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]

Chest pain

Cardiology, Clinical

Common in children esp teenagers, often at rest, sharp but brief. Extremely rare to find a cause…

Differential:

  • Oesophagitis
  • Asthma
  • Pulmonary embolism
  • Tachyarrhythmia – but you would expect palpitations and colour change, “on/off”
  • Precordial catch syndrome
  • Costochondritis (Tietze syndrome)
  • Catecholamine secreting tumours??
  • Cardiomyopathy? Ischaemic cardiomyopathy eg anomalous origin of left coronary artery (from pulmonary artery) – but in kids, either too young to describe pain (infants) or else too mild to present with angina (instead present with failure).  Arrhythmogenic ventricular cardiomyopathy (usually right, but biventricular involvement recognised) can present with pain but usually syncopal episodes.  [Circulation. 2019;140:e9–e68]
  • Fabry’s as cause of bizarre pain (heart involvement but pain usually GI). 
  • Aortic root problem – as seen in Marfan’s and other connective tissue problems.

So red flags would be syncope, colour change, sudden dizziness/confusion, sweating/clamminess suggesting cardiovascular compromise.

Assuming normal physical examination, and no family history of inherited cardiac problems (or sudden death), if not exertional then can be reassured. Pain killers not usually helpful as pain settles so quickly.

If exertional then needs ECG. Unlikely to be significant cardiac problem if normal.

Exercise tests are good for WPW, to see if delta waves disappear (so low risk of SVT). The only other diagnosis you might get is of Catecholaminergic Polymorphic Ventricular Tachycardia (life threatening, rarely survivable in the community unless defib available, not just chest pain).

24hr tapes are notoriously low sensitivity, unless events frequent. Useful for children with known structural disease, esp postop when more prone to arrhythmias. 

Other event monitors are better for possible SVT eg Alivecor (£99).

Advising parents on how to count a pulse is much better – “less than 30 beats in 10 seconds normal” (ie up to 180).

[Archives 2014] [Keir]

Rett Syndrome

General paediatrics, Genetics, Neurology

Exclusively females (lethal in males? Or rate of germ cell mutations higher in male germ cells?).  Virtually always sporadic – so not exactly X linked dominant.

MECP2 gene on X chromosome.

Developmental arrest at 6-18 months, then regression, loss of speech, stereotypies esp hands.

Often epilepsy, then complications of severe neurodisability eg chronic lung issues.

Not degenerative however – can live into middle life.

Chronic pain

General paediatrics, OPD, Psychology

Gate theory useful – it’s not just about the stimulus coming to your nerve endings. That signal has to pass through a gate, to register in your brain, and different things affect whether the gate is more or less open or closed.

A feature of many chronic health conditions, eg juvenile idiopathic arthritis, migraine. Often a feature of chronic fatigue syndrome. Can be part of a functional disorder such as functional abdominal pain. In a limb, can lead to reflex sympathetic dystrophy. But often unexplained.

Think about PTSD – it’s all “in your head” but that doesn’t mean it’s nothing. Or phantom limb pain – there isn’t even a true signal coming from the limb, but you still feel pain.

Pain is performative – no one gets credit for trying to cope and hide it. But you can be accuse of “laying it on thick”.

Having a diagnosis helps socially. 

Pain can make you a different person from who you were. Impatience and irritability can be understood, besides an inability to do some activities that might be important to identity (and to relieving stress). Social isolation is common.

Chronic pain also steals any sense of your future because it is too intolerable to imagine more pain. 

Fear needs to be detached from pain. 

Acceptance therapy – not to accept eternity of pain but to focus on progress and function. 

[Haider Warraich podcast with Kate Bowler]

The Farm effect in allergy

Allergy, Gastro, General paediatrics, Nutrition

Children growing up on farms are less likely to develop allergies and asthma. Farming has been part of human culture for probably 7000 years.

It is widely accepted now that a symbiotic relationship with a diverse population of microbes in the environment, on the skin, in the gut and in the lung is necessary for a healthy immune system (“microbiome“). These microbes influence the balance between inflammation and immune tolerance. That relationship needs to be developed in early life, and nutrition is a major part.

Big European cross sectional studies – PARSIFAL and GABRIEL. Amish and Hutterites in US are genetically similar but Hutterites use industrial rather than traditional farming techniques (and have 4-6x the rate of hay fever and atopic sensitization).

Prenatal maternal exposure to farm animals is protective against eczema in the first 2 years of life, and against asthma symptoms pre-school.

Farm milk consumption in the first year of life is protective against respiratory allergies. Not clear what it is about it – more whey? Higher levels of cytokines or polyunsaturated fatty acids?

In children, exposure to cows and hay was protective against asthma. Some evidence for pigs, but risk seems to go up for sheep.

Mediators thought to potentially be N-gylcolylneuraminic acid (animals/pets) and arabinogalactan (plants).

Lipopolysaccharide (endotoxin) is widespread in the farm environment. Levels in mattresses inversely associated with hay fever, atopic sensitisation and asthma.

Lack of gut microbial diversity in first month of life predicts school age asthma.

Dietary diversity in first 2 years of life protects against asthma and allergic rhinitis. The link between gut microbes and lung health is thought to be short chain fatty acids, such as acetate and butyrate.

[Ped Allergy and Imm 2022]

In a study of 589 children, 1-year microbiota maturation (based on metagenomics – genetic material of a community of micro-organisms – and metabolomics – metabolites in environment) closely related to eczema, asthma, food allergy and allergic rhinitis at age 5 years. Found a core set of “functional and metabolic imbalances” characterized by compromised mucous integrity, elevated oxidative activity, decreased secondary fermentation, and elevated trace amines. [Hoskinson, BC, Canada – Nature communications . 14(1):4785, 2023 08 29.]