Top Papers You May Have Missed in May 2022
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA
Vergano ST. 4 top papers you may have missed in May 2022. Consultant360. Published online June 15, 2022.
Here in Coastal Virginia, our tourist season is well underway. In the office, we have been very busy with a mild resurgence of COVID-19 and more with a spate of other viruses that have started to circulate since social distancing and masking have abated. Just in case you have been busy as well, I share 2 important articles published last month, and 2 additional articles worthy of your attention. I hope you enjoy my selections. Please feel free to share with your colleagues, discuss in your offices, and write to firstname.lastname@example.org with your thoughts and opinions.
Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma1
In this double-blind trial published in the New England Journal of Medicine, adults and children with uncontrolled moderate-to-severe asthma were randomly assigned to receive 1 of 3 different medications as their rescue inhaler. A group received albuterol with 40µg of budesonide, a group received albuterol with 80µg of budesonide, and a group received albuterol alone, each 2 puffs up to 6 times per day, as needed for symptoms. The investigators followed the patients for a minimum of 24 weeks and recorded the time to first severe exacerbation in each patient. Although children age 4 to 11 years were included with the lower-dose budesonide group, 97% of the participants were aged 12 years or older.
The researchers report that the hazard ratio (HR) for time to severe exacerbation in the high-dose steroid group was 0.74 (0.62-0.89) compared with the albuterol alone group. The HR for time to severe exacerbation in the low-dose steroid group was 0.84 (0.71-1.00) compared with albuterol alone. Adverse effects occurred similarly in all 3 groups. The authors conclude that the risk of severe asthma exacerbation was lower by 26% when higher-dose inhaled budesonide was added to the as-needed albuterol in the rescue inhalers for adolescents and adults with poorly controlled moderate-to-severe asthma.
This study adds to a current trend, which is moving away from as-needed albuterol alone as the rescue medication for asthma. Previous studies have confirmed the improved efficacy of steroid-beta agonist combinations in adults with mild asthma, in a pooled analysis of Single Maintenance And Reliever Therapy (SMART) with the combination of inhaled corticosteroid and long-acting beta-agonist (cited in 3 Top Papers You Missed in December 2020), and in Black and Latinx patients with moderate-to-severe asthma (cited in 4 Top Papers You May Have Missed in February 2022). Although an international guideline from the Global Initiative for Asthma now recommends avoiding albuterol alone as a rescue medication in all adults and adolescents,2 the most recent National Heart, Lung, and Blood Institute US asthma guidelines still recommend albuterol in this role, with an option for albuterol with concomitant inhaled corticosteroid as needed in patients aged 12 years or older.
Differentiating Bell’s Palsy From Lyme-Related Facial Palsy3
In this retrospective cohort study, pediatric neurologists at Children’s Hospital of Philadelphia (CHOP) reviewed the presentation and diagnosis of 306 children aged 1 to 18 years who presented in the CHOP care network in Southeast Pennsylvania from 2013 to 2018 with a unilateral peripheral seventh nerve palsy. As is typical even within a Lyme disease-endemic area, the majority of these children (68%) were ultimately diagnosed with a Bell's palsy, while 27% were diagnosed with Lyme-related facial palsy, and 5% with other diagnoses. The authors looked for clinical features that might be useful in distinguishing the 2 conditions at presentation.
Two features seemed most helpful in separating Bell's palsy from Lyme-related facial palsy: seasonality and presence of a systemic prodrome. While Bell's palsy did not show a particular seasonal distribution, 93% of patients with Lyme-related facial palsy presented in the months between June and November. While only 6% of patients with Bell's palsy presented with a preceding systemic prodrome, 55% of patients with Lyme-related facial palsy had at least 3 of the following symptoms in the preceding 6 weeks: fever, headache, malaise, arthralgias, and myalgias. The ability to distinguish the 2 conditions may lead to earlier appropriate treatment, as Bell's palsy is generally treated with systemic steroids, while Lyme-related facial palsy requires antibiotic therapy.
When I worked in an endemic area in New Jersey, I would always send a Lyme titer in any child who presented with a peripheral facial nerve palsy. Armed with the data from this study, I would most likely change my approach to a child presenting in winter or spring without a systemic prodrome. In such a patient, I would likely treat with steroids at presentation and consider not sending Lyme titers. The purpose of antibiotic therapy in Lyme-related facial palsy is to prevent the development of late Lyme disease,4 and I would typically await the results of Lyme titers before starting antibiotics. Ongoing prospective trials of the efficacy of corticosteroids in Bell's palsy will hopefully clarify the role of early steroid treatment in these children. Even though the authors of the current trial did not find an effect on overall recovery rate, I will continue to treat these children while awaiting the results of these prospective trials.
Parents’ Experiences and Needs Regarding Infant Sickle Cell Trait Results5
Although the authors of this study interviewed only 16 families whose infants were recently identified with sickle cell trait on state newborn screening, I think this article was accepted for publication in Pediatrics because it identifies important potential gaps in national guidelines and standard care for the families of infants with sickle cell trait. The semi-structured interviews identified 2 areas in which parents desired more information: (1) more content about rare manifestations of sickle cell trait; and (2) readdressing the discussion of sickle cell trait and its inheritance with their children during adolescence. In my practice, I am rigorous about disclosing the diagnosis and entering it into the problem list for newborns, but I admit to being less consistent in discussing the health and reproductive ramifications with these patients as they grow up. I would be interested to hear from others regarding their practices.
State-by-State Variability in Adolescent Privacy Laws6
The authors of this article published in Pediatrics rigorously investigated state laws relating to the ability of minors to consent for medical care in each of the 50 states. Table 1 in the publication contains a full listing of current state law regarding consent for general medical care, immunizations, dental care, sexual assault evaluation, sexually transmitted infection testing and treatment, HIV testing and treatment, contraceptive care, prenatal care, substance abuse treatment, and mental health care. It provides specific information by state in each of these circumstances and may prove a valuable resource for clinicians in reviewing the laws of their own state.
I hope you stay well. I am eager, as always, to read your comments.
- Papi A, Chipps BE, Beasley R, et al. Albuterol-budesonide fixed-dose combination rescue inhaler for asthma. N Engl J Med. 2022;386(22):2071-2083. doi:10.1056/NEJMoa2203163
- Global strategy for asthma management and prevention. 2022 Global Initiative for Asthma. Updated 2022. Accessed June 9, 2022. 51. https://ginasthma.org/wp-content/uploads/2022/05/GINA-Main-Report-2022-FINAL-22-05-03-WMS.pdf
- Guez-Barber D, Swami SK, Harrison JB, McGuire JL. Differentiating Bell's palsy from Lyme-related facial palsy. Pediatrics. 2022;149(6):e2021053992. doi:10.1542/peds.2021-053992
- Kimberlin DW, Barnette ED, Lynfield R, Sawyer MH; Committee on Infectious Diseases; American Academy of Pediatrics. Red Book: 2021-2024 Report on the Committee on Infectious Diseases. Pediatrics. 2022:488. doi:10.1542/9781610025782
- Sims AM, Cromartie SJ, Gessner L, et al. Parents' experiences and needs regarding infant sickle cell trait results. Pediatrics. 2022;149(5):e2021053454. doi:10.1542/peds.2021-053454
- Sharko M, Jameson R, Ancker JS, Krams L, Webber EC, Rosenbloom ST. State-by-state variability in adolescent privacy laws. Pediatrics. 2022;149(6):e2021053458. doi:10.1542/peds.2021-053458