The continuing evolution of pediatric critical care medicine
1
The continuing evolution of pediatric critical care medicine Since the administration of the first Pediatric Critical Care Medicine subspecialty examination in 1987, the American Board of Pediatrics has provided the public and medical community with an increasingly rich set of objective data to track the growth of this specialty, as well as the characteristics of trainees, and the geographic distribution and career choices of its practitioners. The latest report in this issue of The Journal will prove invaluable in anticipating the available critical care workforce. The clarity of these supply data contrast with the unknown future demand for critical care physicians. Many units have al- ready adopted in-house, 24 hour intensivist presence in critical care units and others are considering similar converage. The specialty is too young to estimate the expected career duration of intensivists, but it is likely to be shorter than that of specialists in other areas. These trends suggest that the specialty must continue to attract increasing numbers of trainees in order to meet current and future demands. —Thomas Green, MD page 390 What is adiponectin? Adipose tissue has often been thought to be a passive storage depot for fat. How then does being overweight have such a broad influence on adverse health outcomes? The answer to that question is not completely known, but it is clear that adipose tissue is metabolically active and expresses cytokines. One of these cytokines is adiponectin. Serum levels of adiponectin are de- creased in obesity and low levels of adiponectin are associated with insulin resistance, Type 2 diabetes, dyslipidemia and blood pressure elevation. Higher serum levels of adiponectin appear to be protective against these and other adverse outcomes. For these reasons, it is important to learn more about the biology of adiponectin. Lanes et al report on a study of adiponec- tin and growth hormone deficiency. They found that growth hormone deficiency is associated with low levels of adiponectin and unfavorable levels of lipids and lipoproteins. Treatment with growth hormone appears to improve these abnormalities. These results establish intriguing links among growth hormone defi- ciency, deposition of visceral fat, adiponectin and insulin resis- tance. —Stephen R. Daniels, MD, PhD page 324 Meta– but not the final–analysis of efficacy of probiotics in prevention of antibiotic-associated diarrhea The meta-analysis performed by Szajewska et al included only placebo-controlled, randomized clinical trials of efficacy of probiotics in preventing antibiotic-associated diarrhea in children. The expected quality of the studies and findings, therefore, would be high. The authors point out that unfortunately, precision of definition of diarrhea, the classes of antibiotics used, the species of probiotic microorganism used were heterogeneous across studies. Although the use of probiotics was associated with relative risk of 0.44 (95% confidence interval 0.25 to 0.77) for antibiotic associated diarrhea, there are several caveats of study design that preclude their definitive recommendation. Larger, better studies are necessary to form the evidence before the next metaanalysis can be performed, which conclusion could guide optimal clinical care. —Sarah S. Long, MD page 367 Effect of newborn screening for cystic fibrosis on CF-related mortality Grosse et al have studied the population impact of newborn screening for cystic fibrosis (CF) on CF-related mortality using data from trials of newborn screening. Several sources of published and unpublished data were identified from both the US and overseas. In addition, data from the North American CF Registry were analyzed. The results indicate that screening reduces the risk of mortality by 10 years of age in children with CF. There appeared to be less benefit from screening in the USA compared to other countries, possibly because outcomes have improved in American CF centers. However, states that were not screening for CF had a relative risk of CF-related death before age 10 years that was 3.5 times that in states with CF screening programs. The benefits of screening on mortality, therefore, seem to be similar for CF compared to sickle cell disease and galactosemia and support the current recommendations that states consider adding CF to their newborn screening programs. —Robert W. Wilmott, MD page 362 Topical fluticasone in atopic dermatitis Fluticasone propionate (FP) is a synthetic corticosteroid with potent anti-inflammatory properties, best known to most pediatricians for use as an inhaled preparation in asthma. More recently, topical FP preparations have been formulated for use in atopic dermatitis. The use of potent corticosteroids on the skin of small infants is always concerning, both for direct cutaneous effect but also because of systemic absorption. The high skin surface to body volume ratio of small infants makes them, in theory, much more susceptible to such systemic effects. Hebert et al report the systematic assessment of hypothalamic pituitary adrenal axis function in 44 children receiving FP for extensive, severe atopic dermatitis; the mean body surface area treated in these children was 65%. There was no significant difference in baseline or cosyntropin-stimulated cortisol in these children from baseline to the end of treatment (which was at least four weeks). This data should be reassuring to practitioners considering topical FP in infants with exten- sive atopic dermatitis. —Thomas R. Welch, MD page 378 2A September 2006 The Journal of Pediatrics
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Transcript of The continuing evolution of pediatric critical care medicine
The continuing evolution of pediatriccritical care medicine
Since the administration of the first Pediatric Critical CareMedicine subspecialty examination in 1987, the American Boardof Pediatrics has provided the public and medical communitywith an increasingly rich set of objective data to track the growthof this specialty, as well as the characteristics of trainees, and thegeographic distribution and career choices of its practitioners.The latest report in this issue of The Journal will prove invaluablein anticipating the available critical care workforce.
The clarity of these supply data contrast with the unknownfuture demand for critical care physicians. Many units have al-ready adopted in-house, 24 hour intensivist presence in criticalcare units and others are considering similar converage. Thespecialty is too young to estimate the expected career duration ofintensivists, but it is likely to be shorter than that of specialists inother areas. These trends suggest that the specialty must continueto attract increasing numbers of trainees in order to meet currentand future demands.
—Thomas Green, MDpage 390
What is adiponectin?Adipose tissue has often been thought to be a passive
storage depot for fat. How then does being overweight have sucha broad influence on adverse health outcomes? The answer to thatquestion is not completely known, but it is clear that adiposetissue is metabolically active and expresses cytokines. One of thesecytokines is adiponectin. Serum levels of adiponectin are de-creased in obesity and low levels of adiponectin are associatedwith insulin resistance, Type 2 diabetes, dyslipidemia and bloodpressure elevation. Higher serum levels of adiponectin appear tobe protective against these and other adverse outcomes.
For these reasons, it is important to learn more about thebiology of adiponectin. Lanes et al report on a study of adiponec-tin and growth hormone deficiency. They found that growthhormone deficiency is associated with low levels of adiponectinand unfavorable levels of lipids and lipoproteins. Treatment withgrowth hormone appears to improve these abnormalities. Theseresults establish intriguing links among growth hormone defi-ciency, deposition of visceral fat, adiponectin and insulin resis-tance.
—Stephen R. Daniels, MD, PhDpage 324
Meta– but not the final–analysis ofefficacy of probiotics in prevention ofantibiotic-associated diarrhea
The meta-analysis performed by Szajewska et al included onlyplacebo-controlled, randomized clinical trials of efficacy of probiotics inpreventing antibiotic-associated diarrhea in children. The expectedquality of the studies and findings, therefore, would be high. Theauthors point out that unfortunately, precision of definition of diarrhea,the classes of antibiotics used, the species of probiotic microorganismused were heterogeneous across studies. Although the use of probioticswas associated with relative risk of 0.44 (95% confidence interval 0.25 to0.77) for antibiotic associated diarrhea, there are several caveats of studydesign that preclude their definitive recommendation. Larger, betterstudies are necessary to form the evidence before the next metaanalysiscan be performed, which conclusion could guide optimal clinical care.
—Sarah S. Long, MDpage 367
Effect of newborn screening for cysticfibrosis on CF-related mortality
Grosse et al have studied the population impact of newbornscreening for cystic fibrosis (CF) on CF-related mortality using datafrom trials of newborn screening. Several sources of published andunpublished data were identified from both the US and overseas. Inaddition, data from the North American CF Registry were analyzed.The results indicate that screening reduces the risk of mortality by 10years of age in children with CF. There appeared to be less benefit fromscreening in the USA compared to other countries, possibly becauseoutcomes have improved in American CF centers. However, states thatwere not screening for CF had a relative risk of CF-related death beforeage 10 years that was 3.5 times that in states with CF screeningprograms. The benefits of screening on mortality, therefore, seem to besimilar for CF compared to sickle cell disease and galactosemia andsupport the current recommendations that states consider adding CF totheir newborn screening programs.
—Robert W. Wilmott, MDpage 362
Topical fluticasone in atopic dermatitisFluticasone propionate (FP) is a synthetic corticosteroid with
potent anti-inflammatory properties, best known to most pediatriciansfor use as an inhaled preparation in asthma. More recently, topical FPpreparations have been formulated for use in atopic dermatitis.
The use of potent corticosteroids on the skin of small infants isalways concerning, both for direct cutaneous effect but also because ofsystemic absorption. The high skin surface to body volume ratio of smallinfants makes them, in theory, much more susceptible to such systemiceffects.
Hebert et al report the systematic assessment of hypothalamicpituitary adrenal axis function in 44 children receiving FP for extensive,severe atopic dermatitis; the mean body surface area treated in thesechildren was 65%. There was no significant difference in baseline orcosyntropin-stimulated cortisol in these children from baseline to theend of treatment (which was at least four weeks). This data should bereassuring to practitioners considering topical FP in infants with exten-sive atopic dermatitis.
—Thomas R. Welch, MDpage 378
2A September 2006 The Journal of Pediatrics
