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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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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Adverse effects of synthetic cannabinoids

Baum RA, et al. Suspected synthetic cannabinomimetic intoxication. J Pharm Pract. 2017 Jan 1:897190017699761.

Recent legislation has failed to curb the public health concerns emanating from SC misuse. Education about the risks of SC use along with additional regulation may be required to remove the false sense of safety that some individuals, especially adolescents and young adults, may associate with these compounds, which are often misconstrued as “herbal marijuana.” Clinicians need to be prepared to identify and treat symptoms of SC intoxication as incidents of toxicity continue to rise.

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Castellanos D, Gralnik LM. Synthetic cannabinoids 2015: An update for pediatricians in clinical practice. World J Clin Pediatr. 2016 Feb 8;5(1):16-24.

Synthetic cannabinoids are a group of substances that are typically much more potent than natural cannabis. These substances have been increasingly abused by youth over the past few years. A number of published reports have emerged documenting the serious health consequences associated with use of these products. Seizures, myocardial infarction and renal damage are some of the significant physical consequences associated with their use. With current limitations of toxicological analyses pediatricians are urged to familiarize themselves with these drugs and the typical presentations of patients who use them.

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Spasmus nutans

Delorme C, Gras D, Roze E. Spasmus nutans: more than meets the eye. Pediatr
Neurol. 2015 Oct;53(4):367-8.

“Spasmus nutans is a rare transient movement disorder of early childhood, defined by the clinical triad (1) nystagmus, (2) head nodding, and (3) torticollis, in the absence of any associated ophthalmological or neurological condition. [1] This condition might be difficult to recognize and is rarely reported in the literature.”

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Practice Based Learning: Management of agitation in Autism Spectrum Disorder

 

 

 

Presented by Mohammed Shahnawaz MD (PGY1)

Objectives:

  • Elucidate Autism Spectrum Disorder (ASD) characteristics and prevalence of aggression
  • Discuss options for relieving agitation and aggression
  • Inform ourselves about pharmaceutical options to reduce aggressive behavior
  • Explore future study opportunities

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Antibiotic treatment for Shigella infections

Klontz KC, Singh N. Treatment of drug-resistant Shigella infections. Expert Rev Anti Infect Ther. 2015 Jan;13(1):69-80.

Since the introduction of sulfonamides in the late 1930s, selective pressure and the widespread dissemination of mobile genetic elements conferring antimicrobial resistance have forced clinicians to seek successive agents for the treatment of multidrug-resistant shigellosis. Over the decades, the principal antibiotics used to treat Shigella infections have included tetracycline, chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, and nalidixic acid. Presently, ciprofloxacin, azithromycin, and ceftriaxone serve as the mainstays of treatment, although growing evidence has documented decreased susceptibility or full resistance to these agents in some regions. With diminishing pharmaceutical options available, there is an enhanced need for preventive measures in the form of improved sanitation and hygiene standards, strict use of currently effective agents, and a safe and effective licensed vaccine.

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Holmes LC. Shigella. Pediatr Rev. 2014 Jun;35(6):261-2.

“The choice of which antibiotic to administer is another treatment question. A 2010 Cochrane review of 16 randomized controlled trials evaluating antibiotics for shigella dysentery found all classes of antibiotics had similar efficacy, and the authors were not able to identify a superior class of antibiotics. In the United States, the 2010 National Antimicrobial Resistance Monitoring System found 41% of Shigella species resistant to ampicillin, 48% resistant to trimethoprim-sulfamethoxazole, 2% resistant to ciprofloxacin, and less than 1% resistant to ceftriaxone. Antibiotic resistance in outbreaks has been reported to be much higher. Arvelo et al found 90% of the Shigella strains involved in a large daycare center–associated outbreak resistant to both ampicillin and trimethoprim-sulfamethoxazole. Knowing regional resistance patterns and the susceptibility pattern of the pathogen once available is essential to guide therapy.”

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Christopher PR, et al. Antibiotic therapy for Shigella dysentery. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD006784.

Antibiotics reduce the duration of Shigella dysentery.Regularly updated local or regional antibiotic sensitivity patterns to different species and strains of Shigella are required to guide empiric therapy. More trials adhering to standard guidelines are required to evaluate the role of antibiotics in the treatment of severe forms of Shigella dysentery and in groups who are at high risk of complications.

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