Emory AAP Fall 2016 Newsletter

Greetings,

We would like to introduce you to our new quarterly newsletter for all things Emory AAP!

The Emory chapter is a part of District X and we are your AAP representatives for the 2016-2017 year. This newsletter will provide information about local, regional and national upcoming events. We will also highlight our outstanding residents and faculty representing Emory with the AAP. There will be websites providing resources for educational opportunities, advocacy activities, scholarships and more. We hope you find this newsletter informative and enjoyable.

Feel free to share your thoughts on information you would like to see in upcoming newsletters.

Sincerely,
Your AAP Class Reps 2016-2017

Multifocal osteomyelitis

Sreenivas T, et al. Acute multifocal haematogenous osteomyelitis in children. J Child Orthop. 2011 Jun;5(3):231-5.

We conclude that acute multifocal haematogenous osteomyelitis in children needs early diagnosis by a high index of clinical suspicion and adequate treatment with timely intervention. The predominance of MRSA in our study shows the changing trend in its association with multiple bone involvement.

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Ileoileal intussusception – surgical intervention needed?

Fallon SC, et al. Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction. J Pediatr Surg. 2013 May;48(5):1032-6.

“In conclusion, our analysis of the treatment of a contemporary cohort of intussusception patients cared for at a large, tertiary-care children’s hospital showed that a longer history of pain, presentation as an infant, and a lead point, bowel wall thickness, and free or interloop fluid identified on ultrasound are independent risk factors for surgery. Practitioners who work in community settings or in hospitals without adequate pediatric surgical capabilities should consider early transfer to a higher level of care when available.”

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Saxena AK, et al. Small bowel intussusceptions: issues and controversies related to pneumatic reduction and surgical approach. Acta Paediatr. 2007 Nov;96(11):1651-4.

Pneumatic reduction is successful in ileoileal intussusceptions with signs of bowel viability. It should be attempted with caution in patients with jejunojejunal or ileoileal SBI with pathologic lead points or bowel ischaemia. Accurate interpretation of ultrasound along with judicious implementation of pneumatic reduction or surgical options can reduce morbidity. Early diagnosis is associated with better outcomes using non-surgical reduction techniques.

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Sudden sensorineural hearing loss (focus on steroid-based treatments)

Metrailer AM, Babu SC. Management of sudden sensorineural hearing loss. Curr Opin Otolaryngol Head Neck Surg. 2016 Oct;24(5):403-6.

Sudden sensorineural hearing loss (SNHL) is an otologic emergency and should be managed quickly and effectively. This review focuses on the management of sudden SNHL, primarily idiopathic sudden SNHL as it is the most common cause.

Management options include observation, oral steroids, intratympanic steroids, or combined oral/intratympanic steroids. One-third to two-thirds of patients will achieve spontaneous recovery, most likely within the first 2 weeks. Despite the lack of randomized controlled trials on steroid therapy efficacy, all patients should be offered steroid treatment given low risk and possible significant benefits. All patients should undergo MRI with gadolinium to rule out retrocochlear disorder. Bilateral sudden hearing loss should alert the clinician to possible systemic disease.

Full-text for Emory users.


Dedhia K, Chi DH. Pediatric sudden sensorineural hearing loss: Etiology, diagnosis and treatment in 20 children. Int J Pediatr Otorhinolaryngol. 2016 Sep;88:208-12.

The true incidence of pediatric SSNHL is not well established in our literature. Unique aspects of pediatric SSNHL are delayed presentation and higher percent of anatomic findings. In our study 70% presented more than 2 weeks after experiencing symptoms. Anatomic abnormalities are in 40% of patients. Hearing improvement occurred in 50% of children treated with oral steroids. Intratympanic steroid treatment is another option but may have practical limitation in the pediatric population.

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Bacterial sinusitis

Wald ER, et al. Clinical practice guideline for the diagnosis and management of acute
bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013 Jul;132(1):e262-80.

RESULTS: The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever[temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the firstline treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening(progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.

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DeMuri G, Wald ER. Acute bacterial sinusitis in children. Pediatr Rev. 2013 Oct;34(10): 429-37; quiz 437.

On the basis of strong research evidence, the pathogenesis of sinusitis involves 3 key factors: sinusostia obstruction, ciliary dysfunction, and thickening of sinus secretions. On the basis of studies of the microbiology of otitis media, H influenzae is playing an increasingly important role in the etiology of sinusitis, exceeding that of S pneumoniae in some areas, and b-lactamase production by H influenzae is increasing in respiratory isolates in the United States. On the basis of some research evidence and consensus,the presentation of acute bacterial sinusitis conforms to 1 of 3 predicable patterns; persistent, severe, and worsening symptoms. On the basis of some research evidence and consensus,the diagnosis of sinusitis should be made by applying strict clinical criteria. This approach will select children with upper respiratory infection symptoms who are most likely to benefit from an antibiotic. On the basis of some research evidence and consensus,imaging is not indicated routinely in the diagnosis of sinusitis. Computed tomography or magnetic resonance imaging provides useful information when complications of sinusitis are suspected. On the basis of some research evidence and consensus,amoxicillin-clavulanate should be considered asa first-line agent for the treatment of sinusitis.

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Practice Based Learning: Sharp Object Ingestion

David Greenky

 

 

 

 

Presented by David Greenky MD (PGY1)

Foreign body Ingestion: General

  • At least 80% of foreign object ingestions will pass on their own
  • Surgical intervention is needed ~12% of the time
  • Vast majority of cases are pediatric, and most between ages of 6 m – 6 y
  • Trouble happens most often at GI angles or narrowing
  • Previous surgery and congenital malformations = greater risk

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Respiratory complications of hydrocarbon aspiration

See also: Hydrocarbon ingestion.


Bahceci Erdem S, et al. Pulmonary complications of chemical pneumonía: a case report. Arch Argent Pediatr. 2016 Aug 1;114(4):e245-e248.

Hydrocarbon aspiration (HA) can cause significant lung disease by inducing an inflammatory response, hemorrhagic exudative alveolitis, and loss of surfactant function. The most serious side effect of HA is aspiration pneumonia. Pneumothorax, pneumatocele, acute respiratory distress syndrome (ARDS), pulmonary abscess, bronchopleural fistula, bilateral hemorrhagic pleural effusion and pyopneumothorax were previously reported. Hereby we report a patient hospitalized due to aspiration pneumonia who developed pleurisy and pneumothorax after drinking paint thinner. It is presented as it was seldom reported in children to cause distinct pulmonary complications. Patients with complaints associated withhydrocarbon poisoning must be fully evaluated. They must not be discharged from the hospital early and must be followed for at least 48 hours even if they don’t have respiratory symptoms. It should be kept in mind that severe pulmonary complications can develop in patients with chemical pneumonia.

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Acute rheumatic fever and post-streptococcal reactive arthritis

Barash J. Rheumatic Fever and post-group a streptococcal arthritis in children. Curr Infect Dis Rep. 2013 Jun;15(3):263-8.

There are several diseases associated with group A beta hemolytic streptococcal infection; the two most common are acute rheumatic fever (ARF) and poststreptococcal reactive arthritis (PsRA). Epidemiological and clinical data for both diseases are described, as well as current recommendations for treatment and prevention. There is an ongoing debate as to whether these two are different diseases or are parts of the spectrum of the same disease. There are some reports of carditis developing after PsRA, suggesting that PsRA may be part of the spectrum of ARF. However, since there are substantial clinical, immunological, and genetic differences between PsRA and ARF, we believe PsRA to be a distinct entity.

Full-text for Emory users.


Uziel Y, et al. Post-streptococcal reactive arthritis in children: a distinct entity from acute rheumatic fever. Pediatr Rheumatol Online J. 2011 Oct 20;9(1):32.

There is a debate whether post-streptococcal reactive arthritis (PSRA) is a separate entity or a condition on the spectrum of acute rheumatic fever (ARF). We believe that PSRA is a distinct entity and in this paper we review the substantial differences between PSRA and ARF. We show how the demographic, clinical, genetic and treatment characteristics of PSRA differ from ARF. We review diagnostic criteria and regression formulas that attempt to classify patients with PSRA as opposed to ARF. The important implication of these findings may relate to the issue of prophylactic antibiotics after PSRA. However, future trials will be necessary to conclusively answer that question.

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Indeterminate pulmonary nodules

Assefa D, Atlas AB. Natural history of incidental pulmonary nodules in children. Pediatr Pulmonol. 2015 May;50(5):456-9.

As there are no evidence based guidelines for the diagnosis and/or management of pulmonary nodules in children, there is an over reliance on the adult based algorithms when dealing with pulmonary nodules in children. We present our experience of pediatric patients evaluated for incidentally found pulmonary nodules.

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