The Care of Children with Medical Complexity (Naber, 1/21/26)

A recording of this presentation is available HERE.

Deep gratitude this week to Dr. Urs Naber, CPMC PICU Medical Director, who jumped in last minute to give a moving Grand Rounds this week on the Care of Children with Medical Complexity (CMC). Please do watch his presentation at the above link if you are interested in the topic. 

In the literature 0.7-11% of ALL children have medical complexity (definition somewhat vague)>> about 1-2% of all children

Defining CMC: chronic condition + substantial family needs + functional limitation + heath care utilization

• previously CF patients were the highest percentage of CMC, but new treatments has changed this.
• Any medical condition can count as a chronic condition, depending on its length >> technology dependence is a driver that makes this population so vulnerable

Children with CMC have specific in home needs: medical equipment, medication administration, assistance with ADLs. CP/MD often have respiratory support technology and functional limitations that lead to high needs and high healthcare utilization

Dr. Naber shared with us a video (included in the link of the full presentation above) about a child with medical complexity named Connor and his two dads and four adopted siblings. Connor was born with Trisomy 9 and is G-tube dependent, wheelchair bound, non-verbal. The video really showed us how complex it is to take care of these children, a reminder of what it means to families to be together. Reminder to

CMC have a substantial impact on healthcare, which is expanding, 2006 <1% population, making up 10% of pediatric hospitalizations, 25% of all hospital days, 41% of all healthcare costs (attributed to hospitalizations). . . 2022, now 1-2% of population, 63% of hospitalizations attributed, 79% of all hospital days, 84% of healthcare costs. Many times these kids have to stay in ICU for their respiratory care. 

Why is this happening? 

• increased survival for children with chronic conditions (e.g. spina bifida, esophageal atresia, biliary atresia, congenital heart disease, prematurity>> previously led to non-survival, but over the last 50 years, rate of survival has increased and continues to increase)
• Total ICU costs are driven dramatically by CMCs (see image below), only 10% of pediatric critical care do not have chronic disease
• ED visits: CMCs comprise 20-30% of all visits (even though 1-2% of population), most commonly respiratory infections, medical device malfunction
• presents unique challenges for ED physician (medical complexity, long medlists), as well as caregiver and patients (subspecialists not available, ED is dangerous)

Dr. Naber shared data from Houston looking at the impact of a comprehensive care program  (JAMA, Mosquera, et al 2014), over 3 year timespan>> care coordinator, nurse, cluster care, how much would that effect care?

• 52% reduction in ED visit
• 55% reduction in days of serious illness
• 42% reduction in cost (including the comprehensive care costs)
• time investment decreased over time>> had to invest 6 hours/month per child up front, down to 2 hours/month per child over time  and still maintain the drastic impact (see image)

Helping families cope with medical complexity-- surrounding structures really matter 

Dr. Naber reminded us of the IHSS program in California, which allows parents to get some income for their caregiving of children with medical complexity. Doesn't cover medical care, but does help cover ADLS (feeding, bathing, clothing)>> family  must register and become a provider through the program. Payment is low but is something for parents who are unable to work due to their children with medical complexity. Caregivers with CMC experience an overwhelming burden (almost double) of financial hardship (JAMA 2025)

Families of CMC struggle with cost of living, housing instability, transportation challenges. 

Access to specialists and subspecialists is particularly challenging: long wait times (more pronounced if poor or brown in CA). These access challenges add to the parental burden>> leading to missed work/school days, delays diagnosis, delays treatment, etc.

Subspecialty access is only readily available in concentrated metropolitan areas of California (SF Bay area and LA area). See map. Most children don't have adequate access. 1/3 of CMC families report they have drastic challenges accessing pediatric specialty care. Can be average 84 minutes of travel one way to access specialists>> every trip is one day. Again, time off work, paying cost, finding childcare for other children. Though families still prefer in person care (over telemedicine)-- feel more of a connection, get physical exam, etc

Transitions of care can be complex: this includes discharge from hospital (changes in meds/regimens), but also the huge transition when patients age out and become adults. Family physicians can care for these patients as children and continue caring for them as they become adults. In SF Bay Area 1,000 CMC age into adulthood (50% of CMCs)>> these patients continue to have high healthcare utilization rates. 

What are additional supports:

• Evidence from the same Houston comprehensive care program>> adding telemedicine support showed even better outcomes and even more decreased cost
• CMC Emergency form, better for patients, caregivers and doctors (especially ED)
• some states have CNA model, where caregivers can get additional training and payment for medical care
• patient/care navigators 
• CPMC in process of building a Bridge program, hoping that will move care for CMC in our area to the next level, where they can get subspecialty access and better long-term care

Care of Patients with Developmental Disabilities (French, 5/7/25)

 A recording of this presentation is available HERE.

***

Many, many thanks to Dr. Anne French, SRFMR Class of '99, who gave a pearl-filled presentation today about caring for patients with autism. Dr. French's many years of caring for patients with Intellectual and Developmental Disabilities (IDD) at Sonoma Developmental Center and now at Santa Rosa Community Health are literally priceless. We are so lucky to have her wisdom!

Please do watch her presentation. 

For those of you who prefer the Cliff's notes and pearls:

• always presume confidence when speaking with an autistic patient (even if non-verbal), speak as if they understand (they often do!)
• autism is often accompanied by other psych comorbidities, including anxiety disorders: GAD, OCD, and disordered sleep -- to name a few-- which impede function at school and work
• other psychiatric comorbidities also exist, including bipolar disorder and ADHD. These may be challenging to tease out
• look for anxiety
• consider GABA, fish oil, probiotics (for parents who don't want to use meds)
• r/o ADHD w/Vanderbilt
• okay to do trial of meds like Strattera without psychiatrist consult
• when you see self-injurious behavior (SIB), think physical discomfort (e.g. allergies, headaches)-- naltrexone can be a miraculous treatment for some with SIB (doesn't always work, but blocks the reward pathway for SIB)
• Dr. French highly recommends the use of Gene Sight, which is covered by both Medicare and Medi-Cal. It is intended to help prescribers understand how individuals process psych meds differently
• can help avoid medications that will have problematic effects
• gives MTHFR status (folate), which can be supplemented. Of note,  patients with autism tend to have decreased folate
• Physicians can only refer autism evaluation to the Northbay Regional Center before age 3, but parents can self refer after that. Give parents the phone number and email address of NBRC if they need to self-refer.
• Dr. MacLeamy is a clinical psychologist in Petaluma. He and associates have the PHP contract to diagnose autism in SoCo
• Applied behavioral analysis (ABA) Therapy, parents can self-refer, certified behavioralists can help treat at home/school (e.g. getting autistic kids to take shower, brush teeth, manage school day)>> many people with autism need extra support to reach their milestones
• Always look for physical causes of agitation (e.g. allergies, dental pain, constipation)
• Social stories is a simple way to teach people with autism, about social situations and expected behaviors (e.g. this is what happens when you go to the doctor, airport, pap smear, etc)
• Use EMLA cream for lab draws
• Medications that help with dysregulation include propranolol, clonidine, guanfacine, May be helpful.
• Disordered sleep should be treated. Extra challenging in children (limited options). Consider melatonin, 5HTP, Consider Buspar (age >6).
• Parents can get defensive and feel othered by the healthcare system. Building relationship and trust with them is key!
• Polypharmacy is a HUGE problem, particularly notable is multiple antipsychotics in boys/men with autism during and after puberty.
• Deprescribe antipsychotics when possible>> start with highest risk meds, if 2 of something, take one away
• Oversedation may occur with age
• Falls and/or ataxia can also be an issue with polypharmacy as patients with IDD age

Gene Sight report

Pediatric Ophthalmology (Qureshi, 3/19/25)

 A recording of this presentation is available HERE. 

My notes:

In pediatric patients, any condition that affects the amount of light passing through the eye will negatively affect the brain's ability to learn and see and result in permanent vision loss. 

Therefore, it is essential to treat pediatric eye disorders as quickly as possible!!

Common causes of childhood blindness, worldwide

• corneal scarring
• vitamin A deficiency
• measles
• opthalmia neonatorum
• harmful eye practices
• infective corneal ulcers
• congenital cataracts
• uncorrected refractive errors
• retinopathy of prematurity
• congenital glaucoma

WHO estimates 19 million visually impaired children worldwide, 1.4 million preventable blindness

Common pediatric eye disorders

• Amblyopia: a decrease in visual development that occurs when the brain doesn't get visual stimulation from the eyes (one or both eye send distorted image to brain, even when glasses are use). Only children get amblyopia, can result in permanent vision loss if not treated in child. Most common cause of vision loss in adults 20-70 is untreated amblyopia
• refractive amblyopia is treatable with glasses/patching
• patch the good eye, let the bad eye function, it works! but does not fix strabismus
• alternatively, drop of atropine in the good eye, to allow bad eye to see better (limits vision in good eye to a certain amount)
• deprivation amblyopia: if you have cataract or congenital ptosis blocking the pupil, very bad for visual development (poor prognosis within even 6 weeks, e.g. cataract, corneal ulcer, congenital ptosis)
• the primary care physician detects amblyopia (e.g. red light reflex), ophthalmology treats it
• asymmetric red light reflex>> urgent eval < 6 weeks of age
• Strabismus: ocular misalignment, "to squint or look obliquely", affects 4% of children <6 years, 30-50% results in reversible amblyopia (vision loss)
• strabismus testing: light reflex is the key (see image below)
• pseudostrabismus: looks like esotropia but light reflex is centered on the pupils (common in kids of Asian descent)
• surgical repair

• Congenital Cataracts: 1/3 hereditary, 1/3 associated with other disorder, 1/3 idiopathic
• must remove within 3 months to prevent irreversible vision loss
• Congenital Ptosis: must be able to see pupil, if kid is using a chin up position, vision is not a threat (ptosis is there, but vision is safe) 
  
  
  
• Horner Syndrome: when you see ptosis, check the pupils. The ptotic eye (SNS innervates the eyelid mm but also the iris dilator), if pupil assymetry with ptosis, patient needs brain/neck/upper chest imaging to follow nerve plexus to make sure there is no problem along the plexus causing the ptosis (e.g. tumor)
• Nevus of Ota: low percentage develop glaucoma (see R eye below, grey in sclera and skin)
• 
• Congenital Glaucoma: enlarged cornea, tearing eyes, spasmodic to light, can develop serious vison loss, need urgent treatment. Very different than an adult. In a kid you should be able to see swollen cornea,  almost like a corneal ulcer or maybe like one eye is bigger than the other. Should be referred urgently

• Retinoblastoma of childhood 
• most common ocular tumor or childhood
• usual onset < 4 years
• 25% present with strabismus
• treatment: radiation, chemo, possibly enucleation
• require systemic work up, including r/o pineal gland and bone tumors
• 
  
  
  
• Red eyes
• Nasolacrimal duct obstruction is very common, usually presents as tearing, common, 5% of newborns, 
• no rush to refer >>90% regress by 12 months (95% by 18 months)
• surgical treatment occurs 18-24 months w/nasolacrimal probe
• Dacryocystocoele (image below): within first few weeks of life, infection and bump w/preseptal cellulitis due to imperforate valve. Have to treat preseptal cellulitis with IV abx and then sedate and probe. It looks better after abx butu if you don't create the passage, it will recur.
  
  
  
• Blepharitis: Very common, redness in conjunctiva and redness in eyelids>> treat the eyelids (warm compresses, abx drops despite no infection> glands work and eyes work better). Can also have stye. Erythromycin ointment doesn't work, but Maxitrol drops do work.

• Neonatal conjunctivitis: neonatal gonorrhea (very violent, first day of life), chlamydia, chemical, HSV (4-5 weeks of life).
• need systemic treatment AND ointment
• Allergic conjunctivitis: itchy red eyes, papillae, zaditor drops OR systemic allergy treatment, temporary steroids okay w/taper if really bad
• vernal conjunctivitis is severe form of allergic, can lead to shield ulcers, giant papillae, often in young men
• Styes: obstruction of meibomian glands, very common 
• hordoleum is a blocked gland
• chalazion is the more chronic granulomatous form
• warm compresses, maxitrol (neomycin/polymyxin/dexamethasone) ointment, only if superinfection can consider antibiotic
• 

Pediatric Vision Screening

Direct visual acuity screening is gold standard

• Start screening age 3/4 w/HOTV or heart/house/square tools for refractive problems

(Tumbling E hard to do with young kids)

• Age 4-5, use HOTV card but can use "match card", looking for 20/40 vision (doesn't have to be better), one eye should NOT be way better than the other> this should trigger referral
• Age 5+, looking for 20/30 or better, move to Sloan Letters and repeat  q1-2 years

Chagas Disease: Why a Neglected Tropical Disease Matters for US Clinicians (Heindel, 3/5/25)

 A recording of this presentation is available HERE. 

Dr. Leah Heindel gave a wonderful Grand Rounds presentation this week on Chagas Disease. Perhaps the most important moment of the presentation was this slide:

"Look," Dr. Heindel, urged, "look at how this little "kissing bug" (aka triatomine) creates a cascade that has impact on immigrant health justice, reproductive health, whole-family care, global health, and how we think of screening and prevention in the US in 2025. This is family medicine."

Family medicine, indeed, is all of these.

Epidemiology and Disease Burden

Chagas Disease, which infects 7-8 million people worldwide, mostly in Latin America, presents a health burden seven times higher than malaria in the Western Hemisphere. There are an estimated 300,000 people living in the US with Chagas disease, many of whom are immigrants from Mexico, El Salvador, Guatemala, and Honduras. Unfortunately, only about 1% of those have been identified. Both vector and vertical transmission occurs in the US (22-100 cases congenital chagas in the annually).

Chagas disease has both an acute and indolent phase. The overwhelming majority of people infected with Chagas disease (90%) will be asymptomatic in the acute phase, but chronic impacts (especially GI, cardiac) typically appear 20-30 years after initial infection. 

Seroprevalence in immigrants from endemic countries is believed to be about 1% in the general population, though it varies widely depending on how these estimates are made. For example, you can see in the table below from the IDSA that there is a MUCH higher seroprevalence in immigrant patients from endemic areas with otherwise unexplained non-ischemic cardiomyopathy (13-19%). 

Vertical transmission occurs in 2-13% of cases, most congenital infection is asymptomatic, but Chagas has been associated with preterm delivery, low birthweight and low APGAR scores. 

Clinical manifestations

Chagas disease is generally spread via the bite of the "kissing bug", usually on the neck and face at night while people are sleeping; the same bug defecates close to that area, then the disease is transferred to the bloodstream via scratching at the site and introduction of bug feces to the broken skin. The acute phase of Chagas (only in about 10% of people infected) presents as a non-specific viral syndrome, including fever malaise, and anorexia. One pathognomonic sign of acute Chagas is Romaña's sign, pronounced swelling of the eyelid (as seen in image below). Domesticated and farm animals serve as reservoirs of the disease, and thatched roofs are a known risk factor in endemic areas.

After decades long latency, most common manifestations include cardiac (sudden cardiac death as #1 cause of death from Chagas, 55-60% of people, also HFrEF (25-30%) and embolic disease (10-15%). It seems that the parasite has a particular predilection for the electrical and conducting system. 

GI effects are also well-documented and occur in 10-21% of people with chronic Chagas, including both esophageal and colonic manifestations. In the esophagus, dysphagia and regurgitation are common; in the colon sigmoid rectal dilatation and progressive constipation. 

Neurologic effects including peripheral neuropathy and even dementia have been suggested. In addition there is a reactivation syndrome that can affect people with transplant or other immunosuppression.

Screening and Diagnosis 

The earlier Chagas is detected, the better the outcomes. Once someone has chronic cardiac or GI effects, treatment has shown to be unhelpful.

Diagnosis is done via is a serum IgG test with reflex to confirmation (goes to CDC), which is available through most laboratories. 

Both the CDC and IDSA recommend targeting screening based on risk factors, in particular being born in or lived in endemic areas, having a family member with Chagas Disease. 

Screening during pregnancy has been shown to be cost effective and may be something we should be integrating locally in our at-risk population-- more on this to come. Options for pregnancy-screening include pre-pregnancy screening (this MOST preferred because cannot treat during pregnancy) vs. routine OB screening vs. L&D serum IgG vs. newborn cord blood or PCR and even the possibility of universal newborn screening.

Diagnostic testing is warranted in patients who come from endemic areas AND present with electrocardiogram abnormalities (wide range, including 1st degree AV block, afib, PVCs, RBB, low voltage), thromboembolic phenomenon, HFrEF otherwise unexplained, and megacolon or megaesophagus.

Treatment

There are two approved treatments for Chagas Disease, both for extended duration (see image below for dosing)

1) Benznidazole x 60 days

2) Nifurtimox 90 days

Both treatments have high side effect profiles (GI, CNS, marrow suppression). They are contraindicated in pregnancy, though safe in lactation, and contraindicated in severe hepatic and renal dysfunction. These medications also may be hard to come by locally.

The IDSA offers guidelines for who should and should NOT be treated. On the list for who should be treated includes: anyone with acute Chagas, all children with acute/chronic infection, reproductive age women, and people with impending immunosuppression. On the list of people NOT to treat, includes adults with advance cardiac and/or GI manifestations (treatment doesn't reverse these), unless people have impending immunosuppression. Also, not during pregnancy and not in severe hepatic or renal dysfunction. 

Finally, Dr. Heindel recommends this book, The Kissing Bug, written by a first generation immigrant journalist and author, whose family was directly impacted by this disease and who follows the socio and geopolitical forces that influence the management of Chagas in the US immigrant population today.

Osteopathic Manipulation in the Hospital (Earl, 12/4/2024)

A recording of this presentation is available HERE.  

Many thanks to Dr. Connie Earl for a FANTASTIC Grand Rounds presentation this week on Osteopathic Manipulation in the Hospital. Dr. Earl, who previously ran the Forestville Wellness Center through West County Health Centers, is currently doing a year of extra "residency" training on Osteopathic and Neuromuscular Medicine (ONMN) at Maine Medical Center. She shared with us her passion for Osteopathic Manipulation (OMM/OMT) and a TON of what she described as "really weird studies that demonstrate ways in which OMN may be used in the hospital setting".

As an allopathic-trained physician, I admit I am often envious of the anatomy knowledge and tremendous skills of my osteopathic colleagues-- and I can tell you from personal experience that Dr. Earl has amazing clinical skills (and hands!)

For those of us less familiar with OMT, she started with the four principles of osteopathy: 

1. The body is a unit; the person is a unit of body, mind and spirit.

2. The body is capable of self-regulation, self-healing and health maintenance.

3. Structure and function are reciprocally interrelated.

4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation and the interrelationship of structure and function.

Aren't these principles cool?  

Dr. Earl also contrasted OMT with allopathic medicine, which often focuses on treating/curing/preventing the disease; whereas osteopathy focuses on what we can do to protect the host. 

Well-structured randomized control trials of OMT are extremely challenging to create because of a wide variety of methodological variants. For example, OMT is a response to a personal and individual host. If you protocolize an OMT intervention (in order to standardize it), you are already compromising the validity of the treatment. OMT techniques vary widely, sham OMT is challenging to replicate, and many studies include trainees of varied levels of experience. 

Where she is currently training at Maine Medical Center, a 700 bed Level 1 Trauma Center, the OMN service typically treats 60-70 patients. These include patient post-CABG, poly-trauma patients, patients after GI surgeries, NICU babies, term babies and mothers, and more. 

Founding father of OMT, AT Still, is famous for his evocative quotes. One that captures another important tenet of OMT is a focus on the lymphatics system: "We strike at the source of life and death when we go to the lymphatics."

Dr. Earl shared some really amazing and interesting observational data of OMT during the 1918 Flu Pandemic, in which there was a remarkable 6% death rate for all-comers. Observational studies found that patients treated with OMT (there was no influenza treatment at the time) had closer to a 0.25% death rate. Dr. Earl stressed that these were not RCTs, and yet. . .OMT has been associated with improved respiratory function, supporting increased circulation and increased lymphatic flow. All of which certainly could have biologic plausibility in terms of helping with viral respiratory illness. 

Canine and rat studies both demonstrate improvement in lymphatic pumps with OMT. Human studies, whose lymphatic pumps are a little more challenging to study, demonstrate increased tidal volumes. 

Here are some examples of patients cared for by OMN providers at Maine Medical Center:

• post-CABG patients: improved peripheral circulation, improved cardiac indices, decreased time to dc (1/2 day), decreased time to first BM, increased functional independence
• post-sternotomy patients:: decreased pain, LOS, increased mean inspiratory volume
• GI surgeries, especially ileus: decreased LOS, decreased time to flatus, less pain, decreased time to first stool, decrease use of opioids
• IBS/constipation: decreased pain, bloating, constipation and increased quality of life
• Inpatient pediatric patients
• breast/chest feeding: latch issues, increased exclusive breastfeeding, better milk transfer, decreased pain
• birth trauma: hypoglossal nerve trauma/compression, hyoid connections and torticollis
• premature neonates/NICU for feeding tolerance
• 

  

Let me know if you want references to any of the OMT studies. I have them!

Vaping: Medicine or Menace (Ling, 11/13/2024)

 A recording of this presentation is available HERE.

***

This was a mind-blowing and practice-changing Grand Rounds this week -- so much to learn and understand about vaping (aka e-cigarettes) as primary care providers. The speaker, Dr. Pamela Ling, is the Director of the UCSF Center for Tobacco Research and Education, and she shared so much valuable data and on-the-ground information about the current state of vaping. The title of her talk was Vaping: Medicine or Menace?

Here's what I learned:

First off, the vaping industry is rapidly evolving. Unfortunately, the science, while forthcoming, lags behind an agile and sneaky industry. The first e-cigarettes came on the market in 2009 and looked like little "fake cigarettes" (they even featured a puff of smoke). Now, vapes come in a shapes and sizes and with increasingly concentrated (and flavored) solutions and changing delivery devices. 

E-cigarettes create an aerosol by using a battery to heat up liquid that usually contains nicotine, flavoring, and other additives. Users inhale this aerosol into their lungs. E-cigs can also be used to deliver cannabinoids, such as marijuana and other drugs. 

OMG check this out! These are vaping products confiscated from high schools in California and North Carolina (1000 products from 25 high schools) from an MMWR publication.

While cigarette smoking levels are down in California (and SoCO), vaping is on the rise, and the youngest have the highest rates.

In fact, SoCo teens seem to have higher rates of vaping than California teens overall.

And, unsurprisingly for those of us who care for marginalized populations, more vulnerable kids (based on gender identity, race, etc) have even higher rates of e-cigarette use

Note that while Sonoma County average of e-cigarette use is 12%, certain groups have MUCH higher rates, namely: SoCo gender questioning kids and kids who identify as black/African American, and Native American.

In addition to vaping nicotine, cannabis is increasingly popular; almost as many people use cannabis as tobacco now in the US. And while smoking is still the most common way to consume cannabis, edibles and vaping are both increasing.

Of note, older generation vapes contained far LESS nicotine. Newer vapes include chemicals that make higher concentrations more palatable and more appealing. As you can see in the image below, whereas older versions (The JUUL) contained the equivalent of about 1 pack of cigarettes, newer versions (e.g. Flum pebble) now contain up to 30 packs of cigarettes. This leads to increased nicotine consumption and dependence. And because of price controls and taxation cigarettes, vaping can save money, which certainly also influence habits and behaviors. Whereas a carton of cigarettes may cost upward of $50-85, a single vape (the equivalent of 3 cartons) costs less than $20 online. 

The same is true for rising THC concentrations in cannabis vapes. 

Do E-cigarettes help people quit smoking?

It is important to understand that there is SOME evidence of the use of e-cigarettes to promote smoking cessation, though the evidence is weak at best. E cigarettes are not approved by the FDA for smoking cessation, though they are recommended by the UK NHS due to this evidence. Under RCT conditions, earlier generations of vape products have been shown to be more effective than nicotine replacement therapy. You can see this data below summarized in the Cochrane review below. 

This has not borne out in population level observational studies-- in other words, when used as a consumer product, e-cigarettes do not help with cessation. Also important to note that the e-cig market is evolving extremely rapidly and the products are increasingly appealing to young people (this is not a coincidence).

Isn't vaping better for us than smoking?

Stella Tomassi and colleagues published a study of young adult vapers who never smoked compared to smokers using quantitative PCR to detect DNA damage (as a marker for future cancer).  They found a dose-dependent formation of DNA damage in oral cells of vapers who had never smoked tobacco cigarettes as well as exclusive cigarette smokers. They also found more damage seen in heavier users, users of pod vapes and sweet flavors) independent of nicotine levels.  

Recent studies of the epigenetic effects of tobacco smoking and e-cigarette use found similar changes in DNA methylation among people using cigarettes and people using e-cigarettes, changes that were associated with lung carcinogenesis.

While we do not have direct human data on vaping and lung cancer outcomes, these newer biomarkers of DNA damage and epigenetic changes are likely to be informative for lung cancer risk.

When people switch completely from cigarettes to e-cigs, there is definitely a decline in those biomarkers. So maybe vaping IS better than cigarette smoking. Unfortunately, many people try to convert to vaping but then continue intermittently also smoking cigarettes. Interestingly, the evidence shows that these "dual users" do not reduce their exposures to carcinogens.  

In terms of cardiovascular disease: a recent study published in NEJM 2024 found that CV disease risk from vaping was NO different than CV disease risk from smoking. So for CV risk the answer is NO.

But here's perhaps one of the most important take home points: dual use (using BOTH vapes and cigarettes) is definitely the worst for patients. Check out this summary table below showing the risk of disease appears higher for dual users. . .

Dr. Ling's closing advice to clinicians:

• Ask about vaping to engage in a cessation conversation
• Ask about both nicotine and cannabis vaping
• Encourage to treat nicotine vapes like any tobacco product
• Encourage complete switching not dual use
• Longer term transition off vaping products (using nicotine-replacement)

Ariel Thomas-Urlik, MPH from the Sonoma County Department of Public Health, who helped make this presentation possible, also shared some local information about local laws aimed at preventing widespread sales of nicotine products to children and adults.  

Did you know that SoCo has a minimum price of $10/pack for cigarettes? No coupons or discounts are allowed to be applied. 

Also California law currently prevents flavored tobacco products from being sold in physical retail stores, and a new law going into effect this week prohibits County of Sonoma do NOT ALL e-cigarette sales in physical retailers that sell tobacco (cannabis dispensary do not apply). While retailers continue to sell, DPH is using volunteer decoys to catch retailers who are violating this law. There is less access in SoCo, and we know that when access goes down, people become more interested in quitting. 

A new state law CA AB3218 which goes into effect on January 1, 2025 makes online purchase of vapes illegal in the state of California!

Neonatal and Infant Eruptions (Sugarman, 1/31/2024)

 A recording of this presentation can be found HERE

***

Many thanks to Dr. Jeff Sugarman, local dermatologist, who gave an excellent Grand Rounds presentation this week on Neonatal and Infant Eruptions: when to worry and when to reassure. See above for the link to watch it.

My notes this week come in the form of a dermatologic photo quiz for your testing pleasure. Answers are below the final photo and question.

1. What is this neonatal rash categorized by fragile pustules that erode very quickly, leaving behind brown collarettes with post-inflammatory hyperpigmentation. It can be present at birth and last days to weeks. More common in neonates with more pigment. Benign.

Source: DermNetNZ.org

2. What is this benign newborn rash often caused by over-bundling newborns? Erythematous papules and pustules often occurring on covered portions of the skin. Totally benign.

Source: DermNetNZ.org

3. What is this benign rash of the neonatal period, often during the first 1-3 weeks of life, acneiform, often occurring on the face and upper chest and scalp. It has NO comedones and is the result of an inflammatory reaction. Treatment is either topical antifungal or  topical 1% hydrocortisone, though no treatment is also acceptable. Often mistaken for neonatal acne, which presents later AND always has comedones.

Source: DermNetNZ.org

4. What is this benign self-resolving rash that is notable for pustules on feet and hands that can last for months, come and go in crops, and look a lot like scabies (but when scraped show no mites). This will resolve on its own but can take months to do so?

Source: DermNetNZ.org

5. What is this papule on the scalp, often solitary with a unique yellow color? The papule is self-resolving but can last years (5-10) before it disappears. Can sometimes occur in multiples and have extra-cutaneous involvement, with particular issues in the eye. In rare cases, multiple of these are associated with leukemia. 

Source: DermNetNZ.org

6) What is this condition characterized by peau d'orange (texture). Often missed by primary care clinicians. Usually solitary but can be present in sheets. Featured by pockets of histamine -- Darier's sign when stimulated (scratched or rubbed), can be accentuated. Can last for years. Activated by cold/hot/rubbing. 

Source: DermNetNZ.org

7) There are four variants of #6: 1) solitary (most common) 2) urticaria pigmentosa with peak onset first year of life 3) diffuse cutaneous mastocytosis and 4) most rarely mast cell leukemia. This is one of those variants, which features flushing, hives, pruritis, blisters and sometimes diarrhea (due to mast cells in the GI system). Treatment involves: antihistamines, oral cromolyn for GI symptoms, consider epi pen. If a high burden of disease, consider monitoring serial serum triptase.

Source: DermNetNZ.org

Of note, activators of mast cells include: alcohol, aspirin, narcotics (including codeine), some contrast agents, and hot/cold/sunlight. Consider limiting these triggers in patients with mastocytosis.

8) What is this eyebrow bump, often seen on the lateral brow, caused by a sequestration of ectodermal tissue during embryogenesis? It is usually present at birth but not noticed. It is rubbery,  not compressible, not tender. It is also not a true cyst. 

Source: DermNetNZ.org

Of note, you need to worry when the location suggests a CNS connection, which is always in the midline (25% of midline dermoids have a CNS connection). If a dermoid cyst is leaking clear fluid, this is likely spinal fluid and is BAD. It is good to remember that the neural tube closes in a series of discontinuous zippers, and there is no CNS connection in any other place than the "hot spots" where the zippers close. 

9) Do you have to worried about a CNS connection in this infant with a dermoid cyst?

Source: https://webeye.ophth.uiowa.edu/eyeforum/cases/115-dermoid-cyst.htm

Of note, dermoid cysts on the lateral brow are generally removed after a child's second birthday. They should be referred to pediatric plastics for the excision for best cosmetic effect. 

10) What vitamin deficiency -- often due to inadequate intake and appearing around the time a baby is weaning -- leads to  this psoriaform rash (well demarcated) on the face and in the diaper area? Hint: the name of the rash is acrodermatitis enteropathica.

Source: MDEdge

11) What is this uniquely pediatric form of this autoimmune disorder, often characterized by raccoon eyes (periorbital accentuation of erythema) and diagnosed by maternal serologies? Hint: photosensitive, 50% of cases have congenital heart block. Rare (10%) have hepatobiliary disease and even rarer (1%) thrombocytopenia.

Source: DermNetNZ

Source: DermNetNZ

12) Cool pearl!! Alternate treatment for umbilical granuloma. Aside from silver nitrate, a study showed that a single application of THIS common household item, covered with bandage tape can resolve this problem. What is the common household item?

13) What is this scary looking fixed erythematous rash (lasting 24+ hours) that often appears on the face, arms and legs. Child tends to be non-toxic appearing, and the trunk is spared. It resolves on its own. It is in the HSP spectrum, but has no cutaneous findings.

Source: DermNetNZ

14) Last but not least, what is this rash in a 6 week old baby that did not respond to topical steroid, topical anti-fungal, systemic antihistamines, or antibiotics?

And the bonus final: how do you treat it? Treatment of infantile scabies, even in children under 2 months and <15kg is the same as for children >2 months and >15kg (though the drug labeling does not promote this). Per Dr. Sugarman, you can confidently treat with either oral ivermectin OR topical permethrin safely and effectively in neonates.

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No cheating!!! Don't look down here until you have really thought about each of the photo questions above!!

Answers:

1) Transient Neonatal Pustular Melanosis

2) Miliaria Rubra

3) Neonatal cephalic pustulosis

4) Acropustulosis of infancy

5) Juvenile Xanthogranuloma

6) Mastocytosis

7) Urticaria pigmentosa

8) Dermoid Cyst

9) YES! This baby needs imaging (CT or MRI) to rule out encephalocele or mucocele prior to excision).

10) Zinc Deficiency: Treatment is rx zinc 3mg/kg/day

11) Neonatal Lupus Erythematosus

12) Table Salt!! A study of 17 infants with umbilical hernia found 100% resolution  (17/17) with a single application of table salt, occluded with medical bandage x 24 hours.

13) Acute hemorrhagic edema of infancy

14) Infant scabies, characterized by vesicles and pustules on the palms and the soles