Nontypeable Haemophilus influenza infections

Langereis JD, de Jonge MI. Invasive Disease Caused by Nontypeable Haemophilus influenza. Emerg Infect Dis. 2015 Oct;21(10):1711-8.

The incidence of severe Haemophilus influenza infections, such as sepsis and meningitis, has declined substantially since the introduction of the H. influenzae serotype b vaccine. However, the H. influenzae type b vaccine fails to protect against nontypeable H. influenzae strains, which have become increasingly frequent causes of invasive disease, especially among children and the elderly. We summarize recent literature supporting the emergence of invasive nontypeable H. influenzae and describe mechanisms that may explain its increasing prevalence over the past 2 decades.

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Globus pharyngeus

Doody J, Fenton JE. Troublesome Throat Awareness (tTA) as a contemporary alternative to ‘globus pharyngeus’. Surgeon. 2017 Aug;15(4):183-185.

““Globus pharyngeus” is a tainted term suggesting that it is time to retire the title, as was done with “globus hystericus” two centuries ago. We suggest that the feeling of having a lump in the throat on dry swallow is a normal sensation that everyone experiences to some degree, is accentuated by an ‘event’ and perhaps some are predisposed to perceive this “regular” sensation more strongly than others. It is our opinion that an alternate and contemporary approach is required on this topic. We propose the new term of “troublesome Throat Awareness” (tTA) which is clear, unambiguous with an inherent and therefore therapeutic reassurance to the patient.”

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Jones D, Prowse S. Globus pharyngeus: an update for general practice. Br J Gen
Pract. 2015 Oct;65(639):554-5.

“Globus pharyngeus is a common condition frequently presenting to primary care. Its aetiology remains unclear; however, gastro-oesophageal reflux may play a role in a subset of patients. It is important to consider red flags and ensure prompt referral to secondary care if present.

Management of this condition includes reassurance, vocal hygiene, and treatment of reflux if this is appropriate. Speech and language therapy and cognitive behavioural therapy may also have a role.”

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Abdominal migraines

Irwin S, et al. Recurrent Gastrointestinal Disturbance: Abdominal Migraine and Cyclic Vomiting Syndrome. Curr Neurol Neurosci Rep. 2017 Mar;17(3):21.

Primary headache disorders, including migraine, are some of the most common neurological disorders presenting to hospital. Episodic syndromes that may be associated with migraine, including recurrent gastrointestinal disturbances such as abdominal migraine and cyclic vomiting, often pre-date or co-occur with the onset of migraine in a child who is at risk of developing the headache condition. The purpose of this review is to evaluate the two most common episodic syndromes, abdominal migraine and cyclic vomiting syndrome, including their pathophysiology, common presentations, and diagnostic criteria. Differential diagnosis and “red flag” features are outlined, and an approach to diagnostic work-up is offered. Finally, we provide an evidence-based review of management options and long-term prognosis. Future research should include randomized trials for the acute and preventive treatment of these disorders, as well as research as to whether early intervention can prevent progression to migraine and/or mitigate migraine severity.


Napthali K, et al. Abdominal migraine. Cephalalgia. 2016 Sep;36(10):980-6.

AM is relatively common, affecting up to 4% of the paediatric population. Whilst AM is not believed to continue into adulthood for the majority of children, it has the propensity to develop into probable migraine and recurrent abdominal pain in adulthood. The pathophysiology of this condition remains unclear and as a result treatment for this condition is suboptimal with avoidance of triggers and prophylactic treatment currently recommended when an episode begins.

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Unilateral hydronephrosis due to ureteropelvic junction obstruction

Weitz M, et al. Primary non-surgical management of unilateral ureteropelvic junction obstruction in children: a systematic review. Pediatr Nephrol. 2017 Dec;32(12):2203-2213.

Ureteropelvic junction obstruction (UPJO) is the most common obstructive uropathy and its optimal management remains controversial. However, there is a current trend towards non-surgical management. We aimed to determine the effects of the non-surgical management in children with unilateral UPJO. For a systematic review, we searched MEDLINE, EMBASE, CENTRAL, clinical trials registries, and selected conference proceedings for eligible studies. Any type of study reporting the outcomes renal function, secondary surgical intervention, drainage pattern or hydronephrosis of non-surgical management in children with unilateral UPJO was included. Data from 20 studies were extracted and evaluated by two independent authors. The pooled prevalence was 21% for split renal function deterioration, 27.9% for secondary surgical intervention, 3.2% for progressive hydronephrosis, and 82.2% for improved drainage pattern. Not all patients with surgical intervention regained split renal function from enrolment. Renal imaging methods did not strongly correlate with each other. Many studies had to be excluded because of a lack of detection of an obstruction or mixed populations with bilateral UPJO or other uropathies. The variable definitions of UPJO, different criteria for surgical intervention, incongruity of management protocols, and the imprecise reporting of outcomes were limiting factors in the comparability of the results, leading to heterogeneity in meta-analyses. Although the available evidence cannot recommend or refute the current non-surgical management, the systematic review clarifies aspects of the ongoing controversy by providing realistic estimates for non-surgical management in children with unilateral UPJO. Additionally, it reveals unclear potential risks, particularly for long-term outcomes, which were rarely reported.

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Toxic shock syndrome (focus on S. aureus infections)

Wilkins AL, et al. Toxic shock syndrome – the seven Rs of management and treatment. J Infect. 2017 Jun; 74 Suppl 1:S147-S152.

Staphylococcal and streptococcal toxic shock syndrome (TSS) are associated with significant morbidity and mortality. There has been considerable progress in understanding the pathophysiology and delineating optimal management and treatment. This article reviews the management of TSS, outlining the ‘Seven Rs of Managing and Treating TSS’: Recognition, Resuscitation, Removal of source of infection, Rational choice of antibiotics, Role of adjunctive treatment (clindamycin and intravenous immunoglobulin), Review of progress and Reduce risk of secondary cases in close contacts.

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Silversides JA, et al. Staphylococcal toxic shock syndrome: mechanisms and management. Curr Infect Dis Rep. 2010 Sep;12(5):392-400.

Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in which bacterial toxins act as superantigens, activating very large numbers of T cells and generating an overwhelming immune-mediated cytokine avalanche that manifests clinically as fever, rash, shock, and rapidly progressive multiple organ failure, often in young, previously healthy patients. The syndrome can occur with any site of S. aureus infection, and so clinicians of all medical specialties should have a firm grasp of the presentation and management. In this article, we review the literature on the pathophysiology, clinical features, and treatment of this serious condition with emphasis on recent insights into pathophysiology and on information of relevance to the practicing clinician.

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Fever of unknown origin (FUO) and fever without a source (FWS)

Definitions:

  • FUO – Children with fever >101ºF (38.3ºC) of at least eight days’ duration, in whom no diagnosis is apparent after initial outpatient or hospital evaluation that includes a careful history and physical examination and initial laboratory assessment.
  • FWS – Children with fever lasting for one week or less without adequate explanation after a careful history and thorough physical examination.

From UpToDate.


Antoon JW, et al. Pediatric fever of unknown origin. Pediatr Rev. 2015 Sep;36(9):380-90; quiz 391.

  • On the basis of strong clinical evidence, the causes of FUO are broad and include both benign and life-threatening medical conditions. (12)
  • On the basis of observational studies, most cases of FUO have shifted to noninfectious etiologies over the past several decades. (10)
  • On the basis of observational studies, completely normal physical examination findings at the time of the initial FUO evaluation suggest a benign underlying cause. (13)
  • On the basis of consensus and expert opinion, a stepwise, tiered approach to FUO should be implemented to decrease cost and time to diagnosis. (13)

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Moyamoya disease

Lee S, et al. Moyamoya Disease in Children: Results From the International Pediatric Stroke Study. J Child Neurol. 2017 Oct;32(11):924-929.

This study aimed to describe children with moyamoya disease from an international multicenter stroke database, and explore risk factors for stroke recurrence. We reviewed data of children >28-days old with moyamoya disease enrolled in the International Pediatric Stroke Study from January 2003 to March 2013. A total of 174 children from 32 sites and 14 countries had moyamoya disease; median age 7.4 years, 49% male. Of these, 90% presented with ischemic stroke, 7.5% with transient ischemic attack, and 2.5% with hemorrhagic stroke. One-third of patients had moyamoya syndrome. Stroke recurrence was 20% over median follow-up of 13 months; 9% had multiple recurrences. Children treated with surgical revascularization were less likely to have stroke recurrence ( P = .046). Moyamoya disease accounted for 8% of arterial strokes in this international pediatric stroke registry. One-third of pediatric patients with moyamoya disease have an underlying syndromic condition. Surgical revascularization is effective at reducing the incidence of stroke recurrence.

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Zhao M, et al. Transient Ischemic Attack in Pediatric Patients With Moyamoya Disease: Clinical Features, Natural History, and Predictors of Stroke. Pediatr Neurol. 2017 Oct;75 :48-54.

“Studies on the characteristics of pediatric TIA are scant. 238 Despite moyamoya disease being one of the leading causes of pediatric TIAs, patients with moyamoya disease have not been studied as a distinct group in the sparse pediatric TIA literature. We identified 60 pediatric patients with moyamoya disease whose initial presentation was TIA. This study extended the present knowledge of pediatric TIA features and identified the female sex, the Suzuki grade greater than 3, and symptom progression as predictors of post-TIA stroke events in pediatric patients with moyamoya.”

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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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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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Evaluation of abnormal liver function tests

Lamireau T, et al. A practical approach to the child with abnormal liver tests. Clin Res Hepatol Gastroenterol. 2014 Jun;38(3):259-62.

The presence of elevated aminotransferases on routine blood tests can reveal liver diseases of various severities. In children, etiologies are more numerous and complex than those usually considered in adults. Information derived from family and personal history, physical examination and basic laboratory data are necessary to reach a timely and correct diagnosis. A stepwise approach is proposed to guide the timing of more specific investigations that are often required.

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