Friday, August 17, 2012

Honey For Pediatric Cough

Sponsored by the Honey Board of Israel, this small study supposes to demonstrate that honey is superior to control in the treatment of pediatric nighttime cough.  Specifically, honey is superior to silan date extract, which apparently resembles and tastes like honey.

This is a prospective, double-blind study of three different honey arms and one control arm.  Each group had approximately the same pre-intervention symptomatology severity – cough severity, bothersome nature of the cough, and sleeplessness for bother parent and child – and all interventions improved symptoms.  The scores, supposing clinical relevance to a 0.75 difference in score on a 4-point scale, were significantly improved by all interventions.  Then, the various types of honey all either strongly trended towards or reached statistical superiority over the silan date extract.

So, if your child has a cough – honey seems to be a reasonable intervention.  If you don't have honey, give them silan date extract!  If you have neither – well, just don't use dextromethorphan.  And, 20% of infant botulism cases are traced to contaminated honey, so the current recommendation is not to give honey to patients aged less than 1 year.

Incidental note is also made by the authors that some children likely disliked the more aromatic eucalyptus and citrus honeys.

"Effect of Honey on Noctural Cough and Sleep Quality:  A Double-blind, Randomized, Placebo-Controlled Study"

Wednesday, August 15, 2012

Platelet Transfusion & Intracerebral Hemorrhage

This systematic review is published in Annals of Emergency Medicine under the section heading of "Best Available Evidence", which somehow to me seems to pleasantly understate the unfortunate lack of data on this topic.

Intracererbral hemorrhage in the setting of antiplatelet use unfortunately is one of those clinical situations where outcomes are so dire that the philosophy seems to be to throw the kitchen sink of potentially beneficial interventions at patients.  Use of clopidogrel, and to a lesser extent aspirin, are associated with increased hematoma size and poorer outcomes.  Platelet transfusions, using measures of platelet aggregation activity, are demonstrated to improve and reverse inhibition in approximately two-thirds of patients.  Therefore, it follows that platelet transfusions would improve outcomes in intracranial hemorrhage.

Unfortunately, the "best" evidence – which is mostly retrospective data of small cohorts – fails to demonstrate any improvement in mortality or morbidity.  It is not possible to say from the data whether the platelets do not show efficacy at treating the extension of the ICH, or whether the poor outcomes result from parallel transfusion-related complications.  The article concludes that withholding platelet transfusion should be considered to be within the standard of care.  I tend to agree that resource-intensive treatments should be required to demonstrate benefit before widespread adoption, and therefore agree with these authors.

The authors additionally note a prospective, multicenter trial is underway.

"Does Platelet Transfusion Improve Outcomes in Patients With Spontaneous or Traumatic Intracerebral Hemorrhage?"

Monday, August 13, 2012

Mistakes Were Made

This is a fascinating series in Pediatric Emergency Care in which interesting cases from published medical malpractice verdicts are featured.  Each case – typically ending poorly – is followed by a short editorial on the underlying disease processes, with pearls regarding treatment, diagnosis, and the case outcome.  Reading these cases, hopefully, will not contribute to recency bias, and ideally serve simply as brief reminders of clinical features of the rare sick children lurking in the haystack of walking well.

Medicine – as much as or greater than any other profession – is a delicate mix of confidence, humility, and the recognition of the underlying biases in our cognition and practice.  Most of this blog focuses on practicing based on evidence, applying the rules and probabilities of populations as guides towards the diagnosis and treatment of individual patients.  Therefore, when reading these Legal Briefs, I simply want to reinforce the dangers of anecdote-based medicine.

"Pediatric Emergency Medicine:  Legal Briefs"