Pediatrics

TOPLINE:

Antiepileptic and anti-infectious agents were the most common drugs associated with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) in children in an analysis of a World Health Organization (WHO) database.

METHODOLOGY:

• SJS and TEN are rare, life-threatening mucocutaneous reactions mainly associated with medications, but large pharmacovigilance studies of drugs associated with SJS-TEN in the pediatric population are still lacking.
• Using the WHO’s pharmacovigilance database (VigiBase) containing individual case safety reports from January 1967 to July 2022, researchers identified 7342 adverse drug reaction reports of SJS-TEN in children (younger than 18 years; median age, 9 years) in all six continents. Median onset was 5 days, and 3.2% were fatal.
• They analyzed drugs reported as suspected treatments, and for each molecule, they performed a case–non-case study to assess a potential pharmacovigilance signal by computing the information component (IC).
• A positive IC value suggested more frequent reporting of a specific drug-adverse reaction pair. A positive IC025, a traditional threshold for statistical signal detection, is suggestive of a potential pharmacovigilance signal.

TAKEAWAY:

• Overall, 165 drugs were associated with a diagnosis of SJS-TEN; antiepileptic and anti-infectious drugs were the most common drug classes represented.
• The five most frequently reported drugs were carbamazepine (11.7%), lamotrigine (10.6%), sulfamethoxazole-trimethoprim (9%), acetaminophen (8.4%), and phenytoin (6.6%). The five drugs with the highest IC025 were lamotrigine, carbamazepine, phenobarbital, phenytoin, and nimesulide.
• All antiepileptics, many antibiotic families, dapsone, antiretroviral drugs, some antifungal drugs, and nonsteroidal anti-inflammatory drugs were identified in reports, with penicillins the most frequently reported antibiotic family and sulfonamides having the strongest pharmacovigilance signal.
• Vaccines were not associated with significant signals.

IN PRACTICE:

The study provides an update on “the spectrum of drugs potentially associated with SJS-TEN in the pediatric population,” the authors concluded, and “underlines the importance of reporting to pharmacovigilance the suspicion of this severe side effect of drugs with the most precise and detailed clinical description possible.”

SOURCE:

The study, led by Pauline Bataille, MD, of the Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades, Paris City University, France, was published online in the Journal of the European Academy of Dermatology and Venereology.

LIMITATIONS:

Limitations include the possibility that some cases could have had an infectious or idiopathic cause not related to a drug and the lack of detailed clinical data in the database.

DISCLOSURES:

This study did not receive any funding. The authors declared no conflict of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

Antiepileptic and anti-infectious agents were the most common drugs associated with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) in children in an analysis of a World Health Organization (WHO) database.

METHODOLOGY:

• SJS and TEN are rare, life-threatening mucocutaneous reactions mainly associated with medications, but large pharmacovigilance studies of drugs associated with SJS-TEN in the pediatric population are still lacking.
• Using the WHO’s pharmacovigilance database (VigiBase) containing individual case safety reports from January 1967 to July 2022, researchers identified 7342 adverse drug reaction reports of SJS-TEN in children (younger than 18 years; median age, 9 years) in all six continents. Median onset was 5 days, and 3.2% were fatal.
• They analyzed drugs reported as suspected treatments, and for each molecule, they performed a case–non-case study to assess a potential pharmacovigilance signal by computing the information component (IC).
• A positive IC value suggested more frequent reporting of a specific drug-adverse reaction pair. A positive IC025, a traditional threshold for statistical signal detection, is suggestive of a potential pharmacovigilance signal.

TAKEAWAY:

• Overall, 165 drugs were associated with a diagnosis of SJS-TEN; antiepileptic and anti-infectious drugs were the most common drug classes represented.
• The five most frequently reported drugs were carbamazepine (11.7%), lamotrigine (10.6%), sulfamethoxazole-trimethoprim (9%), acetaminophen (8.4%), and phenytoin (6.6%). The five drugs with the highest IC025 were lamotrigine, carbamazepine, phenobarbital, phenytoin, and nimesulide.
• All antiepileptics, many antibiotic families, dapsone, antiretroviral drugs, some antifungal drugs, and nonsteroidal anti-inflammatory drugs were identified in reports, with penicillins the most frequently reported antibiotic family and sulfonamides having the strongest pharmacovigilance signal.
• Vaccines were not associated with significant signals.

IN PRACTICE:

The study provides an update on “the spectrum of drugs potentially associated with SJS-TEN in the pediatric population,” the authors concluded, and “underlines the importance of reporting to pharmacovigilance the suspicion of this severe side effect of drugs with the most precise and detailed clinical description possible.”

SOURCE:

The study, led by Pauline Bataille, MD, of the Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades, Paris City University, France, was published online in the Journal of the European Academy of Dermatology and Venereology.

LIMITATIONS:

Limitations include the possibility that some cases could have had an infectious or idiopathic cause not related to a drug and the lack of detailed clinical data in the database.

DISCLOSURES:

This study did not receive any funding. The authors declared no conflict of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

Antiepileptic and anti-infectious agents were the most common drugs associated with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) in children in an analysis of a World Health Organization (WHO) database.

METHODOLOGY:

• SJS and TEN are rare, life-threatening mucocutaneous reactions mainly associated with medications, but large pharmacovigilance studies of drugs associated with SJS-TEN in the pediatric population are still lacking.
• Using the WHO’s pharmacovigilance database (VigiBase) containing individual case safety reports from January 1967 to July 2022, researchers identified 7342 adverse drug reaction reports of SJS-TEN in children (younger than 18 years; median age, 9 years) in all six continents. Median onset was 5 days, and 3.2% were fatal.
• They analyzed drugs reported as suspected treatments, and for each molecule, they performed a case–non-case study to assess a potential pharmacovigilance signal by computing the information component (IC).
• A positive IC value suggested more frequent reporting of a specific drug-adverse reaction pair. A positive IC025, a traditional threshold for statistical signal detection, is suggestive of a potential pharmacovigilance signal.

TAKEAWAY:

• Overall, 165 drugs were associated with a diagnosis of SJS-TEN; antiepileptic and anti-infectious drugs were the most common drug classes represented.
• The five most frequently reported drugs were carbamazepine (11.7%), lamotrigine (10.6%), sulfamethoxazole-trimethoprim (9%), acetaminophen (8.4%), and phenytoin (6.6%). The five drugs with the highest IC025 were lamotrigine, carbamazepine, phenobarbital, phenytoin, and nimesulide.
• All antiepileptics, many antibiotic families, dapsone, antiretroviral drugs, some antifungal drugs, and nonsteroidal anti-inflammatory drugs were identified in reports, with penicillins the most frequently reported antibiotic family and sulfonamides having the strongest pharmacovigilance signal.
• Vaccines were not associated with significant signals.

IN PRACTICE:

The study provides an update on “the spectrum of drugs potentially associated with SJS-TEN in the pediatric population,” the authors concluded, and “underlines the importance of reporting to pharmacovigilance the suspicion of this severe side effect of drugs with the most precise and detailed clinical description possible.”

SOURCE:

The study, led by Pauline Bataille, MD, of the Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades, Paris City University, France, was published online in the Journal of the European Academy of Dermatology and Venereology.

LIMITATIONS:

Limitations include the possibility that some cases could have had an infectious or idiopathic cause not related to a drug and the lack of detailed clinical data in the database.

DISCLOSURES:

This study did not receive any funding. The authors declared no conflict of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

Cutaneous manifestations of cystic fibrosis (CF) include palmar wrinkling, nutrient deficiency dermatitis, vascular disorders, and reactions to CF treatments.

METHODOLOGY:

• Patients with CF, caused by a mutation in the CF Transmembrane Conductance Regulator (CFTR) gene, can develop diverse dermatologic manifestations.
• Researchers reviewed the literature and provided their own clinical experience regarding dermatologic manifestations of CF.
• They also reviewed the cutaneous side effects of CFTR modulators and antibiotics used to treat CF.

TAKEAWAY:

• Aquagenic wrinkling of the palm is common in individuals with CF, affecting up to 80% of patients (and 25% of CF gene carriers), and can be an early manifestation of CF. Treatments include topical medications (such as aluminum chloride, corticosteroids, and salicylic acid), botulinum toxin injections, and recently, CFTR-modulating treatments.
• CF nutrient deficiency dermatitis, often in a diaper distribution, usually appears in infancy and, before newborn screening was available, was sometimes the first sign of CF in some cases. It usually resolves with an adequate diet, pancreatic enzymes, and/or nutritional supplements. Zinc and essential fatty acid deficiencies can lead to acrodermatitis enteropathica–like symptoms and psoriasiform rashes, respectively.
• CF is also associated with vascular disorders, including cutaneous and, rarely, systemic vasculitis. Treatment includes topical and oral steroids and immune-modulating therapies.
• CFTR modulators, now the most common and highly effective treatment for CF, are associated with several skin reactions, which can be managed with treatments that include topical steroids and oral antihistamines. Frequent antibiotic treatment can also trigger skin reactions.

IN PRACTICE:

“Recognition and familiarity with dermatologic clinical manifestations of CF are important for multidisciplinary care” for patients with CF, the authors wrote, adding that “dermatology providers may play a significant role in the diagnosis and management of CF cutaneous comorbidities.”

SOURCE:

Aaron D. Smith, BS, from the University of Virginia (UVA) School of Medicine, Charlottesville, and coauthors were from the departments of dermatology and pulmonology/critical care medicine at UVA. The study was published online in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The authors did not make a comment about the limitations of their review.

DISCLOSURES:

No funding was received for the review. The authors had no disclosures.

A version of this article first appeared on Medscape.com.

TOPLINE:

Cutaneous manifestations of cystic fibrosis (CF) include palmar wrinkling, nutrient deficiency dermatitis, vascular disorders, and reactions to CF treatments.

METHODOLOGY:

• Patients with CF, caused by a mutation in the CF Transmembrane Conductance Regulator (CFTR) gene, can develop diverse dermatologic manifestations.
• Researchers reviewed the literature and provided their own clinical experience regarding dermatologic manifestations of CF.
• They also reviewed the cutaneous side effects of CFTR modulators and antibiotics used to treat CF.

TAKEAWAY:

• Aquagenic wrinkling of the palm is common in individuals with CF, affecting up to 80% of patients (and 25% of CF gene carriers), and can be an early manifestation of CF. Treatments include topical medications (such as aluminum chloride, corticosteroids, and salicylic acid), botulinum toxin injections, and recently, CFTR-modulating treatments.
• CF nutrient deficiency dermatitis, often in a diaper distribution, usually appears in infancy and, before newborn screening was available, was sometimes the first sign of CF in some cases. It usually resolves with an adequate diet, pancreatic enzymes, and/or nutritional supplements. Zinc and essential fatty acid deficiencies can lead to acrodermatitis enteropathica–like symptoms and psoriasiform rashes, respectively.
• CF is also associated with vascular disorders, including cutaneous and, rarely, systemic vasculitis. Treatment includes topical and oral steroids and immune-modulating therapies.
• CFTR modulators, now the most common and highly effective treatment for CF, are associated with several skin reactions, which can be managed with treatments that include topical steroids and oral antihistamines. Frequent antibiotic treatment can also trigger skin reactions.

IN PRACTICE:

“Recognition and familiarity with dermatologic clinical manifestations of CF are important for multidisciplinary care” for patients with CF, the authors wrote, adding that “dermatology providers may play a significant role in the diagnosis and management of CF cutaneous comorbidities.”

SOURCE:

Aaron D. Smith, BS, from the University of Virginia (UVA) School of Medicine, Charlottesville, and coauthors were from the departments of dermatology and pulmonology/critical care medicine at UVA. The study was published online in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The authors did not make a comment about the limitations of their review.

DISCLOSURES:

No funding was received for the review. The authors had no disclosures.

A version of this article first appeared on Medscape.com.

TOPLINE:

Cutaneous manifestations of cystic fibrosis (CF) include palmar wrinkling, nutrient deficiency dermatitis, vascular disorders, and reactions to CF treatments.

METHODOLOGY:

• Patients with CF, caused by a mutation in the CF Transmembrane Conductance Regulator (CFTR) gene, can develop diverse dermatologic manifestations.
• Researchers reviewed the literature and provided their own clinical experience regarding dermatologic manifestations of CF.
• They also reviewed the cutaneous side effects of CFTR modulators and antibiotics used to treat CF.

TAKEAWAY:

• Aquagenic wrinkling of the palm is common in individuals with CF, affecting up to 80% of patients (and 25% of CF gene carriers), and can be an early manifestation of CF. Treatments include topical medications (such as aluminum chloride, corticosteroids, and salicylic acid), botulinum toxin injections, and recently, CFTR-modulating treatments.
• CF nutrient deficiency dermatitis, often in a diaper distribution, usually appears in infancy and, before newborn screening was available, was sometimes the first sign of CF in some cases. It usually resolves with an adequate diet, pancreatic enzymes, and/or nutritional supplements. Zinc and essential fatty acid deficiencies can lead to acrodermatitis enteropathica–like symptoms and psoriasiform rashes, respectively.
• CF is also associated with vascular disorders, including cutaneous and, rarely, systemic vasculitis. Treatment includes topical and oral steroids and immune-modulating therapies.
• CFTR modulators, now the most common and highly effective treatment for CF, are associated with several skin reactions, which can be managed with treatments that include topical steroids and oral antihistamines. Frequent antibiotic treatment can also trigger skin reactions.

IN PRACTICE:

“Recognition and familiarity with dermatologic clinical manifestations of CF are important for multidisciplinary care” for patients with CF, the authors wrote, adding that “dermatology providers may play a significant role in the diagnosis and management of CF cutaneous comorbidities.”

SOURCE:

Aaron D. Smith, BS, from the University of Virginia (UVA) School of Medicine, Charlottesville, and coauthors were from the departments of dermatology and pulmonology/critical care medicine at UVA. The study was published online in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The authors did not make a comment about the limitations of their review.

DISCLOSURES:

No funding was received for the review. The authors had no disclosures.

A version of this article first appeared on Medscape.com.

Emergencies happen anywhere, anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a series telling these stories.

Jennifer Suders, DO: We were in Florida with our 1-year-old daughter visiting my parents. They moved to an area called Hallandale Beach and live in a high-rise community with a few different pools and spas.

Dan and I were in the spa area at the gym. He was getting me to hurry up because we were supposed to meet my parents who were with our daughter. I was sort of moseying and taking my time.

We were walking by one of the pool decks to get into the building when I heard what sounded like a slap. My first thought was that maybe somebody was choking and someone was hitting their back. Choking has always been my biggest fear with our daughter.

I turned and saw some people who seemed frantic. I looked at Dan and started to ask, “Do you think they need help?” I don’t even think I got the whole sentence out before this mom whipped her head around. I’ll never forget her dark brown hair flying. She screamed, “HELP!”

Dan and I just ran. I let go of my backpack and iPad and water bottle. They scattered across the pool deck. I instantly had my phone in my hand dialing 911.

Daniel Suders, DO: That’s what they teach us, to call 911 first. I didn’t think of it in the moment, but Jenny did.

Jennifer Suders: There was a little boy lying on the ground. Totally gray. He looked about 3 years old. His mom was distraught. His grandparents were standing there in shock with his older brother who was around 5. He was scared and whimpering.

Dan and I got down on either side of the boy and checked for a pulse. We couldn’t feel anything. Dan started chest compressions. I was talking to the 911 operator, and then I gave two rescue breaths. We did a sternal rub.

I was kind of yelling in the boy’s face, trying to get him to respond. I tried English and Russian because there’s a big Russian community there, and my family speaks Russian. The grandma asked us if we knew what we were doing.

Daniel Suders: I think she asked if Jenny was a nurse.

Jennifer Suders: Common misconception. Suddenly, the boy started vomiting, and so much water poured out. We turned him on his side, and he had two or three more episodes of spitting up the water. After that, we could see the color start to come back into his face. His eyes started fluttering.

We thought he was probably coming back. But we were too scared to say that in case we were wrong, and he went back under. So, we just held him steady. We didn’t know what had happened, if he might have hit his head, so we needed to keep him still.

Daniel Suders: It was amazing when those eyes opened, and he started to wake up.

Jennifer Suders: It felt like my heart had stopped while I was waiting for his to start.

Daniel Suders: He was clutching his chest like it hurt and started calling for his mom. He was crying and wanting to get in his mom’s arms. We had to keep him from standing up and walking.

Jennifer Suders: He was clearly scared. There were all these strange faces around him. I kept looking at my phone, anxiously waiting for EMS to come. They got there about 8 or 9 minutes later.

At some point, the father walked in with their daughter, a baby under a year old. He was in shock, not knowing what was going on. The grandma explained that the boy had been jumping into the pool over and over with his brother. All of a sudden, they looked over, and he was just lying there, floating, face down. They were right there; they were watching him. It was just that quick.

Daniel Suders: They pulled him out right away, and that was a big thing on his side that it was caught so quickly. He didn’t have to wait long to start resuscitation.

Jennifer Suders: Once EMS got there and assessed him, they put him and his mom on the stretcher. I remember watching them wheel it through the double doors to get to the elevator. As soon as they were gone, I just turned around and broke down. I had been in doctor mode if you will. Straight to the point. No nonsense. Suddenly, I went back into civilian mode, and my emotions just bubbled up.

After we left, we went to meet my parents who had our kid. Dan just beelined toward her and scooped her up and wouldn’t let her go.

For the rest of the day, it was all I could think about. It took me a while to fall asleep that night, and it was the first thing I thought when I woke up the next morning. We were hopeful that the boy was going to be okay, but you never know. We didn’t call the hospital because with HIPAA, I didn’t know if they could tell us anything.

And then the next day — there they were. The family was back at the pool. The little boy was running around like nothing had happened. We were a little surprised. But I would hate for him to be scared of the pool for the rest of his life. His family was watching him like a hawk.

They told us that the boy and his mom had stayed overnight in the ER, but only as a precaution. He didn’t have any more vomiting. He was absolutely fine. They were incredibly grateful.

We got their names and exchanged numbers and took a picture. That’s all I wanted — a photo to remember them.

A day or so later, we saw them again at a nearby park. The boy was climbing trees and seemed completely normal. It was the best outcome we could have hoped for.

Daniel Suders: My biggest worry was any harm to his chest from the resuscitation, or of course how long he was without oxygen. But everyone says that kids are really resilient. I work with adults, so I don’t have a lot of experience.

As a hospitalist, we don’t always see a lot of success with CPR. It’s often an elderly person who just doesn’t have much of a chance. That same week before our vacation, I had lost a 90-year-old in the hospital. It was such a juxtaposition — a 3-year-old with their whole life in front of them. We were able to preserve that, and it was incredible.

Jennifer Suders: I’m a nephrologist, so my field is pretty calm. No big emergencies. We have patients on the floor, but if a code gets called, there’s a team that comes in from the intensive care unit. I always kind of wondered what I would do if I was presented with a scenario like this.

Daniel Suders: We have a lot of friends that do ER medicine, and I felt like those were the guys that really understood when we told them the story. One friend said to me, “By the time they get to us, they’re either in bad shape or they’re better already.” A lot depends on what happens in the field.

Jennifer Suders: I’m even more vigilant about pool safety now. I want to make sure parents know that drowning doesn›t look like flailing theatrics. It can be soundless. Three adults were right next to this little boy and didn›t realize until they looked down and saw him.

If we hadn’t been there, I don’t know if anyone would’ve been able to step in. No one else was medically trained. But I think the message is — you don’t have to be. Anyone can take a CPR class.

When I told my parents, my dad said, “Oh my gosh, I would’ve laid right down there next to that kid and passed out.” Without any training, it’s petrifying to see something like that.

I think about how we could have stayed in the gym longer and been too late. Or we could have gotten on the elevator earlier and been gone. Two minutes, and it would’ve been a story we heard later, not one we were a part of. It feels like we were at a true crossroads in that moment where that boy could have lived or died. And the stars aligned perfectly.

We had no medicine, no monitors, nothing but our hands and our breaths. And we helped a family continue their vacation rather than plan a funeral.

Jennifer Suders, DO, is a nephrologist at West Virginia University Medicine Wheeling Clinic. Daniel Suders, DO, is a hospitalist at West Virginia University Medicine Reynolds Memorial Hospital.

A version of this article appeared on Medscape.com .

Emergencies happen anywhere, anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a series telling these stories.

Jennifer Suders, DO: We were in Florida with our 1-year-old daughter visiting my parents. They moved to an area called Hallandale Beach and live in a high-rise community with a few different pools and spas.

Dan and I were in the spa area at the gym. He was getting me to hurry up because we were supposed to meet my parents who were with our daughter. I was sort of moseying and taking my time.

We were walking by one of the pool decks to get into the building when I heard what sounded like a slap. My first thought was that maybe somebody was choking and someone was hitting their back. Choking has always been my biggest fear with our daughter.

I turned and saw some people who seemed frantic. I looked at Dan and started to ask, “Do you think they need help?” I don’t even think I got the whole sentence out before this mom whipped her head around. I’ll never forget her dark brown hair flying. She screamed, “HELP!”

Dan and I just ran. I let go of my backpack and iPad and water bottle. They scattered across the pool deck. I instantly had my phone in my hand dialing 911.

Daniel Suders, DO: That’s what they teach us, to call 911 first. I didn’t think of it in the moment, but Jenny did.

Jennifer Suders: There was a little boy lying on the ground. Totally gray. He looked about 3 years old. His mom was distraught. His grandparents were standing there in shock with his older brother who was around 5. He was scared and whimpering.

Dan and I got down on either side of the boy and checked for a pulse. We couldn’t feel anything. Dan started chest compressions. I was talking to the 911 operator, and then I gave two rescue breaths. We did a sternal rub.

I was kind of yelling in the boy’s face, trying to get him to respond. I tried English and Russian because there’s a big Russian community there, and my family speaks Russian. The grandma asked us if we knew what we were doing.

Daniel Suders: I think she asked if Jenny was a nurse.

Jennifer Suders: Common misconception. Suddenly, the boy started vomiting, and so much water poured out. We turned him on his side, and he had two or three more episodes of spitting up the water. After that, we could see the color start to come back into his face. His eyes started fluttering.

We thought he was probably coming back. But we were too scared to say that in case we were wrong, and he went back under. So, we just held him steady. We didn’t know what had happened, if he might have hit his head, so we needed to keep him still.

Daniel Suders: It was amazing when those eyes opened, and he started to wake up.

Jennifer Suders: It felt like my heart had stopped while I was waiting for his to start.

Daniel Suders: He was clutching his chest like it hurt and started calling for his mom. He was crying and wanting to get in his mom’s arms. We had to keep him from standing up and walking.

Jennifer Suders: He was clearly scared. There were all these strange faces around him. I kept looking at my phone, anxiously waiting for EMS to come. They got there about 8 or 9 minutes later.

At some point, the father walked in with their daughter, a baby under a year old. He was in shock, not knowing what was going on. The grandma explained that the boy had been jumping into the pool over and over with his brother. All of a sudden, they looked over, and he was just lying there, floating, face down. They were right there; they were watching him. It was just that quick.

Daniel Suders: They pulled him out right away, and that was a big thing on his side that it was caught so quickly. He didn’t have to wait long to start resuscitation.

Jennifer Suders: Once EMS got there and assessed him, they put him and his mom on the stretcher. I remember watching them wheel it through the double doors to get to the elevator. As soon as they were gone, I just turned around and broke down. I had been in doctor mode if you will. Straight to the point. No nonsense. Suddenly, I went back into civilian mode, and my emotions just bubbled up.

After we left, we went to meet my parents who had our kid. Dan just beelined toward her and scooped her up and wouldn’t let her go.

For the rest of the day, it was all I could think about. It took me a while to fall asleep that night, and it was the first thing I thought when I woke up the next morning. We were hopeful that the boy was going to be okay, but you never know. We didn’t call the hospital because with HIPAA, I didn’t know if they could tell us anything.

And then the next day — there they were. The family was back at the pool. The little boy was running around like nothing had happened. We were a little surprised. But I would hate for him to be scared of the pool for the rest of his life. His family was watching him like a hawk.

They told us that the boy and his mom had stayed overnight in the ER, but only as a precaution. He didn’t have any more vomiting. He was absolutely fine. They were incredibly grateful.

We got their names and exchanged numbers and took a picture. That’s all I wanted — a photo to remember them.

A day or so later, we saw them again at a nearby park. The boy was climbing trees and seemed completely normal. It was the best outcome we could have hoped for.

Daniel Suders: My biggest worry was any harm to his chest from the resuscitation, or of course how long he was without oxygen. But everyone says that kids are really resilient. I work with adults, so I don’t have a lot of experience.

As a hospitalist, we don’t always see a lot of success with CPR. It’s often an elderly person who just doesn’t have much of a chance. That same week before our vacation, I had lost a 90-year-old in the hospital. It was such a juxtaposition — a 3-year-old with their whole life in front of them. We were able to preserve that, and it was incredible.

Jennifer Suders: I’m a nephrologist, so my field is pretty calm. No big emergencies. We have patients on the floor, but if a code gets called, there’s a team that comes in from the intensive care unit. I always kind of wondered what I would do if I was presented with a scenario like this.

Daniel Suders: We have a lot of friends that do ER medicine, and I felt like those were the guys that really understood when we told them the story. One friend said to me, “By the time they get to us, they’re either in bad shape or they’re better already.” A lot depends on what happens in the field.

Jennifer Suders: I’m even more vigilant about pool safety now. I want to make sure parents know that drowning doesn›t look like flailing theatrics. It can be soundless. Three adults were right next to this little boy and didn›t realize until they looked down and saw him.

If we hadn’t been there, I don’t know if anyone would’ve been able to step in. No one else was medically trained. But I think the message is — you don’t have to be. Anyone can take a CPR class.

When I told my parents, my dad said, “Oh my gosh, I would’ve laid right down there next to that kid and passed out.” Without any training, it’s petrifying to see something like that.

I think about how we could have stayed in the gym longer and been too late. Or we could have gotten on the elevator earlier and been gone. Two minutes, and it would’ve been a story we heard later, not one we were a part of. It feels like we were at a true crossroads in that moment where that boy could have lived or died. And the stars aligned perfectly.

We had no medicine, no monitors, nothing but our hands and our breaths. And we helped a family continue their vacation rather than plan a funeral.

Jennifer Suders, DO, is a nephrologist at West Virginia University Medicine Wheeling Clinic. Daniel Suders, DO, is a hospitalist at West Virginia University Medicine Reynolds Memorial Hospital.

A version of this article appeared on Medscape.com .

Emergencies happen anywhere, anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a series telling these stories.

Jennifer Suders, DO: We were in Florida with our 1-year-old daughter visiting my parents. They moved to an area called Hallandale Beach and live in a high-rise community with a few different pools and spas.

Dan and I were in the spa area at the gym. He was getting me to hurry up because we were supposed to meet my parents who were with our daughter. I was sort of moseying and taking my time.

We were walking by one of the pool decks to get into the building when I heard what sounded like a slap. My first thought was that maybe somebody was choking and someone was hitting their back. Choking has always been my biggest fear with our daughter.

I turned and saw some people who seemed frantic. I looked at Dan and started to ask, “Do you think they need help?” I don’t even think I got the whole sentence out before this mom whipped her head around. I’ll never forget her dark brown hair flying. She screamed, “HELP!”

Dan and I just ran. I let go of my backpack and iPad and water bottle. They scattered across the pool deck. I instantly had my phone in my hand dialing 911.

Daniel Suders, DO: That’s what they teach us, to call 911 first. I didn’t think of it in the moment, but Jenny did.

Jennifer Suders: There was a little boy lying on the ground. Totally gray. He looked about 3 years old. His mom was distraught. His grandparents were standing there in shock with his older brother who was around 5. He was scared and whimpering.

Dan and I got down on either side of the boy and checked for a pulse. We couldn’t feel anything. Dan started chest compressions. I was talking to the 911 operator, and then I gave two rescue breaths. We did a sternal rub.

I was kind of yelling in the boy’s face, trying to get him to respond. I tried English and Russian because there’s a big Russian community there, and my family speaks Russian. The grandma asked us if we knew what we were doing.

Daniel Suders: I think she asked if Jenny was a nurse.

Jennifer Suders: Common misconception. Suddenly, the boy started vomiting, and so much water poured out. We turned him on his side, and he had two or three more episodes of spitting up the water. After that, we could see the color start to come back into his face. His eyes started fluttering.

We thought he was probably coming back. But we were too scared to say that in case we were wrong, and he went back under. So, we just held him steady. We didn’t know what had happened, if he might have hit his head, so we needed to keep him still.

Daniel Suders: It was amazing when those eyes opened, and he started to wake up.

Jennifer Suders: It felt like my heart had stopped while I was waiting for his to start.

Daniel Suders: He was clutching his chest like it hurt and started calling for his mom. He was crying and wanting to get in his mom’s arms. We had to keep him from standing up and walking.

Jennifer Suders: He was clearly scared. There were all these strange faces around him. I kept looking at my phone, anxiously waiting for EMS to come. They got there about 8 or 9 minutes later.

At some point, the father walked in with their daughter, a baby under a year old. He was in shock, not knowing what was going on. The grandma explained that the boy had been jumping into the pool over and over with his brother. All of a sudden, they looked over, and he was just lying there, floating, face down. They were right there; they were watching him. It was just that quick.

Daniel Suders: They pulled him out right away, and that was a big thing on his side that it was caught so quickly. He didn’t have to wait long to start resuscitation.

Jennifer Suders: Once EMS got there and assessed him, they put him and his mom on the stretcher. I remember watching them wheel it through the double doors to get to the elevator. As soon as they were gone, I just turned around and broke down. I had been in doctor mode if you will. Straight to the point. No nonsense. Suddenly, I went back into civilian mode, and my emotions just bubbled up.

After we left, we went to meet my parents who had our kid. Dan just beelined toward her and scooped her up and wouldn’t let her go.

For the rest of the day, it was all I could think about. It took me a while to fall asleep that night, and it was the first thing I thought when I woke up the next morning. We were hopeful that the boy was going to be okay, but you never know. We didn’t call the hospital because with HIPAA, I didn’t know if they could tell us anything.

And then the next day — there they were. The family was back at the pool. The little boy was running around like nothing had happened. We were a little surprised. But I would hate for him to be scared of the pool for the rest of his life. His family was watching him like a hawk.

They told us that the boy and his mom had stayed overnight in the ER, but only as a precaution. He didn’t have any more vomiting. He was absolutely fine. They were incredibly grateful.

We got their names and exchanged numbers and took a picture. That’s all I wanted — a photo to remember them.

A day or so later, we saw them again at a nearby park. The boy was climbing trees and seemed completely normal. It was the best outcome we could have hoped for.

Daniel Suders: My biggest worry was any harm to his chest from the resuscitation, or of course how long he was without oxygen. But everyone says that kids are really resilient. I work with adults, so I don’t have a lot of experience.

As a hospitalist, we don’t always see a lot of success with CPR. It’s often an elderly person who just doesn’t have much of a chance. That same week before our vacation, I had lost a 90-year-old in the hospital. It was such a juxtaposition — a 3-year-old with their whole life in front of them. We were able to preserve that, and it was incredible.

Jennifer Suders: I’m a nephrologist, so my field is pretty calm. No big emergencies. We have patients on the floor, but if a code gets called, there’s a team that comes in from the intensive care unit. I always kind of wondered what I would do if I was presented with a scenario like this.

Daniel Suders: We have a lot of friends that do ER medicine, and I felt like those were the guys that really understood when we told them the story. One friend said to me, “By the time they get to us, they’re either in bad shape or they’re better already.” A lot depends on what happens in the field.

Jennifer Suders: I’m even more vigilant about pool safety now. I want to make sure parents know that drowning doesn›t look like flailing theatrics. It can be soundless. Three adults were right next to this little boy and didn›t realize until they looked down and saw him.

If we hadn’t been there, I don’t know if anyone would’ve been able to step in. No one else was medically trained. But I think the message is — you don’t have to be. Anyone can take a CPR class.

When I told my parents, my dad said, “Oh my gosh, I would’ve laid right down there next to that kid and passed out.” Without any training, it’s petrifying to see something like that.

I think about how we could have stayed in the gym longer and been too late. Or we could have gotten on the elevator earlier and been gone. Two minutes, and it would’ve been a story we heard later, not one we were a part of. It feels like we were at a true crossroads in that moment where that boy could have lived or died. And the stars aligned perfectly.

We had no medicine, no monitors, nothing but our hands and our breaths. And we helped a family continue their vacation rather than plan a funeral.

Jennifer Suders, DO, is a nephrologist at West Virginia University Medicine Wheeling Clinic. Daniel Suders, DO, is a hospitalist at West Virginia University Medicine Reynolds Memorial Hospital.

A version of this article appeared on Medscape.com .

TORONTO — In the course of a well visit, the way in which clinicians elicit an adolescent’s sexual orientation and gender identity (SOGI) matters, and there are different preferences for those with a gender identity different from their birth assignment or non-heterosexuals relative to those in neither of these categories.

In a study that surveyed more than 60,000 adolescents, one of the messages was that there is a “balancing act” that involves affirming the child’s self-identity while recognizing the substantial vulnerability at this step in development, reported Scott Jelinek, MD, a third-year pediatrics resident in the Children’s Hospital of Philadelphia, University of Pennsylvania.

Based on his work, there are two aims.

“The first is to determine the comfort level of the adolescent in discussing sensitive health information,” said Dr. Jelinek, referring to the discussion of SOGI irrespective of how the adolescent responds. “To understand this is crucial because this first encounter with healthcare can be formative.”

Yet, for those who identify as lesbian, gay, bisexual, transsexual, queer, or with another sexual or gender orientation (LBGTQ+), the encounter can be more delicate, according to Dr. Jelinek. One reason is that there is greater uncertainty about acceptance of these identities from peers, parents, and others, Dr. Jelinek said.

This was reinforced by results of a cross-sectional study of 62,695 adolescents in 31 pediatric clinics in the Philadelphia area. Of these, 10,381 (16.6%) identified as LGBTQ+. The adolescents aged in range from 13 to 21 years with a mean age of 15.3.

These data were presented at the Pediatric Academic Societies annual meeting. Dr. Jelinek received this year’s Society of Pediatric Research Richard D. Rowe Award for clinical research by a fellow.
 

Revealing Sensitive Information

With the intention of comparing responses from LBGTQ+ youth to those of cisgender heterosexuals, the first of two primary questions elicited information about comfort level discussing SOGI in the presence of parents or caregivers during a primary care visit. The second asked for a preference regarding electronic or oral capture of the information. “Almost half [49.4%] of the LGBTQ+ adolescents expressed discomfort discussing this information with the caregiver present,” reported Dr. Jelinek. This proportion, which was close to double the 25.5% rate among the cisgender heterosexual respondents, reached significance (P < .01). After adjustment for covariates, there was a 60% greater odds ratio (OR) among LBGTQ+ adolescents for expressing reluctance to share this information in front of a caregiver (adjusted odds ratio [aOR] 0.37; 95% CI: 0.35-0.39).

The greater preference among LBGTQ+ adolescents for electronic capture of SOGI-relevant information also reached statistical significance. Even though the proportional difference was modest (74.2% vs 72.7%; P < .01), it corresponded to about a 10% greater preference for electronic data collection after adjustment (aOR 1.08; 95% CI: 1.03-1.14), Dr. Jelinek reported.

These results were generally consistent across clinics, which were located in urban, suburban, and rural areas. Responses among Black adolescents, which represented 29.7% of the study population, were similar to those provided by White adolescents, which represented 46.1%, and Hispanics, which represented about 10% of the sample.

The results are not entirely surprising in the context of the potential for LBGTQ+ stigma, but Dr. Jelinek emphasized the need for being aware that this discussion is delicate and might have ramifications after the visit for children trying to accept and affirm their self-identification.

“Let us remember that the healthcare system has the potential to be a powerful ally in the lives of LBGTQ+ youth and to meet their unique needs,” he said.

The interaction is also delicate because parents might not yet be aware of their child’s sexual orientation. Indeed, Dr. Jelinek said that completion of the Attitudes Toward Homosexuality Questionnaire (AHQ) might be the first time that these individuals have revealed this aspect of their identity to anyone.

For confirming a non-heterosexual orientation, “pediatricians are on the front line and often the first point of contact for adolescents seeking health support and affirmation,” he said.

For this reason, it is also essential to maintain confidentiality to the degree that the patient specifies. Dr. Jelinek recognizes tension when balancing visibility and affirmation against the need for privacy, but he said both are important. Even if pediatricians should provide a positive experience for adolescents revealing their sexual orientation, there might be personal, family, and social adjustments to navigate over time.

As a result, Dr. Jelinek warned that there are issues for protecting information that an adolescent is not ready to reveal.

In this regard. “there is an urgent need for innovative solutions to balance visibility with privacy in primary care,” he said, reporting that electronic medical records (EMR) do not necessarily guarantee confidentiality, particularly from family members.

When adolescents arrive at the office to complete an AHQ, front desk staff at Dr. Jelinek’s center are instructed to hand the tablet to the child, not the caregiver. However, he recognizes that this does not prevent the caregiver from reviewing the answers or in some cases taking the tablet to complete the answers.

“If I enter the exam room and see the tablet in a parent’s lap, I am going to want to have a conversation with the patient to verify the answers,” he said.
 

Protecting Patients

The data from this study provoke important questions about how to achieve the goals that Dr. Jelinek described, according to Ashley M. Lekach, MSN, RN, a family nurse practitioner working in pediatric endocrinology at NewYork-Presbyterian’s Methodist Hospital in Brooklyn, New York. Ms. Lekach was not involved with the study.

“My concern is that once we are given this sensitive information, how do we make sure we are going to protect the patient from unwanted disclosure?” Ms. Lekach said. She agreed that there is a risk that EMRs can be accessed by individuals to which the patient would not want SOGI information revealed.

“It is a vote of confidence for the patient to reveal this information to me, and it is clearly our job to make sure the patient feels safe,” she said.

She also expressed concern that adolescents who reveal this information might need resources to cope with issues raised by non-heterosexual identification. She agreed that discussing sexual orientation and gender identity in the clinical setting is often a major step for adolescents, particularly young adolescents, but she believes follow-up and next steps are in the interest of the patient.

Although the need for affirmation and confidentiality are not new ideas, Ms. Lekach said that the talk provided some useful context for thinking about these issues.

Dr. Jelinek and Ms. Lekach report no potential conflicts of interest.

TORONTO — In the course of a well visit, the way in which clinicians elicit an adolescent’s sexual orientation and gender identity (SOGI) matters, and there are different preferences for those with a gender identity different from their birth assignment or non-heterosexuals relative to those in neither of these categories.

In a study that surveyed more than 60,000 adolescents, one of the messages was that there is a “balancing act” that involves affirming the child’s self-identity while recognizing the substantial vulnerability at this step in development, reported Scott Jelinek, MD, a third-year pediatrics resident in the Children’s Hospital of Philadelphia, University of Pennsylvania.

Based on his work, there are two aims.

“The first is to determine the comfort level of the adolescent in discussing sensitive health information,” said Dr. Jelinek, referring to the discussion of SOGI irrespective of how the adolescent responds. “To understand this is crucial because this first encounter with healthcare can be formative.”

Yet, for those who identify as lesbian, gay, bisexual, transsexual, queer, or with another sexual or gender orientation (LBGTQ+), the encounter can be more delicate, according to Dr. Jelinek. One reason is that there is greater uncertainty about acceptance of these identities from peers, parents, and others, Dr. Jelinek said.

This was reinforced by results of a cross-sectional study of 62,695 adolescents in 31 pediatric clinics in the Philadelphia area. Of these, 10,381 (16.6%) identified as LGBTQ+. The adolescents aged in range from 13 to 21 years with a mean age of 15.3.

These data were presented at the Pediatric Academic Societies annual meeting. Dr. Jelinek received this year’s Society of Pediatric Research Richard D. Rowe Award for clinical research by a fellow.
 

Revealing Sensitive Information

With the intention of comparing responses from LBGTQ+ youth to those of cisgender heterosexuals, the first of two primary questions elicited information about comfort level discussing SOGI in the presence of parents or caregivers during a primary care visit. The second asked for a preference regarding electronic or oral capture of the information. “Almost half [49.4%] of the LGBTQ+ adolescents expressed discomfort discussing this information with the caregiver present,” reported Dr. Jelinek. This proportion, which was close to double the 25.5% rate among the cisgender heterosexual respondents, reached significance (P < .01). After adjustment for covariates, there was a 60% greater odds ratio (OR) among LBGTQ+ adolescents for expressing reluctance to share this information in front of a caregiver (adjusted odds ratio [aOR] 0.37; 95% CI: 0.35-0.39).

The greater preference among LBGTQ+ adolescents for electronic capture of SOGI-relevant information also reached statistical significance. Even though the proportional difference was modest (74.2% vs 72.7%; P < .01), it corresponded to about a 10% greater preference for electronic data collection after adjustment (aOR 1.08; 95% CI: 1.03-1.14), Dr. Jelinek reported.

These results were generally consistent across clinics, which were located in urban, suburban, and rural areas. Responses among Black adolescents, which represented 29.7% of the study population, were similar to those provided by White adolescents, which represented 46.1%, and Hispanics, which represented about 10% of the sample.

The results are not entirely surprising in the context of the potential for LBGTQ+ stigma, but Dr. Jelinek emphasized the need for being aware that this discussion is delicate and might have ramifications after the visit for children trying to accept and affirm their self-identification.

“Let us remember that the healthcare system has the potential to be a powerful ally in the lives of LBGTQ+ youth and to meet their unique needs,” he said.

The interaction is also delicate because parents might not yet be aware of their child’s sexual orientation. Indeed, Dr. Jelinek said that completion of the Attitudes Toward Homosexuality Questionnaire (AHQ) might be the first time that these individuals have revealed this aspect of their identity to anyone.

For confirming a non-heterosexual orientation, “pediatricians are on the front line and often the first point of contact for adolescents seeking health support and affirmation,” he said.

For this reason, it is also essential to maintain confidentiality to the degree that the patient specifies. Dr. Jelinek recognizes tension when balancing visibility and affirmation against the need for privacy, but he said both are important. Even if pediatricians should provide a positive experience for adolescents revealing their sexual orientation, there might be personal, family, and social adjustments to navigate over time.

As a result, Dr. Jelinek warned that there are issues for protecting information that an adolescent is not ready to reveal.

In this regard. “there is an urgent need for innovative solutions to balance visibility with privacy in primary care,” he said, reporting that electronic medical records (EMR) do not necessarily guarantee confidentiality, particularly from family members.

When adolescents arrive at the office to complete an AHQ, front desk staff at Dr. Jelinek’s center are instructed to hand the tablet to the child, not the caregiver. However, he recognizes that this does not prevent the caregiver from reviewing the answers or in some cases taking the tablet to complete the answers.

“If I enter the exam room and see the tablet in a parent’s lap, I am going to want to have a conversation with the patient to verify the answers,” he said.
 

Protecting Patients

The data from this study provoke important questions about how to achieve the goals that Dr. Jelinek described, according to Ashley M. Lekach, MSN, RN, a family nurse practitioner working in pediatric endocrinology at NewYork-Presbyterian’s Methodist Hospital in Brooklyn, New York. Ms. Lekach was not involved with the study.

“My concern is that once we are given this sensitive information, how do we make sure we are going to protect the patient from unwanted disclosure?” Ms. Lekach said. She agreed that there is a risk that EMRs can be accessed by individuals to which the patient would not want SOGI information revealed.

“It is a vote of confidence for the patient to reveal this information to me, and it is clearly our job to make sure the patient feels safe,” she said.

She also expressed concern that adolescents who reveal this information might need resources to cope with issues raised by non-heterosexual identification. She agreed that discussing sexual orientation and gender identity in the clinical setting is often a major step for adolescents, particularly young adolescents, but she believes follow-up and next steps are in the interest of the patient.

Although the need for affirmation and confidentiality are not new ideas, Ms. Lekach said that the talk provided some useful context for thinking about these issues.

Dr. Jelinek and Ms. Lekach report no potential conflicts of interest.

TORONTO — In the course of a well visit, the way in which clinicians elicit an adolescent’s sexual orientation and gender identity (SOGI) matters, and there are different preferences for those with a gender identity different from their birth assignment or non-heterosexuals relative to those in neither of these categories.

In a study that surveyed more than 60,000 adolescents, one of the messages was that there is a “balancing act” that involves affirming the child’s self-identity while recognizing the substantial vulnerability at this step in development, reported Scott Jelinek, MD, a third-year pediatrics resident in the Children’s Hospital of Philadelphia, University of Pennsylvania.

Based on his work, there are two aims.

“The first is to determine the comfort level of the adolescent in discussing sensitive health information,” said Dr. Jelinek, referring to the discussion of SOGI irrespective of how the adolescent responds. “To understand this is crucial because this first encounter with healthcare can be formative.”

Yet, for those who identify as lesbian, gay, bisexual, transsexual, queer, or with another sexual or gender orientation (LBGTQ+), the encounter can be more delicate, according to Dr. Jelinek. One reason is that there is greater uncertainty about acceptance of these identities from peers, parents, and others, Dr. Jelinek said.

This was reinforced by results of a cross-sectional study of 62,695 adolescents in 31 pediatric clinics in the Philadelphia area. Of these, 10,381 (16.6%) identified as LGBTQ+. The adolescents aged in range from 13 to 21 years with a mean age of 15.3.

These data were presented at the Pediatric Academic Societies annual meeting. Dr. Jelinek received this year’s Society of Pediatric Research Richard D. Rowe Award for clinical research by a fellow.
 

Revealing Sensitive Information

With the intention of comparing responses from LBGTQ+ youth to those of cisgender heterosexuals, the first of two primary questions elicited information about comfort level discussing SOGI in the presence of parents or caregivers during a primary care visit. The second asked for a preference regarding electronic or oral capture of the information. “Almost half [49.4%] of the LGBTQ+ adolescents expressed discomfort discussing this information with the caregiver present,” reported Dr. Jelinek. This proportion, which was close to double the 25.5% rate among the cisgender heterosexual respondents, reached significance (P < .01). After adjustment for covariates, there was a 60% greater odds ratio (OR) among LBGTQ+ adolescents for expressing reluctance to share this information in front of a caregiver (adjusted odds ratio [aOR] 0.37; 95% CI: 0.35-0.39).

The greater preference among LBGTQ+ adolescents for electronic capture of SOGI-relevant information also reached statistical significance. Even though the proportional difference was modest (74.2% vs 72.7%; P < .01), it corresponded to about a 10% greater preference for electronic data collection after adjustment (aOR 1.08; 95% CI: 1.03-1.14), Dr. Jelinek reported.

These results were generally consistent across clinics, which were located in urban, suburban, and rural areas. Responses among Black adolescents, which represented 29.7% of the study population, were similar to those provided by White adolescents, which represented 46.1%, and Hispanics, which represented about 10% of the sample.

The results are not entirely surprising in the context of the potential for LBGTQ+ stigma, but Dr. Jelinek emphasized the need for being aware that this discussion is delicate and might have ramifications after the visit for children trying to accept and affirm their self-identification.

“Let us remember that the healthcare system has the potential to be a powerful ally in the lives of LBGTQ+ youth and to meet their unique needs,” he said.

The interaction is also delicate because parents might not yet be aware of their child’s sexual orientation. Indeed, Dr. Jelinek said that completion of the Attitudes Toward Homosexuality Questionnaire (AHQ) might be the first time that these individuals have revealed this aspect of their identity to anyone.

For confirming a non-heterosexual orientation, “pediatricians are on the front line and often the first point of contact for adolescents seeking health support and affirmation,” he said.

For this reason, it is also essential to maintain confidentiality to the degree that the patient specifies. Dr. Jelinek recognizes tension when balancing visibility and affirmation against the need for privacy, but he said both are important. Even if pediatricians should provide a positive experience for adolescents revealing their sexual orientation, there might be personal, family, and social adjustments to navigate over time.

As a result, Dr. Jelinek warned that there are issues for protecting information that an adolescent is not ready to reveal.

In this regard. “there is an urgent need for innovative solutions to balance visibility with privacy in primary care,” he said, reporting that electronic medical records (EMR) do not necessarily guarantee confidentiality, particularly from family members.

When adolescents arrive at the office to complete an AHQ, front desk staff at Dr. Jelinek’s center are instructed to hand the tablet to the child, not the caregiver. However, he recognizes that this does not prevent the caregiver from reviewing the answers or in some cases taking the tablet to complete the answers.

“If I enter the exam room and see the tablet in a parent’s lap, I am going to want to have a conversation with the patient to verify the answers,” he said.
 

Protecting Patients

The data from this study provoke important questions about how to achieve the goals that Dr. Jelinek described, according to Ashley M. Lekach, MSN, RN, a family nurse practitioner working in pediatric endocrinology at NewYork-Presbyterian’s Methodist Hospital in Brooklyn, New York. Ms. Lekach was not involved with the study.

“My concern is that once we are given this sensitive information, how do we make sure we are going to protect the patient from unwanted disclosure?” Ms. Lekach said. She agreed that there is a risk that EMRs can be accessed by individuals to which the patient would not want SOGI information revealed.

“It is a vote of confidence for the patient to reveal this information to me, and it is clearly our job to make sure the patient feels safe,” she said.

She also expressed concern that adolescents who reveal this information might need resources to cope with issues raised by non-heterosexual identification. She agreed that discussing sexual orientation and gender identity in the clinical setting is often a major step for adolescents, particularly young adolescents, but she believes follow-up and next steps are in the interest of the patient.

Although the need for affirmation and confidentiality are not new ideas, Ms. Lekach said that the talk provided some useful context for thinking about these issues.

Dr. Jelinek and Ms. Lekach report no potential conflicts of interest.

TORONTO — Driven by evidence that early access to autism services improves long-term outcomes, an evolution is rapidly unfolding to accelerate the diagnosis, often with the direct participation of pediatricians, according to a series of studies presented at the Pediatric Academic Societies annual meeting.

Accelerated Diagnosis

In one study, 80% of the evaluations were conducted within 6 weeks of patient enrollment, according to Corinna Rea, MD, a clinician in the primary care center at Boston Children’s Hospital as well as an assistant professor at Harvard Medical School, Boston, Massachusetts.

This outcome was drawn from a pilot study with 179 children suspected of autism spectrum disorder (ASD) by clinicians in a pediatric clinic. All were under the age of 3 years. In the first step, families completed the Bayley-4 Social-Emotional and Adaptive Behavior Scale.

The next step was a virtual assessment by a trained clinician using the TELE-ADS-PEDs (TAP) tool developed by Vanderbilt University, Nashville, Tennessee. Patients and families participated from their homes. The diagnosis of ASD was made by a psychologist using the patient’s history and data provided by the two assessment tools.

Through this approach, the median time to diagnosis was 30 days, according to Dr. Rea. Relative to a median time of 168 days to diagnosis among patients considered likely to have ASD at Dr. Rea’s center in the year prior to this pilot study, the time was reduced significantly (P < .001).

All patients in the study were subsequently evaluated by traditional methods. One hundred percent of the ASD diagnoses were confirmed with traditional assessment.

On the basis of these data, the accelerated approach “seems efficient and quite accurate,” Dr. Rea reported. When family members were surveyed at the end of the pilot study, 60% were satisfied and 28% were moderately satisfied. Although 59% reported that they would have preferred an in-person assessment, approximately 90% agreed the child’s development was mostly or completely captured in the accelerated assessment.

Dr. Rea pointed out that the psychologists participating in this study offered the opinion that home-based assessments are in their experience better than in-person evaluations due to the more natural behavior of the child in their own environment. However, she said that the diagnostic approach in the pilot study is still being modified, and one of the goals is to make virtual assessment more acceptable to the families.
 

A Commercialized Diagnostic Approach

A similar approach has been commercialized by a firm called As You Are, according to Steven D. Hicks, MD, PhD, who is an associate professor of pediatrics at Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Dr. Hicks is a principal in the enterprise, which is also assessing ASD virtually.

Trained pediatricians are evaluating patients with multiple tools in addition to TAP, including the Childhood Autism Rating Scale (CARS) and the Diagnostic and Statistical Manual (DSM-V) checklist for ASD. The company, which began offering this diagnostic service in 2022, now employs more than 30 pediatricians who participated in a 1-month training program.

At the 2024 PAS meeting, quality assurance data were presented on 215 (2.2%) of the 9632 children evaluated between February 2023 and March 2024. The diagnostic assessments of these randomly selected children were reviewed by one of three randomly assigned experts (a developmental pediatrician, a child psychologist, or a pediatrician with 7 years’ diagnostic experience) blinded to the initial scoring.

The diagnostic agreement was 94%, according to the data presented, providing a specificity of 90% and a sensitivity of 90% for ASD. The commercialized diagnostic approach is providing a diagnosis in a mean time of 29 days from initial contact, compared with delays that typically exceed 1 year for many children with suspected ASD, according to Dr. Hicks.

Additional Studies Aim at Streamlining Diagnosis

Two additional studies also evaluated strategies to streamline the diagnosis of ASD. Both were positive. In one, the accuracy and time to diagnosis among pediatricians trained in TAP and CARS were compared with those of ASD specialists in a dedicated autism clinic. Both were located at Nemours Children’s Health Center, Wilmington, Delaware.

In this study, presented by Meghan Harrison, DO, an attending pediatrician at Nemours Children’s Health, time to diagnosis among the 39 patients evaluated by pediatricians relative to the 349 patients evaluated at the dedicated ASD center (2.0 vs 5.1 months; P = .001) was significantly shorter. The age at diagnosis in the pediatrician-assessed population (27.5 vs 36.5 months; P < .001) was also significantly younger.

In another study, led by Ashely L. Early, MSW, a clinical social worker at the Medical University of South Carolina, Charleston, South Carolina, switching to a screening tool called the Rapid Interactive Screening Test for Autism in Toddlers (RITA-1) reduced the wait time to evaluation by approximately 5 months relative to previous practice with a more cumbersome screening method.
 

An ‘Urgent Need’ to Accelerate Diagnosis

In most places in the United States, children suspected of ASD are referred to specialists for confirmation of the diagnosis, which is needed to quality for ASD services, according to Katherine Zuckerman, MD, a professor of pediatrics the Oregon Health and Science University, Portland, Oregon. Dr. Zuckerman, who was moderator of the session in which all four of these abstracts were presented, explained that there is an urgent need to accelerate the time to diagnosis, which involves long delays for many if not most children with ASD. This is important because treatment and supportive services for ASD are almost always dependent on a diagnosis.

“There are tons of data to show that earlier access to ASD services has important patient benefits, including higher IQs,” she said. Other benefits she listed include a better quality of life for the child and the family.

“It can provide a huge reduction in family stress,” she added, suggesting that early interventions favorably modify the trajectory of the disability over time with accruing benefits.

“The lifetime costs of ASD exceed cancer and most other disease, so there are major implications for the cumulative cost of ASD management,” Dr. Zuckerman said. She suggested that the studies presented at the meeting reflect a likely evolution in who evaluates children for ASD and how quickly the evaluation is performed.

Dr. Rea, Dr. Harrison, Dr. Zuckerman, and Ms. Early reported no potential conflicts of interest. In addition to his executive role in As You Are, Dr. Hicks has financial relationships with Quadrant Biosciences and Spectrum Solutions.

TORONTO — Driven by evidence that early access to autism services improves long-term outcomes, an evolution is rapidly unfolding to accelerate the diagnosis, often with the direct participation of pediatricians, according to a series of studies presented at the Pediatric Academic Societies annual meeting.

Accelerated Diagnosis

In one study, 80% of the evaluations were conducted within 6 weeks of patient enrollment, according to Corinna Rea, MD, a clinician in the primary care center at Boston Children’s Hospital as well as an assistant professor at Harvard Medical School, Boston, Massachusetts.

This outcome was drawn from a pilot study with 179 children suspected of autism spectrum disorder (ASD) by clinicians in a pediatric clinic. All were under the age of 3 years. In the first step, families completed the Bayley-4 Social-Emotional and Adaptive Behavior Scale.

The next step was a virtual assessment by a trained clinician using the TELE-ADS-PEDs (TAP) tool developed by Vanderbilt University, Nashville, Tennessee. Patients and families participated from their homes. The diagnosis of ASD was made by a psychologist using the patient’s history and data provided by the two assessment tools.

Through this approach, the median time to diagnosis was 30 days, according to Dr. Rea. Relative to a median time of 168 days to diagnosis among patients considered likely to have ASD at Dr. Rea’s center in the year prior to this pilot study, the time was reduced significantly (P < .001).

All patients in the study were subsequently evaluated by traditional methods. One hundred percent of the ASD diagnoses were confirmed with traditional assessment.

On the basis of these data, the accelerated approach “seems efficient and quite accurate,” Dr. Rea reported. When family members were surveyed at the end of the pilot study, 60% were satisfied and 28% were moderately satisfied. Although 59% reported that they would have preferred an in-person assessment, approximately 90% agreed the child’s development was mostly or completely captured in the accelerated assessment.

Dr. Rea pointed out that the psychologists participating in this study offered the opinion that home-based assessments are in their experience better than in-person evaluations due to the more natural behavior of the child in their own environment. However, she said that the diagnostic approach in the pilot study is still being modified, and one of the goals is to make virtual assessment more acceptable to the families.
 

A Commercialized Diagnostic Approach

A similar approach has been commercialized by a firm called As You Are, according to Steven D. Hicks, MD, PhD, who is an associate professor of pediatrics at Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Dr. Hicks is a principal in the enterprise, which is also assessing ASD virtually.

Trained pediatricians are evaluating patients with multiple tools in addition to TAP, including the Childhood Autism Rating Scale (CARS) and the Diagnostic and Statistical Manual (DSM-V) checklist for ASD. The company, which began offering this diagnostic service in 2022, now employs more than 30 pediatricians who participated in a 1-month training program.

At the 2024 PAS meeting, quality assurance data were presented on 215 (2.2%) of the 9632 children evaluated between February 2023 and March 2024. The diagnostic assessments of these randomly selected children were reviewed by one of three randomly assigned experts (a developmental pediatrician, a child psychologist, or a pediatrician with 7 years’ diagnostic experience) blinded to the initial scoring.

The diagnostic agreement was 94%, according to the data presented, providing a specificity of 90% and a sensitivity of 90% for ASD. The commercialized diagnostic approach is providing a diagnosis in a mean time of 29 days from initial contact, compared with delays that typically exceed 1 year for many children with suspected ASD, according to Dr. Hicks.

Additional Studies Aim at Streamlining Diagnosis

Two additional studies also evaluated strategies to streamline the diagnosis of ASD. Both were positive. In one, the accuracy and time to diagnosis among pediatricians trained in TAP and CARS were compared with those of ASD specialists in a dedicated autism clinic. Both were located at Nemours Children’s Health Center, Wilmington, Delaware.

In this study, presented by Meghan Harrison, DO, an attending pediatrician at Nemours Children’s Health, time to diagnosis among the 39 patients evaluated by pediatricians relative to the 349 patients evaluated at the dedicated ASD center (2.0 vs 5.1 months; P = .001) was significantly shorter. The age at diagnosis in the pediatrician-assessed population (27.5 vs 36.5 months; P < .001) was also significantly younger.

In another study, led by Ashely L. Early, MSW, a clinical social worker at the Medical University of South Carolina, Charleston, South Carolina, switching to a screening tool called the Rapid Interactive Screening Test for Autism in Toddlers (RITA-1) reduced the wait time to evaluation by approximately 5 months relative to previous practice with a more cumbersome screening method.
 

An ‘Urgent Need’ to Accelerate Diagnosis

In most places in the United States, children suspected of ASD are referred to specialists for confirmation of the diagnosis, which is needed to quality for ASD services, according to Katherine Zuckerman, MD, a professor of pediatrics the Oregon Health and Science University, Portland, Oregon. Dr. Zuckerman, who was moderator of the session in which all four of these abstracts were presented, explained that there is an urgent need to accelerate the time to diagnosis, which involves long delays for many if not most children with ASD. This is important because treatment and supportive services for ASD are almost always dependent on a diagnosis.

“There are tons of data to show that earlier access to ASD services has important patient benefits, including higher IQs,” she said. Other benefits she listed include a better quality of life for the child and the family.

“It can provide a huge reduction in family stress,” she added, suggesting that early interventions favorably modify the trajectory of the disability over time with accruing benefits.

“The lifetime costs of ASD exceed cancer and most other disease, so there are major implications for the cumulative cost of ASD management,” Dr. Zuckerman said. She suggested that the studies presented at the meeting reflect a likely evolution in who evaluates children for ASD and how quickly the evaluation is performed.

Dr. Rea, Dr. Harrison, Dr. Zuckerman, and Ms. Early reported no potential conflicts of interest. In addition to his executive role in As You Are, Dr. Hicks has financial relationships with Quadrant Biosciences and Spectrum Solutions.

TORONTO — Driven by evidence that early access to autism services improves long-term outcomes, an evolution is rapidly unfolding to accelerate the diagnosis, often with the direct participation of pediatricians, according to a series of studies presented at the Pediatric Academic Societies annual meeting.

Accelerated Diagnosis

In one study, 80% of the evaluations were conducted within 6 weeks of patient enrollment, according to Corinna Rea, MD, a clinician in the primary care center at Boston Children’s Hospital as well as an assistant professor at Harvard Medical School, Boston, Massachusetts.

This outcome was drawn from a pilot study with 179 children suspected of autism spectrum disorder (ASD) by clinicians in a pediatric clinic. All were under the age of 3 years. In the first step, families completed the Bayley-4 Social-Emotional and Adaptive Behavior Scale.

The next step was a virtual assessment by a trained clinician using the TELE-ADS-PEDs (TAP) tool developed by Vanderbilt University, Nashville, Tennessee. Patients and families participated from their homes. The diagnosis of ASD was made by a psychologist using the patient’s history and data provided by the two assessment tools.

Through this approach, the median time to diagnosis was 30 days, according to Dr. Rea. Relative to a median time of 168 days to diagnosis among patients considered likely to have ASD at Dr. Rea’s center in the year prior to this pilot study, the time was reduced significantly (P < .001).

All patients in the study were subsequently evaluated by traditional methods. One hundred percent of the ASD diagnoses were confirmed with traditional assessment.

On the basis of these data, the accelerated approach “seems efficient and quite accurate,” Dr. Rea reported. When family members were surveyed at the end of the pilot study, 60% were satisfied and 28% were moderately satisfied. Although 59% reported that they would have preferred an in-person assessment, approximately 90% agreed the child’s development was mostly or completely captured in the accelerated assessment.

Dr. Rea pointed out that the psychologists participating in this study offered the opinion that home-based assessments are in their experience better than in-person evaluations due to the more natural behavior of the child in their own environment. However, she said that the diagnostic approach in the pilot study is still being modified, and one of the goals is to make virtual assessment more acceptable to the families.
 

A Commercialized Diagnostic Approach

A similar approach has been commercialized by a firm called As You Are, according to Steven D. Hicks, MD, PhD, who is an associate professor of pediatrics at Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Dr. Hicks is a principal in the enterprise, which is also assessing ASD virtually.

Trained pediatricians are evaluating patients with multiple tools in addition to TAP, including the Childhood Autism Rating Scale (CARS) and the Diagnostic and Statistical Manual (DSM-V) checklist for ASD. The company, which began offering this diagnostic service in 2022, now employs more than 30 pediatricians who participated in a 1-month training program.

At the 2024 PAS meeting, quality assurance data were presented on 215 (2.2%) of the 9632 children evaluated between February 2023 and March 2024. The diagnostic assessments of these randomly selected children were reviewed by one of three randomly assigned experts (a developmental pediatrician, a child psychologist, or a pediatrician with 7 years’ diagnostic experience) blinded to the initial scoring.

The diagnostic agreement was 94%, according to the data presented, providing a specificity of 90% and a sensitivity of 90% for ASD. The commercialized diagnostic approach is providing a diagnosis in a mean time of 29 days from initial contact, compared with delays that typically exceed 1 year for many children with suspected ASD, according to Dr. Hicks.

Additional Studies Aim at Streamlining Diagnosis

Two additional studies also evaluated strategies to streamline the diagnosis of ASD. Both were positive. In one, the accuracy and time to diagnosis among pediatricians trained in TAP and CARS were compared with those of ASD specialists in a dedicated autism clinic. Both were located at Nemours Children’s Health Center, Wilmington, Delaware.

In this study, presented by Meghan Harrison, DO, an attending pediatrician at Nemours Children’s Health, time to diagnosis among the 39 patients evaluated by pediatricians relative to the 349 patients evaluated at the dedicated ASD center (2.0 vs 5.1 months; P = .001) was significantly shorter. The age at diagnosis in the pediatrician-assessed population (27.5 vs 36.5 months; P < .001) was also significantly younger.

In another study, led by Ashely L. Early, MSW, a clinical social worker at the Medical University of South Carolina, Charleston, South Carolina, switching to a screening tool called the Rapid Interactive Screening Test for Autism in Toddlers (RITA-1) reduced the wait time to evaluation by approximately 5 months relative to previous practice with a more cumbersome screening method.
 

An ‘Urgent Need’ to Accelerate Diagnosis

In most places in the United States, children suspected of ASD are referred to specialists for confirmation of the diagnosis, which is needed to quality for ASD services, according to Katherine Zuckerman, MD, a professor of pediatrics the Oregon Health and Science University, Portland, Oregon. Dr. Zuckerman, who was moderator of the session in which all four of these abstracts were presented, explained that there is an urgent need to accelerate the time to diagnosis, which involves long delays for many if not most children with ASD. This is important because treatment and supportive services for ASD are almost always dependent on a diagnosis.

“There are tons of data to show that earlier access to ASD services has important patient benefits, including higher IQs,” she said. Other benefits she listed include a better quality of life for the child and the family.

“It can provide a huge reduction in family stress,” she added, suggesting that early interventions favorably modify the trajectory of the disability over time with accruing benefits.

“The lifetime costs of ASD exceed cancer and most other disease, so there are major implications for the cumulative cost of ASD management,” Dr. Zuckerman said. She suggested that the studies presented at the meeting reflect a likely evolution in who evaluates children for ASD and how quickly the evaluation is performed.

Dr. Rea, Dr. Harrison, Dr. Zuckerman, and Ms. Early reported no potential conflicts of interest. In addition to his executive role in As You Are, Dr. Hicks has financial relationships with Quadrant Biosciences and Spectrum Solutions.

It’s becoming clear that the adolescent brain is particularly vulnerable to cannabis, especially today’s higher-potency products, which put teens at risk for impaired brain development; mental health issues, including psychosis; and cannabis-use disorder (CUD). 

That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting. 

“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters. 

Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.

The impact of high-potency cannabis products and increased risk for CUD and mental health problems, particularly in adolescents, “must be taken seriously, especially in light of the current mental health crisis,” Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry. 
 

Dramatic Increase in Teen Cannabis Use

A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000. 

“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview. 

“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said. 

Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.

Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”

Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.

The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.

The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
 

Treatment Challenges

For young people who develop CUD, access to and uptake of treatment can be challenging.

“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary. 

Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies. 

“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote. 

Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”

Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said. 

The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier. 

“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote. 

This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures. 

A version of this article appeared on Medscape.com.

It’s becoming clear that the adolescent brain is particularly vulnerable to cannabis, especially today’s higher-potency products, which put teens at risk for impaired brain development; mental health issues, including psychosis; and cannabis-use disorder (CUD). 

That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting. 

“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters. 

Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.

The impact of high-potency cannabis products and increased risk for CUD and mental health problems, particularly in adolescents, “must be taken seriously, especially in light of the current mental health crisis,” Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry. 
 

Dramatic Increase in Teen Cannabis Use

A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000. 

“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview. 

“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said. 

Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.

Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”

Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.

The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.

The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
 

Treatment Challenges

For young people who develop CUD, access to and uptake of treatment can be challenging.

“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary. 

Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies. 

“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote. 

Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”

Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said. 

The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier. 

“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote. 

This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures. 

A version of this article appeared on Medscape.com.

It’s becoming clear that the adolescent brain is particularly vulnerable to cannabis, especially today’s higher-potency products, which put teens at risk for impaired brain development; mental health issues, including psychosis; and cannabis-use disorder (CUD). 

That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting. 

“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters. 

Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.

The impact of high-potency cannabis products and increased risk for CUD and mental health problems, particularly in adolescents, “must be taken seriously, especially in light of the current mental health crisis,” Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry. 
 

Dramatic Increase in Teen Cannabis Use

A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000. 

“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview. 

“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said. 

Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.

Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”

Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.

The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.

The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
 

Treatment Challenges

For young people who develop CUD, access to and uptake of treatment can be challenging.

“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary. 

Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies. 

“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote. 

Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”

Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said. 

The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier. 

“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote. 

This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures. 

A version of this article appeared on Medscape.com.

TORONTO — An ambitious effort at a busy pediatrics clinic to improve follow-up in children and adolescents with a positive depression screen improved this quality metric, and it produced a fundamental change in approach.

“It was a big culture shift,” reported Landon B. Krantz, MD, a clinical fellow in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital in Ohio. From a baseline position of screening, risk identification, and then referral, “we are now taking ownership of the process.”

Based on the substantial risk posed by significant levels of depression, guidelines recommend follow-up for any patient 12 years or older who has a positive screen, according to Dr. Krantz. At his center, they found only 19% had a documented follow-up within 30 days, even though timely intervention is important.

“Nearly half of suicide events in adolescents occur within 30 days after a positive PHQ-9 [9-question Patient Health Questionnaire] is completed,” said Dr. Krantz when presenting his data at the Pediatric Academic Societies annual meeting.

The issue has gained more urgency because of the substantial increase over the past several years in children presenting with depression and suicidal thoughts, according to Dr. Krantz. He said many are characterizing the upsurge as a mental health crisis in the pediatric age group.
 

Improving Follow-Up

The goal of the initiative launched at six primary care practices in Cincinnati was to increase the proportion of children with a positive screen for depression who have a follow-up within 30 days. The goal at the outset was to increase the proportion to 35%.

“We know that a lot of children would receive follow-up at centers outside of our system,” said Dr. Krantz, explaining why the goal was relatively modest. Based on the likelihood that many follow-up visits would not be captured, he expected the final data would represent an underestimate.

Depression at baseline was defined as a score of 10 or higher on the PHQ-9 or any positive answer to item 9 on this screening tool, which asks specifically about thoughts of self-harm.

To be counted, follow-up had to be a documented encounter, whether by phone call, in-person visit, or telehealth visit.

“We needed patients to be checked. We did not count a prescription refill as a true follow-up,” Dr. Krantz specified.

There were numerous strategies implemented to improve follow-up, not least of which was an educational program to reinforce the importance and value of follow-up that was disseminated to clinicians in all of the participating clinics. Medical assistants were instructed to schedule a follow-up appointment for all patients who tested positive before they left the office. A target of 3 weeks was a strategy of overcorrection when so many patients were missing the initial 30-day window by just a few days.

The approach also involved an enhanced collaboration with psychologists to which patients were referred. Asking for expedited appointments when appropriate ensured that those at highest risk were prioritized, although Dr. Krantz said that this step was planned carefully to avoid overwhelming the mental health team.

“We monitored this and made sure it was not increasing the burden for psychologists from a capacity standpoint,” he said.

Other steps, like a depression action plan, which Dr. Krantz compared to an asthma action plan, were also implemented to reduce the risk of losing symptomatic patients before the chance for an effective treatment.

When compared with the 19% 30-day follow-up rate in the preintervention sample of 589 children, the 43.8% 30-day follow-up rate achieved in the 764 patients identified after implementation beat the original goal.

The improvement in follow-up was relatively consistent across all six clinics, which Dr. Krantz believes reflected a broad and shared change in a sense of responsibility for confirming that symptoms of depression were being addressed. Patients were still referred for psychological help, but referral was no longer considered enough.

“Children with mental health issues are still our patients in primary care,” said Dr. Krantz, who considers this an important change in orientation.

While the goal was to schedule patients for a follow-up at the time of a positive depression screen, Dr. Krantz described one important accommodation.

“The screen for depression was being performed in most cases during well visits, so patients and their families were not expecting to be discussing this issue,” he said. The diagnosis might be a particular surprise to parents who were not aware of any symptoms. In this case, Dr. Krantz said patients and families were given time to process the information and were contacted after a week to discuss further workup.

It is also notable that about one third of patients met the criteria for depression by answering positively to the PHQ-9 item on self-harm when they did not meet the 10 or more threshold depression score overall. In other words, these patients would have been missed without this criterion.

In the participating Cincinnati pediatric clinics, about 12%-13% of adolescents met the criteria for depression, which Dr. Krantz said is consistent with reports in the literature. He said the range is about 6%-24%.

Although outcomes were not tracked, there is evidence that early intervention for depression yields better outcomes than delayed intervention, according to Dr. Krantz. Based on approximately 600 positive screens for depression per year at his pediatric clinics, he estimated that his data predict at least 25% more patients will receive timely follow-up.
 

Seeking Solutions to a Growing Problem

There are several studies documenting the growing problem of adolescent depression and suicide and, for this reason, the topic is attracting a lot of attention, according to Corinna Rea, MD, MPH, a pediatrician working in the primary care center at Boston Children’s Hospital in Massachusetts.

Dr. Rea was not involved with the study, but when asked to comment, she said: “The results of this study were encouraging because we know that getting patients to care quickly is probably important.” She also agreed that referring patients with depression for care might not be enough, noting that a lot of patients do not follow up on recommendations to pursue a consultation or treatment.

“I am now involved in a project with the American Academy of Pediatrics to address this issue,” Dr. Rae said. She thinks that more work in this area is needed and agreed with Dr. Krantz that pediatricians should verify that children with depression are getting help even when other specialists are providing the treatment.

Dr. Krantz and Dr. Rae report no potential conflicts of interest.

TORONTO — An ambitious effort at a busy pediatrics clinic to improve follow-up in children and adolescents with a positive depression screen improved this quality metric, and it produced a fundamental change in approach.

“It was a big culture shift,” reported Landon B. Krantz, MD, a clinical fellow in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital in Ohio. From a baseline position of screening, risk identification, and then referral, “we are now taking ownership of the process.”

Based on the substantial risk posed by significant levels of depression, guidelines recommend follow-up for any patient 12 years or older who has a positive screen, according to Dr. Krantz. At his center, they found only 19% had a documented follow-up within 30 days, even though timely intervention is important.

“Nearly half of suicide events in adolescents occur within 30 days after a positive PHQ-9 [9-question Patient Health Questionnaire] is completed,” said Dr. Krantz when presenting his data at the Pediatric Academic Societies annual meeting.

The issue has gained more urgency because of the substantial increase over the past several years in children presenting with depression and suicidal thoughts, according to Dr. Krantz. He said many are characterizing the upsurge as a mental health crisis in the pediatric age group.
 

Improving Follow-Up

The goal of the initiative launched at six primary care practices in Cincinnati was to increase the proportion of children with a positive screen for depression who have a follow-up within 30 days. The goal at the outset was to increase the proportion to 35%.

“We know that a lot of children would receive follow-up at centers outside of our system,” said Dr. Krantz, explaining why the goal was relatively modest. Based on the likelihood that many follow-up visits would not be captured, he expected the final data would represent an underestimate.

Depression at baseline was defined as a score of 10 or higher on the PHQ-9 or any positive answer to item 9 on this screening tool, which asks specifically about thoughts of self-harm.

To be counted, follow-up had to be a documented encounter, whether by phone call, in-person visit, or telehealth visit.

“We needed patients to be checked. We did not count a prescription refill as a true follow-up,” Dr. Krantz specified.

There were numerous strategies implemented to improve follow-up, not least of which was an educational program to reinforce the importance and value of follow-up that was disseminated to clinicians in all of the participating clinics. Medical assistants were instructed to schedule a follow-up appointment for all patients who tested positive before they left the office. A target of 3 weeks was a strategy of overcorrection when so many patients were missing the initial 30-day window by just a few days.

The approach also involved an enhanced collaboration with psychologists to which patients were referred. Asking for expedited appointments when appropriate ensured that those at highest risk were prioritized, although Dr. Krantz said that this step was planned carefully to avoid overwhelming the mental health team.

“We monitored this and made sure it was not increasing the burden for psychologists from a capacity standpoint,” he said.

Other steps, like a depression action plan, which Dr. Krantz compared to an asthma action plan, were also implemented to reduce the risk of losing symptomatic patients before the chance for an effective treatment.

When compared with the 19% 30-day follow-up rate in the preintervention sample of 589 children, the 43.8% 30-day follow-up rate achieved in the 764 patients identified after implementation beat the original goal.

The improvement in follow-up was relatively consistent across all six clinics, which Dr. Krantz believes reflected a broad and shared change in a sense of responsibility for confirming that symptoms of depression were being addressed. Patients were still referred for psychological help, but referral was no longer considered enough.

“Children with mental health issues are still our patients in primary care,” said Dr. Krantz, who considers this an important change in orientation.

While the goal was to schedule patients for a follow-up at the time of a positive depression screen, Dr. Krantz described one important accommodation.

“The screen for depression was being performed in most cases during well visits, so patients and their families were not expecting to be discussing this issue,” he said. The diagnosis might be a particular surprise to parents who were not aware of any symptoms. In this case, Dr. Krantz said patients and families were given time to process the information and were contacted after a week to discuss further workup.

It is also notable that about one third of patients met the criteria for depression by answering positively to the PHQ-9 item on self-harm when they did not meet the 10 or more threshold depression score overall. In other words, these patients would have been missed without this criterion.

In the participating Cincinnati pediatric clinics, about 12%-13% of adolescents met the criteria for depression, which Dr. Krantz said is consistent with reports in the literature. He said the range is about 6%-24%.

Although outcomes were not tracked, there is evidence that early intervention for depression yields better outcomes than delayed intervention, according to Dr. Krantz. Based on approximately 600 positive screens for depression per year at his pediatric clinics, he estimated that his data predict at least 25% more patients will receive timely follow-up.
 

Seeking Solutions to a Growing Problem

There are several studies documenting the growing problem of adolescent depression and suicide and, for this reason, the topic is attracting a lot of attention, according to Corinna Rea, MD, MPH, a pediatrician working in the primary care center at Boston Children’s Hospital in Massachusetts.

Dr. Rea was not involved with the study, but when asked to comment, she said: “The results of this study were encouraging because we know that getting patients to care quickly is probably important.” She also agreed that referring patients with depression for care might not be enough, noting that a lot of patients do not follow up on recommendations to pursue a consultation or treatment.

“I am now involved in a project with the American Academy of Pediatrics to address this issue,” Dr. Rae said. She thinks that more work in this area is needed and agreed with Dr. Krantz that pediatricians should verify that children with depression are getting help even when other specialists are providing the treatment.

Dr. Krantz and Dr. Rae report no potential conflicts of interest.

TORONTO — An ambitious effort at a busy pediatrics clinic to improve follow-up in children and adolescents with a positive depression screen improved this quality metric, and it produced a fundamental change in approach.

“It was a big culture shift,” reported Landon B. Krantz, MD, a clinical fellow in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital in Ohio. From a baseline position of screening, risk identification, and then referral, “we are now taking ownership of the process.”

Based on the substantial risk posed by significant levels of depression, guidelines recommend follow-up for any patient 12 years or older who has a positive screen, according to Dr. Krantz. At his center, they found only 19% had a documented follow-up within 30 days, even though timely intervention is important.

“Nearly half of suicide events in adolescents occur within 30 days after a positive PHQ-9 [9-question Patient Health Questionnaire] is completed,” said Dr. Krantz when presenting his data at the Pediatric Academic Societies annual meeting.

The issue has gained more urgency because of the substantial increase over the past several years in children presenting with depression and suicidal thoughts, according to Dr. Krantz. He said many are characterizing the upsurge as a mental health crisis in the pediatric age group.
 

Improving Follow-Up

The goal of the initiative launched at six primary care practices in Cincinnati was to increase the proportion of children with a positive screen for depression who have a follow-up within 30 days. The goal at the outset was to increase the proportion to 35%.

“We know that a lot of children would receive follow-up at centers outside of our system,” said Dr. Krantz, explaining why the goal was relatively modest. Based on the likelihood that many follow-up visits would not be captured, he expected the final data would represent an underestimate.

Depression at baseline was defined as a score of 10 or higher on the PHQ-9 or any positive answer to item 9 on this screening tool, which asks specifically about thoughts of self-harm.

To be counted, follow-up had to be a documented encounter, whether by phone call, in-person visit, or telehealth visit.

“We needed patients to be checked. We did not count a prescription refill as a true follow-up,” Dr. Krantz specified.

There were numerous strategies implemented to improve follow-up, not least of which was an educational program to reinforce the importance and value of follow-up that was disseminated to clinicians in all of the participating clinics. Medical assistants were instructed to schedule a follow-up appointment for all patients who tested positive before they left the office. A target of 3 weeks was a strategy of overcorrection when so many patients were missing the initial 30-day window by just a few days.

The approach also involved an enhanced collaboration with psychologists to which patients were referred. Asking for expedited appointments when appropriate ensured that those at highest risk were prioritized, although Dr. Krantz said that this step was planned carefully to avoid overwhelming the mental health team.

“We monitored this and made sure it was not increasing the burden for psychologists from a capacity standpoint,” he said.

Other steps, like a depression action plan, which Dr. Krantz compared to an asthma action plan, were also implemented to reduce the risk of losing symptomatic patients before the chance for an effective treatment.

When compared with the 19% 30-day follow-up rate in the preintervention sample of 589 children, the 43.8% 30-day follow-up rate achieved in the 764 patients identified after implementation beat the original goal.

The improvement in follow-up was relatively consistent across all six clinics, which Dr. Krantz believes reflected a broad and shared change in a sense of responsibility for confirming that symptoms of depression were being addressed. Patients were still referred for psychological help, but referral was no longer considered enough.

“Children with mental health issues are still our patients in primary care,” said Dr. Krantz, who considers this an important change in orientation.

While the goal was to schedule patients for a follow-up at the time of a positive depression screen, Dr. Krantz described one important accommodation.

“The screen for depression was being performed in most cases during well visits, so patients and their families were not expecting to be discussing this issue,” he said. The diagnosis might be a particular surprise to parents who were not aware of any symptoms. In this case, Dr. Krantz said patients and families were given time to process the information and were contacted after a week to discuss further workup.

It is also notable that about one third of patients met the criteria for depression by answering positively to the PHQ-9 item on self-harm when they did not meet the 10 or more threshold depression score overall. In other words, these patients would have been missed without this criterion.

In the participating Cincinnati pediatric clinics, about 12%-13% of adolescents met the criteria for depression, which Dr. Krantz said is consistent with reports in the literature. He said the range is about 6%-24%.

Although outcomes were not tracked, there is evidence that early intervention for depression yields better outcomes than delayed intervention, according to Dr. Krantz. Based on approximately 600 positive screens for depression per year at his pediatric clinics, he estimated that his data predict at least 25% more patients will receive timely follow-up.
 

Seeking Solutions to a Growing Problem

There are several studies documenting the growing problem of adolescent depression and suicide and, for this reason, the topic is attracting a lot of attention, according to Corinna Rea, MD, MPH, a pediatrician working in the primary care center at Boston Children’s Hospital in Massachusetts.

Dr. Rea was not involved with the study, but when asked to comment, she said: “The results of this study were encouraging because we know that getting patients to care quickly is probably important.” She also agreed that referring patients with depression for care might not be enough, noting that a lot of patients do not follow up on recommendations to pursue a consultation or treatment.

“I am now involved in a project with the American Academy of Pediatrics to address this issue,” Dr. Rae said. She thinks that more work in this area is needed and agreed with Dr. Krantz that pediatricians should verify that children with depression are getting help even when other specialists are providing the treatment.

Dr. Krantz and Dr. Rae report no potential conflicts of interest.

Imagine this: A 15-year-old male presents to an urgent care center with a one-day history of fever, cough, and shortness of breath. He is mildly tachypneic with bilateral scattered crackles on lung exam. A rapid test for COVID-19 and influenza is positive for influenza A — a surprising result in June.

An oxygen saturation of 90% prompts transfer to the emergency department at the local children’s hospital. The emergency medicine fellow is skeptical of the presumptive diagnosis. Influenza in the summer in a boy who had not traveled outside his small hometown in the southeastern United States? A respiratory viral panel also detected influenza A, but the specimen did not type as influenza A H1 or H3. This result prompted the laboratory technician to place a call to the ordering physician. “Does this patient have risk factors for avian flu?” the tech asked.

University of Louisville

Highly pathogenic avian influenza (HPAI) A(H5N1) is not a new virus. It was discovered in waterfowl in China in 1996 and has since evolved into multiple clades and subclades, spreading to every continent on the globe except Oceania. It is called highly pathogenic because it kills a large number of the birds that it infects. In 2021, Clade 2.3.4.4b HPAI A(H5N1) viruses emerged in North America, causing large outbreaks in wild birds and farmed poultry populations, including backyard flocks. Sporadic infections have been identified in a diverse group of mammals, including foxes, raccoons, baby goats, bears, and harbor seals. In March of this year, HPAI A(H5N1) was detected for the first time in United States dairy cattle. As we go to press, the United States Department of Agriculture has detected HPAI A(H5N1) in dairy cattle on 36 farms in 9 states.

Human infections are rare, but often severe. Following a 1997 outbreak of HPAI A(H5N1) in Hong Kong, 18 people were infected and 6 died. Since then, more than 900 cases have been reported in humans and approximately half of these have been fatal. The spectrum of disease includes asymptomatic infection and mild disease, as occurred recently in Texas. A dairy farm worker who was exposed to dairy cattle presumed to be infected with HPAI A(H5N1) developed conjunctivitis and no other symptoms. An individual infected in Colorado in 2022 had no symptoms other than fatigue and recovered.

Human-to-human transmission was not identified with either of these cases, although very limited, non-sustained transmission has been observed in the past, usually in family members of infected people after prolonged close exposure.

Right now, most people in the United States are not at risk for HPAI A(H5N1) infection. The Centers for Disease Control and Prevention (CDC) urges clinicians to consider the possibility of HPAI A (H5N1) infection in people who show signs and symptoms of acute respiratory illness, including conjunctivitis, who have had close contact with potentially infected sick or dead birds, livestock, or other animals within the week before the onset of symptoms.

Careful history taking with our illustrative and hypothetical case revealed exposure to farm animals but in a state without known cases of HPAI A(H5N1) in dairy cattle. State health department officials nevertheless agreed with further testing of the patient. Some influenza diagnostic tests cleared by the US Food and Drug Administration (FDA) can detect some novel influenza A viruses such as HPAI A(H5N1) but cannot distinguish between infection with seasonal influenza A or novel influenza A viruses. Molecular assays may give an “influenza A untypeable” result, as in our case. The CDC urges further testing on these untypeable specimens at local or state public health laboratories. When HPAI A(H5N1) is suspected, a negative result on a commercially available test is not considered sufficient to exclude the possibility of infection.

Our patient was admitted to the hospital and droplet, contact, and airborne precautions were instituted along with antiviral treatment with oseltamivir. Preliminary analysis of HPAI A(H5N1) viruses predicts susceptibility to currently available antivirals. The admitting physician confirmed that the boy had received influenza vaccine in the preceding season but, unfortunately, seasonal vaccines do not protect against HPAI A(H5N1) infection.
 

Advice for Clinicians

Given the recent media attention and public health focus on HPAI A(H5N1), frontline clinicians may start receiving questions from patients and families and perhaps requests for testing. At this point, testing is generally recommended only for individuals with risk factors or known exposures. Healthcare providers with questions about testing are encouraged to reach out to their local or state health departments.

Public health authorities have provided recommendations for protection from HPAI. These include avoiding unprotected exposures to sick or dead wild birds, poultry, other domesticated birds, and wild or domesticated animals (including cattle). People should avoid unprotected contact with animals with suspected or confirmed HPAI A(H5N1)-virus infection or products from these animals, including raw or unpasteurized milk and raw milk products.

We can, however, reassure families that the commercial milk supply is safe. In late April, the FDA reported that HPAI viral fragments were found in one of five retail milk samples by polymerase chain reaction testing. Additional testing did not detect any live, infectious virus, indicating the effectiveness of pasteurization at inactivating the virus. Of importance to pediatricians and others pediatric clinicians, limited sampling of retail powdered infant formula and powdered milk products marketed as toddler formula revealed no viral fragments or viable virus.

The million-dollar question is whether HPAI A(H5N1) could start a new pandemic. To date, the virus has not acquired the mutations that would make it easily transmissible from person to person. If that changes and the virus does start spreading more widely, candidate vaccines that could protect against HPAI A(H5N1) have been developed and are part of the national stockpile. Let’s hope we don’t need them.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the American Academy of Pediatrics’ Committee on Infectious Diseases and the physician lead for Red Book Online. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected]. (Also [email protected].)

Imagine this: A 15-year-old male presents to an urgent care center with a one-day history of fever, cough, and shortness of breath. He is mildly tachypneic with bilateral scattered crackles on lung exam. A rapid test for COVID-19 and influenza is positive for influenza A — a surprising result in June.

An oxygen saturation of 90% prompts transfer to the emergency department at the local children’s hospital. The emergency medicine fellow is skeptical of the presumptive diagnosis. Influenza in the summer in a boy who had not traveled outside his small hometown in the southeastern United States? A respiratory viral panel also detected influenza A, but the specimen did not type as influenza A H1 or H3. This result prompted the laboratory technician to place a call to the ordering physician. “Does this patient have risk factors for avian flu?” the tech asked.

University of Louisville

Highly pathogenic avian influenza (HPAI) A(H5N1) is not a new virus. It was discovered in waterfowl in China in 1996 and has since evolved into multiple clades and subclades, spreading to every continent on the globe except Oceania. It is called highly pathogenic because it kills a large number of the birds that it infects. In 2021, Clade 2.3.4.4b HPAI A(H5N1) viruses emerged in North America, causing large outbreaks in wild birds and farmed poultry populations, including backyard flocks. Sporadic infections have been identified in a diverse group of mammals, including foxes, raccoons, baby goats, bears, and harbor seals. In March of this year, HPAI A(H5N1) was detected for the first time in United States dairy cattle. As we go to press, the United States Department of Agriculture has detected HPAI A(H5N1) in dairy cattle on 36 farms in 9 states.

Human infections are rare, but often severe. Following a 1997 outbreak of HPAI A(H5N1) in Hong Kong, 18 people were infected and 6 died. Since then, more than 900 cases have been reported in humans and approximately half of these have been fatal. The spectrum of disease includes asymptomatic infection and mild disease, as occurred recently in Texas. A dairy farm worker who was exposed to dairy cattle presumed to be infected with HPAI A(H5N1) developed conjunctivitis and no other symptoms. An individual infected in Colorado in 2022 had no symptoms other than fatigue and recovered.

Human-to-human transmission was not identified with either of these cases, although very limited, non-sustained transmission has been observed in the past, usually in family members of infected people after prolonged close exposure.

Right now, most people in the United States are not at risk for HPAI A(H5N1) infection. The Centers for Disease Control and Prevention (CDC) urges clinicians to consider the possibility of HPAI A (H5N1) infection in people who show signs and symptoms of acute respiratory illness, including conjunctivitis, who have had close contact with potentially infected sick or dead birds, livestock, or other animals within the week before the onset of symptoms.

Careful history taking with our illustrative and hypothetical case revealed exposure to farm animals but in a state without known cases of HPAI A(H5N1) in dairy cattle. State health department officials nevertheless agreed with further testing of the patient. Some influenza diagnostic tests cleared by the US Food and Drug Administration (FDA) can detect some novel influenza A viruses such as HPAI A(H5N1) but cannot distinguish between infection with seasonal influenza A or novel influenza A viruses. Molecular assays may give an “influenza A untypeable” result, as in our case. The CDC urges further testing on these untypeable specimens at local or state public health laboratories. When HPAI A(H5N1) is suspected, a negative result on a commercially available test is not considered sufficient to exclude the possibility of infection.

Our patient was admitted to the hospital and droplet, contact, and airborne precautions were instituted along with antiviral treatment with oseltamivir. Preliminary analysis of HPAI A(H5N1) viruses predicts susceptibility to currently available antivirals. The admitting physician confirmed that the boy had received influenza vaccine in the preceding season but, unfortunately, seasonal vaccines do not protect against HPAI A(H5N1) infection.
 

Advice for Clinicians

Given the recent media attention and public health focus on HPAI A(H5N1), frontline clinicians may start receiving questions from patients and families and perhaps requests for testing. At this point, testing is generally recommended only for individuals with risk factors or known exposures. Healthcare providers with questions about testing are encouraged to reach out to their local or state health departments.

Public health authorities have provided recommendations for protection from HPAI. These include avoiding unprotected exposures to sick or dead wild birds, poultry, other domesticated birds, and wild or domesticated animals (including cattle). People should avoid unprotected contact with animals with suspected or confirmed HPAI A(H5N1)-virus infection or products from these animals, including raw or unpasteurized milk and raw milk products.

We can, however, reassure families that the commercial milk supply is safe. In late April, the FDA reported that HPAI viral fragments were found in one of five retail milk samples by polymerase chain reaction testing. Additional testing did not detect any live, infectious virus, indicating the effectiveness of pasteurization at inactivating the virus. Of importance to pediatricians and others pediatric clinicians, limited sampling of retail powdered infant formula and powdered milk products marketed as toddler formula revealed no viral fragments or viable virus.

The million-dollar question is whether HPAI A(H5N1) could start a new pandemic. To date, the virus has not acquired the mutations that would make it easily transmissible from person to person. If that changes and the virus does start spreading more widely, candidate vaccines that could protect against HPAI A(H5N1) have been developed and are part of the national stockpile. Let’s hope we don’t need them.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the American Academy of Pediatrics’ Committee on Infectious Diseases and the physician lead for Red Book Online. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected]. (Also [email protected].)

Imagine this: A 15-year-old male presents to an urgent care center with a one-day history of fever, cough, and shortness of breath. He is mildly tachypneic with bilateral scattered crackles on lung exam. A rapid test for COVID-19 and influenza is positive for influenza A — a surprising result in June.

An oxygen saturation of 90% prompts transfer to the emergency department at the local children’s hospital. The emergency medicine fellow is skeptical of the presumptive diagnosis. Influenza in the summer in a boy who had not traveled outside his small hometown in the southeastern United States? A respiratory viral panel also detected influenza A, but the specimen did not type as influenza A H1 or H3. This result prompted the laboratory technician to place a call to the ordering physician. “Does this patient have risk factors for avian flu?” the tech asked.

University of Louisville

Highly pathogenic avian influenza (HPAI) A(H5N1) is not a new virus. It was discovered in waterfowl in China in 1996 and has since evolved into multiple clades and subclades, spreading to every continent on the globe except Oceania. It is called highly pathogenic because it kills a large number of the birds that it infects. In 2021, Clade 2.3.4.4b HPAI A(H5N1) viruses emerged in North America, causing large outbreaks in wild birds and farmed poultry populations, including backyard flocks. Sporadic infections have been identified in a diverse group of mammals, including foxes, raccoons, baby goats, bears, and harbor seals. In March of this year, HPAI A(H5N1) was detected for the first time in United States dairy cattle. As we go to press, the United States Department of Agriculture has detected HPAI A(H5N1) in dairy cattle on 36 farms in 9 states.

Human infections are rare, but often severe. Following a 1997 outbreak of HPAI A(H5N1) in Hong Kong, 18 people were infected and 6 died. Since then, more than 900 cases have been reported in humans and approximately half of these have been fatal. The spectrum of disease includes asymptomatic infection and mild disease, as occurred recently in Texas. A dairy farm worker who was exposed to dairy cattle presumed to be infected with HPAI A(H5N1) developed conjunctivitis and no other symptoms. An individual infected in Colorado in 2022 had no symptoms other than fatigue and recovered.

Human-to-human transmission was not identified with either of these cases, although very limited, non-sustained transmission has been observed in the past, usually in family members of infected people after prolonged close exposure.

Right now, most people in the United States are not at risk for HPAI A(H5N1) infection. The Centers for Disease Control and Prevention (CDC) urges clinicians to consider the possibility of HPAI A (H5N1) infection in people who show signs and symptoms of acute respiratory illness, including conjunctivitis, who have had close contact with potentially infected sick or dead birds, livestock, or other animals within the week before the onset of symptoms.

Careful history taking with our illustrative and hypothetical case revealed exposure to farm animals but in a state without known cases of HPAI A(H5N1) in dairy cattle. State health department officials nevertheless agreed with further testing of the patient. Some influenza diagnostic tests cleared by the US Food and Drug Administration (FDA) can detect some novel influenza A viruses such as HPAI A(H5N1) but cannot distinguish between infection with seasonal influenza A or novel influenza A viruses. Molecular assays may give an “influenza A untypeable” result, as in our case. The CDC urges further testing on these untypeable specimens at local or state public health laboratories. When HPAI A(H5N1) is suspected, a negative result on a commercially available test is not considered sufficient to exclude the possibility of infection.

Our patient was admitted to the hospital and droplet, contact, and airborne precautions were instituted along with antiviral treatment with oseltamivir. Preliminary analysis of HPAI A(H5N1) viruses predicts susceptibility to currently available antivirals. The admitting physician confirmed that the boy had received influenza vaccine in the preceding season but, unfortunately, seasonal vaccines do not protect against HPAI A(H5N1) infection.
 

Advice for Clinicians

Given the recent media attention and public health focus on HPAI A(H5N1), frontline clinicians may start receiving questions from patients and families and perhaps requests for testing. At this point, testing is generally recommended only for individuals with risk factors or known exposures. Healthcare providers with questions about testing are encouraged to reach out to their local or state health departments.

Public health authorities have provided recommendations for protection from HPAI. These include avoiding unprotected exposures to sick or dead wild birds, poultry, other domesticated birds, and wild or domesticated animals (including cattle). People should avoid unprotected contact with animals with suspected or confirmed HPAI A(H5N1)-virus infection or products from these animals, including raw or unpasteurized milk and raw milk products.

We can, however, reassure families that the commercial milk supply is safe. In late April, the FDA reported that HPAI viral fragments were found in one of five retail milk samples by polymerase chain reaction testing. Additional testing did not detect any live, infectious virus, indicating the effectiveness of pasteurization at inactivating the virus. Of importance to pediatricians and others pediatric clinicians, limited sampling of retail powdered infant formula and powdered milk products marketed as toddler formula revealed no viral fragments or viable virus.

The million-dollar question is whether HPAI A(H5N1) could start a new pandemic. To date, the virus has not acquired the mutations that would make it easily transmissible from person to person. If that changes and the virus does start spreading more widely, candidate vaccines that could protect against HPAI A(H5N1) have been developed and are part of the national stockpile. Let’s hope we don’t need them.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the American Academy of Pediatrics’ Committee on Infectious Diseases and the physician lead for Red Book Online. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected]. (Also [email protected].)

SAN DIEGO — Compared with medical oncologists, dermatologists were more likely to correctly classify and grade dermatologic adverse events from cancer therapies, results from a multicenter survey showed.

“New cancer therapies have brought a diversity of treatment-related dermatologic adverse events (dAEs) beyond those experienced with conventional chemotherapy, which has demanded an evolving assessment of toxicities,” researchers led by Nicole R. LeBoeuf, MD, MPH, of the Department of Dermatology at Brigham and Women’s Hospital and the Center for Cutaneous Oncology at the Dana-Farber Brigham Cancer Center, Boston, wrote in a poster presented at the American Academy of Dermatology annual meeting.

The authors noted that “Version 5.0 of the Common Terminology Criteria for Adverse Events (CTCAE v5.0)” serves as the current, broadly accepted criteria for classification and grading during routine medical care and clinical trials. But despite extensive utilization of CTCAE, there is little data regarding its application.”

To evaluate how CTCAE is being used in clinical practice, they sent a four-case survey of dAEs to 81 dermatologists and 182 medical oncologists at six US-based academic institutions. For three of the cases, respondents were asked to classify and grade morbilliform, psoriasiform, and papulopustular rashes based on a review of photographs and text descriptions. For the fourth case, respondents were asked to grade a dAE using only a clinic note text description. The researchers used chi-square tests in R software to compare survey responses.

Compared with medical oncologists, dermatologists were significantly more likely to provide correct responses in characterizing morbilliform and psoriasiform eruptions. “As low as 12%” of medical oncologists were correct, and “as low as 87%” of dermatologists were correct (P < .001). Similarly, dermatologists were significantly more likely to grade the psoriasiform, papulopustular, and written cases correctly compared with medical oncologists (P < .001 for all associations).

“These cases demonstrated poor concordance of classification and grading between specialties and across medical oncology,” the authors concluded in their poster, noting that 87% of medical oncologists were interested in additional educational tools on dAEs. “With correct classification as low as 12%, medical oncologists may have more difficulty delivering appropriate, toxicity-specific therapy and may consider banal eruptions dangerous.”

Poor concordance of grading among the two groups of clinicians “raises the question of whether CTCAE v5.0 is an appropriate determinant for patient continuation on therapy or in trials,” they added. “As anticancer therapy becomes more complex — with new toxicities from novel agents and combinations — we must ensure we have a grading system that is valid across investigators and does not harm patients by instituting unnecessary treatment stops.”

Future studies, they said, “can explore what interventions beyond involvement of dermatologists improve classification and grading in practice.”

Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, who was asked to comment on the study, noted that with the continued expansion and introduction of new targeted and immunotherapies in the oncology space, “you can be sure we will continue to appreciate the importance and value of the field of supportive oncodermatology, as hair, skin, and nails are almost guaranteed collateral damage in this story.

“Ensuring early identification and consistent grading severity is not only important for the plethora of patients who are currently developing the litany of cutaneous adverse events but to evaluate potential mitigation strategies and even push along countermeasures down the FDA approval pathway,” Dr. Friedman said. In this study, the investigators demonstrated that work “is sorely needed, not just in dermatology but even more so for our colleagues across the aisle. A central tenet of supportive oncodermatology must also be education for all stakeholders, and the good news is our oncology partners will welcome it.”

Dr. LeBoeuf disclosed that she is a consultant to and has received honoraria from Bayer, Seattle Genetics, Sanofi, Silverback, Fortress Biotech, and Synox Therapeutics outside the submitted work. No other authors reported having financial disclosures. Dr. Friedman directs the supportive oncodermatology program at GW that received independent funding from La Roche-Posay.
 

A version of this article first appeared on Medscape.com.

SAN DIEGO — Compared with medical oncologists, dermatologists were more likely to correctly classify and grade dermatologic adverse events from cancer therapies, results from a multicenter survey showed.

“New cancer therapies have brought a diversity of treatment-related dermatologic adverse events (dAEs) beyond those experienced with conventional chemotherapy, which has demanded an evolving assessment of toxicities,” researchers led by Nicole R. LeBoeuf, MD, MPH, of the Department of Dermatology at Brigham and Women’s Hospital and the Center for Cutaneous Oncology at the Dana-Farber Brigham Cancer Center, Boston, wrote in a poster presented at the American Academy of Dermatology annual meeting.

The authors noted that “Version 5.0 of the Common Terminology Criteria for Adverse Events (CTCAE v5.0)” serves as the current, broadly accepted criteria for classification and grading during routine medical care and clinical trials. But despite extensive utilization of CTCAE, there is little data regarding its application.”

To evaluate how CTCAE is being used in clinical practice, they sent a four-case survey of dAEs to 81 dermatologists and 182 medical oncologists at six US-based academic institutions. For three of the cases, respondents were asked to classify and grade morbilliform, psoriasiform, and papulopustular rashes based on a review of photographs and text descriptions. For the fourth case, respondents were asked to grade a dAE using only a clinic note text description. The researchers used chi-square tests in R software to compare survey responses.

Compared with medical oncologists, dermatologists were significantly more likely to provide correct responses in characterizing morbilliform and psoriasiform eruptions. “As low as 12%” of medical oncologists were correct, and “as low as 87%” of dermatologists were correct (P < .001). Similarly, dermatologists were significantly more likely to grade the psoriasiform, papulopustular, and written cases correctly compared with medical oncologists (P < .001 for all associations).

“These cases demonstrated poor concordance of classification and grading between specialties and across medical oncology,” the authors concluded in their poster, noting that 87% of medical oncologists were interested in additional educational tools on dAEs. “With correct classification as low as 12%, medical oncologists may have more difficulty delivering appropriate, toxicity-specific therapy and may consider banal eruptions dangerous.”

Poor concordance of grading among the two groups of clinicians “raises the question of whether CTCAE v5.0 is an appropriate determinant for patient continuation on therapy or in trials,” they added. “As anticancer therapy becomes more complex — with new toxicities from novel agents and combinations — we must ensure we have a grading system that is valid across investigators and does not harm patients by instituting unnecessary treatment stops.”

Future studies, they said, “can explore what interventions beyond involvement of dermatologists improve classification and grading in practice.”

Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, who was asked to comment on the study, noted that with the continued expansion and introduction of new targeted and immunotherapies in the oncology space, “you can be sure we will continue to appreciate the importance and value of the field of supportive oncodermatology, as hair, skin, and nails are almost guaranteed collateral damage in this story.

“Ensuring early identification and consistent grading severity is not only important for the plethora of patients who are currently developing the litany of cutaneous adverse events but to evaluate potential mitigation strategies and even push along countermeasures down the FDA approval pathway,” Dr. Friedman said. In this study, the investigators demonstrated that work “is sorely needed, not just in dermatology but even more so for our colleagues across the aisle. A central tenet of supportive oncodermatology must also be education for all stakeholders, and the good news is our oncology partners will welcome it.”

Dr. LeBoeuf disclosed that she is a consultant to and has received honoraria from Bayer, Seattle Genetics, Sanofi, Silverback, Fortress Biotech, and Synox Therapeutics outside the submitted work. No other authors reported having financial disclosures. Dr. Friedman directs the supportive oncodermatology program at GW that received independent funding from La Roche-Posay.
 

A version of this article first appeared on Medscape.com.

SAN DIEGO — Compared with medical oncologists, dermatologists were more likely to correctly classify and grade dermatologic adverse events from cancer therapies, results from a multicenter survey showed.

“New cancer therapies have brought a diversity of treatment-related dermatologic adverse events (dAEs) beyond those experienced with conventional chemotherapy, which has demanded an evolving assessment of toxicities,” researchers led by Nicole R. LeBoeuf, MD, MPH, of the Department of Dermatology at Brigham and Women’s Hospital and the Center for Cutaneous Oncology at the Dana-Farber Brigham Cancer Center, Boston, wrote in a poster presented at the American Academy of Dermatology annual meeting.

The authors noted that “Version 5.0 of the Common Terminology Criteria for Adverse Events (CTCAE v5.0)” serves as the current, broadly accepted criteria for classification and grading during routine medical care and clinical trials. But despite extensive utilization of CTCAE, there is little data regarding its application.”

To evaluate how CTCAE is being used in clinical practice, they sent a four-case survey of dAEs to 81 dermatologists and 182 medical oncologists at six US-based academic institutions. For three of the cases, respondents were asked to classify and grade morbilliform, psoriasiform, and papulopustular rashes based on a review of photographs and text descriptions. For the fourth case, respondents were asked to grade a dAE using only a clinic note text description. The researchers used chi-square tests in R software to compare survey responses.

Compared with medical oncologists, dermatologists were significantly more likely to provide correct responses in characterizing morbilliform and psoriasiform eruptions. “As low as 12%” of medical oncologists were correct, and “as low as 87%” of dermatologists were correct (P < .001). Similarly, dermatologists were significantly more likely to grade the psoriasiform, papulopustular, and written cases correctly compared with medical oncologists (P < .001 for all associations).

“These cases demonstrated poor concordance of classification and grading between specialties and across medical oncology,” the authors concluded in their poster, noting that 87% of medical oncologists were interested in additional educational tools on dAEs. “With correct classification as low as 12%, medical oncologists may have more difficulty delivering appropriate, toxicity-specific therapy and may consider banal eruptions dangerous.”

Poor concordance of grading among the two groups of clinicians “raises the question of whether CTCAE v5.0 is an appropriate determinant for patient continuation on therapy or in trials,” they added. “As anticancer therapy becomes more complex — with new toxicities from novel agents and combinations — we must ensure we have a grading system that is valid across investigators and does not harm patients by instituting unnecessary treatment stops.”

Future studies, they said, “can explore what interventions beyond involvement of dermatologists improve classification and grading in practice.”

Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, who was asked to comment on the study, noted that with the continued expansion and introduction of new targeted and immunotherapies in the oncology space, “you can be sure we will continue to appreciate the importance and value of the field of supportive oncodermatology, as hair, skin, and nails are almost guaranteed collateral damage in this story.

“Ensuring early identification and consistent grading severity is not only important for the plethora of patients who are currently developing the litany of cutaneous adverse events but to evaluate potential mitigation strategies and even push along countermeasures down the FDA approval pathway,” Dr. Friedman said. In this study, the investigators demonstrated that work “is sorely needed, not just in dermatology but even more so for our colleagues across the aisle. A central tenet of supportive oncodermatology must also be education for all stakeholders, and the good news is our oncology partners will welcome it.”

Dr. LeBoeuf disclosed that she is a consultant to and has received honoraria from Bayer, Seattle Genetics, Sanofi, Silverback, Fortress Biotech, and Synox Therapeutics outside the submitted work. No other authors reported having financial disclosures. Dr. Friedman directs the supportive oncodermatology program at GW that received independent funding from La Roche-Posay.
 

A version of this article first appeared on Medscape.com.

DENVER — The ability to provide adolescents with highly effective anti-obesity medications that now carry approvals from the US Food and Drug Administration (FDA) and support in guidelines offers reassurance of their use; however, a reality check often awaits for clinicians in terms of challenges ranging from accessing and affording the medications to managing real and rumored side effects.

Weighing in on the issues, experts at Obesity Medicine (OMA) 2024 offered some key strategies and practice hacks for overcoming those hurdles.

The incentive to provide treatment with popular glucagon-like peptide 1 (GLP-1) drugs such as semaglutide or the dual glucose-dependent insulinotropic peptide (GIP) GLP-1 tirzepatide lies in the evidence that their high efficacy in promoting weight loss, and hence preventing metabolic syndrome, has benefits that far outweigh the potential side effects, said Alaina Vidmar, MD, in presenting at the meeting.

“We can look at all the evidence and without question acknowledge that the GLP-1s/GIP agonists are the most effective agents that we currently have, with the least heterogeneity in response, and the most high responders compared with other agents,” said Dr. Vidmar, an assistant professor of clinical pediatrics at the Keck School of Medicine of University of Southern California and director of obesity medicine and bariatric surgery at Children’s Hospital Los Angeles.

The strength of the evidence is reflected in the landmark American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity, which recommends that “pediatricians and other primary healthcare providers should offer adolescents 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks and may offer adolescents 8 years old with obesity weight loss pharmacotherapy, according to medication indications, risks.”

The AAP guidance echoes the recommendations of the drug makers and FDA that “a combination of specific behavioral techniques within the context of family-based behavioral treatment and the use of pharmacotherapy may be necessary to prevent life-limiting complications over time.”

However, in real-world practice, with the various challenges in providing that intensive, comprehensive care, clinicians should be prepared to get creative: “We sometimes have to do the best we can with what we have because the watchful waiting approach is not effective and leads to more harm than good,” Dr. Vidmar said.
 

Facilitating Access

The ongoing reported shortages in the highly popular anti-obesity medications, as well as insurance denials and high costs, are among the leading obstacles, for adolescents and adults alike.

Dr. Vidmar noted that key strategies at her center, Children’s Hospital Los Angeles, have been essential, however, in helping at least facilitate the authorization process.

The center’s approach began with contacting all the payers the center has contracts with to determine which of their policies cover these medications for adults and pediatrics and which agents are covered.

“This took work on the front end, but it was worth it because it helped us understand the framework for what we were going to go up against every time that we prescribed these medications,” she said.

Furthermore, the center’s specialty pharmacy set up contracts to be able to provide the drugs within the institution.

While the strategy can’t entirely mitigate the ongoing distribution concerns, “our pharmacy is now able to share with our weight management program what GLP-1s are available so that we can be more efficient in our work,” Dr. Vidmar said.

The center also created a list of contacts to provide to patients and their families, detailing local pharmacies that were most likely to have the medications.

Another strategy Dr. Vidmar’s center has utilized to allow the timely implementation of a GLP-1 treatment plan while awaiting a drug to become available is to create an alternative protocol, for instance, using liraglutide when awaiting semaglutide.

“If we are unable to get the lower doses of a weekly agent for titration, we have a standard protocol to bridge instead with liraglutide, and our patients, pharmacies, and even our authorizations are aware of the protocol,” Dr. Vidmar said.

“We often do not have a lot of control or agency over the distribution concerns; however, we can be thoughtful within our programs about how we titrate patients up to their full doses,” Dr. Vidmar said.
 

Mitigating Side Effects

When the medications are available, the common gastrointestinal (GI) side effects of nausea, vomiting, and diarrhea of the once-weekly injections are well-known, and these side effects can affect quality of life and daily function, Dr. Vidmar noted.

“We have to acknowledge that the seminal trials of these agents showed that nausea and vomiting occur in more than half of young people who take these agents during the initial titration period, and while the side effects are tolerated by many, they can be disruptive to daily life,” she said.

Encouragingly, “we also do know that for the majority of patients, those effects improve over time, and for many, they can be mitigated with nutrition changes.”

Dr. Vidmar shared a handout her center issues with key recommendations for mitigating GI effects in youth. These include:

• Eat smaller meals and eat slower
• Eat about half of what you usually eat
• Take about 15-20 minutes to eat your meal
• Aim for 60 g of protein per day
• Add fruits, vegetables, whole grains, and lean proteins to meals
• Limit foods that are spicy, greasy, or fried
• Drink water instead of sweet drinks

Consider Zofran as needed during the titration period for GI symptoms. “We’ve started using this at our institution and are teaching patients how to use it; it can really help mitigate any ER visits when there is any vomiting by educating patients and families and providing appropriate expectations, and that has been very helpful,” Dr. Vidmar said.

Regarding the GI effects, Dr. Vidmar noted she has observed that tirzepatide use (though still off-label) in youths “tends to have milder GI side effects among younger people.”
 

Mood Concerns?

Another concern that has emerged in public discussion regarding side effects is that of possible mood and suicidal ideation, raising concerns for adults and adolescents alike.

Upon investigating the reports, the FDA, in a statement, offered cautious reassurance that their review, including reports and clinical trials, “did not find an association between use of GLP-1 RAs and the occurrence of suicidal thoughts or actions.”

Noting that the agency is continuing to look into the issue, however, the FDA recommends that “healthcare professionals should monitor for and advise patients using GLP-1 RAs to report new or worsening depression, suicidal thoughts, or any unusual changes in mood or behavior.”
 

Concurrent Psychiatric Pharmacotherapy

Meanwhile, with weight gain a known and often challenging side effect of various psychiatric drugs, particularly in younger patients, obesity treatment of adolescents may commonly involve patients who are also being treated with those therapies.

Key culprits include certain antidepressants and antipsychotic medications, such as tricyclic antidepressants, and second-generation antipsychotics, such as olanzapine.

In terms of the use of GLP-1 medications for those patients, research includes a recent study of semaglutide in patients who were also being treated with antidepressants.

The study, a post hoc analysis of the STEP trials, showed “clinically meaningful weight loss regardless of baseline antidepressant use, with an adverse event profile consistent with previous studies.”

First author Robert F. Kushner, MD, said the study offers “reassurance that individuals who are taking antidepressant medications have a similar weight loss response and side-effect profile compared to individuals who are not taking these medications.”

Dr. Kushner, a professor of medicine and medicine education at Northwestern University in Chicago, and his team have not evaluated the safety profile for concomitant use with antipsychotic drugs. However, he noted that “there are studies showing that the daily GLP-1 drug liraglutide has been shown to be useful in combating antipsychotic-induced weight gain.”

“Similar studies will need to be conducted for the more effective agents, semaglutide and tirzepatide,” he said.

To counter the weight gain effects of antispychotics, metformin has long been a standard recommendation, and Dr. Vidmar noted that “I have historically always used metformin in this setting and found it very effective.”

However, the newer anti-obesity medications could prove to be important in those cases, Dr. Vidmar added.

“I do think and predict that GLP-1 agonists will be as effective, if not more, in combating the weight gain-promoting effects of these agents and act as a nice adjuvant to this treatment paradigm for psychiatrists.”

Dr. Vidmar has participated in an advisory board for Rhythm Pharmaceuticals. Dr. Kushner is on the advisory boards for Novo Nordisk, Weight Watchers, Lilly, Boehringer Ingelheim, and Altimmune.

A version of this article appeared on Medscape.com.

DENVER — The ability to provide adolescents with highly effective anti-obesity medications that now carry approvals from the US Food and Drug Administration (FDA) and support in guidelines offers reassurance of their use; however, a reality check often awaits for clinicians in terms of challenges ranging from accessing and affording the medications to managing real and rumored side effects.

Weighing in on the issues, experts at Obesity Medicine (OMA) 2024 offered some key strategies and practice hacks for overcoming those hurdles.

The incentive to provide treatment with popular glucagon-like peptide 1 (GLP-1) drugs such as semaglutide or the dual glucose-dependent insulinotropic peptide (GIP) GLP-1 tirzepatide lies in the evidence that their high efficacy in promoting weight loss, and hence preventing metabolic syndrome, has benefits that far outweigh the potential side effects, said Alaina Vidmar, MD, in presenting at the meeting.

“We can look at all the evidence and without question acknowledge that the GLP-1s/GIP agonists are the most effective agents that we currently have, with the least heterogeneity in response, and the most high responders compared with other agents,” said Dr. Vidmar, an assistant professor of clinical pediatrics at the Keck School of Medicine of University of Southern California and director of obesity medicine and bariatric surgery at Children’s Hospital Los Angeles.

The strength of the evidence is reflected in the landmark American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity, which recommends that “pediatricians and other primary healthcare providers should offer adolescents 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks and may offer adolescents 8 years old with obesity weight loss pharmacotherapy, according to medication indications, risks.”

The AAP guidance echoes the recommendations of the drug makers and FDA that “a combination of specific behavioral techniques within the context of family-based behavioral treatment and the use of pharmacotherapy may be necessary to prevent life-limiting complications over time.”

However, in real-world practice, with the various challenges in providing that intensive, comprehensive care, clinicians should be prepared to get creative: “We sometimes have to do the best we can with what we have because the watchful waiting approach is not effective and leads to more harm than good,” Dr. Vidmar said.
 

Facilitating Access

The ongoing reported shortages in the highly popular anti-obesity medications, as well as insurance denials and high costs, are among the leading obstacles, for adolescents and adults alike.

Dr. Vidmar noted that key strategies at her center, Children’s Hospital Los Angeles, have been essential, however, in helping at least facilitate the authorization process.

The center’s approach began with contacting all the payers the center has contracts with to determine which of their policies cover these medications for adults and pediatrics and which agents are covered.

“This took work on the front end, but it was worth it because it helped us understand the framework for what we were going to go up against every time that we prescribed these medications,” she said.

Furthermore, the center’s specialty pharmacy set up contracts to be able to provide the drugs within the institution.

While the strategy can’t entirely mitigate the ongoing distribution concerns, “our pharmacy is now able to share with our weight management program what GLP-1s are available so that we can be more efficient in our work,” Dr. Vidmar said.

The center also created a list of contacts to provide to patients and their families, detailing local pharmacies that were most likely to have the medications.

Another strategy Dr. Vidmar’s center has utilized to allow the timely implementation of a GLP-1 treatment plan while awaiting a drug to become available is to create an alternative protocol, for instance, using liraglutide when awaiting semaglutide.

“If we are unable to get the lower doses of a weekly agent for titration, we have a standard protocol to bridge instead with liraglutide, and our patients, pharmacies, and even our authorizations are aware of the protocol,” Dr. Vidmar said.

“We often do not have a lot of control or agency over the distribution concerns; however, we can be thoughtful within our programs about how we titrate patients up to their full doses,” Dr. Vidmar said.
 

Mitigating Side Effects

When the medications are available, the common gastrointestinal (GI) side effects of nausea, vomiting, and diarrhea of the once-weekly injections are well-known, and these side effects can affect quality of life and daily function, Dr. Vidmar noted.

“We have to acknowledge that the seminal trials of these agents showed that nausea and vomiting occur in more than half of young people who take these agents during the initial titration period, and while the side effects are tolerated by many, they can be disruptive to daily life,” she said.

Encouragingly, “we also do know that for the majority of patients, those effects improve over time, and for many, they can be mitigated with nutrition changes.”

Dr. Vidmar shared a handout her center issues with key recommendations for mitigating GI effects in youth. These include:

• Eat smaller meals and eat slower
• Eat about half of what you usually eat
• Take about 15-20 minutes to eat your meal
• Aim for 60 g of protein per day
• Add fruits, vegetables, whole grains, and lean proteins to meals
• Limit foods that are spicy, greasy, or fried
• Drink water instead of sweet drinks

Consider Zofran as needed during the titration period for GI symptoms. “We’ve started using this at our institution and are teaching patients how to use it; it can really help mitigate any ER visits when there is any vomiting by educating patients and families and providing appropriate expectations, and that has been very helpful,” Dr. Vidmar said.

Regarding the GI effects, Dr. Vidmar noted she has observed that tirzepatide use (though still off-label) in youths “tends to have milder GI side effects among younger people.”
 

Mood Concerns?

Another concern that has emerged in public discussion regarding side effects is that of possible mood and suicidal ideation, raising concerns for adults and adolescents alike.

Upon investigating the reports, the FDA, in a statement, offered cautious reassurance that their review, including reports and clinical trials, “did not find an association between use of GLP-1 RAs and the occurrence of suicidal thoughts or actions.”

Noting that the agency is continuing to look into the issue, however, the FDA recommends that “healthcare professionals should monitor for and advise patients using GLP-1 RAs to report new or worsening depression, suicidal thoughts, or any unusual changes in mood or behavior.”
 

Concurrent Psychiatric Pharmacotherapy

Meanwhile, with weight gain a known and often challenging side effect of various psychiatric drugs, particularly in younger patients, obesity treatment of adolescents may commonly involve patients who are also being treated with those therapies.

Key culprits include certain antidepressants and antipsychotic medications, such as tricyclic antidepressants, and second-generation antipsychotics, such as olanzapine.

In terms of the use of GLP-1 medications for those patients, research includes a recent study of semaglutide in patients who were also being treated with antidepressants.

The study, a post hoc analysis of the STEP trials, showed “clinically meaningful weight loss regardless of baseline antidepressant use, with an adverse event profile consistent with previous studies.”

First author Robert F. Kushner, MD, said the study offers “reassurance that individuals who are taking antidepressant medications have a similar weight loss response and side-effect profile compared to individuals who are not taking these medications.”

Dr. Kushner, a professor of medicine and medicine education at Northwestern University in Chicago, and his team have not evaluated the safety profile for concomitant use with antipsychotic drugs. However, he noted that “there are studies showing that the daily GLP-1 drug liraglutide has been shown to be useful in combating antipsychotic-induced weight gain.”

“Similar studies will need to be conducted for the more effective agents, semaglutide and tirzepatide,” he said.

To counter the weight gain effects of antispychotics, metformin has long been a standard recommendation, and Dr. Vidmar noted that “I have historically always used metformin in this setting and found it very effective.”

However, the newer anti-obesity medications could prove to be important in those cases, Dr. Vidmar added.

“I do think and predict that GLP-1 agonists will be as effective, if not more, in combating the weight gain-promoting effects of these agents and act as a nice adjuvant to this treatment paradigm for psychiatrists.”

Dr. Vidmar has participated in an advisory board for Rhythm Pharmaceuticals. Dr. Kushner is on the advisory boards for Novo Nordisk, Weight Watchers, Lilly, Boehringer Ingelheim, and Altimmune.

A version of this article appeared on Medscape.com.

DENVER — The ability to provide adolescents with highly effective anti-obesity medications that now carry approvals from the US Food and Drug Administration (FDA) and support in guidelines offers reassurance of their use; however, a reality check often awaits for clinicians in terms of challenges ranging from accessing and affording the medications to managing real and rumored side effects.

Weighing in on the issues, experts at Obesity Medicine (OMA) 2024 offered some key strategies and practice hacks for overcoming those hurdles.

The incentive to provide treatment with popular glucagon-like peptide 1 (GLP-1) drugs such as semaglutide or the dual glucose-dependent insulinotropic peptide (GIP) GLP-1 tirzepatide lies in the evidence that their high efficacy in promoting weight loss, and hence preventing metabolic syndrome, has benefits that far outweigh the potential side effects, said Alaina Vidmar, MD, in presenting at the meeting.

“We can look at all the evidence and without question acknowledge that the GLP-1s/GIP agonists are the most effective agents that we currently have, with the least heterogeneity in response, and the most high responders compared with other agents,” said Dr. Vidmar, an assistant professor of clinical pediatrics at the Keck School of Medicine of University of Southern California and director of obesity medicine and bariatric surgery at Children’s Hospital Los Angeles.

The strength of the evidence is reflected in the landmark American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity, which recommends that “pediatricians and other primary healthcare providers should offer adolescents 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks and may offer adolescents 8 years old with obesity weight loss pharmacotherapy, according to medication indications, risks.”

The AAP guidance echoes the recommendations of the drug makers and FDA that “a combination of specific behavioral techniques within the context of family-based behavioral treatment and the use of pharmacotherapy may be necessary to prevent life-limiting complications over time.”

However, in real-world practice, with the various challenges in providing that intensive, comprehensive care, clinicians should be prepared to get creative: “We sometimes have to do the best we can with what we have because the watchful waiting approach is not effective and leads to more harm than good,” Dr. Vidmar said.
 

Facilitating Access

The ongoing reported shortages in the highly popular anti-obesity medications, as well as insurance denials and high costs, are among the leading obstacles, for adolescents and adults alike.

Dr. Vidmar noted that key strategies at her center, Children’s Hospital Los Angeles, have been essential, however, in helping at least facilitate the authorization process.

The center’s approach began with contacting all the payers the center has contracts with to determine which of their policies cover these medications for adults and pediatrics and which agents are covered.

“This took work on the front end, but it was worth it because it helped us understand the framework for what we were going to go up against every time that we prescribed these medications,” she said.

Furthermore, the center’s specialty pharmacy set up contracts to be able to provide the drugs within the institution.

While the strategy can’t entirely mitigate the ongoing distribution concerns, “our pharmacy is now able to share with our weight management program what GLP-1s are available so that we can be more efficient in our work,” Dr. Vidmar said.

The center also created a list of contacts to provide to patients and their families, detailing local pharmacies that were most likely to have the medications.

Another strategy Dr. Vidmar’s center has utilized to allow the timely implementation of a GLP-1 treatment plan while awaiting a drug to become available is to create an alternative protocol, for instance, using liraglutide when awaiting semaglutide.

“If we are unable to get the lower doses of a weekly agent for titration, we have a standard protocol to bridge instead with liraglutide, and our patients, pharmacies, and even our authorizations are aware of the protocol,” Dr. Vidmar said.

“We often do not have a lot of control or agency over the distribution concerns; however, we can be thoughtful within our programs about how we titrate patients up to their full doses,” Dr. Vidmar said.
 

Mitigating Side Effects

When the medications are available, the common gastrointestinal (GI) side effects of nausea, vomiting, and diarrhea of the once-weekly injections are well-known, and these side effects can affect quality of life and daily function, Dr. Vidmar noted.

“We have to acknowledge that the seminal trials of these agents showed that nausea and vomiting occur in more than half of young people who take these agents during the initial titration period, and while the side effects are tolerated by many, they can be disruptive to daily life,” she said.

Encouragingly, “we also do know that for the majority of patients, those effects improve over time, and for many, they can be mitigated with nutrition changes.”

Dr. Vidmar shared a handout her center issues with key recommendations for mitigating GI effects in youth. These include:

• Eat smaller meals and eat slower
• Eat about half of what you usually eat
• Take about 15-20 minutes to eat your meal
• Aim for 60 g of protein per day
• Add fruits, vegetables, whole grains, and lean proteins to meals
• Limit foods that are spicy, greasy, or fried
• Drink water instead of sweet drinks

Consider Zofran as needed during the titration period for GI symptoms. “We’ve started using this at our institution and are teaching patients how to use it; it can really help mitigate any ER visits when there is any vomiting by educating patients and families and providing appropriate expectations, and that has been very helpful,” Dr. Vidmar said.

Regarding the GI effects, Dr. Vidmar noted she has observed that tirzepatide use (though still off-label) in youths “tends to have milder GI side effects among younger people.”
 

Mood Concerns?

Another concern that has emerged in public discussion regarding side effects is that of possible mood and suicidal ideation, raising concerns for adults and adolescents alike.

Upon investigating the reports, the FDA, in a statement, offered cautious reassurance that their review, including reports and clinical trials, “did not find an association between use of GLP-1 RAs and the occurrence of suicidal thoughts or actions.”

Noting that the agency is continuing to look into the issue, however, the FDA recommends that “healthcare professionals should monitor for and advise patients using GLP-1 RAs to report new or worsening depression, suicidal thoughts, or any unusual changes in mood or behavior.”
 

Concurrent Psychiatric Pharmacotherapy

Meanwhile, with weight gain a known and often challenging side effect of various psychiatric drugs, particularly in younger patients, obesity treatment of adolescents may commonly involve patients who are also being treated with those therapies.

Key culprits include certain antidepressants and antipsychotic medications, such as tricyclic antidepressants, and second-generation antipsychotics, such as olanzapine.

In terms of the use of GLP-1 medications for those patients, research includes a recent study of semaglutide in patients who were also being treated with antidepressants.

The study, a post hoc analysis of the STEP trials, showed “clinically meaningful weight loss regardless of baseline antidepressant use, with an adverse event profile consistent with previous studies.”

First author Robert F. Kushner, MD, said the study offers “reassurance that individuals who are taking antidepressant medications have a similar weight loss response and side-effect profile compared to individuals who are not taking these medications.”

Dr. Kushner, a professor of medicine and medicine education at Northwestern University in Chicago, and his team have not evaluated the safety profile for concomitant use with antipsychotic drugs. However, he noted that “there are studies showing that the daily GLP-1 drug liraglutide has been shown to be useful in combating antipsychotic-induced weight gain.”

“Similar studies will need to be conducted for the more effective agents, semaglutide and tirzepatide,” he said.

To counter the weight gain effects of antispychotics, metformin has long been a standard recommendation, and Dr. Vidmar noted that “I have historically always used metformin in this setting and found it very effective.”

However, the newer anti-obesity medications could prove to be important in those cases, Dr. Vidmar added.

“I do think and predict that GLP-1 agonists will be as effective, if not more, in combating the weight gain-promoting effects of these agents and act as a nice adjuvant to this treatment paradigm for psychiatrists.”

Dr. Vidmar has participated in an advisory board for Rhythm Pharmaceuticals. Dr. Kushner is on the advisory boards for Novo Nordisk, Weight Watchers, Lilly, Boehringer Ingelheim, and Altimmune.

A version of this article appeared on Medscape.com.