- Email: [email protected]
Imag(e)ine this and that
February 2016 Volume 169
Metrics for researchers — Thomas R. Welch, MD
Don't just think. Prescribe something? — Paul G. Fisher, MD
Copyright ª 2016 by Elsevier Inc.
M
any clinicians today, both in academic medicine and private practice, find themselves beholden to productivity-based compensation. For clinical work, the most common metric by which such productivity is measured is the relative value unit (RVU). How does one quantitate “productivity” in research? Sure, “publish or perish” has been the reputed standard for generations of scholars, both in medicine and other fields. However, counting the number of reports published during a specific period is clearly too simplistic. Some reports have major impact, and others are rarely or never read or cited. Thus, some measure of productivity that considers both the volume of published work and its impact would seem to be needed. The world of “big data” has now offered a solution. Resources such as Google Scholar make it possible to track citations to published works in a way not feasible (or as inexpensive) previously. In the current issue of The Journal, Tschudy et al introduce us to two metrics proposed as such combined measures—the h- and g-indices. They explain the calculation of these measures, and then apply them to pediatric specialists at various levels of academic attainment, as well as department chairs. This work attempts to benchmark academic productivity in pediatrics. This certainly is not the final word on this topic, and we doubt that the “benchmarks” coming out of this study will be widely adopted. Yet, the report is a very helpful introduction to this topic for the academic pediatrician. For all physicians, it serves as a reminder that clinicians are not the only physicians whose productivity can be measured and compared with that of colleagues. Article page 272<
A
ntacids and antibiotics are routinely among the 10 most prescribed drugs each year in the US. Psychotropics are increasingly prescribed. Are we prone to offer some drugs more for particular subsets of patients? In this issue of The Journal, House et al report results of a cross-sectional study from an all-payer administrative database in Northern New England comparing prescription use intensity and regional variation of prescription rates among 13 100 children diagnosed with autism spectrum disorder (ASD), compared with 936 721 children without ASD, adjusted for age and sex. In children with ASD, psychotropic usage was 900% more. Perhaps more surprising, prescription antacid fills were 350% higher, and antibiotic fills 20% higher. In children 0 to 2 years of age who were ultimately diagnosed with ASD, antibiotic use was more than 200% higher and antacid use nearly 500% greater. Underlying these overall patterns, rates of prescriptions fills in the 19 component health service areas of the database were widely discrepant, pointing to a lack of standardized prescribing practices, particularly in light of similar prevalence of disease throughout Northern New England. Although high psychotropic usage in children with ASD is not unexpected, this high consumption of prescription antacids and antibiotics in the youngest children who are later diagnosed with ASD is alarming. The results could be due to the fact that these children with ASD are seen more often in clinics and hospitals. Higher rates of infections or gastroesophageal reflux are likely not at play, given the wide variation of prescription rates by health service areas. Perhaps the best explanation here is that pediatricians are simply prone to prescribe antibiotics or antacids more often to the puzzling, less communicative child with a delay in social development or behavioral difficulty. Maybe we should step back 1
when encountering children who concern or perplex us and simply think. Is the child autistic? What is the real underlying diagnosis? Article page 277<
My child hurts. Does he have arthritis? — Philip J. Hashkes, MD, MSc
Imag(e)ine this and that — Paul G. Fisher, MD
Ondansetron as an aid to oral rehydration — Thomas R. Welch, MD 2
M
usculoskeletal pain is one of the most common causes of visits to pediatricians but only a very small proportion (<1%) have chronic arthritis. Even among those referred to a pediatric rheumatologist, only a minority has chronic arthritis. Thus, it is important for pediatricians to correctly identify those few children with a high probability of having chronic arthritis in order to facilitate an accurate work-up and prompt referral. In this issue of The Journal, Cattalini et al report their analysis of 178 children referred by primary pediatricians to their practice in Brescia, Italy, for clinical and laboratory variables associated with the diagnosis of chronic (juvenile idiopathic) arthritis. They found that four factors that can be obtained by a simple focused history and translated by a formula to a probability score, can predict, with a high sensitivity and specificity, the likelihood of child having chronic arthritis. These factors include the frequency/persistence of pain, precipitators of pain, duration of morning stiffness, and pattern of joint swelling. The major limitation of this study was the substantial difference in the diagnostic constitution of their Italian practice to many other pediatric rheumatology practices in Western Europe and the US. However, their practice may better resemble that of the general pediatrician where many children with musculoskeletal complaints have postural or minor orthopedic abnormalities. This study stresses that obtaining an accurate history (!) can help pediatricians correctly identify those children needing a quick referral to a pediatric rheumatologist as opposed to those with a low probability of having chronic arthritis. If validated, this study may lead to a more optimized utilization of time, money, and health care resources in investigating musculoskeletal complaints. Article page 188<
n this issue of The Journal, Manchester et al, Debrabant et al, and Watson et al present three separate studies demonstrating the expanding use of magnetic resonance imaging (MRI) to image not only the form of the brain, but also its function. We have entered an era in which we can decipher how brain gray and white matter, specific anatomic structures, and even brain networks change in and contribute to health and disease, whether the underlying disorders are primarily neurologic or based outside the nervous system. In an accompanying editorial, Wintermark explains some of these MRI techniques and makes clear how we can now use neuroimaging to establish diagnosis, clarify pathophysiology, and formulate prognosis. The Journal concurs that future investigations using neuroimaging to explore these specific avenues will be most productive. We can begin to imagine how much that type of research will advance our understanding of the brain. The Journal looks forward to publishing those studies that elucidate brain function, and not report just epiphenomena. Research studies that unravel mechanism of brain and behavior will be well received and most helpful. Those reports that image “this and that” and then associate findings with disorders but do not illuminate brain function will be less instructive and less useful. Article page 21< Article page 28< Article page 36< Editorial page 6<
I
A
lthough evidence of the efficacy and safety of oral rehydration for diarrheal dehydration has been available for decades, barriers to its optimal use remain. One of these is the presence of vomiting. Even though vomiting is not a contraindication to the oral rehydration of infants with gastroenteritis, it certainly complicates it and may be a reason to move to intravenous Volume 169
fluids. Although there is plenty of anecdotal experience with the use of antiemetics in such settings, this strategy never has been tested rigorously. In the current issue of The Journal, Danewa et al from India report a “real world” test of the use of oral ondansetron to facilitate oral rehydration of infants with diarrheal dehydration accompanied by vomiting. Children with diarrheal dehydration complicated by vomiting in their center were enrolled in a double-blind, placebo-controlled trial of a single oral dose of ondansedron. Treated children received more oral fluids, were rehydrated faster, and had better caregiver satisfaction. This study, in a region where diarrheal dehydration is a real threat to children, may inform practice for us all. Article page 105<
Timing of treatment for Pompe disease — Stephen R. Daniels, MD, PhD
The cost of atopic dermatitis – more than meets the eye — Denise M. Goodman, MD, MS
Kingella kingae infections can cluster among young children in close contact — Sarah S. Long, MD
February 2016
E
nzyme replacement therapy is now the standard of care for infant-onset Pompe disease. Currently, with newborn screening, the earliest average age of the start of enzyme replacement therapy is about 21 days. In this issue of The Journal, Yang et al developed a new approach to newborn screening, rapid diagnosis and treatment in Taiwan. Using this clinical approach, treatment could be started at 11 days of age. They found that even starting enzyme replacement therapy about 10 days earlier results in improved physical and developmental outcomes at 2 years of age. These results emphasize the importance of the elements of the system of care in disease processes where time of institution of therapy is important. Article page 174<
n this issue of The Journal, Filanovsky et al report on a survey of 82 caretakers of children with moderate to severe atopic dermatitis (AD), describing the financial impact to families. Most clinicians recognize severe AD as a disease with significant morbidity, but may see less severe manifestations more as a simple nuisance. This report underscores that the emotional and financial burdens are substantial. The mean monthly cost was $28, annualized to over $3000. The relationship between monthly cost and emotional burden was more pronounced for patients receiving Medicaid, suggesting that out-of-pocket expenses become more impactful as they consume a greater proportion of discretionary income. The authors looked at both direct (medical copays, over-the-counter products) and indirect costs (eg, lost work, additional child care expenses). The costs of over-the-counter moisturizers, bath products, etc, was not trivial. We as clinicians would be wise to consider these findings when counseling families. Even simple interventions, such as suggesting a change in bath or laundry products, may be far more difficult than we imagine, and the cost may weigh more heavily on families than we realize. Article page 284<
I
ver the last few decades Kingella kingae has ascended in the family of pathogenic bacteria from a rare cause of endocarditis to a relatively common cause of osteoarticular infections in children younger than 4 years of age. Fastidious nature of growth in culture likely hampered establishing the organism’s rightful place among infectious diseases in children. Molecular diagnostic techniques now available will permit a better assessment of the role(s) of K kingae in an expected wider spectrum of infections and across continents. To date, much of what is known of the clinical epidemiology of disease and colonization patterns in young children are from studies in Israel. In this issue of The Journal, Yagupsky et al add another Kingella insight from studying daycares in relatively close communities in Israel in which contact is intense. They found clustering of disease, in association with clonal spread of presumably more pathogenic strains, and high oropharyngeal transmissibility among colleagues under 24 months of age. Article page 135<
O
3
Metrics for researchers — Thomas R. Welch, MD
Don't just think. Prescribe something? — Paul G. Fisher, MD
Copyright ª 2016 by Elsevier Inc.
M
any clinicians today, both in academic medicine and private practice, find themselves beholden to productivity-based compensation. For clinical work, the most common metric by which such productivity is measured is the relative value unit (RVU). How does one quantitate “productivity” in research? Sure, “publish or perish” has been the reputed standard for generations of scholars, both in medicine and other fields. However, counting the number of reports published during a specific period is clearly too simplistic. Some reports have major impact, and others are rarely or never read or cited. Thus, some measure of productivity that considers both the volume of published work and its impact would seem to be needed. The world of “big data” has now offered a solution. Resources such as Google Scholar make it possible to track citations to published works in a way not feasible (or as inexpensive) previously. In the current issue of The Journal, Tschudy et al introduce us to two metrics proposed as such combined measures—the h- and g-indices. They explain the calculation of these measures, and then apply them to pediatric specialists at various levels of academic attainment, as well as department chairs. This work attempts to benchmark academic productivity in pediatrics. This certainly is not the final word on this topic, and we doubt that the “benchmarks” coming out of this study will be widely adopted. Yet, the report is a very helpful introduction to this topic for the academic pediatrician. For all physicians, it serves as a reminder that clinicians are not the only physicians whose productivity can be measured and compared with that of colleagues. Article page 272<
A
ntacids and antibiotics are routinely among the 10 most prescribed drugs each year in the US. Psychotropics are increasingly prescribed. Are we prone to offer some drugs more for particular subsets of patients? In this issue of The Journal, House et al report results of a cross-sectional study from an all-payer administrative database in Northern New England comparing prescription use intensity and regional variation of prescription rates among 13 100 children diagnosed with autism spectrum disorder (ASD), compared with 936 721 children without ASD, adjusted for age and sex. In children with ASD, psychotropic usage was 900% more. Perhaps more surprising, prescription antacid fills were 350% higher, and antibiotic fills 20% higher. In children 0 to 2 years of age who were ultimately diagnosed with ASD, antibiotic use was more than 200% higher and antacid use nearly 500% greater. Underlying these overall patterns, rates of prescriptions fills in the 19 component health service areas of the database were widely discrepant, pointing to a lack of standardized prescribing practices, particularly in light of similar prevalence of disease throughout Northern New England. Although high psychotropic usage in children with ASD is not unexpected, this high consumption of prescription antacids and antibiotics in the youngest children who are later diagnosed with ASD is alarming. The results could be due to the fact that these children with ASD are seen more often in clinics and hospitals. Higher rates of infections or gastroesophageal reflux are likely not at play, given the wide variation of prescription rates by health service areas. Perhaps the best explanation here is that pediatricians are simply prone to prescribe antibiotics or antacids more often to the puzzling, less communicative child with a delay in social development or behavioral difficulty. Maybe we should step back 1
when encountering children who concern or perplex us and simply think. Is the child autistic? What is the real underlying diagnosis? Article page 277<
My child hurts. Does he have arthritis? — Philip J. Hashkes, MD, MSc
Imag(e)ine this and that — Paul G. Fisher, MD
Ondansetron as an aid to oral rehydration — Thomas R. Welch, MD 2
M
usculoskeletal pain is one of the most common causes of visits to pediatricians but only a very small proportion (<1%) have chronic arthritis. Even among those referred to a pediatric rheumatologist, only a minority has chronic arthritis. Thus, it is important for pediatricians to correctly identify those few children with a high probability of having chronic arthritis in order to facilitate an accurate work-up and prompt referral. In this issue of The Journal, Cattalini et al report their analysis of 178 children referred by primary pediatricians to their practice in Brescia, Italy, for clinical and laboratory variables associated with the diagnosis of chronic (juvenile idiopathic) arthritis. They found that four factors that can be obtained by a simple focused history and translated by a formula to a probability score, can predict, with a high sensitivity and specificity, the likelihood of child having chronic arthritis. These factors include the frequency/persistence of pain, precipitators of pain, duration of morning stiffness, and pattern of joint swelling. The major limitation of this study was the substantial difference in the diagnostic constitution of their Italian practice to many other pediatric rheumatology practices in Western Europe and the US. However, their practice may better resemble that of the general pediatrician where many children with musculoskeletal complaints have postural or minor orthopedic abnormalities. This study stresses that obtaining an accurate history (!) can help pediatricians correctly identify those children needing a quick referral to a pediatric rheumatologist as opposed to those with a low probability of having chronic arthritis. If validated, this study may lead to a more optimized utilization of time, money, and health care resources in investigating musculoskeletal complaints. Article page 188<
n this issue of The Journal, Manchester et al, Debrabant et al, and Watson et al present three separate studies demonstrating the expanding use of magnetic resonance imaging (MRI) to image not only the form of the brain, but also its function. We have entered an era in which we can decipher how brain gray and white matter, specific anatomic structures, and even brain networks change in and contribute to health and disease, whether the underlying disorders are primarily neurologic or based outside the nervous system. In an accompanying editorial, Wintermark explains some of these MRI techniques and makes clear how we can now use neuroimaging to establish diagnosis, clarify pathophysiology, and formulate prognosis. The Journal concurs that future investigations using neuroimaging to explore these specific avenues will be most productive. We can begin to imagine how much that type of research will advance our understanding of the brain. The Journal looks forward to publishing those studies that elucidate brain function, and not report just epiphenomena. Research studies that unravel mechanism of brain and behavior will be well received and most helpful. Those reports that image “this and that” and then associate findings with disorders but do not illuminate brain function will be less instructive and less useful. Article page 21< Article page 28< Article page 36< Editorial page 6<
I
A
lthough evidence of the efficacy and safety of oral rehydration for diarrheal dehydration has been available for decades, barriers to its optimal use remain. One of these is the presence of vomiting. Even though vomiting is not a contraindication to the oral rehydration of infants with gastroenteritis, it certainly complicates it and may be a reason to move to intravenous Volume 169
fluids. Although there is plenty of anecdotal experience with the use of antiemetics in such settings, this strategy never has been tested rigorously. In the current issue of The Journal, Danewa et al from India report a “real world” test of the use of oral ondansetron to facilitate oral rehydration of infants with diarrheal dehydration accompanied by vomiting. Children with diarrheal dehydration complicated by vomiting in their center were enrolled in a double-blind, placebo-controlled trial of a single oral dose of ondansedron. Treated children received more oral fluids, were rehydrated faster, and had better caregiver satisfaction. This study, in a region where diarrheal dehydration is a real threat to children, may inform practice for us all. Article page 105<
Timing of treatment for Pompe disease — Stephen R. Daniels, MD, PhD
The cost of atopic dermatitis – more than meets the eye — Denise M. Goodman, MD, MS
Kingella kingae infections can cluster among young children in close contact — Sarah S. Long, MD
February 2016
E
nzyme replacement therapy is now the standard of care for infant-onset Pompe disease. Currently, with newborn screening, the earliest average age of the start of enzyme replacement therapy is about 21 days. In this issue of The Journal, Yang et al developed a new approach to newborn screening, rapid diagnosis and treatment in Taiwan. Using this clinical approach, treatment could be started at 11 days of age. They found that even starting enzyme replacement therapy about 10 days earlier results in improved physical and developmental outcomes at 2 years of age. These results emphasize the importance of the elements of the system of care in disease processes where time of institution of therapy is important. Article page 174<
n this issue of The Journal, Filanovsky et al report on a survey of 82 caretakers of children with moderate to severe atopic dermatitis (AD), describing the financial impact to families. Most clinicians recognize severe AD as a disease with significant morbidity, but may see less severe manifestations more as a simple nuisance. This report underscores that the emotional and financial burdens are substantial. The mean monthly cost was $28, annualized to over $3000. The relationship between monthly cost and emotional burden was more pronounced for patients receiving Medicaid, suggesting that out-of-pocket expenses become more impactful as they consume a greater proportion of discretionary income. The authors looked at both direct (medical copays, over-the-counter products) and indirect costs (eg, lost work, additional child care expenses). The costs of over-the-counter moisturizers, bath products, etc, was not trivial. We as clinicians would be wise to consider these findings when counseling families. Even simple interventions, such as suggesting a change in bath or laundry products, may be far more difficult than we imagine, and the cost may weigh more heavily on families than we realize. Article page 284<
I
ver the last few decades Kingella kingae has ascended in the family of pathogenic bacteria from a rare cause of endocarditis to a relatively common cause of osteoarticular infections in children younger than 4 years of age. Fastidious nature of growth in culture likely hampered establishing the organism’s rightful place among infectious diseases in children. Molecular diagnostic techniques now available will permit a better assessment of the role(s) of K kingae in an expected wider spectrum of infections and across continents. To date, much of what is known of the clinical epidemiology of disease and colonization patterns in young children are from studies in Israel. In this issue of The Journal, Yagupsky et al add another Kingella insight from studying daycares in relatively close communities in Israel in which contact is intense. They found clustering of disease, in association with clonal spread of presumably more pathogenic strains, and high oropharyngeal transmissibility among colleagues under 24 months of age. Article page 135<
O
3