Keratosis pilaris

Common, Dermatology, General paediatrics

Common (familial) – rough, bumpy skin on upper arms, usually asymptomatic but cosmetically not great. Follicular plugging, basically.

Can get quite inflamed in some people.

Exfoliating, moisturizing may help.

Sometimes goes with inflamed cheeks – Keratosis pilaris rubra faciei, so typical KP of the arms (often perifollicular redness), but can lead to hair loss and atrophy of eyebrows and scalp. 

Urea containing (Balneum, Hydromol Intensive, Eucerin intensive) creams or salicylic acid (in zinc oxide) paste may help. Topical steroids can be tried if very red but risky for face, given tendency to atrophy anyway.

Sesame allergy

Allergy, General paediatrics

An emerging food allergy over the last few decades in the UK.

Sometimes isolated, but 25% of peanut allergic are also sesame allergic.

Black, white, red varieties are found – in allergy terms identical.

Other co-sensitivities are pine nut (!), brazil nut and macadamia [Helen Brough, JACI 2020].

Sesame often used in bakery products, also in Far Eastern (gomashio, furikake are sprinkled over Japanese food) and Middle eastern food. Typical white seeds are obvious (and stick to everything, which makes cross contamination a big problem) but black sesame seeds found in Japanese cooking, and tahini (sesame paste, used in hummus and dressings), are not recognisably sesame seeds at all.

Sesame oil is generally unrefined, which is to say that it is likely to contain significant amounts of sesame protein and therefore trigger reactions. With many other kinds of oil, this isn’t the case because they are refined and lack proteins.

Evidence exists that ingested whole seeds can pass through digestive tract of allergic person without causing a reaction – which can confuse diagnosis and/or suggest tolerance when it isn’t. Or delayed rupture of seed case may cause delayed but severe reactions (90 mins plus after ingestion)

Some sesame allergic appear to be sensitized to oleosins, which are not water soluble so are not found in standard skin prick and IgE test solutions, potentially giving a false negative result. In 2020 study from Israel, SPT only 33% sensitive, cf 86% (although specificity also drops to 50%). So recommended that you test with both commercial solution and shop bought tahini – if never eaten/reacted, they recommend avoiding, especially if eczema and/or other food allergies.

Self-harm

General paediatrics, Mental health

Issues around confidentiality, competence and safe guarding important here.

Involvement of family members and other carers can be really useful, if the young person agrees. Should be collaborative, of course, giving them opportunities to contribute to planning. But not just about minimising self harm behaviour – empowering and supporting (during acute distress and also in recovery) vital too.

Assessment

  • “How is your mood?”
  • “Sometimes people who feel down can start to feel hopeless about the future. Has this happened to you?”
  • “Have you ever had any thoughts about life not being worth living?” [Hurting yourself different??]
  • “Have you thought about how you might do that? Have you done anything towards that plan?”
  • Risk is then on a spectrum – engaging with treatment? Loss of protective factors eg family support?
  • Discuss removing the method of self harm – with therapeutic collaboration or negotiation, to keep the person safe
  • Discuss current support network, any safety plan (see below) or coping strategies
  • Problem solve around dynamic risk factors

Refer

 Refer to mental health professionals urgently where:

  • the person’s levels of concern or distress are rising, high or sustained
  • the frequency or degree of self-harm or suicidal intent is increasing
  • the person asks for further support from mental health services
  • levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help.

Treatment

Work collaboratively with the person, using a strengths-based approach to identify solutions to reduce their distress that leads to self-harm.

Consider developing a safety plan:

  • recognise the triggers and warning signs
  • individualised coping strategies, including problem solving any barriers to those strategies
  • social contacts and settings that can distract from suicidal thoughts or escalating crisis
  • family members or friends to provide support and/or help resolve the crisis
  • contact details for the mental health service, including out-of-hours services and emergency contact details
  • keep the environment safe by working collaboratively to remove or restrict lethal means of suicide.

Underlying depression, anxiety, learning disabilities, autism, eating disorders should all be addressed.

For children and young people with significant emotional dysregulation difficulties who have frequent episodes of self-harm, consider dialectical behaviour therapy adapted for adolescents (DBT-A).

[NICE guidance NG225][BMJ 2017]

Alcohol and drug dependency

General paediatrics, Mental health

Early adolescence appears to be a critical time for determining the long term direction of biopsychosocial development. US studies found that those who reported their first alcoholic drink before age 14 (or drug use before age 15) were 3x more likely to develop dependence.

Regular use of cannabis before age 15 seems linked to subsequent psychosis, and risk appears to be 5x higher in daily users of high strength cannabis. But longitudinal study did not find a link after controlling for confounders. Risk probably highest where genetic or other vulnerability.

Large studies in Australia and New Zealand found frequent cannabis use predicts poor educational outcomes – some evidence for poorer memory performance (for days or even weeks after use), which might explain it (controlled for socioeconomic factors).

Inconsistent moderate associations with suicide and attempted suicide.

[National institute on drug abuse 2020]

Screening

CRAFFT –

  • Have you ever ridden in a Car driven by yourself or someone else who was high or who had been using alcohol/drugs?
  • Do you ever use alcohol/drugs to Relax, feel better about yourself or fit in?
  • Do you ever use alcohol/drugs when you are Alone?
  • Do you ever Forget things you did while using alcohol/drugs?
  • Do your family/friends ever tell you that you should cut down?
  • Have you been in Trouble while using alcohol/drugs?

2 or more yes answers “suggests an important problem”.

Intervention

Brief motivational intervention almost halved frequency of alcohol bingeing among 13-17yr olds presenting to an Emergency department. But rate also reduced in control groups.

A “confiding” parent-child relationship is linked to lower substance abuse rates. Parental knowledge of the child’s whereabouts is protective, although also likely to be proxy for confiding relationship.

Sympathetic, informed, supportive counselling as good as CBT for adolescent depression and adult alcoholism. Flexibility of services is important.

FRAMES –

  • Feedback – personalised, about risk/harm
  • Responsibility – emphasis personal responsibility for change
  • Advice – give clear advice to change habits
  • Menu – offer menu of strategies
  • Empathic – and non judgmental
  • Self efficacy – aim to increase patient’s confidence to change behaviour

Medical Humanities

Communication, Ethics, Generic, Patients

In education, Johanna Shapiro has done interesting work, for example including relevant poems into objective structured clinical examinations (Female, by Ingrid Hughes, about a woman facing a probable diagnosis of breast cancer; Dear Left Knee by John Davis; Back Pain, by Ingrid Hughes; Night on Call, by Dr Rita Iovino). A large proportion said they felt it increased empathy, and had a significant effect on how they might present bad news, on the ultimate treatment plan. Most felt the Night on call poem helped gain perspective. [Medical Education 2005]

In the same paper, adding some readings led students to say (in 1/3 to 2/3 of cases) that they would be more likely to take into consideration psychosocial insights, or that it increased some dimension of empathy for the patient, including helping them take the patient more seriously.

Themes written by doctors or medical students are commonly about the rewards and stresses, relationships, role models, death, the meaning of life – things not directly addressed in the curriculum.

The quality is less important that the utility to a particular audience.

[BMJ 2010]

Long COVID

General paediatrics, Infectious disease, Mental health, OPD, Psychology

Doesn’t seem to be associated with severity of initial illness.

Long COVID is less common if you are vaccinated already. In a community based study of adults aged 18 to 69 years infected with SARS-CoV-2 before vaccination against covid-19, the odds of experiencing long covid symptoms decreased by an average of 13% after a first covid-19 vaccine dose, with a further 9% decrease in the odds of long covid after a second dose. [https://doi.org/10.1136/bmj-2021-069676] 

If you already have long COVID, further COVID immunisations seem to be beneficial, rather than harmful:

  • In a non-controlled study of 900 social media users with long COVID, more than half experienced an improvement in symptoms after vaccination compared with 7% who reported a deterioration.19
  • A study of 44 vaccinated patients and 22 unvaccinated controls previously admitted to hospital with covid-19 in the UK, which inevitably had limited power to detect clinically relevant effects, found no evidence for vaccination being associated with worsening of long covid symptoms or quality of life.20
  • A French study of 455 self-selected participants found reduced long COVID symptom burden and double the rate of remission at 120 days in vaccinated participants compared with unvaccinated controls.

All about symptoms, excluding treatable conditions, then self management. For adults:

https://www.yourcovidrecovery.nhs.uk/

Threadworms

Common, General paediatrics, Infectious disease, OPD

=enterobius. Common in young children, probably due to hygiene issues. Also called pinworms. Small (1-2cm), like white threads. Can be intensely itchy, usually in night when worms emerge to lay eggs.

Mebendazole effective at killing live worms in gut, not effective if eggs in vagina. Licensed from age 2 but can be used off license below that. Does not kill eggs however, and main issue is reinfection so consider treating whole family, with repeat doses after 2 weeks when any eggs will have hatched. NHS Inform advice on hygiene:

  • Lifespan of threadworms is approximately 6 weeks, so follow hygiene measures for at least this length of time.
  • Everyone in the household must follow the advice outlined below.
  • Wash all night clothes, bed linen, towels and soft toys (normal temperatures OK but make sure the washing is well rinsed [presumably at start of treatment; dilution more important than soap?]
  • Vacuum and dust the whole house esp bedrooms – repeat regularly
  • Clean bathroom and kitchen surfaces – again, rinse cloth frequently – repeat regularly
  • Avoid shaking out clothes/bedding that may be contaminated with eggs, to prevent eggs being transferred to other surfaces
  • Don’t eat food in the bedroom
  • Keep fingernails short
  • Discourage nail-biting and sucking fingers/thumbs
  • Wash hands frequently and scrub under your fingernails esp before eating, after going to the toilet, and before and after changing your baby’s nappy
  • wear close-fitting underwear at night and change your underwear every morning
  • bathe or shower regularly – it’s particularly important to bathe or shower first thing in the morning: make sure you clean around your anus and vagina to remove any eggs
  • don’t share towels
  • keep toothbrushes in a closed cupboard and rinse them thoroughly before use!

Eggs probably become unviable after a few days if not in warm and moist environment… Children may of course pick up another threadworm infection from school/nursery…

Sometimes you just have to keep repeating treatment over months/years! Mebendazole is harmless (v little systemic absorption), although symptoms may be caused by clearance of large worm burdens.

Pseudomonas

General paediatrics, Infectious disease

Typically P. aeruginosa. A biofilm producing gram negative bacterium important in multiresistant infections, particularly in the immunocompromised and in cystic fibrosis.

Pretty ubiquitous in the environment, especially in lakes and rivers. Often found in vases of cut flowers, and in spa/whirlpool baths, where it is associated with folliculitis.

The ability to make biofilms makes infection difficult to treat, as the biofilm prevents penetration by antibiotics. The biofilm allows the bugs to survive in low nutrient environments.

Antibiotic resistance is a major issue, with specific anti-pseudomonal antibiotics often required viz tobramycin, ceftazidine.

Ingesting pseudomonas doesn’t pose much of a hazard, unless you are on antibiotics already and have a disturbed intestinal flora. Aerosolizing pseudomonas on the other hand can be lethal to mice.

[DOI: 10.1007/978-1-4419-0032-6_3]