Atopic dermatitis (AD) is the most common, chronic, recurrent, inflammatory disorder of the skin, and it affects 5–30% of children worldwide. An analysis in the Journal of the European Academy of Dermatology & Venereologyof relevant published studies found that early application of emollients is an effective strategy for preventing AD in high-risk infants.
The analysis included 11 randomised controlled trials involving 3483 infants. Three types of emollients, including cream, emulsion, and mixed types were comparable in preventing AD; however, an additional analysis suggested that emollient emulsion may be the best option.
This analysis revealed a surface under the cumulative ranking curve (SUCRA) of 82.6%, 78.0% for high-risk infants and 79.2% for infants with food sensitisation. However, subjects receiving emollients more frequently experienced adverse events.
“The results of this systematic review and network meta-analysis show that early application of skin emollients can effectively prevent AD development in infants,” the authors wrote. “Moreover, among the available three types of emollients, the emollient emulsion is probably the optimal option in infancy to prevent AD development more effectively.”
Amid the ongoing global shortage of medical isotopes, there is at least some good news: two European research reactors have been fired up again and will be delivering molybdenum-99 and iodine-131 isotopes. In addition, a new reactor to produce Mo-99 through a new method has also been completed in the US and is awaiting testing and certification.
Mo-99 is the world’s most important medical diagnostic radioisotope precursor, and is the parent isotope of technetium-99m (Tc-99m). Tc-99m is used in more than 40-million diagnostic procedures each year. The production of this isotope is acutely vulnerable to supply chain disruption and much of the machinery used to produce it is ageing. South African nuclear corporation NTP also produces a small amount of the isotope locally at its Pelindaba facility.
Nuclear Medicine Europe (NMEU) was notified that the LVR-15 reactor resumed operations on Friday morning November 18 and the first irradiated targets from it are being processed today November 23rd. In addition, NMEU was notified that the HFR reactor resumed operations on November 23 and achieved full power operation at 14:30 CET.
The Mo-99 global supply situation will largely return to normal within the next 7-10 days with the I-131 supply situation returning to normal within two weeks, according to NMEU’s predictions. NMEU will provide further communication to the nuclear medicine community as developments warrant.
At the new production facility in the US, the isotope manufacturer NorthStar will produce Mo-99 through a new method, based on irradiation of molybdenum-100 targets using electron accelerators. This will be the first facility in the world to produce commercial-scale Mo-99 using this technology. The facility also includes new, high-capacity equipment for processing and packaging Mo-99 for distribution to radiopharmacies and hospitals.
Airway inflammation and emphysema are more common in marijuana smokers than cigarette smokers, according to a study published in Radiology. Researchers said the difference may be due to the way that marijuana is smoked, which is usually inhaled more deeply and without a filter.
Marijuana is one of the most widely used psychoactive substances in the world and the most-commonly smoked substance after tobacco. Its use has increased in recent years amid legalisation of recreational marijuana in many countries. The growing use has created an urgent need for information on marijuana’s effects on the lungs, something that is currently lacking.
“We know what cigarettes do to the lungs,” said study author Giselle Revah, MD, a cardiothoracic radiologist and assistant professor at the University of Ottawa. “There are well researched and established findings of cigarette smoking on the lungs. Marijuana we know very little about.”
To find out more, Dr Revah and colleagues compared chest CT results from 56 marijuana smokers with those of 57 non-smoking controls and 33 tobacco-only smokers.
Pulmonary emphysema in (A, B) marijuana and (C, D) tobacco smokers. (A) Axial and (B) coronal CT images in a 44-year-old male marijuana smoker show paraseptal emphysema (arrowheads) in bilateral upper lobes. (C) Axial and (D) coronal CT images in a 66-year-old female tobacco smoker with centrilobular emphysema represented by areas of centrilobular lucency (arrowheads). (Murtha, et al.)
Lack of filtering partly to blame
Three-quarters of the marijuana smokers had emphysema, a lung disease that causes difficulty with breathing, compared with 67% of the tobacco-only smokers. Only 5% of the non-smokers had emphysema. Paraseptal emphysema, which damages the tiny ducts that connect to the air sacs in the lungs, was the predominant emphysema subtype in marijuana smokers compared to the tobacco-only group.
Airway inflammation was also more common in marijuana smokers than non-smokers and tobacco-only smokers, as was gynecomastia, enlarged male breast tissue due to a hormone imbalance. Gynecomastia was found in 38% of the marijuana smokers, compared with 11% of the tobacco-only smokers and 16% of the controls.
The researchers found similar results among age-matched subgroups, where the rates of emphysema and airway inflammation were again higher in the marijuana smokers than the tobacco-only smokers.
There was no difference in coronary artery calcification between age-matched marijuana and tobacco-only groups.
Dr. Revah said the results were surprising, especially considering that the patients in the tobacco-only group had an extensive smoking history.
“The fact that our marijuana smokers – some of whom also smoked tobacco – had additional findings of airway inflammation/chronic bronchitis suggests that marijuana has additional synergistic effects on the lungs above tobacco,” she said. “In addition, our results were still significant when we compared the non-age-matched groups, including younger patients who smoked marijuana and who presumably had less lifetime exposure to cigarette smoke.”
The reasons for the differences between the two groups is likely due to several factors. Marijuana is smoked unfiltered, Dr Revah noted, while tobacco cigarettes are usually filtered. This results in more particulates reaching the airways from smoking marijuana.
In addition, marijuana is inhaled with a longer breath hold and puff volume than tobacco smoke.
“It has been suggested that smoking a marijuana joint deposits four times more particulates in the lung than an average tobacco cigarette,” Dr Revah said. “These particulates are likely airway irritants.”
The higher incidence of emphysema may also be due to the way that marijuana is smoked. Full inhalation with a sustained Valsalva manoeuvre, an attempt at exhalation against a closed airway, may lead to trauma and peripheral airspace changes.
More research is needed, Dr Revah said, with larger groups of people and more data on how much and how often people are smoking. Future research could also look at the impact of different inhalation techniques, such as through a bong, a joint or a pipe.
“It would be interesting to see if the inhalation method makes a difference,” Dr Revah said.
“It was very, very critical to me. It was an albatross around my neck. It was something that caused a deep persistent anxiety in me…”
This is how a 61-year-old retired school teacher from a township on the East Rand describes the feelings he had around disclosing to his son that he (the child) was born with HIV.
The man, who taught life orientation skills and history, agreed to be interviewed on condition that their identities are protected.
Speaking to Spotlight he says, “With my son, it became late in his life because I didn’t know how to do it – how to tell him. So I postponed and postponed. It was becoming increasingly difficult.”
Three months after the boy was born in 2001 at the Far East Rand Hospital in Springs, the child’s mother passed away from an HIV-related illness. At the time, hospital staff referred the widowed father and baby boy to HIV and AIDS treatment non-profit organisation Right to Care where Dr Leon Levin diagnosed the child with HIV.
“My wife died three months after giving birth. I didn’t realise then that she had HIV and that I have HIV. I took my son to Dr Levin, who tested him. I started giving my son ARVs. I had to employ someone to look after the child while I was working, and this woman didn’t truly understand about adherence and at times did not give him all his medicine. So she defaulted, which is very bad. It was a time when not much information was available, the time of the president [Thabo Mbeki] denying that HIV causes AIDS.”
Also in 2001, young orphan Nkosi Johnson died of AIDS in Johannesburg at the age of 12. Johnson made headlines the previous year when he told the International AIDS Conference in Durban “care for us and accept us. We are all human beings”.
‘Taking medication as a team’
As the years went by, the man says, the burden in his heart grew bigger. “We would go to Dr Levin every six months for a check-up,” he says. “I would tell my son that he is sick, but I did not explain why.”
Eventually, the man felt comfortable allowing Levin to assist in sharing the news with his son. “Around the age of 16, Dr Levin did a full disclosure with my son. It was the heaviest weight off my shoulders. After that intervention, we could speak properly. We had a heart-to-heart, and we started taking medication as a team. This made it easy for me to explain to the child the advantages of adhering [to ARV treatment], the meaning of defaulting [failing to take ARV treatment regularly, as prescribed], and all these consequences. I could discuss with my son the importance of adherence because when you default, the medication becomes resistant. I told him if you take your medication, you can live a long life. You can get married and you can have children.”
Despite the substantial progress South Africa has made in fighting HIV over the last decade and a half, HIV in children is still quite common. According to the latest estimates from Thembisa – the leading mathematical model of HIV in South Africa – around 238 000 children (under the age of 15) were living with HIV in the country in 2021. There were just over 8 300 cases of mother-to-child transmission of HIV last year. While still a staggering problem, this is a significant improvement from the early 2000s when the number was around 74 000.
Disclosure – how to get it right
Sharing news of being born with HIV to a child (perinatal infection) is perhaps an often overlooked, deeply tender aspect of the country’s broader HIV response. The National Department of Health recommends “partial disclosure” from three years old and “full disclosure” from around 10 years old – ideally before a child is 13 or before their sexual debut.
Levin, who is based in Johannesburg, and Dr Julia Turner, who is based in White River, Mpumalanga – both are with Right to Care – spoke to Spotlight about how they assist parents and children in this regard.
“Parents are so scared to tell their child that they have HIV, so they delay and delay and delay,” says Turner. “If you ask a parent they’ll say, oh no, let’s wait until they’re 15. And then they say, oh no, let’s wait until they’re 18. Because it’s such a difficult thing for them to do. They’re scared that their child will be devastated and become depressed and blame them. So they delay and delay and eventually the child either googles it themselves or reads their own file while they’re waiting for the doctor at the clinic. Teenagers and children are generally much smarter than anyone ever thinks they are.”
Levin and Turner point out that it is unreasonable to expect a child or teenager to regularly take medicine when they don’t know what it is for.
“At some stage, the children will ask why do I need this?” says Turner. “Or they’re refusing to take it and then the parents don’t know what to say, so they end up making up something. So they’ll say, you’ve got TB, or you’ve got asthma, or you’ve got herpes, or they make up any excuse as to why the child must take treatment. Perhaps ‘you must take the treatment, otherwise, you’ll die’, which is a bit scary. None of these answers are satisfactory, plus the child might be angry later if they learn they were lied to.”
Levin has been treating children and adolescents with HIV for 26 years. When he started, there were no guidelines and he had to learn from his own mistakes.
“Leon has been a paediatrician for many years and he was dealing with children and teenagers,” says Turner. “And he had to just figure out a way to tell them. And initially, it ended in tears. The child was crying, the parents were crying, he was crying, everyone… So, he slowly developed this technique of doing it so that it was brought into a positive light. And that really worked.”
Turner has helped to refine the technique. They explain that partial disclosure is explaining to a child that they have to take their treatment – without telling the child untruths but without bringing up HIV. Full disclosure is naming the child’s condition as “HIV”.
“Unfortunately, schools use HIV for their own purposes,” says Levin. “They’re using it basically to encourage children not to be promiscuous. So they’re giving out the message that only bad people get HIV and that people die from HIV. So while this works to encourage children to not be promiscuous, the problem is that as soon as a child hears the word ‘HIV’ or that they’ve got HIV, they immediately think they’re going to die – there’s that bad connotation.”
The story of the ‘soldier cells’
Right to Care recommends providing the young child with full information about HIV, without actually naming the disease, to avoid stigma and fear. The crux of the method is to not use the word “HIV” until myths around HIV are dispelled. The organisation offers illustrated booklets, depicting their narrative where white blood cells are depicted as soldiers.
“So we basically tell them a little story that in their body they have white blood cells,” Turner explains. “We say white blood cells are like soldiers and they go around your body and they protect you from germs. But you weren’t born with enough soldiers in your body. So that’s why you can get sick very easily. But the tablets or the medicine you take can help to keep your soldiers strong, keep your immune system strong, and fight off all the germs. So at least that’s true, and it’s a good reason why they must take their medicine. And they are usually very satisfied with that.”
As the child gets older, the story is expanded.
“As they get older, we can say, okay, well, why don’t you have enough soldiers in your blood?” she says. “And then we tell them it’s because you have a virus. You were born with a virus that kills off your soldier cells. And then as they get older, eventually when they’re about 10 years old, you can then say do you want to know the name of that virus that you have? And that’s when we turn partial disclosure into full disclosure by telling them the name HIV.”
Questions and answers
News of the parent having HIV is shared in a similar manner by framing the virus in a positive light. No blame is placed on the parent ever. Instead, when speaking to the child about their HIV status, the doctors recommend that if any blame is apportioned, that it be on the medical fraternity “for not having better medicine available” at the time of the child’s birth.
“We ask the child what they know about HIV, just to try and find out what negative things they have been told,” says Turner. “Then we tell them no, it’s not true, actually, people with HIV live long and healthy lives… I always ask them, what they want to be when they grow up. And if they say they want to be a pilot or a doctor or a teacher, I say, do you think people with HIV can be a pilot? And they always say no. And then I say, of course, they can. People with HIV can do anything they want to do. They can be doctors, teachers, anything.”
Right to Care is set to bring out a disclosure flip chart to help healthcare workers and primary caregivers with this conversation, which might be rolled out by the health department nationally.
“The thing is, you have to think on your feet because you’re having a conversation with this young child and it’s not so straightforward. But the flip chart tells you exactly what to say, it makes it much easier,” says Levin.
Meanwhile, the retired teacher and his now 22-year-old son are together establishing a small business in their community.
“My advice to parents,” he says. “Sharing their HIV status with children might feel like a bombshell. They must ask for professional help – doctors have techniques to make it easier.”
A comparison of spinal cord stimulators (SCS) revealed that the implants only offer a notable benefit within the first year of use, while also being associated with a high risk of adverse effects – nearly one in five, and a similar number requiring device revision or removal.
In this propensity-matched comparative effectiveness research analysis of 7560 insured individuals published in JAMA Neurology, treatment with SCS was not associated with a reduction in use of opioids, pain injections, radiofrequency ablation, or spine surgery at two years.
The study used administrative claims data, including longitudinal medical and pharmacy claims, from 2020–2021. Patients with incident diagnosis codes for failed back surgery syndrome, complex regional pain syndrome, chronic pain syndrome, and other chronic postsurgical back and extremity pain were included in this study.
Patients were an average age of 63.5 years and 59.3% were female. Among matched patients, during the first year, patients treated with SCSs had higher odds of chronic opioid use (adjusted odds ratio [aOR], 1.14) compared with patients treated with CMM but lower odds of epidural and facet corticosteroid injections (aOR, 0.44), radiofrequency ablation (aOR, 0.57), and spine surgery (aOR, 0.72).
During the second year, these beneficial effects disappeared. Compared to CMM there were no significant differences with SCS use in:
chronic opioid use (aOR, 1.06),
epidural and facet corticosteroid injections (aOR, 1.00)
radiofrequency ablation (aOR, 0.84)
spine surgery (aOR, 0.91)
Overall, 226 of 1260 patients (17.9%) treated with SCS experienced SCS-related complications within 2 years, and 279 of 1260 patients (22.1%) had device revisions and/or removals, which were not always for complications. Total costs of care in the first year were $39 000 higher with SCS than CMM and similar between SCS and CMM in the second year.
In an accompanying editorial, Prasad Shirvalkar, MD, PhD, and Lawrence Poree. MD, PhD, MPH conclude: “The findings appear to belie the popular belief that SCS may result in reduced opioid medication usage or overall fewer physician visits in the years immediately following device implant.”
They continue: “Notably, a formal cost-utility analysis was not done, and therefore caution is advised not to interpret these results as an argument against the therapeutic effectiveness of SCS for reducing symptoms or improving daily function. After all, there is surely some intrinsic social value to alleviating symptoms and improving individual function that may justify health care costs for chronic pain, just as in the practical treatment of cancer or heart disease.”
