Houston Area Pediatric Specialists

Independent pediatric specialists aim to serve our community. We want to share news and analysis regarding our specialties and our practices.

Monday, March 31, 2014

Diuretic may treat autism, study in rodents suggests

While this is a rat model, it offers some biologic evidence for an earlier treatment trial in humans. Interestingly, there are many papers about using diuretics in seizures in infants. JR

Diuretic may treat autism, study in rodents suggests

Drug that affects brain chloride levels staves off symptoms in mice and rats
Curbing chloride in nerve cells could combat symptoms of autism, a study of rats and mice suggests. The results may explain why a small group of children with autism seemed to improve after taking the common diuretic bumetanide in an earlier study.
The new details of how bumetanide works, published in the Feb. 7 Science, provide important clues about how autism spectrum disorders arise in a developing brain, says Susan Connors, an autism specialist at Massachusetts General Hospital for Children in Boston ....
article here

Here is the abstract of the human study....

Transl Psychiatry. Dec 2012; 2(12): e202.

PMCID: PMC3565189
A randomised controlled trial of bumetanide in the treatment of autism in children
E Lemonnier,1,2,* C Degrez,1 M Phelep,1 R Tyzio,3 F Josse,1 M Grandgeorge,1,2 N Hadjikhani,4,5 and Y Ben-Ari3,*

Go to:
Gamma aminobutyric acid (GABA)-mediated synapses and the oscillations they orchestrate are altered in autism. GABA-acting benzodiazepines exert in some patients with autism paradoxical effects, raising the possibility that like in epilepsies, GABA excites neurons because of elevated intracellular concentrations of chloride. Following a successful pilot study,1 we have now performed a double-blind clinical trial using the diuretic, chloride-importer antagonist bumetanide that reduces intracellular chloride reinforcing GABAergic inhibition. Sixty children with autism or Asperger syndrome (3–11 years old) received for 3 months placebo or bumetanide (1 mg daily), followed by 1-month wash out. Determination of the severity of autism was made with video films at day 0 (D0) and D90 by blind, independent evaluators. Bumetanide reduced significantly the Childhood Autism Rating Scale (CARS) (D90−D0; P<0 .004="" a="" above="" accuracy="" activation="" adjikhani="" agent="" al.="" an="" and="" are="" areas="" autism.="" autism="" best="" better="" brain="" bumetanide="" cases="" chronic="" clinical="" companion="" determine="" diagnostic="" effects="" emotional="" et="" facial="" for="" global="" hypokalaemia="" ilcoxon="" impressions="" improved="" in="" increased="" involved="" is="" k="" l="" labelling="" larger="" mean="" mild="" mm="" most="" n="9)" novel="" observation="" occasional="" p-value="0.017)." p="" perception="" placebo="" population="" potassium.="" promising="" removed="" restricted="" s.d.="" s="" schedule="" severe="" side="" significantly="" social="" student="" study="" submitted="" suited="" supplemental="" t-test:="" test:="" that="" the="" therapeutic="" therefore="" this="" to="" treat="" treated="" treatment.="" treatment="" trials="" values="" vs="" warranted="" was="" were="" when="" with="">
Keywords: autism, bumetanide, clinical trial, diuretics, GABA

Sugar doesn’t make kids hyper, and other parenting myths

Sugar, shoes, sleep, baby Mozart....parenting is hard enough without added "wisdom". Our oldest has come to understand that we have a
learning curve. JR

Baby shoes didn’t feature prominently into Baby V’s wardrobe for quite some time. Tiny Chuck Taylors are adorable, obviously, but I questioned their utility for a baby who didn’t use her feet except as wiggly pacifiers. So Baby V spent a lot of time barefoot — a fashion statement that I didn’t really consider until she started toddling around in public. 

Well-meaning observers were quick to tell me that I needed to get that baby some nice stiff shoes. Hard soles will help her get the hang of walking and protect her delicate baby feet, I was told. But when I started looking into this advice, I actually found the opposite is true: These days, people recommend that babies learning to walk wear soft, flexible shoes, or better yet, go barefoot. The minimalist footwear allows the nascent walkers the most sensory feedback from their sweet little feet as they move across the earth.

I offer the shoe advice as just one tiny glimpse into the life of a parent of a young kid. Over the last year, I’ve come to learn that much of the advice I’ve heard, while well-intentioned, might just be wrong. Or at the very least, questionable. So here are my top five parenting myths (shoes didn’t make the cut), with a little dash of science.

1. Sugar makes kids hyper.

Lots of parents swear that a single hit of birthday cake holds the power to morph their well-behaved, polite youngster into a sticky hot mess that careens around a room while emitting eardrum-piercing shrieks. Anyone who has had the pleasure to attend a 5-year-old’s birthday party knows that the hypothesis sounds reasonable, except that science has found that it’s not true.
Sugar doesn’t change kids’ behavior, a double-blind research study found way back in 1994. A sugary diet didn’t affect behavior or cognitive skills, the researchers report. Sugar does change one important thing, though: parents’ expectations. After hearing that their children had just consumed a big sugar fix, parents were more likely to say their child was hyperactive, even when the big sugar fix was a placebo, another study found.
Of course, there are plenty of good reasons not to feed your kids a bunch of sugar, but fear of a little crazed sugar monster isn’t one of them.

2. Listening to Mozart makes babies smarter.

My colleague Rachel Ehrenberg busted this “Mozart Effect” myth in her 2010 feature. The original observation, that 10 minutes of classical music made college students briefly perform better on a paper-folding task, was twisted so out of context that the governor of Georgia used tax money to buy a classical music CD for every baby born in the state.
Many babies adore music, and there’s evidence that suggests music might help soothe babies. There’s also evidence that playing an instrument might be beneficial to brain development, as Ehrenberg points out. But scientists haven’t found that classical music makes your baby smarter. So play music to your child because she loves it and you love it, not because you’re looking to grub a few extra IQ points.

3. Feeding a baby solid food will help her sleep through the night.

Your baby is waking up in the night? Just put some rice cereal in the last bottle before bed, well-intentioned observers urge. The solid food will fill baby’s tummy and keep her satisfied longer, which translates to fewer wakeups. Except that it doesn’t.

Babies fed rice cereal before bedtime slept no better than babies fed only breast milk or formula, a study found. In fact, early introduction to solid food (before 4 months) has been associated with worse infant sleep.  The magical cure of feeding a baby solids before bedtime belongs at the top of the heaping pile of sleep miracles that sound great but don’t really work. And speaking of rice cereal…

Thursday, March 27, 2014

BIG NEWS! Autism begins in pregnancy, according to study: Cortical layers disrupted during brain development in autism

Autism begins in pregnancy, according to study: Cortical layers disrupted during brain development in autism

March 26, 2014
University of California, San Diego Health Sciences
Postmortem analysis of autistic brain tissue revealed patch-like areas of disorganized neurons. Arrows show a patch of decreased or absent expression of genetic markers across multiple layers of the dorsolateral prefrontal cortex.
Credit: Rich Stoner, Ph.D., University of California, San Diego
Researchers at the University of California, San Diego School of Medicine and the Allen Institute for Brain Science have published a study that gives clear and direct new evidence that autism begins during pregnancy.
The study will be published in the March 27 online edition of the New England Journal of Medicine.
The researchers -- Eric Courchesne, PhD, professor of neurosciences and director of the Autism Center of Excellence at UC San Diego, Ed S. Lein, PhD, of the Allen Institute for Brain Science in Seattle, and first author Rich Stoner, PhD, of the UC San Diego Autism Center of Excellence -- analyzed 25 genes in post-mortem brain tissue of children with and without autism. These included genes that serve as biomarkers for brain cell types in different layers of the cortex, genes implicated in autism and several control genes.
"Building a baby's brain during pregnancy involves creating a cortex that contains six layers," Courchesne said. "We discovered focal patches of disrupted development of these cortical layers in the majority of children with autism." Stoner created the first three-dimensional model visualizing brain locations where patches of cortex had failed to develop the normal cell-layering pattern.
"The most surprising finding was the similar early developmental pathology across nearly all of the autistic brains, especially given the diversity of symptoms in patients with autism, as well as the extremely complex genetics behind the disorder," explained Lein.
During early brain development, each cortical layer develops its own specific types of brain cells, each with specific patterns of brain connectivity that perform unique and important roles in processing information. As a brain cell develops into a specific type in a specific layer with specific connections, it acquires a distinct genetic signature or "marker" that can be observed.
The study found that in the brains of children with autism, key genetic markers were absent in brain cells in multiple layers. "This defect," Courchesne said, "indicates that the crucial early developmental step of creating six distinct layers with specific types of brain cells -- something that begins in prenatal life -- had been disrupted."

Tongue tied infant? Nursing? Randomized controlled trial of early frenotomy in breastfed infants.

Tongue tied? Nursing? Considering clipping procedure known as "frenotomy"?
Who is getting treatment? It appears that the babies all work out nursing. Early frenotomy results in a better "self-efficacy" and less bottle feeding in the first 5 days. "...over 80% of both groups were still feeding at the breast at 8 weeks."
Hmm. Tough one. JR

 2013 Nov 18. doi: 10.1136/archdischild-2013-305031. [Epub ahead of print]

Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie.


Trial design A randomised, parallel group, pragmatic trial.
Setting A large UK maternity hospital.
Participants Term infants <2 a="" and="" breastfeeding.="" degree="" difficulties="" having="" mild="" moderate="" mothers="" of="" old="" or="" p="" their="" tongue-tie="" weeks="" were="" who="" with="">
Objectives To determine if immediate frenotomy was better than standard breastfeeding support.
Interventions Participants were randomised to an early frenotomy intervention group or a ‘standard care’ comparison group.
Outcomes Primary outcome was breastfeeding at 5 days, with secondary outcomes of breastfeeding self-efficacy and pain on feeding. Final assessment was at 8 weeks; 20 also had qualitative interviews. Researchers assessing outcomes, but not participants, were blinded to group assignment.
Results 107 infants were randomised, 55 to the intervention group and 52 to the comparison group. 
Five-day outcome measures were available for 53 (96%) of the intervention group and 52 (100%) of the comparison group, and intention-to-treat analysis showed no difference in the primary outcome—Latch, Audible swallowing, nipple Type, Comfort, Hold score. 
Frenotomy did improve the tongue-tie and increased maternal breastfeeding self-efficacy. 
At 5 days, there was a 15.5% increase in bottle feeding in the comparison group compared with a 7.5% increase in the intervention group.
After the 5-day clinic, 44 of the comparison group had requested a frenotomy; 
by 8 weeks only 6 (12%) were breastfeeding without a frenotomy. 
At 8 weeks, there were no differences between groups in the breastfeeding measures or in the infant weight. No adverse events were observed.
Conclusions Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.

Infant Feeding, Neonatology, Nutrition

What is known on this topic

  • Tongue-tie (ankyloglossia) is a common congenital condition which can interfere with breastfeeding.
  • Tongue-tie release (frenotomy) is a well-tolerated procedure that can provide objective and subjective benefits in breast feeding.
  • Evidence from randomised trials supports early frenotomy in severe cases of tongue-tie, but debate continues about management of mild–moderate degrees of tongue-tie resulting in wide variations in clinical practice.

What this study adds

  • A randomised, parallel group, pragmatic trial comparing early frenotomy with usual care in mild–moderate tongue-tie showed that mothers could sustain breastfeeding of infants with tongue-tie for 5 days without a frenotomy.
  • Early frenotomy did not result in an objective improvement in breastfeeding at 5 days.
  • Early frenotomy did improve maternal breastfeeding self-efficacy and resulted in fewer mothers switching to bottle feeding before 5 days.

Wednesday, March 26, 2014

Preemies Aren't Little Term Babies

Disorders of feeding and swallowing, and the risk of aspiration are increased in premie infants.  This study highlights that a routine surgery performed for a common pediatric disorder known as as laryngomalacia (floppy airway) may significantly raise risk for aspiration more so than in term infants. Dr. Susarla

The effects of prematurity on incidence of aspiration following supraglottoplasty for laryngomalacia.



To determine if patients who were born premature have a higher incidence of aspiration following supraglottoplasty compared to patients born full term.


Retrospective study.


Two thousand three hundred sixty (2360) patient charts from Riley Hospital for Children were reviewed retrospectively. Patients had already been treated for laryngomalacia with supraglottoplasty by Dr. Bruce Matt. Estimated weeks gestational age at birth was recorded for each patient. Prematurity was stratified as mild (32-36 weeks gestational age [WGA]), very (28-31 WGA), or extremely (<28 WGA). Patients were excluded from the study if they had suspected aspiration with chronic cough, pneumonia, chronic lung disease, or documented aspiration prior to supraglottoplasty.


As previously shown, 75 patients (3.2%) had aspiration following supraglottoplasty. Twenty of these patients were preterm infants at birth. The rate for aspiration following supraglottoplasty for former premature infants was statistically significant (5.9%, odds ratio = 2.3, P = .0032).


Children who were born premature have a higher rate of postoperative aspiration following supraglottoplasty; however, supraglottoplasty should still be considered as treatment for laryngomalacia as the rate is still relatively low (5.9%).

Monday, March 24, 2014

White Noise Might Be Too Noisy

See below.  Not all "infant sleep machines" are safe for infant ears. Dr. Susarla

Caution urged for infant sleep machines

Infant sleep machines have become a popular aid for parents with a baby getting inadequate sleep because of a busy household, loud neighbors or other noise disturbances.
But a new study says parents should be cautious with the devices because they can generate sound levels that could place infants at risk of developing noise-induced hearing loss. In addition, they are often sold with limited or no instructions for safe use, says the study published online Monday by the journal Pediatrics.
The machines -- which can be used to mask environmental noises or provide ambient noise designed to soothe an infant during sleep -- "are capable of producing levels that may be damaging to babies' hearing," says Blake Papsin, otolaryngologist-in-chief at the Hospital for Sick Children in Toronto and senior author of the study.
Using a sound level meter, Papsin and colleagues tested the maximum noise levels of 65 sounds in 14 different infant sleep machines when placed at three distances: 30 centimeters (11.7 inches -- simulating placement on a crib rail): 100 centimeters (39 inches -- simulating placement on a table near a crib); and 200 centimeters (78 inches -- simulating placement across the room from a crib.) Calculations were added to account for the size and development of a 6-month-old's ear canal.
The sounds included white noise, nature sounds (rain, thunder, wind, ocean, river, campfire, insect and bird sounds), mechanical sounds (including traffic, train, airplane and machinery sounds) and heartbeat sounds.
When set to their maximum volume:
-- All 14 sleep machines exceeded 50 decibels at 30 cm and 100 cm, the current recommended noise limit for infants in hospital nurseries.
-- All but one machine exceeded that recommended noise limit even when placed across the room, 200 centimeters away.
--Three machines produced outputs greater than 85 decibels when placed 30 cm away. If played continuously, as recommended on several parenting websites, infants would be exposed to sound pressure levels that exceed the occupational noise limits for an 8-hour period endorsed by the National Institute for Occupational Safety and Health and the Canadian Centre for Occupational Health and Safety
Regular exposure to white noise through an infant sleep machine on a nightly basis is of particular concern, Papsin says, because an infant's brain needs the stimulation it receives from a range of sounds in order to develop properly. "Completely removing all informational content at a loud, potentially damaging level is the worst," he says.
Most of the devices studied featured a volume control, which suggests that safer use is possible and that the machines can be used in accordance with recommendations for hospital nursery noise, Papsin says.
With that in mind, the study says manufacturers should be required to limit maximum output levels; print warnings about noise-induced hearing loss on the machine's packaging; and include a mandatory timer on machines marketed primarily for infants that would make them automatically shut off after a predetermined period of time.
Families can more safely use the machines if they place them as far away as possible from the infant and never in the crib or on a crib rail; play the the devices at a low volume; and operate them for a short duration of time.
â??Parents "can feel desperate and want to try anything" when a baby has difficulty sleeping, says Nanci Yuan, pulmonologist and sleep medicine specialist at Lucile Packard Children's Hospital Stanford.
She was not involved in the study.
But this research highlights the potential for a previously "unknown harm that can occur," Yuan says. "We're getting more and more concerned about issues related to sound and noise and hearing-loss in children because it's progressive."
Given today's very industrial lifestyle, "there's a lot of noise around, so it's always good, especially with young children, to really know what types of exposures they're getting and the effects they can have long term," adds Linda Hazard, an audiologist certified by the American Speech-Language-Hearing Association â?? and director of the Vermont Early Hearing Detection and Intervention Program.
"It's important to recognize that the authors are not saying not to use (the machines)," says Hazard, who was not involved in the study. "They're saying use them judiciously and get information about how they're performing." The recommendation that manufacturers include instructions about how the devices should be used is equally important, she says.
The paper "intentionally" does not identify any specific brands, models or manufacturers, Papsin says, "because the point is to start the conversation that every one of these is capable of damage if used inappropriately."

Wednesday, March 19, 2014

Losing Sleep Could Kill Brain Cells

This study was conducted in mice, looking at markers that predict injury to neurons.  If the same phenomenon is present in humans, it might change our sleep habits.  Dr. Susarla 

Losing Sleep Could Kill Brain Cells

Late-shift workers, students and other night owls take note –  a new sleep study from researchers at the University of Pennsylvania has shown for the first time that extended periods of sleeplessness can lead to irreversible brain damage. 
While previous studies have shown cognitive performance declines after sleep loss, the latest research challenges the long-held notion that a "sleep debt" could be recovered by makeup rest. Researchers at UPenn and collaborators at Peking University have found extended periods of wakefulness actually kill some neurons and cause damage to others. 
Scientists knew there were certain neurons in the brain stem that are awake when we are awake and "sleep when we sleep," says Dr. Sigrid Veasey, a study author and professor at UPenn's Perelman School of Medicine. 
“This gave us an indication that maybe [the cells] needed their rest,” she says. “We hypothesized that the cells that were going to be the most likely to get injured would be some of the cells that are active during wakefulness.”
These particular neurons located in the brain stem are critical to attention, cognitive performance and also play a role in determining one’s mood.
“So if there’s an injury to these neurons, then you may have poor ability to pay attention and you might also have depression,” Veasey says.
Veasey and her colleagues used a mouse model to explore the impact of imposed wakefulness on mice’s brains. They separated mice into three groups. One group was allowed sleep as usual, another group was kept awake for three additional hours during their normal sleep period in a space outfitted with "play" items – wheels, toys and other mice. A third group of mice was kept awake in a similar environment during their normal sleep period for an additional eight hours, for three days.
Humans and other mammals share these same neural networks, so looking at wakefulness in mice is a good proxy for understanding the sleep habits of humans.  
“There’s every indication that they function the same way,” says Veasey.
After procuring brain tissue from the mice, researchers found an increase in the amount of a protein known as SirT3, that protects these "wake-active neurons" from damage among the mice who were kept from sleeping for shortened periods, but the mice who were kept awake for extended periods did not show any increase in this protective protein. Researchers also found a 25 to 30 percent loss of neurons and an increase in what’s known as oxidative stress in the extended wakefulness group of mice. This stress causes the proteins inside these neurons to fold on top of each other and can prevent them from communicating with other neurons. Some of the mice had a genetic deletion which stopped them from producing this key protein. Those mice also incurred damage to these sleep-sensitive neurons, even with only short-term sleep loss. 
“So really the cells that are remaining just don’t function well,” says Veasey.
The results of the study emphasize the critical importance of sleep, says Veasey. 
“You can push the system a little bit, but you can’t push it too hard and for too long or you’ll have irreversible consequences,” she says.
For students, academics and other professionals looking to gain an edge, Veasey says, “You’re at a time in your life when you really have to pull a couple of all-nighters to sustain that edge academically or professionally, but by cutting our sleep times short then do we end up losing that edge in the long term because we lose those neurons that are so critical for attention?”
Veasey says while she can't repeat this study in humans, there is certainly room for more research.
In addition, having learned the critical importance of this protective protein SirT3, researchers believe that it could provide avenues for new treatment.
"If we can show that we can protect the cells and wakefulness, then we're launched in the direction of a promising therapeutic target for millions of shift workers," said Veasey in a press release.
Future studies could use brain imaging techniques to look at people with sleeping disorders to help researchers better understand the damage that's incurred through sleep loss.
The study was first published Tuesday in the Journal of Neuroscience.

Friday, March 14, 2014

Preterm Birth May Raise Child's Asthma Risk, Study Suggests

Premie infants seem to have a higher risk for early childhood wheezing, which often follows a pattern consistent with asthma. Dr. Susarla

THURSDAY, March 13, 2014 (HealthDay News) -- A new study may add asthma to the list of downsides of being born too early.
Children who were born prematurely appear to be at higher risk for asthma and wheezing disorders, according to a new review.
Researchers led by Dr. Aziz Sheikh, of Brigham and Women's Hospital in Boston, looked at 30 studies focused on links between preterm birth -- defined as less than 37 weeks' gestation -- and asthma or wheezing disorders among more than 1.5 million children.
Their analysis found that preterm babies were 70 percent more likely than full-term infants to develop asthma or wheezing disorders later in childhood. Overall, close to 14 percent of "preemie" babies went on to develop asthma during childhood, compared to 8.3 percent of babies born at term.
The risk was even higher for very preterm babies, defined as children born at less than 32 weeks' gestation. These infants were about three times more likely than full-term babies to develop asthma or wheezing disorders later on.
"Worldwide, more than 11 percent of babies are born preterm," Sheikh said in a hospital news release.
"As asthma is a chronic condition, our findings underscore the need to improve our understanding of the mechanisms underlying the association between preterm birth and asthma or wheezing disorders in order to develop preventive and therapeutic interventions," he said.
Although the study found an association between premature birth and later asthma, it could not prove cause and effect. The findings were published in a recent issue of the journal PLoS Medicine.

Monday, March 10, 2014

Education is the Key to Better Asthma Management

It takes time to educate patients and parents about managing asthma.  The right asthma specialist can condense volumes of evidenced based literature and practice guidelines into  more easily understandable pearls that can be practical in our busy lives.  Dr. Susarla

What Are Some Strategies to Enhance Asthma Education in My Practice?

Primary-care offices are typically very busy places. As a result, the educational needs of parents and children with asthma often go unmet.1Lack of time is a common reason reported for not providing asthma education in the primary-care setting.2 However, providing asthma care consistent with the National Asthma Education and Prevention ProgramExpert Panel Report 3 (NAEPP EPR-3) Guidelines for the Diagnosis and Management of Asthma, which includes self-management education, does not have to be time consuming. One study evaluated the effects on patients 2 years after pediatricians were taught by their peers to enhance their skills in asthma therapies and counseling. This study found that pediatricians who participated in the training benefited in important ways. Trained physicians received higher patient-rated performance scores regarding communication behaviors important to promoting patient’s satisfaction and ability to manage asthma on their own, and in addition, their patients were also less likely to incur disruption of sleep caused by asthma symptoms. Another important finding of this study was that these positive results were achieved even though there was no difference in the time that peer-trained physicians spent with their asthma patients when first diagnosing a patient, seeing a new patient, or seeing a return patient. In fact, the peer-trained physicians spent less time with patients during urgent visits.3 Such a method for enhancing education in your practice requires changing physician behavior.
System-level changes have also been evaluated. In one such study, researchers evaluated the effectiveness of 2 asthma-care improvement strategies in the primary-care setting. One was less time consuming and less expensive and consisted of peer leader education. The other was more intensive and more expensive and consisted of allocating a nurse to conduct planned asthma-care visits. This group also received peer education. Findings revealed that, although both strategies decreased asthma symptom days, the peer leader group did not reach statistical significance.4 Therefore, when attempting to enhance educational practices in your office, it may be more effective to institute changes that target systems-oriented improvements, for example, developing a system that ensures all patients with asthma receive a written asthma action plan as per NAEPP EPR-3 Guidelines. One way to accomplish this is to automate the process by using an electronic medical record system. Such an approach makes it easy for the provider, legible for the patient and family, and a permanent part of the medical record. If instituting an electronic medical record is not feasible in your practice, having asthma action plans that are preprinted with medication names allowing you to check off or circle the treatment prescribed or having asthma action plans with a preprinted short-acting beta-agonist so that you only need to write the long-term control medications are 2 time-saving options. Creative shortcuts can also be useful. For example, color-coded labels for long-term control and quick-relief medications can be preprinted and then added to the action plan at the end of the visit. An example of such a plan can be found in Figure 39-1. All action plans described allow for individualization in an efficient manner.
Sample written asthma action plan with preprinted labelsFigure 39-1.Sample written asthma action plan with preprinted labels. 
Having written asthma action plans is only one step in the process for enhancing education in your office; using them is an even more important step. To encourage use of the action plans in your office, it is important to keep them readily available. Some suggestions include keeping the asthma action plans in each exam room so that they are easily accessible during each patient visit or having them clipped to the front of each asthma patient’s chart before the visit begins.
Another method for enhancing education in your practice is to make resources available to your patients and to view each opportunity as a teachable moment. For example, providing patients and families with internet opportunities (such as the Quest for the Code asthma game found at www.asthma.starlight.org) for self-education while they are sitting in the waiting room or providing them with a list of resources (Table 39-1) that they can access at their convenience allows them to learn at their own pace. However, it is extremely vital to recognize that merely providing patients and families educational materials without providing explanation is not true education. All educational materials and resources provided to patients must be reviewed and reinforced by all members of your health care team. One way to accomplish this is to develop asthma-specific visit forms that include a list of key educational messages. This list can be used to prompt providers to introduce or review a message or messages at each visit. Thus, providing consistent and repeated educational messages by all members of your health care team is another step to enhancing education in your practice.
An alternative or supplementary method for providing self-management education and addressing key educational messages is to offer asthma education classes and resources in your office. Asthma education classes allow you to personally review important self-management concepts in a group setting, thus promoting efficiency as well as education. Numerous examples and forms (print, audio-video, online) of asthma educational resources are available that can also be tailored to meet the needs of an individual practice.
Two final recommendations for enhancing education in your practice include hiring a nationally certified asthma educator to provide education during patient visits as well as via telephone in between visits, and developing a system for referring patients who need additional education to asthma specialists. Both of these strategies are supported by the NAEPP EPR-3 Guidelines. The Guidelines recommend using health professionals and others trained in asthma self-management education to implement and teach asthma self-management. They also recommend referring patients who need additional education to improve adherence to asthma specialists.5National certification for asthma educators has been available since 2002; thus, it is relatively new, and the effectiveness of education provided by certified asthma educators has not been reported. However, numerous randomized controlled studies have reported improved asthma outcomes when patients and families were educated by someone specially trained in asthma care and self-management.6
There are many options for enhancing education in your practice; some are more labor-intensive and costly than others. Developing a system that fits within the confines of your practice makes quality asthma education accessible to all of your patients with asthma and their families, and using all members of your health care team is the best approach to enhancing asthma education in your practice.

Tuesday, March 4, 2014

Lung function changes seen in later childhood in premature infants

Pulmonary Outcome in Former Preterm, Very Low Birth Weight Children with Bronchopulmonary Dysplasia: A Case-Control Follow-Up at School Age.

Maike Hove, Freerk Prenzel, Holm H Uhlig, Eva Tillig


To assess and compare long-term pulmonary outcomes in former preterm-born, very low birth weight (VLBW) children with and without bronchopulmonary dysplasia (BPD) born in the surfactant era.


Pulmonary function tests (ie, spirometry, body plethysmography, and gas transfer testing) were performed in children with a history of VLBW and BPD (n = 28) and compared with a matched preterm-born VLBW control group (n = 28). Medical history was evaluated by questionnaire.


At time of follow-up (mean age, 9.5 years), respiratory symptoms (36% vs 8%) and receipt of asthma medication (21% vs 0%) were significantly more frequent in the preterm-born children with previous BPD than in those with no history of BPD. The children with a history of BPD had significantly lower values for forced expiratory volume in 1 second (z-score -1.27 vs -0.4; P = .008), forced vital capacity (z-score -1.39 vs -0.71 z-score; P = .022), and forced expiratory flow rate at 50% of forced vital capacity (z-score -2.21 vs -1.04; P = .048) compared with the preterm control group.


Preterm-born children with a history of BPD are significantly more likely to have lung function abnormalities, such as airway obstruction and respiratory symptoms, at school age compared with preterm-born children without BPD.

Sunday, March 2, 2014

Researcher may have a cure for Type 1 diabetes

Ben-Gurion University researcher may have a cure for Type 1 diabetes

Click photo to download. Caption: Dr. Eli Lewis (pictured), a world-renowned expert on autoimmune disease and the director of the Clinical Islet Laboratory of the Department of Clinical Biochemistry & Pharmacology at Ben-Gurion University, may have a cure for Type 1 diabetes. Credit: Danny Machlis, Ben-Gurion University.
By Maayan Jaffe/JNS.org
While methods of insulin administration have improved, and modes of measuring how much insulin to give are far superior to those of the 1920s, when insulin was discovered, there have been no major advancements toward a cure for Type 1 diabetes for almost a century.
Until now, Dr. Eli Lewis believes.
“Tissue damage actually plays a role in Type 1 diabetes… but it is often overlooked and under-studied,” Lewis—a world-renowned expert on autoimmune disease and the director of the Clinical Islet Laboratory of the Department of Clinical Biochemistry & Pharmacology at Ben-Gurion University (BGU)—told JNS.org. “There was at least one stone that was left unturned.”
In 2003, Lewis began his research into the role of inflammation in injured islets, tiny clusters of insulin-producing cells scattered throughout the pancreas. And during that time he discovered that Alpha 1 Antitrypsin (AAT), an anti-inflammatory drug based on a natural protein our bodies produce each day and generally used to treat emphysema, not only shows promise for reducing insulin dependence but in some cases can actually cure a person of Type 1 diabetes.
Type 1 diabetes plagues 25.8 million Americans of all ages, about 8.3 percent of the U.S. population, according to the National Diabetes Information Clearinghouse. A similar percentage of the Israeli population is affected, said Lewis, who added that on average 40 more Americans are diagnosed with Type 1 diabetes each day. All Type 1 diabetics require insulin treatment.
Click photo to download. Caption: Insulin vials. While methods of insulin administration have improved and modes of measuring how much insulin to give are far superior than they were in the 1920s, when insulin was discovered, there have been no major advancements toward a cure for Type 1 diabetes for almost a century. But Dr. Eli Lewis of Ben-Gurion University may change that. Credit: Mr Hyde via Wikimedia Commons.
The hormone insulin, produced by clusters of cells found on islets that reside in the pancreas, enables the body to remove glucose (sugar) from the blood into storage locations such as liver and muscle. These cells are the targets of an autoimmune response in Type 1 diabetes. When the cells become inflamed and ultimately malfunction, insulin can no longer be produced. In a healthy individual, the body naturally produces systemic AAT in the liver that helps repair tissue and reduces inflammation. It was recently established that AAT, although present in patients with Type 1 diabetes, does not function in its glycated form.
In three recent clinical trials that took place at BGU, the Barbara Davis Center for Childhood Diabetes at the University of Colorado School of Medicine, and the Joslin Diabetes Center (affiliated with Harvard Medical School), recently diagnosed patients received injections of functioning AAT in the form of a liquid slow-drip infusion. They basically regained the ability to fight inflammation and protect damaged cells from aberrant immune responses. Within eight to 12 weeks AAT therapy was withdrawn, and in several patients proper glucose levels were controlled without the need for insulin injections for more than two years.
Click photo to download. Caption: Pictured in center is Dr. Eli Lewis, a world-renowned expert on autoimmune disease and the director of the Clinical Islet Laboratory of the Department of Clinical Biochemistry & Pharmacology at Ben-Gurion University. Lewis may have a cure for Type 1 diabetes. Credit: Danny Machlis, Ben-Gurion University.
Since AAT was already approved by the Food and Drug Administration (FDA), it received fast-track approval into human clinical trials in the U.S., Lewis said, noting it still will take at least another two years for AAT to receive FDA approval as an on-label treatment for Type 1 diabetes. But some physicians have been prescribing it in the meantime as an off-label treatment.
Dana Heffernan’s son Zach, 11, received AAT treatment from his doctor in San Antonio, Texas. Heffernan said her son was diagnosed on Nov. 12, 2013 and received his first treatment in mid-December.
“He went from approximately 10 units of insulin per day [70 units per week] down to two units per week. So that is pretty significant. Will he ever be off insulin completely? That is my hope, but we will have to see,” Heffernan said.
In another public case, which Lewis discussed, the Consul General of Israel to the Pacific Northwest, Andy David, accessed AAT for use in treating his 9-year-old daughter. She underwent once-a-week slow-drip infusions of AAT for 8 weeks. That was close to three years ago, and she has not had to have insulin since.
The treatment, however, may not be effective for all patients. Dr. Peter A. Gottlieb, professor of pediatrics and medicine at the Davis Center, led the Colorado clinical trial. He said the treatment was promising for about one-third of those who received AAT, but was less effective or even ineffective in others. He attributes this to multiple factors, including how long the person has had the disease and how much of the AAT was administered. He said another set of clinical trials is underway using larger doses. Lewis said in all trials, if one has been diagnosed with Type 1 for more than six months “the benefits are minimal.”