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AAP issues guidance on inguinal hernias
Faraz A. Khan, MD, an adjunct associate professor in the division of pediatric surgery at Loma Linda (Calif.) University Children’s Hospital, led the AAP’s Committee on Fetus and Newborn, sections on surgery and urology, in writing the guidance, published in Pediatrics.
An inguinal hernia, a common pediatric surgical condition (90% are in boys, the authors wrote), appears as a bulge in the groin or scrotum and requires surgical repair to prevent a more severe incarcerated hernia, which occurs when organs from the abdomen become trapped in the hernia.
The risk of that incarceration drives the preference and timing of surgical repair, the authors wrote.
The incidence of inguinal hernias is about 8-50 per 1,000 live births in term infants and is much higher in extremely low-birth-weight infants.
Ankush Gosain, MD, PhD, chief of pediatric surgery at Children’s Hospital Colorado, Aurora, who was not involved in the AAP clinical report, said in an interview that the best timing for the surgery on a premature infant has been an unanswered question and this guidance is helpful.
Inguinal hernias in preterm infants are especially common. The incidence is reported to be as high as 20%.
Repair can wait until babies have left NICU
The authors concluded that there was moderate-quality evidence supporting deferring hernia repair until after discharge from the neonatal intensive care unit because this may reduce the risk of respiratory problems without increasing risk of incarceration or another operation.
But Dr. Gosain noted that the authors left the door open for data from a study that recently finished enrolling patients. That trial (Dr. Gosain is a site investigator) is expected to help determine whether an early- or late-term approach is best in preterm infants.
“There are pluses and minuses that we and the neonatologists and the anesthesiologists recognize,” he said.
Laparoscopic approach as good, sometimes better
Dr. Gosain also said he was glad to see the authors addressed the merits of the laparoscopic approach and when it is preferred.
The authors noted that a laparoscopic approach is increasingly popular – rates have grown fivefold between 2009 and 2018 – and they found it is “at least as effective as, if not better than,” the current preferred method, traditional open high ligation of the hernia sac.
Laparoscopy also appears to be a feasible option in managing recurrent hernias.
Dr. Gosain said that, when the laparoscopic approach was developed, there was concern that it would lead to higher recurrence of the hernias. “That concern has diminished over time,” he added. The paper helps give surgeons and pediatricians peace of mind that this is a safe approach.
Who should perform the surgeries?
The authors concluded that, ideally, pediatric surgical specialists, pediatric urologists, or general surgeons with a significant yearly case volume should perform the surgeries.
They found a significant inverse relationship between recurrence rates and general surgeon case volume: general surgeons who completed fewer than 10 pediatric inguinal hernias per year had the highest recurrence rates and the highest-volume general surgeons had recurrence rates similar to pediatric surgical specialists.
Pediatric surgical specialists trained in fellowships had the lowest rate of hernia recurrences.
Dr. Gosain said he was glad the authors pointed out that both the surgeon and the anesthesiologist ideally should have that specialty training.
No evidence that anesthetic exposure affects neurodevelopment
The researchers found no conclusive evidence that otherwise-healthy children’s exposure to a single relatively short duration of anesthetic adds any significant risk to neurodevelopment or academic performance, or increases risk of ADHD or autism spectrum disorder.
Contralateral exploration with unilateral hernia
Providers continue to debate contralateral exploration among patients with unilateral inguinal hernia. Proponents of exploration cite a 10%-15% rate of developing of a hernia at a later time. Therefore, routine exploration and, if identified, ligation of a patent processus vaginalis (PPV) may avoid a subsequent anesthetic.
Opponents counter that not all PPVs will become clinically significant inguinal hernias, and doing routine exploration exposes the patient to potentially unnecessary complications.
The authors wrote: “In the absence of strong data for or against repair of incidentally discovered contralateral PPV, family values related to the risks and benefits of each approach from a nuanced preoperative discussion should be considered.”
Dr. Gosain said that, with all of the guidance points, “you need to have a true conversation between the surgeon and the parents with pluses and minuses of the different approaches because one is not necessarily absolutely better than the other.”
The authors and Dr. Gosain declare no relevant financial relationships.
Faraz A. Khan, MD, an adjunct associate professor in the division of pediatric surgery at Loma Linda (Calif.) University Children’s Hospital, led the AAP’s Committee on Fetus and Newborn, sections on surgery and urology, in writing the guidance, published in Pediatrics.
An inguinal hernia, a common pediatric surgical condition (90% are in boys, the authors wrote), appears as a bulge in the groin or scrotum and requires surgical repair to prevent a more severe incarcerated hernia, which occurs when organs from the abdomen become trapped in the hernia.
The risk of that incarceration drives the preference and timing of surgical repair, the authors wrote.
The incidence of inguinal hernias is about 8-50 per 1,000 live births in term infants and is much higher in extremely low-birth-weight infants.
Ankush Gosain, MD, PhD, chief of pediatric surgery at Children’s Hospital Colorado, Aurora, who was not involved in the AAP clinical report, said in an interview that the best timing for the surgery on a premature infant has been an unanswered question and this guidance is helpful.
Inguinal hernias in preterm infants are especially common. The incidence is reported to be as high as 20%.
Repair can wait until babies have left NICU
The authors concluded that there was moderate-quality evidence supporting deferring hernia repair until after discharge from the neonatal intensive care unit because this may reduce the risk of respiratory problems without increasing risk of incarceration or another operation.
But Dr. Gosain noted that the authors left the door open for data from a study that recently finished enrolling patients. That trial (Dr. Gosain is a site investigator) is expected to help determine whether an early- or late-term approach is best in preterm infants.
“There are pluses and minuses that we and the neonatologists and the anesthesiologists recognize,” he said.
Laparoscopic approach as good, sometimes better
Dr. Gosain also said he was glad to see the authors addressed the merits of the laparoscopic approach and when it is preferred.
The authors noted that a laparoscopic approach is increasingly popular – rates have grown fivefold between 2009 and 2018 – and they found it is “at least as effective as, if not better than,” the current preferred method, traditional open high ligation of the hernia sac.
Laparoscopy also appears to be a feasible option in managing recurrent hernias.
Dr. Gosain said that, when the laparoscopic approach was developed, there was concern that it would lead to higher recurrence of the hernias. “That concern has diminished over time,” he added. The paper helps give surgeons and pediatricians peace of mind that this is a safe approach.
Who should perform the surgeries?
The authors concluded that, ideally, pediatric surgical specialists, pediatric urologists, or general surgeons with a significant yearly case volume should perform the surgeries.
They found a significant inverse relationship between recurrence rates and general surgeon case volume: general surgeons who completed fewer than 10 pediatric inguinal hernias per year had the highest recurrence rates and the highest-volume general surgeons had recurrence rates similar to pediatric surgical specialists.
Pediatric surgical specialists trained in fellowships had the lowest rate of hernia recurrences.
Dr. Gosain said he was glad the authors pointed out that both the surgeon and the anesthesiologist ideally should have that specialty training.
No evidence that anesthetic exposure affects neurodevelopment
The researchers found no conclusive evidence that otherwise-healthy children’s exposure to a single relatively short duration of anesthetic adds any significant risk to neurodevelopment or academic performance, or increases risk of ADHD or autism spectrum disorder.
Contralateral exploration with unilateral hernia
Providers continue to debate contralateral exploration among patients with unilateral inguinal hernia. Proponents of exploration cite a 10%-15% rate of developing of a hernia at a later time. Therefore, routine exploration and, if identified, ligation of a patent processus vaginalis (PPV) may avoid a subsequent anesthetic.
Opponents counter that not all PPVs will become clinically significant inguinal hernias, and doing routine exploration exposes the patient to potentially unnecessary complications.
The authors wrote: “In the absence of strong data for or against repair of incidentally discovered contralateral PPV, family values related to the risks and benefits of each approach from a nuanced preoperative discussion should be considered.”
Dr. Gosain said that, with all of the guidance points, “you need to have a true conversation between the surgeon and the parents with pluses and minuses of the different approaches because one is not necessarily absolutely better than the other.”
The authors and Dr. Gosain declare no relevant financial relationships.
Faraz A. Khan, MD, an adjunct associate professor in the division of pediatric surgery at Loma Linda (Calif.) University Children’s Hospital, led the AAP’s Committee on Fetus and Newborn, sections on surgery and urology, in writing the guidance, published in Pediatrics.
An inguinal hernia, a common pediatric surgical condition (90% are in boys, the authors wrote), appears as a bulge in the groin or scrotum and requires surgical repair to prevent a more severe incarcerated hernia, which occurs when organs from the abdomen become trapped in the hernia.
The risk of that incarceration drives the preference and timing of surgical repair, the authors wrote.
The incidence of inguinal hernias is about 8-50 per 1,000 live births in term infants and is much higher in extremely low-birth-weight infants.
Ankush Gosain, MD, PhD, chief of pediatric surgery at Children’s Hospital Colorado, Aurora, who was not involved in the AAP clinical report, said in an interview that the best timing for the surgery on a premature infant has been an unanswered question and this guidance is helpful.
Inguinal hernias in preterm infants are especially common. The incidence is reported to be as high as 20%.
Repair can wait until babies have left NICU
The authors concluded that there was moderate-quality evidence supporting deferring hernia repair until after discharge from the neonatal intensive care unit because this may reduce the risk of respiratory problems without increasing risk of incarceration or another operation.
But Dr. Gosain noted that the authors left the door open for data from a study that recently finished enrolling patients. That trial (Dr. Gosain is a site investigator) is expected to help determine whether an early- or late-term approach is best in preterm infants.
“There are pluses and minuses that we and the neonatologists and the anesthesiologists recognize,” he said.
Laparoscopic approach as good, sometimes better
Dr. Gosain also said he was glad to see the authors addressed the merits of the laparoscopic approach and when it is preferred.
The authors noted that a laparoscopic approach is increasingly popular – rates have grown fivefold between 2009 and 2018 – and they found it is “at least as effective as, if not better than,” the current preferred method, traditional open high ligation of the hernia sac.
Laparoscopy also appears to be a feasible option in managing recurrent hernias.
Dr. Gosain said that, when the laparoscopic approach was developed, there was concern that it would lead to higher recurrence of the hernias. “That concern has diminished over time,” he added. The paper helps give surgeons and pediatricians peace of mind that this is a safe approach.
Who should perform the surgeries?
The authors concluded that, ideally, pediatric surgical specialists, pediatric urologists, or general surgeons with a significant yearly case volume should perform the surgeries.
They found a significant inverse relationship between recurrence rates and general surgeon case volume: general surgeons who completed fewer than 10 pediatric inguinal hernias per year had the highest recurrence rates and the highest-volume general surgeons had recurrence rates similar to pediatric surgical specialists.
Pediatric surgical specialists trained in fellowships had the lowest rate of hernia recurrences.
Dr. Gosain said he was glad the authors pointed out that both the surgeon and the anesthesiologist ideally should have that specialty training.
No evidence that anesthetic exposure affects neurodevelopment
The researchers found no conclusive evidence that otherwise-healthy children’s exposure to a single relatively short duration of anesthetic adds any significant risk to neurodevelopment or academic performance, or increases risk of ADHD or autism spectrum disorder.
Contralateral exploration with unilateral hernia
Providers continue to debate contralateral exploration among patients with unilateral inguinal hernia. Proponents of exploration cite a 10%-15% rate of developing of a hernia at a later time. Therefore, routine exploration and, if identified, ligation of a patent processus vaginalis (PPV) may avoid a subsequent anesthetic.
Opponents counter that not all PPVs will become clinically significant inguinal hernias, and doing routine exploration exposes the patient to potentially unnecessary complications.
The authors wrote: “In the absence of strong data for or against repair of incidentally discovered contralateral PPV, family values related to the risks and benefits of each approach from a nuanced preoperative discussion should be considered.”
Dr. Gosain said that, with all of the guidance points, “you need to have a true conversation between the surgeon and the parents with pluses and minuses of the different approaches because one is not necessarily absolutely better than the other.”
The authors and Dr. Gosain declare no relevant financial relationships.
FROM PEDIATRICS
CBSM phone app eases anxiety, depression in cancer patients
CHICAGO – One-third of patients with cancer also experience anxiety or depression, and an estimated 70% of the 18 million patients with cancer and cancer survivors in the US experience emotional symptoms, including fear of recurrence.
Despite many having these symptoms, few patients with cancer have access to psycho-oncologic support.
A digital cognitive-behavioral stress management (CBSM) application may help to ease some of the burden, reported Allison Ramiller, MPH, of Blue Note Therapeutics in San Francisco, which developed the app version of the program.
In addition, patients assigned to the CBSM app were twice as likely as control persons to report that their symptoms were “much” or “very much” improved after using the app for 12 weeks, Ms. Ramiller reported at an oral abstract session at the annual meeting of the American Society of Clinical Oncology (ASCO).
However, the investigators did not report baseline characteristics of patients in each of the study arms, which might have helped to clarify the depth of the effects they saw.
The CBSM program was developed by Michael H. Antoni, PhD, and colleagues in the University of Miami Health System. It is based on cognitive-behavioral therapy but also includes stress management and relaxation techniques to help patients cope with cancer-specific stress.
“”It has been clinically validated and shown to benefit patients with cancer,” Ms. Ramiller said. “However, access is a problem,” she said.
“There aren’t enough qualified, trained providers for the need, and patients with cancer encounter barriers to in-person participation, including things like transportation or financial barriers. So to overcome this, we developed a digitized version of CBSM,” she explained.
Impressive and elegant
“Everything about [the study] I thought was very impressive, very elegant, very nicely done,” said invited discussant Raymond U. Osarogiagbon, MBBS, FACP, chief scientist at Baptist Memorial Health Care Corp in Memphis, Tenn.
“They showed efficacy, they showed safety – very nice – user friendliness – very good. Certainly they look like they’re trying to address a highly important, unmet need in a very elegant way. Certainly, they pointed out it needs longer follow-up to see sustainability. We need to see will this work in other settings. Will this be cost-effective? You’ve gotta believe it probably will be,” he said.
CBSM has previously been shown to help patients with cancer reduce stress, improve general and cancer-specific quality of life at various stages of treatment, reduce symptom burden, and improve coping skills, Ms. Ramiller said.
To see whether these benefits could be conveyed digitally rather than in face-to-face encounters, Ms. Ramiller and colleagues worked with Dr. Antoni to develop the CBSM app.
Patients using the app received therapeutic content over 10 sessions with audio, video, and interactive tools that mimicked the sessions they would have received during in-person interventions.
They then compared the app against the control educational app in the randomized, decentralized RESTORE study.
High-quality control
Ms. Ramiller said that the control app set “a high bar.”
“The control also offered 10 interactive self-guided sessions. Both treatment apps were professionally designed and visually similar in styling, and they were presented as digital therapeutic-specific for cancer patients. And they were also in a match condition, meaning they received the same attention from study staff and cadence of reminders, but importantly, only the intervention app was based on CBSM,” she explained.
A total of 449 patients with cancers of stage I–III who were undergoing active systemic treatment or were planning to undergo such treatment within 6 months were randomly assigned to the CBSM app or the control app.
The CBSM app was superior to the control app for the primary outcome of anxiety reduction over baseline, as measured at 4, 8 and 12 weeks by the Patient-Reported Outcomes Measurement Information System Anxiety Scale (PROMIS-A) (beta = -.03; P = .019).
CBSM was also significantly better than the control app for the secondary endpoints of reducing symptoms of depression, as measured by the PROMIS-D scale (beta = -.02, P = .042), and also at increasing the percentage of patients who reported improvement in anxiety and depression symptoms on the Patient Global Impression of Change instrument (P < .001)
An extension study of the durability of the effects at 3 and 6 months is underway.
The investigators noted that the incremental cost of management of anxiety or depression is greater than $17,000 per patient per year.
“One of the big promises of a digital therapeutic like this is that it could potentially reduce costs,” Ms. Ramiller told the audience, but she acknowledged, “More work is really needed, however, to directly test the potential savings.”
The RESTORE study is funded by Blue Note Therapeutics. Dr. Osarogiagbon owns stock in Gilead, Lilly, and Pfizer, has received honoraria from Biodesix and Medscape, and has a consulting or advisory role for the American Cancer Society AstraZeneca, Genentech/Roche, LUNGevity, National Cancer Institute, and Triptych Health Partners.
A version of this article originally appeared on Medscape.com.
CHICAGO – One-third of patients with cancer also experience anxiety or depression, and an estimated 70% of the 18 million patients with cancer and cancer survivors in the US experience emotional symptoms, including fear of recurrence.
Despite many having these symptoms, few patients with cancer have access to psycho-oncologic support.
A digital cognitive-behavioral stress management (CBSM) application may help to ease some of the burden, reported Allison Ramiller, MPH, of Blue Note Therapeutics in San Francisco, which developed the app version of the program.
In addition, patients assigned to the CBSM app were twice as likely as control persons to report that their symptoms were “much” or “very much” improved after using the app for 12 weeks, Ms. Ramiller reported at an oral abstract session at the annual meeting of the American Society of Clinical Oncology (ASCO).
However, the investigators did not report baseline characteristics of patients in each of the study arms, which might have helped to clarify the depth of the effects they saw.
The CBSM program was developed by Michael H. Antoni, PhD, and colleagues in the University of Miami Health System. It is based on cognitive-behavioral therapy but also includes stress management and relaxation techniques to help patients cope with cancer-specific stress.
“”It has been clinically validated and shown to benefit patients with cancer,” Ms. Ramiller said. “However, access is a problem,” she said.
“There aren’t enough qualified, trained providers for the need, and patients with cancer encounter barriers to in-person participation, including things like transportation or financial barriers. So to overcome this, we developed a digitized version of CBSM,” she explained.
Impressive and elegant
“Everything about [the study] I thought was very impressive, very elegant, very nicely done,” said invited discussant Raymond U. Osarogiagbon, MBBS, FACP, chief scientist at Baptist Memorial Health Care Corp in Memphis, Tenn.
“They showed efficacy, they showed safety – very nice – user friendliness – very good. Certainly they look like they’re trying to address a highly important, unmet need in a very elegant way. Certainly, they pointed out it needs longer follow-up to see sustainability. We need to see will this work in other settings. Will this be cost-effective? You’ve gotta believe it probably will be,” he said.
CBSM has previously been shown to help patients with cancer reduce stress, improve general and cancer-specific quality of life at various stages of treatment, reduce symptom burden, and improve coping skills, Ms. Ramiller said.
To see whether these benefits could be conveyed digitally rather than in face-to-face encounters, Ms. Ramiller and colleagues worked with Dr. Antoni to develop the CBSM app.
Patients using the app received therapeutic content over 10 sessions with audio, video, and interactive tools that mimicked the sessions they would have received during in-person interventions.
They then compared the app against the control educational app in the randomized, decentralized RESTORE study.
High-quality control
Ms. Ramiller said that the control app set “a high bar.”
“The control also offered 10 interactive self-guided sessions. Both treatment apps were professionally designed and visually similar in styling, and they were presented as digital therapeutic-specific for cancer patients. And they were also in a match condition, meaning they received the same attention from study staff and cadence of reminders, but importantly, only the intervention app was based on CBSM,” she explained.
A total of 449 patients with cancers of stage I–III who were undergoing active systemic treatment or were planning to undergo such treatment within 6 months were randomly assigned to the CBSM app or the control app.
The CBSM app was superior to the control app for the primary outcome of anxiety reduction over baseline, as measured at 4, 8 and 12 weeks by the Patient-Reported Outcomes Measurement Information System Anxiety Scale (PROMIS-A) (beta = -.03; P = .019).
CBSM was also significantly better than the control app for the secondary endpoints of reducing symptoms of depression, as measured by the PROMIS-D scale (beta = -.02, P = .042), and also at increasing the percentage of patients who reported improvement in anxiety and depression symptoms on the Patient Global Impression of Change instrument (P < .001)
An extension study of the durability of the effects at 3 and 6 months is underway.
The investigators noted that the incremental cost of management of anxiety or depression is greater than $17,000 per patient per year.
“One of the big promises of a digital therapeutic like this is that it could potentially reduce costs,” Ms. Ramiller told the audience, but she acknowledged, “More work is really needed, however, to directly test the potential savings.”
The RESTORE study is funded by Blue Note Therapeutics. Dr. Osarogiagbon owns stock in Gilead, Lilly, and Pfizer, has received honoraria from Biodesix and Medscape, and has a consulting or advisory role for the American Cancer Society AstraZeneca, Genentech/Roche, LUNGevity, National Cancer Institute, and Triptych Health Partners.
A version of this article originally appeared on Medscape.com.
CHICAGO – One-third of patients with cancer also experience anxiety or depression, and an estimated 70% of the 18 million patients with cancer and cancer survivors in the US experience emotional symptoms, including fear of recurrence.
Despite many having these symptoms, few patients with cancer have access to psycho-oncologic support.
A digital cognitive-behavioral stress management (CBSM) application may help to ease some of the burden, reported Allison Ramiller, MPH, of Blue Note Therapeutics in San Francisco, which developed the app version of the program.
In addition, patients assigned to the CBSM app were twice as likely as control persons to report that their symptoms were “much” or “very much” improved after using the app for 12 weeks, Ms. Ramiller reported at an oral abstract session at the annual meeting of the American Society of Clinical Oncology (ASCO).
However, the investigators did not report baseline characteristics of patients in each of the study arms, which might have helped to clarify the depth of the effects they saw.
The CBSM program was developed by Michael H. Antoni, PhD, and colleagues in the University of Miami Health System. It is based on cognitive-behavioral therapy but also includes stress management and relaxation techniques to help patients cope with cancer-specific stress.
“”It has been clinically validated and shown to benefit patients with cancer,” Ms. Ramiller said. “However, access is a problem,” she said.
“There aren’t enough qualified, trained providers for the need, and patients with cancer encounter barriers to in-person participation, including things like transportation or financial barriers. So to overcome this, we developed a digitized version of CBSM,” she explained.
Impressive and elegant
“Everything about [the study] I thought was very impressive, very elegant, very nicely done,” said invited discussant Raymond U. Osarogiagbon, MBBS, FACP, chief scientist at Baptist Memorial Health Care Corp in Memphis, Tenn.
“They showed efficacy, they showed safety – very nice – user friendliness – very good. Certainly they look like they’re trying to address a highly important, unmet need in a very elegant way. Certainly, they pointed out it needs longer follow-up to see sustainability. We need to see will this work in other settings. Will this be cost-effective? You’ve gotta believe it probably will be,” he said.
CBSM has previously been shown to help patients with cancer reduce stress, improve general and cancer-specific quality of life at various stages of treatment, reduce symptom burden, and improve coping skills, Ms. Ramiller said.
To see whether these benefits could be conveyed digitally rather than in face-to-face encounters, Ms. Ramiller and colleagues worked with Dr. Antoni to develop the CBSM app.
Patients using the app received therapeutic content over 10 sessions with audio, video, and interactive tools that mimicked the sessions they would have received during in-person interventions.
They then compared the app against the control educational app in the randomized, decentralized RESTORE study.
High-quality control
Ms. Ramiller said that the control app set “a high bar.”
“The control also offered 10 interactive self-guided sessions. Both treatment apps were professionally designed and visually similar in styling, and they were presented as digital therapeutic-specific for cancer patients. And they were also in a match condition, meaning they received the same attention from study staff and cadence of reminders, but importantly, only the intervention app was based on CBSM,” she explained.
A total of 449 patients with cancers of stage I–III who were undergoing active systemic treatment or were planning to undergo such treatment within 6 months were randomly assigned to the CBSM app or the control app.
The CBSM app was superior to the control app for the primary outcome of anxiety reduction over baseline, as measured at 4, 8 and 12 weeks by the Patient-Reported Outcomes Measurement Information System Anxiety Scale (PROMIS-A) (beta = -.03; P = .019).
CBSM was also significantly better than the control app for the secondary endpoints of reducing symptoms of depression, as measured by the PROMIS-D scale (beta = -.02, P = .042), and also at increasing the percentage of patients who reported improvement in anxiety and depression symptoms on the Patient Global Impression of Change instrument (P < .001)
An extension study of the durability of the effects at 3 and 6 months is underway.
The investigators noted that the incremental cost of management of anxiety or depression is greater than $17,000 per patient per year.
“One of the big promises of a digital therapeutic like this is that it could potentially reduce costs,” Ms. Ramiller told the audience, but she acknowledged, “More work is really needed, however, to directly test the potential savings.”
The RESTORE study is funded by Blue Note Therapeutics. Dr. Osarogiagbon owns stock in Gilead, Lilly, and Pfizer, has received honoraria from Biodesix and Medscape, and has a consulting or advisory role for the American Cancer Society AstraZeneca, Genentech/Roche, LUNGevity, National Cancer Institute, and Triptych Health Partners.
A version of this article originally appeared on Medscape.com.
AT ASCO 2023
AAP statement on child pedestrian safety: Educate families, advocate for walkable communities
The policy statement recommends that pediatricians advocate for environmental and urban planning that aims for no pedestrian fatalities or serious injuries, according to authors Sadiqa A. I. Kendi, MD, MPH, CPST; and Brian D. Johnston, MD, MPH, and colleagues.
While pedestrian fatalities have declined over the last 3 decades, child pedestrian fatalities have increased by 11% since 2013, the AAP Council on Injury, Violence, and Poison Prevention noted. Many of these fatalities occur in rural areas, during 6 to 9 p.m., mid-block rather than at intersections, and among adolescents aged 10-19 years, according to statistics from the National Highway Traffic Safety Administration.
“The reminder to ‘Look both ways before you cross the street,’ is good advice, but just part of the equation,” Dr. Kendi stated in a press release. “Research tells us that an even more effective way to consistently improve safety is when communities take intentional steps to create pedestrian-safe environments. We live in a busy, distracted world, and when local leaders create walkable spaces, they also enhance the appeal and vibrance of their communities.”
Advocating for safer communities
The AAP’s policy statement recommends that pediatricians advocate for legislation at the federal, state, and local level that supports a “Complete Streets” policy of including all forms of transportation and people on the roadways as well as incorporates a “Vision Zero” policy of reducing traffic fatalities and injuries. Other recommendations include supporting legislation that reduces speeds in urban areas, and the use of photo speed limit enforcement in areas such as school zones.
The AAP also highlighted the need for the adoption of new safety technology such as pedestrian detection systems, automatic braking in vehicles, and the consideration of child pedestrians with the development of new technologies such as autonomous vehicles.
“Drivers may not see small children when backing up their vehicles in a driveway or lot,” Dr. Kendi said. “Newer and self-driving vehicles are increasingly equipped with safety features and technology to detect pedestrians and avoid crashes, but they’re often more likely to detect adults and may not be able to account for the less predictable movements of a small child.”
In addition, the AAP’s policy statement recommends that pediatricians participate in community advocacy for safer and healthier pedestrian environments, community-level Vision Zero interventions, development of safe routes to school, alternative nonmotorized transportation methods to reduce vehicular traffic, the development of pedestrian infrastructure in communities, 20-mph zones in residential and commercial areas, research into pedestrian education, and surveillance systems that could identify locations where pedestrian injury is a high risk.
Educating families on pedestrian safety
There is also an opportunity to engage in anticipatory guidance with children and their parents, according to the policy statement. The AAP recommends pediatricians counsel families on the complexity of the traffic environment, remind parents that children may not be visible to drivers, and that driveways and unfenced yards are considered unsafe play areas. Adults should be with children aged younger than 10 years and teach young children the importance of pedestrian safety based on the child’s developmental level, the AAP said. When children are older, they can be more independent, but should still use “protected routes with signalized crossings in low-traffic environments,” they noted.
For parents of children with limited mobility or another disability, extra time may be needed to help children safely navigate a pedestrian environment, the AAP explained. “This might include selection of routes with low barriers to mobility, interventions to increase pedestrian visibility, instruction on use of audible pedestrian signals, and white-cane skills for children with visual impairment,” they noted.
All children should be educated on the risk of distracted walking, whether through texting, talking on the phone, or listening to music.
“We know that active transportation, like walking or biking, is good for kids and it’s good for the environment,” Brian D. Johnston, MD, MPH, coauthor of the report, said in a press release. “As children grow older, they will be able to be more independent. Each of us can help keep children safe by paying attention to the people around us and by promoting safer environments that benefit all of us.”
‘Pediatricians always find a way to reach their patients’
In an interview, Christina Johns, MD, MEd, pediatric emergency doctor and senior medical adviser at PM Pediatric Care, said that implementing this policy statement “requires a multilayered approach” that includes funding infrastructure and city planning, policy changes, family education, and other stakeholders and “will require support and buy-in at all levels.”
“While challenging to implement, the return in potential lives saved and additional health benefits of increased mobility for children (decreasing obesity burden, for example) cannot be overstated,” Dr. Johns said. “It will be helpful to create a checklist of the recommended counseling points that can be added to health records to keep this topic top of mind and document that it has been discussed at well visits.”
Emma Sartin, PhD, MPH, a research scientist at the Center for Injury Research and Prevention at Children’s Hospital of Philadelphia, said environmental risks will still be present regardless of whether a child is a safe pedestrian. “Adults and children need to balance practical safe mobility behavior with being present and aware in the current moment; as a pedestrian, without the protection of active and passive safety systems in motor vehicles, staying vigilant is critical to safety,” she said. Many pedestrian injuries and fatalities come from marginalized racial and ethnic groups, and those with neurodivergent statuses, Dr. Sartin explained, who “get licensed later than their peers, which may make being a pedestrian or using other modes of transportation (such as cycling) necessary.”
“These groups also often have higher rates of crash injuries and fatalities when they are inside of vehicles,” she said. “We need to be better at supporting safe mobility across different transportation options – driving, walking, cycling, and public transit – for all children and adults.”
Pediatricians excel at using anticipatory guidance to counsel families, and the refinements in the latest AAP policy statement on child pedestrian safety are something pediatricians can focus on at well visits, Dr. Johns said. Specific age groups will require pediatricians to adjust their conversation based on the child’s development as well as the family’s questions and concerns, she noted.
Dorothy Novick, MD, a pediatrician at Children’s Hospital of Philadelphia, said guidance to families will change as a child grows and develops, starting with teaching young children to hold hands when crossing the street, and not to play near driveways and roads.
“As children grow older, I remind families what I myself was surprised to learn as a new parent – that most children don’t develop the depth perception, judgment, and motor skills they need to cross the street safely by themselves until they’re at least 10 years old,” she explained. “Of course, with teens we place enormous emphasis on avoiding distractions, such as texting and watching videos while walking. One message remains the same for all parents, no matter the child’s age – the importance of modeling safe pedestrian behavior.
“Even during busy annual checkups, pediatricians always find a way to reach their patients and families about topics important to child health and wellness, so I have confidence that my colleagues and I will execute this mission,” Dr. Johns said. “The time required for advocacy and lobbying can be challenging however, and so having advocacy groups like the AAP is key to creating agency for pediatricians to have a voice in their communities and the legislature.
“Children cannot speak or advocate for themselves when it comes to funding, development of social programs or safety policy, or infrastructure planning and building, so it’s up to pediatricians to have a loud and unified voice to make sure that we watch out for their safety and incorporate their unique needs into their surroundings as much as possible,” she added.
The AAP reports that it has not accepted commercial involvement in developing the policy statement, and all authors have resolved potential conflicts of interest through a process approved by the AAP board of directors. Dr. Johns, Dr. Novick, and Dr. Sartin report no relevant financial disclosures.
The policy statement recommends that pediatricians advocate for environmental and urban planning that aims for no pedestrian fatalities or serious injuries, according to authors Sadiqa A. I. Kendi, MD, MPH, CPST; and Brian D. Johnston, MD, MPH, and colleagues.
While pedestrian fatalities have declined over the last 3 decades, child pedestrian fatalities have increased by 11% since 2013, the AAP Council on Injury, Violence, and Poison Prevention noted. Many of these fatalities occur in rural areas, during 6 to 9 p.m., mid-block rather than at intersections, and among adolescents aged 10-19 years, according to statistics from the National Highway Traffic Safety Administration.
“The reminder to ‘Look both ways before you cross the street,’ is good advice, but just part of the equation,” Dr. Kendi stated in a press release. “Research tells us that an even more effective way to consistently improve safety is when communities take intentional steps to create pedestrian-safe environments. We live in a busy, distracted world, and when local leaders create walkable spaces, they also enhance the appeal and vibrance of their communities.”
Advocating for safer communities
The AAP’s policy statement recommends that pediatricians advocate for legislation at the federal, state, and local level that supports a “Complete Streets” policy of including all forms of transportation and people on the roadways as well as incorporates a “Vision Zero” policy of reducing traffic fatalities and injuries. Other recommendations include supporting legislation that reduces speeds in urban areas, and the use of photo speed limit enforcement in areas such as school zones.
The AAP also highlighted the need for the adoption of new safety technology such as pedestrian detection systems, automatic braking in vehicles, and the consideration of child pedestrians with the development of new technologies such as autonomous vehicles.
“Drivers may not see small children when backing up their vehicles in a driveway or lot,” Dr. Kendi said. “Newer and self-driving vehicles are increasingly equipped with safety features and technology to detect pedestrians and avoid crashes, but they’re often more likely to detect adults and may not be able to account for the less predictable movements of a small child.”
In addition, the AAP’s policy statement recommends that pediatricians participate in community advocacy for safer and healthier pedestrian environments, community-level Vision Zero interventions, development of safe routes to school, alternative nonmotorized transportation methods to reduce vehicular traffic, the development of pedestrian infrastructure in communities, 20-mph zones in residential and commercial areas, research into pedestrian education, and surveillance systems that could identify locations where pedestrian injury is a high risk.
Educating families on pedestrian safety
There is also an opportunity to engage in anticipatory guidance with children and their parents, according to the policy statement. The AAP recommends pediatricians counsel families on the complexity of the traffic environment, remind parents that children may not be visible to drivers, and that driveways and unfenced yards are considered unsafe play areas. Adults should be with children aged younger than 10 years and teach young children the importance of pedestrian safety based on the child’s developmental level, the AAP said. When children are older, they can be more independent, but should still use “protected routes with signalized crossings in low-traffic environments,” they noted.
For parents of children with limited mobility or another disability, extra time may be needed to help children safely navigate a pedestrian environment, the AAP explained. “This might include selection of routes with low barriers to mobility, interventions to increase pedestrian visibility, instruction on use of audible pedestrian signals, and white-cane skills for children with visual impairment,” they noted.
All children should be educated on the risk of distracted walking, whether through texting, talking on the phone, or listening to music.
“We know that active transportation, like walking or biking, is good for kids and it’s good for the environment,” Brian D. Johnston, MD, MPH, coauthor of the report, said in a press release. “As children grow older, they will be able to be more independent. Each of us can help keep children safe by paying attention to the people around us and by promoting safer environments that benefit all of us.”
‘Pediatricians always find a way to reach their patients’
In an interview, Christina Johns, MD, MEd, pediatric emergency doctor and senior medical adviser at PM Pediatric Care, said that implementing this policy statement “requires a multilayered approach” that includes funding infrastructure and city planning, policy changes, family education, and other stakeholders and “will require support and buy-in at all levels.”
“While challenging to implement, the return in potential lives saved and additional health benefits of increased mobility for children (decreasing obesity burden, for example) cannot be overstated,” Dr. Johns said. “It will be helpful to create a checklist of the recommended counseling points that can be added to health records to keep this topic top of mind and document that it has been discussed at well visits.”
Emma Sartin, PhD, MPH, a research scientist at the Center for Injury Research and Prevention at Children’s Hospital of Philadelphia, said environmental risks will still be present regardless of whether a child is a safe pedestrian. “Adults and children need to balance practical safe mobility behavior with being present and aware in the current moment; as a pedestrian, without the protection of active and passive safety systems in motor vehicles, staying vigilant is critical to safety,” she said. Many pedestrian injuries and fatalities come from marginalized racial and ethnic groups, and those with neurodivergent statuses, Dr. Sartin explained, who “get licensed later than their peers, which may make being a pedestrian or using other modes of transportation (such as cycling) necessary.”
“These groups also often have higher rates of crash injuries and fatalities when they are inside of vehicles,” she said. “We need to be better at supporting safe mobility across different transportation options – driving, walking, cycling, and public transit – for all children and adults.”
Pediatricians excel at using anticipatory guidance to counsel families, and the refinements in the latest AAP policy statement on child pedestrian safety are something pediatricians can focus on at well visits, Dr. Johns said. Specific age groups will require pediatricians to adjust their conversation based on the child’s development as well as the family’s questions and concerns, she noted.
Dorothy Novick, MD, a pediatrician at Children’s Hospital of Philadelphia, said guidance to families will change as a child grows and develops, starting with teaching young children to hold hands when crossing the street, and not to play near driveways and roads.
“As children grow older, I remind families what I myself was surprised to learn as a new parent – that most children don’t develop the depth perception, judgment, and motor skills they need to cross the street safely by themselves until they’re at least 10 years old,” she explained. “Of course, with teens we place enormous emphasis on avoiding distractions, such as texting and watching videos while walking. One message remains the same for all parents, no matter the child’s age – the importance of modeling safe pedestrian behavior.
“Even during busy annual checkups, pediatricians always find a way to reach their patients and families about topics important to child health and wellness, so I have confidence that my colleagues and I will execute this mission,” Dr. Johns said. “The time required for advocacy and lobbying can be challenging however, and so having advocacy groups like the AAP is key to creating agency for pediatricians to have a voice in their communities and the legislature.
“Children cannot speak or advocate for themselves when it comes to funding, development of social programs or safety policy, or infrastructure planning and building, so it’s up to pediatricians to have a loud and unified voice to make sure that we watch out for their safety and incorporate their unique needs into their surroundings as much as possible,” she added.
The AAP reports that it has not accepted commercial involvement in developing the policy statement, and all authors have resolved potential conflicts of interest through a process approved by the AAP board of directors. Dr. Johns, Dr. Novick, and Dr. Sartin report no relevant financial disclosures.
The policy statement recommends that pediatricians advocate for environmental and urban planning that aims for no pedestrian fatalities or serious injuries, according to authors Sadiqa A. I. Kendi, MD, MPH, CPST; and Brian D. Johnston, MD, MPH, and colleagues.
While pedestrian fatalities have declined over the last 3 decades, child pedestrian fatalities have increased by 11% since 2013, the AAP Council on Injury, Violence, and Poison Prevention noted. Many of these fatalities occur in rural areas, during 6 to 9 p.m., mid-block rather than at intersections, and among adolescents aged 10-19 years, according to statistics from the National Highway Traffic Safety Administration.
“The reminder to ‘Look both ways before you cross the street,’ is good advice, but just part of the equation,” Dr. Kendi stated in a press release. “Research tells us that an even more effective way to consistently improve safety is when communities take intentional steps to create pedestrian-safe environments. We live in a busy, distracted world, and when local leaders create walkable spaces, they also enhance the appeal and vibrance of their communities.”
Advocating for safer communities
The AAP’s policy statement recommends that pediatricians advocate for legislation at the federal, state, and local level that supports a “Complete Streets” policy of including all forms of transportation and people on the roadways as well as incorporates a “Vision Zero” policy of reducing traffic fatalities and injuries. Other recommendations include supporting legislation that reduces speeds in urban areas, and the use of photo speed limit enforcement in areas such as school zones.
The AAP also highlighted the need for the adoption of new safety technology such as pedestrian detection systems, automatic braking in vehicles, and the consideration of child pedestrians with the development of new technologies such as autonomous vehicles.
“Drivers may not see small children when backing up their vehicles in a driveway or lot,” Dr. Kendi said. “Newer and self-driving vehicles are increasingly equipped with safety features and technology to detect pedestrians and avoid crashes, but they’re often more likely to detect adults and may not be able to account for the less predictable movements of a small child.”
In addition, the AAP’s policy statement recommends that pediatricians participate in community advocacy for safer and healthier pedestrian environments, community-level Vision Zero interventions, development of safe routes to school, alternative nonmotorized transportation methods to reduce vehicular traffic, the development of pedestrian infrastructure in communities, 20-mph zones in residential and commercial areas, research into pedestrian education, and surveillance systems that could identify locations where pedestrian injury is a high risk.
Educating families on pedestrian safety
There is also an opportunity to engage in anticipatory guidance with children and their parents, according to the policy statement. The AAP recommends pediatricians counsel families on the complexity of the traffic environment, remind parents that children may not be visible to drivers, and that driveways and unfenced yards are considered unsafe play areas. Adults should be with children aged younger than 10 years and teach young children the importance of pedestrian safety based on the child’s developmental level, the AAP said. When children are older, they can be more independent, but should still use “protected routes with signalized crossings in low-traffic environments,” they noted.
For parents of children with limited mobility or another disability, extra time may be needed to help children safely navigate a pedestrian environment, the AAP explained. “This might include selection of routes with low barriers to mobility, interventions to increase pedestrian visibility, instruction on use of audible pedestrian signals, and white-cane skills for children with visual impairment,” they noted.
All children should be educated on the risk of distracted walking, whether through texting, talking on the phone, or listening to music.
“We know that active transportation, like walking or biking, is good for kids and it’s good for the environment,” Brian D. Johnston, MD, MPH, coauthor of the report, said in a press release. “As children grow older, they will be able to be more independent. Each of us can help keep children safe by paying attention to the people around us and by promoting safer environments that benefit all of us.”
‘Pediatricians always find a way to reach their patients’
In an interview, Christina Johns, MD, MEd, pediatric emergency doctor and senior medical adviser at PM Pediatric Care, said that implementing this policy statement “requires a multilayered approach” that includes funding infrastructure and city planning, policy changes, family education, and other stakeholders and “will require support and buy-in at all levels.”
“While challenging to implement, the return in potential lives saved and additional health benefits of increased mobility for children (decreasing obesity burden, for example) cannot be overstated,” Dr. Johns said. “It will be helpful to create a checklist of the recommended counseling points that can be added to health records to keep this topic top of mind and document that it has been discussed at well visits.”
Emma Sartin, PhD, MPH, a research scientist at the Center for Injury Research and Prevention at Children’s Hospital of Philadelphia, said environmental risks will still be present regardless of whether a child is a safe pedestrian. “Adults and children need to balance practical safe mobility behavior with being present and aware in the current moment; as a pedestrian, without the protection of active and passive safety systems in motor vehicles, staying vigilant is critical to safety,” she said. Many pedestrian injuries and fatalities come from marginalized racial and ethnic groups, and those with neurodivergent statuses, Dr. Sartin explained, who “get licensed later than their peers, which may make being a pedestrian or using other modes of transportation (such as cycling) necessary.”
“These groups also often have higher rates of crash injuries and fatalities when they are inside of vehicles,” she said. “We need to be better at supporting safe mobility across different transportation options – driving, walking, cycling, and public transit – for all children and adults.”
Pediatricians excel at using anticipatory guidance to counsel families, and the refinements in the latest AAP policy statement on child pedestrian safety are something pediatricians can focus on at well visits, Dr. Johns said. Specific age groups will require pediatricians to adjust their conversation based on the child’s development as well as the family’s questions and concerns, she noted.
Dorothy Novick, MD, a pediatrician at Children’s Hospital of Philadelphia, said guidance to families will change as a child grows and develops, starting with teaching young children to hold hands when crossing the street, and not to play near driveways and roads.
“As children grow older, I remind families what I myself was surprised to learn as a new parent – that most children don’t develop the depth perception, judgment, and motor skills they need to cross the street safely by themselves until they’re at least 10 years old,” she explained. “Of course, with teens we place enormous emphasis on avoiding distractions, such as texting and watching videos while walking. One message remains the same for all parents, no matter the child’s age – the importance of modeling safe pedestrian behavior.
“Even during busy annual checkups, pediatricians always find a way to reach their patients and families about topics important to child health and wellness, so I have confidence that my colleagues and I will execute this mission,” Dr. Johns said. “The time required for advocacy and lobbying can be challenging however, and so having advocacy groups like the AAP is key to creating agency for pediatricians to have a voice in their communities and the legislature.
“Children cannot speak or advocate for themselves when it comes to funding, development of social programs or safety policy, or infrastructure planning and building, so it’s up to pediatricians to have a loud and unified voice to make sure that we watch out for their safety and incorporate their unique needs into their surroundings as much as possible,” she added.
The AAP reports that it has not accepted commercial involvement in developing the policy statement, and all authors have resolved potential conflicts of interest through a process approved by the AAP board of directors. Dr. Johns, Dr. Novick, and Dr. Sartin report no relevant financial disclosures.
FROM PEDIATRICS
Nurses won $127K after protesting NICU staffing shortage
A New York arbitrator recently fined Mount Sinai Hospital $127,000 for ongoing understaffing of its neonatal intensive care unit (NICU). At issue was the hospital’s failure to meet contractual requirements on staffing ratios, which nurses and administration agreed upon after a January nurses strike, according to Politico.
Following the strike, which primarily centered on safe staffing, the New York State Nurses Association ratified new contracts that included updated nurse-to-patient ratios and established a staffing committee with equal nurse-to-management ratios.
Failure to meet these provisions drove the nurses to seek arbitration, Matt Allen, RN, a labor and delivery nurse at Mount Sinai, said in an interview. “We hoped the administration would see this victory [the nurse strike settlement] as a warning to begin increasing the nursing staff throughout the hospital. Instead, units like the NICU continued to be critically understaffed, sometimes by up to eight nurses per shift.”
NICU nurses were frustrated by having to continue working in “dangerously understaffed shifts,” Mr. Allen said. “They saw it as disrespectful that the hospital wasn’t holding up the ratios they agreed to.” So the nurses decided to take further action to hold the hospital accountable.
Although Mount Sinai followed the arbitrator’s ruling, according to Allen, it expressed its disagreement with the findings.
In a prepared statement, the hospital wrote that the NICU is appropriately staffed to ensure safety and appropriate patient care. The recent penalties are an “unfortunate consequence” of the agreement the hospital reached with NSYNA at the end of the strike. But the ratios set in the agreement do not reflect the fact that the NICU is divided into two sections in which slightly fewer than half of the beds are designated for neonatal intensive care, and the rest are designated for intermediate/continuing care, the statement read.
“Intensive care patients are always staffed at a 1:1–1:2 ratio, while those in intermediate/continuing care are staffed 1:3 or 1:4, based on the clinical needs of the baby.”
According to Mr. Allen, the NICU’s action inspired other departments throughout the hospital to monitor their own ratios. “The hospital administration is finally taking notice,” he said.
Outside of New York, the fight to improve staffing shortages continues. In Minnesota, it was the hospital that scored a win. Mayo Clinic recently pushed back against state legislation that would have required Minnesota hospitals to create hospital nurse staffing committees.
At the end of the state’s legislative session, the bill no longer had enough votes to pass, according to a statement from the Minnesota Nurses Association.
Instead, the state legislature passed a Nurse and Patient Safety Act that included some elements of the original bill, notably, a study on nurse staffing and retention, new protections against workplace violence, provisions for childcare assistance, and student loan forgiveness for nurses, according to the MNA statement.
There’s no quick fix to the nursing shortage as the tug-of-war between hospitals and staff continues and new methods for resolution are considered, Mr. Allen said. “This staffing enforcement is not a cure-all, but it is another tool nurses now have to fight for safe staffing on our units.”
A version of this article first appeared on Medscape.com.
A New York arbitrator recently fined Mount Sinai Hospital $127,000 for ongoing understaffing of its neonatal intensive care unit (NICU). At issue was the hospital’s failure to meet contractual requirements on staffing ratios, which nurses and administration agreed upon after a January nurses strike, according to Politico.
Following the strike, which primarily centered on safe staffing, the New York State Nurses Association ratified new contracts that included updated nurse-to-patient ratios and established a staffing committee with equal nurse-to-management ratios.
Failure to meet these provisions drove the nurses to seek arbitration, Matt Allen, RN, a labor and delivery nurse at Mount Sinai, said in an interview. “We hoped the administration would see this victory [the nurse strike settlement] as a warning to begin increasing the nursing staff throughout the hospital. Instead, units like the NICU continued to be critically understaffed, sometimes by up to eight nurses per shift.”
NICU nurses were frustrated by having to continue working in “dangerously understaffed shifts,” Mr. Allen said. “They saw it as disrespectful that the hospital wasn’t holding up the ratios they agreed to.” So the nurses decided to take further action to hold the hospital accountable.
Although Mount Sinai followed the arbitrator’s ruling, according to Allen, it expressed its disagreement with the findings.
In a prepared statement, the hospital wrote that the NICU is appropriately staffed to ensure safety and appropriate patient care. The recent penalties are an “unfortunate consequence” of the agreement the hospital reached with NSYNA at the end of the strike. But the ratios set in the agreement do not reflect the fact that the NICU is divided into two sections in which slightly fewer than half of the beds are designated for neonatal intensive care, and the rest are designated for intermediate/continuing care, the statement read.
“Intensive care patients are always staffed at a 1:1–1:2 ratio, while those in intermediate/continuing care are staffed 1:3 or 1:4, based on the clinical needs of the baby.”
According to Mr. Allen, the NICU’s action inspired other departments throughout the hospital to monitor their own ratios. “The hospital administration is finally taking notice,” he said.
Outside of New York, the fight to improve staffing shortages continues. In Minnesota, it was the hospital that scored a win. Mayo Clinic recently pushed back against state legislation that would have required Minnesota hospitals to create hospital nurse staffing committees.
At the end of the state’s legislative session, the bill no longer had enough votes to pass, according to a statement from the Minnesota Nurses Association.
Instead, the state legislature passed a Nurse and Patient Safety Act that included some elements of the original bill, notably, a study on nurse staffing and retention, new protections against workplace violence, provisions for childcare assistance, and student loan forgiveness for nurses, according to the MNA statement.
There’s no quick fix to the nursing shortage as the tug-of-war between hospitals and staff continues and new methods for resolution are considered, Mr. Allen said. “This staffing enforcement is not a cure-all, but it is another tool nurses now have to fight for safe staffing on our units.”
A version of this article first appeared on Medscape.com.
A New York arbitrator recently fined Mount Sinai Hospital $127,000 for ongoing understaffing of its neonatal intensive care unit (NICU). At issue was the hospital’s failure to meet contractual requirements on staffing ratios, which nurses and administration agreed upon after a January nurses strike, according to Politico.
Following the strike, which primarily centered on safe staffing, the New York State Nurses Association ratified new contracts that included updated nurse-to-patient ratios and established a staffing committee with equal nurse-to-management ratios.
Failure to meet these provisions drove the nurses to seek arbitration, Matt Allen, RN, a labor and delivery nurse at Mount Sinai, said in an interview. “We hoped the administration would see this victory [the nurse strike settlement] as a warning to begin increasing the nursing staff throughout the hospital. Instead, units like the NICU continued to be critically understaffed, sometimes by up to eight nurses per shift.”
NICU nurses were frustrated by having to continue working in “dangerously understaffed shifts,” Mr. Allen said. “They saw it as disrespectful that the hospital wasn’t holding up the ratios they agreed to.” So the nurses decided to take further action to hold the hospital accountable.
Although Mount Sinai followed the arbitrator’s ruling, according to Allen, it expressed its disagreement with the findings.
In a prepared statement, the hospital wrote that the NICU is appropriately staffed to ensure safety and appropriate patient care. The recent penalties are an “unfortunate consequence” of the agreement the hospital reached with NSYNA at the end of the strike. But the ratios set in the agreement do not reflect the fact that the NICU is divided into two sections in which slightly fewer than half of the beds are designated for neonatal intensive care, and the rest are designated for intermediate/continuing care, the statement read.
“Intensive care patients are always staffed at a 1:1–1:2 ratio, while those in intermediate/continuing care are staffed 1:3 or 1:4, based on the clinical needs of the baby.”
According to Mr. Allen, the NICU’s action inspired other departments throughout the hospital to monitor their own ratios. “The hospital administration is finally taking notice,” he said.
Outside of New York, the fight to improve staffing shortages continues. In Minnesota, it was the hospital that scored a win. Mayo Clinic recently pushed back against state legislation that would have required Minnesota hospitals to create hospital nurse staffing committees.
At the end of the state’s legislative session, the bill no longer had enough votes to pass, according to a statement from the Minnesota Nurses Association.
Instead, the state legislature passed a Nurse and Patient Safety Act that included some elements of the original bill, notably, a study on nurse staffing and retention, new protections against workplace violence, provisions for childcare assistance, and student loan forgiveness for nurses, according to the MNA statement.
There’s no quick fix to the nursing shortage as the tug-of-war between hospitals and staff continues and new methods for resolution are considered, Mr. Allen said. “This staffing enforcement is not a cure-all, but it is another tool nurses now have to fight for safe staffing on our units.”
A version of this article first appeared on Medscape.com.
Migraine device expands treatment possibilities
AUSTIN, TEX – Migraine treatment and prevention is challenging in any population, but some present even more difficulties. Pregnant women and pediatric patients are two such groups where physicians and patients may be hesitant to use drugs.
Neuromodulation devices are proven alternatives to medical interventions, and the remote electrical neuromodulation device Nerivio (Theranica) was cleared by the Food and Drug Administration for acute treatment of migraine patients aged 12 and over in 2021. In March 2023, the agency expanded the clearance to include prevention of migration in adolescents aged 12 and over as well as adults.
Two studies presented at the annual meeting of the American Headache Society showed The latter study yielded similar findings to adults and was used by FDA in its decision to expand the device’s indication in adolescents in 2023, according to Teshamae Monteith, MD, who presented the study at a poster session.
The device, worn on the arm, allows the user to modulate the intensity of the stimulation so that it activates nociceptive pain receptors, but not in a painful way. “Each [patient] raises the intensity until it feels strong, yet comfortable, and when that happens, they activate the nociceptive receptors and the arm sends a signal all the way back up to the brainstem, where the pain control area is. Activating it causes the release of neurotransmitters that inhibit pain. That inhibition is a global pain inhibition mechanism, which causes inhibition of the migraine pain, and also the symptoms associated with migraine like photophobia and vomiting,” said Alit Stark-Inbar, PhD, who presented the study of treatment of pregnant women during a poster session.
Declining treatment days over time in adolescents
Dr. Monteith’s team studied high-frequency remote electrical neuromodulation device use in adolescents who had migraine on 10 days or more per month. They also required at least three treatment days in months 2 and 3 to control for the possibility that patients might stop using the device because they couldn’t afford it or for some reason other than efficacy or because their migraines went away.
The study included 83 adolescents aged 12-17 (mean, 15.9 years, 89% female). In the first month of use, the mean number of migraine treatment days was 12.6, which dropped to 9.0 in month 2 (P < .001), and 7.4 in month 3 (P < .001 from month 2). At 2 hours after treatment, 61.9% had pain relief, 24.5% had freedom from pain, 67.4% had functional disability relief, and 41.3% had functional disability freedom.
“It parallels the findings of the randomized, sham-controlled study in adults. The safety profile was excellent with just one person complaining of minor discomfort of the arm that resolved after treatment. The combination of the exceedingly safe profile and the likelihood of efficacy based on using monthly migraine treatment days as a proxy, the FDA decided to clear this for an adolescent indication,” said Dr. Monteith, associate professor of clinical neurology and chief of the headache division at the University of Miami.
The device design is convenient, according to Dr. Monteith. “The arm is just an easy place to stimulate. It’s a wearable device, and it’s 45 minutes [of treatment] and it’s app controlled. You know adolescents like their technology. They can track their symptoms here, and there’s some biobehavioral power to this because they can do biobehavioral exercises in addition to receiving the simulation,” she said.
The fact that the device is discrete is also an advantage for adolescents in school. “You have to go to the nurse to get your medication versus a device, you can just put it on, it’s easy, no one sees it, and no one’s making fun of you,” said Dr. Monteith.
Advantages for adolescents
The device offers a useful alternative to medication, according to Alan M. Rapoport, MD, who was asked for comment on the adolescent study. “I’d rather not give medication and certainly not preventive medication to an adolescent,” he said. He noted that over-the-counter acute care migraine medications such as aspirin or acetaminophen and combination medications with caffeine, as well as prescription medications such as triptans, “all have possible side effects, and when used to an increased extent can even cause medication overuse headache, increasing the severity and frequency of headache and migraine days per month,” Dr. Rapoport said. Using an effective device with almost no side effects is preferable to any of these acute care medications, especially if there are several headaches a month,” he said. Some newer medications that block calcitonin gene-related peptide might be quite effective when they are approved for adolescents, and should have few adverse events, he added.
In the past, Dr. Rapoport has favored biofeedback training for acute and especially preventive treatment of migraine in adolescents. “[Remote electrical neuromodulation] seems to do just as well, children enjoy it, and it’s easier for a patient to do at home,” said Dr. Rapoport.
Biofeedback training is usually taught to patients by a PhD psychologist. Once the patients have been on the biofeedback equipment and learn the techniques, they can practice on their own at home without equipment. “This new device treatment using Nerivio for acute care and prevention of migraine in adults and children 12 and older, where they can easily apply the device in almost any situation, whether they are at home or possibly even in school or out and about, looks very promising,” said Dr. Rapoport. It is quite effective and has almost no adverse events, which is what you really want, especially for adolescents,” he said.
Also asked to comment on the study of remote electrical neuromodulation use in adolescents, Abraham Avi Ashkenazi, MD, director of the Headache Clinic at Shaare Zedek Medical Center in Jerusalem, who attended the session, was enthusiastic, and said he has begun using it in his own practice. “It shows that remote electrical neuromodulation can not only be effective for the acute migraine attack, but also has a potential preventive effect on future migraine attacks. [This] actually makes sense, because we know that the more migraine attacks a person has, the more likely they are to progress to a more chronic form of the disease,” he said in an interview.
Asked what distinguishes REN from other neuromodulation therapies such as vagus nerve stimulation or transcranial magnetic stimulation (TMS), Dr. Ashkenazi said: “It’s just a different way of modulating the brain system via a different mechanism. In both ways, though, the advantage is that there are literally no adverse effects, as opposed to drug treatment.”
An alternative during pregnancy
Adolescents aren’t the only population where there is reluctance to use medication. Physicians have been prescribing the device for pregnant women, who are reluctant to take medication due to concerns effects on the fetus. However, pregnant women were not included in the pivotal studies. “They expect it to be safe. This study was done in order to validate that assumption. We reached out to women who either used the device during pregnancy or women from the same database who started it using afterwards, but did not use it during the pregnancy,” said Dr. Stark-Inbar, vice president of medical information at Theranica.
The study included 140 women, 59 in the remote electrical neuromodulation device group and 81 controls. The primary endpoint was gestational age, which was 38 weeks and 5 days in the remote electrical neuromodulation device group and 39 weeks among controls (P = .150). There were no significant between-group differences with respect to newborn birth weight, miscarriage rate, preterm birth rate, birth defect rate, developmental milestone rate, or emergency department visit rate.
Dr. Monteith and Dr. Ashkenazi have no relevant financial disclosures. Dr. Rapoport advises AbbVie, Biohaven, Cala Health, Dr. Reddy’s, Pfizer, Satsuma, Teva Pharmaceutical Industries, and Theranica. He is on the speakers bureau of AbbVie, Dr. Reddy’s, Impel, Pfizer and Teva Pharmaceutical Industries. Dr. Rapoport is the editor-in-chief of Neurology Reviews and on the editorial board of CNS Drugs.
AUSTIN, TEX – Migraine treatment and prevention is challenging in any population, but some present even more difficulties. Pregnant women and pediatric patients are two such groups where physicians and patients may be hesitant to use drugs.
Neuromodulation devices are proven alternatives to medical interventions, and the remote electrical neuromodulation device Nerivio (Theranica) was cleared by the Food and Drug Administration for acute treatment of migraine patients aged 12 and over in 2021. In March 2023, the agency expanded the clearance to include prevention of migration in adolescents aged 12 and over as well as adults.
Two studies presented at the annual meeting of the American Headache Society showed The latter study yielded similar findings to adults and was used by FDA in its decision to expand the device’s indication in adolescents in 2023, according to Teshamae Monteith, MD, who presented the study at a poster session.
The device, worn on the arm, allows the user to modulate the intensity of the stimulation so that it activates nociceptive pain receptors, but not in a painful way. “Each [patient] raises the intensity until it feels strong, yet comfortable, and when that happens, they activate the nociceptive receptors and the arm sends a signal all the way back up to the brainstem, where the pain control area is. Activating it causes the release of neurotransmitters that inhibit pain. That inhibition is a global pain inhibition mechanism, which causes inhibition of the migraine pain, and also the symptoms associated with migraine like photophobia and vomiting,” said Alit Stark-Inbar, PhD, who presented the study of treatment of pregnant women during a poster session.
Declining treatment days over time in adolescents
Dr. Monteith’s team studied high-frequency remote electrical neuromodulation device use in adolescents who had migraine on 10 days or more per month. They also required at least three treatment days in months 2 and 3 to control for the possibility that patients might stop using the device because they couldn’t afford it or for some reason other than efficacy or because their migraines went away.
The study included 83 adolescents aged 12-17 (mean, 15.9 years, 89% female). In the first month of use, the mean number of migraine treatment days was 12.6, which dropped to 9.0 in month 2 (P < .001), and 7.4 in month 3 (P < .001 from month 2). At 2 hours after treatment, 61.9% had pain relief, 24.5% had freedom from pain, 67.4% had functional disability relief, and 41.3% had functional disability freedom.
“It parallels the findings of the randomized, sham-controlled study in adults. The safety profile was excellent with just one person complaining of minor discomfort of the arm that resolved after treatment. The combination of the exceedingly safe profile and the likelihood of efficacy based on using monthly migraine treatment days as a proxy, the FDA decided to clear this for an adolescent indication,” said Dr. Monteith, associate professor of clinical neurology and chief of the headache division at the University of Miami.
The device design is convenient, according to Dr. Monteith. “The arm is just an easy place to stimulate. It’s a wearable device, and it’s 45 minutes [of treatment] and it’s app controlled. You know adolescents like their technology. They can track their symptoms here, and there’s some biobehavioral power to this because they can do biobehavioral exercises in addition to receiving the simulation,” she said.
The fact that the device is discrete is also an advantage for adolescents in school. “You have to go to the nurse to get your medication versus a device, you can just put it on, it’s easy, no one sees it, and no one’s making fun of you,” said Dr. Monteith.
Advantages for adolescents
The device offers a useful alternative to medication, according to Alan M. Rapoport, MD, who was asked for comment on the adolescent study. “I’d rather not give medication and certainly not preventive medication to an adolescent,” he said. He noted that over-the-counter acute care migraine medications such as aspirin or acetaminophen and combination medications with caffeine, as well as prescription medications such as triptans, “all have possible side effects, and when used to an increased extent can even cause medication overuse headache, increasing the severity and frequency of headache and migraine days per month,” Dr. Rapoport said. Using an effective device with almost no side effects is preferable to any of these acute care medications, especially if there are several headaches a month,” he said. Some newer medications that block calcitonin gene-related peptide might be quite effective when they are approved for adolescents, and should have few adverse events, he added.
In the past, Dr. Rapoport has favored biofeedback training for acute and especially preventive treatment of migraine in adolescents. “[Remote electrical neuromodulation] seems to do just as well, children enjoy it, and it’s easier for a patient to do at home,” said Dr. Rapoport.
Biofeedback training is usually taught to patients by a PhD psychologist. Once the patients have been on the biofeedback equipment and learn the techniques, they can practice on their own at home without equipment. “This new device treatment using Nerivio for acute care and prevention of migraine in adults and children 12 and older, where they can easily apply the device in almost any situation, whether they are at home or possibly even in school or out and about, looks very promising,” said Dr. Rapoport. It is quite effective and has almost no adverse events, which is what you really want, especially for adolescents,” he said.
Also asked to comment on the study of remote electrical neuromodulation use in adolescents, Abraham Avi Ashkenazi, MD, director of the Headache Clinic at Shaare Zedek Medical Center in Jerusalem, who attended the session, was enthusiastic, and said he has begun using it in his own practice. “It shows that remote electrical neuromodulation can not only be effective for the acute migraine attack, but also has a potential preventive effect on future migraine attacks. [This] actually makes sense, because we know that the more migraine attacks a person has, the more likely they are to progress to a more chronic form of the disease,” he said in an interview.
Asked what distinguishes REN from other neuromodulation therapies such as vagus nerve stimulation or transcranial magnetic stimulation (TMS), Dr. Ashkenazi said: “It’s just a different way of modulating the brain system via a different mechanism. In both ways, though, the advantage is that there are literally no adverse effects, as opposed to drug treatment.”
An alternative during pregnancy
Adolescents aren’t the only population where there is reluctance to use medication. Physicians have been prescribing the device for pregnant women, who are reluctant to take medication due to concerns effects on the fetus. However, pregnant women were not included in the pivotal studies. “They expect it to be safe. This study was done in order to validate that assumption. We reached out to women who either used the device during pregnancy or women from the same database who started it using afterwards, but did not use it during the pregnancy,” said Dr. Stark-Inbar, vice president of medical information at Theranica.
The study included 140 women, 59 in the remote electrical neuromodulation device group and 81 controls. The primary endpoint was gestational age, which was 38 weeks and 5 days in the remote electrical neuromodulation device group and 39 weeks among controls (P = .150). There were no significant between-group differences with respect to newborn birth weight, miscarriage rate, preterm birth rate, birth defect rate, developmental milestone rate, or emergency department visit rate.
Dr. Monteith and Dr. Ashkenazi have no relevant financial disclosures. Dr. Rapoport advises AbbVie, Biohaven, Cala Health, Dr. Reddy’s, Pfizer, Satsuma, Teva Pharmaceutical Industries, and Theranica. He is on the speakers bureau of AbbVie, Dr. Reddy’s, Impel, Pfizer and Teva Pharmaceutical Industries. Dr. Rapoport is the editor-in-chief of Neurology Reviews and on the editorial board of CNS Drugs.
AUSTIN, TEX – Migraine treatment and prevention is challenging in any population, but some present even more difficulties. Pregnant women and pediatric patients are two such groups where physicians and patients may be hesitant to use drugs.
Neuromodulation devices are proven alternatives to medical interventions, and the remote electrical neuromodulation device Nerivio (Theranica) was cleared by the Food and Drug Administration for acute treatment of migraine patients aged 12 and over in 2021. In March 2023, the agency expanded the clearance to include prevention of migration in adolescents aged 12 and over as well as adults.
Two studies presented at the annual meeting of the American Headache Society showed The latter study yielded similar findings to adults and was used by FDA in its decision to expand the device’s indication in adolescents in 2023, according to Teshamae Monteith, MD, who presented the study at a poster session.
The device, worn on the arm, allows the user to modulate the intensity of the stimulation so that it activates nociceptive pain receptors, but not in a painful way. “Each [patient] raises the intensity until it feels strong, yet comfortable, and when that happens, they activate the nociceptive receptors and the arm sends a signal all the way back up to the brainstem, where the pain control area is. Activating it causes the release of neurotransmitters that inhibit pain. That inhibition is a global pain inhibition mechanism, which causes inhibition of the migraine pain, and also the symptoms associated with migraine like photophobia and vomiting,” said Alit Stark-Inbar, PhD, who presented the study of treatment of pregnant women during a poster session.
Declining treatment days over time in adolescents
Dr. Monteith’s team studied high-frequency remote electrical neuromodulation device use in adolescents who had migraine on 10 days or more per month. They also required at least three treatment days in months 2 and 3 to control for the possibility that patients might stop using the device because they couldn’t afford it or for some reason other than efficacy or because their migraines went away.
The study included 83 adolescents aged 12-17 (mean, 15.9 years, 89% female). In the first month of use, the mean number of migraine treatment days was 12.6, which dropped to 9.0 in month 2 (P < .001), and 7.4 in month 3 (P < .001 from month 2). At 2 hours after treatment, 61.9% had pain relief, 24.5% had freedom from pain, 67.4% had functional disability relief, and 41.3% had functional disability freedom.
“It parallels the findings of the randomized, sham-controlled study in adults. The safety profile was excellent with just one person complaining of minor discomfort of the arm that resolved after treatment. The combination of the exceedingly safe profile and the likelihood of efficacy based on using monthly migraine treatment days as a proxy, the FDA decided to clear this for an adolescent indication,” said Dr. Monteith, associate professor of clinical neurology and chief of the headache division at the University of Miami.
The device design is convenient, according to Dr. Monteith. “The arm is just an easy place to stimulate. It’s a wearable device, and it’s 45 minutes [of treatment] and it’s app controlled. You know adolescents like their technology. They can track their symptoms here, and there’s some biobehavioral power to this because they can do biobehavioral exercises in addition to receiving the simulation,” she said.
The fact that the device is discrete is also an advantage for adolescents in school. “You have to go to the nurse to get your medication versus a device, you can just put it on, it’s easy, no one sees it, and no one’s making fun of you,” said Dr. Monteith.
Advantages for adolescents
The device offers a useful alternative to medication, according to Alan M. Rapoport, MD, who was asked for comment on the adolescent study. “I’d rather not give medication and certainly not preventive medication to an adolescent,” he said. He noted that over-the-counter acute care migraine medications such as aspirin or acetaminophen and combination medications with caffeine, as well as prescription medications such as triptans, “all have possible side effects, and when used to an increased extent can even cause medication overuse headache, increasing the severity and frequency of headache and migraine days per month,” Dr. Rapoport said. Using an effective device with almost no side effects is preferable to any of these acute care medications, especially if there are several headaches a month,” he said. Some newer medications that block calcitonin gene-related peptide might be quite effective when they are approved for adolescents, and should have few adverse events, he added.
In the past, Dr. Rapoport has favored biofeedback training for acute and especially preventive treatment of migraine in adolescents. “[Remote electrical neuromodulation] seems to do just as well, children enjoy it, and it’s easier for a patient to do at home,” said Dr. Rapoport.
Biofeedback training is usually taught to patients by a PhD psychologist. Once the patients have been on the biofeedback equipment and learn the techniques, they can practice on their own at home without equipment. “This new device treatment using Nerivio for acute care and prevention of migraine in adults and children 12 and older, where they can easily apply the device in almost any situation, whether they are at home or possibly even in school or out and about, looks very promising,” said Dr. Rapoport. It is quite effective and has almost no adverse events, which is what you really want, especially for adolescents,” he said.
Also asked to comment on the study of remote electrical neuromodulation use in adolescents, Abraham Avi Ashkenazi, MD, director of the Headache Clinic at Shaare Zedek Medical Center in Jerusalem, who attended the session, was enthusiastic, and said he has begun using it in his own practice. “It shows that remote electrical neuromodulation can not only be effective for the acute migraine attack, but also has a potential preventive effect on future migraine attacks. [This] actually makes sense, because we know that the more migraine attacks a person has, the more likely they are to progress to a more chronic form of the disease,” he said in an interview.
Asked what distinguishes REN from other neuromodulation therapies such as vagus nerve stimulation or transcranial magnetic stimulation (TMS), Dr. Ashkenazi said: “It’s just a different way of modulating the brain system via a different mechanism. In both ways, though, the advantage is that there are literally no adverse effects, as opposed to drug treatment.”
An alternative during pregnancy
Adolescents aren’t the only population where there is reluctance to use medication. Physicians have been prescribing the device for pregnant women, who are reluctant to take medication due to concerns effects on the fetus. However, pregnant women were not included in the pivotal studies. “They expect it to be safe. This study was done in order to validate that assumption. We reached out to women who either used the device during pregnancy or women from the same database who started it using afterwards, but did not use it during the pregnancy,” said Dr. Stark-Inbar, vice president of medical information at Theranica.
The study included 140 women, 59 in the remote electrical neuromodulation device group and 81 controls. The primary endpoint was gestational age, which was 38 weeks and 5 days in the remote electrical neuromodulation device group and 39 weeks among controls (P = .150). There were no significant between-group differences with respect to newborn birth weight, miscarriage rate, preterm birth rate, birth defect rate, developmental milestone rate, or emergency department visit rate.
Dr. Monteith and Dr. Ashkenazi have no relevant financial disclosures. Dr. Rapoport advises AbbVie, Biohaven, Cala Health, Dr. Reddy’s, Pfizer, Satsuma, Teva Pharmaceutical Industries, and Theranica. He is on the speakers bureau of AbbVie, Dr. Reddy’s, Impel, Pfizer and Teva Pharmaceutical Industries. Dr. Rapoport is the editor-in-chief of Neurology Reviews and on the editorial board of CNS Drugs.
AT AHS 2023
No safe dose of cardiac radiation in children?
TOPLINE:
METHODOLOGY:
- Review of 25,481 patients in the Childhood Cancer Survivor Study who had no cardiac complications in the first 5 years following cancer treatment from 1970 to 1999; nearly half (48.2%) had been exposed to radiotherapy.
- Radiation doses to the coronary arteries, heart chambers, heart valves, and whole heart were calculated based on radiotherapy records.
- Median age at follow up was 29.8 years and ranged from 5.6 to 65.9 years.
TAKEAWAY:
- Mean radiation doses of 5.0-9.9 Gy to the whole heart did not increase the risk for later cardiac disease.
- Mean doses of 5.0-9.9 Gy to the right coronary artery (rate ratio, 2.6) and left ventricle (RR, 2.2) did increase the risk for subsequent coronary artery disease.
- Mean doses of 5.0-9.9 Gy to the tricuspid valve (RR, 5.5) and right ventricle (RR, 8.4) increased the risk for later valvular disease.
- Linear modeling adequately described the dose-response relationship for many cardiac substructures, suggesting there is no threshold dose necessary for cardiac damage.
IN PRACTICE:
“These findings solidify the need to consider cardiac substructure doses in [pediatric] radiation treatment planning and in survivorship care. Future work to ascertain optimal cardiac dose constraints, especially in the era of highly conformal [radiotherapy] techniques such as [intensity-modulated radiotherapy] and proton therapy, remains critical,” the authors concluded.
STUDY DETAILS:
The study was led by James Bates, MD, of Emory University, Atlanta, and published in the Journal of Clinical Oncology.
LIMITATIONS:
Chronic conditions were self-reported.
Current radiotherapy techniques are much more precise than in the decades when these cancer survivors were treated, allowing preferential sparing of various heart structures.
The study did not assess other treatments and lifestyle issues that may have affected heart health.
DISCLOSURES:
The work was funded by the National Cancer Institute. Investigators reported ties to Doximity, Abbott, Merck, Grail, and other companies.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Review of 25,481 patients in the Childhood Cancer Survivor Study who had no cardiac complications in the first 5 years following cancer treatment from 1970 to 1999; nearly half (48.2%) had been exposed to radiotherapy.
- Radiation doses to the coronary arteries, heart chambers, heart valves, and whole heart were calculated based on radiotherapy records.
- Median age at follow up was 29.8 years and ranged from 5.6 to 65.9 years.
TAKEAWAY:
- Mean radiation doses of 5.0-9.9 Gy to the whole heart did not increase the risk for later cardiac disease.
- Mean doses of 5.0-9.9 Gy to the right coronary artery (rate ratio, 2.6) and left ventricle (RR, 2.2) did increase the risk for subsequent coronary artery disease.
- Mean doses of 5.0-9.9 Gy to the tricuspid valve (RR, 5.5) and right ventricle (RR, 8.4) increased the risk for later valvular disease.
- Linear modeling adequately described the dose-response relationship for many cardiac substructures, suggesting there is no threshold dose necessary for cardiac damage.
IN PRACTICE:
“These findings solidify the need to consider cardiac substructure doses in [pediatric] radiation treatment planning and in survivorship care. Future work to ascertain optimal cardiac dose constraints, especially in the era of highly conformal [radiotherapy] techniques such as [intensity-modulated radiotherapy] and proton therapy, remains critical,” the authors concluded.
STUDY DETAILS:
The study was led by James Bates, MD, of Emory University, Atlanta, and published in the Journal of Clinical Oncology.
LIMITATIONS:
Chronic conditions were self-reported.
Current radiotherapy techniques are much more precise than in the decades when these cancer survivors were treated, allowing preferential sparing of various heart structures.
The study did not assess other treatments and lifestyle issues that may have affected heart health.
DISCLOSURES:
The work was funded by the National Cancer Institute. Investigators reported ties to Doximity, Abbott, Merck, Grail, and other companies.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Review of 25,481 patients in the Childhood Cancer Survivor Study who had no cardiac complications in the first 5 years following cancer treatment from 1970 to 1999; nearly half (48.2%) had been exposed to radiotherapy.
- Radiation doses to the coronary arteries, heart chambers, heart valves, and whole heart were calculated based on radiotherapy records.
- Median age at follow up was 29.8 years and ranged from 5.6 to 65.9 years.
TAKEAWAY:
- Mean radiation doses of 5.0-9.9 Gy to the whole heart did not increase the risk for later cardiac disease.
- Mean doses of 5.0-9.9 Gy to the right coronary artery (rate ratio, 2.6) and left ventricle (RR, 2.2) did increase the risk for subsequent coronary artery disease.
- Mean doses of 5.0-9.9 Gy to the tricuspid valve (RR, 5.5) and right ventricle (RR, 8.4) increased the risk for later valvular disease.
- Linear modeling adequately described the dose-response relationship for many cardiac substructures, suggesting there is no threshold dose necessary for cardiac damage.
IN PRACTICE:
“These findings solidify the need to consider cardiac substructure doses in [pediatric] radiation treatment planning and in survivorship care. Future work to ascertain optimal cardiac dose constraints, especially in the era of highly conformal [radiotherapy] techniques such as [intensity-modulated radiotherapy] and proton therapy, remains critical,” the authors concluded.
STUDY DETAILS:
The study was led by James Bates, MD, of Emory University, Atlanta, and published in the Journal of Clinical Oncology.
LIMITATIONS:
Chronic conditions were self-reported.
Current radiotherapy techniques are much more precise than in the decades when these cancer survivors were treated, allowing preferential sparing of various heart structures.
The study did not assess other treatments and lifestyle issues that may have affected heart health.
DISCLOSURES:
The work was funded by the National Cancer Institute. Investigators reported ties to Doximity, Abbott, Merck, Grail, and other companies.
A version of this article first appeared on Medscape.com.
Girls with congenital diaphragmatic hernia have lower survival rates
TOPLINE:
, a study published in the Journal of Pediatrics has found.
METHODOLOGY:
- The retrospective cohort study used demographic, clinical, and outcomes data from the registry to investigate the role of biological sex for babies with CDH.
- The study included more than 7,200 newborns at 105 hospitals across 17 countries from January 2007 to December 2018.
- The primary outcomes were 30-day, 60-day, and in-hospital mortality.
- The secondary outcomes included weight gain during admission, feeding, and oxygen status at 30 days and at discharge.
TAKEAWAY:
- After controlling for markers of disease severity, girls with CDH had a 32% increased risk for death at 30-days (adjusted hazard ratio, 1.32; P = .02).
- Girls had lower survival rates at 30 days (77.3%), compared with boys (80.1%).
- The disparity remained at 60 days, with the survival rate for girls with CDH (73.5%) modestly lower than that for boys (77.2%), and also at discharge – 70.2%, compared with 74.2%, respectively.
- The survival differences between boys and girls primarily affected babies who did not undergo cannulation; in this group, the survival rate for girls was 77.5%, compared with 82.1% for boys.
- Girls with CDH weighed less at birth (2.8 kg) than boys with the condition (3 kg); birth weight is a for babies with CDH, .
IN PRACTICE:
“Although racial and ethnic outcome disparities have been documented in CDH, disparities between males and females are not well known,” Shaun Kunisaki, MD, MSc, a senior author of the study and professor of surgery at Johns Hopkins University in Baltimore, said in a press release about the findings. “It is really important to understand if those disparities exist, because it may change how we can better manage these patients.”
STUDY DETAILS:
The authors include seven from the division of general pediatric surgery and the division of pediatric respiratory sciences at Johns Hopkins University. Two authors are from the department of pediatric surgery at the University of Texas and Children’s Memorial Hermann Hospital, both in Houston.
LIMITATIONS:
The authors point to potential challenges with data collection, including diagnosis miscoding and missing data. They acknowledge that MRI fetal lung volumes, degree of liver herniation, and emerging markers of socioeconomic status were not available in the database. The study also could not examine long-term outcomes because data were limited to in-hospital variables.
DISCLOSURES:
The authors report no financial conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
, a study published in the Journal of Pediatrics has found.
METHODOLOGY:
- The retrospective cohort study used demographic, clinical, and outcomes data from the registry to investigate the role of biological sex for babies with CDH.
- The study included more than 7,200 newborns at 105 hospitals across 17 countries from January 2007 to December 2018.
- The primary outcomes were 30-day, 60-day, and in-hospital mortality.
- The secondary outcomes included weight gain during admission, feeding, and oxygen status at 30 days and at discharge.
TAKEAWAY:
- After controlling for markers of disease severity, girls with CDH had a 32% increased risk for death at 30-days (adjusted hazard ratio, 1.32; P = .02).
- Girls had lower survival rates at 30 days (77.3%), compared with boys (80.1%).
- The disparity remained at 60 days, with the survival rate for girls with CDH (73.5%) modestly lower than that for boys (77.2%), and also at discharge – 70.2%, compared with 74.2%, respectively.
- The survival differences between boys and girls primarily affected babies who did not undergo cannulation; in this group, the survival rate for girls was 77.5%, compared with 82.1% for boys.
- Girls with CDH weighed less at birth (2.8 kg) than boys with the condition (3 kg); birth weight is a for babies with CDH, .
IN PRACTICE:
“Although racial and ethnic outcome disparities have been documented in CDH, disparities between males and females are not well known,” Shaun Kunisaki, MD, MSc, a senior author of the study and professor of surgery at Johns Hopkins University in Baltimore, said in a press release about the findings. “It is really important to understand if those disparities exist, because it may change how we can better manage these patients.”
STUDY DETAILS:
The authors include seven from the division of general pediatric surgery and the division of pediatric respiratory sciences at Johns Hopkins University. Two authors are from the department of pediatric surgery at the University of Texas and Children’s Memorial Hermann Hospital, both in Houston.
LIMITATIONS:
The authors point to potential challenges with data collection, including diagnosis miscoding and missing data. They acknowledge that MRI fetal lung volumes, degree of liver herniation, and emerging markers of socioeconomic status were not available in the database. The study also could not examine long-term outcomes because data were limited to in-hospital variables.
DISCLOSURES:
The authors report no financial conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
, a study published in the Journal of Pediatrics has found.
METHODOLOGY:
- The retrospective cohort study used demographic, clinical, and outcomes data from the registry to investigate the role of biological sex for babies with CDH.
- The study included more than 7,200 newborns at 105 hospitals across 17 countries from January 2007 to December 2018.
- The primary outcomes were 30-day, 60-day, and in-hospital mortality.
- The secondary outcomes included weight gain during admission, feeding, and oxygen status at 30 days and at discharge.
TAKEAWAY:
- After controlling for markers of disease severity, girls with CDH had a 32% increased risk for death at 30-days (adjusted hazard ratio, 1.32; P = .02).
- Girls had lower survival rates at 30 days (77.3%), compared with boys (80.1%).
- The disparity remained at 60 days, with the survival rate for girls with CDH (73.5%) modestly lower than that for boys (77.2%), and also at discharge – 70.2%, compared with 74.2%, respectively.
- The survival differences between boys and girls primarily affected babies who did not undergo cannulation; in this group, the survival rate for girls was 77.5%, compared with 82.1% for boys.
- Girls with CDH weighed less at birth (2.8 kg) than boys with the condition (3 kg); birth weight is a for babies with CDH, .
IN PRACTICE:
“Although racial and ethnic outcome disparities have been documented in CDH, disparities between males and females are not well known,” Shaun Kunisaki, MD, MSc, a senior author of the study and professor of surgery at Johns Hopkins University in Baltimore, said in a press release about the findings. “It is really important to understand if those disparities exist, because it may change how we can better manage these patients.”
STUDY DETAILS:
The authors include seven from the division of general pediatric surgery and the division of pediatric respiratory sciences at Johns Hopkins University. Two authors are from the department of pediatric surgery at the University of Texas and Children’s Memorial Hermann Hospital, both in Houston.
LIMITATIONS:
The authors point to potential challenges with data collection, including diagnosis miscoding and missing data. They acknowledge that MRI fetal lung volumes, degree of liver herniation, and emerging markers of socioeconomic status were not available in the database. The study also could not examine long-term outcomes because data were limited to in-hospital variables.
DISCLOSURES:
The authors report no financial conflicts of interest.
A version of this article first appeared on Medscape.com.
New cannabis laws, higher binge drinking rates linked
TOPLINE:
METHODOLOGY:
Among adolescents, binge drinking, defined as having five or more drinks for men and four or more drinks for women at one time, is associated with poor academic performance, sexual risk, and injury in the short term, as well as the development of alcohol use disorder and academic disengagement in the long term.
Current evidence regarding the association between recreational cannabis laws (RCLs) and binge drinking is limited.
States in which RCLs have been implemented include Colorado, Washington, Alaska, Oregon, Nevada, California, Massachusetts, and Vermont, as well as the District of Columbia.
The study included 817,359 people aged 12 and older who participated in the 2008-2019 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of the U.S. population.
TAKEAWAY:
Overall, states that have not enacted cannabis laws showed consistently lower rates of binge drinking over time among all age groups.
In all states, there were substantial declines in reporting of past-month binge drinking in some age groups – from 17.5% (95% confidence interval, 16.9-18.2) in 2008 to 11.1% (10.4-11.8) in 2019 among those aged 12-20 and a drop from 43.7% (42.4-44.9) to 40.2% (39.1-41.1) among those aged 21-30.
There were overall increases in binge drinking in all states regardless of cannabis laws among individuals aged 31 and older. The most extensive increases were among people aged 31-40 (from 28.1% [95% CI, 26.6-29.6] to 33.3% [32.1-34.6]), followed by participants aged 51 and over (from 13.3% [95% CI, 12.2-14.4] to 16.8% [15.8-17.7]).
IN PRACTICE:
“Our findings support calls to reinforce health care providers’ discussions about alcohol use with older adults,” particularly in RCL states, the researchers write.
STUDY DETAILS:
The study was conducted out by Priscila Dib Gonçalves, PhD, department of epidemiology, Columbia University School of Public Health, New York, and colleagues. It was published in the International Journal of Drug Policy.
LIMITATIONS:
Alcohol-related measures, including binge drinking, were self-reported, which may introduce recall bias and underreporting. NSDUH binge drinking measures were not adjusted for sex differences from 2008 to 2014, which may result in underreporting of binge drinking in females before 2015. The researchers did not examine cannabis policy provisions, such as cultivation restrictions, pricing control, the tax imposed, and consumption restrictions.
DISCLOSURES:
The study received support from the National Institutes of Health, the National Institute on Drug Abuse, the National Center for Injury Prevention and Control, and the Centers for Disease Control and Prevention. The authors report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
Among adolescents, binge drinking, defined as having five or more drinks for men and four or more drinks for women at one time, is associated with poor academic performance, sexual risk, and injury in the short term, as well as the development of alcohol use disorder and academic disengagement in the long term.
Current evidence regarding the association between recreational cannabis laws (RCLs) and binge drinking is limited.
States in which RCLs have been implemented include Colorado, Washington, Alaska, Oregon, Nevada, California, Massachusetts, and Vermont, as well as the District of Columbia.
The study included 817,359 people aged 12 and older who participated in the 2008-2019 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of the U.S. population.
TAKEAWAY:
Overall, states that have not enacted cannabis laws showed consistently lower rates of binge drinking over time among all age groups.
In all states, there were substantial declines in reporting of past-month binge drinking in some age groups – from 17.5% (95% confidence interval, 16.9-18.2) in 2008 to 11.1% (10.4-11.8) in 2019 among those aged 12-20 and a drop from 43.7% (42.4-44.9) to 40.2% (39.1-41.1) among those aged 21-30.
There were overall increases in binge drinking in all states regardless of cannabis laws among individuals aged 31 and older. The most extensive increases were among people aged 31-40 (from 28.1% [95% CI, 26.6-29.6] to 33.3% [32.1-34.6]), followed by participants aged 51 and over (from 13.3% [95% CI, 12.2-14.4] to 16.8% [15.8-17.7]).
IN PRACTICE:
“Our findings support calls to reinforce health care providers’ discussions about alcohol use with older adults,” particularly in RCL states, the researchers write.
STUDY DETAILS:
The study was conducted out by Priscila Dib Gonçalves, PhD, department of epidemiology, Columbia University School of Public Health, New York, and colleagues. It was published in the International Journal of Drug Policy.
LIMITATIONS:
Alcohol-related measures, including binge drinking, were self-reported, which may introduce recall bias and underreporting. NSDUH binge drinking measures were not adjusted for sex differences from 2008 to 2014, which may result in underreporting of binge drinking in females before 2015. The researchers did not examine cannabis policy provisions, such as cultivation restrictions, pricing control, the tax imposed, and consumption restrictions.
DISCLOSURES:
The study received support from the National Institutes of Health, the National Institute on Drug Abuse, the National Center for Injury Prevention and Control, and the Centers for Disease Control and Prevention. The authors report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
Among adolescents, binge drinking, defined as having five or more drinks for men and four or more drinks for women at one time, is associated with poor academic performance, sexual risk, and injury in the short term, as well as the development of alcohol use disorder and academic disengagement in the long term.
Current evidence regarding the association between recreational cannabis laws (RCLs) and binge drinking is limited.
States in which RCLs have been implemented include Colorado, Washington, Alaska, Oregon, Nevada, California, Massachusetts, and Vermont, as well as the District of Columbia.
The study included 817,359 people aged 12 and older who participated in the 2008-2019 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of the U.S. population.
TAKEAWAY:
Overall, states that have not enacted cannabis laws showed consistently lower rates of binge drinking over time among all age groups.
In all states, there were substantial declines in reporting of past-month binge drinking in some age groups – from 17.5% (95% confidence interval, 16.9-18.2) in 2008 to 11.1% (10.4-11.8) in 2019 among those aged 12-20 and a drop from 43.7% (42.4-44.9) to 40.2% (39.1-41.1) among those aged 21-30.
There were overall increases in binge drinking in all states regardless of cannabis laws among individuals aged 31 and older. The most extensive increases were among people aged 31-40 (from 28.1% [95% CI, 26.6-29.6] to 33.3% [32.1-34.6]), followed by participants aged 51 and over (from 13.3% [95% CI, 12.2-14.4] to 16.8% [15.8-17.7]).
IN PRACTICE:
“Our findings support calls to reinforce health care providers’ discussions about alcohol use with older adults,” particularly in RCL states, the researchers write.
STUDY DETAILS:
The study was conducted out by Priscila Dib Gonçalves, PhD, department of epidemiology, Columbia University School of Public Health, New York, and colleagues. It was published in the International Journal of Drug Policy.
LIMITATIONS:
Alcohol-related measures, including binge drinking, were self-reported, which may introduce recall bias and underreporting. NSDUH binge drinking measures were not adjusted for sex differences from 2008 to 2014, which may result in underreporting of binge drinking in females before 2015. The researchers did not examine cannabis policy provisions, such as cultivation restrictions, pricing control, the tax imposed, and consumption restrictions.
DISCLOSURES:
The study received support from the National Institutes of Health, the National Institute on Drug Abuse, the National Center for Injury Prevention and Control, and the Centers for Disease Control and Prevention. The authors report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Consider mental health and social factors in management of sickle cell disease
Complications from sickle cell disease (SCD) can affect education and life opportunities, and these complications have been associated with social determinants of health such as socioeconomic status, depression, health literacy, and level of education, according to Kelly M. Harris, PhD, of Washington University in St. Louis, and colleagues.
Pain is a hallmark of SCD, and “the current climate around pain management and opioid use has specific implications for individuals with [SCD], especially youth,” Dr. Harris said in an interview.
In a study published in JAMA Network Open, the researchers analyzed 2,264 participants (average age, 27.9 years; 56.2% were female) in the Sickle Cell Disease Implementation Consortium a study that includes patient assessment, treatment, and creation of a longitudinal registry.
The participants completed the Adult Sickle Cell Quality of Life Measurement Information System to provide data on the frequency and severity of pain episodes related to SCD over the past 12 months. Multivariable regression analysis was used to examine the associations of education, employment, and mental health with pain frequency and severity.
Overall, 79.8% of participants reported severe pain, and 47.8% reported more than four episodes of pain in the past year.
Notably, 20% of the participants were diagnosed with depression, and increased pain frequency was significantly associated with depression, although no significant association appeared between pain severity and depression, the researchers said.
A total of 47% of the participants reported using pain medication and 49% reported using hydroxyurea. In addition, 628 participants (28.0%) underwent regular blood transfusions.
Neither education level nor income was associated with increased pain frequency or severity. Age younger than 18 years was significantly associated with both pain frequency and severity, as was daily used of pain medication. Unemployment and female sex also were associated with increased pain frequency.
The findings were limited by several factors including the cross-sectional design that prevents conclusions of causality, and by the reliance on patient reports of depression, which likely led to underreporting, the researchers noted.
However, the results are consistent with previous studies suggesting that pain and negative feelings were associated with reduced quality of life in SCD patients, especially younger patients, and support the need to screen SCD patients for depression, especially those who report more severe and/or more frequent pain, they said.
Take a comprehensive approach to a complex condition
“When treating pain, we cannot just rely on medication,” Dr. Harris said. “It is important that providers consider the full experiences of patients and pursue holistic and comprehensive treatment approaches to reducing pain. Screening for depression should be a regular practice, particularly for patients experiencing frequent and/or severe pain.
“Racial discrimination, stigma, and bias impact pain diagnosis and treatment for individuals with SCD,” said Dr. Harris. “Increasing awareness of the associations between depression and pain frequency and severity ... may help address these barriers.”
Data highlight treatment gaps
Alexander A. Boucher, MD, a member of the division of pediatric hematology and oncology at the University of Minnesota, Minneapolis, noted the researchers included patients as young as midadolescence, with a majority being under 35 years old. “The 18- to 30-year-old range is an especially high-risk age window for increased acute health care utilization, even compared with other chronic adolescent/young adult conditions. “The demographics in the study group also reasonably approximate those for young adults with SCD in urban centers. By taking a multicenter approach across a several-state region, I believe the findings offer better generalizability, since health care access and mental health access can vary state-by-state,” and the current results show a more standard experience.
“It was a bit surprising that female [sex] maintained such an association with pain across the different components of the study,” and that the pain peak was in the 25- to 34-year-old age range, said Dr. Boucher. However, anecdotally, the late teens and early 20s “can be laden with mental health concerns due to the life transitions that accompany most people at that time. The note that hydroxyurea use was associated with more pain and depression symptoms was interesting, and serves as a reminder that what is happening to the red blood cells and in the blood vessels, such as red blood cell breakdown, sickling, and vaso-occlusion are only a part of what causes pain, and hydroxyurea is not likely to play a role in mitigating mental health aspects of pain.”
The findings that overall pain frequency and related pain medication use were associated with higher depression rates “may in part reflect a blind spot for physicians and medical teams, who often resort back to physical pain-based heuristics.” Physicians may misunderstand chronic pain and its management and look for quick fixes for pain out of uncertainty or urgency, said Dr. Boucher. “This serves to diminish the perspectives of patients as people first (not embodiments of a disease) and can lead to missed opportunities to tackle mental health challenges.”
Barriers and limitations
There are barriers to mental health screening in hematology care,” Dr. Boucher said. First, most hematologists are not experts in mental health and while they may have some from their medical training in these disorders, it can be difficult to maintain the level of health literacy needed to stay up to date on treatments. Second, depression screening may not be part of regular patient intake and the Patient Health Questionnaire–2 or PHQ-9 offer only short-term (2-week) snapshots of depression.
“Perhaps most critically, even if we do successfully screen, the access to mental health specialists is severely limited, just as it is across the medical landscape, so intervention opportunities may be suboptimal,” said Dr. Boucher. The problem is magnified if, as the current study suggests, the rates of depression in SCD are approximately three times greater than the population overall.
In the current study, “the fact that only half of those who self-reported depression symptoms actually had depression documented as a diagnosis in their medical records suggests that we are missing a lot of patients affected by mental health disturbances.”
This study is limited in measurement of the contribution of social determinants of health, he said, as they were primarily focused on employment status and income. The study does not describe other factors like support systems, housing, and transportation.
“I would like to see studies that not only identify associated drivers of pain, but also offer evidence for successful interventions,” Dr. Boucher said, and these studies should include patient-centered interventions versus disease-centered interventions.
Undertreatment persists
Other concerns with sickle cell anemia include the underuse of hydroxyurea to reduce complications associated with the disease such as pain, stroke, and even early death. Another recent study in JAMA Network Open suggested that use of hydroxyurea remained low in children and youth despite the issuing of guidelines, and that underserved populations were especially affected. In that study, the researchers found that the patients’ annual days’ supply of hydroxyurea in New York state did not change significantly after the guideline update.
SCD also has been associated with increased risk of other poor outcomes, such as stillbirth and increased risk of poor COVID-19–related outcomes and COVID-19–related deaths.
The study by Dr. Harris and colleagues was supported by the National Institutes of Health through the National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities. Dr. Harris had no financial conflicts to disclose. The hydroxyurea study was supported by the Agency for Healthcare Research and Quality and the NHLBI. The researchers had no financial conflicts to disclose. Dr. Boucher disclosed conducting research with SCL Behring, but had no relevant financial conflicts.
Complications from sickle cell disease (SCD) can affect education and life opportunities, and these complications have been associated with social determinants of health such as socioeconomic status, depression, health literacy, and level of education, according to Kelly M. Harris, PhD, of Washington University in St. Louis, and colleagues.
Pain is a hallmark of SCD, and “the current climate around pain management and opioid use has specific implications for individuals with [SCD], especially youth,” Dr. Harris said in an interview.
In a study published in JAMA Network Open, the researchers analyzed 2,264 participants (average age, 27.9 years; 56.2% were female) in the Sickle Cell Disease Implementation Consortium a study that includes patient assessment, treatment, and creation of a longitudinal registry.
The participants completed the Adult Sickle Cell Quality of Life Measurement Information System to provide data on the frequency and severity of pain episodes related to SCD over the past 12 months. Multivariable regression analysis was used to examine the associations of education, employment, and mental health with pain frequency and severity.
Overall, 79.8% of participants reported severe pain, and 47.8% reported more than four episodes of pain in the past year.
Notably, 20% of the participants were diagnosed with depression, and increased pain frequency was significantly associated with depression, although no significant association appeared between pain severity and depression, the researchers said.
A total of 47% of the participants reported using pain medication and 49% reported using hydroxyurea. In addition, 628 participants (28.0%) underwent regular blood transfusions.
Neither education level nor income was associated with increased pain frequency or severity. Age younger than 18 years was significantly associated with both pain frequency and severity, as was daily used of pain medication. Unemployment and female sex also were associated with increased pain frequency.
The findings were limited by several factors including the cross-sectional design that prevents conclusions of causality, and by the reliance on patient reports of depression, which likely led to underreporting, the researchers noted.
However, the results are consistent with previous studies suggesting that pain and negative feelings were associated with reduced quality of life in SCD patients, especially younger patients, and support the need to screen SCD patients for depression, especially those who report more severe and/or more frequent pain, they said.
Take a comprehensive approach to a complex condition
“When treating pain, we cannot just rely on medication,” Dr. Harris said. “It is important that providers consider the full experiences of patients and pursue holistic and comprehensive treatment approaches to reducing pain. Screening for depression should be a regular practice, particularly for patients experiencing frequent and/or severe pain.
“Racial discrimination, stigma, and bias impact pain diagnosis and treatment for individuals with SCD,” said Dr. Harris. “Increasing awareness of the associations between depression and pain frequency and severity ... may help address these barriers.”
Data highlight treatment gaps
Alexander A. Boucher, MD, a member of the division of pediatric hematology and oncology at the University of Minnesota, Minneapolis, noted the researchers included patients as young as midadolescence, with a majority being under 35 years old. “The 18- to 30-year-old range is an especially high-risk age window for increased acute health care utilization, even compared with other chronic adolescent/young adult conditions. “The demographics in the study group also reasonably approximate those for young adults with SCD in urban centers. By taking a multicenter approach across a several-state region, I believe the findings offer better generalizability, since health care access and mental health access can vary state-by-state,” and the current results show a more standard experience.
“It was a bit surprising that female [sex] maintained such an association with pain across the different components of the study,” and that the pain peak was in the 25- to 34-year-old age range, said Dr. Boucher. However, anecdotally, the late teens and early 20s “can be laden with mental health concerns due to the life transitions that accompany most people at that time. The note that hydroxyurea use was associated with more pain and depression symptoms was interesting, and serves as a reminder that what is happening to the red blood cells and in the blood vessels, such as red blood cell breakdown, sickling, and vaso-occlusion are only a part of what causes pain, and hydroxyurea is not likely to play a role in mitigating mental health aspects of pain.”
The findings that overall pain frequency and related pain medication use were associated with higher depression rates “may in part reflect a blind spot for physicians and medical teams, who often resort back to physical pain-based heuristics.” Physicians may misunderstand chronic pain and its management and look for quick fixes for pain out of uncertainty or urgency, said Dr. Boucher. “This serves to diminish the perspectives of patients as people first (not embodiments of a disease) and can lead to missed opportunities to tackle mental health challenges.”
Barriers and limitations
There are barriers to mental health screening in hematology care,” Dr. Boucher said. First, most hematologists are not experts in mental health and while they may have some from their medical training in these disorders, it can be difficult to maintain the level of health literacy needed to stay up to date on treatments. Second, depression screening may not be part of regular patient intake and the Patient Health Questionnaire–2 or PHQ-9 offer only short-term (2-week) snapshots of depression.
“Perhaps most critically, even if we do successfully screen, the access to mental health specialists is severely limited, just as it is across the medical landscape, so intervention opportunities may be suboptimal,” said Dr. Boucher. The problem is magnified if, as the current study suggests, the rates of depression in SCD are approximately three times greater than the population overall.
In the current study, “the fact that only half of those who self-reported depression symptoms actually had depression documented as a diagnosis in their medical records suggests that we are missing a lot of patients affected by mental health disturbances.”
This study is limited in measurement of the contribution of social determinants of health, he said, as they were primarily focused on employment status and income. The study does not describe other factors like support systems, housing, and transportation.
“I would like to see studies that not only identify associated drivers of pain, but also offer evidence for successful interventions,” Dr. Boucher said, and these studies should include patient-centered interventions versus disease-centered interventions.
Undertreatment persists
Other concerns with sickle cell anemia include the underuse of hydroxyurea to reduce complications associated with the disease such as pain, stroke, and even early death. Another recent study in JAMA Network Open suggested that use of hydroxyurea remained low in children and youth despite the issuing of guidelines, and that underserved populations were especially affected. In that study, the researchers found that the patients’ annual days’ supply of hydroxyurea in New York state did not change significantly after the guideline update.
SCD also has been associated with increased risk of other poor outcomes, such as stillbirth and increased risk of poor COVID-19–related outcomes and COVID-19–related deaths.
The study by Dr. Harris and colleagues was supported by the National Institutes of Health through the National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities. Dr. Harris had no financial conflicts to disclose. The hydroxyurea study was supported by the Agency for Healthcare Research and Quality and the NHLBI. The researchers had no financial conflicts to disclose. Dr. Boucher disclosed conducting research with SCL Behring, but had no relevant financial conflicts.
Complications from sickle cell disease (SCD) can affect education and life opportunities, and these complications have been associated with social determinants of health such as socioeconomic status, depression, health literacy, and level of education, according to Kelly M. Harris, PhD, of Washington University in St. Louis, and colleagues.
Pain is a hallmark of SCD, and “the current climate around pain management and opioid use has specific implications for individuals with [SCD], especially youth,” Dr. Harris said in an interview.
In a study published in JAMA Network Open, the researchers analyzed 2,264 participants (average age, 27.9 years; 56.2% were female) in the Sickle Cell Disease Implementation Consortium a study that includes patient assessment, treatment, and creation of a longitudinal registry.
The participants completed the Adult Sickle Cell Quality of Life Measurement Information System to provide data on the frequency and severity of pain episodes related to SCD over the past 12 months. Multivariable regression analysis was used to examine the associations of education, employment, and mental health with pain frequency and severity.
Overall, 79.8% of participants reported severe pain, and 47.8% reported more than four episodes of pain in the past year.
Notably, 20% of the participants were diagnosed with depression, and increased pain frequency was significantly associated with depression, although no significant association appeared between pain severity and depression, the researchers said.
A total of 47% of the participants reported using pain medication and 49% reported using hydroxyurea. In addition, 628 participants (28.0%) underwent regular blood transfusions.
Neither education level nor income was associated with increased pain frequency or severity. Age younger than 18 years was significantly associated with both pain frequency and severity, as was daily used of pain medication. Unemployment and female sex also were associated with increased pain frequency.
The findings were limited by several factors including the cross-sectional design that prevents conclusions of causality, and by the reliance on patient reports of depression, which likely led to underreporting, the researchers noted.
However, the results are consistent with previous studies suggesting that pain and negative feelings were associated with reduced quality of life in SCD patients, especially younger patients, and support the need to screen SCD patients for depression, especially those who report more severe and/or more frequent pain, they said.
Take a comprehensive approach to a complex condition
“When treating pain, we cannot just rely on medication,” Dr. Harris said. “It is important that providers consider the full experiences of patients and pursue holistic and comprehensive treatment approaches to reducing pain. Screening for depression should be a regular practice, particularly for patients experiencing frequent and/or severe pain.
“Racial discrimination, stigma, and bias impact pain diagnosis and treatment for individuals with SCD,” said Dr. Harris. “Increasing awareness of the associations between depression and pain frequency and severity ... may help address these barriers.”
Data highlight treatment gaps
Alexander A. Boucher, MD, a member of the division of pediatric hematology and oncology at the University of Minnesota, Minneapolis, noted the researchers included patients as young as midadolescence, with a majority being under 35 years old. “The 18- to 30-year-old range is an especially high-risk age window for increased acute health care utilization, even compared with other chronic adolescent/young adult conditions. “The demographics in the study group also reasonably approximate those for young adults with SCD in urban centers. By taking a multicenter approach across a several-state region, I believe the findings offer better generalizability, since health care access and mental health access can vary state-by-state,” and the current results show a more standard experience.
“It was a bit surprising that female [sex] maintained such an association with pain across the different components of the study,” and that the pain peak was in the 25- to 34-year-old age range, said Dr. Boucher. However, anecdotally, the late teens and early 20s “can be laden with mental health concerns due to the life transitions that accompany most people at that time. The note that hydroxyurea use was associated with more pain and depression symptoms was interesting, and serves as a reminder that what is happening to the red blood cells and in the blood vessels, such as red blood cell breakdown, sickling, and vaso-occlusion are only a part of what causes pain, and hydroxyurea is not likely to play a role in mitigating mental health aspects of pain.”
The findings that overall pain frequency and related pain medication use were associated with higher depression rates “may in part reflect a blind spot for physicians and medical teams, who often resort back to physical pain-based heuristics.” Physicians may misunderstand chronic pain and its management and look for quick fixes for pain out of uncertainty or urgency, said Dr. Boucher. “This serves to diminish the perspectives of patients as people first (not embodiments of a disease) and can lead to missed opportunities to tackle mental health challenges.”
Barriers and limitations
There are barriers to mental health screening in hematology care,” Dr. Boucher said. First, most hematologists are not experts in mental health and while they may have some from their medical training in these disorders, it can be difficult to maintain the level of health literacy needed to stay up to date on treatments. Second, depression screening may not be part of regular patient intake and the Patient Health Questionnaire–2 or PHQ-9 offer only short-term (2-week) snapshots of depression.
“Perhaps most critically, even if we do successfully screen, the access to mental health specialists is severely limited, just as it is across the medical landscape, so intervention opportunities may be suboptimal,” said Dr. Boucher. The problem is magnified if, as the current study suggests, the rates of depression in SCD are approximately three times greater than the population overall.
In the current study, “the fact that only half of those who self-reported depression symptoms actually had depression documented as a diagnosis in their medical records suggests that we are missing a lot of patients affected by mental health disturbances.”
This study is limited in measurement of the contribution of social determinants of health, he said, as they were primarily focused on employment status and income. The study does not describe other factors like support systems, housing, and transportation.
“I would like to see studies that not only identify associated drivers of pain, but also offer evidence for successful interventions,” Dr. Boucher said, and these studies should include patient-centered interventions versus disease-centered interventions.
Undertreatment persists
Other concerns with sickle cell anemia include the underuse of hydroxyurea to reduce complications associated with the disease such as pain, stroke, and even early death. Another recent study in JAMA Network Open suggested that use of hydroxyurea remained low in children and youth despite the issuing of guidelines, and that underserved populations were especially affected. In that study, the researchers found that the patients’ annual days’ supply of hydroxyurea in New York state did not change significantly after the guideline update.
SCD also has been associated with increased risk of other poor outcomes, such as stillbirth and increased risk of poor COVID-19–related outcomes and COVID-19–related deaths.
The study by Dr. Harris and colleagues was supported by the National Institutes of Health through the National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities. Dr. Harris had no financial conflicts to disclose. The hydroxyurea study was supported by the Agency for Healthcare Research and Quality and the NHLBI. The researchers had no financial conflicts to disclose. Dr. Boucher disclosed conducting research with SCL Behring, but had no relevant financial conflicts.
FROM JAMA NETWORK OPEN
Low-calorie tastes sweeter with a little salt
Low-calorie tastes sweeter with a little salt
Diet and sugar-free foods and drinks seem like a good idea, but it’s hard to get past that strange aftertaste, right? It’s the calling card for the noncaloric aspartame- and stevia-containing sweeteners that we consume to make us feel like we can have the best of both worlds.
That weird lingering taste can be a total turn-off for some (raises hand), but researchers have found an almost facepalm solution to the not-so-sweet problem, and it’s salt.
Now, the concept of sweet and salty is not a far-fetched partnership when it comes to snack consumption (try M&Ms in your popcorn). The researchers at Almendra, a manufacturer of stevia sweeteners, put that iconic flavor pair to the test by adding mineral salts that have some nutritional value to lessen the effect of a stevia compound, rebaudioside A, found in noncaloric sweeteners.
The researchers added in magnesium chloride, calcium chloride, and potassium chloride separately to lessen rebaudioside A’s intensity, but they needed so much salt that it killed the sweet taste completely. A blend of the three mineral salts, however, reduced the lingering taste by 79% and improved the real sugar-like taste. The researchers tried this blend in reduced-calorie orange juice and a citrus-flavored soft drink, improving the taste in both.
The salty and sweet match comes in for the win once again. This time helping against the fight of obesity instead of making it worse.
Pseudomonas’ Achilles’ heel is more of an Achilles’ genetic switch
Today, on the long-awaited return of “Bacteria vs. the World,” we meet one of the rock stars of infectious disease.
LOTME: Through the use of imaginary technology, we’re talking to Pseudomonas aeruginosa. Thanks for joining us on such short notice, after Neisseria gonorrhoeae canceled at the last minute.
P. aeruginosa: No problem. I think we can all guess what that little devil is up to.
LOTME: Bacterial resistance to antibiotics is a huge problem for our species. What makes you so hard to fight?
P. aeruginosa: We’ve been trying to keep that a secret, actually, but now that researchers in Switzerland and Denmark seem to have figured it out, I guess it’s okay for me to spill the beans.
LOTME: Beans? What do beans have to do with it?
P. aeruginosa: Nothing, it’s just a colloquial expression that means I’m sharing previously private information.
LOTME: Sure, we knew that. Please, continue your spilling.
P. aeruginosa: The secret is … Well, let’s just say we were a little worried when the Clash released “Should I Stay or Should I Go” back in the 1980s.
LOTME: The Clash? Now we’re really confused.
P. aeruginosa: The answer to their question, “Should I stay or should I go? is yes. Successful invasion of a human is all about division of labor. “While one fraction of the bacterial population adheres to the mucosal surface and forms a biofilm, the other subpopulation spreads to distant tissue sites,” is how the investigators described it. We can increase surface colonization by using a “job-sharing” process, they said, and even resist antibiotics because most of us remain in the protective biofilm.
LOTME: And they say you guys don’t have brains.
P. aeruginosa: But wait, there’s more. We don’t just divide the labor randomly. After the initial colonization we form two functionally distinct subpopulations. One has high levels of the bacterial signaling molecule c-di-GMP and stays put to work on the biofilm. The other group, with low levels of c-di-GMP, heads out to the surrounding tissue to continue the colonization. As project leader Urs Jenal put it, “By identifying the genetic switch, we have tracked down the Achilles heel of the pathogen.”
LOTME: Pretty clever stuff, for humans, anyway.
P. aeruginosa: We agree, but now that you know our secret, we can’t let you share it.
LOTME: Wait! The journal article’s already been published. Your secret is out. You can’t stop that by infecting me.
P. aeruginosa: True enough, but are you familiar with the fable of the scorpion and the frog? It’s our nature.
LOTME: Nooooo! N. gonorrhoeae wouldn’t have done this!
What a pain in the Butt
Businesses rise and businesses fall. We all know that one cursed location, that spot in town where we see businesses move in and close up in a matter of months. At the same time, though, there are also businesses that have been around as long as anyone can remember, pillars of the community.
Corydon, IN., likely has a few such long-lived shops, but it is officially down one 70-year-old family business as of late April, with the unfortunate passing of beloved local pharmacy Butt Drugs. Prescription pick-up in rear.
The business dates back to 1952, when it was founded as William H. Butt Drugs. We’re sure William Butt was never teased about his last name. Nope. No one would ever do that. After he passed the store to his children, it underwent a stint as Butt Rexall Drugs. When the shop was passed down to its third-generation and ultimately final owner, Katie Butt Beckort, she decided to simplify the name. Get right down to the bottom of things, as it were.
Butt Drugs was a popular spot, featuring an old-school soda fountain and themed souvenirs. According to Ms. Butt Beckort, people would come from miles away to buy “I love Butt Drugs” T-shirts, magnets, and so on. Yes, they knew perfectly well what they were sitting on.
So, if was such a hit, why did it close? Butt Drugs may have a hilarious name and merchandise to match, but the pharmacy portion of the pharmacy had been losing money for years. You know, the actual point of the business. As with so many things, we can blame it on the insurance companies. More than half the drugs that passed through Butt Drugs’ doors were sold at a loss, because the insurance companies refused to reimburse the store more than the wholesale price of the drug. Not even a good butt drug could clear up that financial diarrhea.
And so, we’ve lost Butt Drugs forever. Spicy food enthusiasts, coffee drinkers, and all patrons of Taco Bell, take a moment to reflect and mourn on what you’ve lost. No more Butt Drugs to relieve your suffering. A true kick in the butt indeed.
Low-calorie tastes sweeter with a little salt
Diet and sugar-free foods and drinks seem like a good idea, but it’s hard to get past that strange aftertaste, right? It’s the calling card for the noncaloric aspartame- and stevia-containing sweeteners that we consume to make us feel like we can have the best of both worlds.
That weird lingering taste can be a total turn-off for some (raises hand), but researchers have found an almost facepalm solution to the not-so-sweet problem, and it’s salt.
Now, the concept of sweet and salty is not a far-fetched partnership when it comes to snack consumption (try M&Ms in your popcorn). The researchers at Almendra, a manufacturer of stevia sweeteners, put that iconic flavor pair to the test by adding mineral salts that have some nutritional value to lessen the effect of a stevia compound, rebaudioside A, found in noncaloric sweeteners.
The researchers added in magnesium chloride, calcium chloride, and potassium chloride separately to lessen rebaudioside A’s intensity, but they needed so much salt that it killed the sweet taste completely. A blend of the three mineral salts, however, reduced the lingering taste by 79% and improved the real sugar-like taste. The researchers tried this blend in reduced-calorie orange juice and a citrus-flavored soft drink, improving the taste in both.
The salty and sweet match comes in for the win once again. This time helping against the fight of obesity instead of making it worse.
Pseudomonas’ Achilles’ heel is more of an Achilles’ genetic switch
Today, on the long-awaited return of “Bacteria vs. the World,” we meet one of the rock stars of infectious disease.
LOTME: Through the use of imaginary technology, we’re talking to Pseudomonas aeruginosa. Thanks for joining us on such short notice, after Neisseria gonorrhoeae canceled at the last minute.
P. aeruginosa: No problem. I think we can all guess what that little devil is up to.
LOTME: Bacterial resistance to antibiotics is a huge problem for our species. What makes you so hard to fight?
P. aeruginosa: We’ve been trying to keep that a secret, actually, but now that researchers in Switzerland and Denmark seem to have figured it out, I guess it’s okay for me to spill the beans.
LOTME: Beans? What do beans have to do with it?
P. aeruginosa: Nothing, it’s just a colloquial expression that means I’m sharing previously private information.
LOTME: Sure, we knew that. Please, continue your spilling.
P. aeruginosa: The secret is … Well, let’s just say we were a little worried when the Clash released “Should I Stay or Should I Go” back in the 1980s.
LOTME: The Clash? Now we’re really confused.
P. aeruginosa: The answer to their question, “Should I stay or should I go? is yes. Successful invasion of a human is all about division of labor. “While one fraction of the bacterial population adheres to the mucosal surface and forms a biofilm, the other subpopulation spreads to distant tissue sites,” is how the investigators described it. We can increase surface colonization by using a “job-sharing” process, they said, and even resist antibiotics because most of us remain in the protective biofilm.
LOTME: And they say you guys don’t have brains.
P. aeruginosa: But wait, there’s more. We don’t just divide the labor randomly. After the initial colonization we form two functionally distinct subpopulations. One has high levels of the bacterial signaling molecule c-di-GMP and stays put to work on the biofilm. The other group, with low levels of c-di-GMP, heads out to the surrounding tissue to continue the colonization. As project leader Urs Jenal put it, “By identifying the genetic switch, we have tracked down the Achilles heel of the pathogen.”
LOTME: Pretty clever stuff, for humans, anyway.
P. aeruginosa: We agree, but now that you know our secret, we can’t let you share it.
LOTME: Wait! The journal article’s already been published. Your secret is out. You can’t stop that by infecting me.
P. aeruginosa: True enough, but are you familiar with the fable of the scorpion and the frog? It’s our nature.
LOTME: Nooooo! N. gonorrhoeae wouldn’t have done this!
What a pain in the Butt
Businesses rise and businesses fall. We all know that one cursed location, that spot in town where we see businesses move in and close up in a matter of months. At the same time, though, there are also businesses that have been around as long as anyone can remember, pillars of the community.
Corydon, IN., likely has a few such long-lived shops, but it is officially down one 70-year-old family business as of late April, with the unfortunate passing of beloved local pharmacy Butt Drugs. Prescription pick-up in rear.
The business dates back to 1952, when it was founded as William H. Butt Drugs. We’re sure William Butt was never teased about his last name. Nope. No one would ever do that. After he passed the store to his children, it underwent a stint as Butt Rexall Drugs. When the shop was passed down to its third-generation and ultimately final owner, Katie Butt Beckort, she decided to simplify the name. Get right down to the bottom of things, as it were.
Butt Drugs was a popular spot, featuring an old-school soda fountain and themed souvenirs. According to Ms. Butt Beckort, people would come from miles away to buy “I love Butt Drugs” T-shirts, magnets, and so on. Yes, they knew perfectly well what they were sitting on.
So, if was such a hit, why did it close? Butt Drugs may have a hilarious name and merchandise to match, but the pharmacy portion of the pharmacy had been losing money for years. You know, the actual point of the business. As with so many things, we can blame it on the insurance companies. More than half the drugs that passed through Butt Drugs’ doors were sold at a loss, because the insurance companies refused to reimburse the store more than the wholesale price of the drug. Not even a good butt drug could clear up that financial diarrhea.
And so, we’ve lost Butt Drugs forever. Spicy food enthusiasts, coffee drinkers, and all patrons of Taco Bell, take a moment to reflect and mourn on what you’ve lost. No more Butt Drugs to relieve your suffering. A true kick in the butt indeed.
Low-calorie tastes sweeter with a little salt
Diet and sugar-free foods and drinks seem like a good idea, but it’s hard to get past that strange aftertaste, right? It’s the calling card for the noncaloric aspartame- and stevia-containing sweeteners that we consume to make us feel like we can have the best of both worlds.
That weird lingering taste can be a total turn-off for some (raises hand), but researchers have found an almost facepalm solution to the not-so-sweet problem, and it’s salt.
Now, the concept of sweet and salty is not a far-fetched partnership when it comes to snack consumption (try M&Ms in your popcorn). The researchers at Almendra, a manufacturer of stevia sweeteners, put that iconic flavor pair to the test by adding mineral salts that have some nutritional value to lessen the effect of a stevia compound, rebaudioside A, found in noncaloric sweeteners.
The researchers added in magnesium chloride, calcium chloride, and potassium chloride separately to lessen rebaudioside A’s intensity, but they needed so much salt that it killed the sweet taste completely. A blend of the three mineral salts, however, reduced the lingering taste by 79% and improved the real sugar-like taste. The researchers tried this blend in reduced-calorie orange juice and a citrus-flavored soft drink, improving the taste in both.
The salty and sweet match comes in for the win once again. This time helping against the fight of obesity instead of making it worse.
Pseudomonas’ Achilles’ heel is more of an Achilles’ genetic switch
Today, on the long-awaited return of “Bacteria vs. the World,” we meet one of the rock stars of infectious disease.
LOTME: Through the use of imaginary technology, we’re talking to Pseudomonas aeruginosa. Thanks for joining us on such short notice, after Neisseria gonorrhoeae canceled at the last minute.
P. aeruginosa: No problem. I think we can all guess what that little devil is up to.
LOTME: Bacterial resistance to antibiotics is a huge problem for our species. What makes you so hard to fight?
P. aeruginosa: We’ve been trying to keep that a secret, actually, but now that researchers in Switzerland and Denmark seem to have figured it out, I guess it’s okay for me to spill the beans.
LOTME: Beans? What do beans have to do with it?
P. aeruginosa: Nothing, it’s just a colloquial expression that means I’m sharing previously private information.
LOTME: Sure, we knew that. Please, continue your spilling.
P. aeruginosa: The secret is … Well, let’s just say we were a little worried when the Clash released “Should I Stay or Should I Go” back in the 1980s.
LOTME: The Clash? Now we’re really confused.
P. aeruginosa: The answer to their question, “Should I stay or should I go? is yes. Successful invasion of a human is all about division of labor. “While one fraction of the bacterial population adheres to the mucosal surface and forms a biofilm, the other subpopulation spreads to distant tissue sites,” is how the investigators described it. We can increase surface colonization by using a “job-sharing” process, they said, and even resist antibiotics because most of us remain in the protective biofilm.
LOTME: And they say you guys don’t have brains.
P. aeruginosa: But wait, there’s more. We don’t just divide the labor randomly. After the initial colonization we form two functionally distinct subpopulations. One has high levels of the bacterial signaling molecule c-di-GMP and stays put to work on the biofilm. The other group, with low levels of c-di-GMP, heads out to the surrounding tissue to continue the colonization. As project leader Urs Jenal put it, “By identifying the genetic switch, we have tracked down the Achilles heel of the pathogen.”
LOTME: Pretty clever stuff, for humans, anyway.
P. aeruginosa: We agree, but now that you know our secret, we can’t let you share it.
LOTME: Wait! The journal article’s already been published. Your secret is out. You can’t stop that by infecting me.
P. aeruginosa: True enough, but are you familiar with the fable of the scorpion and the frog? It’s our nature.
LOTME: Nooooo! N. gonorrhoeae wouldn’t have done this!
What a pain in the Butt
Businesses rise and businesses fall. We all know that one cursed location, that spot in town where we see businesses move in and close up in a matter of months. At the same time, though, there are also businesses that have been around as long as anyone can remember, pillars of the community.
Corydon, IN., likely has a few such long-lived shops, but it is officially down one 70-year-old family business as of late April, with the unfortunate passing of beloved local pharmacy Butt Drugs. Prescription pick-up in rear.
The business dates back to 1952, when it was founded as William H. Butt Drugs. We’re sure William Butt was never teased about his last name. Nope. No one would ever do that. After he passed the store to his children, it underwent a stint as Butt Rexall Drugs. When the shop was passed down to its third-generation and ultimately final owner, Katie Butt Beckort, she decided to simplify the name. Get right down to the bottom of things, as it were.
Butt Drugs was a popular spot, featuring an old-school soda fountain and themed souvenirs. According to Ms. Butt Beckort, people would come from miles away to buy “I love Butt Drugs” T-shirts, magnets, and so on. Yes, they knew perfectly well what they were sitting on.
So, if was such a hit, why did it close? Butt Drugs may have a hilarious name and merchandise to match, but the pharmacy portion of the pharmacy had been losing money for years. You know, the actual point of the business. As with so many things, we can blame it on the insurance companies. More than half the drugs that passed through Butt Drugs’ doors were sold at a loss, because the insurance companies refused to reimburse the store more than the wholesale price of the drug. Not even a good butt drug could clear up that financial diarrhea.
And so, we’ve lost Butt Drugs forever. Spicy food enthusiasts, coffee drinkers, and all patrons of Taco Bell, take a moment to reflect and mourn on what you’ve lost. No more Butt Drugs to relieve your suffering. A true kick in the butt indeed.