Childhood-onset systemic lupus erythematosus

Bundhun PK, et al. Differences in clinical features observed between childhood-onset versus adult-onset systemic lupus erythematosus: A systematic review and meta-analysis. Medicine (Baltimore). 2017 Sep;96(37):e8086.

Significant differences were observed between childhood-onset and adult-onset SLE. Childhood-onset SLE was associated with significantly higher adverse clinical features whereby neurological involvement, renal involvement, oral ulcers, malar rash, vasculitis, fever, ocular, and hematological manifestations were significantly higher, whereas pulmonary involvement, Raynaud phenomenon, and photosensitivity were significantly higher with adult-onset SLE. However, no significant difference was observed in gastrointestinal involvement, cardiovascular involvement, discoid rash, psychosis, alopecia, serositis, and arthritis.

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Pneumatosis intestinalis

Nellihela L, et al. Management of pneumatosis intestinalis in children over the age of 6 months: a conservative approach. Arch Dis Child. 2017 Oct 7.

“Once PI is diagnosed, clinical correlation is essential in order to select the right treatment option. In cases of benign PI, pneumatosis is transient and the gas gradually migrates out of the gut wall resolving with conservative management. Incidental PI in asymptomatic individuals does not require active intervention and is likely to resolve spontaneously. [21] Symptomatic PI requires careful clinical and laboratory assessment to identify patients with ‘red flag’ features who may benefit from early surgical intervention. Studies in adult patients have suggested that high serum lactate, hypotension, peritonitis and acute renal failure are high-risk features requiring immediate surgical exploration. [7 25 26] None of our patients had any of those red flag signs and to the best of our knowledge, there is no such stratification algorithm for children with PI.

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Nephrogenic diabetes insipidus

Bockenhauer D, Bichet DG. Nephrogenic diabetes insipidus. Curr Opin Pediatr. 2017 Apr;29(2):199-205.

In nephrogenic diabetes insipidus (NDI), the kidney is unable to concentrate urine despite elevated concentrations of the antidiuretic hormone arginine-vasopressin. In congenital NDI, polyuria and polydipsia are present from birth and should be immediately recognized to avoid severe episodes of dehydration. Unfortunately, NDI is still often recognized late after a ‘diagnostic odyssey’ involving false leads and dangerous treatments.Once diagnosed, appropriate treatment can be started. Moreover, laboratory studies have identified promising new compounds, which may help achieve urinary concentration independent of vasopressin.

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Necrotizing fasciitis

VanderMeulen H, et al. A 10-Year Review of Necrotizing Fasciitis in the Pediatric Population: Delays to Diagnosis and Management. Clin Pediatr (Phila). 2017 Jun;56(7) :627-633.

“The importance of prompt diagnosis stems from its role in the initiation of therapy. Multiple reports support the association of both timely antibiotic initiation and
timely surgical debridement with reduced morbidity and mortality. [3,9,10] This process begins with proper selection of antibiotic agents. Given the delay associated with
receiving results of tissue and blood cultures, empiric therapy should be started immediately. Our data suggests that while the antibiotics initially prescribed often
covered the causative organism, the majority did not provide protection against worrisome bacteria such as MRSA. We argue that coverage against MRSA is warranted
given that it is contributing to an increasing number of cases in North America. [11,12] While various suggestions have been made in the literature, we recommend a combination of clindamycin, vancomycin, and piperacillin-tazobactam. This affords a broad-spectrum coverage of the organisms most likely to be responsible, including as streptococcal species, staphylococcal species, bacteroides species and gram-negative enterobacteriaceae. [13]”

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Diagnostic imaging of vertebral artery dissection

Shakir HJ, et al. Carotid and Vertebral Dissection Imaging. Curr Pain Headache Rep. 2016 Dec;20(12):68.

Carotid or vertebral artery dissection is the result of a tear in the vessel lining wherein the intima separates the media. This creates a false or pseudo lumen, often accompanied by hemorrhage into the arterial wall. Dissection of these craniocervical vessels often manifests with pain alone but, if untreated, may result in severe neurologic compromise. The causes of dissection are multifactorial, including spontaneous, iatrogenic, and traumatic insults. Regardless of etiology, treatment consists primarily of anticoagulation, whereas endovascular therapy is reserved for cases with persistent thrombus or flow limitation. Given the high risk of neurological compromise or death and the propensity of these injuries to occur in younger individuals, early diagnosis of carotid and vertebral artery dissections is critical. Although angiography remains the criterion standard for diagnosis, advances in noninvasive imaging have placed magnetic resonance and computed tomography at the forefront of diagnosis. This article examines the current imaging modalities used to diagnose this under-recognized entity.

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Pain management in acute pancreatitis (focus on use of opioids)

Grover AS, et al. Initial Pain Management in Pediatric Acute Pancreatitis: Opioid vs. Non-Opioid. J Pediatr Gastroenterol Nutr. 2017 Oct 27.

Nearly all patients with acute pancreatitis (AP) experience some degree of abdominal pain that is severe enough to prompt medical evaluation and necessitate analgesia. Effective analgesia is a priority in caring for such patients. Despite its importance, strategies for pain management in AP have been poorly studied, particularly in the field of pediatrics. Currently, no published data examine the management of pain due to acute pancreatitis in children at the time of initial presentation. Management approaches are often extrapolated from adult practice and based on anecdotal experience in the absence of objective data. The aim of our study was to examine the initial provision of analgesia to children who presented to a pediatric emergency department (ED) with acute pancreatitis.

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Practice Based Learning: Opiates in Pediatric Migraine

 

 

 

 

 

Presented by Katie Waters MD (PGY1)

Clinical questions:

  • Why not opiates?
  • Other than avoiding the classic undesirable side effects and risk of developing addiction…
  • What are the reasons to avoid this class in migraines specifically?

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Methylphenidate-induced psychosis

Martínez-Aguayo JC, et al. Brief psychosis induced by methylphenidate in a child with attention deficit disorder: a case report and literature review. Medwave. 2017 Jun 21; 17(5):e6980.

Methylphenidate-induced psychosis has been scarcely studied due to bioethical and neurobiological issues regarding its research. Although some authors have hypothesized that there might be a vulnerability for the development of a major psychiatric disorder in the long term, there is no agreement about the predictive value of this type of psychosis in children and adolescents, and its origin is also uncertain. It has been suggested that higher dopamine levels in some cerebral regions and a family history of mental disorders might increase the risk of psychosis secondary to psychostimulants. We present the case of a nine-year-old child diagnosed with attention deficit disorder and oppositional defiant disorder, who exhibited visual and auditory hallucinations and delirious ideas about harm during methylphenidate treatment. The patient’s symptoms regressed after drug removal. We discuss the key issues related to the origin, causality, management, and prognosis of psychostimulant-induced psychosis.

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Incomplete and atypical Kawasaki disease

Singh S, et al. Diagnosis of Kawasaki disease. Int J Rheum Dis. 2017 Nov 13.

Kawasaki disease (KD) is a medium vessel vasculitis with predilection for coronary arteries. Due to lack of a reliable confirmatory laboratory test, the diagnosis of KD is based on a constellation of clinical findings that appear in a typical temporal sequence. These diagnostic criteria have been modified from time to time and the most recent guidelines have been proposed by the American Heart Association (AHA) in 2017. However, several children may have incomplete or atypical forms of KD and the diagnosis can often be difficult, especially in infants and young children. In this review, we have detailed the steps involved in arriving at a diagnosis of KD and also highlight the important role of echocardiography in diagnosis and management of children with KD.

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Mansoor S, et al. Weighing evidence and art: a challenging case of early-onset atypical Kawasaki disease. Hosp Pediatr. 2015 Nov;5(11):591-6.

We present a case of a high-risk young patient (<6 months of age) with subacute KD who was successfully treated with a tapering course of systemic steroids along with a concomitant standard treatment protocol. Learning points to be taken from this case include the following:

  • The clinician’s index of suspicion needs to remain heightened to make the diagnosis of early-onset KD, which not uncommonly presents with incomplete diagnostic features.
  • Despite the lack of evidence-based guidance from the literature, important informed treatment decisions need to be made for KD patients diagnosed late in the subacute period who have documented coronary artery aneurysms.
  • Steroids may be an effective and safe therapeutic tool to supplement conventional treatment in the high-risk infant population with atypical KD if used judiciously.

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Vulnerable child syndrome

Mitchell M, Blackburn M. “What We’ve Got Here Is Failure to Communicate”: The Value of Reassurance. Hosp Pediatr. 2016 Jun;6(6):380-2.

“The hospitalist team, with assistance from our infectious disease and forensic pediatric experts, ultimately diagnosed this patient with vulnerable child syndrome. [1] The family was given a set of distinct instructions regarding the patient’s medical care, including discontinuation of lansoprazole, erythromycin, and bethanechol. The family was also instructed to abstain from taking any temperatures at home and provided with information on normal childhood illness patterns. They were agreeable to this plan of care and were given reassurance regarding the benign nature of common childhood viral illnesses, which may be accompanied by fever, along with the benign nature of fever itself. The child’s pediatrician was also given a copy of the plan and agreed to assist in providing reassurance to this family.”

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