Evidence Catalog
Block 9
February 24, 2020
HypoEXIT Trial: Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia
- The HypoEXIT trial was a randomized controlled noninferioty trial comparing neurodevelopmental outcomes at 18 months for newborns who are treated at a traditional hypoglycemia threshold of 47 versus a lower threshold of 36 mg/dL.
- The study found that Bayley Scores of Infant and Toddler Development for cognitive and motor domains were not different between the traditional threshold and lower threshold groups.
- This aligns with the LPCH Newborn Nursery Asymptomatic Hypoglycemia Protocol, which uses 35 as the threshold for the initial feed after birth and 45 as the threshold for subsequent feeds for the first 24 hours of life.
Example Citation
In The New England Journal of Medicine from 2020, the HypoEXIT trial showed that a BG threshold of 36 was non-inferior to a threshold of 47 when comparing developmental outcomes at 18 months. This evidence supports a hypoglycemia algorithm that balances expectant monitoring and treatment.
February 3, 2020
Got The Flu? AAP Reccomendations for Prevention and and Control of Influenza
- WHO can/should receive influenza vaccine:
- AAP recommends annual influenza vaccine for all children ages 6 months and older
- Children with egg allergy CAN receive the influenza vaccine
- Children with a minor illness with or without fever (including viral URI or allergic rhinitis)
- Children who have had an allergic reaction after a previous dose of the influenza vaccine should be evaluated by an allergist -> anaphylaxis is a contraindication
- Moderate to severe febrile illness (high fever, active infection, requiring hospitalization), on the basis of the clinician, can be deferred until illness resolves
- History of Guillain-Barre <6 weeks after prior influenza vaccine is a PRECAUTION
- Multiple contraindications for the live-attenuated vaccine (ie. <2 yo, pregnant, immunocompromised or received other live vaccines with 4 weeks prior)
- AAP recommends annual influenza vaccine for all children ages 6 months and older
- WHAT does the influenza vaccine contain:
- 2 types of influenza vaccine approved for use in children/adolescents this year -> The inactivated influenza vaccine and the live-attenuated influenza vaccine. Both are quadrivalent vaccines
- 2 types of influenza vaccine approved for use in children/adolescents this year -> The inactivated influenza vaccine and the live-attenuated influenza vaccine. Both are quadrivalent vaccines
- HOW and WHEN should the vaccine be given:
- Children ages 6 through 35 months can receive either a 0.25 mL or 0.5 mL dose
- Children 36 months and older should receive the 0.5 mL dose
- Children ages 6 months through 8 years old who are receiving influenza vaccine for the FIRST time or who have received only 1 dose previously, should receive 2 doses of the influenza vaccine
- The AAP recommends all children ideally receive the influenza vaccine by the end of October
- Children ages 6 through 35 months can receive either a 0.25 mL or 0.5 mL dose
January 31, 2020
CaseWatchers: A 13 year Old Goes Inner Tubing!
- A 13 yo M presents to the ED with vague abdominal pain for one morning, worsening throughout day, with NBNB emesis x 2.
- History reveals no other concerning symptoms, fairly negative ROS, and the fact that the family went inner tubing yesterday afternoon though the patient does not remember any specific injuries.
- Exam reveals a slightly uncomfortable patient with a large bruise over the R hip, and mild TTP of abdomen throughout, worst in LUQ. Exam otherwise WNL.
- If we were worried about blunt abdominal trauma in this pediatric patient who is hemodynamically stable, could we do a FAST? Yes!
- FAST was positive for free fluid in Morrison's pouch, so the patient got a CT which revealed a duodenal hematoma.
- Patient was admitted for fluids and pain control, then discharged. However, he quickly returned with new onset bilious emesis! He was admitted again for fluids, NPO, and gastric decompression.
- During his second admission, he broke out in a rash: palpable purpura on the bilateral lower extremities. HSP was diagnosed (and can be associated with duodenal hematoma).
- Keep your differential broad but practical! This patient could have been monitored in many settings prior to extensve workup, but remember more rare causes of abdoinal pain once a patient worsens.
January 27, 2020
What do we know about the use of FAST in kids? The sensitivity of FAST US in pediatric blunt abdominal trauma.
- Plain radiographs are typically not useful in the setting of blunt abdominal trauma (BAT), but suspect abdominal injury if you see lower rib fractures, diaphragmatic hernia, free air under diaphram, or pelvic ring fractures.
- Abdominal CT is the gold stanard (97% sensitivity and specificity) for intra-abdominal injury but the use of CT is restricted to hemodynamically stable patients and incurs a radation risk.
- Abdominal ultrasound is used primarily to detected free intraperitoneal fluid, and is not as helpful for injury to solid organs or in patients who are combative.
- A meta-analysis of of the performance of abdominal US in pediatric BAT evaluated 25 studies to better understand test performace.
- The study found that when looking at all studies, the sensitvity of FAST was 80%, but when looking at high grade methodology studies only, the sensitivity dropped to 66% for intra-abdominal injury.
- Specificity of US remained high at 95% in both sub-analyses.
- Stable children with a positive ultrasound should undergo CT for further detailed characterization, however a negative US is not necessarily sensitive enough to rule out abdoinal injury if clinical suspicion is high.
January 24, 2020
The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees
January 13, 2020
ESCAPE Trial: Strict Blood Pressure Control and Progression of Renal Failure in Children
- RCT of 385 children with chronic kidney disease (GFR 15-80mL/min/1.73m2) all of whom received ramipril 6mg/m2/day
- Objective to assess the renoprotective effect of intensified blood-pressure control among
children receiving a high dose of an angiotensin-converting-enzyme (ACE)
inhibitor
- Primary end point: Time to decline of 50% in GFR or progression to end-stage
renal disease (ESRD)
- Randomized to be in conventional BP group (MAP between 50th and 90th percentile) or intensified BP group (less than 50th percentile). Used anti-hypertensives that did not affect renin-angiotensin symtem to achieve BP goals
- Main Result: In intensified BP group, 29.9% of patients had decrease in GFR by 50% or progressed to ESRD compared to 41.7% in the conventional BP group (hazard ratio 0.65, CI 0.44-0.94, p=0.02)
- Proteinuria rebounding (in all groups) depsite good BP control
Example Citation
In NEJM in 2009, the ESCAPE Trial of 300+ patients with chronic kidney disease showed that intense blood pressure control delayed progression of renal disease. This suggests that keeping this patient’s blood pressure less than the 50%ile can help to protect the patient’s kidneys.
January 10, 2020
Hematology Board Review
- Remember that all residents have access to the last three years of FREE board review questions through the AAP website (Prep Questions).
- Thrombocytopenia with Absent Radius syndrome = a "commonly" tested board topic, look for neonate with absent radius (shortened arm), normal thumb (as opposed to hypoplastic thumb in Fanconi Anemia), and thrombocytopenia.
- Other congenital platelet syndromes to know are Bernard Soulier (absence of glycoprotein 1b, leading to giant platelets) and Wiskott Aldrich (thrombocytopenia, eczema, and recurrent infections).
- Use retic count (production vs destruction problem) or MCV to help think through childhood anemias.
- Normal MCV (in a non-infant child) = approximately 72 + age in years.
- Transient erythroblastopenia of childhood (TEC) is an idiopathic, self-limited anemia with normal WBC and platelet counts; patients need serial Hgb and retic counts to monitor resolution.
January 6, 2020
Randomized Trial of Platelet-Transfusion Thresholds for Neonates
- RCT of 660 neonates (<34 weeks with platelet count <50,000) with primary outcome of death and major bleeding in neonates assigned to high-threshold group (Platelet count less than 50,000) vs. low-threshold group (Platelet count less than 25,000)
- Death or major bleeding episode occurred in 26% of infants in the high-threshold group compared to 19% of infants in the low-threshold group, odds ratio of 1.57 (95% CI 1.06 to 2.32, p=0.02)
- Higher rate of survival at 36 weeks for neonates with BPD in the high-threshold group (63%) compared to the low-threshold group (54%), odds ratio 1.54 (95% CI 1.03 to 2.30)
- 90% of infants in the high-threshold group compared with 53% of infants in the low-threshold group received at least 1 transfusion, hazard ratio 2.75 (95% CI 2.36 to 3.21)
Example Citation
In the NEJM from January 2019, an RCT of preterm neonates showed that use of a high platelet count threshold (50,000) showed that use of a high platelet count threshold (50,000) compared to a low platelet count threshold (25,000) resulted in significantly higher rates of death and major bleeding, therefore I would like to hold off on transfusing our patient.
December 16, 2019
Using The EMR to Practice EBM: An Example of Clinical Decision Support
- We have spent the last 6 months learning guidelines and evidence to guide clinical practice, but barriers remain on actually implementing these into clinical practice!
- Computerized physician order entry (CPOE) has been adopted in many children’s hospitals partly because of its potential to decrease medical errors and enhance efficiency
- The ability to tether CPOE to automatic clinical decision support (CDS) alerts represents a new tool whereby providers might be informed of best-practice and evidence based guidelines in real time
- At our own institution, a cohort study in 2011 assessed whether an automated alert regarding RBC transfusion would impact practice and decrease provider variability
- The alert appeared if Hgb > 7 and patient was normotensive for age; the alert provided a reference to new evidence and was not a hard stop for the clinician
- Results showed decreased pre-transfusion Hgb in the PICU and acute care wards, decreased total number of RBC transfusions per patient day, and decreased relative risk of receiving a transfusion in the study period as compared to the control.
- Consider the EMR as a possible tool in the future to implement practice guidelines on a real-time basis!
Example Citation
Approach your friendly neighborhood clinical informatics team! You might say, “I’m noticing a lot of practice variability in how we order IVF for children, despite strong evidence based guidelines on this topic. A cohort study from Pediatrics 2011 showed that clinical decision support alerts were able to impact RBC transfusion practices in pediatric patients. Is this something we can work on for IVF too?”
December 13, 2019
Teaching Senior Journal Club: Management of Chorioamnionitis-Exposed Infants in the Newborn Nursery Using a Clinical Examination–Based Approach
- Chorioamnionitis is a relatively common intrapartum clinical diagnosis and represents a significant risk factor for neonatal early-onset sepsis (EOS).
- Since the initiation of maternal group B streptococcus screening and intrapartum antibiotic prophylaxis, the risk of culture-positive EOS in chorioamnionitis exposed late preterm and term infants is low, and even lower in infants who are clinically well-appearing at birth.
- Empiric antibiotic approaches in chorioamnionitis exposed infants result in antibiotic exposure for a high number of well-appearing, uninfected infants and may result in impaired maternal-infant bonding.
- In the setting of a QI framework in this institution (LPCH), it was demonstrated that management of well-appearing chorioamnionitis exposed infants by using a clinical examination-based approach during couplet care in the postpartum unit maintained low rates of sepsis laboratory testing and antibiotic use and markedly reduced mother-infant separation, without adverse events.
December 9, 2019
High Index of Suspicion in the Nursery: A Summary of Early Onset GBS Sepsis (EO-GBS)
- Most EO-GBS occurs within the first 24 hours of birth, although the definition includes disease with onset in the first postnatal week.
- 83% of EO-GBS cases manifest as sepsis without a focus, 9% as pneumonia, 7% as meningitis.
- Risk factors include GBS colonization, hx of infant with invasive GBS disease, PROM, prematurity, intrapartum fever, and lesser known: African American race, obesity.
- When suspicious cover broadly with amp/gent, then narrow to Pencillin G or amp alone once GBS confirmed. Duration depends on location of infection.
- Screening and intrapartum abx has had a significant impact on early onset, but not late onset GBS sepsis.
- There are caveats of management based on adequacy of intrapartum antibiotics, GA of infant, hours of rupture of membranes, and clinical status - AAP and CDC have slightly different recommendations regarding who needs empiric coverage, who needs 48h obs, and who needs screening labs.
- EO-GBS case fatality rates are ~5% with worse outcomes for those with neurologic disease.
December 6, 2019
CaseWatchers: 10-month old with mastoiditis
- A 10-month old previously healthy female presented with 5 days of fever and protruding auricle consistent with mastoiditis.
- Mastoiditis is oftentimes a secondary complication of acute otitis media.
- Often polymicrobial, with most common bugs being Strep pneumo, Coag negative Staph, GAS, H. flu, anaerobes, and Staph aureus.
- In uncomplicated cases, CT can be postponed 48 hours while IV antibiotics are initiated, and if no improvement after 48 hours, then proceed to CT scan.
- At LPCH, we typically use an empiric antibiotic to cover Strep, MSSA, and anaerobes, such as Ampicillin-Sulbactam.
- 48 hours later, the patient has continued high fevers and postauricular swelling, concerning for a complicated case of mastoiditis. Complications include intracranial (meningitis, abscess, venous sinus thrombosis) and extracranial (subperiosteal abscess, hearing loss, Bezold abscess).
- CT scan showed coalescent mastoiditis, subperiosteal abscess, epidural abscess, internal jugular vein thrombosis, and sigmoid sinus thrombosis.
- The patient underwent surgical management including mastoidectomy, drainage of subperiosteal abscess, and myringotomy with ear tubes.
- Blood culture grew Fusobacterium, which combined with jugular vein thrombosis, is consistent with Lemierre Syndrome.
December 2, 2019
- Current recommendations for treatment of hematogenous osteomyelitis are IV antibiotics for 3-4 days until signs of clinical improvement, then PO antibiotics to complete a total 3-4 week course
- This systematic review included 6 randomized controlled trials of anitbiotic choice and duration.
- Results showed close to 100% success rates with 3-4 days of IV antibiotics plus PO antibiotics to complete a total 3-4 week course as compared to longer duration of IV antibiotics.
- Clindamycin, Cephalosporins, Ampicillin-sulbactam, showed similar efficacy, but nafcillin showed only a 69% success rate.
- At LPCH, usual practice is to start treatment with Cefazolin IV and narrow coverage based on available culture and susceptibility results.
November 22, 2019
CaseWatchers: 16 year old male with left ankle pain (David Mahoney and Emily Larimer)
- 16 year old male presents with 6 weeks of left ankle pain, 25 pound weight loss, night sweats, and balanitis
- Patient was treated for gonorrhea in the ED but developed additional joint pain in the shoulders.
- Differential includes rheumatologic (juvenile idiopathic arthritis, reactive arthritis, Behcets), oncologic (osteosarcoma, lymphoma), infectious (tuberculosis, septic arthritis, osteomyelitis, gonorrhea, Coccidioides, Bartonella, Brucella)
- The patient underwent an ultrasound of the ankle that was read as an infiltrative bony process with periosteal reaction, so an oncologic diagnosis rose higher on the differential.
- However, a followup MRI showed no bony involvement, and upon reviewing the ultrasound with radiology, there was actually no bony involvement.
- The patient consented to a GU exam, which showed significant penile ulcers.
- Despite the GC/CT NAAT being negative, the decision was made to treat with a 7-day course of Ceftriaxone for disseminated gonorrhea. The patient improved and was discharged.
- The patient re-presented to the ED with rash, shoulder pain, and uveitis, and rheumatology treated the patient with steroids for reactive arthritis.
November 18, 2019
Early Versus Late Parenteral Nutrion in Critically Ill Children
- RCT looking at early (within 24 hours) vs. late (on morning of Day 8) intiation of TPN for critically ill children in the ICU
- Late initiation of TPN resulted in shorter ICU stay
- Late initiation of TPN resulted in shorter hospital stay
- No stastitical difference seen in survival with early vs. late initiation of TPN
- Late initiation of TPN resulted in fewer infections
- Late initiation of TPN resulted in shorter duraction of mechanical ventilation
- Late initiation of TPN resulted in less need for renal replacement therapy
Example Citation
The PEPaNIC Trial from the NEJM in 2016, found in a RCT of 1440 PICU patients, improved clinical outcomes (shorter ICU stay (6.5 vs 9.2 days), less new infections (10.7 vs 18.5%), shorter hospital stay, less renal replacement therapy, and shorter duration of mechanical ventilation in patients started on TPN "late" (day 8 of ICU stay) vs early (within 24 hours of PICU admission). In general, starting TPN later is preferable based on the available evidence.
November 15, 2019
Teaching Senior Journal Club: Feasibility and Accuracy of Fast MRI Versus CT for Traumatic Brain Injury in Young Children
- Fast MRI can be performed in about 6 minutes compared to 1 minute for CT, and is accurate in facilities with a 3 Tesla MRI scanner. 99% of children below the age of 6 years were scanned without the use of sedation.
- Fast MRI was about 92% sensitive for CT findings of traumatic brain injury. No "missed" CT findings required neurosurgical intervention. The most frequently missed MRI finding is skull fracture, which is not a classic traumatic brain injury and of questionable clinical significance. However, MRI identified subdural hemorrhages and cerebral contusions missed by CT scan. MRI was better able to distinguish subarachnoid spaces from subdural hemorrhage in suspected non-accidental trauma.
- The high rate of families who declined consent limit this study's ability to be generalized to all children.
- The bottom line: Fast MRI is feasible and accurate relative to CT in clinically stable children to identify clinical important traumatic brain injury.
November 12, 2019
Pediatric Head Trauma Board Review
- A mnemonic for the symptoms of concussion based on the CDC Heads Up Guidelines and the Sport Concussion Assessment Tool V (SCAT V) is COACH CV: Cognitive, Oculomotor, Affect, Cervical Spine, Headaches, Cardiovascular, Vestibular.
- The CDC Heads Up and SCAT V guidelines for return to play after concussion recommend 24-48 hours of complete physical and cognitive rest, followed by a stepwise return to activity. Each step should take at least 24 hours, and if the patient has any symptoms, they should return the previous step.
- Risk factors for postconcussive syndrome (symptoms > 4 weeks) include history of motion sickness, ADHD and learning disability, mood disorders, and history of previous concussions.
- Highest risk sports for concussion are soccer, basketball, football, and rugby. Lowest risk are baseball, softball, volleyball, and gymnastics.
November 8, 2019
A developmentally delayed female with abnormal uterine bleeding - how do you build a differential?
- A 12 year old non-verbal CPDD female presents with presumed abdominal pain and vaginal bleeding for 2 weeks.
- Major categories for a differential of abnormal uterine bleeding in a young female: anovulatory uterine bleeding, endocrine disorders, pregnancy related complications, cervical problems, uterine problems, ovarian problems, infection, bleeding disorders, vaginal abnormalities, trauma, foreign body, systemic disease, meds.
- CT abdomen obtained in the ER reveals a large pelvic/abdominal mass.
- Differential for pelvic/abdominal masses: abscess, cyst, endometrioma, adnexal torsion, ectopic or uterine pregnancy. Oncologic processes include Wilm's tumor, neuroblastoma, non-Hodgkins lymphoma, rhabdomyosarcoma, germ cell tumor, hepatoblastoma.
- First time prolonged vaginal bleeding with no PMH or FH of abnormal bleeding would not be a common presentation of a bleeding disorder, but can be a presenting symptom of an ovarian malignancy.
- LDH, B-hCG, and AFP are good initial screening markers if suspecting a germ cell tumor.
November 4, 2019
Menstrual Patterns in the First Gynecologic Year: What is "normal" for early menstrual cycles in healthy adolescent females?
- To understand when to further workup abnormal uterine bleeding (AUB) in a healthy female teen, we must first understand what is "normal" during the period of early menses.
- This systematic review of 26 studies evaluted > 2000 female teens and data from > 4000 menstrual cycles (during the first gynecologic year), looking at cycle patterns, symptoms, and presence of ovulation when available.
- There are many tools that can be used in systematic reviews to determine the quality of the evidence you are choosing to include: examples are Downs and Black checklists or Cochrane risk of bias tools.
- Interesting findings: 90% of females have periods lasting 7 days or less, > 50% of patients have at least one cycle length over 45 days, many girls are ovulating even in the presence of abnormal cycles.
- Look at "Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign" - a statement jointly made by ACOG and AAP for recommendations of when to consider further workup.
- Also remember the broad differential for AUB: pregnancy, endocrine, stress, tumors, etc.
November 1, 2019
Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association. Circulation. 2019.
- After routine screening for dyslipidemia in all children ages 9-11 and 17-21 years of age, if the LDL is high, the next step is to risk stratefy into high risk, moderate risk, or at risk according to the AHA Scientific Statement on Cardiovascular Risk Reduction in High-Risk Pediatric Patients.
- If LDL is high, the first step for all risk categories is lifestyle interventions.
- For the high risk patients, initiate statins at the same time as lifestyle interventions.
- The goal of lifestyle interventions is LDL<100 for high risk patients, <130 for moderate risk, and <160 for at risk.
- After 3-6 months of lifestyle interventions, if the LDL is still above goal, then initiate statin therapy.
- Recall that there are two forms of familial hypercholesterolemia, heterozygous (LDL>155) and homozygous (LDL>300-500).
- A 2019 trial of 20-year followup of statin therapy in familial hypercholesterolemia showed reduction in cardiovascular events and mortality.
October 30, 2019
Cochrane Review: Statins for children with familial hypercholesterolemia (2017)
- The National Heart, Lung, and Blood Institute and AAP Bright Futures recommend lipid screening for all children at two time points: once between age 9-11 years and again between ages 17-21 years.
- Screening should start earlier and be repeated every 1-3 years for children with risk factors.
- Familial hypercholesterolemia is common (1 in 250 people), and there is a heterozygous and a homozygous form.
- Familial hypercholesterolemia is diagnosed by high LDL cholesterol plus family history or cutaneous or tendon xanthomas (lipid deposits).
- This 2017 Cochrane Review of over 1000 pediatric patients with heterozygous familial hypercholesterolemia showed that LDL was 30% lower in patients treated with statins than with placebo.
October 25, 2019
Principles of Epidemiology and Study Design: An Overview by Mary Leonard
When asking the question "Are the study results true?", think about internal validity (the structure of a study) and external validity (how universal the results are).
Internal validity is impacted by bias, confounding factors, and chance.
Important types of bias to assess for include selection bias (enrollment errors, non-representative samples) and measurement/information bias (misclassification, recall).
Counfounding factors are factors that have an independent association with both the exposure and the outcome without being part of a causal pathway.
Recognize the limitations of different types of study design: case report (not generalizable), case series (no control group, hard to know what factors are unique to the illness), cohort studies (prolonged, costly, hard to do if disease is rare), case-control (difficult to establish temporal relationships). RCTs are the gold standard!
When interpreting a study, don't just look at bias or design, but always think about how those factors change the outcome of interest- does it make the finding more or less significant?
October 21, 2019
Why formally train providers in relationship-centered communication with patients? Both patients and providers benefit.
- There is a growing body of evidence showing that the "patient experience" directly impacts patient satisfaction and other outcomes including adherence to therapies, return to medical care, and understanding of medical instructions.
- In an observational cohort study, this study assessed patient satisfaction, physician burnout, and physician empathy in relation to a 8 hour interactive course on relationship-centered care.
- Results showed that regardless of specialty or baseline scores, providers who received the training scored higher on patient satisfaction scores in multiple domains such as respect, clear conveyance of information, and understanding of patient medical history.
- Additionally, providers themselves reported improved empathy and burnout that persisted to at least 3 months from the training.
- In efforts to improve patient communication for our own institution, pediatric residents will be participating in ACES (Advancing Excellence in Communication at Stanford) at the upcoming set of academic half days!
October 11, 2019
Teaching Senior Journal Club: Food Insecurity, Health, and Development in Children Under Age Four Years
- Food security is defined as limited or uncertain access to adequate nutritious and safe food for all household members to lead an active and healthy lifestyle.
- USDA 2018 national survey showed 14% of households met criteria for food insecurity.
- Remember the hunger vital signs! Ask 2 questions at every visit.
- Question #1: "Within the past 12 months were you worried whether your food would run out before you had money to buy more?"
- Question #2: "Within the past 12 monthsm did the food you bought not last and you didn't have money to get more?"
- In this study, food insecurity was found to be associated with developmental risks and increased odds of poor health.
- However, food insecurity was not associated with obese or underweight status.
October 7, 2019
Screening for Poverty & Poverty-Related Social Determinants of Health
- The AAP published a policy statement on Poverty and Child Health in the United States in 2016, which outlines recommendations for clinicians and policy makers with regards to childhood poverty.
- In 2014, 43% of US children lived in families with 200% or less of the federal poverty level ($47,700 for a family of 4).
- Social determinants of health include income, food security, housing, literacy, immigration, and personal safety.
- There are many validated screening tools for poverty-related social determinants of health, and the AAP recommends screening at each well child visit.
- Federal programs that have no citizenship or legal residency requirements (as of October 2019) are Women, Infants, and Children (WIC), the National School Lunch Program, and Head Start/Early Head Start.
October 4, 2019
A Teenager with Erythema Nodosum and hypertension: A Case of Takayasu Arteritis
- A 17 year old patient presents with findings consistent with systemic inflammation erythema nodosum. Think of a broad differential, including infectious etiologies (bacterial - eg. Strep, fungal - eg. Cocci, and viral - eg. EBV), drug reactions (sulfa, steroids), IBD, malignancy, and others (sarcoidosis, pregnancy, and more).
- If suspecting a rheumatologic illness, obtain ANA IFA (results reported as titers) if you are suspicious of lupus specifically. If unsure whether an ANA would be helpful, ask rheum!
- The patient also developed oral lesions, intermittent fevers, weight loss, and adenopathy. If unsure of a diagnosis with broad systemic symptoms, be cautious about moving forward without ruling out something oncologic. Steroids can impact an onc diagnosis dramatically, and may be the course of action for a rheumatologic or other inflammatory illness.
- On a PET MRI obtained to rule out an oncologic process, the patient was discovered to have large vessel vasculitis of the aorta secondary to Takayasu arteritis.
- Takayasu is a rare disease with vague pediatric presentation, and is diagnosed with angiographic abnormalities in the setting of elevated ESR and pulse or BP abnormalities. If undiagnosed, patients are at risk for aortic regurgitation, congestive heart failure, and ischemia.
- Treat with steroids, anti-inflammatory agents, and anti-coagulants as needed.
September 30, 2019
Usefulness of antinuclear antibody testing to screen for rheumatic disease
- An ANA should be ordered in a patient who has clinical signs consistent with a rheumatologic disease, such as 4 of the 11 criteria for lupus from the American College of Rheumatology
- This seminal study showed that 41% of the participants had a positive ANA test at titres of 1:20 or greater, but only 15% had a rheumatic disease. 3% had lupus or mixed connective tissue disease.
- The receiver operator characteristic (ROC) curves for ANA showed that ANA at titres of 1:160 to 1:320 had a reasonable true positive rate (sensitivity) with a reasonably low false positive rate for lupus or mixed connective tissue disease, suggesting that ANA at higher titres can be a reasonable screening test for lupus or mixed connective tissue disease in children with clinical symptoms of these disorders.
Example Citation
In The Archives of Disease in Childhood from the 1900s, a retrospective review of over 1000 children with an ANA test showed that ANA had a high true positive rate and low false positive rate for lupus at titres between 1:160 and 1:320 on the receiver operating characteristic curve. At lower titres, the false positive rate was high, indicating that many children without lupus have positive ANA in low titres. This suggests that our patient may have a positive ANA in low titres, but this would not indicate that she necessarily has lupus.
September 23, 2019
Shiga-toxin producing E. Coli Infection, antibiotics and the risk of developing Hemolytic Uremic Syndrome: A Meta-analysis
- Review of literature: Antibiotic use in Shiga-toxin producing E. coli (STEC) infection is controversial. Antibiotic use may increase risk of developing hemolytic uremic syndrome HUS. In vitro, antibiotics increase shiga toxin production by E. coli
- CDC urges against the use of antibiotics for STEC, despite this approximately 1/3rd of HUS patients in a nationwide survery received antibiotics prior to developing HUS
- Eligible studies contained: 1) series of patients with documents STEC infection, 2) development of HUS and 3) antibiotic administration prior to development of HUS documented
- 17 studies included in meta-analysis. 3 independent trained reviewers who were blinded to the other reviewer's scores, assessed the risk of bias using the Newcastle-Ottawa scale for non-randomized studies and used Cochrane risk of bias for randomized trials. Generated pooled OR estimates and 95% confidence intervals using random-effects models
- Results: Pooled OR of ALL studies (regardless of their definition of HUS) was 1.33 (95% CI 0.89-1.99). When restricted to studies with low risk of bias and using accepted definition of HUS, OR of developing HUS after antibiotic treatment increased to 2.24 (95% CI 1.45-3.36).
- New concept Monday: Cochrane Risk of Bias. Risk of Bias covers 6 domains. 1) Selection bias- Random sequence generation and allocation concealment, 2) Performance Bias- blinding of participants and personnel, 3) Detection Bias- blinding of outcome assessment, 4) Attrition Bias- incomplete outcome data, 5) Reporting Bias- selective reporting, 6) other bias. Assined a judgement of high, low or unclear risk of bias in each domain.
Example Citation
In a meta-analysis published in Clinical Infectious Diseases from October, 2015, when assessing studies at low risk of bias and using an accepted definition of HUS, it was found that patients with STEC treated with antibiotics as compared to no antibiotic treatment had increased risk of developing HUS. Therefore, for our patient who presents with STEC, I would recommend not treating with antibiotics as this might increase her risk of developing HUS.
September 20, 2019
Teaching Senior Journal Club State Gun Laws and Pediatric Firearm-related mortality
- Firearm injuries are a leading cause of death among children. ~7 US children die of firearm-related injuries daily
- This repeated cross-sectional study demonstrated that states with stronger gun laws have lower pediatric mortality rates. They showed that for every 10 point increase in the gun law score, the predicted pediatric mortality rate secondary to gun violence decreases by 4%. Gun law score = a composite score created by the Gifford Law Center and the Brady Campaign based on a rubric of gun laws that gives states a score with a range of negative scores to max 100.
- States with universal background checks for firearm purchases have a lower predicted mortality rate with an adjusted IRR of 0.65 (0.46-0.90)
- This study supports the implementation of universal background checks for firearm purchases as a means to reduce pediatric mortality s/t gun violence and supports the claim that stronger gun laws can prevent pediatric mortality s/t gun violence.
September 16, 2019
Firearm Related Injuries Affecting the Pediatric Population: AAP Policy Statement
- If you own a firearm, AAP recommends it be stored unloaded and locked up with ammunition stored seperately
- The risk of dying by suicide is 4 to 10 times higher in homes with guns
- Children as young as 3 years may be strong enough to pull the trigger on a handgun
- Community-based interventions created by pediatricians have reduced firearm-related injuries in children
- Child-based programs, such as NRA's Eddie Eagle GunSafe program are not as effective
- 20% of home with children present have at least one gun
- The ASK (Asking Saves Kids) Campaign promotes the simple idea of asking ʺIs there an unlocked gun in your house?ʺ before sending your child over to play
- Suicide attempts are dependent on the means available (vast majority of suicide in children occur via suffocation or firearm use)
- Suicide death peaks in teh 15- to 19-year old age group
- AAP recommends questions regarding gun possession and accessibility may be integrated into the history and phyiscal examination or a pre-visit screening questionnaire
September 13, 2019
ARDS in A Previously Healthy Adolescent Male: Hypersensitviity Pneumonitis Secondary to E-Cigarette Exposure
- History: 17 yo Male with URI symptoms, fevers, and acute respiratory distress with bilateral opacities on CXR, ultimately requiring intubation for developmend of ARDS.
- Differential: ID (Atypical and typical PNA, viruses (influenza), fungal (cocci)), Rheum (ANCA vasculitis, SLE, Churg Strauss), Allergy/Immuno (Hypersensitivity Pneumonitis), Congenital (CPAM, Cor Triatriatum), Trauma, Heme (HHT, pulmonary hemmorhage), Onc (Pulmonary Mets)
- Hospital Course: Escalated to ECMO. Infectious and Rheumatologic workup negative, but found to have peripheral and BAL eosinophils.
- Hospital Course: Found to have hx of Vaping with friends. Treated with steroid pulse, resulting in significant improvment. Patient now in rehab.
- Diagnosis? Hypersensitivity pneumonitis secondary to e-cigarette exposure.
- Lesson 1: ARDS strategies involve high PEEP, low FiO2, identify trigger. Trauma causes a more indolent ARDS presentation than other triggers.
- Lesson 2: Steroids should not be empirically used in ARDS (no evidence) unless you are concerned for an underlying trigger needing steroids as treatment.
- Lesson 3: Ask about inhalation and substance use, ask specifically about vaping and JUUL (separately), and document social history.
September 9, 2019
Pulmonary Illness Associated with E-cigarette Use, A preliminary Report. Case Series in NEJM Sept 2019.
- Syndromic Surveillance: Identifies early clusters of illnesses before diagnosis is confirmed. Used for early detection of outbreaks.
- Mean monthly rate of visits to the ED in IL for severe respiratory illness as identified by syndromic surveillance between June 1 and August 15, 2019 was twice the monthly rate that occurred between June 1 and August 15, 2018.
- Defintion of confirmed case: 1) Use of E-cigarette or dabbing within 90 days of symptoms onset AND 2) pulmonary infiltrates (opacities on CXR or ground glass opacities on CT AND 3) Absence of pulmonary infection on initial workup AND 4) no evidence of alternative plausible causes
- 53 cases in IL and WI (July- Aug 2019) met the definition of a probable case (25 total) or confirmed case (28 total).
- 100% had history of e-cigarette use within 90 days. 94% reported use in the week before
- 98% had respiratory symptoms with SOB most common, 81% had GI symptoms, 100% of patients had constitutional symptoms
- 69% had SpO2 <95% on admission
- 91% had abnormal chest Xray. 48/53 patients had a chest CT and abnormal results found in 100% of chest CT - opacities in bilateral lungs present in 100% of patients. Ground glass opacities characteristically observed in lower lungs, somtimes with subpleural sparing
- 94% required hospitalization with median duration 6 days
- ICU admission for respiratory failure common (58% of all patients, 62% of hospitalized patients).
- 32% required intubation and mechanical ventilation with 2 requiring ECMO and 1 death
Example Citation
Based on the recent NEJM case series from September, 2019 investigating severe pulmonary disease associated with e-cigarette use, I think our patient meets the case definition and we should report this case to our local/state public health department. Additionally, we should provide supportive case as needed with respiratory support and consider steroids.
August 30, 2019
AAP Febrile UTI Guidelines for Children 2mo-24mo
- The most important risk factor for UTI in males age 2-24 months is being uncircumcised. Risk of UTI in febrile males less than 3 months is 20% in uncircumcised males and 2% in circumcised males.
- The most specific UA finding for UTI is nitrite, but nitrites are not sensitive for UTI because babies do not keep urine in the bladder long enough for bacteria to convert nitrites to nitrate, and gram positive bacteria will not produce nitrites.
- Oral Keflex or Augmentin are common first-line empiric options for UTI management. IV antibiotics are indicated for inability to tolerate PO.
- Renal and bladder ultrasound is indicated after the first febrile UTI, and VCUG is only indicated if the RBUS is abnormal.
- Recall that constipation is an important risk factor for UTI, and constipation management has been shown to significantly reduce the risk of recurrent UTI.
August 26, 2019
Bacteremic UTI in Neonates < 60 days old: How long is too long when it comes to IV antibiotics?
- Approximately 8-10% of patients with UTI have concomitant bacteremia.
- There are not any guidelines in place regarding IV or total duration of antibiotics in infants with bacteremic UTI and many studies (including those on UpToDate) exclude patients with bacteremia in their cohorts.
- In a retrospective cohort study, infants < 60 days old with UTI and bacteremia (with the same organism in urine and blood cultures) were placed into two groups based on the duration of their IV abx therapy: short course = 7 or less days, long course = greater than 7 days.
- Results: There was no significant difference in rates of recurrent UTI or re-hospitalization in 30 days. Long course abx group had longer LOS by an average of 6 days.
- But what if 7 days still seems too long? Another retrospective cohort study by Schroeder et. al 2016 treated duration of IV abx as a continuous spectrum and found recurrence of UTI was unrelated to IV abx duration.
- New concept Monday: Propensity Score Matching (PSM) is a statistical tool used to match patients in control and treatment groups to create a pseudo-study population. The goal is to minimize confounding variables in non-randomized study.
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Example Citation
Based on a few retrospective cohort studies I have read, there hasn’t been a lot of evidence in favor of longer courses of IV antibiotics for bacteremic UTI. One study in Pediatrics suggested that 7 days of IV antibiotics were enough to not have an increased risk of recurrent UTI. Another study suggests that even less than 7 days might be appropriate. I would like to hold off on PICC at this time.
August 23, 2019
Teaching Senior Journal Club: Serious Bacterial Infections in Neonates Presenting Afebrile with a History of Fever
- The prevalence of serious bacterial infection (SBI) is reported to be up to 20% in febrile infants < 28d old; exam is not reliable. Thus, even a history of fever is concerning and prompts full workup.
- This retrospective cohort study divided up "febrile neonates" into 3 groups: febrile at presentation (FP), Hx of fever and never febrile throughout hospitalization (ANF), and Hx of fever and subsequent fever during hospitalization (ASF).
- Objective: Assess risk of SBI (UTI, bacteremia, meningitis) and IBI (invasive = bacteremia, meningitis) in each group.
- Authors say: Neonates with hx of fever who remain afebrile during admission have lower rates of SBI; afebrile patients who become febrile do so within 24 hours of stay and have higher rates of SBI.
- What's the problem? Prediction models exist because you have to make a decision before you have information. Here, you can’t predict what group the patient may end up in (will they be febrile later or not) at the time of presentation. Thus, this is hard to bring into clinical practice.
August 19, 2019
A Neonate with Rash and Fever: A Case of Neonatal HSV
- A 10-day old term neonate born to a G1P1 mother presents with a pustular rash on an erythematous base, and fever to 38.8.
- According to the Rochester and modified Philadelphia critera, this baby is not at low risk for invasive bacterial infection because of the age < 60 days and the presence of skin or soft tissue infection.
- The baby receives a full sepsis workup including: blood, urine, CSF culture. The CSF, blood, and skin lesion HSV PCR returns positive for HSV-1.
- Differential for HSV rash: erythema toxicum, transient neonatal pustular melanosis, varicella, and Staphylococcal pustulosis.
- There are 3 types of neonatal HSV: skin/eye/mouth disease, CNS disease without visceral involvement, or disseminated CNS disease with visceral involvement.
- Treatment for skin/eye/mouth disease: Acyclovir IV for 14 days.
- Treatment for CNS or disseminated disease: Acyclovir IV for 21 days + Acyclovir PO for 6 months + brain MRI + optho exam.
August 12, 2019
Antibiotics for AOM: A placebo controlled RCT of augmentin vs placebo does show siginficantly decreased risk of treatment failure in abx group; however 50% of all patients on placebo still improved without any antibiotics at 8 days.
- There is no true gold standard for the diagnosis of bacterial AOM, but things to consider are degree of bulging of TM, signs of acute inflammation (erythema, fever, pain), and middle ear effusion.
- The 2013 AAP Practice Guidelines on AOM recommends prescribing abx vs observation + FU based on severity (degree of bulding and fever >39), laterality (bilateral worse than unilateral), and age (<2 years = high risk).
- A placebo controlled blinded RCT of ~320 children with a formal diagnosis of AOM (including pneumatic otoscopy) showed a significant difference in rates of treatment failure between augmentin (18% failed) vs placebo (44% failed).
- Treatment failure was defined as no improvment in sx at day 3 FU or later, worsening condition, perforated TM, or severe complicating infection (mastoiditis or pneumonia).
- >50% of patients in the placebo group with clinical AOM improved without abx by the day 8 visit!
Example Citation
In the New England Journal of Medicine in 2011, a placebo-controlled randomized trial of more than 300 children with acute otitis media showed faster improvement in symptoms with antibiotics versus placebo, although more than 50% of the children in the placebo group improved by day 8. This supports the AAP guideline that antibiotics or a period of watchful waiting may be offered for acute otitis media.
August 9, 2019
Visual Diagnosis: Petechial Rashes. The American Society of Hematology Guidelines on ITP from 2011
- ITP:
- ITP caused by auto-antibody mediated destruction of platelets leading to isolated thrombocytopenia.
- Can be preceded by viral infection. Also known associated following MMR vaccine
- Treatment based on bleeding severity. For cutaneous symptoms only, can do careful observation with close following. If any mucosal bleeding present, treat with either 1) IVIG 0.8g/kg x1 or 2) corticosteroids
- ITP caused by auto-antibody mediated destruction of platelets leading to isolated thrombocytopenia.
- Meningococcemia:
- Fever and petechial rash should be treated as meningococcemis until proven otherwise
- Blood and CSF cultures should be obtained, can use PCR to identify organism
- Petechiae due to thrombocytopenia caused by DIC
- Treat with Ceftriaxone x5-7 days (Red Book)
- Postexposure chemoprophylaxis with rifampin, ceftriaxone or ciprofloxacin should be givin to all close contacts, regardless of immunization status within 24 hours
- 2 meningococcal vaccines exist (MenACWY & MenB)
- Henoch-Schonlein Purpura (IgA vasculitis):
- Classic Tetrad: palpable purpura without thrombocytopenia or coagulopathy, arthritis/arthralgia, GI symptoms and renal disease
- If no renal disease present, can be managed with supportive care and often self-limited
- Requires close followup with frequent UA and BP checks (often weekly x1 month then every other week x2 months)
August 7, 2019
Impact on IVIG treatment on patients with ITP; an open RCT shows IVIG treatment does not change the risk of chronic ITP (persistent thrombocytopenia at one year), but may impact other factors such as recovery at 1 month and risk of severe bleeding episodes.
- American Society of Hematology (ASH) guidelines clearly state that patients with ITP and no bleeding or mild bleeding (skin findings only) can be observed (inpatient or outpatient) regardless of platelet count.
- Per the ASH, patients requiring treatment (mild mucosal bleeding or more) can receive a course of steroids or one dose of IVIG.
- A non blinded RCT of patients 3m-16y with ITP and mild-moderate bleeding (skin or mild mucosal) in the Netherlands showed that IVIG (vs close observation) did not change the risk of chronic ITP (persistent thrombocytopenia at one year).
- IVIG did increase the rate of recovery at 1 week and 1 month (but not 3 or 6 months).
- Observation increased the risk of severe bleeding events; however 7 of the 8 patients in the obs group with this outcome presented with initial mucosal (not skin) bleeding. Per the ASH, these patients would already require treatment based on their degree of symptoms.
Example Citation
Based on the 2011 ASH guidelines on ITP, this patient has mild grade 2 bleeding and can be observed outpatient. Additionally, a recent RCT from Blood Nov 2018 showed that although patients who received observation vs IVIG had more severe bleeding events, these occurred primarily in patients who presented with mucosal bleeding. I think she can go home with strict return precautions and close F/U.
August 2, 2019
Mini-cases and Board Review on DM and DKA; The ISPAD (International Society for Pediatric and Adolescent Diabetes) has updated guidelines on DKA management from June 2018.
- There are AAP Clinical Practice Guidelines on Management of Newly Diagnosed Type 2 DM in Children and Adolescents; insulin is indicated if blood glucose > 250 or A1C > 9%.
- If laboratory measure of serum potassium is delayed in DKA, obtain an EKG to assess baseline potassium status.
- Controlled trials have shown no clinical benefit from bicarbonate administration.
- Consensus guidelines recommend initiation of fluid therapy before starting insulin.
- Insulin omission (non-compliance or pump failure) is the most common cause of recurrent DKA.
July 29, 2019
Fluid Choices in DKA: A NEJM 2018 RCT with 4 arms (varying infusion rate and NaCl content) shows no differences between arms in adverse neurologic outcomes.
- Cerebral edema is a rare but feared complication of DKA and the mechanism of how it develops is not fully understood.
- This study evaluated the effect of fluid rehydration rate ("Slow" vs "fast") and fluid NaCl content (NS or 1/2NS) on neurologic outcomes such as GCS, memory, and IQ after DKA.
- "Fast" = 20 cc/kg bolus up front, maintenance + deficit back over 36 hours.
- "Slow" = 10 cc/kg bolus up front, maintenance + deficit back over 48 hours.
- RR values showed no significant difference in neurologic outcomes in any of the 4 arms.
Example Citation
In an NEJM article from 2018, a RCT of pediatric patients with DKA compared 4 fluid resuscitation pathways and found that rate and tonicity did not impact neurologic outcomes. I would like to start the fast NS pathway, since I know now that clinically apparent brain injury in DKA is multi-factorial.
July 26, 2019
Teaching Senior Journal Club: Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode
- Most prior studies have suggested that the use of anti-pyretics does not change the risk of recurrence of febrile seizures (FB).
- This Japanese single-center, prospective, open (non-blinded), randomized controlled trial suggests that the use of Tylenol for 24 hours significantly reduces FS recurrence risk within the same fever episode.
- No adverse events occured in the patients receiving Tylenol.
- Given differences in studies on this topic, one could counsel parents that Tylenol may or may not change FB recurrence risk - but has not been shown to cause harm and thus is reaonable to use for fever control.
July 22, 2019
Case Presentation: A 10 month old Nigerian infant presents with fever and seizures; adapted from Pediatrics in Review Index of Suspicion Series.
- Febrile seizures are seizures accompanied by fever, WITHOUT CNS infection, affecting children 6-60 months old.
- Complex seizures are focal, prolonged > 15 minutes, and/or recurrent within 24 hours.
- Keep an infectious differential broad for patients with high exposure risk; e.g. recent immigration from Sub-Saharan Africa.
- Add Hep C, HIV, TB, Malaria, Toxoplasma, Filariasis, and Tapeworms to differential for CNS infection.
- Thick and thin smears (or nucleic acid testing) are gold standard for Malaria diagnosis.
- Fever + seizure does not always = febrile seizure!
July 19, 2019
Case Presentation: A 17 year old female with complications of acute bacterial sinusitis; learn how the 2013 AAP and 2012 IDSA guidelines for treatment differ.
- Both AAP and IDSA guidelines define acute bacterial sinusitis based on 1) Persistent symptoms > 10 days, 2) Worsening or new onset symptoms ("Double-sickening"), or 3) Severity of symptoms; the exact definitions vary slightly.
- The 2013 AAP guidelines recommend: 10 days of Standard dose (45 mg/kg/day) amoxicillin first line, High dose (90 mg/kg/day) amoxicillin if high levels of resistance, and High dose Augmentin for children <2 yo, moderate/severe disease, patients in childcare, and recent exposure to abx.
- The 2012 IDSA guidelines recommend: 10 days of Standard dose Augmentin for mild/moderate disease, High dose Augmentin for resistance or severe disease.
- If worried about a brain abscess, obtain a MRI Head with Contrast (CT is not sensitive).
July 15, 2019
Diagnosis and Management of Acute Bacterial Sinusitis (ABS): 2013 AAP guidelines aid in defining and managing ABS, based on RCTs suggesting antibiotics lead to higher cure rates than placebo.
- There are limited RCTs on the effectiveness of antibiotics for acute bacterial sinusitis (ABS), but small studies do show statistically significant differences in cure rates when treating ABS with antibiotics as compared to placebo.
- The AAP recommends diagnosing ABS based on 1) Persistent illness (nasal discharge or daytime cough) lasting > 10 days without improvment, OR 2) Worsening course (symptoms or new fever) often after initial signs of recovery, OR 3) severe symptoms including fever >102 and purulent nasal discharge.
- For (1) above, the AAP recommends prescribing abx OR additional outpatient observation for 3 days (Evidence Quality B).
- For (2) and (3) above, the AAP recommends prescribing abx (Evidence Quality B).
- Remember to take guidelines with a grain of salt; there have not been larger systemic reviews or meta-analyses on this topic.
Example Citation
I believe this patient meets criteria for ABS because of his 10 days of symptoms (including nasal discharge) that are acutely worsening. Based on studies such as placebo-controlled RCTs that showed an increase in cure rate and fewer treatment failures when treated with antibiotics, the 2013 AAP guidelines recommend initiating antibiotic therapy for patients with a worsening course. I’d like to prescribe antibiotics.
July 12, 2019
In December 2018, the AAP released clinical practice guidelines on maintenance IV fluids in children.
- Read more than just the Key Action Statement; the background info is interesting and helpful.
- Children who require maintenance IVF should receive isotonic solutions with appropriate KCl and dextrose to decrease the risk of developing hypoNa.
- Tonicity of IVF is primarily impacted by Na and K, not dextrose.
- Children are at high risk of developing symptomatic hypoNa because of large brain:skull size ratio.
- AAP does not make a recommendation about the safety of LR; studies on use of LR for maintenance fluid in pediatrics are very limited.
- Findings apply to ICU patients.
- Mild, asymptomatic hypoNa itself is an indicator of potential harm.
- Patients on isotonic IVF can still develop hypoNa; look for other sources of free water or SIADH if they do.
July 8, 2019
Hypotonic vs Isotonic Fluids in Hospitalized Children: A Pediatrics 2014 meta-analysis found that hypotonic maintenance fluids in patients over 28 days of age significantly increases the risk of hyponatremia.
- Older recommendations for hypotonic fluids originated from energy expenditure and intake requirements of healthy, not hospitalized, children.
- Hospitalized children are prone to elevated levels of ADH from stressors such as inflammation, nausea and vomiting, and inflammation, and therefore are already at risk of hyponatremia.
- In this meta-analysis of 10 RCTs, researchers compared hypotonic and isotonic maintenance fluids and assessed the risk of hyponatremia in patients >28 days old.
- Hypotonic fluids increased the risk of hypoNa (<136) with RR 2.24.
- Hypotonic fluids increased the risk of severe hypoNa (<130) with RR 2.24.
- No significant difference in the risk of hypernatremia (RR 0.73).
Example Citation
July 5, 2019
Chris Stave, Clinical Librarian: Solar System of EBM Resources
- PUBMED: Login w/ stanfordpeds / stanfordpeds to use the All Child search string and publication type filters. Use [ti] to limit terms to title; Use [tw] to search titles, abstracts, and author keywords.
- GOOGLE: Use filetype:.pdf to search full text of PDFs (articles; government documents; society guidelines; etc). Use site: to search specific websites or broad domains. Use -site: to exclude specific websites or broad domains.
- GOOGLE SCHOLAR: Use when you want to search the full text of peer reviewed journal articles.
- WEB OF SCIENCE: Use when looking for seminar articles on a topic. Run your search, then sort by Times Cited.
- DYNAMED: When you want something with explicit evidence grades for recommendations. Also, it looks nice on a mobile device.
July 1, 2019
Re-Asessing the Concurrence of UTI and Viral Bronchiolitis: A JAMA Pediatrics 2019 article updated UTI diagnostic crtieria and found the new UTI prevalence rate to be 0.8% vs >3% in prior studies.
- 2011 AAP guidelines updated UTI definitions to include BOTH pyuria (on urinalysis) and positive urine culture to diagnose UTI.
- This was secondary to the growing population of patients with asymptomatic bacteruria who did not have true UTI despite positive urine culture.
- In this study, by performing a meta-analysis and systemic review of studies reporting UTI in bronchiolitis, the researches re-calculcated UTI prevalence by ADDING the UA component into the definition.
- UTI prevalence based on urine culture alone: 3.3%
- UTI prevalance based on UA and culture critiera: 0.8%
- Testing thresholds are typically based on pre-test probability of 1-3%; this suggests every patient with bronchiolitis might not need to be tested for UTI if otherwise at low risk.
Example Citation