Adolescent Medicine

Little Big Little: What is Vaping?

Adolescent Medicine, Education, Emergency Medicine, Podcast, Pulmonology, Uncategorized

This is the first segment in a series of “shorts” – smaller quick hit episodes on a focused topic. I’m going to affectionately call them “Little Big Littles”.

On this Little Big Little, host Jason Woods speaks with Dr. Heather Hoch about what we might need to know about vaping to take care of our patients.

Guests

Heather Hoch MD – Assistant Professor, Dept. of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado

Important Resources

  1. CDC Electronic Cigarette Information
  2. Smokefree.gov

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Episode 21: HIV Screening in the Pediatric ED

Adolescent Medicine, Emergency Medicine, Infectious Disease, Uncategorized

On this episode, host Jason Woods speaks with Dr. Amy Grover about HIV screening in the pediatric emergency department. Dr. Grover works in both the section of emergency medicine and hospital medicine and has an interest in HIV screening.

The highlights:

  • An estimated 50% of adolescents with HIV do not know they have contracted HIV
  • Acute retroviral syndrome has many non specific symptoms and can be difficult to diagnosis but includes the following
    • Fever
    • Fatigue
    • Myalgias
    • Nausea, vomiting, and/or diarrhea
    • Rash that can involve the hands and feed
    • Pharyngitis is typically not as exudative as EBV
  • CDC guidelines recommend that EVERY person ages 13-64 who is sexually active be screened for HIV at least once in their lives, and yearly if ongoing risk for exposure
  • One of the difficult aspects of setting up a screening program is deciding who is responsible for follow up of the results. Each institution will have to discuss what is appropriate for their setting
  • Do not forget to evaluate for risk of other STI, including Syphilis (prevalence is rising in the US)
  • Most rapid screening tests that do not use whole blood can not detect HIV infection until there is an antibody response (3 weeks – 3 months)
  • The 4th generation HIV test can detect infection starting as early as 15 days after infection. Note that there is still a latent period when detection is not possible.
  • One of the important reasons to screen patients is that there is evidence that knowledge of HIV infection decreases high-risk behavior.
  • The benefit and effect of HIV screening may depend on the regional HIV rates

Guests

Amy Grover MD – University of Colorado School of Medicine, Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado

Important Resources

  1. CDC HIV Resource Library

References

  1. Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatric Adolesc Med. 2000 Apr;154(4):361-5.
  2. Kitahadta MM, et al. Effect of Early vs Deferred Antiretroviral therapy for HIV on Survival. NEJM 2009;360(18):1815-26.
  3. Marks G, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr.2005 Aug 1;39(4):446-53.
  4. Cohen MS, et al. Antiretroviral Therapy for the prevention of HIV-1 Transmission. NEJM 2016; 375(9):830-839.
  5. Marks G, et al. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS.2006 Jun 26;20(10):1447-50.
  6. Wood E, et al. Does this Adult Patient have Early HIV infection? JAMA 2014; 213 (3): 278-285.
  7. Mehta AS, et al. Practices, Beliefs, and Perceived Barriers to Adolescent Human Immunodeficiency Virus Screening in the Emergency Department. Pediatr Emerg Care 2015; 31:621-626.
  8. Akhter A, et al. Rapid Human Immunodeficiency Virus Testing in the Pediatric Emergency Department: A National Survey of Attitudes Among Pediatric Emergency Practitioners. Pediatr Emerg Care 2012; 28:1257-1262.
  9. Haines CJ, et al. Pediatric emergency department – based rapid HIV testing: adolescent attitudes and preferences. Pediatr Emerg Care.2011 Jan;27(1):13-6.

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Episode 20: HIV Pre-exposure Prophylaxis (PrEP)

Adolescent Medicine, Emergency Medicine, HIV, Pediatric Emergency Medicine, Sexual Health

On this episode, host Jason Woods speaks with Martin Walker (Director of HIV Programs for Planned Parenthood of the Rocky Mountains) and Moises Munoz (Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado) about pre-exposure prophylaxis for HIV (PrEP).

The highlights:

  • The only FDA approved PrEP regimen the combination product of emtricitabine/tenofovir (brand name Truvada)
  • It was approved in 2012 for PrEP
  • Typical dosing is one pill (200/300) once per day, for patients > 35 kg (regardless of age)
  • Prior to the start of PrEP, counseling and labs are suggested
    • Labs required before the start of PrEP include baseline creatinine and UA, negative studies for HIV and Hepatitis, pregnancy if applicable, and other STIs (all of these are included in ongoing monitoring as well)
    • Counseling should include discussion of risk factors, compliance, required testing, need for continued protection from other STIs
    • Generally not recommended to use in patients with GFR < 60
  • From the start of use, different tissues require different amounts of time to reach effective concentrations. There is not clear data on this but Martin suggests 7 days for receptive anal intercourse and 21 days for receptive vaginal intercourse.
  • Some studies suggest that for penile-anal intercourse, as few as 4 doses per week may be effective.
  • See below for training resources

Guests

Martin Walker – Director of HIV Programs for Planned Parenthood of the Rocky Mountains

Moises Munoz – Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado

Important Resources

References

  1. Hosek S, Rudy B, Landovitz R, et. al. “An HIV Pre-Exposure Prophylaxis (PrEP) Demonstration Project and Safety Study for Young MSM”. J Acquir Immune Defic Syndr. 2017 Jan 1; 74(1): 21–29. PMID: 27632233
  2. Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis 2014; 14:820. PMID: 25065857.
  3. Krakower DS, Mayer KH. Pre-exposure prophylaxis to prevent HIV infection: current status, future opportunities and challenges. Drugs 2015; 75:243. PMID: 25673022.
  4. Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med 2012; 4:151. PMID: 22972843.
  5. Seifert SM, Glidden DV, Meditz AL, et al. Dose response for starting and stopping HIV preexposure prophylaxis for men who have sex with men. Clin Infect Dis 2015; 60:804. PMID: 25409469
  6. Anderson PL, Meditz A, Zheng JH. Cellular pharmacology of TFV and FTC in blood, rectal, and cervical cells from HIV- volunteers. Presented at the Conference on Retroviruses and Opportunistic Infections 2012.

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Episode 18b: Anti-trafficking and the role of the ED

Adolescent Medicine, Emergency Medicine, Pediatric Emergency Medicine, Sexual Health, Trafficking

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 2 of a 2 part discussion. The highlights:

  1. Definition of trafficking
    1. recruitment, harboring, transportation, provision, and/or obtaining of a person
    2. By the use of force, fraud, and/or coercion
    3. For purposes of labor and/or sexual exploitation
  2. Numbers and general info
    1. Overall labor trafficking is most common
    2. Under age 18 “survival” sex considered victim of trafficking
    3. US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.
    4. On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked
  3. There is no comprehensive trafficking screening tool in existence
    1. The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking
  4. Quotes from Makini’s published work that I loved
    1. It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience.
    2. We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve.

Guests

Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System

Other Resources

  1. HEAL Trafficking
  2. Training for providers that Dr. Chisolm-Straker mentioned
  3. Human trafficking hotline:
    1. Phone: 1-888-373-7888
    2. SMS:233733 text HELP or INFO
    3. Humantraffickinghotline.org
  4. HumantraffickingED.com

References

1.     Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52. 

2.     Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7. 

3.     Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33. 

4.     Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1. 

5.     Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D. Acad Emerg Med 2018.  doi: 10.1111/acem.13552 

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Episode 18a: Anti-trafficking and the role of the ED

Adolescent Medicine, Emergency Medicine, Pediatric Emergency Medicine, Trafficking, Uncategorized

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 1 of a 2 part discussion. The highlights:

  1. Definition of trafficking
    1. recruitment, harboring, transportation, provision, and/or obtaining of a person
    2. By the use of force, fraud, and/or coercion
    3. For purposes of labor and/or sexual exploitation
  2. Numbers and general info
    1. Overall labor trafficking is most common
    2. Under age 18 “survival” sex considered victim of trafficking
    3. US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.
    4. On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked
  3. There is no comprehensive trafficking screening tool in existence
    1. The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking
  4. Quotes from Makini’s published work that I loved
    1. It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience.
    2. We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve.

Guests

Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System

Other Resources

  1. HEAL Trafficking
  2. Training for providers that Dr. Chisolm-Straker mentioned
  3. Human trafficking hotline:
    1. Phone: 1-888-373-7888
    2. SMS:233733 text HELP or INFO
    3. Humantraffickinghotline.org
  4. HumantraffickingED.com

References

1.     Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52. 

2.     Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7. 

3.     Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33. 

4.     Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1. 

5.     Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D. Acad Emerg Med 2018.  doi: 10.1111/acem.13552 

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Episode 13: Adolescent Sexual Health and Education

Adolescent Medicine, Medical Education, Pediatric Emergency Medicine, Podcast, Sexual Health

On this episode, host Jason Woods speaks to Daniela Fellman and Alison Macklin, leaders from the Responsible Sex Education Institute, about a topic that can sometimes be difficult for patients, parents, and care providers…sex! Sexual and reproductive health education is hugely important and frequently politicized. Both interviewees are leading the way when it comes to education and outreach programs in the field of sex education. We talk about a variety of resources which are listed below, as well as get a sneak peek at two books which are being published soon.

Important Links

  1. Responsible Sex Education Institute
  2. ICYC Instagram
  3. ICYC – In Case You’re Curious
  4. Making Sense of “It” by Alison Macklin (available for pre-order now!)

Additional Resources

  1. Glsen
  2. Scarleteen
  3. Healthy Teen Network
  4. Advocates for Youth
  5. Amaze

Guests

Alison Macklin – Vice President of Education and Innovation, Responsive Sex Education, Planned Parenthood of the Rocky Mountains

Daniela Fellman – Program Manager of Texting Initiatives, Planned Parenthood of the Rocky Mountains

 

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