Richard J. Chung

Effects of bupivacaine and tetrodotoxin on carrageenan- induced hind paw inflammation in rats (Part 1) : Hyperalgesia, edema, and systemic cytokines

Background:Local anesthetics exert antiinflammatory actions. To elucidate potential mechanisms, the authors examined effects of bupivacaine or tetrodotoxin, administered to rats by ipsilateral or contralateral sciatic blockade or systemically, on carrageenan-induced hind paw hyperalgesia, edema, and stimulated cytokine production in circulating blood cells. Methods:Twelve groups of rats (n = 9–12) received injections in three sites: (1) right or left hind paw (carrageenan or saline), (2) left sciatic block, and (3) systemically (subcutaneously in the upper back). Sciatic and systemic injections were performed with epinephrine plus bupivacaine, tetrodotoxin, or saline; injections were repeated 6 h later. Fifteen hours later, hyperalgesia and/or sensory and motor block were assessed behaviorally, and paw edema was quantified by magnetic resonance imaging. Stimulated production of tumor necrosis factor &agr;, interleukin 10, and interleukin 1&bgr; in whole blood cultures was measured by enzyme-linked immunosorbent assay. Results:Either ipsilateral or contralateral sciatic blocks using either bupivacaine or tetrodotoxin reduced carrageenan-induced edema and hyperalgesia. Systemic bupivacaine and tetrodotoxin were ineffective in preventing edema and hyperalgesia. Bupivacaine was effective in suppressing systemic tumor necrosis factor &agr; and interleukin 1&bgr; by all three routes, whereas tetrodotoxin was ineffective by all three routes. Conclusion:Bupivacaine and tetrodotoxin, via a contralateral or ipsilateral sciatic block, attenuate local inflammatory edema and hyperalgesia induced by hind paw injection of carrageenan in rats. Mechanisms underlying contralateral effects of sciatic blockade remain unexplained. Bupivacaine inhibits carrageenan-evoked systemic cytokine production by a mechanism not shared by tetrodotoxin; this action may involve tetrodotoxin-resistant sodium channels or a variety of non–sodium-channel targets.

Hormonal Contraception and Thrombotic Risk: A Multidisciplinary Approach

Heightened publicity about hormonal contraception and thrombosis risk and the publication of new guidelines by the World Health Organization in 2009 and the Centers for Disease Control and Prevention in 2010 addressing this complex issue have led to multidisciplinary discussions on the special issues of adolescents cared for at our pediatric hospital. In this review of the literature and new guidelines, we have outlined our approach to the complex patients referred to our center. The relative risk of thrombosis on combined oral contraception is three- to fivefold, whereas the absolute risk for a healthy adolescent on this therapy is only 0.05% per year. This thrombotic risk is affected by estrogen dose, type of progestin, mechanism of delivery, and length of therapy. Oral progestin-only contraceptives and transdermal estradiol used for hormone replacement carry minimal or no thrombotic risk. Transdermal, vaginal, or intrauterine contraceptives and injectable progestins need further study. A personal history of thrombosis, persistent or inherited thrombophilia, and numerous lifestyle choices also influence thrombotic risk. In this summary of one hospitals approach to hormone therapies and thrombosis risk, we review relative-risk data and discuss the application of absolute risk to individual patient counseling. We outline our approach to challenging patients with a history of thrombosis, known thrombophilia, current anticoagulation, or family history of thrombosis or thrombophilia. Our multidisciplinary group has found that knowledge of the guidelines and individualized management plans have been particularly useful for informing discussions about hormonal and nonhormonal options across varied indications.

Systematic Review of the Impact of Transition Interventions for Adolescents With Chronic Illness on Transfer From Pediatric to Adult Healthcare

Transfer from pediatric to adult care is a critical component of a high-quality transition experience for adolescents and young adults (AYA) with chronic illness. To examine the current evidence regarding the effect of transition interventions on care transfer, we performed a systematic review of studies that evaluated the effect of transition interventions on the specific health services outcome of transfer. The Medline, CINAHL, and PsycINFO databases were searched for studies that evaluated 1) a discrete transition intervention for AYA, 2) included a comparison group, and 3) reported on the outcome of transfer from pediatric to adult healthcare. References were screened and reviewed separately by authors, and relevant study details were abstracted during the review process. Five studies from five different countries were included in the final analysis. All five studies were conducted in specialty care clinics, with three interventions involving a nurse practitioner or systems navigator and two interventions involving physicians. Four studies were retrospective observational studies, and one was a pilot randomized controlled trial. Three of the five studies found that the transition intervention was associated with increased rates of transfer while the other two showed no statistically significant effects. Overall, evaluation of transfer appears to be hindered by methodological challenges. Establishing clearer definitions and metrics of transfer and creating the infrastructure needed to monitor the transfer of patients more consistently are important goals.

Systematic review of positive youth development programs for adolescents with chronic illness.

BACKGROUND AND OBJECTIVE: The Positive Youth Development (PYD) framework has been successfully used to support at-risk youth. However, its effectiveness in fostering positive outcomes for adolescents with chronic illness has not been established. We performed a systematic review of PYD-consistent programs for adolescents with chronic illness. METHODS: Data sources included PubMed, CINAHL, and PsychINFO. Guided by an analytic framework, we searched for studies of PYD-consistent programs serving adolescents and young adults aged 13 through 24 with chronic illness. References were screened iteratively with increasing depth until a focused cohort was obtained and reviewed in full. The authors separately reviewed the studies using structured analysis forms. Relevant study details were abstracted during the review process. RESULTS: Fifteen studies describing 14 programs were included in the analysis. Three comprehensive programs included all 3 core components of a PYD program, including opportunities for youth leadership, skill building, and sustained connections between youth and adults. Four programs were primarily mentoring programs, and 7 others focused on youth leadership. Programs served youth with a variety of chronic illnesses. The quality and type of evaluation varied considerably, with most reporting psychosocial outcomes but only a few including medical outcomes. CONCLUSIONS: The PYD-consistent programs identified in this review can serve as models for the development of youth development programs for adolescents with chronic illness. Additional study is needed to evaluate such programs rigorously with respect to both psychosocial and health-related outcomes. PYD-consistent programs have the potential to reach youth with chronic illness and promote positive adult outcomes broadly.

Firm foundations: strength-based approaches to adolescent chronic disease

Purpose of review Chronic disease management is an increasingly important aspect of caring for adolescents. Strength-based approaches hold tremendous promise in the face of current challenges. Recent clinical innovations and research findings that provide evidence of the efficacy of strength-based approaches and represent a fundamental evolution in the clinical approach to adolescent care are reviewed. Recent findings Resilience and positive youth development are important conceptual frameworks in adolescent health, which have recently been brought into the clinic setting in the form of the strength-based approach to care. In parallel, studies of motivational interviewing, a strength-based technique with known efficacy in behavioral change, have begun to demonstrate clinical efficacy in various adolescent chronic disease applications. The coupling of a strength-based approach with motivational interviewing holds promise for not only modifying end behaviors but also helping teens to develop strengths and assets to promote general well-being and healthy development. This distinction in goals might be described as the difference between being transiently problem-free and durably problem-resistant. Summary Strength-based approaches, including motivational interviewing, hold tremendous potential for equipping providers to address the rapidly increasing burden of chronic disease in adolescents.

A “Novel” Intervention: A Pilot Study of Children's Literature and Healthy Lifestyles

OBJECTIVE: To determine if reading an age-appropriate novel has the potential to improve BMI percentile and exercise- and nutrition-related knowledge and behaviors in girls aged 9 to 13 years who were enrolled in a childhood obesity-treatment program. METHODS: This preliminary, randomized, controlled trial followed 81 obese girls aged 9 to 13 years who were enrolled in the Duke University Healthy Lifestyles Program, a comprehensive clinical and behavioral lifestyle-modification program for overweight and obese children. Thirty-one girls were randomly assigned to read the intervention novel, which describes an overweight girl who discovers improved health and self-efficacy, and 33 participants were given a control novel to read. Participants were evaluated at the study intake and again at their scheduled follow-up appointments 1 to 2 months later. Intake and follow-up BMI percentiles were evaluated for 17 girls in the program who did not receive either book. RESULTS: Follow-up data were available for 11 of 31 girls in the intervention-book group, 14 of 33 girls in the control-book group, and 14 of 17 girls who did not receive a book. There was a significantly greater reduction in BMI percentile among those in the intervention-book group (−0.71) versus those in the control-book group (−0.33; P = .03). Girls who read either book had a significantly greater reduction in BMI percentile (−0.49) than girls who were followed in the program but who were not assigned a book (0.05; P = .02). CONCLUSIONS: Age-appropriate fiction, particularly if it addresses health-oriented behaviors, shows potential for augmenting weight loss in girls who participate in a weight-management program. Future research is needed to determine if the novel is effective for healthy lifestyle promotion among all overweight and obese adolescents.

Commercial sexual exploitation and sex trafficking of adolescents

Purpose of review This review describes the current state of commercial sexual exploitation and sex trafficking of adolescents in the United States and globally, the legal and health implications of this severe form of abuse, and the roles that pediatric and adolescent healthcare providers can play in addressing this issue. Although this form of exploitation and abuse is shrouded in secrecy, pediatric and adolescent healthcare providers are well positioned to respond when it arises. However, awareness and understanding of the issue are generally lacking among healthcare professionals, currently limiting their effectiveness in combating this problem. Recent findings Although the empirical evidence base available to guide clinical care of victims of trafficking remains limited given the secretive nature of the abuse, important contributions to the multidisciplinary literature on this issue have been made in recent years, including the Institute of Medicines landmark report in the United States. Summary Commercial sexual exploitation and sex trafficking of adolescents represent a human rights tragedy that remains inadequately addressed. As preeminent advocates for the health and well-being of adolescents, pediatric and adolescent healthcare providers can play a crucial role in advancing efforts not only to intervene but also to prevent further victimization of vulnerable youth.

Depression and suicide in children and adolescents

1. Gary R. Maslow, MD, MPH* 2. Kathleen Dunlap, MD, MPH† 3. Richard J. Chung, MD‡ 1. *Department of Psychiatry and Behavioral Sciences, Department of Pediatrics, Duke University School of Medicine, Durham, NC. 2. †Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC. 3. ‡Adolescent Medicine, Duke University Medical Center, Departments of Pediatrics and Medicine, Duke University School of Medicine, Durham, NC. Despite national recommendations, screening for adolescent depression is generally uncommon and is typically characterized by regional and racial/ethnic disparities. This variability in practice may leave some adolescents disproportionately vulnerable to untreated depression. Further education about depression in general and specifically regarding screening may help address such disparities. After completing this article, readers should be able to: 1. Describe the diagnostic criteria and initial assessment of depression. 2. Outline screening and management strategies for depression. 3. Discuss risk factors for and presentations of suicidal thoughts and behaviors. 4. Determine the acute management and secondary prevention of suicidality. Depression is underrecognized and undertreated in adolescents, with close to 75% of depressed adolescents not receiving treatment. Untreated depression in adolescence is associated with various adverse adult outcomes, including lower educational attainment and poorer physical health. Beyond the suffering and impaired functioning that depressed adolescents experience as well as the potential for future negative outcomes, the reality is that some affected adolescents commit suicide, further heightening the need for proactive assessment and treatment. Given the persistent shortage of mental health clinicians in the United States, significant emphasis has been placed on increasing the role of pediatricians in addressing this burden. In fact, a key pediatric quality metric that has garnered interest in recent years is screening for adolescent depression in primary care settings. In addition, the American Academy of Pediatrics included recognition and initial management of depression in its 2009 policy statement on recommended mental health competencies in primary care. (1) Given that adolescents with depression often present initially in the primary care setting, pediatricians are …

Keen on Teen Vaccines: Improvement of Adolescent Vaccine Coverage in Rural North Carolina

PURPOSE To improve adolescent immunization coverage in a rural North Carolina county. METHODS Adolescent immunization coverage rates in an intervention and four comparison counties were compared over 1 year. We introduced practice-based interventions in seven practices centering on immunization registry-driven recall of adolescents for immunizations with postcard reminders (Phase 1), and 6 months later employed nontargeted school-generated telephone reminders to parents of adolescents (Phase 2). RESULTS Improvements in the intervention county among 11- to 12-year-olds occurred for first-dose human papillomavirus vaccine in both boys (overall change, 14.2%-32.1%) and girls (27.4%-43.4%) and the meningococcal vaccine (34.6%-49.4%). Improvements among adolescents 13-18 years were limited to human papillomavirus vaccine completion in boys (1.6%-4.2%). Improvements were greater during Phase 1 than Phase 2 and among younger adolescents. Coverage improvements in the comparison counties were smaller than those observed in the intervention county. CONCLUSIONS A resource-light two-phase intervention led to modest improvements in immunization coverage, most notably in the largest adolescent practice in the county, and suggested potential for further gains, particularly among younger adolescents.

Exploring the Perspectives of Obese Adolescent Girls

To understand obese adolescent girls’ perspectives regarding their weight and health we studied video intervention/prevention assessment audiovisual narratives created by 14 obese girls ages 12 to 20 years. The narratives included interviews, monologues, and daily activities. Themes included illness conceptualizations, health concerns, health misinformation, and distress regarding appearance deriving from both within and without. The predominant theme was ambivalence about obesity. Close examination of these themes revealed potential footholds for intervention. Sensitive exploration of issues such as appearance and psychosocial distress might strengthen the patient–clinician partnership in identifying a patient’s strengths and motivating weight loss.