Top Papers of the Month

Top Papers You May Have Missed in November 2022

Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

Vergano ST. Top papers you may have missed in November 2022. Consultant360. Published online December 12, 2022.


Highlights from the past month's publications include a new American Academy of Pediatrics (AAP) clinical report on the primary care of patients with cerebral palsy, updated information on the cardiovascular risks of attention-deficit/hyperactivity disorder (ADHD) medication, and a report from the Commonwealth Foundation on levels of stress and burnout among primary care physicians in the United States and 9 other developed countries. I hope that you find these articles interesting and useful. As always, please feel free to send your impressions and thoughts to us at

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy1

This clinical report from the AAP updates the screening, diagnosis, and management of children with cerebral palsy (CP) by primary care clinicians. The statement cites a 2006 consensus definition of cerebral palsy in which the key features of the condition are: (1) a primarily motor disorder; (2) non-progressive; and (3) originating early in fetal or infant development.

The AAP recommends screening for CP along with other causes of developmental delay using a validated screening instrument at 9 months, 18 months, and 30 months. In children for whom CP is suspected, pediatric providers should simultaneously initiate a diagnostic evaluation, refer for specialty care, and refer for therapy to early intervention. The statement reinforces the role of the primary care medical home as the coordinator of care for these children and notes that such a role may require visits more often than annually.

The clinical report is a comprehensive review of the primary care for children and adolescents with CP. For those of us who routinely provide primary care for these patients, it contains nothing particularly new or earth-shattering. I do find the three following areas particularly noteworthy:

  1. The comprehensive delineation of potential complications to be monitored, including "cognitive impairments, epilepsy, sensory impairments, behavioral problems, communication difficulties, breathing and sleep problems, gastrointestinal and nutritional problems, and bone and orthopedic problems."
  2. The establishment as standard of care that each new symptom and each functional decline requires full evaluation in these children and should not be accepted as a part of the disease process of this non-progressive neurologic condition.
  3. The focus on pain assessment with each child, even when pain concerns cannot be adequately vocalized.

Risk of Cardiovascular Diseases Associated With Medications Used in Attention-Deficit/Hyperactivity Disorder2

The FDA raised concern for sudden cardiac death (SCD) in patients taking stimulant medications after unpublished and uncontrolled reports of 25 patients with SCD were identified through the Adverse Event Reporting system in 2006. Further description of these documented and theoretical concerns was elaborated in a commentary, published in the New England Journal of Medicine, from a member of the FDA panel that issued the 2006 statement. It is worth a quick perusal to recall which issues at the time led to the widely publicized warning.3

The current systematic review and meta-analysis included 19 studies with a total of almost 4 million patients. The authors examined the association between the use of stimulant and non-stimulant medications with adverse cardiovascular events, including hypertension, ischemic heart disease, cerebrovascular disease, heart failure, venous thromboembolism, tachyarrhythmias, and cardiac arrest. The researchers found no statistically significant association in their analysis between use of ADHD medications and risk of any cardiovascular events. They noted that their analysis may not have sufficient numbers to rule out an association with tacchyarrhymias or cardiac arrest, or in female patients or patients with significant underlying heart conditions.

Over the past 15 years since the initial FDA warning, researchers have undertaken and published multiple systematic studies of the risks of these medications. The findings of this meta-analysis are reassuring, but I will likely still mention potential cardiovascular risk with my patients and be cautious about using these medications in patients with significant underlying heart disease.

A Survey of Primary Care Physicians on Stress and Burnout4

For this report, published by the Commonwealth Fund this month, a representative sample of primary care physicians was surveyed from the United States and nine other developed nations, including Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom. Questions were focused on levels of stress, burnout, quality of care, and career plans. The analysis distinguished results from younger physicians (less than 55 years of age) with older physicians (55 years of age or older).

The report notes that the majority of primary care clinicians in these high-income countries state that their workload has increased since the start of the COVID-19 pandemic, including 65% of US physicians, 91% of UK's physicians, and 93% of Germany's physicians. According to the survey report, the majority of physicians across these countries report feeling stress and burnout, and many, including 28% of US physicians who report feeling stress or burnout, agree with the statement that the quality of care they provided decreased during the pandemic. Nearly half of the older physician cohort, including 45% of older physicians in the United States, report plans to stop seeing patients within the next 3 years.

The report makes note that younger physicians seem to have higher rates of stress and burnout than older physicians across all counties surveyed. Before drawing generational conclusions, I submit that many of us "younger physicians" (as I am apparently classified despite my 26 years in clinical practice) have family and child-rearing obligations that older physicians may no longer need to balance. As stressful as it may be, I would never give up the joys and rewards of raising my daughter for the decreased stress and increased sleep that I might otherwise have. If you feel this stress or burnout, please do not hesitate to seek out the help that is increasingly available for those of us who need it.

I hope you have some time off to enjoy your family this holiday season (and de-stress!). Thank you for reading my selections.


  1. Noritz G, Davidson L, Steingass K; Council on Children with Disabilities, THE AMERICAN ACADEMY FOR CEREBRAL PALSY AND DEVELOPMENTAL MEDICINE; Council on Children with Disabilities, THE AMERICAN ACADEMY FOR CEREBRAL PALSY AND DEVELOPMENTAL MEDICINE. Providing a primary care medical home for children and youth with cerebral palsy. Pediatrics. 2022:e2022060055. doi:10.1542/peds.2022-060055
  2. Zhang L, Yao H, Li L, et al. Risk of cardiovascular diseases associated with medications used in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. JAMA Netw Open. 2022;5(11):e2243597. doi:10.1001/jamanetworkopen.2022.43597
  3. Nissen SE. ADHD drugs and cardiovascular risk. N Engl J Med. 2006;354(14):1445-8. doi:10.1056/NEJMp068049
  4. Gunja MZ, Gumas ED, Williams RD Jr, Doty MM, Shah A, Fields K. Stressed out and burned out: the global primary care crisis. The Commonwealth Fund. Published November 17, 2022. Accessed December 7, 2022.