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PEDIATRICS & ADOLESCENT MEDICINE

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Selections from Journal Watch Pediatrics and Adolescent Medicine Copyright © 2005 Massachusetts Medical Society. All rights reserved.

STI TESTING: WHAT DO GIRLS WANT? ▸

Chlamydia trachomatis screening is recommended for sexually active young women, but few seek it, and many clinicians are uncomfortable questioning and testing adolescents. In this follow-up to a study of teen attitudes about clinic-based testing for sexually transmitted infections (STIs), 98 ethnically diverse adolescent females (age range, 13 to 20; 63% of original group) were resurveyed by telephone 9 months after their initial clinic visit. Participants were asked how they felt about (1) the specimen-collection techniques used in the clinic (first-void urine [FVU] sample, self-collected vaginal swab, and pelvic examination with endocervical swab) and (2) home FVU testing.

Of 98 participants, 52% preferred the home-based FVU test for STI screening; clinic-based FVU testing was preferred by 30%, pelvic exam by 12%, and self-collected vaginal swab by 6%. Adolescents who worried about having an STI were significantly more likely to favor home FVU testing. Only 22% of participants indicated that they would seek any kind of STI screening if asymptomatic.

Comment▴

Pelvic examination is a substantive barrier to both partners in the physician–patient dyad. With the advent of new types of tests, young women have increased opportunities to become positive agents in their own reproductive health care. The participants’ indifference toward testing when asymptomatic is a cause for concern, however, as is our lack of information about how an adolescent would interpret a positive home-based test and whether she would try to obtain treatment. Nevertheless, home-based testing is a promising addition to STI screening options.

M. Susan Jay, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 25, 2005

BEWARE THE CAT: IDENTIFYING INFANTS WITH CONGENITAL TOXOPLASMOSIS ▸

Congenital toxoplasmosis affects as many as 5000 newborns annually in the U.S., and its outcome can be devastating. Early diagnosis and treatment of infected infants can improve the prognosis, although clinical recognition of infection at birth is difficult. Investigators retrospectively surveyed mothers of 122 infants with confirmed congenital Toxoplasma gondii infection who were referred within 1 month of life to the Chicago Collaborative Treatment Trial over a 20-year period. The goal was to determine whether the mother’s history of exposure or illness during gestation could have identified infants with congenital toxoplasmosis. Mothers were asked about exposure to cats and uncooked foods and about illnesses during pregnancy that were compatible with acute toxoplasmosis. Congenital infection was confirmed by serologic testing of the newborn.

Seventy-five percent of the mothers recalled a conceivable exposure, and 25% did not. Only 39% could recall a specific exposure to cat litter or raw meat, and 48% recalled an illness that could have been toxoplasmosis. Overall, only 48% reported a sign, symptom, or risk factor compatible with toxoplasmosis. The authors conclude that screening mothers’ history of gestational exposure or illness would not have identified all children at risk. They propose systematic serologic screening as an alternative.

Comment ▸

It is difficult to identify the fetus or newborn at risk for congenital toxoplasmosis from historical data, but the effectiveness of serologic screening for this condition is not yet proven. Such screening is complex because it may require multiple tests during pregnancy. It is troubling that the physicians of 29 mothers failed to consider acute toxoplasmosis in the differential diagnosis of a maternal febrile illness associated with lymphadenopathy. This should also remind pediatricians to consider congenital toxoplasmosis in infants whose mothers report such symptoms, as well as in infants and children younger than 1 year with hydrocephalus of unknown etiology, even in the absence of calcifications. Considering the difficulty of diagnosis, universal newborn screening for congenital toxoplasmosis would be helpful.

William P. Kanto, Jr., MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 8, 2005

NEONATAL HERPES SIMPLEX INFECTION: A SAD YET INSTRUCTIVE CASE ▸

Neonatal infection with herpes simplex virus (HSV) continues to be a difficult diagnostic and therapeutic problem despite increased awareness, use of polymerase chain reaction (PCR) for cerebral spinal fluid (CSF), and treatment with high-dose acyclovir. The authors of this report describe a premature infant with HSV infection who developed severe neurologic sequelae after appropriate therapy with acyclovir and a subsequent trial of suppressive doses of acyclovir.

The 1415-g female infant developed an HSV skin lesion when she was 19 days old. She had no signs of systemic infection and had negative CSF PCR results. She was treated with high-dose IV acyclovir (60 mg/kg/day) for 2 weeks. Five days after completing treatment (at age 38 days), she had a recurrent skin lesion and was treated further with IV acyclovir pending further CSF HSV PCR test results. Because this PCR result also was negative, she completed a 5-day course of oral acyclovir followed by suppressive doses of acyclovir (300 mg/m2, three times a day). At age 3 months, the infant developed severe HSV encephalitis, and at age 12 months, she was noted to have macrocystic encephalomalacia.

Comment ▸

This one case report and an accompanying editorial remind us that the efficacy and safety of suppressive acyclovir therapy following neonatal herpes infection are still uncertain and, therefore, that this therapy should not become the standard of care (see JW Pediatr Adolesc Med Apr 8 2005). The case also serves as a reminder that infants who present with only skin, eye, or mouth lesions can have severe neurologic sequelae. Because CSF PCR is only about 70% sensitive early in the course of HSV infection in infants, a negative result does not rule out this diagnosis, especially when there is a high index of suspicion for HSV encephalitis. We must be careful about follow-up and prognostication in such cases.

Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 25, 2005

INFLUENCE OF DIRECT-TO-CONSUMER ADVERTISING ON ANTIDEPRESSANT PRESCRIPTIONS ▸

What are the actual effects of direct-to-consumer (DTC) advertising? In this innovative randomized controlled trial, standardized patients—trained actors following scripted roles—made 298 unannounced and surreptitiously audiotaped visits to 152 primary care physicians during several months (physicians agreed to the blinded visits).

Standardized patients portrayed people with either adjustment disorders or major depressive disorder (MDD). They were trained to ask for a specific antidepressant (paroxetine, which currently was being advertised on television), any antidepressant, or no antidepressant; each physician was scheduled randomly to see six standardized patients, each of whom made one of these requests for each portrayal. Blinded reviewers assessed medication prescribing and adequacy of care.

Standardized patients portraying MDD and making brand-specific, general, or no requests for medication were prescribed any antidepressant in 53%, 76%, and 31% of cases, respectively. For standardized patients portraying adjustment disorder, the corresponding prescription rates were 55%, 39%, and 10%. Paroxetine was prescribed in 27%, 2%, and 4% of MDD portrayals and in 37%, 10%, and 0% of adjustment-disorder portrayals. Overall, of 100 standardized patients making brand-specific requests for paroxetine, 32 received it; of 99 standardized patients making general requests, only 6 received paroxetine. Minimally acceptable care (i.e., antidepressant prescription, mental health referral, or follow-up visit within 2 weeks) for standardized patients portraying MDD and making medication requests as above was provided in 90%, 98%, and 56% of cases.

Comment ▸

The results of this clever study suggest that direct-to-consumer advertising can substantially increase brand-specific prescriptions, often for weak indications (e.g., adjustment disorder). However, it also appears that DTC advertising can stimulate patients to make requests that improve their overall adequacy of care.

Thomas L. Schwenk, MD

Published in Journal Watch May 13, 2005

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