Top Papers Of The Month

Top Papers You May Have Missed in August 2021

AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. Top papers you may have missed in August 2021. Consultant360.com. Published online September 14, 2021.

For those of you in primary care practice, congratulations on finishing a challenging pre-school summer rush. Between school physicals, COVID-19, the resurgence of other respiratory viruses, and the shortage of front-desk and nursing staff, it was a more difficult season than most in our office. In case you were equally occupied, here are my offerings of articles that you might have missed last month. As always, please discuss them with your colleagues and share your thoughts with us: editor@consultant360.com.

​Long-term Follow-up Care for Childhood, Adolescent, and Young Adult Cancer Survivors1

The American Academy of Pediatrics (AAP) has endorsed an update to the Children's Oncology Group (COG) guidelines for follow-up care of survivors of childhood cancer. ​In addition to routine health maintenance, these patients require exposure-based surveillance to screen for complications of the therapies they have received during treatment of their cancer, and promotion of healthy lifestyles for their future. ​With the necessary information contained in a Summary of Cancer Treatment (Figure 2 in the article), which should be provided by the treatment center at the conclusion of cancer treatment, the guidelines can be used by primary care physicians to direct appropriate surveillance in patients who are not followed by an oncologist.

I have used the prior edition of the guidelines once in an adolescent survivor of childhood retinoblastoma who declined to go back to his previous cancer center. I found the information comprehensive, though somewhat difficult to access, for a primary care pediatrician. In general, I have found it best for these patients to be followed ​in a cancer center, in a specialized adolescent-young adult oncology program, or in a multidisciplinary long-term follow-up clinic as we have at our current children's hospital.

What has your experience been? Have you used these guidelines in the past? I find it helpful that COG has made this resource available to all clinicians for us to monitor the systematic and evidence-based surveillance that these patients require, even when directed by their oncologist.

Clinical Practice Guideline by the Pediatric Infectious Disease Society and the Infectious Disease Society of America: 2021 Guideline in Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics2

​These first-ever guidelines on the evaluation and management of pediatric osteomyelitis, which have been in development for several years, were published this month in a free article in the Journal of the Pediatric Infectious Disease Society (JPIDS). The guidelines provide clarity on controversial issues that have long resulted in varying approaches to childhood osteomyelitis. It is recommended that an attempt should be made to obtain an organism from aspirates of fluid or biopsies of tissue, that serum C-reactive protein (CRP) should be used to monitor response to therapy, that patients with initial good response to intravenous antibiotics should be transitioned to oral antibiotics upon discharge rather than discharged on prolonged courses of outpatient parenteral antibiotic therapy, and that the total duration of therapy for uncomplicated osteomyelitis caused by Staphylococcus aureus should be 3 to 4 weeks.

While working in inpatient settings, I have treated osteomyelitis at 3 different pediatric institutions and have been struck by the variability in recommendations from my infectious disease consultants. After a long process of development and endorsement, it is useful to have pediatric guidelines on which to base decisions about evaluation and treatment of these patients. In particular, I am pleased to read the strong recommendation, despite low certainty of evidence, for early transition to oral antibiotics instead of prolonged intravenous therapy.

Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001-20173

​Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement4

Published in the same issue of JAMA, these 2 articles offer clarification on our approach to type 2 diabetes in pediatric and adult populations. In the first pre-pandemic study, the prevalence of both type 1 and type 2 diabetes mellitus was noted to increase significantly over the 17-year timeframe of the investigation. The incidence of type 2 diabetes in patients aged 10 to 19 years doubled from 0.34 to 0.67 per 1000 youths. In the second article, the United States Preventive Services Task Force Recommendation Statement (USPSTF) recommends lowering, from 40 years to 35 years, the age at first screening for type 2 diabetes and prediabetes in adults who are overweight or with obesity.

In recognition of the increasing incidence of type 2 diabetes in teenagers, I have been fairly rigorous in my application of the screening recommendations of the AAP, which have not recently changed. (It is of interest that the AAP and the Americans with Disabilities Act (ADA) recommend screening at-risk overweight and obese adolescents, while the USPSTF recommends starting adult screening at age 35.) For all pediatric patients who are overweight or obese with 2 or more risk factors (family history of type 2 diabetes, non-white race, maternal gestational diabetes, and physical exam evidence of insulin resistance), I routinely check a fasting blood glucose, either in the office or at the laboratory, every 2 years. The absolute incidence of type 2 diabetes in adolescents, although increasing, remains relatively low, and I have diagnosed only a few such teenagers despite aggressive application of the recommendations.

What has your experience been? Do you follow the AAP recommendations, those of the ADA (which recently recommended screening adolescents who are overweight or with obesity with one or more risk factors), or is your approach more consistent with that of the USPSTF? Do you use a fasting glucose​ or a hemoglobin A1C? How often have you diagnosed a new case of type 2 diabetes?

Differences in Lifetime Earning Potential Between Pediatric and Adult Physicians​5

The authors of this article, published in Pediatrics, used national database information to compare the compensation of academic generalist and specialist physicians in pediatrics with those in adult medicine. Their analysis revealed that, regardless of field, compensation for adult physicians was higher. Overall, the earning potential for adult physicians was 25% higher, or $1.2 million more​ over a lifetime, compared with pediatric physicians.

If you accept their findings, what do you think? ​Is this a reflection of supply and demand, a reward for a more difficult and less rewarding field of work, a reflection of gender-based salary inequality, or simply unfair? 

Thanks as always for reading my offerings and for sharing your thoughts with your colleagues and with us.

References:

  1. Hudson MM, Bhatia S, Casillas J, Landier W; Section on Hematology/Oncology, Children’s Oncology Group, American Society of Pediatric Hematology/Oncology. Long-term follow-up care for childhood, adolescent, and young adult cancer survivors. Pediatrics. 2021;148(3):e2021053127. https://doi.org/10.1542/peds.2021-053127
  2. Woods CR, Bradley JS, Chatterjee A, et al. Clinical practice guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 guideline on diagnosis and management of acute hematogenous osteomyelitis in pediatrics. J Pediatric Infect Dis Soc. 2021:piab027. https://doi.org/10.1093/jpids/piab027
  3. Lawrence JM, Divers J, Isom S, et al; SEARCH for Diabetes in Youth Study Group. Trends in prevalence of type 1 and type 2 diabetes in children and adolescents in the US, 2001-2017. JAMA. 2021;326(8):717-727. https://doi.org/10.1001/jama.2021.11165
  4. Davidson KW, Barry MJ, Mangione CM, et al; US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA. 2021;326(8):736-743. https://doi.org/10.1001/jama.2021.12531
  5. Catenaccio E, Rochlin JM, Simon HK. Differences in lifetime earning potential between pediatric and adult physicians. Pediatrics. 2021;148(2):e2021051194. https://doi.org/10.1542/peds.2021-051194