interviewed Bethany Hall, MSN, the owner of Healing Connection, on the role nurse practitioners have in understanding and approaching care for children with complex developmental trauma (CDT).

In this discussion, Hall explains how the COVID-19 pandemic has impact the occurrence of CDT among children during quarantine, and the need for greater awareness of this issue in light of the potential increase in need for care in this area.

 Do you think the COVID-19 pandemic has affected the occurrence of CDT or the need for greater attention to this issue?

 So, I think we're all going through acute trauma, and something I talk a lot about with my colleagues and with my patients is this idea of the window of tolerance.

So, imagine on the table in front of you, you have 3 glasses of water. One glass of water is just barely full, another one is about halfway full, and the next one is full almost to the tippy top. So, if I shake that table in front of you, very different things are going to happen to each glass. The one with very little water probably will spill nothing, the one with the middle amount of water may spill a little bit, but likely would still contain most of that water. The cup that's full almost to the tippy top when you shake that table, water is going to go everywhere. So, the proverbial water is going everywhere right now.

These kids that have a small window of tolerance that already, because of the way their brains and their bodies have been affected by trauma, a new onset of acute trauma really just causes them to react in a much larger way on a much grander scale than a person that did not undergo significant childhood trauma.

So, 100%, yes. I think the acute impact on chronic trauma is a real issue. Then we've seen in cities—like where you're based in Philadelphia—some of these very large cities went to all virtual, so then you have all these children in already poverty-stricken areas who have parents with low resources, many of them who've also experienced trauma that are now stuck in a home 24/7 with very little resources.

So, if you think even just about the effect on the parents’ ability to parent, you have parents who already have a small window of tolerance who may have experienced abuse and neglect in their own lives that now are under an extreme amount of stress. So, I believe that we already have some data, but I believe we will see even more that childhood abuse and neglect go up significantly because of these parents’ inability to have the resources that they need, to have the break that they need, the mental health care and self-care that they need to parent well.

But also, we do see the compounded effect on children that already have a small window of tolerance. This acute trauma on them is also really wreaking havoc, and it's really imperative during this time that we understand how to increase their resiliency, increase their window of tolerance, increase the abilities that we're giving to these parents as far as tools to help promote mental flexibility, resilience, all of those things.

Again, I think, in the future, we're going to, as they say, reap the whirlwind in these coming years as these children grow into adulthood if we are not making a concerted effort to help them process traumatic events so that they do not become traumatic and cause a negative impact on that child.

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Bethany Hall, MSN, the owner of Healing Connection, discusses how the COVID-19 pandemic has impacted the occurrence of complex developmental trauma among children.

Expert: The Experience of the Pandemic May Have a Compounding Effect on Children With Complex Development Trauma

Recent survey results from ValuePenguin found that the rate for sunburn is higher among the younger generations, specifically 61% of Gen Zers and 58% of millennials, according to a press release.

Sun protection etiquette is still low in practice, with many Americans not wearing sunscreen daily. In particular, 82% reported that they do not wear sunscreen every day in the summer whereas 64% typically wear sunscreen 5 to 6 days a week.

In terms of getting checked for skin cancer, half of the survey participants are not confident they can detect a cancerous mole themselves and most have not visited a doctor for a professional skin exam. Approximately 45% do not think they could detect a cancerous mole on their body, and around the same percentage (43%) have never been given a full skin exam.

Cost concerns play a major role in sun protection, with more than a third of respondents (35%) reporting they have not done so due to cost concerns. Additionally, 43% did not know funds from a health savings account (HSAs) or flexible spending account (FSAs) could be used towards sunscreen purchases.

"People may think of contributions as money leaving their pockets since it is taken from their salary before taxes," said ValuePenguin insurance analyst Sterling Price in a press release. "But they need to realize that the money in that account can actually be used for a ton of items that they might be buying anyway."

The online survey was conducted between June 18 to June 22, 2021 and analyzed 1048consumers in the United States using a nonprobability-based sample. Generations were defined as the following ages:

45% of Americans have already been sunburned this year. ValuePenguin. July 12, 2021. Accessed July 14, 2021. 

https://www.valuepenguin.com/skin-care-survey

Articles

Sun protection etiquette is still low in practice, with many Americans not wearing sunscreen daily.

Survey Finds 45% of Americans Already Sunburnt This Year

Being an expert on immunization and cognizant on social determinants of health for communities and patients as a whole are some of the important keys to being a successful nurse practitioner, according to Rachel C. Vandemark, MHA, BSN in an interview with 

Vandemark is a Doctor of Nursing Practice (DNP) student in the Pediatric Nurse Practitioner Primary Care Track at the University of Washington School of Nursing (Class of 2022) with experience in pre-hospital care as well as hospital safety and quality. A mother of 3 children, Vandemark was prepared to take on whatever the School of Nursing’s courses threw at her, even a worldwide pandemic.

Based in Seattle and close to the city of Kirkland, Washington, where the first major COVID-19 outbreak took place, gave her a true firsthand experience of where the pandemic was headed.

“There was a really rapid shift from 100% in-person to 100% online classes, and I saw my DNP classmates provide care to COVID-19 patients while trying to take care of young children at home, and even sharing Wi-Fi with others just to get things done,” Vandemark said.

This experience reminded her about how people’s home lives and lived experiences are not always visible to health care providers, but they are extremely essential to the health care system.

“We need experts on immunizations and such, but we also need to be advocates for systems and policies that optimize health for everyone,” Vandemark said.

As for other nurse practitioners who are about to enter the field, Vandemark highly emphasized being flexible as things begin to unfold, whether it is a pandemic or a change in direction in health care. Additionally, continuing to promote good public health always helps, such as helping with the immunization movement and practicing safe health care policies.

In an interview with Contemporary Clinic, Rachel C. Vandemark, MHA, BSN, spoke about her experience in nursing during the COVID-19 pandemic.

Flexibility, Grit, Gratitude Are Key to Being Great Nurse Practitioner

Contemporary Clinic spoke with John Lee, a recent graduate from the Acute Care cohort at the University of Washington's School of Nursing, about his experience and what he hopes other PNPs can learn in their experiences.

Lee also spoke about being one of the first students in the school's acute care program and gave advice on how to be flexible in the profession.

Being an Acute Care PNP Student During the COVID-19 Pandemic

New research from the American Heart Association found that older adults taking blood pressure-lowering medications known to cross the blood-brain barrier had better memory recollection over time versus those taking other types of medicines to treat high blood pressure, as published in the journal 

Blood pressure-lowering medicines include ACE inhibitors, angiotensin 2 receptor blockers (ARBs), calcium channel blockers, and diuretics, and each class of these medicines acts differently to reduce blood pressure while crossing the blood-brain barrier and impacting cognitive function.

“Research has been mixed on which medicines have the most benefit to cognition,” said study author Daniel A. Nation, PhD, ​in the press release. ”Studies of angiotensin II receptor blockers and angiotensin-converting-enzyme (ACE) inhibitors have suggested these medicines may confer the greatest benefit to long-term cognition, while other studies have shown the benefits of calcium channel blockers and diuretics on reducing dementia risk.”

According to the press release, this is the first meta-analysis to compare the potential impact over time of blood pressure lowering medicines that do compared to those that do not cross the blood-brain barrier. The medicines were then evaluated for their effects on several cognitive domains, including attention, language, verbal memory, learning, and recall.

“Hypertension occurs decades prior to the onset of dementia symptoms, affecting blood flow not only in the body but also to the brain,” Nation said in the press release. “Treating hypertension is likely to have long-term beneficial effects on brain health and cognitive function later.”

The research team gathered information from 14 studies consisting of approximately 12,900 adults from 50 years of age and older, including studies done in the United States, Australia, Canada, Germany, Ireland, and Japan.

A highlight of the study was that older adults who took blood pressure-lowering medicines that cross the blood-brain barrier had better memory recall for up to 3 years of follow-up compared to those taking medicines that do not cross the blood-brain barrier, even with a higher level of vascular risk. Further, adults who were taking hypertension medications that did not cross the blood-brain barrier had improved their attention span for up to 3 years of follow-up, according to the press release.

“These findings represent the most powerful evidence to-date linking brain-penetrant ACE-inhibitors and angiotensin receptor blockers to better memory,” said study co-author Jean K. Ho, PhD, in the press release. “It suggests that people who are being treated for hypertension may be protected from cognitive decline if they medications that cross the blood-brain barrier.”

There were a few limitations to the study, including that the study authors could not account for differences in racial and ethnic background based on the available studies and the difference in proportion between men and women in the group who took medications crossing the blood-brain barrier. Future research should focus on this area, since previous studies have shown that those with various racial/ethnic backgrounds may respond differently to different blood pressure medications, according to the study authors.

Some blood pressure-lowering meds linked to less memory decline in older adults. American Heart Association. Published June 21, 2021. Accessed June 21, 2021. 

https://newsroom.heart.org/news/some-blood-pressure-lowering-meds-linked-to-less-memory-decline-in-older-adults

ACE inhibitors, angiotensin 2 receptor blockers, calcium channel blockers, and diuretics, and each reduce blood pressure while crossing the blood-brain barrier and impacting cognitive function. 

Study Finds Certain Blood Pressure-Lowering Meds Linked to Less Memory Decline in Older Adults

Incidence and acuity of type 2 diabetes in children increased significantly during the peak of the COVID-19 pandemic, according to a poster presented during the virtual 81st Scientific Sessions of the American Diabetes Association (ADA). The data collected from a retrospective chart review show that more pediatric patients were hospitalized from March to December 2020 at Our Lady of the Lake Children's Hospital in Baton Rouge, LA, compared to the same time period in 2019.

“While our study examined hospital admissions for type 2 diabetes in children at 1 center, the results may be a microcosm of what is happening at other children’s hospitals across the country,” said lead study author Daniel S. Hsia MD, associate professor at Pennington Biomedical Research Center in Baton Rouge, Louisiana, in a press release.

According to the ADA, there are a lack of data on the incidence or severity of new-onset type 2 diabetes in the pediatric population during the COVID-19 pandemic.1However, stay-at-home orders linked to the COVID-19 pandemic exacerbated risk factors for type 2 diabetes, including limited physical activity, increased screen time and sedentary behaviors, disrupted sleep, and increased intake of processed foods, which can all lead to weight gain.

According to the ADA, a national survey showed that more than 1 in 4 Americans with diabetes reported disruption to their ability to obtain healthy food during the pandemic. Modest weight gain over a short period of time can increase the risk for long-term health consequences, such as type 2 diabetes and cardiovascular disease.

The data analysis from Our Lady of the Lake Children’s Hospital found the following:

In 2019, the hospitalization rate for new onset type 2 diabetes was 0.27% for 2964 hospitalization cases compared to 0.62% of 2729 in 2020.

Children admitted to the hospital in 2020 had more severe diabetes with higher blood glucose, higher A1C, and higher indicators of dehydration compared to children admitted in 2019.

More children in 2020 also presented with serious conditions that typically require admission to the intensive care unit compared to 2019, such as diabetic ketoacidosis (8 vs. 3) and hyperosmolar hyperglycemic syndrome (2 vs. 0).

Twenty-three of 25 children were Black and 19 children were male.

“Unfortunately, COVID-19 disrupted our lives in more ways than we realize. Our study reinforces the importance of maintaining a healthy lifestyle for children even under such difficult circumstances,” Hsia said in the release.

New study shows hospitalization rates for new onset pediatric type 2 diabetes doubled during COVID-19 pandemic [news release]. June 25, 2021; ADA. Accessed June 25, 2021. [email]

New data alert: COVID-19 brings crisis of access for millions living with diabetes. ADA. Published December 23, 2020. Accessed June 25, 2021. 

https://www.diabetes.org/newsroom/press-releases/COVID-19-brings-crisis-of-access-for-millions-living-with-diabetes

Initial data show that children presented with higher acuity in 2020 compared to the previous year. 

Study Links COVID-19 Pandemic to Increased Hospitalization Rates for Children With New Onset Type 2 Diabetes 

Contemporary Clinic spoke with NAPNAP President Jessica Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN and NAPNAP Secretary Jennifer Sonney, PhD, APRN, PPCNP-BC, FAANP, about their latest study regarding the pandemic's impact on pediatric-focused nurse practitioner workforce.

Peck and Sonney share their inspiration for conducting the study, highlights of the findings, and what they hope this study will teach other NPs about the workforce. 

https://www.jpedhc.org/article/S0891-5245(21)00094-8/fulltext

The Impact of COVID-19 On Pediatric Advanced Practice Registered Nursing Workforces

interviewedLea Davis, PhD, an associate professor of medicine in the Department of Medicine at Vanderbilt University Medical Center and an investigator in the Vanderbilt Genetics Institute, on a recent study she co-authored that was published in 

 on the epidemiology of functional seizures among adults treated at a university hospital.

Could you explain further the novel association in your findings between functional seizures and cerebrovascular disease?

 Yeah. So, in our data, what we saw was basically that that the presence of functional seizures and the presence of cerebrovascular disease, or more specifically stroke, tended to co-occur at a rate higher than what we would expect by chance, just based on how common those 2 conditions are independently.

So, we saw them actually occurring together more often than we would expect. We did do some work to try to figure out which might be coming first, the functional seizure condition or the stroke event.

The challenge with that though is that patients with functional seizures often experience like a 7 to 8 year diagnostic odyssey, so by the time they actually get diagnosed with functional seizures they may have been having functional seizures for a very long time and that can be really hard to tease apart in the medical record.

So, that's part of our challenge in trying to understand the relationship between these 2. I will also say that it's not uncommon for stroke patients to experience or to develop epilepsy after a stroke, and so one of the recommendations that we make in the paper is that, for anybody who's experiencing seizures post-stroke who is not pretty quickly responding to anti-epileptic medications, they should be referred to a video EEG to determine if this is a functional seizure condition or epileptic seizures.

Lea Davis, PhD, of the Vanderbilt University Medical Center and Vanderbilt Genetics Institute, discussed the results of her research showing a novel association between functional seizures and cerebrovascular disease.

Novel Association Observed Between Functional Seizures, Cerebrovascular Disease

Patients with chronic refractory cough (CRC) may benefit from behavioral cough suppression therapy (BCST). In a session of the 2021 American Cough Conference, Laurie Slovarp, PhD, CCC-SLP, associate professor at the University of Montana in Missoula, said increased awareness of BCST is needed for clinicians and patients to know it as a noninvasive, efficacious, and inexpensive form of cough treatment, as well as to understand how this therapy works and how to identify eligible candidates.

According to Slovarp, BCST is known by various names, including speech pathology treatment for chronic cough, respiratory retraining, and cough-suppression physiotherapy.

“Just about every single paper refers to it by a different name,” she said. “If you see ‘speech pathology’ and ‘cough’ together, you can bet that we’re probably talking about the same therapy.”

Prior to using BCST, patients will often see multiple care providers, undergo multiple tests, and try multiple medications, she said.

However, up to 88% of patients with CRC using BCST have shown a reduction in cough severity through published studies. These reductions occurred in cough frequency and sensitivity, while also increasing quality of life for patients.

“These are all patients that have already failed just about every other medical treatment available to them,” Slovarp said.

A survey study published by Slovarp in 2021 investigated the post-BCST satisfaction of 164 patients in the United States and Australia. It found that 58% of patients reported being “quite satisfied” or “completely satisfied” following therapy. The mean change of 6.6 from the Leicester Cough Questionnaire was significant, according to Slovarp.

“There’s pretty reasonable efficacy data on BCST,” she said. “These patients are not just getting better a little bit, many of them have a pretty dramatic improvement.”

According to Slovarp, onset of CRC often occurs with a cough-inducing event, such as a respiratory virus. CRC may present itself in various ways, from a once-a-week coughing fit to a cough that induces gagging or vomiting.

“In my clinic, I see a wide variety of severity,” she said.

BCST is often determined with extensive case history, oral mechanism exam that may find muscle tension or tenderness in the neck, shoulders and suprahyoid, voice evaluation, urge-to-cough testing, and validated patient-report questionnaire.

“The biggest thing for me is the case history,” she said. “Most of the patients we see have been coughing for years.”

Treatment options may be educating patients about coughing including the safety of cough suppression, training patients to suppress coughing; increasing awareness of cough triggers and a pending cough; management of laryngopharyngeal reflux and postnasal drip, voice therapy, and, if needed, a challenge.

Cough-control breathing, relaxation, and swallowing techniques, as well as distractions, and resonant voicing are some of the methods employed in BCST.

“Over time, with suppression, you will feel a reduction in urge to cough,” she said.

Slovarp L. Issues in clinical cough management: Behavioral management of chronic refractory cough. Presented at: American Cough Conference; virtual. June 11, 2021. 

https://app.socio.events/NzMwMw/Agenda/85150/Session/385292

Noninvasive, efficacious treatment options are available to help patient outcomes and improve quality of life.  

Using Behavioral Management to Control Chronic Refractory Cough

Officials with the FDA have approved azelastine hydrochloride 0.15% (Astepro Allergy; Bayer) as an OTC product for the temporary relief of nasal congestion, runny nose, sneezing, and itchy nose associated with upper respiratory allergies such as hay fever. According to Bayer, the approval is the FDA’s first for a steroid-free, antihistamine nasal spray for allergies available OTC in the United States.

More than 50 million Americans are affected by allergies each year, according to Bayer. Azelastine hydrochloride 0.15% is indicated for adults and children 6 years of age and older. 

According to Catherine Vennat, vice president and general manager, GM Bayer Consumer Health US, azelastine HCI 0.15% addresses an unmet need for patients with allergic rhinitis. The approved OTC formulation is full prescription strength and can provide relief from allergy nasal symptoms that will last up to 24 hours.

Azelastine is currently only available with a prescription in the United States. According to Bayer, azelastine hydrochloride 0.15% is expected to become available in retail locations in early 2022.

Currently, OTC allergy medications includes 3 major classes: antihistamines, intranasal steroids, and mast cell stabilizers. Azelastine hydrochloride 0.15% will be the only OTC antihistamine nasal spray for indoor and outdoor allergy relief.

FDA Approves Astepro Allergy Nasal Spray for Over-the-Counter Use in the United States [news release]. June 17, 2021; Bayer. Accessed June 17, 2021. 

https://www.businesswire.com/news/home/20210617005872/en/FDA-Approves-Astepro%C2%AE-Allergy-Nasal-Spray-for-Over-the-Counter-Use-in-the-United-States

Astepro Allergy is the first steroid-free antihistamine of its kind to be available without a prescription.

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