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Clinical ShowCase™: Developing a Personalized Treatment Plan for a Patient with Sickle Cell Disease

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Health care leaders are on notice that physicians, support staff, and patients deserve and expect care settings free from violence.

The U.S. Centers for Medicare & Medicaid Services’ (CMS) 

Center for Clinical Standards and Quality

“Exposure to workplace violence hazards come at a high cost; however, with appropriate controls in place, it can be addressed,” the notice said. “CMS will continue to enforce the regulatory expectations that patient and staff have an environment that prioritizes their safety to ensure effective delivery of healthcare.”

Because of the risk, health care leadership must ensure adequate training, sufficient staffing levels, ongoing assessment of patients and residents for aggressive behaviors, and appropriate care interventions and environment. CMS acknowledged Medicare-certified hospitals already have a regulatory obligation to care for patients in safe settings under current Medicare Hospital Conditions of Participation.

“The intention of this requirement is to specify that each patient receives care in an environment that a reasonable person would consider safe,” with standards ranging from infection control to security that affect emotional and physical health and safety, the memo said.

The Nov. 28 memo sent to state survey agency directors included statistics and examples of workplace violence involving clinicians who face risk factors such as working with people who have a history of aggressive behavior, behavioral issues, or are under the influence of drugs.

An April 2020 facts sheet by the U.S. Bureau of Labor Statistics reported health care workers accounted for 73% of all nonfatal workplace injuries and illnesses due to violence in 2018. That number has grown steadily since tracking began in 2011.

In the latest memo, CMS said hospitals must:

Identify patients at risk for intentional harm to themselves or others.

Identify environmental safety risks, such as ligatures, sharps, access to medications, breakable windows, light fixtures, plastic bags, oxygen tubing, and more.

Take steps to minimize risks, while noting not all strategies are appropriate for all units. For example, strategies for a post-partum unit most likely would not be the same as those in an emergency department.

Implement training for new staff, with ongoing training recommended at least every two years.

Maintain an emergency preparedness plan that accounts for facility risks, community risks, and all hazards.

Workplace violence in hospitals can lead to dire consequences. CMS used examples from facilities that were cited for failing to meet safety obligations:

A nurse in a unit without adequate staffing was sexually assaulted by a behavioral health patient who was stopped by other patients.

A patient died when staff and law enforcement officers performed a takedown that resulted in a custodian holding down the patient on the floor with his knee on the patient’s back.

A patient who was acting out, was shot in a hospital room by police officers when hospital staff failed to assess the patient and de-escalate the situation.

“These cases highlight systemic failures in facilities that place both patients and staff at risk,” the CMS memo said.

The CMS memo is the latest to shine light on the problem and 

 this year began including workplace safety measures among its criteria for evaluating and credentialing hospitals.

 all have condemned aggression toward medical staff. At least two bills have been introduced in Congress to bolster 

 for physicians, nurses and support staff.

This article was published by our sister publication Medical Economics.

Articles

CMS publishes memo to reinforce safety standards for physicians, support staff, and patients.

Hospitals on notice about adding measures to curb growing problems of workplace violence

Congenital hypopigmented macules on a healthy child

You are asked to evaluate an African American boy aged 4 years with a birthmark on his back and right arm. He is healthy with normal growth and development. What's the diagnosis?

Roflumilast cream safe, effective for atopic dermatitis in children 6 years and up

Recently announced data from the INTEGUMENT-1 phase 3 clinical trial demonstrated positive safety and efficacy results for atopic dermatitis patients 6 years and older treated with roflumilast cream (Arcutis Biotherapeutics).

Pfizer announces positive phase 3 data for RSV vaccine

Pfizer announced positive data from a phase 3 trial on a bivalent RSV vaccine.

You are asked to evaluate a healthy 1.5-day-old girl who has a congenital red patch with coarse telangiectasias and a surrounding ring of pallor on the right shoulder. What's your diagnosis?

Facial birthmark and new-onset seizures in infant

The parents of a 3-month-old girl seek medical advice regarding recent seizures and a facial birthmark. What’s the diagnosis?

Does stimulant medication for pediatric ADHD affect adult height?

A recent review found that multiple clinical trials indicated a reduction in adult height potential for children with long-term use of stimulant medication for treatment of ADHD, but other studies conflict with this data.

COVID-19 vaccine effective in adolescents

A real-world study determined the efficacy of mRNA vaccines for protection against COVID-19 in adolescents.

Increased neurologic involvement from COVID-19 in 2021

In a recent study, investigators found that life-threatening neurologic conditions from severe acute COVID-19 were more frequent in 2021 than 2020.

AAP: How to manage the surge of respiratory infections

In a recent statement, the American Academy of Pediatrics discussed how patients with respiratory infections can be managed, along with guidance on RSV treatment.

RSV, influenza, and COVID-19: Gearing up for the threat of a 'triple epidemic'

Tina Q. Tan, MD, FAAP, FIDSA, FPIDS, sits down to discuss the rising threat of a "triple epidemic" consisting of influenza, COVID-19, and RSV in children.

November’s news roundup

Childhood cancer survivors with public health insurance will face more barriers for transferring to adult-oriented care, according to a recent study.

Adolescents and young adults (AYAs) face an increased risk for late effects of childhood cancer after surviving the disease, such as cerebrovascular accidents, congestive heart failure, and cognitive deficits. This has led to recommended follow-up care annually to treat effects and risk of effects.

Care for childhood cancer survivors is provided by subspecialists such as pediatric oncologists, eventually shifting to adult cancer centers or primary care. However, this transition is only seen in 1/3 of survivors, and less than 20% of survivors receive adult-oriented care, which includes education on managing the risk of follow-up effects.

The follow-up effects in childhood cancer survivors are also impacted by health disparities caused by socioeconomic factors, race, and age. This affects the quality of long-term treatment. Investigators sought to analyze how these factors impact goals, expectations, and beliefs for transition.

To evaluate the association between sociodemographic factors and expectations for transition into adult-oriented care, investigators conducted a longitudinal randomized controlled trial. Pediatric patients were recruited into the study, completed baseline measures, and received care at a pediatric center.

Patients were included if they were aged 15 to 29 years, had received cancer treatment at a pediatric cancer center, were in remission at the time, had the cognitive ability to complete the study procedures, and were receiving follow-up care at a pediatric care center.

Liquid cancer diagnoses had been given to 54% of patients, solid tissue diagnoses to 37.4%, and brain tumor diagnoses to 8.7%. Patients were aged an average of about 10 years when diagnosed, and time off treatment for AYAs was an average of 8.17 years. 

About 7.7% of patients’ primary insurance was public insurance, and 9 users of private insurance had received it through school or work. For work status, 33% of participants worked part time, 10.3% full time, 7.2% were part-time students, and 75.2% were full-time students.

AYAs lived with caregivers 86% of the time, while 1.5% lived alone, and the rest lived with a roommate or friend. Of the primary caregivers, 15% were the sole caregiver.

Data was gathered on patients’ race and ethnicity, primary caregiver education, primary caregiver partnered status, insurance type, and home address. Home address was used to measure neighborhood income, with the median neighborhood income used for the study.

A Transition Readiness Inventory (TRI) was used to determine AYAs goals, expectations, and beliefs on transition. A Health Competence Beliefs Inventory was used to determine participants’ health perceptions, satisfaction with healthcare, autonomy, and cognitive competence.

TRI responses were not affected by sociodemographic factors. Health competence beliefs and transition readiness were instead impacted by insurance type. Participants with public insurance had lower transition goals and overall healthcare satisfaction than those with private insurance. Health competence beliefs and transition expectations were significantly associated.

As participants with public insurance had lower health competence beliefs and therefore lower transition goals, expectations, and beliefs, investigators concluded that public insurance is a barrier to positive expectations for transition.

Prussien KV, Barakat LP, Darabos K, Psihogios AM, King-Dowling S, O’Hagan B. Sociodemographics, health competence, and transition readiness among adolescent/young adult cancer survivors. 

. 2022;47(10):1096–1106. doi:10.1093/jpepsy/jsac039

In a recent study, it was found that individuals with public health insurance had worse health competence beliefs, reducing transition goals, expectations, and beliefs.

How public insurance creates barriers for childhood cancer survivors

A recent study found no significant relationship between atopic dermatitis (AD) severity, as measured by patient-oriented scoring of 

 (PO-SCORAD) and Patient Oriented Eczema Measure (POEM) surveys, and peanut sensitivity.

 through Immunoglobulin E (IgE) or skin prick test levels. The study was led by Sara Bilimoria, MD, of the Northwestern University Feinberg School of Medicine.

The investigators noted that AD was a primary risk factor for the developing food sensitisation and IgE-mediated food allergies, which prompted further examination in the study itself. The study population was acknowledged to be smaller and consequently the subject may warrant further research.

“Despite no significant relationship found between PO-SCORAD or POEM score and peanut sensitivity, the hypothesis that AD severity can predict risk of peanut sensitivity may still be valid based on a growing body of evidence,” Bilimoria and colleagues wrote. “The negative results of this study are likely due to the small study population used due to limitations of the COVID-19 pandemic. Moreover, evaluating AD severity through PO-SCORAD and POEM surveys may not be ideal for pediatric patients.”

The investigators recruited study participants between the ages of 3 months and 18-years-old without a previous diagnosis of peanut allergy who were receiving IgE or skin prick testing for peanut allergies. They were pulled from 2 allergy clinics around the Chicago area, with participants or their guardians filling out both a PO-SCORAD survey and a POEM survey.

The PO-SCORAD score is determined 60% through clinical signs and 20% through participants’ subjective symptoms, and possible PO-SCORAD scores can be anywhere from 0 to 83, with 83 being the highest 

The POEM is made up of 7 questions asking about the frequency of AD-related itch, sleep disturbance, cracked skin, weeping, bleeding, oozing, flaking, and dryness within the past week, with a score range of 0 to 28. A 0 points to being clear or almost clear of AD, whereas a score ranging from 25 to 28 points to significant AD severity.

The study reported that 20 total patients were able to meet inclusion criteria in their required time frame, with the mean age of patients recruited being 19.9 months.

The researchers found no significant difference between sexes or age categories in severity of AD as assessed by POEM or PO-SCORAD scores (≥12 months compared to <12 months). They also did not identify a significant relationship between PO-SCORAD or POEM scores and the rate of peanut sensitivity.

The investigators stress that the study’s negative results may be due to the smaller population tested, which they connected to COVID-19 pandemic limitations.

“If providers continue to use the (National Institute of Allergy and Infectious Disease)’s guidelines to direct their clinical decisions, it is crucial to identify those at highest risk of epicutaneous exposure and subsequent peanut allergy by using a tool to objectively evaluate AD severity,” they wrote. “At the same time, recent consensus guidelines…recommend introducing peanuts into children's diets at 6 months of age, irrespective of their baseline risk, as the potential benefit of introducing peanuts early outweighs delayed peanut introduction.”

Evaluating the predictive utility of patient-oriented scoring of atopic dermatitis (PO-SCORAD) versus Patient-Oriented Eczema Measure (POEM) for peanut sensitivity in patients with atopic dermatitis

Journal of the European Academy of Dermatology and Venereology

This article was published by our sister publication HCP Live.

Research suggested no significant relationship between peanut sensitivity and AD severity as measured by two scores, although the study was acknowledged to have a smaller population due to pandemic restrictions.

Study finds no significant link between atopic dermatitis severity scores, peanut sensitivity

Alex, an 18-year-old male, presented to the emergency department with a 4-day history of paranoia, agitation, and disorganized behavior. He had no psychiatric history or prior mental health contact and no known medical conditions.

Alex was admitted to the psychiatry unit due to agitation and violent behavior in the context of new-onset psychosis. In the week leading up to his hospitalization, he had attempted to assault family members and punched holes in the walls. He believed that his father had hacked into his bank account and had been responsible for starting the COVID-19 pandemic. Alex had been sleeping approximately 4 hours per night. Concerned about his escalating agitation, his parents called for EMS to take him to the hospital to be evaluated. Alex had been working out regularly, using pre-workout supplements and occasional marijuana. He had no previous mental status changes, functional decline, or psychiatric contact.

On examination, he appeared afraid and was posturing and yelling loudly. He had no visible lesions, track marks, or skin rashes. Overall, his physical examination was unremarkable. He was tachycardic to 110 bpm, with a temperature of 101 °F and blood pressure within normal limits.

Due to sudden new-onset mental status changes, a workup for reversible causes of mental status change was performed. A CT scan of his head was unremarkable, and laboratory testing was negative for infectious etiologies, malignancy, or thyroid disease. Urine toxicology was positive for marijuana. Alex was seen by internal medicine and psychiatry in the emergency department, from where he was medically cleared, and subsequently admitted to the psychiatry unit on an involuntary basis owing to psychosis and violent behavior.

The differential for new-onset psychosis in an adolescent is broad and can be divided into psychiatric and nonpsychiatric causes. Psychiatric illnesses that present with psychotic symptoms include depression or bipolar disorder, schizophrenia, schizoaffective disorder, and brief psychotic illness. Alex’s presentation is less typical of primary psychotic illness because it had an abrupt onset. Other differentials include metabolic abnormalities, infectious etiologies, malignancy, and substance use (

Table 1. Differential Diagnosis

Upon admission to the inpatient psychiatry unit, Alex was started on oral risperidone due to his level of distress regarding his psychosis. On day 2 of hospitalization, the inpatient psychiatry team spoke with him and his mother and screened him for possible ingestions or changes in behavior. For the past 4 months, Alex had been working out regularly and had begun using a pre-workout supplement powder containing caffeine, branched-chain amino acids, vitamins, and minerals. Two weeks before presentation, he had begun dry scooping (consuming without diluting in water) pre-workout supplement, which is a trend on Tik-Tok. He was consuming up to 2 scoops at a time, which equals 800 mg caffeine. He had used marijuana socially for the previous 3 years, but neither his frequency of use nor supplier had changed during the previous year.

One month after hospitalization, Alex’s mother reported that he had no periods of disorganized thoughts, anger, or paranoia. After discharge, he had stopped all supplements, marijuana, caffeine, and risperidone. At a 3-month follow-up visit, both he and his mother denied that he was having mood or psychotic symptoms. Alex’s cannabis use may have been a contributing factor, but because he had been using cannabis 1 to 2 times per month for 3 years before presentation and there had been no changes in the frequency and quantity of his use or in his supplier, we felt that his psychosis was attributable to dry scooping the pre-workout supplement.

Alex developed substance-induced psychosis in the setting of dry scooping a pre-workout supplement, a trend circulating on TikTok. Pre-workout supplements are sold over the counter and used to enhance anaerobic exercise performance by decreasing fatigue and increasing endurance.

These supplements contain caffeine, amino acids, B vitamins, and other additives. Case reports and review articles have implicated caffeine as a trigger for psychosis,

 and we believe this resulted in Alex’s presentation.

Only 8% of TikTok videos involving pre-workout supplements show people consuming the supplements according to the instructions.

 Cases of cardiac strain and arrhythmia secondary to pre-workout supplement use have been reported,

 but to our knowledge, this is the first report of a person who developed pre-workout supplement–induced psychosis. Overall, the regulation of these supplements is limited, and active ingredients can vary. Due to ease of access, uncertainty of ingredients, and the possible physical and mental health consequences of use, physicians, teachers, and family members should consider counseling young adults on the risks of pre-workout supplement use. We had discussions with Alex and later with him and his mother and recommended talking about social media trends with physicians during routine health maintenance visits.

In addition to dry scooping pre-workout supplements,

 there are many other potentially dangerous trends circulating on TikTok. The “Benadryl challenge” encourages viewers to take at least 12 tablets of Benadryl (a total of more than 300 mg) and stay awake to hallucinate,

 and there have been numerous reports of adolescents requiring hospitalization afterwards.

 L-tyrosine, an over-the-counter amino acid, has been promoted on TikTok as a “natural Adderall” to improve energy and focus.

 Videos also encourage the use of 5-HTP, a naturally occurring amino acid the body uses to create serotonin, to curb appetite and improve sleep and mood.

 Some TikTok users also encourage the consumption of large quantities of nutmeg to induce hallucinations.

 for other TikTok trends that may impact adolescent mental health. Although some social media trends may decrease the stigma surrounding mental health through discussion and normalization, many trends may promote self-diagnosis and self-treatment.

Table 2. Dangerous TikTok Trends 

As the use of social media sites becomes increasingly common among teenagers, health care providers must be aware of the potential spread of misinformation via these sites. TikTok in particular is an algorithm-based platform where users share brief videos with keywords, or hashtags. “Fitness and sports” is now the fourth most popular hashtag.

 Within this category, people share tips on diet and exercise, like dry scooping pre-workout supplements, weight-loss changes, meal plans, and related matters. Rapid and accessible dissemination of information, opinions, and trends through social media platforms may result in the spread of misinformation, self-diagnosis, and self-treatment.

 Some worrisome trends include supplement use as the primary treatment for mental health conditions

 and the promotion of unrealistic body standards.

 On the other hand, these trends offer an opportunity for providers to engage adolescents and decrease the stigma around mental health.

When dealing with this population, it is important to remain up to date on trends likely to impact them. With new-onset personality and behavioral changes, supplement use should remain on the differential. Providers should educate family members on social media trends and exposure and offer appropriate treatment and support for this demographic.

1. Beckner ME, Pihoker AA, Darnell ME, et al. Effects of multi-ingredient preworkout supplements on physical performance, cognitive performance, mood state, and hormone concentrations in recreationally active men and women. 

. 2022;36(9):2493-2501. doi:10.1519/JSC.0000000000003660

2. Wang HR, Woo YS, Bahk W-M. Caffeine-induced psychiatric manifestations: a review. 

. 2015;30(4):179-182. doi:10.1097/YIC.0000000000000076

3. Nelson Chow. Dry scooping and other dangerous pre-workout consumption methods: a quantitative analysis. Presented at: American Academy of Pediatrics Annual Meeting; October 9, 2021; Lynbrook, NY.

4. Wang SSY. Pre-workout supplement induced cardiac ischemia in a young female. 

. 2020;38(2):187-191. doi:10.1080/02640414.2019.1689598

5. Minhaj FS, Leonard J. Dangers of the TikTok Benadryl challenge. 

. 2021;38(1). https://www.contemporarypediatrics.com/view/dangers-of-the-tiktok-benadryl-challenge

6. Scott C. Updated: Most dangerous, foolish, mean Tiktok trends and challenges. Parentology. Published online July 26, 2021.

7. Miller K. People On TikTok Are Calling These Supplements “Natural Adderall”—Here’s Why That’s Not OK. Shape.com. Published online March 15, 2021. 

https://www.shape.com/lifestyle/mind-and-body/l-tyrosine-adderall-tiktok

8. Atherton RR. The ‘Nutmeg Challenge’: a dangerous social media trend. 

. 2021;106(5):517-518. doi:10.1136/archdischild-2020-319407

9. Freer A. These are the top 10 hashtag categories on TikTok. BusinessofApps. August 10, 2020. https://www.businessofapps.com/news/these-are-the-top-10-hashtag-categories-on-tiktok/

10. Koeck P. Viral TikTok challenge highlights stress, depression, anxiety test.

11. de Vries DA, Peter J, de Graaf H, Nikken P. Adolescents’ social network site use, peer appearance-related feedback, and body dissatisfaction: testing a mediation model. 

. 2016;45(1):211-224. doi:10.1007/s10964-015-0266-4

Psychosis in an 18-year-old male

 Because ADHD is a disorder, it’s pernicious and protracted. Obviously, those are the risks, which set the groundwork for considering treatments. We see patients across the first 2 decades of life in pediatrics, and those patients come with families, and parents aren’t always on the same page. I’m curious about your approaches when working with families or children and incorporating them into the decision-making process.

 They come in as families. There are many times when I’ve been evaluating a child and the parent takes one of the checklists. We like to use different checklists to help us with the symptoms so that we can spend time going through them and refining them. Many times, I see the parent write “Little Joe here, and me here,” and they check off what they were like as a kid and what they’re like now. We’re happy to give them an adult symptom checklist, because if the parents have ADHD, we have to engage them to be sure they get treated. They’re going to be better parents, and they’re going to do better in life as treated adults.

I also engage the family because there’s often a lot of stress around ADHD, and it helps to talk about ADHD, to be transparent about what ADHD is, and to educate to get everybody on board. We laugh and cry together. I love the work. One thing I love about child psychiatry is that you have other people in the room, and we can laugh and cry about things. For a period of time, you join the family dynamic as a member, and you’re part of them.

To go back to your question about the family and treatment, it’s important because across the life span, the family is very involved in the treatment. First, with younger children, they’re your eyes and ears. They tell you what the child is doing. Until around age 12, children aren’t very good reporters of their own pathology and symptoms. That has been demonstrated across multiple studies. You’re relying more on parents and teachers as observers to help you with that. In studies that we did with some initial work with extended-release medications that were specifically approved in adolescents, we found that around age 14, the children became better reporters of their own symptoms than the parents. Whereas with younger children, I see the parents as the focus and the children almost as consultants to what’s going on. As children age, the children become the focus and the parents are more the consultants.

The other issue is from an earlier age when children are very young. You’re going to rely much more on behavioral strategies and parent-training strategies. You’re going to want to use these integrated approaches first, before you think of other treatments. As children age into school-age adolescence, you’re going to use those strategies, but you’re going to rely more on pharmacological strategies as opposed to nonpharmacological strategies earlier in the treatment algorithm.

Videos

Robert L. Findling, MD, MBA, and Timothy Wilens, MD, share their thoughts on treatment considerations with the patient’s family in pediatric ADHD.

Role of Shared Decision Making in Treating Pediatric ADHD

 Further in our chat, we’re going to talk about treatment for ADHD. From my perspective, every treatment takes time. Some treatments are associated with risks. None of that matters if there isn’t risk to the disorder itself, when you’re always thinking about a risk-benefit ratio. This might be a good time to ask, what are the risks of ADHD? How does it impact people and their families?

 That’s a great point. Everybody thinks about treatment in isolation, where you have this risk or problem, or every medicine is going to have adverse effects, as a lot of psychotherapies do. But what are you treating? Why are you treating?

I can assure you that ADHD isn’t just a cosmetic disorder. This isn’t just a kid who’s a little hyper or grows a little spacey. It’s well beyond that. You’re talking about impairments that start very early, including things like self-esteem that start very early in life and are hard to eradicate untreated. But as you grow up, you’ve got academic issues, problems staying in day care, problems completing your schoolwork, and problems falling behind. Then there are injuries and motor vehicle accidents as children start to drive, and cigarettes and substance use as children age into that risk. There are interpersonal problems throughout their lives, which escalates in adulthood, including problems with their occupation. It goes on. When you’re balancing treatment, you have to think about that.

We just looked at long-term outcomes with treatment. We looked at the world’s literature and examined big registry studies, millions of patient-years of experience of medicines. Essentially, all the major bad outcomes associated with ADHD—including mood, suicide, traumatic brain injury, and motor vehicle accidents—are reduced greatly in the long term with treatment. There’s a real argument to what you’re saying that you have to see treatment in context to know what the underlying long-term sequelae are if you don’t treat.

Experts in psychiatry discuss the impact of childhood ADHD on self-esteem, at home, and academically.

Impact of Pediatric ADHD on Quality of Life

Benzodiazepines as treatment for sleep disorders have a greater risk of drug overdose in pediatric patients than alternative pharmacologic treatments, according to a recent study.

Inadequate sleep among adolescents was 66% in 2019—a 22% increase from rates in 1991— increasing risk of negative health consequences from insomnia. Treatments for insomnia are both nonpharmacologic and pharmacologic, but the recommended first-time treatment is cognitive behavioral therapy.

Many prescription pharmacologic treatments for treating insomnia are available, but these often have little or weak evidence on their safety and efficacy, especially for long-term treatment. One such treatment is benzodiazepines, a class of medications prescribed for treating sleep disorders in adults.

Benzodiazepines is often prescribed to pediatric patients, despite being recommended less frequently because of lacking evidence on their safety and efficacy in children. Currently, the recommended treatment period with benzodiazepines for all age groups is 4 weeks or less.

Nonmedical use, benzodiazepine use disorders, and overdose are all risks associated with overdose, and these risks increase if benzodiazepines are used with opioids and other central nerve depressants. Since the start of the prescription opioid epidemic, cases of morbidity and mortality from benzodiazepines have increased.

Overdose deaths from benzodiazepines were 1135 in 1999, 6872 in 2011, and 12,290 in 2020. However, data on the risks of drug overdose in youth prescribed benzodiazepines for insomnia is lacking.

To examine the association with benzodiazepines and drug overdose risk in young people, investigators conducted a study with a cohort from the 2009 to 2018 MarketScan US commercial claims database. This database includes data on dispensed prescription medications, insurance enrolment dates, and emergency department (ED) encounters.

Participants were young people with a sleep disorder diagnosis undergoing new use benzodiazepines, which was defined through a 1-year washout period where benzodiazepines and alternative treatments were not used. Patients using alternative pharmacologic treatment for sleep disorders were also included.

Cohort exclusions included epilepsy diagnosis, combination treatments, trazodone initiation at higher doses, clinical contraindications, and initiating treatment with 1 or more medication classes.

Alprazolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, diazepam, estazolam, flurazepam, lorazepam, midazolam, oxazepam, quazepam, temazepam, and triazolam were listed as prescription benzodiazepines.

Drug overdose was the primary outcome, and data was gathered from inpatient or ED records in the 6 months following treatment initiation. Categories of drug overdose included unintentional, intentional, and undetermined drug poisonings. Demographic characteristics and comorbid psychiatric diagnoses of patients were also gathered.

There were 23,084 participants in the study using benzodiazepines for treatment against sleep disorders, 90.3% of which were diagnosed for insomnia and 9.7% an unspecified sleep disorder. 

Characteristics were similar between new users of benzodiazepines and new users of alternative medications, but benzodiazepine initiators more often had recently used selective serotonin reuptake inhibitors. 

Benzodiazepine initiators were also more likely to have unspecified anxiety diagnoses and less likely to have been diagnosed with a prior substance use disorder, cannabis use disorder, or suicidal ideation. Treatment for pediatric patients was often 1 full prescription, with a median days’ supply of 20 days for benzodiazepineand 30 days for alternative medication.

Treatment was still being given to 22.9% of benzodiazepine users and 28.9% of the comparator group 3 months after treatment was initialized. At 6 months, this decreased to 9.7% of benzodiazepineusers and 12.3% of the comparator group.

There were 684 drug overdose events in the 6-month follow-up period, 190 of which were from benzodiazepine initiators. The incidence of drug overdose was 0.9% for benzodiazepine initiators and 0.8% for the comparator group at 6 months. After adjustment, this was 1% for benzodiazepine initiators and 0.8% for the comparator group.

Opioids had been prescribed to 13.8% of the cohort in the 3 months prior to treatment. Drug overdose among benzodiazepine initiators with a recent opioid prescription was 1.6%, and 0.8% for users of alternate medication with a recent opioid prescription.

These results showed that benzodiazepines increase risk of drug overdose among young people. Investigators recommended that health care providers discuss the risks with young people and review patient medications before prescribing benzodiazepines.

Bushnell GA, Gerhard T, Keyes K, Hasin D, Cerdá M, Olfson M. Association of benzodiazepine treatment for sleep disorders with drug overdose risk among young people. 

 2022;5(11):e2243215. doi:10.1001/jamanetworkopen.2022.43215

In a recent study, benzodiazepine use for treating sleep disorders was associated with increased risk of drug overdose.

Benzodiazepines increase drug overdose risk in youth

Bacterial vaginosis during pregnancy may lead to adverse outcomes, such as preterm birth, preterm delivery, and spontaneous abortion, according to results from a meta-analysis.

Researchers conducted a meta-analysis to delve deeper into the connection between bacterial vaginosis in early pregnancy and preterm birth. From November 2018 to March 2020, they searched PubMed, Cochrane, Google Scholar, and LILAC for data relating to bacterial vaginosis and preterm birth. They only included studies that were published from 2008 to 2018 and those that offered statistical data. They excluded studies that only consisted of conceptual and qualitative data. The search ultimately led to data from 20,894 women across 11 studies.

Researchers then evaluated the findings of each study, extracting various outcomes and conclusions. They combined the results—risk ratios (RR) and odds ratios (OR)—for deeper analysis. For women with bacterial vaginosis during pregnancy, the combined odds of preterm birth or preterm delivery was 2.79 (2.29-3.41).

Through their evaluation, they found that preterm birth was more than 2 times as likely in pregnant women with bacterial vaginosis than those without the infection (OR= 2.79; 95% CI, 2.29 to 3.41). Bacterial vaginosis was also found to be a greater risk factor for preterm delivery in late pregnancy, increasing the odds 4-fold.

Researchers also examined the conclusions of each study, ultimately identifying bacterial vaginosis in early pregnancy as a significant risk factor for preterm delivery and spontaneous abortion. They also found that the administration of clindamycin at <22 weeks’ gestation significantly reduced the risk for preterm birth.

Reference
Mohanty T, Doke PP, Khuroo SR. Effect of bacterial vaginosis on preterm birth: a meta-analysis [published online ahead of print, 2022 Oct 17]. 

. 2022;10.1007/s00404-022-06817-5. doi:10.1007/s00404-022-06817-5

Bacterial vaginosis during pregnancy may lead to increased risks for preterm birth, preterm delivery, and spontaneous abortion, according to new research in the Archives of Gynecology and Obstetrics.

Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss

The American Academy of Pediatrics (AAP) and the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) have released new guidance on identifying and treating cerebral palsy in a clinical report, “Providing a Primary Care Medical Home for Children and Youth with Cerebral Palsy.”

Cerebral palsy is seen in 1 to 4 out of every 1000 children, making it the most common motor disorder in youth. Cerebral palsy is defined as permanent motor system disorders caused by disturbances in the developing fetal or infant brain. 

Early identification allows families, physicians, and specialists to provide evidence-based therapy at a time when the brain is most adaptable to change, improving the chance of better outcomes.

In the clinical report, information is given on the definition, manifestations, and management of cerebral palsy. The report was published online on November 21, 2022, and in the December 2022 issue of 

According to Garey Noritz, MD, FAAP, FACP, lead author of the report and chairperson of the AAP Council on Children with Disabilities, the report focuses on early collaboration, family choice, and child and family strengths. Noritz also stated that primary care physicians must implement care across multiple organ systems and specialists.

“Physicians also act as advocates who can help families navigate their relationships with the medical system, therapy providers, school, community groups and other resources,” Noritz said.

Signs of cerebral palsy include delays in meeting development milestones and issues with movement and coordination, development, speech and eating, or muscle tone. Medical history factors such as preterm birth or perinatal difficulties could make some children be identified as at risk of cerebral palsy or other developmental disorders.

Some children with cerebral palsy will not have any identifiable factors that increase risk. Screening and surveillance in primary care medical homes should be used to identify cerebral palsy in these children.

Screening should occur for children aged 9 months, 18 months, and 30 months, according to the AAP. These screenings should also include neuromotor examination focusing on motor milestones and muscle tone.

Additional recommendations form the AAP and AACPDM include standard primary care visits for children with cerebral palsy, acknowledgement from physicians on socioeconomic barriers to screening and treatment, use of a multidisciplinary approach, and encouragement from physicians to engage in social, recreational, and community activities.

The report also states that new symptoms or further declines in patients should be given full investigation and should not be immediately assumed as related to cerebral palsy. Also, the transition from pediatric care to adult care should begin when a patient is aged from 12 to 14 years.

Major health organizations release guidance on identifying, treating cerebral palsy. American Academy of Pediatrics. November 21, 2022. Accessed November 28, 2022. 

https://www.aap.org/en/news-room/news-releases/aap/2022/major-health-organizations-release-guidance-on-identifying-treating-cerebral-palsy2/

A recent report from the AAP and AACPDM discusses how to identify and treat cerebral palsy in children.

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AAP provides guidance on identifying, treating cerebral palsy