JOURNAL CLUB

Commentaries By Michael G. Burke, MD

Versatile duct tape moves into the medicine cabinet

Homeowners long have relied on duct tape to fix a range of household problems. Now, the product appears to have a medical use as well. According to a recent investigation, covering a wart with duct tape removes the wart significantly more effectively than using standard cryotherapy.

A study that compared the two therapies was conducted in 51 youngsters (3 to 22 years of age); most often, subjects' warts were on the finger. Patients in the cryotherapy group received a standard application of liquid nitrogen to the wart for 10 seconds. Patients and parents were instructed to gently debride the wart with an emery board or pumice stone the day before returning for another treatment. The cryotherapy application was repeated every two to three weeks for either six treatments or until the wart resolved. In the duct tape group, the tape was cut to the size of the wart and applied directly to it, where it remained in place for six days. (Parents were told to apply a new piece of tape if the original fell off.) Afterward, parents removed the tape, soaked the area in water, and then gently debrided the wart with an emery board or pumice stone. The tape was left off overnight and then reapplied the following morning. Treatment continued for two months or until the wart resolved.

In the duct tape group, warts completely resolved in 22 (85%) of 26 patients, compared to 15 (60%) of 25 in the cryotherapy group. Most warts that resolved with tape occlusion disappeared within 28 days of the start of therapy. Most warts that responded to cryotherapy resolved after two treatments, spaced at least two weeks apart. Average time to resolution (about a month), therefore, was similar in the two groups. Warts that did not respond to tape occlusion within two weeks were unlikely to respond to that treatment at all (Focht III DR: Arch Pediatr Adolesc Med 2002;156:971).

Commentary: I loved this article. My own children laugh when I bring duct tape along when we rent a vacation house, but it's my contention that a lot in life can be fixed with a little duct tape. Now I can add warts to that list (and tape the list to the wall!).

Why the increase in pediatric ED psychiatric visits?

An analysis of emergency department (ED) pediatric mental health visits between 1993 and 1999 reveals that these visits increased significantly during that period. The rise, investigators conclude, is probably attributable to a shortage of mental health practitioners—not to an increase in mental health problems among youngsters.

Using data from 579 hospitals gleaned from the National Hospital Ambulatory Medical Care Survey, investigators examined differences in utilization and treatment patterns. During the seven-year study period, EDs had an estimated annual average of 434,000 pediatric mental health visits—an average annual rate of 326.8 visits for every 10,000 youngsters. The rate was highest among teenagers and lowest among children 6 years and younger. Girls were slightly more likely than boys to visit an ED for a mental health problem. Children and adolescents in the Northeast were much more likely to have such a visit than were youngsters in the West. The three most common principal diagnoses made at these visits were "unspecified neurotic disorder," "depressive disorder," and "anxiety states," which accounted for 13.1%, 12.9%, and 11.4% of visits, respectively.

Although ED pediatric mental health visits increased overall during the study period, psychoses and suicide attempts—the two categories of diagnosis for which evaluation in the ED is mandatory—did not rise. This, investigators note, suggests that ED pediatric mental health visits have increased because nonurgent complaints that might be managed by primary mental health practitioners are instead being addressed in the ED. They further hypothesize that the shift in ED visit rates reflects the escalating shortage of such clinicians (Sills MR et al: Pediatrics 2002;110:e40).

Commentary: If you work in an ED, it's not news that there has been an increase in children with a psychiatric disorder arriving there. The helpful information here is that most of the increase in visits isn't the result of a surge of suicidal or psychotic children but of those whose disorder is less acute. The authors speculate that these children are brought to the ED for lack of other access to psychiatric care. I suspect that they are right.

Sleeping prone: Contributor to a high SIDS rate among African-Americans

Investigators studied the contribution of the prone sleeping position to racial disparity across rates of sudden infant death syndrome, or SIDS. (The rate of SIDS is more than twice as high among African-Americans as it is among Caucasians.) The case-control study was conducted in 260 infants, newborn to 1 year of age, who died of SIDS during a nearly three-year-long period between 1993 and 1996. To identify risk factors for SIDS, researchers collected data from death scene investigations and conducted follow-up home interviews. They then compared these data with equivalent information from living controls who were matched for race, age, and birth weight. Three quarters of the infants in the study sample for whom SIDS was listed as the cause of death were African-American.

After adjustment for potential confounding variables and other risk factors for SIDS, prone sleeping was found to be a significant risk factor for SIDS—in fact, it accounted for approximately one third of SIDS deaths in the primarily African-American urban sample. Sleeping in the side position did not significantly increase the risk of SIDS. Sociodemographic factors found to be most associated with increased risk of SIDS were maternal age between 20 and 24 years, single marital status, education below the high school level, and inadequate prenatal care. Other sociodemographic factors associated with increased risk of SIDS were high parity, intermediate or low job prestige score, chronic maternal unemployment, and receipt of public assistance.

When control-group mothers were asked how they decided what sleep position to use for their infant, more of them (64%) than case mothers (46%) reported that they were advised about sleep position by a physician or nurse after delivery (Hauck FR et al: Pediatrics 2002;110:772).

Commentary: A different group of investigators, also surveying mothers of well infants in a predominantly African-American population (Moon RY et al: Clin Pediatr 2002;41:569), found that infants were 5.7 times as likely to be put to bed on their back if the parent reported that a health-care professional had provided a verbal "back to sleep" recommendation. So now we know both what needs to be done—babies need to be put to bed on their back—and how to get it done—physicians need to tell mothers to do it!

DR. BURKE, section editor for Journal Club, is chairman of the department of pediatrics at Saint Agnes Hospital, Baltimore. He is a contributing editor for Contemporary Pediatrics.

CLINICAL TIP

Persistent red eye: Is treatment the problem?

When a patient, usually a teenager, complains of persistent redness of the eye without pus, be on the lookout for vasoconstrictor eyedrop abuse. The problem generally starts with a mild redness, which the teen tries to eliminate with over-the-counter eyedrops. Despite using various brands of eyedrops containing vasoconstrictors for weeks or months, the redness becomes worse. The cause is rebound hyperemia. We are all familiar with persistent nasal congestion from prolonged nose drop abuse (rhinitis medicamentosa or chemical rhinitis). Now don't forget the ophthalmic version (conjunctivitis medicamentosa or chemical conjunctivitis).

Barton D. Schmitt, MD
Denver, Colo.

Gentle relief of subungual hematomas

Subungual hematomas are often treated by pushing a heated paper clip through the patient's nail to relieve pressure. This method works, but it has some drawbacks. Paper clips occasionally get too cool by the time they are used to go through the nail the first time. Also, heated paper clips have been known to pull off nails, particularly thick ones like the nail of the big toe.

A disposable, battery-powered cautery device is simpler and faster. A little bigger than a penlight, the device has a thin metal tip that gets red hot within seconds. After heating the tip, push it gently through the nail. You will instantly and painlessly create a small hole that releases the trapped blood. One caution: Make sure not to push the tip in too far or you may hit the soft tissue under the nail.

Howard J. Bennett, MD
Bethesda, Md.

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by e-mail (Molly.Frederick@medec.com), please include your mailing address.

 

Journal Club. Contemporary Pediatrics 2002;12:98.