Category Archives: Pediatrics

Preventing Youth Violence: Where’s the Research?

Photo courtesy of Thierry Geoffroy (Wikimedia CC)

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

Kerri Wachter

6 Comments

Filed under Emergency Medicine, Family Medicine, IMNG, Internal Medicine, Pediatrics, Primary care

Counties Pursue Safer Drug Disposal

New programs to make it easier and safer for San Francisco Bay Area residents to get rid of unused medications are some of the first to try this on a large scale, and may serve as models for other cities and counties.

Since May 2012, a pilot program in San Francisco has allowed residents to drop off old medications at 13 pharmacies and 10 police stations (where controlled substances must be brought). San Francisco supervisors initially considered forcing drug companies to fund the program, and instead agreed to accept $110,000 from Genentech and the Pharmaceutical Research and Manufacturers of America to fund the program.

(Photo by J. Troha, courtesy of National Cancer Institute)

On July 24, supervisors in Alameda County (which includes East Bay cities such as Oakland and Berkeley) are likely to approve a Safe Drug Disposal Ordinance that would require drug companies to pay for disposal of their products or face fines of up to $1,000 per day, The Bay Citizen reports. Public agencies currently fund 25 drug disposal sites there, and the cash-strapped county wants the comparatively wealthy pharmaceutical industry to take more financial responsibility for the lifecycle of its products in order to reduce overdoses, accidental poisonings, and water pollution.

As we reported earlier this year, making prescription-drug “recycling” a cultural norm is one of five emerging public policies that could help the medical system keep opioids available while reducing the risk of addiction, abuse and accidental overdose, according to Keith N. Humphreys, Ph.D. Smaller versions have met with success, such as a drug take-back day organized by sheriffs in a small town in Arkansas (population 20,000) that brought in 25,000 pills, said Dr. Humphreys, acting director of the Center for Health Care Evaluation, Veterans Health Administration, Menlo Park, Calif., and a professor of psychiatry at Stanford University. He reports having no financial conflicts of interest on this issue.

Not everyone is happy with the idea. Trade associations for the pharmaceutical industry and biomedical companies argue that there’s no evidence that these programs will reduce poisonings, and they haven’t ruled out the possibility of suing to block the Alameda County ordinance, The Bay Citizen reports. The compromise that San Francisco reached for voluntary instead of mandatory funding from the pharmaceutical industry may be a middle ground.

In an era when government agencies have less and less money for public programs, it’s probably inevitable that they’ll pursue alternative financing for programs like this.

If your community has a drug disposal program, let us know how it’s working. Will these programs succeed, and will they reduce abuse, addiction, and accidental overdoses? We’ll keep an eye on this topic, and keep you posted.

–Sherry Boschert (@sherryboschert on Twitter)

1 Comment

Filed under Cardiovascular Medicine, Dermatology, Drug And Device Safety, Endocrinology, Diabetes, and Metabolism, Family Medicine, Gastroenterology, Health Policy, Hematology, Hospice and Palliative Care, IMNG, Infectious Diseases, Internal Medicine, Nephrology, Neurology and Neurological Surgery, Obstetrics and Gynecology, Oncology, Pediatrics, Primary care, Psychiatry, Rheumatology, Uncategorized

Can HPV Vaccination Be Simplified?

The human papillomavirus vaccine was recommended for routine use in 11-12 year old girls in 2007. But by 2010, the most recent year for which data are available, less than half had received one dose of the three-dose series and fewer than a third had received all three. The inconvenience of the need for three separate office visits along with the vaccine’s price – about $130 per Gardasil dose, as of July 2011 – have certainly contributed to the low uptake.

©BVDC/Fotolia.com

Now, some parts of the world – including Mexico, Switzerland, and parts of Canada have moved to either a two-dose schedule, or a so-called “extended dose” schedule, in which the third dose is delayed until 5 years after the second one. (In the current U.S. three-dose schedule, doses two and three are given at 2 and 6 months, respectively, after dose one.)

“There has been emerging interest in HPV vaccine schedules with fewer than three doses, for a variety of reasons. These schedules could facilitate implementation, they may be more convenient for providers, parents, and vaccinees, and of course they would be cost-saving,” said Dr. Lauri Markowitz, of the Centers for Disease Control and Prevention, at a recent meeting of the CDC’s Advisory Committee on Immunization Practices.

No data on the efficacy of fewer than three doses have been published by either Merck or GlaxoSmithKline from their pivotal trials of Gardasil and Cervarix, respectively. But some other data are available for both vaccines. A nonrandomized study in Costa Rica that included more than 1,100 women who had received just one or two doses of Cervarix suggested that two doses or maybe even just one – could be as protective as three doses against infection at 4 years.

And in an as-yet unpublished study done in Canada, immune responses against both HPV 16 and 18 at 3 years were similar between two doses of Gardasil given at age 9-13 years and three doses given at age 16-26 years. But, there are limited efficacy data and no long-term data, Dr. Markowitz said.

Electron micrograph of human papillomavirus (HPV) / Courtesy of the National Cancer Institute

In an e-mail, Deb Wambold of Merck Vaccines said that, while the company does support studies of alternative dosing schedules for HPV vaccination including two-dose regimens, so far those studies are “interesting preliminary explorations in select subpopulations of vaccinees,” and “It is important to note that there are no data on the clinical efficacy or durability of effectiveness with two doses of either of the HPV vaccines, as we have for the recommended three-dose vaccination regimen.”

Dr. Joseph A. Bocchini Jr., who chairs the ACIP HPV vaccine working group, concurred. In an interview at the ACIP meeting, he noted that the long-term efficacy of two doses is “worth looking at,” as is the varying of three-dose schedules. “But, at this point, there are too few data to apply this to recommendations in the United States.”

More data from ongoing trials will be available in the next few years, Dr. Markowitz said.

-Miriam E. Tucker (@MiriamETucker on Twitter)

Leave a comment

Filed under Allergy and Immunology, Epidemiology, Family Medicine, IMNG, Infectious Diseases, Internal Medicine, Obstetrics and Gynecology, Oncology, Pediatrics, Primary care, Uncategorized

“Turning the Tide” on HIV/AIDS

In advance of the upcoming XIX International AIDS Conference, the International AIDS Society and the University of California, San Francisco, have issued the “Washington D.C. Declaration,” a nine-point action plan aimed at broadening global support for “Turning the Tide” of the AIDS epidemic.

Everyone is urged to sign the Declaration.

It calls for:

1) An increase in targeted new investments;
2) Evidence-based HIV prevention, treatment, and care in accord with the human rights of those at greatest risk and in greatest need;
3) An end to stigma, discrimination, legal sanctions, and human rights abuses against those living with and at risk for HIV;
4) Marked increases in HIV testing, counseling, and linkages to services;
5) Treatment for all pregnant and nursing women living with HIV and an end to perinatal transmission;
6) Expanded access to antiretroviral treatment for all in need;
7) Identification, diagnosis, and treatment of tuberculosis;
8) Accelerated research on new tools for HIV prevention, treatment, vaccines, and a cure;
9) Mobilization and meaningful involvement of affected communities.

Turning the Tide is the theme of this year’s biennial conference, which will take place July 22-27 in Washington.  It is expected to draw 25,000 attendees, including HIV professionals, activists, politicians, and celebrities. Sir Elton John will open the conference and Bill Clinton will close it. A large delegation of U.S. members of Congress will participate, and Bill Gates will moderate a session. An enormous “Global Village” outside the D.C. Convention Center will be open to the public. “If you haven’t been, it’s a conference like no other,” conference cochair Dr. Diane V. Havlir said at a press briefing.

The recent optimism regarding HIV/AIDS stems from major advances in knowledge regarding prevention of partner transmission with early patient treatment, pre-exposure prophylaxis, and male circumcision as HIV infection prevention (new data will be released at the meeting), all of which are viewed as breakthroughs  in the fight against HIV/AIDS. “So we have now in our hands the tools. The question is how do we combine those tools together, and how do we roll them out,” said Dr. Havlir, professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS division at San Francisco General Hospital.

Dr. Diane V. Havlir / Photo by Miriam E. Tucker

Monday’s plenary session will include an address from Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, on “Ending the HIV Epidemic: From Scientific Advances to Public Health Implementation.” Other plenary topics during the week will include viral eradication, vaccines, TB and HIV, and HIV/AIDS in specific populations including minorities, women, youth, and men who have sex with men. On Friday, there will be a plenary talk that may be of particular interest to the primary care community, “The Intersection of Noncommunicable Diseases and Aging in HIV.”

Plenaries and other conference sessions will be webcast at http://globalhealth.kff.org/aids2012.

-Miriam E. Tucker (@MiriamETucker on Twitter)

Leave a comment

Filed under Allergy and Immunology, Alternative and Complementary Medicine, Anesthesia and Analgesia, Clinical Psychiatry News, Dermatology, Emergency Medicine, Endocrinology, Diabetes, and Metabolism, Epidemiology, Family Medicine, Gastroenterology, Genomic medicine, Geriatric Medicine, Health Policy, IMNG, Infectious Diseases, Internal Medicine, Neurology and Neurological Surgery, Obstetrics and Gynecology, Oncology, Pediatrics, Practice Trends, Primary care, Psychiatry, Uncategorized

Title IX Hits 40

Image courtesy of Sarah Jones via Wikimedia Commons (CC)

What does Title IX mean to you? Athletics is typically high up on the list for many people. Title IX has played an important role in getting girls and young women onto the field. On the 40th anniversary of the landmark gender equity in education legislation, U.S. Secretary of Education Arne Duncan noted in a speech, “when Title IX was enacted in 1972, less than 30,000 female students participated in sports and recreational programs at NCAA member institutions nationwide. Today, that number has increased nearly six-fold. And at the high school level, the number of girls participating in athletics has increased ten-fold since 1972, to three million girls today.”

In an era of nationwide public health concerns over childhood obesity, getting girls and young women involved in sports becomes even more important. However, Title IX’s expansion of school-based athletics programs has more far-reaching benefits as well. As Secretary Duncan pointed out, female athletes “are more likely to graduate from college than female students who don’t play sports.” Female athletes are also less likely to use drugs and become pregnant as teenagers.

Sports are only part of the Title IX picture though. In fact, neither the word “sports” nor “athletics” are used in the text of the legislation. The law has changed the academic landscape for female students.

U.S. Navy photo by Greg Vojtko (Public Domain)

Here’s a few things that you might not know:

  • 57% of students in postsecondary education in 2009-2010 were women; women also accounted for 62.6% of students receiving a master’s degree.
  • Since 1976, girls enrolled in gifted and talented education programs have outnumbered boys enrolled. In 2009, 8.1% of girls participated in gifted and talented education programs, compared to 7.4% of boys.
  • A greater percentage of the girls in 7th or 8th grade (20%) are taking Algebra I, compared with boys (18%).
  • Girls are evenly represented in biology and outnumber boys in chemistry, but are underrepresented in physics.

Welcome to middle age, Title IX. Let’s see what else you can do to get girls on the field and in the classroom.

Kerri Wachter

Data from the “Gender Equity in Education A Data Snapshot” by the U.S. Department of Education’s Civil Rights Data Collection.

Leave a comment

Filed under Family Medicine, Health Policy, IMNG, Obstetrics and Gynecology, Pediatrics, Physical Medicine and Rehabilitation, Primary care, Sports Medicine

Focus Shifts from Children’s Self-Esteem To Self-Control

The child-rearing meme of self-esteem is being replaced by self-control. Well-intentioned efforts to promote children’s self-esteem in recent decades too often produced empty praise and, some argue, an epidemic of over-indulgence.

(Courtesy Wikimedia Commons/Dave Hogg/Creative Commons License)

Among physicians and therapists who counsel parents on effective child-rearing, “These days, self-esteem is out, self-control is in. In terms of concepts, we don’t talk about self-esteem any more,” says Laura Kastner, Ph.D.

Self-control is “a very powerful concept right now and, of course, is an important part of executive functioning,” she said at the annual meeting of the North Pacific Pediatric Society. “It’s not that self-esteem is not important, it’s just very imprecise as a measure.”

Measuring children’s self-control (ability to delay gratification, control impulses, and modulate expression of emotion) not only is easier and more precise, but it is producing important findings in longitudinal studies, added Dr. Kastner of the University of Washington, Seattle. She’s also co-author of the book “Getting To Calm: Cool-Headed Strategies for Parenting Tweens and Teens” (Parent Map 2009).

Children with “undercontrolled temperament” at age 3 were more than twice as likely to show evidence of a gambling disorder as adults at ages 21 and 32 compared with those who were well-adjusted at age 3, according to an analysis of data from a large, 30-year prospective cohort study in New Zealand (Psychological Science 2012;23:510-516).

The degree of childhood self-control predicted the likelihood of physical health, substance dependence, sound personal finances, and criminal records, another analysis of the cohort found (Proc. Natl. Acad. Sci. U.S.A. 2011;108:2693-2698).

Dr. Laura Kastner (Sherry Boschert/IMNG Medical Media)

Dr. Kastner said studies of this longitudinal data have shown that among the 20% of people with the lowest self-control as children, more than 40% had criminal records as adults, compared with criminal records for less than 15% of the 20% of people with the highest childhood self-control. Approximately 10% of the lowest self-control group was dependent on several drugs as adults, compared with less than 5% of the highest self-control group. Multiple health problems were reported by nearly 30% in the lowest self-control group compared with just over 10% of the highest self-control group. An annual income under $20,000 NZ (the equivalent of roughly $15,400 in U.S. dollars) was reported by more than 30% in the lowest self-control group and 10% of the highest self-control group.

The self-control meme is spreading rapidly, with books and articles exploring what it means and cultural differences in child-rearing. For one good example, see The New York Times article “Building Self-Control, the American Way.”

It remains to be seen whether interventions to help parents help their children to develop self-control will improve their lives later on.

–Sherry Boschert (on Twitter @sherryboschert)

2 Comments

Filed under Family Medicine, IMNG, Internal Medicine, Pediatrics, Psychiatry

Teens with Eating Disorders Try Yoga

If the thought of yoga doesn’t bring to mind long-haired, half-naked gurus in India, it probably makes you think of thin young people in pretzel poses. True that, but it’s also become popular among populations that you might not expect. Yoga increasingly is being incorporated into treatment programs for young people who may be too thin or too fat – adolescents with eating disorders.

Yoginis relax and stretch. (Courtesy Wikimedia Commons/zivpu/Creative Commons License)

Dr. Cora C. Breuner helped conduct a study of 50 girls and 4 boys with diagnosed eating disorders. Participants were randomized to treatment with standard care (every-other-week appointments with physicians or dieticians) or standard care plus individualized yoga for 12 weeks. The yoga group showed significantly reduced food preoccupation immediately after each yoga session and significantly decreased Eating Disorder Examination scores at 12 weeks (J. Adolesc. Health;2010;46:346-51).

Speaking at the annual meeting of the North Pacific Pediatric Society, she gave a brief update: the teens in the yoga group showed greater improvements in weight a year after the study ended compared with the control group.

Dr. Cora C. Breuner (Sherry Boschert/IMNG Medical Media)

“Pretty much every eating disorders unit in the country now has yoga,” said Dr. Breuner, professor of pediatrics at the University of Washington, Seattle.

I don’t know about every eating disorders program, but a quick look on the Web found plenty that include yoga and lots of independent yoga classes geared toward people with eating disorders. On this list of eating disorder treatment programs from EDreferral.com, for example, yoga is mentioned by nine facilities in California and one each in Arizona, Hawaii, Mississippi, New Jersey, Pennsylvania, Tennessee, and Virginia. I found others online in Michigan and Washington, too, with just a few clicks.

Dr. Breuner’s 2010 study isn’t the only one endorsing yoga for eating disorders. Here’s another (Psychology of Women Quarterly 2005;29:207-19). Columbia University reported on this trend in 2007. And the Wall Street Journal reported in 2011 on increasing use of yoga not only for kids with disorders but for healthy students, under the clever headline, “Namaste. Now Nap Time.”

Some of the key goals of yoga are to strengthen the mind and body and the connection between the two. It’s not a solo treatment for eating disorders, but it supplements the standard strategies of weight stabilization, nutrition therapy, cognitive behavioral therapy, and family-based therapy.

That last one is another big change in the field that has happened since Stanford University researchers began showing in 2007 that it’s very helpful in treating children and adolescents to use parents as agents for positive change in a non-judgmental manner.

“Now we bring parents in right away to help with refeeding the child,” Dr. Breuner said.

It’s only a matter of time, I suspect, until we see special yoga classes for parents of children with eating disorders.

–Sherry Boschert (on Twitter @sherryboschert)

1 Comment

Filed under Alternative and Complementary Medicine, Clinical Psychiatry News, Family Medicine, IMNG, Internal Medicine, Pediatrics, Primary care, Psychiatry, Uncategorized