Hyponatremia in Kawasaki disease

Lim GW, et al. Hyponatremia and syndrome of inappropriate antidiuretic hormone secretion in kawasaki disease. Korean Circ J. 2010 Oct;40(10):507-13.

The pathogenesis of hyponatremia (serum sodium <135 mEq/L) in Kawasaki disease (KD) remains unclear. We investigated the clinical significance of hyponatremia, and the role of interleukin (IL)-6 and IL-1β in the development of hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (SIADH) in KD.

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Kaneko K, et al. Immunoglobulin preparations affect hyponatremia in Kawasaki disease. Eur J Pediatr. 2010 Aug;169(8):957-60.

Hyponatremia frequently occurs in Kawasaki disease (KD). The aim of this study was to investigate the effect of Na content of the intravenous immunoglobulin (IVIG) preparation on serum Na levels in KD. Seventy-eight subjects, of whom 27 had hyponatremia, were split up into two groups: group A receiving IVIG preparations containing high Na (0.9%) and group B receiving IVIG preparations containing trace Na. While the data before IVIG therapy revealed no significant differences in the median serum Na between the groups, an administration of IVIG preparations increased the serum levels of Na in group A (P < 0.01) but not in group B (P > 0.05). Furthermore, the median serum Na level was significantly higher in group A than that in group B (139.0 vs 137.0 mEq/L, respectively, P < 0.01). No significant difference was found in the prevalence of coronary artery lesions between the groups. In conclusion, we should keep it in mind that the IVIG products without Na have an adverse affect on hyponatremia in KD though their efficacy seems to be equivalent to those containing high Na.

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Diagnosing meningitis: biomarkers and clinical prediction rules

Sanaei Dashti A, et al. Diagnostic value of lactate, procalcitonin, ferritin, serum-C-reactive protein, and other biomarkers in bacterial and viral meningitis: A cross-sectional study. Medicine (Baltimore). 2017 Sep;96(35):e7637.

There are many difficulties distinguishing bacterial from viral meningitis that could be reasonably solved using biomarkers. The aim of this study was to evaluate lactate, procalcitonin (PCT), ferritin, serum-CRP (C-reactive protein), and other known biomarkers in differentiating bacterial meningitis from viral meningitis in children.All children aged 28 days to 14 years with suspected meningitis who were admitted to Mofid Children’s Hospital, Tehran, between October 2012 and November 2013, were enrolled in this prospective cross-sectional study. Children were divided into 2 groups of bacterial and viral meningitis, based on the results of cerebrospinal fluid (CSF) culture, polymerase chain reaction, and cytochemical profile. Diagnostic values of CSF parameters (ferritin, PCT, absolute neutrophil count [ANC], white blood cell count, and lactate) and serum parameters (PCT, ferritin, CRP, and erythrocyte sedimentation rate [ESR]) were evaluated.Among 50 patients with meningitis, 12 were diagnosed with bacterial meningitis. Concentrations of all markers were significantly different between bacterial and viral meningitis, except for serum (P = .389) and CSF (P = .136) PCT. The best rates of area under the receiver operating characteristic (ROC) curve (AUC) were achieved by lactate (AUC = 0.923) and serum-CRP (AUC = 0.889). The best negative predictive values (NPV) for bacterial meningitis were attained by ANC (100%) and lactate (97.1%).The results of our study suggest that ferritin and PCT are not strong predictive biomarkers. A combination of low CSF lactate, ANC, ESR, and serum-CRP could reasonably rule out the bacterial meningitis.

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Bronchodilators for bronchiolitis

Rodriguez-Martinez CE, et al. Bronchodilators should be considered for all patients with acute bronchiolitis, but closely monitored for objectively measured clinical benefits. Acta Paediatr. 2015 Sep;104(9):858-60.

On the other hand, in the 2014 update of the Cochrane systematic review of the efficacy of bronchodilators for patients with bronchiolitis, bronchodilators did not show that they improve oxygen saturation, reduce hospital admission after outpatient treatment, shorten the duration of hospitalisation, nor reduce the time to resolution of the illness at home. However, in this systematic review, the authors acknowledged that the meta-analysis continued to be limited by the small sample sizes and the lack of standardised study design and validated outcomes across the studies. The authors finally concluded that future trials with large sample sizes, standardised methodology across clinical sites and consistent assessment methods were needed to completely answer the question of efficacy [5].

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Sigmoid volvulus

Gunasekaran SS, et al. Common Presentation of a Common Disease in an Unusual Age. J Pediatr. 2017 Jun;185:247-247.e1.

“Although sigmoid volvulus is well reported among adults, it is uncommon among children and occurs when the sigmoid colon wraps around the mesentery, leading to an obstruction. 12 The main risk factor for sigmoid volvulus among children is colonic dysmotility, as seen with chronic constipation. Imaging findings on both AXR and CT are similar and specific for sigmoid volvulus, although a diagnosis can be made with AXR alone, with CT reserved for cases of equivocal findings. On both modalities, a distended and displaced sigmoid colon with transition to a decompressed rectum is diagnostic for sigmoid volvulus. 3 These findings must be differentiated from cecal volvulus, where the transition point is noted within a displaced cecum. Unlike cecal volvulus, which requires surgical intervention, most cases of sigmoid volvulus can be treated with endoscopic decompression and the placement of a rectal tube. Early diagnosis of the sigmoid volvulus is critical because delay can lead to ischemia, perforation, peritonitis, and death.”

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Colinet S, et al. Presentation and endoscopic management of sigmoid volvulus in children. Eur J Pediatr. 2015 Jul;174(7):965-9.

Although rare in children, sigmoid volvulus should be advocated when abdominal pain is associated with dilated sigmoid loops. Sigmoidoscopic exsufflation can be considered as the first-line management in the absence of perforation. However, sigmoidectomy is often required for prevention of recurrence.

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Parolini F, Alberti D. Sigmoid volvulus in children. Surgery. 2017 Feb;161(2):562-563.

Sigmoid volvulus is extremely rare in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. 12 In these patients, redundant sigmoid colon could have a narrow mesenteric attachment to the posterior abdominal wall; this configuration allows close approximation of 2 limbs of sigmoid colon, making it prone to torsion around the mesenteric axis. Less frequently, other predisposing factors are Hirschsprungh’s disease and roundworm infestation, especially in smaller children. Presentations can range from acute to recurrent abdominal pain, often relieved by passage of stool or flatus. 23 Early diagnosis and management are crucial to preventing the appearance of hemorrhagic infarction of the twisted loop and avoiding further complications such as necrosis, perforation, and sepsis.

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More PubMed results on sigmoid volvulus.

Somatic symptom disorders

Malas N, et al. Pediatric Somatic Symptom Disorders. Curr Psychiatry Rep. 2017 Feb;19(2):11.

Somatic symptom disorder (SSD) is a common disorder encountered in pediatric medicine. It involves the presentation of physical symptoms that are either disproportionate or inconsistent with history, physical examination, laboratory, and other investigative findings. SSDs result in significant impairment with considerable increase in healthcare utilization, school absenteeism, and the potential for unnecessary diagnostic evaluation and treatment intervention. Patients and families often feel dismissed and may worry that a serious condition has been missed. Primary care providers are frequently frustrated due to a lack of a successful approach to patients and families impacted by SSD. The result is often a cycle of disability, frustration and missed opportunities for collaboration towards enhanced patient functionality. This review summarizes the current evidence-based understanding, as well as insights from clinician experience, on the evaluation and management of pediatric SSD.

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Serum sickness-like reaction

Yorulmaz A, et al. Demographic and clinical characteristics of patients with serum sickness-like reaction. Clin Rheumatol. 2017 Aug 9.

In this study, we aimed to review the demographic, clinical, and laboratory characteristics of patients who were followed up and treated with the diagnosis of serum sickness-like reactions (SSLR) in our pediatric rheumatology clinic retrospectively and emphasize the importance of early diagnosis and treatment. The files of 29 patients who were hospitalized in the pediatric rheumatology clinic between September 2016 and March 2017 with the diagnosis of type 3 hypersensitivity reaction were reviewed retrospectively. Patient records including C-reactive protein, erythrocyte sedimentation rate, serum electrolytes, blood glucose, urea, and liver function were recorded by using the computerized patient database. The gender, age, length of hospital stay, accompanying clinical findings, family history of atopy, preceding infection, and drug usage data were obtained from the files of the patients. Twenty-nine patients with the diagnosis of type 3 hypersensitivity reaction were evaluated. Fifteen (51.7%) of the patients were male and 14 (48.3%) were female. The male to female ratio was 1.07. The age distribution of patients ranged from 18 to 192 months (mean ± SD 100.66 ± 53.75 months). The hospitalization duration was 3-16 days (mean ± SD 5.14 ± 3.20 days). The use of many drugs, especially antibiotics, has increased even in the treatment of viral upper air way infections. As a result, side effects have also increased. The most important of these is SSLR. However, this disease is not well recognized by clinicians.

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Shiari R, et al. Clinical and laboratory profile of serum sickness-like reaction in children. Ind J Rheumatol. 2011 Dec; 6(4): 173-177.

“This study aims to determine the aetiological factors of serum sickness-like reaction, influence of age and sex, clinical manifestation, and lab findings of this disease during the time period between April 2009 and September 2010 in a university-affiliated children’s hospital.”

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Abusive head trauma

Shaahinfar A, et al. Update on abusive head trauma. Curr Opin Pediatr. 2015 Jun;27(3) :308-14.

This article provides an update on abusive head trauma (AHT), focusing on new developments most salient to the emergency medicine clinician, including epidemiology, clinical recognition, diagnostic work-up, management of neurologic injury, and public health implications.

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Greeley CS. Abusive head trauma: a review of the evidence base. AJR Am J
Roentgenol. 2015 May;204(5):967-73.

The purpose of this article is to review the constellation of findings of abusive head trauma, which may be accompanied by injuries to the appendicular and axial skeleton, brain and spinal cord, and retina. Additional common features include skin and soft-tissue injury, visceral findings, and evidence of oral trauma.

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Management of bite wounds

Rasmussen D, et al. Evaluating and treating mammalian bites. JAAPA. 2017 Mar;30(3):32-36.

Mammalian bites, typically from dogs, cats, or humans, are a common presentation in EDs and family practice settings, and patients present with varying degrees of complexity. Injuries can range from local to systemic, including aggressive bacterial infections and permanent limb impairment. Using a systematic approach to initial wound assessment, followed by appropriate diagnostic testing and treatment, is critical to improved long-term patient outcomes.

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Aziz H, et al. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015 Mar;78(3):641-8.

Animal and human bite wounds represent a significant global health issue. In the United States, animal and human bites are a very common health issue, causing significant morbidity and even, in rare scenarios, mortality. Most animal bite wounds in the United States are caused by dogs, with cat bites being a distant second. Human bite wounds constitute a dominant subset of all bite wounds. Several studies of bite wounds have reported improved outcomes with early diagnosis and immediate treatment. However, the available literature on the initial treatment provides a plethora of conflicting opinions and results. In this review, our aim was to identify and assess the current evidence on the management of animal (dog, cat, insects, scorpions, and snakes) and human bite wounds.

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Caring for LGBTQ youth (focus on mental health)

O’Neill T, Wakefield J. Challenges relating to sexuality and gender identity in children and young people. Arch Dis Child Educ Pract Ed. 2017 May 11. pii: edpract-2016-311449.

Lesbian, gay, bisexual and transgender (LGBT+) young people face several challenges in their daily lives, including specific healthcare inequalities. Negative societal attitudes towards sexual and gender minorities, and the effects of regular experiences of bullying and homophobia/transphobia exacerbate the normal trials and tribulations of childhood and adolescence. Barriers to accessing healthy activities, such as sport, are created by perceived stigma and real-life experiences. Healthcare environments are by default heteronormative and contribute to the isolation and exclusion of LGBT+ young people. Paediatricians are well placed to act on these healthcare inequalities and to advocate for LGBT+ youth, through simple changes to individual practice as well as system-wide improvements.

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Rodgers SM. Transitional Age LGBTQ Youth: Issues of Diversity, Integrated Identities, and Mental Health. Child Adolesc Psychiatr Clin N Am. 2017 Apr;26(2):297-309

Although most LGBTQ youth become healthy young adults, they often face considerable stress over the course of their lives because of bullying, victimization, and overt/covert discrimination. Families, educational and religious institutions, health care professionals, and communities help shape the experience of LGBTQ transitional age youth. LGBTQ youth have higher rates of depression, suicide, anxiety, posttraumatic stress disorder, alcohol and drug use, and preventable sexually transmitted diseases. When best practice guidelines are followed and key stakeholders take action to support LGBTQ youth, health disparities begin to disappear. Much can be done to change the trajectory for LGBTQ youth through advocacy, education, culturally competent health care, and policy-making.

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