Showing posts with label epidemiology. Show all posts
Showing posts with label epidemiology. Show all posts

Tuesday, September 15, 2015

The Great Divide: Examining Social Determinants of Health

By: Joann Schulte  DO, MPH; Editorial Board Member  
       And they lived happily ever after.  Surely you've heard that phrase ending fairy tales or rags to riches stories.  The plot is basically poor boy or girl pulls himself or herself up by the bootstraps with minimal help from anybody else. That myth has endured ever since Horatio Alger started penning his stories in the 1890s.  The reality is that most people who make themselves a success have help along the way from parents, teachers or somebody who cared and took an interest.  Of course,  children who face adversity have dreams, but often have barriers that Horatio Alger just didn't mention.
     One factor that gets short shrift in such stories is how the hero or heroine started out. Specifics such as dealing with hunger or  having to worry about apartment infestations may not be described in detail in a hard luck story, but these issues are common in reality.  Basics like food insecurity, poor housing or a stressed out single parent are among the social determinants of health (SDH) that can crush a child's dreams early on.  The toxic stress model suggests that social determinants of health often disrupt normal physiological processes, get "under a child's skin" and put a child's future and dreams at risk.
       Pediatricians often try to help individual children who go hungry or live in rat infested housing.  One patient at a time is good, but doesn't fix a community.  Recently  innovative programs called Medical - Legal Partnerships have shown some success in addressing SDH on a  broader community scale.
      Research by Lovegrove,et al. (doi:10.1542/peds.2015-2092), published this month in Pediatrics, documents some successes achieved in Ohio.  That's where the Division of General and Community Pediatrics at Cincinnati Children's Hospital Medical Centers has paired with the Legal Aid Society of greater Cincinnati.  The partnership is between pediatricians and attorneys who have experience helping those trying to overcome their poverty status..
      The pediatricians, who provide care for 15,000 children, did an anonymous survey of parents asking what unaddressed needs their children had.   The survey found that 29 % of parents reported living in poor housing with conditions such as cockroaches or mold.  One in five parents reported financial problems limiting their abilities to buy medication for themselves.  Thirty percent of children lived in household where food insecurity was a problem and 15% of families with infants had to stretch their allotted formula to last long enough to get their next allotment.
      Working together, the physicians and attorneys who comprise  the Cincinnati Child Health Law Partnership (Child HeLP) have identified and improved a cluster of substandard housing  areas where problems included pest infestations, broken windows and water leaks.  They also worked  to provide sufficient formula through donations to food banks that helped more than 1,500 families feed their infants.
       The Cincinnati program and others like it often use Maslow's hierarchy of needs   to assess common needs.   The pyramid assesses human needs, starting at a physiological base with food and shelter and progressing to self actualization (see Figure).  The programs then implement community interventions that benefit multiple children and their families with these needs.  The article by Longrove et al. provide a good overview of a process that can link clinical and community resources in programs that can intervene in economic, environmental and psychosocial areas.  That's a good way to reshuffle at least part of the deck that is often stacked against children from poor families.  A better start to the story is more likely to produce a happy ending.

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Wednesday, September 9, 2015

The Mystery of Who’s Giving Babies Pertussis? A New Suspect Emerges!

By: Lewis First, MD, MS; Editor-in-Chief 
Mamma Loves
          While no one wants to contract pertussis, we worry the most about infants coming down with this disease.  They tend to have the least reserve and highest morbidity and mortality from this illness—and sadly even in the setting of high infant pertussis vaccination coverage, the incidence of this disease in babies has been increasing.  This raises the question of who is spreading the disease to our youngest patients.   
     Prior to a study by Skoff et al. (doi: 10.1542/peds.2015-1120) being released this week, we certainly worried about mothers being the most common source of spreading this infection, but with the aggressive campaign to vaccinate pregnant mothers with Tdap vaccine, are there other “suspects?”  The authors reviewed cases of pertussis in infants less than 1 year old and interviewed parents regarding potential sources of infection in contact with a baby within 7 to 20 days before the onset of their cough.   
     Of more than 1300 cases identified, a source was found for almost half with that source being other family members—and most commonly siblings—with parents following behind. In fact siblings have taken over from mothers as the most common source of pertussis infection to the new babies in their families.  So how old were the siblings who tended to spread this infection, and what was their vaccination status in terms of needing or receiving a Tdap booster?  Inject some time into reading this interesting study and learn more, and in turn share the import of getting booster pertussis vaccine where warranted in older sibs and parents especially if a new baby is expected or has arrived into a family.  
    Have you seen siblings as the source of pertussis cases in your practice?  What if anything did you do about the spread of pertussis if you live in an area that has recently seen an uptick in cases?  Share your thoughts on preventive measures via a response to this blog, an e-letter, or posting on Facebook or Twitter.

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Tuesday, August 4, 2015

Mycoplasma pneumonia and Stevens-Johnson Syndrome: A Combination and Complication You Should Know About

       While we are all familiar with Stevens-Johnson Syndrome (SJS) as a somewhat uncommon dermatologic illness in our patients in which the epidermis separates from the dermis due to cell death, we may be less familiar with outbreaks of this disorder and their etiology.   
      This week, Olson et al. (doi: 10.1542/peds.2015-0278) report on an outbreak of 8 cases of SJS seen over a three month period at Children’s Hospital Colorado that was associated with mycoplasma pneumonia infection.  Just how the association was found and what was done about it make for an interesting read.   
       If you are looking for possible etiologies of a patient you care for with SJS, add mycoplasma to your list of “rash-ional” etiologies.

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Thursday, March 26, 2015

Inner-city children with ADHD symptoms- what helps?

By: Lydia Furman, MD Assistant Editor  

      The work of Silverstein et al, (doi:10.1542/peds.2014-3221) “Collaborative Care for children with ADHD symptoms: a randomized comparative effectiveness trial,” is highly intriguing for several reasons. The authors studied a low-income inner-city population of children (and parents) that presented with ADHD symptoms, and randomized them to Enhanced or Basic Collaborative Care.  Enhanced Care included a trained lay facilitator who met with the family up to 5 times to address barriers to treatment and parental mental health concerns, and to provide ways to reduce coercive parenting in response to difficult behaviors. 
        The title raises a very interesting question – does diagnosis of ADHD help clinicians manage symptoms of inattention and hyperactivity? The authors’ approach suggests that it may not, since they enrolled all eligible children who were being evaluated for “ADHD symptoms”, and included both those who were ultimately diagnosed with ADHD, as well as those who were not, in the clinical trial. This empiric research strategy encourages us to think more broadly about how to help children who present with symptoms of inattention, impulsivity and hyperactivity. The diagnosis of ADHD as described “was defined as meeting DSM-IV symptom criteria on both the parent and teacher Vanderbilt scales, in the absence of a plausible alternative explanation for the child’s symptoms- as determined from narrative clinical information.” Given this straightforward and pragmatic evaluation using an instrument with relatively low positive predictive value (PPV of 0.19 and 0.32, respectively; Bard et al J Dev Behav Pediatr 2013; Wolraich et al J Dev Behav Pediatr 2013), it is worth considering the possibility that the 63 “ADHD consistent presentation” subjects (40% of all subjects), as compared to the “ADHD inconsistent presentation” subjects, differed quantitatively not qualitatively from each other. In other words, did children in the former group simply have more symptoms than those in the latter group, rather than a unique disease state?
        The “ADHD consistent presentation” subjects, whose outcomes were analyzed secondarily since the study was powered to look at outcomes of all subjects, showed greater symptom improvement in the Enhanced Collaborative Care group (please read the paper to learn about the summary results for all children!). Given the study design, the authors could not determine which component of the Enhanced Care was the most helpful. However, since there was not a statistically significant difference in specialty behavior services or in medication treatment between groups (52% in basic care vs. 72% in Enhanced care, p=0.10), and there was a difference in receipt of Triple P (Positive Parenting Program with 0% in basic care vs. 47% in the Enhanced Care Group receiving the intervention, the authors speculate that this could explain the impact of the Enhanced Care. In deference to the authors, I note that they believe the clinically meaningful difference in medication use between groups likely was important also, but we know from multiple publications, including the very well monitored MTA study in which actual medication adherence was 53.5% (Pappadopulos et al Medication adherence in the MTA JAACAP 2009), that compliance with medication treatment may be surprisingly low.
        In an accompanying Perspective, Dr. Mark Wolraich,(doi:10.1542/peds.2015-0070) who is the lead author of the AAP ADHD Guidelines and of the Vanderbilt forms, notes that “while progress is being made,” no etiology has been identified for ADHD  in over a decade of research, and “therapy is likely to remain symptom based,”  which is indeed the approach that Silverstein et al take.  Dr. Wolraich also notes that long term outcomes are not yet acceptable, and that even the MTA study found no difference in intensively monitored groups 2 years after treatment ended. In fact at 24 and 36 months post formal intervention, children in the MTA who were taking medication, as compared to those who were not, showed significantly greater symptom deterioration from 24 to 36 months, as well as higher delinquency at both these time points (Jensen et al 3-Year Follow-up of NIMH MTA JAACAP August 2007), information that may be new to many clinicians. Perhaps an entirely new paradigm is needed.

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