Morphine Not a Good Adjunct For Pediatric Pain

Treating acute musculoskeletal pain in the Emergency Department is a common occurrence – and even on the docket as a time-to-analgesia quality measure. Where we frequently see failures and delays, however, are in children, with much written regarding oligoanalgesia and the dragging of feet before any sort of pain management. Furthermore, adults are frequently managed with opiate therapy, which, despite its various pitfalls, may be considered to stand above the commonly used ibuprofen and acetaminophen monotherapy in children.

So, does it work better to combine an oral non-steroidal analgesic with opiate therapy in children? Or, perhaps, is even an opiate alone better with regard to adverse effects? That is the question asked by this three-arm, double-blinded, placebo-controlled, randomized trial. Children with painful musculoskeletal injuries were randomized either ti 10mg/kg oral ibuprofen, 0.2mg/kg oral morphine, or the combination of both.

The winner is: not children. With 91 analyzed in the ibuprofen-only arm, 188 in the morphine-only arm, and 177 in the combination arm, there were no reliable differences between analgesia between groups. More disappointingly, the average pain score on the visual analogue scale was ~60mm across all groups, and no group improved more than 20mm within an hour. The authors considered a VAS score of <30mm at 60 minutes to represent adequate pain control, and less than a third from each group achieved this. There were no serious adverse events in any group, but 20% of those receiving morphine complained of mild adverse events, mostly nausea and abdominal pain, compared with 7% of the ibuprofen-only arm.

So, still at square one for oral analgesia – but, at least, this negative trial helps inform our avoidance of the intervention tested here.

“Oral Analgesics Utilization for Children With Musculoskeletal Injury (OUCH Trial): An RCT”
http://pediatrics.aappublications.org/content/early/2017/10/09/peds.2017-0186

Azithromycin Ruins Everything

For some reason – and by “some reason”, I mean extensive evaluation of immunomodulatory properties – there is an obsession with azithromycin use for more than simply its anti-bacterial indications. It has been hypothesized to diminish inflammation and have antiviral properties, and, of course, functions as a floor wax and dessert topping.

This is a randomized, controlled trial of azithromycin versus placebo in pre-school children with acute wheezing as a primary diagnosis. The primary outcome was time to resolution of respiratory symptoms, and secondary outcomes included any use of short-acting beta-agonists, adverse events, and time to any repeat exacerbation of wheezing.  These authors enrolled 300 before funding ran out, and were able to follow-up 222 with completed symptom diaries. Patients were generally similar between the two groups, and over 80% of each cohort had prior episodes of wheezing, and a similar percentage used or was prescribed a beta-agonist at discharge from the Emergency Department.

The winner: nothing and no one. Azithromycin did not improve any outcomes versus placebo, and should not be used for suspected viral wheezing in the hopes of anti-inflammatory symptom improvement until better evidence of benefit emerges.

“Treatment of preschool children presenting to the emergency department with wheeze with azithromycin: A placebo-controlled randomized trial”
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0182411

Enough with the Coughing!

Every Emergency Physician who has worked a night shift knows this all too well – the child brought to the ED in the middle of the night for a cough, keeping the entire family up, and the cough has been going on for weeks.

And, the not-at-all-satisfying answer: “This is pretty normal.”

This is yet another publication describing the natural history of symptoms following an upper respiratory illness. These authors in Australia enrolled children evaluated in the Emergency Department for an upper respiratory infection featuring cough. They enrolled 839 children and attempted to follow them for four weeks after the index visit, as well as through follow-up with a pulmonology specialist if seen for persistent, unresolving cough. Nearly 300 of the initially enrolled cohort was lost to follow-up over the course of the month, but of those who were contacted, two-thirds still had cough at 7 days, and a quarter were still coughing at day 21. Ultimately 171 – or 20.4% – were still coughing at day 28 and eligible for pulmonologist evaluation. Of these, about a third were identified to have a previously undiagnosed underlying chronic respiratory disorder (asthma, bronchiectasis, etc.) and about half were given the diagnosis of persistent bacterial bronchitis.

The general takeaway here is that coughs generally linger – but once a cough has persisted beyond 2-3 weeks, it is reasonable to consider alternative precipitating diagnoses other than the initial URI.

“Chronic cough postacute respiratory illness in children: a cohort study”
https://www.ncbi.nlm.nih.gov/pubmed/28814419

Predicting Treatment Failure in AOM

Like most infectious diseases, acute otitis media generally breaks down into three cohorts. There are viral infections, for which early antimicrobial therapy is virtually, by definition, unhelpful. Then, there are true bacterial infections – many of which resolve without substantial morbidity regardless of antimicrobial treatment, and those which require antimicrobial therapy to prevent such. The trick, and where modern medicine typically fails miserably, is rapidly predicting into which of these cohorts a patient may fall – a conundrum leading to the epidemic of antibiotic overuse.

This is a secondary analysis of a pediatric AOM trial, first published in the New England Journal of Medicine, looking at which patients were more likely to potentially fail conservative treatment. The intervention arm received amoxicillin/clavulanate, and treatment failure occured in 31.7% of children – vastly favoring the antibiotic arm – 44.9% vs. 18.6%. In theory, this exaggerated treatment effect might help better illuminate any small predictors – but, unfortunately, with only 319 patients, meaningful statistical significance on this data dredge is hard to come by. Worse still, the best predictor of treatment failure (or, really, lack thereof)? A peaked tympanogram (A and C curves) – you know, because we’re all routinely measuring tympanometry. Grossly bulging tympanic membranes were predictive of treatment failure, which has some face validity, at least – but, again, this is as compared between severe, moderate, and mild, which requires pneumatic otoscopy to differentiate.

The question here primarily concerns: can you take away good conclusions from bad data? The magnitude of the treatment effect seen in this trial far exceeded the treatment effect expected from antibiotics in other trials. And, consistent with that questionable generalizability, their findings reflect the stringent criteria determining their diagnosis of AOM. Then, they are relying upon their misguided definition for treatment failure, which relies on otoscopic signs, the same ones that will be colinear with worsened disease on initial examination. Unfortunately, the net result of all of this meandering is essentially no clinically useful insight. Considering the limitations the examination of the screaming ill toddler, more pragmatic approaches are necessary.

“Prognostic Factors for Treatment Failure in Acute Otitis Media”

http://pediatrics.aappublications.org/content/early/2017/08/04/peds.2017-0072

No Pictures of Poop Needed

I like this article – not because of any specific quality improvement reason relating to their intervention, but because it reminded me of something of which I perform too many.

It’s an easy trap to fall into, the – “well, let’s just see how much poop is in there” for diagnostic reassurance and to help persuade the family you’re doing relevant testing in the Emergency Department. However, here are the relevant passages from their introduction:

In a 2014 clinical guideline, the North American and European Societies of Pediatric Gastroenterology, Hepatology, and Nutrition found that the evidence supports not performing an AXR to diagnose functional constipation.

and

Recent studies showed that AXRs performed in the ED for constipation resulted in increased return visits to the ED for the same problem.

I feel some solace in knowing that 50 to 70% of ED visits for constipation may include an abdominal radiograph as part of their workflow – meaning I’m just, at least, part of the herd.

So, regardless of the point of their article – that a plan-do-act cycle of education and provider feedback successfully cut their rate of radiography from 60% to 20% – this is yet another misleading and/or unnecessary test to delete from our practice routine.

“Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency Department.”
https://www.ncbi.nlm.nih.gov/pubmed/28615355

What Does a Sepsis Alert Gain You?

The Electronic Health Record is no longer simply that – a recording of events and clinical documentation.  Decision-support has, for good or ill, morphed it into a digital nanny vehicle for all manner of burdensome nagging.  Many systems have implemented a “sepsis alert”, typically based off vital signs collected at initial assessment. The very reasonable goal is early detection of sepsis, and early initiation of appropriately directed therapy. The downside, unfortunately, is such alerts are rarely true positives for severe sepsis in broadest sense – alerts far outnumber the instances in a change of clinical practice results in a change in outcome.

So, what to make of this:

This study describes a before-and-after performance of a quality improvement intervention to reduce missed diagnoses of sepsis, part of which was introduction of a triage-based EHR alert. These alerts fired during initial assessment based on abnormal vital signs and the presence of high-risk features. The article describes baseline characteristics for a pre-intervention phase of 86,037 Emergency Department visits, and then a post-intervention phase of 96,472 visits. During the post-intervention phase, there were 1,112 electronic sepsis alerts, 265 of which resulted in initiation of sepsis protocol after attending physician consultation.  The authors, generally, report fewer missed or delayed diagnoses during the post-intervention period.

But, the evidence underpinning conclusions from these data – as relating to improvements in clinical care or outcomes, or even the magnitude of process improvement highlighted in the tweet above – is fraught. The alert here is reported as having a sensitivity of 86.2%, and routine clinical practice picked up nearly all of the remaining cases that were alert negative.  The combined sensitivity is reported to be 99.4%.  Then, the specificity appears to be excellent, at 99.1% – but, for such an infrequent diagnosis, even using their most generous classification for true positives, the false alerts outnumbered the true alerts nearly 3 to 1.

And, that classification scheme is the crux of determining the value of this approach. The primary outcome was defined as either treatment on the ED sepsis protocol or pediatric ICU care for sepsis. Clearly, part of the primary outcome is directly contaminated by the intervention – an alert encouraging use of a protocol will increase initiation, regardless of appropriateness. This will not impact sensitivity, but will effectively increase specificity and directly inflate PPV.

This led, importantly, for the authors to include a sensitivity analysis looking at their primary outcome. This analysis looks at the differences in overall performance if stricter rules for a primary outcome might be entertained. These analyses evaluate the predictive value of the protocol if true positives are restricted to those eventually requiring vasoactive agents or pediatric ICU care – and, unsurprisingly, even this small decline in specificity results in dramatic drops in PPV – down to 2.4% for the alert alone.

This number better matches the face validity we’re most familiar with for these simplistic alerts – the vast majority triggered have no chance of impacting clinical care and improving outcomes. It should further be recognized the effect size of early recognition and intervention for sepsis is real, but quite small – and becomes even smaller when the definition broadens to cases of lower severity. With nearly 100,000 ED visits in both the pre-intervention and post-intervention periods, there is no detectable effect on ICU admission or mortality. Finally, the authors focus on their “hit rate” of 1:4 in their discussion – but, I think it is more likely the number of alerts fired for each each case of reduced morbidity or mortality is on the order of hundreds, or possibly thousands.

Ultimately, the reported and publicized magnitude of the improvement in clinical practice likely represents more smoke and mirrors than objective improvements in patient outcomes, and in the zero-sum game of ED time and resources, these sorts of alerts and protocols may represent important subtractions from the care of other patients.

“Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign–Based Electronic Alert and Bedside Clinician Identification”

http://www.annemergmed.com/article/S0196-0644(17)30315-3/abstract

PECARN, CATCH, CHALICE … or None of the Above?

The decision instrument used to determine the need for neuroimaging in minor head trauma essentially a question of location. If you’re in the U.S., the guidelines feature PECARN. In Canada, CATCH. In the U.K., CHALICE. But, there’s a whole big world out there – what ought they use?

This is a prospective observational study from two countries out in that big remainder of the world – Australia and New Zealand. Over approximately 3.5 years, these authors enrolled patients with non-trivial mild head injuries (GCS 13-15) and tabulated various rule criteria and outcomes. Each rule has slightly different entry criteria and purpose, but over the course of the study, 20,317 patients were gathered for their comparative analysis.

And, the winner … is Australian and New Zealand general practice. Of these 20,000 patients included, only 2,106 (10%) underwent CT. It is hard to read between the lines and determine how many of the injuries included in this analysis were missed on the initial presentation, but if rate of neuroimaging is the simplest criteria for winning, there’s no competition. Applying CHALICE to their analysis cohort would have increased their CT rate to approximately 22%, and CATCH would raise the rate to 30.2%. Application of PECARN would place 46% of the cohort into CT vs. observation – an uncertain range, but certainly higher than 10%.

Regardless, in their stated comparison, the true winner depends on the value-weighting of sensitivity and resource utilization. PECARN approached 100% or 99% sensitivity, missing only 1 patient with clinically important traumatic brain injury out of ~10,000. Contrawise, CATCH and CHALICE missed 13 and 12 out of ~13,000 and ~14,000, respectively. Most of these did not undergo neurosurgical intervention, but a couple missed by CHALICE and CATCH would. However, as noted above, PECARN is probably substantially less specific than both CATCH and CHALICE, which has relatively profound effect on utilization for a low-frequency outcome.

Ultimately, however, any of these decision instruments is usable – as a supplement to your clinical reasoning. Each of these rules simplifies a complex decision into one less so, with all its inherent weaknesses. Fewer than 1% of children with mild head injury need neurosurgical intervention and these are certainly rarely missed by any typical practice. In settings with high CT utilization rates, any one of these instruments will likely prove beneficial. In Australia and New Zealand – as well as many other places around the world – potentially not so much.  This is probably a fine example of the need to compare decision instruments to clinician gestalt.

“Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study”

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30555-X/abstract

Making Urine Cultures Great Again

As this blog covered earlier this month, the diagnosis of urinary tract infection – as common and pervasive as it might be – is still fraught with diagnostic uncertainty and inconclusive likelihood ratios. In practice, clinicians combine pretest likelihood, subjective symptoms, and the urinalysis to make a decision regarding treatment – and invariably err on the side of over-treatment.

This is an interesting study taking place in the Nationwide Children’s Hospital network regarding their use of urine cultures. In retrospect, these authors noted only half of patients initially diagnosed with UTI had the diagnosis ultimately confirmed by contemporaneous urine culture. Their intervention, then, in order to reduce harm from adverse effects of antibiotics, was to contact patients following a negative urine culture result and request antibiotics be stopped.

This tied into an entire quality-improvement procedure simply to use the electronic health record to accurately follow-up the urine cultures, but over the course of the intervention, 910 patients met inclusion criteria. These patients were prescribed a total of 8,648 days of antibiotics, and the intervention obviated 3,429 (40%) of those days. Owing to increasing uptake of the study intervention by clinicians, the rate of antibiotic obviation had reached 61% by the end of the study period.

There are some obvious flaws in this sort of retrospective reporting on a QI intervention, as there was no reliable follow-up of patients included. The authors report no patients were subsequently diagnosed with a UTI within 14 days of being contacted, but this is based on only 46 patients who subsequently sought care within their healthcare system within 14 days, and not any comprehensive follow-up contact. There is no verification or antibiotics actually being discontinued following contact. Then, finally, antibiotic-free days are only a surrogate for a reduction the suspected adverse events associated with their administration.

All that said, this probably represents reasonable practice. Considering the immense frequency with which urine cultures are sent and antibiotics prescribed for dysuria, the magnitude of effect witnessed here suggests a potentially huge decrease in exposure to unnecessary antibiotics.

“Urine Culture Follow-up and Antimicrobial Stewardship in a Pediatric Urgent Care Network”
http://pediatrics.aappublications.org/content/early/2017/03/14/peds.2016-2103

The Solution to Dilution is ….

Do we order a lot of urinalyses? Does the sun rise in the east? Does a bear ….

For a test we order with great frequency, there is actually quite a bit of complexity in its interpretation. The combination of symptoms, clinical context, the balance between sample contamination and presence of white blood cells, of nitrites and/or leukocyte esterase, and so on, can make it a relatively tricky test to interpret. The gold standard remains a urine culture.

Now – if you haven’t been already – you probably ought to be taking into account the urine specific gravity, as well.

This retrospective analysis of 14,971 children for whom paired urinalyses and urine cultures were available describes the test characteristics of WBCs/hpf, LE, and nitrites as stratified by urine specific gravity. There are a lot of numbers in this article – a “zillion” to be precise – across eighteen dense tables of +LR/-LR, sensitivity/specificity, and PPV/NPV, but the basic gist of the matter is: variations in urine concentration diminish the value of the test in different ways. As urine specific gravity increases, it becomes more likely a patient will not have a positive urine culture despite having typically diagnostic amounts of WBCs/hpf, +LE, and/or +nitrites. Likewise, with dilute urine, a lower threshold for WBCs/hpf may be needed to have adequate sensitivity.

Just one more layer to consider in this frequently used test of under-appreciated complexity.

“The Importance of Urine Concentration on the Diagnostic Performance of the Urinalysis for Pediatric Urinary Tract Infection”
https://www.ncbi.nlm.nih.gov/pubmed/28169050

Let’s Hyperpronate!

There are two ways to treat a Nursemaid’s elbow (radial head subluxation) – supination/flexion or hyperpronation. I’ve done both. I’m a fan of hyperpronation, so, therefore, I’m highlighting a study that agrees with my practice pattern.

This systematic review covers 7 studies enrolling 701 patients, comparing the success rate and perceived pain of each technique. Trials were, generally and for some obvious reasons, limited in terms of blinding and outcome assessment. Pooled failure rate with hyperpronation 9.1% was while failure with supination /flexion was 27.3%. In studies reporting pain scores, subjective external rating of child pain during procedure also favored the hyperpronation group.

Use it!

This video demonstrates both techniques, although I’ve seen variations on hyperpronation both using extension and flexion.

“Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis”
https://www.ncbi.nlm.nih.gov/pubmed/27836316