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April 2010
Mission: To provide pediatricians with timely synopses and critiques of important new studies relevant to
pediatric practice, reviewing methodology, significance, and practical impact, as part of ongoing CME activity.
YOUNG PHYSICIANS
Commentary by
PICO
esearchers from the University of California, Berkeley,
Question: Among impoverished families in
Mexico participating in a conditional cash
the Instituto Nacional de Salud
transfer program, what are the long-term
Pblica, Cuernavaca, Mexico, and the
(10-year) effects?
Micronutrient Initiative in Ottawa
Question type: Intervention
performed a 10-year follow-up study
Study design: Case control follow-up study
to assess the effect of Oportunidades,
Mexicos multi-ministry conditional
cash transfer (CCT) program. Oportunidades was initiated in 1998 to provide
cash payments (20%-30% increase of household incomes) to impoverished families on the condition that they participate in health education, receive preventive
services, and comply with scholastic enrollment for age-appropriate children. At
the initiation of the program low-income communities were randomly assigned
for immediate enrollment or enrollment 18 months later. An initial follow-up
study 3.5 to 5 years after the program started showed improved height in the
children and gains in both cognitive and language development.1 For the current study, the effects of the dose of the program were assessed by comparing
outcomes in children who were enrolled in the program either early or late,
and by assessing the association of the amount of cash transfer with outcomes.
Outcome measures included physical growth, cognition and language development, and socio-emotional development. The study was conducted in 2007,
when the participants were 8 to 10 years old.
Data were analyzed for 1,093 children from the early enrollment group and
700 from the late enrollment group. There were no differences between enrollment groups in height-for-age z score, BMI-for-age z score, cognitive scores,
or language assessment scores. However, children randomly assigned to early
treatment had fewer maternal-reported
behavior problems than those in the late
treatment group. The amount of cumulaINSIDE
tive cash that was transferred to participating households at the 10-year assessment
Pre-Op Skin Prep: ChlorhexidineAlcohol vs Povidone-Iodine
(median, approximately $4,000) was asHerpes Zoster Following Varicella
sociated with high verbal and cognitive
Vaccine
scores, decreased maternal reporting of
Emergency Contraception
behavior problems, and higher height-forGuidelines: Individual Values &
age z scores in all households. Early enrollAdherence
ment in the program was associated with a
Childhood Predictors of Adult Type
2 Diabetes
1.5 cm increase in height in study children
Acanthosis Nigricans: Cutaneous
whose mothers did not have formal eduMarker of Metabolic Abnormalities
cation, but this was not seen in children
Pediatric Melanoma:
whose mothers were educated. Controlling
One Institutions Experience
for individual, parental, and household
With 150 Patients
characteristics, state of residence, and
Extremity Surgery in Ambulatory
Children with CP
Andi L. Shane, MD, MPH, MSc, FAAP, Emory University School of Medicine,
Atlanta, GA
Dr Shane has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
A 2007 review of six cash transfer programs in Mexico, Nicaragua, Colombia, Honduras, Brazil, and Malawi found that all increased the short-term use
of health services and improved anthropometric and nutritional parameters
among enrollees.2 Some methodological problems limited outcome assessment of the contributions of different aspects of each of the programs. The
cost-effectiveness of programs in severely resource-limited settings as well
as a paucity of data on the optimal size of cash transfer to achieve the desired
outcome remain problematic.
In 2006 Mayor Bloomberg of New York City initiated a privately funded
program (Opportunity NYC Family Rewards) based on the cash transfer model
of Oportunidades to impact child education, family health, and adult workforce
outcomes. This is the first CCT program in the US and is active in six communitybased organizations within the South Bronx, East and Central Harlem in Manhattan, and Brownsville and East New York in Brooklyn. A projected period of
five years will be required to completely assess the impact of the interventions.3
Editors Note
Poverty is a root cause of health disparities and the CCT is one approach to
overcoming this handicap. In a 2008 article these same authors outlined the program in more detail.1 Only a fifth of the mothers and fathers had not completed
any schooling; families owned a small amount of land and most owned small
animals; one-third had piped water; and three quarters had electricity. Families
received a maximum of $59/month/child for a minimum of three years, plus
food supplements for pregnant and lactating mothers and for children up to 24
months, and for those of low weight up to 5 years. Families received cash on the
conditions that the pregnant women receive prenatal care, birth attendance, and
post-partum care; that children receive regular medical check-ups and attend
school; and that men be seen for prevention and control of hypertension and
diabetes. The authors report that a doubling of the cash transfer resulted in an
increase in height-for-age, lowering of stunting, decrease in BMI, and improvement in both short-term and long-term memory and in language development.
References
The AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving
all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.
All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationship or any financial
relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in CME activities.
Commentary by
The finding of reduced surgical-site infection with chlorhexidinealcohol skin preparation compared to povidone-iodine has been
demonstrated previously with skin preparation cleansing prior to
placement of vascular catheters, where usage of chlorhexidine was
reported to reduce the incidence of catheter site infection by 50%.2
As noted by the study authors, the marked decrease in surgical-site
infections with chlorhexidine-alcohol may be multifactorial and
attributable to faster and longer-lasting antiseptic action, shorter
38
Editors Note
Previous studies have demonstrated that the addition of alcohol
increases the effectiveness of chlorhexidine as measured by microbiological endpoints.4 This study is an important addition to the literature in that the increased efficacy is demonstrated using the clinical
outcome of surgical-site infection. There is microbiological evidence
to suggest that alcohol also increases the efficacy of iodophors.4 A
comparison between chlorhexidine-alcohol and iodophor-alcohol
would be of great interest. Because of the role of the manufacturer
in the study, and presumably the choice of comparison groups, we
wonder if the study design foretold the outcome that is, apples to
crabapples, not apples to apples.
References
1.
2.
3.
4.
www.aapgrandrounds.org
INFECTIOUS DISEASES
Editors Note
An important methodologic limitation of this study is that the case
confirmation process was based on medical record review by one author using prespecified criteria. This process resulted in rejection of
40% of the cases that had been identified electronically. If a substantial proportion of the rejected cases were actually HZ, the incidence
rate could be a good bit higher. Nevertheless, it is important to recall
that HZ, although often minimally symptomatic in children, may
be associated with significant pain, disability, and dissemination in
adults as well as the immunocompromised.5 Thus any decrease in its
frequency should be welcomed by both pediatricians and internists.
The two-dose varicella vaccination schedule, recommended since
2006, resulting in an enhanced immune response and greater efficacy
for disease prevention,6 promises even greater reduction of HZ in the
coming decades. We eagerly await studies to confirm this hypothesis.
References
1.
2.
3.
4.
5.
6.
Commentary by
39
ADOLESCENT HEALTH
Commentary by
Editors Note
Some physicians may feel that it compromises their integrity to
participate in clinical activities they consider to be immoral, even
if those activities are dictated by clinical guidelines. Perhaps the
most striking finding in this study is that a residents willingness to
prescribe EC (termed intention to prescribe) was highly associated
with having a faculty preceptor encourage this treatment. While
these residents did not likely change their moral views on the treatment itself, it is possible that this educational interaction reminded
the resident that they have another moral duty: to respect a patients
request for medically appropriate treatments. Regardless of our own
personal values, those of us involved in precepting pediatric residents
should look for opportunities to discuss how to ensure timely access
to EC, consistent with published guidelines, to patients in our care.
The challenge to conscience should not be minimized, but faced
with a tension between our own moral qualms and the welfare of the
patient, our first duty should be the welfare of the patient.
References
1.
2.
3.
4.
In the US, approximately one half of all pregnancies are unplanned. Reducing teenage pregnancy is a national health priority,
and teenage pregnancy has been declining over the past 10 years,
40
www.aapgrandrounds.org
MEDICINE-PEDIATRICS
o determine childhood
PICO
predictors of adult type
Question: In a general pediatric population,
2 diabetes (T2DM), recan standard office and laboratory measures
or questions predict future development of
searchers in Cincinnati evalutype 2 diabetes mellitus?
ated longitudinal data from two
Question type: Diagnosis
studies: the Princeton Follow-up
Study design: Prospective cohort study
Study (PFS), a 22- to 30-year
follow-up of former school children initially enrolled between 6 to 18 years of age, and the National
Growth and Health Study (NGHS), a cohort study of girls enrolled at
9 to 10 years of age followed up at nine years after enrollment. PFS
study office measurements included body mass index (BMI), systolic
blood pressure (SBP), and diastolic blood pressure (DBP). Parental
history of diabetes was recorded, and serum triglycerides, highdensity lipoprotein cholesterol (HDLC), and fasting glucose levels
were measured. Waist circumference and insulin were measured
only during follow-up in PSF, but not in the initial sampling. In the
NGHS study each participant had BMI, SBP, DBP, and fasting lipid
profile measured at age 10 and waist circumference at age 11. Fasting
insulin and glucose were measured at ages 10, 15 to 16, and 19 years.
Diabetes was defined by a fasting glucose of >126 mg/dL. PFS and
NGHS subjects whose first measured fasting blood glucose was >126
mg/dL or who were on insulin were excluded.
Of 822 participants enrolled in the PFS study, 40 were found to
have glucose concentrations 126 mg/dL at follow-up at age 39 years
(4.9%). The incidence of T2DM was greater for African-American
women (9.9%) than for Caucasian women (4%; P=.02). The officebased measures significantly associated with the development of
T2DM were BMI and SBP >95th percentile for age and parental history of diabetes mellitus. Laboratory measurements associated with
the development of T2DM included blood glucose of at least 100 mg/
dl and a triglyceride level in the top 5th percentile for age. When BMI,
SBP, and DBP were all lower than the 75th percentile and there was
no parental history of diabetes mellitus, the likelihood of developing
T2DM at 22 to 30 years follow-up was 1.4%. Childhood BP and BMI
in the top 5th percentile when combined with either a fasting glucose
100 or a triglyceride level in the top 5th percentile were the best
predictors of developing T2DM.
At the nine-year follow-up of the original 1,067 girls (median age
19.2 years) in the NGHS study, T2DM was present in eight participants (0.75%). SBP in the top 5th percentile for age, fasting insulin
level in the top 5th percentile, and a HDLC level in the bottom 5th
percentile were each associated with an increased risk of developing
T2DM. When childhood BMI, SBP, DBP, and fasting insulin levels
were all lower than the 75th percentile and there was no parental
diabetes, the likelihood of developing T2DM at age 19 years was
0.3%. SBP in the top 5th percentile, history of parental DM, and fasting insulin levels in the top 5th percentile were the best predictors of
developing T2DM.
AAP Grand Rounds April 2010
Commentary by
Katrina Johnson, MD, and Marc A. Raslich, MD, FAAP, Internal Medicine
and Pediatrics, Wright State University Boonshoft School of Medicine,
Dayton, OH
Drs Johnson and Raslich have disclosed no financial relationship relevant to this commentary. This commentary does
not contain a discussion of an unapproved/investigative use of a commercial product/device.
Key words: anthropomorphic measurements, type 2 diabetes mellitus, childhood risk factors
41
DERMATOLOGY
canthosis nigricans
PICO
(AN) is a skin disorder
Question: Among youth with acanthosis
typically characterized
nigricans, is there an increased risk of
by symmetric hyperpigmented
metabolic abnormalities?
velvety plaques on the posterior
Question type: Diagnosis
neck, bilateral axillae, and flexStudy design: Cross-sectional,
observational study
ural surfaces of the upper and
1
lower extremities. Commonly
seen in obese children, adolescents, and adults, AN is considered a
potential cutaneous marker of underlying insulin resistance and is
one of the criteria proposed by the American Diabetes Association for
identifying children at risk for developing type 2 diabetes mellitus.2,3
Investigators from Childrens Memorial Hospital and Northwestern University in Chicago sought to determine the prevalence of abnormal glucose homeostasis and cardiovascular risk factors in youth
with AN. Youth aged 8 to 14 years with and without neck AN were
recruited from urban community pediatric offices. Enrolled youth
without AN were required to have a body mass index (BMI) z score
>85th percentile and served as a comparison group. Demographic
information, anthropometric measurements including BMI z score,
blood pressure, neck AN score based on a validated scoring system,4
Tanner stage, oral glucose tolerance test (fasting glucose and insulin
levels followed by glucose and insulin levels obtained 120 minutes after a glucose load of 1.75 g/kg), HgbA1c, glutamic acid decarboxylase
antibody, and fasting lipid profile were obtained for each participant.
Abnormal glucose homeostasis was defined as any combination of
impaired fasting glucose, impaired glucose tolerance, or diabetes
mellitus on the basis of fasting or stimulated results. Homeostasis
model assessment of insulin resistance (HOMA-IR) was calculated
for each study patient.
Compared to those without AN (n=51; 65% Hispanic, 22%
African American), the children with AN (n=236; 60% Hispanic,
30% African American) were more likely to be female, have lower
maternal education, be in later stages of puberty, and have higher
BMI z scores. Compared to those without AN, youth with AN were
more likely to have abnormal glucose homeostasis (29% vs 12%;
P=.044), systolic blood pressures >95th percentile for age (27% vs
14%; adjusted P=.30), and high density lipoprotein cholesterol 5th
percentile (50% vs 35%; adjusted P=.09). After adjusting for sex,
maternal education, pubertal status, and BMI z score, the presence
of AN remained significantly associated with higher stimulated
2-hour glucose concentrations, abnormal glucose homeostasis, and
higher markers of insulin resistance. On multivariate analyses, risk
factors associated with the presence of impaired glucose tolerance in
children with AN included female sex, insulin resistance, and positive
glutamic acid decarboxylase antibodies.
The investigators conclude that the presence of AN in children 8
to 14 years of age is associated with significant insulin resistance and
42
Commentary by
www.aapgrandrounds.org
SURGERY
Commentary by
Historically, the vertical thickness of the primary tumor and the anatomic depth of invasion are the principle measures in local tumor classification of melanoma staging. Sentinel lymph node biopsy (SLNB)
is a methodology increasingly used to stage melanoma. In the current
study this procedure was performed in only 18 of the 150 patients, all
since the year 2000.1 Blue dye is injected intradermally at the site of
the primary melanoma and allowed to be taken up by the lymphatics
which then show that the first blue node in the regional lymphatic basin
is the node that should contain a metastasis if any tumor is present.
This node is termed the sentinel lymph node. The regional lymphatic
basin can also be identified by injecting technetium 99m-labeled colloid intradermally at the primary site and then performing lymphatic
mapping with a hand-held gamma probe intraoperatively.
With accurate diagnosis, the outcomes for pediatric melanoma
are very good, with published five-year survival rates of 74% to 89%.
Melanoma survival rates among children have continued to improve
by 4% per year over the last 30 years. In addition, despite higher rates of
positive SLNB, children and adolescents have a lower incidence of recurrence and improved disease-free survival when compared to adults.1,4
References
1.
2.
3.
4.
EDITORIAL BOARD
Editors-in-Chief
Leslie L. Barton, Tucson, AZ
Edgar K. Marcuse, Seattle, WA
Consulting Editors
Douglas Diekema, Seattle, WA
Tom Newman, San Francisco, CA
William V. Raszka, Jr., Burlington, VT
James A. Taylor, Seattle, WA
Editorial Board
Burris R. Duncan, Tucson, AZ
Joseph Geskey, Hershey, PA
Ronald D. Holmes, Littleton, CO
Daniel R. Neuspiel, Charlotte, NC
Lane S. Palmer, New Hyde Park, NY
Vasundhara Tolia, Bloomfield Hills, MI
Patty Vitale, Clementon, NJ
Marcia Wofford, Clemmons, NC
CME Question Editor
William V. Raszka, Jr., Burlington, VT
43
ORTHOPAEDICS
Commentary by
44
You can complete and claim credit for all of your quizzes
online. Visit the AAP Grand Rounds CME Center at
www.aapgrandrounds.org.
www.aapgrandrounds.org
NEUROLOGY
Commentary by
45
Commentary by
1. Alter J. All Umbrage All the Time. Newsweek. July 28, 2008.
2. Moreno M, et al. Arch Pediatr Adolesc Med. 2009;163:27-34.
3. Moreno M, et al. Arch Pediatr Adolesc Med. 2009;163:35-40.
Dr Shifrin has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.
Although this study was limited by the lack of student involvement, it should serve as a cautionary tale to those unfamiliar with
this generation of students who share their lives online. The postings
highlighted by this survey suggest that the boundaries between private and public spaces have been all but eliminated. That three deans
reported having expelled students as a result of online postings is
46
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CME QUESTIONS
CME OBJECTIVES
a. Incidence rates gradually decrease each year in the first four years
after vaccination
b. Incidence rates gradually increase each year in the first four years
after vaccination
c. Incidence rates remain the same each year in the first four years
after vaccination
a. Age of patient
b. Depth of lesion greater than 2.2 mm
c. Location of lesion
d. Male sex
e. Presence of metastatic disease
8. An 11-year-old girl with spastic diplegia is brought to the physician for a
health care supervision visit. She uses crutches at school to go between
classes. If she undergoes a lower extremity surgical procedure to improve function, which of the following outcomes is most likely?
a. If she has surgery now, she will never need surgery as an adult
b. She will be able to compete in sports that she couldnt do before
c. She will have a clinically important improvement in her some of her gait
parameters
d. She will no longer need to use crutches
e. The surgery will keep her from needing a wheelchair as an adult
9. A 3-year-old boy is brought to the physician for a health care supervision visit. He has had many generalized seizures. He has delayed speech,
abnormal tone, hyperactive behavior, and an unusual gait. Angelmans
syndrome is suspected. Which of the following is most likely to be found
in this patient?
a. Aggressive behavior
b. Large testes
c. Normal EEG
d. Paternal chromosomal deletion
e. Seizures refractory to treatment
a. Faculty member
b. Non-faculty staff
c. Parent
d. Patient
e. Student
9. e
10. e
7. e
8. c
a. Cushing Disease
b. Ewing sarcoma
c. Hypercalcemia
d. Insulin resistance
e. Melanoma
5. a
6. d
Describe the incidence rate of herpes zoster following varicella vaccination in young
children
3. b
4. a
Compare and contrast the risk of surgical-site infections following skin preparation
using either 2% chlorhexidine gluconate and 70% isopropyl alcohol or 10%
povidone-iodine
Answers:
1. e
2. d
47
Editorial
48
References
Erratum
There isnt a published medical study that someone, somewhere, couldnt find legitimate fault with. Thats the nature of human biology. However, we cant let that paralyze us into inaction,
because every day we need to make clinical decisions weighing
the best evidence, our own experience, and incorporating our
patients and their families values and preferences.
I love to learn by talking through ideas, but hate talking to
myself! I look forward to talking with you online, learning from
your experiences, and exchanging ideas. Well also have room for
some lighthearted moments as well such as the connection
between rhinotillexomania and ordering diagnostic tests!
I look forward to meeting you all via Evidence eMended. All
the articles for the month will be listed, with links to the originals
or to the PubMed citation. Ill be posting a blog entry at least
weekly for each AAP GR issue, so be sure to check in throughout
the month. Please join me at www.GrandRoundsBlog.org.
Talk with you soon, on line!
CME INFORMATION
AAP Grand Rounds is an educational publication. The American Academy of Pediatrics is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
The American Academy of Pediatrics designates this educational activity for a maximum of 18
AMA PRA Category 1 Credits or 1.5 AMA PRA Category 1 Credit per issue. Physicians should
only claim credit commensurate with the extent of their participation in the activity.
This activity is acceptable for up to 18 AAP credits. These credits can be applied toward the
AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of
Pediatrics.
This program is approved for 18 NAPNAP contact hours; pharmacology (Rx) contact hours to
be determined per the National Association of Pediatric Nurse Practitioners Continuing Education
Guidelines.
A CME Quiz Sheet can be found in the new CME Activity Center at www.aapgrandrounds.org.
The deadline for submitting the 2009 quiz sheet for 2009 credit is January 31, 2010.
This is a scientific publication designed to present updates and opinion to health care professionals. It does not provide medical advice for any individual case, and is not intended for the layman.
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