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Developing vaccines against enterovirus-A71 called a priority
MADRID – Is there a need for an enterovirus-A71 vaccine?
This is a new question for North American and European physicians, but not so new in Asia.
“China says yes, with more than 15 million cases of hand, foot, and mouth disease resulting in 3,500 deaths since surveillance started in 2009,” Heli Harvala, MD, said at the annual meeting of the European Society for Paediatric Infectious Diseases.
Seroconversion rates 28 days after the second dose of these vaccines, both directed specifically against viral subgenotype C-4, are 92%-100%. Vaccine efficacy is 91%-97%, according to Dr. Harvala, a consultant medical virologist at University College London.
It remains a mystery why major outbreaks of severe EV-A71 disease have mostly occurred in Asia, with the notable exception of a Spanish outbreak of EV-A71 encephalitis in 2016. The possibility of much wider spread is concerning.
The Chinese monovalent EV-A71 vaccines, however, are seen as a stopgap. For one thing, recent evidence suggests that it’s probably not the specific EV-A71 C-4 viral subgenotype that accounts for all severe disease.
“I think we have to aim for a multivalent vaccine,” Dr. Harvala said.
Now in clinical trials, investigational bivalent vaccines are directed against other EV-A71 subgenotypes in addition to C-4, and also against another enterovirus, coxsackievirus serotype A16, the most common cause of classic hand, foot, and mouth disease in the United States. But that’s probably not enough, according to Dr. Harvala. She noted that coxsackievirus A6, which was first identified more than 50 years ago, abruptly became the main cause of mild hand, foot, and mouth disease in China in 2013 and again in 2015. Moreover, its role in severe cases is growing, and there have been important outbreaks in the United States in recent years. These severe cases come in three main presentations, resembling either erythema multiforme, chicken pox, or eczema herpeticum.
Dr. Harvala added that a next-generation vaccine probably also should offer protection against enterovirus-D68. In 2014, there were 1,153 laboratory-confirmed EV-D68 infections and 14 deaths in the United States and Canada. This infection poses a diagnostic challenge: while the virus is readily detectable on throat swabs, it’s only rarely present in stool or cerebrospinal fluid samples.
“It’s important to keep in mind that this infection is still underdiagnosed. We are not really looking for it,” she said.
No specific treatment for enterovirus infections is available. Three capsid-binding antiviral agents now are in clinical trials: pleconaril, vapendavir, and pocapavir. In addition, translational studies have demonstrated that the SSRI fluoxetine inhibits enterovirus replication, but there have been no clinical trials as yet.
Although development of antivirals effective against enterovirus is an active area of research, Dr. Harvala thinks drug resistance will be an issue, underscoring the importance of vaccine development.
She reported having no financial conflicts of interest regarding her presentation.
MADRID – Is there a need for an enterovirus-A71 vaccine?
This is a new question for North American and European physicians, but not so new in Asia.
“China says yes, with more than 15 million cases of hand, foot, and mouth disease resulting in 3,500 deaths since surveillance started in 2009,” Heli Harvala, MD, said at the annual meeting of the European Society for Paediatric Infectious Diseases.
Seroconversion rates 28 days after the second dose of these vaccines, both directed specifically against viral subgenotype C-4, are 92%-100%. Vaccine efficacy is 91%-97%, according to Dr. Harvala, a consultant medical virologist at University College London.
It remains a mystery why major outbreaks of severe EV-A71 disease have mostly occurred in Asia, with the notable exception of a Spanish outbreak of EV-A71 encephalitis in 2016. The possibility of much wider spread is concerning.
The Chinese monovalent EV-A71 vaccines, however, are seen as a stopgap. For one thing, recent evidence suggests that it’s probably not the specific EV-A71 C-4 viral subgenotype that accounts for all severe disease.
“I think we have to aim for a multivalent vaccine,” Dr. Harvala said.
Now in clinical trials, investigational bivalent vaccines are directed against other EV-A71 subgenotypes in addition to C-4, and also against another enterovirus, coxsackievirus serotype A16, the most common cause of classic hand, foot, and mouth disease in the United States. But that’s probably not enough, according to Dr. Harvala. She noted that coxsackievirus A6, which was first identified more than 50 years ago, abruptly became the main cause of mild hand, foot, and mouth disease in China in 2013 and again in 2015. Moreover, its role in severe cases is growing, and there have been important outbreaks in the United States in recent years. These severe cases come in three main presentations, resembling either erythema multiforme, chicken pox, or eczema herpeticum.
Dr. Harvala added that a next-generation vaccine probably also should offer protection against enterovirus-D68. In 2014, there were 1,153 laboratory-confirmed EV-D68 infections and 14 deaths in the United States and Canada. This infection poses a diagnostic challenge: while the virus is readily detectable on throat swabs, it’s only rarely present in stool or cerebrospinal fluid samples.
“It’s important to keep in mind that this infection is still underdiagnosed. We are not really looking for it,” she said.
No specific treatment for enterovirus infections is available. Three capsid-binding antiviral agents now are in clinical trials: pleconaril, vapendavir, and pocapavir. In addition, translational studies have demonstrated that the SSRI fluoxetine inhibits enterovirus replication, but there have been no clinical trials as yet.
Although development of antivirals effective against enterovirus is an active area of research, Dr. Harvala thinks drug resistance will be an issue, underscoring the importance of vaccine development.
She reported having no financial conflicts of interest regarding her presentation.
MADRID – Is there a need for an enterovirus-A71 vaccine?
This is a new question for North American and European physicians, but not so new in Asia.
“China says yes, with more than 15 million cases of hand, foot, and mouth disease resulting in 3,500 deaths since surveillance started in 2009,” Heli Harvala, MD, said at the annual meeting of the European Society for Paediatric Infectious Diseases.
Seroconversion rates 28 days after the second dose of these vaccines, both directed specifically against viral subgenotype C-4, are 92%-100%. Vaccine efficacy is 91%-97%, according to Dr. Harvala, a consultant medical virologist at University College London.
It remains a mystery why major outbreaks of severe EV-A71 disease have mostly occurred in Asia, with the notable exception of a Spanish outbreak of EV-A71 encephalitis in 2016. The possibility of much wider spread is concerning.
The Chinese monovalent EV-A71 vaccines, however, are seen as a stopgap. For one thing, recent evidence suggests that it’s probably not the specific EV-A71 C-4 viral subgenotype that accounts for all severe disease.
“I think we have to aim for a multivalent vaccine,” Dr. Harvala said.
Now in clinical trials, investigational bivalent vaccines are directed against other EV-A71 subgenotypes in addition to C-4, and also against another enterovirus, coxsackievirus serotype A16, the most common cause of classic hand, foot, and mouth disease in the United States. But that’s probably not enough, according to Dr. Harvala. She noted that coxsackievirus A6, which was first identified more than 50 years ago, abruptly became the main cause of mild hand, foot, and mouth disease in China in 2013 and again in 2015. Moreover, its role in severe cases is growing, and there have been important outbreaks in the United States in recent years. These severe cases come in three main presentations, resembling either erythema multiforme, chicken pox, or eczema herpeticum.
Dr. Harvala added that a next-generation vaccine probably also should offer protection against enterovirus-D68. In 2014, there were 1,153 laboratory-confirmed EV-D68 infections and 14 deaths in the United States and Canada. This infection poses a diagnostic challenge: while the virus is readily detectable on throat swabs, it’s only rarely present in stool or cerebrospinal fluid samples.
“It’s important to keep in mind that this infection is still underdiagnosed. We are not really looking for it,” she said.
No specific treatment for enterovirus infections is available. Three capsid-binding antiviral agents now are in clinical trials: pleconaril, vapendavir, and pocapavir. In addition, translational studies have demonstrated that the SSRI fluoxetine inhibits enterovirus replication, but there have been no clinical trials as yet.
Although development of antivirals effective against enterovirus is an active area of research, Dr. Harvala thinks drug resistance will be an issue, underscoring the importance of vaccine development.
She reported having no financial conflicts of interest regarding her presentation.
EXPERT ANALYSIS FROM ESPID 2017
DoD Delays Transgender Ban Pending New Study
Following the directive of the “Military Service by Transgender Individuals” Presidential Memorandum to reinstitute a ban on service for transgender service members, the Secretary of Defense has called for a new study of the impact of transgender service members on “military readiness, lethality, and unit cohesion, with due regard for budgetary constraints and consistent with applicable law.” Secretary of Defense Jim Mattis announced that he will “establish a panel of experts serving within the Departments of Defense and Homeland Security to provide advice and recommendations on the implementation of the president’s direction.”
The study follows on the heels of a July 2016 study issued by the RAND Corporation, which found that there are between 1,300 to 6,600 transgender active duty service members. According to the study, the “costs of gender transition-related health care are relatively low” and they had a “minimal” impact on force readiness.
The new study is due to President Trump by February 21, 2018 and is required to include a plan for implementing the ban. The potential ban on transgender service members is still set to go into effect March 23, 2018. However, there is some disagreement over whether the Presidential Memorandum leave the DoD with latitude to protect currently serving transgender service members or not.
The expected health care costs associated with transgender service members remains a significant factor in the policy decision. The RAND study estimated that health care costs would increase by between $2.4 million and $8.4 million annually with transgender service members out of an estimated $6.2 billion spent on active component health care spending, which would represent a 0.04% to 0.13% of the budget.
Following the directive of the “Military Service by Transgender Individuals” Presidential Memorandum to reinstitute a ban on service for transgender service members, the Secretary of Defense has called for a new study of the impact of transgender service members on “military readiness, lethality, and unit cohesion, with due regard for budgetary constraints and consistent with applicable law.” Secretary of Defense Jim Mattis announced that he will “establish a panel of experts serving within the Departments of Defense and Homeland Security to provide advice and recommendations on the implementation of the president’s direction.”
The study follows on the heels of a July 2016 study issued by the RAND Corporation, which found that there are between 1,300 to 6,600 transgender active duty service members. According to the study, the “costs of gender transition-related health care are relatively low” and they had a “minimal” impact on force readiness.
The new study is due to President Trump by February 21, 2018 and is required to include a plan for implementing the ban. The potential ban on transgender service members is still set to go into effect March 23, 2018. However, there is some disagreement over whether the Presidential Memorandum leave the DoD with latitude to protect currently serving transgender service members or not.
The expected health care costs associated with transgender service members remains a significant factor in the policy decision. The RAND study estimated that health care costs would increase by between $2.4 million and $8.4 million annually with transgender service members out of an estimated $6.2 billion spent on active component health care spending, which would represent a 0.04% to 0.13% of the budget.
Following the directive of the “Military Service by Transgender Individuals” Presidential Memorandum to reinstitute a ban on service for transgender service members, the Secretary of Defense has called for a new study of the impact of transgender service members on “military readiness, lethality, and unit cohesion, with due regard for budgetary constraints and consistent with applicable law.” Secretary of Defense Jim Mattis announced that he will “establish a panel of experts serving within the Departments of Defense and Homeland Security to provide advice and recommendations on the implementation of the president’s direction.”
The study follows on the heels of a July 2016 study issued by the RAND Corporation, which found that there are between 1,300 to 6,600 transgender active duty service members. According to the study, the “costs of gender transition-related health care are relatively low” and they had a “minimal” impact on force readiness.
The new study is due to President Trump by February 21, 2018 and is required to include a plan for implementing the ban. The potential ban on transgender service members is still set to go into effect March 23, 2018. However, there is some disagreement over whether the Presidential Memorandum leave the DoD with latitude to protect currently serving transgender service members or not.
The expected health care costs associated with transgender service members remains a significant factor in the policy decision. The RAND study estimated that health care costs would increase by between $2.4 million and $8.4 million annually with transgender service members out of an estimated $6.2 billion spent on active component health care spending, which would represent a 0.04% to 0.13% of the budget.
Waging war against medical misinformation
When Jennifer Gunter, MD, learned that Marie Claire magazine published an article suggesting that the recent solar eclipse affected menstrual cycles, she turned to social media to dismantle that assertion.
“If the new moon were associated with menstruation, then all women all over the world would be menstruating at the same time,” Dr. Gunter wrote in an Aug. 21, 2017 entry on her personal blog, which includes the slogan “Wielding the Lasso of Truth.” “Have none of these people ever considered that? Maybe that happens in the “Mists of Avalon,” but it doesn’t happen on Earth.”
Disputing such claims “keeps me pretty busy,” said Dr. Gunter, who’s become a hero to many in the ob.gyn. community, with more than 55,000 followers on Twitter and about 5,000 subscribers to her blog, which she launched in 2010.
“When I go to medical conferences, I get lots of physicians high-fiving me and thanking me, and that’s really nice,” she said. “They’re just like me. They’ve sat with patients and tried to explain how bioidentical hormones aren’t ground up yams and why salivary hormone testing is not recommended. They tell me that they’ve taken my blog posts and turned them into handouts. That’s the kind of thing that keeps me going: knowing that I’ve written something that’s going to help somebody else.”
Dr. Gunter, who practices gynecology in San Francisco, said that she established a social media presence because she’s compelled to wage war against medical misinformation, especially content marketed to women. “I can’t stand seeing websites that tell people they can lose weight doing this new fad or by taking certain supplements,” the Winnipeg, Canada, native said. “That’s the same snake oil that used to go town to town in the 1800s. It’s not any different; it’s just on a larger scale. Misinformation makes me sad. If people are making informed choices that’s one thing, but if they are hooked in by fancy websites with attractive celebrities and doctors branding supplements with their names, that bothers me. The Internet is only as good as the information you put into it. When you search for something, it’s really a shame that an accurate website isn’t coming up first, but it’s all driven by page clicks. What’s surprised me the most has been that people were ready for a voice like mine to stand up. I think the same feelings I’ve had have been brewing for a lot of people.”
Dr. Gunter devotes about 45 minutes every weekday to social media. Inspiration for her blog posts and her tweets on @DrJenGunter come from a variety of sources, often from followers who send her links to articles about wild medical claims. “I might post on my lunch hour but never during the work day,” she said. “A lot of people like to unwind at the end of the day by watching TV. I’m divorced and my kids are with their dad half the time so on the evenings when I’m by myself, if I’ve read something interesting, I’ll tweet about it.”
She shared the following tips for ob.gyns. looking to establish a presence on social media:
- Be HIPAA compliant. “I don’t think I’ve ever used my work day to inform what I write about because there’s so much going on in the news,” she said. “You have to be HIPAA compliant because your patients may be following you online. In many ways, I hope that people I’m going to care for do read some of the things that I put out there because I’m trying to give good health information.”
- Be authentic. “When people meet me and have probably read some of my tweets and have heard me talk, they say they can match the voice with the person,” Dr. Gunter said. “People can tell when you’re not being authentic. That doesn’t work for me. I don’t have time to invent another persona!”
- Share articles you think are worthwhile. “If I have a friend who is in the tech industry, and if he posts an article on that topic, I figure he curated that, so maybe I’ll read it,” she said. “Likewise, if you’re a doctor and you have people following you on Facebook who are not physicians, they might say, ‘My friend who I went to high school with who’s a doctor thinks this New York Times article is worth reading. Maybe I should read it.’ People can lurk and share things, and that helps. I follow lots of doctors on Twitter that I don’t regularly engage with, but they post articles, and I’ll read them.”
- Make it clear who you’re speaking for. Are you speaking for your employer or for yourself? Are you giving medical advice, or is the content your opinion only? Include an appropriate disclaimer in your profile. Dr. Gunter’s Twitter profile reads: “Appropriately Confident OB/GYN, Canadian Spice, Sexpert, Lasso of Truth, Pegasister, Not medical advice, I speak for no one but me.”
- If you post regularly, expect criticism at some point. “If social media is not for you, you shouldn’t do it,” Dr. Gunter said. “But if you have a small Facebook account, why not share some good quality articles that you found interesting? You’d be surprised. What you might think is a throwaway message might be of real help to someone who doesn’t practice medicine. There’s a real hunger for good quality curated information.”
When Jennifer Gunter, MD, learned that Marie Claire magazine published an article suggesting that the recent solar eclipse affected menstrual cycles, she turned to social media to dismantle that assertion.
“If the new moon were associated with menstruation, then all women all over the world would be menstruating at the same time,” Dr. Gunter wrote in an Aug. 21, 2017 entry on her personal blog, which includes the slogan “Wielding the Lasso of Truth.” “Have none of these people ever considered that? Maybe that happens in the “Mists of Avalon,” but it doesn’t happen on Earth.”
Disputing such claims “keeps me pretty busy,” said Dr. Gunter, who’s become a hero to many in the ob.gyn. community, with more than 55,000 followers on Twitter and about 5,000 subscribers to her blog, which she launched in 2010.
“When I go to medical conferences, I get lots of physicians high-fiving me and thanking me, and that’s really nice,” she said. “They’re just like me. They’ve sat with patients and tried to explain how bioidentical hormones aren’t ground up yams and why salivary hormone testing is not recommended. They tell me that they’ve taken my blog posts and turned them into handouts. That’s the kind of thing that keeps me going: knowing that I’ve written something that’s going to help somebody else.”
Dr. Gunter, who practices gynecology in San Francisco, said that she established a social media presence because she’s compelled to wage war against medical misinformation, especially content marketed to women. “I can’t stand seeing websites that tell people they can lose weight doing this new fad or by taking certain supplements,” the Winnipeg, Canada, native said. “That’s the same snake oil that used to go town to town in the 1800s. It’s not any different; it’s just on a larger scale. Misinformation makes me sad. If people are making informed choices that’s one thing, but if they are hooked in by fancy websites with attractive celebrities and doctors branding supplements with their names, that bothers me. The Internet is only as good as the information you put into it. When you search for something, it’s really a shame that an accurate website isn’t coming up first, but it’s all driven by page clicks. What’s surprised me the most has been that people were ready for a voice like mine to stand up. I think the same feelings I’ve had have been brewing for a lot of people.”
Dr. Gunter devotes about 45 minutes every weekday to social media. Inspiration for her blog posts and her tweets on @DrJenGunter come from a variety of sources, often from followers who send her links to articles about wild medical claims. “I might post on my lunch hour but never during the work day,” she said. “A lot of people like to unwind at the end of the day by watching TV. I’m divorced and my kids are with their dad half the time so on the evenings when I’m by myself, if I’ve read something interesting, I’ll tweet about it.”
She shared the following tips for ob.gyns. looking to establish a presence on social media:
- Be HIPAA compliant. “I don’t think I’ve ever used my work day to inform what I write about because there’s so much going on in the news,” she said. “You have to be HIPAA compliant because your patients may be following you online. In many ways, I hope that people I’m going to care for do read some of the things that I put out there because I’m trying to give good health information.”
- Be authentic. “When people meet me and have probably read some of my tweets and have heard me talk, they say they can match the voice with the person,” Dr. Gunter said. “People can tell when you’re not being authentic. That doesn’t work for me. I don’t have time to invent another persona!”
- Share articles you think are worthwhile. “If I have a friend who is in the tech industry, and if he posts an article on that topic, I figure he curated that, so maybe I’ll read it,” she said. “Likewise, if you’re a doctor and you have people following you on Facebook who are not physicians, they might say, ‘My friend who I went to high school with who’s a doctor thinks this New York Times article is worth reading. Maybe I should read it.’ People can lurk and share things, and that helps. I follow lots of doctors on Twitter that I don’t regularly engage with, but they post articles, and I’ll read them.”
- Make it clear who you’re speaking for. Are you speaking for your employer or for yourself? Are you giving medical advice, or is the content your opinion only? Include an appropriate disclaimer in your profile. Dr. Gunter’s Twitter profile reads: “Appropriately Confident OB/GYN, Canadian Spice, Sexpert, Lasso of Truth, Pegasister, Not medical advice, I speak for no one but me.”
- If you post regularly, expect criticism at some point. “If social media is not for you, you shouldn’t do it,” Dr. Gunter said. “But if you have a small Facebook account, why not share some good quality articles that you found interesting? You’d be surprised. What you might think is a throwaway message might be of real help to someone who doesn’t practice medicine. There’s a real hunger for good quality curated information.”
When Jennifer Gunter, MD, learned that Marie Claire magazine published an article suggesting that the recent solar eclipse affected menstrual cycles, she turned to social media to dismantle that assertion.
“If the new moon were associated with menstruation, then all women all over the world would be menstruating at the same time,” Dr. Gunter wrote in an Aug. 21, 2017 entry on her personal blog, which includes the slogan “Wielding the Lasso of Truth.” “Have none of these people ever considered that? Maybe that happens in the “Mists of Avalon,” but it doesn’t happen on Earth.”
Disputing such claims “keeps me pretty busy,” said Dr. Gunter, who’s become a hero to many in the ob.gyn. community, with more than 55,000 followers on Twitter and about 5,000 subscribers to her blog, which she launched in 2010.
“When I go to medical conferences, I get lots of physicians high-fiving me and thanking me, and that’s really nice,” she said. “They’re just like me. They’ve sat with patients and tried to explain how bioidentical hormones aren’t ground up yams and why salivary hormone testing is not recommended. They tell me that they’ve taken my blog posts and turned them into handouts. That’s the kind of thing that keeps me going: knowing that I’ve written something that’s going to help somebody else.”
Dr. Gunter, who practices gynecology in San Francisco, said that she established a social media presence because she’s compelled to wage war against medical misinformation, especially content marketed to women. “I can’t stand seeing websites that tell people they can lose weight doing this new fad or by taking certain supplements,” the Winnipeg, Canada, native said. “That’s the same snake oil that used to go town to town in the 1800s. It’s not any different; it’s just on a larger scale. Misinformation makes me sad. If people are making informed choices that’s one thing, but if they are hooked in by fancy websites with attractive celebrities and doctors branding supplements with their names, that bothers me. The Internet is only as good as the information you put into it. When you search for something, it’s really a shame that an accurate website isn’t coming up first, but it’s all driven by page clicks. What’s surprised me the most has been that people were ready for a voice like mine to stand up. I think the same feelings I’ve had have been brewing for a lot of people.”
Dr. Gunter devotes about 45 minutes every weekday to social media. Inspiration for her blog posts and her tweets on @DrJenGunter come from a variety of sources, often from followers who send her links to articles about wild medical claims. “I might post on my lunch hour but never during the work day,” she said. “A lot of people like to unwind at the end of the day by watching TV. I’m divorced and my kids are with their dad half the time so on the evenings when I’m by myself, if I’ve read something interesting, I’ll tweet about it.”
She shared the following tips for ob.gyns. looking to establish a presence on social media:
- Be HIPAA compliant. “I don’t think I’ve ever used my work day to inform what I write about because there’s so much going on in the news,” she said. “You have to be HIPAA compliant because your patients may be following you online. In many ways, I hope that people I’m going to care for do read some of the things that I put out there because I’m trying to give good health information.”
- Be authentic. “When people meet me and have probably read some of my tweets and have heard me talk, they say they can match the voice with the person,” Dr. Gunter said. “People can tell when you’re not being authentic. That doesn’t work for me. I don’t have time to invent another persona!”
- Share articles you think are worthwhile. “If I have a friend who is in the tech industry, and if he posts an article on that topic, I figure he curated that, so maybe I’ll read it,” she said. “Likewise, if you’re a doctor and you have people following you on Facebook who are not physicians, they might say, ‘My friend who I went to high school with who’s a doctor thinks this New York Times article is worth reading. Maybe I should read it.’ People can lurk and share things, and that helps. I follow lots of doctors on Twitter that I don’t regularly engage with, but they post articles, and I’ll read them.”
- Make it clear who you’re speaking for. Are you speaking for your employer or for yourself? Are you giving medical advice, or is the content your opinion only? Include an appropriate disclaimer in your profile. Dr. Gunter’s Twitter profile reads: “Appropriately Confident OB/GYN, Canadian Spice, Sexpert, Lasso of Truth, Pegasister, Not medical advice, I speak for no one but me.”
- If you post regularly, expect criticism at some point. “If social media is not for you, you shouldn’t do it,” Dr. Gunter said. “But if you have a small Facebook account, why not share some good quality articles that you found interesting? You’d be surprised. What you might think is a throwaway message might be of real help to someone who doesn’t practice medicine. There’s a real hunger for good quality curated information.”
The summer job
You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.
However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).
But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.
It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.
While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.
I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.
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.”
You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.
However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).
But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.
It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.
While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.
I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.
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.”
You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.
However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).
But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.
It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.
While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.
I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.
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.”
Clinical trial: Sinai Robotic Surgery Trial in HPVOPC
The Sinai Robotic Surgery Trial in HPV Positive Oropharyngeal Squamous Cell Carcinoma is an interventional trial currently recruiting patients with early to intermediate stage HPVOPC.
People with HPVOPC are generally curable, are young, and will live for extended periods of time, and are also at high risk for long-term toxicity and morbidity from chemotherapy and radiation. The study will explore the necessity of additional intervention in HPVOPC after surgery, and it is estimated that more than half of patients will not require additional therapy.
Patients are eligible for the study if they have stage 1, 2, 3, or early- to mid-stage 4a resectable primary squamous cell carcinoma of the oropharynx that is HPV positive. Patients must be at least 18; cannot be pregnant; cannot have active alcohol addiction or tobacco usage; must have adequate bone marrow, hepatic, and renal functions; have an ECOG performance status of 0 or 1; have a limiting serious illness; and have had no previous surgery, radiation therapy, or chemotherapy for squamous cell carcinoma other than biopsy or tonsillectomy.
The primary outcome measures of the study are disease-free survival and local regional control after 3 and 5 years. Second study outcome measures include overall survival, toxicity rates, and quality of life outcomes after 3 and 5 years, and local regional control after 5 years.
Recruitment for the study ends in March 2019. About 200 people are expected to be included in the final analysis.
Find more information at the study page on Clinicaltrials.gov.
The Sinai Robotic Surgery Trial in HPV Positive Oropharyngeal Squamous Cell Carcinoma is an interventional trial currently recruiting patients with early to intermediate stage HPVOPC.
People with HPVOPC are generally curable, are young, and will live for extended periods of time, and are also at high risk for long-term toxicity and morbidity from chemotherapy and radiation. The study will explore the necessity of additional intervention in HPVOPC after surgery, and it is estimated that more than half of patients will not require additional therapy.
Patients are eligible for the study if they have stage 1, 2, 3, or early- to mid-stage 4a resectable primary squamous cell carcinoma of the oropharynx that is HPV positive. Patients must be at least 18; cannot be pregnant; cannot have active alcohol addiction or tobacco usage; must have adequate bone marrow, hepatic, and renal functions; have an ECOG performance status of 0 or 1; have a limiting serious illness; and have had no previous surgery, radiation therapy, or chemotherapy for squamous cell carcinoma other than biopsy or tonsillectomy.
The primary outcome measures of the study are disease-free survival and local regional control after 3 and 5 years. Second study outcome measures include overall survival, toxicity rates, and quality of life outcomes after 3 and 5 years, and local regional control after 5 years.
Recruitment for the study ends in March 2019. About 200 people are expected to be included in the final analysis.
Find more information at the study page on Clinicaltrials.gov.
The Sinai Robotic Surgery Trial in HPV Positive Oropharyngeal Squamous Cell Carcinoma is an interventional trial currently recruiting patients with early to intermediate stage HPVOPC.
People with HPVOPC are generally curable, are young, and will live for extended periods of time, and are also at high risk for long-term toxicity and morbidity from chemotherapy and radiation. The study will explore the necessity of additional intervention in HPVOPC after surgery, and it is estimated that more than half of patients will not require additional therapy.
Patients are eligible for the study if they have stage 1, 2, 3, or early- to mid-stage 4a resectable primary squamous cell carcinoma of the oropharynx that is HPV positive. Patients must be at least 18; cannot be pregnant; cannot have active alcohol addiction or tobacco usage; must have adequate bone marrow, hepatic, and renal functions; have an ECOG performance status of 0 or 1; have a limiting serious illness; and have had no previous surgery, radiation therapy, or chemotherapy for squamous cell carcinoma other than biopsy or tonsillectomy.
The primary outcome measures of the study are disease-free survival and local regional control after 3 and 5 years. Second study outcome measures include overall survival, toxicity rates, and quality of life outcomes after 3 and 5 years, and local regional control after 5 years.
Recruitment for the study ends in March 2019. About 200 people are expected to be included in the final analysis.
Find more information at the study page on Clinicaltrials.gov.
A Fib ablation surpasses drugs for improving quality of life
BARCELONA – Catheter ablation of symptomatic atrial fibrillation produced significantly better quality of life after 12 months than did continued treatment with antiarrhythmic drugs in a randomized, multicenter trial with 155 patients who had a history of failed drug treatment.
The trial was notable as the first prospective comparison of atrial fibrillation (AF) management by ablation with drug treatment to use quality of life as the primary efficacy endpoint. Such a quality of life–oriented assessment has been lacking “even though the main indication for ablation is symptom relief,” Carina Blomström-Lundqvist, MD, said at the annual congress of the European Society of Cardiology.
Clinicians have traditionally measured residual or recurrent AF after treatment with a periodic ECG to see whether patients experience AF episodes that last at least 30 seconds, but this is “hardly a measure of successful treatment,” said Dr. Blomström-Lundqvist, an electrophysiologist at the University Hospital in Uppsala, Sweden.
She and her associates placed an implanted cardiac monitor into each patient for continuous measurement of residual AF episodes. Twelve months after entry into the study, patients who underwent ablation had their AF burden decreased by an average of 20 percentage points compared with baseline, while the AF burden dropped by an average of 12 percentage points among patients maintained on antiarrhythmic drugs, a between-group difference that was not statistically significant.
Based on that finding, Dr. Blomström-Lundqvist inferred that the significantly better improvement in quality of life seen with ablation compared with drug treatment occurred because the ablated patients all came off antiarrhythmic drug treatment. The study protocol required patients randomized to the ablation regimen to be completely off antiarrhythmic drugs by 6 months after their ablation procedure.
Continued treatment with an antiarrhythmic drug in the drug-arm patients compared with no drug treatment in the ablated patients “is absolutely the explanation” for the observed difference in quality of life, she said. Patients randomized to the antiarrhythmic drug arm of the study received treatment with one of six eligible drugs: amiodarone, disopyramide, dronedarone, flecainide, propafenone, or sotalol. Patients could also be on a beta-blocker.
The Catheter Ablation Compared With Pharmacological Therapy for Atrial Fibrillation (CAPTAF) trial enrolled symptomatic patients with paroxysmal or persistent AF at four Swedish centers and at one center in Finland. All enrolled patients had to have a history of being refractory to or intolerant of a beta-blocker or an antiarrhythmic drug. Patients with paroxysmal AF had to have experienced an AF episode within the prior 2 months, while those with persistent AF had to have had at least two AF episodes within the prior year. The average age of the enrolled patients was 56 years. Nearly three-quarters had paroxysmal AF. Their average AF burden was about a quarter of the time, on average they had been diagnosed with AF for about 5 years, and 70%-80% of the patients had severe or disabling symptoms. At entry, about 90% of patients were on beta-blocker treatment and a bit more than a third were taking an antiarrhythmic drug.
The researchers measured quality of life using the 36-item Short Form Survey Instrument (SF-36). At baseline, the average SF-36 score (measured on a 0-100 scale) was 63 in the 79 patients randomized to ablation and 62 in 76 patients randomized for drug therapy. Patients randomized to an ablation procedure underwent pulmonary vein isolation by whatever technique their attending cardiologists preferred.
The average SF-36 score 12 months after study entry was 73 for the ablation patients, an average gain from baseline of 11 points, and 65 in the drug-treated patients, an average gain of 3 points. The 8-point difference in SF-36 gain between the two groups was statistically significant.
Contributing to the overall superiority of ablation for improving quality of life were statistically significant advantages for ablation over drug treatment in the individual SF-36 domains of general health, physical function, mental health, role-emotional, role-physical, and vitality. The two treatment arms of the study showed no significant differences in the two remaining SF-36 domains of bodily pain and social functioning.
Nine of the 79 patients (11%) who underwent ablation had a procedure-related serious adverse event, including four patients with an infection or septicemia, two patients with tamponade or pericardial effusion, one patient with a transient ischemic attack, and two with a different vascular complication. Serious cardiovascular adverse events during the 12 month follow-up occurred in 14 of the ablated patients (18%) and in 18 of the drug-treated patients (24%), a between-group difference that did not undergo statistical analysis. Dr. Blomström-Lundqvist called the rates “comparable,” but cautioned that the study was not powered to compare serious adverse event rates in the two treatment arms.
Héctor Bueno, MD, a cardiologist at the Spanish National Center for Cardiovascular Research in Madrid and a cochair of the session that included the CAPTAF report, voiced concern about the procedure-related serious adverse events among patients who underwent ablation.
“An 11% serious complication rate is not negligible,” he said. “Some of them were really serious complications.”
[email protected]
On Twitter @mitchelzoler
The CAPTAF trial is the first time that atrial fibrillation ablation has been compared with drug treatment in a prospective study that used quality of life as its primary endpoint. All of the prior prospective comparisons used atrial fibrillation recurrence as their endpoint. Prior reports that looked at the impact of treatment on quality of life were retrospective analyses.
The CAPTAF trial introduces a new way to prospectively assess the efficacy of atrial fibrillation (AF) treatment, and it is a game changer for how we follow patients. All future AF trials should now include quality-of-life assessment. To fully assess the success of AF treatment a clinician needs to do more than get an ECG at follow-up clinic visits because these only give a “snapshot” of a patient’s AF burden.
The CAPTAF results also confirm that pulmonary vein isolation is a reproducible ablation technique for both paroxysmal and persistent AF. The study also shows that implanted cardiac monitors are a very useful and practical tool for more comprehensively measuring rhythm outcomes following AF treatment.
Nassir F. Marrouche, MD, is an electrophysiologist and professor of medicine at the University of Utah in Salt Lake City. He has been a consultant to Abbott, Biosense Webster, Biotronik, Boston Scientific, Cardiac Design, Marrek, Medtronic, Preventice, Vytronus, and Wavelet Health, and he has received research funding from Abbott, Biosense Webster, Biotronik, Boston Scientific, GE Healthcare, Siemens, and Vytronus. He made these comments as designated discussant for the report.
The CAPTAF trial is the first time that atrial fibrillation ablation has been compared with drug treatment in a prospective study that used quality of life as its primary endpoint. All of the prior prospective comparisons used atrial fibrillation recurrence as their endpoint. Prior reports that looked at the impact of treatment on quality of life were retrospective analyses.
The CAPTAF trial introduces a new way to prospectively assess the efficacy of atrial fibrillation (AF) treatment, and it is a game changer for how we follow patients. All future AF trials should now include quality-of-life assessment. To fully assess the success of AF treatment a clinician needs to do more than get an ECG at follow-up clinic visits because these only give a “snapshot” of a patient’s AF burden.
The CAPTAF results also confirm that pulmonary vein isolation is a reproducible ablation technique for both paroxysmal and persistent AF. The study also shows that implanted cardiac monitors are a very useful and practical tool for more comprehensively measuring rhythm outcomes following AF treatment.
Nassir F. Marrouche, MD, is an electrophysiologist and professor of medicine at the University of Utah in Salt Lake City. He has been a consultant to Abbott, Biosense Webster, Biotronik, Boston Scientific, Cardiac Design, Marrek, Medtronic, Preventice, Vytronus, and Wavelet Health, and he has received research funding from Abbott, Biosense Webster, Biotronik, Boston Scientific, GE Healthcare, Siemens, and Vytronus. He made these comments as designated discussant for the report.
The CAPTAF trial is the first time that atrial fibrillation ablation has been compared with drug treatment in a prospective study that used quality of life as its primary endpoint. All of the prior prospective comparisons used atrial fibrillation recurrence as their endpoint. Prior reports that looked at the impact of treatment on quality of life were retrospective analyses.
The CAPTAF trial introduces a new way to prospectively assess the efficacy of atrial fibrillation (AF) treatment, and it is a game changer for how we follow patients. All future AF trials should now include quality-of-life assessment. To fully assess the success of AF treatment a clinician needs to do more than get an ECG at follow-up clinic visits because these only give a “snapshot” of a patient’s AF burden.
The CAPTAF results also confirm that pulmonary vein isolation is a reproducible ablation technique for both paroxysmal and persistent AF. The study also shows that implanted cardiac monitors are a very useful and practical tool for more comprehensively measuring rhythm outcomes following AF treatment.
Nassir F. Marrouche, MD, is an electrophysiologist and professor of medicine at the University of Utah in Salt Lake City. He has been a consultant to Abbott, Biosense Webster, Biotronik, Boston Scientific, Cardiac Design, Marrek, Medtronic, Preventice, Vytronus, and Wavelet Health, and he has received research funding from Abbott, Biosense Webster, Biotronik, Boston Scientific, GE Healthcare, Siemens, and Vytronus. He made these comments as designated discussant for the report.
BARCELONA – Catheter ablation of symptomatic atrial fibrillation produced significantly better quality of life after 12 months than did continued treatment with antiarrhythmic drugs in a randomized, multicenter trial with 155 patients who had a history of failed drug treatment.
The trial was notable as the first prospective comparison of atrial fibrillation (AF) management by ablation with drug treatment to use quality of life as the primary efficacy endpoint. Such a quality of life–oriented assessment has been lacking “even though the main indication for ablation is symptom relief,” Carina Blomström-Lundqvist, MD, said at the annual congress of the European Society of Cardiology.
Clinicians have traditionally measured residual or recurrent AF after treatment with a periodic ECG to see whether patients experience AF episodes that last at least 30 seconds, but this is “hardly a measure of successful treatment,” said Dr. Blomström-Lundqvist, an electrophysiologist at the University Hospital in Uppsala, Sweden.
She and her associates placed an implanted cardiac monitor into each patient for continuous measurement of residual AF episodes. Twelve months after entry into the study, patients who underwent ablation had their AF burden decreased by an average of 20 percentage points compared with baseline, while the AF burden dropped by an average of 12 percentage points among patients maintained on antiarrhythmic drugs, a between-group difference that was not statistically significant.
Based on that finding, Dr. Blomström-Lundqvist inferred that the significantly better improvement in quality of life seen with ablation compared with drug treatment occurred because the ablated patients all came off antiarrhythmic drug treatment. The study protocol required patients randomized to the ablation regimen to be completely off antiarrhythmic drugs by 6 months after their ablation procedure.
Continued treatment with an antiarrhythmic drug in the drug-arm patients compared with no drug treatment in the ablated patients “is absolutely the explanation” for the observed difference in quality of life, she said. Patients randomized to the antiarrhythmic drug arm of the study received treatment with one of six eligible drugs: amiodarone, disopyramide, dronedarone, flecainide, propafenone, or sotalol. Patients could also be on a beta-blocker.
The Catheter Ablation Compared With Pharmacological Therapy for Atrial Fibrillation (CAPTAF) trial enrolled symptomatic patients with paroxysmal or persistent AF at four Swedish centers and at one center in Finland. All enrolled patients had to have a history of being refractory to or intolerant of a beta-blocker or an antiarrhythmic drug. Patients with paroxysmal AF had to have experienced an AF episode within the prior 2 months, while those with persistent AF had to have had at least two AF episodes within the prior year. The average age of the enrolled patients was 56 years. Nearly three-quarters had paroxysmal AF. Their average AF burden was about a quarter of the time, on average they had been diagnosed with AF for about 5 years, and 70%-80% of the patients had severe or disabling symptoms. At entry, about 90% of patients were on beta-blocker treatment and a bit more than a third were taking an antiarrhythmic drug.
The researchers measured quality of life using the 36-item Short Form Survey Instrument (SF-36). At baseline, the average SF-36 score (measured on a 0-100 scale) was 63 in the 79 patients randomized to ablation and 62 in 76 patients randomized for drug therapy. Patients randomized to an ablation procedure underwent pulmonary vein isolation by whatever technique their attending cardiologists preferred.
The average SF-36 score 12 months after study entry was 73 for the ablation patients, an average gain from baseline of 11 points, and 65 in the drug-treated patients, an average gain of 3 points. The 8-point difference in SF-36 gain between the two groups was statistically significant.
Contributing to the overall superiority of ablation for improving quality of life were statistically significant advantages for ablation over drug treatment in the individual SF-36 domains of general health, physical function, mental health, role-emotional, role-physical, and vitality. The two treatment arms of the study showed no significant differences in the two remaining SF-36 domains of bodily pain and social functioning.
Nine of the 79 patients (11%) who underwent ablation had a procedure-related serious adverse event, including four patients with an infection or septicemia, two patients with tamponade or pericardial effusion, one patient with a transient ischemic attack, and two with a different vascular complication. Serious cardiovascular adverse events during the 12 month follow-up occurred in 14 of the ablated patients (18%) and in 18 of the drug-treated patients (24%), a between-group difference that did not undergo statistical analysis. Dr. Blomström-Lundqvist called the rates “comparable,” but cautioned that the study was not powered to compare serious adverse event rates in the two treatment arms.
Héctor Bueno, MD, a cardiologist at the Spanish National Center for Cardiovascular Research in Madrid and a cochair of the session that included the CAPTAF report, voiced concern about the procedure-related serious adverse events among patients who underwent ablation.
“An 11% serious complication rate is not negligible,” he said. “Some of them were really serious complications.”
[email protected]
On Twitter @mitchelzoler
BARCELONA – Catheter ablation of symptomatic atrial fibrillation produced significantly better quality of life after 12 months than did continued treatment with antiarrhythmic drugs in a randomized, multicenter trial with 155 patients who had a history of failed drug treatment.
The trial was notable as the first prospective comparison of atrial fibrillation (AF) management by ablation with drug treatment to use quality of life as the primary efficacy endpoint. Such a quality of life–oriented assessment has been lacking “even though the main indication for ablation is symptom relief,” Carina Blomström-Lundqvist, MD, said at the annual congress of the European Society of Cardiology.
Clinicians have traditionally measured residual or recurrent AF after treatment with a periodic ECG to see whether patients experience AF episodes that last at least 30 seconds, but this is “hardly a measure of successful treatment,” said Dr. Blomström-Lundqvist, an electrophysiologist at the University Hospital in Uppsala, Sweden.
She and her associates placed an implanted cardiac monitor into each patient for continuous measurement of residual AF episodes. Twelve months after entry into the study, patients who underwent ablation had their AF burden decreased by an average of 20 percentage points compared with baseline, while the AF burden dropped by an average of 12 percentage points among patients maintained on antiarrhythmic drugs, a between-group difference that was not statistically significant.
Based on that finding, Dr. Blomström-Lundqvist inferred that the significantly better improvement in quality of life seen with ablation compared with drug treatment occurred because the ablated patients all came off antiarrhythmic drug treatment. The study protocol required patients randomized to the ablation regimen to be completely off antiarrhythmic drugs by 6 months after their ablation procedure.
Continued treatment with an antiarrhythmic drug in the drug-arm patients compared with no drug treatment in the ablated patients “is absolutely the explanation” for the observed difference in quality of life, she said. Patients randomized to the antiarrhythmic drug arm of the study received treatment with one of six eligible drugs: amiodarone, disopyramide, dronedarone, flecainide, propafenone, or sotalol. Patients could also be on a beta-blocker.
The Catheter Ablation Compared With Pharmacological Therapy for Atrial Fibrillation (CAPTAF) trial enrolled symptomatic patients with paroxysmal or persistent AF at four Swedish centers and at one center in Finland. All enrolled patients had to have a history of being refractory to or intolerant of a beta-blocker or an antiarrhythmic drug. Patients with paroxysmal AF had to have experienced an AF episode within the prior 2 months, while those with persistent AF had to have had at least two AF episodes within the prior year. The average age of the enrolled patients was 56 years. Nearly three-quarters had paroxysmal AF. Their average AF burden was about a quarter of the time, on average they had been diagnosed with AF for about 5 years, and 70%-80% of the patients had severe or disabling symptoms. At entry, about 90% of patients were on beta-blocker treatment and a bit more than a third were taking an antiarrhythmic drug.
The researchers measured quality of life using the 36-item Short Form Survey Instrument (SF-36). At baseline, the average SF-36 score (measured on a 0-100 scale) was 63 in the 79 patients randomized to ablation and 62 in 76 patients randomized for drug therapy. Patients randomized to an ablation procedure underwent pulmonary vein isolation by whatever technique their attending cardiologists preferred.
The average SF-36 score 12 months after study entry was 73 for the ablation patients, an average gain from baseline of 11 points, and 65 in the drug-treated patients, an average gain of 3 points. The 8-point difference in SF-36 gain between the two groups was statistically significant.
Contributing to the overall superiority of ablation for improving quality of life were statistically significant advantages for ablation over drug treatment in the individual SF-36 domains of general health, physical function, mental health, role-emotional, role-physical, and vitality. The two treatment arms of the study showed no significant differences in the two remaining SF-36 domains of bodily pain and social functioning.
Nine of the 79 patients (11%) who underwent ablation had a procedure-related serious adverse event, including four patients with an infection or septicemia, two patients with tamponade or pericardial effusion, one patient with a transient ischemic attack, and two with a different vascular complication. Serious cardiovascular adverse events during the 12 month follow-up occurred in 14 of the ablated patients (18%) and in 18 of the drug-treated patients (24%), a between-group difference that did not undergo statistical analysis. Dr. Blomström-Lundqvist called the rates “comparable,” but cautioned that the study was not powered to compare serious adverse event rates in the two treatment arms.
Héctor Bueno, MD, a cardiologist at the Spanish National Center for Cardiovascular Research in Madrid and a cochair of the session that included the CAPTAF report, voiced concern about the procedure-related serious adverse events among patients who underwent ablation.
“An 11% serious complication rate is not negligible,” he said. “Some of them were really serious complications.”
[email protected]
On Twitter @mitchelzoler
AT THE ESC CONGRESS 2017
Key clinical point:
Major finding: After 12 months, average SF-36 scores improved by 11 points with ablation and 3 points with drug therapy.
Data source: CAPTAF, a multicenter, randomized trial with 155 patients.
Disclosures: CAPTAF received partial funding from Medtronic. Dr. Blomström-Lundqvist has received research funding from Medtronic and Cardiome, and she has received honoraria for speaking from Medtronic and also from Bayer, Biotronik, Bristol-Myers Squibb, Merck, Pfizer, and Sanofi. Dr. Bueno has been a consultant to Abbott, Bayer, Bristol-Myers Squibb, Ferrer, Novartis, Pfizer, and Servier, and has received research funding from AstraZeneca, Bristol-Myers Squibb, Janssen, and Novartis.
Pronator Teres Myotendinous Tear
I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.
I would like to note that this pathology was previously reported by our group in 2015.1 We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.
It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.
Brooks W. Ficke, MD
Brent A. Ponce, MD
Birmingham, AL
Authors' Response
We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.
Charles M. Jobin, MD
Usama Qayyum, MBBS
Diego Villacis, MD
New York, NY
1. Ficke BW, Larrison MC, Ponce BA. Isolated rupture of the pronator teres in an amateur golfer: a case report. Int J Orthop. 2015;2(6):481-483.
I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.
I would like to note that this pathology was previously reported by our group in 2015.1 We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.
It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.
Brooks W. Ficke, MD
Brent A. Ponce, MD
Birmingham, AL
Authors' Response
We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.
Charles M. Jobin, MD
Usama Qayyum, MBBS
Diego Villacis, MD
New York, NY
I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.
I would like to note that this pathology was previously reported by our group in 2015.1 We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.
It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.
Brooks W. Ficke, MD
Brent A. Ponce, MD
Birmingham, AL
Authors' Response
We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.
Charles M. Jobin, MD
Usama Qayyum, MBBS
Diego Villacis, MD
New York, NY
1. Ficke BW, Larrison MC, Ponce BA. Isolated rupture of the pronator teres in an amateur golfer: a case report. Int J Orthop. 2015;2(6):481-483.
1. Ficke BW, Larrison MC, Ponce BA. Isolated rupture of the pronator teres in an amateur golfer: a case report. Int J Orthop. 2015;2(6):481-483.
Why Are General Practitioners Reluctant to Play a Significant Role in Managing Childhood Obesity?
Study Overview
Objective. To explore the views of general practice staff on managing childhood obesity in primary care.
Design. Qualitative study.
Setting and participants. General practices across England (n = 7303) of varying practice list size (low/medium/high) and “deprivation” level (low/medium/high, based on Index of Multiple Deprivation (IMD) score, which measures deprivation based on income, employment, health, education, barriers to services, living environment and crime) were stratified into a 3 x 3 matrix, resulting in recruitment targets of 3 to 5 practices per each of 9 recruitment strata. Practices in each strata were grouped into batches and approached in a random list order to take part in the study. Recruitment continued until the strata target was reached. Interviews were conducted by 2 researchers, either in the interviewee’s workplace or by telephone.
Main outcomes measures. The interview topic guide included 2 questions related to childhood obesity: (1) theirperceptions of the barriers and enablers to general practitioners taking a more active role in childhood obesity; and (2) their views on what was needed to improve integrated local pathways to manage childhood obesity. Follow-up questions were used in response to issues raised by interviewees. All interviews were audiotaped, professionally transcribed verbatim, and checked for accuracy. Copies of transcripts were available to interviewees, although none requested to see them. Key themes were identified through thematic analysis of transcripts using an inductive approach. Initial codes were discussed and combined to form themes which were discussed until agreement was reached that these reflected the data. Results are based upon a synthesis of all the interviews.
Main results. A total of 32 practices were recruited, of which 30 identified 52 staff (56% female) to participate in semi-structured interviews: 29 general practitioners (28% female), 14 practice managers (86% female), 7 nursing staff (100% female), 1 health care assistant (female), and 1 administrative staff (female). Almost all interviewees identified childhood obesity as an increasingly important issue with potential long-term health implications. However, most did not frame it as a medical problem in itself or view its management as a general practice responsibility.
Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt that consultation time was limited and focused on addressing acute illness. Generally, raising the issue was described as sensitive. Interviewees also felt ill equipped to solve the issue because they lacked influence over the environmental, economic, and lifestyle factors underpinning obesity. They described little evidence to support general practice intervention and seemed unaware of other services. Interviewees felt their efforts should be directed towards health problems they identified as medical issues where evidence suggests they can make a difference.
Conclusions. Although general practice staff viewed childhood obesity as an important issue with the poten-tial to impact on health outcomes, they were unconvinced that they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistic identification of overweight children and referral to specialist/obesity services
Commentary
The prevalence of childhood overweight and obesity continues to rise in the United States and worldwide with extensive economic, physical, and psychosocial consequences [1–6]. Lifestyle interventions that target obesity-related behaviors including physical activity, sedentary behavior, and diet, are considered the therapy of choice [7–10]. Indeed, the US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status [11]. Similar recommendations can be seen in other national guidelines regarding the management of childhood obesity [12].
Beyond screening and referral, some have outlined more specific opportunities for health professionals to play a more significant role in confronting child obesity, particularly among general practitioners and primary care providers [13–15]. In addition, several reviews have looked at the expanding role of primary care in the prevention and treatment of childhood obesity [16,17]. However, it remains unclear whether provider perspectives about their role in addressing childhood obesity align with such guidelines and suggestions. In fact, several studies have discussed barriers to weight management and obesity counseling among adults by physicians, which include lack of training, time, and perceived ineffectiveness of their own efforts [18–20]. This study adds to the literature by qualitatively assessing perspectives of general practice staff from a variety of practices regarding their role in addressing childhood obesity.
In qualitative research, typically small samples require careful consideration of the representativeness of participants in terms of characteristics and relevance to the wider population. As the authors highlight, a key strength of this study is that staff from a large number of practices in different geographical areas across England were recruited and broadly represented general practices in terms of practice list size and deprivation. This may contribute to greater likelihood of generalizability compared to similar studies that are limited to specific states in a country or small geographic areas. Additional strengths of this study include the use of a specific framework to guide analysis, 2 independent coders to analyze transcripts, and a brief discussion of how the researcher, through the structure of the interview, may have introduced bias to the results. However, the authors did not include whether any outlying or negative/deviant cases were presented that did not fit with discussed themes or if there were any differences in findings by gender or by years since qualified to practice. Additionally, the authors did not specify if results were confirmed or validated by their study participants to increase reliability and trustworthiness of analysis and interpretation.
Applications for Clinical Practice
Although the authors highlight that their findings suggest that policies expanding the role for general practitioners in prevention, identification, and management of childhood obesity at a population-level are unlikely to be successful, findings may instead highlight specific barriers to target and overcome in order to expand the role for general practitioners. Even though contact with well children may be limited, standard practices to incorporate brief counseling could contribute to a shift in practice and patient expectations of what is discussed during visits. Increased training and awareness of resources and innovative technologies that can assist patients with addressing obesity-related environmental, economic, and lifestyle factors can also be incorporated into medical education and professional development. In addition, practices can partner with community-based programs and organizations implementing childhood obesity interventions to expand referral options. General practitioners and primary care providers remain an important source of health information and expertise, and thus should play a key role in supporting broader initiatives to address childhood obesity.
—Katrina F. Mateo, MPH
1. WHO | Facts and figures on childhood obesity. 2014.
2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806–14.
3. de Onis M, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr 2010;92:1257–64.
4. Pizzi MA, Vroman K. Childhood obesity: effects on children’s participation, mental health, and psychosocial development. Occup Ther Health Care 2013;27:99–112.
5. Pulgarón ER. Childhood obesity: a review of increased risk for physical and psychological comorbidities. Clin Ther 2013;35:A18–32.
6. Trasande L, Elbel B. The economic burden placed on healthcare systems by childhood obesity. Expert Rev Pharmacoecon Outcomes Res 2012;12:39–45.
7. Wang Y, Wu Y, Wilson RF, et al. Childhood obesity prevention programs: comparative effectiveness review and meta-analysis. Agency for Healthcare Research and Quality; 2013.
8. Martin A, Saunders DH, Shenkin SD, Sproule J. Lifestyle intervention for improving school achievement in overweight or obese children and adolescents. Cochrane Database Syst Rev 2014;(3):CD009728.
9. De Miguel-Etayo P, Bueno G, Garagorri JM, Moreno LA. Interventions for treating obesity in children. World Rev Nutrition Dietetics 2013;108:98–106.
10. Reinehr T. Lifestyle intervention in childhood obesity: changes and challenges. Nat Rev Endocrinol 2013;9:607–14.
11. US Preventive Services Task Force, Grossman DC, Bibbins-Domingo K, et al. Screening for obesity in children and adolescents. JAMA 2017;317:2417–26.
12. Richardson L, Paulis WD, van Middelkoop M, Koes BW. An overview of national clinical guidelines for the management of childhood obesity in primary care. Prev Med (Baltim) 2013;57:448–55.
13. Brown CL, Halvorson EE, Cohen GM, et al. Addressing childhood obesity: opportunities for prevention. Pediatr Clin North Am 2015;62:1241–61.
Study Overview
Objective. To explore the views of general practice staff on managing childhood obesity in primary care.
Design. Qualitative study.
Setting and participants. General practices across England (n = 7303) of varying practice list size (low/medium/high) and “deprivation” level (low/medium/high, based on Index of Multiple Deprivation (IMD) score, which measures deprivation based on income, employment, health, education, barriers to services, living environment and crime) were stratified into a 3 x 3 matrix, resulting in recruitment targets of 3 to 5 practices per each of 9 recruitment strata. Practices in each strata were grouped into batches and approached in a random list order to take part in the study. Recruitment continued until the strata target was reached. Interviews were conducted by 2 researchers, either in the interviewee’s workplace or by telephone.
Main outcomes measures. The interview topic guide included 2 questions related to childhood obesity: (1) theirperceptions of the barriers and enablers to general practitioners taking a more active role in childhood obesity; and (2) their views on what was needed to improve integrated local pathways to manage childhood obesity. Follow-up questions were used in response to issues raised by interviewees. All interviews were audiotaped, professionally transcribed verbatim, and checked for accuracy. Copies of transcripts were available to interviewees, although none requested to see them. Key themes were identified through thematic analysis of transcripts using an inductive approach. Initial codes were discussed and combined to form themes which were discussed until agreement was reached that these reflected the data. Results are based upon a synthesis of all the interviews.
Main results. A total of 32 practices were recruited, of which 30 identified 52 staff (56% female) to participate in semi-structured interviews: 29 general practitioners (28% female), 14 practice managers (86% female), 7 nursing staff (100% female), 1 health care assistant (female), and 1 administrative staff (female). Almost all interviewees identified childhood obesity as an increasingly important issue with potential long-term health implications. However, most did not frame it as a medical problem in itself or view its management as a general practice responsibility.
Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt that consultation time was limited and focused on addressing acute illness. Generally, raising the issue was described as sensitive. Interviewees also felt ill equipped to solve the issue because they lacked influence over the environmental, economic, and lifestyle factors underpinning obesity. They described little evidence to support general practice intervention and seemed unaware of other services. Interviewees felt their efforts should be directed towards health problems they identified as medical issues where evidence suggests they can make a difference.
Conclusions. Although general practice staff viewed childhood obesity as an important issue with the poten-tial to impact on health outcomes, they were unconvinced that they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistic identification of overweight children and referral to specialist/obesity services
Commentary
The prevalence of childhood overweight and obesity continues to rise in the United States and worldwide with extensive economic, physical, and psychosocial consequences [1–6]. Lifestyle interventions that target obesity-related behaviors including physical activity, sedentary behavior, and diet, are considered the therapy of choice [7–10]. Indeed, the US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status [11]. Similar recommendations can be seen in other national guidelines regarding the management of childhood obesity [12].
Beyond screening and referral, some have outlined more specific opportunities for health professionals to play a more significant role in confronting child obesity, particularly among general practitioners and primary care providers [13–15]. In addition, several reviews have looked at the expanding role of primary care in the prevention and treatment of childhood obesity [16,17]. However, it remains unclear whether provider perspectives about their role in addressing childhood obesity align with such guidelines and suggestions. In fact, several studies have discussed barriers to weight management and obesity counseling among adults by physicians, which include lack of training, time, and perceived ineffectiveness of their own efforts [18–20]. This study adds to the literature by qualitatively assessing perspectives of general practice staff from a variety of practices regarding their role in addressing childhood obesity.
In qualitative research, typically small samples require careful consideration of the representativeness of participants in terms of characteristics and relevance to the wider population. As the authors highlight, a key strength of this study is that staff from a large number of practices in different geographical areas across England were recruited and broadly represented general practices in terms of practice list size and deprivation. This may contribute to greater likelihood of generalizability compared to similar studies that are limited to specific states in a country or small geographic areas. Additional strengths of this study include the use of a specific framework to guide analysis, 2 independent coders to analyze transcripts, and a brief discussion of how the researcher, through the structure of the interview, may have introduced bias to the results. However, the authors did not include whether any outlying or negative/deviant cases were presented that did not fit with discussed themes or if there were any differences in findings by gender or by years since qualified to practice. Additionally, the authors did not specify if results were confirmed or validated by their study participants to increase reliability and trustworthiness of analysis and interpretation.
Applications for Clinical Practice
Although the authors highlight that their findings suggest that policies expanding the role for general practitioners in prevention, identification, and management of childhood obesity at a population-level are unlikely to be successful, findings may instead highlight specific barriers to target and overcome in order to expand the role for general practitioners. Even though contact with well children may be limited, standard practices to incorporate brief counseling could contribute to a shift in practice and patient expectations of what is discussed during visits. Increased training and awareness of resources and innovative technologies that can assist patients with addressing obesity-related environmental, economic, and lifestyle factors can also be incorporated into medical education and professional development. In addition, practices can partner with community-based programs and organizations implementing childhood obesity interventions to expand referral options. General practitioners and primary care providers remain an important source of health information and expertise, and thus should play a key role in supporting broader initiatives to address childhood obesity.
—Katrina F. Mateo, MPH
Study Overview
Objective. To explore the views of general practice staff on managing childhood obesity in primary care.
Design. Qualitative study.
Setting and participants. General practices across England (n = 7303) of varying practice list size (low/medium/high) and “deprivation” level (low/medium/high, based on Index of Multiple Deprivation (IMD) score, which measures deprivation based on income, employment, health, education, barriers to services, living environment and crime) were stratified into a 3 x 3 matrix, resulting in recruitment targets of 3 to 5 practices per each of 9 recruitment strata. Practices in each strata were grouped into batches and approached in a random list order to take part in the study. Recruitment continued until the strata target was reached. Interviews were conducted by 2 researchers, either in the interviewee’s workplace or by telephone.
Main outcomes measures. The interview topic guide included 2 questions related to childhood obesity: (1) theirperceptions of the barriers and enablers to general practitioners taking a more active role in childhood obesity; and (2) their views on what was needed to improve integrated local pathways to manage childhood obesity. Follow-up questions were used in response to issues raised by interviewees. All interviews were audiotaped, professionally transcribed verbatim, and checked for accuracy. Copies of transcripts were available to interviewees, although none requested to see them. Key themes were identified through thematic analysis of transcripts using an inductive approach. Initial codes were discussed and combined to form themes which were discussed until agreement was reached that these reflected the data. Results are based upon a synthesis of all the interviews.
Main results. A total of 32 practices were recruited, of which 30 identified 52 staff (56% female) to participate in semi-structured interviews: 29 general practitioners (28% female), 14 practice managers (86% female), 7 nursing staff (100% female), 1 health care assistant (female), and 1 administrative staff (female). Almost all interviewees identified childhood obesity as an increasingly important issue with potential long-term health implications. However, most did not frame it as a medical problem in itself or view its management as a general practice responsibility.
Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt that consultation time was limited and focused on addressing acute illness. Generally, raising the issue was described as sensitive. Interviewees also felt ill equipped to solve the issue because they lacked influence over the environmental, economic, and lifestyle factors underpinning obesity. They described little evidence to support general practice intervention and seemed unaware of other services. Interviewees felt their efforts should be directed towards health problems they identified as medical issues where evidence suggests they can make a difference.
Conclusions. Although general practice staff viewed childhood obesity as an important issue with the poten-tial to impact on health outcomes, they were unconvinced that they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistic identification of overweight children and referral to specialist/obesity services
Commentary
The prevalence of childhood overweight and obesity continues to rise in the United States and worldwide with extensive economic, physical, and psychosocial consequences [1–6]. Lifestyle interventions that target obesity-related behaviors including physical activity, sedentary behavior, and diet, are considered the therapy of choice [7–10]. Indeed, the US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status [11]. Similar recommendations can be seen in other national guidelines regarding the management of childhood obesity [12].
Beyond screening and referral, some have outlined more specific opportunities for health professionals to play a more significant role in confronting child obesity, particularly among general practitioners and primary care providers [13–15]. In addition, several reviews have looked at the expanding role of primary care in the prevention and treatment of childhood obesity [16,17]. However, it remains unclear whether provider perspectives about their role in addressing childhood obesity align with such guidelines and suggestions. In fact, several studies have discussed barriers to weight management and obesity counseling among adults by physicians, which include lack of training, time, and perceived ineffectiveness of their own efforts [18–20]. This study adds to the literature by qualitatively assessing perspectives of general practice staff from a variety of practices regarding their role in addressing childhood obesity.
In qualitative research, typically small samples require careful consideration of the representativeness of participants in terms of characteristics and relevance to the wider population. As the authors highlight, a key strength of this study is that staff from a large number of practices in different geographical areas across England were recruited and broadly represented general practices in terms of practice list size and deprivation. This may contribute to greater likelihood of generalizability compared to similar studies that are limited to specific states in a country or small geographic areas. Additional strengths of this study include the use of a specific framework to guide analysis, 2 independent coders to analyze transcripts, and a brief discussion of how the researcher, through the structure of the interview, may have introduced bias to the results. However, the authors did not include whether any outlying or negative/deviant cases were presented that did not fit with discussed themes or if there were any differences in findings by gender or by years since qualified to practice. Additionally, the authors did not specify if results were confirmed or validated by their study participants to increase reliability and trustworthiness of analysis and interpretation.
Applications for Clinical Practice
Although the authors highlight that their findings suggest that policies expanding the role for general practitioners in prevention, identification, and management of childhood obesity at a population-level are unlikely to be successful, findings may instead highlight specific barriers to target and overcome in order to expand the role for general practitioners. Even though contact with well children may be limited, standard practices to incorporate brief counseling could contribute to a shift in practice and patient expectations of what is discussed during visits. Increased training and awareness of resources and innovative technologies that can assist patients with addressing obesity-related environmental, economic, and lifestyle factors can also be incorporated into medical education and professional development. In addition, practices can partner with community-based programs and organizations implementing childhood obesity interventions to expand referral options. General practitioners and primary care providers remain an important source of health information and expertise, and thus should play a key role in supporting broader initiatives to address childhood obesity.
—Katrina F. Mateo, MPH
1. WHO | Facts and figures on childhood obesity. 2014.
2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806–14.
3. de Onis M, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr 2010;92:1257–64.
4. Pizzi MA, Vroman K. Childhood obesity: effects on children’s participation, mental health, and psychosocial development. Occup Ther Health Care 2013;27:99–112.
5. Pulgarón ER. Childhood obesity: a review of increased risk for physical and psychological comorbidities. Clin Ther 2013;35:A18–32.
6. Trasande L, Elbel B. The economic burden placed on healthcare systems by childhood obesity. Expert Rev Pharmacoecon Outcomes Res 2012;12:39–45.
7. Wang Y, Wu Y, Wilson RF, et al. Childhood obesity prevention programs: comparative effectiveness review and meta-analysis. Agency for Healthcare Research and Quality; 2013.
8. Martin A, Saunders DH, Shenkin SD, Sproule J. Lifestyle intervention for improving school achievement in overweight or obese children and adolescents. Cochrane Database Syst Rev 2014;(3):CD009728.
9. De Miguel-Etayo P, Bueno G, Garagorri JM, Moreno LA. Interventions for treating obesity in children. World Rev Nutrition Dietetics 2013;108:98–106.
10. Reinehr T. Lifestyle intervention in childhood obesity: changes and challenges. Nat Rev Endocrinol 2013;9:607–14.
11. US Preventive Services Task Force, Grossman DC, Bibbins-Domingo K, et al. Screening for obesity in children and adolescents. JAMA 2017;317:2417–26.
12. Richardson L, Paulis WD, van Middelkoop M, Koes BW. An overview of national clinical guidelines for the management of childhood obesity in primary care. Prev Med (Baltim) 2013;57:448–55.
13. Brown CL, Halvorson EE, Cohen GM, et al. Addressing childhood obesity: opportunities for prevention. Pediatr Clin North Am 2015;62:1241–61.
1. WHO | Facts and figures on childhood obesity. 2014.
2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806–14.
3. de Onis M, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr 2010;92:1257–64.
4. Pizzi MA, Vroman K. Childhood obesity: effects on children’s participation, mental health, and psychosocial development. Occup Ther Health Care 2013;27:99–112.
5. Pulgarón ER. Childhood obesity: a review of increased risk for physical and psychological comorbidities. Clin Ther 2013;35:A18–32.
6. Trasande L, Elbel B. The economic burden placed on healthcare systems by childhood obesity. Expert Rev Pharmacoecon Outcomes Res 2012;12:39–45.
7. Wang Y, Wu Y, Wilson RF, et al. Childhood obesity prevention programs: comparative effectiveness review and meta-analysis. Agency for Healthcare Research and Quality; 2013.
8. Martin A, Saunders DH, Shenkin SD, Sproule J. Lifestyle intervention for improving school achievement in overweight or obese children and adolescents. Cochrane Database Syst Rev 2014;(3):CD009728.
9. De Miguel-Etayo P, Bueno G, Garagorri JM, Moreno LA. Interventions for treating obesity in children. World Rev Nutrition Dietetics 2013;108:98–106.
10. Reinehr T. Lifestyle intervention in childhood obesity: changes and challenges. Nat Rev Endocrinol 2013;9:607–14.
11. US Preventive Services Task Force, Grossman DC, Bibbins-Domingo K, et al. Screening for obesity in children and adolescents. JAMA 2017;317:2417–26.
12. Richardson L, Paulis WD, van Middelkoop M, Koes BW. An overview of national clinical guidelines for the management of childhood obesity in primary care. Prev Med (Baltim) 2013;57:448–55.
13. Brown CL, Halvorson EE, Cohen GM, et al. Addressing childhood obesity: opportunities for prevention. Pediatr Clin North Am 2015;62:1241–61.
FDA grants accelerated approval for treatment of Chagas disease in children
The Food and Drug Administration announced Aug. 29 the accelerated approval of benznidazole for use in children aged 2-12 years who have Chagas disease.
In two placebo-controlled clinical trials, researchers examined pediatric patients aged 6-12 with Chagas disease. In the first trial, about 60% of children treated with benznidazole had an antibody test change from positive to negative, compared with about 14% children who received a placebo. Similar findings were found in the second trial. In that one, about 55% of children treated with benznidazole had an antibody test change from positive to negative, compared with 5% who received a placebo. Also, a different study of the safety and pharmacokinetics of benznidazole in pediatric patients aged 2-12 provided information for dosing recommendations down to 2 years of age.
“The FDA is committed to making available safe and effective therapeutic options to treat tropical diseases,” Edward Cox, MD, director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research, said in a press release.
This is the first treatment approved in the United States for Chagas disease. According to the agency, additional study is needed to “verify and describe the anticipated clinical benefit of benznidazole.”
Read the full press release on the FDA’s website.
The Food and Drug Administration announced Aug. 29 the accelerated approval of benznidazole for use in children aged 2-12 years who have Chagas disease.
In two placebo-controlled clinical trials, researchers examined pediatric patients aged 6-12 with Chagas disease. In the first trial, about 60% of children treated with benznidazole had an antibody test change from positive to negative, compared with about 14% children who received a placebo. Similar findings were found in the second trial. In that one, about 55% of children treated with benznidazole had an antibody test change from positive to negative, compared with 5% who received a placebo. Also, a different study of the safety and pharmacokinetics of benznidazole in pediatric patients aged 2-12 provided information for dosing recommendations down to 2 years of age.
“The FDA is committed to making available safe and effective therapeutic options to treat tropical diseases,” Edward Cox, MD, director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research, said in a press release.
This is the first treatment approved in the United States for Chagas disease. According to the agency, additional study is needed to “verify and describe the anticipated clinical benefit of benznidazole.”
Read the full press release on the FDA’s website.
The Food and Drug Administration announced Aug. 29 the accelerated approval of benznidazole for use in children aged 2-12 years who have Chagas disease.
In two placebo-controlled clinical trials, researchers examined pediatric patients aged 6-12 with Chagas disease. In the first trial, about 60% of children treated with benznidazole had an antibody test change from positive to negative, compared with about 14% children who received a placebo. Similar findings were found in the second trial. In that one, about 55% of children treated with benznidazole had an antibody test change from positive to negative, compared with 5% who received a placebo. Also, a different study of the safety and pharmacokinetics of benznidazole in pediatric patients aged 2-12 provided information for dosing recommendations down to 2 years of age.
“The FDA is committed to making available safe and effective therapeutic options to treat tropical diseases,” Edward Cox, MD, director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research, said in a press release.
This is the first treatment approved in the United States for Chagas disease. According to the agency, additional study is needed to “verify and describe the anticipated clinical benefit of benznidazole.”
Read the full press release on the FDA’s website.
DoD, VA Join Federal Response to Harvey
The VA announced medical centers open in Houston and central Arkansas are providing assistance to veterans affected by Hurricane Harvey across southeastern Texas, Arkansas, Mississippi, Louisiana, and Oklahoma. It also has deployed Mobile Vet Centers to veterans in Corpus Christi, Texas and other effected areas to provide counselling services.
Due to the State of Emergency declared in Louisiana and Texas, TRICARE has implemented emergency refill procedures from August 23rd - September 5th. Phone numbers and advice have been provided to assist in refilling prescriptions. The referral requirement also has been waived for those who have been evacuated in southeastern Texas counties from August 24th- September 5th.
The DoD has deployed about 3,000 Texas National Guardsmen and Guardsmen from other states for search and rescue. Director of domestic operations for the National Guard Bureau, Air Force Maj Gen. James C. Witham, says the bureau has identified “20,000 to 30,000 additional soldiers and airmen that could be used.” The Texas National Guardsmen has its personnel and about 16 aircrafts conducting day and night searches. National Guardsmen from all over the country have been involved in the rescue of more than 3,500 people and 300 pets through boats, vehicles, and helicopters. The DoD also is providing 11 generators, and 50,000 gallons of gasoline and diesel fuel through the Defense Logistics Agency for.
On Tuesday alone, 2 U.S. Navy helicopter squadron detachments rescued 227 flood victims while flying from Fort Worth, Texas. Helicopter Sea Combat Squadrons 7 and 28 have relocated to be closer to the epicenter of the flooding in and around Houston.
In order to drastically reduce response time, the 112 Sailors from the Dusty Dogs and Ghostriders of Helicopter Sea Combat Squadrons (HSC) 7 and 28 (respectively) moved their staging site and six MH-60S Knighthawk helicopters in order to be even closer to the disaster zone in the wake of Hurricane Harvey. USA.gov has provided resources on what to do now that the hurricane has subsided for residents in the affected areas. A list of recommendations from federal officials, advice on how to replace vital documents, and the latest news on the storm are provided with links.
FEMA has provided a list of emergency phone numbers to County Emergency Operation centers and the U.S. Coast Guard Sector Huston Command Center for life-threating situations. Other resources for safety tips, the National Flood Insurance Program, how to apply for assistance, and how to help others needing assistance are provided as well.
The VA announced medical centers open in Houston and central Arkansas are providing assistance to veterans affected by Hurricane Harvey across southeastern Texas, Arkansas, Mississippi, Louisiana, and Oklahoma. It also has deployed Mobile Vet Centers to veterans in Corpus Christi, Texas and other effected areas to provide counselling services.
Due to the State of Emergency declared in Louisiana and Texas, TRICARE has implemented emergency refill procedures from August 23rd - September 5th. Phone numbers and advice have been provided to assist in refilling prescriptions. The referral requirement also has been waived for those who have been evacuated in southeastern Texas counties from August 24th- September 5th.
The DoD has deployed about 3,000 Texas National Guardsmen and Guardsmen from other states for search and rescue. Director of domestic operations for the National Guard Bureau, Air Force Maj Gen. James C. Witham, says the bureau has identified “20,000 to 30,000 additional soldiers and airmen that could be used.” The Texas National Guardsmen has its personnel and about 16 aircrafts conducting day and night searches. National Guardsmen from all over the country have been involved in the rescue of more than 3,500 people and 300 pets through boats, vehicles, and helicopters. The DoD also is providing 11 generators, and 50,000 gallons of gasoline and diesel fuel through the Defense Logistics Agency for.
On Tuesday alone, 2 U.S. Navy helicopter squadron detachments rescued 227 flood victims while flying from Fort Worth, Texas. Helicopter Sea Combat Squadrons 7 and 28 have relocated to be closer to the epicenter of the flooding in and around Houston.
In order to drastically reduce response time, the 112 Sailors from the Dusty Dogs and Ghostriders of Helicopter Sea Combat Squadrons (HSC) 7 and 28 (respectively) moved their staging site and six MH-60S Knighthawk helicopters in order to be even closer to the disaster zone in the wake of Hurricane Harvey. USA.gov has provided resources on what to do now that the hurricane has subsided for residents in the affected areas. A list of recommendations from federal officials, advice on how to replace vital documents, and the latest news on the storm are provided with links.
FEMA has provided a list of emergency phone numbers to County Emergency Operation centers and the U.S. Coast Guard Sector Huston Command Center for life-threating situations. Other resources for safety tips, the National Flood Insurance Program, how to apply for assistance, and how to help others needing assistance are provided as well.
The VA announced medical centers open in Houston and central Arkansas are providing assistance to veterans affected by Hurricane Harvey across southeastern Texas, Arkansas, Mississippi, Louisiana, and Oklahoma. It also has deployed Mobile Vet Centers to veterans in Corpus Christi, Texas and other effected areas to provide counselling services.
Due to the State of Emergency declared in Louisiana and Texas, TRICARE has implemented emergency refill procedures from August 23rd - September 5th. Phone numbers and advice have been provided to assist in refilling prescriptions. The referral requirement also has been waived for those who have been evacuated in southeastern Texas counties from August 24th- September 5th.
The DoD has deployed about 3,000 Texas National Guardsmen and Guardsmen from other states for search and rescue. Director of domestic operations for the National Guard Bureau, Air Force Maj Gen. James C. Witham, says the bureau has identified “20,000 to 30,000 additional soldiers and airmen that could be used.” The Texas National Guardsmen has its personnel and about 16 aircrafts conducting day and night searches. National Guardsmen from all over the country have been involved in the rescue of more than 3,500 people and 300 pets through boats, vehicles, and helicopters. The DoD also is providing 11 generators, and 50,000 gallons of gasoline and diesel fuel through the Defense Logistics Agency for.
On Tuesday alone, 2 U.S. Navy helicopter squadron detachments rescued 227 flood victims while flying from Fort Worth, Texas. Helicopter Sea Combat Squadrons 7 and 28 have relocated to be closer to the epicenter of the flooding in and around Houston.
In order to drastically reduce response time, the 112 Sailors from the Dusty Dogs and Ghostriders of Helicopter Sea Combat Squadrons (HSC) 7 and 28 (respectively) moved their staging site and six MH-60S Knighthawk helicopters in order to be even closer to the disaster zone in the wake of Hurricane Harvey. USA.gov has provided resources on what to do now that the hurricane has subsided for residents in the affected areas. A list of recommendations from federal officials, advice on how to replace vital documents, and the latest news on the storm are provided with links.
FEMA has provided a list of emergency phone numbers to County Emergency Operation centers and the U.S. Coast Guard Sector Huston Command Center for life-threating situations. Other resources for safety tips, the National Flood Insurance Program, how to apply for assistance, and how to help others needing assistance are provided as well.