Asking Saves Kids

Kiesha Fraser Doh, MD
kiesha.fraser @emory.edu

 

As of June 14th there have been 23 school shootings this year!  A total of 1,392 children have been killed or injured by firearms. In comparison during the influenza season from October 2017 to May 2018 a total of 172 children died. [1]This year of 2018 has been especially deadly for children, with 547 firearm deaths this year. [2]Thus more children died from firearm injuries this year compared to influenza deaths despite frequent media reports about influenza death compared to firearm injuries.

On June 21st, the first day of summer, the American Academy of Pediatrics and the Brady Campaign Against Gun Violence advocate for firearm safety in the home. This campaign encourages pediatricians to educate their patient’s parents to inquire about the presence of unlocked firearms in the homes their children visit. It is especially important in Georgia as 1 in 3 homes have firearms with the Georgia gun ownership rate of 31.6%.[3]

One third of all children live in homes with guns and 45% of gun-owning households do not store their firearms safely. [4] Seventy-five percent of children know where their parents store their guns. [5]  In 2016,  Georgia had the 4thhighest death rate in the nation by firearm injury which makes Georgians 2x as likely to die from a firearm injury in compared to New Yorkers[6].

Of note over the last few years at Children’s Healthcare of Atlanta on average we have seen 1 firearm injury every 2.5 weeks. In addition 10% of all Children’s trauma deaths in 2015 were firearm related.

When you consider where the US ranks in the world, 91% of firearm injuries in children of wealthy nations occur in the United States.[7]The U.S. General Accounting Office estimates that 31 percent of accidental deaths caused by firearms might be prevented with the addition of 2 devices: a childproof safety lock and a loading indicator.[8]

In our own Children’s ED-based study we were able to ascertain that when caregivers were educated to ask about firearm storage in the homes of their children’s playmates, 76% indicated they would. Interestingly, in this same study only 16% of parents reported ever being asked about presence of guns in their homes. In a recent published survey at some pediatric practices in Missouri 75% of parents felt pediatricians should ask about firearm safety but only 12% of parents reported having a conversation with their pediatrician.[9]

Thus it behooves us as pediatricians and medical care providers for children to ASK. Just as we ask about other important public safety initiative such as children riding in car seats, helmet while on bike and safe sleep. The AAP and the Brady Campaign have a website askingsaveskids.org which details ways pediatricians can educate their clients. In addition, he American College of Emergency Physicians has  developed a very handy discharge instruction sheet that can be distributed at each visit. (ACEP Discharge Instruction)

So what can you do as health care provider. #1 On June 21stASK parents about the presence of unlocked firearms?  #2 Educate your nursing staff (Asking Saves Kids Resources) #3 When screening for depressions also inquire if firearms are in the homes of your patients.

Don’t forget to ASK on Thursday, June 21st, because ASKING SAVES KIDS.

 

  1. Report WUIS. US Virologic Surveillance. Secondary US Virologic Surveillance 2018. www.cdc.gov.
  2. Gun Violence Archive. Secondary Gun Violence Archive 2018. gunviolencearchive.org.
  3. Kalesan B VM, Keyes K, Galea S. Gun Ownership and Social gun culture. Injury Prevention 2016:22:216-20
  4. Crifasi C DM, McGinty EE, Webster DW, Barry CL. Storage Practices of US Gun Owners in 2016. American Journal of Public Health 2018;108:532-37
  5. Baxley F, Matthew M. Parental Misperceptions about Children and Firearms. Archies of Pediatric Adolescent Medicine 2006;160:542-47
  6. Judd A. You’re twice as likely to be shot to death in Georgian than in New York (and other gun violence facts). Atlanta Journal Constitution2017.
  7. Grinshteyn E HD. Violent Death Rates: The US comparent with other High-income OECD Countries, 2010. American Journal of Medicine 2016;129:266-73
  8. Accidental Shootings: Many Deaths and Injuries Caused by Firearms Could Be Prevented. In: Office USGA, ed. Chairman Subcommittee on Antitrust, Monopolies, and I3usiness Rights, Committee on the PJudiciary,I7.S. Senate, 1991.
  9. Garbutt J BN, Dodd S, Sterkel R, Strunk R. What are Parents Willing to Discuss with Thei Pediatrian about Firearm Safety? A Parental Survey. Journal of Pediatrics 2016;179:166-71

 

Opioid Policies and Pediatrics: When the Pendulum Swings Children Will Get Hurt

Mike Greenwald, MD
mgreenw @emory.edu

 

 

 

 

 

 

Even if you have turned off all news sources over the past 2 years it would be hard to escape the urgent alarms regarding opioid misuse in the US. The statistics are remarkable.

  • Since 1999, overdose deaths involving opioids quadrupled.1
  • 2000-2015:greater than half a million people died from drug overdoses.
  • 91 Americans die every day from an opioid overdose.
  • 1999 to 2010: number of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled.2,3

This is compelling evidence that we have a problem – perhaps some more than others.  Opioid addiction is a frequent challenge for those caring for adults in the Emergency Department with some centers (e.g. rural) seeing more of this than others. Those who care for injured and ill children are left with 2 important questions: (1) What is the evidence regarding opioid addiction in children? (2) To what extent is the management of acute pain in children contributing to an increase in opioid related morbidity and mortality?

You would expect that a large percentage of opioids are prescribed from Emergency Department visits.  That is, after all, the place where we usually go to address severe pain.  Indeed, Emergency Medicine physicians have been targeted as one of the top specialties prescribing opioids. FDA data from 2009 shows that Emergency Physicians prescribe 4.7% of opioids.  However this reflects short acting opioids and the top prescribers are responsible for a far greater percentage: Family Medicine 26.7%, Internists 15.4%, Dentists 7.7%, Orthopedic surgeons 7.7%.4In a 2016 study by Chen et al. Emergency Physicians ranked 9thin opioid prescribing and the top 8 physician groups were responsible for more than 25 times as many opioid prescriptions as Emergency Physicians.5 An analysis of opioid prescribing and subsequent heroin indicates that “1 new heroin abuser might result from the administration of opioids to approximately 7,864 patients”.6  While prescribing practices by Emergency Physicians are a valid target for analysis and guidance, their contribution to the crisis is not clear.

Even less certain is the pediatric part of this equation. The relationship between opioid administration for pediatric pain and the development of opioid addiction is an uncommon and likely rare event.  In contrast, studies comparing opioid use for children and adults consistently demonstrate that children receive opioids in far lower weight based doses (approximately 50% in most studies) and frequency for similar conditions (e.g. post operative pain, procedural pain, acute pain).7

For the past several decades specialists and researchers in pediatric pain have gradually succeeded in dispelling the misconceptions that younger patients do not feel pain and that opioids are more dangerous for them than poorly treated pain.7One of the ironies of the current attention to prescribing practices is the change in terminology.  For many years advocates for better pain treatment have urged colleagues to stop using the term “narcotic” when describing opioid use for pain management.  The term has a pejorative connotation that many found counterproductive in treating pain. Now even lay people know the term “opioid” but in the context of opioid misuse.

Regardless of whether or not the administration of opioids to children in severe pain is contributing to an opioid crisis, the care of pediatric patients will no doubt be affected by the response for adult patients. A quick internet image search for “opioid billboard” reveals multiple versions of the one below:

This shocking message may be working. We now see phrases in the literature such as “Emergency Department: The birthplace of opioid addiction” and “Opioid-Free Emergency Departments”.  How will these attitudes and efforts eventually affect the care of your pediatric patients?

Pendulum swings in public opinion are not surprising.  Our challenge is to temper valid concerns with evidenced based approaches and thoughtful analysis to effectively address problems without creating new ones. Pediatricians need to be front and center in tackling these concerns and not cede that role to those with less expertise and perspective.

The first step is improved education and research. Who is at risk for addiction (e.g. age, co-morbidities)? Where are the misused opioids coming from (e.g. valid prescriptions vs illicit production or diversion)? Physicians who prescribe opioids should have a clear understanding of the pros and cons of opioids for different conditions and the difference between opioid tolerance, dependence, and addiction. Opioid tolerance and sometimes dependence is seen in the setting of regular use of opioids for many consecutive days. Opioid addiction in pediatrics remains a rare condition.

We can lower the risk of diversion by reducing the number of pills prescribed to adequately control severe acute pain without prohibiting the limited use of these medications in appropriate circumstances.  While individual experiences will vary, it is not unreasonable to anticipate a few days of moderate-severe pain after an acute injury or painful procedure.  In many cases regular use of ibuprofen (10mg/kg/dose q6hrs) supplemented with hydrocodone (0.15mg/kg/dose q4hrs prn) is a safe and effective way of getting through this period. Heed the phrase: The Right Tool for the Right Job.  Just as using opioids for less than severe pain introduces unnecessary risk, relying soley on low potency analgesics such as NSAIDs for severe pain will result in needless suffering and undermine the relationship with our patients and their families.

Finally, we can draw lessons from similar challenges in changing physician behavior such as the efforts to reduce inappropriate antibiotic use and ionizing radiation from unnecessary CT scans.  Like antibiotics and CT scans, opioids are an important tool for patient care that have a role for specific indications.  There is no doubt that creating guidelines for opioid use will present unique challenges as pain is ultimately a subjective data point and pain experiences are highly multi-factorial. That challenge, however, is not insurmountable and calls for a nuanced approach that addresses the concerns of patient, clinician, and society.

References

  1. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.
  2. US Department of Justice. Automation of Reports and Consolidated Orders System (ARCOS). Springfield, VA: US Department of Justice, Drug Enforcement Administration (DEA); 2011.
  3. Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999—2008.MMWR 2011; 60(43):1487-1492.
  4. Greene J. Amid Finger-Pointing for an Overdose Epidemic, Emergency Physicians Seek Pain Control Alternatives. Ann Emer Med 2016; (68;2) 17A-20A.
  5. Chen JH et al. Distribution of Opioids by different medicare prescribers. JAMA Int Med. 2016;176;259-261.
  6. Yealy DM and Green SM. Opioids and the Emergency Physician: Ducking Between Pendulum Swings. Annals Emerg Med 2016;68(2) 209-212.
  7. Finley GA and McGrath PJ (eds). Acute and Procedural Pain in Infants and Children. Seattle: IASP Press, 2001; 151, 159-160.

 

 

 

 

CHOA EMERGENCY DEPARTMENT EVALUATIONS OF PSYCHIATRIC ILLNESS

 

Swathi Khrishna sakris2@emory.edu

Sonali Bora Sonali.bora@choa.org

Many primary care providers are on the front lines of fielding questions and identifying symptoms of psychiatric illness in children and adolescents in the community setting.  We have put together a quick guide that addresses some common questions and concerns on how to refer non-emergent psychiatric concerns to community outpatient resources and avoid unnecessary and costly ED visits

What kind of services are and are not available to children with psychiatric/behavioral complaints in the ED?

Psychiatric assessments in the medical ED setting are brief and focused.  They are not full psychiatric evaluations and are not meant to provide new diagnosis or start new medications.   They are simply a crisis assessment to evaluate for the child’s safety and the safety of others. If a patient is deemed unsafe to self or others, they will be transferred to a primary psychiatric facility for further treatment.  It is an assumption of many community providers that patients with psychiatric complaints must first be directed to a medical facility for “medical clearance”.  In fact, all psychiatric facilities are emergency receiving facilities and have the resources to provide medical clearance and directly accept healthy patients with behavioral and psychiatric complaints.  Most psychiatric hospitals perform psychiatric assessments 24/7,  and can place a patient on a 1013 or admit them voluntarily. Psychiatric facilities can also refer families to outpatient or lower levels of care if inpatient psychiatric hospitalization is not warranted. PLEASE NOTE CHOA DOES NOT HAVE INPATIENT PSYCHIATRY SERVICES.

What  intensive outpatient treatment options  are available for patients not in crisis?

Some psychiatric facilities offer Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP). A PHP is a nonresidential treatment program that is hospital-based. The program provides diagnostic and treatment services on a level of intensity similar to an inpatient program, but on less than a 24-hour basis.

An IOP Program offers group and individual services for 10-12 hours each week and allows individuals to participate in daily activities like school or work.

What outpatient resources are available in my area?

The Georgia Crisis Access Line (GCAL) is the first line referral for patients with medicaid or CMO’s looking for mental health services in Georgia.  GCAL can refer for emergency and routine psychiatric services and can be reached at 1-800-715-4225.   Patient or providers may search for community mental health providers in their area based on location and age group at http://georgiacollaborative.com/.  This is an online database of community mental health providers maintained by GCAL.  Providers can also ask parents, to look up mental health providers on their insurance provider’s website.

CHOA’s Behavioral Health Initiative Line (404-785-DOCS) is also available for community providers to ask general questions about psychiatric medications and management of symptoms on an outpatient basis.

What patients should I always send to the Medical ED first?    

Ingestions, psychiatric symptoms with coexisting medical symptoms ( i.e. fever, viral/bacterial illness, abnormal labs) and first break psychosis should  be directed to medical ED first.

Sedation Services at Children Healthcare of Atlanta

David Banks, MD david.banks@pemaweb.com

In the late 1990’s, as pediatric MRI imaging services came of age, pediatric hospitals were faced with a growing need for quality pediatric sedation services. Many institutions met this need initially by assembling experienced nurses and having them manage the sedations.  By the early 2000’s, the nurse-run services were being replaced by physician services, as the Joint Commission developed new standards for deep sedation services.  In compliance with Joint Commission standards, both Children’s campuses Scottish Rite and Egleston developed physician run sedation services.  Pediatric Sedation Services (PSS) was developed on the Scottish Rite campus by the PEMA physician group, and Children’s Sedation Services (CSS) was formed as a combined effort by the critical care and pediatric emergency medicine teams at the Egleston campus.  Both PSS and CSS have grown in volume and scope of services and, as a system, represent one of the largest pediatric procedural sedation services, performing over 11,000 cases per year.  

Services Provided

The sedation services at CHOA provide predominantly “deep sedation,” where the requirements for completing a study involve the patient lying completely still, typically for imaging studies such as MRI, CT, nuclear medicine/PET imaging, or for Auditory Brainstem Response (ABR) hearing studies.  We also provide deep sedation for difficult or painful procedures, commonly referred to as “procedural sedation,” where the patient not only needs to be deeply asleep, and reasonably still, but also have the pain of the procedure appropriately managed.  Deep procedural sedation is provided in multiple areas across the system, including the AFLAC Cancer Centers (bone marrow studies or lumbar punctures for intrathecal chemotherapy,) the emergency departments (fracture reduction, abscess drainage, complex wound management), and interventional radiology (difficult LPs, PICC line placement, percutaneous drainage of appendiceal abscesses).  Deep sedation services account for approximately 95% of the sedation services’ consultations.

In some situations, moderate sedation is appropriate to meet the patient’s needs. One example would be an older patient undergoing lumbar puncture for intrathecal chemotherapy.

Our services also provide anxiolysis for patients undergoing minor procedures that are minimally painful but associated with significant patient stress.  Typical circumstances where anxiolysis is provided include obtaining IV access in challenging situations when the vascular access team is required and for bladder catheterization in a patient with urologic issues requiring a VCUG.

Most patients are also managed in conjunction with Child Life Services to help relieve the patient’s stress and anxiety.

Medications typically utilized by our sedation teams are:

– Deep

propofol, dexmedetomodine, methohexital, ketamine, and fentanyl

– Moderate

fentanyl and midazolam

– Anxiolysis

nitrous oxide gas

midazolam

Preparing Patients and Families for Sedation

The majority of the patients that receive sedation are electively scheduled cases that are previewed well in advance of their appointment and are prescreened for appropriateness for the sedation services. Our current involves having each case reviewed by an experienced sedation nurse in advance. Families are contacted in advance to assure the patient’s appropriateness for the sedation service.  Some of these patients may be deemed to be higher risk and may be referred to the anesthesia service for management.  Specific conditions that may result in referral to the anesthesia service include:

  • Difficult airway
  • Patients with a Z score of >2.5 for BMI for age (patients whose comparative weights are overweight for age based on an international standard scale)
  • Laryngomalacia or stridor at rest
  • Poor airway tone
  • Excessive secretions, GERD
  • Chronic lung disease resulting in O2 requirement of ventilator support
  • Congenital heart disease with R to L shunts or pulmonary hypertension
  • Certain metabolic disorders
  • Patients with significant medical complexity

After screening, families are then given pre-procedure instructions that include arrival time, a discussion of NPO times, and instructions on whether to take the morning dose of routine medications on the day of the procedure. For purely elective procedures, families are encouraged to reschedule if the child is ill just before or at the time of the scheduled procedure.

NPO Guidelines:

Heavy, greasy meal                8 hours

Solids, milk/formula               6 hours

Breastmilk                              4 hours

Clear liquids                            2 hours

 

Be Selective.  Weigh All the Risks

Sedation is not without short term and long-term risks.  As sedationists, we are comfortable managing the well-known short-term risks of deep sedation, including depressed respiratory drive, hypoxemia, and loss of airway tone with subsequent airway obstruction.  These events occur in approximately 1 in 20 deep sedations, and the sedation team is prepared to manage them.  However, if the case is truly elective, and the patient is at greater risk on the day of the procedure due to respiratory illness or other medical issues, then rescheduling for 3 or 4 weeks later may allow the study to be obtained with less risk.

Long term risk of deep sedation and anesthesia is still unclear.  Recent studies demonstrate that pups of multiple species exhibit neuro-developmental delay following prolonged or repeated exposure to propofol, ketamine, sevoflurane, or halothane. Large human population studies associate cognitive delay later in life in children that experienced multiple anesthetic exposures prior to age 3 years. However, there is no direct link demonstrating harm from deep sedation/anesthesia in human studies.

As a result of these studies, in December 2016, the FDA issued a Drug Safety Communication warning that “repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.”

Interpreting animal studies that appear to demonstrate harm from sedation and anesthetic agents is difficult, as the methodologies and logistics of performing these studies are quite challenging.  Drawing conclusions from large human population studies is also fraught with difficulty, as there is no way to assess the effects of potential co-morbidities and surgical complications in patients receiving multiple anesthetics. In an attempt to keep this all-in perspective, it is crucial to remember that there are numerous studies delineating the deleterious effects on children of inadequate sedation or incomplete pain management during difficult or painful procedures. And we have all seen the devastating effects of delayed diagnosis of certain serious medical conditions.

The Society for Pediatric Sedation has been at the forefront of research in the field of pediatric sedation since its inception in 2007.  I recommend visiting the SPS website- www.pedsedation.org and www.SmartTots.org for more information regarding this research.

With all this in mind, please judiciously consider what sedated test you order. Is it necessary or will the results change your patient care?  As providers of healthcare to children, we should all be certain that any study or procedure that has been prescribed for any child is truly indicated, and that the risk-benefit ratio for potential short and long-term risks of harm has been carefully assessed.

For questions or concerns about ordering imaging studies and sedation services for all the CHOA facilities, contact:  404-785-2787 (Monday-Friday)

On weekends or after hours, you may contact the departments directly: 404-785-1487 for Egleston and 404-785-4698 for Scottish Rite.

Thank you for choosing Children’s and entrusting your patients to us.

 

HIV Screening Recommendations in Adolescents

Lauren Middlebrooks, MD
lauren.sullivan. middlebrooks@emory.edu

 

 

 

 

 

 

 

HIV/AIDS
What an illness
My life is meaningless
You make my life lifeless
You make me hopeless
What an illness

You don’t care who you kill
It old and young
Big and small
Bad or good
What an illness

The sky was blue
Now its black
People hate each other
Because of you HIV/AIDS
What an illness

By SN, Primary school KaNyamazane, South Africa

As depicted in the poem above, written by a young child living with HIV in South Africa, HIV and AIDS has carried a reputation deeply rooted in fear, shame, and distrust.  Stigmas have impacted patient disclosure, provider discussion, and have limited early screening and diagnosis of at risk populations1. Once thought of as a disease only extending across international borders, Georgia is now ranked #5 in the United States (U.S.) for some of the highest rates of HIV in our nation.  The rising rates in downtown Atlanta specifically, have been compared to rates of HIV in third world countries, such as “Zimbabwe, Harare or Durban2.”  As if these statistics aren’t alarming enough, adolescents and young adults, ages 13-24, accounted for 22% of all new HIV infections in the U.S. in 2015—that’s roughly 1 in every 5 young people affected by this virus3.  In a 2005 Youth Risk Behavior Surveillance System assessment (YRBS), almost half of high school students surveyed nationwide reported having had sexual intercourse, yet only 11% had ever been tested for HIV4.  Adolescents and young adults quickly became an at-risk cohort, and in response to this new epidemic, the Centers for Disease Control and Prevention (CDC) made national recommends in 2006 for routine, opt-out HIV testing beginning at 13 years of age.  Interestingly, prior studies concluded not only that many clinicians had poor knowledge of these recommendations made over 10 years ago, but that the prevalence of HIV testing did not significantly change amongst high school students between the 2005 and 2015 YRBS’s.

Adolescents and young adults have the most challenges in links to primary care, mainly due to limitations in transportation, health insurance, and concerns for breeched confidentiality.  As a result, approximately 60% of HIV-positive adolescents remain unaware of their status.   Of adolescents who did see a primary provider, only half of primary care physicians even touched on sexual content, and the average amount of time discussing a sexual history was 36 seconds5.  It is our duty as providers to have open conversations with each one of our adolescent patients regarding their sexual history, preferences and practices.  It is also important that they understand the results will remain confidential and that every effort will be made to contact the patient directly with any new positive results. Per official recommendations, all patients 13-64 years of age are recommended to have at least one HIV test in their lifetime.  Persons who frequent high prevalent settings, including homeless shelter, prisons, and adolescent clinics, along with persons engaging in risky sexual behavior (multiple sexual partners, MSM, sex in exchange for money, substance abusers), may be tested at least once per year, or as frequent as every 3-6 months.

The most sensitive and specific tests for HIV are 4th generation antigen-antibody tests.  This is highly encouraged over others as it will more accurately capture true positives as soon as 4 weeks after exposure.  Positive tests should be relayed in person, not over the phone, and those patients can be referred to the Grady Ponce Center for further management and treatment.

Together we can normalize HIV screening in the adolescent and young adult population, reduce stigma associated with HIV/AIDS, and assist in managing this public health crisis.

For more information on the Grady Ponce Center, please visit: https://www.gradyhealth.org/specialty/ponce-de-leon-center/

or Contact Ponce Clinic Nurse-Deborah Ferris-404-516-4340 for any additional questions

References:

  1. 2017 August 29. HIV Stigma and Discrimination.  Retrieved from: https://www.avert.org/professionals/hiv-social-issues/stigma-discrimination
  2. Huddleson D. Atlanta HIV Epidemic Compared to Third World Countries. WSB-TV 2 Atlanta 2016. Retrieved from: http://www.wsbtv.com/news/2-investigates/atlantas-hiv-epidemic-compared-to-third-world-african-countries/263337845
  3. Health TGDoP. HIV Surveillance Fact Sheet, 2014. 2016
  4. Laura Kann P, Tim McManus, MS, William A. Harris, MM, Shari L. Shanklin, MPH, Katherine H. Flint, MA, Joseph Hawkins, MA, Barbara Queen, MS, Richard Lowry, MD, Emily O’Malley Olsen, MSPH, David Chyen, MS, Lisa Whittle, MPH, Jemekia Thornton, MPA, Connie Lim, MPA, Yoshimi Yamakawa, MPH, Nancy Brener, PhD, Stephanie Zaza, MD. Youth Risk Behavior Surveillance-United States 2005. Center for Disease Control and Prevention Morbidity and Mortality Weekly Report 2006;55(SS-5):19-22
  5. Alexander, S. C., Fortenberry, J. D., Pollak, K. I., Bravender, T., Davis, J. K., Ostbye, T., Shields, C. G. (2014). Sexuality Talk During Adolescent Health Maintenance Visits. JAMA Pediatrics, 168(2), 163.doi:10.1001/jamapdiatrics.2013.4338

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The new way to test poop! The GI PCR or FilmArray Gastrointestinal Panel

 

Deborah Bloch, MD
deborah.bloch@emory.edu

Mark Gonzalez, MD
mark.gonzalez@choa.org

Craig Shapiro, MD
cshapi2@emory.ed

FilmArrayTM Gastrointestinal Panel?

The FilmArrayTM Gastrointestinal Panel is a rapid test (~2 hr turnaround time) offered by the CHOA microbiology lab for detection of common gastrointestinal pathogens (see Figure 1), which includes bacteria, viruses and parasites. Because of the comprehensiveness of the panel, in most cases stool culture, ova and parasite (O&P) examination, and antigen testing for Adenovirus 40/41, Rotavirus, Cryptosporidium spp. and Giardia lamblia no longer need to be ordered (see Figure 1 for additional information)

 

When should I order the FilmArrayTM Gastrointestinal Panel?

The panel should be ordered for a patient of any age with diarrhea (> 3 unformed stools in a 24 hour period who is not on a laxative) for whom you are worried about infection with a GI pathogen that may impact patient management or isolation practices. Testing should not be performed on formed stool. Please contact the microbiology lab (404-785-6426) or the ID consult service (404-785-DOCS) with any additional questions.

WHEN TO CONSIDER SENDING GI PCR PANEL FOR A PATIENT WITH DIARRHEA:

  • Fever and frankly bloody/mucusy diarrhea (if concern for C diff, also send stool for C diff toxin – not included in GI PCR panel)
  • Prolonged diarrhea>7 days (or before referral to GI for evaluation)
  • Travel-related diarrhea (if persistent or red flags; if concern for worms, also send stool for ova/parasites)
  • Immunocompromised patient – if concern for non-viral etiology
  • IBD patients- newly suspected or unusual change in stools in established IBD pt

What do the results mean?

For non-severe or prolonged (<7 days) illnesses caused by many of the pathogens detected (e.g. EAEC, EPEC, STEC, non-typhoidal Salmonella, all viral pathogens, Giardia lamblia and Cryptosporidium species), treatment is supportive; however, for patients in certain age groups, and patients with certain comorbidities or immunocompromising conditions, antimicrobial treatment may be indicated.

Because the FilmArrayTM Gastrointestinal Panel detects nucleic acids, it cannot differentiate active infection from treated infection or colonization; this must be done by correlating clinical symptoms. Results can remain positive for weeks or months after an infection especially in young children and immunocompromised patients.

Figure 1. Reported pathogens on the FilmArrayTM Gastrointestinal Panel at CHOA and which reflex to culture.

Should I also order a stool culture to get antimicrobial susceptibility results?

When testing is performed in the CHOA microbiology laboratory, a stool culture order is not necessary as positive panels will automatically reflex to culture, and if the isolate is recovered antimicrobial susceptibility testing will be performed when appropriate (Figure 1).

Should I order an O&P examination? What about for patients who drink and use well water?

O&P examinations should be ordered if you suspect a parasite other than those listed on the panel (e.g., for patients who returned from travel abroad). It should be noted that the top parasitic causes of well water contamination are Giardia and Cryptosporidium, which are tested for on the panel. Maximal sensitivity for parasite detection by O&P examination requires up to three stool specimens collected over a 7-10 day period.\

Should I order C. difficile toxin testing separately?

Yes, but it is not typically recommended for children under 2 year of age due to high rates of colonization. 

Should I reorder the FilmArrayTM Gastrointestinal Panel to test for cure?

No. Nucleic acids detected on the panel may remain positive for an indeterminate amount of time, and the FilmArrayTM Gastrointestinal Panel should only be ordered on unformed stool.

 

Caring for Our Transgender Patients: The Basics

By Atsuko Koyama
atsuko.koyama@emory.edu

Chief Complaint: Rash

Andrew is a 16-year-old transman (female-to-male, FTM) presenting with a red, painful rash of his bilateral inner thighs. On exam, you note an area in the inguinal region concerning for cellulitis. Upon questioning him alone, he reports that he began using a “STP” device 2 weeks ago. “What is a STP device?” He answers that it is a stand-to-pee device that he straps on with a waist harness in order to urinate standing, as other males do. STP devices are used by some FTM who have not had bottom surgery. They can cause skin irritation/breakdown if ill-fitting.

Transgender youth

Transgender is an umbrella term for those whose gender identity (a person’s sense of their own gender as male, female, or some other gender) differs from their biologic sex (typically assigned at birth based on chromosomes or anatomy). Population estimates for transgender youth is not well defined. One study estimates that 0.7 to 3.2% of 13 to 18 year olds identify as transgender.1 A study from 2017 estimated that 1 in every 250 adults are transgender. 2

What’s in a name? Definitions.

There are many terms you may hear when discussing gender. Transgender can refer to an individual or a larger community, and it is an umbrella term for those whose gender identify differs from their biologic sex and from conventional notions of gender. Alternatively, cisgender is someone whose gender identity DOES match up with our cultural notions about gender. Gender identity: A personal conception of oneself as male, female, both, or neither, experienced in self-awareness or behavior. Gender expression: A person’s outward expression of gender. Gender dysphoria: Discontent a person may feel about the biological sex they were assigned at birth.

Gender and sexuality

Gender and sexuality can be viewed on a spectrum and considered fluid rather than being binary entities. They are not either/or concepts. One can be biologically male, identify with a feminine gender identify (as female), and can be attracted to and have sexual relationships with males, females or both. Gender play is a passing interest that involves playing out different gender-typical roles. Gender nonconforming youth behavior is more persistent, consistent and insistent. It is cross gender expression, wanting other gender body parts, or not liking one’s gender or body.

Transgender youth, mental health, and healthcare access

Transgender adolescents have a 2 to 3-fold increased risk of depression, suicidality, anxiety, and mental health treatment. 3 Given these risks, it is important to understand that identifying as transgender is not in and of itself a mental health disorder. It is social stigma, familial rejection, and social isolation that contribute to the higher rates of mental health issues. Research shows that with acceptance and access to healthcare to help transition, youth are protected from gender dysphoria and reactive depression. 4 Lack of access to accepting and transgender friendly health care services is also a barrier to health for transgender youth. One study revealed that 52% of patients who presented to an ER experienced trans-specific negative experiences, while another showed that 13% of transgender patients were denied equal treatment in an ER setting due to their gender identity/expression. 5,6 

How should we communicate with our patients? Language is important so that we can communicate with our transgender patients in a way that is respectful and affirming.

Conversations can start with something as simple as asking, “Do you feel more like a girl, boy, neither, both?” “What name or pronoun fits you/do you prefer?” When examining a patient, use non sex-specific terms. Going back to the initial patient vignette, one may say to Andrew, a FTM teen, “I need to perform a genital exam,” instead of “I need to perform a vaginal” exam. Use the word “chest” vs. “breast,” “genital” vs. “vaginal or penile.” When speaking with transgender patients, ask questions necessary to assess the issue, but avoid unrelated probing. “What’s your anatomy and what surgeries have you had? I need to know this information in order to best treat you.” If you have a patient who presents with a broken finger, it is unnecessary to ask about their reproductive anatomy.

What might we expect from a patient who is transitioning?

Chief complaint: Chest pain, shortness of breath, and URI symptoms

Jenny is a 17-year-old transwoman (male-to-female, MTF) on estrogen therapy. She has a PMH of moderate persistent asthma. What is her risk of a pulmonary embolus?

Phenotypic transitioning occurs in phases: reversible, partially reversible, irreversible, and surgical. The reversible portion of transition includes the adoption of preferred gender hairstyles, clothing, play, perhaps a new name and suppression of biologic gender puberty using GnRH analogues (defined below). The portions of the reversible phase that do not involve suppression of puberty will sometimes occur before the age of ten. Some children may begin GnRH analogues at around age 12 or 13, when they are still Tanner Stage 2, and initiate hormones several years later. GnRH analogues lead to fully reversible changes, provide extra time for psychotherapy and a relief of their gender dysphoria. They prevent secondary sex characteristics that would have required more invasive intervention later. Partially reversible changes are brought about with hormone therapy, which is offered in most centers around age 15 or 16, and irreversible changes with surgery, typically not before age 18.

Medications

All medications have potential side effects and risks, and it is important for providers on the front lines in primary care and urgent/emergency care know what those potential risks are. However, it is important to frame the risks and benefits of treatment for transgender youth in light of the risks of depression, anxiety, and suicide that youth without treatment face. Studies support the mental health of trans youth being much improved with appropriate, early access to health care including the medications discussed below.

GnRH analogues stop puberty. There are few side effects aside from injection pain and withdrawal bleed if menstruating. Estrogens induce the development of female secondary sexual characteristics. The greatest risk for estrogen therapy is the 20-45 fold increase of venous thromboembolism (VTE). 2-6% of hormonally treated MTF patients experience a VTE. Other lower risk, possible complications include prolactinomas, pituitary adenomas, hypertension, hypertriglyceridemia causing pancreatitis, gall bladder and liver disease, and the potential biological female risk of breast cancer. Anti-androgens reduce the effects of endogenous male sex hormones. Most pertinent are spironolactones causing hyperkalemia, hypotension, or ataxia. Testosterone induces the development of male secondary sexual characteristics. Risks include hepatotoxicity, insulin resistance, weight gain, decreasing high-density lipoproteins (HDL), increasing triglycerides and homocysteine levels, and polycythemia. There is a theoretical risk of breast cancer and endometrial cancer (testosterone is aromatized to estrogen), so patients who have chest or genital symptoms need workup appropriate to their anatomy.

Transgender youth flourish

Research shows that transgender people report numerous positive aspects related to successful transitioning. 7 Familiarizing yourself with local resources (medical, mental health, peer and parent support groups) and learning more about transgender youth will help to create a more supportive health care system for trans youth and their families for successful transitioning.

Last words from experts in the field of transgender care

  • Lack of trans friendly health services, transphobia, and real or perceived prejudice and discrimination lead to mental health disorders and undertreatment of medical conditions.
  • Transgender kids need love and acceptance by family, school, and community, like all teens.
  • Using incorrect names or pronouns and misgendering IS a big deal to patients, and we all need to help systems counteract or eliminate this.

 

Local Physicians Accepting Referrals of Transgender Youth

  1. Comprehensive care of transgender youth: David Levine, MD, Morehouse Healthcare, 1800 Howell Mill Rd, Atlanta, Georgia 30318, 404) 756-1400
  2. Comprehensive care of transgender youth: Isabel Lowell, MD, MBA QMed,Website: queermed.com, Email: info@queermed.com, Office phone: 404-445-0350
  3. For medications only: Leonidas Panagiotakopoulos-CHOA Endocrinology-404-785-KIDS

 

Provider Resources 

References

  1. Herman JL, et al. “Age of Individuals Who Identify as Transgender in the United States.” The Williams Institute, UCLA School of Law. January 2017.
  2. Meerwijk EL, et al. “Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples.” Am J Public Health, 2017;107:e1-8.
  3. Reisner SL, et al. “Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study.” J Adolesc Health. 2015;56:274-79.
  4. Ryan C, et al. “Family Acceptance in adolescence and the health of the LGBT Young Adults.” J Child Adolesc Psychiatr Nurs. 2010;23:205-13.
  5. Bauer GR, et al. “Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey.” Ann Emerg Med. 2014;63:713-720.
  6. Grant, JM et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
  7. Riggle, ED et al. “The Positive Aspects of Transgender Self-Identification.” Psychol Sex, 2011;2:147-58