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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Methotrexate toxicity

Chan BS, et al. What can clinicians learn from therapeutic studies about the treatment of acute oral methotrexate poisoning? Clin Toxicol (Phila). 2017 Feb;55(2):88-96.

Management of acute oral poisoning: Due to the low bioavailability of MTX, treatment is not necessary for single ingestions. Oral folinic acid may be used to lower the bioavailability further with large ingestions >1 g m-2. Oral followed by intravenous folinic acid may be used in patients with staggered ingestion >36 h or patients with acute overdose and renal impairment (eGFR <45 mL/min/1.73 m2).

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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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Seizures in fetal alcohol spectrum disorders

Boronat S, et al. Seizures and electroencephalography findings in 61 patients with fetal alcohol spectrum disorders. Eur J Med Genet. 2017 January; 60 (1): 72-78.

Fetal alcohol spectrum disorders (FASD) cause neurodevelopmental abnormalities. However, publications about epilepsy and electroencephalographic features are scarce. In this study, we prospectively performed electroencephalography (EEG) and brain magnetic resonance (MR) imaging in 61 patients with diagnosis of FASD. One patient had multiple febrile seizures with normal EEGs. Fourteen children showed EEG anomalies, including slow background activity and interictal epileptiform discharges, focal and/or generalized, and 3 of them had epilepsy. In one patient, seizures were first detected during the EEG recording and one case had an encephalopathy with electrical status epilepticus during slow sleep (ESES). Focal interictal discharges in our patients did not imply the presence of underlying visible focal brain lesions in the neuroimaging studies, such as cortical dysplasia or polymicrogyria. However, they had nonspecific brain MR abnormalities, including corpus callosum hypoplasia, vermis hypoplasia or cavum septum pellucidum. The latter was significantly more frequent in the group with EEG abnormal findings (p < 0.01).

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Nicita F, et al. Seizures in fetal alcohol spectrum disorders: evaluation of clinical, electroencephalographic, and neuroradiologic features in a pediatric case series. Epilepsia. 2014 Jun;55(6):e60-6.

Seizures are observed with a frequency of 3-21% in children with fetal alcohol spectrum disorders (FASD). However, clinical, neuroradiologic, and electroencephalography (EEG) features are poorly described. In this study, 13 patients with FASD and epilepsy or seizures were identified retrospectively from the databases of seven Italian pediatric neurology divisions. Eleven children were affected by epilepsy, and two had at least one documented seizure. Both generalized and focal seizures were observed. EEG showed diffuse or focal epileptic activity; two children developed electric status epilepticus during sleep (ESES). Structural brain anomalies, including polymicrogyria, nodular heterotopia, atrophy, and Arnold-Chiari type 1 malformation, were discovered in almost 50% of patients. Control of seizures was not difficult to obtain in 11 cases; one patient showed pharmacoresistant epilepsy. EEG and clinical follow-up are recommended in children with FASD and epilepsy, since severe conditions requiring aggressive treatment, such as in ESES, may develop. Neuroradiological evaluation is warranted because several types of brain anomalies could be associated with maternal alcoholconsumption during pregnancy.

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Practice Based Learning: Anti-nuclear antibody testing – to test or not to test…

 

 

 

Presented by Taylor Maturo, MD (PGY-2)

Clinical questions:

  • WHEN do we test for ANA and WHOM should we be testing?
  • WHAT exactly is the ANA test? If we do think it’s indicated, what do we order?
  • HOW do we interpret the results?

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Practice Based Learning: Oral vs IV Antibiotics for Post-Discharge Treatment of Acute Osteomyelitis

 

 

 

Presented by Nathan Yarnall MD (PGY2)

Clinical questions:

In patients with acute osteomyelitis:

  • Is there a difference in treatment failure rates between post-discharge PO vs IV antibiotics?
  • Is there a difference in treatment-related adverse outcomes?
  • Is this generalizable to all cases, including severe and chronic osteomyelitis?

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Pleural effusions and empyema

Cashen K, Petersen TL. Pleural Effusions and Pneumothoraces. Pediatr Rev. 2017 Apr; 38(4):170-181.

After completing this article, readers should be able to:

  1. Describe the pathogenesis of pleural fluid accumulation.
  2. Identify the most likely causes of pleural effusion and pneumothorax.
  3. Understand the basic clinical presentation, diagnostic tests, and management of pleural effusions and pneumothoraces.
  4. Differentiate between transudative and exudative pleural effusions.
  5. Understand the natural history of spontaneous pneumothorax.

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Strutt J, Kharbanda A. Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases. Pediatr Emerg Med Pract.
2015 Nov;12(11):1-24;

Pediatric thoracostomy procedures are used in the emergency department to treat diseases of the pleural space. As children have unique thoracic anatomy and physiology, they may present with management challenges that the emergency clinician must consider. This issue reviews the use of chest tubes and pigtail catheters in pediatric patients, techniques and indications for placement, and possible complications. Diagnostic and treatment options for diseases of the pleural space, such as spontaneous pneumothorax, traumatic injury, and parapneumonic effusions/empyema, are examined. Additionally, this issue discusses the use of imaging modalities to aid in the diagnosis of pleural space diseases and the emerging practice of ambulatory management in certain cases.

Children’s and Emory users, request article from Emily Lawson. 

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Juvenile dermatomyositis

Papadopoulou C, Wedderburn LR. Treatment of Juvenile Dermatomyositis: An Update. Paediatr Drugs. 2017 May 26.

The idiopathic inflammatory myopathies of childhood consist of a heterogeneous group of autoimmune diseases characterised by proximal muscle weakness and pathognomonic skin rashes. The overall prognosis of juvenile myositis has improved significantly over recent years, but the long-term outcome differs substantially from patient to patient, suggestive of distinct clinical phenotypes with variable responses to treatment. High doses of corticosteroids remain the cornerstone of therapy along with other immunosuppressant therapies depending on disease severity and response. The advent of biological drugs has revolutionised the management of various paediatric rheumatologic diseases, including inflammatory myopathies. There are few data from randomised controlled trials to guide management decisions; thus, several algorithms for the treatment of juvenile myositis have been developed using international expert opinion. The general treatment goals now include elimination of active disease and normalisation of physical function, so as to preserve normal growth and development, and to prevent long-term damage and deformities. This review summarises the newer and possible future therapies of juvenile inflammatory myopathies, including evidence supporting their efficacy and safety.

Children’s and Emory users, request article from Emily Lawson. 


McCann LJ, Pain CE. A Practical Approach to Juvenile Dermatomyositis and Juvenile Scleroderma. Indian J Pediatr. 2016 Feb;83(2):163-71.

Juvenile dermatomyositis and juvenile scleroderma are rare multisystem autoimmune disorders. Although they share some pathognomonic hallmarks with adult onset myositis or scleroderma, there are significant differences in presentation, characteristics and associated features when the diseases present in childhood. In view of this, and the rarity of the conditions, it is important for care to be led by teams with expertise in pediatric rheumatology conditions. Prognosis has improved significantly in the West; likely due to early diagnosis and aggressive treatment with immunosuppressive medications. However, this trend is not replicated in the developing world. Early recognition of these diseases is crucial to achieve rapid and sustained remission and prevent disease or medication associated complications. This article aims to provide a practical overview for recognition, diagnosis and treatment of these conditions.

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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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