Download Conference Syllabus

27th Annual SW Virginia Pediatrics Conference
Saturday August 6 and Sunday August 7, 2011
M
Martha Washington Inn
Abingdon, Virginia
Saturday, August 6, 2011
7:00
Registration and Breakfast
7:25
Welcome and Announcements
7:30
Child Obesity Treatment in Primary Care: What‟s the PLAN?
Karen Schetzina, MD, William Dalton, PhD
8:15
Sports Injuries in the Pediatric Athlete:
Considerations for the Stars of Tomorrow
Eric Parks, MD
9:00
KEYNOTE ADDRESS
Seizures: Diagnosis and Management in Primary Care
Tracy Glauser, MD
10:00
Break, Exhibits and Poster Displays
10:30
Anti-epileptics: The Old, the New, and Future Directions
Jim Thigpen, PharmD, BCPS
11:15
Life After Cancer: Cases from the Clinic
Sharon Castellino, MD
12:10
Adolescent Medicine-Jeopardy!
David Chastain, MD
Optional Workshop
2-3:30 Putting a PLAN into Practice for Child Obesity Management in
Primary Care
Karen Schetzina, MPH, MD and Will Dalton, PhD
27th Annual SW Virginia Pediatrics Conference
Saturday August 6 and Sunday August 7, 2011
M
Martha Washington Inn
Abingdon, Virginia
Sunday, August 7, 2011
7:30
Updates in Dermatology: Let‟s Get Sun Safe
Robert Clemmons, MD
8:30
Update on Craniosynostosis and Deformational Plagiocephaly
James Thompson, MD
9:30
Direct Ophthalmoscopy: How to Use One of the Most Powerful
Instruments in Your Office
Jeffery Carlsen, MD
9:55
Break and Poster Session
10:15
Guidelines for Diagnosis and Management of URTI, Rhinitis and PSI
Mark Howell, MD, FACS
11:15
“I‟m Not Listening”! : Assessment & Treatment of
Oppositional/Disruptive Behavior in Primary Care
Jennifer Correll, MA, PhD (2011)
12:00
What's Up With Spit Up?
Darshan Shah, MD
12:45
Adjourn until August 5 - 6, 2012
The 27th Annual SW Virginia Pediatrics Conference is sponsored by
the Department of Pediatrics, Quillen College of Medicine, ETSU,
in association with
Conference Activity Directors and Planning Committee
Activity Directors:
David Kalwinsky, MD, Chair, Department of Pediatrics, Quillen College of Medicine, East
Tennessee State University, Johnson City, TN, &
Des Bharti, MD, Professor, Department of Pediatrics, James H. Quillen College of Medicine,
East Tennessee State University, Johnson City, TN
Planning Committee:
Gayatri Jaishankar, MD, Assistant Professor, Department of Pediatrics, James H. Quillen
College of Medicine, East Tennessee State University, Johnson City, TN
Demetrio Macariola, MD, Assistant Professor, Department of Pediatrics, James H. Quillen
College of Medicine, East Tennessee State University, Johnson City, TN
Marcella Popescu, MD, Assistant Professor, Department of Pediatrics, James H. Quillen
College of Medicine, East Tennessee State University, Johnson City, TN
Dawn Tuell, MD, Assistant Professor, Department of Pediatrics, James H. Quillen College of
Medicine, East Tennessee State University, Johnson City, TN
Joy Wachs, PhD, RN, PHCNS-BC, Professor and Coordinator, Continuing Nursing Education
Honors-in-Discipline Programs, College of Nursing, ETSU
Christine Newell Kwasigroch, MEd, PhD, Program Planner, Office of Continuing Medical
Education, James H. Quillen College of Medicine, East Tennessee State University,
Johnson City, TN
Presenters :
Jeffrey Carlsen, MD
Johnson City Eye Clinic & Johnson City Eye Surgery
Center, Johnson City, TN
Sharon Castellino, MD, FAAP
Wake Forrest Baptist Medical Center
Winston Salem, NC
David Chastain, MD
Department of Pediatrics
Quillen College of Medicine, Johnson City, TN
Robert Clemons, MD, FAAD
TriCities Skin and Cancer, Johnson City, TN
Jennifer Correll, MA, PhD
(2011)
Department of Clinical Psychology
Behavioral Health and Wellness Clinic
East Tennessee State University, Johnson City, TN
William Dalton, PhD
Assistant Professor
Department of Psychology, ETSU
Johnson City, TN
Tracy Glauser, MD
Professor of Pediatrics and Neurology
Director, Comprehensive Epilepsy Center
Co-Director, Genetic Pharmacology Service
Children's Hospital Medical Center
Cincinnati, Ohio
Mark Howell, MD, FACS
Ear, Nose and Throat Associates, Johnson City, TN
Eric Parks, MD
Primary Care Sports Medicine
Watauga Orthopedics, Kingsport, TN
Karen Schetzina, MD, MPH
Assistant Professor, and Director, Division of Community
Pediatrics Research, Department of Pediatrics, Quillen
College of Medicine; Adjunct Professor, Department of
Epidemiology and Biostatistics
ETSU College of Public Health, Johnson City, TN
Darshan Shah, MD
Assistant Professor, Quillen College of Medicine,
Department of Pediatrics, Johnson City, TN
Jim Thigpen, PharmD, BCPS
Assistant Professor, Department of Pharmacy Practice
Bill Gatton College of Pharmacy, ETSU, Johnson City, TN
James Thompson, MD, FACS
Assistant Professor,
Department of Plastic and Reconstructive Surgery
Wake Forest School of Medicine
Winston-Salem, NC
CME Credit: Quillen College of Medicine, East Tennessee State University is accredited by the
Accreditation Council for Continuing Medical Education to provide continuing medical education
ofr physicians. The Quillen College of Medicine, East Tennessee State University designates this
live activity for a maximum of 10.0 AMA PRA Category 1 Credits™. The Optional PLAN
Workshop is designated for 1.5 AMA PRA Category 1 Credits™.
AAFP Credit: This Live activity, 27th Annual SW Virginia Pediatrics Conference, with a beginning
date of August 6, 2011, has been reviewed and is acceptable for up to 11.50 Prescribed credit(s)
by the American Academy of Family Physicians. Physicians should claim only the credit
commensurate with the extent of their participation in the activity. Application #: 52610
TN CNE Credit: 9.75 continuing nursing education contact hours for the conference and an
additional 1.5 contact hours for the optional workshop.
East Tennessee State University College of Nursing is an approved provider of continuing nursing
education by the Tennessee Nurses Association, an accredited approver by the American Nurses
Credentialing Center's Commission on Accreditation.
This event is presented by the Quillen College of Medicine Office of Continuing Medical
Education and the College of Nursing Office of Continuing Nursing Education at East Tennessee
State University.
Nursing Credit: As an Accreditation Council on Continuing Medical Education (ACCME)approved provider, the CME credit offered during this educational activity is accepted by the
ANCC, AACN and the NCCPA for recertification.
CME Certificates: By submitting the „Request for Credit Form‟ (which is part of your Conference
Handouts,) and by signing the sign in sheets each day, credits will be added to your online
TRANSCRIPT, which is maintained in the ETSU Office of CME. You may print your transcript
online from our website, http://www.etsu.edu/cme. Go to „For Learners‟ „Transcript of Your
Earned Credits‟. Please allow 2 weeks from the conference date before requesting your transcript.
Check with the Registration Desk for information on how to access and print your transcript, or
call our office, 423-439-8027, with questions. Instructions are also printed on our monthly
calendar.
Disclosure Information: Quillen College of Medicine, East Tennessee State University‟s Office of
Continuing Medical Education (OCME) holds the standard that its continuing medical education
programs should be free of commercial bias and conflict of interest. It is the policy of the OCME
that each presenter and planning committee member of any CME activity must disclose any
significant financial interest/arrangement or affiliation with corporate organizations whose
products or services are being discussed in a presentation.
Each of the following speakers and conference planners* have completed a disclosure form
indicating that they or members of their immediate family have NO financial
interest/arrangement or affiliation that could be perceived as a real or apparent conflict of
interest related to: (a) the content of this activity or (b) the supporters involved with this
activity:
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*Des Bharti
Jeffrey Carlsen
Sharon Castellino
David Chastain
Robert Clemons
Jennifer Correll
William Dalton
Tracy Glauser
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Mark Howell
*Gayatri Jaishankar
*David Kalwinsky
*Chris Newell Kwasigroch
*Demetrio R. Macariola
Eric Parks
*Marcella Popescu
Karen Schetzina
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Darshan Shah
James Thigpen
James Thompson
*Dawn Tuell
*Joy Wachs
Commercial Support Disclosure: It is the policy of the Office of Continuing Medical
Education at Quillen College of Medicine, East Tennessee State University to disclose all
Commercial Supporters of this educational activity from which educational grants were
received.
Unrestricted Educational Grant Support was received from the following:

Lundquist Pharmaceuticals
The Mission of the Office of Continuing Medical Education at the James H. Quillen College
of Medicine is to provide quality educational programs to physicians and other health
professionals in Northeast Tennessee, Southwest Virginia and contiguous areas. The office
develops and sponsors educational activities that enhance the knowledge, skills, professional
performance and relationships required by health professionals to serve patients, the public
and their professions.
The Syllabus with Full Color Complete Presentations--if permitted by the speaker-- is
available as a pdf document on the conference website:
http://www.etsu.edu/com/cme/Southwestvapeds.aspx
Please note that all presenters may not have provided handouts prior to the conference and
may bring material with them for distribution at the time of their presentation.
CME Senior Conference Planner:
Christine Newell Kwasigroch, MEd-MFT, Ph.D.
423-439-8074
[email protected]
If you have questions, concerns, or comments about this activity, please contact:
Barbara J. Sucher, M.B.A., Associate Dean for Continuing Medical Education
[email protected] or 423-439-8081
We gratefully acknowledge the participation and generous
support of the following sponsors:
This conference is supported in association with
 Unrestricted Educational Grants from:
 Lundbeck, Inc
 Exhibitors
 BABE—Breastfeeding Advocacy Benefits Everyone
 ETSU Pediatric Cardiology
 Niswonger Children’s Hospital
 SW Virginia Care Connection for Children
Learning Resources available though:
Quillen College Medicine Medical Library
website: http://com.etsu.edu/medlib/
Mark Your Calendar for these upcoming events:
Quillen College of Medicine Office of Continuing Medical Education
(CME) offers educational programs for Physicians, Nurse Practitioners
and Physician Assistants, as well as for other health care providers in NE
Tennessee, SE Kentucky, SW Virginia, and Western North Carolina.
Educational Forums on Prescription Drug Abuse
There are no fees for these sessions--However, advance registration is required.
To register go to http://www.etsu.edu/com/cme
• Dates and Locations:
• Saturday, September 17, 2011 – Richlands, VA
• Sunday, September 18, 2011 – Big Stone Gap, VA
• Target Audience: Practicing/Licensed M.D.s/D.O.s, Dentists, APNs, PAs,
Pharmacists, Pharmacy Technicians and Interns, and Medical Students in the
Commonwealth.
•
Learning Objectives: As a result of participating in this activity, the attendee
should be able to:
• Explain and demonstrate the legal and regulatory requirements for using
controlled substances to treat chronic pain in Virginia.
• Illustrate how health care providers can work with law enforcement to curb
prescription drug abuse in our region.
• Compare options available for treatment of opiate dependence (i.e.,
methadone maintenance therapy and buprenorphine) with a focus on
safety, efficacy, and appropriate prescribing precautions.
• Describe the universal precautions for prescribing controlled substances.
• Demonstrate how to use the PMP as a resource in patient-centered care.
Women’s Health Across the Lifespan: A Comprehensive Approach
Website: http://www.etsu.edu/com/cme/womenshealth2011.aspx
 When: October 7, 2011
 Where: The Millennium Center, Johnson City, TN
 Target Audience: Primary care and specialist physicians, nurses, nurse practitioners,
physician assistants, pharmacists, as well as any practitioner working in teams to
provide inter-professional care for their female patients
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Learning Objectives
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Explain the latest evidence for the origins of fibromyalgia
Differentiate fibromyalgia from other similar clinical presentations
Identify new pharmacological and non-pharmacological treatment strategies
for patients with fibromyalgia
Assess women with chest pain and determine the appropriate sequence of
testing and referral for care and cardiac rehabilitation
Develop a plan to screen women for heart disease
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Explain the current recommendations regarding hormone replacement
therapy and its risks and benefits
Differentiate among the various pharmacologic and bio-identical agents with
estrogenic activity and determine when each may or may not be indicated
Compare the risks, benefits and drug interactions of herbal/alternative
medicines and dietary supplements currently in use and be able to explain
this to patients
Identify and distinguish overlapping and confounding symptoms
Psychiatry in the Mountains: Autism & Anxiety Disorder Spectrums
• When: October 21, 2011
• Where: The Millennium Centre, Johnson City, TN
• Target Audience : Physicians, nurses, psychiatrists and other healthcare
professionals on the diagnosis and treatment of autism and anxiety disorders in
adults and children
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Topics Include:
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Asperger’s Syndrome
Family & School Issues
Update on Autism Evaluation, Treatment & Research
Treatment of Anxiety: Including Children with Tics, Trichotillomania &
Tourette’s
Psychotherapeutic Treatment of Appalachian Combat Veterans with PTSD
Psychopharmacology of Anxiety Disorders
FOR MORE INFORMATION
on these or other upcoming CME programs, or to register for any
activity,
please contact our office at 423-439-8027 or visit our website at
http://www.etsu.edu/cme
Check our website for a video recording of this and other CME events
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
William Dalton, PhD
does not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. He reports that he DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
as a real or apparent conflict of interest in the
context of this presentation. DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Karen Schetzina, MD
does not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. She reports that she DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
as a real or apparent conflict of interest in the
context of this presentation. 27th Annual SW VA Pediatrics Conference
Child Obesity Treatment in Primary Care: What's the PLAN? • Describe the latest evidence on effective behavioral treatment approaches for child obesity in primary care • Overcome common challenges in treating child obesity • Integrate evidence‐based behavioral approaches and tools for addressing child obesity into primary care
tools for addressing child obesity into primary care practice 8/6‐7/2011
Notes:
Child Obesity Treatment in Primary Care: What's the
PLAN?
William Dalton, PhD
Karen Schetzina, MPH, MD
William Dalton, PhD
Karen Schetzina, MD, MPH
8/6/2011
Primary Care Research Study
In Memoriam:
Tiejian Wu, MD, PhD
h
1962‐2011
Purpose: Evaluate a parent‐mediated approach utilizing Evaluate a parent mediated approach utilizing
brief motivational interviewing and group visits to treat child (ages 5‐11 years) overweight and obesity in the primary care setting
15-Minute Obesity Prevention Protocol
Steps
Sample Language
STEP 1. ASSESSMENT
Weight and height, convert to BMI. Provide BMI information.
We checked your child’s body mass index (BMI), which is a way of looking at weight
and taking into consideration how tall someone is. Your child’s BMI is in the range
where we start to be concerned about extra weight causing health problems.
Elicit parent’s concern.
—What concerns, if any, do you have about your child’s weight?
— He did jump two sizes this year. Do you think he might get diabetes someday?
Reflect/probe.
So you’ve noticed a big change in his size and you are concerned about diabetes down
the road. What makes you concerned about diabetes in particular? Etc.
Sweetened beverages, fruits and vegetables, TV viewing and
other sedentary behavior, frequency of fast-food or restaurant
eating, consumption of breakfast, and others
(Use verbal questions or brief questionnaires to assess key behaviors.)
Example: About how many times a day does your child drink soda, sports drinks, or
powdered drinks like Kool-Aid?
Provide positive feedback for behavior(s) in optimal range.
Elicit response.
You are doing well with sugared drinks.
I know it’s not healthy. He used to drink a lot of soda, but now I try to give him water whenever possible. I think we are down to just a few soda’s a week.
So you have been able to make a change without too much stress.
Reflect/probe.
Provide neutral feedback for behavior(s) NOT in optimal range.
Elicit response.
Your child watches 4 hours of TV on school days. What do you think about that?
I know it’s a lot, but he gets bored otherwise and starts picking an argument with
his little sister.
So watching TV keeps the household calm.
Reflect/probe
STEP 2. AGENDA SETTING
Query which, if any, of the target behaviors parent/child/adolescent
may be interested in changing or might be easiest to change.
We’ve talked about eating too often at fast-food restaurants, and how TV viewing is more
hours than you’d like. Which of these, if either of them, do you think you and your child
could change?
Well, I think fast food is somewhere we could do better. I don’t know what he would do if
he couldn’t watch TV. Maybe we could cut back on fast food to once a week.
Agree on possible target behavior.
That sounds like a good plan.
STEP 3. ASSESS MOTIVATION AND CONFIDENCE
3a: Willingness/Importance
On a scale of 0 to 10, with 10 being very important, how important is it for you to reduce the amount of fast food he eats?
0
Not at all
1
2
3
4
5
6
Somewhat
7
8
9
10
Very
continued
15-Minute Obesity Prevention Protocol
15-Minute Obesity Prevention Protocol
15-Minute Obesity Prevention Protocol, continued
STEP 3. ASSESS MOTIVATION AND CONFIDENCE, continued
3b: Confidence
On a scale of 0 to 10, with 10 being very confident, assuming you decided to change the amount of fast food he eats, how confident are you that
you could succeed?
0
1
2
3
4
Not at all
5
6
Somewhat
3c: Explore IMPORTANCE and CONFIDENCE ratings with the
following probes:
Benefits
Barriers
Solutions
7
8
9
10
Very
You chose 6. Why did you not choose a lower number?
I know all that grease is bad for him.
You chose 6. Why did you not choose a higher number?
It’s quick, cheap, and he loves it…especially the toys and fries.
REFLECTION: So there are benefits for both you and him.
What would it take you to move to an 8?
Well, I really want him to avoid diabetes. My mother died of diabetes, and it wasn’t
pretty…maybe if he started showing signs of it…maybe if I could get into cooking a bit.
STEP 4. SUMMARIZE AND PROBE POSSIBLE CHANGES
Query possible next steps.
So where does that leave you?
OR
From what you mentioned it sounds like eating less fast food may be a good first step.
OR
How are you feeling about making a change?
Probe plan of attack.
What might be a good first step for you and your child?
Or
What might you do in the next week or even day to help move things along?
Or
What ideas do you have for making this happen?
If patient does not have any ideas…
If it’s OK with you, I’d like to suggest a few things that have worked for some of
my patients.
Summarize change plan, provide positive feedback.
Involving child in cooking or meal preparation
Ordering healthier at fast-food restaurants
Trying some new recipes at home
STEP 5. SCHEDULE FOLLOW-UP
Agree to follow up within X weeks/months.
Let’s schedule a visit in the next few weeks/months to see how things went.
If no plan is made
Sounds like you aren’t quite ready to commit to making any changes now. How about
we follow up with this at your child’s next visit?
OR
Although you don’t sound ready to make any changes, between now and our next visit
you might want to think about your child’s weight gain and lowering his diabetes risk.
We Can! Try Tips To Eat Well
and Move More
Choose to take small steps today! Try these tips to eat well and move
more and see how easy taking small steps toward a healthier life can be.
Eating Well (ENERGY IN)
• Drink water before a meal.
• Eat half your dessert, or choose
fruit as dessert.
• Avoid food portions larger than
your fist.
• Drink diet soda instead of
regular soda.
• Eat off smaller plates.
• Don't eat late at night.
• Skip buffets.
• Grill, steam, or bake instead
of frying.
• Share an entree with a friend.
• Eat before grocery shopping.
• Choose a checkout line without
a candy display.
• Make a grocery list before
you shop.
• Drink water or low-fat milk over
soda and other sugary drinks.
• Flavor foods with herbs, spices,
and other low-fat seasonings.
• Keep to a regular eating schedule.
• Eat before you get too hungry.
• Don't skip breakfast.
• Stop eating when you are full.
• Snack on fruits and vegetables.
• Top your favorite cereal with
apples or bananas.
• Include several servings of
whole-grain foods daily.
• If main dishes are too big, choose
an appetizer or a side dish instead.
• Ask for salad dressing “on
the side.”
• Don't take seconds.
• Try a green salad instead of fries.
• Eat sweet foods in small amounts.
• Cut back on added fats or oils in
cooking or spreads.
• Cut high-calorie foods like cheese
and chocolate into small pieces
and only eat a few pieces.
• Use fat-free or low-fat sour cream,
mayo, sauces, dressings, and
other condiments.
• Replace sugar-sweetened
beverages with water and add a
twist of lemon or lime.
• Every time you eat a meal, sit
down, chew slowly, and pay
attention to flavors and textures.
• Try a new fruit or vegetable (ever
had jicama, plantain, bok choy,
star fruit, or papaya?)
• Instead of eating out, bring a
healthy, low-calorie lunch to work.
• Ask your sweetie to bring you fruit
or flowers instead of chocolate.
Moving More (ENERGY OUT)
• Walk your children to school.
• Take a family walk after dinner.
• Join an exercise group and enroll
your children in community sports
teams or lessons.
• Replace a Sunday drive with
a Sunday walk.
• Do yard work. Get your children
to help rake, weed, plant, etc.
• Get off the bus a stop early
and walk.
• Work around the house. Ask
your children for help doing
active chores.
• Walk the dog to the park.
• Go for a half-hour walk instead
of watching TV.
• Pace the sidelines at kids'
athletic games.
• Choose an activity that fits into
your daily life. Being physically
active with your family is a great
way to spend time together.
• Park farther from the store
and walk.
• Use an exercise video with your
kids if the weather is bad.
• Avoid labor-saving devices, such as
a remote control or electric mixers.
• Play with your kids 30 minutes
a day.
• Dance to music. Play your favorite
dance music for your children and
have them play their favorites
for you.
• Make a Saturday morning walk a
family habit.
• Walk briskly in the mall.
• Choose activities you enjoy—you'll
be more likely to stick with them.
Ask children what activities they
want to do.
• Explore new physical activities.
• Acknowledge your efforts with
non-food related rewards, such as
a family day at the park, lake,
or zoo.
• Take the stairs instead of
the escalator.
• Swim with your kids.
• Turn off the TV and play ball at
the park.
• Take your dog on longer walks.
• When walking, go up the hills
instead of around them.
• Use a family activity planner to
make time each day for activity.
• Buy a set of hand weights and
play a round of Simon Says with
your kids—you do it with the
weights, they do it without.
Source: Adapted from www.smallstep.gov
We Can! Try Tips To Eat Well and
Move More Tracking Sheet
Pick a tip each week from the list of Everyday tips to help you eat well and
move more! Fill in the tips on this tracking chart to encourage you to keep
it up. Put the tracking sheet on your refrigerator or other central location
for your family to see that you are making steps toward maintaining a
healthy weight.
Week
Week 1 (___/___)
Week 2 (___/___)
Week 3 (___/___)
Week 4 (___/___)
Week 5 (___/___)
Week 6 (___/___)
Eating Well Tip
Moving More Tip
Notes
for Healthy Active Living
Name
Date
Ideas for Living a Healthy Active Life
5 Eat at least 5 fruits and vegetables every day.
2 Limit screen time (for example, TV, video games, computer) to 2 hours or less per day.
1 Get 1 hour or more of physical activity every day.
0 Drink fewer sugar-sweetened drinks. Try water and low-fat milk instead.
My Goals (choose one you would like to work on first)
n Eat
fruits and vegetables each day.
n Reduce screen time to
minutes per day.
n Get
minutes of physical activity each day.
n Reduce number of sugared drinks to
per day.
From Your Doctor
Patient or Parent/Guardian signature
Doctor signature
Healthy Active Living
An initiative of the American Academy of Pediatrics
William Dalton, PhD
Karen Schetzina, MD, MPH
8/6/2011
Resources:
AAP Obesity Initiative http://www.aap.org/obesity/index.html
NIH We Can!
http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/
[email protected]
[email protected]
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Eric Parks, MD
does not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. He reports that he DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
h
ld b
d
as a real or apparent conflict of interest in the
context of this presentation. Sports Injuries in the Pediatric Athlete: Considerations for the Stars of Tomorrow • Recognize the common overuse injuries sustained by the young athlete • Make recommendations to parents of young athletes regarding risks of overuse during sports Notes:
Sports Injuries in the Pediatric Athlete:
Considerations for the Stars of Tomorrow
Eric Parks, MD
Eric Parks, MD
8/6/2011
Sports Injuries
The Physis
Epidemiology
• 30-50% of adolescent sports-related injuries are
overuse
– Watkins J. J Sports Med Phys Fitness. 1996;36(1):4348.
• 15% of all adolescent injuries are to the physes and
apophyses
– Pill SG. J Musculoskeletal Med. 2003;20:434-442
27th Annual SW VA
Pediatrics Conference
• Cartilage is less resistant to tensile forces
than bones, ligaments, and muscle-tendon
units
• Bones grow faster than muscle-tendon units
• Same injury leading to a muscle strain in an
adult may result in growth center injuries in
adolescents
• The “Weak Link”
27th Annual SW VA
Pediatrics Conference
Key Points During Evaluation
Treatment
General Principles
• History and physical exam
– Recent change in activity or training
• Insidious onset of pain that worsens with activity
and improves with rest
• Point tenderness with or without swelling
• Pain with passive stretch of attached ligament/
muscle-tendon unit
• Pain with firing muscle-tendon unit against
resistance
• Radiographs?
– Help to rule out other pathology
27th Annual SW VA
Pediatrics Conference
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Relative rest
Cross training
Flexibility
Ice
Counter-balance bracing
?NSAIDS
ORIF with certain avulsions
Resection of retained, non-fused ossicles
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
8/6/2011
PFS
Patellofemoral Friction Syndrome
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Most common cause of anterior knee pain
Estimated prevalance of 20%
Mean age 14 years
“The Great Imitator” of symptoms
Risk Factors and Treatment
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Muscle imbalances
Flexibility issues
Over-pronation, pes planus
Specific sports
– Location and quality of pain
• Walking stairs, incline/decline
• “Theatre sign”
• Treat from the hip to the waist
• Orthotics, bracing, taping?
27th Annual SW VA
Pediatrics Conference
27th Annual SW VA
Pediatrics Conference
Osgood-Schlatter’s Disease (OSD)
Osgood-Schlatter’s Disease (OSD)
Tibial Tubercle Apophysitis
Tibial Tubercle Apophysitis
• Occurs in 20% of young athletes
– most common pediatric overuse injury
•
•
•
•
20% of OSD is bilateral
Girls 8–13yo
8 13yo
Boys 10-15yo
Aggravated by running, jumping, or other
explosive activities
• Occasionally aggravated by kneeling or direct
trauma
27th Annual SW VA
Pediatrics Conference
• Point tender +/- swelling at tibial tubercle
• Pain with quadriceps stretch or contraction, poor
quad flexibility
• Widened
Wid d physis
h i or fragmented
f
t d tibial
tibi l tubercle
t b l on
radiographs
• Tight quadriceps or hip flexors
– Positive Thomas test
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
•
•
•
•
•
8/6/2011
Osgood-Schlatter’s Disease (OSD)
Osgood-Schlatter’s Disease (OSD)
Risk Factors
Treatment
Repetitive explosive activities
Recent increase in activities
Tight quadriceps and/or hip flexors
External tibial torsion
Patella alta
•
•
•
•
•
•
Relative rest
Quadriceps and hip flexor stretching
Ice
NSAIDs
Cho-Pat strap
Knee pads
27th Annual SW VA
Pediatrics Conference
27th Annual SW VA
Pediatrics Conference
Sinding-Larsen-Johansson Syndrome
(SLR)
Sinding-Larsen-Johansson Syndrome
(SLR)
• Apophysitis at the inferior pole of the patella
• 10-12 years old
p g athletes
• Most common in runningg & jjumping
– Basketball, soccer, gymnastics
• “Adolescent Jumper’s Knee”
27th Annual SW VA
Pediatrics Conference
•
•
•
•
Tenderness at the inferior pole of the patella
Pain worsened with explosive activity
Tight quadriceps
Radiographs may reveal fragmentation of the
inferior pole and/or calcification at the
proximal patella tendon
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
8/6/2011
Sinding-Larsen-Johansson Syndrome
(SLR)
Treatment
•
•
•
•
•
Relative rest
Quadriceps
Q
p stretchingg
Ice
NSAIDs
Cho-Pat strap
Osteochondritis Dessicans
• Avascular necrosis of cartilage bed
• May be result of direct trauma vs iatrogenic
• MC location- lateral pportion of medial
femoral condyle
• Age 9-18 years old
• Consider in adolescent presenting with
painless effusion
27th Annual SW VA
Pediatrics Conference
27th Annual SW VA
Pediatrics Conference
Osteochondritis Dessicans
Sever’s Disease
Treatment
Calcaneal Apophysitis
• Treatment will depend on the stability of the
lesion
• Protected/NWB for 6 weeks
• Bracing
• Follow up imaging
• Unstable- surgical
27th Annual SW VA
Pediatrics Conference
• Affects boys and girls equally
• Ages 8-13 years
• Most common in soccer, basketball, &
gymnastics
– Repetitive heel impact & traction stress
from the achilles tendon
• Bilateral in 60% of cases
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
8/6/2011
Sever’s Disease
Sever’s Disease
Calcaneal Apophysitis
Risk Factors
•
•
•
•
•
Heel pain worsened with activity
No swelling
Point tender at posterior calcaneus
Pain with medial-lateral compression
Pain with calf stretch or contraction against
resistance
• Tight heel cord, weak dorsiflexors, subtalar
overpronation
27th Annual SW VA
Pediatrics Conference
Sever’s Disease
Treatment
•
•
•
•
•
Relative rest
Heel cord stretching
Heel cups
Ice
NSAIDs
27th Annual SW VA
Pediatrics Conference
• Repetitive explosive activities
• Repetitive trauma
– Jumping, landing, cleats, etc.
• Recent
R
iincrease in
i activities
i ii
• Tight heel cord
• Before/during rapid periods of growth
• Beginning of new season
27th Annual SW VA
Pediatrics Conference
Pelvic Apophysitis
• 10-14 years old
• Insidious onset of hip pain or sudden sharp
pain
– Running, jumping, kicking sports
• Point tender
• Pain with stretch or contraction of involved
muscle
• Widening of physis or avulsion of
apophysis
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
•
•
•
•
•
•
•
8/6/2011
Pelvic Apophysitis
Medial Epicondyle Apophysitis
Treatment
Little League Elbow
Relative rest until pain free (~4-6 weeks)
WBAT without limping
NSAIDs
Ice
Stretching & strengthening
Progressive return to activities
Rare need for surgery
27th Annual SW VA
Pediatrics Conference
Medial Epicondyle Apophysitis
Little League Elbow
• X-rays may reveal widening of medial
epicondyle apophysis &/or fragmentation of
medial epiphysis
• 85% of X-rays are normal
– Hang DW. Am J Sports Med. 2004
27th Annual SW VA
Pediatrics Conference
• Most common in 9 to 14 y/o overhead athletes
• ~18-29% incidence of elbow pain in youth and HS
baseball players
• Point
P i t tenderness
t d
over medial
di l epicondyle
i d l
• Classically worsened by repetitive throwing
• Hypertrophy of medial epicondyle
• Flexion contracture
• Pain with valgus stress & milking maneuver
27th Annual SW VA
Pediatrics Conference
Little League Elbow
Treatment
• If apophysis not significantly displaced (<5mm)
– (Relative) rest 4 - 6 weeks
– Isometric strengthening, stretching, resistive
strengthening
– Throwing
Thro ing mechanics evaluation
e aluation
– Gradual return to throwing after 6 - 12 weeks
• Interval Throwing Program
– Follow pitch counts & types
• If apophysis significantly displaced (>5mm) surgery
is warranted
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
8/6/2011
USA Baseball Medical & Safety
Advisory Committee
Pitch Counts 2008
27th Annual SW VA
Pediatrics Conference
USA Baseball Medical & Safety
Advisory Committee
Days Off 2008
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
8/6/2011
Little League Shoulder
Proximal Humeral Epiphysiolysis
• Fatigue fracture of the proximal humeral physis
– Does not fuse until ages 14-20
• Typically high-performance male pitchers
• Rotatory torque stresses to the epiphyseal growth plate
• 9-14
9 14 years old
• Pain
• Inability to perform
• Decreased ROM
• TTP at anterior proximal humerus
• Remember– physis is the weak link!
Proximal Humeral Epiphysiolysis
• Treatment
– Relative rest for 4-6 weeks
p g
– Interval throwingg program
– Thrower’s 10 program
27th Annual SW VA
Pediatrics Conference
27th Annual SW VA
Pediatrics Conference
Spondylolysis
Spondylolysis
Epidemiology
•
•
•
•
Little League Shoulder
Lesion in the pars interarticularis of the neural arch
Incidence of 6-8% in general population
6.4% for Caucasian males
1.1% for African-American females
– Roche MA,
MA Rowe GG.
GG Anat Rec.
Rec 1951
• Overall incidence of 4.4% by age 6, 5.2% by age 12, and
6% by adulthood
– Frederickson BE. J Bone Joint Surg. 1984
• Males>>>Females
• 85-95% occur at L5 with the remainder typically at L4
– Amato ME. Radiology. 1984.
27th Annual SW VA
Pediatrics Conference
Clinical Presentation
• Insidious back pain exacerbated by strenuous
activity
• Occasional radiation to the buttocks
• Rising to an upright posture against resistance
elicits pain
• Pain exacerbated by hyperextension & rotation
bilateral, unilateral
• Hamstring tightness in 80% of patients
• Tenderness in lumbar spine to palpation
• Hyperlordosis
27 Annual SW VA
th
Pediatrics Conference
Eric Parks, MD
•
•
•
•
•
8/6/2011
Spondylolysis
Stress Fractures
Treatment
History
Relative rest & activity modification
Time (>3 months)
Flexion-based core strengthening
NSAIDs
Bracing?
– If still painful after the above
• Surgery
• Recent change in activity level, equipment, or
playing surface
• Insidious onset of pain
• Worse with activityy
• Improves with rest
• Prior stress fractures
• Menstrual irregularities, weight changes, eating
disorder, nutrition
– Female Athlete Triad
27th Annual SW VA
Pediatrics Conference
27th Annual SW VA
Pediatrics Conference
Stress Fractures
Stress Fractures
Clinical Examination
• Focal tenderness may be elicited with
compression or percussion
• Fulcrum test, Hop test, & Tuning fork
• Plain xx-rays
rays often normal early in disease
course
– New bone formation after 2-3 weeks
• Further imaging may be needed
– Bone scan or MRI
27th Annual SW VA
Pediatrics Conference
Treatment
• Relative rest
– Cross-training
– Limit impact activities
• Immobilization
• Gradual return to play
• May take 6-8 weeks
• Be aware of tenuous stress fractures
– Anterior tibial cortex, tension-sided femoral
neck, Jones, etc.
27th Annual SW VA
Pediatrics Conference
Eric Parks, MD
8/6/2011
Summary
•
•
•
•
60 minutes of exercise is recommended daily
Video gaming is not intense enough
Adolescents are not little adults
Overuse injuries occur frequently in
adolescents
27th Annual SW VA
Pediatrics Conference
Summary
• Be wary of overuse physeal injuries
• Know where the common overuse physeal
injuries occur
• Relative rest is a good start with most overuse
physeal injuries
• Know common adolescent fractures, including
physeal fractures
27th Annual SW VA
Pediatrics Conference
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Tracy Glauser, M.D.
does not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. He reports that he DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
h
ld b
d
as a real or apparent conflict of interest in the
context of this presentation. Seizures: Diagnosis and Management in Primary Care • Recognize the signs and symptoms of 3 important i h i
d
f3i
epilepsy syndromes • Classify a patient's seizure as either partial onset or generalized onset py
p
• Select first line therapy for partial onset seizures in children Notes:
Seizures: Diagnosis an dManagement in Primary Care
Tracy Glauser, MD
Tracy Glauser, MD
8/6/2011
Definitions
• “Seizure” ‐ an electrical storm on the surface of the brain.
• “Epilepsy” – recurrent unprovoked seizures
• “E
“Epilepsy Syndrome” –
il
S d
” a groups of epilepsy f il
related signs and symptoms that travel together
Current Management of Epilepsy
•
•
•
•
•
Diagnose seizure and epilepsy
Diagnose
seizure and epilepsy
Classify seizure type
Classify epilepsy ‐ identify syndromes
Set treatment goals, establish bond
g
,
Start therapy based on seizure type or epilepsy syndrome
Tracy Glauser, MD
8/6/2011
Current Management of Epilepsy
Diagnosis the Seizure
• History is the key
• Ask about
– Premonitions of the event (aura)
– Repetitive motor movements
– Involuntary head or eye movements
– Alterations in consciousness
– Stereotyped events
– Confusion, tiredness after the event
Imitators of Seizures
•
•
•
•
•
•
Tics
Syncope
Breathholding
Headaches
Night terrors
Night terrors
Non‐epileptics events
Prensky A.L. In: Dodson, Pellock, eds. Pediatric Epilepsy.
Tracy Glauser, MD
8/6/2011
International Classification of Epileptic Seizure Types
• Partial Seizures
– Simple partial
– Complex partial
Complex partial
– Secondarily generalized
• Generalized Seizures
– Absence
– Myoclonic
– Atonic
At i
– Clonic
– Tonic‐clonic
• Unclassified epileptic seizures
ILAE. Epilepsia. 1981;22:489-501.
Classification of Epilepsy
Symptomatic (secondary)
• Focal or diffuse cerebral injury
• Neurologic abnormalities
• Frequent seizures
Frequent seizures
• Difficult to control
Idiopathic (primary)
• No identifiable pathology
• Normal development
• Relatively self‐limited
• Medication‐responsive
• Genetic predisposition
Tracy Glauser, MD
8/6/2011
West Syndrome
• Seizure type: Infantile Spasms
• EEG pattern: Hypsarrhythmia
• Clinical: Psychomotor retardation / regression
Lennox‐Gastaut Syndrome
• Seizure types: – Tonic; atonic atypical absence; generalized tonic clonic, – Myoclonic seizures, CPS less common
• EEG pattern: – Generalized slow spike‐wave (1.5‐2.5 Hz)
– Background slowing
• Clinical: – Psychomotor retardation / regression
Tracy Glauser, MD
8/6/2011
BECTS/BRE
• Seizure type: – Partial with motor, sensory, and autonomic activity of face, mouth, and throat, hypersalivation
common. Seizures can generalize.
– Over 50% only have seizures in sleep. Seizures when awake often occur shortly after awakening. • EEG pattern: centrotemporal
EEG pattern: centrotemporal spikes
• Clinical: – No significant neurological deficits – Normal neuroimaging
Childhood Absence Epilepsy
• Seizure types: –Absence
Absence
• EEG pattern: –Generalized 3 to 3.5 Hz spike‐wave
–Normal background • Clinical: –Normal development
Tracy Glauser, MD
8/6/2011
Summary of Evidence and Recommendations
Partial onset seizures
Seizure
type or
epilepsy
syndrome
Class I
Class
II
Class
III
Level of efficacy and effectiveness evidence
(in alphabetical order)
POS:
Adults
3
1
30
Level A: CBZ, LEV, PHT
Level B: VPA
Level C: GBP, LTG, OXC, PB, TPM, VGB
POS:
Children
1
0
17
Level A: OXC
Level B: None
Level C: CBZ, PB, PHT, TPM, VPA
POS:
Elderly
1
1
2
Level A: GBP, LTG
Level B: None
Level C: CBZ
Summary of Evidence and Recommendations
Generalized onset seizures
Seizure
type or
epilepsy
il
syndrome
Class I
Class
II
Class
III
Level of efficacy and effectiveness evidence
(in alphabetical order)
GTC:
Adults
0
0
23
Level A: None
Level B: None
Level C: CBZ, LTG, OXC, PB, PHT, TPM, VPA
GTC:
Children
0
0
14
Level A: None
Level B: None
Level C: CBZ, PB, PHT, TPM, VPA
Absence
seizures
1
0
6
Level A: ESM, VPA
Level B: None
Level C: LTG
Tracy Glauser, MD
8/6/2011
Summary of Evidence and Recommendations
Epilepsy syndromes
Seizure
type or
epilepsy
il
syndrome
Class I
Class
II
Class
III
Level of efficacy and effectiveness evidence
(in alphabetical order)
BECTS
0
0
2
Level A: None
Level B: None
Level C: CBZ, VPA
JME
0
0
0
Level A: None
Level B: None
Level C: None
The Place of Guidelines in
Clinical Decision Making
Evidence
Patient/Physician
Factors
1.Patient data
1. Cultural beliefs
Knowledge
2.Basic, clinical, and
epidemiologic research
2. Personal values
3.Randomized trials
Clinical
4.Systematic reviews
Decisions
Guidelines
3. Experiences
4. Education
Ethics
Constraints
1. Formal policies, laws
2. Community standards
3. Time
4. Reimbursement
Figure. Factors that enter into clinical decisions.
Mulrow CD, et al. Ann Intern Med. 1997.
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Jim Thigpen, PharmD
does not anticipate discussing the unapproved or investigative use of a commercial product/device during this lecture. He p
reports that he DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
as a real or apparent conflict of interest in the
context of this presentation. Anti‐epileptics: The Old, the New and Future Directions • Describe
Describe the known mechanisms of antiepileptic drug the known mechanisms of antiepileptic drug
classes • Identify the most common and serious adverse drug reactions for the medications discussed • Determine the appropriate medication choices for a specific sei re t pe
specific seizure type • Discuss the potential implication of pharmacogenetics in epilepsy Notes:
Anti-epileptics: The Old, the New and Future Directions
Jim Thigpen, PharmD, BCPS
Jim Thigpen, PharmD
ƒ
Phenytoin (Dilantin®)
8/6/2011
ƒ
ƒ Partial and secondary generalized seizures
ƒ
Phenytoin
ƒ Antiepileptic effect on calmodulin
ƒ Drug interactions
▪ Highly protein bound, CYP450 inducer
ƒ Adverse drug effect profile
▪ GI, rash, blood dyscrasias, headache, vitamin K and folate deficiencies, hormonal dysfunction, bone marrow effects, teratogenic effects
ƒ Serum monitoring
▪ In the presence of low serum albumin or other highly protein bound drugs, “free” (unbound) drug levels should be obtained
Fosphenytoin (Cerebyx®)
ƒ Prodrug for parenteral administration
▪ Far better tolerated than phenytoin through peripheral IV
▪ If central line is used, “regular” phenytion is fine
ƒ Can be infused 3X faster, can be given IM
ƒ May achieve target levels of phenytoin faster
ƒ Far more expensive than phenytoin
ƒ
Carbamazepine (Tegretol®)
ƒ Partial and tonic clonic seizures
ƒ Trigeminal neuralgia and bipolar disorder
ƒ Induces its own metabolism (autoinduction)
▪ Usually seen in the first three weeks
ƒ Active metabolite (10,11‐epoxide)
▪ Must be considered when CNS side effects are seen
Jim Thigpen, PharmD
ƒ
Carbamazepine (Tegretol®)
8/6/2011
ƒ
Oxcarbazepine (Trileptal®)
ƒ CNS side effects are dose‐related
▪ Think 10,11‐epoxide ƒ Partial and secondary generalized seizures
ƒ Aplastic anemia, agranulocytosis, ƒ No epoxide metabolite
ƒ May aggravate myoclonic or absence
thrombocytopenia, rash, and SJS are idiosyncratic
ƒ Hyponatremia
ƒ CNS effects are dose‐related
ƒ Hyponatremia and rash is similar to that seen with ▪ Altered sensitivity to serum osmolality by hypothalamic osmoreceptors or ↑ sensitivity of kidneys to ADH
carbamazepine
ƒ Inducer of CYP3A4
Van Amelsvoort T, et al. Epilepsia 1994 35(1):181‐8.
ƒ
Lamotrigine (Lamictal®)
ƒ Chemically unrelated to any other AED
ƒ Blocks sodium channel conductance and also inhibits release of glutamate
ƒ Partial onset and secondarily generalized tonic‐
clonic seizures and Lennox‐Gastaut
ƒ Can cause worsening of myoclonic seizures
ƒ
Lamotrigine (Lamictal®)
ƒ Few CNS side effects
▪ Headache, ataxia, diplopia, psychosis, somnolence
ƒ Rash is the main concern, SJS in 0.1%
▪ Seen more commonly with taken with valproate
▪ Slow titration ƒ Low incidence of congenital malformations
Jim Thigpen, PharmD
ƒ
Zonisamide (Zonegran®)
8/6/2011
ƒ
ƒ Also affects on T‐type calcium channels and ƒ Avoid with a history of kidney stones
provides neuroprotective effects through free radical scavenging
di l i
ƒ Partial seizures and myoclonus
ƒ Dizziness, anorexia, headache, ataxia, tremor, weight gain
ƒ Confusion, speech abnormalities, mental slowing
ƒ Oligohidrosis due to effect on carbonic anhydrase
ƒ Skin reactions (SJS and TEN) have been reported
▪ Do not use in sulfa‐allergic ƒ Some drug interactions with other AEDs (PHT, CBZ, PB, VPA) leading to reduced ZNS levels
ƒ Good alternative in adherence due to long t1/2
▪ Gradual titration
Gamma‐aminobutyric acid (GABA) is the most important inhibitory neurotransmitter
ƒ Benzodiazepines
ƒ
ƒ
Zonisamide (Zonegran®)
ƒ
Clonazepam (Klonopin®)
ƒ Used for all types of myoclonus and is useful in patients with concomitant anxiety ƒ Emergency treatment
ƒ Higher affinity for the GABA‐A receptor site
ƒ Limited long‐term use
ƒ Caution with withdrawal
Barbiturates
ƒ Children tolerate sedative effects better than ƒ Affect the duration of chloride channel opening
adults
ƒ Some children have hypersalivation
ƒ ADR profile limits use Jim Thigpen, PharmD
ƒ
ƒ
ƒ
Diazepam (Valium®, Diastat®)
Lorazepam (Ativan®)
Midazolam (Versed®)
8/6/2011
ƒ
Phenobarbital
ƒ The most commonly prescribed AED of the 20th
century
ƒ Status epilepticus
ƒ Potent and broad spectrum
ƒ IV, IM, Rectal
ƒ CNS effects, especially cognition, behavior
ƒ Intranasal
▪ midazolam
ƒ Drug interactions (enzyme inducer)
ƒ
Primidone
ƒ Metabolized to phenobarbital
ƒ Also used for essential tremor at low doses
ƒ
Tiagabine (Gabitril®)
ƒ
Vigabatrin (Sabril®)
ƒ Inhibits GABA transporter‐1 (GAT‐1)
ƒ Used as second‐line or add‐on therapy for partial ƒ A structural analog of GABA, binding irreversibly or secondarily generalized seizures
ƒ No significant idiosyncratic adverse reactions
ƒ CNS effects most common (dizziness, asthenia, nervousness, tremor, depressed mood and emotional lability) but also some GI and rash
ƒ Can worsen absence epilepsy or in partial epilepsy with generalized spike wave
ƒ Used for refractory partial seizures
▪ Less effective vs. primarily generalized tonic‐clonic
▪ May worsen myoclonic or generalized absence
▪ Myoclonus or Lennox‐Gastaut do not respond well
to GABA‐T
ƒ Infantile spasms
▪ Tuberous sclerosis Jim Thigpen, PharmD
ƒ
Vigabatrin (Sabril®)
8/6/2011
ƒ
Gabapentin (Neurontin®)
ƒ Developed to have a structure similar to GABA but ƒ Most common side effect is drowsiness
the drug has little or no action on the receptor
ƒ Depression (5%), agitation (7%), confusion and ƒ MOA is only speculated
▪ Increased intracellular concentration of GABA
▪ Inhibits branched chain amino acid transferase, which reduces their conversion to glutamate
ƒ Binds with the alpha2 subunit of calcium channels rarely psychosis
ƒ Little effect on cognitive function
ƒ VGB causes visual field changes (nasal in the brain and spinal cord, which may explain its effect on pain
constriction followed by concentric constriction, with preservation of central vision) in 50%
▪ Use is restricted
ƒ
Gabapentin (Neurontin®)
ƒ No pharmacokinetic drug interactions
ƒ
Pregabalin (Lyrica®)
ƒ Very similar in all aspects to gabapentin
ƒ Only modest reduction in partial seizures and ƒ Approved for adjunct therapy for partial seizures
secondarily generalized seizures
ƒ Well tolerated, most side effects are minor and occur mainly at high doses
ƒ Used mainly as a pain medication
▪ Somnolence, dizziness, ataxia, nystagmus
Jim Thigpen, PharmD
ƒ
Valproate (Depakote®)
8/6/2011
ƒ
ƒ DOC for many primarily generalized epilepsies and Valproate (Depakote®)
ƒ In utero exposure has been linked to lower IQ
▪ VPA should not be used as a first‐line agent for women of childbearing potential
f hildb i t ti l
partial seizures
ƒ Discovered by accident
ƒ Enhances GABA function, may stimulate GAD, also produces selective modulation of sodium channels
ƒ Highly bound to plasma proteins, but decreases at higher levels, kidney or liver disease and during pregnancy
ƒ Nausea, vomiting, tremor, sedation, confusion, irritability and weight gain are dose‐related
ƒ Hepatoxicity is most serious idiosyncratic effect
ƒ Metabolic effects include hypocarnitinemia, hyperglycemia and hyperammonemia
▪ Increased free fraction of drug (7‐9% to 15%)
Meador, et al. NEJM 2009;360(16);1597‐605
ƒ
Felbamate (Felbatol®)
ƒ Blocks NMDA receptors, calcium and sodium channels
ƒ Effective against multiple seizure types
ƒ Occurrence of aplastic anemia and hepatic failure led to withdrawal from the U.S. market
ƒ Available only for a very limited use
▪ Severe partial epilepsy or Lennox‐Gastaut
ƒ
Topiramate (Topamax®)
ƒ Derived from D‐fructose, initially developed as an antidiabetic drug
ƒ Inhibits sodium conductance, enhances GABA, inhibits the AMPA subtype glutamate receptor, and is a weak carbonic anhydrase inhibitor
ƒ Levels are reduced by 50% when given with phenytion or carbamazepine
ƒ Can reduce ethyl estradiol levels by 30%
Jim Thigpen, PharmD
ƒ
Topiramate (Topamax®)
8/6/2011
ƒ
ƒ Adjunct therapy for drug‐resistant generalized ƒ Start slow and titrate to minimize/prevent epilepsies, including juvenile myoclonic epilepsy, absence and generalized tonic‐clonic seizures, b
d li d t i l i i
and Lennox‐Gastaut syndrome
ƒ FDA approved for partial onset and secondarily generalized tonic‐clonic seizures, primary generalized tonic‐clonic, and Lennox‐Gastaut
ƒ
Ezogabine (Potiga®)
Topiramate (Topamax®)
adverse effects
ƒ Ataxia, impairment of concentration, confusion, dizziness, fatigue, paresthesia, somnolence, disturbance of memory, depression, agitation and slowness of speech are common
ƒ Cognitive effects occur more commonly at higher doses and with rapid titration rate
ƒ
Levetiracetam (Keppra®)
ƒ Approved in June, 2011, for adjunct therapy in ƒ Thought to inhibit synaptic vesicle protein 2A uncontrolled partial‐onset seizures
ƒ CNS side effects include dizziness, fatigue, confusion ,tremor, problems with coordination, double vision, attention, memory and weakness
ƒ Should be available by years end
(SV2A) , which appears to be important for the availability of calcium‐dependent il bilit f l i
d
d t neurotransmitter vesicles ready to release their content
ƒ The lack of SV2A results in decreased action potential‐dependent neurotransmission
Jim Thigpen, PharmD
ƒ
Levetiracetam (Keppra®)
8/6/2011
ƒ
ƒ No significant drug interactions
Lacosamide (Vimpat®)
ƒ Enhances the slow inactivation of voltage‐gated ƒ Used for monotherapy for tonic‐clonic, partial‐
onset, myoclonic seizures in children
ƒ Adverse effects include headache (25%), infection (23%), asthenia (22%), somnolence (22%), dizziness (18%), pain (15%), pharyngitis (11%) and flu‐like syndrome (10%) ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Rufinamide (Banzel®)
ƒ Prolongation of the inactive state of the sodium channel, suppressing neuronal hyperexcitability
and stabilizing cell membranes d t bili i ll b
ƒ FDA approved for Lennox‐Gastaut and may be used to treat partial seizures
ƒ Shown to shorten the QT interval
ƒ Headache, dizziness, fatigue, somnolence and nausea most common
Wisniewski CS. Ann Pharmacother 2010;44:658‐67
ƒ
sodium channels and binding collapsing response mediator protein 2
di t t i Low potential for drug interactions
Dizziness, headache, diplopia, N & V
Small increases in P‐R interval
Refractory partial‐onset seizures saw 37% ↓
Secondarily generalized T‐C sz saw 60‐90% ↓
Eslicarbazepine (Stedesa®, Zebinix)
ƒ Investigated for partial‐onset seizures with or without secondary generalization
ƒ Still at the FDA
ƒ Similar side effects to oxcarbazepine
D
Drug
→
Phenytoin
Fosphenytoin
Carbamazepine
Oxcarbazepine
Lamotrigine
Partial and secondarily
generalized
GI, CNS, rash, vitamin K, hormonal dysfunction, etc
etc…
Zonisamide
Partial and secondarily
generalized
Partial and tonic/clonic
Partial and secondarily
generalized
Partial and secondarily
generalized,
Lennox/Gastaut
Partial and myoclonus
Infusion‐
related
CNS, nausea
CNS, nausea
CNS (few), GI, somnolence
CNS, cognitive effects, weight gain
g g
Not likely
Marrow
toxicity, SJS, ↓ Na+
Marrow
toxicity, SJS, ↓ Na+
+++
++
+
++
+/‐
YES
YES
YES
Details ↓
Seizure type
Common
ADRs
Rare/severe Blood dyscrasias
ADRs
Drug Interactions
Preferred P
f
d Drug
++++
NO, but NO
effective and economical
++++
Status, Status
peripheral IV
Rash
Oligohidrosis, Rash, kidney stones
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Sharon Castellino, MD
do not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. She reports that she DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
h
ld b
d
as a real or apparent conflict of interest in the
context of this presentation. Life After Cancer: Cases from the Clinic • Describe the survivor population at risk for chronic health conditions • Describe the leading morbidities in childhood cancer survivors • Review recommendations for health surveillance Review recommendations for health surveillance
following childhood cancer therapy Notes:
Life After Cancer: Cases from the Clinic
Sharon Castellino, MD
Sharon Castellino, MD
8/6/2011
Endocrine problems after cancer
• Most common late effect after cancer
• Affects 20-50% of survivors followed into
adulthood
• Most common in survivors of:
• Stem cell/bone marrow transplant
Endocrine problems after cancer
Seen after radiation of
hormone-producing glands:
• Pituitary (brain radiation)
• Thyroid (neck radiation)
• Ovaries (abdomen/pelvis)
• Testes (pelvis or testes)
• Brain tumors
• Hodgkin’s disease
• Head and Neck irradiation
Wake Forest School of Medicine
1
Thyroid Dysfunction
• Clinically significant dysfunction with elevated TSH
can be seen after thyroid exposure of >10Gy
• Peak incidence of hypothyroidism: 2-4 years
following irradiation
• Risk of benign and malignant thyroid neoplasms
following therapeutic radiation to head and neck
• Serial thyroid function tests and annual thyroid
palpation in all survivors who received radiation in
head/neck field
Wake Forest School of Medicine
2
CCSS
An NCI-funded
Resource
Childhood Cancer Survivor Study (CA 55727)
Mortality Risks
• Mortality highest in
• Patients diagnosed at 0-4 yrs age (SMR 9.1)
• Those with initial diagnosis: Leukemia (SMR
10.0-14.7), CNS tumor (SMR 12.9-17.7),
Ewing Sarcoma (SMR 13.3)
• Compared to: Hodgkin Lymphoma (SMR 7.8);
Kidney tumor (SMR 4.6)
Wake Forest School of Medicine
Sharon Castellino, MD
Chemotherapy associated morbidity
• Alkylators/ VP16: secondary leukemia; MDS;
gonadal toxicity
• Platinum: ototoxicity; renal dysfunction
(impaired GFR and tubular function)
• Vinca alkaloids: peripheral neuropathy; ? CV
• Methotrexate: leukoencephalopathy; hepatic
dysfunction
• Anthracyclines: CV dysfunction
8/6/2011
Medical Late Effects
• Cardiovascular
• Endocrine
• Musculoskeletal
abnormalities
• Growth
• Neurocognitive
• Chronic graft vs host
disease
• Opthalmalogic
• Transfusion acquired
diseases (Hep B, C)
• Renal
• Pulmonary
• Second Malignancies
• Ifosfamide: Fanconi syndrome
• Steroids: osteoporosis
Wake Forest School of Medicine
Psychosocial Late Effects
Dental Abnormalities
• Academic and occupational achievement
• Enamel dysplasia
• Incomplete calcification
• Family and interpersonal relationships
• Disorders of tooth development
• Foreshortening of roots
• Adaptation to chronic illness or disability
• Premature close of apices
• Tooth agenesis, microdontia
• Insurance discrimination and access to
healthcare
Wake Forest School of Medicine
• Arrested tooth development
Wake Forest School of Medicine
Sharon Castellino, MD
Anthracycline
Cardio Vascular (CV) toxicity
• Myocyte death
• myofibrillar loss and vacuolar degeneration
• subsequent hypertrophy of surviving
myocytes -->
> reduced wall thickness
• interstitial fibrosis
• Severity correlates with
• Cum anthracycline dose
• Age at exposure
• Chest radiation fields
Wake Forest School of Medicine
Gonadal dysfunction - male
• Effect of radiation and alkylator therapy on
spermatogenesis is a frequent cause of
infertility
• oligospermia is dose related
• recovery of spermatogenesis can occur later
• Testosterone production is less often affected
• Workup : semen sample, bone age, FSH/LH,
testosterone
Wake Forest School of Medicine
8/6/2011
Gonadal Dysfunction -female
• Oocytes are very radiation sensitive
• Alkylating agents cause destruction of resting
oocytes and absent primordial follicles
• prepubertal gonad is more resistant to
d
damage
• Follow-up: Tanner stage progression; evidence
of primary or secondary amenorrhea
• Risk for perinatal mortality and low birthweight
infant in women treated with abdominal RT
Wake Forest School of Medicine
Neuroendocrine Dysfunction
Growth Impairment
• GH deficiency
• common following > 18-20 Gy to
hypothalamic/pituitary region
• clinically apparent > 2 yrs following
radiotherapy
• 60-80% of irradiated brain tumor patients will
have impaired serum GH response to
provocative stimulation
Wake Forest School of Medicine
Sharon Castellino, MD
Neurocognitive Sequelae
• Risks:
• Age at cranial radiation
8/6/2011
COG Long-Term Follow-Up Guidelines for
Childhood Cancer Survivors
• Goal: Increase quality of life and decrease
health care costs
• Radiation dose
• Promote healthy life-styles
• Female sex
• Provide on-going monitoring of health status
• MTX - intra-thecal and high systemic dose
• Identify late effects at an early stage
• Cognitive deficits
• Timely Intervention against late effects
• Leukoencephalopathy
• Seizures and other overt CNS symptoms
Wake Forest School of Medicine
Wake Forest School of Medicine
Screening and management
Based on treatment exposure
Screening and Management
All Survivors
• Summary of cancer treatment
• Annual screening:
• Diagnosis, age
• Educational and vocational progress
• Chemotherapy agents used with doses and
cumulative doses
• Mental health: Depression/ Anxiety/PTSD/Social
withdraw
• Radiation doses and fields
• Healthcare insurance and access
• Transplant - HSCT(ie BMT)
• Did patient have GVHD
• Surgery history
• Other treatment/exposure: transfusion
Wake Forest School of Medicine
• If patient received chemotherapy:
• Oral and dental exam every 6 months
• Full review of symptoms for subtle issues
• Based on exposures (chemotherapy, radiation,
surgery)
Wake Forest School of Medicine
Sharon Castellino, MD
8/6/2011
Conclusions- PCP
• The general pediatrician’s role in monitoring
growth
th and
d other
th ttoxicities
i iti iis iincreasingly
i l
important
• 75% will develop a chronic disease by 40
years age, and 40% a serious health
problem
•M
Many effects
ff t do
d nott become
b
apparentt for
f
many years following treatment
• Facilitating transition to young adult health
Wake Forest School of Medicine
References
• Diller et. al. Chronic Disease in the Childhood
Cancer Survivor Study Cohort: A Review of
Published Findings. 2009. J Clin Oncol 27:
2339-2355
• http://www.survivorshipguidelines.org
Wake Forest School of Medicine
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
David Chastain, MD
does not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. He reports that he DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
h
ld b
d
as a real or apparent conflict of interest in the
context of this presentation. Adolescent Medicine Jeopardy!
• Cite the predominant mortalities of adolescence • Make a visual diagnosis of common adolescent clinical presentations Notes:
Adolescent Medicine Jeopardy!
David Chastain, MD
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Rob Clemons, MD
does not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. He reports that he does not have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
h
ld b
d
as a real or apparent conflict of interest in the
context of this presentation. Updates in Dermatology: Let's Get Sun Safe • Identify sunscreen ingredients to make better recommendations for your patients • Assess new FDA guidelines for sunscreen manufacturers Notes:
Updates in Dermatology: Let’s Get Sunsafe!
Rob Clemons, MD
Robert Clemons, MD
8/7/2011
The Basics of Ultraviolet Light
| Ultraviolet spectrum
| UVC (200-290nm)- predominately absorbed by water
and ozone in atmosphere. Highly carcinogenic.
Be Sun Smart
| Wear Broad-spectrum UVA/UVB water resistant
sunscreen
| Seek Shade
| UVB (291-320nm)- Burning wavelength. Blocked by
windshields. Strongly associated with non-melanoma
skin cancers in animal models.
| UVA II (321-340nm)(321 340
) Delayed
D l
d tanning
i
wavelength
l
h off
light. Moderately associated with non-melanoma skin
cancers in animal models.
| UVA I (341-400nm)- Long wavelength deeper
penetrating wavelength of light but less associated
with non-melanoma skin cancers. Associated with
several solar dermatosis
| Know the high UV hours of the day 10-4
| When your shadow is shorter than you are tall
| Be extra cautious near water, snow, and sand
| Sun Protective Clothing
| Tight cotton weave clothing
| Universal Protection Factor clothing (UPF)
| Wide brimmed hat
| Avoid Tanning Beds- Think about self tanner
| Supplement Diet with Vitamin D
|
Sunblock (physical agents)
Scatter and physically block UV light
| 4 main types
|
Zinc oxide
Titanium dioxide
| Talc
| Red Veterinary petroleum
Sunblock
| Standard Physical Blocks
|
|
|
|Micronized Zinc Oxide (290-380nm)
|Micronized Titanium Dioxide (290-320nm)
o www.skincancer.org
Sunscreens (chemical agents)
|
Non-opaque and absorb UV radiation of various
wavelengths
Why Do Sunscreens Fail???
| Bad product
| Did not apply frequently enough
| Did not apply enough at each application
|
UV light appears to breakdown many chemical
sunscreens that protect against UVA
| Helioplex (Neutrogena)
| Ecamsule/Mexoryl SX (La Roche-Posay)
Robert Clemons, MD
Chemical Sunscreens
8/7/2011
www.skincancer.org
| UVB Sunscreens
|PABA and PABA Esters (260-315nm)
|PABA (Para Aminobenzoic Acid)
|Padimate A
|Padimate O
|Glycerol aminobenzoate
|Cinnamates (270-320nm)
|Octyl methoxycinnamate (280-310nm)
|Cinoxate (270-328nm)
|Salicylates (290-320nm)
|Homosalicylate
|Octyl salicylate
|Triethanolamine salicylate
Chemical Sunscreens
| UVA Sunscreens
|Etrocrylene (296-380nm)
|Benzophenones
|Oxybenzone (270-350nm)
|Dioxybenzone (206-380nm)
|Sulisobenzone (250-380nm)
|Avobenzone/ Parsol 1789 (310-400nm)
|Methylanthranilate (200-380nm)
owww.skincancer.org
|Octocrylene (280-320nm)
Sun Protection Factor--SPF
| Sun Protection Factor denotes how long it will take
for UVB rays to redden the skin compared to
without the product
| Historically it was felt that sunburn=radiation damage and
if you didn’t burn then you didn’t damage
| Only relates to UVB and not UVA
| An SPF 15 product protects the person from 93% of
the UVB rays
| An SPF 30 product protects the person from 97% of
the UVB rays
| An SPF 50 product protects the person from 98% of
the UVB rays
FDA New Requirements
www.fda.org
|Proposed to eliminate confusion in the
public and mislabeling
|What defines “Broad Spectrum”
|Must be an SPF>15
protection p
proportional
p
|Must demonstrate UVA p
to its UVB protection according to its SPF
|Defines what products can claim they reduce
risks of skin cancer and photo aging
|Eliminate the terms sunblock, waterproof, and
sweat proof
|Eliminate the term “instant protection”
Robert Clemons, MD
8/7/2011
FDA New Requirements, cont...
|New requirements for water resistance claims
|Must label protective for either 40 or 80 minutes
while swimming or sweating
|Products that do not meet these standards must
include directions to use a water resistant
sunscreen if swimming or sweating
|SPF labeling can only go to SPF 50+ since
there is no evidence that higher SPF values
denote better protection
|Rules will take effect by Summer of 2012
Facts About Indoor Tanning
www.aad.org
| 28 million people in the United States tan annually and 2.3
million are teenagers
| World Health Organization finally has labeled indoor tanning
devices as a carcinogen in the same category as cigarettes
| The American Academy of Pediatrics joined the AAD, the
Skin Cancer Foundation
Foundation, and the WHO in demanding a ban
on indoor tanning for young people.
| Studies have shown a 75% increased risk of melanoma
in people who use indoor tanning
| Indoor tanning devices use predominately UVA wavelengths
with some UVB
| UVA wavelengths do not efficiently stimulate Vitamin D
synthesis
Sun Protective Clothing
| The SPF/UPF of clothing differs with many factors
including tightness of the weave, color, dry or wet,
wear and tear/stretching
| Standard cotton T shirt provides an SPF of 7
| Same T shirt when wet becomes an SPF of 3
| Dark blue denim shirt is an SPF or 1,700
| Universal Protection Factor (UPF)
| Colorless dyes and sunblock applied during
manufacturing that provide sun protection analogous
to SPF rating for UVB
| Ratings start at UPF 15 and go up to 50+. Most
advertise at 50+
| Tinosorb- a laundry additive that adds UPF to
standard clothing and lasts for up to 20 washes
Vitamin D: The Great Debate
| Vitamin D can be obtain from 3 sources
| UVB radiation
|5 minutes of noon day sun in the summer maximizes the
extent of Vitamin D synthesis
|UVB is a carcinogen
| Diet
|Oily Fish, Cod Liver
|Fortified orange juice and dairy products and yogurts
|cereals
| Oral supplementation
|400 IU of Vitamin D for infants up to 12 months
|600 IU of Vitamin D for children and adults
|800 IU of Vitamin D for patients over 65 years of age
Robert Clemons, MD
Sun Protection for Newborns
|Sun Avoidance
|Sunscreens have not been tested safe
under six months of age
|UPF clothing
|Shade structures
|If necessary, find a pure physical block
with zinc oxide and titanium dioxide
Polymorphic Light Eruption, cont...
| In adults
|Forearms
|V of the neck
| In children
8/7/2011
Polymorphic Light Eruption
|Most common photosensitivity disorder in
children
|Nonscarring papules and vesicles
|Pruritic
|Sun exposed sites usually within hours to
days of new exposure to sunlight in spring
and summer
|Lasts for 1-6 days
|Diminishes in mid to late summer
Polymorphic Light Eruption
|Treatment
|Antihistamines
|Topical corticosteroids
|Face
|Hydroxychloroquine
|Ears
|Broad spectrum sunblock with physical
barrier protection
| Likely a variant of juvenile spring eruption
occurring on the ears of boys
| Appears to be caused by broad band exposure
to light to include UVA 1-2, UVB, and visible
wavelengths over sites in the body not
acclimated to light
|Prophylaxis using gradually increasing
doses of UVA to “harden” the skin early
in the spring
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
James Thompson, MD
does not anticipate discussing the unapproved /investigative
use of a commercial product/device during this
lecture. He reports that he DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
h
ld b
d
as a real or apparent conflict of interest in the
context of this presentation. Update on Craniosynostosis and Deformational Plagiocephaly
• Differentiate plagiocephaly vs craniosynostosis
• Describe treatment options Notes:
Update on Craniosynostosis and Deformational
Plagiocephaly
James Thompson, MD
James Thompson, MD
Definitions
• Craniosynostosis (craniostenosis) – refers to the fusion of the cranial sutures • Plagiocephaly – Greek “slanting head” is a descriptive term regarding head shape.
– Synostotic – related to fused cranial sutures.
– Deformational – caused by external forces with no suture fusion.
• Brachycephaly – a descriptive term referring to a shortened head shape
– Synostotic or Deformational
Synostotic Scaphocephaly
• Sagittal synostosis
– Most common type ~ 1:1800 births
• about 60% of all nonsyndromic cases – Almost all are nonsyndromic
– 2% hereditary
2% hereditary
– Male : Female = 4 : 1
– Classic features:
• Frontal bossing
• Elongated skull
• Pointed occiput
8/7/2011
Craniosynostosis
• Fusion of one or more cranial sutures leads to the shape abnormality
• Overall incidence ~ 1:2500
• Causes
–Fetal constraint –Abnormal brain development –genetic syndromes
–Maternal smoking
–Amine containing drugs
James Thompson, MD
Synostotic Trigoncephaly
• Metopic synostosis
– Incidence ~ 1:5000 births
– Male : Female = 3:1
– ~ 90% nonsyndromic
y
– ~ 6% hereditary
– Classic features
• Forehead ridging
• Triangular shaped forehead
• Hypotelorism
Synostotic Plagiocephaly
• Unicoronal synostosis
–Incidence ~ 1:5000
–Usually non‐syndromic
–Classic features: • Ipsilateral frontal flattening
• Ipsilateral anterior ear displacement
• Contralateral frontal bossing
8/7/2011
James Thompson, MD
Synostotic Brachiocephaly
• Bicoronal synostosis
– Incidence ~ 1:20,000 births
– Almost always syndromic
• Eg. Crouzons, Aperts, Pfeiffers
Eg Crouzons Aperts Pfeiffers
– Classic features:
• Shortened head
• Tall forehead
• Recessed supraorbital rim
Synostotic Plagiocephaly
• Lambdoid synostosis
– Incidence unkown, less than 2% of craniosynostosis
• Classic features
– Trapezoid shape
– Ipsilateral occipital flattening
– Ipsilateral mastoid bossing
– Ipsilateral posterior ear displacement
– Contralateral occipital bossing
8/7/2011
James Thompson, MD
8/7/2011
Synostotic Plagiocephaly
• Frontosphenoidal synostosis
–Unknown incidence
–Classic features:
• Ipsilateral frontal flattening
• Ipsilateral anterior ear displacement
• Contralateral frontal bossing
Synostotic Plagiocephaly
• Treatment
– Craniosynostosis is usually treated with surgery
– Timing variable but usually between 3‐9 months
– Surgery consists of removing the fused suture and expanding the skull
• Restore cranial volume
• Correct deformity
Synostotic Plagiocephaly
• Treatment
– Traditional surgery
• Bicoronal incision
g
y
y
• Surgically corrected deformity
• Blood loss
• ICU
– Less invasive surgery
• Springs • Endoscopic + Helmets
James Thompson, MD
Deformational Plagiocephaly
– Deformational plagiocephaly
• Associated factors
–Intrauterine restriction / Multiple gestation
–Torticollis
–Premature birth / ICU stay
–Supine positioning
• Incidence unknown but probably 15‐30% of all infants
• Male > Female (3:2)
• R > L 8/7/2011
Deformational Plagiocephaly
• Clinical exam
– Ipsilateral occipital flattening
– Contralateral occipital bossing
– Ipsilateral forehead bossing
– Ipsilateral anterior ear displacement
– “Parallelogram shape”
• Other findings
– Anterior displacement of the skull base
– Anterior displacement of the TMJ
– Crossbite
Deformational Plagiocephaly
James Thompson, MD
Deformational Brachycephaly
• Cephalic index = head width/length
– Normal = 0.75
– >0.80 = brachycephaly
>0 80 = brachycephaly
– <0.70 = dolichocephaly (scaphocephaly)
Treatment
• Positioning
– Avoid car seats (except in the car)
– Avoid reclining “bouncy” seats
– Tummy time
– Bump up one side
– Turn the crib around
– “Entertainment” on one side of the crib
– Rotate head from side to side each night
8/7/2011
Deformational Brachycephaly
Classification
I (6a)
II (6b)
III (6c)
Helmets
– Active • Dynamic helmets, custom made and adjusted weekly to mold head into shape
• $$$$$
– Passive
• Rely on rapid infant head growth as the dynamic factor
Rely on rapid infant head growth as the dynamic factor
• Can be prefabricated and custom fit
• $
– Success correlated significantly with severity, compliance, age at treatment
James Thompson, MD
8/7/2011
Conclusions
• Must differentiate between synostotic and non synostotic plagiocephaly
t ti l i
h l
• Milder cases of plagiocephaly will resolve with positioning
• More severe cases will have lasting effects
• If helmet therapy is desired it is best to refer If helmet therapy is desired it is best to refer
before 6 months of age
Conclusions
• Deformational plagiocephaly is associated with delayed or abnormal motor development ith d l d
b
l
t d l
t
in infants.
• No conclusive evidence that deformational plagiocephaly causes long term neurological deficits.
• Helmet therapy corrects head shape but other benefits are yet to be proven.
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Jeffrey Carlsen, MD
does not anticipate discussing the unapproved or investigative use of a commercial product/device during this lecture. He p
reports that he DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
as a real or apparent conflict of interest in the
context of this presentation. Direct Ophthalmoscopy: How to Use One of the Most Powerful Instruments in Your Office • Improve utilization of direct ophthalmoscope • Recognize common eye conditions with direct ophthalmoscope Notes:
Direct Ophthalmoscopy: How to Use One of the Most
Powerful Instruments in Your Office
Jeffrey Carlsen, MD
Jeffrey Carlsen, MD
8/7/2011
Abnormal red reflex Cornea
STRABISMUS
• Latent or manifest misalignment of the visual axis. i.e. “eyes don’t point the same direction”
• Strabismus is a significant risk factor for amblyopia
y p which is the leading cause of visual g
loss in children
• Strabismus has a profound social and developmental impact on a child
– Self esteem
– Social interaction
Direct ophthalmoscope
Fundus Exam
• Fixation target
• Optic nerve is about 15 degrees nasal
Have patient look at
• Have patient look at your ear
• Turn lens wheel clockwise as you get closer and vice versa
•
•
•
•
Corneal opacity, dystrophy…..
Keratoconus
y
p y
Dystrophy
Scar
Lens
• Cataract
• Types… with systemic diseases
Fundus exam
• Orient yourself. Find a vessel and then follow to the nerve
Jeffrey Carlsen, MD
Subconjunctival Hemorrhage
•
•
•
•
•
Can be subtle or quite dramatic
Minor trauma, valsalva, eye rubbing
/
,
Tx.: r/o bad actors, reassurance Spontaneous resolution
If recurrent, then consider blood dyscrasia
NLD obstruction
• Until tear duct opens, you may need to:
– Apply pressure (or massage) over lacrimal sac area.
– Use antibiotic eye drops or ointment for infection.
– Gently clean eyelids with warm water.
• For persistent tearing, lacrimal surgery may be necessary.
8/7/2011
Tearing in infants
• Abnormal or overflow tearing is common in infants; approx 1/3 of newborns have excessive tears/mucus
• Occurs when membrane in nose fails to open before birth, blocking part of tear duct. Valve of Hasner or Rosenmueller.
• Tears do not drain properly and collect inside tear drainage system; spill over eyelid, causing tearing.
• Strongly predisposes infant to chronic infection, conjunctivitis
• Blocked tear duct often opens spontaneously 6–12 months after birth.
Managing a NLD obstruction
• Most NLD obstructions resolve by 9‐12 months of age; therefore, conservative until then
• If still tearing at 9‐12 months, refer.
If still tearing at 9 12 months refer
• Refer earlier if frequent infections, as this may cause fibrosis of the NLD
Jeffrey Carlsen, MD
8/7/2011
Bacterial conjunctivitis secondary to NLD obstruction
• Standard bacteria. May also be overgrowth of normal flora
• Occurs as normal tear flow is obstructed. (Stagnant fluid is like a petri dish)
• Tx: topical antibiotics
–
–
–
–
Polytrim
Sulfacetamide
Gentamycin
Fluoroquinolones
• (reserve these for recalcitrant cases)
– Set up for microbial resistance. Use sound prescribing practice
Bibliography
• Weis AH, Brinser JH, Nazar‐Stewart V. Acute conjunctivitis in childhood. J Pediatr. 1993; 122(1): 10‐14.
• Martin M, Turco JH, Zegans ME, et al. An outbreak of conjunctivitis due to atypical Streptococcus pneumoniae. N Engl J Med. 2003; 348(12): 112‐1121
• Block S, Hedrick J, Tyler R, et al. Increasing bacterial resistance in pediatric conjunctivitis (1997‐1998). Antimicrob
p
j
(
)
Agents g
Chemother. 2000; 44(6): 1650‐1654
• Pediatric Ophthalmology and Strabismus. American Academy of Ophthalmology Basic and Clinical Science Course, section 6. copyright 2000.
• Ophthalmology. Yanoff M, Duker JS. 1998. Mosby publishing
• Pediatric Ophthalmology and Strabismus. Kenneth Wright, Peter Spiegel. 2002. Springer Publishing
NLD
• If less then 2 yrs old, then simple probing has a very high success rate
• If older then 2 y/o or previous failed probing, then NLD stent or dilatation
then NLD stent or dilatation
• If failed stent or older then 5‐10 y/o, then may need dacrocystorhinostomy
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Mark Howell, MD
does not anticipate discussing the unapproved or investigative use of a commercial product/device during this lecture. He reports that he DOES NOT have a
financial interest/arrangement or affiliation ith
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
as a real or apparent conflict of interest in the
context of this presentation. Current Philosophy and Accurate Diagnosis of Pediatric Rhinitis, URTI and Paranasal Sinus Infection • Review anatomy and physiology of URT • Review pathophysiology of nasal and paranasal sinus infections • Apply current guidelines for accurate diagnosis of URTI’s Apply concepts of appropriate pharmocologic
• Apply concepts of appropriate pharmocologic
intervention Notes:
Current Philosophy and Accurate Diagnosis of Pediatric
Rhinitis, URTI and Paranasal Sinus Infection
Mark Howell, MD
Mark Howell, MD
•
•
•
•
•
•
•
•
Differential Diagnosis and Associations
Viral URTI (Daycare exposure‐ 2‐3x increase)
Rhinitis (allergic, nonallergic, cigarette smoke, environmental)
Bacterial rhinosinusitis
Adenoid (adenoiditis, hypertrophy)
(
)
Congenital (choanal atresia/stenosis)
Foreign body Anatomic abnormality (nose/sinuses)
Odontogenic
Anatomic Associations
• Concha bullosa (10‐24% pt. chronic sinusitis)
• Paradoxical curve middle turbinate (4‐10%)
• Hypoplastic maxillary sinus (7‐17%)
Haller cell (10%; 50% bilateral)
• Haller cell (10%; 50% bilateral)
• Agger nasi cell (frontal sinus)
• Cranialfacial anomaly (Down syndrome, Crouzon’s, Apert’s syndrome, cleft palate)
• Deviated nasal septum (10‐13%)
8/7/2011
Other Related Factors
•
•
•
•
•
•
•
Cystic fibrosis
Ciliary dyskinesia
Immune deficiency (HIV)
Diabetes
Cranial facial abnormalities
Trauma
GERD
Rhinosinusitis
• Acute (up to 4 weeks and total resolution)
• Subacute (4‐12 weeks)
• Recurrent Acute (4 or more episodes year with resolution between attacks)
ith
l ti b t
tt k )
• Chronic (12 weeks or more of signs and symptoms)
• Acute exacerbations of chronic rhinosinusitis
Mark Howell, MD
8/7/2011
Signs and Sx of VURTI
• Activation parasympathic and inflammatory pathways initiate Sx
• Fever, myalgia, pharyngitis
• Nasal congestion, rhinorhea, sneezing, PND
• Cough, sore throat
• Facial pressure and pain, ear fullness
• Hyposmia/anosmia
• Mucopurulent nasal secretions not specific sign of bacterial infection (neutrophil influx)
CDC Position Paper
• Antibiotic Tx moderate severe sinusitis not improving after 7 days
• Severe sinusitis of any duration (purulent nasal discharge with high fever, erythema, swelling, localized pain)
• Clinical judgment Guide Dx ABRS
•
•
•
•
•
•
•
•
Viral URI not resolved 10 days or
URI worsens after 5‐7 days and exhibiting
Nasal congestion, drainage, PND
Facial pain/pressure (esp. unilateral or focused; ear pressure/fullness)
Fever, fatigue, cough
Maxillary dental pain
80% preceded VURTI
20% preceded allergic URTI
Pediatric URI Concensus Team
• Prolonged nonspecific upper respiratory signs and symptoms (rhinosinusitis and cough w/o improvement 10‐14 days)
• Severe URTI worsening signs and symptoms (fever >39 degrees C; facial swelling/facial pain)
Mark Howell, MD
Viral to Bacterial
8/7/2011
Imaging Suggestions
• Persistent symptoms with no improvement
• Not needed in acute uncomplicated sinusitis
• Severe symptoms (clinical judgment)
• Diagnostic uncertainty and/or not responding as expected to appropriate medical therapy
• Worsening symptoms (biphasic illness) o se g sy pto s (b p as c ess)
• Complicated rhinosinusitis with facial cellulitis, orbital and/or suspected intracranial complications should have contrasted CT scans sinuses, orbits and head Possible Referral Indications •
•
•
•
•
Intracranial or orbital complications
Possible need sinus aspiration
Unusual pathogen
Diagnosed or suspected immunodeficiency
Recurrent ABRS especially exacerbation associated pulmonary conditions
Complications of Acute Rhinosinusitis
• Orbital‐usually acute ethmoid sinusitis
• Preseptal cellulitis‐involves eyelid;globe
normal
• Post‐septal cellulitis with or without abcess; involves orbital contents;eyelid
edema;chemosis;proptosis;EOM
impairment;visual changes
• Urgent CT and hospitalization
Mark Howell, MD
Intracranial Complications
• Abscess or meningitis
• Usually from acute frontal and/or sphenoid sinusitis
• More common in adolescents and adults since younger children have no frontal or sphenoid sinuses
8/7/2011
Management Pearls
• Unilateral or isolated “sinusitis” may be related maxillary dental infection and/or abscess; nasal foreign body; neoplasm
Immune compromised pt. As DM,HIV beware of compromised pt. As DM,HIV beware of
• Immune
mucomycosis
• Recurrent rhinosinusitis in children consider cystic fibrosis cilliary dysfunction; adenoids
• CT and MRI may resolve these dilemmas Absolute Indications for Surgery
• Rhinosinusitis causing brain abscess,menigitis;subperiosteal orbital abscess;cavernous sinus thrombosis;facial cellulitis
• Sinus mucocele or pyocele
• Fungal sinusitis
• Neoplasm or suspected neoplasm
Relative Indications Sinus Surgery
• Recurrent acute rhinosinusitis with persistent obstruction of sinus or specific area of recurring disease is identified
• Chronic rhinosinusitis failing to clear on appropriate medical Tx
ABRS
mild to moderate ABRS
moderate
no daycare or antibiotics for 90 days
Amoxicillin (45‐90 mg/kg per day two doses)
Amoxicillin‐clavulanate (45‐90 mg/kg per day two doses)
Daycare and/or antibiotic therapy Amoxicillin‐clavulanate
within 90 days
(80‐90mg/kg day two doses
Switch therapy for pt. not responding to Amoxicillin
Cefdinir (14mg/kg day 1‐2 doses)
Cefuroxime (30mg/kg day)
Cefpodoxime (10mg/kg day 1x)
ABRS
Beta‐lactam sensitivity
Non‐type 1 hypersensitivity
Type 1 hypersensitivity
Cefdinir
Cefuroxime
Cefpodoxime Clarithromycin (15mg/kg two divided doses)
Azithromycin
(10mg/kg day1 and 5mg/kg single dose for 4 days)
TMP/SMX Clindamycin (30‐40mg/kg day 3‐4 divided doses)
ABRS
nonresponsive to oral Tx
Imaging; Aspiration of sinus
Ceftriaxone
(100mg/kg per day divided q 12hr
Cefotaxime
(100‐200mg/kg day divided q6hr)
Mark Howell, MD
8/7/2011
Conclusions
• ABRS may be diagnosed in patients with viral URI of > 10days or worsens after 5‐7 days and is accompanied by signs and symptoms
• A
Antimicrobial therapy should cover key ti i bi l th
h ld
k
respiratory pathogens
• >30% S. pneumoniae decreased sensitivity to penicillin
• 30‐40% H.flu produce B‐lactamase
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Jennifer Correll, PhD
does not anticipate discussing the unapproved or investigative use of a commercial product/device during this lecture. She reports that she DOES NOT have a
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
h
ld b
d
as a real or apparent conflict of interest in the
context of this presentation. I'm Not Listening! Assessment and Treatment of Oppositional/Disruptive Behavior in Primary Care
in Primary Care • Identify the prevalence of oppositional behavior in primary care • Identify brief assessment tools to use in primary care • Demonstrate brief behavioral interventions that can be recommended to parents Notes:
I'm Not Listening!: Assessment and Treatment of
Oppositional/Disruptive Behavior in Primary Care
Jennifer Correll, PhD
Jennifer Correll, PhD
Assessment: Informal
y Ask about noncompliance
y If you asked him/her to do 10 things during the day how
many would s/he do the first time asked?
y How many could you eventually get him/her to do if you
kept on him/her?
Assessment: Formal
y DSM criteria
y Behavior checklist
y Pediatric Symptom Checklist (PSC)
8/7/2011
Treatment in Primary Care
y Conceptualizing the problem for parents
y Skills deficit
y Need to be able to
1. Follow instructions
2. Cope with anger
3. Persist on a task
4. Self-quiet/soothe
5. Independently transition to sleep
y Eyberg Child Behavior Checklist (ECBI)
Treatment in Primary Care
y Balance between reward and discipline
y Time in
y Attending to average behavior
y
“Sprinkles of attention”
y Overboard verbal reinforcement for completing a desired
task
y vs. Time out
y Brief, unpleasant consequence during which there is no
access to attention or anything fun
y What happens when you start to ignore behavior during
time out?
y Extinction Burst!
Treatment in Primary Care
Time-Out
y Procedure
y Adult-sized chair
y Area easy to covertly monitor
y 2-3 minutes
y Parent ends the time-out
y Child completes task after time-out
y Common Parent Misconceptions
1. Child must be quiet
2. Child must sit still
3. Child must be sorry
4. Child must understand
Jennifer Correll, PhD
8/7/2011
Oppositional Defiant Disorder: DSM Criteria
y Oppositional Defiant Disorder (DSM-IV)
y 6-month pattern of negative, hostile, defiant behavior with 4 of the
following:
¾ Often loses temper
¾ Often argues with adults
¾ Often actively defies or refuses to comply with adults’ requests or rules
¾ Often deliberately annoys people
¾ Often blames others for his/her mistakes or behavior
¾ Often touchy
¾ or easily annoyed by others
¾ Often angry
g y or resentful
¾ Often spiteful or vindictive
y Not psychosis
y Not Conduct Disorder
y Causes Impairment
Treatment in Primary Care
y Points to Remember
1. Conceptualize “problem” as skill deficit and
stress two-part/balanced approach
2. Discuss two components to time-in
3. Discuss effective time-out use
4. Warn about extinction burst
5. Set a follow-up meeting to review progress
6. Refer if no improvement
27th Annual SW VA Pediatrics Conference
8/6‐7/2011
DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST:
Darshan Shah, MD
does not anticipate discussing the unapproved or investigative use of a commercial product/device during this lecture. He p
DOES NOT have a
reports that hhe
financial interest/arrangement or affiliation with
one or more organizations that could be perceived
as a real or apparent conflict of interest in the
context of this presentation. What’s Up With Spit Up?
• Identify two important causes of spit up in newborns • Discuss Gastroesophageal Reflux and Cow Milk Allergy
Notes:
What's Up With Spit Up?
Darshan Shah, MD
Darshan Shah, MD
Spit up/vomiting
Common causes of spit up in newborn
‰
Physiological(GER)
‰
GERD
‰
Milk allergy
‰
Over feeding
‰
Pyloric stenosis
Most common cause of vomiting in new born is overfeeding, overfeeding, overfeeding and overfeeding
y GER is not reason to start infant on medication
y Only Gastro Esophageal Reflux Disease; GERD is the only indication to start on medication
GERD:
Esophagatis
Apnea
Growth failure
8/7/2011
Gastro esophageal reflux in newborn
‰Frequently seen in newborn
‰ Incidence: 1 episode/day in 50% in 0‐3 months increases to 75% at 4 months and decreases to 5% at 10‐12 months.
‰GER /Spit up/Vomiting is very common immediately after feeding (with in one hour)
‰Acid reflux is more common before feeding.
Medications for GERD
y H2 Receptor antagonist
y PPI; not cleared by FDA for less than 1year
y Prokinetics
y Always use for short duration of 4
Always use for short duration of 4‐8 weeks rather than 8 weeks rather than 4‐6 months as GER underlying physiology gets better with time!
Darshan Shah, MD
8/7/2011
Cow Milk Allergy
y Prevalence o 2‐8% noted in literature but recent larger cohort 2.2‐
2.8% (Ped Cli Nor Ame 2011)
o Compare to 50‐75% of GER episode in 0‐4 months CMA uncommon
CMA y Lab eval for CMA
y Breast milk allergy:
y Rare
y Incidence <1%
y Maternal avoidance of CMP ƒ Skin test
ƒ Atopy patch test
ƒ Total IgE
ƒ Specific IgE(RAST)
y Duration of elimination diet:
y Minimum of two weeks for improvement in symptoms. If not improved after 4 weeks unlikely CMA.
y Reintroduction of CMP
y Depends on history of previous encounter; if anaphylaxis then do RAST/skin test prior to reintroduction
50‐60% patient can tolerate CM by 1‐2 years and 80‐90% by 2‐3 years.
y Pyloric stenosis
y Incidence: 0.02‐0.06%
y Most important: Vomiting is PROJECTILE y Palpation is positive in epigastric area
y BMP/NP will help great if Ped radiologist/ped ultrasound tech unavailable.
y Growth failure is evident by 3rd week
y Ultrasound/UGI will confirm diagnosis
y Reemergence of symptoms on introduction after elimination confirms CMA. y Look out for allergy to peanuts and egg in patient with definite CMA.