Evidence Catalog

Block 5

November 8, 2019

A developmentally delayed female with abnormal uterine bleeding - how do you build a differential?

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  • 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.

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November 4, 2019

Menstrual Patterns in the First Gynecologic Year: What is "normal" for early menstrual cycles in healthy adolescent females?

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  • 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.

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November 1, 2019

Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association. Circulation. 2019.

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  • 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.

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October 30, 2019

Cochrane Review: Statins for children with familial hypercholesterolemia (2017)

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  • 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.

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Example Citation

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A 2017 Cochrane Review of more than 1000 pediatric patients with familial hypercholesterolemia showed that statins effectively lower LDL cholesterol. This suggests that referral to a lipid specialist for treatment with statins is appropriate in this patient population.

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October 25, 2019

Principles of Epidemiology and Study Design: An Overview by Mary Leonard

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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?

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October 21, 2019

Why formally train providers in relationship-centered communication with patients? Both patients and providers benefit.

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  • 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!

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