HOT TOPICS
From the T. Denny Sanford Pediatric Symposium, presented by the Mayo Clinic in collaboration with Sanford Health,
Rochester, MN
| ADOLESCENT FATIGUE —Philip R. Fischer, MD, Professor of Pediatrics, Mayo Clinic College of Medicine, Rochester,
MN
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| Reasonable assumptions: adolescent fatigue common; patient may be sleep deprived—teenagers need ≈9 hr of sleep/
night (average teenager in United States gets ≈7.5 hr); life out of balance—24% of teenagers watch >4 hr of television
and video games each weekday (68% on weekends); 33% do not get regular strenuous exercise and only 25% have regular
physical education activities at school; obesity may be factor—in teenagers, 30% of calories derived from snacks, desserts,
and fast food; 20% of teenagers overweight; most tired teenagers not overweight
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| Psychologic issues: in recent study, severe fatigue more common in patients who had somatization disorders and depression;
another study suggested that prolonged fatigue more likely related to other familial or environmental factors
than to psychologic issues
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| Differential diagnosis of chronic fatigue: kidney failure or anemia; autoimmune hepatitis; undiagnosed celiac disease;
inflammatory condition; hypothyroidism; adrenal issues
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| Screening laboratory tests: consider checking iron and vitamin D levels; in studies of chronic fatigue in women, iron
improves fatigue by ≈29%; ≈50% of chronically tired teenagers have low iron stores, as demonstrated by ferritin levels
<20; treatment in adults suggests that many patients improve with iron supplementation; recent study showed strong link
between hypovitaminosis D and chronic nonspecific musculoskeletal pain; one-third to one-half of teenagers have had
low vitamin D levels
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| Sleep disorders: few tired teenagers have sleep disorder; however, based on history, physical examination, and screening
tests, sleep evaluation may be indicated; obstructive sleep apnea—associated with ineffective sleep, restlessness, and
not feeling refreshed in morning; typically, patients snore and arouse often during night; possible pauses, then gasping for
breath; if tonsils large, removal may be indicated
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| Autonomic nervous system dysfunction: post-illness pattern (after high fever, long illness [eg, mononucleosis], or
injury that keeps patient “laid up” long time, some patients experience persistent fatigue, dizziness, headaches, nausea,
and other pains); larger-than-average pupillary size; when standing still, hands and feet cool and bluish due to pooling of
blood; postural orthostatic tachycardia syndrome— increase in heart rate of >30 bpm with movement from supine to
standing position; blood flow not adequately regulated (accounts for dizziness, headaches, and fatigue); at speaker’s
institution—approximately two-thirds of chronically tired patients have autonomic dysfunction involving blood flow;
two-thirds deconditioned (on exercise testing, poor oxygen uptake); some overlap between groups
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Treatment
| Restoring balance: make sure teenager gets adequate sleep (≈9 hr); regular physical exercise helps prevent fatigue and
keeps life in balance; patients should stay in school and maintain social relationships; renal failure and hypothyroidism
rare causes of fatigue; if vitamin D level low, consider vitamin D supplementation; if iron stores low, consider iron supplementation;
if patient deconditioned or there is evidence of autonomic dysfunction present, start regular exercise program
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| Managing autonomic dysfunction: increase blood volume by increasing fluid intake (speaker suggests 2 extra liters
fluid/day); supplemental salt helps maintain water within vascular system
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 | Medications: midodrine—α-agonist; stimulates contraction of blood vessels and improves blood flow; β-blockers (eg,
metoprolol)—block overrelaxation of blood vessels and help maintain circulation in patients with poor central perfusion;
serotonin-related medications (eg, citalopram [Celexa])—useful in patients with autonomic dysfunction (particularly
those with nausea and chronic abdominal pains)
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| ANTIBIOTICS UPDATE —Nancy K. Henry, MD, PhD, Associate Professor of Pediatrics, Mayo Clinic College of Medicine,
Rochester, MN
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| Ertapenem: bactericidal carbapenem medication that inhibits cell-wall synthesis by binding penicillin-binding proteins;
like imipenem and meropenem, ertapenem resists degradation by pathogen-produced enzymes (eg, penicillinases and
cephalosporinases, including extended-spectrum β-lactamases [ESBLs]); active against aerobic and anaerobic gram-positive
cocci and gram-negative bacilli; indications for patients >3 mo of age—community-acquired pneumonia; skin or
subcutaneous infection; abdominal infection; complicated urinary tract infections (UTIs); orthopedic infections; administered
once/day intravenously (IV) or intramuscularly (IM); effective for managing serious infections due to ESBL-producing
organisms and ampicillin (AmpC) β-lactamase-producing gram-negative bacilli; ESBLs—hydrolyze all third-
generation cephalosporins (particularly ceftazidime, cefotaxime, and ceftriaxone); ESBL most often produced by Klebsiella
and Escherichia coli but also by Serratia, Enterobacter, and Pseudomonas; any organism resistant to ceftazidime
considered ESBL producer
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| Colistin (polymyxin E): polypeptide antibiotic; effective against gram-negative organisms (especially Pseudomonas
aeruginosa, Enterobacter, E coli, and Klebsiella; disrupts lipopolysaccharide outer membrane); effective in cystic fibrosis
(CF) population after long-term exposure to antibiotics; problem of nephrotoxicity; used primarily as aerosolized
medication (can be used IV if dosed appropriately); primarily used in CF patients
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| Clinical microbiology laboratory: early warning system that alerts physicians to new mechanisms of resistance;
with more rapid characterization of infectious agent, narrower spectrum antimicrobial agent can be used; timely detection
of resistance affects selection of antibiotic and patient outcome; emergence of hypervirulent strain of Clostridium difficile
related to extensive use of broad-spectrum antibiotics
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| Factors that promote antimicrobial resistance: treating nonbacterial infections with antibiotics; treating infections
that might resolve spontaneously; selecting broad-spectrum drug when narrow-spectrum antibiotic sufficient; inappropriate
dose or duration; antibiotic use in animals (humans can become colonized with antibiotic-resistant organisms,
eg, vancomycin-resistant Enterococcus); lack of information on prevalence of antibiotic use and resistance; inability to
implement infection control measures (antimicrobial stewardship more difficult in outpatient setting than in hospitals);
parental pressure to prescribe antibiotics; time required to diagnose specific etiology; worry about risk for complications;
lack of time to educate parents and adolescents about benefits and risks of antibiotic use
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| Guidelines for improved management of antibiotics: Get Smart Campaign (Centers for Disease Control and
Prevention [CDC])—prescribe antibiotics only when likely beneficial; target pathogens at right dose for appropriate
duration; educating parents and adolescents important because of their influence on prescribing patterns; Infectious Disease
Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)—promote use of appropriate
drug, dose, route, and duration; primary goal to optimize clinical outcomes, while minimizing unintended
consequences (ie, exposure to toxicity, selection of more pathogenic organisms, and emergence of resistant bacteria);
secondary goal to reduce health care costs; American Academy of Pediatrics (AAP) has endorsed guidelines
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| More about C difficile: leading cause of nosocomial diarrhea in industrialized countries; use of third-generation cephalosporins,
ampicillin, and clindamycin can disrupt gut flora and permit overgrowth of C difficile; hypervirulent C difficile
associated with resistance to fluoroquinolones and increased production of toxins A and B; if hypervirulent C difficile infection
suspected, patient placed in strict isolation; recent data suggest that reducing inappropriate use of antibiotics decreases
risk for hypervirulent C difficile in hospitalized patients
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| Computer-based antimicrobial monitoring (CBAM) at Mayo Clinic: hospital rules-based system; rapidly
communicates crucial prescribing information to clinicians to optimize patient care and cost efficiency; costs—resources
devoted to information technology and clinicians who view data; benefits—decreased spending on antibiotics, patient
stays, and exposure to adverse effects of antibiotics; infectious disease in adults (study by Wilson, 2005)—83% of CBAM
interventions resulted in improved patient care
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| COMMON PEDIATRIC DERMATOLOGIC PROBLEMS —Dawn M. Davis, MD, Assistant Professor, Departments of
Dermatology and Pediatrics, Mayo Clinic College of Medicine, and Senior Associate Consultant, Mayo Clinic, Rochester,
MN
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Acne
| Pathophysiology: 4 causative factors—skin retention or “sticky skin” inherited from family; Propionibacterium acnes;
sebum production at puberty; inflammation
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| Educating patients: pores on face, chest, and back like house; inherited trait of sticky skin forms “roof” over pores (P
acnes trapped inside); during adolescence, oil secreted due to surges in testosterone and estrogen; oil fuels proliferation
of P acne and rupture of pore walls
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| Presentation: red papules; open comedones—triglycerides in sebum oxidize on exposure to air and darken, forming
blackheads; closed comedones—“roof” still on and inflammation occurs; involvement deeper towards dermis produces
nodules and cysts (if deep enough, scars and pits)
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| Treatment: for sticky skin, topical retinoids (eg, tretinoin [eg, Retin-A], adapalene [Differin], azelaic acid); for P acnes
and inflammation, topical antibiotics; for deeper inflammation, oral antibiotics; isotretinoin (Accutane) for nodular cystic
acne; blue light therapy; wet dressings
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Warts
| Pathophysiology: epidermal overgrowth caused by human papillomavirus (HPV) infection; virus enters through crack
in skin, grows deep into dermis, and forms “roof” to shelter itself; some strains have oncogenic potential
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| Presentation: hyperkeratotic papule; often blood vessels (punctate capillaries) visible because lesions grow own blood
supply (warts can bleed or ulcerate when traumatized)
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| Treatment: strategies (destruction of roof, virus, or blood vessel supply); paring and freezing; topical acid products (eg,
salicylic acid or high-dose benzoyl peroxide); speaker uses vascular (V-beam) laser in refractory cases to obliterate extra
blood vessels (macrophages consume obliterated blood vessels); intralesional chemotherapy with Candida antigen (bleomycin);
consider intentional neglect (eventually, immune system resolves wart); on average, individual wart takes 9 to 24
mo to resolve (however, warts can spread)
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Eczema (Atopic Dermatitis)
| Pathophysiology: inflammatory destruction of epidermis; type 2 helper T cell (Th2) lymphocytic response; immune
system destroys epidermis at dermal-epidermal junction; breakdown of skin structure leads to infection and scarring; eczema
nicknamed “itch that rashes” (itching intense)
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| Eczema worsened by: drool and table foods on face; physical stress (eg, sleep deprivation, dietary changes or malnutrition,
severe illness, [eg, broken bone, pneumonia]); psychologic stress; other atopic diseases
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| Presentation: erythematous serpiginous weeping; crusty patches; usually on trunk and extremities (can affect face, genitalia,
and hands and feet); some children develop ulcerations from scratching; scratching during sleep difficult to manage;
skin dry and rough
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| Treatment: to maintain structure of epidermis—place protective layer between skin and environment with emollients
and oils (creams and lotions water-based and evaporate within 2 hr; addition of oil acts as “greenhouse” to keep moisture
in); to prevent infection—topical and oral antibiotics (if Staphylococcus or streptococci present, eczema will not heal); to
relieve itch—antihistamines; UV light therapy; topical steroids and nonsteroidal immunomodulating creams, eg, tacrolimus
(eg, Protopic) and pimecrolimus (Elidel)
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Tinea (Ringworm)
| Diagnosis: fungal skin infection; on trunk (ringworm); in groin (jock itch); on feet (athlete’s foot); dry scaling erythematous
ring enlarges, leaving central clearing; sources—household pet (eg, cat, dog), sibling, friend, or classmate in day
care
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| Treatment: topical antifungals—apply cream in middle hollow, on red ring where infection active, and additional 1-in
swath around perimeter (direction in which yeast moving); treat until ring clear and for 1 wk thereafter (tinea can persist
in small numbers and resurge); oral antifungals—in patients with scalp, genital, or widespread involvement, and patients
refractory to topical medication (eg, clotrimazole and terbinafine [Lamisil])
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Molluscum
| Pathophysiology: molluscum lesions caused by molluscum contagiosum virus (MCV); only small percentage of people
exposed to MCV develop papules; susceptibility may be linked to blood type; affected patients include young children,
senior citizens, transplant patients, and patients with HIV; atopic dermatitis or psoriasis “welcome wagon” for molluscum;
average molluscum papule takes 9 to 24 mo to resolve (by that time, it has usually spread); mushroom with central
umbilication (viruses concentrated in umbilication); picking at lesion can cause spreading (if core deep into dermis, possible
scarring); molluscum highly contagious (transmissible through direct contact or fomites, eg, boogie boards, ballet
shoes, wrestling headgear, football gear, warm water); look for skin-colored erythematous pedunculated papules; umbilication
may be late sign or absent
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| Treatment: intentional neglect recommended if ≤5 to 10 lesions present; benefit of common treatments not supported by
literature; avoid transmission—no cobathing or cosleeping until molluscum gone; do not shave or wax area; cover lesions;
avoid ballet, wrestling, swimming; clean fomites (eg, boogie board, ballet bar; hand sanitizer effective); destructive
modalities—liquid nitrogen; cantharidin; curettage; potassium hydroxide; laser
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Cradle Cap (Seborrheic Dermatitis)
| Pathophysiology: problem occurs in infants and older people; dysregulation between nerves and oil glands; scalp has
greatest number of oil glands; can be itchy; flakes and dandruff can be embarrassing; orange-colored greasy scaly wax
most commonly seen on scalp; oil glands also numerous on central forehead, lateral cheeks, chin, and upper chest
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| Treatment: antiyeast shampoo (leave in 5-10 min); mild-potency topical steroids to decrease inflammation and help with
dryness; improved hygiene; consider combing with mineral or olive oil; moisturize skin if dry
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Psoriasis
| Pathophysiology: epidermal overgrowth syndrome due to inflammation; Th1 lymphocytic response (in contrast, eczema
is Th2 response); people with psoriasis have hardy strong stubborn skin; red scaly plaques (skin growing so fast, no
time to shed itself); familial (linked to 4 or 5 human leukocyte antigen [HLA antigen] types); associated with psoriatic arthritis
(lifetime risk 30%); psoriasis flares with stress; worsened by systemic steroids (eg, prednisone)
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| Cosmetic concerns: red thick scale (epidermis turns over every 3 days instead of every 28 days); if affected, nails yellow,
thick, and dystrophic; geographic tongue
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| Treatment: to decrease inflammation and modulate immune response, topical steroids and UV light therapy; slow
growth of epidermis with topical vitamin D and topical tar; treat pathogens if present
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Suggested Reading
Arora V, Arora S: Management of infantile seborrheic dermatitis.Am Fam Physician 75:807, 2007; Brune A et al:
Tacrolimus ointment is effective for psoriasis on the face and intertriginous areas in pediatric patients. Pediatr Dermatol
24:76, 2007; Clayton TH et al: The treatment of severe atopic dermatitis in childhood with narrowband ultraviolet B
phototherapy. Clin Exp Dermatol 32:28, 2007; Denys GA et al: Distribution of resistant gram-positive organisms across
the census regions of the United States and in vitro activity of tigecycline, a new glycylcycline antimicrobial. Am J Infect
Control 35:521, 2007; Henry NK et al: Antimicrobial therapy for infants and children: guidelines for the inpatient and
outpatient practice of pediatric infectious diseases. Mayo Clin Proc 75:86, 2000; Krowchuk DP: Managing adolescent
acne: a guide for pediatricians. Pediatr Rev 26:250, 2005; Silverberg N: Pediatric molluscum contagiosum: optimal
treatment strategies. Paediatr Drugs 5:505, 2003; Smith MS: Adolescent chronic fatigue syndrome. Arch Pediatr Adolesc
Med 158:207, 2004; Smolinski KM, Yan AC: How and when to treat molluscum contagiosum and warts in children.
Pediatr Ann 34:211, 2005.
Educational Objectives
| The goals of this program are to improve the diagnosis and management of adolescent fatigue, to promote the judicious
use of antibiotics, and to improve the care of children with common dermatologic problems. After hearing and
assimilating this program, the clinician will be better able to:
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| 1. Identify common and uncommon causes of adolescent fatigue.
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| 2. Describe newer antibiotics and their indications for use in children.
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| 3. Avoid prescribing strategies that promote antimicrobial resistance.
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| 4. Recognize signs and symptoms of common dermatologic problems in children.
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| 5. Choose appropriate therapy for managing dermatologic problems in children.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in
health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee
reported nothing to disclose.
Acknowledgments
Drs. Fischer, Henry, and Davis were recorded at the T. Denny Sanford Pediatric Symposium, presented December 7,
2007, in Rochester, MN, by the Mayo Clinic in collaboration with Sanford Health, Rochester, MN. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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