A case report and literature review: Factitious disorder imposed on another and malingering by proxy

Factitious disorder imposed on another (FDIA) and malingering by proxy (MAL-BP) are two forms of underreported child maltreatment that should remain on physicians’ differential. This case of a 2-year-old boy, which spans 6 years, reveals the complexity in and difficulties with diagnosis. Key features include the patient’s mother using advanced medical jargon to report multiple disconnected concerns and visits to numerous providers. As a result, the patient underwent many investigations which often revealed normal findings. FDIA was suspected by the paediatrician, especially following corroboration with the child’s day care and past primary health care provider. This case demonstrates the possible overlap in diagnoses, which are characterized by a lack of consistent presentation and deceitful caregivers, often complicated by true underlying illness. The authors use clinical experience and limited existing literature to empower paediatricians to confidently diagnose and report FDIA and MAL-BP to limit future harm to children.

Association between knowledge of the pneumococcal vaccine, vaccination status and recommendations for vaccination

BACKGROUND Pneumococcal disease caused by Streptococcus pneumoniae has a high morbidity rate in elderly individuals aged 65 or older. Previous studies have demonstrated that low vaccination rates with the 23-valent pneumococcal polysaccharide vaccine (pneumovax) are due to a lack of awareness and knowledge about the vaccine in the general population. This study measured the association between the public’s knowledge of the pneumococcal vaccine, vaccination status, the type and number of health care facility visits per participant in the past year and number of advertisements seen for the vaccine. METHODS This study used a survey to test the knowledge of its participants on the pneumococcal vaccine and associated the results with nominal data such as vaccination status and recommendation for vaccination by their primary health care providers. The survey tested the participants using 15 true or false questions that assessed their knowledge on the pneumococcal vaccine and pneumococcal disease. RESULTS No association was found between the knowledge individuals have on the pneumococcal vaccine and whether their health care provider recommended the vaccine (p=0.467). However, a statistical difference in knowledge between individuals who are vaccinated and individuals who are not vaccinated was found (p=0.039 (CHI), p=0.011 (ANOVA)). There was also a positive association found between vaccination status and primary health care provider recommendation for the pneumococcal vaccine (p=0.001). No association was found between vaccination status and number of visits to a primary health care provider in the past year (p=0.149). Using an ANOVA analysis, it was found that there was a difference in number of advertising types seen for each vaccination status group (p=0.011). CONCLUSION Based on the results, it can be concluded that individuals who are vaccinated have more knowledge on the pneumococcal vaccine, but their knowledge is not affected by a recommendation to receive the vaccine from their primary health care provider. This suggests that health care providers are not providing sufficient information about the vaccine to their patients when they recommend it. Despite this knowledge gap, the association between vaccination status and primary health care provider recommendation for the vaccine indicates that individuals are more likely to get vaccinated when their primary health care provider recommends it. However, more visits to the provider annually did not influence the vaccination status of the patient. In addition, results from the ANOVA analysis suggest that participants who saw more vaccine advertisements were more likely to be vaccinated.

IBCLC Scope of Practice for Tongue-Tie Assessment

There is vigorous debate in the research, academic, public health, and clinical communities serving families with infants about the impact of infant ankyloglossia (“tongue-tie”) on effective breastfeeding and lactation. Will a tethered tongue (and perhaps even tethered lips and cheeks) negatively impact lactation and result in suboptimal breastfeeding and early weaning? What options can we offer families who seek relief from nipple pain, low-weight gain, and distressed babies? These are legitimate questions, but a more elementary examination is whether it is within the scope of practice for the IBCLC to assess the infant’s oral cavity, observe a feed-at-breast, and share concerns with the primary health-care provider. This article reviews the practice-guiding documents relevant to ethical and clinical care by an IBCLC and highlights the authority that allows the IBCLC to offer evidence-based information and support, including a comprehensive feeding assessment, for the baby suspected of tongue-tie.

Socioeconomic factors associated with pituitary apoplexy

Object Pituitary apoplexy is associated with worse outcomes than are pituitary adenomas detected without acute clinical deterioration. The association between pituitary apoplexy and socioeconomic factors that may limit access to health care has not been examined in prior studies. Methods This study involved retrospectively evaluating data obtained in all patients who underwent surgery for nonfunctioning pituitary adenoma causing visual symptoms between January 2003 and July 2012 at the University of California, San Francisco. Patients were grouped into those who presented with apoplexy and those who did not (“no apoplexy”). The 2 groups were compared with respect to annual household income, employment status, health insurance status, and whether or not the patient had a primary health care provider. Associations between categorical variables were analyzed by chi-square test and continuous variables by Student t-test. Multivariate logistic regression was also performed. Results One hundred thirty-five patients were identified, 18 of whom presented with apoplexy. There were significantly more unmarried patients and emergency room presentations in the apoplexy group than in the “no apoplexy” group. There was a nonsignificant trend toward lower mean household income in the apoplexy group. Lack of health insurance and lack of a primary health care provider were both highly significantly associated with apoplexy. In a multivariate analysis including marital status, emergency room presentation, income, insurance status, and primary health care provider status as variables, lack of insurance remained associated with apoplexy (OR 11.6; 95% CI 1.9–70.3; p = 0.008). Conclusions The data suggest that patients with limited access to health care may be more likely to present with pituitary apoplexy than those with adequate access.