Pediatrics

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

Over two-thirds of sudden unexpected infant deaths classified as accidental suffocation were attributed to airway obstruction by soft bedding, according to research published in Pediatrics.

FamVeld/Thinkstock

Alexa B. Erck Lambert, MPH, of DB Consulting Group in Silver Spring, Md., and her associates conducted an analysis of 1,812 cases of sudden unexpected infant death (SUID) in children aged 1 year or less included in a Centers for Disease Control and Prevention registry. Of those 1,812 SUID cases, 250 (14%) were classified as accidental suffocation.

Airway obstruction by soft bedding was by far the most common mechanism of accidental suffocation, contributing to death in 69% of cases. Overlay was attributed in 19% of cases and wedging was attributed in 12%. The median age for soft bedding, overlay, and wedging death was 3 months, 2 months, and 6 months, respectively. The majority of cases were male (55%), born after at least 37 weeks’ gestation (81%), non-Hispanic white or African American (74%), and insured by Medicaid (70%).

In deaths attributed to soft bedding, 49% occurred while the infant was in an adult bed, 92% occurred while the infant was in a nonsupine position, and 34% occurred while a blanket was obstructing the airway. While infants aged 5-11 months were twice as likely to have had a blanket obstructing their airway as infants aged 0-4 months (55% vs. 27%), younger infants were twice as likely to have had a pillow or couch cushion obstructing their airway (25% vs. 11%).

Of the 51 overlay deaths, 71% occurred in an adult’s bed, 51% were found nonsupine, and 41% were found in a bed with more than one adult. Most deaths were attributed to neck or chest compression, rather than nose or mouth obstruction. Of the 33 wedging deaths, 45% were sharing a sleep surface and 73% were in an adult bed; the most common objects the infant was wedged between were a mattress and wall.

“The safest place for infants to sleep is on their backs, on an unshared sleep surface, in a crib or bassinet in the caregivers’ room, and without soft bedding in their sleep area,” the investigators wrote. “Improving our understanding of the characteristics and risk factors ... of suffocation deaths by mechanism of airway obstruction can inform the development of more targeted strategies to prevent these injuries and deaths.”

The authors reported no potential conflicts of interest. Ms. Erck Lambert was supported by a contract her employer and the Centers for Disease Control and Prevention. Meghan Faulkner’s agency also received funds from the Centers for Disease Control and Prevention.

[email protected]

SOURCE: Erck Lambert AB et al. Pediatrics. 2019 Apr 22. doi: 10.1542/peds.2018-3408.

Over two-thirds of sudden unexpected infant deaths classified as accidental suffocation were attributed to airway obstruction by soft bedding, according to research published in Pediatrics.

FamVeld/Thinkstock

Alexa B. Erck Lambert, MPH, of DB Consulting Group in Silver Spring, Md., and her associates conducted an analysis of 1,812 cases of sudden unexpected infant death (SUID) in children aged 1 year or less included in a Centers for Disease Control and Prevention registry. Of those 1,812 SUID cases, 250 (14%) were classified as accidental suffocation.

Airway obstruction by soft bedding was by far the most common mechanism of accidental suffocation, contributing to death in 69% of cases. Overlay was attributed in 19% of cases and wedging was attributed in 12%. The median age for soft bedding, overlay, and wedging death was 3 months, 2 months, and 6 months, respectively. The majority of cases were male (55%), born after at least 37 weeks’ gestation (81%), non-Hispanic white or African American (74%), and insured by Medicaid (70%).

In deaths attributed to soft bedding, 49% occurred while the infant was in an adult bed, 92% occurred while the infant was in a nonsupine position, and 34% occurred while a blanket was obstructing the airway. While infants aged 5-11 months were twice as likely to have had a blanket obstructing their airway as infants aged 0-4 months (55% vs. 27%), younger infants were twice as likely to have had a pillow or couch cushion obstructing their airway (25% vs. 11%).

Of the 51 overlay deaths, 71% occurred in an adult’s bed, 51% were found nonsupine, and 41% were found in a bed with more than one adult. Most deaths were attributed to neck or chest compression, rather than nose or mouth obstruction. Of the 33 wedging deaths, 45% were sharing a sleep surface and 73% were in an adult bed; the most common objects the infant was wedged between were a mattress and wall.

“The safest place for infants to sleep is on their backs, on an unshared sleep surface, in a crib or bassinet in the caregivers’ room, and without soft bedding in their sleep area,” the investigators wrote. “Improving our understanding of the characteristics and risk factors ... of suffocation deaths by mechanism of airway obstruction can inform the development of more targeted strategies to prevent these injuries and deaths.”

The authors reported no potential conflicts of interest. Ms. Erck Lambert was supported by a contract her employer and the Centers for Disease Control and Prevention. Meghan Faulkner’s agency also received funds from the Centers for Disease Control and Prevention.

[email protected]

SOURCE: Erck Lambert AB et al. Pediatrics. 2019 Apr 22. doi: 10.1542/peds.2018-3408.

Over two-thirds of sudden unexpected infant deaths classified as accidental suffocation were attributed to airway obstruction by soft bedding, according to research published in Pediatrics.

FamVeld/Thinkstock

Alexa B. Erck Lambert, MPH, of DB Consulting Group in Silver Spring, Md., and her associates conducted an analysis of 1,812 cases of sudden unexpected infant death (SUID) in children aged 1 year or less included in a Centers for Disease Control and Prevention registry. Of those 1,812 SUID cases, 250 (14%) were classified as accidental suffocation.

Airway obstruction by soft bedding was by far the most common mechanism of accidental suffocation, contributing to death in 69% of cases. Overlay was attributed in 19% of cases and wedging was attributed in 12%. The median age for soft bedding, overlay, and wedging death was 3 months, 2 months, and 6 months, respectively. The majority of cases were male (55%), born after at least 37 weeks’ gestation (81%), non-Hispanic white or African American (74%), and insured by Medicaid (70%).

In deaths attributed to soft bedding, 49% occurred while the infant was in an adult bed, 92% occurred while the infant was in a nonsupine position, and 34% occurred while a blanket was obstructing the airway. While infants aged 5-11 months were twice as likely to have had a blanket obstructing their airway as infants aged 0-4 months (55% vs. 27%), younger infants were twice as likely to have had a pillow or couch cushion obstructing their airway (25% vs. 11%).

Of the 51 overlay deaths, 71% occurred in an adult’s bed, 51% were found nonsupine, and 41% were found in a bed with more than one adult. Most deaths were attributed to neck or chest compression, rather than nose or mouth obstruction. Of the 33 wedging deaths, 45% were sharing a sleep surface and 73% were in an adult bed; the most common objects the infant was wedged between were a mattress and wall.

“The safest place for infants to sleep is on their backs, on an unshared sleep surface, in a crib or bassinet in the caregivers’ room, and without soft bedding in their sleep area,” the investigators wrote. “Improving our understanding of the characteristics and risk factors ... of suffocation deaths by mechanism of airway obstruction can inform the development of more targeted strategies to prevent these injuries and deaths.”

The authors reported no potential conflicts of interest. Ms. Erck Lambert was supported by a contract her employer and the Centers for Disease Control and Prevention. Meghan Faulkner’s agency also received funds from the Centers for Disease Control and Prevention.

[email protected]

SOURCE: Erck Lambert AB et al. Pediatrics. 2019 Apr 22. doi: 10.1542/peds.2018-3408.

 

For infants with newly diagnosed X-linked severe combined immunodeficiency (SCID-X1), lentiviral gene therapy and targeted busulfan conditioning successfully induced multilineage engraftment of transduced cells, researchers reported.

Pogonic/Getty Images

By 3-4 months after infusion, seven of eight patients had normal numbers of CD3+, CD4+, and naive CD4+ T cells; normal counts of natural killer (NK) cells; and vector marking of T cells, B cells, NK cells, myeloid cells, and bone marrow progenitors, Ewelina Mamcarz, MD, of St. Jude Children’s Research Hospital in Memphis, and her associates reported in the New England Journal of Medicine.

The eighth infant at first lacked a sufficient T-cell response but responded to a boost of gene-corrected cells without busulfan conditioning.

By 6-12 months after infusion, IgM levels also had normalized in seven of the eight infants and showed polyclonal patterns without clonal dominance, according to the investigators. Among four infants who were able to stop intravenous immunoglobulin therapy, three responded to vaccinations with tetanus, diphtheria, pertussis, polio, and pneumococcal polysaccharide. Such restoration of humoral immunity “has not been achieved in previously reported trials of gene therapy for infants with newly diagnosed SCID-X1,” wrote the investigators of this dual-center, phase 1/2 study.

X-linked severe combined immunodeficiency – “bubble boy disease” – is characterized by a lack of T cells, NK cells, and B cells, and is caused by mutations in IL2RG. Some 80% of affected infants have no matched sibling donor for hematopoietic stem cell transplantation, and transplantation from other donors can produce an inadequate response and graft-versus-host disease. Prior attempts at gene therapy with gamma-retroviral vectors had led to vector-induced leukemia or had failed to induce humoral immunity or normal NK cell production.

“Our new lentiviral vector gene therapy combined with nonmyeloablative busulfan conditioning has been successful in restoring immunity in five patients 7-23 years of age in whom a previous allogeneic hematopoietic stem cell transplantation for SCID-X1 had failed,” the investigators wrote. “We hypothesized that the combination of this lentiviral vector and low-exposure busulfan administered by means of pharmacokinetic dose targeting would be safe and effective as the primary treatment in infants with newly diagnosed SCID-X1.”

Their protocol included one to two daily intravenous doses of busulfan, targeting a cumulative area under the curve of 22 mg per hr/L. They calculated the first dose by weight and age using a population-based pharmacokinetic model and adjusted the second dose based on first-dose pharmacokinetics.

After a median of 16.4 months, all infants continued to grow normally and cleared previous infections, and there were no unanticipated side effects from bone marrow harvest, busulfan conditioning, or cell infusion.

“It is hoped that durable, complete adaptive immunity will be achieved in the majority of the patients over time,” the researchers wrote.

They continue to follow the patients to assess therapeutic safety, immune durability, and persistence of the transferred gene in hematopoietic and immune cells.

Study funders included the American Lebanese Syrian Associated Charities, the National Institutes of Health, the California Institute of Regenerative Medicine, and the Assisi Foundation of Memphis. St. Jude Children’s Research Hospital has licensed the gene therapy and partnered with Mustang Bio to develop and commercialize it. Dr. Mamcarz reported receiving grant support from the study funders.

SOURCE: Mamcarz E et al. N Engl J Med. 2019; 380:1525-34.

 

For infants with newly diagnosed X-linked severe combined immunodeficiency (SCID-X1), lentiviral gene therapy and targeted busulfan conditioning successfully induced multilineage engraftment of transduced cells, researchers reported.

Pogonic/Getty Images

By 3-4 months after infusion, seven of eight patients had normal numbers of CD3+, CD4+, and naive CD4+ T cells; normal counts of natural killer (NK) cells; and vector marking of T cells, B cells, NK cells, myeloid cells, and bone marrow progenitors, Ewelina Mamcarz, MD, of St. Jude Children’s Research Hospital in Memphis, and her associates reported in the New England Journal of Medicine.

The eighth infant at first lacked a sufficient T-cell response but responded to a boost of gene-corrected cells without busulfan conditioning.

By 6-12 months after infusion, IgM levels also had normalized in seven of the eight infants and showed polyclonal patterns without clonal dominance, according to the investigators. Among four infants who were able to stop intravenous immunoglobulin therapy, three responded to vaccinations with tetanus, diphtheria, pertussis, polio, and pneumococcal polysaccharide. Such restoration of humoral immunity “has not been achieved in previously reported trials of gene therapy for infants with newly diagnosed SCID-X1,” wrote the investigators of this dual-center, phase 1/2 study.

X-linked severe combined immunodeficiency – “bubble boy disease” – is characterized by a lack of T cells, NK cells, and B cells, and is caused by mutations in IL2RG. Some 80% of affected infants have no matched sibling donor for hematopoietic stem cell transplantation, and transplantation from other donors can produce an inadequate response and graft-versus-host disease. Prior attempts at gene therapy with gamma-retroviral vectors had led to vector-induced leukemia or had failed to induce humoral immunity or normal NK cell production.

“Our new lentiviral vector gene therapy combined with nonmyeloablative busulfan conditioning has been successful in restoring immunity in five patients 7-23 years of age in whom a previous allogeneic hematopoietic stem cell transplantation for SCID-X1 had failed,” the investigators wrote. “We hypothesized that the combination of this lentiviral vector and low-exposure busulfan administered by means of pharmacokinetic dose targeting would be safe and effective as the primary treatment in infants with newly diagnosed SCID-X1.”

Their protocol included one to two daily intravenous doses of busulfan, targeting a cumulative area under the curve of 22 mg per hr/L. They calculated the first dose by weight and age using a population-based pharmacokinetic model and adjusted the second dose based on first-dose pharmacokinetics.

After a median of 16.4 months, all infants continued to grow normally and cleared previous infections, and there were no unanticipated side effects from bone marrow harvest, busulfan conditioning, or cell infusion.

“It is hoped that durable, complete adaptive immunity will be achieved in the majority of the patients over time,” the researchers wrote.

They continue to follow the patients to assess therapeutic safety, immune durability, and persistence of the transferred gene in hematopoietic and immune cells.

Study funders included the American Lebanese Syrian Associated Charities, the National Institutes of Health, the California Institute of Regenerative Medicine, and the Assisi Foundation of Memphis. St. Jude Children’s Research Hospital has licensed the gene therapy and partnered with Mustang Bio to develop and commercialize it. Dr. Mamcarz reported receiving grant support from the study funders.

SOURCE: Mamcarz E et al. N Engl J Med. 2019; 380:1525-34.

 

For infants with newly diagnosed X-linked severe combined immunodeficiency (SCID-X1), lentiviral gene therapy and targeted busulfan conditioning successfully induced multilineage engraftment of transduced cells, researchers reported.

Pogonic/Getty Images

By 3-4 months after infusion, seven of eight patients had normal numbers of CD3+, CD4+, and naive CD4+ T cells; normal counts of natural killer (NK) cells; and vector marking of T cells, B cells, NK cells, myeloid cells, and bone marrow progenitors, Ewelina Mamcarz, MD, of St. Jude Children’s Research Hospital in Memphis, and her associates reported in the New England Journal of Medicine.

The eighth infant at first lacked a sufficient T-cell response but responded to a boost of gene-corrected cells without busulfan conditioning.

By 6-12 months after infusion, IgM levels also had normalized in seven of the eight infants and showed polyclonal patterns without clonal dominance, according to the investigators. Among four infants who were able to stop intravenous immunoglobulin therapy, three responded to vaccinations with tetanus, diphtheria, pertussis, polio, and pneumococcal polysaccharide. Such restoration of humoral immunity “has not been achieved in previously reported trials of gene therapy for infants with newly diagnosed SCID-X1,” wrote the investigators of this dual-center, phase 1/2 study.

X-linked severe combined immunodeficiency – “bubble boy disease” – is characterized by a lack of T cells, NK cells, and B cells, and is caused by mutations in IL2RG. Some 80% of affected infants have no matched sibling donor for hematopoietic stem cell transplantation, and transplantation from other donors can produce an inadequate response and graft-versus-host disease. Prior attempts at gene therapy with gamma-retroviral vectors had led to vector-induced leukemia or had failed to induce humoral immunity or normal NK cell production.

“Our new lentiviral vector gene therapy combined with nonmyeloablative busulfan conditioning has been successful in restoring immunity in five patients 7-23 years of age in whom a previous allogeneic hematopoietic stem cell transplantation for SCID-X1 had failed,” the investigators wrote. “We hypothesized that the combination of this lentiviral vector and low-exposure busulfan administered by means of pharmacokinetic dose targeting would be safe and effective as the primary treatment in infants with newly diagnosed SCID-X1.”

Their protocol included one to two daily intravenous doses of busulfan, targeting a cumulative area under the curve of 22 mg per hr/L. They calculated the first dose by weight and age using a population-based pharmacokinetic model and adjusted the second dose based on first-dose pharmacokinetics.

After a median of 16.4 months, all infants continued to grow normally and cleared previous infections, and there were no unanticipated side effects from bone marrow harvest, busulfan conditioning, or cell infusion.

“It is hoped that durable, complete adaptive immunity will be achieved in the majority of the patients over time,” the researchers wrote.

They continue to follow the patients to assess therapeutic safety, immune durability, and persistence of the transferred gene in hematopoietic and immune cells.

Study funders included the American Lebanese Syrian Associated Charities, the National Institutes of Health, the California Institute of Regenerative Medicine, and the Assisi Foundation of Memphis. St. Jude Children’s Research Hospital has licensed the gene therapy and partnered with Mustang Bio to develop and commercialize it. Dr. Mamcarz reported receiving grant support from the study funders.

SOURCE: Mamcarz E et al. N Engl J Med. 2019; 380:1525-34.

 

After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.¹ This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.²

licsiren/iStock/Getty Images

E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.³ For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.⁴ Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.⁵ An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.⁶

One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.

E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.⁷ “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.

Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.⁸ The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.⁹ An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.¹⁰

Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.¹⁰ In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.

Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” After screening, a brief intervention includes a clear recommendation against e-cigarette use and education about the risks. Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.

Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.¹¹ Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.

The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
 

 

Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].

References

1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.

2. e-cigarettes.surgeongeneral.gov

3. N Engl J Med 2019;380:629-37.

4. Pediatrics. 2018 Dec; 142(6):e20180486.

5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.

6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.

7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).

8. N Engl J Med 2014;371:932-43.

9. N Engl J Med 2019;380:689-90.

10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.

11. Pediatrics. 2019 Feb;143(2). pii: e20183652.

 

After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.¹ This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.²

licsiren/iStock/Getty Images

E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.³ For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.⁴ Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.⁵ An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.⁶

One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.

E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.⁷ “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.

Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.⁸ The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.⁹ An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.¹⁰

Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.¹⁰ In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.

Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” After screening, a brief intervention includes a clear recommendation against e-cigarette use and education about the risks. Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.

Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.¹¹ Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.

The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
 

 

Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].

References

1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.

2. e-cigarettes.surgeongeneral.gov

3. N Engl J Med 2019;380:629-37.

4. Pediatrics. 2018 Dec; 142(6):e20180486.

5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.

6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.

7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).

8. N Engl J Med 2014;371:932-43.

9. N Engl J Med 2019;380:689-90.

10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.

11. Pediatrics. 2019 Feb;143(2). pii: e20183652.

 

After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.¹ This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.²

licsiren/iStock/Getty Images

E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.³ For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.⁴ Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.⁵ An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.⁶

One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.

E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.⁷ “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.

Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.⁸ The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.⁹ An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.¹⁰

Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.¹⁰ In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.

Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” After screening, a brief intervention includes a clear recommendation against e-cigarette use and education about the risks. Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.

Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.¹¹ Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.

The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
 

 

Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].

References

1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.

2. e-cigarettes.surgeongeneral.gov

3. N Engl J Med 2019;380:629-37.

4. Pediatrics. 2018 Dec; 142(6):e20180486.

5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.

6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.

7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).

8. N Engl J Med 2014;371:932-43.

9. N Engl J Med 2019;380:689-90.

10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.

11. Pediatrics. 2019 Feb;143(2). pii: e20183652.

Sending health information videos via text or email to mothers successfully promoted safe sleep behaviors among mothers by changing their attitudes and perceived social norms related to these practices, according to a new study.

monkeybusinessimages/Thinkstock

In the past, the American Academy of Pediatrics has made safe sleep recommendations regarding infant sleep position and location. According to the new study’s authors, Rachel Y. Moon, MD, and her colleagues, parents had poorly adhered to these recommendations in several studies. However, some improvements with adherence were seen when a mobile health intervention was used in the Social Media and Risk Reduction Training Study (JAMA. 2017;318[4]:351-9). The new study, published in Pediatrics, used the same intervention described in that JAMA paper.

The more recent mobile health project sought to identify which factors, as outlined by a theory of planned behavior, were affected by a mobile health intervention through analysis of survey responses. Of the 1,600 women who provided written consent, 1,263 (78.9%) completed the survey.

According to the results, the intervention did more to affect attitudes (adjusted odds ratio, 2.35; 95% confidence interval, 1.72-3.20) than it did to affect perceived norms (aOR, 1.75; 95% CI, 1.27-2.36) regarding supine sleeping position. It had similar effects on attitudes (aOR, 1.91; 95% CI, 1.54-2.36) versus perceived norms (aOR, 1.37; 95% CI, 1.13-1.66) regarding sleep location as well. The intervention had no significant effect on perceived maternal control regarding either sleeping position or location.

While levels of safe sleep adherence were lower in African Americans and subgroups of low economic status at baseline, the intervention improved the rates of adherence in these groups to levels comparable with other groups included in the study.

“Recognition that these attitudes and social norms may be the main drivers of mothers’ choices regarding infant-sleep practices should inform health messaging strategies, including the use of [mobile heath], to promote [safe sleep],” the researchers concluded.

The study was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the CJ foundation for sudden infant death syndrome. The National Institutes of Health also provided funding.

[email protected]

SOURCE: Moon RY et al. Pediatrics. 2019. doi: 10.1542/peds.2018-2799.

Sending health information videos via text or email to mothers successfully promoted safe sleep behaviors among mothers by changing their attitudes and perceived social norms related to these practices, according to a new study.

monkeybusinessimages/Thinkstock

In the past, the American Academy of Pediatrics has made safe sleep recommendations regarding infant sleep position and location. According to the new study’s authors, Rachel Y. Moon, MD, and her colleagues, parents had poorly adhered to these recommendations in several studies. However, some improvements with adherence were seen when a mobile health intervention was used in the Social Media and Risk Reduction Training Study (JAMA. 2017;318[4]:351-9). The new study, published in Pediatrics, used the same intervention described in that JAMA paper.

The more recent mobile health project sought to identify which factors, as outlined by a theory of planned behavior, were affected by a mobile health intervention through analysis of survey responses. Of the 1,600 women who provided written consent, 1,263 (78.9%) completed the survey.

According to the results, the intervention did more to affect attitudes (adjusted odds ratio, 2.35; 95% confidence interval, 1.72-3.20) than it did to affect perceived norms (aOR, 1.75; 95% CI, 1.27-2.36) regarding supine sleeping position. It had similar effects on attitudes (aOR, 1.91; 95% CI, 1.54-2.36) versus perceived norms (aOR, 1.37; 95% CI, 1.13-1.66) regarding sleep location as well. The intervention had no significant effect on perceived maternal control regarding either sleeping position or location.

While levels of safe sleep adherence were lower in African Americans and subgroups of low economic status at baseline, the intervention improved the rates of adherence in these groups to levels comparable with other groups included in the study.

“Recognition that these attitudes and social norms may be the main drivers of mothers’ choices regarding infant-sleep practices should inform health messaging strategies, including the use of [mobile heath], to promote [safe sleep],” the researchers concluded.

The study was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the CJ foundation for sudden infant death syndrome. The National Institutes of Health also provided funding.

[email protected]

SOURCE: Moon RY et al. Pediatrics. 2019. doi: 10.1542/peds.2018-2799.

Sending health information videos via text or email to mothers successfully promoted safe sleep behaviors among mothers by changing their attitudes and perceived social norms related to these practices, according to a new study.

monkeybusinessimages/Thinkstock

In the past, the American Academy of Pediatrics has made safe sleep recommendations regarding infant sleep position and location. According to the new study’s authors, Rachel Y. Moon, MD, and her colleagues, parents had poorly adhered to these recommendations in several studies. However, some improvements with adherence were seen when a mobile health intervention was used in the Social Media and Risk Reduction Training Study (JAMA. 2017;318[4]:351-9). The new study, published in Pediatrics, used the same intervention described in that JAMA paper.

The more recent mobile health project sought to identify which factors, as outlined by a theory of planned behavior, were affected by a mobile health intervention through analysis of survey responses. Of the 1,600 women who provided written consent, 1,263 (78.9%) completed the survey.

According to the results, the intervention did more to affect attitudes (adjusted odds ratio, 2.35; 95% confidence interval, 1.72-3.20) than it did to affect perceived norms (aOR, 1.75; 95% CI, 1.27-2.36) regarding supine sleeping position. It had similar effects on attitudes (aOR, 1.91; 95% CI, 1.54-2.36) versus perceived norms (aOR, 1.37; 95% CI, 1.13-1.66) regarding sleep location as well. The intervention had no significant effect on perceived maternal control regarding either sleeping position or location.

While levels of safe sleep adherence were lower in African Americans and subgroups of low economic status at baseline, the intervention improved the rates of adherence in these groups to levels comparable with other groups included in the study.

“Recognition that these attitudes and social norms may be the main drivers of mothers’ choices regarding infant-sleep practices should inform health messaging strategies, including the use of [mobile heath], to promote [safe sleep],” the researchers concluded.

The study was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the CJ foundation for sudden infant death syndrome. The National Institutes of Health also provided funding.

[email protected]

SOURCE: Moon RY et al. Pediatrics. 2019. doi: 10.1542/peds.2018-2799.

 

The United States has topped 600 cases of measles for 2019 and is likely to pass the postelimination high set in 2014 “in the coming weeks,” according to the Centers for Disease Control and Prevention.

The 71 new measles cases reported during the week ending April 18 bring the total for the year to 626 in 22 states, the CDC reported April 22. Two states, Iowa and Tennessee, reported their first cases last week.

Outbreaks continue in five states: one in California (Butte County), one in Michigan (Oakland County/Wayne County/Detroit), one in New Jersey (Ocean County/Monmouth County), two in New York (New York City and Rockland County), and one in Washington (Clark County/King County), the CDC said.

The most active outbreak since mid-February has been the one occurring in New York City, mainly in Brooklyn, and last week was no exception as 50 of the 71 new U.S. cases were reported in the borough.

On April 18, a judge in Brooklyn “ruled against a group of parents who challenged New York City’s recently imposed mandatory measles vaccination order,” Reuters reported. That same day, the city issued a summons, subject to a fine of $1,000 each, to three people in Brooklyn who were still unvaccinated, according to NYC Health, which also said that four additional schools would be closed for not complying with an order to exclude unvaccinated students.

On April 15, the Iowa Department of Public Health confirmed the state’s first case of measles since 2011. The individual from Northeastern Iowa had not been vaccinated and had recently returned from Israel. The state’s second case of the year, a household contact of the first individual, was confirmed on April 18.

Also on April 18, the Tennessee Department of Health confirmed its first case of the year in a resident of the eastern part of the state. Meanwhile, media are reporting that state health officials in Mississippi are investigating possible exposures on April 9 and 10 in the Hattiesburg area by the infected Tennessee man.

Outside the United States, “many countries are in the midst of sizeable measles outbreaks, with all regions of the world experiencing sustained rises in cases,” the World Health Organization said. Current outbreaks include the Democratic Republic of the Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand, and Ukraine.

Preliminary data for the first 3 months of 2019 show that cases worldwide were up by 300% over the first 3 months of 2018: 112,163 cases vs. 28,124. The actual numbers for 2019 are expected to be considerably higher than those reported so far, and WHO estimates that, globally, less than 1 in 10 cases are actually reported.

[email protected]

 

The United States has topped 600 cases of measles for 2019 and is likely to pass the postelimination high set in 2014 “in the coming weeks,” according to the Centers for Disease Control and Prevention.

The 71 new measles cases reported during the week ending April 18 bring the total for the year to 626 in 22 states, the CDC reported April 22. Two states, Iowa and Tennessee, reported their first cases last week.

Outbreaks continue in five states: one in California (Butte County), one in Michigan (Oakland County/Wayne County/Detroit), one in New Jersey (Ocean County/Monmouth County), two in New York (New York City and Rockland County), and one in Washington (Clark County/King County), the CDC said.

The most active outbreak since mid-February has been the one occurring in New York City, mainly in Brooklyn, and last week was no exception as 50 of the 71 new U.S. cases were reported in the borough.

On April 18, a judge in Brooklyn “ruled against a group of parents who challenged New York City’s recently imposed mandatory measles vaccination order,” Reuters reported. That same day, the city issued a summons, subject to a fine of $1,000 each, to three people in Brooklyn who were still unvaccinated, according to NYC Health, which also said that four additional schools would be closed for not complying with an order to exclude unvaccinated students.

On April 15, the Iowa Department of Public Health confirmed the state’s first case of measles since 2011. The individual from Northeastern Iowa had not been vaccinated and had recently returned from Israel. The state’s second case of the year, a household contact of the first individual, was confirmed on April 18.

Also on April 18, the Tennessee Department of Health confirmed its first case of the year in a resident of the eastern part of the state. Meanwhile, media are reporting that state health officials in Mississippi are investigating possible exposures on April 9 and 10 in the Hattiesburg area by the infected Tennessee man.

Outside the United States, “many countries are in the midst of sizeable measles outbreaks, with all regions of the world experiencing sustained rises in cases,” the World Health Organization said. Current outbreaks include the Democratic Republic of the Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand, and Ukraine.

Preliminary data for the first 3 months of 2019 show that cases worldwide were up by 300% over the first 3 months of 2018: 112,163 cases vs. 28,124. The actual numbers for 2019 are expected to be considerably higher than those reported so far, and WHO estimates that, globally, less than 1 in 10 cases are actually reported.

[email protected]

 

The United States has topped 600 cases of measles for 2019 and is likely to pass the postelimination high set in 2014 “in the coming weeks,” according to the Centers for Disease Control and Prevention.

The 71 new measles cases reported during the week ending April 18 bring the total for the year to 626 in 22 states, the CDC reported April 22. Two states, Iowa and Tennessee, reported their first cases last week.

Outbreaks continue in five states: one in California (Butte County), one in Michigan (Oakland County/Wayne County/Detroit), one in New Jersey (Ocean County/Monmouth County), two in New York (New York City and Rockland County), and one in Washington (Clark County/King County), the CDC said.

The most active outbreak since mid-February has been the one occurring in New York City, mainly in Brooklyn, and last week was no exception as 50 of the 71 new U.S. cases were reported in the borough.

On April 18, a judge in Brooklyn “ruled against a group of parents who challenged New York City’s recently imposed mandatory measles vaccination order,” Reuters reported. That same day, the city issued a summons, subject to a fine of $1,000 each, to three people in Brooklyn who were still unvaccinated, according to NYC Health, which also said that four additional schools would be closed for not complying with an order to exclude unvaccinated students.

On April 15, the Iowa Department of Public Health confirmed the state’s first case of measles since 2011. The individual from Northeastern Iowa had not been vaccinated and had recently returned from Israel. The state’s second case of the year, a household contact of the first individual, was confirmed on April 18.

Also on April 18, the Tennessee Department of Health confirmed its first case of the year in a resident of the eastern part of the state. Meanwhile, media are reporting that state health officials in Mississippi are investigating possible exposures on April 9 and 10 in the Hattiesburg area by the infected Tennessee man.

Outside the United States, “many countries are in the midst of sizeable measles outbreaks, with all regions of the world experiencing sustained rises in cases,” the World Health Organization said. Current outbreaks include the Democratic Republic of the Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand, and Ukraine.

Preliminary data for the first 3 months of 2019 show that cases worldwide were up by 300% over the first 3 months of 2018: 112,163 cases vs. 28,124. The actual numbers for 2019 are expected to be considerably higher than those reported so far, and WHO estimates that, globally, less than 1 in 10 cases are actually reported.

[email protected]

First reported in 1895, nevus sebaceus (NS) is a con genital papillomatous hamartoma most commonly found on the scalp and face. ¹ Lesions typically are yellow-orange plaques and often are hairless. Nevus sebaceus is most prominent in the few first months after birth and again at puberty during development of the sebaceous glands. Development of epithelial hyperplasia, cysts, verrucas, and benign or malignant tumors has been reported. ¹ The most common benign tumors are syringocystadenoma papilliferum and trichoblastoma. Cases of malignancy are rare, and basal cell carcinoma is the predominant form (approximately 2% of cases). Squamous cell carcinoma (SCC) and adnexal carcinoma are reported at even lower rates. ¹ Malignant transformation occurring during childhood is extremely uncommon. According to a PubMed search of articles indexed for MEDLINE using the terms nevus sebaceous, malignancy, and squamous cell carcinoma and narrowing the results to children, there have been only 4 prior reports of SCC developing within an NS in a child. ^2-5 We report a case of SCC arising in an NS in a 13-year-old adolescent girl with perineural invasion.

Case Report

A 13-year-old fair-skinned adolescent girl presented with a hairless 2×2.5-cm yellow plaque at the hairline on the anterior central scalp. The plaque had been present since birth and had progressively developed a superiorly located 3×5-mm erythematous verrucous nodule (Figure 1) with an approximate height of 6 mm over the last year. The nodule was subjected to regular trauma and bled with minimal insult. The patient appeared otherwise healthy, with no history of skin cancer or other chronic medical conditions. There was no evidence of lymphadenopathy on examination, and no other skin abnormalities were noted. There was no reported family history of skin cancer or chronic skin conditions suggestive of increased risk for cancer or other pathologic dermatoses. Differential diagnoses for the plaque and nodule complex included verruca, Spitz nevus, or secondary neoplasm within NS.

 

Excision was conducted under local anesthesia without complication. An elliptical section of skin measuring 0.8×2.5 cm was excised to a depth of 3 mm. The resulting wound was closed using a complex linear repair. The section was placed in formalin specimen transport medium and sent to Walter Reed National Military Medical Center (Bethesda, Maryland). Microscopic examination of the specimen revealed features typical for NS, including mild verrucous epidermal hyperplasia, sebaceous gland hyperplasia, presence of apocrine glands, and hamartomatous follicular proliferations (Figure 2). An even more papillomatous epidermal proliferation that was comprised of atypical squamous cells was present within the lesion. Similar atypical squamous cells infiltrated the superficial dermis in nests, cords, and single cells (Figure 3A). One focus showed perineural invasion with a small superficial nerve fiber surrounded by SCC (Figure 3B). The tumor was completely excised, with negative surgical margins extending approximately 2 mm. Adjuvant radiation therapy and further specialized Mohs micrographic excision were not performed because of the clear histologic appearance of the carcinoma and strong evidence of complete excision.

At 2-week follow-up, the surgical scar on the anterior central forehead was well healed without evidence of SCC recurrence. On physical examination there was neither lymphadenopathy nor signs of neurologic deficit, except for superficial cutaneous hypoesthesia in the immediate area surrounding the healed site. Following discussion with the patient and her parents, it was decided that the patient would obtain baseline laboratory tests, chest radiography, and abdominal ultrasonography, and she would undergo serial follow-up examinations every 3 months for the next 2 years. Annual follow-up was recommended after 2 years, with the caveat to return sooner if recurrence or symptoms were to arise.

Comment

Historically, there has been variability in the histopathologic interpretation of SCC in NS in the literature. Retrospective analysis of the histologic evidence of SCC in the 2 earliest possible cases of pediatric SCC in NS have been questioned due to the lack of clinical data presented and the possibility that the diagnosis of SCC was inaccurate.⁶ Our case was histopathologically interpreted as superficially invasive, well-differentiated SCC arising within an NS; therefore, we classified this case as SCC and took every precaution to ensure the lesion was completely excised, given the potentially invasive nature of SCC.

Our case is unique because it represents SCC in NS with histologic evidence of perineural involvement. Perineural invasion is a major route of tumor spread in SCC and may result in increased occurrence of regional lymph node spread and distant metastases, with path of least resistance or neural cell adhesion as possible spreading methods.^7-9 However, there is a notable amount of prognostic variability based on tumor type, the nerve involved, and degree of involvement.⁹ It is common for cutaneous SCC to occur with invasion of small intradermal nerves, but a poor outcome is less likely in asymptomatic patients who have perineural involvement that was incidentally discovered on histologic examination.¹⁰

In our patient, the entire tumor was completely removed with local excision. Recurrence of the SCC or future symptoms of deep neural invasion were not anticipated given the postoperative evidence of clear margins in the excised skin and subdermal structures as well as the lack of preoperative and postoperative symptoms. Close clinical follow-up was warranted to monitor for early signs of recurrence or neural involvement. We have confidence that the planned follow-up regimen in our patient will reveal any early signs of new occurrence or recurrence.

In the case of recurrence, Mohs micrographic surgery would likely be indicated. We elected not to treat with adjuvant radiotherapy because its benefit in cutaneous SCC with perineural invasion is debatable based on the lack of randomized controlled clinical evidence.^10,11 The patient obtained postoperative baseline complete blood cell count with differential, posterior/anterior and lateral chest radiographs, as well as abdominal ultrasonography. Each returned negative findings of hematologic or distant organ metastases, with subsequent follow-up visits also negative for any new concerning findings.

First reported in 1895, nevus sebaceus (NS) is a con genital papillomatous hamartoma most commonly found on the scalp and face. ¹ Lesions typically are yellow-orange plaques and often are hairless. Nevus sebaceus is most prominent in the few first months after birth and again at puberty during development of the sebaceous glands. Development of epithelial hyperplasia, cysts, verrucas, and benign or malignant tumors has been reported. ¹ The most common benign tumors are syringocystadenoma papilliferum and trichoblastoma. Cases of malignancy are rare, and basal cell carcinoma is the predominant form (approximately 2% of cases). Squamous cell carcinoma (SCC) and adnexal carcinoma are reported at even lower rates. ¹ Malignant transformation occurring during childhood is extremely uncommon. According to a PubMed search of articles indexed for MEDLINE using the terms nevus sebaceous, malignancy, and squamous cell carcinoma and narrowing the results to children, there have been only 4 prior reports of SCC developing within an NS in a child. ^2-5 We report a case of SCC arising in an NS in a 13-year-old adolescent girl with perineural invasion.

Case Report

A 13-year-old fair-skinned adolescent girl presented with a hairless 2×2.5-cm yellow plaque at the hairline on the anterior central scalp. The plaque had been present since birth and had progressively developed a superiorly located 3×5-mm erythematous verrucous nodule (Figure 1) with an approximate height of 6 mm over the last year. The nodule was subjected to regular trauma and bled with minimal insult. The patient appeared otherwise healthy, with no history of skin cancer or other chronic medical conditions. There was no evidence of lymphadenopathy on examination, and no other skin abnormalities were noted. There was no reported family history of skin cancer or chronic skin conditions suggestive of increased risk for cancer or other pathologic dermatoses. Differential diagnoses for the plaque and nodule complex included verruca, Spitz nevus, or secondary neoplasm within NS.

 

Excision was conducted under local anesthesia without complication. An elliptical section of skin measuring 0.8×2.5 cm was excised to a depth of 3 mm. The resulting wound was closed using a complex linear repair. The section was placed in formalin specimen transport medium and sent to Walter Reed National Military Medical Center (Bethesda, Maryland). Microscopic examination of the specimen revealed features typical for NS, including mild verrucous epidermal hyperplasia, sebaceous gland hyperplasia, presence of apocrine glands, and hamartomatous follicular proliferations (Figure 2). An even more papillomatous epidermal proliferation that was comprised of atypical squamous cells was present within the lesion. Similar atypical squamous cells infiltrated the superficial dermis in nests, cords, and single cells (Figure 3A). One focus showed perineural invasion with a small superficial nerve fiber surrounded by SCC (Figure 3B). The tumor was completely excised, with negative surgical margins extending approximately 2 mm. Adjuvant radiation therapy and further specialized Mohs micrographic excision were not performed because of the clear histologic appearance of the carcinoma and strong evidence of complete excision.

At 2-week follow-up, the surgical scar on the anterior central forehead was well healed without evidence of SCC recurrence. On physical examination there was neither lymphadenopathy nor signs of neurologic deficit, except for superficial cutaneous hypoesthesia in the immediate area surrounding the healed site. Following discussion with the patient and her parents, it was decided that the patient would obtain baseline laboratory tests, chest radiography, and abdominal ultrasonography, and she would undergo serial follow-up examinations every 3 months for the next 2 years. Annual follow-up was recommended after 2 years, with the caveat to return sooner if recurrence or symptoms were to arise.

Comment

Historically, there has been variability in the histopathologic interpretation of SCC in NS in the literature. Retrospective analysis of the histologic evidence of SCC in the 2 earliest possible cases of pediatric SCC in NS have been questioned due to the lack of clinical data presented and the possibility that the diagnosis of SCC was inaccurate.⁶ Our case was histopathologically interpreted as superficially invasive, well-differentiated SCC arising within an NS; therefore, we classified this case as SCC and took every precaution to ensure the lesion was completely excised, given the potentially invasive nature of SCC.

Our case is unique because it represents SCC in NS with histologic evidence of perineural involvement. Perineural invasion is a major route of tumor spread in SCC and may result in increased occurrence of regional lymph node spread and distant metastases, with path of least resistance or neural cell adhesion as possible spreading methods.^7-9 However, there is a notable amount of prognostic variability based on tumor type, the nerve involved, and degree of involvement.⁹ It is common for cutaneous SCC to occur with invasion of small intradermal nerves, but a poor outcome is less likely in asymptomatic patients who have perineural involvement that was incidentally discovered on histologic examination.¹⁰

In our patient, the entire tumor was completely removed with local excision. Recurrence of the SCC or future symptoms of deep neural invasion were not anticipated given the postoperative evidence of clear margins in the excised skin and subdermal structures as well as the lack of preoperative and postoperative symptoms. Close clinical follow-up was warranted to monitor for early signs of recurrence or neural involvement. We have confidence that the planned follow-up regimen in our patient will reveal any early signs of new occurrence or recurrence.

In the case of recurrence, Mohs micrographic surgery would likely be indicated. We elected not to treat with adjuvant radiotherapy because its benefit in cutaneous SCC with perineural invasion is debatable based on the lack of randomized controlled clinical evidence.^10,11 The patient obtained postoperative baseline complete blood cell count with differential, posterior/anterior and lateral chest radiographs, as well as abdominal ultrasonography. Each returned negative findings of hematologic or distant organ metastases, with subsequent follow-up visits also negative for any new concerning findings.

First reported in 1895, nevus sebaceus (NS) is a con genital papillomatous hamartoma most commonly found on the scalp and face. ¹ Lesions typically are yellow-orange plaques and often are hairless. Nevus sebaceus is most prominent in the few first months after birth and again at puberty during development of the sebaceous glands. Development of epithelial hyperplasia, cysts, verrucas, and benign or malignant tumors has been reported. ¹ The most common benign tumors are syringocystadenoma papilliferum and trichoblastoma. Cases of malignancy are rare, and basal cell carcinoma is the predominant form (approximately 2% of cases). Squamous cell carcinoma (SCC) and adnexal carcinoma are reported at even lower rates. ¹ Malignant transformation occurring during childhood is extremely uncommon. According to a PubMed search of articles indexed for MEDLINE using the terms nevus sebaceous, malignancy, and squamous cell carcinoma and narrowing the results to children, there have been only 4 prior reports of SCC developing within an NS in a child. ^2-5 We report a case of SCC arising in an NS in a 13-year-old adolescent girl with perineural invasion.

Case Report

A 13-year-old fair-skinned adolescent girl presented with a hairless 2×2.5-cm yellow plaque at the hairline on the anterior central scalp. The plaque had been present since birth and had progressively developed a superiorly located 3×5-mm erythematous verrucous nodule (Figure 1) with an approximate height of 6 mm over the last year. The nodule was subjected to regular trauma and bled with minimal insult. The patient appeared otherwise healthy, with no history of skin cancer or other chronic medical conditions. There was no evidence of lymphadenopathy on examination, and no other skin abnormalities were noted. There was no reported family history of skin cancer or chronic skin conditions suggestive of increased risk for cancer or other pathologic dermatoses. Differential diagnoses for the plaque and nodule complex included verruca, Spitz nevus, or secondary neoplasm within NS.

 

Excision was conducted under local anesthesia without complication. An elliptical section of skin measuring 0.8×2.5 cm was excised to a depth of 3 mm. The resulting wound was closed using a complex linear repair. The section was placed in formalin specimen transport medium and sent to Walter Reed National Military Medical Center (Bethesda, Maryland). Microscopic examination of the specimen revealed features typical for NS, including mild verrucous epidermal hyperplasia, sebaceous gland hyperplasia, presence of apocrine glands, and hamartomatous follicular proliferations (Figure 2). An even more papillomatous epidermal proliferation that was comprised of atypical squamous cells was present within the lesion. Similar atypical squamous cells infiltrated the superficial dermis in nests, cords, and single cells (Figure 3A). One focus showed perineural invasion with a small superficial nerve fiber surrounded by SCC (Figure 3B). The tumor was completely excised, with negative surgical margins extending approximately 2 mm. Adjuvant radiation therapy and further specialized Mohs micrographic excision were not performed because of the clear histologic appearance of the carcinoma and strong evidence of complete excision.

At 2-week follow-up, the surgical scar on the anterior central forehead was well healed without evidence of SCC recurrence. On physical examination there was neither lymphadenopathy nor signs of neurologic deficit, except for superficial cutaneous hypoesthesia in the immediate area surrounding the healed site. Following discussion with the patient and her parents, it was decided that the patient would obtain baseline laboratory tests, chest radiography, and abdominal ultrasonography, and she would undergo serial follow-up examinations every 3 months for the next 2 years. Annual follow-up was recommended after 2 years, with the caveat to return sooner if recurrence or symptoms were to arise.

Comment

Historically, there has been variability in the histopathologic interpretation of SCC in NS in the literature. Retrospective analysis of the histologic evidence of SCC in the 2 earliest possible cases of pediatric SCC in NS have been questioned due to the lack of clinical data presented and the possibility that the diagnosis of SCC was inaccurate.⁶ Our case was histopathologically interpreted as superficially invasive, well-differentiated SCC arising within an NS; therefore, we classified this case as SCC and took every precaution to ensure the lesion was completely excised, given the potentially invasive nature of SCC.

Our case is unique because it represents SCC in NS with histologic evidence of perineural involvement. Perineural invasion is a major route of tumor spread in SCC and may result in increased occurrence of regional lymph node spread and distant metastases, with path of least resistance or neural cell adhesion as possible spreading methods.^7-9 However, there is a notable amount of prognostic variability based on tumor type, the nerve involved, and degree of involvement.⁹ It is common for cutaneous SCC to occur with invasion of small intradermal nerves, but a poor outcome is less likely in asymptomatic patients who have perineural involvement that was incidentally discovered on histologic examination.¹⁰

In our patient, the entire tumor was completely removed with local excision. Recurrence of the SCC or future symptoms of deep neural invasion were not anticipated given the postoperative evidence of clear margins in the excised skin and subdermal structures as well as the lack of preoperative and postoperative symptoms. Close clinical follow-up was warranted to monitor for early signs of recurrence or neural involvement. We have confidence that the planned follow-up regimen in our patient will reveal any early signs of new occurrence or recurrence.

In the case of recurrence, Mohs micrographic surgery would likely be indicated. We elected not to treat with adjuvant radiotherapy because its benefit in cutaneous SCC with perineural invasion is debatable based on the lack of randomized controlled clinical evidence.^10,11 The patient obtained postoperative baseline complete blood cell count with differential, posterior/anterior and lateral chest radiographs, as well as abdominal ultrasonography. Each returned negative findings of hematologic or distant organ metastases, with subsequent follow-up visits also negative for any new concerning findings.

 

Diagnostic error is the most common allegation against pediatricians when sued by patients and their families, a study finds.

Investigators with The Doctors Company, a national medical liability insurer, examined 1,215 closed claims involving children from the company’s database between 2008 and 2017. Results showed that diagnostic mistakes, including delayed diagnosis, incorrect diagnosis, and failure to diagnose, were the most common accusations among claims that involved children ages 1 through 17. Poor medical treatment was the second most common allegation for claims that involved children aged 1-9, while surgical treatment-related error was the second most frequent accusation for children ages 10-17.

Pediatricians, orthopedic surgeons, and emergency medicine physicians were the most frequently named specialists in claims associated with children older than 1 month. Obstetricians were most frequently defendants in claims involving neonates. For these cases, errors during labor and delivery care were the most common complaints.

Of the 1,215 claims, obstetricians were named in 24% of the cases and pediatricians were named in 15% of the cases. The majority of claims were filed against physicians in the first 3 years following the medical incident alleged, according to the study, published by The Doctors Company.

The average patient payment in each case was $630,456, and the average expense to defend each claim was $157,502, according to the analysis. Claims that involved neonates had the highest average payment ($936,843) and the highest defense costs ($187,117), while claims involving children aged 10-17 years had the lowest average payment ($386,849) and cost the least to defend ($129,816).

For cases involving neonates, the type of therapy selected during labor and delivery and how it was managed were the most common factors contributing to the alleged injury, according to the analysis.

The most frequent factors contributing to patient harm for other age groups involved patient assessment issues and communication problems between the patient/family and the physician. Inadequate patient assessments were closely linked to incorrect diagnoses, while incomplete communication between patients/family members and providers impacted clinicians’ ability to make correct diagnoses, according to the study.

This analysis “shows that pediatric malpractice lawsuits impact nearly every area of medicine,” William F. Getman, MD, a pediatrician in Austin, Tex., said in an interview. “I was surprised to see that the most common age of a patient in a malpractice lawsuit was less than 1 month old. This age group also sustained the most severe injuries and had the highest indemnity paid.”

The study offers several key takeaways, including the importance of identifying system weaknesses in your medical practice and evaluating if improvements are needed, according to Darrell Ranum, vice president for patient safety and risk management for The Doctors Company.

Simple improvements, such as implementing tracking mechanisms for test results and referrals, can reduce the chance that important information falls through the cracks and delays diagnosis or treatment, Mr. Ranum said in an interview.

“When parents raise questions about their child’s complaints, this is the best opportunity to identify illnesses and conditions that represent a serious threat to children,” he said. “Prepare office staff members to know what complaints need to be evaluated by a clinician or require immediate care.”

In addition, the study findings point to the need to improve communication in all areas of the practice spectrum, Dr. Getman said.

“Many of the lawsuits could have been avoided by improvements in communication – doctor to patient, patient to doctor, doctor to nurse, doctor to doctor, nurse to patient, etc.,” he said. “Finding more effective and accurate ways to communicate will avoid mistakes, improve care, and improve outcomes. Examples of ways to improve communication include use of an interpreter when indicated, verbal and written explanations of instructions, and system improvements in tracking messages/labs/data. There are innumerable other ways to improve communication in health care.”

[email protected]

SOURCE: Ranum, D. The Doctor’s Advocate. First Quarter 2019.

 

Diagnostic error is the most common allegation against pediatricians when sued by patients and their families, a study finds.

Investigators with The Doctors Company, a national medical liability insurer, examined 1,215 closed claims involving children from the company’s database between 2008 and 2017. Results showed that diagnostic mistakes, including delayed diagnosis, incorrect diagnosis, and failure to diagnose, were the most common accusations among claims that involved children ages 1 through 17. Poor medical treatment was the second most common allegation for claims that involved children aged 1-9, while surgical treatment-related error was the second most frequent accusation for children ages 10-17.

Pediatricians, orthopedic surgeons, and emergency medicine physicians were the most frequently named specialists in claims associated with children older than 1 month. Obstetricians were most frequently defendants in claims involving neonates. For these cases, errors during labor and delivery care were the most common complaints.

Of the 1,215 claims, obstetricians were named in 24% of the cases and pediatricians were named in 15% of the cases. The majority of claims were filed against physicians in the first 3 years following the medical incident alleged, according to the study, published by The Doctors Company.

The average patient payment in each case was $630,456, and the average expense to defend each claim was $157,502, according to the analysis. Claims that involved neonates had the highest average payment ($936,843) and the highest defense costs ($187,117), while claims involving children aged 10-17 years had the lowest average payment ($386,849) and cost the least to defend ($129,816).

For cases involving neonates, the type of therapy selected during labor and delivery and how it was managed were the most common factors contributing to the alleged injury, according to the analysis.

The most frequent factors contributing to patient harm for other age groups involved patient assessment issues and communication problems between the patient/family and the physician. Inadequate patient assessments were closely linked to incorrect diagnoses, while incomplete communication between patients/family members and providers impacted clinicians’ ability to make correct diagnoses, according to the study.

This analysis “shows that pediatric malpractice lawsuits impact nearly every area of medicine,” William F. Getman, MD, a pediatrician in Austin, Tex., said in an interview. “I was surprised to see that the most common age of a patient in a malpractice lawsuit was less than 1 month old. This age group also sustained the most severe injuries and had the highest indemnity paid.”

The study offers several key takeaways, including the importance of identifying system weaknesses in your medical practice and evaluating if improvements are needed, according to Darrell Ranum, vice president for patient safety and risk management for The Doctors Company.

Simple improvements, such as implementing tracking mechanisms for test results and referrals, can reduce the chance that important information falls through the cracks and delays diagnosis or treatment, Mr. Ranum said in an interview.

“When parents raise questions about their child’s complaints, this is the best opportunity to identify illnesses and conditions that represent a serious threat to children,” he said. “Prepare office staff members to know what complaints need to be evaluated by a clinician or require immediate care.”

In addition, the study findings point to the need to improve communication in all areas of the practice spectrum, Dr. Getman said.

“Many of the lawsuits could have been avoided by improvements in communication – doctor to patient, patient to doctor, doctor to nurse, doctor to doctor, nurse to patient, etc.,” he said. “Finding more effective and accurate ways to communicate will avoid mistakes, improve care, and improve outcomes. Examples of ways to improve communication include use of an interpreter when indicated, verbal and written explanations of instructions, and system improvements in tracking messages/labs/data. There are innumerable other ways to improve communication in health care.”

[email protected]

SOURCE: Ranum, D. The Doctor’s Advocate. First Quarter 2019.

 

Diagnostic error is the most common allegation against pediatricians when sued by patients and their families, a study finds.

Investigators with The Doctors Company, a national medical liability insurer, examined 1,215 closed claims involving children from the company’s database between 2008 and 2017. Results showed that diagnostic mistakes, including delayed diagnosis, incorrect diagnosis, and failure to diagnose, were the most common accusations among claims that involved children ages 1 through 17. Poor medical treatment was the second most common allegation for claims that involved children aged 1-9, while surgical treatment-related error was the second most frequent accusation for children ages 10-17.

Pediatricians, orthopedic surgeons, and emergency medicine physicians were the most frequently named specialists in claims associated with children older than 1 month. Obstetricians were most frequently defendants in claims involving neonates. For these cases, errors during labor and delivery care were the most common complaints.

Of the 1,215 claims, obstetricians were named in 24% of the cases and pediatricians were named in 15% of the cases. The majority of claims were filed against physicians in the first 3 years following the medical incident alleged, according to the study, published by The Doctors Company.

The average patient payment in each case was $630,456, and the average expense to defend each claim was $157,502, according to the analysis. Claims that involved neonates had the highest average payment ($936,843) and the highest defense costs ($187,117), while claims involving children aged 10-17 years had the lowest average payment ($386,849) and cost the least to defend ($129,816).

For cases involving neonates, the type of therapy selected during labor and delivery and how it was managed were the most common factors contributing to the alleged injury, according to the analysis.

The most frequent factors contributing to patient harm for other age groups involved patient assessment issues and communication problems between the patient/family and the physician. Inadequate patient assessments were closely linked to incorrect diagnoses, while incomplete communication between patients/family members and providers impacted clinicians’ ability to make correct diagnoses, according to the study.

This analysis “shows that pediatric malpractice lawsuits impact nearly every area of medicine,” William F. Getman, MD, a pediatrician in Austin, Tex., said in an interview. “I was surprised to see that the most common age of a patient in a malpractice lawsuit was less than 1 month old. This age group also sustained the most severe injuries and had the highest indemnity paid.”

The study offers several key takeaways, including the importance of identifying system weaknesses in your medical practice and evaluating if improvements are needed, according to Darrell Ranum, vice president for patient safety and risk management for The Doctors Company.

Simple improvements, such as implementing tracking mechanisms for test results and referrals, can reduce the chance that important information falls through the cracks and delays diagnosis or treatment, Mr. Ranum said in an interview.

“When parents raise questions about their child’s complaints, this is the best opportunity to identify illnesses and conditions that represent a serious threat to children,” he said. “Prepare office staff members to know what complaints need to be evaluated by a clinician or require immediate care.”

In addition, the study findings point to the need to improve communication in all areas of the practice spectrum, Dr. Getman said.

“Many of the lawsuits could have been avoided by improvements in communication – doctor to patient, patient to doctor, doctor to nurse, doctor to doctor, nurse to patient, etc.,” he said. “Finding more effective and accurate ways to communicate will avoid mistakes, improve care, and improve outcomes. Examples of ways to improve communication include use of an interpreter when indicated, verbal and written explanations of instructions, and system improvements in tracking messages/labs/data. There are innumerable other ways to improve communication in health care.”

[email protected]

SOURCE: Ranum, D. The Doctor’s Advocate. First Quarter 2019.

 

The severity and duration of vaccine-proximate febrile seizures (VP-FSs) are no worse than non–vaccine proximate febrile seizures (NVP-FSs), according to a study in Pediatrics.

KatarzynaBialasiewicz/Thinkstock

Lucy Deng, MBBS, of the University of Sydney and her colleagues investigated 1,022 index febrile seizures in children aged 6 years or less, of which 6% (n = 67) were VP-FSs and 94% (n = 955) were NVP-FSs. Both univariate and multivariate analyses showed no increased risk of severe seizure associated with VP-FSs, compared with NVP-FS. Most of the febrile seizures of either type were brief (15 minutes or less) and had a length of stay of 1 day or less; there also were no differences in 24-hour recurrence. The most common symptom was respiratory, and the rates were similar in each group (62.7% with VP-FS vs. 62.8% with NVP-FS). In keeping with a known 100% increased risk associated with measles vaccination, 84% of VP-FSs were associated with measles-containing vaccines. The majority of the remaining VP-FSs occurred after combination vaccines.

One limitation is that, because these cases were documented in sentinel tertiary pediatric hospitals, the case ascertainment may not be representative. Also, the small proportion of VP-FSs and limited cohort size means the study may not have been powered to detect true differences in prolonged seizures between the groups, Dr. Deng and her colleagues wrote.

“This study confirms that VP-FSs are clinically not any different from NVP-FSs and should be managed the same way,” the researchers concluded.

The authors reported no relevant financial disclosures, although Dr. Deng is supported by the University of Sydney Training Program scholarship, and two other study authors are supported by Australian National Health and Medical Research Council Career Development Fellowships. The study was funded by a grant from the Australian Government Department of Health and the National Health and Medical Research Council.

[email protected]

SOURCE: Deng L et al. Pediatrics. 2019 Apr 19. doi: 10.1542/peds.2018-2120.

 

The severity and duration of vaccine-proximate febrile seizures (VP-FSs) are no worse than non–vaccine proximate febrile seizures (NVP-FSs), according to a study in Pediatrics.

KatarzynaBialasiewicz/Thinkstock

Lucy Deng, MBBS, of the University of Sydney and her colleagues investigated 1,022 index febrile seizures in children aged 6 years or less, of which 6% (n = 67) were VP-FSs and 94% (n = 955) were NVP-FSs. Both univariate and multivariate analyses showed no increased risk of severe seizure associated with VP-FSs, compared with NVP-FS. Most of the febrile seizures of either type were brief (15 minutes or less) and had a length of stay of 1 day or less; there also were no differences in 24-hour recurrence. The most common symptom was respiratory, and the rates were similar in each group (62.7% with VP-FS vs. 62.8% with NVP-FS). In keeping with a known 100% increased risk associated with measles vaccination, 84% of VP-FSs were associated with measles-containing vaccines. The majority of the remaining VP-FSs occurred after combination vaccines.

One limitation is that, because these cases were documented in sentinel tertiary pediatric hospitals, the case ascertainment may not be representative. Also, the small proportion of VP-FSs and limited cohort size means the study may not have been powered to detect true differences in prolonged seizures between the groups, Dr. Deng and her colleagues wrote.

“This study confirms that VP-FSs are clinically not any different from NVP-FSs and should be managed the same way,” the researchers concluded.

The authors reported no relevant financial disclosures, although Dr. Deng is supported by the University of Sydney Training Program scholarship, and two other study authors are supported by Australian National Health and Medical Research Council Career Development Fellowships. The study was funded by a grant from the Australian Government Department of Health and the National Health and Medical Research Council.

[email protected]

SOURCE: Deng L et al. Pediatrics. 2019 Apr 19. doi: 10.1542/peds.2018-2120.

 

The severity and duration of vaccine-proximate febrile seizures (VP-FSs) are no worse than non–vaccine proximate febrile seizures (NVP-FSs), according to a study in Pediatrics.

KatarzynaBialasiewicz/Thinkstock

Lucy Deng, MBBS, of the University of Sydney and her colleagues investigated 1,022 index febrile seizures in children aged 6 years or less, of which 6% (n = 67) were VP-FSs and 94% (n = 955) were NVP-FSs. Both univariate and multivariate analyses showed no increased risk of severe seizure associated with VP-FSs, compared with NVP-FS. Most of the febrile seizures of either type were brief (15 minutes or less) and had a length of stay of 1 day or less; there also were no differences in 24-hour recurrence. The most common symptom was respiratory, and the rates were similar in each group (62.7% with VP-FS vs. 62.8% with NVP-FS). In keeping with a known 100% increased risk associated with measles vaccination, 84% of VP-FSs were associated with measles-containing vaccines. The majority of the remaining VP-FSs occurred after combination vaccines.

One limitation is that, because these cases were documented in sentinel tertiary pediatric hospitals, the case ascertainment may not be representative. Also, the small proportion of VP-FSs and limited cohort size means the study may not have been powered to detect true differences in prolonged seizures between the groups, Dr. Deng and her colleagues wrote.

“This study confirms that VP-FSs are clinically not any different from NVP-FSs and should be managed the same way,” the researchers concluded.

The authors reported no relevant financial disclosures, although Dr. Deng is supported by the University of Sydney Training Program scholarship, and two other study authors are supported by Australian National Health and Medical Research Council Career Development Fellowships. The study was funded by a grant from the Australian Government Department of Health and the National Health and Medical Research Council.

[email protected]

SOURCE: Deng L et al. Pediatrics. 2019 Apr 19. doi: 10.1542/peds.2018-2120.

SAN FRANCISCO – Nearly half of all childhood-onset SLE occurs in patients born during the winter months, Simone Appenzeller, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

She presented a cross-sectional study of 760 consecutive SLE patients seen in a university lupus clinic and 700 healthy controls. Ninety-eight of the lupus patients had childhood-onset disease that began no later than age 16 years, while 662 had adult-onset SLE.

Southeastern Brazil, where the study was conducted, features a mostly subtropical climate with relatively mild winters. Because it is in the southern hemisphere, winter lasts from June 21 to September 21, while spring runs from September 22 to December 20.

Forty-six percent of subjects with childhood-onset SLE were born in winter, 17% in spring, another 17% in summer, and just over 19% in autumn, according to Dr. Appenzeller, a rheumatologist at the University of Campinas (Brazil).

In contrast, the occurrence of adult-onset SLE showed no variation by birth month or season.

The birth disparity between childhood- and adult-onset SLE was greatest in August, the depth of Brazilian winter, when 15.3% of all subjects with childhood-onset SLE were born, compared with 9% of adult-onset SLE patients and 8% of healthy controls.

The explanation for the increased likelihood of patients with childhood-onset SLE to be born in the winter months probably involves a gene-environment interaction, Dr. Appenzeller said. The most likely environmental factors are low seasonal maternal vitamin D levels and/or exposure to winter respiratory infections. The existence of a genetic component to the birth month disparity is suggested by another study by the Brazilian investigators in which they determined that the prevalence of SLE in both the first- and second-degree relatives of individuals with childhood-onset SLE was significantly higher than in patients with adult-onset disease.

Dr. Appenzeller reported having no financial conflicts regarding her study, funded by the Brazilian National Council for Scientific and Technological Development and other noncommercial research organizations.

[email protected]

SAN FRANCISCO – Nearly half of all childhood-onset SLE occurs in patients born during the winter months, Simone Appenzeller, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

She presented a cross-sectional study of 760 consecutive SLE patients seen in a university lupus clinic and 700 healthy controls. Ninety-eight of the lupus patients had childhood-onset disease that began no later than age 16 years, while 662 had adult-onset SLE.

Southeastern Brazil, where the study was conducted, features a mostly subtropical climate with relatively mild winters. Because it is in the southern hemisphere, winter lasts from June 21 to September 21, while spring runs from September 22 to December 20.

Forty-six percent of subjects with childhood-onset SLE were born in winter, 17% in spring, another 17% in summer, and just over 19% in autumn, according to Dr. Appenzeller, a rheumatologist at the University of Campinas (Brazil).

In contrast, the occurrence of adult-onset SLE showed no variation by birth month or season.

The birth disparity between childhood- and adult-onset SLE was greatest in August, the depth of Brazilian winter, when 15.3% of all subjects with childhood-onset SLE were born, compared with 9% of adult-onset SLE patients and 8% of healthy controls.

The explanation for the increased likelihood of patients with childhood-onset SLE to be born in the winter months probably involves a gene-environment interaction, Dr. Appenzeller said. The most likely environmental factors are low seasonal maternal vitamin D levels and/or exposure to winter respiratory infections. The existence of a genetic component to the birth month disparity is suggested by another study by the Brazilian investigators in which they determined that the prevalence of SLE in both the first- and second-degree relatives of individuals with childhood-onset SLE was significantly higher than in patients with adult-onset disease.

Dr. Appenzeller reported having no financial conflicts regarding her study, funded by the Brazilian National Council for Scientific and Technological Development and other noncommercial research organizations.

[email protected]

SAN FRANCISCO – Nearly half of all childhood-onset SLE occurs in patients born during the winter months, Simone Appenzeller, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

She presented a cross-sectional study of 760 consecutive SLE patients seen in a university lupus clinic and 700 healthy controls. Ninety-eight of the lupus patients had childhood-onset disease that began no later than age 16 years, while 662 had adult-onset SLE.

Southeastern Brazil, where the study was conducted, features a mostly subtropical climate with relatively mild winters. Because it is in the southern hemisphere, winter lasts from June 21 to September 21, while spring runs from September 22 to December 20.

Forty-six percent of subjects with childhood-onset SLE were born in winter, 17% in spring, another 17% in summer, and just over 19% in autumn, according to Dr. Appenzeller, a rheumatologist at the University of Campinas (Brazil).

In contrast, the occurrence of adult-onset SLE showed no variation by birth month or season.

The birth disparity between childhood- and adult-onset SLE was greatest in August, the depth of Brazilian winter, when 15.3% of all subjects with childhood-onset SLE were born, compared with 9% of adult-onset SLE patients and 8% of healthy controls.

The explanation for the increased likelihood of patients with childhood-onset SLE to be born in the winter months probably involves a gene-environment interaction, Dr. Appenzeller said. The most likely environmental factors are low seasonal maternal vitamin D levels and/or exposure to winter respiratory infections. The existence of a genetic component to the birth month disparity is suggested by another study by the Brazilian investigators in which they determined that the prevalence of SLE in both the first- and second-degree relatives of individuals with childhood-onset SLE was significantly higher than in patients with adult-onset disease.

Dr. Appenzeller reported having no financial conflicts regarding her study, funded by the Brazilian National Council for Scientific and Technological Development and other noncommercial research organizations.

[email protected]