Pediatric Asthma: 2020 Global Initiative for Asthma (Prystowsky, 10/2020)

Many thanks to Sutter Medical Group of the Redwoods Pediatrician, Dr. Brian Prystowsky, for an amazing (and quite unique) Grand Rounds presentation this week on the "New" Global Initiative for Asthma (GINA) 2020 guidelines. 

Dr. Prystowsky took us to The Land of Make Believe and introduced us to:

• The 2020 Global Initiative for Asthma (aka GINA, the elephant in the room)
• Simba (Symbicort=formoterol/budesonide)
• Bert and Ernie (SABA=Albuterol)
• Jose Canseco (inhaled corticosteroids), and
• "The Purple One" (Advair) 

Stick with me here, and the teaching will stick with you. The 46-page GINA Pocket Guide is available for your here for your bedtime reading enjoyment. 

Asthma management has been upended this year by the 2020 GINA Guidelines.  Here's why.

Traditional management of mild asthma, mild/moderate intermittent asthma, persistent asthma, and exercise-induced asthma has been based on a few standard assumptions that may need some re-evaluation

•  First, that bronchoconstriction is the fundamental pathophysiological problem in asthma
• Second, that intermittent symptoms only need intermittent treatment, a short-acting beta agonist (SABA, e.g. albuterol). 
• Third, that inhaled corticosteroids (ICS) work for patients with persistent symptoms if prescribed chronically but are not indicated for intermittent symptoms. 
• Standard management of asthma involved prn SABA for patients with intermittent/exercise-induced asthma and addition of daily maintenance ICS with SABA as rescue for those with persistent symptoms.

ALL this is changing! A batch of studies suggest that asthma is likely more of an inflammatory condition that we might've previously thought-- or at least that inhaled corticosteroids (ICS) used in combination with a Rescue beta agonist is associated with better outcomes. 

The big practice change from GINA is moving away from use of SABA (albuterol) PRN to use of Symbicort PRN for asthmatics over 12. Symbicort, by the way, is a combination inhaler, which includes Budesonide (ICS) and Formoterol (LABA).

Studies in favor of  SYMBICORT PRN for the treatment of asthma: 

NEJM 2018 study (patients >12 with mild asthma x 52 weeks) found that patients treated with Symbicort PRN (compared with SABA prn in one arm and ICS maintenance with SABA prn) had higher percentage of weeks well controlled, LOWEST rate of severe exacerbation and lower median daily steroid dose (57mcg vs. 340mcg in ICS maintenance).

A NEJM 5/2019 study (patients >18 with mild asthma x 52 weeks) had similar findings: lower exacerbation rate, lowest number of severe exacerbations, and lower mean steroid dose.

A study from Thorax 2/2014 study (of patients >12 with exercise induced asthma, x6 weeks) found use of Symbicort PRN had best symptomatic control (compared to SABA prn and ICS maintenance/SABA prn) with much less steroid exposure.

Btw, Steroid exposure in an older study from Lancet 2011 (children 5-18 years old with mild persistent asthma) was associated with 1.1 cm growth restriction. Unclear how clinically significant this is, but as Dr. Brian said, parents don't want their children to be growth restricted..

What about "The Purple One"?

It seems that "the purple one" (aka ADVAIR; fluticasone/salmeterol) is not as effective as Symbicort in the care of asthma. 

Lancet 2011 study (5-18 years, 44 weeks) found that compared to PRN SABA, a QVAR+SABA prn vs. QVAR maintenance + SABA prn did not improve outcomes.

A 1/2020 study from Journal of Allergy and Clinical Immunology (mild asthma, ages 6-17 years) found that the use of QVAR+ SABA prn vs. QVAR maintenance + SABA prn had basically equal outcomes, except children had higher rates of steroid exposure in the maintenance group

And a study from Journal of Allergy and Clinical Immunology 12/2014 (ages 12-64) found Symbicort (vs. ADVAIR) had less exacerbations, lower oral steroid rates,  and less ER visits (though same hospitalization rates).

Can formoterol be an effective rescue?  Yes And is it safe in young children? Yes.

Compared to salmeterol, formoterol has a more rapid onset of action (at 3 minutes) at all doses

A study of 300 children in Pediatric Allergy and Immunology (3/2019) ages 8 months to 4 years found no safety concerns with the use of formoterol in children.

What are Dr. Brian's take home points for GINA?

• For children over age 12, Symbicort should be used both as rescue and maintenance as a PRN. Children will get at least as good control (maybe better) and will get less steroid.
• For children under age 12, the evidence is still not clear enough to change the historical practice. Continue to use albuterol PRN with ICS prn vs. ICS daily.

Thanks neighbors! And thanks Dr. Brian!

Antibiotic Stewardship (Nadeau, 10/21/2020)

 Many thanks to our stellar SSRRH pharmacist team-- namely Sue Nadeau, Carolyn Dam, and Alicia Loh--for a very important Grand Rounds presentation this week on Antibiotic Stewardship. Antibiotic Stewardship is a topic that has gained importance and momentum over the last decade, and the SSRRH pharmacy team and antibiotic stewardship committee has REALLY pushed us to change practice in really good ways. Particular areas for clinicians to consider include 1) initial choice of empiric antibiotics, 2) narrowing antibiotics as soon as possible, and 3) transitioning to oral antibiotics in a timely manner. 

Thanks to the whole team for their diligent work (pushing doctors to change practice is no easy task) and special thanks to Sue for giving the Grand Rounds presentation.

Here are my take homes:

1) SSRRH publishes an annual antibiogram. The antibiogram is available on the Sutter intranet (under pharmacy resources) but also has been copied here for your viewing convenience. Using local data to guide our abx choice is key to choosing empiric antibiotics correctly.

2) SSRRH Antibiotics Stewardship Committee also publishes an annual empiric antibiotic guide. (This is also available on the Sutter intranet) and is similarly pasted here for your reference.

Key take homes from our antibiogram:

• CAP: Take note that the recommended empiric antibiotics for patients admitted with Community Acquired Pneumonia (even ICU level) are 2gm Ceftriaxone (plus either Doxy or Azithro). MRSA coverage is NOT needed unless clinically high suspicion, despite level of care.
• Also be aware that evolving data shows that patients with CAP and a negative MRSA nasal swab likely do NOT need to be treated empirically with vancomycin. So get the swab on admit!
• Pseudomonas: Also don't forget the increased dosing for pip/taz for pseudomonal coverage (4.5gm Q6h vs. 3.375 q6h). Locally, pseudomonas has decreasing susceptibility to pip/taz (down to 91%) and even worse for cefepime (87%).
• Cefepime use may not be recommended and is restricted to ID consult.
• Ciprofloxacin, on the other hand, has had increasing susceptibility locally (up to 91% from nader of 79%)and may be a better empiric choice to cover pseudomonas. 
• Staph Aureus: MRSA rates have been increasing from all our staph isolates (from 27% in 2017 to 41% in 2019)
• 
  Local Staph Aureus has very low susceptibility to clindamycin (MRSA 59% and MSSA 79%) and so clindamycin should not be used empirically for any suspected staph aureus.

De-escalation of antibiotics is a key tenet of antibiotic stewardship. Patients should be assessed daily for decision making for definitive therapy. Culture should be used when available (48-72 hours) to drive decisions, but when not available, patients should be de-escalated to one agent within 3-5 days maximum. Physicians are often hesitant to do so (especially if they presented quite "sick"), but we should push through our fear!

IV to Oral conversion is another central tenet of antibiotic stewardship. PO abx lead to reduce risk of IV catheter infections, reduced thrombophlebitis, less expense, less work and earlier hospital discharge. Generally pts should be converted to PO abx if they have negative blood cultures x 48 hours, have improving clinical status and have received an appropriate amount of parenteral abx prior to conversion

Decreasing our use of Vancomycin. Soon to be rolled out is a program to decrease our empiric use of vancomycin in the hospital. Things to consider include CAP (see above), inappropriate use of vancomycin for skin and soft tissue guidelines (review IDSA guidelines for SSTI here), treatment options for PCN allergic patients (including skin testing) and more. Look for that coming up!

Where is the F in MCH? The Role of Fathers in Pregnancy and Birth (Blair, 10/14/2020)

Many thanks to Dr. Jason Blair, chief resident and father of three (one recently arrived), who gave a thought-provoking Grand Rounds presentation this week on the Role of Fathers in Pregnancy, Birth, and Infancy. 

Dr. Blair made a compelling argument for a link between high neonatal mortality rates in the US and our inclusion (or lack thereof) of fathers in the pregnancy and birthing process. We know that 50% of births in the US are to mothers on Medicaid; these mothers and babies have worse outcomes than women with private insurance (higher mortality, lower birth weight, higher preemie rates and less breastfeeding) and are also statistically more likely to be unwed and get less support at the time of birth and at home.

Dr. Blair also highlighted the effects of paternal participation on maternal breastfeeding rates, peripartum depression rates, and the general health and well being of families. And what about father in the role of continuous birth attendant (aka doula), which we know has strong evidence in reducing surgical birth, length of labor, and birth complications?

The US literature on the topic of fathers in birth is (perhaps not unsurprisingly) sparse, Dr. Blair cautioned, with much of the literature on the role of fathers in birth coming from Europe, where maternity and paternity leaves as well as other policy tends to be more robust.

Here are some highlights and some of my own suggestions in italics below each category.

Navigating fatherhood starts in the prenatal period

• What it means to be a good father extends beyond financial responsibilities to include a hands on role with baby and providing emotional support to their partner. This new role begins long before a baby is born.
• In a study from Iran and Afghanistan, when fathers were engaged in prenatal care, had a positive association between quality of a mother's participation in prenatal care and gestational age at birth, as well as maternal satisfaction.
• In a study from England, greater paternal engagement with associated with earlier access to care, increased number of antenatal checks, attending birthing and parenting classes, and breastfeeding Mothers were also more likely to report feeling very well or quite well at post partum visit
• Many fathers want to be more involved but often feel ignored by healthcare providers and unclear what their role should be. Do you actively engage dads in prenatal visits, birth, and post partum?

While, in theory, we welcome fathers into exam and labor rooms rooms, we all could do a better job of actively including them in the prenatal visits and helping them understand how they can help their partner and new baby.

• Engage father as a crucial member of the process (beyond making sure he received a Flu shot and Tdap, consider including how is his mental and physical health? how may he prepare for the birth of his child?
• Help clarify roles, outline potential tasks dad could participate in in the antepartum and post partum period (e.g. birth classes, sharing night feedings, supporting breastfeeding, etc.)

Paternal health and well-being can have a negative impact on mothers and children.

• A male partner's biological characteristics, work, and non work exposures, and substance abuse have adverse impacts on pregnancy outcomes (e.g. low birth weight, neural tube defects, PTL)
• Intimate partner violence against pregnant women leads to poor birth outcomes
• High prevalence of perinatal depression and anxiety (5-20%) in men is associated with increased struggles for the entire family.
• Verify if father has access to primary care. If he doesn't, offer it to him.

Fathers may understand their negative experiences in the ante and postpartum period as "stress" rather than as depression

• Pregnancy and a new infant can put tremendous strain on fathers in addition to relationships/couples
• Consider inquiring specifically about a father's or family's stress level rather than of depression (or mental health)
• Children with depressed fathers in the peripartum period higher risk of childhood behavior problems 
• Consider screening fathers for perinatal anxiety and depression when you are screening mothers

Fathers taking paternity leave is strongly associated with improved maternal well being at 3 months post partum

• Well, that's not a surprise now, is it?
• California has decent paternity leave; Do you inform you fathers of their rights? Do you encourage them to use it? Do you help them advocate with their employer to take the leave?

Benefit of fathers in support role for mothers

•  Many fathers recognize that the center of focus SHOULD be mother and baby; however helping fathers show up help mothers and babies in birth and beyond
• Labor attendants reduce maternal anxiety and catecholamine levels, minimizing dysfunctional uterine activity and leading to improved birth outcomes 
• A child's father (and a woman's partner) is uniquely able to provide ideal support throughout the pregnancy, during labor and beyond
• Help fathers be the best labor support they can be: this can be by using a professional doula OR by having him participate in reading/classes that help him learn how to support a woman in labor

Dermatologic Emergencies and their Mimics (Sugarman, 9/30/2020)

 Thanks to Dr. Jeff Sugarman for an excellent Grand Rounds this week on Dermatologic Emergencies and their Mimics. Dr. Sugarman's presentations are always replete with photos ("A picture is worth a thousand words" for sure) and probing questions, so this post will be filled with the same. Answers can be found at the very end of the post in the COMMENTS section. Don't cheat; take the quiz and use the HINTS not only to guide you to your answers, but also to enhance your understanding of the condition. 

First, when should you worry about possible dermatologic emergencies?

• Age (newborn and young infants)
• High fever, toxicity
• Morphology: particularly blistering, mucosal involvement, hemorrhage
• Specific medications: anticonvulsants, antibiotics, NSAIDs

Remember the presentation was on dermatologic emergencies and their mimics. This summary/quiz contains both derm emergencies and benign derm conditions that look pretty similar, so keep serious and not serious things on your differential. 

1) What is this rash?

Hint #1: it's really common (especially in children and people with atopy)

Hint #2: morphology includes wheals, annular, dusky centers

Hint #3: time course is VERY helpful: lesions tend to self resolve in hours, disappear and reappear in different locations

Hint #4: triggers include allergy, autoimmunity, drugs (9%), URI (40%), and idiopathic (50%)

Hint #4: Treatment: non-sedating antihistamine (fexofenadine, cetirizine) in day, sedating antihistamine at night (hydroxyzine, diphenhydramine). 

Hint #5: Prednisone is NOT rx of choice-- it works really well, and then the rash will come right back as soon as it's stopped.

2) What is this rash?

Hint #1: Looks a lot like the first rash but is different.

Hint#2: Rash morphology includes target lesions with 3 zones: dusky center, pale edematous ring, peripheral erythematous margin

Hint #3: lesions are discrete, they do NOT coalesce

Hint #4: usually pts have no systemic symptoms

3) What is this rash?

Hint#1: Presents as dusky urticaria PLUS edema, +/- fever, malaise and arthritis (7-21 days after exposure)

Hint #2: Lesions last longer than true urticaria

Hint #3: This is a type III hypersensitivity reaction (immune complexes)

Hint #4: Triggers include meds (cefaclor, PCN, anti-cancer, anti-depressants, anticonvulsants, htn meds, anti-inflammatory meds), biologic agents (rituximab, infliximab, efalizumab), infections (strep, HBC, HCV)

4) What is this rash?

Hint #1: This is a form of leukocytoclastic vasculitis in children age <2 years old

Hint #2: Presents as purpuric edematous plaques with target-like pattern, often described as "cockade or rosette"

Hint #3: This includes dramatic skin findings, but children paradoxically are not really toxic

Hint #4: Rash tends to spare the trunk

Hint #5: Lesions resolve spontaneously in 1-3 weeks

Hint #6: No labs or treatment needed.

5) What is this rash?

Hint#1: This rash may accompany pneumonia by this same organism

Hint #2: Tends to be mucosal predominant (94% oral, 82% ocular, 63% GU) and is mucosal alone in 34% of cases

Hint #3: Mean age is 12 years old

Hint#4: Most patients (81%) have no long term sequelae

Hint #5: I never heard of this before this lecture by Dr. Sugarman

6) What is this rash?

Hint#1: Severe life-threatening mucocutaneous disease involving systemic signs: fever, respiratory symptoms

Hint #2: It's a clinical syndrome, there is no definitive diagnostic test

Hint #3: Always involves at least 2 mucous membranes (mouth, eyes, urethra)

Hint #4: Causes in kids include meds (antibiotics, antiepileptics, chemotherapy), as well as HSV, mycoplasma and some undetermined causes

7) What is this rash?

Hint #1: begins as localized often occult infection (can be in the nasopharynx, perioral, conjunctiva, umbilicus, paronychia, urine, middle ear)

Hint #2: Progresses to generalized erythema and skin fragility

Hint #3: Empiric treatment is anti-staph antibiotics (cover for MRSA)

Hint #4: Peeling is NOT full thickness

8) What is this rash?

Hint #1: Most common cause of nonsexually related acute genital ulcers (NRAGU)

Hint #2: Ulcers are painful, well demarcated, shallow erosions on a clean fibrinous base

Hint #3: Self-limiting condition, usually resolving spontaneously within 2-6 weeks

9) What is this rash?

Hint #1: thick crusts, thick walled pustules are common

Hint #2: facial, periorbital involvement common 

Hint #3: fever and pain are common

Hint #4: You should culture this

Hint #5: Keflex and mid-potency steroid for body (TAC) and low potency steroid (2.5% hydrocortisone) are both indicated

Hint #6: Bleach baths (1/2 cup in full bath, 1/4 cup in 1/2 bath) may also be indicated

10) What is this rash?

Hint #1: People with eczema are particularly vulnerable to this condition due to their disruption of epidermal barrier

Hint #2: Fever, malaise, and lymphadenopathy may be present

Hint#3: This is PAINful

Hint #4: Morphology includes "monomorphous punched out erosions" (especially if you look at the periphery of this rash)

Hint #5: Lesions favor areas of active dermatitis, particularly head, neck and trunk

Hint #4: There is often a delay in diagnosis of this condition

Hint#5: Viral culture/PCR will give you the answer

Hint #6: Prompt high dose acyclovir is treatment of choice (PO for mild, IV for mod/severe)