NEW ORLEANS – Cell-free (cf) DNA looked like an informative biomarker for both the severity of pulmonary artery hypertension and the survival prognosis for patients with this disease, based on results from two preliminary studies involving a total of 173 people.

Mitchel L. Zoler/MDedge News

“Plasma levels of cell-free DNA are elevated in patients with pulmonary artery hypertension, compared with healthy controls, and may predict disease severity and mortality,” Samuel B. Brusca, MD, said at the at the annual meeting of the American College of Cardiology.

A growing biomedical literature has documented a role for cfDNA in tracking the course of cancer, septic shock, and transplanted organs (Transplantation. 2019 Feb;103[2]:273-83) (Cell-Free DNA: Applications in Different Diseases, in “Cell-free DNA as Diagnostic Markers.” [New York: Humana Press, 2018, pp. 3-12]). Based on this background Dr. Brusca and his associates decided to examine whether plasma levels of cfDNA linked with pulmonary artery hypertension (PAH) severity and survival.

Their first study included seven patients with mild PAH (defined as patients with a tricuspid annular plane systolic excursion [TAPSE] of more than 18 mm and a maximum oxygen uptake [VO₂] of at least 75% of predicted), eight with severe PAH (a TAPSE of 18 mm or less and a VO₂ of less than 75%), and seven healthy adult controls. Measurement of plasma cfDNA showed an average level of 19.4 ng/mL among the healthy controls (prior reports had indicated that 10-20 ng/mL were normal levels), 22.0 ng/mL among patients with mild PAH, and 36.2 ng/mL in those with severe PAH. The level among the severe PAH patients was significantly higher than the level in controls by two different statistical tests, said Dr. Brusca, a critical care medicine physician at the National Institutes of Health Clinical Center in Bethesda, Md.

The second analysis by Dr. Brusca and his associates included 151 PAH patients followed by physicians at the Clinical Center for an average of 40 months. Their analysis tracked survival of these patients relative to their baseline levels of cfDNA and divided into tertiles. Patients in the lowest tertile had a starting cfDNA level of up to 39 ng/mL, those in the middle tertile had levels of 39.1-64.0 ng/mL, and those in the top tertile had levels of at least 64.1 ng/mL. A Kaplan-Meier analysis showed statistically significant differences in survival rates between each of the tertiles. Patients in the lowest tertile had a 5-year actuarial survival rate of about 65%, those in the middle tertile had a survival rate of about 48%, and those in the tertile with the highest level of cfDNA had a survival rate of about 28%.

Additional studies of cfDNA are needed in larger numbers of PAH patients, and cfDNA levels should be compared with levels of other, more established biomarkers, such as inflammatory cytokines, Dr. Brusca said in an interview.

Dr. Brusca had no disclosures. The study received no commercial funding.

[email protected]

SOURCE: Brusca SB et al. J Am Coll Cardiol. 2019 March 12;73(9 Suppl 1):1897.

NEW ORLEANS – Cell-free (cf) DNA looked like an informative biomarker for both the severity of pulmonary artery hypertension and the survival prognosis for patients with this disease, based on results from two preliminary studies involving a total of 173 people.

Mitchel L. Zoler/MDedge News

“Plasma levels of cell-free DNA are elevated in patients with pulmonary artery hypertension, compared with healthy controls, and may predict disease severity and mortality,” Samuel B. Brusca, MD, said at the at the annual meeting of the American College of Cardiology.

A growing biomedical literature has documented a role for cfDNA in tracking the course of cancer, septic shock, and transplanted organs (Transplantation. 2019 Feb;103[2]:273-83) (Cell-Free DNA: Applications in Different Diseases, in “Cell-free DNA as Diagnostic Markers.” [New York: Humana Press, 2018, pp. 3-12]). Based on this background Dr. Brusca and his associates decided to examine whether plasma levels of cfDNA linked with pulmonary artery hypertension (PAH) severity and survival.

Their first study included seven patients with mild PAH (defined as patients with a tricuspid annular plane systolic excursion [TAPSE] of more than 18 mm and a maximum oxygen uptake [VO₂] of at least 75% of predicted), eight with severe PAH (a TAPSE of 18 mm or less and a VO₂ of less than 75%), and seven healthy adult controls. Measurement of plasma cfDNA showed an average level of 19.4 ng/mL among the healthy controls (prior reports had indicated that 10-20 ng/mL were normal levels), 22.0 ng/mL among patients with mild PAH, and 36.2 ng/mL in those with severe PAH. The level among the severe PAH patients was significantly higher than the level in controls by two different statistical tests, said Dr. Brusca, a critical care medicine physician at the National Institutes of Health Clinical Center in Bethesda, Md.

The second analysis by Dr. Brusca and his associates included 151 PAH patients followed by physicians at the Clinical Center for an average of 40 months. Their analysis tracked survival of these patients relative to their baseline levels of cfDNA and divided into tertiles. Patients in the lowest tertile had a starting cfDNA level of up to 39 ng/mL, those in the middle tertile had levels of 39.1-64.0 ng/mL, and those in the top tertile had levels of at least 64.1 ng/mL. A Kaplan-Meier analysis showed statistically significant differences in survival rates between each of the tertiles. Patients in the lowest tertile had a 5-year actuarial survival rate of about 65%, those in the middle tertile had a survival rate of about 48%, and those in the tertile with the highest level of cfDNA had a survival rate of about 28%.

Additional studies of cfDNA are needed in larger numbers of PAH patients, and cfDNA levels should be compared with levels of other, more established biomarkers, such as inflammatory cytokines, Dr. Brusca said in an interview.

Dr. Brusca had no disclosures. The study received no commercial funding.

[email protected]

SOURCE: Brusca SB et al. J Am Coll Cardiol. 2019 March 12;73(9 Suppl 1):1897.

NEW ORLEANS – Cell-free (cf) DNA looked like an informative biomarker for both the severity of pulmonary artery hypertension and the survival prognosis for patients with this disease, based on results from two preliminary studies involving a total of 173 people.

Mitchel L. Zoler/MDedge News

“Plasma levels of cell-free DNA are elevated in patients with pulmonary artery hypertension, compared with healthy controls, and may predict disease severity and mortality,” Samuel B. Brusca, MD, said at the at the annual meeting of the American College of Cardiology.

A growing biomedical literature has documented a role for cfDNA in tracking the course of cancer, septic shock, and transplanted organs (Transplantation. 2019 Feb;103[2]:273-83) (Cell-Free DNA: Applications in Different Diseases, in “Cell-free DNA as Diagnostic Markers.” [New York: Humana Press, 2018, pp. 3-12]). Based on this background Dr. Brusca and his associates decided to examine whether plasma levels of cfDNA linked with pulmonary artery hypertension (PAH) severity and survival.

Their first study included seven patients with mild PAH (defined as patients with a tricuspid annular plane systolic excursion [TAPSE] of more than 18 mm and a maximum oxygen uptake [VO₂] of at least 75% of predicted), eight with severe PAH (a TAPSE of 18 mm or less and a VO₂ of less than 75%), and seven healthy adult controls. Measurement of plasma cfDNA showed an average level of 19.4 ng/mL among the healthy controls (prior reports had indicated that 10-20 ng/mL were normal levels), 22.0 ng/mL among patients with mild PAH, and 36.2 ng/mL in those with severe PAH. The level among the severe PAH patients was significantly higher than the level in controls by two different statistical tests, said Dr. Brusca, a critical care medicine physician at the National Institutes of Health Clinical Center in Bethesda, Md.

The second analysis by Dr. Brusca and his associates included 151 PAH patients followed by physicians at the Clinical Center for an average of 40 months. Their analysis tracked survival of these patients relative to their baseline levels of cfDNA and divided into tertiles. Patients in the lowest tertile had a starting cfDNA level of up to 39 ng/mL, those in the middle tertile had levels of 39.1-64.0 ng/mL, and those in the top tertile had levels of at least 64.1 ng/mL. A Kaplan-Meier analysis showed statistically significant differences in survival rates between each of the tertiles. Patients in the lowest tertile had a 5-year actuarial survival rate of about 65%, those in the middle tertile had a survival rate of about 48%, and those in the tertile with the highest level of cfDNA had a survival rate of about 28%.

Additional studies of cfDNA are needed in larger numbers of PAH patients, and cfDNA levels should be compared with levels of other, more established biomarkers, such as inflammatory cytokines, Dr. Brusca said in an interview.

Dr. Brusca had no disclosures. The study received no commercial funding.

[email protected]

SOURCE: Brusca SB et al. J Am Coll Cardiol. 2019 March 12;73(9 Suppl 1):1897.

Two studies published in Pediatrics add new information on potential therapies as adjuncts to intravenous immunoglobulin to treat coronary artery abnormalities in pediatric Kawasaki disease patients.

Marija Stepanovic/iStock/Getty Images Plus

In the phase 3, randomized, placebo-controlled EATAK (Etanercept as Adjunctive Treatment for Acute Kawasaki Disease) trial, Michael A. Portman, MD, and his colleagues examine the effects of adding etanercept to intravenous immunoglobulin (IVIg) to study IVIg resistance in children with Kawasaki disease.

The researchers enrolled 201 participants from eight pediatric centers who received an IVIg infusion followed immediately by either subcutaneous etanercept (0.8 mg/kg; n = 100) or placebo (n = 101) and then received two more weekly doses. They performed a subgroup analysis based on age, gender, and race. The participants were between 2 months and 18 years old with incomplete (10 etanercept, 12 placebo) or complete Kawasaki disease as determined by American Heart Association criteria and American Academy of Pediatrics 2004 criteria.

Of the 35 patients who showed IVIg resistance and received a second dose, the IVIg resistance rate for participants receiving etanercept was 13%, compared with 22% in the placebo group. The overall odds ratio for IVIg resistance was 0.54. While etanercept did not lower the rate of IVIg resistance in participants younger than 1 year old, it significantly reduced IVIg resistance in those older than 1 year.

IVIg fever response significantly differed by race, which ranged from Asian participants having a 7% resistance rate to African Americans having a resistance rate of 57%.

Forty-five of all participants had greater than 2.5 baseline coronary z scores, 23 in the etanercept group and 22 in the placebo group. While etanercept reduced change in coronary z score among participants with baseline dilation (P = .04) and without baseline dilation (P = .001), there was no improvement among participants in the placebo group. Etanercept additionally reduced progression of dilation, compared with the placebo group (P = .03). The researchers noted etanercept had a good safety profile, and there were no differences between the groups receiving the intervention or placebo.

“With these considerations, EATAK results reveal a reasonable risk/benefit profile for etanercept,” Dr. Portman of Seattle Children’s Research Institute, and his colleagues concluded. “Future clinical trials, conducted in these subgroups or stratified according to patient demographics or genotypes, will be necessary to validate our findings before wide clinical adoption.”

In a second study, Audrey Dionne, MD, of Boston Children’s Hospital, and her colleagues explored how corticosteroids or infliximab together with IVIg can reduce the progression of coronary artery aneurysms (CAA). They performed a retrospective study of 121 children (73% boys; median age, 3 years) with Kawasaki disease and CAA at three different centers who received corticosteroid and IVIg therapy (n = 30), infliximab and IVIg therapy (n = 58), or IVIg alone (n = 33). The children had a coronary z score greater than or equal to 2.5 and less than 10, and there were no significant differences between median z scores among the treatment groups (P = .39).

The researchers found that patients who received corticosteroids with IVIg therapy were protected against coronary size progression (coefficient, −1.31); in addition, those patients who received infliximab and IVIg therapy were protected against coronary size progression at follow-up (coefficient, −1.07), the researchers said. Those on placebo were not.

“Our data suggest that adjunctive treatment at the time of diagnosis may be beneficial in patients with CAA,” Dr. Dionne and colleagues concluded. “Future adequately powered, prospective randomized trials are needed to determine the best adjunctive treatment of patients with KD [Kawasaki disease] who present with coronary changes.”

The EATAK trial was funded by the Food and Drug Administration Office of Orphan Product Development, Amgen, and the National Institutes of Health. Dr. Portman and colleagues reported no relevant financial disclosures. The study from Dionne et al. received funding from the McCance Family Foundation and the Vella Fund. One of the authors reported being a paid expert witness for missed diagnoses of Kawasaki disease, which was unrelated to the study. The other authors said they had no conflicts of interest.

SOURCES: Portman MA et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3675; Dionne A et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3341.

Two studies published in Pediatrics add new information on potential therapies as adjuncts to intravenous immunoglobulin to treat coronary artery abnormalities in pediatric Kawasaki disease patients.

Marija Stepanovic/iStock/Getty Images Plus

In the phase 3, randomized, placebo-controlled EATAK (Etanercept as Adjunctive Treatment for Acute Kawasaki Disease) trial, Michael A. Portman, MD, and his colleagues examine the effects of adding etanercept to intravenous immunoglobulin (IVIg) to study IVIg resistance in children with Kawasaki disease.

The researchers enrolled 201 participants from eight pediatric centers who received an IVIg infusion followed immediately by either subcutaneous etanercept (0.8 mg/kg; n = 100) or placebo (n = 101) and then received two more weekly doses. They performed a subgroup analysis based on age, gender, and race. The participants were between 2 months and 18 years old with incomplete (10 etanercept, 12 placebo) or complete Kawasaki disease as determined by American Heart Association criteria and American Academy of Pediatrics 2004 criteria.

Of the 35 patients who showed IVIg resistance and received a second dose, the IVIg resistance rate for participants receiving etanercept was 13%, compared with 22% in the placebo group. The overall odds ratio for IVIg resistance was 0.54. While etanercept did not lower the rate of IVIg resistance in participants younger than 1 year old, it significantly reduced IVIg resistance in those older than 1 year.

IVIg fever response significantly differed by race, which ranged from Asian participants having a 7% resistance rate to African Americans having a resistance rate of 57%.

Forty-five of all participants had greater than 2.5 baseline coronary z scores, 23 in the etanercept group and 22 in the placebo group. While etanercept reduced change in coronary z score among participants with baseline dilation (P = .04) and without baseline dilation (P = .001), there was no improvement among participants in the placebo group. Etanercept additionally reduced progression of dilation, compared with the placebo group (P = .03). The researchers noted etanercept had a good safety profile, and there were no differences between the groups receiving the intervention or placebo.

“With these considerations, EATAK results reveal a reasonable risk/benefit profile for etanercept,” Dr. Portman of Seattle Children’s Research Institute, and his colleagues concluded. “Future clinical trials, conducted in these subgroups or stratified according to patient demographics or genotypes, will be necessary to validate our findings before wide clinical adoption.”

In a second study, Audrey Dionne, MD, of Boston Children’s Hospital, and her colleagues explored how corticosteroids or infliximab together with IVIg can reduce the progression of coronary artery aneurysms (CAA). They performed a retrospective study of 121 children (73% boys; median age, 3 years) with Kawasaki disease and CAA at three different centers who received corticosteroid and IVIg therapy (n = 30), infliximab and IVIg therapy (n = 58), or IVIg alone (n = 33). The children had a coronary z score greater than or equal to 2.5 and less than 10, and there were no significant differences between median z scores among the treatment groups (P = .39).

The researchers found that patients who received corticosteroids with IVIg therapy were protected against coronary size progression (coefficient, −1.31); in addition, those patients who received infliximab and IVIg therapy were protected against coronary size progression at follow-up (coefficient, −1.07), the researchers said. Those on placebo were not.

“Our data suggest that adjunctive treatment at the time of diagnosis may be beneficial in patients with CAA,” Dr. Dionne and colleagues concluded. “Future adequately powered, prospective randomized trials are needed to determine the best adjunctive treatment of patients with KD [Kawasaki disease] who present with coronary changes.”

The EATAK trial was funded by the Food and Drug Administration Office of Orphan Product Development, Amgen, and the National Institutes of Health. Dr. Portman and colleagues reported no relevant financial disclosures. The study from Dionne et al. received funding from the McCance Family Foundation and the Vella Fund. One of the authors reported being a paid expert witness for missed diagnoses of Kawasaki disease, which was unrelated to the study. The other authors said they had no conflicts of interest.

SOURCES: Portman MA et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3675; Dionne A et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3341.

Two studies published in Pediatrics add new information on potential therapies as adjuncts to intravenous immunoglobulin to treat coronary artery abnormalities in pediatric Kawasaki disease patients.

Marija Stepanovic/iStock/Getty Images Plus

In the phase 3, randomized, placebo-controlled EATAK (Etanercept as Adjunctive Treatment for Acute Kawasaki Disease) trial, Michael A. Portman, MD, and his colleagues examine the effects of adding etanercept to intravenous immunoglobulin (IVIg) to study IVIg resistance in children with Kawasaki disease.

The researchers enrolled 201 participants from eight pediatric centers who received an IVIg infusion followed immediately by either subcutaneous etanercept (0.8 mg/kg; n = 100) or placebo (n = 101) and then received two more weekly doses. They performed a subgroup analysis based on age, gender, and race. The participants were between 2 months and 18 years old with incomplete (10 etanercept, 12 placebo) or complete Kawasaki disease as determined by American Heart Association criteria and American Academy of Pediatrics 2004 criteria.

Of the 35 patients who showed IVIg resistance and received a second dose, the IVIg resistance rate for participants receiving etanercept was 13%, compared with 22% in the placebo group. The overall odds ratio for IVIg resistance was 0.54. While etanercept did not lower the rate of IVIg resistance in participants younger than 1 year old, it significantly reduced IVIg resistance in those older than 1 year.

IVIg fever response significantly differed by race, which ranged from Asian participants having a 7% resistance rate to African Americans having a resistance rate of 57%.

Forty-five of all participants had greater than 2.5 baseline coronary z scores, 23 in the etanercept group and 22 in the placebo group. While etanercept reduced change in coronary z score among participants with baseline dilation (P = .04) and without baseline dilation (P = .001), there was no improvement among participants in the placebo group. Etanercept additionally reduced progression of dilation, compared with the placebo group (P = .03). The researchers noted etanercept had a good safety profile, and there were no differences between the groups receiving the intervention or placebo.

“With these considerations, EATAK results reveal a reasonable risk/benefit profile for etanercept,” Dr. Portman of Seattle Children’s Research Institute, and his colleagues concluded. “Future clinical trials, conducted in these subgroups or stratified according to patient demographics or genotypes, will be necessary to validate our findings before wide clinical adoption.”

In a second study, Audrey Dionne, MD, of Boston Children’s Hospital, and her colleagues explored how corticosteroids or infliximab together with IVIg can reduce the progression of coronary artery aneurysms (CAA). They performed a retrospective study of 121 children (73% boys; median age, 3 years) with Kawasaki disease and CAA at three different centers who received corticosteroid and IVIg therapy (n = 30), infliximab and IVIg therapy (n = 58), or IVIg alone (n = 33). The children had a coronary z score greater than or equal to 2.5 and less than 10, and there were no significant differences between median z scores among the treatment groups (P = .39).

The researchers found that patients who received corticosteroids with IVIg therapy were protected against coronary size progression (coefficient, −1.31); in addition, those patients who received infliximab and IVIg therapy were protected against coronary size progression at follow-up (coefficient, −1.07), the researchers said. Those on placebo were not.

“Our data suggest that adjunctive treatment at the time of diagnosis may be beneficial in patients with CAA,” Dr. Dionne and colleagues concluded. “Future adequately powered, prospective randomized trials are needed to determine the best adjunctive treatment of patients with KD [Kawasaki disease] who present with coronary changes.”

The EATAK trial was funded by the Food and Drug Administration Office of Orphan Product Development, Amgen, and the National Institutes of Health. Dr. Portman and colleagues reported no relevant financial disclosures. The study from Dionne et al. received funding from the McCance Family Foundation and the Vella Fund. One of the authors reported being a paid expert witness for missed diagnoses of Kawasaki disease, which was unrelated to the study. The other authors said they had no conflicts of interest.

SOURCES: Portman MA et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3675; Dionne A et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3341.

How many minutes do you spend each day trying to coax new parents off the guilt train? They have delayed their childbearing until they felt comfortable economically and emotionally ready to raise a child. Convinced that up to this point they have done enough correctly to be considered successful, they see no reason that they won’t be able to tackle parenthood just as easily. Their black lab is a model of obedience. Housebreaking him was a breeze. They are skilled at using the Internet and social media to gather the information they will need for raising a child.

Jaimie Duplass/Fotolia.com

However, at some point in the first 72 hours after the birth of their child, most parents are going to hit the wall of reality. It may be that breastfeeding doesn’t work as well their cousin told them it would or simply that babies cry, often for no discernible reason. Desperately wanting to do what’s right for their child, guilt creeps in as the little failures and fatigue begin to accumulate.

In their search for answers, new parents naturally come to us as pediatricians and family practitioners for the facts, but they also will search the Internet, talk to lactation consultants, and be bombarded by unsolicited advice from family members and neighbors. Every source they turn to, including physicians, will be filtered through its own bias.

I recently came across the most sensible advice for new parents I have read in a long time, and it came not from a pediatrician but from an economics professor at Brown University. Emily Oster, PhD, writing in the New York Times, examines the available data on the topics of breastfeeding, sleep training, and parents working out of the home with the objectivity of an economist and the sensitivity of a mother who has been there and done that (“The Data All Guilt-Ridden Parents Need,” New York Times, April 19, 2019).

For example, she observes that many of the benefits of breastfeeding are supported by some evidence, “just not always especially good evidence. And even when the evidence is good, the benefits are smaller than many people realize.” She points out that “most studies of breastfeeding are biased by the fact that women who breastfeed are typically different from those who do not.” I will leave it to you to read her full discussion that includes a comparison of random trials versus observational studies. But she concludes that, if one relies on only good evidence, the only demonstrable benefit of breastfeeding is for mothers who nurse longer than 12 months who may have a 20%-30% decrease in breast cancer risk.

Using the same kind of careful analysis, Dr. Oster finds that sleep training may have a short-term benefit for parents who will have improved sleep and less maternal depression, but in the long run children who were sleep trained were no different than those that weren’t.

She also finds that, when it comes to the “optimal configuration of adult work hours” for a household, there is “no compelling evidence that proves that having a stay-at-home parent affects child outcomes, positively or negatively.” It is up to each household what works best for all it members, not just the child.

I urge you to read Dr. Oster’s article of advice on breastfeeding, sleep training or not, and working outside the home, and recommend it to struggling parents. I found it particularly helpful as a practitioner who has often felt shackled, or at least disadvantaged, by the American Academy of Pediatrics’ overly simplistic and sometimes biased recommendations on issues that send my patients’ parents on unfortunate and avoidable guilt trips.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

How many minutes do you spend each day trying to coax new parents off the guilt train? They have delayed their childbearing until they felt comfortable economically and emotionally ready to raise a child. Convinced that up to this point they have done enough correctly to be considered successful, they see no reason that they won’t be able to tackle parenthood just as easily. Their black lab is a model of obedience. Housebreaking him was a breeze. They are skilled at using the Internet and social media to gather the information they will need for raising a child.

Jaimie Duplass/Fotolia.com

However, at some point in the first 72 hours after the birth of their child, most parents are going to hit the wall of reality. It may be that breastfeeding doesn’t work as well their cousin told them it would or simply that babies cry, often for no discernible reason. Desperately wanting to do what’s right for their child, guilt creeps in as the little failures and fatigue begin to accumulate.

In their search for answers, new parents naturally come to us as pediatricians and family practitioners for the facts, but they also will search the Internet, talk to lactation consultants, and be bombarded by unsolicited advice from family members and neighbors. Every source they turn to, including physicians, will be filtered through its own bias.

I recently came across the most sensible advice for new parents I have read in a long time, and it came not from a pediatrician but from an economics professor at Brown University. Emily Oster, PhD, writing in the New York Times, examines the available data on the topics of breastfeeding, sleep training, and parents working out of the home with the objectivity of an economist and the sensitivity of a mother who has been there and done that (“The Data All Guilt-Ridden Parents Need,” New York Times, April 19, 2019).

For example, she observes that many of the benefits of breastfeeding are supported by some evidence, “just not always especially good evidence. And even when the evidence is good, the benefits are smaller than many people realize.” She points out that “most studies of breastfeeding are biased by the fact that women who breastfeed are typically different from those who do not.” I will leave it to you to read her full discussion that includes a comparison of random trials versus observational studies. But she concludes that, if one relies on only good evidence, the only demonstrable benefit of breastfeeding is for mothers who nurse longer than 12 months who may have a 20%-30% decrease in breast cancer risk.

Using the same kind of careful analysis, Dr. Oster finds that sleep training may have a short-term benefit for parents who will have improved sleep and less maternal depression, but in the long run children who were sleep trained were no different than those that weren’t.

She also finds that, when it comes to the “optimal configuration of adult work hours” for a household, there is “no compelling evidence that proves that having a stay-at-home parent affects child outcomes, positively or negatively.” It is up to each household what works best for all it members, not just the child.

I urge you to read Dr. Oster’s article of advice on breastfeeding, sleep training or not, and working outside the home, and recommend it to struggling parents. I found it particularly helpful as a practitioner who has often felt shackled, or at least disadvantaged, by the American Academy of Pediatrics’ overly simplistic and sometimes biased recommendations on issues that send my patients’ parents on unfortunate and avoidable guilt trips.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

How many minutes do you spend each day trying to coax new parents off the guilt train? They have delayed their childbearing until they felt comfortable economically and emotionally ready to raise a child. Convinced that up to this point they have done enough correctly to be considered successful, they see no reason that they won’t be able to tackle parenthood just as easily. Their black lab is a model of obedience. Housebreaking him was a breeze. They are skilled at using the Internet and social media to gather the information they will need for raising a child.

Jaimie Duplass/Fotolia.com

However, at some point in the first 72 hours after the birth of their child, most parents are going to hit the wall of reality. It may be that breastfeeding doesn’t work as well their cousin told them it would or simply that babies cry, often for no discernible reason. Desperately wanting to do what’s right for their child, guilt creeps in as the little failures and fatigue begin to accumulate.

In their search for answers, new parents naturally come to us as pediatricians and family practitioners for the facts, but they also will search the Internet, talk to lactation consultants, and be bombarded by unsolicited advice from family members and neighbors. Every source they turn to, including physicians, will be filtered through its own bias.

I recently came across the most sensible advice for new parents I have read in a long time, and it came not from a pediatrician but from an economics professor at Brown University. Emily Oster, PhD, writing in the New York Times, examines the available data on the topics of breastfeeding, sleep training, and parents working out of the home with the objectivity of an economist and the sensitivity of a mother who has been there and done that (“The Data All Guilt-Ridden Parents Need,” New York Times, April 19, 2019).

For example, she observes that many of the benefits of breastfeeding are supported by some evidence, “just not always especially good evidence. And even when the evidence is good, the benefits are smaller than many people realize.” She points out that “most studies of breastfeeding are biased by the fact that women who breastfeed are typically different from those who do not.” I will leave it to you to read her full discussion that includes a comparison of random trials versus observational studies. But she concludes that, if one relies on only good evidence, the only demonstrable benefit of breastfeeding is for mothers who nurse longer than 12 months who may have a 20%-30% decrease in breast cancer risk.

Using the same kind of careful analysis, Dr. Oster finds that sleep training may have a short-term benefit for parents who will have improved sleep and less maternal depression, but in the long run children who were sleep trained were no different than those that weren’t.

She also finds that, when it comes to the “optimal configuration of adult work hours” for a household, there is “no compelling evidence that proves that having a stay-at-home parent affects child outcomes, positively or negatively.” It is up to each household what works best for all it members, not just the child.

I urge you to read Dr. Oster’s article of advice on breastfeeding, sleep training or not, and working outside the home, and recommend it to struggling parents. I found it particularly helpful as a practitioner who has often felt shackled, or at least disadvantaged, by the American Academy of Pediatrics’ overly simplistic and sometimes biased recommendations on issues that send my patients’ parents on unfortunate and avoidable guilt trips.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

LOS ANGELES – A phase 3 clinical trial shows promising results for an experimental drug called teprotumumab, which treats thyroid eye disease, researchers reported at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

“For the first time, there appears to be a medicine that can be given during the active phase of the disease and can actually reverse not just the eyelid swelling and the clinical activity score, but also reduce the eye bulging and double vision and [improve] the [patient’s] quality of life. It could be a watershed moment in the treatment of the disease,” said ophthalmologist Raymond Douglas, MD, PhD, professor of surgery at Cedar-Sinai Medical Center Los Angeles and the study’s coprincipal investigator, in an interview at the meeting.

According to Dr. Douglas, thyroid eye disease, which is also known as Graves’ eye disease, is a severely disabling condition that causes swelling, pain, discomfort, and blindness. “The burden really is quite significant,” he said, with an impact that’s been compared with that of breast cancer in quality-of-life studies.

“Current treatments for thyroid eye disease are rather limited,” he said. “They really encompass just reducing the swelling and the short-term manifestations of the disease. Treatments such as IV steroids and radiation have been shown to not have any effect on long-term manifestations such as eye bulging and double vision.”

Teprotumumab is a fully human monoclonal antibody that targets the insulinlike growth factor I receptor (IGF-IR). It seems to downregulate thyroid eye disease, Dr. Douglas said.

Researchers studied the drug in a randomized, placebo-controlled study: 41 patients were designated to receive eight intravenous infusions of the drug over 21 weeks (10 mg/kg for the first infusion, then 20 mg/kg thereafter). At week 24, 83% of the study group (34 of 41 patients) reached the endpoint of a reduction of eye bulging by at least 2 mm, compared with 10% of patients (4 of 42) in the placebo group, which received infusions of saline solution.

Two millimeters is significant, Dr. Douglas said. “If you noticed someone’s eye was bulging 2 millimeters, you’d say, ‘Hey, I think something is wrong with your eye.’ ”

Initial study results were released in February 2019. New data about secondary endpoints were released at the AACE meeting: Researchers reported that the average reduction in proptosis (eye bulging) was 2.82 mm in the study group, compared with 0.54 mm in the placebo group (P less than .001).

Dr. Douglas said he can “achieve 3 mm of reduction through surgery to drill out the bone between the eye and the brain. [The patients in the study group] were able to achieve almost 3 millimeters of reduction by the drug alone. It’s a rather significant improvement.”

The new data also provided some insight into the timing of clinical improvements. According to Dr. Douglas, “most of the endpoints were met as early as 6 weeks or [after] two infusions of this drug.”

The adverse effects were relatively mild and included muscle spasms, said Dr. Douglas. The side effects seem to be “well tolerated,” he noted, and none led to cessation of therapy.

Participants with potential for motherhood or fatherhood during the trial had to agree to take precautions to avoid becoming pregnant or impregnating a partner.

Dr. Douglas didn’t provide cost information about the drug. However, it seems likely to be expensive. A writer with Seeking Alpha, a stock market analysis site, estimated that the cost could reach “$250,000 or $300,000 per patient per year, which translates to a $3.7 billion to $6 billion market in the United States alone (based on the estimated patient population in the 15,000-20,000 range).”

The drug’s manufacturer, Horizon Therapeutics, expects to apply to the Food and Drug Administration later this year for approval of the drug.

If it is approved, endocrinologists will have an opportunity to partner with eye surgeons to treat thyroid eye disease, Dr. Douglas said. “The crux will be the comanagement with the endocrinologist helping to control the thyroid function and manage some of the side effects of this medication, and the oculoplastic surgeon [working on] diagnosis, appropriate use, and management.”

Horizon Therapeutics funded the study. Dr. Douglas disclosed that he is a consultant with the company.
 

LOS ANGELES – A phase 3 clinical trial shows promising results for an experimental drug called teprotumumab, which treats thyroid eye disease, researchers reported at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

“For the first time, there appears to be a medicine that can be given during the active phase of the disease and can actually reverse not just the eyelid swelling and the clinical activity score, but also reduce the eye bulging and double vision and [improve] the [patient’s] quality of life. It could be a watershed moment in the treatment of the disease,” said ophthalmologist Raymond Douglas, MD, PhD, professor of surgery at Cedar-Sinai Medical Center Los Angeles and the study’s coprincipal investigator, in an interview at the meeting.

According to Dr. Douglas, thyroid eye disease, which is also known as Graves’ eye disease, is a severely disabling condition that causes swelling, pain, discomfort, and blindness. “The burden really is quite significant,” he said, with an impact that’s been compared with that of breast cancer in quality-of-life studies.

“Current treatments for thyroid eye disease are rather limited,” he said. “They really encompass just reducing the swelling and the short-term manifestations of the disease. Treatments such as IV steroids and radiation have been shown to not have any effect on long-term manifestations such as eye bulging and double vision.”

Teprotumumab is a fully human monoclonal antibody that targets the insulinlike growth factor I receptor (IGF-IR). It seems to downregulate thyroid eye disease, Dr. Douglas said.

Researchers studied the drug in a randomized, placebo-controlled study: 41 patients were designated to receive eight intravenous infusions of the drug over 21 weeks (10 mg/kg for the first infusion, then 20 mg/kg thereafter). At week 24, 83% of the study group (34 of 41 patients) reached the endpoint of a reduction of eye bulging by at least 2 mm, compared with 10% of patients (4 of 42) in the placebo group, which received infusions of saline solution.

Two millimeters is significant, Dr. Douglas said. “If you noticed someone’s eye was bulging 2 millimeters, you’d say, ‘Hey, I think something is wrong with your eye.’ ”

Initial study results were released in February 2019. New data about secondary endpoints were released at the AACE meeting: Researchers reported that the average reduction in proptosis (eye bulging) was 2.82 mm in the study group, compared with 0.54 mm in the placebo group (P less than .001).

Dr. Douglas said he can “achieve 3 mm of reduction through surgery to drill out the bone between the eye and the brain. [The patients in the study group] were able to achieve almost 3 millimeters of reduction by the drug alone. It’s a rather significant improvement.”

The new data also provided some insight into the timing of clinical improvements. According to Dr. Douglas, “most of the endpoints were met as early as 6 weeks or [after] two infusions of this drug.”

The adverse effects were relatively mild and included muscle spasms, said Dr. Douglas. The side effects seem to be “well tolerated,” he noted, and none led to cessation of therapy.

Participants with potential for motherhood or fatherhood during the trial had to agree to take precautions to avoid becoming pregnant or impregnating a partner.

Dr. Douglas didn’t provide cost information about the drug. However, it seems likely to be expensive. A writer with Seeking Alpha, a stock market analysis site, estimated that the cost could reach “$250,000 or $300,000 per patient per year, which translates to a $3.7 billion to $6 billion market in the United States alone (based on the estimated patient population in the 15,000-20,000 range).”

The drug’s manufacturer, Horizon Therapeutics, expects to apply to the Food and Drug Administration later this year for approval of the drug.

If it is approved, endocrinologists will have an opportunity to partner with eye surgeons to treat thyroid eye disease, Dr. Douglas said. “The crux will be the comanagement with the endocrinologist helping to control the thyroid function and manage some of the side effects of this medication, and the oculoplastic surgeon [working on] diagnosis, appropriate use, and management.”

Horizon Therapeutics funded the study. Dr. Douglas disclosed that he is a consultant with the company.
 

LOS ANGELES – A phase 3 clinical trial shows promising results for an experimental drug called teprotumumab, which treats thyroid eye disease, researchers reported at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

“For the first time, there appears to be a medicine that can be given during the active phase of the disease and can actually reverse not just the eyelid swelling and the clinical activity score, but also reduce the eye bulging and double vision and [improve] the [patient’s] quality of life. It could be a watershed moment in the treatment of the disease,” said ophthalmologist Raymond Douglas, MD, PhD, professor of surgery at Cedar-Sinai Medical Center Los Angeles and the study’s coprincipal investigator, in an interview at the meeting.

According to Dr. Douglas, thyroid eye disease, which is also known as Graves’ eye disease, is a severely disabling condition that causes swelling, pain, discomfort, and blindness. “The burden really is quite significant,” he said, with an impact that’s been compared with that of breast cancer in quality-of-life studies.

“Current treatments for thyroid eye disease are rather limited,” he said. “They really encompass just reducing the swelling and the short-term manifestations of the disease. Treatments such as IV steroids and radiation have been shown to not have any effect on long-term manifestations such as eye bulging and double vision.”

Teprotumumab is a fully human monoclonal antibody that targets the insulinlike growth factor I receptor (IGF-IR). It seems to downregulate thyroid eye disease, Dr. Douglas said.

Researchers studied the drug in a randomized, placebo-controlled study: 41 patients were designated to receive eight intravenous infusions of the drug over 21 weeks (10 mg/kg for the first infusion, then 20 mg/kg thereafter). At week 24, 83% of the study group (34 of 41 patients) reached the endpoint of a reduction of eye bulging by at least 2 mm, compared with 10% of patients (4 of 42) in the placebo group, which received infusions of saline solution.

Two millimeters is significant, Dr. Douglas said. “If you noticed someone’s eye was bulging 2 millimeters, you’d say, ‘Hey, I think something is wrong with your eye.’ ”

Initial study results were released in February 2019. New data about secondary endpoints were released at the AACE meeting: Researchers reported that the average reduction in proptosis (eye bulging) was 2.82 mm in the study group, compared with 0.54 mm in the placebo group (P less than .001).

Dr. Douglas said he can “achieve 3 mm of reduction through surgery to drill out the bone between the eye and the brain. [The patients in the study group] were able to achieve almost 3 millimeters of reduction by the drug alone. It’s a rather significant improvement.”

The new data also provided some insight into the timing of clinical improvements. According to Dr. Douglas, “most of the endpoints were met as early as 6 weeks or [after] two infusions of this drug.”

The adverse effects were relatively mild and included muscle spasms, said Dr. Douglas. The side effects seem to be “well tolerated,” he noted, and none led to cessation of therapy.

Participants with potential for motherhood or fatherhood during the trial had to agree to take precautions to avoid becoming pregnant or impregnating a partner.

Dr. Douglas didn’t provide cost information about the drug. However, it seems likely to be expensive. A writer with Seeking Alpha, a stock market analysis site, estimated that the cost could reach “$250,000 or $300,000 per patient per year, which translates to a $3.7 billion to $6 billion market in the United States alone (based on the estimated patient population in the 15,000-20,000 range).”

The drug’s manufacturer, Horizon Therapeutics, expects to apply to the Food and Drug Administration later this year for approval of the drug.

If it is approved, endocrinologists will have an opportunity to partner with eye surgeons to treat thyroid eye disease, Dr. Douglas said. “The crux will be the comanagement with the endocrinologist helping to control the thyroid function and manage some of the side effects of this medication, and the oculoplastic surgeon [working on] diagnosis, appropriate use, and management.”

Horizon Therapeutics funded the study. Dr. Douglas disclosed that he is a consultant with the company.
 

The United States put 75 new cases of measles on the board last week, bringing the total for the year to 839 as of May 10, according to the Centers for Disease Control and Prevention.

There are 10 states dealing with ongoing outbreaks now that Pennsylvania has been added to the list, the CDC reported May 13. The state has had five cases so far, all in Allegheny County. New York City continued to have the most active outbreak, adding 43 more cases in Brooklyn last week for a total of 410 in the city since the beginning of 2019, NYC Health said.

Several of this year’s outbreaks were predicted in an analysis published in the Lancet Infectious Diseases (2019 May 9. doi: 10.1016/S1473-3099(19)30231-2). Investigators identified the 25 counties most likely to experience a measles outbreak in 2019 – a list that includes Queens, N.Y. (adjacent to Brooklyn), Multnomah, Ore. (adjacent to Clark County, Wash., where 71 people were infected earlier this year), and San Mateo, Calif., where 4 cases have been reported.


“We recommend that public health officials and policymakers prioritize monitoring the counties we identify to be at high risk that have not yet reported cases, especially those that lie adjacent to counties with ongoing outbreaks and those that house large international airports,” senior author Lauren Gardner of Johns Hopkins University, Baltimore, said in a written statement.

The outbreak in Clark County was declared over in late April, but Gov. Jay Inslee signed a bill on May 10 that removes the personal/philosophical exemption for the MMR vaccine from the state’s school and child care immunization requirements. “We must step up our leadership to educate the public about the critical role vaccines have in keeping us healthy and safe, and continue working with communities to improve vaccination rates,” Washington State Secretary of Health John Wiesman said in a written statement.

In Oregon, a bill that would eliminate religious and philosophical exemptions to child vaccination requirements passed the state house of representatives by a 35-25 vote and is moving to the senate. Gov. Kate Brown has said that she plans to sign the bill, according to OregonLive.com.

The United States put 75 new cases of measles on the board last week, bringing the total for the year to 839 as of May 10, according to the Centers for Disease Control and Prevention.

There are 10 states dealing with ongoing outbreaks now that Pennsylvania has been added to the list, the CDC reported May 13. The state has had five cases so far, all in Allegheny County. New York City continued to have the most active outbreak, adding 43 more cases in Brooklyn last week for a total of 410 in the city since the beginning of 2019, NYC Health said.

Several of this year’s outbreaks were predicted in an analysis published in the Lancet Infectious Diseases (2019 May 9. doi: 10.1016/S1473-3099(19)30231-2). Investigators identified the 25 counties most likely to experience a measles outbreak in 2019 – a list that includes Queens, N.Y. (adjacent to Brooklyn), Multnomah, Ore. (adjacent to Clark County, Wash., where 71 people were infected earlier this year), and San Mateo, Calif., where 4 cases have been reported.


“We recommend that public health officials and policymakers prioritize monitoring the counties we identify to be at high risk that have not yet reported cases, especially those that lie adjacent to counties with ongoing outbreaks and those that house large international airports,” senior author Lauren Gardner of Johns Hopkins University, Baltimore, said in a written statement.

The outbreak in Clark County was declared over in late April, but Gov. Jay Inslee signed a bill on May 10 that removes the personal/philosophical exemption for the MMR vaccine from the state’s school and child care immunization requirements. “We must step up our leadership to educate the public about the critical role vaccines have in keeping us healthy and safe, and continue working with communities to improve vaccination rates,” Washington State Secretary of Health John Wiesman said in a written statement.

In Oregon, a bill that would eliminate religious and philosophical exemptions to child vaccination requirements passed the state house of representatives by a 35-25 vote and is moving to the senate. Gov. Kate Brown has said that she plans to sign the bill, according to OregonLive.com.

The United States put 75 new cases of measles on the board last week, bringing the total for the year to 839 as of May 10, according to the Centers for Disease Control and Prevention.

There are 10 states dealing with ongoing outbreaks now that Pennsylvania has been added to the list, the CDC reported May 13. The state has had five cases so far, all in Allegheny County. New York City continued to have the most active outbreak, adding 43 more cases in Brooklyn last week for a total of 410 in the city since the beginning of 2019, NYC Health said.

Several of this year’s outbreaks were predicted in an analysis published in the Lancet Infectious Diseases (2019 May 9. doi: 10.1016/S1473-3099(19)30231-2). Investigators identified the 25 counties most likely to experience a measles outbreak in 2019 – a list that includes Queens, N.Y. (adjacent to Brooklyn), Multnomah, Ore. (adjacent to Clark County, Wash., where 71 people were infected earlier this year), and San Mateo, Calif., where 4 cases have been reported.


“We recommend that public health officials and policymakers prioritize monitoring the counties we identify to be at high risk that have not yet reported cases, especially those that lie adjacent to counties with ongoing outbreaks and those that house large international airports,” senior author Lauren Gardner of Johns Hopkins University, Baltimore, said in a written statement.

The outbreak in Clark County was declared over in late April, but Gov. Jay Inslee signed a bill on May 10 that removes the personal/philosophical exemption for the MMR vaccine from the state’s school and child care immunization requirements. “We must step up our leadership to educate the public about the critical role vaccines have in keeping us healthy and safe, and continue working with communities to improve vaccination rates,” Washington State Secretary of Health John Wiesman said in a written statement.

In Oregon, a bill that would eliminate religious and philosophical exemptions to child vaccination requirements passed the state house of representatives by a 35-25 vote and is moving to the senate. Gov. Kate Brown has said that she plans to sign the bill, according to OregonLive.com.

WASHINGTON – Medical residents learned how to effectively perform telemedicine skills for remote patients, while still providing the same quality of care during clinic visits, according to the results of a new pilot program.

While telephone visits have been shown to be an effective alternative to face-to-face visits for physicians, residents are not trained to perform telemedicine.

“We have no structured training program on how to teach these residents these skills. We assume that the same skills needed in the clinic are applicable through telephone medicine and we’re not sure about that yet,” Jenna L. Laughlin, DO, said at the annual meeting of the Society of General Internal Medicine.

The pilot study took place at Christiana Care Health System, Wilmington, Del., from October 2016 through December 2018. Nine residents were enrolled in the study, but only six participated.

The objective of the pilot was to demonstrate the feasibility of adding telephone visits into the internal medicine residency practice. This feasibility was measured by templating, scheduling, and supervision, noted Dr. Laughlin, an internist at Christiana Care Health System in Newark, Del. Templating was a term used to describe the designing of the program. For example, the researcher templated 1-hour telephone visit blocks, meaning they designed this structure to integrate into the resident’s training program.

Each resident had 1 hour within the weekly schedule to conduct telephone visits. First-year residents were allowed to do one telephone visit during that hour, second-year residents could do two telephone visits within the hour, and third-year residents could do three telephone visits in that hour.

“There were some challenges associated with scheduling and templating, such as initial schedule templates and a high utilization learning curve,” said Dr. Laughlin, lead author of the study and the program’s leader.

Some didn’t schedule enough telemedicine visits; those residents were assigned to acute clinic visits during the times that they should have been practicing telemedicine.

The program’s second objective was to evaluate the resident experience of scheduled telemedicine visits. This included provider-patient continuity and patient ownership.

The six residents who were surveyed about their experiences said these telephone visits increased their patient ownership and allowed them to build rapport with patients. They said the level of supervision they received was appropriate.

In terms of continuity of care, out the 273 telephone visits scheduled, 179 (65%) were with the patient’s primary care provider and 71 (26.0%) were within the primary care provider’s firm.

“As we build primary care practices in the future, there will be many alternative methods of working with our patients, compared to the traditional face-to-face encounters. I think these are increasingly going to be something that our medical residents need for their future,” Dr. Laughlin said.

The authors reported no conflicts of interest.

WASHINGTON – Medical residents learned how to effectively perform telemedicine skills for remote patients, while still providing the same quality of care during clinic visits, according to the results of a new pilot program.

While telephone visits have been shown to be an effective alternative to face-to-face visits for physicians, residents are not trained to perform telemedicine.

“We have no structured training program on how to teach these residents these skills. We assume that the same skills needed in the clinic are applicable through telephone medicine and we’re not sure about that yet,” Jenna L. Laughlin, DO, said at the annual meeting of the Society of General Internal Medicine.

The pilot study took place at Christiana Care Health System, Wilmington, Del., from October 2016 through December 2018. Nine residents were enrolled in the study, but only six participated.

The objective of the pilot was to demonstrate the feasibility of adding telephone visits into the internal medicine residency practice. This feasibility was measured by templating, scheduling, and supervision, noted Dr. Laughlin, an internist at Christiana Care Health System in Newark, Del. Templating was a term used to describe the designing of the program. For example, the researcher templated 1-hour telephone visit blocks, meaning they designed this structure to integrate into the resident’s training program.

Each resident had 1 hour within the weekly schedule to conduct telephone visits. First-year residents were allowed to do one telephone visit during that hour, second-year residents could do two telephone visits within the hour, and third-year residents could do three telephone visits in that hour.

“There were some challenges associated with scheduling and templating, such as initial schedule templates and a high utilization learning curve,” said Dr. Laughlin, lead author of the study and the program’s leader.

Some didn’t schedule enough telemedicine visits; those residents were assigned to acute clinic visits during the times that they should have been practicing telemedicine.

The program’s second objective was to evaluate the resident experience of scheduled telemedicine visits. This included provider-patient continuity and patient ownership.

The six residents who were surveyed about their experiences said these telephone visits increased their patient ownership and allowed them to build rapport with patients. They said the level of supervision they received was appropriate.

In terms of continuity of care, out the 273 telephone visits scheduled, 179 (65%) were with the patient’s primary care provider and 71 (26.0%) were within the primary care provider’s firm.

“As we build primary care practices in the future, there will be many alternative methods of working with our patients, compared to the traditional face-to-face encounters. I think these are increasingly going to be something that our medical residents need for their future,” Dr. Laughlin said.

The authors reported no conflicts of interest.

WASHINGTON – Medical residents learned how to effectively perform telemedicine skills for remote patients, while still providing the same quality of care during clinic visits, according to the results of a new pilot program.

While telephone visits have been shown to be an effective alternative to face-to-face visits for physicians, residents are not trained to perform telemedicine.

“We have no structured training program on how to teach these residents these skills. We assume that the same skills needed in the clinic are applicable through telephone medicine and we’re not sure about that yet,” Jenna L. Laughlin, DO, said at the annual meeting of the Society of General Internal Medicine.

The pilot study took place at Christiana Care Health System, Wilmington, Del., from October 2016 through December 2018. Nine residents were enrolled in the study, but only six participated.

The objective of the pilot was to demonstrate the feasibility of adding telephone visits into the internal medicine residency practice. This feasibility was measured by templating, scheduling, and supervision, noted Dr. Laughlin, an internist at Christiana Care Health System in Newark, Del. Templating was a term used to describe the designing of the program. For example, the researcher templated 1-hour telephone visit blocks, meaning they designed this structure to integrate into the resident’s training program.

Each resident had 1 hour within the weekly schedule to conduct telephone visits. First-year residents were allowed to do one telephone visit during that hour, second-year residents could do two telephone visits within the hour, and third-year residents could do three telephone visits in that hour.

“There were some challenges associated with scheduling and templating, such as initial schedule templates and a high utilization learning curve,” said Dr. Laughlin, lead author of the study and the program’s leader.

Some didn’t schedule enough telemedicine visits; those residents were assigned to acute clinic visits during the times that they should have been practicing telemedicine.

The program’s second objective was to evaluate the resident experience of scheduled telemedicine visits. This included provider-patient continuity and patient ownership.

The six residents who were surveyed about their experiences said these telephone visits increased their patient ownership and allowed them to build rapport with patients. They said the level of supervision they received was appropriate.

In terms of continuity of care, out the 273 telephone visits scheduled, 179 (65%) were with the patient’s primary care provider and 71 (26.0%) were within the primary care provider’s firm.

“As we build primary care practices in the future, there will be many alternative methods of working with our patients, compared to the traditional face-to-face encounters. I think these are increasingly going to be something that our medical residents need for their future,” Dr. Laughlin said.

The authors reported no conflicts of interest.

BALTIMORE – Most pediatricians do not discuss proper tampon use and safety with their adolescent female patients, and a remarkably high proportion of them lack adequate knowledge themselves about the topic, a new survey-based study found.

Rawpixel/Thinkstock

“Significant knowledge gaps [were] noted, for instance, [such as] the maximum time a tampon can safely remain in the body,” Miriam Singer of Cohen Children’s Medical Center of New York told attendees of the Pediatric Academic Societies annual meeting.

More than 80% of females aged 17-21 years have used tampons by themselves or with pads, Ms. Singer noted in her background information, yet many teens have low knowledge about their use and safety.

Past research has found that only 35% of high school junior and senior girls heard about tampon use from their mothers, yet many of these mothers showed low knowledge about proper tampon use as well. That same research found that less than 15% of girls aged 10-19 years reported getting information from a health professional about products for menstruation despite recommendations from the American Academy of Pediatrics to instruct girls on feminine hygiene product usage.

Other research has found minimal to no education about menstruation in schools “due to time constraints and stigma associated with menstruation,” Ms. Singer said.

She and her colleagues emailed 2,500 AAP members in November-December 2018 a 53-question online questionnaire about their self-rated and measured knowledge of proper tampon usage and safety and how frequently they discussed tampons with their female adolescent patients. The survey included questions asking pediatricians to self-rate their knowledge about tampon use and safety on a Likert scale of 1 (not at all knowledgeable) to 5 (extremely knowledgeable).

Two incentives provided for completing the survey were a Feminine Hygiene Fact Sheet offered in the first email and an ADHD Medication Guide offered in the third and final email.

Among the 518 pediatricians who responded (21% response rate), 462 met the inclusion criteria of being a primary care pediatrician currently practicing in the United States. Most were women (79%) and white (79%). Just over half of the pediatricians worked only in private practice (54%) and in a suburban area (52%). About a quarter (26%) were in an urban area and 20% in a rural area. Distribution of years in practice (from 1-5 years to over 25 years in 5-year increments) was fairly even across respondents.

Only 9% of respondents reported they very often or almost always talk to their female adolescent patients about how to insert a tampon. The most common tampon-related conversation pediatricians reported was how often to change tampons, which only 35% of respondents said they very often or almost always do.

Yet a similar proportion, 36%, rarely or almost never discuss how often to change tampons, and 62% said they rarely or almost never discuss how to insert a tampon or talk about using tampons while sleeping. Half of respondents (51%) almost never discuss using tampons while swimming (only 21% very often or almost always do), and 77% have not discussed how tampons might affect the hymen with their patients.

More pediatricians (36%) reported almost never discussing the risks of tampon use with female teens than those who sometimes (32%) or very often/almost always (31%) discussed risks.

Respondents also were generally much more willing to discuss tampons with older adolescents than younger ones. Only 18% of respondents said they were highly likely to discuss them with 12- and 13-year-olds, compared with almost twice as many (33%) who would discuss tampons with 16- and 17-year-olds (P less than .001).

Male pediatricians were significantly less likely to discuss any of these topics with their female adolescent patients than female pediatricians (P less than .001 for all questions except risks [P = .01] and hymen [P = .04]). They also rated their knowledge about tampons as significantly lower than self ratings by female pediatricians (P less than .001). Less than half of pediatricians (43%) rated their knowledge about tampons as high or very high, and one in five (20%) rated it as low.

Actual measured knowledge reflected the self-ratings, but still revealed substantial gaps in knowledge among male and female providers. Just over half of male pediatricians (52%) answered all questions about tampon use and safety correctly; however, female pediatricians were only slightly better, with 71% answering all questions correctly (P less than .001). Less than half of male and female pediatricians knew the maximum time a tampon could stay in before it should be removed to reduce risk of toxic shock syndrome (8 hours).

The only two questions that more than half of male pediatricians answered correctly were that girls can swim in the ocean while wearing a tampon and that it can, rarely but not typically, tear the hymen. Less than half knew girls could sleep while wearing a tampon and that a girl could start using a tampon with her first menstruation.

More than half of female pediatricians answered all these questions correctly, although only about two-thirds gave correct answers on how tampons can affect the hymen (the only question that more male pediatricians than female answered correctly), whether a girl can sleep in a tampon, and that patients should use the lowest effective absorbency tampon to minimize toxic shock syndrome risk.

Although the study is limited by a nonvalidated knowledge assessment instrument, self-reporting and potential selection bias means the study may not accurately represent U.S. primary care pediatricians nationwide; however, the findings still demonstrate notably low self-rated and measured knowledge about tampons.

“Given the AAP’s recommendation that pediatricians instruct girls on the use of feminine products, pediatricians must take steps to ensure they are educating patients about tampons,” Ms. Singer said. She also recommended the development of web-based resources targeting the improvement of pediatrician knowledge about tampon use and safety, and the need for the AAP to raise awareness about the importance of discussing tampons with female adolescent patients.

The study did not use external funding, and the authors reported no relevant financial disclosures.

BALTIMORE – Most pediatricians do not discuss proper tampon use and safety with their adolescent female patients, and a remarkably high proportion of them lack adequate knowledge themselves about the topic, a new survey-based study found.

Rawpixel/Thinkstock

“Significant knowledge gaps [were] noted, for instance, [such as] the maximum time a tampon can safely remain in the body,” Miriam Singer of Cohen Children’s Medical Center of New York told attendees of the Pediatric Academic Societies annual meeting.

More than 80% of females aged 17-21 years have used tampons by themselves or with pads, Ms. Singer noted in her background information, yet many teens have low knowledge about their use and safety.

Past research has found that only 35% of high school junior and senior girls heard about tampon use from their mothers, yet many of these mothers showed low knowledge about proper tampon use as well. That same research found that less than 15% of girls aged 10-19 years reported getting information from a health professional about products for menstruation despite recommendations from the American Academy of Pediatrics to instruct girls on feminine hygiene product usage.

Other research has found minimal to no education about menstruation in schools “due to time constraints and stigma associated with menstruation,” Ms. Singer said.

She and her colleagues emailed 2,500 AAP members in November-December 2018 a 53-question online questionnaire about their self-rated and measured knowledge of proper tampon usage and safety and how frequently they discussed tampons with their female adolescent patients. The survey included questions asking pediatricians to self-rate their knowledge about tampon use and safety on a Likert scale of 1 (not at all knowledgeable) to 5 (extremely knowledgeable).

Two incentives provided for completing the survey were a Feminine Hygiene Fact Sheet offered in the first email and an ADHD Medication Guide offered in the third and final email.

Among the 518 pediatricians who responded (21% response rate), 462 met the inclusion criteria of being a primary care pediatrician currently practicing in the United States. Most were women (79%) and white (79%). Just over half of the pediatricians worked only in private practice (54%) and in a suburban area (52%). About a quarter (26%) were in an urban area and 20% in a rural area. Distribution of years in practice (from 1-5 years to over 25 years in 5-year increments) was fairly even across respondents.

Only 9% of respondents reported they very often or almost always talk to their female adolescent patients about how to insert a tampon. The most common tampon-related conversation pediatricians reported was how often to change tampons, which only 35% of respondents said they very often or almost always do.

Yet a similar proportion, 36%, rarely or almost never discuss how often to change tampons, and 62% said they rarely or almost never discuss how to insert a tampon or talk about using tampons while sleeping. Half of respondents (51%) almost never discuss using tampons while swimming (only 21% very often or almost always do), and 77% have not discussed how tampons might affect the hymen with their patients.

More pediatricians (36%) reported almost never discussing the risks of tampon use with female teens than those who sometimes (32%) or very often/almost always (31%) discussed risks.

Respondents also were generally much more willing to discuss tampons with older adolescents than younger ones. Only 18% of respondents said they were highly likely to discuss them with 12- and 13-year-olds, compared with almost twice as many (33%) who would discuss tampons with 16- and 17-year-olds (P less than .001).

Male pediatricians were significantly less likely to discuss any of these topics with their female adolescent patients than female pediatricians (P less than .001 for all questions except risks [P = .01] and hymen [P = .04]). They also rated their knowledge about tampons as significantly lower than self ratings by female pediatricians (P less than .001). Less than half of pediatricians (43%) rated their knowledge about tampons as high or very high, and one in five (20%) rated it as low.

Actual measured knowledge reflected the self-ratings, but still revealed substantial gaps in knowledge among male and female providers. Just over half of male pediatricians (52%) answered all questions about tampon use and safety correctly; however, female pediatricians were only slightly better, with 71% answering all questions correctly (P less than .001). Less than half of male and female pediatricians knew the maximum time a tampon could stay in before it should be removed to reduce risk of toxic shock syndrome (8 hours).

The only two questions that more than half of male pediatricians answered correctly were that girls can swim in the ocean while wearing a tampon and that it can, rarely but not typically, tear the hymen. Less than half knew girls could sleep while wearing a tampon and that a girl could start using a tampon with her first menstruation.

More than half of female pediatricians answered all these questions correctly, although only about two-thirds gave correct answers on how tampons can affect the hymen (the only question that more male pediatricians than female answered correctly), whether a girl can sleep in a tampon, and that patients should use the lowest effective absorbency tampon to minimize toxic shock syndrome risk.

Although the study is limited by a nonvalidated knowledge assessment instrument, self-reporting and potential selection bias means the study may not accurately represent U.S. primary care pediatricians nationwide; however, the findings still demonstrate notably low self-rated and measured knowledge about tampons.

“Given the AAP’s recommendation that pediatricians instruct girls on the use of feminine products, pediatricians must take steps to ensure they are educating patients about tampons,” Ms. Singer said. She also recommended the development of web-based resources targeting the improvement of pediatrician knowledge about tampon use and safety, and the need for the AAP to raise awareness about the importance of discussing tampons with female adolescent patients.

The study did not use external funding, and the authors reported no relevant financial disclosures.

BALTIMORE – Most pediatricians do not discuss proper tampon use and safety with their adolescent female patients, and a remarkably high proportion of them lack adequate knowledge themselves about the topic, a new survey-based study found.

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“Significant knowledge gaps [were] noted, for instance, [such as] the maximum time a tampon can safely remain in the body,” Miriam Singer of Cohen Children’s Medical Center of New York told attendees of the Pediatric Academic Societies annual meeting.

More than 80% of females aged 17-21 years have used tampons by themselves or with pads, Ms. Singer noted in her background information, yet many teens have low knowledge about their use and safety.

Past research has found that only 35% of high school junior and senior girls heard about tampon use from their mothers, yet many of these mothers showed low knowledge about proper tampon use as well. That same research found that less than 15% of girls aged 10-19 years reported getting information from a health professional about products for menstruation despite recommendations from the American Academy of Pediatrics to instruct girls on feminine hygiene product usage.

Other research has found minimal to no education about menstruation in schools “due to time constraints and stigma associated with menstruation,” Ms. Singer said.

She and her colleagues emailed 2,500 AAP members in November-December 2018 a 53-question online questionnaire about their self-rated and measured knowledge of proper tampon usage and safety and how frequently they discussed tampons with their female adolescent patients. The survey included questions asking pediatricians to self-rate their knowledge about tampon use and safety on a Likert scale of 1 (not at all knowledgeable) to 5 (extremely knowledgeable).

Two incentives provided for completing the survey were a Feminine Hygiene Fact Sheet offered in the first email and an ADHD Medication Guide offered in the third and final email.

Among the 518 pediatricians who responded (21% response rate), 462 met the inclusion criteria of being a primary care pediatrician currently practicing in the United States. Most were women (79%) and white (79%). Just over half of the pediatricians worked only in private practice (54%) and in a suburban area (52%). About a quarter (26%) were in an urban area and 20% in a rural area. Distribution of years in practice (from 1-5 years to over 25 years in 5-year increments) was fairly even across respondents.

Only 9% of respondents reported they very often or almost always talk to their female adolescent patients about how to insert a tampon. The most common tampon-related conversation pediatricians reported was how often to change tampons, which only 35% of respondents said they very often or almost always do.

Yet a similar proportion, 36%, rarely or almost never discuss how often to change tampons, and 62% said they rarely or almost never discuss how to insert a tampon or talk about using tampons while sleeping. Half of respondents (51%) almost never discuss using tampons while swimming (only 21% very often or almost always do), and 77% have not discussed how tampons might affect the hymen with their patients.

More pediatricians (36%) reported almost never discussing the risks of tampon use with female teens than those who sometimes (32%) or very often/almost always (31%) discussed risks.

Respondents also were generally much more willing to discuss tampons with older adolescents than younger ones. Only 18% of respondents said they were highly likely to discuss them with 12- and 13-year-olds, compared with almost twice as many (33%) who would discuss tampons with 16- and 17-year-olds (P less than .001).

Male pediatricians were significantly less likely to discuss any of these topics with their female adolescent patients than female pediatricians (P less than .001 for all questions except risks [P = .01] and hymen [P = .04]). They also rated their knowledge about tampons as significantly lower than self ratings by female pediatricians (P less than .001). Less than half of pediatricians (43%) rated their knowledge about tampons as high or very high, and one in five (20%) rated it as low.

Actual measured knowledge reflected the self-ratings, but still revealed substantial gaps in knowledge among male and female providers. Just over half of male pediatricians (52%) answered all questions about tampon use and safety correctly; however, female pediatricians were only slightly better, with 71% answering all questions correctly (P less than .001). Less than half of male and female pediatricians knew the maximum time a tampon could stay in before it should be removed to reduce risk of toxic shock syndrome (8 hours).

The only two questions that more than half of male pediatricians answered correctly were that girls can swim in the ocean while wearing a tampon and that it can, rarely but not typically, tear the hymen. Less than half knew girls could sleep while wearing a tampon and that a girl could start using a tampon with her first menstruation.

More than half of female pediatricians answered all these questions correctly, although only about two-thirds gave correct answers on how tampons can affect the hymen (the only question that more male pediatricians than female answered correctly), whether a girl can sleep in a tampon, and that patients should use the lowest effective absorbency tampon to minimize toxic shock syndrome risk.

Although the study is limited by a nonvalidated knowledge assessment instrument, self-reporting and potential selection bias means the study may not accurately represent U.S. primary care pediatricians nationwide; however, the findings still demonstrate notably low self-rated and measured knowledge about tampons.

“Given the AAP’s recommendation that pediatricians instruct girls on the use of feminine products, pediatricians must take steps to ensure they are educating patients about tampons,” Ms. Singer said. She also recommended the development of web-based resources targeting the improvement of pediatrician knowledge about tampon use and safety, and the need for the AAP to raise awareness about the importance of discussing tampons with female adolescent patients.

The study did not use external funding, and the authors reported no relevant financial disclosures.

For the first time ever, the SVS Foundation is teaming up with the Society for Vascular Nursing and the Society for Vascular Ultrasound to provide free AAA and peripheral artery disease ultrasound screenings. The event will take place from 8am to 12pm, June 8 at the Medical Faculty Associates Department of Surgery in Washington, DC. Spread the word if you know someone in the DC area who might be interested in attending. Appointments may be scheduled by calling 888-871-3801. View the full details here.

For the first time ever, the SVS Foundation is teaming up with the Society for Vascular Nursing and the Society for Vascular Ultrasound to provide free AAA and peripheral artery disease ultrasound screenings. The event will take place from 8am to 12pm, June 8 at the Medical Faculty Associates Department of Surgery in Washington, DC. Spread the word if you know someone in the DC area who might be interested in attending. Appointments may be scheduled by calling 888-871-3801. View the full details here.

For the first time ever, the SVS Foundation is teaming up with the Society for Vascular Nursing and the Society for Vascular Ultrasound to provide free AAA and peripheral artery disease ultrasound screenings. The event will take place from 8am to 12pm, June 8 at the Medical Faculty Associates Department of Surgery in Washington, DC. Spread the word if you know someone in the DC area who might be interested in attending. Appointments may be scheduled by calling 888-871-3801. View the full details here.

Register today for the Fourth Annual UCLA / SVS Symposium. This year’s program, “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery” will be held Aug. 24 to 26 at the Beverly Hilton, Beverly Hills, Calif. The course, a joint effort of the Division of Vascular and Endovascular Surgery at UCLA and the Society for Vascular Surgery, will offer an in-depth review of the specialty to those preparing to take the vascular board examinations. It will also provide basic didactic education for vascular residents and fellows in training. Read the full details and register here.

Register today for the Fourth Annual UCLA / SVS Symposium. This year’s program, “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery” will be held Aug. 24 to 26 at the Beverly Hilton, Beverly Hills, Calif. The course, a joint effort of the Division of Vascular and Endovascular Surgery at UCLA and the Society for Vascular Surgery, will offer an in-depth review of the specialty to those preparing to take the vascular board examinations. It will also provide basic didactic education for vascular residents and fellows in training. Read the full details and register here.

Register today for the Fourth Annual UCLA / SVS Symposium. This year’s program, “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery” will be held Aug. 24 to 26 at the Beverly Hilton, Beverly Hills, Calif. The course, a joint effort of the Division of Vascular and Endovascular Surgery at UCLA and the Society for Vascular Surgery, will offer an in-depth review of the specialty to those preparing to take the vascular board examinations. It will also provide basic didactic education for vascular residents and fellows in training. Read the full details and register here.

PA programming is set to take place from 1:15 – 5:15pm Thursday, June 13. There will be a PA networking lunch before the section session from 12-1pm, and a PA networking meet-up afterwards at 5:30 in the exhibit hall. The entire Vascular Annual Meeting has been reviewed by the AAPA Review Panel and is compliant with AAPA CME Criteria. This activity is designated for 30 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation. Register for VAM today.

PA programming is set to take place from 1:15 – 5:15pm Thursday, June 13. There will be a PA networking lunch before the section session from 12-1pm, and a PA networking meet-up afterwards at 5:30 in the exhibit hall. The entire Vascular Annual Meeting has been reviewed by the AAPA Review Panel and is compliant with AAPA CME Criteria. This activity is designated for 30 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation. Register for VAM today.

PA programming is set to take place from 1:15 – 5:15pm Thursday, June 13. There will be a PA networking lunch before the section session from 12-1pm, and a PA networking meet-up afterwards at 5:30 in the exhibit hall. The entire Vascular Annual Meeting has been reviewed by the AAPA Review Panel and is compliant with AAPA CME Criteria. This activity is designated for 30 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation. Register for VAM today.