Egyptian_Pediatric yahoo group

Egyptian_Pediatric yahoo group

http://health.groups.yahoo.com/group/
egyptian_pediatric/

http://health.groups.yahoo.com/group/
egyptian_pediatric/

AAP GRAND ROUNDS

Vol. 23 No. 4 | Pages 37-48 |

www.aapgrandrounds.org

April 2010

Mission: To provide pediatricians with timely synopses and critiques of important new studies relevant to
pediatric practice, reviewing methodology, significance, and practical impact, as part of ongoing CME activity.

YOUNG PHYSICIANS

Cash Transfers: Small Investments, Big Child Health Gains

Source: Fernald LC, Gertler PJ, Neufeld LM. 10-year effect of
Oportunidades, Mexicos conditional cash transfer programme, on
child growth, cognition, language, and behaviour: a longitudinal
follow-up study. Lancet. Epub 2009 Nov 04; doi:10.1016/S01406736(09)61676-7

treatment group did not alter the significance of the results.

The authors conclude that these results are consistent with the findings of
the study performed when study children were 3 to 5 years of age and suggest that the benefits of the Oportunidades program may extend beyond the
monetary value to improvements in growth, language, cognition, and behavior.

Commentary by

PICO
esearchers from the University of California, Berkeley,
Question: Among impoverished families in
Mexico participating in a conditional cash
the Instituto Nacional de Salud
transfer program, what are the long-term
Pblica, Cuernavaca, Mexico, and the
(10-year) effects?
Micronutrient Initiative in Ottawa
Question type: Intervention
performed a 10-year follow-up study
Study design: Case control follow-up study
to assess the effect of Oportunidades,
Mexicos multi-ministry conditional
cash transfer (CCT) program. Oportunidades was initiated in 1998 to provide
cash payments (20%-30% increase of household incomes) to impoverished families on the condition that they participate in health education, receive preventive
services, and comply with scholastic enrollment for age-appropriate children. At
the initiation of the program low-income communities were randomly assigned
for immediate enrollment or enrollment 18 months later. An initial follow-up
study 3.5 to 5 years after the program started showed improved height in the
children and gains in both cognitive and language development.1 For the current study, the effects of the dose of the program were assessed by comparing
outcomes in children who were enrolled in the program either early or late,
and by assessing the association of the amount of cash transfer with outcomes.
Outcome measures included physical growth, cognition and language development, and socio-emotional development. The study was conducted in 2007,
when the participants were 8 to 10 years old.
Data were analyzed for 1,093 children from the early enrollment group and
700 from the late enrollment group. There were no differences between enrollment groups in height-for-age z score, BMI-for-age z score, cognitive scores,
or language assessment scores. However, children randomly assigned to early
treatment had fewer maternal-reported
behavior problems than those in the late
treatment group. The amount of cumulaINSIDE
tive cash that was transferred to participating households at the 10-year assessment
Pre-Op Skin Prep: ChlorhexidineAlcohol vs Povidone-Iodine
(median, approximately $4,000) was asHerpes Zoster Following Varicella
sociated with high verbal and cognitive
Vaccine
scores, decreased maternal reporting of
Emergency Contraception
behavior problems, and higher height-forGuidelines: Individual Values &
age z scores in all households. Early enrollAdherence
ment in the program was associated with a
Childhood Predictors of Adult Type
2 Diabetes
1.5 cm increase in height in study children
Acanthosis Nigricans: Cutaneous
whose mothers did not have formal eduMarker of Metabolic Abnormalities
cation, but this was not seen in children
Pediatric Melanoma:
whose mothers were educated. Controlling
One Institutions Experience
for individual, parental, and household
With 150 Patients
characteristics, state of residence, and
Extremity Surgery in Ambulatory
Children with CP

Andi L. Shane, MD, MPH, MSc, FAAP, Emory University School of Medicine,
Atlanta, GA
Dr Shane has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

A 2007 review of six cash transfer programs in Mexico, Nicaragua, Colombia, Honduras, Brazil, and Malawi found that all increased the short-term use
of health services and improved anthropometric and nutritional parameters
among enrollees.2 Some methodological problems limited outcome assessment of the contributions of different aspects of each of the programs. The
cost-effectiveness of programs in severely resource-limited settings as well
as a paucity of data on the optimal size of cash transfer to achieve the desired
outcome remain problematic.
In 2006 Mayor Bloomberg of New York City initiated a privately funded
program (Opportunity NYC Family Rewards) based on the cash transfer model
of Oportunidades to impact child education, family health, and adult workforce
outcomes. This is the first CCT program in the US and is active in six communitybased organizations within the South Bronx, East and Central Harlem in Manhattan, and Brownsville and East New York in Brooklyn. A projected period of
five years will be required to completely assess the impact of the interventions.3

Editors Note
Poverty is a root cause of health disparities and the CCT is one approach to
overcoming this handicap. In a 2008 article these same authors outlined the program in more detail.1 Only a fifth of the mothers and fathers had not completed
any schooling; families owned a small amount of land and most owned small
animals; one-third had piped water; and three quarters had electricity. Families
received a maximum of $59/month/child for a minimum of three years, plus
food supplements for pregnant and lactating mothers and for children up to 24
months, and for those of low weight up to 5 years. Families received cash on the
conditions that the pregnant women receive prenatal care, birth attendance, and
post-partum care; that children receive regular medical check-ups and attend
school; and that men be seen for prevention and control of hypertension and
diabetes. The authors report that a doubling of the cash transfer resulted in an
increase in height-for-age, lowering of stunting, decrease in BMI, and improvement in both short-term and long-term memory and in language development.
References

1. Fernald LCH, et al. Lancet. 2008;371:828-837.

2. Lagarde M, et al. JAMA. 2007;298:1900-1910.
3. Bloomberg MR. Center for Economic Opportunity: Early Achievements and Lessons
Learned 2009. Available at: nyc.gov/ceo, accessed 30 November 2009.

Key words: conditional cash transfer, intervention, psychosocial outcome

See related editorial on back page.

Epilepsy in Angelman Syndrome and

Response to Treatment

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OTOLARYNGOLOGY/HEAD & NECK SURGERY

Pre-Op Skin Prep: Chlorhexidine-Alcohol vs Povidone-Iodine

Source: Darouiche RO, Wall MJ, Itani KMF, et al. Chlorhexidinealcohol versus povidone-iodine for surgical-site antisepsis. N Engl
J Med. 2010;362(1):18-26; doi:10.1056/NEJMoa0810988

esearchers from multiple

institutions conducted a PICO
randomized trial in adult Question: Among patients undergoing
clean-contaminated surgery, does
patients to compare the rate of preoperative skin cleansing with
postoperative surgical-site in- chlorhexidine-alcohol result in decreased
fections following preoperative rates of postoperative infection compared to
cleansing with povidone-iodine?
skin cleansing with either 2%
Question type: Intervention
chlorhexidine gluconate and
Study design: Prospective, randomized trial
70% isopropyl alcohol or 10%
povidone-iodine. The study was
performed at six university-affiliated hospital sites in the US between
2004 and 2008. Eligible study patients were undergoing cleancontaminated surgery (ie, colorectal, small intestinal, gynecologic, or
urologic surgery under controlled conditions with minimal spillage
and not encountering infected urine or bile1). The primary outcome
was any surgical-site infection within 30 days after surgery.
In the intent-to-treat analysis, data from 849 patients were analyzed, including 409 randomized to the chlorhexidine-alcohol group
and 440 to the povidone-iodine group. The surgical-site infection
rate was lower in the chlorhexidine-alcohol group (9.5%) than in
the povidone-iodine group (16.1%; relative risk=0.59; 95% CI, 0.410.85; P=.004). In addition, the time to infection after surgery was
significantly longer in the chlorhexidine-alcohol group than in the
povidone-iodine group (P=.004). When looking at specific infection
types, chlorhexidine-alcohol was found to be more protective than
povidone-iodine against both superficial incisional infections (4.2%
vs 8.6%; P=.008) and deep incisional infections (1% vs 3%; P=.05),
but not against organ-space infections.
The finding of fewer post-surgery infections among patients in the
chlorhexidine-alcohol group was unchanged after categorization by
surgical group (abdominal vs non-abdominal) or type (colorectal,
biliary, small intestine, gastroesophageal, thoracic, gynecologic, or
urologic). Similarly, no significant differences were found between hospitals with respect to the incidence of any type of surgical-site infection.
The authors conclude that preoperative cleansing of the patients
skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for clean-contaminated surgery.

Commentary by

Diego Preciado, MD, PhD, FAAP, Pediatric Otolaryngology, Childrens

National Medical Center, Washington, DC
Dr Preciado has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

The finding of reduced surgical-site infection with chlorhexidinealcohol skin preparation compared to povidone-iodine has been
demonstrated previously with skin preparation cleansing prior to
placement of vascular catheters, where usage of chlorhexidine was
reported to reduce the incidence of catheter site infection by 50%.2
As noted by the study authors, the marked decrease in surgical-site
infections with chlorhexidine-alcohol may be multifactorial and
attributable to faster and longer-lasting antiseptic action, shorter

38

drying time, and more potent bactericidal activity.

Before completely abandoning surgical-site cleansing with
povidone-iodine for pediatric surgery, however, it is important to
point out several issues related to the usage of chlorhexidine-alcohol.
First, it is contraindicated in patients younger than two months of
age, around mucosal membranes such as the eyes or mouth, and for
lumbar puncture skin site preparation due to potential contact with
the meninges.3 Second, the authors of the current study only analyzed
the rate of infection in clean-contaminated surgical sites, where
overall rates of wound infection are relatively high at baseline. It is
unclear whether these results can be extrapolated to clean surgical
sites, where it is possible that both surgical site preparations would
have equal efficacy. Finally, it is worth noting that one of the authors
is an employee of Cardinal Health (the company that sells ChloraPrep, trade name for chlorhexidine-alcohol) although that author did
not participate in data analysis. Most of the other authors reported
receiving educational and research grants from Cardinal Health.
In any case, the studys methodology is clearly robust and the
study was rigorously conducted. The argument for switching to
a chlorhexidine-alcohol type of surgical-site preparation over
povidone-iodine for a majority of cases is compelling, especially for
clean-contaminated cases.

Editors Note
Previous studies have demonstrated that the addition of alcohol
increases the effectiveness of chlorhexidine as measured by microbiological endpoints.4 This study is an important addition to the literature in that the increased efficacy is demonstrated using the clinical
outcome of surgical-site infection. There is microbiological evidence
to suggest that alcohol also increases the efficacy of iodophors.4 A
comparison between chlorhexidine-alcohol and iodophor-alcohol
would be of great interest. Because of the role of the manufacturer
in the study, and presumably the choice of comparison groups, we
wonder if the study design foretold the outcome that is, apples to
crabapples, not apples to apples.
References
1.
2.
3.
4.

Berard F, et al. Ann Surg. 1964;160(Suppl 1):1-192.

Chaiyakunapruk N, et al. Ann Intern Med. 2002;136:792-801.
http://www.chloraprep.com/. Accessed January 15, 2010.
Ostrander RV, et al. J Bone Joint Surg Am. 2005;87:980-985.

Key words: surgical site infection, chlorhexidine, povidone

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INFECTIOUS DISEASES

Herpes Zoster Following Varicella Vaccine

Source: Tseng HF, Smith N, Marcy SF, et al. Incidence of
herpes zoster among children vaccinated with varicella vaccine in a prepaid health care plan in the United States, 20022008. Ped Infect Dis J. 2009;28(12):1069-1072; doi:10.1097/
INF.0b013e3181acf84f

o determine the inciPICO

dence of herpes zoster
Question: Among children immunized with
(HZ) following varicella
one dose of varicella vaccine, what is the
vaccination, investigators from
incidence rate of herpes zoster?
Southern California Kaiser PerQuestion type: Prognosis
manente and UCLA reviewed
Study design: Retrospective review of
records
the medical records of children
12 years of age enrolled in a
health maintenance organization in Southern California who had
received one dose of varicella vaccine between 2002 and 2008. Potential HZ cases were identified utilizing ICD-9 codes from inpatient,
outpatient, and emergency department files. The medical records of
study children identified as potential HZ cases were reviewed by one
of the investigators to confirm the diagnosis using predetermined
criteria. In those with confirmed, probable, or possible HZ, records
were reviewed to note any chronic medical conditions.
During the seven-year study period, 172,163 children received
varicella vaccination, with 80% vaccinated between 12 and 18
months of age. The average duration of follow-up was 2.6 years.
Among 240 electronically identified HZ cases in study children, 111
(46%) cases were classified as confirmed, 11 (5%) were probable, 22
(9%) were possible, and 96 (40%) were rejected. The average age of
children with HZ was 4.1 years (range 1.3 to 15.2 years). HZ occurred,
on average, 2.1 years after varicella immunization; the length of time
between vaccination and HZ was similar among all children regardless of age at immunization. The incidence rate of HZ was 27.4 per
100,000 person years (95% CI, 22.7-32.7) in these children who had
received varicella vaccine.
Among children vaccinated between 12 and 18 months, incidence
rates gradually increased each year in the first four years after vaccination (P<.001). The HZ incidence rate for children vaccinated
after the age of 5 years was not significantly greater than in those who
were vaccinated between 12 and 18 months of age (rates 34.3 and
28.5/100,000 person-years, respectively; P=.54). Of 1,388 children
vaccinated at <12 months of age, none developed HZ. Among the
HZ cases, one child (0.7%) had leukemia and 16 (11.1%) had asthma
characterized by three or more acute exacerbations.
The authors conclude that HZ is rare among children after one
dose of varicella vaccine.

(HZ). Although HZ can occur in patients of any age, it occurs most

commonly in immunocompromised individuals and in those 60
years of age.
In children, HZ is most common in those infected with varicella
before 1 year of age.2 HZ can occur following varicella vaccination,
although to date the data suggest the incidence rate is much lower
than following natural varicella infection.3
The current study is important because of the size and diversity of
the population followed. Furthermore, Southern California Kaiser
Permanentes system allows comprehensive data collection of their
insured population, and utilizes one of the oldest and largest immunization tracking systems in the world. The low incidence rate of
HZ found in this investigation is consistent with results from other,
smaller studies.4 The results of this study that the incidence of HZ
in children following receipt of a single dose of varicella vaccine is low
should be good news to practicing physicians and their patients.
However, these findings do need to be seen as preliminary since HZ
can occur decades after infection with varicella virus.

Editors Note
An important methodologic limitation of this study is that the case
confirmation process was based on medical record review by one author using prespecified criteria. This process resulted in rejection of
40% of the cases that had been identified electronically. If a substantial proportion of the rejected cases were actually HZ, the incidence
rate could be a good bit higher. Nevertheless, it is important to recall
that HZ, although often minimally symptomatic in children, may
be associated with significant pain, disability, and dissemination in
adults as well as the immunocompromised.5 Thus any decrease in its
frequency should be welcomed by both pediatricians and internists.
The two-dose varicella vaccination schedule, recommended since
2006, resulting in an enhanced immune response and greater efficacy
for disease prevention,6 promises even greater reduction of HZ in the
coming decades. We eagerly await studies to confirm this hypothesis.
References
1.
2.
3.
4.
5.
6.

Meyer P, et al. J Infect Dis. 2000;182:383-390.

Harpaz R, et al. MMWR Recomm Rep. 2008;57(RR-5):1-30.
Marin M, et al. MMWR Recomm Rep. 2007;56(RR-4):1-40.
Black S, et al. Pediatr Infect Dis J. 1999;18:1041-1046.
Dworkin RH, et al. Clin Infect Dis. 2007;44:S1-S26.
Bocchini JA, et al. Pediatrics. 2007;120:221-231.

Key words: herpes zoster, varicella vaccine, varicella

Commentary by

Dennis L. Murray, MD, FAAP, Pediatric Infectious Diseases, Medical College

of Georgia, Augusta, GA
Dr Murray has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

Varicella vaccine has been licensed in the US since 1995. Prior to

its introduction, approximately 4,000,000 cases of varicella disease
and 100 deaths occurred each year.1 Reactivation of latent varicella
virus following primary varicella infection results in herpes zoster
AAP Grand Rounds April 2010

39

ADOLESCENT HEALTH

Emergency Contraception Guidelines: Individual Values & Adherence

Source: Upadhya KK, Trent ME, Ellen JE. Impact of individual
values on adherence to emergency contraception practice guidelines among pediatrics residents: implications for training. Arch
Pediatr Adolesc Med. 2009;163(10):944-948; doi:10.1001/archpediatrics.2009.160

nvestigators from Johns

PICO
Hopkins conducted a crossQuestion: Among pediatric residents, how
sectional survey of pediatric
do individual attitudes about adolescent
residents to evaluate the impact
sexual activity and abortion impact practices
and intentions regarding emergency
of individual values on the adcontraception counseling and provision?
herence to practice guidelines
Question type: Treatment
that recommend routine counselStudy type: Cross-sectional survey
ing and provision of emergency
1,2
contraception (EC). Items on
the survey included attitudes about abortion and teen sex, previous
prescribing of EC, prescription of EC in advance of need, and whether
a preceptor has prompted them to prescribe EC. Responses to these
items were compared to two outcomes reported by the respondents:
EC counseling and intention to prescribe EC. Counseling behavior was
assessed using a question regarding frequency of routine EC counseling. Intention to prescribe EC was assessed using a scale developed by
the investigators, who categorized the respondents intention as low
(opponent), ambivalent, or high intention to prescribe (proponent).
Pediatric residency directors at five programs in the Washington,
DC area were asked to have their residents participate in the study
and four agreed. Overall, 141 surveys were completed (50% response
rate), with 79% of respondents being female and 28% first-year
residents. Among the respondents, 48% reported that they had ever
prescribed EC and 30% had done so in advance of need. The proportion of respondents reporting having ever prescribed EC and having
prescribed EC in advance of need increased from those who were
classified as EC-opponent, -ambivalent, and -proponent (25% and
4%, 50% and 30%, and 71% and 63%, respectively). Residents with
the less favorable abortion attitudes were more likely to have low
intention to prescribe EC than those with more favorable attitudes
regarding abortion. As attitudes about teen sex and abortion became
more favorable, there was increased reporting of EC counseling and
intention to prescribe. Residents who had a preceptor encourage EC
prescription were six times more likely to be classified as high intention to prescribe EC than as ambivalent intention.
The investigators conclude that residents counseling of adolescents about EC and intention to prescribe EC are affected by their
individual attitudes about abortion and teen sex. They suggest that
efforts to affect attitudes may be needed to encourage proactive EC
practices in accordance with national guidelines.

Commentary by

Sara Levine, MD, MPH, FAAP, Greenwich Adolescent Medicine, Greenwich, CT

Dr Levine has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

mostly due to increased contraceptive use.3 EC in this discussion

referring to the use of hormonal medication within 120 hours of
unprotected intercourse to prevent an unwanted pregnancy is a
critical option for all women, particularly adolescents.
Both the AAP and the Society for Adolescent Medicine have set
forth clear policy statements in support of routine counseling of all
adolescents regarding EC.1,2 Both organizations support over-thecounter access to emergency contraceptive medications, and the
Society for Adolescent Medicine explicitly suggests that advance
prescription of EC should be provided for future use.
Previous studies among pediatric residents have assessed knowledge
about EC itself and assumptions about effects of EC use on adolescent
sexual behavior.4 The current study adds the critical factor of individual values to the assessment of providers behaviors and intentions
regarding EC counseling and provision. The authors acknowledge that
sampling pediatric residents in an urban east coast setting may lack
national generalizability; however, the relationship between values and
behavior may be generalizable even if the values are not.
Physicians are confronted regularly with issues that strike at
individual values. The authors suggest that values clarification, to
explicitly identify the internal processes that lead individuals toward
certain behaviors, may be useful in the education of residents regarding EC. They also suggest that strategies to impact adherence to EC
practice guidelines need to acknowledge and address the role of
attitudes as well as knowledge. This study clearly demonstrates that
physicians attitudes and values affect their practice and that such
values can profoundly impact our patients access to care.

Editors Note
Some physicians may feel that it compromises their integrity to
participate in clinical activities they consider to be immoral, even
if those activities are dictated by clinical guidelines. Perhaps the
most striking finding in this study is that a residents willingness to
prescribe EC (termed intention to prescribe) was highly associated
with having a faculty preceptor encourage this treatment. While
these residents did not likely change their moral views on the treatment itself, it is possible that this educational interaction reminded
the resident that they have another moral duty: to respect a patients
request for medically appropriate treatments. Regardless of our own
personal values, those of us involved in precepting pediatric residents
should look for opportunities to discuss how to ensure timely access
to EC, consistent with published guidelines, to patients in our care.
The challenge to conscience should not be minimized, but faced
with a tension between our own moral qualms and the welfare of the
patient, our first duty should be the welfare of the patient.
References
1.
2.
3.
4.

AAP Committee on Adolescence. Pediatrics. 2005;116:1026-1035.

Gold MA, et al. J Adolesc Health. 2004;35:67-70.
Santelli JS, et al. Am J Pub Health. 2007;97:1-7.
Lim SW, et al. J Pediatr Adolesc Gynecol. 2008;21:129-134.

Key words: emergency contraception, values, pediatric residents

In the US, approximately one half of all pregnancies are unplanned. Reducing teenage pregnancy is a national health priority,
and teenage pregnancy has been declining over the past 10 years,

40

www.aapgrandrounds.org

MEDICINE-PEDIATRICS

Childhood Predictors of Adult Type 2 Diabetes

Source: Morrison J, Glueck C, Horn PS, et al.
Childhood predictors of adult type 2 diabetes at 9- and 26-year follow-ups. Arch
Pediatr Adolesc Med. 2010;164(1):53-60; doi:10.1001/archpediatrics.2009.228

o determine childhood
PICO
predictors of adult type
Question: In a general pediatric population,
2 diabetes (T2DM), recan standard office and laboratory measures
or questions predict future development of
searchers in Cincinnati evalutype 2 diabetes mellitus?
ated longitudinal data from two
Question type: Diagnosis
studies: the Princeton Follow-up
Study design: Prospective cohort study
Study (PFS), a 22- to 30-year
follow-up of former school children initially enrolled between 6 to 18 years of age, and the National
Growth and Health Study (NGHS), a cohort study of girls enrolled at
9 to 10 years of age followed up at nine years after enrollment. PFS
study office measurements included body mass index (BMI), systolic
blood pressure (SBP), and diastolic blood pressure (DBP). Parental
history of diabetes was recorded, and serum triglycerides, highdensity lipoprotein cholesterol (HDLC), and fasting glucose levels
were measured. Waist circumference and insulin were measured
only during follow-up in PSF, but not in the initial sampling. In the
NGHS study each participant had BMI, SBP, DBP, and fasting lipid
profile measured at age 10 and waist circumference at age 11. Fasting
insulin and glucose were measured at ages 10, 15 to 16, and 19 years.
Diabetes was defined by a fasting glucose of >126 mg/dL. PFS and
NGHS subjects whose first measured fasting blood glucose was >126
mg/dL or who were on insulin were excluded.
Of 822 participants enrolled in the PFS study, 40 were found to
have glucose concentrations 126 mg/dL at follow-up at age 39 years
(4.9%). The incidence of T2DM was greater for African-American
women (9.9%) than for Caucasian women (4%; P=.02). The officebased measures significantly associated with the development of
T2DM were BMI and SBP >95th percentile for age and parental history of diabetes mellitus. Laboratory measurements associated with
the development of T2DM included blood glucose of at least 100 mg/
dl and a triglyceride level in the top 5th percentile for age. When BMI,
SBP, and DBP were all lower than the 75th percentile and there was
no parental history of diabetes mellitus, the likelihood of developing
T2DM at 22 to 30 years follow-up was 1.4%. Childhood BP and BMI
in the top 5th percentile when combined with either a fasting glucose
100 or a triglyceride level in the top 5th percentile were the best
predictors of developing T2DM.
At the nine-year follow-up of the original 1,067 girls (median age
19.2 years) in the NGHS study, T2DM was present in eight participants (0.75%). SBP in the top 5th percentile for age, fasting insulin
level in the top 5th percentile, and a HDLC level in the bottom 5th
percentile were each associated with an increased risk of developing
T2DM. When childhood BMI, SBP, DBP, and fasting insulin levels
were all lower than the 75th percentile and there was no parental
diabetes, the likelihood of developing T2DM at age 19 years was
0.3%. SBP in the top 5th percentile, history of parental DM, and fasting insulin levels in the top 5th percentile were the best predictors of
developing T2DM.
AAP Grand Rounds April 2010

The authors conclude that office-based childhood measurements

(BMI and SBP), fasting insulin levels in the top 5th percentile, and
presence or absence of parental diabetes predict the future development of T2DM, 9 and 26 years after baseline. This data could be
used to identify those children most likely to benefit from primary
prevention measures.

Commentary by

Katrina Johnson, MD, and Marc A. Raslich, MD, FAAP, Internal Medicine
and Pediatrics, Wright State University Boonshoft School of Medicine,
Dayton, OH
Drs Johnson and Raslich have disclosed no financial relationship relevant to this commentary. This commentary does
not contain a discussion of an unapproved/investigative use of a commercial product/device.

The prevalence of obesity and T2DM has substantially increased

over the past few decades.1 The factors that affect the development
of T2DM are diverse. The authors of this study were able to demonstrate that simple office and laboratory measurements along with
knowledge of parental diabetes status predicted the development of
T2DM. Accurate identification of children at increased or substantially decreased risk for adult T2DM would be valuable for development of further diagnostic testing strategies and targeted therapeutic
interventions as well as potentially distinguishing those children who
would benefit most from primary prevention.
This article is particularly relevant as the use of therapeutic and
pharmacologic interventions for childhood obesity increases. Currently, studies are examining the role of metformin in addition to diet
and vigorous exercise in reversing development of T2DM.2
References

1. Mokdad AH, et al. Diabetes Care. 2000;23:1278-1283.

2. Wilson AJ, et al. BMC Public Health. 2009;9:434.

Key words: anthropomorphic measurements, type 2 diabetes mellitus, childhood risk factors

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41

DERMATOLOGY

Acanthosis Nigricans: Cutaneous Marker of Metabolic Abnormalities

Source: Brickman WJ, Huang J, Silverman BL, et al. Acanthosis
nigricans identifies youth at risk for metabolic abnormalities.
J Pediatr. 2010;156(1):87-92; doi:10.1016/j.jpeds.2009.07.011

canthosis nigricans
PICO
(AN) is a skin disorder
Question: Among youth with acanthosis
typically characterized
nigricans, is there an increased risk of
by symmetric hyperpigmented
metabolic abnormalities?
velvety plaques on the posterior
Question type: Diagnosis
neck, bilateral axillae, and flexStudy design: Cross-sectional,
observational study
ural surfaces of the upper and
1
lower extremities. Commonly
seen in obese children, adolescents, and adults, AN is considered a
potential cutaneous marker of underlying insulin resistance and is
one of the criteria proposed by the American Diabetes Association for
identifying children at risk for developing type 2 diabetes mellitus.2,3
Investigators from Childrens Memorial Hospital and Northwestern University in Chicago sought to determine the prevalence of abnormal glucose homeostasis and cardiovascular risk factors in youth
with AN. Youth aged 8 to 14 years with and without neck AN were
recruited from urban community pediatric offices. Enrolled youth
without AN were required to have a body mass index (BMI) z score
>85th percentile and served as a comparison group. Demographic
information, anthropometric measurements including BMI z score,
blood pressure, neck AN score based on a validated scoring system,4
Tanner stage, oral glucose tolerance test (fasting glucose and insulin
levels followed by glucose and insulin levels obtained 120 minutes after a glucose load of 1.75 g/kg), HgbA1c, glutamic acid decarboxylase
antibody, and fasting lipid profile were obtained for each participant.
Abnormal glucose homeostasis was defined as any combination of
impaired fasting glucose, impaired glucose tolerance, or diabetes
mellitus on the basis of fasting or stimulated results. Homeostasis
model assessment of insulin resistance (HOMA-IR) was calculated
for each study patient.
Compared to those without AN (n=51; 65% Hispanic, 22%
African American), the children with AN (n=236; 60% Hispanic,
30% African American) were more likely to be female, have lower
maternal education, be in later stages of puberty, and have higher
BMI z scores. Compared to those without AN, youth with AN were
more likely to have abnormal glucose homeostasis (29% vs 12%;
P=.044), systolic blood pressures >95th percentile for age (27% vs
14%; adjusted P=.30), and high density lipoprotein cholesterol 5th
percentile (50% vs 35%; adjusted P=.09). After adjusting for sex,
maternal education, pubertal status, and BMI z score, the presence
of AN remained significantly associated with higher stimulated
2-hour glucose concentrations, abnormal glucose homeostasis, and
higher markers of insulin resistance. On multivariate analyses, risk
factors associated with the presence of impaired glucose tolerance in
children with AN included female sex, insulin resistance, and positive
glutamic acid decarboxylase antibodies.
The investigators conclude that the presence of AN in children 8
to 14 years of age is associated with significant insulin resistance and

42

abnormal glucose homeostasis in more than one quarter of affected

individuals. Identification of these high-risk youth based upon their
cutaneous findings should hopefully lead to appropriate screening
for insulin resistance and possible intervention that may attenuate
the development of diabetes mellitus and metabolic abnormalities.

Commentary by

Kimberly A. Horii, MD, FAAP, Dermatology, Childrens Mercy Hospitals and

Clinics, Kansas City, MO
Dr Horii has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

These results mirror prior studies associating AN with obesity and

insulin resistance and showing an increased prevalence of AN in certain ethnicities.3,5 Previous studies have shown an association of AN
with both increasing BMI and insulin resistance, but which of these
factors confers a greater risk for AN has been unclear.1,5 Importantly,
the current investigators found a significant association between AN
and insulin resistance regardless of BMI z score.
There are, however, some limitations to the study. Families were
provided study information at their pediatric office visit and then
required to contact the investigators to set up the first screening visit.
Enrolled patients may have been more concerned about risk factors
for diabetes or truly higher risk for metabolic abnormalities, which
could have biased the results. The sample size was relatively small,
and ideally should have included an equal proportion of various
ethnicities in both the affected and control groups including more
Caucasians. Ideally, the BMI z scores, age, and Tanner stage of the
control youth without AN should have been matched to the youth
with AN.
AN is a condition that is often referred to dermatologists for evaluation. Results of this study confirm that the presence of this cutaneous sign in a child should prompt physicians to consider evaluation
for metabolic abnormalities.
Unfortunately, there are no good treatment options for AN aside
from weight loss and control of existing insulin resistance, which may
be accompanied by substantial regression of AN. As this condition
can be cosmetically bothersome, it may motivate some to develop
healthy dietary and lifestyle modifications in order to improve the
appearance of their skin.
References
1.
2.
3.
4.
5.

Sinha S, et al. J Am Acad Dermatol. 2007;57:502-508.

American Diabetes Association. Diabetes Care. 2000;23:381-389.
Copeland K, et al. J Okla State Med Assoc. 2006;99:19-24.
Burke JP, et al. Diabetes Care. 1999;22:1655-1659.
Brickman WJ, et al. Pediatr Dermatol. 2007;24:601-606.

Key words: acanthosis nigrans, insulin resistance, metabolic abnormalities

www.aapgrandrounds.org

SURGERY

Pediatric Melanoma: One Institutions Experience With 150 Patients

Source: Aldrink JH, Selim MA, Diesen DL, et al. Pediatric
melanoma: a single-institution experience. J Pediatr Surg.
2009;44(8):1514-1521; doi:10.1016/j.jpedsurg.2008.12.003

esearchers from Duke

PICO
University reviewed
Question: Among children with
their experience with pemelanoma, what is the survival rate?
diatric melanoma. The medical
Question type: Prognosis
records of all children <20 years
Study design: Retrospective review of
of age treated for melanoma at
records
their institution between 1973
and 2007 were reviewed. A total
of 150 subjects with a mean age of 15.1 years were identified. At the
time of diagnosis, 11% were 0 to 11 years of age, 42% were 12 to 16
years, and 47% were 17 to 19 years. Only 2% of the patients were
black, all in the youngest age group. Common locations for primary
lesions included trunk (37.8% of study patients), extremity (36.5%),
and head and neck (24.3%); two children had ocular lesions.
Follow-up data were available on 140 patients, with a mean length
of follow-up of 8.5 years (range 1 month to 34 years). Overall survival
was 84%. Survival in those initially misdiagnosed, however, was 66%.
A total of 41 patients developed recurrences (29%), with the highest rate of recurrence among those aged 17 to 19 years at diagnosis
(31%). Primary location of the tumor, sex, and thickness of the tumor
were not significantly associated with chance of recurrence. Patients
initially misdiagnosed had the same risk of recurrence as those who
were correctly diagnosed (28.4% and 18.8%, respectively; P=.56). Of
the 29 patients who developed metastatic melanoma, 24 died.
The authors conclude that pediatric melanoma requires increased
awareness by physicians and pathologists to make a timely and accurate diagnosis.

Commentary by

Clinton M. Cavett, MD, FAAP, Carilion Clinic Childrens Hospital, Roanoke, VA

Dr Cavett has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

Melanoma remains an uncommon diagnosis in the pediatric age

group, accounting for only 2% of all melanoma cases.1 Nevertheless,
the incidence of melanoma is increasing worldwide and this change
is expected to become manifest in children as well.2 Practicing pediatricians and surgeons must work closely with their pathologists to,
first, identify those patients who actually require excisional biopsy,
and then select those who should proceed with wide excision with
lymph node biopsy and further therapy as dictated by depth of lesion
and nodal staging.
A few definitions are necessary to help clarify discussion of pediatric melanoma. Spitz nevus was originally described in 1948 as
a benign juvenile melanoma, an unfortunate term as this lesion is
benign yet histologically alarming. This entity continues to present a
significant diagnostic challenge to both clinicians and pathologists.3
The pathologist must examine the entire lesion as these melanocytes
are atypical, and vary from spindled to epithelioid, but unlike melanoma, are symmetrical, show maturation and junctional cleavage,
and lack mitotic figures deep in the dermal melanocytes. Still, expert
dermatopathologists can disagree in some cases.
AAP Grand Rounds April 2010

Historically, the vertical thickness of the primary tumor and the anatomic depth of invasion are the principle measures in local tumor classification of melanoma staging. Sentinel lymph node biopsy (SLNB)
is a methodology increasingly used to stage melanoma. In the current
study this procedure was performed in only 18 of the 150 patients, all
since the year 2000.1 Blue dye is injected intradermally at the site of
the primary melanoma and allowed to be taken up by the lymphatics
which then show that the first blue node in the regional lymphatic basin
is the node that should contain a metastasis if any tumor is present.
This node is termed the sentinel lymph node. The regional lymphatic
basin can also be identified by injecting technetium 99m-labeled colloid intradermally at the primary site and then performing lymphatic
mapping with a hand-held gamma probe intraoperatively.
With accurate diagnosis, the outcomes for pediatric melanoma
are very good, with published five-year survival rates of 74% to 89%.
Melanoma survival rates among children have continued to improve
by 4% per year over the last 30 years. In addition, despite higher rates of
positive SLNB, children and adolescents have a lower incidence of recurrence and improved disease-free survival when compared to adults.1,4
References
1.
2.
3.
4.

Jafarian F, et al. J Am Acad Derm. 2005;53:816.

Strouse J, et al. J Clin Onc. 2005;23:4735.
Kapur P, et al. Mod Pathol. 2005;18:197-204.
Roaten J, et al. J Pediatr Surg. 2005;40:988-992.

Key words: melanoma, characteristics, survival

EDITORIAL BOARD
Editors-in-Chief
Leslie L. Barton, Tucson, AZ
Edgar K. Marcuse, Seattle, WA
Consulting Editors
Douglas Diekema, Seattle, WA
Tom Newman, San Francisco, CA
William V. Raszka, Jr., Burlington, VT
James A. Taylor, Seattle, WA
Editorial Board
Burris R. Duncan, Tucson, AZ
Joseph Geskey, Hershey, PA
Ronald D. Holmes, Littleton, CO
Daniel R. Neuspiel, Charlotte, NC
Lane S. Palmer, New Hyde Park, NY
Vasundhara Tolia, Bloomfield Hills, MI
Patty Vitale, Clementon, NJ
Marcia Wofford, Clemmons, NC
CME Question Editor
William V. Raszka, Jr., Burlington, VT

Contributing Section Editors April Issue

Adolescent Health: Sara Levine,
Greenwich, CT
Communications and Media:
Donald Shifrin, Bellevue, WA
Dermatology: Kimberly Horii,
Kansas City, MO
Infectious Diseases: Dennis Murray,
Augusta, GA
Medicine-Pediatrics: Marc A. Raslich,
Dayton, OH
Neurology: J. Gordon Millichap,
Chicago, IL
Orthopaedics: Richard Schwend,
Kansas City, MO
Otolaryngology/Head &
Neck Surgery: Diego Preciado,
Washington, DC
Surgery: Clinton Cavett, Roanoke, VA
Young Physicians: Andi Shane,
Atlanta, GA

43

ORTHOPAEDICS

Extremity Surgery in Ambulatory Children with CP

Source: Gorton GE, Abel MF, Oeffinger DJ, et al. A

prospective cohort study of the effects of lower extremity orthopaedic

surgery on outcome measures in ambulatory children with cerebral palsy. J Pediatr Orthop. 2009;29(8):903-909; doi:10.1097/
BPO.0b013e3181c11c0c

his multicenter study

PICO
assessed whether lower
Question: Among ambulatory children with
extremity orthopaecerebral palsy, does orthopaedic surgical
dic surgery improves function
intervention improve gait or function?
and quality of life in ambulaQuestion type: Intervention
tory children with cerebral palsy
Study design: Prospective, nonrandomized, comparative study
(CP). Study subjects were part
of a larger six-year prospective
multicenter study at seven US pediatric orthopaedic facilities. Children 4 to 18 years of age with Gross Motor Functional Classification
System (GMFCS) levels I-III (I: normal; II: walks with limitation; III:
walks with hand-held mobility) were eligible. Patients were excluded
if they had had dorsal rhizotomy, previous orthopaedic surgery,
botulinum toxin A injections, or a functioning baclofen pump. Subjects for whom outcome data were available after at least one year of
follow-up were matched 1:1 to a nonsurgical group of 294 subjects by
sex, type of CP, and GMFCS. Outcome measures included the GMFCS
level, Gillette Functional Assessment Questionnaire, Gillette Gait Index (GGI), and the Pediatric Quality of Life Inventory. The minimum
clinically important difference (MCID) was determined to show
changes beyond those expected to occur as a result of standard care.1
The study and control groups each consisted of 75 subjects. The
matched data set included 28 pairs in GMFCS level I, 30 in level II,
and 17 in level III. Mean age at the time of surgery was 11.3 years.
Mean length of follow-up was 1.5 years for the surgical group and 1.3
years for the control group.
At follow-up, of 22 clinical outcome scores evaluated, significantly
greater improvement was seen in the surgical group than in the nonsurgical group in the GGI, the Pediatric Outcomes Data Collection
Instrument Expectations domain, and the Pediatric Quality of Life
Inventory Physical Functioning domain. A MCID was noted only
for the GGI. The control group showed no improvement between
baseline assessment and follow-up in any functional outcome scores.
Factors such as anatomic type of CP, earlier surgical procedures, or
type of surgical procedure performed showed no functional advantages among the subgroups of surgical patients.
The authors conclude that surgery in ambulatory children with CP
leads to significant improvement (exceeding the MCID) compared to
routine nonsurgical care.

Commentary by

Richard M. Schwend, MD, FAAP, Pediatric Orthopaedics, Department of

Orthopaedics, Childrens Mercy Hospital, Kansas City, MO
Dr Schwend has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

Lower extremity orthopaedic surgery is a standard treatment

for ambulatory children with CP to address joint contractures and
correct torsional limb deformity. Current treatment principles en-

44

courage limiting the number of times that a child receives surgery

and performing all surgical procedures during the same operative
intervention. This study included seven experienced, but independent, centers that collectively care for a large number of patients
with CP, but have their own preferences for patient selection and
type of procedure used. The authors carefully matched each surgical
patient with a similar control. They found significant improvement
in three and a minimum clinically important difference in one of the
22 outcome measures.
The authors acknowledge many study limitations. Selection bias
may have influenced the decision to do surgery, particularly since
gait analysis and individual surgeon preference was utilized in the
decision making. Additional features, such as motivation, supportive therapist, and home situation, may have influenced the surgical
results. The parent-reported outcome measurements may have introduced bias, since parents may perceive their children to function
better after the investment of surgical treatment. Whether surgical
treatment was recommended for control patients was not reported.
Other treatments such as selective dorsal rhizotomy, baclofen pump
therapy, or botulinum toxin A injections that could be as effective
as surgery were not evaluated. Since the average age of treatment
was 11.3 years, longer follow-up would be needed to determine if
the surgical success lasts into adulthood and if the results of the two
groups might diverge or converge over time.
Since over 20 outcome scores were evaluated, chance alone would
account for at least one of the three statistically significant differences. A MCID was seen in only one outcome score that related to gait
improvement, so the evidence suggesting that orthopaedic surgery
makes a clinically important difference is not overwhelming, even
in the short term. The most improvement was seen in the surgical
group with GMFCS III, indicating that orthopaedic surgery may be
the most helpful in children with more functional impairment. As the
authors point out, these results provide support for a future randomized, controlled trial to evaluate surgical therapy of patients with CP.
References

1. Oeffinger D, et al. Dev Med Child Neurol. 2008;50:918-925.

Key words: cerebral palsy, lower extremity surgery, gait

AAP Journal CME

You can complete and claim credit for all of your quizzes
online. Visit the AAP Grand Rounds CME Center at
www.aapgrandrounds.org.

www.aapgrandrounds.org

NEUROLOGY

Epilepsy in Angelman Syndrome and Response to Treatment

Source: Thibert RL, Conant KD, Braun EK, et al. Epilepsy
in Angelman syndrome: a questionnaire-based assessment of
the natural history and current treatment options. Epilepsia.
2009;50(11):2369-2376; doi:10.1111/j.1528-1167.2009.02108.x

sing an electronic surPICO

vey, investigators from
Question: Among patients with Angelman
the Massachusetts Gensyndrome, what is the natural history
eral Hospital in Boston; Angelof epilepsy and the response to various
man Syndrome Foundation in
treatments?
Aurora, IL; Texas Southwestern
Question type: Description, Intervention
Medical Center, Dallas; and Rady
Study design: Survey
Childrens Hospital, San Diego,
studied the natural history and
response to treatment of epilepsy in a large population of patients
with Angelman syndrome (AS). Approximately 1,000 families of
individuals with AS were asked to complete an online questionnaire
made available for three months from February through May 2007.
The survey included questions related to the nature of the childs seizures, response to various medications, and medication side effects.
Family members of 461 individuals (56% male) with AS completed
the interview (46% response rate). The average age of patients at the
time of the survey was 13.9 years (1.3-45 years) and their average age
at diagnosis was 5.3 years (<1-35 years). Of the 461 subjects, 86% had
experienced seizures with an average age of seizure onset of 2.9 years.
The most frequently reported types of seizures were atonic (41%),
generalized tonic-clonic (40%), atypical absence (37%), and complex
partial (32%). Sixty percent of patients had at least two types of seizures. Convulsive status epilepticus occurred in 12%. Developmental
regression occurred in 35%.
Rates of epilepsy differed among genetic subtypes. Among study
subjects, 65% had a maternal deletion, 18% an unknown subtype, 7%
uniparental disomy, 7% ubiquitin-protein ligase E3 (UBE3A) mutations, and 2% imprinting defects. Patients with maternal deletions
(89%) and unknown subtypes (90%) had the highest rates of epilepsy.
Those with imprinting defects (55%) were least affected. At the time
of the survey, 34% of patients were reported to be seizure-free for a
median period of 3.2 years, beginning at an average age of 8.8 years.
The most commonly prescribed antiepileptic medications (AED)
were valproic acid (62%) and clonazepam (34%), but lamotrigine
(24%) and levetiracetam (20%) had similar efficacy and tolerability.
Only 15% responded to the initial AED. An additional 8% responded
to a second agent but 77% had refractory seizures. Ketogenic diet was
reported to be the most effective treatment in 11 of 31 subjects and
vagus nerve stimulation in 8 of 16. The authors conclude that the
newer AEDs are similarly effective to valproate and clonazepam but
have similar or better side effect profiles and that further studies of
nonpharmacologic therapies are needed.

AAP Grand Rounds April 2010

Commentary by

J. Gordon Millichap, MD, FAAP, Neurology, Childrens Memorial Hospital,

Northwestern University Medical School, Chicago, IL
Dr Millichap has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

AS is a neurodevelopmental genetic disorder characterized by

severe intellectual disability, severely impaired or absent speech,
tongue protrusion, hypotonia from birth followed by hypertonia,
ataxia, and frequent bouts of laughter. The behavior of children with
AS is described as overactive, exuberant, sociable, and happy, and
they have a wide-based gait, foot eversion, elbow flexion, and wrist
supination. Epilepsy is a presenting symptom in >80% of patients,
with onset between age 1 and 3 years.1
These children were first described as puppet children in the
original report of three cases by Angelman.2 Most cases (70%) result
from de novo maternal deletions involving chromosome 15q-11q13,
2% from paternal uniparental disomy of the same gene, and 2% to 3%
from imprinting defects. The remaining 25% are caused by mutations
in the gene encoding UBE3A.3 Occurrence is mainly sporadic with an
estimated prevalence of 1:10,000 to 1:40,000.4 Paternal inheritance
of a deletion of this region is associated with Prader-Willi syndrome.
In the above study molecular categories are linked to two phenotypes, one that is more severe with more refractory seizures and seen
in association with 15q11-q13 microdeletion or UBE3A mutation,
and the other less severe with a low incidence of microcephaly and
milder seizures and seen in association with uniparental disomy or
imprinting defects. The core phenotypic features and a characteristic
EEG pattern are shared.
The interictal EEG pattern is helpful in the early diagnosis of AS
before the clinical features become obvious. Typically EEG abnormalities include high amplitude rhythmic 2 to 3 per second activity,
more prominent anteriorly, and spikes mixed with 3 to 4 per second
slow waves in posterior regions, activated by eye closure.5 AS is usually considered a generalized seizure disorder, and the relatively high
frequency of partial seizures noted by Thibert and associates is of
interest, correlating with both focal and generalized EEG interictal
discharges reported by others.6 Sleep problems associated with epilepsy in AS may be related to the severity of seizures and the use of
anticonvulsant medication.7
References
1.
2.
3.
4.
5.
6.
7.

Dan B. Epilepsia. 2009;50:2331-2339.

Angelman H. Dev Med Child Neurol. 1965;7:681-688.
Kishino T, et al. Nature Genet. 1997;15:70-73.
Petersen MB, et al. Am J Med Genet. 1995;60:261-262.
Boyd SG, et al. Eur J Pediatr. 1988;147:508-513.
Cersosimo R, et al. Rev Neurol (Madrid). 2003;37:14-18.
Conant KD, et al. Epilepsia. 2009;50:2497-2500.

Key words: Angelman syndrome, epilepsy, anti-epileptic therapy

45

COMMUNICATIONS AND MEDIA

Do Medical Students Cross the Line Online?

Source: Chretien KC, Greysen SR, Chretien J-P, et al. Online
posting of unprofessional content by medical students. JAMA.
2009;302(12):1309-1315; doi:10.1001/jama.2009.1387

esearchers from three

PICO
institutions in the WashQuestion: Among US medical schools,
ington, DC area sought
what is the experience in recognizing
to describe reported incidents
students posting unprofessional content
online, and do policies exist to deal with
of US medical students posting
this problem?
unprofessional content online.
Question type: Descriptive
In 2009, all US medical school
Study design: Cross-sectional survey
Deans of Student Affairs were
asked to complete an anonymous survey. Survey items included incidents of unprofessional
online posting by medical students, level of concern about such
behavior, any disciplinary action taken, and policies in place.
Of the 130 deans surveyed, 60% (78/130) responded. Among responding deans, 60% (47/78) reported ever having incidents involving students posting unprofessional content. Incidents of unprofessional postings involved profanity (52%), discriminatory language
(48%), intoxication (40%), sexually suggestive content (38%), and
violations of patient confidentiality (13%).
Deans learned of unprofessional online posting incidents from
trainees (57%), non-faculty staff (37%), faculty (35%), and patients
or their family members (4%). Among deans reporting incidents,
67% reported issuing informal warnings, 27% held formal disciplinary meetings, 2% temporarily suspended a student, and 7%
dismissed a student.
Only 38% of schools had professionalism policies covering
student-posted online content. Deans reporting incidents were
significantly more likely to report having such a policy (51% vs 18%;
P=.006). Few schools (19%) had committees or task forces responsible for dealing with these kinds of online postings. Ninety-one percent of schools with reported incidents and 63% of schools without
reported incidents answered that they were able to deal effectively
with content (P=.003).
The authors conclude that schools should increase faculty training
and awareness of Web 2.0 applications and incorporate instruction
and discussions among both students and faculty regarding posting
inappropriate online content.

Commentary by

Don Shifrin, MD, FAAP, Pediatrics Associates, Bellevue, WA

shocking: Like senior citizens suffering from dementia, web users

often fall prey to disinhibition the lack of a filter for their most
brutal thoughts.1 This generation has become used to detailing their
lives in a much more public way.
No matter how intelligent these students, they have grown up
in a media-saturated world: Beavis and Butthead, South Park, The
Simpsons, the insults of reality TV and American Idol. Sexuality and
certainly profanity are commonplace across all media venues. The
anonymity of the Internet is mistakenly thought to provide cover for
anger, frustration, envy, vengeance, disrespect, resentment, irritation, or condescension as a start.
The authors acknowledge that their results indicate a substantial
proportion of these schools had incidents, but what is concerning
was the disconnect between reported incidents (60%) and the availability of committees responsible for addressing the issue at these
same schools (22%).
What can be done? A 2007 analysis of MySpace websites belonging to 18-year-olds showed that over 50% revealed risk behaviors.2
In a targeted follow-up, the same researchers sent a brief e-mail to
similar adolescents on MySpace from an unknown physician along
with her web address. The e-mail expressed concern about privacy
issues and the sexuality portrayed on the individuals site. A threemonth review of the same websites revealed profile changes in 42%
(P=.07).3 This suggests that an intervention is possible, and can be
moderately successful. Hopefully, medical students would be at least
as responsive if schools quickly and consistently address this issue
and develop policies defining the behaviors that will be considered
unprofessional conduct.
Online communication between physicians and their patients will
likely increase. Professionalism, defined as a commitment to carrying out professional responsibilities, adherence to ethical principles,
and sensitivity to diverse populations, must be extended to online
communications. Students must be aware that digital footprints are
hard, if not impossible, to erase. To address this ongoing challenge
it would be prudent for medical and nursing school leadership to
charge a multidisciplinary task force of students, medical informatics
specialists, and faculty to develop guidance that might be applied to
health professional students.
References

1. Alter J. All Umbrage All the Time. Newsweek. July 28, 2008.
2. Moreno M, et al. Arch Pediatr Adolesc Med. 2009;163:27-34.
3. Moreno M, et al. Arch Pediatr Adolesc Med. 2009;163:35-40.

Key words: medical students, online posting, unprofessional

Dr Shifrin has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.

Although this study was limited by the lack of student involvement, it should serve as a cautionary tale to those unfamiliar with
this generation of students who share their lives online. The postings
highlighted by this survey suggest that the boundaries between private and public spaces have been all but eliminated. That three deans
reported having expelled students as a result of online postings is

46

www.aapgrandrounds.org

CME QUESTIONS

5. A 9-year-old girl is brought to the physician for a health care supervision

visit. Which of the following findings is associated with this girl having
an increased risk of developing type 2 diabetes mellitus?

The following continuing medical education questions cover the content of

the April 2010 issue of AAP Grand Rounds. Please keep this issue. Each years
material is worth up to 18 AMA PRA Category 1 Credit(s)TM.
Complete and claim credit online at www.aapgrandrounds.org. Need
username and password? Contact customer service at 866-843-2271.

CME OBJECTIVES

6. A 12-year-old boy is brought to the physician because of hyperpigmented

lesions on his neck and axillae. His BMI is greater than the 95th percentile for age and he has velvety, hyperpigmented, well-demarcated symmetric lesions in his axillae and neck. This boy should be evaluated for
which of the following conditions?

a. Children must attend at least eight hours of school a day

b. Infants are required to breast feed
c. Infants must be tested for HIV
d. Pregnant women deliver children by caesarian section
e. Pregnant women receive prenatal care

2. A 21-year-old man undergoes appendectomy for suspected appendicitis.

Before surgery, the abdomen is washed with 2% chlorhexidine gluconate
and 70% isopropyl alcohol. Compared to skin preparation with 10%
povidone-iodine, which of the following is the major advantage of 2%
chlorhexidine gluconate and 70% isopropyl alcohol?

a. Decreased need for prophylactic antibiotics

b. Decreased risk of hypoglycemia
c. Decreased risk of skin irritation
d. Decreased risk of surgical-site infection
e. Decreased scrubbing time

3. A previously healthy 15-month-old boy is brought to the physician for

a health care supervision visit. He is given the first dose of the varicella
vaccine. Which of the following describes the risk of developing zoster
after the varicella vaccine in a patient such as this?

a. Incidence rates gradually decrease each year in the first four years
after vaccination
b. Incidence rates gradually increase each year in the first four years
after vaccination
c. Incidence rates remain the same each year in the first four years
after vaccination

4. A 16-year-old girl goes to her physician for a health care supervision

visit. She episodically has unprotected sex. Which of the following factors has been positively associated with a pediatric resident prescribing
emergency contraception for a patient such as this before the need actually arises?

a. A preceptor who encourages emergency contraception prescriptions

b. Age
c. Gender
d. Having had children
e. Year of residency

7. A 16-year-old boy is brought to the physician because of an expanding

pigmented lesion on his neck. The pigmented lesion has been present
for at least five years, but recently has tripled in size, become darker in
color, and developed irregular borders. An excisional biopsy confirms the
diagnosis of malignant melanoma. Which of the following would be most
predictive of a poor prognosis in this patient?

a. Age of patient
b. Depth of lesion greater than 2.2 mm
c. Location of lesion
d. Male sex
e. Presence of metastatic disease

8. An 11-year-old girl with spastic diplegia is brought to the physician for a
health care supervision visit. She uses crutches at school to go between
classes. If she undergoes a lower extremity surgical procedure to improve function, which of the following outcomes is most likely?

a. If she has surgery now, she will never need surgery as an adult
b. She will be able to compete in sports that she couldnt do before
c. She will have a clinically important improvement in her some of her gait
parameters
d. She will no longer need to use crutches
e. The surgery will keep her from needing a wheelchair as an adult

9. A 3-year-old boy is brought to the physician for a health care supervision visit. He has had many generalized seizures. He has delayed speech,
abnormal tone, hyperactive behavior, and an unusual gait. Angelmans
syndrome is suspected. Which of the following is most likely to be found
in this patient?

a. Aggressive behavior
b. Large testes
c. Normal EEG
d. Paternal chromosomal deletion
e. Seizures refractory to treatment

10. A 25-year-old medical student posts a picture of himself apparently

drunk, holding a bottle of rum, and saying party all night on his Facebook page. Which of the following is most likely to report such a finding
to the Dean of Student Affairs at the students medical school?

a. Faculty member
b. Non-faculty staff
c. Parent
d. Patient
e. Student

9. e
10. e

AAP Grand Rounds April 2010

7. e
8. c

1. A family in rural Mexico is considering participating in a conditional cash

program. Which of the following is a usual condition of such a program?

a. Cushing Disease
b. Ewing sarcoma
c. Hypercalcemia
d. Insulin resistance
e. Melanoma

5. a
6. d

Describe the incidence rate of herpes zoster following varicella vaccination in young
children

3. b
4. a

Compare and contrast the risk of surgical-site infections following skin preparation
using either 2% chlorhexidine gluconate and 70% isopropyl alcohol or 10%
povidone-iodine

Answers:
1. e
2. d

Describe the long-term benefits of conditional cash transfer programs

a. A parent with diabetes mellitus

b. BMI between the 50th and 75th percentile for age
c. Low fasting serum glucose levels
d. Low fasting serum insulin levels
e. Systolic blood pressure in the lowest 5th percentile for age

47

Editorial

By Erik A. Berg, MPH Candidate, Mel and Enid Zuckerman College of

Public Health, University of Arizona

Mexico has achieved and sustained major improvements in

child health indicators in the past two decades. Most notably,
under-5 mortality has been reduced by nearly one third,1 so that
Mexico is one of the few countries on track to meet Millennium
Development Goal 4.2 This progress stems, in part, from a collection of public health interventions, including universal childhood
immunization, water sanitation measures, and most recently, a
poverty-alleviation program known as Oportunidades.3
Initiated in 1997 (under the name PROGRESA), Mexicos
Oportunidades is arguably the most important existing mechanism for the continued decline of under-5 mortality in Mexico.
Oportunidades is a large-scale, national strategy to reduce
poverty through conditional cash transfers (CCT) essentially,

Provoking Thoughts Evidence eMended*

From the Co-Editors:
Leslie Barton, MD, FAAP
Ed Marcuse, MD, MPH, FAAP
AAP GR is joining the blogosphere to facilitate our readers
discussion of the articles and commentaries featured in each issue. Our blog, Evidence eMended, will be hosted by Bud Wiedermann, MD, MA, FAAP. Bud is a former member of our Editorial
Board who will serve as Consulting Editor for New Media.
Our goal is to add value (and fun) for our readers by creating
an easily accessed way to enter into interactive discussion of
specific studies, discuss the perceived weight of the evidence as
applied to your practice situations and the patient populations
you serve, and in the process learn more about critical appraisal.
Our sincere thanks to Bud for leading the way.

In the March 2010 issue, an incorrect name was

listed as Contributing Editor for Otolaryngology/
Head & Neck Surgery. The current contributor for
that Section is Diego Preciado.

48

References

1. UNICEF State of the Worlds Children, 2009.

2. The Countdown Coverage Writing Group, on behalf of the Countdown to 2015 Core
Group. Lancet. 2008;371:1247-1258.
3. Sepulveda J, et al. Lancet. 2006;368:2017-2027.
4. Gertler P. American Economic Review. 2004;94:336-341.
5. Rivera JA, et al. JAMA, 2004;291:2563-2570.
6. Barham T, et al. Beyond 80%: Are There New Ways of Increasing Vaccination Coverage? HNP Discussion Paper. Washington, DC: The World Bank; 2007.

From the Editor for Digital Media:

Bud Wiedermann, MD, MA, FAAP

*emend from the Latin (c. 1400), to free from fault;

to improve by critical editing

Erratum

a social contract by which income-eligible families, who make

pre-specified investments in the health and education of their
children, receive bimonthly cash transfers. Child health benefits of the program include better health outcomes (decreased
morbidity and mortality),4 improved nutritional outcomes,5 and
increased on-time vaccination rates.6
The efficacy of the CCT approach, particularly Oportunidades in sustaining improvement in child health in Mexico
should be of interest to the global pediatric community.

There isnt a published medical study that someone, somewhere, couldnt find legitimate fault with. Thats the nature of human biology. However, we cant let that paralyze us into inaction,
because every day we need to make clinical decisions weighing
the best evidence, our own experience, and incorporating our
patients and their families values and preferences.
I love to learn by talking through ideas, but hate talking to
myself! I look forward to talking with you online, learning from
your experiences, and exchanging ideas. Well also have room for
some lighthearted moments as well such as the connection
between rhinotillexomania and ordering diagnostic tests!
I look forward to meeting you all via Evidence eMended. All
the articles for the month will be listed, with links to the originals
or to the PubMed citation. Ill be posting a blog entry at least
weekly for each AAP GR issue, so be sure to check in throughout
the month. Please join me at www.GrandRoundsBlog.org.
Talk with you soon, on line!

CME INFORMATION
AAP Grand Rounds is an educational publication. The American Academy of Pediatrics is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
The American Academy of Pediatrics designates this educational activity for a maximum of 18
AMA PRA Category 1 Credits or 1.5 AMA PRA Category 1 Credit per issue. Physicians should
only claim credit commensurate with the extent of their participation in the activity.
This activity is acceptable for up to 18 AAP credits. These credits can be applied toward the
AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of
Pediatrics.
This program is approved for 18 NAPNAP contact hours; pharmacology (Rx) contact hours to
be determined per the National Association of Pediatric Nurse Practitioners Continuing Education
Guidelines.
A CME Quiz Sheet can be found in the new CME Activity Center at www.aapgrandrounds.org.
The deadline for submitting the 2009 quiz sheet for 2009 credit is January 31, 2010.
This is a scientific publication designed to present updates and opinion to health care professionals. It does not provide medical advice for any individual case, and is not intended for the layman.

www.aapgrandrounds.org