Recent Developments in the Assessment and Treatment of Pediatric Obsessive-Compulsive Disorder

Although tremendous strides have recently been made in the development of assessment and treatment methods for pediatric obsessive-compulsive disorder (OCD), more accurate methods for diagnosis, more effective treatments, and more refined instruments for monitoring progress during therapy are still needed. The present commentary highlights the papers in this series of articles. The excellent work by the contributors to this special edition highlights critical elements and limitations of the assessment process for OCD, the importance of monitoring symptom changes, and possible augmentation strategies for treatment refractory cases. The findings from these studies will almost certainly impact the management of pediatric OCD and lead to further refinements.     

“It’s a tool,not a cure”: the preoperative teen perspective on bariatric surgery

BackgroundBariatric surgery is well established in adults as the most effective tool for sustained weight loss and reduction of obesity-related co-morbidities, and is an emerging option for adolescents in whom conservative approaches have failed. Narratives are vital in understanding the motivating reasons and psychosocial profiles of adolescents considering bariatric surgery during a developmental period of evolving self-concept, body image sensitivity, peer pressure, and increased opportunity for risky behaviors.ObjectivesTo explore preoperative adolescent patient perspectives on their decision to pursue bariatric surgery, anticipated physical and psychosocial effects, and preparation process.SettingsThe Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada.MethodsWe conducted 14 semi-structured interviews with adolescents (16–18 yr old) 2–4 months before bariatric surgery. A theoretical thematic analysis was conducted with 3 independent reviewers (interrater reliability, Cronbach’s α= .81) and conflicts were resolved through discussion.ResultsPatients’ perspectives are captured in 4 themes: motivation for surgery, effects on health and habits, psychosocial changes, and support systems during preparation. Participants perceived surgery as a tool but not a solution for weight loss. Most were motivated for health and daily functional improvement rather than aesthetic reasons, and some anticipated improved social interactions while maintaining their self-identity. Participants were selective in sharing news of their surgery, and received varying levels of support from families, friends, and healthcare teams.ConclusionAdolescents seem generally prepared for and informed about surgery, with expectations for weight loss and psychosocial improvements, although uncertainty and contradictory thoughts were prevalent. Insights provided by these adolescent patients will help optimize bariatric surgery assessments and support from clinical teams and inform preoperative education for future patients and families.     

Site of metastatic recurrence impacts prognosis in patients with high-grade upper tract urothelial carcinoma

PurposeMetastatic recurrence occurs in over 25% of upper tract urothelial carcinoma patients treated with radical nephroureterectomy. While metastatic recurrence suggests poor prognosis, the impact of the specific site of recurrence on prognosis is not well documented.Materials and methodsWe retrospectively analyzed 188 patients who underwent radical nephroureterectomy for high-grade, node-negative upper tract urothelial carcinoma at our institution from 2003 to 2018 without receiving neoadjuvant or adjuvant chemotherapy. Competing-risks survival analysis was performed to evaluate the cumulative incidence and predictors of metastatic recurrence. The Kaplan-Meier method and log-rank test were used to estimate and compare recurrence site-specific survival probabilities following metastatic recurrence. Cox regression analyses were performed to assess site-specific prognoses.ResultsOf the 188 patients, 47 (25%) developed metastatic recurrence over a median follow-up of 30 months (interquartile range: 10.5–58.5 months). The 1- and 2-year cumulative incidences of metastatic recurrence were 13.6% and 23.6%, respectively. On multivariable analysis, lymphovascular invasion was significantly predictive of metastatic recurrence (subhazard ratio: 2.6, P = 0.01). Of the 47 patients who developed recurrence, 38 (80.9%) died over a median follow-up of 10 months (interquartile range: 5–20 months). Metastatic recurrence was most common in the lungs (n= 13, 28%) and at multiple sites (n= 14, 30%). Median time to recurrence was shorter for recurrences at multiple sites (6.5 months) and those in the liver (13 months) and bone (18 months) compared to other sites. Patients who recurred in the liver (hazard ratio: 6.3, P = 0.007), bone (hazard ratio: 4.9, P = 0.02), and multiple sites (hazard ratio: 4.6, P = 0.01) had significantly worse prognosis compared to those who recurred in lymph nodes. Statistical significance persisted after adjusting for treatment with salvage therapy.ConclusionsA significant proportion of high-grade upper tract urothelial carcinoma patients recur systemically after radical nephroureterectomy. Lymphovascular invasion is a predictor of metastatic recurrence and may inform decisions regarding perioperative chemotherapy. Hepatic and osseous recurrences have relatively quicker onset and less favorable prognosis compared to other sites. These findings may benefit future efforts to develop recurrence site-specific treatment plans and highlight the necessity of subsequent endeavors to explore the genetic associations of recurrence in upper tract urothelial carcinoma.     

U.S. military officer participation in the Centers for Disease Control and Prevention's Epidemic Intelligence Service (1951-2001)

The Epidemic Intelligence Service (EIS) was created in 1951 to provide epidemiologists to investigate natural and intentional disease epidemics. From an initial class of 23 U.S. citizens, the program has evolved into a globally recognized, hands-on learning experience, accepting approximately 65 to 75 new officers each year. The first U.S. military epidemic intelligence service officer (EISO) was accepted into the program in 1994. Since that time, 12 such officers have completed, or have begun, EIS training. They have comprised 2.1% of all EISOs from 1994 to 2001 and 0.47% of all EISOs. This total has included nine Air Force veterinarians, one Army veterinarian, one Army physician, and one Navy physician. Each military EISO had the opportunity to lead investigations of significant public health events (e.g., Ebola, monkeypox, malaria, Nipah virus, West Nile fever, and anthrax outbreaks). All graduates from the military returned to active duty assignments in operational medical units, research institutes, or the intelligence community.     

Trends in the use of cameras and computer technology among dermatologists in New York City 2001-2002.

BACKGROUND: Photography and computers can enhance dermatologic visit documentation and care. OBJECTIVE: To determine dermatologists' use of cameras and computers. METHODS: We surveyed computer and camera use during the Dermatologic Society of Greater New York's meetings in January 2001 and 2002. RESULTS: Approximately 75% of dermatologists can use computers. Between 2001 and 2002, 35-mm film camera use by attending and resident dermatologists fell from 60% to 47% and 43% to 32%, respectively, and digital camera increased from 25% to 38% and 35% to 59%, respectively. Approximately 50% of dermatologists use instant cameras. Approximately 15% of dermatologists use no camera. Most find images useful; however, medical dermatologists usually image only interesting patients, and dermatologic surgeons image almost all patients. Approximately 15% of dermatologist used electronic medical records (EMRs). CONCLUSION: Computers and cameras are widely used but have not changed dermatologic practice. Images are not used to track skin disease or integrated with EMRs nor are EMRs widely used, probably because of difficulty of use and limited computer literacy. Where images appear to add value, for example, for preoperative and postoperative documentation among dermatologic surgeons, camera use is common, suggesting that utility drives technology adoption.     

Vinca alkaloids,thalidomide and eribulin‐induced peripheral neurotoxicity: From pathogenesis to treatment

Vinca alkaloids, thalidomide, and eribulin are widely used to treat patients with childhood acute lymphoblastic leukemia (ALL), adults affected by multiple myeloma and locally invasive or metastatic breast cancer, respectively. However, soon after their introduction into clinical practice, chemotherapy‐induced peripheral neurotoxicity (CIPN) emerged as their main non‐hematological and among dose‐limiting adverse events. It is generally perceived that vinca alkaloids and the antiangiogenic agent thalidomide are more neurotoxic, compared to eribulin. The exposure to these chemotherapeutic agents is associated with an axonal, length‐dependent, sensory polyneuropathy of mild to moderate severity, whereas it is considered that the peripheral nerve damage, unless severe, usually resolves soon after treatment discontinuation. Advanced age, high initial and prolonged dosing, coadministration of other neurotoxic chemotherapeutic agents and pre‐existing neuropathy are the common risk factors. Pharmacogenetic biomarkers might be used to define patients at increased susceptibility of CIPN. Currently, there is no established therapy for CIPN prevention or treatment; symptomatic treatment for neuropathic pain and dose reduction or withdrawal in severe cases is considered, at the cost of reduced cancer therapeutic efficacy. This review critically examines the pathogenesis, epidemiology, risk factors (both clinical and pharmacogenetic), clinical phenotype and management of CIPN as a result of exposure to vinca alkaloids, thalidomide and its analogue lenalidomide as also eribulin.     

Electrographic seizures during therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy

Electrographic seizures are common in neonates with hypoxic-ischemic encephalopathy, but detailed data are not available regarding seizure incidence during therapeutic hypothermia. The objective of this prospective study was to determine the incidence and timing of electrographic seizures in term neonates undergoing whole-body therapeutic hypothermia for hypoxic-ischemic encephalopathy as detected by conventional full-array electroencephalography for 72 hours of therapeutic hypothermia and 24 hours of normothermia. Clinical and electroencephalography data were collected from 26 consecutive neonates. Electroencephalograms were reviewed by 2 pediatric neurophysiologists. Electrographic seizures occurred in 17 of 26 (65%) patients. Seizures were entirely nonconvulsive in 8 of 17 (47%), status epilepticus occurred in 4 of 17 (23%), and seizure onset was in the first 48 hours in 13 of 17 (76%) patients. Electrographic seizures were common, were often nonconvulsive, and had onset over a broad range of times in the first days of life.     

Internal Medicine chief residents suggest need to improve health care delivery and public policy education. Internal Medicine Center to Advance Research and Education

The primary objective in medical training remains skill development in the delivery of medical care through the understanding of bedside data collection, natural history of disease, use of diagnostic tools and the influence of therapy--all applied to a specific patient. More recently, also considered important is training on the broader issues of health care delivery and public policy, especially since the environment of medicine is changing rapidly. With limited curricular time these issues must compete with the traditional and important clinical training. To evaluate how these subjects have been included in internal medicine training, the Resident Physicians Section (RPS) of the American Society of Internal Medicine (ASIM) sponsored a survey of United States internal medicine chief residents which was conducted by the Internal Medicine Center to Advance Research and Education (IMCARE). The objectives of the study were to 1) study the extent of training on health care delivery and public policy issues offered to residents by internal medicine residency programs; 2) assess training opportunities now available; and 3) determine areas of study not fulfilling perceived needs. The questionnaire contained 12 questions. Chief residents rated the 1) quality of their program in preparing residents on health care delivery, public policy issues and practice management; 2) level of instruction provided on 12 topics; and 3) degree of priority these same topics should have. Respondents were asked to identify 1) any other relevant areas their residency program covered particularly well; 2) the amount of time which should be devoted to these socioeconomic topics in each year of training; and 3) the most appealing formats for learning about these topics. Despite the rapidly growing influence of socioeconomic issues on medical practice, many chief residents perceive that important topics are not being addressed adequately. This study provides information on areas addressed well and topics that should receive greater attention. Recommendations are made for further studies and strategies to increase the emphasis on socioeconomic topics during medical education.