart device (such as a tablet) and wireless Internet access at home. One week after the infant’s discharge from the NICU, the caregivers received one telemedicine visit with a team that included neonatologists, neonatal fellows, nurse practitioners, and a telemedicine coordinator or support staffer. During the visit, the providers observed the infant and the home environment, and evaluated care practices, including tube feedings, respiratory support, management of surgical wound sites, and administration of medications.
The providers also reviewed how to use the medical equipment, gathered follow-up information about the child’s health, and answered caregivers’ questions. The providers did not bill for telemedicine visits since it was part of a pilot study, but the participants did need to reside in Pennsylvania or New Jersey to meet provider licensing regulations.
Among the 93 telemedicine visits, half (50%) prevented the family from calling or visiting a provider, and 12% of them led to an earlier follow-up appointment for the child. During the video observations, providers addressed 14 issues related to the child’s sleep environment, respiratory status, surgical sites, or dermatological issues. Among 78 total concerns identified in the visits, 35% related to the surgical site, 33% related to feeding, 19% related to respiratory concerns, and 13% related to medication administration.
The provider team also asked families during the visit about their experiences during discharge. A quarter of the families (26%) said they needed more parental education during discharge. In addition, 14% mentioned problems with scheduling follow-up appointments, and 12% had problems related to case management and insurance. Other issues raised by parents related to home equipment, early intervention, home feeding or medications, and diagnostic logistics.
In subsequent satisfaction surveys filled out by caregivers about the telemedicine visit itself, the median rating was 94.5 on a scale of 0 (not at all satisfied) to 100 (extremely satisfied). The overall intervention was 92% successful in its completion. The only follow-up telemedicine visits that did not occur resulted from malfunctioning wireless connection or a mobile app problem. On a scale of 1 to 100 (best), caregivers rated the video quality as an average 78, the Internet reliability as 79, and the ease of using the camera as 91. One of the biggest benefits of the intervention, Dr. Brant pointed out, is that using telemedicine bypasses some of the geographic and time-related obstacles that can occur with follow-ups.
Dr. Brant had no relevant financial disclosures and did not report using any external funding.
SAN FRANCISCO – Using telemedicine for a follow-up appointment 1 week after discharge of medically complex infants reduced extra visits or calls to a clinic or emergency department, a recent study found.
The telemedicine visits also helped providers identify ways to improve the neonatal ICU (NICU) discharge process while assessing infants’ home care and answering parents’ questions.
The researchers assessed whether telemedicine visits could ease the transition from neonatal intensive care to home care, respond adequately to caregivers’ needs during that transition, reduce emergency department visits and readmissions, and detect and address any potential problems. The visits also provided an opportunity for feedback on caregivers’ experiences during discharge.
The 92 patients all were medically complex infants who went home with respiratory or feeding equipment, surgical sites and/or complex medication administration. For example, 28 infants had been sent home with a nasogastric tube, 13 had a gastrostomy tube, and 13 had an apnea monitor. Overall, participants had been discharged with an average 2.3 medications and 4.8 scheduled subspecialty follow-up appointments.
The most common conditions among the participants were gastrointestinal disease, neurologic disease, and congenital diaphragmatic hernia or lung lesions. Other conditions included omphalocele, genetic disorders, tracheoesophageal fistula or esophageal atresia and chronic lung disease, or another respiratory disease, Dr. Brant reported at the Pediatric Academic Societies meeting.
Families could enroll in the study only if they had a smart device (such as a tablet) and wireless Internet access at home. One week after the infant’s discharge from the NICU, the caregivers received one telemedicine visit with a team that included neonatologists, neonatal fellows, nurse practitioners, and a telemedicine coordinator or support staffer. During the visit, the providers observed the infant and the home environment, and evaluated care practices, including tube feedings, respiratory support, management of surgical wound sites, and administration of medications.
The providers also reviewed how to use the medical equipment, gathered follow-up information about the child’s health, and answered caregivers’ questions. The providers did not bill for telemedicine visits since it was part of a pilot study, but the participants did need to reside in Pennsylvania or New Jersey to meet provider licensing regulations.
Among the 93 telemedicine visits, half (50%) prevented the family from calling or visiting a provider, and 12% of them led to an earlier follow-up appointment for the child. During the video observations, providers addressed 14 issues related to the child’s sleep environment, respiratory status, surgical sites, or dermatological issues. Among 78 total concerns identified in the visits, 35% related to the surgical site, 33% related to feeding, 19% related to respiratory concerns, and 13% related to medication administration.
The provider team also asked families during the visit about their experiences during discharge. A quarter of the families (26%) said they needed more parental education during discharge. In addition, 14% mentioned problems with scheduling follow-up appointments, and 12% had problems related to case management and insurance. Other issues raised by parents related to home equipment, early intervention, home feeding or medications, and diagnostic logistics.
In subsequent satisfaction surveys filled out by caregivers about the telemedicine visit itself, the median rating was 94.5 on a scale of 0 (not at all satisfied) to 100 (extremely satisfied). The overall intervention was 92% successful in its completion. The only follow-up telemedicine visits that did not occur resulted from malfunctioning wireless connection or a mobile app problem. On a scale of 1 to 100 (best), caregivers rated the video quality as an average 78, the Internet reliability as 79, and the ease of using the camera as 91. One of the biggest benefits of the intervention, Dr. Brant pointed out, is that using telemedicine bypasses some of the geographic and time-related obstacles that can occur with follow-ups.
Dr. Brant had no relevant financial disclosures and did not report using any external funding.
SAN FRANCISCO – Using telemedicine for a follow-up appointment 1 week after discharge of medically complex infants reduced extra visits or calls to a clinic or emergency department, a recent study found.
The telemedicine visits also helped providers identify ways to improve the neonatal ICU (NICU) discharge process while assessing infants’ home care and answering parents’ questions.
The researchers assessed whether telemedicine visits could ease the transition from neonatal intensive care to home care, respond adequately to caregivers’ needs during that transition, reduce emergency department visits and readmissions, and detect and address any potential problems. The visits also provided an opportunity for feedback on caregivers’ experiences during discharge.
The 92 patients all were medically complex infants who went home with respiratory or feeding equipment, surgical sites and/or complex medication administration. For example, 28 infants had been sent home with a nasogastric tube, 13 had a gastrostomy tube, and 13 had an apnea monitor. Overall, participants had been discharged with an average 2.3 medications and 4.8 scheduled subspecialty follow-up appointments.
The most common conditions among the participants were gastrointestinal disease, neurologic disease, and congenital diaphragmatic hernia or lung lesions. Other conditions included omphalocele, genetic disorders, tracheoesophageal fistula or esophageal atresia and chronic lung disease, or another respiratory disease, Dr. Brant reported at the Pediatric Academic Societies meeting.
Families could enroll in the study only if they had a smart device (such as a tablet) and wireless Internet access at home. One week after the infant’s discharge from the NICU, the caregivers received one telemedicine visit with a team that included neonatologists, neonatal fellows, nurse practitioners, and a telemedicine coordinator or support staffer. During the visit, the providers observed the infant and the home environment, and evaluated care practices, including tube feedings, respiratory support, management of surgical wound sites, and administration of medications.
The providers also reviewed how to use the medical equipment, gathered follow-up information about the child’s health, and answered caregivers’ questions. The providers did not bill for telemedicine visits since it was part of a pilot study, but the participants did need to reside in Pennsylvania or New Jersey to meet provider licensing regulations.
Among the 93 telemedicine visits, half (50%) prevented the family from calling or visiting a provider, and 12% of them led to an earlier follow-up appointment for the child. During the video observations, providers addressed 14 issues related to the child’s sleep environment, respiratory status, surgical sites, or dermatological issues. Among 78 total concerns identified in the visits, 35% related to the surgical site, 33% related to feeding, 19% related to respiratory concerns, and 13% related to medication administration.
The provider team also asked families during the visit about their experiences during discharge. A quarter of the families (26%) said they needed more parental education during discharge. In addition, 14% mentioned problems with scheduling follow-up appointments, and 12% had problems related to case management and insurance. Other issues raised by parents related to home equipment, early intervention, home feeding or medications, and diagnostic logistics.
In subsequent satisfaction surveys filled out by caregivers about the telemedicine visit itself, the median rating was 94.5 on a scale of 0 (not at all satisfied) to 100 (extremely satisfied). The overall intervention was 92% successful in its completion. The only follow-up telemedicine visits that did not occur resulted from malfunctioning wireless connection or a mobile app problem. On a scale of 1 to 100 (best), caregivers rated the video quality as an average 78, the Internet reliability as 79, and the ease of using the camera as 91. One of the biggest benefits of the intervention, Dr. Brant pointed out, is that using telemedicine bypasses some of the geographic and time-related obstacles that can occur with follow-ups.
Dr. Brant had no relevant financial disclosures and did not report using any external funding.
FROM PAS 17
Key clinical point:
Major finding: Telemedicine visits prevented 50% of participants from calling or visiting a provider and led 12% of families to bring infants in sooner than originally scheduled.
Data source: The findings are based on a pilot project at the Children’s Hospital of Philadelphia involving 93 medically complex infants discharged from the NICU with medical equipment, surgical sites, and/or complex medication administration.
Disclosures: Dr. Brant had no relevant financial disclosures and did not report external funding.
State e-cigarette laws linked to reduced youth use
Several state regulations governing the sales or use of e-cigarettes and related products were associated with lower proportions of youth trying or regularly using vaping products, a new study found.
Restricting sales of electronic vapor products to minors, however, was not linked to a lower risk of vaping among teens.
Dr. Keim and her associates investigated possible associations between various state laws related to vaping products, all passed before 2015, and youth use of the products. They relied on 2015 data from 35 state-specific surveys of youth regarding use of vaping products and from the Youth Risk Behavior Survey from the Centers for Disease Control and Prevention, a nationally representative, biannual survey of students in grades 9-12. The Tobacco Control Laws Database of the American Nonsmokers’ Rights Foundation provided information on state laws related to electronic vapor products.
Among the 200,513 teens whose responses were included in the study, 44% had ever used any kind of electronic vapor product. Rates were similar between girls and boys for ever having tried one or currently using one, Dr. Keim reported at the Pediatric Academic Societies annual meeting.
The researchers looked at associations with each of the following types of laws:
• Statewide prohibition of vaping products on school property or in workplaces, which includes Arizona, New Hampshire, Vermont, and Virginia for schools and North Dakota for workplaces.
• Prohibition of sales to minors under age 18 years, present in 24 states.
• Prohibition or restriction of sales of e-cigarette products from vending machines, present in 17 states.
• Prohibition or restriction of self-service displays of vaping products, present in 11 states.
• Prohibition or restriction of sampling of electronic vapor products, present in Arizona, Delaware, Kentucky, Maryland, New Hampshire, North Carolina, Oklahoma, and South Carolina.
For most of the regulations, teens had a reduced likelihood of trying or currently using vaping products after adjusting for age, ethnicity, grade level, race, region, and sex. Risk of ever trying a vaping product was 12% lower in states that prohibited their use on school grounds or in workplaces, 6% lower in states that barred sales to those under age 18, and 7% lower in states that restricted or prohibited self-service vaping displays.
The risk of youth currently using electronic vapor products was 5% lower in states with the school grounds and workplace restrictions, and 13% lower in states that restricted self-service displays. Laws restricting minor sales were unrelated to the risk of current vaping among youth. Restricting vending machine sales of vaping products had no association with the risk of a teen ever trying vaping, but it was linked to a 7% lower risk of current use of the products among teens. All these associations were statistically significant based on confidence interval values.
Interestingly, a statistically significant risk increase in vaping use occurred for teens in states that restricted or outlawed sampling of vaping products. The risk was 8% higher for ever trying a product and 20% higher for current use. But those findings also could indicate the possibility of reverse causation.
“It’s possible that states that were particularly concerned about sampling had the worst problems – were the ones more likely to institute a ban on that practice, and that would generate the counterintuitive finding,” Dr. Keim said in an interview. “With the data currently available, we can’t look at teen use both before and after the restrictions, just afterwards, but with more data for 2017, it would provide a clearer picture of all of the associations we examined.”
Aside from these laws, other interventions have the potential to reduce vaping among teens as well.
“Restrictions on use in various types of public places and on school grounds may be additional helpful approaches, similar to what has been done with cigarettes,” Dr. Keim said. Although their analysis included laws that prohibited use on school grounds, only four states have one of these laws.
Several state regulations governing the sales or use of e-cigarettes and related products were associated with lower proportions of youth trying or regularly using vaping products, a new study found.
Restricting sales of electronic vapor products to minors, however, was not linked to a lower risk of vaping among teens.
Dr. Keim and her associates investigated possible associations between various state laws related to vaping products, all passed before 2015, and youth use of the products. They relied on 2015 data from 35 state-specific surveys of youth regarding use of vaping products and from the Youth Risk Behavior Survey from the Centers for Disease Control and Prevention, a nationally representative, biannual survey of students in grades 9-12. The Tobacco Control Laws Database of the American Nonsmokers’ Rights Foundation provided information on state laws related to electronic vapor products.
Among the 200,513 teens whose responses were included in the study, 44% had ever used any kind of electronic vapor product. Rates were similar between girls and boys for ever having tried one or currently using one, Dr. Keim reported at the Pediatric Academic Societies annual meeting.
The researchers looked at associations with each of the following types of laws:
• Statewide prohibition of vaping products on school property or in workplaces, which includes Arizona, New Hampshire, Vermont, and Virginia for schools and North Dakota for workplaces.
• Prohibition of sales to minors under age 18 years, present in 24 states.
• Prohibition or restriction of sales of e-cigarette products from vending machines, present in 17 states.
• Prohibition or restriction of self-service displays of vaping products, present in 11 states.
• Prohibition or restriction of sampling of electronic vapor products, present in Arizona, Delaware, Kentucky, Maryland, New Hampshire, North Carolina, Oklahoma, and South Carolina.
For most of the regulations, teens had a reduced likelihood of trying or currently using vaping products after adjusting for age, ethnicity, grade level, race, region, and sex. Risk of ever trying a vaping product was 12% lower in states that prohibited their use on school grounds or in workplaces, 6% lower in states that barred sales to those under age 18, and 7% lower in states that restricted or prohibited self-service vaping displays.
The risk of youth currently using electronic vapor products was 5% lower in states with the school grounds and workplace restrictions, and 13% lower in states that restricted self-service displays. Laws restricting minor sales were unrelated to the risk of current vaping among youth. Restricting vending machine sales of vaping products had no association with the risk of a teen ever trying vaping, but it was linked to a 7% lower risk of current use of the products among teens. All these associations were statistically significant based on confidence interval values.
Interestingly, a statistically significant risk increase in vaping use occurred for teens in states that restricted or outlawed sampling of vaping products. The risk was 8% higher for ever trying a product and 20% higher for current use. But those findings also could indicate the possibility of reverse causation.
“It’s possible that states that were particularly concerned about sampling had the worst problems – were the ones more likely to institute a ban on that practice, and that would generate the counterintuitive finding,” Dr. Keim said in an interview. “With the data currently available, we can’t look at teen use both before and after the restrictions, just afterwards, but with more data for 2017, it would provide a clearer picture of all of the associations we examined.”
Aside from these laws, other interventions have the potential to reduce vaping among teens as well.
“Restrictions on use in various types of public places and on school grounds may be additional helpful approaches, similar to what has been done with cigarettes,” Dr. Keim said. Although their analysis included laws that prohibited use on school grounds, only four states have one of these laws.
Several state regulations governing the sales or use of e-cigarettes and related products were associated with lower proportions of youth trying or regularly using vaping products, a new study found.
Restricting sales of electronic vapor products to minors, however, was not linked to a lower risk of vaping among teens.
Dr. Keim and her associates investigated possible associations between various state laws related to vaping products, all passed before 2015, and youth use of the products. They relied on 2015 data from 35 state-specific surveys of youth regarding use of vaping products and from the Youth Risk Behavior Survey from the Centers for Disease Control and Prevention, a nationally representative, biannual survey of students in grades 9-12. The Tobacco Control Laws Database of the American Nonsmokers’ Rights Foundation provided information on state laws related to electronic vapor products.
Among the 200,513 teens whose responses were included in the study, 44% had ever used any kind of electronic vapor product. Rates were similar between girls and boys for ever having tried one or currently using one, Dr. Keim reported at the Pediatric Academic Societies annual meeting.
The researchers looked at associations with each of the following types of laws:
• Statewide prohibition of vaping products on school property or in workplaces, which includes Arizona, New Hampshire, Vermont, and Virginia for schools and North Dakota for workplaces.
• Prohibition of sales to minors under age 18 years, present in 24 states.
• Prohibition or restriction of sales of e-cigarette products from vending machines, present in 17 states.
• Prohibition or restriction of self-service displays of vaping products, present in 11 states.
• Prohibition or restriction of sampling of electronic vapor products, present in Arizona, Delaware, Kentucky, Maryland, New Hampshire, North Carolina, Oklahoma, and South Carolina.
For most of the regulations, teens had a reduced likelihood of trying or currently using vaping products after adjusting for age, ethnicity, grade level, race, region, and sex. Risk of ever trying a vaping product was 12% lower in states that prohibited their use on school grounds or in workplaces, 6% lower in states that barred sales to those under age 18, and 7% lower in states that restricted or prohibited self-service vaping displays.
The risk of youth currently using electronic vapor products was 5% lower in states with the school grounds and workplace restrictions, and 13% lower in states that restricted self-service displays. Laws restricting minor sales were unrelated to the risk of current vaping among youth. Restricting vending machine sales of vaping products had no association with the risk of a teen ever trying vaping, but it was linked to a 7% lower risk of current use of the products among teens. All these associations were statistically significant based on confidence interval values.
Interestingly, a statistically significant risk increase in vaping use occurred for teens in states that restricted or outlawed sampling of vaping products. The risk was 8% higher for ever trying a product and 20% higher for current use. But those findings also could indicate the possibility of reverse causation.
“It’s possible that states that were particularly concerned about sampling had the worst problems – were the ones more likely to institute a ban on that practice, and that would generate the counterintuitive finding,” Dr. Keim said in an interview. “With the data currently available, we can’t look at teen use both before and after the restrictions, just afterwards, but with more data for 2017, it would provide a clearer picture of all of the associations we examined.”
Aside from these laws, other interventions have the potential to reduce vaping among teens as well.
“Restrictions on use in various types of public places and on school grounds may be additional helpful approaches, similar to what has been done with cigarettes,” Dr. Keim said. Although their analysis included laws that prohibited use on school grounds, only four states have one of these laws.
FROM PAS 2017
Key clinical point: The two state laws associated with lower risks of teens trying or currently using e-cigarette products were prohibiting their use at school or work and prohibiting or restricting self-service displays.
Major finding: , depending on the law.
Data source: The findings are based on an analysis of 200,513 high school students’ use of electronic vapor products and their states’ laws regarding vaping use, marketing, or sales.
Disclosures: The research did not use any external funding, and Dr. Keim had no relevant financial disclosures.
Microneedle pretreatment shortened ALA incubation time
Pretreatment with microneedles provided a faster, less painful, way to treat facial actinic keratoses (AKs) with photodynamic therapy, with similar clearance rates as would be expected with traditional therapy, in a study of 33 patients.
This approach reduced the incubation time of aminolevulinic acid (ALA) to 20 minutes, with comparable results to one-hour ALA incubation times. “Interestingly, the secondary outcome of pain associated with blue light exposure during photodynamic therapy was nominal and not significantly different from the sham side,” reported Tatyana A. Petukhova, MD, and her associates in the department of dermatology at the University of California, Davis (JAMA Dermatol. 2017 May 17. doi: 10.1001/jamadermatol.2017.0849).
“Pain associated with PDT is the most severe adverse effect and may lead to interruption or discontinuation of treatment, resulting in refusal to repeat the process at a future date owing to unbearable discomfort,” they wrote. Patients also reported little to no swelling or pain after treatment and minimal erythema and peeling.
The randomized, split-face, single-blinded controlled trial enrolled 33 patients, with at least eight AKs on their faces, from a university dermatology outpatient clinic from 2015 to 2016. They were randomized to receive either 10 minutes or 20 minutes incubation time with ALA, and 32 completed the study. Those in the 20-minute group had a mean of 25 grade II facial AKs, and those in the 10-minute group had an average of 31 grade II facial AKs.
Before administration of ALA, each patient received pretreatment with a microneedle roller on one side of their face and a sham roller on the other side. On each half of their faces, the microneedle device (a single-use sterile array of microneedles measuring 200 mcm) or sham roller was rolled forward and backward eight times in four directions.
They were exposed to blue light for 1,000 seconds at an average wavelength of 478 nm, an overall fluence of 10 J/cm2, and advised to avoid sun exposure for 36 hours after treatment.
At follow-up one month later, among the patients with a 20-minute ALA incubation time, the mean AK clearance rate was 76% on the side with microneedle pretreatment, compared with 58% on the sham side (P less than .01). This included three patients with complete clearance. The efficacy of microneedle pretreatment with a 20-minute incubation time is similar to that of 1-hour incubation times with ALA. PDT typically uses 1-4 hours of incubation time.
Among the patients who received a 10-minute ALA incubation time, a mean of 43% of AKs on the microneedle side and 38% on the sham side cleared, a difference that was not statistically significant. Participants did not rate the pain as significantly different between each side of their face and both groups reported low levels of pain overall.
One limitation of the study was the short follow-up time. “Because actinic damage is cumulative, there is potential for thicker AKs to recur or for new lesions to develop during a longer follow-up period,” the authors noted.
The research was partly funded by an author’s University of California, Davis, Medical Student Research Fellowship. The authors reported having no disclosures.
The effectiveness of photodynamic therapy (PDT) as a field therapy option for actinic keratoses (AKs) has been well documented. However, treatment is limited by poor or variable transepidermal absorption owing to the hydrophilic nature of aminolevulinic acid (ALA).
To overcome the problem of transepidermal delivery, patients wait for hours at a time between ALA application and the light treatment. These prolonged incubation times limit usefulness. Petukhova et al. hypothesized that microneedles would enhance penetration and decrease incubation period without compromising safety and efficacy. The results suggest that an effective and safe PDT treatment can be achieved by using microneedles as means to expedite drug penetration. These results also suggest that further reduction of incubation time will not be achieved by better transepidermal penetration.
As envisioned in 1971, microneedles can have an important clinical role and can be an important tool in the dermatologist’s armamentarium. Microneedles are painless when compared with hypodermic needles, do not require specific training, minimize risk of needlestick injuries, can potentially reduce cost, and improve patient compliance and access. Therefore, microneedle-based devices can potentially be used at home by patients in a safe manner. Mostly in preclinical trials, as well as in some clinical trials, microneedles have been successfully used to deliver various drugs and vaccines.
Importantly, dermatologists are uniquely positioned to research this novel drug delivery method because they routinely treat cutaneous disease. This can be leveraged by dermatologists to use microneedles not only for dermal rejuvenation purposes but also to enhance drug delivery for dermatological indications. Therefore, the study by Petukhova et al. not only provides practical information for treatment of AKs with PDT but can also be viewed as a call for action to all dermatologists to lead innovation in the field and revolutionize dermatological drug delivery.
These comments are adapted from an accompanying editorial by Hadar Lev-Tov, MD, of the University of Florida, Miami. He reported having no disclosures.
The effectiveness of photodynamic therapy (PDT) as a field therapy option for actinic keratoses (AKs) has been well documented. However, treatment is limited by poor or variable transepidermal absorption owing to the hydrophilic nature of aminolevulinic acid (ALA).
To overcome the problem of transepidermal delivery, patients wait for hours at a time between ALA application and the light treatment. These prolonged incubation times limit usefulness. Petukhova et al. hypothesized that microneedles would enhance penetration and decrease incubation period without compromising safety and efficacy. The results suggest that an effective and safe PDT treatment can be achieved by using microneedles as means to expedite drug penetration. These results also suggest that further reduction of incubation time will not be achieved by better transepidermal penetration.
As envisioned in 1971, microneedles can have an important clinical role and can be an important tool in the dermatologist’s armamentarium. Microneedles are painless when compared with hypodermic needles, do not require specific training, minimize risk of needlestick injuries, can potentially reduce cost, and improve patient compliance and access. Therefore, microneedle-based devices can potentially be used at home by patients in a safe manner. Mostly in preclinical trials, as well as in some clinical trials, microneedles have been successfully used to deliver various drugs and vaccines.
Importantly, dermatologists are uniquely positioned to research this novel drug delivery method because they routinely treat cutaneous disease. This can be leveraged by dermatologists to use microneedles not only for dermal rejuvenation purposes but also to enhance drug delivery for dermatological indications. Therefore, the study by Petukhova et al. not only provides practical information for treatment of AKs with PDT but can also be viewed as a call for action to all dermatologists to lead innovation in the field and revolutionize dermatological drug delivery.
These comments are adapted from an accompanying editorial by Hadar Lev-Tov, MD, of the University of Florida, Miami. He reported having no disclosures.
The effectiveness of photodynamic therapy (PDT) as a field therapy option for actinic keratoses (AKs) has been well documented. However, treatment is limited by poor or variable transepidermal absorption owing to the hydrophilic nature of aminolevulinic acid (ALA).
To overcome the problem of transepidermal delivery, patients wait for hours at a time between ALA application and the light treatment. These prolonged incubation times limit usefulness. Petukhova et al. hypothesized that microneedles would enhance penetration and decrease incubation period without compromising safety and efficacy. The results suggest that an effective and safe PDT treatment can be achieved by using microneedles as means to expedite drug penetration. These results also suggest that further reduction of incubation time will not be achieved by better transepidermal penetration.
As envisioned in 1971, microneedles can have an important clinical role and can be an important tool in the dermatologist’s armamentarium. Microneedles are painless when compared with hypodermic needles, do not require specific training, minimize risk of needlestick injuries, can potentially reduce cost, and improve patient compliance and access. Therefore, microneedle-based devices can potentially be used at home by patients in a safe manner. Mostly in preclinical trials, as well as in some clinical trials, microneedles have been successfully used to deliver various drugs and vaccines.
Importantly, dermatologists are uniquely positioned to research this novel drug delivery method because they routinely treat cutaneous disease. This can be leveraged by dermatologists to use microneedles not only for dermal rejuvenation purposes but also to enhance drug delivery for dermatological indications. Therefore, the study by Petukhova et al. not only provides practical information for treatment of AKs with PDT but can also be viewed as a call for action to all dermatologists to lead innovation in the field and revolutionize dermatological drug delivery.
These comments are adapted from an accompanying editorial by Hadar Lev-Tov, MD, of the University of Florida, Miami. He reported having no disclosures.
Pretreatment with microneedles provided a faster, less painful, way to treat facial actinic keratoses (AKs) with photodynamic therapy, with similar clearance rates as would be expected with traditional therapy, in a study of 33 patients.
This approach reduced the incubation time of aminolevulinic acid (ALA) to 20 minutes, with comparable results to one-hour ALA incubation times. “Interestingly, the secondary outcome of pain associated with blue light exposure during photodynamic therapy was nominal and not significantly different from the sham side,” reported Tatyana A. Petukhova, MD, and her associates in the department of dermatology at the University of California, Davis (JAMA Dermatol. 2017 May 17. doi: 10.1001/jamadermatol.2017.0849).
“Pain associated with PDT is the most severe adverse effect and may lead to interruption or discontinuation of treatment, resulting in refusal to repeat the process at a future date owing to unbearable discomfort,” they wrote. Patients also reported little to no swelling or pain after treatment and minimal erythema and peeling.
The randomized, split-face, single-blinded controlled trial enrolled 33 patients, with at least eight AKs on their faces, from a university dermatology outpatient clinic from 2015 to 2016. They were randomized to receive either 10 minutes or 20 minutes incubation time with ALA, and 32 completed the study. Those in the 20-minute group had a mean of 25 grade II facial AKs, and those in the 10-minute group had an average of 31 grade II facial AKs.
Before administration of ALA, each patient received pretreatment with a microneedle roller on one side of their face and a sham roller on the other side. On each half of their faces, the microneedle device (a single-use sterile array of microneedles measuring 200 mcm) or sham roller was rolled forward and backward eight times in four directions.
They were exposed to blue light for 1,000 seconds at an average wavelength of 478 nm, an overall fluence of 10 J/cm2, and advised to avoid sun exposure for 36 hours after treatment.
At follow-up one month later, among the patients with a 20-minute ALA incubation time, the mean AK clearance rate was 76% on the side with microneedle pretreatment, compared with 58% on the sham side (P less than .01). This included three patients with complete clearance. The efficacy of microneedle pretreatment with a 20-minute incubation time is similar to that of 1-hour incubation times with ALA. PDT typically uses 1-4 hours of incubation time.
Among the patients who received a 10-minute ALA incubation time, a mean of 43% of AKs on the microneedle side and 38% on the sham side cleared, a difference that was not statistically significant. Participants did not rate the pain as significantly different between each side of their face and both groups reported low levels of pain overall.
One limitation of the study was the short follow-up time. “Because actinic damage is cumulative, there is potential for thicker AKs to recur or for new lesions to develop during a longer follow-up period,” the authors noted.
The research was partly funded by an author’s University of California, Davis, Medical Student Research Fellowship. The authors reported having no disclosures.
Pretreatment with microneedles provided a faster, less painful, way to treat facial actinic keratoses (AKs) with photodynamic therapy, with similar clearance rates as would be expected with traditional therapy, in a study of 33 patients.
This approach reduced the incubation time of aminolevulinic acid (ALA) to 20 minutes, with comparable results to one-hour ALA incubation times. “Interestingly, the secondary outcome of pain associated with blue light exposure during photodynamic therapy was nominal and not significantly different from the sham side,” reported Tatyana A. Petukhova, MD, and her associates in the department of dermatology at the University of California, Davis (JAMA Dermatol. 2017 May 17. doi: 10.1001/jamadermatol.2017.0849).
“Pain associated with PDT is the most severe adverse effect and may lead to interruption or discontinuation of treatment, resulting in refusal to repeat the process at a future date owing to unbearable discomfort,” they wrote. Patients also reported little to no swelling or pain after treatment and minimal erythema and peeling.
The randomized, split-face, single-blinded controlled trial enrolled 33 patients, with at least eight AKs on their faces, from a university dermatology outpatient clinic from 2015 to 2016. They were randomized to receive either 10 minutes or 20 minutes incubation time with ALA, and 32 completed the study. Those in the 20-minute group had a mean of 25 grade II facial AKs, and those in the 10-minute group had an average of 31 grade II facial AKs.
Before administration of ALA, each patient received pretreatment with a microneedle roller on one side of their face and a sham roller on the other side. On each half of their faces, the microneedle device (a single-use sterile array of microneedles measuring 200 mcm) or sham roller was rolled forward and backward eight times in four directions.
They were exposed to blue light for 1,000 seconds at an average wavelength of 478 nm, an overall fluence of 10 J/cm2, and advised to avoid sun exposure for 36 hours after treatment.
At follow-up one month later, among the patients with a 20-minute ALA incubation time, the mean AK clearance rate was 76% on the side with microneedle pretreatment, compared with 58% on the sham side (P less than .01). This included three patients with complete clearance. The efficacy of microneedle pretreatment with a 20-minute incubation time is similar to that of 1-hour incubation times with ALA. PDT typically uses 1-4 hours of incubation time.
Among the patients who received a 10-minute ALA incubation time, a mean of 43% of AKs on the microneedle side and 38% on the sham side cleared, a difference that was not statistically significant. Participants did not rate the pain as significantly different between each side of their face and both groups reported low levels of pain overall.
One limitation of the study was the short follow-up time. “Because actinic damage is cumulative, there is potential for thicker AKs to recur or for new lesions to develop during a longer follow-up period,” the authors noted.
The research was partly funded by an author’s University of California, Davis, Medical Student Research Fellowship. The authors reported having no disclosures.
Key clinical point:
Major finding: The mean facial AK clearance rate one month after microneedle pretreatment and 20 minutes incubation of ALA was 76%.
Data source: The findings are based on a randomized, controlled, single-blinded study of 33 outpatients with actinic keratoses.
Disclosures: The research was partly funded by an author’s University of California, Davis, Medical Student Research Fellowship. The authors reported having no disclosures.
Marijuana-related visits to Colorado ED steadily increasing
SAN FRANCISCO – Visits to the emergency department and urgent care by adolescents using marijuana in Colorado increased from 2005 to 2015, a retrospective study showed.
The state legalized medical marijuana use in 2000 and recreational marijuana use in 2014.
“Adolescents with psychiatric illness comprised a large proportion of marijuana exposures,” said lead author George Sam Wang, MD, of the University of Colorado at Denver in Aurora. “Coingestants were common and included ethanol, amphetamines, and opiates,” he said at the Pediatric Academic Societies meeting.
However, only eight states have legalized recreational use, and federal data may not reflect the reality within states with legalization. In Colorado, 8% of youth in that age range have used marijuana in the past month.
Dr. Wang and his colleagues therefore conducted a retrospective review of adolescent and young adult visits to the Children’s Hospital Colorado ED or any of the system’s urgent care clinics between January 2005 and December 2015. They included all individuals 13-21 years old who had a positive urine drug screen for marijuana or whose visit was coded for marijuana use (ICD-9 codes of 305.20, 969.6, or E854.1).
During those 11 years, 3,844 visits occurred, and the rate of visits related to cannabis increased from 2/1,000 emergency department/urgent care visits in 2009 to 4/1,000 in 2015. A little over half (55%) of the patients were male, and the average age was 16 years.
A nearly linear steady increase in the number of visits occurred over the study period, from 146 visits in 2005 to 639 visits in 2015. Similarly, the number of annual psychiatry evaluations increased fivefold, from 75 in 2005 to 394 in 2015. Two-thirds of the patients overall (66%) underwent a psychiatric evaluation.
The most common ICD codes reported were for unspecified cannabis use (50% of visits), unspecified episodic mood disorder (20%), and alcohol abuse (15%). Urine drug screens for alcohol were positive in 70% of the patients, while amphetamines, benzodiazepines, opiates, and cocaine were each present in 4% of the patients. Less than 1% had positive drug screens for phencyclidine, barbiturates, oxycodone, and 3,4-methylenedioxy-methamphetamine.
Close behind unspecified alcohol abuse were codes for suicidal ideation and depressive disorder, both noted in 14% of visits. Additional codes, present in 9%-12% of visits, included educational circumstance, ADHD, unspecified anxiety, unspecified asthma, and tobacco use disorder.
Just over half of all patients (53%) were discharged home. Approximately one-quarter (27%) were admitted, and 10% were transferred to another facility. Information was not provided for the remaining 10%.
“Targeted education and prevention strategies for marijuana use are necessary in the adolescent population to reduce the public health impact,” Dr. Wang said, adding that the ED should initiate behavioral health screenings and/or interventions, such as referral to treatment, with adolescents using marijuana.
Because the study was conducted at a tertiary care hospital in a state with legalized recreational marijuana, the findings are not likely generalizable, and the researchers relied only on ICD codes and drug screens without conducting full chart reviews. The data set also began 5 years after medical marijuana was legalized, precluding the ability to make in-state comparisons to when marijuana was completely illegal.
The study had no external funding. Dr. Wang disclosed he has a Colorado department of public health and environment (CDPHE) grant evaluating pharmacokinetics of cannabidiol in pediatric epilepsy patients. He also serves on a CDPHE advisory committee on health effects and impact of cannabis on public health and is a contributing author on related topics for UpToDate.
SAN FRANCISCO – Visits to the emergency department and urgent care by adolescents using marijuana in Colorado increased from 2005 to 2015, a retrospective study showed.
The state legalized medical marijuana use in 2000 and recreational marijuana use in 2014.
“Adolescents with psychiatric illness comprised a large proportion of marijuana exposures,” said lead author George Sam Wang, MD, of the University of Colorado at Denver in Aurora. “Coingestants were common and included ethanol, amphetamines, and opiates,” he said at the Pediatric Academic Societies meeting.
However, only eight states have legalized recreational use, and federal data may not reflect the reality within states with legalization. In Colorado, 8% of youth in that age range have used marijuana in the past month.
Dr. Wang and his colleagues therefore conducted a retrospective review of adolescent and young adult visits to the Children’s Hospital Colorado ED or any of the system’s urgent care clinics between January 2005 and December 2015. They included all individuals 13-21 years old who had a positive urine drug screen for marijuana or whose visit was coded for marijuana use (ICD-9 codes of 305.20, 969.6, or E854.1).
During those 11 years, 3,844 visits occurred, and the rate of visits related to cannabis increased from 2/1,000 emergency department/urgent care visits in 2009 to 4/1,000 in 2015. A little over half (55%) of the patients were male, and the average age was 16 years.
A nearly linear steady increase in the number of visits occurred over the study period, from 146 visits in 2005 to 639 visits in 2015. Similarly, the number of annual psychiatry evaluations increased fivefold, from 75 in 2005 to 394 in 2015. Two-thirds of the patients overall (66%) underwent a psychiatric evaluation.
The most common ICD codes reported were for unspecified cannabis use (50% of visits), unspecified episodic mood disorder (20%), and alcohol abuse (15%). Urine drug screens for alcohol were positive in 70% of the patients, while amphetamines, benzodiazepines, opiates, and cocaine were each present in 4% of the patients. Less than 1% had positive drug screens for phencyclidine, barbiturates, oxycodone, and 3,4-methylenedioxy-methamphetamine.
Close behind unspecified alcohol abuse were codes for suicidal ideation and depressive disorder, both noted in 14% of visits. Additional codes, present in 9%-12% of visits, included educational circumstance, ADHD, unspecified anxiety, unspecified asthma, and tobacco use disorder.
Just over half of all patients (53%) were discharged home. Approximately one-quarter (27%) were admitted, and 10% were transferred to another facility. Information was not provided for the remaining 10%.
“Targeted education and prevention strategies for marijuana use are necessary in the adolescent population to reduce the public health impact,” Dr. Wang said, adding that the ED should initiate behavioral health screenings and/or interventions, such as referral to treatment, with adolescents using marijuana.
Because the study was conducted at a tertiary care hospital in a state with legalized recreational marijuana, the findings are not likely generalizable, and the researchers relied only on ICD codes and drug screens without conducting full chart reviews. The data set also began 5 years after medical marijuana was legalized, precluding the ability to make in-state comparisons to when marijuana was completely illegal.
The study had no external funding. Dr. Wang disclosed he has a Colorado department of public health and environment (CDPHE) grant evaluating pharmacokinetics of cannabidiol in pediatric epilepsy patients. He also serves on a CDPHE advisory committee on health effects and impact of cannabis on public health and is a contributing author on related topics for UpToDate.
SAN FRANCISCO – Visits to the emergency department and urgent care by adolescents using marijuana in Colorado increased from 2005 to 2015, a retrospective study showed.
The state legalized medical marijuana use in 2000 and recreational marijuana use in 2014.
“Adolescents with psychiatric illness comprised a large proportion of marijuana exposures,” said lead author George Sam Wang, MD, of the University of Colorado at Denver in Aurora. “Coingestants were common and included ethanol, amphetamines, and opiates,” he said at the Pediatric Academic Societies meeting.
However, only eight states have legalized recreational use, and federal data may not reflect the reality within states with legalization. In Colorado, 8% of youth in that age range have used marijuana in the past month.
Dr. Wang and his colleagues therefore conducted a retrospective review of adolescent and young adult visits to the Children’s Hospital Colorado ED or any of the system’s urgent care clinics between January 2005 and December 2015. They included all individuals 13-21 years old who had a positive urine drug screen for marijuana or whose visit was coded for marijuana use (ICD-9 codes of 305.20, 969.6, or E854.1).
During those 11 years, 3,844 visits occurred, and the rate of visits related to cannabis increased from 2/1,000 emergency department/urgent care visits in 2009 to 4/1,000 in 2015. A little over half (55%) of the patients were male, and the average age was 16 years.
A nearly linear steady increase in the number of visits occurred over the study period, from 146 visits in 2005 to 639 visits in 2015. Similarly, the number of annual psychiatry evaluations increased fivefold, from 75 in 2005 to 394 in 2015. Two-thirds of the patients overall (66%) underwent a psychiatric evaluation.
The most common ICD codes reported were for unspecified cannabis use (50% of visits), unspecified episodic mood disorder (20%), and alcohol abuse (15%). Urine drug screens for alcohol were positive in 70% of the patients, while amphetamines, benzodiazepines, opiates, and cocaine were each present in 4% of the patients. Less than 1% had positive drug screens for phencyclidine, barbiturates, oxycodone, and 3,4-methylenedioxy-methamphetamine.
Close behind unspecified alcohol abuse were codes for suicidal ideation and depressive disorder, both noted in 14% of visits. Additional codes, present in 9%-12% of visits, included educational circumstance, ADHD, unspecified anxiety, unspecified asthma, and tobacco use disorder.
Just over half of all patients (53%) were discharged home. Approximately one-quarter (27%) were admitted, and 10% were transferred to another facility. Information was not provided for the remaining 10%.
“Targeted education and prevention strategies for marijuana use are necessary in the adolescent population to reduce the public health impact,” Dr. Wang said, adding that the ED should initiate behavioral health screenings and/or interventions, such as referral to treatment, with adolescents using marijuana.
Because the study was conducted at a tertiary care hospital in a state with legalized recreational marijuana, the findings are not likely generalizable, and the researchers relied only on ICD codes and drug screens without conducting full chart reviews. The data set also began 5 years after medical marijuana was legalized, precluding the ability to make in-state comparisons to when marijuana was completely illegal.
The study had no external funding. Dr. Wang disclosed he has a Colorado department of public health and environment (CDPHE) grant evaluating pharmacokinetics of cannabidiol in pediatric epilepsy patients. He also serves on a CDPHE advisory committee on health effects and impact of cannabis on public health and is a contributing author on related topics for UpToDate.
FROM PAS 2017
Key clinical point: Visits to the ED and urgent care have steadily increased among adolescents using marijuana in a state with legal recreational marijuana.
Major finding: Visits related to cannabis increased from 2/1,000 ED and urgent care visits in 2009 to 4/1,000 in 2015.
Data source: A retrospective study from 2005 to 2015 of 3,844 Colorado ED and urgent care visits involving adolescents who used marijuana.
Disclosures: The study had no external funding. Dr. Wang disclosed he has a Colorado department of public health and environment (CDPHE) grant evaluating pharmacokinetics of cannabidiol in pediatric epilepsy patients. He also serves on a CDPHE advisory committee on health effects and impact of cannabis on public health and is a contributing author on related topics for UpToDate.
Preterm infants at high risk for RSV morbidity without immunoprophylaxis
SAN FRANCISCO – Preterm infants born at 29-35 weeks’ gestation and hospitalized for respiratory syncytial virus (RSV) can experience particularly severe morbidity if they have not received immunoprophylaxis, according to new industry-funded research.
Across two RSV seasons at more than 40 study sites, nearly half of preterm infants admitted for lab-confirmed RSV required ICU admission, and one in five required invasive mechanical ventilation.
“Severity of illness and resource utilization are greatest in infants aged less than 3 months,” said John DeVincenzo, MD, professor in the pediatric infectious diseases division at the University of Tennessee, Memphis. “The results from the two seasons were consistent with one another and with previous and recent studies,” he said at the annual Pediatric Academic Societies meeting.
Previous research has shown that preterm infants born at 35 weeks or less gestation have a higher risk of RSV-related hospitalizations and subsequent morbidity, and that monthly immunoprophylaxis reduced RSV-related hospitalization in high-risk infants, including preterm infants.
Until 2014, the American Academy of Pediatrics recommended respiratory syncytial virus (RSV) immunoprophylaxis for all preterm infants under 32 weeks’ gestation and for infants between 32-35 weeks with additional risk factors, such as chronic lung disease or cyanotic heart disease (Pediatrics. 2003 Dec;112[6]:1442-6).
New recommendations in 2014 restricted immunoprophylaxis to preterm infants younger than 29 weeks’ gestational age unless they had additional risk factors such as chronic lung disease or hemodynamically significant heart disease (Pediatrics. 2014 Aug. doi: 10.1542/peds.2014-1665).
This study compared outcomes among all preterm infants born at 29-35 weeks’ gestation who were hospitalized during RSV season (October-April) for at least 24 hours with laboratory-confirmed RSV and who had not received RSV immunoprophylaxis within the 35 days before symptom onset. The 1,378 infants were younger than age 12 months when they were hospitalized at one of 43 sites during the 2014-2015 RSV season or one of 42 sites in the 2015-2016 season.
Of the 702 preterm infants hospitalized in 2014-2015, 42% were admitted to intensive care, and 20% needed invasive mechanical ventilation. Nearly half (48%) of the 676 infants admitted during the 2015-2016 season went to the ICU, and 19% required mechanical ventilation. One infant died of RSV in each season.
Throughout both seasons, more than three quarters (78%) of all RSV hospitalizations were infants younger than 6 months old. In 2014-2015, infants younger than 6 months accounted for 87% of all RSV admissions to the ICU and 92% of those needing mechanical ventilation. Similarly, young infants accounted for 81% of ICU admissions and 90% of RSV-related mechanical ventilation during the 2015-2016 season. Overall, preterm infants younger than 6 months old without immunoprophylaxis accounted for 84% of RSV-related ICU admissions and 91% of RSV-related mechanical ventilation.
The younger the infants were, the more likely they were to need ICU care and/or mechanical ventilation, the researchers found. Across both seasons, 56% of infants under 3 months old with RSV were admitted to the ICU, compared to 34% of those between 3 and 12 months old. Likewise, 29% of those under 3 months old and 10% of those between 3 and 12 months needed invasive mechanical ventilation.
Nearly half (46%) of all infants hospitalized for RSV had been discharged from their birth hospital within the previous 30 days, and 82% of all hospitalizations occurred within 2 months of birth discharge.
A cost analysis revealed that mean hospital charges for RSV-related hospitalizations of preterm infants ranged from $31,366 for 35-week gestation infants between ages 3-6 months to $122,301 for infants under 3 months old born between 29-32 weeks.
AstraZeneca/MedImmune funded the study. Dr. DeVincenzo and a number of his colleagues have received grants/research support from AstraZeneca/MedImmune, and some of his colleagues are or were AstraZeneca employees.
SAN FRANCISCO – Preterm infants born at 29-35 weeks’ gestation and hospitalized for respiratory syncytial virus (RSV) can experience particularly severe morbidity if they have not received immunoprophylaxis, according to new industry-funded research.
Across two RSV seasons at more than 40 study sites, nearly half of preterm infants admitted for lab-confirmed RSV required ICU admission, and one in five required invasive mechanical ventilation.
“Severity of illness and resource utilization are greatest in infants aged less than 3 months,” said John DeVincenzo, MD, professor in the pediatric infectious diseases division at the University of Tennessee, Memphis. “The results from the two seasons were consistent with one another and with previous and recent studies,” he said at the annual Pediatric Academic Societies meeting.
Previous research has shown that preterm infants born at 35 weeks or less gestation have a higher risk of RSV-related hospitalizations and subsequent morbidity, and that monthly immunoprophylaxis reduced RSV-related hospitalization in high-risk infants, including preterm infants.
Until 2014, the American Academy of Pediatrics recommended respiratory syncytial virus (RSV) immunoprophylaxis for all preterm infants under 32 weeks’ gestation and for infants between 32-35 weeks with additional risk factors, such as chronic lung disease or cyanotic heart disease (Pediatrics. 2003 Dec;112[6]:1442-6).
New recommendations in 2014 restricted immunoprophylaxis to preterm infants younger than 29 weeks’ gestational age unless they had additional risk factors such as chronic lung disease or hemodynamically significant heart disease (Pediatrics. 2014 Aug. doi: 10.1542/peds.2014-1665).
This study compared outcomes among all preterm infants born at 29-35 weeks’ gestation who were hospitalized during RSV season (October-April) for at least 24 hours with laboratory-confirmed RSV and who had not received RSV immunoprophylaxis within the 35 days before symptom onset. The 1,378 infants were younger than age 12 months when they were hospitalized at one of 43 sites during the 2014-2015 RSV season or one of 42 sites in the 2015-2016 season.
Of the 702 preterm infants hospitalized in 2014-2015, 42% were admitted to intensive care, and 20% needed invasive mechanical ventilation. Nearly half (48%) of the 676 infants admitted during the 2015-2016 season went to the ICU, and 19% required mechanical ventilation. One infant died of RSV in each season.
Throughout both seasons, more than three quarters (78%) of all RSV hospitalizations were infants younger than 6 months old. In 2014-2015, infants younger than 6 months accounted for 87% of all RSV admissions to the ICU and 92% of those needing mechanical ventilation. Similarly, young infants accounted for 81% of ICU admissions and 90% of RSV-related mechanical ventilation during the 2015-2016 season. Overall, preterm infants younger than 6 months old without immunoprophylaxis accounted for 84% of RSV-related ICU admissions and 91% of RSV-related mechanical ventilation.
The younger the infants were, the more likely they were to need ICU care and/or mechanical ventilation, the researchers found. Across both seasons, 56% of infants under 3 months old with RSV were admitted to the ICU, compared to 34% of those between 3 and 12 months old. Likewise, 29% of those under 3 months old and 10% of those between 3 and 12 months needed invasive mechanical ventilation.
Nearly half (46%) of all infants hospitalized for RSV had been discharged from their birth hospital within the previous 30 days, and 82% of all hospitalizations occurred within 2 months of birth discharge.
A cost analysis revealed that mean hospital charges for RSV-related hospitalizations of preterm infants ranged from $31,366 for 35-week gestation infants between ages 3-6 months to $122,301 for infants under 3 months old born between 29-32 weeks.
AstraZeneca/MedImmune funded the study. Dr. DeVincenzo and a number of his colleagues have received grants/research support from AstraZeneca/MedImmune, and some of his colleagues are or were AstraZeneca employees.
SAN FRANCISCO – Preterm infants born at 29-35 weeks’ gestation and hospitalized for respiratory syncytial virus (RSV) can experience particularly severe morbidity if they have not received immunoprophylaxis, according to new industry-funded research.
Across two RSV seasons at more than 40 study sites, nearly half of preterm infants admitted for lab-confirmed RSV required ICU admission, and one in five required invasive mechanical ventilation.
“Severity of illness and resource utilization are greatest in infants aged less than 3 months,” said John DeVincenzo, MD, professor in the pediatric infectious diseases division at the University of Tennessee, Memphis. “The results from the two seasons were consistent with one another and with previous and recent studies,” he said at the annual Pediatric Academic Societies meeting.
Previous research has shown that preterm infants born at 35 weeks or less gestation have a higher risk of RSV-related hospitalizations and subsequent morbidity, and that monthly immunoprophylaxis reduced RSV-related hospitalization in high-risk infants, including preterm infants.
Until 2014, the American Academy of Pediatrics recommended respiratory syncytial virus (RSV) immunoprophylaxis for all preterm infants under 32 weeks’ gestation and for infants between 32-35 weeks with additional risk factors, such as chronic lung disease or cyanotic heart disease (Pediatrics. 2003 Dec;112[6]:1442-6).
New recommendations in 2014 restricted immunoprophylaxis to preterm infants younger than 29 weeks’ gestational age unless they had additional risk factors such as chronic lung disease or hemodynamically significant heart disease (Pediatrics. 2014 Aug. doi: 10.1542/peds.2014-1665).
This study compared outcomes among all preterm infants born at 29-35 weeks’ gestation who were hospitalized during RSV season (October-April) for at least 24 hours with laboratory-confirmed RSV and who had not received RSV immunoprophylaxis within the 35 days before symptom onset. The 1,378 infants were younger than age 12 months when they were hospitalized at one of 43 sites during the 2014-2015 RSV season or one of 42 sites in the 2015-2016 season.
Of the 702 preterm infants hospitalized in 2014-2015, 42% were admitted to intensive care, and 20% needed invasive mechanical ventilation. Nearly half (48%) of the 676 infants admitted during the 2015-2016 season went to the ICU, and 19% required mechanical ventilation. One infant died of RSV in each season.
Throughout both seasons, more than three quarters (78%) of all RSV hospitalizations were infants younger than 6 months old. In 2014-2015, infants younger than 6 months accounted for 87% of all RSV admissions to the ICU and 92% of those needing mechanical ventilation. Similarly, young infants accounted for 81% of ICU admissions and 90% of RSV-related mechanical ventilation during the 2015-2016 season. Overall, preterm infants younger than 6 months old without immunoprophylaxis accounted for 84% of RSV-related ICU admissions and 91% of RSV-related mechanical ventilation.
The younger the infants were, the more likely they were to need ICU care and/or mechanical ventilation, the researchers found. Across both seasons, 56% of infants under 3 months old with RSV were admitted to the ICU, compared to 34% of those between 3 and 12 months old. Likewise, 29% of those under 3 months old and 10% of those between 3 and 12 months needed invasive mechanical ventilation.
Nearly half (46%) of all infants hospitalized for RSV had been discharged from their birth hospital within the previous 30 days, and 82% of all hospitalizations occurred within 2 months of birth discharge.
A cost analysis revealed that mean hospital charges for RSV-related hospitalizations of preterm infants ranged from $31,366 for 35-week gestation infants between ages 3-6 months to $122,301 for infants under 3 months old born between 29-32 weeks.
AstraZeneca/MedImmune funded the study. Dr. DeVincenzo and a number of his colleagues have received grants/research support from AstraZeneca/MedImmune, and some of his colleagues are or were AstraZeneca employees.
AT PAS 17
Key clinical point: Preterm infants, particularly those younger than 3 months, can experience severe respiratory syncytial virus (RSV) illness without immunoprophylaxis.
Major finding: Of the 702 preterm infants hospitalized during 2014-2015, 42% went to the ICU and 20% needed invasive mechanical ventilation. Nearly half (48%) of the 676 infants admitted during 2015-2016 went to the ICU and 19% required mechanical ventilation.
Data source: An analysis of 1,378 preterm infants born at 29-35 weeks’ gestation and hospitalized at under 1 year for lab-confirmed RSV during the 2014-2015 and 2015-2016 RSV seasons.
Disclosures: AstraZeneca/MedImmune funded the study. Dr. DeVincenzo and a number of his colleagues have received grants/research support from AstraZeneca/MedImmune, and some of his colleagues are or were AstraZeneca employees.
HPV vaccine training video improved provider knowledge, confidence
SAN FRANCISCO – Showing pediatric providers a 22-minute online training video about the human papillomavirus (HPV) vaccine and how to counsel families on it improved the providers’ knowledge, attitudes, and confidence in recommending the vaccine, according to a study.
“This video may be a cost-effective way to train providers across the nation to strongly recommend the HPV vaccine, which may ultimately impact vaccination rates,” lead author Maya Kumar, MD, of the University of California, San Diego, said at the Pediatric Academic Societies meeting.
Previous research has shown that one of the biggest obstacles to uptake of the HPV vaccine is the lack of a strong provider recommendation.
“Common reasons for this include inadequate knowledge of the impact of HPV-related disease, perceptions that the vaccine is less important for preteens or less important for boys, and discomfort with addressing parental concerns about the vaccine,” explained Dr. Kumar.
She therefore wanted to see whether a video addressing these concerns and knowledge gaps would improve providers’ knowledge, confidence, and their likelihood of strongly recommending the HPV vaccine to their clients.
The AAP California Chapter 3 created a 22-minute video that explains the burden of HPV-related disease, provides general information about the vaccine, and reviews common provider-related obstacles to vaccination (although not patient-related or systemic barriers). Then the video provides counseling strategies to help providers in improving HPV vaccine uptake at their clinic. Following the discussion of those strategies are eight clinical vignettes in which experienced pediatricians model those techniques with “patients” and “parents” played by actors.
The researchers then showed the video to 109 providers from four large pediatric practices in San Diego and the San Diego Immunization Coalition. The group included 47% of pediatricians and nurse practitioners, 25% of allied health professionals, 20% nurses and 7% of trainees.
Before viewing, the providers filled out a questionnaire assessing their knowledge and attitude toward the HPV vaccine and how they perceived their skill in recommending the vaccine. Then they filled out the same questionnaire after viewing the video.
Providers’ correct answers to questions on their knowledge about the vaccine all increased substantially after viewing the video. The biggest improvement was seen in response to the question about whether the vaccine’s efficacy changes with age. Before viewing the video, 49% of the providers knew that the immune response to the vaccine was stronger among younger recipients and that its efficacy dropped off as people reach their mid-20s. After seeing the video, 89% of providers correctly answered that question (P less than .01).
Another substantial improvement occurred for the question about HPV-related cancers’ prevalence in men. Before the video, 37% of providers answered correctly that a large proportion of these cancers do occur in men; after the video, 67% answered correctly (P less than .01).
The proportion of providers who correctly responded that HPV infects the majority of sexually active people increased from 85% to 90%. Similarly, those who knew HPV catch-up vaccination can be offered up until age 26 years increased from 88% to 96%, and those who knew HPV-related cancer is more prevalent than meningococcal disease increased from 91% to 97% (P less than .01 for all of these). The increase in providers who knew HPV infects the majority of sexually active people, from 85% to 97%, was the only one that didn’t reach statistical significance.
Similar improvements were seen in providers’ attitudes after viewing the video. On a Likert scale of 1 (strongly disagree) to 5 (strongly agree), statistically significant increases occurred for responding to whether it’s important to vaccinate girls against HPV (.07 increase) and the importance of the HPV vaccine for cancer protection rather than wart protection (.22 increase).
Likewise, statistically significant decreases occurred for whether it’s acceptable to delay the vaccine for a child before sexual debut (–0.38), whether it’s more important to give the Tdap and meningococcal vaccines than the HPV vaccines (–0.44), and whether the provider is concerned about short-term (–0.20) or long-term (–0.12) side effects of the vaccine.
Every one of the questions about providers’ skills improved statistically significantly, from increases of 0.19 to 0.66 points:
• Making a strong recommendation for the HPV vaccine.
• Discussing HPV vaccination again with a family who has previously declined it.
• Facilitating completion of a three-dose vaccine series once initiated.
• Presenting the HPV vaccine as a cancer-prevention vaccine.
• Addressing parental concerns about safety and side effects.
• Addressing parental concerns about HPV being sexually transmitted and the need to vaccinate before sexual debut.
• Counseling about the need to routinely vaccinate boys against HPV.
• Counseling about the rationale for routinely giving the HPV vaccine at age 11-12 years.
“There was positive feedback from the viewing providers, particularly about the use of clinical vignettes to model effective counseling strategies for recommending vaccination,” Dr. Kumar said.
She acknowledged that the results may not be generalizable to providers in other regions, and the study was unable to assess whether providers’ actual behavior or practice vaccination rates changed after viewing the video.
The study was funded by an American Academy of Pediatrics Adolescent Vaccinations and Wellness Education Grant, supported by Merck. Dr. Kumar had no relevant financial disclosures.
SAN FRANCISCO – Showing pediatric providers a 22-minute online training video about the human papillomavirus (HPV) vaccine and how to counsel families on it improved the providers’ knowledge, attitudes, and confidence in recommending the vaccine, according to a study.
“This video may be a cost-effective way to train providers across the nation to strongly recommend the HPV vaccine, which may ultimately impact vaccination rates,” lead author Maya Kumar, MD, of the University of California, San Diego, said at the Pediatric Academic Societies meeting.
Previous research has shown that one of the biggest obstacles to uptake of the HPV vaccine is the lack of a strong provider recommendation.
“Common reasons for this include inadequate knowledge of the impact of HPV-related disease, perceptions that the vaccine is less important for preteens or less important for boys, and discomfort with addressing parental concerns about the vaccine,” explained Dr. Kumar.
She therefore wanted to see whether a video addressing these concerns and knowledge gaps would improve providers’ knowledge, confidence, and their likelihood of strongly recommending the HPV vaccine to their clients.
The AAP California Chapter 3 created a 22-minute video that explains the burden of HPV-related disease, provides general information about the vaccine, and reviews common provider-related obstacles to vaccination (although not patient-related or systemic barriers). Then the video provides counseling strategies to help providers in improving HPV vaccine uptake at their clinic. Following the discussion of those strategies are eight clinical vignettes in which experienced pediatricians model those techniques with “patients” and “parents” played by actors.
The researchers then showed the video to 109 providers from four large pediatric practices in San Diego and the San Diego Immunization Coalition. The group included 47% of pediatricians and nurse practitioners, 25% of allied health professionals, 20% nurses and 7% of trainees.
Before viewing, the providers filled out a questionnaire assessing their knowledge and attitude toward the HPV vaccine and how they perceived their skill in recommending the vaccine. Then they filled out the same questionnaire after viewing the video.
Providers’ correct answers to questions on their knowledge about the vaccine all increased substantially after viewing the video. The biggest improvement was seen in response to the question about whether the vaccine’s efficacy changes with age. Before viewing the video, 49% of the providers knew that the immune response to the vaccine was stronger among younger recipients and that its efficacy dropped off as people reach their mid-20s. After seeing the video, 89% of providers correctly answered that question (P less than .01).
Another substantial improvement occurred for the question about HPV-related cancers’ prevalence in men. Before the video, 37% of providers answered correctly that a large proportion of these cancers do occur in men; after the video, 67% answered correctly (P less than .01).
The proportion of providers who correctly responded that HPV infects the majority of sexually active people increased from 85% to 90%. Similarly, those who knew HPV catch-up vaccination can be offered up until age 26 years increased from 88% to 96%, and those who knew HPV-related cancer is more prevalent than meningococcal disease increased from 91% to 97% (P less than .01 for all of these). The increase in providers who knew HPV infects the majority of sexually active people, from 85% to 97%, was the only one that didn’t reach statistical significance.
Similar improvements were seen in providers’ attitudes after viewing the video. On a Likert scale of 1 (strongly disagree) to 5 (strongly agree), statistically significant increases occurred for responding to whether it’s important to vaccinate girls against HPV (.07 increase) and the importance of the HPV vaccine for cancer protection rather than wart protection (.22 increase).
Likewise, statistically significant decreases occurred for whether it’s acceptable to delay the vaccine for a child before sexual debut (–0.38), whether it’s more important to give the Tdap and meningococcal vaccines than the HPV vaccines (–0.44), and whether the provider is concerned about short-term (–0.20) or long-term (–0.12) side effects of the vaccine.
Every one of the questions about providers’ skills improved statistically significantly, from increases of 0.19 to 0.66 points:
• Making a strong recommendation for the HPV vaccine.
• Discussing HPV vaccination again with a family who has previously declined it.
• Facilitating completion of a three-dose vaccine series once initiated.
• Presenting the HPV vaccine as a cancer-prevention vaccine.
• Addressing parental concerns about safety and side effects.
• Addressing parental concerns about HPV being sexually transmitted and the need to vaccinate before sexual debut.
• Counseling about the need to routinely vaccinate boys against HPV.
• Counseling about the rationale for routinely giving the HPV vaccine at age 11-12 years.
“There was positive feedback from the viewing providers, particularly about the use of clinical vignettes to model effective counseling strategies for recommending vaccination,” Dr. Kumar said.
She acknowledged that the results may not be generalizable to providers in other regions, and the study was unable to assess whether providers’ actual behavior or practice vaccination rates changed after viewing the video.
The study was funded by an American Academy of Pediatrics Adolescent Vaccinations and Wellness Education Grant, supported by Merck. Dr. Kumar had no relevant financial disclosures.
SAN FRANCISCO – Showing pediatric providers a 22-minute online training video about the human papillomavirus (HPV) vaccine and how to counsel families on it improved the providers’ knowledge, attitudes, and confidence in recommending the vaccine, according to a study.
“This video may be a cost-effective way to train providers across the nation to strongly recommend the HPV vaccine, which may ultimately impact vaccination rates,” lead author Maya Kumar, MD, of the University of California, San Diego, said at the Pediatric Academic Societies meeting.
Previous research has shown that one of the biggest obstacles to uptake of the HPV vaccine is the lack of a strong provider recommendation.
“Common reasons for this include inadequate knowledge of the impact of HPV-related disease, perceptions that the vaccine is less important for preteens or less important for boys, and discomfort with addressing parental concerns about the vaccine,” explained Dr. Kumar.
She therefore wanted to see whether a video addressing these concerns and knowledge gaps would improve providers’ knowledge, confidence, and their likelihood of strongly recommending the HPV vaccine to their clients.
The AAP California Chapter 3 created a 22-minute video that explains the burden of HPV-related disease, provides general information about the vaccine, and reviews common provider-related obstacles to vaccination (although not patient-related or systemic barriers). Then the video provides counseling strategies to help providers in improving HPV vaccine uptake at their clinic. Following the discussion of those strategies are eight clinical vignettes in which experienced pediatricians model those techniques with “patients” and “parents” played by actors.
The researchers then showed the video to 109 providers from four large pediatric practices in San Diego and the San Diego Immunization Coalition. The group included 47% of pediatricians and nurse practitioners, 25% of allied health professionals, 20% nurses and 7% of trainees.
Before viewing, the providers filled out a questionnaire assessing their knowledge and attitude toward the HPV vaccine and how they perceived their skill in recommending the vaccine. Then they filled out the same questionnaire after viewing the video.
Providers’ correct answers to questions on their knowledge about the vaccine all increased substantially after viewing the video. The biggest improvement was seen in response to the question about whether the vaccine’s efficacy changes with age. Before viewing the video, 49% of the providers knew that the immune response to the vaccine was stronger among younger recipients and that its efficacy dropped off as people reach their mid-20s. After seeing the video, 89% of providers correctly answered that question (P less than .01).
Another substantial improvement occurred for the question about HPV-related cancers’ prevalence in men. Before the video, 37% of providers answered correctly that a large proportion of these cancers do occur in men; after the video, 67% answered correctly (P less than .01).
The proportion of providers who correctly responded that HPV infects the majority of sexually active people increased from 85% to 90%. Similarly, those who knew HPV catch-up vaccination can be offered up until age 26 years increased from 88% to 96%, and those who knew HPV-related cancer is more prevalent than meningococcal disease increased from 91% to 97% (P less than .01 for all of these). The increase in providers who knew HPV infects the majority of sexually active people, from 85% to 97%, was the only one that didn’t reach statistical significance.
Similar improvements were seen in providers’ attitudes after viewing the video. On a Likert scale of 1 (strongly disagree) to 5 (strongly agree), statistically significant increases occurred for responding to whether it’s important to vaccinate girls against HPV (.07 increase) and the importance of the HPV vaccine for cancer protection rather than wart protection (.22 increase).
Likewise, statistically significant decreases occurred for whether it’s acceptable to delay the vaccine for a child before sexual debut (–0.38), whether it’s more important to give the Tdap and meningococcal vaccines than the HPV vaccines (–0.44), and whether the provider is concerned about short-term (–0.20) or long-term (–0.12) side effects of the vaccine.
Every one of the questions about providers’ skills improved statistically significantly, from increases of 0.19 to 0.66 points:
• Making a strong recommendation for the HPV vaccine.
• Discussing HPV vaccination again with a family who has previously declined it.
• Facilitating completion of a three-dose vaccine series once initiated.
• Presenting the HPV vaccine as a cancer-prevention vaccine.
• Addressing parental concerns about safety and side effects.
• Addressing parental concerns about HPV being sexually transmitted and the need to vaccinate before sexual debut.
• Counseling about the need to routinely vaccinate boys against HPV.
• Counseling about the rationale for routinely giving the HPV vaccine at age 11-12 years.
“There was positive feedback from the viewing providers, particularly about the use of clinical vignettes to model effective counseling strategies for recommending vaccination,” Dr. Kumar said.
She acknowledged that the results may not be generalizable to providers in other regions, and the study was unable to assess whether providers’ actual behavior or practice vaccination rates changed after viewing the video.
The study was funded by an American Academy of Pediatrics Adolescent Vaccinations and Wellness Education Grant, supported by Merck. Dr. Kumar had no relevant financial disclosures.
Key clinical point:
Major finding: Statistically significant improvements occurred among providers for five questions on HPV vaccine knowledge, six questions about attitudes toward the vaccine, and all eight questions concerning self-assessed skills in counseling families about the vaccine.
Data source: The findings are based on a cohort of 109 California pediatric providers whose knowledge, attitudes, and self-reported skills were assessed before and after the intervention.
Disclosures: The study was funded by an American Academy of Pediatrics Adolescent Vaccinations and Wellness Education Grant, supported by Merck. Dr. Kumar had no relevant financial disclosures.