Diagnostic methods for appendicitis

Benabbas R, et al. Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2017 May;24(5):523-551.

Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.

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Article of interest: Hormonal Contraception and Breast Cancer Risk.

Hormonal Contraception and Breast Cancer Risk.
AAP Grand Rounds Mar 2018, 39 (3) 28.

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“While a statistically significant increased risk of breast cancer sounds alarming, it is important to mention some nuances of the relationship between HC and breast cancer. First, though the data are presented as RRs, the absolute increase in risk is only one additional breast cancer case per 50,000 females under the age of 35. Second, the results are not causal proof between HC and breast cancer, and the investigators were unable to control or account for known (eg, alcohol use, physical activity) or unknown contributors to breast cancer risk. Finally, HC has also been shown to substantially protect against other cancers (eg, ovarian, endometrial, and colorectal cancers), with a potential overall reduced risk of total risk of cancer.” [1,3,4]

Commentary on: Mørch LS, et al. Contemporary Hormonal Contraception and the Risk of Breast Cancer. N Engl J Med. 2017 Dec 7;377(23):2228-2239.

Genetic testing of early-onset epilepsy

Berg AT, et al.. Early-Life Epilepsies and the Emerging Role of Genetic Testing. JAMA Pediatr. 2017 Sep 1;171(9):863-871.

Genetic investigations, particularly broad sequencing methods, have high diagnostic yields in newly diagnosed early-life epilepsies regardless of key clinical features. Thorough genetic investigation emphasizing sequencing tests should be incorporated into the initial evaluation of newly presenting early-life epilepsies and not just reserved for those with severe presentations and poor outcomes.

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Pericardial effusion

Bolin EH, et al. Characteristics of Non-postoperative Pediatric Pericardial Effusion: A Multicenter Retrospective Cohort Study from the Pediatric Health Information System (PHIS). Pediatr Cardiol. 2018 Feb; 39(2):347-353.

Little is known about the causes and risks of non-postoperative pericardial effusion (PCE) in pediatric patients. We sought to assess the diagnoses most frequently associated with admissions for PCE, and to determine if certain conditions were associated with higher in-hospital mortality and rates of readmission.

Children admitted with non-postoperative PCE have multiple associated conditions. Neoplasm and renal disease in the setting of PCE are associated with the highest odds of in-hospital mortality among concomitant conditions; children with a neoplasm, renal disease, and those undergoing pericardiocentesis have the highest odds of readmission.

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Diagnosing staphylococcal scalded skin syndrome in neonates

From VisualDx:

Best tests: Cultures should be obtained from the nasopharynx, nostrils, conjunctivae, blood, and any suspected sites of infection. Fluid from bullae is usually sterile.

Sloughed skin can be excised and examined by frozen sections. SSSS will reveal intraepidermal cleavage at the granular level, whereas TEN will reveal full thickness necrosis down to the dermal-epidermal junction.

Skin biopsy is usually unnecessary but will reveal a noninflammatory subcorneal split at the level of the stratum granulosum.”

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Failure to Thrive

Smith AE, Gossman WG. Failure To Thrive. 2017 Oct 6. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.

Failure to thrive (FTT) is a common term used to describe lack of adequate weight gain in pediatric-aged patients. Accepted definitions include a weight for age less than the fifth percentile on standardized growth charts, a decrease in weight percentile of more than two major percentile lines on the growth chart, or less than the 80 percentile of median weight for height ratio weight/length ratio. Failure to thrive is important to recognize and treat because it can result in developmental delays and other long-term effects for the developing child.

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Neonatal herpes simplex virus infections

Pinninti SG, Kimberlin DW. Neonatal herpes simplex virus infections. Semin Perinatol. 2018 Mar 12. pii: S0146-0005(18)30010-7.

Neonatal herpes simplex virus (HSV) is an uncommon but devastating infection in the newborn, associated with significant morbidity and mortality. The use of PCR for identification of infected infants and acyclovir for treatment has significantly improved the prognosis for affected infants. The subsequent use of suppressive therapy with oral acyclovir following completion of parenteral treatment of acute disease has further enhanced the long-term prognosis for these infants. This review article will discuss the epidemiology, risk factors and routes of acquisition, clinical presentation, and evaluation of an infant suspected to have the infection, and treatment of proven neonatal HSV disease.

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Psychogenic nonepileptic seizures (PNES)

Milán-Tomás Á, et al. An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management. Can J Neurol Sci. 2018 Mar;45(2):130-136.

The purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.

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Doss JL, Plioplys S. Pediatric Psychogenic Nonepileptic Seizures: A Concise Review. Child Adolesc Psychiatr Clin N Am. 2018 Jan;27(1):53-61.

Psychogenic nonepileptic seizures is a complicated biopsychosocial disorder with significant morbidity and high cost in children’s social, emotional, family, and academic functioning as well as health care service utilization. Misdiagnosis and diagnostic delay, resulting from both lack of access to approved standards for diagnosing and service providers comfortable with diagnosing and treating this disorder, impact prognosis. Treatment in close proximity to symptom onset is thought to provide the best chance for remission.

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Hypertrophic pyloric stenosis

Wu SF, et al. Efficacy of Medical Treatment for Infantile Hypertrophic Pyloric Stenosis: A Meta-analysis. Pediatr Neonatol. 2016 Dec; 57(6) :515-521.

“This meta-analysis shows that either oral or IV atropine sulfate was an effective treatment for IHPS in all but one study.

The etiology of IHPS remains unclear although several hypotheses have been postulated, including impaired function of acetylcholine and muscarinic receptors, decreased nitric oxide synthase activity, elevated prostaglandin and gastrin levels, infectious causes, and a genetic basis. [23,24,25,26,27,28]The mechanism of atropine sulfate in IHPS therapy mainly involves a cholinergic blocking agent with potent antimuscarinic activity that decreases peristaltic contractions by relaxing the pyloric smooth muscles. [29] The effective range varies widely, perhaps because of the alterations in the muscarinic receptor sensitivity of the muscle, [29] variations in drug clearance, compromised blood flow secondary to pyloric spasm, lack of nitric oxide synthase, and poor innervation of the pyloric circular musculature. [23,24,30]”

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Peters B, et al. Advances in infantile hypertrophic pyloric stenosis. Expert Rev Gastroenterol Hepatol. 2014 Jul;8(5):533-41.

Infantile hypertrophic pyloric stenosis (IHPS) is a common condition in infancy, characterized by an acquired narrowing of the pylorus, which requires surgery. These infants usually present with projectile, nonbilious vomiting, with a palpable ‘olive’ in the abdomen and sometimes a ‘peristaltic wave’ after being fed with formula or breast milk. Although IHPS is a common disorder, its etiology is largely unknown. Surgical intervention is the standard treatment, preoperative preparation, however is essential to optimal outcome. In this review, the latest advances in IHPS regarding epidemiology, etiology, diagnostics and treatment will be discussed.

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Pulmonary embolism in sickle cell disease

Tivnan P, et al. Imaging for Pulmonary Embolism in Sickle Cell Disease: a 17-Year Experience. J Nucl Med. 2018 Feb 1. pii: jnumed.117.205641.

In sickle cell disease patients with suspected pulmonary embolism, positive imaging rates were low for any given clinical presentation, but 11% of the cohort was diagnosed with pulmonary embolism over the 17-year study period. CTPA and V/Q performed comparably for pulmonary embolism diagnosis when the choice of imaging was guided by results of chest radiography. Hence, V/Q is a reasonable first choice for sickle cell disease patients with normal chest radiographs.

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