“Ideally, SPA should be used for microbiological assessment of urine in young children,” states the abstract conclusion for this article from Australia.
Looking retrospectively at urine samples from 599 children with an average age of 7 months, these authors conclude that suprapubic aspiration is superior to all other methods of obtaining urine samples for contamination rates. Contamination rates were 46% with bag urine, 26% for clean catch, 12% for catheterization, and 1% for suprapubic aspiration.
We generally rely on catheterized urine samples in our Emergency Departments – and we even have difficulty convincing some parents that this is required, let alone a suprapubic aspiration. In fact, I’m rather surprised they had 84 patients (14%) in their cohort receiving suprapubic aspiration, considering I have never seen it performed.
While I have no issue with their conclusion from a microbiologic accuracy standpoint, I’m not so sure such an invasive and painful procedure has a place in routine practice.
“Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: An observational cohort study.“
www.ncbi.nlm.nih.gov/pubmed/22537082
Category: Pediatrics
Hopping To Rule Out Appendicitis
The “Best Evidence Topic” reports from the Manchester Royal Infirmary are published in the Journal of Emergency Medicine. Overall, they are meant to summarize evidence regarding more practical, clinical applications. One of the recent summaries focuses on appendicitis, and whether eliciting pain during coughing, percussion, or hopping is useful in ruling in or out disease.
For this topic, they summarize a few articles – mostly following a prospective derivation study in which hopping/percussion/coughing was 93% sensitive and 100% specific for appendicitis. Unfortunately, the test performance didn’t quite hold up – sensitivity ranging from 72% to 89%, depending on age group, and highly variable specificities.
So, unfortunately, somewhat like the “hamburger test,” you won’t be able to base the entirety of your clinical disposition on this, but it’s not an irrelevant input into your general clinical gestalt.
“BET 1: Is abdominal pain when asked to hop suggestive of appendicitis in children?”
Most Severe Mechanism Children Don’t Need Head CTs
The PECARN group has published a set of criteria that identify children at very low risk for significant traumatic injury. This is publicly available and an excellent decision instrument to enhance your clinical judgement. But, the problem is, with excellent sensitivity, the specificity is weak – such that a great number of patients who fail to meet low-risk criteria will still have good outcomes.
So, this is a follow-on study attempting to determine whether the severe mechanism portion of the decision instrument was predictive of significant TBI, or whether scans could be avoided if mechanism was the only positive feature in their decision instrument. And, yes, a severe injury mechanism in isolation – at least in the 35% of their cohort who received a head CT – had only a 0.3% chance of significant injury in age <2 years and 0.6% chance of significant injury in age >2 years. Severe injury mechanisms associated with additional PECARN criteria, however, had 4% and 6% incidence of TBI, depending on age.
Probably the most important aspect of these numbers is they allow for a better discussion of risks with parents and families. While 1 in 150 or 1 in 300 sound like pretty good odds, when you practice long enough, those odds will catch up with you. Even with severe mechanism and additional features, 19 of 20 CTs will be negative – you can still make a reasonable case for observation rather than knee-jerk scanning.
“Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms”
“Malodorous” Urine Isn’t Necessarily a UTI
Which is to say, when a parent brings in a child with a fever and the urine “smells bad”, plenty of those kids have normal urine cultures and plenty of children with Febreeze for urine have a urinary tract infection, regardless.
This is a prospective cohort study enrolling children receiving a urine culture as part of an evaluation for fever without a source in the Emergency Department – and then they went back and data mined for associations between the group diagnosed with UTI and not. The overall incidence of UTI was 15%. The overall incidence of UTI in those with “malodorous” urine was 24%. It was the most significant contributing factor they found, but it’s still not sensitive or specific enough to use in isolation to change management.
Other interesting tidbits: no circumcised male had a UTI, known high-grade vesicoureteral reflux predicted UTI.
“Association of Malodorous Urine With Urinary Tract Infection in Children Aged 1 to 36 Months”
http://www.ncbi.nlm.nih.gov/pubmed/22473364
The Dexamethasone Dose for Croup is 0.15mg/kg
Unfortunately, this is still probably not the trial that convinces everyone. In fact, it’s been over 15 years since the original single-center trials/reports showing that 0.15mg/kg of dexamethasone was every bit as effective as 0.6mg/kg of dexamethasone. This makes intuitive sense, considering the steroid equivalencies, and the doses used in studies that have established prednisolone as an adequate treatment for croup, as well.
Regardless, this is a very small – 30-odd patients – with mild croup, randomized to dexamethasone at 0.15mg/kg vs. placebo. The point of this study was not to test the efficacy of dexamethasone, but rather to show that, despite it’s long half-life, it had immediate effects. And, I think it’s fair to say this study demonstrates those significant effects in reduction in croup score, gaining statistical significance by 30 minutes.
I don’t know where the attachment came from in terms of the 0.6mg/kg dose of dexamethasone, but it’s just preposterously high.
“How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial.”
http://www.ncbi.nlm.nih.gov/pubmed/22313564
Early Steroids Probably Better for Asthma
Not sure if this is the study that proves it – since due to ethical considerations it’s simply observational, and doesn’t control for confounders and introduces a lot of bias – but, it’s a small piece of the puzzle.
This is a cohort in a Montreal pediatric emergency department in which they prospectively collected data on moderate and severe asthma exacerbations as patients progressed through their care pathway. They see, essentially, a nonsignificant trend in increased odds of hospital admission for patients in whom administration of systemic steroids was delayed. This is mostly a data mining exercise, so any significant associations should be considered hypothesis generating. However, considering the patients who received delayed steroids had milder exacerbations overall – yet still seemed to go on to have higher admission rates – it might be tempting to interpret these findings as appropriately confirmatory of physiologic foundations of treatment.
At least, there’s no suggestion of harm from early steroid administration in asthma with exacerbation in children. Perhaps some prospective interventional data with patient-oriented outcomes will surface in response.
“Early Administration of Systemic Corticosteroids Reduces Hospital Admission Rates for Children With Moderate and Severe Asthma Exacerbation”
http://www.ncbi.nlm.nih.gov/pubmed/22410507
Please Stop Using Azithromycin Indiscriminantly
There is a time and a place for a macrolide with a long half-life, and it is not empirically for pharyngitis.
And, it’s even less appropriate empirically for pharyngitis now that it’s been overused to the point where it’s nearly in the drinking water – because it can no longer be considered second-line for group A streptococcus for your penicillin allergic patients.
This is a case report and evidence review from Pediatrics that discusses two cases of rheumatic fever, both of which presented after treatment of GAS pharyngitis with azithromycin. While rheumatic fever has been almost completely wiped out – there are so few of the RF emm types in circulation, that it’s almost nonexistent in the United States – there are still sporadic cases. Macrolides are listed as second-line therapy for GAS, but single-institution studies have shown macrolide resistant streptococcus in up to 48% of patients. Macrolide resistance varies greatly worldwide, from a low of 1.1% in Cyprus to 97.9% in Chinese children.
Why is macrolide resistance so high? Azithromycin is the culprit; because it has such a long-half life, it spends a long time in the body at just below its mean inhibitory concentration, and preferentially selects for resistant strains.
Please stop using azithromycin. Use doxycycline, or another alternative, when possible. There has never been reported resistance to pencillin in GAS.
“Macrolide Treatment Failure in Streptococcal Pharyngitis Resulting in Acute Rheumatic Fever”
http://www.ncbi.nlm.nih.gov/pubmed/22311996
Discharging Bronchiolitis on Home Oxygen
This is another one of those window-to-the-future articles, where an enterprising department has taken a commonplace disease with a relatively high admission rate and tried to change the status quo.
As they note, bronchiolitis is the #1 cause of admission for children < 1 year, it accounts for 150,000 admissions annually, and costs $500 million. One of the key clinical features that keeps otherwise well-appearing children in the hospital is hypoxia, specifically < 90% saturation by pulse oximetry as recommended by the American Academy of Pediatrics.
This is a retrospective chart review that essentially says “we did this and we like it.” 4,194 relevant charts were reviewed, 57% of which were discharged without home oxygen, 15% were discharged on oxygen, and 28% were admitted. Of the discharged patients, 4% of the no-home-oxygen patients returned for eventual admission compared with 6% of the discharge-on-oxygen patients. Overall, this led to a 25% relative decrease in admissions for bronchiolitis at their institution, compared to historical controls.
More confirmatory study is needed – it’s a little different at mile-high Denver than the rest of the U.S. – but this may be a promising way to reduce admissions for bronchiolitis. It is also suggestive of what is likely the new future of cost-containment medicine, at least where the malpractice environment will tolerate it – an increasing proportion of higher-risk discharges with, in theory, closer follow-up that saves money in the long run.
“Discharged on Supplemental Oxygen From an Emergency Department in Patients With Bronchiolitis”
http://www.ncbi.nlm.nih.gov/pubmed/22331343
Eat Your Vegetables!
This may be a candidate for an IgNobel Prize, published as a research letter in JAMA: how to get schoolchildren to eat their vegetables!
Control group: normal lunch trays. Intervention group: lunch trays with compartments specifically labeled with photographs of green beans and carrots. Results: success! Green bean choice went from 6.3% of children to 14.8% of children, and carrot choice went from 11.6% to 36.8%. Amount of green bean and carrot consumption was stable on an individual basis, resulting in an overal net consumption of both green beans and carrots by their cohort.
Of course, this was only a single day intervention – my guess is the effect would fatigue – but, at least, for one day, children ate more vegetables.
This has far-reaching implications for Emergency Medicine.
“Photographs in Lunch Tray Compartments and Vegetable Consumption Among Children in Elementary School Cafeterias”
http://jama.ama-assn.org/content/early/2012/01/31/jama.2012.170.full
Half of Fractures Received No Analgesia
One of the new CMS quality measures involves measuring time to receipt of pain medication for patients diagnosed with long bone fractures. While this isn’t the most exciting quality measure in terms of outcomes, it is probably a reasonable expectation that fractures receive pain control, and it might be a plausible surrogate marker for overall Emergency Department operations – at least, until the powers that be focus solely on these few measures at the expense of other clinical operations.
This article is a retrospective review of all pediatric long bone fractures evaluated at their facility. They used the electronic medical record to track the timing of any “adequate” pain medication. They have a specific weight-based definition of “adequate” for IV narcotics, PO narcotics, and non-narcotic analgesics, and they specifically break down pain medication received within 1 hour of arrival.
They identified 773 cases in their records, and by their definitions, 75 patients received an “adequate” dose of pain medication within 1 hour. One can quibble with their definition of “adequate” because there is a range of pain needs that don’t necessarily require maximal dosing. But, you cannot quibble with the fact that 353 children received no pain medication at all within an hour of ED arrival (or prior to ED arrival). Certainly, some individual factors at play would result in reasonable delays to pain medication, but definitely not nearly half.
“Analgesic Administration in the Emergency Department for Children Requiring Hospitalization for Long-Bone Fracture”
http://www.ncbi.nlm.nih.gov/pubmed/22270501