Factores en Dermatitis atopica.

Journal Scan / Research · November 27, 2018

Factors Associated With Persistent Atopic Dermatitis in Childhood

Importance

Knowledge about factors associated with persistence of atopic dermatitis (AD) during childhood is sparse.

Objective

To explore heritable, environmental, and clinical factors associated with persistent AD based on 13 years' follow-up of an at-risk birth cohort.

Design, Setting, and Participants

In the Copenhagen Prospective Study on Asthma in Childhood 2000 (COPSAC2000) clinical birth cohort study, 411 children born to mothers with asthma were followed up until the age of 13 years at a clinical research unit in Copenhagen, Denmark, from August 1998 to June 2015. Atopic dermatitis was diagnosed prospectively during close clinical follow-up according to the criteria of Hanifin and Rajka. Data were gathered on parental history, social circumstances, and environmental factors through parent interviews. The cohort was followed up with biannual visits to the clinic until the age of 7 years and were seen again at age 13 years. Data were analyzed from August 2015 to January 2018.

Main Outcomes and Measures

Atopic dermatitis was diagnosed using Hanifin and Rajka major and minor criteria, and severity was determined by Scoring Atopic Dermatitis (SCORAD) index, with possible scores from 0 to 83, with higher scores indicating more severe AD.

Results

Of the 411 children in the cohort, 203 (49.4%) were male and 186 (45.3%) were diagnosed with AD before the age of 13 years; 40 of 166 children (24.1%) had persistent AD at the age of 13 years, and 126 (76.0%) experienced remission. Factors associated with persistent AD to age 13 years included heritability, environmental exposures, asthma and allergic sensitization, clinical presentation at the time of diagnosis, the composition of Hanifin and Rajka diagnostic minor criteria, and AD severity according to SCORAD. A higher AD genetic risk score was associated with an increased the risk for persistent AD (multivariable odds ratio [OR], 1.8; 95% CI, 1.1-2.9; P = .02), together with paternal asthma (multivariable OR, 3.7; 95% CI, 1.2-11.5; P = .02); paternal AD (multivariable OR, 6.2; 95% CI, 1.17-23.2; P = .007), and higher social circumstances (multivariable OR, 1.6; 95% CI, 1.0-2.5; P = .05). Particular clinical presentations at time of diagnosis were also associated with specific minor criteria of Hanifin and Rajka (Dennie-Morgan and anterior neck folds, white dermographism, intolerance to wool, itching when sweating, tendency to skin infection, food intolerance, and food allergy) (OR, 2.6; 95% CI, 1.1-6.2; P = .03) as well as increased severity at diagnosis (OR, 1.1; 95% CI, 1.0-1.1; P = .007).

Conclusions and Relevance

In a birth cohort of children at risk for asthma who received close clinical follow-up to age 13 years, known genetic AD risk variants, paternal asthma and AD, high social circumstances, diagnostic minor criteria, and disease severity at onset were associated with persistent AD at age 13 years. These findings may be applied in clinical practice to evaluate the likely disease course for individual patients.

TAKE-HOME MESSAGE

• This prospective cohort study explored heritable, environmental, and clinical factors associated with persistent AD based on a follow-up of 13 years in an at-risk birth cohort. The study results indicated that 24.1% children diagnosed with AD during childhood had persistent disease at the age of 13 years. Paternal asthma, paternal AD, and filaggrin mutation were associated with increased risk for persistent AD in children. An AD genetic risk score representing the impact of various genetic factors was the strongest nonclinical risk factor for persistent AD at 13 years of age. Environmental exposures largely were not significantly associated with persistent AD, except for a higher level of social circumstances score at 2 years of age. 

• These findings suggest that genetic risk assessment combined with AD clinical characteristics and disease severity at diagnosis may be useful tools in clinical practice to estimate the disease course. 

– Caroline K. Crabtree, MD

JAMA Dermatology

Genetic, Clinical, and Environmental Factors Associated With Persistent Atopic Dermatitis in Childhood

JAMA Dermatol 2018 Nov 14;[EPub Ahead of Print], S Thorsteinsdottir, J Stokholm, JP Thyssen, S Nørgaard, J Thorsen, BL Chawes, K Bønnelykke, J Waage, H Bisgaard

Filtros solares y el ambiente... que no usar.

Journal Scan / Review · November 27, 2018

Impact of Oxybenzone and Other Sunscreen Active Ingredients on the Environment

TAKE-HOME MESSAGE

• Organic UV filters including oxybenzone (benzophenone-3), octocrylene, octinoxate (ethylhexyl methoxycinnamate), and ethylhexyl salicylate have been identified in water sources and in aquatic animals worldwide. These filters are not easily removed by common waste water treatment plant techniques. Oxybenzone has specifically been implicated in coral reef bleaching, which prompted the Hawaiian state legislature to pass a bill banning certain sunscreens.

• The impact of sunscreens on the environment should not detract healthcare providers from promoting photoprotective efforts, including seeking shade, wearing photoprotective clothing, and wearing physical sunscreens with inorganic filters (titanium dioxide and zinc oxide). This will help in protecting the skin from the deleterious effects of sunlight while protecting the environment.

– InYoung Kim, MD, PhD

With increasing awareness regarding the risks of sunburn, photoaging and skin cancer, the use of sunscreens has increased. Organic and inorganic filters are used in sunscreen products worldwide. Concerns have been raised on commonly used organic UV filters including oxybenzone (benzophenone-3; BP-3), 4-methylbenzylidene camphor (4-MBC), octocrylene (OC), and octinoxate (ethylhexyl methoxycinnamate; EHMC) on their effects on the environment. Studies have identified UV filters such as oxybenzone, octocrylene, octinoxate and ethylhexyl salicylate (ES) in almost all water sources around the world and have commented that these filters are not easily removed by common waste water treatment plant techniques. Additionally, in laboratory settings, oxybenzone has specifically been implicated as a possible contributor to coral reef bleaching. Furthermore, UV filters such as 4-methylbenzylidene camphor, oxybenzone, octocrylene and octinoxate have been identified in various species of fish worldwide, which has possible consequences for the food chain. As dermatologists, it is important for us to continue to emphasize the public health impact of excessive sun exposure, and to advise our patients about proper photoprotection practice, which consists of seeking shade, wearing photoprotective clothing including hats and sunglasses, and application of appropriate sunscreens.

Journal of the American Academy of Dermatology

Review of Environmental Effects of Oxybenzone and Other Sunscreen Active Ingredients

J Am Acad Dermatol 2018 Nov 14;[EPub Ahead of Print], SL Schneider, HW Lim

• SUMMARY AND COMMENT | 
 
• GENERAL MEDICINE
 
• HOSPITAL MEDICINE

INFORMING PRACTICE

November 27, 2018

Lidocaine, Dripped on the Skin, Attenuates Procedural Pain

Patricia Kritek, MD reviewing Patel BK et al. Chest 2018 Oct 

Bedside procedures were less painful when lidocaine was dripped on the skin before subcutaneous lidocaine injections.

We commonly use lidocaine to numb the skin and soft tissue prior to performing bedside procedures, but its administration causes an uncomfortable burning sensation. Previous research has shown that nerve fibers transmit pain sensation more slowly when they are "occupied" with other stimuli, such as vibration or cold. With the hypothesis that a cool, wet stimulus on the skin would attenuate pain associated with lidocaine injections and the bedside procedures that followed, investigators randomized 481 patients at a single center in Chicago to receive preprocedural subcutaneous injection of 1% lidocaine alone or to receive1 to 2 mL of 1% lidocaine dripped on the skin prior to subcutaneous injection of 1% lidocaine. Most of the procedures were peripherally inserted central catheter (PICC) placements, paracenteses, thoracenteses, lumbar punctures, or central line placements.

PICC patients who received dripped lidocaine prior to injections reported significantly less procedural pain on a visual analog scale (VAS) than did usual-care patients. Differences were not significant for other procedures.

COMMENT

We often minimize the discomfort of lidocaine injections with phrases like "just a little bee sting," but patients often find this to be the worst part of their procedures. Although the difference in scores on the VAS was less than what is thought to be clinically significant, I am intrigued. If these results could be replicated in other proceduralists' hands, incorporating this low-cost, low-risk step to improve patient comfort would make sense.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for Patricia Kritek, MD at time of publication

Speaker's Bureau	American College of Chest Physicians (Critical Care Board Review Course)
Editorial boards	American Journal of Respiratory and Critical Care Medicine
Leadership positions in professional societies	American Thoracic Society (Chair of the Nominating Committee, Section on Medical Education)

CITATION(S):

Patel BK et al. Comparison of two lidocaine administration techniques on perceived pain from bedside procedures: A randomized clinical trial. Chest 2018 Oct; 154:773. (https://doi.org/10.1016/j.chest.2018.04.018)

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Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 2224-0654
Momentum Escazu: 2101-9574

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Trombosis guías

New Guidelines Issued on Venous Thromboembolism

By Amy Orciari Herman

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

The American Society of Hematology has issued guidelines on preventing, diagnosing, and managing venous thromboembolism (VTE).

Here are some of the highlights from the 200-plus recommendations:

• For hospitalized patients with high VTE risk and an acceptable bleeding risk, anticoagulants are preferred over mechanical prophylaxis. For those at high bleeding risk, mechanical prophylaxis is preferred.
• Most patients who need to stop warfarin to undergo an invasive procedure do not need bridge therapy.
• Many patients who experience major bleeding during anticoagulant therapy should resume anticoagulation after recovery.
• For superficial thrombosis during pregnancy, low-molecular-weight heparin is likely the best option in most cases.

American Society of Hematology guidelines (Free)

Background: NEJM Journal Watch General Medicine coverage of direct oral anticoagulant use to treat VTE in patients with cancer (Your NEJM Journal Watch subscription required)

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 2224-0654
Momentum Escazu: 2101-9574

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Gastroenteritis y probioticos 2

Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis

• Stephen B. Freedman, M.D.C.M.,
• Sarah Williamson-Urquhart, B.Sc.Kin.,
• Ken J. Farion, M.D.,
• Serge Gouin, M.D.C.M.,
• Andrew R. Willan, Ph.D.,
• Naveen Poonai, M.D.,
• Katrina Hurley, M.D.,
• Philip M. Sherman, M.D.,
• Yaron Finkelstein, M.D.,
• Bonita E. Lee, M.D.,
• Xiao-Li Pang, Ph.D.,
• Linda Chui, Ph.D.,
• David Schnadower, M.D., M.P.H.,
• Jianling Xie, M.D., M.P.H.,
• Marc Gorelick, M.D.,
• and Suzanne Schuh, M.D.
• 
  

• for the PERC PROGUT Trial Group^*

• Article
• Figures/Media

Metrics

• 54 References
• 1 Citing Article

Abstract

Background

Gastroenteritis accounts for approximately 1.7 million visits to the emergency department (ED) by children in the United States every year. Data to determine whether the use of probiotics improves outcomes in these children are lacking.

Methods

We conducted a randomized, double-blind trial involving 886 children 3 to 48 months of age with gastroenteritis who presented to six pediatric EDs in Canada. Participants received a 5-day course of a combination probiotic product containing Lactobacillus rhamnosus R0011 and L. helveticus R0052, at a dose of 4.0×10⁹ colony-forming units twice daily or placebo. The primary outcome was moderate-to-severe gastroenteritis, which was defined according to a post-enrollment modified Vesikari scale symptom score of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease). Secondary outcomes included the duration of diarrhea and vomiting, the percentage of children who had unscheduled physician visits, and the presence or absence of adverse events.

Results

Moderate-to-severe gastroenteritis within 14 days after enrollment occurred in 108 of 414 participants (26.1%) who were assigned to probiotics and 102 of 413 participants (24.7%) who were assigned to placebo (odds ratio, 1.06; 95% confidence interval [CI], 0.77 to 1.46; P=0.72). After adjustment for trial site, age, detection of rotavirus in stool, and frequency of diarrhea and vomiting before enrollment, trial-group assignment did not predict moderate-to-severe gastroenteritis (odds ratio, 1.06; 95% CI, 0.76 to 1.49; P=0.74). There were no significant differences between the probiotic group and the placebo group in the median duration of diarrhea (52.5 hours [interquartile range, 18.3 to 95.8] and 55.5 hours [interquartile range, 20.2 to 102.3], respectively; P=0.31) or vomiting (17.7 hours [interquartile range, 0 to 58.6] and 18.7 hours [interquartile range, 0 to 51.6], P=0.18), the percentages of participants with unscheduled visits to a health care provider (30.2% and 26.6%; odds ratio, 1.19; 95% CI, 0.87 to 1.62; P=0.27), and the percentage of participants who reported an adverse event (34.8% and 38.7%; odds ratio, 0.83; 95% CI, 0.62 to 1.11; P=0.21).

Conclusions

In children who presented to the emergency department with gastroenteritis, twice-daily administration of a combined L. rhamnosus–L. helveticus probiotic did not prevent the development of moderate-to-severe gastroenteritis within 14 days after enrollment. (Funded by the Canadian Institutes of Health Research and others; PROGUT ClinicalTrials.gov number, NCT01853124.)

Libre de virus. www.avast.com

Gastroenteritis en Niños

Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children

• David Schnadower, M.D., M.P.H.,
• Phillip I. Tarr, M.D.,
• T. Charles Casper, Ph.D.,
• Marc H. Gorelick, M.D., M.S.C.E.,
• J. Michael Dean, M.D.,
• Karen J. O'Connell, M.D.,
• Prashant Mahajan, M.D., M.P.H.,
• Adam C. Levine, M.D., M.P.H.,
• Seema R. Bhatt, M.D.,
• Cindy G. Roskind, M.D.,
• Elizabeth C. Powell, M.D.,
• Alexander J. Rogers, M.D.,
• Cheryl Vance, M.D.,
• Robert E. Sapien, M.D.,
• Cody S. Olsen, M.S.,
• Melissa Metheney, B.S., R.N.,
• Viani P. Dickey, A.B.,
• Carla Hall-Moore, B.S.,
• and Stephen B. Freedman, M.D.C.M.
• 
  

• Article
• Figures/Media

Metrics

• 46 References
• 1 Citing Article

Abstract

Background

Acute gastroenteritis develops in millions of children in the United States every year, and treatment with probiotics is common. However, data to support the use of probiotics in this population are limited.

Methods

We conducted a prospective, randomized, double-blind trial involving children 3 months to 4 years of age with acute gastroenteritis who presented to one of 10 U.S. pediatric emergency departments. Participants received a 5-day course of Lactobacillus rhamnosus GG at a dose of 1×10¹⁰ colony-forming units twice daily or matching placebo. Follow-up surveys were conducted daily for 5 days and again 14 days after enrollment and 1 month after enrollment. The primary outcome was moderate-to-severe gastroenteritis, which was defined as an illness episode with a total score on the modified Vesikari scale of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease), within 14 days after enrollment. Secondary outcomes included the duration and frequency of diarrhea and vomiting, the duration of day-care absenteeism, and the rate of household transmission (defined as the development of symptoms of gastroenteritis in previously asymptomatic household contacts).

Results

Among the 971 participants, 943 (97.1%) completed the trial. The median age was 1.4 years (interquartile range, 0.9 to 2.3), and 513 participants (52.9%) were male. The modified Vesikari scale score for the 14-day period after enrollment was 9 or higher in 55 of 468 participants (11.8%) in the L. rhamnosus GG group and in 60 of 475 participants (12.6%) in the placebo group (relative risk, 0.96; 95% confidence interval, 0.68 to 1.35; P=0.83). There were no significant differences between the L. rhamnosus GG group and the placebo group in the duration of diarrhea (median, 49.7 hours in the L. rhamnosus GG group and 50.9 hours in the placebo group; P=0.26), duration of vomiting (median, 0 hours in both groups; P=0.17), or day-care absenteeism (median, 2 days in both groups; P=0.67) or in the rate of household transmission (10.6% and 14.1% in the two groups, respectively; P=0.16).

Conclusions

Among preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT01773967.)

Libre de virus. www.avast.com

Actividad fisica

HHS Releases New Physical Activity Guidelines

By Amy Orciari Herman

Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD

The Department of Health and Human Services (HHS) released updated guidelines on physical activity at the American Heart Association conference on Monday. Here are the main recommendations, published in JAMA:

• Children aged 3 through 5 years should be physically active throughout the day.
• Children aged 6 through 17 should engage in moderate-to-vigorous activity for at least one hour each day. This should be mostly aerobic activity, but bone- and muscle-strengthening should be included at least 3 days a week.
• Adults should get 150–300 minutes of moderate-intensity aerobic activity — or 75-150 minutes of vigorous-intensity aerobic activity — each week. They should also do muscle strength-training at least 2 days a week.
• Older adults should include balance training in their regimens.

The HHS previously said only 10-minute increments (or more) of activity counted. Now, the group says any increment counts.

Physical activity guidelines in JAMA (Free)

JAMA editorial (Free)

JAMA viewpoint (Free)

HHS news release (Free)

Background: Physician's First Watch coverage of activity and CV risk in those at high genetic risk (Free)

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 2224-0654
Momentum Escazu: 2101-9574

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