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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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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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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Henoch–Schonlein purpura

Reid-Adam J. Henoch-Schonlein purpura. Pediatr Rev. 2014 Oct; 35(10) :447-9; discussion 449.

“The hallmark of HSP is cutaneous palpable purpura, often involving the lower extremities and buttocks. The appearance of the rash in this pattern reflects its tendency to distribute in pressure-dependent areas, so that in infants the rash may actually appear in upper body areas, such as the upper extremities or face. Lesions, which arise in crops and last 3 to 10 days, vary in size from petechiae to large, confluent, palpable ecchymoses. Although HSP is largely a clinical diagnosis, a skin biopsy specimen would reveal leukocytoclastic vasculitis or granulocytic infiltration of the small vessels, along with IgA deposition in the vessel walls. A nonpitting edema that involves the scalp, face, trunk, and/or extremities is also common, especially in infants and young children. This swelling does not correlate with the degree of proteinuria or level of serum albumin, although patients with HSP may also have pitting edema as a consequence of protein loss in the urine.”

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Diagnostic value of imaging for Guillain-Barre syndrome

Zuccoli G, et al. Redefining the Guillain-Barré spectrum in children: neuroimaging findings of cranial nerve involvement. AJNR Am J Neuroradiol. 2011 Apr;32(4):639-42.

“GBS and its MFS variant are acute polyneuropathies that are considered to represent a continuum rather than distinct entities, due to the overlap in their clinical features. Enhancement of the CE roots represents the neuroradiologic hallmark of GBS, while findings of neuroimaging studies in MFS are usually unremarkable. Our purpose was to evaluate the MR imaging findings of polyneuropathy in 17 children affected by GBS and its MFS variant. Fourteen of our 17 patients demonstrated CE  enhancement, with predominant involvement of the anterior roots. Of 6 patients who underwent MR imaging of the brain, 5 had cranial nerve involvement. In children affected by GBS-MFS, involvement of the CE roots may be considered part of a more extensive autoimmune neuropathy, as demonstrated by enhancement of cranial nerves. Brain MR imaging should be considered in the routine evaluation in pediatric patients with GBS-MFS for the evaluation of the cranial nerves.”

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