Top Papers of the Month

4 Top Papers You May Have Missed in December 2021

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

CITATION:
Vergano ST. 4 top papers you may have missed in December 2021. Consultant360. Published online January 7, 2021

 

Happy New Year to all of you! I read some surprisingly important articles in December, and I am eager to share publications from the American Academy of Pediatrics (AAP) Committee on Pediatric Acquired Immunodeficiency Syndrome (AIDS), the Centers for Disease Control and Prevention (CDC), and 2 groups of independent researchers. Please feel free to share with your colleagues, discuss in your offices, and write to editor@consultant360.com with your thoughts and opinions.

Adolescents and Young Adults: The Pediatrician’s Role in HIV Testing and Pre- and Post-Exposure HIV Prophylaxis1, 2, 3

The clinical report from the AAP Committee on Pediatric AIDS1 updates recommendations from previous AAP statements from 2001 and 2011 that encouraged HIV testing of all sexually active adolescents. Consistent with statements from the CDC and the US Preventive Services Task Force,2 the current clinical report recommends universal screening of all adolescents aged 15 years or older at least once, with repeat screening annually or more frequently depending on risk factors. The initial screening should be a combination HIV-1 and HIV-2 antibody test with an HIV p24 antigen test, with more definitive testing for positive or equivocal results or recent exposures. The report also recommends including HIV testing for adolescents who present with mononucleosis or influenza-like illness, as these symptoms are consistent with acute retroviral syndrome, the mononucleosis-like illness that usually accompanies primary HIV infection.

In addition, the statement recommends that pediatricians be comfortable and willing to prescribe pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) to adolescent patients at risk for HIV, as defined in Table 2 of the article.1 PEP should be offered after a high-risk encounter, and PrEP should be offered to a broad definition of at-risk adolescents, as well as any teenager who desires protection. A newly approved injectable form of PrEP can be administered once every 2 months, instead of once daily oral medication.3 The report also references a "purview paradox," in which the HIV specialists in the United States see predominantly HIV-positive patients and, therefore, are too late to use PrEP and PEP, while the primary care providers have little training and comfort in providing these services.

What have your experiences been? In my practice, I have routinely tested for HIV in any adolescent with a documented sexually transmitted infection. Having cared for a patient hospitalized with acute retroviral syndrome, I consider the diagnosis in any adolescent with a mononucleosis-like illness but have not routinely performed HIV testing in my initial laboratory evaluation. I have not implemented routine HIV testing of all adolescents and do not yet feel comfortable with prescribing PrEP or PEP. I admit that reading this report has provided me with motivation and interest in implementing changes to my current practices. I encourage you to read through the evidence underlying the committee recommendations to decide for yourself.

Mumps in Vaccinated Children and Adolescents: 2007–20194

The authors from the CDC who wrote this report in Pediatrics have included all reported cases of mumps in the United States from 2007 to 2019 in patients younger than age 18 years. The 9172 pediatric cases of mumps represented one-third of the total cases of mumps reported during this period. Most of the pediatric patients with mumps were previously vaccinated, and only 2% were known to have been exposed through international travel. Of all pediatric mumps cases, some of whose symptoms were unknown, 84% of patients presented with parotitis, 2% with orchitis, and less than 1% each with deafness, meningitis, and encephalitis, and 2% of all pediatric patients were admitted to the hospital.

The take-home message for me is to consider mumps in any patient who presents with parotitis compatible with the diagnosis, regardless of age, vaccination, or travel status. The authors recommend obtaining a buccal swab specimen for reverse transcriptase polymerase chain reaction testing in all suspected cases, and a serum mumps immunoglobulin M titer if symptoms have been present for at least 3 days. Lastly, they discuss the importance of performing parotid gland massage for 30 seconds prior to obtaining the buccal swab specimen.

Female Physicians Earn an Estimated $2 Million Less Than Male Physicians Over a Simulated 40-Year Career5

The authors of this article published in Health Affairs used income data from 80,342 full-time physicians in the United States to estimate lifetime career earnings of female compared with male physicians. According to their simulation, male physicians would earn an estimated $8.31 million over a 40-year career, compared with $6.26 million for female physicians. Even controlling for differences in hours worked, clinical revenue, practice type, and specialty, the authors found that the average full-time female physician in the United States earned $2 million less than her male colleagues over the course of a 40-year career.

What are your thoughts? Does this mirror your experience? While some of the difference may be related to personal choices made by physicians, the magnitude of the difference strongly suggests that systemic issues embedded in our current system of reimbursement lead to this significant income discrepancy. The sooner that our profession and our society can address these systemic issues, the more fair, rewarding, and equitable the practice of medicine will become for all practicing physicians.

“It’s not rocket science” and “It’s not brain surgery”—“It’s a walk in the park”: prospective comparative study6

The authors of this tongue-in-cheek article set out to discover which of the above statements is more meritorious by examining cognitive testing scores of neurosurgeons and aerospace engineers. Overall, the scores of each group were comparable with each other, as well as with the general population. When compared with the general population, they note that neurosurgeons performed better in measures of problem-solving speed but worse in measures of memory recall speed. As neither of the groups performed markedly better than the general population, they conclude that a generic comparison, like "it's a walk in the park," might be more appropriate.

Wishing you a happy, healthy, and safe 2022!

References:

  1. Hsu KK, Rakhmanina NY. Adolescents and young adults: the pediatrician's role in HIV testing and pre- and postexposure HIV prophylaxis. Pediatrics. 2022;149(1):e2021055207. https://doi.org/10.1542/peds.2021-055207
  2. FDA approves first injectable treatment for HIV pre-exposure prevention. US Food and Drug Administration. December 20, 2021. Accessed January 6, 2022. https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention
  3. Pre-Exposure prophylaxis for the prevention of HIV infection in the United States–2021 update: a clinical practice guideline. Centers for Disease Control and Prevention. Accessed January 6, 2021. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf
  4. Shepersky L, Marin M, Zhang J, Pham H, Marlow MA. Mumps in vaccinated children and adolescents: 2007-2019. Pediatrics. 2021;148(6):e2021051873. https://doi.org/10.1542/peds.2021-051873
  5. Whaley CM, Koo T, Arora VM, Ganguli I, Gross N, Jena AB. Female physicians earn an estimated $2 million less than male physicians over a simulated 40-year career. Health Aff (Millwood). 2021;40(12):1856-1864. https://doi.org/10.1377/hlthaff.2021.00461
  6. Usher I, Hellyer P, Lee KS, et al; Brainbook. "It's not rocket science" and "It's not brain surgery"-"It's a walk in the park": prospective comparative study. BMJ. 2021;375:e067883. https://doi.org/10.1136/bmj-2021-067883