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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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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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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Nutrition therapy for the pediatric patient

Mehta NM, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2017 Jul;41(5):706-742.

The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

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Autoimmune hemolytic anemia

Liebman HA, Weitz IC. Autoimmune Hemolytic Anemia. Med Clin North Am. 2017 Mar;101(2):351-359.

Autoimmune hemolytic anemia is an acquired autoimmune disorder resulting in the production of antibodies directed against red blood cell antigens causing shortened erythrocyte survival. The disorders can present as a primary disorder (idiopathic) or secondary to other autoimmune disorders, malignancies, or infections. Treatment involves immune modulation with corticosteroids and other agents.

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Sankaran J, et al. Autoimmune Hemolytic Anemia in Children: Mayo Clinic Experience. J Pediatr Hematol Oncol. 2016 Apr;38(3):e120-4.

We studied 35 pediatric patients with autoimmune hemolytic anemia seen at Mayo Clinic from 1994 to 2014. The median age was 10.0 years and 65.7% were males. Most had warm antibodies (80.0%) and some secondary to viral (14.3%) or autoimmune disorders (31.4%). Seven (20.0%) patients presented with Evans syndrome, 3 of whom also had common variable immunodeficiency. The median hemoglobin at diagnosis was 6.1 g/dL and 62.8% patients required red cell transfusions. The severity of anemia was worse among children below 10 years (median 5.5 vs. 7.0 g/dL, P=0.01). Steroid was the initial treatment for 88.5% patients, with overall response rate of 82.7% (68.5% complete, 14.2% partial) and median response duration of 10.7 months (range, 0.2 to 129.7+ mo). After median follow-up of 26.6 months, 8 (22.8%) patients relapsed. Salvage treatments included splenectomy, intravenous immunoglobulin, rituximab, and mycophenolate mofetil. Infectious complications occurred in 9 (25.7%) patients and 1 patient died of cytomegalovirus infection. Four patients had cold agglutinin disease and 3 (75.0%) responded to steroids. Autoimmune hemolytic anemia is a rare disorder in pediatric population and most respond well to steroids regardless of the type of antibody. Infectious complications are common and screening for immunodeficiency is recommended among those with Evans syndrome.

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Snake bite complications (with focus on compartment syndrome)

Schulte J, et al. Childhood Victims of Snakebites: 2000-2013. Pediatrics. 2016 Nov; 138(5). pii: e20160491.

The last comprehensive assessment of epidemiology of snakebites among children and adolescents of which we are aware was published in 1965 when inpatient hospital records in 10 states were reported.1 The present study provides data from 50 states, Puerto Rico, and Washington, DC, and finds both similarities and differences. Copperheads and rattlesnakes remain the most common domestic venomous snakes reported; most snakebites are reported during summer months; and few deaths occurred. More than 1100 children and adolescents are bitten each year, and ∼20% of victims require ICU admission. Almost 50% of the reported snakebites were venomous, but 84% of all domestic snakebites could have been potentially treated with antivenom therapy.

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Hsu CP, et al. Predictors of the development of post-snakebite compartment syndrome. Scand J Trauma Resusc Emerg Med. 2015 Nov 11;23:97.

PSCS is a critical problem that requires multiple surgical interventions. Elevated WBC and AST upon ED arrival are highly likely to be risk factors for the development of PSCS and may be useful as clinical markers. Thus, patients with snakebites and locoregional symptoms with elevated markers should be observed for 48 h to exclude the possibility of PSCS. In the future, there may be an opportunity to develop a decision tool that combines observations of clinical symptoms and measurement of WBC and AST levels. Such a tool may be a reasonable and safe way to distinguish patients who can be discharged without needing the 48-h observation period from those who may require surgery.

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Necrotizing pneumonia

Masters IB, et al. Necrotizing pneumonia: an emerging problem in children? Pneumonia (Nathan). 2017 Jul 25;9:11.

“NP is an uncommon but increasingly recognized severe complication of pneumonia in previously healthy young children. The major pathogens are S. pneumoniae and S. aureus and the diagnosis should be considered when, despite appropriate antibiotics, the child remains febrile and unwell with persistent signs of respiratory distress and pneumonia. Most will have a PPE, empyema and/or BPF that has not improved despite chest drainage or surgical intervention. The diagnosis is confirmed by chest imaging, usually by a CT scan or sonography, while treatment requires prolonged IV antibiotics, which can be changed to oral medication for an additional 10–14 days, once the child is afebrile and clinically stable. Ideally, surgical intervention is kept to a minimum, but this is not always possible if there are mass effects from gas and fluid in the pleural cavity or pulmonary gangrene leading to massive hemoptysis, uncontrolled sepsis, or difficulties with assisted ventilation. Nevertheless, despite its severity, mortality in children is uncommon; the children improve clinically within a couple of months, radiographic changes are largely resolved after 5–6 months, and only a minority are left with mildly impaired lung function. Important targets for future research include identifying host–pathogen interactions leading to disease, improving the microbiologic diagnostic gap, optimizing medical and surgical management, and ultimately preventing this severe complication of pediatric pneumonia.”

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